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19914314-DS-9 | 19,914,314 | 23,447,403 | DS | 9 | 2176-07-23 00:00:00 | 2176-07-25 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
nitrofurantoin
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Left Cardiac Catheterization and bare metal stent placement to
left circumflex on ___
History of Present Illness:
___ h/o of significant GIB ___ years ago at ___, HTN,
breast cancer s/p mastectomy and tamoxifen, recent BI admission
for V5-v6 STEMI (during which pt declined cath), who presents
with recurrent nausea and chest pain.
Ms. ___ was admitted ___ to ___ for one week of
intermittent chest pain, found to have STEs in V5-V6 and
troponin elevation. The patient declined cath and was treated
with aspirin, sublingual nitro with resolution of chest pain.
TTE showed severe aortic stenosis, EF 50-55%, focal mild
hypokinesis of the lateral wall. She declined further discussion
of aortic valve replacement while inpatient, preferring to
discuss further as outpatient.
Upon discharge home, she reports that she initially was feeling
well. She had no CP or SOB. However, on the day of readmission
she awoke with nausea, and then developed chest pain similar to
her prior episodes of chest pain, prompting her to return to
___.
In the ED she was found to have ST elevations of V5, V6, with ST
depressions in III, AVR, V1, V2. She was taken to the cath lab
where she was found to have complete occlusion of the first OM.
Bare metal stent was placed, and she was started on Plavix. All
other coronaries were normal.
On the floor, patient reports that her chest pain has resolved.
She denies any shortness of breath and is breathing comfortably
on room air.
Past Medical History:
PAST MEDICAL HISTORY:
1. Arthritis: Knees.
2. Breast cancer: Right,Stage 2 ->MRM -> tamoxifen ___ years
3. Hypertension.
4. Irritable bowel.
5. Diverticulits and h/o hemorrhoids
6. Macular degeneration.
7. Vertigo.
8. Gallstones.
9. Polymyalgia rheumatica.
10. s/p upper GI bleed (Dieulafoy's lesion) in ___
11. ___ syndrome
PAST SURGICAL HISTORY
1. Mastectomy.
2. Cataract extraction bilateral.
3. Fibula fracture
Social History:
___
Family History:
Mother ___ ___ CORONARY ARTERY DISEASE, DEGENERATIVE JOINT
DISEASE
Father ___ ___ PULMONARY EMBOLISM
Sister ___ RENAL DISEASE
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T 97.4 HR 68 BP 95/46 97% on RA
Tele: NSR
Gen: alert, well appearing, looks younger than stated age
HEENT: EOM intact, perrl, MMM
NECK: JVP not elevated
CV: loud ___ midpeaking systolic murmur loudest at LUSB,
audible s2
LUNGS: CTAB
GROIN: no hematoma, no bruit, +femoral pulse
ABD: soft, nontender, nondistended
EXT: wwp no edema, +DP and ___ pulses
SKIN: no rash
NEURO: a/o x3, moving all extremities
DISCHARGE PHYSICAL EXAM:
=========================
vitals: 98.1 110/47 82 21 96%RA
Tele: NSR
Gen: alert, well appearing, looks younger than stated age
HEENT: EOM intact, perrl, MMM
NECK: JVP not elevated
CV: loud ___ midpeaking systolic murmur loudest at LUSB,
audible s2
LUNGS: CTAB
GROIN: no hematoma, no bruit, +femoral pulse
ABD: soft, nontender, nondistended
EXT: wwp no edema, +DP and ___ pulses
SKIN: no rash
NEURO: a/o x3, moving all extremities
Pertinent Results:
Admission Labs:
===============
___ 09:00PM BLOOD WBC-10.5* RBC-3.49* Hgb-9.5* Hct-31.3*
MCV-90 MCH-27.2 MCHC-30.4* RDW-14.3 RDWSD-46.3 Plt ___
___ 02:43AM BLOOD ___ PTT-27.9 ___
___ 09:00PM BLOOD Glucose-129* UreaN-18 Creat-1.1 Na-132*
K-4.9 Cl-97 HCO3-23 AnGap-17
___ 09:00PM BLOOD ALT-19 AST-32 CK(CPK)-100 AlkPhos-165*
TotBili-1.0
___ 02:43AM BLOOD Calcium-8.8 Phos-3.7 Mg-1.6
Troponin Trend:
===============
___ 09:00PM BLOOD cTropnT-0.04*
___ 02:43AM BLOOD CK-MB-28* cTropnT-0.48*
___ 08:00AM BLOOD CK-MB-6 cTropnT-0.54*
Micro:
======
Urine ___: No growth
Imaging:
========
+ TTE (___): The left atrium is mildly dilated. There is
moderate symmetric left ventricular hypertrophy. The left
ventricular cavity size is normal. There is mild regional left
ventricular systolic dysfunction with focal mild hypokinesis of
the lateral wall. Overall left ventricular systolic function is
low normal (LVEF 50-55%). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
number of aortic valve leaflets cannot be determined. The aortic
valve leaflets are severely thickened/deformed. There is severe
aortic valve stenosis (valve area <1.0cm2). No aortic
regurgitation is seen. The mitral valve leaflets are moderately
thickened. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. [Due to acoustic shadowing, the severity
of mitral regurgitation may be significantly UNDERestimated.]
The left ventricular inflow pattern suggests impaired
relaxation. There is moderate pulmonary artery systolic
hypertension. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Moderate symmetric left
ventricular hypertrophy with mild regional systolic dysfunction.
Severe aortic stenosis. At least mild mitral regurgitation.
Pulmonary hypertension.
+ CARDIAC CATH (___): complete occlusion of LCx first
marginal artery s/p BMS
TTE ___:
The left atrium is elongated. Left ventricular wall thicknesses
and cavity size are normal. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. There is mild regional left ventricular systolic
dysfunction with hypokinesis of the basal-distal lateral wall.
The remaining segments contract normally (LVEF = 50-55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The number of aortic valve
leaflets cannot be determined. The aortic valve leaflets are
severely thickened/deformed. Significant aortic stenosis is
present (not quantified due to the presence of a mild resting
outflow tract gradient). Trace aortic regurgitation is seen. The
mitral valve leaflets are moderately thickened. There is no
mitral valve prolapse. Trivial mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The left ventricular
inflow pattern suggests impaired relaxation. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
regional and global biventricular systolic function are similar.
Aortic valve area could not be quantified as indicated above.
Other findings are similar.
CXR ___:
Heart size and mediastinum are stable. Lungs are essentially
clear. Small amount of left pleural effusion is present. Left
minimal basal atelectasis is noted but improved as compared to
the prior study. Overall no new consolidations to suggest
infectious process noted.
Discharge Labs:
================
___ 08:00AM BLOOD WBC-8.1 RBC-3.17* Hgb-8.6* Hct-28.5*
MCV-90 MCH-27.1 MCHC-30.2* RDW-14.6 RDWSD-47.2* Plt ___
___ 08:00AM BLOOD ___ PTT-27.4 ___
___ 08:00AM BLOOD Glucose-91 UreaN-15 Creat-1.0 Na-139
K-4.8 Cl-104 HCO3-23 AnGap-17
___ 08:00AM BLOOD Calcium-9.2 Phos-3.6 Mg-1.5*
Brief Hospital Course:
___ h/o of significant GIB ___ years ago at ___, HTN,
breast cancer s/p mastectomy and tamoxifen, recent BI admission
for V5-v6 STEMI (during which pt declined cath), who presented
with recurrent nausea and chest pain found to have ST elevations
of V5, V6, with ST depressions in III, AVR, V1, V2. She was
taken to the cath lab where she was found to have complete
occlusion of the first OM s/p bare metal stent.
#) ACUTE CORONARY SYNDROME: The patient presented with recurrent
chest pain and nausea found to have ST elevations in V5-V6 and
ST depressions in III, AVR, V1, and V2. The patient was amenable
to catheterization during this admission where she was found to
have complete occlusion of ___ s/p bare metal stent. All other
coronaries were clean. Following the procedure, the patient's
chest pain and EKG changes resolved. TTE on ___ showed LVEF
50-55% with hypokinesis of the basal-distal lateral wall
consistent with TTE on ___. She was started on Plavix 75mg
daily and continued on her home Aspirin 81mg and statin. Her
metoprolol was down-titrated to 12.5mg daily in the setting of
low blood pressures. Plan to follow-up as an ___ to
adjust her metoprolol dose and determine if an ___ needed
(not started given low BPs). Repeat TTE in ___
#) Severe aortic stenosis: TTE ___ showed severe aortic
stenosis with valve area 0.9, peak velocity 4.0 m/sec, peak
gradient 65 mm hg, mean gradient of 40mmHg and LVEF 50-55%.
After extensive conversation with the patient during her
previous and current admission, she declined further evaluation
for TAVR or SAVR.
#)History of GIB: The patient has a history of GIB in ___
Dieulafoy's lesion treated at ___. Required MICU stay and
intubation, however, no bleeding episodes since then. She was
continued on her home protonix and her CBC remained stable. The
patient experienced bleeding from her hemorrhoids for which we
recommended stool softeners, high fiber diet, and hemorrhoid
creams for symptomatic management with plans to follow-up with
her PCP as an ___.
#) Hypotension: The patient was mildly hypotensive with SBPs ___
on admission. Her home spironolactone was held and her
Metoprolol was decreased to 12.5mg daily. She was not started on
an ACE-inhibitor during this admission given her soft BPs. Plan
to follow-up with ___ cardiologist for further
medication adjustments as needed.
CHRONIC ISSUES:
================
#) Hypertension: Patient mainly hypotensive on admission.
Discontinued home Spironolactone and decreased metoprolol dose
as above. Continue to monitor as an ___.
#) Vertigo: Continued on home meclizine.
#) Arthritis: Managed w/Tylenol prn.
TRANSITIONAL ISSUES:
[]CODE STATUS: DNR/DNI
[]Patient will need dual antiplatelet therapy (ASA 81 mg PO
QDaily and Clopidogrel (Plavix) 75 mg PO QDaily) x1 month (end
date ___
[]Home Spironolactone 25 mg PO QDaily held and Metoprolol
Succinate was decreased to 12.5 mg PO QDaily for hypotension,
will need to be modified as outpatient
[]Will encourage to followup with PCP regarding hemorrhoids:
recommend hemorrhoid cream and high fiber diet, may need
colorectal surgery evaluation if patient continues to have
symptoms. Monitor H/H upon discharge.
[]Patient will need repeat TTE in ___ months
[]Patient will have PCP and ___ followup at ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Meclizine 25 mg PO TID
3. Mirtazapine 7.5 mg PO QHS
4. Ondansetron 4 mg PO Q8H:PRN nausea
5. Pantoprazole 40 mg PO Q12H
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 80 mg PO QPM
8. Artificial Tears Preserv. Free ___ DROP BOTH EYES ONCE
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Meclizine 25 mg PO TID
5. Metoprolol Succinate XL 12.5 mg PO DAILY
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
6. Mirtazapine 7.5 mg PO QHS
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. Pantoprazole 40 mg PO Q12H
9. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
10. Artificial Tears Preserv. Free ___ DROP BOTH EYES ONCE
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Coronary Artery Disease
ST Elevation Myocardial Infarction
Severe Aortic Stenosis
SECONDARY:
Hypertension
Hemorrhoids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure participating in your care while you were
inpatient at ___. You came back to us after you had another
episode of chest pain and suffered a second heart attack. You
had a stent placed to open up a blockage in the vessels of your
heart; this blockage was the cause of your heart attack. You did
very well afterwards and are being discharged to home with
visiting nursing services.
You will have a few new medications that must be taken every
day. These are shown below, but include aspirin and plavix.
Best Wishes,
Your ___ Team
Followup Instructions:
___
|
19914512-DS-6 | 19,914,512 | 29,040,656 | DS | 6 | 2187-06-10 00:00:00 | 2187-06-11 19:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right abdominal and flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of nephrolithiasis
who presents with right upper quadrant/right flank pain x4
hours. He states that he was at work and felt the sudden onset
of pain. He endorsed associated sweating, as well as an episode
of vomiting after which his pain improved. However, the pain
returned about an hour later. He had 3 episodes of emesis,
nonbilious/nonbloody. Endorses current nausea, denies
fevers/chills, chest pain, blood in his urine, additional
symptoms.
In the ED initial vitals: 97.0 63 149/87 18 99%. Laboratory
analysis revealed WBC 12.1 Hct 37.6 Plt 225. Chemistry notable
for K 6.4 (4.5 on repeat), Creatinine 1.4 (baseline unknown).
AST 60, AP 27. UA notable for large blood, 83 RBCs, negative
leuk esterase, negative nitrites. CT A/P revealed "1. There is a
3 mm stone in the distal right ureter at the pelvic rim with
upstream mild hydroureteronephrosis and right perinephric
stranding. 2. Fatty liver
3. Chronic appearing 9mm splenic artery aneurysm." He was given
Ativan 1 mg x2, Reglan 10 mg x1, ketorolac x1, tamsulosin x1,
Zofran 4 mg IV x2, 3L NS, Morphine 5 mg IV x1. Given persistent
pain and nausea as well as inability to tolerate PO, he is being
admitted to medicine.
On the floor, afebrile, BP 113/52, HR 77. Currently ___ pain.
Feels pain in right upper quadrant with some radiation to the
back. Having some chills. One week ago he had some milder right
upper abdominal pain and thought he had a stone. He drank a lot
of water and passed a stone. Last episode of kidney stone was ___
years ago. Has been told that he has calcium stones. He was
started on multivitamins and B complex vitamins 2 months ago,
but discontinued them on his own.
Past Medical History:
Nephrolithiasis
High blood pressure
hyperlipidemia
Depression
GERD
Social History:
___
Family History:
Mother has history of kidney stones. Brother has kidney stones.
Physical Exam:
ON ADMISSION:
VS: 98, BP 113/52, HR 77, 98% RA
General: Alert, oriented, diaphoretic, visibly uncomfortable
HEENT: Pupils constricted, Sclera anicteric, MMM, mild
fasiculations of his tongue
Neck: supple, 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
Abdomen: soft, tender in right upper quadrant, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
Back: right CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes, lesions
Neuro: no focal neurologic deficits, ___ strength, gait
deferred
ON DISCHARGE:
Vitals: T:98.3 BP: 96/50 P: 61 R: 20 O2: 97% RA
General: Alert, oriented, no acute distress
HEENT: Pupils constricted, Sclera anicteric, MMM
Neck: supple, 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
Abdomen: soft, tender in right upper quadrant, non-distended,
loud bowel sounds present, abdominal bruit, no rebound
tenderness or guarding, no organomegaly
Back: minimal right CVA tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes, lesions
Neuro: no focal neurologic deficits, ___ strength, gait
deferred
Pertinent Results:
ON ADMISSION:
___ 05:48AM WBC-12.1* RBC-4.36* HGB-13.0* HCT-37.6*
MCV-86 MCH-29.8 MCHC-34.5 RDW-13.5
___ 05:48AM NEUTS-81.2* LYMPHS-12.7* MONOS-3.3 EOS-2.4
BASOS-0.4
___ 05:48AM GLUCOSE-132* UREA N-26* CREAT-1.4* SODIUM-139
POTASSIUM-6.4* CHLORIDE-105 TOTAL CO2-26 ANION GAP-14
___ 05:48AM ALT(SGPT)-19 AST(SGOT)-60* ALK PHOS-27* TOT
BILI-0.3
___ 05:48AM LIPASE-39
___ 05:48AM ALBUMIN-4.6
___ 05:24AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:24AM URINE RBC-83* WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
ON DISCHARGE:
___ 06:30AM BLOOD WBC-7.1 RBC-3.71* Hgb-11.1* Hct-31.7*
MCV-86 MCH-30.0 MCHC-35.1* RDW-13.7 Plt ___
___ 06:30AM BLOOD Glucose-101* UreaN-22* Creat-1.5* Na-140
K-4.2 Cl-110* HCO3-24 AnGap-10
___ 06:30AM BLOOD Calcium-8.5 Phos-2.5* Mg-1.9
STUDIES:
CT abdomen ___: prelim read
1. There is an obstructing 3 mm stone in the distal right ureter
at the pelvic brim with upstream mild hydroureteronephrosis and
right perinephric stranding.
2. Hepatic steatosis.
3. Chronic appearing 9mm splenic artery aneurysm.
EKG: normal sinus rhythm, normal axis, normal intervals, QTc
421, no ST changes, T wave inversions.
Brief Hospital Course:
___ presenting with right upper quadrant and flank pain, found
to have nephrolithiasis. CT showed 3mm stone in the distal
ureter with mild hyproureteralnephrosis. UA showed blood, but no
evidence of urinary infection. Although there was mild right
perinephric stranding, the patient remained afebrile and
hemodynamically stable with WBC improved without antibiotics to
suggest concominent infection. Cr 1.4-1.5 during this admission,
which is within his recent baseline (1.4). Pain was initially
controlled with IV Toradol and morphine. When the patient was
able to tolerate PO medications and diet, pain regimen was
transitioned to ibuprofen 800mg q8h PRN nad oxycodone 5mg q4h
PRN breakthrough pain. Patient advised to strain urine and
collect stone for stone analysis. He was advised to call PCP
___ return to ___ ED if develops fever.
CHRONIC ISSUES
# Hypertension: hold atenolol inpatient and at time of
discharge.
# Hyperlipidemia: held fenofibrate and restarted once Cr stable
# Depression: continue sertraline 25mg qHS
====================================
TRANSITIONAL ISSUES
====================================
MEDICATIONS
- STARTED Tamsulosin x 7 days or until stone passes
- STARTED ibuprofen 800mg Q8H PRN and oxycodone 5mg Q4H PRN for
pain. High dose ibuprofen to be taken with PPI. Also provided
Zofran PRN for nausea.
- HELD atenolol in the setting of ___ and normal blood
pressure while on tamsulosin
___
- Patient advised aggressive oral hydration.
- Patient advised to strain urine and collect stone for analysis
- PCP ___ scheduled for ___
- Transitional issue: noted to have 9mm chronic splenic aneurysm
on CT abdomen.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atenolol 50 mg PO DAILY
2. fenofibrate 200 oral daily
3. Sertraline 25 mg PO QHS
4. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Sertraline 25 mg PO QHS
2. Omeprazole 20 mg PO DAILY
3. fenofibrate 200 oral daily
4. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #*8
Capsule Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth Every 4 hours as needed
for pain Disp #*12 Tablet Refills:*0
6. Ibuprofen 800 mg PO Q8H:PRN pain
RX *ibuprofen 800 mg 1 tablet(s) by mouth Every 8 hours as
needed for pain Disp #*9 Tablet Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth as needed for nausea
Disp #*9 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Nephrolithiasis
SECONDARY
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during this
hospitalization. You were admitted to ___
___ for a kidney stone. You had significant pain,
nausea, and vomiting in the emergency room, so you were
admitted. The day after you were admitted, you were able to
tolerate food so you were sent home with oral pain medications.
It is VERY important that you drink lots of fluids. Please
strain your urine and try to collect your kidney stone so you
can take it to your primaryc are doctor for analysis.
If you develop a fever, please call your PCP or come to the ED.
Best of luck in your future health,
Your ___ Team
Followup Instructions:
___
|
19914556-DS-24 | 19,914,556 | 21,171,044 | DS | 24 | 2191-01-18 00:00:00 | 2191-01-23 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
transfer from OSH, intubated for status epilepticus
Major Surgical or Invasive Procedure:
Intubation. Mechanical ventilation.
History of Present Illness:
The pt is a ___ man with a history of seizure disorder
who presents as a transfer from ___ for prolonged
seizure
activity. He reportedly presented to ___ tonight after
seizing for an hour at home. His wife had given him 3mg ativan
PO
without improvement. She then called EMS and he received an
additional 2mg ativan IO en route. Upon arrival to ___ he
was
continuing to have reportedly generalized tonic/clonic movements
and received an additional 2mg IV ativan. This seemed to help
somewhat, although he continued to have some rhythmic eye
movements so he was then given an additional 2mg IV ativan as
well as 1g Keppra. The abnormal movements stopped but he
remained
altered and there was concern he was obstructing his airway and
retaining CO2. He was therefore intubated and started on
propofol for sedation. It was reportedly a difficult intubation
requiring multiple attempts, and he also had to be paralyzed
with
rocuronium afterward due to persistent biting on the tube
despite
sedation. He was then transferred to ___ for further
management.
Currently he is intubated and sedated on propofol. No family is
currently available for collateral information.
Of note, he was recently admitted to the neurology service in
___ for increased seizure frequency and confusion. EEG
showed mildly slow backgroun in addition to right sided slowing
but no epileptiform features and no seizures were captured.
Toxic/metabolic work-up was negative and he quickly returned to
his baseline. His seizures were thought to be related to
increased stress at home and poor sleep. He denied missing any
medication doses and AED trough levels were therapeutic. No
medication changes were made during his admission. He was
discharged home with instructions to follow up with Dr. ___ within one week but it appears this visit did
not occur. He is scheduled to see Dr. ___ in clinic tomorrow
___.
In regard to his seizure history, according to OMR, the patient
has had seizures since ___ when he was diagnosed with CNS
lymphoma. He was last admitted here for a generalized seizure in
___ that required intubation. Per OMR: "His seizure
semiology is of left arm abnormal sensation, abnormal smells,
sometimes out of body sensation, followed by LOC and then
secondary generalization (sometimes). Frequency is about ___ per
month for his partial seizures. "
ROS: Currently unable to be obtained as pt is intubated and
sedated.
Past Medical History:
Gathered from multiple notes in OMR:
- hx of CNS lymphoma in the ___ that resulted in seizures
- seizure history as per HPI. Previous AEDs in the past per OMR:
Dilantin, Zonegran, Depakote and carbamazepine. Follows in
clinic
with Dr. ___.
- hx of right temporal lobectomy in the 1990s in attempt to
diminish seizures
- likely idiopathic Parkinsons disease - seen in Movement clinic
by Dr. ___ ___ - primarily LUE tremor - not on medications
- depression
- tobacco abuse
Social History:
___
Family History:
Breast ca, no sz or lymphoma
Physical Exam:
Exam on admission:
Vitals: 97.3 64 143/87 17 100%
General: Intubated and sedated
HEENT: NC/AT, no scleral icterus noted, ETT in place
Neck: Supple, no nuchal rigidity
Pulmonary: Lungs rhonchorous b/l
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Intubated and sedated, no response to voice or
noxious stimulation
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. No blink to threat.
III, IV, VI: Doll's eyes negative
V: Corneals absent
VII: Face appears grossly symmetric with ETT
VIII: Unable to assess
IX, X: Absent gag
XI: Unable to assess
XII: Unable to assess
-Motor: Normal bulk, tone throughout. Withdraws weakly to
noxious
stimulation in all four extremities.
-Sensory: Withdraws to noxious stimulation as above
-DTRs: ___ but symmetric throughout, toes appear to be
upgoing bilaterally
-Coordination: Unable to assess
-Gait: Unable to assess
Exam on discharge:
Mr. ___ was out in the hallway walking around with a coffee
cup this morning. He is anxious to leave hospital and states he
is feeling well, back to his baseline. He reports no seizure
activity overnight. No new neurologic symptoms. He is afebrile
and VSS. Pleasant, cooperative. Oriented. Language and praxis
are
intact. Able to follow simple and complex commands consistently.
PERRL. Visual field testing demonstrates a left superior
quadrantanopia (baseline), and he wears a prism on his glasses.
EOMI. No nystagmus. Mild left facial. Tongue midline. Mild
pronation left. Good power throughout. No
asterixis. Decreased coordination on left unchanged. At rest
there is alternating tremor on left and mild tremor present on
right in comparison, which is made worse with intention. Gait is
narrow based, slightly stiff but steady and turn is steady. No
Romberg sign present.
Pertinent Results:
___ 01:08AM BLOOD WBC-9.5 RBC-3.61* Hgb-11.7* Hct-34.7*
MCV-96 MCH-32.3* MCHC-33.6 RDW-13.5 Plt ___
___ 04:55AM BLOOD WBC-10.5 RBC-4.02* Hgb-13.0* Hct-38.9*
MCV-97 MCH-32.2* MCHC-33.3 RDW-13.7 Plt ___
___ 01:08AM BLOOD ___ PTT-31.1 ___
___ 04:55AM BLOOD Plt ___
___ 01:08AM BLOOD Glucose-82 UreaN-11 Creat-0.5 Na-138
K-4.7 Cl-103 HCO3-22 AnGap-18
___ 04:55AM BLOOD Glucose-97 UreaN-17 Creat-0.7 Na-142
K-4.1 Cl-105 HCO3-25 AnGap-16
___ 01:08AM BLOOD Calcium-8.8 Phos-2.7 Mg-2.4
___ 04:55AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.3
___ 09:59PM BLOOD Calcium-8.4 Phos-2.8 Mg-2.5
___ 10:07PM BLOOD Type-ART pO2-212* pCO2-52* pH-7.33*
calTCO2-29 Base XS-0 Intubat-INTUBATED
HEAD CT:
No evidence of an acute intracranial process. Evidence of right
temporal
lobectomy. If clinically warranted, MRI would be more sensitive
for evaluation
of worsening seizures.
CXR:after intubation
1. Appropriately positioned endotracheal tube, ending 4.2 cm
above the level
of the carina.
2. No acute cardiac or pulmonary process.
EEG ___:
IMPRESSION: This is an abnormal continuous EEG monitoring study
due to
diffuse and excessive low amplitude beta activity and right
hemispheric focal
slowing, more pronounced on fronto-central region. These
findings are
suggestive of focal cerebral dysfunction in the right
hemisphere. There are
frequent epileptiform discharges in right fronto-central and
left posterior
temporal region indicative of potential epileptogenic areas.
There are no
clinical or electrographic seizures captured during this study.
EEG ___:
IMPRESSION: This is an abnormal continuous EEG monitoring study
due to
diffuse excess low amplitude beta activity present at the start
of the study
but background improves to ___ Hz alpha/theta during
wakefulness. There is
frequent right hemispheric focal slowing, more pronounced on
fronto-central
region. These findings are suggestive of focal cerebral
dysfunction in the
right hemisphere. There are frequent epileptiform discharges in
right fronto-
central, right posterior temporal, and left posterior temporal
regions
indicative of potential epileptogenic areas. There are no
clinical or
electrographic seizures captured during this study.
EEG ___:
IMPRESSION: This is an abnormal continuous ICU monitoring study
because of
the presence of a mild diffuse encephalopathy with clear focal
and lateralized
features. There is a fairly continuous slow wave abnormality
over the right
frontal central region compatible with a structural abnormality
of that area.
There is superimposed multifocal independent interictal activity
seen in the
right frontal, right posterior temporal, and left mid-temporal
regions. There
were no clinical seizures nor were there any clear
electrographic seizures
present.
MR head w/ & w/o contrast ___:
FINDINGS: The patient is status post right temporal lobectomy.
A tiny
punctate focus of diffusion abnormality is seen in the right
putamen. This is
possibly an artifact or may represent a small acute infarct.
Otherwise, there
is no evidence of acute infarct or intracerebral hemorrhage. No
extra-axial
blood or fluid collection is present. The ventricles and sulci
are normal in
size and configuration. No intracranial mass is identified.
The major
intracranial vessel flow voids are preserved. White-matter
hyperintensities
in the periventricular region and in the pons are consistent
with chronic
small vessel ischemic disease.
The brainstem, posterior fossa, and cervical medullary junction
are preserved.
The orbits and periorbital and paracavernous spaces are normal.
No
abnormality of the skull base or calvarium is identified. A
small retention
cyst is seen in the left maxillary sinus. The there is fluid in
the left
mastoid air cells. The other visualized paranasal sinuses,
right mastoid air
cells, and middle ear cavities are clear.
There is no abnormal enhancement after contrast administration.
IMPRESSION:
1. No abnormal enhancement after contrast administration.
2. Tiny punctate focus of diffusion abnormality in the right
putamen, likely
artifact but may represent a small acute infarct.
3. Status post right temporal lobectomy.
4. Chronic small vessel disease in the periventricular white
matter and pons.
5. Retention cyst in the left maxillary sinus and fluid in the
left mastoid
air cells.
Brief Hospital Course:
___ man with a history of seizure disorder (secondary
epilepsy secondary to CNS lymphoma), who presented as a transfer
from ___ on ___ for status epilepticus. Limited history
regarding possible precipitating factors such as missed
medication doses or infectious symptoms. However, the severity
of this event was quite atypical for him, as his seizures are
typically partial with only occasional secondary generalization.
On admission, intubated on propofol with no further clinical
evidence of seizure activity, although he was sedated and also
received paralytics, as well as 1 gm of levetiracetam prior to
transfer. CT head did not show any acute intracranial process,
only encephalomalacia in the right frontotemporal region,
subjacent to craniotomy site.
Pt was extubated uneventfully in ICU on ___.
Pt underwent an MRI epilepsy protocol on day of discharge and
final read as below was communicated to his outpatient
neurologist Dr. ___ :
"1. No abnormal enhancement after contrast administration.
2. Tiny punctate focus of diffusion abnormality in the right
putamen, likely
artifact but may represent a small acute infarct.
3. Status post right temporal lobectomy.
4. Chronic small vessel disease in the periventricular white
matter and pons.
5. Retention cyst in the left maxillary sinus and fluid in the
left mastoid
air cells. "
There is plan at time of discharge for follow up with Dr.
___ on ___.
Pt will be discharged with an increase in lamotrigine and
lacosamide dosing
initiated during this hospitalization: lacosamide 250 mg bid,
lamotrigine 200 mg bid. Levetiracetam continues at ___ mg bid.
He has lorazepam PRN seizures
Medications on Admission:
1. Lorazepam 1 mg PO Q4H:PRN seizure
2. Sertraline 200 mg PO DAILY
3. Lacosamide 250 mg PO QAM
4. Lacosamide 200 mg PO QPM
5. LaMOTrigine 200 mg PO QAM
6. LaMOTrigine 100 mg PO QHS
7. LeVETiracetam ___ mg PO BID
Discharge Medications:
1. Lacosamide 250 mg PO BID
RX *lacosamide [Vimpat] 100 mg 2 and ___ tablet(s) by mouth
twice daily Disp #*150 Tablet Refills:*0
2. LaMOTrigine 200 mg PO BID
RX *lamotrigine 200 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
3. LeVETiracetam ___ mg PO BID
4. Sertraline 200 mg PO DAILY
5. Lorazepam 1 mg PO Q4H:PRN seizure
Discharge Disposition:
Home
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because of prolonged seizures
(status epilepticus). To protect your airway, you were intubated
and sedated for some time but we were able to extubate you
without a problem. During this admission, we increased your
lamotrigine (Lamictal) to 200mg twice daily, and increased your
lacosamide (Vimpat) to 250mg twice daily.
You have a follow-up appointment in epilepsy clinic with
___. You should also follow up with your PCP.
It was a pleasure taking care of you in the hospital.
Followup Instructions:
___
|
19914556-DS-26 | 19,914,556 | 20,088,959 | DS | 26 | 2194-11-25 00:00:00 | 2194-11-25 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:
Breakthrough seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old R-handed man pmh of CNS lymphoma
S/P surgical resection with resulting epilepsy s/p VNS, s/p
right temporal lobectomy, and ___ disease responsive to
sinemet, who presents with a seizure today.
Per event note by Dr. ___ was in "the Cognitive Neurology
office today with a social work visit. During the social work
visit the patient stated that ___ felt ___ was about to have a
seizure, but that ___ had usually forgotten to bring his Ativan
today, which ___ normally takes during his visit.
The social worker then noted onset of L arm shaking, head
shaking, and slurred speech. ___ initially tried to talk through
the episode, but then it progressed to a tonic-clonic
generalized
seizure with whole body shaking. The entire episode lasted 10
minutes. Neurology was contacted who was down the hall who came
in, and the seizure ended within 30 seconds of coming into the
office.
After the seizure ___ was post-ictal and confused, but able to
state the day of the week ___ ___ was able to follow
simple commands. ___ appeared to have difficulty looking fully
left. ___ also had a L sided Todds paralysis with L face and arm
weakness (leg not tested). Pupils equally round and reactive.
Dr. ___ with ___ is normally pretty well
controlled with his epilepsy and uses the VNS and Ativan to
prevent seizures from progressing when ___ feels one coming on.
In the past,
however, ___ has had long seizures which can cluster and recur.
This can occur in the setting of infection."
Dr. ___ patient to ED for observation and further workup
as well as coordination of care with outpatient Epilepsy
providers, with initial plan as below
"- 1 mg IV Ativan upon arrival to the ED
- please check keppra and lamictal levels upon arrival to the ED
- check infectious work up: CXR, UA, Utox, Stox, LFTs, CBC, chem
- contact ___ and ___ to discuss management
- if weakness does not resolve, consider NCHCT
- if weakness does not resolve, or the patient does not clear
from his post ictal state, or seizures recur, Neurology consult"
On my visit, ___ was explains that ___ was here for a regularly
scheduled social work visit, when his "seizure came on". ___
felt tingling and then had loss of control of his left hand. ___
used VNZ without effect. ___ forgot his abortive Ativan at home.
___ is not sure of the details. ___ is back to his normal self
current in the ED. Denies difficultly talking or weakness.
___ denies: fevers or recent illness. ___ denies missed
medications. ___ denies changes in sleep, but states his sleep is
not restful to apneas, but does not use CPAP. At times, ___ has
noticed stress as a trigger. His father used to be a trigger for
him, as ___ was mean and spiteful such that ___ would laugh when
the patient had trouble affording food or his mortgage while
showering his other children with large value gifts. ___ has
passed away. The patient's current stress is affording college.
Seizure Semiology:
1) Partial complex: Begins with Left UE tingling and "loss of
control", affecting speech, then generalize. These seizures were
previously weekly, now can occur every few months.
2) Generalized Tonic Clonic Seizures. Denies TB or UI. Last
event several years ago. Has previously gone into status.
3) left sided tingling and "loss of control of LUE". previously
weekly, now ___ in a month.
** Sometimes ___ is confused by his left hand tremor.
Per chart review, ___ was last admitted in ___ in setting of
seizure clusters ___ UTI and PNA. ___ was also admitted in ___
and ___ for status epilepticus. ___ has also had elective
admissions for medication titration.
Past Medical History:
Gathered from multiple notes in OMR:
- hx of CNS lymphoma in the ___ that resulted in seizures
- seizure history as per HPI. Previous AEDs in the past per OMR:
Dilantin, Zonegran, Depakote and carbamazepine. Follows in
clinic
with Dr. ___.
- hx of right temporal lobectomy in the 1990s in attempt to
diminish seizures
- likely idiopathic Parkinsons disease - seen in ___ clinic
by Dr. ___ ___ - primarily LUE tremor - not on medications
- depression
- tobacco abuse
Social History:
___
Family History:
Breast ca, no sz or lymphoma
Physical Exam:
ADMISSION:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits.
Pulmonary: CTABL. No R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, +BS, no masses or organomegaly noted.
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were 1 paraphasic errors
(sociologist for social worker). Pt was able to name both high
and low frequency objects. Able to read without difficulty.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. Pt was able to register 3 objects and
recall ___ at 5 minutes. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. VFF to confrontation. Visual acuity
___ bilaterally. Fundoscopic exam revealed no papilledema,
exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: L NLFF, decreased activation of L mouth.
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. Increased tone with
minimal cog-wheeling with distraction tasks. No pronator drift
bilaterally.
Postural (L >R, low frequency and amplitude) in UE. Bilateral
action tremor in UE. Pill rolling tremor R>L. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: bilateral intention tremor (L>R), no
dysdiadochokinesia noted. No dysmetria on FNF bilaterally.
-Gait: Deferred.
DISCHARGE:
Not significantly changed since admission
Pertinent Results:
___ 06:04AM BLOOD WBC-7.7 RBC-3.79* Hgb-12.4* Hct-36.7*
MCV-97 MCH-32.7* MCHC-33.8 RDW-13.3 RDWSD-47.8* Plt ___
___ 03:16PM BLOOD WBC-8.9 RBC-4.01* Hgb-12.3* Hct-37.9*
MCV-95 MCH-30.7 MCHC-32.5 RDW-13.1 RDWSD-45.4 Plt ___
___ 03:16PM BLOOD ___ PTT-27.1 ___
___ 06:04AM BLOOD Glucose-87 UreaN-9 Creat-0.7 Na-141 K-4.9
Cl-103 HCO3-28 AnGap-15
___ 03:16PM BLOOD Glucose-98 UreaN-14 Creat-0.7 Na-140
K-4.6 Cl-101 HCO3-27 AnGap-17
___ 03:16PM BLOOD ALT-<5 AST-15 CK(CPK)-200 AlkPhos-100
TotBili-0.2
___ 06:04AM BLOOD Calcium-9.1 Phos-2.9 Mg-2.3
___ 03:16PM BLOOD Albumin-4.4 Calcium-9.2 Phos-2.5* Mg-2.2
___ 03:16PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:20PM BLOOD Lactate-2.4*
___ 03:20PM BLOOD O2 Sat-60 COHgb-6*
___
No acute cardiopulmonary process.
Brief Hospital Course:
Mr. ___ was hospitalized at ___ due to breakthrough seizure
with concern for infection or seizure clusters. ___ was given
Ativan 1mg and monitored on Neurology floor. ___ underwent
laboratory workup for infection and received CXR which were
negative. Due to no continued seizures and no clear sign of
infection, ___ was discharged home.
Transition Issues:
-Pt will need to follow up with Neurology as scheduled.
-Pt instructed to keep home At___ with him to prevent further
breakthrough seizures
Medications on Admission:
1. Carbidopa-Levodopa (___) 1.5 TAB PO TID
2. LACOSamide 200 mg PO DAILY
3. LACOSamide 300 mg PO QHS
4. LamoTRIgine 200 mg PO BID
5. LevETIRAcetam ___ mg PO BID
6. Sertraline 200 mg PO DAILY
7. Ativan 1mg prn
Discharge Medications:
1. Carbidopa-Levodopa (___) 1.5 TAB PO TID
2. LACOSamide 200 mg PO DAILY
3. LACOSamide 300 mg PO QHS
4. LamoTRIgine 200 mg PO BID
5. LevETIRAcetam ___ mg PO BID
6. Sertraline 200 mg PO DAILY
7. Ativan 1mg prn
Discharge Disposition:
Home
Discharge Diagnosis:
Epilepsy
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 ___ and treated by Neurology due to a
breakthrough seizure with concern for subsequent recurrent
seizures as well as an underlying infection. You underwent a
laboratory and imaging workup with no sign of infection and were
seen to have no new seizure activity. Due to these findings, you
are clinically stable for discharge.
Please continue your home medications as prescribed.
Please follow up with Neurology as listed below.
It was a pleasure taking care of you,
___ Neurology Team
Followup Instructions:
___
|
19915124-DS-22 | 19,915,124 | 29,902,030 | DS | 22 | 2164-12-13 00:00:00 | 2164-12-14 13:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
coughing blood
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with PMHx AML diagnosed ___ s/p 7+3 induction,
MEC salvage, and decitabine consolidation (last dose
chemotherapy on ___ currently on supportive care with blood
and platelet transfusions who is presenting with coughing blood.
He was lying down to sleep last night and had a feeling of
liquid pooling in the back of his throat. He spit and bright red
blood came out of his mouth. He had about 6 recurrent episodes
throughout the night of spitting and coughting. Of note, he had
not been coughing prior to this occuring. He has not had
hematemesis, hematochezia, or melena. No other bleeding
currently or in the past. He has never had nosebleeds. He was
unable to sleep well, and because of continued bleeding
presented to the ED. His bleeding last occurred around 6:00am
this mroning. He has not had fevers, chills, or cough at home.
He has chronic dyspnea on exertion but this has not been worse
in the last week.
In the ED, initial VS: R 98.1 HR 86 BP 106/78 RR 18 SaO2 100%.
Labs were notable for WBC 0.8, Hct 26.6, and Plt 21. He received
1 unit of platelets; he was premedicated with benadryl, pepcid,
hydrocortisone, and acetaminophen for known hives with blood
products. He was evaluated by the ___ fellow who recommended
close monitoring in the FICU given concern for possible
hemopysis.
On arrival to the FICU, he corroborated the above story. His
only complaint is hunger as he has not eatn for > 12 hours.
Review of systems:
(+) Per HPI. New non-painful, non-purutic rash over chest and
upper back. His weight fluctuates, but has not had significant
weight loss or gain. Has exertional shortness of breath over the
last several months, but no worse recently. Occasional nausea.
Occasional consitpation. Short term memory difficulty since TBI
___ years ago.
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies arthralgias or myalgias.
Past Medical History:
- AML diangosed ___ (with trisomy 21 cytogenetic abnormality,
NPM1, FLT3, and CEBPA mutational analysis were all negative),
s/p 7+3 with persistent disease. Received salvage treatment with
MEC on ___. Started on Decitabine ___ for consolidation
therapy with cytopenias (D7D1 ___. Bone marrow biopsy on
___ with evidence of leukemia with ___ blasts and 28%
peripheral blasts. Was offerred a clinical trial of cabozantinib
but deferred given concern for side effects. He is receiving
transfusion support.
- Thrombocytopenia - secondary to AML, last platelet transfusion
___ for Plt 17
- Anemia - secondary to AML, last pRBC transfusion ___ for
Hb 7.2
- Aortic Insufficiency s/p rheumatic heart disease as a child
- TBI in ___ and ___ (rollerblading without a helmet)
resulting in severe short term memory loss
- Depression
- Hypertension, not on medication
- S/p craniotomy ___
Social History:
___
Family History:
No leukemia.
Physical Exam:
On Admission
Vitals: T 98.0 BP 139/80 HR 52 RR 15 SaO2 96% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear without any
current bleeding or old blood
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + soft S2, no murmurs,
rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: scattered erythematous papules and few paches that do not
blanch over chest and upper back
On Discharge
Exam unchanged
Pertinent Results:
On Admission:
___ 09:20AM BLOOD WBC-.8* RBC-2.80* Hgb-8.9* Hct-26.6*
MCV-95 MCH-31.9 MCHC-33.6 RDW-17.7* Plt Ct-21*
___ 09:20AM BLOOD Neuts-0* Bands-0 Lymphs-44* Monos-0 Eos-0
Baso-0 ___ Myelos-0 Blasts-56* NRBC-16*
___ 09:20AM BLOOD ___ PTT-20.5* ___
___ 09:20AM BLOOD Glucose-77 UreaN-17 Creat-0.8 Na-136
K-4.6 Cl-102 HCO3-25 AnGap-14
___ 09:20AM BLOOD ALT-23 AST-33 LD(LDH)-583* AlkPhos-60
TotBili-0.7
___ 09:36AM BLOOD Lactate-1.0
.
Pertinent Labs:
___ 03:24PM BLOOD WBC-0.6* RBC-2.71* Hgb-8.5* Hct-25.7*
MCV-95 MCH-31.4 MCHC-33.2 RDW-18.7* Plt Ct-27*
___ 04:43AM BLOOD WBC-0.4* RBC-2.70* Hgb-8.6* Hct-25.1*
MCV-93 MCH-32.1* MCHC-34.5 RDW-17.9* Plt Ct-41*#
.
Imaging/Studies:
___ CXR
No acute cardiopulmonary process.
.
Microbiology:
___ Blood cultures - no growth at time of discharge
Brief Hospital Course:
This is a ___ with PMHx AML s/p 7+3, salvage with MEC, and
consolidation with decitabine with recurrent and progressive
disease presenting with possible hemoptysis. He had no recurrent
bleeding while hospitalized, and it was felt that he likely had
epistaxis. He was discharged home in stable condition.
.
Active Issues
.
# Blood per os
He had sudden onset of painless bleeding in his oropharyngeal
cavity that started when lying down for sleep. He had no prior
coughing or other new respiratory symptoms to suggest
hemoptysis. He has not had vomiting to suggest hematemesis. He
most likely had epistaxis, possibly posterior, and given his
thrombocytopenia it took a long time to achieve hemostasis. He
received a total of 3U platelets. He was monitored for > 24
hours and had no recurrent bleeding.
.
# Transfusion Reaction
He developed urticaria after the completion of his third
platelet transfusion. He had been premedicated because of
history of known urticarial reactions. He remained
hemodynamically unstable without respiratory compromise. He
received additional H2 and H1 blockers as well as hydrocortisone
and this reaction resolved within 20 minutes.
.
# Rash
Was noted to have a new red, non-blanching papules and plaques
over his chest and upper back. These were non painful and non
puruitic. They were most consistent with leukemia cutis given
his known AML and recent progression on bone marrow biopsy.
Unlikely vasculitis, drug rash, or infection.
.
Chronic Issues
.
# Pancytopenia
Secondary to marrow involvement of AML. Currently getting
supportive platelet and RBC transfusions. Recieved 3U of
platelets for a count of 21 on admission and active bleeding.
.
# AML
He is s/p 7+3, salvage with MEC, and consolidation with
decitabine with recurrent and progressive disease. He has
declined participation in a clinical trial, and is currently
receiving supportive care with transfusions as needed. ___ was
aware of his admission.
.
# Depression
Stable, continued sertraline.
.
# Mild cognitive impairment
Has short term memory deficits s/p TBI x 2. During this
admission he was oriented and appropriate in conversation.
.
## Transitional Issues
- Monitor for recurrent bleeding, continue to reeducate patient
on safety measures
- Patient has pending blood cultures from admission on ___ that
need to be followed-up
# Communication: HCP is sister ___, ___
# Code: Full
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q8H
2. Amoxicillin ___ mg PO ONCE
3. Ciprofloxacin HCl 500 mg PO Q12H
4. LACOSamide 100 mg PO BID
5. Lorazepam 1 mg PO HS
6. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
7. Sertraline 50 mg PO QAM
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Ciprofloxacin HCl 500 mg PO Q12H
3. LACOSamide 100 mg PO BID
4. Lorazepam 1 mg PO HS
5. Sertraline 50 mg PO QAM
6. Amoxicillin ___ mg PO ONCE
7. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: epistaxis
Secondary: acute myelogenous leukemia, thrombocytopenia,
urticarial reaction to platelet transfusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ because of bleeding in your throat.
You did not have any recurrent bleeding for 24 hours while you
were here. This was most likely a nose bleed that bled into your
throat instead of out your nose because you were lying in bed.
You are more succeptible than other to having nosebleeds because
of your low platelts. You also received two bags of platelets.
We gave you medication prior to these bags to prevent a
reaction. You did develop a rash after the second bag of
platelets but this resolved quickly with extra medication. You
are safe for discharge. Please call your doctors ___ to the ED
if you have recurret bleeding that does not stop on its own.
Please continue all of your medications. We are not making
changes to your medications.
Followup Instructions:
___
|
19915270-DS-18 | 19,915,270 | 29,339,659 | DS | 18 | 2127-03-25 00:00:00 | 2127-03-25 13:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Nizoral
Attending: ___.
Chief Complaint:
Muscle/joint pains
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ year old woman with no past medical
history.
She states that she is was in her usual state of health, which
is
good, she has no medical problems, until this ___. On
___ during the day she began to notice pain over her R calf
area. She states that this pain is similar to when pain when
experiencing a bruise, except she did not notice any bruising or
skin changes. It was a pressure like constant sensation. At some
point in the day she noted that this had also occurred in the L
calf as well, and her thighs. The following day ___, she
noted
that the same pain was now in her forearms bilaterally. When she
woke up on ___ she also noted a headache and some nausea, but
no vomiting. The headache resolved after she took some aspirin
and a nap but was severe when it initially started. She has had
some headaches before occasionally, but none similar to this.
She
reports having electricity like shooting pains in her arms and
hands and legs as well. These start in the forearm area and move
distally in the arms. They do not start at the back. She
reports
some joint soreness in the toes ankles fingers and wrists
starting today. She denies any weakness, she feels that the
pain
sometimes limits her ability to do some things. She feels that
she is also limited due to fatigue she has been having. She
denies any shortness of breath. She has not had any numbness.
She began having a sore throat late last night. She denies any
sick contacts but notes that her daughter is in daycare. She
states that she has been sick on and off again with URI symptoms
the last year, due to her daughter being in daycare. She
reports
having the flu several months ago. She had a cold 6 weeks ago.
She reports somewhat of a cough in the last few days but not
very
severe. She denies any recent vaccines. She reports several
episodes of diarrhea earlier in the week but they had resolved
NIF in ED was -60.
Past Medical History:
None
Social History:
___
Family History:
mother with ___
uncle with fibromyalgia
Physical Exam:
ADMISSION EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
counts to 20 in a single breath, after multiple attempts with
improvement with coaching, initially only 15. appears
comfortable
on room air.
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 4 to 2mm and brisk. EOMI without
nystagmus. no double vision on sustained upgaze. Normal
saccades.
VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric. no eyelid
closure weakness
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- 4+ 4 4+ ___ 5 5 5 5 5
R 5 5- 4+ 4+ 4 4+ ___ 5 5 5 5 5
-Sensory: Slightly decreased vibration sense at toes
bilaterally.
Temperature gradient R>L foot around ankle level. Otherwise
elsewhere 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 0 0
R 2 2 2 0 0
Plantar response was flexor bilaterally.
no lower extremity reflexes were elicited despite multiple
attempts, with reinforcement, in sitting and laying position.
-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:
No focal deficits. Mild discomfort to muscle and joint palpation
Pertinent Results:
___ 08:08AM BLOOD WBC-4.2 RBC-4.48 Hgb-13.9 Hct-39.6 MCV-88
MCH-31.0 MCHC-35.1 RDW-12.9 RDWSD-42.0 Plt ___
___ 12:55PM BLOOD WBC-7.4 RBC-4.38 Hgb-13.4 Hct-39.0 MCV-89
MCH-30.6 MCHC-34.4 RDW-12.5 RDWSD-41.4 Plt ___
___ 02:23PM BLOOD ___ PTT-28.4 ___
___ 08:08AM BLOOD Glucose-81 UreaN-15 Creat-0.7 Na-138
K-4.3 Cl-103 HCO3-25 AnGap-10
___ 12:55PM BLOOD Glucose-97 UreaN-18 Creat-0.7 Na-140
K-4.4 Cl-106 HCO3-23 AnGap-11
___ 12:55PM BLOOD ALT-9 AST-19 AlkPhos-41 TotBili-0.6
___ 12:55PM BLOOD Lipase-32
___ 08:08AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9
___ 12:55PM BLOOD Albumin-4.1 Calcium-8.9 Phos-3.0 Mg-1.7
CXR
IMPRESSION:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Ms. ___ was admitted to ___ due to evolving pain over
muscles and joints of extremities over past few days with
associated headache, nausea, and sore throat. On evaluation in
ED by Neurology, she appeared to have mild weakness in distal
UEs as well as dropped reflexes in LEs. Out of concern for sx
and signs on exam, she underwent LP in ED which showed no
inflammation or albuminocytologic dissociation. NIF/VC was
normal. She arrived on Neurology service and follow up exam by
floor Neurology team showed no concerning neurologic deficits.
Based on her clinical history, Lyme studies were sent. Based on
clinical stability, pt was discharged home from hospital.
-F/u Lyme study
-Plan for pt to f/u with PCP as ___
___ on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Arthralgias/Myalgias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of muscle/joint pains and
decreased reflexes concerning for a neurologic condition. Based
on this concern, we assessed you for medical conditions that
might produce your symptoms. We will continue lab workup to
investigate for these conditions and inform you of these results
as outpatient.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19915715-DS-15 | 19,915,715 | 23,569,430 | DS | 15 | 2146-02-05 00:00:00 | 2146-02-05 16:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
___ 10:14AM BLOOD WBC-4.7 RBC-5.19 Hgb-13.8 Hct-44.4 MCV-86
MCH-26.6 MCHC-31.1* RDW-14.2 RDWSD-44.8 Plt ___
___ 10:14AM BLOOD Neuts-45.6 ___ Monos-11.7 Eos-2.5
Baso-0.8 Im ___ AbsNeut-2.15 AbsLymp-1.85 AbsMono-0.55
AbsEos-0.12 AbsBaso-0.04
___ 10:14AM BLOOD Plt ___
___ 10:22AM BLOOD ___ PTT-29.8 ___
___ 10:14AM BLOOD Glucose-103* UreaN-11 Creat-0.8 Na-141
K-4.6 Cl-105 HCO3-26 AnGap-10
___ 10:14AM BLOOD cTropnT-<0.01
PERTIENENT LABS
___ 10:14AM BLOOD cTropnT-<0.01
___ 02:05PM BLOOD cTropnT-<0.01
___ 08:05PM BLOOD cTropnT-<0.01
___ 07:46AM BLOOD calTIBC-290 Ferritn-100 TRF-223
___ 07:46AM BLOOD %HbA1c-5.9 eAG-123
___ 07:46AM BLOOD Triglyc-151* HDL-46 CHOL/HD-3.7
LDLcalc-96
___ 07:46AM BLOOD TSH-5.2*
DISCHARGE LABS
___ 07:46AM BLOOD WBC-3.8* RBC-5.17 Hgb-13.7 Hct-43.7
MCV-85 MCH-26.5 MCHC-31.4* RDW-14.4 RDWSD-43.9 Plt ___
___ 07:46AM BLOOD Plt ___
___ 07:46AM BLOOD Glucose-104* UreaN-14 Creat-0.8 Na-143
K-4.9 Cl-103 HCO3-27 AnGap-13
___ 07:46AM BLOOD ALT-12 AST-15 CK(CPK)-54 AlkPhos-107*
TotBili-0.5
___ 07:46AM BLOOD Albumin-4.0 Calcium-9.2 Phos-3.7 Mg-2.3
Iron-94 Cholest-172
IMAGING
CHEST XRAY: ___
FINDINGS: No focal consolidation. No large pleural effusion or
pneumothorax. The cardiomediastinal silhouette is within normal
limits.
IMPRESSION: No acute cardiopulmonary process.
TRANSTHORACIC ECHOCARDIOGRAM: ___
IMPRESSION: Suboptimal image quality. Borderline pulmonary
artery systolic hypertension. Normal left ventricular wall
thickness and biventricular cavity sizes and regional/global
biventricular systolic function. Quantitative biplane left
ventricular ejection fraction is 73% (normal
54-73%).
Brief Hospital Course:
SUMMARY STATEMENT
___ year old woman with a history of previous coronary vasospasm,
GERD and prediabetes presented with c/o atypical chest pain and
dyspnea on exertion. Initial workup, including EKG and troponin,
was not concerning for coronary ischemia. A stress echo from
___ was notable for a medium area of moderate stress-induced
ischemia in the LAD distribution with normal LV function,
however cardiac catheterization at ___ from ___ revealed
normal coronary arteries. The patient was admitted for
monitoring and treatment for suspected coronary vasospasm vs.
non-cardiac chest pain.
ACUTE ISSUES:
=============
# History of coronary vasospasm
The patient felt that recent sub-sternal chest pain was similar
in sensation to previous episode of coronary vasospasm in ___.
The patient's cardiac risk factors included history of coronary
vasospasm, pre-diabetes and obesity. Noted history of abnormal
stress test in ___, however reassured by normal cath in ___.
EKG and troponin remained normal throughout admission and the
patient's pain improved. It was thought there may have been
contribution of non-cardiac chest pain, particularly GI as the
patient has a known history of GERD gastritis with prior
treatment of H.pylori. TTE revealed: Suboptimal image quality.
Borderline pulmonary artery systolic hypertension. LVEF 73%.
Amlodipine 2.5 mg was started for vasospasm, with monitoring of
blood pressure tolerance. The patient tolerated the medication
with continued improvement in chest pain and was considered
stable for discharge home.
- TSH: 5.2, mildly elevated
# Dyspnea on Exertion
Sub-acute worsening DOE was thought to be associated with
vasospasm. The patient had no occupational exposure and had
never smoked. She did note a nocturnal cough, which could have
been related to cough variant asthma or GERD. The patient was
clinically euvolemic on exam and her O2 saturation remained
normal throughout the admission and she reported that her
dyspnea improved prior to discharge.
# Hypertension
BP was noted to be elevated to 150/90 systolic in the ED.
Improved to 120/74 upon transfer to the floor and remained in
the 100s-120s systolic throughout admission. The patient noted
that her prior blood pressures tended to be lower. Started on
amlodipine 2.5mg daily.
CHRONIC ISSUES:
===============
# GERD
Reports she was previously treated for H.pylori. Was unsure of
date of last EGD. Continued home omeprazole 40 mg daily.
# Pre-diabetes
Documented of history of pre-diabetes, not on medication. HbA1c
measured this admission was: 5.9%
TRANSITIONAL ISSUES:
[ ] Discharge creatinine: 0.8
[ ] Discharge weight: 204.14 lb (92.6 kg)
[ ] Discharge blood pressures: 100s-120s/50s-60s
[ ] Discharge heart rate: 50s-60s
[ ] Consider further uptitration of amlodipine as patient
tolerates
[ ] ___ consider the need for a statin for primary prevention of
CAD for this patient. Discharge lipid panel: Chol 172, Trig 151,
HDL 46, LDL 96
[ ] Continue outpatient diet, exercise, and weight loss
counseling in the setting of pre-diabetes with A1C 5.9%
[ ] TTE with borderline pulmonary artery systolic hypertension.
LVEF 73%
[ ] TSH with mild elevation to 5.2, consider repeating TSH and
measuring free T4
[ ] Consider additional work-up for GERD if symptoms persist
despite PPI treatment. Instructed to continue omeprazole 40 mg
daily (start date: ___. Can consider EGD.
[ ] ___ consider outpatient PFTs to evaluate obstructive
pulmonary process such as asthma if dyspnea and nocturnal cough
persist.
#CODE: Full Code
#Contact: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Omeprazole 40 mg PO DAILY GERD
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 40 mg PO DAILY GERD
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Non-ischemic coronary vasospasm
Secondary
Hypertension
Gastric esophageal reflux 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 taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were having chest pain and shortness of breath
WHAT WAS DONE WHILE I WAS IN THE HOSPITAL?
- The function of your heart was monitored
- Studies were completed which showed that the function of your
heart was normal
- You were given a medication to treat the pain in your chest
- Your home medications were continued
- Your pain improved and we felt it was safe for you to be
discharged home
WHAT SHOULD I DO WHEN I GET HOME FROM THE HOSPITAL?
- Be sure to take all of your new and previous medications as
prescribed
- Please follow-up at all of the appointments listed below
- If you have fevers, chills, chest pain, palpitations, problems
breathing, dizziness or generally feel unwell, please call your
doctor or to go the emergency room
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19915727-DS-13 | 19,915,727 | 22,326,711 | DS | 13 | 2169-06-16 00:00:00 | 2169-06-17 13:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin
Attending: ___.
Chief Complaint:
Right lower extremity pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female with a history of recent diagnosis
of AML NPM1+, FLT3, who presents with worsening right lower
extremity calf pain and ankle swelling. She is now d+15 after
7+3. She is being admitted for workup of her worsening right
calf pain.
Ms ___ first developed these symptoms 1.5 weeks ago
and they have progressed over the last week. She feels some
pain with weight-bearing and has begun favoring walking on her
left foot. She denies fevers, chills or erythema at the site
over the past four days. Dorsiflexion and plantar flexion
worsens the right calf pain which begins at the calf and runs
down to the foot along the back of the leg.
She had an ultrasound performed on ___ for these symptoms which
revealed a nodule measuring 2.7 x 1 x 1.7 cm in the distal,
medial portion of the calf.
Given her worsening pain over the last few days, she presented
to the ED for re-evaluation. In the ED, a repeat US was
performed which showed a nodule of 3.65 x 1.25 x 1.4 cm, which
is significantly larger than previous. The appearance is
vascular and heterogenous.
Review of systems is negative for chest pain, chest pressure,
shortness of breath, nausea, vomiting, diarrhea, anorexia,
jaundice, dysuria. No muscle or joint pain at any other sites
other than described above.
Past Medical History:
AML (NPM1+, FLT3) normal cytogenetics
Induction chemotherapy c/b typhlitis
Pulmonary nodules ___
SEASONAL ALLERGIES
s/p Breast Implants
ECZEMA
asthma
migraines
Social History:
___
Family History:
Her father has HTN. Brothers with HTN and HLD. Her mother has
hypertension and there is breast or any types of cancer in her
family.
Physical Exam:
VS: 97.8, 118/60, 67, 20, 98% RA
Gen: Pleasant, Caucasian female in no apparent distress
HEENT: Anicteric, oral mucosa clear
Cardiac: Nl s1/s2 RRR no murmurs appreciable
Pulm: clear bilaterally
Abd: soft, nontender and nondistended with normoactive bowel
sounds
Ext: right ankle 1+ edema at ankle and extending upward to the
right calf; no palpable mass on the right calf, no evidence of
erythema; left foot/ankle normal in appearance and on palpation
VSS
Heart, lungs, abd were all within normal limits
Right ankle 1+ edema at lateral malleolus and extending upward
to right calk. No palpable mass on right calf, no evidnece of
overlying skin changes or erythema
Pertinent Results:
ADMIT LABS:
___ 01:21AM BLOOD WBC-4.8 RBC-3.02* Hgb-9.3* Hct-25.6*
MCV-85 MCH-30.6 MCHC-36.1* RDW-15.6* Plt ___
___ 01:21AM BLOOD Neuts-36* Bands-1 ___ Monos-19*
Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-5* Promyel-1* Blasts-4*
NRBC-1*
___ 01:21AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-1+ Spheroc-2+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-OCCASIONAL
___ 01:21AM BLOOD ___ PTT-36.6* ___
___ 01:21AM BLOOD Plt Smr-VERY HIGH Plt ___
___ 01:21AM BLOOD Glucose-90 UreaN-6 Creat-0.4 Na-144 K-4.1
Cl-105 HCO3-31 AnGap-12
___ 01:21AM BLOOD ALT-14 AST-19 LD(LDH)-307* AlkPhos-50
TotBili-0.2
___ 01:21AM BLOOD Albumin-4.0 Calcium-9.3 Phos-4.2 Mg-2.2
DISCHARGE LABS:
___ 06:25AM BLOOD WBC-6.7 RBC-3.35* Hgb-9.9* Hct-29.1*
MCV-87 MCH-29.6 MCHC-34.1 RDW-16.5* Plt ___
___ 07:45PM BLOOD Neuts-64 Bands-2 ___ Monos-7 Eos-0
Baso-0 Atyps-2* Metas-2* Myelos-2* Other-1*
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-87 UreaN-8 Creat-0.5 Na-142 K-4.2
Cl-104 HCO3-28 AnGap-14
___ 06:25AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.2
IMAGING:
US: ___:
There is normal compression and augmentation in the right common
femoral, superficial femoral and popliteal veins. There is
normal flow seen within the calf veins. Normal respiratory
phasicity is seen within the common femoral veins bilaterally.
Again, seen with in the distal medial portion of the calf is a
heterogeneous nodule which has increased in size, now measuring
3.65 x 1.25 x 1.4 cm and previously measuring 2.7 x 1 x 1.7 cm.
This nodule again demonstrates internal flow as demonstrated on
Power Doppler.
Brief Hospital Course:
A/P:
___ year old female who is s/p 7+3 for NPM1+ FLT3+ AML presenting
with persistent right lower extremity pain and swelling.
# Right lower extremity pain: Pt presents with right lower
extremity pain, which is not a DVT. Based on US findings, may be
consistent with hematoma, given flow characteristics. ___ denies
any fevers, chills. While pt has pulm nodules, given lack of
other infectious sx, would not think that nodules in leg
represents fungal process. Also would consider whether this
represents leukemic involvement. Given recent neutropenia and
abnormal findings, will obtain MRI RLE to furhter characterize
the lesion. As pt is reliable and egaer to return home and does
not clinically appear to have evidence of significant leg
pain/tenderness or other evidnece pathology, that would be
worrisome for other emergent processes (e/g/ fasciitis), will DC
pt with MRI final read pending with plan to call pt and ask her
to return should MRI of RLE reveal issues that require urgent
intervention such as biopsy.
.
# AML with normal cytogenetics NPM1+, FLT3+: Day 14 BM negative.
BM from day ___ is pending.
.
# Pulm nodules: Was noted on prior CT which was suspected to be
possible infection (questionably fungal) - bronchoscopy was
considered on prior admission however was not performed because
patient decided against procedure. Pt will continue voriconazole
for treatment of presumed fungal infection with plan to check
B-glucan and galactomannan.
.
# Migraines: Pt may take tylenol prn, though advised not to take
standing adn to check temperature prior to taking tylenol.
.
# Anxiety: Patient is understandably very emotional and gets
easily worked up. Pt was continued on lorazepam 0.5mg PO q4h prn
.
#Asthma - albuterol nebs prn
TRANSITION ISSUES
# check beta d glucan and galactomannan from ___ and beta D
glucan on ___
# follow-up on pulm nodules with repeat CT in 2 weeks
# follow-up on RLE MRI results
# f/u BM biopsy to assess for CR1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation prn wheezing
2. Multivitamins 1 TAB PO DAILY
3. Acyclovir 400 mg PO Q8H
4. Voriconazole 300 mg PO Q12H
5. Lorazepam 0.5 mg PO/IV Q6H:PRN nausea, insomnia, anxiety
please do not take this and drink alcohol or drive because it
causes drowsiness
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Lorazepam 0.5 mg PO/IV Q6H:PRN nausea, insomnia, anxiety
3. Multivitamins 1 TAB PO DAILY
4. Voriconazole 300 mg PO Q12H
5. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation prn wheezing
Discharge Disposition:
Home
Discharge Diagnosis:
right lower extremity nodule
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 ___ in ___. You
were readmitted for pain in your right lower leg with new
swelling. We performed an ultrasound of your right lower leg,
which did not show a clot, but revealed a nodule that was hard
to characterize, but may have been a resolving pool of blood or
an infection or leukemia. We decided to obtain an MRI of your
right lower leg to further characterize the lesion. Since you
were feeling better, and ready to go home, we discussed that you
could leave after the MRI with the plan that if anything
abnormal was seen on the MRI that required you to return to
___, that we would contact you and you would return.
Followup Instructions:
___
|
19915727-DS-14 | 19,915,727 | 29,860,853 | DS | 14 | 2169-06-23 00:00:00 | 2169-06-23 18:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / ciprofloxacin
Attending: ___.
Chief Complaint:
Left upper quadrant pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old female with a history of recent diagnosis
of AML NPM1+, FLT3, and who recently completed 7+3 about three
weeks ago who is presenting with acute onset of left upper
quadrant pain. She describes the pain as pleuritic occuring on
deep inspiration (and only on deep inspiration). The pain is
described as though she "cracked a rib." She has been coughing
constantly over the past two weeks (nonproductive) but she does
not remember a coughing fit before the onset of the pain or any
specific trauma. The pain began yesterday evening just after
eating spicy Cajun food. She denies fevers, chills, chest pain,
nausea, vomiting, diarrhea. In the ED, CTA was performed which
revealed stable pulmonary nodules on the left (felt to be
atypical pneumonia) and stable splenomegaly. She received
tylenol with some relief. Review of systems otherwise negative.
Past Medical History:
AML (NPM1+, FLT3) normal cytogenetics
Induction chemotherapy c/b typhlitis
Pulmonary nodules ___
SEASONAL ALLERGIES
s/p Breast Implants
ECZEMA
asthma
migraines
Social History:
___
Family History:
Her father has HTN. Brothers with HTN and HLD. Her mother has
hypertension and there is breast or any types of cancer in her
family.
Physical Exam:
Admission
VS: temp 98.2, BP 114/67, 71, 16, 97% RA
Gen: Caucasian female, pleasant, in no apparent distress
Cardiac: Nl s1/s2 RRR no murmurs appreciable
Pulm: clear bilaterally; deep inspiration reproduces left upper
quadrant pain
Abd: soft nontender and nondistended with normoactive bowel
sounds, no reproduction of pain on palpation
Ext: no edema noted
Discharge:
VS: Tm 98.4 ___ 18 99%RA
Gen: Caucasian female, pleasant, in no apparent distress
Cardiac: Nl s1/s2 RRR no murmurs appreciable
Pulm: clear bilaterally; deep inspiration reproduces pain in
LUQ/lower thorax
Abd: soft nontender and nondistended with normoactive bowel
sounds, no reproduction of pain on palpation
Ext: no cce
Pertinent Results:
Labs:
___ 11:40PM BLOOD WBC-11.5* RBC-3.60* Hgb-10.7* Hct-32.0*
MCV-89 MCH-29.8 MCHC-33.5 RDW-16.7* Plt ___
___ 11:40PM BLOOD Neuts-77.2* Lymphs-13.6* Monos-8.0
Eos-0.2 Baso-1.1
___ 11:40PM BLOOD Glucose-103* UreaN-11 Creat-0.6 Na-141
K-4.1 Cl-104 HCO3-27 AnGap-14
___ 11:40PM BLOOD ALT-17 AST-22 AlkPhos-63 TotBili-0.2
___ 11:40PM BLOOD Lipase-41
___ 11:40PM BLOOD Albumin-4.4
___ 11:51PM BLOOD Lactate-1.0
================================================
IMAGING/OTHER STUDIES
CXR ___
1. No acute cardiopulmonary process.
2. Faint nodule projecting over the left mid lung zone
corresponds to a
pulmonary nodule seen on the prior chest CT possibly
representing
atypical/fungal infection in the setting of neutropenia
CTA CHEST / CT ABDOMEN W/ CONTRAST ___
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Decreased size of left pulmonary nodules with surrounding
ground-glass
opacity compared to ___, which may represent
atypical/fungal pneumonia in the setting of neutropenia.
3. Filling defect in the right and main portal vein most likely
reflects
contrast mixing on this late arterial /early venous phase of
imaging given patency and normal flow on same day abdominal
ultrasound ; however, acute thrombus is not entirely excluded.
4. Stable hepatic hemangioma and additional hepatic lesions
incompletely
characterized on this single phase of imaging, some of which are
not seen on the prior CT and could represent new possibly
infectious lesions. Further evaluation with MRI is recommended
for characterization.
5. Stable splenomegaly.
MRI Liver ___ (preliminary report):
IMPRESSION:
1. Multiple ill-defined T2 hyperintense lesions within the liver
that
demonstrate rim enhancement post-contrast. These are new since
___ and appear most consistent with multiple small liver
abscesses, likely secondary to fungal infection.
2. Two cavernous hemangiomas within segments VIII and IVb of the
liver.
Brief Hospital Course:
In summary, this is a ___ year old female who is s/p 7+3 for
NPM1+ FLT3+ AML presenting with acute onset left upper quadrant
pain.
# Left upper quadrant pain: Unclear etiology but possibly
musculoskeletal chest wall or diaphragmatic strain in the
setting of persistent coughing vs. splenic etiology. Though the
history of spicy foods might suggest gastritis, the acute nature
and presentation otherwise would be atypical. This could
possibly represent pleurisy, but LUQ may be slightly low for
this. No signs of pneumothorax or PE on CTA chest. Her
pulmonary nodules are stable and therefore the acute
presentation does not fit with this, but it could also represent
pulmonary disease with ?new-onset pleural involvement. The
appearance of new hepatic lesions is not consistent with the
location of the pain. Her pain was well-controlled with
acetaminophen PRN. Most likely etiology is muscular strain in
setting of non-productive cough. She was discharged home with
plans to f/u with oncology at ___ as outpatient prior to
planned stem-cell transplant.
# AML M5a: s/p 7+3, now D34, with cytogenetics NPM1+, FLT3 ITD
mutation. Of note, per prior notes, she has been planning to
transfer her care to ___. Her counts have since recovered and
most recent BMBx from ___ showed blasts that likely represent
normal marrow regenerative activity (as opposed to abnormal AML
blasts). Most of her pre-transplant work-up has been completed
and communicated to ___. The plan was to get PFTs,
echocardiogram, and PPD to be done at ___, though they are
scheduled at ___ at this time.
# Pulmonary nodules: Stable, if not decreased, from prior CT
which was previously suspected to be possible infection
(?fungal). She had been offered bronchoscopy, but declined
this. She was continued on voriconazole for treatment of
presumed fungal infection. Consideration should be made to
biopsy of her pleural-based left lung nodule.
# Hepatic lesions: CT showed new hepatic lesions, felt to be
concerning for ?infectious etiology. Prior to discharge, she had
a liver MRI. Preliminary read demonstrates multiple
sub-centimeter ring-enhancing lesions most consistent with
fungal abscesses.
# Migraines: currently stable
# Anxiety: Continued home lorazepam 0.5mg PO q4h prn
# Asthma: albuterol nebs prn
=
=
=
=
=
=
================================================================
TRANSITIONAL ISSUES:
1) F/u results of MRI abdomen. Preliminary report demonstrates
multiple sub-centimeter, ring-enhancing liver lesions consistent
with fungal abscesses. Patient is afebrile and well appearing,
on voriconazole. Unclear if these abscesses are growing or
receding, so will likely need repeat liver MRI prior to SCT.
2) f/u repeat CBC w/ diff, LFTs, galactommanan, beta-glucan.
2) Further work-up needed for thrombocytosis and high ferritin,
?representative of continued infection.
3) ?VATS for pleural-based left lung nodule, concerning for
ongoing fungal infection. Biospy has not been done yet since
she had declined bronchoscopy.
Medications on Admission:
1. Lorazepam 0.5 mg PO/IV Q6H:PRN nausea, insomnia, anxiety
2. Multivitamins 1 TAB PO DAILY
3. Voriconazole 300 mg PO Q12H
4. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation prn wheezing
Discharge Medications:
1. Lorazepam 0.5 mg PO/IV Q6H:PRN nausea, insomnia, anxiety
2. Multivitamins 1 TAB PO DAILY
3. Voriconazole 300 mg PO Q12H
4. ProAir HFA *NF* (albuterol sulfate) 90 mcg/actuation
Inhalation prn wheezing
5. Acetaminophen w/Codeine ___ TAB PO Q4H:PRN pain/cough
RX *acetaminophen-codeine [Tylenol-Codeine #3] 300 mg-30 mg ___
tablet(s) by mouth q6h PRN Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Left upper quadrant pain of unclear etiology
Acute myelogenous leukemia
Liver abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___. You were admitted
with acute onset of pain in your left upper abdomen. Your
initial CT scan showed some additional areas of your liver that
were furthur evaluated with an MRI. The preliminary results show
what appear to be several small abscesses, possibly from a
fungal infection. Your oncologists will likely repeat an MRI
prior to your transplant to determine if these abscesses are
growing or shrinking. You should continue to take the
antifungal, voriconazole.
Your persistent cough may explain your pain or it could be due
to an abnormality in your spleen. It is unclear exactly what is
causing this pain; however, we excluded any life-threatening
conditions and you are safe for discharge. You can followup with
your oncologist as an outpatient.
Followup Instructions:
___
|
19915864-DS-17 | 19,915,864 | 29,831,147 | DS | 17 | 2155-03-08 00:00:00 | 2155-03-08 13:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
Ms. ___ is a ___ woman with a history of type 2
diabetes, hypertension, PVD, who presents with dizziness.
Patient states that yesterday at noon she started to feel dizzy.
This has been gradually worsening, and is now severe. It is
associated with some nausea, and is worse when she gets up from
lying or sitting. She felt unsteady on her feet as though she
might fall today, so she came to the ED for further evaluation.
Otherwise, she denies fevers, chills, chest pain, shortness of
breath, abdominal pain, vomiting, diarrhea or constipation, or
any bloody or jet black stools.
On review of records, patient was hospitalized in ___ for
dizziness and anemia. She was found at the time to have h
pylori, and received treatment.
In the ED, initial vitals: T 97.8, HR 82, BP 164/57, RR 16, 99%
RA
Exam significant for guaiac positive brown stools
Labs were significant for
- CBC: WBC 6.1, Hgb 4.7, Plt 334
- Lytes:
142 / 109 / 27
-------------- 86
4.9 \ 19 \ 0.8
- lactate 1.2
Imaging was significant for a chest x-ray with mild interstitial
pulmonary edema
In the ED, pt received IV pantoprazole 40mg and a unit of pRBCs
Vitals prior to transfer: T 98.1 , HR 78, BP 144/99, RR 17, 100%
RA
Currently, patient recounts story as above. She also notes that
her legs have been swollen, which is new for her. No shortness
of breath.
Past Medical History:
Type 2 diabetes mellitus, on insulin
Hypertension
Hyperlipidemia
Social History:
___
Family History:
No family history of peptic ulcer disease
Physical Exam:
GENERAL: NAD
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
CV: Heart regular, systolic ejection murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
MSK: Neck supple, moves all extremities. Bilateral 1+ lower
extremity edema to knees.
SKIN: No new rashes
NEURO: Alert, oriented, speech fluent
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 04:50PM BLOOD WBC-6.1 RBC-2.53* Hgb-4.7* Hct-17.8*
MCV-70* MCH-18.6* MCHC-26.4* RDW-18.6* RDWSD-47.3* Plt ___
___ 05:54AM BLOOD WBC-7.5 RBC-4.18 Hgb-9.2* Hct-32.4*
MCV-78* MCH-22.0* MCHC-28.4* RDW-22.8* RDWSD-60.0* Plt ___
___ 06:15AM BLOOD Glucose-143* UreaN-16 Creat-0.7 Na-143
K-4.5 Cl-107 HCO3-24 AnGap-12
___ 04:50PM BLOOD calTIBC-472* ___ Ferritn-6.2*
TRF-363*
___ 06:30AM BLOOD Triglyc-41 HDL-67 CHOL/HD-1.9 LDLcalc-52
___ 06:15AM BLOOD TSH-5.4*
TTE: The left atrium is mildly dilated. The right atrium is
mildly enlarged. There is no evidence for an atrial septal
defect by 2D/color Doppler. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
The visually estimated left ventricular ejection fraction is
60-65%. There is no resting left ventricular outflow tract
gradient. Mildly dilated right ventricular cavity with normal
free wall motion. The aortic sinus diameter is normal for gender
with normal ascending aorta diameter for gender. The aortic
valve leaflets (3) are mildly thickened. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is mild [1+]
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. IMPRESSION:
Normal LV systolic function, mild LVH. Mild RV dilation with
normal function. Mild pulmonary hypertension.
EGD: Non-bleeding ulcers and erosions in stomach
DVT US: No evidence of deep venous thrombosis in the right or
left lower extremity
veins. The right calf veins were not visualized.
Brief Hospital Course:
# Iron deficiency anemia secondary to blood loss
# Gastric ulcer disease
Patient presented with symptomatic anemia and a Hgb in the 4s.
Had a history of peptic ulcer disease ___ h pylori. She had no
hematochezia, melena, or hematemesis. EGD showed non-bleeding
gastric ulcers, potentially related to NSAID use. In total she
received 3 U pRBCs with continued improvement in her Hgb.
- pantoprazole 40mg PO BID for 8 weeks
- Iron sulfate liquid mixed with orange juice 30 minutes before
breakfast
# Lower extremity edema
# Sublinical hypothyroidism
No DVT on LENIs. TTE with normal systolic function and only mild
pulm HTN with mild hypertrophy. Consequently, slight diastolic
dysfunction may be present, but BNP not elevated and therefore
would not clearly benefit from spironolactone. Urine protein cr
ratio was only 388 mg/g and therefore not suggestive of
nephrotic syndrome (prot: cr of 3500 mg/g). TSH was slightly
above the upper limit of normal with a normal T4. T4
administration in mild TSH elevations in older patients is not
recommended as this slight elevation may be age appropriate. TSH
can be repeated in several weeks if clinical concern remains
CHRONIC/STABLE PROBLEMS:
# Hypertension: Increased lisinopril to 40 mg daily and started
chlorthalidone 25 mg for HTN, especially in setting of mild TTE
findings. Titrate chlorthalidone as needed based on patient
response to 50 mg once daily; maximum: 100 mg/day
# Diabetes type II: Continue home glargine 17u
# Hyperlipidemia: continue home atorvastatin
Transitional issues:
[ ] TSH can be repeated in several weeks if clinical concern
remains
[ ] Titrate chlorthalidone as needed based on patient response
to 50 mg once daily; maximum: 100 mg/day
[ ] PPI for 8 weeks
Ms. ___ was seen and examined on the day of discharge and
is clinically stable for discharge today. The total time spent
today on discharge planning, counseling and coordination of care
was greater than 30 minutes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Glargine 17 Units Breakfast
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. Chlorthalidone 25 mg PO DAILY
4. Ferrous Sulfate (Liquid) 300 mg PO EVERY OTHER DAY
mixed in one-fifth of a glass of orange juice and taken 30
minutes before breakfast
5. Pantoprazole 40 mg PO Q12H
6. Glargine 17 Units Breakfast
7. Lisinopril 40 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Iron deficiency anemia from chronic blood loss
Gastric ulcer disease
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to ___ with anemia and low iron stores. This
is problem from chronic, slow bleeding from a stomach ulcer. You
received blood transfusions, and we are providing supplemental
iron. We started a new medication to help lower your blood
pressure.
Followup Instructions:
___
|
19915864-DS-18 | 19,915,864 | 21,418,790 | DS | 18 | 2156-02-09 00:00:00 | 2156-02-11 21:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lightheadedness
Headache
Major Surgical or Invasive Procedure:
Colonoscopy
Endoscopy
Capsule Study
Barium swallow
History of Present Illness:
Ms. ___ is a ___ year old F w/ HTN, type II DM, PVD, macular
edema presenting with dizziness and a headache. She notes that
she was in her normal state of health until ___
morning when she woke up and felt very lightheaded. She felt
laying flat
improved this. She denies any nausea, vomiting, poor oral
intake,
black or red stools, hematemesis or coffee ground emesis,
bruising, abdominal pain, heart burn, hemoptysis, confusion,
jaundice, dark urine, scleral icterus, or menstrual bleeding.
She
has been taking her PPI at home regularly. Serum antigen was
positive for h. pylori in ___, but biopsies were negative, so
she was not treated. EGD in ___ showed gastric ulcers and
erosions. Colonoscopy in ___ showed a single sessile 6 mm
polyp of benign appearance, but due to poor prep, she was due
for
a repeat colonoscopy in ___. Her last menstrual period was over
___ years ago and she has not had any breakthrough bleeding.
Otherwise, she notes that her sugars have been "all over the
place". She did not take her insulin the morning prior to
presenting. Her most recent A1c was 9.5% in ___ per
___ records. Otherwise, she has had new R-sided vision loss,
for which she is seeing an ophthalmologist and was diagnosed
with a retinal artery occlusion and macular degeneration. She
also has had chronic lower extremity weakness, which she states
have been going on for months.
In the ED, vitals were notable for hypertension to 164/66. Exam
showed lethargy, difficulty opening her eyes, R-sided nystagmus,
and bilateral lower extremity weakness. Rectal exam showed brown
guaiac positive stool. Labs notable for Hgb 4.4, alk phos 154,
Na
133, bicarb 18 with normal AG, and glucose 358. Troponins were
negative. She was given 2 units of pRBCs with repeat CBC showing
an
increase of Hgb to 4.8 in the middle of the first unit of prBCs.
Urinalysis showed no ketones. NCHCT was normal. CTA head/neck
showed patent vasculature. She was given 0.25 mg IV lorazepam
and 8 units
insulin lispro.
Upon arrival to the floor, she gave the above story. She was
working up until presenting on ___ but felt so diffusely
weak that she had to come into the hospital. Her headache at
presentation is significantly improved from the ED.
Past Medical History:
Type 2 diabetes mellitus, on insulin
Hypertension
Hyperlipidemia
Social History:
___
Family History:
No family history of peptic ulcer disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITALS: ___ / ___
GENERAL: Older woman laying in bed in NAD. Alert and
interactive.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Grade
___ systolic ejection murmur heard throughout precordium. 2+
radial pulses
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXT: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash. No jaundice. No ecchymoses.
No petechiae.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 1646)
Temp: 97.6 (Tm 98.8), BP: 140/58 (140-183/58-85), HR: 74
(70-106), RR: 18, O2 sat: 99% (96-100), O2 delivery: RA
GENERAL: Older woman laying in bed in NAD. Alert and
interactive.
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Grade
___ systolic ejection murmur heard throughout precordium. 2+
radial pulses
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXT: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rash. No jaundice. No ecchymoses.
No petechiae.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength in blt ___.
Normal sensation.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:30PM BLOOD WBC-5.6 RBC-2.28* Hgb-4.4* Hct-17.1*
MCV-75* MCH-19.3* MCHC-25.7* RDW-17.6* RDWSD-48.1* Plt ___
___ 08:30PM BLOOD Neuts-67.4 ___ Monos-7.9 Eos-2.1
Baso-0.5 NRBC-0.4* Im ___ AbsNeut-3.77 AbsLymp-1.21
AbsMono-0.44 AbsEos-0.12 AbsBaso-0.03
___ 08:30PM BLOOD ___ PTT-24.2* ___
___ 08:30PM BLOOD Glucose-358* UreaN-27* Creat-1.2* Na-133*
K-5.2 Cl-102 HCO3-18* AnGap-13
___ 08:30PM BLOOD ALT-12 AST-17 AlkPhos-154* TotBili-<0.2
___ 08:30PM BLOOD cTropnT-<0.01
___ 08:30PM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.2 Mg-2.2
___ 08:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
PERTINENT LABS:
===============
___ 12:40AM BLOOD Iron-13*
___ 12:40AM BLOOD calTIBC-423 VitB12-450 Folate-20
___ Ferritn-5.1* TRF-325
___ 04:59AM BLOOD %HbA1c-9.7* eAG-232*
___ 07:28AM BLOOD TSH-2.9
PERTINENT IMAGING:
=================
___ CTA head/neck:
1. No acute intracranial process or mass.
2. Mild bilateral atherosclerotic stenosis of the intracranial
ICA, more
pronounced on the left.
3. Otherwise patent circle of ___ without evidence of
stenosis,occlusion,or
aneurysm.
4. Mild atherosclerotic stenosis of the bilateral vertebral
artery origins and
proximal left internal carotid artery.
5. Otherwise patent bilateral cervical carotid and vertebral
arteries without
evidence of stenosis, occlusion, or dissection.
6. Mild periventricular and subcortical white matter
hypodensities,
nonspecific but likely sequelae of chronic small vessel disease.
___ KUB:
There is an endoscopy capsule projecting over the right upper
quadrant, likely
within the ascending colon. No features of bowel obstruction.
DISCHARGE LABS:
===============
___ 05:42AM BLOOD WBC-8.1 RBC-3.73* Hgb-8.5* Hct-29.5*
MCV-79* MCH-22.8* MCHC-28.8* RDW-18.5* RDWSD-52.1* Plt ___
___ 05:42AM BLOOD Glucose-128* UreaN-13 Creat-0.8 Na-142
K-4.1 Cl-108 HCO3-19* AnGap-15
___ 05:42AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ year old F w/ HTN, type II DM, PVD, macular
edema who presented with dizziness and a headache. In the ED,
she was found to have a Hgb of 4.4 with positive guaiac and
received 3 units of pRBCs. She denied any noticeable bleeding.
She underwent EGD, colonoscopy, and capsule study during this
admission. On the capsule study, she was found to have a
non-bleeding AVM in the duodenum. On ___, she underwent push
endoscopy with plan to ablate the AVM, but it could not located.
Subsequent with stable Hgb, able to be discharged with Hgb
stable at 8.5.
# Anemia of chronic blood loss
Patient with a history of admission for severe anemia, with
workup notable for gastric ulcers and erosions, with a single
sessile 6 mm polyp of benign appearance, subsequently treated
with PPI, who presented with weakness and was found to have a
Hgb of 4.4 with brown guaiac positive stool. She was transfused
3 units of pRBCs and admitted for additional workup She denied
any episodes of over bleeding or dark stools. Continued on high
dose PPI. She underwent repeat EGD and colonoscopy without
obvious sources of bleeding. A capsule study showed
non-bleeding AVM in the duodenum. On ___, she underwent push
enteroscopy with plan to ablate the AVM, however it was not able
to be located. Hgb subsequently remained stable and per
discussion with GI consult service, she was discharged home Hgb
8.5. For low ferritin, she was given two infusions of Ferrous
gluconate prior to transitioning to oral iron supplementation.
Of note, capsule did not reach cecum--future workup if anemia
recurs might consider repeat capsule study, repeat push
enteroscopy, or hematology workup for primary bone marrow
process. Was found to have gastric erythema--continued home PPI
# Headache
Presented with headache and weakness, as well as reports of
fluctuating dizziness. She underwent a CTA head and neck in ED
without causative etiology identified. Symptoms resolved after
transfusion and initiation of PO diet. No concern for acute
neurologic process.
# Bilateral ___ cramping
In setting of anemia and iron deficiency she reported cramping
in her legs. Electrolytes normal. Thought to relate to
restless leg syndrome from her severe iron deficiency. Her
anemia and iron deficiency were treated as above, with
improvement in symptoms.
# ___
On admission her Cre was 1.2, thought to be due to her severe
anemia. Cr improved to 0.8 and remained there prior to
discharge.
# Elevated alk phos
She presented with Alk-phos of 154. She denied any abdominal
pain and the rest of her LFTs were within normal limits. Her alk
phos downtrended to within normal limits prior to discharge.
Unclear etiology of this transient elevation of her alk phos.
# type II DM
Her last A1c on record was 9.5% in ___. She reports taking
lantus 10 or 17 units qam based on her previous night's blood
sugar. Given extent of her chronic anemia, and her recent
transfusion, A1c 9.7% not felt to be accurate representation of
her 3month glucose control. While inpatient, she was continued
on glargine 17units qam with an overlying humalog sliding scale.
Consider referral for diabetes education.
# Fungal dermatitis
She was found to have a fungal rash around her waist band and
was started on nystatin powder this admission with improvement.
Please reassess at follow-up
# HTN
She was continued on her home lisinopril.
# Vision loss
Recent ophtho workup as an outpatient shows macular edema
bilaterally and subhyaloid hemorrhage in L eye. It also showed
likely R central artery occlusion. She has been undergoing
retinal photocoagulation treatment in both eyes. There was no
change in her vision during her hospital stay.
# HLD
She was continued on her home atorvastatin.
TRANSITIONAL ISSUES:
[ ] Consider Hgb recheck at follow-up to ensure stability.
Would also consider periodic checks for stability as well.
Consider GI referral. If anemia recurs without signs of GI
losses, would also consider hematology referral to rule out
potential primary bone marrow process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. Glargine 17 Units Breakfast
4. Atorvastatin 40 mg PO QPM
5. Janumet XR (SITagliptin-metformin) 100-1,000 mg oral QPM
Discharge Medications:
1. Ferrous Sulfate 325 mg PO EVERY OTHER DAY
RX *ferrous sulfate [Feosol] 325 mg (65 mg iron) 1 tablet(s) by
mouth every other day Disp #*30 Tablet Refills:*0
2. Nystatin Ointment 1 Appl TP QID Itching/rash
RX *nystatin 100,000 unit/gram apply to affected area four times
per day Refills:*0
3. Glargine 17 Units Breakfast
4. Atorvastatin 40 mg PO QPM
5. Janumet XR (SITagliptin-metformin) 100-1,000 mg oral QPM
6. Lisinopril 40 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Acute on chronic Microcytic Anemia
Secondary diagnoses
AV malformation
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 IN THE HOSPITAL?
==========================
- You were admitted because you were weak and lightheaded and
found to have low blood levels. A test of your stool was
positive for blood.
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You were given blood and iron to help bring your levels
higher.
-In the hospital we performed several studies to look for a
source of the bleed. These studies demonstrated an abnormal
blood vessel in your small intestine that likely is the source
of the bleed. The GI (stomach) doctors tried to ___ and stop the
blood vessel from bleeding anymore but the blood vessel was no
longer visible by that time.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Be sure to take all your medications and attend all of your
appointments listed below. If you feel weak and lightheaded
again please contact your doctor or go to the emergency
department.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19915923-DS-17 | 19,915,923 | 22,730,128 | DS | 17 | 2177-04-09 00:00:00 | 2177-04-09 13:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin
Attending: ___.
Chief Complaint:
progressive weakness, myalgias, dysphagia
Major Surgical or Invasive Procedure:
IVIG administration ___ and ___
History of Present Illness:
___ with diagnosis of antisynthetase antibody presenting with
progressive
weakness, myalgias, and dysphagia despite outpatient management.
Pt recalls that she received IVIG on ___ and ___, immediately
after which (on ___ she noted progressive myalgias and
weakness. She was unable to eat until ___ nausea,
vomiting. Emesis was nonbloody, bilious. She recounts inability
to take any solids during that period, only able to take water
and iced tea. A migraine accompanied her anorexia. On ___
she
tolerated ice cream. On ___ her appetite improved such that she
was able to eat a cheeseburger ("It was awesome!"). She
describes
dysphagia, requiring small bites followed by liquid intake
between every bite. She has no dysphagia to liquids. On ___,
she felt that her fatigue and nausea (which she attributes to
IVIG infusion) had improved. Since that time, she has been
eating
one meal per day, typically late afternoons, and has noted
associated nonbloody diarrhea, brown/green, not associated in
any
clear way with PO intake. She describes 3 falls always in the
setting of trying to stand from sitting, ___ ___ weakness. Her
weakness is worse than at the time of initial diagnosis in
___. She apparently had a single fever to 102 the week
prior to presentation, which self resolved. She was seen in
___ clinic on ___, at which time CK was elevated to
27,655 (prior peak value 13,928 on admission ___.
Prednisone was increased to 40 mg PO BID, without improvement in
weakness and myalgias. After 3 falls at home, and in discussion
with her primary rheumatologist (Dr. ___, she
presented to the ED for inpatient management of refractory
antisynthetase syndrome.
Per Dr. ___ dated ___:
"She was [initially] treated with high dose prednisone (started
60mg qday on ___ followed by gradually uptitrated cellcept to
3gm daily, prednisone tapered to 40mg daily (20mg BID) after CK
improved on ___ labs. However, she then had gradually rising
CK prompting initiation of IVIG with 2gm/kg in ___ then 1gm/kg
(adjusted BW) in ___ with severe post infusion side effects.
MMF dose also decreased slightly to 2.5gm daily due to diarrhea
and hair loss.
"CK initially improved after ___ IVIG dose (5015->3363->1840)
but
she then developed severe proximal lower extremity myalgias,
weakness, and new dysphagia (liquids> solids) x 3 weeks. Labs on
___ confirmed recurrence with CK 27,655 and worsening
transaminitis. Plan to resume high dose IVIG in weekly doses,
change MMF to AZA, but on today's visit, she's had no response
to
several doses of prednisone at 1mg/kg/day (since ___ ___. She
has markedly reduced strength in her proximal lower extremities,
new dysphagia, and two recent falls. At this point, she is
failing outpatient management and admission for pulse steroids
will be initiated."
Of note, she completed a course of valacyclovir for VZV
infection
over L eyelid, and now continues on ppx.
She denies chest pain although has constant chest tightness.
Breathing gets more difficulty in the heat, but otherwise has
been stable. She has noted intermittent vision "haziness," which
she has noticed since IVIG infusions. Described as blurriness
when standing up. Also noted darker urine.
In the ___ ED:
VS 98.2, 97, 123/72, 98% RA
Exam notable for weakness ___
Labs notable for WBC 21.8, Hb 13.3, Plt 379
Cr 0.4
CK 8877
Urine HCG negative
UA negative
ALT 191
AST 214
Alk phos 55
Tbili 0.2
Albumin 3.4
Received:
IVF
Oxycodone 5 mg
Methylprednisolone 1000 mg IV x1
On arrival to the floor, pain is ___, worst in bilateral LEs,
symmetric pain, UEs also are painful, unable to lift above level
of her shoulders. Nausea is well controlled. No current
headaches.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
Hypothyroidism with ? childhood thyroiditis
Antisynthetase syndrome (+ ___
Endometriosis
Migraines
Social History:
___
Family History:
Father (deceased) with RA
Paternal aunt with RA, psoriasis
Mother also deceased
No history of OA, SLE, Scleroderma, Sjogren's disease, IBD,
thyroid disease, diabetes mellitus.
Physical Exam:
Admission physical exam
VS: ___ Temp: 98.5 PO BP: 116/71 L Sitting HR: 70 RR:
18 O2 sat: 97% O2 delivery: ra Dyspnea: 0 RASS: 0 Pain Score:
___
GEN: alert and interactive, delightful, comfortable at rest, no
acute distress
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles, good air movement throughout
GI: soft, diffuse abdominal wall TTP, no rebounding or guarding,
nondistended with normal active bowel sounds, no hepatomegaly
appreciated
EXTREMITIES: no clubbing, cyanosis, or edema; diffuse mild TTP
LEs>UEs
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation, multiple tattoos
NEURO: Alert and interactive, cranial nerves II-XII grossly
intact, sensation grossly intact to light touch. Strength is
4+/5
R shoulder abduction and adduction, ___ L shoulder abduction,
4+/5 L shoulder adduction, 4+/5 elbow flexion and extension, ___
bilateral hip flexion, ___ bilateral knee flexion, 3+/5
bilateral
knee flexion, 4+/5 bilateral dorsiflexion and plantarflexion.
Grimaces with all strength testing, LEs>UEs. Negative Hoover's
sign (ie contralateral heel does push down into examiner's hand,
reflecting effort to flex contralateral hip). With great effort,
able to abduct bilateral UEs above shoulder level.
PSYCH: normal mood and affect
Discharge physical exam
VITALS: ___ Temp: 98.5 PO BP: 95/62 HR: 86 RR: 16 O2 sat:
98% O2 delivery: Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, no conjunctival injection, pupils equally round
CV: Heart regular, no murmur, no S3, no S4.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, mild diffuse tenderness, non-distended. No
rebound or guarding.
EXT: Warm and well perfused. No ___ edema. Diffusely tender to
palpation (thighs, calves, shoulders)
NEURO: Alert, oriented, face symmetric, gaze conjugate with EOM,
speech fluent, moves all limbs did not test strength today
PSYCH: pleasant, appropriate mood and affect
Pertinent Results:
___ 06:00AM BLOOD WBC-13.5* RBC-4.47 Hgb-13.3 Hct-41.9
MCV-94 MCH-29.8 MCHC-31.7* RDW-14.0 RDWSD-47.5* Plt ___
___ 06:25AM BLOOD WBC-12.4* RBC-4.52 Hgb-13.4 Hct-42.7
MCV-95 MCH-29.6 MCHC-31.4* RDW-14.1 RDWSD-48.1* Plt ___
___ 06:25AM BLOOD Glucose-76 UreaN-10 Creat-0.4 Na-144
K-4.7 Cl-103 HCO3-26 AnGap-15
___ 06:00AM BLOOD ALT-116* AST-119* CK(CPK)-2578*
___ 06:25AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.1
___ 06:30AM BLOOD TSH-8.8*
Brief Hospital Course:
___ with hx of hypothyroidism and anti-synthetase syndrome
(___) diagnosed ___, treated with prednisone, MMF, and
IVIG now presenting with progressive myalgias, weakness, and
dysphagia despite escalating doses of prednisone as outpatient.
When she was admitted to the hospital she was initiated on high
dose pulse steroids. Following this, azathioprine was started
followed by IVIG, which she tolerated well. Ultimately she will
be discharged home with Prednisone 60mg, Azathioprine, and IVIG
weekly infusions as well as rheum f/u. Her dysphagia improved
with steroids.
# Refractory anti-synthetase syndrome:
# Dysphagia:
-With elevated CPK as outpatient, myalgias and dysphagia, as
well as progressively worsening weakness. Weakness improved with
use of pulse steroids and subsequently IVIG. She was also
initiated on azathioprine. She was seen by speech & swallow who
advised a regular diet, her dysphagia symptoms improved
significantly with steroids. She was continued on home Bactrim,
calcium, vitamin D.
-Continue Azathioprime, Prednisone 60mg, and Weekly IVIG until
she sees rheumatology on ___.
-Could consider EGD if dysphagia recurs, tolerating regular diet
on discharge
#Elevated LFTs- Likely related to myositis and anti-synthetase
syndrome.
-Trend lft's with CPK at ___ clinic
# Diarrhea: Resolved
# Recent VZV reactivation:
- Continue Acyclovir on discharge until she sees rheumatology
# Hypothyroidism:
- Continue home levothyroxine 50 mcg daily
- TSH 8.8, free t4 1.1, no changes made to levothyroxine (TSH
likely abnormal in the setting of acute illness)
Time spent: > 30 minutes on discharge planning, care,
coordination
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 40 mg PO BID
2. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
3. Ondansetron ODT 4 mg PO Q8H:PRN nausea
4. Amitriptyline 10 mg PO QHS
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Pantoprazole 40 mg PO Q24H
7. Docusate Sodium 100 mg PO BID
8. Cyanocobalamin 1000 mcg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Calcium Carbonate 500 mg PO DAILY
11. Senna 8.6 mg PO BID:PRN Constipation - First Line
12. ValACYclovir 500 mg PO Q24H
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Acyclovir 800 mg PO Q8H
2. AzaTHIOprine 100 mg PO QHS
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
4. PredniSONE 60 mg PO DAILY
5. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
6. Amitriptyline 10 mg PO QHS
7. Calcium Carbonate 500 mg PO DAILY
8. Cyanocobalamin 1000 mcg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Ondansetron ODT 4 mg PO Q8H:PRN nausea
12. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Severe
13. Pantoprazole 40 mg PO Q24H
14. Senna 8.6 mg PO BID:PRN Constipation - First Line
15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Anti-synthetase syndrome
-Abdominal Pain
-Elevated LFTs
-VZV reactivation
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 with weakness and muscle aches
attributed to your condition, anti synthetase syndrome. You
received high dose IV steroids and IVIG, and ultimately you will
be discharged on a regimen of weekly IVIG and Prednisone as well
as Azathioprine. You will need to continue home physical therapy
and occupational therapy in rehabilitation. You will continue
IVIG in the ___ weekly and follow-up with
Rheumatology in the clinic.
We wish you the best going forward!
Sincerely,
Your care team at ___
Followup Instructions:
___
|
19915985-DS-18 | 19,915,985 | 28,996,362 | DS | 18 | 2132-11-24 00:00:00 | 2132-12-01 15:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___ Laparoscopic appendectomy
History of Present Illness:
___, no PMH, presenting with 24 hours of abdominal pain and
distention. He reports that he woke up yesterday morning with
diffuse abdominal pain that migrated to the RLQ today. He
reports
subjective fevers at home, but no other symptoms.
Past Medical History:
Past Medical History: none
Past Surgical History: gum surgery
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
Vitals: 101.9 103 156/69 21 95%RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, tender to palpation in the RLQ, no
rebound or guarding
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS:
GEN: Awake, alert, pleasant and interactive.
CV: RRR
PULM: Clear to auscultation bilaterally
ABD: Soft, non-tender, non-distended. Active bowel sounds.
EXT: Warm and dry. 2+ ___ pulses.
NEURO: A&Ox3. Follows commands and moves all extremities equal
and strong. Speech is clear and fluent.
Pertinent Results:
___ 06:05AM BLOOD WBC-9.4 RBC-4.27* Hgb-13.0* Hct-40.0
MCV-94 MCH-30.4 MCHC-32.5 RDW-12.3 RDWSD-42.2 Plt ___
___ 03:02AM BLOOD WBC-14.6* RBC-4.35* Hgb-13.3* Hct-40.9
MCV-94 MCH-30.6 MCHC-32.5 RDW-12.0 RDWSD-42.0 Plt ___
___ 12:15PM BLOOD WBC-20.6* RBC-5.40 Hgb-16.8 Hct-50.0
MCV-93 MCH-31.1 MCHC-33.6 RDW-12.0 RDWSD-40.8 Plt ___
___ 04:15PM BLOOD ___ PTT-28.0 ___
___ 03:02AM BLOOD Glucose-127* UreaN-11 Creat-1.0 Na-140
K-3.8 Cl-103 HCO3-23 AnGap-14
___ 12:15PM BLOOD Glucose-122* UreaN-11 Creat-1.3* Na-135
K-4.1 Cl-94* HCO3-27 AnGap-14
___ 03:02AM BLOOD Calcium-8.4 Phos-2.5* Mg-1.8
___ 11:40AM URINE Blood-TR* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.5 Leuks-NEG
___ 11:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
CT A/P ___
1. Appendicitis with dilatation of the appendix to 1.2 cm near
the tip. Trace foci of free air are concerning for perforation.
A focal area of high density near the base of the appendix
could represent an appendicolith. There is a small amount of
free fluid. Small volume fluid at the base of the cecum, with
no evidence of organized drainable collection.
2. Adjacent to the appendicitis there is substantial right lower
quadrant
stranding and thickening involving the nearby cecum and terminal
ileum as well as a focal area of prominence of the mid to distal
ureter, most likely secondary to the appendicitis.
Brief Hospital Course:
Mr. ___ is a ___ M who was admitted to the acute Care Surgery
Service on ___ with abdominal pain and CT scan consistent
with perforated appendicitis. White blood cell count elevated at
20.6. He was made NPO and give IV antibiotics. Informed consent
was obtained and hew as taken to the operating room late on
___ for laparoscopic appendectomy. After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating clears on IV fluids, and IV for pain control. The
patient was hemodynamically stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. On POD1 surgical drain was
removed. 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. The patient was discharged to complete a
course of antibiotics with Augmentin.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
Discharge Disposition:
Home
Discharge Diagnosis:
Acute perforated appendicitis
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 Acute Care Surgery Service with
abdominal pain and were found to have an infection in your
appendix. You were given antibiotics and underwent surgery to
removed your appendix. You are doing better, tolerating a
regular diet, and pain is better controlled. You are now ready
to be discharged home to continue your recovery.
Please note the following discharge instructions:
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 gauze over your drain
site. You can replace it if it continues to drain with gauze and
paper tape.
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:
___
|
19916349-DS-14 | 19,916,349 | 29,238,144 | DS | 14 | 2201-09-07 00:00:00 | 2201-09-07 19:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
___ F p/w 2 hours of severe RUQ and lower abdominal pain.
Patient reports no issues until 2 hours ago had severe RUQ pain
after eating eggs. She also has lower abdominal pain mainly on
th left side. She reports a similar episode of pain several
months ago but never presented to a hospital. She denies
fevers,
chills, nausea, emesis or diarrhea. She reports associated
sweats. Currently she is having significant pain and is
clutching her upper abdomen moaning.
Past Medical History:
PMH: h/o multinodular goiter s/p L thyroid lobectomy and
isthmectomy, h/o Polio as a child (has residual weaknes, but is
able to ambulate without a walker)
PSH: ___ (Dr. ___ - Left thyroid lobectomy and
isthmectomy
for multinodular goiter (dominant on L) and right midthyroid
excision of small benign nodule
PSH: thyrodectomy, ventral hernia repair (small defect above
umbilicus)
Social History:
___
Family History:
Mo - cancer in abdomen (patient does not recall what kind);
Sister - cardiac disease
Physical Exam:
PE: ___:
VS: 97.6 80 119/90 18 100% RA
Gen: NAD/AOx3
___: reg
Pulm: no resp distress
Abd: S/ND/TTP RUQ + ___, also min TTP LLQ, seems
distractable. No peritonitis.
___: no LLE
Pertinent Results:
___ 02:43PM BLOOD WBC-6.1 RBC-3.63* Hgb-11.3* Hct-34.4*
MCV-95 MCH-31.3 MCHC-32.9 RDW-12.7 Plt ___
___ 02:43PM BLOOD Neuts-58.9 ___ Monos-5.3 Eos-1.4
Baso-0.7
___ 10:40AM BLOOD ___ PTT-40.2* ___
___ 02:43PM BLOOD Plt ___
___ 02:43PM BLOOD Glucose-121* UreaN-8 Creat-0.6 Na-140
K-3.5 Cl-101 HCO3-25 AnGap-18
___ 02:43PM BLOOD Albumin-4.2 Calcium-8.9 Phos-3.3 Mg-1.5*
___: liver/gallbladder US:
The gallbladder is distended and contains multiple gallstones.
These findings can be seen in the setting of acute cholecystitis
in the correct clinical setting although no other findings of
acute cholecystitis are noted.
___: cat scan of abdomen and pelvis:
Distended gallbladder with pericholecystic fluid. In the
appropriate clinical setting these findings could represent
acute cholecystitis.
Brief Hospital Course:
Patient was admitted on ___ under the acute care surgery
service for management of her symptomatic cholelithiasis. She
was taken to the operating room and underwent a laparoscopic
cholecystectomy. Please see operative report for details of this
procedure. She tolerated the procedure well and was extubated
upon completion. She was subsequently taken to the PACU for
recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. She was voiding adequate amounts of urine
without difficulty. She was encouraged to mobilize out of bed
and ambulate as tolerated, which she was able to do
independently. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
On ___, she was discharged home with scheduled follow up in
___ clinic on ___.
Medications on Admission:
tramadol 50 mg''
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with symptomatic
cholilithiasis and possible acute cholecystitis. You were taken
to the operating room and had your gallbladder removed
laparoscopically. You tolerated the procedure well and are now
being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19916836-DS-19 | 19,916,836 | 20,562,862 | DS | 19 | 2141-12-04 00:00:00 | 2141-12-05 13:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lipitor
Attending: ___.
Chief Complaint:
left leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with hx of PVD with 3 right-sided iliac
stents, CAD s/p 1 stent in ___, presenting to ___ with
chief complaint of worsening LLE and calf pain/claudication. She
works as a ___ and started a new route about 1 month
ago which has more stairs and is also working longer hours. Her
pain gradually started about 2 months ago while walking as
left-sided, relatively focal mid-latera calf pain. The pain
feels like a blow torch inside her leg. It would force her to
stop walking and either sit or simply stand for a couple of
minutes to let it ease down, after which she could then walk
with some lingering discomfort without needing to stop again. If
she stopped for a prolonged period of time and then started
walking again, the pain would again recur more severely
requiring a brief rest before easing down and allowing her to
continue walking.
This pain has been increasing in severity and frequency over the
past couple of weeks in particular, prompting her to seek
medical care. She saw her PCP who performed ___ left knee x-ray
that was reportedly normal. Today she developed similar, severe
pain that persisted despite rest, prompting her to go to the
___ for further work-up. Given vascular history and
concern for ongoing rest pain, she was started on Heparin drip
prior to transfer from ___. She does take Plavix and ASA
daily for her stents and has not missed a dose. She denies any
other notable symptoms including numbness, tingling, weakness,
cool/pale extremities, or trauma.
She has chronic right-sided sciatica pain which is very distinct
from her current left calf pain. She also has chronic lower back
pain which is unchanged from her baseline. She has no radiation
of her current pain, no knee, hip, or groin pain either.
In the ___ initial vitals were: 98.3 51 99/66 16 98% RA
- Labs were significant for normal CBC, chem 7, and CK 84. PTT
57 on heparin gtt.
- Seen by vascular who felt there were no signs of vascular
ischemia.
- ___ showed no DVT.
- Patient was given heparin bolus + gtt.
Vitals prior to transfer were: 54 128/102 16 96% RA
On the floor, initial VS: 97.5 99/59 55 14 97%RA
She was lying comfortably in bed in NAD.
Past Medical History:
- COPD
- GERD
- PAD with L iliac stenting
- CAD with single PCI in ___
- arthritis
- cervical radiculopathy
- anxiety/depression
- hyperlipidemia
- overactive bladder
Social History:
___
Family History:
Significant for coronary artery disease,
hypercholesterolemia, pulmonary disease, peripheral arterial
disease, and stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.5 99/59 55 14 97%RA
GENERAL: thin, well-developed, well-nourished, adult female
lying comfortably in bed in NAD.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no external abnormalities ___ bilaterally. no
overlying erythema or any other lesions over left calf. no
edema. pain over mid-left lateral calf is reproducible with
palpation over the muscle/soft tissue in this area. no bony pain
along shin. full ROM of ankle, knee, and hip without any
discomfort or limitation including with ___. pedal pulses
easily dopplerable b/l. strength and sensation ___ b/l fully
intact. small, subtle 1cm bruise present below the area of pain
on left calf which is not tender.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals - 98.7, 110/67, 59, 16, 97% on RA
GENERAL: thin, well-developed, well-nourished, adult female
lying comfortably in bed in NAD.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no external abnormalities ___ bilaterally. no
overlying erythema or any other lesions over left calf. no edema
of BLE. pain over mid-left lateral calf is reproducible with
palpation over the muscle/soft tissue in this area. no bony pain
along shin. full ROM of ankle, knee, and hip without any
discomfort or limitation including with ___. pedal pulses
easily dopplerable b/l. strength and sensation ___ b/l fully
intact. small, subtle 1cm bruise present below the area of pain
on left calf which is not tender.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
=====================================
___ 07:14PM GLUCOSE-74 UREA N-13 CREAT-0.7 SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
___ 07:14PM CALCIUM-9.3 PHOSPHATE-3.9 MAGNESIUM-2.2
___ 07:14PM WBC-4.0 RBC-4.19* HGB-12.9 HCT-38.0 MCV-91
MCH-30.8 MCHC-34.0 RDW-13.5
___ 07:14PM NEUTS-46.0* LYMPHS-46.5* MONOS-4.6 EOS-2.3
BASOS-0.6
___ 07:14PM ___ PTT-57.1* ___
___ 07:14PM CK(CPK)-84
DISCHARGE LABS
=====================================
None
STUDIES
=====================================
___ ART DUP EXT LO UNI
FINDINGS: Duplex was performed of the left lower extremity
arterial system.
Common femoral artery is patent with a triphasic waveform. The
profunda is patent with a monophasic waveform. The SFA is
patent with triphasic waveforms. Popliteal is patent with
triphasic waveforms. The posterior tibial, peroneal and
anterior tibial are patent with biphasic waveforms.
Plaque is seen within the common femoral artery. Peak
velocities are 154 in the external iliac distally, 141 in the
common femoral, 131 in the profunda, 117, 123, 179 and 125 in
the SFA, 53 and 47 in the popliteal, 41 in the posterior tibial,
34 in the peroneal and 43 in the anterior tibial.
IMPRESSION: Left common femoral plaque without evidence of
velocity step up from the external iliac through the tibial
vessels.
___ UNILATERAL LOWER EXT VEINS
IMPRESSION: No evidence of DVT in the left lower extremity.
___ Left TIB-FIB XRAY
IMPRESSION: No evidence of displaced fracture or
dislocation of the left tibia or fibula.
Brief Hospital Course:
___ year old female with hx of PVD with 3 iliac stents, CAD s/p 1
stent, presenting with chief complaint of worsening LLE and calf
pain.
# Left calf pain: Presentation is most consistent with
claudication in the setting of her significant PVD. Although
her arterial study showed no flow abnormalities, she likely has
occlusion of a smaller artery not directly visualized. The
patient was evaluated by Vascular Surgery who will schedule her
for an angiogram early this next week as an outpatient. The
patient's heparin gtt was stopped. Normal CK ruled out myositis
so she was restarted on her home Lipitor. The patient was
instructed to avoid NSAIDs given her history significant for CAD
and PAD.
# COPD: Pt denied home meds.
# GERD: Omeprazole while in-house (esomeprazole non-formulary).
# PAD with L iliac stenting: Continued home ASA, plavix.
# CAD with single PCI in ___: Continued home ASA, plavix.
# HLD: Patient's home statin was held prior to hospitalization
because of concern for drug-related myalgias. Her CK was normal
however, so her Lipitor was restarted at discharge.
***TRANSITIONAL ISSUES***
- Restarted home Lipitor
- Patient will be contacted by Vascular Surgery Clinic regarding
appointment on ___ she was instructed to call Dr.
___ if she does not hear from them by ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. NexIUM (esomeprazole magnesium) 40 mg oral Daily
5. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. NexIUM (esomeprazole magnesium) 40 mg oral Daily
3. ALPRAZolam 0.25 mg PO QHS:PRN insomnia
4. Aspirin 325 mg PO DAILY
5. Clopidogrel 75 mg PO DAILY
6. Metoprolol Tartrate 50 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain
Do not take when operating machinery, driving, or with alcohol.
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Lower left extremity claudication
Secondary:
Peripheral vascular disease
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___. You were admitted for left leg pain. You were
evaluated by the Vascular Surgery who found that you have no
decreased blood flow in your leg. However, you may have a small
artery that might be somewhat blocked and causing your leg pain.
The vascular surgeons will see you in their clinic. They will
contact you regarding your appointment.
You should continue taking your home medications, including your
Lipitor.
Thank you for allowing us to participate in your care. All best
wishes for your recovery.
Sincerely,
Your ___ medical team
Followup Instructions:
___
|
19916882-DS-23 | 19,916,882 | 26,055,942 | DS | 23 | 2141-02-06 00:00:00 | 2141-02-07 08:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
codeine
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of ex-lap/splenectomy (___) and multiple SBOs (>10
managed conservatively) who is s/p ex-lap for SBO on ___ with
extensive LOA. He is now presenting with worsening abdominal
pain x24 hours. He endorses associated
nausea but no vomiting. He reports most recent flatus was 1:30
AM ___ (4.5 hours prior to presentation). Last BM was in the
morning ___ (1 day ago). He denies associated fevers/chills,
sick contacts, other interim changes to medical history.
Past Medical History:
PMH: GERD, SBOs, ?glaucoma, sickle cell trait
PSH: ex-lap/splenectomy ___, foot surgery
Social History:
___
Family History:
non contributory
Physical Exam:
Physical Exam on Admission:
Vitals:
Pain 10, T 98.9, HR 101, BP 135/68, RR 17, O2 99% RA
Gen: AAOx3, distressed ___ discomfort
CV: NSR
Resp: CLAB
Abd: Soft, very TTP worse at incision but diffusely, and without
guarding; incision is c/d/i with staples, no masses or hernia
Extrem: palp distal pulses
Physical Exam on Discharge:
Gen: AAOx3, NAD
CV: RRR, no murmur
Resp: CTAB, no respiratory distress
Abd: Soft, non-tender, non-distended, and without guarding;
incision is c/d/i with staples, no masses or hernia
Extrem: palp distal pulses, warm well perfused
Pertinent Results:
___ 04:40AM BLOOD WBC-8.2 RBC-4.39* Hgb-11.4* Hct-34.4*
MCV-78* MCH-26.0 MCHC-33.1 RDW-14.6 RDWSD-40.2 Plt ___
___ 12:21AM BLOOD WBC-6.6 RBC-4.12* Hgb-10.8* Hct-31.9*
MCV-77* MCH-26.2 MCHC-33.9 RDW-14.3 RDWSD-39.8 Plt ___
___ 07:20AM BLOOD WBC-5.9 RBC-4.23* Hgb-11.2* Hct-33.8*
MCV-80* MCH-26.5 MCHC-33.1 RDW-14.7 RDWSD-42.2 Plt ___
___ 04:40AM BLOOD Neuts-76.1* Lymphs-13.4* Monos-8.1
Eos-1.3 Baso-0.5 Im ___ AbsNeut-6.23* AbsLymp-1.10*
AbsMono-0.66 AbsEos-0.11 AbsBaso-0.04
___ 12:21AM BLOOD Neuts-65.0 ___ Monos-9.7 Eos-2.3
Baso-0.6 Im ___ AbsNeut-4.30 AbsLymp-1.45 AbsMono-0.64
AbsEos-0.15 AbsBaso-0.04
___ 04:40AM BLOOD Glucose-112* UreaN-9 Creat-0.8 Na-137
K-4.5 Cl-99 HCO3-23 AnGap-20
___ 12:21AM BLOOD Glucose-91 UreaN-9 Creat-0.8 Na-138 K-4.0
Cl-101 HCO3-26 AnGap-15
___ 07:20AM BLOOD Glucose-99 UreaN-9 Creat-1.0 Na-139 K-4.6
Cl-99 HCO3-20* AnGap-25*
___ 12:21AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.8
___ 07:20AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.1
IMAGING:
KUB ___
IMPRESSION:
No evidence small bowel obstruction.
Brief Hospital Course:
The patient presented to the Emergency Department on ___
with abdominal pain . KUB was done that did now show any signs
of obstruction, but due to his symptoms, the patient was
admitted to the acute care surgery service for management. NGT
was placed for decompression. Immediately after placement of
NGT, patient felt abdominal pain relief.
On HD2, patient states much improved abdominal pain and was also
passing flatus. Clamp trial was conducted with low residual and
the NGT was removed. Patient did well after NGT removal.
HD3, diet was advanced and patient tolerated diet, continued to
pass flatus and having bowel movement. At the this time patient
was ready for discharge.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You were admitted to the hospital with a small
bowel obstruction after recent abdominal surgery. You had a
nasogastric tube placed to help decompress your bowels. Once
your abdominal pain improved, this tube was removed and you then
resumed having bowel function. You are now tolerating a
regular diet and your pain has improved. You are now ready to
be discharged home to continue your recovery. Please follow the
discharge instructions below to ensure a safe recovery at home:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19916931-DS-10 | 19,916,931 | 21,668,263 | DS | 10 | 2133-01-18 00:00:00 | 2133-01-18 10:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
___: Upper EUS/EGD
___: Upper EUS/EGD
___: Palliative gastrojejunostomy, G-tube insertion, and
J-tube insertion.
History of Present Illness:
___ with a longstanding history of NSAID use who was recently
was diagnosed with a duodenal ulcer now presents with
post-prandial pain relieved with emesis. Mr. ___ notes that
he has had several months of abdominal pain and emesis so
underwent EGD on ___. The EGD was severely limited by food
contents, but revealed a large deep ulcer at junction of D1-2
with mild D2 obstruction. Tissue biopsies were not obtained. He
was started on omeprazole 20mg twice daily but his symptoms
never completely improved on PPI therapy and have worsened over
the past two weeks. He is now reports pain and non-bilious
emesis approximately two hours after every meal. Given poor PO
intake he
presented to the ED. Weight has been largely stable despite
minimal po intake; states possible weight loss of ___.
Past Medical History:
Pre-diabetic
Hyperlipidemia
Aortic aneurysm
Social History:
___
Family History:
Father: ulcers
No family hx of cancer
Physical Exam:
On admission:
Vitals: 97.6 136/66 70 16 97%RA
GEN: WDWN elderly male, No acute distress.
HEENT: Dry mucous membranes, no lesions noted. Sclerae
anicteric. No conjunctival pallor noted.
NECK: JVP not elevated. No lympadenopathy.
CV: Regular rate and rhythm, no murmurs, rubs ___
PULM: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
ABD: Soft, non-tender, moderately distended, bowel sounds
present. No hepatosplenomegaly
EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally.
NEURO: Alert and oriented x3. Hard of hearing.
SKIN: No ulcerations or rashes noted.
On Discharge:
VS: 97.1, 68, 118/56, 12, 96% RA
GEN: NAD
CV: RRR, no m/r/g
Lungs: CTAB
Abd: Midline incision open to air with steri strips and c/d/i.
G-tube/J-tube clamped with dry dressing on sites, minimal
erythema around insertion sites, no leak or drainage.
Extr: Warm, no c/c/e
Pertinent Results:
CT A/P ___:
IMPRESSION:
1. Gastric outlet obstruction with soft tissue thickening of the
pylorus and duodenum which may be due to inflammatory changes
from ulcer disease, as seen on recent prior EGD. While
malignancy cannot be excluded, there is no evidence of
metastatic disease.
2. Diverticulosis without diverticulitis.
3. Left parapelvic cyst. Cortical hypodensities in the kidneys
that are too small to characterize but most likely represent
cysts.
4. 3.2 cm infrarenal abdominal aortic aneurysm.
CTA pancreas ___:
IMPRESSION:
1. Interval decompression of the stomach following NG tube
insertion with
persistent obstruction at the pylorus/first portion of the
duodenum. There is an ill-defined, enhancing mass lesion
measuring 3.9 cm. The differential of this finding is wide.
Possibilities include lymphoma, granulomatous infiltration,
ulcerative gastritis, ___ syndrome, infectious
etiology such as TB, eosinophilic gastritis, or metastatic
disease. No pancreatic mass is identified.
2. Diverticulosis without diverticulitis.
3. 3.1 infrarenal abdominal aortic aneurysm.
EGD ___:
Impression: Abnormal mucosa in the lower third of the esophagus
Retained fluids in stomach
The duodenal bulb was compressed and deformed. The scope was
unable to pass beyond the duodenal bulb.
Otherwise normal EGD to duodenal bulb
Recommendations: NG tube to suction given complete gastric
outlet obstruction.
IV hydration/nutrition
Continue high dose IV PPI: Protonix 40mg IV.
F/u with inpatient GI team for further recommendations
EUS ___:
Impression:
There was severe stenosis, near complete obstruction, was found
in the duodenum blub. The mucosa was erythematous. There was
ulceration within the stenosis. The stenosis was maneuvered to
traverse with the regular gastroscope with difficulty. It was
biopsied. D2/D2 appeared normal.
EUS exam showed a hypoechoic mass with poorly defined borders at
the duodenal bulb. It measured 3.8x3.4 cm. The lesion involved
the mucosa, submucosa, muscularis propria and adventia. Few
''pseudopodia'' were noted extending beyond the adventia.
Differentials include penetrating post-bulbar ulcer, primary
duodenal cancer, or other malignancy .
No local ymphadenopathy was seen.
Summary: mucosal changes are very compatible with severe
duodenal ulcer disease. EUS appearance is somewhat mass-like and
hypoechoic, which increases concern regarding malignancy. Will
follow-up biopsies and discuss with surgery.
[other EGD/EUS findings: Z line was irregular. There were small
tongues from Z line. There were patches of mild erythema at the
body of stomach likely caused by the NG tube. otherwise the exam
of the stomach was normal. (biopsy) The exam of the second part
of duodenum was normal. The take-off of celiac artery was
normal. The pancreas appeared diffusely hyperechoic likely fatty
changes. PD was normal.
Pathology Examination
SPECIMEN SUBMITTED: Liver Nodule, LIVER NODULE, OMENTAL IMPLANT.
Procedure date Tissue received Report Date Diagnosed
by
___ ___. ___/dsj
Previous biopsies: ___ GI BX'S (2 JARS)
************This report contains an addendum***********
DIAGNOSIS:
I. Liver nodule #1, biopsy (A):
Adenocarcinoma, see note.
II. Liver nodule #2, biopsy (B):
Distorted hepatic parenchyma with focal portal chronic
inflammation.
No carcinoma seen.
III. Omental implant, biopsy (C):
Adenocarcinoma, see note.
Note: Immunostains are pending.
ADDENDUM: Tumor cells stain strongly for CK7 and do not stain
for CK20. Tumor cells do not stain for the lung marker TTF1.
Tumor cells stain focally for CDX2. The findings are not
specific but are consistent with an adenocarcinoma arising in
the upper gastrointestinal tract, including stomach, pancreas,
bile duct, etc. Clinical correlation is needed.
Brief Hospital Course:
___ presenting with recently diagnosed duodenal ulcer presenting
with N/V and abdominal pain
Nausea/vomiting: Pt presented with N/V following meals and CT
abdomen showing gastric outlet obstruction. He had recent
outpatient EGD on ___ showing findings suspicious for
___ esophagus as well as duodenal ulcer with clean base.
Gastric outlet obstruction was likely cause of his abdominal
discomfort and N/V following meals. GI and surgery were
consulted. He was initially managed conservatively with NG tube,
keeping patient NPO with IV hydration, and IV PPI BID. He was
started on TPN through a PICC line. First outpatient EGD was
limited due to retained food in stomach. He underwent an
inpatient EGD on ___ which showed complete obstruction at
duodenal bulb; no biopsies could be taken because the scope
could not be advanced. Of note, per family, blood testing at
PCP's office had been negative for Hpylori. He underwent a CTA
pancreas showing 3.9cm enhancing mass lesion between pyloris and
duodenum. An EUS on ___ showed persistent GOO, biopsies
were largely unremarkable (no evidence of malignancy).
Hyperlipidemia: Pt on simvastatin 10mg daily at home. This was
held while pt was NPO
Anemia: Hct 44 on admission and downtrended to mid ___. Likely
dilutional as pt has been receiving much IV fluids and was
likely hemoconcentrated on admission due to poor po intake. He
had one episode of specks of blood in NG tube but otherwise did
not have evidence of GI bleed. Hct was stable in mid ___
throughout remainder of hospital stay. He was hemodynamically
stable.
On ___ patient was transferred to the General Surgery
Service. He underwent gastrojejunostomy, G-tube insertion and
J-tube insertion which went well without complication. After a
brief, uneventful stay in the PACU, the patient arrived on the
floor NPO/NGT, on IV fluids and TPN, with a foley catheter, and
epidural catheter for pain control. The patient was
hemodynamically stable.
Neuro: The patient received Fentanyl/Bupivacaine via epidural
catheter with good effect and adequate pain control. When
tolerating oral intake, the patient was transitioned to oral
pain medications.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI/GU/FEN: Pre operatively patient was kept on TPN from ___ to
___ (POD # 3). NGT was removed on POD # 1 and Jtube was
clamped on POD # 1. Diet was advanced to clears on POD # 3, and
G-tube was clamped as well. The patient was started on TF on POD
# 2. Diet was advanced when appropriate, G-tube was vented to
relieve several episodes of nausea. TF was cycled before
discharge and patient able to tolerate regular diet. He was
discharge home on cycled TF with plan to wean TF with increased
PO intake. Electrolytes were routinely followed, and repleted
when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. No treatment with
antibiotics was indicated.
Endocrine: The patient's blood sugar was monitored throughout
his stay; no insulin administration was indicated.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet and cycling TF, 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:
Fish oil 1200mg daily
Omeprazole 20mg BID
Aspirin 81mg daily (being held due to duodenal ulcer)
MVI
VItamin C
CoQ 10 100mg daily
Simvastatin 10mg daily
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H
(Every 8 Hours) as needed for pain.
2. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4)
hours as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day): hold if diarrhea.
Disp:*60 Capsule(s)* Refills:*2*
4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY
(Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. ascorbic acid ___ mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
9. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a
day.
10. Tube feed
Tubefeeding: Glucerna 1.0 Cal Full strength; Additives: Banana
flakes, 3 packets per day
Starting rate: 75 ml/hr; Do not advance rate Goal rate: 75 ml/hr
Cycle start: 1800 Cycle end: 0600
Flush w/ 50 ml water BID
1 month supply total
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Gastric outlet obstruction
2. Metastatic duodenal adenocarcinoma
Discharge Condition:
As tolerated
Discharge Instructions:
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
.
G-tube/J-tube:
*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 you feel nausea or distended, please unclamp your G-tube and
vent for 30 min.
*Flash you J-tube with 50 cc of tap water before starting TF in
___ and before discontinuing TF in AM.
*Wash the area gently with warm, soapy water or ___ strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
19917153-DS-21 | 19,917,153 | 20,579,779 | DS | 21 | 2163-08-19 00:00:00 | 2163-08-22 11:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / aspirin
Attending: ___.
Chief Complaint:
abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F with EtOH abuse, depression presenting to her PCP ___ 5
months of post-prandial emesis and 5 months of intermittent
abdominal pain, referred to ___ for abnormal LFTs,
transferred to ___ for intrahepatic and peripancreatic
fluid collections. Last drink 2 days ago. Previously drank 1
bottle of wine per day. Denies hematemsis, melena, or BRBPR.
.
In ___, labs showed WBC 8.6, Hct 36.5, Plt 106, INR 1.4, Na
3.3, K 3.3, Cr 0.5, ALT 362, AST 102, AP 387, Tbili 2.79, alb
2.4, lipase 178. RUQ ultrasound showed 4 cm intrahepatic fluid
collection, as well as multiple peripancreatic fluid
collections. CT abdomen/pelvis was performed, showing loculated
peripancreatic fluid collections and 3x3 cm hepatic mass. The
patient was given 1 L NS and transferred to ___ for
further management.
.
At ___, initial VS: 99.4 81 106/71 16 98%. The patient
was seen by transplant surgery and admitted to the liver-kidney
service.
.
REVIEW OF SYSTEMS:
Denies fever. +chills. No chest pain. No shortness of breath or
cough. GI ROS per HPI. No dysuria. No weakness, tingling, or
numbness. +depression.
Past Medical History:
EtOH abuse
asthma
OCD
depression
Social History:
___
Family History:
EtOHism, liver cancer, emphysema, stomach cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - 100.2 114/77 56 18 96%/RA
GENERAL - chronically-ill appearing in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - Quiet bowel sounds, soft, tender in epigastrium with
no R/G, no masses or HSM
EXTREMITIES - WWP, no c/c/e
NEURO - awake, A&Ox3, CNs II-XII intact, muscle strength ___
throughout
DISCHARGE PHYSICAL EXAM
VSS
GEN- laying in bed comfortably, NAD
ABDOM- BS, not TTP, no rebounding or guarding
Rest of physical exam unchanged from admission
Pertinent Results:
Admission Labs:
___ 06:30AM BLOOD WBC-10.6 RBC-3.07* Hgb-10.9* Hct-34.0*
MCV-111* MCH-35.6* MCHC-32.2 RDW-16.9* Plt ___
___ 06:30AM BLOOD Neuts-88.4* Lymphs-7.7* Monos-3.4 Eos-0.2
Baso-0.3
___ 06:30AM BLOOD ___ PTT-26.4 ___
___ 06:30AM BLOOD Glucose-76 UreaN-6 Creat-0.5 Na-133
K-3.1* Cl-97 HCO3-27 AnGap-12
___ 06:30AM BLOOD ALT-268* AST-98* AlkPhos-299*
TotBili-2.6*
___ 06:30AM BLOOD Calcium-7.9* Phos-2.7 Mg-2.1
___ 06:30AM BLOOD Triglyc-142
___ 06:30AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE
___ 06:30AM BLOOD CEA-3.4 AFP-5.2
___ 06:30AM BLOOD Acetmnp-NEG
___ 06:30AM BLOOD HCV Ab-NEGATIVE
___ 07:09
CA ___
Test Result Reference
Range/Units
CA ___ 41 H <37 U/mL
Pertinent Labs:
___ 04:00PM BLOOD ALT-243* AST-110* AlkPhos-326*
TotBili-2.5*
___ 06:48AM BLOOD ALT-184* AST-116* AlkPhos-290*
TotBili-2.3*
___ 06:40AM BLOOD ALT-151* AST-121* AlkPhos-271*
TotBili-2.2*
___ 06:48AM BLOOD VitB12-1645* Folate-7.2
___ 06:30AM BLOOD Triglyc-142
MRI ABDOMEN W/O & W/CONTRAST Study Date of ___ 8:53 ___
FINDINGS:
A 4 mm nodule is noted peripherally within the left lower lobe
as previously described on prior CT examination from ___. No pleural or pericardial effusions are identified.
There is diffuse drop in signal intensity on the out-of-phase
imaging of the hepatic parenchyma consistent with fatty
deposition within the liver with focal areas of sparing in the
gallbladder fossa (series 6, image 21). Within the subcapsular
aspect of segments V-VI of the liver, a 2.5 x 3.7 cm lesion is
identified. It has a peripheral hyperintense ring on T1-weighted
imaging with some central areas of isointense signal intensity
on T1-weighted imaging (series 5, image 47) and it is minimally
hyperintense relative to hepatic parenchyma on T2-weighted
imaging (series 6, image 29). It demonstrates no internal
enhancement post-contrast (series 1101, image 40). Findings are
associated with volume loss within the adjacent segments and
associated capsular retraction and most likely represents a
chronic hematoma; most likely related to sequelae of previous
trauma or prior liver biopsy if there is a history of same.
There are no concerning focal hepatic liver lesions. There is no
intra- or extra-hepatic biliary dilatation. No gallstones are
evident within the gallbladder. There is conventional hepatic
arterial anatomy, and the visualized hepatic and portal veins
are patent.
The spleen is normal in size with a congenital cleft seen
posteriorly (series 6, image 21). The splenic vein is somewhat
attenuated (series 6, image 22), however, is patent throughout
its length.
Pancreas is homogeneous in parenchymal signal intensity on the
T1-weighted
imaging. There is marked peripancreatic stranding and free
fluid, most
notable surrounding the distal body and tail of the pancreas.
There are
numerous peripancreatic collections identified which are of
heterogeneous
increased signal intensity on T2-weighted imaging and most
likely represent walled-off regions of ___ fat
necrosis, which appears to have liquefied. The first is seen
lateral to the greater curvature of the stomach measuring 2.7 x
2.6 cm and inferior to this measuring 3.2 x 4.4 cm. There is a
larger collection seen longitudinally along the body of the
pancreas inferiorly measuring 3.3 x 6.9 cm. Post- contrast
administration, there is homogeneous enhancement of the gland
except in the region of the tail which is surrounded by
extensive peripancreatic stranding and early necrosis cannot be
entirely excluded. There are no pancreatic cystic or solid
lesions. There is no pancreatic ductal dilatation.
The adrenal glands are unremarkable. Posteriorly in the
interpolar region of the right kidney, there is a 5 mm lesion
identified which is hyperintense relative to renal parenchyma on
T1-weighted imaging (series 5, image 15) and does not
demonstrate enhancement post-contrast (series 1101, image 11)
consistent with a hemorrhagic / proteinaceous cyst. In addition,
a 5 mm simple cyst is noted in the upper pole of the right
kidney which is hyperintense relative to renal parenchyma on
T2-weighted imaging and does not enhance post-contrast (series
1101, image 29). There are no retroperitoneal masses or
adenopathy. No abnormally dilated or thickened small or large
bowel loop in the visualized upper abdomen.
Bone marrow signal is normal, and no osseous lesions are
identified.
IMPRESSION:
1. Subcapsular segment V-VI liver lesion which has MR imaging
characteristics consistent with a chronic hematoma. Findings
most likely represent prior sequelae of trauma or liver biopsy
if this has been performed previously. No concerning focal
hepatic lesion seen.
2. Evidence for resolving pancreatitis with minimal decreased
enhancement
noted within the tail of the pancreas, and early necrosis of the
gland cannot be entirely excluded. There is peripancreatic
stranding and free fluid most notable surrounding the tail of
the pancreas.
3. Numerous walled-off regions of peripancreatic fat necrosis,
which appear to have liquefied surrounding the pancreas, as
described.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
2 Blood Cx pnding from ___ no growth to date
Brief Hospital Course:
___ yo F with EtOHism and depression with abdom pain for approx
5mos duration, presents with elevated LFTs and lipase, and
intrahepatic and ___ fluid collections.
.
# Acute pancreatitis: Epigastric tenderness in setting of
elevated lipase and peripancreatic fluid collections was
suggestive of pancreatitis. MRI confirmed the presence of
resolving pancreatitis with necrosis noted in the tail of the
pancreas. ETOH was the likely prescipitant as pt admitted to
drinking 1 bottle wine per day prior to this event. She was
initially placed NPO and her diet was slowly advanced as she
tolerated it. She was agressively rehydrated with IVF and her
urine out put increased appropriately. Her pain slowly resolved
and at time of discharge she was experiencing minimal abdominal
discomfort tolerating a full diet.
.
# Intrahepatic mass: A 3x3 cm intrahepatic pancreatic mass noted
on CT of the abdomen. Intially concerning for a carcinoma, AFP,
CEA, CA ___, hep serologies were sent and were all negative. A
follow up MRI showed the mass to be hematoma. Surgery was
consulted and followed along during this admission. No surgical
intervention was made. They wanted to follow up with her in ___
weeks post discharge.
.
# Abnormal LFTs / Alcoholism: Her elevated LFTs were likely
related to EtOH abuse leading to alcoholic hepatitis. Her LFTs
were trended during this admission and continued to decrease.
She was placed on a CIWA scale throughout this hospitalization.
Social work was consulted and provided her with a list of
programs to assist with her ETOH dependence.
.
# Depression/Anxiety: We continued her home doses of Prozac,
clonazepam, Abilify.
.
# Asthma: We continued albuterol prn.
.
#Transitional: She has follow up appointments with her PCP, the
___ and the Liver tumor center post discharge. She has
2 blood cultures still pending from ___.
Medications on Admission:
albuterol PRN
Prozac 80 mg daily
clonazepam 1 mg four times daily
Abilify 2 mg daily
Discharge Medications:
1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath, wheezing.
2. fluoxetine 40 mg Capsule Sig: Two (2) Capsule PO once a day.
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times
a day).
4. aripiprazole 2 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Alcoholic pancreatitis
Alcohol Dependence
Secondary Diagnosis:
Depression
Anxiety
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted to the hosptial with abdominal
pain and abnormal liver tests. Both of these problems are most
likely related to your continued alcohol use. Imaging of your
abdomen showed that you have pancreatitis which was most likely
causing your abdominal pain. It is very important that you stop
drinking alcohol. Continued use could further damage both your
liver and pancreas and will lead to DEATH.
Imaging of your liver also revealed the presence of a hematoma.
It is not concerning at the present time and no further action
needs to be taken currently. You have a follow up appointment
with the Liver Clinic who will follow up with this abnormality
and evaluate your liver dysfunction further.
You were also given information regarding follow up with
outpatient alcohol programs. Again, if you continue to drink
your liver and pancreas with continue to fail which will lead to
DEATH.
We have made the following changes to your medications:
START
- Folic Acid 1mg by mouth daily
- Thiamine 100mg by mouth daily
- Please eat a well balanced diet and supplement your diet with
ensure nutrition shakes.
Please see below for follow up appointments that have been made
for you:
Followup Instructions:
___
|
19917153-DS-23 | 19,917,153 | 27,795,890 | DS | 23 | 2167-10-15 00:00:00 | 2167-10-20 20:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / aspirin / sulfonamide antibiotics
Attending: ___.
Chief Complaint:
abd pain, n/v
Major Surgical or Invasive Procedure:
ERCP ___:
Procedure: The procedure, indications, preparation and potential
complications were explained to the patient, who indicated her
understanding and signed the corresponding consent forms. A
physical exam was performed. The patient was administered
moderate sedation. The patient was placed in the prone position
and an endoscope was introduced through the mouth and advanced
under direct visualization until the third part of the duodenum
was reached. Careful visualization was performed. The procedure
was not difficult. The quality of the preparation was good. The
patient tolerated the procedure well. There were no
complications.
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.
Biliary Tree/Fluoroscopic Interpretation: The proximal CBD and
CHD were diffusely dilated to a maximal diameter of 15mm. The
left and right hepatics were also dilated. The cystic duct
briskly filled with contrast. The distal CBD tapered smoothly to
the level of the ampulla. There was no evidence of stricture.
There was a possible filling defect in the CBD consistent with
sludge. I supervised the acquisition and interpretation of the
fluoroscopic images. The quality of the fluoroscopic images was
good.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Balloon sweeps were performed of the common bile duct which
yielded sludge and dark bile but no stone. Further sweeps were
performed until no debris was noted. Completion occlusion
cholangiogram revealed no further filling defects.
Impression: Normal major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
A cholangiogram was performed:
___ proximal CBD and CHD were diffusely dilated to a
maximal diameter of 15mm.
___ left and right hepatics were also dilated.
___ cystic duct briskly filled with contrast.
___ distal CBD tapered smoothly to the level of the
ampulla.
___ was no evidence of stricture.
___ was a possible filling defect in the CBD consistent
with sludge.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Balloon sweeps were performed of the common bile duct which
yielded sludge and dark bile but no stone.
Further sweeps were performed until no debris was noted.
Completion occlusion cholangiogram revealed no further filling
defects.
Recommendations: Return to ward under ongoing care.
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
CT Pancreas Protocol to further evaluate pancreas nodule seen
on ___ ultrasound
Continue with antibiotics - Ciprofloxacin 500mg BID x 5 days.
No aspirin, Plavix, NSAIDS, Coumadin for 5 days.
Follow-up with Dr. ___ as previously scheduled.
Follow for response and complications. If any abdominal pain,
fever, jaundice, gastrointestinal bleeding please call ERCP
fellow on call ___
History of Present Illness:
Ms ___ is a pleasant ___ with history of alcohol abuse,
previous elevated LFTs and chronic dilated CBD (15mm),
pancreatitis, who presented to the ___ with 4 days of
N/V, one day of abdominal pain/vomiting, decreased PO intake for
the last ___ days. Last drink this AM at 0700, no hx of
withdrawal seizures; pt states she has been drinking ___ glasses
of wine a day for the last ___ yrs. Pt states the pain is
primarily in the RUQ, intermittent, unclear if it is worse with
food. She also endorses subjective fever, chills, non-blood
emesis, SOB ___ year, worse with activity, no recent worsening.
States she has felt weaker since the abd pain started, has had
increased difficulty with walking requiring a cane and holding
on to the wall. Had a fall 1.5 wks ago, hit the front of her
face but no LOC. Denies dysuria. Depressed recently, no SI,
HI. No dark or bloody bms
In the ___, labs were notable for elevated LFTs, Tbili
1.9, Alk phos 700. Normal lipase. RUQ u/s with persistent CBD
dilatation, moderately distended gallbladder with sludge,
+sonographic murphys but no pericholecystic fluid or wall edema.
She was therefore transferred to ___ for ERCP eval.
In our ___, initial vitals were: 98.1 80 133/97 15 96% RA. Labs
were notable for pancytopenia, transaminitis and elevated alk
phos. She was treated with valium, thiamine, MV, cipro and
IVFs.
On the floor she c/o nausea and ongoing abd pain.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
cough. Denies chest pain or tightness, palpitations. Denies
diarrhea, constipation. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
-COPD
-asthma
-gastritis-pt denies
-pancreatitis
-depression, anxiety (panic, agoraphobia, OCD)
ETOH DEPENDENCE
COPD
ASTHMA
Social History:
___
Family History:
alcoholism, liver cancer, dad-emphysema, mother-stomach cancer
Physical Exam:
Vitals: 98.4 156/94 85 20 97% RA fs 83
General: appears older than stated age, alert, oriented, no
acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
horizontal nystagmus
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally except for faint R
sided wheeze
Abdomen: Soft, TTP in RUQ, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, + ___ sign, no
fluid wave
GU: No foley
Ext: Warm, well perfused, no CCE
Neuro: CNII-XII intact, strength grossly intact, gait deferred
Discharge exam:
Vitals: 98.6, HR ___, BP 120s-140s/70s. 99% RA
GEN: ill appearing, malnourished appearing woman.
HEENT: red rimmed eyelids. Moist mucous membranes
CV: RRR, no m/r/g. No peripheral edema.
PULM: CTAB. No w/r/r/
ABD: Epigastrum is TTP. TTP in LLQ or RLQ. Soft and non
distended with no masses appreciated. Hypoactive bowel sounds.
SKIN: dry. 2.5 cm fungating mass over left extensor surface of
elbow, per pt has been there ___ years and PCP wants her to biopsy
it
PSYCH: somewhat guarded, but easily answers questions
appropriately.
NEURO: A, O x 3. No tremors.
Pertinent Results:
ON admission:
___ 01:50AM URINE HOURS-RANDOM
___ 01:50AM URINE GR HOLD-HOLD
___ 01:50AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 01:50AM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-1
___ 01:50AM URINE MUCOUS-RARE
___ 01:20AM GLUCOSE-66* UREA N-7 CREAT-0.5 SODIUM-137
POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-14* ANION GAP-28*
___ 01:20AM estGFR-Using this
___ 01:20AM ALT(SGPT)-178* AST(SGOT)-306* ALK PHOS-555*
TOT BILI-1.2 DIR BILI-0.6* INDIR BIL-0.6
___ 01:20AM LIPASE-56
___ 01:20AM ALBUMIN-3.9
___ 01:20AM WBC-1.6*# RBC-3.00* HGB-9.9* HCT-31.5*
MCV-105* MCH-33.0* MCHC-31.4* RDW-18.0* RDWSD-69.6*
___ 01:20AM NEUTS-49.7 ___ MONOS-16.0* EOS-0.0*
BASOS-0.6 IM ___ AbsNeut-0.81* AbsLymp-0.52* AbsMono-0.26
AbsEos-0.00* AbsBaso-0.01
___ 01:20AM PLT SMR-LOW PLT COUNT-89*#
___ labs reviewed, notable for pancytopenia, lactate of 2.3,
INR of 1.0, neg tox screen, nl lipase, mild hyponatremia, LFTs
as above
MICRO: none
DISCHARGE LABS:
LABORATORY STUDIES:
CBC: wbc 1.7, Hb 8.7, Hct 27.5, Plt 80
BMP: Na 140, K 3.6, Cl 107, HCO3 25, BUN 3, Cr 0.5. Ca 8.5, Ph
5.1, Mg 1.7
LFT: ALT 68, AST 71 ALP 305, Tot bili 0.7, Alb 3.3
Hep panel all negative. Hep C negative
STUDIES:
CXR: no acute CP process
RUQ u/s: intra and extrahepatitic ductal dilatation, CBD
15mm(chronic), +moderately distended gallbladder with sludge, no
pericholecystic fluid or wall edema. +sonographic murphys
EKG: Sinus tach, no acute ST/TWI
IMAGING:
ultrasound from ___ ___:
IMPRESSION: Increased hepatic parenchymal echogenicity
consistent with fatty infiltration or other diffuse
hepatocellular abnormality.
Dilatation of the common bile duct, not significantly changed.
Persistent focal abnormality overlying the right lobe of the
liver most consistent with a subcapsular hematoma better
demonstrated on MRI.
Persistent abnormality in the pancreas wall consistent with a
hematoma. This was also better demonstrated on MRI.
ERCP ___
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.
Biliary Tree/Fluoroscopic Interpretation: The proximal CBD and
CHD were diffusely dilated to a maximal diameter of 15mm. The
left and right hepatics were also dilated. The cystic duct
briskly filled with contrast. The distal CBD tapered smoothly to
the level of the ampulla. There was no evidence of stricture.
There was a possible filling defect in the CBD consistent with
sludge. I supervised the acquisition and interpretation of the
fluoroscopic images. The quality of the fluoroscopic images was
good.
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
Balloon sweeps were performed of the common bile duct which
yielded sludge and dark bile but no stone. Further sweeps were
performed until no debris was noted. Completion occlusion
cholangiogram revealed no further filling defects.
Impression:
Normal major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
A cholangiogram was performed:
___ proximal CBD and CHD were diffusely dilated to a
maximal diameter of 15mm.
___ left and right hepatics were also dilated.
___ cystic duct briskly filled with contrast.
___ distal CBD tapered smoothly to the level of the
ampulla.
___ was no evidence of stricture.
___ was a possible filling defect in the CBD consistent
with sludge.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
Balloon sweeps were performed of the common bile duct which
yielded sludge and dark bile but no stone.
Further sweeps were performed until no debris was noted.
Completion occlusion cholangiogram revealed no further filling
defects.
CTA Pancreas ___:
IMPRESSION:
1. Hepatic steatosis without evidence of concerning focal
hepatic
lesions.
2. New mild stranding adjacent to the duodenum and pancreatic
head, compatible
with mild pancreatitis after ERCP.
3. Stable CBD and intrahepatic ductal dilation.
4. Stable hepatic and pancreatic fluid collections, previously
characterized
as chronic hematomas.
Brief Hospital Course:
Pleasant ___ yo F with hx EtOH abuse, anxiety, depression, COPD,
p/w abd pain, N/V and found to have elevated LFTs and
obstructive biliary sludge on ERCP.
# biliary obstruction: Pt has hx of abnormal LFTs, pancreatitis,
chronically dilated ductal dilation however now with worsening
abd pain, positive ___ sign and distended gallbladder with
sludge concerning for cholangitis. ERCP found biliary sludging,
cleaned out and performed sphincterotomy. Lipase is
reassuringly
normal. She received 5 days of IVF, 5 days of ciprofloxacin
empirically. LFTs, bilirubin all downtrending. Pain improving,
no nausea.
A CT pancreas protocol was done which showed a steatotic liver
and chronic hematomas in the liver and the pancreas. Per
radiology these are usually found in the setting of a previous
injury, do not appear consistent with malignancy, and have been
stable since an MRI done in ___ and an ultrasound done in ___.
Hepatology has agreed to discuss case with hepatology, they
think she does not need an inpatient consult but would be able
to see her as an outpatient.
# EtOH abuse: has been a problem for longer than pt is
admitting given admission in ___ where she reported similar
amounts of EtOH use. Interested in quitting, has quit in the
past for 4 months. Given nystagmus and reported difficulty
walking will treat with IV thiamine. She now wants to stop and
has asked brother who lives with her to throw away all the
alcohol or store it in the basement. Not interested in AA.
Encouraged her to speak again with her PCP about options should
she need assistance. She was discharged on MVI and folate. She
did not require any diazepam per our CIWA protocol during her
entire hospitalization but was continued on her home clonazepam.
# Chronic liver disease without signs of cirrhosis on imaging:
likely due to excessive EtOH use. On presentation, did not have
encephalopathy, had a normal INR, no ascites on exam/US, bili
only mildly elevating making acute EtOH hepatitis unlikely. Has
had ALT/AST in the 200s in ___. Transaminases downtrended by
discharge. Hep panel negative. CT pancreatic protocol ___
showed no nodularity of liver, no ascites but did show steatosis
of the liver. Will have appointment arranged with ___
hepatology as an outpatient.
# pancytopenia: worsening since last labs in our system, likely
exacerbated by fluids. Likely due to EtOH use. No e/o active
bleeding or hx concerning for GIB, however with 6 pt crit drop
since labs at ___ (was likely hemoconcentrated there and is
now hemodilute). Infection suppressing her WBC also possible
but this is significant suppression. Infectious workup
including urine, CXR negative. Will pass on to PCP as ___ item to
watch and follow up.
# pulmonary hypertension: previously detected on TTE ___ as
"moderate pulmonary arterial hypertension". will ask PCP to
continue investigation if she thinks warranted.
# Depression/anxiety: no active SI. Continued on home
fluoxetine/olanzapine, home clonazepam.
# COPD: no e/o active flare. Continued albuterol, Spiriva
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheezing
2. ClonazePAM 0.5 mg PO QID
3. Fluoxetine 20 mg PO DAILY
4. OLANZapine 10 mg PO BID
5. OLANZapine 5 mg PO Q NOON
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. OLANZapine 10 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
6. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour (28)-14 mg/24 hour (14)-7 mg/24 hour
(14) use if you would like to abstain from smoking. STart with
the 21 mg patch, then when you feel ready can decrease to 14 mg
daily Disp #*21 Patch Refills:*0
7. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob/wheezing
8. ClonazePAM 0.5 mg PO QID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
# biliary obstruction
# early liver disease/ hepatic steatosis
# pancytopenia
# alcohol dependence
# depression
# anxiety
Discharge Condition:
Good. A, O x 3, ambulatory.
Discharge Instructions:
Continue to eat and drink 3 meals a day
You are being discharged after being treated for biliary sludge
build up which was removed by endoscopic method. You were given
antibiotics to prevent an infection from developing after the
procedure and a lot of intravenous fluid to flush out the liver
and bile ducts. You should continue to drink plenty of water.
Your liver on CT scan showed sign of early liver disease, called
steatosis. Your liver enzymes are also slightly elevated (they
were very high when you came in but have come down
significantly over your admission). This is most likely due to
drinking; you were tested for Hepatitis B and C and do not have
these infections. Our liver doctors ___ to set up an
outpatient appointment so that you can follow with them.
You also have low white blood cell count, low platelets and low
hemoglobin (anemia). These appear to have been low previously
but now are quite low. This can be related to your liver
disease, but you should also follow up with Dr. ___ to see
if further testing is warranted.
Followup Instructions:
___
|
19917249-DS-11 | 19,917,249 | 27,437,373 | DS | 11 | 2183-07-01 00:00:00 | 2183-07-01 16:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Minoxidil
Attending: ___.
Chief Complaint:
left proximal tibia fracture
Major Surgical or Invasive Procedure:
left tibia intramedullary nail
History of Present Illness:
This is a ___ w/hx of DM1, kidney transplant, osteoporosis,
OSA who was transferred from OSH and found to have a L proximal
tibia fracture--he was standing in his home and went to initiate
a step when he felt his bone "crunch" and he fell down. He had
immediate pain and swelling over the left leg. Of note, he had a
distal tibia fracture fixed by KRod in ___.
Past Medical History:
Carpal tunnel syndrome, lumbar back pain, ___
hernia, fractures of R heel, L tibia, L fibula, R heel ulcer,
IDDM, Neuropathy, GERD, HTN, asthma
PSH: L ___ toe amputation, internal fixation of L tibia +
fibula, internal fixation of bilateral wrists, umbilical hernia
repair with mesh
Social History:
___
Family History:
nc
Physical Exam:
Exam:
Vitals: VSS
General: Well-appearing, breathing comfortably
LLE
Dressing c/d/I
Compartments soft and compressible
___ faintly palpable
SILT in all dist, though slightly diminished
no sensation distal to mid-point of tibia
Pertinent Results:
___ 04:50AM BLOOD WBC-9.7 RBC-3.04* Hgb-8.8* Hct-28.9*
MCV-95 MCH-28.9 MCHC-30.4* RDW-13.6 RDWSD-46.5* Plt ___
___ 04:25AM BLOOD Glucose-157* UreaN-28* Creat-1.3* Na-140
K-5.0 Cl-104 HCO3-22 AnGap-14
___ 04:25AM BLOOD tacroFK-7.2
Brief Hospital Course:
Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left proximal tibia fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a left tibial intramedullary nail,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular low
carb, low K diet and oral medications. The patient was given
___ antibiotics and anticoagulation per routine.
Given the patient's history of a renal transplant, nephrology
was consulted and followed the patient throughout the hospital
course. Given the patient's history of T1DM, ___ was
consulted and followed the patient throughout the hospital
course. The patient worked with ___ who determined that discharge
to rehab was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. 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:
Finasteride 1 mg PO DAILY
Gabapentin 300 mg PO QHS
Mycophenolate Sodium ___ 360 mg PO TID
PARoxetine 10 mg PO DAILY
PredniSONE 5 mg PO DAILY
Tacrolimus 1.5 mg PO Q12H
Tamsulosin 0.8 mg PO QHS
Zolpidem Tartrate 10 mg PO QHS
Bactrim SS 1 tab PO Daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*100 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
hold for loose stools
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily while taking narcotics Disp #*80 Capsule Refills:*0
3. Heparin 5000 UNIT SC BID
RX *heparin (porcine) 5,000 unit/mL 1 syringe subq twice daily
Disp #*56 Syringe Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*60 Tablet Refills:*0
6. Vitamin D 5000 UNIT PO DAILY Duration: 12 Weeks
RX *ergocalciferol (vitamin D2) 2,000 unit 2.5 tablet(s) by
mouth daily Disp #*210 Tablet Refills:*0
7. Finasteride 1 mg PO DAILY
8. Gabapentin 300 mg PO QHS
9. Mycophenolate Sodium ___ 360 mg PO TID
RX *mycophenolate sodium 360 mg 1 tablet(s) by mouth every 8
hours Disp #*100 Tablet Refills:*0
10. PARoxetine 10 mg PO DAILY
11. PredniSONE 5 mg PO DAILY
12. Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY
13. Tacrolimus 1.5 mg PO Q12H
14. Tamsulosin 0.8 mg PO QHS
15. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
left proximal tibia fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weightbearing as tolerated on the left lower extremity
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take subq heparin daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
Activity: Activity: Activity as tolerated
Left lower extremity: Full weight bearing
ROMAT LLE
Treatments Frequency:
-per f/u appt
Followup Instructions:
___
|
19917249-DS-13 | 19,917,249 | 24,378,207 | DS | 13 | 2183-09-19 00:00:00 | 2183-09-19 09:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Minoxidil
Attending: ___.
Chief Complaint:
Recurrent L leg cellulitis
Major Surgical or Invasive Procedure:
L tibial removal of hardware and bone biopsy, ___, ___
___ of Present Illness:
HPI: ___ male w/ PMHx of T1DM and CKD s/p transplant presents as
a
direct admit from clinic for left tibial cellulitis in the
setting of a recent IMN. Patient underwent L tibial IMn ___
(___). His post-op course was c/b LLE cellulitis requiring
admission for IV abx (___). He was started on vanc
with improvement of his symptoms and subsequently transitioned
to
and discharged on a 10d course of Keflex (___). After
finishing this cours ehe noted progressive erythema and
tenderness to his LLE and he was started on Keflex ___. He
represented to clinic today with progression of his erythema and
was directly admitted.
Past Medical History:
Carpal tunnel syndrome, lumbar back pain, ___
hernia, fractures of R heel, L tibia, L fibula, R heel ulcer,
IDDM, Neuropathy, GERD, HTN, asthma
PSH: L ___ toe amputation, internal fixation of L tibia +
fibula, internal fixation of bilateral wrists, umbilical hernia
repair with mesh
Social History:
___
Family History:
nc
Physical Exam:
Vital signs:
AFVSS
Gen: NAD, calm & comfortable
RLE:
Erythema stable
Dressings c/d/i
Thigh & leg compartments soft
Sensation intact to light touch in saphenous, sural, deep
peroneal & superficial peroneal distributions
Motor intact for ___, FHL, GSC, TA
Dorsalis pedis palpable, toes warm & well perfused
Pertinent Results:
___ 11:10AM BLOOD WBC-7.4 RBC-4.05* Hgb-11.2* Hct-36.9*
MCV-91 MCH-27.7 MCHC-30.4* RDW-15.4 RDWSD-51.0* Plt ___
___ 11:10AM BLOOD CRP-30.4*
___ 08:00PM BLOOD CRP-15.4*
___ 06:40AM BLOOD Vanco-19.9
___ 11:10AM BLOOD tacroFK-3.6*
Brief Hospital Course:
The patient presented to clinic with increasing erythema of his
left leg and was directly admitted. ID was consulted and
requested a bone biopsy and removal of hardware given lucency
around the tibial nail locking screws appreciated on x-ray. The
patient was taken to the operating room on ___ for bone
biopsy and removal of hardware, 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 and he was followed by
the Renal Transplant service and Transplant ID service. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on aspirin for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
.
1. Zolpidem Tartrate 5 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24h Disp
#*29 Intravenous Bag Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Finasteride 1 mg PO DAILY
5. Gabapentin 300 mg PO QHS:PRN pain
6. Glargine 60 Units Breakfast
Humalog 5 Units Breakfast
Humalog 10 Units Lunch
Humalog 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Mycophenolate Sodium ___ 360 mg PO TID
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*84 Tablet Refills:*0
9. PredniSONE 5 mg PO DAILY
10. Senna 8.6 mg PO BID
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
13. Tacrolimus 2 mg PO Q12H
14. Vancomycin 1250 mg IV Q 24H
RX *vancomycin 1 gram 1 g IV q24h Disp #*29 Vial Refills:*0
15. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
___:
LLE cellulitis +/- osteomyelitis
Discharge Condition:
AVSS
NAD, A&Ox3
LLE: Cellulitis, improving. Incision well approximated. Dressing
clean and dry. Fires FHL, ___, TA, GCS. SILT ___ n
distributions. 1+ DP pulse, wwp distally.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take ASA 81mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
WBAT
Treatments Frequency:
IV antibiotic therapy vancomycin/ceftriaxone
Followup Instructions:
___
|
19917249-DS-19 | 19,917,249 | 23,538,355 | DS | 19 | 2185-01-19 00:00:00 | 2185-01-19 15:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Minoxidil
Attending: ___
Chief Complaint:
Left lower extremity pain
Major Surgical or Invasive Procedure:
Removal of hardware and intramedullary nailing ___ with
Dr. ___
___ of Present Illness:
HPI: ___ male with multiple comorbidities to include
end-stage renal disease status post kidney transplant (on
immunosuppressive therapy and peritoneal dialysis), CAD status
post multiple stents (on Plavix and aspirin), type 2 diabetes on
insulin pump and status post multiple revisions for a left
tibial
nonunion most recently ___ by Dr. ___ presents with an
acute tibial shaft fracture through the distal and of the
proximal plate. He sustained this injury while slipping down
stairs and missing a step. He noticed an immediate crack and
was
concerned that his ankle was broken. He denies any new onset
numbness, tingling in her motor weakness from his baseline. He
does notice that his left leg is not more formerly of a varus
and
usual. He denies sustaining any other injuries or any loss of
consciousness.
Past Medical History:
CHRONIC KIDNEY DISEASE
DIABETES MELLITUS
HYPERLIPIDEMIA
HYPERTENSION
KIDNEY TRANSPLANT
FRACTURE TIBIA
DIABETIC RETINOPATHY
NEUROPATHY
CHARCOT'S
Carpal tunnel syndrome, lumbar back pain, ___
hernia, fractures of R heel, L tibia, L fibula, R heel ulcer,
IDDM, Neuropathy, GERD, HTN, asthma
PSH: L ___ toe amputation, internal fixation of L tibia +
fibula, internal fixation of bilateral wrists, umbilical hernia
repair with mesh
Social History:
___
Family History:
nc
Physical Exam:
ADMISSION PHYSICAL Exam:
24 HR Data (last updated ___ @ 549)
Temp: 98.1 (Tm 98.1), BP: 147/71 (114-178/69-77), HR: 86
(79-89), RR: 18 (___), O2 sat: 98% (93-98), O2 delivery: ___
General: Well-appearing, breathing comfortably
MSK:
Left lower extremity in splint, splint with stable
serosanguineous strikethrough.
First toe is missing, sensation intact to light touch in all
dermatomes
___ FHL fire, toe flexors and extensors intact, ___ intact
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
VS:
24 HR Data (last updated ___ @ 849)
Temp: 97.5 (Tm 98.9), BP: 144/72 (135-175/67-77), HR: 78
(69-81), RR: 18 (___), O2 sat: 90% (90-98), O2 delivery: Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva, MMM, no
teeth on top
NECK: nontender supple neck
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: R base crackles, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: soft, obese, nontender in all quadrants, no
rebound/guarding. soft reducible umbilical hernia.
EXTREMITIES: 1+ ___ bilaterally. R leg with dressing c/d/I at
ankle. L leg with small incision with overlying staples healing
well at ankle, larger incision at knee with staples that that is
covered by dressing d/c/I.
NEURO: AAOX3, fluent speech, moving all extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
==============
___ 01:01AM BLOOD WBC-9.4 RBC-4.17* Hgb-10.0* Hct-34.4*
MCV-83 MCH-24.0* MCHC-29.1* RDW-17.3* RDWSD-51.7* Plt ___
___ 01:01AM BLOOD Neuts-76.9* Lymphs-11.7* Monos-9.0
Eos-1.6 Baso-0.4 Im ___ AbsNeut-7.21* AbsLymp-1.10*
AbsMono-0.84* AbsEos-0.15 AbsBaso-0.04
___ 01:01AM BLOOD ___ PTT-27.7 ___
___ 01:01AM BLOOD Glucose-148* UreaN-38* Creat-1.6* Na-143
K-5.1 Cl-106 HCO3-19* AnGap-18
___ 05:37AM BLOOD Calcium-8.4 Phos-4.9* Mg-1.8
___ 01:01AM BLOOD CRP-37.9*
___ 05:37AM BLOOD tacroFK-4.6*
STUDIES:
==========
TIB/FIB (AP & LAT) LEFTStudy Date of ___
1. There is an acute nondisplaced fracture through the mid
tibial diaphysis
at approximately the level of the inferior most screw.
2. Increased lucency surrounding the inferior most screw and
the distal
aspect of the lateral fixation plate in the tibia suggest
hardware loosening
at this level.
3. Evidence of continued healing of the mid fibular fracture,
which is in
unchanged alignment.
CHEST (SINGLE VIEW)Study Date of ___
Low lung volumes with bibasilar atelectasis.
TIB/FIB (AP & LAT) LEFTStudy Date of ___
1. Re-demonstration of a nondisplaced periprosthetic fracture
in the mid
tibial diaphysis at approximately the level of the inferior most
screw. No
additional fractures are identified.
2. Unchanged lucency surrounding the lateral fixation plate may
suggest
hardware loosening.
TIB/FIB (AP & LAT) LEFTStudy Date of ___
There has been removal of the screws within the medial fracture
plate. There
is an intramedullary rod with proximal and distal interlocking
screws within
the tibia. There are several screw fragments within the
proximal tibia.
Distal fibular fracture plate is also seen. Fractures of the
proximal and mid
fibular shafts are seen. Healed fracture deformities throughout
the tibia are
also seen. There are skin staples consistent with the recent
surgery.
Forming of the calcaneus remains unchanged.
CHEST (PA & LAT)Study Date of ___
Stably enlarged heart with minimal pulmonary vascular
congestion.
RENAL TRANSPLANT U.S.Study Date of ___
Elevated resistive indices of the intrarenal arteries. No
hydronephrosis is
identified.
DISCHARGE LABS:
================
___ 05:34AM BLOOD WBC-5.8 RBC-3.20* Hgb-7.8* Hct-27.0*
MCV-84 MCH-24.4* MCHC-28.9* RDW-17.3* RDWSD-53.6* Plt ___
___ 05:34AM BLOOD Glucose-206* UreaN-58* Creat-1.7* Na-142
K-4.9 Cl-105 HCO3-22 AnGap-15
___ 05:34AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.0
___ 06:58AM BLOOD tacroFK-6.4
___ 05:34AM BLOOD tacroFK-PND
Brief Hospital Course:
___ with h/o diabetes on insulin pump, ESRD ___ diabetic
nephropathy s/p DCD kidney transplant (___) c/b rejection
after low dose IL-2, CAD (s/p DES x2 RCA x2 LAD ___& ___, HTN,
HLD, left tibial fractures c/b nonunion s/p multiple surgeries,
who presented as a transfer from ___ with left tibia and
fibula fracture, s/p ORIF L tibial fracture ___ ___
with course c/b ___ for which he was transferred from ortho to
medicine.
ACUTE ISSUES:
#L tibia fracture
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left tibia fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for removal of hardware and ORIF by intramedullary
nail, which the patient tolerated well. 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 (with his home ASA/Plavix). The patient worked with
___ who determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications with standing Tylenol and prn oxycodone,
incisions were clean/dry/intact. The patient is weightbearing as
tolerated left lower extremity, and will be discharged on home
aspirin and Plavix for DVT prophylaxis. The patient will follow
up with Dr. ___ routine (outpatient follow up 2 weeks
post op), and staples will be removed at that point.
ACUTE ISSUES:
___
Baseline Cr 1.3-2.0. On admission, Cr 1.6, which then uptrended
to peak of 3.1 on ___. Renal U/S with elevated resistive
indices of intrarenal arteries, no hydronephrosis. ___ was felt
to have possible prerenal component iso fluid shifts post op,
with potential contribution from relative hypotension. Urine was
spun but showed only hyaline casts. Renal function improved with
holding of home diuretics and decreasing home antihypertensives
(goal SBP >130). Once renal function improved, he was restarted
on home diuretic and antihypertensive regimen prior to
discharge. Discharge creatinine 1.7.
# ESRD ___ diabetic nephropathy s/p DCD kidney transplant
(___)
Tacrolimus was increased to 2.5 BID (goal tacro ___. He was
continued on mycophenolate sodium 360mg TID, prednisone 5mg
daily, and ppx Bactrim.
# Anemia
He had post op anemia requiring 1U pRBC on ___. Hemoglobin
since then has been stable in 7s-8s.
CHRONIC ISSUES:
# RLE burn
He follows with podiatry outpatient (Dr. ___ the ___
___) for weekly debridements of RLE burn wound.
He received routine debridement by inpatient podiatry on ___.
Recommendations for R leg burn wound care per podiatry: Please
dress wounds every other day with medihoney, adaptic, gauze,
kerlix, and ACE for compression.
# HFpEF
History of HFpEF. Home diuretics were held as above iso ___ and
antihypertensives were also decreased in this setting. He had 1+
___, no cardiopulmonary symptoms otherwise. Home diuretic and
antihypertensive regimen were restarted by discharge (torsemide
20 daily, amlodipine 2.5, hydralazine 20 TID, isosorbide
dinitrate 10 TID, metoprolol succinate 50 qAM and 100 qPM).
Discharge standing weight: 239.2 lbs.
# CAD
Significant h/o CAD with 90% pRCA, 70% pLAD s/p DES x2 to RCA
___ and and mid-LAD ___. He was continued on ASA 81,
Plavix, metoprolol, and rosuvastatin.
# T1DM
Insulin pump in place. Followed by ___ while inpatient.
Patient managed his own insulin pump this admission.
# Psych
Continued Venlafaxine XR 225 mg PO DAILY
# BPH
Continued home Tamsulosin 0.8 mg PO DAILY
# Hypothyroidism
Continued home levothyroxine
TRANSITIONAL ISSUES:
====================
[] Per ortho recs, dvt ppx with patient's home ASA/Plavix.
[] He needs outpatient ortho follow up 2 weeks post op. Staples
will be removed at that time.
[] Weight bearing as tolerated LLE
[] Needs weekly follow up with his outpatient podiatrist (Dr.
___ the ___ - ___ ) for
routine debridement of his right leg burn wound. Last debrided
by inpatient podiatry on ___.
[] Recommendations for R leg burn wound care per podiatry:
Please dress wounds every other day with medihoney, adaptic,
gauze, kerlix, and ACE for compression.
[] Recheck BMP for renal function around ___ to ensure
stability of renal function on home diuretic and
antihypertensive regimen.
[] Monitor volume status and weights to adjust diuretic regimen
prn. Discharge standing weight: 239.2 lbs.
#CODE: Full
#CONTACT:
Name of health care proxy: ___
Relationship: Friend
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. Gabapentin 300 mg PO QHS:PRN neuropathy
4. Metoprolol Succinate XL 100 mg PO QHS at 9PM
5. Denosumab (Prolia) 60 mg SC ONCE
6. amLODIPine 2.5 mg PO DAILY
7. HydrALAZINE 20 mg PO TID
8. Rosuvastatin Calcium 20 mg PO QPM
9. Mycophenolate Sodium ___ 360 mg PO TID
10. Tacrolimus 2 mg PO Q12H
11. Torsemide 20 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Isosorbide Dinitrate 10 mg PO TID
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
15. Clopidogrel 75 mg PO DAILY
16. Aspirin 81 mg PO DAILY
17. Venlafaxine XR 225 mg PO DAILY
18. Tamsulosin 0.8 mg PO DAILY
19. Levothyroxine Sodium 50 mcg PO DAILY
20. Vitamin D 6000 UNIT PO DAILY
21. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
22. Metoprolol Succinate XL 50 mg PO QAM
Discharge Medications:
1. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Basal Rates:
Midnight - 5a: 1.75 Units/Hr
5a - 8a: 1.25 Units/Hr
8a - 7p: 2.2 Units/Hr
7p - 12a: 2 Units/Hr
Meal Bolus Rates:
Breakfast = 1:10
Lunch = 1:10
Dinner = 1:10
Snacks = 1:10
High Bolus:
Correction Factor = 1:20
Correct To ___ mg/dL
Use of ___ medical equipment: Insulin pump
Reason for use: medically necessary and justified as ___
cannot provide this type of equipment or suitable alternative
not appropriate.
Provider acknowledges patient competent
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth twice daily Disp #*10
Tablet Refills:*0
3. Pantoprazole 40 mg PO Q24H
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Acetaminophen 1000 mg PO Q8H
7. Tacrolimus 2.5 mg PO Q12H
8. amLODIPine 2.5 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Clopidogrel 75 mg PO DAILY
11. Denosumab (Prolia) 60 mg SC ONCE
12. Gabapentin 300 mg PO QHS:PRN neuropathy
13. HydrALAZINE 20 mg PO TID
14. Isosorbide Dinitrate 10 mg PO TID
15. Levothyroxine Sodium 50 mcg PO DAILY
16. Metoprolol Succinate XL 100 mg PO QHS at 9PM
17. Metoprolol Succinate XL 50 mg PO QAM
18. Multivitamins 1 TAB PO DAILY
19. Mycophenolate Sodium ___ 360 mg PO TID
20. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
21. PredniSONE 5 mg PO DAILY
22. Rosuvastatin Calcium 20 mg PO QPM
23. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
24. Tamsulosin 0.8 mg PO DAILY
25. Torsemide 20 mg PO DAILY
26. Venlafaxine XR 225 mg PO DAILY
27. Vitamin D 6000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
L tibia and fibula fracture
Acute kidney injury
anemia
SECONDARY DIAGNOSIS:
s/p kidney transplant
right leg burn
heart failure with preserved ejection fraction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Weightbearing as tolerated left lower extremity
MEDICATIONS:
1) Take Tylenol standing 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.
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 your home aspirin and Plavix daily
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.
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
In addition, this admission you developed kidney injury which
may have been related to dehydration and lower blood pressures
after surgery. Your kidney function improved to your baseline by
discharge.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19917318-DS-21 | 19,917,318 | 23,197,120 | DS | 21 | 2160-10-16 00:00:00 | 2160-10-16 16:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
vision changes
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ year old man with a history of
hypercholesterolemia who presents to the ED after a brief
episode
of vision changes tonight.
He was in his usual state of health tonight and was watching TV
on the couch. He states that at 10:45 ___ he experienced the
acute onset of vision loss in the right upper quadrant of his
visual field. He denies any associated floaters or other
positive visual phenomena. He believes he close his left eye
and
continued to experience this problem, but that the problem went
away when he closed his right eye. There was no associated
headache, vertigo, tinnitus, difficulty speaking or
understanding
speech, or any other focal weakness or sensory abnormality. He
then stood up and felt somewhat lightheaded for about 30 seconds
but then quickly returned to normal. His visual changes went
away after about 30 seconds total. After this, he has felt well
and has not had any recurrence of his symptoms. Still, he and
his wife felt he should be checked out in the emergency room.
He denies any prior history of similar visual problems. He has
never had any episodes of inability to speak or facial droop or
focal weakness/sensory changes in the past.
Of note, he is followed in neurology clinic by Dr. ___
chronic gait difficulties. This is been attributed to a mild
peripheral neuropathy.
On neuro ROS, the pt denies headache, 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 hab
Past Medical History:
Gait disorder/peripheral neuropathy, HLD, depression, parotid
cancer s/p RT
Social History:
___
Family History:
No family history of stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
Vitals: T: 98.6 P: 74 R: 16 BP: 160/84 SaO2: 98% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. No scalp tenderness.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented 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 and brisk. Slight left ptosis.
EOMI without nystagmus. Normal saccades. VFF to confrontation.
Visual acuity ___ bilaterally. Fundoscopic exam revealed no
papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Very hard of hearing.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 5 5 5 5 5 5
R 5 5 4+ ___ 5 5 5 5 5
-Sensory: Diminished sensation to all modalities below the
ankles. No extinction to DSS. Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was mute bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Slightly wide based.
DISCHARGE PHYSICAL EXAM
=======================
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx. No scalp tenderness.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: soft, non-distended
Extremities: No ___ edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented 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 and brisk. No ptosis. EOMI
without nystagmus. Normal saccades. VFF to confrontation.
Visual acuity right ___, left ___. Fundoscopic exam revealed
no
papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Very hard of hearing.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis
noted.
Delt Bic Tri WrE FE IP Quad Ham TA ___ ___
L 5 ___ 5 5 5 5 5 5 5
R 5 ___ 5 5 5 5 5 5 5
-Sensory: Diminished sensation to all modalities below the
ankles. No extinction to DSS. Romberg absent.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 0
R 2 2 2 1 0
Plantar response was mute bilaterally.
-Coordination: No intention tremor. Normal finger-tap
bilaterally. No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Slightly wide based.
Pertinent Results:
ADMISSION LABS
=============
___ 12:07AM BLOOD WBC-6.0 RBC-3.71* Hgb-12.3* Hct-35.6*
MCV-96 MCH-33.2* MCHC-34.6 RDW-12.5 RDWSD-44.6 Plt ___
___ 12:07AM BLOOD Neuts-56.7 ___ Monos-13.4*
Eos-2.0 Baso-0.3 Im ___ AbsNeut-3.39 AbsLymp-1.62
AbsMono-0.80 AbsEos-0.12 AbsBaso-0.02
___ 12:07AM BLOOD Plt ___
___ 12:07AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-135
K-4.1 Cl-99 HCO3-27 AnGap-9*
___ 12:07AM BLOOD ALT-20 AST-18 AlkPhos-52 TotBili-0.2
___ 12:07AM BLOOD Lipase-44
___ 12:07AM BLOOD cTropnT-<0.01
___ 10:57AM BLOOD Cholest-194
___ 12:07AM BLOOD Albumin-3.5
___ 10:57AM BLOOD VitB12-___ Folate->20
___ 10:57AM BLOOD %HbA1c-5.5 eAG-111
___ 10:57AM BLOOD Triglyc-56 HDL-92 CHOL/HD-2.1 LDLcalc-91
___ 10:57AM BLOOD TSH-4.4*
___ 12:07AM BLOOD CRP-0.6
___ 12:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
IMAGING
=======
CTA HEAD AND CTA NECKStudy Date of ___
CTA HEAD:
The vessels of the circle of ___ and their principal
intracranial branches
appear normal without stenosis, occlusion, or aneurysm
formation. The A1
segment of the right anterior cerebral artery is hypoplastic, a
normal
variant. The dural venous sinuses are patent.
CTA NECK:
There are calcified plaques at the origins the internal carotid
arteries
bilaterally without stenosis on the left by NASCET criteria.
The plaque
produces an approximately 20% stenosis of the right internal
carotid artery by
NASCET criteria. Otherwise, the carotid and vertebral arteries
and their
major branches appear normal with no evidence of stenosis or
occlusion.
OTHER:
The visualized portion of the lungs are clear. The visualized
portion of the
thyroid gland is within normal limits. There is no
lymphadenopathy by CT size
criteria.
MR HEAD W/O CONTRASTStudy Date of ___
IMPRESSION:
1. No evidence of mass, hemorrhage or recent infarction.
2. Chronic left putamen lacune and extensive white matter
hypodensity
suggesting chronic small vessel ischemia.
3. Normal head CTA.
4. Calcified plaque at the origins of the internal carotid
arteries
bilaterally. On the right, this results in approximately 20%
stenosis
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift
or infarction. There are confluent deep and periventricular
white matter T2
signal abnormalities, most consistent with severe chronic small
vessel
ischemic changes, worsened since ___. Component of chronic
demyelination
cannot be excluded; sequela of distant metabolic or inflammatory
process is
statistically unlikely. Brain parenchymal atrophy. Vascular
flow voids are
preserved. Minimal paranasal sinus disease. Minimal
opacification right
mastoids. Clear left mastoids
IMPRESSION:
1. No acute infarct.
2. Findings most consistent with severe chronic small vessel
ischemic changes.
3. Brain parenchymal atrophy
TTE ___
1) Moderate mitral regurgitation of unclear mechanism
originating from posteriormedial
commisure. 2) Mild aortic regurgitation. 3) No specific
echocardiographic evidence of cardiac
embolism.
DISCHARGE LABS
================
___ 06:29AM BLOOD WBC-5.5 RBC-4.23* Hgb-13.9 Hct-40.8
MCV-97 MCH-32.9* MCHC-34.1 RDW-12.9 RDWSD-45.8 Plt ___
___ 06:29AM BLOOD Plt ___
___ 06:29AM BLOOD Glucose-95 UreaN-15 Creat-0.8 Na-135
K-4.8 Cl-98 HCO3-26 AnGap-11
___ 06:29AM BLOOD Calcium-9.8 Phos-3.5 Mg-2.0
___ 06:29AM BLOOD T4-5.8
Brief Hospital Course:
SUMMARY STATEMENT
==================
Mr. ___ is an ___ year old man with a past medical history
of hyperlipidemia who presented to the ED after a transient
episode of monocular vision changes at home prompting ED visit,
he was admitted to the Neurology Stroke service and ruled out
for acute stroke.
#Vision changes:
Patient reports a brief episode of right-sided vision changes at
home after standing, lasting approximately 30 seconds. Described
as the "right side of the room was cut in half", no true vision
loss. Immediately prior to this, he experienced some dizziness
and lightheadedness while sitting, when attempting to stand he
drifted forward and caught himself without an actual fall. His
symptoms resolved after standing. He went to the ED and his
symptoms were largely resolved, his NIHSS was 0. His general and
neurologic review of systems was otherwise unremarkable. His
neurologic exam was notable for poor vision (right ___, left
___, blurry right-sided vision when left eye covered, full
visual fields, normal fundoscopic exam, slight right arm
pronation, and slightly wide based gait (see below #gait
disorder). He had a brain MRI that was negative for acute or
prior stroke (notably, ADC demonstrated questionable bright
lesion in L basal ganglia area, per review with neuroradiology
likely volume averaging, not stroke), CTA does with significant
carotid atherosclerosis. While his monocular symptoms are
certainly concerning for transient ischemic event, particularly
an atherothrombolic event, this is unlikely given reassuring
visual exam and MRI, as well as a history that does not suggest
true vision loss. His serum risk factors for stroke were LDL 91,
HgA1c 5.5. He was started on aspirin and his home simvastatin
dose was increased. Other explanations for his vision changes
include poor baseline vision given age. Low suspicion for
amaurosis fugax per description of event, or temporal arteritis
given normal inflammatory markers and lack of headache, temporal
pain. Given low suspicion for ischemic event, ophthalmology
evaluated the patient and found no occular pathology.
#Gait disorder
#Peripheral Neuropathy
Patient with longstanding history of mild peripheral neuropathy
of unclear etiology and gait instability. He is seen in as an
outpatient in neurology clinic (Dr. ___. His symptoms are
largely thought to be related to anxiety, as they are
subjectively out of proportion to his examination findings. On
admission, his gait was slightly wide based, he states this is
chronic. His A1c of 5.5 does not suggest diabetic neuropathy,
although he is close to pre-diabetic range. Notably, he is a
daily drinker ___ beers per day), and this may be contributory.
#HLD
Increased home statin dose as above.
TRANSITIONAL ISSUES:
=====================
[] continue to encourage reduction in alcohol consumption
[] increased simvastatin dose 20 to 40 mg QD
[] initiated aspirin 81 QD
Medications on Admission:
FLUOCINONIDE - fluocinonide 0.05 % topical cream. apply twice a
day
IBUPROFEN - ibuprofen 600 mg tablet. TAKE 1 TABLET BY MOUTH
THREE
TIMES DAILY
LORAZEPAM - lorazepam 0.5 mg tablet. TAKE 1 TABLET BY MOUTH
TWICE
DAILY - Entered by MA/Other Staff
SILDENAFIL [VIAGRA] - Viagra 100 mg tablet. TAKE 1 TABLET BY
MOUTH EVERY DAY 1 HOUR PRIOR TO INTERCOURSE.
SIMVASTATIN - simvastatin 20 mg tablet. TAKE 1 TABLET BY MOUTH
EVERY DAY
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain -
(Prescribed by Other Provider)
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Aspirin Regimen] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. Sildenafil 20 mg PO DAILY:PRN intercourse
3. Simvastatin 40 mg PO QPM
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Fluocinonide 0.05% Cream 1 Appl TP BID
5. Ibuprofen 600 mg PO TID
6. LORazepam 0.5 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
#Vision changes
SECONDARY
==========
#Gait disorder
#Peripheral Neuropathy
#HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at the ___
___. You came to the hospital because you developed
some vision changes at home. These symptoms were concerning for
a stroke. We evaluated you with blood tests and imaging of your
brain and determined that you did not have a stroke. However, we
did find that you have some blockage in your arteries leading to
your brain which places you at risk for future stroke. Your eyes
were examined by our eye doctors and were ___ to be healthy.
We started you on a new medication called aspirin which will
keep your blood thin and will help prevent future strokes. We
increased the dose of your home simvastatin medicatin to keep
your cholesterol levels down, this will also help prevent future
strokes.
Please follow up with your primary care physician and eye doctor
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19917446-DS-14 | 19,917,446 | 20,856,545 | DS | 14 | 2124-01-21 00:00:00 | 2124-01-21 09:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / Clindamycin
Attending: ___
Chief Complaint:
Pain
Major Surgical or Invasive Procedure:
___ -
1. Redo sternotomy.
2. Redo aortic valve replacement with a 19 ___
Ease tissue valve.
3. Mitral valve replacement with 27 mm ___ tissue valve.
.
___- PEG tube
___- Trach
4. Tricuspid valve repair with 28 mm Physio ring.
History of Present Illness:
Mr. ___ is an ___ year old man with a history of HTN, HLD,
impaired glucose tolerance, CAD s/p CABG x3 (___), aortic
stenosis s/p tissue AVR (___), and HF who presents with several
month history of increased weakness, weight loss, worsened
appetite, and worsened BLE edema - found have GPC
bacteremia.
Per the ED: He is an ___ yo male s/p AVR in ___ with acute heart
failure symptoms, minimally responsive to PO diuretics with
positive blood cultures (GPC in chains x2 out of 4 bottles), who
was sent in today for evaluation from his primary care doctor
for admission secondary to the positive blood cultures. The
patient has a lot of progressive symptoms over the last few
months per his daughter. He does have low back pain, increasing
weakness, he has had bilateral lower extremity edema, decreased
appetite, ~25 lb weight loss since ___.
On the floor, Mr. ___ and his daughter endorse the above
history. Specifically, they note that since ___ he had
an abrupt onset low back pain (reported non-traumatic, worsened
with movement but no pain at rest, no ___ paresthesias/saddle
paresthesias/ urinary or stool incontinence/retention) as well
as decreased appetite and unintentional weight loss (~25 lb
weight loss). Denies associated fevers, night sweats, chest
pain, palpitations, worsening SOB/DOE, nausea, vomiting,
abdominal pain, dysuria, diarrhea, or constipation.
Of note, he does note that ~2 weeks ago he had one episode of
orthopnea, PND, and worsened BLE edema - subsequently relieved
after receiving an increased dose of Furosemide. Notes that
while he still has BLE edema, it is much better than before.
Past Medical History:
Aortic Stenosis
Allergic Rhinitis
Anemia
Benign Prostatic Hyperplasia
Colonic Adenoma
Erectile Dysfunction
Gastroesophageal Reflux Disease
Hyperlipidemia
Hypertension
Impaired Glucose Tolerance
Osteoarthritis
Trigger Finger
Cataracts
s/p appendectomy
s/p polypectomy
Social History:
___
Family History:
No premature coronary artery disease. Father died suddenly at
age ___ - unknown cause
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.1, 105 / 65, 73, 20, 98% RA
GENERAL: Alert, older gentleman in NAD, non-toxic
HEENT: Normocephalic, atraumatic. Sclera anicteric and without
injection. Moist mucous membranes.
NECK: Trachea mid-line. +JVP slightly about clavicle at 60'
CARDIAC: RRR. Audible S1 and S2. No rubs/gallops. ___
crescendo-decrescendo murmur head throughout precordium w/
radiation to carotids (mechanical sounds heard best at the
apex).
LUNGS: No increased work of breathing. +Very mild L basilar
crackles, but otherwise clear.
BACK: No spinous process tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing or cyanosis. 1+ pitting edema to knees
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: CN2-12 intact. ___ strength throughout (of note, R
hip flexion 4+/5 limited by LBP). Normal sensation.
========================
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs and Intake/Output:
Temp: 97.1 BP: 109/53 HR:80-90's RR: 18
O2 sat: 100% trach collar
___: 126
I/O: 60/400
Physical Examination:
General/Neuro: A&O, very interactive and alert, NAD [x]
Cardiac: RRR [x] Irregular [] Nl S1 S2 [x]
Lungs: CTA {x} Diminshed bases
Abd: BS {x} [x]Soft [x] ND [x] PEG site c/d/I mild
tenderness at site
Extremities: no CCE[x] Pulses palpable [x]
Wounds: Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x]
Pertinent Results:
ADMISSION LABS
==============
___ 03:53PM BLOOD WBC-10.7* RBC-3.68* Hgb-10.3* Hct-31.2*
MCV-85 MCH-28.0 MCHC-33.0 RDW-15.6* RDWSD-47.8* Plt ___
___ 03:53PM BLOOD Neuts-89.6* Lymphs-5.1* Monos-4.6*
Eos-0.1* Baso-0.1 Im ___ AbsNeut-9.62* AbsLymp-0.55*
AbsMono-0.49 AbsEos-0.01* AbsBaso-0.01
___ 03:53PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+* Macrocy-OCCASIONAL Microcy-1+* Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-1+*
___ 03:53PM BLOOD ___ PTT-30.1 ___
___ 03:53PM BLOOD Glucose-110* UreaN-18 Creat-1.1 Na-131*
K-3.6 Cl-90* HCO3-29 AnGap-12
___ 03:53PM BLOOD ALT-16 AST-36 LD(LDH)-353* AlkPhos-128
TotBili-0.9 DirBili-0.3 IndBili-0.6
___ 03:53PM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.9 Mg-1.8
Iron-43*
___ 03:53PM BLOOD calTIBC-195* VitB12-451 Folate-4
Hapto-<10* Ferritn-340 TRF-150*
==================
PERTINENT RESULTS:
==================
___ 08:30AM BLOOD Glucose-128* UreaN-16 Creat-1.2 Na-135
K-3.2* Cl-92* HCO3-29 AnGap-14
___ 04:42AM URINE Color-Yellow Appear-Clear Sp ___
___ 04:42AM URINE Blood-SM* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-NEG
___ 04:42AM URINE RBC-1 WBC-3 Bacteri-NONE Yeast-NONE Epi-0
___ 04:42AM URINE CastHy-1*
___ 04:42AM URINE Mucous-RARE*
===============
DISCHARGE LABS:
===============
___ 01:23AM BLOOD WBC-5.8 RBC-2.92* Hgb-8.8* Hct-27.3*
MCV-94 MCH-30.1 MCHC-32.2 RDW-15.9* RDWSD-54.4* Plt ___
___ 01:23AM BLOOD Glucose-126* UreaN-18 Creat-0.6 Na-139
K-4.2 Cl-96 HCO3-33* AnGap-10
___ 03:14AM BLOOD Calcium-7.4* Phos-3.7 Mg-2.3
___ 02:33PM BLOOD Type-ART pO2-___ pCO2-54* pH-7.44
calTCO2-38* Base XS-10
.
Cxray ___
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The cardiomediastinal silhouette is stable since the most recent
comparison.
Midline sternal wires are well aligned and intact. Other
support catheter are
unchanged. Fluid within the right major fissure is unchanged
since the prior
studies. Vascular congestion may be slightly improved since the
most recent
prior.
IMPRESSION:
Minimally improved edema since the most recent prior.
.
EXAMINATION ___: Video oropharyngeal swallow study
INDICATION: ___ year old man with ? aspiration// eval for
aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was
performed in
conjunction with the Speech-Language Pathologist from the Voice,
Speech &
Swallowing Service. Multiple consistencies of barium were
administered.
DOSE: Fluoro time: 5 minutes 3 seconds
COMPARISON: None available.
FINDINGS:
There is aspiration noted with thin liquids, most notably with
mixed
consistency. Residuals were noted within the vallecula.
IMPRESSION:
Aspiration of thin liquids, most notably with mixed consistency.
Please note that a detailed description of dynamic swallowing as
well as a
summative assessment and recommendations are reported separately
in a
standalone note by the Speech-Language Pathologist (OMR, Notes,
Rehabilitation
Services).
Portable CXR ___
The tracheostomy and left-sided PICC line are again seen.
Mediastinal wires
are present. There is cardiomegaly. There are bilateral
pleural effusions
and a left retrocardiac opacity, stable. Partially loculated
pleural fluid is
seen within the right minor fissure, unchanged. There is
moderate pulmonary
edema. There are no pneumothoraxes
Brief Hospital Course:
Mr. ___ was admitted to the hospital on ___ for surgical
management of his endocarditis. He was worked-up and evaluated
by the infectious disease service. Cultures grew streptococcus
gordonii and ceftriaxone was started. He was worked-up in the
usual manner for surgery. A dental consult was obtained. He was
undecided about surgery and thus was allowed to think things
over for a few days. On ___, he was taken to the operating
room where he underwent Redo sternotomy, Redo aortic valve
replacement with a 19 ___ Ease tissue valve, Mitral
valve replacement with 27 mm ___ tissue valve, Tricuspid
valve repair with 28 mm Physio ring. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring.
The patient developed post-operative bleeding and hypotension
and was taken back to the OR the following morning. There was a
chest wall bleeder found that was cauterized and the patient was
closed again. His chest tubes were removed and he failed his
initial vent wean. He developed a right sided PTX and a chest
tube was replaced. The patient was extubated the following day
on ___. His chest tube was again removed on ___ with
subsequent re-development of a PTX and the right sided chest
tube was replaced again. The patient developed atrial
fibrillation which was controlled with amiodarone and he was
started on Coumadin. The thoracic surgery team was consulted for
recurrent PTX and after several days of a clamp trial his right
chest tube was removed and he did not re-develop a pneumothorax.
He developed a left pleural effusion and underwent a
therapeutic thoracentesis with drainage of 1500ccs of serous
fluid. The patient developed intermittent delirium that
responded to Seroquel. He had continued dysphagia and he
required supplemental nutrition through a DHT. He was
transferred to the ___ 8 on ___.
The patient had continued dysphagia and had a video swallow exam
on ___. He showed aspiration with thin liquids and his diet was
advanced to ground solids. On a follow up CXR on ___ he was
found to have a re-accumulation of a left pleural effusion and a
chest tube was placed with 1100ccs of serous drainage. The
following day the patient developed worsening SOB with concern
for aspiration and the patient was transferred back to the ICU
for monitoring. He developed right sided atelectasis that
improved with aggressive chest ___ and use of a Theravest. With
aggressive chest physiotherapy he was able to be transferred
back to the floor. Given his continued dysphagia and poor PO
intake along with risk of aspiration, the decision was made to
proceed with a PEG tube. A PEG was placed without complication
on ___ and tube feeds were started. The patient again developed
shortness of breath and hypoxia and was intubated on ___. Given
the high level of pulmonary hygiene the patient needed the
decision was made to proceed with a tracheostomy, which occurred
on ___. The patient tolerated the procedure well was gradually
weaned to trach collar. His delirium gradually improved prior to
discharge.
The patient completed his course of Ceftriaxone for endocarditis
on ___. By the time of discharge on POD 47 the patient was able
to be out of bed with assistance, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to ___ in good condition with appropriate
follow up instructions.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 1200 UNIT PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Calcium Carbonate 500 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. ipratropium bromide 42 mcg (0.06 %) nasal TID
10. Potassium Chloride 10 mEq PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 325 mg ___ capsule(s) by mouth every six (6)
hours Disp #*60 Capsule Refills:*1
2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN dyspnea
3. Amiodarone 200 mg PO DAILY
until reevaluated by Cardiologist
4. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q4H:PRN cough
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Insulin SC
Sliding Scale. Fingerstick q6h. Insulin SC Sliding Scale
using REG Insulin
8. Ipratropium Bromide MDI 2 PUFF IH Q6H:PRN SOB
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Lidocaine 5% Patch 2 PTCH TD QAM low back
11. Metoprolol Tartrate 6.25 mg PO BID
12. Miconazole Powder 2% 1 Appl TP TID:PRN buttocks
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. QUEtiapine Fumarate 12.5 mg PO Q NOON
16. QUEtiapine Fumarate 50 mg PO QHS
17. QUEtiapine Fumarate 75 mg PO QHS
18. Ramelteon 8 mg PO QHS
19. Senna 17.2 mg PO DAILY
20. ___ MD to order daily dose PO DAILY16
goal INR ___ for ___ team to manage
21. Furosemide 20 mg PO BID
22. Aspirin 81 mg PO DAILY
23. Atorvastatin 80 mg PO QPM
24. Calcium Carbonate 500 mg PO DAILY
25. Docusate Sodium 100 mg PO DAILY
26. Potassium Chloride 10 mEq PO DAILY
27. Vitamin D 1200 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
-Endocarditis
-HFpEF: EF 55-60% (___)
-Allergic Rhinitis
-Anemia
-Benign Prostatic Hyperplasia
-Colonic Adenoma
-Erectile Dysfunction
-Gastroesophageal Reflux Disease
-Hyperlipidemia
-Hypertension
-Impaired Glucose Tolerance
-Osteoarthritis
-Trigger Finger
-Cataracts
Discharge Condition:
Alert and oriented x ___, non-focal
max assist
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Edema trace
Discharge Instructions:
Please shower daily -wash incisions gently with mild soap, no
baths or swimming, look at your incisions daily
Please - NO lotion, cream, powder or ointment to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics
Clearance to drive will be discussed at follow up appointment
with surgeon
No lifting more than 10 pounds for 10 weeks
Encourage full shoulder range of motion, unless otherwise
specified
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19917510-DS-21 | 19,917,510 | 26,039,287 | DS | 21 | 2168-06-21 00:00:00 | 2168-06-24 14:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
chest pressure/shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ male with PMH of atrial fibrillation with RVR on
anticoagulation, SSS c/b syncope and dizziness s/p dual chamber
pacemaker placement who presents with acute worsening of chest
pressure and SOB. The patient reports that on ___ (2 days
prior to admission) the patient felt pressure in his chest with
associated increase in his baseline SOB. The pressure extended
from the substernal area to his neck, was ___ in severity at
its worst, and did not radiate. Lying down flat made the pain a
little better. Denies nausea, vomiting, fever, sweats.
The patient says that he felt no palpitations and that he began
to feel better after ___ hours, though he had the pressure again
yesterday and this morning. On the morning of admission the
patient presented to the ___ for evaluation of his
symptoms despite overall improvement. The patient was told that
his EKG showed a fast heart with with some "changes" that may
indicate ischemic disease, and he was sent to the ED.
The patient has a history of atrial fibrillation and is
currently on long-term anticoagulation with Coumadin. He was
seen by his electrophysiologist, Dr. ___ in ___
on ___ for adjustment of his pacemaker.
In the ED, initial vitals were pain:9 T: 97.8 HR: 116 BP: 124/78
RR:20 O2 SAT: 99% 2L Nasal Cannula. Patient's weight on day of
admission as recorded in clinic was 189lbs (dry weight is
188lbs). Patient was given sublingual nitroglycerin x1, which
didn't make any difference in terms of his pain. He also got
500cc NS bolus x2 and 324mg ASA chewed in the ED. Patient was
admitted to ___ for observation.
On arrival to the floor the patient was noted to be in Afib with
RVR rates into the 150s without symptoms of chest tightness or
pressure, except with deep breaths. Vital signs were: 97.6
129/92 135 18. The patient reported that he felt well and was
A+Ox4. The patient was given 5mg of IV metoprolol (his home dose
is Metoprolol succ 25mg BID) with a decrease in his rate to the
110's. He was then given 12.5mg of metoprolol tartrate.
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. 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, ankle edema, palpitations, syncope
or presyncope.
Past Medical History:
- Hyperlipidemia
- Atrial Fibrillation with RVR on coumadin for anticoagulation
- SSS with pacemaker
- Lumbago
- Epilepsy (hasn't had a seizure or needed medication for
decades)
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T97.6, BP 129/92, HR 135, RR 18, O2 100%RA
General: pleasant man in bed in NAD
HEENT: NCAT, MMM, EOMI
Neck: flat neck veins
CV: tachycardic, irregularly irregular, no m/r/g appreciated
Lungs: CTAB, no crackles or wheezes appreciated
Abdomen: soft, nontender, nondistended, +BS
GU: no foley
Extr: feet cool (pt endorses lifelong cold feet), no cyanosis,
clubbing, edema, 2+ DP pulses bilaterally
Neuro: A&Ox3
Skin: no lesions appreciated
DISCHARGE PHYSICAL EXAM:
VS: Tm=97.1, BP=94/56 (94-121/56-83), HR=83 (83-116) (in ___'s
overnight on tele), RR=16 O2 sat= 96%RA
I/O: BRP
Wt: 83.5 <- 83.4 <- 84.1 <- 86.3
General: pleasant man in bed in NAD
HEENT: NCAT, MMM, EOMI
Neck: flat neck veins
CV: tachycardic, irregularly irregular, no m/r/g appreciated
Lungs: CTAB, no crackles or wheezes appreciated
Abdomen: soft, nontender, nondistended, +BS
GU: no foley
Extr: feet cool (pt endorses lifelong cold feet), no cyanosis,
clubbing, edema, 2+ DP pulses bilaterally
Neuro: A&Ox3
Skin: no lesions appreciated
Pertinent Results:
ADMISSION LABS:
___ 12:52PM WBC-7.2 RBC-4.44* HGB-14.3 HCT-42.6 MCV-96
MCH-32.2* MCHC-33.6 RDW-13.2 RDWSD-46.7*
___ 12:52PM ___ PTT-40.7* ___
___ 12:52PM GLUCOSE-110* UREA N-15 CREAT-1.1 SODIUM-134
POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-21* ANION GAP-18
___ 12:52PM CALCIUM-9.0 PHOSPHATE-3.3 MAGNESIUM-2.2
___ 12:52PM cTropnT-<0.01
___ 12:52PM proBNP-1415*
___ 12:47PM LACTATE-2.5* K+-4.4
DISCHARGE LABS:
___ 05:05AM BLOOD WBC-6.1 RBC-4.22* Hgb-13.5* Hct-40.9
MCV-97 MCH-32.0 MCHC-33.0 RDW-13.3 RDWSD-47.3* Plt ___
___ 05:05AM BLOOD Glucose-126* UreaN-20 Creat-0.9 Na-140
K-4.1 Cl-106 HCO3-21* AnGap-17
___ 05:05AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.0
TROPONIN TREND:
___ 12:52PM BLOOD cTropnT-<0.01
___ 09:27PM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:02AM BLOOD cTropnT-<0.01
MICROBIOLOGY:
Blood culture ___: no growth prelim
IMAGING/PROCEDURES:
Stress MIBI ___:
Stress:
No ischemic ECG changes. No anginal type symptoms. Exaggerated
ventricular response to exercise in the setting of atrial
fibrillation. Poor functional capacity demonstrated. Nuclear
report sent separately.
Perfusion:
The image quality is adequate.
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 64%.
CXR ___:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ male with PMH of atrial fibrillation with RVR on
anticoagulation, SSS c/b syncope and dizziness s/p dual chamber
pacemaker placement who presents with acute worsening of chest
pain and SOB, found to be in RVR with rate in the 150's in the
ED. Rate responded well to IV metoprolol on the floor.
# Atrial fibrillation with RVR. The patient presented with Afib
with RVR into the 150s. The patient received no beta blockade
while in the ED and it is possible that the patient's symptoms
over the weekend were caused by increasing heart rate with
possible rate-related ischemia. The patient's pacemaker was
interrogated on admission and showed poorly controlled rate over
the last several months (only below 100BPM ~30% of the time). He
has also been in persistent AFib since ___. The
patient does report compliance with his home medications, which
include metoprolol succinate 25mg BID and coumadin for
anticoagulation. He took his metoprolol on the morning of
admission. An EKG on admission showed no ischemic changes, and
troponins were trended and negative. The patient's heart rate
initially responded well to IV metoprolol 5mg on the floor, with
decrease of HR from 130's to 110's. After this IV dose, we
initially struggled to control the patient's heart rate with
oral medication. Ultimately, the patient's rate was controlled
by increasing his metoprolol tartrate to 75mg q6h ___, and
adding digoxin with loading dose of 0.5mg BID, then maintainence
dose of 0.125 QD. The patient was discharged on this dose of
digoxin and metoprolol succinate 150mg q12h. In terms of his
anticoagulation, the patient's INR was slightly subtherapeutic
during this admission (INR decreased to 1.9 then 1.7), so we
increased his home warfarin regimen from 2.5mg ___ and
___, 3.75mg other 5 days, to 3.75mg daily, and discharged him
on this new regimen. The patient was discharged on ___ given
good rate control.
# Chest Pressure/shortness of breath: The patients' chest pain
is atypical. Troponins were trended and negative. There were no
ischemic changes on EKG. The patient's ProBNP was 1415, but
there were no signs of volume overload on exam. An exercise MIBI
on ___ showed no focal perfusion deficits, normal wall
motion, EF 64%, no ischemic EKG changes. With stress during the
MIBI, there were no anginal symptoms, exaggerated ventricular
response to exercise in the setting of Afib, and poor functional
capacity. Given these findings, we believe that the patient's
chest pressure and shortness of breath were likely secondary to
RVR, see above.
# SSS s/p Pacemaker: Chronic. The patient's pacemaker was
interrogated ___ and showed poorly controlled rate over the
last several months (only below 100BPM ~30% of the time). The
patient has also been in persistent AFib since ___.
# Lumbago: Chronic. We continue the patient's home gabapentin
100mg BID.
# Hyperlipidemia: Chronic. We continued the patient's home
simvastatin 20mg daily.
***Transitional Issues***
[ ] continued monitoring of INR and warfarin dosing. Pt given
script to have INR drawn on ___.
[ ] continued monitoring of heart rate and titration of rate
control medications, consider pacemaker interrogation for rate
trends.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Warfarin 2.5 mg PO 2X/WEEK (MO,FR)
4. Metoprolol Succinate XL 25 mg PO BID
5. Warfarin 3.75 mg PO 5X/WEEK (___)
6. Lunesta (eszopiclone) 1 mg oral QHS:PRN insomnia
Discharge Medications:
1. Gabapentin 300 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Digoxin 0.125 mg PO DAILY
RX *digoxin 125 mcg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
4. Lunesta (eszopiclone) 1 mg oral QHS:PRN insomnia
5. Metoprolol Succinate XL 150 mg PO Q12H
RX *metoprolol succinate [Toprol XL] 50 mg 3 tablet(s) by mouth
every twelve (12) hours Disp #*180 Tablet Refills:*0
6. Warfarin 3.75 mg PO DAILY16
take this dose 7 days per week.
7. Outpatient Lab Work
ICD-9 42___.31 Atrial Fibrillation
Please draw INR on ___ and fax results to PCP: ___
___, MD, Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
atrial fibrillation with rapid ventricular response
SECONDARY:
chest pain
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 chest pain and a rapid
heart rate. Your heart rate was from uncontrolled AFib. To treat
this, we increased your metoprolol and started you on a new
medicine called Digoxin. For your chest pain, you underwent a
nuclear stress test which showed that you were not having a
heart attack.
You should follow up with your PCP and your cardiologist. These
appointments are listed below. Your medications are detailed in
your discharge medication list. You should review this carefully
and take it with you to any follow up appointments.
It was a pleasure taking care of you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19917746-DS-18 | 19,917,746 | 22,227,729 | DS | 18 | 2194-10-13 00:00:00 | 2194-10-14 17:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lovastatin
Attending: ___.
Chief Complaint:
Dyspnea, chest discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with a h/o NSCLC with mets to LNs s/p VATS/right lower
lobectomy in ___, s/p prior chemo now on clinical trial of
Kevetrin p/w dyspnea/chest pain. Pt reports progressively
worsening dyspnea over the past 3 days with severe episodes
lasting ___ hours. Episodes associated with ___ substernal chest
"discomfort." He usually uses ___ L of O2 for activities
requiring increased exertion at home. However, he has needed his
home oxygen more frequently with less strenuous activity.
Finally, yesterday morning pt's symptoms were at their most
severe and pt's wife pushed him to go in to the ED. EMS
contacted, found to have HR in the 150s, given 21 mg of dilt and
HR improved to the ___. On arrival to the ___ parking lot,
HR again in the 150s and pt given 30 mg dilt prior to arrival in
triage.
.
In the ED, initial vitals: 124 ___ 22 95% ra. Pt noted to be
in A fibt to 150s-160s on arrival but converted to NSR in the
___ within 10 mins. K 5.2, lytes o/w ok. hct 33. bnp 1385. tpn
neg. lactate 3.1. ECG: A fib VR in the 120s, no ischemic
changes. CXR: "Increased opacification of the right lung,
probably reflecting increasing pleural effusion and lung
collapse." CTA showed: "1. interval progression of disease,
dominant R hilar mass, w/ new complete collapse of R lung w/ new
occlusion of RUL brinchus and R bronchus intermedius, the latter
if not both bronchial occlusions are likely due to direct tumor
ingrowuth but tumor ___ are poorly assessed given
adjacent collapsed ling 2. worsening severe attenuation/invasion
of R main pulmonary artery w/o new embolus 3. new lingular
peribronchial opacification in location of previosuly increased
nodules concerninf for mets 4. new irregular beading of left
septal and pleural surfaces concerning for lymphagitic spread 5.
new small left pleural effusion 6. stable moderate pericardial
effusion w/o evidence of tamponade 7. incompletely assessed
intraabd LAD." Pt given 1 L NS with and admitted to OMED.
ROS: as above; otherwise complete ROS negative.
Past Medical History:
Per OMR:
Oncologic History:
- ___: CT chest shows a 10 mm pleural-based nodule inferior
to the medial margin of the right major fissure.
- ___: PET shows 12 mm nodule in the anteromedial aspect of
the right lower lobe inferior to the hilum, without FDG-avidity.
- ___: Repeat CT chest demonstrates increase in size of this
nodule to 18 x 15 x 14 mm, with increased pleural thickening and
calcified pleural plaques in the left lung base, ground glass
opacities in the posterior segment of the bilateral lower lobes,
and a small 4 mm nodular density in the right upper lobe.
- ___: Repeat PET shows that the solitary right lower lobe
pulmonary nodule is FDG-avid, SUV 6.3. No pleural effusion or
FDG-avid mediastinal or hilar lymphadenopathy.
- ___: Undergoes VATS/ right lower lobe wedge resection,
followed by VATS/right lower lobectomy, mediastinal lymph node
dissection, and bronchoscopy with bronchoalveolar lavage by Dr.
___. Pathology reveals adenocarcinoma, 1.6 cm. Second
nodule 1.5 cm, adenosquamous carcinoma, invading the visceral
pleural. Grade 2. Margins uninvolved, venous invasion absent,
lymphatic invasion present. Ten lobar lymph nodes, all with no
evidence of malignancy. Five level 7 nodes, all negative. One
of
three level 11R lymph nodes positive for adenocarcinoma. One of
five level 12R lymph nodes positive for adenocarcinoma.
Initially
staged as pT2aN1Mx, Stage IIA.
- ___: Adjuvant chemotherapy x 4 cycles with
carboplatin/pemetrexed, treated by Dr. ___ at ___.
- ___: CT torso at ___ shows no evidence of recurrent
disease.
- ___: Develops cough and shortness of breath.
- ___: Surveillance CT chest at ___ reveals new right
greater than left mediastinal lymphadenopathy and confluent
right
hilar lymphadenopathy with narrowing of RUL and
RML arteries and bronchi. Increased small right pleural effusion
with a questionable new pleural mass at posterior right base,
and
a new irregular pleural lesion along the right mediastinum.
These
findings suggest either lung cancer progression or mesothelioma,
given evidence of asbestos exposure. New right retroperitoneal
lymphadenopathy indicates distal metastatic disease.
- ___: Undergoes bronchoscopy with EBUS. Fine needle
aspiration demonstrates metastatic adenocarcinoma in level 4R
lymph node, level 7 lymph node, and level 11R lymph node.
Negative for EGFR, ALK, k-Ras, or ROS1 mutations.
- ___: PET scan shows extensive lymphadenopathy in the
chest,
including the right hilum, mediastinum, left axilla,
supraclavicular, and retrocaval lymph nodes, consistent with
recurrent lung cancer. Small right pleural effusion and FDG-avid
costophrenic sulcus also likely malignant in nature.
- ___: Initial medical oncology evaluation at ___.
Referred
urgently to Radiation Oncology.
- ___: Begins palliative radiotherapy to the right chest.
- ___: C1D1 concurrent carboplatin/paclitaxel for
radiosensitization.
- ___: C3D1 concurrent carboplatin/paclitaxel for
radiosensitization.
- ___: C4D1 concurrent carboplatin/paclitaxel for
radiosensitization.
- ___: Completes radiotherapy.
- ___: CT torso shows mixed response in right lung and
intrathoracic lymph node lesions, as well as extensive
retroperitoneal and para-aortic lymphadenopathy, increased in
size since the previous examination.
- ___: C1D1 carboplatin (AUC 6)/paclitaxel (200 mg/m2).
- ___: Admitted to ___ with minor hematochezia,
thought to be hemorrhoidal in nature.
- ___: C2D1 carboplatin/paclitaxel.
Past Medical History:
- Non-small cell lung cancer, as above
- Prostate cancer (diagnosed ___, ___ 3+3, ___ cores
positive on the right involving 5%, ___ cores on the left
involving 2%, T1c, treated with brachytherapy by Dr. ___
- Small bowel desmoid tumor, s/p resection ___
- Left adrenal cortical adenoma s/p resection ___
- Hypercholesterolemia
- Migraine headache
- Left inguinal hernia repair
- Appendectomy
Social History:
___
Family History:
Per OMR:
Maternal grandfather died at age ___, possibly of
colon cancer. Mother had "heart problems" and congestive heart
failure, lived until age ___. Father had multiple sclerosis and
died at age ___. A brother has no medical problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
t97.7 130/72 83 22 95% 2LNC
NAD
eomi, perrl
neck supple
no ___ BSs on R
rrr
abd benign
ext w/wp trace b/l edema
neuro non-focal
no rash
DISCHARGE PHYSICAL EXAM:
General: Lying in bed, mildly tachypneic but in no acute
distress
HEENT: MMM, pupils equal, round and reactive to light
CV: Regular rate and normal rhythm, no m/r/g
Resp: Bronchial breath sounds on the right, intermittent
wheezing on the left
Abdomen: Distended but soft and non-tender to palpation
Ext: Warm and well perfused, no edema
Neuro: Alert and oriented x3, appropriate
Pertinent Results:
ADMISSION LABS:
___ 09:42PM LACTATE-3.1*
___ 09:30PM GLUCOSE-126* UREA N-19 CREAT-0.9 SODIUM-134
POTASSIUM-5.2* CHLORIDE-97 TOTAL CO2-24 ANION GAP-18
___ 09:30PM cTropnT-<0.01
___ 09:30PM proBNP-1385*
___ 09:30PM WBC-10.5 RBC-3.73* HGB-11.2* HCT-33.0* MCV-88
MCH-30.0 MCHC-33.9 RDW-17.8*
___ 09:30PM PLT COUNT-473*
___ 09:30PM ___ PTT-26.3 ___
PERTINENT INTERIM LABS:
___ 01:30AM BLOOD TSH-2.0
DISCHARGE LABS:
___ 03:36AM BLOOD WBC-9.1 RBC-3.92* Hgb-11.5* Hct-34.8*
MCV-89 MCH-29.3 MCHC-33.1 RDW-17.9* Plt ___
___ 03:36AM BLOOD Plt ___
___ 03:36AM BLOOD ___ PTT-31.1 ___
___ 03:36AM BLOOD Glucose-96 UreaN-17 Creat-0.7 Na-133
K-4.3 Cl-96 HCO3-28 AnGap-13
___ 03:36AM BLOOD Calcium-8.2* Phos-3.9 Mg-1.7
MICROBIOLOGY: None.
PATHOLOGY: None.
IMAGING/STUDIES:
# CXR (___):
Increased opacification of the right lung, probably reflecting
increasing pleural effusion and lung collapse.
# CTA Chest (___):
1. Interval progression of malignant disease with new complete
right lung consolidation and occlusion of the central right
upper lobe bronchus as well as bronchus intermedius, with at
least the latter likely due to direct tumor invasion. Worsening
severe attenuation and invasion of the right main pulmonary
artery, but no large pulmonary embolus identified. 2. Increased
size of left lingular peribronchiolar opacifications, previously
millimetric nodules, concerning for metastatic disease. In
addition, increased beading of the interlobular septa and
pleural surfaces concerning for lymphangitic spread. 3. New
small left layering non-complex pleural effusion.
4. Stable small to moderate pericardial effusion without
evidence of cardiac tamponade.
# CXR AP ___:
As compared to the previous radiograph, there is unchanged
complete collapse of the right lung, which shift of the
mediastinum to the right. The left perihilar vessels show slight
increase in diameter, potentially reflecting mild pulmonary
edema. Increasing retrocardiac and left basilar atelectasis.
Brief Hospital Course:
___ yo M with a h/o NSCLC with mets to LNs s/p VATS/right lower
lobectomy in ___, s/p prior chemo now on clinical trial of
Kevetrin p/w dyspnea/chest pain found to have PAF in the setting
of complete R lung collapse.
ACTIVE ISSUES
# Dyspnea: Due to RUL/RML lobe collapse secondary to tumor
progression and exacerbated by atrial fibrillation with RVR as
below. Interventional Pulmonary consulted and found that he was
not a candidate for stenting. He had an increased oxygen
requirement. His symptoms improved slightly with increased
supplemental oxygen and duonebs. He is discharged home with
hospice as below with morphine for symptom control as needed.
# Paroxysmal Atrial Fibrillation: New onset afib likely due to
worsening pulmonary disease and high catecholamine state from
stress. He was given a total of 50mg of diltiazem for heart
rates in the 150s on the way to the ER. He was in normal sinus
rhythm by the time he arrive to the ER. In the evening of
hospital day one he had Afib with RVR that did not respond to IV
diltiazem. He was transferred to the ICU where he was put on
diltiazem drip for ___ hours. He converted to normal sinus
rhythm and was put on dilt 30mg PO Q8H, and dose was
subsequently titrated to HR. He did not receive any
anticoagulation as his CHADS score was 0. He had another
symptomatic episode of afib with RVR in the early morning hours
of ___, for which he received IV dilt boluses and a dilt
infusion. He converted back to sinus rhythm. He remained in
the hospital another day to titrate his dilt dosages in efforts
to avoid further recurrences of RVR after discharge. He had
some atrial fibrillation during the night prior to discharge but
remained asymptomatic. He was discharged on diltiazem ER 360mg
PO daily with instructions to take an extra dose of short acting
90 mg if he becomes symptomatic.
# Chest Pain: Likely secondary to right lung collapse. Cardiac
enzymes were negative.
CHRONIC ISSUES
# NSCLC with mets to the LNs s/p prior chemo and RLL VATS on a
clinical trial of Kevetrin with right lung collapse secondary to
tumor progression. Interventional Pulmonology stated that a
stent would not be able to be placed. Palliative care consulted
about end of life care. He was made comfort measures only and he
was discharged home with hospice and is "do not re-hospitalize."
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheeze
2. Benzonatate 200 mg PO TID
3. Guaifenesin-CODEINE Phosphate 15 mL PO Q6H:PRN cough
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Lorazepam 0.5 mg IV BID:PRN n/v
6. Ondansetron 8 mg PO BID:PRN n/v
7. OxycoDONE Liquid 5 mg PO Q6H:PRN pain
8. PredniSONE 30 mg PO DAILY
9. Prochlorperazine 10 mg PO Q6H:PRN n/v
10. Aspirin 81 mg PO DAILY
11. Cyanocobalamin 1000 mcg PO DAILY
12. DiphenhydrAMINE ___ mg PO BID
13. Docusate Sodium 100 mg PO BID
14. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Medications:
1. Benzonatate 200 mg PO TID
2. Cyanocobalamin 1000 mcg PO DAILY
3. DiphenhydrAMINE ___ mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
6. Ondansetron 8 mg PO BID:PRN n/v
7. PredniSONE 30 mg PO DAILY
8. Prochlorperazine 10 mg PO Q6H:PRN n/v
9. Diltiazem Extended-Release 360 mg PO DAILY
RX *diltiazem HCl 360 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*1
10. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ ml by mouth Every 6 hours
Refills:*0
11. Morphine Sulfate (Concentrated Oral Soln) ___ mg PO
Q1H:PRN dyspnea
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ mg by mouth
Every hours Refills:*0
12. Ipratropium Bromide Neb 1 NEB IH Q6H
RX *ipratropium bromide 0.2 mg/mL (0.02 %) 1 nebulizer Inhaled
Every 6 hours Disp #*5 Vial Refills:*0
13. Lorazepam 0.5-2 mg PO Q4H:PRN anxiety
RX *lorazepam 0.5 mg ___ mg by mouth Every 4 hours Disp #*60
Tablet Refills:*0
14. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
RX *albuterol sulfate 1.25 mg/3 mL 3 ml inh q4hr Disp #*60 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Atrial fibrillation with RVR
RUL/RML collapse
Secondary:
Non-small cell lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for shortness of breath and to
the ICU because your heart was in a very fast heart rhythm. Your
chest X-ray also showed that parts of your right lung were
collapsed. We started you on a medication to control your heart
rhythm. It will be very important for you to continue taking
this medication to help prevent the symptoms you had when you
first came in.
At this time our mutual goal is to focus on your quality of
life. We will send you home with hospice services, which will
help to make your time at home as comfortable as possible.
It was a pleasure to be a part of your care,
Your ___ treatment team.
Followup Instructions:
___
|
19917861-DS-10 | 19,917,861 | 20,674,522 | DS | 10 | 2157-09-04 00:00:00 | 2157-09-04 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:
Falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with history of
neurodegererative condition and gait disorder presenting with
recent increase in falls. As per his daughter, she suspects he
has been falling more at home over the past few weeks (although
she has not been home to witness these falls.) As per his
daughter he has fallen 7 times at home since waking up this
morning. He has right leg pain, but no other pain on
examination. He denies pain or any toehr symptoms. Other than
falls, he has no new symptoms that his daughter has noticed. He
denies fever, chills, shortness of breath, cough, difficulty
urinating, dysuria. Patient is supposed to use a walker at
home, but often uses his hand to steady himself.
.
Initial VS in the ED: 99.7 85 118/72 20 100% on RA. Patient has
found to have full ROM of RLE without tenderness or deformity.
He had an infectious work-up - no pneumonia on CXR, and small
leuk/17 WBC on UA. He had right hip films that showed no acute
fracture. He had a CT of his head and c-spine showing no
fractures or acute intracranial process. EKG showed NSR at 70
BPM with diffuse TWF. Patient was given cipro 400mg IV x1.
.
Neurology saw the patient in the emergency department and felt
that he neurodegenerative condition was worsening over time as
they would expect and UTI was contributing to his frequent
falls. They recommended treating teh UTI and evaluating for
possible rehab placement. They suggested his outpatient
neurologist may consider sinemet as an outpatient, but this does
not need to be done urgently. VS prior to transfer: 98.7 100%
76 ___.
.
On the floor, patient has no complaints and denies pain, but
feels slightly uncomfortable in bed and is trying to get up.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. Denied chest pain
or tightness, palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthr myalgias.
Past Medical History:
Neurodegenerative disorder (cortical basal degeneration along
with symptoms of progressive supranuclear palsy: this
combination of disorders is referred to as tauopathy)
Dementia
Cataract
Eye globe replacement
Osteoarthritis
Elevated PSA (as per daughter he may have had prostate bx, but
she thinks it was negative)
Social History:
___
Family History:
On family history, his father lived until about ___ and passed
away from unclear causes. He has a number of siblings and they
are unsure about their health issues. His mother passed away
from unclear medical causes.
Physical Exam:
On Admission:
Vitals: T: 98.2 BP: 118/70 P: 72 R: 16 O2: 100% on RA
General: Alert, oriented to self and "hospital", but ___, does
not know year
HEENT: Right eye prosthetic, left eye EOMI and PRRL, oropharynx
clear, moist mucus membranes
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
Ext: Warm, well perfused, 2+ pulses, no edema. Right knee with
slight tenderness at medial aspect of patella, no obvious
deformity, full ROM, no crepitus, no swelling, no hematoma,
ecchymosis
NEURO: A&Ox1, speach not fluent, No right eye, but CN otherwise
intact, ___ strength upper and lower extremity, sensation intact
bilaterally
On discharge:
General: Alert, oriented to self and hospital
HEENT: Right eye prosthetic, oropharynx clear, moist mucus
membranes
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
Ext: Warm, well perfused, 2+ pulses, no edema. Right and left
knee appear enlarged, full ROM, no obvious deformtiy
NEURO: A&Ox1, stuttering speech, No right eye, but CN otherwise
intact, gait observed with walker, no heel strike, small steps,
appears very unsteady even with assistance of walker
Pertinent Results:
Admission labs:
___ 01:40PM BLOOD WBC-4.9 RBC-4.40* Hgb-13.0* Hct-40.6
MCV-92 MCH-29.6 MCHC-32.1 RDW-11.7 Plt ___
___ 01:40PM BLOOD Neuts-56.1 ___ Monos-7.2 Eos-5.8*
Baso-0.4
___ 01:40PM BLOOD Glucose-84 UreaN-14 Creat-0.9 Na-141
K-4.7 Cl-102 HCO3-28 AnGap-16
___ 06:25AM BLOOD Calcium-9.1 Phos-3.7 Mg-2.0
___ 06:53PM BLOOD Lactate-1.2
Images:
Right Knee x-ray:
RIGHT KNEE, THREE VIEWS: No acute fracture or dislocation is
identified. There are moderate to severe tricompartmental
degenerative changes, worst in the lateral and patellofemoral
compartments with severe joint space narrowing, osteophyte
formation, subchondral irregularity. There is a moderate-sized
joint effusion. No suspicious lytic or sclerotic osseous
abnormalities are seen.
IMPRESSION: No acute fracture or dislocation. Moderate to severe
osteoarthritis.
.
CT C-Spine:
FINDINGS: There is no evidence of fracture or subluxation in the
cervical spine. The prevertebral and paravertebral soft tissues
are within normal limits. There are mild multilevel degenerative
changes including mild disc bulging at C5-6 and C6-7 resulting
in mild central canal narrowing. No critical canal or neural
foraminal narrowing is identified. Mastoid air cells are well
aerated. Posterior fossa content is within normal limits. Deep
cervical soft tissues are unremarkable. Lung apices are clear,
with minimal emphysema.
IMPRESSION: No fracture or subluxation.
.
CT Head Without Contrast:
FINDINGS: There is no intracranial hemorrhage, mass effect,
edema, or shift of normally midline structures. The gray-white
matter differentiation is preserved. Ventricles and sulci are
prominent, consistent with age-related involution. There are
scattered areas of subcortical and periventricular white matter
hypoattenuation, consistent with small vessel ischemic disease.
Suprasellar and basilar cisterns are patent.
Paranasal sinuses and mastoid air cells are well aerated. There
is no skull base fracture. Trace vascular calcification is seen
in the cavernous carotid artery. Right orbital prosthesis is
seen. The left globe appears within normal limits.
IMPRESSION:
1. No acute intracranial process or evidence of fracture.
2. Age-related involution and small vessel ischemic disease.
.
Hip X-Ray:
No acute fracture or dislocation is identified. Hips and
sacroiliac joints are not diastatic. Heterotopic ossification
is seen medial to the lesser trochanter on the left. Mild joint
space narrowing is seen involving both hips, with mild
degenerative changes in the imaged lumbar spine. No suspicious
lytic or sclerotic osseous
abnormalities are present.
IMPRESSION: No acute fracture or dislocation.
.
Chest PA/Lateral:
FINDINGS: Frontal and lateral views of the chest demonstrate
normal
cardiomediastinal silhouette. The thoracic aorta is mildly
unfolded. The lungs are clear. There is no pneumothorax,
vascular congestion, or pleural effusion.
IMPRESSION: No acute cardiopulmonary process. Specifically, no
pneumonia.
Urine culture: No growth.
___ Blood culture: No growth to date x2
Brief Hospital Course:
Mr. ___ is a ___ year-old gentleman with history of
dementia and neurodegenerative disorder presenting with
increased frequency of falls at home.
ACTIVE PROBLEMS:
1. Frequent Falls: Patient has had increased difficulty walking
and is falling frequently at home. Neurology was consulted and
felt his falls were secondary to worsening of patient's
neurodegenerative disorder as it is expected to progress over
time. Neurology did not recommend any changes to medications,
but did recommend patient follow-up with his outpatient
neurologist to consider sinemet or other medical management.
There was initial concern he may have a urinary tract infection,
so there was concern his falls may also be exacerbated by the
infection. In the ED he had a CT of his head an c-spine, which
did not show acute intracranial process or fracture. He had
plain films of his hip and knee that did not show any fracture.
Knee films showed osteoarthritis.
___ evaluated patient and recommended rehab placement for
functional mobility training and balance training. This was
communicated to his primary neurologist. Patient has planned
follow-up with his neurologist in one month.
2. Neurodegenerative disorder: Patient thought to have
neurodegenerative disorders (CBD and PSP), which as per notes
tends to be a progressive disorder minimally responsive to
medications. Neurology saw patient in ED and did not recommend
any acute intervention at this time, but that patient follow-up
with outpatient neurologist for further management.
3. UTI: In ED patient had urine specimen with small leuk and 17
WBC, and few bacteria (clean catch with no epis). Patient
received cipro in ED and it was continued on the floor. Urine
culture showed now growth. Antibiotics were stopped and patient
remained symptom free.
CHRONIC/INACTIVE ISSUES:
1. Hyperlipidemia: Not taking any medications. Patient can
restart aspirin and statin as per PCP on outpatient basis.
TRANSITIONAL ISSUES:
1. Follow-up planned with primary neurologist. Patient has been
tried on sinemet without improvement in the past, could consider
trying in the future.
2. Code status: Patient full code during hospitalization.
3. Hyperlipidemia: Consider restarting statin and aspirin on
outpatient basis if it is consistent with patient's wishes.
4. Blood cultures pending at discharge - will be followed up by
primary team.
Medications on Admission:
None
Discharge Medications:
1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Falls, gait instability, cortical basal degeneration,
progressive supranuclear palsy
SECONDARY: Right knee osteoarthritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane) - patient requires significant assistance of staff
member and walker.
Discharge Instructions:
It was a pleasure to participate in your care Mr. ___.
You were admitted to the hospital after falling at home. You
were seen by the neurologists, who felt that this was likely
from progression of your neurologic disease. The physical
therapist evaluated you and felt you should go to rehab to gain
strenth and improve walking.
Please make the following changes to your medications:
1. START tylenol ___ mg three times per day
2. START colace 100 mg twice a day
3. START senna 1 tab twice a day as needed for constipation
Please see below for your follow-up appointments.
Followup Instructions:
___
|
19917861-DS-11 | 19,917,861 | 23,447,757 | DS | 11 | 2158-04-27 00:00:00 | 2158-05-07 22:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall, ?chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with neurodegererative condition and gait disorder known as
tauopathy as well as dementia potentially related to this who
was brought to the ___ ER by EMS due to a fall.
Patient unable to tell much of history due to his neuro
condition. He says he cannot remember what happened at home.
Currently denies body pain, chest pain, SOB, cough, HA. Denies
pain in abdomen or dysuria. Says at home he lives with daughter.
___ with ___. Unable to give much other history.
Sub-Intern discussed situation with daughter. She was not in
room when patient "fell". Just heard him call out and when in
next room and he was on ground on his right side. Did not have
LOC. Briefly reported chest pain but then later didn't. He
didn't report any other symptoms to her. She gave him 4 baby
aspirin because the EMS did that a few months back when a
similar thing happened. EMS brought him to ED. She was of
impression that he was just going to be observed overnight in
the ER and not admitted. She would like him to come home and
does not want him to go to rehab. She expresses interest in
pursuing very non-invasive care (not on any meds at home as she
has stopped all previously recommended meds), although would
want him to be full code if he suffered an acute event.
In the ED, initial vitals: 98.5 80 122/77 18 99%. EKG was sinus
with 1 PVC, no ST changes, similar to prior. UA was benign and
troponin was negative. Patient admitted for ___. Vitals
prior to transfer: 99.8 p 76 r 16 BP 145/80
ROS: per HPI, unable to obtain further ROS as limited ability to
take history.
Past Medical History:
Neurodegenerative disorder (cortical basal degeneration along
with symptoms of progressive supranuclear palsy: this
combination of disorders is referred to as tauopathy)
Dementia
Cataract
Eye globe replacement
Osteoarthritis
Elevated PSA (as per daughter he may have had prostate bx, but
she thinks it was negative)
Social History:
___
Family History:
On family history, his father lived until about ___ and passed
away from unclear causes. He has a number of siblings and they
are unsure about their health issues. His mother passed away
from unclear medical causes.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.5, HR 58, BP 106/59, RR 18, O2Sat 99% on RA
GENERAL - NAD, comfortable, appropriate
HEENT - right eye with globe replacement, left eye: pupil round,
reactive to light 3->2 mm. EOMI, sclerae anicteric, MMM, OP
clear
NECK - supple, no thyromegaly, no JVD, no LAD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, though difficult
for patient to follow directions to take a deep breath
ABDOMEN - soft/NT/ND, +BS, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ DP pulses; right lower extremity
internally rotated at hip; right knee swollen but without any
appreciable effusion, no warmth or errythema
SKIN - no rashes or lesions
NEURO - awake, A&Ox2 (name, hospital, not date), CNs II-XII
grossly intact, muscle strength ___ throughout on left, one
right ___ in UE proximal muscles, ___ in the UE ___, ___ in
___, and ___ in ___. Increased tone on right side
of body, most pronounced the upper extremity with rigid
resistance to movement. Sensation grossly intact throughout,
rapid alternating movements and finger-nose-finger intact in
left hand, unable to test on right. Did not walk the patient ___
fall risk.
DISCHARGE PHYSICAL EXAM:
VS: T 98.4, HR 59, BP 100/70, RR 18, O2Sat 97% on RA
GENERAL - NAD, comfortable, appropriate
HEENT - right eye with globe replacement, left eye: sclerae
anicteric. MMM, OP clear
NECK - supple, no JVD
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh
ABDOMEN - soft/NT/ND, +BS, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ DP pulses; right lower extremity
internally rotated at hip; right knee swollen but without any
appreciable effusion, no warmth or errythema
SKIN - no rashes or lesions
NEURO - awake, A&Ox2 (name, hospital, not date), remainder of
neurological exam consistent with admission exam
Pertinent Results:
ADMISSION LABS:
___ 11:15AM BLOOD
WBC-6.6# RBC-4.19* Hgb-12.6* Hct-38.8* MCV-93 MCH-30.1 MCHC-32.5
RDW-12.2 Plt ___
Neuts-66.4 ___ Monos-5.7 Eos-4.3* Baso-0.3
Glucose-87 UreaN-10 Creat-0.9 Na-139 K-4.0 Cl-102 HCO3-29
AnGap-12
cTropnT-<0.01
U/A: Color Yellow, Appear Clear, SpecGr 1.015, pH 5.5
Urobil 2, Bili Neg, Leuk Tr, Bld Neg, Nitr Neg
Prot Neg, Glu Neg, Ket Neg
RBC <1, WBC 4, Bact None, Yeast None, Epi 0
PERTINENT LABS / TRENDS:
___ 11:15AM BLOOD cTropnT-<0.01 (admission)
___ 08:15AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:15AM BLOOD CK(CPK)-336*
IMAGING:
EKG: sinus rhythm, with some PVCs, lateral T wave flattening,
and left axis deviation but no acute ST or T wave changes;
consistent with prior EKG on ___.
CXR (PA and LAT): No acute cardiopulmonary process. No displaced
fracture seen.
Plain film of knee (AP, LAT, OBLIQUE): Small right knee
effusion, similar to ___. No acute fracture or
dislocation.
CT Head (w/o Contrast): No intracranial hemorrhage or calvarial
fracture.
CT C-spine (w/o contrast): (PRELIMINARY) No c-spine frx, acute
alignment abnormality, or prevertebral soft tissue abnormality.
MICRO:
Urine culture: PENDING
Brief Hospital Course:
___ with neurodegererative condition and gait disorder known as
tauopathy as well as dementia potentially related to this who
was brought to the ___ ER by EMS due to a fall.
# Fall:
Further history indicated that "fall" was likely not even a fall
and rather patient slipping out of his chair. No LOC or concern
for syncopal event. No head strike or seizure-like activity.
Neuro exam normal on presentation and head imaging with no
abnormalities. Labs showed no metabolic disturbances and
daughter/HCP felt that patient safe to come home with her the
next day so he was discharged home.
# Neurodegenerative Disorder:
Question if this had progressed slightly since last visit. His
difficulties with being steady and with weakness likely related
to his neurologic disease. Disease was discussed with his
daughter who espoused goals of care focused on limiting
medications and interventions although she did want him to be
full code. Will f/u with neurology per daughter.
Medications on Admission:
None
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
cortical basal degeneration
dementia
fall
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your stay. You were
admitted due to concern for a fall. CT scans of your head and
neck showed no damage. Xrays of your knee were also unchanged.
Your heart testing showed no abnormalities and you bloodwork was
normal. You were discharged home the next day with your
daugther.
No changes were made to home medications.
Followup Instructions:
___
|
19917861-DS-12 | 19,917,861 | 24,725,844 | DS | 12 | 2159-01-27 00:00:00 | 2159-02-03 14:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Decreased PO intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of neurogenerative condition and gait disorder
(Tauopathy) with dementia, who presents with worsening weakness
and refusal to eat. Patient also increasingly weak, normally
will transfer and stand but has not been doing so. His daughter
says that in the past he has sometimes been very weak but will
often "bounce back" after a few days or weeks and be back to
himself, so his level of lethargy and weakness is not quite as
concerning to her as his refusal to eat. In the past even when
he wouldn't eat he would drink tea and could hold the cup
himself, but currently he is unable to even hold a tea cup. She
has also noticed that he never moves his right side any more and
has been complaining of right knee pain for a few months now. He
prefers to keep his right leg bent and says it hurts when he
tries to straighten it. He also is less verbal and interactive
with her. She doesn't believe he has had any falls recently.
Doesn't believe he's had any nausea, vomiting, fevers/chills,
just refusing to eat. No complaints of shortness of breath or
chest pain.
In the ED, initial vs were: 99.2 103 135/78 18 99% ra. Labs were
remarkable for CK 5027. CT head showed bilateral chronic SDHs vs
hygromas, so neurosurgery was consulted but did not recommend
any intervention. He was admitted to medicine for failure to
thrive and work up of CK elevation.
On the floor, the patient is minimally verbal and the history is
obtained as above through his daughter, who is at bedside and
quite dedicated to him.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
Neurodegenerative disorder (cortical basal degeneration along
with symptoms of progressive supranuclear palsy: this
combination of disorders is referred to as tauopathy)
Dementia
Cataract
Eye globe replacement
Osteoarthritis
Elevated PSA (as per daughter he may have had prostate bx, but
she thinks it was negative)
Social History:
___
Family History:
On family history, his father lived until about ___ and passed
away from unclear causes. He has a number of siblings and they
are unsure about their health issues. His mother passed away
from unclear medical causes.
Physical Exam:
Admission
PHYSICAL EXAM:
Vitals: T: 98.2 BP: 114/50 P: 80s R: 18 O2: 99% RA
General: Elderly male lying in bed curled up, minimally
interactive with environment unless directly spoken too
HEENT: Sclera anicteric, right eye is false (had an old globe
injury), dry MM, oropharynx clear
Neck: supple, JVP ~9cm
Lungs: Poor inspiratory effort (not following commands for deep
breaths) but sounds clear to auscultation bilaterally, no
audible wheezes, rales, ronchi
CV: Regular rate with frequent ectopic beats, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen: firm over epigastrium, moderately tender to deep
palpation in upper and mid abdomen, no bowel sounds heard. no
rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ edema of right foot, trace edema of
left foot. Right knee with moderate sized joint effusion but no
warmth, minimally tender to palpation. Major muscle groups not
tender to palpation
Skin: warm and dry.
Neuro: opens eyes to voice, speaking softly and answering some
questions though not always appropriately. Difficulty following
commands, but cursory neuro exam reveals no facial droop,
symmetric palate elevation, able to squeeze hands but L stronger
than R, able to resist in bilateral UEs (4+/5) but unable to
test much in the legs. Can dorsiflex/plantarflex left foot but
doesn't move right foot except when withdrawing to babinski. No
spontaneous movement of right leg. Babinski downgoing
bilaterally
Discharge
Vitals- 98.4 (99.9) 122/64 85 20 97% RA
General- NAD, awake and alert, mumbles words although mostly
non-verbal.
HEENT- Sclera anicteric, MMM, oropharynx clear. R globe with
chronic, likely post-op changes. Pupil is reactive although
sluggish in left eye
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally from anterior, no
wheezes, rales, ronchi. Appears to be working mildly harder and
breathing more through his nose
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Moving upper extremities to command today, will not move
lower extremities
Pertinent Results:
Admission Labs
___ 07:27PM WBC-9.8 RBC-4.10* HGB-12.8* HCT-39.3* MCV-96
MCH-31.2 MCHC-32.5 RDW-12.3
___ 07:27PM NEUTS-71.9* ___ MONOS-5.4 EOS-2.1
BASOS-0.7
___ 07:27PM PLT COUNT-262
___ 07:27PM GLUCOSE-132* UREA N-22* CREAT-0.9 SODIUM-140
POTASSIUM-4.6 CHLORIDE-100 TOTAL CO2-27 ANION GAP-18
___ 07:27PM estGFR-Using this
___ 07:27PM TOT PROT-7.5 CALCIUM-9.7 PHOSPHATE-3.2
MAGNESIUM-2.3
___ 07:27PM CK(CPK)-5027*
___ 07:27PM TSH-1.7
___ 07:45PM URINE RBC-3* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:45PM URINE RBC-3* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 07:45PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-5.5
LEUK-NEG
___ 07:45PM URINE COLOR-Yellow APPEAR-Clear SP ___
Discharge Labs
___ 07:05AM BLOOD WBC-5.5 RBC-3.42* Hgb-10.4* Hct-32.2*
MCV-94 MCH-30.5 MCHC-32.4 RDW-12.6 Plt ___
___ 07:05AM BLOOD Glucose-78 UreaN-11 Creat-0.6 Na-140
K-3.7 Cl-107 HCO3-23 AnGap-14
CK
___ 06:45AM BLOOD CK(CPK)-1423*
___ 07:27PM CK(CPK)-5027*
Micro
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
Blood cultures x 2- negative
Reports
CT Head
IMPRESSION:
New bilateral subdural hypodense collections causing mild mass
effect likely secondary to subdural hygromas or chronic subdural
hematomas. No evidence of herniation.
The study and the report were reviewed by the staff radiologist.
CXR
There is increase in the left retrocardiac opacity concerning
for aspiration. Heart size and mediastinal contours are stable.
Lungs are otherwise essentially clear with no appreciable
pleural effusion or pneumothorax demonstrated.
Brief Hospital Course:
Impression: ___ with hx of neurogenerative condition and gait
disorder (Tauopathy) with dementia, who presented with worsening
weakness and refusal to eat, found to have elevated CK to >5000.
# Failure to thrive: Likely from progression of
neurodegenerative disease. Pt had new CT findings (see below)
which were likely the major cause of his FTT. Patient was found
to have a UTI which was treated (also see below). There was no
evidence to suggest other medical causes of his decreased PO
intake besides the aforementioned issues. TSH was normal, CK
was treated with IV fluids, and nutrition was maximized with
help of nursing staff and patient's daughter. Along with his
failure to thrive were various other issues which were all
addressed
#UTI- Patient grew out enterococcus UTI which was initially
treated with IV Vancomycin and then switched to ampicillin was
susceptibilities returned. Given he is male, he was treated as
complicated UTI and discharged with a 7 day course of ampicillin
# ?Aspiration risk: Nurses were finding food in back of
patient's mouth during stay. He also appeared to be slightly
tachypneic once during the admission and CXR was suspicious for
aspiration. A formal speech and swallow eval was obtained which
proved the patient to be at risk for aspiration. Appropriate
dietary changes were made. The primary team spoke with daughter
regarding risks of feeding patient with aspiration risk. She
understood that he is at risk for pneumonia, and that
non-compliance with the recommended diet may result. Med were
also crushed before administering
# Subdural hemorrhages vs hygromas: found on head CT in the ED,
appear chronic, likely from past falls. Seen by neurosurg in the
ED who did not feel there was any intervention necessary
(including decadron). Patient's neuro exam was monitored
throughout the admission
)
# CK elevation: had been essentially bedbound recently, so
likely due simply to relative immobilization. Muscles were not
tender, so did not suspect myositis or other inflammatory
process. Patient did not show evidence of renal failure. He was
put on maintenence fluid with quick downtrend of CK.
# Knee pain: continued home dose of tylenol BID
Transitional Issues:
# CONTACT: Daughter ___ is PCA and HCP ___ DO
NOT GIVE INFO TO ANYONE ELSE OVER THE PHONE. Only Grandson ___
___ are allowed to get patient info and only in
person
# Recommendations from speech and swallow were as follows: They
recommended a pureed solids and thin liquids diet, in addition
to all medications being crushed and to have a 1:1 supervision
with meals to reduce the risk of aspiration. Additionally, his
daughter should use a ___ suction device to allow her for
safest PO administration during feeds
#Patient's code status was changed to DNR/DNI per daughter. He
was set up with hospice services and sent home with daughter.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID
2. Cyanocobalamin Dose is Unknown PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Ampicillin 500 mg PO Q6H
RX *ampicillin 500 mg 1 capsule(s) by mouth q6 hrs Disp #*17
Capsule Refills:*0
2. Acetaminophen 650 mg PO BID
3. Cyanocobalamin 100 mcg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. ___ suction valve
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
-Neurogenerative condition and gait disorder
-Urinary tract infection
Discharge Condition:
Mental Status: Pt non-verbal, minimally interactive, but tracks
with eyes and mumbles words
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you while at ___. You were
admitted for concern of not eating as well. You were found to
have a urinary tract infection which we treated with
antibiotics. We also obtained a test to assess your ability to
swallow which showed you were at risk from aspiration.
Please continue the ampicillin four times daily THROUGH ___
Please note that the speech and swallow therapist evaluated you
and thought you were at risk for aspirating. They recommended a
pureed solids and thin liquids diet, in addition to all of your
medications being crushed and for you to have a 1:1 supervision
with meals to reduce the risk of aspiration. Additionally, your
daughter should use a yankauer suction device to allow her for
safest PO administration. Should you not adhere to these
measures, there is a risk of aspirating into your lungs which
means you may develop pneumonia, become very sick, which may
result in death.
Followup Instructions:
___
|
19917945-DS-15 | 19,917,945 | 23,176,017 | DS | 15 | 2124-05-17 00:00:00 | 2124-05-17 11:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute left ureteral obstruction, flank pain, hydronephrosis
Major Surgical or Invasive Procedure:
Cystoscopy, left stent exchange, right stent placement.
IMPLANTS: 6 x 24 ___ double-J ureteral catheters times 2.
History of Present Illness:
Ms. ___ is a very pleasant ___ known to the BI oncology
service with gastric cancer presenting this AM with severe right
sided flank/back pain that woke her from sleep. She describes
the pain as sharp with radiation down to her groin. She has had
similar pain in the past on her left side which was attributed
to right ureteral obstruction for which she was stented in ___
at ___.
She denies hematuria, pyuria, fevers, sweats. She does have some
nausea, and has vomitted once in the ED.
Per oncology note, she is currently in week 2 of cycle 2 of ECX.
Past Medical History:
PAST HISTORY:
Gastric cancer, currently undergoing chemotherapy
Bartholin cyst
Stent placement, ___
Social History:
___
Family History:
-mother developed breast cancer at age ___ and
died one year later
- maternal grandmother also developed breast cancer and died
very young prior to her birth
- aunt - ? "bone" tumor
- father died at age ___ of a cerebral aneurysm
- uncle had lung cancer
- unt had spina bifida, diabetes
- one sister and two brothers, all of whom are in good health.
Physical Exam:
well developed woman in NAD, AVSS
Abdomen soft, nt/nd
extremities w/out edema/pitting
Pertinent Results:
___ 08:25AM BLOOD WBC-2.6* RBC-4.45 Hgb-10.8* Hct-34.7*
MCV-78* MCH-24.3* MCHC-31.1 RDW-19.8* Plt ___
___ 08:25AM BLOOD Glucose-116* UreaN-18 Creat-0.7 Na-139
K-4.4 Cl-103 HCO___ AnGap-11
Brief Hospital Course:
Ms. ___ was admitted to Dr. ___ service from the
ED for observation, pain control, and IV fluids and IV
antibiotics. She was monitored for fever, nausea and vomiting
and prepared for ureteral stent placement. She was taken to the
OR and she underwent right ureteral stent placement and left
ureteral stent exchange. No concerning intra-operative events
occurred; please see dictated operative note for full details.
The patient received ___ antibiotic prophylaxis. At
the end of the procedure the patient was extubated and
transported to the PACU for further recovery before being
transferred to the floor. She was transferred from the PACU in
stable condition to the general surgical floor. She voided prior
to discharge. At discharge Ms. ___ pain was well controlled
with oral pain medications, she was tolerating a regular diet
and ambulating without assistance and voiding without
difficulty. She was given explicit instructions to follow-up
with Dr. ___ ureteral stent removal/exchange.
Medications on Admission:
1. CAPECITABINE [XELODA] - 500 mg Tablet - 2 Tablet(s) by mouth
twice a day ICD 9: 151.4
2. DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth twice a
day as
needed for 2 days after chemotherapy (take as prescribed
following chemotherapy)
3. LORAZEPAM - 0.5 mg Tablet - ___ Tablet(s) by mouth q8hr as
needed
for nausea, anxiety, insomnia
4. ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth Q8hr as
needed for nausea/vomiting
5. PROCHLORPERAZINE MALEATE - 5 mg Tablet - ___ Tablet(s) by
mouth
Q6hr as needed for nausea/vomiting
6. ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg
Tablet -
Tablet(s) by mouth as needed
Discharge Medications:
1. capecitabine 500 mg Tablet Sig: Two (2) Tablet PO Q12H (every
12 hours): Capecitabine 1000 mg PO Q12H on Days 1, 2, 3 and 4.
___ and ___
(1000 mg) .
2. acetaminophen 500 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
3. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for anxiety, insomnia.
4. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
Q6H (every 6 hours) as needed for nausea refractory to zofran.
5. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
6. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO Q8H
(every 8 hours) as needed for bladder spasm.
Disp:*30 Tablet(s)* Refills:*0*
7. phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3
times a day) for 3 days.
Disp:*9 Tablet(s)* Refills:*0*
8. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO every eight
(8) hours as needed for pain.
Disp:*40 Tablet(s)* Refills:*0*
9. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO twice a day:
1 Tablet(s) by mouth twice a day as
needed for 2 days after chemotherapy.
10. ondansetron 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO every eight (8) hours as needed for nausea.
11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
Acute left ureteral obstruction, flank pain, hydronephrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge instructions with or without URETERAL STENT PLACEMENT
:
You have an indwelling ureteral stent that MUST be removed
and/or exchanged in the next few weeks time. Please follow-up as
advised.
You may experience some normal discomfort or pain associated
with spasm of your ureter. This is especially true when there
is an INDWELLING URETERAL STENT.
Discharge Instructions:
-Resume all of your pre-admission/ home medications, unless
otherwise noted. Please avoid Aspirin unless otherwise advised.
-No vigorous physical activity for 2 weeks.
-Expect to see occasional blood in your urine and to experience
urgency and frequency over the next month.
-You may experience some pain associated with spasm of your
ureter. This is normal. Take IBUPROFEN as directed and take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Tylenol should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-Make sure you drink plenty of fluids to help keep yourself
hydrated and facilitate passage of stone fragments.
-You may shower and bathe normally.
-Do not drive or drink alcohol while taking narcotics or operate
dangerous machinery
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative
Followup Instructions:
___
|
19918048-DS-10 | 19,918,048 | 22,309,325 | DS | 10 | 2135-03-09 00:00:00 | 2135-03-12 10:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: PICC placement.
History of Present Illness:
___ with history of muscle invasive urothelial carcinoma s/p
radical cystectomy and orthotopic neobladder creation on
___ for pT3a/pN1 disease, clinical course c/b MDR e.coli
bacteremia, now presents via ED with vague complaints including
mild abdominal pain, decreased PO intake x1 day. He has an
indwelling SP tube and foley, both have been draining well. His
foley was kept in place for an additional week due to small leak
at level of L urethral-neobladder anastamosis. In the ED he was
found to have a temperature to 104 which decreased to 102 after
a dose of tylenol.
Past Medical History:
hypertension
nephrolithiasis ___
traumatic mandibular fracture s/p reconstruction ___
right knee arthroscopy ___
removal of salivary stone from right parotid ___
Social History:
___
Family History:
Father: lung cancer
Physical Exam:
WdWn male, NAD, AVSS
Abdomen soft, tender along SPT
Well healed surgical scar. At inferior distal aspect of surgical
scar, in suprapubic area, there is a 1cm sized wound being
packed with ___ gauze. It is approx 1cm deep with pink, clean
wound edges.
extremities w/out edema.
Pertinent Results:
___ 06:30AM BLOOD WBC-8.9 RBC-3.40* Hgb-9.6* Hct-28.5*
MCV-84 MCH-28.2 MCHC-33.6 RDW-14.0 Plt ___
___ 12:50PM BLOOD Hct-25.9*
___ 06:25AM BLOOD WBC-11.9* RBC-2.99* Hgb-8.5* Hct-25.1*
MCV-84 MCH-28.4 MCHC-33.9 RDW-14.4 Plt ___
___ 08:30PM BLOOD WBC-13.3* RBC-3.16* Hgb-9.2* Hct-26.5*
MCV-84 MCH-29.1 MCHC-34.7 RDW-14.0 Plt ___
___ 06:30AM BLOOD Glucose-111* UreaN-13 Creat-0.6 Na-140
K-3.7 Cl-106 HCO3-25 AnGap-13
___ 06:25AM BLOOD Glucose-134* UreaN-23* Creat-0.9 Na-139
K-4.2 Cl-109* HCO3-19* AnGap-15
___ 08:30PM BLOOD Glucose-123* UreaN-33* Creat-1.2 Na-133
K-4.0 Cl-102 HCO3-16* AnGap-19
___ 06:30AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.9
___ 06:25AM BLOOD Calcium-8.7 Phos-2.6* Mg-1.9
___ 08:30PM BLOOD Calcium-9.2 Phos-3.4 Mg-1.9
___ ABD/PELVIS CT SCAN IMPRESSION:
1. Loss of corticomedullary delineation involving both kidneys,
most marked on the left. Findings consistent with bilateral
pyelonephritis, left greater than right. This overall appears
uncomplicated without any associated abscess or perirenal
abnormality.
2. Flash hemangioma versus arteriovenous malformation involving
the liver as described, no sequela, this is likely congenital
and unchanged compared to the prior outside study.
3. No confirmed on a prior No evidence of pelvic fluid to
suggest leak from this patient's neobladder.
4. Mildly prominent right inguinal lymph node adjacent to the
common femoral vein. Not meeting size criteria for pathologic
enlargement but has increased in size compared to the prior
exams and therefore attention to this area on followup is
warranted.
Brief Hospital Course:
Mr. ___ was admitted to Dr. ___ service from the
emergency department where he presented with vague abdominal
complaints and fevers. There were no surgical interventions
during this admission but back on ___ he underwent
radical cystoprostatectomy with a neobladder creation. Mr.
___ was continued on intravenous antibiotics based on his
pre-admission cultures and with awareness that he was found to
have multi-drug resistant E. coli. ID was consulted and
recommended a 14 day course of Ertapenem and thus and PICC line
was placed. The patient was ambulating and pain was controlled
on oral medications by the time of discharge and his fevers had
resolved. He did require a two-unit packed red blood cells
transfusion for a hematocrit that was as low as 25.On ___ he
underwent a CT Scan (resuls listed). At the time of discharge
the wound was healing well with no evidence of erythema,
swelling, or purulent drainage and the 1cm incision wound was
packed with ___ inch gauze. His Uretheral Foley was removed and
his SPT was in place. He will be discharged home with his
suprapubic tube and he was scheduled to follow up weekly for lab
tests per ID and follow-up appointments.
Medications on Admission:
Allergies: Lisinopril
Meds:
diovan 160', atenolol 50', HCTZ 25', KCl ER 20mEQ', ASA 81'
Discharge Medications:
1. ertapenem 1 gram Recon Soln Sig: One (1) Intravenous once a
day: LAST DOSE ___.
Disp:*20 QS* Refills:*0*
2. Heparin Flush (10 units/ml) 2 mL IV PRN line flush
PICC, heparin dependent: Flush with 10mL Normal Saline followed
by Heparin as above daily and PRN per lumen.
3. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas pain.
4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every
4 hours) as needed for pain.
7. valsartan-hydrochlorothiazide 160-25 mg Tablet Sig: One (1)
Tablet PO once a day.
8. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4
hours) as needed for pain ___.
Disp:*30 Tablet(s)* Refills:*0*
10. Outpatient Lab Work
Please f/u via your PCP for WEEKLY lab work to be sent to ___
___ @ ___
11. aspirin, buffered 81 mg Tablet Sig: One (1) Tablet PO once a
day: Do NOT resume until cleared by your PCP or Dr. ___.
12. potassium chloride 10 mEq Tablet Extended Release Sig: Two
(2) Tablet Extended Release PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bladder transitional cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
-Please also refer to your instructions from the nursing staff
on Supra-pubic tube care.
- a ___ Malecot catheter is being used as as suprapubic
tube. The SPT is to gravity drainage and should remain secured
to
abdomen at ALL times to prevent trauma, accidental removal.
Routine care and handling instructions
Please flush GENLTY and FORWARD ONLY with ___ NS QD and prn
Measure UOP every 8 hours and prn.
-Resume your pre-admission/home medications except as noted.
ALWAYS call to inform, review and discuss any medication changes
and your post-operative course with your primary care doctor.
-___ should be your first line pain medication, a narcotic
pain medication has been prescribed for breakthrough pain >4.
Replace Tylenol with narcotic pain medication.
-Max daily Tylenol (acetaminophen) dose is 4 grams from ALL
sources, note that narcotic pain medication also contains
Tylenol
-If you have been prescribed IBUPROFEN (the ingredient of Advil,
Motrin, etc.) , you may take this and Tylenol together
(alternating) for additional pain control---please try TYLENOL
FIRST and take the narcotic pain medication as prescribed if
additional pain relief is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark tarry stools)
-You may shower normally but do NOT immerse your incisions or
bathe
-Please do not operate dangerous machinery or consume alcohol
while taking narcotic pain medications.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener--it is NOT a laxative.
-No heavy lifting (more than ten pounds or a case of soda)
-___ medical attention for fevers (temp>101.5), worsening pain,
drainage or excessive bleeding from incision, chest pain or
shortness of breath.
-Your suprapubic tube (SPT)--which is draining into a urine bag
via gravity--should be secured at ALL times to inhibit
accidental trauma and dislodging.
-DO NOT have anyone else other than your urology surgeon, Dr.
___ your drains FOR ANY REASON. If something should
happen beyond your control and either of the drains
dislodges---please notify the surgeon IMMEDIATELY and save the
ALL COMPONENTS for inspection.
- Wear Large drainage bag for majority of time as the smaller
leg bag is only for short-term when leaving house.
Followup Instructions:
___
|
19918048-DS-13 | 19,918,048 | 29,564,451 | DS | 13 | 2136-09-06 00:00:00 | 2136-09-07 13:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Nausea, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with recurrent bladder cancer
s/p surgery with consrtuction of neobladder and now on
Taxol/Gemcitabine who is s/p LBO with diverting loop left
colostomy as well as recent admission for SBO which resolved
spontaneously, presenting with recurrent nausea and abdominal
pain.
He was admitted ___ for SBO treated conservatively and it
resolved. Now, for the past 1 day he has had worsening
abdominal
pain which is described as strong cramps across the entire upper
abdomen. Associated with nausea and minimally decreased ostomy
output; stil passing some gas through ostomy. No vomiting. He
called the Heme-Onc fellow and was referred to the ED.
In the ED, initial VS were: pain ___, T 97.9, HR 112
(decreased to 90's), BP 123/70, RR 26 (decreased to 18), POx
100%RA. Labs with WBC down from 10 to 3 (65%N), Hct 33 (recent
baseline 35), plt 565. CHEm7 unchanged from prior with Cr 0.9.
LFTs normal (Alk Phos has been elevated). He underwent x-ray
abdomen which showed dilated loops of bowel suggestive of an
SBO. He was given his home meds Dilaudid 6mg PO and Oxycontin
40mg, as well as Dilaudid 1mg IV and Morphine 5mg IV. Received
Ondansetron for nausea. Colorectal Surgery was consulted and
recommended Oncology admission.
On arrival to the floor, he just urinated and passed a small
amount of urine with blood clots. Feels extremely crampy but
the pain medication helped. Has had poor PO intake with 4 lb
weight loss in 1 week. The ostomy output is light ___
colored as usual. he feels that if he pressed on his abdomen he
can hear a gurgling sound
Review of Systems:
(+) Per HPI
(-) Denies fever, chills, night sweats. Denies blurry vision,
diplopia, loss of vision, photophobia. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies chest pain or
tightness, palpitations, lower extremity edema. Denies cough,
shortness of breath, or wheezes. Denies melena, hematemesis,
hematochezia. Denies arthralgias or myalgias. Denies rashes or
skin breakdown. No numbness/tingling in extremities. All other
systems negative.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___ developed gross painless hematuria, which resolved,
but
recurred again in ___.
- PCP ordered ___ urine cytology which was concerning for bladder
cancer
- ___ A CT torso showed a 3.9 x 2.0 cm bladder mass
- ___ TUR of the lesion which showed a muscle invasive T2
bladder cancer, grade 3
- ___ bladder resection, LN dissection, and prostatectomy
with construction of a neobladder
- pathology --> T3 invasive urothelial carcinoma, high grade,
with invasion into lamina propria and muscularis propria with
metastatic LN involvement, N1, M0
- postoperative course was complicated by urosepsis with Ecoli
ESBL UTI
- ___ represented with recurrent Ecoli ESBL UTI, CT abdomen
for pyelonephritis did not show recurrent disease
- 3 week course of ertapenem completed ___
- ___ CT scan with decrease in size of right inguinal lymph
node, no metastatic disease
- ___ started gemcitabine 1000 mg/m2 D1,8 and cisplatin 70
mg/m2 D1. Plan for 3 cycles instead of 4 per patient preference.
- ___: began noticing smaller caliber of stools, lower
pelvic
peain and pressure.
- ___: CT at ___ with focal inflammation in sigmoid
read as "uncomplicated diverticulitis"
- ___: colonoscopy at ___ unable to pass scope past
25cm.
- ___: repeat CT with new infiltrating soft tissue mass
centered along pelvic sidewalls bilterally with larger burden on
left with involvement of the sigmoid colon and rectum causing an
obstruction at this level. Additional mass in right obturator
internus muscle.
- ___: EUS with irrgular and diffuse soft tissue mass
adjacent to neobladder involving the recto-sigmoid walls.
- ___: ex lap and diverting loop colostomy
-___ Start Taxol/Gemcitabine
OTHER PAST MEDICAL HISTORY:
HTN
nephrolithiasis
Social History:
___
Family History:
Father: lung cancer
Physical Exam:
ADMISSION EXAM:
VS: T 98.3, BP 168/90, HR 93, RR 20, POx 100%RA
General: no acute distress, though intermittently squirms in bed
due to crampy pain
HEENT: MMM
Neck: no cervical or supraclavicular lymphadenopathy
CV: S1 and S2, tachycardic, no murmur
Lungs: CTA throughout all fields
Abdomen: ostomy in place with small amount of light brown stool,
small amount of gas; abdomen minimally distended but not tense;
(+)bowel sounds (not high-pitched or tinkling); tenderness to
palpation across superior aspect with no rebound or guarding
GU: no foley
Ext: no edema
Neuro: alert, oriented x3, answers all questions appropriately,
moves all extremeties in bed
DISCHARGE EXAM:
VS: T 98.3, BP 167/85, HR 65, RR 19, POx 98%RA;
General: no acute distress, sitting up in bed
HEENT: neck supple, EOMi, oropharynx dry
Neck: no cervical or supraclavicular lymphadenopathy
CV: RRR, normal S1 and S2, no murmur
Lungs: CTA throughout all fields
Abdomen: ostomy in place with about ___ filled with brown stool,
minimal gas (pt notes he last emptied ostomy bag 2 nights
prior); abdomen not distended, nontender; (+)bowel sounds
GU: condom cath, dark yellow urine in foley bag
Ext: no edema
Neuro: alert, oriented x3, answers all questions appropriately,
moves all extremeties; slow moving gait with cane.
Pertinent Results:
ADMISSION LABS:
=============
___ 05:50PM BLOOD WBC-3.0*# RBC-4.03* Hgb-11.5* Hct-33.4*
MCV-83 MCH-28.5 MCHC-34.4 RDW-12.6 Plt ___
___ 05:50PM BLOOD Neuts-64.6 ___ Monos-2.2 Eos-1.4
Baso-1.1
___ 05:50PM BLOOD Glucose-134* UreaN-32* Creat-0.9 Na-141
K-4.0 Cl-103 HCO3-24 AnGap-18
___ 05:50PM BLOOD ALT-20 AST-19 AlkPhos-156* TotBili-0.7
___ 05:50PM BLOOD Albumin-3.6
DISCHARGE LABS:
=============
___ 06:50AM BLOOD WBC-7.5 RBC-3.96* Hgb-11.2* Hct-33.8*
MCV-85 MCH-28.4 MCHC-33.3 RDW-13.6 Plt ___
___ 06:50AM BLOOD Glucose-97 UreaN-23* Creat-0.9 Na-142
K-3.7 Cl-102 HCO3-28 AnGap-16
___ 06:50AM BLOOD Calcium-9.2 Phos-3.2 Mg-2.1
IMAGING:
=============
Abdominal xray ___:
FINDINGS:
Multiple dilated loops of small bowel measuring up to 6.5 cm are
noted within
predominantly the left hemiabdomen with several differential
air-fluid levels
noted. Paucity of gas is seen within the colon. Left lower
quadrant
colostomy is visualized. Numerous clips are demonstrated within
the pelvis.
There is no free intraperitoneal air. Moderate to severe
degenerative changes
are noted in the hips bilaterally.
IMPRESSION:
Small bowel obstruction. No evidence for free intraperitoneal
air.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with recurrent bladder cancer
s/p surgery with construction of neobladder and on
Taxol/Gemcitabine who is s/p LBO with diverting loop left
colostomy as well as recent admission for SBO which resolved
spontaneously, presenting with recurrent nausea and abdominal
pain found to have SBO.
ACUTE ISSUES:
==============
#. Partial small bowel obstruction: Abdominal X ray showed small
bowel obstruction. Pt was made NPO and given IV fluids. His pain
was controlled with Oxycontin, Dilaudid, Acetaminophen. The
colorectal surgeons saw the pt and felt that there were no
surgical options given pt's extensive disease. SBO resolved
spontaneously and pt was gradually advanced to a regular diet.
Pt was started on octreotide 200mcg SC q8hrs to help decrease
secretions in malignant bowel obstruction. He should receive a
depot injection as an outpatient and then discontinue SC
injections after specified time of overlap. Given his recurrent
SBOs, pt was encouraged to eat slowly, small amounts at a time,
and start with soft foods.
CHRONIC ISSUES:
==============
#. Bladder cancer: Chronic issue, followed by Dr. ___. All
blood cell counts were initially low, likely secondary to chemo
that he last received on ___. Blood counts gradually increased
throughout the hospitalization. Pt met with palliative care and
is having an evolving acceptance of his disease, however he
declined hospice and will go home with ___, and pt remains full
code. Chemotherapy was held. Pt has outpatient f/u with Dr.
___ for ___.
#. HTN: Continued home medications Atenolol, Valsartan, and
HCTZ. Pt's BP ranged from SBP 120s-160s, was initially thought
to be elevated when he was in pain. However BP remained 160s/90s
without pain. Pt was asymptomatic. His HCTZ was increased from
25mg to 37.5 mg upon discharge. Pt was instructed to follow up
with his PCP regarding his blood pressure, and ___ will check BP
daily and notify PCP for SBP > 160.
TRANSITIONAL ISSUES:
================
- We started octreotide 200mcg SC q8hrs. He should receive a
depot injection as an outpatient and then discontinue SC
injections after specified time of overlap.
- HCTZ was increased from 25mg to 37.5 mg upon discharge. Please
f/u BP and adjust medications as necessary. ___ will check BP
daily and notify PCP for SBP > 160.
-Pt met with palliative care and discussed future goals and code
status, and pt remains full code.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
3. Atenolol 50 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Valsartan 160 mg PO DAILY
6. Acetaminophen 500 mg PO Q8H
7. Aspirin 81 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN hard stools
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H
2. Aspirin 81 mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 4 mg 1 - 1.5 tablet(s) by mouth every 4 hours
as needed Disp #*50 Tablet Refills:*0
5. OxyCODONE SR (OxyconTIN) 40 mg PO Q8H
RX *oxycodone [OxyContin] 40 mg 1 (One) tablet extended release
12 hr(s) by mouth every eight (8) hours Disp #*40 Tablet
Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN hard stools
7. Valsartan 160 mg PO DAILY
8. Octreotide Acetate 200 mcg SC Q8H
RX *octreotide acetate 200 mcg/mL 200 mcg SC every eight (8)
hours Disp #*9 Vial Refills:*0
9. Hydrochlorothiazide 37.5 mg PO DAILY
so please take one and a half tablets of your 25mg tablets once
daily.
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 (One) tablet,delayed release (___)
by mouth once a day Disp #*30 Tablet Refills:*0
12. Simethicone 40-80 mg PO QID:PRN constipation
13. Lorazepam 0.5 mg PO Q8H:PRN anxiety
RX *lorazepam 0.5 mg 1 (One) tablet by mouth every eight (8)
hours as needed Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Partial small bowel obstruction
Secondary: Bladder cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted to the hospital because you had another bowel
obstruction. You were given IV fluids and pain medications, and
your obstruction seemed to improve on its own. Unfortunately
your advanced cancer continues to affect your bowel function,
and per the colorectal surgeons there are no surgical options
for your bowel obstruction.
You will have visiting nurses come to your house to give you
your octreotide injection 3 times per day, and we are arranging
for you to get a depot injection of octreotide at Dr. ___
___. Dr. ___ will call you next week to let you
know about this injection. If you do not hear from them in the
next few days, you should call his office at ___.
We are sending you home with octreotide vials that will cover
you through ___. ___ pharmacy will mail you the
octreotide on ___, so you should receive it in the mail on
___. If for some reason you do not receive the octreotide on
___, please call ___ at ___.
You may continue to eat as you feel comfortable and as you
tolerate. Please eat slowly, small amounts at a time, and start
with soft foods. If you start having abdominal pain again, you
should try a clear liquid diet for a few days and use your pain
medications as needed.
You should follow up with your primary care doctor ___ Dr.
___. You already have an appointment scheduled with Dr.
___ below). We ask that you please call your primary
care doctor on ___ to schedule an appointment in ___ days.
Followup Instructions:
___
|
19918125-DS-10 | 19,918,125 | 26,757,981 | DS | 10 | 2170-02-03 00:00:00 | 2170-02-03 12:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending: ___
Chief Complaint:
Fevers rigors
Major Surgical or Invasive Procedure:
___. Bilateral antegrade nephrostogram shows distal ureteral
obstruction with no flow through the nephroureterostomy stents
into the bladder. Both tubes appeared pulled back. 2.
Appropriate final position of bilateral 8 ___
nephroureterostomy tubes.
___. Left antegrade nephrostogram shows a patent left PCNU.
2. Right antegrade nephrostogram demonstrates a obstructed right
PCNU with contrast flowing down to the mid ureter with no
opacification of the tube lumen distally. 3. Post exchange and
upsize of the right tube, there is rapid transit of contrast to
the bladder. 4. Appropriate final position of bilateral PCNU
tubes. IMPRESSION: Technically successful right 8 ___ 22cm
PCNU exchange for a 10 ___ 24cm PCNU. Patent left 8 ___ 24
cm PCNU
History of Present Illness:
Mr. ___ is a pleasant ___ w/ CAD, HTN, DL, T1DM, and
metastatic neuroendocrine tumor complicated by carcinoid
syndrome
and obstructive uropathy with recurrent UTIs who p/w a fever. He
was recently discharged s/p JJ exchange on ___ and watched
overnight for fever. He has had fever for the past 2 days, since
his discharge, as high as 103 PTA. Fevers have not resolved with
tylenol. Patient has also had nausea, but no vomiting. had
non-bloody diarrhea (baseline)and lower abdominal pain. He
denies
any chest pain or shortness of breath.
In ED Tmax 101. HR ___. UA c/w UTI. ER resident reportedly
uncapped PCNUs and 300 cc of dark urine drained from R and at
least 600cc of clear urine drained from L. Received Vanc and
Zosyn and morphine. Seen by ___ and wil plan on doing a b/l PCNU
check.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
Neuroendocrine tumor of the small bowel stage III (T3N1M0) with
metastatic progression
- ___ had one week of crampy abdominal pain which led to a
colonoscopy that was unremarkable.
- ___ CT showed free air and evidence of perforation. He was
admitted here for further management and underwent right
ileocolectomy on ___. Pathology was consistent with carcinoid
tumor that was T3N1M0. The tumor was a 2.5 cm diameter endocrine
tumor that extended through the wall to adjacent adipose tissue.
Two of 13 lymph nodes were positive. An MRI of the abdomen
demonstrated three liver lesions consistent with hemangiomas and
two additional exophytic appearing lesions over the dome of the
liver that were thought to be inconsistent with extrahepatic
implants. His octreotide scan showed no areas of uptake. His
chromogranin A was elevated at 44 (upper limit of normal being
36.4) and his urinary 5-HIAA was normal. Since that time, he
continued to have frequent loose stools and dumping
postprandially.
- In ___ and ___, both his serotonin and urinary 5-HIAA were
elevated.
- On ___, he had an octreotide scan which showed a possible
recurrence of carcinoid in segment VII of the liver.
- ___ He started Sandostatin and received five doses. He
continued to have intermittent flushing and diarrhea.
- ___ Repeat MRI showed a peripherally based enhancing lesion
along the posterior aspect of the liver with a nodular
configuration, not significantly changed from prior imaging but
consistent with peritoneal studding of tumor.
- ___ Octreotide scan showed focal increased tracer uptake in
hypodense lesion in segment VII of the liver, along with focal
increased uptake in his pelvis, likely due to bilateral internal
iliac adenopathy.
- ___ He received Sandostatin 30mg on ___ and
___.
- ___ His dose was increased to 40mg IM.
- ___ MRI of the liver in ___ showed stable hemangiomas
and stable peripherally based enhancing lesions c/w studding.
- ___ MRI abdomen and octreotide scan showed stable
hemangiomas and stable peripherally based enhancing lesions c/w
studding. Octreotide scan showed focal uptake within the liver
can be correlated to a hypodense segment VII liver lesion, not
significantly changed in both uptake and size since prior
examination from ___. Stable uptake and size of the inguinal
adenopathy as well.
- ___ MRI Abdomen: Unchanged, now new lesions.
- ___ Octreotide Scan: Unchanged focal uptake in the liver,
bilateral internal iliac lymph nodes and in the left seminal
vesicle. No new lesions
- ___ continued on Monthly Sandostatin 40mg IM
- ___ MRI showed slowly enlarging subcapsular segment VII
liver lesions and slowly enlarging but still small right
inferior
phrenic lymph nod
- ___ Octreotide scan showed stable liver and bilateral
pelvic disease
- ___ MR abdomen showed stable metastatic disease
- ___ Octreotide scan showed multiple sites of
pentetreotide avid disease, with the right seminal vesicle mass
increasing in size from 2.3 to 3.2cm. There is a new equivocal
area of uptake at the anterior aspect of the bladder that may
correspond to additional disease. No other new foci seen.
- ___ Increased octreotide to 40 mg LAR Q21 days given
rising serotonin and chromogranin A
- ___ MR abdomen showed interval increase in size of some
metastatic lesions including the larger subcapsular hepatic
lesion, paracaval lymph node, right pelvic sidewall lymph node
and other small peritoneal implants. Some lesions remain
stable.
- ___ MR abdomen and pelvis showed stable disease
- ___ MR abdomen and pelvis showed stable disease
- ___ MR abdomen and pelvis showed new right-sided
hydroureteronephrosis, with transition point in the right ureter
as it passes the patient's known right pelvic mass. The
bilateral pelvic masses have mildly increased in size compared
to
prior. Interval decrease in size in a nodule / lymph node in the
epiphrenic fat. No significant interval change in size in the
patient's liver metastases and perihepatic / subcapsular liver
implants.
- ___ Ga dotatate PET showed slowly progressive avid
disease
- ___ MRI abdomen/pelvis shows slight increase in pelvic
mass, stable liver mets
- ___ CT torso shows stable severe right hydronephrosis,
stable metastatic disease with 1 new 5mm LLL nodule, recommend
repeat CT chest in 3 months
- ___ Admitted to ___ for
?capecitabine vasospasm, hypoglycemia, hydronephrosis. Bilateral
double-J stents placed.
- Continued octreotide 40 mg LAR Q21 days since ___
-Screened for ___ PEN221, ineligible since he took 4 days of
capecitabine
PAST MEDICAL HISTORY (Per OMR, reviewed):
-Metastatic prostate cancer
-Type 1 Diabetes
-Hyperlipidemia
-Hypertension
-CAD
Social History:
___
Family History:
Father - ___ Cancer
No other family history of malignancy
Physical Exam:
VITAL SIGNS: 98.3 PO 128 / 80 95 20 97% RA
___: NAD, ambulating in his room
HEENT: MMM, no OP lesions
CV: RR, NL S1S2 no S3S4 No MRG
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, b/l PCNUs in place w/ dressings c/d/i, both capped
LIMBS: No ___, left midline in place dressing c/d/i
SKIN: Facial flushing improving
NEURO: Grossly WNL, gait intact
Pertinent Results:
___ 06:00AM BLOOD WBC-7.1 RBC-3.37* Hgb-9.0* Hct-27.6*
MCV-82 MCH-26.7 MCHC-32.6 RDW-13.3 RDWSD-39.9 Plt ___
___ 06:00AM BLOOD Glucose-190* UreaN-15 Creat-1.1 Na-140
K-4.5 Cl-99 HCO3-25 AnGap-16
___ 05:12AM BLOOD ALT-34 AST-19 AlkPhos-158*
___ 06:00AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.1
___ 03:24PM BLOOD %HbA1c-7.3* eAG-163*
___ CULTURE-FINAL {ESCHERICHIA COLI}
___ CULTURE-PRELIMINARY {ESCHERICHIA COLI}
Brief Hospital Course:
___ w/ CAD, HTN, DL, T1DM, and metastatic neuroendocrine tumor
complicated by carcinoid syndrome and obstructive uropathy with
recurrent UTIs who p/w sepsis from pyelonephritis in context of
obstructed b/l PCNUs.
# Sepsis
# E.Coli Pyelonephritis
Found to have e.coli urinary tract infection and obstructed
PCNUs. Both PCNUs exchanged on ___. Clinically improved w/ a
few days of low grade temps, par for the course. Reassuring
blood cultures NGTD. His carcinoid has not caused fevers so do
not expect that to be the culprit. ID was consulted because he
spiked again on ___ in the evening and felt poorly. They
recommended
contuing meropenem x 2 weeks total from time of PCNU exchange.
He continued to improve but he failed a capping trial. He had
both PCNUs evaluated again on ___ and the R was found to be
obstructed and so it was exchanged with a 10 ___ and
he tolerated the capping well with vague lower abd discomofrt
which is anticipated to improve.
- Meropenem ___, switched to Ertapenem at time for discharge
and will cont IV Ertapenem last day ___
- per ID NO suppressive abx indicated now we have source control
- he will f/u ___ and urology
# Coping
Had difficulty coping while inpatient. Was seen by SW and
discharged
in better spirits.
# Transaminitis
Found to have slightly elevated LFTs (hepatocellular pattern) on
___, up from ___. ? due to zosyn, and improved.
# Neuroendocrine Tumor
Undergoing palliative treatment with octreotide. His oncologist
was well aware of his hospital course and helped coordinate a
consultation
with DFCI.
- cont wellbutrin
# T1DM
Pt dictating and self-administered his own long acting and
sliding
scale, declined our meds. He seems to have a strong handle on
his diabetes and permitted him to do so. ___ checked this admit
7.3%
# CKD III: Cr chronically elevated since ___, improved to 1.1
at
time of discharge. This is likely due to obstructive uropathy in
backdrop of diabetes
# CAD/HTN: hold carvedilol in setting of sepsis
FEN: Regular diet
DVT PROPH: he declined hsq, opting to ambulate frequently
ACCESS: Midline placed ___
CODE STATUS: Full code, presumed
DISPO: HOme w/ ___
BILLING: >30 min spent coordinating care for discharge
________________
___, D.O.
Heme/___ Hospitalist
p: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carvedilol 3.125 mg PO BID
2. Tamsulosin 0.4 mg PO QHS
3. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3 mL)
subcutaneous DAILY
4. BuPROPion 75 mg PO DAILY
5. LOPERamide 2 mg PO QID:PRN every loose stool
Discharge Medications:
1. Ertapenem Sodium 1 g IV 1X daily Duration: 1 Dose
RX *ertapenem 1 gram 1 gm iv daily Disp #*9 Vial Refills:*0
2. BuPROPion 75 mg PO DAILY
3. Carvedilol 3.125 mg PO BID
4. LOPERamide 2 mg PO QID:PRN every loose stool
5. Tamsulosin 0.4 mg PO QHS
6. Tresiba FlexTouch U-100 (insulin degludec) 100 unit/mL (3
mL) subcutaneous DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sepsis
Malignant Obstructive Uropathy
Obstructive PCNUs
E.coli Pyelonephritis
Metastatic Neuroendocrine Tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for sepsis from a urinary tract infection. You
will need to continue IV antibiotics for a total of 2 weeks
until ___. Please call Interventional Radiology if you have
any issues with your percutaneous nephroureterostomy tube.
Followup Instructions:
___
|
19918125-DS-14 | 19,918,125 | 29,631,735 | DS | 14 | 2171-02-04 00:00:00 | 2171-02-05 11:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Zosyn
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
___ 02:12AM ___ COMMENTS-GREEN TOP
___ 02:12AM LACTATE-0.7
___ 12:54AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:54AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD*
___ 12:54AM URINE BLOOD-TR* NITRITE-POS* PROTEIN-TR*
GLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 12:54AM URINE RBC-2 WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 12:54AM URINE RBC-4* WBC-45* BACTERIA-MOD* YEAST-NONE
EPI-0
___ 12:54AM URINE MUCOUS-RARE*
___ 08:43PM LACTATE-2.3*
___ 08:10PM GLUCOSE-277* UREA N-21* CREAT-1.5*
SODIUM-131* POTASSIUM-4.5 CHLORIDE-95* TOTAL CO2-24 ANION GAP-12
___ 08:10PM estGFR-Using this
___ 08:10PM ALT(SGPT)-22 AST(SGOT)-23 ALK PHOS-145* TOT
BILI-0.4
___ 08:10PM LIPASE-9
___ 08:10PM ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-2.4*
MAGNESIUM-2.0
___ 08:10PM WBC-7.8 RBC-3.98* HGB-11.4* HCT-35.0* MCV-88
MCH-28.6 MCHC-32.6 RDW-13.8 RDWSD-44.2
___ 08:10PM NEUTS-86.0* LYMPHS-2.4* MONOS-9.5 EOS-0.8*
BASOS-0.5 IM ___ AbsNeut-6.68* AbsLymp-0.19* AbsMono-0.74
AbsEos-0.06 AbsBaso-0.04
___ 08:10PM PLT COUNT-166
WBC: 3.7 <-- 7.8
Hb: 9.9 <-- 11.4
Plt: 134 <-- 166
Cr: 1.3 <-- 1.5 (B/L 1.3)
Na: 138 <-- 131
Lactate: 0.7 <-- 2.3
UA LPCN: 2 WBC, few bacteria, mod ___, -Nitries
___ LPCN: NG
UA RPCN: 45 WBC, Mod bacteria, +Nitrie, large ___ RPCN:
URINE CULTURE (Final ___:
CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL.
Cefepime test result confirmed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- =>___ R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Prior ___ (___): Acinetobacter (pan-sensitive)
___ (___): Acinetobacter (pan-sensitive)
___ (___): MDR E Coli (sensitive to Gent, ___, Zosyn,
TObramycin, Bactrim, Macrobid)
___ (___): Enterococcus (sensitive Amp, Gent, Macrobid, Vanc)
___ (___): Enterococcus (sensitive Amp, Gent, Macrobid, Vanc)
B/L Perc Nephrostomy Tube Exchange (___)
1. Bilateral antegrade nephrostogram shows contrast filling of
the bilateral
ureters with reflux bilaterally and no contrast passage into the
bladder.
2. Appropriate final position of Bilateral nephrostomy tubes.
CT A/P w/ IV Contrast (___)
1. Progressed right hydroureteronephrosis, now moderate to
severe, and
interval resolution of left hydroureteronephrosis. Bilateral
percutaneous
nephrostomy tubes are in unchanged positions.
2. Stable metastatic disease involving the liver, lymph nodes,
peritoneal and
retroperitoneal implants, pelvic masses and possible right iliac
bone.
Brief Hospital Course:
___ man with metastatic small bowel
neuroendocrine tumor, complicated by carcinoid syndrome and
hydronephrosis with bilateral PCNU and on Lutathera treatment
presenting with a fever and rigors likely ___ UTI in setting of
obstructive mass and R nephrostomy tube obstruction.
ACUTE/ACTIVE PROBLEMS:
#UTI
#Possible R-sided hydronephrosis
CT A/P revealing worsened R Hydrouteronephrosis with unchanged
metastatic disease near R PCN c/w R PCN tube malfunction. R PCN
UA c/w complicated cystitis. Prior ___ growing Acinetobacter,
Enterococcus and MDR E Coli. S/p successful B/L PCN tube
exchange with adequate drainage. ___ growing Citrobacter
sensitive to Bactrim. Given complicated UTI, will treat with 14
day course of DS Bactrim (to end ___
#T2DM
- C/w home regimen (40U Tresiba) + Fiasp TID
based on carb-counted sliding scale
#Carcinoid tumor
- Anti-diarrheal as needed as per home meds
- Next Lutathera infusion on ___
To do:
[] C/w 14 day course of DS Bactrim (to end ___
[] Outpatient Onc f/u for continued treatment of carcinoid tumor
Greater than 40 mins were spent in discharge planning,
coordination of care, patient education and counseling
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CARVedilol 6.25 mg PO BID
2. Fiasp FlexTouch U-100 Insulin (insulin aspart (niacinamide))
100 unit/mL (3 mL) subcutaneous TID W/MEALS
3. Tresiba U-100 Insulin (insulin degludec) 40 units
subcutaneous BREAKFAST
4. LOPERamide 2 mg PO Q4H:PRN diarrhea
5. LORazepam 0.5 mg PO Q4H:PRN nasuea, anxiety, insomnia
6. Octreotide Acetate 100 mcg SC Q8H:PRN diarrhea
7. Tamsulosin 0.4 mg PO DAILY:PRN stent discomfort
8. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN loose stools
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 12 Days
To end in ___ of ___
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*23 Tablet Refills:*0
2. CARVedilol 6.25 mg PO BID
3. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN loose stools
4. Fiasp FlexTouch U-100 Insulin (insulin aspart (niacinamide))
100 unit/mL (3 mL) subcutaneous TID W/MEALS
5. LOPERamide 2 mg PO Q4H:PRN diarrhea
6. LORazepam 0.5 mg PO Q4H:PRN nasuea, anxiety, insomnia
7. Octreotide Acetate 100 mcg SC Q8H:PRN diarrhea
8. Tamsulosin 0.4 mg PO DAILY:PRN stent discomfort
9. Tresiba U-100 Insulin (insulin degludec) 40 units
subcutaneous BREAKFAST
Discharge Disposition:
Home
Discharge Diagnosis:
R PCN malfunction c/b complicated UTI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for an obstruction in your R nephrostomy tube,
resulting in an infection. We replaced both your left and right
nephrostomy tubes and determined that the bacteria growing in
your urine (CITROBACTER FREUNDII) was sensitive to a pill
antibiotic that you have taken in the past.
We recommend you take Bactrim DS twice a day for a total of 14
days (___). Follow up with Dr. ___ (___)
scheduled for the week after you complete your antibiotics.
It was a pleasure taking care of you.
Your ___ Team
Followup Instructions:
___
|
19918125-DS-8 | 19,918,125 | 29,294,931 | DS | 8 | 2169-11-07 00:00:00 | 2169-11-07 16:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, Hyperglycemia
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a history of T1DM
on insulin pump, metastatic small bowel carcinoid c/b
obstructive uropathy s/p bilateral PCN who presents with fever
and hyperglycemia.
Of note, he was admitted ___ for enteroccal UTI,
cholangitis and acute kidney injury being discharged to complete
a 10-day course of pip-tazo. After completing this course he
presented to the ED on ___ with flank pain, had exchange of
bilateral PCNs and was discharged on cefpodoxime. On ___ since
culture came back positive for pan-sensitive enterococcus he was
switched to nitrofurantoin which he continued to this day.
Since ___ patient has been having FSGs 400-500s and
temperatures up to 100.8. He reports having >6 BM/d, loose,
during the week but he attributed this to his carcinoid
syndrome. He has had frequent chills and has had recurrence of
mild-moderal bilateral flank pain. He has required more than
twice of his usual amount of insulin. He called to report this
to his oncologist who advised him to come into the ED.
ED initial vitals were 98.6 108 131/72 20 100% RA
Prior to transfer vitals were 100.5 100 113/68 18 99% RA
Exam in the ED showed : "HEENT: No scleral icterus, no
sublingual jaundice. Cardiovascular: Normal S1, S2, regular rate
and rhythm, no murmurs/rubs/gallops, 2+ peripheral pulses
bilaterally. Pulmonary: Clear to auscultation bilaterally.
Abdominal: Soft, nontender, nondistended, no masses.
Extremities: No lower leg edema. Integumentary: Nephrostomy tube
site C/D/I"
ED work-up significant for:
-CBC: WBC: 11.4* Hgb: 11.1* Plt Ct: 253 AbsNeut: 9.04*
-Chemistry: Na: 133* K: 4.3 Cl: 92* HCO3: 22 UreaN: 26* Creat:
1.5* Glucose: 208* Albumin: 3.9
-Lactate:Lactate: 1.8
-Coags: ___: 1.1 PTT: 26.2
-LFTs: ALT: 20 AST: 17 AlkPhos: 124 TotBili: 0.5
-UA: RBC: 11* WBC: 33* Bacteri: FEW* Nitrite: NEG Protein: 30*
Glucose: 150*
-CXR: "Mild patchy left lower lobe opacity, likely atelectasis
."
-CT A/P: "1. No acute intra-abdominal or intrapelvic process.
2. Mild thickening of the bladder wall could be secondary to
underdistention, however, correlation with urinalysis is
recommended. 3. Interval improvement in bilateral
hydronephrosis, however, there is a persistently delayed
nephrogram on the right.
4. No significant change in known metastatic disease, as
described."
ED management significant for:
-Medications:amp-sulbactam, CTX, APAP 1g, 1L NS, glargine 30U
sc, lispro 10u sc
-Procedures: Insulin pump removed at time of SC insulin
administration
-Consult: ___ - stop pump : glargline 30u qhs, lispro 10u
w/meals, lispro SS >150, 2U q 50mg/dL
On arrival to the floor, patient reports continuing to feel
"beaten" which is usual when his sugars are high. He did not
have much diarrhea today but has been having significant
diarrhea the days prior. He notes that he has an event to attend
this ___ at noon and would like every effort to be made for
him to go home before that.
Patient denies night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations, abdominal
pain, nausea/vomiting, hematemesis, hematochezia/melena,
hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
Neuroendocrine tumor of the small bowel stage III (T3N1M0) with
metastatic progression
- ___ had one week of crampy abdominal pain which led to a
colonoscopy that was unremarkable.
- ___ CT showed free air and evidence of perforation. He was
admitted here for further management and underwent right
ileocolectomy on ___. Pathology was consistent with carcinoid
tumor that was T3N1M0. The tumor was a 2.5 cm diameter endocrine
tumor that extended through the wall to adjacent adipose tissue.
Two of 13 lymph nodes were positive. An MRI of the abdomen
demonstrated three liver lesions consistent with hemangiomas and
two additional exophytic appearing lesions over the dome of the
liver that were thought to be inconsistent with extrahepatic
implants. His octreotide scan showed no areas of uptake. His
chromogranin A was elevated at 44 (upper limit of normal being
36.4) and his urinary 5-HIAA was normal. Since that time, he
continued to have frequent loose stools and dumping
postprandially.
- In ___ and ___, both his serotonin and urinary 5-HIAA were
elevated.
- On ___, he had an octreotide scan which showed a possible
recurrence of carcinoid in segment VII of the liver.
- ___ He started Sandostatin and received five doses. He
continued to have intermittent flushing and diarrhea.
- ___ Repeat MRI showed a peripherally based enhancing lesion
along the posterior aspect of the liver with a nodular
configuration, not significantly changed from prior imaging but
consistent with peritoneal studding of tumor.
- ___ Octreotide scan showed focal increased tracer uptake in
hypodense lesion in segment VII of the liver, along with focal
increased uptake in his pelvis, likely due to bilateral internal
iliac adenopathy.
- ___ He received Sandostatin 30mg on ___ and
___.
- ___ His dose was increased to 40mg IM.
- ___ MRI of the liver in ___ showed stable hemangiomas
and stable peripherally based enhancing lesions c/w studding.
- ___ MRI abdomen and octreotide scan showed stable
hemangiomas and stable peripherally based enhancing lesions c/w
studding. Octreotide scan showed focal uptake within the liver
can be correlated to a hypodense segment VII liver lesion, not
significantly changed in both uptake and size since prior
examination from ___. Stable uptake and size of the inguinal
adenopathy as well.
- ___ MRI Abdomen: Unchanged, now new lesions.
- ___ Octreotide Scan: Unchanged focal uptake in the liver,
bilateral internal iliac lymph nodes and in the left seminal
vesicle. No new lesions
- ___ continued on Monthly Sandostatin 40mg IM
- ___ MRI showed slowly enlarging subcapsular segment VII
liver lesions and slowly enlarging but still small right
inferior
phrenic lymph nod
- ___ Octreotide scan showed stable liver and bilateral
pelvic disease
- ___ MR abdomen showed stable metastatic disease
- ___ Octreotide scan showed multiple sites of
pentetreotide avid disease, with the right seminal vesicle mass
increasing in size from 2.3 to 3.2cm. There is a new equivocal
area of uptake at the anterior aspect of the bladder that may
correspond to additional disease. No other new foci seen.
- ___ Increased octreotide to 40 mg LAR Q21 days given
rising serotonin and chromogranin A
- ___ MR abdomen showed interval increase in size of some
metastatic lesions including the larger subcapsular hepatic
lesion, paracaval lymph node, right pelvic sidewall lymph node
and other small peritoneal implants. Some lesions remain
stable.
- ___ MR abdomen and pelvis showed stable disease
- ___ MR abdomen and pelvis showed stable disease
- ___ MR abdomen and pelvis showed new right-sided
hydroureteronephrosis, with transition point in the right ureter
as it passes the patient's known right pelvic mass. The
bilateral pelvic masses have mildly increased in size compared
to
prior. Interval decrease in size in a nodule / lymph node in the
epiphrenic fat. No significant interval change in size in the
patient's liver metastases and perihepatic / subcapsular liver
implants.
- ___ Ga dotatate PET showed slowly progressive avid
disease
- ___ MRI abdomen/pelvis shows slight increase in pelvic
mass, stable liver mets
- ___ CT torso shows stable severe right hydronephrosis,
stable metastatic disease with 1 new 5mm LLL nodule, recommend
repeat CT chest in 3 months
- ___ Admitted to ___ for
?capecitabine vasospasm, hypoglycemia, hydronephrosis. Bilateral
double-J stents placed.
- Continued octreotide 40 mg LAR Q21 days since ___
-Screened for ___ PEN221, ineligible since he took 4 days of
capecitabine
PAST MEDICAL HISTORY (Per OMR, reviewed):
-Metastatic prostate cancer
-Type 1 Diabetes
-Hyperlipidemia
-Hypertension
-CAD
Social History:
___
Family History:
Father - ___ Cancer
No other family history of malignancy
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: ___ 0150 Temp: 98.2 PO BP: 145/84 HR: 87 RR: 18 O2 sat:
98% O2 delivery: RA
___: Well- appearing gentleman, in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLL, Mucous membranes dry, oropharynx clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
GU: Bilateral PCN insertion sites appear dry, without erythema
or secretion.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to light touch intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
VS: Temp: 98.4 PO BP: 113/62 R Lying HR: 93 RR: 18 O2 sat: 95%
O2 delivery: RA
___: Well- appearing gentleman, in no distress lying in bed
comfortably.
HEENT: Anicteric, PERLLA, moist mucous membranes, oropharynx
clear.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
GU: Bilateral PCN insertion sites appear dry, without erythema
or secretion.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout. Sensation
to light touch intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
___ 02:51PM BLOOD WBC-11.4* RBC-3.92* Hgb-11.1* Hct-32.4*
MCV-83 MCH-28.3 MCHC-34.3 RDW-12.7 RDWSD-38.4 Plt ___
___ 02:51PM BLOOD Neuts-79.6* Lymphs-7.9* Monos-10.3
Eos-0.5* Baso-0.6 Im ___ AbsNeut-9.04* AbsLymp-0.90*
AbsMono-1.17* AbsEos-0.06 AbsBaso-0.07
___ 02:51PM BLOOD ___ PTT-26.2 ___
___ 02:51PM BLOOD Glucose-208* UreaN-26* Creat-1.5* Na-133*
K-4.3 Cl-92* HCO3-22 AnGap-19*
___ 02:51PM BLOOD ALT-20 AST-17 AlkPhos-124 TotBili-0.5
___ 02:51PM BLOOD Lipase-11
___ 02:51PM BLOOD Albumin-3.9
___ 02:51PM BLOOD Lactate-1.8
___ 02:51PM BLOOD O2 Sat-81
___ 04:11PM URINE Color-Straw Appear-Hazy* Sp ___
___ 04:11PM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-150* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5
Leuks-MOD*
___ 04:11PM URINE RBC-11* WBC-33* Bacteri-FEW* Yeast-NONE
Epi-0
CXR - IMPRESSION:
Mild patchy left lower lobe opacity, likely atelectasis .
CT A/P - IMPRESSION:
1. Mild thickening of the bladder wall could be secondary to
underdistention, however, correlation with urinalysis is
recommended. Otherwise, no acute CT findings in the abdomen or
pelvis.
2. Interval improvement in bilateral hydronephrosis, however,
there is a
persistently delayed nephrogram on the right.
3. No significant change in known metastatic disease, as
described above.
DISCHARGE LABS:
___ 06:29AM BLOOD WBC-5.8 RBC-3.66* Hgb-10.4* Hct-30.8*
MCV-84 MCH-28.4 MCHC-33.8 RDW-12.7 RDWSD-38.7 Plt ___
___ 06:29AM BLOOD Glucose-122* UreaN-17 Creat-1.5* Na-141
K-4.2 Cl-102 HCO3-26 AnGap-13
___ 06:29AM BLOOD Calcium-8.9 Phos-3.8 Mg-2.5
MICROBIOLOGY:
___ MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL {ACINETOBACTER
BAUMANNII COMPLEX} EMERGENCY WARD
___ 4:11 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ACINETOBACTER BAUMANNII COMPLEX. >100,000 CFU/mL.
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII COMPLEX
|
AMPICILLIN/SULBACTAM-- <=2 S
CEFEPIME-------------- 8 S
CEFTAZIDIME----------- 8 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ y/o M with PMHx of DM1 on insulin pump as well as metastatic
small bowl carcinoid c/b obstructive uropathy s/p B PCN, who
presented with fevers and hyperglycemia for the past 5 days
found to have complicated E. coli UTI.
# SEPSIS, due to # COMPLICATED E. coli UTI: The patient met SIRS
criteria on presentation. Given recent history as well as UA
findings, highest concern is for UTI. Prior cultures have grown
pan-sensitive enterococcus; however, the patient does have
increased risk for resistant pathogens. He was placed on
vanc/zosyn initially and then narrowed to zosyn monotherapy.
Ultimately, he was treated with ciprofloxacin based on
sensitivity results which showed E. coli sensitive to
ciprofloxacin. He will complete a 7 day course total for
complicated UTI with end date on ___.
# DIARRHEA: Initially concerning for possible c.diff given
recent course; however, stools have largely been formed on the
floor. Perhaps this is related to underlying carcinoid vs.
antibiotic-associated diarrhea. On day of discharge, patient
reported 3 loose stools early in the morning but repeated
attempts to collect stool sample failed. He preferred to be
discharged nonetheless given planned fundraiser later this
afternoon. After extensive discussion of potential risks of
undiagnosed and untreated C diff including serious infection,
sepsis and perforation, patient opted to be discharged without
ruling out C diff infection. He was advised to avoid
anti-diarrheal agents until we have rule out C diff and
encouraged to return to the ED should he develop fevers, chills,
abdominal pain and 3 or more loose stools a day. Alternatively,
should he continue to have mild loose stool without fever,
chills, abdominal pain or distension, he was advised not to take
Imodium until ___ and have his PCP order outpatient labs to
rule out C diff. While his risk of C diff is high,m he is
reassuringly well-appearing, afebrile with benign abdominal exam
and without leukocytosis on morning labs today.
# DM1 # HYPERGLYCEMIA: Hyperglycemia likely related to
concurrent infection. Insulin pump stopped, and patient has been
placed on glargine + standing and sliding scale. ___ was
consulted. At discharge he was advised to hold his insulin pump
and discharged on the following insulin regimen per ___ recs:
> Lantus 34 units in the evening
> Humalog pre-meal : Insulin to Carb ratio of 1:8 for breakfast
and lunch, and 1:6 for dinner
> Humalog Correction: 1:30 - correct to ___ during the daytime,
and 1:50- correct to ___ during the night
He will follow up in ___ in 1 week (appointment to be
arranged by ___ team after discharge).
# HTN / CAD: Continued on home carvediolol and ASA
# CARCINOID: Onc aware of admission. Continued octreotide 100mg
sc tid prn.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 3.125 mg PO BID
3. Octreotide Acetate 100 mcg SC Q8H:PRN diarrhea from carcinoid
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Tamsulosin 0.4 mg PO QHS
6. Nitrofurantoin (Macrodantin) 100 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
2. Glargine 34 Units Bedtime
Humalog premeal: Insulin to Carbohydrate ratio of 1:8 for
breakfast + lunch and 1:6 for dinner. Humalog Correction: during
the day correction factor 1:30 and correct to ___ during the
day, correction factor of 1:50 and correct to ___ at night.
RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100
unit/mL (3 mL) 34 U SC at bedtime Disp #*1 Package Refills:*5
RX *insulin lispro [Humalog KwikPen Insulin] 100 unit/mL AS DIR
ASDIR Disp #*1 Package Refills:*5
RX *insulin syringe-needle U-100 [Lite Touch Insulin Syringe] 30
gauge ASDIR Disp #*100 Syringe Refills:*5
3. Aspirin 81 mg PO DAILY
4. Carvedilol 3.125 mg PO BID
5. Octreotide Acetate 100 mcg SC Q8H:PRN diarrhea from
carcinoid
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary Tract Infection, due to E. coli
Diabetes / Hyperglycemia
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You presented to the hospital with fevers and elevated blood
sugars. There was concern for another urinary infection, so your
were started on strong IV antibiotics, and urinary cultures were
sent. Based on your urine culture results, we switched you to an
oral antibiotic (Ciprofloxacin) which you will take twice a day
starting tomorrow for 5 more days to complete a 7 day course
total. You no longer need to be seen in the ___
tomorrow for intravenous antibiotics but make sure you follow up
next week with your hematologist as scheduled.
You have been having loose stool which raises concern for the
possibility of C difficile infection. This is a serious
infection that typically requires 14 days of antibiotics (oral)
and sometimes can lead to serious complications especially if
left untreated. We have attempted to collect a stool sample from
you and will call you with the results. Should you require
antibiotics for this as well, we can call in the prescription.
It is important that you adhere to strict contact precautions in
the meantime. This means strict handwashing with water and soap,
avoiding close contact with any ___ or elderly patients.
The lack of fevers and stable blood counts for this morning all
speak against C. difficile infection but if you continue to have
3 or more loose stools a day, it will be important to rule this
out.
You were also seen by the ___. Your insulin pump was
stopped and you were start on insulin injections, which you will
continue after discharge. The ___ team is working on
arranging a follow up appointment for you in the next week to
check in.
Followup Instructions:
___
|
19918413-DS-19 | 19,918,413 | 27,785,816 | DS | 19 | 2130-09-24 00:00:00 | 2130-09-27 19:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ male with cervical spinal stenosis
(bedbound), ESRD s/p renal transplant c/b by graft failure on HD
3d/week,HEFpEF(EF40-45%), recurrent C. diff, and recent
hospitalization for C4-C6 laminectomy c/b diarrhea, hypokalemia,
and NSVT (___) presenting with shortness of breath and fever.
Pt and his wife notes that he has had cough productive of white
sputum for about 24 hours. He notes generalized lethargy w/
fever
to 101 at home last night. Notes that he is short of breath at
rest, but it is worse w/ inspiration. Denies CP, abdominal pain.
Additionally he notes LLE pain that begins at his knee and
radiates to his foot. He also has pain at his left buttocks from
a pressure ulcer.
Of note the pt finished PO Vanco on ___ for recurrent C.diff.
Currently having ___ watery BM daily. At baseline pt is
incontinent of urine and stool. Per the pt's wife he notes that
his BMs decreased to normal ___ soft BMs daily on the vancomycin
however within a week the diarrhea had returned.
In the ED the pt was noted to be febrile to 101.6, HR 81, BP
124/55, o2 sat 97% on 2L (not on home O2). H
Labs were notable for: Trop 1.08, CK 66 MB 2, AP 135, Alb 2.2,
hypoNa 133, Cr 4.2 BUN 46, leuko 10.2 neutrophil ___
A CXR revealed bilateral L>R consolidation w/ left sided pleural
effusions concerning for pneumonia. The pt was started on
Vanc/Zosyn/Azithro for HCAP and given loperamide and Tylenol for
diarrhea and fever.
Vitals on transfer:100.6 PO 131 / 55 78 18 98 2L
Upon arrival to the floor, pt endorsed the above and noted that
he did not have any SOB. He was feeling much less tachypnic than
previously. His only complaint was pain in his left buttocks.
Past Medical History:
-Cervical stenosis s/p ACDF C5-C6 on ___
-ESRD on HD
-Kidney transplant in ___, unrelated donor, no longer on
immunosuppression
-Heart failure with borderline EF (40-45% in ___
-Mitral regurgitation
-C difficile diarrhea
-Hypercholesterolemia
-Ocular hypertension
-Hypertension, essential
-Proliferative retinopathy
-Anemia
-History of tobacco use
-Diverticulosis
-Goiter
-Hyperparathyroidism
-Colonic polyp
-Vitreous hemorrhage
-Senile osteoporosis
-Type II diabetes mellitus, on insulin
-?TIA
Social History:
___
Family History:
Mother and brother with HTN.
Maternal Aunt and Brother with DM type II.
Physical Exam:
ADMISSION EXAM:
====================
VITALS:100.6 PO 131 / 55 78 18 98 2L
GENERAL: Elderly thin man in NAD, Alert and interactive.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diminished breath sounds L > R, mild basilar crackles. No
wheezing. No increased work of breathing. On 2L
ABDOMEN: Hyperactive bowels sounds, mild distension, non-tender
to deep palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally. Healing R. heal eschar.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength in bilateral lower
extremities. diminished sensation sensation. bed bound. AOx3.
DISCHARGE EXAM:
=====================
Temp: 98.8 BP: 112/57 HR: 80 RR: 16 O2 sat: 95% O2
delivery: Ra FSBG: 215
GENERAL: frail man resting in bed, comfortable
HEENT: AT/NC, anicteric sclera, MMM, adentous
NECK: supple, no JVD
CV: RRR S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, breathing comfortably without use of accessory
muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: atrophic but with no cyanosis, clubbing, 1+ pitting
edema; HD fistula in LUE
Skin: stage 2 pressure ulcer 2 x 3 cm on coccyx. Completely
intact skin with evidence of healing.
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 11:30PM CK(CPK)-29*
___ 11:30PM CK-MB-2 cTropnT-1.04*
___ 05:15PM cTropnT-1.12*
___ 08:37AM BLOOD CK-MB-2 cTropnT-1.08*
___ 08:49AM BLOOD Lactate-1.5
___ 06:08AM BLOOD ALT-17 AST-15 LD(LDH)-171 AlkPhos-117
TotBili-0.9
___ 06:17AM BLOOD Glucose-196* UreaN-35* Creat-4.0* Na-135
K-3.8 Cl-95* HCO3-28 AnGap-12
___ 06:17AM BLOOD WBC-7.0 RBC-2.90* Hgb-8.0* Hct-27.3*
MCV-94 MCH-27.6 MCHC-29.3* RDW-18.3* RDWSD-63.3* Plt ___
___ 04:24AM BLOOD WBC-10.2* RBC-3.12* Hgb-8.8* Hct-28.6*
MCV-92 MCH-28.2 MCHC-30.8* RDW-17.5* RDWSD-58.2* Plt ___
Brief Hospital Course:
___ is a ___ male with cervical spinal stenosis
(bedbound), ESRD s/p renal transplant c/b by graft failure on HD
3d/week,HEFpEF(EF40-45%), recurrent C. diff, and recent
hospitalization for C4-C6 laminectomy who presented with
shortness of breath and fever. He was found to have a pneumonia
and positive cdiff antigen, and demonstrated improvement with
antibiotic therapy.
ACUTE ISSUES:
===============
# HCAP
The patient presented with SOB, fevers, mild hypoxia and CXR was
revealing for bilateral lower lobe consolidations concerning for
pneumonia. He had a history of a previous L>R consolidation with
an associated pleural effusion, so given this recurrence there
is also concern for possible post-obstructive cause or
underlying malignancy. The patient was initially treated with
vanco, azithro, and zosyn x 1 day on ___, and then narrowed
to Levofloxacin ___. White count trended downward
appropriately with improvement of respiratory symptoms. He was
discharged with plans to complete a 5 day course of Levoquin
(dosed for HD the next day).
# Recurrent C.Diff
The patient has a history of recurrent C.diff and was now s/p
___ round of PO vancomycin(finished ___. C.diff was stool PCR
and toxin antigen assay were both positive on admission. The
patient was started on PO vancomycin to continue for 2 weeks
after finishing course of levoquin for HCAP as above.
# Coccygeal pressure ulcer, R heel
Per the patient and his wife, pressure ulcers were chronic
issues given bed bound state. There was no signs of active
infection. Wound care was consulted and recommended frequent
dressings and position changes. He was discharged with plans for
further wound care with visiting nurses.
# Troponemia
Mild troponin elevation likely due to demand ischemia from
pneumonia in the setting of ESRD. He had no chest pain or EKG
changes. His troponins were trended until peaked.
CHRONIC ISSUES:
===============
# Pancreatic Insufficiency
A previous colonoscopy showed no evidence of colitis. Diarrhea
was
diagnosed as severe exocrine pancreatic insufficiency with stool
elastase <15. Pancreatic insufficiency likely due to to chronic
pancreatitis with imaging findings on CT abdomen. He was
continued on home creon.
# Chronic HF with borderline EF (40-45% in ___
Patient was euvolemic on exam.
# Atrial tachycardia
The patient was continued on his home metoprolol fractionated
while in house.
# ESRD
History of renal transplant, no longer taking
immunosuppressives. On
___ as outpatient, but shifted to ___ as inpatient.
Dialyzed ___, and is scheduled to go again on ___ at his
outpatient
dialysis center. Started on nephrocaps as inpatient per renal
recommendation.
# Spinal Stenosis s/p laminectomy c/b incontinence
The patient was given Tylenol for pain.
# T2DM
The patient was given ISS while admitted. Will resume prior
regimen on discharge.
# Pancytopenia
Mild, stable since last admission. Unclear etiology. Possibly
due
to ESRD and nutritional deficiencies due to chronic diarrhea.
DDx includes MDS or marrow infiltrative process esp w/ tear drop
cells on previous blood smear. Per conversation w/ heme/onc at
last admission there was high suspicion for MDS but not at
threshold where would benefit from BM biopsy. Hx of normal TSH,
SPEP, folate, hemolysis labs, B12.
TRANSITIONAL ISSUES
=====================
[] The patient endorsed night sweats for approximately one year.
Please ensure age appropriate cancer screening. Would also
consider heme outpatient follow up given concerns for MDS.
[] Levoquin course to be completed on ___, with last dose given
after dialysis.
[] Oral vancomycin course to continue until ___.
[] The patient has had recurrent cdiff infections (the present
admission marks his ___ CDI), each treated with PO vancomycin.
Would consider alternative methods of treatment if reoccurs
again, such as fecal transplant.
[] Please ensure adequately wound care and evaluate for proper
healing of coccyx and heel.
[] It was not known when the patient was started on vitamin D.
Consider discontinuing if adequately repleted to avoid vitamin D
toxicity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain
2. Artificial Tears ___ DROP BOTH EYES TID:PRN dry eyees
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Calcitriol 0.25 mcg PO ___
6. Famotidine 20 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. HumaLOG (insulin lispro) 100 unit/mL subcutaneous sliding
scale ___ units S.C. 3 times daily
9. Creon 12 3 CAP PO TID W/MEALS
10. Creon 12 1 CAP PO QID:PRN snacks
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Vitamin D ___ UNIT PO 1X/WEEK (MO)
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Medications:
1. Levofloxacin 750 mg PO ONCE Duration: 1 Dose
TAKE AFTER HEMODIALYSIS SESSION ON ___. Nephrocaps 1 CAP PO DAILY
3. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*61 Capsule Refills:*0
4. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain
5. Artificial Tears ___ DROP BOTH EYES TID:PRN dry eyees
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Calcitriol 0.25 mcg PO ___
9. Creon 12 3 CAP PO TID W/MEALS
10. Creon 12 1 CAP PO QID:PRN snacks
11. Famotidine 20 mg PO DAILY
12. Finasteride 5 mg PO DAILY
13. HumaLOG (insulin lispro) 100 unit/mL subcutaneous sliding
scale ___ units S.C. 3 times daily
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
==========
# Health Care Associated Pneumonia
# Clostridium difficile infection, recurrent
SECONDARY
===========
# Malnutrition
# Coccygeal pressure ulcer, R heel pressure ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had trouble breathing and were diagnosed with pneumonia.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were given antibiotics to treat your pneumonia
- You were given antibiotics to treat your C diff infection that
is causing you to have diarrhea.
- You were seen by wound care to treat the pressure ulcers on
your back and heel.
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:
___
|
19918413-DS-21 | 19,918,413 | 20,849,922 | DS | 21 | 2130-12-04 00:00:00 | 2130-12-04 17:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lethargy, dyspnea, cough, fever
Major Surgical or Invasive Procedure:
Right chest tube placement ___
Right chest tube removal ___
History of Present Illness:
___ male with history of spinal stenosis (bedbound),
ESRD on HD ___ (s/p renal transplant that failed, no longer
on immunosuppression), CHF (EF 40-45% in ___, recurrent
pneumonia/c diff in the past (most recent hospitalization
___ presents with 1 week of cough, SOB, fever to T-max
101,
loss of appetite, and increasing generalized lethargy.
Per the family, he was diagnosed with PNA a few days ago and
started on oral antibiotics (amoxicillin). Since then, he has
been having worsening lethargy, and becoming hypotensive as the
wife checks his vitals daily (has been ___ systolic, but his
typical range is between 110 and 160 systolic per his wife). He
normally takes metoprolol, but his wife stopped this about 2
days
ago given his low blood pressure. He has had fevers to ___ on
the morning prior to coming to ED. He has no other complaints,
but feels tired. He went to HD yesterday and felt well.
He denies any cough, runny eyes, runny nose, sore throat, chest
pain, palpitations, or abdominal pain. He denies any nausea,
vomiting, or diarrhea. He denies any back pain. He makes no
urine
at baseline and is non-ambulatory. However, his wife
intermittently straight caths him, last cath was 3 days ago,
with
scant urine output. His wife changes his dressings on his foot
where he has a well healing ulcer on his right heel and a skin
tear on his right shin. She denies any purulence, blood, or foul
odor. His family also changes his coccygeal sacral pressure
ulcer
dressings daily.
In the ED, initial vitals were: 0 37.5 80 97/47 27 93, then T
up
to 102.1
- Exam notable for: normal MS,
- EKG: prolonged QTC and STD V4-V6
- Labs notable for: WBC 4.4, Trop 1.90->1.47, CK 39, CK-MB 2,
lactate 1.6
- CXR: pleural effusions increased since ___, no pulmonary
edema, chronic LLL, consolidation,
- Patient was given: Vanc/Zosyn, 2L IVF, Tylenol
- VS prior to transfer: 0 99.2 71 96/45 16 97% 2L NC
Upon arrival to the floor, patient reports feeling much better.
He only complained of weakness and fatigue, denied any further
fevers and also continued to deny any palpitations or CP. He
also
stated that his SOB had resolved.
Past Medical History:
-Cervical stenosis s/p ACDF C5-C6 on ___
-ESRD on HD
-Kidney transplant in ___, unrelated donor, no longer on
immunosuppression
-Heart failure with borderline EF (40-45% in ___
-Mitral regurgitation
-C difficile diarrhea
-Hypercholesterolemia
-Ocular hypertension
-Hypertension, essential
-Proliferative retinopathy
-Anemia
-History of tobacco use
-Diverticulosis
-Goiter
-Hyperparathyroidism
-Colonic polyp
-Vitreous hemorrhage
-Senile osteoporosis
-Type II diabetes mellitus, on insulin
Social History:
___
Family History:
Mother and brother with HTN.
Maternal Aunt and Brother with DM type II.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Elderly, thin, frail man in NAD, Alert and interactive.
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no JVD
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Diminished breath sounds L > R, mild basilar crackles. No
wheezing. No increased work of breathing.
ABDOMEN: Normal bowel sounds, non-tender to palpation, no
distension, no organomegaly
EXTREMITIES: Mild 1+ pitting edema bilaterally. L ___ digit
amputated in L hand.
NEUROLOGIC: CN2-12 intact. ___ strength in bilateral lower
extremities, ___ strength in UE b/l. diminished sensation. bed
bound. AOx3.
SKIN: Large coccygeal pressure ulcer w/o evidence or purulence,
erythema, or drainage. Pressure ulcers over R lower leg, R heel,
L Achilles tendon w/o drainage or purulence
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T 97.4F, HR 74, BP 103/52, RR 18, 99% on RA
GEN: Elderly and frail man in NAD.
HEENT: EOMI, Pupils constricted b/l with annulus senilis.
RESP: Breathing comfortably on RA. CTAB anteriorly, was unable
to
auscultate posteriorly due to lack of mobility.
CV: RRR, systolic murmur heard emanating from fistula on L arm.
ABD: Normoactive bowel sounds. No TTP.
EXT: Warm and well perfused. 1+ pedal edema and 1+ pitting
in dependent areas of legs. +AV fistula on left UE,
+thrill/bruit.
NEURO: AO x person, place, year.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:47AM BLOOD WBC-4.4 RBC-2.97* Hgb-8.5* Hct-28.4*
MCV-96 MCH-28.6 MCHC-29.9* RDW-17.9* RDWSD-62.6* Plt ___
___ 07:47AM BLOOD Neuts-61.6 ___ Monos-7.3 Eos-4.1
Baso-0.5 Im ___ AbsNeut-2.69 AbsLymp-1.15* AbsMono-0.32
AbsEos-0.18 AbsBaso-0.02
___ 07:47AM BLOOD Glucose-160* UreaN-22* Creat-2.1*#
Na-133* K-3.5 Cl-90* HCO3-27 AnGap-16
___ 07:47AM BLOOD Albumin-2.7* Calcium-9.6 Phos-3.8 Mg-1.9
___ 07:47AM BLOOD ALT-23 AST-92* CK(CPK)-31* AlkPhos-153*
TotBili-0.6
___ 07:47AM BLOOD Lipase-4
___ 07:47AM BLOOD CK-MB-2 cTropnT-1.90*
___ 11:30AM BLOOD cTropnT-1.47*
___ 07:53AM BLOOD Lactate-1.6
PERTINENT LABS/MICRO/IMAGING:
=============================
___ 08:27AM BLOOD ___ PTT-31.7 ___
___ 08:45AM BLOOD ___ PTT-32.7 ___
___ 07:20AM BLOOD Ret Aut-2.7* Abs Ret-0.07
___ 07:20AM BLOOD Hapto-202*
___ 08:27AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:35PM BLOOD Lactate-3.2*
___ 09:28PM BLOOD Lactate-2.3*
ZINC (SPIN NVY/EDTA)
Test Result Reference
Range/Units
ZINC 42 L 60-130 mcg/dL
COPPER (SPIN NVY/NO ADD)
Test Result Reference
Range/Units
COPPER 131 70-175 mcg/dL
___ 01:00PM URINE Color-Yellow Appear-Cloudy* Sp ___
___ 01:00PM URINE Blood-LG* Nitrite-POS* Protein->300*
Glucose-100* Ketone-NEG Bilirub-SM* Urobiln-0.2 pH-8.5*
Leuks-LG*
___ 01:00PM URINE ___ Bacteri-MOD*
Yeast-NONE ___ 01:00PM URINE Mucous-MANY*
___ 02:03PM PLEURAL TNC-506* RBC-300* Polys-4* Lymphs-15*
Monos-0 Eos-1* Meso-2* Macro-78*
___ 02:03PM PLEURAL TotProt-4.9 Glucose-168 LD(LDH)-112
Cholest-40 proBNP-GREATER TH
Micro:
-------
___ 7:47 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 12:53 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. SPARSE
GROWTH.
___ 5:08 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date.
___ 5:30 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date.
___ 10:14 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
___ 2:03 pm PLEURAL FLUID LEFT PLUERAL EFFUSSION.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ 2:03 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
LEFT PLEURAL EFFUSION.
Fluid Culture in Bottles (Pending): No growth to date.
Cytology:
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells, lymphocytes, and histiocytes.
Imaging:
---------
CXR ___:
1. Pleural effusion increased since ___..
2. Chronic left lower lobe consolidation, collapse or infection.
3. Chronic moderate cardiomegaly, slightly improved. Pulmonary
vascular
engorgement decreased. No pulmonary edema.
4. Heavy atherosclerotic calcification, carotid arteries.
CXR ___:
Comparison to ___. The pre-existing right pleural
effusion or was drained with a right pigtail catheter. There
only some minimal basal portion of effusion but the patient has
developed a small pneumothorax at the site of tube insertion.
There is no evidence of tension. Stable moderate cardiomegaly
and retrocardiac atelectasis.
CXR ___:
Re-accumulation of right pleural effusion despite unchanged
position of the right pleural drain.
RUQUS ___:
Normal appearance of the liver and gallbladder. Extrahepatic
biliary dilation appears stable from prior. Increased
hydronephrosis in the left lower quadrant transplant kidney is
noted.
DISCHARGE LABS:
===============
___ 06:18AM BLOOD WBC-4.2 RBC-2.93* Hgb-8.3* Hct-28.1*
MCV-96 MCH-28.3 MCHC-29.5* RDW-17.1* RDWSD-59.9* Plt ___
___ 06:18AM BLOOD Glucose-169* UreaN-23* Creat-2.6* Na-135
K-3.9 Cl-97 HCO3-28 AnGap-10
___ 06:18AM BLOOD Calcium-9.3 Phos-4.0 Mg-2.0
___ 08:45AM BLOOD ALT-24 AST-72* AlkPhos-179* TotBili-0.5
Brief Hospital Course:
PATIENT SUMMARY:
================
___ male with history of spinal stenosis (bedbound),
ESRD on HD ___ (s/p renal transplant that failed, no longer
on immunosuppression), CHF (EF 45-50% in ___, recurrent
pneumonia and c. diff in the past (most recent hospitalization
for PNA ___ who presented with sepsis likely secondary to
pneumonia, also found to have bilateral uncomplicated pleural
effusions likely secondary to heart failure. On admission he
also had a type 2 NSTEMI in the setting of sepsis. He completed
a 7-day course of vanc/cefepime with clinical improvement.
ACUTE ISSUES:
=============
#Sepsis:
#Pneumonia:
Patient presented with relative hypotension, mental status
change,
tachypnea, cough, and fever to ___. Likely secondary to
pneumonia with CXR showing possible retrocardiac infiltrate and
history of recurrent PNA in the past. He also had bilateral
pleural effusions, so there was concern over possible
complicated pleural effusion vs. empyema - chest tube placed and
fluid analysis showed exudative but other studies including gram
stain and culture negative and rapid re-accumulation more
consistent with transudative (see below). Initially considered
possible UTI or wound infection given chronic wounds however he
is essentially anuric without urinary symptoms and wounds not
draining or erythematous. He received a total of 3.5L of IVF
over the first few days due to drops in SBP to 80. He was given
a dose of vanc/Zosyn in the ED then switched to vanc/cefepime on
the floors and completed a total 7-day course. He was found to
be MRSA positive. Blood cultures no growth to date.
Intermittently on 2L NC however weaned to room air and O2 sat
mid-90s%. He clinically improved back to baseline mental status
with SBPs 120s and on room air.
#Acute on Chronic HF (EF 45-50% in ___:
#Pleural effusions:
CXR on admission showed bilateral pleural effusions, initial
concern for complicated effusion vs. empyema given history of
recurrent PNA and delay in clinical improvement on antibiotics.
Chest tube placed ___ and removed ___ by IP and pleural fluid
studies showed exudate by Light's criteria however normal pH and
glucose with negative gram stain and culture, also with
re-accumulation of pleural effusion despite chest tube, overall
more consistent with heart failure. Patient with pedal and
dependent edema on exam, also with elevated JVP, all improved
with HD. Likely acute HF exacerbation in setting of PNA/sepsis
per above. He was continued on HD ___ and continued home
metoprolol. He should follow up in ___ clinic ___ weeks after
discharge - they will set up appointment and call him.
#NSTEMI Type 2:
ECG in ED showed ST depressions in V4-V6 and troponins were
elevated to 1.9 from baseline of 1.0, downtrended to 1.4. Likely
demand ischemia in setting of sepsis/hypotension. Repeat ECG a
few days later was stable. He was continued on his home ASA,
atorvastatin, and metoprolol.
#Transaminitis:
Patient with mild persistent AST and ALP elevations, denies any
abd pain. Notes a history of drinking a 6 pack of beer daily
however
quit at least ___ years ago and looks like LFTs previously normal.
RUQUS negative for hepatobiliary pathology. Could be from
cardiac ischemia.
#Acute on chronic anemia:
Baseline Hgb ~8, likely secondary to ESRD. Initially stable
since last admission but downtrended on ___ to 6.9, so was
given 1 unit pRBCs with HD. Subsequently, Hgb back to baseline
and stable. Likely secondary to hemodilution in setting of 3.5L
IVF, hemolysis panel negative. However stool was tested and was
guaiac positive. Needs follow-up outpatient as to whether to
pursue further workup.
CHRONIC ISSUES:
===============
#Diarrhea:
#Pancreatic insufficiency:
#Hx of C.diff:
Chronic, denies abdominal pain, nausea, vomiting. C.diff
negative this admission. He was continued on his home
loperamide, diphenoxylate/atropine, Creon. He was also started
on C.diff prophylaxis vancomycin 125mg PO BID given history of
recurrent C.diff and on broad-spectrum antibiotics. He should
continue through ___, which will be 5-days post antibiotics.
#ESRD on HD ___:
Continued on HD as scheduled.
#Coccygeal pressure ulcer:
Chronic, followed by wound care inpatient.
#Malnutrition:
Hx of pancreatic insufficiency, with copper and multiple vitamin
deficiencies. Nutrition saw patient and recommended ascorbic
acid and zinc supplements for 10 days.
#Hx of NSVT:
Patient has hx of episodes of NSVT, thought to be atrial
tachycardia vs. atrial flutter, on metoprolol. Remained regular
rate and rhythm. Continued on home metoprolol.
#Spinal Stenosis s/p laminectomy c/b incontinence:
At baseline. Bedbound.
#T2DM:
On sliding scale Humalog at home. Continued on sliding scale in
hospital.
#Code Status:
Patient previously DNR/DNI on last admission, but expressed
desire to
be Full Code with limited trial of life-sustaining interventions
most recently. Recommend continued GOC discussion in outpatient
environment.
TRANSITIONAL ISSUES:
====================
- C. difficile prophylaxis:
[] Patient should continue PO Vancomycin 125mg BID through ___
for C.diff ppx given on broad-spectrum antibiotics.
- Pleural effusions:
[] IP to set up follow-up appointment ___ weeks post-discharge,
please ensure he has an appointment.
- Other:
[] Mild elevations in AST/ALP with negative RUQUS and
asymptomatic. Recheck in ___ weeks.
[] Hgb drop from baseline 8s to 6.9 likely in setting of
hemodiluation from 3.5L IVF, however stool guaiac positive.
Please check in ___ weeks and decide whether further workup is
warranted. Discharge hemoglobin 8.3
[] Patient started on 10-day course of Ascorbic Acid ___ mg
daily to be completed ___.
[] Patient started on 10-day course of Zinc Sulfate 220 mg daily
to be completed ___.
[] Continue ___ discussions
# CODE: full (presumed)
# CONTACT: ___ (wife) ___
Patient seen and examined. Medically stable for discharge.
Greater than 30 minutes was spent in care coordination
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain
2. Artificial Tears ___ DROP BOTH EYES TID:PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Creon 12 3 CAP PO TID W/MEALS
6. Famotidine 20 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
9. HumaLOG (insulin lispro) 100 unit/mL subcutaneous ___ units
S.C. 3 times daily
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Triphrocaps (B complex with C#20-folic acid) 1 mg oral DAILY
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Amoxicillin 500 mg PO Q12H Pnuemonia
14. TraZODone 25 mg PO QHS:PRN insomnia
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY Duration: 10 Days
RX *ascorbic acid (vitamin C) 250 mg 1 tablet(s) by mouth daily
Disp #*4 Tablet Refills:*0
2. Vancomycin Oral Liquid ___ mg PO BID C.Diff ppx while on
broad spectrum antibiotics
RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp
#*11 Capsule Refills:*0
3. Zinc Sulfate 220 mg PO DAILY Duration: 10 Days
RX *zinc sulfate 220 mg (50 mg zinc) 1 capsule(s) by mouth daily
Disp #*7 Capsule Refills:*0
4. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain
5. Artificial Tears ___ DROP BOTH EYES TID:PRN dry eyes
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Creon 12 3 CAP PO TID W/MEALS
9. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
10. Famotidine 20 mg PO DAILY
11. Finasteride 5 mg PO DAILY
12. HumaLOG (insulin lispro) 100 unit/mL subcutaneous ___
units S.C. 3 times daily
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Metoprolol Succinate XL 25 mg PO DAILY
15. TraZODone 25 mg PO QHS:PRN insomnia
16. Triphrocaps (B complex with C#20-folic acid) 1 mg oral
DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Sepsis secondary to pneumonia
-Acute on chronic heart failure
-Pleural effusions
SECONDARY:
-Type 2 Non-ST-elevation myocardial infarction
-Diarrhea
-Transaminitis
Discharge Condition:
Mental Status: Confused - sometimes. Oriented to person, place,
year.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were having
fevers, cough, and shortness of breath, and you were more tired
than usual. Your blood pressures were also lower than normal.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You were given fluids through your IV for your low blood
pressure, and your blood pressure improved to normal.
-You completed a course of antibiotics for pneumonia.
-You had a chest tube placed for a day to drain some of the
fluid from around your lung. The fluid from around your lung did
not look like it was infected, and was probably from your heart
failure.
-You received a blood transfusion because your hemoglobin was a
little low, probably because you got a lot of IV fluids.
-You were started on an antibiotic (vancomycin) to prevent
C.diff while you were being treated for your pneumonia.
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Continue to take all medications as prescribed.
-Please attend all ___ clinic appointments.
-You will need to set up an appointment with your primary care
doctor ___ ___ within the next ___
weeks so that she can make sure you are still feeling well.
-The interventional pulmonology team (the team that put
in/removed your chest tube for the fluid around your lungs) will
be calling you next week to set up a follow-up appointment in
clinic.
-Continue to take the oral vancomycin twice a day through ___
to prevent C.diff.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
19918694-DS-33 | 19,918,694 | 23,585,993 | DS | 33 | 2189-06-16 00:00:00 | 2189-06-16 13:44:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Latex / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
claudication
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ M w/ PVD and multiple prior ___ revascularization
procedures including multiple bypass grafts. He has not followed
up in clinic for over a year. He reports that over the past 5
months, he has had a progressive increase in claudication
symptoms to the point that now he can only walk around 100 ft
before getting ___ severe L midfoot and calf pain. The pain is
significantly decreased when the patient is sitting or laying
down. He states the pain is sharp/ stabbing/burning in quality.
He reports Chest Pain last evening which he has had worked up
multiple times in the past. He states that the pain is now gone.
Past Medical History:
Past Medical History: HTN, hyperlipidemia, atypical chest pain,
PVD, Dyslipidemia,COPD, GERD, Diverticulosis/diverticulitis,
GIB,
Myalgias, BPH, Bladder CA, depression, DM.
Past Surgical History: L CIA/EIA stent, L fem-AKP PTFE BPG (___),
R CIA/EIA stent, R fem-AKP PTFE BPG (___), L graft thrombectomy
(___), L calf fasciotomy (___), L fem-AT BP w NRGSV (06), removal
LLE infected fem-pop PTFE BPG (08), L fem-AT vein graft
stenting
(08), L fem-AT BPG (08), thrombolysis L fem-AT BPG (09),
multiple balloon angioplasties BLE (09), R pop stent (10), b/l
LSV harvest and R PFA-BKP with (11R)TMA (11), Multiple TMA
debridements (11), R TAL(12),inguinal hernia repair,
appendectomy, TURP.
Social History:
___
Family History:
Mother died of a brain tumor at the age of ___.
Father died of a myocardial infarction at the age of ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.1 82 159/91 20 95%
Gen: AAO, NAD
___: RRR, S1S2
Pulm: Prolonged Exp phase
Abd: Soft, midline laparotomy scar, nontender, nondistended
Ext: No edema, warm, Well healed R. TMA amp site.
Vascular:
Pulses: Fem: bilateral palp
Pop: bilateral dop
Left: DP & ___ signals
Right: AT signal
Graft on left medial ___ is non dopplerable
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 54 117/64 18 95%
Gen: AAO, NAD laying comfortably in bed
___: RRR, normal S1/S2. No murmurs, rubs or gallops
Pulm: CTAB. Prolonged expiratory phase. No wheezes, rales or
rhonchi
Abd: +BS, soft, non-tender, non-distended. Midline laparotomy
scar.
Ext: No edema. Warm. Well healed R TMA amp-site.
Vascular:
Pulses: Fem: bilateral palpation
Pop: bilateral doppler
Left: DP & ___ dopplerable
Right: AT dopplerable.
Graft on left medial ___ is non-dopplerable.
Pertinent Results:
___ 11:42PM BLOOD WBC-10.8 RBC-5.68 Hgb-16.5 Hct-49.8
MCV-88 MCH-29.0 MCHC-33.2 RDW-14.5 Plt ___
___ 04:50PM BLOOD WBC-12.2*# RBC-6.14# Hgb-17.8# Hct-53.8*#
MCV-88 MCH-29.1 MCHC-33.1 RDW-14.5 Plt ___
___ 05:10AM BLOOD Glucose-111* UreaN-12 Creat-0.6 Na-138
K-4.3 Cl-108 HCO3-20* AnGap-14
___ 11:42PM BLOOD Glucose-128* UreaN-14 Creat-0.5 Na-142
K-4.2 Cl-105 HCO3-26 AnGap-15
___ 05:10AM BLOOD Calcium-9.8 Phos-2.8 Mg-1.6
___ 11:42PM BLOOD Calcium-9.5 Phos-2.8 Mg-1.4*
___ 11:42PM BLOOD %HbA1c-6.0* eAG-126*
Final Report
EXAMINATION: CTA AORTA/BIFEM/ILIAC RUNOFF W/ AND W/O C AND
RECONS
INDICATION: ___ year old man with rest pain multiple bypasses
// iliac/tibial
patency, anatomy
TECHNIQUE: MDCT-acquired axial images were first acquired from
the lung bases
through the feet using low radiation dose technique. Next,
immediately after
rapid intravenous administration of 100 mL Omnipaque, early
arterial-phase
axial images were acquired from the lung bases through the feet.
Lower
extremity runoff images were obtained by scanning from the feet
to the knees
in reverse direction. Multiplanar reformations performed to
generate 2.5 mm
slice thickness axial images, coronal MIPs, and sagittal MIPs.
Curved
reformats, 3D MIPs, and volumetric rendering was performed by
the Imaging Lab,
on a separate 3D workstation.
DOSE: DLP: 2469 mGy-cm.
COMPARISON: CT of the abdomen pelvis from ___ was
reviewed.
FINDINGS:
CTA ABDOMEN/PELVIS:
The abdominal aorta is normal in caliber and without evidence of
aneurysmal dilation or dissection. The celiac axis, SMA,
bilateral renal arteries, and ___ are grossly patent. There are
bilateral endoluminal stent grafts extending from the aortic
bifurcation in the common iliacs to the level of the external
iliacs bilaterally. There is internal soft plaque bilaterally
with mild to moderate stenosis of the right common and external
iliac artery (3a:112) and mild stenosis of the left external
iliac artery (3a:128). Atherosclerotic mural calcifications are
seen throughout the aorta and its major branches. Hepatic
arterial anatomy is conventional. Assessment of the venous
vasculature is limited by the timing of contrast.
CTA LOWER EXTREMITIES:
On the right, there is an unchanged ectasia of the common
femoral artery
measuring 1.8 x 1.7 cm (3a:150) at the graft anastamosis. There
is complete occlusion of the right superficial femoral artery
which contains a stent graft extending to the level of the
popliteal artery. There is reconstitution of the popliteal
artery through collaterals from the deep femoral artery, with
diminished caliber. A three-vessel runoff is demonstrated
proximally, but there is severe attenution of the anterior
tibial, posterior tibial, and peroneal arteries until the distal
third of the lower leg where the peroneal artery and posterior
tibial artery are no longer opacified. The dorsalis pedis is
diminutive. There has been prior amputation of the right
forefoot.
On the left are two grafts extending from the common femoral
artery, both of which are occluded, one within the superficial
femoral artery terminating in the distal medial thigh, and a
femoral-to-anterior tibial artery bypass. The bypass graft
demonstrates two insertions into the anterior tibial artery
(3a:334, 390), with both limbs completely occluded. There is
mild stenosis at the graft insertion site of the left common
femoral artery. There is reconstitution of the popliteal
artery, which is diminutive, via collaterals from the deep
femoral artery. A three-vessel runoff is demonstrated with
moderate attention of the anterior tibial, peroneal and
posterior tibial arteries until the mid lower leg, where the
anterior tibial artery is partially obscured by the lower
portion of the femoral-AT bypass. The posterior tibial artery is
opacified throughout its course mild irregular attenuation along
the distal portion. The peroneal artery is opacified to the
level of the ankle joint. The dorsalis pedis artery is patent.
ABDOMEN:
Evaluation is limited by the arterial phase of image
acquisition. The liver is steatotic with no concerning focal
lesion. The gallbladder and biliary tree are normal. In the
pancreas, there is an unchanged 7 mm hypodense lesion that may
represent an IPMN (03:31). The spleen is normal in size, without
focal lesion. The adrenal glands are normal. In the kidneys,
there unchangedright upper pole renal cyst and another 2 left
renal hypo enhancing lesions that may also represent cysts
(3a:24, 3a:34, 3a:68). There may be a small duodenum
diverticulum involving the second stage of the duodenum (
3a:51). There is colonic diverticulosis. The small bowel and
large bowel are normal in caliber, without wall thickening or
mass. There is no intra- or retroperitoneal lymphadenopathy.
There is no ascites, fluid collection, or pneumoperitoneum.
PELVIS:
The urinary bladder is without wall thickening or mass. The
rectum is
unremarkable. The prostate gland is mildly enlarged with coarse
calcifications. There is no free fluid. There is no pelvic or
inguinal
lymphadenopathy.
BONES AND SOFT TISSUES:
There are degenerative changes within the lumbosacral spine with
no fracture.
There are no destructive osseous lesions concerning for
malignancy or
infection. There are no soft tissue masses.
IMPRESSION:
1. Complete occlusion of bilateral superficial femoral arteries
and left
femoral to anterior tibial grafts, with popliteal reconstitution
from the deep femoral collaterals.
2. Moderate attention of the left anterior tibial, peroneal and
posterior tibial arteries, appearing patent to the level of the
ankles. Patent dorsalis pedis.
3. Severe attenuation of the right peroneal and posterior
tibial arteries with no appreciable flow beyond the distal third
segment. Severe attenuation of the right anterior tibial artery
with flow extending to the dorsalis pedis
artery. Post right forefoot amputation.
4. Patent bilateral iliac stents with mild to moderate stenosis
as described above.
5. Likely 7 mm side-branch IPMN in the pancreatic body remains
stable and can be followed in ___ years to ensure stability.
Brief Hospital Course:
The patient was admitted to the hospital with claudication. His
pain was controlled with po pain medication that he was on while
at home. He underwent arterial studies that showed severly
decreased flow to his lower left extremity. He underwent a CTA
that showed a possible new lesion in the profunda artery. He was
stable and he was scheduled to return as an outpatient for an
angiogram and possible angioplasty to try to improve his
claudication.
Due to concerns over not taking his home medications it was
arranged that his home medications were delivered to him prior
to his discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
2. Lorazepam 1 mg PO HS:PRN sleep
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Naproxen 500 mg PO Q12H
5. Atorvastatin 40 mg PO HS
Discharge Medications:
1. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth six hours Disp #*50
Tablet Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*30 Tablet Refills:*0
3. Aspirin 325 mg PO DAILY
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
5. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice a day
Disp #*30 Capsule Refills:*0
7. Atorvastatin 40 mg PO HS
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Lorazepam 1 mg PO HS:PRN sleep
RX *lorazepam 1 mg 1 tablet by mouth daily Disp #*14 Tablet
Refills:*0
9. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Claudication
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 for the pain in your leg. Your
pain was controlled with pain medications. A CT was done that
showed a possible new obstruction in the artery to that leg. You
will be discharged now and will come back for an angiogram in 2
weeks.
1) Please take the medications that we have prescribed for you.
2) Please call Dr. ___ office on ___ to confirm
the timing of your angiogram.
Followup Instructions:
___
|
19918694-DS-36 | 19,918,694 | 28,820,960 | DS | 36 | 2192-09-17 00:00:00 | 2192-09-17 18:17:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Latex / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
left leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hypercoagulability and severe PAD having undergone
multiple ___ revascularizations for symptoms of critical limb
ischemia including wounds and claudication presents with acute
complaints of left lower extremity pain and numbness/tingling
extending from foot to proximal calf. He denies color change,
skin breakdown, ulceration or loss of motor/sensation.
Past Medical History:
PMH: DM, HTN, HLD, atypical chest pain, PVD, COPD, GERD,
diverticulosis/itis, GIB, Myalgias, BPH, Bladder CA, depression
PSH:
L CIA/EIA stent, L fem-AKP PTFE BPG (05),
R CIA/EIA stent, R fem-AKP PTFE BPG (06), L graft thrombectomy
(___), L calf fasciotomy (___), L fem-AT BP w NRGSV (06), removal
LLE infected fem-pop PTFE BPG (08), L fem-AT vein graft
stenting
(08), L fem-AT BPG (08), thrombolysis L fem-AT BPG (09),
multiple balloon angioplasties BLE (09), R pop stent (10), b/l
LSV harvest and R PFA-BKP with (11R)TMA (11), Multiple TMA
debridements (11), R TAL(12),inguinal hernia repair,
appendectomy, TURP.
L FEM COMMON/PROFUDNA EA, L ILIAC THROMB, B/L CIA KISSING
STENTS,
R EIA STENT, L ILIO-PROFUNDA BYPASS USING HYBRID GRAFT (___)
Pertinent Results:
___ 04:23AM BLOOD WBC-7.0 RBC-4.97 Hgb-13.6* Hct-42.3
MCV-85 MCH-27.4 MCHC-32.2 RDW-15.7* RDWSD-48.0* Plt ___
___ 04:23AM BLOOD ___ PTT-150* ___
___ 04:23AM BLOOD Glucose-122* UreaN-19 Creat-0.8 Na-142
K-4.1 Cl-102 HCO3-30 AnGap-10
___ 05:49PM BLOOD %HbA1c-5.8 eAG-120
___ 04:23AM BLOOD Calcium-9.4 Phos-3.2 Mg-1.6
CTA, abd and pelvis wit run off.
1. The left anterior tibial artery is occluded distal to the
level of the
occluded femoral-anterior tibial bypass graft. There is transit
occlusion of
the left posterior tibial artery distally with reconstitution
above the ankle.
The left peroneal artery is patent to the level of the ankle.
2. Pancreatic cystic lesions measuring up to 1.0 cm branch
IPMNs. Recommend
further evaluation with MRCP if not previously worked up.
3. Multiple bilateral pulmonary nodules measuring up to 8 mm.
For incidentally detected multiple solid pulmonary nodules
measuring 6 to
8mm, a CT follow-up in 3 to 6 months is recommended in a
low-risk patient,
with an optional CT follow-up in 18 to 24 months. In a high-risk
patient, both
a CT follow-up in 3 to 6 months and in 18 to 24 months is
recommended.
4. Bilateral upper lobe paramediastinal radiation fibrosis.
5. Extensive collaterals along the right upper chest secondary
to occlusion of
the right internal jugular vein.
Brief Hospital Course:
VASCULAR SURGERY DISCHARGE SUMMARY
Mr ___ is a ___ year old man with hypercoaguability and severe
bilateral ___ vascular disease sp multiple revascularizations was
transferred to the ___ on
___ for evaluation of a cool, dusky painful left leg. CTA
showed occlusion of the left common iliac and left external
iliac arteries as well as the left anterior tibial artery is
occluded distal to the level of the
occluded femoral-anterior tibial bypass graft. There is transit
occlusion of
the left posterior tibial artery distally with reconstitution
above the ankle.
The left peroneal artery is patent to the level of the ankle.
After review of the CT scan, we discussed with Mr ___ that
there are no other endovascular or surgical intervention to
restore circulation to the left leg. We also discussed that if
the ischemic pain becomes intolerable and he develops an
infection or wound in the left foot or leg, an above the knee
amputation would be an option. Lovenox as well as other usual
medications should be continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) ___ mg PO TID pain
2. Pregabalin 100 mg PO TID
3. Ranitidine 150 mg PO BID
4. Simvastatin 40 mg PO QPM
5. Aspirin 81 mg PO DAILY
6. LORazepam 1 mg PO QHS:PRN insomnia
7. Enoxaparin Sodium 70 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. Enoxaparin Sodium 70 mg SC BID
Start: Today - ___, First Dose: Next Routine Administration
Time
4. LORazepam 1 mg PO QHS:PRN insomnia
5. OxycoDONE (Immediate Release) ___ mg PO TID pain
6. Pregabalin 100 mg PO TID
7. Ranitidine 150 mg PO BID
8. Simvastatin 40 mg PO QPM
9. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Arterial Disease with left leg critical limb
ischemia.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were transferred to ___ from an OSH with a cool, painful
leg. We did a CT scan that showed occlusion/blockage to the
level of the
occluded femoral-anterior tibial bypass graft as well as
occlusion/blockage of the left posterior tibial artery.
Unfortunately, after a conference with Dr. ___ his
colleagues, we have concluded that there are no other
endovascular or surgicial options to restore blood flow to your
foot.
We also discussed that if the ischemic pain becomes intolerable
or you develop an infection or wound in the left foot or leg, an
above the knee amputation would be an option. You should
continue lovenox as well as your other usual medications.
Please follow up with Dr. ___ oncologist as previous
arranged next week for symptom management.
Followup Instructions:
___
|
19918888-DS-6 | 19,918,888 | 22,777,662 | DS | 6 | 2135-11-24 00:00:00 | 2135-11-24 12:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
L hip femoral neck fracture
History of Present Illness:
The patient is a healthy active ___ yo M who presents with L hip
pain after a fall from a bike. He was cycling with a friend when
he stopped and the friend crashed into the back of his bike
falling on top of him. He experience immediate L hip pain. He
denies head strike or LOC. He was taken to OSH where xrays
showed L femoral neck fracture and he was transferred to ___
for further management. He denies numbness or paresthesias in
the L leg. No previous L hip pain.
Past Medical History:
none
Social History:
___
Family History:
nc
Physical Exam:
AFVSS
GEN: NAD, A&Ox3
LLE:
Skin intact with out abrasions
No erythema, ecchymosis or gross deformity
Leg is shortened and externally rotated
No tenderness to palpation of knee or ankle
Tender to palpation over L hip
SILT DP/SP/S/S
___
2+ ___
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a L femoral neck fracture. The patient was taken to
the OR and underwent an uncomplicated open reduction internal
fixation. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
The patient was transfused 0 units of blood for acute blood loss
anemia.
Weight bearing status: touch down weight bearing.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
please inject subcutaneaously into your abdomen
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L femoral neck fracture
Discharge Condition:
stable
Discharge Instructions:
Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
touch down weigh bearing left lower extremity
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively.
Followup Instructions:
___
|
19918916-DS-21 | 19,918,916 | 28,208,760 | DS | 21 | 2164-08-27 00:00:00 | 2164-08-27 13:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Trouble speaking, slurred speech, and right sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo RH woman with history of prior stroke and
residual left sided weakness who fell at work and was found to
have trouble speaking, slurred speech, and right sided weakness
at 1245 on ___ (fall was witnessed on a video surveillance
camera). CT Head negative for hemorrhage, CT C-spine negative
for
fracture. NIHSS 4 (right facial droop, aphasia, dysarthria),
labetalol 20 mg IV given for BP control (230/112-> 135/108),
then
tPA given at 1524. On re-evaluation, NIHSS 5 (right leg drift).
Nicardipine gtt started to maintain BP <180/105, then stopped
when BP dropped to 105/78.
The patient was transferred to ___ for further care. On
arrival, NIHSS 9 (see above). Repeat CT head did not show
hemorrhage, but did show new hypodensity in left midbrain and
thalamus, likely acute evolving infarct. CTA did not show vessel
cutoff. In ED, nicardipine gtt was restarted for SBP 198.
Past Medical History:
HTN
DM
Stroke (with residual left hand clumsiness and left leg
weakness-walks with a brace)
Social History:
___
Family History:
Unknown
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
OSH: ___, 230/112, 84, 16, 97%
75, 152/86, 22, 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, able to state name and ___ but forms a
sentence of word salad when asked where she is or what the year
is. Able to follow most simple commands to complete the
neurological examination, occasionally requires prompting. Has
word salad with neologisms when describing the ___ jar
picture. Unable to name any items on the stroke card. Unable to
repeat. Able to read some short sentences but not others. Recall
was unable to be tested due to aphasia. Patient also had
variable
dysarthria, occasionally extremely severe and other times
absent.
-Cranial Nerves:
I: Olfaction not tested.
II: R pupil 3.5mm, L 3mm, both reactive. right visual field cut.
III, IV, VI: Preserved upgaze, downgaze and left gaze. Able to
cross midline but not completely bury sclera on the right.
V: Facial sensation grossly intact bilaterally
VII: No facial droop but decreased eye blink on right, facial
musculature symmetric and ___ strength in upper and lower
distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Right pronator drift
bilaterally. Left hand and left whole leg occasional brief
tremulous movements, coarse, suppressible. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ 3 4+ ___ 5 4+ 4+ 5 5
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 3+ 3+ 3+ 4 4
R 3 3 3 3 2
- Plantar response was extensor bilaterally.
- Pectoralis Jerk was present L>R, and Crossed Adductors are
present L>R.
- left ankle clonus
-Sensory: No deficits to light touch, pinprick throughout. No
extinction to DSS.
-Coordination: No intention tremor noted. No dysmetria on FNF
bilaterally
-Gait: not tested - s/p tPA.
=========================
DISCHARGE PHYSICAL EXAM
=========================
Upon discharge, she was able to name and repeat. She can
intermittently speak fluently but does have significant
paraphasic errors and word salad, often at the end of sentences.
She comprehends complex commands. She has a L drift with 4+/5
strength in the L delt, tri, and finger extensors; ___ L ECR
with otherwise full strength.
Pertinent Results:
========
LABS
========
___ 12:50AM BLOOD cTropnT-<0.01
___ 05:45PM BLOOD Lipase-43
___ 12:50AM BLOOD %HbA1c-9.1* eAG-214*
___ 12:50AM BLOOD Triglyc-96 HDL-49 CHOL/HD-4.9
LDLcalc-171*
___ 12:50AM BLOOD TSH-2.5
___ 06:36PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
==========
IMAGING
==========
MRI BRAIN WITHOUT CONTRAST (___): Acute left basal ganglia
and hypothalamic infarct.
ECHO (___): Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
No valvular pathology or pathologic flow identified. No definite
structural cardiac source of embolism identified.
NCHCT (___):
1. No acute hemorrhage.
2. Re-demonstration of hypodensity within the left internal
capsule remains concerning for acute infarction.
CTA HEAD/NECK (___):
1. Focal hypodensity in the posterior limb of the left internal
capsule is
concerning for an area of acute infarction.
2. No intracranial hemorrhage.
3. Patent intracranial vasculature with no evidence of aneurysm
formation,
stenosis or dissection.
4. Patent cervical vasculature with 33% stenosis of the left
internal carotid artery by NASCET criteria.
5. Mild sinus inflammatory disease as described above.
Brief Hospital Course:
Ms. ___ is a ___ year old right handed woman with a past
medical history of a prior infarct with residual left sided
weakness who presented ___ with acute onset aphasia, dysarthria
and right sided weakness. She initially presented to an outside
hospital where she received IV tPA at 1524 (see HPI for further
details). She was then transferred to ___ for further
management.
At ___ showed early hypodensity in left midbrain and
thalamus. CTA H/N showed 33% stenosis of the left internal
carotid artery and was otherwise unremarkable. As SBP was >180,
she was placed on a nicardipine drip while in the ED. She was
then admitted to the neurology ICU for post-tPA care. Of note,
while in the ED, she had a repeat NCHCT for altered mental
status that was unchanged from prior.
While in the ICU, the nicardipine was discontinued and BP
remained at goal <180/105. Pt was clinically monitored and her
right sided weakness resolved and her aphasia and dysarthria
persisted but improved, and she had intact comprehension,
naming, and repetition with intermittent paraphasic errors and
word salad on the day of discharge. Her 24hr post-tPA imaging
(MRI) revealed an acute left basal ganglia and hypothalamic
infarct. Following this imaging, she was started on aspirin 81mg
daily and atorvastatin 80mg daily for secondary stroke
prevention and transferred out of the ICU to the floor.
Her stroke was felt to be related to small vessel disease. Pt
was hypertensive while in the hospital and also had a LDL of 171
and A1C of 9.1%. She denied taking any medications at home prior
to presentation or seeing a PCP in years (this was confirmed by
calling ___ ___ who stated pt hadn't
had an appointment since ___. Cardioembolus was less likely as
pt did not have any atrial fibrillation while in the hospital
and echocardiogram did not show any intracardiac thrombus.
However, she will be sent home on ___ cardiac
monitor to monitor for any arrhythmias.
___ was consulted to assist with diabetic management who
recommended starting Metformin 500mg BID. She is on a sliding
Humalog insulin scale that can be titrated as tolerated at rehab
in addition to lantus.
She had significant orthostasis thought to be ___ deconditioning
and autonomic dysfunction from diabetes. She did have an episode
of vasovagal syncope ___ but was able to stand with ___ with
improved orthostasis on day of discharge and was asymptomatic.
She was started on captopril 12.5mg qHS that can be uptitrated
to 25mg qHS on ___ for hypertension, but dosed at night given
orthostasis. Additionally, low dose midodrine 2.5-5mg can be
considered prior to rehab to decrease symptoms in addition to
increased hydration. If given, please give 1 hour prior to ___
and have her stand or sit upright for at least ___ hours after
dose as she has hypertension and a recent stroke.
She was evaluated by ___ and will be discharged to acute rehab
and subsequent outpatient speech therapy.
TRANSITION ITEMS:
1. Establish care for DM and HTN management, PCP appt scheduled.
2. Follow-up BP and blood glucose at rehab. Patient with
orthostasis likely ___ autonomic dysfunction in the setting of
diabetes -- increased hydration, moderate salt intake, and qHS
ACE inhibitor can be titrated at rehab. Additionally, low dose
midodrine 2.5-5mg can be considered prior to rehab to decrease
symptoms in addition to increased hydration. If given, please
give 1 hour prior to ___ and have her stand or sit upright for at
least ___ hours after dose as she has hypertension and a recent
stroke.
3. UA could not be checked prior to discharge, though
asymptomatic. Please check at rehab to assure absence of UTI.
=
=
=
=
=
=
=
=
=
=
================================================================
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
=
=
=
=
=
=
=
=
=
=
================================================================
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(X) Yes - () No
4. LDL documented? (X) Yes (LDL = 171) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (X) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (X) No [reason
(X) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? (X) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X) Yes [Type: (X)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (X) N/A
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Senna 8.6 mg PO BID constipation
7. Outpatient Speech/Swallowing Therapy
434.___ Stroke
PCP: ___ ___ ___
8. Captopril 25 mg PO QPM
9. Glargine 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of word finding
difficulties and confusion resulting from an ACUTE ISCHEMIC
STROKE, a condition where a blood vessel providing oxygen and
nutrients to the brain is blocked by a clot. The brain is the
part of your body that controls and directs all the other parts
of your body, so damage to the brain from being deprived of its
blood supply can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- high blood pressure
- high cholesterol
- diabetes
We are changing your medications as follows:
- aspirin 81mg daily
- metformin 500mg twice daily + lantus insulin
- atorvastatin 80mg daily
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
It was a pleasure taking care of you, and we wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19918916-DS-22 | 19,918,916 | 20,063,422 | DS | 22 | 2167-04-12 00:00:00 | 2167-04-12 21:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dysarthria and left leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ right-handed woman with history
notable for DMII, HTN, prior right pontine infarct c/b left hand
clumsiness and left leg weakness) as well as left basal ganglia
and hypothalamic infarct (___) transferred from ___
___ after presenting with dysarthria and left leg weakness.
History is limited by Ms. ___ aphasia at time of
evaluation, but per review of ___ records, she reported onset of
dysarthria as well as gait disturbance ("difficulty making her
left leg work correctly") while walking uphill at 16:45. Her
symptoms resolved with rest, but due to concern for an infarct,
she activated EMS, who found her to be hypertensive and brought
her to ___. There, she presented with SBP of 221/118 but was
asymptomatic; she was started on a nicardipine infusion and
underwent CT/CTA. Following completion of her imaging, she was
hypertensive to 256/125 and experienced intermittent aphasia,
which improved with reduction of her BP to 169/63. She developed
right hemiparesis and aphasia at 19:40 with SBP back up to
236/142, which resolved with SBP reduction to 147/126 at 20:04.
She experienced unspecified recurrent symptoms with SBP 182/102
at 20:23 prior to transfer.
On arrival at ___, Ms. ___ had a BP of 127/82, and was
able to relate part of her history with some dysarthria per ED
report. She was noted to have mild left-sided weakness felt to
be at her baseline, but was otherwise asymptomatic, with ED
NIHSS of 1. At time of neurology evaluation, within ___ minutes,
Ms. ___ was hypertensive to the 190s and was noted to be
aphasic with right hemiparesis (as noted below). Despite further
reduction of her
blood pressures, no improvement in her examination was noted.
Unable to obtain ROS due to aphasia.
Past Medical History:
HTN
DM
Stroke (with residual left hand clumsiness and left leg
weakness-walks with a brace)
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 97.4 HR: 121 BP: 127/82 RR: 17 SpO2: 95% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: regular, tachycardic
Pulmonary: upper airway rhonchi
Abdomen: Soft, ND
Extremities: BLE edema
Neurologic Examination:
- Mental status: Awake, alert, regards and tracks examiner, able
to respond to questions appropriately by raising thumb (in so
doing following midline and appendicular commands). No speech
output.
- Cranial Nerves: PERRL (3 to 2 mm ___. VF full to hand
movement.
EOMI. No facial movement asymmetry. Hearing intact to
conversation. Tongue midline.
- Motor: Able to provide some antigravity effort with marked
drift in LUE, no voluntary movement of RUE/RLE/LLE.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1+ 0
R 1+ 1+ 1+ 1+ 0
- Sensory: No deficits to light touch or pinprick bilaterally.
- Coordination: No gross dysmetria out of proportion to weakness
in LUE.
- Gait: Unable to assess.
DISCHARGE EXAM:
===============
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: regular, tachycardic
Pulmonary: upper airway rhonchi
Abdomen: Soft, ND
Extremities: no edema
Back: sacral pressure ulcer
Neurologic Examination:
- Mental status: Awake, alert, regards and tracks examiner, able
to respond to questions appropriately by raising thumb (in so
doing following midline and appendicular commands). No speech
output.
- Cranial Nerves: PERRL, slight anisicoria, EOMI with bilateral
end gaze nystagmus. VF full to hand movement. EOMI. Slight
activation of the left face with smiling. Hearing intact to
conversation. Tongue midline.
- Motor: Able to provide some antigravity effort with marked
drift in LUE (Delt ___, Bi ___, Tri ___, WE ___, FE ___, FF
___, no voluntary movement of RUE/RLE/LLE.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1+ 0
R 1+ 1+ 1+ 1+ 0
- Tone: spasticity of the ___
- Sensory: No deficits to light touch or pinprick bilaterally.
reports pain with light touch in the lower extremities
- Coordination: No gross dysmetria out of proportion to weakness
in LUE.
- Gait: Unable to assess.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:02PM TYPE-ART PO2-72* PCO2-38 PH-7.44 TOTAL CO2-27
BASE XS-1
___ 07:00AM GLUCOSE-182* UREA N-8 CREAT-0.7 SODIUM-141
POTASSIUM-3.4* CHLORIDE-106 TOTAL CO2-26 ANION GAP-9*
___ 07:00AM CALCIUM-8.7 PHOSPHATE-3.0 MAGNESIUM-1.8
CHOLEST-213*
___ 07:00AM TRIGLYCER-79 HDL CHOL-48 CHOL/HDL-4.4
LDL(CALC)-149*
___ 07:00AM WBC-8.9 RBC-4.34 HGB-13.1 HCT-39.5 MCV-91
MCH-30.2 MCHC-33.2 RDW-12.6 RDWSD-42.2
___ 07:00AM PLT COUNT-225
___ 11:47PM %HbA1c-8.2* eAG-189*
___ 10:55PM URINE HOURS-RANDOM
___ 10:55PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 10:55PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 10:55PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-TR*
GLUCOSE-1000* KETONE-40* BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 10:55PM URINE RBC-7* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:55PM URINE MUCOUS-RARE*
___ 10:15PM LACTATE-1.1
___ 10:05PM GLUCOSE-240* UREA N-8 CREAT-0.7 SODIUM-137
POTASSIUM-3.5 CHLORIDE-102 TOTAL CO2-23 ANION GAP-12
___ 10:05PM estGFR-Using this
___ 10:05PM ALT(SGPT)-30 AST(SGOT)-27 ALK PHOS-150* TOT
BILI-0.6
___ 10:05PM LIPASE-26
___ 10:05PM cTropnT-<0.01
___ 10:05PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-2.4*
MAGNESIUM-1.8
___ 10:05PM TSH-4.3*
___ 10:05PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 10:05PM WBC-9.3 RBC-4.74 HGB-14.2 HCT-43.3 MCV-91
MCH-30.0 MCHC-32.8 RDW-12.4 RDWSD-41.2
___ 10:05PM NEUTS-78.9* LYMPHS-11.6* MONOS-7.6 EOS-0.9*
BASOS-0.6 IM ___ AbsNeut-7.30* AbsLymp-1.07* AbsMono-0.70
AbsEos-0.08 AbsBaso-0.06
___ 10:05PM PLT COUNT-222
IMAGING:
========
CT HEAD ___:
1. No acute findings.
2. Chronic infarct left thalamus, basal ganglia, internal
capsule, similar.
CXR ___:
Study limited by patient positioning on the lateral view. There
are low lung volumes. There is no focal consolidation, pleural
effusion or pneumothorax. The cardiomediastinal silhouette is
within normal limits. No acute osseous abnormalities are
identified.
MRI HEAD WITHOUT CONTRAST ___:
1. Moderate size acute infarct left pons. Punctate acute/early
subacute
infarcts left temporal lobe, left internal capsule.
2. Chronic infarcts left thalamus, internal capsule, globus
pallidus, and
right pons.
3. No hemorrhage.
4. Remainder as above.
CXR ___:
Comparison to ___. The patient has received a
nasogastric tube. The tip of the tube projects over the
proximal parts of the stomach. Moderate cardiomegaly persists.
Lung volumes are low. No pulmonary edema. No pleural
effusions. No pneumothorax.
RUE ULTRASOUND ___:
There is normal flow with respiratory variation in the bilateral
subclavian vein. The right internal jugular, axillary and
brachial veins are patent, show normal color flow and
compressibility. The right basilic and cephalic veins are
patent, compressible and show normal color flow.
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
TTE ___:
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. Overall
left ventricular systolic function is normal. The visually
estimated left ventricular ejection fraction is >=60%. There is
no resting left ventricular outflow tract gradient. Normal right
ventricular cavity size
with normal free wall motion. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic valve leaflets (3) appear structurally
normal. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid regurgitation. The
pulmonary artery systolic pressure could not be estimated. There
is a trivial pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and global
biventricular systolic function. No definite valvular pathology
or pathologic flow identified. No definite structural cardiac
source of embolism identified. Compared with the prior TTE
(images reviewed) of ___, the findings are similar.
PORTAL ABDOMINAL X-RAY ___:
Severely limited study secondary to habitus and telemetry leads.
NG tube is seen with the side port at the GE junction and the
tip in the body of the stomach, recommend advancement by 5 cm.
CXR ___:
Frontal view centered at the diaphragm shows nasogastric
drainage tube ending in the upper portion of a nondistended
stomach.
CTA C/A/P ___ (obtained for malignancy screening
1. 4 cm left adnexal soft tissue lesion for which pelvic
ultrasound is
recommended. 2. Nonspecific hypodense lesion in relation to the
proximal vagina. Clinical
correlation advised.
3. 15 mm left adrenal nodule is indeterminate.
4. Mild pneumoperitoneum likely related to recent gastrostomy
tube placement.
5. Reference is made to CT chest report of the same day for
chest findings.
PELVIC ULTRASOUND ___
IMPRESSION:
1. 4.0 x 3.6 x 3.5 cm complex cyst with low level internal
echoes and
reticular, lace-like areas of echogenicity, likely hemorrhagic
cyst. No
demonstrable internal vascularity. Follow-up pelvic ultrasound
in 3 months
versus nonemergent pelvic MRI for further characterization.
2. Homogeneous thickening of the endometrium in this
postmenopausal patient,
measuring 9 mm. Recommend endometrial biopsy for further
evaluation as
neoplasia cannot be excluded.
RECOMMENDATION(S):
-Pelvic ultrasound in ___ year to ensure stability of complex
cysts versus
nonemergent MRI of the pelvis to further characterize.
-Thickened endometrium for which endometrial biopsy is
recommended.
Brief Hospital Course:
PATIENT SUMMARY:
================
Ms. ___ is a ___ right-handed woman with history
notable for DMII, HTN, prior right pontine infarct c/b left hand
clumsiness and left leg weakness as well as left basal ganglia
and hypothalamic infarcts (___) transferred from ___
___ after presenting with dysarthria and left leg
weakness
subsequently found to have new infarcts of the left pons, left
temporal lobe, and left internal capsule.
Her exam is notable for grossly preserved mental status with
severe oropharyngeal weakness (rendering her unable to speak),
bilateral facial weakness, right sided hemiparesis, and lead
pipe rigidity in the legs.
The paramedian pontine location of her brainstem stroke is most
consistent with hypertensive disease. It is hard to say whether
or not the other strokes (left temporal lobe and left internal
capsule) are also acute as there is no ADC correlate.
Unfortunately, given her prior right pontine infarct and now new
left pontine infarct, the patient is clinically locked in. She
regained her strength distally in the left hand and arm over the
course of her hospitalization. She worked with speech, ___, OT.
For stroke risk factor optimization she was continued on ASA 81
and Atorva 81. Alc 8.2, LDL 149, TSH 4.3
Other medical issues during this hospital course included:
1) Bacteremia with enterococcus for which he completed a course
of ampicillin on ___, thought secondary to cellulitis on her
arm
2) E.Coli UTI I/s/o foley catheter (CAUTI) for which she was
started on ceftriaxone on ___ to complete at 7 day course
(___)
3) Upper GI bleed which occurred ~ ___ that was secondary to
ulceration around the PEG tube. She was given Protonix and tube
feeds were held. She did not require transfusion. Her hemoglobin
recovered well to 9s
4) PEG tube placed ___
5) You developed spasticity and neuropathic pain which was
treated with baclofen, Tizanidine, and gabapentin
TRANSITIONAL ISSUES:
====================
[] Neurology follow up in stroke clinic, ___
[] Pelvic ultrasound in ___ weeks follow up by clinic
appointment. Call ___ to schedule these appointments
[] Daily Ceftriazone through ___ for E Coli CAUTI
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 149) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - If no, why not (I.e.
bleeding risk, etc.) (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Lisinopril 30 mg PO DAILY
5. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eye
2. Baclofen 5 mg PO TID
3. CefTRIAXone 1 gm IV Q24H Duration: 7 Doses
to be continued through ___. Gabapentin 400 mg PO BID
5. Gabapentin 600 mg PO QHS
6. Glargine 9 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
7. omeprazole 20 mg PEG BID
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second
Line
9. Tizanidine 4 mg PO TID
10. Aspirin 81 mg PO DAILY
11. Atorvastatin 80 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke
Hypertension
Diabetes
Hyperlipidemia
Discharge Condition:
Non verbal, answers yes/no with thumbs up/down
Non ambulatory
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of trouble speaking and
leg weakness resulting from an ACUTE ISCHEMIC STROKE, a
condition where a blood vessel providing oxygen and nutrients to
the brain is blocked by a clot. The brain is the part of your
body that controls and directs all the other parts of your body,
so damage to the brain from being deprived of its blood supply
can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- Hypertension
- Diabetes
- Hyperlipidemia
You also had stomach ulcers which caused bleeding therefore you
were started on an acid blocker. You had a blood stream
infection and received antibiotics. You also got a urinary tract
infection that you are getting antibiotics for. Your legs
developed spasticity and neuropathic pain from your strokes so
you were given medicine, gabapentin, Tizanidine, and baclofen to
help with this.
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19918917-DS-18 | 19,918,917 | 20,083,057 | DS | 18 | 2127-06-08 00:00:00 | 2127-06-09 11:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p blunt abdominal trauma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Otherwise healthy ___ yo M presents 11 hours s/p a handlebar
injury to the LUQ of his abd after a fall while riding his
bicycle. No LOC, no head strike, full recall. Presented to OSH
where was found to have abrasion on his abd, stable vitals,
normal lipase, but a CT scan read as concerning for serval foci
of free fluid consistent w blood, and several specks of free
air.
Thus transfered to ___ for trauma surgery eval.
While he initially had pain at the area of the handlebar strike,
this has subsided. Now, he reports pain only at the skin. Denies
fevers, chills, rigors.
Past Medical History:
None
PSH:
Bilateral inguinal hernia repairs appx age ___
Social History:
___
Family History:
N/C
Physical Exam:
Admit PE:
VS: 98.1 55 130/70 16 100%RA
GEN: NAD, well-appearing, A&Ox3, GCS 15, not in c-collsr.
HEENT: NC/AT, EOMI, PERRLA ___
Chest: Atraumatic, nontender
Abd: 3x3cm abrasion circular over LUQ which is tender to direct
palpation but non-tender peripherally. Abd otherwise soft and
completely nontender.
Ext: MAEW, atraumatic
Back: No posterior signs of trauma on the spine or back.
Discharge PE:
VS: 98.1 57 120/67 18 98%RA
GEN: NAD, WA, A&Ox3
HEENT: MMM, no scleral icterus
CV: RRR, WWP
Pulm, Clear, normal WOB
Abd: soft, non distended. 3x3cm circular excoriation at LUQ
which is locally TTP. the remainder of the abdomen is NTTP. No
rebound or guarding.
Ext: no CCE
Pertinent Results:
___ 01:15PM BLOOD WBC-10.3* RBC-4.52* Hgb-13.2* Hct-40.6
MCV-90 MCH-29.2 MCHC-32.5 RDW-12.7 RDWSD-41.3 Plt ___
___ 07:05AM BLOOD WBC-8.7 RBC-4.94 Hgb-14.5 Hct-44.5 MCV-90
MCH-29.4 MCHC-32.6 RDW-12.8 RDWSD-42.0 Plt ___
___ 01:15PM BLOOD Neuts-65.4 ___ Monos-10.9
Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.75* AbsLymp-2.35
AbsMono-1.12* AbsEos-0.04 AbsBaso-0.02
___ 01:15PM BLOOD Glucose-101* UreaN-11 Creat-0.8 Na-139
K-3.7 Cl-103 HCO3-27 AnGap-13
___ 07:05AM BLOOD Glucose-93 UreaN-13 Creat-0.9 Na-140
K-4.5 Cl-103 HCO3-28 AnGap-14
___ 01:15PM BLOOD ALT-27 AST-21 AlkPhos-57 Amylase-24
TotBili-1.1 DirBili-0.3 IndBili-0.8
___ 07:05AM BLOOD ALT-22 AST-22 AlkPhos-62 TotBili-0.8
___ 01:15PM BLOOD Lipase-25
___ 07:05AM BLOOD Lipase-29
CXR ___ IMPRESSION: No acute cardiopulmonary process. No
pneumothorax.
Brief Hospital Course:
Mr. ___ is a ___ year old man who was riding his bicycle at ~7
___ on ___ when he lost control the handle bar turned and he
fell and struck the end of the handlebar in his LUQ. He
presented to an OSH and had a CT Scan that showed question of
hemoperitoneum adjacent to his Liver and Spleen and question of
pneumoperitonuem around the pancreas. He had a completely benign
exam and lab values and was transferred to ___ for further
management. He presented to ___ 11 hours after his injury and
on primary survey there were no findings and on secondary only
mild
tenderness at the site of the handlebar strike with a small
superficial abrasion. He denied abdominal pain on exam. After
review of his images demonstrating intact fat planes and in
light of the fact that patient presented 12 hours post injury
with normal labs and otherwise well, the decision was made to
admit him, make him NPO and observe with serial abdominal exams
and trend labs. His abdominal exam and laboratory values
remained normal throughout his admission. HD 2 the patient was
advanced sequentially to a regular diet which he tolerated well.
His abdomen remained benign and he had no leukocytosis, elevated
LFTs or Lipase, or fever/tachycardia.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
none
Discharge Medications:
none
Discharge Disposition:
Home
Discharge Diagnosis:
left abdominal abrasion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You were admitted to ___ and
underwent observation and management. You are recovering well
and are now ready for discharge. Please follow the instructions
below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
19918971-DS-34 | 19,918,971 | 25,439,611 | DS | 34 | 2150-09-12 00:00:00 | 2150-09-14 22:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___ / paper tape
Attending: ___.
Chief Complaint:
Epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o chronic pancreatitis s/p distal
pancreatectomy in ___, SBO s/p lysis of adhesions in ___, and
intermittent colonic pseudo-obstruction who p/w postprandial
abdominal pain with distention, nausea, and diarrhea x1 week.
She has had multiple prior admissions for similar symptoms, most
recently ___, during which time she experienced
abdominal pain with distention and constipation, attributed to
recurrent flare of pseudo-obstruction, and responsive to
conservative management, including IVF, analgesics, and bowel
rest. She reports that she was in her USOH until 1 week PTA,
when she developed sharp postprandial epigastric pain, ___ in
intensity and radiating to the back, with each meal, noting that
the pain is reminiscent of previous exacerbations of chronic
pancreatitis, though discomfort has not been associated with
meals in the past. Over the same period, she has experienced a
6-lb weight loss, abdominal bloating/distention with increased
flatus, postprandial nausea without emesis, and watery,
non-bloody diarrhea, which she indicates is atypical of her
admissions; she does note that onset of diarrhea roughly
corresponds with initiation of standing colace by her GI for
longstanding constipation. She has experienced diarrhea in the
past in the setting of bacterial overgrowth. She reports cutting
out dairy, fructose, sorbitol, and other additives from her diet
approximately 2 weeks ago, but otherwise has made no dietary
changes over the past week, recalling that her PO intake has
been minimal and includes Carnation Instant Breakfast drink with
Lactaid, which she tolerates well, as well as fruit smoothies,
which have caused abdominal discomfort. She denies f/c, chest
pain, melena/BRBPR, or recent sick contacts. She does not drink
EtOH, noting that it causes severe heartburn.
In the ED, initial VS were as follows: 97, 82, 128/74, 16, 99%
RA. Admission labs were notable for wbc of 17.2, normal LFTs
with the exception of alkaline phosphatase to 139, and normal
lipase. She received morphine 5mg IV x2, ondansetron 2mg IV x2,
and Dilaudid 1mg IV x1. VS prior to transfer were as follows:
97.7, 73, 124/71, 16, 100% RA.
On arrival to the floor, she reports ___ epigastric pain
without nausea following multiple analgesics and ondansetron in
the ED; pain is tolerable to her at present.
Past Medical History:
Idiopathic chronic pancreatitis.
Diabetes mellitus type 2.
Bacterial overgrowth
Generalized bowel dysmotility/Constipation.
Thrombocytosis secondary to splenectomy.
Distal pancreatectomy/splenectomy/cholecystectomy,
pancreaticojejunostomy (Roux-en-Y) for pancreatic
intraepithelial (benign) neoplasm, ___.
Seizure disorder, last seizure ___ years - off seizure meds now
SBO, s/p adhesiolysis, ___.
Hyperlipidemia.
Panic disorder, depression, anxiety.
Basal cell on back s/p removal
Nephrolithiasis.
Left knee arthritis.
Appendectomy.
Renal cyst excision - benign.
Social History:
___
Family History:
There is no known family h/o GI illness.
Physical Exam:
On admission:
VS 98.5 108/70 72 18 99% RA
FSBG 101
GEN Alert, oriented, mildly uncomfortable-appearing in no acute
distress
HEENT MMM EOM grossly intact sclera anicteric, OP clear
NECK supple, no JVD
PULM Good aeration, scattered rhonchi throughout
CV RRR normal S1/S2, no mrg
ABD tympanitic, softly distended, diffusely TTP, particularly in
the epigastric region, normoactive bowel sounds, +voluntary
guarding, +rebound
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
At discharge:
VS 98.7 100/59 61 18 97% RA
GEN Alert, oriented, comfortable-appearing in no acute distress
HEENT MMM EOM grossly intact sclera anicteric, OP clear
NECK supple, no JVD
PULM Good aeration, CTAB
CV RRR normal S1/S2, no mrg
ABD softly distended without fluid wave/shifting dullness, less
TTP, particularly in the epigastric region, normoactive bowel
sounds, no guarding/ rebound
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
On admission:
CBC: 17.2/45.8/501
Lytes: ___
LFTs: ___
At discharge:
CBC: 15.2/43/501
Lytes: ___
KUB (___): No evidence of bowel obstruction or ileus.
CT abdomen/pelvis with contrast (___): No evidence of
obstruction as p.o. contrast is seen flowing freely through to
the large bowel. Unremarkable appearance of the
pancreaticojejunostomy site. Slight post-stenotic dilatation at
the jejunojejunostomy site is grossly unchanged from the prior
study and could be due to a side to side anastomosis.
Brief Hospital Course:
Ms. ___ is a ___ with h/o chronic pancreatitis s/p distal
pancreatectomy in ___, SBO s/p lysis of adhesions in ___, and
intermittent colonic pseudo-obstruction who p/w postprandial
abdominal pain with distention, nausea, and diarrhea x1 week,
due to chronic pancreatitis versus gastrointestinal motility
disorder NOS.
#Epigastric pain/nausea/diarrhea: Patient with known h/o chronic
pancreatitis p/w epigastric pain radiating to the back, largely
symptomatically c/w chronic pancreatitis, with the exception of
postprandial pattern of pain (previously unassociated with
meals) and diarrhea (resolved by admission). Normal lipase and
essentially unremarkable abdominal CT called into question
causal relationship of chronic pancreatitis to presenting
symptoms, though normal lipase potentially could be explained by
chronicity. Although KUB demonstrated air-fluid levels, there
was no e/o obstruction on abdominal CT. Gastrointestinal
motility disorder NOS remained a distinct possibility, given her
complicated GI anatomy. Her symptoms improved with analgesics,
IVF, and bowel rest, and she was tolerating a regular diet, with
appropriate bowel movements by the time of discharge; pancreatic
enzyme replacements and bowel regimen were held while she was
NPO, but were resumed with reinitiation of regular diet. She
remained afebrile/HD stable throughout admission, and abdominal
distention was c/w baseline appearance at discharge.
#Leukocytosis: Leukocytosis (17.2 on admission) likely reflected
chronic pancreatitis versus stress response. She remained
afebrile/HD stable throughout admission, and UA and abdominal CT
were negative for infection. Diarrhea had resolved by the time
of admission. Leukocytosis was largely downtrending over the
course of her hospital stay.
#DM: FSBGs remained well-controlled on Humalog insulin SS. Home
metformin was held in the setting of possible infection and
resumed at discharge.
#Depression/anxiety/panic disorder: Mood remained stable on home
fluoxetine, mirtazapine, and quetiapine.
#HL: Home simvastatin was continued.
#Transitional issues:
-Epigastric pain: Close PCP and GI ___ were arranged.
-Leukocytosis: Wbc was mildly elevated at discharge without
signs of infection, and repeat CBC may be useful at PCP
___.
Medications on Admission:
1. Amphetamine Salt Combo *NF* (amphetamine-dextroamphetamine) 5
mg Oral BID
At 8am and 12noon
2. Fluoxetine 20 mg PO QAM
3. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN pain
4. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
5. Zenpep *NF* (lipase-protease-amylase) 25,000-85,000- 136,000
unit Oral tid
6 capsules at each meal
6. Lorazepam 3 mg PO BID
7. MetFORMIN (Glucophage) 500 mg PO BID
With dinner
8. Mirtazapine 15 mg PO HS
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 8 mg PO BID:PRN nausea
11. Quetiapine Fumarate 600 mg PO HS
12. Simvastatin 40 mg PO DAILY
13. Zolpidem Tartrate 10 mg PO HS
14. Bisacodyl 5 mg PO BID:PRN constipation
15. Docusate Sodium 250 mg PO DAILY
16. Polyethylene Glycol 17 g PO BID
Discharge Medications:
1. Amphetamine Salt Combo *NF* (amphetamine-dextroamphetamine) 5
mg Oral BID
At 8am and 12noon
2. Docusate Sodium 250 mg PO DAILY
3. Fluoxetine 20 mg PO QAM
4. HYDROmorphone (Dilaudid) 2 mg PO BID:PRN pain
RX *hydromorphone 2 mg 1 tablet(s) by mouth Twice a day Disp
#*16 Tablet Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
6. Lorazepam 3 mg PO BID
7. Mirtazapine 15 mg PO HS
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 8 mg PO BID:PRN nausea
10. Polyethylene Glycol 17 g PO BID
11. Quetiapine Fumarate 600 mg PO HS
12. Simvastatin 40 mg PO DAILY
13. Zolpidem Tartrate 10 mg PO HS
14. Zenpep *NF* (lipase-protease-amylase) 25,000-85,000- 136,000
unit Oral tid
6 capsules at each meal
15. Bisacodyl 5 mg PO BID:PRN constipation
16. MetFORMIN (Glucophage) 500 mg PO BID
With dinner
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic pancreatitis
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
for abdominal pain, thought to be a flare of your chronic
pancreatitis. For this, you had bowel rest, IV fluids, and pain
medications. This improved your pain.
Followup Instructions:
___
|
19918971-DS-39 | 19,918,971 | 26,908,409 | DS | 39 | 2151-10-22 00:00:00 | 2151-10-22 15:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Dilantin Kapseal / paper tape
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ h/o multiple SBOs (2 requiring ex lap and adhesiolysis)
p/w diffuse abd pain and no BM or flatus x 5 days. She has
vomited twice in the past 5 days (4 and 3 days ago). The emesis
was dark, but not bilious. She reports she had been mildly
distended, but became very distended today after taking a
double-dose of Miralax. + low grade temps (100.3).
Past Medical History:
Past Medical History:
Idiopathic chronic pancreatitis.
Diabetes mellitus type 2.
Bacterial overgrowth
Generalized bowel dysmotility/Constipation.
Thrombocytosis secondary to splenectomy.
Seizure disorder, last seizure ___ years - off meds now
SBO
Hyperlipidemia.
Panic disorder, depression, anxiety.
Basal cell on back s/p removal
Nephrolithiasis.
Left knee arthritis.
PSH:
-___ Exploratory laparotomy with adhesiolysis
-Distal pancreatectomy, splenectomy, cholecystectomy,
pancreaticojejunostomy (Roux-en-Y) for pancreatic
intraepithelial
(benign) neoplasm, ___
-BCC excision
-renal cyst excision
-appendectomy
Social History:
___
Family History:
Both of her brothers had prostate cancer, her mother had EtOH
cirrhosis, father with CHF and esophageal cancer
Physical Exam:
On Admission:
97.7 74 129/90 16 97% RA
Gen: NAD, nontoxic appearance
___: RRR
Pulm: CTA b/l
Abd: very distended, tympanitic, diffusely mildly tender -
reportedly worst in epigastrium, + rebound, no guarding,
hypoactive BS
Ext: no c/c/e
Prior Discharge:
VS: 98.5, 60, 97/47, 16, 97% RA
GEN: Pleasant, NAD
CV: RRR, no m/r/g
PULM: CTAB
ABD : Soft nontenderf, nondistended. ols surgical scars healed
well.
EXTR: Warm, no c/c/e
Pertinent Results:
___ 06:50AM BLOOD WBC-9.5 RBC-3.41*# Hgb-10.1*# Hct-30.3*#
MCV-89 MCH-29.7 MCHC-33.5 RDW-13.1 Plt ___
___ 06:50AM BLOOD Glucose-105* UreaN-8 Creat-0.5 Na-137
K-3.9 Cl-102 HCO3-24 AnGap-15
___ 02:25PM BLOOD ALT-16 AST-20 AlkPhos-127* TotBili-0.2
___ KUB:
IMPRESSION:
Nonspecific bowel gas pattern without findings to suggest
obstruction. NG tube side port above the diaphragm and should
be advanced at least several cm for optimal positioning
Brief Hospital Course:
The patient well known for Dr. ___ was admitted to
the General Surgical Service with recurrent small bowel
obstruction. NGT was placed for decompression. KUB demonstrated
nonspecific bowel gas pattern without findings to suggest
obstruction (preliminary read). On HD # 2, patient started to
pass flatus and had two bowel movements. On HD # 3, she
tolerated clamping trial and her NGT was removed. Her diet was
advanced to clears on HD # 4 and progressively advanced to
regular diabetic diet on HD # 6. Patient tolerated diet well and
continue to have regular bowel movements throughout
hospitalization. All her home medications were restarted
including aggressive bowel regiment. Patient was discharged home
in stable condition on HD # 6.
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:
vit B12 1000mcg;, amphetamine salt combo 1", dronabinol 5',
hydroxyzine 25 prn, lidocaine 5% patch, Zenpep 6 caps''', Ativan
1 qAM/2 qPM/3 qhs, metformin 500", mirtazapine 45 qhs,
omeprazole
20', Zofran prn, quetiapine 200 qhs + ___ prn, simvastatin
40',
venlafaxine ER 37.5', Ambien prn, Dulcolax 10", Colace 250",
Miralax 17g"
Discharge Medications:
1. Dronabinol 5 mg PO DAILY
2. HydrOXYzine 25 mg PO BID:PRN anxiety
3. Lorazepam ___ mg PO TID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Mirtazapine 45 mg PO HS
6. Omeprazole 20 mg PO DAILY
7. QUEtiapine Fumarate 200 mg PO QHS
8. Venlafaxine XR 37.5 mg PO DAILY
9. Zolpidem Tartrate 5 mg PO HS
10. Amphetamine Salt Combo (dextroamphetamine-amphetamine) 10 mg
Oral BID
11. Zenpep (lipase-protease-amylase) 25,000-85,000- 136,000 unit
Oral tid
take 6 cap with meals
12. Docusate Sodium 250 mg PO BID
13. Simvastatin 40 mg PO DAILY
14. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN pain
15. Polyethylene Glycol 17 g PO BID
16. QUEtiapine Fumarate 25 mg PO QAM
17. Bisacodyl 10 mg PO BID:PRN constipation
18. Cyanocobalamin 1000 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at ___ for treatment
of your small bowel obstruction. You have done well and are now
safe to return home to complete your recovery with the following
instructions:
.
Please call Dr. ___ office at ___ if you have any
questions or concerns.
.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
19919213-DS-11 | 19,919,213 | 27,654,579 | DS | 11 | 2202-12-27 00:00:00 | 2202-12-27 17:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Clindamycin / Proscar
Attending: ___.
Chief Complaint:
Headache and gait instability
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old male presents to emergency department
complaining of a new severe head pain and unsteady balance which
began overnight. He states he woke up in the middle of the night
to use the bathroom and noticed in the bathroom that his balance
was a little off and he had severe head pain. Patient states
that
this is not a headache but pain on his forehead. He used his
walker to get to the bathroom which he uses at baseline. He
denies falling, or having any type of head injury. Patient
denies
nausea or vomiting, visual changes, weakness or
numbness/tingling
in extremities.
Past Medical History:
- Chronic Renal Insufficiency
- HTN
- CHF
- CAD
- SDH
- HLD
- BPH
- AFib
- MV prolapse
- PNA
- Prolactinemia
- Glaucoma
Social History:
___
Family History:
No Hx of malignancy. Father- MI at age ___, mother: stroke mid
___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
T:98.3 BP:136/65 HR: 83 RR: 24 O2Sats: 96% 2LNC
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRL EOMI
Neck: Supple.
Lungs: Observed normal RR, equal expansion of lungs
Cardiac: Per monitor, Irregular rate and rhythm, history of
A.Fibb
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
DISCHARGE PHYSICAL EXAM
========================
VS: 98.1 Fahrenheit, 88, 113/72, 18, 95% on room air.
Fluid balance: -980 mL ___
General: well appearing, pleasant, thin man in NAD
HEENT: PERRL, EOMI, sclera anicteric, MMM
CV: regular rate and rhythm, no S3/4, holosystolic murmur at
the apex.
Lungs: Bibasilar inspiratory crackles and posterior fields, left
more than right.
Abdomen: soft, NTND, normal BS
GU: condom cath
Ext: WWP, no peripheral or sacral edema.
Neuro: CN grossly intact, no focal deficits, moving all
extremities
Skin: no rash
Pertinent Results:
ADMISSION LAB
==============
___ 10:44AM PLT COUNT-263
___ 10:44AM NEUTS-72.3* LYMPHS-16.7* MONOS-7.5 EOS-2.4
BASOS-0.2 IM ___ AbsNeut-3.37 AbsLymp-0.78* AbsMono-0.35
AbsEos-0.11 AbsBaso-0.01
___ 10:44AM WBC-4.7 RBC-2.71* HGB-8.2* HCT-24.9* MCV-92
MCH-30.3 MCHC-32.9 RDW-16.0* RDWSD-52.4*
___ 10:44AM PEP-NO SPECIFI
___ 10:44AM TOT PROT-6.0*
___ 10:44AM UREA N-33* CREAT-1.2 SODIUM-141 POTASSIUM-4.5
CHLORIDE-97 TOTAL CO2-29 ANION GAP-15
___ 06:24PM URINE U-PEP-ALBUMIN IS
___ 06:24PM URINE HOURS-RANDOM TOT PROT-25
___ 06:35AM PARST SMR-NEGATIVE
___ 06:35AM ___ PTT-35.6 ___
___ 06:35AM PLT COUNT-259
___ 06:35AM NEUTS-79.7* LYMPHS-12.3* MONOS-5.8 EOS-1.2
BASOS-0.2 IM ___ AbsNeut-4.10 AbsLymp-0.63* AbsMono-0.30
AbsEos-0.06 AbsBaso-0.01
___ 06:35AM WBC-5.1 RBC-2.81* HGB-8.4* HCT-26.0* MCV-93
MCH-29.9 MCHC-32.3 RDW-16.3* RDWSD-54.2*
___ 06:35AM WBC-5.1 RBC-2.75* HGB-8.2* HCT-25.5* MCV-93
MCH-29.8 MCHC-32.2 RDW-16.5* RDWSD-54.0*
___ 06:35AM Free K-47.1* Free L-35.3* Fr K/L-1.3 IgG-891
IgA-219 IgM-27*
___ 06:35AM HAPTOGLOB-302*
___ 06:35AM ALBUMIN-3.3*
___ 06:35AM proBNP-5012*
___ 06:35AM cTropnT-0.03*
___ 06:35AM LIPASE-33
___ 06:35AM GLUCOSE-100 UREA N-38* CREAT-1.3* SODIUM-136
POTASSIUM-4.6 CHLORIDE-94* TOTAL CO2-29 ANION GAP-13
___ 06:52AM LACTATE-1.5
___ 06:55AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 06:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 06:55AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:45PM cTropnT-0.02*
___ 09:45PM UREA N-36* CREAT-1.1 POTASSIUM-4.2
PERTINENT INTERVAL LABS
=======================
___ 04:45AM BLOOD Hapto-292*
___ 06:35AM BLOOD FreeKap-47.1* FreeLam-35.3* Fr K/L-1.3
IgG-891 IgA-219 IgM-27*
DISCHARGE LABS
==============
___ 05:45AM BLOOD WBC-3.2* RBC-2.62* Hgb-7.8* Hct-23.9*
MCV-91 MCH-29.8 MCHC-32.6 RDW-16.7* RDWSD-54.0* Plt ___
___ 05:45AM BLOOD Glucose-79 UreaN-28* Creat-1.0 Na-140
K-4.1 Cl-98 HCO3-29 AnGap-13
___ 05:45AM BLOOD Calcium-7.7* Phos-3.6 Mg-2.2
IMAGING
=======
___ CT HEAD W/O CONTRAST
1. New small right frontal subdural acute to early subacute
hemorrhage.
Remainder as above.
___ CHEST (PA & LAT)
Increased bilateral interstitial markings suggestive of severe
bilateral
interstitial pulmonary edema. Small bilateral pleural
effusions.
___ CT HEAD W/O CONTRAST
1. No significant interval change in acute to subacute on
chronic subdural
hematoma/effusion over the right frontal region. No new foci of
hemorrhage.
___ CXR
No interval changes since ___.
Brief Hospital Course:
Mr. ___ is a ___ yo man with a history of atrial tachy
arrhythmias (atrial fibrillation s/p cardioversion in ___,
flutter, and atrial tachycardia) on Warfarin, MVP, severe MR,
and diastolic CHF, who presented to the ED with headache & gait
instability, and was found to have a spontaneous subdural
hematoma on head CT, and was then transferred to medicine for
management of hypoxemia in the setting of pulmonary edema. NHCT
X2 showed stable SDH and patient was managed non-surgically. Per
neurosurgery recs, he was restarted on ASA with Coumadin to be
resumed on ___. Patient also came in with a new O2 requirement
and elevated BNP indicating acute on chronic diastolic heart
failure that was managed with diuresis. Patient also has a
history of stable anemia that will be followed up as outpatient.
At discharge, he was breathing comfortably room air.
ACUTE ISSUES
============
# ___
Pt found to have a SDH on ___ upon admission. Coumadin was
reversed with K Centra. He was closely monitored overnight and
remained stable. Repeat head CT ___ showed no significant
changes. Neurosurgery was consulted. No AED or surgical
intervention was indicated.
# Acute on chronic diastolic heart failure
Patient came in with a new oxygen requirement, elevated BNP
suggestive of acute on chronic dCHF exacerbation. CXR c/w
pulmonary edema. Of note, pt had been recently receiving a
decreased diuretic dose due to hypotension that likely
contributed to worsening of his respiratory status. His
respiratory status has improved with IV Lasix and he was
transitioned to PO Lasix 80 mg upon discharge, and was
encouraged to use incentive spirometery. At discharge, he was
breathing comfortably on room air.
# Atrial fibrillation:
Remained stable this hospitalization with anticoagulation being
held until ___. Metoprolol was fractionated initially and was
discontinued given low HR (50s).
======================
CHRONIC ISSUES
======================
# Anemia
Anemia had unclear etiology with concern for MDS. ___
patient
missed his outpatient hematology appointment on ___, but we
have
arranged for follow up with Dr. ___.
TRANSITIONAL ISSUES
===============================
- Continue Furosemide 80 mg PO daily
- Continue ASA 81 mg PO daily
- On ___ please check serum sodium, potassium, chloride,
bicarbonate, urea, creatinine, and glucose. Titrate Lasix dose
pending BMP.
- To start warfarin ___ at 4 mg daily for 3 days. Check INR
___ and readjust for INR goal of ___.
- Please follow up with Dr. ___ hematology for anemia on
___ at 3:30 ___.
- Considering his increased diuretic requirement, he should have
an echocardiographic evaluation to assess for progression of his
underlying valvular dysfunction.
- Maintain Goal BP <160 and do not give keppra.
# CONTACT: ___ (son) ___
# CODE: Presumed Full
Time spent coordinating discharge > 30 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Docusate Sodium 200 mg PO DAILY:PRN constipation
4. Multivitamins W/minerals 1 TAB PO DAILY
5. Senna 17.2 mg PO QHS:PRN constipation
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QPM
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Simvastatin 20 mg PO QPM
9. sulfacetamide sodium 10 % topical BID
10. cabergoline .25 mg oral 2X/WEEK gynecomastia
11. Furosemide 40 mg PO DAILY
12. Warfarin 2 mg PO DAILY16
13. Famotidine 20 mg PO DAILY Heartburn
14. Sertraline 25 mg PO DAILY
15. Melatin (melatonin) 3 mg oral QHS
Discharge Medications:
1. Furosemide 80 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. cabergoline .25 mg oral 2X/WEEK gynecomastia
5. Docusate Sodium 200 mg PO DAILY:PRN constipation
6. Famotidine 20 mg PO DAILY Heartburn
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QPM
8. Melatin (melatonin) 3 mg oral QHS
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 17.2 mg PO QHS:PRN constipation
12. Sertraline 25 mg PO DAILY
13. Simvastatin 20 mg PO QPM
14. sulfacetamide sodium 10 % topical BID
15. HELD- Warfarin PO DAILY16 This medication was held. Do not
restart Warfarin until ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
====================
- Subdural hematoma
- Acute on chronic diastolic heart failure
SECONDARY DIAGNOSIS
====================
- Acute hypoxemic respiratory failure
- Atrial fibrillation
- Anemia
- BPH
- Hyperlipidemia
- Depression
- Glaucoma
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:
===================================
WHAT BROUGHT YOU INTO THE HOSPITAL
===================================
- You came to ___ because of severe head pain and unsteady
balance. - You also had shortness of breath and fluid in your
lungs.
===================================
WHAT HAPPENED AT THE HOSPITAL?
===================================
- You were seen by the neurosurgery team and received a CT scan
of your brain that showed a small bleed, that was did not
require surgical treatment.
- You received a chest x-ray that showed fluid in your lungs
that was treated with medication. We also rescheduled your
appointment with your hematologist for ___ at 3:30 ___.
==================================================
WHAT NEEDS TO HAPPEN WHEN YOU LEAVE THE HOSPITAL?
==================================================
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- It is very important to continue your water pill, furosemide,
every day at its new dose of 80 mg.
- Follow up with the hematologist on ___ at 1:40 ___
for your decreased blood counts.
Discharge Instructions
Brain Hemorrhage without Surgery
Activity
· We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
· You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
· No driving while taking any narcotic or sedating medication.
· If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
· No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
· ***Please do NOT take any blood thinning medication (
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You are clear to take aspirin at discharge.
· You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
· You may have difficulty paying attention, concentrating, and
remembering new information.
· Emotional and/or behavioral difficulties are common.
· Feeling more tired, restlessness, irritability, and mood
swings are also common.
· Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
· Headache is one of the most common symptom after a brain
bleed.
· Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
· Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
· There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
· Severe pain, swelling, redness or drainage from the incision
site.
· Fever greater than 101.5 degrees Fahrenheit
· Nausea and/or vomiting
· Extreme sleepiness and not being able to stay awake
· Severe headaches not relieved by pain relievers
· Seizures
· Any new problems with your vision or ability to speak
· Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
· Sudden numbness or weakness in the face, arm, or leg
· Sudden confusion or trouble speaking or understanding
· Sudden trouble walking, dizziness, or loss of balance or
coordination
· Sudden severe headaches with no known reason
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19919930-DS-14 | 19,919,930 | 22,621,778 | DS | 14 | 2176-03-05 00:00:00 | 2176-03-05 18:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
Abdominal Pain, Renal Colic
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old Female with diverticulosis, ___ disease and
anxietywho presented to the ED 3 days prior to admission and
found with a ___ small left sided kidney stone who
now presents with recurrent left flank pain. The patient reports
that the pain resolved after discharge, but returned last night.
The patient was concerned as in the past she has had
diverticulitis with microperforations which caused severe flank
pain, and was concerned that this was recurring.
She reports that the pain is primarily located on the Left flank
and left upper quadrant, and is constant. She reports that on
initial presentation was ___ in severity, but overnight has
dropped to ___. Patient did not notice a passed stone before
pain resolved, though she has not strained her urine. She
reports that she was drinking 10 glasses of water at home daily
and was urinating well. She did not take the flomax as she has a
severe sulfa allergy. She was given ibuprofen, but stopped
taking it after she developed dizziness and nausea. She report
chills with the pain, but no fever, nausea, vomiting. She
reports constipation with no BM for 3 days, but is passing
flatus.
Exam: afebrile, vitals normal, +Left CVA tenderness, mild LUQ
abdominal pain, Labs normal, U/A small blood. Given ketoralac,
with improvement of pain. VS on transfer 98.7 °F (37.1 °C),
Pulse: 83, RR: 16, BP: 150/71, O2Sat: 98, O2Flow: ra, Pain:
___.
Past Medical History:
___ Disease
GERD
Benign positional vertigo
B12 deficiency
Diverticulosis
Arthralgia
Hypercholesterolemia
Hx Breast cancer
Osteoporosis
Social History:
___
Family History:
Father deceased when pt ___ yrs old. Nephew with ___ disease
and colostomy
Physical Exam:
ROS:
GEN: - fevers, + Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, + Abdominal Pain, +
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 99.4, 138/74, 79, 18, 97%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: Mild LUQ TTP, ND, +BS, - CVAT, - rebound, - guarding
EXT: - CCE
NEURO: CAOx3, ___, anxious
Discharge Physical Exam
VS 97.1 146/78 76 19 97% RA
eneral: 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, ___, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Left CVA TTP
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAO x 3
Pertinent Results:
___ 05:35AM BLOOD ___
___ Plt ___
___ 01:00PM BLOOD ___
___ Plt ___
___ 01:00PM BLOOD ___
___
___ 05:35AM BLOOD ___
___
___ 01:00PM BLOOD ___
___
___ 05:35AM BLOOD ___
___ 03:00PM URINE ___ Sp ___
___ 03:00PM URINE ___
___
Time Taken Not Noted ___ Date/Time: ___ 12:46 am
URINE Site: NOT SPECIFIED
URINE CULTURE (Pending):
CT ABD & PELVIS W/O CONTRAST Study Date of ___ 4:56 ___
IMPRESSION: Obstructing ___ left UVJ stone with mild
hydroureteronephrosis, unchanged from three days prior.
Brief Hospital Course:
1. Abdominal Pain LUQ due to Nephrolithiasis
- Stone is a very small obstructing stone. It would be unusual
for a stone this small to require lithotripsy.
- The patient cannot take flomax due to the sulfa allergy
- She has an upcoming urology appointment at ___ on ___
- Encourage large volume PO hydration
- Pain control with NSAIDs and Tylenol
2. Chron's Disease
- Mesalamine
3. Anxiety, Depression
- Citalopram
- PRN Ativan
Full Code
Social work consult as patient feels very alone, and clearly is
having trouble coping at home.
Medications on Admission:
- Citalopram 40 mg Oral Tablet TAKE ONE TABLET DAILY
- Prednisolone Acetate 1 % Ophthalmic Drops, Suspension 1 drop
to operated eye two times daily and as directed by physician
- ___ 0.5 mg Oral Tablet Take 1 tablet every 8 hours as
needed for anxiety
- PREDNISOLONE ACETATE (PRED FORTE OPHT) twice a day in left eye
___ Wipes 4 gram/60 mL Rectal Kit use 1
rectally AT BEDTIME
- Mesalamine (ASACOL) 400 mg Oral Tablet, Delayed Release (E.C.)
Take 12 tabs daily or as directed
- METHYLCELLULOSE (CITRUCEL ORAL) 2 tabs daily
- FOLIC ACID ORAL 2 tabs daily
- VITAMIN ___ 500 MCG TAB (CYANOCOBALAMIN) 1 by mouth once
daily
- CALCIUM CARBONATE TABLET 1.25G PO 500 mg cal bid
- MULTIVITAMIN ___ CAPSULE PO Daily
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. Cyanocobalamin 500 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lorazepam 0.5 mg PO Q8H:PRN anxiety
5. Mesalamine ___ 1200 mg PO TID
6. Naproxen 500 mg PO Q8H:PRN pain
RX *naproxen 500 mg 1 Tablet(s) by mouth every eight (8) hours
Disp #*21 Tablet Refills:*0
7. Omeprazole 20 mg PO DAILY gastric ulcer prophylaxis for NSAID
use
RX *omeprazole 20 mg 1 Capsule(s) by mouth daily Disp #*1
Capsule Refills:*0
8. calcium carbonate *NF* 500 mg calcium (1,250 mg) Oral BID
9. Citrucel *NF* (methylcellulose (laxative);<br>methylcellulose
(with sugar)) 0 ORAL DAILY
10. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
Discharge Disposition:
Home
Discharge Diagnosis:
Nephrolithiasis
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 because you were having left
flank pain. A CAT scan was completed which showed stable and
migrating kidney stone. You will need to remain well hydrated
while this passes. You are being given a medication to help with
your pain. Please be sure to take this with food as to prevent
stomach irritation.
You will need to follow up with your PCP. (see below)
Followup Instructions:
___
|
19919951-DS-19 | 19,919,951 | 25,997,087 | DS | 19 | 2139-12-27 00:00:00 | 2139-12-28 10:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
RhoGam
Attending: ___.
Chief Complaint:
lower abdominal pain
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, sigmoid resection and
___ colostomy
History of Present Illness:
HPI: ___ without medical care for ___ years p/w crampy lower
abdominal pain, nausea, vomiting, rectal bleeding, and decreased
stool caliber. Past 6 months, diarrhea and decreased stool size.
Past month, intermittent LLQ pain (___) alleviated by flatus.
Past 3 weeks, "clear pink white pus" per rectum. Previous 24
hours, increased quantity/blood from rectal discharge, new
"lower
crampy abdominal pain" (___) w/ abdominal distension alleviated
by flatus/burping, and new vomiting/nausea. Most recent BM was 3
days ago. Currently passing flatus.
Past Medical History:
none
Social History:
___
Family History:
nc
Physical Exam:
Physical Exam: upon admission: ___:
Vitals: 99.8, 122, 147/92, 16, 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, distended & tympanitic, nontender, no rebound/
guarding, normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Physcial examination upon discharge:
vital signs: t= 98.4, bp=152/88, hr=88, resp. rate 18, oxygen
sat=95% room air
General: NAD
CV: Ns1, s2, -s3, -s4
Lungs: Diminshed BS bil.
Abdomen: soft, ostomy left side with mild retraction of stoma,
stoma dark red, staple line clean, no erythema
Neuro: alert and oriented x 3, speech clear, no tremors
EXT: lower ext. cool, + dp bil., no calf tenderenss bil.
Pertinent Results:
___ 07:46AM BLOOD WBC-8.1 RBC-5.04 Hgb-13.8 Hct-40.6
MCV-81* MCH-27.4 MCHC-34.0 RDW-14.7 Plt ___
___ 01:00PM BLOOD WBC-9.1 RBC-5.14 Hgb-13.8 Hct-41.3
MCV-81* MCH-26.8* MCHC-33.3 RDW-14.7 Plt ___
___ 08:50PM BLOOD WBC-8.6 RBC-5.78* Hgb-15.7 Hct-46.8
MCV-81* MCH-27.1 MCHC-33.5 RDW-14.7 Plt ___
___ 08:50PM BLOOD Neuts-80.0* Lymphs-13.4* Monos-5.2
Eos-0.8 Baso-0.5
___ 07:46AM BLOOD Plt ___
___ 08:19AM BLOOD Glucose-100 UreaN-11 Creat-0.4 Na-134
K-4.6 Cl-101 HCO3-25 AnGap-13
___ 07:46AM BLOOD Glucose-112* UreaN-14 Creat-0.5 Na-135
K-4.1 Cl-95* HCO3-33* AnGap-11
___ 08:50PM BLOOD ALT-17 AST-21 AlkPhos-85 TotBili-0.6
___ 08:19AM BLOOD Calcium-8.3* Phos-2.3* Mg-2.2
___ 09:20PM BLOOD Lactate-2.1*
___: EKG:
Sinus tachycardia. Right bundle-branch block. Left anterior
hemiblock. Notching in lead II on the downslope requires
exclusion of inferior wall myocardial infarction, although there
are no other criteria for that diagnosis.
___: cat scan of abdomen and pelvis:
IMPRESSION:
1. Circumferential wall thickening of the sigmoid colon with a
probable
hyperenhancing intraluminal mass lresulting in a large bowel
obstruction.
2. Prominence of the intrahepatic bile ducts within the left
lobe of the
liver. No discrete liver mass identified on this single phase
study.
3. Cholelithiasis without evidence of acute cholecystitis.
___: chest x-ray:
IMPRESSION:
1. Probable mild cardiomegaly.
2. Minimal patchy opacity left base. While this likely
represents
atelectasis, in the appropriate clinical setting, the
differential diagnosis could include an early pneumonic
infiltrate.
Brief Hospital Course:
The patient was admitted to the acute care service with crampy
lower abdominal pain. Upon admission, she was made NPO, given
intravenous fluids, and underwent imaging. Cat scan of the
abdomen showed 5.3 x 4.9 cm mass lesion within the sigmoid colon
causing large bowel obstruction. She was taken to the operating
room where she underwent an exploratory laparotomy, sigmoid
resection and
___ colostomy. The operative course was stable with a
250cc blood loss. She was extubated after the procedure and
monitored in the recovery room.
The post-operative course has been stable. Her vital signs were
closely monitored and her hematocrit remained stable. The
patient was started on clear liquids on HD #4 after she began
passing flatus. Shortly after this bowel function returned. She
advanced to a regular diet on HD #5. Her surgical pain was
controlled with intravenous analgesia and later converted to an
oral agent. She was seen by the Ostomy nurse and instruction
given in care of the ostomy. Given her recent diagnosis and
surgical procedure, she was evaluated by the Social worker who
provided her with additonal support.
She was discharged from the surgical floor on HD #6.
Appointments have been scheduled to follow-up care in the acute
care clinic.
Of note: she has been instructed to call GI oncology if she
does not hear from them. The telephone number is ___.
She has also been encouraged to establish a primary care, which
she wishes to establish at ___.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
3. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*20 Tablet Refills:*0
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
hold for loose stool
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
large bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with crampy abdominal pain.
You underwent a cat scan of the abdomen which showed a large
bowel obstruction caused by a mass in your colon. You were
taken to the operating room for resection of the large bowel to
remove the mass and a colostomy. You did well during the
surgery. You are slowly recovering. You are tolerating a
regular diet and your colostomy is working. Your vital signs
are stable and 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.
* Any serious change in your symptoms, or any new symptoms that
concern you.
* Please resume all regular home medications and take any new
meds
as ordered.
Activity:
No heavy lifting of items ___ pounds for 6 weeks. You may
resume moderate exercise at your discretion, no abdominal
exercises.
Wound Care:
You may shower, no tub baths or swimming
Please record ostomy output and bring report to post-op visit.
Followup Instructions:
___
|
19920091-DS-10 | 19,920,091 | 29,749,483 | DS | 10 | 2128-04-24 00:00:00 | 2128-04-24 15:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
anesthesia med
Attending: ___.
Chief Complaint:
Back pain.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This is a ___ patient seen for primary care by Dr.
___ in Geriatrics who presented with sudden onset lower back
pain after bending over to pick up a book off the floor. She
presented to the ED where she was HD stable, afebrile, denied
any paresthesia, weakness, bowel or bladder incontinency, no
history of cancer. Plain films of her lumbar spine were
negative for acute fracture. Upon review of the OMR, patient
has a history of back pain including requiring a lidocaine patch
daily for chronic discomfort. She is now admitted for further
management. Of note, in the ED, the patinet was treated with 5
mg of diazepam, 1 Percocet (___) x 2, ketorolac 15 mg IV x 1,
and morphine 4 mg IV.
.
Presently at 0200 the patient states she has severe nausea and
just threw up. Her daughter ___ RN) at the bedside says that
ever since the patient got the morphine she's felt lightheaded
and sick to her stomach. She says she was fine before the
morphine with regard to these symptoms. The daughter says the
patient notes significant lower back pain limiting her ability
to ambulate.
REVIEW OF SYSTEMS: The patient denies fevers, chills, nausea,
vomiting, weight loss, headaches, chest pain, palpitations,
shortness of breath. The patient denies cough, hemoptysis or
wheeze. She denies abdominal pain, changes in bowel movements
or urination.
Past Medical History:
--Joint aches x years, seen by Rheumatology who felt she likely
has osteoarthritis
--H/o glomerulonephritis in ___ per OMR
--Acute hepatitis in ___ per OMR
--Hypothyroidism per OMR
--Atrial fibrillation per OMR
Social History:
___
Family History:
Per OMR: no sudden death, cardiac disease, son and daughter in
good health.
Physical Exam:
VITAL SIGNS: 98.3 138/88 66 18 98% RA
GENERAL: awake, but eyes closed due to feeling + nausea
SKIN: No rash.
NECK: Supple
HEENT: Pupils reactive and round to light. Dry mucous
membranes. Normal oropharynx and nasopharynx.
CARDIOVASCULAR: Regular rate and rhythm. No murmurs, gallops
or rubs.
PULMONARY: Clear to auscultation bilaterally. No wheezing,
rhonchi or rales.
ABDOMEN: Nontender, nondistended. Positive bowel sounds.
Soft.
BACK: Has no spinous tenderness. There is no CVA tenderness.
There is no palpable bulging discs. ++ paraspinal muscle
tenderness in lumbar region R >> L
EXTREMITIES: No cyanosis, ecchymosis or edema.
NEURO: able to move both ___ equally but with reluctance due to
professed lower back pain, DTRs at knees 2+ bilaterally, toes
downgoing bilaterally, able to roll over in bed
slowly/deliberately but with good coordination, no nystagmus,
strength in UE's intact bilaterally, sensation to light touch
preserved throughout. Further complete Neurologic w/u
challenged by patient's nausea. Thorough review of Dr. ___
documentation in the ED states: "normal motor and sensory of
both legs. Toes downgoing. No saddle anesthesia."
DISCHARGE EXAM:
VS: 98.4, 130/81, 65, 18, 97% on RA
GENERAL: Well appearing, no acute distress, sitting on edge of
bed eating, pleasant and smiling
HEENT: Mucous membranes moist
CHEST: CTA bilaterally, no wheezes, rales, or rhonchi
CARDIAC: RRR, no MRG
ABDOMEN: +BS, soft, ___, non-distended
EXTREMITIES: No edema bilaterally
NEURO: Alert and oriented x3, good strength in flexion and
extension of feet bilaterally, no numbeness, straight leg raise
positive bilaterally
Pertinent Results:
___: L-spine: No fracture or subluxation.
Frontal and lateral views of the lumbosacral spine. There are 5
non
rib-bearing lumbar type vertebral bodies which are maintained in
height and alignment. Degenerative changes are noted with mild
endplate osteophyte formation. The intervertebral discs are
grossly preserved in height. The bones are diffusely
osteopenic. Soft tissues are unremarkable.
___: T- spine:
IMPRESSION:
1. Minimal superior endplate scalloping of T4, without other
evidence of
compression fracture. Probable osteopenia and osteoarthritis as
described.
2. Suspected patchy opacities at left> right lung bases.
Further assessment with chest PA and lateral view is recommended
___ 08:30AM BLOOD WBC-4.8 RBC-3.82* Hgb-12.5 Hct-36.7
MCV-96 MCH-32.8* MCHC-34.2 RDW-13.1 Plt ___
___ 07:00AM BLOOD WBC-7.2 RBC-3.82* Hgb-12.7 Hct-35.9*
MCV-94 MCH-33.3* MCHC-35.4* RDW-13.3 Plt ___
___ 08:30AM BLOOD Glucose-93 UreaN-17 Creat-0.8 Na-141
K-4.4 Cl-105 HCO3-31 AnGap-9
___ 07:00AM BLOOD Glucose-135* UreaN-22* Creat-0.7 Na-141
K-4.3 Cl-105 HCO3-27 AnGap-13
___ 08:30AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.3
Brief Hospital Course:
Ms. ___ is a ___ year old woman with HTN, hypothyroidism, history
of osteoarthritis admitted with worsening chronic low back pain
after stooping to pick up a book off the floor. She denies any
worrisome symptoms including fevers, chills, weakness,
paresthesias, or incontinence. Likely musculoskeletal strain in
the setting of chronic osteoarthritis and OA.
ACUTE MUSCULOSKELETAL STRAIN WITH CHRONIC OA AND BACK PAIN: No
concerning signs or symptoms such as point tenderness,
numbness/tingling in lower extremities, urinary incontinence.
No fracture seen on XRAYS. Patient was continued on ibuprofen,
tylenol ___ tid around the clock, and a lidocaine patch. Ms.
___ was feeling better on second hospital day. She was
evaluated by ___, who recommended home safety evaluation and home
___. Ms. ___ will follow-up closely with her outpatient
providers and the orthopedics clinic. If symptoms persist,
patient may benefit from further work-up with CT or MRI.
Alendronate continued as an outpatient.
ABNORMAL XRAY ON ___: Read with, "suspected patchy
opacities at left> right lung bases. Further assessment with
chest PA and lateral view is recommended." A follow-up CXR was
deferred to outpatient providers as patient was having no
pulmonary symptoms on this admission. This information was
conveyed to patient and her daughter, who will ensure follow-up
with PCP.
HYPOTHYROIDISM: Levothyroxine was continued.
SUPRAVENTRICULAR TACHYCARDIA: Metoprolol and aspirin were
continued.
Medications on Admission:
PER OMR:
Medications - Prescription
ALENDRONATE - alendronate 70 mg tablet 1 tab(s) by mouth weekly
HYDROCORTISONE - hydrocortisone 2.5 % Rectal Cream
1 application rectally twice daily as needed for hemorrhoid
irritation
LEVOTHYROXINE - levothyroxine 25 mcg tablet 1 Tablet(s) by mouth
daily
LIDOCAINE - lidocaine 5 % (700 mg/patch) Adhesive Patch Apply
to lower back daily Keep on for 12 hours, off for 12 hours daily
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr 1 Tablet(s) by mouth daily
NAPROXEN - naproxen 500 mg tablet 1 Tablet(s) by mouth twice
daily Take with food
TRIAMCINOLONE ACETONIDE - triamcinolone acetonide 0.05 %
Ointment Apply to scalp Twice daily
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release 1 Tablet(s) by
mouth once a day
CALCIUM CITRATE-VITAMIN D3 - calcium citrate-vitamin D3 315
mg-200 unit tablet
2 Tablets(s) by mouth twice a day with food
SENNOSIDES-DOCUSATE SODIUM - sennosides-docusate sodium 8.6
mg-50 mg tablet
1 Tablet(s) by mouth twice daily as needed for constipation
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 25 mcg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Senna 1 TAB PO BID:PRN constipation
6. Acetaminophen 1000 mg PO/PR TID
RX *acetaminophen 500 mg Two tablet(s) by mouth Three times a
day Disp #*30 Tablet Refills:*0
7. Ibuprofen 400 mg PO Q8H:PRN Pain
RX *ibuprofen 400 mg One tablet(s) by mouth Three times a day
Disp #*30 Tablet Refills:*0
8. Alendronate Sodium 70 mg PO QMON
9. Calcitrate-Vitamin D *NF* (calcium citrate-vitamin D3)
315-250 mg-unit Oral bid
Take 2 tabs twice daily
10. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN
hemorrhoidal irritation
11. triamcinolone acetonide *NF* 0.5 % Topical bid scalp
12. Outpatient Physical Therapy
As per physical therapy recommendations.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Musculoskeletal back strain.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you on this admission. You
came to the hospital for back pain. You had XRAYs of your back
that did not show any acute fracture. You were seen by physical
therapy who reommended that you have a "home safety assessment"
and ___ as an outpatient.
You should take ibuprofen 400mg three times a day for the next
one week. Please take this medication with food. It is very
important that you call your doctor or return to the hospital if
you develop worsening back pain, numbness or tingling in your
legs, or problems with your urine or stool.
Of note, you had an XRAY of your thoracic spine on ___ that
showed: "patchy opacities at left> right lung bases. Further
assessment with chest PA and lateral view is recommended." You
will need a repeat CXR to follow-up these findings as an
outpatient.
We were unable to make outpatient appointments for you as you
went home over the weekend. Please call your PCP's office
tomorrow to schedule an appointment in the next 1 week.
Followup Instructions:
___
|
19920484-DS-11 | 19,920,484 | 27,474,215 | DS | 11 | 2199-09-29 00:00:00 | 2199-09-29 12:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right hip pain
Major Surgical or Invasive Procedure:
Right hip DHS
History of Present Illness:
___ female s/p mechanical fall onto right hip outside her
kitchen door with immediate pain and inability to bear weight.
She denies any headstrike, LOC, or other injuries associated
with
this incident.
Past Medical History:
hypothyroidism, asthma, HTN
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
Vitals: 98 80 ___
GEN: NAD, AOx3
CV: regular
CHEST: no respiratory distress
ABD: soft, non-tender, non-distended
RUE
skin intact
no tenderness, deformity, erythema, edema, induration or
ecchymosis
arm and forearm are soft
no pain with passive motion
R M U SILT
___ EPL FPL EDC FDP FDS
2+ radial pulses
LUE
skin intact
no tenderness, deformity, erythema, edema, induration or
ecchymosis
arm and forearm are soft
no pain with passive motion
R M U SILT
___ EPL FPL EDC FDP FDS
2+ radial pulses
RLE
Skin: clean and intact, trace edema of leg
no gross deformity, erythema, edema, induration or ecchymosis;
thigh and leg are soft
no pain with passive motion
saph sural DPN SPN SILT
___ ___ FHL ___ TA
2+ ___ and DP pulses
LLE
Skin: skin intact except for old 2cm wound on posterior distal
leg (old) covered with xeroform dressing, trace edema of leg
no gross deformity, erythema, edema, induration or ecchymosis;
thigh and leg are soft
no pain with passive motion
saph sural DPN SPN SILT
___ ___ FHL ___ TA
2+ ___ and DP pulses
PHYSICAL EXAMINATION ON DISCHARGE:
Alert and oriented, pleasant, conversational
RLE: Incision is clean, dry, and intact with staples in place.
___, FHL, TA, and ___ fire, and sensation is intact to light
touch over the SPN, DPN, TN, saphenous, and sural distributions.
The foot is warm and well-perfused.
Pertinent Results:
___ 05:02AM BLOOD WBC-8.1 RBC-3.32* Hgb-9.8* Hct-28.3*
MCV-85 MCH-29.5 MCHC-34.6 RDW-14.3 Plt ___
___ 05:02AM BLOOD Glucose-104* UreaN-17 Creat-0.7 Na-142
K-3.7 Cl-108 HCO3-27 AnGap-11
___ 05:02AM BLOOD Calcium-7.9* Phos-2.1* Mg-1.9
___ 05:40AM BLOOD TSH-4.3*
Brief Hospital Course:
Ms. ___ was admitted to the Orthopaedic Trauma service for
repair of a right intertrochanteric hip fracture. She was taken
to the Operating Room on ___, at which time she underwent
open reduction and internal fixation of the right hip fracture
with a DHS. Please see Operative Report for full details. The
patient tolerated the procedure well, and there were no
complications. She received perioperative antibiotics as well
as Lovenox for DVT prophylaxis. Post-operatively, she was taken
to the recovery room before being transferred back to the floor.
Her pain was controlled with both IV and oral pain medications,
which were eventually transitioned to an exclusively oral
regimen.
In the post-operative period, the patient worked with Physical
Therapy throughout her hospitalization and made steady progress.
She received blood transfusions of 2 units of packed red blood
cells on POD#0 ___s another unit on POD#1 for acute blood
loss anemia. There were otherwise no complications, and the
patient did well. She was able to void spontaneously after the
Foley catheter was removed.
On POD#3, the day of discharge, the Medicine team was consulted
due to a recent cough. The cough did not appear to be acute,
and CXR demonstrated no acute pulmonary process. On the day of
discharge, the patient was afebrile and her vital signs were
stable. She expressed readiness for discharged to a
rehabilitation facility, and her hematocrit was stable. She was
not started on bisphosphonates due to the fact that she reports
a previous ___ history of bisphosphonate use. The patient
was given both precautionary instructions as well as
instructions regarding appropriate follow-up care. She was
discharged to rehab in stable condition.
Medications on Admission:
cholecalciferol 800, ASA 81, milk of magnesia prn, ProAir
HFA 90 2 puff qid prn, lisinopril 2.5 every other day, zolpidem
5
qhs prn, levothyroxine 100, sertraline 50, MVI, Flovent HFA 110
1
puff
Discharge Medications:
1. oxycodone 5 mg Tablet Sig: ___ Tablet PO Q4H (every 4
hours) as needed for Pain.
Disp:*45 Tablet(s)* Refills:*0*
2. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig:
___ MLs PO Q6H (every 6 hours) as needed for Dyspepsia.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for
Constipation.
5. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30)
ML PO BID (2 times a day) as needed for Constipation.
6. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily).
7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for wheeze.
10. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO EVERY OTHER DAY
(Every Other Day): HOLD if SBP <100.
11. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY
EXCEPT ___ ().
12. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime).
13. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff
Inhalation BID (2 times a day).
15. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours).
16. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One
(1) Tablet PO TID (3 times a day).
17. enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Syringe
Subcutaneous QHS (once a day (at bedtime)).
Disp:*28 Syringes* Refills:*0*
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right intertrochanteric hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Wound Care:
- Keep incision clean and dry.
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dressing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Activity:
- Continue to be weight-bearing as tolerated on your right leg
- You should not lift anything greater than 5 pounds.
- Elevate right leg to reduce swelling and pain.
Other Instructions
- Resume your regular diet.
- Avoid nicotine products to optimize healing.
- Resume your home medications. Take all medications as
instructed.
- Continue taking the Lovenox to prevent blood clots.
- You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so plan ahead. You can either have them mailed
to your home or pick them up at the clinic located on ___ 2.
We are not allowed to call in narcotic (oxycontin, oxycodone,
percocet) prescriptions to the pharmacy. In addition, we are
only allowed to write for pain medications for 90 days from the
date of surgery.
- Narcotic pain medication may cause drowsiness. Do not drink
alcohol while taking narcotic medications. Do not operate any
motor vehicle or machinery while taking narcotic pain
medications. Taking more than recommended may cause serious
breathing problems.
- If you have questions, concerns or experience any of the below
danger signs then please call your doctor at ___ or go
to your local emergency room.
Physical Therapy:
WBAT RLE
Treatments Frequency:
- You can get the wound wet or take a shower starting from 7
days after surgery, but no baths or swimming for at least 4
weeks.
- Dry sterile dressing may be changed daily. No dressing is
needed if wound continues to be non-draining.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
Followup Instructions:
___
|
19920625-DS-9 | 19,920,625 | 28,853,019 | DS | 9 | 2146-08-29 00:00:00 | 2146-08-29 16:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vomiting, altered mental status with MI several days before
admission
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with CABG in ___ with normal echo a year ago at ___
with very advanced dementia, doesn't eat much and lives with
wife who is primary care taker. On ___ prior to admission,
he had severe nausea and vomiting that was severe but got better
during the day. The next day back to baseline but his wife
noticed he was sluggish and more confused on ___ than his
baseline. Evaluated at ___ where EKG was noteable for R
bundle with J point elevation in inferior leads, troponin-T 12
and CK-MB 22.
Labs and imaging significant for BUN/sCR 52/1.8 with troponin at
11.47.
Past Medical History:
1. CARDIAC RISK FACTORS: (-)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
-CABG: ___, x3, LIMA to LAD, SVG to the right posterior
ventricular branch and a SVG to the ramus.
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
-Atrial tachycardia, SVT.
-Congestive heart failure, diastolic
-Hyperlipidemia.
-Chronic renal insufficiency.
-Neuropathy.
-Hypothyroidism
Social History:
___
Family History:
Patient does not remember family history.
Physical Exam:
ADMISSION EXAM
==============
VS: T= 98.5 BP= 113/66 HR= 88 RR= 22 O2 sat= 96% on 2 L by NC
General: Awake and alert, trouble orienting to place, person,
and time. No acute distress.
HEENT: EOMI, PERRL, MM mild to moderate dryness
Neck: Supple, JVD to collarbone b/l
CV: Reg rate irreg rhy no MRG appreciated
Lungs: CTA b/l with decreased breath sounds at bases b/l
Abdomen: Soft, NT/ND/NG/NR, BS+
Ext: WWP 2+ at DP and ___
Neuro: NFDs appreciated, CNs II-XII grossly intact, face
symmetric, no slur
Skin: No rashes appreciated, sutures in left upper arm closing
incision with well approximated borders
DISCHARGE EXAM
==============
Tmax/T:97.8, 112-121/62-72, HR ___ SR with PACs, RR 18 94%
2LNC.
I/O: 24hr: 820/700++ 8hr: 180/400
Tele: sinus with PAC's.
Exam:
General: NAD, pleasant and cooperative.
HEENT: JVP at 3cm above clavicle
CV: irreg irreg, ___ systolic murmur at LUSB
Resp: BB crackles
ABD: soft, no TTP, mild guarding, no rebound, pos BS
Extr: no edema
Neuro: Alert, speech clear, no focal defects
Pertinent Results:
ADMISSION LABS
==============
___ 11:30AM BLOOD WBC-12.9*# RBC-4.52* Hgb-14.5 Hct-46.5
MCV-103* MCH-32.1* MCHC-31.2 RDW-12.7 Plt ___
___ 11:30AM BLOOD Neuts-84.7* Lymphs-6.2* Monos-6.8 Eos-2.0
Baso-0.4
___ 11:30AM BLOOD Plt ___
___ 12:01PM BLOOD PTT-120.4*
___ 11:30AM BLOOD Glucose-123* UreaN-52* Creat-1.8* Na-140
K-4.6 Cl-102 HCO3-24 AnGap-19
___ 11:30AM BLOOD cTropnT-11.47*
___ 05:50PM BLOOD CK-MB-19* cTropnT-13.49* ___
___ 03:04AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.9
DISCHARGE LABS
==============
___ 07:20AM BLOOD WBC-8.6 RBC-4.63 Hgb-15.2 Hct-47.8
MCV-103* MCH-32.8* MCHC-31.8 RDW-13.3 Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD ___ PTT-37.6* ___
___ 07:20AM BLOOD Glucose-109* UreaN-44* Creat-1.5* Na-143
K-4.1 Cl-101 HCO3-33* AnGap-13
___ 03:04AM BLOOD CK-MB-14* cTropnT-16.20*
___ 07:20AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0
PERTINENT RESULTS
=================
___ 03:04AM BLOOD CK-MB-14* cTropnT-16.20*
URINE AND BLOOD CULTURES NEGATIVE FINAL
Brief Hospital Course:
___ M with known CAD with CABG triple vessel in ___ with likely
missed MI three to four days prior to admission with troponin-T
elevated on presentation now with persistent O2 requirement.
#) STEMI: No further symptoms. EF dec to 30%. No cath because of
delayed presentation, treating medically. We continued ASA 81mg
daily, put him on atorvastatin 80mg daily, transitioned to
metoprolol XL 50mg daily. Plan to start ACE-i as outpatient when
sCr stabilized.
# Acute systolic heart failure (Ef on echo ___ on ___:
Persistent mild O2 requirement but despite being euvolemic and
without evidence of effusions/edema on CXR. Likely some
underlying pulonary component such as fibrosis, discharging on
low dose oxygen. Started lasix 20 mg PO at discharge.
# AF RVR: Been in sinus rhythm since 3 pm ___ with back to
atrial fibrillation morning of ___. Asymptomatic. Continue
coumadin for INR goal 2.0-3.0 without bridge. Holding warfarin
for the last 2 days because of rising INR. Please see warfarin
sheet. Metoprolol XL 50 mg daily.
# DEMENTIA: ___ year history, family serves as primary care
takers primarily wife, ___ to ambulate. Fall precautions. We
continued donepezil 10 mg HS and modafinil 200 mg QD. Constant
supportive care including periodic re-orientation to person and
place.
# Aspiration: is aspirating all consistancies according to
speech therapy evaluation here. Mild coughing at times at home.
Likely a long standing problem. Discussed with wife and will not
plan PEG as not consistant with wishes and will not prevent
aspiration in long standing dementia. Strict aspiration
precautions needed.
# UTI: Urine culture negative while inpatient so antibiotics
stopped.
# MILD LEUKOCYTOSIS: Resolved. Cultures negative
# HYPOTHYROIDISM: Chronic h/o. We continued Synthroid ___ mcg PO
QD while inpatient.
# DEPRESSION: Chronic h/o. We Continued mirtazipine 30 mg QHS
# BPH: Chronic h/o. Foley out when it was possible. We continued
tamsulosin 0.4 mg HS.
# Gout: Chronic h/o. We continued allopurinol ___ mg PO QD.
TRANSITIONAL ISSUES
===================
- start ACE-i when creat stable as outpatient
- reassess swallowing once pt is more ambulatory and stronger.
- likely some component of pumlonary fibrosis should be worked
up as outpatient
- oxygen to rehab
- restart warfarin when INR falling.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Pravastatin 40 mg PO DAILY
3. Tamsulosin 0.4 mg PO DAILY
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Allopurinol ___ mg PO DAILY
6. Donepezil 10 mg PO HS
7. Mirtazapine 30 mg PO HS
8. Metoprolol Succinate XL 25 mg PO DAILY
9. modafinil 200 mg oral QD
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Donepezil 10 mg PO HS
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Mirtazapine 30 mg PO HS
7. modafinil 200 mg oral QD
8. Tamsulosin 0.4 mg PO DAILY
9. Atorvastatin 80 mg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Furosemide 20 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Senna 17.2 mg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ST elevation myocardial infarction
acute systolic heart failure exacerbation
paroxysmal atrial fibrillation
dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr ___,
You were admitted following a heart attack at home likely ___
days before admission. You have been in and out of an irregular
heart rhythm called atrial fibrillation but now are in sinus
rhythm with the use of medications. The pumping function of your
heart is also lower than normal and we have added medications to
help decrease the workload of the heart and assist in getting
rid of some fluid the heart is not able to get rid of on its
own.
You were started on a blood thinner called warfarin to prevent a
stroke from the atrial fibrillation. This medicine requires that
blood levels are checked frequently. After you go home, there is
a ___ clinic at ___ that will help you regulate the
blood levels of warfarin.
Additionally you have had a persistent oxygen requirement
despite using medicines to decrease the amount of fluid in the
lungs. At this point we believe there may be a long standing
lung issue to and that your primary care doctor ___ discuss
with you as an outpatient.
Weigh yourself every morning, call Dr. ___ weight goes up
more than 3 lbs in 1 day or 5 pounds in 3 days.
Followup Instructions:
___
|
19920828-DS-26 | 19,920,828 | 22,990,000 | DS | 26 | 2205-02-22 00:00:00 | 2205-02-22 23:08:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Thimerosal / Interferons / Lamictal / neomycin-polymyxin-HC
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old woman with PTSD, anxiety,
somatization, hepatitis C cirrhosis with biliary cystadenoma,
with MVA in ___ and resultant chronic neck and back pain who
presents from Dr. ___ Clinic with acute on
chronic diffuse bilateral weakness.
She was injured in an MVC in ___ when she was hit by a drunk
driver. Since then she has had neck and lower back pain,
stiffness in her neck, and numbness/tingling of the bilateral
hands and feet.
She lives at home alone and has been recently receiving ___
services for the past 3 weeks. She has also been undergoing ___
twice weekly and states that this has been very beneficial. At
baseline her gait is unsteady, requiring her to lean to one side
hold on to walls to ambulate. She is unable to climb stairs. She
is able to walk from her bed to her bathroom and back but is
generally homebound given her poor functional status. With ___
she has required less aid with ambulation.
She was previously taking valium TID a few months ago for neck
spasms but reported daily falls on this medication, eventually
discontinuing valium in ___. She has had no falls in the
past month.
Over the past two months she reports daily diarrhea up to 10
times daily, but no urinary symptoms. She has also had a 40 lb
weight loss in the past two months, attributing this to the
diarrhea, sensitivity to food smells, and inability to access
food herself. She states there is no one to pick up food for
her.
A couple of days ago she bent over to sort a pile of laundry.
This level of activity is beyond her usual capabilities. She
exerted herself again today by trying to sort the belongings on
her bed. She notes that this level of activity is far beyond
what she has been used to over the past year. As a result she
noted increased pain and acute on chronic weakness and presented
to Dr. ___ neurologist.
Dr. ___ of the clinic visit is as follows: "I
could not put my finger on any particular weakness although she
has give way throughout and splits the midline on the forehead
for vibration sense so there is clearly a good deal of overlay.
She walks holding onto the walls and occasionally sways, or one
knee gives out. She did not fall, but claims multiple falls. I
think there is a psychiatric component but equally she may be
ill."
She was transferred to the ED. In the ED initial vitals were:
Pain 10 98.1 HR 66 BP 122/86 RR 18 100% RA. Labs were
significant for normal CBC and chemistry panel, dirty UA
(contaminated). She was given 2L IVF, ativan 2 mg, morphine 5
mg, zofran 4 mg
Exam was notable for absence of rectal tone and saddle
anesthesia. Urgent Code Cord was called. Of note- Review of OMR
notes at least 3 separate presentations for weakness with spine
MRIs since ___ mostly showing
multilevel cervical degenerative disease, worst at C5-C6 and
lumbar L3-L4 disk without cord signal. CT-spine flex/ext in
___ showed no dynamic subluxation.
Neurology was consulted, and MR ___ spine obtained, which was
notable for chronic known disc bulges but no cord compromise.
She is admitted to medicine for neck pain, inability to
ambulate, and weight loss.
On the floor, she appears comfortable at rest but continues to
endorse ___ neck pain.
Review of Systems: Endorses "feeling cold" for the past year, no
fevers. Endorses diarrhea and weight loss as above. Denies
melena, hematochezia, chest pain, abdominal pain, nausea,
vomiting, dysuria.
Endorsed dyspnea when trying to reach Dr. ___, but
currently denies shortness of breath.
Past Medical History:
- MVA in ___ with subsequent chronic neck/back pain
- Anxiety, PTSD, somatization disorder, recent hospitalization
psychiatry unit at ___
- Hepatitis C with cirrhosis (unclear hx of transmission, not on
treatment)
- Hepatic cystadenoma
- Pancreatic IPMN- alphafetoprotein 24.7
- Hx of Pyelonephritis: dx via CT imaging in ___
- History of vulvar cancer s/p resection
- s/p mastectomy for breast mass which was benign
- recurrent syncopal episodes
Social History:
___
Family History:
Mother with diabetes, hyperlipidemia, hypertension; Father
deceased secondary to MDS --> leukemia; Brother is alive and
well. She has two daughters. She has no history of kidney
stones.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.5 HR 58 BP 108/56 100% RA
General: Anxious, comfortable at rest, visibly uncomfortable
with movement of legs, arms, neck. Tearful at times, alludes to
prior sexual abuse.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Extremely limited neck ROM. Significant pain with any
movement. Tenderness and spasm of paraspinal cervical
musculature. No focal tenderness of the thoracic/lumbar spine
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR. 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
Neuro: Alert and oriented x3. CN II-XII assessed and intact.
Sensation to light touch limited from dorsum of feet to the
bilateral thighs. Decreased pinprick and temperature sensation
of the lower extremities bilaterally. Strength ___ in the lower
extremities bilaterally, ___ in the upper extremities
bilaterally.
DISCHARGE PHYSICAL EXAM:
Vitals - 97.5 HR56 BP 109/58 100% RA
General: Sitting up in bed. Mild distress
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Limited neck ROM secondary to pain. No lymphadenopathy
appreciated.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR. S1S2, no M/R/G noted
Abdomen: Soft, ND, normoactive bowel sounds, tenderness to
palpation in RLQ. No rebound/guarding
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Back: no CVA tenderness
Skin: no rashes or lesions noted
Neuro: Alert and oriented x3. Strength ___ in the lower
extremities bilaterally, ___ in the upper extremities
bilaterally.
Pertinent Results:
ADMISSION LABS:
___ 07:27PM BLOOD WBC-7.1 RBC-4.52 Hgb-14.7 Hct-40.8
MCV-90# MCH-32.7* MCHC-36.2*# RDW-14.4 Plt ___
___ 07:27PM BLOOD Neuts-33.1* Lymphs-57.0* Monos-6.8
Eos-1.9 Baso-1.1
___ 07:27PM BLOOD ___ PTT-34.9 ___
___ 07:27PM BLOOD Glucose-91 UreaN-13 Creat-0.5 Na-142
K-3.8 Cl-108 HCO3-21* AnGap-17
___ 06:55AM BLOOD LD(LDH)-176
___ 07:27PM BLOOD Calcium-9.4 Phos-3.1 Mg-1.9
NOTABLE LABS:
___ 12:56PM BLOOD ZINC-52
___ 12:56PM BLOOD COPPER (SERUM)-76
___ 06:55AM BLOOD AFP-22.3*
___ 07:32AM BLOOD T4-10.1
___ 06:55AM BLOOD TSH-4.4*
STUDIES:
MRI spine ___: 1. No spinal cord compression.
2. Small disc protrusions in the cervical spine at C3-4 through
C6-7 that do not cause cord deformity, unchanged from prior MRI
on ___.
3. The patient has transitional spine anatomy, described in the
findings
section of the report. Mild diffuse disc bulges in the lumbar
spine cause
subarticular zone stenosis at L4-5 and L5-6, not significantly
changed from MRI on ___.
CT abdomen ___
1. 4.8 x 3.3 cm cystic hepatic lesion at the junction of the
left and right
hepatic lobes. Although this lesion has only minimally increased
in size
compared to the prior MRI abdomen dated ___, it has
more than
doubled in volume as compared to ___. Given this interval
growth,
surgical resection is a valid consideration.
2. Ill-defined, subcentimeter cystic lesion within the
pancreatic head, better
characterized on prior MRI. Please see recommended follow up per
MR imaging.
3. Diverticulosis without evidence of diverticulitis.
4. For description of the intrathoracic findings, please see
the separate CT chest report.
CT chest ___:
IMPRESSION:
1.8 x 1.9 cm left upper lobe part-solid ground-glass opacity
may be infectious or inflammatory in etiology. 8 x 7 mm mixed
attenuation sub-solid right lower lobe nodule may also be
infectious or inflammatory in etiology, however a three-month
followup chest CT is recommended for both of these lesions to
exclude neoplasia.
Mild centrilobular and paraseptal emphysema.
MICRO:
___ stool: C. difficile DNA amplification assay (Final
___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
UA:
___ 09:39AM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:43PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.5 Leuks-LG
DISCHARGE LABS:
___ 06:38AM BLOOD WBC-4.6 RBC-4.19* Hgb-13.4 Hct-38.2
MCV-91 MCH-31.9 MCHC-35.0 RDW-14.1 Plt ___
___ 06:38AM BLOOD Plt ___
___ 06:38AM BLOOD Glucose-104* UreaN-13 Creat-0.6 Na-140
K-4.1 Cl-109* HCO3-26 AnGap-9
___ 06:38AM BLOOD ALT-77* AST-74* AlkPhos-74 TotBili-0.4
___ 06:38AM BLOOD Calcium-8.7 Phos-4.4 Mg-1.9
Brief Hospital Course:
___ is a ___ year-old woman with PTSD, anxiety,
somatization, hepatitis C cirrhosis with biliary cystadenoma,
with MVA in ___ and resultant chronic neck and back pain
presented with failure to thrive with acute on chronic diffuse
bilateral weakness, weight loss and diarrhea. Her weakness
improved during hospitalization and neuro workup was negative
for acute event.
# Neck/back pain with acute on chronic bilateral weakness: Ms.
___ has a history of neck and back pain since an MVC in ___
with radiographic evidence of multiple disc bulges with
resultant poor functional status. Repeat MRI here showed no new
changes. She was evaluated with PR and was able to work with
them. Her pain was controlled with oxycodone and lidocaine
patch. Labs did not show zinc excess or copper deficiency.
Weakness improved during the hospitalization course with ___,
pain control and PO intake.
# Weight loss: Ms. ___ has a had a 40 lb weight loss this
year. UA on admission showed ketones, consistent with decreased
PO intake. Albumin also low at 2.8. Her extensive smoking
history and GI symptoms, there was concern for possible
malignancy contributing to weakness and weight loss CT torso
showed 2 small nodules that require follow up. Weight loss is
likely secondary to poor access to food. Given diarrhea,
differential also includes Celiac's disease. Anti-TTG is
pending.
# Diarrhea/abdominal pain: Patient notes that she has been
having diarrhea 10 times daily for the past two months. She had
several loose bowel movements while hospitalized. C diff and
stool culture/O&P were negative. CT Abdomen/pelvis was normal
with no signs of colitis. Anti-TTG for Celiac's is pending. She
also had RLQ pain. No evidence of appendicitis. UA with no blood
concerning for kidney stone. Irritable bowel syndrome continues
to be on the differential.
# Hepatitis C cirrhosis: Followed by Dr. ___ seen in
clinic ___. She has 3cm biliary cystadenoma in the liver but
appears to be growing over serial images with increase in size
on CT scan this admission compared to ___ (see transitional
issues). AFP stable.
# Anxiety: Continued home low dose ativan
TRANSITIONAL ISSUES:
-Follow up with Dr. ___ for repeat CT chest to monitor
lung nodules (1.8cm x 1.9cm LUL and 8 x 7 mm RLL)
-Follow up with Dr. ___ 4.8 x 3.3 cm cystic
hepatic lesion which has increased in size since ___
-Follow up with PCP regarding ___ antibody result
-Code: full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1250 mg PO BID
2. Citalopram 30 mg PO DAILY
3. Ibuprofen 600 mg PO Q8H:PRN pain
4. Lidocaine 5% Patch 1 PTCH TD QAM
5. Lorazepam 0.5-1 mg PO Q4H:PRN nausea, anxiety
6. Cetirizine 10 mg oral qd
7. mometasone 50 mcg/actuation nasal daily
Of note, patient had not been taking any medications recently
due to inability to access medications/pharmacy. These are
medications that she was meant to be taking.
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Lorazepam 0.5-1 mg PO Q4H:PRN nausea, anxiety
3. Acetaminophen 650 mg PO Q8H
4. OxycoDONE (Immediate Release) 5 mg PO BID:PRN breakthrough
pain Duration: 5 Days
5. Calcium Carbonate 1250 mg PO BID
6. Cetirizine 10 mg oral qd
7. Citalopram 30 mg PO DAILY
8. Ibuprofen 600 mg PO Q8H:PRN pain
9. mometasone 50 mcg/actuation nasal daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Failure to thrive
Secondary:
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with pain and weakness. Our
neurologists saw you and we performed an MRI of your spine which
showed no new changes. Because you have also had significant
weight loss, we performed a CAT scan of your chest and abdomen.
This showed two small lung nodules. You will need to have a
repeat CAT scan of your chest in 3 months to monitor these
nodules. The CAT scan of your abdomen showed an increase in the
size of your liver lesion which Dr. ___ has been monitoring.
You can discuss further steps for this with Dr. ___ you
see him in clinic. Please take your medications as prescribed.
Please follow up with your doctors as below.
It has been a pleasure taking care of you and we wish you all
the ___,
Your ___ Care team
Followup Instructions:
___
|
19920914-DS-20 | 19,920,914 | 27,145,902 | DS | 20 | 2134-07-04 00:00:00 | 2134-07-04 08:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
Augmentin / Bactrim / Cefadroxil / adhesive tape
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___, recently admitted to Thoracic
Surgery on ___ and underwent a 1) left thoracotomy, left
pneumonectomy, mediastinal lymph node dissection, bronchoscopy
with lavage and intercostal muscle flap buttress for poorly
differentiated squamous cell carcinoma of the lung. She was
discharged on ___. She presents to the ER complaning of
dyspnea on exertion that has remained the same since her
surgery.
Patient states that she cannot walk more than 20 feet without
getting short of breath. Denies chest pain, fevers, chills,
hemoptysis. She denies any shortness of breath at rest. Reports
some lower extremity swelling bilaterally that has improved
since
her discharge. After initially presenting to the ___, she
had negative LENIs and a chest x-ray consistent with post-op
pneumonectomy.
Past Medical History:
PMH: HTN, Vasovagal syncope, HLD, hypothyroid
PSH: CCY, C-section x3
Social History:
___
Family History:
Family History:
Brother: MI at age ___
Physical Exam:
98.3 97.8 70 116/70 18 100RA
NAD/A&O
CTAB
RRR
Abd Soft - NTND
Pertinent Results:
___ - CTA PE
1) No evidence of pulmonary arterial embolism in the right
pulmonary arterial tree.
2) Status post left pneumonectomy with ligation of the left
pulmonary artery. Left hemithorax is fluid and air-filled as
would be expected post pneumonectomy.
Brief Hospital Course:
The patient was seen and evaluated in the ED for ocmplaint of
shortness of breath. A CTA PE protocol and ambulatory O2
saturations were obtained. Ambulatory O2 was as low as the mid
___ in the ED, and CTA was negative for PE. The patient was
started on O2 with improvement in her symptoms, and was planned
for discharge to home with home O2 and ___ to assist her. She
will continue her current postoperative plan and follow up w/
Dr. ___ as scheduled.
Medications on Admission:
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 81 mg PO DAILY
3. Disopyramide Phosphate 150 mg PO BID
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
Do not drive while taking narcotic medications. You may take
tylenol in addition to this medication
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4hrs Disp #*40
Tablet Refills:*0
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Disopyramide Phosphate 150 mg PO BID
4. Heparin 5000 UNIT SC TID
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Simvastatin 20 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Shortness of Breath
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with difficulty breathing on
ambulation. You were worked up for a variety of potential causes
of shortness of breath, and it was determined that your
difficulty was due to your recent surgery. On discharge, please
continue to ambulate as you are able, and continue all your
previous discharge instruction.
Followup Instructions:
___
|
19921006-DS-11 | 19,921,006 | 23,788,788 | DS | 11 | 2145-04-29 00:00:00 | 2145-04-29 22:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Ceclor / Sulfa (Sulfonamide Antibiotics) /
Combigan / tramadol / Zofran / citalopram
Attending: ___
Chief Complaint:
Rectal Bleeding
Major Surgical or Invasive Procedure:
Attempted ___ embolization complicated by ___ dissection
History of Present Illness:
Ms. ___ is an ___ year old female with a history of atrial
fibrillation (not on AC), and HTN who presented to the ED for
BRBPR.
She states that earlier this morning she had a soft brown bowel
movement that was surrounded by some bright red blood. She
notes that she has had about 2 episodes since this started
earlier this morning. She notably denies any associated
abdominal pain, cramping nausea or vomiting. She has not had
any hematemesis. She apparently started naproxen about 3 days
ago for ongoing low back pain.
There is reportedly one episode of about 200-300 cc of bright
red blood per rectum that occurred while in the emergency
department. Other episodes that occurred earlier in the day
were about 30 cc each.
OSH ED: At the outside hospital her initial vitals showed a
blood pressure in the 160s and heart rates in the ___ which did
increase to the 100s. She was notably found to have a
hemoglobin on admission of 12.5 which 4 hours later was down to
10.9 on a point-of-care check. She had a CTA at that hospital
that demonstrated active sigmoid extravasation. She was given 2
units of PRBCs and transferred to ___.
___: ED Course notable for:
While she was in the ED she was examined and notably on her
rectal exam there was no report of hemorrhoids or mass
appreciated but there was obvious bright red blood per rectum.
A CTA of her abdomen was obtained which demonstrated active
extravasation of the sigmoid colon. Thereafter she had multiple
other episodes of bright red blood per rectum.
From ___ Sign out: Angiogram by ___ in IMI injected at the
osteum did show sigmoid bleeding, with short segment dissection
with flow that is still ongoing. They did not probe further. Rec
getting GI or surgery involved. Concerned about bowel ischemia
if they would dissect all the way. They are holding manual
pressure. Got fentanyl. Had BRBPR from below in the ___ suite.
Initial vitals in the ED demonstrated: Temp 97.8 heart rate
85-93, blood pressure ___ on room air satting 99%.
Her initial labs in the ED demonstrated
lactate 2.1
BMP: Sodium 138, potassium pending, chloride 108, bicarb 19, BUN
22, creatinine 0.7
LFTs: AST 62 ALT 14, total bili 1.2 albumin 3.6
INR: 1.1, PTT 28.6
GI and interventional radiology were both consulted.
Gastroenterology thought that this was most likely a
diverticular bleed versus an AVM and recommended flex sig versus
colonoscopy on this admission. However she required 4 units of
blood for blood pressures that are not documented, and based on
this finding interventional radiology felt that an emergent
mesenteric angiogram with embolization was warranted.
Apparently 4 units of PRBCs were initiated for transfusion
based on a hemoglobin drop from ___ however there are no CBCs
in our record this may be from the outside hospital.
On arrival to the MICU, she confirms her above history. She
says she has never had a bleed like this ever before. She
denied any ongoing nausea or vomiting and says that she was
pain-free at the time of our interview. However about 20
minutes later she did develop some crampy abdominal pain that
was about 5 out of 10 in severity and located diffusely
throughout her lower abdomen. She otherwise says that nothing
changed differently in the days leading up to this new bleed.
Past Medical History:
-Atrial fibrillation (not on anticoagulation)
-Basal cell carcinoma
-Hyperlipidemia
-Hypertension
-Idiopathic gastroparesis
-Gastritis
-Chronic low back pain
-Prior history of nephrolithiasis in the ___
- OSTEOPOROSIS
- LACTOSE INTOLERANCE
- Menopause in late ___, never had HRT
- L3-4 fx ___
- T12,L1-2 fx___
Social History:
___
Family History:
She has no family history of inflammatory arthritis or
connective tissue disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: HR 94 BP: 135/91 02 98% RA
GENERAL: Laying in bed resting comfortably in no acute pain or
distress
HEENT: Sclera anicteric, oropharynx clear, dry mucous membranes
NECK: supple, no masses
LUNGS: Clear to auscultation in anterior lung fields
bilaterally, no wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no obvious masses or lesions, no ecchymosis on the right
anterior thigh or back
NEURO: awake alert, and oriented X3
DISCHARGE PHYSICAL EXAMINATION
24 HR Data (last updated ___ @ 716)
Temp: 98.0 (Tm 98.6), BP: 130/77 (118-146/72-87), HR: 84
(84-103), RR: 18, O2 sat: 96% (95-98), O2 delivery: Ra
General: Frail-appearing. lying in bed comfortably. Pleasant and
answering questions appropriately
HEENT: Sclera anicteric, oropharynx clear, MMM. No cervical LAD
or masses
Lung: CTAB, no wheezes/rales/rhonchi
Card: Tachycardic, normal S1/S2. systolic murmur
Abd: Nondistended. Soft, nontender. No rebound
Ext: Warm, 2+ pulses
Neuro: AOX3. CN2-12 intact. Moving all extremities spontaneously
Pertinent Results:
ADMISSION LABS:
===================
___ 05:28PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 05:28PM URINE RBC-2 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:34PM ___ PTT-28.6 ___
___ 05:34PM ALBUMIN-3.6
___ 05:34PM LIPASE-23
___ 05:34PM ALT(SGPT)-14 AST(SGOT)-62* ALK PHOS-81 TOT
BILI-1.2
___ 05:34PM GLUCOSE-123* UREA N-22* CREAT-0.7 SODIUM-138
POTASSIUM-8.6* CHLORIDE-108 TOTAL CO2-19* ANION GAP-11
___ 05:34PM GLUCOSE-123* UREA N-22* CREAT-0.7 SODIUM-138
POTASSIUM-8.6* CHLORIDE-108 TOTAL CO2-19* ANION GAP-11
___ 05:54PM LACTATE-2.1*
___ 07:00PM PLT COUNT-140*
___ 07:00PM NEUTS-73.5* LYMPHS-14.9* MONOS-7.4 EOS-3.4
BASOS-0.5 IM ___ AbsNeut-10.10* AbsLymp-2.05 AbsMono-1.02*
AbsEos-0.47 AbsBaso-0.07
___ 07:00PM WBC-13.8* RBC-5.05 HGB-14.9 HCT-45.0 MCV-89
MCH-29.5 MCHC-33.1 RDW-13.6 RDWSD-43.7
MICROBIOLOGY:
==============
___ Urine Culture: No growth
KEY IMAGING/RESULTS:
====================
___ GI Bleed Embolization:
FINDINGS:
Inferior mesenteric arteriogram demonstrated active
extravasation into the
sigmoid colon.
Cone beam CT aortogram dissection of the inferior mesenteric
artery ostium, with only a few mm distal extension, no
associated aortic dissection, and patent inferior mesenteric
artery distal to the short-segment dissection.
IMPRESSION:
Active extravasation was seen into the sigmoid colon from a
branch of the
inferior mesenteric artery, however due to iatrogenic
short-segment inferior mesenteric artery dissection,
embolization could not be safely performed.
The inferior mesenteric artery remains patent distal to the
ostium.
___ Sigmoidoscopy:
Impression:
Multiple blood clots were visualized throughout the visualized
colon. The prep was poor. There were multiple non bleeding
divertiuculi seen. No visible active bleeding seen. Multiple
diverticuli seen. Scope was advanced up to 40 cm into sigmoid
colon at which point solid stool was encountered and scope was
withdrawn.
Recommendations:
-No source of active bleeding seen, multiple clots and some red
blood suggestive of recent bleeding was seen
-Continue to monitor for signs of active bleeding, appreciate ___
and colorectal surgery evaluation
-If Hb remains stable and no signs of active bleeding, may
advance diet
DISCHARGE LABS:
================
___ 04:32AM BLOOD WBC-11.1* RBC-3.36* Hgb-10.0* Hct-30.5*
MCV-91 MCH-29.8 MCHC-32.8 RDW-14.6 RDWSD-48.8* Plt ___
___ 04:32AM BLOOD Glucose-93 UreaN-18 Creat-0.7 Na-146
K-4.1 Cl-115* HCO3-21* AnGap-10
___ 04:32AM BLOOD Calcium-7.8* Phos-1.8* Mg-2.0
Brief Hospital Course:
Ms. ___ is an ___ year old female with a history of atrial
fibrillation (not on AC), and HTN who presented to the ED for
BRBPR with active sigmoidal extravasation seen on CTA who went
for ___ embolization complicated by ___ dissection. Her GI bleed
resolved. She was also noted to have urinary frequency with
suprapubic tenderness and dirty UA, concerning for uncomplicated
UTI. She was started on a 3-day course of Macrobid. On ___, she was noted to have some redness and serous drainage from
her prior peripheral IV site, concerning for cellulitis. She was
discharged on a 5-day course of clindamycin.
TRANSITIONAL ISSUES:
====================
[ ] Patient to complete 5 day course of Macrobid ___ BID
(___) for uncomplicated UTI
[ ] Patient to complete 5 day course of Clindamycin 300mg q6h
___ - ___ for L forearm cellulitis
[ ] Diltiazem-ER was decreased to 120mg daily (from 120mg BID)
given hypotension in the setting GI bleed. This can be
uptitrated as an outpatient as needed.
[ ] Trandolapril was held given hypotension in the setting of GI
bleed. This can be restarted in the outpatient setting as
needed.
[ ] Aspirin was held given GI bleeding and unclear indication
for primary prevention (no known CAD). Should consider as an
outpatient
[ ] Patient has AFib but is not anticoagulated: ASA does not
decrease risk of cardioembolic stroke so DCed as above
[ ] Naproxen was held given GI bleed
[ ] Discharge Hgb: 10.0: Please get CBC at first follow up
ACUTE ISSUES:
===============
#Bright red blood per rectum:
#Diverticular bleed:
# Inferior Mesenteric Artery Dissection:
Patient had sudden onset bright red blood per rectum that was
painless. There were multiple occasions that prompted her to
present to an outside hospital, where her hemoglobin on
presentation was 12.3 with a subsequent point-of-care hemoglobin
that was 10.9 4 hours later (baseline hgb ___. She
underwent a CTA there that showed a focus of active
extravasation near the sigmoid colon with colonic diverticula,
and was transferred to ___ for further management. She
was transfused at the outside hospital and then on arrival after
evaluation by both GI and ___ she was taken for an emergent
embolization given her ongoing visualized bleeding. The
attempted embolization was not performed due to ___ dissection
during the procedure. Her hemoglobin remained stable and was
10.7 on discharge from the ICU. Bleed was likely triggered by
NSAID use, which patient was instructed to discontinue going
forward. Aspirin was held.
#Uncomplicated UTI:
Patient reported urinary frequency and suprapubic discomfort. A
urinalysis was grossly positive for urinary tract infection. The
patient was started on Macrobid for a 5-day course.
#Cellulitis:
On ___, the patient was noted to have some redness
overlying 1 of her peripheral IV sites. Her skin was reportedly
pruritic but not tender. There was some serous drainage from the
prior IV site but no purulence noted. She was started at
discharge on clindamycin 300 mg 4 times a day for 5 days.
CHRONIC ISSUES:
===============
#Atrial fibrillation:
Patient with prior history of atrial fibrillation not on
anticoagulation given history of ocular hemorrhage. CHADsVASC 4.
Diltiazem was fractionated and her ASA, which she takes for
anticoagulation for her afib, was held during her bleeding
episode. Note that ASA does not decrease risk of cardioembolic
stroke but does increase risk of major bleeding so would
continue to hold ASA unless giving for primary prevention of
CAD, though she likely would not benefit from this either.
#Hyperlipidemia:
Continued home atorvastatin 20 mg daily
#HTN:
Held home trandolapril 2mg BID given her ongoing bleed. The
patient's home diltiazem was halved given hypotension in the
setting of bleeding.
#Chronic Back Pain:
# Osteoporosis:
Acetaminophen 650mg PRN
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Trandolapril 2 mg PO BID
2. Lidocaine 5% Ointment 1 Appl TP TID
3. Levobunolol 0.5% 1 DROP BOTH EYES DAILY
4. Diltiazem Extended-Release 120 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Aspirin 162 mg PO DAILY
7. Vitamin D 400 UNIT PO DAILY
8. Simvastatin 20 mg PO QPM
9. Naproxen 500 mg PO Q12H:PRN Pain - Mild
10. Methocarbamol 500 mg PO QHS:PRN Muscle Spasm
11. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
Discharge Medications:
1. Clindamycin 300 mg PO Q6H Duration: 5 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth four times a
day Disp #*20 Capsule Refills:*0
2. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*7 Capsule Refills:*0
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Levobunolol 0.5% 1 DROP BOTH EYES DAILY
6. Lidocaine 5% Ointment 1 Appl TP TID
7. Methocarbamol 500 mg PO QHS:PRN Muscle Spasm
8. PreserVision AREDS-2 (vit C,E-Zn-coppr-lutein-zeaxan)
250-200-40-1 mg-unit-mg-mg oral DAILY
9. Simvastatin 20 mg PO QPM
10. Vitamin D 400 UNIT PO DAILY
11. HELD- Aspirin 162 mg PO DAILY This medication was held. Do
not restart Aspirin until told by your cardiologist
12. HELD- Naproxen 500 mg PO Q12H:PRN Pain - Mild This
medication was held. Do not restart Naproxen until told by your
doctor
13. HELD- Trandolapril 2 mg PO BID This medication was held. Do
not restart Trandolapril until told by your doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Inferior mesenteric artery dissection
Diverticular bleed
Uncomplicated urinary tract infection
-Cellulitis
Secondary diagnoses:
Atrial fibrillation
Hyperlipidemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
================================================
Discharge Worksheet
================================================
Dear Ms. ___,
WHY WERE YOU ADMITTED?
-You came to ___ because you are having bleeding
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
-In the hospital, you were found to have bleeding in your large
intestine and transferred to ___.
The interventional radiology team attempted to stop the
bleeding through a procedure, but the procedure was stopped due
to a complication with 1 of your blood vessels.
You were also found to have a urinary tract infection and were
treated with antibiotics.
You were also found to have infection of your skin surrounding
1 of your IV sites and were treated with antibiotics.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please be sure to attend your follow up appointments (see
below)
- Please take all of your medications as prescribed (see below).
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19921130-DS-6 | 19,921,130 | 20,086,609 | DS | 6 | 2164-05-17 00:00:00 | 2164-05-17 23:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Losartan / metformin
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None this hospitalization.
History of Present Illness:
This patient is an ___ female with a history of HTN,
psychosis, and recent Right breast partial mastectomy with 20 cm
tissue rearrangement for a fungating poorly-differentiated
breast tumor on ___ who is presenting for evaluation of
weakness and found to have a fever. She has had generalized
weakness for past day. Reports difficulty getting up, fevers to
101 at home.
Family said drainage from breast wound in JP has been more foul
smelling but serosanguinous. Patient denies any cough,
congestion, cp, sob, abd pain, n/v/d, dysuria, flank pain, HA,
confusion. She spoke with her breast surgery clinic, and was
instructed to come in for evaluation. She had her JP drain
removed in clinic today.
In the ED, initial vital signs were: 100.8 72 145/45 18 99% RA.
The patient was given acetaminophen and evaluated by the surgery
team. The patient was noted to have grossly normal labs,
borderline UA and normal CXR. The surgical consult did not feel
the breast wound looked infected and the patient was admitted to
medicine for workup. The patient was not given ABX in the ED.
On arrival to the floor the patient was asymptomatic with VS:
97.3 113/40 70 16 98RA. The patient was noted to have some
oozing from the JP drain site and erythema around the closure
site over the right breast. It is unclear if this is normal
post-op changes. The patient had no tenderness or discomfort
over the area.
Past Medical History:
- Poorly differentiated carcinoma of the right chest wall with
possible breast primary (ER negative, PR negative, HER-2
negative) with local recurrence following excisional biopsy BI
___ on ___, now s/p right breast partial mastectomy with
20 cm tissue rearrangement by Dr. ___ in ___
- Hypertension
- Hypothyroidism
- DMII
- Depression with Psychosis
- Osteoporosis
- Anxiety
- Macular Degeneration
- s/p sigmoid colectomy in ___ at ___ for benign adenoma
- s/p cholecystectomy
Social History:
___
Family History:
Paternal cousin with breast cancer.
Physical Exam:
========================
Admission Physical Exam:
========================
VITALS: Temp 98.4/98.4, BP 133/47, HR 81, RR 18, O2 sat 99% RA.
GENERAL: Pleasant, elderly woman, in no apparent distress.
HEENT: Normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
BREAST: Right breast with large well-healing 10cm incision
laterally across the breast without clear erythema or drainage.
PULMONARY: Clear to auscultation bilaterally.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing. Right
leg with 1+ pitting edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout in upper extremities; ___ in lower
extremities.
========================
Discharge Physical Exam:
========================
Vitals: Temp 98.0/99.2, BP 142/68, HR 82, RR 18, O2 sat 99% RA.
Exam otherwise unchanged.
Pertinent Results:
===============
Admission Labs:
===============
___ 06:35PM BLOOD WBC-9.0 RBC-3.35* Hgb-10.4* Hct-32.2*
MCV-96 MCH-31.0 MCHC-32.3 RDW-13.9 RDWSD-48.9* Plt ___
___ 06:35PM BLOOD Neuts-67.3 ___ Monos-11.1
Eos-0.3* Baso-0.2 Im ___ AbsNeut-6.04 AbsLymp-1.87
AbsMono-1.00* AbsEos-0.03* AbsBaso-0.02
___ 06:35PM BLOOD ___ PTT-24.5* ___
___ 06:35PM BLOOD Glucose-105* UreaN-15 Creat-0.5 Na-136
K-3.9 Cl-101 HCO3-24 AnGap-15
___ 07:55PM BLOOD Lactate-1.1
___ 10:42AM BLOOD Albumin-3.5 Calcium-9.1 Phos-2.9 Mg-2.0
===============
Discharge Labs:
===============
___ 06:54AM BLOOD WBC-5.4 RBC-3.42* Hgb-10.5* Hct-33.5*
MCV-98 MCH-30.7 MCHC-31.3* RDW-14.0 RDWSD-50.1* Plt ___
___ 06:54AM BLOOD Glucose-96 UreaN-20 Creat-0.5 Na-140
K-4.1 Cl-104 HCO3-25 AnGap-15
=============
Microbiology:
=============
___ Influenza PCR - Negative
___ Blood Culture x 2 - Pending
___ Urine Culture - Mixed Bacterial Flora
========
Imaging:
========
CXR ___
Impression: No acute cardiopulmonary abnormality.
Right Lower Extremity Duplex Ultrasound ___
Impression: No evidence of deep venous thrombosis in the right
lower extremity veins.
Brief Hospital Course:
Ms. ___ is an ___ female with a history of
hypertension, depression, and recent right breast partial
mastectomy for a fungating poorly-differentiated breast tumor
who presents with generalized weakness/failure to thrive and a
fever to 100.8 in the ED.
# Generalized Weakness/Invasive Breast Cancer: No clear sources
of infection. No metabolic abnormalities or clear reason for
weakness. Thought that her weakness and overall fatigue may be
related to poorly differentiated invasive ductal carcinoma for
which she recently underwent a right breast partial mastectomy.
She has had no further work-up of her cancer and was scheduled
to follow-up with breast clinic. At this time, the patient was
not interested in knowing her diagnosis and not interested in
further treatment including chemotherapy and radiation. She may
have metastatic disease of which can be contributing to her
generalized weakness. She was evaluated by ___ who recommended
rehab given no supervision at home. Rehab stay anticipated less
than 30 days. Please continue goals of care discussion
# Fever: Patient spiked on fever to 100.8 in the ED. Initial
concern for breast cellulitis and started on vancomycin.
However, exam is reassuring. Per surgical evaluation in the ED
there was no evidence of infection. CXR and UA negative.
Currently afebrile and feeling well. Vancomycin was discontinued
and she had not further fevers with negative cultures. Possible
cause of low-grade fever also includes her malignancy.
# Hypertension: Continued home losartan. Held home atenolol.
# Depression/Anxiety: Continue home doxepin.
# Hypothyroidism: Continued home levothyroxine.
====================
Transitional Issues:
====================
- Atenolol discontinued at time of discharge. Please continue to
monitor blood pressure and heart rate and restart as needed.
- Patient with invasive ductal carcinoma. Concern for potential
metastasis given extent of disease. At this time, patient was
not interested in further work-up or treatment. Please continue
to address goals of care and consider hospice referral as well
as Palliative Care follow-up.
- Please ensure follow-up with Oncology, Breast Surgery, and
PCP.
- Please follow-up pending blood cultures from ___.
- ___ stay anticipated less than 30 days.
- Contact: ___ (daughter/HCP) ___ (home)
___ (cell)
- Code Status: Full Code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atenolol 25 mg PO DAILY
3. Doxepin HCl 50 mg PO HS
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Doxepin HCl 50 mg PO HS
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Weakness
- Invasive Breast Cancer
Secondary Diagnosis:
- Hypertension
- Depression/Anxiety
- Hypothyroidism
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 ___
___. You were admitted to the hospital
because of weakness. You were evaluated for a possible infection
which did not show any signs of infection. Your other blood work
did not show any cause of your weakness. It is very possible
that your weakness is related to your other medical conditions.
You were evaluated by Physical Therapy. They recommended to go
to rehab for a short period to regain your strength.
You have several follow-up appointments which are listed below.
All the best,
Your ___ Team
Followup Instructions:
___
|
19921217-DS-15 | 19,921,217 | 22,370,196 | DS | 15 | 2146-06-29 00:00:00 | 2146-07-30 18:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"non healing foot ulcer"
Major Surgical or Invasive Procedure:
- None.
History of Present Illness:
___ Hispanic F with significant vascular history ___ bypass
___, revision ___, HTN, DMII, HLD p/w non-healing foot ulcer.
She has a had an ulcer on the ___ digit of L foot since ___.
It started as a small, pinpoint-sized ulceration that appeared
without any preceding trauma/injury to foot. Since ___,
the wound has steadily worsened, most noticeably in the last
couple of weeks & now occupies the entire plantar surface of the
toe. She has also had increased lower extremity pain (L worse
than R) that has significantly limited her walking (she
previously was able to walk all day "until ___ pm" & now cannot
walk for more than 5 minutes).
.
Ms. ___ has also had 2 presyncopal/syncopal episodes in the
past 10d (8d ago & 3d ago). These episodes are poorly described,
but the first came on 10 days ago. She was seated at the time
when she suddenly lost vision in both of her eyes & subsequently
developed right arm numbness & paralysis. The numbness spread to
the rest of her body several minutes later. While the numbness &
paralysis resolved after several minutes, she stated that her
vision did not return for approx. 30 minutes.
.
The second episode took place 3 days ago. Ms. ___ states that
she was seated when she felt some "heavy" chest pain that began
in the ___ her chest and radiated to both sides as well as
her back. There was no assocaited SOB, diaphoresis, n/v. She
also lost her vision during this episode & states that she
fainted for roughly 3 minutes.
.
Of note, the patient recalls her blood glucose being low around
the time of these events (in the ___. Last BS = 131 on
___. Has continued to take medications as prescribed.
.
Pt also reports intermittent abdominal pain with diarrhea. She
has had diarrhea ___ times per day for the past several months.
.
Vital signs in the ED:
T: 97 HR: 80 BP: 126/54 RR: 18 O2: 100%
.
In the ED, CXR & foot films were obtained, labs drawn. 1L NS,
repeat lactate 2.2.
.
REVIEW OF SYSTEMS:
(+): DOE, bilateral leg & foot pain, subjective "fevers &
chills"
(-): HA, changes in hearing, change in taste, weakness,
myalgias, palpitations, cough, wheezing, constipation, dark
stool, hematochezia, dysuria, urinary frequency/urgency, poor PO
intake, arthralgias, rashes.
Past Medical History:
PAST MEDICAL HISTORY:
- Peripheral Artery Disease
----> ___: SVG from L SFA to ___
----> ___: L great toe amputation
----> ___: Debridement of wounds on L lower extremity
----> ___: Revision of L SFA to ___ bypass graft with R
cephalic v
----> ABIs ___: 0.5 on R, 0.8 on L
- HTN
- DMII
- HLD
.
PAST SURGICAL HISTORY:
- Total abdominal Hysterectomy
- Tubal ligation
- Vascular procedures as outlined above
.
Stress MIBI ___ with atypical symptoms without ischemic EKG
change on exercise portion and moderate, reversible perfusion
defect in the apical portion of the anterior with associated
hypokinesis. Left ventricular ejection fraction of 56%.
Social History:
___
Family History:
FAMILY HISTORY:
- Father: Died at an old age with dementia
- Mother: Died of unspecified cancer
- Strong history of diabetes among siblings
- 3 daughters, 2 sons: 1 son with diabetes
Physical Exam:
Admission PE
GEN: Well-appearing, NAD.
HEENT: NCAT, MMM. OP clear.
NECK: Soft, no carotid bruits.
COR: +S1S2, RRR, no m/g/r.
PULM: CTAB, no c/w/r.
___: +NABS in 4Q. Soft, NTND.
EXT: Dry ischemic deep ulcer of ___ toe on L foot with bone
protrusion. DP, ___ pulses monophasic on L, biphasic on R. ABI
.65 on R, 0.4 on L.
NEURO: SCM intact, VFF, palate elevation midline, facial
sensation intact, EOMI intact (although R eye deviated),
shoulder shrug intact.
Discharge PE
VS: Tm-98.2 Tc-98.2 HR-65 BP-120/70 RR-18 SaO2-98 RA
-unchanged
Pertinent Results:
EKG ___
Sinus rhythm. Left ventricular hyertrophy with repolarization
changes.
However, the upward ST segment in leads V2 and V3 and T wave
inversions
in leads V4-V6 are worrisome for an acute myocardial process.
Clinical
correlation is suggested.
.
___
Precordial lead placement is apparently significantly altered.
Otherwise,
no significant change.
.
___ CXR
IMPRESSION: No acute intrathoracic process with top normal heart
size.
.
___ MRI/MRA
CONCLUSION: Intracranial atheromatous disease as described
above. No
evidence of infarction.
.
BC negative X2
.
TnI negative X2
.
Brief Hospital Course:
ASSESSMENT: ___ F vasculopath s/p SVG (L SFA to ___ ___ which
required revision in ___, DM2 presents with non-healing toe
ulcer since ___ & presyncopal episodes.
.
# L ___ Toe Ulcer:
Most likely an ischemic/arterial ulcer given know PAD & prior
interventions on L left leg. No evidence of infection currently.
Plain films of the foot not consistent with osteomyelitis or
soft tissue infection. CRP/ESR also not in osteomyelitis range.
Vascular surgery and podiatry were consulted in house and both
recomended outpatient follow up and wound care for the toe.
.
# Presyncope/Syncope:
The etiologies of these episodes was considered after a work up
either due to dehydration or hypoglycemia. She had reported a
blood glucose in the 50 range and also abdominal pain and
diarrhea in the vicinity of these episodes. CVA/TIA was
considered as an etiology of these episodes and an MRI/MRA was
done which didn't reveal any evidence of infarction but
atheromatous disease in her intracranial vasculature. The
patient did not have any further episodes in house. The patient
also had serial TnI's drawn which were negative, had no events
on tele and had no progressive EKG changes. The patient should
have a TTE done as an outpatient. We added a beta blocker and
statins for secondary prevention and lipid management. We also
discontinued her glyburdie and increased her metformin. Her
diabetic regimen likely needs to further modified as an
outpatient. The outpatient care plan was reviewed with case
management/SW and it was determine that the patient got free
care and it was possible for her to get these tests as an
outpatient.
.
# ___
You Hgb A1C was 11.6 in house. We stopped you glyburide and
increased your metformin prior to your discharge. It is likely
that you will need to be started on insulin as an outpatient.
.
#HLD
You lipids were checked in house and your LDL was 153. We
changed your lovastatin to atorvastatin for more aggresive lipid
management.
.
#Transitional Issues:
-Follow up with PCP ___ ___ weeks for further diabetic regimen
titration
-Follow up with Vascular surgery and Podiatry for further
management of your toe ulcer
-Please arrange for an outpatient TTE and if abdnormal consider
following up with a Cardiologist
Medications on Admission:
MEDICATIONS:
- Calcium 600 + D(3) 600 mg-400 2 Tablet(s) BID
- Ecotrin 325 mg QD
- Lisinopril 20 mg QD
- Lovastatin 20 mg QD
- Glyburide 5 mg QD
- Metformin SR 1000 mg Q24H
- Gabapentin 400 mg BID
Discharge Medications:
1. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO BID (2 times a day).
2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: Two (2) Tablet, Chewable PO BID (2 times a day).
3. gabapentin 400 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*2*
5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2
times a day).
Disp:*30 Tablet(s)* Refills:*2*
7. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. metformin 500 mg Tablet Extended Release 24 hr Sig: Three (3)
Tablet Extended Release 24 hr PO twice a day.
Disp:*180 Tablet Extended Release 24 hr(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Non-healing arterial ulcer
- Syncope
SECONDARY DIAGNOSES:
- Peripheral Artery Disease
- Coronary artery disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, it was a pleasure to participate in your care while
you were at ___. You came to the hospital because you had a
non-healing ulcer on your left foot. Given your history of
peripheral arterial disease, we had the vascular surgeons
evaluate your toe. This toe ulcer is is the result of poor
blood flood to your feet. The vascular team would like you to
have ultrasound studies of your legs to evaluate blood flow,
which will take place after you leave the hospital. We also had
podiatry evaluate your toe, and they felt you should followup
with the vascular surgeons as an outpatient but that there was
no indication for their services at this time.
You also came in with 2 episodes of visual disturbance and
passing out in the past 10 days. It was difficult to determine
the cause of these symptoms. We monitored your heart while you
were and did not find any abnormal heart beats that would
explain these symptoms. We also did an MRI of your head to
determine if a problem with the blood flow in your brain could
be causing these symptoms. It showed no abnormalities that
would account for the findings.
MEDICATION CHANGES:
- Medications ADDED:
---> Please start taking metoprolol 12.5 mg twice a day. This
medication is important for heart health.
---> Please start Atorvastatin 40mg daily.
- Medications STOPPED: Glyburide, Lovastatin
- Medications CHANGED:
---> Please increase your dose of metformin from 1000mg daily to
1500mg twice daily.
Should you have any symptoms concerning to you, please call your
doctor or go to the emergency room.
Followup Instructions:
___
|
19921217-DS-17 | 19,921,217 | 24,498,868 | DS | 17 | 2147-10-03 00:00:00 | 2147-10-03 14:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
necrotic toe
Major Surgical or Invasive Procedure:
___ - diagnostic angiography
History of Present Illness:
___ female with peripheral artery disease, diabetes,
osteomyelitis of left foot presenting with necrotic toe. Pt
states that for the last 8 days her right pinky toe has been
bothering her but noted worsened pain yesterday to the point she
could not walk on it. She was in ___ where she was treated
with an antibiotic and returned today. Believes she was having
fevers last ___. Also complains of throat pain that
began on evening of presentation, resolved by time she was
evaluated at ED.
Of note, she was last admitted in ___ for left foot pain and
was found to have osteomyelitis. She underwent angiography of
LLE with stening of left superficial femoral artery and PTA of
peroneal artery. She underwent amputation of left ___ toe.
In the ED, initial VS were: 98.2 82 133/60 18 100% ra. He
received IV unasyn, IV vancomycin, and oxycodone. She was
evaluated by podiatry who agreed with admission to medicine.
Past Medical History:
- Peripheral Artery Disease
----> ___: SVG from L SFA to ___
----> ___: L great toe amputation
----> ___: Debridement of wounds on L lower extremity
----> ___: Revision of L SFA to ___ bypass graft with R
cephalic v
----> ABIs ___: 0.5 on R, 0.8 on L
- HTN
- DMII
- HLD
- Total abdominal Hysterectomy
- Tubal ligation
- Vascular procedures as outlined above
Social History:
___
Family History:
- Father: Died at an old age with dementia
- Mother: Died of unspecified cancer
- Strong history of diabetes among siblings
- 3 daughters, 2 sons: 1 son with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.4 144/66 77 18 100%RA
GENERAL: well appearing, no acute distress
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, JVD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: 2+ pitting edema b/l, right ___ toe is black and
painful to touch. Faint DP pulses b/l.
NEURO: awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
___ 09:50PM BLOOD WBC-11.1*# RBC-4.45 Hgb-11.3* Hct-37.3
MCV-84 MCH-25.4*# MCHC-30.3* RDW-13.7 Plt ___
___ 09:50PM BLOOD Neuts-55.3 ___ Monos-4.2 Eos-3.2
Baso-0.9
___ 09:50PM BLOOD Glucose-256* UreaN-30* Creat-1.0 Na-135
K-4.5 Cl-97 HCO3-25 AnGap-18
___ 09:55PM BLOOD Lactate-2.0
___ 09:50PM BLOOD CRP-14.6*
___ 09:50PM BLOOD ESR-60*
___ 09:50PM BLOOD cTropnT-<0.01
MICRO:
___ Blood Culture, Routine-PENDING
EKG: normal sinus rhythm. Axis appears normal with leftward
tendency. Normal intervals. TWI in lead aVL is stable. Otherwise
without ST changes and similar to prior.
IMAGING:
___ CHEST (PA & LAT):The lungs are clear without
consolidation or edema. There is no Preliminary Reportpleural
effusion or pneumothorax. The cardiomediastinal silhouette is
normal.
___ RIGHT FOOT AP,LAT & OBL RIGHT: There is soft tissue
swelling overlying the left fifth toe. There is no subcutaneous
gas. The underlying bone appears normal without erosions or
resorption. No fracture or dislocation is identified. There is a
moderate amount of degenerative changes with spurring at the
tibiotalar joint and the calcaneus. Vascular calcifications are
noted.
Brief Hospital Course:
___ female with peripheral artery disease, diabetes,
history of osteomyelitis of left foot presenting with necrotic
right ___ figit of the right lower extremity.
# RIGHT FIFTH TOE ISCHEMIA ARTERIAL ULCER - Evidence of an
aterial ulceration with overlying eschar of the right ___ digit.
No purulent drainage or surrounding erythema. Started on
Vancomycin, Ciprofloxacin and Metronidazole overnight and
continued to empirically cover MRSA, gram negative and anaerobic
organisms. Radiographs of the foot and toe were without evidence
of osteomyelitic changes. Inflammatory markers were elevated on
admission. Podiatry was initially consulted and recommended
antibiotics, however, vascular surgery was notified and admitted
the patient to their service given the need for further
non-invasive arterial imaging of the right lower extremity with
the plan for possible angiography and intervention. We continued
her daily Aspirin dosing on admission. She discontinued
clopidogrel 2.5 months prior.
# THROAT PAIN - Vague sore throat on admission in a diabetic
patient warranted EKG evaluation and cardiac enzymes, which were
both reassuring and without evidence of ischemia.
# INSULIN-DEPENDENT DIABETES MELLITUS - Glucose well controlled
on admission. Held oral hypoglycemic agent given potential need
for angiography; started on insulin sliding scale for glucose
control.
# HYPERTENSION - Continue home Furosemide and Amlodipine for
blood pressure control.
TRANSITIONAL CARE ISSUES:
1. Medication reconcilation needs to be performed.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Gabapentin 600 mg PO BID
5. Acetaminophen 1000 mg PO Q8H
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Senna 2 TAB PO BID:PRN constipation
8. Amlodipine 10 mg PO DAILY
9. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral BID
10. Furosemide 20 mg PO DAILY
11. Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO DAILY
4. Gabapentin 600 mg PO BID
5. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Senna 2 TAB PO BID:PRN constipation
7. Acetaminophen 1000 mg PO Q8H
8. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 600 mg(1,500mg) -400 unit Oral BID
9. MetFORMIN (Glucophage) 1000 mg PO BID
10. Sulfameth/Trimethoprim DS 2 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 2
tablet(s) by mouth twice a day Disp #*36 Tablet Refills:*0
11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every 4 hours Disp #*30
Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
status post diagnostic angiography
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Lower Extremity Angioplasty/Stent Discharge Instructions
MEDICATION:
TMP/SMX (Bactrim) double strength once daily
If instructed, take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
19921217-DS-19 | 19,921,217 | 20,697,883 | DS | 19 | 2149-01-12 00:00:00 | 2149-01-12 23:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ___ toe redness/pain
Major Surgical or Invasive Procedure:
R SFA angioplasty and stent
History of Present Illness:
___ is a ___ year old female with a history of right fem
to DP bypass graft on ___, last seen by Dr. ___ ___ clinic
on ___. The patient reports that she has had increased foot
pain for approximately 15 days. She has had a small amount of
light ___ drainage. She denies any motor difficulties, but
has had some numbness ___ the right foot. She has had 3 episodes
of fever over the past 15 days. At home it was measured to be
101.2. She also reports some hand numbness/stiffness.
Past Medical History:
Vascular procedures:
-___: SVG from L SFA to ___
-___: L great toe amputation
-___: Revision of L SFA to ___ bypass graft with R cephalic v
-___: LLE angio - mod-severe stenosis distal SFA into AK
pop, occluded AT & TP w/ reconstitution, occluded ___
-___: L peroneal PTA, stent PTA
-___: L ___ ray amp
Other surgeries: total abdominal hysterectomy, tubal ligation
Social History:
___
Family History:
- Father: Died at an old age with dementia
- Mother: Died of unspecified cancer
- Strong history of diabetes among siblings
- 3 daughters, 2 sons: 1 son with diabetes
Physical Exam:
97.8 78 148/68 16 99%
Gen: No acute distress, alert, responsive
Pulm: unlabored breathing, no respiratory distress
CV: regular rate and rhythm
Abd: soft, nontender, nondistended
Ext: warm, increased swelling on right foot, bilaterally grafts
weakly palpable, eschar on right, prior left ___ and ___ toe
amputation sites
L: p/p/d/d
R: p/p/d/d
Discharge physical exam
Vitals: 98.4 65 126/61 18 97RA
General: no acute distress, alert responsive
Pulm: no respiratory distress
CV: regular rate and rhythm
Abd: obese, soft, nontender, nondistended, +BS
Ext: warm, right ___ toe amputation with stitches, pale with
slow capillary refill at amputation site, prior left ___ and ___
toe amputation sites
L: p/p/d/d
R: p/p/p/d
Pertinent Results:
LABS:
___ 06:10AM BLOOD WBC-10.2 RBC-3.54* Hgb-10.2* Hct-31.4*
MCV-89 MCH-28.7 MCHC-32.3 RDW-13.0 Plt ___
___ 06:10AM BLOOD Glucose-106* UreaN-16 Creat-0.9 Na-134
K-4.4 Cl-102 HCO3-27 AnGap-9
___ 06:10AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.9
___ 04:41AM BLOOD %HbA1c-12.0* eAG-298*
___ 04:41AM BLOOD CRP-27.4*
___ 06:15PM BLOOD Vanco-16.8
IMAGING:
Foot X-ray (___)
Findings highly worrisome for acute osteomyelitis involving the
first distal phalanx, as above, with associated gas ___ the soft
tissue which may ___ part relate ulceration versus additional
focus of subcutaneous gas. Soft tissue swelling.
Left lower extremity arterial duplex (___)
Native proximal left SFA is patent; however, no graft was
identified, likely occluded.
Vein mapping (___)
Bilateral great saphenous veins were not identified, consistent
with given clinical history of great saphenous vein harvesting.
The right small saphenous vein is patent and ranges ___ diameter
from 0.25-0.34cm. The right small saphenous vein measures 0.34
cm at the level of the knee
and 0.25 cm at the level of the ankle. The left small saphenous
vein is patent and ranges ___ diameter from 0.14cm to 0.22 cm.
The left small saphenous vein measures 0.22 cm at the level of
the knee and 0.14 cm at the level of the ankle.
MICROBIOLOGY
___ 2:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:55 am SWAB Source: R hallux.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
WORKUP REQUESTED BY ___. ___ ___.
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 BELOW, THEY ARE NOT
PRESENT ___
this culture..
Work-up of organism(s) listed below discontinued
(excepted
screened organisms) due to the presence of mixed
bacterial flora
detected after further incubation.
___. SPARSE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
___
| ENTEROCOCCUS SP.
| |
STAPHYLOCOCCUS, COAGULASE N
| | |
AMPICILLIN------------ <=2 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
CLINDAMYCIN----------- <=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=1 S =>16 R
LEVOFLOXACIN---------- 4 R
MEROPENEM-------------<=0.25 S
OXACILLIN------------- =>4 R
PENICILLIN G---------- 2 S
PIPERACILLIN/TAZO----- <=4 S
RIFAMPIN-------------- =>32 R
TETRACYCLINE---------- 2 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
VANCOMYCIN------------ 1 S 1 S
ANAEROBIC CULTURE (Preliminary):
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens,
and C.septicum is being ruled out.
___ 9:56 am TISSUE Source: R hallux bone.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM NEGATIVE COCCI.
TISSUE (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 BELOW, THEY ARE NOT
PRESENT ___
this culture..
FURTHER WORK UP REQUESTED BY ___. ___ ___
___.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___-___ ___.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
___. RARE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___-___
___.
ANAEROBIC CULTURE (Preliminary):
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens,
and C.septicum is being ruled out.
___ 1:18 pm TISSUE RIGHT HALLUX MARGIN.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Preliminary):
GRAM POSITIVE BACTERIA. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 1:19 pm TISSUE RIGHT HALLUX.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI ___
PAIRS.
TISSUE (Preliminary):
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Brief Hospital Course:
Patient was admitted to the vascular surgery inpatient service
for evaluation and treatment of her right ___ toe ulcer. Xray of
right foot was highly suggestive for osteomyelitis. She was
started on Vanc, Cipro, and flagyl (___). Angiogram on ___
showed occluded right fem-DP bypass graft. Angioplasty and stent
of the right SFA was performed to increase inflow to the right
lower extremity. Left arterial duplex was performed, showing a
patient native proximal SFA and no visualization of a bypass
graft (likely occluded). Vein mapping was also performed for
potential bypass conduit. Per ID recs, cipro was changed to
cefepime starting ___.
On post-op day one, podiatry performed beside debridement and
bone biopsy of her right ___ toe. Bone and tissue cultures were
sent to microbiology for speciation. PICC line was placed on
___. PICC line was pulled back by 5cm per follow-up CXR. She
was taken back to the OR on ___ to improve distal flow to her
___ toe. Balloon angioplasty was performed on her right AT
artery via both contralateral femoral artery access and
retrograde access through the dorsalis pedis artery.
Post-operatively, she had a palpable DP. On ___, her distal
right first hallux was amputated by podiatry and closed with
nondisolvable sutures. Tissue cultures were sent to
microbiology.
The infectious disease team helped aid ___ the management of
patient's antibiotic regimen. Per ID, the patient will be
transferred to rehab on Vanc, cipro PO, and flagyl PO for
diabetic polymicrobial osteomyelitis infection. Abx course
should be at least 6 weeks, but will be tailored clinically by
the rehab physicians. At time of transfer, patient was afebrile
and stable. She will have close follow-up with vascular surgery
and podiatry ___ the outpatient setting.
Medications on Admission:
amlodipine 10 mg', gabapentin 600 mg'', glipizide 10 mg'',
Lantus 20 units SC qPM, Lopressor 50 mg',
Pravachol 40 mg', aspirin 81 mg', Calcium carbonate-Vit D3, ISS
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. CefePIME 2 g IV Q24H
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Gabapentin 600 mg PO Q12H
8. GlipiZIDE 5 mg PO BID
9. Glargine 20 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
10. Metoprolol Succinate XL 50 mg PO DAILY
11. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
13. Pravastatin 40 mg PO DAILY
14. Vancomycin 750 mg IV Q 12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R ___ toe osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATION:
Take Aspirin 325mg (enteric coated) once daily
Take Plavix (Clopidogrel) 75mg once daily
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the legs:
Elevate your leg above the level of your heart with pillows
every ___ hours throughout the day and night
Avoid prolonged periods of standing or sitting without your
legs elevated
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist ___ wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over groin incision,
rinse and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain ___ lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from groin puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site)
Lie down, keep leg straight and have someone apply firm
pressure to area for 10 minutes. If bleeding stops, call
vascular office ___. If bleeding does not stop, call
___ for transfer to closest Emergency Room.
Followup Instructions:
___
|
19921217-DS-20 | 19,921,217 | 28,251,378 | DS | 20 | 2151-11-12 00:00:00 | 2151-11-16 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
iodine
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ Percutaneous ultrasound-guided biopsy of omental
thickening and diagnostic paracentesis of ascitic fluid.
___ Cardiovascular Cath, POBA
History of Present Illness:
___ year old female with a history of PVD (s/p bypass procedures
of bilateral LEs, toe amp), hypertension, IDDM2, who presents
with abdominal pain.
Patient is a poor historian. She returned from ___ last
week after being there for 4 months. She has not been seen by a
physician in greater than one year according to both her and her
daughter. It is not entirely clear how she has been getting her
medications, including insulin, filled. Her daughter thinks she
is getting them filled in ___ without seeing a doctor.
They do not know what her medications are, but think the
patient's husband, who is in ___, will be able to help
clarify when they call him in the morning.
Patient reports 5 days of nausea and vomiting that resolved
about 1 week ago. After that time she has had RLQ pain that has
now become diffuse sever abdominal pain. The pain continued to
get worse so she came to the ED for evaluation. Denies any known
history of TB or close exposures to anybody with TB. She denies
fevers, chills, chest pain, shortness of breath.
In the ED, VS were T 99.1, P 84, BP 146/66, RR 18, O2 99%. Exam
notable for RLQ tenderness. Labs notable for Na 130, WBC 12.7.
CT abdomen with contrast showed extensive omental fat stranding
and nodularity most likely due to peritoneal carcinomatosis, but
could consider TB peritonitis or abdominal mesothelioma (less
likely). Also showed focal loop of proximal jejunum dilated to
4.3cm with transition point and tethering of multiple loops of
bowel concerning for partial SBO. She was seen by surgery, who
recommended NPO, IVF, no NGT, admit for evaluation of peritoneal
carcinomatosis.
Past Medical History:
- PVD (s/p bypass procedures of bilateral LEs, toe amp)
- Hypertension
- IDDM2
Vascular procedures:
-___: SVG from L SFA to ___
-___: L great toe amputation
-___: Revision of L SFA to ___ bypass graft with R cephalic v
-___: LLE angio - mod-severe stenosis distal SFA into AK
pop, occluded AT & TP w/ reconstitution, occluded ___
-___: L peroneal PTA, stent PTA
-___: L ___ ray amp
Other surgeries: total abdominal hysterectomy, tubal ligation
Social History:
___
Family History:
- Father: Died at an old age with dementia
- Mother: Died of unspecified cancer
- History of diabetes among siblings
- 3 daughters, 2 sons: 1 son with diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital signs: T 98.2, BP 165/73, P 91, RR 17, O2 95% RA
Gen: Well appearing, in no apparent distress
HEENT: NCAT, oropharynx clear
Lymph: no cervical lymphadenopathy
CV: No JVD present, regular rate and rhythm, no murmurs
appreciated
Resp: CTA bilaterally in anterior and posterior lung fields, no
increased work of breathing
GI: Obese, mildly distended abdomen, diffuse tenderness with
light-palpation, +rebound
GU: No suprapubic tenderness
Extremities: no clubbing, cyanosis, or edema
Neuro: no focal neurologic deficits appreciated. Moves all 4
extremities purposefully and without incident, no facial droop.
Psych: Euthymic, speech non-tangential, appropriate
DISCHARGE PHYSICAL EXAM
=======================
Pertinent Results:
ADMISSION LABS
==============
___ 05:00PM BLOOD WBC-12.7* RBC-3.80* Hgb-9.3* Hct-30.5*
MCV-80* MCH-24.5*# MCHC-30.5* RDW-14.3 RDWSD-41.8 Plt ___
___ 05:00PM BLOOD Neuts-78.9* Lymphs-12.3* Monos-6.8
Eos-0.9* Baso-0.2 Im ___ AbsNeut-10.00* AbsLymp-1.56
AbsMono-0.86* AbsEos-0.11 AbsBaso-0.03
___ 07:45AM BLOOD ___ PTT-26.9 ___
___ 05:00PM BLOOD Glucose-259* UreaN-15 Creat-0.9 Na-130*
K-4.8 Cl-93* HCO3-24 AnGap-18
___ 07:45AM BLOOD ALT-16 AST-15 LD(LDH)-139 AlkPhos-87
TotBili-<0.2
___ 03:43AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 11:00PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 07:45AM BLOOD Albumin-3.0* Calcium-8.8 Phos-3.9 Mg-1.6
___ 07:45AM BLOOD Osmolal-285
___ 07:45AM BLOOD CEA-0.8 CA125-124*
___ 05:16PM BLOOD Lactate-1.7
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:00PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE
Epi-<1
___ 11:09AM URINE Hours-RANDOM UreaN-481 Creat-90 Na-92
Cl-100
___ 11:09AM URINE Osmolal-562
PERTINENT LABS
==============
IMAGING:
CT Abdomen/Pelvis with contrast (___):
1. Extensive omental fat stranding and nodularity with small
volume ascites and areas of avid peritoneal enhancement. While
these are findings most commonly seen with ovarian and GI
metastatic disease, no primary candidate is identified. If
infection is a strong clinical consideration, tuberculous
peritonitis is a consideration, though metastasis with a
nonvisualized primary remains more likely. Much less likely on
the differential is primary abdominal mesothelioma.
2. Wall thickening at the fundus of the gallbladder with poorly
defined margins. While this could be secondary to findings
detailed above, dedicated imaging of the gallbladder is
suggested to further characterize to exclude possible underlying
primary lesion, preferably by MRI.
3. A focal loop of proximal jejunum demonstrates dilation to 4.3
cm with a transition point in the mid abdomen associated with
tethering of multiple loops of bowel. This finding is
concerning for partial small bowel obstruction, though the
duodenum just proximal to this loop of jejunum is not dilated.
4. Cholelithiasis.
5. Severe left hip osteoarthritis.
CYTOLOGY/PATHOLOGY
=====================
___ Pathology Tissue: OMENTUM, BIOPSY
___ Cytology PERITONEAL FLUID
POSITIVE FOR MALIGNANT CELLS.
Consitent with metastatic adenocarcinoma.
See pathology report ___ for further characterization.
One hematopathology reviewed.
CARDIOVASCULAR
=================
___ Cardiovascular ECHO
Conclusions
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). There is mild regional left ventricular systolic
dysfunction with mild focal hypokinesis of the mid to distal
septum. The remaining segments contract normally. The estimated
cardiac index is normal (>=2.5L/min/m2). Doppler parameters are
indeterminate for left ventricular diastolic function. Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no mitral valve prolapse.
The pulmonary artery systolic pressure could not be determined.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild regional left ventricular dysfunction c/w CAD
(LAD distribution) with overall preserved ejection fraction.
Normal right ventricular systolic function.
___ Cardiovascular Cath Physician ___
___ the thrombotic appearance of the RCA
and ongoing ST elevation (confirmed by 12 lead ECG inthe cath
lab) the decision was made to proceed with PCI of the RCA. A 6
___ JR4 guiding catheterwas used to engage the RCA and
provided sub-optimal support. A 180 cm ChoICE ___ XS
Wireguidewire was then successfully delivered across the lesion.
PTCA alone using 2.5 mm balloons wasperformed in the ostium and
proximal RCA as well as the distal RCA. A Guideliner was
necessary todeliver the balloons to the distal RCA. There was
distal 40% stenosis residual after PTCA and the originRCA had
10% residual stenosis. Attention was then turned to the LMCA and
LAD. The patient still ___ chest pain so the decision was
made to intervene. A ChoICE ___ XS wire was placed in the
distalLAD. PTCA was performed of the LMCA and LAD with a 2.5 mm
balloon. THere was residual 30%stenosis in the LMCA and proximal
LAD. The Cx was no suitable for PCI given its small caliber. She
was transferred to the CCU in stable condition still with
residual chest pain.
Impressions:
1. Successful PTCA of the LMCA, LAD and RCA.
Recommendations
1. ASA 81 mg a day
2. Secondary prevention CAD.
3. OK to hold clopidogrel.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
___ year old female with a history of PVD (s/p bypass procedures
of bilateral LEs, toe amp), hypertension, IDDM2, who presents
with abdominal pain, found to have small bowel obstruction,
omental caking and peritoneal carcinomatosis concerning for
metastatic disease and metastatic adenocarcinoma of unclear
primary. Hospital course complicated by anterolateral NSTEMI for
which she went for cardiac catherization on ___ with POBA. Given
goals of care, definitive treatment of malignancy deferred as to
prioritize patient's safe travel back to ___.
HOSPITAL COURSE
# MALIGNANCY
# PERITONEAL CARCINOMATOSIS: Patient presented with omental
nodularity and ascites concerning for an advanced malignancy. ___
consulted to perform ometal biopsy and paracentesis which
confirmed metastatic adenocarcinoma. CEA and CA ___ within
normal limites, but CA 125 elevated at 124 (ULN). Preliminary
biopsy results likely GU primary. Per patient and family's
wishes, would not like to pursue definitive treatment for
malignancy, but rather return to ___. Palliative care
consulted who recommended concentrated oral morphine, oral
Ativan, and IV fluids. On ___ confirmed with family that
preferences would be to decrease suffering and standing morphine
and Ativan were ordered and plan adjusted per palliative care.
The patient died on ___. Family refused autopsy.
# PARTIAL SMALL BOWEL OBSTRUCTION: Patient presented with
abdominal pain and CT findings concerning for partial small
bowel obstruction, particularly in the setting of recent
vomiting. General surgery team consulted, patient managed
conservatively with NPO/IVF. NG tube placed, but pulled for
patient comfort. A g-tube was discussed for venting, but family
did not want one placed. Patient was given SQ octreotide to help
control secretions.
# NSTEMI: Hospital course complicated by severe chest pain in
setting of severe
hypertension (185/78, HR 93) associated with dynamic ECG changes
in enterolateral distribution which resolved with nitroglycerin.
Patient with recurrent rest chest pain and worsening ischemic
changes. Patient given aspirin, clopidogrel, taken to cath lab
where LHC complicated by inferior STEs on monitor in cath lab.
An ostial RCA thrombotic occlusion was thought to culprit
lesion, subsequently treated with with PTCA. LMCA and mid LAD
also s/p PTCA. Patient maintained on heparin drip until
troponins peaked. No further events prior to transition to
comfort focused care.
Medications on Admission:
Unable to verify home medications. Needs clarification.The
Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Glargine 30 Units Bedtime
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Aspirin 81 mg PO DAILY
4. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*50
Suppository Refills:*0
2. Fleet Enema (Mineral Oil) 1 Enema PR TID W/MEALS
RX *mineral oil 1 enema(s) rectally three times a day
Refills:*0
3. LORazepam 0.25-0.5 mg PO Q4H:PRN nausea
RX *lorazepam 0.5 mg 0.5-1 mg by mouth q4h:prn Disp #*30 Tablet
Refills:*0
4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q4H:PRN Pain - Moderate
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) ___ SL by mouth
q2:prn Refills:*0
5. Octreotide Acetate 200 mcg SC Q8H
RX *octreotide acetate 200 mcg/mL 1 ml SQH three times a day
Disp #*2 Vial Refills:*4
6. Aspirin ___AILY
RX *aspirin 300 mg 1 suppository(s) rectally daily Disp #*7
Suppository Refills:*2
7. Glargine 30 Units Bedtime
8.IVF
D5NS with 20mEq K per 1L
Please give 2L daily
Discharge Disposition:
Expired
Discharge Diagnosis:
PRIMARY
=======
Stage IV Adenocarcinoma of unknown primary
NSTEMI s/p PTCA
SBP
SECONDARY
=========
HTN
IDDM
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 ___ after you had severe
abdominal pain. You were found to have an intestinal
obstruction, caused by a new cancer that we found in your belly.
We think it came from either your bladder or gastrointestinal
tract, but aren't sure.
You also developed severe chest pain, and had to be transferred
to the cardiac intensive care unit. You had a cardiac
catheterization procedure. They found that all the arteries that
supply your heart were blocked, and the interventional
cardiologists performed balloon angioplasty to manually open up
the arteries.
You continued to have severe nausea and vomiting, which we think
is due to the cancer causing continued blockages to your
intestines. After extensive discussion with your family and the
palliative care doctors, we narrowed your medications to only
those that would help with comfort and that would help you get
back home to ___, which was your main wish.
It was a pleasure taking care of you!
___ Medical de ___
Followup Instructions:
___
|
19921471-DS-13 | 19,921,471 | 22,494,573 | DS | 13 | 2150-12-22 00:00:00 | 2150-12-22 13:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
HMED Admission Note
___
cc: cough
Major ___ or Invasive Procedure:
None
History of Present Illness:
___ yo M with COPD, bladder CA and L RCC here with cough and
abdominal pain. Pt with new cough today, says it's non
productive. Mild dyspnea but not too much changed from his
baseline. Also developed abdominal pain at his ventral hernia
site, so he came to the ED for evaluation of the above.
In the ED, pt satting well on room air. Noted to be wheezy. CXR
showed no infiltrates. He was given duo nebs, 60 mg of
prednisone, and azithromycin for COPD exacerbation with
improvement. CT abdomen showed stable ventral hernia with fat
protrusion. While in ED, pt got up to walk to the bathroom and
became dizzy, so he was admitted for monitoring.
ROS: negative except as above
Past Medical History:
# s/p L nephrectomy for ___ ___ at ___
# bladder CA - followed by urology at ___, diagnosed ___
# COPD, s/p left lobectomy per ___ and ___ records, Gold Stage
III
# HTN
# BPH
# Colon polyps per patient report
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure
Physical Exam:
Vitals: T 97.9 143/69 70 18 94%RA
Gen: NAD
HEENT: NCAT, no cervical LAD
CV: rrr, no r/m/g
Pulm: good air movement, no wheezing
Abd: soft, reducible midline hernia
Ext: no edema
Neuro: alert and oriented x 3, no focal deficits
Discharge Exam: No significant change from above.
Pertinent Results:
___ 04:10PM WBC-12.3* RBC-4.03* HGB-12.9* HCT-37.0*
MCV-92 MCH-32.0 MCHC-34.9 RDW-18.5*
___ 04:10PM PLT COUNT-209
___ 04:10PM CALCIUM-10.6* PHOSPHATE-3.3 MAGNESIUM-1.8
___ 04:10PM GLUCOSE-103* UREA N-21* CREAT-1.3* SODIUM-141
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-27 ANION GAP-13
___ 04:10PM cTropnT-<0.01
___ 06:50PM URINE RBC-4* WBC-4 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 06:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
CXR:
Patient is status post left diaphragmatic hernia repair with
elevation of the left hemidiaphragm and shift of the cardiac
silhouette to the right, similar in appearance as compared to
the prior study. The right lung is hyperinflated and there is
chronic blunting of the right costophrenic angle. Chain sutures
in the lungs bilaterally are compatible with prior wedge
resections. Panlobular and centrilobular emphysema are again
seen with chronic interstitial nodular abnormality, most
pronounced in the upper lobes, similar in appearance as compared
to the recent prior study. The cardiac and mediastinal
silhouettes are stable. Multiple old left-sided rib deformities
are re- demonstrated.
CT Abdomen/Pelvis:
1. Moderate fat containing ventral hernia without evidence of
complication.
2. Stable, moderate right hydronephrosis and hydroureter without
obstructing stone identified.
3. Severe emphysema.
4. Grossly abnormal appearance of the bladder is stable from ___ consistent with previous history bladder cancer.
Brief Hospital Course:
___ yo M s/p L renal and ureteral resection for CA, COPD s/p
pulmonary wedge resection who presents with cough and abdominal
pain and was admitted for treatment of a COPD exacerbation.
1. COPD with mild exacerbation: Patient given Prednisone 40mg
for an anticipated ___zithromycin not continued
given lack of change in sputum and mild symptoms on
presentation. Patient remained on room air throughout his
hospitalization.
2. Dizziness - Transient in ED, resolved without intervention.
Orthostatic VS within normal limits on arrival to the floor.
3. Abdominal pain: Abdominal CT showed stable ventral hernia
without cause for patient's pain. At the time of discharge
patient noted only mild discomfort and tolerated a PO diet
without difficulty.
Transitional Issues:
-- Preliminary read of abdominal CT also notable for, "Focal,
rounded thickening of the superior bladder wall appears more
prominent in comparison to ___. Urology followup with
possible tissue sampling or cystoscopy is recommended." Patient
informed of findings; should follow-up with outpatient Urologist
for further discussion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Finasteride 5 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
8. acetylcysteine 600 mg oral TID
9. Simvastatin 40 mg PO QPM
10. Tiotropium Bromide 1 CAP IH DAILY
11. Aspirin 81 mg PO DAILY
12. Nicotine Patch 14 mg TD DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Finasteride 5 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
7. Simvastatin 40 mg PO QPM
8. Tiotropium Bromide 1 CAP IH DAILY
9. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
10. acetylcysteine 600 mg oral TID
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
12. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
dyspnea
13. Nicotine Patch 14 mg TD DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
COPD Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with abdominal pain and
shortness of breath. You were treated for a COPD exacerbation
with steroids, which you will continue for an additional three
days. You had a CT scan of your abdomen which showed no acute
problems with your hernia. It did show bladder wall thickening
which you should discuss with your Urologist and primary care
physician.
Followup Instructions:
___
|
19921471-DS-18 | 19,921,471 | 27,461,335 | DS | 18 | 2151-06-14 00:00:00 | 2151-06-15 11:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w h/o papillary RCC, bladder ca, COPD, DM, HTN, CKD,
presenting for evaluation of recurrent UTI. Patient has been
having suprapubic pain for at least 3 days. Diagnosed with UTI
during recent admission and was given cipro without improvement
(after taking it for about a week). Has been self-cathing self
TID for the last few months. Today went to PCP and given IM CTX
250mg and was started on bactrim. No fevers or chills.
He has also been experiencing cough with light green mucous. He
has no increase in his baseline dyspnea, and no chest pain. He
has completed his course of prednisone from last
hospitalization.
Of note, in past smoked 6ppd when younger. Quit smoking
completely 30 days ago.
In the ED, initial vitals were: 97.6 79 118/100 20 100% RA
- Labs were significant for WBC 16.6, H/H 12.3/38.3, K 5.3, Cr
1.5 (baseline 1.0-1.2), positive UA
- Imaging revealed CXR with no acute change
- The patient was given: 1L IVF
Upon arrival to the floor, patient states that suprapubic pain
improved after getting dose of CTX in PCP ___.
Past Medical History:
# papillary RCC, incidentally discovered on left
nephroureterectomy for bladder TCC, 9 mm in size, early stage
# bladder TCC s/p multiple resections - most recently TUR
___
# COPD, s/p left lobectomy per ___ and ___ records
# Perioperative Afib
# ___ DVT
# DM
# Hypertension
# BPH
# CKD - Cr baseline 1.3
# Colon polyps per patient report
# Was told he had an MI in ___ at ___, no PCI
# Severe L knee pain since crush injury by a multi-ton bag of
fish, being followed by Dr. ___ patient has ACL and
meniscus tear
# Ventral hernia
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.7 97/67 79 18 95% RA wt 100.1 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Mild expiratory wheezing, otherwise clear
Abdomen: Soft, mild mid-abdominal and suprapubic tenderness,
incisional hernia on left, non-distended, bowel sounds present
Back: No CVA tenderness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AOx3, grossly intact
DISCHARGE PHYSICAL EXAM:
VITALS: 97.9 111/65 72 18 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM
Neck: Supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB
Abdomen: Soft, mildly distended, no pain with palpation. Has an
incisional hernia on left that is reducible. Bowel sounds
present
Back: No CVA tenderness
GU: No foley
Ext: No edema
Neuro: AOx3, grossly intact
Pertinent Results:
ADMISSION LABS:
___ 04:20PM BLOOD WBC-16.6* RBC-4.07* Hgb-12.3* Hct-38.3*
MCV-94 MCH-30.2 MCHC-32.1 RDW-16.9* RDWSD-56.2* Plt ___
___ 04:20PM BLOOD Glucose-145* UreaN-28* Creat-1.5* Na-138
K-5.3* Cl-101 HCO3-28 AnGap-14
___ 05:30AM BLOOD Lipase-30
___ 04:50AM BLOOD Calcium-9.8 Phos-3.6 Mg-1.5*
DISCHARGE LABS:
___ 04:50AM BLOOD WBC-8.7 RBC-3.44* Hgb-10.6* Hct-32.3*
MCV-94 MCH-30.8 MCHC-32.8 RDW-16.7* RDWSD-56.1* Plt ___
___ 04:50AM BLOOD Glucose-145* UreaN-23* Creat-1.4* Na-142
K-4.7 Cl-108 HCO3-25 AnGap-14
___ 04:50AM BLOOD Calcium-9.4 Phos-3.1 Mg-1.5*
STUDIES:
CXR ___: No interval change from the previous exam without new
acute cardiopulmonary
abnormality.
MICRO: Urine culture ___ contaminated
Brief Hospital Course:
___ yo male with h/o COPD, bladder cancer (self caths at home),
afib (not on anticoag), DM2, CKD presents with 3 weeks of
bladder pain not responsive to ciprofloxacin.
ACTIVE ISSUES:
# Urinary tract infection: The patient presented with 3 weeks of
bladder pain, not improving with a course of ciprofloxacin. UA
was consistent with infection, with many red and white blood
cells in his urine. His urine culture was contaminated. He was
initially started on ceftriaxone which was switched to Bactrim
before discharge. He will complete a 7 day course of antibiotics
until ___. He will follow up with his PCP and urologist
after discharge.
CHRONIC ISSUES:
# Chronic urinary retention: The patient has had urinary
retention since his transurethral resection of his bladder
cancer in ___. He straight-caths three times daily. He was
observed by nursing and had a good understanding of
clean/sterile practices.His tamsulosin and finasteride were
continued.He will follow up with his urologist.
# ___ on CKD: Patient with baseline creatinine around 1.2. Was
elevated during admission and at discharge was 1.4. Possibly
false elevation given Bactrim. He should have his creatinine
monitored as an outpatient when off bactrim.
# Chronic leukocytosis: Unclear etiology; possibly related to
bladder cancer. Downtrended during admission.
# Bladder TCC: Patient with bladder cancer for several years. He
is s/p cystoscopy and TUR of bladder tumor ___. Renal US
earlier this month showing bladder wall irregularity concerning
for tumor recurrence. He will need follow up with Dr. ___ in 3
months for repeat surveillance cystoscopy.
# COPD: Was recently treated for exacerbation. No active issues.
His home inhalers were continued.
# DM2: Recent A1C 6.8. Recently restarted on metformin. Was
treated with sliding scale insulin in-house.
# Atrial fibrillation: Continued aspirin, metoprolol.
# Chronic knee pain/ACL tear: Continued home opioid pain
regimen.
TRANSITIONAL ISSUES:
- Monitoring of creatinine given mild ___ during admission
- Bactrim until ___
- Monitoring of chronic leukocytosis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Finasteride 5 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Senna 8.6 mg PO BID:PRN c
9. Simvastatin 40 mg PO QPM
10. Tamsulosin 0.4 mg PO QHS
11. Tiotropium Bromide 1 CAP IH DAILY
12. oxyCODONE-acetaminophen ___ mg oral Q8H:PRN pain
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
14. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. oxyCODONE-acetaminophen ___ mg oral Q8H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN c
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Sulfameth/Trimethoprim DS 1 TAB PO BID
Please continue until ___.
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg one tablet(s) by
mouth twice a day Disp #*2 Tablet Refills:*0
16. Phenazopyridine 100 mg PO TID Duration: 3 Days
Take until ___
Discharge Disposition:
Home
Discharge Diagnosis:
Complicated urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay. You were
admitted due to an urinary tract infection. You were initially
started on ceftriaxone but were transitioned to oral Bactrim
before discharge. Please take this until ___. Please follow
up with Dr. ___ Dr. ___ discharge. We wish you
the best!
Your ___ care team
Followup Instructions:
___
|
19921471-DS-19 | 19,921,471 | 24,078,680 | DS | 19 | 2151-06-26 00:00:00 | 2151-06-26 17:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
Dysuria and Suprapubic Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ yo M w h/o papillary RCC s/p L nephrectomy,
bladder cancer, DM, CKD (Cr 1.2), presenting for evaluation of
recurrent UTI.
He presented to the ED after 4 hours of right flank pain and
suprapubic pain. He is concerned about the health of his kidney
given his history of recurrent urinary tract infections. He
denies any recent fever, chills, chest pain, bowel changes. He
does note having suprapubic pain ___, that worsens with
position and with food at times. He notes it is relieved with
Percocet. Patient also notes having a weak urinary stream,
passing clots and pink urine at times.
Patient has shortness of breath at baseline due to a history of
COPD and this has been unchanged lately. He notes he can become
out of breath, requiring albuterol inhaler, and has a chronic
cough.
In the ED, initial VS were 97.4 78 108/64 15 95% RA. Labs showed
WBC 13.1, Hgb 11.9 (stable), Cr 1.6 (baseline 1.0-1.2), UA
showed 101 RBCs, >182 WBCs, moderate bacteria, nitrate positive.
UCx sent. No imaging obtained. Patient was given 1g CTX.
Of note, patient has had several recent admission for UTIs,
despite negative urine cultures. Most recently discharged ___
after being hospitalized on ___ for suprapubic pain. UCx
contaminated. Treated with CTX while inpatient, discharged on
Bactrim, completed the course ___. Prior to that, hospitalized
___ with COPD flare and UTI; initially treated with CTX,
discharged on cipro, UCx contaminated. Also hospitalized ___
for COPD exacerbation, again with dirty UA, but contaminated
UCx, initially treated with CTX, discharged on cipro.
On arrival to the floor, patient reported having suprapubic pain
and is eager to have work up completed. Would like to meet with
Dr. ___ in the morning.
Past Medical History:
# papillary RCC, incidentally discovered on left
nephroureterectomy for bladder TCC, 9 mm in size, early stage
# bladder TCC s/p multiple resections - most recently TUR
___
# COPD, s/p left lobectomy per ___ and ___ records
# Perioperative Afib
# ___ DVT
# DM
# Hypertension
# BPH
# CKD - Cr baseline 1.3
# Colon polyps per patient report
# Was told he had an MI in ___ at ___, no PCI
# Severe L knee pain since crush injury by a multi-ton bag of
fish, being followed by Dr. ___ patient has ACL and
meniscus tear
# Ventral hernia
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
GENERAL: Well nourished male, in NAD, speaking in full sentences
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: end expiratory wheezes without rales, rhonchi; breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
Rectal: Good rectal tone, prostate non-tender without hard
nodules
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
========================
VS: 98.5 75 159/72 20 98%RA
GENERAL: Well nourished male, speaking in full sentences
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: prolonged end expiratory; breathing comfortably without
use of accessory muscles;
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
================
WBC-13.1*# RBC-3.89* Hgb-11.9* Hct-37.4* MCV-96 MCH-30.6
MCHC-31.8* RDW-17.3* RDWSD-59.4* Plt ___
Glucose-106* UreaN-26* Creat-1.6* Na-137 K-4.9 Cl-102 HCO3-25
AnGap-15
PERTINENT FINDINGS:
====================
Renal U.S. ___. No hydronephrosis in the right kidney. The patient is status
post left
nephrectomy.
2. Markedly abnormal appearance of the bladder with multiple
mass-like
protrusions from the bladder wall. These areas could be
consistent with post
resection changes versus recurrent tumor, correlation with
cystoscopy is
recommended as clinically indicated.
CXR ___
Emphysema is severe. Elevation of the left hemidiaphragm is
chronic, and maybe related to the chest trauma responsible for
multiple healed left rib fractures. Patient may have had wedge
resection from the left upper lobe as well.
There is no evidence of current cardiac decompensation or
pneumonia. No
pleural effusion.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
DISCHARGE LABS:
===============
___ 01:00PM BLOOD WBC-13.1*# RBC-3.89* Hgb-11.9* Hct-37.4*
MCV-96 MCH-30.6 MCHC-31.8* RDW-17.3* RDWSD-59.4* Plt ___
___ 01:00PM BLOOD Glucose-106* UreaN-26* Creat-1.6* Na-137
K-4.9 Cl-102 HCO3-25 AnGap-15
Brief Hospital Course:
Mr ___ is a ___ yo M w h/o papillary RCC s/p L nephrectomy,
bladder cancer, DM, CKD (Cr 1.2), presenting for evaluation of
recurrent UTI.
# Recurrent UTI: Has been treated for UTI at least 3 times in
past 1 month without resolution and with cultured organism.
Given leukocytosis and UA with positive WBC/bacteria/nitrates,
as well as leukocytosis there was a strong suspicion that this
represented infection. Patient underwent renal US shows bladder
wall changes (possible CA), but no signs of pyelonephritis or
renal dysfunction. Was started on CTX. Patient was discussed
case with ___, who recommend treating UTI, without
indication for continuous bladder irrigation or further
investigation. Speciated urine cultures, but only grew mixed
flora with gram + cocci concerning for skin flora. Patient was
transitioned to Cefepime given history of re-current UTIs with
no identified species. Straight cath UA was sent and grew no
colonies. Given recurrent history and lack of speciation, the
decision was made for the patient to complete a 7 day course of
cefepime. At discharge, the patient no longer had pain or
difficulty with urination, and no longer complained of
suprapubic pain. He was discharged with plans to follow up with
his PCP and ___ appointment.
# ___ on CKD: Cr baseline around 1.2, Cr 1.6 on admission.
Patient was given 1L IV and had improvement to 1.3 suggesting
pre-renal disorder. Given patients history of weak urine stream,
performed post void residuals to ensure no post-renal
dysfunction. Did not require straight catheterization.
Underlying CKD likely ___ DM, HTN, and only having one kidney.
Cr at discharge was 1.4.
# Bladder TCC: Patient with bladder cancer for several years. He
is s/p cystoscopy and TUR of bladder tumor ___. Renal US
earlier this month showing bladder wall irregularity concerning
for tumor recurrence. Inpatient Renal US showed no signs of
hydronephrosis, but did reveal markedly abnormal appearance of
the bladder with multiple mass-like
protrusions from the bladder wall. These areas could be
consistent with post
resection changes versus recurrent tumor. Urology was alerted,
patient has planned follow up with outpatient Urologist, Dr.
___.
CHRONIC ISSUES:
# DM2: Recent A1C 6.8. Recently restarted on metformin. Held
metformin in house, maintained on ISS.
# BPH/Chronic urinary retention: Continue home finasteride and
tamsulosin without need for straight catheterization. Patient
was also started on Oxybutynin with good effect. Was discharged
with a prescription given marked benefit.
# COPD: Continued home tiotropium and albuterol prn. Occasional
wheeziness, responded well to inhalers.
# Knee Pain: Continue home narcotics (oxycodone/acetaminophen)
and bowel regimen.
# CAD: Well controlled, continued home aspirin, statin,
metoprolol.
# GERD: No symptoms, continued home omeprazole.
TRANSITIONAL ISSUES:
=====================
- Renal US earlier this month showing bladder wall irregularity
concerning for tumor recurrence. He will need follow up with Dr.
___ in 3 months for repeat surveillance cystoscopy.
- Added Oxybutinin 2.5mg for bladder spasms
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. oxyCODONE-acetaminophen ___ mg oral Q8H:PRN pain
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN c
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Sulfameth/Trimethoprim DS 1 TAB PO BID
16. Phenazopyridine 100 mg PO TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 40 mg PO DAILY
8. Phenazopyridine 100 mg PO TID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
10. Senna 8.6 mg PO BID:PRN c
11. Simvastatin 40 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Tiotropium Bromide 1 CAP IH DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. oxyCODONE-acetaminophen ___ mg oral Q8H:PRN pain
16. Oxybutynin 2.5 mg PO BID
RX *oxybutynin chloride 5 mg 0.5 (One half) tablet(s) by mouth
Once a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
UTI
Secondary:
- papillary RCC, incidentally discovered on left
nephroureterectomy for bladder TCC, 9 mm in size, early stage
- bladder TCC s/p multiple resections - most recently TUR
___
- COPD, s/p left lobectomy per ___ and ___ records
- Perioperative Afib
- ___ DVT
- DM
- Hypertension
- BPH
- CKD - Cr baseline 1.2
- Urinary retention (straight caths)
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 ___ due to
pain on urination and suprapubic pain. You were found to have a
urinary tract infection, however cultures we were unable to
identify any organisms. Given your history of recurrent UTIs,
you were given a 7 day course of antibiotics and started on
oxybutynin, a medication to help with bladder urgency. You
stayed in the hospital until the antibiotics were completed.
It was a pleasure taking care of you at ___. If you have any
questions in the care you received, please do not hesitate to
ask.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19921471-DS-20 | 19,921,471 | 29,783,497 | DS | 20 | 2151-08-01 00:00:00 | 2151-08-01 16:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
Dysuria, lower abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M w h/o papillary RCC s/p L nephrectomy, bladder cancer,
DM, COPD, CKD, presenting for lower abdominal pain. The patient
states that about 3 days ago, he stopped taking his finasteride
because the pharmacy ran out of it. Since then, he has had
burning in his lower abdomen, especially on the left lower side.
He says this pain is positional such as when he lies on his
side, and is located below the umbilicus. He feels like it is
related to stomach acid, and has been taking 10 tablets of tums
every 4 hours, which does help. He states he has had some
difficulty urinating, but has been able to urinate on his own
without catheterization. No gross hematuria. He denies
fever/chills, dyspnea, chest pain, N/V/D.
In the ED, initial VS were 97.3, 85, 126/74, 18, 100% RA
Labs showed WBC 19.8, BUN 24, Cr 1.2, UA with
blood/WBC/nitrite/bacteria.
Imaging showed CXR with subtle nodular opacities in the right
mid lung and left lower lung, background emphysema
CTX 1g was given
Decision was made to admit to medicine for further management.
On arrival to the floor, patient reports feeling well overall,
but does complain of abdominal pain as described above.
Past Medical History:
COPD
Type 2 Diabetes
Recurrent UTI's
Papillary RCC s/p L nephrectomy
BPH
Bladder cancer s/p several resections, seen by Dr. ___ s/p MI
A-Fib not on anticoagulation
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased
Physical Exam:
ADMISSION EXAM
VS - temp 97.7, HR 72, BP 123/75, RR 18, 96% RA
GENERAL: NAD, A+Ox3, talkative, nontoxic appearing
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Bilateral end expiratory wheezes, no resp distress
ABDOMEN: nondistended, +BS, mild tenderness bilateral lower
quadrants L>R
EXTREMITIES: no edema, WWP
NEURO: no gross focal deficits
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE EXAM
VS - Tmax 98.4, HR 67-75, BP 133-140/73-87, RR 18, 94-97% RA
GENERAL: NAD, A+Ox3, nontoxic appearing, pleasant, talkative
NECK: supple
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Bilateral end expiratory wheezes but otherwise clear and
with no respiratory distress
ABDOMEN: nondistended, +BS, nontender, midline reducible hernia
present
EXTREMITIES: no edema, WWP
NEURO: no gross focal deficits
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 11:30AM BLOOD WBC-19.8*# RBC-4.44* Hgb-13.8 Hct-41.0
MCV-92 MCH-31.1 MCHC-33.7 RDW-16.6* RDWSD-55.1* Plt ___
___ 11:30AM BLOOD Neuts-69.0 Lymphs-16.0* Monos-11.2
Eos-1.2 Baso-1.0 NRBC-0.2* Im ___ AbsNeut-13.65*
AbsLymp-3.17 AbsMono-2.21* AbsEos-0.24 AbsBaso-0.20*
___ 11:30AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-1+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
___ 11:30AM BLOOD ___ PTT-28.8 ___
___ 11:30AM BLOOD Glucose-167* UreaN-24* Creat-1.2 Na-139
K-4.7 Cl-101 HCO3-27 AnGap-16
___ 11:30AM BLOOD ALT-20 AST-17 AlkPhos-98 TotBili-0.8
___ 11:30AM BLOOD Albumin-4.3
___ 06:11AM BLOOD Calcium-9.9 Phos-2.7 Mg-1.7
___ 12:30PM URINE RBC-118* WBC->182* Bacteri-MANY
Yeast-NONE Epi-<1
___ 12:30PM URINE Blood-SM Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 12:30PM URINE Color-Yellow Appear-Hazy Sp ___
DISCHARGE LABS
___ 06:31AM BLOOD WBC-16.8* RBC-4.19* Hgb-12.9* Hct-38.6*
MCV-92 MCH-30.8 MCHC-33.4 RDW-16.8* RDWSD-56.3* Plt ___
___ 06:31AM BLOOD Glucose-154* UreaN-29* Creat-1.2 Na-137
K-4.8 Cl-105 HCO3-22 AnGap-15
___ 06:31AM BLOOD Calcium-10.5* Phos-2.7 Mg-1.8
MICROBIOLOGY
URINE CULTURE (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. >100,000 ORGANISMS/ML..
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 2 S
Blood cultures: no growth to date
IMAGING/REPORTS
EKG ___
Normal sinus rhythm. Right bundle-branch block. Left posterior
fascicular
block. Compared to the previous tracing of ___ no
significant change.
CXR ___
Subtle nodular opacities in the right mid lung and left lower
lung raise
concern for atypical infection versus chronic aspiration.
Severe background emphysema.
Noncon CT Head ___. No acute intracranial abnormality on noncontrast head CT.
2. Parenchymal atrophy and chronic small vessel ischemic
disease.
Brief Hospital Course:
___ y/o M with a history of DM, papillary RCC s/p L nephrectomy,
bladder cancer s/p resections, COPD, who is presenting with
lower abdominal pain, urinary symptoms, and leukocytosis; found
to have Staph Epi UTI.
ACTIVE ISSUES
# Staph Epi Urinary tract infection: Presenting with
leukocytosis, dirty UA, and urinary symptoms. He remained
nontoxic appearing throughout the hospital course despite a mild
leukocytosis. He has a history of numerous UTI's, with many
admissions, though most of his urine cultures had grown mixed
flora or contaminants, with the exception of the last 2 (Staph
___ as outpatient, Staph epi this admission). The
recurrent UTI's in this gentleman are likely related to his
defunctionalized bladder and possibly urinary retention. Rectal
exam was negative for evidence of prostatitis. Urine culture
this admission grew Staph Epi, sensitive to Vanco and
tetracycline. He was started on Vancomycin and Cefepime
initially. This was narrowed to Vancomycin monotherapy once the
culture resulted for GP Cocci. This was changed to Tetracycline
500mg QID per ID once sensitivities and speciation returned. He
will finish a 2 week course of this as an outpatient, last day
___. Per ID, she should continue QID Straight Cath with good
technique, though of note PVR's in house were on the lower side
(50-150cc). He has outpatient Urology follow up ___. They can
consider the possibility of suppressive therapy at that time.
Urodynamic studies should be considered as well.
# H/o BPH, RCC, Bladder cancer: History of transitional cell
neoplasms and follows with Urologist Dr. ___ as an outpatient.
S/p L nephrectomy due to RCC. S/p cystoscopy and TUR of bladder
tumor ___. Straight catheterizes at home. His bladder has
undergone multiple resections and is somewhat defunctionalized.
He was originally supposed to have cystoscopy this week, but
missed the appointment due to being hospitalized. He has
follow-up with Dr. ___ for ___. Continue
finasteride 5mg daily, tamsulosin 0.4mg daily.
# Fall with headstrike: Early morning ___ he fell out of bed
after getting startled by his beeping IV. Mechanical fall.
Normal neuro exam by multiple providers. CT head negative. No
residual symptoms.
CHRONIC ISSUES
# DM2: Recent A1C 6.8. On metformin as outpatient, which was
resumed on discharge. Insulin sliding scale was used in house.
# COPD: Had good O2 sats on room air, no resp distress. Quit
smoking ~10 weeks ago. Continued home tiotropium daily,
Fluticasone-salmeterol BID, and Albuterol PRN. We encouraged his
good efforts to quit smoking.
# Knee Pain: On oxycodone/acetaminophen and bowel regimen as
outpatient. These were continued in house.
# HTN/HLD: Resumed home Metop Succinate 25mg daily (dose
recently decreased by PCP ___ 50mg, per patient). ASA 81mg
daily, Simvastatin 40mg daily.
# GERD: omeprazole 40mg daily
# Lung nodules seen on CTA: 2 parenchymal nodules seen on CTA in
___. He will need 3 month follow-up recommended for
reassessment of these nodules, due for ___.
# Bone health: Vitamin D ___ unit daily
TRANSITIONAL ISSUES
- Discharged on Tetracycline 500mg QID per ID. Last day ___,
will complete a 2 week course.
- Follow-up with PCP and ___ to determine if suppressive
antibiotic therapy should be considered. Could consider
Nitrofurantoin suppression (after current antibiotic course
complete), vs. methenamine.
- Pt will do intermittent straight catheterization 4 times daily
in order to prevent urinary stasis and infection risk. He has
been trained for good hygiene.
- Consider urodynamic studies
- Lung nodules seen on CTA: 2 parenchymal nodules seen on CTA in
___. 3 month follow-up recommended for reassessment of
these nodules, due for ___.
- Full code
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Finasteride 5 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
8. Simvastatin 40 mg PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Aspirin 81 mg PO DAILY
11. Vitamin D ___ UNIT PO DAILY
12. Docusate Sodium 100 mg PO BID
13. Nicotine Patch 14 mg TD QAM
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
15. Senna 8.6 mg PO BID:PRN constipation
16. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth once daily
Disp #*30 Tablet Refills:*0
7. Nicotine Patch 14 mg TD QAM
8. Omeprazole 40 mg PO DAILY
9. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
12. Simvastatin 40 mg PO QPM
13. Tamsulosin 0.4 mg PO QHS
14. Tiotropium Bromide 1 CAP IH DAILY
15. Vitamin D ___ UNIT PO DAILY
16. MetFORMIN (Glucophage) 500 mg PO BID
17. Tetracycline 500 mg PO Q6H
RX *tetracycline 500 mg 1 capsule(s) by mouth four times daily
Disp #*47 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Urinary tract infection
Bladder cancer
Benign prostatic hyperplasia
Secondary diagnoses:
Hypertension
COPD
Arthritis
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 to our hospital because of a urinary tract infection.
You were treated with IV antibiotics. Once we found out what
type of bacteria was causing your symptoms, we changed to a pill
antibiotic. You will need to continue taking this pill until
___ in order to fully kill the bacteria that caused this
infection.
Follow up appointments with Dr. ___ Dr. ___
scheduled for you.
Once again, it was a pleasure participating in your care, and we
wish you the best.
___ Medicine Team
Followup Instructions:
___
|
19921471-DS-23 | 19,921,471 | 23,611,859 | DS | 23 | 2151-10-16 00:00:00 | 2151-10-16 15:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
___ MEDICINE ATTENDING ADMISSION NOTE .
Date: ___
Time: 1132 pm
_
________________________________________________________________
PCP:
Name: ___
Location: HEALTHCARE ASSOCIATES
___
Address: ___, ___, ___
___
Phone: ___
Fax: ___
Email: ___
.
CC: ___ retention, hematuria, persistent UTI despite 9 days
of linezolid and acute renal failure
Major Surgical or Invasive Procedure:
Foley placement with CBI and subsequent removal of catheter on
___
History of Present Illness:
HPI:
___ w h/o RCC s/p left nephrectomy, TCC of bladder s/p TURBT
___ here at ___, post-op course c/b MDR enterococcus UTI,
discharged ___ on course of PO linezolid. Self-catheterizes
TID for incomplete emptying, had gross hematuria on first
emptying this AM. He had had recurrence of hematuria 2 days ago.
Of note when he start abx on ___ his RCVAT, supra-pubic
tenderness and dysuria improved. It then recurred on the day of
presentation while in his PCP's office. Saw PCP who sent him to
urology. Urology examined him and placed a foley with plans to
have him f/u again with Dr. ___. Per patient the
irrigation in office was positive for multiple clots. He then
developed worsening supra-pubic pain along with dysuria.
Patient accidentally cut his foley bag while showering and
subsequently self-d/c'd catheter (after deflating balloon) as it
was causing him pain. Output in bag and subsequently at home was
frankly bloody.
Patient denies fever/chills, flank pain, suprapubic pain now
that foley is out, abdominal pain, nausea/vomiting, diarrhea,
blood or melena in stool, petechia, cough.
He has been on linezolid ___ PO BID since ___, with one
missed dose a few days ago.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: No f/c
HEENT: [X] All normal
RESPIRATORY: [X] All normal
CARDIAC: [X] All normal
GI: + nausea one week ago without emesis
GU: [+]dysuria
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
COPD
Type 2 Diabetes
Recurrent UTI's
Papillary RCC s/p L nephrectomy
BPH
Bladder cancer s/p several resections, seen by Dr. ___ s/p MI
A-Fib not on anticoagulation
Likely primary hyperparathyroidism
Social History:
___
Family History:
Confirmed on admission.
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased
Multiple family members with bladder cancer.
Physical Exam:
ADMISSION EXAM:
Vitals: Wt = 220.3 lbs, Ht = 71.5 inches
T 97.5 P 72 BP 118/77 RR 20 SaO2 96%on RA
GEN: NAD, comfortable appearing,
HEENT: PERRL
NECK: supple
CV: s1s2 rr no m/r/g
RESP: Diminished BS throughout
ABD: +bs, soft, + supra-pubic tenderness with deep palpation
GU: No R CVAT
EXTR:no c/c/e 2+pulses
DERM: scaling of skin on b/l toes
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
DISCHARGE EXAM:
Vitals: T 98 ___ P64 R18 97% on RA
General: alert, oriented x 3, no acute distress, he has dressed
himself in street clothes and is "ready to go or I'm leaving
A-M-A!"
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, slight suprapubic tenderness, well healed ab scar
from nephrectomy, slightly distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: foley has been discontinued
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
___ 07:35AM BLOOD WBC-11.1* RBC-3.80* Hgb-11.9* Hct-35.2*
MCV-93 MCH-31.3 MCHC-33.8 RDW-16.8* RDWSD-54.5* Plt ___
___ 07:25AM BLOOD WBC-12.1* RBC-3.83* Hgb-12.0* Hct-35.5*
MCV-93 MCH-31.3 MCHC-33.8 RDW-16.5* RDWSD-54.5* Plt ___
___ 08:05PM BLOOD WBC-20.5* RBC-4.32* Hgb-13.6* Hct-39.6*
MCV-92 MCH-31.5 MCHC-34.3 RDW-16.5* RDWSD-54.4* Plt ___
___ 07:35AM BLOOD Glucose-134* UreaN-17 Creat-1.3* Na-138
K-4.2 Cl-106 HCO3-26 AnGap-10
___ 07:25AM BLOOD Glucose-95 UreaN-23* Creat-1.5* Na-139
K-4.2 Cl-105 HCO3-28 AnGap-10
___ 08:05PM BLOOD Glucose-134* UreaN-27* Creat-1.7* Na-135
K-4.7 Cl-100 HCO3-22 AnGap-18
Renal ultrasound ___:
"FINDINGS:
The right kidney measures 11.7 cm. The patient is status post
left
nephrectomy. There is no hydronephrosis, stones, or masses in
the right
kidney. A 2.0 cm simple cyst is noted in the lower pole of the
right kidney.
Normal cortical echogenicity and corticomedullary
differentiation are seen in
the right kidney.
Note is made of the patient's history of bladder cancer. The
bladder wall is
moderately thickened, but not well distended. A rounded
echogenic focus the
dependent portion of the partially collapsed bladder is
consistent with a
hematoma, given that this lesion was not seen on ultrasound ___.
Gallstones or tiny polyps are incidentally noted on limited
evaluation of the
gallbladder.
IMPRESSION:
1. A large echogenic focus in the dependent portion of the
bladder is
consistent with an intravesicular blood clot given that this
lesion is new
from ultrasound of ___. "
Brief Hospital Course:
Mr. ___ is a ___ year old man with COPD, DM type 2, recurrent
UTIs, CAD s/p MI ___, no stents), remote hx of RLE DVT/PE (at
___ about ___ ago treated w lovenox per the patient but later
d/c'd), afib (not on ac), remote h/o cdiff, and renal cell
cancer s/p L nephrectomy, TCC of bladder s/p TURBT ___ c/b
post-op MDR Enteroccus UTI (discharged on ___ on a 2wk course
of linezolid) who presented with hematuria/dysuria x 2 days
along with low grade temps (rpeotedly at home, afebrile while
inpatient), WBC 20.5 (although quickly resolved without changing
his antibiotics), and acute renal failure (cr 1.7 up from
baseline 1.3); admitted for continuous bladder irrigation. A new
UTI was considered given his WBC however UA was unimpressive and
he symptomatically improved with bladder irrigation BEFORE
cefepime was given empirically (for gram negative coverage since
linezolid does not cover gm negative enterobacteriaceae).
Subsequent urine culture (drawn before cefepime) was negative
and so cefepime was discontinued and he was continued on
linezolid to complete his previously planned course of linezolid
which is to finish on ___. Infectious diseases was consulted
while inpatient given his complicated history of UTI and MDR VRE
and agreed with discontinuing cefepime and felt this did not
constitute a new infection.
CBI was started and his urine quickly turned clear. He was seen
by urology who discontinued his foley on the morning of ___.
Prior to admission, the patient had been self-catheterizing
himself TID but on further discussion with the patient, turns
out that his self-cath hygiene had been very poor (not washing
his hands, etc) and clearly was causing trauma with repeated
episodes of bleeding such as this one. It was not entirely clear
if he needed to be self-cathing himself at all and so a voiding
trial was attempted while inpatient which he tolerated well with
minimal residual volumes noted on serial bladder scans. The
patient had no difficulty urinating on his own. He will be
discharged with instructions to stop self-catheterizing unless
symptoms develop again.
His acute kidney injury resolved with IV fluids and after
irrigation to clear his urine. This may have been due to a
urinary obstruction due to possible clots leading to obstruction
which is now resolved.
Rest of hospital course/plan are outlined below by issue:
#COMPLICATED URINARY TRACT INFECTION W/ HEMATURIA/DYSURIA:
positive ___ and >182 WBCs however difficult to interpret in the
setting of hematuria and in the middle of treatment for previous
enterococcal UTI.
-he had been on linezolid since last admission for
Enterococcus(prior culture ___ showed R to amp,
tetracycline, vanco, and S to linezolid only) , and he admitted
to missing only one dose. Failure of linezolid is highly
unlikely.
-one dose of zosyn was given on ___ but changed to cefepime
___ zosyn shortage and per ID recs, cefepime was stopped
on ___ after urine culture came back negative.
-continued linezolid ___ - ?)(linezolid course was planned
from ___ --> last day was supposed to be ___
-Note that flagyl was briefly started over concern for cdiff but
only one loose BM noted and no ongoing diarrhea so was d/c'd
#HEMATURIA/URINARY OBSTRUCTION:
-CBI was started on admission, urology consulted, CBI d/c'd on
___
-continued finasteride
-renal ultrasound did not show any findings of new
hydronephrosis but did note some residual blood clot in the
bladder which I discussed with urology who mentioned that since
his urine was running so clearly, that this will most likely
break down over time and did not require a repeat cystoscopy.
#CHEST PAIN/CAD: He mentioned some mild R sided chest discomfort
on morning of ___ but resolved spontaneously and reproduceable
with palpation on the R side of his chest. Notably, he does have
two lung nodules which had increased in size on recent CTA chest
from ___, including one in the RUL, which may account for
his pain on that same side. He stated the pain was not like his
previous PE and non-pleuritic. Ddx also includes MSK versus
pneumothorax (given COPD but unlikely given lack of SOB). EKG
showed unchanged old RBBB sinus rhythm, rate 67. We considered
CTA chest however due to ___ it was relatively contraindicated.
He remained chest pain free for the remainder of this
hospitalization.
-continued home aspirin, beta blocker
-no events seen on telemetry
#Acute renal failure: clearly concerning for urinary obstruction
+/- sepsis from UTI. Also notably has a single remaining R
kidney. Baseline cr around 1.3, up to 1.7 on admission. Improved
to near baseline 1.5 after placement of foley and IV fluids.
#COPD
- Pt with 150 pack year of smoking
- largely asx
- quit 7 weeks prior to admission
- pt not taking advair but takes albuterol and Spiriva
- encouraged pt to resume daily advair and Spiriva with
albuterol prn
#DIABETES MELLITUS
-held metformin while inpatient, will continue all home meds.
#HLD: continue statin and asa
#GERD: omeprazole
#FULL CODE (confirmed)
#Transitional:
-Urology f/u Dr. ___ to be arranged prior to
discharge)
-unclear why not taking tamsulosin, would suggest to be
addressed as outpatient - defer to urology
#Disposition: was living at home with girlfriend prior to
admission without services. he was at his baseline mobility.
Spent > 30 minutes seeing patient and organizing discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Tiotropium Bromide 1 CAP IH DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H
10. Linezolid ___ mg PO Q12H
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob/wheezing
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Linezolid ___ mg PO Q12H
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H
8. Simvastatin 40 mg PO QPM
9. Tiotropium Bromide 1 CAP IH DAILY
10. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Hematuria, ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted for blood in your urine and kidney injury in
the context of your recent urinary tract infection and likely
trauma from straight catheterization leading to an episode of
bleeding from your bladder that has resolved after bladder
irrigation.
We were able to take out the foley yesterday and you are voiding
well without straight catheterization. You should be able to
proceed without straight catheterizing yourself unless you
develop abdominal pain, urinary discomfort, or trouble
urninating again, in which case you should call your doctor or
come back to the hospital immediately.
You are to continue the linezolid as prescribed to complete your
full course. Your last dose of linezolid will be on the
afternoon of ___ which is to treat your previous UTI.
You should follow up with your outpatient providers as below.
Followup Instructions:
___
|
19921471-DS-24 | 19,921,471 | 23,371,091 | DS | 24 | 2151-10-29 00:00:00 | 2151-11-03 17:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
dysuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with h/o COPD, T2DM, CAD s/p MI (___),
afib not on anticoagulation, h/o RCC s/p left nephrectomy, non
invasive low grade papillary urothelial cancer s/p TURBT/TURP on
___ c/b MDR enterococcus UTI who presents with persistent
dysuria and flank pain.
Patient was recently hospitalized and discharged on ___ for
___ and hematuria. He did required CBI but hematuria quickly
resolved. At the time, he was in the middle of a course of
linezolid. He initially had a leukocytosis to 20.5 and symptoms
of UTI but these resolved without any change in his antibiotics.
His foley was initially discontinued and patient had trial of
intermittent self straight-catheterizations but his technique
was thought to be exceeding poor (he did not wash his hands,
etc). He was discharged with a foley and had a voiding trial
with urology on ___ and foley was discontinued. He completed his
course of linezolid on ___ and was asked to take the remainder
of his linezolid pills starting on ___ at his urology
appointment.
Mr. ___ reports that he has had continuous burning pain in
his groin and right-sided flank pain since his discharge from
the hospital. He says the pain is not any better and not any
worse. He did have a temperature to ~99.5 at home, but denies
any chills. He saw his PCP today and was referred into the ED
for ongoing dysuria and flank pain, concerning for repeated
infection.
In the ED, initial vital signs were: 98 73 121/74 18 98% RA
- Exam was notable for: R CVAT, suprapubic ttp
- Labs were notable for: WBC 15.6
- Imaging: none
- The patient was given: 2g cefepime, 600mg IV linezolid, 1g
Tylenol, 5mg oxycodone, 1L NS
Vitals prior to transfer were: 97.5 72 117/71 16 97%RA
Upon arrival to the floor, patient was feeling well. He is
requesting a regular diet, not a diabetic diet. He has continued
lower abdominal pain and flank pain.
Past Medical History:
COPD
Type 2 Diabetes
Recurrent UTI's
Papillary RCC s/p L nephrectomy
BPH
Bladder cancer s/p several resections, seen by Dr. ___ s/p MI
A-Fib not on anticoagulation
Likely primary hyperparathyroidism
Social History:
___
Family History:
Confirmed on admission.
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased
Multiple family members with bladder cancer.
Physical Exam:
ON ADMISSION
VITALS - 97.3 117/72 68 20 96% RA
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, OP clear
NECK - supple, no LAD
CARDIAC - regular rate & rhythm, normal S1/S2, no m/r/g
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, mildly TTP in the
suprapubic region, non-distended, no organomegaly.
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
GU - foley in place, draining clear urine without any clots.
There is some right costovertebral angle tenderness to palpation
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
LABS: reviewed. See below.
ON DISCHARGE
Vitals: BP 109-135/67-84 HR 66-70 ___ RA ___ RR Afebrile
overnight
General: alert, oriented, no acute distress. Dressed and
standing up. when still.
HEENT: sclera anicteric, dry mucous membranes, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs:Few bibasilar crackles with prolonged expiratory phase and
occasional wheeze on posterior chest unchanged from prior
CV: RRR
Abdomen: soft, suprapubic tenderness. significant right CVAT.
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ON ADMISSION
___ 05:35PM BLOOD WBC-15.6* RBC-3.89* Hgb-12.0* Hct-36.9*
MCV-95 MCH-30.8 MCHC-32.5 RDW-17.2* RDWSD-57.6* Plt ___
___ 05:35PM BLOOD Glucose-182* UreaN-20 Creat-1.5* Na-140
K-4.7 Cl-103 HCO3-25 AnGap-17
___ 06:46AM BLOOD Calcium-10.2 Phos-2.6* Mg-1.7
ON D/C
___ 07:00AM BLOOD WBC-13.1* RBC-4.05* Hgb-12.6* Hct-39.1*
MCV-97 MCH-31.1 MCHC-32.2 RDW-17.9* RDWSD-61.5* Plt ___
___ 07:00AM BLOOD Glucose-149* UreaN-23* Creat-1.2 Na-140
K-4.5 Cl-106 HCO3-24 AnGap-15
___ 07:00AM BLOOD Calcium-10.4* Phos-3.1 Mg-1.___BD PELVIS
EXAMINATION: CT abdomen/pelvis without contrast
INDICATION: ___ year old man with recurrent UTIs, severe CVAT,
s/p TURBT/TURP
on ___ c/b MDR enterococcus UTI, now sever right sided back
pain // r/o
renal calculi vs abscess
TECHNIQUE: Multidetector CT images of the abdomen and pelvis
were acquired
without intravenous contrast. Non-contrast scan has several
limitations in
detecting vascular and parenchymal organ abnormalities,
including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 16.2 s, 55.8 cm; CTDIvol = 11.7 mGy
(Body) DLP =
636.1 mGy-cm.
Total DLP (Body) = 650 mGy-cm.
COMPARISON: ___ CT abdomen/pelvis without contrast
FINDINGS:
LOWER CHEST: There is severe emphysematous changes the bilateral
lung bases.
There is elevation of the left hemidiaphragm with numerous round
surgical
clips. There is no pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation
throughout.
There is no evidence of focal lesions within the limitations of
an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic
biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions within the limitations of an unenhanced scan.
There is no
pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions. Incidental note is made of 2 small
accessory
spleens.
ADRENALS: The right adrenal gland is normal in size and shape.
An
approximately 1.7 x 1.4 cm left adrenal adenoma is stable.
URINARY: Evaluation the kidneys is limited on this unenhanced CT
scan. Within
this limitation, multiple simple appearing renal cysts are
unchanged. There
is new gas within the collecting system (3:45, 3:47). There is
no
hydronephrosis or nephrolithiasis. The distal right ureter is
dilated with an
additional focus of loculated gas (3:84). A Foley catheter is
placed within
the prostate, likely the TURPT defect, with a small amount of
dependent gas
and a single locule of anti dependent gas (3:81). The patient
is status-post
left nephrectomy. There are no abnormal soft tissue nodules
within the left
nephrectomy bed. Calcifications are noted within the bladder
wall. On best
seen on series 3, ___ 81 and 87.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber and wall thickness throughout. The colon and
rectum are within
normal limits. The appendix is normal.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Irregularities of the posterior eleventh and twelfth ribs a post
or fifth rib
are compatible with prior, healed fractures.
SOFT TISSUES: There is a large, fat containing ventral hernia
(5b:45).
IMPRESSION:
1. Locules of gas in the distal right ureter and within the
right renal
collecting system are new, raising the possibility of
emphysematous pyelitis.
2. A Foley catheter is placed within the prostate, and should be
advanced
approximately 6 cm.
3. Several renal cysts.
4. Calcifications in the bladder wall may relate to chronic
inflammation over
be due to be in known tumor recurrence. .
NOTIFICATION: The findings concerning for emphysematous
pyelitis were
discussed with ___, M.D. by ___, M.D. on
the telephone
on ___ at 12:02 ___, approximately 10 minutes after
discovery of the
findings.
The findings related to the Foley catheter balloon were
discussed with ___, M.D. by ___, M.D. on the telephone on
___ at 14:39,
approximately 10 minutes after discovery of the findings.
CXR
Comparison to ___. Unchanged moderate
overinflation on the right
and elevation of the left hemidiaphragm. Healed left-sided rib
fractures.
Right mid lung and right apical calcified granulomas.
Relatively extensive
apical scarring as well as right perihilar scarring. In
addition, there is
unchanged mild right perihilar nodularity. Overall, the changes
continue to
suggest the presence of an atypical mycobacterial or viral
infection. Neither
the frontal nor the lateral radiograph show evidence of pleural
effusions.
MICROBIOLOGY
__________________________________________________________
___ 7:43 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
___. ___.
Further workup requested by ___. ___ ON
___.
YEAST SUSCEPTIBILITY:. Fluconazole MIC = 1 MCG/ML =
SENSITIVE.
__________________________________________________________
___ 6:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 5:35 pm BLOOD CULTURE #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ is a ___ man with h/o COPD, T2DM, CAD s/p MI (___),
afib not on anticoagulation, h/o RCC s/p left nephrectomy, non
invasive low grade papillary urothelial cancer s/p TURBT/TURP on
___/b MDR enterococcus UTI who presents with persistent
dysuria and flank pain, havening likely UTI. He was put on broad
spectrum antibiotics given his history of MDR organisms, and
ultimately narrowed to ciprofloxacin monotherapy. He had foley
put in place and will see Dr ___ transition to ___. Of
note he had chest congestion during hospital stay and
intermittent heartburn sympto0ms; trops were negative, but CXR
showed viral infection vs mycobacterial process. Given lack of
risk factor and lack of hemoptysis it was felt patient had
likely viral bronchitis vs bronchiolitis and discharged with
guaifenesine. Please repeat CT chest on discharge for F/U
resolution of tehse symptoms and follow up lymphadenopathy noted
on ___ CT.
ACTIVE ISSUES
# Dysuria: In setting of pyuria, was concerning for recurrent
UTI as patient recently had Foley removed and has been
performing straight-catheterizations at home. Patient known to
have poor hygiene and technique as documented in previous
admission. Ct abdomen/pelvis was performed on ___ (for concern
of abscess) showed possible emphysematous pyelonephritis. Per
Urology, this is likely ___ reflux and not emphysematous pyelo.
Patient was kept on linezolid given hx of enterococcus, this was
d/ced am of ___ as cultures grew on no enterococcus; meaning
prior treatment course of linezolid was sufficient and
eradicated pathogen. For other common causes of UTI, was
switched to ciprofloxacin ___ for 21 total course for
suppressive therapy. He is to have follow up with Dr. ___ in
one week regarding chronic foley, and with his PCP ___.
# Urinary retention: Had successful voiding trial on ___ in
___ clinic but now with foley. Urology was consulted who
recommended switch back from ___ to foley for 7 days after
discharge, and follow up with Dr. ___ in clinic for voiding
trial.
# Chest congestion/feeling tightness: During hospital stay,
patient reported subjective sensation of congestion. CXR showed
apical scarring as well as right perihilar scarring and
unchanged mild right perihilar nodularity, notable for possible
viral vs mycobactyerial infection. Given lack of risk factors
and fevers, it was felt patient likely had a bronchitis. Patient
initially refused his home inhalers (advair, albuterol), as he
felt they had a reaction with linezolid. After dcing linezolid
___, restarted nebs ___. Also patient likely has significant
component of GERD, complaining of pain after meals and in am
after lying down. Trops in house negative. Of note, back in
___hets which showed:
"2 parenchymal nodules which raise suspicion as there are
slightly increased in
size, including a 6 mm nodule in the right upper lobe (05:39)
any 5 x 10 mm
nodule in the left upper lobe (05:48). Short-term 3 month
follow-up is
recommended for reassessment of these nodules. "
We advised PCP via ___ to F/U on these nodules.
CHRONIC ISSUES
# HTN: continued home metoprolol, aspirin
# diabetes: held home metformin, used ISS while in house
# HLD: continued home statin
TRANSITIONAL ISSUES
===============================
-discharged with po ciprofloxacin to end on ___ (2 week course)
-home omeprazole doubled for worsening heartburn during
admission
-plan to see Dr. ___ to transition from foley to CIC
- On next PCP or urology appointment please recheck CBC and Cr;
cr on d/c 1.2, WBC 13 (range ___ typically)
-repeat CT to follow up pulmonary nodules noted on CT chest down
in ___ on next PCP ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Metoprolol Succinate XL 50 mg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Senna 8.6 mg PO BID:PRN constipation
6. Simvastatin 40 mg PO QPM
7. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
8. Omeprazole 40 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Linezolid ___ mg PO Q12H
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
7. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Simvastatin 40 mg PO QPM
10. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*32 Tablet Refills:*0
11. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN chets
congestion
RX *dextromethorphan-guaifenesin [Adult Cough Formula DM Max]
200 mg-10 mg/5 mL 5 ml by mouth every 6 hours Refills:*0
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
URINARY TRACT INFECTION
HEARTBURN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you hda flank pain. At the
hospital it was determined you had another urinary tract
infection. Our urologists and infectious disease doctors saw ___
and we are discharging you on 21 days total of antibiotics. We
ask that you follow up with Dr. ___ Dr. ___.
We wish you all the best!
-Your ___ Care Team
Followup Instructions:
___
|
19921471-DS-25 | 19,921,471 | 20,860,951 | DS | 25 | 2151-11-22 00:00:00 | 2151-11-29 20:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
Hematuria, flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o COPD, T2DM, CAD s/p MI (___), afib not on
anticoagulation, h/o RCC s/p left nephrectomy, non-invasive low
grade papillary urothelial cancer s/p multiple TURBTs, and MDR
UTIs, currently with an indwelling foley; presents today with 2d
of burning at the site of foley insertion, in addition to R
flank pain and hematuria.
According to patient, he has been experiencing intermittent
hematuria since his most recent TURBT in ___. He has had
multiple UTIs since that time. He was admitted to ___ from
___ for pyelonephritis. He was discharged on cipro, but
waited a week to fill the prescription and has not yet finished
his course. He last saw his Urologist ~1 week ago, at which time
his foley was changed and he reports "20 clots came out". He
also noted small amount of bright red blood in his foley bag 2
days prior to admission when he had to re-inflate the balloon.
He complains today of right flank pain consistent with his prior
known UTIs and upon further questioning it appears this pain is
chronic for the past 3 months.
He reports no fevers, chills, abdominal pain, nausea or
vomiting.
In the ED,
- Initial vitals were: T 97.2 HR 63 BP 111/77 RR 16 SpO2 100% RA
- Labs were significant for WBC 15.9, H/H 13.1/39.3, Cr 1.1,
lactate 1.3. UA revealed Lg leukocytes, Lg bld, >182 WBC, >182
RBC's and few bacteria.
- Renal US showed: The bladder is not well-distended and
assessment is significantly limited, however there is suggestion
of some debris, likely intravesicular clot given the patient's
history of hematuria and previously seen clot. The right kidney
is unremarkable.
- She received:
___ 00:18 PO Oxycodone-Acetaminophen (5mg-325mg) 2 TAB
___ 00:54 PO/NG Linezolid ___ mg
___ 00:54 PO Ciprofloxacin HCl 500 mg
___ 07:46 PO/NG Oxycodone-Acetaminophen (5mg-325mg) 1 TAB
___ 11:07 PO/NG Linezolid ___ mg
___ 12:04 PO/NG Ciprofloxacin HCl 500 mg
___ 15:52 PO/NG Oxycodone-Acetaminophen (5mg-325mg) 2 TAB
___ 16:38 PO/NG Aspirin 81 mg
___ 16:38 PO Omeprazole 40 mg
Past Medical History:
COPD
Type 2 Diabetes
Recurrent UTI's
Papillary RCC s/p L nephrectomy
BPH
Bladder cancer s/p several resections, seen by Dr. ___ s/p MI
A-Fib not on anticoagulation
Likely primary hyperparathyroidism
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased
Multiple family members with bladder cancer.
Physical Exam:
ADMISSION EXAM:
================
Vital Signs: T 97.6 BP 118/82, P 91, RR 18 O2 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Poor air movement throughout, few expiratory wheezes ,no
rales
Abdomen: Soft, TTP in RUQ without rebound or guarding
Back: R flank TTP
GU: Foley draining dark urine.
Rectal: prostate not boggy or TTP.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No focal deficits
DISCHARGE EXAM:
================
Vital Signs: T 97.8 BP 112/63, P 65, RR 16 O2 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Poor air movement throughout, few expiratory wheezes ,no
rales
Abdomen: Soft, TTP in RUQ without rebound or guarding
Back: Severe CVA TTP, worse than on presentation
GU: Foley draining dark urine.
Rectal: prostate not boggy or TTP.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: No focal deficits
Pertinent Results:
ADMISSION LABS:
================
___ 10:30PM BLOOD WBC-15.9* RBC-4.15* Hgb-13.1* Hct-39.3*
MCV-95 MCH-31.6 MCHC-33.3 RDW-17.1* RDWSD-58.3* Plt ___
___ 10:30PM BLOOD Neuts-63.5 ___ Monos-9.6 Eos-3.4
Baso-1.1* NRBC-0.1* Im ___ AbsNeut-10.07* AbsLymp-3.34
AbsMono-1.53* AbsEos-0.54 AbsBaso-0.17*
___ 10:30PM BLOOD Glucose-125* UreaN-23* Creat-1.1 Na-142
K-4.2 Cl-108 HCO3-26 AnGap-12
___ 10:54PM BLOOD Lactate-1.3
DISCHARGE LABS:
================
___ 07:52AM BLOOD WBC-11.8* RBC-3.73* Hgb-11.7* Hct-34.7*
MCV-93 MCH-31.4 MCHC-33.7 RDW-16.8* RDWSD-55.9* Plt ___
___ 07:52AM BLOOD Glucose-133* UreaN-27* Creat-1.4* Na-138
K-4.3 Cl-105 HCO3-24 AnGap-13
___ 07:52AM BLOOD Calcium-9.7 Phos-2.9 Mg-1.9
MICROBIOLOGY:
==============
___: Blood culture negative
___: Blood culture negative
URINE CULTURE (Final ___: <10,000 organisms/ml.
IMAGING:
=========
Renal ultrasound (___):
FINDINGS:
The right kidney measures 10.4 cm. A 1.9 cm simple cyst in the
lower pole of the right kidney is unchanged. The left kidney is
surgically absent. There is no hydronephrosis, stones, or
masses bilaterally. Normal cortical echogenicity and
corticomedullary differentiation are seen bilaterally. A Foley
catheter is noted in a nearly collapsed bladder. There is some
suggestion of debris, although assessment is limited due to
bladder underdistention.
IMPRESSION:
The bladder is not well-distended and assessment is
significantly limited,
however there is suggestion of some debris, likely
intravesicular clot given the patient's history of hematuria and
previously seen clot.
Brief Hospital Course:
Mr. ___ is a ___ with h/o COPD, T2DM, CAD s/p MI (___), Afib
not on anticoagulation, h/o RCC s/p left nephrectomy,
non-invasive low grade papillary urothelial cancer s/p multiple
TURBTs, and MDR UTIs, currently with an indwelling Foley who
presented with two days of burning at the site of his Foley,
right flank pain, and hematuria.
# Positive urinalysis: Given report of burning and positive
urinalysis, patient was started on linezolid and cefepime given
history of MDR organisms and VRE. Urine culture grew only yeast,
thought to be a colonizer, so antibiotics were stopped.
Patient's right flank pain was at baseline. There was no
evidence of hematuria during his hospitalization. Renal
ultrasound showed no hydronephrosis. Pain at the site of the
Foley improved with lidocaine jelly. Per ID, he was continued on
ciprofloxacin for one week for suppression (he had been on
ciprofloxacin for one week prior to admission). Patient's
outpatient urologist, Dr. ___ discontinuation of
Foley and intermittent self-catheterizations, but patient
declined. He has follow-up with Dr. ___ Dr. ___.
# Urothelial cancer: Patient had no ongoing hematuria during
this hospitalization. His Foley was exchanged. Dr. ___
___ discontinuation of Foley and intermittent
self-catheterizations, but patient declined. This will be
readdressed as an outpatient.
# CKD: Creatinine on admission was 1.1, which rose to 1.6 and
was 1.4 on discharge after IVF. Urine output remained excellent
with Foley in place. Creatinine should be rechecked as an
outpatient.
Transitional Issues
====================
Discharge Creatinine: 1.4
[ ] Patient should complete 7 day course of Ciprofloxacin, per
recent discharge instructions by ID.
[ ] Patient to follow up with Dr. ___ removal of his
Foley.
[ ] Patient at high risk for pyelonephritis; he should be
referred to the ED at any sign of fevers, worsening back pain.
[ ] Patient has had ongoing issues with hematuria, with
occasional clots. Drop in urine output due to obstruction by
clot may require flushing and or continuous bladder irrigation.
[ ] Patient should have Creatinine checked at outpatient
appointment on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Omeprazole 40 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Simvastatin 40 mg PO QPM
10. Ciprofloxacin HCl 500 mg PO Q12H
11. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN chets
congestion
12. MetFORMIN (Glucophage) 500 mg PO BID
13. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*10 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. Omeprazole 40 mg PO BID
8. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 40 mg PO QPM
11. Lidocaine Jelly 2% 1 Appl TP DAILY:PRN pain at foley site
RX *lidocaine HCl [Xolido] 2 % 1 application daily Refills:*2
12. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN chets
congestion
13. MetFORMIN (Glucophage) 500 mg PO BID
14. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
==================
Hematuria
Flank pain
Secondary Diagnosis
====================
COPD
Diabetes Mellitus
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted with pain around the site of
your foley, back pain and blood in your urine. Your urine
culture did not grow bacteria, so we do not believe you had an
active urinary tract infection. You should continue to take
Ciprofloxacin for 7 more days to help suppress infection. We
recommended that you have the catheter removed to further reduce
risk of infection, but you did not wish to have it removed. You
should follow up with Dr. ___ Dr. ___ appointment
below) to discuss this matter further.
Please seek medical attention immediately if you develop fevers,
worsening back pain or have a drop off in your urine output.
We wish you all the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19921471-DS-28 | 19,921,471 | 28,048,361 | DS | 28 | 2152-01-22 00:00:00 | 2152-01-22 07:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
R flank pain
Major Surgical or Invasive Procedure:
foley cathter placement on ___
History of Present Illness:
Mr. ___ is a ___ year old man with T2DM, RCC s/p left
nephrectomy, non-invasive low grade papillary urothelial cancer
s/p multiple TURBTs who is dependent on straight caths (although
recently not doing this and urinating regularly), and recurrent
UTIs (including VRE and ESBL, recently discharged with a
recommendation for fosfomycin every 2 weeks for a UTI
suppression however had not been taking due to nausea), recently
admitted in ___ but left AMA on ___ who presented back to the
ED for readmission on ___ for ongoing R flank pain and in the
ED, also c/o ongoing DOE when walking up hills.
ID consultation during his recent hospitalization initially
recommended cefepime/linezolid pending culture data. final Ucx
from ___ grew only yeast.
per d/c summary from yesterday "On ___ patient decided to
leave
against medical advice to be with his long-time girlfriend as
she was very upset. He was counseled extensively on the risks of
leaving prior to finalized urine cultures and follow up ID
consultation, however he insisted on leaving, verbalizing
understanding of the risks. We discussed again the importance of
TID catheterization as well as need to return to the hospital
should he develop recurrent pain or fevers."
"Given the lack of culture data, discussed with ID that any oral
antibiotic upon discharge would probably be empiric, and
potentially harmful long-term given lack of culture data and
recurrent admissions for similar complaints. Discussed no clear
indication to treat yeast in this patient."
Regarding his dyspnea, he states "this was my COPD and I don't
think this is related to the pain in my kidney". states that he
believes this was overplayed in the ED and that all that
happened was that he was walking up a hill to go to the train
when he noticed he was wheezing a little bit and used his
inhaler (which he normally does in this scenario with his COPD)
and he felt better. He denies chest pain or pleuritic component
of his R flank pain.
he has been straight cathing himself three times a day. He
recorded his post void residuals with every straight cath today
at 120, 147, and 136 cc's respectively. Prior to each straight
cath he says he urinated on his own approximately 250-500 cc's.
He noticed one episode of a small amount of blood in his urine
(which is typical for him) but no more hematuria than usual. He
denies cystitis, fevers, chills. He was previously told to try
PO fosfomycin weekly to prevent UTIs however states he developed
one episode of diarrhea, nausea, the day after and hasn't used
it since. Denies diarrhea currently.
when asked why he left AMA, he states he had to break up with
his "old lady" and "I'm done catering to her." and states that
now he is willing to stay in the hospital and do "whatever needs
to be done."
ROS: Rest of comprehensive ROS was negative except as above
Past Medical History:
COPD
Type 2 Diabetes
Recurrent UTI's
Papillary RCC s/p L nephrectomy
BPH
Bladder cancer s/p several resections, seen by Dr. ___ s/p MI
A-Fib not on anticoagulation
Likely primary hyperparathyroidism
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased
Multiple family members with bladder cancer.
Physical Exam:
Admission Physical Exam
Vitals: 97.8 120/80 P62 R16 99% on RA
GEN: well appearing, smells of cigarette smoke.
PULM: no wheezing but prolonged expiratory phase, no rales
CV: RRR, no murmurs
SKIN: dry, no rashes
GI: reduceable nontender ventral hernia, active bs, nontender
in all quads
MSK: exquisitely tender R flank to minimal percussion, no ___
swelling
PSYCH: full range of affect
HEENT: nonicteric, EOMI
NEURO: moving all extremities, ambulates without issue, A/O x 3
GU: no foley, rest was deferred
Discharge Physical Exam
Vitals: 97.6 112/62 P67 R16 97% on RA
GEN: well appearing, comfortable, alert and conversant
PULM: no wheezing but prolonged expiratory phase, no rales
CV: RRR, no murmurs
SKIN: dry, no rashes
GI: reduceable nontender ventral hernia, active bs, nontender
in all quads
GU: foley catheter in place draining clear yellow urine, bag is
full this morning when I checked it after it was emptied halfway
through the night
MSK: exquisitely tender R flank to minimal percussion, no ___
swelling
PSYCH: full range of affect
HEENT: nonicteric, EOMI
NEURO: moving all extremities, ambulates without issue, A/O x 3
Pertinent Results:
___ 07:31AM GLUCOSE-113* UREA N-21* CREAT-1.2 SODIUM-140
POTASSIUM-4.7 CHLORIDE-103 TOTAL CO2-29 ANION GAP-13
___ 07:31AM WBC-11.6* RBC-4.41* HGB-12.8* HCT-40.0 MCV-91
MCH-29.0 MCHC-32.0 RDW-15.8* RDWSD-52.1*
___ 07:31AM NEUTS-65.9 LYMPHS-18.3* MONOS-9.8 EOS-4.0
BASOS-1.1* NUC RBCS-0.2* IM ___ AbsNeut-7.65* AbsLymp-2.12
AbsMono-1.14* AbsEos-0.47 AbsBaso-0.13*
___ 07:31AM PLT COUNT-230
___ 07:00AM GLUCOSE-119* UREA N-20 CREAT-1.3* SODIUM-139
POTASSIUM-4.5 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
___ 07:00AM CALCIUM-10.1 PHOSPHATE-2.5* MAGNESIUM-1.7
___ 07:00AM WBC-10.1* RBC-4.17* HGB-12.3* HCT-37.9*
MCV-91 MCH-29.5 MCHC-32.5 RDW-15.4 RDWSD-50.9*
___ 07:00AM PLT COUNT-198
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
Discharge Labs:
___ 07:00AM BLOOD WBC-10.1* RBC-4.17* Hgb-12.3* Hct-37.9*
MCV-91 MCH-29.5 MCHC-32.5 RDW-15.4 RDWSD-50.9* Plt ___
___ 07:00AM BLOOD Glucose-119* UreaN-20 Creat-1.3* Na-139
K-4.5 Cl-103 HCO3-28 AnGap-13
Renal U/s on ___:
FINDINGS:
The right kidney measures 12.5 cm. The patient is status post
left
nephrectomy.
There is mild-to-moderate right-sided hydronephrosis, slightly
worse than on
prior evaluation. There are 2 simple appearing renal cysts seen
at the lower
pole measuring 1.4 x 2.3 cm and 1.8 x 1.6 cm.
A definite ureteral jet was not identified at the left UVJ.
A 1.4 x 2.7 cm diverticular was seen at the superior aspect of
the bladder.
IMPRESSION:
1. Mild-to-moderate right-sided hydronephrosis, slightly worse
on prior
evaluation. No definite cause for obstruction identified on the
current
evaluation. Further evaluation may be performed by CT abdomen
and pelvis - as
clinically warranted.
Repeat Renal U/s on ___: FINDINGS:
The right kidney measures 12.0 cm. The patient is status post
left
nephrectomy.
There is been improvement in the degree of right hydronephrosis,
which is now
only mild in degree and seen only at two lower pole calices.
Re- demonstration of 2 simple appearing cysts as previously
described at the
lower pole, measuring 2.4 x 2.0 x 2.3 cm and 1.7 x 2.8 x 1.7 cm
respectively.
The bladder is completely collapsed, with an indwelling Foley
catheter.
IMPRESSION:
Interval improvement of the hydronephrosis status post Foley
catheter
insertion, with only mild hydronephrosis seen at 2 lower pole
calices as
detailed above..
Brief Hospital Course:
Mr. ___ is a ___ year old man with T2DM, RCC s/p left
nephrectomy, non-invasive low grade papillary urothelial cancer
s/p multiple TURBTs who is dependent on straight caths (although
recently not doing this and urinating regularly), and recurrent
UTIs (including VRE and ESBL, recently discharged with a
recommendation for fosfomycin every 2 weeks for a UTI
suppression however had not been taking due to nausea), recently
just a few days prior in ___ but left AMA on ___ who presented
back to the ED for readmission on ___ for ongoing R flank pain
concerning for ongoing UTI, found to have increased
hydronephrosis of R kidney and distended bladder which is likely
from poor compliance with straight caths at home. Hydronephrosis
and pain are now resolved following placement of a foley and I
believe this was the reason for his R flank pain.
Given possible ongoing UTI but lack of micro data, ID was
consultated again and recommended resuming cefepime/linezolid
(was off of antibiotics for a day after left AMA) while
inpatient and will plan to discharge on a course of PO
fosfomycin. His pyuria had improved which was reassuring that
our antibiotics were effective and he remained hemodynamically
stable. He will be discharged home today with foley in place to
f/u with his urologist Dr. ___. Rest of hospital course/plan
are outlined below by issue.
# Mild increase in hydronephrosis seen on renal u/s ___:
discussed findings with urology consultants inpatient who agreed
with my suspicion that the pt is noncompliant with straight
caths (pt initially stated that he has been doing self straight
caths TID religiously but outpatient notes with his PCP he is
quoted as stating that he hasn't "needed" to straight cath
himself in 10 days so clearly he is not being entirely
truthful). Creatinine has remained at his baseline throughout
this episode.
# Recent urinary tract infection (with history of MDR UTIs) and
ongoing R flank pain suspicious for ongoing UTI
-will attempt again to obtain culture data to guide antibiosis
-recent Bedside US: no hydronephrosis, PVR 49 cc, thickened
bladder wall c/w cystitis
-effective start date of abx was ___.
-repeat UA on ___ showed pyuria had improved compared to prior
one
-per ID, will discharge on 3g (1 packet) q3d x 3 doses. will
continue 3g weekly thereafter for suppression therapy.
# urothelial ca s/p TURPs with history of retention: Patient has
a history of RCC s/p L nephrectomy, currently has been stable.
He follows with Dr. ___ at ___. Question of pyelonephritis on
admission, however urine culture growing yeast preliminarily
which ID agreed was not a primary pathogen. Hydro more likely
explains his pain (now resolved after foley) but treating for
UTI anyway with broad antibiotics.
- outpatient urologist is Dr. ___
- continued finasteride
# Dyspnea on exertion with history of COPD: This is not clearly
a new symptom for him, he has known COPD but does not appear to
be in an exacerbation currently. Trop recently negative. EKG
chronically abnormal with RBBB, no change from prior.
- continued home advair, albuterol
-pt denied smoking (it was his girlfriend) and he recently broke
up with her so hopefully will not have any further smoke
exposure.
# Chronic kidney disease: s/p nephrectomy, obstructive
component with chronic retention. continuing foley catheter.
Creatinine remained stable this admission.
# Normocytic anemia: Chronic, stable.
# Afib not on anticoagulation/# CAD s/p MI: continued
metoprolol, simvastatin
# GERD: continued home omeprazole.
# DMII: ISS, continued metformin
# Transitional:
- he will follow up with his urologist Dr. ___ as an
outpatient to address the foley catheter and decide if he is to
continue with the catheter. I contacted Dr. ___ email to
notify him of the situation.
>30 minutes spent seeing the patient and organizing discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Finasteride 5 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 40 mg PO BID
8. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 40 mg PO QPM
11. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Oxycodone-Acetaminophen (5mg-325mg) 3 TAB PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. Simvastatin 40 mg PO QPM
12. Fosfomycin Tromethamine 3 g PO Q72H Duration: 3 Doses
Dissolve in ___ oz (90-120 mL) water and take immediately. Take
every 3days for 3 doses then weekly
RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by
mouth every three days for three doses then weekly thereafter
Disp #*6 Packet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
bladder outlet obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for right flank pain due to hydronephrosis and
an ongoing urinary tract infection. Your UTI was treated with IV
antibiotics and you will be discharged on oral antibiotic called
fosfomycin. You should take the fosfomycin 3 grams every 3 days
starting today to complete treatment for your current UTI then
take 3 grams weekly thereafter for prophylaxis against future
UTIs.
The hydronephrosis (pressure backed up from your bladder) was
relieved after we placed a foley catheter and I'm glad to hear
that your pain is better as well.
You should follow up with Dr. ___ from his office
should call you for an earlier appointment to follow up but he
does not call you, then call that office to schedule an
appointment to be seen within ___ weeks after discharge.
Followup Instructions:
___
|
19921471-DS-29 | 19,921,471 | 22,566,005 | DS | 29 | 2152-02-24 00:00:00 | 2152-02-24 19:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast
Attending: ___.
Chief Complaint:
R flank pain, dysuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ PMHx T2DM, RCC s/p L nephrectomy,
non-invasive low grade papillary urothelial cancer s/p multiple
TURPs and now depending on straight caths (still is able to
urinate regularly), and recurrent UTIs who re-presents to ___
with R flank pain and dysuria.
He has been admitted multiple times over the past year for
recurrently tract infections (including VRE and ESBL) and was
most recently discharged from ___ in ___ for recurrent R
flank pain and ? UTI. He had previously been discharged on
fosfomycin q2weeks for UTI suppressive therapy (which he had not
been taking do to possible GI intolerance). His R flank pain
was felt to be ___ hydronephrosis in the setting of poor
compliance with straight caths at home. ID has been involved
multiple times during his recent hospitalizations and given his
history of medication noncompliance and recurrent UTIs/pyuria,
he has been treated in the past with cefepime/linezolid while
inpatient before being transitioned to PO fosfomycin. His most
recent urine culture in ___ grew only yeast for which he was
treated with a 10 day course (prescribed during recent ED
visit).
The patient has had a significant history of medication
noncompliance. He was supposed to f/u with his outpatient
urologist Dr. ___ as well as Dr. ___ PCP), but has
DNK'd multiple appointments. He also reports that he has not
been taking his PO fosfomycin because he was instructed by Dr.
___ Dr. ___ to stop this (although there is no
documentation of this in OMR).
He reports that over the past several days, he has had worsening
R flank pain; this is similar to his chronic R flank pain but
more severe in quality. He has been straight cathing himself at
home ___ x/day and noticed that his urine appeared darker than
normal as well. He also reports that 5 days ago he had ___ EtOH
drinks preceding symptoms onset.
In the ED, initial VS 97.0, 94, 121/84, 18, 96% on RA. Initial
labs showed Cr 1.4 (baseline 1.2-1.4), WBC 13.4 w/o left shift
(chronically has elevated WBCs, today's lab is improved from
prior), Hgb/Hct 13.5/42.6, Plt 313. UA was notable for large
leuks, negative nitrites, >182 WBC, few bacteria, <1 epi. GU
ultrasound showed no e/o hydronephrosis. Lactate 1.6.
Upon arrival to the floor, the patient reports an inconsistent
history of taking his medications. He states that he has been
off the fosfomycin because he was told to stop taking it and
that he has seen Dr. ___, although he has missed all
of his recent outpatient clinic visits with him. He reports
that his R flank pain is tolerable. He has not had any fevers,
night sweats, abdominal pain, and no diarrhea.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation.
Denies arthralgias or myalgias.
Past Medical History:
COPD
Type 2 Diabetes
Recurrent UTI's
Papillary RCC s/p L nephrectomy
BPH
Bladder cancer s/p several resections, seen by Dr. ___ s/p MI
A-Fib not on anticoagulation
Likely primary hyperparathyroidism
Social History:
___
Family History:
Father and sister with bladder cancer, mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Multiple family members with bladder cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97.8, 95/67, 70, 20, 100% on RA
General: Alert, oriented, elderly male in no acute distress,
smells of smoke
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no m/r/g
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, obese, nondistended, nontender, + bowel sounds.
Well-healed midline abdominal scar.
GU: No foley
Back: R CVAT tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. No
pitting edema of BLE
Neuro: AOx3, moving all extremities spontaneously
Psych: normal affect and appropriately interactive
Derm: no rash or lesions
Discharge Physical Exam:
Vital Signs reviewed: afebrile, HR 62-72, BP 119/75
Tele: ___ second sinus pause around ___.
GEN: NAD, well-appearing, alert interactive, pleasant
EYES: conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
CV: RRR s1s2 nl, no m/r/g
PULM: CTA, no r/r/w
GI: normal BS, NT/ND, no HSM, improving R flank tenderness
EXT: warm, no ___
SKIN: no rashes
NEURO: alert, oriented x 3, answers ? appropriately, follows
commands, non focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: absent
Pertinent Results:
ADMISSION LABS
==============
___ 11:13AM LACTATE-1.6
___ 11:03AM GLUCOSE-131* UREA N-16 CREAT-1.4* SODIUM-139
POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
___ 11:03AM WBC-13.4* RBC-4.72 HGB-13.5* HCT-42.6 MCV-90
MCH-28.6 MCHC-31.7* RDW-16.6* RDWSD-53.6*
___ 11:03AM NEUTS-67.7 ___ MONOS-6.9 EOS-2.2
BASOS-1.1* IM ___ AbsNeut-9.03* AbsLymp-2.80 AbsMono-0.92*
AbsEos-0.30 AbsBaso-0.15*
___ 11:03AM PLT COUNT-313
___ 11:03AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:03AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-LG
___ 11:03AM URINE RBC-14* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-<1
___ 11:03AM URINE HYALINE-2*
___ 11:03AM URINE WBCCLUMP-FEW MUCOUS-OCC
MICROBIOLOGY:
=============
___ Urine culture
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 ORGANISMS/ML..
___ BCx x 2 No growth
___ UCx: >100K Enterococcus, S- Ampicillin
IMAGING & STUDIES:
==================
___ GU ULTRASOUND
IMPRESSION:
1. Resolution of right hydronephrosis.
2. Enlarged prostate with bladder wall thickening and
trabeculation, likely due to chronic bladder outlet obstruction.
3. Postvoid residual of 23 cc.
Brief Hospital Course:
Pyelonephritis: Pt was initially started on PO Linezolid and IV
Cefepime given his multiple prior resistant organisms. His urine
cultures grew >100K Enterococcus S-Ampicillin, and he was
narrowed to PO Amoxicillin and will complete a total of 14 days
of antibiotics on discharge. prostatitis was ruled out based on
unremarkable rectal exam. No stones were seen on his admission
renal US. He will need to follow-up closely with his Urologist,
Dr. ___, to come up with a definitive plan to reduce his risk
of recurrent infections going forward.
Palpitations: pt endorsed intermittent palpitations and
dizziness, starting several weeks prior to admission. He was
placed on telemetry, and his metoprolol was increased to 50mg XL
daily under the assumption that his palpitations may have been
due to paroxysmal AFib. However, on ___ he had a symptomatic
3-second sinus pause, and his metoprolol was reduced back to its
prior dose of 25mg XL daily. He was arranged to wear a holter
monitor on discharge and will follow-up with his PCP to discuss
the results.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Omeprazole 40 mg PO BID
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 40 mg PO QPM
11. Fosfomycin Tromethamine 3 g PO Q72H
12. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN Pain - Moderate
Discharge Medications:
1. Amoxicillin 500 mg PO Q8H pyelonephritis Duration: 10 Days
RX *amoxicillin 500 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
2. Acetaminophen w/Codeine 1 TAB PO Q4H:PRN Pain - Moderate
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Omeprazole 40 mg PO BID
11. Senna 8.6 mg PO BID:PRN constipation
12. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis of the Right kidney
Sinus pause
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure looking after you, Mr. ___. As you know,
you were admitted with a recurrent episode of kidney infection
(pyelonephritis) due to a bacteria called Enterococcus. You were
treated with antibiotics with improvement in your condition.
Your recurrent infections are likely caused by poor bladder
drainage, perhaps due to insufficient straight cathing at home.
We recommend that you adhere to a strict regimen of straight
cathing 4 times a day, to keep the bladder sufficiently drained
and to prevent bacteria from ascending from your bladder into
your remaining kidney. It will be important for you to follow-up
closely with your Urologist, Dr. ___ he may have
other ideas to help prevent recurrent infections in the future.
We wish you the best of luck following your discharge from the
hospital.
Your ___ team.
Followup Instructions:
___
|
19921471-DS-36 | 19,921,471 | 24,624,119 | DS | 36 | 2153-07-13 00:00:00 | 2153-07-13 19:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ M with a history of COPD who presented to
the ED on ___ ___ with two weeks of worsening dyspnea
associated with 1.5 weeks of increased green sputum, as well as
2 weeks of chest pressure sub sternal, ___. Patient reports
having more shortness of breath when he is working on his boat
and when he is ambulating. He also has noted runny nose for
about a month. Nobody is sick around him. On arrival to the ED,
he was treated for a COPD exacerbation with albuterol nebulizer,
IV solumedrol on ___. On ___ he received azithromycin,
Lasix, but no steroids. On ___ he received prednisone 40 and
inhalers. The initial hope was to discharge him, but on 10 feet
of ambulation with no oxygen he desaturated to 85%, which
persisted after several minutes. Patient is supposed to use home
oxygen however he has not been using it due to leaving with his
girlfriend who smokes. He also complained of new bilateral calf
aching for which he was ordered a bilateral ___ ultrasound which
was negative and an echo which showed preserved EF and RV wall
abnormalities. Patient says that he has been having worsening
leg edema for about a month. He thinks that the Lasix he
received in the ED reduced the swelling.
Past Medical History:
COPD (stage III COPD, FEV1 47%, FVC 87%, FEV1/FVC 54; most
recent CT w/ severe pan-lobular emphysema)
renal cancer s/p L nephrectomy
urinary cancer w/ recurrent UTIs & pyelonephritis
T2DM
HTN
HLD
GERD
BPH
anxiety & depression
Social History:
___
Family History:
Father and sister with bladder cancer. Mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
ADMISSION EXAM:
================
VITALS: 98.3 136 / 82 66 18 93 RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. No JVD.
LUNGS: scattered wheezes, low air flow throughout lung fields
BACK: No spinous process tenderness. no CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: 1+ pitting bilateral edema
NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria.
DISCHARGE EXAM:
================
VITALS: T97.8 111/70 63 16 96%2L
GENERAL: AOx3, NAD, able to speak in full, long sentences
HEENT: Sclera anicteric, PERRL, MMM
CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: minor expiratory wheezes scattered throughout lung
fields, moving more air than yesterday
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation.
EXTREMITIES: warm, well perfused, no edema
NEUROLOGIC: AOx3, motor and sensory function grossly intact
Pertinent Results:
ADMISSION:
==========
___ 10:17PM BLOOD WBC-12.3* RBC-3.86* Hgb-12.1* Hct-37.2*
MCV-96 MCH-31.3 MCHC-32.5 RDW-16.6* RDWSD-58.4* Plt ___
___ 10:17PM BLOOD Neuts-62.9 ___ Monos-8.8 Eos-4.1
Baso-0.8 NRBC-0.2* Im ___ AbsNeut-7.77* AbsLymp-2.70
AbsMono-1.09* AbsEos-0.50 AbsBaso-0.10*
___ 10:17PM BLOOD ___ PTT-28.6 ___
___ 10:17PM BLOOD Glucose-147* UreaN-20 Creat-1.2 Na-139
K-4.6 Cl-101 HCO3-26 AnGap-12
___ 10:17PM BLOOD proBNP-184
___ 10:17PM BLOOD cTropnT-<0.01
___ 10:17PM BLOOD Calcium-9.9 Phos-2.3* Mg-1.6
___ 10:25PM BLOOD Lactate-1.4
DISCHARGE:
==========
___ 05:30AM BLOOD WBC-22.0* RBC-4.11* Hgb-13.0* Hct-38.8*
MCV-94 MCH-31.6 MCHC-33.5 RDW-16.2* RDWSD-55.5* Plt ___
___ 05:30AM BLOOD Glucose-110* UreaN-28* Creat-1.0 Na-139
K-4.5 Cl-101 HCO3-27 AnGap-11
___ 05:30AM BLOOD Calcium-10.8* Phos-3.5 Mg-1.8
IMAGING:
========
CXR:
Re-demonstration of chronic elevation of the left hemidiaphragm
and chronic left-sided rib fractures. Severe emphysematous
changes are again seen, most prominent at the right lung base.
The cardiomediastinal silhouette is within normal limits. No
focal consolidations are seen. There is no pulmonary edema or
pleural abnormality.
ECHO:
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Normal left ventricular wall
thickness, cavity size, and global systolic function (biplane
LVEF = 66 %). Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Right ventricular
chamber size is top normal in size with depressed free wall
contractility. The aortic root is mildly dilated at the sinus
level. The ascending aorta is mildly dilated. 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. Normal biventricular
cavity sizes with preserved global left ventricular systolic
function. Top normal right ventricular cavity size with
depressed free wall motion. Mildly dilated ascending aorta.
Compared with the prior study (images reviewed) of ___,
the ascending aorta is now mildly dilated. The other findings
are similar.
___ DOPPLER:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the tibial and peroneal
veins.
There is normal respiratory variation in the common femoral
veins bilaterally.
MICROBIOLOGY:
==============
___ 3:44 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: YEAST. 10,000-100,000 CFU/mL.
___ 10:15 pm 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
LINEZOLID------------- 2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ w/ COPD (stage III COPD, FEV1 47%,
FVC 87%, FEV1/FVC 54; most recent CT w/ severe pan-lobular
emphysema), renal cancer s/p L nephrectomy, urinary cancer w/
recurrent UTIs & pyelonephritis, T2DM, HTN, HLD, GERD, BPH,
anxiety & depression, presenting w/ SOB.
The patient initially presented to the ___ ED on ___ w/ 2
weeks of increasing dyspnea & sputum w/ character change. On
arrival to the ED, he was thought to be in COPD exacerbation. He
was given nebulizers, O2, IV methylprednisolone then switched to
PO prednisone. Azithromycin was initiated on ___. He was
planned for discharge but was unable to walk 10-feet w/o
desaturation to 85%. He also had no home oxygen so was admitted
for further treatment and Case Management arrangement for home
O2. He completed a course of prednisone/azithromycin for COPD
exacerbation and was discharged with portable condensed home
oxygen. He also had bacteriuria vs UTI and was treated with 10
day course macrobid ___, last day ___.
ISSUES ADDRESSED:
==================
# COPD exacerbation:
He met at least ___ WHO criteria for COPD exacerbation given
increase in dyspnea & increase in sputum production w/ change in
character and thus we decided to treat as such. Gave
supplemental O2 for goal 88-93%. 5-day steroid course:
prednisone 40mg QD (___). Ipratropium-albuterol
Q6H w/ albuterol Q2H PRN. Azithromycin 500mg QD x3 days (___). Continued chronic treatment w/
fluticasone-salmeterol 500/50 BID. Arranged for home oxygen
compressor to be delivered due to patient and girlfriend concern
that having condensed oxygen tanks is a safety hazard given that
the girlfriend still actively smokes. Compliance was an issue
for the patient and his previous oxygen company declined
providing condenser to him so new arrangements were made which
delayed discharge after acute issues were managed.
# Venous insufficiency:
Had lower extremity edema that bothered him. Likely chronic w/
contributions from right-heart strain ___ pulmonary HTN ___
COPD. Echocardiogram without heart failure. We initiated
furosemide 10mg PO QD which patient tolerated well. He will be
discharged on this medication with plan to discuss continued use
with PCP (transitional issue).
# Asymptomatic Enterobacter bacteriuria vs. UTI:
# Urinary cancer w/ recurrent UTIs & pyelonephritis:
Continued home nitrofurantoin, which would treat ___
ENTEROCOCCUS culture. Foley in place initially, patient declined
to discontinue prior to discharge despite multiple conversations
about elevated risk of UTI. He previously was provided with
instructions to straight cath 6x/day per email communication
with his outpatient urologist but said this caused pain and
bleeding. Patient reported feeling comfortable straight
catheterizing and has done so ___ in the past but refused
to remove the foley on this occassion. Recommend discussing
foley with his urologist and discontinuing it at follow up
appointment
# T2DM: ISS.
# HTN: Continued home metoprolol XL.
# HLD: Continued home statin, ASA.
# GERD: Continued home PPI, calcium carbonate.
# BPH: Continued home finasteride.
# Anxiety & Depression: Continued home escitalopram & lorazepam.
CODE STATUS & CONTACT:
=======================
FULL CODE
___, ___
TRANSITIONAL ISSUES:
=====================
NEW MEDICATIONS
[ ] Oxygen compressor delivered to home.
[ ] Lasix 10mg PO daily - started for ___ edema (thought to be
___ venous insufficiency).
[ ] Macrobid ___ BID x11 days ___ to ___ (discuss
continuation at ppx dosage w Dr. ___ at urology appt on ___.
[ ] Discharged with foley catheter, should be discontinued at
followup.
[ ] Pt noted to have asymptomatic hypercalcemia w normal albumin
for several years. Had elevated PTH in ___, has not been
further investigated. Of note, pt does take calcium carbonate
daily. Please check PTH, PTHrP given hx of malignancy.
[ ] Please check lytes at followup ___ given recent initiation
of Lasix (as above). Please discuss continued vs intermittent
(ie, when symptomatic ___ edema) use with patient.
[ ] UROLOGY-please discuss with patient suppressive tx for UTIs.
Appears he was prescribed macrobid for this in the past but was
not adherent.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Docusate Sodium 100 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
7. MetFORMIN (Glucophage) 500 mg PO QHS
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Senna 8.6 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Escitalopram Oxalate 2.5 mg PO DAILY
14. LORazepam 0.5 mg PO Q8H:PRN anxiety
15. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
16. Calcium Carbonate 500 mg PO QID
17. Mens Daily Multivit-Mineral (multivit with min-FA-lycopene)
0.4-600 mg-mcg oral DAILY
18. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain -
Severe
Discharge Medications:
1. Furosemide 10 mg PO DAILY
RX *furosemide 20 mg 0.5 (One half) tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Docusate Sodium 100 mg PO DAILY
6. Escitalopram Oxalate 2.5 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. LORazepam 0.5 mg PO Q8H:PRN anxiety
10. Mens Daily Multivit-Mineral (multivit with min-FA-lycopene)
0.4-600 mg-mcg oral DAILY
11. MetFORMIN (Glucophage) 500 mg PO QHS
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
Twice a day (once in the morning and once at night) Disp #*14
Capsule Refills:*0
14. Omeprazole 40 mg PO DAILY
15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
- Severe
16. Senna 8.6 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Vitamin D 1000 UNIT PO DAILY
19.oxygen
ICD10 J44.9, O2 via NC 2L pulse dose portability to keep O2 sat
>90%, ___ 99 months, continuous oxygen need
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DX:
- COPD EXACERBATION
- VENOUS INSUFFICIENCY
- URINARY TRACT INFECTION vs. asymptomatic pyuria
SECONDARY DIAGNOSIS
- Type II diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for allowing us to care for you at ___
___.
WHY YOU WERE ADMITTED:
-You felt short of breath and we thought that this is consistent
with a worsening of your COPD.
WHAT HAPPENED WHEN YO WERE HERE:
-We treated you for a COPD exacerbation with nebulizers,
steroids, antibiotics, and oxygen.
-We arranged for you to receive an oxygen condenser at home.
WHAT YOU SHOULD DO WHEN YOU GO HOME:
-You need oxygen! You should be wearing it at all times.
-Keep up the good work not smoking. Try to avoid being around
other people who are actively smoking.
-It is very important that you follow-up w/ Dr. ___
___ at 8:40 AM to follow-up on all of your
medical issues.
-It is also very important that you go to your other
appointments w Dr. ___ and Dr. ___
doctor). See below for the dates.
-Continue your antibiotics (macrobid) and discuss if you need to
continue them longterm with Dr. ___.
*** You should have your foley catheter removed as soon as
possible because of the risk of infection. Please talk to Dr.
___ Dr. ___ this. ***
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19921471-DS-40 | 19,921,471 | 26,949,917 | DS | 40 | 2153-09-20 00:00:00 | 2153-09-20 13:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ with history of
BPH, kidney cancer s/p L nephrectomy ___ years ago, known
bladder
mets and recurrent UTIs with foley in place due to obstructive
uropathy from bladder masses who presents with ___ days R flank
and back pain extending to the R groin. No fevers or frank
pyuria. Intermittent hematuria. UCX drawn in the ED on ___
growing VRE sensitive only to linezolid. Pt had not yet been
started on abx on arrival to the ED.
In the ED, initial vitals were: 97.2 114 158/98 16 99% RA. Labs
were notable for WBC 20.1, positive UA. He was found to have
R-sided abd pain and CVA tenderness. CTAP showed no acute
process. EKG showed NSR. Pt was given linezolid and 1 L NS,
admitted to medicine for further management of urosepsis.
On the floor, he c/o on and off again pain in "lower R bladder",
denies back pain. Denies respiratory complaints. He has
sternal
CP which has been present for ___ years. No fevers at home. No
cough.
Past Medical History:
COPD (stage III COPD, FEV1 47%, FVC 87%, FEV1/FVC 54; most
recent CT w/ severe pan-lobular emphysema)
renal cancer s/p L nephrectomy
Bladder cancer w/ recurrent UTIs & pyelonephritis
T2DM
HTN
HLD
GERD
BPH
anxiety & depression
CAD
Social History:
___
Family History:
Father and sister with bladder cancer. Mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
Admission physical exam
Vitals: 97.7 PO106 / ___
Constitutional: Sleepy but arousable, no acute distress
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, CP reproducible with palpation of sternum
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, ttp in suprapubic region, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: Foley in place draining clear urine, + bilat CVA tenderness
EXT: Warm, well perfused, 1+ bilat ___
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
Discharge physical exam
Vitals: 97.7 93/63 72 18 95 RA
General: well appearing, non-toxic, refusing physical exam
Eyes: anicteric
ENT: moist tongue
CV: pulse regular
Respi: unlabored
Neuro: face symmetric, gait normal, speech fluent, oriented x3
Psych: agitated
Pertinent Results:
Admission labs
___ 12:10AM BLOOD WBC-20.1* RBC-3.84* Hgb-11.7* Hct-35.7*
MCV-93 MCH-30.5 MCHC-32.8 RDW-16.6* RDWSD-53.7* Plt ___
___ 12:10AM BLOOD Glucose-76 UreaN-16 Creat-1.0 Na-141
K-7.5* Cl-106 HCO3-27 AnGap-8*
___ 06:10AM BLOOD Calcium-9.7 Phos-2.9 Mg-1.7
___ 12:23AM BLOOD Lactate-2.0 K-4.9
Discharge labs
___ 07:38AM BLOOD WBC-12.7* RBC-3.91* Hgb-12.0* Hct-36.9*
MCV-94 MCH-30.7 MCHC-32.5 RDW-16.4* RDWSD-56.1* Plt ___
___ 07:38AM BLOOD Glucose-122* UreaN-20 Creat-1.2 Na-143
K-4.6 Cl-107 HCO3-25 AnGap-11
___ 07:38AM BLOOD Calcium-10.2 Phos-3.1 Mg-1.6
Microbiology
___ 12:10 am URINE Site: NOT SPECIFIED
URINE CULTURE (Preliminary):
ENTEROCOCCUS SP.. >100,000 CFU/mL.
___ 12:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 11:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ENTEROCOCCUS SP.. >100,000 CFU/mL. PREDOMINATING
ORGANISM.
INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
Brief Hospital Course:
___ yo M with hx COPD, renal ca, bladder cancer with chronic
indwelling foley now presenting with flankpain and abnormal UA
with VRE growing in urine cxs.
ACTIVE ISSUES
# Sepsis
# VRE UTI
Has chronic indwelling Foley due to known bladder cancer.
Refused exchange of Foley, as noted this was done just prior to
presentation at ___ (no documentation of this found in ___
record). Was non-toxic appearing and vitals stabilized on
admission. Urine culture grew VRE. Treated with linezolid x7
days (to continue at home) -- HELD escitalopram until ___ to
avoid Serotonin syndrome. Patient counseled on this.
Patient improved from sepsis rapidly, though WBC still slightly
elevated. Clinically sepsis resolved, and infection improving.
Patient very angered and believed was never seen by physician at
___ (though documented 2 visits with MD). Demanded to leave
hospital. Patient was medically stable for discharge; reviewed
with patient medical plan on discharge. An Rx was generated for
linezolid, though patient eloped from hospital before PIV
removed and Rx given. ___ and RN searched floor & lobby and
patient not found. Called patient, though phone message
indicated "not receiving calls." Similar message also
encountered when called HCP and alternate HCP. No prior history
of IV drug use, but communicated with PCP that eloped with PIV
in place. Rx sent to patient's preferred pharmacy, in event they
can reach him -- also included note to pharmacy to hold
escitalopram, as above, given concomitant linezolid use.
CHRONIC ISSUES
# Chest pain, likely
# Costochondritis: chronic, reproducible on exam, EKG WNL, very
low concern for ACS.
# Depression: held ecitalopram given interaction with linezolid
# DM: ISS while in house; resumed metformin on discharge.
# COPD: Continued albuterol, tiotropium
# CAD: continued home asa, metop, statin
# GERD: continued metoprolol
TRANSITIONAL ISSUES
=====================
- Pulmonary nodule: repeat CT in 12 months
- Treatment of UTI with linezolid final day, ___
- Restart escitalopram on ___
35 minutes was spent on coordination of care, counseling &
discharge planning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Escitalopram Oxalate 2.5 mg PO DAILY
5. Finasteride 5 mg PO DAILY
6. fluticasone-salmeterol 100-50 mcg/dose inhalation BID
7. Furosemide 20 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Senna 8.6 mg PO BID:PRN constipation
12. Tiotropium Bromide 1 CAP IH DAILY
13. Atorvastatin 40 mg PO QPM
Discharge Medications:
1. Linezolid ___ mg PO Q12H Duration: 11 Doses
RX *linezolid ___ mg 1 tablet(s) by mouth twice daily Disp #*11
Tablet Refills:*0
2. Phenazopyridine 100 mg PO TID:PRN bladder spasm Duration: 3
Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times a
day Disp #*9 Tablet Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Docusate Sodium 100 mg PO BID
7. Finasteride 5 mg PO DAILY
8. fluticasone-salmeterol 100-50 mcg/dose inhalation BID
9. Furosemide 20 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Senna 8.6 mg PO BID:PRN constipation
14. Tiotropium Bromide 1 CAP IH DAILY
15. HELD- Escitalopram Oxalate 2.5 mg PO DAILY This medication
was held. Do not restart Escitalopram Oxalate until 72 hours
after completing your antibiotics (Linezolid), ___, to
avoid a potentially LIFE THREATENING drug-drug
interaction/effect.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
Urinary tract infection
Sepsis
Secondary
Chronic chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
You were admitted due to flank pain and found to have a urinary
tract infection. The bacteria you had was very resistant to a
few antibiotics thus you were started treatment on Linezolid.
Please continue to take your antibiotics and we recommend
straight cath rather than the foley tube.
It was a pleasure being part of your care
Your ___ Team
Followup Instructions:
___
|
19921471-DS-41 | 19,921,471 | 28,870,061 | DS | 41 | 2153-09-29 00:00:00 | 2153-09-29 16:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo ___ with PMHx of BPH, Kidney Cancer s/p L
nephrectomy ___ years ago, known bladder mets, and recurrent
UTIs
from chronic foley due obstruction from bladder mets who
recently
was admitted for a complicated VRE UTI. During his last
admission
(___) ___ left AMA with PIV in and also did not leave
with his prescription of linezolid. ___ then went to ___
where he received Amoxicillin for his UTI and then returned to
the ___ on ___ and said that the amoxicillin was not helping. The
___ prescribed ___ his linezolid and was discharged home.
___ came back to the ___ last night noting increased back
pain
consistent with the "kidney pain" he has had with infections in
the past.
___ endorses chills, but no fevers during that time period.
He notes that he does not want to change his foley catheter and
that he does that at home himself every 3 days.
Of note, on interview with ___ about what meds he takes he
exclaims "Oh no! I put my linezolid in the left part of my
medicine cabinet and not the right... so I may not have been
taking it."
Past Medical History:
COPD (stage III COPD, FEV1 47%, FVC 87%, FEV1/FVC 54; most
recent CT w/ severe pan-lobular emphysema)
renal cancer s/p L nephrectomy
Bladder cancer w/ recurrent UTIs & pyelonephritis
T2DM
HTN
HLD
GERD
BPH
anxiety & depression
CAD
Social History:
___
Family History:
Father and sister with bladder cancer. Mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
___ 0721 Temp: 97.4 PO BP: 107/66 HR: 82 RR: 18 O2 sat: 96%
O2 delivery: RA
Constitutional: acute distress. Very talkative.
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops,
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, ttp in suprapubic region, ND
GU: Foley in place draining clear urine, right slight CVA
tenderness. Most tenderness around right posterior axillary line
close to area of iliac bones
EXT: Warm, well perfused, 1+ bilat ___
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
Exam on discharge:
97.8 BP: 120 / 72 65 18 95% RA
Constitutional:in no acute distress. speaks in full sentences
EYES: Sclera anicteric, EOMI, PERRL
ENMT: MMM, oropharynx clear, normal hearing, normal nares
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Respiratory: Clear to auscultation bilaterally, no wheezes,
rales, rhonchi
GI: Soft, non-tender. +midline hernia.
GU: Foley in place draining clear yellow urine, no CVAT
EXT: Warm, well perfused, 1+ bilat ___
NEURO: aaox3 CNII-XII and strength grossly intact
SKIN: no rashes or lesions
Pertinent Results:
___ 11:50PM GLUCOSE-92 UREA N-15 CREAT-1.1 SODIUM-143
POTASSIUM-4.4 CHLORIDE-108 TOTAL CO2-23 ANION GAP-12
___ 11:50PM estGFR-Using this
___ 11:50PM WBC-12.6* RBC-3.90* HGB-11.9* HCT-35.6*
MCV-91 MCH-30.5 MCHC-33.4 RDW-16.1* RDWSD-52.9*
___ 11:50PM NEUTS-57.0 ___ MONOS-10.2 EOS-3.8
BASOS-1.0 NUC RBCS-0.2* IM ___ AbsNeut-7.17* AbsLymp-3.48
AbsMono-1.29* AbsEos-0.48 AbsBaso-0.12*
___ 11:50PM PLT COUNT-223
___ 09:30PM URINE HOURS-RANDOM
___ 09:30PM URINE UHOLD-HOLD
___ 09:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:30PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-2* PH-6.0
LEUK-MOD*
___ 09:30PM URINE RBC-33* WBC-55* BACTERIA-NONE YEAST-OCC*
EPI-0
___ 09:30PM URINE MUCOUS-RARE*
Urine culture:
___ 9:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___
IMPRESSION:
Chronic emphysema, but no focal consolidations.
Renal ___
IMPRESSION:
No evidence of hydronephrosis on the right. Status post left
nephrectomy.
Brief Hospital Course:
___ yo M with hx COPD, renal ca, bladder cancer with chronic
indwelling foley now presenting with flank pain and abnormal UA
with VRE growing in prior urine culture with urine culture now
negative.
# Sepsis
# Leukocytosis
# UTI, with concern for pyelo
Pt at high risk for UTI given chronic indwelling foley, solitary
right kidney and open ureteral orifeces (per note by Dr.
___. The ___ was recently admitted and noted to
have VRE on culture. It is not clear if he completed his course
of antibiotics as an outpatient. He has been seen in the ___ ___
a number of times recently and had a negative urine culture
there. He was treated with linezolid until cultures here
returned negative. The ___ reports his Foley was changed 3
days prior to admission. The ___ requested discharge and
given negative cultures and stable vital signs he was safe for
discharge home.
# Bladder cancer
Per note from Dr. ___ with solitary R kidney and open
ureteral orifice increasing risk for pyleonephritis. Per chart
review he was scheduled for surgery ___. ___ reports he is
now planning on following up with Dr. ___ at ___
___ and that he has an appointment on ___. Stressed the
importance of outpatient follow up.
# Depression
-hold ecitalopram given severe interaction with linezolid, can
resume when linezolid completed at home
# COPD: No signs of exacerbation, continued on home inhalers
# CAD: continuted home asa, metop, statin
# GERD: continuted metop
# pulm nodule: repeat CT in ___ m
# Utilization of ___:
Discussed importance of ___ only for emergent issues. The ___
reports if he has any symptoms that concern him, he presents to
the ___. This was explored with SW and psychiatry consults during
___ admission. It was felt that the ___ frequent
presentation likely represents some form of obsessive compulsive
disorder with some component of panic attacks. The ___ would
benefit from outpatient psychotherapy.
Transitonal issues:
- Outpatient follow up with urology- ___ will follow up at
___
# CODE: presumed full
# ___
Relationship: brother in law
Phone number: ___
>30 minutes on discharge/coordination of care
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Finasteride 5 mg PO DAILY
2. Tiotropium Bromide 1 CAP IH DAILY
3. MetFORMIN (Glucophage) 500 mg PO DAILY
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
5. Phenazopyridine 100 mg PO TID
6. Atorvastatin 40 mg PO QPM
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. Furosemide 20 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Linezolid ___ mg PO Q12H
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
2. Atorvastatin 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Furosemide 20 mg PO DAILY
6. Linezolid ___ mg PO Q12H
7. MetFORMIN (Glucophage) 500 mg PO DAILY
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Phenazopyridine 100 mg PO TID
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic urinary retention with indwelling foley
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you during your admission. You
were admitted with concerns for a urinary tract infection. Your
urine was tested and did not show an infection. If you have not
completed the antibiotics you were prescribed previously, you
should complete these antibiotics. It is important that you
follow up with your urologist for management of your bladder
cancer.
We wish you the best,
Your ___ Care team
Followup Instructions:
___
|
19921471-DS-43 | 19,921,471 | 24,675,778 | DS | 43 | 2153-10-14 00:00:00 | 2153-10-14 21:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ man with BPH, RCC s/p L nephrectomy, bladder CA with
outlet obstruction c/b reflux and recurrent
cystitis/pyelonephritis. On ___, he underwent TURBT at ___
(Urologist ___ under spinal anesthesia. The procedure
was uncomplicated and he returned home with his catheter in
place.
On ___, at approximately 1300, he noted onset of bitemporal
headache, which
was different than his typical tension headaches. He says it's
not positional, but is worse with coughing. He denies fever,
chills, nausea, vomiting, photophobia, stiff neck, focal
neurologic symptoms. This persisted throughout the day and
prompted him present to the Emergency room for evaluation.
Past Medical History:
COPD (GOLD III COPD, FEV1 47%, FVC 87%, FEV1/FVC 54; most
recent CT w/ severe pan-lobular emphysema)
Ongoing tobacco use
RCC s/p L nephrectomy
Recurrent bladder cancer, s/p TURBT ___
BPH
Bladder outlet obstruction with indwelling Foley
VUR with recurrent VRE pyelonephritis
DM type 2
History of HTN
HLD
CAD
Anxiety, especially anxiety about health issues, which seems to
drive high utilization of emergency & ___ medical care
Social History:
___
Family History:
Father and sister with bladder cancer. Mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
DISCHARGE EXAM:
VITALS: last 24-hour vitals were reviewed.
GEN: NAD
HEENT: EOMI, sclerae anicteric, MMM, OP clear
NECK: No LAD, no JVD
CARDIAC: RRR, no M/R/G
PULM: normal effort, no accessory muscle use, LCAB. Increased AP
diameter
GI: soft, NT, ND, NABS
GU: mild R flank pain (not new per chart review)
MSK: No visible joint effusions or deformities.
DERM: No visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
CT HEAD
1. No acute intracranial abnormality.
2. Brain parenchymal atrophy.
CXR
Chronic emphysema without definite new focal consolidation.
DISCHARGE LABS
___ 11:15AM BLOOD WBC-4.6 RBC-3.62* Hgb-10.9* Hct-32.6*
MCV-90 MCH-30.1 MCHC-33.4 RDW-15.9* RDWSD-51.3* Plt ___
___ 06:31AM BLOOD Glucose-98 UreaN-17 Creat-1.2 Na-140
K-4.9 Cl-104 HCO3-25 AnGap-11
MICRO
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
Brief Hospital Course:
___ w/ RCC s/p L nephrectomy, VUR w/ recurrent VRE
pyelonephritis, bladder CA with outlet obstruction requiring
indwelling Foley, s/p TURBT ___ under spinal anesthesia, who
was admitted for post-LP headache, which resolved with time and
NSAIDs. While admitted, he has been noted to be markedly
orthostatic.
#ORTHOSTATIC HYPOTENSION
BP was found to drop to 63/37 on standing. Looking at clinic
records, his BP is highly variable and I suspect he has been
orthostatic for a while; he also reports a recent history of
frequent syncope and near-syncope. On careful history, he
reported a visit to ___ ED between his procedure and his ___
admission where he was given Lasix (unclear indication), which
may be why it was so bad on this admission.
After aggressive IV fluids, the orthostasis markedly
improved. He still dropped by greater than 20 points, but SBP
was 101 standing and he was asymptomatic. He was started on
low-dose midodrine, which he says makes him feel great.
I was very concerned for Mr. ___ safety while
orthostatic, given the hazards of his work as a ___
___. He was educated to stay hydrated and avoid diuretics
unless clearly indicated (like if they are recommended by a
cardiologist or nephrologist). If symptoms persist, will also
have to weigh risks/benefits of continuing his finasteride and
also his metoprolol.
___
Resolved with IVF
#POST LP HEADACHE
Resolved with time and ketorolac. Option of a blood patch was
explored, but he improved before a plan could be established.
#QUESTION OF UTI
Patient reported RLQ pain typical of what he experiences when
found to have UTIs, which has been an issue recently even when
urine culture has been clean. Empiric linezolid was started
pending urine cultures given strong VRE history, but urine
cultures are polymicrobial. Given negative cultures, will just
give Bactrim PPx for 10 days after TURBT as prescribed by his
urologist.
OUTSTANDING ISSUES
1) Repeat orthostatic vital signs. If orthostasis is persistent,
consider stopping metoprolol, stopping finasteride, and/or
increasing midodrine.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
2. Atorvastatin 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Furosemide 20 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Phenazopyridine 100 mg PO TID
10. Tiotropium Bromide 1 CAP IH DAILY
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Metoprolol Succinate XL 12.5 mg PO QHS
RX *metoprolol succinate 25 mg 0.5 (One half) tablet(s) by mouth
at bedtime Disp #*30 Tablet Refills:*0
3. Midodrine 2.5 mg PO BID
RX *midodrine 2.5 mg 1 tablet(s) by mouth Twice daily Disp #*60
Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
5. Atorvastatin 40 mg PO QPM
6. Finasteride 5 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Phenazopyridine 100 mg PO TID
11. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
12. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
post spinal anesthesia headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for a headache. We believe this was caused by
your spinal anesthesia. It resolved with some pain meds and
time.
We also were worried you might have a UTI, but the urine culture
looked good. Just take Bactrim to prevent infection as
instructed by your urologist.
Your big problem was ORTHOSTATIC HYPOTENSION, a condition where
your blood pressure dropped as low as 63/37 when you stood up.
You clearly have a tendency to get this problem, but it is
always made worse by dehydration. You got much better with
fluids. Please make the following changes to keep safe:
1) Stay hydrated!!
2) Avoid Lasix and other diuretic medications if possible; if a
doctor wants to give you Lasix, make sure they are aware you
have bad orthostatic hypotension and know to be really careful.
3) Decrease your metoprolol to 25 mg daily,
4) Start taking midodrine 2.5 mg to help keep your blood
pressure up. You can take this twice a day, but no need to take
it before bedtime because your blood pressure is fine when you
are lying down anyway.
Followup Instructions:
___
|
19921471-DS-44 | 19,921,471 | 22,817,414 | DS | 44 | 2153-10-27 00:00:00 | 2153-10-27 09:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
hematuria, dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old male with past medical history of bladder
cancer, renal cell carcinoma status post L nephrectomy, urinary
retention requiring indwelling foley, vesicular ureteral reflux
complicated by multiple urinary tract infections, COPD, history
otherwise notable for 11 ___ admissions (and ___ ___ admissions)
over last 6 months for reasons including atypical chest pain,
dyspnea without clear medical cause from which he eloped,
anxiety, COPD exacerbation requiring home O2 arrangement,
hematuria, abdominal pain attributed to GERD, UTI,
abdominal/flank pain without signs of infection attributed to
his
known malignancy, orthostatic hypotension, also with recent
outpatient Transurethral Resection of Bladder Tumor under spinal
anesthesia on ___, now presenting with hematuria.
Per discussion with patient and review of ___ and Partners
records (has not been seen in their ED since ___, since last
discharge on ___, he was seen in the ___ ED on ___ for
chronic dyspnea and pelvic pain, discharged home, again on ___
with dizziness thought to be from dehydration, volume
resuscitated and discharged home. He then presented to
___ on ___ with continued orthostatic symptoms was
found to have foley obstruction secondary to clot, with
prompting
initiation of foley with significant hematuria, requiring 3-way
foley for continuous bladder irrigation, and transfer to ___
ED.
In the ___ ED, initial VS were 98.1 115 91/63 22 92% 2L NC.
Labs were notable for WBC 12.7, Hgb 8.5, Plt 207, Mg 1.3, Phos
2.1, K 5.2, Cr 1.4; UA with >182 WBCs, 28 WBCs, no bacteria.
Patient was given 1L NS x 2, 1mg IV Ativan x 1, 4mg IV morphine
x
1. He was given 2 units pRBCs. He was seen by urology and
admitted to medicine for further management.
On arrival to the floor, patient confirmed above. He reported
feeling that his mouth was dry. Full 10 point review of systems
positive where noted, otherwise negative.
Past Medical History:
COPD (GOLD III COPD, FEV1 47%, FVC 87%, FEV1/FVC 54; most
recent CT w/ severe pan-lobular emphysema)
Ongoing tobacco use
RCC s/p L nephrectomy
Recurrent bladder cancer, s/p TURBT ___
BPH
Bladder outlet obstruction with indwelling Foley
VUR with recurrent VRE pyelonephritis
DM type 2
History of HTN
HLD
CAD
Anxiety, especially anxiety about health issues, which seems to
drive high utilization of emergency & ___ medical care
Social History:
___
Family History:
Father and sister with bladder cancer. Mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
Admission exam
O:
VS: 97.9 Axillary 96 / 62 L Lying ___ RA ___ 131
Gen: sitting up in bed, comfortable appearing
Eyes - EOMI, anicteric
ENT - OP clear, dry MM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
GU - continuous bladder irrigation draining punch red urine
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, although occasionally inattentive; ___ x 4
extremities
Psych - odd affect
Discharge exam
Patient examined on the day of discharge. Ambulating at his
baseline without desaturations, good air movement, scattered
expiratory wheezes.
Pertinent Results:
Admission labs
___ 06:34AM BLOOD WBC-12.7* RBC-2.84* Hgb-8.5* Hct-26.2*
MCV-92 MCH-29.9 MCHC-32.4 RDW-16.0* RDWSD-53.9* Plt ___
___ 06:34AM BLOOD Glucose-167* UreaN-31* Creat-1.4* Na-141
K-5.2 Cl-111* HCO3-20* AnGap-10
Discharge labs
___ 06:28AM BLOOD WBC-10.1* RBC-2.54* Hgb-7.4* Hct-22.1*
MCV-87 MCH-29.1 MCHC-33.5 RDW-15.4 RDWSD-48.1* Plt ___
___ 06:28AM BLOOD Glucose-140* UreaN-13 Creat-1.0 Na-144
K-4.6 Cl-112* HCO3-21* AnGap-11
___ 07:05AM BLOOD Calcium-9.3 Phos-2.5* Mg-1.6
Renal ___ ___
IMPRESSION:
1. New mild to moderate right hydroureteronephrosis since prior
renal
ultrasound from ___. Status post left nephrectomy.
2. Bladder is mildly distended with debris and blood products.
A Foley
catheter is seen within the bladder lumen.
CXR ___
IMPRESSION:
There is upper lobe predominant emphysema with superimposed
patchy parenchymal opacities left greater than right which could
represent pneumonia. There are healing left-sided rib
fractures. There is stable elevation of left hemidiaphragm.
Cardiomediastinal silhouette is stable. There are no pleural
effusions. No pneumothorax is seen
Brief Hospital Course:
This is a ___ year old male with past medical history of bladder
cancer, renal cell carcinoma status post L nephrectomy, urinary
retention requiring indwelling foley,
vesicular ureteral reflux complicated by multiple urinary tract
infections, COPD, orthostatic hypotension, anxiety, with 19
admissions over last 6 months for issues related to above
issues, status post recent transurethral Resection of Bladder
Tumor ___, admitted with hematuria, anemia and clot retention
requiring continuous bladder irrigation. Hospital course
complicated by sepsis ___ hospital acquired pneumonia and a COPD
exacerbation.
# Acute blood loss anemia
# Hematuria (resolved) - Patient with complex GU history notable
for hematuria secondary to bladder mass, recently status post
Transurethral Resection of
Bladder Tumor at ___, presented with worsening hematuria with
associated anemia; Hgb on admission was 8.5, decreased from
recent baseline of ___ was seen by urology in ED and started
on CBI; CBI complicated by patient's small capacity bladder and
frequent obstruction by clots requiring hand irrigation and
foley upsize. He required 4 units PRBC total over admission. His
hematuria eventually resolved and CBI was discontinued. He
completed a course of antibiotics for post-operative ppx
(combination of bactrim and linezolid/cefepime while septic). He
will discharge with a foley in place and is following up with
Dr. ___ in ___ weeks for voiding trial.
# Sepsis ___ HAP and COPD exacerbation - on ___ patient
developed fever and leukocytosis. Source initially thought to be
pulmonary vs. GU. Flu PCR negative. He was started on CTX then
broadened to cefepime and linezolid. Urine culture returned with
mixed flora c/w skin contamination therefore source determined
to be hospital acquired pneumonia. He was narrowed to cefepime
then levofloxacin. On ___ he was noted to be increasingly
wheezy and hypoxic, with O2 saturations dropping to the ___ on
ambulation. He was started on prednisone and DuoNebs for a COPD
exacerbation, with improvement back to his baseline. He will
complete a five day course of prednisone and a 7-day course of
levofloxacin as an outpatient.
# Thrombocytopenia - initial plts 130, related to consumption
from bleeding. Resolved when hematuria improved.
# Obstructive ___ on CKD stage 3 (resolved) - Cr appears to vary
between 1.0 and 1.3; up to 1.9 on ___ with evidence of
hydronephrosis on renal ___ resolved with continued bladder
irrigation and removal of clots from foley.
#Mild cognitive impairment - seen by psychiatry, ___ noted to
be 24 and patient with clear memory deficits. Patient will need
frequent repetition of plan of care and reminders of goals. OT
evaluated him for additional services, and felt he was safe for
discharge.
#Hx of anxiety - seen by psychiatry, started on Lexapro 2.5 mg
# Orthostatic Hypotension - Previously noted during prior
admissions with associated symptoms prompting initiation of
Midodrine; sypmtoms were more pronounced on admission ___ acute
blood loss. He was continued on midodrine.
# CAD. Home metoprolol, statin, and aspirin.
# COPD - Baseline inhalers.
# Chronic Urinary retention - Continue finasteride
# Diabetes type 2 - Continue home metformin
# GERD - Continue home PPI
TRANSITIONAL ISSUES:
- patient will follow up with Dr. ___ in ___ weeks for trial
of discontinuing foley
>35 minutes spent on discharge activities
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
2. Atorvastatin 40 mg PO QPM
3. Finasteride 5 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. MetFORMIN (Glucophage) 500 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Phenazopyridine 100 mg PO TID
8. Tiotropium Bromide 1 CAP IH DAILY
9. Aspirin 81 mg PO DAILY
10. Midodrine 2.5 mg PO BID
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
12. Metoprolol Succinate XL 12.5 mg PO QHS
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY Duration: 3 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
2. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*6 Tablet
Refills:*0
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Finasteride 5 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO QHS
10. Midodrine 2.5 mg PO BID
11. Omeprazole 40 mg PO DAILY
12. Phenazopyridine 100 mg PO TID
13. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hematuria ___ recent tumor ___ Acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for bleeding from the bladder. You were
treated with continous bladder irrigation and the bleeding
stopped. You also developed a pneumonia during admission as well
which was treated with antibiotics. You will discharge to finish
a course of antibiotics and steroids.
As for your blood in your urine, you will follow up with Dr.
___ in ___ weeks after discharge. You can do your foley
exchange as previously at home.
Followup Instructions:
___
|
19921471-DS-45 | 19,921,471 | 27,901,425 | DS | 45 | 2153-11-01 00:00:00 | 2153-12-09 13:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI(4): Mr. ___ is a ___ male with history of bladder
cancer, renal cell carcinoma status post L nephrectomy, urinary
retention requiring indwelling foley, vesicular ureteral reflux
complicated by multiple urinary tract infections, COPD,
orthostatic hypotension, anxiety, who re-presents 2 days after
recent discharge with ongoing symptoms of cough, chest tightness
and shortness of breath.
Patient has had 20 admissions over last 6 months for issues
related to above issues, status post recent transurethral
Resection of Bladder Tumor ___ and was admitted here on ___
with
acute on chronic anemia in the setting of hematuria requiring
CBI
via 3-way foley cathter. His hospital course was
complicated by sepsis ___ hospital acquired pneumonia and a COPD
exacerbation for which he was started on a course of levaquin
and
prednisone, with 3 more days left of his course at time of
discharge on ___.
Today he returns with complaints of ongoing SOB, productive
cough
and congestion associated with worsening chest pain. Per recent
d/c summary, patient has had 11 ___ admissions (and ___ ___
admissions) over last 6 months for reasons including atypical
chest pain, dyspnea without clear medical cause from which he
eloped, anxiety, COPD exacerbation requiring home O2
arrangement,
hematuria, abdominal pain attributed to GERD, UTI,
abdominal/flank pain without signs of infection attributed to
his known malignancy, orthostatic hypotension (on midodrine). He
was evaluated by psych team due to concern for MCI, with MOCA
noted to be 24 and patient with clear memory deficits. OT
evaluated him for additional services, and felt he was safe for
discharge.
Past Medical History:
- COPD (GOLD III COPD, FEV1 47%, FVC 87%, FEV1/FVC 54; most
recent CT w/ severe pan-lobular emphysema)
- ___ s/p L nephrectomy
- Recurrent bladder cancer, s/p TURBT ___
- BPH
- Bladder outlet obstruction with indwelling Foley
- VUR with recurrent VRE pyelonephritis
- DM type 2
- History of HTN
- HLD
- CAD
- Anxiety, especially anxiety about health issues, which seems
to drive high utilization of emergency & ___ medical care
- Orthostatic hypotension
Social History:
___
Family History:
Father and sister with bladder cancer. Mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
VITALS: Temp: 97.9 PO BP: 101/62 R Sitting HR: 76 RR: 20 O2 sat:
96% O2 delivery: Ra
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema. 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
symmetric
SKIN: No obvious rashes or ulcerations noted on cursory skin
exam
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Brief Hospital Course:
___ male with history
of bladder cancer, renal cell carcinoma status post L
nephrectomy, urinary retention requiring indwelling foley,
vesicular ureteral reflux complicated by multiple urinary tract
infections, COPD, orthostatic hypotension, anxiety, who
re-presents 2 days after recent discharge with ongoing symptoms
of cough, chest tightness and shortness of breath.
ACUTE/ACTIVE PROBLEMS:
##Chest pain - now he describes the chest pain as more of a
discomfort, uneasiness, associated with nausea and no vomiting.
Without any dynamic EKG changes, and negative troponins, still
not suspicious of a cardiac process. He had both a COPD
exacerbation and a pneumonia, simultaneously, so this has
knocked
him back a few notches. He continues to be slightly
rhonchorous,
but improving. He is not volume overloaded in any way. He is
currently afebrile
-- will continue supportive care w/ expectorant / mucolytic
-- IS, and pulmonary toilet prn
-- continue inhalers prn and standing home inhalers
-- clear and equal air movement today. Not on supplemental O2.
#Leukocytosis #Reported fevers -
-remains afebrile since admission, without any infectious
signs/symptoms.
-leukocytosis may mainly be driven by steroids. Trend.
-- as long as clinically stable, will hold off on further abx.
Sp one dose of ceftriaxone in the ED.
- white count is coming down (makes sense as his prednisone has
been stopped for two days).
CHRONIC/STABLE PROBLEMS:
# CKD stage 3 - Cr appears to vary between 1.0 and 1.3; up to
1.9
during recent admission however now improved to 1.4.
- continue to trend
- maintain foley, ___ Fr- 3 way to prevent further blockages
from clots
#Orthostatic hypotension
-still complains of dizziness when he gets up from seated
position (this has been a chronic issue for him, and is on a
small dose of midodrine at home, which is continued in the
hospital.)
-we rechecked orthostatic vitals this morning, and did not rule
in.
- I will increase his midodrine to 5 bid, and assess tomorrow
for
any improvement. I explained to him that we will be unlikely to
completely fix this issue while inpatient, but this should be
addressed with his pcp.
# CAD
- continue statin and ASA
- continue Toprol, with holding parameters
# Chronic Urinary retention
Multifactorial, requiring chronic foley
- continue Finasteride
# Diabetes type 2
- hold home metformin
- sliding scale Humalog
# GERD
- continue PPI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
6. Midodrine 2.5 mg PO BID
7. Omeprazole 40 mg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO QHS
10. Phenazopyridine 100 mg PO TID
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Midodrine 5 mg PO BID
RX *midodrine 5 mg 5 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Finasteride 5 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
7. MetFORMIN (Glucophage) 500 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO QHS
9. Omeprazole 40 mg PO DAILY
10. Phenazopyridine 100 mg PO TID
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Noncardiac chest pain, orthostatic hypotension
Discharge Condition:
Ambulatory, clear mental status, tolerating diet.
Discharge Instructions:
You were admitted with chest pain and dizziness. To better
treat the dizziness, related to orthostatic hypotension, we
increased the midodrine dosing to 5mg BID. Please follow up
with your primary care doctor about this dizziness, as this
appears to be a chronic issue for you.
Followup Instructions:
___
|
19921471-DS-46 | 19,921,471 | 22,396,114 | DS | 46 | 2153-11-06 00:00:00 | 2153-11-06 14:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___
Chief Complaint:
Dizziness, lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with a history of bladder
cancer, renal cell carcinoma status post L nephrectomy, urinary
retention requiring indwelling Foley, vesicular ureteral reflux
complicated by multiple urinary tract infections, COPD,
orthostatic hypotension, and anxiety, who presents 1 day after
his last discharge with dizziness.
The patient has had > 20 admissions over the last 6 months
related to his chronic medical problems. He is status post
recent transurethral resection of bladder tumor on ___ and was
admitted from ___ with acute on chronic anemia in the
setting of hematuria requiring CBI via 3-way foley cathter. His
hospital course at that time was complicated by sepsis secondary
hospital acquired pneumonia and a COPD exacerbation for which he
was given Levaquin and prednisone.
He then was re-admitted from ___ for chest pain, shortness
of breath, and dizziness. His chest pain was felt to be
non-cardiac in etiology and his dizziness related to his known
orthostatic hypotension. He was also found to have a UTI for
which he was placed on Levaquin. The patient's midodrine was
increased to 5mg BID and he was discharged. He was seen by his
PCP ___ ___ and was told to increase his midodrine to 10mg BID.
At this time the patient was requesting admission to the
hospital, but his PCP encouraged him that he could be treated as
an outpatient. Nonetheless, the patient went to the ED.
On arrival to the ED, the patient states that he went home, and
while attempting to walk to the store, lost his balance and fell
down. He landed on his left shoulder, but did not hit his head.
He was able to get up after. He did not report any associated
headache or dizziness. He does not report chest pain or
shortness of breath. He does not report fevers, chills, nausea,
vomiting, and diarrhea. This battle with balance has reportedly
been an issue for an extended period of time. The patient
believes the midodrine is making his dizziness worse.
In the ED:
Initial vital signs were notable for: T 97.6, HR 85, BP 126/76,
RR 16, O2 sat 100% on RA
Exam notable for:
-Right clavicle tenderness
-Normal neuro exam, slightly off balance with his gait when
first getting up. Normal ability to ambulate with walker.
Labs were notable for: WBC 20.7, Hgb 9.3, platelets 589, Mg 1.3,
K 5.6--> 5.0, HCO3 20, Cr 1.4--> 1.3
Studies performed include:
CXR- Stable appearance of the lungs with interstitial lung
disease.
NCHCT- No acute intracranial abnormality.
R shoulder XR- No acute fracture or dislocation of the right
shoulder.
Patient was given: 1L NS, Aspirin 81 mg, MetFORMIN (Glucophage)
500 mg, Finasteride 5 mg, Phenazopyridine 100 mg x2, Magnesium
Oxide 400 mg, Fluticasone-Salmeterol Diskus (100/50) 1 INH,
Midodrine 10 mg
Consults: ___- recommend discharge to rehab
Vitals on transfer: T 97.8, HR 75, BP 119/61, RR 18, O2 sat 99%
on RA
Upon arrival to the floor, the patient states that he is feeling
much better now that he is receiving 10mg of midodrine. No
longer feeling consistently dizzy or lightheaded. Otherwise,
feels as if his breathing is at his baseline. Does not report
fevers, chills, chest pain, vomiting, and changes in bowel
habits. Has mild abdominal pain and nausea that he associates
with midodrine, but this is tolerable.
Past Medical History:
- COPD (GOLD III COPD, FEV1 47%, FVC 87%, FEV1/FVC 54; most
recent CT w/ severe pan-lobular emphysema)
- RCC s/p L nephrectomy
- Recurrent bladder cancer, s/p TURBT ___
- BPH
- Bladder outlet obstruction with indwelling Foley
- VUR with recurrent VRE pyelonephritis
- DM type 2
- History of HTN
- HLD
- CAD
- Anxiety, especially anxiety about health issues, which seems
to drive high utilization of emergency & ___ medical care
- Orthostatic hypotension
Social History:
___
Family History:
Father and sister with bladder cancer. Mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
ADMISSION PHYSICALE EXAM:
=========================
VITALS: T 98.1 PO, BP 166 / 82 (130/63 sitting, 98/62 standing),
HR 55, RR 18, O2 sat 96% on RA
GENERAL: Alert and interactive. In no acute distress. Pleasant.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes.
Oropharynx is clear.
NECK: No JVD. Supple.
CARDIAC: Regular rhythm, normal rate. Distant heart sounds.
Audible S1 and S2. No murmurs/rubs/gallops/thrills.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. Prolonged expiratory phase
with
mild end expiratory wheezing at the bases.
ABDOMEN: Normal bowels sounds, non distended, tender to deep
palpation in the LLQ around large ventral hernia. No
organomegaly.
EXTREMITIES: No clubbing, cyanosis, or lower extremity edema,
though wearing compression stockings. Pulses Radial 2+
bilaterally.
GU: Foley in place draining yellow urine.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: A&Ox3. Moving all 4 extremities with purpose.
DISCHARGE PHYSICAL EXAM:
========================
VS: 97.9 108 / 71 59 18 96 Ra
Lying BP 128/76 HR 60 Standing after 2 minutes BP 108/70 HR 71
GENERAL: Alert and interactive. Sitting at edge of bed, well
appearing, animated
HEENT: EOM intact with no nystagmus, PERRL, sclera anicteric
w/out injection. MMM, oropharynx is clear without erythema or
exudate.
CARDIAC: Regular rate and rhythm, no murmurs
LUNGS: Clear to auscultation bilaterally w/ prolonged expiratory
phase, no crackles, wheeze, or rhonchi appreciated.
ABDOMEN: non tender, non distended, ventral hernia protrudes
with abdominal flexion.
EXTREMITIES: No clubbing, cyanosis, or lower extremity edema, DP
pulses 2+.
GU: Foley in place draining urine into bag.
CVA: none
SKIN: Warm and without rashes.
NEUROLOGIC: A&Ox3. ___ strength upper and lower extremities,
sensation to light touch in tact in upper and lower extremities.
Able to ambulate with walker.
Pertinent Results:
============
INITIAL LABS
============
___ 07:25AM BLOOD WBC-13.7* RBC-3.12* Hgb-8.8* Hct-27.0*
MCV-87 MCH-28.2 MCHC-32.6 RDW-15.8* RDWSD-49.9* Plt ___
___ 08:52PM BLOOD Neuts-87.3* Lymphs-5.4* Monos-2.6*
Eos-0.0* Baso-0.6 NRBC-0.1* Im ___ AbsNeut-18.08*
AbsLymp-1.11* AbsMono-0.54 AbsEos-0.01* AbsBaso-0.12*
___ 08:52PM BLOOD WBC-20.7* RBC-3.31* Hgb-9.3* Hct-28.4*
MCV-86 MCH-28.1 MCHC-32.7 RDW-15.9* RDWSD-49.5* Plt ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD Glucose-93 UreaN-37* Creat-1.1 Na-140
K-5.1 Cl-105 HCO3-28 AnGap-7*
___ 07:25AM BLOOD Calcium-10.4*
===========================
RELEVANT ___ COURSE LABS
==========================
___ 03:50PM URINE Hours-RANDOM Creat-26 Na-140 K-30 Cl-132
Phos-21.8
___ 01:55PM URINE Hours-RANDOM UreaN-478 Creat-37 Na-130
K-37 Cl-130
___ 01:55PM URINE RBC-7* WBC-86* Bacteri-FEW* Yeast-NONE
Epi-0
___ 03:50PM URINE RBC->182* WBC-106* Bacteri-FEW*
Yeast-NONE Epi-0
___ 01:55PM URINE Blood-TR* Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 03:50PM URINE Blood-MOD* Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-LG*
___ 03:50PM URINE Color-ORANGE* Appear-Hazy* Sp ___
==============
DISCHARGE LABS
==============
___ 05:30AM BLOOD WBC-11.5* RBC-3.06* Hgb-8.5* Hct-27.6*
MCV-90 MCH-27.8 MCHC-30.8* RDW-16.7* RDWSD-54.1* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-88 UreaN-24* Creat-1.1 Na-142
K-5.1 Cl-106 HCO3-23 AnGap-13
___ 05:30AM BLOOD Calcium-9.7 Phos-3.9 Mg-1.7
=============
TESTS/IMAGING
=============
___ RENAL U.S
COMPARISON: ___.
FINDINGS:
The right kidney measures 12.4 cm. The left kidney is surgically
removed.
There is now only minimal right pelvocaliectasis, markedly
improved from the prior scan. 2 simple cysts are noted in the
right kidney ranging up to 2.5 cm in diameter. Cortical
echogenicity and architecture is normal. No stones are
identified. The bladder is empty via a Foley catheter in place.
IMPRESSION:
Status post left nephrectomy. Near complete resolution of the
right hydronephrosis following insertion of Foley catheter.
___ CT HEAD
No acute intracranial abnormality.
___ CXR & RIGHT SHOULDER XRAY
Stable appearance of the lungs with interstitial lung disease.
No acute fracture or dislocation of the right shoulder.
============
MICROBIOLOGY
============
URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3
COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL
CONTAMINATION.
Brief Hospital Course:
Mr. ___ is a ___ man with a history of recurrent low
grade bladder cancer s/p 12+ TURBTs, renal cell carcinoma status
post L nephrectomy, urinary retention requiring indwelling
Foley, vesicular ureteral reflux complicated by multiple urinary
tract infections, COPD, T2DM, CKD (baseline cr. 1.1-1.3)
orthostatic hypotension, and anxiety, who presented one day
after his last discharge with dizziness/lightheadedness, who was
admitted to medicine for orthostatic hypotension and
leukocytosis.
HOSPITAL COURSE BY PROBLEM
=========================
# Orthostatic hypotension
Mr. ___ presented with dizziness and lightheadedness found to
be consistent with diagnosis of orthostatic hypotension for
which he has been treated in the past (per the patient last
treated in ___. He had positive orthostatics in the ED and on
the medical floor. Dizziness and lightheadedness worsened when
his BPs were ___, but his symptoms improved when his BPs
were 100-110s. His hypotension is likely multifactorial with a
significant contribution from autonomic instability related to
aging and also hypovolemia. On admission, his home midodrine
was uptitrated to 10 mg TID. He received 3L normal saline in
total. At the time of discharge his BPs were improved but still
orthostatic, however patient was asymptomatic. He was able to
ambulate without lightheadedness or other symptoms on day of
discharge. Discharge BPs 128/76 lying with 108/70 on standing.
# Leukocytosis
Did not suspect infection, admission WBC count 20.7. Recently
given prednisone course as outpatient for COPD exacerbation. Of
note, urine culture grew VRE x 3 times during previous
admissions. Suspect colonizer as patient was not treated for
this infection in recent past and has remained clinically well
without symptoms. Renal ultrasound obtained to revaluate right
kidney w/o evidence of pyelonephritis or abscess and patient
without fevers, chills, or suprapubic tenderness. No issues or
discomfort with chronic foley. He remained afebrile throughout
the admission and his WBC was downtrending 20.7 ->11.5.
#Anxiety
Patient demonstrated significant anxiety regarding his health
throughout the admission. This has likely contributed to >20
admissions to the hospital over the past 6 months. He was seen
by social work during this hospitalization who recommended that
a psycho social assessment at rehab be done directly prior to
returning home. He was encouraged to contact his primary care
doctor's office and the ___ Urgent Care ___ his medical
needs upon discharge.
CHRONIC ISSUES:
==============
# COPD: No issues this hospitalization. Home inhalers were
continued.
# CKD: Creatinine baseline this admission. Cr appears to vary
between 1.0 and 1.3.
# CAD: No issues, statin and ASA were continued.
# Chronic urinary retention: No issues his hospitalization.
Patient with chronic Foley. Home finasteride was continued.
# T2DM: His home metformin was held during his admission and he
was given sliding scale Humalog in-house.
# GERD: He was continued on home PPI.
TRANSITIONAL ISSUES:
====================
[ ] Anticipate length of stay <30 days
[ ] Continue midodrine 10 mg PO TID
[ ] Encouraged daily use of compression stockings
[ ] Encourage adequate hydration with 8-ounce glasses of water
or other fluid per day and adequate salt intake.
[ ] Consider addition of florinef if orthostatics persist.
[ ] PCP ___ after discharge from rehab.
[ ] Consider outpatient psychiatry or social work for health
related anxiety
[ ] Continue indwelling Foley catheter; patient changes this
himself every few days and is competent in this.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN coughing or wheezing
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Midodrine 10 mg PO BID
5. Omeprazole 40 mg PO DAILY
6. Phenazopyridine 100 mg PO Q8H:PRN bladder pain
7. Tiotropium Bromide 1 CAP IH DAILY
8. Atorvastatin 40 mg PO QPM
9. MetFORMIN (Glucophage) 500 mg PO DAILY
10. Escitalopram Oxalate 2.5 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. Furosemide 10 mg PO DAILY
13. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Midodrine 10 mg PO TID
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN coughing or wheezing
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Escitalopram Oxalate 2.5 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. MetFORMIN (Glucophage) 500 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Phenazopyridine 100 mg PO Q8H:PRN bladder pain
11. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Orthostatic hypotension
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 ___.
You were admitted to the hospital for dizziness,
lightheadedness, and low blood pressures.
WHILE YOU WERE IN THE HOSPITAL:
- You received the medications midodrine to help improve your
blood pressures. You also received intravenous fluids to improve
your blood pressures. You then felt better and your blood
pressures improved.
- Your other home medications were given as deemed appropriate
by the medical team.
- You had an ultrasound study of your kidney because you were
having pain in your right side. The ultrasound did not show any
evidence of an active infection of your kidney. You did not
have a urine infection.
- Your blood sugars were monitored and were within the normal
range during your hospitalization.
WHEN YOU ARE DISCHARGED FROM THE HOSPITAL:
- For your low blood pressures or "orthostatic hypotension" you
should:
1) Continue to take midodrine as prescribed as well as your
home medications.
2) When you need to stand up from a lying or sitting position,
first, please sit up slowly and move your feet vigorously for
___ minutes before SLOWLY standing up all the way.
3) Be sure to stay well hydrated five to eight 8-ounce glasses
(1.25 to 2.5 L) of water or other fluid per day.
4) Continue to wear compression stockings.
5) Follow the recommendations from the Rehabilitation team
regarding exercise and fall prevention.
We wish you the best in your continued recovery!
Your ___ Care Team
Followup Instructions:
___
|
19921471-DS-47 | 19,921,471 | 23,035,956 | DS | 47 | 2153-12-12 00:00:00 | 2153-12-13 05:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ multiple medical comorbidities including bladder cancer
s/p transurethral tumor rsxn ___ at ___, renal cell
carcinoma s/p L nephrectomy in ___ at ___, urinary retention
requiring indwelling Foley, vesicular ureteral reflux c/b
multiple UTIs, COPD, DMII, orthostatic hypotension requiring
midodrine, and anxiety p/w 5-days of recurrent abdominal pain
c/f biliary colic vs chronic cholecystitis.
Patient reports that he has recurrent epigastric and RUQ pain
that has been constant over the past 5 days. Reports low-grade
temp to 100.4 and chills, as well as nausea, no emesis. He last
had an episode of similar abdominal pain several weeks ago. He
was most recently hospitalized at ___ from ___ for
management of orthostasis and a UTI, was discharged to rehab on
___ and then requested readmission to ___ on ___ for
chest pain. He did complain of abdominal pain at the time as
well. It appears that his workup was negative and he was then
discharged again on ___. He is now back in ___ ED w/
complaints of 5 days of abdominal pain. He was reportedly worked
up and scheduled for cholecystectomy at ___, but is here
requesting his operation be performed at ___ due to his PCP
being here.
He has been seen at the ___ and ___ ED multiple times over the
past few months for various complaints. Per recent medical
records, patient has had 11 ___ admissions (and ___ ___
admissions) over last 6 months for reasons including atypical
chest pain, dyspnea without clear medical cause from which he
eloped, anxiety, COPD exacerbation requiring home O2
arrangement, hematuria, abdominal pain attributed to GERD, UTI,
abdominal/flank pain without signs of infection attributed to
his known malignancy, orthostatic hypotension (on midodrine),
and epigastric pain. Patient was seen in ___ by ACS for an
episode of epigastric pain that self-resolved a/w nausea with
exam that was notable for a reducible ventral hernia and
gallstones.
Past Medical History:
PMHx:
COPD (stage III COPD, FEV1 47%, FVC 87%, FEV1/FVC 54; most
recent CT w/ severe pan-lobular emphysema)
renal cancer s/p L nephrectomy
Bladder cancer w/ recurrent UTIs & pyelonephritis
T2DM
HTN
HLD
GERD
BPH
anxiety & depression
PSH:
- s/p transurethral resection x3 of bladder tumor (Dr. ___
- s/p L nephrectomy ___
Social History:
___
Family History:
Father and sister with bladder cancer. Mom with ___
Spotted Fever and subsequent renal failure, now deceased.
Physical Exam:
Admission Physical Exam:
Vitals - T 97.8 / HR 92 / BP 114/71 / RR 18 / O2sat 100% RA
General - comfortable, NAD
HEENT - moist mucous membranes, PERRLA, EOMI
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - reproducible TTP RUQ, reducible ventral hernia, soft,
nondistended, unreliably positive ___ sign
GU - indwelling catheter
Extremities - warm and well-perfused
Neuro - A&OX3
Discharge Physical Exam:
T 98.6 / HR 51 / BP 163/74 / RR 18 / O2sat 93% RA
General - comfortable, NAD
HEENT - moist mucous membranes, PERRLA, EOMI
Cardiac - RRR, no M/R/G
Chest - CTAB
Abdomen - mild TTP RUQ, reducible ventral hernia, soft,
non distended.
GU - indwelling catheter
Extremities - warm and well-perfused
Neuro - A&OX3
Pertinent Results:
IMAGING:
___: Gallbladder US:
Cholelithiasis. No evidence of acute cholecystitis. Normal CBD
and
intrahepatic biliary tree.
___: HIDA:
Normal hepatobiliary scan.
LABS:
___ 04:20AM URINE COLOR-Yellow APPEAR-Cloudy* SP
___
___ 04:20AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-300*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-LG*
___ 04:20AM URINE RBC-112* WBC->182* BACTERIA-FEW*
YEAST-FEW* EPI-0
___ 04:20AM URINE HYALINE-28*
___ 04:20AM URINE WBCCLUMP-MANY* MUCOUS-MOD*
___ 02:45AM GLUCOSE-108* UREA N-26* CREAT-1.7* SODIUM-143
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-24 ANION GAP-14
___ 02:45AM ALT(SGPT)-11 AST(SGOT)-14 ALK PHOS-87 TOT
BILI-0.8
___ 02:45AM LIPASE-12
___ 02:45AM ALBUMIN-3.6 CALCIUM-10.8* PHOSPHATE-3.1
MAGNESIUM-1.9
___ 02:45AM WBC-14.4* RBC-3.44* HGB-9.4* HCT-30.2* MCV-88
MCH-27.3 MCHC-31.1* RDW-19.7* RDWSD-60.1*
___ 02:45AM NEUTS-69.6 LYMPHS-16.9* MONOS-9.8 EOS-2.1
BASOS-0.8 IM ___ AbsNeut-10.00* AbsLymp-2.42 AbsMono-1.40*
AbsEos-0.30 AbsBaso-0.11*
___ 02:45AM PLT COUNT-268
Brief Hospital Course:
Mr. ___ is a ___ w/ multiple medical comorbidities including
bladder cancer s/p transurethral tumor rsxn ___ at ___,
renal cell carcinoma s/p L nephrectomy in ___ at ___, urinary
retention requiring indwelling Foley, vesicular ureteral reflux
c/b multiple UTIs, COPD, DMII, orthostatic hypotension requiring
midodrine, and anxiety who presented to ___ on ___ with
5-days of recurrent abdominal pain c/f biliary colic vs chronic
cholecystitis.
The patient presented to the hospital this admission with
recurrent epigastric and RUQ pain. The patient was started on
IV ciprofloxacin and flagyl, made NPO and received IVF for
hydration. The patient had a gallbladder ultrasound which showed
cholelithiasis without evidence of cholecystitis. HIDA scan was
normal. The patient was started on a regular diet which was
well-tolerated. Intake and output was monitored. Cipro/flagyl
were discontinued. Pain was managed with acetaminophen.
The patient remained alert and oriented throughout
hospitalization. He remained stable from a cardiopulmonary
standpoint; vital signs were routinely monitored.
The patient received subcutaneous heparin and ___ dyne boots
were used during this stay and was encouraged to get up and
ambulate as early as possible. At the time of discharge, the
patient was doing well, afebrile and hemodynamically stable.
The patient was tolerating a diet, ambulating, voiding without
assistance, and pain was well controlled. The patient received
discharge teaching and follow-up instructions with understanding
verbalized and agreement with the discharge plan. It was
discussed that he would follow-up in outpatient ___ clinic to
discuss elective cholecystectomy.
Medications on Admission:
Advair Diskus 500 mcg-50 mcg/dose BID, Colace 100 mg BID,
Ventolin HFA 90 mcg/actuation aerosol q4 prn, aspirin 81 mg
daily, atorvastatin 40 mg daily, escitalopram 5 mg daily,
finasteride 5 mg daily, furosemide 10 mg daily, metformin 500 mg
daily, metoprolol 12.5 mg daily, omeprazole 40 mg daily,
phenazopyridine 100 mg q8 prn, senna 8.6 mg tablet, midodrine 15
mg TID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. TraMADol 50 mg PO Q6H:PRN Pain - Severe
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Escitalopram Oxalate 5 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Furosemide 10 mg PO DAILY
10. Metoprolol Succinate XL 12.5 mg PO DAILY
11. Midodrine 15 mg PO TID
12. Omeprazole 40 mg PO DAILY
13. Phenazopyridine 100 mg PO TID Duration: 3 Days
14. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ with
abdominal pain and had an ultrasound showing you to have
gallstones without evidence of acute cholecystitis (inflammation
of the gallbladder). You also had a HIDA scan which was normal
and did not demonstrate acute cholecystitis. The pain you had
was likely reflective of chronic inflammation of your
gallbladder or biliary colic (intermittent pain caused by
gallstones). It is recommended you follow-up in the outpatient
Acute Care Surgery clinic to discuss timing of an elective
gallbladder removal surgery.
You were resumed on a regular diet which you are now tolerating
and your pain has improved. You are now ready to be discharged
home to continue your recovery.
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.
Followup Instructions:
___
|
19921471-DS-50 | 19,921,471 | 29,068,055 | DS | 50 | 2154-05-26 00:00:00 | 2154-05-26 21:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
Right flank pain, paranoid delusions
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ w/ COPD, anxiety disorder, recurrent bladder
cancer
s/p 12+ TURBTs (resulting low-volume bladder), RCC s/p L
nephrectomy, recurrent UTI/pyelonephritis who presents w/
paranoid delusions. Feels occasional fevers, diagnosed with C.
difficile 2 months ago with explosive diarrhea is up to 5 times
per day. He endorsed having better formed stool while he was an
inpatient here. Now with ___ stools/day with better consistency
with lighter color. He is currently denying
dysuria/urgency/frequency but endorses R sided pain with CVA
tenderness. Recently left AMA from ___ as an inpatient
because he said he had been waiting for a bed for 5 days and did
not think the psychiatrist was trying hard enough. He is
returning today because his brother told him to, the cops are
looking for him and he was under the threat of some kids who he
has a grudge with. He is currently denying SI/AH/VH and says he
never had hallucinations except when he was acutely infected
with
c.diff when he came in.
In the ED:
Initial vital signs were notable for:
T96.8, 87, 139/81, 22, 98% RA
Exam notable for:
VSS stable on room air
Lungs CTA, RRR/no murmurs
Mildly TTP to LLQ
Positive left-sided CVAT
Labs were notable for:
UA +182 WBC, neg bacteria
WBC 13.2
K 6.4 (hemolyzed) > 6.2 > 4.5
Studies performed include:
CXR: No definite new focal consolidation; signs of emphysema
Patient was given:
IV Augmentin
PO Flagyl
PO Vanc
Dicyclomine 10 mg
Insulin
Consults: None
Vitals on transfer: T97.9, 60, 110/73, 16, 96% RA
Upon arrival to the floor, pt was feeling fine overall but
endorses being dizzy on his feet. Also complains of a pain on
his
R side that he said he took aspirin for. Otherwise, he denies
N/V/F/C/chest pain. Denies SI/HI/AH/VH.
Past Medical History:
Bladder cancer s/p transurethral tumor rsxn ___ at ___
Renal cell carcinoma s/p L nephrectomy in ___ at ___
Hx of urinary retention requiring indwelling Foley (no longer
active issue)
*Chronic right hydroureteronephrosis
*Possible recurrence of bladder cancer (___)
Vesicular ureteral reflux c/b multiple UTIs
DMII
Orthostatic hypotension
Recurrent abdominal pain
COPD (FEV1 47%, FVC 87%, FEV1/FVC 54; most recent CT w/ severe
pan-lobular emphysema)
HTN
HLD
GERD
BPH
Anxiety & depression
* = new Dx added during this hospitalization
Social History:
___
Family History:
- Father and sister with bladder cancer.
- Mom with ___ Spotted Fever and subsequent renal
failure, now deceased.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VITALS: 98.0, 124/77, 72, 16, 99% RA
GENERAL: Thin elderly Caucasian gentleman, pleasant and
cooperative, in NAD.
HEENT: Sclerae anicteric, MMM.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, mild inspiratory wheezing in lower and mid lungs
b/l, no rales, no rhonchi, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, +BS, tender in R abdomen, no
rebound/guarding, no hepatosplenomegaly
BACK: R CVA tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose.
PULSES: 2+ DP pulses bilaterally
NEURO: Moves all four extremities with purpose. A&O x3.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 756)
Temp: 98.2 (Tm 98.3), BP: 122/68 (122-149/68-81), HR: 66
(56-69), RR: 18, O2 sat: 97% (94-97), O2 delivery: Ra
GENERAL: Thin elderly gentleman, pleasant and cooperative, in
NAD.
HEENT: Sclerae anicteric, MMM.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs.
LUNGS: CTAB, no wheezes, rales, or rhonchi, breathing
comfortably
without use of accessory muscles.
ABDOMEN: nondistended, +BS, nontender to palpation in all four
quandrants, no rebound or guarding. Does have incisional hernia,
non erythematous, nontender.
EXTREMITIES: no cyanosis, clubbing or edema.
NEURO: AOx3. Not responding to external stimuli. Moves all four
extremities with purpose.
Pertinent Results:
ADMISSION LABS:
===============
___ 10:18AM BLOOD WBC-13.2* RBC-4.25* Hgb-11.7* Hct-36.8*
MCV-87 MCH-27.5 MCHC-31.8* RDW-21.2* RDWSD-64.2* Plt ___
___ 10:18AM BLOOD Neuts-60.4 ___ Monos-11.5 Eos-2.3
Baso-1.3* NRBC-0.2* Im ___ AbsNeut-7.97* AbsLymp-3.01
AbsMono-1.52* AbsEos-0.30 AbsBaso-0.17*
___ 10:18AM BLOOD Glucose-102* UreaN-32* Creat-1.3* Na-141
K-6.4* Cl-105 HCO3-25 AnGap-11
___ 10:26AM BLOOD Lactate-1.3 K-6.2*
___ 01:01PM BLOOD K-4.5
PERTINENT LABS/MICRO/IMAGING:
============================
___ 06:22AM BLOOD Albumin-3.7 Calcium-10.5* Phos-3.3 Mg-1.6
___ 01:13PM BLOOD PTH-87*
___ 06:22AM BLOOD 25VitD-26*
___ 08:33AM BLOOD Cortsol-17.4
___ 07:28AM URINE Color-Straw Appear-Hazy* Sp ___
___ 07:28AM URINE Blood-TR* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 07:28AM URINE RBC-6* WBC->182* Bacteri-NONE Yeast-NONE
Epi-1
___ 07:28AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 7:28 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 1 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
___ 10:00 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:18 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Imaging:
-----------
CXR ___:
No definite new focal consolidation to suggest pneumonia.
Severe bullous
emphysema with unchanged mild chronic interstitial abnormality.
CT A/P w/o contrast ___:
1. Moderate right hydroureteronephrosis to the level of the
bladder with
posterior bladder wall thickening and new nodularity measuring
up to 14 mm
with associated calcifications concerning for recurrent
malignancy.
2. No obstructing renal, ureteral, or bladder stones identified.
Multiple
punctate nonobstructing renal stones demonstrated.
3. Cholelithiasis without findings to suggest cholecystitis.
4. Diverticulosis without findings of diverticulitis.
DISCHARGE LABS:
===============
___ 07:15AM BLOOD WBC-10.8* RBC-4.03* Hgb-11.5* Hct-35.6*
MCV-88 MCH-28.5 MCHC-32.3 RDW-20.0* RDWSD-63.5* Plt ___
___ 10:48AM BLOOD Glucose-97 UreaN-23* Creat-1.1 Na-143
K-5.0 Cl-107 HCO3-29 AnGap-7*
___ 10:48AM BLOOD Calcium-10.9* Phos-3.2 Mg-1.7
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ man with Gold stage 3 COPD, anxiety
disorder, recent C.diff infection, recurrent bladder cancer s/p
12+ TURBTs (resulting in low-volume bladder), RCC s/p L
nephrectomy, recurrent UTI/pyelonephritis, and several ED
admissions, who presented to the ED with paranoid delusions and
right flank pain a day after eloping from ___ while medically
cleared and waiting for a bed on Deac 4. Completed treatment for
C.diff, currently treating for UTI, and optimizing orthostatic
hypotension.
ACUTE ISSUES:
=============
# Paranoid Delusions:
# Auditory Hallucinations:
No known psych diagnosis before prior admission in ___. During that admission, he presented with paranoid
delusions and auditory hallucinations and was awaiting a Deac 4
bed when he eloped. Per the psych resident, he was less agitated
and doing well on standing/PRN Haldol before elopement and was
agreeable to treatment for his delusions. He then re-presented a
day after elopement again with paranoid delusions of being on
morning news for eloping and his family who wanted him to ensure
"he's not a nut." UTox was negative this admission, and patient
remained psychiatrically stable on his standing haldol. Per his
PCP, he had never reported hallucinations or other psychotic
symptoms. Per psychiatry, given this acute change and
improvement with treatment of his medical issues as below, his
presentation was most likely in the setting of toxic metabolic
encephalopathy, less likely underlying psychiatric disorder.
Haldol was discontinued prior to discharge per psychiatry. He
remained on ___ with a 1:1 sitter to prevent elopement,
which was discontinued prior to discharge following psychiatric
clearance.
# R flank pain:
# R hydroureteronephrosis:
# Hx of Bladder Cancer:
Patient complaining of RLQ abdominal pain that also extends to
the R lumbar paraspinal region, now much improved. CT A/P w/o
contrast from ___ shows c/f new bladder tumor and moderate
right hydroureteronephrosis. Patient is currently followed by
___ urology (previously be Dr. ___. Urine cytology from
recent admission was negative for high-grade urothelial
carcinoma. Patient has severely contracted bladder at baseline,
in review of urological records and discussion with urology
(likely related to his cancer and multiple prior procedures).
Touched base with urology during this admission and noted no
role for acute surgical intervention at this time, given stable
Cr and stable HD. Urology recommended Foley to decompress
bladder, however patient refused given urinating fine with no
complaints of retention. He will need follow up with urology and
likely oncology re: this new tumor.
# Leukocytosis:
# UTI w/ h/o VRE:
Pt with bladder cancer s/p 12+ TURBTs with resultant low volume
bladder and recurrent UTIs. Has h/o VRE UTI (___) sensitive
to Augmentin/Ampicillin. UA this admission positive for pyuria
with no bacteria. Urine cx growing Enterococcus sensitive to
ampicillin. On admission reported occasional dysuria with
suprapubic tenderness, now resolved. No CVA tenderness on exam.
Started antibiotics on ___, most recently ampicillin, with
total 10-day course to be completed on ___.
#Orthostatic hypotension:
Patient still with symptomatic orthostatic hypotension,
midodrine decreased on most recent admission. During this
admission, midodrine was increased back up to max dose of 15mg
TID. Given IVF bolus challenge after which he remained
significantly orthostatic. In that setting, started on
fludrocortisone 0.1mg daily, which can be uptitrated by 0.1mg
per week. Encouraged the use of compressions stockings.
#Mild C.diff infection:
Positive C. diff PCR and toxin last admission, despite having
been treated ___ times since ___ as an outpatient with
questionable compliance. Whether or not he was symptomatic vs.
colonized is unclear. Completed his treatment with PO vanc on
___, then was started on prophylactic PO vanc while on
ampicillin for UTI and to remain on ppx for 5 days following
completion of ampicillin (through ___.
#History of Elopement:
Patient eloped from the hospital on ___. He was on a ___ given his persistent delusions and hallucinations. ___
was discontinued prior to discharge following psychiatric
clearance.
CHRONIC ISSUES:
===============
# CHRONIC ABDOMINAL PAIN:
Continued home dicyclomine.
# CORONARY ARTERY DISEASE:
Continued home aspirin/statin.
# URINARY RETENTION:
Continued home finasteride.
# COPD:
Continued home advair, ipratropium, albuterol.
# T2DM:
Held home metformin and put on ISS while inpatient.
# ANXIETY:
Continued home lexapro.
TRANSITIONAL ISSUES:
===================
Psych:
-Patient with history of paranoid delusions and auditory
hallucinations, esp. in the setting of infection. Cleared for
discharge by psychiatry.
[] Consider referral to psychiatry urgent care at ___ for any
new or worsening psychiatric symptoms.
Urology:
- New bladder tumor and moderate right hydroureteronephrosis
identified on CT A/P ___.
[] Will need urology follow-up at ___, Urology appointment
pending in CareConnection. Dr. ___ ___ ___ indicated
that the patient left his practice on poor terms (though the
patient himself does not seem to recall this) and asked that the
patient be scheduled with a different Urologist for follow-up.
[] Will need oncology follow-up at ___. This has not yet been
scheduled.
Primary Care:
-Discharged on ampicillin 500mg PO q6h for total 10-day course
for treatment of UTI, to be completed on ___.
-Discharged on Vancomycin 125mg PO BID for c.diff ppx while on
antibiotics for UTI + 5 days afterwards, to be completed ___.
-Continued orthostatic hypotension despite IVF. Maxed out on
midodrine (15mg TID) and started fludrocortisone 0.1mg daily on
___. Can be uptitrated by 0.1mg weekly to max dose of 1mg daily
(though 0.3mg is likely the max therapeutic dose).
[] Calcium found to be slightly elevated at 10.7 corrected, with
PTH slightly up at 87. Recommend further workup (primary
hyperparathyroidism vs. familial hypocalcuric hypercalcemia).
#CODE: FC (presumed)
#CONTACT: ___, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. DICYCLOMine 10 mg PO QID:PRN Abdominal Pain
6. Escitalopram Oxalate 5 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. Midodrine 10 mg PO TID
10. Omeprazole 40 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Phenazopyridine 100 mg PO TID
13. Haloperidol 2.5-5 mg PO Q4H:PRN agitation
14. Haloperidol 2.5 mg PO QHS
15. Vancomycin Oral Liquid ___ mg PO QID
16. MetFORMIN (Glucophage) 500 mg PO QHS
Discharge Medications:
1. Ampicillin 500 mg PO Q6H
RX *ampicillin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*9 Capsule Refills:*0
2. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Midodrine 15 mg PO TID
RX *midodrine 5 mg 3 tablet(s) by mouth three times a day Disp
#*270 Tablet Refills:*0
4. Vancomycin Oral Liquid ___ mg PO BID C.Diff prophylactic
dosing
RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp
#*15 Capsule Refills:*0
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 40 mg PO QPM
9. DICYCLOMine 10 mg PO QID:PRN Abdominal Pain
10. Escitalopram Oxalate 5 mg PO DAILY
11. Finasteride 5 mg PO DAILY
12. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
13. MetFORMIN (Glucophage) 500 mg PO QHS
14. Omeprazole 40 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
-Right flank pain
-Urinary tract infection
-Paranoid delusions
SECONDARY:
-Orthostatic hypotension
-Clostridium difficile infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital because you were having right
sided abdominal pain and urinary symptoms that were concerning
for a recurrent urinary tract infection.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
-You were treated with antibiotics for a urinary tract
infection.
-You finished your course of antibiotics for C. diff and your
diarrhea resolved. You were then started on a prophylactic dose
of the same antibiotic to prevent a recurrent episode of C.
diff.
-You had a scan of your abdomen which showed thickening of the
bladder that may represent a recurrent bladder tumor. You should
follow up with your urologist to further work this up.
-Your midodrine was increased and you were started on a new
medication (fludrocortisone) to improve your orthostatic
hypotension (the drops in your blood pressure when standing).
WHAT SHOULD I DO WHEN I LEAVE THE HOSPITAL?
-Continue to take all medications as prescribed.
-Please attend all ___ clinic appointments.
-Please make sure you have an appointment with a urologist in
the next few weeks. The ___ Urology office should be
contacting you in the next few days.
-If you feel that you are not urinating well, or that you are
not completely emptying your bladder, please return to the ED.
-As we discussed, when sitting up from lying down and standing
up from sitting, please move slowly. Also, continue to use your
compression socks.
We wish you all the best,
Your ___ Care Team
Followup Instructions:
___
|
19921471-DS-53 | 19,921,471 | 29,020,907 | DS | 53 | 2155-02-19 00:00:00 | 2155-02-19 16:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
hematuria, dysuria/flank pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o M with PMhx of Anxiety/Depression with Psychosis, Renal
Cell Ca s/p L nephrectomy in ___, Bladder Cancer s/p
transurethral tumor resection in ___, Chronic right
hydronephrosis, Ureteral reflux, frequent UTIs, DM and COPD who
was sent in from his locked unit for dysuria, hematuria and
right flank pain.
On arrival to the ED, pt was afebrile with T 97.5, HR 75, BP
114/81, RR 18 Sats 94% on RA. Labs were notable for
leukocytosis, mild ___ and UA with many RBC as well as WBCs. Pt
underwent CT abd/pelv that showed chronic right sided
hydronephrosis and possible bladder wall thickening vs
underdistension. Pt was given IV unasyn and IVF. However, pt
eloped from the ED around 4pm and ___ was notified.
Upon return to the ED at 1am, pt reports that he left because
there were too many people around. Labs were repeated and
notable for rising leukocytosis, further increase in creatinine
and persistent hematuria. Pt was given a dose of Linezolid for
hx of VRE.
On arrival to the floor, history is limited by what seems to be
some baseline confusion. However he is able to report a recent
worsening in dysuria, flank pain, and hematuria (though the
hematuria has been present for quite some time). Denies CP, SOB,
orthopnea, lower extremity swelling.
Past Medical History:
- Anxiety, Depression with Psychotic Disorder, currently has a
guardian - ___ and ___ in locked unit ___
- Bladder cancer s/p transurethral tumor rsxn ___ at ___
- Renal cell carcinoma s/p L nephrectomy in ___ at ___
- Hx of urinary retention requiring indwelling Foley (no longer
active issue)
- Chronic right hydroureteronephrosis
Likely recurrence of bladder cancer ___ - workup pending)
- Vesicular ureteral reflux c/b multiple UTIs
- DMII
- Orthostatic hypotension
- COPD (FEV1 47%, FVC 87%, FEV1/FVC 54; most recent CT w/ severe
pan-lobular emphysema)
- Hypertension
- GERD
- BPH
Social History:
___
Family History:
- Father and sister with bladder cancer.
- Mom with ___ Spotted Fever and subsequent renal
failure, now deceased.
Physical Exam:
ADMISSION:
=========
___ ___ Temp: 97.7 PO BP: 117/74 HR: 69 RR: 18 O2 sat: 94%
O2 delivery: Ra
GEN: very pleasant gentleman resting in bed in NAD, answering
questions appropriately.
HEENT:anicteric sclera, EOMI, OP clear
CV: RRR, no m/r/g
RESP: CTA b/l without significant wheeze or other adventitious
sounds.
ABD: soft, + suprapubic tenderness and right CVA tenderness
GU: tenderness as above, no foley
EXTR: well perfused, no edema
DERM: no rashes or other lesions
PSYCH: calm, answering questions appropriately, does not appear
preoccupied with internal stimuli.
DISCHARGE:
=========
___ ___ Temp: 97.7 PO BP: 136/83 R Lying HR: 79 RR: 18
O2 sat: 93% RA
GEN: very pleasant gentleman resting in bed in NAD, sleepy but
arousable
HEENT: anicteric sclera, OP clear
CV: RRR, no m/r/g
RESP: CTA b/l without significant wheeze or rales
ABD: soft, nontender, nondistended, +BS
BACK: No CVAT
GU: no foley
EXTR: well perfused, no edema
DERM: no rashes or other lesions
PSYCH: calm, answering questions appropriately, though
intermittently confused about location, making somewhat
non-sensical statements
Pertinent Results:
ADMISSION/SIGNFICANT LABS:
=======================
___ 02:40PM BLOOD WBC-12.3* RBC-4.43* Hgb-11.5* Hct-37.1*
MCV-84 MCH-26.0 MCHC-31.0* RDW-20.7* RDWSD-61.8* Plt ___
___ 02:40PM BLOOD Neuts-70.2 Lymphs-16.7* Monos-9.3 Eos-2.3
Baso-0.8 Im ___ AbsNeut-8.63* AbsLymp-2.05 AbsMono-1.14*
AbsEos-0.28 AbsBaso-0.10*
___ 02:40PM BLOOD Glucose-114* UreaN-31* Creat-1.5* Na-143
K-4.6 Cl-107 HCO3-22 AnGap-14
___ 02:40PM BLOOD ALT-12 AST-15 AlkPhos-98 TotBili-0.4
MICRO:
=====
BCx ___ x2, ___ - no growth to date
UCx ___- skin contamination
UCx ___- ___ >100,000 CFU, sensitivities pending
IMAGING/OTHER STUDIES:
====================
CXR ___: No pneumonia or acute cardiopulmonary process.
CT abd/pelv from ___
1. Similar appearance of the right kidney compared to priors
with
moderate right hydroureteronephrosis and perinephric stranding.
No visualized cause of underlying obstruction, no obstructing
renal or ureteral calculus. This appearance is similar compared
to the multiple priors. Cannot exclude the possibility of an
underlying infection and correlation with UA is suggested.
2. Lobulated contour of the bladder with multiple diverticula
near the dome. Apparent wall thickening may be due to
underdistention though underlying mass is difficult to exclude
on
this unenhanced CT scan. Of note, the partially calcified 2.2
cm
soft tissue density lesion seen on most recent prior exam from
___ is not seen today.
3. Anterior abdominal wall supraumbilical hernias, one of which
contains anterior wall of the transverse colon which is
nonobstructed.
LABS ON DISCHARGE:
=================
___ 06:00AM BLOOD WBC-12.0* RBC-3.75* Hgb-9.9* Hct-31.2*
MCV-83 MCH-26.4 MCHC-31.7* RDW-20.7* RDWSD-61.1* Plt ___
___ 06:00AM BLOOD Glucose-111* UreaN-20 Creat-1.2 Na-141
K-4.0 Cl-108 HCO3-21* AnGap-12
___ 06:00AM BLOOD ALT-9 AST-13 AlkPhos-89 TotBili-0.6
___ 06:00AM BLOOD Calcium-9.5 Phos-2.6* Mg-1.7
Brief Hospital Course:
Over 30 min were spent in discharge planning and coordination of
care.
___ with PMhx of Depression with Psychosis, Hx of RCC s/p L
nephrectomy, Bladder Cancer s/p resection in ___, reflux with
frequent UTIs, DM and COPD who p/w hematuria, dysuria and ___.
___ improved with IVF and hydration. Hematuria resolved on its
own with no further bleeding. Iniitially dysuria, flank pain
concerning for UTI but first culture with skin contamination and
repeat culture with ___. ID was consulted and
felt this was chronic and not a true infection, which is
consistent with prior presentations. They recommended no
treatment unless he is undergoing urologic procedure.
TRANSITIONAL ISSUES:
====================
[] Patient needs Urology follow-up for his bladder cancer. He
has missed several appointments. Urology was contacted in-house
and are working to schedule an appointment, tentatively for
___. Will need to confirm appointment and make sure patient
goes to it
[] will need ID consult prior to urologic procedure for
treatment of ___ given previous fluconazole resistance
#Code status:Full Code
#Contact: Guardian ___ ___
# UTI/Pyelonephritis:
#Hematuria:
Presented with worsening hematuria, dysuria, and
suprapubic/flank tenderness consistent clinically with
pyelophritis. Pt with hx of bladder ca s/p resection in ___ and
hx of recurrent UTIs. Most recent Urine Cx (and several others)
notable for VRE and no documented MDR GNR organisms. He was
empirically started on ampicillin. His hematuria resolved on its
own and his symptoms resolved. Urine cultures showed skin flora
contamination and on repeat grew out ___. Patient
was started on Fluconazole therapy, but in discussion with the
Infectious Disease team, yeast was likely a
contaminant/colonizer and thus treatment was discontinued. Given
fluconazole-resistant ___ in the past, speciation
and sensitivities were obtained for current sample to guide
management in the setting of any urologic interventions.
#Hx of Bladder Cancer
History of bladder cancer s/p resection in ___. He was supposed
to follow up with Urology based on noted from ___ and
___, but does not appear to have done so for unclear reasons.
CT a/p ___ with possible recurrent bladder mass, and he will
need cystoscopy/resection. In discussion with Urology in-house,
patient will follow up with them in clinic, likely on ___ (will
schedule tomorrow once clinics open) to re-evaluate and plan for
resection of tumor.
# Acute Kidney Injury:
Paitent with one remaining kidney and chronic right sided
hydronephrosis c/b ureteral reflux. Creatinine baseline in ___ was 1.1 and was 1.7 on admission. Suspect this is
related to infection and dehydration. R. hydronephrosis appears
stable on CT a/p ___. No evidence of clots or urinary retention
on PVR. Received 1L IVF and Cr improved to baseline.
# SOB
Patient reported shortness of breath that was unresolved with
albuterol neb and duoneb. CXR was WNL. O2 sat remained 93% RA.
Symptoms resolved on their own and were thought to be likely
secondary to anxiety.
# Anxiety/Depression c/b Psychosis:
Per notes and facility personel, pt has guardian and lives in a
locked unit. Pt was in the ED on ___ and eloped for 8hrs. Had a
1:1 sitter due to elopement risk but otherwise no concern for
psychiatric decompensation or worsening of mental status from
baseline. After sitter was discontinued, patient tried to leave
the unit again and required repeat redirection and additional
dose olanzapine. He was continued on his home depression regimen
consisting of lexapro and olanzapine.
# Orthostatic Hypotension:
No documented history of adrenal insufficiency. AM cortisol
___ normal at 17. Thus no role for stress dose steroids.
Likely related to side effect of antipsychotic. Continued
midodrine 2.5mg BID and fludrocortisone 0.1mg daily.
# HTN:
# primary ppx:
Seems to be on metop for this for some reason. No documented hx
of CAD in the record. In setting of orthostatic hypotension
above, favor less aggressive BP target. Metop succ held in
setting of infection and ASA discontinued due to hematuria.
# COPD: No evidence of acute flare. Continued home
bronchodilator/inhaled steroid regimen
# Acute on Chronic Abd pain: continued dicyclomine prn
# DM: held oral agents -covered with HISS as needed; continued
atorvastatin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. DICYCLOMine 10 mg PO QID:PRN Abdominal Pain
6. Escitalopram Oxalate 5 mg PO DAILY
7. Finasteride 5 mg PO DAILY
8. Fludrocortisone Acetate 0.1 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Omeprazole 40 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. OLANZapine 5 mg PO BID
13. MetFORMIN (Glucophage) 500 mg PO QHS
14. Midodrine 2.5 mg PO BID
15. OLANZapine 5 mg PO DAILY:PRN agitation
16. Metoprolol Succinate XL 25 mg PO DAILY
17. 2.5 mg Other BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
3. Atorvastatin 80 mg PO QPM
4. DICYCLOMine 10 mg PO QID:PRN Abdominal Pain
5. Escitalopram Oxalate 5 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fludrocortisone Acetate 0.1 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. MetFORMIN (Glucophage) 500 mg PO QHS
10. Midodrine 2.5 mg PO BID
11. OLANZapine 5 mg PO DAILY:PRN agitation
12. OLANZapine 5 mg PO BID
13. Omeprazole 40 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. 2.5 mg Other BID
16. HELD- Metoprolol Succinate XL 25 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until your PCP or other doctor tells you it's needed
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
HEMATURIA
DYSURIA
BLADDER CANCER
CHRONIC HYDRONEPHROSIS
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you during your hospitalization
at ___!
Why were you hospitalized?
-Because you were having bloody urine, pain with urination and
back pain.
What was done for you this hospitalization?
-We treated you for a urinary tract infection
-Your bleeding stopped and your symptoms improved
What should you do after you leave the hospital?
-Follow up with the Urology doctors for the ___ procedure
you need to have.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19921471-DS-54 | 19,921,471 | 29,980,163 | DS | 54 | 2155-03-07 00:00:00 | 2155-03-07 16:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor / montelukast /
tamsulosin / garlic
Attending: ___.
Chief Complaint:
right flank pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ M with PMH of renal cell carcinoma
s/p left nephrectomy ___, bladder cancer s/p transurethral
tumor
resection ___, chronic right hydronephrosis and ureteral
reflux,
chronic UTIs, diabetes, COPD, depression, and anxiety, who
presents with flank pain.
History is limited secondary to confusion. Patient states that
he
was at home with a woman, and sometimes they do not get along
when she wants things done her way. When this happens, he tries
to find another place to go to stay, and when he was offered a
bed here he took it. When asked specifically about flank pain,
he
states that he doesn't have any now, but states that he does get
"kidney pain" sometimes. Denies fevers or chills. Of note, per
ED
note patient reported that he has new sharp, stabbing right
flank
pain that started yesterday and is persisting today. Patient
also
endorses dysuria. Patient was supposed to follow-up with urology
after last discharge but states that he had to go boating
instead. Denies fevers, chills, nausea, vomiting, abdominal
pain,
chest pain.
On review of records, patient was last admitted to ___ from
___, also with flank pain and hematuria. He was
empirically started on ampicillin. His hematuria resolved on its
own and his symptoms resolved. Urine cultures showed skin flora
contamination and on repeat grew out ___. Patient
was started on Fluconazole therapy, but in discussion with the
Infectious Disease team, yeast was likely a
contaminant/colonizer
and thus treatment was discontinued.
In the ED:
Initial vital signs were notable for: T 99.0, HR 79, BP 104/90,
RR 16, 95% RA
Exam notable for:
AAOx3, pleasant man
RRR, normal S1, S2
CTAB
R CVA tenderness
Labs were notable for:
- CBC: WBC 14.9, hgb 12.3, plt 237
- Lytes:
147 / 106 / 18 AGap=14
-------------- 124
4.5 \ 27 \ 1.3
- u/a with lg leuks, mod blood, >182 WBCs, few bacteria
Patient was given: IV ampicillin
Vitals on transfer: T 98.7, HR 67, BP 111/72, RR 16, 95% RA
Upon arrival to the floor, patient recounts history as above. No
current pain. He asks me if I work for the ___, and seems
surprised that he is at ___.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Anxiety, Depression with Psychotic Disorder, currently has a
guardian - ___ and ___ in locked unit ___
- Bladder cancer s/p transurethral tumor rsxn ___ at ___
- Renal cell carcinoma s/p L nephrectomy in ___ at ___
- Hx of urinary retention requiring indwelling Foley (no longer
active issue)
- Chronic right hydroureteronephrosis
Likely recurrence of bladder cancer ___ - workup pending)
- Vesicular ureteral reflux c/b multiple UTIs
- DMII
- Orthostatic hypotension
- COPD (FEV1 47%, FVC 87%, FEV1/FVC 54; most recent CT w/ severe
pan-lobular emphysema)
- Hypertension
- GERD
- BPH
Social History:
___
Family History:
- Father and sister with bladder cancer.
- Mom with ___ Spotted Fever and subsequent renal
failure, now deceased.
Physical Exam:
Admission Physical EXAM
=====================
VITALS: T 97.5, HR 62, BP 113/74, RR 18, 94% RA
GENERAL: Alert and in no apparent distress, lying comfortably in
bed
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. No CVA
tenderness
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented to hospital though not ___, 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: ___ ___ Temp: 97.8 PO BP: 150/80 HR: 63 RR: 18 O2
sat: 94% O2 delivery: Ra
GENERAL: Alert and in no apparent distress, lying comfortably in
bed
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, inconsistent left sided pain,
no rebound or guarding. Bowel sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation. Nearly
resolved TTP over right CVA
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: erythema around facial hair
PSYCH: pleasant, appropriate affect
NEURO: AOx3 (He knew he was at ___. He knew the year, the
month, the president, his name and DOB). Face symmetric, gaze
conjugate with EOMI, speech fluent, moves all limbs, sensation
to light touch grossly intact throughout
Pertinent Results:
.
Admission Labs:
.
___ 01:45PM BLOOD WBC-14.9* RBC-4.74 Hgb-12.3* Hct-39.9*
MCV-84 MCH-25.9* MCHC-30.8* RDW-20.9* RDWSD-63.1* Plt ___
___ 01:45PM BLOOD Glucose-124* UreaN-18 Creat-1.3* Na-147
K-4.5 Cl-106 HCO3-27 AnGap-14
___ 06:45AM BLOOD Calcium-10.3 Phos-3.2 Mg-1.5*
___ 11:54AM BLOOD HIV Ab-NEG
___ 11:54AM BLOOD HBsAg-NEG
___ 11:54AM BLOOD HCV Ab-NEG
.
Discharge Labs:
.
___ 06:37AM BLOOD WBC-11.0* RBC-3.88* Hgb-10.1* Hct-32.1*
MCV-83 MCH-26.0 MCHC-31.5* RDW-19.7* RDWSD-59.5* Plt ___
___ 06:37AM BLOOD Glucose-122* UreaN-15 Creat-1.0 Na-142
K-4.2 Cl-110* HCO3-23 AnGap-9*
___ 06:37AM BLOOD Mg-1.6
.
MICRO:
.
___ blood culture- NO GROWTH (FINAL)
___ blood culture- NO GROWTH (FINAL)
.
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
YEAST. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
.
_________________________________________________________
PROTEUS MIRABILIS
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 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---- <=1 S
.
Imaging:
.
CT abd/pelvis ___ w/o contrast:
1. Persistent right hydroureteronephrosis and perinephric
stranding similar in appearance to ___. There is no
evidence of an obstructing stone or lesion.
2. Lobulated contour of the bladder, soft tissue thickening at
the dome and
multiple diverticula are similar in appearance to the recent
imaging.
.
CT-Urogram w/ and w/o contrast ___:
1. Moderate right hydroureteronephrosis with fixed kinking in
the mid third ureter and mild dilatation of the more distal
ureter is unchanged compared to the most recent exams in ___. However, compared to ___, this has become
slightly more apparent.
2. Lobulation and scarring at the bladder dome, similar compared
to prior exams. Of note intravenous contrast has never reached
the bladder and its evaluation remains limited. Per OMR, patient
is scheduled for a cystoscopy.
3. Gallstones.
.
RECOMMENDATION(S): Cystoscopy is recommended for further
evaluation. Per
OMR, patient is already scheduled
.
Brief Hospital Course:
Mr. ___ is a ___ M with PMH of renal cell carcinoma
s/p left nephrectomy ___, bladder cancer s/p transurethral
tumor resection ___, chronic right hydronephrosis and ureteral
reflux, chronic UTIs, diabetes, COPD, depression, and anxiety,
who presented with flank pain, now resolved.
# UTI/Pyelonephritis:
# Recurrent urothelial bladder carcinoma:
# Right hydronephrosis:
# Leukocytosis:
Patient presented with right flank and suprapubic pain, however
did inconsistently report these symptoms. Has had multiple
admission, including one earlier this month, for similar
symptoms, and u/a appears similar to prior though urine culture
was negative at that time. White count is elevated, but this is
also consistent with prior admissions. Was seen by ID on last
admission, and it is felt that many of these episodes are not
from acute infection. Urine culture ___ grew out ___
proteus mirabilis and ___ yeast. Touched based with ID who
again felt yeast in his urine culture was colonization and not
true infection. Given dysuria and reported CVA pain he was
treated for UTI/pyelonephritis. He completed 7 day course of
ceftriaxone --> cipro while admitted (finished on ___. After
review of recent imaging and discussion with patient's
outpatient urologist Dr. ___, it is presumed that his pain is
due to ureteral obstruction and hydronephrosis on the right. He
had a CT-urogram which showed fixed kinking in the mid third of
the urteter and mild dilatation of the more distal ureter, which
is increased since ___. He is planned to return for
outpatient urology follow-up one week after hospitalization for
cystoscopy. Continued on home finasteride 5mg daily.
# Acute toxic metabolic encephalopathy:
# Anxiety/Depression c/b Psychosis:
Notably, does have a history of paranoia and delusions, as well
as hallucinations. He
reports hearing voices occasionally though denies hearing them
during admission. He denies they tell him to hurt himself or
others. Discussed with his guardian who reports he sounds close
to baseline and he normally hears voices. Unable to reach his
facility to get further collateral data. Currently is AOx3 and
appears to be at baseline. Continued home olanzapine 5mg BID and
PRN and homeescitalopram 5mg daily
# Chronic kidney disease: Cr 1.3 on admission, with reported
prior baseline of 1.2, down to 1.0 by discharge.
# Orthostatic Hypotension:
No documented history of adrenal insufficiency. Possibly related
to side effect of antipsychotic. Repeat orthostatic vitals
positive though he is denying symptoms. Encourage PO intake.
Continued home midodrine 2.5mg BID and fludrocortisone 0.1mg.
# HTN:
# Primary ppx:
Metoprolol and aspirin stopped during previous admission.
# COPD: No evidence of acute flare this admission. Continued
home Advair, Spiriva.
# Acute on Chronic Abd pain: Continued dicyclomine 10mg QID prn
pain.
# DM: Continued home metformin 500mg QHS.
# HLD: Continued atorvastatin 80mg QHS.
# Employee exposure: There was an employee exposed to the
patients blood through a needle stick ___. Patient and guardian
consented for blood testing including HIV and hepatitis. HIV,
Hep B/C was negative.
Transitional Issues:
[] It is IMPERATIVE that patient get to urology appointment
after discharge, patient's guardian made aware and Dr. ___
office knows to speak to guardian to ensure compliance
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Atorvastatin 80 mg PO QPM
3. DICYCLOMine 10 mg PO QID:PRN Abdominal Pain
4. Finasteride 5 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. Midodrine 2.5 mg PO BID
7. OLANZapine 5 mg PO BID
8. Omeprazole 40 mg PO DAILY
9. Fludrocortisone Acetate 0.1 mg PO DAILY
10. Escitalopram Oxalate 5 mg PO DAILY
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
12. Tiotropium Bromide 1 CAP IH DAILY
13. OLANZapine 5 mg PO DAILY:PRN agitation
14. MetFORMIN (Glucophage) 500 mg PO QHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN Dyspnea
3. Atorvastatin 80 mg PO QPM
4. DICYCLOMine 10 mg PO QID:PRN Abdominal Pain
5. Escitalopram Oxalate 5 mg PO DAILY
6. Finasteride 5 mg PO DAILY
7. Fludrocortisone Acetate 0.1 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. MetFORMIN (Glucophage) 500 mg PO QHS
10. Midodrine 2.5 mg PO BID
11. OLANZapine 5 mg PO BID
12. OLANZapine 5 mg PO DAILY:PRN agitation
13. Omeprazole 40 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
UTI/Pyelonephritis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted with flank pain. You underwent evaluation and
were found to have possible kidney infection. You were started
on antibiotics and remained stable. You underwent imaging that
was unchanged from previously, showing minor inflammation around
that kidney. You remained stable so were discharged home. You
were started on antibiotics, which were finished on ___ prior
to your discharge.
Best of luck in your recovery,
Your ___ care team
Followup Instructions:
___
|
19921471-DS-8 | 19,921,471 | 22,171,330 | DS | 8 | 2150-08-21 00:00:00 | 2150-08-22 07:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor
Attending: ___.
Chief Complaint:
cc: dyspnea
Major ___ or Invasive Procedure:
None
History of Present Illness:
___ yo M with COPD, RCC s/p L nephrectomy, bladder CA, BPH, COPD
who presents with dyspnea and chest pain. Pt reported recent
increased cough productive of green phlegm. On crossing the
street he reported feeling chest tightness and dyspnea, so he
decided to come to the ED for evaluation. Pt came via ___. Pt
reports a day of increased productive cough prior to symptoms.
No fevers or chills. Pt typically gets his care at ___ and the
___, but came to the BI because he recently transferred his
primary care here, but has not been seen yet.
ROS: otherwise negative except as above
Past Medical History:
# s/p L nephrectomy for RCC
# bladder CA - followed by urology at ___
# COPD
# HTN
# BPH
Social History:
___
___ History:
no family history of copd
Physical Exam:
ADMISSION
Vitals: 98.5 117/62 90 18 94%RA
Gen: NAD
HEENT: NCAT
CV: RRR, no r/m/g
Pulm: poor air movement b/l, no wheezing
Abd: soft, nt/nd, +bs
Ext: trace edema bilaterally
Neuro: alert and oriented x 3, no focal deficits
DISCHARGE
VS - 98.5 130/75 68 18 97%RA
Gen - sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear
Heart - RRR no mrg
Lungs - CTA bilaterally, much improved from prior
Abd - soft nontender
Ext - trace ankle edema
Skin - scratches over R hand and forearm attributed to his cat
Neuro - AOx3, moving all extremities
Psych - appropriate
Vascular 2+ DP/radial pulses
Pertinent Results:
ADMISSION
___ 11:40AM BLOOD WBC-14.7* RBC-4.14* Hgb-12.8* Hct-38.9*
MCV-94# MCH-30.9 MCHC-32.9 RDW-18.8* Plt ___
___ 11:40AM BLOOD Glucose-166* UreaN-21* Creat-1.2 Na-139
K-5.2* Cl-110* HCO3-22 AnGap-12
___ 11:40AM BLOOD cTropnT-<0.01 proBNP-141
___ 01:00AM BLOOD cTropnT-<0.01
DISCHARGE
___ 07:00AM BLOOD WBC-15.0* RBC-3.90* Hgb-12.0* Hct-35.6*
MCV-91 MCH-30.8 MCHC-33.7 RDW-19.3* Plt ___
___ 07:00AM BLOOD Glucose-126* UreaN-29* Creat-1.1 Na-142
K-4.1 Cl-107 HCO3-25 AnGap-14
CXR
Increased upper lobe predominant interstitial abnormality and
bilateral
nodular opacities. Further imaging evaluation with dedicated
chest CT is
recommended at this time.
CT Abd/Pelvis
1. No bowel obstruction or true ventral hernia.
2. Moderate right-sided hydronephrosis and hydroureter without
obstructing stone evident. The acuity is unknown, but last
renal cortex is not significantly thinned. Urology followup for
further evaluation is advised.
3. Markedly abnormal bladder contour, however evaluation for
mass is not
possible without intravenous contrast. Correlation with
patient's surgical and oncologic history, as well as comparison
to prior imaging is recommended.
4. Multiple pulmonary nodules up to 7 mm should be correlated
with prior
imaging, since they could represent metastatic disease. If
imaging cannot be obtained, nonemergent evaluation with chest CT
is recommended.
5. Severe emphysema.
6. Left adrenal adenoma.
Brief Hospital Course:
Hospital Course Summary
This is a ___ year old male with history of COPD, bladder cancer
s/p L nephrectomy, admitted with productive cough and dyspnea,
being treated for COPD exacerbation, significantly improved and
ready for dischcarge with plan for outpatient follow-up of
incidental radiographic findings.
Active Issues
# COPD Exacerbation - patient admitted with productive cough and
dyspnea, ruled out for ACS on admission, with symptoms
consistent with acute COPD exacerbation. He was treated with
steroids and azithromycin with improvement in symptoms.
Initially he desaturated to 89% on room air with ambulation;
following treatment he maintained his saturation at 92% while
ambulating. Of note, he reported that prednisone caused him to
hallucinate at night. Given his improvement he was switched to
inhaled steroid combination formulation (Advair). Continued
home inhalers. Stressed the importance of tobacco cessation
(see below).
# R Hydronephrosis on CT scan - patient with R hydronephrosis
and bladder irregularities seen on admission CT scan; I spoke
with the the physician assistant for Dr. ___ urologist
at ___), who reported R hydro was seen on study in ___, is a
chronic finding, and he has had a recent cystoscopy with fluro
without evidence of significant obstruction. Cr was at baseline
(obtained prior records, appears to be anywhere between 1.1 and
1.5). Patient discharged with follow-up with Dr. ___ ___.
Discharge summary to be faxed to Dr. ___.
# Pulmonary abnormalities / nodules - On admission CXR several
abnormalities were noted (increased upper lobe predominant
interstitial abnormality, bilateral
nodular opacities); on history patient reported a history of
pulmonary nodules, for which prior wedge resection only showed
benign pathology. Discussed abnormalities with the patient, who
reported these were chronic. Given improvement in pulmonary
symptoms and reported chronic pressence of these abnormalities,
recommended that he bring prior imaging to his upcoming new PCP
appointment where additional elective chest imaging could be
considered.
# Tobacco Abuse - he reported that he was ready to quit smoking;
provided emotional support and prescription for a nicotine patch
at discharge.
Inactive Issues
# BPH - continue finasteride
# Hypertension / Hyperlipidemia - continued home metoprolol,
statin, ASA
# GERD - continued home PPI
Transitional Issues
- Discharged home
- Would like to transfer his care to ___ has a previously
scheduled first appointment with Dr. ___ for
___
- Had radiographic abnormalities that will need to be followed
up (see above regarding hydronephrosis and pulmonary
abnormalities)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Omeprazole 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN pain
6. Simvastatin 40 mg PO QPM
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
7. Azithromycin 250 mg PO Q24H
last day ___
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose 1
puff inh twice a day Disp #*1 Disk Refills:*0
9. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
cough/wheezing
10. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 patch every 24 hours once a day
Disp #*14 Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute COPD Exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure taking care of you at ___. You were
admitted with a cough and found to have a COPD exacerbation.
You were treated with steroids and antibiotics and improved. You
felt that the oral steroids made you confused so you were
switched to an inhaled steroid medication called advair. You
are now ready for discharge.
On the CT scan and chest Xray you had in the emergency room you
were found to have an enlarged ureter and abnormalities in your
lung. We spoke with your urologist's office who says this has
been present before, and that you should follow-up with him at
your previously scheduled appointment in ___. It will be
important for you to see your primary care doctor to discuss
monitoring the nodules seen in your lungs.
It will be very important for you to quit smoking.
Followup Instructions:
___
|
19921471-DS-9 | 19,921,471 | 22,209,661 | DS | 9 | 2150-09-05 00:00:00 | 2150-09-05 13:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
terazosin / doxazosin / chocolate flavor
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of coronary artery disease,
COPD, renal cell carcinoma s/p nephrectomy, and DVT who
presented with chest pain and shortness of breath. Patient was
seen the day prior to admission in ED for similar symptoms. At
that time, he had ACS ruled out by serial troponin, pulmonary
embolism ruled out by d-dimer, and unstable angina excluded by
stress test. The patient had a recurrence of his sharp chest
pain after leaving the ED, thus returned for further evaluation.
The patient reported that his pain was constant, ___, sharp, in
the midsternum. It was nonradiating. He denied an exacerbating
or alleviating factor. Patient reported that this was different
from previous cardiac chest pain episodes, but was similar to an
episode that brought him in the day before. He reported fevers
to ___, chills, nasal congestion, shortness of breath, wheezing
and increased green sputum production. He also stated he had
some mild dysuria consistent with prior UTIs. He denied nausea,
vomiting, abdominal pain, diarrhea.
In the ED initial vital signs were 98.4 58 116/76 18 97% RA.
Labs were significant for wbc 16.7, h/h 12.3/37.0, trop <0.01,
Cr 1.4, UA with lg leuks, 68 wbc, few bacteria , flu negative.
Patient was given aspirin 324 mg, duo nebs, 1L NS and PredniSONE
60 mg.
Past Medical History:
# s/p L nephrectomy for RCC
# bladder CA - followed by urology at ___
# COPD
# HTN
# BPH
Social History:
___
Family History:
No family history of COPD.
Physical Exam:
ADMISSION:
Vitals - 97.9, 139/80, 65, 94% on RA
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, pink conjunctiva, MMM, good
dentition
NECK: nontender supple neck
CARDIAC: distant heart sounds
LUNG: diffuse expiratory wheezes, rhonchi bilaterally as bases
ABDOMEN: well healed surgical scar, reducible ventral hernia, no
rebound or guarding
EXTREMITIES: trace edema
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE:
VS: 97.8 110/56 66 18 95RA
GENERAL: Upright in bed, no acute distress, eating breakfast
HEENT: NCAT, MMM
NECK: Supple neck
CARDIAC: RRR (+)S1/S2, distant
LUNG: Prolonged expiration, generally clear
ABDOMEN: well healed surgical scar, reducible ventral hernia, no
rebound or guarding
EXTREMITIES: trace edema
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
MSK: reproducible chest pain along sternum
Pertinent Results:
ADMISSION:
___ 10:10AM BLOOD WBC-15.1* RBC-4.15* Hgb-13.0* Hct-39.1*
MCV-94 MCH-31.3 MCHC-33.2 RDW-19.0* Plt ___
___ 10:10AM BLOOD Neuts-69.3 ___ Monos-5.6 Eos-2.8
Baso-0.8
___ 10:10AM BLOOD Glucose-97 UreaN-22* Creat-1.3* Na-140
K-4.8 Cl-105 HCO3-27 AnGap-13
___ 06:13AM BLOOD Calcium-9.8 Phos-2.6* Mg-1.8
IMAGING:
___ CT Chest
1. There are a large number of peribronchovascular pulmonary
nodules up to 7mm the differential diagnosis for which includes
metastasis or infection. Followup evaluation with CT in 3 months
is recommended to document change.
2. Severe panlobular emphysema and diffuse bronchial wall
thickening
consistent with bronchitis.
3. Borderline left hilar lymph node can also be re-evaluated on
the followup study.
4. Probable pulmonary arterial hypertension
Brief Hospital Course:
Mr. ___ is a ___ with history of COPD, CAD, VTE who presented
with ongoing shortness of breath consistent with acute
bronchitis/COPD exacerbation.
ACUTE ISSUES
#Acute bronchitis/COPD exacberbation
Patient presented with symptoms of increasing shortness of
breath, sputum production, and wheeze coupled with lack of
findings on chest x-ray and negative cardiac work-up which
strongly suggested acute bronchitis/COPD exacerbation as the
cause of his symptoms. An infectious trigger was most
convincing, though the patient was tested negative for
influenza. He was continued on a five day course of azithromycin
and prednisone which he completed while in the hospital. His
home fluticasone-salmeterol was uptitrated to 500/50 and he was
started on tiotropium at discharge. A CT scan was performed
which demonstrated extensive emphysematous changes with
pulmonary nodules that require follow-up, as below. The patient
was encouraged to continue to pursue complete tobacco cessation.
#Urinary tract infection
Patient found to have pyuria on urinalysis ___ the ED without
endorsing any symptoms. Urine culture eventually grew
corynebacterium. Given lack of symptoms, treatment was deferred.
Should patient develop symptoms, consider treatment for
corynebacterium.
#Lower extremity edema
No other signs of heart failure. Per patient, the swelling was
intermittent. BNP was negative on admission suggesting no heart
failure. Outpatient echocardiogram could be considered for
further evaluation as well as for further evaluation of his
probably pulmonary hypertension noted on CT.
#Pulmonary nodules
Patient found to have bilateral pulmonary nodules on CXR, new
since ___. Nodules were sub-centimeter, thus short-term
follow-up was recommended.
#Chronic kidney disease
Creatinine 1.4 on admission with baseline creatinine of 1.1-1.5
per recent discharge summary based on obtained OSH records.
#BPH
The patient was continued on his home finasteride.
#CAD
The patient was continued on his home metoprolol and ASA.
#HLD
The patient was continued on his home statin.
#GERD
The patient was continued on his home PPI.
#Left knee pain
The patient was continued on his home oxycodone-acetaminophen.
TRANSITIONAL ISSUES
-Three month follow-up is recommended for several pulmonary
nodules identified on CT scan.
-The patient should consider outpatient PFTs and eventual
decrease in his dose of fluticasone-salmeterol once his current
symptoms improve.
-Should patient develop symptoms consistent with UTI, consider
treatment of corynebacterium infection.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
3. Nicotine Patch 14 mg TD DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Simvastatin 40 mg PO QPM
6. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Omeprazole 40 mg PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva Respimat] 2.5 mcg/actuation 1
cap IH daily Disp #*1 Inhaler Refills:*0
2. Aspirin 81 mg PO DAILY
3. Finasteride 5 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Nicotine Patch 14 mg TD DAILY
6. Omeprazole 40 mg PO DAILY
7. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
8. Simvastatin 40 mg PO QPM
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose 1
INH IH twice a day Disp #*1 Disk Refills:*0
10. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H
11. Dextromethorphan-Guaifenesin (Sugar Free) ___ mL PO Q6H:PRN
cough
12. Benzonatate 200 mg PO TID
RX *benzonatate 200 mg 1 capsule(s) by mouth three times daily
Disp #*30 Capsule Refills:*0
13. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) Apply to chest daily Disp #*30
Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation, acute bronchities
Chronic kidney disease
Chest pain - musculoskeletal (costochondritis)
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted with chest pain and shortness of breath. Your
shortness of breath was most likely because of acute bronchitis
related to your COPD. Your chest pain is unlikely to be caused
by your heart -- you had several blood tests and a stress test
which were reassuring. This is most likely rib pain caused by
your coughing and will improve once your COPD exacerbation gets
better.
You should follow-up with a lung doctor after discharge to help
prevent against future COPD exacerbations. You had several
nodules on CT scan which will require a follow-up CT scan in the
near future.
Followup Instructions:
___
|
19921864-DS-15 | 19,921,864 | 28,873,591 | DS | 15 | 2132-06-11 00:00:00 | 2132-06-11 16:51:00 |
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:
___ perc choly from ___
History of Present Illness:
This is a ___ male with past medical history significant
for multiple back surgeries, BPH, CKD and remote history of
enterococcal endocarditis (in ___, and recent admission to
___ for aspiration pneumonia and UTI, who is presenting with
sepsis secondary to a gallbladder related infection.
He has been staying at rehab since his last hospitalization for
PNA and UTI (dced ___ PNA was felt to be due to an aspiration
event and UTI secondary to staph epidermidis - patient was on
augmentin).
On ___, he developed abdominal pain, vomiting, and fevers at
his rehab which persisted for 12 hours. He presented to ___
where he was found to be febrile, tachycardic, and hypoxemic
with elevated LFTs. ___ US showed gallbladder wall thickening
with stones and pericholecystic fluid. CT showed gallbladder
wall thickening as well. CXR showed atelectasis or early
airspace disease left lung base. Labs at ___ significant
for WBC 11.6, hemoglobin 13.9, hematocrit 43.7, INR 1.2,
creatinine 1.25 (at baseline), AST 197, AST 544, alk phos 265,
bilirubin 1.86 (direct 1.13). Blood culture drawn ___ grew out
gram negative bacilli. He was given 4L IVF, vancomycin, and
pip-tazo and transferred to ___.
In the ED, initial vitals: 98.2 74 ___ 99% RA
- Exam notable for ___ pain, persistent hypotension
- Labs were notable for:
Na 140 K 5.5 (hemolyzed) Cl 101 HCO3 19 BUN 18 Cr 1.3
ALT 268 AST 536 Alk phos 266 Tbili 3.1 Lipase 13
WBC 22.7 (N:87 Band:3 ___ M:5 E:0 Bas:0) Hgb 13.8 Hct 46.2 Plt
UA: ___, mod leuks, small blood, 30 protein, 16 RBCs, 14 WBCs,
mod bacteria
Patient had a RIJ placed for concern given worsening WBC and
LFTS he might require pressors.
He had CXR which showed:
Interval placement of a right internal jugular venous central
catheter, its tip projecting within the right atrium. Chest is
otherwise unchanged in appearance with persistent atelectasis or
early airspace disease involving the left lung base.
- Patient was given: Pip-Tazo 4.5 gram, 1 L LR, 1000 mg
acetaminophen
- Consults: Surgery, who felt patient had cholangitis vs
cholecystitis, and desired admission to MICU with ___ for perc
drainage of gallbladder and ERCP c/s for consideration of
cholangitis.
- Vitals on transfer: 100.8 108 128/80 20 99% Nasal Cannula
On arrival to the MICU, patient is in good spirits. He reports
no nausea or abdominal pain. Of note, patient and his wife (over
phone) were slightly stresses (appropriately so) over ICU
consent, given patient's history of being DNR per wife (HCP) as
documented on pripr MOLST. They are ok for short term intubation
for OR if needed however.
Past Medical History:
- Prior episodes of unilateral weakness or numnbess lasting
minutes, at times associated with dysarthria. Tends to occur
more on the L than the R. Negative stroke work up and negative
ambulatory EEG, felt to be possibly migranous phenomenon.
- Dementia: extensive atrophy and white matter disease is
present so vascular dementia has been postulated, although the
patient does not have significant vascular risk factors
- s/p L1-5 fusion
- s/p C5-6 fusion
- Macular degeneration
- Cataracts
- Essential tremor
- L ulnar neuropathy on EMG
- h/o headaches when he was first married per wife
Social History:
___
Family History:
Ovarian cancer in his mother, heart attack in his father,
___ in his sister, cirrhosis in his brother. Daughter
with migraine headaches
Physical Exam:
On Admission:
VITALS: HR 80 RR 22 spo2 97 %
GENERAL:
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD, R IJ on right
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, bibasilar lateral
crackles
ABDOMEN: No ___ tenderness on deep or light palpation
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
On Discharge:
VITALS - 97.9; 109/71; 84; 18; 93 2L NC
GENERAL - Pleasant, NAD. AOx3
HEENT - NC/AT. EOMI. MMM. Mild scleral icterus.
NECK - Supple. Right IJ CVL in place.
CARDIAC - Tachycardic, regular. +S4. No MRG.
LUNGS - Bibasilar crackles up to mid-lung field.
ABDOMEN - Soft, nondistended. TTP in ___. Perc chole drain in
place on Right axilla.
EXTREMITIES - WWP. No c/c/e
SKIN - Warm and dry
NEUROLOGIC - CNII-XII grossly intact.
Pertinent Results:
ADMISSION LABS:
=========================
___ 10:00PM BLOOD WBC-22.7*# RBC-4.93 Hgb-13.8 Hct-46.2
MCV-94 MCH-28.0# MCHC-29.9*# RDW-15.7* RDWSD-54.3* Plt ___
___ 10:00PM BLOOD Neuts-87* Bands-3 Lymphs-5* Monos-5 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-20.43* AbsLymp-1.14*
AbsMono-1.14* AbsEos-0.00* AbsBaso-0.00*
___ 12:47AM BLOOD ___ PTT-48.8* ___
___ 10:00PM BLOOD Glucose-92 UreaN-18 Creat-1.3* Na-140
K-5.5* Cl-101 HCO3-19* AnGap-26*
___ 10:00PM BLOOD ALT-268* AST-536* AlkPhos-266*
TotBili-3.1*
___ 10:00PM BLOOD Albumin-3.5 Calcium-8.3* Phos-4.1 Mg-1.7
___ 12:47AM BLOOD ___ pO2-37* pCO2-44 pH-7.39
calTCO2-28 Base XS-0
___ 12:47AM BLOOD O2 Sat-66
___ 12:47AM BLOOD Lactate-2.0 K-4.3
DISCHARGE LABS:
=========================
___ 07:05AM BLOOD WBC-10.0 RBC-4.64 Hgb-12.6* Hct-39.3*
MCV-85 MCH-27.2 MCHC-32.1 RDW-15.5 RDWSD-46.8* Plt ___
___ 07:05AM BLOOD Glucose-100 UreaN-25* Creat-1.1 Na-143
K-4.2 Cl-105 HCO3-25 AnGap-17
___ 07:05AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1
MICRO/STUDIES:
=========================
Blood and urine culture pending at ___ growing out of ___ blood culture at ___
___ US ___
FINDINGS: The study was somewhat limited as the patient was
unable
to cooperate. LIVER: The hepatic parenchyma appears within
normal
limits. 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. The CHD
measures 5 mm.
GALLBLADDER: The gallbladder contains dependent stones and
sludge.
There is mild wall thickening up to 3.7 mm. A small amount of
pericholecystic fluid is noted as well as hyperechogenicity of
the
surrounding fat suggestive of inflammation. There was a
negative
sonographic ___ sign as per the ultrasound technologist.
PANCREAS: The pancreas is not well visualized, largely obscured
by
overlying bowel gas.
KIDNEYS: Limited views of the right kidney show no
hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are
within
normal limits.
IMPRESSION: Findings as described above are suggestive of acute
cholecystitis.
CT ABD/Pelvis ___. There is evidence of gallbladder wall thickening as well.
This
may be due to edema and further evaluation by sonography may be
helpful. There is a small amount of free fluid adjacent to the
liver.
2. Atherosclerotic cardiovascular disease.
3. Left renal parapelvic cyst and stable 4 mm hypodensity in the
left
kidney also likely representing a cyst.
4. Postsurgical changes in the spine. The patient is status
post
vertebroplasty as well. Stable compression deformities at L1,
L2 and
L3.
5. The prostate gland remains mildly enlarged.
6. Small to moderate fat containing umbilical hernia.
- ECG: HR 139 SR nl axis with RBBB, repeat HR 87. EKG ___
shows RBBB.
Brief Hospital Course:
BRIEF SUMMARY STATEMENT:
===========================
___ male with past medical history significant for
multiple back surgeries, CPH, CKD and history of enterococcal
endocarditis, with recent admission to ___ for aspiration
pneumonia and UTI, who presented with sepsis secondary to
cholangitis vs cholecystitis. He had perc choly drai placed by
___, and subsequently was tachycardia and hypotensive, briefly
requiring levophed. He improved with drainage of biliary fluid &
broad-spectrum antibiotics, and was transferred to the floor on
___. His floor course was notable for continued oxygen
requirement and atrial tachycardia. He was discharged to rehab
with a plan to continue to wean oxygen (2L at discharge).
ACTIVE ISSUES:
===========================
# Sepsis likely secondary to cholangitis vs cholecystitis:
Patient presented with abdominal pain, leukocytosis, and
transaminitis, with imaging showing gallbladder thickening and
stones, concerning for acute cholangitis vs cholecystitis. He
was treated with Vanc/Zosyn, and ___ performed perc choly on
___. Procedure went well without complications. Patient
briefly required Levophed after the procedure, weaned off in <24
hours. Cultures grew E. coli resistant to cefazolin, ampicillin
and Unasyn. Patient was initially transitioned to CTX/Flagyl,
and subsequently to ciprofloxacin PO monotherapy on ___. He was
stable and afebrile during the remainder of his hospitalization.
He was discharged with a plan to complete a 10-day course of
antibiotics (d10 = ___
# GNR Bacteremia: Initial ___ blood cultures growing GNR's.
Source likely biliary, given GNR's are also growing from
cultures taken from perc chole. Ecoli shown growing in blood;
patient narrowed to ceft/flagyl on ___, and final sensitivities
showed E. coli resistant to cefazolin/ampicillin/Unasyn. As
above, he was transitioned to ciprofloxacin PO. He was
discharged with a plan to complete a 10-day course of
antibiotics (d10 = ___
# Hypoxia: Patient is not on oxygen at home, and
post-procedurally required 4Lnc. He had possible aspiration with
pills, and CXR with left basilar opacity. HE passed his S&S
evaluation, and had no further aspiration. Hypoxemia also
thought to be ___ volume overload from fluid resuisciation, so
he was gently diuresed with small boluses of IV Lasix. Patient
was stabilized on 2L NC. Further diuresis was held prior to
discharge because of tachycardia. It was felt that his hypoxemia
was related to both atelectasis from his cholecystitis vs
cholangitis and some component of volume overload.
# Tachycardia: Patient intermittently developed runs of
tachycardia while in the ICU and on the floor, which appeared to
be atrial tachycardia. This was worsened with aggressive
diuresis. Patient was started on metoprolol 12.5mg PO BID with
good control of heart rates.
CHRONIC STABLE ISSUES:
===========================
# BPH: Tamsulosin initially held in the setting of sepsis, but
this was restarted prior to discharge.
# Osteoporosis: Hold home alendrenate
# History of Seizure Disorder: Continue home keppra
# Cardiac primary prevention: Aspirin was restarted prior to
discharge after discussion with ___.
# CKD: At last D/C ___ Cr was 1.33. Cr improved to 1.1 at the
time of discharge.
# Chronic constipation: Hold home clearlax
# Chronic Back pain: Hold home acetaminophen to trend fever
curve
TRANSITIONAL ISSUES:
===========================
New Medications:
Metoprolol 12.5mg PO BID
Ciprofloxacin
Transitional Issues
- Continue ciprofloxacin to complete a 10-day course (d10 = ___
- Wean oxygen as able. Consider giving 20mg PO Lasix if stable
- Encourage inspiratory spirometer
- Patient will follow up with Dr. ___ consideration of
cholecystectomy. Patient will keep drain in place until then.
Code: DNR/ok to intubate for procedures only
Communication: HCP: ___ wife ___
___ Drain Care:
-Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
-Note color, consistency, and amount of fluid in the drain.
Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
-Be sure to empty the drain bag or bulb frequently. Record the
output daily. You should have a nurse doing this for you while
in
the hospital and at home on an every-other day basis as they
can.
-You may shower; wash the area gently with warm, soapy water.
-Keep the insertion site clean and dry otherwise.
-Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
-Change the dressing daily. Cleanse skin with ___ strength
hydrogen peroxide. Rinse with saline moistened q-tip. Apply a
DSD.
-Catheter Flushing: Do not flush catheter. Can flush 5 cc
saline
into bag as needed to clear line.
-Catheter Security: Every shift check the patency of tube and
that the tube and drainage bag are secured to the patient.
For questions regarding care of catheter call: in-patient
___ out-patient call ___.
Troubleshooting: If catheter stops draining suddenly:
1) Check that the stopcock is open.
2) Remove dressing carefully and inspect to make sure that
there
is no kink in the catheter.
3) inspect to be sure that there is no debris blocking the
catheter. If there is, then firmly flush 5 cc of sterile saline
into the catheter.
- If you develop worsening abdominal pain, fevers or chills
please call your surgeon or Interventional Radiology at ___
at
___ and page ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Alendronate Sodium 70 mg PO QMON
4. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
5. Tamsulosin 0.4 mg PO QHS
6. LevETIRAcetam 750 mg PO BID
7. ClearLax (polyethylene glycol 3350) 17 gram/dose oral DAILY
8. Omeprazole 20 mg PO BID
9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Ciprofloxacin HCl 750 mg PO Q12H
2. Docusate Sodium 100 mg PO BID
3. Metoprolol Tartrate 12.5 mg PO BID
4. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate
5. Alendronate Sodium 70 mg PO QMON
6. Aspirin 81 mg PO DAILY
7. ClearLax (polyethylene glycol 3350) 17 gram/dose oral DAILY
8. LevETIRAcetam 750 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Omeprazole 20 mg PO BID
11. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
12. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Sepsis
Bacteremia
Cholecystitis
Atrial tachycardia
Secondary:
BPH
Seizure disorder
Constipation
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were transferred to ___
because you had an infection near your gallbladder.
You were treated with antibiotics, and our radiologists placed a
drain in your gallbladder.
You will need to follow up with Dr. ___ surgeon who saw
you during this hospitalization, to determine whether or not you
should have your gallbladder removed.
After you leave, you will need to take 2 more days of
antibiotics. You were also found to have a fast heart rate, and
you were started on a medication called metoprolol to control
this.
It was a pleasure to help care for you during this
hospitalization, and we wish you all the best in the future.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19921885-DS-21 | 19,921,885 | 21,011,050 | DS | 21 | 2181-02-21 00:00:00 | 2181-02-24 18:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall, hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with history of etOH abuse, alcoholic cirrhosis,
osteoarthritis, osteoporosis, and chronic LBP who presents after
mechanical fall on ___. She states that she was walking in
socks on a cardboard surface when she tripped and fell backwards
on her back. She states that she felt this pain was worse than
her usual back pain and that "something was wrong." She called
911 and was BIBA to ___, where she had head CT, CT c-spine,
and CT L-spine, which were read as normal. Patient was
discharged home. On second read, however, she was noted to have
C7 spinous process fracture and so was told to return to ED. She
came to ___ for spine surgery evaluation. Spine evaluated the
patient in the ED who determined that there was no surgical
intervention.
Of note, she does have a history of alcohol abuse with several
quitting attempts. Recently she was sober for 3 months but "had
a trigger" ___ which caused her to drink ___ mini vodka
bottles. She says this did not contribute to her fall.
In the ED, initial vitals were: 7 98.2 93 122/77 16 96% Nasal
Cannula.
- Labs were significant for H&H 12.0/36.1, WBC 4.8, plts 156.
ALT/AST 34/52, BUN/Cr ___. UA negative for infection.
- Imaging revealed moderate compression deformities of L1 and L2
vertebral bodies are moderately worsened from ___.
- The patient was given 5mg IV morphine x 3, 10mg PO diazepam x
2, 30mg IV ketorolac x 1, multivitamin, thiamin, folate, calcium
gluconate, and zofran.
In the ED, she was noted to have blood glucose of 56. Since she
was persistently on the lower end of blood glucose levels seen,
especially in hospitalized patients (123, 83, 73, 68), she was
admitted to medicine for further management.
Vitals prior to transfer were: T 98.3 HR 97 BP 151/97 RR 19 95%
RA
Upon arrival to the floor, patient reports that her pain is well
controlled with ED interventions although she still has some
soreness and "muscle spasm" from her upper back down. She states
that she has never been told she had low blood sugars before.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies perineal numbness, bowel or bladder incontinence
Past Medical History:
Alcohol abuse
Chronic low back pain
Osteoarthritis
Osteoporosis
Alcoholic cirrhosis
Depression
Alcohol-related neuropathy
Social History:
___
Family History:
DM in mother and father
Physical Exam:
Admission exam:
Vitals: T 98.7 BP 141/92 HR 86 RR 18 98%RA
General: Alert, oriented, no acute distress
HEENT: NC/AT Sclera anicteric, MMM, oropharynx clear, EOMI,
PERRL, poor dentition
Neck: Supple, JVP not elevated, no LAD
CV: RRR, no m/r/g, normal S1, S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, BS+, +hepatomegaly
noted, no rebound or guarding, no ascites fluid wave
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. +spider angiomata, no palmar erythema. No midline
tenderness of the spine, no gross deformity
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. no asterixis
Discharge exam:
Vitals: T 97.5 HR 81 BP 108/71 RR 18 98%RA.
General: Alert, oriented, no acute distress
HEENT: NC/AT Sclera anicteric, MMM, oropharynx clear, EOMI,
PERRL, poor dentition
Neck: Supple, JVP not elevated, no LAD
CV: RRR, no m/r/g, normal S1, S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, BS+, +hepatomegaly
noted, no rebound or guarding, no ascites fluid wave
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. +spider angiomata, no palmar erythema. No midline
tenderness of the spine, no gross deformity
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally. no asterixis.
Pertinent Results:
Labs:
___ 03:49PM WBC-4.8 RBC-3.65* HGB-12.0 HCT-36.1 MCV-99*
MCH-32.9* MCHC-33.2 RDW-17.3* RDWSD-60.9*
___ 03:49PM HCG-<5
___ 03:49PM VIT B12-125* FOLATE-4.7
___ 03:49PM ALBUMIN-3.3* CALCIUM-7.9* PHOSPHATE-3.6
MAGNESIUM-1.6
___ 03:49PM LIPASE-21 GGT-515*
___ 03:49PM ALT(SGPT)-34 AST(SGOT)-52* ALK PHOS-164* TOT
BILI-0.5
___ 03:49PM GLUCOSE-78 UREA N-7 CREAT-0.7 SODIUM-143
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-15
___ 04:59PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 03:05PM BLOOD WBC-5.2 RBC-3.69* Hgb-12.2 Hct-38.5
MCV-104* MCH-33.1* MCHC-31.7* RDW-17.0* RDWSD-64.1* Plt ___
___ 06:47AM BLOOD Glucose-87 UreaN-9 Creat-0.8 Na-134 K-4.3
Cl-96 HCO3-32 AnGap-10
___ 06:47AM BLOOD ALT-26 AST-36 AlkPhos-169* TotBili-1.3
___ 03:49PM BLOOD Lipase-21 GGT-515*
___ 03:49PM BLOOD Albumin-3.3* Calcium-7.9* Phos-3.6 Mg-1.6
___ 03:49PM BLOOD VitB12-125* Folate-4.7
Discharge labs:
___ 03:05PM BLOOD WBC-5.2 RBC-3.69* Hgb-12.2 Hct-38.5
MCV-104* MCH-33.1* MCHC-31.7* RDW-17.0* RDWSD-64.1* Plt ___
___ 06:47AM BLOOD Glucose-87 UreaN-9 Creat-0.8 Na-134 K-4.3
Cl-96 HCO3-32 AnGap-10
___ 06:47AM BLOOD ALT-26 AST-36 AlkPhos-169* TotBili-1.3
Imaging:
CT torso ___
CHEST: The thyroid is normal. There is no lymphadenopathy. The
heart size is
normal in size and shape, without pericardial effusion. There
is mild to
moderate coronary artery calcification. Thoracic aorta is
mildly calcified
though appears intact without dissection or aneurysm. Main
pulmonary artery
and central branches appear normal. No pneumothorax or
pneumomediastinum.
Incidental note is made of a varix at the junction of the left
IJ and left
subclavian vein best seen on series 601b, image 75. There is a
small hiatal
hernia.
There are ground-glass nodules (series 3, image 32, series 3,
image 28) in the
right upper lobe measuring up to 5 mm. There is no pleural or
pericardial
effusion. Basilar dependent atelectasis is noted.
ABDOMEN:
HEPATOBILIARY: The liver is nodular with atrophic right lobe
and enlarged
caudate and left lobe compatible with cirrhosis. No focal
worrisome lesion.
The main portal vein is patent. Numerous portosystemic varices
are seen
including in the paraesophageal and perigastric region. Small
volume
perihepatic ascites is noted. There is intrahepatic or
extrahepatic biliary
dilatation. Cholelithiasis noted without evidence of acute
cholecystitis.
PANCREAS: Pancreas appears unremarkable.
SPLEEN: Spleen is mildly enlarged measuring 14 cm in length. No
focal splenic
lesion is seen.
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 focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is decompressed. There is a small
periampullary
duodenum diverticulum. Otherwise the duodenum is normal. Loops
of small
bowel demonstrate no signs of ileus or obstruction. The colon
and rectum are
within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: Chronic moderate compression deformities of multiple T12,
L1, L2, L4
vertebral bodies. No acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits. There is
moderate edema the superficial soft tissues.
IMPRESSION:
1. No acute sequelae of trauma.
2. Cirrhosis with splenomegaly and numerous portosystemic
collateral veins.
Small volume ascites.
3. Pulmonary nodules measuring up to 5 mm. Outpatient followup
per
___ criteria is recommended.
RECOMMENDATION(S): Nodule followup: Chest CT recommended in
___ months.
RUQ ultrasound ___
FINDINGS:
There is a trace perihepatic ascites. When comparing to the
recent CT there
is suggestion of a 1 cm enhancing focus in the right lobe of the
liver,
without definite US correlate. Given this finding and
underlying nodularity
of the liver, MRI is recommended for further evaluation.
IMPRESSION:
Trace perihepatic ascites. Suggestion of 1 cm enhancing focus
in the right
lobe of the liver, not seen on US. Liver MRI is recommended to
rule out
underlying lesion.
RECOMMENDATION(S): Liver MRI
Brief Hospital Course:
___ F with a history of alcohol abuse, osteoporosis, chronic low
back pain who presents after a fall with a stable c-spine
fracture, admitted for further management of hypoglycemia.
#C7 spinous process fracture: Patient was evaluated in the ED by
spine surgery, who felt that there was no surgical intervention
for the fracture. She was treated with home gabapentin, fentanyl
patch, and oxycodone PRN. She had a 1x dose of tizanidine but
this was discontinued due to drowsiness and risk of fall.
#fall: patient does not have a history of frequent falls, but
she does have risk factors, including peripheral neuropathy,
chronic pain and resultant gait instability, and alcohol abuse.
Her orthostatic vital sigs were negative. She was seen by
physical therapy who recommended cane use, which the patient has
at home. She was started on B12 replacement due to B12
deficiency and concerned for peripheral neuropathy. She was also
discharged with services for further home care.
#B12 deficiency: may be contributing to peripheral neuropathy.
Received B12 IM ___, continued po B12 supplementation.
#Hypoglycemia: resolved in the ED. Most likely this was related
to poor po intake in a patient with underlying nutritional
deficiency with etOH abuse and cirrhosis. She was evaluated by
nutrition, who recommended a change to low sodium diet and
encouragement of po intake.
# Alcohol abuse: Patient was initially on CIWA protocol for
withdrawal precautions but never scored on CIWA. She received IV
thiamine x3 days then was continued on po thiamine, folate, and
multivitamins. She was evaluated by social work, who provided
resources for substance abuse.
#history of alcoholic cirrhosis: MELD 1.46 Childs ___ A.
Continued on home nadolol, lasix, potassium repletion. She did
have an abdominal ultrasound that showed trace ascites. A liver
nodule was noted on ultrasound with recommendation for MRI. The
team recommended follow up as outpatient, and patient was made
aware of need for MRI follow up
#Osteoporosis: Continued home alendronate, calcium citrate
TRANSITIONAL ISSUES FROM IMAGING:
From CT chest: Pulmonary nodules measuring up to 5 mm.
Outpatient followup per
___ criteria is recommended. RECOMMENDATION(S): Nodule
followup: Chest CT recommended in ___ months.
From liver ultrasound: Trace perihepatic ascites. Suggestion of
1 cm enhancing focus in the right
lobe of the liver, not seen on US. Liver MRI is recommended to
rule out
underlying lesion. RECOMMENDATION(S): Liver MRI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 5 mg PO DAILY
2. Fentanyl Patch 25 mcg/h TD Q72H
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 20 mg PO BID
5. Nadolol 20 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Sertraline 25 mg PO DAILY
8. Spironolactone 50 mg PO DAILY
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Zolpidem Tartrate 10 mg PO QHS
11. Potassium Chloride 40 mEq PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Calcitrate (calcium citrate) 200 mg (950 mg) oral DAILY
14. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
15. Gabapentin 600 mg PO BID
16. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
Discharge Medications:
1. Furosemide 20 mg PO DAILY
2. Alendronate Sodium 5 mg PO DAILY
3. Fentanyl Patch 25 mcg/h TD Q72H
RX *fentanyl 25 mcg/hour 1 patch every 72 hours Disp #*5 Patch
Refills:*0
4. Magnesium Oxide 400 mg PO DAILY
5. Nadolol 20 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Potassium Chloride 40 mEq PO DAILY
8. Sertraline 25 mg PO DAILY
RX *sertraline 25 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Spironolactone 50 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
11. Zolpidem Tartrate 10 mg PO QHS
RX *zolpidem 5 mg ___ tablet(s) by mouth at bedtime Disp #*14
Tablet Refills:*0
12. Calcitrate (calcium citrate) 200 mg (950 mg) oral DAILY
13. Ferrous Sulfate 325 mg PO DAILY
14. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
15. Gabapentin 600 mg PO BID
RX *gabapentin 300 mg 2 capsule(s) by mouth daily Disp #*20
Capsule Refills:*0
16. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
17. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six hours Disp
#*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
C7 spinous process fracture
Alcohol abuse
Peripheral neuropathy
B12 deficiency
Secondary:
Chronic lower back pain
Alcohol cirrhosis
HTN
MDD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ after you
had a fall in which you had a fracture of one of your vertebrae.
You were seen by our spine surgeons, who did not think surgery
was necessary for you. It was recommended that you were treated
primarily for pain control. Although you have a diagnosis of
alcohol-related neuropathy, we also checked your vitamin B12
levels, which were low. This can also contribute to peripheral
neuropathy. We started you on B12 supplementation to help with
neuropathy. Because of the concerns for home safety and fall
risk, you were seen by physical therapy twice during this
admission. We have collaborated to create a comprehensive fall
risk management plan for you, please see below.
In addition, you were admitted to the hospital due to low blood
sugar. This was felt to be due to low food intake during your
emergency room visit and may be related to your cirrhosis. We
had our nutrition team see you and give us recommendations for
managing your nutrition.
You had an ultrasound of your abdomen to make sure there was no
significant fluid from your liver. It showed minimal fluid from
your liver but it did show a 1 cm nodule in your liver as we
discussed. You should follow up with your PCP for further
evaluation and work up of this nodule as deemed necessary.
Please take all of your medications as prescribed and please
follow up with the appointments we have arranged for you. It was
a pleasure taking care of you.
Your ___ care team.
COMPREHENSIVE FALL PLAN:
- You have been started on B12 supplementation to help with your
neuropathy.
- You will use your cane at home as recommended by physical
therapy.
- You will be seen by our chronic pain service to minimize pain
causing falls.
- Although you were not at risk for fainting because of
dehydration, please drink plenty of water and eat full meals to
help with blood sugar and hydration.
- You will be evaluated by a visiting nurse, who will provide
and assess you for a) continued physical therapy and occupation
therapy; b) skilled nursing level care c) use of a shower chair
to prevent falls while bathing, and d) visiting nurse assessment
for life alert device.
Followup Instructions:
___
|
19922115-DS-10 | 19,922,115 | 27,034,872 | DS | 10 | 2115-07-17 00:00:00 | 2115-07-17 19:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMHx of asthma and chronic
lower extremity venous stasis and DVT previously on rivaroxaban
who is presenting with LLE pain
Mr. ___ is currently homeless (for at least the last several
months). He was admitted in ___ after a scrape on
his leg became infected. On that admission, he was treated with
Keflex for ___nd also diagnosed with a chronic LLE
DVT
for which he was initiated on Rivaroxaban. He was discharged
with
plans to hook into Health Care for the Homeless to establish
primary care as he was not being followed outpatient at that
time. Unfortunately, it appears that he did not establish care
following this admission.
He was readmitted in ___ with persistent leg pain iso not
taking prescribed rivaroxaban. His leg pen and swelling/skin
changes were thought to be predominantly due to chronic venous
stasis and poor wound care during that hospitalization. He did
have ___ US that showed L superficial femoral vein and L
popliteal
vein thrombosis without visualization of deep veins as pt did
not
tolerate due to pain. He was restarted on rivaroxaban and pain
and swelling improved with this and wound care. It was unclear
at
that time if his DVT was provoked or not, and he was recommended
to follow up with heme/onc outpatient for determination of AC
duration. He was discharged to ___.
In the ED: afebrile, HR 95-108, BP 140/80-155/77, SpO2 98% RA
labs notable for Hgb 11.6 (unknown bl), normal BMP, lactic acid
wnl.
Imaging: LLE with nonocclusive mid and distal femoral vein
thrombosis
Meds: Started on IV heparin gtt
On arrival to the floor today, pt provides limited history. He
reports that his leg pain worsened over the last week. He is
currently homeless and reports that he has not been doing
anything for the current pain or skin changes. He denies any CP,
SOB, f/c, or nausea. He did not answer further questions and
reports being in severe leg pain.
ROS: 10 point review of systems is otherwise negative except as
listed above
Past Medical History:
Asthma
LLE DVT
chronic venous stasis
Social History:
___
Family History:
Denies known family history of blood clots
Physical Exam:
Admission Exam:
=================
VITALS: Afebrile HR 95-108, BP 140/80-155/77, SpO2 98% RA
(seeeFlowsheet)
GENERAL: appears disheveled, alert, awake, NAD.
EYES: Anicteric, PERRL
ENT: Ears and nose without visible erythema, masses, or trauma.
MMM
CV: RRR, no m/r/g.
RESP: no increased wob, lungs clear to auscultation in all
fields
GI: +BS, abd soft, ND. no tenderness to palpation
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities.
SKIN: bilateral ___ with chronic venous stasis changes L > R. LLE
with swelling and pain to palpation. bilateral ___ to touch
but no evidence of streaking erythema or fluid collection. No
purulence or open drainage appreciated. Skin breakdown above L
mid calf/knee
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, speech fluent, moves all limbs, sensation to light touch
grossly intact throughout
PSYCH: reserved
Discharge Exam:
================
Vitals: 98.2 PO 114 / 74 R Lying 58 18 98 Ra
General: Dishevled but comfortable, lying in bed
HEENT: Anicteric, eyes conjugate, MMM
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema, significant muscle mass
Skin: B/l lower extremities with chronic venous stasis changes,
much more significant on LLE with swelling and ttp along the
skin at the left lateral ankle with normal ROM without
significant pain, warm to touch but not hot, no evidence of
erythema. Skin breakdown just distal to the left knee medially
without purulence
Neurological: Alert, interactive, speech fluent
Psychiatric: tangential, intermittently paranoid
Pertinent Results:
Admission Labs:
===============
___ 02:25PM BLOOD WBC-6.1 RBC-3.79* Hgb-11.6* Hct-36.0*
MCV-95 MCH-30.6 MCHC-32.2 RDW-14.7 RDWSD-51.1* Plt ___
___ 02:25PM BLOOD Neuts-60.7 ___ Monos-12.6 Eos-2.3
Baso-0.3 Im ___ AbsNeut-3.70 AbsLymp-1.45 AbsMono-0.77
AbsEos-0.14 AbsBaso-0.02
___ 02:25PM BLOOD Glucose-134* UreaN-17 Creat-1.0 Na-140
K-4.8 Cl-108 HCO3-24 AnGap-8*
___ 02:40PM BLOOD Lactate-1.5
Imaging:
=========
___ US ___:
Nonocclusive deep venous thrombus in the left mid and distal
femoral vein. Enlarged left groin lymph node, nonspecific.
***Refused further labs this admission stating we had already
taken enough blood***
Brief Hospital Course:
Mr. ___ is a ___ homeless gentleman with h/o asthma, LLE
cellulitis and DVT, chronic venous stasis who is presenting with
LLE pain and swelling likely progression of DVT iso medication
non-adherence.
ACUTE/ACTIVE ISSUES:
====================
# LLE Swelling, Pain
# Non occlusive DVT in L mid and distal femoral vein
Patient with LLE swelling with skin changes consistent with
chronic venous stasis likely due to untreated DVT on the left.
Per discussion with patient, he took Xarelto in past but just
for short while because he didn't have refills on his script. On
exam, he had no erythema or purulence and no leukocytosis on
admission however he did have area of slight skin breakdown on
his left medial shin with some erythema so decision was made to
treat for possible overlying cellulitis with 5 day course of
Keflex. For his DVT, he was restarted on a dose pack of Xarelto
and given a prescription for Xarelto to fill in one month to
allow continued adherence to anticoagulation. He was seen by
pharmacy to fill out an application to receive Xarelto through
the drug company in the future (received voucher this admission)
and was discharged as below to establish care at ___
with Health Care for the Homeless. He was seen by wound care
this admission and discharged with supplies to care for his leg.
# Psychosocial Determinants of health
# Fixed beliefs around medical Care: Patient is homeless and has
been for several years. He declined to tell me exactly where he
stays and expressed some paranoid behavior this admission though
some spurs from prior psychiatric hospitalization here at ___
against his will. During his hospitalization, he perseverated on
concerns about infection in his leg, particularly given that he
reports previously being prescribed abx but the script was
stolen. We discussed that this was most likely due to his blood
clot which he at times seemed to understand and at others was
not open to considering. Based on this and concern about his
possible fixed delusions and capacity, psych was consulted and
did not feel that he met criteria for axis 1 disorders and felt
he had capacity to disagree with the medical assessment.
Ultimately, patient was amenable to treatment with
anticoagulants long term and short term antibiotic course. He
was discharged with plan to go directly to ___
to establish PCP at ___ care for the homeless given his lack
of insurance however patient declined to get in the Lyft to ___
after leaving the hospital.
Transitional Issues:
===================
[ ]Given recurrent DVTs (vs non-healed DVT), would likely
benefit from lifelong anticoagulation however would favor repeat
imaging prior to stopping anticoagulation in the future if being
stopped to ensure resolution of current blood clot
[ ]Noted to have enlarged left groin lymph nodes on US of ___.
Please follow-up as outpatient and consider additional imaging
to further evaluate
[x]>30 minutes spent on discharge planning and care coordination
on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
2. Cephalexin 500 mg PO QID Duration: 5 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*18 Tablet Refills:*0
3. Miconazole Powder 2% 1 Appl TP BID Duration: 7 Days
Apply to left leg
RX *miconazole nitrate 2 % Apply to left leg twice a day Disp
#*1 Spray Refills:*0
4. Rivaroxaban 15 mg PO BID
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) As directed
tablet(s) by mouth As directed (Twice daily for 3 weeks then
daily) Disp #*1 Dose Pack Refills:*0
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth Daily at
dinner Disp #*30 Tablet Refills:*1
5. Sarna Lotion 1 Appl TP QID:PRN pruritis
RX *camphor-menthol [Sarna Anti-Itch] 0.5 %-0.5 % Apply to left
daily as needed for itching Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
LLE DVT
Chronic venous stasis changes ___ DVT
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 worsening swelling and
pain in your left leg. You had an imaging study of your leg
which showed that you have a blood clot (also known as a DVT or
deep vein thrombosis) in your leg. This is causing your symptoms
of swelling and pain. It is VERY important that you continue to
take your Xarelto (rivaroxaban) as prescribed (indefinitely) to
prevent your clot from worsening. You should NOT skip a dose of
this medication.
We are also treating you with Keflex (cephalexin), an
antibiotic, for any infection in your leg. Please continue to
take this medication until the script finishes (in 5 days).
Medication plan:
=================
Take Xarelto (rivaroxaban) 15mg Twice daily for 3 weeks
THEN
Take xarelto (rivaroxaban) 20mg daily ongoing (Script for this
provided)
Take Keflex (cephalexin) 500mg Every 6 hours for 5 days
For the skin changes on your legs, you were seen by the wound
care nurses who recommended a cleanser and dressing plan to help
the swelling improve. Please continue with their recommendations
after discharge.
You are now ready for discharge. We are discharging you to
___ ___ to establish primary care with Health Care
for the Homeless. When you get there, Please tell them you are
there to set up care with a primary care doctor. It is VERY
important that you establish with a primary care doctor to
continue to prescribe your Xarelto for your DVT (blood clot).
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
19922271-DS-10 | 19,922,271 | 23,647,306 | DS | 10 | 2142-04-08 00:00:00 | 2142-05-01 18:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Cats
Attending: ___
___ Complaint:
Left pneumothorax
Major Surgical or Invasive Procedure:
Left pigtail chest tube placement
History of Present Illness:
Ms. ___ is a ___ with history of stage IIIc sigmoid
adenocarcinoma s/p lap sigmoid colectomy on ___, most
recently s/p port placement yesterday at ___. The patient
reports she was tol the port placement was difficult. The team
initially tried to place the port on the left side, however
aborted, and ultimately placed the port on the right. After the
procedure, she went home with increased bilateral chest pain
L>R
and SOB. This morning the chest pain continued, worse with deep
breath, she called her physician who recommended she present to
the ED for evaluation. Other than her mild chest pain and SOB,
the patient feels well. She has been afebrile, denies nausea,
vomiting or diarrhea, no dysuria, but has been constipated for
the past two days. She has no other complaints at this time.
She has plans to begin chemo on ___.
Past Medical History:
PMH: appendicitis, small bowel obstruction
PSH: laparoscopic appendectomy ___, laparoscopic lysis of
adhesions ___
Social History:
___
Family History:
Grandfather with skin cancer
Brother w/multiple colonic adenomas @ ___ yo (___)
Physical Exam:
On admission:
VS: 97.7 78 111/68 16 99% on 2L NC
Gen: NAD, A&Ox3
Neuro: A&oX3
CV:RRR
Pulm: Left chest with decreased breath sounds, right chest
clear,
unlabored. Right chest with port dressing in place with minimal
staining and Left chest with steris in place.
Abd: port incisions clean, dry and intact, no sign of infection,
healing appropriately, soft, NT, ND
___: no edema, WWP
On discharge:
VS: 97.8 63 100/70 18 99RA
Gen: NAD, A+Ox3
CV: RRR
Pulm: No respiratory distress. Dressings c/d/i s/p removal of
CT.
Abd: port incisions clean, dry and intact, no sign of infection,
healing appropriately, soft, NT, ND
___: no edema, WWP
Pertinent Results:
___ 12:30PM BLOOD WBC-12.7* RBC-4.54 Hgb-9.5* Hct-31.3*
MCV-69* MCH-20.9* MCHC-30.3* RDW-18.6* Plt ___
___ 12:30PM BLOOD Neuts-73.7* ___ Monos-5.1 Eos-2.0
Baso-0.2
___ 12:30PM BLOOD Glucose-85 UreaN-12 Creat-0.8 Na-139
K-5.3* Cl-104 HCO3-21* AnGap-19
___ 12:30PM BLOOD HCG-<5
Brief Hospital Course:
Ms. ___ presented to the ___ ED on ___ with chest
pain and shortness of breath in the setting of port placement,
and was found to have a L pneumothorax. A pigtail chest tube was
placed in the ED. She tolerated the procedure well without
complications (Please see Thoracic surgery consult note for
further details). She was admitted to the Colorectal surgery
service for further management. She was stable overnight, and
her chest tube was clamped, and then discontinued without issue.
Xray confirmed reduction in her pneumothorax. Thoracic surgery
service was comfortable with discharge to home.
Neuro: The patient was given oral pain medications as needed.
Stable from a neurological standpoint.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Pulmonary: Respiratory status was stable after placement of the
chest tube. She tolerated water seal and discontinuation of the
chest tube without complication. Chest xrays were performed to
confirm stability of her pneumothorax after each manipulation of
the chest tube.
GI/GU: She tolerated a regular diet. Intake and output were
closely monitored.
ID: 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 ___, the patient was discharged to home. At discharge,
she was stable from a respiratory and hemodynamic perspective.
She will follow-up in the clinic in ___ weeks. This information
was communicated to the patient directly prior to discharge.
Include in Brief Hospital Course for Every Patient and check of
boxes that apply:
Post-Surgical Complications During Inpatient Admission:
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[ ] Abscess
[x] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. norethindrone-e.estradiol-iron ___ /1mg-35mcg (9)
oral QHS
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. norethindrone-e.estradiol-iron ___ /1mg-35mcg (9)
oral QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Left pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the Colorectal surgery service for Left
lung pneumothorax sustained during placement of a port-a-cath.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Please take any
new medications as prescribed. Please take the prescribed
analgesic medications as needed. You may not drive or heavy
machinery while taking narcotic analgesic medications. You may
also take acetaminophen (Tylenol) as directed, but do not exceed
4000 mg in one day. Please get plenty of rest, continue to walk
several times per day, and drink adequate amounts of fluids.
Avoid strenuous physical activity and refrain from heavy lifting
greater than 10 lbs., until you follow-up with your surgeon, who
will instruct you further regarding activity restrictions.
Please also follow-up with your primary care physician.
Please continue to monitor your bowel function closely after
your laparoscopic sigmoid colectomy on ___. If you notice
that you are passing bright red blood with bowel movements or
having loose stool without improvement please call the office or
go to the emergency room if the symptoms are severe. If you are
taking narcotic pain medications there is a risk that you will
have some constipation. Please take an over the counter stool
softener such as Colace, and if the symptoms do not improve call
the office. If you have any of the following symptoms please
call the office for advice or go to the emergency room if
severe: increasing abdominal distension, increasing abdominal
pain, nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
You may shower; pat the incisions dry with a towel, do not rub.
The small incisions may be left open to the air. Please no baths
or swimming for 6 weeks after surgery unless told otherwise by
Dr. ___.
You will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
You may take Tylenol as recommended for pain. Please do not take
more than 3000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
No heavy lifting greater than 6 lbs for until your first
post-operative visit after surgery. Please no strenuous activity
until this time unless instructed otherwise by Dr. ___.
Thank you for allowing us to participate in your care. Our hope
is that you will have a quick return to your life and usual
activities.
Followup Instructions:
___
|
19922982-DS-2 | 19,922,982 | 22,336,612 | DS | 2 | 2157-04-30 00:00:00 | 2157-04-30 15:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hand weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ RHF with pmhx of HTN, HLD and
blindness who presents with chief complaint of sudden onset hand
weakness.
Patient was in her usual state of health till around ___
evening
when she felt her right hand was weak. She states she was unable
to grab on to the pill bottle well and felt as if her hand was
asleep. Patient states she did not feel her hand was clumsy.
Denied associated arm/leg/face symptoms. No N/V, no dizziness,
numbness or tingling anywhere else. Per patient she still feels
the same symptoms however slightly improved in intensity. CT
scan
at OSH showed chronic microvascular ischemic change. She went to
___ who gave her one dose of ASA and transferred her to ___
for further workup for possible stroke.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. No vertigo, tinnitus, hearing
difficulty, dysarthria, or dysphagia. Denies focal muscle
weakness, numbness, parasthesia. Denies loss of sensation.
Denies
bowel or bladder incontinence or retention. Denies difficulty
with gait.
On general review of systems, the patient denies fevers, chest
pain, palpitations, cough, nausea, vomiting, diarrhea,
constipation, abdominal pain, dysuria or rash.
Past Medical History:
DM, HLD, uterine fibroids, blindness
Social History:
___
Family History:
No family history of early stroke
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
General: NAD, resting in bed
HEENT: NCAT, no oropharyngeal lesions, moist mucous membranes,
sclerae anicteric
Neck: Supple
___: RRR
Pulmonary: CTAB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Recalls a
coherent
history. Speech is fluent with full sentences, intact
repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect. No left-right agnosia.
- Cranial Nerves - PERRL 3->2 brisk. VF full to finger wiggling.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. No dysarthria. Palate elevation
symmetric. Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. Rt pronator drift with weak gem.
No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ 4+ ___ 5 5 5
- Sensory - No deficits to light touch
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating
movements.
- Gait - Normal initiation. Narrow base. Normal stride length
and
arm swing. Stable without sway. Negative Romberg.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.7, HR 62-75, RR ___, BP 157-172/67-71, >97%RA
General: NAD, sitting up in bed
HEENT: NCAT, left eye sclerotic, right eye anicteric, no
oropharyngeal lesions, moist mucous membranes
Neck: Supple
___: RRR, well perfused
Pulmonary: Normal WOB
Abdomen: Soft, ND
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status - Awake, alert, oriented to person, place and
time. Attention to examiner easily maintained. Speech is fluent
in ___ with full sentences, intact repetition,
and intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No evidence of hemineglect.
- Cranial Nerves - Left eye sclerotic, right pupil reactive
3to2mm. Unable to see light with the left eye, legally blind in
right eye, eomi, no nystagmus. V1-V3 without deficits to light
touch bilaterally. Subtle R NLFF with good activation. Decreased
hearing bilaterally. No dysarthria. Palate elevation symmetric.
Trapezius strength ___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. R pronator drift.
No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5
R 4+ 5 4+ ___ ___ 5 5 5
- Sensory - No deficits to light touch
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response mute bilaterally.
- Coordination - No dysmetria reaching for objects although
limited by R hand weakness
- Gait - able to ambulate independently
Pertinent Results:
___ 05:55AM BLOOD WBC-3.5* RBC-3.64* Hgb-11.5 Hct-33.9*
MCV-93 MCH-31.6 MCHC-33.9 RDW-13.7 RDWSD-46.8* Plt ___
___ 01:00AM BLOOD Neuts-55.8 ___ Monos-13.5*
Eos-1.6 Baso-0.8 Im ___ AbsNeut-2.03 AbsLymp-1.02*
AbsMono-0.49 AbsEos-0.06 AbsBaso-0.03
___ 09:43AM BLOOD ___ PTT-35.1 ___
___ 05:55AM BLOOD Glucose-85 UreaN-10 Creat-0.8 Na-135
K-3.4 Cl-97 HCO3-25 AnGap-14
___ 09:43AM BLOOD ALT-14 AST-21 AlkPhos-81 TotBili-0.3
___ 09:43AM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:55AM BLOOD Calcium-9.2 Phos-3.7 Mg-2.1
___ 09:43AM BLOOD Albumin-4.0 Calcium-8.9 Phos-3.4 Mg-2.1
Cholest-149
___ 09:43AM BLOOD %HbA1c-6.5* eAG-140*
___ 09:43AM BLOOD Triglyc-61 HDL-66 CHOL/HD-2.3 LDLcalc-71
___ 09:43AM BLOOD TSH-1.0
___ 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING:
MRI/A ___:
FINDINGS:
MRI BRAIN:
There is slow diffusion surrounding the left paracentral gyrus
with associated FLAIR hyperintensity. There is no evidence of
intracranial hemorrhage. There is mild diffuse parenchymal
volume loss. There is moderate nonspecific periventricular
subcortical FLAIR hyperintensities, likely a sequela of chronic
small vessel ischemic disease. There is a focus of chronic
infarction in the left midbrain (8:8). The ventricles are
normal in size without mass effect or midline shift. The major
visualized arterial vascular flow voids are preserved. There is
mild mucosal thickening of the bilateral ethmoid air cells.
There is a 1.3 x 1.2 cm cystic lesion within the left nasal
cavity anteriorly demonstrating intrinsic T1 and T2
hyperintensity with layering hemorrhagic content, likely
representing a nasolabial cyst with proteinaceous content.
MRA BRAIN:
The bilateral intracranial internal carotid arteries and
vertebral arteries in the principal intracranial branches appear
patent without stenosis, occlusion, or aneurysm.
MRA NECK:
The bilateral common carotid arteries and internal carotid
arteries appear
patent without internal carotid artery stenosis by NASCET
criteria. The
bilateral vertebral arteries appear patent. The bilateral
visualized
subclavian arteries and origins of great vessels appear patent.
IMPRESSION:
1. Acute to early subacute infarction in the left paracentral
gyrus.
2. No evidence of intracranial hemorrhage.
3. Diffuse parenchymal volume loss with moderate chronic small
vessel ischemic disease.
4. Focus of chronic infarction in the left midbrain.
5. 1.3 cm left nasal labial proteinaceous cyst with hemorrhagic
content.
6. MRA brain demonstrates no stenosis, occlusion, or aneurysm of
the major
intracranial branches.
7. MRA neck demonstrates patency of the bilateral common and
internal carotid arteries and the vertebral arteries.
Brief Hospital Course:
Ms. ___ is a ___ right-handed female with
history of HTN, HLD and blindness who presented with acute onset
right hand weakness and numbness after being at home and
noticing that she was unable to grab onto a pill bottle well and
felt as if her hand was asleep.
She went to ___ where she had a head CT that showed
chronic microvascular ischemic change but no acute process; she
received one dose of ASA and was transferred to ___ for further
workup. MRI showed an acute to early subacute infarction in the
left paracentral gyrus with moderate chronic small vessel
ischemic disease. MRA head and neck were unremarkable.
Etiology likely artery to artery atherothrombolic vs.
cardioembolic. She had a TTE that showed normal LA size, no
PFO, mild symmetric LVH with normal LV EF >55%; mild dilatation
of the aorta with mild to moderate AR and mild MR. ___ was
monitored on telemetry with no evidence of arrhythmia. She will
be discharged with ___ of Hearts monitor. She had stroke
risk factors including HbA1c 6.5%, LDL 71, TSH 1.0. She should
___ with her PCP to follow her blood sugars and consider
initiation of treatment for DM if they remain high. She was
continued on her home pravastatin 20mg daily given LDL 71. She
was continued on aspirin 81mg daily and started on Plavix 75mg
daily for a 3 month course. She was evaluated by ___ and OT who
recommended discharge home with 24 hour care which her daughter
stated she can provide. She will have outpatient Neurology and
PCP ___.
Discharge Issues:
___ with PCP ___: HbA1c
2. Monitor blood pressures on current regiment
3 Continue Plavix for 3 months then stop. Continue
aspirin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Labetalol 100 mg PO TID
2. Valsartan 160 mg PO DAILY
3. amLODIPine 5 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Pravastatin 20 mg PO QPM
6. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*5
2. Clopidogrel 75 mg PO DAILY
Take for 3 months then stop
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*2
3. amLODIPine 5 mg PO DAILY
4. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Labetalol 100 mg PO TID
7. Pravastatin 20 mg PO QPM
8. Valsartan 160 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left paracentral gyrus infarction
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of right hand weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension
High cholesterol
We are changing your medications as follows:
Continue Aspirin 81mg daily
START Plavix 75mg daily for 3 months then stop
Please take your other medications as prescribed.
Please ___ with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19923013-DS-19 | 19,923,013 | 28,442,398 | DS | 19 | 2206-03-06 00:00:00 | 2206-03-10 12:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Optiray 300 / IV Dye, Iodine
Containing Contrast Media
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___. ___ is a "self-described ___
woman with essential thrombocytosis, parathyroid adenoma, s/p
parathyroidectomy, cervical spondylosis, and headaches
thought to be related to ___ syndrome who presents with
headache. The headache was sudden in onset and associated with
nausea and escalated to a ___ in an hour. She states this is
one of her typical headache semiologies, but just more severe
than typical. She states it is one of the ___ most severe
episodes of this type of headache. Her headache improved from
___ after migraine cocktail. Neurologic exam nonfocal in
the ED. Overall her headaches are well controlled and she only
has to come to the ED once or twice per year. She does not
report
any slurred speech, change in vision or focal weakness.
Her case was discussed with heme-onc on call who requested an
MRI
to evaluate for ___ thrombosis. Seen by neurology who
thought her presentation was c/w an exacerbation of her headache
syndrome. Her sx were worsened by bright lights.
Upon arrival to the floor her pain had improved to ___. The
toradol helped the most.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
She was recently seen in urgent care for URI. Also dx'ed w/ UTI
now s/p course of macrobid.
+++++++++++++++++++++++++++++++++++++++++++++
++++++++++++++++++++++++++++++++++++++++++++++++
SOCIAL HISTORY:
___
FAMILY HISTORY:
Her mother died at ___ from carcinoid malignancy. Her father is
___
and healthy works every day.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
#ATYPICAL PAP SMEARS
#DEPRESSION
#ESSENTIAL THROMBOCYTHEMIA ___
#JAK2 MUTATION, CELL-BASED POSITIVE A on anagrelide over ___
years, discontinued ___ on since hydroxyurea ___ and on
ASA
#HYPERCALCEMIA ___
primary hyperparathyroidism, s/p parathyroidectomy on ___
found to have parathyroid adenoma
#MIGRAINE HEADACHES
managed with verapamil - thought to be secondary to cerebral
vasospasm, ___ syndrome - reversible cerebral
vasoconstriction syndrome (RCVS) group - no history of stroke
followed by Dr. ___
#HYPERTENSION
previously on verapamil/HCTZ switched to lisinopril/verapamil
___ due to hyponatremia work-up for secondary causes of HTN
with mild elevation in urine metanephrines, not consistent with
pheo
#BREAST LUMP
left breast, s/p wire localized excision biopsy ___ and
___ with Dr. ___. Path revealed benign findings: focal
ductal hyperplasia, adenosis, calcifications
#HYPONATREMIA
followed by Dr. ___ HCTZ to lisinopril in ___
#UTERINE FIBROIDS
seeing Dr. ___ ___
#CERVICAL SPONDYLOSIS ___
#MVA in ___ intermittent pain, s/p ___
#LOW BACK PAIN ___
injured while ice skating in ___ intermittent pain, s/p ___
Family History:
Very significant
Mother - carcinoid ___ tumor, MI age ___, very
hypertensive at a young age
Father - 2xMIs, HTN
Sibs - brother - very hypertensive dx ___ at age ___ felt to have
hereditary cardiomyopathy
Children - sone dx HTN age ___
No strokes, neuromuscular disorders or movement disorders.
Physical Exam:
VITALS: 98.1 PO 107 / 68 55 18 98 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 04:10PM BLOOD WBC-6.4 RBC-3.63* Hgb-13.3 Hct-39.5
MCV-109* MCH-36.6* MCHC-33.7 RDW-12.8 RDWSD-50.8* Plt ___
___ 04:29PM BLOOD ___ PTT-28.9 ___
___ 04:10PM BLOOD Glucose-85 UreaN-20 Creat-0.8 Na-139
K-5.1 Cl-102 HCO3-20* AnGap-17
MRI/MRA
1. No acute intracranial abnormality. Specifically, no evidence
for dural
venous thrombosis.
2. Patent Circle of ___ without evidence of significant
stenosis.
3. Mild inflammatory changes of the ethmoid air cells.
4. Unchanged mild bifrontal volume loss.
Brief Hospital Course:
SUMMARY/ASSESSMENT: Ms. ___ is a ___ female
with the past medical history and findings noted above who
.
ACUTE/ACTIVE PROBLEMS:
HEADACHE:
Pt with acute onset of severe headache and nausea c/w flare of
underlying headache syndrome now improved with toradol and
reglan. Will continue toradol.
She was seen by neurology service who felt that she had a flare
of her chronic headache syndrome. She received toradol prior to
departure and her headache was ___. Neurology staff was
working to get her a f/u with Dr ___ her discharge.
.
HTN: reduced lisinopril dose from 20 mg to 10 mg given
borderline low blood pressures; advised her to f/u with PCP
.
CHRONIC/STABLE PROBLEMS:
#ESSENTIAL THROMBOCYTOSIS
Discussed with hematologist (___) who advised continuation of
hydroxyurea. Aspirin resumed on discharge
#DEPRESSION
- continue wellbutrin and celexa
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. butalbital-acetaminophen-caff 50-325-40 mg oral Q 6 hrs prn
2. Lisinopril 20 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. Hydroxyurea 500 mg PO DAILY
5. Verapamil SR 240 mg PO Q24H
6. Aspirin 81 mg PO DAILY
7. Citalopram 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion (Sustained Release) 150 mg PO QAM
4. butalbital-acetaminophen-caff 50-325-40 mg oral Q 6 hrs prn
5. Citalopram 40 mg PO DAILY
6. Hydroxyurea 500 mg PO DAILY
7. Verapamil SR 240 mg PO Q24H
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Headache
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with a severe headache and you had an MRI/MRA
to look at your brain and the blood vessels and this testing was
normal. You were seen by the neurologist and they feel that you
are stable to go home.
Your blood pressures are a bit lower than normal so I recommend
that you take half of your lisinopril at home (for a 10 mg
amount) and that you followup with Dr ___ a blood
pressure check.
Followup Instructions:
___
|
19923191-DS-11 | 19,923,191 | 25,876,678 | DS | 11 | 2144-03-29 00:00:00 | 2144-04-01 07:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dizziness/Fatigue/Hypotension
Major Surgical or Invasive Procedure:
___ Right Internal Jugular Line
History of Present Illness:
Ms. ___ is a ___ year old female with h/o HTN, HLD, and MM for
which she was initially enrolled in a clinical trial for chemo
vs transplant. She initially received chemo but did not do well
so she is now preparing for transplant. She had chemo on ___
and states that since then she has been extremely fatigued with
diarrhea ___ daily and lightheadedness. She has been trying to
keep up with her PO intake but has not been eating very much
given poor apatite. On ___ she had a fall onto her knee while
trying to go up stairs in her home. She denies LOC, head strike
syncope or lightheadedness around the fall and says that she was
just so tired she couldn't keep her gait up. She has been
compliant with her medications including her antihypertensives
and her filgrastim injections. She otherwise denies dark or
bloody stools, fever or chills, night sweats, SOB, CP, abdominal
pain, nausea, headaches, changes in vision, hearing, smell or
taste.
Of note she was treated empirically for UTI with ciprofloxacin
on ___ because of polyuria and foul smelling urine.
In the ED, initial vitals: T 98.4, HR 107, BP 93/52, RR 18,
SPO2 99% on RA.
Labs showed pancytopenia with neutropenia and mild ___ Cr 1.2.
Her BP decreased to ___ while in the ED and she received 2L
NS, her BP improved temporarily then dropped again so and IJ was
placed and she got an additional 1L NS. She also received
empiric vanc and zosyn.
She was admitted to the ICU with concern for refractory
hypotension. On transfer, vitals were: T 98.2, HR 70, BP
97/49, RR 18, SPO2 98% o RA.
On arrival to the MICU, patient ambulated into her room and
states that she is feeling better.
Past Medical History:
ONCOLOGY/TREATMENT HISTORY (PER OMR):
___: Evaluated in the ___ clinic for the first time and PET
ordered for other focal lesions. Repeat labs did not demonstrate
any anemia, hypercalcemia or elevated creatinine. Repeat K.L
ratio was 0.04 with free Lambda elevated at 315.4 and free
kappa.
24 hr urinary collection recommended.
___: PET demonstrated a lytic, destructive lesion in the
left eleventh rib with an SUV max of 13.6. A lytic lesion is
seen in the left scapula as well demonstrating FDG avidity with
an SUV max of 5.1. In addition to the bony lesions in the chest,
there was a focus of FDG avidity, with SUV max of 7.2, along the
lateral cortex of the
left femur. A similar lesion is also seen in the right femur
with an SUV max of 3.8. These do not correspond to a definite
lesion on CT.
___: Repeat serum IFE demonstrated IgG lambda M ptn 0.2 gm.
K/L ratio was 0.04 and Lambda estimated at 306.1
BM aspirate performed for study enrollment was inadequate for
study evaluation due to lack of spicules.
UPEP did not show any monoclonal ptn. Urine IFE showed tRACE
MONOCLONAL FREE (___) LAMBDA DETECTED CONCENTRATION IS
TOO LOW TO BE SEEN ON PEP FOR QUANTITATION.
24 hour urinary ptn collection demonstrated 140mg ptn only.
___: BM aspirate and biopsy repeated which confirmed ___
monoclonal plasma cells.
Final Diagnosis: Active symptomatic MM based on serum IFE
demonstrating IgG Lambda and more than focal lytic lesion on
PET.
___: Enrolled in clinical trial # ___ "A Randomized Phase
III Study Comparing Conventional Dose Treatment Using a
Combination of Lenalidomide, Bortezomib and Dexamethasone (RVD)
to High-Dose Treatment with Peripheral Stem Cell Transplant in
the Initial Management of Myeloma in Patients up to ___ Years of
Age".
___: C1D1 of RVD started. Tolerated it well without any
major
complications.
___: Improvement in free Lambda burden from 324 to 11.6. M
pin quantity improved from 0.2 gm/dl to undetectable levels.
C2D1
of RVD started. C.b rash likely sec to Revlimid, ___ and
neuropathy requiring inpatient hospitalization. She was found to
have a complex cyst concerning for clear cell RCC during the
hospital course.
___: MRI abdomen confirmed the suspicion of clear cell RCC.
___: Evaluated by Dr ___ agreed with the concern of
low grade clear cell RCC and felt pt would be a candidate for
partial nephrectomy.
___: CT chest did not show any e.o metastasis.
___: After discussion with ___ medical oncology team and Dr
___ made to complete induction chemo followed by partial
nephrectomy followed by HDT and autoBMT.
___: Due to a new diagnosis of a second cancer presumed RCC,
pt came off the trial.
Trace M ptn noted after 2 cycles of therapy (<0.06 gm).
___: Started on cycle 3 of RVD off trial although at reduced
dose of 1 mg/m2 and eventually 0.7 mg/m2 along with Rev at 20mg
and Dex ___.
___: Disappearance of M ptn after 3 cycles on serum IFE.
Started on cycle 4 of RVD. Velcade given at 0.7 mg/m2 on D1 and
4
and then discontinued due to persistent neuropathy grade 2 at
least. Revlimid continued at 20mg/day.
___: Continued to have no e.o M ptn on serum IFE after 4
cycles.
___: After extensive discussion within the ___ team and with
Dr ___ made to withhold further therapy for MM given
the
immunomodulatory effects of Revlimid on RCC and hence pt
underwent a robotic assisted laproscopic partial left
nephrectomy
on ___.
Surgical path c.w pT1a papillary RCC. No e.o high risk features
seen. Recommended 6 month follow up as tolerated the procedure
very well.
___: Seen in clinic for follow up and seemed to be doing
very
well. Completely recovered from surgery. Resumed treatment with
Rev/Dex at cycle 5 (Rev 20mg/day D1-14 every 21 days and Dex
___.
___: Started cycle 6 of Rev/Dex, completed on ___.
Tentative Transplant Calendar:
___: admission for chemo pre-collection
___: start neupogen/cipro
___: pheresis for collection
___: admission for auto transplant
PAST MEDICAL HISTORY:
-HTN
-HLD
-s/p CCY
-s/p L oopherectomy
-Sickle trait
Social History:
___
Family History:
Uncle died of colon cancer. Mother is living with hypertension,
type 2 diabetes, hypercholesterolemia and glaucoma and father is
deceased at age ___ from sickle cell disease. She has three
healthy children without medical issues. There is no other
family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: afebrile BP: 95/55 P: 77 R: 18 O2: 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,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, trace edema around the
ankles
SKIN: no rash or concerning lesions
NEURO: CN II_XII grossly intact
DISCHARGE EXAM:
VS: 98.4 92/52 66 17 100RA
GEN: NAD, ambulatory but seated in bed
HEENT: AT/NC, MMM, no mucositis, nares nonbloody; EOMI, PERRL
NECK: no LAD, supple throat
CV: RRR, no M/R/G
PULM: CTAB
ABD: S/NT/ND, +BS
GU: no Foley
EXT: nontender, nonedematous
NEURO: A/Ox3; CNII-XII grossly intact
SKIN: no visible skin changes
Pertinent Results:
ADMISSION LABS
==============
___ 07:30PM BLOOD WBC-0.4*# RBC-4.51 Hgb-11.9# Hct-35.3
MCV-78* MCH-26.4 MCHC-33.7 RDW-16.4* RDWSD-46.3 Plt Ct-96*
___ 07:30PM BLOOD Neuts-9* Bands-2 ___ Monos-13
Eos-46* Baso-0 ___ Myelos-0 AbsNeut-0.04*
AbsLymp-0.12* AbsMono-0.05* AbsEos-0.18 AbsBaso-0.00*
___ 07:30PM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-OCCASIONAL
Polychr-NORMAL Ovalocy-OCCASIONAL Burr-OCCASIONAL Tear
Dr-OCCASIONAL
___ 07:30PM BLOOD ___ PTT-26.7 ___
___ 07:30PM BLOOD Glucose-134* UreaN-24* Creat-1.2* Na-138
K-4.0 Cl-96 HCO3-25 AnGap-21*
___ 07:30PM BLOOD ALT-24 AST-25 AlkPhos-67 TotBili-1.5
___ 07:30PM BLOOD Lipase-31
___ 07:30PM BLOOD proBNP-92
___ 07:30PM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.7 Mg-2.1
DISCHARGE LABS
==============
___ 08:05AM BLOOD WBC-0.4* RBC-3.47* Hgb-9.2* Hct-27.4*
MCV-79* MCH-26.5 MCHC-33.6 RDW-15.9* RDWSD-45.7 Plt Ct-39*
___ 08:05AM BLOOD Neuts-0* Bands-0 ___ Monos-17*
Eos-30* Baso-12* Atyps-1* ___ Myelos-0 AbsNeut-0.00*
AbsLymp-0.16* AbsMono-0.07* AbsEos-0.12 AbsBaso-0.05
___ 08:05AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-1+ Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-OCCASIONAL
___ 08:05AM BLOOD Plt Smr-VERY LOW Plt Ct-39*
___ 08:05AM BLOOD Glucose-129* UreaN-9 Creat-0.7 Na-139
K-3.5 Cl-107 HCO3-24 AnGap-12
___ 08:05AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.8
___ 08:05AM BLOOD Cortsol-17.0
URINALYSIS
===========
___ 09:22PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:22PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:22PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-1
___ 09:22PM URINE CastHy-23*
FLU STUDIES
===========
___ 01:30AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICROBIOLOGY
============
___: BLOOD CULTURE X 2: PENDING
___: URINE CULTURE: PENDING
Brief Hospital Course:
___ year old woman with past medical history of papillary renal
cell carcinoma (3.9 cm, T1) status-post left partial nephrectomy
in ___, sickle cell trait, and IgG lambda multiple myeloma
previously randomized to non-transplant arm of study comparing
conventional dose therapy with RVD to SCT in initial management
of myeloma, now s/p C6 RVD ___, given cyclophosphamide ___
prior to planned stem cell mobilization admitted with fatigue,
dizziness, loose stools, ___, and borderline hypotension, also
noted to be neutropenic.
# Hypotension: Patient presented to ___ with fatigue,
lightheadedness, weakness, and hypotension with SBP in the ___.
Infectious workup including UA (negative), urine culture
(pending), blood cultures x 2 (pending), and CXR (negative) were
obtained. Given patient's ANC of 30 on admission, patient
initially received vancomycin/piperacillin-tazobactam in the
Emergency Department. This was transitioned to cefepime. Patient
required a total of 5L normal saline. Patient did not require
any pressors in the intensive care unit and right internal
jugular catheter was removed. On the floor her antihypertensives
were held and she remained normotensive. On discharge she was
without antibiotics for 24 hours and had a stable pressure, and
was taking PO at her baseline at home.
# Diarrhea: A possible cause of the above hypotension,
attributable to high dose Cytoxan. The patient was still having
___ loose BMs at the time of her discharge but will be planned
readmission on ___ for apheresis and will re-present if
her symptoms worsen in the interval.
# Peripheral Eosinophilia: Differential diagnosis included
malignant eosinophilia, neupogen effect, drug reaction, adrenal
insufficiency. Patient had negative Strongyloides antibodies on
___.
# IgG lambda multiple myeloma s/p C6 RVD ___: Patient is
preparing for transplant high dose Cytoxan ___ prior to SC
mobilization. She was continued on filgrastim at 960 mg daily,
with prophylaxis of Bactrim and acyclovir. She was continued on
B6 and vitamin D. Her cipro prophylaxis was restarted on
transfer from the floor, and continued upon discharge.
# Pancytopenia: Thought to be due to high dose Cytoxan. Her
filgrastim was continued through the admission, as was her
Bactrim and acyclovir. Plt 58 at time of discharge.
# Hyperkalemia: Thought to be secondary to poor PO intake and
elevated creatinine. Resolved with IVF.
# Hypertension: Patient has baseline hypertension but presented
with hypotension. Continued to hold lisinopril and
hydrochlorothiazide, which may be restarted upon outpatient
follow up in the setting of low-normal BPs.
TRANSITIONAL ISSUES:
- please evaluate eosinophilia (if true on repeat studies); may
consider AM cortisol
- held lisinopril and HCTZ on discharge, please resume when BP
room adequate
- continue per schedule for stem cell collection and
auto-transplant
- Code: full
- Contact: ___ (NoK) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 30 mg PO DAILY
2. Gabapentin 300 mg PO QHS
3. Simvastatin 40 mg PO QPM
4. Hydrochlorothiazide 25 mg PO DAILY
5. Pyridoxine 100 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Ciprofloxacin HCl 500 mg PO Q12H
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Acyclovir 400 mg PO Q12H
Discharge Medications:
1. Filgrastim 960 mcg SC Q24H
2. Acyclovir 400 mg PO Q12H
3. Ciprofloxacin HCl 500 mg PO Q12H
4. Gabapentin 300 mg PO QHS
5. Pyridoxine 100 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was
held. Do not restart Hydrochlorothiazide until instructed by
your oncology team because you have had low BPs.
10. HELD- Lisinopril 30 mg PO DAILY This medication was held.
Do not restart Lisinopril until instructed by your oncology team
because you have had low BPs.
Discharge Disposition:
Home
Discharge Diagnosis:
- hypotension
- diarrhea
- neutropenia
- thrombocytopenia
- IgG lambda multiple myeloma, C6 RVd ___
- acute kidney injury
- eosinophilia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure caring for you while you were at ___. You
were admitted to the ICU for low blood pressure and mild kidney
injury in the setting of eating and drinking less as well as
multiple episodes of diarrhea. You were treated with fluids as
well a brief course of antibiotics. Once you were feeling better
you were transferred to the medical floor. It was thought that
your symptoms were a side effect of the chemotherapy you were
given in preparation of your stem cell mobilization. You were
feeling better and able to eat and drink more at the time of
your discharge, and were sent home with instruction to return on
___ for your planned admission for line placement and stem
cell collection.
Thank you for allowing us to participate in your care while
here.
Best regards,
Your ___ Care Team
Followup Instructions:
___
|
19923506-DS-14 | 19,923,506 | 21,528,712 | DS | 14 | 2160-06-02 00:00:00 | 2160-06-02 11:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain and fever
Major Surgical or Invasive Procedure:
1. Incision and drainage.
2. Removal of instrumentation.
3. Fusion exploration.
4. V.A.C. placement.
History of Present Illness:
___ woman with recent spinal surgery presenting
with upper back pain, fever, and abnormal laboratory tests x
24 hours. The patient has been inpatient at ___ after a Revision spinal surgery. She
noted a fever last night which was measured as high as
101.6, which did return despite Tylenol. Per the staff at her
rehabilitation hospital, there has been significantly more
swelling and erythema around the incision site. Her labs
were also notable for an elevated wbc and decreased hct.
Past Medical History:
Hyperlipidemia
Asthma
Hypertension
Scoliiosis s/p surgical correction
Mild CHF
Social History:
___
Family History:
Non-contributory.
Physical Exam:
On examination the patient is well developed, well nourished,
A&O x3 in NAD. AVSS.
Range of motion of the thoracolumbar spine is somewhat limited
on flexion, extension and lateral bending due to pain.
Halo is in place.
Ambulating well with the assistance of a walker and ___, with
CTLSO brace for support.
Gross motor examination reveals good strength throughout the
bilateral lower extremities.
There is no clonus present.
Sensation is intact throughout all affected dermatomes.
The posterior thoracolumbar incision is clean, dry and intact
without erythema, edema or drainage.
The patient is voiding well without a foley catheter.
Pertinent Results:
___ 04:08AM BLOOD WBC-6.2 RBC-3.33* Hgb-9.9* Hct-28.8*
MCV-87 MCH-29.7 MCHC-34.3 RDW-14.5 Plt ___
Brief Hospital Course:
___ presented to the ___ emergency department on
___ from her rehabilitation facility with fever, back pain
and leukocytosis and decreased hct. CT scan of her thoracic
spine revealed loss of fixation of the thoracic instrumentation
from prior revision fusion on ___. She was taken to the
operating room on ___ for emergency incision and drainage,
removal of instrumentation, and washout of posterior wound. A
wound vac was placed at the time of surgery. Refer to the
dictated operative note for further details. The surgery was
performed without complication, the patient tolerated the
procedure well, and was transferred to the PACU in a stable
condition. TEDs/pneumoboots were used for postoperative DVT
prophylaxis. Intravenous antibiotics were started in the
emergency department and continued postoperatively. Urine
culture was positive for pseudomonas. Intra-operative cultures
were negative. She was closely monitored for signs of infection
postoperatively. Initially, postoperative pain was controlled
with a PCA. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
___ remained in halo and traction to 20lbs. She was
also fitted for CTLSO brace for when out of bed. The wound vac
and hemovac were removed on post-operative day three. Infectious
disease was consulted and recommends continuing parenteral
antibiotics, specifically vancomycin and cefepime for about 6
weeks. PICC line placement was consented for and placed on ___.
Traction was discontinued on ___ and she was placed back in
halo vest. She will remain in halo vest for about 3 months. On
the day of discharge she was tolerating oral pain medication,
urinating without difficulty, and tolerating regular diet.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
3. Amlodipine 5 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. CefePIME 2 g IV Q12H
RX *cefepime [Maxipime] 2 gram 2 gram IV every twelve (12) hours
Disp #*60 Vial Refills:*0
6. Docusate Sodium 100 mg PO BID
7. Heparin 5000 UNIT SC BID
8. Omeprazole 20 mg PO DAILY
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #*90 Tablet
Refills:*0
10. Senna 8.6 mg PO BID:PRN constipation
11. Timolol Maleate 0.5% 1 DROP RIGHT EYE BID
12. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 1 gram 1 gram IV every twelve (12) hours Disp
#*60 Vial Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
failure of fixation and possible wound infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
ACTIVITY: DO NOT lift anything greater than 10 lbs for 2 weeks.
___ times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
You will be more comfortable if you do not sit or stand more
than ~45 minutes without changing positions.
BRACE: You have been given a brace. This brace should be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
WOUND: Remove the external dressing in 2 days. If your incision
is draining, cover it with a new dry sterile dressing. If it is
dry then you may leave the incision open to air. Once the
incision is completely dry, (usually ___ days after the
operation) you may shower. Do not soak the incision in a bath or
pool until fully healed. If the incision starts draining at any
time after surgery, cover it with a sterile dressing. Please
call the office.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
MEDICATIONS: You should resume taking your normal home
medications. Refrain from NSAIDs immediately post operatively.
You have also been given Additional Medications to control your
post-operative pain. Please allow our office 72 hours for refill
of narcotic prescriptions. Please plan ahead. You can either
have them mailed to your home or pick them up at ___
___, ___. We are not able
to call or fax narcotic prescriptions to your pharmacy. In
addition, per practice policy, we only prescribe pain
medications for 90 days from the date of surgery.
Followup Instructions:
___
|
19923624-DS-5 | 19,923,624 | 28,094,656 | DS | 5 | 2137-06-13 00:00:00 | 2137-06-14 09:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall from ladder, 15 feet. With ___ rib fractures and small
subcapsular hematoma.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This patient is a ___ year old male with a prior history of
heavy alcohol ingestion, is transferred with no rib
fractures from a fall. He was doing a roofing job and fell
off a one-story roof, he struck ___ the way down, and
then to his right flank fell onto the ground landing on
diver weights. He has severe right back pain. He was taken
to ___ where a head CT and C-spine CT were
negative, and a CT of his torso demonstrated fractures to
ribs 7, 8, 9 and a small right hemothorax. No injury to the
arms or legs. No numbness, tingling, weakness in the arms or
legs.
Past Medical History:
PMH: Alcohol and opiod abuse, recent Detox end of ___, relapsed
prior to admission.
PSH: Excision of SCC on head
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Discharge Physical Exam:
VS: 99.8/97.7 68 148/92 18 96%RA
GEN: AA&O x 3, non-toxic, verbally combative, intermittently
cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL, laceration with crusting to upper left orbital ridge.
CHEST: Minimal wheezes to auscultation bilaterally, (-)
cyanosis.
ABDOMEN: (+) BS x 4 quadrants, soft, non-tender, non-distended.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema.
Pertinent Results:
___ 11:19PM ___ PTT-31.9 ___
___ 11:19PM PLT COUNT-198
___ 11:19PM NEUTS-79.9* LYMPHS-14.5* MONOS-5.2 EOS-0.2
BASOS-0.2
___ 11:19PM WBC-9.5 RBC-4.04* HGB-12.5* HCT-36.6* MCV-91
MCH-30.8 MCHC-34.1 RDW-12.6
___ 11:19PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:19PM estGFR-Using this
___ 11:19PM GLUCOSE-92 UREA N-10 CREAT-0.6 SODIUM-135
POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-27 ANION GAP-13
___ 11:23PM LACTATE-1.0
___ 02:38AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 02:38AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:38AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 04:35AM HCT-34.9*
___ 05:35PM HCT-34.3*
___ ___ 11:10 ___
CHEST (PORTABLE AP) Clip # ___
Reason: assess for pntx
COMPARISON: Chest radiograph and CT torso from ___.
FINDINGS: A single portable AP semi-upright view of the chest
was obtained.
Heart is normal in size and cardiomediastinal contour is
unremarkable. Lungs
are clear. Right lower rib fractures are better evaluated on the
CT scan.
There is no pleural effusion or pneumothorax.
IMPRESSION: No significant change compared to the most recent
study.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___ ___ 3:52 ___
___ CC6A ___ 9:32 AM
CHEST (PA & LAT) Clip # ___
Reason: evaluate for changes
COMPARISON: ___.
FINDINGS: Known rib fractures, known lung contusion. The
conclusion is less
severe and extensive than on the previous image. The presence
of a minimal
right pleural effusion is better appreciated on the lateral than
on the
frontal view. The rib fractures are better visualized on the CT
examination
performed on ___.
___. ___
___ ___ 12:15 ___
___ ___ M ___ ___
Radiology Report HAND (AP, LAT & OBLIQUE) RIGHT Study Date of
___ 3:24 ___
___ CC6A ___ 3:24 ___
HAND (AP, LAT & OBLIQUE) RIGHT Clip # ___
Reason: evaluate for middle and ring finger fractures, MP and
PIP ___
UNDERLYING MEDICAL CONDITION:
___ year old man with multiple injuries s/p falling from 15 ft
off ladder now
has increased swelling and pain of right elbow with decreased
ROM r/t pain
REASON FOR THIS EXAMINATION:
evaluate for middle and ring finger fractures, MP and PIP
joints specifically
Final Report
STUDY: Right hand, ___.
CLINICAL HISTORY: ___ man with multiple injuries status
post fall
from 15 foot ladder, now with increased swelling and pain of the
right elbow.
FINDINGS: There is a peripheral IV catheter in the dorsal soft
tissues of the
hand. There are degenerative changes of the first CMC and
triscaphe joints.
No acute fractures or dislocations are seen. There are
degenerative changes
of the distal radioulnar joint. There are no bony erosions.
___. ___
___ ___ 9:19 ___
___ CC6A ___ 3:24 ___
ELBOW (AP, LAT & OBLIQUE) RIGH Clip # ___
Reason: evaluate for fracture of elbow
UNDERLYING MEDICAL CONDITION:
___ year old man with multiple injuries s/p falling from 15 ft
off ladder now
has increased swelling and pain of right elbow with decreased
ROM r/t pain
REASON FOR THIS EXAMINATION:
evaluate for fracture of elbow
Final Report
STUDY: Right elbow, ___.
CLINICAL HISTORY: ___ man with multiple injuries status
post fall off
a 15-foot ladder.
FINDINGS: There is a small elbow joint effusion. However, no
definite
fracture of the radial head is seen. There are spurs about the
radial head
and capitellum which limits evaluation for subtle fractures.
There is also
joint space narrowing between the radius and capitellum. A
peripheral
intravenous catheter is seen. Along the posterior aspect of the
joint, there
are loose bodies within the olecranon fossa.
IMPRESSION:
1. Small joint effusion. No obvious fractures seen. Although
there has been
trauma, given the degenerative change involving the
radiocapitellar joint, the
effusion maybe related to the osteoarthritis. If there is
persistent pain,
would recommend repeat images in ___ days to exclude a radial
head fracture.
Alternatively, MRI could be performed to establish for an occult
fracture.
2. Degenerative changes of the radiocapitellar joint as well as
loose bodies
versus spurring in the olecranon fossa.
___. ___
___ ___ 9:19 ___
Brief Hospital Course:
Mr. ___ is a ___ male who was admitted to the ___
Acute Care Surgery service after a 15-foot fall from a ladder.
He suffered a right ___ rib fracture with associated pulmonary
contusion, a small hemathorax, and a small hepatic subcapsualr
hematoma.
Neuro: The patient had difficulty with deep breathing on
presentation due to his rib fractures, and was spliting, so he
received an epidural for pain control, which worked well. He is
an alcohol abuser and recently stopped drinking in ___, with
a few binges of unclear amount since then. His last drink was
on the day of admission. He was placed on a CIWA scale and
became agitated on HD3 and pulled his epidural. He was
subsequently placed on a dilaudid PCA with okay pain relief, and
transitioned to oral oxycodone. He also received toradol once
his hematocrits were stable for pain relief.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. He had some
chest pressure/discomfort on HD2 which appeared to be due to his
rib fractures, however an EKG was performed which was normal and
a troponin was cycled which was also normal.
Pulmonary: The patient suffered the above rib injuries. He had
difficulty with splinting which improved with pain control and
he was able to use the incentive spirometer effectively. Vital
signs were routinely monitored. He was weaned off O2 by HD3 and
he would desaturate to around 90%, however given his smoking
history he was discharged with an O2 saturation stable just
above 90%. Good pulmonary toilet, early ambulation and
incentive spirrometry were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was started on a regular diet Patient's
intake and output were closely monitored, and IV fluid was
adjusted when necessary. Electrolytes were routinely followed,
and repleted when necessary.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
MSK: He had left elbow pain for which we performed a left elbow
xray which demonstrated no fracture. He did have an associated
effusion in that joint, which may be a sign of a fracture that
could not be visualized on the plain films. He was informed of
this and instructed to follow up with his PCP for ___ possible
repeat xray in a week if his pain did not improve.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
3. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN Pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q3hr Disp #*30
Tablet Refills:*0
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) Apply one patch
daily Disp #*2 Kit Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Rib fractures ___ ribs.
Small subcapsular hepatic hematoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You sustained an injury to your liver. You should go to the
nearest Emergency department if you suddenly feel dizzy or
lightheaded, as if you are going to pass out. These are signs
that you may be having internal bleeding from your liver injury.
Your liver injury will heal in time. It is important that you do
not participate in any contact sports or any other activity for
the next 6 weeks that may cause injury to your abdominal region.
Avoid aspirin products, non-steroidal anti-inflammatory (NSAID)
drugs such as Advil, Motrin, Ibuprofen, Naprosyn, or Coumadin
for at least ___ weeks unless otherwise directed as these can
cause bleeding internally.
Rib Fracture:
* Your injury caused ___ rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay
ahead of the pain otherwise you won't be able to take deep
breaths. If the pain medication is too sedating take half the
dose and notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to
hold against your chest and guard your rib cage while coughing
and deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non steroidal antiinflammatory drugs
are very effective in controlling pain (ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
19923690-DS-7 | 19,923,690 | 26,079,417 | DS | 7 | 2139-03-15 00:00:00 | 2139-03-16 14:42:00 |
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/vomit
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
Ms. ___ is ___ with history of dementia (baseline AAOx2),
atrial fibrillation on coumadin, osteoporosis, h/o ulcerative
colitis, who is presenting with nausea and vomit. As per the
patient's home health aide, the patient had one episodes of
nonbloody, nonbilious vomit this morning. She also did not want
to eat her breakfast and reported feeling unwell. The patient
also reported feeling dizzy this morning. Also with some
abdominal pain. Denies any recent fevers/chills, no changes in
her bowel movements. Has bowel movements daily, with two BMs the
day of presentation, soft in quality, not diarrhea.
At her baseline, the patient is AAOx2. She has a home health
aide 24 hours a day. As per her great niece, the patient's
memory waxes and wanes, and she cannot generally hold
conversant; typically answers with yes/no responses. Her home
health aide helps with all of her ADLs, including feeding,
bathing, and getting dressed. Of note, the patient's great
niece was not aware of any diagnosis of UC in the past, and at
least in the last ___ years since the patient's great niece has
been actively caring for her, UC has not been an issue. Bowel
and bladder incontinence at her baseline; unable to ambulate.
On ROS, denies any recent fevers/chills. No chest pain or
trouble breathing. Has baseline cough and will intermittently
use Duonebs and cough suppressants. No changes in her bowel
movements, no increased constipation. Of note, her great niece
recently had sore throat, but not other sick contacts with any
GI complaints.
In the ED, initial vitals, initial vitals 98.5 90 138/75 16 95%
2L. Exam notable for LLQ abdominal pain. Labs notable for
lactate 2.3 and white count of 9.5. The patient had CT
abd/pelvis which was negative for any e/o diverticulitis, but
could not rule out colitis. The patient was given cipro/flagyl
and admitted to medicine for further work up.
Past Medical History:
Atrial fibrillation
Benign hypertension
Hypercholesterolemia
Osteoporosis
Vertigo
History of ulcerative colitis
Cognitive impairments
Gait abnormalities
Social History:
Denies alcohol, tobacco, or other illicit drugs. She lives at
home with a home health aide.
She has a ___ from 7:30 - 7:30 pm but is alone at night. She
doesn't usually get out of bed at night. She fell out of bed
once a few months ago, but there have not been other accidents.
She has home ___. She also has ___ and home INR checks.
.
>65
ADLS:
Independent of ADLS: [ ]dressing [ ]ambulating [ ]hygiene
[X]eating [ ]toileting
Requires assitance with: [X]dressing [X]ambulating [ X]hygiene [
]eating [X]toileting
Requires assitance with IADLS: [X]shopping [x ] accounting [
X]telephone use- she can't dial but she can talk on the phone
[X]food preparation
She has pre-existent home care services
___- brother/executor- ___
___ niece- ___
Family History:
Father with MI at age ___, Mother with pancreatic cancer, Sister
with breast cancer
Physical Exam:
Admission PE:
VS: 97.5 (axillary) 121/85 91 20 94RA
General: well appearing elderly woman, NAD, laying comfortably
in bed sleeping, alert and oriented to place and name
CV: irregular, S1, S2 with SEM heard loudest at USB
lungs: poor inspiratory effort, bronchial breath sounds
throughout, bibasilar crackles
abdomen: soft, + tenderness in lower abdomen, no rebound or
guarding, no palpable massess appreciated, +BS
extremities: warm, well perfused, 2+ DP pulses, 1+ pitting edema
b/l
Neuro: moving extremities spontaneously, able to follow
commands, responsive and interactive
Discharge PE:
VS: 97.9 124/76 97 20 92RA
General: well appearing elderly woman, NAD, laying comfortably
in bed sleeping, alert and oriented to place and name
CV: irregular, S1, S2 with SEM heard loudest at USB
lungs: poor inspiratory effort, bronchial breath sounds
throughout, bibasilar crackles
abdomen: soft, nontender, nondistended, no rebound or guarding,
no palpable massess appreciated, +BS
extremities: warm, well perfused, 2+ DP pulses, 1+ pitting edema
b/l
Neuro: moving extremities spontaneously, able to follow
commands, responsive and interactive
Pertinent Results:
Admission labs:
___ 12:30PM BLOOD WBC-9.5# RBC-4.05* Hgb-12.5 Hct-40.2
MCV-99* MCH-30.7 MCHC-31.0 RDW-13.5 Plt ___
___ 12:30PM BLOOD Neuts-80.3* Lymphs-13.8* Monos-3.9
Eos-1.7 Baso-0.4
___ 12:30PM BLOOD ___ PTT-42.4* ___
___ 12:30PM BLOOD Glucose-139* UreaN-13 Creat-0.9 Na-142
K-3.8 Cl-101 HCO3-29 AnGap-16
___ 12:30PM BLOOD ALT-9 AST-17 LD(LDH)-180 AlkPhos-87
TotBili-0.7
___ 12:30PM BLOOD Albumin-3.7 Calcium-9.0 Phos-3.8 Mg-2.1
___ 12:35PM BLOOD Lactate-2.3*
Discharge labs:
___ 05:40AM BLOOD WBC-7.3 RBC-3.94* Hgb-12.2 Hct-39.3
MCV-100* MCH-31.0 MCHC-31.0 RDW-13.5 Plt ___
___ 05:40AM BLOOD ___ PTT-41.3* ___
___ 05:40AM BLOOD Glucose-105* UreaN-13 Creat-0.9 Na-143
K-3.5 Cl-102 HCO3-30 AnGap-15
___ 05:40AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.0
Imaging:
CT abd/pelvis prelim
IMPRESSION:
1. Right inguinal hernia containing a loop of distal ileum
without evidence of bowel ischemia or obstruction.
2. Diffuse colonic and sigmoid diverticulosis without evidence
of diverticulitis.
3. Mild thickening of descending colon wall with hyperemia
although not well evaluated due to collapsed bowel. Underlying
colitis cannot be excluded.
4. Moderate to large amount of stool in the rectosigmoid vault.
5. 1.8 cm left adnexal cyst. Non-urgent followup with ultrasound
could be considered.
6. 7 mm pancreatic hypodensity could be further evaluated with
MRCP if
clinically appropriate.
CXR:
IMPRESSION: Bibasilar opacities are most likely due to
atelectasis, but consolidation due to infection/aspiration not
excluded in the appropriate clinical setting.
Brief Hospital Course:
Ms. ___ is ___ with history of dementia, atrial
fibrillation on coumadin, osteoporosis, h/o ulcerative colitis,
who is presenting with nausea, vomit, abdominal pain, found to
have diffuse diverticulosis w/o e/o diverticulitis. However,
there was mild thickening of colon and colitis could not be
excluded.
# nausea/vomit, abdominal pain: Unclear etiology of the
patient's symptoms, but by the time she was on the floor, the
patient's symptoms were resolving. She was able to tolerate PO
without any abdominal pain. The patient was given cipro/flagyl
while in the ED, but because her symptoms were resolving and she
did not have a white count or fever, further antibiotics were
held. Her nausea and vomit also resolved, and upon discharge,
the patient reported feeling well. As per the patient's ___,
the patient was back at her baseline. The patient was continued
on an aggressive bowel regimen and continued to have good BMs
while in patient.
Of note, the patient has a documented history of UC, but as per
her great niece, this has not been an active issue for the last
___ years.
# atrial fibrillation: The patient is rate controlled on dilt
and takes coumadin for anticoagulation. Her INR on presentation
was 3.6 and her coumadin was initially held. Her INR trended
down to 2.8 and she was discharged home on coumadin 2 mg daily.
The patient should have her INR rechecked within one week of
discharge and send the results to her PCP. She was also
continued on her Dilt 60 mg QID for rate control.
# dementia: The patient lives at home with 24h ___, AAO x2 at
her baseline. Fully dependent on her ___. Upon discharge, as
per the patient's ___, the patient's mental status was at
baseline.
# depression: The patient was continued on her home mirtazapine
7.5 mg qhs and citalopram 10 mg daily.
# cough: As per ___, patient has baseline cough; CXR with e/o
bibasilar opacities most likely atelectasis, but cannot rule out
consolidation. The patient was written for nebulizers as
needed, and was encouraged to continue these at home if
symptomatic.
Transitional Issues:
# adnexal cyst: The patient was found to have L adnexal cyst on
CT. Radiology recommended follow up u/s if patient and family
want to pursue further diagnosis
# pancreatic hypodensity: The patient was found to have
pancreatic hypodensity; an MRCP was recommended if clinically
indicated, and patient and family want to pursue further
diagnosis.
# R inguinal hernia: The patient was found to have R inguinal
hernia on CT. There was no evidence of ishchemia or
obstruction. This should be monitored clinically.
# INR: The patient's INR on the day of discharge was 2.8. She
was discharged on coumadin 2 mg daily. The patient should have
her INR rechecked within one week of discharge and send results
to her PCP, ___.
Phone: ___
Fax: ___
# of note, the patient was found to have ___ positive blood
cultures, resulted after she was discharged, growing GPCs in
chains and clusters, thought to most likely be contamination.
As per nightfloat, the patient was contacted and instructed to
return to ER if developed fever or felt unwell in any way.
Medications on Admission:
citalopram 10 mg daily
mirtazapine 7.5 mg qhs
Vitamin D 1000 units daily
diltiazem 60 mg QID
colace 100 mg BID
calcium 300 mg chewable daily
Lasix 40 mg daily
coumadin dose varies depending on INR (usually ___ mg)
pravastatin 20 mg daily
miralax
duonebs PRN
MVI
Discharge Medications:
1. citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
2. mirtazapine 15 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime).
3. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4
times a day).
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. Tums 300 mg (750 mg) Tablet, Chewable Sig: One (1) Tablet,
Chewable PO once a day.
9. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day.
10. pravastatin 20 mg Tablet Sig: One (1) Tablet PO once a day.
11. Miralax 17 gram/dose Powder Sig: One (1) PO once a day.
12. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) Inhalation every six (6) hours as
needed for shortness of breath or wheezing.
13. multivitamin Tablet Sig: One (1) Tablet PO once a day.
14. nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical
twice a day as needed for skin irritation.
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
nausea/vomit
secondary diagnosis:
dementia
atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you while you were hospitalized
at ___. You were admitted to the hospital because you were
having nausea and vomit. In the emergency department, you had a
scan of your belly, and it was thought that you could have an
infection in your intestines, and you were given a dose of
antibiotics.
However, on the general medicine floor, your abdominal pain was
resolving, and your did not have a fever or any other signs of
infection, so we decided to stop your antibiotics. You were no
longer nauseous and you were eating well.
We made the following changes to your medications:
START Nystatin cream -->apply to areas under breasts twice daily
Please follow up with your primary care doctor, ___
___ one week. You will need to have your INR checked at this
visit.
Followup Instructions:
___
|
19923870-DS-9 | 19,923,870 | 21,666,788 | DS | 9 | 2168-11-17 00:00:00 | 2168-11-18 11:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache, confusion, visual disturbance
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history notable for
HTN, HLD, and ___ transferred from ___ after
presenting with headaches, visual disturbance, and confusion.
Ms. ___ son reports that she first reported a mild
right
parietooccipital headache two nights prior to presentation,
around which time she was noted to be slightly more confused
than
usual, having some inappropriate speech and some difficulty
finding her way around her home. By the next day, her symptoms
had somewhat progressed, prompting her family to contact her
PCP,
who recommended outpatient imaging. However, yesterday evening,
Ms. ___ was noted to have apparent visual disturbance,
reporting that she wasn't able to see a donut placed on a plate
in front of her; she similarly reported difficulty identifying
objects in space, though it is not clear to her family whether
this was more pronounced on either side. By this morning, her
confusion and headaches had continued to progress, prompting
presentation to ___, where ___ revealed a right
occipital IPH, resulting in transfer to ___ for further
evaluation. Ms. ___ family denies a prior history of
similar symptoms. Notably, Ms. ___ has been noted to
have
memory difficulties more so over the past ___ years, during
which
time she has become dependent in her IADLs while remaining
independent in her ADLs, allowing her to live with her daughter
at home.
Unable to directly confirm ROS but family denies recent reports
of focal weakness, sensory disturbance, dizziness, gait
disturbance, bowel or bladder incontinence, fevers, chills, or
rash. Ms. ___ had briefly reported some abdominal
discomfort in the past few days.
Past Medical History:
HTN
HLD
Hypothyroidism
Diverticulitis
OA
Social History:
___
Family History:
Notable for sister with cerebral aneurysm, otherwise negative
for
neurological disorders.
Physical Exam:
Admission physical exam:
Vitals: T: 97.8 HR: 76 BP: 144/102 RR: 21 SpO2: 98% RA
General: NAD
HEENT: NCAT, neck supple
___: RRR
Pulmonary: No tachypnea or increased WOB
Abdomen: Soft, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, not oriented to time or place.
Unable to provide history. Speech largely fluent in ___ per
family, though with perhaps some comprehension deficit vs.
marked
inattention. Follows, with encouragement, some axial and
appendicular commands, and perseverates on prior task. No
apparent dysarthria per family. ?Left neglect vs. hemianopia.
- Cranial Nerves: Pupils 3 to 2.5 mm ___, slightly corectopic OS.
Unable to participate in confrontational visual fields with
somewhat inconsistent BTT, but overall attends to examiner in
right hemifield but not left. Spontaneous EOMI. Subtle L NLFF
with reasonably symmetric activation. Hearing intact to
conversation. Tongue midline.
- Motor: Does not participate in confrontational examination but
able to provide sustained antigravity effort with all
extremities
as well as with intact proximal power in BUE and distal power in
BLE.
- Reflexes: Limited by impaired relaxation, but 3+ at the
patellae with crossed adductors.
- Sensory: Response to touch in all extremities.
- Coordination: No dysmetria on reaching for examiner's hand in
right hemifield bilaterally.
- Gait: Widened base, mildly unsteady.
Discharge physical exam:
___ ___ Temp: 98.0 Axillary BP: 109/63 HR: 94 RR: 18 O2
sat: 96% O2 delivery: RA
___ ___ Dyspnea: 0 RASS: 0 Pain Score: ___
General: lying in bed, in NAD
HEENT - ~1cm x 3cm area of erythema, no fluctuance or induration
noted on exam
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: awake, pleasant, does not answer questions
appropriately. Babbles in a mixture of ___ and ___. When
asked questions, will answer ___ words coherently and then say
non-sensical words. Her speech is soft, though no apparent
dysarthria.
- Cranial Nerves: spontaneous EOMI. Subtle L NLFF.
- Motor: moving all limbs spontaneously to antigravity, does not
participate in confrontational examination. Pushes examiner away
with good strength.
- Reflexes: 2+ patellar and 1+ Achilles bilaterally
- Sensory: withdraws to tickle equally in all extremities
Pertinent Results:
___ 06:35AM BLOOD WBC-6.8 RBC-3.62* Hgb-11.1* Hct-35.6
MCV-98 MCH-30.7 MCHC-31.2* RDW-12.9 RDWSD-46.1 Plt ___
___ 06:35AM BLOOD Plt ___
___ 06:35AM BLOOD Glucose-92 UreaN-28* Creat-0.8 Na-138
K-4.2 Cl-102 HCO3-26 AnGap-10
___ 06:35AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.2
___ 01:36PM URINE RBC-22* WBC->182* Bacteri-MOD* Yeast-NONE
Epi-1
___ 01:36PM URINE Blood-TR* Nitrite-POS* Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG*
___ 01:36PM URINE Color-Yellow Appear-Cloudy* Sp ___
Imaging:
CTA head and neck (___):
IMPRESSION:
1. Evolving intraparenchymal hemorrhage in the right occipital
lobe, overall
similar in size when compared with the prior study obtained 5
hours earlier.
Similar mild regional edema and mass effect. No significant
midline shift.
2. No new intracranial hemorrhage or acute large vessel
infarct.
3. Patent circle of ___ without definite evidence of
arteriovenous
malformation, aneurysm, high-grade stenosis or occlusion.
4. Patent bilateral cervical carotid and vertebral arteries
without definite
evidence of stenosis, occlusion, or dissection.
5. Chronic lacunar infarcts in the anterior limb of the right
internal capsule
bilateral basal ganglia.
CT head w/o contrast (___):
IMPRESSION:
No substantial interval change in the right occipital lobe
intraparenchymal
hemorrhage compared to study from 12 hours prior. There is no
significant
mass effect or midline shift. No new intracranial hemorrhage.
US neck soft tissue:
IMPRESSION:
Targeted exam evaluating a palpable abnormality in the right
anterolateral
neck demonstrates no drainable fluid collection.
EKG:
Sinus rhythm with occasional premature ventricular
depolarizations
Minimal voltage criteria for LVH, may be normal variant
T wave abnormalities
When compared with ECG of ___ 05:41,
premature ventricular depolarizations are now present
Brief Hospital Course:
___ w/ hx of HTN, HLD, hypothyroidism, dementia transferred from
___ after presenting with headaches, visual disturbance,
and confusion.
#R occipital lobar IPH ___ CAA
Initial CT head shows R occipital IPH, which was stable on
repeat CT head. Given age, dementia, and cortical location,
likely etiology is cerebral amyloid angiopathy. Antiplatelets,
anticoagulants, and NSAIDs were held during hospitalization as
these medications increase risk of bleeding. They should
continue to be held as an outpatient as CAA predisposes patient
to hemorrhage. MRI was not completed as patient could not
tolerate exam; while GRE sequence on MRI would definitively
determine if patient has amyloid angiopathy, clinical picture
seemed consistent with amyloid such that information from study
not worth harm and distress to patient. She will need a repeat
MRI prior to stroke follow up, and evaluation for amyloid
angiopathy can be done at this point. MRI brain with and without
contrast (to look for underlying mass lesion, also on
differential) was ordered in OMR for ___ weeks prior to follow
up in stroke clinic.
#Agitation
Agitation was a significant issue during hospitalization,
treated with PRN medications including Ativan, olanzapine, and
Seroquel. The most effective PRN was Seroquel at low dose.
Patient was diagnosed with a UTI which was thought to be
contributing to some of this agitation.
#UTI
Patient was diagnosed with a UTI (UA checked ___ for
agitation), and was started on Bactrim DS for a 5 day course
(___). The reflexed urine culture was pending at time of
discharge.
#Urinary retention
Patient also had intermittent urinary retention, for which she
was straight-cathed. Intermittently.
#Dysphagia
Swallow evaluation deemed patient safe for pureed diet with
nectar thick and thin liquids. Continued outpatient follow up
for dietary progression is needed; coordinate this through PCP.
#Hypertension
Home metoprolol ER 50mg daily was transitioned to 12.5mg Q6H
while inpatient. This can be transitioned to ER on discharge,
and patient should follow up with PCP for very strict blood
pressure control. In CAA, hypertension predisposes patients to
intracerebral hemorrhage so strict blood pressure control <130
is imperative.
Transitional Issues:
[] F/U with PCP ___: blood pressure control <130 systolic,
swallow referral for dietary progression when clinically
appropriate.
[] MRI brain with and without contrast 2 weeks prior to stroke
follow up appointment ___ ___
[] Continue to hold antiplatelets, anticoagulants, and NSAIDs
[] UTI Rx: Bactrim DS ___
Pending Results at discharge:
- Urine culture ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Rosuvastatin Calcium 10 mg PO QPM
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Omeprazole Dose is Unknown PO DAILY
5. TraZODone 25 mg PO QHS:PRN Sleep
6. Aspirin 81 mg PO DAILY
7. Donepezil 10 mg PO QHS
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID until ___
2. Omeprazole 40 mg PO DAILY
3. Donepezil 10 mg PO QHS
4. Levothyroxine Sodium 125 mcg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Rosuvastatin Calcium 10 mg PO QPM
7. TraZODone 25 mg PO QHS:PRN Sleep
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute hemorrhagic stroke
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
You were hospitalized due to symptoms of headache, visual
disturbance, confusion resulting from an ACUTE HEMORRHAGIC
STROKE, a condition where a blood vessel breaks and blood pools
in the brain tissue. The brain is the part of your body that
controls and directs all the other parts of your body, so a
bleed in the brain can result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
-dementia
-old age
We are changing your medications as follows:
- START Bactrim 1 double-strength tab for 4 days
- STOP aspirin
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19924542-DS-14 | 19,924,542 | 26,500,551 | DS | 14 | 2162-08-17 00:00:00 | 2162-08-17 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right closed, bimaleolar ankle fracture
L1 superior endplage fracture
Major Surgical or Invasive Procedure:
___ Open reduction and internal fixation of right ankle
History of Present Illness:
___ y/o F s/p fall off 15ft ladder on afternoon of ___, who
presents to ___ ED as a transfer from OSH with c/o right ankle
pain. Patient denies denies LOC or head trauma. Patient also
with c/o back pain. Denies numbness, paresthesias. At OSH,
patient was was reduced, splinted, and subsequently transferred
to ___ for further management.
Past Medical History:
C5-C7 arthritis, left shoulder arthritis, ADHD, TMJ arthritis,
bilateral carpal tunnel syndrome s/p release, multiple plastic
surgeries
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Examination
General: No acute distress prior to palpation.
AVSS
Neuro: A&Ox4.
HEENT: NCAT.
Resp: Nml WOB.
MSK:
Spine: TTP thoracolumbar junction. No pain to palpation
vertebrae. No palpable step-off. Perineal sensation intact. Full
motor and sensation of BUE and BLE. 2+ symmetric reflexes.
Silent babinski. Negative ___.
RLE: Grossly deformed ankle. Moderate swelling with loss of skin
wrinkles but no fracture blisters. Compressible. Skin is c/d/i
without contusions, abrasions. WWP. SILT ___. +motor
___. Unwilling to d-flex/p-flex ankle ___ pain.
Discharge Physical Examination
General: well-developed, well-nourished, no acute distress
Vitals: T = 98.4, HR = 68, BP = 106/50, RR = 18, O2Sat = 95% RA
Spine: TTP thoracolumbar junction. No pain to palpation
vertebrae. No palpable step-off. Full motor and sensation of BUE
and BLE. 2+ symmetric reflexes. Silent babinski. Negative
___.
RLE: Incisions c/d/i. WWP. SILT ___. (+) motor
___.
Pertinent Results:
Admission Laboratory Results
___ 08:00AM BLOOD WBC-8.7 RBC-3.26* Hgb-10.3* Hct-30.3*
MCV-93 MCH-31.5 MCHC-34.0 RDW-12.6 Plt ___
___ 08:00AM BLOOD ___ PTT-33.7 ___
___ 08:00AM BLOOD Glucose-97 UreaN-15 Creat-0.8 Na-138
K-4.1 Cl-103 HCO3-29 AnGap-10
___ 08:00AM BLOOD Calcium-8.2* Phos-2.7 Mg-1.8
Imaging
___ Plain Film Right Ankle: Detail is obscured by cast.
Allowing for this, there is a transverse fracture at the base of
the medial malleolus, with approximately 5.3 mm distraction and
slight lateral displacement of the distal fragment. There is
also an oblique fracture of the distal fibular metadiaphysis
(Weber C), in grossly anatomic alignment.
___ OSH CT Lumbar Spine: Fracture of the superior endplate
of L1. No retropulsion.
Brief Hospital Course:
The patient was admitted to the orthopaedic surgery service on
___ with right closed bimaleolar fracture and L1 superior
endplate fracture. Patient was taken to the operating room and
underwent ORIF Right ankle. Patient tolerated the procedure
without difficulty and was transferred to the PACU, then the
floor in stable condition. Please see operative report for full
details.
Musculoskeletal: prior to operation, patient was non-weight
bearing on RLE. After procedure, patient's weight-bearing
status was transitioned to touch-down weight-bearing in air cast
boot. Throughout the hospitalization, patient worked with
physical therapy.
Neuro: post-operatively, patient's pain was controlled by
Dilaudid PCA and was subsequently transitioned to oral dilaudid
with good effect and adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient remained hematologically stable
thoughout the hospitalization
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started on
a bowel regimen to encourage bowel movement. Intake and output
were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, POD #3. the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The incision was clean, dry, and intact
without evidence of erythema or drainage; the extremity was NVI
distally throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on full-dose
aspirin as DVT prophylaxis for 2 weeks post-operatively. All
questions were answered prior to discharge and the patient
expressed readiness for discharge.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Duloxetine 60 mg PO DAILY
2. Adderall *NF* (amphetamine-dextroamphetamine) 20 mg Oral bid
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 4 mg 1 tablet(s) by mouth every
four (4) hours Disp #*30 Tablet Refills:*0
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every
four (4) hours Disp #*40 Tablet Refills:*0
3. Duloxetine 60 mg PO DAILY
4. Adderall *NF* (amphetamine-dextroamphetamine) 20 mg ORAL BID
5. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*1
6. Aspirin 325 mg PO DAILY Duration: 2 Weeks
RX *aspirin 325 mg 1 tablet(s) by mouth qday Disp #*14 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right closed bimaleolar fracture
L1 superior endplate 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:
******SIGNS OF INFECTION********
- Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
********Wound Care********
- You can get the wound wet/take a shower starting from 3 days
post-op. 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.
******WEIGHT-BEARING*******
- You may touch down weight bear in your aircast boot on your
right leg
- Please wear your TLSO brace while ambulating
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Aspirin for DVT prophylaxis for 2 weeks post-operatively
Followup Instructions:
___
|
19924597-DS-5 | 19,924,597 | 21,017,999 | DS | 5 | 2197-12-09 00:00:00 | 2197-12-10 10:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever, abdominal pain
Major Surgical or Invasive Procedure:
ERCP attempt - unsuccessful
History of Present Illness:
___ w/prior cholangitis s/p Roux-en-Y and CCY presents with
fever and abdominal pain. Fevers and rigors started 4 days PTA,
resolved with tylenol and has not recurred. She has had constant
pain in her epigastrum and RUQ which is similar to the symptoms
she had with her gallbladder many years ago, although less
severe. She denies nausea, vomiting, diarrhea.
In ED, MRCP found cholangitis. Pt was started on IV unasyn and
IVF. ERCP team was consulted
ROS: +as above, otherwise reviewed and negative in 12 systems
Past Medical History:
- s/p Roux-en-Y (hepaticojejunostomy)...unclear indication, but
apparent from MRCP
- s/p open cholecystectomy in ___ ___ years ago
- HTN
- endometrial hyperplasia
- s/p TAH/BSO ___
Social History:
___
Family History:
No known GI cancers
Physical Exam:
Vitals: T:98.4 BP:145/100 P:70 R:16 O2:100%ra
PAIN: 8
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, tender RUQ
Ext: no e/c/c
Skin: no rash
Neuro: alert, follows commands
On DISCHARGE:
AVSS
anicteric
lungs cta
cor rrr
abd soft, NT/ND no hsm
Ext no edema
neuro fluent speech, nl cognition, ambulatory w/o deficits
Pertinent Results:
___ 02:45PM GLUCOSE-107* UREA N-18 CREAT-0.7 SODIUM-138
POTASSIUM-3.4 CHLORIDE-105 TOTAL CO2-24 ANION GAP-12
___ 02:45PM ALT(SGPT)-123* AST(SGOT)-38 ALK PHOS-126* TOT
BILI-0.3
___ 02:45PM ALBUMIN-4.4 CALCIUM-9.6 PHOSPHATE-3.2
MAGNESIUM-2.0
___ 04:40PM LACTATE-1.0
___ 02:45PM WBC-4.5 RBC-5.62* HGB-12.2 HCT-39.4 MCV-70*
MCH-21.8* MCHC-31.0 RDW-14.8
___ 02:45PM NEUTS-61.7 ___ MONOS-6.8 EOS-1.7
BASOS-0.7
___ 02:45PM PLT COUNT-188
___ 02:45PM ___ PTT-34.2 ___
MRCP ___:
1. Irregular, moderate dilatation of the intrahepatic biliary
ducts with
atrophy and fibrosis of the left hepatic lobe, findings
compatible with
chronic cholangitis, potentially recurrent pyogenic cholangitis
with concern
for a stricture at the level of the hepaticojejunostomy. No
choledocholithiasis is present.
2. 3 mm cystic pancreatic head lesion, likely side branch IPMN.
___ year
followup is recommended.
3. Transient jejuno-jejunal intussusception.
RUQ US IMPRESSION:
Status post cholecystectomy. No biliary ductal dilatation.
___ 02:45PM BLOOD WBC-4.5 RBC-5.62* Hgb-12.2 Hct-39.4
MCV-70* MCH-21.8* MCHC-31.0 RDW-14.8 Plt ___
___ 06:05AM BLOOD WBC-3.2* RBC-5.32 Hgb-11.5* Hct-36.8
MCV-69* MCH-21.6* MCHC-31.2 RDW-14.1 Plt ___
___ 07:15AM BLOOD WBC-4.4 RBC-5.69* Hgb-12.1 Hct-39.5
MCV-70* MCH-21.3* MCHC-30.6* RDW-14.1 Plt ___
___ 06:40AM BLOOD WBC-3.3* RBC-5.35 Hgb-11.5* Hct-36.8
MCV-69* MCH-21.5* MCHC-31.2 RDW-14.1 Plt ___
___ 02:45PM BLOOD ALT-123* AST-38 AlkPhos-126* TotBili-0.3
___ 06:05AM BLOOD ALT-78* AST-22 AlkPhos-109* TotBili-0.6
___ 07:15AM BLOOD ALT-62* AST-17 AlkPhos-109* TotBili-0.9
___: BCx (___) no growth at time of DC summary
Brief Hospital Course:
ASSESSMENT AND PLAN: ___ s/p roux-en-Y and CCY, recurrent
cholangitis presents with fever and abdominal pain due to
cholangitis
# Acute Cholangitis: Improved immediately with IV Unasyn.
Underwent ERCP, but unable to travese hepaticojejunostomy
anastamosis. In light of rapid clinical improvement, in
consultation with ERCP team, decision to treat medically for
this to complete 10 day of treatment with PO Cipro/Flagyl. If
recurrent cholangitis in future, would likely need ___ to place
PCT biliary drain. Patient tolerated diet without difficulty
prior to discharge.
# ?Incidental IPMN: as per MRCP report. Recommended f/u imaging
in ___ year. Letter will be sent to patient and PCP.
# HTN: resumed home meds.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Felodipine 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Felodipine 10 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*15 Tablet Refills:*0
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*14 Tablet Refills:*0
5. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with with fever and abdominal pain with
concern for recurrent cholangitis. Your symptoms improved with
antibiotics. An MRCP was done and an ERCP was attempted. It
was confirmed that you had a prior Roux-en-Y and cholecystectomy
surgery. Your biliary tree could not be reached via ERCP. Since
you were improved, a diet was advanced without difficulty. You
should complete another week of antibiotics as prescribed. If
you have recurrent cholangitis symptoms recur, you would
possibly need Inerventional radiologic percutaneous biliary
drainage
Followup Instructions:
___
|
19924597-DS-6 | 19,924,597 | 25,269,610 | DS | 6 | 2200-02-25 00:00:00 | 2200-03-05 21:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: fever and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI(4): Ms. ___ is a ___ female with the past medical
history
noted below including history of cholangitis s/p
hepaticojejunostomy who presents with fevers and abdominal pain.
Patient notes 1 day history of subjective fever, chills,
headache
(6 out of 10 pressure-like pain in the frontal aspect
bilaterally), myalgias, associated with abdominal pain worse
with
leaning forward and eating and better with Tylenol and laying
down. Patient was given a prescription for Tylenol as well as
amoxicillin this morning by her primary care physician in
___.
Patient denies chest pain, shortness of breath, urinary
symptoms,
new onset numbness tingling. She further denies dysuria, urinary
frequency, diarrhea, constipation, nausea, vomiting or
palpitations.
In the ED: Tmax 100.2, P 80-90, BP 120-150/80's, 99% on RA.
Exam: anicteric, Normal S1-S2, regular rate and rhythm, no
murmurs/gallops, ___ systolic murmur best heard at L ICS, 2+
peripheral pulses bilaterally, lungs CTAB, abdomen soft, + ttp
in
RUQ. Labs: CBC at baseline, chem panel notable for anion gap of
16, transaminitis with AST 49, ALT 100, ALP 168, Tbili 0.5,
lipase 23, albumin 4.4. UA with trace ketones. RUQ ultrasound
was
concerning for recurrent pyogenic cholangitis. GI was called and
decision made to admit patient and keep NPO for possible ERCP.
She received 4.5mg IV zosyn in the ED as well as 1g Tylenol and
started on IVF (NS at 150 cc/hr).
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- s/p Roux-en-Y (hepaticojejunostomy)...unclear indication, but
apparent from MRCP
- s/p open cholecystectomy in ___ ___ years ago
- HTN
- endometrial hyperplasia
- s/p TAH/BSO ___
Social History:
___
Family History:
No known GI cancers
Physical Exam:
Gen: Lying in bed in no apparent distress
Vitals: 98.1PO BP 118 / 78, HR 76, RR 16, O2Sat 100 Ra
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
___ 09:47AM NEUTS-78.2* LYMPHS-13.1* MONOS-8.3 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-3.93 AbsLymp-0.66* AbsMono-0.42
AbsEos-0.00* AbsBaso-0.01
___ 09:47AM ALT(SGPT)-112*
___ 10:43AM URINE AMORPH-RARE*
___ 08:40PM PLT COUNT-189
___ 08:40PM NEUTS-70.2 LYMPHS-16.9* MONOS-12.2 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-2.98 AbsLymp-0.72* AbsMono-0.52
AbsEos-0.00* AbsBaso-0.01
___ 08:40PM WBC-4.3 RBC-5.97* HGB-12.5 HCT-41.0 MCV-69*
MCH-20.9* MCHC-30.5* RDW-14.6 RDWSD-35.3
___ 08:40PM LIPASE-23
___ 08:40PM ALT(SGPT)-100* AST(SGOT)-49* ALK PHOS-168*
TOT BILI-0.5
___ 08:47PM LACTATE-1.8
INDICATION: ___ female with the past medical history including
history of
cholangitis s/p hepaticojejunostomy who presents with fevers and
abdominal
pain, ERCP concerned about anatomy. Assess for cholangitis.
TECHNIQUE: T1- and T2-weighted multiplanar images of the
abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 6 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was
administered
for oral contrast.
COMPARISON: MR abdomen ___
MRCP ___
FINDINGS:
Lower Thorax: Limited evaluation of the lung bases are clear.
No pleural
effusion. No pericardial effusion
Liver: There is persistent atrophy of the left hepatic lobe with
caudate lobe
hypertrophy. No hepatic steatosis. Few scattered arterially
hyperenhancing
foci do not persist on additional sequences and are consistent
with transient
hepatic intensity differences (1300:31). Largest is band shaped
in
configuration within segment 4A/4B (13:71). There is a new 2.7
x 1.3 cm
segment VII peripherally located lesion with subtle ill-defined
T2
hyperintensity and a rounded 0.5 cm T2 hyperintense nonenhancing
component
centrally which demonstrates restricted diffusion, consistent
with a hepatic
abscess and reactive hyperemia (1300:69). No drainable
collection.
Biliary: Status post cholecystectomy and hepaticojejunostomy.
Again seen is
moderate irregular central and left intrahepatic biliary duct
dilatation with
persistent narrowing at the hepaticojejunostomy anastomosis,
unchanged in
configuration dating back to ___ (600:1). Largest
caliber measures 0.5
cm within the left intrahepatic biliary ducts (previously 0.5
cm) (04:10). No
choledocholithiasis. Mild enhancement with wall thickening and
restricted
diffusion of the right anterior segmental bile ducts is
consistent with
cholangitis.
Pancreas: The pancreas is atrophic but normal in signal
intensity. 0.4 cm
pancreatic head cystic lesion is unchanged since ___ and
statistically
likely to represent a side branch IPMN (05:38). No worrisome
lesion. No
dilatation of main pancreatic duct.
Spleen: The spleen is normal in size. Splenosis in the left
upper quadrant
again noted.
Adrenal Glands: The adrenal glands are normal in size and shape.
Kidneys: Subcentimeter right renal cysts are noted. The kidneys
are otherwise
unremarkable. No hydronephrosis. No perinephric fat stranding.
Gastrointestinal Tract: Unremarkable. No obstruction. No
ascites.
Lymph Nodes: No retroperitoneal or mesenteric lymph node
enlargement.
Vasculature: No abdominal aortic aneurysm. Marked narrowing at
the celiac
axis origin, without poststenotic dilatation, may be related to
median arcuate
ligament effect. Celiac axis, SMA, bilateral renal arteries are
otherwise
patent. Again seen is the right hepatic artery arising from the
SMA and left
hepatic artery arising left gastric artery. Hepatic veins main
portal vein,
splenic vein, and proximal SMV are patent.
Osseous and Soft Tissue Structures: 3.3 x 1.2 cm left paraspinal
muscle lipoma
is stable (05:18). Osseous structures and soft tissues
otherwise
unremarkable. Note is made of a osseous hemangioma in the L1
vertebral body.
IMPRESSION:
1. Active segmental cholangitis of the anterior right biliary
ducts. 0.5 cm
segment VII hepatic microabscess with peripheral hyperemia. No
drainable
collection.
2. Moderate central and intrahepatic biliary duct dilatation
with narrowing
at hepaticojejunostomy, unchanged in configuration since ___.
3. Unchanged 0.4 cm pancreatic head cystic lesion, likely to
represent a side
branch IPMN.
Brief Hospital Course:
Ms. ___ is a ___ woman s/p ccy and hepaticojejunostomy with
recurrent episodes of cholangitis presents again with fevers and
abdominal pain c/w cholangitis now stable on antibiotics.
ACUTE/ACTIVE PROBLEMS:
#Fever
#Abdominal pain
#Chronic cholangitis: Patient has a complicated GI history
including h/o cholelithiasis and pyogenic cholangitis requiring
surgical drainage. She underwent Roux-en-Y hepaticojejunostomy
in
___ followed by an open cholecystectomy. She was admitted here
in ___ and underwent extensive workup including MRCP and CT
abdomen with workup consistent with chronic cholangitis and
suggestive of IPMN as well possible stricture. Unfortunately
given her anatomy ERCP was not successful at that time. ERCP
team
was again consulted and recommended repeat MRCP which again
shows
cholangitis. Will need two weeks of antibiotics and was
discharged on cipro and flagyl.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Felodipine 10 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin HCl 750 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*42 Tablet Refills:*0
3. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth twice a day Disp #*10
Tablet Refills:*0
4. Felodipine 10 mg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Discharge Condition:
Mental Status: Clear and coherent.
Mental Status: Confused - sometimes.
Mental Status: Confused - always.
Discharge Instructions:
Dear ___,
You were admitted after you began to have abdominal Pain at
home. You had an MRI of your liver which showed infection of
your bile ducts. The gastroenterology team was consulted and
given your usual anatomy felt that a repeat ERCP would not be
successful. You were treated with IV antibiotics and improved.
You will be discharged on two antibiotics and will need to
complete two full weeks. You were also given a medication for
nausea. It was a pleasure caring for you.
Followup Instructions:
___
|
19924849-DS-21 | 19,924,849 | 20,413,690 | DS | 21 | 2182-09-28 00:00:00 | 2182-09-30 21:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with hx SLE s/p multiple episodes of GN on
cellcept and DVT on Coumadin presents with orthostatic changes
and diarrhea. Patient reports 2 week history of intermittant
watery diarrhea with associated diffuse crampy abdominal pain
and decreased appetite. She had mild symptoms approximately 2
weeks ago after her son had a diarrheal illness which resolved
after a few days. Shortly after that, she went camping in
___, ___ (but reports drinking only potable water). Upon
return, she developed recurrent diarrhea ___ watery stools per
day, no fecal urgency or incontinence) and crampy, gassy
abdominal pain. Denies associated nausea or vomiting, no bloody
or tarry stools. Does report fevers to 100.9. Over the past few
days, she has developed muscle weakness, lightheadedness and
dyspnea on exertion and reports feeling "like when I was anemic
before". She presented to her PCP today, and was found to have
orthostatics as following: Lying BP 116/60, HR 111 Sitting
110/66, HR 121 Standing 100/62, HR 133.
Of note, patient missed 3 concurrent doses of her Cellcept the
past 3 days due to poor appetite.
In the ED, initial vitals: 99.0 116 108/62 16 100% ra
access: 18 g, 20 g
Guiac Negative.
Labs: HCT 18 (hct on ___ ___ was 21 but baseline
is in the ___, Hb 6, PLT 209, WBC 10, Iron 12, Ferritin 290,
TRF 16, Hapto<5, TIBC 216. LFTs wnl. Ca 8, Mg 1.9, trop <0.01.
Lytes wnl, Cr 0.6. INR 15, PTT 150. UA wnl.
Given: 1 u pRBC starting a 1700, vit K PO 5, tylenol, given 2 L
IVF.
Vitals prior to transfer: 100.___ 104/56 100% ___
Upon arrival to floor, vitals were 99.7 109/71 115 16 99%/RA.
Patient complaining of mild abdominal pain, but no other
symptoms when at rest.
ROS: per HPI, denies chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria, abnormal vaginal bleeding,
back pain, joint pain, muscle pain.
Past Medical History:
-SLE course:
-Dx in ___, presented with fevers, pericarditis, pleurisy,
diffuse proliferative GN and DVT; treated with steroids and
cyclophosphamide for six cycles then CellCept for nine months
-episode of GN in ___, treated with cyclophosphamide for six
cycles.
-relapse of GN in ___, treated with high-dose steroids and
CellCept
-mild cataract from past steroid use
-DVT in ___, on warfarin, goal INR 2.5 - 3.5
-endometrial ablation
Social History:
___
Family History:
Per OMR Mother with hypertension currently after menopause.
Maternal
grandmother with stroke in age ___. Maternal grandfather with
stroke in ___ and hypertension. Paternal granfather with
?Rheumatic heart disease? No family hx of heart attacks.
Maternal Uncles x3 with cancers. No colon cancers, no breast
cancers, no ovarian cancers.
No history of lupus or autoimmune disease. No diabetes
Physical Exam:
Admission Physical Exam
VS - 99.7 109/71 115 16 99%/RA
GENERAL - Well-appearing ___ yo F who appears comfortable,
appropriate and in NAD
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, + conjunctival
pallor, dry MM, OP clear
NECK - supple, no JVD
LUNGS - Lungs are clear to ausculatation bilaterally, moving air
well and symmetrically, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, S1-S2 clear and of good quality
without murmurs, rubs or gallops
ABDOMEN - NABS, mildly distended, soft, diffuse mild tenderness
worst in the LLQ, no masses or HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
SKIN: hyperpigmentation of bilateral shins. Few small ecchymoses
on arms. No skin lesions or bruising of back, abdomen or thighs
Discharge Physical Exam
VS - 99.6 116/82 108 20 97% RA
GENERAL - Well-appearing ___ yo F who appears comfortable,
appropriate and in NAD
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, moist MMM
NECK - supple, no JVD
LUNGS - Pleuritic friction rub auscultated best over anterior
left lung field. Diminished breath sounds at b/l bases.
HEART - PMI non-displaced, tachycardic, regular, S1-S2 clear and
of good quality without murmurs, rubs or gallops
ABDOMEN - NABS, mildly distended, soft, no TTP, no masses or
HSM, no rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
SKIN: hyperpigmentation of bilateral shins. Few small ecchymoses
on arms. No skin lesions or bruising of back, abdomen or thighs
Pertinent Results:
ADMISSION LABS;
___ 01:23PM BLOOD WBC-10.8# RBC-1.92*# Hgb-6.2*# Hct-18.7*#
MCV-97 MCH-32.3* MCHC-33.2 RDW-13.8 Plt ___
___ 01:23PM BLOOD Neuts-84.1* Lymphs-11.5* Monos-4.2
Eos-0.2 Baso-0.1
___ 02:30PM BLOOD ___ PTT-107.4* ___
___ 01:23PM BLOOD Ret Aut-5.1*
___ 01:23PM BLOOD Glucose-100 UreaN-14 Creat-0.6 Na-137
K-3.6 Cl-103 HCO3-25 AnGap-13
___ 01:23PM BLOOD ALT-25 AST-32 LD(LDH)-238 AlkPhos-42
TotBili-0.5
___ 01:23PM BLOOD cTropnT-<0.01
___ 01:23PM BLOOD Albumin-3.9 Calcium-8.4 Phos-2.5* Mg-1.9
Iron-12*
___ 01:23PM BLOOD calTIBC-216* Hapto-<5* Ferritn-292*
TRF-166*
___ 02:36PM BLOOD Lactate-2.0
TRANSFER FROM MICU TO FLOOR:
___ 11:00AM BLOOD WBC-11.4* RBC-3.52* Hgb-11.2* Hct-33.0*
MCV-94 MCH-31.9 MCHC-34.0 RDW-15.8* Plt ___
___ 03:23AM BLOOD ___ PTT-29.8 ___
___ 08:46PM BLOOD WBC-10.8 RBC-3.55* Hgb-10.9* Hct-32.2*
MCV-91 MCH-30.7 MCHC-33.8 RDW-16.3* Plt ___
___ 03:23AM BLOOD WBC-10.3 RBC-3.23* Hgb-10.1* Hct-29.3*
MCV-91 MCH-31.3 MCHC-34.6 RDW-16.1* Plt ___
___ 11:00AM BLOOD WBC-11.4* RBC-3.52* Hgb-11.2* Hct-33.0*
MCV-94 MCH-31.9 MCHC-34.0 RDW-15.8* Plt ___
___ 07:30PM BLOOD WBC-9.3 RBC-3.37* Hgb-10.6* Hct-31.5*
MCV-94 MCH-31.5 MCHC-33.7 RDW-15.7* Plt ___
___ 05:45AM BLOOD WBC-8.4 RBC-3.44* Hgb-10.8* Hct-31.7*
MCV-92 MCH-31.5 MCHC-34.2 RDW-15.7* Plt ___
___ 03:18PM BLOOD Hct-33.5*
___ 05:35AM BLOOD WBC-6.6 RBC-3.56* Hgb-11.1* Hct-32.6*
MCV-92 MCH-31.2 MCHC-34.1 RDW-15.6* Plt ___
___ 02:30PM BLOOD ___ PTT-107.4* ___
___ 04:20PM BLOOD ___ PTT-89.3* ___
___ 04:38AM BLOOD ___
___ 05:50AM BLOOD ___ PTT-65.8* ___
___ 05:00PM BLOOD ___ PTT-47.4* ___
___ 08:00PM BLOOD ___ PTT-27.9 ___
___ 03:59AM BLOOD ___ PTT-27.6 ___
___ 11:42AM BLOOD ___ PTT-28.5 ___
___ 07:30PM BLOOD ___ PTT-29.6 ___
___ 05:35AM BLOOD ___ PTT-27.4 ___
___ 05:35AM BLOOD Glucose-100 UreaN-5* Creat-0.4 Na-138
K-3.5 Cl-105 HCO3-26 AnGap-11
___ 05:35AM BLOOD ALT-28 AST-29 AlkPhos-44 TotBili-0.6
___ 05:35AM BLOOD Calcium-8.1* Phos-2.2* Mg-1.9
___ 07:30PM BLOOD Hapto-<5*
___ 03:23AM BLOOD TSH-1.6
___ 05:50AM BLOOD HCG-<5
___ 04:17AM BLOOD freeCa-1.17
MICRO:
__________________________________________________________
___ 2:38 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
__________________________________________________________
___ 8:00 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 6:41 pm STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
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.
__________________________________________________________
___ 11:14 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
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.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 6:10 pm
BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING:
___ CT ABD/PELVIS; IMPRESSION:
1. Large volume hemorrhagic intraperitoneal ascites with complex
hematoma
centered in the midline pelvis.
2. Hematocrit level within the right posterior pelvis,
suggesting that the
source of the hemorrhage may be pelvic origin, possibly due to
rupture of a hemorrhagic ovarian cyst.
___ CTA ABD/PELVIS: IMPRESSION:
1. Large volume hemoperitoneum and organized pelvic hematoma. No
focal
active extravasation within the abdomen or pelvis.
2. Rim-enhancing left adnexal lesion with apparent discontinuity
of the
posterior inferior wall, findings suggestive of a ruptured
hemorrhagic cyst as the source of hemorrhage. If clinically
indicated, pelvic ultrasound could be performed for further
evaluation of the adnexa.
3. Ill-defined 7-mm hypodensity within segment VII of the liver,
likely a
small hemangioma. Non-emergent ultrasound could be performed for
further evaluation if clinically indicated.
4. Trace bilateral non-hemorrhagic pleural effusions.
___ ECG: Sinus tachycardia. Diffuse non-specific ST segment
changes. Compared to the previous tracing of ___ the
findings are similar.
___ TTE: 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 diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Normal estimated pulmonary pressures.
Compared with the report of the prior study (images unavailable
for review) of ___, the findings appear similar.
___ Chest CTA
FINDINGS: MEDIASTINUM: There is no mediastinal, hilar, or
axillary
lymphadenopathy by CT criteria.
HEART AND PERICARDIUM: The heart and pericardium appear
unremarkable with no
evidence of lesions or significant pericardial effusion. The
pulmonary
vessels show no central filling defects.
LUNGS: The lungs are clear of any opacities concerning for an
infectious
process. There is bilateral atelectasis, left greater than
right.
PLEURA: Bilateral small-to-moderate pleural effusions, greater
on the right,
are layering, but slightly more dense than would be expected of
simple pleural
fluid, consistent with a known hemoperitoneum.
BONES: No suspicious lytic or sclerotic lesions are seen.
IMPRESSION: Bilateral pleural effusions, moderate in size on
the left,
small-to-moderate in size on the right with associated adjacent
compressive
atelectasis. No evidence of pericardial abnormality on the CT.
___: Bilateral upper extremity venous ultrasound
1. Occlusive thrombus within the right cephalic vein. Of note,
the cephalic vein is not a deep vein. No ceep venoud thrombosis.
2. Wispy echogenic strands within the left internal jugular
vein, which
compresses fully and shows wall-to-wall flow. These echogenic
strands are not thought to represent an acute thrombus and could
be sequela from prior clot that has recanalized.
Brief Hospital Course:
___ yo F with lupus and DVTs on warfarin, who presented with
orthostatic hypotension, tachycardia, and fatigue in the setting
of 2 weeks of watery diarrhea and decreased PO intake. She was
found to have drop in Hct from 40 baseline to 18, INR 22.0.
#Acute blood loss anemia/Intraperitoneal hemorrhage: Admitted to
floor for management of coagulopathy. Guiac neg, CT abd/pelvis
with very large intraperitoneal hemorrhage, likely hemorrhagic
ovarian cyst with rupture and continued bleeding. CT angio
showed no active bleeding so nothing for ___ to do. In
consideration for control of the bleeding, GYN and acute
surgical service were consulted but there were no acute surgical
interventions indicated. On the floor, BP remained stable but
tachycardic to 120s continually since admission. She got PO and
IV vitamin K 5 mg each, 2 units of FFP, 5 units pRBCs. Her INR
corrected to 1.3. Hematocrit did not bump appropriately so she
was transferred to the MICU for closer monitoring. On arrival
to the MICU, she was mentating well with warm extremities but
remained tachycardic. She was given another 2 units of pRBCs
and she bumped her hematocrit to ___. She remained
tachycardic but was stable for transfer to the floor. On the
floor her tachycardia improved slightly to low 100s. She
remained hemodynamically stable. Her HCT remained stable at
around 33. INR stabalized at 1.4. GYN recommend 6 week ___
with transvaginal ultrasound to assess for resolution of pelvic
hematoma and hemoperitoneum.
#Supratherapeutic INR: Most likely explanation is vitamin K
deficiency in setting of decreased PO intake and 2-week
diarrheal illness preceeding presentation. INR initially 22 on
presentation. Pt. received 2 units FFP, 10mg Vit. K, and
warfarin was held. INR stable at 1.4 on discharge.
#Diarrhea: stool cultures, O&P, C. Diff all negative. Diarrhea
resolved by time of discharge without specific therapy. Likely
represented a viral gastroenteritis.
#Lupus with antiphospholipid antibody syndrome: Because she was
bleeding as above, her warfarin was stopped. Heme/onc was
consulted about whether to restart given history of
antiphospholipid antibody syndrome. However, they felt that she
did not meet diagnostic criteria for this and did not need
ongoing anticoagulation. She was not restarted on the warfarin.
Given findings of cephalic vein thrombus and old left internal
jugular thrombus, pt. is scheduled for close ___ with Dr.
___ hematology to address issue of further need for
anticoagulation.
#H/o DVT: Had been in ___, was fully anticoagulated with
warfarin and as above, did not have ongoing indications for
continuing.
#Pleuritic chest pain: Patient has had episodes of pericarditis
and pleuritis in the past. Physical exam was notable for what
sounded like a pleural friction rub. This pleuritic chest pain
was evaluated with ECG and TTE, which were negative for
pericarditis. Also evaluated with Chest CTA, which was negative
for PE, but did reveal moderate b/l, R>L pleural effusions. Of
note, these effusions were noted to have characteristics between
simple pleural effusion and hemoperitoneum. Likely that these
effusions contained some blood extravasated from large volume
hemoperitoneum. By discharge, patient stated that the pleuritic
chest pain was minimal. Decision was made to not perform
thoracentesis.
Transitional issues:
#Needs repeat HCT/INR check on ___. Will f/u results with
her PCP, ___.
#Sinus tachycardia: Remained with sinus tachycardia, though
with a much lower rate, despite correction of hematocrit.
Unclear etiology. If persistent as outpatient, will require
further work-up.
#Pt. to ___ with hematology with regards to u/s findings
of new and old venous thromboses and need for further
anticoagulation.
___ with GYN in 6 weeks to assess for resolution of
pelvic hematoma and decide on further management of hemorrhagic
ovarian cyst
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Hydroxychloroquine Sulfate 300 mg PO DAILY
2. Mycophenolate Mofetil 500 mg PO BID
3. Warfarin 10 mg PO 5X/WEEK (___)
4. Warfarin 15 mg PO 2X/WEEK (___)
5. Citracal + D *NF* (calcium citrate-vitamin D3;<br>calcium
phosphate-vitamin D3) 315-200 mg-unit Oral daily
6. Multivitamins 1 TAB PO DAILY
7. Acetaminophen 1000 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Hydroxychloroquine Sulfate 300 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Mycophenolate Mofetil 500 mg PO BID
5. Citracal + D *NF* (calcium citrate-vitamin D3;<br>calcium
phosphate-vitamin D3) 315-200 mg-unit Oral daily
6. Outpatient Lab Work
285.9 Anemia unspecified.
286.9 Coagulation defect other
Test to be performed: CBC, INR. To be done on ___.
Provider to ___ on results: ___, MD. Phone:
___
Fax: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoperitoneum
Hemorrhagic Pelvic Cyst
Acute blood loss anemia
coagulopathy NOS
Cephalic vein thrombosis
Secondary diagnoses:
SLE
Discharge Condition:
Mental status: clear, alert, oriented
Ambulation: ambulates without assistance
Discharge Instructions:
Dear ___,
It was a pleasure taking part in your care at ___. You were
admitted for anemia and were found to have a large amount of
bleeding in your abdomen. This was most likely caused by the
rupture of a benign hemorrhagic cyst in your pelvis. The large
amount of bleeding was likely caused by your very high level of
anticoagulation (INR = 22) when you were admitted. This high
level of warfarin anticoagulation may have been caused by a
vitamin K deficiency caused by your recent diarrheal illness.
The bleeding in your abdomen was evaluated by surgery and OBGYN,
and it was decided that there was no need for surgery at this
time. You were treated with multiple blood transfusions to
correct your anemia, as well as plasma and vitamin K to reverse
your anticoagulation. Once your anticoagulation was reversed,
your blood counts remained stable. You also had an episode of
pleuritic chest pain (pain with deep breathing), which was
likely caused by some bloody fluid that had accumulated around
your lungs. Upon discharge, this problem was resolving
spontaneously, and should continue to resolve. You were also
found to have a blood clot in one of the superficial veins in
your left arm. This will need to be monitored, but we will not
restart warfarin at this time because of your recent large
volume bleeding.
You will need to follow up with your PCP on ___ for a
check of your hematocrit to make sure there is no continued
bleeding. Also you will follow up with the gynecologists to look
for resolution of the blood in your abdomen. You will also need
to follow up with the hematologists to determine whether or not
you need to be on warfarin anymore. Until this appointment, you
should remain off of warfarin. You can schedule an appointment
with Dr. ___ of ___ for next week by calling the
number ___
Followup Instructions:
___
|
19925345-DS-8 | 19,925,345 | 27,277,627 | DS | 8 | 2110-01-31 00:00:00 | 2110-02-01 11:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ who presented as a transfer from an OSH
with a chief complaint of fall that resulted in a C2 lateral
mass fracture and an non displaced ___ posterior rib fx.
Patient reports being in her usual state of health when she
experienced a fall from a bunk bed (from around 5 feet) and
landed on the floor. She remembers the event but indicates that
it took her a few minutes to realize that she had fallen to the
ground. She was able to get up after the fall, get in the car
and go to the hospital (her uncle was driving). She does not
believe that she had any head strike. Upon arrival to the OSH
she started experiencing more pain throughout her back and her
chest. On examination from the ___ team she is laying in bed
with a C-collar in place. She reports pain in her back and
bilaterally in her mid chest. She is breathing comfortable. She
denies any alcohol consumption prior to this event. She
attributes the fall to the rail of the bed bunk malfunctioning.
Past Medical History:
Past Medical History:
Ulcer in small bowel- diagnosed with EGD ___ food intolerances
Past Surgical History:
None
Social History:
___
Family History:
Father died from heart attack at an early age
Brother has SVT
Grandfather suffered from cancer unsure what type
Physical Exam:
Vitals: T97.4. BP94 / 62, HR 74, RR 18, O2 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l; tender on the left posterior
lower ribs.
ABD: Soft, nondistended, nontender
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 08:36AM BLOOD WBC-10.6* RBC-3.92 Hgb-10.3* Hct-32.0*
MCV-82 MCH-26.3 MCHC-32.2 RDW-14.6 RDWSD-42.4 Plt ___
___ 08:36AM BLOOD Neuts-87.6* Lymphs-8.5* Monos-3.2*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-9.29* AbsLymp-0.90*
AbsMono-0.34 AbsEos-0.00* AbsBaso-0.02
___ 08:36AM BLOOD Glucose-105* UreaN-4* Creat-0.5 Na-139
K-4.4 Cl-107 HCO3-17* AnGap-15
CT CHEST without contrast ___: Nondisplaced fracture of the
left eleventh posterior rib. Ground-glass opacity in the left
lower lobe likely secondary to poor respiratory effort.
MRI ___:
1. Nondisplaced fracture of the right lateral mass at C 2, which
extends to
the anterior margin of the right transverse foramen, is better
assessed on the
preceding CT.
2. Fluid in the joint between the right lateral masses of C1 and
C 2. Mild
posterior paravertebral edema along the right lateral mass of
C2.Mild edema
in the C1-C2 interspinous ligament without clear evidence for
ligamentum
flavum involved.
3. Anterior and posterior longitudinal ligaments appear intact.
No spondylolisthesis, disc edema, vertebral body marrow edema.
4. No epidural collection. Normal spinal cord signal.
Brief Hospital Course:
The patient presented to Emergency Department on ___. Upon
arrival to ED, she underwent CT scan which demonstrated 11th rib
fracture, pulmonary contusion, and C2 fracture. She was
evaluated by neurosurgery, who determined this fracture should
be treated nonoperatively with hard cervical collar use at all
times until follow up imaging in 4 weeks. She was admitted for
further monitoring and pain control. She was given Tylenol,
ibuprofen, and oxycodone PRN with good pain relief. She was
tolerating a regular diet without issue and her pain was
controlled with deep breathing and inspiratory spirometer use.
She also utilized a lidocaine patch over her fractured ribs. At
the time of discharge on HD2, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a diet, ambulating, voiding without assistance, and pain was
well controlled. She was discharged home with plan to follow up
with Dr. ___ primary care doctor, ___.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN Constipation - Second Line
hold for loose stool.
3. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % Apply 1 patch to affected area 12 hours on; 12
hours off Disp #*30 Patch Refills:*0
4. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: dc oxycodone
Take lowest effective dose.
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Non displaced L ___ posterior rib fx
lateral mass fracture of C2
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 ___nd found to have a fracture in your cervical spine
and Left sided rib fractures. You had a CT scan that showed a
fracture at the level of C2 but the spinal cord was intact. You
were seen by the Neurosurgery team for this injury who
recommended non-operative management. You should continue to
wear your hard cervical collar at all times until cleared to
remove it. Your breathing was closely monitored because rib
fractures can make it difficult to take deep breaths. You were
given pain medication to help your breath and move around.
You may remove the hard neck collar briefly for a daily shower
but otherwise you should wear the collar full time including
during sleep. Do not lift anything greater than 30 pounds and
avoid strenuous physical activity.
You are now doing better, pain is better controlled, and you are
ready to be discharged to home to continue your recovery.
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.
* Your injury caused Left sided rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ 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:
___
|
19925583-DS-10 | 19,925,583 | 20,379,432 | DS | 10 | 2123-03-16 00:00:00 | 2123-03-17 12:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Vaginal Bleeding
Major Surgical or Invasive Procedure:
Dilation and Suction curretage
History of Present Illness:
Ms. ___ is a ___ year-old G5P3 Jehovah's witness who
presents as a transfer from ___ with an 8wk missed
abortion.
She reports that she started having bleeding and passed some
clots 4 days ago, but for the past few days she has only had
some
spotting like the end of a period. She was seen for her first
prenatal visit which is when the miscarriage was diagnosed, and
she wanted to have a D&C performed. She was set up for a D&C at
___, but upon hearing that she was a Jehovah's witness in
pre-op holding, the covering surgeon did not feel comfortable
performing the procedure and so recommended transfer to ___.
Her vitals were 98.2, 69, 127/72. CBC was 5.5>10.4/29.5<189 and
blood type AB+.
She has had a small amount of cramping today which has resolved
with 2mg of morphine that was administered at ___. She
denies any fever/chills, SOB/CP, dizziness, nausea, or change in
bowel or bladder habits.
Past Medical History:
Obstetric History: G5P3
-G1: ___ tri SAB with uncomplicated D&C
-G2: SVD, uncomplicated pregnancy and delivery at term
-G3: SVD, uncomplicated pregnancy and delivery at term
-G4: SVD, uncomplicated pregnancy at 37wks. Per pt she had more
bleeding postpartum but did not need any medications for this.
-G5 current. Has had significant nausea/vomiting early in the
pregnancy that has since improved. No other problems during the
pregnancy.
Gynecologic History:
- Menses regular qmonth. Denies h/o menorrhagia.
- Denies h/o abnormal Pap test
- Denies h/o STIs or pelvic infections
- Previously had used Mirena IUD for ___ years and had it removed
in ___
Past Medical History: Denies
- denies history of HTN, asthma or breathing/lung problems, or
bleeding/clotting problems
Past Surgical History: D&C. Denies any complications with
anesthesia or bleeding
Physical Exam:
Admission Exam:
Vitals in ED: 98.7 68 120/78 18 100% RA
98.6 66 121/75 16 100% RA
General: comfortable appearing ___ woman in NAD,
accompanied by two friends
CV: ___, no murmur
Resp: CTAB, no crackles or wheezes
Abd: soft, nondistended, nontender throughout
Ext: no calf tenderness
Speculum Exam: multiparous cervix appears visually closed. ___
scopette of old blood cleared from the vault. no abnormal
discharge, no evidence of ongoing vaginal bleeding
Bimanual Exam: cervix closed and long, uterus 8wks sized, no
fundal tenderness, no adnexal masses or tenderness
Upon discharge:
Upon discharge
VSS, AF
Gen: NAD, A&O x 3
CV: ___, S1 S2
Pulm: CTAB, no r/w/c
Abd: soft, NT ND, no r/g/d
Ext: no c/c/e
Dressing: c/d/i
Pertinent Results:
___ 08:28PM GLUCOSE-89 UREA N-4* CREAT-0.7 SODIUM-141
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 08:28PM estGFR-Using this
___ 08:28PM WBC-5.6 RBC-3.38* HGB-10.4* HCT-31.5* MCV-93
MCH-30.8 MCHC-33.0 RDW-12.8
___ 08:28PM NEUTS-44.4* LYMPHS-46.8* MONOS-4.9 EOS-2.9
BASOS-1.0
___ 08:28PM PLT COUNT-184
___ 08:28PM ___ PTT-27.4 ___
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
after undergoing a D&C for a missed AB. She was transferred here
for her procedure since she is a Jehovah's witness who will not
receive any blood products, albumin or plasma. She was observed
overnight, and proceeded with her surgery on ___. Please
see the H&P and operative report for full details.
Her post-operative course was uncomplicated. Immediately
post-op, her pain was controlled with toradol.
By post-operative day 0, she was tolerating a regular diet,
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:
PNV, tylenol PRN pain
Discharge Medications:
1. Ibuprofen 600 mg PO Q6H:PRN pain
take with food. do not take more than 4 tabs in 24 hrs
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hrs Disp #*20
Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN pain
do not take more than 4000mg of acetaminophen in 24 hrs
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hrs Disp
#*20 Tablet Refills:*0
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
do not drink or drive on this med
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hrs Disp #*5
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Missed abortion
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 at ___
___ after one night of observation and your
dilation and suction curretage surgery. You have recovered well,
and met all of your post-operative milestones, including, pain
controlled with medications, walking independently, urinating
spontaneously and tolerating a regular diet. We have determined
that you are in a stable condition to go home. Please follow-up
as scheduled, and follow the instructions below
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
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet
Call your doctor for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19925814-DS-21 | 19,925,814 | 22,422,521 | DS | 21 | 2155-04-19 00:00:00 | 2155-04-19 07:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Polytrauma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male w/ hx of HTN s/p MCC at high speed, -
LOC,+EOTH, GCS 15 at the scene, c-collar in place, helmeted w/o
intrusion. Patient complaining of right shoulder pain, right arm
pain, and back pain requiring frequent redirection while on the
scene. On imaging pt. found to have right mid-shaft claviclular
fx, rib fx ___, right scapular fx. right lung contusions,right
pneumothorax w/ effusion, 4 mm right glut hematoma, right renal
hilum hematoma, right SAH/SDH, and right abdominal road rash.
Pt.
was then transferred to ___ for further
trauma workup.
Past Medical History:
HTN
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam
Head:Head abrasion, no bony crepitus, no c-spine tenderness/step
offs
Eyes:PERRLA
ENT: Trachea midline, obvious signs of hematoma formation
Respiratory: Diminished on the right,
Cardiovascular: RRR on monitor,2+ radial, ___ btl
Chest:No chest wall tenderness
GI:soft, nondistended, right abdomen road rash w/ tenderness
Genitourinary:No blood in urethral meatus
Musculoskeletal:Btl chest wall tenderness, Abraisions to right
shoulder, btl knees and RLE. Right shoulder clavicular, and
scapular tenderness.
Neurologic: ___ strength on right, ___ LLE
Discharge exam:
Physical Exam
___: NAD
Cardiac: RRR
Chest: right chest wall tenderness over ribs
Pulm: CTAB
GI: soft, nondistended, nontender
Neurologic: ___ strength of extremities
Pertinent Results:
MRI spine:
IMPRESSION:
1. Normal cord. No vertebral body fracture. No ligamentous
injury..
2. Dependent consolidations in the right greater than left
lungs, largely
atelectasis, consider component of contusion, aspiration.
3. Rib fractures..
4. Degenerative changes lumbar spine, as above.
CT head and torso obtained at ___
Brief Hospital Course:
This is a ___ yo M, s/p MCC who presented with R SAH/SDH, R
clavicle & scapula & ___ Lateral rib fx, R PTX,R R renal hilum
hematoma, R gluteal hematoma.
Regarding his MSK injuries, the patient was managed
non-operatively. He is scheduled for follow up with the ___
___ clinic to assess interval improvement and further
management on ___.
Regarding his neurological status, there was initially some
concern for spinal cord pathology given his lower extremity
weakness on presentation but given his normal MRI spine this was
then felt to be secondary to traumatic brain injury involving
his premotor/motor cortex. The patient continued to re-gain
function in the course of this hospitalization working with
physical therapy. He is intermittently not oriented to time but
it is unclear how much of this is chronic vs secondary to his
TBI. Neurosurgery has no further recommendations for
evaluation/care at this time.
Medications on Admission:
3. Enalapril Maleate 10 mg PO DAILY
4. Famotidine 20 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
Duration: 20 Doses
DO not drink or drive with this med.
3. Enalapril Maleate 10 mg PO DAILY
4. Famotidine 20 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polytrauma with ___/SDH; r clavicle, scapula, and ___ lateral
rib fx, right renal hilum hematoma, r gluteal hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear Mr. ___,
You came here after a motorcycle crash and had head trauma with
bleeding and multiple fractures including those of the rib,
clavicle, and scapula. The orthopedic team evaluated you and
felt your fractures were non-operative at this time. The
neurosurgery team was reassured by your improving neurologic
exam and did not pursue further intervention.
You are being discharged to a rehabilitation facility to help
you regain function.
You have an orthopedic appointment on ___. Please arrive at
9:30 to take x-rays beforehand.
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.
*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.
Followup Instructions:
___
|
19926301-DS-24 | 19,926,301 | 24,898,520 | DS | 24 | 2135-07-15 00:00:00 | 2135-07-15 21:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Flonase
Attending: ___.
Chief Complaint:
R knee pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o untreated CLL, untreated bipolar disorder, HTN, CKD,
gait disorder, chronic lower extremity edema, and ischemic
colitis p/w R knee pain x 1 day. States last night he stood up
from seated position and experienced acute onset of spasm in his
medial R knee. No ___ swelling beyond baseline edema, motor or
sensory loss, fever, chills, chest pain, dyspnea. Able to
ambulate with pain. No fever, chills or constitutional symptoms.
No calf swelling or tenderness.
In the ED, initial vitals were 101 84 126/45 16 97%. Xray R knee
negative, CXR c/w chronic pulmonary process. UA unremarkable,
97.8 68 113/54 18 96%. He received acetaminophen 1g, home lasix
80mg x1, and levofloxacin 750mg x1. Refused home ___ since he
doesn't allow visitors to his home due to his "vegan lifestyle."
On the floor, he is only interested in having an injection to
relieve his knee pain and does not want to be treated or further
evaluated for possible fever, since he does not believe that he
had a true fever in the ED.
Past Medical History:
1. CLL. Diagnosed in ___, followed most recently by
Dr. ___
2. Asthma. Never intubated.
3. Seasonal allergies.
4. Bipolar disorder.
5. Thoracentesis in ___ at ___ per Pt report (unclear what
for)
6. Hypertension.
7. Chronic kidney disease
8. Borderline diabetes. At one point, his hemoglobin A1c was
7.0 in ___
9. Anemia from chronic kidney disease and marrow
suppression because of his CLL
Social History:
___
Family History:
According to the Pt, he suffers from a "metabolic disorder" and
as a child was examined by a number of doctors in ___. When
asked for more information, he states that his grandmother also
suffered from this condition and that he has overdeveloped
senses and that he cannot tolerate UV light. He gives no further
inoformation about his condition.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.8, 114/54, 73, 97% RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: Good aeration, CTAB no wheezes, rales, ronchi
CV: RRR, normal S1/S2, no m/r/g
ABD: soft, NT/ND, normoactive bowel sounds, no r/g
EXT: WWP, 2+ pulses palpable bilaterally, 1+ bilateral ___ edema
to knees with chronic-appearing mild erythema of BLE to
mid-shins
NEURO: CN II-XII intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
VS: 97.8, 114/54, 73, 97% RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT MMM EOMI sclera anicteric, OP clear
NECK: supple, no JVD, no LAD
PULM: Good aeration, CTAB no wheezes, rales, ronchi
CV: RRR, normal S1/S2, no m/r/g
ABD: soft, NT/ND, normoactive bowel sounds, no r/g
EXT: WWP, 2+ pulses palpable bilaterally, 1+ bilateral ___ edema
to knees with chronic-appearing mild erythema of BLE to
mid-shins
NEURO: CN II-XII intact, motor function grossly normal
Pertinent Results:
___ 10:25AM BLOOD WBC-105.1* RBC-2.91* Hgb-9.0* Hct-27.8*
MCV-96 MCH-30.8 MCHC-32.3 RDW-16.7* Plt ___
___ 10:25AM BLOOD Glucose-124* UreaN-40* Creat-2.2* Na-139
K-4.1 Cl-99 HCO3-30 AnGap-14
-CXR ___:
Increased mid and lower right lung streaky opacities are more
suggestive of a chronic pulmonary process. Comparison with any
priors since ___ and continued ___. Mild blunting of
the posterior right costophrenic angle, small pleural effusion
vs pleural thickening.
-R knee x-ray ___:
No fracture or dislocation. Extensive vascular calcifications.
Brief Hospital Course:
___ h/o untreated CLL, untreated bipolar disorder, HTN, CKD,
gait disorder, chronic lower extremity edema, and ischemic
colitis p/w R knee pain x 1 day. Admitted for fever 101,
leukocytosis WBC 105 (though has been this high previously due
to untreated CLL)
# FEVER: Mild concern for cellulitis as well, since it is
difficult to tell how chronic his BLE have lasted, though less
likely since it is bilateral. Unlikely PNA given that CXR more
consistent with chronic pulmonary process. ___ have been
associated with CLL as well.
-f/u bcx, ucx
-planning to continue to monitor, but patient left AMA, and we
deemed that he had capacity to make that decision as he was able
to express the risks of leaving
# R KNEE PAIN: Of great concern to patient, and unclear
etiology. ___ have strained ligament though no significant
trauma.
-standing tylenol and PRN valium
-patient left AMA before we were able to tell the effects
-may f/u with PCP
# CKD: stable, Cr 2.2 at baseline
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 80 mg PO BID
Discharge Medications:
1. Furosemide 80 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
fever of unknown origin, chronic lymphocytic leukemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted for right knee pain and a fever of 101. You
have chosen to leave against medical advice, which you have the
right to do. Please ___ soon with your primary care
physician.
Followup Instructions:
___
|
Subsets and Splits