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19901341-DS-8 | 19,901,341 | 24,456,392 | DS | 8 | 2166-10-29 00:00:00 | 2166-10-30 10:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Levaquin / Bactrim / Penicillins / Tetracyclines / codeine
Attending: ___.
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ year old lady with history of anorexia
presenting to the emergency room from her primary care
physician's office for evaluation of confusion.
The patient had a fall last ___ after slipping in her
bathroom while washing her feet in the sink. She hit her R ribs,
R elbow, R hip, and hit the back of her head on the toilet. No
LOC. Laid down in bed but then noted blood on the pillow so
called the nurses at ___ iving (She lives at ___
___ and they sent her to ___ instead of ___ on ___.
There, a CT head showed a right parietal fracture as well as an
intraparenchymal and subdural hematoma. The patient was admitted
to the Neuro ICU, CT head was stable so was transferred to Neuro
step down ___, kept trying to leave the hospital while
wearing all her hospital paraphernalia, while family left for a
short time on ___ she was discharged by a team that didn't
know her. She was re-admitted after famiyl discussed with case
management, but became agitated and wanted to leave. She was
discharged on Keppra ___ ICH.
She went to stay at a family member's home in ___. Since
___, she has been sleeping almost constatly, staying awake
___ hours out of the da, awaking with a splitting headache.
Today they took her to her doctor's office who felt that she was
not ready to be out of the hospital alone as she is still having
intermittent confusion, increased sleeping and unable to care
for herself (she lives in assisted living).
In the ED initial vitals were: 16:50 (unable) 99 56 112/68 18
100% RA.
In the ED she was noted to be awake, alert, complaining of
headache without nausea or emesis and constipation.
- Labs were significant for thrombocytosis, CKD (cre 1.4 from
1.6), hypoalbuminemia, and anemia (20s-> 42-> 31).
- Patient was given 650 of acetaminophen and 500 of
levetiracetam.
- CT head showed subacute left temporal contusion X2 x 2.5 cm in
diameter with local vasogenic edema association with sah and
tiny
SDH along tentorium.
Neurosurgery saw the patient and felt she was neurologically
stable, though did note occasional Wernicke's aphasia. No acute
neurosurgical issue or intervention. They recommended workup for
___ rehab. She was admitted to medicine service for
observation and need for placement for TBI/anorexia.
On the floor, she reports constipation, no BMs for 10 days, felt
she is bloated with fluid and stool. She generally eats 1 meal a
day with ___ ox protein, vegetables, carb 1 cup rice etc, and
milk. She sees her psychiatrist ___ times per week and has a
good therapeutic relationship with her, and with nutrionist as
well. Only new med is keppra. Over the last year, levothyroxine
has been changed but she can't recall how.
Past Medical History:
Anorexia since age ___, used to have bulimia in her ___ with
binge behavior, has been hospitalized for anorexia, also at
___ in ___
Chronic laxative abuse
Chronic kidney disease (baseline 1.2-1.5) felt to be ___
anorexia
Hypothyroidism
s/p CCY
Depression
Osteoporosis
Irritable bowel syndrome
h/o GI polyps
Thrombocytosis
Anemia
Hyperlipidemia
h/o nephrolithiasis
medullary nephrocalcinosis (thought to be ___ anorexia)
Social History:
___
Family History:
Lynch syndrome- brother died in his ___
Physical Exam:
ADMISSION EXAM:
================
Vitals 98.1 - 116/65 - 57 - 16 - 100RA admit weight 37 kg
GENERAL: NAD, extremely thin pleasant lady who is interactive,
conversing, no respiratory distress
HEENT: EOMI, exophthalmos, anicteric sclera, MMM, puffy cheeks,
non tender over parotids, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: thin, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, very thin
extremities
NEURO: CN II-XII intact, follows commands. speech fluent. UEs
strength is at least anti gravity but strength is poor, ___
with adduction, abductio, flexion, extension. Legs: anti gravity
(but unable to oppose) w leg flexion, extension, ___ hip
flexion, extension, add, abduction. ankle flex/ext antigravity.
patellar and ankle reflexes wnl. no loss of sensation. alert,
oriented x3, no asterixis, able to say days of week forward and
backward, but cannot recall president before obama.
SKIN: chronic skin changes over shins
DISCHARGE EXAM:
=================
Vitals 97.9 100s-120s/60s ___ 16 100RA
Q8 Neuro checks have all been completely normal
GENERAL: NAD, extremely thin pleasant lady who is interactive,
conversing, AAOx3
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: thin, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, very thin
extremities
Pertinent Results:
ADMISSION LABS:
=================
___ 05:15PM BLOOD WBC-6.8 RBC-3.05* Hgb-10.1* Hct-31.8*#
MCV-104* MCH-33.3* MCHC-31.9 RDW-14.1 Plt ___
___ 05:15PM BLOOD Neuts-68.9 ___ Monos-7.4 Eos-1.5
Baso-0.8
___ 05:15PM BLOOD Glucose-66* UreaN-29* Creat-1.4* Na-140
K-4.5 Cl-105 HCO3-20* AnGap-20
___ 05:15PM BLOOD ALT-21 AST-24 AlkPhos-71 TotBili-0.2
___ 05:15PM BLOOD Lipase-55
___ 05:15PM BLOOD Albumin-3.2*
___ 05:15PM BLOOD VitB12-___* Ferritn-101
___ 05:15PM BLOOD TSH-0.086*
___ 05:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
=================
___ 07:35AM BLOOD WBC-7.4 RBC-3.10* Hgb-10.1* Hct-32.6*
MCV-105* MCH-32.6* MCHC-31.0 RDW-14.0 Plt ___
___ 07:35AM BLOOD Glucose-63* UreaN-29* Creat-1.2* Na-137
K-4.3 Cl-104 HCO3-19* AnGap-18
STUDIES:
=================
___ CT Head:
IMPRESSION:
1. Intraparenchymal hemorrhage with surrounding edema is seen
within the left temporal lobe. This could represent hemorrhagic
contusion in the appropriate clinical context. However, an
underlying mass lesion cannot be excluded if clinical history
does not corroborate mechanism of injury.
2. Small amount of subdural hematoma with subarachnoid
hemorrhage seen along the left frontal convexity. Subdural
hematoma seen also along the left tentorium. No evidence of
mass effect.
___ EKG: Sinus bradycardia. QS deflections in leads V1-V3
consistent with prior anteroseptal myocardial infarction.
Compared to the previous tracing of ___ the voltage has
diminished. Otherwise, no apparent diagnostic interim change.
Brief Hospital Course:
___ with hx of anorexia and recent SDH/intracranial hemorrhages
___ trauma, presenting with ongoing confusion and headache.
# Post-concussive syndrome: Continuous headache in the setting
of traumatic brain injury with intermittent aphasia c/w temporal
injury. CT head shows minimal changes since recent CT head.
Patient was evaluated by neurosugery who found no abnormalities
on exam other than intermitent Wernicke's aphasia c/w temporal
injury. Patient was monitored with q8hr neuro checks, which were
all normal. She will follow up with ___ clinic in ___
weeks. Continue keppra for seizure prophylaxis until
neurosurgery follow up.
# Hyperthyroidism: TSH 0.08. Has been taking twice her usual
daily dose of levothyroxine on MWF. ?intentional abuse given
anorexia nervosa. Continue daily dose of levothyroxine 75.
Recheck TSH on this dose in ___ weeks.
# Chronic Anorexia Nervosa: Height 5'4" and 37kg on the standing
scale. BMI is roughly 13.9 - she is below 70% of IBW (38.2kg) at
37 kgs today. However, she does not have significant electrolyte
abnormalities, though does have hypoalbuminemia. She has a
strong therapeutic relationship with her outpatient psychiatrist
and sees a nutritionist regularly.
# Thrombocytosis: Thrombocytosis is known, but unclear cause.
Could be ___ ongoing reactive thrombocytosis vs
myeloproliferative or myelodysplastic disorders vs essential
thrombocytosis, esp given her macrocytic anemia. Consider heme
referral as outpatient.
# Constipation in the setting of laxative abuse: Would manage
with bulking agents as oppose to senna given history of laxative
abuse and likely derangement of gut motility in the setting of
this and anorexia. ___ require enema (did in past).
# CKD: Baseline creatinine 1.2-1.5. Within baseline, as such
will continue home meds, avoid NSAIDs and use caution with
nephrotoxins.
# Hyperlipidemia: Continue home pravastatin.
# Depression: Continue home sertraline
Transitional Issues:
- Continue keppra for seizure prophylaxis until neurosurgery
follow up.
- Recheck TSH in ___ weeks.
# Code: Full, confirmed
# Emergency Contact: ___ HCP/brother ___.
Second/alternate HCP: ___ MD ___ contact him at
___ - he is chief there)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Oystercal-D (calcium carbonate-vitamin D3) 500 mg(1,250mg)
-400 unit oral daily
4. Pravastatin 20 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. Sodium Bicarbonate 1300 mg PO TID
7. Klor-Con M20 (potassium chloride) 40 mEq oral daily
8. LeVETiracetam 500 mg PO BID
Discharge Medications:
1. LeVETiracetam 500 mg PO BID
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Pravastatin 20 mg PO DAILY
5. Sertraline 50 mg PO DAILY
6. Sodium Bicarbonate 1300 mg PO TID
7. Klor-Con M20 (potassium chloride) 40 mEq oral daily
8. Oystercal-D (calcium carbonate-vitamin D3) 500 mg(1,250mg)
-400 unit oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Post-concussive syndrome
Intraparenchymal, subarachnoid, and subdural hemorrhages
Secondary:
Anorexia Nervosa
Hyperthyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital for some confusion after a
recent fall with intracranial bleeding. You were evaluated by
neurosurgery, and a CT scan of your head was stable. You should
continue to take Keppra to prevent seizures until you follow up
in the ___ clinic. You will be discharged to a
___ rehabilitation facility to continue recovering from
your concussion.
Followup Instructions:
___
|
19901661-DS-19 | 19,901,661 | 29,337,046 | DS | 19 | 2179-04-17 00:00:00 | 2179-04-25 14:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
hematochezia
Major Surgical or Invasive Procedure:
___ Flexible Sigmoidoscopy
History of Present Illness:
___ yo F with hx of UC who presents today with bloody diarrhea.
She was doing well until 2 weeks ago when she started to develop
severe abdominal cramps, nausea, and ___ loose bowel movements
per day with blood and mucus. She initially attempted to resolve
her issue with dietary modification as this had helped her in
the past but her symptoms escalated to the point where eating
became painful. As a result, she has had decreased PO intake.
She presented to the ED on ___, was given solumedrol 40mg
once in ED and prescribed prednisone ___, asacol 1600mg
tid and discharged to follow-up with her gastroenterologist in 2
weeks. Her symptoms persisted and she represented today.
She initially presented to GI clinic about ___ year ago. At that
time she had been having rectal bleeding for about 1 month. She
developed urgency and was passing blood and mucus ___ times per
day. She was seen in the ED and had stool studies which were
negative and she was started on cipro and flagyl. She was
subsequently seen in GI clinic and a sigmoidoscopy was performed
which showed continuous erythema, ulceration, granularity, and
friability with contact bleeding in the rectum to splenic
flexure. The scope was not advanced further due to patient
discomfort and severe colitis. It was felt that the findings
were compatible with ulcerative colitis. She was started on 4.8g
of asacol and 40 mg of prednisone.
In the ED, initial vital signs were: 98.5 76 129/75 18 100% RA
- Labs were notable for unremarkable CBC, CMP, LFTs, lactate of
1.6 and a CRP of 6.5
- Studies performed include abdomenal x-ray which showed no
evidence of bowel obstruction or free intraperitoneal air.
- Patient was given Zofran 4mg IV x2, methylprednisone 20 mg
IVx1, Morphine Sulfate 5 mg IV x1
Upon arrival to the floor, the patient denies abdominal pain but
reports that its exacerbated when eating or per-defecation.
Past Medical History:
Ulcerative Colitis dx ___
Social History:
___
Family History:
No family hx of inflammatory bowel disease or colon CA.
Physical Exam:
==============
ADMISSION EXAM
==============
Vitals: 98.0 125/80 65 16 96%RA
General: WDWN woman laying comfortably in hospital bed
HEENT: NCAT EOMI MMM
Neck: Supple, full ROM, no cervical LAD
CV: S1/S2 RRR
Lungs: CTAB
Abdomen: +BS soft, ND. diffusely TTP in all four quadrants to
1-2cm depth palpation
Ext: No c/c/e
Neuro: AAOx3
Skin: Warm and dry
==============
DISCHARGE EXAM
==============
Vitals: 98.3 ___ 99/ra
General: laying comfortably in hospital bed
Abdomen: +BS soft, ND. No tenderness to deep palpation.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 10:42AM BLOOD WBC-6.8 RBC-4.60 Hgb-14.3 Hct-41.5 MCV-90
MCH-31.2 MCHC-34.6 RDW-13.6 Plt ___
___ 10:42AM BLOOD Neuts-65.5 ___ Monos-8.9 Eos-1.4
Baso-0.3
___ 10:42AM BLOOD Plt ___
___ 10:42AM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-143 K-4.0
Cl-107 HCO3-24 AnGap-16
___ 10:42AM BLOOD Lipase-22
___ 10:42AM BLOOD ALT-18 AST-15 AlkPhos-42 TotBili-0.3
___ 10:42AM BLOOD Albumin-4.0
___ 10:42AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE
___ 10:42AM BLOOD CRP-6.5*
___ 11:01AM BLOOD Lactate-1.4
___ 01:35PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:35PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:35PM URINE UCG-NEGATIVE
==============
PERTINENT LABS
==============
___ 07:45AM BLOOD WBC-5.8 RBC-4.46 Hgb-14.1 Hct-39.9 MCV-90
MCH-31.5 MCHC-35.2* RDW-13.6 Plt ___
___ 01:45PM BLOOD WBC-9.7# RBC-4.92 Hgb-15.5 Hct-43.7
MCV-89 MCH-31.4 MCHC-35.3* RDW-13.9 Plt ___
___ 08:15AM BLOOD WBC-12.9* RBC-5.11 Hgb-15.4 Hct-45.8
MCV-90 MCH-30.2 MCHC-33.7 RDW-13.4 Plt ___
___ 08:05AM BLOOD WBC-12.1* RBC-4.75 Hgb-14.9 Hct-41.1
MCV-87 MCH-31.4 MCHC-36.3* RDW-13.1 Plt ___
___ 08:05AM BLOOD ___ PTT-25.7 ___
___ 08:10AM BLOOD ___ PTT-24.8* ___
___ 07:45AM BLOOD Glucose-105* UreaN-7 Creat-0.6 Na-139
K-3.6 Cl-105 HCO3-24 AnGap-14
___ 01:45PM BLOOD Glucose-131* UreaN-11 Creat-0.8 Na-141
K-3.6 Cl-105 HCO3-22 AnGap-18
___ 08:15AM BLOOD Glucose-95 UreaN-8 Creat-0.8 Na-141 K-3.9
Cl-103 HCO3-27 AnGap-15
___ 08:05AM BLOOD Glucose-104* UreaN-11 Creat-0.7 Na-140
K-3.9 Cl-104 HCO3-26 AnGap-14
___ 07:45AM BLOOD QUANTIFERON-TB GOLD-Test - Negative
==============
DISCHARGE LABS
==============
___ 08:10AM BLOOD WBC-11.8* RBC-4.92 Hgb-15.4 Hct-42.4
MCV-86 MCH-31.4 MCHC-36.4* RDW-13.0 Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD Glucose-103* UreaN-12 Creat-0.7 Na-138
K-3.9 Cl-102 HCO3-25 AnGap-15
___ 08:10AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.1
=======
IMAGING
=======
CT Abdomen (___): No evidence of bowel obstruction or free
intraperitoneal air.
Flexible Sigmoidoscopy (___)
Segmental continuous granularity, erythema, friability and loss
of vasculature with contact bleeding were noted in the rectum.
These findings are compatible with proctitis. Noticeable
improvement in the sigmoid colon with loss of vasculature (25
cm). Cold forceps biopsies were performed for histology at the
sigmoid colon (25 cm). Cold forceps biopsies were performed for
histology at the rectum (10 cm).
Flexible Sigmoidoscopy (___)
Segmental erythema, granularity and abnormal vascularity were
noted in the rectum and sigmoid colon. There was a 20 mm linear
ulcer and several small ulcers in the distal rectum. Overall,
the inflammation appeared to be improved endoscopically.
=============
OTHER STUDIES
=============
Colonic Mucosal Biopsies (___)
1. Colon at 25 cm:
- Chronic mildly active colitis.
- A CMV immunostain is negative, with adequate controls.
2. Colon at 10 cm:
- Chronic moderately active colitis.
- A CMV immunostain is negative, with adequate controls.
Brief Hospital Course:
Ms. ___ was admitted to the hospital for a moderate UC flare:
2 weeks of hematochezia (>8 bloody stools daily) and severe
abdominal pain without systemtic symptoms suggestive of a
moderate UC flare. Sigmoidoscopy (___) with proctitis. Complete
stool studies and CMV were negative. She had poor response to 3
days IV steroids (persistent symptoms, slight elevation in CRP)
and no change on repeat sigmoidoscopy (___). Biologic therapy
with infliximab was initated and resulted in marked improvement
of symptoms: only 1 formed stool, non-bloody stool in last 24
hours, no abdominal pain, no nausea. She was discharged on a
prednisone taper and will continue with infliximab injections as
directed by her outpatient GI.
# Ulcerative Colitis Flare: Patient presented with abdominal
pain and hematochezia over the course of 2 weeks in the setting
of having discontinued medication ~10 months prior and
discontinuation of regimented diet 6 months prior. Most
consistent with UC flare given prior dx and recent non-adherence
to diet and medication. Over 10 bloody stools a day with severe
abdominal pain. No systemic symptoms. Current presentation
consistent with Moderate flare. GI consulted and patient
initated on IV methylprednisolone therapy. Sigmoidoscopy
revealed granularity, erythema, friability and loss of
vasculature in the rectum compatible with proctitis (biopsy,
biopsy). Patient had continued bloody BMs and abdomnial pain
despite >48 hrs of IV therapy. Repeat sigmoidoscopy revealed
erythema, granularity and abnormal vascularity in the rectum and
sigmoid colon compatible with colitis. Given her lack of
clinical and pathologic improvement, patient initated on
infliximab therapy. Significant improvement in symptoms was seen
by the next hospital day. The patient was converted to oral
prednisone to be tapered as an outpatient and scheduled
infusions to be set up with gastroenterology.
TRANSITIONAL ISSUES
- Dicharged on prednisone taper
- Started on infliximab infusions. Will plan for additional
infusions at 2 and 6 weeks. Further infusions will be scheduled
directly with Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Asacol HD (mesalamine) 800 mg oral TID
2. PredniSONE 20 mg PO DAILY
Discharge Medications:
1. PredniSONE 40 mg PO DAILY Duration: 14 Doses
Start: ___, First Dose: Next Routine Administration Time
RX *prednisone 10 mg As directed tablet(s) by mouth once a day
Disp #*112 Tablet Refills:*0
2. PredniSONE 30 mg PO DAILY Duration: 7 Doses
Start: After 40 mg tapered dose
3. PredniSONE 20 mg PO DAILY Duration: 7 Doses
Start: After 30 mg tapered dose
4. PredniSONE 15 mg PO DAILY Duration: 7 Doses
Start: After 20 mg tapered dose
5. PredniSONE 10 mg PO DAILY Duration: 7 Doses
Start: After 15 mg tapered dose
6. PredniSONE 5 mg PO DAILY Duration: 7 Doses
Start: After 10 mg tapered dose
7. Hydrocortisone Enema 100 mg PR QHS Duration: 14 Days
RX *hydrocortisone 100 mg/60 mL 1 enema(s) rectally at bedtime
Refills:*0
8. Benzonatate 100 mg PO TID:PRN cough
RX *benzonatate 100 mg 1 capsule(s) by mouth once a day Disp
#*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
- Ulcerative Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital due to frequent bloody
diarrhea and crampy abdominal pain. Given your previous
diagnosis of ulcerative colitis (UC), these symptoms were most
likely the result of a UC flare. While you were in the hospital
we performed an imaging study of your colon (flexible
sigmoidoscopy) which showed inflammation of the lower portion of
your colon (proctitis) consistent with UC. We treated you with
steroids but your symptoms did not improve as we had hoped. At
this point we began treatment with infliximab (Remicade) which
you tolerated well and led to a marked improvement in your
symptoms. You will be discharged on prednisone and also continue
to receive infliximab.
The single most importatnt thing you can do to prevent future
episodes is to regularly take the medication prescibed to you by
your gastroenterologists. This is critical even when you are
feeling well.
You should receive a phone call from Dr. ___ to schedule
your next infusion of infliximab. If you do not hear from him
please call his office at ___.
Please follow-up with your primary care provider and Dr.
___ as noted below.
It was a pleasure caring for you during this hospitalization. We
wish you the very best in health.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19901866-DS-9 | 19,901,866 | 25,036,286 | DS | 9 | 2191-04-18 00:00:00 | 2191-04-18 22:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Intermittent Chest/Back Pressure
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with PMH of DVT/PE (DVT in early ___, PE in ___,
identified via CT chest, placed on chronic A/C, coumadin), who
p/w chronic intermittent back pressure which began ___ yrs ago,
but increased in frequency over the past 4 weeks. He reported
that the pressure occurs episodically ___ at a time) then
goes away, is not felt to be painful, but makes him
uncomfortable/nervous and provokes his anxiety. He stated that
the pressure is non-exertional, non-anginal, and is not a/w
cardiac sx (SOB, diaphoresis, nausea, vomiting, syncope). He
recently found that his INR was 1.7 at clinic (___,
q3-4wks), so there was concern that he could have had another
PE. He went to PCP who saw ___ changes in his EKG, and was
concerned for ACS/PE so he referred him to ED. He stated that
his BP is normally 130s at home.
On arrival to ED, pts vitals were T 98.1, HR 58, BP 164/91, RR
18, O2 sat 100% on RA. Pt was given 325 ASA. Labs were notable
for neg trop and INR 2.4. EKG looked similar to prior, but
T-waves in V2 were deeper than in last EKG in ___. CTA was
negative for PE. Bedside u/s showed no evidence of right heart
strain or obvious focal wall deficit (especially no septal wall
abnormalities w/ the v2 changes). Pt was admitted to cardiology
floor for cardiac workup.
On arrival to floor, pt's vitals were T=97.8 BP=183/91 HR=58
RR=16 O2 sat=100%RA. Pt was comfortable, CP free, without HA,
vision changes, or nausea/vomiting. He was given 6.25 captopril,
and BP decreased to 150/90.
Past Medical History:
1. CARDIAC RISK FACTORS: Dyslipidemia (+), Hypertension (+)
2. CARDIAC HISTORY:
-CABG: Never
-PERCUTANEOUS CORONARY INTERVENTIONS: Never
-PACING/ICD: Never
3. OTHER PAST MEDICAL HISTORY:
HTN (per Atrius records, "high normal", pt denies h/o HTN)
HLD
Migraine
DVT/PE (DVT in early ___, PE in ___, identified via CT
chest, placed on chronic A/C, coumadin)
Social History:
___
Family History:
No h/o coagulopathies in family. Otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL:
VS: T= 97.8 BP=183/91 HR=58 RR=16 O2 sat=100%RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
PULSES: 2+ DP and radial pulses
DISCHARGE PHYSICAL:
TM 97.9 BP129-150/70-90, P58-62, R16, ___-100RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
PULSES: 2+ DP and radial pulses
Pertinent Results:
PERTINENT LABS:
___ 06:30PM BLOOD WBC-4.8 RBC-4.75 Hgb-15.1 Hct-43.1 MCV-91
MCH-31.7 MCHC-35.0 RDW-13.0 Plt ___
___ 06:15AM BLOOD WBC-4.2 RBC-4.67 Hgb-15.0 Hct-41.7 MCV-89
MCH-32.1* MCHC-35.9* RDW-13.0 Plt ___
___ 06:30PM BLOOD ___ PTT-43.9* ___
___ 06:15AM BLOOD ___ PTT-39.0* ___
___ 06:30PM BLOOD Glucose-103* UreaN-24* Creat-0.9 Na-137
K-3.9 Cl-99 HCO3-30 AnGap-12
___ 06:15AM BLOOD Glucose-90 UreaN-17 Creat-0.9 Na-137
K-3.7 Cl-100 HCO3-30 AnGap-11
___ 06:30PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:30PM BLOOD Calcium-9.5 Phos-3.0 Mg-2.2
CXR: No acute cardiopulmonary process.
CT CHEST W&W/OUT CONTRAST: No acute aortic pathology or
pulmonary embolus.
CARDIAC PERFUSION:
1. Normal myocardial perfusion.
2. Normal wall motion with Ejection Fraction of 63%.
EXERCISE STRESS:
Good exercise tolerance. No anginal symptoms with
uninterpretable ST-T wave changes (see above). Baseline systolic
hypertension with an appropriate blood pressure and heart rate
response to exercise. Nuclear report sent separately.
Brief Hospital Course:
___ year old gentleman with history of DVT/PE on coumadin
presenting with 4 weeks of atypical chest/back discomfort,
referred by PCP for DVT/cardiac work-up.
==================================
ACTIVE ISSUES:
1. INTERMITTENT CHEST/BACK PRESSURE: Pt has long history of
intermittent back/chest discomfort, that are atypical for
anginal sx (relieved by exertion, no a/w cardiac sx such as SOB,
diaphoresis, nausea, vomiting, syncope). However, given his hx
of predisposition toward clotting (DVT/PE), and recent finding
of sub-therapeutic INR, and new EKG changes (deepening T wave in
V2, concerning for ___ type changes), he was admitted to
rule out ACS/PE. In the ED he underwent a CT chest w/ and w/out
contrast which was negative for PE. He had two sets of cardiac
enzymes which were negative (trop<0.01 both times), and did not
have any symptoms while hospitalized, so concern for active
ischemia was low, and cardiac catheterization was deferred.
Prior to discharge, he underwent a perfusion study and stress
test ___ concerning EKG findings (T wave changes in V2, V3). The
exercise MIBI was negative for perfusion and wall motion
abnormalities. EKG changes persisted during exercise but were
not indicative of ischemia. He did not experience any more chest
discomfort. Accordingly, he was discharged to home with follow
up appointments with both his PCP and ___.
Since the etiology of his discomfort was not ascertained during
this admission, he was encouraged to keep a log of his symptoms
and bring it to his next outpatient appointment.
2. HTN - On admission, pt had elevated SBP in 180s. After
receiving 6.25mg of captopril, his BP dropped to systolic of
150's. Throughout the rest of his hospital course, he remained
within a normal range. Since he did not come in on an Anti-HTN
regimen, he was not discharged on one, as it was unclear whether
or not his elevated value represented anxiety, a spurious value,
or a true measurement. Moreover, his short hospital course
prevented us from ascertaining his actual baseline BP.
Accordingly, he was instructed to follow up with his PCP and
___ at his next visit and have his BP checked. If he is
determined to have persistent HTN it would be worthwhile to
initiate an anti-HTN medication.
=============================
CHRONIC MEDICAL ISSUES:
1. DVT/PE - Pt has a known hx of DVT/PE that he is on systemic
anti-coagulation for. He was continued on his home dose coumadin
while he was hospitalized as his INR ranged from 2.4 to 2.3
2. Insomnia - Pt was written for home dose lorazepam 0.5mg prn
for insomnia.
=============================
TRANSITIONAL ISSUES
1. Though initially hypertensive on admission, his blood
pressures ranged from 110s-130s during admission. Please monitor
blood pressure as an outpatient.
- Code status: Full code.
- Emergency contact: ___, ___
- Studies pending on discharge: None.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO 5X/WEEK (___)
2. Warfarin 6.25 mg PO 2X/WEEK (WE,SA)
3. Lorazepam 0.5 mg PO HS:PRN insomnia
Discharge Medications:
1. Lorazepam 0.5 mg PO HS:PRN insomnia
2. Warfarin 5 mg PO 5X/WEEK (___)
3. Warfarin 6.25 mg PO 2X/WEEK (WE,SA)
Discharge Disposition:
Home
Discharge Diagnosis:
Chest pain, non-cardiac etiology
Back pain, non-cardiac etiology
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care at ___! You were
admitted because you had chest and back discomfort and EKG
changes. You underwent an exercise stress test with perfusion
imaging, which showed you have normal perfusion of your coronary
arteries and normal movement and function of your heart walls.
You also underwent a CT scan of your chest which showed that
there were no blood clots. This is good news! We made you a
follow up appointment with your cardiologist, as well as a
follow up with an NP in your primary care physician's practice
to follow up on your symptoms.
Please continue to take your medications as directed.
Followup Instructions:
___
|
19901886-DS-11 | 19,901,886 | 27,911,354 | DS | 11 | 2148-06-10 00:00:00 | 2148-06-10 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Percocet
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with advanced Alzheimer's dementia, HTN, CAD, and T2DM who
presents after fall at his ALF. He initially presented to ___.
___ where he was thought to have an intracranial hemorrhage
on head CT. As there was no neurosurgery consult available, he
was transferred to ___.
In the ED, initial VS are not recorded. He had a head CT which
did not show any evidence of ICH on prelim read. Neurosurgery
was consulted who felt that there was no intervention necessary
and recommended holding ASA. VS on transfer to the floor were
___ 133/54 100ra.
Currently, he is unable to provide any history and is mumbling
incorherently. He denies pain which is the only question he is
able to answer.
REVIEW OF SYSTEMS: Unable to obtain.
Past Medical History:
-Advanced Alzheimer's dementia
-HTN
-CAD
-T2DM
Social History:
___
Family History:
Unable to obtain due to dementia
Physical Exam:
Admission exam:
VITALS: T 97.5 BP 192/99 HR 64 RR 20 Spo2 100/RA
GENERAL: awake and mumbling incoherently
HEENT: PERRL, EOMI
LUNGS: CTAB
HEART: RRR, normal S1 S2, no MRG (exam limited by patient
continually talking). Well-healed midline sternotomy scar.
ABDOMEN: Soft, NT, NABS, no organomegaly
EXTREMITIES: Trace ___ edema
NEUROLOGIC: A&Ox1 (name only), mumbling incoherently. Moving all
extremities and non-cooperative with neuro exam. PERRL.
Discharge exam:
VS: T 98-98.2; BP 124-167/47-50; P 59; RR 20; 93RA
General: NAD, alert
HEENT: PERRL, EOMI
Neck: supple, no carotid bruits
Lungs: CTAB
Heart: RRR, normal S1 S2, no MRG
Abdomen: Soft, NT, NABS, no organomegaly
Extremities: trace ___ edema
NEUROLOGIC: Oriented to self only. Fluid nonsensical speech.
Pertinent Results:
ADMISSION LABS:
___ 12:00AM BLOOD WBC-6.5 RBC-3.87* Hgb-10.4* Hct-32.8*
MCV-85 MCH-26.7* MCHC-31.6 RDW-15.2 Plt ___
___ 12:00AM BLOOD Neuts-62.2 ___ Monos-6.2 Eos-3.8
Baso-0.8
___ 12:00AM BLOOD ___ PTT-27.4 ___
___ 12:00AM BLOOD Glucose-113* UreaN-23* Creat-0.8 Na-144
K-3.9 Cl-105 HCO3-31 AnGap-12
___ 12:00AM BLOOD CK(CPK)-85
___ 09:00AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.1
OTHER PERTINENT LABS:
___ 12:00AM BLOOD CK-MB-2
___ 12:00AM BLOOD cTropnT-<0.01
___ 11:20AM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-5.4 RBC-4.05* Hgb-10.8* Hct-34.0*
MCV-84 MCH-26.6* MCHC-31.7 RDW-15.3 Plt ___
___ 07:00AM BLOOD UreaN-14 Creat-0.8 Na-140 K-4.0 Cl-101
HCO3-31 AnGap-12
MICRO:
Ucx ___: negative
Bcx ___: no growth at the time of discharge
IMAGING:
ECHO ___:
The left atrium is moderately dilated. The right atrium is
markedly dilated. There is moderate symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. Overall
left ventricular systolic function is mildly depressed (LVEF~45
%). There is inferior akinesis and inferolateral
hypokinesis/akinesis. Regional wall motion could not be not
fully assessed.Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets are moderately thickened.
There is systolic doming of the aortic valve leaflets. There is
probably a borderline increased gradient consistent with minimal
aortic valve stenosis. (NOTE: Aortic valve Doppler recordings
were limited.) No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Mild (1+) mitral regurgitation is
seen. There is no pericardial effusion.
Head CT ___:
IMPRESSION: 4 mm focus of resolving blood products along the
periphery of encephalomalacia in the superior left MCA
territory, likely subdural in location. No new hemorrhage. No
mass effect.
(Of note, in discussion with neurosurgical team, subdural
hemorrhage unlikely based on available imaging)
CXR ___:
PA and lateral radiographs of the chest are somewhat technically
limited, especially the lateral view. The lungs are clear and
aside from
aortic tortuosity, the hilar and cardiomediastinal contours are
normal. There is no pneumothorax or pleural effusion, and the
pulmonary vascularity is normal, without edema. Median
sternotomy cerclage wires are intact.
IMPRESSION: No evidence of pneumonia.
Brief Hospital Course:
___ y/o male with PMHx of advanced Alzheimer's dementia s/p fall
and admitted for concern of subdural hemorrhage that was found
to be negative on repeat head CT as reviewed by neurosurgery
team. Patient neurologically at baseline. Syncope workup
negative.
# S/P fall: Most likely mechanical etiology. Healthcare proxy
reports history of tripping. CXR negative for PNA, Ucx
negative, blood culture no growth at the time of discharge. No
evidence of significant arrhythmia on telemetry, cardiac ECHO
shows no significant valvular disease. Serial cardiac enzymes
negative and EKG without concern for acute ischemia. ___ consult
supports mechanical explanation, however, ___ felt patient safe
to return to his Alzhiemer's unit at ___.
# Intracranial bleed: Neurosurgery reviewed CT head images and
did not believe they were consistent with bleed. Neurosurgery
team agreed with primary team on restarting home dose aspirin
325mg daily given history of CAD s/p CABG.
# Advanced Alzheimer's dementia: Patient is A&Ox1 which appears
to be baseline. Continued namenda, celexa and seroquel.
# CAD: CABG in ___. Evidence of old inferior infarction on EKG.
Restarted aspirin on discharge.
# HTN: BP initially high, required one dose of hydralazine.
Otherwise controlled on home dose lisinopril 20mg daily.
# Transitional issues:
- Code status: full code
- HCP: ___ (partner)
- pending labs: blood culture final results
- medication change: none
- follow up: with PCP, ___
___ on Admission:
-ASA 325mg daily
-Celexa 10mg daily
-Lisinopril 20mg daily
-Namenda 10mg daily
-Multivitamin 1 tab daily
-Seroquel 12.5mg qAM and 37.5mg qHS
-Vitamin B12 - 100mcg
-Ibuprofen 200mg bid
-Metamucil wafers daily
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Cyanocobalamin 100 mcg PO DAILY
3. Lisinopril 20 mg PO DAILY
Hold for SBP <100
4. Multivitamins 1 TAB PO DAILY
5. Namenda *NF* (MEMAntine) 10 mg Oral daily
6. Psyllium Wafer 1 WAF PO DAILY
7. Quetiapine Fumarate 37.5 mg PO HS
8. Quetiapine Fumarate 12.5 mg PO DAILY
At noon
9. Aspirin 325 mg PO DAILY
10. Ibuprofen 200 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Mechanical fall
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure take care of you at ___. You were admitted
after a fall out of concern for a head bleed. The neurosurgery
team reviewed your head scan and found no bleed. You had no
abnormal heart rhythm and your heart ultrasound did not show any
abnormalities that would have caused your fall. We monitored
you in the hospital for a few days. You did well and are now
ready to go home.
We made the following changes to your medications:
NONE
Followup Instructions:
___
|
19902204-DS-18 | 19,902,204 | 29,874,966 | DS | 18 | 2156-09-24 00:00:00 | 2156-09-24 14:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: SOB, weight gain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with PMH chronic systolic CHF
with recurrent bilateral pleural effusions, Afib (s/p
cardioversion in ___ on Eliquis), DM, HTN, CVA L ___, and
gout
who was transferred from ___ with progressive dyspnea and
weight gain over the past ___ weeks. He states he gets SOB when
walking to the mailbox. Denies chest pain, fever, or
lightheadedness. Trigger unclear as patient denies dietary
indiscretions and has been compliant with meds.
At ___, his heart rate was in the ___, without
symptoms. He is not on any rate controlling agents. Troponin
was
0.05; Cr 1.3; proBNP 4900. Chest x-ray showed a large
right-sided
and small left-sided pleural effusion. He received IV Lasix and
was comfortable on BiPap. He was transferred to ___ for
possible pacemaker.
On arrival to the ED, his O2 sat was 70%. He was experiencing
SOB
with 3+ BLE edema. CXR showed large right-sided and small
left-sided pleural effusions. proBNP was 4529, Troponin-T was
0.03, Cr 1.3. He received atropine 0.5mg when his HR dropped to
the 30's; HR then in the ___'s. EP service saw him in the ED and
recommended Lasix gtt at 10/h with 120 iv Lasix. He also
received
his home allopurinol ___, apixaban 5mg BID, losartan 100mg qd.
He received 600mg ibuprofen for gout.
On arrival to the floor, he was on 6L O2 NC but tolerated
decreased to 3L. He denied SOB while in bed. No CP, n/v, fever,
or chills. States he has a chronic cough, productive of white
phlegm.
Past Medical History:
hypertension
diabetes mellitus
s/p gunshot wound, lung injury, exploratory laparotomy with
___ filter placement in ___
new onset afib ___ s/p cardioversion ___, recurrent afib
treated medically on apixaban
Social History:
___
Family History:
Mother passed in ___ from MI
Father had UC and passed at old age
Physical Exam:
General: Comfortable and well-appearing, sitting up in bed
HEENT: JVP not elevated, sclera anicteric, EOMI, MMM, PERRL
Lungs: improved air movement bilaterally with persistent
diminished sounds at bases (R>L), improved inspiratory effort,
no accessory muscle use, no crackles appreciated
CV: Irregularly irreguly rate, no murmur appreciated, no rubs or
gallops
Abdomen: LUQ reducible hernia, soft, non-tender, obese, +BS
GU: No Foley
Ext: 1+ bilateral pitting edema with wrinkling of skin c/w
diuresis, BLEs with skin changes c/w chronic venous
insufficiency
Neuro: Grossly intact, responding appropriately, moving all 4
extremities spontaneously
Pertinent Results:
Admission Labs:
___ 09:31PM GLUCOSE-123* UREA N-30* CREAT-1.2 SODIUM-146*
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-33* ANION GAP-10
___ 09:31PM ALT(SGPT)-11 AST(SGOT)-14 LD(LDH)-172
CK(CPK)-80 ALK PHOS-145* TOT BILI-1.4
___ 09:31PM CK-MB-4 cTropnT-0.04*
___ 09:31PM CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-1.8
___ 08:23PM %HbA1c-5.5 eAG-111
___ 09:15AM GLUCOSE-115* UREA N-28* CREAT-1.3*
SODIUM-147* POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-30 ANION GAP-15
___ 09:15AM CALCIUM-9.4 PHOSPHATE-4.0 MAGNESIUM-1.9
___ 09:15AM TSH-6.2*
___ 01:40AM URINE HOURS-RANDOM
___ 01:40AM URINE UHOLD-HOLD
___ 01:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:29AM LACTATE-1.4
___ 01:29AM ___ PO2-29* PCO2-65* PH-7.34* TOTAL
CO2-37* BASE XS-6
___ 01:00AM GLUCOSE-89 UREA N-28* CREAT-1.3* SODIUM-145
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-32 ANION GAP-11
___ 01:00AM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-139* TOT
BILI-1.4
___ 01:00AM cTropnT-0.03*
___ 01:00AM proBNP-4529*
___ 01:00AM ALBUMIN-3.7 CALCIUM-8.8 PHOSPHATE-3.8
MAGNESIUM-1.7
___ 01:00AM WBC-5.5 RBC-3.77*# HGB-12.9*# HCT-39.3*#
MCV-104* MCH-34.2* MCHC-32.8 RDW-16.1* RDWSD-61.0*
___ 01:00AM NEUTS-62.1 ___ MONOS-11.2 EOS-2.9
BASOS-1.1* IM ___ AbsNeut-3.39 AbsLymp-1.23 AbsMono-0.61
AbsEos-0.16 AbsBaso-0.06
___ 01:00AM PLT COUNT-168
___ 01:00AM ___ PTT-31.7 ___
___ 01:00AM ___ PTT-31.7 ___
Discharge Labs:
___ 06:33AM BLOOD WBC-6.0 RBC-3.62* Hgb-12.3* Hct-37.6*
MCV-104* MCH-34.0* MCHC-32.7 RDW-14.8 RDWSD-57.3* Plt ___
___ 06:33AM BLOOD Plt ___
___ 09:21AM BLOOD Glucose-88 UreaN-37* Creat-1.2 Na-141
K-3.6 Cl-88* HCO3-44* AnGap-9
___ 09:21AM BLOOD Calcium-10.0 Phos-3.9 Mg-1.9
Imaging
Echo
___: The left atrium is elongated. The right atrium is markedly
dilated. No atrial septal defect is seen by 2D or color Doppler.
There is mild symmetric left ventricular hypertrophy. The left
ventricular cavity is moderately dilated. Overall left
ventricular systolic function is mildly depressed (LVEF= 45-50
%) with inferior hypokinesis suggested. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular free wall is hypertrophied. The
right ventricular cavity is dilated with mild global free wall
hypokinesis. There is abnormal systolic septal motion/position
consistent with right ventricular pressure overload. The aortic
root is moderately dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic arch is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. Mild to moderate (___) aortic
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
cxr ___ IMPRESSION:
Comparison to ___. The extent of the right pleural
effusion has
minimally decreased. Stable minimal left pleural effusion.
Both the right
and the left lung basis show proportional areas of atelectasis.
Moderate
cardiomegaly without pulmonary edema persists.
Brief Hospital Course:
HOSPITAL COURSE
===============
Mr. ___ is a ___ with a h/o HFpEF, COPD, HTN, NIDDM,
recurrent bilateral pleural effusions, Afib (s/p cardioversion
in ___ on Eliquis), who was transferred from ___ for
pacemaker evaluation (brady to ___ after being admitted for a
3wk h/o progressive dyspnea and weight gain at home. His
bradycardia was asymptomatic and no interventions were
performed, but he was found to be grossly fluid overloaded. He
was diuresed ~30lb and discharged on increased regimen.
ACTIVE ISSUES
=============
# Acute on chronic heart failure with preserved ejection
fraction
Pt presented with progressive SOB, ___ pitting edema, and weight
gain over past 3 weeks. Was compliant with diet and was taking
Lasix BID for "months" before symptoms began, but on further
interview found to be taking Lasix only PRN. TTE showed mildly
decreased EF (45-50%). Diuresed with Lasix drip, spironolactone,
metolazone before switching to oral regimen on ___.
# Afib with Bradycardia
Continued to have episodes of bradycardia, mostly overnight (to
___. Patient reported no symptoms associated with this
bradycardia. Continued home apixaban and explored the idea of
PPM but deferred for now.
# Hypoxemia / COPD / pleural effusions
Patient required nasal cannula, as high as 4L, to maintain
adequate oxygen saturation. Patient was also given
ipratropium/bromide IH q6PRN wheezing. Slowly weaned O2 during
hospital course, still desatting to 80's on ambulation so
discharged on home oxygen.
CHRONIC ISSUES
==============
# HTN
Pressures were stable on home regimen of losartan.
# DM
Per patient, this has been controlled without medication, A1c
5.5%.
# Gout
Continued home allopurinol.
TRANSITIONAL ISSUES
===================
[] Follow up with Dr. ___ at 1:30PM, will check
weight and BMP, adjusting diuretic regimen as needed
[] PCP to follow up Elevated TSH and evaluate need for home COPD
treatment
[] Discharged on continued home O2, ___ to re-assess O2 sats and
see if improved to the point he no longer need it
# NEW MEDS
- Metolazone 2.5 mg PO BID
- Spironolactone 12.5 mg PO/NG BID
- AcetaZOLamide 500 mg PO/NG Q24H
# CHANGED MEDS
- Furosemide increased to Furosemide 80 mg PO BID
Discharge weight: 251.1lb
Discharge creatinine: 1.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Doxazosin 4 mg PO HS
3. Losartan Potassium 100 mg PO DAILY
4. Tamsulosin 0.4 mg PO QHS
5. Furosemide 40 mg PO Q AM
6. Furosemide 40 mg PO QPM
7. Apixaban 5 mg PO BID
Discharge Medications:
1. AcetaZOLamide 500 mg PO Q24H
RX *acetazolamide 250 mg 2 tablet(s) by mouth Daily Disp #*60
Tablet Refills:*0
2. Metolazone 2.5 mg PO BID
RX *metolazone 2.5 mg 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*0
3. Spironolactone 12.5 mg PO BID
RX *spironolactone 25 mg 0.5 (One half) tablet(s) by mouth Twice
a day Disp #*30 Tablet Refills:*0
4. Furosemide 80 mg PO BID
RX *furosemide 80 mg 1 tablet(s) by mouth Twice a day Disp #*60
Tablet Refills:*0
5. Allopurinol ___ mg PO DAILY
6. Apixaban 5 mg PO BID
7. Doxazosin 4 mg PO HS
8. Losartan Potassium 100 mg PO DAILY
9. Tamsulosin 0.4 mg PO QHS
10.Rolling Walker
Dx: Acute on chronic heart failure with reduced ejection
fraction (I50.9)
Px: Good
___: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Heart failure with preserved ejection fraction
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
You were admitted to the hospital with the aim of placing a
pacemaker in your heart; you were also noted to have a 3wk h/o
progressive dyspnea and weight gain at home.
WHAT HAPPENED IN THE HOSPITAL?
==============================
While in the hospital we diuresed you with the aim of removing
___ fluid per day
WHAT SHOULD I DO WHEN I GO HOME?
================================
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs. Please continue to take your medications as
prescribed and follow up with appointments scheduled with you.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19902376-DS-21 | 19,902,376 | 29,059,273 | DS | 21 | 2127-09-17 00:00:00 | 2127-09-18 08:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Flagyl
Attending: ___.
Chief Complaint:
BRBPR
Major Surgical or Invasive Procedure:
EGD
Colonoscopy
Capsule study
History of Present Illness:
___ with Crohn's disease with hospitalization last year with
BRBPR requiring 2 u PRBC who presents for significant episodes
of BRBPR.
She was in her usual state of health until the day of
presentation. She reports having 5 BM per day with trace blood
which is typical of her Crohn's disease. Yesterday, she had an
episode with about 15 minutes of bleeding from her rectum which
saturated at least 15 wads of toilet paper. Afterwards she had
diffuse abdominal discomfort (dull ache, ___. She denies
rectal spasms, constipation or straining, nausea, vomiting,
fevers. She denies travel or sick contacts. No food that sets
off. Stress usually worsens. No NSAIDs.
She presented to OSH ED who recommended admission. She requested
transfer to ___ given her GI care is here. She was admitted to
medicine for further evaluation and management.
Currently, she feels okay. Continues to have ___ diffuse
abdominal pain. No bleeding currently. No BM yet this AM. No
nausea, vomiting.
ROS: Full review of systems comleted. Positive per above,
otherwise negative.
Past Medical History:
Crohn's with prior ileocolonic resection in ___
IBS
CCY
Nephrolithiasis
Social History:
___
Family History:
"Awful stomachs" but nothing diagnosed
Physical Exam:
Admission Exam:
General: no apparent distress
Vitals: 98.0, 128/78, 89, 18, 100% RA
Pain: ___
HEENT: OP clear, no lesions, somewhat crowded
Neck: low JVD
Cardiac: rr, nl rate, no murmur
Lungs: CTAB
Abd: soft, nondistended, pos tenderness in lower quadrants and
RUQ, no tenderness in LUQ. No r/r/g. +BS.
Ext: wwp, no edema, no observed rashes
Neuro: AOx3, no observed deficits
Psych: pleasant
Discharge Exam
Afebrile, aVSS
General: Appears well, seated in bed playing on iPad.
Comfortable, pleasant and interactive and in NAD. Affect appears
discongruent with her clinical course. Excited at potentially
finding a diagnosis today
HEENT: OP clear, no lesions, MMM, halitosis
Abd: soft, nondistended, non-tender to palpation. NABS
Lungs: CTAB
CV: RRR, S1S2 clear and of good quality, no MRG
Neuro: AOx3
Pertinent Results:
Admission labs:
___ 01:58AM BLOOD WBC-8.0 RBC-4.57 Hgb-13.0 Hct-37.3 MCV-82
MCH-28.4 MCHC-34.8 RDW-14.2 Plt ___
___ 01:58AM BLOOD Neuts-62.8 ___ Monos-4.8 Eos-3.0
Baso-0.5
___ 01:58AM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-139
K-4.5 Cl-105 HCO3-24 AnGap-15
___ 06:30AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
___ 01:58AM BLOOD ALT-18 AST-19 AlkPhos-62 TotBili-0.2
___ 06:00PM BLOOD calTIBC-449 Ferritn-44 TRF-345
___ 01:58AM BLOOD CRP-1.9
Hct Labs:
___ 01:58AM BLOOD WBC-8.0 RBC-4.57 Hgb-13.0 Hct-37.3 MCV-82
MCH-28.4 MCHC-34.8 RDW-14.2 Plt ___
___ 06:30AM BLOOD WBC-4.8 RBC-4.21 Hgb-12.0 Hct-34.3*
MCV-81* MCH-28.4 MCHC-34.9 RDW-14.2 Plt ___
___ 06:35AM BLOOD WBC-5.8 RBC-4.01* Hgb-11.5* Hct-32.7*
MCV-82 MCH-28.7 MCHC-35.2* RDW-14.3 Plt ___
___ 06:30AM BLOOD WBC-5.0 RBC-3.91* Hgb-11.1* Hct-31.9*
MCV-82 MCH-28.4 MCHC-34.8 RDW-14.5 Plt ___
___ 06:40AM BLOOD Hct-35.9*
___ 06:30AM BLOOD WBC-6.8 RBC-4.04* Hgb-11.5* Hct-33.0*
MCV-82 MCH-28.5 MCHC-34.9 RDW-14.4 Plt ___
Iron Studies
___ 06:00PM BLOOD calTIBC-449 Ferritn-44 TRF-345
___ 01:58AM BLOOD CRP-1.9
Reports:
Endoscopy capsule within the ascending colon.
EGD:
Other
findings: A capsule endsocopy camera was delivered to the
duodenal bulb and released using an Olympus delivery device. The
capsule was visualized in the third portion of the duodenum
following removal of the delivery device and re-examination.
Impression: Normal mucosa in the whole esophagus
Normal mucosa in the whole stomach
Limited visualization but appeared grossly normal.
A capsule endsocopy camera was delivered to the duodenal bulb
and released using an Olympus delivery device. The capsule was
visualized in the third portion of the duodenum following
removal of the delivery device and re-examination.
Otherwise normal EGD to third part of the duodenum
EGD:
Impression: Normal mucosa in the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum
No fresh or old blood was seen nor ulcers
Otherwise normal EGD to third part of the duodenum
Recommendations: - No source of bleeding identified nor ulcers
- Follow up with inpatient GI team
Colonoscopy:
Previous end to side ileo-colonic anastomosis of the
mid-ascending colon
Otherwise normal colonoscopy to terminal ileum
Brief Hospital Course:
___ with Crohn's disease who presents with BRBPR from unclear
source
# GI bleed:
# Acute blood loss anemia:
She presented with BRBPR likely indicated lower GI bleed. GI was
consulted and recommended bowel prep with EGD and colonoscopy.
These were completed without evidence of bleed. They then
recommended capsule study. This first study with capsule
unfortunately stuck in patient's stomach and so was unsuccessful
study. Repeat EGD performed with post-pyloric Capsule placement.
This study also did not reveal a source of bleeding either.
Given negative EGD and ___ suspect small bowel source though
given BRBPR would expect her to be HD unstable or with
significant Hct drop since this would indicate a brisk bleed
however she remained HD stable and with stable Hct for several
days. She did not receive a transfusion
# Crohn's disease:
Inflammatory markers were low and colonoscopy was without
evidence of inflammation. She is not on any controlling agents.
# Anxiety:
She reports taking depakote ER at home (750mg total dose). This
did not match our formulary and this medication was held. Social
work also discussed with patient who has been frustrated about
care though her expressed frustrations seemed discongruent with
her affect. Social work was involved during admission
# Abdominal pain:
She has chronic abdominal pain following her prior surgery. She
was treated with low dose oxycodone in the acute setting. Her
abdominal exam was benign and labs were reassuring. No abdominal
imaging due to age and risks or radiation exposure and low
pre-test probability for a positive finding. Given 2 capsule
studies no MRI can be performed until confirmed passed capsules.
Transitional issues:
- No source of bleeding found on EGD, ___ or capsule study
- Full Code
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Nortriptyline 50 mg PO QAM
2. Nortriptyline 25 mg PO HS
3. Divalproex (EXTended Release) Dose is Unknown PO DAILY
4. melatonin unknown oral qHS
Discharge Medications:
1. Nortriptyline 50 mg PO QAM
2. Nortriptyline 25 mg PO HS
3. melatonin 1 dose ORAL QHS
4. Divalproex (EXTended Release) 1 dose PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
Acute blood loss anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
It was a pleasure treaing you during this hospitalization. You
were admitted with bloody bowel movements. You were seen by GI
who recommended EGD, colonoscopy and capsule study to determine
the etiology of the bleed. EGD, Colonoscopy and capsule study
were all negative for source of bleeding. Since your blood
pressure was stable and your blood levels remained relatively
normal you are being discharged in stable condition with plan
for out patient follow up.
Followup Instructions:
___
|
19902511-DS-18 | 19,902,511 | 21,360,377 | DS | 18 | 2168-02-06 00:00:00 | 2168-02-06 11:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Bilateral ankle/foot pain after fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old otherwise healthy male transferred from OSH with
complaints of bilateral foot pain. Patient was working on a
ladder at approximately 515PM today when he fell approximately
___ feet and landed on his feet. He experienced immediate
onset of pain and was taken initially to ___ where he was found to have isolated R calcaneus and L
ankle fractures. At that time, he was transferred to ___ for
further management.
Past Medical History:
none
Social History:
___
Family History:
Non contributory
Physical Exam:
AFVSS
Gen: A&Ox3, no actue distress
Ext: LLE ___, SILT ___, WWP
RLE ___, SILT sp/dp WWP, Bulky ___ splint in place
Pertinent Results:
___ Foot AP Lateral Oblique: IMPRESSION: Posterior
malleolar, distal fibular, second metatarsal base, and third
metatarsal neck fractures noted within the left foot with soft
tissue swelling. If there is clinical concern for a Lisfranc
injury, weight bearing views or MRI may be performed.
___ Ankle AP, Mortise, Lateral: IMPRESSION: Status post cast
placement over left ankle with fracture lines at the distal
fibula and posterior malleolus. Slight widening of the medial
ankle mortise.
___ 11:15PM ___ PTT-26.6 ___
___ 11:15PM PLT COUNT-231
___ 11:15PM NEUTS-92.1* LYMPHS-4.1* MONOS-3.4 EOS-0.1
BASOS-0.2
___ 11:15PM WBC-14.1* RBC-4.87 HGB-14.3 HCT-41.4 MCV-85
MCH-29.3 MCHC-34.4 RDW-13.0
___ 11:15PM estGFR-Using this
___ 11:15PM GLUCOSE-133* UREA N-19 CREAT-0.9 SODIUM-137
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-12
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R calcaneous and L bimalleolar, ___ and ___ metatarsal
fractures and was admitted to the orthopedic surgery service. It
was determined that no surgical intervention was needed upon
admission. The patient would be splinted, able to touch down on
the right and bear weight on the left as tolerated and to come
back in a week for more x-rays and re-evaluation of the left
ankle. The patient was fitted with a right bulky ___ splint,
left air cast boot, and given pain medications. The patient
worked with ___ who determined that discharge to home with home
physical therapy and a wheelchair 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
left lower extremity, touch down weight bearing in the right
lower extremity and will be discharged on lovenox 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. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
daily as needed for constipation Disp #*14 Capsule Refills:*0
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every ___ hours as
needed for pain control Disp #*80 Tablet Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY Start: ___, First Dose:
Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sub-q Daily for 10 days Disp
#*10 Syringe Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Right calcaneous fracture and L bi-malleolar ankle fracture, ___
and ___ metatarsal fxs
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
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
-Splint must be left on until follow up appointment unless
otherwise instructed
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated left lower extremity with air cast
boot, touch down weight bearing right lower extremity with bulky
___ splint
Physical Therapy:
Weight bearing as tolerated in left lower extremity air cast
boot
Non weight bearing on right lower extremity in bulky ___
___ Frequency:
N/A
Followup Instructions:
___
|
19902684-DS-8 | 19,902,684 | 23,141,738 | DS | 8 | 2148-11-29 00:00:00 | 2148-11-29 17:41:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of CAD (90% LAD, 95% LCX, ?RCA
done at ___ in ___, HFpEF (LVEF 50%), HTN, DMII, CKD
III, who presents with dyspnea. She has been evaluated by CT
surgery on ___ for possible CABG and went for a nuclear stress
today which showed reversible ischemia in the RCA and LCx
territories. She has not taken her home medications on day of
testing. Following stress testing, patient went home and
developed burning in her throat, associated with fluid in her
lungs which she states she could hear. She denies chest pain or
abdominal pain. She states that she was never short of breath.
She subsequently called EMS, who found her to be hypoxic to the
___. She was then placed on BiPAP with good improvement in
oxygenation to 100. Of note, she has had two sequential
admissions at CHA in ___ for flash pulmonary edema in the
setting of significant 3-vessel disease.
On initial assessment in the ED, patient was tachypneic and
hypertensive to the 180s with exam notable for bibasilar
crackles. Initial vitals were HR 99, BP 182/101 RR 18 O2Sat 100%
BiPAP
Initial EKG in the ED with ST depressions laterally with minimal
AVR/V1 elevations.
Labs/studies notable for: lactate 2.5, BNP 5177, CXR with
moderate pulmonary edema, troponin 0.03
Patient was given: SL nitro, ASA 325 mg, IV Lasix 40 mg
Vitals on transfer: 97.7 HR 71 BP 147/75 RR 25 O2Sat 100% 2L NC
On arrival to the CCU, patient denied shortness of breath or
chest pain. She received Lisinopril 40 mg and Metoprolol
tartrate 50 mg. Patient was weaned off NC satting 97% on RA.
Past Medical History:
CAD (90% proximal LAD, 81% mid-LAD, and 95% circumflex). Cath at
___ ___
HLD
HTN
DMII (A1C ___
CKD III
HFpEF (EF 50%)
Social History:
___
Family History:
No known family history of early MI, arrhythmia,
cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.5 BP 160/83 HR 77 RR 16 O2 SAT 97% on 2L
GENERAL: Well developed, well nourished in NAD. Oriented x3.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL.
NECK: Supple.
CARDIAC: RRR, nl S1 S2, no M/R/G
LUNGS: + Bibasilar crackles, no accessory muscle use
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
=======================
VS: refused
GENERAL: NAD
HEENT: Normocephalic atraumatic.
NECK: Supple.
CARDIAC: RRR, nl S1 S2, no M/R/G
LUNGS: CTAB. No accessory muscle use
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
Pertinent Results:
ADMISSION LABS
==============
___ 12:15AM BLOOD WBC-10.5* RBC-4.73 Hgb-12.5 Hct-41.5
MCV-88 MCH-26.4 MCHC-30.1* RDW-14.5 RDWSD-46.1 Plt ___
___ 12:15AM BLOOD Neuts-73.5* ___ Monos-2.5*
Eos-0.4* Baso-1.0 Im ___ AbsNeut-7.70* AbsLymp-2.30
AbsMono-0.26 AbsEos-0.04 AbsBaso-0.10*
___ 12:15AM BLOOD Plt ___
___ 12:15AM BLOOD Glucose-485* UreaN-37* Creat-2.0* Na-135
K-5.7* Cl-104 HCO3-10* AnGap-27*
___ 12:15AM BLOOD ALT-29 AST-42* CK(CPK)-234* AlkPhos-121*
TotBili-0.3
___ 12:15AM BLOOD CK-MB-10 MB Indx-4.3 proBNP-___*
___ 12:15AM BLOOD cTropnT-0.03*
___ 12:15AM BLOOD Albumin-4.0 Calcium-9.3 Mg-2.2
___ 12:15AM BLOOD Lactate-2.5*
MICROBIOLOGY
============
Urine cx (___): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Staph aureus Screen (Final ___: NO STAPHYLOCOCCUS AUREUS
ISOLATED.
IMAGING
=======
CXR Portable (___):
FINDINGS:
Lung volumes are low. There is moderate pulmonary edema. There
is mild
cardiomegaly. There is a small bilateral pleural effusion.
There is no
pneumothorax. There is no free air underneath the diaphragm.
IMPRESSION:
Moderate pulmonary edema and mild cardiomegaly.
CXR Portable (___):
IMPRESSION:
Comparison to ___. Substantial decrease in severity of
the
pre-existing pulmonary edema that is now mild to moderate in
severity.
Moderate cardiomegaly. Low lung volumes persist. Mild
bilateral basilar
atelectasis.
CXR Portable (___):
FINDINGS:
There is no focal consolidation, pleural effusion or
pneumothorax identified. Mild bibasilar atelectasis. Vascular
redistribution without overt pulmonary edema. The size of the
cardiac silhouette is enlarged but unchanged.
IMPRESSION:
Mild bibasilar atelectasis.
CARDIAC STUDIES
===============
STRESS TEST ___:
INTERPRETATION: This ___ year old IDDMII woman with known history
of
sever CAD; 90% LAD and 95% LCX, refused CABG in ___ was
referred to the
lab for evaluation. She exercised for 6 minutes on modified
Gervino
protocol and the test stopped due to fatigue. The peak estimated
MET
capacity is 2.5, which represents a poor exercise tolerance for
her age.
NO chest, arm, neck or back discomfort reported. In the setting
of
baseline ST-T wave abnormality, at peak exercise an additional
___ segment depression noticed in the inferolateral
leads, as
well as a 1.0-1.___levation in aVR. These ST segment
changes
returned to baseline by 18 minutes post-exercise. Rhythm was
sinus with
one APB, rare isolated VPBs in recovery. HR and BP increased in
response
to low achieved level of exercise. ASA 325 mg given to the
patient to
chew at 2.5 minutes post-exercise.
IMPRESSION : Ischemic EKG changes with ST elevation in aVR in
the
absence of anginal symptoms to the very low achieved workload.
Poor
functional capacity. Nuclear report sent separately.
CARDIAC PERFUSION ___:
IMPRESSION:
1. Reversible, medium sized, moderate severity perfusion defect
involving the RCA territory.
2. Partially reversible, large, moderate severity perfusion
defect involving the LCx territory.
3. Normal left ventricular cavity size. Mild systolic
dysfunction with
hypokinesis in the LCx territory.
TTE ___:
No atrial septal defect is seen by 2D or color Doppler. There is
mild symmetric left ventricular hypertrophy with normal cavity
size. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the inferior and lateral walls
(the septal segments contract best). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve leaflets are
structurally normal. An eccentric, posteriorly directed jet of
mild to moderate (___) mitral regurgitation is seen. Due to the
eccentric nature of the regurgitant jet, its severity may be
significantly underestimated (Coanda effect). Moderate [2+]
tricuspid regurgitation is seen. There is mild pulmonary artery
systolic hypertension.
IMPRESSION: Mildly reduced left ventricular systolic function
consistent with multivessel coronary artery disease. Increased
left ventricular filling pressure. Mild to moderate mitral
regurgitation. Moderate tricuspid regurgitation. Mild pulmonary
artery systolic hypertension
DISCHARGE/INTERVAL LABS
=======================
___ 01:15PM BLOOD WBC-6.5 RBC-4.21 Hgb-11.3 Hct-35.5 MCV-84
MCH-26.8 MCHC-31.8* RDW-14.6 RDWSD-44.2 Plt ___
___ 01:15PM BLOOD ___ PTT-28.2 ___
___ 01:15PM BLOOD Glucose-169* UreaN-41* Creat-1.9* Na-138
K-4.8 Cl-103 HCO3-25 AnGap-15
___ 01:15PM BLOOD Calcium-9.6 Phos-4.7* Mg-2.3
___ 01:30PM BLOOD %HbA1c-10.6* eAG-258*
___ 05:52AM BLOOD Lactate-1.3
___ 01:41PM URINE Color-Straw Appear-Clear Sp ___
___ 01:41PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:41PM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE
Epi-<1
Brief Hospital Course:
Information for Outpatient Providers: ___ y/o F with history of
CAD (90% LAD, 95% LCX, ?RCA done at ___ in ___, HFpEF
(LVEF 50%), HTN, DMII, CKD III, admitted for management of acute
pulmonary edema.
# ACUTE HYPOXIC RESPIRATORY FAILURE.
# ACUTE ON CHRONIC HFpEF (Last known dry weight 72.8lbs)
Likely flash pulmonary edema in the setting of medication
non-adherence resulting in acute on chronic HFpEF. Patient
underwent stress test on day of presentation and did not take
her home medications. Exam was notable for tachypnea and
bibasilar crackles and she initailly required BiPAP resulting in
CCU admission. Studies were notable for BNP 5177, CXR with
moderate pulmonary edema, and TTE showed newly reduced EF of
45%. She was diuresed with IV lasix 40 mg to euvolemia, and her
O2 requirement decreased, allowing transfer to the floor. She
was transitioned to her home Lasix PO 40mg BID and her home
lisinopril 40mg daily was also restarted. Her metoprolol XL
200mg daily was changed to carvedilol 25mg BID. Discharge
Creatinine is 1.9 and discharge weight is 75 kg.
# NSTEMI
# CAD. Has known 3-v disease. Likely in the setting of demand
ischemia. EKG on presentation with STD in the lateral leads.
Trops peaked at 0.03. Patient was evaluated by interventional
cardiology for possible high-risk PCI and cardiac surgery for
possible CABG. Per Cardiac surgery, patient is a candidate for
revascularization, but patient is unsure if she wants surgery at
this time, as she lives alone and is concerned about who will be
able to look after her finances, rent, etc., while she undergoes
surgery and during the subsequent rehabilitation. Social work
has been engaged with the patient to determine what support
services could assist. In the end, after discussions with
cardiac surgery and CCU team, patient would like to be
discharged home and follow-up as an outpatient for CABG workup.
Patient was continued on her home ASA 81mg daily, atorvastatin
80mg daily, and lisinopril 40mg daily. Her home Plavix 75mg
daily was held initially given possibility of CABG, but was
restarted on discharge. She was also started on Carvedilol
during this hospital stay with discontinuation of her home
Metoprolol.
# HYPERTENSION.
Patient was continued on her home lisinopril 40mg daily as
above. She was also started on Carvedilol 25 mg BID.
# CKD STAGE III. Cr remained at baseline of 2.0 throughout
admission. Cr 1.9 at time of discharge.
# TYPE II DIABETES MELLITUS. Recent A1c ___.
Patient was continued on home Lantus 28U qAM as well as in-house
insulin sliding scale.
# GLAUCOMA.
Patient was continued on her home timolol and latanoprost.
Discharge Cr: 1.9
Discharge weight:
TRANSITIONAL
============
- Discharge Cr 1.9
- Discharge weight 75 kg
- Patient's metoprolol was replaced with carvedilol 25mg BID
- Patient would like additional time to take care of social
supports and finances before undergoing CABG. She will be
followed as an outpatient and will need to call cardiac surgery
(___) to make an appointment when she would like to
further discuss her surgery.
- MEDICATIONS ADDED: Carvedilol
- MEDICATIONS STOPPED: Metoprolol
# CODE: Full (confirmed)
# CONTACT/HCP: ___ (friend): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Furosemide 40 mg PO BID
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Aspirin EC 81 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
8. Glargine 28 Units Breakfast
9. Atorvastatin 80 mg PO QPM
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
2. Glargine 28 Units Breakfast
3. Aspirin EC 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Furosemide 40 mg PO BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Lisinopril 40 mg PO DAILY
9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
ACUTE HYPOXIC RESPIRATORY FAILURE.
ACUTE EXACERBATION OF CHRONIC HEART FAILURE WITH PRESERVED
EJECTION FRACTION
NON ST-SEGMENT ELEVATION MYOCARIAL INFARCTION
SECONDARY DIAGNOSES
===================
HYPERTENSION
CHRONIC KIDNEY DISEASE STAGE III
TYPE II DIABETES MELLITUS
GLAUCOMA
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! You were admitted with
shortness of breath and we found that you had a mild heart
attack as a result of blockages in your coronary arteries, which
supply blood to your heart. We treated you with medications. We
discussed that you would likely benefit from a cardiac surgery
to unblock the coronary arteries. After discussions with the
cardiac surgery team, you would like additional time to think
about this procedure. We have scheduled important follow-up
appointments (as listed below) that you should attend.
Please continue to take your medications as directed and try
your best to keep your scheduled medical appointments.
NEW MEDICATIONS ADDED: Carvedilol
MEDICATIONS STOPPED: Metoprolol
We wish you the best!
Your ___ Cardiology Team
Followup Instructions:
___
|
19902687-DS-17 | 19,902,687 | 22,802,020 | DS | 17 | 2137-11-19 00:00:00 | 2137-11-21 23:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a h/o hypothyroidism, s/p sleeve
gastrectomy in ___, s/p hernia repair x2, s/p appendectomy
who
was BIBA to ___ for abdominal pain. She reports sudden onset,
___ sharp epigastric pain x1h, waxing and waning. The pain
began around 1am and woke her from sleep, and is non-radiating.
It was associated with nausea and NBNB emesis x2, as well as a
sense of needing to evacuate her bowels. She had one normal
bowel
movement without diarrhea or blood at 1am. She continues to pass
flatus. Reports pain is different from the past, never had any
similar pain similar. She endorses subjective fever, chills, and
lightheadedness. She denies any abdominal distention, diarrhea,
dysuria, urinary frequency, hematuria, chest pain, SOB, cough.
She has been unable to eat since last night. LMP 2 days prior,
currently with normal menses. She denies any sick contacts or
recent travel.
In the ED, initial vitals: T 97.4 HR 60 BP 96/65 RR 15 SpO2
100%
RA
- Exam notable for: epigastric tender and LUQ
- Labs notable for: WBC 13.8 w left shift, CMP wnl, LFTs wnl,
lipase wnl, lactate 1.3, beta-hCG neg, UA dirty
- Imaging notable for:
CT A/p w contrast:
1. Mild wall thickening and wall edema of distal small bowel
loops without evidence of obstruction. This is nonspecific and
could be secondary to inflammation or infection.
2. Status post sleeve gastrectomy without evidence of
complication. No
evidence of hernia.
- Surgery was consulted who recommended: no hernia, no evidence
of mesh infection, clinical picture most consistent with GI
infection no acute surgical needs at this time recommend
admission to medicine
- Pt given: 1L NS, acetaminophen 1000mg, morphine 4mg x2,
metoclopramide
- Vitals prior to transfer: T 98.1 HR 63 BP 113/72 RR 16 SpO2
100% RA
On the floor, she reports improvement in her pain and nausea
after morphine and Zofran.
Past Medical History:
PAST MEDICAL HISTORY:
Hypothyroidism
Appendicitis
PAST SURGICAL HISTORY:
Ex-lap for perforated appendicitis ___ yrs ago
Hernia repair x2
Sleeve gastrectomy ___ in ___
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL:
====================
VITALS: T 98.1 HR 63 BP 113/72 RR 16 SpO2 100% RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Somewhat dry mucous membranes.
Oropharynx is clear.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, tender to
palpation
in epigastrium. No e/o hernia. No organomegaly appreciated.
Negative ___ sign.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: No rash or jaundice.
NEUROLOGIC: No focal neurological deficits grossly appreciated.
Moving all four extremities.
DISCHARGE PHYSICAL:
====================
VITALS: ___ 1142 Temp: 98.2 PO BP: 97/62 R Lying HR: 49 RR:
18 O2 sat: 100% O2 delivery: Ra
GENERAL: AOx3, NAD, ambulating in room without difficulty
HEENT: Pupils equal, round, and reactive bilaterally,
extraocular
muscles intact. Sclera anicteric and without injection. MMM.
Oropharynx is clear.
CARDIAC: Regular rhythm, normal rate. Normal S1 and S2. No m/r/g
LUNGS: CTAB, no increased WOB; no c/r/w
ABDOMEN: Normal bowels sounds, non distended, minimal tender to
palpation in epigastrium without any r/g, BS+
EXTREMITIES: WWP, no pitting edema in b/l ___. 2+ distal pulses
bilaterally
SKIN: No rash or jaundice. multiple hyperpigmented prior
surgical
scars on abdomen, well healed, nodular feeling, non-tender
NEUROLOGIC: alert, appropriately interactive on exam; moving all
extremities with purpose
Pertinent Results:
ADMISSION LABS:
=================
___ 06:30AM BLOOD WBC-13.8*# RBC-4.63 Hgb-12.8 Hct-39.9
MCV-86 MCH-27.6 MCHC-32.1 RDW-13.4 RDWSD-41.9 Plt ___
___ 06:30AM BLOOD Neuts-85.5* Lymphs-8.2* Monos-5.4
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.82*# AbsLymp-1.14*
AbsMono-0.74 AbsEos-0.03* AbsBaso-0.03
___ 07:45AM BLOOD ___ PTT-24.9* ___
___ 06:30AM BLOOD Glucose-86 UreaN-12 Creat-0.8 Na-142
K-4.4 Cl-107 HCO3-21* AnGap-14
___ 06:30AM BLOOD ALT-10 AST-17 AlkPhos-59 TotBili-0.5
___ 06:30AM BLOOD Albumin-3.7 Calcium-8.8 Phos-2.8 Mg-2.1
___ 06:38AM BLOOD Lactate-1.3
___ 11:56PM BLOOD Lactate-1.2
DISCHARGE LABS:
=================
___ 08:45AM BLOOD WBC-6.0# RBC-4.16 Hgb-11.8 Hct-36.6
MCV-88 MCH-28.4 MCHC-32.2 RDW-13.4 RDWSD-43.4 Plt ___
___ 08:45AM BLOOD ___ PTT-28.1 ___
___ 08:45AM BLOOD Glucose-77 UreaN-5* Creat-0.9 Na-143
K-3.9 Cl-109* HCO3-24 AnGap-10
___ 08:45AM BLOOD ALT-9 AST-14 LD(LDH)-141 AlkPhos-51
TotBili-0.3
___ 08:45AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9
OTHER IMPORTANT LABS:
======================
___ 09:00AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 09:00AM URINE Blood-LG* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-SM*
___ 09:00AM URINE RBC-2 WBC-17* Bacteri-FEW* Yeast-NONE
Epi-13
___ 09:00AM URINE UCG-NEGATIVE
MICROBIOLOGY:
=============
___ Urine culture: contaminant
___ Blood culture: pending, NGTD
___ Blood culture x2: pending, NGTD
IMAGING AND OTHER STUDIES:
==========================
___ CT Abd/Pelvis with contrast:
1. Wall thickening and edema of distal ileal loops and terminal
ileum in the right lower quadrant, compatible with infectious or
inflammatory enteritis. No bowel obstruction.
2. Status post sleeve gastrectomy without evidence of
complication.
___ CXR: No evidence of acute cardiopulmonary process.
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with PMH notable for hypothyroidism,
prior sleeve gastrectomy, and multiple abdominal surgeries p/w
abdominal pain and nausea/vomiting most consistent with a viral
gastroenteritis, admitted for continued pain and intolerance of
PO.
ACUTE ISSUES:
=============
# Gastroenteritis, likely viral:
# Abdominal pain, vomiting: The patient presented with acute
onset abdominal pain with NBNB vomiting and subjective fevers,
chills. She had evidence of terminal ileitis without any
clinical signs of lower GI involvement. Clinically, she was
hypovolemic due to poor PO intake, but did not appear septic.
Initially, there was a broad differential for her symptoms,
including infectious causes (viral, less likely bacterial
gastroenteritis, which would not necessarily require abx),
inflammatory (IBD/celiac disease, which are possible but less
likely in absence of more chronic symptoms), or
mechanical/obstructive (nothing evidenced on CT) pathology.
However, most likely her symptoms were attributed to viral
gastroenteritis, potentially from contacts such as her children
at home, with associated hypovolemia. With supportive care in
the form of IVF, analgesics, and anti-emetics, the patient
improved dramatically. Orthostatics were negative and patient
was clinically improving, tolerating PO intake prior to
discharge.
# Contaminated UA: The patient had a contaminated sample on
urinalysis (epithelial cells). She did have large blood, likely
due to recent menses. She did not have any symptoms of UTI and
was not treated for an infection.
CHRONIC ISSUES:
===============
# Hypothyroidism: The patient was continued on her home
levothyroxine during this admission.
TRANSITIONAL ISSUES:
====================
NEW MEDICATIONS:
-Zofran 4mg PO Q8H:PRN nausea
-Acetaminophen 650mg PO Q4H:PRN pain
-Ibuprofen 600mg PO Q6H:PRN
-Meclizine 12.5mg PO Q12H:PRN vertigo
-Please make an appointment to follow up at your primary care
clinic in the next week.
#Code status: Full Code
#Emergency contact: ___
> 30 minutes spent on discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
RX *acetaminophen 325 mg 2 capsule(s) by mouth every 4 hours
Disp #*84 Capsule Refills:*0
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild NOT relieved by
Acetaminophen Duration: 2 Weeks
Please take with food and for no more than 2 weeks.
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*56 Tablet Refills:*0
3. Meclizine 12.5 mg PO Q12H:PRN vertigo Duration: 7 Days
RX *meclizine 12.5 mg 1 tablet(s) by mouth Q12H:PRN Disp #*14
Tablet Refills:*0
4. Ondansetron ODT 4 mg PO Q8H:PRN nausea Duration: 1 Week
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp
#*21 Tablet Refills:*0
5. Levothyroxine Sodium 112 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS/ES:
======================
-Gastroenteritis, Acute, Viral
-Hypovolemia
SECONDARY DIAGNOSIS/ES:
=========================
-Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WERE YOU ADMITTED TO THE HOSPITAL:
-You were having nausea and vomiting
-There was concern for an infection of your intestines
WHAT WAS DONE FOR YOU IN THE HOSPITAL:
-You had a CAT scan of you belly. This showed a possible
infection of your small intestines.
-This was most likely caused by a virus.
-You were given fluids through your IV to rehydrate you
-You were given medications to help with your nausea and
abdominal pain
WHAT YOU SHOULD DO AFTER LEAVING THE HOSPITAL:
-Please avoid rich, fatty, or high lactose foods for at least a
week after discharge. These include fried foods and foods with
any dairy products such as milk or ice cream.
-Please take your medications only as needed for abdominal pain,
nausea, and dizziness.
-Please follow-up with your outpatient doctor.
Thank you for allowing us to be a part of your care,
Your ___ Team
Followup Instructions:
___
|
19902791-DS-9 | 19,902,791 | 27,957,067 | DS | 9 | 2200-09-09 00:00:00 | 2200-09-09 20:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / tomato / lisinopril / chocolate flavor / caffeine
Attending: ___
Chief Complaint:
arm swelling, malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, Mrs. ___ is a ___ year-old-female who has
history of right breast cancer with lymph node spread s/p right
total mastectomy in ___, previously on tamoxifen, HTN, HLD,
HFrEF (40% in ___, and poorly controlled DM2 (A1c 13.3%), who
presented with right arm cellulitis c/b sepsis and DKA now
resolved, BCx with GPCs in pairs and clusters, on vancomycin and
ceftriaxone.
Patient presented to the ED on ___ with one right arm pain,
redness, and swelling, a/w nausea, vomiting, and confusion. She
first noticed redness around her right wrist, which then quickly
spread to involve her entire right hand including the axilla.
She
denies having fevers or chills. She does not remember any cuts
or
bug bites, but says she always gets bit by mosquitos when she is
outside during the evening. She denies IVDU. Shortly prior to
her
admission, she noticed she was feeling unwell, her mind was
clouded, and she felt very nauseous up to the point of vomiting.
Her blood sugars were poorly controlled prior to her
presentation, at times in the 800s. She also noted frequent
urination.
She was diagnosed with right arm cellulitis with leukocytosis to
12.5 and found to be in DKA, with lactate to 1.3, bicarb to 12,
glucose 379, AG to 22, UA with glucosuria and ketonuria. Right
hand, forearm, and humerus x-rays were normal. Chest x-ray
demonstrated low lung volumes and bibasilar atelectasis. Right
upper extremity U/S was without evidence of DVT. She received 4L
LR, IV vanc/zosyn, and started on insulin drip and admitted to
the ICU.
In the ICU, her AG closed and she was transitioned to SC insulin
on ___. ___ is following her diabetes management. Her
cellulitis improved on IV vanc/zosyn with quick resolution of
her
sepsis, and she was transitioned to PO bactrim and cephalexin on
___. However, her blood culture collected in the ED grew ___
bottles with GPC in pairs and clusters and patient was started
on
IV vanc/ceftriaxone, while speciation is pending. Repeat blood
cultures from ___ with no NGTD.
Patient was first noted to have decreased platelet count in
___.
Her platelets on admission were 119 and were 108 today.
On the floor, patient complains of mild headache. She denies any
shortness of breath, chest pain, dizziness, lightheadness,
abdominal pain, nausea, vomiting, constipation, diarrhea,
dysuria, lower extremity edema.
Past Medical History:
1) HTN c/b hypertensive cardiomyopathy
2) morbid obesity
4) Long h/o irregular periods/painful periods
5) hyperlipidemia
6) GERD
7) adjustment disorder
8) myalgias and arthralgias.
Past Surgical Hx:
1) Carpal Tunnel s/pp release
2)neck pain s/p MVC
3) C-section
4) closed manipulation of the right shoulder under anesthesia in
___
5) laparoscopic cholecystectomy.
Social History:
___
Family History:
Multiple family members with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GEN: Well appearing, no acute distress
HEENT: PERRLA
NECK: Trachea midline
CV: Tachycardic, regular rhythm, no murmur, no peripheral
edema,
radial pulse 2+ bilaterally
RESP: No accessory muscle use, clear lung sounds
GI: Soft non-tender, no rebound or gaurding
MSK: Area of erythema/warmth in the RUE from the wrist to above
the elbow not extending past skin marker markings, no crepitus,
no abscess, no purulent drainage, distal pulse, sensation, and
motor intact
NEURO: A&Ox4. Moving all 4 extremities
DISCHARGE PHYSICAL EXAM
========================
24 HR Data (last updated ___ @ 1711)
Temp: 98.0 (Tm 98.9), BP: 97/67 (97-135/67-88), HR: 89 (82-102),
RR: 18 (___), O2 sat: 99% (96-99), O2 delivery: RA, Wt: 230.3
lb/104.46 kg
___ 1711 FSBG: 287
___ 1249 FSBG: 250
___ 0611 FSBG: 136
___ 0303 FSBG: 105
___ 2235 FSBG: 177
Gen: lying comfortably in bed in NAD
HEENT: PERRL, EOMI
CV: RRR, nl S1, S2, no m/r/g, no JVD
Chest: CTAB
Abd: obese, + BS, soft, NT, ND
MSK: lower ext warm without edema
Skin: minimal erythema of the R forearm, substantially receded
from previously marked borders without induration, TTP,
fluctuance, or crepitus
Neuro: AOx3, CN II-XII intact, ___ strength all ext, sensation
grossly intact to light touch, gait not tested
Psych: pleasant, appropriate affect
Pertinent Results:
===============
Admission labs
===============
___ 11:01PM BLOOD WBC-12.5* RBC-4.43 Hgb-13.0 Hct-41.4
MCV-94 MCH-29.3 MCHC-31.4* RDW-13.1 RDWSD-45.0 Plt ___
___ 11:01PM BLOOD Neuts-80.8* Lymphs-11.4* Monos-6.9
Eos-0.0* Baso-0.1 Im ___ AbsNeut-10.10* AbsLymp-1.42
AbsMono-0.86* AbsEos-0.00* AbsBaso-0.01
___:01PM BLOOD Glucose-379* UreaN-8 Creat-1.1 Na-132*
K-6.2* Cl-98 HCO3-12* AnGap-22*
___ 11:01PM BLOOD ALT-32 AST-50* AlkPhos-47 TotBili-0.6
___ 11:01PM BLOOD Albumin-4.0 Calcium-9.2 Phos-4.2 Mg-1.5*
___ 11:01PM BLOOD ___ pO2-105 pCO2-25* pH-7.40
calTCO2-16* Base XS--6
___ 11:01PM BLOOD Lactate-1.3 K-5.6*
===============
Pertinent labs
===============
___ 08:15AM BLOOD Beta-OH-1.0*
C-peptide 1.8 (WNL)
===============
Discharge labs
===============
Plt 132 (from 106)
Cr 0.9, Cl 109, HCO3 20
INR ___
Fibrinogen 637
A1c 13.3%
CMV VL (___): not detected
CMV IgM +, CMV IgG + on ___
HIV neg on ___
===============
Studies
===============
___ RUE ___: No evidence of deep vein thrombosis in the
right upper extremity.
R hand x-ray ___: Normal right hand radiographs.
R forearm x-ray ___: No fracture. No subcutaneous
emphysema.
CXR ___: No acute intrathoracic process. Low lung volumes
with bibasilar atelectasis.
===============
Microbiology
===============
BCx (___): pending x 2
BCx (___): pending x 2
UCx (___): mixed flora
BCx (___): CoNS in 1 of 2 bottles
Brief Hospital Course:
___ year-old-female with hx R-sided breast cancer metastatic to
nodes s/p total mastectomy (tamoxifen currently on hold), HTN,
HLD, HFrEF (EF 40% in ___, poorly-controlled DM presenting
with R forearm cellulitis, sepsis, and DKA, with course c/b CoNS
in blood, likely contaminant.
# R forearm cellulitis:
# CoNS in 1 of 2 bottles:
# Sepsis:
P/w sepsis ___ to R forearm cellulitis without purulence with
low suspicion for osteomyelitis or necrotizing fasciitis given
unremarkable Xray of humerus, forearm, hand and RUE U/s with no
e/o DVT. Improved with Vanc/Zosyn and then transition to PO
antibx, subsequently
re-broadened to Vanc/CTX prior to MICU callout given GPCs in 1
of 2 bottles drawn in ED. BCx speciated to CoNS, likely a
contaminant, with subsequent BCx NGTD. Given improvement in her
cellulitis, she was transitioned to PO Keflex/doxycycline on ___
to complete a 10-day course through ___.
# Diabetic ketoacidosis:
# Uncontrolled diabetes mellitus:
A1c 7.2% ___, up to 13.3% on admission for DKA, likely in
setting of infection and metformin non-adherence (had confused
metoprolol and metformin). DKA resolved, and sugars improved on
lantus 35u qAM/15u qPM with Humalog 8u qAC + SS. Ms. ___ is
reluctant to start insulin, hoping for improvement in her
diabetes with metformin alone. In discussion with ___, she
has agreed to discharge on metformin 500mg BID, along with
lantus and humalog insulin pens. She will check her fingersticks
before meals. If sugar is >200, she has agreed to administer
lantus 35u qAM with a humalog sliding scale beginning with 8u
for fingerstick >200. She was provided a glucometer, lancets,
and test strips prior to discharge and received teaching from
the ___, nursing, and nutrition. She was instructed
on identifying and managing hypoglycemia as well. She will f/u
with ___ endocrinology and with her PCP ___ ___.
# Acute on chronic thrombocytopenia:
Plt have ___ slowly downtrending over the last year or so. Was
recently seen by heme/onc (Dr. ___ on ___ who attributed
thrombocytopenia to tamoxifen (now on hold since ___ in setting
of likely initiation of aromastase inhibitor). W/u notable for
CMV IgM/IgG positivity, but CMV VL was negative. HIV negative.
No e/o DIC. Plt were uptrending at discharge (from 106 on ___ to
132 on ___ with no e/o bleeding.
# HFrEF (EF 40% in ___:
# HTN:
# Risk factors for CAD:
EF 40% on stress echo ___ with e/o prior inferior MI without
inducible ischemia. Received IVF iso sepsis and DKA, but no e/o
volume overload during admission. Continued home Toprol and half
dose of home losartan (25mg daily in place of home 50mg daily).
___ benefit from outpatient cardiology f/u and addition of
low-dose ASA and a statin, which were deferred to PCP.
# R-sided breast cancer metastatic to nodes s/p total
mastectomy:
Tamoxifen on hold since ___, with plan for initiation of AI.
She will f/u with her outpatient oncologist, Dr. ___,
___ discharge.
TRANSITIONAL ISSUES
===================
[ ] F/u BCx, pending at discharge
[ ] ___ diabetes management and insulin titration
[ ] Insulin plan as above: discharged on metformin 500mg BID
with plan to dose lantus 35u qAM for AM fingerstick >200 and
humalog SS beginning with 8u for pre-prandial fingerstick >200
[ ] ABx with cephalexin/doxycycline x 10 days to complete ___
[ ] Reduced losartan to 25mg qd from 50mg. Titrate as needed
[ ] Consider starting moderate intensity statin and ASA for
primary prevention given ASCVD risk >10%. ___ benefit from
outpatient cardiology f/u.
[ ] Further ___ deferred to outpatient
hematology/oncology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Losartan Potassium 50 mg PO DAILY
3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
4. Omeprazole 20 mg PO DAILY GERD
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Oxybutynin XL (*NF*) 10 mg Other DAILY
Discharge Medications:
1. BD Ultra-Fine Mini Pen Needle (pen needle, diabetic) 31
gauge x ___ miscellaneous QID
RX *pen needle, diabetic [BD Ultra-Fine Mini Pen Needle] 31
gauge X ___ four times a day Disp #*90 Each Refills:*0
2. Cephalexin 500 mg PO QID Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth q6hr Disp #*28
Tablet Refills:*0
3. Doxycycline Hyclate 100 mg PO BID Duration: 7 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
4. FreeStyle Lancets (lancets) 28 gauge miscellaneous QID
RX *lancets [FreeStyle Lancets] 28 gauge four times a day Disp
#*360 Each Refills:*0
5. FreeStyle Lite Meter (blood-glucose meter) miscellaneous
QID
RX *blood-glucose meter [FreeStyle Lite Meter] four times a
day Disp #*1 Kit Refills:*0
6. FreeStyle Lite Strips (blood sugar diagnostic)
miscellaneous QID
RX *blood sugar diagnostic [FreeStyle Lite Strips] four times
a day Disp #*360 Strip Refills:*0
7. HumaLOG KwikPen Insulin (insulin lispro) 100 unit/mL
subcutaneous sliding scale (beginning at 8u for fingerstick
>200)
8. Lantus Solostar U-100 Insulin (insulin glargine) 100 unit/mL
(3 mL) subcutaneous DAILY, 35u qAM if fingerstick >200
9. Losartan Potassium 25 mg PO DAILY
10. MetFORMIN XR (Glucophage XR) 500 mg PO BID
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Omeprazole 20 mg PO DAILY GERD
14. Oxybutynin XL (*NF*) 10 mg Other DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
CELLULITIS
DIABETIC KETOACIDOSIS
THROMBOCYTOPENIA
SECONDARY
=========
BACTEREMIA - Coagulase negative staph
OBESITY
HYPERLIPIDEMIA
HYPERTENSION
HEART FAILURE WITH REDUCED EJECTION FRACTION
BREAST CANCER
TYPE 2 DIABETES MELLITUS
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital because you were not feeling well and
had an infection on your arm.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were also given insulin for your high blood sugar levels.
You met with the ___ diabetes experts, who came up with a
plan for managing your diabetes. You were given IV antibiotics
for your infection that had spread to your blood and discharged
on PO antibiotics.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please measure your blood sugars at home while on metformin.
If your sugars are > 200, please administer insulin as
recommended (lantus 35U in the morning as well as Humalog per
the sliding scale provided to you)
- Please go to your ___ appointment at ___
- Please see your PCP to ___ on your medical conditions
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19903067-DS-11 | 19,903,067 | 28,945,206 | DS | 11 | 2165-03-15 00:00:00 | 2165-03-16 14:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril / Flomax
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Hx HTN presents after syncopal event, CT finding of
carotid narrowing and 2 extraaxial hyperdensities with IV
contrast enhancement concerning for metastatic foci.
Two days prior to admission, the patient was in the kitchen
making breakfast when he suddenly noticed R neck tightness, and
then he dropped to floor with LOC, unknown time but perhaps a
minute. Enough time for egg carton to catch fire. He awoke
without confusion, put the fire out, and continued making
breakfast. His daughter did not hear him fall and when she found
him at kitchen table noted his head lack. He denies any
prodrome, diaphoresis, chest pain, dyspnea, visual changes,
N/V/D, numbness/tingling or weakness. He believes he hit his R
forehead on the counter, sustaining a laceration. He noticed
that a drawer handle under the stove had broken off, he assumed
due to being damaged in his fall. He had no tongue biting, no
post-ictal confusion, no incontinence.
Of note, these events took place 1 day after the ___
anniversary of his wife's death. He had previously been noted
to have a purposeful 8-lb weight loss over the last year due to
dietary changes. No other recent changes in his health. He had
one prior syncopal event ___ year prior in the context of
drinking EtOH on an empty stomach.
The patient initially presented to his PCP. Differential
included concerning for neurogenic versus cardiogenic syncope.
He had a normal neurological exam, although he was noted to have
audible right carotid murmur and contusions on his right
forehead and lip. EKG SR with rate in the ___ and no acute
ischemic changes.
He was referred to ___-N for workup given the new bruit. CTA
demonstrated approximately 50% narrowing of both carotids. It
also demonstrated 2 extraaxial hyperdensities with IV contrast
enhancement, concerning for possible metastatic lesions. The
patient was transferred to ___ for neurosurgical evaluation.
In the ED intial vitals were: ___ 98.4 68 167/77 18 100% RA.
Neurosurgery evaluated the patient and felt that although there
is no immediate surgical indication, they recommended admission
for syncope workup and also possible search for primary
malignancy given these imaging abnormalities.
On the floor, patient is feeling well, daughter is at his
bedside.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
BENIGN PROSTATIC HYPERTROPHY
COLON POLYP ON SCOPE ___ - DUE IN ___
HYPERLIPIDEMIA
HYPERTENSION
MENISCAL TEAR
NEGATIVE EXERCISE ECHO ___
SYNCOPE
Social History:
___
Family History:
son died MI age ___
daughter had pituitary tumor removed benign age ___
Physical Exam:
ADMISSION:
==========
Vitals - T: 97.2 BP: 180/75 HR: 68 RR: 12 02 sat:100%RA
GENERAL: NAD
HEENT: R frontotemporal head lac with minimal swelling and
tenderness, bandage c/d/i, EOMI, PERRL, anicteric sclera, pink
conjunctiva, patent nares, MMM, R upper lip swollen with mild
ecchymosis, nontender, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, no carotid
bruit or murmur
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ ___ pulses bilaterally
NEURO: CN II-XII intact, nonfocal, strength ___ throughout,
sensation intact, coordination intact, gait narrow based and
steady
SKIN: warm and well perfused
DISCHARGE:
==========
Vitals- 98.1, 97.6, 55-68, 118-182/60-75, 18, 100%RA
General- Alert, oriented, no acute distress. Has small lac on R
frontal scalp that is without erythema or exudate
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no rubs or gallops.
___ murmur heard at R carotid.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact to testing, ___ strength in upper and
lower extremities.
Labs: Reviewed, please see below.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:50AM BLOOD WBC-5.6 RBC-4.17* Hgb-13.0* Hct-40.3
MCV-97# MCH-31.2 MCHC-32.2 RDW-14.9 Plt ___
___ 05:50AM BLOOD Glucose-86 UreaN-12 Creat-0.8 Na-138
K-3.7 Cl-103 HCO3-28 AnGap-11
___ 05:50AM BLOOD CK(CPK)-65
___ 05:50AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:50AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.2
IMAGING:
========
___ MRI:
FINDINGS:
Within the right frontal region there is a 0.8 x 1.9 cm
extra-axial T2
hyperintense lesion with slow diffusion and homogeneous
enhancement. Findings likely represent a meningioma. There is no
abnormal signal within the adjacent brain. There are nonspecific
periventricular and subcortical white matter T2/FLAIR
hyperintensities, likely reflecting sequela of chronic small
vessel ischemic disease. There is no infarct, hemorrhage or mass
effect. The ventricles, and sulci a are prominent indicative of
mild parenchymal volume loss.
The principal intracranial flow voids are present. There is mild
ethmoid and bilateral maxillary sinus mucosal thickening. There
is a small amount of fluid within the right mastoid air cells.
IMPRESSION:
There is 0.8 x 1.9 cm enhancing right frontal extra-axial mass
most likely representing a meningioma.
Nonspecific white matter abnormalities, likely sequela of
chronic small vessel ischemic disease.
___ ECHO:
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
borderline pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Normal biventricular size and function. No
clinically significant valvular disease is seen. Borderline
elevated pulmonary artery systolic pressure.
Compared with the report of the prior study (images unavailable
for review) of ___, left atrial volume index is now
reported. The right atrium isenlarged. The PASP is slightly
increased compared with previous exam. Otherwise, the findings
are similar.
___ CT ___:
FINDINGS:
CHEST: Please refer to separate report of CT chest performed on
the same day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There
is no evidence of focal lesions. There is no evidence of
intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within
normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The adrenals glands are unremarkable bilaterally.
KIDNEYS: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of stones or hydronephrosis. Multiple round
hypodensities
are seen within the bilateral kidneys, the largest measuring 4.2
x 2.8 cm
within the left lower pole representing a cyst (3:65).
BOWEL: The stomach opacifies with oral contrast. The stomach is
distended with
residual fluid and tapers at the second duodenum in the area of
mesenteric
vessels. The small bowel opacifies with contrast without wall
thickening or
evidence of obstruction. Large bowel contains stool without
evidence for wall
thickening or obstruction. There is no abdominal free air free
fluid.
RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric
lymphadenopathy.
VASCULAR: The abdominal aorta demonstrates severe
atherosclerosis.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There
is no evidence
of pelvic or inguinal lymphadenopathy. There is no free fluid in
the pelvis.
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions.
IMPRESSION:
No evidence of malignancy within the abdomen or pelvis.
CT CHEST: read pending
DISCHARGE LABS:
===============
___ 08:35AM BLOOD WBC-5.7 RBC-4.41* Hgb-14.1 Hct-43.3
MCV-98 MCH-32.0 MCHC-32.5 RDW-14.9 Plt ___
___ 08:35AM BLOOD Glucose-144* UreaN-15 Creat-1.0 Na-138
K-4.1 Cl-100 HCO3-28 AnGap-14
___ 08:35AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.1
___ 05:50AM BLOOD TSH-5.9*
___ 08:35AM BLOOD T4-6.4
MICROBIOLOGY:
=============
/___ am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ with Hx HTN presents after syncopal event, CT finding of
carotid narrowing and 2 extraaxial hyperdensities with IV
contrast enhancement concerning for metastatic foci.
# Syncope: Neurogenic vs cardiogenic. Vasovagal is unlikely
given lack of prodrome. TIA is certainly possible and would
pursue this given CT findings especially given concern for mets.
Arrythmia is concern given acute onset and acute return to
normal function. I do not believe his R neck pain is related to
this episode as he reports R sided muscular pain that resolves
with hot packs when he does a lot of housework, and this pain
was consistent with those previous episodes. He had no events on
telemetry, cardiac enzymes were negative. MRI brain and CT
abdomen and pelvis were negative for malignancy (see below).
Patient was instructed not to drive until syncope workup is
complete.
# UTI: Patient had >100,000 E.coli in urine sensitive to
ciprofloxacin. On exam, prostate was nontender. He was treated
with a 7 day course of PO antibiotics and should follow up with
his PCP if he continues to have symptoms of frequency.
# CT finding of extraaxial abnormalities: Concerning for
metastatic foci. MRI head was negative as was CT chest abdomen
and pelvis.
# HTN: Relatively recent diagnosis, started lisinopril last
fall. He was continued on lisinopril.
# HLD: continued atorvastatin
# Colon polyp: Colonoscopy ___, due for repeat now
# BPH: nocturia x2-3 nightly. Brought home medication Avodart.
TRANSITIONAL ISSUES:
-needs colonoscopy
-further workup for syncope as cardiac and neuro workup negative
to date. ___ need tilt table testing, stress test or holter
-meningioma on MRI should be followed closely in the event that
it is somehow contributing to his syncopal episodes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. dutasteride 0.5 mg oral daily
2. Lisinopril 5 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Atorvastatin 80 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. dutasteride 0.5 mg oral daily
5. Lisinopril 5 mg PO DAILY
6. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: syncope
Secondary diagnoses:
BENIGN PROSTATIC HYPERTROPHY
COLON POLYP ON SCOPE ___ - DUE IN ___
HYPERLIPIDEMIA
HYPERTENSION
MENISCAL TEAR
NEGATIVE EXERCISE ECHO ___
SYNCOPE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at ___. You were admitted for faiting of unclear cause. You
had imaging of your neck which did not show significant
narrowing of your arteries, but did show some soft tissue
enlargement that may have been related to your fainting episode.
Your chest xray didn't show any evidence of infection and your
echo showed normal heart function. MRI was normal. You were
found to have a urine infection and were started on antibiotics.
You were also found to have low thyroid function and should
follow this up with your PCP.
No changes were made to your medications. Please continue to
take them as you have been doing.
Please do not drive until further notice.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19903141-DS-13 | 19,903,141 | 24,421,078 | DS | 13 | 2172-11-06 00:00:00 | 2172-11-08 22:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Penicillins / seasonal allergies / ibuprofen
Attending: ___.
Chief Complaint:
Shortness of breath.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old woman with a history of asthma presenting with SOB.
On ___ started to feel like she was getting a cold
(congested, runny nose) and body aches. Felt hot and cold and
had a fever to 102.1. Has a non-productive cough. Developed SOB
and wheezing which progressively worsened. Has some mild chest
tightness when she coughs but no chest pain. Took nyquil and her
albuterol inhaler without relief so came to the ED. Also had 2
episodes of diarrhea this morning. No vomiting. Has chronic
abdominal pain which is unchanged. Has been hospitalized once
for her asthma many years ago, has never needed to be intubated.
.
In the ED initial vitals were 98.8, 106, 130/77, 22, 88% RA.
Wheezing on exam. Peak flow 100, received duonebs x3 with
methylpred 125mg and post-treatment peak flow was 210, then 160
and patient still wheezy. Labs unremarkable. CXR neg for
pneumonia or acute process. Patient also given tylenol 1g and
dilaudid 2mg (for chronic back pain), and 2g magnesium sulfate.
Vitals prior to transfer were 98.0, 100, 141/85, 20, 100% on 4L.
.
On the floor patient appears comfortable, is talking in complete
sentences w/o SOB, and states that she feels more comfortable
than she did when she came in.
.
REVIEW OF SYSTEMS: As noted in HPI. In addition, denies
headache, vision changes, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria, or rash.
Past Medical History:
HTN.
Asthma.
Diabetes.
.
PSH
- L5-S1 laminectomy +discectomy
- multiple pain management spine injections for back pain
-C4-C5 fusion
-Left RC surgery
-hysterectomy
-3 C-sections
-2 carpal tunnel surgeries
Social History:
___
Family History:
Family history notable for diabetes, mother and father; heart
disease, mother and father; kidney disease, mother.
Mother with CHF, Father ? MI, Aunt with ? GI ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 97.7, 128/74, 89, 16, 97% on 3L
GENERAL: WDWN woman, appears very comfortable, able to speak in
full sentences w/o any SOB, no use of accessory muscles
HEENT: PERRL, EOMI
NECK: Supple, no JVD
LUNGS: Diffuse end-expiratory wheezes, no rales
HEART: RRR, normal S1/S2, no MRG
ABDOMEN: Obese, soft, mildly TTP across upper abdomen, no
guarding or rebound
EXTREMITIES: WWP, no c/c/e
NEUROLOGIC: A&Ox3, CN II-XII intact, strength and sensation
grossly intact
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.0, Tc 97.9, P 75 (84-105), BP 100/D (100-133/D-90)
20, 95%RA
I/O: ___ PO, 0 IV, ___+ urine.
GENERAL: Alert, interactive, well-appearing obese ___
___ woman in NAD. Affect somewhat blunted but improves with
discussion of discharge.
SKIN: warm and dry without lesions or rashes.
HEENT: PERRLA, sclerae anicteric, MMM, OP clear
HEART: RRR, nl S1-S2, no MRG
LUNGS: Wheezing throughout. No accessory muscule use.
ABDOMEN: Obese, hypoactive bowel sounds, soft, tender to
palpation in the epigastrum and RUQ. No rebound or guarding. No
suprapubic tenderness.
EXTREMITIES: WWP, no clubbing, cyanosis or edema
NEURO: awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
LABORATORY RESULTS:
___ 06:55AM BLOOD WBC-11.4*# RBC-4.43 Hgb-12.6 Hct-39.6
MCV-89 MCH-28.4 MCHC-31.8 RDW-14.6 Plt ___
___ 02:15PM BLOOD WBC-7.1 RBC-4.91 Hgb-14.1 Hct-43.7 MCV-89
MCH-28.7 MCHC-32.2 RDW-14.5 Plt ___
___ 06:55AM BLOOD Glucose-165* UreaN-9 Creat-0.7 Na-136
K-4.2 Cl-95* HCO3-33* AnGap-12
___ 02:15PM BLOOD Glucose-157* UreaN-8 Creat-0.9 Na-137
K-4.1 Cl-93* HCO3-31 AnGap-17
___ 06:55AM BLOOD ALT-19 AST-21 AlkPhos-92 TotBili-0.2
___ 06:55AM BLOOD Calcium-9.1 Phos-3.0# Mg-2.5
___ 02:32PM BLOOD Lactate-1.6
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
IMAGING:
CXR ___:
New right middle lobe opacity could be related to atelectasis in
the setting
of lower low lung volumes or pneumonia. A repeat radiograph with
a better
inspiratory effort could be obtained if clinically necessary.
Brief Hospital Course:
Ms. ___ is a ___ year-old female with DM, HTN and asthma
presenting with SOB and fever x3 days. Found to have RML
infiltrate on CXR.
ACUTE ISSUES:
# Pneumonia/asthma exacerbation: The patient presented with
shortness of breath thought to be due to an asthma exacerbation.
She was given nebulizers in the ED and was started on 60mg of
prednisone. She was afebrile in the ED but reported temperatures
to 99 at home. Her lung exam was monitored and she was given
standing nebulizers with improvement. Chest x-ray on admission
was suggestive of a right middle lobe pneumonia. She was started
on Levofloxacin IV and transitioned to oral antibiotics for
discharge home to complete a 7 day course. She had one episode
of O2 desaturation to 88% while sleeping but this quickly
resolved upon waking and sitting up. Her breathing gradually
improved. On the day of discharge, she was ambulating in the
hall with saturations of 93-99%.
# Chronic abdominal pain: The patient presented with mild
tenderness to percussion across upper abdomen which patient
states has been there for several months and is unchanged. She
had one episode of nausea and vomiting shortly after eating
along with complaints of epigastric pain. An EKG was done which
showed sinus rhythm unchanged from a previous EKG. Liver
function tests and lipase were within normal limits. She was
given Maalox and continued on her home omeprazole. The abdominal
pain gradually improved over her stay.
STABLE ISSUES:
# Diabetes mellitus: The patient was continued on her metformin
and started on an insulin sliding scale while in the hospital.
# Hypertension: The patient was continued on her
hydrochlorothiazide and her blood pressures remained in good
control.
# Chronic back pain: The patient was continued on her home
gabapentin, dilaudid, and oxycontin. She was given supplemental
Tylenol for additional pain relief.
# Depression: The patient was continued on her bupropion,
sertraline and diazepam during admission.
TRANSITIONAL ISSUES:
- Blood cultures are pending at the time of discharge.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Gabapentin 600 mg PO TID
2. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN pain
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. BuPROPion (Sustained Release) 150 mg PO QAM
5. Sertraline 200 mg PO DAILY
6. Diazepam 2 mg PO Q12H:PRN anxiety
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Sumatriptan Succinate 50 mg PO PRN headache
9. Omeprazole 20 mg PO DAILY
10. beclomethasone dipropionate *NF* 80 mcg/actuation Inhalation
2 puffs twice a day
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. Diazepam 2 mg PO Q12H:PRN anxiety
3. Gabapentin 600 mg PO TID
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. HYDROmorphone (Dilaudid) 2 mg PO DAILY:PRN pain
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. Sertraline 200 mg PO DAILY
9. beclomethasone dipropionate *NF* 80 mcg/actuation Inhalation
2 puffs twice a day
10. Sumatriptan Succinate 50 mg PO PRN headache
11. PredniSONE 60 mg PO DAILY
12. Levofloxacin 750 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
asthma
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for shortness of breath and found to have an
asthma exacerbation likely caused by a pneumonia in your right
lung. You were given nebulizers, oral steroids and antibiotics
and improved with treatment. You had worsening abdominal pain
for which an EKG was checked to ensure that the cause of your
pain was not your heart. Your EKG was normal and unchanged since
your last EKG. You were given pain medications and medications
for stomach pain with some improvement. Please take all your
medications as directed and attend all followup appointments as
indicated below.
Followup Instructions:
___
|
19903197-DS-12 | 19,903,197 | 28,801,714 | DS | 12 | 2193-02-01 00:00:00 | 2193-02-01 20:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___
Chief Complaint:
Abnormal labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of COPD, IVDU, HCV, Cirrhosis complicated ___ s/p
liver resection and ascites who is referred in from her
outpatient hepatologist for ___ on routine lab testing. Cr was
noted to be 1.2 on ___ from a baseline of 0.6-0.8. However on
arrival to the ED and with repeat labs, Cr noted to be at the
patients baseline and not elevated. Patient reports ~ ___ lb
weight loss per month for the past several months. She denies CP
or SOB. Otherwise, she denies any symptoms.
In the ED, initial vitals with pain ___, afebrile 98.3, HR 88,
BP 139/97, RR 20, 95% on RA. ED Exam notable for a "large
ventral hernia and diffuse Labs notable for mild leukocytosis to
11. Chem 7 with BUN/Cr ___, LFTs with AST 50, AP 143, TBili
1.3, Alb 3.1. Bedside US in ED did not note any tappable
ascites. Patient received Diazepam 2mg x2. Despite the fact that
the patint's labs were at baseline on repeat in the ED, her
outpatient liver doctor requested that she be admitted per the
ED. Reportedly, the patient is non-complaint with medications
and requires a ___.
On arrival to the floor, pt reports that she is very anxious
regarding her kidneys, liver, neck pain, abdominal pain. She
denies recent fevers, chills, N/V, change in bowel habits. She
is tearful regarding her medications and is overall unable to
explain which medications she is taking at home.
Past Medical History:
ANXIETY/DEPRESSION
BIPOLAR DISORDER ___
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
HEPATITIS C
HYPERTENSION
NEUROPATHY ___
OSTEOARTHRITIS
OSTEOPOROSIS
CARDIAC ARREST - reportedly during surgery at ___ in ___
UMBILICAL HERNIA
H/O ALCOHOL ABUSE
H/O INTRAVENOUS DRUG ABUSE
H/O OVARIAN TORTION s/p TAH/BSO
Social History:
___
Family History:
Her mother died with lung cancer. Her father was an alcoholic
with diabetes. Another alcoholic brother who died with liver
cirrhosis. Three aunts with breast cancer. Denies any history of
liver cancer. Her healthcare proxy is ___,
___. She lives in ___ or ___.
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
Vitals: 98.1; 135/83l HR 79; RR 16; 93% RA
General: Alert, oriented, mildly anxious and borderline tearful
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Neck: TTP over R trapezius muscle
Lungs: Diffuse ronchi and transmitted upper airway sounds
bilaterally. No wheezes, rales.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild TTP in LUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly.
Large ventral hernia, easily reducible.
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact. No Asterixis
DISCHARGE PHYSICAL EXAM
======================
Vitals: 98.2 PO 105 / 71 60 18 94 RA
General: Alert, oriented, mildly anxious and borderline tearful
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Neck: TTP over R trapezius muscle
Lungs: Decreased breath sounds in LLL.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, moderate TTP in LUQ, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. Two
large ventral hernias, easily reducible.
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. Grossly intact. No Asterixis
Pertinent Results:
ADMISSION LAB RESULTS
===================
___ 03:10PM BLOOD WBC-11.0* RBC-4.06 Hgb-11.9 Hct-36.3
MCV-89 MCH-29.3 MCHC-32.8 RDW-15.7* RDWSD-51.8* Plt ___
___ 04:03PM BLOOD ___ PTT-34.3 ___
___ 03:10PM BLOOD Glucose-88 UreaN-28* Creat-0.8 Na-133
K-4.0 Cl-94* HCO3-27 AnGap-16
___ 03:10PM BLOOD ALT-22 AST-50* AlkPhos-143* TotBili-1.3
___ 09:12AM BLOOD Calcium-9.3 Phos-2.7 Mg-1.8
DISCHARGE LAB RESULTS
====================
___ 05:29AM BLOOD WBC-8.9 RBC-3.69* Hgb-10.7* Hct-33.3*
MCV-90 MCH-29.0 MCHC-32.1 RDW-15.5 RDWSD-50.5* Plt ___
___ 05:29AM BLOOD ___ PTT-32.4 ___
___ 05:29AM BLOOD Glucose-121* UreaN-28* Creat-1.1 Na-136
K-3.5 Cl-97 HCO3-29 AnGap-14
___ 05:29AM BLOOD ALT-18 AST-33 AlkPhos-111* TotBili-0.9
___ 05:29AM BLOOD Calcium-9.0 Phos-3.0 Mg-2.1
IMAGING
=======
___ RUQ Ultrasound:
1. Partially occlusive SMV thrombosis. The intrahepatic portion
of the main
portal vein is patent, but the SMV thrombus could conceivably
extend into the
extrahepatic portion of the portal vein, which is not fully
visualized.
2. Cirrhotic liver and a 2.9 cm mass in the left lobe.
3. Mild intra and extrahepatic biliary ductal dilation.
4. Splenomegaly has worsened since prior.
___ CXR:
Right lower lung opacification concerning for developing
pneumonia.
___ CT Abdomen and Pelvis with Contrast:
1. 2.1 cm liver lesion in the left lateral segment with imaging
findings
consistent with hepatocellular carcinoma.
2. 0.1 cm lesion in the dome of the liver with imaging findings
also
concerning for hepatocellular carcinoma
3. Nonocclusive thrombosis of the main portal vein
4. Moderate amount of ascites
5. Splenomegaly of 17.6 cm and venous collaterals in the left
upper quadrant
as well as esophageal varices consistent with portal
hypertension
6. Status post liver resection with the majority of the right
lobe having been
removed.
7. Multiple ___ opacities at the lung bases consistent
with
aspiration. More focal consolidation in the left lower lobe is
concerning for
pneumonia
Brief Hospital Course:
The patient is a ___ with a history of HCV Cirrhosis (MELD 9)
complicated by ___ s/p liver resection and ascites, COPD and a
history of IVDU, who is referred in from her outpatient
hepatologist for ___ on routine lab testing. The ___ was no
longer present on repeat check in the ED. She was admitted to
establish ___ services as she is reportedly "non-compliant" with
outpatient medications.
#HCV Cirrhosis/HCC: The patient recently transferred all of her
care to ___ hepatology from ___ on ___. Per the outpatient
hepatolgoy note on ___, she has been treated for HCV but did
not complete the treatment in ___. She has Grade 2 varices, and
she also has history of ___ s/p hepatic resection at ___. A
right upper quadrant ultrasound was performed, which showed a
partially occlusive SMV thrombosis and splenomegaly (she was not
started on anticoagulation because of her ongoing
"non-compliance" with medications). A CT scan of the abdomen was
obtained, and it showed two small lesions in the liver
concerning for HCC. Alpha fetoprotein was ~4. For diuresis,
there was confusion as to what the patient was taking at home.
She was re-started on spironolactone 25mg and torsemide 20mg on
___. Her Cr increased slightly, so she was changed to
spironolactone 25mg and torsemide 10mg. Her Creatinine continued
to show interval increases in setting of poor PO intake and
decreased diuretic so she was taken off diuretics completely at
discharge as her volume exam was unimpressive, even at
admission. She was discharged with close follow-up with ___
___ the management of ___, HCV, and SMV clot.
#Gastric Varices: Given the patients history of gastric
varices, she was started on Nadolol 20mg daily
#Community Acquired Pneumonia: Patient presented with two weeks
of productive cough, and CT imaging concerning for pneumonia.
She did not have any leukocytosis, objective fevers, and she had
an unremarkable physical exam. Given her two weeks of worsening
productive cough and imaging findings, she was started on
Levofloxacin 750mg Q48 as treatment for CAP. She will need to
complete a 5 day course of treatment. Day 1 = ___, Day 5 =
___.
#Medication Management: Many of the patients medications were
discontinued during the hospitalization due to patient's
non-compliance and because it was unclear if the patient needed
them. She will be set up for ___ services to help with
medication administration.
#Severe malnutrition: The nutrition team evaluated the patient
while she was in the hospital. She reports that she has lost a
significant amount of weight over the last year. She was started
on Ensure supplements with meals.
#Abdominal pain: The patient had continuation of her chronic LUQ
pain during the hospitalization. RUQ US with doppler show
worsening splenomegaly, which could explain worsening LUQ pain.
Her pain was controlled on Percocet PRN.
#Neck Pain: Patient was complaining of 10 days worth of right
neck pain over the area of the trapezius muscle. It improved
with massage, heat, and a lidocaine patch, so it was determined
to be muscular in nature. Tinazadine was trialed for two days
without effect, so she was changed to cyclobenzaprine on ___ x 1 day, also without effect. Because both medications were
ineffective during the hospitalization, they were not continued
at discharge
CHRONIC ISSUES
=============
#GERD -Her home home omeprazole 20mg daily was continued.
Ranitidine was stopped
#HTN - Her home lisinopril was stopped because her blood
pressures were borderline soft during the admission, and she
does not need it.
#Bipolar/Anxiety - not currently on medications for this per
patient
#Neuropathy - Her home Gabapentin was stopped as patient only
takes it intermittently, and is unclear if she actually has
neuropathy
#COPD - Her home Spiriva, Adviar and albuterol was continued
#HLD - Fasting lipids were checked, and were normal. Her home
Simvastatin was stopped since the patient reports that she had
not been taking it everyday.
#Prophylaxis - Her home ASA 81mg was stopped because patient
does not know why she is taking it
TRANSITIONAL ISSUES
===================
- Patient should complete a 5-day course of levofloxacin for
community acquired pneumonia. Day 1 = ___, Day 5 = ___.
- Patient was started on nadolol for grade 2 varices
- Patient should have close follow-up with ___ Hepatology for
management of her SMV thrombosis, HCV, and HCC.
- Patient should have close follow-up with her PCP for
medication management given the change in medications during
this hospitalization.
-As per Dr. ___ patient's statin was stopped after
fasting lipids were checked. Can consider restarting, but
removed from list to streamline medications for patient.
-We also stopped aspirin, lisinopril, gabapentin, and ranitidine
as pt was confused as to what medications she was supposed to
take
-She is set up with bubble packs through her pharmacy and is set
up with ___ to ensure she is taking medications as directed.
Weight on ___: 111.7 lbs
#Code: Full
# CONTACT: ___ (sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Gabapentin 400 mg PO TID
3. LOPERamide 2 mg PO QID:PRN loose stool
4. Tiotropium Bromide 1 CAP IH DAILY
5. Simvastatin 40 mg PO QPM
6. Spironolactone 50 mg PO DAILY
7. Torsemide 60 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. Omeprazole 20 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Vitamin D Dose is Unknown PO DAILY
12. albuterol sulfate 90 mcg/actuation inhalation q4H:PRN
13. Ranitidine 150 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*28 Capsule Refills:*0
2. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth Every 48 hours Disp
#*2 Tablet Refills:*0
3. Nadolol 20 mg PO DAILY
RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*28 Tablet Refills:*0
5. albuterol sulfate 2 puffs inhalation Q4H:PRN wheezing
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs IH Q4 hours
Disp #*1 Inhaler Refills:*0
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/dose 1
cap IH twice a day Disp #*1 Disk Refills:*0
7. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*28
Capsule Refills:*0
8. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap IH
daily Disp #*1 Inhaler Refills:*0
9. Vitamin D Dose is Unknown PO DAILY
10. HELD- Spironolactone 50 mg PO DAILY This medication was
held. Do not restart Spironolactone until talking with Dr.
___
11. HELD- Torsemide 60 mg PO DAILY This medication was held. Do
not restart Torsemide until talking with Dr. ___
12.Outpatient Physical Therapy
ICD10 Code: ___
Please evaluate and treat for general deconditioning. Please
provide ___ treatments per week for ___ weeks.
13.Outpatient Lab Work
ICD10: ___
Please check Chem 10. Fax results to: Attn Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- HCV cirrhosis complicated by hepatocellular carcinoma
Secondary Diagnosis:
- Community acquired pneumonia
- Severe malnutrition
- Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at ___.
Why did you come in?
====================
- Dr. ___ you into the hospital because your kidney
function was worse
What did we do for you?
=======================
- We obtained an ultrasound of your belly, which showed that
your spleen was bigger than it used to be. This could be a cause
for your left-sided pain.
- A CT scan of your belly showed two small masses in your liver
that are concerning for liver cancer. It also showed a possible
infection in your lungs (pneumonia), so we started you on
antibiotics.
- We changed a lot of your home medications and set you up with
a visiting nurse service who will help you at home with
medications.
What do you need to do?
=======================
- It is very important that you follow up with Dr. ___
___ for further management of the liver mass and the blood
clot in the veins around your liver.
- It is also very important that you follow up with your primary
care doctor, since a lot of your medications were changed during
this hospitalization.
- Continue taking Levofloxacin (two more doses on ___
for a total treatment of 5 days. (Day 1 = ___, Day 5 = ___.
- You have a prescription to get lab work done. Please do this
by ___.
It was a pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19903197-DS-19 | 19,903,197 | 21,534,969 | DS | 19 | 2194-11-20 00:00:00 | 2194-11-21 05:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of HCV cirrhosis
c/b ascitesm HE, and recurrent HCC s/p resection & TACE
(___), PVT/SMV clot, COPD, OSA, anxiety, and depression
who
presents with rib pain following a fall.
The patient was recently admitted to ___ from ___ for
confusion, felt to be ___ HE (no prior diagnosis) vs ___ and
dehydration. Infectious work up was unremarkable. She was
treated
with lactulose, rifaxamin and IV fluids with improvement in
mental status. Her spironolactone and torsemide were held at
discharge given ___.
One week ago, the patient sustained a fall while walking and
trying to turn around to find her grandson. She felt her right
knee buckle and then collapsed onto her right knee and right
side, with her arm over her ribs. No head strike or loss of
consciousness. No ___ medical illness. Her pain was
overall well controlled at that time so she did not seek medical
attention. The following day, she developed pain over her right
middle ribs anteriorly that has progressed since. Her pain is
worse with deep breaths and is now impairing her breathing. She
has had a mild nonproductive cough; also had a fever to ___
initially (none in last 5 days) and two days of chills. Given
ongoing pain, she presented to our ED.
Past Medical History:
1. Chronic hepatitis C.
2. Decompensated cirrhosis with ascites since ___. No history
of SBP. No history of GI bleed or encephalopathy.
3. History of HCC, status post liver resection in ___ or ___,
unclear.
4. COPD, asthma, actively smoking.
5. Anxiety, depression, bipolar.
6. History of alcohol and drug abuse. Reports being sober for
more than ___ years.
7. Sleep apnea. She is not on BiPAP right now.
8. Anorexia, weight loss, malnutrition.
9. Hypercholesterolemia.
10. Osteoporosis.
11. Osteoarthritis.
12. Liver resection for HCC per patient in ___, but chart was
actually in ___ at ___. She had a cardiac arrest during
surgery
at that time per chart.
13. TAH/BSO secondary to ovarian torsion.
Social History:
___
Family History:
Her mother died with lung cancer. Her father was an alcoholic
with diabetes. Another alcoholic brother who died with liver
cirrhosis. Three aunts with breast cancer. Denies any history of
liver cancer. Her healthcare proxy is ___,
___.
Physical Exam:
ADMISSION EXAM:
===============
VS: Temp 98.3 BP 120/70 HR 59 RR 22 94% on RA
GENERAL: Elderly female in NAD. Lying comfortably in bed.
HEENT: AT/NC, anicteric sclera, MMM, oropharynx clear.
NECK: supple, no LAD
CV: RRR with normal S1 and S2. No murmurs, gallops, or rubs
PULM: Normal respiratory effort. Faint crackles over right base.
No wheezes or rhonchi.
Chest: TTP over right chest wall.
GI: Normoactive BS. Soft, mildly distended, non-tender. No
guarding or masses. Dull to percussion.
EXTREMITIES: Warm, well perfused. Trace ___ edema, no erythema.
Ecchymosis over right medial knee and medial malleolus.
PULSES: 2+ radial pulses bilaterally
NEURO: A&Ox3. CN II-XII grossly intact. Moves all extremities.
No
asterixis.
DERM: Warm, dry. No rashes.
DISCHARGE EXAM:
===============
GENERAL: Sitting up in bed, intermittently appears distressed
but
interactive and alert
HEENT: AT/NC, anicteric sclera, MMM, oropharynx clear
NECK: JVD elevated to ~10-11 cm when sitting at 45 degrees
CV: RRR, S1 and S2, no murmurs, gallops, or rubs
PULM: Coarse rales over the anterior right lung and the
posterior
right mid-lung field to base with diffuse end-expiratory wheeze
CHEST: TTP over right anterior chest wall
ABDOMEN: Soft, mildly distended, mildly tender over multiple
hernias, which are soft and reducible
EXTREMITIES: No ___ edema bilaterally. Ecchymosis over right
medial and lateral knee and medial malleolus
PULSES: 2+ radial pulses bilaterally
NEURO: AOx3, no asterixis
DERM: (+) palmar erythema, no spider angiomata
Pertinent Results:
Admission Labs:
===============
___ 03:04PM BLOOD WBC-5.6 RBC-3.68* Hgb-11.5 Hct-34.7
MCV-94 MCH-31.3 MCHC-33.1 RDW-16.3* RDWSD-56.9* Plt Ct-73*
___ 03:04PM BLOOD Glucose-72 UreaN-15 Creat-0.8 Na-143
K-5.3 Cl-109* HCO3-21* AnGap-13
___ 03:04PM BLOOD ALT-24 AST-52* AlkPhos-97 TotBili-1.0
___ 03:04PM BLOOD Albumin-3.5 Calcium-9.1 Phos-3.4 Mg-1.8
Discharge Labs:
===============
___ 05:45AM BLOOD WBC-9.7 RBC-3.53* Hgb-11.0* Hct-33.0*
MCV-94 MCH-31.2 MCHC-33.3 RDW-17.2* RDWSD-56.9* Plt ___
___ 05:45AM BLOOD UreaN-16 Creat-0.9 Na-137 K-4.2 Cl-101
HCO3-23 AnGap-13
___ 05:13AM BLOOD ALT-21 AST-34 LD(LDH)-228 AlkPhos-98
TotBili-1.0
___ 07:22AM BLOOD Calcium-8.5 Phos-2.2* Mg-2.0
Microbiology:
=============
___ 8:45 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ (___), ___ @
11:54AM.
Studies:
========
___ CTA chest
IMPRESSION:
1. Minimally displaced fractures of the anterior right second,
third and
fourth ribs.
2. New small simple appearing right pleural effusion,
compressive atelectasis
in the right lung base.
3. Mild interstitial pulmonary edema.
4. No acute pulmonary embolism.
5. Enlarged pulmonary artery, suggestive of pulmonary arterial
hypertension.
6. Cirrhosis, partially visualized ascites and splenomegaly.
___ Abdominal ultrasound
IMPRESSION:
No paracentesis could be performed as there was no pocket of
ascites large
enough to access.
Brief Hospital Course:
___ with history of HCV cirrhosis complicated by ascites,
hepatic encephalopathy, varices, and recurrent hepatocellular
carcinoma status post resection & TACE x2 (___), remote
opioid use disorder with IV drug use, portal vein
thrombosis/superior mesenteric vein clot, COPD, anxiety,
depression, and recurrent falls over the past 6 months who
presents with pleuritic chest pain following a fall, found to
have multiple right-sided rib fractures complicated by E coli
bacteremia in the setting of right lower lobe consolidation,
possibly community-acquired pneumonia. She was treated with
antibiotics, and her pain was controlled with a combination of
therapies. She was discharged to home with instructions for
close follow-up and counseling around safe use of narcotics with
a naloxone kit.
ACUTE ISSUES:
=============
#E coli bacteremia
Patient presented about a week after a fall at home due to
progressively worsening rib pain and was found to have multiple
anterior rib fractures and right lower lobe consolidation on CT
chest. She was found to have ___ blood cultures positive for E
coli (with negative surveillance blood cultures thereafter). She
reported a 2-day fever at home after the fall that resolved
spontaneously and was afebrile and hemodynamically stable
throughout her hospital course. There was concern for a true
infectious process precipitated by splinting from pain
complicated by aspiration pneumonia. Her urine culture was
negative, and there was low concern for SBP given minimal
ascites on abdominal ultrasound (untappable even by
interventional radiology). As such, she was treated for
community-acquired pneumonia and discharged with PO Augmentin
875mg q12h for a 10-day course in total (day 1: ___, planned
end ___. She also completed 3 days of azithromycin 500mg daily
while in-house.
#Pleuritic chest pain
#Multiple rib fractures
Patient's chest pain was thought to be most likely ___ multiple
rib fractures (minimally displaced fractures of the anterior
right second, third, and fourth ribs) with possible contribution
from possible PNA. There was less concern for ACS given her
non-ischemic EKG and negative troponins x2, and CTA chest on
admission showed no evidence of PE. Her pain was controlled with
lidocaine patches, guaifenisen, standing Tylenol, and PO
oxycodone. Of note, prior to discharge, she was using about
30mg/24hrs. As such, she was discharged with 7 days' of PO
oxycodone 5mg q8h for a total of 21 pills. She was also
counseled around safe use of narcotics and given a naloxone kit,
which she says she will give to her patient care assistant.
#Traumatic fall in the setting of recurrent falls
Patient describes a fall at home while ambulating without her
walker. She denied preceding fever/chills, chest pain/pressure,
dyspnea, syncopal or orthostatic symptoms, less concerning for
cardiac, infectious, or autonomic cause(s). She has been
participating in outpatient physical therapy/aquatherapy. The
likely etiology of her fall is postural instability compounded
by the patient's reluctance to use a walker (per her report), as
she reports a similar history for prior falls over the past 6
months. On exam, she ambulated well with her walker without
instability, steppage gait, or ataxia and with a normal base.
She had negative orthostatic vitals. Physical therapy noted the
patient is at her baseline.
CHRONIC ISSUES:
===============
#HCV cirrhosis
Decompensated by ascites, grade I varices (seen on EGD in
___, recent HE, and recurrent HCC s/p resection and TACE x2.
Followed by Dr. ___ in Liver ___. She was continued on
home nadolol 20mg daily, lactulose and rifaximin, and
spironolactone 25mg daily. Home torsemide was held in the
setting of possible infection; please consider restarting if she
has signs/symptoms of volume overload.
#Opioid use disorder
Patient has a history of remote IV drug use (reported last use
___ years ago). Given discharge with opioids for pain management,
patient was also given a naloxone kit and counseled around safe
use of narcotics.
#Depression
#Anxiety
- continued home sertraline
#GERD
- continued home omeprazole
#Umbilical hernia
- continued home dicyclomine PRN
#COPD
- continued home spiriva, Advair, duonebs
TRANSITIONAL ISSUES:
====================
- Complete antibiotic course of PO Augmentin 875mg q12h for 10
days (day 1: ___, planned end ___
- Patient given naloxone to be administered in the event of
overdose
- Please consider restarting torsemide if patient develops
signs/symptoms of volume overload
- Please monitor patient for lethargy, confusion, or decreased
respiratory rate on oxycodone
- Please follow up with patient's pain to ensure it is
well-controlled
MEDICATION CHANGES:
===================
CONTINUE PO Augmentin through ___
HOLD torsemide until you follow up with Dr. ___ Dr. ___
___ (sister), ___
Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rifaximin 550 mg PO BID
2. Lactulose 15 mL PO DAILY
3. TraMADol 50 mg PO QHS:PRN Pain - Severe
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortnes of breath
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Omeprazole 40 mg PO DAILY
7. Sertraline 100 mg PO DAILY
8. DICYCLOMine 20 mg PO TID:PRN muscle cramps
9. Nadolol 20 mg PO DAILY
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*13 Tablet Refills:*0
2. Calcium Carbonate 500 mg PO TID W/MEALS
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth three times a day with meals Disp #*90 Tablet
Refills:*0
3. GuaiFENesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 5 mL by mouth every 8 hours
Refills:*0
4. naloxone 4 mg/actuation nasal ONCE:PRN
RX *naloxone [Narcan] 4 mg/actuation 1 spray when needed Disp
#*1 Spray Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Mild
Duration: 7 Days
RX *oxycodone 5 mg 1 capsule(s) by mouth every 8 hours Disp #*21
Capsule Refills:*0
6. Spironolactone 25 mg PO DAILY
RX *spironolactone [Aldactone] 25 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
7. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
8. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortnes of breath
9. DICYCLOMine 20 mg PO TID:PRN muscle cramps
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Lactulose 15 mL PO DAILY
12. Nadolol 20 mg PO DAILY
13. Omeprazole 40 mg PO DAILY
14. Rifaximin 550 mg PO BID
15. Sertraline 100 mg PO DAILY
16. TraMADol 50 mg PO QHS:PRN Pain - Severe
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Rib fractures
E coli bacteremia
SECONDARY DIAGNOSES
===================
HCV cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You had progressively worsening chest pain after a fall.
What did you receive in the hospital?
- You were found to have multiple right-sided rib fractures
causing your chest pain.
- There was concern that you developed a pneumonia, so you were
treated with antibiotics.
- Your pain was controlled with a combination of different
medications.
What should you do once you leave the hospital?
- Please complete your course of antibiotics.
- Please continue physical therapy and aquatherapy and use your
walker at home and when you are outside.
- Please give the naloxone kit to your patient care assistant
and educate him around using it in the event of an emergency.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19903312-DS-13 | 19,903,312 | 24,654,700 | DS | 13 | 2117-01-20 00:00:00 | 2117-01-20 17:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right sided weakness
Major Surgical or Invasive Procedure:
___ C3-C6 laminectomy and fusion w/ Dr. ___
___ of Present Illness:
___ is a ___ year old male with Celiac disease who
presented to ___ with progressive R arm/leg weakness and
was transferred to ___ with concern for cervical septic
arthritis.
Patient reports that right sided weakness started in early
___ of this year, initially with difficulty of small
movements of the hand such as manipulating coins which was
troublesome since he used to work as a ___. He had a fall
during a house fire in early ___ as well but unclear if this
exacerbated symptoms. Over the last ___ months his right sided
weakness has progressed to where his entire right arm feels weak
and has difficulty lifting objects. In last ___ months, he has
had onset of right lower extremity weakness. He reports
difficulty with lifting his right leg at the knee, causing him
to
walk with a limp and resulting in multiple falls. The falls have
increased in frequency and have included multiple falls on the
stairs.
Over the last week, patient reports onset of burning low back
pain. He reports the pain is intermittently in his bilateral
shoulders but does not radiate down arms or legs. He reports the
pain is severe and worse in the morning, making it difficult to
get out of bed. He also endorses tingling in his right
fingertips. He denies numbness. No bowel/bladder incontinence,
saddle or ___ anesthesia, or fever/chills. Patient denies
any visual changes. He does endorse a history of IV drug use in
the ___ but no recent use.
At ___ he had a CT-cervical spine that was concerning for
septic arthritis. He was given Unasyn and started on vancomycin
prior to transfer.
Past Medical History:
Anxiety/ panic disorder
Depression
ADHD
Bilateral carpal tunnel
Meniscus tear (unsure which side)
Celiac disease
Sciatica right leg
Social History:
___
Family History:
noncontributory
Physical Exam:
ON ADMISSION:
O: T: 97.6 BP: 133/70 HR: 84 R: 18 O2Sats: 98%RA
Gen: WD/WN, comfortable, NAD.
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
T D B T WE WF FI G IP Q H AT ___ G
R ___ 4 4 ___ 4 4+ 4 4+ 4 4+
L ___ 5 5 ___ 5 ___ 5 5
Sensation: Intact to light touch
+3 beat clonus on R, - clonus on L
- ___ bilaterally
ON DISCHARGE:
O: T: 99.2 BP: 113/77 HR: 98 R: 18 O2Sats: 96%RA
Gen: WD/WN, comfortable, NAD.
Neck: Supple.
Extrem: Warm and well-perfused.
Motor:
TrapDeltoidBicepTricepGrip
Right 5 5 5 5 4
Left 5 5 5 5 5
IPQuadHamATEHLGast
Right4+54+444
Left5 5 5 5 5 5
Sensation: Intact to light touch
+3 beat clonus on R, - clonus on L
- ___ bilaterally
Pertinent Results:
___ 10:29AM BLOOD WBC-8.4 RBC-5.09 Hgb-14.8 Hct-44.5 MCV-87
MCH-29.1 MCHC-33.3 RDW-13.3 RDWSD-42.3 Plt ___
___ 05:00PM WBC-7.3 RBC-5.22 HGB-14.7 HCT-44.7 MCV-86
MCH-28.2 MCHC-32.9 RDW-13.6 RDWSD-42.5
___ 05:00PM GLUCOSE-90 UREA N-19 CREAT-0.7 SODIUM-140
POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-26 ANION GAP-12
___ 05:00PM ___ PTT-31.9 ___
Brief Hospital Course:
#Cervical spinal stenosis/arthritis s/p C3-C6 laminectomy and
fusion ___
Patient was transferred from ___ to ___, seen in ED in
stable condition with right sided weakness and imaging
consistent with cervical spinal stenosis/arthritis. Patient
underwent C3-C6 laminectomy on ___, tolerated procedure well
without any intra-op complications, post-op check with stable
neuro exam. Patient transferred to floor in stable condition,
dressing removed POD2, JP drain pulled POD3, diet advanced,
tolerating pain on po medication, patient cleared by ___ with
home ___.
Medications on Admission:
Klonopin 0.5 mg tablet three times day
Adderall 30 mg tablet twice daily
Wellbutrin SR 200 mg tablet, 12 hr sustained-release daily
Gabapentin 600 mg tablet twice daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
300-650mg by mouth every 6 hours as needed for pain
Do not exceed 4g in 24 hours
RX *acetaminophen 325 mg ___ tablet(s) by mouth every six (6)
hours Disp #*56 Capsule Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate Duration: 1 Week
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*56 Tablet Refills:*0
3. BuPROPion (Sustained Release) 200 mg PO BID
RX *bupropion HCl [Wellbutrin SR] 200 mg 1 tablet(s) by mouth
twice a day Disp #*14 Capsule Refills:*0
4. ClonazePAM 0.5 mg PO TID anxiety Duration: 1 Week
RX *clonazepam 0.5 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___.
Discharge Diagnosis:
cervical arthritis
Discharge Condition:
stable
Discharge Instructions:
Discharge Instructions
Cervical Spinal Fusion
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples or sutures. You will need
suture/staple removal.
Do not apply any lotions or creams to the site.
Please keep your incision dry until removal of your
sutures/staples.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Do NOT smoke. Smoking can affect your healing and fusion.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc
until cleared by your
neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
19903484-DS-12 | 19,903,484 | 21,511,003 | DS | 12 | 2128-08-28 00:00:00 | 2128-09-16 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
erythromycin base
Attending: ___.
Chief Complaint:
Neck pain, chest pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
A ___ y/o F presents to the ED as a transfer with chest pain s/p
a MVC. The patient was an unrestrained driver in a MCV earlier
today. The patient had severe pain over her sternum and
presented to OSH. At OSH, the patient had a CT which showed a C2
lateral mass fracture as well as an anterior mediastinal
hematoma and sternal fracture. The patient was transferred here
for further evaluation and management. Currently, the patient
notes chest pain. She reports that she does not remember the
entire accident and does not know if she lost consciousness or
not. The patient denies a headache, neck pain, nausea, and
vomiting.
Past Medical History:
None
Social History:
___
Family History:
Non-contributory
Physical Exam:
Temp: 98. HR: 74 BP: 108/70 Resp: 14 O(2)Sat: 100 Normal
Constitutional: Awake and alert
HEENT: Pupils equal, round and reactive to light, tender to
palpation over R maxilla and R orbit, Extraocular muscles intact
no laceration to the scalp
blood in the lower dentition and dried blood on the lip, no
battle sign, no blood in the nares
Chest: tenderness to palpation of the sternum and chest wall
bilaterally, no ecchymosis over the chest wall, Clear to
auscultation, normal effort, airway intact, bilateral breath
sounds
Cardiovascular: Regular Rate and Rhythm, Normal first and second
heart sounds, DP pulses 2+ symmetric
Abdominal: Soft, Nontender, Nondistended
Rectal: rectal tone intact
Extr/Back: Pelvis stable and nontender, no deformity or
tenderness of the extremities, TTP mid thoracic spine with no
other midline spine tenderness, no deformity or stepoff of spine
Skin: mild ecchymosis to the R anterior knee
Neuro: GCS 15, Speech fluent, moves all extremities
Psych: Normal mood, Normal mentation
Pertinent Results:
___ 04:50AM BLOOD WBC-6.8 RBC-3.66* Hgb-10.8* Hct-33.8*
MCV-92 MCH-29.5 MCHC-32.0 RDW-11.4 RDWSD-38.8 Plt ___
___ 03:40AM BLOOD WBC-10.1* RBC-4.13 Hgb-12.4 Hct-37.1
MCV-90 MCH-30.0 MCHC-33.4 RDW-11.7 RDWSD-37.6 Plt ___
___ 04:50AM BLOOD ___ PTT-29.2 ___
___ 03:40AM BLOOD ___ PTT-29.3 ___
___ 04:50AM BLOOD Glucose-71 UreaN-10 Creat-0.6 Na-137
K-3.8 Cl-100 HCO3-27 AnGap-10
___ 05:30AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-139
K-3.7 Cl-102 HCO3-25 AnGap-12
___ 03:40AM BLOOD Glucose-86 UreaN-10 Creat-0.8 Na-133*
K-9.3* Cl-98 HCO3-27 AnGap-8*
___ 10:50AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS* Barbitr-NEG Tricycl-NEG
___ 08:51AM URINE bnzodzp-POS* barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG mthdone-NEG
___ CTA:
IMPRESSION:
1. Fracture right lateral mass C 2, involves foramen
transversarium, stable.
2. Normal CTA. No dissection.
Brief Hospital Course:
Ms. ___ is a ___ yo F who presented to the Emergency
department as a transfer from outside hospital after sustaining
a motor vehicle crash. She underwent CT head, chest, and torso
that showed a C2 transverse foramen fracture, sternal fracture,
and mediastinal hematoma. Neurosurgery was consulted and
recommended CTA to rule out vascular injury and there was none.
The patient was maintained in a hard cervical collar and
admitted to the floor on continuous telemetry monitoring for
pain control and hemodynamic monitoring.
The patient underwent tertiary survey that was negative for any
further injuries. Pain was controlled on oral medications. She
had no cardiac events on continuous telemetry monitoring. Diet
was tolerated without difficulty. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching, including cervical
collar care, and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
FLUoxetine 60 mg PO DAILY
lisdexamfetamine 70 mg oral Q24H
VYVANSE 70 MG CAPSULE
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
DO NOT exceed 4000 mg acetaminophen/24 hours.
2. Docusate Sodium 100 mg PO BID
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
alternate with tylenol
4. Lidocaine 5% Patch 1 PTCH TD QAM
12 hours on; 12 hours off.
RX *lidocaine 5 % apply 1 patch to affected area daily Disp #*30
Patch Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
take lowest effective dose.
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*10 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
7. FLUoxetine 60 mg PO DAILY
8. lisdexamfetamine 70 mg oral Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Fracture right lateral mass C 2
deep sternal hematoma with possible fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
after a motor vehicle crash sustaining a fracture in you neck
and a deep bruise on your chest bone (sternum). You were
evaluated by the neuro spine team and your spinal cord remains
intact. You should continue to wear your hard cervical collar at
all times and avoid all twisting, strenuous activity, and heavy
lifting. You will follow up in the spine clinic to determine how
long you need to wear this brace.
Please continue to follow the diet prescribed by your outpatient
dentist.
You are now ready to be discharged home with the following
instructions:
* Your injury caused chest and rib pain which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19904083-DS-10 | 19,904,083 | 21,331,630 | DS | 10 | 2167-02-21 00:00:00 | 2167-02-21 17:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with type I DM diagnosed age ___, presented
with nausea and hyperglycemia. She had discontinued her insulin
pump this ___ because the pump was disconnecting with
activity. She transitioned herself to basal bolus regimen, but
has been having trouble staying with her schedule since college
began a few weeks ago. She has been having epigastric pressure
the past two weeks, and this morning had nausea, headache, and
fatigue with decreased appetite and increased abd pressure. She
noticed her BS 400's at home and went to the ED. Had nonbloody
emesis en route to ED. She denies fever, cough, sore throat. She
denies chest pain, SOB, or chest pressure. Denies diarrhea.
Denies dysuria, frequency, or urgency. No vaginal dc, LMP two
months ago, no oral contraceptive in past year, irregular menses
since then.
In the ED initial VS were: 98.9 122 ___ 97%
Remained afebrile, remained tachycardic, abdomen soft.
Initial K 4.6, AG 32, HCO3 12, BG 444.
ALT 103, AST 99, Alk Ph 200, T Bili 0.2, Alb 4.4, Lipase 28.
UA with glucose 1000, ketones 150, 8WBC, few bact, trace ___, 2
epi UCG -ve
WBC 6.4, H/H 15.3/46.7, MCV 101, platelets 444
RUQ US-> hepatomeg, no gallstone, no acute process
Given 40 IV K, 10U insulin, started on insulin gtt, given 2.5L
NS before transfer and 1gm cefriaxone.
Repeat K Glucose fell to 161 on insulin gtt, D5W started,
insulin gtt stopped.
On arrival to the MICU, she feels like her normal self, except
with some epigastric discomfort. She does not feel short of
breath.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies sinus tenderness, rhinorrhea or congestion. Denies
cough, shortness of breath, or wheezing. Denies chest pain,
chest pressure, palpitations, or weakness. Denies diarrhea,
constipation, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
Type I DM, diagnosed age ___, only prior episode DKA at ___
secondary to EtOH use
Social History:
___
Family History:
Family History:
Cousin and grandfather with T1DM, father had gallbladder removed
Physical Exam:
Vitals: T:98.9 BP: 128/109 P: 115 R: 33 O2:97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils
round/reactive
Neck: supple, no LAD
CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: No accessory muscle use, good air movement, bibasilar
crackles, no wheezes, rales, ronchi
Abdomen: Soft, some epigastric tenderness to deep palpation,
non-distended, hypoactive bowel sounds, no organomegaly.
Ext: warm, well perfused, 2+ pulses bilaterally, no clubbing,
cyanosis or edema
Neuro: ___ strength upper/lower extremities, grossly normal
sensation
Pertinent Results:
___ 05:27PM BLOOD WBC-6.4 RBC-4.64 Hgb-15.3 Hct-46.7
MCV-101* MCH-33.0* MCHC-32.9 RDW-13.0 Plt ___
___ 05:27PM BLOOD Neuts-51.8 Lymphs-43.3* Monos-3.1 Eos-0.7
Baso-1.0
___ 08:22PM BLOOD ___ PTT-27.3 ___
___ 05:27PM BLOOD Glucose-520* UreaN-12 Creat-0.9 Na-135
K-4.6 Cl-91* HCO3-12* AnGap-37*
___ 05:27PM BLOOD ALT-103* AST-99* AlkPhos-200* TotBili-0.2
___ 05:27PM BLOOD Lipase-28
___ 05:27PM BLOOD Albumin-4.4
___ 10:43PM BLOOD ___ Temp-36.9 pO2-34* pCO2-33*
pH-7.17* calTCO2-13* Base XS--16
___ 07:49PM BLOOD Lactate-2.3* K-3.6
___ 05:50PM URINE Color-Straw Appear-Clear Sp ___
___ 05:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 05:50PM URINE RBC-<1 WBC-8* Bacteri-FEW Yeast-NONE
Epi-2
___ 05:50PM URINE UCG-NEGATIVE
Brief Hospital Course:
___ yo F type I DM presenting with DKA.
MICU Course:
# DKA: Secondary to noncompliance. Not pregnant with neg HCG,
CXR clear for PNA, EKG unconcerning for MI, denies drug use. K
not sig elevated, anion gap closed with insulin bolus and gtt.
Sugars dropped swiftly prior to transfer to MICU, 444->141, gtt
was paused, sugars returned to 300's after gtt was restarted,
remained on ICU insulin protocol thereafter, pH 7.17.
Transitioned to SQ insulin with overlap 2hrs on gtt. Maintained
on ___ with 40mEq K at 125/hr. ___ consulted and
recommended Lantus 27, HISS 5 units breakfast, 4 before lunch, 7
before dinner, correct 1:40 above 120, self reported carb
consumption 40g with breakfast, 30 with lunch, 60 with dinner.
Following transition to diabetic PO diet the patient's anion gap
was noted to remain closed and the patient was without
complaints.
# ?UTI: Patient with 7WBC on initial UA, received dose of
Ceftriaxone. Patient was asymptomatic and urine culture was
negative. No plan for further antibiotics.
Transition Issues:
# Transaminitis: Could be secondary to EtOH or critical illness
in setting of DKA alcohol. Elevated GGT, Fe studies normal, Hep
B Ab positive, Hep B SAg neg, HepC Ab neg, acetaminophen neg.
Transaminases trended down during stay. Would recommend
re-evaluation of liver function tests in ___ months.
# Macrocytosis: Etiology unclear, not anemic. Considering
possible liver disease in context of transaminitis and DM. Would
recommend re-evaluation in ___ months.
Transitional Issues:
Follow up with PCP
___ on ___:
Lantus 27 units at 6PM
NovaLog SS
Discharge Medications:
Lantus 27 units at 6PM
NovaLog SS
Discharge Disposition:
Home
Discharge Diagnosis:
Diabetic Ketoacidosis.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please continue to take your insulin as perscribed with pre-meal
insulin doses of 5units before breakfast, 4 before lunch and 7
before dinner. Please continue to carefully monitor your blood
glucose level. Call your doctor or return to the hospital if
you have any of the warning signs listed below or any
new/concerning complaints.
Followup Instructions:
___
|
19904101-DS-10 | 19,904,101 | 23,626,019 | DS | 10 | 2131-05-03 00:00:00 | 2131-05-03 16:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Erythromycin Base
Attending: ___
Chief Complaint:
L foot pain, chills, nausea
Major Surgical or Invasive Procedure:
L foot Incision and drainage surgery x 2 (___)
L foot debridement and closure (___)
History of Present Illness:
___ female with a history of uncontrolled diabetes and
hypertension presenting with necrotic left second toe.
Patient struck her second toe on her left foot approximately 4
days ago. Since that time, she has noted progressive pain and
erythema ___ association with that toe. Around this time, she
also
lost her appetite.
She denies any nausea or vomiting or abdominal pain, purely loss
of appetite. To the emergency department, she stated she had
fevers and chills, but she denied this when I asked her. She
also
denied chest pain, cough, SOB, diarrhea, unintentional
weight-loss.
Patient was seen initially ___ the ED and noted to have necrotic
L
___ digit that probed to bone as well as a L plantar foot wound
that probed to bone. Decision was made to take her to the OR for
the debridement.
___ the ED,
Initial Vitals: T 98.9 HR 118 BP 157/87 RR 18 99% RA
Exam:
-Concern for wet gangrene ___ association with patient's left
second toe and erythema spreading proximally
-No pain out of proportion to the exam suggestive of necrotizing
fasciitis.
-Palpable DP and ___ pulses
Labs:
Imaging: L foot
FINDINGS: AP, lateral, oblique views of the left foot provided.
There is soft tissue gas ___ the webspace between the first and
second toe, concerning for soft tissue infection. No definite
bone destruction to suggest osteomyelitis. There is significant
soft tissue swelling to the level of the midfoot though there is
no linear tracking of soft tissue gas extending proximally. The
bones are diffusely demineralized. No definite fracture is
seen.
No significant DJD. Tiny heel spurs are noted.
IMPRESSION: Soft tissue swelling of the midfoot and forefoot
with
soft tissue gas localized ___ the webspace between the great toe
and second toe concerning for necrotizing soft tissue infection.
No signs of osteomyelitis.
Consults: Podiatry - needs OR.
Interventions:
___ 22:11IVCiprofloxacin 400 mg ordered
___ 00:21IVAcetaminophen IV 1000 mg
___ 00:49IVHYDROmorphone (Dilaudid) .2 mg
___ 00:58IVClindamycin 900 mg
___ 01:00IVFNS @ Started 125 mL/hr
___ 01:21IVInsulin Regular 14 units
___ 01:37IVVancomycin 1000 mg
VS Prior to Transfer: T 100.4 HR 109 BP 172/89 RR 19 99% RA
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
- Diabetes
- Hypertension
Social History:
___
Family History:
Pt unsure
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GEN: WDWN, NAD, eyes closed but conversing well
HEENT: sclera anicteric, MMM
CV: rrr, no mrg
RESP: CTABL, nl WOB on RA
GI: soft, NTND, +BS, no rebound or guarding
EXT: L foot wrapped ___ thick white gauze, clean, ___ and ___
toes visible with some dried blood and possible infxn on ___
toe,
R foot warm w/o edema
NEURO: AOx3, keeps R eye closed more than L eye but son and pt
state this is personal preference/chronic and she is able to
open
both eyes fully when asked, otherwise face symmetric, moving all
limbs antigravity and w purpose when asked (unable to move L
toes
given recent operation). superficial numbness ___ L foot,
sensation intact to light touch ___ R foot.
Discharge Exam:
============================
GEN: NAD, conversant, alert and oriented
HEENT: sclera anicteric, MMM
CV: RRR, no M/R/G
RESP: CTABL, nl WOB on RA
GI: soft, NTND, +BS, no rebound or guarding
EXT: L foot wrapped ___ thick white gauze, s/p amputation of ___
digit. R foot warm w/o edema.
R hip tender to palpation, full ROM, no ecchymosis or edema
NEURO: AOx3, Superficial numbness ___ L foot,
sensation intact to light touch ___ R foot.
Pertinent Results:
===============
Admission labs
===============
___ 09:30PM BLOOD WBC-23.9* RBC-4.53 Hgb-13.3 Hct-40.9
MCV-90 MCH-29.4 MCHC-32.5 RDW-12.3 RDWSD-40.5 Plt ___
___ 09:30PM BLOOD Neuts-81.2* Lymphs-4.5* Monos-10.7
Eos-0.0* Baso-0.5 Im ___ AbsNeut-19.39* AbsLymp-1.08*
AbsMono-2.56* AbsEos-0.00* AbsBaso-0.12*
___ 09:30PM BLOOD ___ PTT-31.8 ___
___ 09:30PM BLOOD Glucose-303* UreaN-17 Creat-0.8 Na-131*
K-4.5 Cl-98 HCO3-7* AnGap-26*
___ 03:19AM BLOOD Calcium-8.3* Phos-2.2* Mg-2.0
___ 09:30PM BLOOD Beta-OH-7.3*
___ 09:30PM BLOOD CRP-152.4*
===============
Pertinent labs
===============
___ 03:30AM BLOOD TSH-1.9
___ 03:30AM BLOOD Free T4-1.3
___ 03:30AM BLOOD Triglyc-146 HDL-26* CHOL/HD-4.0
LDLcalc-50
===============
Discharge labs
===============
___ 05:21AM BLOOD WBC-13.2* RBC-3.73* Hgb-11.0* Hct-34.0
MCV-91 MCH-29.5 MCHC-32.4 RDW-12.5 RDWSD-40.9 Plt ___
___ 05:21AM BLOOD Glucose-216* UreaN-11 Creat-0.4 Na-136
K-4.6 Cl-101 HCO3-24 AnGap-11
___ 05:21AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.2
===============
Studies
===============
L foot x-ray ___: IMPRESSION: Soft tissue swelling of the
midfoot and forefoot with soft tissue gas localized ___ the
webspace between the great toe and second toe concerning for
necrotizing soft tissue infection. No signs of osteomyelitis.
L foot x-ray ___ IMPRESSION: Expected postoperative changes
as described above. Possible tiny erosion at the base of the
left first proximal phalanx concerning for osteomyelitis.
L foot x-ray ___ IMPRESSION: There has been resection of the
distal aspect of the second metatarsal shaft. The bony margins
appear sharp. There is soft tissue swelling and gas consistent
the recent surgery.
Hip x-ray ___ FINDINGS: There is no evidence of fracture,
dislocation or lysis. Hip joint spaces appear preserved ___
with.
IMPRESSION: No fracture identified.
Chest x-ray for PICC ___
IMPRESSION: No previous images. There has been placement of
right subclavian PICC line that is somewhat difficult to follow
over the vertebral bodies. However, the tip appears to be ___
the mid to lower SVC.
Cardiac silhouette is within normal limits and there is no
vascular congestion, pleural effusion, or acute focal pneumonia.
===============
Microbiology
===============
__________________________________________________________
___ 5:54 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 3:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:12 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
Time Taken Not Noted ___ Date/Time: ___ 4:28 pm
SWAB LEFT FOOT.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Final ___:
PREVOTELLA SPECIES. SPARSE GROWTH. BETA LACTAMASE
POSITIVE.
__________________________________________________________
___ 12:00 am SWAB ABSCESS LEFT FOOT.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND ___ SHORT
CHAINS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened
for the
presence of B.fragilis, C.perfringens, and C.septicum.
None of
these species was found.
FUNGAL CULTURE (Preliminary):
NO FUNGUS ISOLATED.
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
__________________________________________________________
___ 9:30 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ANAEROBIC GRAM POSITIVE ROD(S).
SENT TO ___ FOR IDENTIFICATION AND SUSCEPTIBILTIES ON
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE ROD(S).
Reported to and read back by ___ (___) @10:55
(___).
Brief Hospital Course:
Discharge Worksheet:
Discharge To: Home with Services
Discharge Instructions: Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I ___ THE HOSPITAL?
==========================
- You came to the hospital with an infection of the left foot.
WHAT HAPPENED ___ THE HOSPITAL?
==============================
- You were first seen ___ the ED for L foot infection. You had
emergent L foot surgery due to the severity of your infection.
- We admitted you for further surgical intervention, diabetes
management, and IV antibiotics
- We started you on insulin ___ order to maintain better diabetes
control. The diabetes educator showed you how to use home
insulin.
- Physical therapy saw you and helped you with daily activities
since you will be non weight bearing on your Left foot.
- We placed a long term IV ___ you for antibiotics at home which
is tentatively started
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Follow your ___ line instructions
- Follow your physical therapy instructions
- Take your daily insulin
- Continue your antibiotics daily as instructed below.
- please follow up with all the appointments scheduled with
your doctor
Thank you for allowing us to be involved ___ your care, we wish
you all the best!
Your ___ Healthcare Team
Did the patient have a TIA or stroke (ischemic or hemorrhagic)
diagnosed during this admission?: No
Will this patient be discharged on an opioid pain medication?:
No
Final Diagnosis: Primary Diagnosis
=============================
Osteromyelitis
Diabetes
SECONDARY DIAGNOSIS:
====================
Hypertension
Recommended Follow-up: Primary Care Follow up
Name: ___.
When: ___ at 2:15pm
Location: ___.
Address: ___
Phone: ___
Podia___ Follow up
Department: ___ CLINIC
When: ___ at 2:20 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
Endocrinology Follow up
Name: ___, NP
When: ___ at 3:30pm
Location: ___
Address: ___, ___
Phone: ___
Pending Results at Discharge: Send Outs
___ 21:30 ANTIMICROBIAL SUSCEPTIBILITY, ANAEROBIC BACTERIA,
MIC (other body fluid)
___ 21:30 ORGANISM REFERRED FOR IDENTIFICATION, ANAEROBIC
BACTERIA (other body fluid)
Microbiology
___ 02:29 SWAB FUNGAL CULTURE
___ 21:35 BLOOD CULTURE Blood Culture, Routine
Diagnostic Reports
___ Tissue: BONE FRAGMENT(S), OTHER THAN PATHOLOGIC
FRACTURE
Pending Results Contact: ___ ___
Key Information for Outpatient Providers: ___
=========================
[ ] IV ___ 1g daily for 6 weeks - anticipated completion
on ___
[ ] Weekly: cbc w/diff, BUN, Cr, AST, ALT, Tbili, alk phos, CRP
- OPAT labs should be faxed to ___ clinic
[ ] continue monitor PICC line ___ left arm
[ ] Ensure podiatry follow up - NWB left foot until podiatry
clears
[ ] ensure ___ follow up.
[ ] F/U L foot bone specimen sent for pathology
[ ] patient was mildly hypertensive ___ the hospital to 140s.
Would follow up blood pressure.
Brief Hospital Course
==========================
___ presented with left foot osteomyelitis and necrotizing
fasciitis infection, and DKA. L foot urgent I&D and rapid fluid
repletion. Patient had a high white count and high blood sugars.
She has been on vanc and ___ throughout her stay. Her white
count has come down significantly, but still remains high.
Patient was started on insulin for the first time. She got
education on insulin usage and nutrition. Her daily sugar levels
have come down and being managed by ___. Physical therapy
worked with patient for non weight bearing on left foot until
surgical site heals. PICC line was placed for 6 weeks IV
antibiotics of ___.
Active Issues
============================
# Acute osteomyelitis
# Bacteremia Anaerobic Gram positive rods
Presented with severe diabetic foot ulcer with gas gangrene. s/p
debridement with podiatry x2 with L ___ ray amputation with
closure on ___. Biopsy positive for osteomyelitis and grew
MIXED BACTERIAL FLORA, STAPH AUREUS COAG +, BETA STREPTOCOCCUS
GROUP B. Pathology of proximal bone margins were taken and are
pending. She was initially started on meropenem and vancomycin
was added. Patient had positive blood cx for Anaerobic Gram +
rods that were not speciated. Further blood cultures were
negative for bacteremia. ID recommended narrowing to IV
___ 1g q24 hours and will continue to follow as an
outpatient. Discharged ___ L foot.
# Diabetes
Patient was not diagnosed with diabetes before this hospital
visit. She had never taken any previous medicine for it before.
Upon arrival blood sugars were ___ the 300s and a1C 13%. ___
saw patient and started her on basal insulin with meal time
correction. Patient got extensive education on at home nutrition
and insulin regiment. Her discharge regimen will be Lantus 30U
qAM and Humalog 10U at breakfast, lunch, and dinner with sliding
scale.. Anti GAD, C-peptide, insulin antibodies, and islet cell
antibodies were negative for autoimmune diabetes. She will
follow up with ___ as an outpatient.
# Hypertension
Patient carries diagnosis of HTN but had not been on any
medications at home. Currently normotensive.
FULL CODE
son ___, ___
Major Surgical or Invasive procedures: L foot Incision and
drainage surgery x 2 (___)
L foot debridement and closure (___)
Diet: Nutrition consult: Diet education (please specify diet
type) for diet: Diabetic
Danger Signs: Glucose greater than 300 for 24 hours
Glucose less than 70 more than twice
Increased urination
Increased thirst
Blurry vision
Fever greater than 101
Redness that is spreading
Pain not adequately relieved with medication
Drainage from wound
Opening of incision
Nausea and vomiting
Increased redness, swelling or pain
Rash
Bleeding or drainage from wound
Opening of incision
Discharge Condition: Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Medications/Orders:
NEW Medications/Orders Physician ___
___ 1 g IV ONCE Duration: 1 Dose Please continue
until ___ unless instructed by your doctors ___ is a new
medication to treat your infection
Glargine 30 Units Breakfast Humalog 10 Units Breakfast Humalog
10 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale
using HUM Insulin This is a new medication to treat your
diabetes
Page 1: Page 1 includes Final Diagnosis, Major Surgical
Invasive Procedures, Recommended Follow-up, Key Information for
Outpatient Providers, and ___ Diet displayed under
Discharge Worksheet
Patient Aware of Diagnosis: Yes
Family Aware of DIagnosis: Yes
Treatments and Frequency: Wound care:
Site: left foot
Type: Surgical
Dressing: Gauze - dry
Comment: Leave dressing intact, do not get dressing wet,
podiatry will change at next follow up appointment ___ 10 days
Transitional Issues
=========================
[ ] IV ___ 1g daily for 6 weeks - anticipated completion
on ___
[ ] Weekly: cbc w/diff, BUN, Cr, AST, ALT, Tbili, alk phos, CRP
- OPAT labs should be faxed to ___ clinic
[ ] continue monitor PICC line ___ left arm
[ ] Ensure podiatry follow up - NWB left foot until podiatry
clears
[ ] ensure ___ follow up.
[ ] F/U L foot bone specimen sent for pathology
[ ] patient was mildly hypertensive ___ the hospital to 140s.
Would follow up blood pressure.
Home Health Services: Evaluation for home services
Home Intravenous Therapy
Physical Therapy
Weight-Bearing/Activity/Other Info: Activity: Activity:
Activity as tolerated
Left lower extremity: Non weight bearing
Crutches
Surgical Shoe
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. ___ Sodium 1 g IV ONCE Duration: 1 Dose
Please continue until ___ unless instructed by your
doctors
2. Glargine 30 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
=============================
Osteromyelitis
Diabetes
SECONDARY DIAGNOSIS:
====================
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___
___!
WHY WAS I ___ THE HOSPITAL?
==========================
- You came to the hospital with an infection of the left foot.
WHAT HAPPENED ___ THE HOSPITAL?
==============================
- You were first seen ___ the ED for L foot infection. You had
emergent L foot surgery due to the severity of your infection.
- We admitted you for further surgical intervention, diabetes
management, and IV antibiotics
- We started you on insulin ___ order to maintain better
diabetes control. The diabetes educator showed you how to use
home insulin.
- Physical therapy saw you and helped you with daily activities
since you will be non weight bearing on your Left foot.
- We placed a long term IV ___ you for antibiotics at home which
is tentatively started
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Follow your PICC line instructions
- Follow your physical therapy instructions
- Take your daily insulin
- Continue your antibiotics daily as instructed below.
- please follow up with all the appointments scheduled with
your doctor
Thank you for allowing us to be involved ___ your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19904365-DS-9 | 19,904,365 | 26,365,597 | DS | 9 | 2145-05-18 00:00:00 | 2145-05-18 16:49:00 |
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:
NA
attach
Pertinent Results:
ADMISSION LABS
===============
___ 02:15PM BLOOD WBC-121.3* RBC-2.25* Hgb-6.8* Hct-24.2*
MCV-108* MCH-30.2 MCHC-28.1* RDW-17.9* RDWSD-69.1* Plt ___
___ 02:15PM BLOOD Neuts-63 Bands-8* Lymphs-6* Monos-6 Eos-5
Baso-3* ___ Metas-2* Myelos-4* Blasts-3* NRBC-2.1*
AbsNeut-86.12* AbsLymp-7.28* AbsMono-7.28* AbsEos-6.07*
AbsBaso-3.64*
___ 02:15PM BLOOD UreaN-58* Creat-1.8* Na-136 K-6.4* Cl-100
HCO3-12* AnGap-24*
___ 02:15PM BLOOD ALT-31 AST-31 LD(LDH)-1222* AlkPhos-269*
TotBili-0.4
___ 02:15PM BLOOD Calcium-8.2* Phos-5.0* UricAcd-5.7
___ 03:15AM BLOOD Albumin-4.2 UricAcd-7.0*
___ 02:15PM BLOOD Hapto-<10*
___ 02:15PM BLOOD TSH-5.4*
___ 02:15PM BLOOD Free T4-0.8*
___ 03:25AM BLOOD Lactate-1.2 K-5.8*
POTASSIUM TREND:
================
___ 03:15AM BLOOD Glucose-165* UreaN-56* Creat-1.5* Na-140
K-6.1* Cl-112* HCO3-17* AnGap-11
___ 08:35AM BLOOD Glucose-96 UreaN-49* Creat-1.6* Na-143
K-5.8* Cl-112* HCO3-16* AnGap-15
___ 05:00PM BLOOD Glucose-193* UreaN-42* Creat-1.6* Na-145
K-5.6* Cl-117* HCO3-16* AnGap-12
___ 06:35AM BLOOD Glucose-160* UreaN-50* Creat-2.0* Na-144
K-5.9* Cl-109* HCO3-19* AnGap-16
___ 07:40AM BLOOD Glucose-224* UreaN-43* Creat-1.7* Na-142
K-5.4 Cl-112* HCO3-17* AnGap-13
___ 03:05PM BLOOD Glucose-280* UreaN-40* Creat-1.6* Na-142
K-5.1 Cl-115* HCO3-17* AnGap-13
___ 05:58AM BLOOD Glucose-297* UreaN-41* Creat-1.7* Na-142
K-5.6* Cl-112* HCO3-16* AnGap-14
___ 02:55PM BLOOD Glucose-294* UreaN-38* Creat-1.7* Na-140
K-5.6* Cl-111* HCO3-17* AnGap-12
___ 05:38AM BLOOD Glucose-221* UreaN-37* Creat-1.7* Na-141
K-5.7* Cl-110* HCO3-15* AnGap-16
___ 05:08AM BLOOD K-4.9
___ 11:17AM BLOOD K-5.0
___ 03:11PM BLOOD K-5.2
___ 02:55PM BLOOD K-5.4
___ 09:40PM BLOOD K-5.4
DISCHARGE LABS
=============
___ 05:38AM BLOOD WBC-102.0* RBC-2.48* Hgb-7.6* Hct-25.1*
MCV-101* MCH-30.6 MCHC-30.3* RDW-17.1* RDWSD-62.1* Plt ___
___ 05:50AM BLOOD Glucose-113* UreaN-40* Creat-1.8* Na-142
K-5.2 Cl-112* HCO3-15* AnGap-15
___ 05:50AM BLOOD Calcium-8.8 Phos-5.6* Mg-1.8
___ 05:50AM BLOOD Osmolal-303
___ 05:57AM BLOOD K-5.0
IMAGING
========
___ CXR
No pneumonia.
Brief Hospital Course:
TRANSITIONAL ISSUES
====================
#Hyperkalemia
[ ]Patient was started on bicarbonate 1300mg BID to treat her
hyperkalemia. Please recheck chemistry panel at next visit.
[] Follow up with Nephrology outpatient
#Loose stool
[ ]Patient has complained about some small volume loose stools,
which occurred before her admission. This may be a side effect
of her ruxolitinib. At her next appointment with her
hematologist/oncologist, she can discuss if dose adjustment is
needed.
#HTN:
[] Held patient's losartan and HCTZ were held inpatient given
___. Consider restarting lower dose ___ or ACE-I if
cardiovascular protection still desired iso CVA history.
[] Started Labetalol 200mg BID inpatient for BP control.
#CODE: full presumed
#CONTACT: ___ ___ (grandson) *can translate*
___ ___ (___)
PATIENT SUMMARY
===============
Ms. ___ is a ___ y/o woman with type 1 DM, h/o CVA, gastric
GIST s/p resection (Low risk) and JAK2 V617F positive
polycythemia ___, previously treated with phlebotomy and
hydroxyurea, recently started on ruxolitinib with newly
diagnosed post-PV myelofibrosis (WHO MF3), who presents with ___
and hyperkalemia, as well as acute on chronic anemia.
ACUTE ISSUES
============
___
#AG metabolic acidosis
#Hyperkalemia
#Hypocalcemia
Suspect worsening renal function is secondary to poor PO intake
as well as high cell turnover from primary PCV. No evidence
obstructive etiology, no nephrotoxic medications. Temporized
hyperkalemia with IVF, insulin/ dextrose, calcium gluconate. EKG
without peaked T-waves.
# Polycythemia ___ with early post PV myelofibrosis WHO MF3:
# Anemia
# Leukocytosis
# Chronic hemolysis
See above for full onc history. Bone marrow biopsy on ___
showed early evolution to myelofibrosis, now likely having
intramedullary hemolysis. Hemolysis labs stable. Transfused 1u
on ___, subsequently stable. Follow up with Dr. ___ in
clinic.
CHRONIC ISSUES
==============
#HTN:
BP elevated to 160s systolic on arrival, however given ___ will
hold home losartan, HCTZ for now.
# Gout
Reduced allopurinol to 50mg while renal function was elevated.
Increased to home dose 100mg once back to baseline renal
function.
#Hx CVA:
Continued on aspirin 81mg (reduced from home dose 325mg)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Jakafi (ruxolitinib) 5 mg oral BID
2. GlipiZIDE XL 10 mg PO DAILY
3. Clotrimazole 1% Vaginal Cream 1 Appl VG QHS
4. omeprazole 20 mg oral DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
7. Allopurinol ___ mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
2. Labetalol 200 mg PO BID
RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Sodium Bicarbonate 1300 mg PO BID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
7. Clotrimazole 1% Vaginal Cream 1 Appl VG QHS
8. GlipiZIDE XL 10 mg PO DAILY
9. Jakafi (ruxolitinib) 5 mg oral BID
10. omeprazole 20 mg oral DAILY
11. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you've seen
your doctor.
12. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until you see your
oncologist.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute on chronic kidney injury
Hyperkalemia
SECONDARY DIAGNOSES
====================
Polycythemia ___
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 because your kidneys were not working well.
This led to a high level of potassium in your blood.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were treated with medicines to lower your potassium.
- Your blood level of potassium was monitored closely.
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:
___
|
19904800-DS-19 | 19,904,800 | 27,949,623 | DS | 19 | 2207-05-15 00:00:00 | 2207-05-15 21:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee stings
Attending: ___
___ Complaint:
syncope, night sweats, fevers, tender lymphadenopathy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male to female transgender recently diagnosed with DLBCL
admitted from the ED with syncope.
Patient was recently diagnosed with DLBCL after having severfal
months of night sweats, chills, and lymphadenopathy. Developed
recurrent syncopal episodes and CP in ___ before she was
able to start any chemotherapy. She was recently admitted
___ for syncope and further diagnostic w/u of her
lymphoma. Syncope workup was unrevealing. She was discharged on
___ following repeat biopsy that showed DLBCL.
Since returning home, she has continued to have several
syncopal episodes per week with occaisional fevers. Day of
admission she reports syncopal episode that began while lying on
her couch; she developed a sweaty/dizzy feeling and passed out.
Partner reports she was unconscious for a few seconds. She
missed her oncology appt and presented to the ED.
In the ED, initial VS were pain 7, T 97.4, HR 92, BP 129/80, RR
18, O2 100%RA. Initial labs were notable for WBC 7.4, HCT 37.5,
PLT 387, Nl chem 7, LDH 201, uric acid 6.3, trop negative x1.
CXR showed no acute process and patient was given 1LNS prior to
transfer to ___ for further managment. VS prior to transfer were
T 98.2, HR 87, BP 114/66, RR 16, O2 98%RA.
On arrival to the floor, patient reports ___ chest and right
arm pain that is mildly pleuritic. She notes fevers at home up
to 102. No cough, no SOB, no wheeze. No N/V/abdominal pain. No
dysuria, no new joint pains or rashes. Remainder of ROS is
unremarkable.
Past Medical History:
-Tonsils out ___
-M to F on estradiol
-Breast implants ___ at ___
-Positive PPD (___) w/ negative CXR, positive Quant Gold ___
(___), on isoniazid/pyridoxine
Social History:
___
Family History:
Mother: COPD, thyroid cancer
Father: Recent health unknown to Mrs. ___
___ Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.0, BP 120/70, HR 88, RR 20, O2 100%RA
General: Comfortable in bed, NAD
HEENT: AT/NC, PERRL, MMM
Neck: Bilateral cervical and submandibular lymphadenopathy;
rubbery, non-tender, L>R. L clavicular lymphadenopathy.
CV: Normal S1, loud S2. No m/r/g.
Lungs: Lungs clear to auscultation bilaterally. 3cm lymph node
in R axilla, 1 cm lymph node in L axilla.
Abdomen: Soft, non-distended, non-tender to palpation. No
rebound or guarding. No hepatomegaly, no splenomegaly.
Ext: No edema
Neuro: Alert and oriented x3.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.5 Tc 98.1, BP 114/60, HR 70, RR 18, O2 97%RA Wt
NR<-185.8
General: Comfortable in bed, NAD
HEENT: AT/NC, PERRL, MMM
Neck: decreased bilateral cervical and submandibular
lymphadenopathy;
rubbery, tender, L>R. L clavicular lymphadenopathy.
CV: Normal S1, loud S2. No m/r/g.
Lungs: Lungs clear to auscultation bilaterally. 3cm lymph node
in R axilla, 1 cm lymph node in L axilla.
Abdomen: Soft, non-distended, non-tender to palpation. No
rebound or guarding. No hepatomegaly, no splenomegaly.
GU: small L inguinal lymphadneopathy
Ext: No edema
Neuro: Alert and oriented x3.
Pertinent Results:
ADMISSION LABS:
=================================
___ 01:46PM BLOOD WBC-7.4 RBC-4.24* Hgb-12.6* Hct-37.5*
MCV-88 MCH-29.7 MCHC-33.6 RDW-13.9 RDWSD-43.8 Plt ___
___ 01:46PM BLOOD Neuts-68.2 Lymphs-12.7* Monos-13.5*
Eos-3.9 Baso-0.9 Im ___ AbsNeut-5.06 AbsLymp-0.94*
AbsMono-1.00* AbsEos-0.29 AbsBaso-0.07
OTHER PERTINENT LABS/RESULTS
=================================
___ 07:35AM BLOOD ___ PTT-35.7 ___
___ 07:35AM BLOOD Lipase-28
___ 01:46PM BLOOD cTropnT-<0.01
___ 07:35AM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:00PM BLOOD Albumin-3.9 Calcium-9.6 Phos-3.4 Mg-2.1
UricAcd-4.3
___ 06:25AM BLOOD HCV Ab-NEGATIVE
___ 01:46PM BLOOD Lactate-1.8
ECG ___
Sinus rhythm. Findings are within normal limits. Compared to the
previous
tracing of ___ there is no significant diagnostic change.
Rate PR QRS QT QTc (___) P QRS T
84 146 84 386 428 59 71 51
DISCHARGE LABS:
=================================
___ 11:20AM BLOOD WBC-7.5 RBC-3.94* Hgb-11.4* Hct-34.7*
MCV-88 MCH-28.9 MCHC-32.9 RDW-14.1 RDWSD-45.1 Plt ___
___ 11:20AM BLOOD Neuts-87.9* Lymphs-8.3* Monos-2.7*
Eos-0.4* Baso-0.3 Im ___ AbsNeut-6.57* AbsLymp-0.62*
AbsMono-0.20 AbsEos-0.03* AbsBaso-0.02
___ 11:20AM BLOOD Glucose-95 UreaN-15 Creat-0.7 Na-141
K-4.1 Cl-109* HCO3-24 AnGap-12
___ 05:50AM BLOOD ALT-10 AST-15 LD(LDH)-159 AlkPhos-48
TotBili-0.1
___ 11:20AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.0 UricAcd-4.2
IMAGING:
=================================
___ CT ABD AND PELVIS WITH CONTRAST
TECHNIQUE: Single phase split bolus contrast: MDCT axial images
were acquired through the abdomen and pelvis following
intravenous contrast administration with split bolus technique.
IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on
PACS.
Oral contrast was administered.
DOSE: Total DLP (Body) = 401 mGy-cm.
COMPARISON: CTA chest of ___ and CT interventional
procedure of ___.
FINDINGS:
LOWER CHEST: There is mild dependent bibasilar atelectasis
without pleural
effusion. Bilateral breast implants are partially visualized.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. Sub cm hypodensity in the left lower renal
pole is too small to characterize, but statistically likely a
cyst. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal
limits.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal, mesenteric, or pelvic
lymphadenopathy by CT size criteria. There is a 2.0 x 1.4 cm
right inguinal lymph node (5:98).
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease is noted.
BONES: A 2.2 x 1.4 cm hemagnioma is identified in the L1
vertebral body. No significant degenerative changes are
present.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. 2.0 x 1.4 cm enlarged right inguinal lymph node.
2. 2.2 x 1.4 cm hemangioma in the L1 vertebral body.
3. No evidence of mesenteric, retroperitoneal or pelvic
sidewall lymphadenopathy by CT size criteria.
___ - CXR
PA and lateral views the chest provided. Increased opacity
projecting over the lower lungs on the frontal view likely
reflects known breast implants. There is prominence of the
mediastinum most notably along the right peritracheal stripe
which is compatible with no lymphadenopathy. Lungs are clear.
No large effusion or pneumothorax. Heart size is normal. Bony
structures are intact.
MICROBIOLOGY:
=================================
___ - blood culture, pending at discharge, NGTD
PATHOLOGY:
=================================
___ - R axillary LN
Touch prep of core: Consistent with involvement by non-Hodgkin
lymphoma.
Immunophenotyping: Immunophenotypic findings are highly
suspicious for involvement by a B cell lymphoproliferative
disorder. Correlation with morphology (see separate pathology
report ___ is necessary for confirmation and further
subclassification.
Additional pathology pending.
Cytogenetics: Approximately 90% of the metaphase lymph node
cells available
for examination had an abnormal karyotype with a translocation
involving chromosomes 14 and 18 that ___ has confirmed has
resulted in the IGH/BCL2 gene rearrangement (see below). Two
related neoplastic clones were detected. One clone had the
t(14;18)(q32;q21) translocation as a
single abnormality and the other clone had the translocation and
several other chromosome aberrations. FISH has excluded
rearrangement of the MYC and BCL6 genes. Taken together, these
findings are consistent with transformation of low grade
follicular lymphoma to a higher grade
follicular lymphoma or diffuse large B-cell lymphoma of germinal
center origin. There was no evidence of a "double hit" lymphoma.
FISH: 12.5% of the interphase lymph node cells examined had a
probe signal pattern consistent with the IGH/BCL2 gene
rearrangement associated with follicular lymphoma and diffuse
large B-cell lymphoma of germinal center origin. There was no
evidence of rearrangement of the BCL6 and MYC genes.
FISH: No evidence of interphase lymph node cells with
rearrangement of the IRF4 gene.
Brief Hospital Course:
___ y/o male to female transgender with recent diagnosis of
follicular lymphoma who presented with syncope.
# Syncope/Chest pain: Low concern for intrinsic cardiac
etiology. Suspect likely due to mediastinal LAD due to lymphoma,
especially given proximity to great arteries. EKG unremarkable.
Negative cardiac enzymes x2. No syncope while inpatient. ECHO
last admission ___ showed no structural cause of syncope
identified. Preserved biventricular regional and global systolic
function. Small pericardial effusion.
# Lymphoma. Patient with 2.5 months of progressive
lymphadenopathy (submandibular, axillary, inguinal), fevers,
night sweats, and weight loss. Right axillary LN biopsy was done
on ___ under general anesthesia (per patient request). Prelim
reports appear c/w DLBCL. Received R-CHOP inpatient
(___) this hospitalization with no complications. Pt to
complete 2 additional days of prednisone after discharge which
she was given prior to discharge.
- cytogenetics t(14;18)(q32;q21) c/w low grade follicular
lymphoma transforming to higher-grade follicular; DLCBL of
germinal center origin
- F/u ___ bx results and imaging - Concern for germinal center
B-cell lymphoma, possibly FL in process of transforming to
DLBCL.
# Latent TB. Patient with history of positive PPDs in the past
but negative chest X ray and with positive quantiferon Gold at
___ on recent admission. She was seen by ID and started on
isoniazid and pyridoxine (___). She was continued
on this therapy. ID did not recommend any additional diagnostics
or therapies after starting chemotherapy.
# Tobacco use: Pt declined nicotine patch and left hospital
floor frequently to smoke.
# DVT prophylaxis - pt counseled on elevated risk of
DVT/PE/clotting with combination of estrogen therapy, active
malignancy, cigarette use. Pt continues to decline both
subcutaneous heparin and enoxaparin injections and states
understanding of these risks. Used TEDS.
# Broken ___ L toe. Suffered during syncope episode prior to
last admission. A foot X ray showing a transverse fracture of
the fifth phalanx with minimal displacement. Podiatry attempted
reduction last admission but repeat x-ray showed persistent
(although still minimal) displacement. Per podiatry, no acute
intervention needed and was to follow up in two weeks as
outpatient.
# Male to female transition. - Continued on her home estradiol
and spironolactone.
TRANSITIONAL ISSUES:
-Patient preferred name ___
-Patient needs neulasta injection on ___, arranged apt in
___
-Patient needs hematology/oncology follow-up in the next ___
days.
-Patient discharged with 15 day supply of oxycodone. Defer
additional pain management to PCP.
-Patient to complete 2 additional days of 100mg prednisone as
outpatient
-Code status: Full
-Emergency contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Estradiol 4 mg PO DAILY
2. Spironolactone 300 mg PO DAILY
3. Isoniazid ___ mg PO DAILY
4. Acetaminophen 650 mg PO Q8H
5. Pyridoxine 50 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Estradiol 4 mg PO DAILY
3. Isoniazid ___ mg PO DAILY
4. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 2 tablet(s) by mouth every 6 hours Disp #*120
Tablet Refills:*0
5. Pyridoxine 50 mg PO DAILY
6. Spironolactone 300 mg PO DAILY
7. PredniSONE 100 mg PO Q24H Duration: 2 Days
RX *prednisone 50 mg 2 tablet(s) by mouth in the morning Disp
#*4 Tablet Refills:*0
8. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every 12 hours Disp
#*28 Tablet Refills:*6
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: diffuse large B cell lymphoma of germinal cell origin
SECONDARY: latent tuberculosis, 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 pleasure caring for you at the ___
___. You were recently admitted after losing
consciousness at home in the setting of several months of
enlarged lymph nodes, unintentional weight loss, night sweats,
and fevers. You underwent diagnostic testing including CT scans
and were diagnosed with diffuse large b-cell lymphoma. You
underwent treatment with chemotherapy known as R-CHOP. You will
need to take the following new medications at home: 100mg
prednisone for the next 2 days; acyclovir 400mg twice daily
ongoing. You are being discharged with a 15 day supply of pain
medication. You will need to come to clinic tomorrow ___, to
get an injection to help your immune system recover after the
chemotherapy.
Please take all of your medications as prescribed and keep all
of your follow-up appointments.
It was a pleasure caring for you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19904800-DS-20 | 19,904,800 | 26,949,881 | DS | 20 | 2207-06-23 00:00:00 | 2207-06-25 15:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee stings
Attending: ___
___ Complaint:
Fatigue, vomiting, nausea
Major Surgical or Invasive Procedure:
Port-a-cath placement
History of Present Illness:
___ MtoF transgender woman (___), diagnosed with DLBCL in
___, now on C2D18 of R-CHOP, presenting with two weeks of
fever (Tm 102), weakness, nausea, vomiting, and diarrhea.
She states since her cancer diagnosis, she has felt generalized
fatigue. Her most recent cycle of RCHOP was ___ and she
received Neulasta on ___. She was seen in our ED on ___
for sore throat symptoms. The workup was negative and the
patient apparently signed out against medical advice (refused to
wait for urinalysis) and was discharged home with treatment.
Denies sick contacts. She has been taking Tylenol for fever. She
received influenza vaccine this year.
She had fever to 102 two days ago treated with Tylenol. She had
8 episodes of nonbloody diarrhea with some abdominal pain
yesterday. The vomiting is nonbloody and nonbilious with mostly
food contents. She has had some dizziness similar to prior
syncopal episodes. She did have a syncopal episode this morning
similar to prior. She had prodromal symptoms, feeling weak, and
lowered herself to the ground. She awoke within seconds. Her
fiancée witnessed the event.
In the ED, initial vitals were T97.6 HR96 114/63 RR18 100RA.
Labs were unremarkable with stable anemia. CXR negative. Flu
swab negative. She was given vancomycin 1g IV, Zosyn 4.5g IV, 1L
NS, Zofran 4mg IV, clonazepam 0.5mg, oxycodone 10mg, isoniazid
___.
On arrival to the floor, she had no specific complaints.
REVIEW OF SYSTEMS:
Positive for fever to 102 at home, diarrhea, nausea, mild
cough, weakness, abdominal pain. Denies rhinorrhea, congestion,
sore throat, shortness of breath, chest pain, constipation,
BRBPR, melena, hematochezia, dysuria, frequency, discharge,
hematuria.
Past Medical History:
___: The patient had been experiencing night
sweats, fevers, chills, nausea, and decreased p.o. intake. She
also had been experiencing substernal chest pain and tender
progressive lymphadenopathy involving her right axilla,
leftneck, and right inguinal canal. She first presented to ___
and Pathology at ___ wassigned out as follicular lymphoma;
however, there were areas ofincreased proliferation (Ki-67 of
60%) and the patient's clinical course did not completely fit
with this diagnosis. Thus, the patient underwent core needle
biopsies of the left cervical node for pathology and
cytogenetics. She then missed her initial outpatient Oncology
visit that was scheduled for ___. She re-presented to
the ___ Emergency Department that same day after another syncopal
episode. She was admitted to the inpatient Hematologic
Malignancy Service, where she got her first cycle of rituximab
and CHOP chemotherapy (C1D1 = ___. She tolerated
chemotherapy well and was discharged on ___. She then
returned for Neulasta on ___.
-cycle 2 D1 R-Chop ___
-Plan was for C3 of R-CHOP to be given on ___. With plan to
arrange port placement that day prior to chemotherapy.
PAST MEDICAL HISTORY:
-Tonsils out ___
-M to F on estradiol
-Breast implants ___ at ___
-Positive PPD (___) w/ negative CXR, positive Quant Gold ___
(___), on isoniazid/pyridoxine
Social History:
___
Family History:
Mother: COPD, thyroid cancer
Father: Recent health unknown to Mrs. ___
___ Exam:
ADMISSION EXAM:
VS: T98 104/62 82 20 100RA
GEN: Well appearing female in no acute distress, ambulatory
HEENT: No scleral icterus. MMM, no oral lesions, oral pharynx
clear, no tonsillar or cervical lymphadenopathy
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes, rales, or rhonchi
ABD: Soft, NT ND, hyperactive BS, no mass lesions
EXT: No ___ edema
NEURO: Alert, oriented, interactive, pleasant
DISCHARGE EXAM:
VS: Tm:98.8 Tc97.7 BP110/60 HR67 RR18 98%RA
GEN: Well appearing female in no acute distress
HEENT: No scleral icterus. MMM, no oral lesions, oral pharynx
clear, no tonsillar or cervical lymphadenopathy
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes, rales, or rhonchi
ABD: Soft, mild tenderness in left lower quadrant, ND,
hyperactive BS, no mass lesions. No rebound or guarding.
EXT: No ___ edema
NEURO: Alert, oriented
Pertinent Results:
ADMISSION LABS:
___ 11:40AM BLOOD WBC-9.1 RBC-3.79* Hgb-11.4* Hct-34.8*
MCV-92 MCH-30.1 MCHC-32.8 RDW-15.1 RDWSD-49.1* Plt ___
___ 11:40AM BLOOD Neuts-82.5* Lymphs-6.6* Monos-9.4
Eos-0.2* Baso-0.5 Im ___ AbsNeut-7.53* AbsLymp-0.60*
AbsMono-0.86* AbsEos-0.02* AbsBaso-0.05
___ 06:25AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 11:40AM BLOOD Plt ___
___ 11:40AM BLOOD Glucose-84 UreaN-11 Creat-0.6 Na-139
K-4.5 Cl-105 HCO3-24 AnGap-15
___ 11:40AM BLOOD Albumin-3.9 Calcium-8.7 Phos-4.0 Mg-1.9
DISCHARGE LABS
___ 05:00PM BLOOD HIV Ab-Negative
___:51AM BLOOD Lactate-1.1
___ 12:40AM BLOOD Calcium-8.8 Phos-4.5 Mg-1.9 UricAcd-4.6
___ 11:40AM BLOOD Lipase-27
___ 12:40AM BLOOD ALT-29 AST-35 LD(LDH)-242 AlkPhos-53
TotBili-0.1
___ 12:40AM BLOOD Glucose-113* UreaN-17 Creat-0.6 Na-138
K-4.2 Cl-103 HCO3-25 AnGap-14
___ 12:40AM BLOOD ___ PTT-32.8 ___
___ 12:40AM BLOOD Neuts-93.1* Lymphs-5.1* Monos-0.9*
Eos-0.0* Baso-0.4 Im ___ AbsNeut-7.09*# AbsLymp-0.39*
AbsMono-0.07* AbsEos-0.00* AbsBaso-0.03
___ 12:40AM BLOOD WBC-7.6# RBC-3.82* Hgb-11.5* Hct-34.8*
MCV-91 MCH-30.1 MCHC-33.0 RDW-15.1 RDWSD-49.7* Plt ___
MICROBIOLOGY:
___ 10:31 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FEW POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
Brief Hospital Course:
Ms ___ is a ___ MtoF transgender woman, diagnosed with DLBCL
in ___, now on C2D20 of R-CHOP, presenting with two weeks of
weakness, fevers at home to 102, nausea, vomiting, diarrhea.
# FEVER, NAUSEA, VOMITING, DIARRHEA. Suspect viral
gastroenteritis. No documented episodes during inpatient
admission. Clinically well appearing and labs are unremarkable
with normal LFTs. She received empiric vanc/Zosyn in ED but
these were not continued once admitted as no further evidence of
infection. cdiff, stool studies, norovirus, O+P pending. Blood
cultures pending with no growth so far. Zofran and
Prochlorperazine given PRN for nausea.
# Mild sore throat: No erythema or exudate to indicate
bacterial infection, patient reports it may be due to dry air.
Cepacol lozenges PRN.
# DLBCL. Germinal center derived diffuse large B-cell lymphoma
arising from follicular lymphoma. Multiple admissions for
syncope attributed to extensive mediastinal lymphadenopathy
causing mass effect on the bilateral main pulmonary arteries and
central airways. Now C2D18 of RCHOP with good response in
peripheral lymphadenopathy. Did not receive chemotherapy
in-house. Continued oxycodone PRN for pain and acyclovir for
prophylaxis
#Chronic Hep B Continued lamivudine
# Latent TB. Patient with history of positive PPDs in the past
but negative chest X ray and with positive quantiferon Gold at
___. She was seen by ID and started on isoniazid and pyridoxine
___. Current illness is unlikely to be active TB
given lack of chest xray findings. She missed a follow up
appointment with ID. They were notified she was admitted and
they will get her another appointment and contact her with that
information. Continued isoniazid and pyridoxine.
# Tobacco use:nicotine patch, patient left to smoke several
times against medical advice
# Male to female transition. Off estradiol now, on injections
per patient. Held spironolactone given recurrent syncope and SBP
100s.
TRANSITIONAL ISSUES:
#Patient will need further ID follow up for latent TB
#Spironolactone was held initially while inpatient as patient
reports an episode of near syncope at home and BP were SBP 100s.
Consider adjusting as necessary.
#Patient lost her pain medications prior to admission.
Attempted to re-write to get her to her next appointment however
pharmacy said they would not fill as she is not due until
___. Advised she may need a police report to be able to get
re-fill at this point.
# CODE: Full
# CONTACT: fiancée ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Isoniazid ___ mg PO DAILY
2. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
3. Pyridoxine 50 mg PO DAILY
4. Spironolactone 300 mg PO DAILY
5. Acyclovir 400 mg PO Q12H
6. ClonazePAM 0.5 mg PO TID:PRN anxiety
7. LaMIVudine 100 mg PO DAILY
8. Mirtazapine 15 mg PO QHS
9. Ondansetron ___ mg PO Q8H:PRN nausea
10. Paroxetine 20 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. ClonazePAM 0.5 mg PO TID:PRN anxiety
3. Isoniazid ___ mg PO DAILY
RX *isoniazid ___ mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. LaMIVudine 100 mg PO DAILY
5. Mirtazapine 15 mg PO QHS
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every 4 hrs as needed
Disp #*21 Tablet Refills:*0
7. Paroxetine 20 mg PO DAILY
8. Pyridoxine 50 mg PO DAILY
RX *pyridoxine 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Ondansetron ___ mg PO Q8H:PRN nausea
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 10 mg 1 tablet(s) by mouth every 6
hours as needed Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
DLBCL
Viral gastroenteritis
Secondary:
Nicotine dependence
Latent TB
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ on ___ after having had ___
weeks of nausea, vomiting, diarrhea, and fevers. You did not
have fevers or diarrhea while admitted but you continued to
experience nausea and vomiting. We suspect you had a viral
infection which is passing as no bacteria grew out of your
cultures. Please continue to take all of your medications as
prescribed and attend all of your follow up appointments. You
have a cancer that is potentially curable but if you do not
attend your appointments regularly a cure will not be possible.
You received a port for your chemo therapy and you started your
third cycle of therapy during this admission.
It was a pleasure taking part in your care, thank you for
choosing ___.
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19904800-DS-21 | 19,904,800 | 28,410,318 | DS | 21 | 2207-07-03 00:00:00 | 2207-07-04 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee stings
Attending: ___
___ Complaint:
Fevers, Night Sweats
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M->F transgender woman (goes by ___, DLBCL (dx ___,
now on C3 of R-CHOP) s/p port placement ___, Cycle 3 R-CHOP
___ w/Neulasta ___, Latent TB (on INH), chronic hepatitis B
(On lamivudine) who was recently admitted for presumed viral
gastroenteritis 1 week ago, now returns with fever and night
sweats and c/f possible port infection.
Patient states that following her recent admission, on the day
of her discharge her diarrheal and febrile symptoms had abated,
however she still c/o nausea, which is chronic. States that
three days PTA she noticed some difficulty swallowing and warm.
Took temp and fever of 101. Over the next few days she reports
increasing difficulty in swallowing solids and liquids w/o
choking, and palpable lymph nodes of neck and bilateral axilla.
Denies dynophagia or mouth sores. No recent sick contacts.
Endorses daily cough, but unchanged from her baseline (smoker's
cough). No increased production of mucus, no hemoptysis. Does
endorse recurrence of diarrheal symptoms stating the she isn't
rushing to the bathroom, but does have large volume watery
diarrhea ___ times a day "when I do use the toilet."
Continues to be febrile throughout the day and having drenching
night sweats nightly. She also voices her concern over her port
site (right chest wall) which remains mildly tender and appears
erythematous to her. Endorses mild bone pain.
Denies chest pain, shortness of breath, light
headedness/dizziness and syncope. Denies weight gain/loss,
numbness or tingling or extremities.
With respect to her DLBCL, known to have germinal center derived
diffuse large B-cell lymphoma arising from follicular lymphoma
w/ multiple admissions for syncope attributed to extensive
mediastinal lymphadenopathy causing mass effect on the bilateral
main pulmonary arteries and central airways. Now s/p C3 of RCHOP
with prior good response in peripheral lymphadenopathy. Received
chemotherapy on recent admission ending ___.
Past Medical History:
PAST ONCOLOGIC HISTORY
-___ The patient had been experiencing night
sweats, fevers, chills, nausea, and decreased p.o. intake. She
also had been experiencing substernal chest pain and tender
progressive lymphadenopathy involving her right axilla,
leftneck, and right inguinal canal. She first presented to ___
and Pathology at ___ wassigned out as follicular lymphoma;
however, there were areas ofincreased proliferation (Ki-67 of
60%) and the patient's clinical course did not completely fit
with this diagnosis. Thus, the patient underwent core needle
biopsies of the left cervical node for pathology and
cytogenetics. She then missed her initial outpatient Oncology
visit that was scheduled for ___. She re-presented to
the ___ Emergency Department that same day after another syncopal
episode. She was admitted to the inpatient Hematologic
Malignancy Service, where she got her first cycle of rituximab
and CHOP chemotherapy (C1D1 = ___. She tolerated
chemotherapy well and was discharged on ___. She then
returned for Neulasta on ___.
-cycle 2 D1 R-Chop ___
-Plan was for C3 of R-CHOP to be given on ___ but was
interrupted given viral gastroenteritis
-Port placed ___
-Cycle 3 D1 R-CHOP ___
-Neulasta ___
-Staging CT Torso w/con showing response to R-CHOP therapy
___
PAST MEDICAL HISTORY:
-Tonsils out ___
-M to F on estradiol (goes by ___
-Breast implants ___ at ___
-Positive PPD (___) w/ negative CXR, positive Quant Gold ___,
on isoniazid/pyridoxine
-Chronic Hepatitis B
-Tobacco Use
Social History:
___
Family History:
Mother: COPD, thyroid cancer
Father: Recent health unknown to Mrs. ___
___ Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.4 126/78 89 16 100%RA
GENERAL: AOx3 NAD.
HEENT: NC/AT, EOMI, PERRL, anicteric sclera w/o conjunctival
injection. MMM without mucositis, with left sided dime sized
gray clean based ulceration of buccal mucosa. Prominent
bilateral anterior cervical lymphadenopathy R>L. No occipital,
posterior or supraclavicular lymphadenopathy.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes, rales or rhonchi
(transmission of upper airway rhonchus breath sound diffusely).
ABD: +BS, soft, Non distended. Mild tenderness to palpation of
RUQ with liver percussed to 2 cm below costal margin and tip
crossing midline.
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: A&O x 3, CN II-XII intact
SKIN: Warm and dry, without rashes, well healing port on right
chest wall without palpable cord. Mild tenderness to palpation.
Without clear erythema thought pigmentation of skin makes
difficult to appreciate.
LYMPH: ENT lymph as above. Prominent bilateral axillary
lymphadenopathy. Left posterior chain and tail of spence. >4
palpable. Right mid axillary prominent lymphadenopathy. Right
deep inguinal LN vs post operative scarring. Not present on left
inguinal region.
DISCHARGE PHYSICAL EXAM:
VS: 97.7 120/53 87 18 100%RA
GENERAL: AOx3 NAD.
HEENT: NC/AT, EOMI, PERRL, anicteric sclera w/o conjunctival
injection. MMM without mucositis, with left sided dime sized
gray clean based ulceration of buccal mucosa. No evidence of new
ulcerations. Prominent bilateral anterior cervical
lymphadenopathy R>L. Variable inter-nodal size variation. Hard.
Non fixed.
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: clear to auscultation, no wheezes, rales or rhonchi
(transmission of upper airway rhonchus breath sound diffusely).
ABD: +BS, soft, Non distended. Mild tenderness to palpation of
RUQ
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: A&O x 3, CN II-XII intact
SKIN: Warm and dry, without rashes, well healing port on right
chest wall without palpable cord or erythema.
LYMPH: ENT lymph as above. Prominent bilateral axillary
lymphadenopathy, freely mobile. Left posterior chain and tail
of spence. >4 palpable. Right mid axillary prominent
lymphadenopathy. Bilateral inguinal lymphadenopathy is
appreciated to much lesser extent. ___ <0.5cm nodes.
Pertinent Results:
ADMISSION LAB VALUES:
___ 06:30PM WBC-6.8 RBC-3.83* HGB-12.0* HCT-35.0* MCV-91
MCH-31.3 MCHC-34.3 RDW-15.2 RDWSD-49.3*
___ 06:30PM NEUTS-61 BANDS-1 ___ MONOS-9 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-4.22 AbsLymp-1.97
AbsMono-0.61 AbsEos-0.00* AbsBaso-0.00*
___ 06:30PM HYPOCHROM-NORMAL ANISOCYT-1+
POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-NORMAL
POLYCHROM-NORMAL OVALOCYT-OCCASIONAL
___ 06:30PM PLT SMR-NORMAL PLT COUNT-379
___ 06:30PM ALBUMIN-4.3 CALCIUM-9.4 PHOSPHATE-4.3
MAGNESIUM-2.0
___ 06:30PM LIPASE-25
___ 06:30PM ALT(SGPT)-18 AST(SGOT)-17 ALK PHOS-81 TOT
BILI-0.2
___ 06:30PM GLUCOSE-96 UREA N-11 CREAT-0.6 SODIUM-140
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
___ 07:41PM LACTATE-1.7
___ 11:30PM URINE RBC-9* WBC-7* BACTERIA-FEW YEAST-NONE
EPI-7
___ 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-TR
___ 11:30PM URINE HYALINE-1*
PERTINENT IMAGING:
___ ABDOMINAL ULTRASOUND:
IMPRESSION:
1. No sonographic evidence of cholelithiasis or acute
cholecystitis.
2. Mildly echogenic liver consistent with steatosis. Other
forms of liver
disease and more advanced liver disease including
steatohepatitis or
significant hepatic fibrosis/cirrhosis cannot be excluded on
this study.
___ CXR:
FINDINGS:
The lungs are well inflated and clear. There is persistent
prominence of the right paratracheal station, compatible with
known lymphadenopathy. The cardiac silhouette is normal. There
is no pleural effusion or pneumothorax. A right chest
Port-A-Cath is noted terminating at the mid SVC. Bilateral
breast implants are identified.
IMPRESSION:
Persistent fullness at the right paratracheal station compatible
with known lymphoma. No focal consolidation.
___ CT CHEST W/CON
IMPRESSION:
Substantial improvement in the mediastinal lymphadenopathy an
resolution of the bilateral axillary lymphadenopathy. Minimal
apical emphysema.
Status post bilateral breast implants. Port-A-Cath catheter tip
terminates at the proximal right atrium. Suspected respiratory
bronchiolitis.
___BD & PELVIS W/CON:
IMPRESSION:
1. No evidence of lymphadenopathy within the abdomen or pelvis.
2. Several lucent lesions with a thick sclerotic rim and
associated cortical thickening are present, as described above.
Given the patient's history of malignancy, these lesions are
concerning for osseous involvement, although the level of
activity of these lesions cannot be assessed. Several of these
lesions would be amenable to biopsy.
**OF NOTE; IN SUBSEQENT FOLLOW UP OF THESE LESIONS THEY WERE
PRESENT ON PRIOR IMAGING, STABLE. NOT LYTIC. COULD STILL
CONSIDER BX**
3. Please see separate chest CT report for details of
intrathoracic findings.
DISCHARGE LAB VALUES:
___ 06:33AM BLOOD WBC-9.0 RBC-3.59* Hgb-10.8* Hct-33.0*
MCV-92 MCH-30.1 MCHC-32.7 RDW-15.5 RDWSD-50.2* Plt ___
___ 06:33AM BLOOD Neuts-65 Bands-4 ___ Monos-5 Eos-0
Baso-1 ___ Metas-2* Myelos-3* AbsNeut-6.21* AbsLymp-1.80
AbsMono-0.45 AbsEos-0.00* AbsBaso-0.09*
___ 06:33AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+
Stipple-OCCASIONAL
___ 06:33AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:33AM BLOOD Glucose-86 UreaN-15 Creat-0.7 Na-139
K-4.7 Cl-106 HCO3-27 AnGap-11
___ 06:33AM BLOOD TotProt-6.0* Calcium-9.5 Phos-5.5* Mg-2.2
___ 06:33AM BLOOD PEP-PND b2micro-PND
Brief Hospital Course:
___ is a ___ M->F transgender woman with a history of DLBCL
(dx ___, now on R-CHOP) s/p port placement ___, Cycle 2
R-CHOP ___ w/Neulasta ___, Latent TB (on INH), chronic
hepatitis B (On lamivudine) who was recently admitted for
presumed viral gastroenteritis 1 week ago, now returns with
diarrhea, fever and night sweats and reports of increased
lymphadenopathy. Symptoms were concerning for progression of
lymphoma so staging CT scan was obtained, which showed reduction
in lymphadenopathy. Patient was afebrile during admission
without any hemodynamic instability. She will return for cycle 3
on ___.
#Diarrhea
Patient with recent admission for diarrheal illness believed
to be viral gastroenteritis representing for symptoms of fever,
night sweats, diarreha and exam findings signifcant for RUQ pain
and general aches.
DDx is broad and included AE of R-CHOP versus
viral/bacterial/parasitic etiology, additionally, patient known
to have substance use history and narcotics contract and states
that she lost her most recent prescription therefore possibly
symptoms could represent withdrawl. Low suspicion for
inflammatory bowel disease.
Patient is immunosuppressed and chronic Hep B on viral
suppressive therapy. At risk for uncommon infections. Prior
diarrheal disease not resolved which was prominent prior to
third cycle of R-CHOP decreasing likelihood of medication side
effect. In setting of diarrhea and RUQ pain must also consider
hepatitides and viral infection also associated with diarrhea
however suspicion low given relatively normal LFTs. Patient on
INH w/known potential hepatotoxicity, but LFTs normal at this
time.
Extensive workup sent for viral, bacterial and parasitic
causes of diarrhea including serum and stool analyses. Negative
for C. diff. Prior admission w/o test for norovirus. Negative on
this admission.
During admission patient expressed desire to obtain fourth
cycle of R-CHOP early as she had a family vacation plan.
Given extensive infectious workup for diarrheal disease and
lack of significant symptoms on admission
Tests still pending at time of discharge include:
-Viral Panel: CMV Viral Load; Hepatitis C Viral Load;
Hepatitis B Viral Load; HIV-1 viral load by PCR; Hepatitis C
Viral RNA, Genotype; EBV PCR, Quantitative; Varicella zoster
Antibody, IgM; Varicella Zoster (VZV) IgG Antibody; EBV Antibody
Panel. Norovirus PCR
-Parasitic: Cryptosporidium/Giardia (DFA); Cyclospora; Stool
culture; Microsporidium; Stool culture - Yersinia; Stool culture
- Vibrio; Ova and Parasites (1 of 3);
-C. difficile DNA amplification assay;
TRANSITIONAL ISSUES:
==========================
# CODE: Full
# CONTACT: fiancée ___ ___
# Patient will need further ID follow up for latent TB
# Patient may need follow up on sclerotic lesions noted on CT
Chest ___ (stable)
# Patient will return for cycle 3 of RCHOP on ___.
# Patient discharged on 10mg Q6H of oxycodone to last until
___. (7 days x 4 times a day x 2 (5mg oxycodone tabs) = 56
tablets.) Dr. ___ prescription.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q12H
2. ClonazePAM 0.5 mg PO TID:PRN anxiety
3. Isoniazid ___ mg PO DAILY
4. LaMIVudine 100 mg PO DAILY
5. Mirtazapine 15 mg PO QHS
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. Paroxetine 20 mg PO DAILY
8. Pyridoxine 50 mg PO DAILY
9. Ondansetron ___ mg PO Q8H:PRN nausea
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Spironolactone 300 mg PO DAILY
12. Estradiol 4 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. ClonazePAM 0.5 mg PO TID:PRN anxiety
3. Isoniazid ___ mg PO DAILY
4. LaMIVudine 100 mg PO DAILY
5. Mirtazapine 15 mg PO QHS
6. Ondansetron ___ mg PO Q8H:PRN nausea
7. Paroxetine 20 mg PO DAILY
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Pyridoxine 50 mg PO DAILY
10. Spironolactone 300 mg PO DAILY
11. Estradiol 4 mg PO DAILY
12. Acetaminophen 325 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg 1 tablet(s) by mouth every 6 hours Disp
#*90 Tablet Refills:*0
13. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six hours Disp
#*56 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: DLBCL
SECONDARY: Nicotine dependence, Latent TB
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 meeting you and taking care of you. You were
admitted with subjective fevers and night sweats. We were
concerned that this represented progression of your diffuse
large B cell lymphoma so we obtained a staging CT scan. This
showed decrease in the size of your lymph nodes which was very
reassuring. You were monitored in the hospital and were stable
without fevers or signs of infection. We felt that it was safe
for you to go home and return for further outpatient
chemotherapy.You should continue your R-CHOP as an outpatient.
Your next appointment is on ___. It is VERY important
that you keep this appointment.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19904800-DS-23 | 19,904,800 | 27,675,246 | DS | 23 | 2207-08-10 00:00:00 | 2207-08-12 13:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee stings / ___
Attending: ___
___ Complaint:
fever, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female (transgender M->F) with hx of
chronic hepatitis B, Latent TB and recently diagnosed DLBCL on
R-CHOP regimen, presenting with nausea, diarrhea, fevers/chills
and cough.
Of note, she was admitted ___ - ___ with fevers and
diarrhea. Has had negative infectious work up so far. Was
discharged on augmentin which she stopped on her own. She does
report some improvement of her diarrhea at that time with not
recent increase. Was seen and discharged from the ED on ___
with nausea, fevers and a wrist injury.
She presents to the ED today reporting that she feels generally
unwell with fever, chills, cough, nausea, and diarrhea. She has
had symptoms for about two weeks, and now has upper respiratory
symptoms as well including cough, runny nose, and sore throat.
She reports fevers up to 102 at home. She denies any sick
contacts. Of note she was supposed to have chemotherapy this
week but she did not show up for her appointment.
Past Medical History:
PAST ONCOLOGIC HISTORY
-___ The patient had been experiencing night
sweats, fevers, chills, nausea, and decreased p.o. intake. She
also had been experiencing substernal chest pain and tender
progressive lymphadenopathy involving her right axilla,
leftneck, and right inguinal canal. She first presented to ___
and Pathology at ___ wassigned out as follicular lymphoma;
however, there were areas ofincreased proliferation (Ki-67 of
60%) and the patient's clinical course did not completely fit
with this diagnosis. Thus, the patient underwent core needle
biopsies of the left cervical node for pathology and
cytogenetics. She then missed her initial outpatient Oncology
visit that was scheduled for ___. She re-presented to
the ___ Emergency Department that same day after another syncopal
episode. She was admitted to the inpatient Hematologic
Malignancy Service, where she got her first cycle of rituximab
and CHOP chemotherapy (C1D1 = ___. She tolerated
chemotherapy well and was discharged on ___. She then
returned for Neulasta on ___.
-cycle 2 D1 R-Chop ___
-Plan was for C3 of R-CHOP to be given on ___ but was
interrupted given viral gastroenteritis
-Port placed ___
-Cycle 3 D1 R-CHOP ___
-Neulasta ___
-Staging CT Torso w/con showing response to R-CHOP ___
-Cycle 5 D1 R-CHOP ___
PAST MEDICAL HISTORY:
-Tonsils out ___
-M to F on estradiol (goes by ___
-Breast implants ___ at ___
-Positive PPD (___) w/ negative CXR, positive Quant Gold ___,
on isoniazid/pyridoxine
-Chronic Hepatitis B
-Tobacco Use
Social History:
___
Family History:
Mother: COPD, thyroid cancer
Father: Recent health unknown to Mrs. ___
___ Exam:
ADMISSION:
General: NAD
VITAL SIGNS: T 97.9 HR 80 RR 16 BP 114/70 O2 96%%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
SKIN: Hand lesion bandaged, did not want it examined.
NEURO: Alert and oriented, no focal deficits.
DISCHARGE:
General: laying in bed; NAD.
VITAL SIGNS: 97.5 118/58 96%RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: bs+, soft, non distended, tender to palpation in RUQ but
improved. No rebounding or guarding. No hepatosplenomegaly.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
ADMISSION LABS:
---------------
___ 03:15PM BLOOD WBC-5.6 RBC-3.03* Hgb-9.4* Hct-28.4*
MCV-94 MCH-31.0 MCHC-33.1 RDW-16.8* RDWSD-57.0* Plt ___
___ 05:10AM BLOOD ALT-22 AST-20 LD(LDH)-166 AlkPhos-43
TotBili-0.1
___ 03:15PM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-139
K-4.1 Cl-105 HCO3-25 AnGap-13
DISCHARGE LABS:
---------------
___ 05:30AM BLOOD WBC-5.8 RBC-3.29* Hgb-10.3* Hct-30.8*
MCV-94 MCH-31.3 MCHC-33.4 RDW-15.9* RDWSD-54.4* Plt ___
___ 05:30AM BLOOD Glucose-101* UreaN-17 Creat-0.6 Na-138
K-3.7 Cl-107 HCO3-24 AnGap-11
MICRO:
------
___ Blood Cultures x2: no growth to date
Stool: C. diff negative; crypto/giardia pending.
IMAGING:
--------
CXR ___
Right chest wall port is again seen with catheter tip in the
upper SVC. The lungs are clear. There is no consolidation,
effusion, or edema. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ female with DLBCL on R-CHOP presenting with recurrent
fevers, nausea, and diarrhea. Due to start C5 of R-CHOP.
#Fever and diarrhea: Ms. ___ has reported the symptoms of
nausea, abdominal pain, and diarrhea over the past several
months. As per admission note, patient with two hospitalizations
in ___ for similar complaints with entirely negative
infection work up. She was evaluated by GI during her last visit
and started on antibiotics for possible bacterial overgrowth
syndrome which wasn't helpful. During her admission, patient was
never febrile and had only a few episodes of diarrhea. She was
not neutropenic and repeat infectious workup was once again
negative. Low suspicion for inflammatory bowel disease. GI
recommended that work up be completed as an outpatient.
Suspected etiology is IBS.
# DLBCL: Diagnosed ___. S/P 4 cycles of R-CHOP prior to
admission. Received her fifth cycle as an inpatient with C5d1 =
___. She tolerated chemotherapy well without issue. She was
continued on acyclovir ppx. Further treatment as per her
primary oncologist.
# Hepatitis B: Lamivudine 100 mg PO DAILY
# Hormone therapy: Patient is transgenger and spironolactone and
estradiol were continued.
# Latent Tuberculosis: +PPD w/negative CXR. Continued INH and
pyridoxine.
# Anxiety/Depression: continued home clonazepam, Seroquel,
paroxetine, and remeron.
TRANSITIONAL ISSUES
-Recommend outpatient GI f/u for diarrhea/abdominal pain.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Estradiol 4 mg PO DAILY
4. Isoniazid ___ mg PO DAILY
5. LaMIVudine 100 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
7. Paroxetine 20 mg PO DAILY
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Pyridoxine 50 mg PO DAILY
10. Spironolactone 300 mg PO DAILY
11. Nicotine Patch 14 mg TD DAILY
12. Ondansetron ___ mg PO Q8H:PRN nausea
13. Promethazine 25 mg PO Q6H:PRN Nausea
14. QUEtiapine Fumarate ___ mg PO QHS
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Estradiol 4 mg PO DAILY
4. Isoniazid ___ mg PO DAILY
5. LaMIVudine 100 mg PO DAILY
6. Nicotine Patch 14 mg TD DAILY
7. Ondansetron ___ mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
9. Paroxetine 20 mg PO DAILY
10. Promethazine 25 mg PO Q6H:PRN Nausea
11. Pyridoxine 50 mg PO DAILY
12. QUEtiapine Fumarate ___ mg PO QHS
13. Prochlorperazine 10 mg PO Q6H:PRN nausea
14. Spironolactone 300 mg PO DAILY
15. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
16. Lorazepam 0.5 mg PO DAILY Duration: 6 Doses
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth daily Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: diarrhea, nausea
Secondary diagnosis: Diffuse Large B cell lymphoma
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 to care for you here at ___. You were
admitted because of your diarrhea. Tests for an infectious cause
were negative and you were started on medication to prevent
further episodes. If you continue to have abdominal discomfort
and diarrhea, then we encourage you to follow up with a
gastroenterologist as an outpatient.
You were given your fifth dose of chemotherapy for your
lymphoma. You tolerated this well and are ready to go home.
Please keep all your scheduled doctors' appointments including
your upcoming oncology appointment on ___. We wish you the
best.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19904800-DS-24 | 19,904,800 | 29,926,865 | DS | 24 | 2207-09-14 00:00:00 | 2207-09-14 14:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee stings / nickel
Attending: ___
___ Complaint:
Fever, headache, photophobia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ male to female transgender patient with
a germinal center-derived diffuse large B-cell lymphoma(cycle #6
of R-CHOP d1: ___ (day8)) recently admitted to ___ for
influenza A who is admitted from the ___ ED w/fever, diarrhea,
nausea, and headache.
Ms. ___ presented and admitted to ___ for fever
and neutropenia ___ to ___. Per ___ report from Dr. ___ to
our heme/onc nursing team at ___ at the time of admission her
ANC of 800 with Tmax to 100.9 with no focal cause of fevers. She
was started on broad spectrum Abx for febrile neutropenia and on
___ she tested positive for Influenza A. She was initiated on
Oseltamivir for a planned 20 day course.
Following her discharge from ___ patient reports that she
continued to have diffuse body aches, sore throat, and runny
nose. She missed her ___ appt for C6 RCHOP, which was given
on ___. She missed her appointment for neulasta on ___
because she felt very tired. On ___ she developed new diarrhea,
approximately ___ episodes daily, with associated nausea and
vomiting. Day prior to admission she developed a 'severe'
bifrontal headache, up to ___, with photophobia. Day of
admission, she reported a fever of 102 at home. Because of these
symptoms, she presented to the ED.
In ED, initial VS were pain 8, T 97.5, HR 113, BP 127/96, RR
20, O2 100%RA. Exam was significant for minimal b/l basilar
crackles on pulmonary exam. Port uninfected, no obvious
mucositis. Patient was unable to tolerate flu swab and LP. Labs
significant for UA with large leukocytosis negative nitrites and
WBC of 2.2 w/ANC 1700. Lactate 2.3. Imaging significant for
Chest XRay w/o acute pulmonary process and CT Head w/o showing
no intracranial abnormality or meningeal enchancements. Patient
received: Bolus NS 1L x1, CeftriaXONE 2 gm IV Q 12H, Acyclovir
400 mg IV Q8H, Vancomycin 1000 mg IV Q 12H, OSELTAMivir 75 mg
PO/NG Q12H
On arrival to the floor, patient reports ___ bifrontal
headache with nausea. Reports diarrhea is somewhat improved ___
BM today). Also notes diffuse body aches. Reports having fevers
at home, along with sore throat and rhinitis. Has associated
sore throat, rhinitis, and cough productive of green phlegm.
Denies CP or shortness of breath. No abdominal pain. No swelling
or rash. No joint paints. No dysuria. She does have some
heartburn. Patient was to finish her Tamiflu on ___, but
reports poor compliance at home. Remainder of ROS is
unremarkable.
Past Medical History:
PAST MEDICAL HISOTRY
ONCOLOGIC HISTORY:
--___ The patient had been experiencing night
sweats, fevers, chills, nausea, and decreased p.o. intake. She
also had been experiencing substernal chest pain and tender
progressive lymphadenopathy involving her right axilla,
leftneck, and right inguinal canal. She first presented to ___
and Pathology at ___ wassigned out as follicular lymphoma;
however, there were areas ofincreased proliferation (Ki-67 of
60%) and the patient's clinical course did not completely fit
with this diagnosis. Thus, the patient underwent core needle
biopsies of the left cervical node for pathology and
cytogenetics. She then missed her initial outpatient Oncology
visit that was scheduled for ___. She re-presented to
the ___ Emergency Department that same day after another
syncopal
episode. She was admitted to the inpatient Hematologic
Malignancy Service, where she got her first cycle of rituximab
and CHOP chemotherapy (C1D1 = ___. She tolerated
chemotherapy well and was discharged on ___. She then
returned for Neulasta on ___.
-cycle 2 D1 R-Chop ___
-Plan was for C3 of R-CHOP to be given on ___ but was
interrupted given viral gastroenteritis
-Port placed ___
-Cycle 3 D1 R-CHOP ___
-Neulasta ___
-Staging CT Torso w/con showing response to R-CHOP ___
-Cycle 5 D1 R-CHOP ___ (per reports did not get Neulasta
w/this cycle)
-Cycle 6 D1 R-CHOP ___ (Missed Neulasta w/this cycle)
-Given neupogen ___ as inpatient during influenza tx
PAST MEDICAL HISTORY:
-Tonsils out ___
-M to F on estradiol (goes by ___
-Breast implants ___ at ___
-Positive PPD (___) w/ negative CXR, positive Quant Gold
___,
on isoniazid/pyridoxine
-Chronic Hepatitis B
-Tobacco Use
SURGICAL HISTORY:
Breast Augmentation (___)
M to F Sexual Reassignment surgery
Tonsillectomy
ALLERGIES:
Bee stings / nickel
Social History:
___
Family History:
Mother: COPD, thyroid cancer
Father: Recent health unknown to Mrs. ___
___ Exam:
ADMISSION EXAM:
VS - T 97.3 BP 110/70 HR 93 RR 20 O2 100%RA
General: Pleasant, well appearing. NAD
HEENT: PERLLA, EOMI. OP clear.
Neck: Supple, no LAD
CV: RRR, no MRG
Lungs/Back: Nonlabored appearing on RA. CTAB.
Abdomen: Soft, NT/ND
GU: No foley
Ext: WWP. No edema
Skin: No rashes noted
Neuro: Pleasant, AAOx3. CNIII-XII intact. Moving all
extremities equally. Gait normal.
DISCHARGE EXAM:
VS - 98.0 100/68 98 18 95%RA
General: AOx3 Pleasant, well appearing. NAD
HEENT: PERLLA, EOMI. OP clear.
Neck: Supple, no LAD
CV: RRR, no MRG
Lungs/Back: Nonlabored appearing on RA. CTAB.
Abdomen: Soft, NT/ND
GU: No foley
Ext: WWP. No edema
Skin: No rashes noted
Neuro: Pleasant, AAOx3. CN II-XII intact. Moving all extremities
equally. Gait normal.
Pertinent Results:
ADMISSION LABS:
================
___ 02:31PM URINE HOURS-RANDOM
___ 02:31PM URINE UHOLD-HOLD
___ 02:31PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 02:31PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 02:31PM URINE RBC-11* WBC-51* BACTERIA-NONE YEAST-NONE
EPI-11
___ 01:15PM ___ PTT-31.6 ___
___ 12:20PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 12:12PM LACTATE-2.3*
___ 11:50AM GLUCOSE-81 UREA N-12 CREAT-0.7 SODIUM-138
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-24 ANION GAP-15
___ 11:50AM estGFR-Using this
___ 11:50AM WBC-2.2*# RBC-2.99* HGB-9.5* HCT-27.9* MCV-93
MCH-31.8 MCHC-34.1 RDW-14.4 RDWSD-47.7*
___ 11:50AM NEUTS-76* BANDS-1 ___ MONOS-2* EOS-1
BASOS-0 ___ MYELOS-0 AbsNeut-1.69 AbsLymp-0.44*
AbsMono-0.04* AbsEos-0.02* AbsBaso-0.00*
___ 11:50AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
___ 11:50AM PLT SMR-NORMAL PLT COUNT-261
DISCHARGE LABS:
================
___ 12:00AM BLOOD WBC-31.7*# RBC-3.12* Hgb-9.5* Hct-29.5*
MCV-95 MCH-30.4 MCHC-32.2 RDW-15.4 RDWSD-51.4* Plt ___
___ 12:00AM BLOOD Neuts-55 Bands-2 Lymphs-8* Monos-13 Eos-0
Baso-0 Atyps-1* Metas-7* Myelos-11* Promyel-3* NRBC-1*
AbsNeut-18.07* AbsLymp-2.85 AbsMono-4.12* AbsEos-0.00*
AbsBaso-0.00*
___ 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ Schisto-1+ Tear
Dr-OCCASIONAL
___ 12:00AM BLOOD Plt Smr-LOW Plt ___
___ 12:00AM BLOOD ___ 12:00AM BLOOD Glucose-87 UreaN-10 Creat-0.7 Na-142
K-3.7 Cl-105 HCO3-27 AnGap-14
___ 12:00AM BLOOD ALT-13 AST-34 LD(___)-870* AlkPhos-76
TotBili-0.1
___ 12:00AM BLOOD ALT-16 AST-54* LD(LDH)-1268* AlkPhos-54
TotBili-0.1
___ 12:00AM BLOOD LD(LDH)-682*
___ 12:15AM BLOOD ALT-12 AST-17 LD(LDH)-192 AlkPhos-45
TotBili-0.1
___ 12:00AM BLOOD Albumin-3.5 Calcium-8.6 Phos-5.6* Mg-2.0
UricAcd-7.0*
___ 12:00AM BLOOD Calcium-8.6 Phos-4.6* Mg-1.9 UricAcd-8.6*
___ 12:00AM BLOOD Calcium-8.5 Phos-4.2 Mg-2.0 UricAcd-5.6
MICRO DATA:
============
OTHER BODY FLUID VIRAL, MOLECULAR FluAPCR FluBPCR
___ NEGATIVE NEGATIVE
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
URINE CULTURE (Final ___: NO GROWTH.
CMV Viral Load (Final ___:
CMV DNA not detected.
___ 1:43 pm SPUTUM Site: EXPECTORATED
Source: Expectorated.
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
___ 09:51
Streptococcus pneumoniae Antigen Detection
Test Result Reference
Range/Units
SOURCE URINE
S.PNEUMONIAE AG DETECT.LA NOT DETECTED
REFERENCE RANGE: NOT DETECTED
IMAGING:
=========
___ Imaging CHEST (PA & LAT)
IMPRESSION:
No acute findings. Port-A-Cath appropriately positioned.
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
No acute intracranial process.
Brief Hospital Course:
Ms. ___ is a ___ male to female transgender patient
with a germinal center-derived diffuse large B-cell
lymphoma(cycle #6 of R-CHOP d1: ___ (day8) having missed
neulasta ___ recently seen at ___ and started on 20d course of
Tamiflu for PCR positive Influenza A(d1: ___ who presented to
___ ED w/new HA with photosensitivity, fever/chills admitted
to ___ afebrile and HD stable for empiric treatment of possible
meningitis now s/p de-escalation and off abx, whose clinical
picture is most consistent with resolving influenza vs
adenovirus started on neupogen.
ACUTE ISSUES:
==============
#Influenza A
Patient w/known influenza A by PCR at ___ w/initiation of tx
___. Has inconsistently taken Tamiflu since ___ discharge.
Admission w/sx of photophobia and tension headache and 3 day
history diarrhea. Sx resolved at time of admission. Empirically
covered for meningitis x48 hours and Abx de-escalated. Continues
Tamiflu BID (presumed d1: ___. All culture data negative.
Repeat Flu PCR negative. At time of discharge had completed ~3
week course of BID Tamiflu (end ___.
?Viral Enteritis
Patient w/self reported diarrheal symptoms prior to and during
admission. Observed BM soft and loose, but infrequent. Afebrile
and otherwise asymptomatic during admission. Tolerated PO intake
well since admission. No N/V. C. diff and norovirus stool
ordered, but sample not obtained. Clinically, symptoms not
consistent with infectious diarrhea.
# DLBCL:
# Neutropenia
Diagnosed ___. cycle #6 d13 of R-CHOP (d1: ___ w/expected
neutropenia and having missed scheduled appointment for Neulasta
___. Started Neupogen ___. ___ nadir of 120 on ___ w/count
recovery. Patient experienced significant bone pain w/neupogen
and was given additional oxycodone after discussing rules of
narcotics contract. At time of d/c ANC >500 and no fevers
appreciated at any point during admission. Continued on
acyclovir prophylaxis. Pt was not discharged with any additional
oxycodone.
CHRONIC ISSUES:
===============
#Narcotics contract
Pt w/outpatient contract limited to Oxycodone 5 mg tablet. ___
tablet(s) by mouth q6h prn: pain. Historically, from prior
admissions pt has not requested more than this. Given additional
oxycodone for bone pain during admission as above.
# Hepatitis B:
-Cont. Lamivudine 100 mg PO DAILY
# Hormone therapy:
Patient is transgenger (M to F) s/p breast augmentation and
sexual reassignment surgery. Has been on spironolactone and
estradiol, although not on current outpatient med list. States
no longer taking aldactone. Does receive weekly estradiol
injections. Not given on admission.
# Latent Tuberculosis:
Hx Positive PPD (___) w/ negative CXR, positive Quant Gold
___,
on isoniazid/pyridoxine while immunocompromised.
-Continued INH and pyridoxine
# Anxiety/Depression:
-Cont. Clonazepam 1 mg tablet. 1 tablet(s) TID PRN: anxiety
-Cont. Paroxetine 20 mg tablet. 1 tablet(s) by mouth qAM
-Cont. Seroquel 25 mg tablet. ___ tablet(s) by mouth QHS
# Tobacco abuse:
- Patient noted to frequenty leave room to smoke. Explained to
patient that this was not safe, and was against hospital policy.
Will continue to discourage smoking, but also recognize that
patient is AMA risk if denied this liberty. Discontinued
nicotine patch.
*****TRANSITIONAL ISSUES*****
# CODE: Full
# EMERGENCY CONTACT/HCP: ___
Relationship: Fiance Phone number: ___ Cell:
___
#Completed ~3 week course of Tamiflu BID (___)
#Experienced significant bone pain w/neupogen: d/c WBC: 31.7 w/
ANC of 18.07 (d1: ___ to ___
#PET-CT Scan not currently covered by ___. Per case
management ordering office needs to have prior authorization
sent. Then would help navigate coverage of PET
#Discharge Weight: 206.1 lb
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Isoniazid ___ mg PO DAILY
4. LaMIVudine 100 mg PO DAILY
5. Nicotine Patch 14 mg TD DAILY
6. Ondansetron ___ mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
8. Paroxetine 20 mg PO DAILY
9. Pyridoxine 50 mg PO DAILY
10. QUEtiapine Fumarate ___ mg PO QHS
11. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Isoniazid ___ mg PO DAILY
4. LaMIVudine 100 mg PO DAILY
5. Nicotine Patch 14 mg TD DAILY
6. Ondansetron ___ mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
8. Paroxetine 20 mg PO DAILY
9. Pyridoxine 50 mg PO DAILY
10. QUEtiapine Fumarate ___ mg PO QHS
11. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Influenza A, Neutropenia
Secondary: germinal center-derived diffuse large B-cell lymphoma
Primary: Influenza A, Neutropenia
Secondary: germinal center-derived diffuse large B-cell lymphoma
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 ___
for fevers, chills and diarrheal symptoms described at home
w/new symptoms concerning for possible viral versus bacterial
meningitis.
You were admitted and started on broad coverage antibiotics.
You remained w/o fevers or ongoing symptoms concerning for
meningitis and your antibiotics were removed over the course of
two days. You were continued on your home prophylaxis
medications.
Additionally, it became apparent that you had missed your
scheduled appointment in clinic for your Neulasta following your
sixth cycle of R-CHOP. As such, your cell counts were
predictably very low. This required that we start a daily
equivalent medication called Neupogen. You experienced a common,
but unfortunate, side effect of bone pain for which you were
given pain medications.
For your diarrheal symptoms we tested your stool for common
causes of infectious diarrhea for which all results returned
negative.
With respect to your diagnosis of influenza A (the flu), you
were instructed to take Tamiflu twice daily for three weeks
starting on ___. For all intents and purposes you have completed
this regimen. At the time of your discharge a repeat PCR was
negative for Flu and your symptoms had resolved.
You should continue to follow up with Dr. ___ as scheduled.
It was a pleasure taking part in your care, ___.
___,
Your ___ Team
Followup Instructions:
___
|
19904800-DS-26 | 19,904,800 | 22,014,497 | DS | 26 | 2207-10-03 00:00:00 | 2207-10-03 15:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee stings / nickel
Attending: ___
___ Complaint:
nausea diarrhea fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M->F transgender woman with DLBCL (dx ___, now s/p 6C
of R-CHOP) s/p port placement ___, Latent TB (on INH), chronic
hepatitis B (On lamivudine) who was recently admitted for
+influenza early ___ tx with Tamiflu then presenting with n/v
for
ED, was recently at ___ with + pantoea b culture completed
ceftriaxone ___ but did not comply with gent locks at home,
presents from ED with fatigue, nausea diarrhea x 1.
Past Medical History:
PAST MEDICAL HISOTRY
ONCOLOGIC HISTORY:
--___ The patient had been experiencing night
sweats, fevers, chills, nausea, and decreased p.o. intake. She
also had been experiencing substernal chest pain and tender
progressive lymphadenopathy involving her right axilla,
leftneck, and right inguinal canal. She first presented to ___
and Pathology at ___ wassigned out as follicular lymphoma;
however, there were areas ofincreased proliferation (Ki-67 of
60%) and the patient's clinical course did not completely fit
with this diagnosis. Thus, the patient underwent core needle
biopsies of the left cervical node for pathology and
cytogenetics. She then missed her initial outpatient Oncology
visit that was scheduled for ___. She re-presented to
the ___ Emergency Department that same day after another
syncopal
episode. She was admitted to the inpatient Hematologic
Malignancy Service, where she got her first cycle of rituximab
and CHOP chemotherapy (C1D1 = ___. She tolerated
chemotherapy well and was discharged on ___. She then
returned for Neulasta on ___.
-cycle 2 D1 R-Chop ___
-Plan was for C3 of R-CHOP to be given on ___ but was
interrupted given viral gastroenteritis
-Port placed ___
-Cycle 3 D1 R-CHOP ___
-Neulasta ___
-Staging CT Torso w/con showing response to R-CHOP ___
-Cycle 5 D1 R-CHOP ___ (per reports did not get Neulasta
w/this cycle)
-Cycle 6 D1 R-CHOP ___ (Missed Neulasta w/this cycle)
-Given neupogen ___ as inpatient during influenza tx
PAST MEDICAL HISTORY:
-Tonsils out ___
-M to F on estradiol (goes by ___
-Breast implants ___ at ___
-Positive PPD (___) w/ negative CXR, positive Quant Gold
___,
on isoniazid/pyridoxine
-Chronic Hepatitis B
-Tobacco Use
SURGICAL HISTORY:
Breast Augmentation (___)
M to F Sexual Reassignment surgery
Tonsillectomy
ALLERGIES:
Bee stings / nickel
Social History:
___
Family History:
Mother: COPD, thyroid cancer
Father: Recent health unknown to Mrs. ___
___ Exam:
ADMISSION PHYSICAL EXAM:
GEN: NAD fatigue appearing
VS: T 98.6 HR 92 BP 120/52 Resp 18 spO2 95%
Pain (___): 7 Location: diffuse bony
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary LAD
CV: Regular, normal S1 and S2 no S3, S4, or murmurs
PULM: Clear to auscultation bilaterally
ABD: BS+, soft, non-tender, non-distended, no masses, no
hepatosplenomegaly
LIMBS: No edema, no inguinal adenopathy
SKIN: +slight erythematous scattered papules on R forearm,
denies pain,itching, no ulcers/lesions/active bleeding
NEURO: Grossly nonfocal, alert and oriented
DISCHARGE PHYSICAL EXAM;
GEN: NAD fatigue appearing
VS: refused overnight and this morning
Pain (___): 7 Location: diffuse bony
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary LAD
CV: Regular, normal S1 and S2 no S3, S4, or murmurs
PULM: Clear to auscultation bilaterally
ABD: BS+, soft, non-tender, non-distended, no masses, no
hepatosplenomegaly
LIMBS: No edema, no inguinal adenopathy
SKIN: +slight erythematous scattered papules on R forearm,
denies pain,itching, no ulcers/lesions/active bleeding
NEURO: Grossly nonfocal, alert and oriented
Pertinent Results:
___ 04:20AM BLOOD WBC-6.1 RBC-2.89* Hgb-8.8* Hct-26.4*
MCV-91 MCH-30.4 MCHC-33.3 RDW-15.1 RDWSD-49.3* Plt ___
___ 04:20AM BLOOD Neuts-69.4 Lymphs-16.8* Monos-10.7
Eos-2.1 Baso-0.7 Im ___ AbsNeut-4.26# AbsLymp-1.03*
AbsMono-0.66 AbsEos-0.13 AbsBaso-0.04
___ 04:20AM BLOOD Plt ___
___ 04:20AM BLOOD ___ PTT-34.5 ___
___ 04:20AM BLOOD Glucose-89 UreaN-14 Creat-0.7 Na-134
K-4.0 Cl-99 HCO3-24 AnGap-15
Brief Hospital Course:
Ms. ___ is a ___ male to female
transgender patient with a germinal ___ diffuse large
B-cell lymphoma(cycle #6 of R-CHOP d1: ___ admitted from ED
with
fatigue, nausea and diarrhea.
#Diarrhea: x2 episode with no abd pain/cramping, recently
completed ceftriaxone for GNR bactermia as below, increasing
susceptibility to develop C diff in setting of ___ use and
immunosuppressed state.
-refused stool sample
-not agreeable to IVF
#Tooth Pain: New onset ___ overnight. Improved since previous
admission, diffuse bony pain main c/o. Per patient's report,
left
upper tooth cracked after chewing candy. Gums appears edematous
w/o exudate. Overall, there are visible cavities. Obtain panorex
___ with dental consultation for further evaluation, rec
multiple teeth extractions, consulted ___ hold off
extractions for now while awaiting PET results because if
persistent lymphoma, will need systemic chemotherapy. If not,
can
extract with planned healing time of ___ weeks.
#GNR Bacteremia: Blood culture on ___ at ___ + pantoea
agglomaranas, states she has not had ongoing fevers. Repeat bcx
at ___ NTD. Switched from cefepime to ceftriaxone (___) + added gentamicin locks (___) x 14D.
Discussion about potential POC removal - holding off for now
-went home with cefpodoxime but did not take, also not complaint
with gent lock for additional 5 days outpatient
-resent b culture
-hold ___ in setting of non neutropenic, no fevers, will f/u
repeat b culture and u culture to r/o infection as cause of
fatigue-b culture ___ NTD, refusing u culture.
-agreed to finish gent locks for 4d course that patient missed
last week, will give 1x dose prior to discharge and daily in
7Stoneman for an additional 3 days, patient agreeable to
complete antibiotic treatment
#DLBCL: Diagnosed ___, now s/p cycle #6 of R-CHOP (d1:
___. Counts have now recovered after last cycle. Continue
oxycodone for bony pain present since dx + acyclovir ppx
-patients counts have recovered fully post last cycle
-restaging with CT Chest ___ concerning for centrilobular
ground-glass opacities, differential diagnosis includes
infection vs drug reaction vs bronchiolitis. New more denser
peribronchial opacities in the right upper lobe are likely
infectious in etiology. There's increased size of lymph nodes
coupled with new rupture of left breast implant.
-CT Abd/Pelvis ___ w/o evidence of lymphadenopathy.
-CT Neck ___ w/o specific evidence to suggest lymphoma
-Plan to obtain breast MRI given CT chest findings of new
rupture of left breast implant - held off initially as may not
be
more informative than CT Chest per radiologist and Plastic
surgery team. However, after much discussion with Dr. ___ was obtained on ___, result consistent with silicon
injection
as cause for breast nodularity, no infectious etiology no fluid
collection
-Consulted plastic surgery ___ and rec holding off on MRI for
now. They felt that there is no need for acute surgical
intervention, to defer all surgical intervention while patient
is actively receiving chemotherapy and would also recommend
mammography/further evaluation of breast nodularity prior to any
surgical intervention. Patient may follow up as an outpatient
for planning of elective removal/ replacement of ruptured
implant
-Dr. ___ patient ___ and recommended outpatient CT for
restaging on ___ as set up and to keep POC in until that time,
however patient adamant about getting POC removed. Patient
agreeable to keep POC in after discussion with RN, PA, fellow,
and SW and discussion with her partner. Will finish ___ locks
and follow up daily as above. Plan for restaging ___ outpatient.
#Nausea: no emesis, lack of appetite over the last few days,
will
continue Zofran prn, additional work up if continues such as
norovirus PCR, may be secondary to chemotherapy although has
been
off >3weeks and/or recent ___ course. continue to monitor.
#?Lung Infection: Incidental finding on CT Chest on ___
concerning although per ID thinks it could be evidence of ?
influenza resolution. Initiated on Levaquin 750mg daily (___) given concern for community acquired PNA per Dr.
___. Patient afebrile and w/o respiratory symptoms except
mild rhinorrhea. Will continue to monitor closely.
#Influenza A: Patient with known influenza A by PCR at ___
w/initiation of treatment on ___. Empirically covered for
meningitis x 48 hours and ___ de-escalated. Completed course of
Tamiflu BID. Repeat Flu PCR negative. At time of discharge had
completed ~3 week course of BID Tamiflu (end ___. The
significance of the rhinovirus/enterovirus PCR positivity from
___ is not clear as she does not have any URTI symptoms right
now, but given risk to other patients it may be worth repeating
here to see if she has cleared the infection.
-Repeat rhinovirus/enterovirus PCR sent ___ but lab unable to
complete as not enough cells. Patient refused subsequent testing
#Narcotics Contract: Patient with outpatient contract limited to
Oxycodone 5 mg tablet. ___ tablet(s) by mouth q6h prn: pain.
Historically, from prior admissions patient has not requested
more than this. Currently on oxycodone prn for now due to
vitamin D deficiency pain, remains on 1x week vitamin D
supplementationas well
#Hepatitis B: Cont. Lamivudine 100 mg PO DAILY
#Hormone Therapy: Patient is transgender (M to F) s/p breast
augmentation and sexual reassignment surgery. Had been on
spironolactone and estradiol, although not on current outpatient
med list. States no longer taking aldactone. Does receive weekly
estradiol injections but has not been receiving since admission.
#Latent Tuberculosis: History of Positive PPD (___) with
negative CXR, positive Quant Gold ___ on isoniazid and
pyridoxine while immunocompromised.
#Anxiety/Depression:
-Cont. Clonazepam 1 mg tablet. 1 tablet(s) TID PRN: anxiety
-Cont. Paroxetine 20 mg tablet. 1 tablet(s) by mouth qAM
-Cont. Seroquel 25 mg tablet. ___ tablet(s) by mouth QHS
#Tobacco Abuse: continue nicotine patch although pt refuses
#Recreational Drug Use/Psych: Admit to smoking K2 at ___. Had
liability discussed with patient as frequently leaves the
hospital for cigarette breaks, not allowed to do and against
medical advice. patient aware and understands policy. Will
continue to reinforce. If leaves the hospital will enforce
hospital policy including no return to floor but recommended ED
readmission.
The patient expressed a desire to terminate the patient doctor
relationship with Dr. ___. It was discussed with the patient
that Dr. ___ was part of a team. The patient expressed that
she would only receive care from Dr. ___ ever Dr. ___ is
a trainee and leaving the institution in ___. The patient was
given the opportunity to discuss her concerns with patient
relations and other services. The patients care was transitioned
back to ___ where she had received care
previously. All appropriate records were transferred and person
contact was made with ___ medical staff and the NP at health
___ for the homeless.
# CODE: Full
# EMERGENCY CONTACT/HCP: ___
Relationship: Fiancée Phone number: ___ Cell:
___
Prophylaxes:
# Access: POC deaccessed prior to discharge
# FEN: Regular diet
# Pain control: oxy as above
# Bowel regimen: prn
# Disposition: home
# Code status: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Vitamin D ___ UNIT PO 1X/WEEK (WE)
4. Isoniazid ___ mg PO DAILY
5. LaMIVudine 100 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
8. Paroxetine 20 mg PO DAILY
9. QUEtiapine Fumarate ___ mg PO QHS
10. Multivitamins 1 TAB PO DAILY
11. Pyridoxine 50 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. ClonazePAM 1 mg PO TID:PRN anxiety
3. Isoniazid ___ mg PO DAILY
4. LaMIVudine 100 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
8. Paroxetine 20 mg PO DAILY
9. Pyridoxine 50 mg PO DAILY
10. QUEtiapine Fumarate ___ mg PO QHS
11. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home
Discharge Diagnosis:
lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted due to fatigue, nausea, diarrhea. We
recommended restarting your gentamycin antibiotic locks in your
port to finish your treatment for your bacterial infection in
your bloodstream. You will continue this outpatient for 3 more
days. Per your wishes we have transitioned your care back to the
doctors at ___. After completion of these
three days of antibiotic flushes you will receive all your
future care there.
Followup Instructions:
___
|
19905277-DS-13 | 19,905,277 | 29,787,558 | DS | 13 | 2164-08-04 00:00:00 | 2164-08-05 12:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Lopressor / Opioids-Morphine &
Related / Ciprofloxacin / gabapentin
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 09:05PM BLOOD WBC-7.0 RBC-5.62 Hgb-16.3 Hct-48.8 MCV-87
MCH-29.0 MCHC-33.4 RDW-14.5 RDWSD-45.5 Plt ___
___ 09:05PM BLOOD Glucose-174* UreaN-11 Creat-1.0 Na-137
K-3.1* Cl-96 HCO3-28 AnGap-13
___ 09:05PM BLOOD ALT-40 AST-30 AlkPhos-52 TotBili-0.4
___ 09:05PM BLOOD Lipase-59
___ 09:05PM BLOOD Albumin-3.8
___ 09:22PM BLOOD Lactate-1.4
LAB RESULTS ON DISCHARGE:
==========================
___ 06:25AM BLOOD WBC-10.8* RBC-5.26 Hgb-15.2 Hct-46.5
MCV-88 MCH-28.9 MCHC-32.7 RDW-14.7 RDWSD-47.2* Plt ___
___ 06:25AM BLOOD Glucose-175* UreaN-14 Creat-0.9 Na-137
K-3.7 Cl-100 HCO3-25 AnGap-12
___ 06:25AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.4
MICROBIOLOGY:
=============
___ 03:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 03:20PM URINE Blood-TR* Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-7.0 Leuks-NEG
___ 03:20PM URINE ___ Bacteri-FEW* Yeast-NONE
___ 07:10PM URINE CT-NEG NG-NEG
___ 3:20 pm URINE ****** ___ Urgent Care
******.
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 9:05 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
IMAGING:
========
CT A/P WITHOUT CONTRAST ___:
1. Enlarged prostate with bladder base indentation. No discrete
lesion within the prostate on this unenhanced exam.
2. No hydronephrosis.
MRI PELVIS WITH CONTRAST ___:
INDICATION: ___ year old man with concern for prostatitis,
continuing symptoms despite 1 week of antibiotic treatment.
Prostate abscess?
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired
on a 3.0 T
magnet.
Intravenous contrast: 9 mL Gadavist.
COMPARISON MR urogram ___. CT abdomen and pelvis ___.
FINDINGS:
The prostate gland measures 6.0 x 6.6 x 6.7 cm (AP x SI x TV),
yielding a
calculated volume of 139 cc. The central gland is enlarged and
shows a
heterogenous swirled and whorled appearance with well defined
nodules,
indicative of BPH.
There is no evidence of focal abscess within the prostate gland.
Seminal vesicles are grossly normal.
No overt pelvic lymphadenopathy.
There is mild circumferential thickening and trabeculation of
the urinary
bladder wall, likely on a background of chronic outlet
obstruction.
Visualized bowel is unremarkable.
No marrow replacing process.
IMPRESSION:
Background BPH and prostatic enlargement, with urinary bladder
wall thickening
compatible with features of chronic outlet obstruction. No
focal prostate
abscess is identified on today's study.
Brief Hospital Course:
Mr. ___ is a ___ year old male with recent diagnosis of
Enterococcal prostatitis, complex urologic history including
reported bladder polyps and BPH, chronic systolic heart failure
with recovered ejection fraction, and hypertension, who
presented for worsening dysuria, chills, and lower abdominal
pain concerning for undertreated prostatitis (or at least a
complicated UTI), improving on antibiotic therapy, without
evidence of prostatic abscess.
# Complicated urinary tract infecton
# Prostatitis
Patient presenting with worsening lower abdominal pain, urinary
symptoms, malaise, after being diagnosed with Enterococcal
prostatitis 8 days ago. Notably, he was first treated with
cefpodoxime, which does not cover enterococcus, and then
nitrofurantoin, which does not have adequate prostate
penetration. He was again given
ceftriaxone in the ED.
ID was hence consulted, with recommendation for further imaging
to r/o complication such as prostatic abscess. He received MRI
prostate after being premedicated with prednisone/Benadryl,
without evidence of abscess.
He was given ampicillin 2 mg q4H on ___, then transitioned to
amoxicillin 500 mg q8H ___ with plan for total ___nding ___. He had improvement in dysuria, and no further
fevers or chills while on this regimen.
Outpatient urology team was also updated.
# Leukocytosis, hyperglycemia: Likely in setting of prednisone
as premedication for MRI with contrast given time course, with
peak WBC 13.9 and glucose up to 300s. On discharge this had
improved to 10.8, and BG in 100s.
CHRONIC/STABLE PROBLEMS:
# Chronic systolic heart failure with recovered ejection
fraction: Followed at ___, per notes, he is thought to have
congestive heart failure myocarditis secondary to intravenous
contrast (___). He is not on diuretics
as an outpatient other than acetazolamide for complex sleep
apnea. Initially home carvedilol was held due to borderline
blood pressures with SBP ___ to 100s, this was able to be
restarted at home dose, with BP at discharge 110-120s.
# Hypertension: Initial SBP in ___ in setting of infection,
and home carvedilol and chlorthalidone were held. He was able to
be restarted on carvedilol on ___, with SBP in 110-120s, but
continued to hold home chlorthalidone at time of discharge with
recommendation for close monitoring of BP to see if this
medication would need to be restarted. Notably patient reports
intermittent dizziness at home, with occasional SBP in ___, and
on outpatient records here does have intermittent recordings of
BP 90-100/50-60s.
# Insomnia
- Continue home zolpidem 10mg QHS
# Complex sleep apnea
- Continue home acetazolamide
# Chronic pain
- Continue home tramadol
- Continue home methocarbamol
# Enlarged prostate
- Continued home tadalafil and alfuzosin once BP COULD TOLERATE
# Low T/low libido
- Continued home cabergoline
TRANSITIONAL ISSUES:
====================
Discharge weight 98.2 kg (216.49 lb)
Discharge Cr 0.9
[] Amoxicillin 500 mg q8H ___ with plan for total ___nding ___
[] Home chlorthalidone held at discharge given BP well
controlled with SBP 110-120s without this medication and reports
of intermittent dizziness at home as well as report of
occasional SBP 70S-90s at home (none in house), orthostatics on
current regimen were negative. Please monitor BP and restart as
needed
[] ___ consider if candidate for ambulatory BP monitoring
[] Please recheck CBC at PCP follow up
[] Final BCX pending at discharge, please follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. cabergoline 0.5 mg oral 2X/WEEK
2. alfuzosin 20 mg oral QAM
3. Zolpidem Tartrate 10 mg PO QHS
4. AcetaZOLamide 62.5 mg PO QHS
5. CARVedilol 25 mg PO BID
6. Chlorthalidone 25 mg PO DAILY
7. Methocarbamol 750 mg PO QID:PRN muscle spasms
8. Aspirin 81 mg PO DAILY
9. Cialis (tadalafil) 4 mg oral DAILY
10. Meclizine 25 mg PO Q6H:PRN dizziness
11. TraMADol 50 mg PO BID:PRN Pain - Moderate
12. Fexofenadine 60 mg PO BID:PRN seasonal allergies
13. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H
RX *amoxicillin 500 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 1 dose by
mouth once a day Refills:*0
3. AcetaZOLamide 62.5 mg PO QHS
4. alfuzosin 20 mg oral QAM
5. Aspirin 81 mg PO DAILY
6. cabergoline 0.5 mg oral 2X/WEEK
7. CARVedilol 25 mg PO BID
8. Cialis (tadalafil) 4 mg oral DAILY
9. Fexofenadine 60 mg PO BID:PRN seasonal allergies
10. Fluticasone Propionate NASAL 1 SPRY NU BID:PRN allergies
11. Meclizine 25 mg PO Q6H:PRN dizziness
12. Methocarbamol 750 mg PO QID:PRN muscle spasms
13. TraMADol 50 mg PO BID:PRN Pain - Moderate
14. Zolpidem Tartrate 10 mg PO QHS
15. HELD- Chlorthalidone 25 mg PO DAILY This medication was
held. Do not restart Chlorthalidone until your doctor tells you
to
Discharge Disposition:
Home
Discharge Diagnosis:
Complicated UTI, possible prostatitis secondary to Enterococus
Steroid induced hyperglycemia
Hypertension
Chronic systolic heart failure, now with recovered ejection
fraction
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 us for fevers, chills, and difficulty with
urination. While you were here, received an MRI of your prostate
which did not reveal any evidence of an abscess, and you were
seen by our infectious diseases team, who made recommendations
for antibiotics. It is thought that you may have had at least a
complicated urinary tract infection with possible underlying
prostatitis, and recommendation was made for a total of 14 days
of antibiotics (amoxicillin three times a day) ending on ___.
We were in communication with your outpatient urology team.
At time of discharge, we are temporarily holding your
chlorthalidone, as your systolic blood pressure was well
controlled in the 110-120s off of this medication, and at home
you reported episodes of feeling dizzy as well as occasional
blood pressures of ___. Please take your blood pressure at home
and discuss with your primary care doctor.
Please take care, we wish you the very best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19905351-DS-10 | 19,905,351 | 29,354,118 | DS | 10 | 2115-12-01 00:00:00 | 2115-12-01 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion - "brain fogginess"
Major Surgical or Invasive Procedure:
Lumbar puncture ___
History of Present Illness:
The patient is a ___ man with history of depression who
presented with a six-month history of cognitive slowing and
memory loss. History obtained from patient and mother.
For comprehensive details about the patient's long-standing
cognitive issues over the past 6 months, please see prior
documentation by both the PCP and neurology visit on ___.
To summarize, the patient was in his usual state of health until
approximately 6 months ago. At that time, he developed
intermittent sensation of "brain fog" and periods when he would
be more forgetful than usual. Initially, this sensation was
intermittent, however it has been present all of the time for
the
last ___ months. He reports an associated sense of
"dissociation," and describes a feeling of "being drunk all the
time, without feeling pleasantly drunk." He denies any
olfactory or gustatory hallucinations. Denies any headache
throughout this time. Denies any fever or infectious symptoms.
The symptoms continued and became gradually more severe over the
last several months. It reached a point where he was unable to
maintain his job approximately 1 month ago and had to leave his
job. He worked in ___, and had difficulty "processing
information" in meetings and remembering tasks for the day. He
also reports intermittent slurred speech, without any other
evidence of weakness. Over the last month, he has been
minimally engaged and spends the majority of the day sleeping.
His mother
notes that he spends the majority of the day locked in his
bedroom. He spends the majority of the day sleeping and does
not have the drive to do daily tasks.
Approximately 1 week ago, the patient developed severe neck pain
that appeared to occur out of the blue. Denies any preceding
trauma or neck manipulation. Denied any associated headache,
but he has had persistent photophobia for the last several
months. The patient and his mother contacted his primary care
physician for further guidance, but had difficulty getting in
touch with the office staff. They did not seek medical
attention. His neck pain resolved over a few hours, and he was
able to proceed about his weekend.
The patient presents to emergency department now after his
mother was concerned that he had minimal recollection of his
prior neck pain.
I interviewed the patient without his mother present privately.
He reported he had no further information to share. He denied
depressed mood, apart from "being anxious about everything that
is going on.". Denied alcohol and illicit drug use. Denies any
recent stressors. Reported he felt safe at home. Denied suicidal
or homicidal ideation.
Of note, the patient's sleep schedule typically consists of
going to bed at 12 AM and sleeping until noon the following day.
For workup and evaluation of the symptoms, the patient has had
an extensive toxic metabolic workup that has been negative,
including CBC, BMP, LFTs, vitamin B12, and RPR, among others.
He has been evaluated by a BI Neurologist about 1 month ago, Dr.
___ felt that symptoms were likely due to depression
and recommended psychiatric evaluation. The patient was
subsequently
seen by his psychiatrist and primary care physician, who
questioned whether there was an organic cause for these symptoms
and did not attribute the symptoms to depression.
Past Medical History:
Depression, previously tried bupropion and escitalopram.
Social History:
___
Family History:
Denies family history of epilepsy or neurologic
disorders. His brother is ___ years old with bipolar disorder.
Physical Exam:
Admission examination:
Physical Exam:
Vitals: 90 7.3F, heart rate 75, blood pressure 118/72,
respiratory rate 18, O2 99% on room air
General: Awake, cooperative, NAD. Pale-appearing
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused; regular on telemetry
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
Mental Status:
Awake, alert, oriented to self, place, time and situation.
Makes poor eye contact with examiner. Throughout most of the
interview, he is flat affect, but at the conclusion of the
interview became tearful without being able to articulate why.
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 (he was able to get the final word with category cue).
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.
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
R 5 ___ 5 ___ 5 5 5 5 5
Sensory:
No deficits to light touch, 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 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.
Discharge examination:
Vitals (last 24 hours):
Temperature: Afebrile
Blood pressure: 94/58 - 113/63
Pulse: 45 - 66
RR: 16 - 20
Oxygen saturation: 97 -99%
General physical examination:
General: Comfortable and in no distress
Head: No irritation/exudate from eyes, nose, throat
Neck: Supple with no pain to flexion or extension
Cardio: Regular rate and rhythm, warm, no peripheral edema
Lungs: Unlabored breathing
Abdomen: Soft, non tender, non distended
Skin: No rashes or lesions
Neurologic examination:
Mental status:
Alert and oriented to name, time, and place. Comprehends
questions and is able to fully hold communication with no
difficulty, but has slowed flat speech. Can repeat months of
years backwards, but slowed. Remembers ___ items at five
minutes, another ___ with category, and the last ___ with
multiple choice. Patient with no difficulties with repetition
and no difficulty naming objects. Patient does not appear
overtly depressed.
Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
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
R 5 ___ 5 ___ 5 5 5 5 5
Sensory:
No deficits to light touch, proprioception throughout.
No extinction to DSS.
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 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:
___ 04:45AM BLOOD WBC-6.7 RBC-4.25* Hgb-13.2* Hct-38.2*
MCV-90 MCH-31.1 MCHC-34.6 RDW-11.9 RDWSD-38.3 Plt ___
___ 04:45AM BLOOD Glucose-95 UreaN-13 Creat-0.8 Na-143
K-3.4 Cl-104 HCO3-23 AnGap-19
___ 04:45AM BLOOD Calcium-9.4 Phos-5.1* Mg-2.0
___ 10:27AM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-9* Polys-0
___ ___ 10:27AM CEREBROSPINAL FLUID (CSF) TotProt-21 Glucose-65
Brief Hospital Course:
Patient was admitted from the emergency department on ___
because of chief complaint of brain fogginess with reduced
ability to complete tasks. Patient had basic laboratory studies
which were un revealing and had mri brain, continuous eeg, and
lumbar puncture which were also un revealing. Based on our
examination we feel that he has difficulty with attention and
motivation and that he might benefit from evaluation with
behavioral neurology. Patient has upcoming appointment.
Patient had prescription written for sertraline to determine if
this would be of benefit before his scheduled appointment, but
per mother it is uncertain if he will take medication. Patient
denied suicidal ideation.
Medications on Admission:
None
Discharge Medications:
1. Sertraline 25 mg PO DAILY Inattention/lack of motivation
Please take one pill once daily.
RX *sertraline 25 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Abulia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
During this hospitalization, we did a full neurologic
examination including blood work, electroencephalogram, lumbar
puncture, and imaging tests and all studies were negative. We
believe that you have issues with attention and motivation, but
it is uncertain what is causing this to occur. We believe your
symptoms have both components in the realm of psychiatry and
neurology and have therefore scheduled for you an appointment
with behavioral neurology.
For the mucous cyst we have put in a referral for you to be see
otolaryngology with Dr. ___ his office will contact you
when the appointment is upcoming.
Thank you for allowing us to care for you
___ neurology
Followup Instructions:
___
|
19905556-DS-13 | 19,905,556 | 27,689,540 | DS | 13 | 2170-11-26 00:00:00 | 2170-11-26 14:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Sulfa (Sulfonamide Antibiotics) / Nsaids / lisinopril /
egg / iodine
Attending: ___.
Chief Complaint:
BLE pain, fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ PMHx asthma/COPD, T2DM c/b neuropathy,
HTN, recurrent cellulitis, bilateral venous stasis and BLE
edema, chronic LBP ___ spinal stenosis, fibromyalgia, and OSA on
BiPAP who presents with fall.
The patient was trying to get off her commode 3 days when she
fell from a seated position. Since then, she has been having
worsened bilateral foot pain. She presents for worsening BLE
foot pain.
In the ED, her initial VS 98.3, 84, 150/80, 18, 97% on RA. On
exam, the patient had diffuse TTP of her BLE with cellulitic
skin changes of her posterior left foot. She as incontinent in
the ED in the setting of not being able to get off the stretcher
to commode; PVR was only 25 cc's. No traumatic injury to the
head was noted. Initial labs showed wnl chemistries, WBC 12.1,
Hgb 10.9, Plt 229. X-ray imaging of her BLE extremities showed
no fracture/dislocations. The patient received IV vancomycin
prior to transfer to the floor for treatment of cellulitis.
Upon arrival to the floor, the patient reports ongoing BLE pain
R > L, but states that she is overall feeling better than
initial presentation in the ED. She states that she may have
had some erythema of her LLE which is now resolved and states
that she is unsure if her chronic BLE edema is significantly
worse than baseline. She states that she has not been able to
be compliant with her compression stockings because she has
difficulty putting them on and taking them off by herself.
Of note, the patient has had recurrent hospitalizations at ___
for BLE edema, inability to care for self, and UTI. Per her
prior records, her BLE exam showed BLE TTP, significant
puckering/depigmented skin and mild BLE edema.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
OSA on BiPAP
Asthma with COPD/chronic resp failure, on ___ at home
IDDM2 with neurological, retinal complications, last A1c 6.3
(___)
Anemia
Hypertension, essential
Vit D deficiency
Crohn's Disease - no treatment, followed by Dr. ___ at ___
___
MRSA carriage (documented at OSH)
lower GI bleed last ___ s/p hemorrhoid banding
Diverticulitis
Chronic LBP ___ spinal stenosis
OA of Hip
PAST SURGICAL HISTORY:
Uterine ablation
Cholecystectomy
Recent hemorrhoidal banding
Tubal Ligation
Social History:
___
Family History:
Mother deceased from leukemia
Father with unknown CA, deceased
Brother with lung cancer
Sister with unknown cancer
Niece with breast cancer, deceased
Physical Exam:
ADMISSION EXAM:
Vitals- 98.9 121 / 76 85 20 97 2L
GENERAL: intermittently tearful, morbidly obese, elderly female
in mild discomfort
HEENT: MMM, NCAT, EOMI, anicteric sclera
CARDIAC: RRR, nml S1 and S2, II/VI systolic murmur best heard at
LUSB
LUNGS: CTAB, no w/r/r, unlabored respirations
BACK: pressure ulcers over buttocks
ABDOMEN: soft, obese, NTND
EXTREMITIES: chronic hypopigmentation of BLE without any open
wounds, no erythema or warmth of BLE, trace pitting edema of
BLE. Full PROM intact though patient tearful during exam.
SKIN: as described above
NEUROLOGIC: AOx3, grossly nonfocal.
DISCHARGE EXAM:
VITALS- afebrile, BP: 133/66, HR: 74, RR: 18, O2 97% on RA
GENERAL: morbidly obese, elderly female in NAD, eating
breakfast
EYES: EOMI, anicteric sclera
ENT: MMM, clear OP, normal hearing
CARDIAC: RRR, nl S1 and S2, II/VI systolic murmur best heard at
LUSB
LUNGS: CTAB, no w/r/r, unlabored respirations
ABDOMEN: soft, obese, NT, umbilical hernia noted
EXTREMITIES: chronic hypopigmentation of RLE without any open
wounds, no erythema or warmth of BLE, trace pitting edema of
BLE.
NEUROLOGIC: AOx3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 06:54AM GLUCOSE-262* UREA N-12 CREAT-0.7 SODIUM-138
POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-26 ANION GAP-19
___ 06:54AM WBC-12.1* RBC-3.93 HGB-10.9* HCT-35.8 MCV-91
MCH-27.7 MCHC-30.4* RDW-14.6 RDWSD-49.1*
___ 06:54AM NEUTS-77.6* LYMPHS-11.0* MONOS-7.7 EOS-2.8
BASOS-0.4 IM ___ AbsNeut-9.34* AbsLymp-1.33 AbsMono-0.93*
AbsEos-0.34 AbsBaso-0.05
___ 06:54AM PLT COUNT-229
Micro:
___ BCx pending
Imaging/Studies:
___ FOOT 2 VIEWS BILAT
No fracture or dislocation.
___ KNEES BILAT
No fracture or dislocation.
___
Final Addendum
A
D
D
E
N
D
U
M
Bilateral lower extremity veins were evaluated. The impression
s
h
o
u
l
d
r
e
a
d
:
No evidence of deep venous thrombosis in the left or right lower
extremity veins.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on ___ ___
10:55 AM
Final Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
C
O
M
P
A
R
I
SON: ___ bilateral lower extremity Doppler ultrasound
FINDINGS:
T
h
e
r
e
i
s
n
ormal compressibility, flow, and augmentation of the left common
f
e
m
o
r
a
l
,
f
e
m
oral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the tibial and peroneal veins.
T
h
e
r
e
i
s
n
o
r
m
a
l respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
N
o
e
v
i
d
e
nce of deep venous thrombosis in the left lower extremity veins.
BY ELECTRONICALLY SIGNING THIS REPORT, I THE ATTENDING PHYSICIAN
ATTEST THAT ___ HAVE REVIEWED THE ABOVE IMAGES FOR THE ABOVE
EXAMINATION(S) AND AGREE WITH THE FINDINGS AS DOCUMENTED ABOVE.
___, MD
___, MD electronically signed on ___
11:30 ___
___
Final Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT
TECHNIQUE: Pelvis single view, left hip two views
COMPARISON: CT ___
FINDINGS:
D
e
g
e
n
e
r
a
t
i
ve arthritis lower lumbar spine. Degenerative changes bilateral
h
i
p
s
,
m
o
r
e prominent in the left hip, with joint space narrowing, similar
c
o
m
p
a
r
e
d
w
i
th ___. surgical clips low abdomen. No evidence of
fracture.
IMPRESSION:
No evidence of fracture.
D
e
g
e
n
e
r
ative arthritis bilateral hips, greater on the left, similar to
prior.
Discharge labs:
___ 10:58AM BLOOD ___ 10:58AM BLOOD %HbA1c-9.3* eAG-220*
___ 06:40AM BLOOD Triglyc-119 HDL-70 CHOL/HD-2.8
LDLcalc-101
___ 10:58AM BLOOD TSH-1.1
___ 10:58AM BLOOD TSH-1.1
___ 06:50AM BLOOD 25VitD-15*
___ 07:25AM BLOOD WBC-8.4 RBC-3.79* Hgb-10.7* Hct-35.1
MCV-93 MCH-28.2 MCHC-30.5* RDW-15.4 RDWSD-52.0* Plt ___
___ 06:55AM BLOOD Glucose-124* UreaN-15 Creat-0.7 Na-141
K-3.8 Cl-98 HCO3-32 AnGap-15
Brief Hospital Course:
Ms. ___ is a ___ PMHx asthma/COPD, T2DM c/b neuropathy,
HTN, recurrent cellulitis, bilateral venous stasis and BLE
edema, chronic LBP ___ spinal stenosis, fibromyalgia, and OSA on
BiPAP who presents with fall and BLE pain
# Fall
# BLE pain:
Pt presented with mechanical fall in the setting of being unable
to support her weight during transition off commode at home.
She had no LOC or head strike and states that she landed on her
bottom on the floor. She c/o BLE pain L > R without any
evidence of fracture/dislocation. On further review with the
patient, she
says this pain is chronic and on discussion with RN's at ___
___, they also confirm this is chronic. They were giving her
morphine and tramadol but are unable to provide doses or other
info about the MAR. Though she was given IV antibiotics in the
ED, she has no evidence of cellulitic skin changes on admission
exam so these were not continued. Her BLE pain may be related
to acute osteoarthritic pain vs her venous stasis, however given
her elevated Hemoglobin A1c 9.3, neuropathy likely contributing
to her symptoms. Doppler ___ was negative for DVT. Her home
tramadol was increased to 50mg and she was restarted on 15mg of
morphine ___ (Previously on 30mg morphine ___ which was
discontinued on last admission d/t oversedation, however ___
___ had been giving her morphine for pain), morphine was later
discontinued during her admission.
-Given likely underlying neuropathy, her Gabapentin continued to
be titrated and on discharge she is on 400mg TID.
#Vitamin D deficiency: Vitamin D level 15, was started on ___
units qweekly on ___, she will be discharged with an
additional 8 weeks of Vitamin D weekly, please recheck a level
post discharge.
# Pressure ulcers over buttocks:
Patient reports that she has been having significant bilateral
buttock pain from her stay at rehab due to aggressive skin care.
Currently has skin breakdown over her buttocks without any
evidence of active infection.
# Morbid obesity:
BMI 62-63. Patient not ambulatory, only able to apply partial
weight bearing with transfers from wheelchair. Pt worked with
patient and plan to d/c back to ___. Her estimated length of
stay is <30 days.
# T2DM: A1c was noted to be 9.3, ___ was consulted given her
increased A1c since being in rehab. She stated she was eating a
regular diet while in rehab. Diet was continued as diabetic diet
while hospitalized. Her insulin dosing was modified and on
discharge she is on 66 units 70/30 insulin in the morning and 44
units at dinner along with a sliding Humalog scale. In addition,
she was started on a statin while hospitalized given her
underlying diabetes and hypertension.
# Asthma/COPD: Continue home albuterol, fluticasone, montelukast
# HTN: Continued home Bumex, ___ (on valsartan here as
irbesartan is non-formulary). Can resume irbersartan on
discharge.
# OSA: Patient initially refused BiPAP then was continued on
BiPAP while hospitalized. BiPAP: Settings:
Inspiratory pressure (Pressure support) 3 cm/H2O
Expirator
# Seasonal allergies: Continued home medications
Transitional issues:
-Follow-up Vitamin D level in 2 months, complete ___ units on
8 weeks from ___
-Repeat CBC and chemistries/LFTs, and lipids as outpatient
-Yearly ophthalmology exam given underlying diabetes
-Monitor glucose as outpatient and recheck A1c in 3 months
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eye
2. Baclofen 10 mg PO TID
3. Gabapentin 300 mg PO TID
4. NPH 30 Units Breakfast
NPH 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
8. Aspirin 81 mg PO DAILY
9. Bumetanide 2 mg PO DAILY
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
11. Cyanocobalamin 1000 mcg PO DAILY
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Fluticasone Propionate NASAL 1 SPRY NU BID
14. irbesartan 150 mg oral BID
15. Montelukast 10 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Cetirizine 10 mg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD QPM right lower back
4. Lidocaine 5% Patch 1 PTCH TD QAM to hip
5. Senna 8.6 mg PO BID constipation
6. Vitamin D ___ UNIT PO 1X/WEEK (FR)
7. NPH 30 Units Breakfast
NPH 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
11. Artificial Tears ___ DROP BOTH EYES PRN dry eye
12. Aspirin 81 mg PO DAILY
13. Baclofen 10 mg PO TID
14. Bumetanide 2 mg PO DAILY
15. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral BID
16. Cyanocobalamin 1000 mcg PO DAILY
17. Fluticasone Propionate 110mcg 2 PUFF IH BID
18. Fluticasone Propionate NASAL 1 SPRY NU BID
19. Gabapentin 300 mg PO TID
20. irbesartan 150 mg oral BID
21. Montelukast 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall at home
Chronic bilateral lower extremity pain
Uncontrolled diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with lift device to chair or
wheelchair.
Discharge Instructions:
Ms. ___,
You came in after having a fall at home. We did some x-rays
which did not show any fractures or obvious injuries. We think
that your leg pain is due to your chronic back and neuropathy
issues. We do not think there was any obvious infection of your
skin or soft tissues. We are discharging you to a rehab
facility so that you can continue to get physical therapy and
the help that you need so that you don't have further falls.
It was a pleasure taking care of you at ___
___.
Followup Instructions:
___
|
19905556-DS-5 | 19,905,556 | 27,307,539 | DS | 5 | 2166-12-29 00:00:00 | 2166-12-31 05:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Sulfa (Sulfonamide Antibiotics) / Nsaids / lisinopril /
egg / iodine
Attending: ___
Chief Complaint:
left leg cellulitis
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
60 morbidly obese female with PMH IDDM, ___ DVT in past,
diverticulosis, HTN, COPD on 3L home O2 p/w RLE welling, warmth,
erythema, and exquisite tenderness to palpation since yesterday
afternoon. Patient reports that she has had infections in her R
leg before. She is not sure how long the redness and swelling
has been there. She also notes that she has had fevers and
chills for a couple days duration.
Patient unable to quantify how long leg as been swollen and
erythematous. Reports some difficulty recalling vents since
yesterday in the setting of brother-in-law's funeral. Reports
some fevers/chills with feelings of skin tightness in RLE.
Denies chest pain, shortnesss of breath, dysuria. Reports she
was out in the sun yesterday but her legs were covered. Low
grade temp and tachycardia on admit. Skin sloughing, erythema,
edema of RLE xtending up right lateral thigh, with no crepitus
noted on exam. exquisitly tender to touch.
In the ED, initial vs were:10 100.3 112 136/63 18 98%. Physical
exam was notable for skin sloughing, erythema, edema of RLE
extending up right lateral thigh, with no crepitus noted on
exam, exquisetly tender. Labs were remarkable for WBC of 16.8.
Ultrasound negative for DVT. Patient was given vancomycin and
morphine and 2 liters of IVF.
On the floor, vs were: 99.1, 140/62, 86, 20, 100% 2 L NC.
Patient reports that pain is improved and ankle movement is also
improved.
Past Medical History:
-COPD, 3L home O2
-Diabetes mellitus
-Hypertension
-Coronary artery disease
-Crohn's Disease
-Umbilical hernia, s/p repair, s/p recurrence, h/o SBO
-S/p cholecystectomy and appendectomy
-Spinal stenosis
-Chronic back pain
-History of DVT during hospitalization
-Morbid obesity
-OSA, on BIPAP at home
-OA/DJD
Social History:
___
Family History:
-Mother: ___, leukemia
-Father: No pertinent history
-Brother: ___, lung cancer with metastases
-Sister: ___ cancer
-Niece: ___ cancer
-___ bleeding diastheses or GI cancers
Physical Exam:
ADMISSION EXAM:
.
Vitals: 99.1, 140/62, 86, 20, 100% 2 L NC
General: alert, obese, NAD
HEENT: PERRLA, EOMI
Neck: supple, no LAD
Lungs: CTAB, poor inspiratory effort
CV: RRR no MRG, distant heart sounds
Abdomen: soft, NT, obese, exam limited by body habitus
Ext: RLE with warmth, erythema and tenderness to palpation,
desquamated and depigmented area on medial lower leg
Skin: see above
Neuro: CN II-XII intact, alert and oriented
Discharge exam:
Tc 98.5, BP 110/68, HR 93, RR 18, ___
General: well-appearing, AO x 3, NAD
Back: non-tender spinous processes without any obvious
deformities
Ext: RLE with markedly decreased erythema, warmth, minimal TTP;
+resolving bullae w/eschar overlying prior bullae
Neuro: distal MS in ___ ___ no saddle anesthesia
Pertinent Results:
ADMISSION LABS:
.
___ 10:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-1
___ 10:30PM URINE HYALINE-3*
___ 04:00PM LACTATE-1.2
___ 03:55PM GLUCOSE-175* UREA N-12 CREAT-0.7 SODIUM-141
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-29 ANION GAP-17
___ 03:55PM estGFR-Using this
___ 03:55PM CALCIUM-9.7 PHOSPHATE-2.4* MAGNESIUM-1.7
___ 03:55PM WBC-16.8*# RBC-4.07*# HGB-11.5*# HCT-35.0*#
MCV-86 MCH-28.3 MCHC-32.9 RDW-13.7
___ 03:55PM NEUTS-87.5* LYMPHS-7.4* MONOS-4.4 EOS-0.6
BASOS-0.2
___ 03:55PM PLT COUNT-221
.
___ Dopplers ___: neg for DVTs
.
DISCHARGE LABS:
___ 05:55AM BLOOD WBC-10.4 RBC-4.40 Hgb-12.0 Hct-37.9
MCV-86 MCH-27.4 MCHC-31.8 RDW-13.5 Plt ___
___ 03:55PM BLOOD Neuts-87.5* Lymphs-7.4* Monos-4.4 Eos-0.6
Baso-0.2
___ 05:55AM BLOOD Glucose-135* UreaN-13 Creat-0.7 Na-141
K-3.6 Cl-93* HCO3-39* AnGap-13
___ 05:55AM BLOOD Calcium-9.9 Phos-3.7 Mg-1.7
.
___ LS spine plain film: degenerative changes; no fracture or
dislocation
Brief Hospital Course:
___ yo F with PMH morbidly obese female with PMH IDDM, ___ DVT
in past, diverticulosis, HTN, COPD on 3L home O2 presenting with
RLE swelling, warmth, erythema.
.
ACUTE ISSUES:
.
# RLE Cellulitis: Patient presented with RLE swelling, warmth,
erythema. She has a history notable for ___ DVTs, however lower
extremity dopplers were negative. Exam was most consistent with
cellulitis. There was no evidence of deeper soft tissue
infection on exam. Given her history of DM and recent freshwater
exposure, she was intially treated with Vancomycin and Zosyn IV
for broad coverage. After 48 hours and no sign of abscess or
crepitation with improvement of exam, patient was switched to PO
Augmentin. Prior to discharge Doxycycline was added to her
treatment regimen as it was discovered she had a positive MRSA
nasal swab on prior hospitalization at OSH. She was discharged
and advised to complete a ten day course of Augmentin and
Doxycyline from day of discharge.
#Urinary retention: Foley catheter was placed due to limited
mobility and difficulty urinating in bed. It was discontinued
___, however patient was unable to urinate and foley was
re-inserted producing 500cc of urine. The retention is likely
secondary to medication. A neurologic cause was unlikely with
no spinal point tenderness or signs of cauda equina on exam. LS
spine film without any actue pathology. Patient had foley d/c'd
on day of discharge with good urine output prior to leaving the
hospital.
CHRONIC ISSUES:
.
#Diabetes:
- Home NPH plus sliding scale was continued
#Hypertension:
- Home irbesartan was continued
#Coronary Artery Disease: CAD status post stent placement in
past.
- Home aspirin 81 mg daily was continued
#Obstructive Sleep Apnea: She has chronic and long-standing OSA.
- Home CPAP was continued
#Chronic Obstructive Pulmonary Disease: Chronic and stable. No
evidence of acute exacerbation. On 3 L NC at home.
- Home montelukast Sodium 10 mg PO/NG daily was continued
- Home Albuterol 0.083% Neb Soln 1 NEB IH every 6 hours as
needed was continued
#Chronic Pain: She has chronic and stable back pain.
- Home MS ___ was continued
- Home Baclofen 10 mg PO/NG TID as needed for pain was continued
- Home Tramadol 100 mg PO QAM and QHS, and 50mg PO at noon was
continued
TRANSITIONAL ISSUES:
- Continue Augmentin 500 mg PO every 8 hours and Doxycycline 500
mg PO twice a day for total post-hospitalization course of 10
days
- Will require rehab for ___ weeks given limited mobility
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Montelukast Sodium 10 mg PO DAILY
2. Fluticasone Propionate NASAL 1 SPRY NU BID
3. TraMADOL (Ultram) 50-100 mg PO TID:PRN pain
4. Morphine SR (MS ___ 30 mg PO DAILY
5. Baclofen 10 mg PO TID:PRN pain
6. irbesartan *NF* 75 mg Oral BID
7. Fluticasone Propionate 110mcg 2 PUFF IH BID
8. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q ___ hrs PRN dyspnea
9. Bumetanide 4 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Protopic *NF* (tacrolimus) 0.1 % Topical BID
to right ankle
12. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
13. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3)
600-125 mg-unit Oral BID
14. Ascorbic Acid ___ mg PO DAILY
15. NPH 20 Units Breakfast
NPH 22 Units Bedtime
Insulin SC Sliding Scale using lispro Insulin
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Baclofen 10 mg PO TID:PRN pain
5. Bumetanide 4 mg PO DAILY
6. Cyanocobalamin 50 mcg PO DAILY
7. Fluticasone Propionate NASAL 1 SPRY NU BID
8. NPH 20 Units Breakfast
NPH 22 Units Bedtime
Insulin SC Sliding Scale using lispro Insulin
9. irbesartan *NF* 75 mg ORAL BID
10. Montelukast Sodium 10 mg PO DAILY
11. Morphine SR (MS ___ 30 mg PO DAILY
12. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
last dose ___
13. Docusate Sodium 100 mg PO BID
14. Doxycycline Hyclate 100 mg PO Q12H
last dose ___
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 1 TAB PO BID
17. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3)
600-125 mg-unit Oral BID
please administer at least 2 hours before or after doxycycline
18. Fluticasone Propionate 110mcg 2 PUFF IH BID
19. HydrOXYzine 10 mg PO DAILY:PRN itching
20. Potassium Chloride 20 mEq PO BID
Hold for K > 4.5
21. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation Q ___ hrs PRN dyspnea
22. Protopic *NF* (tacrolimus) 0.1 % Topical BID
23. TraMADOL (Ultram) 100 mg PO QAM AND QHS pain
RX *tramadol 50 mg 2 tablet(s) by mouth qAM and qHS Disp #*12
Tablet Refills:*0
24. TraMADOL (Ultram) 50 mg PO NOON pain
RX *tramadol 50 mg one tablet(s) by mouth at noon daily Disp #*3
Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#PRIMARY:
- cellulitis
- urinary retention
#SECONDARY:
- COPD, 3 liters home oxygen
- Diabetes mellitus
- Hypertension
- low back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___
___.
You were admitted due to an infection of the skin on your leg or
cellulitis. We made sure you did not have a clot in your leg by
doing an ultrasound. You were treated with intravenous
antibiotics initially, but we transitioned to oral antibiotics
when the infection in your skin began to improve. We performed
an XR of your lower spine which showed no fracture or
dislocation as a cause of your pain.
NEW MEDS:
Augmentin 500mg PO every 8 hours (last dose ___
Doxycycline 100mg twice a day (last dose ___
Followup Instructions:
___
|
19905556-DS-7 | 19,905,556 | 26,911,900 | DS | 7 | 2169-04-23 00:00:00 | 2169-04-23 21:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Sulfa (Sulfonamide Antibiotics) / Nsaids / lisinopril /
egg / iodine
Attending: ___.
Chief Complaint:
___ w/ COPD, T2DM, prior cellulitis presents with 2 weeks of
drainage from RLE lesions.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Two weeks prior to admission, Ms. ___ was in her usual state
and had noticed wide-based blisters developing on her right
lower extremity (RLE). While she was using a washcloth on her
right leg, she noted the removal of skin from a blister with
immediate drainage of clear fluid. Given her body habitus, she
cannot directly visualize her lower extremities. However, she
noted continued leakage based on the wetness on her clothes. She
believes the leakage rate increased over time, and 4 days prior
to admission noted the leakage of milky white fluid from the
lesions. That day, she was seen by her PCP who believed the
lesions to be venous stasis ulcers. She denies fevers and
endorses feeling chilly. On ___ she presented to the
___ ED due to concern about possible cellulitis.
She denies interaction with cats or dogs, any recent trauma,
gardening, and exposure to freshwater.
#Review of Systems:
(+) per HPI and chronic intermittent headache, vision changes,
dyspnea on exertion, periumbilical abdominal pain, constipation.
(-) fever, night sweats, sore throat, cough, shortness of
breath at rest, chest pain, nausea, vomiting, diarrhea,
hematochezia, dysuria.
Past Medical History:
SLEEP APNEA, nonadherent to BIPAP at home due to nosebleeds
Asthma with chronic obstructive pulmonary disease (COPD), on 3L
NC at home
DM (diabetes mellitus), type 2 with neurological complications
ANEMIA
Hypertension, essential
DEPRESSIVE DISORDER
ANXIETY STATES, UNSPEC
VITAMIN D DEFIC, UNSPEC
CROHN'S DISEASE
Fibromyalgia
Cellulitis ___ years ago, hospitalized at ___ for rx)
MRSA ___ (documented at ___)
Social History:
___
Family History:
-Mother: ___, leukemia
-Father: ___, cancer not specified
-Brother: ___, lung cancer with metastases
-Sister: ___ cancer
-Niece: lung cancer
Physical Exam:
==================
EXAM ON ADMISSION
==================
Vitals- T 98.3 HR 90 BP 166/51 RR 18 SaO2 95%(3L)
General: Woman with large body habitus laying in bed.
CV: RRR, mild systolic murmur
Lungs: CTAB
Abdomen: Bowel sounds present, protuberant, nontender
GU: no foley
Ext: Pitting edema throughout lower extremities up to the knee.
RLE: 3 1x1 cm contiguous areas of apparent granulation
tissue w/ serous drainage w/ a single 0.5x0.5 cm area of similar
appearance just proximal. These areas are raised compared to
surrounding skin and tender to palpation. Just medial to these
is a raised, tense lesion that appears as though it could be a
precursor lesion. Surrounding all of these is mild induration,
erythema, and warmth. In addition, there is deeper pigmentation
of the distal extremity along with an area of hypopigmentation
on the medial heel.
LLE: Dry and scaly, with a few isolated areas of deeper
pigmentation.
Neuro: AOx3, responsive to questions and commands, moves all 4
extremities at will. Diminished sensation to light touch on
plantar aspects bilaterally.
Skin: see above
==================
EXAM ON DISCHARGE
==================
Vitals- Tmax 98.7, Tcurr 98.5, HR 80, BP 158/62, RR 20, SaO2
96%(BiPAP)
General: Woman with large body habitus sitting in her power
chair.
CV: RRR, mild systolic murmur
Lungs: CTAB
Abdomen: Bowel sounds present, protuberant, nontender
GU: no foley
Ext: Pitting edema throughout lower extremities up to the knee.
RLE: Under dressing, there are 3 1x1 cm contiguous areas of
apparent granulation tissue (was purulent yesterday) w/ a single
0.5x0.5 cm area of similar appearance just proximal. These areas
are tender to palpation. Interval decrease in the surrounding
induration, erythema, and warmth. In addition, there is deeper
pigmentation of the distal extremity along with an area of
hypopigmentation on the medial heel that is erythematous.
LLE: Dry and scaly, with a few isolated areas of deeper
pigmentation.
Neuro: AOx3, responsive to questions and commands, moves all 4
extremities at will. Diminished sensation to light touch on
plantar aspects bilaterally.
Skin: see above
Pertinent Results:
LABS AT ADMISSION:
___ 01:50PM BLOOD WBC-9.4 RBC-4.02 Hgb-10.9* Hct-36.9
MCV-92 MCH-27.1 MCHC-29.5* RDW-14.2 RDWSD-47.8* Plt ___
___ 01:50PM BLOOD Neuts-71.1* Lymphs-17.0* Monos-6.8
Eos-4.3 Baso-0.4 Im ___ AbsNeut-6.69* AbsLymp-1.60
AbsMono-0.64 AbsEos-0.40 AbsBaso-0.04
___ 01:50PM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-142
K-4.7 Cl-103 HCO3-32 AnGap-12
___ 01:50PM BLOOD Calcium-10.6* Phos-3.6 Mg-1.8
___ 06:30AM BLOOD CRP-10.2*
___ 02:58PM BLOOD Lactate-1.4
IMAGING:
X-ray right tib/fib ___:
No radiographic evidence for osteomyelitis. Diffuse soft tissue
swelling.
Right lower extremity ultrasound ___:
Extremely limited examination secondary to patient's known right
lower extremity cellulitis. No evidence of deep venous
thrombosis in the right lower extremity veins.
LABS PRIOR TO DISCHARGE:
___ 07:00AM BLOOD WBC-9.7 RBC-3.98 Hgb-10.7* Hct-37.0
MCV-93 MCH-26.9 MCHC-28.9* RDW-14.2 RDWSD-48.2* Plt ___
___ 07:00AM BLOOD Glucose-178* UreaN-11 Creat-0.6 Na-140
K-4.4 Cl-100 HCO3-32 AnGap-12
___ 06:30AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.6
Brief Hospital Course:
Ms. ___ is a ___ with T2DM, COPD, and prior cellulitis who
presents with RLE lesions most consistent with cellulitis ___
venous stasis dermatitis.
ACTIVE ISSUES:
# Right ___ Cellulitis: patient presented with lesions most
consistent w/ cellulitis ___ venous stasis dermatitis. Notably,
patient had cellulitis in the RLE in ___. Differential included
uninfected stasis dermatitis, but the pt-reported milky-white
drainage and surrounding erythema argue against this. Thus, we
empirically treated for MRSA (given documented carrier status at
OSH) and Strep w/ vanc and penicillin G along with mild limb
elevation (which was limited by patient's body habitus).
On HD2, there was interval worsening of pain and purulence,
likely ___ antibiotic treatment and release of pro-inflammatory
substances from killed bacteria. A right lower extremity US was
limited but negative for DVT. CRP was 10.2, below the range
concerning for osteo. Wound care placed a dressing. On HD3, the
erythema and purulence were markedly improved compared w/
presentation, and we transitioned to clindamycin PO. She was
discharged on HD4 w/ plan for 12 more days of treatment.
CHRONIC CONTROLLED ISSUES:
# COPD: remained stable on home medications and 3L O2.
# Sleep apnea: currently not using BIPAP at home, we encouraged
BiPAP use in the hospital.
# T2DM: remained stable on home medications.
# Back pain: remained stable on home medications.
TRANSITIONAL ISSUES:
# RLE Cellulitis: needs to continue taking PO clindamycin for 10
days
Last day ___
# Lower extremity edema: could be ___ right heart failure,
itself possibly ___ cor pulmonale.
- please consider echocardiogram (none in our records)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 150 mg oral BID
2. Montelukast 10 mg PO DAILY
3. Morphine Sulfate ___ 30 mg PO Q8H:PRN pain
4. NPH 33 Units Breakfast
NPH 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Potassium Chloride 20 mEq PO BID
6. TraMADOL (Ultram) 50 mg PO TID:PRN pain
7. Baclofen 20 mg PO TID
8. HydrOXYzine 10 mg PO DAILY:PRN very itchy
9. Fluticasone Propionate 110mcg 4 PUFF IH BID
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
13. Aspirin 81 mg PO DAILY
14. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
The Preadmission Medication list is accurate and complete.
1. irbesartan 150 mg oral BID
2. Montelukast 10 mg PO DAILY
3. Morphine Sulfate ___ 30 mg PO Q8H:PRN pain
4. NPH 33 Units Breakfast
NPH 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Potassium Chloride 20 mEq PO BID
6. TraMADOL (Ultram) 50 mg PO TID:PRN pain
7. Baclofen 20 mg PO TID
8. HydrOXYzine 10 mg PO DAILY:PRN very itchy
9. Fluticasone Propionate 110mcg 4 PUFF IH BID
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
13. Aspirin 81 mg PO DAILY
14. Ascorbic Acid ___ mg PO DAILY
15. Clindamycin 450 mg PO Q6H Until ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Cellulitis
Venous stasis dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at the ___. You were
admitted for treatment of cellulitis. You were treated with
antibiotics and with elevation of your right leg to help drain
the infected fluids. We also had our wound care nurses place ___
dressing over the blisters. The cellulitis improved so we felt
you were ready to continue treatment from home.
However, the cellulitis infection is not yet cured, please
continue to take the antibiotic called Clindamycin until
___. We also will have a visiting nurse assist with
changing your leg dressing.
We'd also like you to follow-up with your PCP.
Sincerely,
-- Your ___ Care Team
Followup Instructions:
___
|
19905604-DS-13 | 19,905,604 | 28,930,379 | DS | 13 | 2176-05-15 00:00:00 | 2176-05-15 13:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / ciprofloxacin /
pregabalin / metoprolol
Attending: ___
Chief Complaint:
Facial droop/dysarthria
Major Surgical or Invasive Procedure:
left craniotomy for tumor resection on ___
History of Present Illness:
___ with history of ETOH use presents as transfer from OSH with
facial droop and dysarthria for the past 3 days. He feels that
the facial droop has improved, but was concerned for stroke so
presented to the ED on ___. NCHCT at OSH revealed and area of
left frontoparietal edema concerning for underlying lesion. He
was given 10mg dexamethasone and transferred to ___.
Past Medical History:
Asthma
CAD
NIDDM
GERD
High Cholesterol
Hypertension
MI
Shift work sleep disorder
ETOH abuse
PTSD
Bipolar Type II
fibromyalgia
Social History:
___
Family History:
Non-contributory
Physical Exam:
At time of discharge:
Patient is alert and oriented to person, place and time. Left
pupil 4R, R 3R. Slight right facial asymmetry that activates
with smiling.
No pronator drift
Moves all extremities ___.
Incision is clean, dry and intact.
Pertinent Results:
Please see OMR for pertinent laboratory or imaging results.
Brief Hospital Course:
Mr. ___ was admitted on ___ from OSH for urgent
work-up & treatment of left frontoparietal edema concerning for
underlying lesion.
#Left brain mass
The patient was admitted to the ___ Neurosurgery service on
___ and started on Keppra for seizure prophylaxis and
Dexamethasone for cerebral edema. Pre-op work-up including CT
C/A/P was negative for intrathoracic or abdominopelvic
pathology. MRI head demonstrated a 2.5 cm irregular peripheral
enhancing mass with moderate associated vasogenic edema within
the left operculum and subinsular region. No other lesions were
identified.
The patient was taken to the operating room for left craniotomy
for tumor resection on ___ with Dr. ___. There were no
adverse events in the operating room; please see operative note
for full details. Frozen pathology revealed high grade glioma. A
subgaleal JP drain was placed intraoperatively & was closely
monitored post-op until output was minimal; the JP drain was
subsequently removed on POD 2. The patient was extubated in the
OR, and taken to the PACU. Postop head CT showed "Expected
postoperative changes status-post left frontotemporal craniotomy
and left temporal lobe mass resection. No large intracranial
hemorrhage."
He was transferred to the Neuro Step Down Unit on POD#0. MRI of
the head with and without contrast on POD#1 demonstrated no
acute complication.
The patient was alert and oriented throughout his
hospitalization; pain was well managed with IV+PO and then only
PO pain regimen. He was continued on a regimen of Keppra 1g BID
for seizure prophylaxis for 7 days post-operatively and
Dexamethasone 4mg 6hr. He was discharged on a dexamethasone
taper.
Blood Sugars
The patient had moderately elevated blood sugars during his
hospitalization secondary to his Decadron. After review of his
sugar and insulin intake, the patient was deemed safe to go home
with ___ and daily blood sugar checks while on his Decadron
wean. The patient expressed understanding and wiliness to go
home. He was advised to follow up with his PCP if ___ found him
to have continued elevated sugars.
Dispo
On POD#2, he was evaluated by the inpatient radiation oncology
service who will follow up on final pathology for treatment
planning. He was scheduled for outpatient follow up with the
Brain Tumor Clinic after discharge for treatment planning.
The patient was discharged on ___. At the time of
discharge, the patient was doing well, was afebrile and
hemodynamically stable. The patient was tolerating a regular
diet, ambulating independently with steady gait, voiding without
issues, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
Lamictal 200mg daily
Norvasc 5mg daily
Provigil 200mg daily
losartan 25mg BID
lorazepam 0.5mg daily PRN
Wellbutrin XL 300mg daily
ProAir HFA
Niacin 1000mg daily
Sildenafil 100mg daily PRN
Fish oil 1200mg daily
Vit D3 1000units daily
QVar 2puff BID PRN
MVI with Iron
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4G in a 24 hour period.
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Dexamethasone 4 mg PO Q8H
4mgq8hx1dose, 3mgq8x6doses, 2mgq8hx6doses, then continue on
1mgBIDx4doses
Tapered dose - DOWN
RX *dexamethasone 1 mg 4 tablet(s) by mouth see tapered
instructions Disp #*34 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Famotidine 20 mg PO BID
RX *famotidine 40 mg 1 tablet(s) by mouth daily Disp #*10 Tablet
Refills:*0
6. Insulin SC
Sliding Scale
Fingerstick QACHS, HS
Insulin SC Sliding Scale using REG Insulin
7. LevETIRAcetam 1000 mg PO BID Duration: 7 Days
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*5 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 17.2 mg PO QHS:PRN constipation
Use when taking narcotic medication.
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
12. amLODIPine 5 mg PO DAILY
13. BuPROPion XL (Once Daily) 300 mg PO DAILY
14. LamoTRIgine 200 mg PO DAILY
15. Losartan Potassium 25 mg PO BID
16. Modafinil 200 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left brain mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Brain Surgery
You underwent surgery to remove a brain lesion from your
brain.
Please keep your incision dry until your staples are removed.
You may shower at this time but keep your incision dry.
It is best to keep your incision open to air but it is ok to
cover it when outside.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may experience headaches and incisional pain.
You may also experience some post-operative swelling around
your face and eyes. This is normal after surgery and most
noticeable on the second and third day of surgery. You apply
ice or a cool or warm washcloth to your eyes to help with the
swelling. The swelling will be its worse in the morning after
laying flat from sleeping but decrease when up.
You may experience soreness with chewing. This is normal from
the surgery and will improve with time. Softer foods may be
easier during this time.
Feeling more tired or restlessness is also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Please call ___ with any questions or concerns.
Followup Instructions:
___
|
19905646-DS-18 | 19,905,646 | 23,539,856 | DS | 18 | 2161-07-25 00:00:00 | 2161-07-26 15:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceftriaxone / Codeine / Rocephin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary Catheterization
History of Present Illness:
___ with hx of CAD s/p CABG (LIMA-LAD and SVG-OM) and DES to Lcx
___, DM, COPD, and CVA who presents with chest pain since
___ AM (<___). Pain started acutely at 4AM yesterday
described as left-sided with radiation to the right side. She
describes it as lasting minutes at a time. She states she felt
some dyspnea during her shower on ___ afternoon and had to
rest afterwards, which is unusual for her. She described the
pain as feeling similar to her prior heart attacks when they
started. She states that last night it worsened with significant
diaphoresis and continued intermittent pain throughout the day
today, always lasting <5min and usually <2min. She endorses
night sweats x 2 days but no fever/chills/cough. Denies
orthopnea, palps, PND. She does endorse 2 weeks of R leg
swelling, which she has had unilaterally and bilaterally in the
past. She denies recent plane travel. The pain is worse with
yawning but not necessarily all deep breaths. She describes
relief with nitroglycerin and took aspirin 325mg x2 prior to
arrival.
In the ED, initial vitals were 98.6, 66, 112/52, 16, 100%RA
Labs and imaging significant for EKG in NSR @ 61, TWI's in V1-V3
which is her baseline, initial trop negative, Chem 7 significant
for glucose of 304, CBC with baseline anemia of 30.6, nl coags.
Patient given SL nitroglycerin x 1, morphine 5mg IV x 1 and
started on a heparin drip with bolus for CP experienced in ED.
Admitted to ___ for further management per cardiology
attending. VS prior to transfer were: 97.9 61 16 110/52 100%ra.
On arrival to the floor, she states her neuropathy pain is
bothering her but denies CP or SOB. She declines DRE at this
time, not done in ED though denies BRBPR or melena.
REVIEW OF SYSTEMS
On review of systems, s/he denies any prior history of 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 dyspnea on
exertion, orthopnea, PND, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: (+) Diabetes, (+) Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
___ mm BMS to mid-LCx
___ Cypher to mid-LAD
___ CABG LIMA-LAD and SVG-OM totally occluded RCA
___ s/p DES to Lcx
-PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
Hypertension
Diabetes Type 1 since age ___
Neuropathy
Retinopathy
CVA with short term memory loss - ___
COPD
Hypothyroidism
Multiple UTI
S/P arthroscopic left knee surgery
Bulging discs
Social History:
___
Family History:
The patient reports that her father had an MI in his ___ and
recently had CABG x2; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS- T=98.4 BP=120/63 HR=63 RR= 18 O2 sat=
GENERAL- WDWN female in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Upper dentures in place.
NECK- Supple with no JVD, -HJR.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- Trace pitting edema in RLE, none in LLE. No femoral
bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ DP palp ___ palp
Left: Carotid 2+ Femoral 2+ DP palp ___ palp
.
DISCHARGE PHYSICAL EXAMINATION:
VS- 98.3, 98.4, 93/44 (90-115/41-64), 70 (65-80), 18, 98RA
GENERAL- WDWN female in NAD. AOx3. Mood, affect appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
Upper dentures in place.
NECK- Supple with no JVD, -HJR.
CARDIAC- RRR, normal S1, S2, soft ___ SEM at LSB. No thrills,
lifts. No S3 or S4.
LUNGS- CTAB, no w/r/r
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- Trace pitting edema in RLE, none in LLE. No femoral
bruits. Right groin site with clean dressing, minimal
tenderness, good femoral pulse, and palpable ___ pulses
Pertinent Results:
ADMISSION LABS:
---------------
___ 06:30PM BLOOD WBC-7.8 RBC-3.41* Hgb-10.1* Hct-30.6*
MCV-90 MCH-29.6 MCHC-33.0 RDW-14.0 Plt ___
___ 06:30PM BLOOD Neuts-75.4* ___ Monos-2.9 Eos-1.3
Baso-0.2
___ 06:30PM BLOOD ___ PTT-22.8* ___
___ 06:30PM BLOOD Glucose-304* UreaN-17 Creat-0.8 Na-137
K-4.2 Cl-103 HCO3-20* AnGap-18
___ 06:30PM BLOOD CK-MB-5
___ 06:30PM BLOOD cTropnT-<0.01
___ 06:30PM BLOOD Calcium-8.8 Phos-3.2# Mg-1.9
.
DISCHARGE LABS:
---------------
___ 06:33AM BLOOD WBC-5.0 RBC-3.48* Hgb-10.2* Hct-31.6*
MCV-91 MCH-29.3 MCHC-32.3 RDW-14.2 Plt ___
___ 06:33AM BLOOD Glucose-233* UreaN-15 Creat-0.8 Na-135
K-4.6 Cl-99
___ 06:33AM BLOOD Mg-2.0
.
PERTINENT LABS:
---------------
___ 06:30PM BLOOD CK-MB-5
___ 06:30PM BLOOD cTropnT-<0.01
___ 03:09AM BLOOD CK-MB-4 cTropnT-<0.01
___ 10:35AM BLOOD CK-MB-3 cTropnT-<0.01
___ 03:09AM BLOOD %HbA1c-11.1* eAG-272*
.
MICRO/PATH: NONE
-----------
.
IMAGING/STUDIES:
----------------
ECG ___:
Sinus rhythm. Short P-R interval. Compared to prior tracing of
___, the rate has slowed. There is variation in precordial
lead placement which may account for the right precordial T wave
changes. There is Q-T interval prolongtaion. Followup and
clinical correlation are suggested.
.
CXR PA/LAT ___:
IMPRESSION: No evidence of acute disease.
.
Coronary Catheterization ___:
1. Left heart catheterization and selective coronary angiography
was
performed via right femoral access under ultrasound guidance,
with
placement of a 5 fr femoral sheath. A JL4 catheter was used for
the
native left coronary angiography. A JR 4 catheter was used to
perform
arterial conduit angiography of the SVG-OM. A ___ Fr ___ catheter
was used
to visualize the LIMA. Left heart catheterization was performed
using a
___ Fr pigtail catheter.
2. Limited hemodynamic studies showed normal central aortic
pressure of
110/47/63 mm Hg. LVEDP was elevated at about 20 mm Hg. There was
no
gradient across the aortic valve on pullback.
3. The left main was free of any visible luminal disease.
Proximal LAD
had diffuse 40-50% disease. LAD was chronically occluded at the
level of
the mid-LAD. Distal LAD was visualized via LIMA, and was widely
patent
with minor disease. The circumflex had diffuse 50-60% in-stent
restenosis proximally. The first obtuse marginal was diffusely
diseased
with a proximal 80% stenosis unchanged from before. Multiple
distal
obtuse marginal branches are widely patent and are also supplied
by a
widely patent SVG-OM. The right coronary artery is known to be
occluded,
and was not engaged with a catheter. Left-to-right collaterals
were
seen during injection of the left coronary artery.
4. Arterial conduit angiography demonstrated a widely patent
SVG-OM, and
a widely patent LIMA.
5. At the end of the procedure, the right femoral arteriotomy
site was
closed with an Exoseal closure device with excellent hemostasis.
FINAL DIAGNOSIS:
1. Three vessel coronary artery disease.
2. Patent LIMA-LAD, and SVG-OM.
3. Normal arterial pressure.
4. Mildly elevated LVEDP indicating diastolic dysfunction.
5. Advise intensive medical therapy. Did not find a good target
for PCI
that would explain her symptoms.
Brief Hospital Course:
___ with hx of CAD s/p CABG ___ LIMA-LAD and SVG-OM) and DES
to Lcx ___, DM, COPD, and CVA who presents with 1 day of
anginal chest pain and mild exertional SOB.
ACTIVE DIAGNOSES:
-----------------
# Anginal Chest Pain: Patient presented with symptoms concerning
for angina with suboptimal exercise echo stress test ___ year ago
showing possible ischemic changes on EKG. EKG during this
admission were without new ischemic changes, trops negative x 2,
exam without reproducibility of pain on palpation. Her pain was
predominantly sharp, transient (lasting seconds), induced by
exertion, relieved with rest, and non-radiating. She was started
on ranolazine 1000mg by mouth twice daily with decrease in the
frequency of her symptoms but did not become symptom-free. She
underwent a coronary catheterization without mostly stable prior
disease (three vessel CAD, patent LIMA-LAD, and SVG-OM). She was
discharged on aspirin 81mg PO daily (down from 650mg PO daily
that she had been taking), plavix 75mg PO daily, Imdur 90mg PO
daily (uptitrated from 60mg PO daily), and ranolazine as above.
She has outpatient follow-up arranged with her PCP and Dr.
___ in Cardiology.
CHRONIC DIAGNOSES:
------------------
# DM Type 1: Long term type 1 diabetic. A1c 11.1 on admission.
Hyperglycemic to 454 at one point likely exacerbated by pain and
with-holding some of her lantus due to NPO status. Her sugars
improved markedly with continuing her home lantus dose.
# HTN/HLD: Stable. No recent lipids in our system. Continued on
Atorvastatin 80mg daily and lisinopril 5mg PO daily.
# Chronic Neuropathic Pain: Stable. Likely neuropathic from
long-term poorly controlled DM1. Continued on neurontin at night
as well as home oxycontin and morphine. She was referred for
outpatient appointment for Dr. ___ in the pain clinic here.
# Depression: Stable. Continued on home prozac.
TRANSITIONAL ISSUES:
--------------------
-She is full-code
-She has outpatient follow-up with her cardiologist, PCP, and ___
pain specialist to attempt to wean her off some of her pain
medications as she states they don't help her
Medications on Admission:
ATORVASTATIN [LIPITOR] - 80 mg Tablet - 1 Tablet(s) by mouth
once a day
CLOPIDOGREL [PLAVIX] - 75 mg Tablet - one Tablet(s) by mouth
once a day
FLUOXETINE - (Prescribed by Other Provider) - 20 mg Tablet - 2
Tablet(s) by mouth once daily
INSULIN GLARGINE [LANTUS] - (Prescribed by Other Provider) - 100
unit/mL Solution - 24 Units q am
INSULIN LISPRO [HUMALOG] - (Prescribed by Other Provider) - 100
unit/mL Cartridge - to sliding scale ___ times daily
ISOSORBIDE MONONITRATE [IMDUR] - 30 mg Tablet Extended Release
24 hr - 2 Tablet(s) by mouth once a day
LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth once a day
MORPHINE - (Prescribed by Other Provider) - 15 mg Tablet - 2
Tablet(s) by mouth four times a day
NITROGLYCERIN [NITROSTAT] - 0.4 mg Tablet, Sublingual - one
Tablet(s) sublingually PRN for CP
OXYCODONE - (Prescribed by Other Provider) - 40 mg Tablet
Extended Release 12 hr - 1 Tablet(s) by mouth three times daily
ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet,
Delayed Release (E.C.) - 2 Tablet(s) by mouth once a day
GABAPENTIN 300 mg Tablet - 1 Tablet by mouth at bedtime
Discharge Medications:
1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
4. insulin glargine 100 unit/mL Solution Sig: ___ (24)
Units Subcutaneous QAM.
5. insulin lispro 100 unit/mL Cartridge Sig: One (1) unit
Subcutaneous As Directed: As directed per sliding scale.
6. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. morphine 15 mg Tablet Sig: Two (2) Tablet PO four times a day
as needed for pain.
8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1)
Sublingual once a day.
9. oxycodone 40 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO TID (3 times a day).
10. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
11. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
12. Imdur 30 mg Tablet Extended Release 24 hr Sig: Three (3)
Tablet Extended Release 24 hr PO once a day.
Disp:*90 Tablet Extended Release 24 hr(s)* Refills:*2*
13. ranolazine 1,000 mg Tablet Extended Release 12 hr Sig: One
(1) Tablet Extended Release 12 hr PO twice a day.
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
-Chronic Unstable Angina
Secondary:
-Poorly controlled DMI
-CAD s/p CABG and PCI
-Chronic Neuropathic Pain
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! You were admitted to ___
___ for evaluation and treatment of
chest pain. You were found to not be having a heart attack and
were started on ranolazine and had your home imdur dose
increased to help with your chest pain. You underwent a coronary
catheterization without significant changes in your coronary
disease from prior. Following the above medication changes your
symptoms improved but did not resolve completely.
The following changes have been made to your medications:
-START Ranolazine 1000mg by mouth BID
-INCREASE Imdur SR to 90mg by mouth once daily
-DECREASE Aspirin to 81mg by mouth daily
Please follow-up as instructed below.
Followup Instructions:
___
|
19906067-DS-19 | 19,906,067 | 24,552,279 | DS | 19 | 2132-06-19 00:00:00 | 2132-07-01 13:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cephalexin / Allopurinol And
Derivatives / Lasix
Attending: ___.
Chief Complaint:
Anemia, shortness of breath
Major Surgical or Invasive Procedure:
Transfusion 2 units packed red blood cells
History of Present Illness:
___ year old woman with multiple medical problems including DM2,
Hypertension,, CAD s/p MI with stent x 2 to RCA, breast CA with
ongoing anastozole tx, probable cirrhosis with known
GAVE/gastritis/grade I varices who presents with worsening
anemia. She was referred in by PCP for drop in Hct noted on
outpatient labs. She endorses increasingly frequent episodes of
chest pressure associated with SOB, for which she uses an
albuterol inhaler that helps some. She has also noticed
increasing swelling in her legs and weight gain over the past
few weeks amounting to ~20lbs. Her outpatient dose of Bumex was
increased to 2 mg PO daily with some improvement. Otherwise,
most of her chronic health issues have otherwise been at
baseline. She saw her orthopedist this morning and underwent
routine plain films to assess healing from her knee operations,
and these looked normal.
In the emergency room, initial vitals were T 97.5, HR 71, BP
151/54, RR 16, O2 sat 100% on RA. Hct was 22.9 with normal coags
and platelets of 141. She was noted to be guaiac positive in the
ED with yellow stool. Two ___ PIVs were placed. She was
referred for admission to medicine for further GI work up.
Vitals on transfer were T 98.4, HR 71, BP 155/47, RR 16, O2 sat
97% RA.
On the floor, she appears well. She has had occasional dry
cough, but no other cold or flu symptoms and no fevers. She has
___ normal bowel movements per day, no diarrhea or constipation,
and has never had blood in the stool or dark/tarry stool.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies palpitations. Denies cough, shortness of
breath, or wheezes. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias other
than her baseline osteoarthritis. Denies rashes or skin
breakdown. No numbness/tingling in extremities. No feelings of
depression or anxiety. All other review of systems negative.
Past Medical History:
- MI in ___ s/p 2 bare metal stents to RCA
- Type II diabetes
- Hypertension
- Diverticulosis (no history of GIB)
- History of gastritis, erosions, ulcer (___), followed by GI
and hepatology
- Cirrhosis by imaging (no biopsy, but followed by hepatology)
- Osteoarthritis s/p bilateral TKR (plate replacement in ___,
followed by ortho)
- Chronic UTI/cystitis
- Chronic kidney disease stage IV (estimated GFR 27)
- Breast cancer (right breast ___, s/p total mastectomy,
adjuvant radiotherapy and chemo, ___ left breast ___ s/p
partial mastectomy, radiation, chemo)
- Neutropenia (attributed to chemo vs. medication)
- TB age ___ admitted to sanatorium, treated with INH and
rifampin in ___
- B12 deficiency on outpatient injections
- Status post cholecystectomy
- ___ x 1
- Gout
Social History:
___
Family History:
Both of Mrs. ___ parents died of tuberculosis when she was
___, and she was an only child. More remote family history has
not been taken. Her six adult children are well.
Physical Exam:
Admission:
Vitals: T 96.7, BP 142/79, HR 68, RR 18, 100% on RA
GEN: No acute distress. Sitting up in bed, husband and son at
bedside.
HEENT: Mucous membranes moist, no lesions noted. Sclerae
anicteric. Mild conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
CV: Regular rate and rhythm, no murmurs, rubs ___
PULM: Clear to auscultation bilaterally, no wheezes, or rhonchi.
Faint rales at bases.
ABD: Soft, ___, non distended, bowel sounds present. No
hepatosplenomegaly.
EXTR: Peripheral edema bilaterally to the knees. Scars and some
distortion of the knees present from prior surgeries. 2+
Dorsalis pedis and radial pulses bilaterally.
NEURO: Alert and oriented x3.
SKIN: Mild palmar pallor. No ulcerations or rashes noted.
Prominant superficial capillaries noted on trunk.
Discharge:
Vital signs stable. Remainder of examination essentially
unchanged.
Pertinent Results:
Labs on admission:
___ 08:50AM UREA ___
___ TOTAL ___ ANION ___
___ 08:50AM ALT(SGPT)-21 AST(SGOT)-34 ALK ___ TOT
___
___ 08:50AM ___
___ 08:50AM ___
___
___ 08:50AM ___ VIT ___ TH
___
___ 08:50AM ___
___ 08:50AM ___
___ 08:50AM ___
___
___ 08:50AM ___
___
___ 08:50AM PLT ___
Labs at discharge:
___ 09:07AM BLOOD ___
___ Plt ___
___ 09:07AM BLOOD ___
___
ECG ___:
Artifact is present. Sinus rhythm. Left ventricular hypertrophy
with associated ___ wave changes, although ischemia or
infarction cannot be excluded. Compared to the previous tracing
of ___ there is no significant change.
Patella/femur films, left ___:
IMPRESSION: 1. No hardware complication. 2. Interval healing of
distal femur periprosthetic fracture.
CXR ___:
Moderate cardiomegaly is stable. Right lung is clear. Leftward
mediastinal shift is probably due to pleural restriction from
chronic calcific pleuritis, best seen on the lateral view, and
reflected in chronic left lower lobe atelectasis. No findings to
suggest acute infection or cardiac decompensation, although
moderate cardiomegaly including left atrial enlargement are both
chronic.
ECG ___: Sinus rhythm. Left ventricular hypertrophy with
associated ___ wave changes, although ischemia or infarction
cannot be excluded. There is a late transition which is probably
normal. Compared to the previous tracing of ___ there is no
significant change.
Brief Hospital Course:
HOSPITAL SUMMARY: Ms. ___ is an ___ with multiple medical
problems including GAVE, gastritis, and likely cirrhosis who was
referred for admission by her PCP with ___ low hematocrit (24 on
referral from baseline of ~30; 22.9 at the time of admission).
She was noted to be guaiac positive in the ED, but otherwise
asymptomatic including no BRBPR or dark/tarry stool. Her known
GAVE and gastritis and probable cirrhosis based on MRI imaging
(no liver bx) were felt to be likely contributing factors to
slow bleed, and given some concern for the possibility of
varices (grade I on prior EGD), the hepatology team was
consulted to perform EGD (vs. GI). Her gastroenterologist Dr.
___ was contacted regarding this admission (she follows
with both gastroenterology AND hepatology as an outpatient), and
also came by to see her during this admission. Iron studeis were
repeated as above. She was initially placed on IV PPI BID, and
Hct was trended BID. She received 2 units of pRBCs, with initial
good response; however, Hct then dipped to 25 the following
morning so she was kept ___ an additional night for
observation. Hct normalized on its own to 29 at discharge, and
she was discharged with plans to follow up with her outpatient
gastroenterologist. Given that she likely does have a slow
bleed, she may require small bowel follow through to be arranged
as an outpatient study. Until that time, she was asked to
decrease aspirin use to 81 mg QOD. Her cardiologist Dr. ___
was contacted and is aware of this change. She was also started
on carafate per hepatology recommendations.
CHRONIC ISSUES:
# HISTORY OF CIRRHOSIS: Platelets, INR stable. LFTs largely
normal and at her baseline. Dr. ___ hepatologist)
was notified of this admission, and she was evaluated by the
inpatient hepatology consult team (as above).
# CHRONIC KIDNEY DISEASE STAGE II: Creatinine is 1.7, near
baseline. Renally dosed medications. Trended creatinine
___, which was stable.
# LOWER EXTREMITY SWELLING: Recent worsening of peripheral edema
with increased Bumex dosing. She has not had an echo since ___,
at which time EF was normal. She has known LVH and possible
diastolic dysfunction. Continue Bumex at 2 mg PO daily (new
dose). On the evening of the blood transfusions, she also
received an additional ___ dose of 2 mg Bumex to prevent
volume overload/pulmonary edema with good effect. Her outpatient
cardiologist Dr. ___ was notified of this admission and
stopped by to see her ___ he will follow up as an
outpatient to ensure a planned echocardiogram continues to be
required, and titrate diuretics as needed.
# DIABETES MELLITUS TYPE II: On Lantus at home. Continued Lantus
22 units QHS. Continue humalog insulin SS (does not take
standing insulin with meals). Diabetic diet while ___.
Continued gabapentin, but at a lower dose of 300 mg PO daily
given renal dysfunction. Her PCP was updated regarding this
change of dose.
# HISTORY OF BREAST CANCER: Continued anastrozole (pharmacy able
to obtain off of formulary). Her outpatient oncologist Dr. ___
was notified of this admission.
# S/P KNEE REPLACEMENTS: Plain films done on the day of
admission (previously scheduled) are WNL for expected. Continued
calcium, vitamin D. Continued alendronate. OOB with walker as
tolerated. She will have outpatient F/U with ortho as previously
planned. Oxycodone PRN was used for breakthrough pain.
# INSOMNIA: Zolpidem 5 mg PO PRN (takes occasionally at home).
# OPHTHALMOLOGY: Continued timolol eye drops.
# GOUT: Allopurinol QOD was continued.
# CHRONIC UTI: Patient was previously on nitrofurantoin as UTI
suppression. However, given mixed evidence for efficacy at her
current GFR, this medication was held. Her nephrologist Dr.
___ PCP were contacted and made aware of this change.
Decision regarding an alternative suppressive agent was deferred
to the outpatient setting.
TRANSITION OF CARE:
- Follow up with gastroenterology for consideration of
outpatient small bowel follow through.
- Follow up with cardiology for consideration of outpatient
echocardiogram and further titration of Bumex dosing.
- Follow up with PCP (patient will confirm need for alternative
agent for UTI suppression, as well as lower dose of gabapentin).
- Patient was FULL CODE during this admission.
- Contact was daughter ___ is HCP (H: ___ C:
___
Medications on Admission:
- Anastrozole 1 mg PO daily
- Calcium ___ D3 500 ___ IU tab PO daily
- Vicodin ___ mg PRN (rarely takes)
- Lantus 22 units QHS
- Humalog insulin SS (no standing)
- B12 1000 mcg IM Qmonth
- Vitamin D3 5,000 IU daily
- Aspirin 81 mg PO daily
- Allopurinol ___ mg PO QOD (unsure whether took today)
- Acetaminophen ___ tab 325 mg PO daily
- Bumex 2 mg PO daily
- Albuterol 90 mcg IH PRN
- Timolol 0.5% eye drops
- Alendronate 70 mg PO Q ___
- Omeprazole 40 mg PO daily
- Zolpidem 5 mg PO QHS (takes infrequently)
- Metoprolol tartrate 50 mg QAM 100 mg QPM
- Oxycodone ___ tab 5 mg PO Q4H PRN (takes rarely)
- Amlodipine 10 mg PO daily
- Gabapentin 300 mg PO TID
- Ammonium lactate 12% topical cream to legs twice daily
- Folic acid 1 mg PO daily
- Hexavitamin 1 tab PO daily
- Nitrofurantoin
Discharge Medications:
1. anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily ().
2. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1)
Tablet PO once a day.
3. Vicodin ___ mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
4. Percocet ___ mg Tablet Sig: One (1) Tablet PO once a day.
5. insulin lispro 100 unit/mL Solution Sig: As directed
according to sliding scale Subcutaneous four times a day.
6. insulin glargine 100 unit/mL Solution Sig: ___ (22)
units Subcutaneous at bedtime.
7. cyanocobalamin (vitamin ___ 1,000 mcg/mL Solution Sig: One
(1) Injection once a month.
8. Vitamin D 5,000 unit Tablet Sig: One (1) Tablet PO once a
day.
9. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO EVERY OTHER DAY (Every Other
Day).
10. allopurinol ___ mg Tablet Sig: One (1) Tablet PO EVERY OTHER
DAY (Every Other Day).
11. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six
(6) hours as needed for pain.
12. bumetanide 2 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB.
14. timolol maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
15. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime)
as needed for insomnia.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
17. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO QAM
(once a day (in the morning)).
18. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO HS
(at bedtime).
19. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
20. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H
(every 24 hours).
21. ammonium lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR
(AS DIRECTED).
22. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
23. alendronate 70 mg Tablet Sig: One (1) Tablet PO QSUN (every
___.
24. sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times
a day).
Disp:*120 Tablet(s)* Refills:*2*
25. hexavitamin Sig: One (1) once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Gastrointestinal bleed (unconfirmed source)
Secondary:
- Type II diabetes
- Hypertension
- Volume overload/peripheral edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you during this hospital stay. You
were admitted with a low hematocrit (red blood level). You
received transfusion of two units of red blood cells with an
appropriate response. You were seen by the hepatology service
and underwent EGD to look for a source of the bleeding, but none
was discovered.
We have made the following changes to your medication:
- DECREASE FREQUENCY of aspirin to every other day (to minimize
bleeding complications)
- DECREASE FREQUENCY of gabapentin to once daily (this should
provide appropriate blood levels given your kidney dysfunction)
- STOP TAKING nitrofurantoin unless/until directed to resume by
your physician
- BEGIN TAKING carafate 1 g four times a day
Please take your medications as prescribed and follow up with
your doctors as recommended below.
Followup Instructions:
___
|
19906067-DS-26 | 19,906,067 | 20,311,554 | DS | 26 | 2134-12-01 00:00:00 | 2134-12-01 16:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Cephalexin / Allopurinol And
Derivatives / Lasix / Zolpidem
Attending: ___.
Chief Complaint:
Bloody Stools
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o GAVE ___ portal HTN from ___ cirrhosis with cx anemia
on blood transfusions q3weeks (last on ___, DM, asthma,
diverticulosis, CAD/___, p/w bloody diarrhea and ___ sent in
from rehab for bloody stools.
Pt was admitted in ___ for hemoptysis/melena. Last EGD in
___ showed angioectasia and ulcer in the stomach, two grade I
varices. Per rehab notes Hct was 26 on AM of ___. Denies having
hemoptysis or abdominal pain. Only has pain in L arm.
Pt comes from a rehab after having a R proximal humerus fracture
s/p fall (on dilaudid for pain). Pt was getting vanc for an
enterococcus UTI sensitive only to ampicillin and vanc, but vanc
was d/c'd secondary to ___ and switched to ampicillin. Per rehab
note, ___ was treated initially w/ Bumex, presumably thought to
be cardiorenal syndrome, but since then with IVF and 2U PRBC's.
Was noted to be more somnolent than usual yesterday and so
lactulose uptitrated to 5x/day. This AM pt continued to be
somnolent after dilaudid so came to ED.
In ED initial vitals were: 96.0 69 116/57 18 97% RA.
On exam: Pt AAOx3, conversant, drifts off to sleep every few min
but o/w interactive (per family, is vast improvement from
yesterday). No TTP; stool heme positive, dark red, nonmelenotic.
Lab studies significant for Cr 3.2 (baseline 2.6) with BUN 96
(up from 63), HCO3 was 18, HgB 8.7, which is slightly above an
unclear baseline around ___. LFTs at baseline. Albumin 2.8.
EKG with sinus at 69. Left axis. New TWI in III. Bedside US:
difficult given habitus, but no easily discernible fluid. In ED
pt with 1 episode of watery diarrhea, with dark red blood, no
clots. guiac positive. She was given 2L of IVF.
Past Medical History:
Gastric antral vascular ectasia (GAVE), thought secondary to
portal HTN from ___ w/cirrhosis, leading to chronic anemia,
transfusion dependent, q3wks
History of gastric ulcer many years ago, per bx was herpetic
GERD
Diverticulosis
CAD status post IMI in ___, treated with a bare-metal stents to
RCA
Diastolic heart failure, s/p multiple hospitalizations in the
setting of blood transfusions
Hypertension
hyperlipidemia
Stage IV CKD, baseline Cr ~3
IDDM2 c/b autonomic and peripheral neuropathy
Asthma
Breast cancer s/p surgery (bilat mastectomies in ___),
radiation and chemotherapy, now on letrozole
H/o basal cell carcinoma, actinic keratoses
Depression/anxiety
Chronic lymphedema and venous stasis
Gout with tophi, and pseudogout
Low back pain, osteoarthritis s/p bilat TKR
Urge incontinence and h/o urinary tract infections
History of tuberculosis, treated at ___ for ___ year (INH,
rifampin ___
Tinnitus
Glaucoma
Social History:
___
Family History:
Mother and father with TB -- Both of Mrs. ___ parents died of
tuberculosis when she was ___, and she was an only child. More
remote family history has not been taken. Her six adult children
are well.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
97.3 144/50 72 98RA 93.2kg
Gen: elderly woman lying upright in bed, alert but occasionally
drifting to sleep during conversation, cooperative, pleasant,
NAD
AOx3, days of the week forwards/backwards intact, 3 word recall
intact, able to spell WORLD forwards/backwards
HEENT: anicteric, PERRL, dry mucous membranes
Neck: JVP flat
Pulm: rales at bases bilaterally, no wheezes or rhonchi.
Cardiovasc: RRR, soft I/VI systolic murmur loudest at the upper
sternal border without significant radiation
Abd: obese, soft, nontender, tympatnic to percussion anteriorlly
but dull to percussion on sides
GU: no foley
Extr/Skin: + Asterixis on R arm, extensive brusing on R arm L
arm in sling, ___ in ___ with ___ edema bilaterally
Psych: normal affect
DISCHARGE PHYSICAL EXAM:
========================
Pertinent Results:
ADMISSION LABS:
================
___ 04:59PM BLOOD WBC-6.6 RBC-2.60*# Hgb-8.7*# Hct-27.0*
MCV-104* MCH-33.3* MCHC-32.1 RDW-19.3* Plt ___
___ 06:00AM BLOOD WBC-5.7 RBC-2.53* Hgb-8.1* Hct-26.6*
MCV-105* MCH-32.1* MCHC-30.6* RDW-19.0* Plt ___
___ 08:05AM BLOOD WBC-6.0 RBC-2.33* Hgb-7.6* Hct-24.5*
MCV-105* MCH-32.5* MCHC-31.0 RDW-19.1* Plt ___
___ 04:59PM BLOOD Neuts-82.9* Lymphs-8.1* Monos-5.9 Eos-2.8
Baso-0.3
___ 06:00AM BLOOD Neuts-84.6* Lymphs-6.4* Monos-5.7 Eos-2.8
Baso-0.5
___ 04:59PM BLOOD ___ PTT-36.7* ___
___ 06:00AM BLOOD ___ PTT-36.7* ___
___ 08:05AM BLOOD ___ PTT-34.9 ___
___ 04:59PM BLOOD Glucose-175* UreaN-96* Creat-3.2* Na-134
K-4.8 Cl-104 HCO3-18* AnGap-17
___ 06:00AM BLOOD Glucose-125* UreaN-97* Creat-2.9* Na-136
K-4.3 Cl-103 HCO3-20* AnGap-17
___ 08:05AM BLOOD Glucose-120* UreaN-97* Creat-2.6* Na-137
K-4.1 Cl-106 HCO3-19* AnGap-16
___ 04:59PM BLOOD ALT-27 AST-56* AlkPhos-159* TotBili-1.0
___ 06:00AM BLOOD ALT-30 AST-51* LD(LDH)-238 CK(CPK)-70
AlkPhos-157* TotBili-0.9
___ 08:05AM BLOOD ALT-29 AST-52* LD(LDH)-239 AlkPhos-145*
TotBili-0.8
___ 04:59PM BLOOD Lipase-51
___ 09:15AM BLOOD CK-MB-12* cTropnT-0.55*
___ 04:40PM BLOOD CK-MB-11* cTropnT-0.59*
___ 06:00AM BLOOD Calcium-9.6 Phos-5.8* Mg-2.8* Iron-63
___ 08:05AM BLOOD Albumin-2.6* Calcium-9.6 Phos-5.3*
Mg-2.8*
___ 06:00AM BLOOD calTIBC-276 Ferritn-313* TRF-___
DISCHARGE LABS:
================
IMAGING:
========
Abdominal US (___):
FINDINGS:
ABDOMINAL ULTRASOUND: The liver is coarsened and heterogeneous
in
echotexture, compatible with cirrhosis. There are no focal liver
lesions
identified. The gallbladder is surgically absent. There is no
intra or
extrahepatic biliary ductal dilation. The spleen is enlarged,
measuring 15.6 cm, slightly increased from ___. There
is trace ascites within the lower abdomen.
Evaluation of the pancreas is limited by overlying bowel gas.
The kidneys show no hydronephrosis, nephrolithiasis or solid
mass. Atrophy and cortical
thinning is similar to the prior MRI.
LIVER DOPPLER: The portal venous system is patent with normal
hepatopetal
flow. The main hepatic artery shows normal acceleration and
waveforms.
Expected respiratory variation is seen within the inferior vena
cava and
hepatic veins.
IMPRESSION:
1. Cirrhosis with splenomegaly and trace lower abdominal
ascites. 2. Patent portal venous system. 3. Atrophic kidneys
without hydronephrosis.
Brief Hospital Course:
___ h/o GAVE ___ portal HTN from NASH cirrhosis leading to
anemia requiring intermittent transfusions q3 weeks, DM2,
asthma, diverticulosis, and CAD/dCHF who presented with bloody
diarrhea, ___ on CKD and mild encephalopathy from rehab.
Family meetings on ___ and ___ with palliative care and
medical team--family came to conclusion that patient would be
comfort-focused care. Family chose to avoid ICU transfer,
heparin or catheterization for any chest pain. They wanted to
discontinue PRBC transfusions for chronic anemia ___ GAVE, any
long-term medications, and only continue medications for pain
and comfort.
ACTIVE ISSUES:
==============
# CAD s/p IMI s/p BMS x2 to RCA:
Patient has two reported episodes of chest pain while inpatient
with EKG changes: new aVR STE and TWI in inferolateral leads.
Trop and MB sent which came back positive. Gave 325mg ASA, NTG.
Ordered 1 unit of blood. Cardiology felt that heparin would not
likely benefit her and would increase her risk of GIB. Has old
90% ___ and 80% distal RCA stenosis on last cath in ___, and
had BMS x2 to RCA. Left circulation was clean. Family elected to
avoid heparin drip or any invasive measures. Discontinued
atorvastatin, aspirin, PRBCs as per family. Continued metop tart
50mg BID.
# GIB/GAVE: No evidence of significant GIB while here.
Differential included recurrent UGIB (elevated BUN and known
GAVE) vs. LGIB (BRBPR per rehab report). Pt also with known
diverticulosis and bleeding described as grossly bloody
diarrhea. Per liver, likely ongoing slow bleed from known GAVE.
Family/patient elected to d/c PRBC transfusios.
- Cont Omeprazole 40mg daily regiment
# ___ CIRRHOSIS w/ ENCEPHALOPATHY:
Decompensated with hepatic encephalopathy in the past and is now
on lactulose and rifaximin. MELD ___ during hospitalization.
Ultrasound results x2 and no abdominal pain do not support the
likelihood of SBP. Lactulose titrated to balance mental status
with discomfort from diarrhea (bed bound). Rifaximin continued.
Nutrition, ___, and pall care all consulted.
# ___ on CKD:
At baseline patient's Cr is around 2.4, elevated to 3.2 on
admission, and dropped to 2.6 with holding Bumex. Low bicarb
supports likely etiology of overdiusesis with bumex and
overtreatment with lactulose.
# UTI:
Patient was placed on ampicillin through ___ for enterococcus
UTI. Discontinued once diarrhea increased ___ concern for C.
diff.
# R ___ HUMERUS FX:
Present after recent fall prompting evaluation in the ED. Per
ortho, will only require sling and supportive care with no
surgical intervention needed.
# dCHF:
Last ECHO ___ with LVEF of 35%. Pt is s/p multiple
hospitalizations in the setting of blood transfusions but during
course of hospitalization was breathing comfortably without e/o
significant volume overload.
TRANSITIONAL ISSUES:
====================
None. Goals of care are hospice, comfort.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO EVERY OTHER DAY
2. ammonium lactate 12 % topical BID
3. Docusate Sodium 100 mg PO BID
4. Ampicillin 500 mg PO Q12H
5. Aspirin 81 mg PO DAILY
6. Ferrous Sulfate 325 mg PO TID
7. FoLIC Acid 1 mg PO DAILY
8. Lactulose 15 mL PO Q8H:PRN Titrate to 3BM/day
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. Metoprolol Tartrate 25 mg PO BID
12. Terbinafine 1% Cream 1 Appl TP BID
13. Omeprazole 40 mg PO DAILY
14. Rifaximin 550 mg PO BID
15. Sucralfate 1 gm PO QID
16. Bisacodyl 10 mg PR HS:PRN constipation
17. HYDROmorphone (Dilaudid) 0.5-1 mg PO Q4H:PRN pain
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
19. levemir 22 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Decompensated NASH Cirrhosis
Acute kidney injury
Non-ST segment myocardial infarction
Secondary:
GAVE
Left humerus fracture
Urinary tract infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having bloody
diarrhea and elevated kidney labs while you were being treated
for a urinary tract infection at rehab. You were also more
sleepy and confused the day before you came into the hospital.
Your liver function was noted to be declining in the hospital
and you also sustained a heart attack. After discussion with you
and your family, it was decided that you would be most
comfortable going home with your family. You have been set up
with services to assist with you pain management and care at
home.
Take care.
- Your ___ Team
Followup Instructions:
___
|
19906407-DS-44 | 19,906,407 | 21,285,940 | DS | 44 | 2193-04-09 00:00:00 | 2193-04-12 17:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Reglan / Morphine / Prochlorperazine
Attending: ___.
Chief Complaint:
Right foot pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man with a complicated PMH of type I
DM c/b frequent infections including fourneir's gangrene and
osteomyelitis (s/p toe amputation in ___, hidradenitis,
morbid obesity and HTN who presented to the ED from home due to
right foot swelling and pain. The patient reports these Sx have
been ongoing over the past month but worst over the last 5 days.
Pain began after ___ toe on left foot amputated for
osteomyelitis. No reported trauma. No known breaks in skin of
right foot. The patient reports taking up to 1,200mg of advil
daily for the pain.
.
Noticed reduced urine output over last few days. Urine appeared
more concentrated. No dysuria or hematuria. No foamy urine.
Believes he has been doing well with PO hydration. The patient
is ambulatory with a cane baseline. Recent travel includes
flight from ___ to ___ ~3 weeks ago.
.
On ROS, the patient describes DOE and cough productive of white
sputum.
Past Medical History:
- type I DM (last A1c 7.3% per patient report, 8.1% in ___
- osteomyelitis of ___ toe on left foot amputated in ___
1 month ago
- hidradenitis
- fourniers gangrene
- pulmonary embolism
- depression
- mood disorder
- malingering disorder
- HLD
- HTN
- chronic pancreatitis
- psoriasis
- arthritis
- s/p scrotal resection ___
- s/p colostomy reversal ___
- s/p abdominal wall abscess drainage ___
- s/p umbilical hernia repair
- s/p cholecystectomy
- s/pmultiple excisions / incisions for hidradenitis
- depression, multiple SI attempts, attemped tylenol OD ___
Social History:
___
Family History:
Relatives with COPD, MS, ovarian CA, uterine CA, bladder CA,
mother and uncle with diabetes mellitus II, aunt with SLE,
mother has hidradenitis ___ (severe, in axillae and
groin). Mother also has MS. ___ aunt has very high cholesterol
and triglycerides.
Physical Exam:
On Admission:
VS - 98.4 184/80 106 20 97%RA
GENERAL - anxious appearing, in moderate distress from pain
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear
NECK - supple, no LAD
LUNGS - good air entry b/l, no crackles on my exam
HEART - tachycardic, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT, RLQ ventral hernia, no masses or HSM,
no rebound/guarding
EXTREMITIES - UE WNL, ___: wwp, 2+ pitting edema to mid shins
b/l. right calf larger than left. righ foot exquisitely tender
to palpation especially around medial ankle but good ROM. two
small breaks in skin were noted with monor erythema around great
toe and on anke
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3,
On Discharge:
Vitals - 98.7 ___ 97%RA
___ - ___
GENERAL - Anxious appearing, in moderate distress from pain
HEENT - NC/AT, PERRLA, EOMI, MMM, OP clear.
NECK - supple, no LAD. TLC w/o surrounding erythema.
LUNGS - good air entry b/l, no crackles on my exam
HEART - tachycardic, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT, RLQ ventral hernia, no masses or HSM,
no rebound/guarding
EXTREMITIES - UE WNL, ___: wwp, 1+ pitting edema to mid shins
b/l. right calf larger than left. righ foot exquisitely tender
to palpation especially around medial ankle but good ROM. two
small breaks in skin were noted with monor erythema around great
toe and on anke. Loss of arch on right. Left second toe
amputated.
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3,
Pertinent Results:
On Admission:
___ 08:40PM BLOOD WBC-6.8 RBC-4.44* Hgb-12.2* Hct-38.0*
MCV-86 MCH-27.4 MCHC-32.0 RDW-15.0 Plt ___
___ 08:40PM BLOOD Glucose-253* UreaN-26* Creat-2.1* Na-137
K-3.8 Cl-104 HCO3-22 AnGap-15
___ 06:33AM BLOOD ALT-14 AST-13 AlkPhos-120 TotBili-0.1
___ 06:33AM BLOOD Albumin-2.6* Calcium-7.1* Phos-3.5
Mg-1.5*
___ 08:44PM BLOOD Glucose-235* Lactate-2.1*
On Discharge:
___ 06:40AM BLOOD WBC-6.6 RBC-4.26* Hgb-11.4* Hct-35.5*
MCV-83 MCH-26.8* MCHC-32.2 RDW-14.7 Plt ___
___ 06:40AM BLOOD Glucose-156* UreaN-21* Creat-1.2 Na-138
K-3.9 Cl-108 HCO3-22 AnGap-12
___ 06:40AM BLOOD Albumin-2.9* Calcium-8.5 Phos-3.3 Mg-1.9
___ 02:35PM BLOOD Lactate-1.6
Studies:
Foot Xray - IMPRESSION: 1. Amputation changes in the left foot
extending to the mid portion of the
right second proximal phalanx. 2. Bilateral calcified
atherosclerotic vascular disease in the feet. 3. No acute
fractures. 4. Mild right dorsal foot soft tissue swelling.
Lower Extremity Doppler: IMPRESSION: No evidence of deep vein
thrombosis in the right leg
Brief Hospital Course:
Mr. ___ is a ___ year-old man with extensive medical history
including poorly controleld DMI who presented with right foot
pain and swelling. Found to have acute kidney injury (___) in
the setting of heavy NSAID use.
Hospital Course
-------------
The patient presented with right foot pain and R>L swelling to
the ankle. In the ED, laboratory studies were remarkable for a
creatinine of 2.1 (baseline ~1.0) and lactate of 2.1. Due to
difficult access, a left sided central venous line was placed
and 1L of IVF infused. Films of the right foot were taken and
the patient was admitted to the floor. On the floor the patient
continued to complain of foot pain but was otherwise afebrile
and HD stable. Xrays returned w/o evidence of osteo or fracture.
Lower extremity dopplers were performed and showed no evidence
of clot. The patient's pain was controlled with tylenol and
opiates (low dose). Seen by podiatry who felt this was overuse
injury due to the patient's recent amputation on the left.
Precribed a CAM boot and 2 week follow-up. Mr. ___
creatinine improved with fluids and avoidance of nephrotoxins.
His lactate came down to the normal range. The patient was
discharged with tylenol and a limited number of oxycdone pills.
He will follow with Dr. ___ as his new PCP in early
___.
Chronic Conditions
--------------
#. HTN: The patient has a long history of hypertension and is
managed with carvedilol + valsartan. Given ___ on admission, the
patient's valsartan was held and he was started on labetolol.
BPs ran in the 160s during this admission. Re-started on
valsartan ___ resolved and discharged on his home regimen.
# HLD: Stable. Continue niacin, fenofibrate and atorvastatin.
# DM2: Stable. Continued on home insulin regimen.
Medications on Admission:
niaspan Extended-Release 1,000 mg BID
carvedilol 25 mg BID
lipitor 80mg qhs
fenofibrate nanocrystallized 145 mg daily
gabapentin 600 mg PO TID
insulin NPH 70 units BID
insulin lispro 100 unit/mL: 30 units with meals
omega-3 fatty acids PO BID
valsartan 160 mg PO BID
duloxetine 60 mg PO daily
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
3. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times
a day).
4. niacin 500 mg Capsule, Extended Release Sig: One (1) Capsule,
Extended Release PO BID (2 times a day).
5. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO
daily ().
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
7. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO Q8H (every
8 hours).
8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours): It is VERY important that you do not use more
than 6 pills a day.
Disp:*60 Tablet(s)* Refills:*2*
9. valsartan 160 mg Tablet Sig: One (1) Tablet PO twice a day.
10. insulin glargine 100 unit/mL Solution Sig: 80 Units
Subcutaneous twice a day: To be taken before breakfast and
before dinner.
11. insulin lispro 100 unit/mL Solution Sig: Thirty (30) Units
Subcutaneous With Meals.
12. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6)
hours as needed for pain.
Disp:*28 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Charcot Foot, Acute Kidney Injury
Secondary: Diabetes Mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you at ___!
You were admitted due to foot pain. In the hospital you were
found to have decreased renal function which was likely due to
high levels of anti-inflammatory (Advil) use. Your kidney
function improved during your stay and you were seen by podiatry
for your foot pain and they suspected an overuse injury. You
will need to wear a CAM boot until you follow-up with them in 2
weeks.
See below for changes made to your home medication regimen:
1) Please STOP all non-steroidal anti-inflammatory medications
(advil, alleve, aspirin, motrin, naproxen) as these can damage
your kidneys
2) Please START Tylenol (acetaminophen) 650mg three times a day.
Do NOT exceed this dose
3) Please START Oxycodone 5mg by mouth every 6 hours as needed
for severe pain
4) Please INCREASE your NPH dosing to 80 units before breakfast
and 80 units before dinner
See below for instructions regarding follow-up care:
Followup Instructions:
___
|
19906444-DS-20 | 19,906,444 | 23,511,401 | DS | 20 | 2178-04-23 00:00:00 | 2178-04-23 15:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo male with no significant past medical
history presenting with epigastric pain and vomiting.
Pt was seen in the ED 3 days with nausea/vomiting after eating,
diagnosed with viral gastroenteritis, treated with IVF and
symptoms resolved. He was doing well the day after discharge,
however last night developed severe ___ abdominal pain
beginning after eating gnocchi. He vomited and was able to sleep
last tonight. Today, he has had pain with every meal. He has
been making himself vomit, which helps with the pain, resulting
in ___ episodes of vomiting today. Two hours prior to presenting
to the ED, he at a tomato/spinach/feta pannini. He denies any
fevers, chills, constipation or diarrhea.
In the ED, initial vitals: 8 97.6 64 127/61 16 100%. Labs
notable for nl WBC (down from 11.4 3 days ago), nl H/H, nl
platelets, ALT 195, AST 149, AP 127, Tbili 1.6, lipase 204.
Given ongoing abdominal pain, pt had CT A/P with no evidence of
cholelithiasis, no appendicitis, no imaging evidence of
pancreatitis. His exam was notable for a non-tender abdomen,
though still complained of constant mid-epigastric pain
unaffected by palpation. Pt is being admitted for pancreatitis
and LFT abnormalities. Vitals prior to transfer: 98.9 66 113/77
16 99% RA
Currently, pt's only complaint is that his IV is bothering him.
He denies any recent sick contacts, no unusual foods, no recent
travel other than to ___ in ___, no new medications, no
tylenol or ibuprofen use, no alcohol, no herbs or supplements.
He does state that in the past ___ years ago), he had a similar
episode in his home country of ___. At that time, he says
he had a tube to "suck out the bile", and was told there was a
problem with his pancreas.
ROS:
30 lbs weight loss over the past several months
Past Medical History:
prior episode ___ years ago where he had similar symptoms and had
what appears to be an ERCP to "drain bile"
Social History:
___
Family History:
No known history of GI issues
Physical Exam:
===============================
ADMISSION PHYSICAL EXAM
===============================
Vitals- 98.7 107/45 61 95%RA
General- Alert, oriented, no acute distress, lying comfortably
in bed
HEENT- Sclera anicteric, dry mucous membranes, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, mildly tender to deep palpation in epigastric
area, bowel sounds present, no rebound tenderness or guarding,
no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
===============================
DISCHARGE PHYSICAL EXAM
===============================
Vitals- T 98.0 H 65 BP 135/67 RR 18 O2 99%
General- Asleep but easily awakable, alert, no acute distress,
lying comfortably in bed
HEENT- EOMI, MMM
Lungs- CTAB except for loud rhonhi at base of R lung
CV- RRR, Nl S1, S2, no murmurs rubs or gallops
Abdomen- soft, mildly tender to very deep palpation in
epigastric area, normoactive bowel sounds present, no guarding,
no hepatosplenomegaly
Ext- warm, well perfused, 2+ pulses
Neuro- motor function grossly normal, no focal neurologic
deficits
Pertinent Results:
===============================
LABS ON ADMISSION
===============================
___ 08:07PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 06:10PM GLUCOSE-101* UREA N-15 CREAT-0.8 SODIUM-144
POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-29 ANION GAP-14
___ 06:10PM ALT(SGPT)-195* AST(SGOT)-149* ALK PHOS-127
TOT BILI-1.6* DIR BILI-0.9* INDIR BIL-0.7
___ 06:10PM LIPASE-204*
___ 06:10PM ALBUMIN-4.6 CALCIUM-9.9 PHOSPHATE-2.4*
MAGNESIUM-1.8 IRON-142
___ 06:10PM calTIBC-332 FERRITIN-82 TRF-255
___ 06:10PM WBC-7.6 RBC-5.41 HGB-15.0 HCT-46.3 MCV-86
MCH-27.6 MCHC-32.3 RDW-12.8
___ 06:10PM NEUTS-79.4* LYMPHS-13.9* MONOS-4.1 EOS-1.6
BASOS-1.0
___ 06:10PM PLT COUNT-204
===============================
LABS WHILE INPATIENT
===============================
___ 05:35AM BLOOD WBC-6.4 RBC-5.10 Hgb-14.1 Hct-44.5 MCV-87
MCH-27.6 MCHC-31.6 RDW-12.7 Plt ___
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD ___ PTT-34.3 ___
___ 05:35AM BLOOD Glucose-83 UreaN-11 Creat-0.8 Na-143
K-4.3 Cl-105 HCO3-28 AnGap-14
___ 05:35AM BLOOD ALT-133* AST-40 AlkPhos-119 TotBili-0.4
___ 05:35AM BLOOD Lipase-19
___ 05:35AM BLOOD Albumin-4.2 Calcium-9.9 Phos-4.8* Mg-1.9
___ 06:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
___ 06:10PM BLOOD calTIBC-332 Ferritn-82 TRF-255
___ 05:45AM BLOOD CEA-27* CA125-18
___ 05:45AM BLOOD CA ___ -PND
___ 06:10PM BLOOD HCV Ab-NEGATIVE
===============================
IMAGING REPORTS
===============================
# CT Abdomen/Pelvis (___)
---PRELIMINARY REPORT---
The bases of the lungs are clear. There is no pericardial
effusion. The liver enhances homogeneously, with no evidence of
focal lesions. The portal vein is patent. A type 1 choledochal
cyst is noted, measuring 4.6 x 4.2 x 6.5 cm (TRV x AP x CC),
best seen on (series 2, image 23 and series 601, image 16).
Otherwise, there is no pancreatic ductal dilatation or
intrahepatic ductal dilatation. The pancreas is unremarkable.
The gallbladder itself is normal in appearance, and thin-walled,
with no evidence of gallstones or gallbladder wall thickening.
The spleen, bilateral adrenal glands, bilateral kidneys, stomach
and intra-abdominal loops of large and small bowel are normal in
appearance. The kidneys demonstrate symmetric nephrograms and
excretion of contrast, with no evidence of obstruction or
hydronephrosis. Enteric contrast is seen to the level of the
sigmoid. There is no retroperitoneal or mesenteric
lymphadenopathy. No intraperitoneal free air or free fluid is
identified.
CT PELVIS: The pelvic loops of large and small bowel are normal
in
Preliminary Report appearance. Although the appendix is not
definitely visualized, no secondary signs of appendicitis are
seen. Trace simple free fluid is noted in the pelvis (2:64). The
bladder and terminal ureters are unremarkable. The prostate is
normal. There is no pelvic sidewall or inguinal lymphadenopathy.
OSSEOUS STRUCTURES: No lytic or blastic lesion suspicious for
malignancy is identified.
IMPRESSION:
1. No acute pathology in the abdomen or pelvis.
2. Incidentally noted type 1 choledochal cyst, with no evidence
of complication. No cholelithiasis or cholecystitis is present.
---PRELIMINARY REPORT---
# MRCP w/ and w/p ___
At the junction of the left hepatic duct, right anterior hepatic
duct, right posterior hepatic duct there is bulbous dilatation
of the origin of the common hepatic duct to 2.0 cm (TV) x 1.0 cm
(AP) x 1.3 cm (CC) which is continuous with a common bile duct
bulbous dilatation to 6.5 cm (TV) x 3.1 cm (AP) x 6.6 cm (CC).
These findings are suggestive of a bilobed choledochal cyst,
type IV. Within the common bile duct portion of this bilobed
choledochal cyst, there is a 3.8 cm (TV) x 1.7 cm (AP) x 3.7 cm
(CC) lesion which is hypoinense to liver and pancreas on
T1-weighted imaging, hyperintense on T2-weighted imaging, and
demonstrating enhancement as well as restricted diffusion, and
suggestive of a malignancy, likely cholangiocarcinoma. This
mass has a broad
attachment to the posterior wall of the common bile duct with
irregularity of the posterior aspect of the common bile duct
which are concerning for invasion through the wall. At the
junction of the IVC and left renal vein, no clear fat plane is
identified between this mass within the posterior aspect of the
common bile duct and the left renal vein. A non-enhancing focus
is noted in this mass and likely representative of necrosis
(1003:76).
The intrapancreatic portion of the common bile duct appears
within normal
limits and the pancreatic duct is not clearly identified on this
study. The liver is otherwise within normal limits. There is
conventional hepatic arterial anatomy. The splenic, super
mesenteric, main portal, and right and left portal veins are
patent.
The cystic duct inserts into the common bile duct portion of the
choledochal cyst. The gallbladder, pancreas, spleen, stomach,
bilateral kidneys, bilateral adrenal glands are within normal
limits. There is no significant free fluid. There is no
mesenteric or retroperitoneal lymphadenopathy. Bone marrow
signal is within normal limits.
IMPRESSION:
Bilobed choledochal cyst involving the common hepatic duct and
the proximal common bile duct to the level of the pancreas.
Within the common bile duct choledochal cyst is a 3.8 cm
enhancing mass with restricted diffusion that is highly
concerning for cholangiocarcinoma. This mass has a broad
attachment to the posterior wall of the common bile duct with
irregularity of the posterior aspect of the common bile duct,
which is concerning for invasion into and through the wall;
particularly at the junction of the IVC and left renal vein
where no clear fat plane is identified between this mass within
the posterior aspect of the common bile duct and the left renal
vein. No lymphadenopathy or other lesions.
No intrahepatic bile duct dilation with the tiny right and left
hepatic ducts inserting into the dilated CHD. Normal cystic
duct caliber and normal appearance of the gallbladder.
ERCP report ___
Findings: Esophagus: Limited exam of the esophagus was normal
Stomach: Limited exam of the stomach was normal
Duodenum: Limited exam of the duodenum was normal
Major Papilla: Normal major papilla
Cannulation: Cannulation of the biliary duct was successful and
deep with a sphincterotome using a free-hand technique. Contrast
medium was injected resulting in complete opacification.
Fluoroscopic Interpretation of the Biliary Tree: The scout film
was normal. The bile duct was deeply cannulated with the
sphincterotome. Contrast was injected and there was brisk flow
through the ducts. Contrast extended to the entire biliary tree.
There was diffuse fusiform dilation of the CBD extending from
the distal CBD to the CHD in keeping with a possible Type I
choledochocele. The LHD was filled with contrast and appeared
normal. The RHD and IHBDs were not well visualized. There were
no filling defects/strictures seen. A biliary sphincterotomy was
made with a sphincterotome. There was no post-sphincterotomy
bleeding. Excellent bile and contrast drainage was seen
endoscopically and fluoroscopically.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Spyglass cholangioscopy was performed. Abnormal mucosa
characterized by erythema, friability and vascularity was seen.
The appearance was concerning for malignancy. Spybite biopsies
were performed for histology.
Cytology samples were obtained for histology using a brush in
the main duct. A double pigtail plastic biliary stent was placed
successfully.
Radiologic interpretation: I supervised the acquisition and
interpretation of the fluoroscopic images. The quality of the
fluoroscopic images was good. The total fluoroscopy time was
14.9 mins.
Impression: The scout film was normal
Normal major papilla
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree.
There was diffuse fusiform dilation of the CBD extending from
the distal CBD to the CHD in keeping with a possible Type I
choledochocele.
The LHD was filled with contrast and appeared normal.
The RHD and IHBDs were not well visualized. There were no
filling defects/strictures seen.
A biliary sphincterotomy was made with a sphincterotome. There
was no post-sphincterotomy bleeding.
Spyglass cholangioscopy was performed.
Abnormal mucosa characterized by erythema, friability and
vascularity was seen.
The appearance was concerning for malignancy.
Spybite biopsies were performed for histology.
Cytology samples were obtained for histology using a brush in
the main duct
To ensure ongoing biliary drainage, a double pigtail plastic
biliary stent was placed successfully.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Overall successful ERCP with sphincterotomy and cholangioscopy
in the setting of a choledochal cyst with findings concerning
for cholangiocarcinoma.
Recommendations: Repeat ERCP in ___ weeks for stent pull and
re-evaluation.
Review at pancreas conference
Follow-up with surgery (___) re: next steps in management
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.
Follow up with cytology reports. Please call Dr. ___
___ ___ in 7 days for the pathology results
Brief Hospital Course:
Mr. ___ is a ___ w/ no significant PMH presenting with
epigastric pain and vomiting (which resolved) and MRCP showed
choledochal cyst with an enhancing mass concerning for possible
cholangiocarcinoma.
================================
ACUTE CARE
================================
# Intrahepatic biliary duct mass. CT showed a choledochal cyst
and MRCP showed an enhancing mass in the choledochal cyst
concerning for malignancy. His CEA was a bit elevated at 27 and
he has lost 30 lbs over the past few months. ERCP was done and
pathology is pending. Sphincterotomy was done as prophylaxis. He
was seen by ___ surgery while admitted and it was
recommended he follow up with Dr ___ a ___. Even if
this isnt cholangiocarcinoma, choledochal cysts run a risk of
transformation to cancer and should be resected. He has follow
up appointments with Dr ___ Dr ___ heme/onc.
# Abdominal pain/elev LFTs and lipase. Mr. ___ initially
presented with abdominal pain associated emesis which resolved a
few hours after he was admitted. His LFTs initially were in the
low 100s and returned to normal on discharge. His lipase was
initially in the 200s and returned to normal on discharge. The
etiology of this is unclear, it is possible it is related to the
choledochal mass though it is odd his symptoms improved and LFT
abnormalities normalized while the choledochal mass has
remained. It is possible he had a gallbladder stone that passed.
================================
TRANSITIONS IN CARE
================================
-needs hep A and B vaccination
-Results of ERCP biopsy need to be followed up given critical
importance of appropriate treatment
-needs follow up with surgery and heme/onc
CONTACT INFORMATION
patient's cell ___
parent's info: + ___, ___
___friend) ___
___ (girlfriend) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO/NG Q12H Duration: 5 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*8 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Choledochal cyst concerning for malignancy
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. You were admitted to ___
___ because of abdominal pain,
nausea, and vomiting. While you were here we found your liver
and pancreas enzymes to be elevated. You started to feel better
and your liver and pancreas enzymes normalized. You had an MRI
of your liver and biliary system that showed a mass seen in the
common bile duct and you had an ERCP to biopsy the tissue,
pathology is pending. It is hard to say what this it, it may be
a choledochal cyst, it is also possible this could be cancer.
You were seen by the surgeons who feel you will likely need
surgery to remove this mass. You will follow up with them.
At some point you need vaccination for hep A and B
Please avoid aspirin and NSAIDS (such as ibuprofen) for 5 days
You will follow up with the surgeons, cancer doctors and myself,
___, who will be your new primary care doctor.
Thank you for allowing us to participate in your care. It is
important you attend all of your follow up appointments!
Followup Instructions:
___
|
19906564-DS-10 | 19,906,564 | 24,594,046 | DS | 10 | 2124-09-18 00:00:00 | 2124-09-18 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L knee periprosthetic joint infection
Major Surgical or Invasive Procedure:
L TKA I+D and liner exchange with Dr. ___ ___
History of Present Illness:
___ male history of rheumatoid arthritis and prostate cancer
concern for left knee periprosthetic joint infection. Had a
total knee arthroplasty done around ___ with Dr. ___ in
___, decubitus and to become part of the ___. States 1 day ago he noted acute onset of mild left knee
pain. Knee was previously asymptomatic no issues. By the
morning the pain had worsened and he presented for evaluation.
Denies any fevers or chills. Denies any trauma. Denies any
twisting movements. Denies any headache nausea vomiting changes
in appetite sick contacts. Denies any numbness or paresthesias.
Of note patient has a history of prostate cancer status post
prostatectomy ___ years ago. Postoperatively he required
radiation
treatment for disease recurrence. Recently he was noted to have
a rising PSA.
Past Medical History:
rheumatoid arthritis
prostate cancer
Social History:
___
Family History:
Father with heart disease
Physical Exam:
On Discharge:
98.2 138/78 100 21 95% RA (HRs fluctuate from 80-120s in Afib)
GEN: elderly male in NAD
HEENT: MMM
CV: irreg/irreg
RESP CTAB no w/r appreciated
ABD: soft, NT, ND, NABS
GU: no foley
EXTR: RLE without any edema, LLE with 1+ edema, post-operative
changes from left knee hardware explant
NEURO: alert, appropriate, mentating at baseline
Pertinent Results:
Pertinent results include:
BCx (___): MSSA
BCx (___): MSSA ___
BCx (___): MSSA ___
BCx (___): Negative for growth
BCx (___): No growth to date
Joint fluid and tissue culture (___): MSSA
___ 3:58 pm Foreign Body - Sonication Culture
LEFT KNEE EXPLANTED HARDWARE.
Gram stain / culture not called - prior positive.
Sonication culture, prosthetic joint (Final ___:
STAPH AUREUS COAG +. <16 CFU /10ML.
________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
TTE: IMPRESSION: Mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global biventricular
systolic function. Echocardiographic evidence for diastolic
dysfunction with
elevated PCWP. Mild to moderate mitral and tricuspid
regurgitation. Mild pulmonary hypertension.
___:
IMPRESSION:
There has been interval removal of the left knee prosthesis and
placement of an antibiotic spacer. There is no evidence of an
acute fracture.
CXR Portable ___
The cardiomediastinal silhouette is unchanged since prior study,
the heart is enlarged but stable in size. There is no pulmonary
edema, no effusions, no pneumothorax or focal consolidation.
There has been interval placement of a left-sided PICC line with
its tip in the distal SVC.
IMPRESSION: Left PICC line is seen with its tip in the distal
SVC.
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 L periprosthetic joint infection and was admitted to
the medicine service. The patient was taken to the operating
room on ___ for L TKA I+D with liner exchange by Dr. ___,
___ 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 TSICU with a hemovac
drain in place to the L knee. In the TSICU patient was
extubated, arterial line was discontinued, pressor support
weaned as appropriate. Patient developed Afib with RVR
refractory to diltiazem drip, transitioned to metoprolol and
heparin gtt with appropriate improvement in symptoms. Patient
was started on IV antibiotics of vancomycin and ceftriaxone
empirically, transitioned to ancef per culture sensitivities of
MSSA bacteremia/PJI. Pt was transferred to the medicine floor:
Interval Medicine course:
#Septic Left knee prosthetic joint infection now s/p explant: pt
had persistently AFib with RVR and positive blood cultures with
MSSA concerning for retained infection and pt was taken back to
the OR on ___ for complete explant of hardware and antibiotic
spacer placement. The hardware subsequently grew MSSA and
infectious disease felt that source control was achieved on
___. All subsequent blood cultures have remained negative for
growth. WBC appropriately down trending. Pt had a PICC line
placed on ___ and will need to complete a 6 week course of
IV Cefazolin for MSSA BSI and Septic PJI - last day of therapy
is ___. Pt is being discharged to rehab and needs weekly
safety monitoring labs obtained every ___ - faxed to the ___
___ clinic at ___. Pt has an antibiotic spacer and should only
toe touch with the LLE. He has follow up orthopedics 2 weeks
post op for staple removal and evaluation.
#Afib with RVR: Pt had difficult to control Afib with RVR
throughout admission and was notably tachycardic with low blood
pressures after his second surgery with explant of hardware. Pt
received diltiazem boluses x3 and was placed on a diltiazem drip
at 10mg/hr. Cardiology was involved and pt was managed with max
doses of metoprolol and diltiazem. Pt was Digoxin loaded in the
ICU and weaned from a diltiazem drip. Pt was transferred to
medicine floor and did well with oral nodal agents. He
continues to have labile heart rates in 80-120s but remains
asymptomatic with normal blood pressures and is tolerating high
dose Toprol XL at 300mg daily and Diltiazem 480mg daily. He was
transitioned to Apixaban 5mg BID for anticoagulation and will
need outpt follow up with cardiology after pt is discharged from
rehab. If necessary for high heart rates with exertion, Toprol
XL may be increased to a max dose of 400mg daily
Rheumatoid Arthritis: Pt presented with sepsis, MSSA bloodstream
infection and prosthetic joint infection. His immunosuppressive
regimen was held in the setting of sepsis and pt is scheduled to
follow up with his primary rheumatologist to discuss
re-initiation of therapy. Pt will be treated with Ibuprofen
800mg TID prn for 10 days post operatively with H2 blocker and
PPI.
Transition issues:
- Atrial fibrillation with RVR on high dose Toprol but can be
increased to 400mg daily if needed. Pt is already on maximum
dose of diltiazem 480mg and digoxin was started.
- please make sure pt keeps follow up with ortho for post op
follow up appointment and with rheumatology to discuss
restarting home regimen for RA.
- please ensure pt gets weekly labs sent to ID OPAT as outlined
in the page one for safety monitoring while on Cefazolin for
6weeks
> 30min spent on clinical care on the day of discharge including
time spent at bedside and coordinating transition of care
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Hydroxychloroquine Sulfate 400 mg PO DAILY
4. AzaTHIOprine 150 mg PO DAILY
5. Sildenafil 100 mg PO PRN sexual activity
6. adalimumab 40 mg/0.8 mL subcutaneous every 10 days
7. Acetaminophen Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
3. CeFAZolin 2 g IV Q8H bacteremia/septic arthritis
Last day of therapy is ___
4. Diazepam 5 mg PO Q8H:PRN Spasm
RX *diazepam 5 mg one tablet by mouth every 8hrs as needed Disp
#*15 Tablet Refills:*0
5. Digoxin 0.25 mg PO DAILY
6. Diltiazem Extended-Release 480 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 200 mg PO TID
9. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate Duration: 10
Days
Reason for PRN duplicate override: Alternating agents for
similar severity
10. Metoprolol Succinate XL 300 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OxyCODONE (Immediate Release) ___ mg PO Q3H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3hrs as needed
Disp #*30 Tablet Refills:*0
14. Ranitidine 150 mg PO DAILY
15. Senna 8.6 mg PO BID
16. Acetaminophen 1000 mg PO Q8H
17. HELD- adalimumab 40 mg/0.8 mL subcutaneous every 10 days
This medication was held. Do not restart adalimumab until you
are seen by rheumatology and the infection has cleared
18. HELD- AzaTHIOprine 150 mg PO DAILY This medication was
held. Do not restart AzaTHIOprine until until you are seen by
rheumatology and the infection has cleared
19. HELD- Hydroxychloroquine Sulfate 400 mg PO DAILY This
medication was held. Do not restart Hydroxychloroquine Sulfate
until until you are seen by rheumatology and the infection has
cleared
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L prosthetic joint infection, MSSA
Sepsis from ___ blood stream infection
Atrial fib with RVR
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had a severe infection of the
left knee with spread of bacteria to your bloodstream.
What happened while I was in the hospital?
- You underwent washout of the left knee and then removal of all
the joint hardware. There is now an antibiotic spacer and you
will need 6 weeks of IV antibiotics to ensure clearance of the
infection. You required brief ICU stays because of rapid heart
rates and are doing much better with additional medications.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments. Please AVOID weight
bearing on the left leg.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19906572-DS-7 | 19,906,572 | 29,750,360 | DS | 7 | 2135-09-19 00:00:00 | 2135-09-19 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hyperbilirubenemia
Major Surgical or Invasive Procedure:
___ Successful up size of existing percutaneous
transhepatic biliary drainage catheter with a new 12 ___
biliary drainage catheter.
___ Successful placement of a left ___ internal-external
biliary drain.
___ Successful US-guided placement of ___ pigtail
catheter into the collection. Samples was sent for microbiology
evaluation.
___:
1. Lysis of adhesions, right salpingo-oophorectomy, cystoscopy.
1. Exploratory laparotomy.
2. Revision and reconstruction of Roux-en-Y biliary conduit
by ___ entero-enteric anastomosis.
3. Extensive lysis of adhesions (>1.5 hours).
4. Right salpingo-oophorectomy and cystoscopy.
History of Present Illness:
___ with past surgical history of Roux-en-Y due to biliary
injury from previous cholecystectomy who presents with painless
jaundice. The patient has been noticing that for the past 2
months, since she started Lexapro, she has been having darker
urine. Over the past few days, the patient's noticed that she
has
become more jaundiced, with increased nausea and food
intolerance but denies any vomiting. She denies any abdominal
pain, nausea, vomiting, fevers, chills, changes in her stool.
She has never had ascites.
Past Medical History:
Depression, hypothyroidism, open cholecystectomy with subcequent
Roux en Y hepatico-jejunostomy for biliary injury in ___
Social History:
___
Family History:
No family history of pancreatic cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.7 66 109/58 16 96% RA
GEN: A&O, NAD, jaundiced
HEENT: Scleral icterus, mucus membranes moist
CV: RRR
PULM: non labored breathing
ABD: Soft, nondistended, nontender, no rebound or guarding,
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM:
VS: 98.0 PO 103 / 63 69 18 98 Ra
GEN: A&O, pleasant and interactive.
HEENT: No deformity. Scleral icterus. PERRL. EOMI. Neck supple.
Mucus membranes pink/moist.
CV: RRR
Pulm: Clear to auscultation bilaterally.
Abd: soft, obese, non-distended, non-tender. Midline incision
well approximated. LLQ drain in place; capped.
Ext. No edema. 2+ ___ pulses.
Skin: Warm and dry. Jaundice.
Pertinent Results:
ADMISSION LABS:
================
___ 08:20PM BLOOD WBC-6.7 RBC-4.57 Hgb-14.2 Hct-43.2 MCV-95
MCH-31.1 MCHC-32.9 RDW-17.2* RDWSD-59.8* Plt ___
___ 08:20PM BLOOD Neuts-73.9* Lymphs-12.3* Monos-12.0
Eos-1.0 Baso-0.4 Im ___ AbsNeut-4.97 AbsLymp-0.83*
AbsMono-0.81* AbsEos-0.07 AbsBaso-0.03
___ 08:20PM BLOOD Glucose-131* UreaN-15 Creat-0.7 Na-136
K-4.5 Cl-101 HCO3-18* AnGap-22*
___ 08:20PM BLOOD ALT-186* AST-247* AlkPhos-724*
TotBili-10.0*
___ 08:20PM BLOOD Lipase-38
___ 08:20PM BLOOD Albumin-4.1
___ 10:00PM URINE Color-Yellow Appear-Hazy Sp ___
___ 10:00PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-2* pH-6.0 Leuks-SM
___ 10:00PM URINE RBC-2 WBC-13* Bacteri-MANY Yeast-NONE
Epi-5
___ 10:00PM URINE CastHy-1*
MICRO:
=======
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
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-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 2143,
___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
___ 11:27 am ABSCESS Source: Bile.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ENTEROCOCCUS FAECIUM. FINAL SENSITIVITIES.
Daptomycin (MIC) 3 MCG/ML.
Daptomycin Sensitivity testing performed by Etest.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECIUM
|
AMPICILLIN------------ =>32 R
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
1720.
GRAM POSITIVE COCCI IN CHAINS.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Time Taken Not Noted Log-In Date/Time: ___ 9:20 am
CATHETER TIP-IV Source: Picc in left arm.
**FINAL REPORT ___
WOUND CULTURE (Final ___: No significant growth.
MRSA SCREEN (Final ___: No MRSA isolated.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
PATHOLOGY:
===========
Right fallopian tube and ovary right salpingo-oophorectomy:
- Ovary with serous cystadenofibroma (see note).
Note: A fallopian tube is not identified.
IMAGING:
========
___ Imaging BILIARY CATH CHECK/REPO
Successful exchange of existing occluded percutaneous
transhepatic biliary
drainage catheter with a new ___ catheter. There is no evidence
of HJ
anastomotic stenosis noting brisk antegrade flow. The jejunal
biliary limb is severely distended with fluid suggestive of
outflow stenosis or partial obstruction.
___ Imaging DX CHEST PORTABLE PICC
Comparison to ___. The left PICC line was removed. A
new right PICC line has been placed. The course of the line is
unremarkable, the tip projects over the mid SVC. No
complications, notably no pneumothorax.
___ Imaging PTC
1. Dilated biliary system with purulent/stool-like material,
sent for culture.
2. Hepaticojejunostomy anastomotic stricture.
3. Successful placement of a left ___ internal-external biliary
drain.
___BD & PELVIS WITH CO
1. Patient is status post hepaticojejunostomy and entero-enteric
anastomotic revision with persistent dilation of the biliary
limb extending from the site of anastomosis to the perihepatic
loops.
2. Status post right salpingo-oophorectomy with a 4.0 cm fluid
collection
right adnexa and 4.3 cm fluid collection in the left adnexa.
3. Bibasilar atelectasis, left worse than right with trace
pericardial effusion.
___ Imaging CHEST (PORTABLE AP)
In comparison with the study of ___, the nasogastric tube
is been
removed. The left subclavian PICC line is stable. Continued low
lung volumes with bibasilar atelectatic changes and probable
small pleural effusions. The right hemidiaphragmatic contour
remains elevated.
Although node definite focal consolidation is appreciated, the
low volumes and pulmonary changes make it difficult to
unequivocally exclude superimposed pneumonia in the appropriate
clinical setting, especially in the absence of a lateral view.
___ Imaging PORTABLE ABDOMEN
1. Mild interval increase in significant gaseous distention in
mid abdominal and right upper quadrant loops of small bowel.
2. Assessment of the upper abdomen and diaphragm is limited on
this study due to technical considerations.
___ Imaging PORTABLE ABDOMEN
Stable dilatation of bowel loops in the mid abdomen, may be
postsurgical or from obstruction.
Contrast is now within nondilated colon.
___BD & PELVIS W/O CON
1. Status post hepaticojejunostomy with similar appearance of
the markedly
dilated biliary conduit. It is uncertain whether this
represents chronically dilated biliary conduit since a revision
has been recently performed or if this is secondary to
obstruction. Of note, oral contrast passes beyond the
jejuno-jejunal anastomosis and reaches the ileum.
2. New small volume ascites is likely related to recent surgery.
3. Pneumobilia is no longer seen with persistent mild
intrahepatic biliary
ductal dilatation, raising concern for obstruction at level of
the hepaticojejunostomy.
4. Status post right salpingo-oophorectomy.
5. Small bilateral pleural effusions with atelectasis in both
lower lobes.
___ Imaging CHEST (PORTABLE AP)
NG tube tip isin the stomach. Mild cardiomegaly is accentuated
by the
projection . The right hemidiaphragm is elevated. There are
minimal
bibasilar atelectasis right greater than left. There is no
pneumothorax or pleural effusion
___ Imaging GALLBLADDER SCAN
Delayed images demonstrate radiotracer in the right upper
quadrant
which may correspond to loops of jejunum, as seen on the recent
CT, however there was interval bowel surgery and a biliary leak
cannot entirely be excluded. Additional imaging with SPECT-CT to
precisely localize the radiotracer could be performed if
clinically indicated.
___ Cardiovascular ECHO
The left atrium is normal in size. Left ventricular wall
thicknesses and cavity size are normal. Left ventricular
systolic function is hyperdynamic (EF>75%). with normal free
wall contractility. The right ventricle is not well seen, but
its size and function is likely normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. No mitral regurgitation is seen. There is
no pericardial effusion.
IMPRESSION: Hyperdynamic left ventricle. Likely normal right
ventricular size and systolic function.
___ Imaging PELVIS, NON-OBSTETRIC
7.3 x 8.4 x 7.5 cm complex cystic mass in the right adnexa with
thick,
irregular, and nodular septations. While no definite internal
vascularity is seen within this cystic mass, findings are
concerning for a malignant ovarian epithelial neoplasm and
surgical evaluation is recommended.
___BD & PELVIS WITH CO
1. Status post hepaticojejunostomy with marked dilatation of the
biliary limb with fluid and air. Of note, the biliary limb
appears to be circular in configuration with 2 anastomoses noted
to a bowel loop in the left upper quadrant. The stomach,
duodenum, and proximal jejunum leading to the jejunostomy as
well as the small bowel loops distal to the jejunojejunostomy
(efferent limb) appear relatively decompressed. Findings are
concerning for afferent loop syndrome secondary to narrowing at
the jejunojejunostomy leading to the efferent limb.
2. Mild intrahepatic biliary dilatation may be due to dilatation
and
obstruction of the biliary limb. Pneumobilia is expected post
hepaticojejunostomy.
3. Complex right adnexal cystic lesion measuring 9.3 x 7.3 cm
with apparent thickened irregular septations, suspicious for a
cystic epithelial ovarian neoplasm. Pelvic ultrasound is
recommended for further delineation.
4. Right lobe of the liver is atrophic.
5. Splenomegaly with cystic lesion containing calcified
septations, possibly a posttraumatic cyst.
___ Imaging LIVER OR GALLBLADDER US
1. Mild intrahepatic biliary dilatation with pneumobilia and
nonvisualization of the common bile duct. Findings may be
related to prior reported hepaticojejunostomy, but if there is
concern for biliary obstruction, MRCP should be considered for
further assessment.
2. Patent portal vein.
3. Prominent tortuous vessels in the porta hepatis which may
represent
varices.
4. Splenomegaly with septated cyst.
Brief Hospital Course:
Ms. ___ presented to the Emergency Department on ___
with jaundice. She has a history of a prior hepaticojejunosotomy
after a biliary injury during cholecystectomy. In the ED, she
underwent a CT scan and right upper quadrant ultrasound, which
showed dilatation of the biliary limb with fluid and air and
intrahepatic biliary dilatation, indicating afferent limb
obstruction. She was also noted to have a complex right adnexal
cystic lesion suspicious for a cystic epithelial ovarian
neoplasm. Given findings, the patient was taken to the operating
room for an exploratory laparotomy, revision and reconstruction
of Roux-en-Y biliary conduit by ___ entero-enteric
anastomosis, extensive lysis of adhesions (>1.5 hours), and
right salpingo-oophorectomy and cystoscopy. Please refer to
operative reports for details.
Post-operatively, the patient was admitted to the ICU from ___
through ___ as she was requiring phenylephrine for blood
pressure support.
Preoperatively, her total bilirubin has increased markedly. Post
operatively, it remained elevated, prompting study with a HIDA
scan. There was insufficient uptake of the radiotracer,
rendering the exam inconclusive. It was decided to trend her
bilirubin and allow the roux limb to decompress with the new
anastamosis proximal to her prior JJ anastamosis. She was also
noted to have new atrial fibrillation. Overall, she progressed
and was stable on nasal cannula, was off of phenylephrine, and
her pain was managed with IV narcotics. Her NGT was removed, a
PICC was placed, and she was transferred to the floor for
further management
On the floor, the patient's HCTs were monitored and she was
transfused as needed. Her foley was removed and she was able to
void. She was started on a diet and had return of bowel
function. After being advanced to regular diet, patient
experienced nausea and vomiting. She was started on TPN given
minimal PO intake, which was eventually stopped once patient was
able to tolerate more of a diet.
She noted feeling depressed and psychiatry was consulted who
recommended restarting home Lexapro with hepatic dosing.
On ___, she developed atrial fibrillation with RVR and received
metoprolol 5mg IV x3. Her heart rate was subsequently in the
110's. Her hematocrit was stable at this time, and her total
bilirubin was 19.9. Overall, she was lethargic and unwell; in
that context, a CT scan was ordered and she was transferred to
the ICU. Her CT scan showed an anterior intraabdominal fluid
collection, which was drained and sent for culture. At this
time, her blood cultures returned positive ___ bottles for GNRs.
She was initiated on broad spectrum antibiotics at this time.
Over the next several days, she required low dose pressors to
sustain her blood pressure and there was suspicion of
cholangitis secondary to inadequate drainage through her prior
hepaticojejunostomy. On ___, her total bilirubin was 21, and
the utility of a PTBD drain was discussed with the patient and
her daughter. Initially, she declined the PTBD, but over sever
conversations with her and her family, she ultimately agreed. On
___ a PTBD was placed and cultures sent.
On ___ her pressers declined. She at times did still require
transient blood pressure support, for which she spent the next
several days in the ICU. At that time, her blood cultures
demonstrated sensitivity to ceftriaxone. Her other cultures grew
VRE, for which she was started on daptomycin.
On ___ she was transferred out of the ICU for further care. She
underwent a PTBD clamp trial, which she did not tolerate ___
nausea and emesis. PTBD was unclamped and she underwent ___
cholangio with placement of new PTBD. She was then noted to have
increased PTBD output, for which hepatology was consulted and
recommended ___ LR repletions for PTBD output. Transplant
surgery was also consulted for further operative planning to
revise hepaticojejunostomy, with the plan to evaluate the
patient for surgery after discharge. The PTBD was capped again,
which the patient was able to tolerate.
She was also evaluated by ___, who recommended rehab at time of
discharge. ___ rehab stay is expected to be less than 30
days.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, tolerating PTBD being
capped, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Calcium Carbonate 500 mg PO QID:PRN GERD
5. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
6. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
7. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
8. Docusate Sodium 100 mg PO BID
9. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
10. Glucose Gel 15 g PO PRN hypoglycemia protocol
11. Heparin 5000 UNIT SC BID
12. LORazepam 0.5 mg PO DAILY:PRN panic attack, anxiety
13. Midodrine 10 mg PO BID
14. Midodrine 15 mg PO QHS
15. Ondansetron ___ mg IV Q8H:PRN Nausea
16. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h PRN Disp #*20
Tablet Refills:*0
17. Pantoprazole 40 mg PO Q24H
18. Polyethylene Glycol 17 g PO DAILY
19. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
20. Senna 8.6 mg PO BID:PRN constipation
21. Simethicone 40-80 mg PO QID:PRN gas
22. Escitalopram Oxalate 5 mg PO DAILY
23. Levothyroxine Sodium 50 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Adnexal mass
Obstructive jaundice due to obstruction of Roux-en-Y biliary
conduit
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Acute Care Surgery Service on ___
with painless jaundice. You were found to have a back up in your
biliary system causing inadequate clearance of bilirubin
secretion leading to skin yellowing or jaundice. You underwent
surgery with revision of the previous drainage system and an
oopheorectomy with the gynecology team. Your post operative
course was complicated by infection and abcess formation. The
abcess was drained and you were given IV antibiotics through a
PICC line. You were evaluated by the physical therapist, who
recommended acute rehab.
You are now doing better, tolerating a regular diet, and ready
to be discharged from the hospital to continue your recovery
from surgery.
Please note the following discharge 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.
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.
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:
___
|
19906623-DS-15 | 19,906,623 | 20,871,993 | DS | 15 | 2141-05-02 00:00:00 | 2141-05-03 15:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Ceclor / erythromycin base / amoxicillin / Sulfa
(Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Left eyelid ptosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a hx of asthma and seasonal
allergies presenting with left eyelid droop and inability to
look up in the left eye.
Initially developed a headache about four days ago. Had been
drinking over the weekend, and thought initially it was a
hangover. Over the next few days noted L ptosis, which has
progressively worsened. Also associated with L blurry vision.
Went to ___ where he had CT, CTA head/neck, and MRI
brain which were all negative. Discharged home and today has
persistent symptoms so went back. Transferred here for further
management. No FH of autoimmune disease. Has also been having on
an off fevers since ___ up to 101. No sore throat, rhinorrhea,
vomiting, abdominal pain, urinary symptoms. No
numbness/tingling.
In the ED, initial vitals were: 5 98.5 87 134/94 16 98% RA
- Exam notable for: L ptosis. Unable to look up L eye. Other
EOMI. Pupils PERRL. ___ OD. ___ OS. IOP 20 b/l.
- Labs notable for: WBC 8.2 (60.7% PMNs), ALT/AST 53/41, serum
tox/utox negative, U/A unremarkable,
- Imaging was notable for: MRI Orbits/Brain demonstrating no
intracranial abnormalities with partial opacification of the
right maxillary sinus with 7mm enhancing nodule, which may
represent a polyp.
- Neurology was consulted and recommended MRI brain/orbits with
thin cuts through the orbit w/ and w/o contrast.
- Vitals prior to transfer: 98.6 71 129/83 16 98% RA
Upon arrival to the floor, patient reports left sided headache
with left eye discomfort. Endorses blurred vision and changes in
how he sees color. Some pain with movement. Has had fevers up to
101, controlled with Advil at home. Associated with decreased
headache. Denies sinus tenderness, rhinorrhea. No sick contacts
or eye trauma. Nonproductive cough that is somewhat chronic with
his smoking.
Had recent strep throat a few weeks ago and completed 10-days
of antibiotics. Denies sick contacts. No known tick bites, but
was in the woods recently.
Past Medical History:
Asthma
Seasonal Allergies
Bilateral club feet w/ multiple surgeries
L knee surgery
s/p appendectomy
L index finger surgery
Social History:
___
Family History:
Diabetes
Uncle with heart problems
Mom with thyroid problem
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 97.5PO 126/91 78 18 98 ra
General: Alert, oriented, no acute distress; sitting up in bed
HEENT: left eye ptosis with swelling of the eyelid; left eyebrow
retraction; mild scleral injection; no scleral icterus; mild
discomfort with extraocular eye movements
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
Neuro: Sensation intact on face, PERRL, EOMI, tongue midline,
strength full in upper and lower extremities; sensation intact
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 97.8PO 109 / 77L Lying 66 18 96 RA
General: Alert, oriented, no acute distress; sitting up in bed
HEENT: improved left eyelid droop. no scleral icterus. PEARRL.
EOM intact.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Sensation intact on face, PERRL, EOMI, tongue midline,
strength full in upper and lower extremities; sensation intact
Skin: improving area of erythema on anterior L shin, receding
from outline.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 05:18PM BLOOD WBC-8.2 RBC-5.31 Hgb-16.3 Hct-46.0 MCV-87
MCH-30.7 MCHC-35.4 RDW-12.5 RDWSD-39.8 Plt ___
___ 05:18PM BLOOD Neuts-60.7 ___ Monos-11.0 Eos-2.7
Baso-0.5 Im ___ AbsNeut-4.94 AbsLymp-2.03 AbsMono-0.90*
AbsEos-0.22 AbsBaso-0.04
___ 07:20AM BLOOD ___ PTT-32.3 ___
___ 05:18PM BLOOD Glucose-86 UreaN-8 Creat-0.7 Na-141 K-3.7
Cl-102 HCO3-27 AnGap-16
___ 05:18PM BLOOD ALT-53* AST-41* AlkPhos-74 TotBili-0.5
___ 01:12PM BLOOD IgG-771 IgA-188 IgM-146
DISCHARGE LAB RESULTS
=====================
___ 07:40AM BLOOD WBC-8.9 RBC-5.25 Hgb-16.1 Hct-45.8 MCV-87
MCH-30.7 MCHC-35.2 RDW-12.2 RDWSD-39.2 Plt ___
___ 01:12PM BLOOD Glucose-105* UreaN-14 Creat-0.7 Na-142
K-3.9 Cl-102 HCO3-26 AnGap-18
MICROBIOLOGY
============
Blood culture: pending
Urine culture: GRAM POSITIVE BACTERIA. 10,000-100,000 CFU/mL.
Lyme: preliminary positive. Sent to ___ Clinic for Western Blot
CMV: IgA and IgG negative
IMAGING/STUDIES
===============
___ MRI Orbits
1. Faint enhancement surrounding the left optic nerve, which is
normal in size. Finding is nonspecific, but given the clinical
presentation, finding may be related to infectious or
inflammatory process, suggest perineuritis. No evidence of
orbital abscess. Clinical correlation and attention on
follow-up imaging is recommended, as clinically warranted.
2. Right maxillary sinus mucosal retention cysts or polyps.
Brief Hospital Course:
Mr. ___ is a ___ male with a hx of asthma and seasonal
allergies presenting with five days of fevers, headache, and
left eyelid droop and inability to look up in the left eye with
MRI findings concerning for right sided sinusitis as well as
___.
# Left eye ptosis:
The patient presented with five days of left sided eyelid droop
in the setting of fevers, left sided headaches, photophobia, and
phonophobia. CT/CTA and MRI at OSH was reportedly negative for
any pathology. Patient did not have any other evidence of CNIII
palsy as pupils were equal round and reactive, and EOM are
intact. MRI findings c/f perineruitis on L and sinusitis on R.
Patient was evaluated by ___. Per ophthalmology,
his sensorimotor examination is consistent with mild superior
division ___ nerve palsy on the left that could be due to an
orbital inflammatory process. His visual acuity and visual
fields were intact in the L eye. RPR negative. HIV negative.
Monospot negative. Lyme is preliminarily positive, so patient
was started on doxycycline for treatment. Quantitative
immunoglobulins were normal. CMV IgG and IgM were negative. ___,
ANCA, Rheumatoid factor, and Quantiferon gold were all pending
at discharge and require follow-up.
#Transaminitis
Patient with mild transaminitis. Given alcohol history, ddx is
alcoholic hepatitis vs viral hepatitis as patient has given
himself his own tattoos. Hepatitis C negative
#Asthma
Continued home albuterol inhaler PRN for exacerbations.
TRANSITIONAL ISSUES
===================
- Patient should continue 14 day course of doxycycline for Lyme
Disease. Day 1 = ___. Day 14 = ___
- Patient should follow-up with Dr. ___ ___
___ regarding further testing.
- The following labs were pending upon discharge: ___, ANCA, RF,
Quant-Gold, Lyme serologies, CMV IgG/M
# CODE: full (presumed)
# CONTACT: ___ (mother) ___ ___ (girlfriend)
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4-6H PRN shortness of breath
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*26 Capsule Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q4-6H PRN shortness of breath
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
- Left ptosis
Secondary Diagnosis:
- Fever
- Transaminitis
- Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized at ___.
Why did you come to the hospital?
=================================
- You came to the hospital with headache, fever, and an eyelid
droop.
What did we do for you?
=======================
- The neurology team and the ___ team evaluated
you.
- We sent off a lot of blood work to try and determine the cause
of your symptoms
- We started treating you with antibiotics (doxycycline) for
Lyme disease
- We recommended a lumbar puncture for further workup, but you
declined it at this time.
What do you need to do?
=======================
- It is very important that you follow-up with your primary care
doctor as well as the ___ Neuro-Ophthalmologist
- Please take doxycycline two times per day until ___.
- Please come back to the hospital if you have worsening
headache, weakness, blurry vision, eyelid droop.
It was a pleasure caring for you. We wish you the best.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19906885-DS-2 | 19,906,885 | 21,216,663 | DS | 2 | 2146-06-28 00:00:00 | 2146-06-28 18:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Lanolin
Attending: ___.
Chief Complaint:
?molar pregnancy, vaginal bleeding
Major Surgical or Invasive Procedure:
D&C
History of Present Illness:
___ yo G5P2 with likely molar pregnancy presents to the ED for
evaluation of vaginal bleeding.
She reports that since ___ has felt off with nausea, no
appetite, bloated, tired, diarrhea. The symptoms then worsened.
On ___ pm she stood up and had large gush of vaginal bleeding,
bled through and soaked her pants. After her initial heavy
bleeding on ___ for ___ hrs, it then stopped. Now she reports
spotting since ___. No abdominal pain. Continued bloating
and nausea. No weight loss. +Breast tenderness
Past Medical History:
POBH: G5P2
- G1: LTCS, ___
- G2: SVD, ___
- SAb x3 after
PGYNH:
- LMP: Beginning of ___, before that was ___. Not very
regular every ___ months. Always been irregular
- Denies STIs
- Denies abnormal Pap tests
- Denies fibroids, ovarian cysts
PMH:
- Breast atypical ductal hyperplasia
PSurgH:
- Open appendectomy
- Lumpectomy
- Hemorrhoidectomy
- Lymph node removal
Social History:
___
Family History:
Sister with soft tissue sarcoma, diagnosed age ___. Father with
testicular, prostate and AML. No breast, ovary, uterine,
cervical, colon, pancreas cancers
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, no
rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ 08:02PM LACTATE-0.9
___ 07:50PM GLUCOSE-80 UREA N-11 CREAT-0.6 SODIUM-133
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-22 ANION GAP-12
___ 07:50PM WBC-8.6 RBC-4.43 HGB-9.7* HCT-30.1* MCV-68*
MCH-21.8* MCHC-32.1 RDW-16.7*
___ 07:50PM NEUTS-70.3* ___ MONOS-5.5 EOS-0.9
BASOS-0.4
___ 07:50PM PLT COUNT-222
___ 07:50PM ___ PTT-24.2* ___
___ 07:00PM URINE HOURS-RANDOM
___ 07:00PM URINE HOURS-RANDOM
___ 07:00PM URINE UHOLD-HOLD
___ 07:00PM URINE GR HOLD-HOLD
___ 07:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
Brief Hospital Course:
Ms. ___ was admitted to the gynecologic oncology service after
undergoing dilation and curretage. Please see the operative
report for full details.
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with PO percocet and
motrin. Her diet was advanced without difficulty. She was given
methergine for 24 hours. Patient was recommended barrier
contraception vs Paragard IUD given history of DCIS, which will
be addressed at follow-up visit.
By post-operative day 1, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled.
Medications on Admission:
zofran prn
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
suspected molar pregnancy (pathology report pending)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms ___,
You were admitted with suspected molar pregnancy and underwent
uncomplicated D&C. You should follow up as scheduled. It is
particularly important that your HCG levels be trended to zero
then followed, and that you prevent any interim pregnancy.
Please follow these instructions:
- Nothing in the vagina for at least 1 week
- You may take ibuprofen and/or tylenol for pain, both available
over the counter
- You may walk up stairs.
- Please use condoms or a diaphragm if you have intercourse to
prevent pregnancy. You may also be a candidate for a Paragard
IUD. You can discuss these options at your followup visit.
Followup Instructions:
___
|
19906916-DS-13 | 19,906,916 | 26,067,035 | DS | 13 | 2157-12-15 00:00:00 | 2157-12-18 16:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Episodes of dizziness
Major Surgical or Invasive Procedure:
pacemaker placement
History of Present Illness:
Ms. ___ is a ___ year old woman with no significant past
medical history who presents with symptomatic lightheadedness,
dizziness.
Patient reports history syncopal episodes, fainting without
prodrome that begin while on a trip in ___ with
subsequent episode when she returned home. Her last syncopal
episode was in ___. She additionally reports feeling "dizzy"
and strange lately. She denies feeling the room spinning, vision
changes. She also denies associated chest pain, palpitations,
shortness of breath. She has been undergoing outpatient workup
with her PCP. Evaluation with neurology has not revealed
underlying neurologic etiology of her symptoms, reportedly
negative MRI brain in the past. Her PCP then placed her on a
holter monitor for further evlauation. Last night she had a
particularly bad episode of dizziness that occurred around
___. No associated lightheadedness, dizziness, chest pain,
palpitations, shortness of breath, diaphoresis. Her PCP then
referred her to the ___ ED as her holter monitor identified 2
10 second pauses and 1 13 second pause.
In the ED, initial vitals were: 98.6 55 150/64 18 100% ra
Physical exam notable for Neuro: Unremarkable, Cardiac: Sinus
brady, Normal S1/S2
- Labs were significant for normal CBC, normal BMP including
creatinine 0.9 with K 4.1 Mg 2.2
CXR unremarkable
- The patient did not receive any medications
Vitals prior to transfer were: 58 131/93 16 100% RA
Upon arrival to the floor, Ms. ___ is feeling very well.
She currently is not having any dizziness. She denies any
changes in her vision or any other associated symtoms. Has been
otherwise feeling very well. No fevers or chills
Past Medical History:
GERD
Social History:
___
Family History:
father with rheumatic heart disease, mom with heart disease,
brother with heart disease. No family members with history of
sudden cardiac death.
Physical Exam:
ADMISSION EXAM
Vitals: 97.8 136/90 70 18 97% on RA
General: Alert, oriented, very pleasant, comfortable appearing
in 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: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, no CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
DISCHARGE EXAM
VS: T=98.8 BP=122-136/41-78 ___ RR=18 O2 sat=94-99% RA
I/O: not strict
Wt: not done today
GENERAL: well developed, well nourished, caucasian female in
NAD. Alert. Oriented x3. Mood, affect appropriate. Pleasant.
HEENT: Sclera anicteric. Conjunctiva were pink, no pallor or
cyanosis of the oral mucosa. MMM. Oopharynx within normal
limits.
NECK: Supple without JVD
CARDIAC: RRR, no murmurs/rubs/gallops. Dressing in place over
pacemaker site, no drainage or erythema. Arm in sling
LUNGS: CTAB
ABDOMEN: Nontender, nondistended, soft, +BS
EXTREMITIES: Warm, well perfused, no edema
Pertinent Results:
ADMISSION LABS
___ 12:55PM BLOOD WBC-4.9 RBC-4.33 Hgb-13.1 Hct-39.5 MCV-91
MCH-30.3 MCHC-33.2 RDW-13.1 RDWSD-43.4 Plt ___
___ 12:55PM BLOOD Glucose-92 UreaN-14 Creat-0.9 Na-141
K-4.1 Cl-106 HCO3-26 AnGap-13
___ 12:55PM BLOOD Calcium-9.5 Phos-3.6 Mg-2.2
___ 01:15PM BLOOD Lactate-0.9
DISCHARGE LABS
___ 06:40AM BLOOD WBC-6.5 RBC-4.33 Hgb-13.1 Hct-38.9 MCV-90
MCH-30.3 MCHC-33.7 RDW-12.8 RDWSD-42.1 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-85 UreaN-13 Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-24 AnGap-15
___ 06:40AM BLOOD Calcium-9.9 Phos-4.5 Mg-2.2
REPORTS
EKG (___): Sinus bradycardia. Otherwise, normal ECG. Compared to
the previous tracing of ___ no significant change.
CXR (___): The lungs are clear. The cardiomediastinal
silhouette is within normal limits. No acute osseous
abnormalities
CXR (___): There has been interval placement of a transvenous
dual lead pacemaker. The these appear to be in appropriate
position. No pneumothorax seen. No pleural effusion or
consolidation seen. Air-filled bowel loops are seen under the
diaphragm consistent with Chilaiditi syndrome. No free air
under the diaphragm.
Brief Hospital Course:
___ y/o previously healthy female presenting with several months
of intermittent dizziness. Was given Holter monitor by PCP, and
found to have sick sinus syndrome. Pacemaker was placed ___.
ACTIVE ISSUES
# Sick sinus syndrome: Intermittent episodes of dizziness,
confirmed by holter monitor to be sick sinus syndrome. Otherwise
without complaints, no other cardiovascular history. TTE ___
without evidence of structural heart diease. TSH normal ___.
Labs otherwise unremarkable. Pacemaker placed ___ without
complication. No abnormal episodes on telemetry. She was
discharged and set up with Dr. ___ further EP outpatient
follow-up. She will complete 3 day course of post-op
antibiotics, was treated with IV cefazolin while inpatient, and
was sent home on Keflex ___ Q6hours, last day of therapy ___.
CHRONIC ISSUES
# GERD: she was treated with omeprazole while inpatient, and
continued on home nexium after discharge.
TRANSITIONAL ISSUES
- Last day of antibiotics (Keflex) on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NexIUM (esomeprazole magnesium) 40 mg oral DAILY
Discharge Medications:
1. NexIUM (esomeprazole magnesium) 40 mg oral DAILY
2. Cephalexin 500 mg PO Q6H
last day ___
RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 (six) hours
Disp #*6 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
sick sinus syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for dizziness and we found
that your heart rates were at times very low. We believe you
have sick sinus syndrome. Because of your low heart rates and
your dizziness, you were evaluated by the Electrophysiology
Service and received a pacemaker. You received antibiotics for
your incision; your last day of antibiotics will be on ___.
Please follow-up with your outpatient providers as instructed
below.
Thank you for allowing us to participate in your care.
All best wishes,
Your ___ medical team
Followup Instructions:
___
|
19906947-DS-6 | 19,906,947 | 29,264,555 | DS | 6 | 2179-08-09 00:00:00 | 2179-08-09 12:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Abdominal pain; admitted to ICU for hypotension and anemia with
guaiac positive stool
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with HTN, HLD, GERD who presented for
colonosopy and EGD on ___ (for workup of recurrent abdominal
pain). She had a 9mm cecal polyp removed via hot snare. EGD
showed erythema in entire stomach and irregular Z-line (biopsy
taken). After returning home, she began having severe diffuse
lower abdominal pain, vomited x 1 and felt weak and lightheaded
prompting her to present to the ED.
Initial ED vitals, T97.8 P83 BP 91/50 RR16 O2 sat 100%. She
denied fevers, chills, CP, SOB. Exam notable for diffuse
abdominal tenderness, guaic positive with dark brown stool, but
no gross blood. Labs were significant for WBC 11.4, HCT 39.1,
Lactate 1.2 and were otherwise normal. CT abd/pelvis showed no
perforation but shows stranding/edema consistent with
postpolypectomy electrocautery syndrome. FAST exam was negative.
GI was consulted and recommended NPO, Abx and IVF. Patient was
given 2L IVF, Cipro/Flagyl, Percocet, omeprazole PO and Zofran.
She continued to have episodes of hypotension, responsive to IVF
while in the ED. Patient appeared pale, diaphoretic on one
occasion, prompting repeat HCT which was 31. She was then
admitted to the ICU for further monitoring and management for
possible lower GIB.
Vitals prior to transfer: T98.7 P90 BP106/64 RR13 O2 sat 99% RA.
She reported that after she went home she drank tea, ate pita
bread and took her BP meds which she did not take prior to the
procedure. She then started having worsening abdominal pain and
vomited prompting her to present to the ED. In the ED, she at
some broth which she tolerated ok and she says she felt better
after eating something and keeping it down.
In the ICU, fluid resuscitation was continued. She was continued
on cipro/flagyl. Her BPs stabilized. Her abdominal pain
improved, and her diet was advanced. She was then called out to
the floor.
She currently has no complaints except for persistent abdominal
pain and tenderness on exam. She denied fevers, chills, sweats,
dysphagia, cough, shortness of breath, chest pain, palpitations,
trouble with hot or cold, skin changes, rash, arthralgias.
Remainder of 10 point ROS was negative.
Past Medical History:
HTN
GERD
IBS / recurrent epigastric abdominal pain of unclear etiology
Anxiety
Hyperlipidemia
Raynaud's
OA, hip pain
Cervicalgia
Denies prior surgery
Social History:
___
Family History:
No family history of colon cancer.
Mom deceased, had hx CVA and HTN, brother with HTN and sister
with PMR.
Physical Exam:
ON ADMISSION TO THE ICU
=======================
Vitals- T:99.1 BP:113/63 P:96 R:26 O2:100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, flat JVP, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, soft ___ SEM, no rubs, gallops
Abdomen: soft, non-distended, TTP over lower abdomen, +BS, no
rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
ON TRANSFER FROM ICU
====================
Vitals T:Afebrile/99.1 BP:90s-110s/60s P:70s-90s ___
O2:99%RA
General: Alert, oriented, no acute distress; sitting up in a
chair
Eyes: Sclera anicteric, EOMI
HENT: MMM, OP clear
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, soft ___ SEM, no rubs, gallops
Abdomen: soft, non-distended, TTP over lower abdomen worst in
LLQ, +BS, no rebound tenderness, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
GU: no foley
ON DISCHARGE
====================
Vitals: Afebrile, max 99.0, 110s-150s/50s-80s, 80s-130, ___,
99%RA
General: Alert, oriented, no acute distress; sitting up at her
bedside
Eyes: Sclera anicteric, EOMI
HENT: MMM, OP clear
Lungs: CTAB, no wheezes, rales, ronchi
CV: RRR, normal S1 + S2, soft ___ SEM, no rubs, gallops
Abdomen: soft, non-distended, very minimal tenderness in LLQ,
+BS, no rebound tenderness, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
GU: no foley
Pertinent Results:
ON ADMISSION/TRANSFER:
======================
Labs ___ 10:59PM: WBC-13.6* HGB-10.0* HCT-30.1* PLT
COUNT-275 GLUCOSE-124* UREA N-15 CREAT-0.9 SODIUM-138
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-14 LACTATE-1.0
CT abd/pelvis w/contrast ___: Cecal wall edema and minimal
adjacent simple fluid and fat stranding at the site of patient's
polypectomy. Consistent with postpolypectomy electrocautery
syndrome. No evidence of perforation. Multiple uterine fibroids.
AFTER ADMISSION/TRANSFER:
=========================
CBC remained stable.
No additional imaging was performed.
GI consult assessment ___: ___ yo F w/ h/o HTN p/w abdominal
pain, n/v after colonoscopy, noted to have leukocytosis, anemia
and cecal wall edema and fat stranding at the site of patient's
polypectomy c/w postpolypectomy electrocautery syndrome. There
is no evidence of perforation on the CT scan read. She has a
new anemia, with a risk of post-polypectomy bleed, but no
evidence of overt blood loss. Therefore, at this time we
recommend ongoing supportive management, monitoring of labs,
signs of overt GI bleed and emperic antibiotics for
post-polypectomy syndrome." Verbal recommendations were for 5
days of antibiotics (given limited evidence of benefit), advance
diet as tolerated, discharge OK if patient able to advance diet
and no evidence of ongoing GI bleeding.
Brief Hospital Course:
ISSUES ADDRESSED THIS HOSPITAL STAY:
[Active]
# Abdominal pain: postpolypectomy electrocautery syndrome vs
microperforation. No free air on CT, which was reassuring
perforation; LFTs and lipase normal made cholecystitis,
cholangitis, pancreatitis unlikely; no diverticula on CT to
suggest diverticulitis; she was low risk for ischemic colitis,
though was an initial consideration, lactates unremarkable.
Improved with IVF, pain medication, cipro/flagyl, and bowel
rest. Diet advanced on day of discharge, tolerated well. Had
normal BM morning of DC. Plan for 3 more days of cipro/flagyl
after DC.
# Anemia: Probably acute blood loss anemia in setting of GI
biospies given guaiac positive stool, but there was also
probably a component of dilution. CBC remained stable on serial
checks, and she had a normal stool without melena or gross blood
prior to discharge.
# Hypotension: Resolved with IVF. Likely SIRS and acute blood
loss. Cultures negative (though asymptomatic bacteriuria).
# GERD with EGD evidence of gastritis: Continued PPI, but
transitioned to high dose BID.
[Stable/Chronic/Minor]
# HTN: Held home anti-hypertensives while here. Resumed BB at
___, but instructed her to monitor her BPs at home and resume her
valsartan only if BPs >140/90.
# Anxiety: Continued home buspar. She had a mild anxiety attack
on the night prior to discharge with tachycardia and mild
hypertension, which resolved with a single dose of Ativan.
# HLD: Continued home simvastatin.
# Hypothyroidism: Continued home levothyroxine. TSH was 1.7.
NARRATIVE:
Patient is a ___ year old female with PMHx of HTN, HLD, GERD who
presented with abdominal pain, nausea, and vomiting after
colonoscopy w/ polypectomy and EGD w/ biopsy who was found to
have anemia, guaiac positive stool, and CT scan showing fat
stranding around cecum. She was hypotensive (responsive to
fluids) in the emergency department and initially admitted to
the MICU (___) where she was hemodynamically stable,
afebrile, and without signs of active bleeding. Her anemia was
stable and she was placed on maintenance fluids. Her abdominal
exam remained relatively benign (tender in LLQ). She was seen by
GI who recommended continued conservative management with bowel
rest, antibiotics, and cautious advancement of diet. As her pain
improved, her diet was advanced. She requested discharge. She is
being discharged with a short course of cipro and flagyl. Of
note, her EGD showed diffuse erythema. I placed her on a BID PPI
for possible gastritis, and gave her a prescription for a
month's supply of BID high dose PPI.
TRANSITIONAL:
# She needs PCP follow up for her abdominal pain and blood
pressure
# Code: Full (confirmed)
# Contact person: ___ (husband): ___
BILLING: >30 minutes spent coordinating discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. Valsartan 320 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 5 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
7. BusPIRone 10 mg PO DAILY:PRN anxiety
Discharge Medications:
1. Levothyroxine Sodium 50 mcg PO DAILY
2. Simvastatin 5 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice
daily Disp #*6 Tablet Refills:*0
4. MetRONIDAZOLE (FLagyl) 500 mg PO TID Duration: 3 Days
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*9 Tablet Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. BusPIRone 10 mg PO DAILY:PRN anxiety
8. Metoprolol Tartrate 50 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, nausea and vomiting, likely post-polypectomy
syndrome
Fluid responsive hypotension, likely dehydration and
inflammation
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, nausea, and vomiting
after a colonoscopy and EGD where they did biopsies and removed
a polyp. You were sick enough to go to the ICU, and you were
started on antibiotics and given fluids for low blood pressure.
You had a CT scan that showed some inflammation in the colon.
You may have had what is called "post polypectomy syndrome"
which is a known complication of colonoscopy with polyp removal.
You got better and advanced your diet to a regular diet.
Followup Instructions:
___
|
19907026-DS-25 | 19,907,026 | 25,632,267 | DS | 25 | 2163-05-22 00:00:00 | 2163-05-22 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___, PMH significant for DM, afib, HTN, CHF and morbid obesity,
presenting with increasing shortness of breath. She is on no
oxygen at home and has long been unable to sleep lying flat. She
noted increased dyspnea beginning last night which worsened over
night and prevented her from sleeping. It was most severe this
AM, leading her family to call an ambulance. SHe has not had
fevers or cough recently. SHe has no history of lung disease and
takes no inhalers. She has not had recent changes to her
medications or diet. Of note, she has been immobile since a fall
five months ago. She lives at home and uses a wheel chair to get
around.
On ROS she complains of R knee pain. Initially in the ED she
was afebrile and on a NRB. However, she was rapidly weaned to
room air. She got 40 mg IV lasix with symptomatic improvement.
EKG was notable for SR, old trifasicular block. Labs were
notable for a BNP about 5000 up from a baseline of ___. Trops
were native. A CXR was difficult to interpret given the
overlying soft tissue but was read as stable cardiomegaly and
mild pulmonary edema.
Past Medical History:
afib on warfarin/BB/amiodarone, CHADS score of 3, s/p DCCV ___
with improvement in EF from 25% to 45% after reverting to sinus
rhythm
DMT2 - last A1c 7.1 in ___
HTN
HLD
morbid obesity
Social History:
___
Family History:
Patient does not know.
Physical Exam:
ADMISSION
VS - 97.8 HR 62 BP 153/90 RR 24 95% RA since floor: I 120 out
750
General: appears well, speaking in full sentences.
HEENT: MMM.
Neck: unable to asess JVP given obesity
CV: RRR. difficult to assess for murmur.
Lungs: difficult to assess through soft tissue but no obvious
asymmetry or crackles.
Abdomen: Soft, distended.
Ext: WWP. feet and hands warm. R calf (and knee) tenderness,
worse with foot in dorsiflexion. L calf non-tender.
Gait: Patient only minimally ambulatory; with great effort can
get from bed to chair at side of bed.
DISCHARGE:
VS - 98.1 56 156/76 RR 20 99% RA.
General: appears well, eating breakfast.
HEENT: MMM.
Neck: unable to asess JVP given obesity
CV: RRR. difficult to assess for murmur.
Lungs: difficult to assess through soft tissue but no obvious
asymmetry or crackles.
Abdomen: Soft, distended.
Ext: WWP. feet and hands warm. R calf (and knee) tenderness,
worse with foot in dorsiflexion. L calf non-tender.
Pertinent Results:
___ 03:45PM URINE HOURS-RANDOM
___ 03:45PM URINE UHOLD-HOLD
___ 03:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-MOD
___ 03:45PM URINE RBC-1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 03:45PM URINE HYALINE-8*
___ 03:45PM URINE MUCOUS-RARE
___ 11:55AM ___ PTT-41.3* ___
___ 11:48AM LACTATE-1.8
___ 11:38AM URINE HOURS-RANDOM
___ 11:38AM URINE UHOLD-HOLD
___:38AM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 11:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 11:38AM URINE RBC-3* WBC-0 BACTERIA-FEW YEAST-NONE
EPI-1
___ 11:30AM GLUCOSE-149* UREA N-28* CREAT-1.1 SODIUM-136
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-11
___ 11:30AM estGFR-Using this
___ 11:30AM cTropnT-0.01 proBNP-5950*
___ 11:30AM CALCIUM-9.0 PHOSPHATE-2.8 MAGNESIUM-2.0
___ 11:30AM WBC-4.9 RBC-4.43 HGB-11.1* HCT-37.6 MCV-85
MCH-25.0* MCHC-29.5* RDW-15.6*
___ 11:30AM NEUTS-69.7 ___ MONOS-8.4 EOS-2.0
BASOS-0.6
___ 11:30AM PLT COUNT-257
___ 05:45AM BLOOD WBC-5.2 RBC-4.63 Hgb-11.3* Hct-37.6
MCV-81* MCH-24.4* MCHC-30.0* RDW-15.8* Plt ___
___ 10:55AM BLOOD ___ PTT-33.0 ___
___ 05:45AM BLOOD Glucose-179* UreaN-29* Creat-1.2* Na-138
K-4.2 Cl-100 HCO3-28 AnGap-14
___ 05:45AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.2
___ 11:30AM BLOOD cTropnT-0.01 proBNP-___*
ECHO:
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function. Mild-moderate mitral regurgitation with
normal valve morphology. Right ventricular cavity dilation.
Compared with the prior study (images reviewed) of ___,
the image quality is improved on the current study and global
LVEF appears improved.
CXR
Stable marked cardiomegaly.
2. Mild pulmonary edema and bibasilar atelectasis
LENIS:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
The study and the report were reviewed by the staff radiologist.
MICRO:
___ CULTURE-FINAL {GRAM POSITIVE
BACTERIA}INPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE};
Anaerobic Bottle Gram Stain-FINAL; Aerobic Bottle Gram
Stain-FINALEMERGENCY WARD
___ CULTURE-FINALEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-FINALEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-FINALEMERGENCY WARD
___ CULTURE-FINAL
Brief Hospital Course:
___ yo morbidly obese woman with a history of systolic CHF,
atrial fibrillation who presented with shortness of breath
worsening over the night before presentation. She was treated
for an exacerbation of her systolic heart failure with diuresis
and she got symptomatic improvement rapidly and dramatically. A
repeat TTE actually showed a normal LVEF and evidence of LVH,
suggesting that her hear failure may now be in the HFpEF
subclass. It was not clear to us what triggered her pulmonary
edema, she had no medication changes or dietary changes we could
identify from the history. It's possible that she briefly
flipped into atrial fibrillation and in this setting dropped her
EF. In the ED she was also hypertensive, and its possible that
worsening BP control was contributing.
#dyspnea: Likely from acute on chronic systolic CHF vs new
diastolic heart failure. She presented with BNP appears slightly
above baseline. CXR with mild pulmonary edema, no clear
infiltrate. TTE with LVEF >55%, LVH and slightly dilated RV
cavity. No obvious precipitant for her exacerbation. Since the
onset was relative acute, a reversion of her rhythm to Afib was
potentially responsible for the acute buildup of pulmonary
edema. Her EF has been known to decrease with changes in her
rhythm in the past. LENIS negative and PE is unlikely given that
she come in slightly supratherapeautic on her couamdin. She
improved drmatically with diuresis. Her home carvedilol,
valsartan, ASA and torsemide were restarted at discharge. She
appeared to be below her prior discharge dry weight; however,
her weights were obtained using a bed scale and may have been
inaccurate.
# Afib: Warfarin was held while supratherapeautic, restarted
once in normal range (at her home dose). She was otherwise
continued on her carvedilol and amiodarone at their home doses.
#Microcytic Anemia: Hb borderline low, MCV 81. Can be worked up
as an outpatient (stool guiac, Fe studies)
# DM2: Metformin was held and a sliding scale was used.
# HLD/hypothyroidism/GERD: Continued her statin, levothyroxine
and her omeprazole.
# Team met with patient and family on a few occasions to confirm
that patient taking her medication appropriately and that she
has adequate care at home. One of her children serves as PCA.
#
Transitional Issue:
-has an appointment with her PCP for the day after discharge to
check renal function, INR and blood pressure.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Amiodarone 200 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Clotrimazole Cream 1 Appl TP BID rash
4. Diazepam 5 mg PO HS Sleep
5. Docusate Sodium 100 mg PO BID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Topiramate (Topamax) 25 mg PO HS
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
9. Warfarin 2.5 mg PO DAYS (___)
10. Warfarin 5 mg PO DAYS (___)
11. Carvedilol 12.5 mg PO BID
12. Miconazole Powder 2% 1 Appl TP BID:PRN rash
13. Torsemide 40 mg PO DAILY
14. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN Pain
15. calcium carbonate-vit D3-min 600 mg calcium- 200 unit oral
daily
16. Cetirizine 10 mg oral nightly
17. esomeprazole magnesium 40 mg oral daily
18. MetFORMIN (Glucophage) 500 mg PO DAILY
19. Aspirin 81 mg PO DAILY
20. Valsartan 160 mg PO BID
Discharge Medications:
1. Amiodarone 200 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
5. Diazepam 5 mg PO HS Sleep
6. Docusate Sodium 100 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Miconazole Powder 2% 1 Appl TP BID:PRN rash
9. Topiramate (Topamax) 25 mg PO HS
10. Torsemide 40 mg PO DAILY
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. Valsartan 160 mg PO BID
13. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN Pain
14. calcium carbonate-vit D3-min 600 mg calcium- 200 unit oral
daily
15. Cetirizine 10 mg oral nightly
16. Clotrimazole Cream 1 Appl TP BID rash
17. esomeprazole magnesium 40 mg oral daily
18. MetFORMIN (Glucophage) 500 mg PO DAILY
19. Warfarin 5 mg PO DAYS (___)
20. Warfarin 2.5 mg PO DAYS (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Heart failure with preserved ejection fraction (history of
systolic heart failure)
Secondary:
Atrial Fibrillation
Diabetes Mellitus type 2
morbid obesity
Discharge Condition:
alert and oriented. bed bound, unable to stand without
assistance.
Discharge Instructions:
Ms. ___, you were admitted with shortness of breath. We feel
that this was related to heart failure leading to fluid build up
in your lung. We gave you increased doses of a diuretic and your
breathing quickly improved. Please attempt to weigh yourself
every morning, call MD if weight goes up more than 3 lbs. Also,
it would be prudent to limit your sodium intake to <3g daily.
Otherwise we have made no changes to your medications.
Followup Instructions:
___
|
19907026-DS-26 | 19,907,026 | 28,499,285 | DS | 26 | 2164-05-13 00:00:00 | 2164-05-22 19:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ primarily ___- speaking with a past medical
history significant for Afib on Coumadin, CHF, DM2, HTN,
hypercholesterolemia, morbid obesity, presents s/p mechanical
fall. She reports she was getting out of her bed to go to the
restroom when she lost her balance while turning and fell onto
her knees with her body ___ falling onto her knees. She denies
HS/LOC. She denies pain elsewhere. She denies any chest pain,
palpitations, or dizziness prior to fall.
The patient denies fevers, chills, nausea, vomiting, abdominal
pain, chest pain, shortness of breath, change in bowel or
bladder habits. ROS as above, otherwise reviewed and negative in
5 other systems.
Past Medical History:
afib on warfarin/BB/amiodarone, ___ score of 3, s/p DCCV ___
with improvement in EF from 25% to 45% after reverting to sinus
rhythm
DMT2 - last A1c 7.1 in ___
HTN
HLD
morbid obesity
Social History:
___
Family History:
Patient does not know.
Physical Exam:
PHYSICAL EXAM on Admit:
Gen: NAD
Vitals: 97.6 56 124/61 18 97%
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Exam on Discharge
===========================
VS: 97.8 138/54 79 20 92 on RA
Foley in place (1200/1850)
Glu= 189
GENERAL: morbidly obese woman in NAD. Alert, interactive
HEENT: No JVP noted, sclerae anicteric.
LUNGS: CTAB no w/r/r
HEART: reg pulse. no murmurs/rubs/gallops
ABDOMEN: NABS, soft/NT/ND. +ve Bowel Sounds
EXTREMITIES: WWP, cast on the left foot.
Pertinent Results:
ADMISSION LABS:
======================
___ 03:50AM BLOOD WBC-11.8*# RBC-4.31 Hgb-10.0* Hct-33.5*
MCV-78* MCH-23.2* MCHC-29.9* RDW-18.7* RDWSD-51.8* Plt ___
___ 03:50AM BLOOD Neuts-82.9* Lymphs-8.9* Monos-7.4
Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.76* AbsLymp-1.05*
AbsMono-0.87* AbsEos-0.02* AbsBaso-0.03
___ 03:50AM BLOOD ___ PTT-30.2 ___
___ 03:50AM BLOOD Glucose-231* UreaN-45* Creat-1.5* Na-136
K-4.7 Cl-102 HCO3-23 AnGap-16
___ 08:10PM BLOOD ___ 06:20AM BLOOD CK(CPK)-194
___ 08:10PM BLOOD Calcium-8.3* Phos-7.2*# Mg-2.3
___ 10:10AM BLOOD TSH-2.3
___ 06:55AM BLOOD Cortsol-14.8
DISCHARGE LABS:
=======================
___ 06:15AM BLOOD WBC-5.6 RBC-3.78* Hgb-8.5* Hct-29.4*
MCV-78* MCH-22.5* MCHC-28.9* RDW-19.4* RDWSD-54.4* Plt ___
___ 06:15AM BLOOD ___ PTT-42.0* ___
___ 06:15AM BLOOD Glucose-129* UreaN-37* Creat-1.0 Na-139
K-4.2 Cl-103 HCO3-26 AnGap-14
___ 06:15AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0
STUDIES:
=======================
___: Tib/Fib Ankl Foot:
There is a spiral - shaped minimally displaced fracture of the
distal tibia. The distal fragment is mildly medially displaced.
There is no evidence of dislocation. The mortise is congruent
on this non stress view. The tibial talar joint space is
preserved and no talar dome osteochondral lesion is identified.
Visualized portions of the knee demonstrates severe degenerative
changes of the medial compartment, characterized by joint space
narrowing and spur formation, progressed since prior
examination. Note is also made of
chondrocalcinosis. No suspicious lytic or sclerotic lesion is
identified.
IMPRESSION: Spiral mildly displaced fracture of the distal
tibia.
Brief Hospital Course:
ORTHO COURSE:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left distal tibia fracture and was admitted to the
orthopedic surgery service. The patients left leg was placed in
a short leg cast. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
She was treated with tylenol and oxycodone for leg pain.
MEDICINE COURSE:
Overall summary:
Mrs. ___ is an ___ ___ Female with a PMH of Afib
on Coumadin, ___, DM2, HTN, presents s/p mechanical fall,
admitted to the orthopedic service with tibial fracture, and
transferred to medicine for acute kidney injury and
encephalopathy.
# Acute renal failure: She had a prior ___ on ___ to 1.5
(baseline 1.1). Labs drawn on ___ were significant for Na 127,
K 5.7, Cr 2.9, Hgb 8.8, BNP ___. Prior to that day, she had
intermittent blood pressures that were in the low ___ and ___
during the day, and was given 500cc IV fluid bolus. the patient
Cr peak at a level of 3.6 during admission, however with
aggressive fluid therapy along the course of the admission the
levels dropped back to her baseline 1.0.
# Hyperkalemia: Initially in her hospitalization the patient
had electrolyte abnormalities secondary to her ___ including
hyperkalemia which was initially improving with the IVF. However
after the fluids were stopped towards the end of her hospital
course the patient was started on Kayexalate which improved her
potassium level to normal.
# Hypertension: since the patient was admitted with hypotension
and ___ her ___ and diuretic was held during admission. The
patient remained normotensive during most of her hospital
course. Towards the end of her hospital stay the patient blood
pressure was noted to return to its hypertensive baseline.
Therefore her carvedilol was restarted as it does not have renal
side effects. Her ___ continued to be held on the day of
discharge with the consideration of restarting it in the
outpatient setting.
# Bradycardia: during admission the patient's heart rate was
consistently slow. An EKG showed sinus bradycardia which seems
to be her baseline. This was explained by her dose of carvedilol
and amiodarone. We temporarily stopped the carvedilol for most
of her hospital stay. Two days before her discharge the
patient's blood pressure started to rise to the 140's systolic.
Given her ___ we preferred starting her back on her carvedilol
rather than her ___. Her heart rates did not change from her
baseline which was in the low 60.
# Atrial fibrillation: on presentation the patient's warfarin
was held since she was initially hypotensive and bleeding was
considered. however since the cause of her hypotension was later
found to be hypovolemia due to poor po intake her warfarin dose
was restarted. she was started on her home regimen however since
her INR did not pick up in time he increased her dose to reach
therapeutic INR levels of ___. as a result her INR overshoot to
3.5 and warfarin was held for a day and then restarted on her
home dosing. her INR on discharge was 3.7
# constipation: She had significant constipation, most likely
opioid induced since the patient is on pain medication for her
left tibial fracture. She was treated with an aggressive
regimen, including senna, and colace and miralax, with
lactulose if no BM for two days, as well as suppositories and
enemas as needed.
# sleep apnea: the patient was noted to have low O2 saturation
when she is asleep. given her body habitus and large neck
circumference, the patient may suffer from sleep apnea. We
recommend following up her sleep apnea in the outpatient setting
for proper treatment.
# chronic diastolic CHF: she has chronic diastolic CHF, and
diuretics were held for most of her admission. Her torsemide
was restarted at a lower dose prior to discharge, at which time
she was off O2.
# Acute encephalopathy: In the setting of her acute illness,
she had a confusional state, which improved throughout her
hospitalization with improvement in her medical condition.
Orthopedic discharge instructions:
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
coumadin 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:
ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - Tylenol-Codeine #3
300 mg-30 mg tablet. 1 Tablet(s) by mouth q ___ hours
AMIODARONE - amiodarone 200 mg tablet. 1 Tablet(s) by mouth once
a day
ATORVASTATIN [LIPITOR] - Lipitor 40 mg tablet. ___ Tablet(s) by
mouth daily
BARIATRIC BED - Bariatric bed . use daily 428.0 : 357.2 278.00
278.01 719.46
CARVEDILOL - carvedilol 12.5 mg tablet. 1 tablet(s) by mouth
twice daily
CLOTRIMAZOLE-BETAMETHASONE [LOTRISONE] - Lotrisone 1 %-0.05 %
topical cream. apply to affected areas twice a day
DIAZEPAM - diazepam 5 mg tablet. 1 (One)to 2 tablet(s) by mouth
PRN at bedtime as needed for sleep
DICLOFENAC SODIUM [VOLTAREN] - Voltaren 1 % topical gel. apply
to
knee three times a day
ESOMEPRAZOLE MAGNESIUM [NEXIUM] - Nexium 40 mg capsule,delayed
release. 1 capsule(s) by mouth daily
LEVOTHYROXINE - levothyroxine 50 mcg tablet. 1 tablet(s) by
mouth
daily
METFORMIN - metformin 500 mg tablet. 1 Tablet(s) by mouth daily
OXYCODONE - oxycodone 5 mg tablet. 1 to 2 tablet(s) by mouth
every six (6) hours as needed for pain
TOPIRAMATE - topiramate 25 mg tablet. 1 tablet(s) by mouth at hs
TORSEMIDE - torsemide 20 mg tablet. 2 tablet(s) by mouth daily
TRAMADOL - tramadol 50 mg tablet. 1 (One) tablet(s) by mouth
every 6 hours as needed for pain WATCH FOR DIZZINESS
VALSARTAN [DIOVAN] - Diovan 160 mg tablet. 1 tablet(s) by mouth
twice daily
WARFARIN - warfarin 5 mg tablet. 1 tablet(s) by mouth ON
___
& ___
WARFARIN - warfarin 2.5 mg tablet. 1 tablet(s) by mouth on days
___ & ___
X-LARGE WHEEL CHAIR - X-large wheel chair . use for doctor
appointments as needed dx 278.01 719.46 wt ___
inches
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amiodarone 200 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Carvedilol 12.5 mg PO BID
5. Diazepam 5 mg PO QHS:PRN insomnia
6. Docusate Sodium 100 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Topiramate (Topamax) 25 mg PO QHS
12. Torsemide 40 mg PO DAILY
13. 70/30 32 Units Breakfast
70/30 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Polyethylene Glycol 17 g PO DAILY
15. esomeprazole magnesium 20 mg oral DAILY
16. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Left distal tibia fracture
Acute kidney injury
Hypertension
Chronic diastolic CHF
Hyperkalemia
Constipation
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:
W
Dear ___
___ were admitted in the hospital because of a fracture in ___
left tibial bone in your leg due to a fall. during ___
hospitalization we found that ___ had low blood pressure and ___
kidney's were not working properly. your low blood pressure and
poor kidney function were both treated by giving ___ fluids
through your veins. since your warfarin was stopped for a short
period during ___ hospital stay, we kept ___ in the hospital
until the warfarin took its proper effect as measure by the INR.
___ last INR reading was 3.7. This will be rechecked in two
days.
we also stopped some of ___ blood pressure medication
(valsartan) since your kidney's were not working properly. but
now since ___ kidney's are working we encourage ___ to visit ___
primary care physician to see if they was to put ___ back on
that medication now since ___ condition improved.
We also noted that ___ have been experiencing difficulty with
maintaining your oxygen level while ___ are asleep. So, we
recommend ___ seeing your primary care physician for pursuing
this problem further.
___ were discharged with a urinary catheter that help your
urinate in a bag. once ___ mobility is improved your health care
facility may consider removing the catheter.
Here are some additional instructions:
GENERAL INSTRUCTIONS:
- please come to the hospital next week to perform blood lab
test.
- please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- do not bare weight on the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so ___ should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please continue to take coumadin
WOUND CARE:
- ___ may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment
- Do NOT get splint wet
FOLLOW UP:
Please follow up with your surgeon's team (Dr. ___, with
___, NP in the Orthopaedic Trauma Clinic 14 days
for evaluation. Call ___ to schedule appointment upon
discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
We wish ___ all the best,
Your ___ team
Followup Instructions:
___
|
19907026-DS-27 | 19,907,026 | 24,069,513 | DS | 27 | 2165-05-21 00:00:00 | 2165-05-21 19:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
bilateral leg pain and rash
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is an ___ y/o ___ speaking female with AFIB
(on Coumadin), HTN, DM, HLD, and morbid obesity, presenting from
her nursing home with b/l lower extremity burning pain and
tenderness to palpation, swelling, and erythema. The bilateral
lower extremity pain started about 10 days ago ___ on the R
side and then 2 days later, on the left side, with the rash
"creeping up her legs and then with skin flaking and with
blisters that were breaking open"). The patient denies
trauma/bites/stings or recent travel. She has never had symptoms
like this before. She notes that a nurse at her nursing home
noticed the rash and gave her "oxycodone for the pain and some
cream." She denies receiving any antibiotics. The patient was
transferred to the ___ ED for care today as the patient's pain
was worsening.
In the ED, initial vital signs were: T: 97.2 BP: 110/65 HR: 86
RR: 17 O2%: 97 RA
- Exam notable for erythematous lesions on RLE and LLE,
abdominal pannus, and right axilla.
- Labs were notable for:
WBC: 19.2, Neuts: 90.3 Lactate: 1.6, BUN/Cr: 91/2.5, Albumin:
2.7, AP: 113
Upon transfer to the floor, patient is accompanied by her three
daughters and granddaughter. Interview is conducted with help of
___ interpreter. The patient denies any
numbness/tingling over the involved sites. She also denies any
weakness, urinary, or bowel incontinence. She also denies
fevers, chills, headaches, nausea, or vomiting, SOB, chest pain,
diarrhea, or dysuria. She does report feeling constipated since
receiving the pain medications at the nursing home.
Past Medical History:
Atrial fibrillation (on warfarin and amiodarone)
CHF
DM
HTN
HLD
Morbid Obesity
Migraines
Anxiety
Hypothyroidism
Social History:
___
Family History:
Patient and daughters do not know.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: BP: 148/77 HR: 67 RR: 18 O2%: 97 RA
GENERAL: AAOx3, NAD, obese woman, in tears because of pain
HEENT: Normocephalic, atraumatic. No conjunctival pallor or
injection, sclera anicteric and without injection. Turbinates
non-edematous with clear discharge. Moist mucous membranes,
good dentition. Oropharynx is clear.
LYMPH NODES: No inguinal lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Tympanic to percussion. No
organomegaly.
EXTREMITIES: Numerous shallow, bloody ulcers with chafing on R>L
posterior thigh and buttocks. No clubbing, cyanosis. Pulses
DP/Radial 2+ bilaterally. Edema as below. Strength ___ on ankle
dorsiflexion/plantar flexion.
SKIN:B/l ___ 2+ pitting edema in R>L, extending all thigh to
knees. Erythematous patches on b/l ___, significantly greater on
R>L. On L, erythema extends from feet to abdominal panus. On R
mid-calf, there is an 2 cm eroded bullae with clear discharge.
Very warm and tender to palpation on R>L No e/o of trauma,
bites, or stings. No crepitus. Sensation intact to light touch
and proprioception in b/l ___. Extensive xerosis with flaky,
bran-like scales extending up her b/l ___, with some superficial
cracks and fissures.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: Tc 98.5 Tm 98.7 BP 122/56 (121-155/47-79) HR 67 (63-86)
RR 18 O2 95 on RA, 24 hr I/O: 1262/1550 net -288
GENERAL: AAOx3, NAD, obese woman
HEENT: Normocephalic, atraumatic. No conjunctival pallor or
injection, sclera anicteric and without injection. Turbinates
non-edematous with clear discharge. Moist mucous membranes,
good dentition. Oropharynx is clear.
LYMPH NODES: No inguinal lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
Resonant to percussion.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. Tympanic to percussion. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis. Pulses DP/Radial 2+
bilaterally. Edema as below. Strength ___ on ankle
dorsiflexion/plantar flexion.
SKIN:
B/l ___ 2+ pitting edema in R>L, extending along thighs to knees,
significantly improved from yesterday. Erythematous patches on
b/l ___, greater on L>R. On L, erythema is resolving and is
extending only up to knee as opposed to up to abdominal panus as
on admission. On R mid-calf, there is an 2 cm eroded bullae,
clear discharge now dried, and healing. No longer warm and
tender to palpation on b/l ___. No e/o of trauma, bites, or
stings. No crepitus. Sensation intact to light touch and
proprioception in b/l ___.
Extensive xerosis with flaky, bran-like scales extending up her
b/l ___, with some superficial cracks and fissures. Also some
erythema in b/l axillae with some slight linear fissuring and
erosion w/o papules or pustules. Numerous shallow, bloody ulcers
with chafing on R>L posterior thigh and buttocks.
Pertinent Results:
ADMISSION LABS:
======================
___ 02:57AM URINE HOURS-RANDOM
___ 02:57AM URINE UHOLD-HOLD
___ 02:57AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:57AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 01:47AM LACTATE-1.6
___ 01:30AM GLUCOSE-95 UREA N-91* CREAT-2.5* SODIUM-138
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-22 ANION GAP-18
___ 01:30AM ALT(SGPT)-7 AST(SGOT)-13 ALK PHOS-113* TOT
BILI-0.5
___ 01:30AM ALBUMIN-2.7*
___ 01:30AM WBC-19.2* RBC-3.95 HGB-10.5* HCT-34.3 MCV-87
MCH-26.6 MCHC-30.6* RDW-18.4* RDWSD-57.3*
___ 01:30AM NEUTS-90.4* LYMPHS-4.0* MONOS-3.9* EOS-0.8*
BASOS-0.3 IM ___ AbsNeut-17.32* AbsLymp-0.77* AbsMono-0.75
AbsEos-0.16 AbsBaso-0.05
___ 01:30AM PLT COUNT-363
MICROBIOLOGY:
======================
Blood cultures x2 (___): No growth to date (final)
Urine culture (___): No growth (final)
Urine culture (___): YEAST. >100,000 CFU/mL (final)
C. difficile DNA amplification assay (___): negative
IMAGING:
======================
LENIs (___):
Limited examination due to reduced acoustic penetration related
to body habitus. No evidence of deep vein thrombosis in right
or left lower extremity, with limited views of distal
superficial femoral, popliteal, and calf veins.
CHEST PORTABLE X-RAY (___):
There is a right-sided PICC line with the distal lead tip at the
cavoatrial junction. Heart size is enlarged. There remains
pulmonary vascular congestion and likely small bilateral
effusions. There are no pneumothoraces.
CHEST PA & LAT (___):
There is a right-sided PICC line with the distal lead tip at the
cavoatrial junction. Heart size is enlarged. There is
atelectasis at the lung bases. There are no pneumothoraces.
CARDIAC STUDIES:
======================
ECG (___): Atrial fibrillation. Left axis deviation. HR 69,
Intervals: RR 861 ms, QRS 166 ms, QT 454 ms, QTc 469; NS lateral
ST-T changes. Possible anteroseptal infarct- age undetermined.
PERTINENT AND DISCHARGE LABS:
======================
___ 08:30PM BLOOD WBC-9.7 RBC-3.70* Hgb-9.7* Hct-31.3*
MCV-85 MCH-26.2 MCHC-31.0* RDW-18.2* RDWSD-55.5* Plt ___
___ 08:30PM BLOOD Neuts-84.9* Lymphs-6.4* Monos-6.9 Eos-1.3
Baso-0.1 Im ___ AbsNeut-8.19*# AbsLymp-0.62* AbsMono-0.67
AbsEos-0.13 AbsBaso-0.01
___ 05:23AM BLOOD WBC-8.3 RBC-3.64* Hgb-9.5* Hct-30.9*
MCV-85 MCH-26.1 MCHC-30.7* RDW-18.2* RDWSD-55.5* Plt ___
___ 05:35AM BLOOD WBC-7.5 RBC-3.49* Hgb-9.1* Hct-30.5*
MCV-87 MCH-26.1 MCHC-29.8* RDW-18.0* RDWSD-57.3* Plt ___
___ 06:15AM BLOOD WBC-4.9 RBC-3.33* Hgb-8.6* Hct-28.6*
MCV-86 MCH-25.8* MCHC-30.1* RDW-18.0* RDWSD-56.3* Plt ___
___ 06:03AM BLOOD WBC-5.9 RBC-3.37* Hgb-8.9* Hct-28.8*
MCV-86 MCH-26.4 MCHC-30.9* RDW-18.0* RDWSD-55.1* Plt ___
___ 04:39AM BLOOD WBC-6.6 RBC-3.31* Hgb-8.8* Hct-28.7*
MCV-87 MCH-26.6 MCHC-30.7* RDW-17.9* RDWSD-56.8* Plt ___
___ 05:55AM BLOOD WBC-5.6 RBC-3.41* Hgb-8.9* Hct-28.9*
MCV-85 MCH-26.1 MCHC-30.8* RDW-18.3* RDWSD-56.2* Plt ___
___ 08:30PM BLOOD ___ PTT-28.2 ___
___ 08:30PM BLOOD Plt ___
___ 05:23AM BLOOD ___
___ 05:23AM BLOOD Plt ___
___ 05:35AM BLOOD ___
___ 05:35AM BLOOD Plt ___
___ 06:15AM BLOOD ___
___ 06:15AM BLOOD Plt ___
___ 06:03AM BLOOD ___ PTT-34.5 ___
___ 06:03AM BLOOD Plt ___
___ 04:39AM BLOOD ___ PTT-42.1* ___
___ 04:39AM BLOOD Plt ___
___ 05:55AM BLOOD Plt ___
___ 08:30PM BLOOD Glucose-163* UreaN-74* Creat-1.6* Na-132*
K-4.4 Cl-100 HCO3-23 AnGap-13
___ 05:23AM BLOOD Glucose-93 UreaN-75* Creat-1.7* Na-134
K-4.5 Cl-100 HCO3-25 AnGap-14
___ 05:35AM BLOOD Glucose-124* UreaN-68* Creat-1.6* Na-136
K-4.4 Cl-103 HCO3-25 AnGap-12
___ 06:15AM BLOOD Glucose-82 UreaN-60* Creat-1.5* Na-137
K-4.2 Cl-104 HCO3-26 AnGap-11
___ 06:03AM BLOOD Glucose-79 UreaN-46* Creat-1.4* Na-140
K-4.1 Cl-106 HCO3-27 AnGap-11
___ 04:39AM BLOOD Glucose-84 UreaN-34* Creat-1.2* Na-137
K-3.8 Cl-104 HCO3-26 AnGap-11
___ 05:55AM BLOOD Glucose-109* UreaN-23* Creat-1.1 Na-139
K-3.3 Cl-105 HCO3-27 AnGap-10
___ 08:30PM BLOOD ALT-7 AST-12 LD(LDH)-177 AlkPhos-95
TotBili-0.5
___ 08:30PM BLOOD Albumin-2.5* Calcium-8.0* Phos-4.1
Mg-2.8*
___ 05:23AM BLOOD Calcium-8.1* Phos-4.3 Mg-3.0*
___ 05:35AM BLOOD Calcium-8.1* Phos-3.5 Mg-2.9*
___ 06:15AM BLOOD Calcium-7.9* Phos-3.2 Mg-2.7*
___ 06:03AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.4
___ 04:39AM BLOOD Calcium-8.1* Phos-2.8 Mg-2.2
___ 05:55AM BLOOD Calcium-8.3* Phos-3.0 Mg-1.9
___ 05:23AM BLOOD Vanco-4.8*
___ 06:15AM BLOOD Vanco-17.4
___ 06:03AM BLOOD Vanco-26.5*
___ 04:39AM BLOOD Vanco-26.6*
___ 11:37AM URINE Color-Yellow Appear-Hazy Sp ___
___ 11:37AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
___ 11:37AM URINE RBC-32* WBC-17* Bacteri-FEW Yeast-NONE
Epi-<1
___ 11:37AM URINE Mucous-RARE
Brief Hospital Course:
ASSESSMENT AND PLAN:
Ms. ___ is an ___ year-old ___ speaking female with
AFIB (on Coumadin), CHF, HTN, DM, HLD, and morbid obesity,
presenting from her nursing home with bilateral lower extremity
burning pain, erythema, swelling, and tenderness to palpation,
and leukocytosis, c/f cellulitis.
#Cellulitis: Patient is at risk given diabetes, cardiovascular
morbidity. On admission, she presented with over a week of b/l
___ burning pain and ttp, swelling and erythema. She was afebrile
and normotensive, with leukocytosis with 19.2 with 90.4% bands.
LFTs wnl. Skin exam was notable for b/l edema R>L and
erythematous patches L>R extending into her abdominal pannus
that were ttp, with eroded bulla with clear discharge on R
mid-calf. No frank pus. No crepitus, cutaneous anesthesia, or
pain out of portion to exam to suggest necrotizing fasciitis. On
___, leukocytosis resolved to WBC of 9.7 and since then WBC
wnl. LENIs on ___ negative for DVT. Patient failed PIV
placement x4 and PICC was placed on ___. Position of PICC could
not be verified initially with portable CXR given pt's body
habitus, but was verified on ___ AM with chest x-ray in
department. Was on vancomycin 1500 gm IV q48hr (1st dose of vanc
1gm in ED ___, 2nd dose on ___ AM). Random vanc trough
4.8 on ___. Subsequently changed vanc to 1g IV q12 on ___ per
pharmacy recs. Patient was also started on ampicillin-sulbactam
3 gm IV q12hr (1st dose ___. This was changed to
amoxicillin-clauvulinic acid ___ mg PO q12hr on ___ to reduce
the amount of IV medication and therefore IVF administration, in
context of pt's history of CHF. Pt complained of progressive
nausea on ___. Therefore, discontinued PO
amoxicillin-clauvulanic acid and restarted ampicillin-sulbactam
3 gm IV q6hr on ___. Ampicillin-sulbactam was discontinued on
___ and cephalexin 500 q8hr was started in order to begin
converting the patient to PO medications. On ___, pt endorsed
improving leg pain and slightly less swelling and less ttp. Vanc
trough 26.5 on ___ and vancomycin 1g IV dose was held, and
vancomycin was restarted at 750 gm IV q12hr at 20:00 on ___.
Patient was discontinued on vancomycin and cephalexin and
converted to clindamycin 700 mg PO q8hr prior to discharge on
********. She will complete a total 10-day course of antibiotics
that will end on ___.
#Pressure Ulcers: Patient's exam on admission was notable for
shallow, bloody ulcers on posterior thigh, R>L; likely Stage II
(partial thickness skin loss) pressure ulcers. These were likely
___ to being bed bound at nursing home. Pt's daughter was very
concerned about the care pt is receiving at nursing home and SW
was consulted, who has reached out to the patient's nursing
home. Pt is has several BMs daily, making wound care difficult.
C. diff ___ negative. Attempted flexiseal, but could not install
properly. Wound care team was consulted and their
recommendations for the care of the ulcers were as following:
Cleanse with Commerical wound cleanser, pat dry; Apply Xeroform
gauze, dry gauze, Kerlix wrap; Change daily. These
recommendations were followed. Also provided pressure relief per
pressure ulcer guidelines, support surface: mighty Air low air
loss bariatric bed, and ensured that patient was turned and
repositioned every ___ hrs and prn off affected area.
#UTI: On ___, pt, who had a Foley in place, complained of
dysuria. UA on ___ notable for RBC 37, WBC 17, and few
bacteria. Urine cxs ___ and ___ NGTD. Urine cx from ___
positive for yeast. Patient was started on 14 day course of
fluconazole 200 mg QD (Day 1: ___, Day 14: ___.
___: Patient had BUN 91 and CR 2.5 on admission. Baseline Cr
1.1 per prior OMR notes. This was likely pre-renal ___ to
cellulitis, given improvement to Cr 1.6 on ___ after receiving
IVF. Cr initially 1.5-1.7 since then, but 1.4 on ___ and 1.2 on
___ (likely normalizing to new baseline) and 1.1 on ___.
Possible that new baseline is related to the voltaren that she
started 3 months ago per OMR notes. Had initially held home
voltaren, valsartan and torsemide 80 mg QD, but restarted
torsemide on ___ at 40 mg QD. Patient has been net neg
___ since restarting torsemide. Valsartan and voltaren
were not restarted.
#Type II DM: Patient was continued on home insulin regimen of
70/30 29U in the AM with breakfast and 70/30 15U in the ___ with
dinner as well as Insulin sliding scale. FSBG ___
throughout hospitalization. The only exceptions were in the AM
on ___, and ___ when patient FSBGs were 92, 80, and 89,
respectively, and this was in the context of not eating
breakfast. In all of these instances, patient was given 14 U of
29 U and AM ISS was held.
#AFIB: Patient was in AFIB throughout hospitalization and was
maintained on telemetry. ECG on ___ showed AFIB, HR in ___.
Home amiodarone was continued throughout hospitalization.
Initially held home Coumadin 5 mg PO QD until INR resulted. INR
was 1.4 on ___ and restarted coumadin 5 mg QD on ___. INR was
1.3-1.4 through ___. INR increased to 2.0 on ___ and decreased
to Coumadin 2.5 mg PO QD on ___. INR was 2.4 on ___ and
decreased to Coumadin 1 mg PO QD on ___. INR on ___ was 2.9 at
time of discharge. Patient discharged on Coumadin 0.5 mg QD.
#CHF, systolic: Patient has hx of systolic heart failure ___
tachycardia-related cardiomyopathy iso of AFIB. ECHO in ___
shows EF>55%. ECG as above with NS ST changes. Patient was
continued on home carvedilol. Home valsartan was discontinued as
above iso ___. Home torsemide 80 mg PO QD was initially held iso
___ as above, but was restarted on ___ at 40 mg QD when Cr
improved to 1.5 as above. Since then, patient was negative ___
daily. Patient discharged on home carvedilol and reduced
torsemide 40 mg PO QD. Valsartan was not restarted.
#Hypertension: SBP in 110s-150s throughout the hospitalization.
Home carvedilol has been continued throughout the
hospitalization. Initially home valsartan and torsemide 80 mg PO
QD was held in the setting ___ as above, and then torsemide
40 mg PO QD was started on ___ (Cr 1.5). Pt has been negative
___ daily since restarting the torsemide. Valsartan was not
restarted. Patient will be discharged on home carvedilol and
reduced dose of torsemide 40 mg QD.
#Intertrigo: chronic for this pt; On exam, pt has erythema in
b/l axillae and under abdominal pannus, bilateral groin, and
medial thighs with some slight linear fissuring and erosion w/o
papules or pustules c/f infection. Patient's home clotrimazole
and nystatin were applied daily to b/l axillae. Wound care team
was consulted. Their recommendations were followed: Perianal and
gluteal of tissue was cleansed with gentle foam cleanser, and
then pat dry; A thin layer of antifungal critic Aid was applied
dialy; A clear moisture barrier ointment was applied daily and
prn; Large Sofsorb sponge was placed under groin tissue to
separate skin from skin and absorb moisture- this was changed
daily and prn. Recommend that this regimen be continued upon
discharge.
#HLD: Patient was continued on home atorvastatin.
#Migraines: Patient was continued on home topiramate and home
ondansetron.
#Anxiety: Patient was continued on home diazepam.
#Hypothyroidism: Patient was continued on home levothyroxine.
#GERD: Patient was continued on home omeprazole.
#B/l knee pain: Patient denied knee pain throughout
hospitalization. Home voltaren was held as above given ___
bump and was not restarted on discharge.
#Constipation: This is chronic for the patient. Initially
continued on standing home regimen of senna, docusate,
polyethylene glycol, and lactulose. Had ___ BM daily since
admission, but had 4 BM on ___. On ___, changed senna,
docusate, polyethylene glycol, and lactulose from standing to
prn. For the remainder of her hospitalization, she had ___ BM
daily.
TRANSITIONAL ISSUES:
====================
- Patient to complete clindamycin 600 mg PO q8hr for a total
10-day course of antibiotics to treat cellulitis (Day 10:
___.
- Patient to complete fluconazole 200 mg qd PO for 14 day course
to treat ___ UTI (day 14: ___.
- Patient's Coumadin requirement lower while inpatient, likely
in part due to antibiotic therapy. Please consider titration of
Coumadin regimen when pt completes antibiotic and systemic
antifungal regimen.
- In light of patient's acute kidney injury (Cr bump from
baseline 1.1 to 2.5 on admission), patient's home torsemide was
initially held, and restarted (when Cr 1.5) at half of the home
dose, at 40 mg PO QD. On this regimen, pt was net negative 1L
daily. Recommend continued evaluation of patient's diuresis
regimen with daily weights.
- Patient's home valsartan 160 mg PO BID was stopped iso Cr
___. Consider restarting pending renal recovery
- Discharge Cr 1.1
- Please check chem10 on ___ following discharge to evaluate
renal recovery and consider restarting valsartan.
- Patient's home Voltaren 1 % topical TID, which she took for
bilateral knee pain, was discontinued iso Cr ___ given
concern for systemic NSAID absorption. Patient did not complain
of knee pain during admission and medication was not restarted.
If recurring knee pain, would consider alternative therapy.
-Patient with numerous pressure ulcers on admission. Recommend
continued wound care and moisture management.
-Code Status: FULL (Confirmed with patient ___
-Emergency Contact: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Polyethylene Glycol 17 g PO BID
2. Lactulose 30 mL PO BID
3. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
4. OxyCODONE (Immediate Release) 10 mg PO DAILY
5. Simethicone 80 mg PO QID:PRN gas pain
6. Voltaren (diclofenac sodium) 1 % topical TID
7. Valsartan 160 mg PO BID
8. Clotrimazole Cream 1 Appl TP DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. clotrimazole-betamethasone ___ % topical BID
11. Ondansetron 4 mg PO Q8H:PRN nausea
12. 70/30 29 Units Breakfast
70/30 15 Units Dinner
13. Torsemide 80 mg PO DAILY
14. Atorvastatin 10 mg PO QPM
15. Diazepam 5 mg PO BID:PRN insomnia/anxiety
16. Topiramate (Topamax) 25 mg PO QHS
17. Multivitamins W/minerals 1 TAB PO DAILY
18. Omeprazole 20 mg PO DAILY
19. Warfarin 5 mg PO DAILY16
20. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
21. Amiodarone 200 mg PO DAILY
22. Carvedilol 12.5 mg PO BID
23. Docusate Sodium 200 mg PO DAILY
24. Senna 17.2 mg PO DAILY
Discharge Medications:
1. Clindamycin 600 mg PO Q8H
2. Fluconazole 200 mg PO Q24H Duration: 14 Days
3. Nystatin Cream 1 Appl TP BID
4. 70/30 29 Units Breakfast
70/30 15 Units Dinner
5. Torsemide 40 mg PO DAILY
6. Warfarin 1 mg PO DAILY16
7. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
8. Amiodarone 200 mg PO DAILY
9. Atorvastatin 10 mg PO QPM
10. Carvedilol 12.5 mg PO BID
11. clotrimazole-betamethasone ___ % topical BID
12. Diazepam 5 mg PO BID:PRN insomnia/anxiety
13. Docusate Sodium 200 mg PO DAILY
14. Lactulose 30 mL PO BID
15. Levothyroxine Sodium 50 mcg PO DAILY
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Omeprazole 20 mg PO DAILY
18. Ondansetron 4 mg PO Q8H:PRN nausea
19. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
20. OxyCODONE (Immediate Release) 10 mg PO DAILY
21. Polyethylene Glycol 17 g PO BID
22. Senna 17.2 mg PO DAILY
23. Simethicone 80 mg PO QID:PRN gas pain
24. Topiramate (Topamax) 25 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES:
==============
Cellulitis
Pressure Ulcers
Acute Kidney Injury
Intertrigo
Urinary tract infection
SECONDARY DIAGNOSES:
================
Type II Diabetes Mellitus
Congestive Heart Failure
Atrial Fibrillation
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of ten days of
worsening pain, swelling, and rash on both of your legs. You
were found to have a skin infection called cellulitis. You were
treated with antibiotics with improvement in your pain and
swelling, and rash, suggesting that your infection is improving.
You were also treated for painful bed sores on your back side
that were likely related to being bed-bound at your nursing
home. Finally, we found that you had a urinary tract infection
and we started you on antibiotic treatment for that as well.
We have scheduled the following appointments for you:
Please make sure that you make an appointment to make sure that
you see your PCP within three days of leaving your nursing
facility.
It was a pleasure taking care of you!
We wish you the best!
Your team at ___
Followup Instructions:
___
|
19907138-DS-4 | 19,907,138 | 21,846,712 | DS | 4 | 2134-02-07 00:00:00 | 2134-02-08 13:42:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
Colonoscopy with polyp removal.
History of Present Illness:
___ female with collagenous colitis presenting with 4
episodes of BRBPR. Pt reports that she has not been feeling well
for a few days (general malaise). Last night, she began to
notice blood mixed with stool; this happened on 4 occassions. On
the last episode in ED, she had loose stool first and then just
frank blood. Denies fevers (though has some chills); denies N/V.
Has chronic abdominal pain that is at baseline. Frequency of
bowel movements ___ loose BMs daily) is at baseline, although
she has noted that her stool has been more green for the last
two days. Denies sick contacts, raw/unusual foods, or recent
antibiotics. She believes her last colonoscopy was ___ year ago at
OSH; she was diagnosed with collagenous colitis at this time.
She has been on prednisone previously for her colitis and two
other medications she cannot recall. Currently does not take any
medications for her colitis.
She also has herniated disks in cervical spine and has
intermittent neck pain. She noted numbness in her left arm in ED
with pain radiating to neck and chest. Pain worse with weight
bearing, not associated with exertion. EKG showed NSR, no
ischemic changes. CXR was unremarkable. Trop was negative x 1.
In the ED, initial VS: 97.9 80 137/86 20 100%. Rectal exam
revealed frank blood. Labs were largely unremarkable. Hct was
stable at 41
REVIEW OF SYSTEMS:
Reports chills, headache, dry cough
Denies vision changes, rhinorrhea, sore throat, shortness of
breath, nausea, vomiting, constipation
Past Medical History:
collagenous colitis
herniated disks
depression/anxiety
Social History:
___
Family History:
Mother: IBD
Physical ___:
ADMISSION:
VS - 98.2 109/71 87 20 100%RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact
DISCHARGE:
Vitals: 98.8 98.5 105/64 85 29 99 RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTA B/L
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
___ 02:25AM BLOOD WBC-10.7 RBC-4.72 Hgb-13.7 Hct-41.0
MCV-87 MCH-28.9 MCHC-33.3 RDW-13.3 Plt ___
___ 08:17AM BLOOD WBC-12.2* RBC-4.47 Hgb-12.7 Hct-39.4
MCV-88 MCH-28.3 MCHC-32.1 RDW-13.3 Plt ___
___ 03:05PM BLOOD WBC-7.3 RBC-4.22 Hgb-12.1 Hct-37.3 MCV-88
MCH-28.6 MCHC-32.3 RDW-13.4 Plt ___
___ 02:25AM BLOOD Neuts-71.9* ___ Monos-4.0 Eos-3.1
Baso-0.5
___ 02:25AM BLOOD ___ PTT-31.2 ___
___ 02:25AM BLOOD Glucose-98 UreaN-11 Creat-0.8 Na-141
K-3.4 Cl-106 HCO3-23 AnGap-15
___ 08:17AM BLOOD Glucose-92 UreaN-10 Creat-0.7 Na-142
K-4.5 Cl-109* HCO3-24 AnGap-14
___ 02:25AM BLOOD ALT-15 AST-23 AlkPhos-83 TotBili-0.3
___ 08:17AM BLOOD CK(CPK)-125
___ 02:25AM BLOOD cTropnT-<0.01
___ 08:17AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:17AM BLOOD Calcium-8.4 Phos-3.9 Mg-1.9
CHEST (PA & LAT) Study Date of ___ 3:13 AM
FINDINGS:
Faint opacity in the left upper lobe might represent possible
early pneumonia
in the appropriate clinical setting. Follow-up CXR after
antibiotic therapy
may be helpful. The cardiomediastinal silhouette and hila are
normal. There is
no pleural effusion and no pneumothorax.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
Time Taken Not Noted Log-In Date/Time: ___ 12:20 pm
Immunology (CMV) TAKEN FROM HEM # 414R.
CMV Viral Load: NOT DETECTED
Brief Hospital Course:
___ female with collagenous colitis presenting with 4
episodes of BRBPR
ACTIVE ISSUES:
# GI bleed: Pt presented with 4 episodes of BRBPR. Differential
included diverticular bleed as pt reports large amount of frank
blood; as well as colitis and pt has collagenous colitis.
Hemorrhoids, AVMs, polyps are also on the differential. Upper GI
source is less likely given nature of bleed. She was
hemodynamically stable and underwent colonoscopy which revealed:
Colonoscopy REPORT:
Impression: Normal mucosa in the colon (biopsy)
Polyp in the sigmoid colon (polypectomy)
Grade 1 internal hemorrhoids
Otherwise normal colonoscopy to cecum
Recommendations: follow-up biopsy results
Etiology of BRBPR is likely Internal hemorrhoids.
Follow-up with Gastroenterologist as an outpatient in ___ weeks.
Her diet was advanced and she was discharged in stable
condition.
# Chest pain: Pt reported left arm pain radiating to chest and
neck. She has herniated disks in neck and reports intermittent
pain at baseline. EKG was not concerning for ACS; trop negative
x 2.
# ? Infiltrate on CXR: she was afebrile, not tachypneic, on room
air, with no cough, but with mild leukocytosis. which resolved
on ___ in the afternoon. Thus she was not diagnosed nor
treated for a pneumonia.
# Collagenous colitis: Had previously been on prednisone with
good relief as well as two other medications she cannot recall.
Followed by Dr ___ at ___ Ctr.
INACTIVE ISSUES:
# Depression/anxiety: continued fluoxetine and diazepam.
# Tobacco use: Smokes 10 cigarettes daily. Used nicotine patch
while in hospital
# CODE: Full
Transitional issues:
[ ] Colonoscopy biopsy and pathology results
Medications on Admission:
fluoxetine 80mg qAM
diazepam 10mg qd prn anxiety
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: Four (4) Capsule PO DAILY
(Daily).
2. diazepam 10 mg Tablet Sig: One (1) Tablet PO once a day as
needed for anxiety.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Rectal bleeding
Internal hemorrhoids
Colon polyp removal
Secondary:
Collagenous colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure participating in your care at ___. You were
admitted to the hospital for rectal bleeding. This was
attributed most likely to internal hemorrhoids however please
followup with your Gastroenterologist as the results from your
pathology specimens will be pending.
REGARDING YOUR MEDICATIONS...
It is important that you continue to take all of your usual home
medications as directed in your discharge paperwork.
Followup Instructions:
___
|
19907150-DS-12 | 19,907,150 | 26,334,868 | DS | 12 | 2167-09-09 00:00:00 | 2167-09-09 18:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Transfer, Coffee Ground Emesis
Major Surgical or Invasive Procedure:
Intubation ___
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of CAD,
COPD, IDDM, Hepatitis C, IVDU, alcohol abuse who presents from
___ with hematemesis.
Patient reports 1 episode of hematemesis at 1830 on ___ as
well as 6 dark, tarry stools which prompted him to report to ___
___ for evaluation. He endorses 1 day of dyspnea which feels
similar to previous MI, no chest pain. He has recently moved to
___ from ___, ___ in ___.
At ___ patient found to be hyperkalemic with K 6.1, received
10u IV insulin, D50 2amps, albuterol 10mg INH, and calcium
gluconate. He had 1 witnessed episode of hematemesis approx.
300-500cc and received octreotide bolus, protonix bolus. Hgb
11.1-> 10.3. Cr 3.3 from unknown baseline. Patient had right
femoral line placed for access. As there were no ICU beds
available at ___ patient was transferred to ___ for further
management.
In the ED, initial vitals:
98.8 94 135/95 16 95% Nasal Cannula
On exam pt was: axox2 with waxing and waning mental status, no
asterixis, noted to have melenic stool that was guaiac positive,
hypoxic requiring 4L via nasal cannula (with no previous home O2
requirement).
EKG: rate 76, TWI and ST depressions V1-V3
Labs were significant for: wbc 10.9, h/h 9.1/27.9, plts 115, INR
1.2,
K 5.4, bicarb 17, BUN 71, Cr 3.4, normal LFTs, trop <0.01, vbg
7.23/46/41 lactate 0.8.
Imaging was significant for: CXR (my read) large lung volumes,
no effusions, no obvious infiltrates
patient was started on octreotide and pantoprazole gtts.
Consults: GI who recommended 50G albumin for ___, 1G CTX, PPI
and octreotide,
On transfer, vitals were:
78 141/65 17 93% Nasal Cannula
On arrival to the MICU, patient complains of chronic bilateral
lower extremity pain, R >L. Denies chest pain, lightheadedness,
dizziness, orthopnea. Endorses shortness of breath, nausea, and
non productive cough. No fevers or chills. He reports hep C, no
diagnosis of cirrhosis, no history of encephalopathy requiring
lactulose or variceal bleed. Has not been treated for hep C due
to medication cost.
Review of systems:
(+) HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies abdominal pain, or changes in
bowel habits. Denies urinary frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
CAD
IDDM
Hep C
IVDU
Alcohol Abuse
CKD
Chronic RLE wound ___ gunshot
Social History:
___
Family History:
not obtained
Physical Exam:
ADMISSION:
98.5, 72 ___ 28 95% on 4L
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, prolonged expiratory
phase, no crackles, wheezes, rhonchi
CV: distant heart sounds, Regular rate and rhythm, normal S1 S2,
no murmurs, rubs, gallops
ABD: soft, non-tender, distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: no foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: bandage on right lower extremity patient is refusing to
have removed, has changed once/week with wound care at ___
NEURO: A&O x3. CN II-XII intact. Sensation, strength intact.
ACCESS: R fem line placed at ___
DISCHARGE:
Vitals: 97.9 ___ 18 91 RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: Protuberant, soft, TTP at epigastrum and LUQ w/o
rebound or guarding, non-distended, bowel sounds present
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal.
Pertinent Results:
ADMISSION:
___ 01:05AM BLOOD WBC-10.9* RBC-2.86* Hgb-9.1* Hct-27.9*
MCV-98 MCH-31.8 MCHC-32.6 RDW-14.3 RDWSD-51.3* Plt ___
___ 01:05AM BLOOD Neuts-67.1 ___ Monos-8.7 Eos-1.0
Baso-0.3 Im ___ AbsNeut-7.29* AbsLymp-2.41 AbsMono-0.94*
AbsEos-0.11 AbsBaso-0.03
___ 03:14AM BLOOD ___ PTT-30.9 ___
___ 01:05AM BLOOD Glucose-236* UreaN-71* Creat-3.4* Na-142
K-5.4* Cl-114* HCO3-17* AnGap-16
___ 01:05AM BLOOD ALT-11 AST-15 CK(CPK)-101 AlkPhos-66
TotBili-0.4
___ 01:05AM BLOOD CK-MB-10 MB Indx-9.9*
___ 01:05AM BLOOD cTropnT-<0.01
___ 06:06AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Positive*
___ 06:06AM BLOOD HCV Ab-Positive*
___ 03:26AM BLOOD ___ pO2-41* pCO2-46* pH-7.23*
calTCO2-20* Base XS--8
___ 01:17AM BLOOD Lactate-0.8 K-5.4*
___ 06:17AM BLOOD ___ RUQ US:
IMPRESSION:
Markedly limited study due to poor sonographic penetration
related to body
habitus. Limited assessment for cirrhosis and focal liver
lesions. Patent
main portal vein, no ascites, borderline splenomegaly.
___ EGD:
Esophageal varices
Erythema and superficial erosion in the fundus
Blood in the stomach
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: Erythema/surface erosion in the fundus
suggestive of healing ___ tear.
Small varices without stigmata of recent bleeding.
Continue IV PPI BID.
Would recommend discontinuation of octreotide and antibiotics
___ CXR:
IMPRESSION:
Support lines and tubes are unchanged in position. There is
unchanged
cardiomegaly. There are opacities at the lung bases which may
represent
developing pneumonia or aspiration. Follow-up to resolution is
recommended.
There is slight pulmonary vascular congestion. There are no
pneumothoraces
___ CXR:
Compared to chest radiographs ___.
Heterogeneous opacification at the lung bases has improved,
probably resolving
pneumonia. Cardiomediastinal silhouette is normal and there is
no pleural
effusion. Pulmonary arteries are mildly enlarged suggesting
elevated
pulmonary artery pressure. Healed left middle rib fractures are
chronic.
This examination neither suggests nor excludes the diagnosis of
acute
pulmonary embolism.
Right PIC line is been withdrawn to the origin of the right
brachiocephalic
vein.
Discharge Labs:
___ 03:00PM BLOOD WBC-8.5 RBC-2.53* Hgb-8.2* Hct-24.0*
MCV-95 MCH-32.4* MCHC-34.2 RDW-14.8 RDWSD-49.7* Plt ___
___ 11:06AM BLOOD Glucose-171* UreaN-43* Creat-3.8* Na-140
K-4.1 Cl-103 HCO3-16* AnGap-25*
___ 11:06AM BLOOD Calcium-8.4 Phos-4.1 Mg-2.8*
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of CAD,
COPD, IDDM, Hepatitis C, hx IVDU and etoh abuse who presents
from ___ with hematemesis concerning for UGIB, also with
TWI in precordial leads concerning for myocardial demand,
hyperkalemia, ___ on CKD.
#Hematemesis: Patient with witnessed hematemesis as well as
melenic stools most concerning for upper GI bleed. Given
cirrhosis history concern for variceal bleeding, so patient was
initially on octreotide. Patient was intubated and received EGD
on ___, which revealed surface erosions suggestive of healing
___ tear. Small varices were seen without stigmata of
recent bleeding. He was continued on IV PPI. He received 1uPRBC
initially, but his hemoglobin remained stable throughout his
admission. He was on antibiotics for SBP prophylaxis for a 7 day
course.
#Hypoxemic Respiratory Failure
#Pneumonia
Patient was electively intubated for EGD on ___ although was
found to be hypoxemic and therefore unable to be Extubated. CXR
revealed consolidations concerning for pneumonia so he was
initially started on ceftriaxone/azithromycin. Due to copious
secretions, he was broaded to vanc/zosyn on ___ due to concern
for VAP and completed an 8 day course of zosyn on ___.
Vancomycin was discontinued when MRSA screen came back negative.
He was diuresed to optimize extubation. Patient was successfully
extubated on ___. Suspect that his underlying COPD also
contributing to his hypoxemia. Once discharged from the ICU he
was weaned to room air on the medicine service.
___ on CKD: Patient with baseline CKD with Cr 2.9 in ___.
CKD secondary to DM, arterionephrosclerosis, ?Hep C, presented
with Cr of 3.4, which uptrended to a peak of 5.3. ___ likely
secondary to ATN in setting of GI bleed, intermittent
hypotension (70s systolic) and infection. UOP increased and Cr
downtrending on discharge. Patient will need follow up with
nephrology for CKD and ___. He was continued on home calcitriol
and bicarb. His lisinopril was discontinued in this setting and
held at discharge.
#Alcohol Abuse
Reports daily alcohol use with last drink day prior to
admission. He was started on phenobarb load with taper. However,
patient had worsening mental status thought secondary to
phenobarb in setting of poor clearance from underlying liver
disease, so phenobarb taper was discontinued. He had no symptoms
of withdrawal throughout his admission. He was started on
thiamine, multivitamin, and folic acid.
#TWI in precordial leads: Patient with history of CAD with
dyspnea, hypoxia, and ischemic ECG changes. Trop negative x3, MB
peaked at 20. Suspect demand and dynamic ECG changes with UGIB.
#Tachycardia
Developed episodes of tachycardia EKG showing accelerated
junctional rhythm @104 tried adenosine with minimal slowing,
back to tachy rhythm--> likely atrial tach. Restarted home BB
and patient converted back to sinus. He was continued on
telemetry throughout his admission and was maintained in sinus
rhythm.
#Hepatitis: Hep C positive, negative VL. Unknown if cirrhosis.
Decompensated with UGIB. MELD-Na= 20. Unknown to ___. Hep B VL
and Hep C not detected. He was seen by our hepatology inpatient
team who recommended outpatient hepatology evaluation.
#Hypertension
Home antihypertensives were held in the setting of hypotension
and bleed. Normotensive at discharge. Please continue to hold
lisinopril until evaluated by nephrology. Can restart amlodipine
as necessary.
#IDDM: with neuropathy.
Continued lantus and Humalog insulin sliding scale. Gabapentin
dose reduced in setting of worsening renal function
Transitional issues:
[] Home anti-hypertensives were held on admission. Please
continue to hold lisinopril until evaluated by nephrology. Can
restart amlodipine as necessary.
[] Gabapentin was decreased in the setting of renal failure to
200mg BID.
[] Started on folate/MV/thiamine for alcohol use
[] Please ensure follow up with hepatology for workup of
potential cirrhosis
[] please ensure follow up with nephrology for CKD
[] please arrange for PCP appointment at discharge
# Communication/HCP: sister ___ ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. amLODIPine 5 mg PO DAILY
3. Calcitriol 0.25 mcg PO 3X/WEEK (___)
4. Carvedilol 6.25 mg PO BID
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. GlipiZIDE 10 mg PO BID
7. Gabapentin 600 mg PO TID
8. ___ 14 Units Breakfast
9. Lisinopril 10 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Sodium Bicarbonate 1300 mg PO TID
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Lactulose 30 mL PO DAILY
3. Nephrocaps 1 CAP PO DAILY
4. Nystatin Oral Suspension 5 mL PO QID thrush
5. Pantoprazole 40 mg PO Q24H
6. Thiamine 100 mg PO DAILY
7. Gabapentin 200 mg PO BID
8. Glargine 7 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
9. Aspirin 81 mg PO DAILY
10. Calcitriol 0.25 mcg PO 3X/WEEK (___)
11. Carvedilol 6.25 mg PO BID
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Sodium Bicarbonate 1300 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
___ tear
ventilator associated pneumonia
___ on CKD, likely ATN
Hypoxic respiratory failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because of a bleed in your esophagus.
You were in the ICU where you were also treated for pneumonia.
Your kidneys have not been functioning well, which is due to how
sick you were when you come in. It is important that you see a
kidney doctor when you leave.
It is important for you to meet with a new primary care
physician. Please call: ___ to schedule an appointment
with a doctor near where you live.
You were seen by our liver team who believed that you may have
liver disease. Please make sure to follow with a liver doctor
Followup Instructions:
___
|
19907191-DS-16 | 19,907,191 | 21,112,927 | DS | 16 | 2154-07-16 00:00:00 | 2154-07-16 17:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
oxaliplatin
Attending: ___.
Chief Complaint:
confusion, lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ man with history of metastatic colon cancer with new brain
mets s/p resection x2 in ___ presents with 1 day of
worsening
confusion, dizziness, headache, and lethargy.
Per review of call-in request: ___ year old male with chief
complaint of AMS. Patient with metastatic colon cancer with new
brain mets s/p resection x2 in ___ who is having new
confusion and increased lethargy. Spoke with wife and patient
has been more confused lately and feeling like he is dreaming
while awake. Patient has mixed up days of taking his medications
but has not doubled up on any doses (taking valium and oxycodone
for R flank pain). He was in the ED on ___ for a forinocele
rupture due to chronic uretral obstruction. Percutaneous
nephrostomy tubes were offered by urology, but declined
initially
by patient. He also admits to drinking and eating less over the
past few days after being diagnosed with a UTI and treated with
macrobid.
In the ED, initial vitals: 99.2 122 131/94 18 97% RA
- Exam notable for: reportedly normal neuro exam
- Patient was given: 1L NS, 10mg IV dex
- Decision was made to admit to Omed for lethargy
On arrival to the floor, patient is conversant and appropriate
able to relate a full history recall past events and has no
diminishment in his level of orientation.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
Rectal cancer stage IV MSI stable, KRAS mutated
- ___ Colonoscopy revealed a very distal friable rectal
mass,
biopsy of which confirmed adenocarcinoma. KRAS G12V mutation
confirmed; intact IHC for MLH1, PMS2, MSH2, and MSH6. Staging
CT
showed numerous pathologically enlarged mediastinal and hilar
lymph nodes as well as multiple bilateral pulmonary nodules.
Rectal MRI revealed a large rectal tumor, radiographically
staged
as T4 N2.
- ___ PET CT showed FDG-avidity of the rectal mass and of
the enlarged mediastinal and hilar nodes, as well as the
pulmonary nodules. Also noted focal FDG-avidity in segment VI
of
the liver and in the right posterior iliac spine and in the
right
L5-S1 region of the spine.
- ___ EBUS-guided FNA of station 7 and 11L lymph nodes
showed
only benign lymphoid tissue.
- ___ C1D1 FOLFOX6
- ___ CT-guided bone biopsy of right iliac spine confirmed
metastatic adenocarcinoma (pM1b).
- ___ Bevacizumab 5 mg/kg on days 1 and 15 was added with
the start of cycle 2 of FOLFOX6.
- ___ Began zoledronic acid
- ___ Oxaliplatin stopped with C6D15 FOLFOX due to
neuropathy.
- ___: CT torso with stable metastatic disease with no new
sites of disease.
- ___ Restart ___ every 2 weeks with
zometa
after a 3 week treatment break
- ___ CT torso showed stable bilateral pulmonary nodules
and
hilar lymph node enlargement with slight interval increase in
size of subcarinal lymph node (3.1 x 1.9 cm -> 3.7 x 2 cm). No
new focal sites of disease.
- ___ CT torso: stable bilateral pulmonary nodules, hilar
lymphadenopathy, and right iliac sclerotic lesion without
evidence of new metastatic disease. New small RUL ground glass
opacity, likely infectious
- ___ CT chest: The GGOs in the RUL have disappeared. All
the nodules described in examination ___ are stable,
but
there are at least two new lung nodules in the right upper
lobe.
The lymph nodes are overall stable or reduced; only the right
lower paratracheal lymph node is minimally larger.
- ___ Treatment hold
- ___ CT showed pulmonary nodules growing, continued chemo
break per patient preference
- ___ CT showed pulmonary nodules growing
- ___ restart ___ with zometa
- ___ skipped dose to attend family function
- ___ C25 D1 of ___, leucovorin and bevacizumab
- ___ C26 D1 of ___, leucovorin and bevacizumab
- ___ C27 D1 of ___, leucovorin and Bevacizumab
- ___ C28 D1 of ___, leucovorin and bevacizumab
- ___ C29 D1 of ___, leucovorin and bevacizumab
- ___ C30 D1 of ___, leucovorin and bevacizumab, CEA
rising
- ___ C1D1 FOLFIRI bevacizumab (c31)
- ___ C31 D1 of ___, leucovorin and bevacizumab
- ___ C32 D1 of ___, leucovorin and bevacizumab
- ___ C33 D15 ___ 20% infusion dose reduced, leucovorin
and
bevacizumab
- ___ Start treatment break
- ___ C1D1 Irinotecan 350mg/m2
- ___ C2D1 Irinotecan 350mg/m2
- ___ C3D1 Irinotecan 350mg/m2, transfer care from Dr.
___ to Dr. ___
- ___ CT torso showed stable pulmonary mets and slight
improvement in rectal mass
- ___ Taking a treatment break given considerable
toxicity
from irinotecan.
- ___ MR ___ for back pain showed progression of a
known nerve sheath tumor
- ___ CT torso showed substantial progression of lung
mets
and retroperitoneal adenopathy, stable nerve sheath tumor.
- ___ C1D1 FOLFOX7 (ci5FU 1800 mg/m2) reduced for past
___
toxicity
- ___ C2D1 FOLFOX7 (ci5FU 1800 mg/m2) - aborted due to
allergic reaction to ? oxaliplatin vs leucovorin
- ___ Failed oxaliplatin desensitization attempt due to
fever/rigors
- ___ C3D1 FOLFOX7 (ci5FU 1800 mg/m2) with oxaliplatin 3
bag desensitization
- ___ CT torso showed mixed response with control of
most
lung mets, but progression of 2 lesions
- ___ C1D1 ___ + bevacizumab
- ___ C2D1 ___ + bevacizumab
- ___ C3D1 ___ + bevacizumab
- ___ C4D1 ___ + bevacizumab
- ___ CT torso showed progression of lung mets
- ___ C5D1 ___ + bevacizumab
- ___ C6D1 ___ + bevacizumab
- ___ CT torso showed stable liver and lung mets,
progression of disease in the prostate and seminal vesicle
invading the bladder
___ Cystoscopic biopsy
Pathology: metastatic rectal cancer
___ - ___ XRT to pelvis 14x? Gy
___ MRI cord stable
___ Brain MRI showed many lesions
___ Resection of the left posterior fossa mass by Dr.
___
___: Metastatic adenocarcinoma, consistent with
metastasis
from a colorectal primary, epithelial neoplasm forming glands
and
nests with extensive areas of necrosis, positive for CK20 and
CDX-2 and negative for CK7, focal mucin is highlighted by
mucicarmine stain
___ Resection of the right frontal mass by Dr. ___
___: Metastatic adenocarcinoma with extensive necrosis,
similar to prior biopsies of metastasis to the bladder and
cerebellum.
___ Brain MRI
PAST MEDICAL HISTORY:
- Rectal cancer, as above
- Bilateral hydronephrosis
- Right L5/S1 schwannoma
- HTN
Social History:
___
Family History:
CAD
Physical Exam:
97.7PO 150 / 97 98 18 93 RA
GENERAL: well NAD
HEENT: prior craniotomy scars, OP clear
NECK: no adenopathy
LUNGS: crackles at the bases bilaterally, otherwise clear
CV: s1s2 no MRG
ABD: soft non-tender active bowel sounds
EXT: no edema, clubbing of hands bilaterally
NEURO: ___ back and forward, serial sevens, PERRLA, EOMI,
CN2-12
intact, normal cerebellar exam and full visual fields.
ACCESS: PIV
Pertinent Results:
___ 05:14AM BLOOD WBC-9.6 RBC-2.99* Hgb-8.9* Hct-26.1*
MCV-87 MCH-29.8 MCHC-34.1 RDW-13.8 RDWSD-44.1 Plt ___
___ 05:46AM BLOOD WBC-6.8 RBC-2.89* Hgb-8.5* Hct-25.5*
MCV-88 MCH-29.4 MCHC-33.3 RDW-13.5 RDWSD-43.8 Plt ___
___ 04:06PM BLOOD WBC-8.5 RBC-3.04* Hgb-9.1* Hct-27.0*
MCV-89 MCH-29.9 MCHC-33.7 RDW-13.8 RDWSD-44.8 Plt ___
___ 04:06PM BLOOD Neuts-82* Bands-1 Lymphs-7* Monos-8 Eos-0
Baso-0 ___ Metas-2* Myelos-0 AbsNeut-7.06* AbsLymp-0.60*
AbsMono-0.68 AbsEos-0.00* AbsBaso-0.00*
___ 05:46AM BLOOD ___ PTT-27.4 ___
___ 05:14AM BLOOD Glucose-131* UreaN-14 Creat-1.0 Na-139
K-3.9 Cl-103 HCO3-23 AnGap-17
___ 05:46AM BLOOD Glucose-144* UreaN-12 Creat-1.2 Na-139
K-4.1 Cl-103 HCO3-22 AnGap-18
___ 04:06PM BLOOD Glucose-107* UreaN-13 Creat-1.5* Na-140
K-4.0 Cl-100 HCO3-23 AnGap-21*
___ 04:06PM BLOOD ALT-49* AST-45* AlkPhos-125 TotBili-0.2
___ 04:06PM BLOOD Albumin-2.8*
___ 04:06PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT head:
IMPRESSION:
1. There is interval increase in size of multiple scattered
hemorrhagic/hyperdense metastatic lesions since ___.
For example, the largest left cerebellar lesion is slightly
enlarged with vasogenic edema causing mass-effect in the
posterior fossa and fourth ventricle. No evidence of acute
major vascular territory infarction or new hemorrhage.
2. The patient is status post right frontal craniotomy and
suboccipital left craniotomy with resection changes in the right
frontal lobe.
Brief Hospital Course:
Pt is a ___ y.o male with h.o metastatic colon ca with new brain
mets s/p resection x 2 in ___ who presents with 1 day of
worsening confusion, dizziness, headache, and lethargy found to
have increased vasogenic edema on CT and ___.
#lethargy/confusion-improved. Suspect was due to new vasogenic
edema related to brain mets and ___ with sedating medications.
Resolved quickly on admission with initiation of steroid therapy
and resolution of ___.
#vasogenic edema in the setting of metastatic hemorrhagic brain
mets: non focal neuro exam during floor admission. Head CT
showed concern for increased metastasis with associated
vasogenic edema. Therefore, he was started on dexamethasone 4mg
q6 with good effect. He will continue this upon discharge and
further titration to be arranged by his primary oncologist. He
was continued on his outpt keppra dosing. He was started on a
PPI, daily Bactrim and weekly fluconazole for ppx. Would check
an EKG at upcoming visit to ensure QTC stability. Last QTC wnl.
___ NsAids for now. Suspect prerenal. Improved with IVF.
#UTI-continue already prescribed course of macrobid
#metastatic rectal cancer-palliative care following. Will t/b
with primary team. Primary team had discussion with pt and
decision was made to transition to hospice care upon discharge.
His oncologist will be directing this transition.
Transitional care
-please check EKG to ensure QTC stability while on multiple
agents that can prolong QTC
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO QHS
2. OxyCODONE (Immediate Release) ___ mg PO BID:PRN Pain -
Severe
3. Gabapentin 400 mg PO TID
4. LevETIRAcetam 1000 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
9. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
10. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
11. Diazepam 5 mg PO Q8H:PRN anxiety
Discharge Medications:
1. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 6 hours Disp
#*120 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
you can purchase over the counter
3. Fluconazole 200 mg PO 1X/WEEK (FR)
RX *fluconazole 200 mg 1 tablet(s) by mouth weekly Disp #*4
Tablet Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN c
You can purchase over the counter
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
7. Citalopram 20 mg PO DAILY
8. Diazepam 5 mg PO Q8H:PRN anxiety
9. Gabapentin 400 mg PO TID
10. LevETIRAcetam 1000 mg PO BID
11. Lidocaine 5% Ointment 1 Appl TP BID:PRN pain
12. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
13. Ondansetron 8 mg PO Q8H:PRN nausea
14. OxyCODONE (Immediate Release) ___ mg PO BID:PRN Pain -
Severe
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Tamsulosin 0.4 mg PO QHS
17. HELD- Ibuprofen 600 mg PO Q6H:PRN Pain - Mild This
medication was held. Do not restart Ibuprofen until you further
discuss with your oncologist due to concern for bleeding
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
metastatic colon cancer with brain metastasis
vasogenic edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted for evaluation of confusion. A head CT showed
concern for worsening of your brain metastasis with associated
swelling. For this, you were started on steroid therapy with
good effect. Your steroids will continue at current dosing for
now and further treatment plans to be arranged by Dr. ___.
After a discussion, it was decided that you would transition
home with the assistance of hospice care.
Followup Instructions:
___
|
19907318-DS-11 | 19,907,318 | 22,468,325 | DS | 11 | 2191-06-09 00:00:00 | 2191-06-12 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ hx type II dm, HTN, CAD, afib, ckd, on
warfarin presenting with abdominal pain x 1 week. Patient
describes it as diffuse/across his abdomen it was worsened with
eating. ___ thought it was a virus. ___ took pepto-bismol which
made his stool black. His nurse called the ambulance to take him
to the hospital. ___ had a small amount of dry heaves and phlegm
this morning. ___ has not had chest pressure or tightness. ___ was
having urgent liquid stools. ___ has not noticed that ___ has lost
weight. Prior to his sx beginning ___ felt well. No fevers or
chills. ___ is always cold which is his baseline. ___ does not
have
pain with urination. ___ has a mild intermittent cough which is
not new for him. At first ___ said that ___ has not had any
changes
to his medications and then later ___ said that ___ thinks that ___
may have had a change in one of his night time meds but ___
cannot
remember the name of it nor what it is for. No insect bites. No
foreign travel. His last drink was during ___ a week
ago. ___ does not drink ETOH often.
.
Past Medical History:
Insulin-dependent type 2 diabetes
Peripheral vascular disease
Hypertension
Atrial fibrillation on anti-coagulation
Chronic kidney disease
Thyrotoxicosis
Status post bilateral above-the-knee amputations
Remote h/o CCY approximately ___ years ago
Social History:
___
Family History:
Mother - died of heart failure
Physical Exam:
Temp: 97.7 PO BP: 120/64 HR: 88 RR: 18 O2 sat: 94%
O2 delivery: Ra
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round 3 mm and sluggish b/l
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
s/p b/l AKA. R wound site exposed and c/d/I.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, + southern accent, moves all limbs, sensation to
light touch grossly intact throughout
PSYCH: very pleasant, appropriate affect
Pertinent Results:
___ 01:42PM BLOOD WBC-9.1 RBC-4.31* Hgb-13.5* Hct-41.2
MCV-96 MCH-31.3 MCHC-32.8 RDW-12.8 RDWSD-45.4 Plt ___
___ 01:42PM BLOOD Glucose-187* UreaN-18 Creat-0.9 Na-137
K-4.7 Cl-102 HCO3-23 AnGap-12
___ 06:05AM BLOOD Glucose-83 UreaN-12 Creat-0.9 Na-146
K-4.3 Cl-106 HCO3-29 AnGap-11
___ 01:42PM BLOOD Lipase-106*
CT abdomen
1. Mild focal soft tissue stranding surrounding the pancreatic
head and body may reflect a mild acute pancreatitis in the
setting of elevated lipase.
2. 1.5 cm proximal pancreatic body cystic lesion may represent a
pseudocyst and appears slightly increased in size compared to
___. This may be further evaluated with dedicated
MRCP.
3. Small splenic hypodensity likely reflects an
age-indeterminate infarct, new compared to ___.
CXR
No acute intrathoracic process.
Brief Hospital Course:
ACUTE/ACTIVE PROBLEMS:
#ACUTE PANCREATITIS
Appears to be idiopathic, as ___ is s/p CCY, has no clearly
offending medicines, triglycerides are low.
___ does have a pancreatic cyst seen on imaging; discussed with
advanced endoscopy team and they advised f/u with Dr ___
EUS, which was arranged prior to discharge.
___ was started on a clear liquid diet and advanced to full
liquids, and ___ preferred to remain on full liquids to "take it
easy".
His abdomen remained soft, ___ felt that the oxycodone that ___
used for back pain treated his mild abdominal pain as well.
DARK STOOLS: Guiaic negative, ? due to pepto bismol use at
home, not anemic on arrival to ED.
ATRIAL FIBRILLATION CHA2DS2VASC =4
? complicated by splenic infarct
Resumed Coumadin in house; confirmed with outpatient providers
that ___ Home Calls manages his Coumadin dosing.
CHRONIC/STABLE PROBLEMS:
#HTN: continue amlodipine/toprol
.
#PAD: continue Lipitor
.
DM:
Will give 70% of glargine- erring on the side of hyperglycemia
since ___ feels better with his sugars over 100.
Held his trulicity during hospitalization given that his po
intake was less than normal and that it is not on formulary.
PCP can discuss restart with him when ___ follows up.
Asymptomatic bacteruria; Screening UA/UCx sent from ED; grew
out 10,000-100,000 Enterococcus, did not treat given lack of
symtpoms, no fever, leukocytosis, suprapubic pain.
Chronic lower back pain and phantom Limb pain: Confirmed with
outpatient providers use of oxycodone 5 mg bid-tid prn for pain;
this was continued in hospital, but ___ voiced confusion about
dosage, saying that ___ sometimes used half a pill. ___ also
requested a short supply as ___ said had "run out" at home, so ___
was given 3 days supply of oxycodone.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous Q week
4. Gabapentin 400 mg PO QHS
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 200 mg PO DAILY
7. Warfarin 5 mg PO DAILY16
8. FiberCon (calcium polycarbophil) 625 mg oral DAILY
9. Polyethylene Glycol 17 g PO DAILY
10. Glargine 36 Units Breakfast
11. OxyCODONE (Immediate Release) 5 mg PO TID:PRN Pain -
Moderate
Discharge Medications:
1. Glargine 21 Units Breakfast
2. amLODIPine 5 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. FiberCon (calcium polycarbophil) 625 mg oral DAILY
5. Gabapentin 400 mg PO QHS
6. Lisinopril 2.5 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO TID:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth tablet Disp #*9 Tablet
Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
10. Warfarin 5 mg PO DAILY16
11. HELD- Trulicity (dulaglutide) 0.75 mg/0.5 mL subcutaneous Q
week This medication was held. Do not restart Trulicity until
you see your PCP, Dr ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Pancreatitis
2. Diabetes Mellitus
3. Chronic back pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound - bilateral AKA, can transfer to
wheelchair at bed height
Discharge Instructions:
You were admitted with abdominal pain and found to have
pancreatitis, or inflammation in your pancreas. It is unclear
as to why you developed pancreatitis. You have improved
rapidly, and you will be discharged today. You can continue on
a full liquid diet, and start to eat more foods as you feel
better. Since you are eating a bit less, we are cutting down
the amount of insulin that you are using.
Please check your blood sugar before meals, and record the
readings. If you are unable to do so, the ___ can check your
blood sugar when they come to see you.
You have a cyst on your pancreas, and so you will need to return
on ___ for an endoscopic ultrasound so that we may get a
better look at the cyst and then figure out if it needs to be
drained.
If your pancreas is inflamed it is important to avoid alcohol.
Followup Instructions:
___
|
19907318-DS-9 | 19,907,318 | 20,704,814 | DS | 9 | 2184-08-17 00:00:00 | 2184-08-17 18:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/hx CAD s/p MI, AF, HTN and ___ PVD presented to PCP this
AM ___ week diffuse abdominal pain; subsequently referred to the
ED for abdominal pain workup and management of hyperglycemia.
.
He describes his abd pain as a band-like swath of dull
discomfort across his mid-abdomen, ___ severity, not actually
"stabbing" or "painful," just uncomfortable. Some relief with
lying on his right side; real relief last ___ when he
passed a few pellets followed by a rush of non-bloody watery
diarrhea. Abdominal discomfort worsens with meals; reports
recent poor PO intake due to mild nausea (without vomiting) and
poor appetite. Occasionally has difficulty with hard BMs and
constipation, which he can usually self-medication with
milk-of-magnesia and prune juice. However, he was hesitant to
take these this week because his abd discomfort was worse than
usual. At this time he denies fever/chills, nausea/vomiting,
hematochezia, and melena. Some urinary frequency and baseline
urinary urgency/incontinence is unchanged. He is passing gas
regularly; also complains of hiccups x2 weeks.
.
Per PCP note from this morning, in their office he was diffusely
ttp in his mid-abdomen with absent bowel sounds.
.
In the ED, his VS were 97.4 85 114/70 16 99% RA. On ED exam,
abdomen minimally distended with some diffuse tenderness to
palpation, no rebound, no guarding, normoactive bowel sounds
throughout. Labs notable for BS 500, Na 125, K 5.5, CO3 21,
lipase 101, lactate 2.1, and INR 3.6. Chemistry panel including
BS all improved significantly w/1L NS. Vascular surgery saw him
because of concern for abdominal angina/mesenteric ischemia. On
their exam he had no abdominal pain; they reviewed a CTA abdomen
which showed stenotic but patent mesenteric vessels and felt
constipation was the best explanation for his symptoms. After 1
dose maalox and 1 dose donnatal he tolerated lunch in the ED.
Admitted for ongoing hyperglycemia and possible demand
mesenteric ischemia (due to lactate and stenotic mesenteric
vessels on CTA. Transfer VS 97.4 85 114/70 16 99% RA.
.
On the floor, he reports the story as above. Also reports
weakness since he is not eating much. Some increased thirst and
urination. Had not been checking his BS at home for the past
week of so because he ran out of glucometer strips, so he was
just taking 27 70/30 insulin qAM/qPM as prescribed. His last
colonoscopy was ___ years ago and reportedly normal.
.
ROS: As above. Also denies weight loss, chest pain, shortness of
breath, diarrhea, myalgias/arthralgias, and URI sx.
Past Medical History:
DM (DIABETES MELLITUS) 250.00B c/b (A1C ___
NEPHROPATHY - DIABETIC 250.40CJ (STAGE II CKD, CR 1.2-1.4)
AUTONOMIC NEUROPATHY ___
CORONARY ARTERY DISEASE 414.00BW
PERIPHERAL VASCULAR DISEASE 443.9CC (CATH/STENTS ___ AGO BWH)
HYPERCHOLESTEROLEMIA 272.0BE
HYPERTENSION, ESSENTIAL 401.9CS
ATRIAL FIBRILLATION 427.31 (ON COUMADIN)
ANEMIA ___
OSTEOPOROSIS, UNSPEC 733.00C
GOITER 240.9AQ
HYPERTHYROIDISM 242.90A
ERECTILE DYSFUNCTION 607.84S
.
PSH:
Laparoscopic CCY
Appendectomy
R AKA (after diabetic wound infection)
L ___ toe amputation, L ___ finger amputation
Social History:
___
Family History:
Mother with diabetes.
Physical Exam:
ADMISSION
VS 98.0 156/48 89 18 97/RA ___ pain
GEN well-appearing well-nourished middle-aged man lying in bed
in NAD, moves around easily without assistance for exam
HEENT NCAT EOMI OP clear neck supple, + hiccups, no cough
CV - irregularly irregular, nl S1 S2 no mrg
PULM CTAB no r/rw
ABD moderately distended, no subcostal flaring, diffusely tender
to deep palpation L>R; no tenderness w/shallow palpation or
auscultation, no rebound/guarding, liver edge nonpalpable. bowel
sounds normoactive throughout except left lateral hypoactive BS.
EXT - RLE AKA (stump well-healed, w/skin graft); LLE warm ___
pulses palpable, skin moist, 0.5 cm round dry eschar posterior L
heel, no surrounding erythema. LLE bypass graft harvest scar
well-healed. digital amputations L ___ toe & L ___ finger. R leg
prosthesis & cane at bedside.
WWP, R AKA, well healed left ___ toe amp (L heel bulla?)
NEURO AOX3 speech fluent CNII-XII intact, strength ___
throughout, sensation intact; reflexes/gait not assessed
.
DISCHARGE
VS afebrile BP 142/78 HR 68 RR 18 O2 94/RA
GEN well-appearing well-nourished middle-aged man lying in bed
in NAD, moves around easily without assistance for exam
HEENT NCAT EOMI OP clear neck supple, + hiccups, no cough
CV - irregularly irregular, nl S1 S2 no mrg
PULM CTAB no r/rw
ABD less distended, nontender. bowel sounds normoactive
throughout.
EXT - RLE AKA (stump well-healed, w/skin graft); LLE warm ___
pulses palpable, skin moist, 0.5 cm round dry eschar posterior L
heel, no surrounding erythema. LLE bypass graft harvest scar
well-healed. digital amputations L ___ toe & L ___ finger. R leg
prosthesis & cane at bedside.
WWP, R AKA, well healed left ___ toe amp (L heel bulla?)
NEURO AOX3 speech fluent CNII-XII intact, strength ___
throughout, sensation intact; reflexes/gait not assessed
Pertinent Results:
ADMISSION LABS
___ 11:50AM BLOOD WBC-7.4 RBC-4.62 Hgb-15.0 Hct-44.0#
MCV-95 MCH-32.4* MCHC-34.0 RDW-12.9 Plt ___
___ 11:50AM BLOOD Neuts-65.8 ___ Monos-5.0 Eos-1.8
Baso-0.7
___ 11:50AM BLOOD ___ PTT-45.6* ___
___ 11:50AM BLOOD Glucose-500* UreaN-29* Creat-1.3* Na-125*
K-5.5* Cl-93* HCO3-21* AnGap-17
___ 01:00PM BLOOD Glucose-385* UreaN-26* Creat-1.2 Na-130*
K-5.0 Cl-98 HCO3-22 AnGap-15
___ 11:50AM BLOOD ALT-35 AST-40 AlkPhos-91 TotBili-0.3
___ 11:50AM BLOOD Lipase-101*
___ 11:50AM BLOOD cTropnT-<0.01
___ 11:54AM BLOOD Lactate-2.1* K-6.1*
.
DISCHARGE LABS
___ 09:50AM BLOOD WBC-8.6 RBC-4.87 Hgb-15.4 Hct-46.1 MCV-95
MCH-31.7 MCHC-33.5 RDW-13.1 Plt ___
___ 09:50AM BLOOD ___ PTT-46.8* ___
___ 09:50AM BLOOD Glucose-167* UreaN-21* Creat-1.1 Na-134
K-4.9 Cl-101 HCO3-26 AnGap-12
___ 09:50AM BLOOD Lipase-49
___ 09:50AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.2 Cholest-156
.
ADMISSION URINALYSIS
___ 01:00PM URINE Color-Straw Appear-Clear Sp ___
___ 01:00PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 01:00PM URINE RBC-1 WBC-0 Bacteri-FEW Yeast-NONE Epi-0
.
MICRO: NONE
.
IMAGING
.
___ CXR
FINDINGS: The heart size is at the upper limits of normal,
likely exaggerated by technique. The mediastinal and hilar
contours are unremarkable. The lungs are clear. There is no
pleural effusion or pneumothorax. Old left rib fractures are
seen in the area of metallic fragments. Numerous radiopaque
structures again project over the thorax, bilaterally, stable,
question shrapnel. There is no evidence of free air beneath the
diaphragms. IMPRESSION: No acute cardiopulmonary process.
.
___ CTA ABD/PELVIS
FINDINGS
LOWER CHEST:
The imaged lung bases feature minimal basilar atelectasis, but
are otherwise clear. There is no pleural effusion. There is
focal thinning of the myocardium at the cardiac apex with a
calcification, suggestive of old
infarction (4B:205). There are coronary arterial atherosclerotic
calcifications present. There is no pericardial effusion. There
is minimal
dilation of the right atrium.
ABDOMEN:
The liver enhances normally and contains no concerning focal
lesions. The
patient is status post cholecystectomy. The inferior vena cava,
portal vein, splenic vein, superior and inferior mesenteric
veins are patent.
There is subtle stranding of fat surrounding the pancreatic
head. The body
and tail appear normal. There is no fluid collection. Borderline
1 cm
peripancreatic lymph node it seen (4:239). There is a 1.7 x 1.3
cm left
adrenal nodule (2:23). This mass is of fat density on
non-contrast images,
and homogeneous in appearance, consistent with benign adrenal
adenoma. The
right adrenal gland appears normal. There is a wedge-shaped
hypodensity
within the spleen in the delayed phase, which may indicate an
area of prior
infarction. The kidneys enhance normally and excrete contrast
symmetrically.
There is a 2.3 x 2.0 cm simple cyst in the upper pole of the
right kidney.
Another, 1.2 x 0.9 cm simple cyst is found in the lower pole of
the right
kidney. A subcentimeter hypodensity in the mid pole of the left
kidney is too small to characterize by CT, however, also has the
appearance of a simple cyst. Cortical thinning seen at the
posterior aspect of the right kidney, likely scarring.
There is no intraperitoneal free air or fluid. The
intra-abdominal loops of
small and large bowel appear normal, without dilation, wall
thickening, or
abnormal enhancement. The abdominal aorta features extensive
atherosclerotic calcification, which extend into many of the
main branches. There is no aneurysmal dilation or dissection.
There is focal narrowing of the celiac trunk due to
atherosclerotic disease (4B:246). There is mild stenosis of the
origin of the superior mesenteric artery caused by non-calcified
plaque (4B:251). Similarly, there is mild stenosis of the
proximal superior mesenteric artery (4B:260). The inferior
mesenteric artery contains extensive calcifications, but appears
to be patent. There is no mesenteric arterial occlusion seen.
PELVIS:
The pelvic loops of small and large bowel, rectum, and sigmoid
colon are
normal. The appendix is not seen. The bladder, prostate, and
seminal
vesicles appear normal. There is no pelvic free fluid. There is
no
intraperitoneal or pelvic lymphadenopathy.
OSSEOUS STRUCTURES: There are no destructive lesions or acute
fractures. Old left ___ and 10th rib fractures seen. Chronic
appearing deformity of the right superior pubic ramus is also
seen, may be sequela of prior trauma.
IMPRESSION:
1. Extensive peripheral vascular disease without evidence of
mesenteric
arterial occlusion. There is no evidence of ischemic enteritis
or colitis.
2. Focal fat stranding around the pancreatic head, in the
setting of elevated serum lipase, is consistent with mild acute
pancreatitis.
3. Incidental findings as described above.
Brief Hospital Course:
___ M w/hx CAD/PVD/DM2 p/w 2 weeks abdominal pain, constipation
and hyperglycemia, all of which resolved by the following
morning with a laxative-induced bowel movement and his home
insulin regimen.
.
# CONSTIPATION
Admitted via PCP's office for abdominal pain and concern for
demand mesenteric ischemia despite lack of mesenteric vascular
occlusion on CTA abd/pelvis and vascular surgery consult in the
ED. On the floor, constipation (given excellent story for this)
and/or mild pancreatitis (given mildly elevated lipase and mild
___ fat stranding seen on CT. There was no evidence
of SBO on CT, so he was given an agressive bowel regimen
(colace, senna, miralax, lactulose and glycerin suppositories)
and had three large bowel movements overnight. Felt better in
the morning. Discharged with prescriptions for colace and senna;
may also need miralax and/or lactulose if constipation recurs.
.
# HYPERGLYCEMIA
Longstanding type II diabetes. Takes insulin 27U qbreakfast and
dinner. Today he had a ___ 475 in PCP's office, then 500 in ED on
arrival. Asymptomatic. Review of atrius records show that he
called in 6 days ago w/report of running out of glucometer test
strips but "was eating the right things" so we suspect he was
taking insufficient insulin in the interim. Intial electrolyte
derangements resolved w/IVF, so unlikely to be ___
hyperglycemia. Received his usual of 27U 70/30 insulin on the
evening of admission; ___ was 147 the following morning.
.
#Hiccups
Going on for 2 weeks, contemporaneous with abdominal
pain/distension. Likely due to diaphragmatic irritation. Managed
with reglan overnight. Resolved by morning, after constipation
resolved.
.
# CKD
Creatinine within baseline of 1.2-1.4. Continued lisinopril.
.
# Hx PVD
Pt has suffered AKA previously for an infected diabetic ulcer;
Atrius notes show that he has a blister on his L heel now which
___ podiatry is following. The ulcer was a dry 0.5 cm eschar,
not infected appearing. Vascular surgery agreed that it looked
well and not in need of any special wound care at this time.
.
# Hx CAD
No chest pain or SOB. TRoponins checked in the ED were negative.
Not repeated on the floor because his history of 2 weeks
abdominal pain without diaphoresis, SOB or elevated trop in ED
was not concerning for an anginal equivalent. Continued home
meds: Isosorbide Mononitrate 60 mg ER QD, Furosemide 40 mg Oral
Tablet take 1 tablet QD, Lisinopril 5 mg Oral Tablet take 2
tablet QD, ASPIRIN 81 MG TAB QD, Metoprolol ER 200 QD.
.
# Hx Atrial fibrillation
On long-term anticoagulation with coumadin. Per ___ records,
his most recent coumadin dosing (adjusted ___ is Warfarin
7.5mg x FRI/TUES; 6.25 mg x5d. Supratherapeutic in the ED w/INR
3.6. Coumadin was held during this admission because he was
supratherapeutic, likely ___ poor PO intake recently. Restarted
at discharge at unchanged doses. Patient instructed to follow-up
with ___ clinic in ___ days.
.
# Hyponatremia
125 on admission corrects to 135 in setting of hyperglycemia. Na
improved to 130 with 1L NS in the ED.
.
# Hypertension
BP wnl in the ED today. Atrius records show baseline 130s with
one isolated reading of 180 ~2 weeks ago at his PCP's office.
Continued lisinopril 5 QD, metoprolol
.
# Hx Anemia
Last Hct in PCP's office was 41.9. Higher here.
.
TRANSITIONAL ISSUES
1. Needs close ___ clinic follow-up given
supratherapeutic INR here
2. Follow-up and trend blood sugars, adjust insulin scale PRN
3. Monitor patient's bowel movements - history suggests
constipation is an ongoing problem.
Medications on Admission:
Warfarin 7.5mg x FRI/TUES; 6.25 mg x5d (ANTICOAG WORKSHEET
___
Isosorbide Mononitrate 60 mg ER QD
Insulin NPH & Regular Human (NOVOLIN 70/30)
Furosemide 40 mg Oral Tablet take 1 tablet QD
Lisinopril 5 mg Oral Tablet take 2 tablet QD
Metoprolol Succinate 100 mg ER 2 tablets by mouth QD
ASPIRIN 81 MG TAB QD
VITAMIN A ORAL QD
VITAMIN B COMPLEX ORAL QD
VITAMIN C ORAL QD
VITAMIN D ORAL QD BID
VITAMIN E ORAL QD
Testosterone (TESTIM) 50 mg/5 gram (1 %) Transdermal Gel QD
Alprostadil (EDEX) 40 mcg Intracavernosal Kit use as directed
Discharge Medications:
1. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO 2X/WEEK
(___).
2. warfarin 2.5 mg Tablet Sig: 2.5 Tablets PO 5X/WEEK
(___).
3. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
4. insulin NPH & regular human 100 unit/mL (70-30) Suspension
Sig: ___ (25) units Subcutaneous twice a day.
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
6. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. metoprolol succinate 100 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO once a day.
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. vitamin A 10,000 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
10. B complex vitamins Capsule Sig: One (1) Cap PO DAILY
(Daily).
11. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
13. vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY
(Daily).
14. testosterone 50 mg/5 gram (1 %) Gel Sig: One (1)
Transdermal once a day.
15. alprostadil 40 mcg Kit Sig: One (1) Intracavernosal as
directed.
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day): titrate to ___ bowel movements/day.
Disp:*60 Capsule(s)* Refills:*2*
17. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): titrate to ___ bowel movements/day.
Disp:*60 Tablet(s)* Refills:*2*
18. test strips Sig: One (1) strip once a day: Please check
your blood sugar daily.
Disp:*30 * Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: constipation
Secondary: hyperglycemia, diabetes, atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
You were admitted to the hospital for belly pain and was found
to be constipated and with elevated blood sugars. We treated
you with medications to help move your bowels and your symptoms
have improved. You were discharged in good condition.
The following changes were made to your meds:
-start senna and docusate as needed for constipation
-continue to take your insulin twice daily. Please address with
your PCP further adjustment of your insulin and check your
sugars daily. If your sugars are greater than 400 please
contact your PCP.
Followup Instructions:
___
|
19907351-DS-9 | 19,907,351 | 22,349,990 | DS | 9 | 2158-06-08 00:00:00 | 2158-06-08 13:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R intertrochanteric fracture
Major Surgical or Invasive Procedure:
R TFN
History of Present Illness:
___ female with a history of hypertension, GERD,
diverticulitis, recent L2-L3 synovial cyst removal, durotomy
repair, and L2-L3, L4-L5, L5-S1 keyhole foraminotomy ___
at
___ with a subsequent course complicated by aspiration
pneumonia, A. fib with RVR, pulmonary edema, heart block, MICU
admission, who is transferred here for medical management in
___, transferred from ___ with a right
intertrochanteric hip fracture due to prior medical complexity.
Patient reports that this morning at 11:30 a.m., she is feeling
groggy after night not sleeping, which he attributes to
trazodone. Denies chest pain, shortness of breath, fever,
chills. Denies diarrhea, bloody stools. Patient had a
mechanical misstep, falling onto her right hip. Immediate pain
in her right hip. Was seen at ___ where she had an x-ray
notable for a right intertrochanteric hip fracture. Patient
denies weakness, numbness, coolness, tingling in the leg.
Past Medical History:
1. Lumbar spinal stenosis with herniation of nucleus pulposus
2. Hypertension
3. Hypothyroidism
4. Asthma
5. Osteoporosis
6. GERD
7. Chronic back pain
8. Diverticulitis ___
9. History of recurrent respiratory tract infections for which
she takes azithromycin 250 mg PO every ___ for "immune
deficient state"
PAST SURGICAL HISTORY:
1. S/p L2-L3 synovial cyst removal, durotomy repair, and L2-L3,
L4-L5, L5-S1 keyhole foraminotomy ___
2. S/p partial colectomy ___ for diverticulitis
3. S/p hernia repair x ___
4. S/p hysterectomy
5. S/p cataract resection ___
Social History:
___
Family History:
Patient without clear recollection of any major illnesses.
Physical Exam:
VSS
General: Well-appearing, breathing comfortably
Patient sleeping comfortably. Exam deferred per geriatric
protocol.
Exam:
RLE lower extremity:
- Bandage c/d/i
- +TTP in right trochanter
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
See OMR for all lab and imaging results.
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 R intertrochanteric fx and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for R TFN, 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, with
medicine following to monitor medication management with
continued home medications.
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 RLE extremity, and will be discharged on Lovenox
40mg daily for DVT prophylaxis. The patient will follow up with
Dr. ___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge.
Medications on Admission:
-spironolactone 25 mg
-sacubitril-valsartan 49-51 mg
-Lasix 40 mg po qd
-synthroid ___ mcg qd
- omeprazole 20 mg qd
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QHS
RX *enoxaparin 40 mg/0.4 mL 1 syringe sc daily Disp #*28 Syringe
Refills:*0
4. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
Please decrease in dose and frequency as pain decreases
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
5. Senna 17.2 mg PO HS
6. Furosemide 20 mg PO DAILY
7. Levothyroxine Sodium 100 mcg PO ___
8. Levothyroxine Sodium 50 mcg PO ___
___ OTHER DOSE)
9. Omeprazole 20 mg PO DAILY
10. Sacubitril-Valsartan (49mg-51mg) 1 TAB PO DAILY
11. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R intertrochanteric fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated
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 40 mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- 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
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Physical Therapy:
WBAT RLE
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Call your surgeons office with any questions.
Followup Instructions:
___
|
19907502-DS-12 | 19,907,502 | 27,996,858 | DS | 12 | 2168-03-05 00:00:00 | 2168-03-05 12:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Latex, Natural Rubber / shellfish
Attending: ___.
Chief Complaint:
Left ___ digit distal pulp avulsion, ___ digit laceration.
Major Surgical or Invasive Procedure:
Antegrade ___ flap, skin graft
History of Present Illness:
___ RHD F w/PMH DM2 presents after geting LEFT ___ and ___
fingers in converyor belt at work. She works at ___ and was
___, when her fingers got caught in conveyor belt.
Denies any other injuries. No numbness/tingling. Able to flex/ex
all digits. Tetanus up to date.
Found to have L ___ digit distal pulp avulsion, ___ digit
laceration.
Past Medical History:
DM2
Social History:
___
Family History:
NC
Physical Exam:
Vitals: AVSS
In general, the patient is comfortable, in NAD
LUE:
LEFT volar finger tip pulp avulsion of ___, and 7cm laceration
of
___ distal phalanx
EPL/FPL/APB/DIO intact
SILT axillary/radial/median/ulnar nerve distributions
2+Radial pulse
Splint and dressing placed s/p skin graft, antegrade ___ flap. all digits wwp, bcr. nvi.
Pertinent Results:
___ 12:40PM GLUCOSE-101* UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14
___ 12:40PM estGFR-Using this
___ 12:40PM WBC-6.7 RBC-4.52 HGB-11.0* HCT-35.9* MCV-79*
MCH-24.2* MCHC-30.5* RDW-16.0*
___ 12:40PM NEUTS-51.5 ___ MONOS-4.8 EOS-1.6
BASOS-0.6
___ 12:40PM PLT COUNT-299
___ 12:40PM ___ PTT-25.9 ___
Brief Hospital Course:
The patient was admitted to the Plastic Surgery Service for
antegrade ___ flap and skin graft.
The patient was taken to the OR and underwent an uncomplicated
antegrade ___ flap and skin graft.
The patient tolerated the procedure without complications and
was transferred to the PACU in stable condition. Please see
operative report for details. Post operatively pain was
controlled with IV pain meds with a transition to PO pain meds
once tolerating POs. The patient tolerated diet advancement
without difficulty and made steady progress to ambulate without
difficulty.
The patient received ___ antibiotics as well as
Fragmin for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage. The patient
was discharged home in stable condition with written
instructions concerning precautionary instructions and the
appropriate follow-up care. All questions were answered prior to
discharge and the patient expressed readiness for discharge.
Medications on Admission:
metformin, motrin
Discharge Medications:
Oxycodone 5mg PO q4h prn.
Resume home metformin
Hold motrin
Discharge Disposition:
Home
Discharge Diagnosis:
L ___ digit distal pulp avulsion, ___ digit laceration.
Discharge Condition:
Improved.
Discharge Instructions:
-Maintain your hand in the splint that was made for you. Keep
splint on at all times until follow-up in clinic on ___
- no swimming until wound has closed.
- cover splint when engaging in activities that could
contaminate your wound (such as diaper changes).
- If your hand wound begins to worsen after discharge home with
an acute increase in swelling or pain, please call the plastic
surgery clinic ___ or return to the ED.
.
Medications:
* Resume your regular medications unless instructed otherwise.
* You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
* Take Colace, 100 mg by mouth 2 times per day, while taking the
prescription pain medication to prevent constipation. You may
use a different over-the-counter stool softener if you wish.
* Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from wound, chest pain, shortness of breath, or
anything else that is troubling you.
Followup Instructions:
___
|
19907527-DS-5 | 19,907,527 | 27,177,954 | DS | 5 | 2173-03-20 00:00:00 | 2173-03-20 11:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
___
WBC-16.6* RBC-5.12 Hgb-15.7 Hct-45.7 MCV-89 MCH-30.7 MCHC-34.4
RDW-12.5 RDWSD-41.3 Plt ___
___
WBC-7.1 RBC-4.77 Hgb-14.5 Hct-43.1 MCV-90 MCH-30.4 MCHC-33.6
RDW-13.1 RDWSD-43.1 Plt ___
___
Neuts-82.8* Lymphs-9.5* Monos-7.0 Eos-0.0* Baso-0.2 Im ___
AbsNeut-11.49* AbsLymp-1.32 AbsMono-0.97* AbsEos-0.00*
AbsBaso-0.03
___
___ PTT-30.8 ___
___
Glucose-98 UreaN-9 Creat-0.9 Na-143 K-4.4 Cl-105 HCO3-22
AnGap-16
___
ALT-402* AST-255* LD(LDH)-257* AlkPhos-128 TotBili-6.7*
___
ALT-197* AST-70* AlkPhos-124 TotBili-1.6*
___
DirBili-3.1*
___
Lipase-34
___
Albumin-3.9 Calcium-9.0 Phos-2.7 Mg-1.7
___
HBsAg-NEG HBsAb-NEG HBcAb-NEG IgM HAV-NEG
___
AMA-PND Smooth-PND
___
___
___
IgG-1304 IgA-297 IgM-134
___
CMV IgG-PND CMV IgM-PND CMVI-PND EBV IgG-PND EBNA-PND EBV
IgM-PND EBVI-PND
___
ASA-NEG Acetmnp-NEG Tricycl-NEG
___
HCV Ab-NEG
___
Lactate-1.1
___
Blood-NEG Nitrite-NEG Protein-50* Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NORMAL pH-6.0 Leuks-NEG
___
RBC-<1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-<1
MRCP
TECHNIQUE: T1- and T2-weighted multiplanar images of the
abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 11 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was
administered
for oral contrast.
COMPARISON: CT of the abdomen and pelvis from ___.
Abdominal ultrasound from ___.
FINDINGS:
Lower Thorax: Mild bibasilar atelectasis. No pleural or
pericardial effusion.
Liver: Normal in morphology without significant steatosis or
deposition. In
hepatic segment VII, there is a 1.2 cm T2 intermediate to
hyperintense focus
which demonstrates mild progressive peripheral nodular
enhancement compatible
with a hemangioma (series 5, image 21). No other focal hepatic
lesions
identified within the limits the examination which is mildly
limited by
motion.
Biliary: No intrahepatic or extrahepatic biliary dilation.
Cholelithiasis
without evidence of cholecystitis.
Pancreas: Normal in signal and bulk. No main ductal dilation or
focal
lesions.
Spleen: Normal size and signal. No focal lesions.
Adrenal Glands: Normal in size and shape bilaterally.
Kidneys: As seen on prior CT, centered in the interpolar region
and lower pole
of the right kidney is a heterogeneous enhancing mass which
appears to involve
the renal pelvis and measures 5.3 x 6.6 x 5.6 cm (series 5,
image 41; series
1403, image 129). There is no hydronephrosis or evidence of
tumor thrombus in
the renal vessels although the right renal vein comes in close
proximity to
the mass as it enters the renal pelvis (series 1403, image
133).. In the
interpolar region of the left kidney a T2 hyperintense
nonenhancing cyst
demonstrates thin septation (series 5, image 38). No
hydronephrosis.
Gastrointestinal Tract: No evidence bowel obstruction or
inflammation.
Colonic diverticulosis again noted.
Lymph Nodes: No pathologically enlarged lymph nodes identified.
Vasculature: Single bilateral renal arteries and veins. Hepatic
arterial
anatomy is conventional. Patent hepatic and mesenteric
vasculature.
Osseous and Soft Tissue Structures: No definite osseous lesions.
Degenerative
changes in the spine.
IMPRESSION:
1. No evidence of biliary obstruction or abscess.
2. No definite cholangitis although motion limits assessment.
3. Cholelithiasis without evidence of cholecystitis.
4. Redemonstrated 6.6 cm enhancing right renal mass encroaches
on the renal
pelvis and is concerning for renal cell carcinoma. No evidence
of vascular
invasion or metastasis.
EKG sinus rhythm ,
CT A/P
TECHNIQUE: Single phase contrast: MDCT axial images were
acquired through the
abdomen and pelvis following intravenous contrast
administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
COMPARISON: Ultrasound abdomen dated ___. Chest
CT from ___.
FINDINGS:
LOWER CHEST: The heart is normal in size. There is no
pericardial effusion.
Ground-glass opacities at the lung bases and bronchiolectasis
may be due to
interstitial lung disease better characterized by prior chest
CT.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or
extrahepatic biliary dilatation. The gallbladder contains
gallstones without
wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: There is a right renal mid to lower pole 4.9 x 5.9 x
5.4 cm
heterogeneous mass. There is a left renal midpole
low-attenuation lesion
measuring 1.2 cm likely a cyst. There is a 6 mm calculus
visualized in the
right renal lower pole. There is no hydronephrosis or
hydroureter.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout.
There is diffuse
sigmoid diverticulosis without evidence of diverticulitis. The
appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is mildly enlarged measuring
4.9 cm
transverse..
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No
atherosclerotic disease
is noted.
BONES: There is chronic deformity of the right iliac wing.
There is moderate
multilevel degenerative changes of the thoracolumbar spine with
anterior
osteophyte formation.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Right renal 4.9 x 5.9 x 5.4 cm heterogeneous mass concerning
for
malignancy.
2. Diffuse sigmoid diverticulosis without evidence of
diverticulitis.
3. Mild prostatomegaly.
4. Chronic right iliac wing deformity.
CXR no acute changes
RUQ US
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were
obtained.
COMPARISON: Prior MRI lumbar spine ___.
FINDINGS:
LIVER: The liver is echogenic, with areas of fatty sparing about
the
gallbladder fossa. The contour of the liver is smooth. There is
no focal
liver mass. The main portal vein is patent with hepatopetal
flow. There is no
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: The pancreas is not well visualized, largely obscured
by overlying
bowel gas.
SPLEEN: Normal echogenicity, mild splenomegaly.
Spleen length: 13.4 cm
KIDNEYS: Limited views of the kidneys show no
hydronephrosis.There is a
heterogeneously isodense to mildly hyperechoic mass relative to
the renal
parenchyma measuring 4.9 x 5.2 x 4.8 cm in the right kidney,
which appears new
from the scout images from the MRI of the lumbar spine from
___.
there is minimal internal vascularity within this mass.
Right kidney: 13.6 cm
Left kidney: 11 cm
IMPRESSION:
1. 4.9 x 5.2 x 4.8 cm mass in the right kidney worrisome for
neoplasm. Renal
MRI is recommended for further evaluation.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease
and more advanced liver disease including steatohepatitis or
significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
See
recommendations below.
3. Cholelithiasis without evidence of cholecystitis.
RECOMMENDATION(S):
1. Renal MRI is recommended for further characterization of the
right renal
mass.
2. Radiological evidence of fatty liver does not exclude
cirrhosis or
significant liver fibrosis which could be further evaluated by
___.
This can be requested via the ___ (FibroScan), or the
Radiology
Department with MR ___, in conjunction with a
GI/Hepatology
consultation" *
Brief Hospital Course:
___ yo M with hx of ILD follows at ___, chronic lumbar
radiculopathy, here with abdominal pain found to have fevers and
transaminitis ultimately though to be a passed stone also found
incidentally to have a right renal mass concerning for new ___.
Transitional issues
[ ] f/u hepatology for transaminitis, some lab workup pending on
discharge
[ ] f/u urology for renal mass
#) Abdominal pain
#) Fevers
#) Transaminitis
Patient presented with acute onset crampy diffuse abdominal
pain. Says that he has had this before right after meals
associated with bloating but then goes away within hours. This
didn't prompting admission.
He was then found to be febrile here ad there was initially
concern for paraneoplastic syndrome/B symptoms from renal mass
seen on imaging.
However, he had elevated LFTS and D. bili which were more likely
to be the source of possible infection.
I spoke with urology and they recommended outpatient follow up
for the mass rather than dedicated MRI or ___ biopsy here.
Hepatology was consulted for his elevated LFTs. To completely
rule out stone, MRCP was done and was normal. IT also served as
another form of imaging for his renal mass which is concerning
for RCC. Given the transient fever, pain and elevated LFTS, it
is suspected that he passed a biliary stone.
He will follow up with hepatology in clinic.
Patient did received one dose of broad spectrum Abx in the ED,
but fevers and abdominal resolved quickly after admission and
due to lack of obvious source he was taken off Abx and was
monitored for 48 hrs without fevers or recurrence of abdominal
pain.
#) New right sided renal mass
He will follow up with urology as above.
Low suspicion that this was causing any symptoms.
Patient denies hematuria and had no RBCs on UA here.
#) Lumbar radiculopathy
Patient takes NSAIDs tid and an opioid from ___ (thinks
hydrocodone) once a week.
He is on famotidine for GI ppx.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
2. Gabapentin 300 mg PO QHS
3. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
4. Hydrocortisone Cream 2.5% 1 Appl TP DAILY
5. Famotidine 20 mg PO BID
Discharge Medications:
1. Famotidine 20 mg PO BID
2. Gabapentin 300 mg PO QHS
3. Hydrocortisone Cream 2.5% 1 Appl TP DAILY
4. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Passed biliary stone
Renal mass
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 fevers.
You were then found to have abnormalities in your liver test and
had an MRI which did not show any stone. Most likely, you had a
stone that you passed.
You were also found to have a right kidney mass on imaging which
is unrelated to any symptoms you were having.
Please see below for followup.
Followup Instructions:
___
|
19907622-DS-12 | 19,907,622 | 27,564,876 | DS | 12 | 2153-05-28 00:00:00 | 2153-05-28 15:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of alcohol abuse ___ beers/day) and
bipolar disorder who was brought to the ED by ambulance s/p
fall. Patient is suspected to have fallen down approximately 10
stairs, with unknown LOC and unknown down time. Per report,
patient was found by neighbor lying at the bottom of the stairs
and was brought back upstairs into bed. Per EMS, both patient
and neighbor were found unresponsive with scattered pill bottles
in the vicinity. Patient was responsive to Narcan, becoming
alert and oriented x2 but with slurred speech.
Upon arrival to ED, patient is disengaged and lethargic, not
providing any reliable history.
Past Medical History:
ETOH abuse
Bipolar disorder
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission:
Pertinent Results:
Labs on admission:
WBC-6.6 RBC-3.10* Hgb-11.7* Hct-34.9* MCV-112* MCH-37.7*
MCHC-33.5 RDW-13.5 Plt ___ PTT-26.6 ___
Glucose-80 Lactate-1.3 Na-149* K-4.0 Cl-110* calHCO3-25
ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
Lipase-99*
Imaging:
___ CXR:
- Segmental fractures of right ___ and 9th ribs.
- Focal consolidation or right lower lobe may represent a
pneumonia.
___ CT c-spine: No fracture, dislocation or malalignment.
___ CT head: No acute intracranial abnormality.
___ CT chest:
1. Segmental fractures of the right eighth and ninth ribs. No
pneumothorax.
2. Focal consolidation in the right lower lobe. This may
represent pneumonia.
3. No intra-abdominal traumatic injury identified.
Brief Hospital Course:
Ms ___ was admitted to the Acute Care Surgery team with alcohol
intoxication and right ___, 9th rib fractures following a fall.
She was admitted to the Trauma Surgical ICU for close monitoring
given her altered mental status. Given significant concern for
alcohol withdrawal, she was given scheduled diazepam and
additionally treated with lorazepam based on CIWA scale. Her
mental status progressively improved to a state of alertness and
full orientation. She was then able to identify herself and
give additional history that she consumed 6 oxycodone prior to
her fall, with the goal of getting high (not a suicide attempt).
Her respiratory status and oxygen saturation were continuously
monitored, and her supplemental oxygen was weaned as her mental
status cleared. She was given acetaminophen, IV ketorolac, and
intermitent oxycodone for pain control associated with her rib
fractures. She was advanced to a regular diet, and IV fluids
were discontinued as her intake increased. Her home medications
were restarted.
Given concern for potential sexual assault in the setting of her
altered mental status, a sexual assault nurse examination with
associated testing was offered to the patient when her mental
status cleared. She declined, indicating that she did not
believe any nonconsensual activity occurred. Additionally, the
patient was interviewed at length, in collaboration with the
social worker, regarding any suicidality associated with the
events leading to her admission. She adamantly denied any past
or current suicidal attempts or ideation. She was counseled on
the risks and longterm consequences of alcohol and narcotic
consumption. She was offered information and assistance with
alcohol cessation; she indicated she would follow up with her
PCP if she desired assistance.
By hospital day #2, Ms ___ was alert, fully oriented,
ambulating independently, voiding without difficulty, with her
pain controlled on oral analgesics and maintaining good oxygen
saturation on room air. A tertiary survery was performed,
revealing no additional injuries. She was deemed appropriate
for discharge home with recommendations to follow up with her
PCP regarding her rib fractures and potential alcohol cessation.
Medications on Admission:
- lamictal 100mg PO BID
- sertraline 100md PO BID
- seroquel 50mg QHS
- propranolol 10mg PO BID
- mirtazapime 15 QHS
- gabapentin 600mg TID
- ibuprofen prn
- MVI
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
2. Tylenol ___ mg Tablet Sig: Two (2) Tablet PO every six (6)
hours as needed for pain.
Disp:*60 Tablet(s)* Refills:*2*
3. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as
needed for constipation.
Disp:*60 Capsule(s)* Refills:*1*
4. Lamictal 100 mg Tablet Sig: One (1) Tablet PO twice a day.
5. sertraline 100 mg Tablet Sig: One (1) Tablet PO twice a day.
6. Seroquel 50 mg Tablet Sig: One (1) Tablet PO at bedtime.
7. propranolol 10 mg Tablet Sig: One (1) Tablet PO twice a day.
8. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime.
9. gabapentin 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
10. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
1. Alcohol intoxication
2. Right ___ rib fractures
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 following a
fall in the setting of severe alcohol intoxication and narcotic
ingestion.
General Discharge Instructions:
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed.
Please take the prescribed analgesic medications as needed. You
may not drive or heavy machinery while taking narcotic analgesic
medications. You may also take acetaminophen (Tylenol) as
directed, but do not exceed 4000 mg in one day.
Please get plenty of rest, continue to walk several times per
day, and drink adequate amounts of fluids. Avoid strenuous
physical activity and refrain from heavy lifting greater than 10
lbs., until you follow-up with your your primary care physician,
who can instruct you further regarding activity restrictions.
Your primary care physician can also discuss alcohol cessation
options with you.
Followup Instructions:
___
|
19907692-DS-13 | 19,907,692 | 20,302,559 | DS | 13 | 2186-05-31 00:00:00 | 2186-06-05 16:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Sinus pauses
Major Surgical or Invasive Procedure:
PPM placement on ___
Indication: Sick sinus syndrome
Device brand/name: ___ ___ ___: ___
History of Present Illness:
Mr. ___ is a ___ man with a PMH notable for paroxysmal
AFib, CVA in ___ with residual right-sided weakness, T2DM,
hypertension, and recent admission for cholecystitis, who was
referred by outpatient cardiologist for evaluation of 5.6 sec
pause on cardiac monitor.
The patient has had many irregular heart rhythms in past few
months. In ___, the patient suffered a left pontine CVA
prompting hospitalization at ___. He was found there to have a
lot of ventricular ectopy, and was started on metoprolol 12.5 mg
BID. On followup with his cardiologist, patient was placed on
lifewatch to monitor for further events. He was noted to have
sinus pauses in early ___. The patient was then
hospitalized in late ___ at ___. He initially
presented on ___ with chest pain symptoms, and had stress
testing without obvious abnormalities. He had evidence of
cholecystitis, and a catheter placed in his gallbladder to drain
on ___. He was found to be in AFib on ___. However, he was
also found to have sinus pauses, and his home metoprolol was
stopped. He was discharged with monitoring. On ___, the on call
cardiologist was notified that the patient had a 5.6 sec pause.
During this time he was on his way to a doctor's appointment,
and did not notice any symptoms. As the patient is now found to
have pauses despite being off of his beta blocker, and is at
high risk for syncope, it was recommended that he present to the
ED for possible hospitalization and further workup.
In the ED initial vitals were: T 97.0, HR 72, BP 148/61, RR 18,
O2 SAT 100% RA. His EKG showed sinus rhythm. ___ Cardiology
was consulted and recommended admission to ___ for possible
pacemaker placement on ___.
On the floor, the patient reports feeling still somewhat ill
from his hospitalization at ___ recently for
cholecystitis. Otherwise, he has not had any cardiac symptoms,
such as chest pain, dyspnea, palpitations, lightheadedness, or
dizziness.
REVIEW OF SYSTEMS:
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope, or presyncope.
On further review of systems, denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. Denies exertional
buttock or calf pain. Denies recent fevers, chills or rigors.
All of the other review of systems were negative.
Past Medical History:
1. CARDIAC RISK FACTORS
- Type 2 diabetes
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- Paroxysmal atrial fibrillation
- Patent foramen ovale
3. OTHER PAST MEDICAL HISTORY
- Left pontine CVA ___
- Chronic kidney disease, stage III (baseline Cr 1.5)
- Hearing loss, sensorineural
- Macular degeneration
- Nephrolithiasis
- BPH
- Obesity
- Obstructive sleep apnea
- Gout
- Gastroesophageal reflux disease
- Hyperparathyroidism
- s/p partial colectomy
Social History:
___
Family History:
Mother had breast cancer. Father may have had a heart condition,
died at ___ years.
Physical Exam:
====================
ADMISSION EXAM
====================
VS: T 97.9 BP 134/67 HR 73 RR 18 O2 SAT 98% on RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate. Appears sluggish.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa.
NECK: Supple with JVP of 5-6 cm.
CARDIAC: RRR, normal S1, S2. ___ systolic murmur heard at the
base and apex. No thrills, lifts.
LUNGS: Respiratory were unlabored, no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, nontender, mild distension. Percutaneous tube in
the RUQ draining orange colored serous fluid.
EXTREMITIES: Trace lower extremity swelling.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: CN II-XII intact but has a slight left facial resting
droop. ___nd RLE, ___ in the LUE and LLE.
====================
DISCHARGE EXAM
====================
Wt: 77.8kg (88.5kg on ___
VS: 97.3-98.3F, bp curr 132/53, bp 112-147/53-72, HR 58-68, RR
18, O2sat 94-98% on RA
TELE: No sinus pauses, few single PVCs, NSR, with some beats
paced and some not paced on the review of overnight telemetry
GENERAL: Awake, alert, resting comfortably in bed
HEENT: NC/AT, PERRLA, clear conjunctiva b/l, MMM
NECK: Supple, no cervical lymphadenopathy
CARDIAC: RRR, normal S1, S2. ___ systolic murmur heard at the
base and apex.
CHEST: Bandage c/d/I in place on the R chest, mildly-tender to
palpation, no discharge, no hematoma
LUNGS: CTAB, no wheezes
ABDOMEN: Soft, obese, mildly distended, +BS, non-tender to
palpation in all four quadrants. Percutaneous tube in place in
the RUQ (bandage in place, c/d/i), site is non-tender to
palpation, draining serous yellow fluid.
EXTREMITIES: Warm, no edema, 2+ peripheral pulses
SKIN: No skin lesions or rashes
Pertinent Results:
================
ADMISSION LABS
================
___ 05:45PM BLOOD WBC-7.1 RBC-4.21* Hgb-12.2* Hct-38.4*
MCV-91 MCH-29.0 MCHC-31.8* RDW-13.4 RDWSD-44.7 Plt ___
___ 05:45PM BLOOD Neuts-76.8* Lymphs-12.4* Monos-6.2
Eos-3.5 Baso-0.4 Im ___ AbsNeut-5.46 AbsLymp-0.88*
AbsMono-0.44 AbsEos-0.25 AbsBaso-0.03
___ 05:45PM BLOOD Glucose-237* UreaN-31* Creat-1.5* Na-138
K-4.6 Cl-103 HCO3-22 AnGap-18
___ 06:38AM BLOOD Calcium-8.2* Phos-3.5 Mg-2.2
====================
PERTINENT RESULTS
====================
CXR (___):
1. Newly placed right chest wall dual chamber pacemaker with
leads projecting over the right atrium and right ventricle.
2. No radiographic evidence of acute cardiopulmonary
abnormality.
====================
DISCHARGE LABS
====================
___ 06:45AM BLOOD WBC-8.6 RBC-3.75* Hgb-10.9* Hct-34.0*
MCV-91 MCH-29.1 MCHC-32.1 RDW-12.8 RDWSD-42.4 Plt ___
___ 06:45AM BLOOD Glucose-128* UreaN-17 Creat-1.1 Na-141
K-4.2 Cl-105 HCO3-21* AnGap-19
___ 06:45AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ man with a PMH notable for paroxysmal
AFib, CVA in ___ with residual right-sided weakness, T2DM,
hypertension, and recent admission for cholecystitis s/p
percutaneous drain placement, who was referred by his outpatient
cardiologist for evaluation of 5.6 sec pause on cardiac monitor.
No sinus pauses were observed during this hospitalization.
Patient was diagnosed with sick sinus syndrome and a
dual-chamber pacemaker was placed successfully on ___
(Device brand/name: ___ ___ ___:
___).
In addition, patient has a history of paroxysmal atrial
fibrillation. Not on anticoagulation because of plan for future
cholecystectomy. Dr. ___ will call the patient with a
date for the surgery.
Percutaneous biliary drain currently in place and draining light
yellow fluid (placed during hospitalization at ___).
Patient completed a course of Augmentin, with ultimate plan for
cholecystectomy. Patient will follow-up outpatient with Dr.
___ with recommendation to hold Plavix 1 week prior to
cholecystectomy.
==================
ACTIVE ISSUES
==================
# Sick sinus syndrome: Patient has had several sinus pauses
since being monitored on Lifewatch. Though the majority of these
have been asymptomatic, he continues to have them off of a beta
blocker and is at high risk of syncope. No sinus pauses were
observed during this hospitalization. Patient was diagnosed with
sick sinus syndrome and a dual-chamber pacemaker was placed
successfully on ___ (Device brand/name: ___
___ ___: ___). Patient to continue ___
antibiotics to complete 3-day course (cephalexin 500 mg Q8H;
last day ___.
# Paroxysmal Atrial Fibrillation: Two recent atrial fibrillation
events noted, though both in the setting of cholecystitis. Not
on anticoagulation at this time due to plan for future
cholecystectomy. After PPM was placed, patient was started on
metoprolol succinate 25 mg daily.
# Cholecystitis: Patient diagnosed with cholecystitis and had
percutaneous biliary drain placed during hospitalization at
___ the week prior to admission. Patient completed a
course of Augmentin, with ultimate plan for cholecystectomy.
Patient will follow-up with Dr. ___ as an outpatient.
======================
CHRONIC ISSUES:
======================
# CVA: Left pontine CVA diagnosed ___ with right sided
hemiplegia. Patient has had significant improvement in right
sided strength since then. Was found at that time to have a PFO,
though it is of unclear significance. At___ Neurology started
clopidogrel and stopped aspirin for secondary prevention.
Continue home clopidogrel, atorvastatin.
# CKD: Baseline ~ 1.4. Creatinine 1.1 on day of discharge.
# Diabetes Mellitus Type 2: Continued metformin and insulin.
# Hypertension: Continued home amlodipine, lisinopril
# BPH: Continued home tamsulosin
# GERD: Continued home omeprazole
========================
TRANSITIONAL ISSUES
========================
- Placed PPM on ___ (Device brand/name: ___ ___
___: A2DR01).
- Patient started on metoprolol succinate 25 mg daily.
- Patient to continue ___ antibiotics to complete
3-day course (cephalexin 500 mg Q8H; last day ___.
- Once surgery has a date for cholecystectomy, the patient will
be directed to hold Plavix for 1 week prior.
- Patient on omeprazole and Plavix; given potential interaction
between these medications consider changing omeprazole to
pantoprazole.
- CODE: FULL
- CONTACT: ___ (wife, HCP, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
4. Atorvastatin 80 mg PO QPM
5. Clopidogrel 75 mg PO DAILY
6. Glargine 18 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
7. Lisinopril 5 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Tamsulosin 0.8 mg PO QHS
10. MetFORMIN (Glucophage) 1000 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO Q8H Duration: 4 Doses
Start taking this medication on ___ ___.
RX *cephalexin 500 mg 1 capsule(s) by mouth Every 8 hours Disp
#*4 Capsule Refills:*0
2. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 25 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
3. Glargine 18 Units Bedtime
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
4. Allopurinol ___ mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Clopidogrel 75 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. MetFORMIN (Glucophage) 1000 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Tamsulosin 0.8 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary diagnosis: Sick sinus syndrome
Secondary diagnosis: Paroxysmal 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 the ___
___. You were admitted because you were
having sinus pauses in your heart rhythm. You did not have any
sinus pauses during this hospital admission. You were diagnosed
with sick sinus syndrome and a dual-chamber pacemaker was placed
successfully on ___ (Device brand/name: ___
___ ___: ___). For your pacemaker care at home,
please see handout.
We wish you the best with your health,
Your ___ Cardiac Care Team
Followup Instructions:
___
|
19907884-DS-25 | 19,907,884 | 25,339,336 | DS | 25 | 2181-10-20 00:00:00 | 2181-10-22 19:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / picc dressing
/ lisinopril
Attending: ___.
Chief Complaint:
nausea/vomiting
Major Surgical or Invasive Procedure:
left femoral central line placement
History of Present Illness:
___ F with history of distal pancreatectomy on ___, on
chronic tube feeds,type 2 DM, who presents with 3 days of
nausea, bilious vomiting and abdominal pain. Her abdominal pain
is minimal, located diffusely, present for 3 days, constant
___, worsened with food intake. Her vomitus is green with few
specks of red in her last vomiting episode earlier today , she
denies any frank hematemesis, melena, hematochezia,
diarrhea.Last BM was normal yesterday, brown and formed. She at
times feels sleepy, but denies confusion.
In the ED, initial VS were: 96.1 128 136/92 16 . She was found
to have elevated blood glucose and in DKA. Started on Insulin
drip and IV fluids.She also recieved 4 mg IV dilaudid, 8 mg IV
Morphine for abdominal pain and IV/p.o Zofran, compazine, for
nausea.For her leukocytosis she was given Vancomycin and
Meropenem.She recieved 4 Liters of NS and one liter of ___.
She was given calcium gluconate for questionable T waves.
On arrival to the MICU, her vitals are pulse 122, 99% RA,
BP-120/95. The above hx was obtained and she was oriented X 3.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath, or wheezing.
Denies chest pain, chest pressure, palpitations, or weakness.
Denies dysuria, frequency, or urgency. Denies arthralgias or
myalgias. Denies rashes or skin changes.
Past Medical History:
1. Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections, plans to try botox if approved
-first headaches ___
2. Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age ___
3. Type 2 Diabetes Mellitus
4. Hypertension
5. Obesity
6. Complex Regional Pain Syndrome of the right face and right
upper extremity on methadone
7. Right eye blindness
8. Left pupil dysfunction - ADIE
9. PUD
10. Rheumatoid Arthritis
11. Vitamin D deficiency
12. abnormal LFT's - no response to Hep B vaccines x3
___. Pancreatitis: complicated by necrotizing pancratitis ___
w/ multiple admissions for abdominal pain
Social History:
___
Family History:
Father and sister with HTN. Family history of CAD. No family
history of CVA or headache.
Physical Exam:
Admission exam:
Vitals:pulse 122, 99% RA, BP-120/95.
General: Alert, oriented, no acute distress, sleepy at times but
wakes up to verbal stimuli
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, diffusley tender, no rebound, no guarding, BS +,
non-distended, bowel sounds present, no organomegaly
GU: foley placed
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, finger-to-nose intact. Oriented X 3, with poor
attention not able to say days of week backward.
Discharge exam:
T 97.5, 98/50, 78, 18, 98% on RA
General: Alert, oriented, covering her eyes with her arm, but in
no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: very soft, diffuse mild tenderness, no rebound, no
guarding, BS +, non-distended, bowel sounds present, no
organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: left pupil dysfunction (at baseline), CNIII-XII intact,
___ strength upper/lower extremities
Pertinent Results:
___ URINE CULTURE:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha streptococcus or
Lactobacillus sp.
___ Urine Culture: No growth.
CT Abdomen/Pelvis:
IMPRESSION:
1. Omental infarct along the left lateral aspect of the abdomen.
Clinically correlate with the patient's pain.
2. The patient is status post distal pancreatectomy,
splenectomy, and
cholecystectomy.
3. At least three walled off collections are again seen in the
pancreas which probably represent chronic hematomas and are
slightly smaller. No evidence for chronic pancreatitis.
4. Mild dilation of the common bile duct. MRCP may be performed
to further evaluate.
Admission labs:
___ 01:30PM BLOOD WBC-34.0*# RBC-5.05 Hgb-11.0* Hct-40.9#
MCV-81*# MCH-21.8* MCHC-27.0* RDW-17.5* Plt ___
___ 01:30PM BLOOD Glucose-965* UreaN-34* Creat-1.5* Na-140
K-5.6* Cl-101 HCO3-8* AnGap-37*
___ 01:30PM BLOOD ALT-26 AST-33 AlkPhos-216*
___ 01:30PM BLOOD Lipase-913*
___ 01:30PM BLOOD Albumin-4.9 Calcium-9.6 Phos-5.5* Mg-2.6
___ 04:25PM BLOOD Triglyc-189*
___ 04:25PM BLOOD Osmolal-359*
___ 09:04PM BLOOD ___ pO2-68* pCO2-47* pH-7.30*
calTCO2-24 Base XS--3
___ 01:54PM BLOOD Lactate-1.9
Discharge labs:
___ 09:06AM BLOOD WBC-13.7* RBC-4.03* Hgb-8.7* Hct-30.0*
MCV-75* MCH-21.6* MCHC-29.0* RDW-17.6* Plt ___
___ 09:06AM BLOOD Glucose-351* UreaN-13 Creat-0.5 Na-139
K-4.4 Cl-103 HCO3-26 AnGap-14
___ 09:06AM BLOOD Calcium-9.2 Phos-5.1* Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ F with history of distal pancreatectomy on
___, on chronic tube feeds, who presented with 1 day of
nausea, blilious vomiting and abdominal pain. Patient was found
to have pancreatitis and diabetic ketoacidosis.
ACTIVE ISSUES:
1. Diabetic ketoacidosis: In the ED, she was found to have
elevated blood glucose to 900s and to be in DKA. Her anion gap
was 31. She was started on an Insulin drip and IV fluids. In
the ICU she was continued on the insulin drip and her anion gap
closed within 12 hours. She was ruled out for MI. No infectious
etiology of hyperglycemia was found (had urine culture with
10,000-100,000 colonies of gram positive alpha hemolytic
colonies consistent with alpha streptococcus or Lactobacillus
sp). Pt was not treated for UTI as it was felt that this was a
contaminant. She denied insulin noncompliance or recent drug
abuse. Mental status was stable and not obtunded Anion gap
closed with insulin drip and IV fluids ___ liters). On
hospital Day # 2 tolerated orals and was transitioned to SC
Insulin.
2. Pancreatitis: Patient was found to have elevated lipase to
913 on admission and diffuse abdominal tenderness. Surgery was
consulted and recommended CT scan, which did not any changes
except for omental infarct in the left upper abdomen (nothing to
do for this as per surgery). No surgical intervention was
recommended. Surgery followed patient throughout
hospitalization. She was able to tolerate a regular diet in
addition to her tube feeds.
Patient was controlled with IV morphine in the ICU. When
patient tolerated PO, her pain medication was changed to
oxycodone. Patient was discharged with several days of
oxycodone as she continued to have some abdominal pain at
discharge.
3. Hyperglycemia: When tube feeds were restarted, hyperglycemia
was a problem for patient. ___ consulted. Glargine insulin
was increased from 12 BID to 34 BID at discharge. Given tube
feeding, patient was changed from humalog insulin sliding scale
to regular insulin sliding scale.
4. Leukocytosis: Likely secondary to pancreatitis. No other
localizing symptoms of infection. Improved throughout admission
and was 13 at last check prior to discharge. Patient should
have her CBC checked next week at visit with her PCP.
CHRONIC INACTIVE ISSUES:
1. Hypertension: Normotensive. Continued clonidine.
2. Chronic pain: Worse than typical pain in setting of acute
pancreatitis. Continued fentanyl patch, gabpentin, tizanidine.
Patient received Oxycodone PRN for breakthrough pain.
TRANSITIONAL ISSUES:
1. Repeat CBC in one week as patient had elevated WBC count
throughout hospitalization.
2. Patient instructed to track finger stick glucose and insulin
requirement. She will bring this information to next ___
appointment.
Medications on Admission:
Fentanyl patch 75 mcg q72 hours
Tizanidine 4 mg qhs
Naratriptan 2.5 mg prn migraine
lantus/humalog,
clonidine 0.4 BID
lorazepam 0.5 mg qhs,
promethazine 12.5 q6h prn nausea,
doxepim 50 mg qhs
gabapentin 800 BID, 1600 qhs,
zofran 4 mg daily
Discharge Medications:
1. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
3. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO QHS (once a day
(at bedtime)).
4. naratriptan 2.5 mg Tablet Sig: One (1) Tablet PO As needed as
needed for migraine headache.
5. gabapentin 400 mg Capsule Sig: Four (4) Capsule PO HS (at
bedtime).
6. Lantus 100 unit/mL Solution Sig: ___ (34) units
Subcutaneous twice a day.
Disp:*20 mL* Refills:*2*
7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime.
8. doxepin 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
9. gabapentin 800 mg Tablet Sig: As directed Tablet PO three
times a day: Take 1100 mg in AM and afternoon, 1600 mg at
bedtime.
10. naratriptan 2.5 mg Tablet Sig: One (1) Tablet PO As needed
as needed for headache.
11. ondansetron 4 mg Film Sig: One (1) PO every eight (8) hours
as needed for nausea.
12. promethazine 12.5 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
13. tizanidine 4 mg Tablet Sig: Two (2) Tablet PO at bedtime:
Please take as directed by your PCP. .
14. multivitamin Oral
15. Tube Feeds
NUTRITIONAL SUPPLEMENT - FIBER [REPLETE/FIBER] - Liquid - 90
cc via tube feed per hour x 16 hours Please give 90cc/hr via
j-tube with a pump for 16 hours daily.
16. insulin regular human 100 unit/mL Solution Sig: As directed
units Injection QACHS: Please take subcutaneously as directed by
sliding scale. Pt will use 14 - 26 units four times per day.
Disp:*30 mL* Refills:*2*
17. oxycodone 10 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain: Do not drive while taking this
medication. .
Disp:*15 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Diabetic ketoacidosis, pancreatitis, hyperglycemai
SECONDARY: Chronic abdominal pain, hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care Ms. ___. You
were admitted to the hospital with pancreatitis and diabetic
ketoacidosis. You were initially in the ICU and received an
insulin drip. The diabetic ketoacidosis improved. You were
seen by the surgeons. The pancreatitis improved. You were
transferred to the medical floor and restarted tube feeds. Your
blood surgar was high so we increased your insulin.
Please check your fingerstick four times per day. Please record
this information and bring it to your next appointment with your
___ doctor.
Please make the following changes to your medications:
1. INCREASE lantus insulin to 34 units twice a day
2. STOP humalog insulin
3. START oxycodone 10 mg every 6 hours as needed for pain. This
medication may make you drowsy. Do not drive while taking this
medication.
4. START regular insulin as per sliding scale
Breakfast Lunch Dinner Bedtime
Regular Regular Regular Regular
Glucose Breakfast Lunch Dinner Bedtime
71-80 mg/dL 2 Units 2 Units 2 Units 2 Units
81-120 mg/dL 14 Units 14 Units 14 Units 14 Units
121-160 mg/dL 18 Units 18 Units 18 Units 18 Units
161-200 mg/dL 20 Units 20 Units 20 Units 20 Units
201-240 mg/dL 22 Units 22 Units 22 Units 22 Units
241-350 mg/dL 26 Units 26 Units 26 Units 26 Units
Followup Instructions:
___
|
19907884-DS-26 | 19,907,884 | 21,322,115 | DS | 26 | 2182-01-04 00:00:00 | 2182-01-05 07:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / picc dressing
/ lisinopril
Attending: ___.
Chief Complaint:
leakage of J-tube and increased purulence
Major Surgical or Invasive Procedure:
Interventional radiology replacement of J-tube ___
History of Present Illness:
Ms. ___ is a ___ F with history of distal pancreatectomy on
___ now on chronic tube feeds through J tube, chronic pain and
type 2 DM who presents with leaking from her J tube. Of note,
her J-tube recently became dislodged on ___ and was replaced by
___. Today, she complains of fevers to 102 and malaise with some
mild purulent discharge from around the tube. She notes
mild vague, diffuse abdominal pain, headache and nausea which is
chronic for her. She had an episode of non-bloody, bilious
emesis on ___ but no emesis since then.
.
In the ED, initial VS: 98.2, 88, 107/62, 16, 100% RA. Her labs
were notable for leukocytosis of 20, glucose of 347 and lactate
of 3.9 which decreased to 1.6 after 3 liters of IVF. Her J-tube
was flushing appropriately. CT A/P showed soft tissue thickening
around the tub at the anterior abdominal wall w/out drainable
fluid collection with tiny focus of gas seen in subq tissue
along the tube felt to be questionably related to tube
placement. Patient was given vancomycin, ceftriaxone, flagyl,
potassium, morphine and 8 units of regular insulin. She became
hypoglycemic and required two doses of D50 with transition to
D5NS. Vitals on transfer were 97.8, 68, 16, 117/83 98%RA.
.
Currently, she complains of abdominal pain that she describes as
dull and constant surroudning her J-tube site without radiation.
She has had her chronic nausea but no changes in bowel habits:
no diarrhea, constipation, hematochezia or melena. Prior to
fever this AM, she has been afebrile and without chills. Her
headaches are at her baseline.
.
REVIEW OF SYSTEMS:
Denies night sweats, worsening headache, vision changes, neck
stiffness, rhinorrhea, congestion, sore throat, cough, shortness
of breath, chest pain, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections
2. Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age ___
3. Type 2 Diabetes Mellitus
4. Hypertension
5. Obesity
6. Complex Regional Pain Syndrome of the right face and right
upper extremity on methadone
7. Right eye blindness
8. Left pupil dysfunction - ADIE
9. PUD
10. Rheumatoid Arthritis
11. Vitamin D deficiency
12. abnormal LFT's - no response to Hep B vaccines x3
___. Pancreatitis: complicated by necrotizing pancreatitis ___,
s/p distal pancreatectomy ___. Iron deficiency anemia
15. s/p distal pancreatectomy/ splenectomy, cholecystectomy, and
J-tube placement ___
Social History:
___
Family History:
Father and sister with HTN. Family history of CAD. No family
history of CVA or headache.
Physical Exam:
Admission Physical Exam:
VS - Temp 97.7F, BP 135/90, HR 68, R 22, O2-sat 100% RA
GENERAL - Drowsy but interactive, well-appearing in NAD
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no cervical LAD appreciated but R sided exam
limited
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/ND, tenderness over RUQ, epigastric,
surrounding J tube insertion and RUL without rebound or
guarding, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - erythema surrounding J-tube insertion site with minimal
amount of purulent material on dressing
NEURO - awake, A&Ox3
Discharge Physical Exam:
VS - T97.8 BP 137/87 HR 80 RR 20 O2 100% RA
___- ___ 304
ABDOMEN - NABS, soft/ND, tenderness over J tube insertion
without rebound or guarding, no masses or HSM
SKIN - stable erythema surrounding J-tube insertion site with
minimal amount of TF material on dressing.
Exam otherwise unchanged
Pertinent Results:
Admission Labs:
WBC 20.0 Hgb 11.7 Hct 39.9 Plts 475
Lactate 3.9
ALT 20 AST 20 AP 172 Tbili 0.2 Lipase 9
Serum tox- ASA neg, ethanol neg, APAP 9, benzo neg, barb neg,
TCA neg
NA 133 K 3.4 Cl 95 Co2 24 BUN 6 Cr 0.7 Gluc 347
Urinalysis negative for ketones, leuk, nitrites, bili, glucose
100
Urine tox- benzo neg, barb neg, opiates neg, cocaine neg, amphet
neg, methadone neg
Pertinent Labs:
___ 06:51PM BLOOD Lactate-1.6 K-2.8*
___ 01:00PM BLOOD Albumin-3.5 Iron-38
___ 01:00PM BLOOD calTIBC-212* Ferritn-256* TRF-163*
___ 01:00PM BLOOD Triglyc-44
Discharge Labs:
___ 07:10AM BLOOD WBC-10.1 RBC-4.27 Hgb-10.9* Hct-37.1
MCV-87 MCH-25.6* MCHC-29.4* RDW-25.2* Plt ___
___ 07:10AM BLOOD Calcium-9.3 Phos-5.2* Mg-1.9
Microbiology:
Wound swab ___-
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
This culture contains mixed bacterial types (>=3) so an
abbreviate workup is performed. Any growth of P.aeruginosa,
S.aureus and bet hemolytic streptococci will be reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in
this culture..
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
OXACILLIN------------- 0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Blood culture ___- pending x 2
Urine culture ___- GRAM POSITIVE BACTERIA 10,000-100,000 ORG/ML.
Alpha hemolytic colonies consistent with alpha streptococcus
or
Lactobacillus sp.
Imaging:
CXR ___- Frontal and lateral views of the chest were obtained.
There are low lung volumes and bronchovascular crowding. There
is prominence of the hila suggesting pulmonary vascular
engorgement with possible mild pulmonary vascular congestion. No
pleural effusion or pneumothorax is seen. Left infrahilar and
left basilar opacity may relate to vascular crowding, although
infectious process cannot be excluded in the appropriate
clinical setting. There are right paramediastinal surgical
clips. Cardiac and mediastinal
silhouettes are stable.
Abdominal xray ___- Tube/catheter projecting over left lower
quadrant is migrated in position as compared to the prior study.
If the tube has not been changed, question migration out of
position. Consider tube check with contrast for further
evaluation.
CT abd/pelvis ___- Tube entering in left lower quadrant is
coiled in the anterior abdominal wall with adjacent soft tissues
thickening/stranding without drainable fluid collection seen.
Tiny focus of gas along the subcutaneous tissues along the tube
site, could relate to tube insertion, although superimposed
infections cannot be excluded. No drainable abscess seen.
Bladder is markedly distended, and thin-walled. Query whether
patient requires Foley catheter or can urinate on own.
Small amount of pelvic free fluid.
Pancreatic pseudocysts again seen. Left flank subcutaneous
edema.
TTE ___- The left atrium is mildly dilated. The left atrium is
elongated. Left ventricular wall thicknesses and cavity size are
normal. Regional left ventricular wall motion is normal. Overall
left ventricular systolic function is normal (LVEF 55-65%).
Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no pericardial effusion.
IMPRESSION: Preserved biventricular systolic function.
Brief Hospital Course:
___ F with history of HTN, DMII, chronic pancreatitis s/p
distal pancreatectomy/ splenectomy with J tube, presenting with
fever, leukocytosis and drainage from J tube site.
# Leukocytosis and fevers due to abdominal cellulitis, J-tube
tunnel infection: Grossly elevated white count secondary to
infection and exacerbated by asplenia. Patient started on broad
spectrum antibiotics with vancomycin, ceftriaxone and
metronidazole as source of infection unclear and patient
asplenic. Urine negative, CXR negative and CT abd/pelvis with
evidence of soft tissue infection at site of J-tube without
fluid collection. Culture of purulent drainage from Jtube entry
site positive for mixed flora, but notable for MSSA. As patient
was afebrile and white count was trending down, antibiotics were
narrowed to ceftriaxone. She was changed to cefpodoxime at the
time of discharge for additional 7 days (total 10 days). Pain
was controlled with increased doses of oxycodone, but patient
was encouraged to wean back to home BID dosing.
# Tube feed leakage: Tube feeds were leaking and causing
irritation to skin. Seen by surgery who recommended larger tube
be placed. Patient seen by nutrition who felt that tube feeds
were in fact still necessary in order for patient to meet her
nutritional needs. ___ replaced tube and tube feeds were
restarted without leakage at goal 60cc/h.
# Hyperglycemia: She has known type 2 DM and takes insulin at
home. Blood sugar was elevated on admission in the setting of
infection. Patient was continued on home glargine 34U BID with
insulin sliding scale. Finger sticks were often high in ___,
and best at noon.
# Chronic pain: She has chronic headaches, right face and arm
complex regional pain syndrome requiring pain clinic nerve
blocks, chronic abdominal pain from pancreatitis. She takes
oxycodone, fentanyl patch and gabapentin for pain control at
home. Other than increasing oxycodone for acute pain, no
changes were made to home pain medications.
# Chronic nausea: She follows with GI for this and recently
started metoclopramide as needed. Metoclopramide, omeprazole
and doxepin were continued.
# Hypertension: Continued home clonidine.
# Iron deficiency anemia: Hematocrit stable throughout admission
from 37-39. Iron studies also showed improvement in iron
levels, now low normal.
# Transitional issues:
- f/u final blood cultures
- cefpodoxime to be continued through
- patient to be called with follow-up PCP appointment within the
week
- TF continued at home rate 60cc/h
- oxycodone increased to TID until pain improves
Medications on Admission:
- fentanyl 75 mcg/hr Transderm Patch q 72 hr
- tizanidine 4 mg Tab ___ Tablet(s) by mouth at bedtime
- naratriptan 2.5 mg Tab prn migraine
- Lantus 34 units BID
- Humulin R sliding scale
- clonidine 0.4 mg BID
- lorazepam 0.5 mg Tab ___ Tablet(s) by mouth qhs prn insomnia
- propranolol 40 mg BID
- doxepin 75 mg qHS
- oxycodone 5 mg BID prn
- gabapentin 1100 mg qAM, 1100 mg noon, 1600 mg qHS
- Replete/Fiber Oral Liquid 90 cc via tube feed per hour x 16
hours
- Multivitamin daily
- ondansetron HCl 4 mg q6hr prn
- Miralax 17 gram/dose Oral Powder daily prn
- omeprazole 40mg BID
- metoclopramide 10mg BID PRN
Discharge Medications:
1. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
2. tizanidine 2 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as
needed for pain.
3. insulin glargine 100 unit/mL Solution Sig: ___ (34)
Units Subcutaneous twice a day.
4. insulin regular human 100 unit/mL Solution Sig: per sliding
scale Injection four times a day.
5. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO twice a day.
6. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO HS (at bedtime)
as needed for insomnia.
7. propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
8. doxepin 75 mg Capsule Sig: One (1) Capsule PO at bedtime.
9. gabapentin 800 mg Tablet Sig: AS DIRECTED Tablet PO three
times a day: ONE TABLET IN AM, ONE TABLET IN AFTERNOON, TWO
TABLETS BEFORE BEDTIME.
10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO in AM and
at NOON: for total 1100mg in AM and at NOON.
11. multivitamin Capsule Sig: One (1) Capsule PO once a day.
12. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for nausea.
13. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
15. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for nausea.
16. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO BID (2 times a day).
17. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO every
twelve (12) hours for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
18. oxycodone 5 mg Tablet Sig: One (1) Tablet PO three times a
day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
# Soft tissue infection surrounding J-tube
# J-tube leakage
SECONDARY DIAGNOSIS:
# Chronic pancreatitis
# Malnutrition
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.
You were admitted with an infection at the site of your J-tube.
You were treated with antibiotics and the infection improved.
In addition, the J-tube was leaking, so a larger tube was placed
to prevent leakage.
The following changes were made to your medication regimen:
- START cefpodoxime, an antibiotic, through ___
- take oxycodone 1 tab three to four times a day. Your pain
should improve and you should be able to take your normal twice
daily dosing
Followup Instructions:
___
|
19907884-DS-27 | 19,907,884 | 26,463,137 | DS | 27 | 2182-01-31 00:00:00 | 2182-01-31 17:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / picc dressing
/ lisinopril
Attending: ___
Chief Complaint:
Problem with feeding tube (leakage).
Major Surgical or Invasive Procedure:
J tube change by interventional radiology
History of Present Illness:
Ms. ___ is a ___ year old woman with a history of chronic
pancreatitis s/p distal pancreatectomy, who is admitted with 1
day of leakage from the J tube site.
.
In the ED, initial VS 96.7 92 146/98 18 100%. WBC was 12
(recently elevated baseline on last admission). Blood sugar 409.
Surgery evaluated the patient and felt there was no acute
surgical issue, and suggested ___ tube change for J-tube being
too small for the fistula tract. She was given 10 units regular
insulin, oxycodone 5mg x 1 and admitted to medicine.
.
The patient notes multiple previous problems with the J-tube,
and has required changes in the past. She also was admitted
earlier this month with cellulitis around the J-tube. The
patient has a history of chronic nausea which is at her
baseline, and also notes difficulty with glucose control
secondary to chronic pancreatitis and subsequent surgery. She
currently denies f/c/s, cough, sob, vomitting, abdominal pain
worse than baseline.
Past Medical History:
1. Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections
2. Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age ___
3. Type 2 Diabetes Mellitus
4. Hypertension
5. Obesity
6. Complex Regional Pain Syndrome of the right face and right
upper extremity on methadone
7. Right eye blindness
8. Left pupil dysfunction - ADIE (tonically dilated pupil)
9. PUD
10. Rheumatoid Arthritis
11. Vitamin D deficiency
12. Iron deficiency anemia
13. Chronic Pancreatitis: c/b necrotizing pancreatitis ___. s/p distal pancreatectomy/splenectomy, cholecystectomy, and
J-tube placement ___. Recent replacement of J-tube ___,
___
Social History:
___
Family History:
Father and sister with HTN. Family history of CAD. No family
history of CVA or headache.
Physical Exam:
Admission:
VS - 97.7 110/70 74 97%RA
Gen - Pleasant, interactive, and NAD
Heart - RRR, no excess sounds appreciated
lungs - CTA b/l, good inspiratory effort
Abd - Tender across epigastric region without rebound or
guarding, patient notes similar to chronic pain
Skin - minimal erythema around J-tube site with some exudative
discharge, some tenderness around site but not marked
.
Discharge:
VS - 98.6 123/74 98%rA
Gen - Pleasant, interactive, and NAD
Heart - RRR, no excess sounds appreciated
lungs - CTA b/l, good inspiratory effort
Abd - Tender across epigastric region without rebound or
guarding, patient notes similar to chronic pain
Skin - minimal erythema around J-tube site with some exudative
discharge (less than admission), some tenderness around site but
not marked
Pertinent Results:
Admission labs:
___ 01:40PM BLOOD WBC-12.0* RBC-4.63 Hgb-12.8 Hct-40.7
MCV-88 MCH-27.6 MCHC-31.3 RDW-22.0* Plt ___
___ 01:40PM BLOOD Neuts-58 Bands-0 ___ Monos-5 Eos-5*
Baso-0 ___ Myelos-0
___ 01:40PM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-1+
Schisto-OCCASIONAL Acantho-OCCASIONAL Ellipto-OCCASIONAL
___ 05:35AM BLOOD ___ PTT-26.7 ___
___ 01:40PM BLOOD Glucose-409* UreaN-10 Creat-0.7 Na-134
K-3.8 Cl-93* HCO3-30 AnGap-15
___ 01:40PM BLOOD Calcium-9.2 Phos-4.7* Mg-1.7
.
Micro:
.
___ blood culture x2: No growth at discharge
___ Swab of area surrounding J-tube:
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. IN
PAIRS.
WOUND CULTURE (Preliminary): This culture contains mixed
bacterial types (>=3) so an abbreviated workup is performed. Any
growth of P.aeruginosa, S.aureus and beta hemolytic streptococci
will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY
ARE NOT PRESENT in this culture.
.
Reports:
GJ tube replacement: IMPRESSION: Successful exchange of a 12
___ ___ J-tube to a 14 ___ ___ J tube
.
Discharge labs:
___ 05:30AM BLOOD WBC-9.5 RBC-4.36 Hgb-12.2 Hct-39.7 MCV-91
MCH-27.9 MCHC-30.7* RDW-22.2* Plt ___
Brief Hospital Course:
SUMMARY: Ms. ___ is a ___ year old woman with a history of
chronic pancreatitis s/p distal pancreatectomy on tube feeds,
type 2 diabetes, who was admitted with leakage from J tube site.
.
# J-tube leakage: Patient had the tube size increased in ___
after this was recommended by the surgery consult team. Due to
some exudative drainage, she was given IV vancomycin and later
converted to PO Cefpodoxime to complete 10-day course once the
drainage and surrounding erythema had improved. She was also
given mupiricin to apply to the area around the wound. A wound
culture did not yield a definitive result. Nutrition was
consulted and recommended continuing her tube feeds. The
patient's surgeon, Dr. ___, saw the patient in house since
her outpatient appointment coincided with her admission.
.
# Type 2 Diabetes: Ms. ___ has difficult to control blood
sugars secondary to DMII and pancreatectomy. ___ was
consulted and her insulin regimen was changed substantially. She
was provided a print-out of what sliding scale to use with tube
feeds. It was stressed to the patient multiple times that she
must decrease her sliding scale insulin if she turns off her
tube feeds. She will ___ very closely with ___ as an
outpatient.
.
# Chronic pain: She has chronic headaches, right face and arm
complex regional pain syndrome requiring pain clinic nerve
blocks, and chronic abdominal pain from pancreatitis. On
admission, the patient was very sleepy, and several outpatient
bottles of sedative medications were found in her possession. A
Utox was negative. These outpatient bottles were taken and
stored in locked storage area. She was subsequently continued
on her home oxycodone, fentanyl patch, and gabapentin.
.
# Chronic nausea: Followed by GI as an outpatient, she was
continued on Metoclopramide, omeprazole and doxepin.
.
# Hypertension: Continued home clonidine.
.
# Iron deficiency anemia: Not active this admission. She has
received IV iron in the past with good result.
====
TRANSITIONAL ISSUES:
-Patient was scheduled for close PCP ___ where she will
need evaluation of the J-tube site to determine whether she has
failed PO antibiotics for treatment. The patient was also
instructed to call her PCP with any worsening symptoms.
.
-Patient to ___ closely with ___ due to her difficult
to control blood sugars.
Medications on Admission:
CLONIDINE - 0.2 mg Tablet - 2 Tablet(s) by mouth A.m. and p.m.
DOXEPIN - 50 mg Capsule - 1 Capsule(s) by mouth Q.h.s.
DOXEPIN - 25 mg Capsule - 1 Capsule(s) by mouth at bedtime
FENTANYL - 75 mcg/hour Patch 72 hr - 1 q 72 hr
gabapentin 800 mg Tablet: ONE TABLET IN AM, ONE TABLET IN
AFTERNOON, TWO TABLETS BEFORE BEDTIME.
gabapentin 300 mg Capsule One (1) Capsule PO in AM and at NOON:
for total 1100mg in AM and at NOON.
INSULIN GLARGINE [LANTUS] - 34u BID
LORAZEPAM - 0.5 mg Tablet - ___ Tablet(s) by mouth qhs prn
insomnia
METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth twice a
dayas needed for nausea
NARATRIPTAN - 2.5 mg Tablet - 1 Tablet(s) by mouth as needed for
migraine
OMEPRAZOLE - 40 mg Capsule, Delayed Release(E.C.) - 1
Capsule(s)by mouth twice a day
ONDANSETRON HCL - 4 mg Tablet - 1 Tablet(s) by mouth q6hr
OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day
asneeded for prn
PROPRANOLOL - 40 mg: 1 tab BID.
TIZANIDINE - 4 mg Tablet - ___ Tablet(s) by mouth at bedtime,
and
as directed
INSULIN REGULAR HUMAN [HUMULIN R] - 100 unit/mL Solution - dose
according to blood sugars four times a day
MULTIVITAMIN - 1 Capsule(s) by mouth once a day
NUTRITIONAL SUPPLEMENT - FIBER [REPLETE/FIBER] - Liquid - 90
cc
via tube feed per hour x 16 hours Please give 90cc/hr via j-tube
with a pump for 16 hours daily. Please dispense sufficient
amount for 30 days supply with 2 refills.
POLYETHYLENE GLYCOL 3350 [MIRALAX] - (OTC) - 17 gram/dose
Powder
- Mix 17g (1 capful) in ___ oz of beverage and drink daily as
needed for as needed for constipation
Discharge Medications:
1. clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
2. doxepin 25 mg Capsule Sig: Three (3) Capsule PO HS (at
bedtime).
3. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr
Transdermal Q72H (every 72 hours).
4. Gabapentin
gabapentin 800 mg Tablet: ONE TABLET IN AM, ONE TABLET IN
AFTERNOON, TWO TABLETS BEFORE BEDTIME.
gabapentin 300 mg Capsule One (1) Capsule PO in AM and at NOON:
for total 1100mg in AM and at NOON.
5. insulin glargine 100 unit/mL Solution Sig: Forty (40) units
Subcutaneous twice a day.
6. Regular Insulin
According to sliding scale provided. If you stop tube feeds, YOU
NEED TO DECREASE THE SLIDING SCALE SIGNIFICANTLY:
With meals:
Start for a blood sugar of 151-200 at 2 units and increase by 2
units for each finger stick increase of 50 (so take 4 units for
201-250, etc)
At Night:
Start for a blood sugar of 201-250 at 2 units and increase by 2
units for each finger stick increase of 50 (so take 4 units for
251-300)
7. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO HS (at bedtime)
as needed for Insomnia.
8. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO BID (2
times a day) as needed for nausea.
9. naratriptan 2.5 mg Tablet Sig: One (1) Tablet PO once a day
as needed for migraine.
10. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day.
11. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for nausea.
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as
needed for pain.
13. propranolol 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. tizanidine 4 mg Tablet Sig: ___ Tablets PO at bedtime as
needed for discomfort.
15. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
16. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
17. Tube Feeds
Glucerna 1.0 Cal Full strength at 60 mL per hour, Continuous
18. mupirocin calcium 2 % Cream Sig: One (1) Appl Topical BID (2
times a day): Apply to skin around the J tube site.
Disp:*1 tube* Refills:*0*
19. cefpodoxime 200 mg Tablet Sig: Two (2) Tablet PO twice a day
for 7 days.
Disp:*28 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Type 2 diabetes
J-tube related infection and leakage
Chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for drainage around the site of your J tube.
This was probably related to an infection, as well as the tube
being too small. Because of this, we treated you with
antibiotics and had the tube changed to a larger size.
.
Your blood sugars were also very high, and we changed your
sliding scale of insulin. It will be VERY IMPORTANT to decrease
your sliding scale substantially if you turn off your tube
feeds. Not doing so will put you at a high risk of low blood
sugar which can be very dangerous.
.
Please make sure to call your doctor if you have any worsening
symptoms, like fever or increased pain, redness, or swelling
around the site of your J tube. When you ___ with your
primary care doctor, you should discuss whether the oral
antibiotic is working, or whether you ___ need to be re-admitted
for additional IV antibiotics.
.
Please note the following medication changes:
-Please Adjust your insulin sliding scale if you stop tube feeds
-Please START mupiricin topical
-Please START cefpodoxime
Followup Instructions:
___
|
19907884-DS-43 | 19,907,884 | 28,354,879 | DS | 43 | 2187-10-02 00:00:00 | 2187-10-02 16:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / lisinopril /
hot peppers / metoclopramide
Attending: ___.
Chief Complaint:
DKA
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ female s/p Whipple for chronic pancreatitis, p/w
intractable vomiting for the past 4 days. Patient states
vomiting ___, NBNB. Patient has had DKA several times in
the past and states this feels like DKA. She does endorse
diffuse abdominal pain for the past several days as well.
Patient denies diarrhea. She denies any recent alcohol use.
Patient states nothing seems to make the pain better or worse.
ROS otherwise negative.
In the ED, initial vitals: 99.1 HR 90 BP 163/89 RR18 SaO2 100%
RA FSBS 452
Exam notable for:
appears dry
diffusely ttp in abd
Labs notable for:
VBG pH 7.34 pCO2 38 pO2 40 HCO3 21 BaseXS -4
BMP: 144 90 6 481 AGap=34
3.7 20 0.9
Ca: 11.0 Mg: 2.0 P: 3.7
LFTs: ALT: 50 AP: 163 Tbili: 0.4 Alb: 5.2 AST: 26
CBC: 17.7 17.4 343 Neutrophils:83.1 %
51.0
UCG: Negative
Urine: Straw colored, SpecGr 1.030, pH 6.0, Urobil Neg Bili
Neg Leuk Neg Bld Neg Nitr Neg Prot 30 Glu 1000 Ket 150
RBC 5 WBC 3 Bact Few Yeast None Epi 1
Imaging:
CXR: Frontal and lateral views
IMPRESSION:
No acute cardiopulmonary abnormalities.
CT A/P:
1. Status post distal pancreatectomy, splenectomy, and
cholecystectomy. No CT findings of acute pancreatitis.
2. Prominent CBD with mild central intrahepatic biliary ductal
dilation, similar to prior.
3. Small hiatal hernia. Partially imaged distal esophagus
appears thickened. If this has not been recently evaluated,
suggest further assessment with endoscopy or upper GI series.
4. Moderately distended stomach.
5. Moderate to abundant colonic stool burden.
6. Left ovarian corpus luteum. Physiologic amount of free fluid
in the pelvis.
Patient received:
1L NS
1L LR
Bolus
1L NS K, 40 K PO, q3h labs per protocol
HYDROmorphone (Dilaudid) 1 mg x2
Ondansetron 4 mg x1
Consults: ___
Vitals on transfer: HR 82 BP 156/89 RR 14 SaO2 100% RA
Upon arrival to ___, patient is resting, has abdominal pain, 1
episode of vomiting. Endorses the above history. Has nausea and
abdominal pain. No other complaints.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Otherwise
Past Medical History:
-Chronic Pancreatitis: c/b necrotizing pancreatitis ___, s/p
distal pancreatectomy/splenectomy, cholecystectomy, and J-tube
placement ___, since that time removed
-Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections
-Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age ___ consisting of -complex Regional
Pain Syndrome of the right face and right upper extremity
-Type 2 Diabetes Mellitus
-Hypertension
-Obesity
-Right eye blindness
-Left pupil dysfunction - ADIE (tonically dilated pupil)
-PUD
-Seronegative erosive arthritis previously followed by Dr. ___
___ she has stopped following up with him
-Iron deficiency anemia
-Esophagitis
-Gastroparesis
Social History:
___
Family History:
Father and sister with HTN. Family history of CAD in father. No
family history of CVA. No family history of pancreatitis .
Sister has DM. Her father died of an MI at age ___ and he also
had DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 76, 152/82, 14, 98%
GENERAL: Well appearing in no acute distres
HEENT: Aniscoria (L > R), small amount of pooling under the
tongue
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Flat, diffuse tenderness, BS+
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Intact
NEURO: R eye blindness, CNIII-XII intact, purposefully moves all
extremities, neuropathy affecting hands, not feet
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM:
GENERAL: Well appearing in no acute distres
HEENT: Aniscoria (L > R), small amount of pooling under the
tongue
NECK: JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Flat, diffuse tenderness, BS+
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Intact
NEURO: R eye blindness, CNIII-XII intact, purposefully moves all
extremities, neuropathy affecting hands, not feet
ACCESS: PIVs
Pertinent Results:
ADMISSION LABS:
___ 02:15PM BLOOD WBC-17.7* RBC-5.51* Hgb-17.4*# Hct-51.0*
MCV-93 MCH-31.6 MCHC-34.1 RDW-12.0 RDWSD-41.0 Plt ___
___ 02:15PM BLOOD Neuts-83.1* Lymphs-11.5* Monos-4.3*
Eos-0.1* Baso-0.5 Im ___ AbsNeut-14.72*# AbsLymp-2.03
AbsMono-0.76 AbsEos-0.02* AbsBaso-0.08
___ 02:15PM BLOOD Glucose-481* UreaN-6 Creat-0.9 Na-144
K-3.7 Cl-90* HCO3-20* AnGap-34*
___ 02:15PM BLOOD ALT-50* AST-26 AlkPhos-163* TotBili-0.4
___ 02:15PM BLOOD Albumin-5.2 Calcium-11.0* Phos-3.7 Mg-2.0
___ 02:30PM BLOOD ___ pO2-40* pCO2-38 pH-7.34*
calTCO2-21 Base XS--4
___ 06:50PM BLOOD Glucose-353* Na-141 K-3.5 Cl-104
calHCO3-14*
DISCHARGE LABS:
IMAGING:
CT A/P (___):
IMPRESSION:
1. Status post distal pancreatectomy, splenectomy, and
cholecystectomy. No CT findings of acute pancreatitis.
2. Prominent CBD with mild central intrahepatic biliary ductal
dilation,
similar to prior.
3. Small hiatal hernia. Partially imaged distal esophagus
appears thickened. If this has not been recently evaluated,
suggest further assessment with endoscopy or upper GI series.
4. Moderately distended stomach.
5. Moderate to abundant colonic stool burden.
6. Left ovarian corpus luteum. Physiologic amount of free fluid
in the
pelvis.
CXR (___):
IMPRESSION:
No acute cardiopulmonary abnormalities.
Brief Hospital Course:
___ female s/p Whipple for chronic pancreatitis, p/w
intractable vomiting for the past 4 days, found to have DKA
without a focal source of infection, most likely secondary to
medication non-adherence.
=================
ACTIVE ISSUES
=================
#Diabetic ketoacidosis
#IDDM:
Unclear trigger, possible viral illness, though no infectious
symptoms beyond malaise. Urinalysis did not demonstrate
infection, negative urine ___, CXR wnl. Therefore, suspect
tipping point was medication non-adherence. Entered DKA protocol
while in ___. Started on insulin gtt and transitioned to SQ
insulin once tolerating food. Received levofloxacin as patient
asplenic. ___ consulted to assist in insulin management.
-Resolved, on new insulin therapy
#Leukocytosis:
Patient with history of splenectomy, and known history of labile
WBCs, especially in the setting of pancreatitis flares. WBCs
fluctuated while in FICU. Received levofloxacin prophylactically
as asplenic per above.
-patient with chronic leukocytosis, stable
#Chronic pancreatitis
#Abdominal pain:
Patient has history of chronic abdominal pain and is followed by
pain service as outpatient. Started on IV morphine as unable to
tolerate po opioids. Nausea/emesis controlled with Zofran and
Ativan.
-pain at baseline now
TRANSITIONAL ISSUES:
[] pill in pocket for asplenia
[] Partially imaged distal esophagus appears thickened. If this
has not been recently evaluated, suggest further assessment with
endoscopy or upper GI series.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Carvedilol 12.5 mg PO BID
2. CloNIDine 0.4 mg PO BID
3. Doxepin HCl 75 mg PO HS
4. Felodipine 10 mg PO QHS
5. Gabapentin 1100 mg PO BID
6. Gabapentin 1600 mg PO QHS
7. LORazepam 1 mg PO QHS
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Rosuvastatin Calcium 40 mg PO QPM
10. Tizanidine 8 mg PO QHS
11. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral QIDACHS
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Prochlorperazine 10 mg PO Q6H:PRN nausea
14. tapentadol 75 mg oral QID
15. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
16. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
1. Return home
2. Pain control with PO medications
3. Continue your home medications
Followup Instructions:
___
|
19907884-DS-44 | 19,907,884 | 20,895,196 | DS | 44 | 2188-02-29 00:00:00 | 2188-03-01 09:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / lisinopril /
hot peppers / metoclopramide
Attending: ___.
Chief Complaint:
acute on chronic LUQ and flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
As per HPI by Dr. ___ in H&P dated ___:
___ with hx of idiopathic chronic pancreatitis (c/b necrotizing
pancreatitis ___, s/p distal pancreatectomy, splenectomy,
cholecystectomy), highly insulin resistant DM presenting with
acute on chronic LUQ and L flank pain, and acute
on chronic N/V.
Pain describes acute on chronic epigastric pain, and increased
N/V x6 days. At baseline, pain LUQ radiating to her back, ___,
constant but fluctuates in intensity, intermittently sharp,
unaffected by food, so long as she takes pancreatic enzymes with
food. Nausea is constant; at baseline, she vomits at least 4
times per week. She has had multiple EGDs - most recently ___
- with multiple mucosal ulcers, grade C esophagitis. At
baseline, she takes tapentadol 75 mg QID, and very rare dilaudid
4 mg PO - received 15 tabs in ___, and took the last pill
on ___. She typically does not tolerate much PO intake:
90% of the time eats dinner, tries to eat breakfast, rare lunch.
She is
currently on Tresiba 80u and 110u at night, and Humalog SS.
Acute on chronic abdominal pain is same quality compared to
baseline, but more intense. She vomited dinner the night prior
to presentation. This feels similar to DKA in the past. She
denies fevers, chills, sick contacts. She traveled to ___
(and "all the states in between"). She never misses her insulin.
She also endorses diarrhea, despite baseline constipation. On
the day prior to presentation, she noted gray stools twice on
the day prior to presentation, without blood. Her BMs look like
they normally do with pancreatitis flares.
Pt is highly insulin resistant: ___ records are not available
for review at time of admission (no notes in OMR portal to
___ records), but pt appears to be a very reliable historian,
and reports that her HbA1c on day of presentation (checked at
___ was 16% despite a total of 170u Tresiba and a high
sliding scale.
In the ___ ED:
VS 97.4, 117-->74, 172/111->105/62, 100% RA
FSBG >500->249->347->182->424
Exam notable for TTP in epigastrium
Labs notable for
WBC 19.3, Hb 15.7, plt 351
Cr 0.6
K 4.4
ALT 23, AST 25, Alk phos 137, Tbili 0.4, Albumin 4.4
UHCG negative
UA negative for UTI, no ketones
VBG 7.47/42->7.36/49
CXR without acute process
Received:
IVF
Morphine sulfate 2 mg IV, then 4 mg IV
Dilaudid 0.5 mg IV
Regular insulin 8u
Zofran 4 mg IV
Dilaudid 2 mg PO x3
Insulin lispro 10u
Carvedilol
Clonidine
Regular insulin 15u
On arrival to the floor, she describes ___ LUQ and L flank
pain, with associated nausea. She again denies dysuria. She is
nauseated.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI"
Past Medical History:
-Chronic Pancreatitis: c/b necrotizing pancreatitis ___, s/p
distal pancreatectomy/splenectomy, cholecystectomy, and J-tube
placement ___, since that time removed
-Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections
-Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age ___ consisting of -complex Regional
Pain Syndrome of the right face and right upper extremity
-Type 2 Diabetes Mellitus
-Hypertension
-Obesity
-Right eye blindness
-Left pupil dysfunction - ADIE (tonically dilated pupil)
-PUD
-Seronegative erosive arthritis previously followed by Dr. ___
___ she has stopped following up with him
-Iron deficiency anemia
Social History:
___
Family History:
Father and sister with HTN. Family history of CAD in father. No
family history of CVA. No family history of pancreatitis .
Sister has DM. Her father died of an MI at age ___ and he also
had DM.
Physical Exam:
ADMISSION EXAM:
VS: 97.7 PO 153 / ___ 97 RA
GEN: very pleasant, tired-appearing female, alert and
interactive, appears mildly comfortable, NAD.
HEENT: anisocoria, pupils are not reactive to light (chronic per
pt), anicteric, conjunctiva pink, oropharynx without
lesion or exudate, dry MM
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, TTP at LUQ>epigastrium, with voluntary guarding, some
degree of distractibility when pressure applied with
stethoscope,
but not entirely distractible, nondistended with hypoactive
bowel
sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: alert and interactive, strength and sensation grossly
intact
PSYCH: normal mood and affect
DISCHARGE EXAM:
***
Pertinent Results:
ADMISSION LABS:
___ 02:35PM BLOOD WBC-19.3* RBC-4.98 Hgb-15.7 Hct-46.4*
MCV-93 MCH-31.5 MCHC-33.8 RDW-12.0 RDWSD-41.1 Plt ___
___ 02:35PM BLOOD Glucose-378* UreaN-6 Creat-0.6 Na-138
K-4.4 Cl-95* HCO3-24 AnGap-19*
___ 02:35PM BLOOD Albumin-4.4 Phos-3.7 Mg-1.8
___ 02:35PM BLOOD ALT-23 AST-25 AlkPhos-137* TotBili-0.4
___ 02:44PM BLOOD ___ pO2-36* pCO2-42 pH-7.47*
calTCO2-31* Base XS-6 Intubat-NOT INTUBA
___ 09:29PM BLOOD ___ pO2-36* pCO2-49* pH-7.36
calTCO2-29 Base XS-0
MICRO:
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING:
CXR: IMPRESSION:
No acute cardiopulmonary process.
# EGD (___): Previously seen esophagitis appeared to have
improved. Multiple cold forceps biopies performed for histology
in the GE junction. Erythema of mucosa was noted in the antrum.
NJ tube was placed the ___ portion of the duodenum. Bridled at
120 cm.
EGD biopsy: No squamous metaplasia identified.
Discharge Labs
___ 07:42AM BLOOD WBC-18.0* RBC-4.05 Hgb-12.6 Hct-39.5
MCV-98 MCH-31.1 MCHC-31.9* RDW-13.6 RDWSD-48.7* Plt ___
___ 07:42AM BLOOD Glucose-212* UreaN-5* Creat-0.5 Na-140
K-4.6 Cl-103 HCO3-24 AnGap-13
___ 07:42AM BLOOD Calcium-8.9 Phos-4.7* Mg-1.7
___ 09:29PM BLOOD ___ pO2-36* pCO2-49* pH-7.36
calTCO2-29 Base XS-0
Brief Hospital Course:
SUMMARY/ASSESSMENT:
___ with hx of idiopathic chronic pancreatitis (c/b necrotizing
pancreatitis ___, s/p distal pancreatectomy, splenectomy,
cholecystectomy), highly insulin resistant DM
presenting with acute on chronic LUQ and L flank pain, and acute
on chronic N/V, found to have hyperglycemia without DKA.
# Hyperglycemia:
# DM:
She was seen by ___ consult service who followed her after
transition to tube feeds and they changed her regimen to include
bid lantus, and humalog.
# Acute on chronic abdominal pain and N/V:
# Chronic pancreatitis:
# Esophagitis - improving on EGD
# Inability to tolerate solids
She has had extensive prior evaluation that has revealed
esophagitis, otherwise suggestive of known chronic pancreatitis
and presumed gastroparesis. She was treated with bowel rest, IV
fluids, clear liquid diet, antiemetics, pain medications and
continued on sucralfate and high dose PPI. EGD showed
improving esophagitis, but given her inability to tolerate po,
GI advised NJ feeds for ___ weeks to give her a "rest"; patient
in agreement with this plan. She tolerated ___ tube feeds well
and will cycle with them overnight. She has ___ with Dr
___ in ___ clinic to discuss when to come off tube
feeds and to consider 24h pH monitoring and Barium swallow as
outpt
She was tolerating small amounts of liquids in addition to tube
feeds.
PROLONGED ___
Of note, AVOID QT PROLONGING MEDICATIONS IN SETTING OF ___ 560.
Advised patient not to take Zofran; pcp should recheck ___ at
followup.
# Hypertension:
- Continue all home antihypertensives She is on high amounts of
clonidine chronically for CPRS; her BP was lower than normal in
the hospital, and on the morning of discharge, has BP 78/50.
She was asymptomatic, and occurred after taking Ativan and
dilaudid (nucynta on hold here as it is not on formulary). Her
BP increased to 120/80s without intervention. She was advised
to hold felodipine on discharge, to continue clonidine, and to
take half dose of carvedilol until PCP ___.
# HLD:
- Continued home rosuvastatin
# Leukocytosis:
# s/p splenectomy: Per prior notes, history of elevated WBC
thought to be ___ post-splenectomy effects. WBC 18 on day of
discharge, patient without dysuria, cough, fevers or other
systemic symptoms.
Greater than ___ hour spent on care on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 25 mg PO BID
2. CloNIDine 0.4 mg PO BID
3. Doxepin HCl 75 mg PO HS
4. Felodipine 5 mg PO QHS
5. Gabapentin 1100 mg PO BID
6. Gabapentin 1600 mg PO QHS
7. LORazepam 0.5-1 mg PO QHS:PRN sleep
8. Omeprazole 40 mg PO BID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Promethazine 25 mg PO Q8H:PRN nausea / vomiting
11. Rosuvastatin Calcium 40 mg PO QPM
12. tapentadol 75 mg oral QID
13. Tizanidine ___ mg PO QHS
14. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral 2 capsules with each meal
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN BREAKTHROUGH PAIN
17. tresiba 60 Units Breakfast
tresiba 110 Units Bedtime
Insulin SC Sliding Scale using HUM InsulinMax Dose Override
Reason: Home regimen
18. Sucralfate 1 gm PO QID
Discharge Medications:
1. Carvedilol 12.5 mg PO BID
2. Glargine 34 Units Breakfast
Glargine 10 Units Bedtime
Humalog 2 Units Breakfast
Humalog 2 Units Lunch
Humalog 2 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. CloNIDine 0.4 mg PO BID
4. Doxepin HCl 75 mg PO HS
5. Gabapentin 1100 mg PO BID
6. Gabapentin 1600 mg PO QHS
7. LORazepam 0.5-1 mg PO QHS:PRN sleep
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Omeprazole 40 mg PO BID
10. Promethazine 25 mg PO Q8H:PRN nausea / vomiting
11. Rosuvastatin Calcium 40 mg PO QPM
12. Sucralfate 1 gm PO QID
13. tapentadol 75 mg oral QID
14. Tizanidine ___ mg PO QHS
15. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000
unit oral 2 capsules with each meal
16. HELD- Felodipine 5 mg PO QHS This medication was held. Do
not restart Felodipine until your PCP rechecks your blood
pressure
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Diabetes
Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized when you were very sick, with difficulties
in your pancreatitis and diabetes. You are now doing better, and
can go home to continue your care in the outpatient clinics.
Please be sure to follow-up with your appointments listed below.
We wish you the best with your health.
Warm regards,
___ Medicine
Followup Instructions:
___
|
19907884-DS-46 | 19,907,884 | 27,481,511 | DS | 46 | 2188-08-10 00:00:00 | 2188-08-10 17:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Compazine / Penicillins /
Cipro Cystitis / Zostrix / Prednisone / Bactrim / lisinopril /
hot peppers / metoclopramide
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
right hip girdlestone resection with antibiotic cement spacer
I&D with functional spacer
removal of deep hip implant
History of Present Illness:
___ with hx of idiopathic chronic pancreatitis (c/b necrotizing
pancreatitis ___, s/p distal pancreatectomy, splenectomy,
cholecystectomy, with Dobhoff ___ place for malnutrition), and
highly insulin resistant DM (w/ hx of DKA), recent R-septic hip
arthritis s/p femoral head removal with antibiotic spacer placed
___ who presents w/ fever + confusion.
Recently discharged 5 days ago s/p 1 month admission
(___) for e-coli bactermia c/b R-hip infection.
During hospitalization blood Cx, Urine Cx, intraop tissue
cultures and right hip Joint Aspirate all Positive for Ecoli.
Patient treated with meropenem during hospitalization and
discharged on Ertapenem with plan to complete 6 week course with
end date planned for ___. Also with J tube infection during
hospitalization treated with Vancomycin x 7 days. Course further
complicated by DKA requiring uptitration of insulin regimen and
chronic pain.
Procedure summary:
J tube placement ___
Right hip washout/debridement on ___
___ drainage and fluid sampling of the fluid collection
adjacent to the femoral head on ___
___ guided interrogation of the joint capsule with sampling of
fluid was performed on ___
Over the last two days ago noted pt was more lethargic. Today
___
found pt to be more confused, FSBG 600, T100.3. Per sister, pt
has become confused prior when she had DKA and her bacteremia.
She has PICC ___ place, taking ertapenem Q-daily. PICC/J-tube
working without issues. She reports worsening R-hip pain. Denies
any CP, SOB, abdominal pain, drainage or rash from
PICC/j-tube/surgical site.
___ the ED:
Initial vital signs were notable for:100.3 88 104/62 18 98% RA
Exam notable for:
PICC R-arm without surrounding erythema. not TTP
J-tube w/o surrounding erythema. abdomen w/o TTP
R-hip surgical site C/D/I without surrounding erythema. R-hip
warm, TTP.
Labs were notable for: WBC 18, Hb 10, platelets 852, lipase 11,
AP 312, chemistry panel unremarkable.
Lactate 2.1->1.2. H 7.52, pCOs 32.
Studies performed include:
CT Pelvis: Evaluation of the right hip is severely limited by
artifact from right hiparthroplasty. Hypodense fluid is seen
posterosuperior to the right hip,similar to prior, with interval
increase ___ edema surrounding the right hip.
These findings are nonspecific and may be related to recent
surgical
intervention, however septic arthritis cannot be excluded on the
basis of this exam
RUQ US: Normal abdominal ultrasound. No intrahepatic or
extrahepatic biliary dilation.
CXR: PICC line positioned appropriately. Right mid upper lung
linear density most
likely represent atelectasis.
Patient was given:
Vancomycin, Ertapenem, 66 units lantus, 2L NS.
Consults: Ortho- recommended repeat arthrocentesis of R hip
joint
and consideration of R thigh imaging.
Vitals on transfer: 98.8 84 103/58 14 96% RA
Past Medical History:
-Chronic Pancreatitis: c/b necrotizing pancreatitis ___, s/p
distal pancreatectomy/splenectomy, cholecystectomy, and J-tube
placement ___, since that time removed
-Intractable migraines with muscle spasm and neuralgia, and
status migrainous, currently treated with trigger point
injections
-Chronic pain due to reflex sympathetic dystrophy secondary to
being hit by a car at age ___ consisting of -complex Regional
Pain Syndrome of the right face and right upper extremity
-Type 2 Diabetes Mellitus
-Hypertension
-Obesity
-Right eye blindness
-Left pupil dysfunction - ADIE (tonically dilated pupil)
-PUD
-Seronegative erosive arthritis previously followed by Dr. ___
___ she has stopped following up with him
-Iron deficiency anemia
Social History:
___
Family History:
Father and sister with HTN. Family history of CAD ___ father. No
family history of CVA. No family history of pancreatitis .
Sister has DM. Her father died of an MI at age ___ and he also
had DM.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.6PO 109 / 70L Sitting 83 20 95 RA
GENERAL: Alert and interactive. ___ no acute distress.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
.
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: J tube ___ place, greenish drainage around tube, Abdomen
diffusely tender to palpation.
EXTREMITIES: R hip with lateral incision, clean dry intact. No
edema.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
DISCHARGE PHYSICAL EXAM
========================
VITALS: ___ 0729 T 97.9 BP 128/85 HR 105 RR 18 Sat 96% on
room air
GENERAL: Alert and interactive. ___ no acute distress. Lying ___
bed.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs, rubs, or gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: J tube ___ place, greenish drainage around tube, abdomen
non-tender to palpation.
EXTREMITIES: R hip with lateral incision, clean dry intact and
dressed. No edema. Mildly tender and swollen lateral right
thigh. Marked area of prior erythema receded.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. AOx3.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 06:06PM BLOOD WBC-18.0* RBC-3.57* Hgb-10.1* Hct-33.2*
MCV-93 MCH-28.3 MCHC-30.4* RDW-15.5 RDWSD-52.9* Plt ___
___ 06:06PM BLOOD Glucose-281* UreaN-14 Creat-0.7 Na-137
K-4.4 Cl-94* HCO3-23 AnGap-20*
___ 06:06PM BLOOD ALT-37 AST-47* AlkPhos-312* TotBili-0.4
___ 06:06PM BLOOD Albumin-3.7 Calcium-10.0 Phos-4.7*
Mg-1.5*
___ 06:11PM BLOOD pO2-118* pCO2-34* pH-7.46* calTCO2-25
Base XS-1
___ 06:11PM BLOOD Lactate-2.1* K-3.7
IMAGING
=======
___ RUQ Ultrasound:
Status post cholecystectomy. No intrahepatic biliary ductal
dilation. CBD measures 7 mm, likely normal post
cholecystectomy.
___ CT Pelvis:
1. Evaluation of the right hip is severely limited by artifact
from right hip arthroplasty. Hypodense fluid is seen
posterosuperior to the right hip, with interval increase ___
edema surrounding the right hip, and small locules of gas within
the hip joint concerning for infection.
___ Ultrasound of PEG tube site
Mild skin thickening and subcutaneous edema ___ the area of the
patient'sJ-tube without evidence of a drainable fluid
collection, or deeper infection.The J-tube was otherwise
appropriately positioned.
___ CT Right Hip and Fever
Suboptimal examination is secondary to metallic hardware
artifact. Persistent rim enhancing collection measuring at least
3.2 cm ___ diameter posterior to the right hip joint ___ keeping
with ongoing septic arthritis. Circumferential skin thickening
and subcutaneous edema most pronounced about the lower aspect of
the proximal thigh which may represent cellulitis ___ the correct
clinical context. Recommend clinical correlation.
Circumferential bladder wall thickening which may represent
cystitis. Recommend clinical correlation with urinalysis.
LENIS ___
No evidence of deep venous thrombosis ___ the right lower
extremity veins.
Subcutaneous soft tissue edema ___ the distal right thigh.
CXR ___
1. No pulmonary edema.
2. Increased hilar contours, which may represent worsening
adenopathy.
3. No definitive evidence of pneumonia.
CT A/P/THIGH ___
1. Hypoenhancing area involving the left kidney could represent
pyelonephritis.
2. Interval removal of right hip prosthesis, gas containing
collection now
seen at this level and involving the right thigh. Postsurgical
changes can have this aspect, although this is concerning for
superinfection. Correlate clinically.
#RUQ US ___- s/p splenectomy and distal pancreatectomy.
Otherwise unremarkable
MICRO/OTHER PERTINENT LABS
===========================
___ 06:13AM BLOOD ___
___ 06:13AM BLOOD Ret Aut-2.0 Abs Ret-0.06
___ 06:13AM BLOOD Lipase-10
___ 06:13AM BLOOD Hapto-321*
___ 06:06PM BLOOD HCG-<5
___ 01:31AM BLOOD CRP-73.0*
blood cultures ___- NGTD from PIV and PICC Line
blood culture ___ bottles staph aureus
urine culture ___- >100k yeast
___ 6:18 pm FOREIGN BODY Site: HIP
RIGHT HIP EXPLANTS FOR SONICATION.
Sonication culture, prosthetic joint (Preliminary): NO
GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 5:42 pm TISSUE Site: HIP RIGHT HIP SYNOVIAL
FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 2:07 pm SWAB Source: around J tube.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
___ 10:32 am JOINT FLUID Source: R Hip.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 11:12 pm URINE PLAIN RED TOP.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. >100,000 CFU/mL.
DISCHARGE LAB RESULTS
======================
___ 05:26AM BLOOD WBC-15.3* RBC-3.57* Hgb-9.8* Hct-31.9*
MCV-89 MCH-27.5 MCHC-30.7* RDW-16.1* RDWSD-52.8* Plt ___
Brief Hospital Course:
___ is a ___ y/o F h/o idiopathic chronic pancreatitis
(c/b necrotizing pancreatitis ___, s/p distal pancreatectomy,
splenectomy, cholecystectomy, with J tube ___ place for
malnutrition), and poorly controlled DM (w/ hx of DKA), recent
prolonged admission (___) for MDR e coli septic hip
infection s/p femoral head removal with antibiotic spacer placed
___ who presents w/ fever and confusion on ___, went to the
OR for removal of deep hip implant on ___. Hospital course c/b
brief ICU stay for hemorrhagic shock.
# Sepsis
# E coli right hip septic arthritis:
# Leukocytosis:
Patient with recent hospitalization for MDR E coli bacteremia
c/b R septic hip infection. s/p I&D and femoral head rsxn
(___), OR exploration, s/p spacer placement (___). Developed
fluid collection around the femoral head and on ___, ___ placed
a drain with fluid sample, cultures negative. Was initially on
meropenem and discharged on ertapenem to ease antibiotic
administration. Patient re-presented after becoming more
lethargic and concern for recurrent septic joint. Restarted on
___ and returned to the OR on ___ for removal of deep
hip implant. Post-op course complicated by hypotension as noted
below felt to be most likely from acute blood loss, requiring
brief ICU stay. Blood cultures ___ grew out ___ bottles of
staph aureus which was felt to likely represent contaminant.
Blood cultures from ___ no growth (final). There was some
concern for infection around PEJ site as had purluent drainage
___ the past but does not appear currently infected. Had Jtube
infection during previous hospitalization and treated with 7
days of vancomycin with improvement of erythema and drainage. CT
A/P with no acute abdominal findings. Per ID recommendations,
antibiotics were descelated to meropenem which she was
discharged on to complete 6 week course through ___. If she
was to be discharged from rehab prior to completing abx course,
would discuss with ID about transitioning to daptomycin at home.
She will need weekly labs (see transitional issues below). She
was seen by ___ who recommended discharge to rehab. Patient was
initially hesitant but ultimately agreeable. Per orthopedics she
is WBAT to RLE.
# Hemorrhagic shock (resolved)
# Elevated Lactic acid:
Post-op was found to have a hgb of 6.4 during the day on ___
and received a unit of pRBCs. Transfusion was stopped due to
concern for transfusion reaction as the patient developed a
fever to 102.8. The patient became hypotensive on ___ to
60-70/30-40s with labs showing Hgb 5.4 and lactate elevated to
5.8. Received 1L of fluid with improvement ___ BP. She was
transferred to ICU given concern for hemorrhagic shock vs septic
shock. Given swift decrease ___ Hgb and improvement with just 1L,
likely hemorrhagic. R thigh appeared tense, concerning for
hematoma. Spiked a fever as well iso blood transfusion. WBC
count downtrended, broadedly covered by ___, and responded
well to IVF making septic shock less likely. Dilaudid PCA also
likely contributed though had been on the PCA for several days.
Hematoma clnically developed on exam with ortho saying no need
for urgent evacuation. H/H stable after 3u pRBCs. Lactate
improved with fluid resuscitation. Continued antibiotics. CT
thigh with no expanding hematoma and likely postsurgical
changes. Repeat blood cultures ___ revealed ___ bottles growing
staph aureus felt to be contaminant as subsequent blood cultures
were negative. Vancomying was discontinued and she remained
stable along with not requiring further blood transfusions.
# Acute blood loss Anemia
# R thigh hematoma:
Concern for hematoma formation post-operatively. DIC/hemolysis
labs unremarkable. Developed fever while receiving a
transfusion, but no additional symptoms. Unlikely transfusion
reaction given no hemolysis. Hematoma did not expand and no
worsened wound vac drainage. Stable H/H s/p 3u pRBCs.
Orthopedics with no recommendations for evacuation and to
continue monitoring. H/H has been stable since transfusion.
Wound vac was removed and replaced with aquacell dressing.
# Malnutrition s/p J-tube placement (___)
# Concern for J tube site skin/soft tissue infection:
Wound culture showed mixed bacterial flora though clinically,
concern has been raised for psuedomonal infection (purulent,
sweet smelling drainage). Skin with excoriation around tube site
but no findings concerning for cellulitis. ___ consulted given
persistent drainage around the J tube, and they pushed the tube
back ___ with improved leakage. She was resumed on TF that per
nutrition recommends and patient preference was changed to
glucerna 1.5 @ 95cc/hr x 12hrs with 50ml water flushes Q6h.
T2DM: : Home insulin regimen consistents of lantus 37Qam and 66
QHS. Humalog ___ with sliding scale. Home insulin regimen
initially decreased as had several hypoglycemic episodes on the
day of admission. Has infection and diet improved she was noted
to have poorly controlled FSBS. ___ was consulted and
recommended uptitrating to lantus 35 units qAM and 75 units QHS
along with humalog ___ with ISS with improved control. She was
discharged to rehab on this regimen.
# Chronic pancreatitis
# Esophagitis/Dysphagia:
Patient with chronic pancreatitis and gastroparesis. Also with
esophagitis. For malnutrition underwent J-tube placement by ___
on ___. Continued home omeprazole 40mg bid, promethazine 25mg
q8h prn for nausea, and sucralfate 1gm qid.
# Acute post operative pain I/s/o chronic pain syndrome
# RSD/CPRS:
On intensive outpt pain regimen for chronic pancreatitis pain,
RSD/CPRS pain of the right face and upper extremity ___ MVA,
arthritis, and intractable migraines. During admission was
placed on IV dilaudid PCA for optimal pain control. Chronic pain
services was consulted and she was able to be weaned off the PCA
and resumed back on her home regimen of oxycontin 20mg BID and
dilaudid ___ Q4h PRN. She was continued on home doxepin 75mg
QHS, gabapentin 100mg BID and 1600mg QHS. She reported ongoing
pain mainly due to spasms. Her home tizanidine was uptritated
with no improvement of pain so was replaced with flexeril that
was uptitrated to current dose of 10mg TID which she was
discharged on. She was also placed on naproxen 500mg BID which
she was discharged on.
# Insomnia: Continued home lorazepam 0.5mg qhs prn.
# Hypertension: Home regimen consisted of carvedilol and
clonidine. Both medications initially held given sepsis.
Clonidine was resumed due to worsening BP control however this
had to be downtitrated from home dose to clondidine 0.2mg BID
given soft BP. Carvedilol was held on discharge to BP well
controlled on clonidine alone.
#Transaminitis
#Alk Phos elevation
Significantly improved from last admission. RUQ U/S neg. LFTs
noted to acutely rise ___ from unclear etiology. Repeat RUQ US
was unremarkable. She was not started on any medications new to
her. Vancomycin level noted to be elevated around the same time
but low suspicion as cause and it has since been discontinued.
Meropenem is possible but has been on previously without
issues. She was continued on same medications excluding
vancomycin with improvement of LFTs back towards baseline.
TRANSITIONAL ISSUES
====================
[] continue to titrate pain medications for optimal control
[] monitor weekly CBC w/diff, Bun/Cr, LFTs, CRP and fax to ___
___ CLINIC - FAX: ___
[] monitor FSBS and adjust insulin as needed
[] f/u with ID and if discharge home prior to completion of abx
course discuss switching to daptomycin for ease of management at
home
[] f/u with orthopedics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxepin HCl 75 mg PO HS
2. Gabapentin 1100 mg PO BID
3. Gabapentin 1600 mg PO QHS
4. LORazepam 0.5-1 mg PO QHS:PRN sleep
5. Omeprazole 40 mg PO BID
6. Promethazine 25 mg PO Q8H:PRN nausea / vomiting
7. Rosuvastatin Calcium 40 mg PO QPM
8. Sucralfate 1 gm PO QID
9. Tizanidine ___ mg PO QHS
10. Ertapenem Sodium 1 g IV 1X
11. Clotrimazole Cream 1 Appl TP BID
12. HYDROmorphone (Dilaudid) ___ mg PO Q6H
13. OxyCODONE SR (OxyconTIN) 20 mg PO BID
14. Senna 8.6 mg PO BID
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000 unit
oral 2 capsules with each meal
17. Glargine 37 Units Breakfast
Glargine 66 Units Bedtime
Humalog 3 Units Breakfast
Humalog 3 Units Lunch
Humalog 3 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild/Fever
2. CloNIDine 0.2 mg PO BID
3. Cyclobenzaprine 10 mg PO TID
4. Docusate Sodium 100 mg PO BID hold for loose stool
5. Hydrocortisone Cream 1% 1 Appl TP QID
6. Meropenem 500 mg IV Q6H
7. Multivitamins 1 TAB PO DAILY
8. Naproxen 500 mg PO Q12H
9. Polyethylene Glycol 17 g PO DAILY hold for loose stool
10. Glargine 35 Units Breakfast
Glargine 75 Units Bedtime
Humalog 4 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
11. Doxepin HCl 75 mg PO HS
12. Gabapentin 1100 mg PO BID
13. Gabapentin 1600 mg PO QHS
14. HYDROmorphone (Dilaudid) ___ mg PO Q6H
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 6 hours Disp
#*10 Tablet Refills:*0
15. LORazepam 0.5-1 mg PO QHS:PRN sleep
RX *lorazepam 0.5 mg 0.5-1 mg by mouth at bedtime Disp #*5
Tablet Refills:*0
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. Omeprazole 40 mg PO BID
18. OxyCODONE SR (OxyconTIN) 20 mg PO BID
RX *oxycodone 20 mg 1 tablet(s) by mouth twice daily Disp #*10
Tablet Refills:*0
19. Promethazine 25 mg PO Q8H:PRN nausea / vomiting
20. Rosuvastatin Calcium 40 mg PO QPM
21. Senna 8.6 mg PO BID
22. Sucralfate 1 gm PO QID
23. Zenpep (lipase-protease-amylase) 20,000-68,000 -109,000
unit oral 2 capsules with each meal
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
hemorrhagic shock
right septic hip
encephalopathy
sepsis
anemia
transaminitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with fevers and confusion found to likely be
to underlying infection ___ her right hip. You underwent repeat
surgery to remove the infected material and were started on IV
antibiotics with improvement of symptoms. You developed anemia
from blood loss that improved following tranfusion and brief ICU
stay. You were seen by ___ who recommended rehab which you were
discharged to.
New Medications:
1) Meropenem is an antibiotic to treat your infection. Please
take as prescribed.
2) Naproxen is a medication to help control your pain. Please
take as prescribed.
3) Your insulin dosages were adjusted by the ___.
Please monitor your sugars and continue taking your insulin at
the new recommended dosages. Please continue to adjust your
regimen as needed as per physician ___.
4) Flexeril is a medication to help control your pain/spasm.
This was added to REPLACE your home tizanidine. Please stop
taking your home tizanidine while on flexeril.
5) Please REDUCE your home dose of clonidine from 0.4mg to 0.2mg
twice a day
6) Please HOLD your home carvedilol as your blood pressure was
well controlled without it.
Best of luck ___ your recovery,
Your ___ care team
Followup Instructions:
___
|
19908221-DS-21 | 19,908,221 | 21,397,883 | DS | 21 | 2141-04-29 00:00:00 | 2141-04-29 19:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Hyponatremia, hyperkalemia.
Major Surgical or Invasive Procedure:
___ - Tunneled plasmapheresis line placement
History of Present Illness:
___ M with HCV cirrhosis c/b HCV-related MPGN with potential
nephrotic syndrome with CKD and chronic volume overload admitted
with hyponatremia, worsening hyperK and relatively stable renal
function.
Since last discharge in ___, Mr. ___ has had ongoing
anasarca depsite increasing dose of toresemide to 100mg daily.
Additionally, he has tried 2x to intiate HCV therapy but has
been declined by his insurance. An attempt was made to place him
on simeprevir/sofosbuvir but his insurance denied the medication
and an attempt is being made to appeal this decision given his
rapidly progressing renal failure.
He was seen in Dr. ___ on ___. As he was extremely
anasarcic with 4+ edema and weeping from his legs. Labs drawn
were notable for K 5.8, Na 125 and Cr 2.6. He was called and
asked to come in for futher management. At the time of
admission, cryos and HCV VL pending.
In the ED initial vitals were: 98.6 66 138/63 16 100% RA. Labs
were significant for Na 119, K 5.8. He was given 25g albumin and
admitted.
On the floor, he is feeling well and has no other concerns
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
- hepatitis C, diagnosed ___, treated with interferon/ribavirin
but relapsed after initial clearance
- CKD III of unclear cause, thought to have MPGN in the setting
of hepC and cryoglobulins. Baseline Cr ___
- pulmonary hemorrhage treated with plasmapheresis and steroids
at ___, ___
- Diastolic heart failure EF 55% ___
- cryoglobulinemic vasculitis diagnosed on skin biopsy
- diabetes mellitus type II
- diastolic congestive heart failure EF 55% in ___
- morbid obesity
- COPD
- hypertension
- left total knee replacement ___
- chronic hyponatremia
- pancytopenia with frequent transfusions
- anemia on procrit
- cholelithiasis
- peripheral neuropathy
- coronary artery disease, recent NSTEMI treated medically, per
___ records, due to poor revascularization candidacy
- BPH
- C2 fracture following MVA ___ requiring trach/PEG
Social History:
___
Family History:
Noncontributory. No family history of chronic liver disease or
liver-related problems. No family history of colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
Vitals: 97.5 98.0 155/85 73 18 95% RA
I/O: MN - 50/2500 24 - NR
Wt: 121.5 kg
GENERAL: NAD, anisarca
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: Supple, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Decreased air entry as bases, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: Mildy distended, non-tender, no HSM appreciated.
Bruising on right flank
EXTREMITIES: 3+ ___ b/l
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, no asterixis
SKIN: Mild jaundice, multiple violacious patches on UE
DISCHARGE EXAM - Unchanged from above, except as below:
=========================================================
Weight:
CHEST: Right sided plasmapheresis catheter site with dried blood
EXTREMITIES: 3+ Edea bilaterally
Pertinent Results:
ADMISSION LABS
===============
___ 01:40PM BLOOD WBC-9.3# RBC-3.19* Hgb-9.7* Hct-29.7*
MCV-93 MCH-30.4 MCHC-32.7 RDW-15.9* Plt ___
___ 01:40PM BLOOD Neuts-93.2* Lymphs-3.8* Monos-2.8 Eos-0.2
Baso-0.1
___ 01:40PM BLOOD UreaN-144* Creat-2.6* Na-125* K-5.8*
Cl-88* HCO3-26 AnGap-17
___ 09:10AM BLOOD Calcium-7.2* Phos-7.1*# Mg-2.2
___ 01:40PM BLOOD ALT-75* AST-75* AlkPhos-115 TotBili-0.4
___ 01:40PM BLOOD Cryoglb-POSITIVE *
___ 01:40PM BLOOD RheuFac-142* AFP-1.8
___ 01:40PM BLOOD C3-67* C4-LESS THAN
DISCHARGE LABS
=================
___ 01:05PM BLOOD WBC-3.2*# RBC-2.35* Hgb-6.9* Hct-21.4*
MCV-91 MCH-29.6 MCHC-32.4 RDW-15.0 Plt Ct-69*
___ 04:52AM BLOOD ___ PTT-29.2 ___
___ 04:52AM BLOOD Glucose-184* UreaN-117* Creat-3.1* Na-137
K-4.2 Cl-96 HCO3-29 AnGap-16
___ 04:52AM BLOOD ALT-63* AST-60* LD(LDH)-330* AlkPhos-102
TotBili-0.9
___ 04:52AM BLOOD Albumin-3.2* Calcium-7.3* Phos-3.9 Mg-2.0
CSF STUDIES
===============
___ 11:29AM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0
Bands-4 ___ Macroph-36
___ 11:28AM CEREBROSPINAL FLUID (CSF) TotProt-28
Glucose-120
IMAGING/STUDIES
================
___ CT Head without Contrast
No acute intracranial abnormality.
___ MRI Head with and without Contrast
1. Differences in FLAIR contrast may be due to changes in the
oxygen tension rather than technical differences. On the current
FLAIR images, the white matter signal is not strikingly abnormal
and now is now in keeping with what can normally be seen in a
___ patient with small vessel ischemic disease.
2. The etiology of the right frontal lobe lesion remains unclear
though there may be slightly less cortical swelling associated
with the lesion, and this may be due to seizure swelling with an
area of underlying tissue loss in the deep white matter
secondary to previous injury. There is no abnormal enhancement.
Followup is recommended.
___ EEG
This is an abnormal continuous ICU monitoring study because of
the presence of mild diffuse background slowing with periods of
frontal
central irregular delta activity, all compatible with both
cortical and
subcortical neuronal dysfunction. This is most likely related to
metabolic
factors. No clear focal or lateralized abnormalities were seen
and no clear
interictal activity was identified. There was no evidence for
sustained
electrographic seizure activity during this recording.
MICRO
========
___ 1:40 pm IMMUNOLOGY
**FINAL REPORT ___
HCV VIRAL LOAD (Final ___:
6,410,000 IU/mL.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
___ 5:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Brief Hospital Course:
___ M with HCV cirrhosis c/b HCV-related MPGN with potential
nephrotic syndrome with CKD and chronic volume overload admitted
with hyponatremia, worsening hyperK and relatively stable renal
function.
ACUTE ISSUES
#AMA Discharge: Patient decided to leave AMA on ___ despite
ongoing management of his acute kidney injury and incomplete
work-up for his seizure. He was clear and competent, he was able
to understand and repeat back the risks of leaving AMA,
including: worsening renal function potentially leading to
dialysis, worsening anemia, recurrent seizures, and death. Close
outpatient follow-up was arranged.
# HCV cirrhosis: Child's B9, decompensated by hepatic
encephaloapthy and ascites in past, no record of EGD. Genotype
1b, has previously failed interferon-based therapy. In the
process of obtaining sofosbuvir and simeprivir approval but has
been rejected by insurance 2x already. No evidence of
decompensated liver disease this admission. For interim
treatment of HCV associated cryoglobulinemia, the decision was
made to proceed with plasmapheresis (which he has had at ___
in the past) for 5 treatments followed by rituximab.
Unfortunately, during plasmapheresis the patient experienced a
seizure, which is discussed further below. Plasmapheresis was
not continued during this admission and his pheresis catheter
was removed. He was otherwise continued on lactulose and
rifaxamin. He had mild hepatic encephalopathy at times this
admission which was managed with lactulose and rifaximin.
However, he was not encephalopathic and had no asterixis when he
decided to leave AMA. Diuretics stopped as below.
# Acute kidney injury on CKD: Patient has bx proven MPGN thought
to be ___ cryoglobulinemia from HCV. Cr on admimssion 2.6, which
was is stable from ___ but was above most recent baseline of
2.0 earlier this year. He is on a prednisone taper as an
outpatient. He had significant diffuse and global sclerosis seen
on kidney bx, as well as interstitial fibrosis suggesting a
large degree of irreversible damage. Cr initially improved with
diuresis, however, Cr rose to 3.1 by the day of discharge. His
diuretics were held and he was given intravenous albumin.
Valsartan was held. As he left AMA, renal function was unable to
be closely monitored. He had follow-up arranged with his
outpatient nephrologist and will have labs checked later this
week.
# Cryoglobulinemia: Associated with HCV infection. He underwent
plasmapharesis on ___. Given complication of seizures during
plasmapheresis, plan to defer further sessions for now. Pheresis
catheter removed prior to discharge.
# Seizures: Immediately following plasmapheresis on ___ he had
two witnessed tonic clonic seizures. Seizure started as focal in
his left arm and subsequently generalized. He was intubated and
transferred to the ICU. He was loaded with Keppra. He was
successfully extubated. EEG for 24 hours did not show further
seizures. MRI brain with and without contrast showed no evidence
of focal lesions or vasculitis other than likely chronic small
vessel ischemic changes. LP showed no evidence of infection,
protein negative, and HSV PCR neg. HIV testing for potential PML
pending at discharge. Patient continued on Keppra 500 mg PO BID
at discharge.
# HF with preserved EF: Patient was initially admitted for
volume overload. He has history of diastolic dysfunction which
may be further contributing to anisarca. He has not experienced
any recent chest pain recently and ECG on admission was at his
baseline. He was initially diuresed with IV lasix with excellent
UOP and improvement in his Cr with diuresis. Patient was
initially transitioned back to PO toresemide. Ultimatey,
torsemide was stopped prior to AMA discharge given that his
kidney function was worsenng. Discharge weight 108.7kg.
# Hyponatremia: Na decreased on outpatient labs compared to last
discharge (135->125) and found to be 119 on admission. No
evidence of neurologic complications. Most likely secondary to
intravascular depletion in setting of increased toresemide dose
and hyervolemia related to cirrhosis. Low urine sodium (35 while
on diuretic) and improvement with albumin resuscitation supports
diagnosis. Na at discharge was 137.
# Hyperkalemia: Elevated in the setting of worsening renal
function over the last month prior to admission. No ECG changes
noted and downtrending with fluids. Additionally received a dose
of kayelxalate in ED. Subsequently resolved.
# Tracheobronchitis: E. coli growing in sputum when he was
intubated in the ICU, no PNA on CXR. He was treated with 7 days
of levofloxacin.
CHRONIC ISSUES
# DM II: Continued home lantus and HISS. Metformin held in the
setting of ___.
# CAD: No recent CP or concern for ischemia. Continued home
aspirin, atorvastatin.
# COPD: Stable. Continued home advair.
# Chronic pain: Continued home oxycodone. Stopped long acting
morphine given renal impairment.
# BPH: Continued home tamsulosin.
TRANSITIONAL ISSUES
- Prednisone taper to be further discussed as an outpatient by
nephrologist
- Follow-up pending CSF studies, including: ___ virus, flow
cytometry, culture
- Monitor renal function and consider restarting diuretics
and/or valsartan when appropriate
- Consider stopping Keppra in ___ months if patient has no
further seizures
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Fluoxetine 20 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Lactulose 20 mL PO BID
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Morphine SR (MS ___ 15 mg PO Q12H
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Polyethylene Glycol 17 g PO DAILY
12. Tamsulosin 0.4 mg PO HS
13. Rifaximin 550 mg PO BID
14. Ferrous Sulfate 325 mg PO BID
15. Gabapentin 600 mg PO TID
16. MetFORMIN (Glucophage) 500 mg PO BID
17. Terazosin 5 mg PO HS
18. Valsartan 160 mg PO DAILY
19. Torsemide 100 mg PO DAILY
20. PredniSONE 40 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Ferrous Sulfate 325 mg PO BID
4. Fluoxetine 20 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Lactulose 20 mL PO BID
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY
10. PredniSONE 40 mg PO DAILY
Tapered dose - DOWN
11. Rifaximin 550 mg PO BID
12. Tamsulosin 0.4 mg PO HS
13. Terazosin 5 mg PO HS
14. Amlodipine 10 mg PO DAILY
15. Metoprolol Succinate XL 200 mg PO DAILY
16. Outpatient Lab Work
PLEASE CHECK CHEM-7 ON ___. ICD-9 585.9
Forward results to: ___, NP
Fax: ___
17. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth Twice
daily Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. HCV cirrhosis
2. Cryoglobulinemia
3. Membranoproliferative glomerulonephritis
4. Acute on chronic heart failure with preserved ejection
fraction
5. Hyponatremia
6. Hyperkalemia
7. Seizure
8. Acute kidney injury on chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with significant leg swelling.
While in the hospital you were give intravenous diurestics,
which helped removed a significant amount of fluid. However,
your kidney function worsened and we had to stop the diuretics.
Please STOP taking valsatran and torsemide at home until you see
your doctors in follow-up.
Additionally, to treat your HCV-related issue of
cryoglobulinemia, you received a session of plasmapheresis.
However, you had a seizure during this procedure, the cause of
which remains somewhat unclear. You will continue on an
anti-seizure medication after discharge.
You have chosen to leave the hospital against medical advice
(AMA) despite the fact that your work-up for kidney failure and
seizures is not complete. You were told of the risks of leaving
before work-up is complete, including permanent renal failure,
recurrent seizures and death.
Please have your labs checked ___, they will be
faxed to the ___.
As always, please weigh yourself daily and call your MD if
weight increases by more than 3 lbs.
Followup Instructions:
___
|
19908221-DS-22 | 19,908,221 | 22,170,002 | DS | 22 | 2141-05-18 00:00:00 | 2141-05-18 17:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zestril
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ Tunneled HD catheter placed by ___
History of Present Illness:
___ year old male with hx. hep. C cirrhosis s/p IFN (___) c/b
cryoglobulinemia, leukocytoclastic vasculitis with MPGN,
pulmonary hemorrhage treated with plasmapharesis (___), chronic
anasarca, dCHF (EF 55%), IDDM, morbid obesity, COPD, CAD with
hx. NSTEMI medically managed presenting with worsening renal
function.
Patient was recently hospitalized ___ for
hyponatremia/hyperkalemia in the setting of worsening renal
function, hospitalization notable for development of tonic
clonic seizures during plasmapharesis session in an attempt to
treat cryoglobulinemia. Patient was intubated and transferred to
the ICU and was started on levetiracetam. In terms of his ___,
nephrology was consulted, biopsy consistent with largely
irreversible process and dialysis was considered but deferred.
Patient was treated with albumin and diuretics were held. Of
note, patient left AMA prior to resolution of ___.
In the ED, initial vitals were 98.9 73 152/69 18 98% RA. Labs
were notable for sodium 125, potassium 6.6, Bun/Cr 151/4.1,
proBNP 2897, CBC with pancytopenia (2.3>8.1<112), INR 1.1.
Patient was given 5mg oxycodone, 120mg IV furosemide, 2mg IV
lorazepam, 10 units IV insulin, dextrose IV, 2gm calcium IV, and
60 gm Kaexylate PO. Foley placed. Patient given 1L NS as well
earlier in the afternoon.
On the floor, he reports his SOB is stable ("I have a tiny bit
always"), no chest pain, abdominal pain, diarrhea, fevers.
Positive for nausea ___ kayexalate. Positive for feeling
"freezing."
He notes the only med changes are stopping his diuretics after
last admission. Since then he notes his leg swelling is worse
and he's gained ___ pounds in the last week or so. He also
endorses feeling "a little fuzzier" this evening, reports
anxiety and had requested ativan for this in the ED. He reports
he left AMA last hospitalization because he was just very
frustrated that he was not getting anywhere in terms of his
treatment for HCV. He has been rejected twice now by insurance
company and his renal failure is getting worse. This is a huge
source of stress and frustration for him. Also reports falling 3
weeks ago, easy bruising, with left arm and left buttock/thigh
hematomas that have been stable/improving. Had a BM downstairs.
ROS: see above please, no dysuria as well. +easy bruising
Past Medical History:
- hepatitis C (gen. 1b), diagnosed ___, treated with
interferon/ribavirin but relapsed after initial clearance
- CKD III of unclear cause, thought to have MPGN in the setting
of hepC and cryoglobulins. Baseline Cr ___
- pulmonary hemorrhage treated with plasmapheresis and steroids
at ___, ___
- Diastolic heart failure EF 55% ___
- cryoglobulinemic vasculitis diagnosed on skin biopsy
- diabetes mellitus type II
- diastolic congestive heart failure EF 55% in ___
- morbid obesity
- COPD
- hypertension
- left total knee replacement ___
- chronic hyponatremia
- pancytopenia with frequent transfusions
- anemia on procrit
- cholelithiasis
- peripheral neuropathy
- coronary artery disease, recent NSTEMI treated medically, per
___ records, due to poor revascularization candidacy
- BPH
- C2 fracture following MVA ___ requiring trach/PEG
Social History:
___
Family History:
No family history of chronic liver disease or
liver-related problems. No family history of colon cancer.
Physical Exam:
ADMISSION EXAM
VS: 97.5 - 179/81 - 88 - 20 - 98% RA weight 111.8kg 72"
urine output 400
General: obese gentleman with moon facies lying in bed, no
respiratory distress
HEENT: sclera anicteric, NC/AT
Neck: supple, obese
CV: heart w/ regular rate and rhythm
Lungs: slight crackles, otherwise CTA
Abdomen: soft, obese, firm, +flank dullness
GU: foley in place, draining urine
Ext: ___ symmetric severe pitting edema to mid thigh
Neuro: alert, oriented x3, able to to days of week forward,
backward, president, not able to do A1/B2/C3 pattern
Skin: large ecchymosis left hip, thigh, buttock, left arm, non
tender.
DISCHARGE EXAM:
VS: Tm 99 Tc 98.2 136/71 85 20 100% RA
General: Obese, lying in bed, appearing comfortable
HEENT: sclera anicteric, NC/AT
Neck: supple, obese
CV: heart w/ regular rate and rhythm
Lungs: crackles at the bases bilaterally
Abdomen: soft, obese, nontender, some firmness
GU: no foley present
Ext: 2+ symmetric severe pitting edema to hips bilaterally.
Right forearm is swollen and warm compared to left forearm to
the elbow. Erythema over right elbow slightly improved from
prior outline. No crepitus. 2+ radial pulses.
Neuro: Nonfocal, A&Ox3
Pertinent Results:
ADMISSION LABS
===============================
___ 05:15PM ___ PTT-24.1* ___
___ 05:15PM PLT COUNT-112*
___ 05:15PM NEUTS-85.2* LYMPHS-9.0* MONOS-5.5 EOS-0.2
BASOS-0.1
___ 05:15PM WBC-2.3* RBC-2.67* HGB-8.1* HCT-24.7* MCV-92
MCH-30.1 MCHC-32.6 RDW-15.2
___ 05:15PM ALBUMIN-3.1___ 05:15PM proBNP-2897*
___ 05:15PM ALT(SGPT)-92* AST(SGOT)-80* ALK PHOS-182* TOT
BILI-0.7
___ 05:15PM GLUCOSE-289* UREA N-151* CREAT-4.1*
SODIUM-125* POTASSIUM-6.6* CHLORIDE-91* TOTAL CO2-24 ANION
GAP-17
___ 05:35PM K+-6.3*
___ 05:35PM COMMENTS-GREEN TOP
___ 06:33PM K+-6.2*
___ 06:33PM COMMENTS-GREEN TOP
___ 06:35PM URINE MUCOUS-RARE
___ 06:35PM URINE HYALINE-2*
___ 06:35PM URINE RBC-5* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 06:35PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-600
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:35PM URINE GR HOLD-HOLD
___ 06:35PM URINE UHOLD-HOLD
___ 06:35PM URINE HOURS-RANDOM
___ 06:35PM URINE HOURS-RANDOM
___ 08:45PM URINE OSMOLAL-333
___ 08:45PM URINE HOURS-RANDOM UREA N-572 CREAT-63
SODIUM-10 POTASSIUM-56 CHLORIDE-LESS THAN TOT PROT-401
CALCIUM-0.1 PHOSPHATE-41.8 MAGNESIUM-2.0 TOTAL CO2-LESS THAN
PROT/CREA-6.4*
___ 08:45PM SODIUM-128* POTASSIUM-5.6* CHLORIDE-92*
PERTINENT RESULTS
===============================
___ 04:45AM BLOOD WBC-3.0* RBC-2.66* Hgb-8.0* Hct-24.5*
MCV-92 MCH-29.9 MCHC-32.5 RDW-14.9 Plt ___
___ 04:30AM BLOOD WBC-2.1* RBC-2.56* Hgb-7.7* Hct-23.7*
MCV-93 MCH-29.9 MCHC-32.3 RDW-15.0 Plt Ct-66*
___ 05:20AM BLOOD WBC-1.8* RBC-2.74* Hgb-8.3* Hct-25.9*
MCV-95 MCH-30.3 MCHC-32.1 RDW-15.0 Plt Ct-66*
___ 09:40PM BLOOD Glucose-399* UreaN-152* Creat-3.9*
Na-131* K-5.0 Cl-93* HCO3-22 AnGap-21*
___ 03:15PM BLOOD Glucose-234* UreaN-154* Creat-3.6*
Na-131* K-4.9 Cl-93* HCO3-24 AnGap-19
___ 04:30AM BLOOD Glucose-122* UreaN-122* Creat-2.9*
Na-130* K-3.8 Cl-95* HCO3-25 AnGap-14
___ 05:20AM BLOOD Glucose-73 UreaN-59* Creat-2.4* Na-134
K-3.7 Cl-94* HCO3-29 AnGap-15
___ 05:30AM BLOOD ALT-62* AST-62* LD(___)-407* AlkPhos-132*
TotBili-0.5
___ 04:30AM BLOOD ALT-54* AST-68* LD(LDH)-432* AlkPhos-126
TotBili-0.4
___ 05:20AM BLOOD ALT-51* AST-71* AlkPhos-135* TotBili-0.5
___ 06:05AM BLOOD Albumin-3.0* Calcium-7.6* Phos-7.0*
Mg-2.1
___ 04:50AM BLOOD Albumin-2.4* Calcium-7.0* Phos-5.9*
Mg-2.1
___ 08:45PM BLOOD Cryoglb-POSITIVE
___ 04:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 06:00AM BLOOD RheuFac-211*
___ 06:17AM BLOOD RheuFac-166*
___ 08:45PM BLOOD C3-55* C4-LESS THAN
DISCHARGE LABS
================================
___ 04:55AM BLOOD WBC-1.5* RBC-2.52* Hgb-7.3* Hct-23.5*
MCV-93 MCH-28.9 MCHC-30.9* RDW-14.6 Plt ___
___ 04:55AM BLOOD Glucose-118* UreaN-45* Creat-2.7* Na-131*
K-3.8 Cl-94* HCO3-29 AnGap-12
___ 04:55AM BLOOD ALT-56* AST-71* CK(CPK)-114 AlkPhos-123
TotBili-0.6
___ 04:55AM BLOOD Calcium-7.0* Phos-3.8 Mg-1.9
MICRO
================================
URINE CULTURE (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
IMAGING
================================
___ Imaging CHEST (PA & LAT)
IMPRESSION: Mild pulmonary edema.
___ Imaging RENAL U.S.
IMPRESSION:
1. No evidence of hydronephrosis. Normal renal ultrasound.
2. Small amount of ascites.
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION: No acute intracranial process.
___ Imaging US ABD LIMIT, SINGLE OR
IMPRESSION:
1. Normal liver ultrasound. Patent hepatic vasculature.
2. Cholelithiasis without gallbladder wall thickening.
3. Splenomegaly.
4. Small ascites.
ECHO ___
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size and global systolic function
(LVEF>55%). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. 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 (?#) appear structurally normal with good
leaflet excursion. There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved global biventricular
systolic function.
XRAY RIGHT ELBOW ___
FINDINGS
There are soft tissue changes and presumed edema along the
medial aspect of the elbow. No fracture, bone destruction, or
other osseous abnormality. I doubt the presence of an effusion.
Normal mineralization.
IMPRESSION: Normal osseous structures.
XRAY RIGHT WRIST ___
FINDINGS:
No fracture or bone destruction. Minimal degenerative changes
first see IMC joint with no joint space narrowing here or
elsewhere. Soft tissue changes probably reflect a bandage over
the distal forearm and wrist. Equivocal incidental slight
positive ulnar variance. Vascular calcifications are
noteworthy in this age group. Normal mineralization.
IMPRESSION:
No fracture. Vasculopathy
RUE U/S ___
IMPRESSION: No evidence of deep vein thrombosis in the right
upper extremity. There is a small thrombosed superficial vein
noted in the right forearm. Superficial edema is also noted in
the right forearm.
___ MRI: Findings suggesting myonecrosis involving the
volar compartment musculature of the forearm with areas of
hemorrhage and diffuse subcutaneous soft tissue edema. Infection
is not excluded, however is considered less likely.
___ RUE US: Complex heterogeneous collection in the volar
aspect of the right forearm corresponds to the area of
myonecrosis with areas of hemorrhage and overlying subcutaneous
edema as seen on the prior MR examination performed 1 day prior.
Not amenable to percutaneous drainage.
___ CT RUE: IMPRESSION (prelim): Skin thickening and
superficial soft tissue fat stranding of mainly the ventral soft
tissues of the right upper extremity starting from the level of
the mid humerus to the wrist suggestive of cellulitis. No fluid
collection, subcutaneous gas or bony erosions.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with HCV s/p inteferon
treatment with relapse, c/b cryoglobulinemia, leukocytoclastic
vasculitis with MPGN, pulmonary hemorrhage treated with
plasmapharesis (___), chronic anasarca, dCHF (EF 55%), IDDM,
morbid obesity, COPD, CAD who presents with volume overload,
hyperkalemia, and worsening creatinine.
ACTIVE ISSUES:
# ___: Unclear etiology. Possibly related to pre-exisiting
cryoglobulinemia or vasculitis however urine protein
inconsistent with MPGN. Patient responded to lasix and given
hyponatremia, may be prerenal picture. Although patient's MELD
24, driven by creatinine (falsely elevated). Synthetic function
good making HRS less likely etiology. Patient continued on lasix
120 mg BID with goal of ___ L/day out. Renal ultrasound showed
no evidence of hydronephrosis and a small amount of ascites.
Ultimately patient's diuresis to Lasix and Metolazone was
minimal. A tunneled HD line was placed and patient began HD
(with the goal of 2L fluid removal daily). He tolerated this
well. An ECHO showed over all preserved biventricular function
so heart failure was not thought to be a contributing factor.
The patient was on a long Prednisone taper for his
cryoglobulinemia and on 40mg was not showing improving renal
function and was having uncontrollable hyperglycemia. He was
tapered down to Prednisone 20mg daily which he tolerated well.
Renal team recommended re-initiation of diuretics while patient
was on HD as he was still having urine output so started
Torsemide 80mg daily. He will continue on a ___ HD schedule
as an outpatient.
# Right forearm pain: Patient initially mentioned some right
forearm pain in setting of pulling himself up in the bed,
attributing it to muscle strain. His exam was overall benign
when the pain was first noticed. He had a CK that was normal.
Patient continued to complain of severe pain, out of proportion
to exam which was minimally controlled with Oxycodone and
Tylenol. He had plain films that showed no fracture and no
osteoporosis. He underwent an U/S to rule out DVT. By U/S a
small thrombosed superficial vein was noted but no DVT. His
exam progressed to have soft tissue swelling around the elbow
and forearm as well as warmth. There was some mild erythema
noted but given his baseline skin breakdown and ecchymoses, it
was difficult to differentiate. He had MRI which showed
findings concerning for myonecrosis and deep tissue infection.
Orthopedic surgery was consulted as was Rheumatology and
Infectious disease. Considered the possibility that patient had
cryoglobulins contributing to the myonecrosis but Rheumatology
thought very unlikely. They also considered diabetic myonectoris
unlikely as well. Orthopedic surgery did not see any indication
for intervention at time of consult. Patient was started on
broad spectrum antibiotics (Vanc, Zosyn and Clindamyin) and
blood cultures were drawn. Given rapid progression of his
symptoms further imaging was performed. MRI revealed evidence of
myonecrosis. CT scan was negative for gas formation or abscess.
His exam was monitored closely and improved with antibiotics.
Despite counseling regarding the need to monitor his symptoms
and exam on PO antibiotics prior to discharge home, he did not
want to stay in-house beyond ___. He received 2 days of IV
antibiotics and is discharged on Bactrim and Keflex. He will
take Keflex to complete a ___nd will continue to
take Bactrim for PCP prophylaxis as below.
#AMS: Patient had poor concentration on presentation. Head CT
was negative. Hepatic encephalopathy unlikely given that
patient's synthetic function was okay. Patient was continued on
lactulose and rifaximin for possible hepatic encephalopathy.
Mental status for duration of hospitalization was largely at
baseline though patient experienced significant fatigue with
initiation of HD and pain medications for above issue.
# Cirrhosis: Child ___ class B, due to hepatitis C (gen. 1b)
s/p failed treatment with IFN. Given multiple complications
related to cryoglobulinemia attempted to initiate sofosbuvir and
simeprivir however denied by insurance on multiple attempts.
Decompensated with hepatic encephalopathy and ascites, no report
of bleeding varices or SBP in the past. MELD currently 21 but
falsely elevated due to creatine. Patient should get EGD as
outpatient. Patient's U/S on admission showed normal liver and
patent hepatic vasculature, splenomegaly, and Small ascites.
# Cryoglobulinemia: Complications include leukocytoclastic
vasculitis, CKD as above, and pulmonary hemorrhage (___)
treated with high dose steroids and plasmapharesis in the past
though had seizure on plasmaphereisis. He was continued on a
prednisone taper and at discharge was on 20mg daily to continue
long taper per his outpatient nephrologist. He is discharged on
Bactrim for PCP prophylaxis and ___ continue taking this until
he completes the prednisone taper per his outpatient
nephrologist.
# Diabetes: During this admission he had uncontrolled
hyperglycemia with blood sugars to >500 and a widening anion
gap. He briefly required an insulin gtt for glycemic control and
___ was consulted. Given his worsening renal function, his
cryoglobulinemia was not thought to be very responsive to
steroid treatment and in the setting of hyperglycemia, his
Prednisone dose was reduced. His insulin regimen was adjusted
and NPH was added to assist with coverage. He prefers to follow
up with his outpatient endocrinologist for further management
rather than at ___ as he has been with him for several years.
# Hyponatremia: Most likely hypervolemic hyponatremia. Improved
with diuresis/HD. Patient was put on fluid restriction of 1500mL
daily.
CHRONIC ISSUES:
#Anemia: H/H on admission ___.7/___.1. Patient also had bruising
on exam (platelets 122) most likely due to poor platelet
function in setting of elevated BUN. Overall this remained
stable and worsening renal failure is likely a contributing
factor. No evidence of bleeding this admission.
# Seizure disorder: New onset last hospitalization in setting of
plasmapharesis, MRI with right frontal lobe lesion and chronic
small vessel disease ?___ cryoglobulinemic vasculitis. He was
continued on keppra and should follow with neuro as an
outpatient.
# Chronic pain: given MS changes with MS contin this was
recently changed to oxycodone which was continued this
admission. He additionally required small prn doses of Dilaudid
in setting of acute arm pain as above.
# HTN: Held vasodilators until HRS ruled out
# CAD: Unrevascularized as per prior records. He continued
Aspirin 81mg daily and Atorvastatin 80mg daily.
# BPH: Patient's Tamsulosin was held in setting of initiation of
HD and worsening renal function.
TRANSITIONAL ISSUES:
- He will have outpatient HD on ___ schedule
- He is discharged on Bactrim/Keflex for cellulitis to complete
a 10 day course of Keflex THROUGH ___
- He should continue on Bactrim for PCP prophylaxis while he is
on prednisone
- He will follow up with his nephrologist for prednisone taper
- He is discharged on Torsemide per renal recs
- He will follow up with Dr. ___ primary endocrinologist,
for further management of his diabetes
- He will be scheduled for follow up with Dr. ___ in the GI
clinic
- ___ as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Ferrous Sulfate 325 mg PO BID
4. Fluoxetine 20 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Lactulose 20 mL PO BID
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY
10. PredniSONE 40 mg PO DAILY
Tapered dose - DOWN
11. Rifaximin 550 mg PO BID
12. Tamsulosin 0.4 mg PO HS
13. Terazosin 5 mg PO HS
14. Amlodipine 10 mg PO DAILY
15. Metoprolol Succinate XL 200 mg PO DAILY
16. LeVETiracetam 500 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Ferrous Sulfate 325 mg PO BID
5. Fluoxetine 20 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Lactulose 20 mL PO BID
8. LeVETiracetam 500 mg PO BID
9. Omeprazole 20 mg PO DAILY
10. Rifaximin 550 mg PO BID
11. Terazosin 5 mg PO HS
12. Metoprolol Succinate XL 200 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. Tamsulosin 0.4 mg PO HS
15. PredniSONE 20 mg PO DAILY
RX *prednisone 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
16. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth daily Disp #*120 Tablet
Refills:*0
17. Nephrocaps 1 CAP PO DAILY
RX *B complex & C ___ acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
18. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 capsule(s) by mouth every 8 hours Disp
#*22 Capsule Refills:*0
19. Sulfameth/Trimethoprim DS 2 TAB PO Q8H
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth every 8 hours Disp #*180 Tablet Refills:*0
20. Glargine 35 Units Bedtime
NPH 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *NPH insulin human recomb [Humulin N KwikPen] 100 unit/mL (3
mL) 0.___ Units before BKFT; Disp #*1 Syringe Refills:*0
21. OxycoDONE (Immediate Release) 10 mg PO Q3H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every ___ hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Myonecrosis of right forearm
Cryoglobulinemia
Acute on Chronic Kidney Disease
HCV Cirrhosis
Diabetes Type II, Insulin Dependent
Secondary: Seizure Disorder
Chronic Pain
Hypertension
CAD
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 participating in your care at ___
___. You were admitted because of
worsening kidney failure and swelling of your body. Initially,
we tried to remove fluid from your body using diuretics but this
did not work very well. You ultimately had a catheter placed
and started on hemodialysis where they removed liters of the
extra fluid in your body. You are scheduled for outpatient
hemodialysis for a ___ schedule. You are
also discharged on a new medication, Torsemide, which will help
with the fluid removal.
You had right forearm pain during this admission. Imaging
studies showed that you had "myonecrosis" of the right forearm,
essentially destruction of the muscle there. We think that this
has been caused by an infection in the soft tissue and you were
started on broad spectrum antibiotics. Your symptoms improved
with IV antibiotics and we will send you home with oral
antibiotics to take THROUGH ___. You will take the
Keflex through ___ and will take the Bactrim until your
kidney doctors ___ to stop.
You were seen by the rheumatology team for your
cryoglobulinemia. You will be discharged on prednisone ___s an antibiotic (Bactrim) to prevent a lung infection,
which patients on prednisone are susceptible to. You will follow
up with the kidney specialists and they will tell you when you
can stop the antibiotic.
Please also follow up with the ___ team as scheduled below
for further management of your diabetes.
Followup Instructions:
___
|
19908221-DS-25 | 19,908,221 | 27,717,842 | DS | 25 | 2141-09-29 00:00:00 | 2141-10-01 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zestril / lisinopril / metolazone / ezetimibe
Attending: ___
Chief Complaint:
confusion/hero
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with HCV cirrhosis, diastolic CHF, diabetic neuropathy and
ESRD from MPGN and cryoglobulinemic vasculitis presents with
fever and confusion. Per wife's report, the patient has had
confusion on and off for the past few days. He was recently
admitted here in ___ for groin cellulitis and ulcerations and
discharged on antibiotic course to complete through HD. He has
been having neck pain but that is chronic for the patient. Due
to concerns, he presented to ___. There was concern for
pneumonia and he received vancomycin, gentamicin, ceftriaxone
prior to transfer to ___. Labs at ___: ___ 7.9, Hb 10.4,
Hct 33.3, Plt 191, Na 128, K 4.9, Cl 87, CO3 27, BUN 67, Cr 4.0,
AG 14, lactate 1.1, transaminases WNL, AP 142.
In the ___ initial vitals were T99.5 (Tm 103 in ___ 88 115/62 18
95% RA. No UA as patient is anuric. LP was attempted but
unsuccessful. CT abd pelvis was negative. CT head with no acute
findings. He received acetaminophen 1000mg PO x1. He then
desatted to 85% room air. Respiratory Therapy was called. He has
no known history of CPAP use or OSA diagnosis. He was placed on
Autoset CPAP with sats now ___. He had a Foley placed although
he is anuric.
On the floor, patient remains confused and is unable to
consistently answer questions. He admits to lactulose
noncompliance because he ran out.
ROS: +Fever and confusion. Denies pain. Otherwise cannot answer
ROS questions due to altered mental status.
Past Medical History:
- Cirrhosis due to hepatitis C (gen. 1b), diagnosed ___,
treated with interferon/ribavirin but relapsed after initial
clearance, not candidate for new therapies based on ESRD
- End stage renal disease on hemodialysis, ?MPGN in the setting
of hepC and cryoglobulins.
- pulmonary hemorrhage treated with plasmapheresis and steroids
at ___, ___
- chronic anasarca
- cryoglobulinemic vasculitis diagnosed on skin biopsy
- diabetes mellitus type II on insulin
- diastolic congestive heart failure EF 55% in ___
- morbid obesity
- COPD
- hypertension
- left total knee replacement ___
- chronic hyponatremia
- pancytopenia
- anemia
- cholelithiasis
- peripheral neuropathy
- coronary artery disease, h/o NSTEMI treated medically, per
___ records, due to poor revascularization candidacy
- BPH
- C2 fracture following MVA ___ requiring trach/PEG
Social History:
___
Family History:
No family history of chronic liver disease or liver-related
problems. No family history of colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T100.6 112/56 77 16 100 4L NC
GENERAL: Chronically ill appearing, obese, in no acute distress
NECK: Soft brace on neck, 1 cm superficial abrasion R cervical
area
HEENT: pinpoint pupils reactive to light
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear anterolaterally
ABD: Soft, BS+, nontender, nondistended
GU: groin area superior to penis with scarred areas,
significantly improved from prior admission 2 months ago when I
saw him with groin cellulitis
EXT: 2+ pitting edema in calves at baseline, 1+ DP and ___ pulses
NEURO: +asterixis, somnolent, but arousable, oriented to name,
hospital, ___, unable to answer other questions
DISCHARGE PHYSICAL EXAM:
VS: 99.1 130/59 76 20 94% on RA
GENERAL: NAD, neck collar
NECK: Soft brace on neck
HEENT: PERRL
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Crackles at bases bilaterally
ABD: Soft, BS+, nontender, nondistended
EXT: 2+ pitting edema in calves at baseline, 1+ DP and ___
pulses; lower extremities have purpuric legions bilaterally
NEURO: No asterixis, interactive, alert and oriented
Pertinent Results:
ADMISSION LABS
___ 09:25AM VANCO-<1.7*
___ 09:20AM GLUCOSE-165* UREA N-80* CREAT-4.7*
SODIUM-132* POTASSIUM-5.2* CHLORIDE-90* TOTAL CO2-27 ANION
GAP-20
___ 09:20AM ALT(SGPT)-46* AST(SGOT)-81* ALK PHOS-124 TOT
BILI-0.4
___ 09:20AM ALBUMIN-3.2* CALCIUM-8.6 PHOSPHATE-7.3*#
MAGNESIUM-2.2
___ 09:20AM WBC-7.7 RBC-4.00* HGB-10.7* HCT-33.8* MCV-85
MCH-26.7* MCHC-31.6 RDW-16.5*
___ 09:20AM PLT COUNT-186
___ 02:51AM ___ PTT-20.4* ___
___ 09:20AM ___ PTT-25.7 ___
___ 01:07AM LACTATE-1.2
___ 01:00AM GLUCOSE-200* UREA N-72* CREAT-4.2*
SODIUM-130* POTASSIUM-5.3* CHLORIDE-91* TOTAL CO2-25 ANION
GAP-19
___ 01:00AM estGFR-Using this
___ 01:00AM ALT(SGPT)-44* AST(SGOT)-83* ALK PHOS-127 TOT
BILI-0.3
___ 01:00AM LIPASE-22
___ 01:00AM ALBUMIN-3.1*
___ 01:00AM TSH-0.53
___ 01:00AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:00AM WBC-9.4# RBC-3.81* HGB-10.2* HCT-32.1* MCV-84
MCH-26.8* MCHC-31.8 RDW-16.5*
___ 01:00AM NEUTS-71.3* ___ MONOS-5.7 EOS-0.2
BASOS-0.6
___ 01:00AM PLT COUNT-191
DISCHARGE LABS
___ 07:30AM BLOOD WBC-3.1* RBC-3.52* Hgb-9.5* Hct-29.5*
MCV-84 MCH-26.9* MCHC-32.1 RDW-16.1* Plt ___
___ 07:30AM BLOOD Plt ___
___ 05:58AM BLOOD Plt ___
___ 05:58AM BLOOD ___ PTT-24.3* ___
___ 07:30AM BLOOD Glucose-371* UreaN-46* Creat-3.8* Na-130*
K-4.4 Cl-92* HCO3-27 AnGap-15
___ 05:58AM BLOOD ALT-38 AST-53* AlkPhos-93 TotBili-0.3
___ 08:37AM BLOOD Vanco-9.9*
STUDIES
Cardiovascular ReportECGStudy Date of ___ 1:29:50 AM
Sinus rhythm. Within normal limits. No change compared to the
previous
tracing of ___.
Read ___.
IntervalsAxes
___
___ HEAD W/O CONTRAST
IMPRESSION:
1. No evidence of acute intracranial hemorrhage or large
vascular territory
infarction.
2. Moderate cerebral atrophy and sequelae of chronic small
vessel ischemic
disease.
Correlate clinically to decide on the need for further workup or
followup.
3. Multifocal paranasal sinus disease, as above.
___ ABD & PELVIS W/O CON
IMPRESSION:
1. No acute intra-abdominal process. Normal appendix.
2. Splenomegaly, similar to prior examinations.
3. Recent appearing left seventh rib fracture.
___ CT CHEST W/CONTRAST
IMPRESSION:
Lower lobe predominant bronchial wall thickening with
peribronchial
ground-glass opacities and consolidations are likely due to
chronic
aspiration. Stable infectious or inflammatory small airways
disease in the
right upper and both lower lobes.
Resolved small bilateral pleural effusions.
Splenomegaly with associated splenorenal shunt is in keeping
with the provided
history of cirrhosis.
Moderately distended partially imaged gallbladder.
Stable mediastinal lymphadenopathy, which is likely reactive in
nature.
Brief Hospital Course:
___ with HCV cirrhosis, diastolic CHF, diabetic neuropathy and
ESRD from MPGN and cryoglobulinemic vasculitis presents with
fever and confusion. Per wife's report, the patient has had
confusion on and off for the past few days in the setting of
refusing to take his lactulose. The patient also presented with
a fever. CXR at OSH read as pneumonia. Patient started treatment
for HCAP on presentation with vanc/cefepime. Pt fever curve
trended down and CXR did not show large consolidation, CT showed
evidence of chronic aspiration but no evidence of active
infection. Patient transitioned to Levaquin on ___ and
received his last dose of antibiotics on ___. Patient was
counseled on making sure to take his Lactulose daily and
titrating BMs in order to avoid worsening encephalopathy.
Patient will follow up with his Liver team and with his Primary
___ Physician.
ACUTE ISSUES
# ACUTE HEPATIC ENCEPHALOPATHY. Pt presented with confusion,
which has improved with lactulose suggesting HE as etiology.
Pt's fever overnight suggests infection as contributing
component as well. Mental status improved since fevers broke.
We titrated lactulose to ___ per day; Dr. ___
conversation with patient and he agreed to take his lactulose at
home after explanation of why it prevents confusion. At time of
discharge patient was A+Ox3 and mentating well.
# FEVERS. Fever to 102 on evening prior to presentation. No
clear source of infection. CXR without new consolidation to
suggest interval development of infectious process. No UA given
anuria. LP unsuccessful. History of cellulitis, but no sources
on exam. CBC without leukocytosis. No ascites on CT seen to
evaluate for SBP. Patient started on Vanc/cefepime/flagyl on
admission for broad coverage. Was transitioned to levofloxacin
for treatment of community aquired pneumonia. CT did not show
focal consolidation prior to discharge, but did show evidence of
chronic aspiration.
# HYPOXIA. Requiring CPAP in ___, and weaned down to room air
with clearance of his delirium. Was likely due to acute
confusion vs OSA vs opiate use. Patient will need outpatient
follow up for possible CPAP with sleep study.
CHRONIC ISSUES
# HEP C CIRRHOSIS: MELD score of 22 on admission. Child's ___
B, due to Hepatitis C s/p failed treatment with IFN. Not
eligible for new treatments due to ESRD per hepatology. No
history of esophageal varices or SBP, however he has had hepatic
encephalopathy in the past and is on daily lactulose, but did
not take it at home. Restarted lactulose, rifaximin.
# TYPE 2 DIABETES. HbA1c 6.1% in ___. Cont home NPH,
glargine, HISS
# CRYOGLOBULINEMIA: Previous labs in support of cryoglobulinemia
with RF 325, C4 levels <2. Most likely due to Hepatitis C, and
would benefit from treatment if he were eligible. He had no
other evidence of other organ involvement related to
cryoglobulinemia.
# CHF, DIASTOLIC, CHRONIC. Euvolemic on exam. Cont torsemide,
metoprolol and HD as scheduled.
#ESRD: Cont HD while in patient.
# CAD. Continue aspirin and atorvastatin.
# ASTHMA. Continue Advair.
# SEIZURE DISORDER. Continue Keppra.
# CHRONIC PAIN. Held opiates for now given acute confusion on
admission. Restarted after patient's mental status cleared.
TRANSITIONAL ISSUES
-Pt will be discharged on Lactulose 30ml PO TID (titrate to ___
BMs per day)
-pt will be discharge on Rifaximin 550mg PO BID
-pt will take last dose of levofloxacin 500mg PO x1 after his
next hemodialysis apt (after leaving the hospital)
-pt will need to go to his regularly scheduled dialysis apts
after leaving the hospital
-pt will f/u with the ___ after discharge
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO BID
4. Fluoxetine 20 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Lactulose 20 mL PO DAILY
7. LeVETiracetam 500 mg PO BID
8. LeVETiracetam 250 mg PO 3X/WEEK ___, TH, SAT
9. Metoprolol Succinate XL 200 mg PO DAILY
10. Nephrocaps 1 CAP PO DAILY
11. Omeprazole 20 mg PO DAILY
12. OxyCODONE SR (OxyconTIN) 20 mg PO TID
13. Rifaximin 550 mg PO BID
14. Tamsulosin 0.4 mg PO HS
15. Terazosin 5 mg PO HS
16. Torsemide 80 mg PO DAILY
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
19. Glargine 20 Units Bedtime
NPH 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
20. Albuterol 0.083% Neb Soln 1 NEB IH BID:PRN Wheezing
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO BID
4. Fluoxetine 20 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Glargine 20 Units Bedtime
NPH 6 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. Lactulose 30 mL PO QID
RX *lactulose 20 gram/30 mL 30 ml by mouth three times a day
Disp ___ Milliliter Refills:*0
8. LeVETiracetam 500 mg PO BID
9. LeVETiracetam 250 mg PO 3X/WEEK ___, TH, SAT
please take this dose after your dialysis sessions
10. Metoprolol Succinate XL 200 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Omeprazole 20 mg PO DAILY
13. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
14. OxyCODONE SR (OxyconTIN) 20 mg PO TID
15. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*56 Tablet Refills:*0
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. Tamsulosin 0.4 mg PO HS
18. Terazosin 5 mg PO HS
19. Torsemide 80 mg PO DAILY
20. Levofloxacin 500 mg PO Q48H Duration: 1 Dose
please take dose after your next dialysis session
RX *levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth once
Disp #*1 Tablet Refills:*0
21. Albuterol 0.083% Neb Soln 1 NEB IH BID:PRN Wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY: Hepatic Encephalopathy; Pneumonia
SECONDARY: HCV cirrhosis; ESRD on dialysis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was pleasure to take part in your ___ during your stay here
at ___. You came to the hospital after your family was
concerned about you being confused and having a fever. You were
treated upon your arrival with antibiotics for an infection in
your lungs and for your confusion using a medication called
lactulose. You were started on IV antibiotics and then
transitioned to oral antibiotics prior to discharge. You will be
given one dose of antibiotic (levofloxacin). You will take this
last pill after your next outpatient hemodialysis apt.
Your lactulose regimen was increased during you hospital stay.
It is vital that your take your lactulose at home every day. You
should titrate the amount you take in order to have at least 2
BMs per day. If you start to feel confused or begin to have
recurrent fevers you should call your Liver Doctor immediately.
You will follow up with your Liver Doctor and your Primary ___
Physician.
Thank you for allowing us to participate in your ___ during
your stay in the hospital.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19908221-DS-28 | 19,908,221 | 29,801,241 | DS | 28 | 2142-12-10 00:00:00 | 2142-12-15 19:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Zestril / lisinopril / metolazone / ezetimibe / Zosyn
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
This patient is a ___ year old male who complains of Abd pain.
Patient presents with right upper quadrant abdominal pain for
one day. Patient lives in a rehabilitation when he had onset of
abdominal pain nausea vomiting. No fevers or
chills. Patient went to outside hospital was found to have a
distended gallbladder with stone in the neck on CT. Patient was
given broad-spectrum antibiotics and transferred
Timing: Constant
Quality: Crampy
Severity: Moderate
Past Medical History:
# HCV Cirrhosis (genotype 1b):
- HCV diagnosed ___, failed ___, now on Harvoni for
planned 24wk treatment (last VL UD ___.
- complicated by encephalopathy and Grade 1 nonbleeding varices
(EGD ___
# ESRD thought ___ MPGN and cryoglobulinemic vasculitis.
Previously on HD, now off since HCV treatment. Fistula
previously did not function, HD catheter recently removed.
# pulmonary hemorrhage treated with plasmapheresis and steroids
at ___, ___
# cryoglobulinemic vasculitis diagnosed on skin biopsy
# diabetes mellitus type II on insulin
# diastolic congestive heart failure EF 55% in ___
# morbid obesity
# COPD
# hypertension
# left total knee replacement ___
# pancytopenia
# cholelithiasis
# peripheral neuropathy
# coronary artery disease, h/o NSTEMI treated medically, per
___ records, due to poor revascularization candidacy
# BPH
# C2 fracture following MVA ___ requiring trach/PEG
Social History:
___
Family History:
No family history of chronic liver disease or liver-related
problems. No family history of colon cancer.
Physical Exam:
Admission Physical Exam:
Temp: 98.2 HR: 86 BP: 146/82 Resp: 16 O(2)Sat: 100
Constitutional: Comfortable
HEENT: Icteric sclera
Oropharynx within normal limits
Chest: Clear to auscultation
Cardiovascular: Normal first and second heart sounds,
Regular Rate and Rhythm
Abdominal: Right upper quadrant tenderness, no rebound, no
guarding
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Discharge Physical Exam:
VS: 98.3, 77, 133/71, 20, 100%ra
Pertinent Results:
___ 08:52AM LACTATE-1.9
___ 08:25AM GLUCOSE-279* UREA N-28* CREAT-2.5*
SODIUM-132* POTASSIUM-3.7 CHLORIDE-91* TOTAL CO2-26 ANION GAP-19
___ 08:25AM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-140* TOT
BILI-0.5 DIR BILI-0.3 INDIR BIL-0.2
___ 08:25AM LIPASE-19
___ 08:25AM ALBUMIN-3.3* CALCIUM-8.6 PHOSPHATE-2.1*
MAGNESIUM-1.7
___ 08:25AM WBC-10.6* RBC-3.78* HGB-10.8* HCT-33.6*
MCV-89# MCH-28.6 MCHC-32.1 RDW-15.0 RDWSD-48.2*
___ 08:25AM NEUTS-84.1* LYMPHS-7.2* MONOS-7.7 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-8.89*# AbsLymp-0.76* AbsMono-0.81*
AbsEos-0.02* AbsBaso-0.02
___ 08:25AM PLT COUNT-138*
___:25AM ___ PTT-29.4 ___
___ 07:28AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:28AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-300
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-SM
___ 07:28AM URINE RBC-4* WBC-28* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:28AM URINE MUCOUS-RARE
Imaging:
___: Gallbladder US:
Moderately distended gallbladder containing intraluminal air
status post ERCP, better visualized on the patient's reference
CT torso performed on the same day. There is no evidence of
focal gallbladder wall thickening, gallstones, or
pericholecystic fluid.
___: CXR:
Small right pleural effusion and mild right basilar atelectasis.
Brief Hospital Course:
Mr. ___ is a ___ year-old male with a history of cirrhosis,
ESRD, HCV who was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission gallbladder US in correlation with his clinical exam
were concerning for acute cholecystitis. On HD1, the patient
underwent laparoscopic cholecystectomy, which went well without
complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating on IV fluids, and po
pain medicine for pain control. The patient was hemodynamically
stable.
On POD1, the patient received dialysis in accordance with his
___ dialysis schedule.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. A follow-up appointment was made with the
Acute Care Surgery team.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 10 mg PO QPM
2. Ferrous Sulfate 325 mg PO DAILY
3. Fluoxetine 20 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. HydrALAzine 25 mg PO BID
6. Lactulose 20 mL PO BID
7. LeVETiracetam 500 mg PO DAILY
8. Metoprolol Succinate XL 200 mg PO DAILY
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
10. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
11. PredniSONE 20 mg PO DAILY
12. Rifaximin 550 mg PO BID
13. sevelamer CARBONATE 1600 mg PO TID W/MEALS
14. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
15. Tamsulosin 0.4 mg PO QHS
16. Torsemide 60 mg PO BID
17. Ciprofloxacin HCl 500 mg PO Q24H
18. Omeprazole 20 mg PO BID
19. Aspirin 81 mg PO DAILY
20. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheeze
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluoxetine 20 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. HydrALAzine 25 mg PO BID
8. Lactulose 20 mL PO BID
9. LeVETiracetam 500 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
12. PredniSONE 10 mg PO EVERY OTHER DAY
13. Rifaximin 550 mg PO BID
14. sevelamer CARBONATE 1600 mg PO TID W/MEALS
15. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
16. Tamsulosin 0.4 mg PO QHS
17. Cephalexin 500 mg PO Q12H
18. Glucose Gel 15 g PO PRN hypoglycemia protocol
19. Glargine 8 Units Bedtime
Humalog 3 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
20. Metoprolol Succinate XL 200 mg PO DAILY
21. Torsemide 60 mg PO BID
22. Temazepam 30 mg PO QHS:PRN insomnia
23. Nephrocaps 1 CAP PO DAILY
24. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth Q3H Disp #*90 Tablet
Refills:*0
25. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You presented to the ___ and
were found to have acute cholecystitis, an inflammation of your
gallbladder. You were admitted to the Acute Care Surgery
service for further medical care. You were taken to the
Operating Room and underwent a laparoscopic cholecystectomy and
had your gallbladder removed. You tolerated this procedure
well.
You are now tolerating a regular diet and your pain is better
improved. You are now medically cleared to be discharged home
to continue your recovery. Please note the following discharge
instructions:
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19908277-DS-22 | 19,908,277 | 29,906,543 | DS | 22 | 2175-08-01 00:00:00 | 2175-08-01 13:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Heparin Agents / watermelon
Attending: ___.
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with a PMH notable for
recurrent DVT/PE on lifelong warfarin, remote history of HITT,
diabetes complicated by neuropathy, and chronic venous stasis
ulcers who presents from rehab with ___ and worsening
thrombocytopenia.
The patient was recently discharged to rehab on ___ after
being admitted on ___ to ___ for an elective left ___ toe
amputation with an anticoagulation bridge. The patient was found
to have osteomyelitis during that admission and was started on
vancomycin 1000 mg IV Q 12H, ciprofloxacin 500 mg PO Q12H, and
metronidazole 500 mg PO TID per ID recommendations.
While the at rehab, around ___, he started developing a bright
red rash over his chest then his arms and abdomen. As a result,
the rehab switched his antibiotics to Zosyn and linezolid on
___. Labs drawn on ___ showed a slightly lower PLT count but a
new ___ up to Cr 2.22 from 0.79 (per ED documentation, no lab
results with patient's chart from the ED). Given these findings,
the patient was ultimately sent to the ED for further
evaluation.
Hematology was consulted in the ED for new PLT of 16. After
evaluating his blood smear, the consult team felt that the
etiology was unlikely to be TTP given no evidence of hemolysis.
Most likely diagnosis is flare of ITP vs. drug induced
thrombocytopenia.
On the floor, the patient reports that his rash has already
gotten better. The rash on his chest has disappeared and that
one
his abdomen is much improved. He has a new, nonblanching rash
that is different from the presenting rash. Otherwise, he feels
well without any headache, dizziness, lightheadedness, chest
pain, dyspnea, or abdominal pain. He has been having loose
stools
while at rehab, going up to ___ times per day.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
DVT/PEs (life long Coumadin)
Post phlebitis syndrome
Venous insufficiency
HTN
BCC
Obesity
DMII neuropathy
venous stasis ulcers
Social History:
___
Family History:
Marital Status - Married, Occupation - ___, Children - Two
Physical Exam:
Admission exam
VITALS: T 97.9 BP 155/81 HR 100 RR 18 SAT 96 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, bleeding, mucosal petechiae,
erythema, or exudate.
CV: Heart regular, ___ systolic ejection murmur loudest at the
base, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, protuberant habitus, non-tender to palpation.
Bowel sounds present. No HSM.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. Left ___ toe is s/p
amputation, currently wrapped in dressing.
SKIN: Diffuse petechial, nonblanching rash throughout the
bilateral forearms and abdomen and bilateral upper thigh on a
background of blanching erythematous rash, most prominent in the
upper thighs near the groins. Extensive venous stasis changes
in
the lower extremities.
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
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: regular rhythm, III/VI systolic murmur at RUSB, non-pitting
___ edema
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, s/p L ___ toe amputation
SKIN: ecchymoses resolved over abdomen and upper thighs, minimal
erythema over forearms with several scattered petecchaie, much
improved from initial exam
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 07:55PM BLOOD WBC-6.2 RBC-2.83* Hgb-9.5* Hct-28.0*
MCV-99* MCH-33.6* MCHC-33.9 RDW-13.2 RDWSD-47.7* Plt Ct-16*#
___ 05:26AM BLOOD WBC-3.7* RBC-2.20* Hgb-7.5* Hct-22.2*
MCV-101* MCH-34.1* MCHC-33.8 RDW-13.0 RDWSD-48.1* Plt Ct-50*
___ 07:55PM BLOOD Glucose-126* UreaN-20 Creat-1.6* Na-140
K-3.8 Cl-102 HCO3-23 AnGap-15
___ 05:26AM BLOOD Glucose-123* UreaN-16 Creat-1.2 Na-139
K-4.7 Cl-103 HCO3-24 AnGap-12
Renal US ___
FINDINGS:
The right kidney measures 12.1 cm. The left kidney measures 13.9
cm. There is
no hydronephrosis, stones, or masses bilaterally. Normal
cortical
echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is moderately well distended and normal in
appearance.
___ 01:35PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:35PM URINE RBC-2 WBC-6* Bacteri-NONE Yeast-NONE
Epi-2 TransE-<1
___ 01:35PM URINE Hours-RANDOM UreaN-685 Creat-149 Na-33
___ 01:12PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:12PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 01:12PM URINE Hours-RANDOM UreaN-810 Creat-164 Na-24
Brief Hospital Course:
# Rash
# Thrombocytopenia - Admitted with plts of 16. Hematology was
consulted and reviewed smear due to concern for TTP (given renal
failure). No schistocytes visualized therefore not c/w TTP. They
did not recommend steroids as patient without s/s of bleeding.
Rash and thrombocytopenia thought to be due to antibiotics.
Antibiotics were held and rash and platelets both improved.
#Acute renal failure - previous baseline 0.8-0.9, admitted with
Cr 1.6. UA and renal US unremarkable, UNa low c/w pre-renal. ___
have been due to diuretic use and concurrent diarrhea. His ACEI
and Lasix were held. He was given fluids and Cr improved to 1.2
on day of discharge. He was encouraged to push PO fluids.
Lisinopril restarted at half prior dose on day of discharge.
Lasix will also need to be restarted once renal function has
recovered further.
#Diarrhea - C. diff negative, improved with cessation of
antibiotics and Imodium.
# Chronic Venous Insufficiency
# Chronic Venous Stasis Ulcers
# Osteomyelitis -Had amputation of left ___ digit due to
concerns for infection and osteomyelitis. He was discharged
after his prior admission on cipro, flagyl, and vanc with EOT
___. Wound was evaluated by vascular surgery, felt to be
healing well. ID was also consulted and recommended d/c abx due
to side effects, did not feel there was residual infection and
that course could be completed early. Wound care also evaluated
patient and recommended lactic acid cream to LEs for
keratolysis.
CHRONIC/STABLE PROBLEMS:
# Recurrent DVT/PE - held initially for low plts, restarted on
___
# Diabetes
Complicated by neuropathy.
- Continued home Gabapentin 100 mg PO BID
- Held home MetFORMIN XR (Glucophage XR) 500 mg PO DAILY given
___, can be restarted on discharge
# Hypertension
- Continued home Carvedilol 25 mg PO BID
- Held home Lisinopril 40 mg PO DAILY on admission, restarted 20
mg on ___, will need further titration after d/c
-will also need Lasix restarted once Cr improves further
# Hyperlipidemia
- Continue home Atorvastatin 10 mg PO QPM
Greater than 30 minutes spent providing and coordinating care on
day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. Ciprofloxacin HCl 500 mg PO Q12H
3. Furosemide 40 mg PO BID
4. Gabapentin 100 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
7. Acetaminophen 650 mg PO TID
8. Bisacodyl ___AILY:PRN Constipation - Second Line
9. Carvedilol 25 mg PO BID
10. Docusate Sodium 100 mg PO BID constipation
11. LORazepam 1 mg PO BID:PRN anxiety
12. MetroNIDAZOLE 500 mg PO TID
13. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
15. Senna 8.6 mg PO BID:PRN constipation
16. Thiamine 100 mg PO DAILY
17. Vancomycin 1000 mg IV Q 12H
18. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
Discharge Medications:
1. Lactic Acid 12% Lotion 1 Appl TP DAILY
2. LOPERamide 2 mg PO QID:PRN diarrhea
3. Lisinopril 20 mg PO DAILY
4. Acetaminophen 650 mg PO TID
5. Atorvastatin 10 mg PO QPM
6. Bisacodyl ___AILY:PRN Constipation - Second Line
7. Carvedilol 25 mg PO BID
8. Docusate Sodium 100 mg PO BID constipation
9. Gabapentin 100 mg PO BID
10. LORazepam 1 mg PO BID:PRN anxiety
11. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
12. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
14. Senna 8.6 mg PO BID:PRN constipation
15. Thiamine 100 mg PO DAILY
16. Warfarin 5 mg PO DAILY16
17. HELD- Furosemide 40 mg PO BID This medication was held. Do
not restart Furosemide until renal function closer to baseline
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Drug induced thrombocytopenia
Drug induced rash
Acute renal failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___
___ were admitted for low platelets, rash, and acute renal
failure. Your rash and platelets improved after stopping
antibiotics. Your renal failure improved with fluids and holding
diuretics. Your warfarin was briefly held for low platelets then
restarted. Hematology was consulted for your low platelets and
did not recommend steroids. They would like ___ to follow up
with them as an outpatient. Vascular surgery evaluated your foot
wound and felt it was healing well. Infectious disease also
evaluated your foot and did not think it was infected any
longer.
Followup Instructions:
___
|
19908451-DS-21 | 19,908,451 | 23,247,757 | DS | 21 | 2119-04-14 00:00:00 | 2119-04-14 21:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ hx of dementia, CAD s/p CABG, ___ transferred from
OSH (___) with reported coffee ground emesis. This
is his first presentation to our system; the history below is
obtained from the patient and from limite OSH records.
He initially presented ___ to ___ from his assisted living
with lethargy after having recieved oxycodone, possible coffee
ground emesis and reported desaturation to <80%.
OSH (___) ED Course: VS - 160s/50s; RR ___ O2 sat 94% on RA.
Rectal exam notable for brown, heme pos stool. No lab data
available. Recieved PPI bolus, gtt. He was transferred to ___
due to the possible need for endoscopy, as no endoscopy nurses
were available for the next 3 days.
___ ED COURSE:
VS - Tmax 98.1; HR max 84; 54 prior to transfer; BP
154-180/50-60s; RR ___ 94% on RA
Access placed: 18G, 20G
Labs notable for H/H 10.4/30.4 (unknown baseline); nl plts; INR
1.1
On admission to the floor, he is in good spirits but wishes he
wasn't in the hospital. He has history of dementia, but is
oriented to "Hospital in ___, maybe ___, is only
one day off on the date (___) and gives a coherent history.
He has no complaints. He states that he had some dry heaves
prior to admission but denies vomiting. He has been having
normal, daily brown bowel movements without any BRBPR or black
stool. He has had no abdominal pain. He denies chest pain,
palpitations or shortness of breath. He hopes to get home for
___ dinner tomorrow.
Past Medical History:
#Dementia
#Afib
#CAD s/p CABG (___)
#COPD
#Afib
#CKD
#Macular degeneration
#Colon Ca
Social History:
___
Family History:
Non contributory in this ___ year old pt
Physical Exam:
ADMISSION PHYSICAL EXAM:
Access: 18G, 20G
VS - L 190/68; R 175/54; HR 58; 20; 96% on RA
Gen - very pleasant elderly M in no distress, sitting on the
commode
Mental status - oriented to "hospital in ___ (thinks it is
___, one off on the date (___)
Cor - bradycardic, regular, SEM throughout the precordium
Pulm - breathing comfortably on room air, clear throughout
Abd - normal bowel sounds, non-tender
Rectal - deferred, pt on commode; RN will page w/ report of
stool appearance and guiac status (pt arrived to floor at 6am)
Extrem - bilateral pre-tibial pitting edema
DISCHARGE PHYSICAL EXAM:
Access: 18G, 20G
VS - BP: 128/49 HR 52; 16; 94% on RA
Gen - Pleasant elderly M in no distress
Mental status - Alert, oriented X3
Cards - bradycardic, regular, SEM throughout the precordium
Pulm - breathing comfortably on room air, mild wheezing in all
lung fields
Abd - normal bowel sounds, non-tender, nondistended
Rectal - pt stooled x 1 shortly before exam, formed, guaiac
negative.
Extrem - bilateral pre-tibial pitting edema, R>L
Pertinent Results:
___ 03:09AM BLOOD WBC-7.1 RBC-3.53* Hgb-10.4* Hct-30.4*
MCV-86 MCH-29.4 MCHC-34.2 RDW-15.2 Plt ___
___ 09:00AM BLOOD WBC-6.4 RBC-3.55* Hgb-10.2* Hct-31.4*
MCV-89 MCH-28.6 MCHC-32.3 RDW-15.1 Plt ___
___ 03:09AM BLOOD Glucose-141* UreaN-34* Creat-1.2 Na-139
K-4.9 Cl-102 HCO3-27 AnGap-15
___ 03:09AM BLOOD Ferritn-78
CHEST XRAY:
Intact medial sternal hardware. Evidence of prior CABG. Heart
size is normal. Mediastinal and hilar contours are unremarkable.
No evidence of pneumonia, pulmonary edema, or pleural effusions.
Lungs are clear.
___ DOPPLER:
No evidence of deep venous thrombosis in the right lower
extremity veins.
Brief Hospital Course:
Pt admitted w/ episode of vomiting at his assisted living
facility after starting oxycodone for his back pain. No blood by
report. Pt sent to ___, where he was transferred to
___ to be evaluated for EGD. At ___ he was found to have stable
H/H from labs drawn in ___. He had a formed, guaiac neg
stool on the morning after admission. No recurrence of vomiting,
tolerated full meal. Vomiting thought likely secondary to
oxycodone, new for him. C/o no chest pain, abdominal pain, SOB,
or nausea. Had some back pain, chronic for him, resolved w/
tylenol. Low concern for GIB. Pt also noted to have ___ edema
R>L, ___ doppler negative for DVT. Pt advised to take standing
tylenol, max 3 g/day. Follow up was arranged with patient's PCP,
and patient was discharged back to his assisted living under the
care of his daughter and HCP.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. nebivolol 10 mg oral daily
4. Lisinopril 40 mg PO DAILY
5. Tiotropium Bromide 1 CAP IH DAILY
6. Memantine 2 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
8. Ranitidine 150 mg PO BID
9. Docusate Sodium 100 mg PO BID
10. I-Caps (antiox#10-om3-dha-epa-lut-zeax) ___ mg oral BID
11. Multivitamins 1 TAB PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. I-Caps (antiox#10-om3-dha-epa-lut-zeax) ___ mg oral BID
7. Memantine 2 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. nebivolol 10 mg oral daily
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
11. Ranitidine 150 mg PO BID
12. Vitamin D 1000 UNIT PO DAILY
13. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
14. Acetaminophen 500 mg PO TID pain or fever
Take regardless of pain level
15. Acetaminophen 500 mg PO Q8H:PRN breakthrough pain
Take in addition to standing dose of tylenol if you still have
pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Dyspepsia
Secondary diagnoses:
Hypertenstion
CAD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for a vomiting episode, which may have been
caused by a new medication you were taking, called oxycodone.
Your blood levels have not changed, and your stool showed no
evidence of blood. All of this indicates that you are likely NOT
bleeding. Your PCP has apparently scheduled an endoscopy, which
you can pursue as an outpatient if it is deemed necessary.
You should probably not take oxycodone. Instead, we recommend
taking an increased dose of tylenol for your back pain: You can
take 500 mg three times a day regardless of your level of pain.
If you are having pain despite this, you can take another 500 mg
up to three times in one day. You can also refer to the
medication sheet included in this discharge paperwork for our
recommended changes. You can also start taking omeprazole 20 mg
daily, taken 30 min before your largest meal. This should help
any element of your problem caused by acid reflux.
You have an appointment scheduled with Dr. ___
appointments below) where you can discuss these issues further.
Followup Instructions:
___
|
19908844-DS-2 | 19,908,844 | 24,760,592 | DS | 2 | 2148-07-22 00:00:00 | 2148-07-25 21:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
cefuroxime
Attending: ___.
Chief Complaint:
Trauma: fall:
Small left frontal and right parietal SAH
hematoma left thigh
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old female transferred from an
outside hospital after a fall reported as a witnessed
mechanical fall, and diagnosed by head CT with bilateral
subarachnoid hemorrhages. The husband reports that she
tripped but had also had some drinks earlier in the day. Per
the husband she had no loss of consciousness but the patient
is amnestic to the event. She is neurologically intact
without any deficits in a GCS of 15 prior to transfer. She
received Were and morphine, tetanus was updated, and she was
transferred
Past Medical History:
unknown
Social History:
___
Family History:
non-tributory
Physical Exam:
PHYSICAL EXAMINATION: ___
Temp: 97.8 HR: 84 BP: 108/67 Resp: 16 O(2)Sat: 98 Normal
Constitutional: Normal
HEENT: Abrasion/skin tear to left forehead, Extraocular
muscles intact, Pupils equal, round and reactive to light
Normal
Extr/Back: Ecchymosis left thigh, pain in the left wrist
without significant swelling or difficulty with range of
motion.
Neuro: Awake, alert, oriented x3. Cranial nerves are intact
and symmetric. She has no focal motor weakness or sensory
deficit.
Physical examination upon discharge: ___:
Vital signs: 98.6, 69, bp=122/54, rr=18, 99% room air
General: NAD
CV: ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: large, soft, hematoma left lateral flank, no pedal edema
bil, no calf tenderness bil, muscle st. upper ext. +5/+5, lower
ext. +5.+5
NEURO: alert and oriented x 3, speech clear, full EOM's, ___
3mm bil.
Pertinent Results:
___ 05:05AM BLOOD WBC-6.8 RBC-2.61* Hgb-7.9* Hct-24.7*
MCV-95 MCH-30.3 MCHC-32.0 RDW-13.9 RDWSD-47.8* Plt ___
___ 04:30AM BLOOD WBC-6.7 RBC-2.77* Hgb-8.4* Hct-25.9*
MCV-94 MCH-30.3 MCHC-32.4 RDW-13.9 RDWSD-47.3* Plt ___
___ 04:00AM BLOOD WBC-10.9* RBC-3.28* Hgb-9.7* Hct-30.4*
MCV-93 MCH-29.6 MCHC-31.9* RDW-13.7 RDWSD-46.6* Plt ___
___ 04:00AM BLOOD Neuts-87.2* Lymphs-4.4* Monos-7.5
Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.48* AbsLymp-0.48*
AbsMono-0.81* AbsEos-0.00* AbsBaso-0.03
___ 05:05AM BLOOD Plt ___
___ 04:30AM BLOOD Glucose-102* UreaN-8 Creat-0.5 Na-138
K-3.8 Cl-103 HCO3-27 AnGap-12
___ 04:30AM BLOOD Calcium-8.5 Phos-2.8 Mg-1.8
___ 04:00AM BLOOD ASA-NEG Ethanol-71* Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___: cat scan of the chest:
Unchanged left lateral thigh hematoma. No additional sequela of
trauma.
___: cat scan of the head:
Stable subarachnoid hemorrhage as described above without
significant mass effect. No new intracranial hemorrhage.
___: cat scan of the c-spine:
. No acute fracture or traumatic malalignment.
2. Degenerative changes at C5-C6 as described above.
___: x-ray of left wrist:
No fracture or dislocation.
Mild degenerative changes at the first carpometacarpal,
radiocarpal and
triscaphe joints.
Brief Hospital Course:
___ year-old female who presented to an OSH on ___ after a
mechanical fall. Imaging studies showed a small left frontal
and right parietal SAH. She was also found to have a large left
forehead laceration and a large left lateral thigh
hematoma. She was placed in a cervical collar and admitted to
the trauma intensive care unit for neurological and hematocrit
checks. During her stay in the intensive care unit, her vital
signs and hematocrit remained stable. She was evaluated by the
Neurosurgery service and placed on a 7 day course of keppra. Her
cervical spine was cleared and the c-collar was removed.
The patient was transferred to the surgical floor on HD #2. Her
vital signs remained stable and she was afebrile. She was
tolerating a regular diet and voiding without difficulty. She
was ambulatory without the need of assistance. Her hematocrit
stabilized at 25. There was no further enlargement of the thigh
hematoma. She was evaluated by Occupational therapy because of
her loss of consciousness. Out-patient cognitive follow-up was
recommended if the patient developed post-concussive symptoms
post-discharge. The patient was relocating to ___ at the
time of discharge. She was encouraged to seek a primary care
provider and undergo ___ ___ in 4 weeks. She was instructed to
complete her course of keppra. Post-concussive symptoms were
reviewed with her and her husband. The ___ hospital record
and reports were given to her at the time of discharge.
Medications on Admission:
prozac 40mg QD, vitamin D, iron supp
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Docusate Sodium 100 mg PO BID
3. Famotidine 20 mg PO BID
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
4. Fluoxetine 40 mg PO DAILY
5. LeVETiracetam 500 mg PO BID Duration: 5 Days
last dose ___
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*12 Tablet Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
avoid driving while on this medication, may cause drowsiness
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: fall:
Small left frontal and right parietal SAH
Hematoma left thigh
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 a fall resulting in a
small bleed in your head. After your fall, you were monitored
in the intensive care unit. You did not require any surgical
intervention. You are preparing for discharge home with the
following instructions:
Please call your doctor or return to the emergency room if you
have any of the following:
* You experience new chest pain, pressure, squeezing or
tightness.
* New or worsening cough or wheezing.
* If you are vomiting and cannot keep in fluids or your
medications.
* You are getting dehydrated due to continued vomiting,
diarrhea or other reasons. Signs of dehydration include dry
mouth, rapid heartbeat or feeling dizzy or faint when standing.
* You see blood or dark/black material when you vomit or have a
bowel movement.
* You have shaking chills, or a fever greater than 101.5 (F)
degrees or 38(C) degrees.
* Because of your head bleed, you may experience experience
concussive like symptoms. Please follow-up in the emergency
room if you develop the following:
*severe headache
*visual changes
*weakness upper/lower extremity
*difficulty speaking
*facial droop
As a result of the fall, you sustained a bruise to your left
thigh, please watch for:
*increase size left thigh
*increase pain left thigh
*dizziness, weakness
*numbness left leg
*taut skin left thigh
NO ASPIRIN, you may take advil or motrin
Followup Instructions:
___
|
19908911-DS-8 | 19,908,911 | 29,807,161 | DS | 8 | 2157-07-30 00:00:00 | 2157-07-31 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Azathioprine / mycophenolate mofetil
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumbar puncture x2
History of Present Illness:
The patient is a ___ right-handed woman followed by
rheumatology for connective tissue disorder of unclear etiology
who now presents with a one month history of headaches, found to
have a right temporal hyperintensity on MRI. Please see recent
rheumatology note for full details of her complicated past
history. In brief, her symptoms first began in ___
with a severe gum infection followed by bilateral ear swelling,
and then development of bruise-like lesions over her hands, feet
and tongue. Biopsy of the tongue lesion showed leukoclastic
vasculitis with associated thrombi. She was started
on a prednisone 60mg taper in ___ and was then started
on MTX. A subsequent biopsy of her right foot showed focal
vascular thrombi without evidence of vascultiis. She was then
started on heparin and was transitioned to coumadin. This was
subseuqently stopped after she was seen by hematology. She was
subsequently seen by rheumatology in ___ and underwent
trials of multiple steroid-sparing agents including azathioprine
and cellcept which were stopped due to intolerance. She was
restarted on prednisone and was also started on
hydroxychloroquine, on which she remains. After several
additional opinions the decision was then made to start
rituximab infusions. She had her first infusion on ___ and so
far is tolerating this well. Her prednisone had initially been
tapered to 5mg daily due to adverse effects including weight
gain and frequent UTI's, but due to recent recurrence of lesions
on her hands and feet she has now been increased back to 10mg
daily.
Throughout this course she had no neurologic symptoms, until
about a month ago when she began to develop headaches. She has
had a few nonspecific headaches before in her life, but these
were very different. The current headaches are always centered
around her right eye and temple and could be quite severe.
Occasionally the pain will radiate over the top of her head to
the right side of her neck as well. She describes the pain as
constant although occasionally she thinks it could be throbbing
as well. The headaches could last anywhere from ___ minutes up
to ___ hours but typically responded well to tylenol. The
headaches are better with lying down and do not worsen with
coughing, straining, or bending over. She denies any associated
photo-/phonophobia, vision changes, nausea/vomiting. She reports
that she has been feeling more fatigued recently as well, and
has also had a runny nose as well as some intermittent pain on
the right side of her nose. These symptoms seem to occur
independently from the headaches. She also reports some
intermittent dizziness.
On neuro ROS, the patient denies loss of vision, blurred vision,
diplopia, dysarthria, dysphagia, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait.
On general review of systems, the patient reports that she was
recently found to have a UTI for which she was started on
antibiotics yesterday. She denies recent fever or chills. No
night sweats or recent weight loss or gain. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
Denies arthralgias or myalgias.
Past Medical History:
1. Undifferentiated connective tissue disease as above with
focal vascular thrombi on skin biopsy and leukocytoclastic
vasculitis on tongue biopsy
2. Obesity with 50 pound weight gain on prednisone
3. Herniated disc
Social History:
___
Family History:
Parents: both living in their ___ and healthy
Siblings: healthy
___ year old son: healthy
Grandmother: stroke in her ___
No other known family history of any neurologic disorders. There
is also no known history of any autoimmune, connective tissue,
or clotting disorders.
Physical Exam:
General: Awake, pleasant and cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
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
Extremities: No C/C/E bilaterally
Skin: Several small purplish lesions on L palm and b/l feet,
some with crusting and excoriation
Neurologic:
-Mental Status: Alert, oriented x 3. Attentive, able to relate
history without difficulty. Language is fluent with intact
repetition and comprehension. Normal prosody. There were no
paraphasic errors. Speech was not dysarthric. Able to follow
both midline and appendicular commands. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 5 to 3mm and brisk. 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, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, 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.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Slightly unstead on tandem gait. Slight sway on Romberg.
Pertinent Results:
___ 01:50PM BLOOD WBC-10.0 RBC-4.35 Hgb-12.5 Hct-37.7
MCV-87 MCH-28.8 MCHC-33.2 RDW-13.1 Plt ___
___ 01:50PM BLOOD Neuts-81.0* Lymphs-11.9* Monos-4.9
Eos-1.6 Baso-0.6
___ 01:50PM BLOOD ___ PTT-31.3 ___
___ 01:50PM BLOOD Plt ___
___ 01:50PM BLOOD Glucose-86 UreaN-11 Creat-0.7 Na-139
K-4.3 Cl-105 HCO3-27 AnGap-11
___ 01:50PM BLOOD ALT-21 AST-12 AlkPhos-62 TotBili-0.3
___ 01:50PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 08:25AM BLOOD WBC-10.6 RBC-4.46 Hgb-12.9 Hct-39.0
MCV-88 MCH-28.9 MCHC-33.0 RDW-13.1 Plt ___
___ 08:25AM BLOOD Plt ___
___ 08:25AM BLOOD Glucose-80 UreaN-12 Creat-0.8 Na-139
K-4.2 Cl-103 HCO3-27 AnGap-13
___ 08:25AM BLOOD TotProt-7.5 Calcium-9.7 Phos-4.4 Mg-2.2
___ 08:00PM BLOOD WBC-11.2* RBC-4.65 Hgb-13.6 Hct-41.2
MCV-89 MCH-29.1 MCHC-32.9 RDW-13.4 Plt ___
___ 08:00PM BLOOD Neuts-74.4* ___ Monos-4.9 Eos-1.2
Baso-0.5
___ 08:00PM BLOOD Plt ___
___ 08:00PM BLOOD WBC-11.2* Lymph-19 Abs ___ CD3%-90
Abs ___ CD4%-66 Abs CD4-1401* CD8%-24 Abs CD8-512
CD4/CD8-2.7
___ 08:00PM BLOOD IgG-1379 IgA-290 IgM-307*
___ 08:00PM BLOOD HIV Ab-NEGATIVE
___ 08:25AM BLOOD PEP-PND
___ 08:00PM BLOOD HERPES 6 DNA PCR, QUANTITATIVE-PND
TOXOPLASMA IgG ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgG ANTIBODY BY EIA.
TOXOPLASMA IgM ANTIBODY (Final ___:
NEGATIVE FOR TOXOPLASMA IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
CSF:
___ 04:05PM CEREBROSPINAL FLUID (CSF) WBC-16 RBC-0 Polys-1
___ Monos-26 Eos-1
___ 04:05PM CEREBROSPINAL FLUID (CSF) WBC-15 RBC-0 Polys-5
___ ___ 04:05PM CEREBROSPINAL FLUID (CSF) TotProt-54*
Glucose-50
___ 04:05PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY
PCR-PND
___ 04:12PM CEREBROSPINAL FLUID (CSF) ___ VIRUS (JCV) DNA
QUANTITATIVE PCR-PND
___ 04:12PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-PND
CSF;SPINAL FLUID LP TUBE 3.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ACID FAST CULTURE (Preliminary):
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
URINE:
___ 09:20PM URINE Color-Straw Appear-Hazy Sp ___
___ 09:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
IMAGING:
___ MRI/A brain: T2 HYPERINTENSITY INVOLVING THE MEDIAL
ASPECT OF THE RIGHT TEMPORAL LOBE, RIGHT INTERNAL CAPSULE,
LENTIFORM NUCLEUS, AND RIGHT CEREBRAL PEDUNCLE. DIFFERENTIAL
DIAGNOSIS INCLUDES A NEOPLASTIC PROCESS, BUT IN LIGHT OF YOUR
PROVIDED HISTORY OF KNOWN SYSTEMIC VASCULITIS, SOME UNUSUAL
INFLAMMATORY/ISCHEMIC PROCESS COULD ALSO BE CONSIDERED.
___ CXR : No evidence of parenchymal fibrosis or other
pathologic
parenchymal process. Mild scoliosis of the thoracic spine. No
pleural effusions. Normal size and appearance of the cardiac
silhouette.
___ CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC & RECONS:
HEAD CTA: there is a hypoplastic left A1 segment. The anterior
and posterior circulations are otherwise unremarkable. There is
no significant stenosis, vessel occlusion or aneurysm greater
than 2 mm. There are no definite imaging findings of
vasculitis.
NECK CTA: Incidentally noted is a left vertebral artery arising
from the
aortic arch. The vertebral arteries are otherwise unremarkable.
The common carotid, internal carotid and external carotid
arteries are widely patent without evidence of significant
stenosis based on NASCET criteria.
There is no evidence of arterial dissection.
There is a hypodensity corresponding to the MRI signal
abnormalities within the posterior limb of the right internal
capsule with extension into the medial right temporal lobe and
cerebral peduncle. There is no hemorrhage. Unremarkable head and
neck CTA without evidence of significant stenosis, aneurysm or
dissection.
Brief Hospital Course:
___ right-handed woman followed by Rheumatology for
connective tissue disorder of unclear etiology who now presents
with a one month history of headaches, found to have a right
temporal hyperintensity on MRI concerning for inflammation vs.
infection vs. vasculitis. CSF showed elevated protein as well as
a leukocytosis (15 WBC) with lymphocytic predominance. Head and
neck CTA did not show significant evidence of stenosis,
aneurysm, dissection or vasculitis; angiogram was considered,
but since rheumatology team indicated that it would not
definitively change their management regardless of whether it
demonstrated findings consistent with vasculitis (because of the
poor sensitivity and specificity) it was deferred. CSF studies
were sent to look for possible infectious etiologies of her
imaging findings and CSF leukocytosis. CSF was also sent for
cytology to look for an underlying neoplastic process and for
oligoclonal bands to look for an underlying autoimmune process
in her CNS. Her work-up was largely unrevealing; however
numerous studies are still pending at the time of discharge. In
the context of her (known) systemic vasculitis, the most likely
explanation for her imaging and CSF findings is a
autoimmune/vasculitic process, although infectious and
neoplastic etiologies are being evaluated. She will follow-up
as an outpatient and decisions will be made in that setting
regarding any necessary changes to her medication regimen based
on the remainder of her studies.
Medications on Admission:
Same as discharge medications
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
2. Alendronate Sodium 70 mg PO QMON
3. Calcium Carbonate 1500 mg PO DAILY
4. Gabapentin 600 mg PO TID
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. PredniSONE 10 mg PO DAILY
7. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Days
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Intraparenchymal brain lesion
Connective tissue disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the Neurology Service at ___
___ for headache and an abnormal MRI. You
had a spinal tap in the Emergency Room that was notable for an
increased number of white blood cells. You had multiple labs
sent from your spinal fluid to look for viral, bacterial and
fungal infections. Most of these tests are still pending,
however you have no other signs of infection currently. Most
likely the imaging finding is inflammation, likely related to
your skin and mouth lesions. You also had spinal fluid sent to
be looked at by the pathologist to look for inflammation or
abnormal cells. You were seen by both Rheumatology and
Infectious Diseases while you were here. Rheumatology
recommended that you follow up with clinic and they may make
changes on your medications based on test results. Infectious
Diseases gave recommendations on which tests to send. Please
follow up in clinic with our neuroinfectious specialists, Drs.
___. These appointments are scheduled below.
Followup Instructions:
___
|
19909210-DS-15 | 19,909,210 | 24,421,958 | DS | 15 | 2124-09-20 00:00:00 | 2124-09-20 22:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Quinidine-Quinine Analogues / digoxin / Oxycodone
Attending: ___
___ Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with history of atrial
fibrillation on apixiban s/p admission for ___ with
cardioversion ___, presenting with syncope and dyspnea. Patient
reports syncopal episode today while getting out of car. No head
strike. Prodromal symptoms of lightheadedness. Also reports DOE
over past 2 weeks without improvement after cardioversion.
Denies any chest pain/pressure.
In ED, initial vitals were at 19:40: ___ pain 98.2 48 114/66 18
96%. On exam noted to be in sinus brady, HR 45-50s. Requiring O2
after ambulating, able to wean to RA while at rest.
[x]EKG SB 53, nl axis, TWI V2-V3 new from ___
[x]CBC anemia per baseline
[x]Lytes Cr 1.2 from baseline 0.9
[]Coags
[x]CXR - small right pleural eff, fluid in fissure, mild pulm
congestion
[x]Trop wnl
[x]BNP ___
[x]Lactate 2.2
[x]UA showed pyuria, bacteriuria, and +leuk esterase, felt to
have a UTI and given one dose of ceftriaxone. EP was contacted
and reported they would follow as inpatient.
Recently admitted to ___ service ___ for management of
atrial fibrillation. Patient started on Flecainide 150 mg BID
and underwent successful DC cardioversion. Post cardioversion
patient had episode of bradycardia but remained stable
thereafter on telemetry. Metoprolol was decreased from 50mg TID
to 25mg BID at discharge.
On the floor, she reports poor intake recently. No confusion,
bowel/bladder inc/tongue biting after the event. Sometimes feels
lightheaded when standing up after long car trips, esp more
recently since d/c. No urinary symptoms. Sometimes has ankle
swelling, but usually after long car trips. No chest pain, never
had chest pain, no jaw pain, no arm pain. Had palpitations prior
to cardioversion, but no more.
Past Medical History:
1. Alcoholic liver disease - stage IV fibrosis based on her
FibroScan done in ___.
2. Atrial fibrillation - persistent; diagnosed in ___, s/p
cardioversion in ___, return to afib ___ wks afterwards per
records.
3. Thyroid nodule status post resection.
4. Whipple procedure in ___ for a pancreatic lesion. This
proved to be a low-grade intraductal papillary mucinous tumor
and
she was cured.
5. Status post laminectomy in ___. She had a lumbar
laminectomy for back pain and leg weakness.
6. MVA ___ with right arm fracture and facial fracture and
nose
laceration.
7. Status post appendectomy.
8. History of breast cysts
Social History:
___
Family History:
Notable for diabetes and coronary disease in her father. She
does not know her mother's history.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.9 - 101/61 - 57 (on recheck, 49-50), 18 - 98 on 2L (on
recheck 98 on RA), weight 72.9
GENERAL: 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 JVD.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE PHYSICAL EXAMINATION:
VS: 98 63 96/54 95RA
I/O: ___ (-930)
Wt 67.8kg 68.6 <- 70.4 (72.9kg on admit)
GENERAL: sitting in bed in NAD
HEENT: NCAT. MMM
NECK: Supple with JVD 6cm.
CARDIAC: RRR, normal S1, S2.
LUNGS: Decreased BS at right base, and mild basilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
NEURO: non-focal
Pertinent Results:
ADMISSION LABS:
___ 08:25PM BLOOD WBC-6.0 RBC-3.03* Hgb-10.0* Hct-31.9*
MCV-105* MCH-33.0* MCHC-31.5 RDW-13.8 Plt ___
___ 08:25PM BLOOD Glucose-100 UreaN-25* Creat-1.2* Na-135
K-4.3 Cl-101 HCO3-22 AnGap-16
PERTINENT RESULTS:
___ 07:00AM BLOOD Protein Electrophoresis-NO SPECIFIC
ABNORMALITIES
___ 08:25PM BLOOD proBNP-___*
___ 08:25PM BLOOD cTropnT-<0.01
___ 07:20AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:02AM BLOOD VitB12-367 ___ Ferritn-192*
___ 11:02AM BLOOD TSH-2.7
___ 08:25PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:25PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
___ 08:25PM URINE RBC-4* WBC-37* Bacteri-FEW Yeast-NONE
Epi-4 TransE-3
___ 08:25PM URINE CastHy-113*
___ 10:07AM URINE U-PEP:No Protein Detected
___ 8:25 pm URINE
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-5.2 RBC-3.13* Hgb-10.5* Hct-31.4*
MCV-100* MCH-33.4* MCHC-33.3 RDW-13.2 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-33.4 ___
___ 07:15AM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-141
K-4.3 Cl-103 HCO3-27 AnGap-15
___ 07:08AM BLOOD ALT-11 AST-17 AlkPhos-95 TotBili-0.3
___ 07:15AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.9
___ 11:02AM BLOOD VitB12-367 ___ Ferritn-192*
___ 07:00AM BLOOD ___
___ 11:02AM BLOOD TSH-2.7
___ 07:00AM BLOOD PEP-NO SPECIFI
___ 12:40PM BLOOD Metanephrines (Plasma)-PND
___ 07:00AM BLOOD RO & ___
___ Cardiovascular ECG
Rate PR QRS QT/QTc P QRS T
53 ___ 84 86 18
Normal sinus rhythm with A-V conduction delay. Q-T interval
prolongation.
T wave inversions in leads II and III suggesting possible
anterior ischemia. Compared to tracing #2 the anterior T wave
inversions are new as is the Q-T interval prolongation.
TRACING #3
___ Cardiovascular ECG
Rate PR QRS QT/QTc P QRS T
51 198 98 492/476 71 85 3
Sinus bradycardia with Q-T interval prolongation and prominent T
wave
inversions in the anterior leads. No diagnostic change from
tracing #3.
TRACING #4
___ Cardiovascular ECG
Intervals Axes
Rate PR QRS QT/QTc P QRS T
64 ___ 27 74 -56
Sinus rhythm. Non-specific intraventricular conduction delay.
Poor R wave
progression. Non-specific diffuse T wave flattening. Compared to
the previous tracing of ___ the inverted T waves in leads
V2-V3 are flat.
___ Cardiovascular ECHO
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 = 60%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). The right ventricular free wall
thickness is normal. The right ventricular cavity is moderately
dilated with normal free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Moderate (2+) 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 moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
Compared with the prior study (images reviewed) of ___, the
tricuspid regurgitation is increased and the right ventricle is
now dilated.
___ ECHO
There is moderate regional left ventricular systolic dysfunction
with severe hypokinesis of the mid- and distal segments of the
septum and anterior wall, as well as the apex. The remaining
segments contract normally (LVEF = 35%). The right ventricular
cavity is mildly dilated with normal free wall contractility.
There is no pericardial effusion.
___ Imaging CHEST (PA & LAT)
FINDINGS: Frontal and lateral views of the chest were obtained.
There is a small right pleural effusion and overlying
atelectasis. There may also be some fluid tracking in the right
fissure. The cardiac silhouette is mildly enlarged. There is
no overt pulmonary edema. No evidence of pneumothorax is seen.
The mediastinal contours are stable, and there is calcification
of the aortic knob.
IMPRESSION: Small right pleural effusion and enlargement of the
cardiac
silhouette
___ 07:15AM BLOOD WBC-5.2 RBC-3.13* Hgb-10.5* Hct-31.4*
MCV-100* MCH-33.4* MCHC-33.3 RDW-13.2 Plt ___
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-33.4 ___
___ 07:15AM BLOOD Glucose-90 UreaN-17 Creat-0.8 Na-141
K-4.3 Cl-103 HCO3-27 AnGap-15
___ 07:08AM BLOOD ALT-11 AST-17 AlkPhos-95 TotBili-0.3
___ 07:15AM BLOOD Calcium-9.0 Phos-4.4 Mg-1.9
___ 11:02AM BLOOD VitB12-367 ___ Ferritn-192*
___ 07:00AM BLOOD ___
___ 11:02AM BLOOD TSH-2.7
___ 07:00AM BLOOD PEP-NO SPECIFI
___ 12:40PM BLOOD Metanephrines (Plasma)-PND
___ 07:00AM BLOOD RO & ___
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of atrial
fibrillation on apixiban s/p admission for ___ with
cardioversion ___, presenting with syncope and dyspnea.
# Syncope:
Likely secondary to known orthostatic hypotension w/ similar
prior episodes in the past. Patient reported poor PO intake
prior to admission w/ elevated creat and BUN/creat ratio.
Troponins neg, unlikely to be PE as patient is anticoagulated.
No arrhythmias on telemetry to explain syncope. Patient
evaluated by autonomic Neurology service who recommended further
w/u of underlying etiology. Her B12 was considered borderline
low so she was started on PO B12. Her ___, SPEP, TSH, Ro, and La
were normal. Additionally there a concern for possible
pheochromocytoma so workup was started but was still pending at
discharge. They recommended continuing midodrine (should not
take a bedtime dose, due to risk of supine hypertension),
increased PO intake, physical therapy, and further outpatient
assessment. Patient will need outpatient autonomic testing. In
addition, deconditioning may have exacerbated orthostatic
hypotension. Physical therapy should be carried daily if
possible, i.e., walking or standing with support. Brief periods
of standing followed by sitting when symptomatic will help with
reconditioning. Reclining bike and water exercises (with
careful supervision) may also be helpful in the outpatient
setting.
#Flecanaide Toxicity: During hospital course there was concern
for Flecainide toxicity due to initial prolonged QT then an
episode of Ventricular Tachycardia. Flecainide was stopped She
was started on Aldactone and Normal Saline to counteract the Na
channel blockade. She was given IV Lasix to try to keep her net
even. She was additionally stopped on her TCA. She has follow up
with EP in 1 month. QTc on ___ was 406.
#ATRIAL FIBRILLATION: in SR s/p DC/CV ___ and flecainide
initiation. On admission patient in sinus bradycardia with
prolonged QTc. Discontinued Amitriptyline. Decreased dose of
metoprolol to 12.5mg BID (hold for HR<45) and continued
Flecainide. QTc normalized, patient with no concerning events on
telemetry, in SR at 50-72. Patient to f/u with EP/cards
outpatient.
# Acute systolic on chronic diastolic CHF (new systolic
dysfuncion, known diastolic)- admission, mild shortness of
breath, worse with exertion, for weeks concerning for heart
failure. She was diuresed with lasix prn. A repeat echo was
obtained given concerns for flecainide toxicity which showed a
newly depressed EF of 35%, thought to be due to takatsubo's vs.
flecainide induced cardiomyopathy. A final echo was obtained on
day of discharge ___ which showed improved RV function but
stable LVEF of 35%. Patient was adequately diuresed and
asymptomatic by time of discharge. Discharge weight was 67.8kg.
# Depression- lorazemam prn.
# Anemia
Macrocytic. Stable. No e/o active bleeding. Folate, Ferritin
WNL. B12 was borderline low, started PO repletion and f/u
outpatient. Her spep, upep neg
***TRANSITIONAL ISSUES:***
- f/u with PCP after discharge
- f/u with autonomics neurology outpatient
- patient should follow up with Dr ___ in 1 month
- needs repeat Echo prior to Cards appt
- f/u metanephrines (sent to rule out pheochromocytoma given BP
lability and new heart failiure
- PCP to determine need for B12 repletion (level was 376)
- Patient may benefit from brief periods of standing followed by
sitting when symptomatic will help with reconditioning.
Reclining bike and water exercises (with careful supervision)
may also be helpful in the outpatient setting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 25 mg PO HS
2. Apixaban 5 mg PO BID
3. Lorazepam 0.5 mg PO TID:PRN anxiety
4. Midodrine 10 mg PO TID
5. Flecainide Acetate 150 mg PO Q12H
6. Metoprolol Tartrate 25 mg PO BID
7. Potassium Chloride 16 mEq PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Lorazepam 0.5 mg PO TID:PRN anxiety
3. Metoprolol Tartrate 12.5 mg PO BID
hold for HR<45
RX *metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth
twice a day Disp #*24 Tablet Refills:*0
4. Midodrine 10 mg PO TID
5. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*15 Tablet Refills:*0
6. Potassium Chloride 16 mEq PO DAILY
7. Aspirin 81 mg PO DAILY
RX *aspirin [Aspirin Low-Strength] 81 mg 1 tablet(s) by mouth
daily Disp #*15 Tablet Refills:*0
8. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*15
Tablet Refills:*0
9. Spironolactone 25 mg PO BID
RX *spironolactone 25 mg 1 tablet(s) by mouth twice a day Disp
#*24 Tablet Refills:*0
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Syncope
Orthostatic hypotension
Atrial Fibrillation
Flecainide toxicity
Anemia
Ventricular Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane).
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital with syncope. We were
concerned that this was related to your heart, so you were
monitored on the cardiology service. Your syncope was likely
related to orthostatic hypotension (drop in your blood pressure
and dizziness when you stand). You were seen by the neurologists
who specialize in this, who they recommended physical therapy,
increase intake of fluid to prevent dehydration, and wearing
compression stockings. We also sent additional tests to try to
determine the cause of your neuropathy, some of which are still
pending. You were found to have borderline low vitamin B12
levels, so you were started on supplements. You will need to get
additional testing and follow up with neurology and your primary
care doctor outpatient. You were seen by the the cardiologists
who beleive you had flecainide toxicity. Your flecainide was
STOPPED. You were given medications to counteract the toxicity.
You were STARTED on some new medications: Lisinopril, Aspirin,
Spironolactone, and some vitamins. Your Metoprolol dose was
CHANGED.
Please follow up at the appointments below.
Followup Instructions:
___
|
19909406-DS-6 | 19,909,406 | 23,136,411 | DS | 6 | 2134-07-13 00:00:00 | 2134-07-21 09:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumbar Puncture
History of Present Illness:
___ who awoke with sudden onset severe headache accompanied with
photo/phonophobia neck pain, nausea and tunnel vision. Initially
able to go to work in AM, but symptoms proved disabling and
reported to urgent care where she was ruled out for ___ by CT
and referred to ED. LP performed with results c/f meningitis.
Started on empiric antibiotics. 5 days prior to admission
experienced symptoms of sore throat, cough and was prescribed
amoxicillin over the phone. Symptoms improved within a few days.
Past Medical History:
Anxiety
Social History:
___
Family History:
Not taken -
Physical Exam:
Admission Physical Exam:
VITALS: 97.8 ___ 16 99/EA
GENERAL: awake, alert, NAD, pleasant
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: pain and stiffness with neck flexion no LAD
CARDIAC: RRR, nl S1+S2 no g/r/m, no JVD, peripheral pulses
intact
LUNG: CTAB with good movement b/l in all fields no w/r/r
ABDOMEN: soft nt/nd normoactive BS, no r/g
EXTREMITIES: dry and WWP, no c/c/e
NEURO: Moving all extremities with purpose. Facial movements are
symmetric and sithout droop. Full visual fields, EOMI, PERRLA,
facial sensation intact, clear appreciation of light sound,
palate elevation and tongue extension midline. Full lateral neck
turn and full and equal shoulder shrug b/l. ___ strenght b/l
grossly to UE and ___. Sensation grossly intact to all extrem.
SKIN: no excoriations or lesions, no rashes
Discharge Physical Exam:
Vitals: 98.9 105/58 68 16 99RA
General: laying comfortably, in no acute distress
HEENT: EOMI w/o nystagmus, PERRLA.
Lymph: no cervical or clavicular lymphadenopathy
Lungs: CTAB w/o adventitious sounds
CV: RRR , audible S1 and S2, no M/R/G
Abdomen: Soft, nontender
Ext: WWP. no c/c/e
Neuro: positive get-up-and-go. CN II-XII present and in tact
bilaterally. Full visual fields. No nuchal rigidity. Full neck
ROM.
Skin: no rash
Pertinent Results:
Discharge Labs:
___ 05:55AM BLOOD WBC-5.6 RBC-4.01* Hgb-11.4* Hct-33.6*
MCV-84 MCH-28.3 MCHC-33.9 RDW-14.3 Plt ___
___ 05:55AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-136 K-3.6
Cl-101 HCO3-26 AnGap-13
___ 05:55AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.9
Admission Labs:
___ 10:05PM BLOOD WBC-9.3 RBC-4.34 Hgb-12.5 Hct-36.9 MCV-85
MCH-28.7 MCHC-33.8 RDW-14.0 Plt ___
___ 10:05PM BLOOD Glucose-104* UreaN-13 Creat-0.9 Na-139
K-4.0 Cl-102 HCO3-25 AnGap-16
___ 05:40AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.6
___ 02:04AM BLOOD Lactate-1.6
___ 05:40AM BLOOD HIV Ab-NEGATIVE
___ 12:34AM CEREBROSPINAL FLUID (CSF) WBC-228 RBC-705*
Polys-77 ___ Macroph-17
___ 12:34AM CEREBROSPINAL FLUID (CSF) WBC-201 RBC-3*
Polys-85 ___ Macroph-12
___ 12:34AM CEREBROSPINAL FLUID (CSF) TotProt-53*
Glucose-65
___ 01:20AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Pertinent Labs:
HIV viral load - not detected
Gram Stain - no organisms / PMNs
CSF Cultures: neg x 48 hours
CT HEAD ___:
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, shift of
normally
midline structures or acute major vascular territorial
infarction. Ventricles and sulci are normal in size and
configuration. The basal cisterns appear patent and there is
preservation of gray-white matter differentiation.
There is no fracture. The visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION:
No acute intracranial abnormality.
Brief Hospital Course:
# aseptic meningitis: Patient admitted after LP suggestive of
bacterial vs viral meningitis. Empiric coverage started with
vancomycin, ceftriaxone, and acyclovir. Patient's neurologic
status was minimally impaired on admission and improved
throughout hospitalization. Repeat exams demonstrated no
neurologic defecits. Pain control requirements were minimal.
Gram stain negative for organisms, and cultures were negative.
Given CSF profile and preceding history of pharyngitis, symptoms
were thought likely to be due to viral infection, with very low
suspicion for HSV. As such, antibiotics and acyclovir were
discontinued. Patient had excellent social support and met
clinical criteria for discharge, so was sent home with close PCP
follow up.
TRANSITIONAL ISSUES:
- Patient has had normocytic anemia over last two days of
admission for which she should follow up with her PCP.
- Patient should follow up with her PCP to verify continued
improvement of symptoms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q24H
2. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Oxycodone 5mg tabs Q8H PRN headache (dispense #3)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Viral Meningitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital with headache and vision
changes. You were diagnosed with meningitis after a lumbar
puncture was performed. You were initially treated with
antibiotics and anti-virals. Your blood and cerebral spinal
fluid tests were not concerning for a bacterial or herpes
simplex virus meningitis, so these medications were stopped. As
you continued to do well and show no signs of neurologic
dysfunction, you were discharged home with instructions to
follow up with your primary care physician.
It was a pleasure taking care of you!
Your ___ Care Team
Followup Instructions:
___
|
19909671-DS-21 | 19,909,671 | 20,359,453 | DS | 21 | 2191-10-03 00:00:00 | 2191-10-05 17:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
___ with severe aortic stenosis presents with shortness of
breath, melena, HCT 18.9 from 37 (___).
Mr. ___ experienced worsening dyspnea, chest discomfort
while climbing the stairs this evening. While he notes
progressively worsening exertional dyspnea in the context of his
severe AS, this was markedly worse. He has also experienced
constipation, abdominal cramping since starting levofloxacin for
CAP on ___. His stool has become dark, tarry sticky the last 4
days with blood noted on toilet paper and possibly in bowel.
Last bowel movement ___, eat full dinner ___ denies
post-prandial lower abdominal pain, endorses occasional GERD. He
has h/o of long-term NSAID use until last year for DJD of knee
although he has increased use of 400mg q6hrs ibuprofen with
recent fever, he drinks approximately one bottle of wine per
day, he denies every experiencing withdrawal symptoms. He has
had hemorrhoids in the past, never any surgeries or
interventions for this or other GIBs.
EMS brought him to ___ from home, he received aspirin during
transport to ___. In the ED, initial vitals: T: 98.2 HR: 60
BP: 140/91 RR: 22 SO2: 1005 RA. Hemodynamically stable
throughout. No orthopnea. No fevers or cough. Exam notable for
melanotic stool on DRE and benign abdominal exam.
Labs notable for: WBC 13.3 Hgb: 6.0 Hct: 18.9 Plt: 343, BUN 62
Crt 0.8. Coagulation WNL. CTA revealed no active GIB. Received
one unit pRBC, protonix 80mg IV, fentanyl 50mcg x2 for angina.
On arrival to the MICU, T: 97.6 HR: 85 BP: 98/53 So2: 110% on
2___. First unit of pRBC still infusing during interview and
exam. Patient reports current orthopnea, anxiety and left-sided
sharp chest pain less than ___.
Past Medical History:
1. Aortic stenosis/bicuspid aortic valve ().
2. Prostate cancer.
3. Erectile dysfunction.
4. Arthralgias.
5. Hypertension.
6. Hypercholesterolemia.
7. PAD
8. DJD knee
9. colonic adenoma
10. carotid stenosis, asymptomatic
recently completed 5day course of abx for pNA
Social History:
___
Family History:
CAD/PVD; DM; HTN. Father had MI in ___ and stroke after PAD
surgery in ___.
Physical Exam:
ADMISSION EXAM
Vitals: T: 97.6 HR: 85 BP: 98/53 So2: 110% on ___
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric but pale, 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, SEM ___ radiating to
carotids, ?diastolic murmur, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No spider angioma, gynecomastia nor other stigmata of
cirrhosis, no koilonychia
NEURO: CN2-12 intact, moving all 4 extremities
ACCESS: 3 PIVs
DISCHARGE EXAM:
Vitals: 98.4 123/40 64 16 98% RA
Gen: Alert, lying comfortably in bed, no acute distress
HEENT: MMM, EOMi, PERLA, Conjunctival pallor, sclera anicteric
CV: Grade ___ midsystolic, cresendo-decrescendo murmur heard
beast at RUSB and apex. Radiates to carotids and clavicles,
increase with passive leg raise. Delayed carotid pulse. Bruits?
+s1 and S2
RESP: CTAB, no wheezes, rales, rhonchi
ABD: Soft, non-tender, non distended, no rebound or guarding
EXTR: WWP, no edema, 2+ pedal pulses
NEURO: Alert and attentive, CN2-12 intact, Motor ___ strength in
___, sensation grossly intact
SKIN: no signs of petechiae or rashes
Pertinent Results:
==============
ADMISSION LABS
==============
___ 02:10AM BLOOD WBC-13.3* RBC-1.96* Hgb-6.0* Hct-18.9*
MCV-96 MCH-30.6 MCHC-31.7* RDW-13.5 RDWSD-46.5* Plt ___
___ 07:30AM BLOOD WBC-13.2* RBC-2.34* Hgb-7.1* Hct-21.6*
MCV-92 MCH-30.3 MCHC-32.9 RDW-14.6 RDWSD-48.4* Plt ___
___ 01:15PM BLOOD Hgb-7.2* Hct-21.9*
___ 05:05PM BLOOD WBC-14.9* RBC-2.36* Hgb-7.1* Hct-21.5*
MCV-91 MCH-30.1 MCHC-33.0 RDW-14.7 RDWSD-47.6* Plt ___
___ 11:22PM BLOOD WBC-16.4* RBC-2.70* Hgb-8.1* Hct-25.0*
MCV-93 MCH-30.0 MCHC-32.4 RDW-14.5 RDWSD-48.4* Plt ___
___ 06:00AM BLOOD WBC-17.3* RBC-3.07* Hgb-9.2* Hct-27.6*
MCV-90 MCH-30.0 MCHC-33.3 RDW-15.5 RDWSD-50.0* Plt ___
___ 03:00PM BLOOD Hgb-9.8* Hct-28.8*
___ 08:00PM BLOOD WBC-15.5* RBC-3.38* Hgb-10.0* Hct-29.8*
MCV-88 MCH-29.6 MCHC-33.6 RDW-16.2* RDWSD-50.7* Plt ___
___ 04:07AM BLOOD WBC-13.0* RBC-3.21* Hgb-9.7* Hct-28.1*
MCV-88 MCH-30.2 MCHC-34.5 RDW-16.3* RDWSD-50.6* Plt ___
___ 02:10AM BLOOD Neuts-68.8 ___ Monos-5.4 Eos-1.6
Baso-0.1 Im ___ AbsNeut-9.13* AbsLymp-2.95 AbsMono-0.71
AbsEos-0.21 AbsBaso-0.01
___ 07:30AM BLOOD Neuts-83.6* Lymphs-11.6* Monos-2.5*
Eos-0.4* Baso-0.1 Im ___ AbsNeut-11.04* AbsLymp-1.53
AbsMono-0.33 AbsEos-0.05 AbsBaso-0.01
___ 02:10AM BLOOD Plt ___
___ 03:08AM BLOOD ___ PTT-27.4 ___
___ 07:30AM BLOOD ___ PTT-23.3* ___
___ 07:30AM BLOOD Plt ___
___ 05:05PM BLOOD Plt ___
___ 11:22PM BLOOD Plt ___
___ 06:00AM BLOOD Plt ___
___ 08:00PM BLOOD Plt ___
___ 04:07AM BLOOD Plt ___
___ 02:10AM BLOOD Glucose-142* UreaN-62* Creat-0.8 Na-139
K-4.6 Cl-105 HCO3-23 AnGap-16
___ 07:30AM BLOOD Glucose-160* UreaN-54* Creat-0.8 Na-139
K-4.3 Cl-104 HCO3-21* AnGap-18
___ 05:05PM BLOOD Glucose-111* UreaN-42* Creat-0.7 Na-139
K-3.7 Cl-105 HCO3-26 AnGap-12
___ 06:00AM BLOOD Glucose-133* UreaN-32* Creat-0.6 Na-137
K-5.1 Cl-105 HCO3-24 AnGap-13
___ 04:07AM BLOOD Glucose-120* UreaN-24* Creat-0.6 Na-137
K-4.5 Cl-103 HCO3-25 AnGap-14
___ 07:30AM BLOOD ALT-38 AST-24 LD(LDH)-182 AlkPhos-54
TotBili-0.3
___ 10:25AM BLOOD CK(CPK)-110
___ 05:05PM BLOOD CK(CPK)-176
___ 11:22PM BLOOD CK(CPK)-158
___ 06:00AM BLOOD CK(CPK)-133
___ 02:10AM BLOOD cTropnT-<0.01
___ 04:45AM BLOOD cTropnT-<0.01
___ 10:25AM BLOOD CK-MB-12* MB Indx-10.9* cTropnT-0.09*
___ 05:05PM BLOOD CK-MB-19* MB Indx-10.8* cTropnT-0.28*
___ 11:22PM BLOOD CK-MB-16* MB Indx-10.1* cTropnT-0.38*
___ 06:00AM BLOOD CK-MB-11* MB Indx-8.3* cTropnT-0.27*
___ 07:30AM BLOOD Albumin-3.3* Calcium-8.6 Phos-3.7 Mg-2.2
___ 05:05PM BLOOD Calcium-8.7 Phos-3.8 Mg-2.2
___ 06:00AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.3
___ 04:07AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.2
==============
DISCHARGE LABS
==============
___ 03:59PM BLOOD WBC-7.5 RBC-3.15* Hgb-9.3* Hct-29.4*
MCV-93 MCH-29.5 MCHC-31.6* RDW-16.3* RDWSD-51.8* Plt ___
___ 06:52AM BLOOD Glucose-103* UreaN-13 Creat-0.7 Na-139
K-4.9 Cl-100 HCO3-25 AnGap-19
___ 06:52AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.2
============
MICROBIOLOGY
============
__________________________________________________________
___ 5:00 pm SEROLOGY/BLOOD
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
POSITIVE BY EIA.
(Reference Range-Negative).
__________________________________________________________
___ 2:58 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:58 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 8:50 am URINE
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
===============
IMAGING/STUDIES
===============
ECHO (___):
Conclusions
The left atrium is mildly dilated. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
half of the inferior and inferolateral walls. The remaining
segments contract normally (biplane LVEF = 62 %). The estimated
cardiac index is normal (>=2.5L/min/m2). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve is bicuspid with moderately
thickened leafles. There is severe aortic valve stenosis (valve
area <1.0cm2). Mild (1+) aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Severe aortic valve stenosis. Mild symmetric left
ventricular hypertrophy with regional systolic dysfunction but
overall preserved systolic function. Mild aortic regurgitation.
Mild mitral regurgitation. Mild pulmonary artery systolic
hypertension.
CLINICAL IMPLICATIONS:
The patient has severe aortic valve stenosis. Based on ___
ACC/AHA Valvular Heart Disease Guidelines, if the patient is
asymptomatic, it is reasonable to consider an exercise stress
test to confirm symptom status. In addition, a follow-up study
is suggested in ___ months. If they are symptomatic (angina,
syncope, CHF) and a surgical or TAVI candidate, a mechanical
intervention is recommended.
CHEST (PA & LAT) (___):
FINDINGS:
Streaky opacities more prominent in the left upper lung and
bilateral lungn bases in the appropriate clinical setting may
represent pneumonia. There is multilevel mild loss of vertebral
body height throughout the thoracic spine.
Cardiomegaly is mild.
IMPRESSION:
Bibasilar and left upper lobe opacities in the appropriate
clinical setting are concerning for pneumonia.
RECOMMENDATION(S): Followup of the patient 4 weeks after
completion of
antibiotic therapy is required, in particular to document the
resolution of left upper lobe perihilar opacity. If findings
are unchanged, assessment with chest CT is required.
Additionally giving the presence of left lower lobe pulmonary
nodule, followup with chest CT in 3 months based on the size of
the left lower lobe nodule is recommended as well.
CTA ABD & PELVIS (___):
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is moderate
calcium burden in
the abdominal aorta and great abdominal arteries.
LOWER CHEST: Emphysematous changes are noted at the lung bases.
A 3 mm
pulmonary nodule is noted at the left lung base (series 3A,
image 10). There
is no pleural or pericardial effusion. Cardiomegaly is mild.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There
is no evidence of focal lesions. There is no evidence of
intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within
normal limits,
without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of stones, focal renal lesions, or
hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no
perinephric
abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Rounded soft
tissue and
partially calcified hypodensity along the greater curvature of
the stomach
measures 2.1 x 1.9 cm. This appears to have a soft tissue
component. 2
additional lesions along the greater curvature of the stomach on
image 34 and
31 to not have soft tissue components and are entirely
calcified. Small bowel
loops demonstrate normal caliber, wall thickness and enhancement
throughout.
Hyperdense material within several loops of small bowel and the
sigmoid colon
are present on the noncontrast images and likely represent
ingested material.
Colon and rectum are within normal limits. Appendix contains
air, has normal
caliber without evidence of fat stranding. There is no evidence
of mesenteric
lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal
lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
evidence of pelvic or inguinal lymphadenopathy. There is no
free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Brachytherapy seeds are noted in the
prostate.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Subchondral cystic changes noted at the right sacroiliac joint.
SOFT TISSUES: At the proximal most portion of the left inguinal
canal there is
a small focus of soft tissue, likely post surgical. There is a
small fat
containing umbilical hernia.
IMPRESSION:
1. No evidence of GI bleed.
2. 2.1 cm lesion along the greater curvature of the stomach.
Contains
calcifications but also has a soft tissue component. As 2
additional
completely calcified lesions are seen in this location these may
represent
calcified, torsed epiploic appendages, however the appearance of
the largest
lesion is unusual due to its larger soft tissue component in 3
months followup
with MRI is recommended to exclude a gist tumor.
3. Small hiatal hernia.
4. A small focus of soft tissue at the proximal-most portion of
the left
inguinal canal is nonspecific. Correlation with prior surgery
is recommended.
5. 3 mm pulmonary nodule at the left lung base.
RECOMMENDATION(S): 1. 3 months followup MRI for evaluation of
lesion along
the greater curvature of the stomach
2. The ___ pulmonary nodule recommendations
are intended as guidelines for follow-up and management of newly
incidentally
detected pulmonary nodules smaller than 8 mm, in patients ___
years of age or
older. Low risk patients have minimal or absent history of
smoking or other
known risk factors for primary lung neoplasm. High risk patients
have a
history of smoking or other known risk factors for primary lung
neoplasm.
In the case of nodule size <= 4 mm: No follow-up needed in
low-risk patients.
For high risk patients, recommend follow-up at 12 months and if
no change, no
further imaging needed.
Brief Hospital Course:
___ w/ PMH of severe aortic stenosis present with shortness of
breath, melena and significant hemoglobin drop (12.4 on ___ to
6.0 on ___ and developed Type II NSTEMI. He was admitted to
the MICU for monitoring (___).
# GI Bleed: Pt presented with melena and a Hgb drop of
12.4->6.0) in the setting of new and significant NSAID use and
drinking one bottle of wine daily. He received 4 units of PRBCs
and underwent an EGD in the MICU on ___. Unfortunately he
became hypotensive at the onset of sedation and the procedure
was aborted. Later that day he developed T-wave inversion on EKG
with a rise in troponin. Cardiology was consulted and believed
that this was secondary to demand ischemia in the setting of an
acute GI bleed. He was transfused another unit of blood to keep
the Hgb above 9.0. He was maintained on PPI BID per GI on
transfer out of the MICU. ___ ___ he had another melanotic
bowel movment which prompted ___ AM EGD. EGD showed bleeding
ulcer in duodenum, which was cauterized and injected with
epinephrine. He was transferred to medicine for monitoring. On
the medical floor, his hemoglobin was stable, 8.9-9.9 with
discharge hemoglobin 9.3 g/dL. He no longer had melanotic
stools. Per GI recommendations, he received Pantoprazole 40 mg
PO Q12H. He was also instructed to discontinue NSAID and alcohol
use. H. pylori IgG test was positive by ___ ___, for
which he was started on a 14 day course of clarithromycin and
amoxicillin in addition to his BID PPI. Per GI and At___
cardiology recommendations, his aspirin dose was downtitrated
and he was restarted on Aspirin 81 mg daily on ___.
# Community acquired pneumonia: CXR showed bilateral opacities
with a recent 5 day course of levofloxacin. He was treated with
ceftriaxone and azithromycin for 1 day. Since he was clinically
asymptomatic with no cough or fever, did not continue to treat.
He is recommended to have repeat imaging in 4 weeks to confirm
resolution.
# Type II NSTEMI: Active angina with lateral ST depressions,
likely demand ischemia in the setting of anemia vs hypotension
during EGD attempt. Troponin rise on ___ to 0.28 and CK-MB 19.
Trop rose to 0.38 but downtrended ___. CK-MB downtrended ___
to 11.
# Severe aortic stenosis: Patient underwent evaluation by
cardiac surgery on ___ and was deemed a moderate risk for TAVR
surgery. He will have further workup as an outpatient for TAVR
per At___ attending. Medicine spoke with and confirmed that ___
___ will be coordinating his follow up care for the AVR. GI
recs that work up for TAVR that requires anticoagulation be
completed after two weeks (after ___
# Leukocytosis: Initially WBC of 13.3 with predominance of
PMNs, felt to be reactive. CXR showed bilateral opacities with
recent completion of a 5 day course of levofloxacin ending on
___. He was afebrile and without cough, and upon transfer out of
the MICU, his WBC had resolved.
#HTN: He was normo- to hypertensive throughout admission. He was
restarted on amlodipine 10 mg PO daily and carvedilol 6.25 PO
BID with instructions to restart home lisinopril and
chlorthalidone in outpatient setting.
=====================
TRANSITIONAL ISSUES
=====================
# Medication changes. Started on pantoprazole 40 mg PO Q12H.
Downtitrated aspirin 325 mg to 81 mg daily. Atorvastatin
downtitrated to 20 mg daily while on macrolide therapy; please
consider uptitrating after completion of antibiotic course.
Chlorthalidone and lisinopril temporarily halted in the setting
of acute GI bleed; will be restarted individually as outpatient.
# Antibiotic course. Will require amoxicillin 1 g BID and
clarithromycin 500 mg BID x14 days (end ___ for treatment
of H. pylori. Please monitor for signs of rhabdomyolysis while
on concurrent macrolide and statin therapy.
# Repeat EGD. EGD ___ showed irregular Z-line, with concern
for ___, needs EGD follow up
# Repeat imaging (CXR, MRI abdomen, CT chest). Please f/u CXR in
4 weeks after resolution of pneumonia. CT ABD/Pelvis showed
lesion along the greater curveature of the stomach concerning
for possible GIST; please order 3 month followup MRI. Incidental
pulmonary nodule 3 mm at left lung base: High risk patient
(extensive smoking history), please follow-up at 12 months and
if no change, no further imaging needed.
# Severe aortic stenosis. Will be contacted by ___ team for
outpatient work-up.
# Communication/HCP: ___ ___
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 6.25 mg PO BID
2. Atorvastatin 80 mg PO QPM
3. Lisinopril 40 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. amLODIPine 10 mg PO DAILY
6. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Amoxicillin 1000 mg PO Q12H Duration: 14 Days
RX *amoxicillin 500 mg 2 (two) tablet(s) by mouth twice a day
Disp #*54 Tablet Refills:*0
2. Clarithromycin 500 mg PO Q12H Duration: 14 Days
RX *clarithromycin 500 mg 1 (one) tablet(s) by mouth twice a day
Disp #*27 Tablet Refills:*0
3. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 (one) tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 (one) tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg 1 (one) tablet(s) by mouth every night
Disp #*30 Tablet Refills:*0
6. amLODIPine 10 mg PO DAILY
7. Carvedilol 6.25 mg PO BID
8. HELD- Chlorthalidone 25 mg PO DAILY This medication was
held. Do not restart Chlorthalidone until ___ unless your blood
pressure is high at home.
9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until ___ unless your blood pressure is
high at home.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Duodenal/peptic ulcer disease
- Type II NSTEMI
- Melena
- Anemia secondary to bleeding
- H. pylori infection
SECONDARY DIAGNOSIS:
-HTN
-HLD
-Carotid Artery Stenosis
-Prostatic Adenocarcinoma s/p brachytherapy
-alcohol use disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the medical intensive care unit at ___
___ for shortness of breath and
chest pain caused by low red blood cell count secondary to
bleeding from a duodenal (intestinal) ulcer.
For your low red blood cell count, you were treated with red
blood cell transfusions. For your ulcer, the gastroenterologist
performed an esophagogastroduodenscopy (EGD) and cauterized and
injected medicine to help constrict the vessel to help prevent
future bleeding. We monitored your hemoglobin levels and they
were stable.
To minimize your risk of developing more ulcers, it is important
for you to stop taking NSAIDs such as ibuprofen and aleve and to
also refrain from alcohol use. These two things can exacerbate
ulcers. Also, you were positive for H. pylori antibody which
indicates an infection of H. pylori in your intestines which
will also be contributing to ulcer formation. For this, you will
be treated with two antibiotics as well as your acid suppressing
medication. One of these medications (clarithromycin) has the
potential to interact with your statin. If you experience any
muscle pains, stop taking your statin and call your PCP right
away.
We are discharging you home. Please follow up with your PCP ___.
___ on ___. At that appointment, she will
work with you to coordinate follow-up imaging for your
pneumonia. In terms of your aortic stenosis, the ___ team
will be coordinating your appointments.
It was a pleasure taking care of you,
Your ___ Healthcare Team
Followup Instructions:
___
|
19909906-DS-18 | 19,909,906 | 22,846,620 | DS | 18 | 2190-04-06 00:00:00 | 2190-04-06 15:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest + shoulder pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ old man with a history of CAD, s/p RCA
stent in ___ (95% stenosis RCA s/p ___/ additional 50%
proximal RCA stenosis, 40% OM1 stenosis), obesity, OSA, HTN who
presents with chest pain and L shoulder pain.
The patient is a very limited historian with ___ phone
interpreter, who has difficulty understanding his speech. He
reports that he has had left-sided chest and shoulder pain for 2
weeks. This is accompanied by profound fatigue and shortness of
breath. He does think it feels similar to chest pain he had
prior
to his catheterization in ___, but it is all the time and
not associated with exertion. Not associated with eating. He is
not sure if the pain improved after the catheterization, and he
is also not sure what occurred during the procedure, and
mentions
he thinks he might have gotten a pacemaker. He is unable to give
more details about the pain, or the history surrounding its
onset. He was referred to the ED by his primary care physician
after he called in reporting recurrent chest pain.
Of note, he has seen At___ cardiology as an outpatient for
anginal chest pain, and underwent elective catheterization in
___ with 50% ___. RCA stenosis and 95% mid, 80%
stenosis extending into distal segment. The mid and distal RCA
were stented. He had an ETT was done in ___ for cardiac rehab,
which was non-diagnostic but notable for markedly decreased
exercise capacity, bradycardia, and dizziness and fatigue with
exertion.
In the ED initial vitals were:
97.9 | 138/84 | 49 | 16 at 95% on RA
EKG: Sinus bradycardia with PAC, no e/o ischemia
Labs/studies notable for troponin negative x2, CXR without acute
intrathoracic process.
At___ cardiology was consulted and recommended pharmacologic
stress, which the patient could not tolerate due to
claustrophobia. The patient was admitted per ED given
inconsistent history and concern for possible ischemia.
Patient was given: Acetaminophen 1000mg PO, ketorolac 15mg, ASA
324, chlorthalidone 12.5mg, clopidogrel 75mg, losartan 100mg,
lorazepam 1mg prior to transfer.
On the floor, patient history is limited as above. He reports
taking his medications but does not know what they are. He
reports ongoing ___ chest pain, which is not improved with
nitroglycerin. He has a headache which he thinks his from not
drinking coffee.
Past Medical History:
HEALTH MAINTENANCE
SLEEP APNEA
___
NECK PAIN
LEFT KNEE PAIN
CERVICAL RADICULOPATHY
REFLUX
CHEST PAIN SYNDROME
LEFT SOFT PALATE LESION
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
===============
VS: T 98.0 BP 169/88 HR 53 RR 18 O2 sat 95% ra
GENERAL: Well developed obese male, appears mildly
uncomfortable.
Oriented x3. Mood
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Crowded oropharynx.
NECK: JVP assessment limited by body habitus.
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. Reproducible chest pain on palpation of
sternum.
LUNGS: Respiration is unlabored with no accessory muscle use. No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, mildly tender diffusely, distended. No
hepatomegaly. No splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
===============
VITALS: ___ 0743 Temp: 97.6 PO BP: 157/90 HR: 61 RR: 20 O2
sat: 99% O2 delivery: RA
GENERAL: Well-developed, well-nourished. NAD.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink,
no
pallor or cyanosis of the oral mucosa.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, normal S1, S2. No murmurs
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. No crackles or wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
Pertinent Results:
ADMISSION LABS:
===============
___ 11:30AM BLOOD WBC-6.7 RBC-4.58* Hgb-12.8* Hct-41.2
MCV-90 MCH-27.9 MCHC-31.1* RDW-13.8 RDWSD-45.1 Plt ___
___ 11:30AM BLOOD Neuts-61.0 ___ Monos-10.1
Eos-7.6* Baso-0.7 Im ___ AbsNeut-4.09 AbsLymp-1.34
AbsMono-0.68 AbsEos-0.51 AbsBaso-0.05
___ 11:30AM BLOOD ___ PTT-27.3 ___
___ 11:30AM BLOOD Glucose-98 UreaN-10 Creat-1.2 Na-141
K-4.5 Cl-105 HCO3-25 AnGap-11
___ 11:30AM BLOOD CK(CPK)-174
___ 07:03AM BLOOD ALT-62* AST-40 LD(LDH)-180 AlkPhos-74
Amylase-62 TotBili-0.4
___ 11:30AM BLOOD cTropnT-<0.01
___ 03:30PM BLOOD CK-MB-4 cTropnT-<0.01
___ 11:30AM BLOOD Calcium-9.3 Phos-3.2 Mg-2.1
DISCHARGE LABS:
===============
___ 07:03AM BLOOD WBC-6.9 RBC-4.90 Hgb-13.7 Hct-43.7 MCV-89
MCH-28.0 MCHC-31.4* RDW-13.9 RDWSD-45.0 Plt ___
___ 07:03AM BLOOD Plt ___
___ 07:03AM BLOOD Glucose-110* UreaN-20 Creat-1.1 Na-139
K-4.4 Cl-101 HCO3-23 AnGap-15
___ 07:03AM BLOOD ALT-62* AST-40 LD(LDH)-180 AlkPhos-74
Amylase-62 TotBili-0.4
___ 07:03AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:03AM BLOOD Calcium-9.3 Phos-3.8 Mg-2.1 Iron-101
___ 07:03AM BLOOD calTIBC-371 Ferritn-243 TRF-285
___ 07:03AM BLOOD TSH-1.1
IMAGING/STUDIES:
==================
___ CXR
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
___ old ___ man with a history of CAD, s/p RCA
stent in ___ (95% stenosis RCA s/p ___/ additional 50%
proximal RCA stenosis, 40% OM1 stenosis), obesity, OSA, HTN, who
presented with chest pain and L shoulder pain.
CORONARIES: See above
PUMP: Unknown
RHYTHM: Sinus Bradycardia
===============
ACTIVE ISSUES:
===============
# Coronary Artery Disease s/p RCA DES
# Chest pain
Patient presented with atypical chest pain, not convincingly
cardiac in nature. Pain was of weeks duration, non-exertional,
not relieved with nitro, Trops neg and EKG reassuring. Pain most
likely related to known rotator cuff tendonitis given
reproducibility on shoulder exam. Nonetheless, given recent DES
and risk factors, cardiology consulted. Recommended pMIBI, but
initial attempt aborted due to claustrophobia. Admitted with
plans for inpatient pMIBI and ongoing monitoring. Unfortunately
he was unable to be scheduled for pMIBI the following day while
inpatient. Given that that pain had resolved with negative
troponins and no events on telemetry, with relatively lower
suspicion for cardiac chest pain, decision was made to discharge
patient with plans for short-term followup outpatient pMIBI
scheduled for ___ (day post discharge). He was continued on
home ASA, clopidogrel, atorvastatin, losartan, chlorthalidone.
Home metoprolol was held in setting of bradycardia (HR ___ on
admission, to low of 42 overnight while sleeping). SBPs elevated
the following morning in 150s-160s, with recovery to HRs to
___, so he was started on carvedilol 3.125 bid prior to
discharge.
#Fatigue: Patient complains of marked fatigue accompanying
recurrence of chest pain. No obvious signs of infection or
profound metabolic abnormalities. Possibly related to CAD, but
most likely chronic and related to deconditioning and underlying
sleep apnea. Iron studies and TSH wnl.
================
CHRONIC ISSUES:
================
#HTN
Continued home chlorthalidone and losartan this admission. Home
metoprolol was held in setting of bradycardia (50s on admission,
to low of 42 overnight while sleeping). SBPs the following
morning in 150s-160s, started on carvedilol 3.125 bid.
#Asthma
Resumed home symbicort, Albuterol Q4hr PRN on discharge.
====================
TRANSITIONAL ISSUES:
====================
[] Nuclear Stress test scheduled for ___ at ___. Patient
instructed to not eat or consume caffeine prior to this test.
Please follow up stress test results.
[] Medication Changes: Started carvedilol 3.125 BID,
discontinued home Toprol (given bradycardia on metoprolol, and
also his concurrent hypertension)
[] Monitor HR and BPs for bradycardia and hypertension; adjust
carvedilol prn.
[] Monitor for recurrence of chest pain.
[] Consider outpatient TTE
[] ___ benefit from physical therapy for rotator cuff
# CODE STATUS: FC
# CONTACT:
Proxy name: ___
Relationship: Wife Phone: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 100 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
6. Chlorthalidone 12.5 mg PO DAILY
7. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
8. Atorvastatin 80 mg PO QPM
9. Benzonatate 200 mg PO TID:PRN cough
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. CARVedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Benzonatate 200 mg PO TID:PRN cough
7. Chlorthalidone 12.5 mg PO DAILY
8. Clopidogrel 75 mg PO DAILY
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
11. Losartan Potassium 100 mg PO DAILY
12. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
13. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Chest pain
Coronary artery disease
Bradycardia
SECONDARY DIAGNOSIS:
Hypertension
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure to care for you at ___.
WHY WERE YOU ADMITTED?
- You had chest pain.
WHAT HAPPENED THIS ADMISSION?
- We had planned to perform a stress test while you were here,
however you were unable to tolerate it due to claustrophobia.
Unfortunately, performing this test in a more environment
friendly area would require you to stay in the hospital for an
extra day or so. Because your chest pain has largely resolved,
and your lab work and EKGs have been reassuring, we felt
comfortable discharging you with plans to perform this test as
an outpatient.
WHAT SHOULD YOU DO ON DISCHARGE?
- Take your medications as prescribed.
- Go to your follow up appointments as scheduled.
- You are scheduled to undergo this stress test at 7:15 am on
___ at ___. They are located at ___.
-IMPORTANT: DO NOT EAT PRIOR TO YOUR APPOINTMENT TOMORROW
MORNING. ADDITIONALLY, DO NOT DRINK COFFEE OR ANY BEVERAGES
CONTAINING CAFFINE UNTIL AFTER YOUR TEST.
-IMPORTANT: DO NOT TAKE YOUR NEW MEDICATION ("CARVEDILOL")
TOMORROW MONRING. PLEASE RESUME AFTER YOUR STRESS TEST.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19909991-DS-12 | 19,909,991 | 21,532,847 | DS | 12 | 2146-05-06 00:00:00 | 2146-05-12 22:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chronic uncal herniation in setting of cognitive decline,
tremor, and behavioral changes
Major Surgical or Invasive Procedure:
intubation/extubation for MRI on ___
History of Present Illness:
Ms. ___ is a ___ year-old right-handed woman who presents
for admission for accelerated evaluation of rapid cognitive
decline, tremor, and pending herniation on brain imaging.
She has not seen a physician ___ ___ years, and her family became
worried. The patient saw Dr. ___ in Neurology clinic in
___ and ___ with concerns for tremor, cognitive
decline, and behavior changes since ___. Given the
concern for frontal-temporal dementia, an MR head was ordered to
assess for atrophy. MR head demonstrated chronic uncal
herniation, and the patient was advised to go to the ED for
inpatient workup.
Her tremor is present in her hands (R>L), tongue and voice, but
not her head or legs. Her tremors are not present upon rest, but
are exacerbated by positioning and action; they have caused
significant difficulties with ADLs. She was seen by Dr.
___ in Movement ___ in ___. She was prescribed
primidone, but this has not helped with the tremor. She has been
much more lightheaded with position change, and has had a couple
of falls. The patient denies changes in her gait or balance;
family members report a wider-based stance when she initially
stands up, improved with walking.
With regards to her behavior and cognitive changes, the patient
reports waking up one day and suddenly "not feeling herself."
Her family reports that she has not been keeping up with her
hygiene. They report that her memory is intact, but that her
concentration has seemed off. Per patient, her mood is not
"down", although she has been treated with antidepressants in
the past.
Additionally, she has stopped paying her own bills or making
meals for herself. Regarding the meals, she eats well when her
sister cooks for her, but has lost 35 lbs over the past 6
months. Patient denies actively trying to lose weight, but
appears to have had difficulty hydrating herself.
She has had trouble sleeping secondary to generalized pruritus,
which wakes her up at night; she is then frequently fatigued
during the day. Her husband also notes lots of thrashing during
the night, and she has a long-standing history of "jumpy legs"
while falling asleep.
Of note, patient did not have insurance for some time and did
not see any doctors ___ ___ years before presenting to Neurology
for tremor in ___. Her last mammogram, ___ years ago, was
normal, per patient. Her last colonoscopy was about ___ years
ago.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel incontinence or retention. Denies
difficulty with gait.
On general review of systems, the pt reports stress incontinence
and several months of pruritus on arms and legs. She denies
recent fever or chills. No night sweats. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No dysuria. Denies arthralgias or
myalgias.
Past Medical History:
Iron deficiency anemia
Essential tremor
Chronic pruritis x 6 months
Social History:
___
Family History:
Mother had tremor in the hands as well as Alzheimer's disease,
symptoms that began in late ___.
Father had prostate cancer. No other tremors, memory
difficulties, or cancers in the family. Siblings and sons
healthy.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.2 P: 80 BP:126/65 RR: 18 SaO2: 100% RA
General: Awake, cooperative, distressed by constant itching and
scratching.
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: Scattered excoriations on the skin, no other erythema or
rash underlying excoriated areas
Lymph: No neck or underarm LAD
.
Neurologic:
-Mental Status: Alert, oriented x 3 (mild difficulty with date,
___. Mild inattention/executive dysfunction, able to name ___
forward, with MOYB, stops at ___, then 5 minutes later, in
the
midst of another cognitive task, patient spontaneously finished
the MOYB (from ___ to ___ correctly, unprompted. Able to relate
history, but vague with details and sometimes timespan. 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:
I: Olfaction not tested.
II: PERRL 4 to 3mm 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 and has symmetric strength.
Mild
tremor of tongue at rest and extension.
.
-Motor: Normal bulk, tone throughout. No pronator drift. Action
and postural tremor in the right > left hands, slightly
increased in wing-beating posture. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
.
-Sensory: No deficits to light touch, cold sensation, vibratory
sense, proprioception throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
.
-Coordination: No dysmetria on FNF or HKS bilaterally.
.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to toe, heel, and walk in tandem without
difficulty. Romberg absent.
.
==========================================
Discharge examination:
General: No distress, no agitation
Card: RRR no m/r/g
PULM: CTAB no r/r/w
ABD: Soft NT ND NABS
Skin: Scabs of various ages healing
Neurologic:
- MS: Awake, alert, oriented x3 promptly. Months of the year in
reverse done slowly and with interruption, but correctly. Naming
to high and low frequency objects is intact. Some difficulty
with complex commands. Comprehension and repetition are normal.
- CN: Normal
- MOTOR: Full strength. No tremor present now.
- SENSORY: Intact to basic modalities (touch, temperature)
- REFLEXES: Normal throughout
- CEREBELLAR: No dysmetria, tremor.
Pertinent Results:
ADMISSION LABS:
___ 10:50AM BLOOD WBC-6.9 RBC-5.59* Hgb-11.9* Hct-38.0
MCV-68* MCH-21.3* MCHC-31.4 RDW-16.2* Plt ___
___ 10:50AM BLOOD Neuts-66.7 ___ Monos-6.0 Eos-5.3*
Baso-0.5
___ 02:28AM BLOOD ___ PTT-27.9 ___
___ 10:50AM BLOOD Glucose-84 UreaN-17 Creat-0.6 Na-139
K-5.0 Cl-103 HCO3-31 AnGap-10
___ 10:50AM BLOOD ALT-30 AST-24 AlkPhos-66 TotBili-0.3
___ 02:34AM BLOOD Calcium-8.7 Phos-3.0 Mg-2.1
___ 10:50AM BLOOD Albumin-4.1
___ 10:50AM BLOOD CRP-1.3
___ 09:29AM BLOOD ___
___ 07:45PM BLOOD RheuFac-16*
___ 06:00AM BLOOD Anti-Tg-LESS THAN Thyrogl-5 antiTPO-21
___ 09:29AM BLOOD ANCA-POSITIVE *
___ 12:17PM BLOOD calTIBC-261 Ferritn-309* TRF-201 Iron-14*
___ 05:35AM BLOOD C3-151 C4-55*
___ 09:29AM BLOOD HIV Ab-NEGATIVE
___ 07:15AM BLOOD QUANTIFERON-TB GOLD-negative
___ CITRULLINATED PEPTIDE (CCP) ANTIBODY, IGG-negative
___ 07:45PM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-negative
___ 09:29AM BLOOD C2-negative
___ 09:29AM BLOOD C1 INHIBITOR-negative
___ 09:29AM BLOOD ANGIOTENSIN 1 - CONVERTING ___
URINE:
___ Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG
Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG RBC-<1 WBC-0
Bacteri-FEW Yeast-NONE Epi-0
MICROBIOLOGY:
___ CRYPTOCOCCAL ANTIGEN NOT DETECTED.
___ 3:45 pm Blood (EBV)
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE <1:10 BY IFA.
___ Urine culture: NGTD
___ Urine culture: NGTD
___ BLOOD CULTURE NGTD x2
IMAGING:
___ ___: No significant interval change in appearance of the
brain from ___ allowing for differences in imaging
modality. Unchanged effacement of the right cerebral sulci and
the suprasellar and ambient cisterns with uncal herniation
bilaterally possibly related to metabolic encephalopathy given
lack of mass effect or cerebral edema.
CT CHEST ___:
1. A few bilateral patchy and ground-glass opacities, which may
be of
infectious or inflammatory etiology; however, follow-up after
treatment in ___ months is recommended.
2. Left axillary lymph nodes are at upper limits of normal.
3. Tiny right lobe of thyroid nodule.
CT ABD/PELVIS ___:
1. No definite intra-abdominal malignancy.
2. 3.5cm simple cystic lesion arising from the left ovary for
which a six month follow-up pelvic ultrasound is recommended for
further assessment.
UPPER EXT ULTRASOUND ___:
Focal left cephalic vein thrombophlebitis and focal right
basilic vein
thrombophlebitis in the regions of recent peripheral IV
insertion attempts. No extension into the deep venous system.
MRI ___:
IMPRESSION:
The pachymeningeal enhancement has essentially resolved. There
is improved
mass effect on the left lateral ventricle, and the midbrain.
There is
persistent but improved bilateral uncal herniation with a better
visualization
of the ambient cistern.
Post-operative changes are seen.
MR spectroscopy is unremarkable without evidence of elevated
choline to NAA
ratio to suggest a neoplasm.
EEG ___
Status post left frontal craniotomy with expected changes in the
left frontal surgical bed, including small amount of blood and
minimal edema. Unchanged intracranial mass effect.
EEG ___
This telemetry captured several pushbutton activations, but
none for definite seizures. Throughout the recording, there were
very frequent generalized sharp wave discharges, especially
before the late evening of ___. Some of these lasted a
minute or 2 at a time and could be considered electrographic
seizures, but they were not particularly rhythmic throughout
most of their occurrence, and no definite sign of seizure could
be seen clinically on video. Nevertheless, the discharges were
occasionally rhythmic (for several seconds at a time) and they
were extremely frequent for much of the daytime on the ___.
They were relatively infrequent after midnight.
EEG ___: This telemetry captured two pushbutton
activations, without evidence of seizures.. The background
appeared to reflect a mild
encephalopathy, without prominent focal slowing. There were very
frequent
epileptiform spike or sharp and slow wave discharges,
essentially all with a generalized appearance but never
occurring in prolonged runs to suggest ongoing seizures. The
sharp waves were more frequent in the first several hours of
recording. They did occur later in sleep. They could occur up to
twice a second though only irregularly over a ___ second period
or so, and without evidence of seizure by clinical observation,
as recorded on video.
EEG ___: This was an abnormal continuous video EEG
monitoring study because of background slowing in the theta
frequency range consistent with a moderate encephalopathy force
etiology is non-specific. Diffuse slowing was also seen over the
entire left hemisphere with attenuation of faster rhythms
throughout the recording consistent with a structural lesion
causing subcortical dysfunction diffusely over the left
hemisphere. As well, there were generalized spike and wave
discharges that occur in isolation, and in runs of up to three
seconds in duration, without clear evolution to suggest
electrographic seizures. There was no significant clinical
change seen on video during any of these episodes. These
findings are consistent with highly epileptogenic cortex in a
generalized distribution. There were no electrographic seizures
recorded.
EEG ___: This is an abnormal continuous video EEG
monitoring study due to the presence of frequent runs of
periodic generalized epileptiform discharges at ___ Hz lasting
two to eight seconds in duration. Occasionally, these discharges
can be prolonged, lasting up to 15 seconds. Although these
longer runs of discharges are concerning for ictal activity,
there is no evolution of
the discharges and do not meet criteria for electrographic
seizures. Review of video during these bursts reveals no clear
clinical change during these bursts. T hese generalized
discharges are most frequent during wakefulness. These findings
suggest highly epileptogenic cortex in a generalized
distribution. Additionally, diffuse background slowing is seen
in the theta frequency range consistent with a moderate
encephalopathy for which the etiology is non-specific.
DISCHARGE LABS:
___ 11:15AM BLOOD WBC-4.5 RBC-5.08 Hgb-11.0* Hct-35.2*
MCV-69* MCH-21.6* MCHC-31.1 RDW-17.9* Plt ___
___ 11:15AM BLOOD Glucose-107* UreaN-15 Creat-0.7 Na-136
K-4.2 Cl-102 HCO3-25 AnGap-13
___ 07:10AM BLOOD ALT-71* AST-42* LD(LDH)-298* AlkPhos-181*
TotBili-0.3
Brief Hospital Course:
Ms. ___ is a ___ RH woman who was admitted for accelerated
evaluation of rapid cognitive decline, RUE tremor, and an
abnormal outpatient MRI with pachymeningitis and bilateral uncal
herniation. Ultimately, no cause was found for her meningeal
enhancement and near-herniation, though the former resolved and
the latter was improved at discharge. She was also treated for
seizure, scabies, and beta thalassemia minor.
.
# NEUROLOGY:
On admission, her neurological examination was notable for
inattention and frontal disinhibition, occasional tremor R >L
which was difficult to characterize. She has had episodes of
somnolence/agitation, requiring ICU level monitoring for 3 days
at the beginning of her hospital course. In the ICU, she was
placed on EEG which showed frequent electrographic seizures
along with spike-and wave biposterior centrotemporal discharges.
She ultimately required 4 AEDs to control her seizures (Keppra,
phenytoin, lacosamide, zonisamide) and her mental status slowly
improved. While persistent discharges were seen on EEG, these
did not appear to have any clinical correlate. Brain biopsy was
done on ___ of dura, bone, parenchyma and was notable for
heterotopia of the parenchyma and slight hypercellularity of the
dura. No CSF sample was obtained at that time. Serum studies
showed elevated ESR, positive atypical ANCA, most concerning for
an autoimmune or paraneoplastic cause of her pachymeningitis.
CT torso did not show clear cause (only small thyroid nodule
and an ovarian cyst). Serum paraneoplastic panel, autoimmune
work-up, and hepatitis panels were negative. Systemic steroids
were given ___ which may have helped her mental status
(although confounded by simultaneous AED changes). Imaging
(MRI, MRS, MR ___) were repeated on ___ and showed resolution
in the previously shown pachymeningeal enhancement and
improvement of near-herniation (the ambient cisterns were
visible). Due to resolution of enhancement, repeat biopsy was
deferred. For unclear reasons, the patient's cognitive status
improved steadily and was near her baseline at time of
discharge.
.
# DERMATOLOGY:
She presented with multiple severe excoriations in the setting
of a 6 month history of diffuse itching. There was no metabolic
or toxic derangements to explain this. Dermatology was
consulted who recommended treatment for possible scabies given
exposure at home. Skin scrapings were negative. She was
treated with ivermectin on ___ and again on ___ with subsequent
resolution of symptoms. It was eventually concluded that she did
have scabies. Topical lidocaine and oral benadryl were also
given. At time of discharge, her pruritus was very minimal.
.
# HEMATOLOGY:
She presented with microcytic anemia and an iron panel
consistent with anemia of chronic disease. Family history of
thalassemia minor. Peripheral smear most suggestive of
thalassemia. Retic 2.3. Hgb electropheresis showed
beta-thalassemia minor. She was started on folate
supplementation.
.
# HEPATOLOGY
Transaminitis ALT > AST, in the setting of phenytoin toxicity,
trended downward as phenytoin lowered.
.
# RHEUMATOLOGY:
Given her pANCA atypical result and pruritis, rheum was
consulted. The team felt this was not a primary rheum issue.
They did note that atypical pANCA can accompany PSC.
.
# INFECTIOUS DISEASE:
Apart from the concerns for scabies (treated with ivermection)
all cultures of blood and urine and sputum were negative. CSF
sample for culture was lacking.
.
# GYNECOLOGY:
CT torso showed an incidental 3.5cm simple cystic lesion arising
from the left ovary for which a six month follow-up pelvic
ultrasound is necessary.
.
TRANSITIONAL ISSUE:
# Re-check phenytoin level once a week. The free percentage in
Mrs. ___ is 12%. Please multiply the serum phenytoin level
by 0.12 and that will yield the FREE PHENYTOIN LEVEL. This
should be between 1.5 and 2.5. If it is less than 1.5 or greater
than 2.5, please contact Dr. ___ IMMEDIATELY at ___.
.
# Follow up with Dr. ___ in neurology. An MRI brain with and
without contrast is scheduled to be done at:
Department: RADIOLOGY
When: ___ at 2:20 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
.
# Transaminitis: Repeat LFTs 1 month from discharge to insure
that they continue to trend down
.
# She will need a follow-up pelvic ultrasound in ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PrimiDONE 50 mg PO HS
2. Cyanocobalamin Dose is Unknown PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. PrimiDONE 50 mg PO HS
2. Multivitamins 1 TAB PO DAILY
3. Clobetasol Propionate 0.05% Cream 1 Appl TP BID Duration: 2
Weeks
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. LACOSamide 200 mg PO BID
7. LeVETiracetam 1500 mg PO QAM
8. LeVETiracetam ___ mg PO QPM
9. Lorazepam 1 mg IV Q4H:PRN generalized seizure >3 min
10. Phenytoin (Suspension) 160 mg PO BID
11. Phenytoin Infatab 100 mg PO DAILY
12. QUEtiapine Fumarate 25 mg PO QHS
13. QUEtiapine Fumarate 25 mg PO DAILY:PRN agitation
14. Senna 8.6 mg PO BID:PRN constipation
15. Zonisamide 400 mg PO HS
16. FoLIC Acid 1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
pachymeningitis
seizures
scabies
beta-thalassemia minor
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 while you were at ___.
You were hospitalized for further work-up of altered mental
status, tremor, and an abnormal MRI, which demonstrated swelling
of the brain. It is not completely clear why this happened, but
it has improved. Inflammation of the brain sheath (the meninges)
was present on admission but has resolved.
We found seizure activity on your EEG (a test which records
brain waves) and were able to treat this with a combination of
drugs which you will take for at least the near future.
In addition, we determined that your itch was due to scabies for
which you received a drug called ivermectin. Thankfully your
itch improved substantially after that. You have a mild anemia
caused by a genetic blood abnormality (called beta thalassemia
minor) which has not caused you any serious problems.
Call ___ or your physician for any of the "danger signs" below.
Your medication list has changed; please be sure that you
receive a paper copy of your medication list when you leave
rehab to go home. BRING THAT LIST TO ALL FUTURE APPOINTMENTS AND
UPDATE IT IF YOUR MEDICATIONS CHANGE.
Please note that you have a follow-up appointment scheduled with
Dr. ___ as below. Please call ___ to schedule an MRI
of your brain for about 2 weeks prior to your neurology
appointment.
Followup Instructions:
___
|
19909991-DS-13 | 19,909,991 | 23,267,730 | DS | 13 | 2146-08-05 00:00:00 | 2146-08-21 18:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
lethargy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ RH F with a recent admission to the
general neruology service from ___ to ___ ___ognitive
decline, tremor and pending herniation on brain imaging. MRI
showed pachymeningitis and bilateral uncal herniation, which was
of unclear cause. She was monitored on cvEEG which demonstrated
frequent electrographic seizures and spike and wave bilateral
posterior and centrotemproal discharges. These electrographic
seizures were not associated with a clinical correlate. She
ultimately required 4 AEDs (Keppra, dilantin, lacosamide and
zonisamide) for seizure control, which gave slow improvement in
her mental status. She had a brain biopsy on ___ which showed
herterotopia o fhte the parenchyma and slight hypercellularity
of the dura. She was foudn to have elevated ESR and ANCA arising
concern for autoimmune or paraneoplastic etiology. A Ct torso,
paraneoplastic panel and autoimmune work up were unrevealing.
She was treated empirically with systemic steroids from ___ to
___, which also may have contributed to improved mental status.
Repeat MR imaging demonstrated resolution of the previously seen
pachymeningeal enhancement and improvement in previously seen
herniation. Ultimately the cause of her neurologic syndrome was
not determined. DDx includes idiopathic hypertrophic
pachymeningitis, a lymphomatous process, or other
automimmune/inflammatory process. She was discharged and
followed by ___ in neurology clinic.
Ms. ___ was seen in clinic on ___. At that time she had
been doing well at rehab, but did complain of some loneliness
and feeling isolated. She continued to have some postural
tremor. She was able to do activities such as play the piano
from memory and cook for herself. She also reported subjective
improvement in her cognition, stating that she had returned to
her baseline of ___ years prior. She also reported some morning
headaches at that time that were relieved by tylenol. An MRI on
___ appeared slightly worse than prior. A second repeat MRI on
___ was read as unchanged.
Since her last clinc visit she has again begun to worsen
clinically. Her husband reports frequent episodes of "nodding
off" and periods of falling alseep during which she is difficult
to arouse. These tend to happen after taking her morning and
evening medication dosing. She is reporting feeling dizzy and
off balance and has fallen at least once. She is also having
episodes of urinary incontinence.
With these symptoms there is concern for either medication
toxicity or intermittent seizure activity causing her somnolence
and urinary incontinence. She has not been taking her Vimpat as
her insurance company did not approve this medication, but has
been taking all other AEDs as prescribed. These concerns were
realted to Dr. ___ the telephone who recommended
presentation to the ED and admission to the epilepsy service for
repeat imaging, cvEEG monitoring and titration of AEDs.
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, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Iron deficiency anemia
Essential tremor
Chronic pruritis x 6 months
Neurologic syndrome of unclear etiology as detailed above
possible scabies
Social History:
___
Family History:
Mother had tremor in the hands as well as Alzheimer's disease,
symptoms that began in late ___. Father had prostate cancer.
No other tremors, memory difficulties, or cancers in the
family. Siblings and sons healthy.
Physical Exam:
On Admission:
Vitals:
98.2 75 118/66 18 100% RA
GEN: Awake, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
NECK: Supple, no carotid bruits.
RESP: CTAB no w/r/r
CV: RRR, no m/r/g
ABD: soft, NT/ND, normoactive bowel sounds
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS:
Alert, oriented x 3.
Able to relate history without difficulty.
Able to name ___, but then gets hung up and unable to
proceed
Language is fluent with intact repetition and comprehension.
Normal prosody.
There were no paraphasic errors.
Speech was not dysarthric.
Able to follow both midline and appendicular commands.
Good knowledge of current events.
No evidence of apraxia or neglect.
CN:
II:
PERRLA 3 to 2mm and brisk.
VFF to confrontation.
III, IV, VI: EOMI, no nystagmus. Normal saccades.
V: Sensation intact to LT.
VII: Facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk, tone throughout. No pronator drift bilaterally.
No adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ ___ 5 5
R ___ ___ ___ ___ 5 5
Sensory: No deficits to light touch, pinprick. Diminished
proproprioception at left toe, intact on right. No extinction to
DSS.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Right to mute, left toe up slightly
Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on FNF or HKS bilaterally.
On Discharge: Exam is largely unchanged apart from increased
alertness.
Pertinent Results:
Labs:
___ 09:30PM BLOOD WBC-3.7* RBC-5.20 Hgb-11.7* Hct-37.4
MCV-72* MCH-22.4* MCHC-31.2 RDW-16.0* Plt ___
___ 09:30PM BLOOD Neuts-68.2 ___ Monos-5.1 Eos-1.7
Baso-0.8
___ 09:05PM BLOOD ESR-4
___ 09:30PM BLOOD Glucose-122* UreaN-22* Creat-1.0 Na-144
K-3.8 Cl-106 HCO3-26 AnGap-16
___ 08:41AM BLOOD ALT-41* AST-20 AlkPhos-129* TotBili-0.3
___ 10:00AM BLOOD Albumin-3.9
___ 08:41AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1
___ 10:00AM BLOOD TSH-2.4
___ 10:00AM BLOOD Free T4-0.95
___ 10:00AM BLOOD Cortsol-32.0*
___ 07:10PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 09:05PM BLOOD Smooth-NEGATIVE ANCA-NEGATIVE
___ 05:27PM BLOOD CA125-8.6
___ 09:05PM BLOOD ___
___ 09:05PM BLOOD RheuFac-7 CRP-2.6 Anti-Tg-LESS THAN
Thyrogl-6 antiTPO-LESS THAN
___ 09:05PM BLOOD b2micro-2.2 IgG-591*
___ 09:05PM BLOOD C3-118 C4-35
___ 07:45AM BLOOD Phenyto-13.9
___ 09:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:35 QUANTIFERON-TB GOLD - Negative test result.
M. tuberculosis complex infection unlikely.
___ 07:35 ANGIOTENSIN 1 - CONVERTING ___ - 34 ___
U/L)
___ 17:27 CA ___ - 12 (<34 U/mL)
___ 21:05 RO & LA - Negative
___ 18:55 ZONISAMIDE(ZONEGRAN) - 2.6 L (10.0-40.0
mcg/mL)
___ 23:00 LEVETIRACETAM (KEPPRA) - 41.0
Imaging:
CXR ___: No acute intrathoracic process
CT Sinus ___:
Minimal mucosal thickening of the bilateral maxillary sinuses
and leftward
deviation of the nasal septum. Otherwise, unremarkable CT
examination of the sinuses.
EEG ___:
IMPRESSION: Abnormal cEEG because of (1) frequent two to eight
second bursts
of ___ Hz biparietally predominant generalized spike wave and
sharp wave
discharges, without clear clinical correlate, and without
evolution or
organization to suggest that they are electrographic seizures.
These are
present primarily during the awake state when the patient's eyes
are closed
and during drowsiness and are markedly diminished during eyes
open wakefulness
and deeper sleep. There is no clinical correlate to these
bursts. These are
indicative of generalized cortical irritability, maximal in the
posterior
regions; (2) significant intermixed theta activity in the awake
state
consistent with a mild encephalopathy. In comparison to the
prior EEG from
___ and to the prior cEEG study from ___, there are no
significant changes.
EEG ___:
IMPRESSION: Abnormal cEEG because of (1) an unusual pattern
defined by
frequent intermittent two to eight second bursts of ___ Hz
generalized,
bifrontocentrally predominant rhythmic delta activity with
superimposed
centroparietally predominant spikes as well as superimposed
frontocentrally
predominant fast polyspike activity. These bursts are present
primarily
during the awake eyes closed state and during drowsiness and are
markedly
diminished to almost completely absent during eyes open
wakefulness and deeper
sleep. There is no clinical correlate to these bursts. While the
presence of
generalized spikes would typically indicate generalized cortical
irritability,
the significance of this specific more complex pattern is
unclear; (2)
isolated generalized parietally predominant spikes and frontally
predominant
polyspikes during sleep indicative of generalized cortical
irritability; (3)
significant intermixed theta activity in the awake state
consistent with a
mild encephalopathy. In comparison to the prior day's study, the
bursts are
less frequent than on the prior day, particularly in the
afternoon.
MRI Head W and W/out contrast ___:
Interval worsening of diffuse pachymeningeal thickening and
enhancement, and bilateral uncal herniation with associated
deformity of the midbrain. Again, these findings may reflect
intracranial hypotension, related to occult "CSF leak."
CT Abd/Pelvis ___:
1. No evidence of intrapelvic or intra-abdominal malignant
disease.
2. 3.7 x 2.7 cm left paraovarian lesion, which is slightly
enlarged from the prior exam. However, pelvic ultrasound is
recommended for further evaluation and characterization.
CT Chest ___:
No evidence of intrathoracic malignancy.
Mild bilateral axillary adenopathy improved since ___.
No
intrathoracic lymph node enlargement.
Right periscapular bursal cyst does not require further
evaluation unless the
patient is symptomatic.
MRI C,T,L-Spine ___:
1. Interval worsening of previously noted dural thickening and
enhancement
which now extends intermittently down the length of the spine.
2. No interval change in large perineural cysts in the thoracic
spine and
multiple Tarlov cysts. No findings to suggest CSF leak.
3. Multilevel degenerative changes as described above which have
not
significantly changed.
Pelvic Ultrasound ___:
Normal uterus and ovaries.
Parovarian cyst which does not demonstrate any features
suggestive of ovarian neoplasm.
Microbiology:
___ 11:21 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ is a ___ right handed woman with a recent
admission to the general neruology service from ___ to ___
___ognitive decline, tremor and pending uncal
herniation on brain imaging. Work up revealed evidence of
pachymeningitis of unclear cause and frequent electrographic
seizures without clinical correlate. Seizures were controlled
with 4 AEDs and an empriric course of systemic steroids provided
improvement in the patient's mental status.
Over the past month or so the patient has begun to have frequent
periods of nodding off and urinary incontinence. There was
concern for either medication toxicity or intermittent seizures
and she was admitted for repeat imaging of the brain, continuous
video EEG monitoring and possible titration of her AEDs. She was
found to have a UTI and is completed a course of antibiotics.
Her symptoms of incontinence have resolved and her sleepiness is
improving.
# CHRONIC UNCAL HERNIATION / PACHYMENINGITIS: Appears worse on
repeat MRI compared with prior. On exam she continues to be
alert. She does have some cognitive deficits (can only name 5
words that start with the letter "s" in 1 min). The etiology of
her uncal herniation could be either secondary to increased
intracranial pressure or low CSF pressure in the spine from an
occult CSF leak. Fundoscopic exam did not reveal papilledema.
The pain service was consulted with a question of empiric blood
patch but ultimately the procedure was deemed to risky because
an accidental puncture of the dura could be fatal in the setting
of increased intracranial pressure. Her workup for an etiology
of her pachymeningitis including imaging to look for CSF leak,
malignancy workup, and rheumatologic workup was repeated and
unrevealing. Concerns regarding her safety at home were raised
and a family meeting was held to arrange a safe discharge plan.
# SEIZURES: In the setting of chronic pachymeningitis and uncal
herniation Ms. ___ has abnormal EEG findings. Although
abnormal at baseline, her EEG did not show new abnormalities.
She was discharged on Keppra XR ___ daily, phenytoin BID,
Zonisamide 400mg qhs. She also continued primidone, folate, and
her multivitamin. Her Seroquel was held in the setting of
increased sleepiness.
# URINARY TRACT INFECTION: UA and urine culture revealed a
urinary tract infection and she was treated for an uncomplicated
UTI with 3 days of ceftriaxone. Likely this was the etiology of
the urinary incontinence and possibly waxing and waning mental
status, both of which improved with treatment of her UTI.
# PRURUTIS: Ms. ___ has chronic itching with a questionable
history of scabies last hospitalization for which she was
empirically treated. She had no rash on exam. Dermatology was
consulted and felt her itching is not consistent with scabies.
It improved with topical creams including Vaseline and sarna.
Systemic illness including Hepatitis B and abnormal liver
function were ruled out as well.
TRANSITIONAL ISSUES
- follow up in neurology clinic
- elder services is following her outpatient regarding a safe
home plan
- PET scan outpatient to rule out occult malignancy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PrimiDONE 50 mg PO HS
2. Multivitamins 1 TAB PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. LeVETiracetam 1500 mg PO QAM
6. LeVETiracetam ___ mg PO QPM
7. Lorazepam 1 mg IV Q4H:PRN generalized seizure >3 min
8. Phenytoin (Suspension) 160 mg PO BID
9. Phenytoin Infatab 100 mg PO DAILY
10. QUEtiapine Fumarate 25 mg PO QHS
11. QUEtiapine Fumarate 25 mg PO DAILY:PRN agitation
12. Senna 8.6 mg PO BID:PRN constipation
13. Zonisamide 400 mg PO HS
14. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Heparin 5000 UNIT SC TID
4. Keppra XR (levETIRAcetam) ___ oral daily
RX *levetiracetam [Keppra XR] 500 mg 4 tablet(s) by mouth once a
day Disp #*240 Tablet Refills:*0
5. Lorazepam 1 mg IV Q4H:PRN generalized seizure >3 min
6. Multivitamins 1 TAB PO DAILY
7. Phenytoin (Suspension) 210 mg PO Q12H
RX *phenytoin 100 mg/4 mL 210 mg by mouth every twelve (12)
hours Refills:*0
8. PrimiDONE 50 mg PO HS
9. Senna 8.6 mg PO BID:PRN constipation
10. Zonisamide 400 mg PO HS
11. Sertraline 50 mg PO QHS
RX *sertraline 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
12. Sarna Lotion 1 Appl TP BID:PRN itchy areas
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % apply to skin
twice a day Refills:*0
13. Clotrimazole Cream 1 Appl TP BID Duration: 4 Weeks
RX *clotrimazole 1 % apply to feet twice a day Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Urinary Tract Infection, chronic uncal herniation
Secondary: Pachymeningitis, epilepsy
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 increased sleepiness and
urinary symptoms. You were found to have a urinary tract
infection which was treated with antibiotics. We repeated an MRI
of your brain and monitored you on EEG to see if there were any
changes to your brain abnormalities. Your MRI has worsened since
your last MRI so we repeated a workup to investigate why you
have this brain problem. You will follow up with Dr. ___
___.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19910237-DS-12 | 19,910,237 | 29,164,900 | DS | 12 | 2131-08-18 00:00:00 | 2131-08-18 23:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache, Disorientation
Major Surgical or Invasive Procedure:
No
History of Present Illness:
Patient is a ___ year old male with hypertension, bipolar
disorder
and substance use (cocaine, alcohol) who presents with
intracranial hemorrahage and hypertension.
He is unable to remember much history. He lives alone with his
dog, woke up this AM was a severe headache and felt
confused/disoriented. Reportedly has a history of headaches,
takes ibuprofen 200mg daily. Does not recall a fall or injury,
but notes suggest a fall and he has multiple abrasions.
Presented to OSH where SBP in the 180s. HCT showed ICH.
Transferred.
*** not a code stroke ***
Time/Date the patient was last known well: last night per his
report
Patient arrived with CT done
NIHSS, GCS, and ICH score performed within 6 hours of
presentation at: 1700 on ___
NIHSS Total: 5
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 2
4. Facial palsy: 0
5a. Motor arm, left: 1
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0
9. Language: 0
10. Dysarthria: 0
11. Extinction and Neglect: 2
GCS Score at the scene: in ED 15
ICH Volume by ABC/2 method: 10 cc
ICH Score: 0
Pre-ICH mRS: 0
Past Medical History:
Hypertension - lisinopril, reports good control, last saw PCP
this past year
Substance use (cocaine, alcohol)
Bipolar disorder not on meds
Social History:
___
Family History:
no family history of stroke or bleeding/clotting disorders or
vascular disorders
Physical Exam:
Physical exam at the day of admission
Vitals: reviewed in ED Dash, most notable for SBPs in 200s
General: Awake, agitated and in pain
HEENT: NC/AT, no scleral icterus noted, lacerations and swelling
of his tongue R>L
Neck: Supple, No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: warm, well-perfused.
Extremities: No ___ edema.
Skin: Multiple abrasions
Neurologic:
-Mental Status: Awake and alert. Oriented to name, hospital,
month, year, situation. Able to relate some history but has gaps
in his memory. Able to name days of week backwards x3 then
started going forwards. Language is fluent with intact
repetition
and comprehension. Normal prosody. There were rare paraphasic
errors. Able to name both high and low frequency objects. Able
to read but stumbled on a few words. No dysarthria. Able to
follow both midline and appendicular commands. Evidence of
neglect - regarding people on his right more than his left,
identified objects on right side of stroke card only, described
woman washing dishes but not children despite prompts, did not
identify his own left hand in front of him.
-Cranial Nerves:
II, III, IV, VI: PERRL 2-->1mm and brisk. EOMI without
nystagmus. Normal saccades. Left sided visual field defect vs
dense neglect.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally. Hearing neglect.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: unable to interpret with swelling
-Motor: Normal bulk and tone throughout. Left arm drift. No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 4 5 5 5 5- 5- 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Denies deficits to touch and temperature. Sensory
neglect present.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Some dysmetria on the left
on
FNF
-Gait: Deferred for safety. Able to stand without sway.
Physical exam at the day of discharge
___ T=98.1, PO, BP:127 / 85 R Sitting, HR: 75,
RR:16, SPO2: 97
General: Awake, not currently agitated. Not in pain
HEENT: NC/AT, no scleral icterus noted, laceration on the right
side of the tongue, swelling improved
neck: Supple, No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: warm, well-perfused.
Extremities: Left lower extremity edema with venous stasis
changes on the medial side
Skin: Multiple abrasions
Denied any suicidal or homicidal intention.
Neurologic:
-Mental Status: Awake and alert. Oriented to name, hospital,
month, year, situation. Able to relate some history but has gaps
in his memory. Able to name days of week backwards. Language is
fluent with intact repetition and comprehension. Normal prosody.
No dysarthria. Able to follow both midline and appendicular
commands. No evidence of visual, tactile neglect. .
-Cranial Nerves:
II, III, IV, VI: PERRL 2-->1mm and brisk. EOMI without
nystagmus. Normal saccades. Field defect ? Left lower quadrant
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally. Hearing neglect
over the left side.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezius bilaterally.
XII: tongue midline
-Motor: Normal bulk and tone throughout. Left upper extremity
with mild drift. no adventitious movements, such as tremor or
asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 5 5 5 5 5 5 5* 5 5 5 5
R 5 5 5 5 5 5 5 * 5 5 5 5
*Bilateral giveaway given pain
-Sensory: Denies deficits to touch and temperature. Sensory
neglect present.
-Reflexes:
[Bic] [Tri] [___] [Pat] [Ach]
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on the left on
FNF
-Gait: Deferred for safety.
Pertinent Results:
___ 03:50PM BLOOD WBC-11.9* RBC-4.97 Hgb-15.5 Hct-46.1
MCV-93 MCH-31.2 MCHC-33.6 RDW-14.2 RDWSD-47.8* Plt ___
___ 03:50PM BLOOD Neuts-85.7* Lymphs-7.0* Monos-6.4
Eos-0.1* Baso-0.3 Im ___ AbsNeut-10.24* AbsLymp-0.83*
AbsMono-0.76 AbsEos-0.01* AbsBaso-0.04
___ 03:50PM BLOOD ___ PTT-28.8 ___
___ 03:50PM BLOOD Glucose-124* UreaN-11 Creat-0.8 Na-135
K-4.5 Cl-101 HCO3-21* AnGap-13
___ 03:50PM BLOOD ALT-41* AST-43* CK(CPK)-644* AlkPhos-83
TotBili-1.7*
___ 03:50PM BLOOD CK-MB-11* MB Indx-1.7 cTropnT-<0.01
___ 03:50PM BLOOD Albumin-4.2 Calcium-9.9 Phos-2.4* Mg-2.2
Cholest-259*
___ 11:50PM BLOOD %HbA1c-5.4 eAG-108
___ 03:50PM BLOOD Triglyc-89 HDL-62 CHOL/HD-4.2
LDLcalc-179*
___ 03:50PM BLOOD TSH-0.86
___ 03:50PM BLOOD TSH-0.86
___ 03:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 06:19AM BLOOD WBC-8.6 RBC-5.15 Hgb-15.9 Hct-48.8 MCV-95
MCH-30.9 MCHC-32.6 RDW-14.0 RDWSD-48.5* Plt ___
___ 06:19AM BLOOD Plt ___
___ 06:19AM BLOOD Glucose-109* UreaN-19 Creat-0.9 Na-143
K-4.0 Cl-106 HCO3-22 AnGap-15
___ 06:05AM BLOOD ALT-47* AST-56* AlkPhos-75 TotBili-2.0*
___ 06:05AM BLOOD ALT-47* AST-56* AlkPhos-75 TotBili-2.0*
___ 06:19AM BLOOD Calcium-9.8 Phos-4.1 Mg-2.2
Brief Hospital Course:
He was transferred to ___ for further care and admitted to the
stroke service for further care. Vessel imaging did not show any
abnormal blood vessel. He had MRI scan of the brain which showed
stable hemorrhage and no evidence of infarct. CAA is possibility
given evidence of prior lobar hemorrhage right frontal lobe.
Tumor could not be ruled out given hemorrhage. He initially was
on nicardipine gtt for SBP goal <160. He requiring increase of
his home lisinopril to 40 mg daily, addition of chlorthalidone
20 mg daily, amlodipine 10 mg daily and labetolol 200 mg three
times per day. We recommended he stay in the hospital for
further titration of these medications and ideally wean off
labetolol given his concomitant cocaine use. He had episode of
SBP to 190 on day of discharge in the setting of agitation.
However, he opted to leave against medical advice as above.
#Seizure, provoked
He had tongue lac on admission and loss of time per history. EEG
was done which showed some lateralized rhythmic delta concerning
for epileptic potential, but no seizures or discharges. He was
started on lacosamide 100 mg bid. He left AMA prior to seeing if
prior authorization was needed for this medication. PR was
monitored and stable on discharge.
#Bipolar disorder
#polysubstance use disorder
Psychiatry evaluated for pressured speech and polysubstance use
disorder. He was counseled re cessation and seen by social work
re his polysubstance use. Psychiatry recommended initiation of
olanzapine 5 mg QHS. His QTc was monitored given value of 505,
but then trended down to QTc 470 on discharge. This should
continued to be monitored as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Labetalol 200 mg PO TID
RX *labetalol 200 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
5. LACOSamide 100 mg PO BID
RX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
7. OLANZapine 5 mg PO QHS
RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
8. OLANZapine 2.5 mg PO BID PRN Agitation, Anxiety
RX *olanzapine 2.5 mg 1 tablet(s) by mouth bid:PRN Disp #*60
Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
10. Lisinopril 40 mg PO DAILY
RX *lisinopril 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right parieto occipital hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of headache and
disorientation resulting from an right parieto-occipital
hemorrhage.
We are changing your medications as follows:
<>
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19910990-DS-13 | 19,910,990 | 24,031,375 | DS | 13 | 2175-06-13 00:00:00 | 2175-06-14 13:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old gentleman with history of tobacco abuse (76pkyr hx),
hyperlipidemia, presents with fever, muscle aches, and dyspnea
on exertion x 1 week. He went to the ___ for 1
week and came back on ___. Late ___ the patient woke with
cold sweats, shakes, body aches. He was able to work on ___
but stayed in all weekend with continued sweats, rigors,
myalgias, decreased appetite. During this time he reports taking
2 tabs of ibuprofen q4h. On ___ and ___ he was able to go
to work, but has had persistence of decreased appetite, DOE,
feeling dehydrated. He also noted some confusion over the past
few days. He began developing a Right sided chest discomfort but
was not pleuritic in nature. He also noted a sometimes pounding
headache when trying to cough, though denied frequent cough, or
persistent headache, denied retroorbital pain, photophobia or
vision changes. He states that when he did cough it was
minimally productive and not purulent. When he felt getting
worse, he went to his PCP who found him febrile with crackles in
right upper lobe and subsequently send to ED.
.
Of note, when he was in the ___ ___ he went to ___,
___, and the ___. He drank mainly bottled water
but did drink beverages with ice, consumed fresh
fruits/vegetables. He did swim in saltwater. He denies
bug-bites, and did not take anti-malarials or get any
vaccinations preceding his trip.
.
In the ED, initial VS: 99.6 142/59 88 16 95%RA. He had a CXR
which showed R upper and middle lobe PNA, WBC 24, Cr 3.1, AST
124/ ALT 90. He was given 2L NS and Levaquin 750mg IV x1,
acetaminophen 1g x1 for T 101.
.
On the floor, he denied significant dyspnea or chest discomfort,
but does endorse some warmth and sweats, does endorse some
confusion but could say months of the year backward with no
trouble.
.
REVIEW OF SYSTEMS:
Denies vision changes, rhinorrhea, congestion, sore throat,
abdominal pain, nausea, vomiting, diarrhea (but mentioned 2
slightly loose stools), constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Low testosterone - receives injections
Tobacco abuse
Hyperlipidemia
Social History:
___
Family History:
mother had lung cancer and melanoma
Physical Exam:
Admission physical exam:
VS - 98.6 109/69 70 22 93%RA
GENERAL - Pt in NAD, affect slightly strange though A&Ox3
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, non-tender cervical LAD
LUNGS - diffuse expiratory wheezes, Crackles throughout Right
upper and middle lung.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, tan
LYMPH - +cervical LAD
NEURO - awake, A&Ox3, good strength throughout, some difficulty
with recall and calculations, esp considering baseline
functional level
.
Discharge physical exam:
VS - T99.4 Tmax 99.4 106/55 (100-130/50-80) 60-70's 13 96%RA
GENERAL - Pt in NAD, A&Ox3
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly
LUNGS - Crackles throughout Right upper and middle lung.
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions, tan
NEURO - awake, A&Ox3, good strength throughout, could tell
months of the year backward
Pertinent Results:
CBC:
====
___ BLOOD WBC-24.0*# RBC-4.20* Hgb-13.6* Hct-41.3 MCV-98
MCH-32.5* MCHC-33.1 RDW-14.9 Plt ___
___ BLOOD Neuts-92.5* Lymphs-6.1* Monos-0.9* Eos-0.1
Baso-0.4
___ BLOOD WBC-25.8* RBC-3.95* Hgb-12.8* Hct-38.9* MCV-98
MCH-32.4* MCHC-33.0 RDW-15.3 Plt ___
.
Blood chemistry:
================
___ 07:00PM BLOOD Glucose-137* UreaN-97* Creat-3.1*# Na-135
K-3.5 Cl-94* HCO3-20* AnGap-25*
___ 06:15AM BLOOD Glucose-118* UreaN-59* Creat-1.3* Na-142
K-4.1 Cl-106 HCO3-25 AnGap-15
___ 07:00PM BLOOD ALT-90* AST-124* CK(CPK)-68 AlkPhos-121
TotBili-0.3
___ 06:40AM BLOOD ALT-69* AST-76* AlkPhos-112 TotBili-0.4
___ 06:40AM BLOOD Calcium-8.4 Phos-4.1 Mg-3.2*
___ 06:15AM BLOOD Calcium-9.3 Phos-2.9 Mg-2.5
___ 07:08PM BLOOD Lactate-2.2*
.
Microbiology:
=============
Blood culture pending
Urine legionella Ag negative
.
Imaging:
=======
CXR PA and LAT ___
FINDINGS:
There are right middle and anterior segment of the right upper
lobe involving confluent opacities with an oval component in the
upper lobe consistent with pneumonia. There is no pleural
effusion and no pneumothorax. The cardiomediastinal shilhouette
and hila are normal.
IMPRESSION:
Right middle and upper lobe pneumonia with widespread dense
consolidation.
Short-term follow-up chest radiographs are recommended within
six weeks to
resolution is recommended to rule out underlying coinciding
malignancy noting a area of somewhat oval confluent
opacification in the right upper lobe. In a high risk patient
chest CT could also be considered preferably with intravenous
contrast if that course is pursued.
Brief Hospital Course:
___ year old gentleman with history of of tobacco abuse (___
hx), hyperlipidemia, presents with fever, dyspnea on exertion x
1 week found to have Right upper and middle lobe pna, acute
kidney injury and elevated liver enzymes. During his stay, he
clinically improved, acute kidney injury improved and liver
enzymes were trending down. He is discharged in stable
condition.
.
# Pneumonia: He came with history of significant tobacco abuse
and recent trip to the ___ presented with Right
upper and middle lobe PNA. Given history, unclear if this
reflects a superinfection of a viral process or the progression
of a primary bacterial infection to which he may be more
susceptible given his cigarette smoking history. Could also be
concerned for post-obstructive PNA if he has underlying mass.
Regardless of travel, most likely pathogen is S. pneumo. Also
considered Legionella given his mild confusion, hepatic and
renal dysfunction and 2 slightly loose stools, but urine
legionella Ag was negative. However, given recent travel to the
___, viral processes could include Dengue, which would be
consistent with fevers, myalgias, however pt without
retro-orbital pain, no e/o thrombocytopenia. Also frequently
involves respiratory symptoms but rarely associated with PNA.
Initially he received IV levofloxacin which was then switched to
PO cefpodoxime and azithromycin PO (cefpodoxime 200 mg twice
daily through ___ and azithromycin 250 mg daily through
___. He will need follow up CXR in ___ weeks to confirm
resolution given he is heavy smoker. Also recommend follow up of
a significant leukocytosis to ~25k which remained this high at
discharge.
.
# Acute Kidney Injury: Cr on admission was 3.1 up from baseline
0.9-1. On discharge day his Cr was 1.3 after 3L NS on admission.
FeNa 0.37 with BUN/Cr > 20:1 however urine Na is 15 (not < 10)
suggesting that pre-renal etiology is possibly not the only
reason to explain this. NSAID induced renal injury is very
possible given his frequent iborpufen use recently when his
symptoms started but quick recovery makes it unlikely. He is on
statin in the setting of myalgias and hypovolemia, however CK 68
so rhabdo unlikely. To be followed up at his primary care follow
up appointment.
.
# ___: He came with AST 124, ALT 90. These trended
down (please see results). Possibly related to underlying
infectious process, or hypoperfusion. He also endorses drinking
___ drinks ___, may have a more significant EtOH intake.
Levels too low to suspect acute hepatic infection.
.
# Confusion: He was A&Ox3 though somewhat seemed confused on
admission from baseline. Likely related to underlying illness.
No nuchal rigidity or photophobia to suggest CNS infection. Less
likely withdrawal as patient denies etoh consumption this week,
is not tachycardic, no agitated. This resolved after few hours
of hospitalization.
.
# Hyperlipidemia: We held simvastatin in the setting of
hypovolemia, ___ and ___.
.
# ?Depression: continue escitalopram
.
.
Transitional issues:
====================
1. Please repeat Chem 7, LFT and CBC
2. Please repeat CXR in ___ weeks after discharge to confirm
resolution of infiltrates
Medications on Admission:
Simvastatin 20mg daily
Escitalopram 20mg daily
Discharge Medications:
1. escitalopram 10 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
2. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours) for 2 days: through ___.
Disp:*2 Tablet(s)* Refills:*0*
3. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO twice a day
for 4 days: through ___.
Disp:*8 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Right upper and middle lobe pneumonia
Acute Renal Failure
.
Secondary Diganoses:
Hyperlipidemia
Tobacco use
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a great pleasure taking care of you as your doctor. As
you know you were admitted to ___
___ because of fever, shortness of breath on effort,
generalized aches and cough. We did chest XRAY for you which
showed right sided upper and middle lobe lung infection in
addition to high white cell count, all pointing towards the
infection. Your symptoms improved after initiation of
antibiotics and IV fluids.
Please discuss with your primary care physican about repeating
chest XRAY after ___ weeks of your discharge.
You received antibiotics during your stay in addition to IV
fluids given your dehydration on admission.
Initially when you came in your kidney function was worse
compared to your baseline. However this improved after receiving
good IV fluids. Please be cautious when taking iboprofen or
alike medications such as motrin etc since those can cause
kidney injury if taken frequently.
We made the following changes in your medication list:
-Please START cefpodoxime 200 mg twice daily through ___
-Please START azithromycin 250 mg daily through ___
-Please HOLD simvastatin for now. Your liver enzymes were
slightly elevated on admission which were improving during your
stay. Please discuss with your primary care physician when to
restart this medication.
Please continue the rest of your home medications the way you
were taking them at home prior to admission.
Please discuss about the rash on your hand with your primary
care physician.
Please follow up with your appointments as illustrated below.
Followup Instructions:
___
|
19910997-DS-22 | 19,910,997 | 22,925,411 | DS | 22 | 2162-10-08 00:00:00 | 2162-10-08 18:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Haldol / peanut / Fish Containing Products / egg / amoxicillin /
vancomycin / gluten / lactose / adhesive / Penicillins /
Thorazine / Benadryl / Zyprexa / Vistaril
Attending: ___
Major Surgical or Invasive Procedure:
___ Pericranial nerve blocks (occipital, auriculotemporal,
supraorbital), trigger point injections
attach
Pertinent Results:
LAB RESULTS ON ADMISSION:
==========================
___ 09:30PM BLOOD WBC-9.0 RBC-4.32 Hgb-12.2 Hct-38.0 MCV-88
MCH-28.2 MCHC-32.1 RDW-11.9 RDWSD-38.5 Plt ___
___ 09:30PM BLOOD Glucose-96 UreaN-7 Creat-0.9 Na-142 K-4.0
Cl-105 HCO3-26 AnGap-11
___ 06:05AM BLOOD Calcium-8.8 Phos-4.4 Mg-1.8
___ 05:50AM URINE UCG-NEGATIVE
LAB RESULTS ON DISCHARGE:
==========================
___ 06:25AM BLOOD WBC-6.2 RBC-4.19 Hgb-11.9 Hct-36.6 MCV-87
MCH-28.4 MCHC-32.5 RDW-12.1 RDWSD-38.9 Plt ___
___ 06:25AM BLOOD Glucose-72 UreaN-11 Creat-0.7 Na-141
K-3.6 Cl-102 HCO3-23 AnGap-16
___ 06:25AM BLOOD Calcium-8.8 Phos-3.9 Mg-1.6
IMAGING:
========
CT HEAD WITHOUT CONTRAST ___
No acute intracranial abnormality.
MRV HEAD WITH AND WITHOUT CONTRAST ___
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction.
The ventricles and sulci are normal in caliber and
configuration.
There is no abnormal enhancement after contrast administration.
The major intracranial arteries appear patent without
significant flow limiting stenosis. The dural sinuses are
patent without
venous sinus thrombosis.
IMPRESSION:
Dural sinuses are patent without venous sinus thrombosis.
Brief Hospital Course:
Ms. ___ is a ___ female with migraine,
post-concussive syndrome ___ MVC ___ mos ago),
cervicalgia/occipital neuralgia, POTS, depression, anorexia
nervosa, and odynophagia/dysphagia ___ caustic ingestion in ___ who presents with severe headaches thought multifactorial-
post concussive headache, prior migraine, tension headache,
occipital neuralgia and myofascial ___ features- significantly
improved after ___ nerve blocks and trigger point
injections.
# Severe headache, multifactorial
# Post-concussive headache
Patient presenting with constant, severe headaches since an MCV
2 months ago, which has been quite disruptive to her quality of
life. These are described as pressure-like ("exploding")
sensation that starts at neck and spreads to be holocephalic,
associated with nausea. She was evaluated by neurology, and MRV
was obtained without evidence of VST, hemorrhage, edema, masses,
mass effect, midline shift
or infarction, no abnormal enhancement. Recommendation was made
for symptomatic management. Given that she has been refractory
to multiple agents including duloxetine 60 mg BID, gabapentin
(reports that this makes her tired), celecoxib 200 mg BID PRN,
cyclobenzapine 10 mg qHS PRN, also reportedly trialed TCA,
dexamethasone in ED, we consulted chronic ___ service for
consideration of injections.
She received pericranial nerve blocks (occipital,
auriculotemporal, supraorbital), trigger point injections ___
with >50% relief of symptoms, and felt well enough to go home.
We considered various medication changes (for instance switching
from celecoxib to meloxicam, switching to low dose diazepam from
flexiril, possible uptitration of gabapentin, or even steroids)-
but given significant relief after injections, these were not
pursued.
She may benefit from further follow up with the headache center
with consideration of botox information, and was provided with
contact information. Unable to schedule over weekend.
# Dysphagia: Patient reports ongoing difficulty with swallowing
since a caustic injection in ___. She was evaluated by ENT and
is ordered for a barium swallow
but has not yet had this done. While in house, she was able to
tolerate food including yogurt and bacon and 100% breakfast. She
was encouraged to continue to follow up with ENT as an
outpatient. Of note, she does report some apprehension with ENT
follow up.
# POTS:
Note that patient had episode of hypotension to 70/50 in setting
of POTS and home metoprolol, for which she received 1L IVF, with
subsequent SBP in 110s. She notes that she feels at baseline,
and she was able to ambulate around the halls and tolerate AM
metoprolol prior to discharge. She was continued on home
fludrocortisone and metoprolol.
# Depression/PTSD
- Continue duloxetine
- continue prasozin
- continue home Ativan prn
- continue home Methylphenidate
# Asthma
- continue home albuterol
- continue home flovent
# GERD
- continue home omeprazole
TRANSITIONAL ISSUES:
====================
[] No changes made to home medication regimen at this time given
significant improvement after pericranial nerve block; in future
could consider options such as switching from celecoxib to
meloxicam, switching to low dose diazepam from flexiril,
possible uptitration of gabapentin if needed
[] Please help patient schedule follow up with ___
management/headache center: Dr. ___
Management Center, ___
[] Please continue to encourage follow up with ENT for further
evaluation of dysphagia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam ___ mg PO DAILY:PRN anxiety
2. Metoprolol Tartrate 25 mg PO BID
3. Omeprazole 40 mg PO DAILY
4. Prazosin 4 mg PO QHS
5. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
7. Albuterol Inhaler 2 PUFF IH BID:PRN shortness of breath
8. Celecoxib 200 mg oral BID:PRN ___
9. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm
10. DULoxetine ___ 60 mg PO BID
11. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY
12. Fludrocortisone Acetate 0.1 mg PO DAILY
13. Fluticasone Propionate 110mcg 1 PUFF IH BID
14. Methylphenidate SR 20 mg PO BID
15. Metoclopramide 5 mg PO QIDACHS
16. Ferrous GLUCONATE 324 mg PO EVERY OTHER DAY
17. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Albuterol Inhaler 2 PUFF IH BID:PRN shortness of breath
3. Celecoxib 200 mg oral BID:PRN ___
4. Cyclobenzaprine 10 mg PO HS:PRN muscle spasm
5. DULoxetine ___ 60 mg PO BID
6. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1 anaphylaxis
7. Ferrous GLUCONATE 324 mg PO EVERY OTHER DAY
8. Fludrocortisone Acetate 0.1 mg PO DAILY
9. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY
10. Fluticasone Propionate 110mcg 1 PUFF IH BID
11. LORazepam ___ mg PO DAILY:PRN anxiety
12. Methylphenidate SR 20 mg PO BID
13. Metoclopramide 5 mg PO QIDACHS
14. Metoprolol Tartrate 25 mg PO BID
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 40 mg PO DAILY
17. Prazosin 4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Headache- multifactorial (post concussive headache, prior
migraine, tension headache, occipital neuralgia and myofascial
___ features)
POTS
Dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
EXAM ON DISCHARGE:\GENERAL: Alert and in no apparent distress,
tired appearing
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, PERRL, EOMI though with some wandering,
increased sensation on left side of face, smile symmetric,
hearing decreased on right, tongue midline. ___ strength and
sensation of upper and lower extremities
PSYCH: depressed affect, almost no eye contact, soft voice
NEURO EXAM:
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. Pt was able to register 3 objects and recall ___ at 5
minutes. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VF exam limited by intermittent R
eye closure limited R temporal superior quadrant vision.
Fundoscopic exam performed, but patient unable to tolerate,
frequently closing eyes & looking away from ophthalmoscope.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Reports decreased sensation to light touch (30% on right
compared to left), temperature, and vibration (reports tuning
fork in middle of forehead not felt on right).
VII: Intermittent R NLFF w/ asymmetric smile
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ 5 ___ 5 5 5 5 5
R 5 ___ 5 ___ 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
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 flexor bilaterally.
-Coordination: Fluctuating severity RUE dysmetria. No
dysdiadochokinesia noted. No dysmetria on HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Difficulty w/ tandem walk but does not sway towards a
particular side. Sways backwards consistently on Romberg.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___!
You came to us for evaluation of a severe, intractable headache.
You were seen by both our neurologists and our ___ specialists,
with a normal MRI. Overall it is thought that your headache has
many different causes including post concussive headache, prior
migraine, tension headache, occipital neuralgia and myofascial
___ features.
You received a pericranial nerve block and your ___
significantly improved. On discharge, you should follow up
closely with your primary care doctor who is aware of your
admission- please call ___, tentatively she should be able to
see you on ___. You may also benefit from
follow up with our ___ management/headache center (Dr. ___,
___ Management Center, ___.
Otherwise, we noticed that you had seen our ENT doctors for
___ of difficulty swallowing as an outpatient, and would
encourage you to continue to follow up with them! At this time,
you were able to eat including yogurt and bacon, so we did not
arrange for further evaluation while you were admitted.
Please take care, we wish you the very best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19911133-DS-17 | 19,911,133 | 20,826,988 | DS | 17 | 2146-06-15 00:00:00 | 2146-06-15 15:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Novocain
Attending: ___.
Chief Complaint:
Hypoxemia secondary to CHF exacerbation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of diastolic CHF, atrial
fibrillation, sick sinus syndrome s/p pacer, presenting with
dyspnea x 3 days and cough productive of white sputum. EMS
called to her rehab earlier today, sats were 80% and she was in
Afib with RVR to the 130s. She was started on BiPAP and
transferred to the ED.
In the ED, initial rates were sAFib in the 130s. She was given
40 IV lasix, aspirin 325, and was started on a nitro gtt. CXR
showed fluid overload, no overt pneumonia. Labs notable for a
WBC count of 14.5, BNP 7029, K 5.3, Dig level .8 (Per EMS
report, was recently started on dig). She was able to be weaned
from BiPAP to a NRB. On transfer, vitals were afebrile, HRs in
the low 100s, 95% NRB, BP 135/75. ECG showed rate related ST
depressions. She was given levofloxacin prior to transfer.
Of note, she was recently admitted to ___ ___ - ___ with Afib
with RVR in the setting of not taking her nodal blockade agents
due to nausea as well as CHF exacerbation. She was diuresed with
IV lasix, yet was not discharged on lasix. She was discharged on
metoprolol succinate as well as dilt ER 300.
Past Medical History:
Atrial fibrillation not on coumadin
Diastolic HF
HTN
Sick sinus s/p pacer
GERD
HLD
Dementia
Gait Instability
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
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, finger-to-nose intact
Discharge Physical Exam:
98.1, 140/78, 94, 20, 96% RA
JVD not elevated
Dry mucus membranes
Irregular heart rate with ___ systolic murmur at RUSB
Decreased breath sounds at LLL, otherwise clear
Neuro exam normal
Pertinent Results:
ADMISSION LABS:
___ BLOOD WBC-14.5* RBC-4.54 Hgb-15.4 Hct-47.9 MCV-106* Plt
___
___ BLOOD Neuts-92.6* Lymphs-2.3* Monos-4.8 Eos-0.1
Baso-0.2
___ BLOOD Glucose-187* UreaN-22* Creat-1.0 Na-143 K-5.3*
Cl-104 HCO3-22
___ BLOOD ALT-26 AST-57* AlkPhos-159* TotBili-1.3
___ BLOOD Digoxin-0.8*
___ BLOOD ___ PTT-46.0* ___
___ BLOOD ALT-26 AST-57* AlkPhos-159* TotBili-1.3
___ BLOOD cTropnT-<0.01 proBNP-7029*
___ BLOOD CK-MB-3 cTropnT-<0.01
___ BLOOD Lactate-2.0
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-7.0 RBC-4.10* Hgb-13.7 Hct-42.4
MCV-103* MCH-33.4* MCHC-32.3 RDW-13.2 Plt ___
___ 07:55AM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-141
K-3.2* Cl-101 HCO3-30 AnGap-13
___ 07:55AM BLOOD Calcium-9.0 Phos-3.2 Mg-1.7
___ 05:45AM BLOOD VitB12-543 Folate-6.8
___ 06:45AM BLOOD TSH-1.8
CXR ___:
Moderate bilateral pleural effusions, cardiomegaly and pulmonary
edema. Left lung base consolidation, likely atelectasis,
however, superimposed infection cannot be excluded.
CXR ___:
FINDINGS: As compared to the previous radiograph, a
pre-existing left pleural effusion has slightly increased in
extent. The pre-existing right pleural effusion is constant.
Bilateral areas of atelectasis at the lung bases. Borderline
size of the cardiac silhouette without pulmonary edema. No
evidence of pneumonia in the well-ventilated lung areas. Left
pectoral pacemaker. Normal course and position of the pacemaker
leads.
Micro:
___ BCx: negative
___ UCx: negative
___ Urine Legionella: negative
Brief Hospital Course:
___ year old female presenting with SOB and productive cough,
found to be hypoxemic secondary to a CHF exacerbation likely
precipitated by uncontrolled atrial fibrillation.
1.) Acute on Chronic Diastolic Heart Failure Exacerbation: The
patient has diastolic heart failure secondary to hypertension.
She has been managed by a cardiologist in ___, however, she
has been living in the ___ area and she has had multiple
exacerbations over the last four months. The patient's recent
admission was likely precipitated by afib with RVR to the 130s,
on account of missing her Diltiazem and Metoprolol due to
nausea. The patient's initial CXR showed a moderate left pleural
effusion and slight pulmonary edema. The patient was diuresed
with 40mg IV lasix with good output and weaning off of BiPap
onto nasal cannula. The patient was also covered for community
acquired PNA with levofloxacin, due to a small opacity that
could represent infection, but is more likely compressive
atelectasis from her effusion. The patient was continued on
Metoprolol, which was increased to 150mg XL Daily. The patient
was continued on Diltiazem 300mg XL Daily. She has a PPM that
will pace if her rate drops too low. She will also be discharged
on 40mg PO lasix. She is euvolemic on discharge - weights here
were inaccurate, so it may be prudent to get a standing weight
on admission to rehab. The patient's digoxin was stopped. The
patient will have follow-up with a cardiologist in ___ for
further management. It is important for the patient to take her
rate control medications to prevent readmission.
2.) AFib with RVR: Patient's metoprolol was increased to 150mg
XL Daily and 300mg Daily of diltiazem was continued. The
patient's HR ranged from 60-110. She is on aspirin 81mg for
stroke prevention, as discussed by the patient with her PCP.
3.) Hypothyroid: On levothyroxine. TSH here was normal on
current dose.
4.) GERD: Omeprazole was stopped.
5.) Depression: On sertraline.
TRANSITIONAL ISSUES:
- Cardiology f/u
- Recheck potassium in one week
- The patient has a left sided pleural effusion. This is likely
from CHF. If patient continues to decompensate, this fluid may
need to be removed with a thoracentesis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diltiazem Extended-Release 300 mg PO DAILY
2. Digoxin 0.125 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Sertraline 50 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. traZODONE 12.5 mg PO Q6H:PRN pain
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation PRN
11. Acetaminophen 325 mg PO Q6H:PRN pain
12. Bisacodyl 10 mg PO DAILY:PRN constipation
13. Milk of Magnesia 30 mL PO Q6H:PRN constipation
14. Fleet Enema ___AILY:PRN constipation
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN constipation
4. Diltiazem Extended-Release 300 mg PO DAILY
5. Levothyroxine Sodium 88 mcg PO DAILY
6. Metoprolol Succinate XL 150 mg PO DAILY
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
8. Sertraline 50 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. DuoNeb *NF* (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg
base)/3 mL Inhalation PRN
11. Fleet Enema ___AILY:PRN constipation
12. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Acute on chronic diastolic heart failure, Atrial
fibrillation
Secondary: GERD, Depression, Hypothyroid
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to the hospital with an exacerbation of your
CHF, likely from a fast heart rate called atrial fibrillation.
We removed most of the fluid with a medicine called lasix. We
trimmed down your medication list so that you were not
overburdoned with too many meds. However, the medications that
you are on are very important ans you need to take them as
directed to prevent having to come back into the hospital.
We have arranged cardiology follow-up as below.
Followup Instructions:
___
|
19911159-DS-5 | 19,911,159 | 25,747,548 | DS | 5 | 2174-12-26 00:00:00 | 2174-12-26 14:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Skeletal Muscle Relaxants Classifier
Attending: ___.
Chief Complaint:
?intraparenchymal bleed on CT
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year old ___ with history of chronic headaches
who
presents with incidental CT finding of hyperdensity upon workup
of headache.
She has a longstanding of headaches since childhood which
consists of monthly headaches, usually before her menstrual
period. Usually this presents retroorbitally more often right
than left, described as constant stabbing but with some
throbbing
if the headache lasts long enough. There is no preceding aura or
involvement of any visual symptoms including blurriness,
diplopia, photopsias, etc. They usually improve with a cocktail
of imitrex, Excedrin, and if needed butalbital. Frequency
initially improved after IUD placement but last ___ they
recurred again, about once a month. This has been stable.
About 2 weeks ago on ___ she had gradual onset of same type
of
headache semiology. It lasted for 9 days, which per the patient
can be typical. This headache was slightly more severe than
usual
and she did not experience improvement right away with her
medications, which is unusual, however she was still able to
function and go to work despite the headache. One week later,
she
called her neurologist requesting imaging. However by ___
the
headache resolved. Yesterday, she presented for outpatient CT
noncontrast which showed a 2cm hyperdensity in the left frontal
lobe. She was referred in to the ED for urgent workup.
The patient denies worsening of her headache with straining or
lying down. She denies loss of vision, blurred vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Chronic headaches
Collapsed lung and T3 fracture after MVA in ___, s/p surgery
Social History:
___
Family History:
Mother, brother, and maternal grandmother all with migraines.
Father passed away due to renal malformation.
Physical Exam:
==============
ADMISSION EXAM
==============
Physical Exam:
Vitals: 98.3 73 131/89 14 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
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 x3. 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 5 to 3mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Fundoscopic
exam revealed no papilledema, exudates, or hemorrhages.
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, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor bilaterally.
-Coordination: 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
==============
Essentially unchanged from above. Scalp is non-tender to
palpation. Heart with RRR and lungs CTAB. Relates history with
ease. Comprehension, naming, and repetition intact. No evidence
of apraxia. Performs Luria well with L hand; makes an error with
R hand, but corrects on second try. EOMI, VFF, face symmetric,
PERRL. Sensation full to LT throughout. Normal bulk and tone,
full power throughout. No dysdiadiokinesia, no dysmetria on FNF
bilaterally. Gait has normal initiation, narrow base. Tandems
well. Smooth turns.
Pertinent Results:
==========
LABORATORY
==========
___ 08:10PM BLOOD WBC-8.2 RBC-4.70# Hgb-15.1# Hct-44.8#
MCV-95# MCH-32.1* MCHC-33.7 RDW-11.9 RDWSD-41.8 Plt ___
___ 08:10PM BLOOD Neuts-62.1 ___ Monos-5.6 Eos-1.8
Baso-0.5 Im ___ AbsNeut-5.05 AbsLymp-2.44 AbsMono-0.46
AbsEos-0.15 AbsBaso-0.04
___ 08:10PM BLOOD ___ PTT-25.8 ___
___ 10:07PM BLOOD Glucose-105* UreaN-13 Creat-0.7 Na-139
K-4.2 Cl-105 HCO3-24 AnGap-14
___ 10:07PM BLOOD Calcium-9.6 Phos-2.6* Mg-1.9
___ 08:10PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 08:10PM URINE UCG-NEGATIVE
=======
IMAGING
=======
CTA H&N - ___ (prelim read)
1. 1.3 x 0.8 cm hyperdensity in the left frontal lobe (02:14).
This is most consistent with an intraparenchymal hemorrhage,
however there is borderline enhancement following contrast
administration, which may represent an underlying mass lesion or
normal enhancement of brain parenchyma following contrast
administration. No ancillary findings are present to
differentiate mass from hemorrhage such as vasogenic edema,
additional enhancing lesions, or intraventricular extension of
blood products. MRI brain with and without contrast may provide
useful additional information. Alternatively, followup
noncontrast head CT can be performed to evaluate for interval
change. Prior studies, if they can be obtained, would be useful
to evaluate for stability.
2. No stenosis, occlusion, dissection, or aneurysm greater than
4 mm in the great vessels of the head or neck.
MRI HEAD W AND WO CONTRAST - ___
Left frontal lobe intraparenchymal hematoma with a small amount
of adjacent subarachnoid hemorrhage, containing acute and
subacute blood products, which may be due to an underlying
occult vascular malformation. However, the possibility of a
neoplasm should also be considered. No nodular enhancement.
Serial follow-up contrast-enhanced MRI is recommended.
Brief Hospital Course:
___ year old woman with long standing history of headache who was
found to have a L frontal hyperdensity (hemorrhage vs mass)
after ___ was performed for prolonged headache. She is
neurologically stable on exam with some minor difficulty
performing Luria task with the right hand.
CTA brain did not show an aneurysm or arteriovenous
malformation.
MRI was performed during admission. Preliminary read of MRI
states: "left frontal lobe intraparenchymal hematoma with a
small amount of adjacent subarachnoid hemorrhage, containing
acute and subacute blood products." No AVM, aneurysm, cerebral
venous sinus thrombosis was seen. MRI was performed ~24hrs
following her first scan (done at ___ and
demonstrated stability of the lesion.
The differential for this hemorrhage includes a cavernoma or
neoplasm. She will need a repeat MRI in ~8 weeks to assess for
underlying neoplasm. She is a non-smoker. There was no history
of weight loss or skin changes. No known family history of
vascular malformations or bleeding disorders. No coagulopathy
seen on labs. Will contact ___ neurologist to arrange f/u
MRI.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q6H:PRN pain
2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
3. Sumatriptan Succinate 100 mg PO ONCE
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN migraine
Discharge Medications:
1. Sumatriptan Succinate 100 mg PO ONCE
2. Cyclobenzaprine 10 mg PO TID:PRN muscle spasm
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN migraine
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Left frontal lobe intraparenchymal hematoma with small amount of
adjacent subarachnoid hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to the neurology service for further
evaluation of a concerning finding on a cat (CT) scan of the
head. An MRI was performed and showed a very small area of
bleeding on the left side of the brain. The amount of blood was
stable when compared with the CT scan done 24 hours earlier. The
bleeding is most likely due to a mis-formed blood vessel (called
a "cavernoma"). However it is impossible to completely exclude
the presence of a small mass while there is still blood in that
area. We recommend a repeat MRI in ~8 weeks (after much of the
blood has been resorbed by the body) to confirm that there is no
mass present.
We recommend avoiding medications that can cause increased
bleeding such as aspirin and NSAIDs (Ibuprofen, toradol, etc).
Sumatriptan and Tylenol are safe to take.
It was our pleasure caring for you during this hospitalization,
___ Neurology
Followup Instructions:
___
|
19911351-DS-8 | 19,911,351 | 25,037,898 | DS | 8 | 2139-04-13 00:00:00 | 2139-04-13 16:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
___: ORIF bilateral femurs (with ortho)
___: C3-T9 fusion, T6 laminectomy
___: Pigtail catheter placement
___: Percutaneous endoscopic gastrostomy tube placement
___: ___ placement
___: Pigtail catheter placement
___: Pigtail catheter placement removal
History of Present Illness:
Mr. ___ is an ___ yo M who presented to an OSH after a
mechanical trip and fall down 6 concrete stairs. Per the
patient he did not lose consciousness. He was pan-scanned at the
outside hospital and had a identified C2-C7 spinal process
fractures, C4 vertebral body fracture, and bilateral femur
fractures. He was also hypotensive ___ blood loss from the femur
fractures. He received 2L NS and 3uPRBC prior to transfer.
Past Medical History:
HTN
HLD
Prior epidural hematoma and T9-S1 spinal fusion
spinal fusion T9-S1, prostetic hip, hernia repair
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge exam:
===============
___ 1057 Temp: 97.3 AdultAxillary BP: 116/66 HR: 87 RR: 24
O2 sat: 97% O2 delivery: Ra
HEENT: PERRL, no facial droop noted
CARDIAC: Regular, nl S1/S2, no MRG
PULMONARY: CTAB on anterior auscultation, no crackles
ABDOMEN: Soft, NT/ND, PEG in place
SKIN: No rashes, warm and well perfused, PICC site c/d/I, no
evidence of ecchymosis anywhere on extremities, chest tube
bandage c/d/I
NEURO: AOx3, no facial droop, CN ___ grossly intact, moving all
extremities appropriately.
Pertinent Results:
Admission labs:
===============
___ 07:00PM BLOOD WBC-13.0* RBC-3.09* Hgb-9.4* Hct-29.9*
MCV-97 MCH-30.4 MCHC-31.4* RDW-15.3 RDWSD-53.9* Plt ___
___ 01:54AM BLOOD WBC-16.0* RBC-2.61* Hgb-7.9* Hct-25.5*
MCV-98 MCH-30.3 MCHC-31.0* RDW-17.7* RDWSD-59.8* Plt ___
___ 10:00PM BLOOD Glucose-127* UreaN-30* Creat-1.4* Na-146
K-4.3 Cl-110* HCO3-19* AnGap-17
___ 10:00PM BLOOD Calcium-8.5 Phos-4.5 Mg-1.7
___ 10:15PM BLOOD ___ pO2-29* pCO2-46* pH-7.28*
calTCO2-23 Base XS--5
Imaging:
========
___: Pelvis/Femur AP
IMPRESSION:
1. Comminuted displaced fracture of the right proximal to mid
femoral diaphysis fracture with varus angulation, distal to the
femoral stem.
2. Comminuted displaced fracture of the left proximal femoral
fracture.
___: CXR
IMPRESSION:
Read in conjunction with chest torso CT 14:56 on ___.
Lung volumes are low. No focal consolidation or collapse. No
pneumothorax or pleural effusion. Heart size normal. Although
no acute or other chest wall lesion is seen, conventional chest
radiographs are not sufficient for detection or characterization
of most such abnormalities. If the demonstration of trauma or
other soft tissue abnormality involving the chest wall is
clinically warranted, the location of any referable focal
findings should be clearly marked and imaged with either bone
detail radiographs or Chest CT scanning.
___ MRI cervical spine:
IMPRESSION:
1. Posterior acute spinal hematoma, likely with both epidural
and subdural components, extending from C3 to at least the level
of T4, largest in diameter (up to 9-10 mm) from T1-T4 over an
approximately 8 cm range length, with mass effect on the cord,
causing central canal narrowing and right anterolateral
displacement of the thoracic cord. No cord signal abnormality.
2. Extensive posterior ligamentous complex injury, including
evidence of injury or disruption to the interspinous ligaments
spanning at least C2-3 inferiorly to the level of C5-6.
3. Apparent focal disruption of the anterior longitudinal
ligament (ALL) at C4-5.
4. Although no discrete fracture is seen on the CT or on this
study, there is marrow edema on either side of the right C3-4
facet joint, with trace facet joint fluid, raising the
possibility of injury to the joint capsule at this level.
Similarly, trace but less conspicuous facet joint fluid also on
the right at C2-3 and ___ reflect degenerative changes or
subtle injury to
these joint capsules.
5. Known fractures through the C2-C7 spinous processes as well
as the right and left C7 pars interarticularis, better assessed
on outside hospital CT.
6. Marrow edema associated with the transverse fracture through
the C7 vertebral body and the anteroinferior endplate fracture
of the C4 vertebral body, also better visualized by CT.
7. Small volume multilevel prevertebral fluid, most conspicuous
at C7.
___: Femur
IMPRESSION:
Images from the operating suite show placement of an extensive
fixation device in the proximal femur. Further information can
be gathered from the operative report.
___ read CTA
IMPRESSION:
1. Acute comminuted bilateral proximal femur fractures.
Periprosthetic on the right involving the femoral shaft.
Severely comminuted and angulated with fracture planes involving
the intertrochanteric region and femoral neck on the left.
2. Transverse L1 vertebral body 2 column fracture. Absence of
surrounding hematoma and presence of fusion hardware above and
below but not involving this level suggests that it is an
already treated recent fracture. Correlation with history of
prior fracture repair suggested. No severe retropulsion.
3. No additional acute fractures identified in the thoracic or
lumbar spine.
4. Acute bilateral clavicle fractures; comminuted and displaced
on the left and nondisplaced but angulated on the right.
5. No intraabdominal traumatic injury. Trace simple perisplenic
ascites, likely third spacing.
6. Numerous bilateral subacute to chronic rib and sternal
fractures. No acute displaced rib fracture or pneumothorax.
7. 2 cm right adrenal cyst or adenoma.
___ ECHO:
IMPRESSION: Suboptimal image quality. Small hyperdynamic left
ventricle with asymmetric septal hypertrophy. Moderate
mid-cavitary gradient. Moderate pulmonary hypertension.
Echocardiographic evidence for diastolic dysfunction with
elevated PCWP. Consider hypertrophic cardiomyopathy versus
hypertensive heart disease. No RV strain. No prior TTE available
for comparison.
___:
Femur: IMPRESSION: Status post fixation of a left proximal
femur fracture without evidence of
hardware related complication. Status post plate and screw
fixation of a periprosthetic right femoral diaphysis fracture
without evidence of hardware related complication.
___:
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins.
2. Bilateral subcutaneous edema from mid thighs to calves.
___:
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Signs of interstitial pulmonary edema.
3. Multiple ribs, clavicles and vertebral body fractures.
Unstable T5-T6 vertebral body fractures is again noted with
extensive orthopedic hardware in place.
___ RUQUS
1. The patient is status post cholecystectomy without evidence
of biliary
ductal dilatation.
2. Normal liver parenchyma without evidence of suspicious focal
hepatic
lesions.
3. Mild splenomegaly measuring up to 13.8 cm.
___ ECHO
Symmetric left ventricular hypertrophy with normal cavity size
and regional
systolic function. Hyperdynamic global systolic function with
moderate dynamic mid-cavitary gradient.
___ Cervical and thoracic radiographs:
Vertebral body fractures at C4, T6 and T12 allowing for
technical differences appears similar. Allowing for technical
differences and limited assessment alignment of the thoracic
spine with retrolisthesis of T5 relative to T6 and T11 relative
to T12 appears relatively unchanged. Additional fractures not
well seen. Multilevel flowing osteophytes of the thoracic and
lumbar spine suggestive of ankylosing spondylitis.
___ bilateral clavicle radiographs:
Right clavicle: Again seen is the minimally displaced fracture
of the proximal clavicle. The acromioclavicular joint is
preserved with moderate degenerative change. Left clavicle:
There is a minimally displaced distal clavicle fracture as
before as well as a proximal clavicle fracture which is more
difficult to visualize. The acromioclavicular joint appears
preserved. There are pleural effusions at both lung apices.
___ bilateral femur radiographs:
Healing bilateral femur fractures status post ORIF.
___ lumbosacral radiographs:
No previous images. There is an extensive fusion involving d
what appears to be L4 extending at least to the lower thoracic
region. No definite
hardware-related complication, but the absence of a film for
comparison makes assessment difficult. Kyphoplasty material is
seen at what appears to be L3 and L4. There is substantial loss
of height that was appears to be the T12 vertebral body with
retrolisthesis of the superior vertebral body. Severe diffuse
degenerative changes seen.
___ pleural fluid cytology negative for malignancy
___ CTA chest
1. No evidence of pulmonary embolism or aortic abnormality.
2. Interval worsening of small to moderate right pleural
effusion and
unchanged appearance of a small left pleural effusion.
3. Slight interval improvement in interstitial pulmonary edema.
4. Stable vertebral, rib, clavicular, and sternal fractures as
described
above. Unchanged appearance of the posterior spinal fusion
hardware.
Discharge labs:
===============
___ 05:05AM BLOOD WBC-6.9 RBC-2.69* Hgb-8.6* Hct-27.7*
MCV-103* MCH-32.0 MCHC-31.0* RDW-18.1* RDWSD-67.7* Plt ___
___ 11:00AM BLOOD Glucose-86 UreaN-30* Creat-0.9 Na-138
K-5.2 Cl-101 HCO3-25 AnGap-12
___ 05:05AM BLOOD ALT-6 AST-14 AlkPhos-253* TotBili-0.4
___ 07:30AM BLOOD K-4.5
___ 11:27AM BLOOD K-4.6
Microbiology:
=============
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed fecal flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
GRAM NEGATIVE ROD(S). >100,000 CFU/mL.
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
___ 9:32 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
DAPTOMYCIN------------ S
LINEZOLID------------- 2 S
PENICILLIN G---------- 8 S
VANCOMYCIN------------ =>32 R
___ 11:00 pm BLOOD CULTURE Source: Line-picc.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:59 pm PLEURAL FLUID PLEURAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Brief Hospital Course:
PATIENT SUMMARY:
___ with h/o HTN and HLD, who presented s/p fall c/b neck and
femur fxs now s/p bilateral femur fixation (___) and C3-T9
fusion, T6 laminectomy (___), with hospital course complicated
by acute on chronic HFpEF exacerbation, HAP, hypoxemic
respiratory failure, and septic shock ___ VRE
urosepsis/bacteremia. He was treated with ampicillin. He was
diuresed and had a chest tube placed and removed for his dyspnea
with significant improvement. He was weaned off of oxygen
supplementation and was stable on room air.
TRANSITIONAL ISSUES:
CODE STATUS: DNR/DNI
HCP: ___ (son): ___
Contacts: ___ (son): ___
___ - Second Alternate (son): ___
___ - Third Alternate (daughter): ___
[ ]Follow up labs
- Check CBC with diff on ___. Has eosinophilia from likely
ampicillin, but given no end organ damage, was continued given
need for ampicillin for VRE bacteremia
- Check BMP on ___. Cr on discharge was 0.9. Baseline most
likely around 0.8.
[ ]Specialist followup
- Orthopedic Surgery: Dr. ___, 2 weeks post discharge.
Please get b/l femur and b/l clavicle x-rays prior to
appointment.
- Neurosurgery: Dr. ___. Please get cervical, thoracic, and
lumbar spine x-rays prior to appointment.
- Cardiology: patient will require repeat TTE prior to follow up
appointment given in house finding of LVOT obstruction
pathophysiology.
- Consider ENT appointment as outpatient for assessment of vocal
fold function per SLP (left vocal fold sluggish per SLP FEES
examination)
- Will need urology follow up given urinary retention.
[ ] Other:
- Per in house urology assessment, foley catheter removal and
voiding trial may be attempted when patient is ambulatory and
closer to his baseline. Also has a urology follow up as well to
assess for urinary retention.
- Discharge weight (bed weight) 77kg (169lbs) on discharge.
Given that it was a bed weight, recommend scaling to in house
bed weight at your facility on day of arrival.
- As patient is off of oxygen supplementation, should transition
to maintenance furosemide to keep him net even and his weight
stable. Please trial furosemide 20mg PO on ___ adjust for net
even I/O and stable weight.
- If needs active diuresis, please target gentle diuresis (ie.
___ IV furosemide) for goal of net negative 500cc/day given
that patient has VLOT obstruction pathophysiology.
- Please have wound care evaluate for post op surgical incision
central around level of T6. No primary closure. Wound was clean
on day of discharge.
- Last doses of ampicillin should be on ___. Will finish a
2 week course for VRE bacteremia (___)
- TLSO brace is required to be on at all times when out of bed.
No need for rigid c-collar while in bed.
- Orthopedic recommendations for bilateral femur and clavicle
fractures: WBAT LLE, TDWB RLE, ___ WBAT B/L UE no sling
necessary, PFO for right foot drop
- On C-T radiograph read: Multilevel flowing osteophytes of the
thoracic and lumbar spine suggestive of
ankylosing spondylitis. Follow up if clinically indicated.
- On CTA chest ___: 7. There are 2 subpleural pulmonary
nodules in the right middle lobe measuring 4-5 mm respectively.
For incidentally detected multiple solid pulmonary nodules
smaller than 6mm, no CT follow-up is recommended in a low-risk
patient, and an optional CT follow-up in 12 months is
recommended in a high-risk patient.
- Receiving tube feeds at goal per nutrition note: Vital 1.5;
Full strength; goal rate 60 ml/hr; Banana flakes: Mix each
packet with 120 ml water & stir until dissolved. Administer by
syringe through feeding tube. Flush each packet with 30 ml
water; #packets: 1; times/day: 3. Free water amount: 100 mL;
Free water frequency: Q6H.
- f/u vitamin D level and restart home calcium carb and vitamin
D if low
ACTIVE ISSUES:
# VRE urosepsis/bacteremia
# Septic shock, resolved
The patient was found to be tachypneic, tachycardic, with rigors
in the evening of ___, prompting an urgent response by the
medical team. He spiked a fever to Tmax 102.6 later that
evening, prompting transfer to the MICU.
UA demonstrated likely urinary source of infection. The
patient's foley was discontinued and a fresh foley was placed
with urology. CXR re-demonstrated RLL opacity. The patient blood
cultures were positive for VRE. He was initiated on Zosyn and
linezolid which was narrowed to ampicillin when sensitivities
had returned. The patient was treated with ampicillin 2g IV q6hr
for two weeks from the first negative BCx (d1 = ___, d14
= ___.
# HFpEF
# Pulmonary Edema
# Pleural effusions
# LVOT Obstruction
After patient's ORIF and spinal fusion surgeries on ___ and
___, respectively, he had a tenuous respiratory status.
Initially post op from ORIF, there was concern for PE vs fat
embolism considering b/l femur fractures. The patient underwent
a CT Chest Angio which ruled out PE. After the spinal fusion
surgery, he had a tenuous respiratory status, and was placed on
HFNC and Lasix gtt.
TTE on ___ concerning for left ventricular outflow tract
obstruction likely related to longstanding hypertension.
TTE on ___ demonstrated normal left ventricular wall
thickness and biventricular cavity sizes and global systolic
function with evidence of a dynamic moderate mid-cavitary
gradient with mild-moderate tricuspid regurgitation, though
notably the study was limited by poor image quality.
Patient's respiratory status was c/b HAP/aspiration PNA as well
as continued pressor requirement (see hospital acquired PNA
below). On ___ a right pigtail catheter was placed by
interventional pulmonology to drain right pleural effusion. The
pleural fluid analysis was consistent with transudate.
The patient's respiratory status gradually improved and his
diuresis was weaned from Lasix drip and all diuresis was held.
He was transferred from the ICU to the floor on ___.
Unfortunately the patient's respiratory status declined,
necessitating initiation of BiPAP and prompting ICU transfer on
___. He was again aggressively diuresed, weaned off BiPAP
and returned to the floor on RA on ___. On ___, the
patient was again tachypneic to the ___, tachycardic, with
rigors. He spiked a fever that night to 102.6, again prompting
MICU transfer (see urosepsis, above).
On ___, the patient had another TTE that demonstrated
symmetric left ventricular hypertrophy with normal cavity size
and regional systolic function. It demonstrated hyperdynamic
global systolic function with moderate dynamic mid-cavitary
gradient, which was felt to be similar to the previous echo
completed on ___.
Patient's blood pressures were maintained on pressors in the
unit as well as midodrine 15mg TID. His home metoprolol and his
verapamil 80mg TID (initiated by cardiology on ___ iso LVOT)
were held in the setting of septic shock. The patient's clinical
status improved with treatment for urosepsis and he was
transferred back to the ___ medicine floor on ___.
There, the patient's midodrine was weaned off and metoprolol was
re-started for HR control to improve LV filling in the setting
of LVOT. Per cardiology, there is no goal HR for this patient
and his HRs remained in the ___ on 12.5mg metoprolol q6hr.
The patient continued to experience dyspnea and shortness of
breath on the floor. Given patient's bedbound state, PE was of
concern, so CTA chest was performed on ___, which
demonstrated no evidence of PE but interval worsening of right
pleural effusion. Given patient's LVOT and preload dependence,
cardiology recommended only gentle diuresis ___ IV Lasix
with goal net negative 500). In light of this, interventional
pulmonology was again consulted. They placed a R pigtail
catheter on ___, which drained ~1.2L of fluid before d/c on
___. Pleural fluid was again transudate. Final cytology report
negative for malignant cells. Patient should transition to PO
maintenance furosemide (trial 20mg furosemide daily) on ___.
# Toxic metabolic encephalopathy; resolved
# Delirium; resolved
Patient experienced waxing and waning mental status with
evidence of disorientation felt to be consistent with delirium
in the setting of infection and prolonged hospitalization. The
patient was kept on strict delirium precautions and was
initiated on ramelteon 7.5mg at night with Trazadone as needed
for continued insomnia. After transfer to ___ medicine floor
on ___, patient's mental status gradually normalized.
# Severe malnutrition
# Diarrhea
Patient with significant weakness post-operatively. Patient is
s/p PEG placement on ___ (prior to that was fed through NG
tube). He was followed with nutrition and SLP throughout this
hospitalization. Patient had negative C diff tests throughout
this hospitalization, most recently ___. His tube feeds
were supplemented with banana flakes and he was treated with
loperamide TID standing, which was transitioned to a PRN
medication. His diarrhea was likely multifactorial, caused by an
adverse medication effect (it worsened on starting IV ampicillin
for VRE urosepsis as above) and tube feeds.
# Dysphagia
Patient with evidence of aspiration with oral intake since
admission. He was actively followed by SLP throughout his
complicated hospitalization. He was initially fed through NG
tube, which was replaced with PEG on ___. Patient was
maintained on a strict NPO diet except ice chips. Upon
stabilization of his respiratory status, he was able to
participate in further SLP evaluation. On ___, he underwent
a FEES study with SLP which demonstrated "moderate oropharyngeal
dysphagia characterized by prolonged mastication, delayed
swallow response, absent epiglottic inversion and reduced
pharyngeal squeeze. This resulted in silent aspiration of nectar
thick liquids, penetration of puree solids and pharyngeal
residue. The use of compensatory strategies such as cued cough
and follow up dry swallows were effective in reducing
aspiration/penetration. Of note, pt reported feeling tired after
a few trials." He was re-evaluated by SLP on ___, but due to
overall deconditioning, fatigue and moderate oropharyngeal
dysphagia, was recommended to remain NPO with ice chips with RN
and trials of puree solids and honey thick liquids with SLP
ONLY. Will require ongoing work with SLP in order to optimize PO
tolerance.
# Traumatic Injuries
Patient was walking outside when he tried to kick a box and fell
down multiple concrete stairs. Trauma eval at ___
___ revealed spinous process fractures of C2-C7 with a
non-displaced anterior inferior C4 vertebral body fracture as
well as bilateral femur fractures. On presentation at the OSH he
was hypotensive and transfused 3u pRBCs. He was transferred to
___ for further care. On arrival to ___, he remained
hypotensive and received an additional 2L IVF, 2u of pRBCs, 1u
of FFP, and 1u platelets. Additionally, he received 1g CTX for
UTI and his tetanus was updated.
- Femur fractures s/p ORIF of bilateral femurs (___)
Patient suffered bilateral femur fractures during his fall. On
___, he had an ORIF with Dr. ___. Intraoperatively, he
required 3u pRBCs and received 2.5L of fluid. Due to the complex
nature of his fractures, the surgery required a larger incision
than normal. Repeat imaging performed 5 weeks post op on ___
demonstrated healing bilateral femur fractures without acute
change in hardware. Per orthopedics, recommend repeat imaging 2
weeks post-discharge with f/u with Dr. ___.
- C-Spine/T-spine fractures: s/p C3-T9 fusion with T6
laminectomy (___)
Patient underwent a C3-T9 fusion with T6 laminectomy with Dr.
___ on ___. Patient had 2 JP drains placed
intra-operatively, these were removed on ___. Patient was
maintained in a rigid cervical collar for 5 weeks post-op per
neurosurgery recommendations. Repeat imaging cervical, thoracic,
and lumbar spine imaging was performed on ___, per
neurosurgery patient was allowed to d/c hard cervical collar
while in bed on ___, but patient is required to continue to
use TLSO brace when OOB. Patient will require f/u with
neurosurgery with repeat imaging on or around ___.
- B/l clavicular fxs
Felt to be non-operative. Will follow up with orthopedics with
repeat imaging on ___ demonstrating minimally displaced b/l
clavicular fractures with preserved acromioclavicular joints.
Per orthopedics, recommend f/u with repeat imaging 2 weeks
post-discharge.
# Macrocytic Anemia
Pt required total 11U pRBCs this admission last ___ iso trauma
and surgical repairs described above. Hb stable ___
post-surgery. Unclear etiology of macrocytosis, could be ___
increased reticulocytes iso acute blood loss compensation.
Patient is on Vitamin B12 supplementation at home. Reassuringly,
patient's LDH and total bilirubin are within normal limits,
making hemolysis an unlikely source of patient's anemia.
#Eosinophilia
Patient demonstrated new eosinophilia in the setting of
initiation of ampicillin. Reassuringly, patient's creatinine,
urine output, and LFTs remained within normal limits. The
patient's eosinophilia peaked at 0.92 on ___ and downtrended
to 0.72 by ___. This may require follow up after
ampicillin course is completed in order to ensure resolution.
# BPH
Patient required foley after initial surgeries after failed
trial of void. Per urology, foley was difficult to place. Per
Urology recommendations, patient was kept on foley catheter
throughout this hospitalization, they recommend discontinuation
of foley when patient is closer to his baseline. The patient was
continued on tamsulosin 0.4mg qHS in house.
# GOC
Patient initially presented as Full Code, but this status was
changed to DNR/DNI by HCP and family on ___.
# Hospital Acquired Pneumonia; resolved
On ___, patient was demonstrating increasing pressor
requirement in the setting of reduced diuresis despite Lasix
gtt. CXR demonstrated RLL pneumonia. Given concern for HAP vs
aspiration PNA, patient was initiated on an 8 day course of
vancomycin/cefepime/flagyl (___). Vancomycin/flagyl
were stopped on ___, and he completed the cefepime course.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 6.25 mg PO DAILY
2. Tamsulosin 0.8 mg PO QHS
3. Calcium Carbonate 500 mg PO QD
4. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral QD
5. Mirtazapine 3.25 mg PO QHS
6. Metoprolol Succinate XL 6.25 mg PO DAILY
7. Cyanocobalamin 100 mcg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Riboflavin (Vitamin B-2) 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Ampicillin 2 g IV Q4H
3. Heparin 5000 UNIT SC BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob
5. LOPERamide 4 mg PO TID:PRN diarrhea
6. Multivitamins W/minerals 15 mL PO DAILY
7. Ramelteon 8 mg PO QHS:PRN insomnia
8. sevelamer CARBONATE 800 mg PO Q6H
9. Metoprolol Tartrate 12.5 mg PO Q6H
10. Mirtazapine 7.5 mg PO QHS
11. Tamsulosin 0.8 mg PO QHS
12. HELD- Calcium Carbonate 500 mg PO QD This medication was
held. Do not restart Calcium Carbonate until patient returns to
normal diet (currently on tube feeds)
13. HELD- Cyanocobalamin 100 mcg PO DAILY This medication was
held. Do not restart Cyanocobalamin until patient returns to
normal diet (currently on tube feeds)
14. HELD- Docusate Sodium 100 mg PO BID This medication was
held. Do not restart Docusate Sodium until diarrhea has resolved
15. HELD- Riboflavin (Vitamin B-2) 50 mg PO DAILY This
medication was held. Do not restart Riboflavin (Vitamin B-2)
until patient returns to normal diet (currently on tube feeds)
16. HELD- Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit
oral QD This medication was held. Do not restart Vitamin D3
until assessed by pcp
___:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
bilateral displaced femur fractures
C7 vertebral body fracture
C4 anterior vertebral body fracture
C3-7 spinous process fractures
unstable T6 fracture
Oropharyngeal dysphagia
Heart failure with preserved ejection fraction
SECONDARY DIAGNOSIS:
Hospital acquired pneumonia
Benign prostatic hypertrophy
Urosepsis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___!
You were admitted after you fell. You were found to have many
broken bones, including both femurs (the large bone in your
leg), both clavicles, and many broken vertebrae.
You had surgery with orthopedics called an open reduction and
internal fixation of both of your femurs on ___. You had
a c3-t9 fusion of your vertebrae by neurosurgery on ___.
Your post-operative recovery was complicated by trouble
breathing. You were treated for a lung infection called
pneumonia. You were also given medicine called diuretics, which
helped take fluid off of your lungs. You also had fluid around
your lungs drained with a chest tube.
You also experienced an infection and low blood pressures, we
believe this infection came from your urinary catheter. This
infection was treated with an antibiotic called ampicillin.
Please note any new medications as per below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19911351-DS-9 | 19,911,351 | 26,733,842 | DS | 9 | 2139-10-07 00:00:00 | 2139-10-07 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cervical hardware failure s/p c3-t9 fusion with wound
dehiscence.
Major Surgical or Invasive Procedure:
___ - Wound revision
History of Present Illness:
___ with hx of ankylosing spondylitis s/p C3-T9 fusion for
C7-T5-T6 fracture after fall down stairs on ___.
Postoperatively he remained in TLSO brace until ___. He was
seen in follow-up on ___ at that time he had a small
opening in his incision with no signs of infection. The patient
at that visit was noted to be cachectic and instrumentation was
palpable through the skin, but there was no breakdown. He was
referred for x-ray which showed hardware failure.
Patient is currently demonstrating improvement- PEG is still in
place but began taking medication by mouth and slowly advancing
diet. Patient currently walks ___ FT with a walker. Patient
reports slight tingling to his hands and feet. Foley catheter
still in place. Denies any pain.
Past Medical History:
HTN
HLD
Prior epidural hematoma and T9-S1 spinal fusion
spinal fusion T9-S1, prostetic hip, hernia repair
Social History:
___
Family History:
Non-contributory
Physical Exam:
9On Admission: ___
============================
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 4 5 4 5 5 4 4 4 5 3 5
L 4 5 4 5 5 4 4 4 5 5 5
Bilater finger intrinsics ___ Bilateral grip ___
No ___, no clonus
ON DISCHARGE: ___
=========================
General:
___ ___ Temp: 97.8 PO BP: 105/67 R Lying HR: 90 RR: 30 O2
sat: 95% O2 delivery: 1.5L
Bowel Regimen: [x]Yes [ ]No Last BM: ___
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
Right54-4+4+4+
Left54+554+
IPQuadHamATEHLGast
Right4+ 4 4+ 5 5 5
Left4+ 4+ 4+ 5 5 5
[no]Clonus ___
[x]Sensation intact to light touch
Wound:
- Palpable hardware in cervical spine, no pain to palpation, no
skin tenting or breakdown.
- Revised wound:
[x]Clean, dry, intact, no active drainage noted. Small
portion
of superior aspect of incision with separation.
[x]Sutures in place
Pertinent Results:
See OMR for pertinent results
Brief Hospital Course:
# Hardware failure
Mr. ___ presented to ___ on ___ after c-spine xray on
___ demonstrated hardware loosening. At clinic hardware was
palpable in the cervical spine, no threatened skin, no pain with
palpation. Patient admitted to floor in stable condition, CT and
MRI c/t/L spine were ordered for preoperative planning. Plan for
OR on ___ with Dr. ___ cervical hardware removal
and wound exploration. Patient restarted on tube feeds with oral
supplementation per SNF regimen and nutrition consult. Patient
restarted on home medication, preoperative cxr wnl, patient went
to OR on ___ for planned removal of cervical instrumentation
and wound exploration. During the case, when the patient was
flipped into the prone position he became acutely hypotensive
requiring epinephrine and IVF boluses and to be returned to
___ position. TEE done in OR demonstrated hyperdynamic left
ventricle, concerning for hypertrophic obstructive
cardiomyopathy. Patient was unable to tolerate prone position
and the case was aborted. Distal end of incision was revised
with patient in lateral position in the OR. Please read Dr.
___ report for further details of case. Patient was
brought out to the PACU intubated and was managed by the TSICU
overnight. He was started on IV fluids. He was weaned off
sedation, phenylephrine drip, and extubated. He remained
hemodynamically and neurologically stable so patient was
transferred back to the floor. Patient's surgical dressing was
removed on POD #2 and his surgical incision appeared intact with
sutures in place, no active drainage noted. On POD #3 patients
surgical incision with slight opening at the superior portion of
the incision but no active drainage. Patient remained
neurologically stable.
# Chest pain
Overnight on ___, patient complained of sternal chest pain
which was worse with inspiration. EKG was done, reviewed by the
Medicine team, and felt to be grossly stable from EKGs on prior
admission. Troponins were elevated at 0.04 x4. Chest pain
resolved with pain management. Patient continued to complain of
chest pain on ___ worsening with deep breaths and cough. A
repeat EKG was obtained on ___ which was stable compared to
prior EKGs. Pain was thought to be musculoskeletal in nature s/p
OR positioning. On ___ patient stated that his chest pain has
improved.
#Hypoxia
Overnight on ___ into ___ patient with tachypnea and hypoxia
to the 80's. Patient was placed on supplemental O2 via NC with
some improvement in O2 sat. CXR on ___ revealed low lung
volumes, small bilateral pleural effusions with no
consolidation. Patient also underwent a CTPE which was negative
for an acute PE.
# Dysphagia
Patient presented from SNF with PEG tube on tube feeds.
Nutrition was consulted for recommendations regarding tube
feeds. Post-op, patient was restarted on tube feeds and puree
diet per nutrition recommendations. SLP was consulted who
recommended upgrading diet to soft food, thin liquids, meds
whole or crushed in puree, 1:1 supervision with meals and to
slowly decrease TF after 24 hour supervision of tolerating new
diet.
# Urinary retention
Patient presented from ___ with foley catheter in place. Void
trial was attempted on ___, but patient was unable to void and
coude catheter was replaced. Urology was contacted and it was
recommended that patient follow up 2 weeks from time of
discharge for a void trial. Patient was found to have a UTI on
___ when the urine culture resulted as enterobacter. Patient
was given 1Gm of ceftriaxone on ___ and sent to rehab with
Bactrim BID for a ___nd the nursing facility can
extend course to 14 days if needed.
# Dispo
___ and OT evaluated the patient on ___ and ___ and recommended
discharge to rehab. Patient was discharged back to his ___ on
___.
Medications on Admission:
Atropine prn secretions
Pantoprazole 40mg qday
Levalbuterol TID
Melaotonin 9mg qhs
Mirtazapine 15mg Qday
Sevelamer Carbonate 0.8g oral powder TID
Tamsulosin 0.4mg qday
trazodone 25mgqhs
albuterol sulfate nebs Q4hr prn
Zofran 4mg PRN
Oxycodone 5mg PRN
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4G per day.
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN wheezing/SOB
3. Atropine Sulfate 1% 1 DROP SL DAILY:PRN excessive secretions
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC BID
7. Lidocaine 5% Patch 1 PTCH TD QPM
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone [Oxaydo] 5 mg 1 tablet(s) by mouth Q6hrs Disp #*20
Tablet Refills:*0
9. Ramelteon 8 mg PO QPM:PRN insomnia
10. Senna 17.2 mg PO QHS
11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
Start date ___
end date ___
12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
13. Mirtazapine 15 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Reason for PRN duplicate override: Alternating agents for
similar severity
15. sevelamer CARBONATE 800 mg PO TID W/MEALS
16. Tamsulosin 0.4 mg PO QHS
17. TraZODone 25 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
C3-t9 fusion with interval cervical spine hardware failure
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
Surgery
· Your dressing came off on the second day after surgery.
· Your incision is closed with sutures. You will need suture
removal. Please keep your incision dry until suture removal.
· Do not apply any lotions or creams to the site.
· Please avoid swimming for two weeks after suture removal.
· Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
· We recommend that you avoid heavy lifting, running,
climbing, or other strenuous exercise until your follow-up
appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· No driving while taking any narcotic or sedating
medication.
· No contact sports until cleared by your neurosurgeon.
Medications
· Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
· *** You may take Ibuprofen/ Motrin for pain.
· You may use Acetaminophen(Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
· It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the
incision site.
· Fever greater than 101.5 degrees Fahrenheit
· New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
19911519-DS-6 | 19,911,519 | 27,636,003 | DS | 6 | 2160-01-05 00:00:00 | 2160-01-05 13:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Lethargy and somnolence
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History was obtained from the patient's daughter (___).
___ with a history of dementia and diabetes presents from a
nursing home with lethargy and somnolence. At that time, she was
noted to be responsive to pain and voice, but only by moaning.
She did not have any focal neurological findings. In the nursing
home, she was found to be febrile, and with elevated sodium. She
had decreased PO intake over the last 24 hours. Of note, per the
daughter, she is interactive at baseline, and somtimes answers
questions appropriately.
In the ED, vitals: T 99.2F, BP 169/74, HR 70, RR 20, O2 sat 97%
on RA. EKG showed sinus rhythm with a slightly prolonged QTc.
Labs were notable for Na 158, Ca ___, Glucose 257, lactate 2.3,
and UA consistent with UTI. CXR was negative for acute
cardio-pulmonary process. Head CT did not demonstrate any acute
intracranial process. She was started on Ceftriaxone for
treatment of UTI, and was given NS IVF for treatment of presumed
hypovolemic hypernatremia.
Vitals on transfer: T 98.4F, BP 160/82, HR 74, RR 18, O2 Sat 97%
RA
Currently, she is minimially interactive, mumbles, and
occasionally answers questions appropriately.
Past Medical History:
Alzeimers Dementia
Diabetes Mellitus
HTN
Anxiety/Depression
Social History:
___
Family History:
Father had ___ dementia, stroke, DM, HTN.
Physical Exam:
ON AMISSION:
VS - T 98.4, BP 160/82, HR 74, RR 18, O2 Sat 97% RA
GENERAL - Elderly women, comfortable, in NAD
HEENT - NC/AT, PERRL, sclerae anicteric. Refusing to open mouth.
LUNGS - Lungs are clear to ausculatation bilaterally in the
anterior lung fields
HEART - RRR, normal S1-S2, no M/R/G
ABDOMEN - NABS, soft/NT/ND
EXTREMITIES - WWP, 1+ pitting edema to the knee
NEURO - Awake, A&Ox0, minimally responsive (will withdraw to
pain), CNs II-XII grossly intact, only occasionally answers
questions appropriately
Discharge exam notable for improved mental status. Oriented to
name alone but more talkative and interactive.
Pertinent Results:
Admission labs:
___ 03:20PM URINE RBC-3* WBC-40* BACTERIA-FEW YEAST-NONE
EPI-5
___ 03:45PM ALBUMIN-4.4 CALCIUM-11.5* PHOSPHATE-3.3
MAGNESIUM-2.4
___ 03:45PM GLUCOSE-257* UREA N-41* CREAT-1.1 SODIUM-158*
POTASSIUM-3.6 CHLORIDE-115* TOTAL CO2-26 ANION GAP-21*
Discharge sodium: 139
CXR: No evidence of acute cardiopulmonary process.
CT HEAD: No acute intracranial process. Moderate sequela of
small vessel
ischemic disease.
Brief Hospital Course:
# Somnolence / Metabolic encephalopathy: Acute worsening of
mental status in the setting of UTI and multiple electrolyte
abnormalities. Hypernatremia is likely the main culprit (see
below). Mental status improved and was felt to be at baseline on
the day of discharge.
# UTI: UA consistent with UTI so patient was treated with 3 day
course of ceftriaxone. She remained afebrile with no
leukocytosis. Urine culture with alpha hemolytic colonies
consistent with alpha streptococcus or lactobacillus sp.
# Hypernatremia: Most likely hypovolemic hypernatremia. She was
found to have sodium of 158 on arrival to the hospital and was
calculated to have free water deficit of 3876 ml. On discharge,
sodium was 139.
# Hypercalcemia: Corrected Ca=11.8. Patient without symptoms or
EKG changes. PTH normal. Calcium trended down during
hospitalization.
# HTN: Patient continued on home metoprolol and lisinopril and
HCTZ.
# ___ Dementia: Communicative and interactive at baseline
but was somnolent on arrival. Upon discharge she was back at her
baseline. While hospitalized ___ was held (non-formulary),
but it was re-started on discharge.
# Anxiety/Depression: Stable. No issues on this admission. She
was maintained on citalopram and trazodone.
# Diabetes: On admission she was started on a humalog insulin
sliding scale and given basal NPH insulin.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ___ records.
1. traZODONE 12.5 mg PO QAM Start: In am
2. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
3. Citalopram 20 mg PO DAILY Start: In am
4. Hydrochlorothiazide 25 mg PO DAILY Start: In am
hold for SBP < 105
5. Lisinopril 40 mg PO DAILY Start: In am
hold for SBP < 105
6. MetFORMIN XR (Glucophage XR) 250 mg PO DAILY Start: In am
Do Not Crush
7. Multivitamins 1 TAB PO DAILY Start: In am
8. Cyanocobalamin 100 mcg PO DAILY Start: In am
9. Vitamin D 400 UNIT PO DAILY Start: In am
10. Donepezil 10 mg PO HS
11. Acetaminophen 1000 mg PO BID
12. Metoprolol Tartrate 50 mg PO BID
hold for SBP < 105, HR < 60
13. Namenda *NF* (MEMAntine) 10 mg Oral BID
14. Acetaminophen 650 mg PO Q6H:PRN pain
15. Bisacodyl 10 mg PR HS:PRN constipation
16. Milk of Magnesia 30 mL PO Q8H:PRN constipation
17. Guaifenesin 5 mL PO Q4H:PRN cough
18. traZODONE 12.5 mg PO BID:PRN agitation
Discharge Medications:
1. Bisacodyl 10 mg PR HS:PRN constipation
2. Citalopram 20 mg PO DAILY
3. Cyanocobalamin 100 mcg PO DAILY
4. Donepezil 10 mg PO HS
5. Hydrochlorothiazide 25 mg PO DAILY
hold for SBP < 105
6. Lisinopril 40 mg PO DAILY
hold for SBP < 105
7. Metoprolol Tartrate 50 mg PO BID
hold for SBP < 105, HR < 60
8. Multivitamins 1 TAB PO DAILY
9. traZODONE 12.5 mg PO QAM
10. traZODONE 12.5 mg PO BID:PRN agitation
11. Vitamin D 400 UNIT PO DAILY
12. Acetaminophen 1000 mg PO BID
13. Acetaminophen 650 mg PO Q6H:PRN pain
14. Calcium 600 + D(3) *NF* (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit Oral daily
15. Guaifenesin 5 mL PO Q4H:PRN cough
16. MetFORMIN XR (Glucophage XR) 250 mg PO DAILY
Do Not Crush
17. Milk of Magnesia 30 mL PO Q8H:PRN constipation
18. Namenda *NF* (MEMAntine) 10 mg Oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary- Hypernatremia
UTI
Secondary- Alzheimer's dementia
Diabetes
HTN
Anxiety/depression
Discharge Condition:
Stable.
Awake, A+Ox1 (self), interactive, able to occassionally answer
questions appropriately, able to follow simple commands.
Discharge Instructions:
Dear ___,
___ were hospitalized for lethargy and somnolence. While in the
hospital, ___ were found to have a urinary tract infection and
your sodium level was found to be high. Both of these findings
could have contributed to your lethargy and somnolence. ___ were
given antibiotics to treat your urinary tract infection. Your
sodium level was corrected as well. Your symptoms improved.
Thank ___ for allowing us to participate in your care.
Followup Instructions:
___
|
19911542-DS-26 | 19,911,542 | 20,158,711 | DS | 26 | 2131-09-29 00:00:00 | 2131-10-01 21:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking male with significant past cardiac
history including critical AS, CHF, CAD s/p PCTA presenting with
CHF exacerbation and NSTEMI. The patient and his two sons report
that he has been in his usual state of baseline health since he
was discharged from ___ in ___. Two days prior to
admission, he had one episode of chest tightness and dyspnea.
This resolved without intervention, and his son took his O2 sat
with a home meter which was 97% on RA. The son did note some ___
edema and spoke to Dr. ___ increasing his Lasix from 40mg
qam, 20mg qpm to 40mg BID, which was done. However, this am, the
patient again developed chest tightness and dyspnea, his O2 sat
was 85% on room air, so an ambulance was caleld. The patient
initially went to ___ and was found to
have troponin of 0.14 and was given ASA, nitro paste (still
applied on admission to the floor), morphine, lovenox, 80mg
lasix (rec'd 20 from son in the morning prior to transfer to
OSH), placed on CPAP with improvement in symptoms and oxygen
saturation. He was on CPAP upon arrival to ___ ER, but this
was discontinued on arrival. The patient in the ER did not
appear dyspneic and was speaking in full sentences
Of note, patient was admitted in ___ for dyspnea, found to
have NSTEMI thought to be ___ strain from critical aortic
stenosis, but not a surgical AVR candidate due to multiple
medical problems and because the patient does not want to pursue
this.
In the ED, initial vitals were 96.9 65 126/58 20 98% cpap. Labs
are notable for troponon of 0.08. Patient was given no
medication. VS upon transfer were 98.3 71 143/44 19 95%. He had
between 300-500cc of urine output.
The patient does endorse hemoptysis, which started yesterday. He
has had 2 episodes of about a teaspoon of blood not mixed with
sputum. He has some during the exam, which is as described. He
denies nose bleeds or bleeds from inside the mouth.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, black stools or red
stools. He denies recent fevers, chills or rigors. He denies
exertional buttock or calf pain. All of the other review of
systems were negative.
Cardiac review of systems is notable for absence of paroxysmal
nocturnal dyspnea, orthopnea, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
-Systolic and diastolic CHF with an ejection fraction of 35% on
___ echo.
-Severe aortic stenosis with aortic valve area 0.7 cm2 on TEE in
___.
-PERCUTANEOUS CORONARY INTERVENTIONS: bare-metal stent to left
circumflex in ___ and drug-eluting to left circumflex
in ___, status post drug-eluting stent x3 to LAD in
___.
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
1. Insulin-dependent diabetes, most recent hemoglobin A1c 7.5%
in ___.
2. Peripheral vascular disease status post right SFA and
popliteal stents and left SFA, popliteal, and posterior tibialis
stents
3. 60-65% bilateral carotid stenosis and proximal right
vertebral stenosis on ___ ultrasound. Followed by Dr.
___. 4. Renal insufficiency with a baseline creatinine
of approximately 1.5.
5. CLL. Diagnosed in ___. Followed by Dr. ___ ___.
6. Peptic ulcer disease.
7. Hypertension.
8. Gastritis.
9. Hypogammaglobulinemia. SPEP in ___ revealed low IgG and
IgA levels but no monoclonal immunoglobulin or UPEP abnormality
UPEP
10. Normocytic anemia with a baseline hematocrit of
approximately 28% 13. MSSA bacteremia. ___, treated
with four weeks of nafcillin.
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAMINATION:
VS: T=98 BP=149/54 HR=73 RR=18 O2 sat=98% 2L
___: elderly gentleman in NAD. Alert, answering all
questions appropriately with minimal ___ and sons
interpreting. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 5 cm.
CARDIAC: RR, normal S1, S2. Loud blowing murmer heard throughout
the precordium and posterior lung fields. Systolic
crescendo-descrendo. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at bilateral
bases clear at apices, no wheezes.
ABDOMEN: Soft, NTND. No HSM or tenderness. No abdominal bruits.
EXTREMITIES: No c/c/e.
SKIN: No ulcers, scars, or xanthomas. Dry flaking skin on ___
bilaterally.
PULSES:
Right: DP 2+ ___ 2+
Left: DP 2+ ___ 2+
Discharge:
Tele: sinus, long PR (220-230), rare PVCs
VS: 97.6, 93-133/29-51, 66, 18, 95% RA net even Weight 52.4 kg
(down from 53.2)
___: elderly, thin and frail appearing gentleman in NAD
HEENT: MMM, EOMI
NECK: Supple with JVP of 8 cm
CARDIAC: Loud blowing murmer heard throughout the precordium and
posterior lung fields. Systolic crescendo-descrendo. No S3 or
S4.
LUNGS: Resp were unlabored, no accessory muscle use. Decreased
breath sounds at bases, rales right base > left, slight
expiratory wheeze
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No cyanosis, clubbing, or edema. No femoral bruits.
Pertinent Results:
Admission:
___ 09:35PM CK(CPK)-64
___ 09:35PM CK-MB-6 cTropnT-0.10*
___ 04:50PM LACTATE-0.9
___ 04:45PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 04:45PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 04:45PM URINE HYALINE-17*
___ 04:45PM URINE MUCOUS-RARE
___ 04:35PM GLUCOSE-151* UREA N-47* CREAT-1.6* SODIUM-142
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-20* ANION GAP-19
___ 04:35PM estGFR-Using this
___ 04:35PM cTropnT-0.08*
___ 04:35PM ___
___ 04:35PM WBC-5.8 RBC-3.76* HGB-11.0* HCT-34.1* MCV-91
MCH-29.2 MCHC-32.1 RDW-17.0*
___ 04:35PM NEUTS-67.9 LYMPHS-16.6* MONOS-7.2 EOS-6.5*
BASOS-1.9
___ 04:35PM PLT COUNT-637*#
___ 04:35PM ___ PTT-54.0* ___
Discharge:
___ 06:57AM BLOOD WBC-3.7* RBC-3.14* Hgb-9.4* Hct-28.0*
MCV-89 MCH-29.9 MCHC-33.5 RDW-16.8* Plt ___
___ 06:05AM BLOOD Glucose-73 UreaN-48* Creat-1.5* Na-141
K-4.4 Cl-107 HCO3-21* AnGap-17
___ 06:05AM BLOOD Calcium-8.2* Phos-4.6* Mg-2.6
___ 04:35PM BLOOD ___
___ 04:35PM BLOOD cTropnT-0.08*
___ 09:35PM BLOOD CK-MB-6 cTropnT-0.10*
___ 02:29AM BLOOD CK-MB-5 cTropnT-0.12*
___ 05:31AM BLOOD CK-MB-5 cTropnT-0.10*
Imaging:
CHEST (PORTABLE AP) Study Date of ___
FINDINGS: Comparison is made to the prior study from ___.
There is again seen moderate congestive heart failure with
increased vascular cephalization, stable. There are large
bilateral pleural effusions but decreased since previous. There
is cardiomegaly. No pneumothoraces are identified.
Calcifications of thoracic aorta are present.
___ Cardiovascular ECHO
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. The estimated right atrial pressure is ___
mmHg. There is mild symmetric left ventricular hypertrophy with
normal cavity size. There is mild to moderate global left
ventricular hypokinesis (LVEF = 40 %). The estimated cardiac
index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests
an increased left ventricular filling pressure (PCWP>18mmHg).
Right ventricular chamber size is normal. with borderline normal
free wall function. The aortic valve leaflets are severely
thickened/deformed. There is critical aortic valve stenosis
(valve area 0.6 cm2). Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. [Due to acoustic
shadowing, the severity of mitral regurgitation may be
significantly UNDERestimated.] The tricuspid valve leaflets are
mildly thickened. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
mild to moderate global hypokinesis. Borderline right
ventricular free wall systolic function. Critical aortic
stenosis. Mild pulmonary hypertension.
___ Radiology CHEST (PORTABLE AP
FINDINGS:
Heart size likely is moderately enlarged but difficult to assess
given the presence of moderate bilateral pleural effusions,
increased from the prior exam. Bibasilar airspace opacities may
reflect compressive atelectasis. There is mild to moderate
pulmonary edema. No pneumothorax is identified. There are no
acute osseous abnormalities.
IMPRESSION:
Moderate congestive heart failure with moderate size bilateral
pleural
effusions, bibasilar atelectasis, mild to moderate pulmonary
edema.
ECG Study Date of ___ 4:26:44 ___
Normal sinus rhythm, rate 68. Right bundle-branch block. ST
segment
depression which is downsloping in the inferolateral leads which
looks
suspicious for ischemia. Clinical correlation is suggested. A
right
bundle-branch like pattern is also present. What is somewhat
discerning
is the fact that the T wave is upright in lead V2 and is
concordant with the QRS complex.
Brief Hospital Course:
___ yo ___ speaking male with significant past cardiac
history including critical AS, CHF, CAD s/p PCTA presenting with
acute CHF exacerbation in setting of worsening severe aortic
stenosis and depressed LVEF on ECHO.
# Acute on chronic CHF systolic exacerbation: The patient
initially presented with what sounds like pulmonary edema, he
may have flashed due to increased demand causing ischemia in the
setting of his critical AS. He also had a new oxygen requirement
of 2 L NC and 2 days of hemoptysis. CXR consistent with fluid
overload and BNP > 30,000. EF was 50-55%. Trop 0.14-->0.08-->
0.1-->0.12-->0.12. EKG without new ischemic changes. This seems
likely secondary to demand with acute CHF exacerbation in
setting of severe AS. Repeat ECHO on this admission with EF of
40%. Patient was treated with IV lasix. ASA, Plavix, statin,
metoprolol continued. Discharge weight 52.4kg. CXR with improved
pulmonary edema and oxygen requirement resolved.
# Critical AS: Severe AS (mean gradient 55 mm Hg and aortic
valve area 0.6 cm2). Goals of care were discussed with patient
and family and decision was made not to persue aortic valve
repair or replacement. Code status changed to DNI/DNI in
accordance with patient wishes.
Chronic Issues:
# HTN: Patient hypertensive on admission. He was continued on
home amlodipine, lisinopril, metoprolol and hydralazine and
diuresed with improvement in blood pressure.
# CLL: The patient has CLL which has resulted in anemia and per
the sons, his hypogammaglobulinemia is also a result of the CLL
treatment. He gets monthly Procrit infusions at his
hematologist's office. He was continued on home anagrelide
0.5mg daily.
# IDDM: Patient continued on home HISS with conversion of
levemir to glargine at a slightly lower dose due to episodes of
hypoglycemia. Patient discharged on home regimen.
# CKD: Cr currently baseline around 1.4-1.6.
# Hyperlipidemia- Continued home statin.
Transitional Issues:
- No pending test results
- Patient to follow up with cardiologist
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
hold for SBP < 90
2. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP < 90, HR < 55
3. Amlodipine 10 mg PO DAILY
hold for SBP < 90
4. Atorvastatin 80 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Epoetin Alfa Dose is Unknown IV ONCE PER MONTH Start: HS
7. Furosemide 40 mg PO BID
hold for SBP < 90
8. HydrALAzine 25 mg PO TID
hold for SBP < 90
9. Ranitidine 150 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Levemir 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. anagrelide *NF* 0.5 mg Oral daily
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
hold for SBP < 90
2. anagrelide *NF* 0.5 mg Oral daily
3. Atorvastatin 80 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
hold for SBP < 90
6. Ranitidine 150 mg PO DAILY
7. Epoetin Alfa 0 UNIT IV ONCE PER MONTH
8. Aspirin 81 mg PO DAILY
9. Furosemide 40 mg PO BID
hold for SBP < 90
10. HydrALAzine 25 mg PO TID
hold for SBP < 90
11. Levemir 14 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Metoprolol Succinate XL 100 mg PO DAILY
hold for SBP < 90, HR < 55
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute on chronic systolic congestive heart failure,
severe aortic stenosis
Secondary: Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with congestive heart failure and treated with diuretics to get
rid of fluid.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Medication changes: none
Followup Instructions:
___
|
19911629-DS-16 | 19,911,629 | 22,262,825 | DS | 16 | 2123-08-25 00:00:00 | 2123-08-25 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
intoxication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr ___ is a ___ man with a history of HCV and polysubstance
abuse, who presents with acute intoxication. He was found
altered, with wet clothing, and needles, a full bottle of Prozac
and clonazepam on him. He states that he drank alcohol earlier
on ___ at night, but denies any other ingestions or taking any
medications other than his prescriptions. Otherwise, he was
unable to provide history.
* In ED initial VS: 98.8 80 177/110 24 97% RA
* Exam: very altered, screaming. No meningismus.
* Labs notable for ETOH 179, +opiates, +cocane
* He became tachycardic to 120s, and then hyperthermic to 105.2.
Cooling was started with ice packs, and he received benzos.
Since then, he was alternating somnolent and agitated, with
hyperreflexia & clonus on exam. He was cooled.
* Imaging notable for: CT head with no acute process
* He was given:
___ 02:11 IM Lorazepam 2 mg ___
___ 03:04 IM Lorazepam 2 mg ___
___ 03:40 IV Diazepam 10 mg ___
___ 03:57 IV Diazepam 20 mg ___
___ 04:36 IV Diazepam 20 mg ___
* VS prior to transfer: 39.6 108 150/83 28 97% RA
On arrival to the MICU, he is somnolent. He wakes to loud voice
and moans, but otherwise will not answer questions.
Past Medical History:
- HCV
- ETOH abuse
- polysubstance abuse
Social History:
___
Family History:
unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 100.2 103 158/79 26 96% on ra
GENERAL: Lying in bed sleeping, nontoxic, awakes briefly to loud
voice
HEENT: Sclera anicteric, pupils small but reactive, mmm
NECK: supple, JVP not elevated
LUNGS: clear in anterior fields, no wheezes or crackles
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes or jaundice
NEURO: Sleepy, will not answer questions, can't assess
orientation
DISCHARGE EXAM:
98.2; 156/95; 71; 18; 97 RA
Left AMA before examination on ___.
Pertinent Results:
ADMISSION LABS:
============================
___ 11:30PM BLOOD WBC-5.1 RBC-4.32* Hgb-12.6* Hct-38.5*
MCV-89 MCH-29.2 MCHC-32.7 RDW-13.6 RDWSD-44.9 Plt ___
___ 11:30PM BLOOD Neuts-58.1 ___ Monos-6.1 Eos-3.1
Baso-0.4 Im ___ AbsNeut-2.95 AbsLymp-1.62 AbsMono-0.31
AbsEos-0.16 AbsBaso-0.02
___ 04:05AM BLOOD ___ PTT-28.7 ___
___ 11:30PM BLOOD Plt ___
___ 11:30PM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-136
K-3.6 Cl-98 HCO3-26 AnGap-16
___ 03:25AM BLOOD ALT-56* AST-95* CK(CPK)-208 AlkPhos-97
TotBili-0.5
___ 03:25AM BLOOD Lipase-35
___ 03:25AM BLOOD Albumin-3.7
___ 11:30PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS
==========================
___ 07:46AM BLOOD WBC-4.7 RBC-3.84* Hgb-11.6* Hct-34.3*
MCV-89 MCH-30.2 MCHC-33.8 RDW-14.1 RDWSD-45.6 Plt ___
___ 07:46AM BLOOD Glucose-112* UreaN-15 Creat-0.6 Na-141
K-3.4 Cl-104 HCO3-24 AnGap-16
___ 07:46AM BLOOD ALT-57* AST-94* AlkPhos-93 TotBili-0.4
REPORTS
=========================
CT Head ___
-No acute intracranial abnormality on noncontrast head CT.
Specifically no intracranial hemorrhage or large territory
infarct.
-Moderate mucosal thickening of the anterior ethmoid air cells
and mild
mucosal thickening of the maxillary sinuses.
MICRO
========================
Hep C Ab -positive
Hep C VL -pending
HIV VL -pending
Brief Hospital Course:
Mr ___ is a ___ man with a history of HCV and polysubstance
abuse, who presented with acute intoxication, and was admitted
to the ICU for altered mental status, hyperthermia, and
tachycardia.
# HYPERTHERMIA: Patient was febrile to 105 in the ED, concerning
for infection vs toxidrome vs serotonin syndrome. He was cooled
and vital signs normalized throughout the rest of his ICU stay.
Infectious workup was negative. Most likely etiology due to
acute intoxication (especially given positive for cocaine).
Patient was transferred to the floor on ___, but left AMA early
on ___.
# TACHYCARDIA: Patient was tachycardic to the 120s in the ED.
DDx includes acute agitation, withdrawal, cocaine ingestion, or
serotonin syndrome. This resolved over the course of his stay
without further intervention.
# MYOCLONUS: Patient had inducible myoclonus on ED exam,
concerning for serotonin syndrome, however this quickly resolved
without further intervention
# ETOH ABUSE & POLYSUBSTANCE ABUSE: Patient has history of
polysubstance abuse, including cocaine & opiates. Tox screen
positive for ETOH, cocaine, opiates. He received high dose
thiamine, folate, Multivitamin. He left AMA on ___, and he
was not seen by social work prior to discharge.
# TRANSAMINITIS: Patient with AST 95, ALT 56, consistent with
alcoholic hepatitis. He also has hepatitis C. Synthetic
function normal. HIV VL and Hep C VL both pending on discharge.
# AMA Discharge: The morning of ___, Mr. ___ insisted on
leaving immediately. We discussed with him the risks of leaving
and ensured that he was able to rationally discuss the reasons
he was hospitalized, the risks of leaving, and the reason we
wanted him to stay. He understood the risks to his health of
leaving, signed the AMA paperwork, and left.
TRANSITIONAL ISSUES
====================
- Hep C positive (known). Hep C viral load pending on discharge
- HIV viral load pending on discharge
- Encourage further follow-up regarding substance use and
abstinence as an outpatient
Medications on Admission:
1. CloNIDine 0.2 mg PO TID
2. ClonazePAM 1 mg PO DAILY
3. FLUoxetine 20 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
2. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
4. CloNIDine 0.2 mg PO TID
5. ClonazePAM 1 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Polysubstance intoxication
Hyperthermia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure caring for you at ___. You were admitted to
the hospital after being found intoxicated. We are concerned you
may have overdosed on your Prozac (fluoxetine). You were
monitored overnight. You have chosen to leave the hospital. If
you would like to stay and seek further treatment for substance
use, please return to seek further care. You should stop taking
your Prozac.
Followup Instructions:
___
|
19911969-DS-16 | 19,911,969 | 26,326,405 | DS | 16 | 2154-06-08 00:00:00 | 2154-06-10 10:27:00 |
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 hypothyroidism and sessile serrated adenoma of the
right colon s/p laparoscopic right colectomy ___ with
uncomplicated course, presents with acute onset generalized
abdominal pain, likely viral gastroenteritis.
She had uncomplicated postoperative course. On day of
presentation, she developed sudden abdominal pain. One hour
later, she developed chills, crampy intermittent pain. She had a
BM with small amount of BRBPR at home and then 5 BMs in ED
without blood. Her husband recently had acute gastroenteritis
with nausea, vomiting, diarrhea, which has resolved. No recent
travel, antibiotics, or other sick contacts. She called Dr.
___ these symptoms and was asked to come to the ED
for further evaluation.
In the ED, initial vital signs: 102.1 ->98.5 104 133/59 16 100%
RA
- Labs were notable for: WBC 13.9 then 6.1. Hct 28.2. Chem-7,
LFTs, lipase normal. Lactate 1.4. UA neg. Noro neg. CDiff pnd.
- Imaging:
RUQUS- Cholelithiasis without evidence of cholecystitis.
CT- 1. No free air or extraluminal fluid to suggest leak.
2. Cholelithiasis with possible mild gallbladder wall edema. If
there is clinical concern for cholecystitis this could be
further evaluated with right upper quadrant ultrasound.
- The patient was given:
___ 01:45 IVF 1000 mL NS 1000 mL
___ 01:45 IV Morphine Sulfate 4 mg
___ 01:54 IV LORazepam .5 mg
___ 03:31 IV Morphine Sulfate 4 mg
___ 08:34 PO/NG Levothyroxine Sodium 100 mcg
___ 11:50 IVF 1000 mL NS 1000 mL
- Consults:
Colorectal- Discussed with Dr. ___. Admit to medicine for
fever and leukocytosis work-up. CT scan with no evidence of leak
and patient is ___ month out from her operation.
On the floor, patient was found in the kitchen making herself
some toast. She had mild abdominal discomfort but was otherwise
fine.
Past Medical History:
Hypothyroidism
Laparoscopic right colectomy ___
Social History:
___
Family History:
Father - colon cancer
Mother - volvulus
___ - HTN, cervical cancer, thyroid cancer
Physical Exam:
ON ADMISSION:
VITALS: 98.6 78 113/78 16 98% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: MMM, OP clear.
CARDIAC: RRR, normal S1/S2, no murmurs.
PULMONARY: Clear, without wheezes or rhonchi.
ABDOMEN: Normal bowel sounds, soft, mildly tender suprapubic,
non-distended, no organomegaly. No rebound or guarding.
EXT: Warm, well-perfused, no edema.
SKIN: Without rash.
ON DISCHARGE:
VITALS: 98.6 ___ 96-98% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT: MMM, OP clear.
CARDIAC: RRR, normal S1/S2, no murmurs.
PULMONARY: Clear, without wheezes or rhonchi.
ABDOMEN: Normal bowel sounds, soft, mildly tender suprapubic,
non-distended, no organomegaly. No rebound or guarding.
EXT: Warm, well-perfused, no edema.
SKIN: Without rash.
Pertinent Results:
ON ADMISSION:
___ 01:25AM BLOOD WBC-13.9*# RBC-3.54* Hgb-10.6* Hct-31.9*
MCV-90 MCH-29.9 MCHC-33.2 RDW-12.3 RDWSD-40.8 Plt ___
___ 01:25AM BLOOD Neuts-88.7* Lymphs-7.6* Monos-3.1*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.31* AbsLymp-1.06*
AbsMono-0.43 AbsEos-0.01* AbsBaso-0.03
___ 03:04AM BLOOD ___ PTT-29.5 ___
___ 01:25AM BLOOD Glucose-119* UreaN-16 Creat-0.6 Na-141
K-4.5 Cl-104 HCO3-24 AnGap-18
___ 01:25AM BLOOD ALT-17 AST-25 AlkPhos-57 TotBili-0.3
___ 01:25AM BLOOD Lipase-30
___ 01:25AM BLOOD Albumin-4.1
___ 01:36AM BLOOD Lactate-1.4
ON DISCHARGE:
___ 05:10AM BLOOD WBC-5.1 RBC-3.32* Hgb-9.9* Hct-30.8*
MCV-93 MCH-29.8 MCHC-32.1 RDW-12.2 RDWSD-41.7 Plt ___
___ 05:10AM BLOOD Glucose-68* UreaN-11 Creat-0.6 Na-140
K-3.8 Cl-106 HCO3-23 AnGap-15
___ 05:10AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.1
OTHER STUDIES:
___ CT A/P with contrast:
1. No free air or extraluminal fluid to suggest leak.
2. Cholelithiasis with possible mild gallbladder wall edema. If
there is
clinical concern for cholecystitis this could be further
evaluated with right upper quadrant ultrasound.
___ RUQ Ultrasound: Cholelithiasis without evidence of
acute cholecystitis.
Brief Hospital Course:
___ with hypothyroidism and sessile serrated adenoma of the
right colon status post laparoscopic right colectomy ___
with uncomplicated course, who presented with acute onset
generalized abdominal pain, bloody bowel movement, and fever.
Right upper quadrant ultrasound and CT abdomen/pelvis were
normal. Colorectal surgery was consulted and felt that given
normal imaging her symptoms were not related to her recent
colectomy.
Patient's abdominal symptoms improved on day of discharge and
she no longer had loose, bloody bowel movements. Her initial
leukocytosis quickly downtrended and she was afebrile during her
admission. Patient's symptoms were initially thought to be
secondary to viral gastroenteritis, which her husband had
recently. However, her stool sample was positive for c.diff. She
was therefore started on 14-day course of metronidazole 500mg
q8h for mild c.diff.
CHRONIC ISSUES:
# Normocytic Anemia: Normal H/H pre-op, Hct this admission
around ___. This was thought to be secondary to recent blood
loss and inflammation.
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES:
- New medications: Metronidazole 500mg q8h x14d
- Patient treated empirically for mild c.diff given positive
stool sample. However, patient no longer had bloody or loose
bowel movement by discharge.
- Code status: Full
- Contact: ___ (husband, HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
2. Levothyroxine Sodium 50 mcg PO 1X/WEEK (___)
Discharge Medications:
1. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
2. Levothyroxine Sodium 50 mcg PO 1X/WEEK (___)
3. MetroNIDAZOLE 500 mg PO Q8H Duration: 14 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Clostridium difficile gastroenteritis, mild
SECONDARY:
History of laparoscopic colectomy ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___. You were admitted
because you were experiencing abdominal pain, diarrhea, and
fever. You had imaging of your abdomen, which your colorectal
surgeon reviewed, which was normal. Your stool sample grew a
bacteria called clostridium difficile, which is likely the cause
of your symptoms. You were started on an antibiotic called
metronidazole, which you should take as prescribed for 2 weeks.
You have a follow-up appointment with surgery, scheduled below.
Please also set up an appointment with your PCP for ongoing
management.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19912242-DS-16 | 19,912,242 | 20,940,637 | DS | 16 | 2169-01-11 00:00:00 | 2169-01-11 10:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
cefaclor
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
Admission note appreciated.
Briefly, ___ w choledocholithiasis, HTN, Roux-en-Y gastric
bypass p/w fever. Was admitted to ___ about a week prior to
this admission, had a partial ERCP which was aborted due to
hypotension. Stent was placed and pt received IVF and was
discharged on ppx cipro. Hypotension was attributed to dumping
syndrome, hypovolemia, anesthesia. Had some ___ that resolved
with IVF and holding of home ACEi, which he has not yet resumed.
Pt had been home for a few days with poor PO. Noted to have
orthostasis and presyncope about 3d PTA, and felt very cold
despite it being very warm outside. Never checked temperature.
Was driving with grandson and noted diplopia that resolved with
closing one eye.
Denies HA, confusion, weakness, numbness, tingling, seizure,
syncope, head trauma, vertigo, hearing loss, aphasia. Pt denies
chest pain, but does have some intermittent cough, worse with
eating fast, non-productive. No wheeze, abdominal pain,
jaundice, dysuria, hematuria, diarrhea, joint pain, myalgias.
Though he initially denies rash, on exam a rash is noted and he
reports that this started as a "blood blister" on his L forearm
that popped. He lives in a wooded but urban area.
Per MICU admission note:
On arrival to ___ patient was febrile and
hypotensive. He was diagnosed with possible cholangitis given
Unasyn at 0140 and 1L NS and transferred to ___ for further
management.
In the ED, initial vitals: 101.4 (104.8), 110, 147/79 (118/79),
18 100% RA
- Exam notable for: anxious appearing male wretching,
Tachycardic, obese soft NTND, rectal heme neg
- Labs were notable for: Bicarb 21, Cr 1.3, Lactate 4.4, WBC
9.7, ALT: 12, AST: 24, Lip: 17
- Imaging: RUQ US showed layering sludge and stones in
gallbladder and sludge with layering in common hepatic duct.
Mild intrahepatic biliary ductal dilatation and extrahepatic
biliary ductal dilatation, pancreatic duct dilatation.
- Patient was given: 1L NS, 1G acetaminophen, 4mg IV Zofran,
500mg IV flagyl.
He was admitted to ICU in preparation for an MRCP and then a
repeat ERCP. He was started on vanc/unasyn.
He feels almost completely back to baseline, except he is still
seeing some mild diplopia. 10 pt ROS otherwise negative.
PMH/PSH/Meds/All/SHx/Fhx as per MICU admit note and all
confirmed by me
vital signs reviewed personally in metavision, notable for SBP
140s now, ranging 110-140/50-90, HR 55, 16 100%RA, 3.8L/850cc
pleasant, NAD, comfortable
NCAT, MMM, no oral lesions
RRR, S4, no mr
CTAB
___, neg ___, NABS
neg CVAT
wwp, neg edema
no foley
L forearm bullseye rash under PIV dressing
A&Ox3, ___ BUE/BLE, SILT BUE/BLE, CN exam notable for mild R
sided ptosis (pt says new--noted on MICU admit), intact visual
fields and EOMI but mild diplopia that resolves with covering an
eye, CNs otherwise intact, FTN wnl
negative Jolt accentuation test but range of motion limited by
baseline neck pain (h/o cervical stenosis at baseline)
Labs reviewed
Micro reviewed
Imaging reviewed
Meds reviewed
Past Medical History:
Hypertension
Depression
Restless leg syndrome
Duodenal ulcer
Cholelithiasis
Osteoarthritis
OSA (not on CPAP)
s/p Roux-en-Y gastric bypass in ___
s/p Throat surgery for OSA
s/p L5 discectomy at age ___
s/p Appendectomy age ___
Social History:
___
Family History:
Gallstones in his mother, 2 sisters with lung cancer, and
"diabetes on his father's side".
Physical Exam:
Prior to Discharge:
VS: 98.1, 62, 145/77, 18, 97% RA
GEN: NAD
HEENT: No scleral icterus
CV: RRR, no m/r/g
PULM: CTAB
ABD: Laparoscopic incisions with occlusive dressing and c/d/I
EXTR: Warm, no c/c/e
Pertinent Results:
RECENT LABS:
___ 07:42AM BLOOD WBC-6.9 RBC-3.66* Hgb-12.0* Hct-36.0*
MCV-98 MCH-32.8* MCHC-33.3 RDW-12.7 RDWSD-45.3 Plt ___
___ 07:42AM BLOOD Glucose-80 UreaN-7 Creat-0.9 Na-139 K-3.9
Cl-105 HCO3-24 AnGap-14
___ 07:42AM BLOOD ALT-10 AST-15 AlkPhos-52 TotBili-0.6
___ 07:42AM BLOOD Calcium-8.3* Phos-3.7 Mg-2.1
___ 5:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BACTEROIDES FRAGILIS GROUP. BETA LACTAMASE POSITIVE.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0305.
GRAM NEGATIVE ROD(S).
___ US:
IMPRESSION:
1. Gallbladder contains layering sludge and stones, without
evidence of
gallbladder-wall thickening or pericholecystic fluid. Sludge
also appears to be layering within the common hepatic duct.
2. Mild central intrahepatic biliary ductal dilatation and
extrahepatic
biliary ductal dilatation, as well as mild dilatation of the
pancreatic duct.
___ MRCP:
IMPRESSION:
1. No intraductal filling defects to indicate
choledocholithiasis.
2. Increased enhancement of the wall of the cystic duct and to a
lesser degree the CBD without intrahepatic ductal wall
enhancement, suggests a component of cholangitis. Sludge/stones
within the gallbladder without evidence of acute cholecystitis.
___ MRI BRAIN:
IMPRESSION:
1. Mild atrophy and white matter hyperintensity on FLAIR.
Otherwise normal study.
2. No evidence of hemorrhage or infarction.
3. No evidence of vascular occlusion or stenosis.
4. Mild dilatation of the proximal right internal carotid
artery, likely due to atheromatous disease.
Brief Hospital Course:
___ yo w HTN, OSA, s/p ___ bypass, recent choledocholithiasis
s/p
recent incomplete ERCP p/w fevers, chills, hypotension and
possible polymicrobial bacteremia with likely
#Sepsis: Now resolved, likely hepatobiliary source (recent
instrumentation, known choledocholithiasis, but MRCP without
frank evidence of this) versus less likely pneumonia (mild cough
but no infiltrate). Negative UA. OSH BCx growing C. ramosum
(beta
lactamase negative)and BCx here growing B. fragilis beta
lactamase
positive). As no evidence bacteria on cx that require vancomycin
coverage, stopped vanc and continued Unasyn as doing well. ID
c/s agreed with stopping vanc and recommended continuing unasyn
until surgery, then switch to Augmentin for 14 day total course
(starting ___.
# h/o choledocholithiasis: Failed ERCP on last admission ___
hypotension, though also appears to have difficult anatomy.
Stent
placed at that time. Patient transferred to surgery service ___
after CCY.
# Thrombocytopenia: Likely ___ sepsis as resolved with tx of
infection. Less likely hit though SQH was stopped due to concern
for possible HIT and not restarted as ambulating frequently.
Given possible rash anaplasma and lyme
studies checked though no concern at this time; no hemolysis to
suggest babesia. Lyme, anaplasma negative.
#Anemia: some component of iron deficiency anemia by transferrin
saturation, borderline B12 could suggest deficiency (especially
s/p bypass) but MMA normal. continued on iron BID, will need o/p
colonoscopy for screening
# HTN: SBPs to 160s without sx. As in hospital and planning for
surgery, did not adjust meds at this time but will need
outpatient followup. Continued home amlodipine/lisinopril after
improvement in BP, as they were initially on
hold due to sepsis.
#Depression: Stable on home bupropion, on QID dosing given s/p
gastric bypass
with decreased absorption per patient.
#Restless Leg: iron as above, cont home tramadol prn
#OSA: Needs outpatient sleep study, likely CPAP.
TRANSITIONAL ISSUES:
[] OSA: Needs outpatient sleep study, likely CPAP.
[] will need o/p colonoscopy for screening
[] Should complete course of Augmentin on ___
[] Should evaluate BP management with PCP
___ ___ patient was transferred to HPB Surgery Service.
Patient underwent laparoscopic cholecystectomy, which went well
without complications. Post operatively patient was transferred
on the floor tolerating clear liquid diet, PO Morphine for pain
control and IV antibiotics. On POD 1, diet was advanced to
regular, IV fluid was discontinued, patient voided without
difficulties and pain was well control. Patient was discharged
home, prior to discharge antibiotic was changed to PO Augmentin
in oreder to complete 14 days course of treatment.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion 75 mg PO QID
2. Morphine Sulfate ___ 15 mg PO Q8H:PRN Pain - Moderate
3. Lisinopril 40 mg PO DAILY
4. amLODIPine 2.5 mg PO DAILY
5. TraMADol 50 mg PO DAILY:PRN restless legs
6. meloxicam unknown oral unknown
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet by mouth
every twelve (12) hours Disp #*15 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
5. amLODIPine 2.5 mg PO DAILY
6. BuPROPion 75 mg PO QID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Lisinopril 40 mg PO DAILY
9. Morphine Sulfate ___ 15 mg PO Q8H:PRN Pain - Moderate
10. TraMADol 50 mg PO DAILY:PRN restless legs
Discharge Disposition:
Home
Discharge Diagnosis:
1. Bacteremia
2. Choledocholithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for fever. You were initially
admitted to the intensive care unit where you were found to have
a blood stream infection. You had an MRCP which showed some
inflammation of your bile duct but no obstructing stone.
Because you were asymptomatic, repeat ERCP procedure was
deferred. You were treated with IV antibiotics for your
bloodstream infection with dramatic improvement. You were
evaluated by surgery and a cholecystectomy (removal of
gallbladder) was performed. You should continue oral antibiotics
through ___.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
Followup Instructions:
___
|
19912403-DS-8 | 19,912,403 | 27,781,958 | DS | 8 | 2169-12-07 00:00:00 | 2169-12-07 13:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Azithromycin / Gluten / Tetanus
Attending: ___
Chief Complaint:
L sided weakness
Major Surgical or Invasive Procedure:
plasma pahresis
History of Present Illness:
Ms. ___ is a ___ woman with NMO on azathioprine
and steroids who presents from clinic after reporting L sided
weakness and vomiting.
Last ___, she developed a sharp pain only with palpation
over her left ear drum. This then spread to her left jaw, behind
her ear, and into her left neck and shoulder over the following
days. She went to OSH where CT of her head was negative. She
followed up with her PCP, where the NP was concerned for
shingles
except there was no rash vs trigeminal neuralgia. After hearing
that her nerves may be involved, she called the neurology office
and came in today for an appointment.
She was in her usual state of health without any recent
infections when at 3:30am, she woke up and started vomiting. She
felt generally weak and went to bed. Also noted some diarrhea.
At
5:30am when she went to turn off her phone, her left arm was
limp, and she rolled off the bed on her left side. She presented
to clinic, where she was redirected to the emergency room for
?stroke vs acute NMO flare. She denies any fevers, dysuria,
cough, or congestion.
At baseline, L eye has some light/dark perception, R eye with
full visual fields. R IP, AT weaker than left. Neurologic
history
started in ___ when she developed painful loss of sight in her
left eye. She was treated with steroids and was left with only
light perception in that eye. In ___, she developed toe and
finger numbness, and MRI brain showed periventricular enhancing
subependymal nodules. She was again treated with steroids. In
___, she developed L leg numbness and weakness and was found to
have a contrast enhancing lesion at T1 and T3. She also had
hypersensitivity around the left thorax under her left breast.
CSF showed 13 WBC in setting of 1753 RBC, 24 poly and 61 lymphs.
Protein 28, glucose 64. Oligoclonal bands negative, CSF ACE
normal, but serum NMO was positive at 1:7680. She received IV
steroids and was started on Cytoxan as an outpatient. This was
transitioned to steroids and azathioprine, which she has done
well on. She has not had any further flares since ___.
Past Medical History:
1. Hypothyroidism
2. Neurodemyleinating syndrome- including left optic nerve but
also involves brain. this is a variant of MS.
___ History:
___
Family History:
No h/o demyelination, MS, autoimmune disease. Her mother had an
ICH at age ___.
Physical Exam:
Admission exam:
Vitals: T: 97.5F HR: 70 BP: 120/71 RR: 16 SaO2: 98% RA
General: NAD
HEENT: NCAT, unable to visualize L eardrum ___ impacted ear wax,
R tympanic membrane intact with light reflex, pain to palpation
over the L ear lobe that radiates down into her left jaw and
back
behind the ear into neck and shoulder
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
- Cranial Nerves: R pupil 3->2 brisk. +RAPD in L eye. Right VF
full to finger movement, unable to see anything out of left eye
(baseline). L optic disc crisp but flat and pale, R optic disc
margins are mildly blurred but normal color. EOMI, no nystagmus.
Saccadic intrusions of L eye. 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. L pronator drift. No tremor or
asterixis.
[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1]
L 4 5 5- 5 4 4+ 5 4 5- 5
R 5 5 5 5 4 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 3+ 3+ 3+ 2
R 2+ 2+ 2+ 3+ 2
Plantar response flexor on right, extensor on left. Crossed
adductor present on L, bilateral pectoralis jerk present more
pronounced on L
- Sensory: No deficits to light touch in all extremities,
baseline numbness in L breast, decreased sensation to pin over L
shin and L hand up to mid-arm, no sensory level on back, no
decreased sensation to proprioception along the back
- Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait: deferred
Discharge exam:
Vitals: T: 97.7, BP:125/73, HR 60's, 97% RA
General: Awake, alert, lying in bed, cooperative
HEENT: NC/AT, non-icteric sclera
Cardiac: Skin warm, well-perfused.
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Abdomen: soft, ND
Extremities: symmetric, no edema.
Neurologic:
-MS: Awake, alert, oriented x4. Attentive to exam. Language is
fluent with intact comprehension and no paraphasic errors. Able
to follow both midline and appendicular commands.
-CN: PERRL 3->2. EOMI without nystagmus. Face symmetric at
rest
and with activation. Hearing intact to conversation. No
dysarthria. Tongue protrudes towards right but moves briskly to
each side.
-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 Gastroc
L 4+ 4+ 4+ 4+ ___ 5- 5 5-
R 5 ___ ___ 5 5 5
-Sensory: Intact to LT throughout except RLE decr to LT.
-DTR: deferred
-___: No intention tremor.
No dysmetria on FNF on R. Unable to test due to weakness on L.
Pertinent Results:
___ 02:35PM %HbA1c-5.5 eAG-111
___ 12:20PM URINE HOURS-RANDOM
___ 12:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 12:20PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0
LEUK-NEG
___ 12:20PM URINE RBC-3* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:30AM GLUCOSE-122* UREA N-19 CREAT-1.0 SODIUM-137
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14
___ 09:30AM estGFR-Using this
___ 09:30AM ALT(SGPT)-34 AST(SGOT)-49* ALK PHOS-48 TOT
BILI-0.5
___ 09:30AM cTropnT-<0.01
___ 09:30AM ALBUMIN-4.1 CALCIUM-9.4 PHOSPHATE-3.1
MAGNESIUM-2.0 CHOLEST-205*
___ 09:30AM TRIGLYCER-109 HDL CHOL-75 CHOL/HDL-2.7
LDL(CALC)-108
___ 09:30AM TSH-1.3
___ 09:30AM CRP-0.5
___ 09:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 09:30AM WBC-9.6# RBC-3.70* HGB-13.0 HCT-38.3
MCV-104*# MCH-35.1*# MCHC-33.9 RDW-13.9 RDWSD-53.1*
___ 09:30AM NEUTS-88.4* LYMPHS-4.2* MONOS-6.6 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-8.45* AbsLymp-0.40* AbsMono-0.63
AbsEos-0.00* AbsBaso-0.03
___ 09:30AM PLT COUNT-249
___: CXR: Borderline heart size, pulmonary vascularity. Right
medial basilar opacities new since prior in ___. Trace left
effusion.
___: MRI brain w/o contrast:
1. There is no evidence of acute intracranial process
hemorrhage
or diffusion abnormalities to indicate acute/subacute ischemic
changes.
2. Scattered foci of high signal intensity identified on FLAIR
and T2 weighted images, distributed in the subcortical white
matter, which are nonspecific and may reflect changes due to
small vessel disease.
___ MRI brain w/ contrast:
1. No evidence of abnormal enhancement to suggest active
process.
2. Please refer to MRI head without contrast of ___ for
additional details.
___ MRI C-spine w/ contrast:
1. T2 hyperintense central cord signal with expansion of the
cord
spanning the cervicomedullary junction to the C5 level, with
enhancement along the left aspect of the C2 level. The findings
are overall compatible with NMO given prior history.
2. Subtle T2 hyperintense signal of the T2 cord with associated
mild volume loss corresponding to lesion described on prior
examination of ___.
3. Additional findings as described above.
Brief Hospital Course:
Ms. ___ is a ___ yo woman with history of NMO who presented
with nausea, L ear pain which spread to her neck and then
developed L hemiparesis. Neurologic exam was significant for L
hemiparesis. MRI showed large enhancing lesion extending from
the
cervicomedullary junction to approx. C5-C6 on the left, which is
consistent with her symptoms. This likely represent NMO flare
given imaging appearance, clinical presentation and history of
the same. She was treated with high dose steroids, and her
symptoms improved minimally. After three days, plasmapheresis
was pursued with plan for 5 treatments. First PLEX performed on
___ and she received her last treatment on ___.
She was noted to have elevated LFT's for which she underwent a
RUQ US which showed steatosis. Hepatitis serologies and HIV test
were negative. She will need repeat LFT's as an outpatient.
Etiology thought to be related possibly to her celiac disease,
hypothyroidism or to non alcoholic fatty liver disease.
Ramealton was discontinued as it can be associated with hepatic
abnormalities. She has follow up with her outpatient neurologist
and PCP.
Of note she also complained of urge incontinence during her
admission. UA was negative. She was started on low dose
oxybutynin. She will follow up with her PCP.
Transitional issues:
- follow up with PCP and repeat LFT's
- Neurology follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO EVERY OTHER DAY
2. Lisinopril 10 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. AzaTHIOprine 75 mg PO DAILY
5. AzaTHIOprine 100 mg PO QHS
6. Calcium+D (calcium carbonate-vitamin D3) 250 mg calcium-500
unit tablet oral BID
7. Aspirin 81 mg PO DAILY
8. Levothyroxine Sodium 25 mcg PO DAILY
Discharge Medications:
1. Oxybutynin 5 mg PO BID
2. Aspirin 81 mg PO DAILY
3. AzaTHIOprine 75 mg PO DAILY
4. AzaTHIOprine 100 mg PO QHS
5. Calcium+D (calcium carbonate-vitamin D3) 250 mg calcium-500
unit tablet oral BID
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. PredniSONE 10 mg PO EVERY OTHER DAY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
NMO flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___ were admitted to ___ for symptoms of left sided weakness.
___ underwent a MRI c-spine which showed an enhancing lesion
extending from the cervicomedullary junction to approximately
C5/6. This was concerning for NMP flare up and ___ were started
on steroids with some improvement. ___ also underwent a 5 day
course of plex.
___ were noticed to have elevated liver function tests for which
___ will need repeat lab work as an outpatient. Please follow up
with your PCP as mentioned below.
No changes were made to our medications
Please take your medications as instructed.
Please follow up with neurology as mentioned below.
It was a pleasure taking care of ___.
Best,
Your ___ team
Followup Instructions:
___
|
19912403-DS-9 | 19,912,403 | 29,695,735 | DS | 9 | 2170-09-23 00:00:00 | 2170-09-23 17:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Azithromycin / Gluten / Tetanus
Attending: ___
Chief Complaint:
Right leg pain
Major Surgical or Invasive Procedure:
Plasma exchange catheter placement
History of Present Illness:
The patient is a ___ with hx of NMO followed by Dr ___
with history of prior flares of L optic neuritis, L
cervicomedullary lesion causing L arm/leg numbness and
nausea/vomiting, now here with 2 weeks of intermittent - burning
pain in her right lateral leg and dorsal aspect of her right
foot.
Regarding her history of NMO, she was diagnosed in ___ when she
had painful sensory loss in her left eye. She ultimately was
left with only light/dark perception in the left eye after this
episode of optic neuritis. In ___, she developed toe and
finger
numbness and MRI brain showed periventricular enhancing nodules
which improved with steroids. In ___ she developed left leg
numbness and weakness and was found to have a contrast-enhancing
lesion at T1 and T3 as well as sensitivity around her left
thorax
under her left breast. Workup at this time showed CSF 13 WBC,
1753 RBC, 24% PMN and 61% lymphs, protein 28, glucose 64. OCB
negative. Serum and NMO positive 1:7680. CSF ACE negative.
She
received IV steroids and was started on Cytoxan as an outpatient
which was eventually transitioned to steroids and azathioprine.
In ___ she developed pain in her left eardrum, left jaw,
into left neck and shoulder followed by numbness and weakness
over her left arm and leg as well as severe nausea and vomiting.
She was ultimately found to have a large enhancing lesion
extending from the left cervicomedullary junction to
approximately C5-C6 treated initially with high-dose steroids
without improvement followed by plasmapheresis with improvement.
Interestingly her chronic pain in her left thorax also resolved
with PLEX. She reports mild residual numbness in her left foot
and weakness in her left leg. Dr. ___ has been trying to
switch her from azathioprine to CellCept for some time but
insurance authorization has been repeatedly rejected.
Currently,
the plan is to obtain CellCept from a pharmacy in ___ but
this
has not yet been done. Rituxan has also been considered but has
been avoided given her age and possible side effects.
Her outpatient neurologic exams vary but prior to ___
documented
predominantly left sided weakness. In ___ she had weakness
in bilateral interossei, left wrist extensor, left deltoid, left
biceps, left triceps bilateral iliopsoas, left quadriceps,
bilateral hamstrings, left anterior tibialis. In ___
she had weakness in bilateral interossei, left biceps, right
iliopsoas, left hamstring, left anterior tibialis. When seen
yesterday ___, she had weakness in bilateral interossei, right
biceps, right iliopsoas, right hamstring, right tibialis
anterior. Her strength on the left leg was documented as full.
She reports today that around 2 weeks ago on ___ she
developed intermittent burning pain over the right lateral calf
and the dorsum of the right foot that would come and go for at
most 1 minute at a time and recurring every several minutes.
There was no positional component and she did not notice any
involvement of her face or arm. She denied noticing any
weakness. He reached out to Dr. ___ prescribed 6 days of
IV steroids which finished ___. During the steroids her
symptoms seem to improve and that the time in between her
episodes seem to increase. However, her husband noted that her
gait became more shuffled than previously and that her stride
length decreased. After her steroid course ended, she has
noticed increase in the frequency of her symptoms. At baseline
she walks with a cane and favors the right leg due to baseline
left leg weakness. During her examination with Dr. ___
felt that her left leg was weaker than normal and she has
presented today to the emergency department at the direction of
Dr. ___ plasmapheresis as she has continued to have her
symptoms despite treatment with high-dose steroids.
She was recently treated for UTI with 5 days of antibiotics
which
finished ___. Her symptoms with urinary tract infection
included urinary urgency/frequency. She does not currently have
urgency or frequency. She is currently on oxybutynin as she
normally has spastic urinary incontinence and was referred to
urology as an outpatient has not seen them yet. Otherwise, she
denies any recent illness, fevers, chills, abdominal pain,
diarrhea (she usually is constipated and has a bowel movement
every several days with milk of magnesia).
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies new loss of vision, blurred
vision (nothing acute - she sees ophthalmology regularly),
diplopia, vertigo, hearing difficulty, dysarthria, or dysphagia.
Denies loss of sensation.
Past Medical History:
Hypothyroidism
Neuromyelitis optica
Hypertension
Spastic urinary incontinence
Social History:
___
Family History:
No h/o demyelination, MS, autoimmune disease. Her mother had an
ICH at age ___.
Physical Exam:
ADMISSION EXAM:
Vitals:
98.6F, 96 HR, 145/67, RR 17, 99% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
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 ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm on the right, 3mm and
unreactive
on the left. +RAPD on the left. EOMI without sustained
nystagmus.
VFF to confrontation. Visual acuity with
only light perception on the left and ___ on the right.
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 clear pronator drift
bilaterally though right arm slightly pronated.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ EDB
L 4+ ___ 5 4+ 4+ 4+ 5 5 4+ 5 4+
R 5 ___ ___ 4+ 5 5 4+ 5 4+
Hamstring initially when tested in the bed with giveway and 4 at
most - then retested when sitting up and both were strong. IPs
above were tested in the bed, they were weaker when sitting at
___.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense (8 sec at both toes - slightly decreased),
proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 1
R 3 3 3 2 1
Plantar response was extensor on the left with ___, right
with some withdrawal and equivocal. She is very ticklish. b/l
pectoral jerks. No hoffmans. L crossed adductor.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, shortened. Uses cane in
her
right hand to support her left leg more with gait.
============================
DISCHARGE EXAM:
___ 1203 Temp: 97.9 PO BP: 126/76 HR: 84 RR: 18 O2 sat:
100% O2 delivery: RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, extremities WWP
Abdomen: soft, NT/ND.
Extremities: No ___ edema.
Skin: ~1x1cm area of ecchymosis on L distal medial forearm
without surrounding erythema or warmth.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, with fluent language and normal
prosody. There were 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:
II, III, IV, VI: PERRL 3 to 2mm on the right, 3mm to 2.5mm on
the left. +RAPD on the left. EOMI without sustained nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 ___ ___ ___ 5 5
R 5 ___ ___ ___ 5 5
-Sensory: No deficits to light touch and cold sensation
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
Plantar response was flexor bilaterally.
-Coordination: Deferred
-Gait: Deferred
Pertinent Results:
Admission labs:
___ BLOOD WBC-10.9* RBC-3.64* Hgb-12.3 Hct-37.6 MCV-103*
MCH-33.8* MCHC-32.7 RDW-13.9 RDWSD-53.8* Plt ___
Diff: Neuts-87.4* Lymphs-3.6* Monos-6.2 Eos-0.3* Baso-0.1 Im
___ AbsNeut-9.50* AbsLymp-0.39* AbsMono-0.67 AbsEos-0.03*
AbsBaso-0.01
Chemistry: Glucose-128* UreaN-26* Creat-1.0 Na-140 K-5.4* Cl-102
HCO3-26 AnGap-12 Albumin-3.3* Calcium-8.9 Phos-4.2 Mg-2.4
LFTS: ALT-132* AST-94* AlkPhos-57 TotBili-0.8
Additional labs:
___ 07:55AM BLOOD ALT-37 AST-34
___ 05:25AM BLOOD WBC-9.1 RBC-3.05* Hgb-10.5* Hct-32.0*
MCV-105* MCH-34.4* MCHC-32.8 RDW-16.4* RDWSD-61.4* Plt ___
___ 06:47AM BLOOD WBC-9.1 RBC-3.01* Hgb-10.3* Hct-31.5*
MCV-105* MCH-34.2* MCHC-32.7 RDW-16.6* RDWSD-63.3* Plt ___
___ 06:47AM BLOOD Glucose-95 UreaN-23* Creat-0.8 Na-144
K-4.7 Cl-107 Calcium-9.4 Phos-4.7* Mg-2.0
Imaging:
None
Brief Hospital Course:
___ with hx of NMO followed by Dr ___ with history of prior
flares of L optic neuritis, L cervicomedullary lesion with mild
residual L leg weakness, presenting with 2 weeks of intermittent
burning pain in her right lateral leg and dorsum of her right
foot and new subtle RLE weakness on exam concerning for NMO
flare and refractory to outpatient course of high dose steroids.
Acute issues:
#NMO flare:
Patient received 5 sessions of PLEX between ___ and ___. She
tolerated sessions with stable vital signs but did develop
episodic right leg pain shooting up into shoulder for the
duration of her last three sessions (resolving afterwards).
Acetaminophen, extra Gabapentin and low dose oxycodone were all
attempted without improvement in symptoms. Etiology of the
worsened pain was unclear and not a typical side effect observed
during PLEX therapy. Her motor symptoms of the flare did improve
with therapy and she had full strength in all extremities at the
time of discharge. However, the pain did not improve, raising
question of additional central etiology in addition to the NMO
contributing to her presentation. Gabapentin was also started as
adjunct to help control her pain but without immediate
appreciable effect.
#Mild thrombocytopenia:
Platelets were noted to trend down from 226K on admission to
136K on ___. Etiology unclear as she was receiving only
Gabapentin as a new medication, and PLEX may reduce platelets a
small amount but usual not so dramatically. They stabilized and
were trending up at the time of discharge.
#Cellulitis:
Patient developed leaking at IV site in L forearm and IV was
removed but she subsequently developed warmth, erythema and
tenderness around the site. She was started on Keflex PO and had
rapid improvement, and will be discharged to complete a total of
5-day course.
Chronic issues:
#HTN: Lisinopril held after first 2 sessions to minimize BP
fluctuations with fluid shifts during PLEX sessions. Her BP
remained well controlled throughout her stay.
Transitional Issues:
#NMO: Azathioprine and prednisone were continued at home doses.
Cellcept has been prescribed but not yet obtained and started
due to insurance issues. This will be started as appropriate as
an outpatient.
#Neuropathic pain: Gabapentin was started at 300mg BID and
increased to 300mg TID prior to discharge and may be uptitrated
as appropriate as an outpatient. Consider workup for lumbar
spine structural pathology as an outpatient if pain persists.
#Cellulitis: Started on Keflex for L arm cellulitis, to complete
a total of 5 days. Her last dose will be on ___.
#Hypertension: Lisinopril was held during course of PLEX
therapy. Because her BP was normal without the medication, we
are restarting her on half her home dose (2.5mg vs 5mg) for now
and this may be increased as needed at follow-up.
#Thrombocytopenia: CBC should be repeated in ___ weeks to ensure
normalization of platelet count.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. AzaTHIOprine 75 mg PO QAM
2. AzaTHIOprine 100 mg PO QPM
3. Lisinopril 5 mg PO DAILY
4. PredniSONE 10 mg PO DAILY
5. Oxybutynin 5 mg PO BID
6. Aspirin 81 mg PO DAILY
7. calcium phosphate-vitamin D3 250 mg calcium- 500 unit oral
BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Mycophenolate Mofetil 250 mg PO BID
11. Mycophenolate Mofetil 1000 mg PO BID
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*8 Capsule Refills:*0
2. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*1
3. Aspirin 81 mg PO DAILY
4. AzaTHIOprine 75 mg PO QAM
5. AzaTHIOprine 100 mg PO QPM
6. calcium phosphate-vitamin D3 250 mg calcium- 500 unit oral
BID
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Oxybutynin 5 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. PredniSONE 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Neuromyelitis optica flare
Neuropathic 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 Ms. ___,
You were admitted for treatment of right leg pain and new
weakness, which did not improve with a course of high dose
steroids as an outpatient. We think this was most like related
to an NMO flare. We performed 5 sessions of plasma exchange
therapy (PLEX), and you had improvement of your weakness, but
unfortunately less relief of your pain. We started a new
medication, Gabapentin, to help with the nerve-related pain. We
held your blood pressure medication, Lisinopril, while you were
getting PLEX to help avoid drop in blood pressure during your
sessions. Because your blood pressure was normal even without
the medication, you should restart the medication at half your
usual dose until you follow up with your PCP.
We monitored your blood counts daily and found that one type of
cells, your platelets, was decreasing during your stay,
potentially related to the PLEX therapy. The blood count was
stable in the last several days and we expect it to return to
normal.
Finally, you developed a small infection on your left arm which
has improved significantly with antibiotics. You will need to
take 2 more days of antibiotics after discharge.
After discharge, you should continue to take all your
medications as prescribed, including the new medication
Gabapentin.
You should follow up with your PCP ___ ___ weeks to recheck blood
pressure and labs to make sure your counts are normalizing. You
should also follow up with Dr. ___ her office will be in
touch with you to schedule this.
Followup Instructions:
___
|
19912537-DS-10 | 19,912,537 | 29,825,378 | DS | 10 | 2161-03-03 00:00:00 | 2161-03-05 19:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Wellbutrin
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
EGD x 3
Tongue Mass biopsy
History of Present Illness:
___ F with a hx of reflux (but no liver disease) who presents to
___ ED after several episodes of hematemesis small volume. She
had a syncopal episode and vomited ___ liter of blood with small
piece of plastic and then subsequently had multiple small
episodes of hematemsis
In the ED she had a NG lavage with bright red blood that would
not clear. She was subsequently intubated and GI was consulted,
recomended ppi drip, T+S 2 units, and serial crit checks ,ad
nerythromycin. Patient was started on PPI drip, was intubated
for airway protection, and recieved erythromycin (per GI's
recommendations). CTA abd chest and pelvis showed no active
bleeding, but showed RLL findings suspicious for PNA, so patient
recieved azithromycin and ceftriaxone.
In the ED, initial vitals: 96.7 96 163/70 18 94% RA
- Labs were signficant for
On transfer, vitals were: 97.0 70 120/59 20 100% Intubation
On arrival to the MICU, patient is intubated and sedated,
recieving 1 unit pRBCS. Contact was attempted with brother but
failed. GI fellow contacted GI fellow at ___ who got the
following collateral:
Pt has hx of CAD, HTN, HPL, GERD and DJD. She last had a EGD in
___ which showed an irregular Z line but normal pathology and
NO ulcers. On ___ she had an increase in her reflux sxs, and
her home 325 mg asa dose was lowered to 81 mg. Patient has
contact information for her brother in ___ records ___
___ who was contacted and consent was obtained.
Review of systems:
(+) Per HPI
Past Medical History:
CAD s/p DES in ___, negative nuclear stress ___
HTN
HPL
DJD
allergic rhinitis
IBS
spinal stenosis (baseline RLE pain)
osteopenia
plantar fascitis
hyperkalemia
HPL
Diverticular disease
cyst of kidney noted in CT scan ___
Appendicitis s/p appendectomy ___
Social History:
___
Family History:
Brother with BCC of skin, ankylosing spodylitis
Brother with CAD, depression
Mother with HTN
Father with ___ tumour of bladder
Physical Exam:
Admission Physical Exam:
Vitals- HR 73 BP 125/52 afebrile
GENERAL: Intubated, sedated.
HEENT: Sclera anicteric, endotrachealk tube in place, no
epistaxis.
NECK: supple, JVP not elevated, no LAD
LUNGS: Intubated breath sounds b/l, otherwise clear, no crackels
or wheezing on anterior chest. posterior chest not ausculted
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, non distended. Could not determine tenderness ___
sedation.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge Physical Exam:
Vitals: T 98.5, BP 103/45, P 72, R 20, O2 92% on RA
General: Alert, oriented, no acute distress
HEENT: MMM, no signs of active bleeding
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
Pertinent Results:
Admission Labs:
.
___ 11:45PM HCT-32.0*
___ 09:54PM LACTATE-1.7
___ 09:50PM GLUCOSE-166* UREA N-44* CREAT-0.7 SODIUM-142
POTASSIUM-5.3* CHLORIDE-112* TOTAL CO2-26 ANION GAP-9
___ 09:50PM CALCIUM-7.3* PHOSPHATE-3.5 MAGNESIUM-1.9
___ 08:00PM HCT-29.4*
___ 08:00PM ___ PTT-24.3* ___
___ 06:20PM TYPE-ART RATES-16/ TIDAL VOL-400 PEEP-5
O2-100 PO2-462* PCO2-53* PH-7.31* TOTAL CO2-28 BASE XS-0
AADO2-193 REQ O2-41 -ASSIST/CON INTUBATED-INTUBATED
___ 06:20PM O2 SAT-99
___ 05:15PM HCT-27.0*
___ 02:35PM LACTATE-1.6
___ 02:20PM GLUCOSE-123* UREA N-40* CREAT-0.8 SODIUM-143
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-28 ANION GAP-12
___ 02:20PM estGFR-Using this
___ 02:20PM WBC-7.7 RBC-3.73* HGB-11.5* HCT-35.1* MCV-94
MCH-30.8 MCHC-32.7 RDW-13.0
___ 02:20PM NEUTS-73.9* LYMPHS-17.1* MONOS-8.0 EOS-0.7
BASOS-0.3
___ 02:20PM ___
___ 02:20PM PLT COUNT-292
.
Discharge Labs:
.
___ 09:45AM BLOOD WBC-8.8 RBC-3.13* Hgb-9.6* Hct-29.1*
MCV-93 MCH-30.7 MCHC-33.0 RDW-13.3 Plt ___
___ 09:45AM BLOOD Glucose-152* UreaN-8 Creat-0.7 Na-143
K-3.7 Cl-105 HCO3-28 AnGap-14
___ 05:41AM BLOOD TSH-0.97
.
Microbiology:
.
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
.
Studies:
.
CXR ___
Impression: No evidence of acute cardiopulmonary disease
.
CTA Chest/Abdomen/Pelvis ___
1.. Right mainstem bronchus intubation.
2. No arterial extravasation within the chest, abdomen, or
pelvis.
3. Right lower lobe opacity most consistent with pneumonia.
4. 0.8 cm solid-appearing nodule within left lower lobe is
likely
inflammatory in nature. Followup in ___ months is recommended
5. Right middle lobe nodule could represent scarring however
given history of hemoptysis differential includes tiny aneurysm
or AVM. Considering causes of hemoptysis pneumonia is likely the
etiology rather then the RML lesion given absence of bronchial
involvement. Recommend short interval followup
6. Trace pericardial effusion.
7. Multiple hepatic and splenic hemangiomas.
8. Renal hypodensities, too small to characterize.
9. Diverticulosis without evidence of acute diverticulitis.
.
EKG: SR; no ST changes
.
EGD ___: Evidence of blood in the esophagus that was
flushed away with some evidence of underlying esophagitis, as
well as evidence of clots and old blood in the cardia/fundus
that was flushed and suctioned.
.
EGD ___: Blood in the oral pharynx, esophagus and stomach.
DDx include Deulafoy lesion vs. bleeding from nasopharyngeal
source. (injection)Given the bleeding in the mouth ENT was
consulted and found a small laceration at the lateral aspect of
the tongue that they treated that was likely secondary to trauma
during an intubation. This was not the source of bleeding. In
the duodenal bulb there was an area of hypertrophied mucosa that
may be consistent with brunners gland hyperplasia but biopsies
were not obtained in the setting of bleeding. Repeat endoscopy
with biopsies and careful evaluation at a later date is
recommended.Otherwise normal EGD to third part of the duodenum.
.
EGD ___:
Impression:
Normal mucosa in the esophagus
Normal mucosa in the stomach
Normal mucosa in the duodenum
No fresh or old blood was seen in the esophagus, stomach or
duodenum
Upon endoscopic evaluation of the oropharynx, there was a 2 cm
clot-like material with overlying exudate which appeared
adherent to the base of the tongue. This was mobile but could
not be removed. Nearby on the soft palate was a white pigmented
1 cm lesion which also appeared compatible with a healing ulcer.
These lesions may potentially explain some of the upper tract
bleeding which she had but will need further evaluation by ENT.
Otherwise normal EGD to third part of the duodenum
Recommendations:
- No active bleeding was found and no source for esophageal,
gastric or duodenal bleeding was present. Thus, lesion at base
of tongue is suspicious for potential source of bleeding. A
gastric dieulafoy's is still in the differential given bleeding
seemed to stop during the prior EGD following epinephrine
injection into the fundus.
- Recommend ENT evaluation for base of tongue lesion, soft
palate ulcer, nasopharynx given patient complaint of sinusitis
as well as laryngeal examination given patient's complaint of
sore throat with still no clear source of upper tract bleeding.
.
CT Neck w/ Contrast (___)
1. 1.2 x 0.7 cm tongue base mass with peripheral calcification.
Differential would include a malignant lesion of the oral
cavity, though lack of local extension or adenopathy is noted
suggesting alternative diagnosis. Minor salivary gland tumors
such as adenoid cystic lesion should additionally be considered
as well as mucoepidermoid carcinoma or adenocarcinoma.
2. Enlarged thyroid gland without a focal nodule identified.
Correlation with thyroid function tests recommended.
Brief Hospital Course:
Patient is a ___ with a history of CAD s/p DES ___,
hypertension, and reflux who presented with hematemesis. The
patient was urgently intubated for airway protection and
transferred to the ICU. She initially underwent two EGDs without
a clear source of bleeding identified, though visualization was
limited due to frank blood in the stomach. Epinephrine was
injected into the fundus of the stomach out of concern for a
possible Dieulafoy lesion. It was also noted that she had a
lesion or laceration on the base of her tongue, originally
thought to be from traumatic intubation/extubation or scoping.
Her bleeding stabilized spontaneously and she was extubated and
transferred to the general medicine floor. She had a third EGD
once on the floor which showed no signs of a bleeding source in
the esophagus, stomach, or duodenum. However, a lesion/adherent
clot was noted on the base of the tongue. ENT evaluated the
lesion and requested a CT scan of the neck, which confirmed a
mass but no local destruction/invasion and no lymphadenopathy.
ENT then biopsied the lesion and the pathology results are
pending. It is notable that the patient has a 40+ pack-year
smoking history.
After transfer to the floor the patient showed no other overt
signs of bleeding, had a rising HCT, and did not have melena.
She was continued on a PPI due to concern for an unseen GI
source for bleeding, and given her history of reflux.
Other active issues:
A RLL opacity concerning for pneumonia was noted on CT of the
chest. She was treated with a 5 day course of levofloxacin.
She was incidentally noted to have an enlarged thyroid on CT of
the neck. Her TSH was checked and was normal at 0.97.
Chronic Issues:
CAD/HTN - aspirin, HCTZ, lisinopril, and atenolol were held
initially due to the concern for bleeding. Aspirin was restarted
on transfer to the general medicine floor. Atenolol and her
antihypertensives were started the day prior to discharge.
TRANSITIONAL ISSUES:
[ ] patient will need a repeat EGD in 8 weeks, which our GI
department will arrange
[ ] radiology recommended a repeat chest CTA in ___ weeks to
evaluate an AVM and also to re-evaluate a 0.8 cm solid-appearing
nodule within left lower lobe in ___ months
[ ] ENT follow up with the patient regarding the biopsy results
from the tongue mass - Dr. ___, ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 25 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 1250 mg PO DAILY
4. Hydrochlorothiazide Dose is Unknown PO Frequency is Unknown
5. Ibuprofen Dose is Unknown PO Frequency is Unknown
6. Lisinopril 10 mg PO DAILY
7. Magnesium Oxide 400 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO QHS
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Magnesium Oxide 400 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simethicone 40 mg PO DAILY:PRN gas pains
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
9. Pantoprazole 40 mg PO Q12H
10. Calcium Carbonate 1250 mg PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: hematemesis
SECONDARY: tongue mass
pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
___ were admitted to ___ for vomiting blood. Upon admission,
___ were bleeding significantly and were intubated to prevent
___ from aspirating blood. At CT scan of your chest and abdomen
did not show where the bleeding was coming from but was
concerning for a pneumonia, so ___ were treated with
antibiotics. Our GI doctors tried multiple ___ to find and
stop the source of the bleeding using a scope, or EGD.
Ultimately, no site of bleeding was seen in your GI tract,
however it was noticed that ___ had a mass on the base of your
tongue which may have been the source of your bleeding. Our Ear,
Nose, and Throat (ENT) doctors examined the ___ and decided
that they should biopsy it while ___ were in the hospital. The
results of the biopsy are still pending. ___ can call the number
below to schedule a follow up appointment with the ENT doctor
who did the biopsy (Dr. ___.
___ were started on an antacid because of your bleeding and ___
can continue to take that at home. Otherwise no changes were
made to your home medications. ___ will be discharged to a
rehabilitation facility.
___ should have a repeat EGD in 8 weeks because the GI doctors
saw ___ of your small intestine that they feel should be
biopsied. ___ will also need a repeat CT scan of your chest in
several weeks to evaluate a vascular lesion that was
incidentally seen here.
It was a pleasure taking care of ___,
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19912620-DS-18 | 19,912,620 | 29,903,947 | DS | 18 | 2121-06-16 00:00:00 | 2121-06-21 10:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cimetidine / Motrin / Zocor / Pravastatin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP with stent replacement
PICC placement x2
History of Present Illness:
___ yo F w/ h/o HTN, HLD, DM2, CKD, adrenal mass w/ ___,
heart block s/p PPM and recent ERCP p/w abdominal pain.
Pt s/p recent ERCP ___ for elevated LFTs. ERCP showed mildly
dilated PD, dilated intrahepatics, dilated CBD, filling defect
suggestive of stone, and CBD stricture with upstream dilation.
She is s/p biliary and pancreatic stent, sphincterotomy, and
brush samples were taken (given difficult passage concern for
head of pancreas mass). She was d/c'd w/ outpt EUS-ERCP on
___ scheduled.
Pt states she developed abdominal pain while in the hospital on
___, but didn't tell anyone about it. ___ night she
tolerated soup. Today, the pain worsened, it is predominantly R
sided, radiates diffusely, and involves the back, is sharp, and
___ at its worst. No diarrhea, constipation, nausea, vomiting,
fevers, chills, urinary sx. ___ elevated 400s.
In the ED, VS: 8 97.2 65 138/58 16 99%. ECG showed RBBB. ERCP
was consulted. LFTs were elevated w/ elevated tbili. Lipase
5000s. She was given LR, morphine, and insulin.
Currently, pain is ___.
ROS: Also + for 30lb weight loss over 6 months. 12 point ROS is
otherwise negative.
Past Medical History:
# HTN
# HLD
# ___ - last Hgb A1c 7.2 (___)
# adrenal mass with ___ syndrome
- 2.6 cm R adrenal mass
- Urine free cortisol mildly elevated at 54 mg
- Overnight 1 mg dexamethasone suppression test yielded an AM
cortisol of 9.2 with ACTH 6 (Dex level 146 ng/dL, within
expected range)
- Repeat overnight 1 mg dex suppression test again yielded a
high AM cortisol of 13.0 and ACTH 7 (again Dex level within
expected range).
- A subsequent 8mg overnight dex suppression test yielded AM
cortisol of 13.1 with ACTH 6.
- A baseline AM fasting ACTH level was 6.
- Salivary cortisols in ___ all elevated
- Cortisol binding globulin normal at 37 (___)
- Low DHEAS 11
- Repeat 24 hour urine free cortisols have been normal, after
initial mild elevation:
# heart block s/p pacemaker
- Echo (___): mild LVH. no regional WMA, LVEF 60-65%,
diastolic filling nl, trace AR
# CKD stage III
# GERD
# glaucoma
# obesity
# TAH-BSO ___ years ago open
Social History:
___
Family History:
Brother with ___. Another brother died of prostate ca and a
sister died of gastric ca.
Physical Exam:
Admission PE
Gen: C/o pain, NAD
HEENT: OP clear, dry mm
Neck: No LAD, no JVD
CV: RR
Pulm: CTAB
Abd: TTP diffusely, no guarding/rebound, no palpable mass
Ext: wwp, no edema
Neuro: A&Ox3
Discharge PE
T 98.1, BP 146/70, HR 68, RR 20, SvO2 98% RA, Fasting AM BS 133
Gen: NAD, sitting in chair, pleasant
Neck: No LAD
CV: RR, nl rate
Pulm: CTAB
Abd: soft, nontender, nondistended, pos bowel sounds, no mass
Ext: WWP, no edema, mild tenderness to ankle, picc left arm,
right arm with some edema
Neuro: AOx3, pleasant
Psych: at times frustrated about hospital course, otherwise
pleasant
Pertinent Results:
Pertinent Labs:
___ 03:16PM BLOOD WBC-9.8 RBC-3.27* Hgb-10.1* Hct-33.7*
MCV-103* MCH-30.8 MCHC-30.0* RDW-13.1 Plt ___
___ 10:55PM BLOOD WBC-22.3* RBC-2.57* Hgb-8.1* Hct-26.1*
MCV-102* MCH-31.6 MCHC-31.1 RDW-13.8 Plt ___
___ 07:15AM BLOOD WBC-15.3* RBC-3.19* Hgb-9.5* Hct-30.8*
MCV-97 MCH-29.8 MCHC-30.8* RDW-17.8* Plt ___
___ 07:15AM BLOOD ___ PTT-32.6 ___
___ 03:16PM BLOOD Glucose-393* UreaN-21* Creat-1.3* Na-132*
K-5.0 Cl-100 HCO3-23 AnGap-14
___ 01:26AM BLOOD Glucose-293* UreaN-61* Creat-3.6* Na-147*
K-4.6 Cl-114* HCO3-22 AnGap-16
___ 07:15AM BLOOD Glucose-147* UreaN-27* Creat-1.0 Na-142
K-4.1 Cl-107 HCO3-28 AnGap-11
___ 03:16PM BLOOD ALT-151* AST-123* AlkPhos-799*
TotBili-3.5*
___ 04:38AM BLOOD ALT-218* AST-369* AlkPhos-376*
TotBili-18.5*
___ 04:10AM BLOOD ALT-20 AST-21 AlkPhos-209* TotBili-1.4
___ 03:16PM BLOOD Lipase-5920*
___ 03:55AM BLOOD Lipase-299*
___ 10:55PM BLOOD Calcium-8.7 Phos-3.6 Mg-1.3*
___ 07:15AM BLOOD Calcium-7.7* Phos-3.6 Mg-1.7
___ 05:52AM BLOOD calTIBC-170* Hapto-422* Ferritn-1038*
TRF-131*
___ 02:20AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HAV
Ab-POSITIVE IgM HBc-NEGATIVE
___ 02:20AM BLOOD HCV Ab-NEGATIVE
___ 02:20AM BLOOD ALPHA-FETOPROTEIN (AFP) AND AFP-L3-Test
___ 03:01PM JOINT FLUID ___ RBC-125* Polys-98*
___ ___ 03:01PM JOINT FLUID Crystal-FEW Shape-NEEDLE
Locatio-INTRAC Birefri-NEG Comment-c/w monoso
___ 07:36AM STOOL PANCREATIC ELASTASE 1, STOOL-PND
___ 8:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
PREVOTELLA SPECIES. BETA LACTAMASE NEGATIVE.
___ IMPRESSION: 1. Moderate intrahepatic biliary dilation
and pneumobilia status post biliary stent placement. No stones
are visualized in the common bile duct stent. 2. Distended
gallbladder with layering sludge balls or small, non shadowing
gallstones. No wall thickening or sonographic ___ sign to
suggest acute cholecystitis.
___ SUPINE ABDOMEN RADIOGRAPHS: Both the CBD and pancreatic
stent have an abnormal orientation compared to the ERCP image
from ___, suggesting that both stents have dislodged and
migrated to the duodenal loop. Moderate amount of fecal
material is seen within the right colon. There is gaseous
distention of the left colon. There is no evidence of bowel
obstruction or intra-abdominal free air in these supine images.
___ Gallbladder scan: INTERPRETATION: Serial images over the
abdomen show homogeneous uptake of tracer into the hepatic
parenchyma. The gallbladder and bowel are not visualized,
consistent with complete biliary obstruction, likely obstruction
of the biliary stent.
___ CTAP: IMPRESSION: 1. Circumferential gallbladder wall
thickening and mild pericholecystic fat stranding, concerning
for acute cholecystitis. HIDA correlation is advised. 2.
Peripancreatic fat stranding, suggestive of acute pancreatitis.
Correlation with serum lipase is recommended. 3. Biliary
stents, one of which extends from the lower common duct into the
duodenum and the other of which extends from the ampulla to the
duodenojejunal junction. 4. Nonobstructing 14 mm left lower
pole renal calculus, not significantly changed compared to CT
from ___. 5. 2.5 cm right adrenal lesion, unchanged in size
compared to CT from ___, likely an adenoma. 6.
Hepatic steatosis.
___ EGD: Normal mucosa in the whole esophagus
Gastric ulcer
Evidence of recent biliary stent placement was noted in the
ampulla.
Subsequently, a nasojejunal tube was placed into the jejunum
while withdrawing the endoscope using standard technique. At the
conclusion of the procedure, the tube was switched over from the
oropharynx to nasopharynx, and was bridled using standard
techniques. Post-procedure CXR confirmed placement of the
feeding tube in the jejunum.
Otherwise normal EGD to third part of the duodenum
___ ERCP:
A biliary stent was found in the major papilla. The
pancreatic stent had migrated out of the pancreatic duct
distally into the duodenum.
The biliary plastic stent was removed using a snare. Upon
removal pus, sludge, and stone fragments were seen coming from
the papilla.
The distal biliary stricture was present with upstream
dilation. The cystic duct was dilated. The gallbladder did not
fill.
The stricture was brushed for cytology.
Two biliary stents were placed.
[stent placement, stent removal, cytology / brushings]
Excellent flow of bile and contrast.
Otherwise normal ercp to third part of the duodenum
___ Renal U/S: IMPRESSION: 13 mm non-obstructive left kidney
stone with no evidence of hydronephrosis.
___ CTAP: 1. Multiple hepatic hypodensities, new compared to
___ and minimally increased in size compared to ___. Differential considerations for this would include
hepatic abscesses. Metastatic disease is less likely. Dedicated
cross-sectional imaging with contrast-enhanced CT or MRI is
recommended. 2. The gallbladder has decompressed compared to the
previous examination. There is persistent wall thickening and
pericholecystic inflammatory stranding. 3. Post ERCP
pancreatitis and peripancreatic inflammatory changes. No
evidence of abscess or phlegmonous formation. 4. Incidentals
findings are stable and include the left lower pole renal
calculus, right ureteric calculus, and the right adrenal nodule.
___: IMPRESSION: Occlusive PICC-associated thrombus within
the right axillary and one of the right brachial veins.
Brief Hospital Course:
___ with history of HTN, HLD, DM2, CKD, adrenal mass with
___, heart block s/p pacemaker who presented with
abdominal pain after ERCP. She was found to have post ERCP
pancreatitis. She had a very complicated hospital course
including ARF, bacteremia and liver abscesses, PICC line
associated DVT, acute gout flare and hyperglycemia.
Active issues:
# Acute pancreatitis, post ERCP: ERCP performed for undefined
periampullary mass. She subsequently developed transaminitis,
w/elevated tbili. Sludge observed on US, no obstructive stone
seen. Subsequently CT showed dilated gallbladder with
surrounding fat stranding but no obvious stone c/w acalculous
cholecystitis, likely ___ biliary stent obstruction. She was
started on broad spectrum Abx with vanc and zosyn. She
underwent repeat ERCP and had a new stent placed with subsequent
decrease in her LFTs. The patient was treated conservatively
with NPO and post-pyloroic tube feeds. She slowly improved. She
will need to have a repeat EUS and CT abdomen for further
evaluation of CBD narrowing and pancreas findings (an
appointment is scheduled with ___). CT abdomen was not done as
inpatient as she had ATN.
# Malnutrition: The patient was made NPO during the course of
her treatment for pancreatitis. She was placed on tube feeds.
As her abdominal pain resolved, her diet was advanced. She then
underwent a calorie count which was determined to be low. Thus
tube feeds were continued. However, her dobhoff became clogged
and she refused to have another ___ tube placed.
# Prevotella Bacteremia: She had blood cx positive for
prevotella likely from a biliary source either from cholangitis
or from instrumentation from ___'s. Her empiric abx were
narrowed to CTX and flagyl per ID recs. Surveillance cultures
were all negative. A PICC line was placed for continued IV
antibiotics. She will need at least ___ month of antibiotics
prior to discontinuation (the exact course will be determined by
ID upon follow up). She will need safety labs send to the ___
clinic. Please check CBC, Chem 10, LFTs qweek and fax to
___ attn ___, SPYROS.
# Hepatic abscesses and cholangitis: The patient spiked a
temperature to 102, had AMS and a leukocytosis during her
course. Repeat CT showed multiple liver lesions likely ___
abscess formation vs. mets. She was ultimately palced on CTX
and Flagyl. A MRI pancreas protocol was recommended for better
visualization of pancreatic and hepatic lesions, but unlikely to
be safe given patient has a PPM. A US was repeated in ___ and
showed stable lesions. The patient will likely need to be
treated with ___ months of antibiotics and be re-imaged prior to
discontinuing her antibiotics. She will need safety labs send to
the ___ clinic. Please check CBC, Chem 10, LFTs qweek and fax to
___ attn ___, SPYROS. Upon completion of her
antibiotics the PICC should be removed.
# Normocytic anemia: This was due to her acute inflammatory
condition. The patient was given several blood transfusions
during her course with a appropriate response. Her hct was
stable prior to discharge ~30.
# Uncontrolled DM2, w/ complications: Multifactorial felt to be
___ ___, prednisone and acute pancreatitis. Followed by
endocrinology, and w/ high insulin requirements at baseline. She
was discharged on insulin with NPH and insulin sliding scale.
Given the steroid taper her insulin dose will need to be
monitored very closely. A recommendation for down titration of
NPH is 25u (with 10mg prednisone) and 15u (with 5mg
prednisone)(however, this may need to be adjusted pending her
response). She was previously on lantus but this was
discontinued during the admission. She may need to return to
lantus once she is finished with steroids and NPH. This will be
deferred to the rehab physicians. Of note, we have had some
difficulty with noncompliance with her diabetic diet, which
leads to some significant hyperglycemic episodes.
# Acute on chronic renal dysfunction (stage III CKD): Her
creatinine peaked at 3.6 and was thought to be secondary to ATN.
This trended down to 1.0 and was stable at the time of
discharge.
#Diarrhea: Pt developed diarrhea while in the MICU. C. diff was
checked given rising WBC and was negative. Her diarrhea was
likely ___ post-pyloric feeding in setting of pancreatitis and
was improving prior to transfer to regular floor. A fecal
elastase was sent and was pending at the time of discharge.
Pancrealipase was started on the patient empirically and may be
discontinued in the future if not indicated.
#HTN, benign: The patient blood pressure medications were slowly
re-started on the medical floor. Her blood pressure was
normotensive to very mildly hypertensive at the time of
discharge.
#Acute gout flare: Initially thought to be ___ gout with
elevated uric acid. Rheumatology was consulted out of concern
for septic joint given bacteremia who did a arthrocentesis which
revealed findings consistent with gout. The patients was
started on high dose prednisone and QOD colchicine. Her
symptoms and ROM improved. She is currently undergoing a steroid
taper.
# RUE DVT, PICC associated: She developed RUE swelling. She was
diagnosed with an occulusive DVT. She was started on lovenox and
had the PICC placed on her LUE (she has a pacemaker on her left
but it was cleared by EP). Her RUE PICC was discontinued. She
was started on warfarin but was not yet at goal at the time of
discharge. Warfarin 4mg with a goal of INR ___. She will need at
least 3 months from ___ (which picc was removed). She has
not be set up with an ___ clinic yet.
TRANSITIONAL ISSUES:
- Follow up EUS in 2 weeks for further characterization of CBD
narrowing and possible pancreatic lesions -- She will need
CT-pancreas and EUS as outpatient
- GI follow up
- Endocrinology follow up
- close titration of insulin as her requirements will change
with decreasing prednisone dose
- ID follow up to determine course of antibiotics
- weekly safety labs (CBC, Chem-10, LFTs send to ___
- Lovenox until INR ___ for 48 hours
- Adjust warfarin for goal INR ___ -- arrange ___
clinic follow up with PCPs office
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CloniDINE 0.2 mg PO DAILY
2. CloniDINE 0.3 mg PO HS
3. Labetalol 400 mg PO BID
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
5. NIFEdipine CR 90 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Spironolactone 50 mg PO BID
8. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
9. Glargine 60 Units Breakfast
Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. Furosemide 120 mg PO DAILY
11. irbesartan *NF* 300 mg ORAL DAILY
12. colesevelam *NF* 625 mg Oral BID
take THREE tablets twice daily
13. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
Discharge Medications:
1. CloniDINE 0.2 mg PO DAILY
2. CloniDINE 0.3 mg PO HS
3. Furosemide 60 mg PO DAILY
4. NPH 30 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
5. irbesartan *NF* 300 mg ORAL DAILY
6. Labetalol 400 mg PO BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
8. NIFEdipine CR 90 mg PO DAILY
9. Timolol Maleate 0.5% 1 DROP BOTH EYES DAILY
10. Acetaminophen 650 mg PO Q6H:PRN pain
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
12. CeftriaXONE 2 gm IV Q24H
13. Colchicine 0.6 mg PO Q48H
14. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
15. Docusate Sodium 100 mg PO BID
16. Enoxaparin Sodium 100 mg SC Q12H
please stop once INR ___ for 48 hours
17. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
18. Glucose Gel 15 g PO PRN hypoglycemia protocol
19. Lactulose 15 mL PO BID:PRN constipation
20. MetRONIDAZOLE (FLagyl) 500 mg IV Q12H
21. Pancrelipase 5000 1 CAP PO TID W/MEALS
22. Polyethylene Glycol 17 g PO DAILY:PRN constipation
23. PredniSONE 20 mg PO DAILY Duration: 1 Days
to end ___
Tapered dose - DOWN
24. PredniSONE 10 mg PO DAILY Duration: 3 Days
Tapered dose - DOWN
25. PredniSONE 5 mg PO DAILY Duration: 5 Days
Tapered dose - DOWN
26. Quetiapine Fumarate 12.5 mg PO QHS
27. Senna 1 TAB PO BID:PRN constipation
28. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush
29. Warfarin 4 mg PO DAILY16
This medication will need adjustment for INR ___. colesevelam *NF* 625 mg Oral BID
take THREE tablets twice daily
31. Omeprazole 20 mg PO BID
32. Spironolactone 50 mg PO BID
33. Outpatient Lab Work
Date: weekly
Diagnosis: liver abscesses
Labs: CBC, LFTs, ___
Fax: ___ clinic ___
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
post ercp pancreatitis
acute renal failure
diabetes mellitus, uncontrolled
acute gout flare
provetella bacteremia
liver abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with abdominal pain after an ERCP. This was
due to post-ERCP pancreatitis. The rest of your hospitalization
was complicated by kidney dysfunction, bacteria in your blood,
liver abscesses, gout flare and diabetes mellitus with
hyperglycemia, and an upper extremity blood clot. You were doing
better and you were discharged to rehab on IV antibiotics and
blood thinners for the blood clot.
You will need to have follow up with GI with a CT scan of your
pancreas and EUS for further evaluation of your pancreas. You
will see ID in clinic for further evaluation of your infection.
You will need to continue your antibiotics until they tell you
it is okay to stop. Also, upon discharge from rehab, you will
need to be seen by your endocrinologist and an ___
clinic.
Followup Instructions:
___
|
19913456-DS-24 | 19,913,456 | 24,965,231 | DS | 24 | 2188-04-25 00:00:00 | 2188-04-25 16:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / cat / pine pollen / adhesive
Attending: ___.
Chief Complaint:
BLE edema, fevers and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with family history of left breast cancer
diagnosed in ___ now s/p radiation and left partial mastectomy
and tram flap reconstruction p/w fever. She was discharged from
the Plastics service yesterday on ___ s/p left mastectomy with
immediate TRAM flap reconstruction ___ was c/b
hypotension s/p evacuation L chest hematoma on ___ and
transfusion. Her hospital course was complicated by fevers that
resolved on ___. She was afebrile for 48 hours, was started on
Vit C and discharged home yesterday.
.
She awoke this morning feeling swollen by her account and
febrile. Temp was 100.5, she took Tylenol and she defervesced.
However she then began to have exertional dyspnea, no chest
pain, cough, hemoptysis, palpitations, n/v. She called Dr.
___ nurse who advised her to present to the ED.
.
In the ED she had bilateral LENIs which were negative for DVT.
She had a CTA of her chest that was also negative.
.
She was feeling better upon evaluation however still complained
malaise and weakness.
Past Medical History:
L breast cancer, recent diagnosis of fibromyalgia due to bone,
joint and muscle aches, asthma, arthritis, anxiety, depression,
obesity, sleep apnea, diverticulitis in the past and
gastroesophageal reflux.
Social History:
___
Family History:
Positive for breast cancer.
mother - diagnosed with breast cancer at age ___ and went on to
die at ___.
maternal first cousin - breast cancer
maternal aunt - colon cancer.
father - died in the ___ of a myocardial infarction
brother - died at 58 of complications of renal failure and
noncompliance with diabetes, stroke and cirrhosis
brother - MI at ___
sister - arthritis and obesity
Physical Exam:
GEN: well appearing in no acute distress
LUNGS: minimal crackles in lower lobes bilaterall
EXT: 2+ edema in BLE, 1+ edema in BUE
CHEST: left breast is diffusely swollen an erythematous, but
blanches to compression. There are flat pustules present 5cm
superior to the nipple. The incision is dark red with deep
purple/black color on the at the mid clavicular incision
extending inferior 3cm and along the incision 4cm left and
right. No TTP. no fluctuance.
Pertinent Results:
ADMISSION LABS:
___ 08:30PM cTropnT-<0.01
___ 03:11PM LACTATE-1.8
___ 03:00PM GLUCOSE-103* UREA N-8 CREAT-0.6 SODIUM-141
POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-25 ANION GAP-18
___ 03:00PM estGFR-Using this
___ 03:00PM cTropnT-<0.01
___ 03:00PM proBNP-1870*
___ 03:00PM WBC-16.7* RBC-2.88* HGB-8.4* HCT-25.9* MCV-90
MCH-29.2 MCHC-32.4 RDW-14.9 RDWSD-48.7*
___ 03:00PM NEUTS-82.2* LYMPHS-7.0* MONOS-6.3 EOS-2.7
BASOS-0.4 IM ___ AbsNeut-13.68* AbsLymp-1.17*
AbsMono-1.05* AbsEos-0.45 AbsBaso-0.07
___ 03:00PM PLT COUNT-432*
___ 03:00PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
.
DISCHARGE LABS:
___ 09:03AM BLOOD WBC-12.8* RBC-3.11* Hgb-9.0* Hct-27.8*
MCV-89 MCH-28.9 MCHC-32.4 RDW-14.7 RDWSD-48.0* Plt ___
___ 09:03AM BLOOD Calcium-8.9 Phos-4.3 Mg-2.2
.
IMAGING:
Radiology Report BILAT LOWER EXT VEINS Study Date of ___
2:43 ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
.
Radiology Report CHEST (PA & LAT) Study Date of ___ 4:10
___
IMPRESSION:
Bibasilar atelectasis without definite focal consolidation. No
pleural
effusion or pulmonary edema.
.
Radiology Report CTA CHEST Study Date of ___ 6:26 ___
IMPRESSION:
1. Somewhat poor opacification of the segmental and subsegmental
pulmonary
arteries, particularly in the lower lobes, part due to noise
artifact from
patient body habitus shin patient's left arm being down. Given
this, no
evidence of pulmonary embolism. No evidence of aortic
dissection.
2. Subsegmental atelectasis in the bilateral lower lobes, right
upper lobe, and lingula.
3. TRAM flap in the left breast is partially imaged, with
postoperative
changes grossly similar compared to the prior study from ___.
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ one day after being discharged home with reported
fevers, swelling and shortness of breath. She had BLE venous
ultrasound studies as well as a chest CT all of which were
negative. She was admitted for continued observation and
treatment. She did well and was afebrile in the hospital. She
was discharged home to follow up as an outpatient and schedule
treatment at the hyperbaric oxygen chamber.
.
Neuro: The patient's pain was treated with Tylenol and tramadol
with good pain control reported.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored. Oxygen saturations were >
95% on room air. Patient was continued on her home respiratory
medications.
.
GI/GU: Patient was maintained on a regular diet with
supplemental protein shakes for healing. She was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
.
ID: The patient was re-started on vancomycin and zosyn on
admission. She was discharged home to resume and complete her
original discharge antibiotics, clindamycin and levolfloxacin.
The patient's temperature was closely watched for signs of
infection.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible. On discharge home you will resume her original
discharge script of Lovenox 40mg SC Q12H x 1 month.
.
At the time of discharge on HD#4, the patient was doing well,
afebrile with stable vital signs, tolerating a regular diet,
ambulating, voiding without assistance, and pain was well
controlled.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*30 Tablet Refills:*0
2. Ascorbic Acid ___ mg PO TID
RX *ascorbic acid (vitamin C) 500 mg 1 tablet(s) by mouth three
times a day Disp #*60 Tablet Refills:*1
3. Clindamycin 300 mg PO Q6H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth once a
day Disp #*15 Capsule Refills:*0
5. Enoxaparin Sodium 40 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin [Lovenox] 40 mg/0.4 mL 40 mg SC twice a day Disp
#*60 Syringe Refills:*0
6. Levofloxacin 750 mg PO Q24H
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a
day Disp #*10 Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours
Disp #*30 Capsule Refills:*0
8. BuPROPion (Sustained Release) 300 mg PO QAM
9. Carvedilol 6.25 mg PO BID
10. Cetirizine 10 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
12. Gabapentin 100 mg PO QHS
13. LORazepam 0.5 mg PO Q12H:PRN anxiety
14. Mirtazapine 30 mg PO QAM
15. Torsemide 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. BuPROPion XL (Once Daily) 300 mg PO DAILY
3. Carvedilol 6.25 mg PO BID
4. Cetirizine 10 mg PO DAILY
5. Clindamycin 300 mg PO Q6H
6. Docusate Sodium 100 mg PO BID
7. Enoxaparin Sodium 40 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH DAILY
9. Gabapentin 100 mg PO QHS
10. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate
11. Levofloxacin 750 mg PO Q24H
12. Lisinopril 5 mg PO DAILY
13. Mirtazapine 30 mg PO QHS
14. Multivitamins 1 TAB PO DAILY
15. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
16. Torsemide 10 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fevers and bilateral lower extremity edema and shortness of
breath
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Personal Care:
1. You should apply a fresh xeroform sheet to your left breast
reconstruction daily.
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. Your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. DO NOT wear a bra for 3 weeks. You may wear a camisole for
comfort as desired.
6. You may shower daily with assistance as needed. Be sure to
secure your drains to a lanyard that hangs down from your neck
so they don't hang down and pull out.
7. No pressure on your chest or abdomen
8. Okay to shower, but no baths until after directed by Dr.
___.
9. You will start hyperbaric oxygen treatments to increase
healing ability of your left breast tissue.
.
Diet/Activity:
1. You may resume your regular diet.
2. Keep hips flexed at all times, and then gradually stand
upright as tolerated.
3. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity for 6 weeks following surgery.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
4. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
5. Resume the antibiotics and Lovenox injections that you were
discharged home with on ___.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
___
|
19913456-DS-25 | 19,913,456 | 25,567,316 | DS | 25 | 2188-05-17 00:00:00 | 2188-05-17 15:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Sulfa (Sulfonamide Antibiotics) / cat / pine pollen / adhesive
Attending: ___.
Chief Complaint:
left chest pain, redness and 2 days of fever tmax 102.2F
w/chills
Major Surgical or Invasive Procedure:
___ intervention:
___ - ___ Fr x 2 into two infected seromas. Catheter #1 into
more lateral collection, 40 cc out, straw colored, slightly
cloudy. Catheter #2 into more medial collection, 500 cc out,
serosanguinous, cloudy.
History of Present Illness:
___ h/o left breast cancer s/p TRAM flap reconstruction presents
with 2 days of fever tmax 102.2F w/ chills and 1 day of left
lower abdominal pain described as dull/achy. The pain is not
constant and only occurs when touching her abdomen and sitting
upright worsens the pain.
.
Patient had 2 left breast drains removed during last admission,
right abdominal drain removed ___, and the left removed ___.
She has some serosanguinous drain from her abdominal incision
site with new erythema around the left lower quadrant. She
developed left breast skin necrosis about 3 weeks ago with wound
dehiscence 2 days ago and increased swelling.
.
In the ED plastic surgery and ___ were consulted recommending ___
guided biopsy and placement of drains tomorrow. Due to complex
medical history, plastic surgery requested medicine admission
and they would follow as consultants.
.
ROS: as above otherwise 10point ROS negative
Past Medical History:
-left breast cancer, stage 1 T1B infiltrating ductal carcinoma,
initially diagnosed in ___: s/p radiation, partial mastectomy
with breast reduction, and tamoxifen
-secondary left breast cancer EGR+: s/p left mastectomy with
immediate TRAM flap reconstruction (___) complicated by left
chest hematoma with evacuation ___ requiring blood
transfusion. She was admitted ___ with fevers treated
with IV antibiotics and discharged with PO antibiotics. She also
received Herceptin, which resulted in cardiomyopathy and
subsequently stopped.
-asthma, GERD
-anxiety, depression, fibromyalgia
.
-surgeries: cholecystectomy, right knee replacement, bunions
removed, tonsillectomy
Social History:
___
Family History:
-Positive for breast cancer.
-Mother: diagnosed with breast cancer at age ___, died age ___
-Maternal first cousin and maternal aunt with breast cancer.
-Father: died in the ___ of a myocardial infarction
-Brother: died at ___ of complications of renal failure and
noncompliance with DM, CVA, and cirrhosis
-Brother: MI at ___
-Sister: arthritis and obesity
Physical Exam:
ADMISSION PHYSICAL EXAM
-VS: 97.8F (tmax ___, HR 92 (max 108), BP 117/57, RR 18, SpO2
98%
-General Appearance: pleasant, comfortable, no acute distress
-Eyes: PERLL, EOMI
-ENT: moist mucus membranes, no goiter
-Chest: right chest port-a-cath without erythema, swelling,
tenderness
-Breast: left breast with upper inner breast ulceration (stage
___. Left lower breast with 5x5cm necrosis and lateral skin
splitting. Significant granulation tissues.
-Respiratory: clear b/l, no wheeze
-Cardiovascular: RRR, no murmur
-Gastrointestinal: left lower quadrant tenderness. lower
horizontal incision well-healed with faint lower quadrant
erythema. Apparent swelling left lateral hip. nondistended,
bowel sounds present.
-Extremities: no cyanosis, clubbing, or edema
-Skin: warm, no rashes/no jaundice/no skin ulcerations noted
-Neurological: AAOx3, CN ___ grossly intact
-Psychiatric: pleasant, appropriate affect
-GU: no catheter in place
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS:
___ 04:00PM ___ PTT-30.2 ___
___ 03:45PM GLUCOSE-126* UREA N-12 CREAT-0.7 SODIUM-138
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
___ 03:45PM estGFR-Using this
___ 03:45PM WBC-14.1* RBC-3.67* HGB-10.6* HCT-33.3*
MCV-91 MCH-28.9 MCHC-31.8* RDW-15.3 RDWSD-51.0*
___ 03:45PM NEUTS-80.5* LYMPHS-8.9* MONOS-9.2 EOS-0.5*
BASOS-0.4 IM ___ AbsNeut-11.34* AbsLymp-1.26 AbsMono-1.29*
AbsEos-0.07 AbsBaso-0.05
___ 03:45PM PLT COUNT-243
.
DISCHARGE LABS:
___ 05:51AM BLOOD WBC-10.6* RBC-3.05* Hgb-8.8* Hct-27.7*
MCV-91 MCH-28.9 MCHC-31.8* RDW-15.1 RDWSD-51.0* Plt ___
___ 05:51AM BLOOD Glucose-120* UreaN-9 Creat-0.7 Na-137
K-3.8 Cl-104 HCO3-24 AnGap-13
___ 05:51AM BLOOD ALT-27 AST-21 AlkPhos-119* TotBili-0.3
___ 05:51AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.1
.
IMAGING:
___
-CT chest/abdomen/pelvis with contrast:
1. Patient is status post left mastectomy. Postoperative changes
are seen following left breast reconstruction including probable
seroma along the lateral aspect of the reconstructed breast.
2. Postoperative changes seen along the anterior abdominal wall
donor site following left breast tram flap reconstruction with a
dominant 14.7 cm fluid collection with possible rim enhancement.
This is compatible with a seroma, noting that superimposed
infection cannot be excluded by imaging.
3. A second thin linear fluid collection is seen inferior and
lateral to the dominant collection, also similar in appearance.
4. Extensive diverticulosis without diverticulitis.
5. A 0.6 cm cm right adrenal nodule, unchanged.
.
___
-PERC IMAGE GUID FLUID COLLECT DRAIN W CATH
Using continuous sonographic guidance, ___ drainage
catheter was advanced via trocar technique into the more lateral
collection (#1). A sample of fluid was aspirated, confirming
catheter position within the collection. The pigtail was
deployed. The position of the pigtail was confirmed within the
collection via ultrasound.
.
Approximately 40 cc of slightly cloudy, straw-colored fluid was
drained with a sample sent for microbiology evaluation. The
catheter was secured by a StatLock. The catheter was attached to
bag. Sterile dressing was applied.
.
The patient was placed in a supine position on the US scan
table. Limited
preprocedure ultrasound was performed to localize the more
medial collection (#2). Based on the ultrasound findings an
appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
.
Using continuous sonographic guidance, ___ drainage
catheter was advanced via trocar technique into the more medial
collection (#2.). A sample of fluid was aspirated, confirming
catheter position within the collection. The pigtail was
deployed. The position of the pigtail was confirmed within the
collection via ultrasound.
.
Approximately 500 cc of slightly cloudy, serosanguineous fluid
was drained with a sample sent for microbiology evaluation. The
catheter was secured by a StatLock. The catheter was attached to
bag. Sterile dressing was applied. Fluid component of both
seromas were completely aspirated. Both seromas are also
lavaged with 20 cc of sterile saline with reaspiration of the
fluid.
.
The procedure was tolerated well, and there were no immediate
post-procedural complications.
.
MICROBIOLOGY:
___ 10:36 am ABSCESS Source: abdomen . LUQ COLLECTION
2.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- 8 R
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
.
___ 10:35 am ABSCESS Source: abdomen. LLQ COLECTION
1.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
___ female with h/o left breast cancer ___ s/p radiation,
mastectomy, and TRAM flap reconstruction presents with fever and
abdominal pain found to have abdominal fluid collection seroma
vs abscess. Admitted to medicine ___.
.
1. Left abdomen fluid collection with SIRS h/o left breast
infiltrating ductal carcinoma s/p left mastectomy and flap
reconstruction
-SIRS (fever, leukocytosis, tachycardia) with high suspicion of
infectious etiology (sepsis) CT consistent with seroma vs
abscess.
-Plastic surgery and ___ consulted with plans for ___ guided
biopsy/drain placement tomorrow. NPO midnight and confirm with
___ procedure.
-Blood cultures pending. Cover with empiric broad spectrum
antibiotics piperacillin-tazobactam and vancomycin (premedicate
with zofran); although antibiotics may lower culture yield
patient has potential to decompensate quickly.
-?history of cardiomyopathy with preserved EF. Hold torsemide
and continue with gentle IV fluids.
-PRN acetaminophen for fever. Continue oxycodone PRN for pain.
.
2. Acute anemia
-Patient has been anemic with baseline hemoglobin 9 since ___
h/o left chest wall hematoma requiring evacuation and blood
transfusion ___ s/p flap reconstruction. Hemoglobin
currently stable without bleeding.
-Continue to monitor.
.
Chronic Medical Problems
1. Herceptin-induced cardiomyopathy: most recent ECHO in OMR
___ with EF 58%, however patient mentions Herceptin induced
cardiomyopathy started on lisinopril, carvedilol, and torsemide.
Hold these in setting of sepsis with SBP 110s.
2. Depression, anxiety, fibromyalgia: continue buproprion,
gabapentin, mirtazapine
.
PATIENT SAFETY
#PPX (DVT): SCDs, hold enoxaparin prior to ___ procedure
#Code Status: Full
#Diet: regular, NPO midnight
#Disposition: Admit to hospitalist service.
.
On ___, ___ inserted two 10 ___ pigtail catheters into two
left abdomen fluid collections. The first yielded 40cc of straw
colored fluid and the second yielded 500cc of cloudy,
serosanguinous fluid. Samples from both collections were sent
for microbiology.
.
Left breast wounds lightly debrided at bedside and wet to dry
dressings applied.
.
The patient was admitted to the plastic surgery service on
___ for observation and treatment of left breast wounds and
infected abdominal seromas.
.
Neuro: The patient received Tylenol for pain relief.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient tolerated a regular diet. She was also
started on a bowel regimen to encourage bowel movement. Intake
and output were closely monitored.
.
ID: The patient was continued on vancomycin and zosyn until
cultures revealed MSSA growing from both abdominal fluid
collections. ID was consulted and recommended ___ weeks of IV
cefazolin with likely transition to ___ weeks of PO. The
patient's temperature was closely watched for signs of infection
and she remained afebrile. A wound vac dressing was applied to
inferior left breast wound and superior left breast wound was
continued on wet to dry dressings.
.
Prophylaxis: The patient received subcutaneous lovenox during
this stay, and was encouraged to get up and ambulate as much as
possible.
.
At the time of discharge on hospital day #5, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. She was afebrile with improved abdominal
erythema and tenderness. Pigtail drains x 2 draining thin,
serous fluid to JP suction bulbs. Left breast wound vac was
changed on day of discharge and connected to home VAC for
discharge home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. biotin unknonw oral daily
2. Multivitamins 1 TAB PO DAILY
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. Mirtazapine 30 mg PO QHS
5. Torsemide 5 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH DAILY
7. Enoxaparin Sodium 40 mg SC Q12HRS
Start: ___, First Dose: Next Routine Administration Time
8. Carvedilol 6.25 mg PO BID
9. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
10. Ascorbic Acid ___ mg PO TID
11. Cetirizine 10 mg PO DAILY
12. Gabapentin 100 mg PO DAILY
13. Anastrozole 1 mg PO DAILY
14. Cyanocobalamin Dose is Unknown PO DAILY
15. Vitamin D Dose is Unknown PO DAILY
16. Lisinopril 5 mg PO DAILY
17. LORazepam 0.5 mg PO Q12HOURS PRN anxiety
18. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
19. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
RX *albuterol sulfate [ProAir HFA] 90 mcg ___ puffs INH every
six (6) hours Disp #*1 Inhaler Refills:*2
2. Carvedilol 6.25 mg PO BID
3. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 1 gram/50 mL 2 gms IV every
eight (8) hours Disp #*63 Intravenous Bag Refills:*1
4. Heparin Flush (10 units/ml) 5 mL IV DAILY and PRN, line
flush
5. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
6. biotin ? mg oral DAILY
7. Cyanocobalamin unk mcg PO DAILY
8. Enoxaparin Sodium 40 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 30 mg/0.3 mL 40 mg subcutaneous every twelve (12)
hours Disp #*28 Syringe Refills:*1
9. Torsemide 10 mg PO DAILY
10. Vitamin D unk UNIT PO DAILY
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. Anastrozole 1 mg PO DAILY
13. Ascorbic Acid ___ mg PO TID
14. BuPROPion (Sustained Release) 300 mg PO QAM
15. Cetirizine 10 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH DAILY
18. Gabapentin 100 mg PO DAILY
19. Lisinopril 5 mg PO DAILY
20. LORazepam 0.5 mg PO Q12HOURS PRN anxiety
21. Mirtazapine 30 mg PO QHS
22. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
-Left breast wounds
-two infected seromas left abdomen
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted with fever and abdominal pain found to have
two abdominal fluid collections that were infected. You also
have two open areas on your left breast reconstruction that
require wound care.
.
Personal Care:
1. You will have a wound VAC dressing with a wound vac machine
in place for discharge home. This dressing will be changed by
the visiting nurse twice ___ week or so when you return home.
2. While VAC is in place, please clean around the VAC site and
monitor for air leaks of the VAC
3. You should bring a VAC dressing kit to your follow up
appointments with Dr. ___ that he may remove your VAC
dressing, evaluate your wound and then apply fresh VAC dressing.
Your VAC dressing will be removed as soon as possible and when
it is determined that the wound is healthy enough.
4. You may shower daily with assistance as needed. You should
do this with wound vac apparatus disconnected from you. Once
you have showered you will need to reconnect your dressing to
the wound vac apparatus and make sure it is functioning
properly.
5. No baths until after directed by Dr. ___.
6. Wet to dry dressing daily for the wound on the top of your
left breast reconstruction.
7. Lovenox 40 mg subcutaneous injection twice/day while
recovering at home.
8. Drain care. Keep a daily log of each drain output and bring
with you to follow up appointment with Dr. ___.
.
Activity:
1. Avoid strenuous activity with wound vac in place.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered .
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging. Please note that
Percocet and Vicodin have Tylenol as an active ingredient so do
not take these meds with additional Tylenol.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Continue to take your antibiotic as prescribed by Infectious
Disease.
5. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
6. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or drain(s).
3. Fever greater than 101.5 oF
4. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
19913536-DS-13 | 19,913,536 | 23,298,703 | DS | 13 | 2163-08-15 00:00:00 | 2163-08-22 10:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
morphine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
D+C under US guidance
History of Present Illness:
___ s/p uncomplicated MVA on ___ for missed AB.
Was approx 10 weeks by LMP, but only measuring 1.78mm CRL
(approx
8 weeks) by U/S. She received doxycycline for post-op abx ppx.
Now reports 3 day h/o severe abd pain with some spotting.
Reports
strong lower abdominal cramps. Passed small clot in ED, about
walnut sized. Otherwise, bleeding is minimal.
No N/V initially, but now that she has rec'd morphine in ED, she
is nauseous. No fevers. +flatus. +BM. No diarrhea. GC/CT
obtained
prior to MVA both negative. O+, abs neg prior to MVA.
REVIEW OF SYSTEMS
Constitutional: Negative.
Eyes: Negative.
ENT: Negative.
Cardiovascular: Negative.
Respiratory: Negative.
Gastrointestinal: Negative.
Genitourinary: Negative.
Musculoskeletal: Negative.
Skin/Breast: Negative.
Neurological: Negative.
Mental Health: Negative.
Endocrine: Negative.
Hematologic/Lymphatic: Negative.
Allergic/Immunologic: Negative.
Past Medical History:
GYN HISTORY:
LMP: ___, irregular
HISTORY of Abnormal pap smears: denies
HISTORY of STIs: denies
ISSUES: denies
OB HISTORY:
G: 3 P: 2 LIVE CHILDREN: 2 SAB: 1 TAB: ECTOPIC:
- SVD x2, term, no issues
- missed AB, s/p MVA, as above
PAST MEDICAL HISTORY:
*) GERD
PAST SURGICAL HISTORY:
*) MVA
Social History:
SOCIAL HISTORY:
Patient denies tobacco, alcohol or drug use.
Physical Exam:
PHYSICAL EXAM:
VS 98.0 76 ___ 98RA
CONSTITUTIONAL: NAD, AOx3
RESP: Lungs clear
HEART: Normal rate, regular rhythm, no murmurs/rubs/gallops,
normal S1, S2
ABDOMEN: Soft, TTP bilateral lower quadrants, no r/g
PELVIC:
External Genitalia: No lesions, blood at vulva/introitus
Vagina: Well estrogenized, no lesions
Cervix: Parous os, no lesions, no active bleeding, dark
blood/clot cleared easily with 2 scopettes
Uterus: AV, +fundal tenderness, +CMT
Adnexa: No masses papreciated bilaterally, no adnexal
tenderness
Pertinent Results:
___ 01:30AM GLUCOSE-102* UREA N-12 CREAT-0.6 SODIUM-138
POTASSIUM-4.1 CHLORIDE-104 TOTAL CO2-25 ANION GAP-13
___ 01:30AM estGFR-Using this
___ 01:30AM URINE HOURS-RANDOM
___ 01:30AM URINE UHOLD-HOLD
___ 01:30AM WBC-6.8 RBC-4.05* HGB-11.0* HCT-34.8* MCV-86
MCH-27.3 MCHC-31.7 RDW-15.4
___ 01:30AM NEUTS-37* BANDS-0 LYMPHS-56* MONOS-5 EOS-2
BASOS-0 ___ MYELOS-0
___ 01:30AM PLT COUNT-266
___ 01:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:30AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 01:30AM URINE RBC-8* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 01:30AM URINE MUCOUS-RARE
___ pelvic u/s:IMPRESSION:
Extensive heterogeneous material within the endometrial cavity
may be
secondary to blood products from patient's prior D&C, however is
highly
concerning for non vascularized retained products of conception.
Brief Hospital Course:
The patient was admitted to the gynecology service for retained
products of conception vs. hematometra and endometritis. The
received IV antibiotics and underwent an ultrasound guided
dilation and curretage. Her post operative course was
uncomplicated and she was discharged home in stable condition on
oral antibiotics.
Medications on Admission:
none
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN pain
take with food
RX *ibuprofen 600 mg 1 tablet(s) by mouth q6 hours Disp #*50
Tablet Refills:*1
2. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
do not drive
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
q4 hours Disp #*8 Tablet Refills:*0
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 7 Days
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tab by mouth q12
hours Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
hematometra, endometritis
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 gynecology service for your procedure.
You have recovered well and the team believes you are ready to
be discharged home. Please call Dr. ___ office with any
questions or concerns at ___. Please follow the
instructions below. Take the oral antibiotic for 7 days as
prescribed.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 2
weeks.
Followup Instructions:
___
|
19913577-DS-9 | 19,913,577 | 20,973,939 | DS | 9 | 2113-10-11 00:00:00 | 2113-10-11 18:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope and VT episode with ICD Shock
Major Surgical or Invasive Procedure:
Amiodarone loading, monitoring on telemetry
Dobutamine stress echocardiogram
History of Present Illness:
This is a ___ year old male admitted from the ED s/p syncope. He
was walking into a bank when he sat down on a bench ___ leg
pain. He syncopized and had no preceding symptoms that he
recalls. He fell and his head. Of note, he had been feeling
lightheaded over the past couple days with exertion. Also of
note, he reports that he got shocked X2 the night before
admission (although this was not noted on ICD interrogation).
ICD interrogation showed 1 VT episode which was terminated by 1
shock. He denies chest pain, dyspnea, cough, palpitations,
lightheadedness, dizziness, nausea, vomiting, changes in vision.
His device showed a history of 5 such shocks.
Past Medical History:
CAD s/p CABG ___ in ___
ICD
HTN
DM type II
PAD
Social History:
___
Family History:
There is no family history of premature coronary artery disease,
unexplained heart failure, or sudden death.
Physical Exam:
On Admission ___:
PHYSICAL EXAM:
VS; 98.0 150/85 67 20 95% RA
Gen: A&OX3, NAD
Neuro: Grossly intact.
Neck/JVD: Normal JVP
CV: RR, normal S1, S2. III/VI systolic murmur heard best over
apex with radiation to axilla
Chest: CATB
ABD: soft, NT, ND
Extr: WWP. 1+ edema bilateraly
On Discharge:
VS: T 97.7 HR 50 RR 20 BP 121/65 96% RA
tele: SB 50's
Gen: A&OX3, NAD
Neuro: Grossly intact
Neck/JVD: No distension
CV: RRR, normal S1, S2. III/VI systolic murmur heard best over
apex with radiation to axilla
Chest: CTAB
ABD: obese, soft, NT, +BS
Extr: trace to 1+, improved over ___
Pertinent Results:
___ 09:10AM BLOOD Hct-38.6* Plt Ct-80*
___ 03:10PM BLOOD WBC-3.7* RBC-4.07* Hgb-12.6* Hct-40.2
MCV-99* MCH-31.0 MCHC-31.3* RDW-15.1 RDWSD-54.9* Plt Ct-88*
___ 03:10PM BLOOD Neuts-43.1 ___ Monos-19.3*
Eos-2.2 Baso-0.3 Im ___ AbsNeut-1.59* AbsLymp-1.28
AbsMono-0.71 AbsEos-0.08 AbsBaso-0.01
___ 09:10AM BLOOD Plt Ct-80*
___ 09:10AM BLOOD ___
___ 09:10AM BLOOD UreaN-16 Creat-1.0 Na-137 K-4.1 Cl-101
HCO3-27 AnGap-13
___ 03:10PM BLOOD cTropnT-<0.01
___ 09:10AM BLOOD Mg-2.5
DISCHARGE LABS:
___ 05:41AM BLOOD Plt Ct-83*
___ 05:41AM BLOOD UreaN-25* Creat-1.0 Na-134 K-3.9
___ 05:41AM BLOOD Mg-2.2
NUCLEAR PERFUSION STRESS:
FINDINGS:
The image quality is adequate but limited due to soft tissue
attenuation. There is motion.
Left ventricular cavity size is increased.
Rest and stress perfusion images reveal a fixed, moderate
reduction in photon counts involving the mid and basal anterior
and anterolateral walls. There is also a fixed, moderate
reduction in photon counts involving the mid and basal
inferolateral walls and the distal lateral wall.
Gated images reveal hypokinesis of the basal anterior and
anterolateral walls and akinesis of the mid anterior, basal
inferolateral, and mid inferolateral walls.
The calculated left ventricular ejection fraction is 35% with an
EDV of 218 ml.
IMPRESSION:
1. Fixed, medium sized, moderate severity perfusion defect
involving the LAD territory.
2. Fixed, medium sized, moderate severity perfusion defect
involving the LCx
territory.
3. Increased left ventricular cavity size. Moderate systolic
dysfunction with
hypokinesis of the basal anterior and anterolateral walls and
akinesis of the mid anterior, basal inferolateral, and mid
inferolateral walls.
Compared to the prior study of ___, the LAD territory is
now fixed and larger. The LCx territory is now fixed. The RCA
territory defect is no longer seen.
SUPINE AP VIEW OF CHEST:
FINDINGS:
Left-sided AICD device is noted with leads terminating in the
regions of the right atrium and right ventricle. The patient is
status post median
sternotomy and CABG. Moderate to severe enlargement of the
cardiac silhouette may be accentuated by a VP technique and
supine positioning. There is mild pulmonary edema, new in the
interval, with hazy opacification in both hemithoraces likely
reflective of small layering pleural effusions. No focal
consolidation or pneumothorax is present. Moderate multilevel
degenerative changes are seen in the thoracic spine.
IMPRESSION:
Moderate to severe cardiomegaly with mild pulmonary edema and
probable small bilateral pleural effusions.
LEFT KNEE XRAY (3 views):
FINDINGS:
No acute fracture or dislocation is present. Moderate
degenerative changes are seen in all 3 compartments of the knee
with mild joint space narrowing and osteophyte formation.
Chondrocalcinosis is also visualized. There are no concerning
lytic or sclerotic osseous abnormalities. No sizeable joint
effusion is present. Diffuse vascular calcifications are
present along with multiple clips along the medial aspect of the
knee.
IMPRESSION:
No acute fracture or dislocation. Moderate osteoarthritis with
chondrocalcinosis.
LEFT ANKLE XRAY:
FINDINGS:
No acute fracture or dislocation identified. There are mild
degenerative
changes around the ankle joint and midfoot. Dorsal and plantar
calcaneal
enthesophytes are noted as is mild enthesopathic change around
the base of the fifth metatarsal. The mortise is congruent on
this non stress view. The tibial talar joint space is preserved
and no talar dome osteochondral lesion is identified. No
suspicious lytic or sclerotic lesion is identified. Vascular
calcification is present. Mild diffuse soft tissue swelling
around the ankle may be secondary to venous stasis.
IMPRESSION:
No acute fracture or dislocation of the left ankle. Mild
degenerative changes are present as described above.
CT SPINE:
FINDINGS:
Alignment is normal. No fractures are identified.Multilevel
moderate to severe degenerative changes are noted with
ossification of the posterior longitudinal ligament and
posterior disc bulges causing moderate to severe vertebral canal
narrowing, most pronounced at C4-C5 and C6-C7. Multilevel
anterior, posterior, and uncovertebral osteophytosis is worse at
C4-C5. There is multilevel facet arthropathy including facet
arthrosis at C3-C4. There is mild osseous right neural
foraminal narrowing at C3-C4 and moderate bilateral neural
foraminal narrowing at C4-C5. There is no prevertebral soft
tissue swelling. There is no evidence of infection or neoplasm.
Evaluation of the lung apices is limited by respiratory motion
artifact.
Despite this limitation, there are no gross abnormalities.
Atherosclerotic calcifications are worst at the carotid
bifurcations.
IMPRESSION:
1. No evidence of fracture or traumatic malalignment.
2. Moderate to severe multilevel degenerative changes include
ossification of the posterior longitudinal ligament and
posterior disc bulges causing moderate to severe vertebral canal
narrowing at C4-C5 and C6-C7. Mild to moderate osseous neural
foraminal narrowing caused by osteophytosis is also present at
C3-C4 and C4-C5.
CT ABDOMEN/PELVIS:
LOWER CHEST: Severe cardiomegaly is unchanged. There is mild
interlobular septal thickening and reflux of contrast into the
hepatic veins. The main pulmonary artery is again enlarged to
3.7 cm suggestive of pulmonary hypertension. Small
nonhemorrhagic left and trace right pleural effusions have
decreased in size. Multiple new peripheral nodular pulmonary
ground glass opacities include a 1.0 x 0.6 cm subpleural opacity
(02:34) within the lateral right middle lobe, and 0.8 x 0.6 cm
ground-glass opacity (02:20) in the posterior right upper lobe.
In the inferior right upper lobe, there is a 0.4 x 0.3 cm
pulmonary nodule (02:32). A 0.7 cm calcified granuloma in left
lower lobe is unchanged. There is no evidence of pericardial
effusion. Median sternotomy wires are noted.
IMPRESSION:
1. New peripheral nodular pulmonary ground glass opacities raise
the
possibility of septic emboli or fungal infection.
2. Small calcified gallstone in the gallbladder neck.
Peripheral
calcification of the gallbladder fundus may be related to a
large underlying gallstone or porcelain gallbladder. No
evidence of cholecystitis.
3. Mild interlobular septal thickening, small pleural effusions,
severe
cardiomegaly, and reflux of contrast into the hepatic veins
suggest a
component of heart failure.
4. Trace perihepatic ascites.
5. Nodular adrenal glands likely reflect adrenal hyperplasia.
6. Severe atherosclerotic calcification and a chronic dissection
flap of the infrarenal abdominal aorta are unchanged.
7. No acute traumatic injury identified including no fracture
CT HEAD:
FINDINGS:
There is no evidence of acute infarction, hemorrhage, edema, or
mass. The
ventricles and sulci are normal in size and configuration.
There is a tiny right parietal subgaleal hematoma (601b:67).
There is no
evidence of fracture. The visualized portion of the paranasal
sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. Cavernous
carotid atherosclerotic
calcifications are noted.
IMPRESSION:
Tiny right parietal subgaleal hematoma. No fracture,
intracranial hemorrhage, or large territorial infarction.
Brief Hospital Course:
The patient had a relatively unremarkable hospital course. He
was monitored closely on telemetry and started on Amiodarone
following admission at 400 mg PO TID. This will be tapered to a
daily dose, likely after 6 doses. His Toprol was halved from 50
mg daily to 25 mg Daily. His telemetry improved with the
reduction in his beta blocker and he continued his Amiodarone
load without incident, electrolytes and ECG remained stable. At
discharge, he was discharged on Amiodarone 400 mg Daily and
Toprol 25 mg Daily with close follow up with both Device Clinic
and Dr. ___.
He continued to complain of musculoskeletal type pain, and his
X-RAYS revealed no acute process. He does have tricompartmental
osteoarthritis of the knee as noted on X-RAY. There was no
fracture or dislocation or joint effusion noted clinically or on
radiograph. He was maintained on PRN Tylenol for pain. Three
views of the left ankle were taken on ___ after reports of
ankle pain and tenderness to palpation about the left lateral
malleolus. These radiographs did not reveal any acute fracture
or dislocation, just chronic mild enthesopathic change around
the base of the fifth metatarsal. He was ordered for ice,
elevation and PRN Tylenol. He was evaluated with ___ and
recommended for use of a cane given his ankle bruising/sprain.
He utilized ice and Tylenol to good effect and reported
significant improvement overnight.
He was placed on a sliding scale insulin and continued with his
chronic Glipizide dosing. His blood glucose remained stable on
his Glipizide.
He underwent a nuclear stress echo given his history of coronary
artery disease and CABG in ___ in ___. Review of a TTE
in ___ was also reviewed that indicated an EF of ___. He
was found to have increased fixed perfusion defects but no
further need for intervention through catheterization. He was
felt to have ischemic cardiomyopathy and the stress test was
performed. He has been under the care of Dr. ___
___. Attempts were made in the past to have the patient obtain
his records from ___ to assist in his ongoing care.
Results of this examination are pending and will be included
under the pertinent results section of this discharge summary.
It will be important for him to continue with his Device Clinic
follow up and with Dr. ___ management of his ischemic
cardiomyopathy and device.
He also has peripheral arterial disease with calf claudication
and is followed by Vascular Surgery, Dr. ___. He was
recommended to continue ongoing follow up with ABI's, PVRs and
toe pressures twice yearly. Minimally invasive procedures were
discussed including stenting of the right common iliac artery to
help improve inflow but his calf claudication would not likely
be relieved without bypass surgery which the patient elected to
defer. He does continue to complain of calf pain which is
directly related to his clauditory symptoms. On exam, his
compartments remain soft and perfused, with no erythema or
evidence of DVT.
His abrasions remained stable and his tiny hematoma is without
change, remains small and less tender. His knee abrasions are
also stable and his pain gradually improving.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. GlipiZIDE XL 5 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. losartan-hydrochlorothiazide 100-25 mg oral DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Amiodarone 400 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
Listed separately for Quality Measures/system issues. Do not
take add'l dose of Losartan
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. GlipiZIDE XL 5 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. losartan-hydrochlorothiazide 100-25 mg oral DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
syncope and atrial fibrillation with slow ventricular response
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted following presentation to the ED following a
syncopal (fainting like episode) with a ventricular tachycardia
and an ICD shock from your device. Your heart rate was slow and
you were started on a new medication, Amiodarone. Your device
was interrogated and you were found to have a history of five
shocks in the past. Your Toprol was decreased to 25 mg Daily
from 50 mg Daily. Additionally, you had a stress echocardiogram
given your history of heart disease and CABG. This test
revealed fixed perfusion defects but does not require a return
to the catheterization lab to assess your coronary arteries.
You should continue all of your current medications. Your
Toprol dose was decreased to 25 mg Daily, and you will be
discharged on Amiodarone 400 mg Daily. This medication was
escripted to your pharmacy. You will follow up in Device Clinic
as noted below(appointment information noted below).
Additionally you should follow up with Dr. ___ 2 weeks.
Follow up with your PCP ___ 2 weeks and continue your follow up
with Dr. ___ as previously scheduled. All appointments
are listed below.
Your telemetry remained stable with heart rates running from the
30's to the 50's and parameters were placed on your Toprol. You
were followed closely by the Electrophysiology team while here.
You were monitored while starting your Amiodarone and remained
stable.
In the course of your fall, you hit your head and had a
superficial abrasion with a tiny hematoma noted on the top of
your head in the parietal area. This was monitored carefully
while you were here. Additionally, you had two abrasions on
your lower extremities, one on your right knee and one on the
front part of your left leg. There was no drainage and skin
loss on the knee was only superficial. You complained of left
ankle pain and an ankle X-Ray was performed which showed no
acute fracture or dislocation. You reported tenderness to
palpation about the lateral aspect of the ankle. Your edema was
felt to be related to your venous stasis. You were evaluated by
Physical Therapy and advised to continue ice and elevation of
the ankle, along with PRN Tylenol. A walking boot was provided
as were crutches. You should establish outpatient physical
therapy (script provided) to work on range of motion of your
ankle, a home exercise program and gait training. We recommend
you follow up with your PCP ___ 2 weeks for re-evaluation.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19913597-DS-11 | 19,913,597 | 24,520,975 | DS | 11 | 2163-01-12 00:00:00 | 2163-01-13 11:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
lower abdominal/groin pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of abdominal mass s/p resection and chemo in 1980s, pw 3
weeks of lower abdominal and groin pain. Pt ha not seen
physician in ___ number of years. Pt states has had difficulty
urinating with dribbles for the last few weeks and also cannot
control urine. He reports having trouble maintaining PO intake
of fluids, but had a good appetite. He believes he's had
associated weight loss, fatigue, weakness, chills and sweats. He
had a cough productive of thick sticky yellow/ green sputum
intermittently throughout this time period. He endorses periods
of shortness of breath. He has been intermittently nauseous and
dizzy and has had persistent diarrhea. He endorses escalating
abdominal pain. He denies chest pain. Seen at ___ PCP today
where pt seemed confused. Per ___ labs Cr today 3.4 last was
0.75 in ___.
Pt. went to PCP today for first time in ___ years. He lives alone
and it is unclear if he has been med compliant. He is AAOx3 but
very forgetful which is off his baseline. Also noted his
creatinine was elevated. Pt. states chills, and abd. pain and
dysuria with white discharge from penis. Also states only
voiding small amounts. ___ placed a 2L of cloudy urine
removed, pt. states abd. pain improved. AAox3 however forgetful
and lives alone, PCP does no think he is taking his home
medications. Cefepime IV given. VSS.
In the ED, initial VS were 98.1 86 159/89 18 98%RA .
Pt unable to urinate. Foley placed for 1L purulent urine. Pt
given Cefepime
Pt CT shows concern for bladder cancer. Pt also with UTI. ALso
elevated lipase. Receiving IVF 2L NS. Plan for admission to
medical service. Is hemodynamically stable. A+Ox4 here but
complaints of pain at bladder.
Received 2L NS and cefepime. Transfer VS were 98.5 72 125/81 18
97%
On arrival to the floor, patient reports decreased pain from
earlier presentation but appears somewhat confused. He is A+Ox3.
Past Medical History:
- NEPHROLITHIASIS- ___
- RETROPERITONEAL LIPOSARCOMA- ___ with radical resection
including right nephrectomy and radiation, no chemo.
- LEFT TOTAL KNEE REPLACEMENT ___
- ANXIETY
- HYPERTENSION
- HYPERCHOLESTEROLEMIA
- GOUT
- OBESITY
- OSTEOARTHRITIS
- PSORIASIS- per patient
- COPD
- BPH
- HERPES ZOSTER ___
Social History:
___
Family History:
Deferred. No known history of heart disease, cancer, diabetes.
Positive for HTN.
Physical Exam:
Admission Exam:
VS - BP 151/90 HR 76 RR 18 97%RA
General: Patient appears confused but is A+Ox3 and recites the
days of the week forward and backward successfully though with
some difficulty. He is a pleasant man who appears to be in NAD.
HEENT: Scaly white plaques in the right external ear. MM dry.
PERRLA.
Neck: No bruits. Unable to appreciate JVP.
CV: RRR. No m/r/g. No carotid bruits.
Lungs: Decreased lung sounds at the bases bilaterally
Abdomen: +BS. Soft, nondistended. No tenderness to palpation, no
rebound and guarding. Some firmness to the LUQ.
GU: Bladder not evident on percussion.
Ext: RLE edema > LLE edema. WWP.
Discharge Exam:
VS - 98.3 140/79 50 16 95%RA
GEN - NAD. Answering questions appropiately, but extreemly slow
to answer and tangential in his thoughts.
PULM - CTAB in anterior lung fields.
CV - RRR, no m/r/g
ABD- + bowel sounds, soft, non-tender, non-distended, no r/g
EXT - 1+ edema of the ___ bilaterally.
Pertinent Results:
Admission Labs:
___ 02:45PM BLOOD WBC-10.6 RBC-4.24* Hgb-13.0* Hct-40.3
MCV-95 MCH-30.7 MCHC-32.3 RDW-12.4 Plt ___
___ 02:45PM BLOOD Neuts-79.0* Lymphs-12.0* Monos-6.4
Eos-1.7 Baso-1.0
___ 03:00PM BLOOD ___ PTT-33.4 ___
___ 02:45PM BLOOD Glucose-85 UreaN-77* Creat-2.9* Na-142
K-4.9 Cl-108 HCO3-19* AnGap-20
___ 02:45PM BLOOD ALT-51* AST-57* AlkPhos-90 TotBili-0.5
___ 08:10AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.1
___ 02:49PM BLOOD Lactate-0.9
Additional Labs:
___ 03:42PM BLOOD CK-MB-4 cTropnT-0.04*
___ 06:50AM BLOOD CK-MB-4 cTropnT-0.05*
___ 01:10PM BLOOD CK-MB-4 cTropnT-0.04*
___ 06:24AM BLOOD proBNP-1578*
___ 01:10PM BLOOD TSH-1.6
___ 08:10AM BLOOD Triglyc-104
___ 01:10PM BLOOD VitB12-GREATER TH
RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE.
Urine on admission:
___ 02:45PM URINE Color-Straw Appear-Hazy Sp ___
___ 02:45PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 02:45PM URINE RBC-37* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
Imaging:
___ CT Abd/Pelvis without contrast: FINDINGS: The lung bases
are clear. The heart size is top normal. There is no pleural or
pericardial effusion.
The unenhanced appearance of the liver, spleen, pancreas, and
adrenal glands is unremarkable. Dependent stones seen in the
gallbladder which is otherwise unremarkable. The patient is
status post right nephrectomy with atrophy of the right
paraspinal muscles. There is hydronephrosis of the left kidney
with punctate calcifications in the collecting system and a mild
amount of fat stranding. The left ureter is dilated with
nonobstructive layering calcification just proximal to the UVJ.
A Foley is in expected position. There are multiple bladder
calculi. Despite being decompressed, the bladder has an
irregular lobulated appearance. There is also mild fat
stranding adjacent to the bladder with several soft tissue
nodules, likely lymph nodes. The seminal vesicles are
unremarkable.
The stomach and small bowel are unremarkable without any
evidence of wall
thickening or obstruction. The colon is unremarkable. A
circular fat density is seen along the antimesenteric border of
the colon in the right lower quadrant, likely an epiploic
appendage. There is no retroperitoneal or mesenteric
lymphadenopathy. There is no abdominal or pelvic free fluid or
free air. There is a small fat-containing umbilical hernia.
Atherosclerotic calcifications are present in the abdominal
aorta and the common iliac vessels. No suspicious lesion is seen
in the visualized osseous structures.
IMPRESSION: 1. Irregular lobulated appearance of the bladder
with adjacent small lymph nodes and fat stranding concerning for
a malignant process. Correlation with urine cytology and
urinalysis is recommended. An MRI or CT cystogram may be
obtained for further assessment.
2. Left hydronephrosis with punctate calcifications in the
collecting system and layering non-obstructing calcifications in
the distal ureter.
3. Right nephrectomy.
___ Urine cytology: NEGATIVE FOR MALIGNANT CELLS. Reactive and
degenerated urothelial cells and numerous neutrophils.
___ CXR: IMPRESSION: Severe cardiomegaly. No acute
cardiopulmonary process.
___ CT Head w/o contrast: FINDINGS: There is no evidence of
acute intracranial hemorrhage, mass effect, shift of the
normally midline structures or vascular territory infarct.
Gray-white matter differentiation is preserved throughout.
Ventricles and sulci are
enlarged consistent with age related global atrophy.
Periventricular white matter hypodensities are consistent with a
sequelae of chronic small vessel ischemic disease. Mastoid air
cells are well aerated. Paranasal sinuses are well aerated. No
osseous or soft tissue abnormalities. IMPRESSION: No evidence
of acute intracranial process.
___ KUB: IMPRESSION: Air-filled distended loops of small and
large bowel favoring ileus.
___ EKG: Sinus rhythm with frequent ventricular ectopy. Left
axis deviation. Poor R wave progression. Cannot rule out
anterior myocardial infarction of indeterminate age. Inferior
myocardial infarction of indeterminate age. Non-specific ST-T
wave abnormalities. No previous tracing available for
comparison.
___ KUB: IMPRESSION: Markedly dilated air-filled loops of small
and large bowel, could represent progressive ileus; however,
potentially concerning for distal colonic obstruction. Equivocal
increased density in left inguinal region could be artifactual,
but correlate with palpation to exclude an inguinal hernia. If
there is clinical concern for obstruction,recommend CT for
further evaluation.
___ KUB: IMPRESSION: 1. Slight interval increase in colonic
and small bowel dilatation which could reflect severe ileus,
although distal colonic obstruction should be considered.
___ MRI: There is global generalized volume loss. There is
both punctate and confluent FLAIR hyperintensity in the
periventricular subcortical white matter bilaterally as well as
T2 FLAIR hyperintensity in the midbrain and pons likely
representing the sequela of chronic small vessel disease. There
is no evidence of acute infarct or hemorrhage. There is no mass
lesion, mass effect or shift of the midline structures. There is
no abnormal intra or extra-axial fluid collection. There are
normal major intracranial vascular flow voids. The visualized
paranasal sinuses, mastoids, and orbits are unremarkable.
IMPRESSION:
1. No acute intracranial abnormality, with no evidence of acute
infarct.
2. Global atrophy. Extensive white matter signal abnormality
likely
represents the sequela of severe chronic small vessel disease.
___ CXR: There is a re-demonstration of the left ventricular
enlargement. Mediastinum is unremarkable. Lungs are essentially
clear. Prominence of the pulmonary arteries might be consistent
with pulmonary hypertension. No pleural effusion or pneumothorax
is seen. Degenerative changes in both humeral heads are noted.
___ CT CHest: There is significant pulmonary emboli with
thrombus in the distal right main pulmonary artery, going down
into segmental and subsegmental level in the right lower lobe.
Most of the ground-glass opacities and triangular subpleural
consolidation are found in the same area as the pulmonary emboli
and probably represent infarct and pulmonary hemorrhage. A
superimposed infection in the consolidated part cannot be
excluded.
A few less than 4 mm lung nodules are seen throughout the lungs.
They are in series 5, image 54, 118, 149 and are nonspecific.
Two of them are calcified, images 80 and 87. Secretion is seen
in the trachea and right main stem.
Thyroid is unremarkable. Mildly enlarged lymph nodes could be
reactive, but will have to be followed up. The biggest one in
subcarinal station measures 27 x 15 mm. The main pulmonary
artery is dilated to 3.3 cm, but the right heart chambers are
not dilated. Coronary arteries are moderately calcified. The
aorta is atheromatous. There is no pericardial effusion.
Associated right pleural effusion is small. Multiple venous
collaterals are seen, possibly due to partial stenosis of the
left subclavian vein which remains patent.
UPPER ABDOMEN: This study is not tailored for assessment of
intra-abdominal organs in this patient with right nephrectomy
for renal cancer. The hypertrophic left kidney is not fully
included in this study. There is a gallstone without any sign
of cholecystitis and the stomach is moderately distended.
OSSEOUS STRUCTURES: There is no bony lesion concerning for
malignancy.
CONCLUSION:
1. Significant pulmonary emboli in the distal right main
pulmonary artery going into the segmental and subsegmental
levels in the right lower lobe, accompanied by pulmonary infarct
and hemorrhage.
2. Superimposed right lower lobe pneumonia cannot be excluded.
3. Mildly enlarged central lymph nodes and a few lung nodules
could be
followed up with a chest CT in three months considering the past
medical
history of cancer.
4. Stigmata of previous granulomatous infection.
DISCHARGE LABS:
___ 07:35AM BLOOD WBC-11.1* RBC-4.30* Hgb-13.6* Hct-39.8*
MCV-93 MCH-31.6 MCHC-34.2 RDW-13.4 Plt ___
___ 07:35AM BLOOD ___ PTT-46.8* ___
Brief Hospital Course:
___ with poor urine flow and abdominal pain found to have
urinary retention, pyuria, multiple bladder stones, a new
bladder mass, ___ and AMS, who now presents with continued
waxing and waning AMS, resolved ___, and resolving ileus.
Active issues:
# Altered Mental Status/Dementia: Patient was initially thought
to be delirious as had numerous underlying medical decisions
that could lead to delirium in an ___ yo patient (see below).
However, it soon became clear after treating this medical
problems that patient had underlying dementia. He was waxing and
waning, but not observed to be fully lucid. CT showed atrophy
particularly in the FT regions consistent with frontotemporal
dementia. TSH and B12 were normal. RPR is negative. Psych
consult found pt to be cooperative and to have a basic
understanding of his situation, but felt he may have a
personality disorder characterized by isolative and odd behavior
and paranoia. Psych agreed with concerns about pt's limited
insight, poor judgment, paranoia. Neurology was also consulted
who felt patient had an underlying dementia. Multiple attempts
were made to have patient designate a health care proxy but he
refused. Patient was unable to understand and manipulate basic
medical information and come to an informed decision that he
could articulate to the team. Collateral information from pt's
nephew and neighbor revealed concerns about pt's hoarding
behaviour and safety at home. THe patient's brother ___
(brother, in ___: ___ (home) is the ___.
# Pulmonary Embolism: In the setting of the below possible PNA
on ___ the patient developed hemoposis and a CT chest w/ and w/o
contrast was ordered and on that a large right PE was visulized.
The patient was placed on lovenox to coumadin bridge. He
continued to have hemoposis but was slowly improving. His blood
counts continued to be stable. INR theraputic on ___ and
lovenox stopped.
#A-fib: In the setting of the above PE the patient was noted to
be in A-fib. His rate was controlled without medication. He was
anticoagualted with coumadin as above the the PE. His CHADS2
score was ___ (he carries the diagnosis of HTN, but he is on no
antihypertensives as an outpatient). Follwoing anticoagulation
for PE, consideration of aspirin for anticoagulation should be
considered.
# Abdominal pain: Patient came in with low abdominal and groin
pain improved with placement of foley. Had an acute worsening of
his abdominal pain on ___ and had not had a BM since admission.
KUB was suggestive of ileus. Had no BM night of ___, pain and
exam worsened ___. Second KUB showed worsening ileus with ?SBO.
Clinically improved and then had several BM's throughout that
day. Had multiple BMs over the next few days. Patient started on
senna, colace and miralax to prevent recurrence.
# Possible UTI/pyelonephritis: Stranding around kidney on CT abd
on admission was concerning for pyelonephritis combined with
pyuria on UA. Patient given 7 day course of CTX which finished
___. Two urine cultures were sent which were negative and thus
this may represent a sterile pyuria. Patient did have a bump in
his WBC to peak of 14.4 which fell back to normal with
completion of abx therapy. Patient remained afebrile
#Nephrogenic DI: Presented with ___ (see below) that steadily
resolved with foley and IVF. Subsequently had a nephrogenic
DI/postobstructive diuresis. He experienced subsequent
hypernatremia and hypokalemia. Had a >3L free water deficit
corrected with D5W. Beginning on ___ pt was found to be able to
maintain electrolytes in the normal range with PO intake and did
not require further IVF support.
#HTN: Patient had been on atenolol previously for HTN. However,
had not seen a doctor in ___ year so had no active Rx. VS were
monitored in the hospital and pt's BP ranged SBPs ~120-140. Did
not restart atenolol in the setting of ___.
# ___: Creatinine 2.9 on admission. ___ due to urinary retention
(postrenal etiology). With placement of foley and IVF, Cr
resolved to baseline of ~1.0.
# New bladder mass: Seen on CT Abd/Pelvis. Per urology, suspect
that this is likely chronic inflammation/thickening ___
irritation from large bladder stones. However, cannot rule out
malignancy. Urine cytology was sent which was negative but this
does not rule out a malignancy and sterile pyuria can be seen in
the setting of cancer. Patient will need surgery (to be setup as
outpt) to remove bladder stones at which point tissue biopsy
will be performed. Will ultimately be discharged with foley in
place.
# Mild transaminitis: Noted on admission. Unclear etiology. CT
indicated no obstruction or overt liver masses or nodules/
changes/ inflammation. Were not trended further. Can be
re-evaluated as an outpt if indicated.
# Elevated lipase: Noted on admission. Also of unclear etiology.
No clinical signs of pancreatitis. ___ have occurred in the
setting of ileus (see above).
# COPD: Patient carries an unclear diagnosis of COPD based on
review of outpatient records. No active issue during this
admission.
Transitional issues:
- ___ appointed by the court. The patient's brother ___
___ (brother, in ___: ___ (home) is the
___. The patient's nephem is also invloved in his care
___ (nephew, most involved with patient, lives in
___ ___ (home) and (___)
-___ MUST REMAIN IN PLACE while bladder stones are present as
pt will have recurrence of urinary retention. He will follow up
in ___ clinic to see about stones being removed.
-Bladder thickening concerning for malignancy vs chronic
inflammation/irritation
-Contact information:
___ (nephew, most involved with patient, lives in
___ ___ (home) and (___)
___ (brother, in ___: ___ (home)
-PCP is ___ ___
-Patient is full code as lacks capacity to make decision
regarding code status. If questions arise these should be
directed to the patient gaurdian: ___ (brother, in ___
___: ___ (home)
-Following anticoagulation for PE, consideration of aspirin for
anticoagulation should be considered
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 100 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
**NOTE: Patient had not seen a doctor for ___ years prior to this
admission so was not actually taking these medications**
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Multivitamins W/minerals 1 TAB PO DAILY
4. Polyethylene Glycol 17 g PO DAILY
5. Senna 1 TAB PO BID
6. Simethicone 40-80 mg PO QID:PRN gas pain
7. Benzonatate 100 mg PO TID:PRN cough
8. Dextromethorphan-Guaifenesin (Sugar Free) ___ mL PO Q6H:PRN
cough
9. Warfarin 5 mg PO DAILY16
Will be titrated to goal by checking INR
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Dementia
Urinary retention
Acute kidney injury
Bladder stones
Nephrogenic diabetes insipidus
Ileus
Pulmonary Embolism
Atrial Fibrilation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of ___ at ___. ___ were admitted
and found to have urinary retention. ___ have very large bladder
stones. We placed a foley catheter (a tube that drains the urine
from the bladder) and your symptoms improved. The catheter will
need to stay in place until ___ see the urologist. ___ may need
a surgery to remove the stones and to biopsy your bladder which
was noted to be thickened on CT scan.
While ___ were in the hosptial ___ were found to have a large
right sided pulmonary embolism. ___ were started on blood
thinners and ___ are at goal with your anticoagulation. ___ were
also noted to be in atrial fibrilation.
Additionally, ___ were unable to walk without assisstance. ___
need physical therapy at a rehab facility in order to regain
your strength.
Followup Instructions:
___
|
19913620-DS-5 | 19,913,620 | 28,109,286 | DS | 5 | 2178-05-29 00:00:00 | 2178-05-30 21:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
his is ___ yof with PMH of overactive bladder who presents with a
rash.
She reports that on ___ she was started on Bactrim SS
BID for a urinary tract infection. She also started fluconazole
for a yeast infection 3 days ___. On ___, she noticed
the onset of a rash on her wrists and inner thighs. She says the
lesions were red, small, and flat, and were not itchy or
painful. Over the subsequent 12 hours the rash spread over her
thighs to the lower legs and up the arms to the chest. 1 day
prior to admission on ___ she noticed the onset of "craters"
over her face which she described as bad acne. She said the
lesions were scabbed and her face was swollen. She also endorses
mild odynophagia and dysuria (was not present at the time of her
UTI diagnosis). She also reports some blurred vision and
photophobia when walking outside in the sun 3 days ago. She also
had a fever to ___ yesterday but currently afebrile. She denies
CP, SOB, abdominal pain, n/v/d, edema bruising or bleeding
She presented to her ___ PCP today for her symptoms
and was given IVF and tylenol, and referred to the ED for
further management.
In the ED, initial VS were 98.8 95 113/55 18 97% RA. Labs were
significant for leukopenia to 3.5 with 8.8% eos. Bicarb was low
at 21, but electrolytes, LFTs, and lactate were all normal. CXR
was no acute process. UA with 12 WBC and few bacteria. Urine
culture and blood cultures were pending. Urine Hcg was negative.
She was sent to the floor for concern of SJS.
On arrival to the floor, VS are 98.9 113/75 85 16 100%ra. The pt
is in no distress. She reports the above HPI. She still
complains of dysuria.
Past Medical History:
overactive bladder
Social History:
___
Family History:
-Maternal grandmother had ___ and ? sulfa allergy
-Paternal grandfather had 4 vessel CABG
-Paternal grandmother had a stroke
Physical Exam:
Admission Exam:
VS: 98.9 113/75 85 16 100%ra
GENERAL: well appearing female in NAD
HEENT: NC/AT, No mucosal lesions or erythema. PERRLA, EOMI,
sclerae anicteric, MMM, No lymphadednopathy
NECK: supple, no JVD
LUNGS: CTA bilat
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
SKIN: Erythematous blanching morbilliform papules throughout the
arms legs, chest, and back. No palm/sole involvement.
Per Derm resident exam: Labium minora and medial surface of the
majora with confluent red erosions
Discharge Exam:
Vitals- 98.4, Tm 99.2, 102/69, 81, 16, 97% RA
GENERAL: well appearing female in NAD
HEENT: NC/AT, No mucosal lesions or erythema. PERRLA, EOMI,
sclerae anicteric, MMM, No lymphadednopathy. No conjunctival
involvement.
NECK: supple, no JVD
LUNGS: CTA bilat, no w/r/r
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
SKIN: Erythematous blanching morbilliform papules throughout the
arms legs, chest, and back. No palm/sole involvement.
Per Derm resident exam: Labium minora and medial surface of the
majora with confluent red erosions
Pertinent Results:
Admission labs:
___ 06:00PM BLOOD WBC-3.5* RBC-3.79* Hgb-12.0 Hct-35.4*
MCV-93 MCH-31.6 MCHC-33.8 RDW-12.6 Plt ___
___ 06:00PM BLOOD Neuts-63.4 ___ Monos-2.7 Eos-8.8*
Baso-0.4
___ 06:40AM BLOOD ___ PTT-27.1 ___
___ 06:00PM BLOOD Glucose-104* UreaN-6 Creat-0.6 Na-135
K-3.8 Cl-104 HCO3-21* AnGap-14
___ 06:00PM BLOOD ALT-9 AST-16 AlkPhos-43 TotBili-0.1
___ 06:40AM BLOOD Calcium-8.6 Phos-3.5 Mg-1.8
___ 06:00PM BLOOD Albumin-3.7
___ 06:06PM BLOOD Lactate-0.8
___ 06:00PM URINE Color-Straw Appear-Clear Sp ___
___ 06:00PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 06:00PM URINE RBC-2 WBC-12* Bacteri-FEW Yeast-NONE
Epi-1
___ 06:00PM URINE Hours-RANDOM
___ 06:00PM URINE UCG-NEGATIVE
___ 06:00PM URINE Color-Straw Appear-Clear Sp ___
___ 06:00PM URINE Blood-SM Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 06:00PM URINE RBC-2 WBC-12* Bacteri-FEW Yeast-NONE
Epi-1
___ 06:00PM URINE Hours-RANDOM
___ 06:00PM URINE UCG-NEGATIVE
Pertinent Micro:
Blood cultures pending
Urine culture negative
Pertinent Imaging:
none
Discharge labs:
___ 06:40AM BLOOD WBC-1.3*# RBC-3.74* Hgb-11.9* Hct-35.2*
MCV-94 MCH-31.9 MCHC-33.8 RDW-12.7 Plt ___
___ 06:40AM BLOOD Neuts-36* Bands-0 Lymphs-49* Monos-12*
Eos-0 Baso-0 Atyps-3* ___ Myelos-0
___ 06:40AM BLOOD Glucose-160* UreaN-5* Creat-0.4 Na-138
K-3.9 Cl-105 HCO3-24 AnGap-13
___ 06:40AM BLOOD ALT-10 AST-16 AlkPhos-41 TotBili-0.1
Brief Hospital Course:
Ms. ___ is a ___ year old otherwise healthy female who was
seeing a urologist for symptoms of overactive bladder. She was
started on empiric treatment for UTI with bactrim and
subsequently developed a diffuse rash and fever. Her exam was
consistent with a morbilliform exanthematous drug eruption, with
the presence of painful vulvar erosions is concerning for early
SJS. Dermatology was consulted, who recommended 5 days of
prednisone 1mg/kg daily. Her lab results showed no signs of
DRESS. Rash and labs were monitored overnight with interval
improvement of her rash over 24 hrs. The pt was counseled on
avoiding bactrim, sulfa products, and NSAIDs.
On her labs, the pt showed pancytopenia, likely secondary to
bactrim. She should have her CBC with diff and LFTs checked on
___ prior to PCP ___.
Pt also complained of dysuria, which is likely due to mucosal
irritation of the urethra. Her urine culture was negative.
Lastly, pt was advised to stop all unnecessary medications,
including oxybutynin and fluconazole. Given that she has been
taking her OCP for several years without reaction, she was not
advised to stop this.
Transitional issues:
# follow up of pending blood cultures
# repeat CBC and CMP and f/u with PCP
# restart medications as deemed appropriate
# return to urologist for further eval of overactive bladder
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxybutynin 5 mg PO TID
2. Sulfameth/Trimethoprim SS 1 TAB PO BID
3. Ibuprofen 800 mg PO Q8H:PRN pain
4. YAZ 28 *NF* (drospirenone-ethinyl estradiol) ___ mg-mcg Oral
Daily
5. clotrimazole *NF* 1 % Vaginal BID
Discharge Medications:
1. YAZ 28 *NF* (drospirenone-ethinyl estradiol) ___ mg-mcg Oral
Daily
2. Desonide 0.05% Cream 1 Appl TP BID PRN vaginal/mucosal pain
RX *desonide 0.05 % apply a small amount topically to vaginal
mucosa irritation or pain Disp #*1 Tube Refills:*0
3. Dexamethasone Oral Soln (0.1mg/1mL) 5 mL ORAL BID
RX *dexamethasone 0.5 mg/5 mL 5 mL by mouth twice a day Disp #*1
Bottle Refills:*0
4. Phenazopyridine 200 mg PO TID:PRN dysuria Duration: 3 Days
RX *phenazopyridine 200 mg 1 tablet(s) by mouth three times
daily Disp #*9 Tablet Refills:*0
5. PredniSONE 70 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*3 Tablet
Refills:*0
6. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP BID-TID
7. Outpatient Lab Work
ICD-9: V14.2
Labs: CBC with diff, CMP
Provider: ___, ___
at phone number ___ (fax # not listed)
Discharge Disposition:
Home
Discharge Diagnosis:
Severe drug hypersensitivity reaction
Bactrim allergy
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 ___ for a severe rash. You were evaluated
by the dermatology team, who felt that this is most likely a
severe hypersensitivity reaction to Bactrim. You were prescribed
prednisone which you will need to take for a total of five days
(last day ___. For the rest of your life, you will need to
avoid the medication Bactrim or any other "sulfa" containing
drugs.
Use caution when taking medicines from the family "non-steroidal
anti-inflammatory drugs," as these are closely related to the
sulfa group. NSAIDs include aspirin, advil, motrin, ibuprofen,
naproxen, and aleve. The box will include NSAIDs as one of its
ingredients.
Once you leave the hospital, please have your labs rechecked
prior to seeing your PCP before the end of the week.
Lastly, we will follow up your urine culture results to be sure
of whether or not you have an infection. In the meantime, please
try pyridium for urinary pain relief. Use vaseline on the
vaginal area as needed for irritation. You may also use steroid
cream on your skin if you have itching.
If you have any worsening rash, fevers, flank pain,
nausea/vomiting, abdominal pain, or any other symptoms that
concern you, please call your PCP or return to the emergency
department.
We made the following changes to your medications:
STOP Bactrim (trimethoprim/sulfamethoxazole)
START prednisone for 3 more days
START Desonide 0.05% Cream vaginal pain
START Dexamethasone Oral Solution for throat pain
START pyridium (phenazopyridine) for urinary burning
START triamcinolone cream for skin itching
Followup Instructions:
___
|
19913645-DS-3 | 19,913,645 | 26,440,030 | DS | 3 | 2122-08-10 00:00:00 | 2122-08-11 13:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Lexapro
Attending: ___.
Chief Complaint:
Aspirin / Caffeine Overdose
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ woman with a past medical history of
depression, PTSD, eating disorder, with prior suicide attempts
and psychiatric hospitalizations, who presents to the ED after
taking 30 extra strength aspirin with caffeine. Patient states
that around 1 week ago she was sexually assaulted. She has been
working with her therapist and with her eating disorder clinic.
On ___, she went to ___ and bought "first painkiller I could
find". She states that she did not take these in an attempt to
commit suicide but rather to "feel nothing". She states she
took about 30 pills at 4:30 ___. Around 5 ___ she became
nauseous, developed ringing in her ears, she denies any chest
pain abdominal pain, vomiting, or diarrhea. She googled aspirin
overdose, and presented to the ED.
Of note, patient is actively in treatment for an eating
disorder. She is in a day program, which she attends every
morning 5 days a week.
In the ED, initial vitals: T 97.8, HR 91, BP 113/90, RR 18, 99%
RA
Labs were significant for normal CBC and electrolytes.
- ASA level 31.
Imaging was significant for:
- KUB with No radiopaque foreign body seen. Nonobstructive bowel
gas pattern.
- CXR with No acute cardiopulmonary process.
Poison control was contacted, recommending bolusing ___ amps of
bicarb with maintenance bicarbonate at 200 cc an hour following
with a goal serum pH of 7.45-7.55, . Recommended 50 mg of
activated charcoal. Recommended trending aspirin levels every 2
hours, with renal consult for dialysis of greater than 90 or for
pulmonary or cerebral edema.
In the ED, pt received
___ 19:50 PO/NG Charcoal Aqueous (Activated) 50 gm
___ 20:43 IV Sodium Bicarbonate 50 mEq
___ 21:21 IVF 150 mEq Sodium Bicarbonate/ D5W ( 1000 mL
ordered) 200 mL/hr
___ 21:39 PO Potassium Chloride 6 0 mEq
Vitals prior to transfer: T 97.9, HR on74, BP 106/65, RR 16, 99%
RA
Currently, patient states that her hearing still feels muffled.
She states that her balance is improved. She would like to know
when her ___ was activated, so that she can know when she
would be able to leave the hospital. She wonders if she will be
able to leave later today.
ROS: Positive as noted above. Negative for: No fevers, chills,
night sweats, or weight changes. No changes in vision or
hearing, no changes in balance. No cough, no shortness of
breath, no dyspnea on exertion. No chest pain or palpitations.
No nausea or vomiting. No diarrhea or constipation. No dysuria
or hematuria. No hematochezia, no melena. No numbness or
weakness, no focal deficits.
Past Medical History:
- major depressive disorder
- PTSD
- eating disorder
Social History:
___
Family History:
Reports dad and grandfather are alcoholics
Physical Exam:
ADMISSION EXAM:
VITALS: T 98.0, HR 102, BP 125/84, RR 20, 97% RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate. Reports
hearing less in left ear
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, reports diminished hearing in left ear,
otherwise CN ___ intact.
PSYCH: somewhat anxious affect
DISCHARGE EXAM:
24 HR Data (last updated ___ @ 741)
Temp: 98.4 (Tm 99.2), BP: 87/54 (87-112/54-70), HR: 63
(56-86), RR: 18 (___), O2 sat: 98% (98-99), O2 delivery: Ra
GEN - Alert, NAD
HEENT - NC/AT
CV - RRR, no m/r/g
RESP - CTA B
ABD - S/NT/ND, BS present
EXT - No ___ edema or calf tenderness
SKIN - Superficial skin injuries noted on the upper extremities
NEURO - Non-focal
PSYCH - Calm, appropriate
Pertinent Results:
ADMISSION LABS
___ 06:50PM BLOOD WBC-8.6 RBC-4.49 Hgb-12.9 Hct-38.5 MCV-86
MCH-28.7 MCHC-33.5 RDW-12.9 RDWSD-40.1 Plt ___
___ 06:50PM BLOOD Neuts-70.2 ___ Monos-7.6 Eos-0.3*
Baso-0.5 Im ___ AbsNeut-6.06 AbsLymp-1.80 AbsMono-0.66
AbsEos-0.03* AbsBaso-0.04
___ 06:50PM BLOOD ___ PTT-27.9 ___
___ 06:50PM BLOOD Glucose-117* UreaN-6 Creat-0.7 Na-140
K-3.9 Cl-101 HCO3-23 AnGap-16
___ 06:50PM BLOOD ALT-14 AST-22 AlkPhos-56 TotBili-<0.2
___ 06:50PM BLOOD Lipase-29
___ 06:50PM BLOOD Albumin-5.2 Calcium-9.7 Phos-2.6* Mg-2.0
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-5.9 RBC-3.86* Hgb-11.2 Hct-34.7
MCV-90 MCH-29.0 MCHC-32.3 RDW-13.3 RDWSD-43.5 Plt ___
___ 06:30AM BLOOD Glucose-77 UreaN-5* Creat-0.5 Na-141
K-4.4 Cl-106 HCO3-22 AnGap-13
OTHER PERTINENT LABS:
___ 06:50PM BLOOD ASA-31* Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 09:05PM BLOOD ASA-36* Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 11:31PM BLOOD ASA-41* Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 01:50AM BLOOD ASA-42* Acetmnp-NEG
___ 06:15AM BLOOD ASA-35*
___ 11:20AM BLOOD ASA-21
___ 03:10PM BLOOD ASA-13
___ 10:00PM BLOOD ASA-7
___ 07:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
CXR - IMPRESSION:
No acute cardiopulmonary process.
Air-fluid level is incidentally noted in the stomach without
definite
radiographic findings to suggest bezoar.
KUB - IMPRESSION:
No radiopaque foreign body seen. Nonobstructive bowel gas
pattern.
Brief Hospital Course:
___ y/o F with PMHx of depression, PTSD, eating disorder in
outpatient program, as well as prior suicide attempts and
psychiatric hospitalizations, who presented to the ED after
taking 30 ASA/caffeine tablets.
# ACUTE SALICYLATE AND CAFFEINE OVERDOSE
Poison control / tox involved. Per tox assessment, given
relatively normal K/glucose and lack of significant GI s/s,
tremor, or seizure, low concern about caffeine overdose. The
patient was given activated charcoal and bicarb in the ED. She
was started on bicarb fluids. Aspirin level initially uptrended
and then began to downtrend. Subsequent aspirin levels showed
ongoing downtrend after fluids were stopped.
# HYPOTENSION: Pt reports that her baseline BP generally runs
low. Given small body habitus, known eating disorder, and lack
of symptoms overnight, suspect that this is likely the case.
Orthostatics were negative.
# EATING DISORDER: Currently in active outpatient treatment.
# RECENT SEXUAL TRAUMA: Pt has been involved with rape crisis
intervention services.
# MDD: Not on any meds per report. Seen by psych consult service
here who recommended inpatient psych admission once discharged.
Medications on Admission:
No home medications.
Discharge Medications:
None.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Aspirin / Caffeine Overdose
Major Depressive Disorder
Post-Traumatic Stress Disorder
Eating Disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital after taking too many aspirin
pills at home. You were given charcoal as well as fluids. You
were monitored until your aspirin levels decreased.
You were also seen by the psychiatry team, who recommended an
admission to the inpatient psychiatry unit at this time.
Followup Instructions:
___
|
19913743-DS-6 | 19,913,743 | 20,807,239 | DS | 6 | 2131-03-18 00:00:00 | 2131-03-18 20:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine
Attending: ___
___ Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ yo F with PMH significant
for CAD (ostial RCA 90% occlusion managed medically), severe AS
s/p recent balloon valvuloplasty ___, and ___ stage
IV heart failure who presents with sudden onset worsening
shortness of breath and leg swelling. No cough or fever known.
She presents also with decreased mentation. Per patient daughter
she has a 2 day history of not feeling well with rhinorrhea,
shivering, and poor appetite. Then the evening prior to
admission pt started to experience shortness of breath. Of note
patient was hospitalized one week ago at ___ at
which time she was treated for pneumonia. Per report her dry
weight is 135 lbs.
In the ED initial VS were 99.2 94 100/74 34 100% on nebulizer.
Alert and oriented to name only, thinks it's ___ and thinks she
is a dentist office. CXR concerning for pulmonary edema without
infiltrate, but had temp to 102 in ED so was given a dose of
cefepime, vancomycin and levofloxacin for possible PNA however
no cough. Also with concern for COPD exacerbation, although no
hx of COPD so given solumedrol 125mg and nebs in ED. BNP was
12,488 (baseline of 1200 in ___ and given CXR findings,
patient was also treated with lasix 20 mg IV (on 20 mg PO) at
home. Cardiology consulted in ED, symptoms thought to be ___
CHF exacerbation and recommended diuresis. Pt also started on
nitroglycerin gtt and BiPAP in ED. VS on transfer hr 92, rr 24,
98% on BiPAP, 127/50, nitro at 0.14 mcg/kg/min.
On arrival to the MICU, pt is awake alert in no acute distress.
On nitro gtt at 0.14 mcg/kg/min.
REVIEW OF SYSTEMS:
(+) Per HPI, rhinorrhea, SOB
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, or congestion. Denies
cough, or wheezing. Denies chest pain, chest pressure,
palpitations, or weakness. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Denies rashes or skin changes.
Past Medical History:
Hypertension
Aortic stenosis, diagnosed on last hospitalization in ___, s/p
balloon valvuloplasty ___
Hypothyroidism
Osteoporosis
s/p appendectomy at age ___
s/p lysis of adhesions
s/p small bowel ischemia and ileal resection
CHF EF 50-55% on Echo ___
h/o GASTROINTESTINAL BLEEDING
TIA ___ years ago
TRICUSPID STENOSIS
Social History:
___
Family History:
Mother -- died at age ___ of pancreatic cancer
Father -- died of stroke
Physical Exam:
Vitals: T:97.6 BP:142/56 P:95 R:20 18 O2:97% on 2L wt: 133.1
General: Alert, oriented x1, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
loudest at RUSB
Lungs: Clear to auscultation bilaterally, no wheezes, ronchi,
faint crackles in bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, ___ lower extremity edema
no clubbing or cyanosis
Neuro: Oriented x1, thinks it ___ and she is at her daughter
house, knows the president, CNII-XII intact, ___ strength
upper/lower extremities, grossly normal sensation
Discharge Exam:
General: Alert, oriented x1, no acute distress
HEENT: Sclera anicteric, dry MM, oropharynx clear, EOMI, PERRL
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
loudest at RUSB
Lungs: Clear to auscultation bilaterally, no wheezes, ronchi,
faint crackles in bases
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: foley
Ext: warm, well perfused, 2+ pulses, ___ lower extremity edema
no clubbing or cyanosis
Neuro: Oriented x1, thinks it ___ and she is at her daughter
house, knows the president, CNII-XII intact, ___ strength
upper/lower extremities, grossly normal sensation
Pertinent Results:
ADMISSION
___ 07:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 07:00PM URINE RBC-2 WBC-5 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:00PM URINE HYALINE-3*
___ 07:00PM URINE MUCOUS-FEW
___ 06:20PM GLUCOSE-116* UREA N-13 CREAT-0.6 SODIUM-137
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-19* ANION GAP-22*
___ 06:20PM estGFR-Using this
___ 06:20PM ALT(SGPT)-26 AST(SGOT)-41* ALK PHOS-206* TOT
BILI-2.1*
___ 06:20PM LIPASE-9
___ 06:20PM ___
___ 06:20PM ALBUMIN-3.9
___ 06:20PM COMMENTS-GREEN
___ 06:20PM LACTATE-3.5*
___ 06:20PM WBC-9.8 RBC-5.31 HGB-14.0 HCT-44.7 MCV-84
MCH-26.3* MCHC-31.3 RDW-18.5*
___ 06:20PM NEUTS-81.2* LYMPHS-11.8* MONOS-6.3 EOS-0.4
BASOS-0.4
___ 06:20PM PLT COUNT-277#
DISCHARGE
CXR (___) : Mild pulmonary vascular congestion without
consolidation.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Ms. ___ is an ___ yo F with PMH significant for CAD, severe
AS s/p recent balloon valvuloplasty, and NYHA class IV heart
failure who presented with fever, worsening shortness of breath
and leg swelling, found to have influenza and acute on chronic
systolic CHF with exacerbation
ACTIVE ISSUES:
# Influenza A: She presented with fever and SOB and her
influenza swab was positive for influenza A. She was treated
with a 5 day course of oseltamivir, which was completed in the
hospital.
# Acute on chronic systolic CHF exacerbation: She had an
elevated BNP and felt to have an elevated intravascular volume
on presentation. It was felt she had a CHF exacerbation, likely
triggered by influenza. She required Bipap while in the medical
ICU but was eventually transitioned to room air. She was
diuresed with IV lasix initially, and then transitioned to lasix
20mg po daily. She was seen by the cardiology consult service
while in the hospital. She was also continued on albuterol
nebulizer therapy and her home metoprolol.
# Anion gap metabolic acidosis: Present on admission. Likely
due to lactic acidosis and perhaps ketoacidosis due to poor oral
intake.
# Elevated LFTs: Appears to have chronic indirect
hyperbilirubinemia and elevated alkaline phosphatase. This
should be followed up as an outpatient.
# Hypertension: She was continued on metoprolol succinate 50 mg
daily.
# GERD: She was continued pantoprazole 20 mg daily.
# Hypothyroidism: She was continued levothyroxine 137 mcg daily.
Should have TSH checked after discharge.
# CAD: H/o ostial RCA 90% occlusion managed medically. She was
continued on aspirin 81mg daily and beta blocker.
# Encephalopathy: She was persistently confused during this
admission, and typically oriented x 1 (only to self). Per her
daughter, her mental status has worsened significantly since her
recent valvuloplasty. She likely had acute encephalopathy as
well due to influenza and CHF exacerbation. She was discharged
home with 24 hour care with home ___ and OT. Would recommend
that PCP check TSH after acute illness resolves.
TRANSITIONAL ISSUES:
- Would recommend outpatient workup for reversible causes of
cognitive impairment (especially TSH)
- Should have daily weights and monitor fluid status closely.
She may not need daily lasix indefinitely as she appeared
euvolemic at the time of discharge. Should also have creatinine
checked at PCP ___ since she is now on daily lasix.
- Code status: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO TID
4. Levothyroxine Sodium 137 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Furosemide 20 mg PO PRN weight gain 3 lbs
7. NexIUM *NF* (esomeprazole magnesium) 20 mg ORAL DAILY
8. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dyspnea
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO TID
4. Furosemide 20 mg PO DAILY
5. Levothyroxine Sodium 137 mcg PO DAILY
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. NexIUM *NF* (esomeprazole magnesium) 20 mg ORAL DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnoses:
Influenza A pneumonia
Acute systolic CHF exacerbation
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 to the hospital with difficulty breathing and
fever due to influenza and an episode of heart failure. You
completed a course of Tamiflu for influenza and your breathing
improved. You were also seen by the cardiology service and
given diuretics for volume overload for an exacerbation of your
heart failure.
You should weigh yourself daily and call your physician if your
weight goes up by more than 3 pounds.
Followup Instructions:
___
|
19914232-DS-14 | 19,914,232 | 23,287,814 | DS | 14 | 2164-03-28 00:00:00 | 2164-03-28 15:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness/lightheadedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ male with a past medical history of
CAD s/p remote CABG and HTN, who presented with cough and
dizziness/lightheadedness.
He recently traveled to ___ and returned on ___. The
___ after ___ he developed a GI illness with
diarrhea and vomiting. His wife and great-grandson also had
similar symptoms at the time. He was seen in ___ urgent care.
These symptoms resolved but he eventually started developing a
cough and intractable hiccups. The cough is productive of yellow
sputum. He reports some rhinorrhea but no other URI symptoms. He
has also been very tired and has experienced subjective fevers
and chills. In addition, he has some associated chest tightness
and shortness of breath. This is very unusual for him since he
exercises regularly without any dyspnea or respiratory
complaints.
He had not had any abdominal pain, dysuria, blood on his stool,
or any other complaints.
He was seen again at ___ and prescribed thorazine for hiccups
which has been helping somewhat. However, he eventually
presented to the ___ on ___ for this complaint. He was diagnosed
with a pneumonia and discharged on azithromycin. However, his
symptoms continued to worsen at home and he became progressively
weaker. He has also had very poor PO intake at home. He stood up
and almost collapsed but was caught by a family member.
In the ___ he was hypotensive to 78/49. He had later episodes of
hypotension to 81/43 and 81/47. He eventually received 4L of IV
fluids with improvement in blood pressure. CTA revealed patchy
ground glass opacities and he received CTX and azithromycin for
presumed pneumonia.
On the floor, he feels well at the moment but is still reporting
persistent cough, shortness of breath, and chest discomfort.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- CAD s/p MI and CABG (___)
- HTN
- CKD III
- DM II
- HLD
- Gout
- BPH
- Cataract
- Tremor
Social History:
___
Family History:
Reviewed and found to be not relevant to this illness/reason for
hospitalization.
Physical Exam:
ADMISSION EXAM
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Rales at bilateral bases, R ? L. Crackles also present
over R mid lung
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VITALS: afebrile, VSS
GEN: alert, NAD
CV: regular rate & rhythm
RESP: lungs clear to auscultation bilaterally
GI: abd soft, nd, nt
EXT no clubbing or edema
NEURO: grossly intact w/o focal deficits
PSYCH: normal affect & mentation
Pertinent Results:
___ 06:12AM BLOOD WBC-11.5* RBC-3.32* Hgb-8.7* Hct-25.6*
MCV-77* MCH-26.2 MCHC-34.0 RDW-15.2 RDWSD-42.3 Plt ___
___ 06:12AM BLOOD ___
___ 06:12AM BLOOD Glucose-134* UreaN-6 Creat-1.3* Na-138
K-3.8 Cl-98 HCO3-23 AnGap-17
___ 01:05PM BLOOD CK(CPK)-865*
___ 07:10AM BLOOD CK(CPK)-744*
___ 06:12AM BLOOD CK(CPK)-516*
___ 03:19AM BLOOD ALT-21 AST-22 LD(LDH)-153 AlkPhos-46
TotBili-1.0
___ 03:19AM BLOOD cTropnT-<0.01 proBNP-258
___ 06:10AM BLOOD calTIBC-185* Hapto-396* Ferritn-277
TRF-142*
___ 01:05PM BLOOD RheuFac-14 ___ CRP-267*
___ 01:05PM BLOOD ALDOLASE-Test
___ 01:05PM BLOOD SED RATE-Test Name
___ 07:10AM BLOOD ANTI-JO1 ANTIBODY-Test
___ 07:10AM BLOOD CYCLIC CITRULLINATED PEPTIDE (CCP)
ANTIBODY, IGG-Test
___ 07:10AM BLOOD RNP ANTIBODY-Test
Brief Hospital Course:
___ with CAD s/p remote CABG, HTN, CKD, gout, recent diagnosis
of
pneumonia in context of GI illness with hiccups (discharged on
Thorazine and Azithromycin) who presented with cough and
dizziness/lightheadedness, found to have hypotension and chest
CT
with GGOs and background fibrotic changes, and admitted for
treatment for pneumonia with broad spectrum antibiotics. After
some possible initial improvement, he has since had daily high
fever with intermittent rest hypoxia and persistent ambulatory
hypoxia.
# Community acquired pneumonia, appears atypical. Patient and
wife did travel to ___ for several months and came back ___. In transit back, wife reported that they had to go through
several screening process where they were in very close quarters
with hundred of other people for hours.
# Sepsis (subjective fever, tachycardia, bandemia)
# Scant hemoptysis: Reported cough and fevers at home, obviously
observed here as well. CTA with ground glass opacities read as
pulmonary edema vs. infection, but more likely infection given
normal BNP and infectious symptoms. Also with mediastinal and
hilar lymphadenopathy along with fibrotic changes suggestive of
chronic lung disease. After initial improvement, now having
continued cough and high fever with intermittent rest hypoxia
and
persistent ambulatory hypoxia. Pulmonary felt he most likely has
acute pneumonia superimposed on chronic lung disease like ILD,
but cannot rule out ILD flare.
# Elevated ESR/CRP, ?etiology. Possibly related to pulmonary
process
# Elevated CK
- Pulmonary consulted
- follow up with remainder results of serology, including
myositis panel
- ST consulted - no signs of overt aspiration
- maintained on zosyn/azithro (___) goal ___ day course
- maintained on duonebs, IS for pulmonary toileting
- monitored CK
# Hiccups: Seemingly resolved. Possible nerve irritation
secondary to infectious process, but perhaps most likely related
to gastroesophageal irritation in setting of recent GI illness
that manifest with N/V.
- STOPPED Thorazine
- Continue PPI daily for (at least) ___nemia: Hct downtrending in setting of IVF.
- Send anemia workup
- Trend CBC
# Hypertension: Stable.
- Hold home atenolol, lisinopril due to hypotension (consider
permanent discontinuation of atenolol given his CKD)
# CAD s/p CABG: Stable.
- Continue home ASA 325mg
- Hold Rosuvastatin given CK
- Hold home Imdur
# DM: Stable.
- Hold home glimepiride while hospitalized
- Continue ISS
# CKD: Creatinine at baseline of 1.5-1.7
- Continue to monitor
- Renally dose meds, avoid nephrotoxins
# Chest pain: Resolved day after admission. Likely secondary to
cough and pneumonia. EKG without evolution. Trop negative x2.
PPX: Heparin
Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ChlorproMAZINE 25 mg PO QID:PRN hiccups
2. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Lisinopril 5 mg PO DAILY
5. glimepiride 2 mg oral DAILY
6. Colchicine 0.6 mg PO BID:PRN pain
7. Rosuvastatin Calcium 40 mg PO QPM
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
9. Multivitamins 1 TAB PO DAILY
10. Aspirin 325 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Community acquired pneumonia,
# Sepsis (subjective fever, tachycardia, bandemia)
# Scant hemoptysis. Possible underlying ILD
# Elevated ESR/CRP, ?etiology. Suspected relating to pulmonary
process
# Elevated CK
# Hiccups
# Anemia of chronic disease
# Hypertension
# CAD s/p CABG
# DM2
# CKD III
# non-cardiac chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with atypical community acquired pneumonia
along with a suspected underlying chronic lung disease.
Pulmonology was consulted. Workups are still pending. But with
improvement on antibiotics, you are being discharge home to
finish therapy and further outpatient follow ups.
Followup Instructions:
___
|
Subsets and Splits