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19926355-DS-11 | 19,926,355 | 20,454,530 | DS | 11 | 2149-10-02 00:00:00 | 2149-10-03 23:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd pain, diarrhea
Major Surgical or Invasive Procedure:
Colonoscopy ___
History of Present Illness:
Mr. ___ is a ___ year old man with PMHx of Crohn's disease,
CAD (s/p coronary stent ___ years ago), and polymyalgia rheumatica
who presents today with complaint of 2 weeks of nonbloody
diarrhea (worse at night), periumbilical/mid-abdominal pain, and
inability to tolerate PO. Patient had GI appointment today and
was sent to ED.
Pt states that symptoms began 2 weeks ago. Previously his
Crohn's
disease had generally been controlled for the past ___ years on
mesalamine. He had a colonoscopy most recently on ___ which
showed multiple areas of scarred mucosa c/f worsening Crohn's
colitis.
He describes his pain as constant and "achy, sharp, dull,
stabbing, and throbbing." He reports pain immediately after
eating and he hasn't eaten solid food "for weeks". No nausea or
vomiting. He reports some improvement of his abdominal pain
after
his gastroenterologist increased his home prednisone to 40mg
daily one week ago, but the diarrhea has not improved with this
therapy. He is presently having 2 BM per day, ___ BM per night.
Pt required 2 visits to ___ for these
complaints, including one stay x1 day, without significant
therapeutic improvement. Per review of records, one visit
resulted in a CT abd/pelvis which showed moderate colitis from
the transverse to descending colon. Further workup from OSH
notable for: Negative C. diff, Shiga toxin, stool cultures.
Pt has not had any recent travel, ill contacts, new/exotic food
consumption, or antibiotic use. He complains of some achiness in
his neck and shoulders bilaterally, which started shortly after
the diarrhea and abdominal pain. He denies any fevers, chills,
SOB, CP, palpitations, lightheadedness/dizziness, syncope,
nausea/vomiting, hematochezia, melena, dysuria, hematuria, and
numbness/tingling.
In the ED, patient had one large bloody BM around ___. GI was
made aware.
In the ED, initial vitals: T 96.2 HR 100 BP 110/84 RR 16 Pox
100% RA
- Exam notable for: tachycardia; TTP in periumbilical area,
epigastrium, RUQ, and LUQ; rebound tenderness in epigastrium and
periumbilical area
- Labs notable for: WBS 14.5; CRP 94.5; ALT 48; Alk Phos 137;
negative stool cultures ; Lactate 1.2
- Imaging notable for: OSH CT A/P showed colitis from transverse
to descending; chest CT showed inflammation in the colon but
nothing else.
- Pt given: 1L NS, IV Tylenol 1 g, and 20 mg IV solumedrol
- Vitals prior to transfer: T 97.4 HR 66 BP 112/70 RR 16 Pox 99%
RA
GI team recommended prepping for colonoscopy and holding further
steroids and mesalamine.
Upon arrival to the floor, the patient reports some improvement
in abdominal pain.
Past Medical History:
Crohn's disease (previously well controlled for 30+ years)
CAD (s/p stent ___ years ago, unclear site)
Polymyalgia rheumatic (on prednisone, recently uptitrated)
Anemia
Social History:
___
Family History:
no history of IBD
Physical Exam:
============================
ADMISSION PHYSICAL EXAM:
============================
VITALS: T 97.8 HR 66 BP 114/70 (lying down) Pox 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, tender in all quadrants, rebound tenderness in
epigastrium, LUQ, and RUQ; bowel sounds present; no guarding
Rectal: deferred given colonoscopy in AM
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no cyanosis or edema
Skin: Warm, dry, no rashes. Puncture wound on right elbow from
dog bite
Neuro: ___ strength upper/lower extremities, grossly normal
sensation
==============================
DISCHARGE PHYSICAL EXAM:
==============================
Vitals: 97.4, 108 / 72, 72, 16, 96 Ra
General: Alert, oriented, in bed in no acute distress
HEENT: Sclerae anicteric
Neck: supple
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: CTAB on anterior exam, comfortable on RA
Abdomen: Soft, nondistended, no TTP, no guarding or rebound
Ext: thin, Warm, no ___ edema
Neuro: alert and oriented, moving all extremities spontaneously
Pertinent Results:
=======================
ADMISSION LABS:
=======================
___ 02:35PM BLOOD WBC-14.5* RBC-3.79* Hgb-11.0* Hct-34.3*
MCV-91 MCH-29.0 MCHC-32.1 RDW-15.5 RDWSD-50.1* Plt ___
___ 02:35PM BLOOD Neuts-92* Bands-4 Lymphs-2* Monos-2*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-13.92*
AbsLymp-0.29* AbsMono-0.29 AbsEos-0.00* AbsBaso-0.00*
___ 02:35PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 02:35PM BLOOD ___ PTT-25.9 ___
___ 02:35PM BLOOD Glucose-113* UreaN-26* Creat-0.9 Na-139
K-5.1 Cl-100 HCO3-24 AnGap-15
___ 02:35PM BLOOD ALT-48* AST-31 AlkPhos-137* TotBili-0.3
___ 02:35PM BLOOD Lipase-15
___ 02:35PM BLOOD Albumin-3.0* Calcium-8.8 Phos-3.9 Mg-2.3
___ 02:35PM BLOOD CRP-94.6*
___ 02:46PM BLOOD Lactate-1.2
=======================
RELEVANT LABS:
=======================
___ 02:35PM BLOOD CRP-94.6*
___ 07:45AM BLOOD CRP-79.8*
___ 10:23AM BLOOD CRP-86.1*
___ 07:45AM BLOOD CRP-196.5*
___ 08:31AM BLOOD CRP-93.4*
___ 07:49AM BLOOD CRP-47.5*
___ 07:36AM BLOOD CRP-42.9*
___ 07:17AM BLOOD CRP-19.7*
___ 07:20AM BLOOD CRP-18.1*
___ 10:23AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 12:00AM BLOOD WBC-14.2* RBC-3.38* Hgb-10.1* Hct-30.9*
MCV-91 MCH-29.9 MCHC-32.7 RDW-15.4 RDWSD-51.0* Plt ___
___ 07:45AM BLOOD WBC-10.0 RBC-3.15* Hgb-9.3* Hct-29.1*
MCV-92 MCH-29.5 MCHC-32.0 RDW-15.6* RDWSD-52.6* Plt ___
___ 07:25AM BLOOD WBC-11.9* RBC-3.13* Hgb-9.6* Hct-29.1*
MCV-93 MCH-30.7 MCHC-33.0 RDW-15.7* RDWSD-52.9* Plt ___
___ 06:30AM BLOOD WBC-11.0* RBC-3.08* Hgb-9.0* Hct-27.6*
MCV-90 MCH-29.2 MCHC-32.6 RDW-15.3 RDWSD-50.4* Plt ___
___ 07:45AM BLOOD WBC-10.0 RBC-3.26* Hgb-9.4* Hct-29.7*
MCV-91 MCH-28.8 MCHC-31.6* RDW-15.2 RDWSD-50.6* Plt ___
___ 08:31AM BLOOD WBC-15.9*# RBC-3.64* Hgb-10.6* Hct-33.4*
MCV-92 MCH-29.1 MCHC-31.7* RDW-15.3 RDWSD-51.0* Plt ___
___ 07:49AM BLOOD WBC-16.0* RBC-3.52* Hgb-9.9* Hct-31.7*
MCV-90 MCH-28.1 MCHC-31.2* RDW-15.4 RDWSD-50.5* Plt ___
___ 07:36AM BLOOD WBC-13.5* RBC-3.25* Hgb-9.5* Hct-29.1*
MCV-90 MCH-29.2 MCHC-32.6 RDW-15.2 RDWSD-49.9* Plt ___
___ 07:17AM BLOOD WBC-13.7* RBC-3.39* Hgb-9.8* Hct-30.9*
MCV-91 MCH-28.9 MCHC-31.7* RDW-15.4 RDWSD-50.8* Plt ___
=======================
DISCHARGE LABS:
=======================
___ 07:20AM BLOOD WBC-13.8* RBC-3.51* Hgb-10.3* Hct-32.0*
MCV-91 MCH-29.3 MCHC-32.2 RDW-15.5 RDWSD-50.9* Plt ___
___ 07:20AM BLOOD Glucose-131* UreaN-23* Creat-0.8 Na-136
K-4.7 Cl-100 HCO3-25 AnGap-11
___ 07:20AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.3
___ 07:20AM BLOOD CRP-18.1*
=======================
MICROBIOLOGY:
=======================
___:
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay.
=======================
IMAGING:
=======================
KUB ___
Gaseous distention of the large and small bowel which tapers at
the level of the descending and sigmoid colon. Decreased
haustral markings are noted in the descending colon. There is no
gross pneumoperitoneum, however evaluation for free
intraperitoneal air is limited on supine radiographs.
SECOND OPINION CT TORSO: CT from outside hospital dated ___.
Extensive colitis from the splenic flexure to the mid portion of
the
descending colon with extension to the transverse colon without
signs of
perforation. Small bowel and terminal ileum are intact.
====================
PATHOLOGY
====================
PATHOLOGY (from colonoscopy ___
Intestinal mucosal biopsies, seven:
1. Terminal ileum:
Small intestinal mucosa, within normal limits.
2. Cecum:
Colonic mucosa, within normal limits.
3. Ascending:
Colonic mucosa within normal limits.
4. Transverse:
Colonic mucosa, within normal limits.
5. Descending:
Chronic severely active colitis with ulceration.
6. Sigmoid:
Paneth cell metaplasia consistent with chronic inactive colitis.
7. Rectum:
Focal Paneth cell metaplasia consistent with chronic inactive
colitis.
Brief Hospital Course:
==================
BRIEF SUMMARY
==================
Mr. ___ is a ___ year old male with history of Crohn's
disease previously well controlled on mesalamine, CAD s/p stent
___ years ago, and polymyalgia rheumatica who presented with 2
weeks of abdominal pain, diarrhea and poor PO, found to have a
Crohn's flare as well as concurrent c diff infection. He was
treated with IV methylprednisolone without marked improvement,
so he was started on infliximab on ___, to good effect, and
transitioned to PO prednisone for discharge. He is receiving PO
Vancomycin for the c diff infection.
=====================
PROBLEM-BASED SUMMARY
=====================
ACUTE/ACTIVE PROBLEMS:
# Crohn's disease
Patient has a long history of Crohn's disease, previously well
controlled on mesalamine with the last flare ___ years ago. CT
A/P performed on ___ at ___, and reviewed
by ___ radiology, showed colitis from the transverse to the
descending colon. Colonoscopy this admission showed deep
circumferential ulcerations from the transverse colon through to
the sigmoid colon, with pathology revealing chronic severely
active colitis with ulceration in the descending colon.
Presentation felt to be most consistent with Crohn's flare. He
received IV methylprednisolone without appropriate improvement,
so was started on infliximab (first infusion ___, 10 mg/kg),
which he tolerated well. He was evaluated by colorectal surgery;
no need for acute intervention. He improved symptomatically
after the infliximab and was transitioned to PO prednisone for
discharge. He is planned for a repeat infusion of infliximab at
1 week (10mg/kg), for an escalated induction dosing, arranged
with his outpatient GI, Dr. ___ ___. He will be
discharged on prednisone PO 40mg daily.
# C Diff
Patient presented with abdominal pain and diarrhea, WBC 14.5 on
admission, positive c diff. He was treated with PO Vancomycin,
for a planned 14-day course (day ___, last day will be on
___. To our knowledge, this is his first episode of c diff
infection.
# Hematochezia
Patient had one episode of hematochezia in the ED, with no other
events. Possible source may be related to colitis. There was no
concern for active GI bleeding during admission.
# Malnutrition
Patient was followed by nutrition while inpatient. By discharge,
he was tolerating improved PO and eating well.
CHRONIC PROBLEMS:
# Anemia
Patient reports a history of chronic anemia on home B12.
Discharge hemoglobin was 10.3.
# CAD
Home clopidogrel was held this admission, as his last stent was
placed ___ years ago. He was continued on home atorvastatin and
aspirin. Attempt was made to reach out to outpatient
cardiologist Dr. ___ by email regarding the clopidogrel.
Please readdress clopidogrel at his outpatient cardiology
appointment.
# PMR: Stable.
====================
TRANSITIONAL ISSUES
====================
- Please evaluate for depression and consider starting an
antidepressant as an outpatient. Wife notes that patient seems
to have depressed mood at home, does not leave the house.
- Follow up with cardiology, to readdress clopidogrel
(clopidogrel was held this admission, as his last stent was ___
years ago).
- Patient is to complete 14-day course of PO Vancomycin for c
diff (day ___, last day on ___.
- He will need HBV/HAV vaccines, pneumovax, prevnar and flu
vaccines as an outpatient.
- He will need regular skin check with either dermatology or PCP
as an outpatient.
New medications: PO Vancomycin, Remicade
Stopped medications: Clopidogrel, mesalamine
Changed medications: Prednisone 40 daily
# Code status: Full
# Health care proxy/emergency contact: ___, wife,
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. PredniSONE 40 mg PO DAILY
4. Mesalamine ___ 1200 mg PO TID
5. Cyanocobalamin ___ mcg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg/2.5 mL 125 mg by mouth every 6 hours Disp
#*21 Syringe Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Cyanocobalamin ___ mcg PO DAILY
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. PredniSONE 40 mg PO DAILY
7. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until you discuss it with your
cardiologist.
Discharge Disposition:
Home
Discharge Diagnosis:
=====================
PRIMARY DIAGNOSIS:
=====================
Crohn's disease
Clostridium difficile infection
Hematochezia
=====================
SECONDARY DIAGNOSIS:
=====================
Anemia
Coronary artery disease
Polymyalgia rheumatica
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___. Please find detailed discharge instructions
below:
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were admitted because you had abdominal pain and diarrhea.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
- Your symptoms were thought to be primarily from a flare of
your Crohn's disease.
- You were also found to have a GI infection, called "c diff",
that can also cause diarrhea and abdominal pain.
- You received a colonoscopy, which showed inflammation in parts
of your large intestine.
- You required IV steroids for your Crohn's flare.
- You required an additional therapy to suppress inflammation
called Remicade (infliximab) to treat your Crohn's flare.
- You did well after receiving the Remicade, so you were
transitioned to oral steroids for discharge.
- You were treated with oral antibiotics (vancomycin) for your c
diff infection.
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please go to all your appointments as scheduled.
- Please take all your medications as prescribed.
- You will need another infusion of the Remicade 1 week after
the first one, so please make sure to follow up at your GI
doctor appointment.
We wish you the best!
- Your ___ treatment team
Followup Instructions:
___
|
19926655-DS-3 | 19,926,655 | 28,059,348 | DS | 3 | 2136-09-17 00:00:00 | 2136-10-11 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prevpac
Attending: ___.
Chief Complaint:
Weakness, fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with a history of leukemia refractory to
chemotherapy who presents from home after a fall. He did not
strike his head or lose consciousness and is not suffering any
residual pain. He declines any imaging studies for further
evaluation. He states he was feeling extremely weak and fell due
to weakness. He has been living at home with ___, but
after the fall would prefer to be in an inpatient setting for
the remainder of his life. The family attempted to arrange
transfer to an inpatient hospice unit through ___,
but given the holiday weekend this was unsuccessful so he came
into the ED. He is not interested in any life-prolonging
treatment, including no blood transfusions.
In the emergency room, initial vitals were T 97.3, HR 88, BP
96/46, RR 18 and he was placed on a NRB for shortness of breath.
The patient received Zofran and Maalox for nausea with good
effect. Labs were notable for severe anemia with Hct of 8.6,
lactate of 6.2, and new renal failure. He was comfortable at the
time of transfer to the floor. Vitals on transfer: HR 82, RR 15,
O2 sat 84% 4l by NC, BP 85/39.
On the floor, the patient has his son ___ and ___ at
the bedside. He reports feeling comfortable, no pain. He
confirms wishes to be CMO and agrees to no vitals checks or
blood draws. He has had constipation over the last few weeks,
but took Colace at home and has had several soft stools in the
last 24 hours. His breathing feels comfortable on oxygen.
Remainder of ROS is negative.
Review of systems:/i>
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies chest pain or tightness, palpitations. Denies
cough. Denies vomiting or abdominal pain. No recent change in
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rashes or skin breakdown. No numbness/tingling in
extremities. No feelings of depression or anxiety. All other
review of systems negative.
Past Medical History:
Type 2 Diabetes
Benign Hypertension
Diabetic Neuropathy
Hypercholesterolemia
Vitamin B12 Deficiency
Gastritis/H. Pylori
Leukemia refractory to chemotherapy
Social History:
___
Family History:
Father: CAD
Mother: Died of MI
Son: ___
Physical ___:
Admission:
General: Patient resting in bed, alert, communicating. Somewhat
hard of hearing. Family with him at bedside.
Remainder of exam: Deferred given CMO status.
Pertinent Results:
Labs on admission:
___ 06:50AM WBC-1.7*# RBC-0.98*# HGB-2.8*# HCT-8.6*#
MCV-88 MCH-28.4 MCHC-32.2 RDW-28.8*
___ 06:50AM NEUTS-24* BANDS-0 LYMPHS-59* MONOS-9 EOS-0
BASOS-0 ATYPS-3* ___ MYELOS-1* NUC RBCS-5* OTHER-4*
___ 06:50AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-1+
MACROCYT-1+ MICROCYT-2+ POLYCHROM-NORMAL SCHISTOCY-OCCASIONAL
STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
___ 06:50AM PLT COUNT-104*
___ 06:50AM ___ PTT-24.6* ___
___ 06:55AM LACTATE-6.2* K+-4.8
___ 06:55AM HGB-3.1* calcHCT-9
___ 06:50AM GLUCOSE-161* UREA N-55* CREAT-1.8* SODIUM-141
POTASSIUM-4.6 CHLORIDE-109* TOTAL CO2-16* ANION GAP-21*
___ 06:50AM ALT(SGPT)-15 AST(SGOT)-25 ALK PHOS-71 TOT
BILI-1.9*
___ 06:50AM LIPASE-25
___ 06:50AM cTropnT-0.04*
___ 06:50AM CALCIUM-8.8 PHOSPHATE-4.8* MAGNESIUM-3.0*
MICROBIOLOGY
- Blood culture ___: No growth
Brief Hospital Course:
HOSPITAL SUMMARY: Mr. ___ is a ___ with end-stage leukemia
refractory to chemotherapy who presented from home after a fall
for consideration of inpatient hospice vs. end-of-life care in
hospital. Labs on admission (see above) were notable for
profound anemia with hematocrit of 8 and lactate of > 6. Both
the patient and his family understood that he was at the end of
his life, and requested that the priority be on maximizing
comfort. The patient passed away on hospital day#1.
# GOALS OF CARE: Patient was recognized to be very near the end
of his life. He and his family were aware of this fact, and
requested only for the patient to be comfortable. Mr. ___
expressed concern that he would feel like he was struggling to
breathe, and was able to verbalize that he would want pain
medications to limit labored breathing as needed. He was
initially pain free and ordered for morphine IV PRN, but over
the following day as his breathing became increasingly labored
and he became increasingly somnolent, he received several PRN
doses of morphine and was then transitioned to a morphine gtt.
His family communicated that all of his friends and relatives
who had wanted to have a chance to say goodbye had done so, and
that the priority should be to limit respiratory distress. He
passed away peacefully in his sleep on the evening of hospital
day#1 (___). Of note, a palliative care consult was
called in anticipation of sharing options regarding inpatient
vs. home hospice with the family; this ultimately proved to be
unnecessary. The family was made aware of the option of a social
work consult, but declined feeling that they had all of the
resources and support that they required. Patient was CMO
throughout this admission.
# NAUSEA: Patient's only active complaint at the time of
admission. He was ordered for Compazine, Maalox and Zofran PRN.
# LEUKOPENIA: WBC count of 1.7 with 24% neutrophils suggests ANC
of 408; therefore he was placed on neutropenic precautions while
in-house
# RECENT FALL: Fall precautions were taken.
Medications on Admission:
- Statin (per family, has continued to take at home)
- Colace PRN
- Maalox PRN
- Compazine PRN
Discharge Medications:
None
Discharge Disposition:
Expired
Discharge Diagnosis:
Chief cause of death -- leukemia (interval months), immediate
cause of death -- severe anemia.
Discharge Condition:
deceased
Discharge Instructions:
Patient expired, on ___, time of death ___. Son ___
contacted, declined autopsy.
Followup Instructions:
___
|
19926727-DS-21 | 19,926,727 | 25,546,472 | DS | 21 | 2185-06-02 00:00:00 | 2185-06-03 14:42:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / pollen / Actos / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Please see medicine admission note for full details. This is a
___ yo male w/ h/o Stage V CKD, HTN, DM2, and schizoaffective d/o
who presents with ___ weeks of worsening shortness of breath and
non-productive cough. His SOB has been progressive over the past
2 weeks, worse at night. He endorses orthopnea, paroxysmal
nocturnal dyspnea, and mild DOE (still able to walk from ___
to ___ with only mild dyspnea). He has also had a
non-productive cough for past ___ weeks associated with nasal
congestion and sore throat. Denies any fevers/chills/myalgias.
He has noted increased swelling in b/l LEs. He notes
mid-anterior chest pain only with coughing and occasionally with
deep respiration. He denies any abdominal pain, nausea,
vomiting, dysuria.
With regards to his renal failure, he had a fistula placed in
the right wrist in ___ in anticipation of likely
dialysis requirement. He is also on the transplant list.
Given his SOB and cardiomegally on CXR, pt underwent echo on ___
which showed large pericardial effusion with tamponade
physiology. Given these findings, he went to the cath lab where
he was noted to have hemodynamic evidence of pericardial
tamponade with elevation of the right and left heart pressures.
He underwent perciardiocentesis with approximately 600 of bloody
fluid removed. Repeat echocardiogram showed complete resolution
of the effusion. After the procedure, the RA pressure was 17
mmHg; RV ___ mmHg; PWCP 21 mmHg; PA mean 32 consistent with a
residual constrictive picture with volume overload. He was sent
to the CCU for further management of his drain.
On arrival to the floor, patient is complaining of cough and
pain at pericardiocentisis catheter site. He says is SOB is
improved but still present. He denies abdominal pain, n/v/d.
He has been having left knee pain in the setting of a gout flare
but this has been improving after starting prednisone.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Stage V CKD (likely ___ DM2/HTN, being evaluated for transplant)
Right radial fistula placed in ___
Schizoaffective d/o
Anemia of chronic disease
Social History:
___
Family History:
Father: HTN
Brother: congenital heart disease
Multiple family members with cancer, though patient unsure what
kind
Physical Exam:
CCU Admission Physical Exam:
VS: 97.9 152/76 98 17 985 ra
GENERAL: WDWN male, coughing but in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple without elevation of JVP
CARDIAC: S1, S2. possible friction rub. No S3 or S4.
pericardiocentesis catheter is in place c/d/i. Bloody drainage
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, decreased BS at right base, no wheezes or
crackles appreciated.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES: Trace peripheral edema, 2+ distal pulses. Mild
left knee effusion.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Physical Exam:
Vitals: 97.2 138/78 92 18 98%RA
GENERAL: well appearing male in NAD.
HEENT: NCAT. Sclera anicteric. MMM
NECK: Supple without elevation of JVP
CARDIAC: RRR, no friction rub, murmur, or gallops appreciated.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, ctab, no wheezes or crackles appreciated.
ABDOMEN: Soft, distended, NT. No HSM or tenderness.
EXTREMITIES: Trace peripheral edema, 2+ distal pulses. Mild left
knee effusion now resolved, full range of motion without pain,
no tenderness to palpation. Mild TTP over left achilles tendon.
Full ROM at left ankle. No effusion
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: A&Ox3, no focal deficits.
Pertinent Results:
LABS:
ADMISSION
___ 01:40PM WBC-5.7 RBC-2.51* HGB-7.8* HCT-24.0* MCV-96
MCH-31.1 MCHC-32.5 RDW-14.9
___ 01:40PM NEUTS-75.5* LYMPHS-15.8* MONOS-7.2 EOS-1.1
BASOS-0.4
___ 11:30AM URINE HOURS-RANDOM CREAT-152 TOT PROT-416
PROT/CREA-2.7*
___ 01:40PM proBNP-592*
___ 01:40PM cTropnT-0.04*
___ 01:40PM GLUCOSE-282* UREA N-71* CREAT-6.5* SODIUM-141
POTASSIUM-4.3 CHLORIDE-109* TOTAL CO2-18* ANION GAP-18
___ 02:09PM LACTATE-1.7
INTERIM/DISCHARGE LABS
___ 10:20AM BLOOD WBC-6.2 RBC-2.93* Hgb-8.9* Hct-26.9*
MCV-92 MCH-30.4 MCHC-33.2 RDW-14.2 Plt ___
___ 10:20AM BLOOD Glucose-172* UreaN-34* Creat-3.7* Na-139
K-3.8 Cl-97 HCO3-30 AnGap-16
___ 10:20AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0
___ 05:55AM BLOOD calTIBC-355 Ferritn-36 TRF-273
___ 12:38PM BLOOD PTH-242*
___ 12:38PM BLOOD 25VitD-15*
MICROBIOLOGY
___ 1:54 pm JOINT FLUID Source: Kneeleft.
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 8:10 am BLOOD CULTURE #1.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:57 pm BLOOD CULTURE Source: Line-dialysis 1 OF
2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:06 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:10 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:17 am BLOOD CULTURE Source: Line-dialysis #1.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 4:40 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
JOINT FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
__________________________________________________________
___ 4:46 pm JOINT FLUID Source: Knee.
ACID-FAST SMEAR & CULTURE ADDED ___ PER FAX.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Pending):
__________________________________________________________
___ 6:00 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 2:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERICARDIAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___:
STAPHYLOCOCCUS ___.
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.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS ___
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ <=0.5 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ ___,
___.
GRAM POSITIVE COCCI IN CLUSTERS.
__________________________________________________________
___ 2:30 pm FLUID,OTHER PERICARDIAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
__________________________________________________________
___ 1:45 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:40 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING/OTHER STUDIES
CXR ___: Frontal and lateral views of the chest. There are
new small bilateral effusions. There is mild engorgement of the
central vasculature and enlargement of the azygous and
suggesting mild fluid overload. Cardiac silhouette is enlarged,
slightly more so on compared to prior poor. No acute osseous
abnormality detected. IMPRESSION: New mild fluid overload and
small effusions. No consolidation.
___ ___: No evidence of DVT in the left lower extremity.
ECHO ___: IMPRESSION: Large circumferential pericardial
effusion with echocardigraphic evidence of increased
intrapericardial pressure/tamponade physiology. Compared with
the prior study (images reviewed) of ___, the pericardial
effusion is much larger, the right ventricle is smaller, and
tamponade physiology is now suggested. The severity of mitral
regurgitation is now reduced.
RIGHT HEART CATHETERIZATION AND PERICARDIOCENTESIS ___:
Using ultrasound guidance, the left parasternal space above the
7th rib was entered using a micropuncture needle and the
position in the pericardial space was confirmed with agitated
saline. Approximately 600 of bloody fluid was removed and an
echocardiogram showed complete resolution of the effusion. After
the procedure, the RA pressure was 17 mmHg; RV ___ mmHg; PWCP
21 mmHg; PA mean 32 consistent with a residual constrictive
picture with volume overload.
ASSESSMENT
1. Pericardial tamponade due to uremic pericarditis
2. Successful pericardiocentesis
TTE ___: There is mild symmetric left ventricular hypertrophy
with normal cavity size and regional/global systolic function
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. There is abnormal septal motion suggestive of
pericardial constriction. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The estimated pulmonary
artery systolic pressure is normal. There is a small pericardial
effusion. The effusion appears circumferential. The effusion is
echo dense, consistent with blood, inflammation or other
cellular elements. There are no echocardiographic signs of
tamponade. The echo findings are suggestive but not diagnostic
of pericardial constriction.
Compared with the prior study (images reviewed) of ___,
most of the pericardial fluid has been removed. There is some
residual fluid present, mostly behind the left ventricle. There
are cellular elements seen over the right ventricle. The right
ventricle appears normal in size without evidence of diastolic
collapse or other tamponade physiology. There is a septal bounce
seen, consistent with effusive-constrictive physiology, which is
often seen in the few days post-pericardiocentesis.
TTE ___: Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal. There
is a small to moderate (0.8-1.2cm) sized partially echo filled
pericardial effusion primarily inferior, inferolateral and
anterolaterally around the left ventricle with minimal effusion
around the apex and anterior to the right ventricle. There are
no echocardiographic signs of tamponade physiology.
TTE ___: The estimated right atrial pressure is ___ mmHg.
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size and free wall motion are normal.
There is a small to moderate sized pericardial effusion
measuring from 0.8 to 1.4 centimeters in greatest dimension. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. The effusion is circumferential, but
there is preferential fluid deposition along the inferior,
inferolateral and anterolateral aspects of the left ventricle
with minimal effusion around the apex and anterior to the right
ventricle. Adherant/organizing clot is appreciated anteriorly to
the right ventricle. There are no echocardiographic signs of
tamponade.
Compared with the prior study (images reviewed) of ___, the
findings are similar.
LEFT KNEE X-RAY ___: FINDINGS: Mild periarticular soft
tissue swelling. Suspicion of joint effusion is strong. The
pre-existing minimal patellofemoral spurring has minimally
increased in severity. The joint space is normal and shows no
evidence of major degenerative changes. There is no safe
evidence of any meniscal calcification. The cortical surfaces
are intact. No evidence of fractures. No erosions potentially
indicative of a chronic inflammatory joint disease.
Brief Hospital Course:
___ yom with Stage V CKD, admitted with SOB/DOE found to have
large pericardial effusion with tamponade, thought to be
secondary to uremia, now s/p pericardiocentsis and initiation of
hemodyalsis through matured right radiocephalic fistula.
# Pericardial effusion with cardiac tamponade: Patient is s/p
pericardiocentesis on ___. Approximately 900cc of hemorrhagic
effusion fluid was drained. Per nephrology and cardiology, this
effusion was likely secondary to uremia though ddx includes
infectious (given positive culture), viral, malignancy,
infiltrative disease, pericarditis (___ syndrome, uremia,
rheumatological). Cytology was negative, making malignancy less
likely. Symptoms improved s/p pericardiocentsisis and furthur
drainage was minimal. Cultures from pericardial fluid grew
STAPHYLOCOCCUS LUG___. Repeat Echo on ___ with minimal
effusion and abnormal septal motion suggestive of pericardial
constriction. Patient was seen by infectious disease with
regards to staph lugdunensis in pericardial fluid. Although
staph lugdunensis is typically a very virulent pathogen, the
fact that the patient remained afebrile and clinically stable
suggested that its growth in the pericardial fluid sample likely
represented a contaminant rather than true infection. Patient
never recevied antibiotics and remained clinically well
throughout rest of admission. Repeat surveillance blood cultures
remained negative.
# Left knee inflammatory arthritis: Patient's home colchicine
was initially held on admission given his worsening renal
function. Patient underwent left knee arthrocentesis which
showed a large number of WBCs, but no needles, and culture was
negative. He completed 5 days of prednisone 40mg daily with
improvement in his knee pain, though not completely resolved.
The effusion began to reaccumulate and patient underwent second
arthrocentesis, which was hemorrhagic in nature. Again no
crystals were seen and culture was negative. Per rheumtology,
this was treated as a mono-articular gout flare and his left
knee was injected with steroids, leading to complete resolution
of his effusion and pain. As the etiology of this inflammatory
arthritis remains somewhat obscure, patient will followup with
rheumatology. Rheumatology has also recommended once weekly
prophylactic colchicine dosing for now.
# Stage V CKD: Most likely etiology of patient's anemia, uremia
and anion gap acidosis. Patient underwent 6 days of hemodialysis
induction during this admission. Access was through his now
matured right radiocephalic AVF. The patient tolerated HD well.
He is now scheduled for ___ outpatient
dialysis. He was started on calcium acetate and nephrocaps. His
colchicine dosing was reduced from daily to once weekly for gout
prophylaxis. Patient is PPD negative.
# Anemia - HCT is around patient's baseline. Likely ___ CKD.
Iron is low at 39 but normal ferritin and TIBC. Per renal,
epogen therapy was initiated with dialysis.
# Anion gap metabolic acidosis: Bicarb on Chem-7 was as low as
14. ABG showed pH 7.37, pC02 30, pO2 75, Bicarb 18. This is
suggestive of a chronic primary anion gap metabolic acidosis
with appropriate respiratory compensation likely in setting of
renal failure.
# HTN - per renal, hold home amlodipine 10mg on dialysis days
# HLD - continued home pravastatin 40mg daily
# DM2 - SSI and FSS while in house, will resume home glipizide
upon discharge
# Schizoaffective d/o - continued home depakote, risperidone,
benztropine
# EMERGENCY CONTACT: emergency contact is pts brother ___
___ cell# ___ ___ cell ___
=
=
=
=
=
=
================================================================
TRANSITIONAL ISSUES:
#Left knee effusion/arthritis: this was attributed to gout;
however, this was unable to be confirmed by the presence of
crystals in the joint fluid. If this were to reoccur, furthur
diagnostic w/u would be warranted. Patient is scheduled to
follow-up with rheumatology
#Left achilles pain: no evidence of tendon tear/rupture, will
likely improve with rehabilitation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Benztropine Mesylate 2 mg PO DAILY
3. Divalproex (EXTended Release) 500 mg PO Q12H
4. Colchicine 0.6 mg PO DAILY
5. Risperidone 2 mg PO DAILY
6. Amlodipine 10 mg PO DAILY
7. Pravastatin 40 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. tadalafil *NF* 10 mg Oral prn impotence
10. GlipiZIDE 20 mg PO QAM
11. GlipiZIDE 10 mg PO QPM
12. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Benztropine Mesylate 2 mg PO DAILY
3. Pravastatin 40 mg PO DAILY
4. Risperidone 2 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate 667 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
7. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
8. Divalproex (EXTended Release) 500 mg PO Q12H
9. GlipiZIDE 20 mg PO QAM
10. GlipiZIDE 10 mg PO QPM
11. Multivitamins 1 TAB PO DAILY
12. tadalafil *NF* 10 mg Oral prn impotence
13. Amlodipine 10 mg PO 4X/WEEK (___)
take once daily on non-dialysis days ___,
___
RX *amlodipine 10 mg 1 tablet(s) by mouth 4 times per week Disp
#*16 Tablet Refills:*0
14. Colchicine 0.6 mg PO QFRI Duration: 1 Weeks
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth every
___ Disp #*12 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pericardial Effusion with tamponade
Uremia
End-stage renal disease
Inflammatory arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent w/ walker.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___. You
were admitted for shortness of breath and a cough and were found
to have a pericardial effusion (fluid around your heart), which
was likely caused by your kidney failure. This fluid was drained
and your symptoms improved. You were started on dialysis and
received 6 sessions of dialysis. You will continue getting
dialysis as an outpatient on ___, and ___.
You also had inflammation and pain in your left knee. This was
treated with a steroid called prednisone for 5 days and your
pain improved, however the swelling remained. You should
followup with a rheumatologist (as scheduled below) to help
determine the cause of this inflammation.
Again, it was a pleasure taking part in your care, and I wish
you all the best in the future!
Followup Instructions:
___
|
19926727-DS-22 | 19,926,727 | 21,367,380 | DS | 22 | 2185-06-10 00:00:00 | 2185-06-18 19:16:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / pollen / Actos / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug)
Attending: ___
Chief Complaint:
presyncope
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo male w/ ESRD (recently started on HD), HTN, DM2,
schizoaffective d/o, and recent admission for pericardial
tamponade who presents with presyncope following HD. 1.5L were
taken off during HD. The patient acutely felt dizziness, did not
syncopize. Following the brief episode, dizziness resolved. The
patient presented to the ED.
In the ED, initial VS: 98.4 89 122/80 18 99% 4l. The patient
underwent bedside ultrasound that showed a small-to-moderate
pericardial effusion. Pulsus was 8. He also endorsed that he had
suicidal ideation with a plan yesterday, but that he is not
suicidal today. He was admitted out of concern for recurrent
tamponade and for suidical ideation. VS on transfer: 98.3 92
133/70 18 97%.
Of note, during his recent admission, tamponade was thought to
be due to uremia. A total of 900 cc fluid was drained and repeat
echo showed total resolution of the effusion. After
pericardiocentesis, the RA pressure was 17 mmHg; RV ___ mmHg;
PWCP 21 mmHg; PA mean 32 consistent with a residual constrictive
picture with volume overload. He was started on hemodialysis and
received 6 sessions consecutively before starting outpatient HD.
Symptoms completely resolved at the time of discharge.
On the floor the patient feels well. He complains of mild
dyspnea since previous discharge, but is able to walk far
distances without difficulty. He denies dizziness since earlier
today. No chest pain, palpitations. He endorses intermittent
suicidal ideation related to depression regarding dialysis. He
does have a psychiatrist and therapist at ___
___ with whom he feels comfortable managing his depression.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Stage V CKD (likely ___ DM2/HTN, being evaluated for transplant)
Right radial fistula placed in ___
Schizoaffective d/o
Anemia of chronic disease
Social History:
___
Family History:
Father: HTN
Brother: congenital heart disease
Multiple family members with cancer, though patient unsure what
kind
Physical Exam:
ADMISSION:
VS: 98.3 124/63 85 20 96%RA
GENERAL: well appearing male in NAD, tangential in conversation
HEENT: NCAT. Sclera anicteric. MMM
NECK: Supple without elevation of JVP
CARDIAC: RRR, no friction rub, murmur, or gallops appreciated.
LUNGS: Scattered rhonchi bilaterally; good air movement
ABDOMEN: Soft, distended, NT. No HSM or tenderness.
EXTREMITIES: Trace peripheral edema, 2+ distal pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: A&Ox3, no focal deficits.
PSYCH: Mood sometimes sad. Makes appropriate eye contact, but
tangential in conversation (references nightmares about
concentration camps while asking about dizziness)
.
DISCHARGE:
VS: 98.7/97.5, 112/73-124/75, 77-96, NML RR, satting in ___ on
RA
FSBG 137-221
GENERAL: well appearing male in NAD
HEENT: NCAT. Sclera anicteric. MMM
NECK: Supple without elevation of JVP
CARDIAC: RRR, no friction rub, murmur, or gallops appreciated.
LUNGS: Scattered rhonchi bilaterally; good air movement
ABDOMEN: Soft, distended, NT. No HSM or tenderness.
EXTREMITIES: Trace peripheral edema, 2+ distal pulses.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
NEURO: A&Ox3, no focal deficits.
PSYCH: Denies suicidality.
Pertinent Results:
LABS:
___ 06:30PM BLOOD WBC-4.2 RBC-2.70* Hgb-8.3* Hct-24.7*
MCV-92 MCH-30.8 MCHC-33.6 RDW-14.3 Plt ___
___ 06:30PM BLOOD Neuts-64.8 ___ Monos-10.0 Eos-1.9
Baso-0.4
___ 06:35AM BLOOD WBC-3.9* RBC-2.39* Hgb-7.4* Hct-22.2*
MCV-93 MCH-30.8 MCHC-33.1 RDW-15.0 Plt ___
___ 06:30PM BLOOD ___ PTT-28.2 ___
___ 06:30PM BLOOD Glucose-163* UreaN-17 Creat-3.0* Na-146*
K-4.4 Cl-109* HCO3-30 AnGap-11
___ 06:06AM BLOOD Glucose-74 UreaN-26* Creat-4.2*# Na-146*
K-4.3 Cl-109* HCO3-30 AnGap-11
___ 06:20AM BLOOD Glucose-128* UreaN-41* Creat-5.2* Na-145
K-5.2* Cl-111* HCO3-25 AnGap-14
___ 06:35AM BLOOD Glucose-49* UreaN-51* Creat-6.0* Na-145
K-5.0 Cl-111* HCO3-23 AnGap-16
___ 06:06AM BLOOD CK(CPK)-64
___ 06:20AM BLOOD ALT-29 AST-21 LD(LDH)-218 AlkPhos-87
TotBili-0.3
___ 06:30PM BLOOD cTropnT-0.05*
___ 06:06AM BLOOD CK-MB-2 cTropnT-0.07*
___ 06:06AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.0
___ 06:20AM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.9 Mg-1.9
___ 06:35AM BLOOD Calcium-8.9 Phos-4.8* Mg-1.9
___ 06:00AM BLOOD %HbA1c-6.1* eAG-128*
___ 06:20AM BLOOD Valproa-53
___ 06:52PM BLOOD Lactate-1.1
___ Blood Culture, Routine-FINAL no growth
.
EKG ___:
Sinus rhythm. Delayed precordial R wave progression. Diffuse
non-specific ST-T wave abnormalities. No major change from
previous tracing.
TRACING #1
Rate PR QRS QT/QTc P QRS T
88 152 80 366/415 64 21 136
.
CXR ___:
FINDINGS: Frontal and lateral views of the chest were obtained.
No focal consolidation, pleural effusion, or pneumothorax is
seen. The cardiac silhouette is top normal to mildly enlarged
but decreased in size as compared to ___. No overt
pulmonary edema is seen. The mediastinal contours are
unremarkable.
IMPRESSION: Top normal to mildly enlargement of the cardiac
silhouette, decreased in size as compared to the prior study.
.
EKG ___:
Sinus rhythm. Delayed precordial R wave progression. Mild
non-specific ST-T wave abnormalities. No major change from
previous tracing.
TRACING #2
Rate PR QRS QT/QTc P QRS T
87 158 80 ___
.
ECHO ___:
There is a small to moderate sized pericardial effusion. The
epicardial surface of the posterior wall may be thickened. There
are no echocardiographic signs of tamponade.
Compared with the findings of the prior study (images reviewed)
of ___, the findings are similar.
IMPRESSION: Unchanged small to moderate effusion without
evidence of tamponade.
Brief Hospital Course:
Patient was admitted to the hospital with pre-syncope. He was
found to be orthostatic. He had had 1.5L of fluid taken off at
outpatient dialysis. PO fluids were encouraged. Orthostasis
resolved until after patient had dialysis here at ___ on ___.
After dialysis on ___, his standing SBP was 84 compared to
supine SBP of 118, but he was asymptomatic. Amlodipine was
decreased from 10mg to 5mg daily, and he will take it in the
afternoon (after dialysis) instead of in the mornings.
Antihypertensive regimen may need to be further adjusted in the
outpatient setting.
He had a recent admission for pericardial effusion and tamponade
requiring pericardiocentesis. His echo during this admission
showed stable size of pericardial effusion (~1cm) and no
evidence of tamponade physiology.
Patient was restarted on home glipizide prior to discharge, but
became hypoglycemic to 47. Therefore, glipizide dose was
decreased by half (from 20 to 10mg QAM and from 10 to 5mg QPM)
prior to discharge. He will need close follow up of his blood
sugar and may need further adjustment of his diabetes regimen.
Patient reported that he had felt suicidal prior to admission.
He was evaluated by psychiatry, who felt that he was safe to be
discharged home. He denied suicidality in the days prior to
discharge. Depakote dose was increased from 500mg BID to ___
BID.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Benztropine Mesylate 2 mg PO DAILY
3. Pravastatin 40 mg PO DAILY
4. Risperidone 2 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Calcium Acetate 667 mg PO TID W/MEALS
7. Nephrocaps 1 CAP PO DAILY
8. GlipiZIDE 20 mg PO QAM
9. GlipiZIDE 10 mg PO QPM
10. Multivitamins 1 TAB PO DAILY
11. tadalafil *NF* 10 mg Oral prn impotence
12. Amlodipine 10 mg PO 4X/WEEK (___)
take once daily on non-dialysis days ___,
___
13. Colchicine 0.6 mg PO QFRI Duration: 1 Weeks
14. Divalproex (DELayed Release) 500 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Benztropine Mesylate 2 mg PO DAILY
RX *benztropine 2 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Calcium Acetate 667 mg PO TID W/MEALS
RX *calcium acetate 667 mg 1 capsule(s) by mouth TID w/ meals
Disp #*90 Capsule Refills:*0
4. Colchicine 0.6 mg PO QFRI Duration: 1 Weeks
5. Nephrocaps 1 CAP PO DAILY
RX *B complex-vitamin C-folic acid [Nephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
6. Pravastatin 40 mg PO DAILY
7. Risperidone 2 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. GlipiZIDE 5 mg PO QPM
10. GlipiZIDE 10 mg PO QAM
RX *glipizide 5 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
11. tadalafil *NF* 10 mg Oral prn erectile dysfunction
12. Amlodipine 5 mg PO QPM
Take in the afternoons (take after -- not before -- dialysis on
dialysis days)
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Divalproex (DELayed Release) 750 mg PO BID
RX *divalproex ___ mg 3 tablet(s) by mouth twice a day Disp
#*180 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- pre-syncope due to hypovolemia and orthostatic hypotension
- pericardial effusion
- end-stage renal disease
- diabetes
Secondary:
- anemia
- schizoaffective disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with lightheadedness. This
was thought to be due to orthostatic hypotension, which means
that your blood pressure was low when you stood up. In the
future, please take amlodipine in the afternoon, not in the
morning, especially on dialysis days. In addition, the dialysis
center will have to be cautious about removing too much fluid.
Make sure to get up slowly from sitting or lying down to
decrease your chances of feeling lightheaded.
While you do continue have a pericardial effusion (fluid around
your heart), we do not think this was the cause of your
symptoms.
Please take your medication as prescribed (updated medication
list is included below), and please follow up by attening the
appointments listed below.
It was a pleasure taking part in your care.
Followup Instructions:
___
|
19926727-DS-28 | 19,926,727 | 29,182,633 | DS | 28 | 2190-10-09 00:00:00 | 2190-10-10 15:38:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / pollen / Actos / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / ibuprofen / cefazolin
Attending: ___.
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
None
Last hemodialysis session on ___
History of Present Illness:
Mr. ___ is a ___ gentleman with ESRD (on HD MWF),
chronic anemia, BPD, who is being admitted for further
evaluation
and management of suspected symptomatic anemia.
The patient was recently admitted from ___ to ___ with
dizziness
attributed to acute on chronic anemia. The patient endorsed
hematochezia, but was guaiac negative with no recurrent blood
per
rectum inpatient. Iron studies were obtained and consistent with
chronic inflammation. He was given 1u pRBCs and Hg remained
stable on that admission and was 7.3 on discharge. Following
discharge, he resumed HD on his usual MWF schedule. On today's
session, labs allegedly revealed worsening anemia and he was
sent
into ___ for further evaluation.
In the ED, initial VS were: T98, HR 95, BP 139/82, RR 20, 98%
RA.
Labs showed: Hg 7.5, plt 95, WBC 3.5; Na 138, K 4.2, bicarb 29
Imaging showed: CXR with mild pulm edema; no focal
consolidations.
Consults: none.
Patient received: 1u pRBCs
Transfer VS were: T99, HR 100, BP 178/77, RR 20, 99% RA.
On arrival to the floor, patient reports that he felt dizzy
earlier today during HD, which improved after he ate something.
He denies any associated chest pain. While he does endorse SOB,
he attributes this to having a cold with significant nasal
congestion.
Of note, the patient was also admitted in ___ of this year as
a
transfer from CHA with high grade MSSA bacteremia and RUE AV
graft infection and was started on six weeks of cefazolin.
However, his course was complicated by new ___ rash with biopsy
consistent with leukocytoclastic vasculitis attributed to the
cefazolin and therefore his antibiotic regimen was changed to
vancomycin on ___. Plan is continue 1g vancomycin post-HD until
___.
Past Medical History:
ESRD on HD
HTN
HLD
NIDDM
Schizoaffective disorder
Gout
Tremors
H/o uremic pericarditis s/p emergent pericardiocentesis
R radiocephalic AVF (___)
AVF ulceration w/ AV loop graft on ___
R ankle arthrocentesis (___)
B/l cataract surgery
Social History:
___
Family History:
Mother: Passed away at age ___ from non-Hodgkins lymphoma,
ovarian cancer
Father: Alive and well at ___
Grandfather: ___
Otherwise, no family history of heart disease or kidney disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:
___ 0050 Temp: 98.7 PO BP: 159/75 L Sitting HR: 100 RR: 20
O2 sat: 95% O2 delivery: RA
GENERAL: disheveled appearing man in NAD.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, + systolic ejection murmur.
LUNGS: diffuse crackles bilaterally
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: RUE with healing AV graft wound with wet to dry bandage in
place, no purulence or eryhtema; warm and well perfused,
resolving petechial rash bilaterally
DISCHARGE PHYSICAL:
___ 1551 Temp: 98.7 PO BP: 170/82 HR: 93 RR: 18 O2 sat: 94%
O2 delivery: Ra
GENERAL: NAD, laying back in bed
HEENT: Sclerae anicteric, AT/NC, EOMI, no JVD
HEART: RRR, + systolic ejection murmur.
LUNGS: Mild bibasilar crackles bilaterally
ABDOMEN: +BS, soft, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: RUE with healing AV graft wound with wet to dry bandage in
place, no purulence or eryhtema; warm and well perfused,
resolving petechial rash bilaterally
Pertinent Results:
ADMISSION LABS:
___ 07:59PM ___ PTT-28.3 ___
___ 06:24PM GLUCOSE-73 UREA N-11 CREAT-3.5*# SODIUM-138
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-29 ANION GAP-14
___ 06:24PM estGFR-Using this
___ 06:24PM ALT(SGPT)-13 AST(SGOT)-37 ALK PHOS-104 TOT
BILI-0.5
___ 06:24PM LIPASE-76*
___ 06:24PM ALBUMIN-3.6 CALCIUM-9.6 PHOSPHATE-3.1
MAGNESIUM-1.8 IRON-56
___ 06:24PM calTIBC-259* FERRITIN-1305* TRF-199*
___ 06:24PM VANCO-26.0*
___ 06:24PM WBC-3.5* RBC-2.38* HGB-7.5* HCT-22.2* MCV-93
MCH-31.5 MCHC-33.8 RDW-16.1* RDWSD-53.3*
___ 06:24PM NEUTS-65.6 ___ MONOS-9.4 EOS-2.3
BASOS-0.3 IM ___ AbsNeut-2.31 AbsLymp-0.73* AbsMono-0.33
AbsEos-0.08 AbsBaso-0.01
___ 06:24PM PLT COUNT-95*
DISCHARGE LABS:
___ 04:56AM BLOOD WBC-4.0 RBC-2.41* Hgb-7.5* Hct-22.2*
MCV-92 MCH-31.1 MCHC-33.8 RDW-16.2* RDWSD-54.4* Plt Ct-73*
___ 04:56AM BLOOD Plt Ct-73*
___ 04:56AM BLOOD Glucose-71 UreaN-29* Creat-6.3*# Na-135
K-4.1 Cl-91* HCO3-30 AnGap-14
___ 04:56AM BLOOD Calcium-9.6 Phos-4.4 Mg-1.8
___ 06:21AM BLOOD Vanco-18.3
IMAGING:
___ CXR:
Mild interstitial pulmonary edema with central pulmonary
vascular congestion, increased compared the prior study.
Trace bilateral pleural effusions.
MICRO:
___ 12:17 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ (___) @
2130,
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ Blood Cx 2x: PND
Brief Hospital Course:
Mr. ___ is a ___ gentleman with ESRD (on HD MWF),
chronic anemia, BPD, who was admitted from his outpatient
dialysis center due to dizziness and weakness during dialysis,
concerning for recurrent anemia. His hemoglobin stable was on
arrival. He received 1u PRBC transfusion which improved his
symptoms, and he did not have any further dizziness.
ACTIVE ISSUES:
# DIZZINESS/WEAKNESS: Possibly due to volume shifts of
hemodialysis vs. hypovolemia from his chronic diarrhea. He did
not have any recurrent dizziness here, and tolerated his
dialysis session on ___ without issue.
# ANEMIA OF CHRONIC INFLAMMATION, STABLE: Blood counts stable
from his last admission. Given 1uPRBC on ___.
# DIARRHEA: Chronic outpatient issue per brother and prior
nursing staff. Positive C diff toxin assay in house. Started on
PO vanc overnight on ___ to complete a 2 week total course
on ___.
# RECENT RUE AV GRAFT INFECTION: Continuing IV vancomycin until
___.
# LOWER EXTREMITY LEUKOCYTOCLASTIC VASCULITIS: Taking home
topical triamcinolone, but can likely be discontinued as has
completed 2 weeks of therapy and having improved rash on the
legs.
CHRONIC/STABLE ISSUES:
# ESRD ON HD MWF: Last HD session on ___. Should continue on
his usual schedule, and receive concurrent vancomycin.
# PANCYTOPENIA: Stable. Would likely benefit from outpatient
heme/onc evaluation.
# ALLERGIC RHINITIS: Home fluticasone and fexofenadine.
# TREMOR: Propranolol held after his last admission due to sinus
bradycardia. Continued home benztropine.
# HYPERLIPIDEMIA: Home pravastatin
# NIDDM:
Per brother, Pt had been considered for insulin initiation at a
previous ___ visit. His blood sugars on ISS here were
euglycemic. Pt was seen by the ___ Diabetes educator, who
recommended no insulin at this time. However he was set up for
an outpatient appointment for this discussion.
# SCHIZOAFFECTIVE DISORDER: Home risperidone, home Depakote
TRANSITIONAL ISSUES:
#CODE: Full (confirmed)
#CONTACT: ___ (brother/HCP) ___ cell ___
[ ] Consider outpatient heme/onc follow up for evaluation of his
thrombocytopenia and anemia. Check CBC in the next visit.
[ ] Per brother had previously been considered for insulin
initiation, though Pt with normal glucoses in house while on
low-dose ISS. Scheduled for outpatient appointment at ___ for
this discussion on ___.
[ ] Continue PO vancomycin for C diff treatment until ___ to
complete a 2 week course.
[ ] Continue vancomycin 1000mg IV with HD until ___ ___V graft infection.
[ ] f/u on recurrence of dizziness and lightheadedness.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Benztropine Mesylate 2 mg PO QHS
3. Nephrocaps 1 CAP PO DAILY
4. Pravastatin 40 mg PO DAILY
5. RisperiDONE 3 mg PO DAILY
6. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
7. Vancomycin 1000 mg IV POST HD (___)
8. Divalproex (DELayed Release) 1000 mg PO QHS
9. GlipiZIDE 20 mg PO QAM
10. GlipiZIDE 10 mg PO QPM
11. Viagra (sildenafil) 20 mg oral PRN
12. Vitamin D 1000 UNIT PO DAILY
13. Fexofenadine 60 mg PO DAILY
14. Fluticasone Propionate NASAL 2 SPRY NU BID
15. amLODIPine 10 mg PO DAILY
16. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Vancomycin Oral Liquid ___ mg PO QID
RX *vancomycin 125 mg 1 capsule(s) by mouth every 6 hours Disp
#*52 Capsule Refills:*0
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
3. amLODIPine 10 mg PO DAILY
4. Benztropine Mesylate 2 mg PO QHS
5. Divalproex (DELayed Release) 1000 mg PO QHS
6. Fexofenadine 60 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. GlipiZIDE 20 mg PO QAM
9. GlipiZIDE 10 mg PO QPM
10. Lisinopril 5 mg PO DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Pravastatin 40 mg PO DAILY
13. RisperiDONE 3 mg PO DAILY
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID
15. Vancomycin 1000 mg IV POST HD (___)
16. Viagra (sildenafil) 20 mg oral PRN
17. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Anemia of chronic inflammation
Dizziness
SECONDARY DIAGNOSES:
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why was I seen in the hospital?
You were feeling unwell after your scheduled session of
dialysis.
Some of the people caring for you worried about your blood
counts.
What happened while I was in the hospital?
You received a blood transfusion.
We checked your blood counts. These were stable.
-You did not have any more dizziness.
-We checked your diarrhea for signs of an infectious diarrhea
("C. diff"); this test showed that you do have C. diff, and you
were started on treatment which you should continue for 2 weeks
total.
You received your scheduled session of hemodialysis on ___.
What should I do when I leave the hospital?
-Please follow up with your primary care doctor as previously
scheduled.
-Please see your diabetes doctor at ___ to discuss whether or
not you need to start insulin.
We wish you the best,
Your ___ Care Team
Followup Instructions:
___
|
19926727-DS-29 | 19,926,727 | 25,228,652 | DS | 29 | 2191-11-06 00:00:00 | 2191-11-06 21:18:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / pollen / Actos / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / ibuprofen / cefazolin / coriander
Attending: ___.
Chief Complaint:
Arm Swelling
Major Surgical or Invasive Procedure:
Fistulogram with angioplasty ___
History of Present Illness:
___ y/o male with ESRD ___ DM on Dialysis MWF with recent right
arm graft placement in ___ presenting from dialysis center
today given concern for swelling of the RUE.
Patient states that he has had swelling in the right arm, from
elbow down for a long time but has been having new, worsening
swelling in the right upper arm. During Last dialysis session on
___, swelling was noted but was able to complete
dialysis. However, swelling has gotten worse since then and he
was sent in directly from dialysis without starting the session.
Of note, patient had an AV fistulogram in ___ without
evidence
of stenosis or other significant abnormality in the access or
outflow venous system. The SCV stenosis that was previously
known
showed ~30% stenosis after angioplasty in ___. However, given
patient's symptoms of ongoing swelling in the arm, angioplasty
was performed with 10%residual stensosis. He was later seen by
Dr. ___ in ___ with plan for possible repeat procedure by Dr.
___ central vein stenosis evaluation with possible banding
of
the access due to persistent high flow to reduce the persistent
right arm swelling.
- In the ED, initial vitals were:
T 97.6 HR 88 BP 129/79 RR 16 O2 99% RA
- Exam was notable for:
Gen: Lying in bed comfortably, eyes closed but conversant and
opens eyes to command
CV: RRR, no r/m/g
Pulm: CTAB
Abdom: soft, NTND
Ext: Right arm with significant swealling throughout without
evidence of erythema or warmth, no pain on plapation. RUE AV
graft with palpable thrill in the distal end and without clear
thrill on the proximal side, +bruit
- Labs were notable for:
139 98 50 AGap=19
-------------< 175
4.3 22 9.9
8.7
4.8>----<66
27.4
Ca: 9.5 Mg: 1.6 P: 8.1
- Studies were notable for:
RUQUS
1. Patent right brachiocephalic AV graft.
2. No evidence of deep vein thrombosis in the right upper
extremity, though exam limited for evaluation of compressibility
of the axillary and brachial veins.
- The patient was given:
___ 19:02 PO/NG Benztropine Mesylate 2 mg
___ 19:02 PO Pravastatin 40 mg
Consults in the ED included:
- Renal: No acute HD needs. Pending ___ fistulogram. Will need to
be re-assessed for HD need post-procedure
- ___: will plan on tomorrow pending schedule
- Transplant surgery: Progressively swollen right arm iso RUE AV
graft, has had prior SCV angioplasty as well as angioplasty
w/stenting of venous anastamosis earlier this year for similar
issue. Patient needs ___ fistulogram. Would have patient seen by
renal dialysis team as well, as he missed his dialysis today due
to his RUE swelling.
On arrival to the floor, the patient endorses the history as
above. Endorses 1 day history of right arm swelling without pain
or parathesias. Does endorse a cough for the last ___ days,
without fevers or chills.
Past Medical History:
ESRD on HD
HTN
HLD
NIDDM
Schizoaffective disorder
Gout
Tremors
H/o uremic pericarditis s/p emergent pericardiocentesis
R radiocephalic AVF (___)
AVF ulceration w/ AV loop graft on ___
R ankle arthrocentesis (___)
B/l cataract surgery
Social History:
___
Family History:
Mother: Passed away at age ___ from non-Hodgkins lymphoma,
ovarian cancer
Father: Alive and well at ___
Grandfather: ___
Otherwise, no family history of heart disease or kidney disease
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 97.5 PO 164 / 60 Lying 88 18 99 Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Ext: RUE AVG with +thrill, palpable distal radial
pulse, ___ grip strength, intact sensation to light touch. RUE
with marked
swelling and edema from fingers up to shoulder.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength
throughout. Normal sensation.
DISCHARGE EXAM:
===============
___ 0817 Temp: 97.9 PO BP: 137/81 L Sitting HR: 71 RR: 18
O2
sat: 96% O2 delivery: Ra FSBG: 124
GENERAL: Alert and interactive. In no acute distress.
HEENT: Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: Ext: RUE AVG with +thrill, palpable distal radial
pulse, ___ grip strength, intact sensation to light touch. RUE
with marked swelling and edema from fingers up to shoulder. LUE
erythema and tenderness proximal to elbow
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength
throughout. Normal sensation.
Pertinent Results:
ADMISSION LABS:
==============
___ 12:18PM BLOOD WBC-4.8 RBC-2.69* Hgb-8.7* Hct-27.4*
MCV-102* MCH-32.3* MCHC-31.8* RDW-13.8 RDWSD-51.2* Plt Ct-66*
___ 12:18PM BLOOD Glucose-175* UreaN-50* Creat-9.9*# Na-139
K-4.3 Cl-98 HCO3-22 AnGap-19*
___ 12:18PM BLOOD Calcium-9.5 Phos-8.1* Mg-1.6
PERTINENT RESULTS:
=================
Upper Extremity Ultrasound: ___
"1. Patent right brachiocephalic AV graft.
2. No evidence of deep vein thrombosis in the right upper
extremity, though
exam limited for evaluation of compressibility of the axillary
and brachial
veins."
Fistulogram with angiogram: ___
"FINDINGS: The procedure indications, risks, benefits and
alternatives were explained in detail to the patient and
written,
informed consent was obtained. The patient was placed supine on
the table in the OR suite. The right upper extremity
was prepped and draped in usual sterile fashion.
Using 1% lidocaine for local anesthesia, the dialysis access was
cannulated at the upper arm AV graft using a 21 gauge
micropuncture kit in the antegrade direction.
A complete dialysis access angiogram was performed which
revealed 80% stenosis at the brachiocephalic vein.
Retrograde angiogram was performed by injecting contrast through
the sheath while occluding the outflow. It revealed
no evidence of stenosis of the arterial portion of the access
and adjacent artery.
A wire was advanced through the sheath under fluoroscopic
guidance and across the area of stenosis. The angioplasty
balloon (12 MM Conquest ) was advanced over the wire to the
brachiocephalic vein stenosis. Angioplasty was
performed. The balloon was then removed. A post angioplasty
angiogram was performed which revealed no residual
stenosis.
A wire was advanced through the sheath under fluoroscopic
guidance and across the area of stenosis. The angioplasty
balloon (12 MM x 40 mm Lutonix drug eluting balloon) was
advanced over the wire to the brachiocephalic vein stenosis.
Angioplasty was performed. The balloon was then removed. A post
angioplasty angiogram was performed which
revealed no residual stenosis.
CONCLUSIONS: The patient has a right upper arm straight graft. -
Percutaneous angioplasty of the brachiocephalic
vein with a 12 mm lutonix drug eluting balloon and no residual
stenosis."
DISCHARGE LABS:
==============
___ 06:05AM BLOOD WBC-4.3 RBC-2.70* Hgb-8.8* Hct-26.2*
MCV-97 MCH-32.6* MCHC-33.6 RDW-13.7 RDWSD-48.7* Plt Ct-71*
___ 07:53AM BLOOD Glucose-117* UreaN-30* Creat-6.0*# Na-135
K-4.2 Cl-89* HCO3-28 AnGap-18
___ 07:53AM BLOOD Calcium-9.7 Phos-5.6* Mg-1.8
Brief Hospital Course:
SUMMARY:
========
___ y/o male with ESRD ___ DM on Dialysis MWF with recent right
arm graft placement in ___ presenting from dialysis center w/
severely edematous RUE concerning for possible SCV stenosis.
Fistula was able to be accessed for dialysis and patient
underwent HD without complication this admission with
fistulogram with angioplasty notable for proximal stenosis of
the brachiocephalic vein without residual stenosis
ACUTE/ACTIVE ISSUES:
====================
#RUE swelling c/f subclavian stenosis
#ESRD on HD (___)
Patient presenting with progressively swollen right arm in the
setting of RUE AV graft. He has had prior SCV angioplasty as
well as angioplasty w/ stenting of venous anastamosis earlier
this year for similar issue. He was admitted for fistulogram and
underwent this procedure ___. Fistulogram was notable for
proximal stenosis of the brachiocephalic vein now s/p
angioplasty with drug eluting balloon and no residual stenosis.
Fistula was still functional during hospitalization and he was
able to continue with his normal dialysis schedule (MWF). Will
recommend R arm elevation at home and AV care will arrange
follow up within ___ weeks as an outpatient.
CHRONIC/STABLE ISSUES:
======================
#Macrocytic anemia
Stable from prior. Chronic. No signs of active bleeding. Vitamin
B12, folate within normal limits. No evidence of iron
deficiency. Likely ___ renal disease and chronic illness. Please
continue follow up with renal and primary care provider as an
outpatient.
#Thrombocytopenia
Stable from prior. Chronic dating back to ___. Will differ
further workup to PCP as an outpatient.
#Hyperlipidemia: Continue home pravastatin 40 mg PO QPM.
#NIDDM: Resume home glipizide at discharge.
#Schizoaffective disorder: Continue home divaloproex,
risperidone, benztropine.
#HTN: Continue home lisinopril.
TRANSITIONAL ISSUES:
====================
[ ] Underwent angioplasty of RUE AV graft with good result per
AV care team during admission. Please ensure follow up with AV
care team within ___ weeks of discharge and continued R arm
elevation at home. The AV care team will call Mr. ___ within
the next ___ days to schedule this appointment.
[ ] Please continue to monitor anemia as an outpatient per renal
team/PCP
[ ] Workup of chronic thrombocytopenia as per PCP
# CONTACT: ___
Relationship: Brother
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Benztropine Mesylate 2 mg PO QHS
2. Divalproex (DELayed Release) 1000 mg PO QHS
3. Divalproex (DELayed Release) 500 mg PO QAM
4. RisperiDONE 2 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Calcium Acetate 1334 mg PO TID W/MEALS
7. sildenafil 50 mg oral DAILY:PRN
8. GlipiZIDE 20 mg PO DAILY
9. GlipiZIDE 10 mg PO QHS
10. amLODIPine 10 mg PO DAILY
11. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Benztropine Mesylate 2 mg PO QHS
3. Calcium Acetate 1334 mg PO TID W/MEALS
4. Divalproex (DELayed Release) 1000 mg PO QHS
5. Divalproex (DELayed Release) 500 mg PO QAM
6. GlipiZIDE 10 mg PO QHS
7. GlipiZIDE 20 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Pravastatin 40 mg PO QPM
10. RisperiDONE 2 mg PO DAILY
11. sildenafil 50 mg oral DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
AV fistula stenosis
Secondary Diagnosis:
ESRD on HD
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 the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had R arm swelling.
What happened while I was in the hospital?
-You underwent a fistulogram procedure to evaluate your dialysis
graft. The procedure showed a blockage in your graft which was
likely causing your symptoms. This blockage was opened during
the procedure to allow adequate blood flow.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Healthcare Team
Followup Instructions:
___
|
19926727-DS-30 | 19,926,727 | 28,936,456 | DS | 30 | 2192-04-09 00:00:00 | 2192-04-09 22:02:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Haldol / pollen / Actos / NSAIDS (Non-Steroidal
Anti-Inflammatory Drug) / ibuprofen / cefazolin / coriander
Attending: ___.
Major Surgical or Invasive Procedure:
Fistulogram ___ revealing 99% subclavian vein stenosis
attach
Pertinent Results:
ADMISSION LABS
===================
___ 03:20PM URINE HOURS-RANDOM
___ 03:20PM URINE UHOLD-HOLD
___ 03:20PM URINE COLOR-Straw APPEAR-CLEAR SP ___
___ 03:20PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-200*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NORMAL PH-7.0
LEUK-NEG
___ 03:20PM URINE RBC-4* WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-<1
___ 03:20PM URINE HYALINE-1*
___ 03:20PM URINE MUCOUS-RARE*
___ 12:30PM GLUCOSE-58* UREA N-55* CREAT-11.7*#
SODIUM-139 POTASSIUM-5.0 CHLORIDE-100 TOTAL CO2-19* ANION
GAP-20*
___ 12:30PM estGFR-Using this
___ 12:30PM WBC-4.2 RBC-2.78* HGB-9.8* HCT-29.9* MCV-108*
MCH-35.3* MCHC-32.8 RDW-13.9 RDWSD-55.4*
___ 12:30PM NEUTS-64.0 ___ MONOS-8.8 EOS-1.4
BASOS-0.2 IM ___ AbsNeut-2.69 AbsLymp-0.99* AbsMono-0.37
AbsEos-0.06 AbsBaso-0.01
___ 12:30PM PLT COUNT-66*
DISCHARGE LABS
===================
___ 06:50AM BLOOD WBC-3.4* RBC-2.75* Hgb-9.4* Hct-28.3*
MCV-103* MCH-34.2* MCHC-33.2 RDW-13.5 RDWSD-50.9* Plt Ct-54*
___ 06:50AM BLOOD Neuts-60.4 ___ Monos-12.2 Eos-1.8
Baso-0.3 Im ___ AbsNeut-2.03 AbsLymp-0.76* AbsMono-0.41
AbsEos-0.06 AbsBaso-0.01
___ 06:50AM BLOOD Glucose-110* UreaN-35* Creat-8.0* Na-136
K-4.1 Cl-92* HCO3-25 AnGap-19*
___ 06:50AM BLOOD Calcium-9.3 Phos-7.1* Mg-2.0
IMAGING
===============
RUE US ___
No evidence of deep vein thrombosis in the right upper
extremity.
CXR ___
No acute cardiopulmonary abnormality.
FISTULOGRAM ___
The patient has a right upper arm loop graft. - Percutaneous
angioplasty of the subclavian vein with no residual stenosis. -
Percutaneous angioplasty of the brachial vein with no residual
stenosis.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
========================
Mr. ___ is a ___ year old man with ESRD ___ type 2 diabetes
with HD MWF with right arm graft placement in ___
complicated by multiple stenoses, who presented from dialysis
center with edematous RUE concerning for possible stenosis. He
was seen by the transplant team in the ED who felt he likely had
another stenosis. He had a fistulogram with ___ on ___ that
revealed 99% stenosis of the right subclavian vein, and he had
balloon angioplasty with residual 0% stenosis. He had iHD during
his stay on ___ and ___ and ___.
===================
TRANSITIONAL ISSUES
=====================
[] Please continue to monitor for increased bleeding at dialysis
that would suggest that the graft has developed stenosis
[] Please continue to monitor his right arm for swelling. It was
still swollen on ___ when discharged but with full ROM and
sensation and 2+ pulses.
LAST DIALYSIS: ___
CODE: FULL
CONTACT: ___, brother, ___
ACTIVE ISSUES
===================
#RUE swelling c/f subclavian stenosis
#ESRD on HD (___)
Patient presented with progressively swollen right arm with RUE
AV graft. He has had prior subclavian angioplasty with stenting
of venous anastomosis twice so far this year. He most recently
saw transplant surgery on ___ who noted recurring outflow
stenosis that they decided to treat conservatively. He had mild
swelling at that point. On exam this admission he had
significant right arm swelling from hand up to shoulder, did not
have any RUE pain but did have few paresthesias. He had good
radial pulses and no loss of sensation or motor function. ___ was
consulted and he underwent a fistulogram on ___ that showed
99% stenosis of subclavian vein that underwent successful
balloon angioplasty. He underwent iHD on ___ and ___ and
___ without complication.
# Anion Gap
Likely anion gap metabolic acidosis with bicarb 19, AG 20,
secondary to uremia from last HD 3 days prior to admission.
Improved with dialysis during admission.
#Hypoglycemia
Likely given he was NPO for ___ procedure. Glucose was monitored
during his stay and he was given dextrose while NPO.
CHRONIC ISSUES:
===============
#Macrocytic anemia
Stable from prior, Hb range in ___ as a chronic issue. No signs
of active bleeding this admisison. Prior workups while inpatient
have shown normal vitamin B12, folate and no evidence of iron
deficiency. Likely ___ renal disease and chronic illness.
#Thrombocytopenia
Stable from prior. Chronic dating back to ___.
#NIDDM:
Patient takes glipizide as an outpatient. He was given ISS while
inpatient
#Hyperlipidemia:
- Continued home pravastatin 40 mg PO QPM.
#Schizoaffective disorder:
- Continued home divaloproex, risperidone, benztropine.
#HTN:
- Continued home lisinopril.
>30 minutes spent on complex discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Divalproex (DELayed Release) 1000 mg PO QHS
3. Divalproex (DELayed Release) 500 mg PO QAM
4. amLODIPine 2.5 mg PO DAILY
5. Benztropine Mesylate 2 mg PO QHS
6. Calcium Acetate 1334 mg PO TID W/MEALS
7. Pravastatin 40 mg PO QPM
8. RisperiDONE 2 mg PO DAILY
9. GlipiZIDE 20 mg PO DAILY
10. sildenafil 50 mg oral DAILY:PRN
11. GlipiZIDE 10 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
2. Benztropine Mesylate 2 mg PO QHS
3. Calcium Acetate 1334 mg PO TID W/MEALS
4. Divalproex (DELayed Release) 1000 mg PO QHS
5. Divalproex (DELayed Release) 500 mg PO QAM
6. GlipiZIDE 20 mg PO DAILY
7. GlipiZIDE 10 mg PO QHS
8. Lisinopril 2.5 mg PO DAILY
9. Pravastatin 40 mg PO QPM
10. RisperiDONE 2 mg PO DAILY
11. sildenafil 50 mg oral DAILY:PRN
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
RUE AV graft stenosis
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 the ___
___!
WHY WAS I IN THE HOSPITAL?
==========================
- Your right arm was swollen because your veins had become very
narrow
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had HD while you were in the hospital
- You were seen by the interventional radiology team and had a
study done of the graft in your upper arm. They found that the
veins in your upper arm were narrowed, so they opened them up
and now there is no more narrowing.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- Please continue to take all of your medications as directed
- Please follow up with all the appointments scheduled with your
doctor
___ you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19926820-DS-6 | 19,926,820 | 27,364,080 | DS | 6 | 2162-07-28 00:00:00 | 2162-07-28 14:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Acute renal failure and hyperbilirubinemia
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
___ year old gentleman with history of alcohol abuse with
resultant cirrhosis, sCHF (LV EF 20%) thought to be secondary to
non-ischemic cardiomyopathy/alcohol induced, hypertension,
esophageal stricture s/p dilation, HZ keratitis, atrial
fibrillation on apixiban, who presents with two week history of
nausea, vomiting, diarrhea after stopping drinking. He noted
approximately ___ weeks ago he had an episode of drinking 5
beers x 1 day with subsequent development of jaundice over the
past week. Also experienced weakness and lightheadedness.
Of note, patient did have a history of fall one week prior to
admission in which he struck his left rib cage, leading to left
upper quadrant abdominal discomfort.
In the ED initial vitals were 97.1, 68, 70/37, 16, 99% on RA.
Labs were notable for WBC 15.8, H/H 11.5/31.3, platelets 211.
Chemistry notable for creatinine 9.0 (from baseline 1.0),
potassium 6.4 (EKG without acute changes).
LFT's notable for AST 146, ALT 45, Alk Phos 127, Lipase 87, T.
bili 38.5, D. bili 27.9, Albumin 3.3. INR 2.0.
Trop 0.13, BNP 1210.
Lactate 3.8.
UA showed few bacteria but no leuks and negative nitrites.
Urine toxicology negative for benzos, barbs, opiates, cocaine,
amphetamine, methadone, oxycodone.
Serum toxicology negative for ASA, EtOH, acetaminophen, Benzo,
barb, tricyclics.
CT A/P showed acute left seventh through ninth anterior rib
fracturesm 2. cirrhotic liver with mild splenomegaly/no ascites,
3. ectatic common iliac arteries."
CXR showed no acute findings.
In the ED: patient received 2 L normal saline, 4.5 grams
piperacillin-tazobactam, 1000 mg vancomycin, 125 mg
methylprednisolone, 10 units regular insulin x ___ grams 50%
dextrose x 2, 1 gram calcium gluconate.
Given hypotension, patient had a right IJ placed.
Denies any fevers, chills, night sweats, but has had numerous
episodes of non-bilious, non-bloody emesis. Denies melena. No
cough or urinary urgency.
Review of systems: Please see HPI.
Past Medical History:
Esophageal stricture, ___, found on evaluation for
dysphagia s/p dilation
HSV keratitis, followed at ___
History of basal cell carcinoma
Elevated PSA
Alcoholic cirrhosis
Alcohol abuse
Non-ischemic cardiomyopathy
Hypertension
Atrial fibrillation
Social History:
___
Family History:
Mother died of lung cancer. Father died of brain aneurysm. One
brother was shot while in the line of duty as ___ ___
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=================
Vitals: 98, 99, 107/53, 22, 100% on RA.
GENERAL: Alert and oriented x 3, appears somewhat fidgety, but
comfortable, does not appear in any acute distress.
HEENT: Sclera icteric, dry mucous membranes.
NECK: supple, JVP not elevated.
LUNGS: Clear to auscultation, no wheezes, rales or rhonchi.
CV: tachycardic, irregularly irregular.
ABD: slightly distended but non-tender to palpation, no rebound
or guarding.
EXT: Warm, well perfused, 2+ pulses, no lower extremity edema.
SKIN: Jaundiced
NEURO: CN II-XII intact, minimal asterixis.
DISCHARGE PHYSICAL EXAM
=================
VS: 98.1 94-118/47-71 ___ 98-100 2L
GEN: resting comfortably in bed though with increased work of
breathing, AAOx3
HEENT: Sclera icteric
NECK: supple
LUNGS: Wheezes on expiration diffusely
CV: irregularly irregular, NL S1 S2
ABD: distended but non-tender to palpation, no rebound or
guarding.
EXT: Warm, well perfused, 2+ pulses, no lower extremity edema.
SKIN: Jaundiced
NEURO: no asterixis
Pertinent Results:
ADMISSION LABS:
===========
___ 09:14AM BLOOD WBC-15.8*# RBC-2.76* Hgb-11.5* Hct-31.3*
MCV-113*# MCH-41.7* MCHC-36.7 RDW-17.0* RDWSD-70.7* Plt ___
___ 09:14AM BLOOD Neuts-77.6* Lymphs-11.3* Monos-6.4
Eos-2.8 Baso-0.8 Im ___ AbsNeut-12.23*# AbsLymp-1.78
AbsMono-1.01* AbsEos-0.44 AbsBaso-0.13*
___ 09:14AM BLOOD Glucose-153* UreaN-121* Creat-9.0*#
Na-132* K-6.4* Cl-90* HCO3-13* AnGap-35*
___ 09:14AM BLOOD ALT-45* AST-146* AlkPhos-127
TotBili-38.5* DirBili-27.9* IndBili-10.6
___ 09:14AM BLOOD cTropnT-0.13* proBNP-1210*
___ 04:51PM BLOOD CK-MB-6 cTropnT-0.07*
___ 09:14AM BLOOD Lipase-87*
___ 09:14AM BLOOD Albumin-3.3* Calcium-10.3 Phos-6.3*#
Mg-1.7
___ 09:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:25AM BLOOD Lactate-3.8* K-5.7*
PERTINENT INTERMITTENT LABS
==========
___ 06:55AM BLOOD WBC-22.2* RBC-2.13* Hgb-9.4* Hct-25.8*
MCV-121* MCH-44.1* MCHC-36.4 RDW-15.8* RDWSD-70.2* Plt ___
___ 07:05AM BLOOD WBC-15.5* RBC-1.82* Hgb-8.0* Hct-21.8*
MCV-120* MCH-44.0* MCHC-36.7 RDW-15.4 RDWSD-68.1* Plt Ct-69*
___ 07:05AM BLOOD Plt Ct-69*
___ 06:39AM BLOOD Glucose-153* UreaN-119* Creat-2.4*#
Na-136 K-4.7 Cl-94* HCO3-18* AnGap-29*
___ 06:03AM BLOOD Glucose-149* UreaN-117* Creat-1.8* Na-135
K-3.9 Cl-94* HCO3-18* AnGap-27*
___ 05:35AM BLOOD Glucose-87 UreaN-116* Creat-2.1*# Na-137
K-3.8 Cl-96 HCO3-18* AnGap-27*
___ 07:05AM BLOOD Glucose-99 UreaN-69* Creat-1.4* Na-128*
K-4.4 Cl-89* HCO3-25 AnGap-18
___ 06:50AM BLOOD Glucose-155* UreaN-68* Creat-1.5* Na-127*
K-4.1 Cl-88* HCO3-24 AnGap-19
___ 04:40AM BLOOD Glucose-126* UreaN-39* Creat-1.0 Na-129*
K-3.9 Cl-90* HCO3-24 AnGap-19
___ 04:34AM BLOOD Glucose-122* UreaN-43* Creat-1.4* Na-127*
K-3.8 Cl-88* HCO3-25 AnGap-18
___ 07:06PM BLOOD Glucose-105* UreaN-48* Creat-1.5* Na-129*
K-4.1 Cl-89* HCO3-21* AnGap-23*
___ 07:30AM BLOOD ALT-49* AST-93* AlkPhos-177*
TotBili-38.7*
___ 07:01AM BLOOD ALT-42* AST-87* AlkPhos-197*
TotBili-35.3*
___ 07:05AM BLOOD ALT-42* AST-89* AlkPhos-162*
TotBili-36.4*
___ 06:50AM BLOOD ALT-41* AST-87* AlkPhos-174*
TotBili-37.9*
___ 07:09AM BLOOD ALT-36 AST-85* AlkPhos-148* TotBili-36.4*
___ 07:05AM BLOOD ALT-41* AST-90* AlkPhos-142*
TotBili-39.6*
___ 06:16AM BLOOD ALT-44* AST-99* AlkPhos-150*
TotBili-43.3*
___ 04:40AM BLOOD ALT-39 AST-86* AlkPhos-167* TotBili-37.3*
___ 04:34AM BLOOD ALT-41* AST-83* AlkPhos-179*
TotBili-40.0*
MICROBIOLOGY
=========
___ 11:42AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:42AM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-MOD Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:42AM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 11:42AM URINE Mucous-RARE
___ 06:50PM URINE Hours-RANDOM UreaN-297 Creat-61 Na-70
___ 11:42AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Time Taken Not Noted Log-In Date/Time: ___ 11:42 am
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___: NO GROWTH.
IMAGING
___: CHEST (PORTABLE AP)
IMPRESSION: No acute findings on this limited chest radiograph.
___: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
IMPRESSION:
1. Acute left seventh through ninth anterior rib fractures.
2. Cirrhotic liver with mild splenomegaly. No ascites.
3. Ectatic common iliac arteries.
___: RUQ US
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded
on the basis of this examination.
2. Patent portal vein with slow flow.
3. Mild splenomegaly.
___ RENAL DOPPLER ULTRASOUND
Renal Doppler: Intrarenal arteries show normal waveforms with
sharp systolic
peaks and continuous antegrade diastolic flow. The resistive
indices of the
right intra renal arteries range from 0.70-0.75, which is normal
to minimally
elevated. The resistive indices on the left range from
0.63-0.73, which is
normal to minimally elevated. Bilaterally, the main renal
arteries are patent
with normal waveforms. The peak systolic velocity on the right
is ___
centimeters/second. The peak systolic velocity on the left is
approximately
150 centimeters/second. Main renal veins are patent bilaterally
with normal
waveforms.
The bladder is moderately well distended and normal in
appearance.
IMPRESSION:
Normal renal ultrasound. No specific evidence of renal artery
stenosis.
___ CXR
Compared to chest radiographs starting ___, most recently
___. Mild cardiomegaly is chronic. Pulmonary
vasculature is
unremarkable. Lungs are clear. No pleural abnormality.
Feeding tube passes
into the stomach and out of view
___ Abd US
Transverse ultrasound images were obtained of the 4 quadrants of
the abdominal
cavity. No intra-abdominal free fluid is identified.
IMPRESSION:
No evidence of ascites.
___ CXR:
IMPRESSION:
New mild pulmonary edema, evidenced by peribronchial cuffing and
increased
interstitial lung markings. No new focal consolidation.
___ RUQ Doppler:
IMPRESSION:
1. No portal vein thrombus identified.
2. Coarsened nodular hepatic architecture consistent with the
patient's known cirrhosis.
3. Splenomegaly.
4. Moderate ascites.
___ CXR:
In comparison to previous radiograph of 1 day earlier, the
cardiac silhouette remains enlarged. Mild pulmonary vascular
congestion is present without overt pulmonary edema. No focal
areas of consolidation are evident within the lungs.
DISCHARGE LABS
==========
No labs drawn on day of discharge.
Brief Hospital Course:
Mr. ___ is a ___ year old man with alcohol cirrhosis c/b
ascites and possible hepatic encephalopathy with active drinking
at the time of admission, non-ischemic cardiomyopathy/alcohol
induced sCHF (LV EF 40%) and atrial fibrillation on apixiban at
home, who presented alcohol hepatitis and acute kidney failure.
Patient was discharged with home hospice ___.
#Alcohol Hepatitis/Childs C Alcohol cirrhosis:
Patient was actively drinking as an outpatient and then after a
binge developed symptoms consistent with etoh hepatitis. DF 86
on admission, elevated to 107 at maximum. After initial
infectious workup yielded no growth, patient was started on
prednisone for treatment. He received prednisone for 7 days
(___). Lille 0.7 on day 7 of steroids indicated he was not
steroid responsive and steroids were stopped. He also has had a
feeding tube placed for maximal nutrition along with thiamine
and folate supplemention. He was given ursodiol for cholestasis.
Bilirubin remained stably elevated between low ___ after
steroids completed. He was started on 400mg Pentoxifylline TID
on ___, with some improvement in renal failure but no
improvement in liver function. The patient's kidneys then began
to worsen again, and diuresis became challenging. He was 20
pounds up from his admission weight, and grossly volume
overloaded. He had been comfortable during most of his
admission, and then began to develop shortness of breath due to
volume overloaded, requiring multiple doses of 80-100 mg IV
Lasix, which he did respond to. Given his failure to improve and
worsening respiratory status and difficulty diuresing without
causing worsening renal failure, a family meeting was held on
___, and patient expressed his clear desire to go home with
home hospice. He wants to be at home with his family, and to
maximize comfort and quality of life at this point in time.
#Acute renal failure: Admission creatinine was 9.0 from baseline
___. Workup yielded like prerenal from
decreased PO intake, diarrhea, alcohol hepatitis. He improved
with albumin and supportive care. However, when we attempted to
restarted diuresis, creatinine markedly came up, and diuresis
was again held. His kidney function began to improve, and then
slowly began to decline again, and his volume status worsened as
above. Volume status was then what team focused on as he was
dyspneic.
#Afib: CHADS: 2. Metoprolol was started after the patient was
hemodynamically stable. Apixaban was held as it is
contraindicated in Childs C patients, and his INR was ___ from
liver disease.
#Leukocytosis: Elevated to 27 on ___ from 20. No focal signs
of infection. A repeat infectious workup was negative x2. Likely
secondary to alcohol hepatitis.
# Alcohol Induced Cardiomyopathy: EF 40% on echo this admission.
Lisinopril was held in the setting of acute renal failure.
Metoprolol was restarted when he was hemodynamically stable.
# Rib Fracture: Patient admitted with left sided rib fracture
due to fall, pain initially was controlled with lidocaine
patches and oxycodone prn, both of which he was not requiring at
discharge.
# Herpes Keratitis: He was started on acyclovir and
transitioned to his home valacyclovir 1000mg BID as renal
function improved. He shared he did not want to continue this
medication when discharged with hospice, and therefore it was
discontinued.
TRANSITIONAL ISSUES
================
#Patient discharged with home hospice to maximize comfort and
quality of life
#Code: DNR/DNI, MOLST filled out with patient.
#Contact/HCP: ___, Wife.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Apixaban 5 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Lisinopril 10 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Omeprazole 40 mg PO BID
6. Potassium Chloride 20 mEq PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Sucralfate 1 gm PO TID
9. Torsemide 80 mg PO DAILY
10. ValACYclovir 1000 mg PO Q12H
11. Vitamin D ___ UNIT PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Lactulose 30 mL PO TID constipation
Please take this so that you have ___ bowel movements per day.
RX *lactulose 20 gram/30 mL 30 ml by mouth three times a day
Refills:*0
2. Ursodiol 300 mg PO BID
***If you feel like this isn't helping you, you can stop it***
RX *ursodiol 300 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
3. Metoprolol Succinate XL 25 mg PO DAILY
4. Torsemide 80 mg PO PRN shortness of breath
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Alcoholic Hepatitis, acute kidney failure
Secondary: Alcoholic Cirrhosis, chronic systolic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospitalization
at the ___. You were admitted
to ___ because your liver and kidneys became very sick from
drinking too much alcohol. You were supported with IV fluids,
and watched very closely. You were also given one week of
steroids to help treat your liver injury, but that medication
was stopped because it did not help much. You were started on a
new medication, Pentoxifylline, to attempt to improve you liver
function and kidney function. This also did not work very well.
Because your liver and kidneys were both very sick, and you have
a history of heart failure, your body became very full of fluid.
It became difficult to manage the fluid in your body without
hurting your kidneys.
After many discussions with you and your family, you decided you
would prefer to go home and spend your time with your family and
focus on comfort and quality of life at this time. If you ever
decide you want to come back to the hospital, you absolutely
can.
You are being discharged with home hospice care, and can
continue to contact us, your primary care team, and your liver
doctor, for whatever you may need or questions you might have.
It was a pleasure caring for you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19926992-DS-17 | 19,926,992 | 23,088,200 | DS | 17 | 2158-06-02 00:00:00 | 2158-06-02 21:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Altered mental status, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Obtained per chart, patient not reliable historian, son not
available.
Per son in ___ and chart: ___, h/o dementia, TIA, HTN
alterntating with hypotension, afib on coumadin, ___, mild MS,
mild pulm htn, lower extremity edema discharged from OSH about 2
weeks ago after being treated for PNA saw PCP today and referred
to the ___ for confusion, weakness, ? hypotension. Per son she
has had decreased PO intake and weakness x3 days, required more
supervision taking medications. Also, she had a fall about 4
days ago and hit her head. Has had a cough, no fevers. Also with
abdominal pain, no n/v, no diarrhea/constipation or bloody
stool.
In the ___ initial vitals: 0 97.3 82 100/52 20 100% .
Labs notable for Cr 1.9 (baseline 1.47), K was hemolyzed and
normal on repeat. UA with 8wbc's, <1 epi, neg nitrite. Lactate
2.1. BNP 1881, INR 2.3. Given 500cc NS, 1g Ceftriaxone. CT
abdomen showed
fecal loading. cxr, ct cspine and head unrevealing.
Vitals on transfer :
Today 21:26 0 97.7 72 112/60 18 100% RA
Past Medical History:
Permanent atrial fibrillation, CHADS2 score of 5, on
Coumadin.
Fluctuating blood pressures with periodic hypertension and
hypotension.
Diastolic CHF, ___ Heart Association Class 3.
known ___ systolic ejection murmur loud P2 and a ___ diastolic
murmur heard loudest at the base.
Mild functional MS.
___ pulmonary hypertension.
Lower extremity edema.
Dementia.
History of TIA ___ years ago.
Right hip fracture in ___.
Borderline diabetes.
Fibromyalgia.
GERD.
Hearing loss.
Sinusitis.
Vertigo.
Social History:
___
Family History:
N/c
Physical Exam:
ADMISSION
Vitals - T: 97.5, 162/76, 84, 18, 99%RA
GENERAL: NAD,
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, dentures
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, ___ systolic murmur
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mildly tender in suprapubic region
and superior to this, no rebound
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. Oriented to person, date of birth,
___ "snow outside". Could not guess year or date or her age.
Able to do days of week backwards. Speech fluent and
appropriate.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE
Vitals: 98.4 98.1 134-157/59-67 ___ 96-98% RA
General: asleep in bed, easily aroused, NAD
HEENT: sclera anicteric, MMM
Lungs: diffuse crackles, no incr WOB
CV: irregularly irregular, nl rate, nl S1/S2, ___ systolic
murmur best heard over RLSB, no rubs or gallops; no carotid
bruit appreciated
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding
GU: no foley
Ext: warm, well perfused, no clubbing, cyanosis or edema
Neuro: MS: oriented x name only. More attentive and more linear
thought process than yesterday.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:10PM BLOOD WBC-4.6 RBC-4.74 Hgb-13.5 Hct-41.8 MCV-88
MCH-28.5 MCHC-32.4 RDW-15.2 Plt ___
___ 04:10PM BLOOD Neuts-52.8 ___ Monos-12.2*
Eos-2.2 Baso-0.4
___ 04:10PM BLOOD ___ PTT-41.7* ___
___ 04:10PM BLOOD Plt ___
___ 04:10PM BLOOD Glucose-99 UreaN-52* Creat-1.9* Na-134
K-7.5* Cl-97 HCO3-26 AnGap-19
___ 04:10PM BLOOD ALT-23 AST-81* CK(CPK)-135 AlkPhos-78
TotBili-0.3
___ 04:10PM BLOOD Lipase-97*
___ 04:10PM BLOOD proBNP-1881*
___ 04:10PM BLOOD Albumin-3.5 Calcium-8.7 Phos-4.0 Mg-2.4
___ 04:27PM BLOOD Lactate-2.1* Na-135 K-4.6
___ 06:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:15PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 06:15PM URINE RBC-1 WBC-8* Bacteri-FEW Yeast-NONE
Epi-<1 TransE-1
___ 06:15PM URINE CastHy-32*
___ 06:15PM URINE Mucous-RARE
PERTINENT LABS:
===============
___ 07:31AM BLOOD ___ PTT-47.9* ___
___ 07:31AM BLOOD Lipase-60
___ 05:59PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:59PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:59PM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-1
___ 05:59PM URINE CastHy-6*
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-5.7 RBC-4.46 Hgb-12.5 Hct-38.9 MCV-87
MCH-27.9 MCHC-32.0 RDW-15.0 Plt ___
___ 10:15AM BLOOD ___
___ 06:50AM BLOOD Glucose-80 UreaN-21* Creat-1.1 Na-141
K-3.9 Cl-105 HCO3-28 AnGap-12
___ 06:50AM BLOOD Calcium-8.6 Phos-2.6* Mg-2.1
MICROBIOLOGY:
=============
___ BLOOD CULTURE
Blood Culture, Routine (Pending):
___ URINE
URINE CULTURE (Final ___: <10,000 organisms/ml
IMAGING:
========
CXR ___: Hiatal hernia, small right pleural effusion. No overt
edema or pneumonia.
CT C-spine ___: No acute fracture, malalignment, or prevertebral
soft tissue abnormality.
CT Head ___: 1. No acute infarct, hemorrhage, or fracture.
2. Age-related involutional changes and sequela of chronic small
vessel
ischemic disease.
CT A/P ___: 1. Large fecal loading of the colon, most severe in
the rectum, with probable
mild proctitis.
2. Large hiatal hernia.
CT Head ___: No acute intracranial hemorrhage or mass effect.
Other details as above.
Correlate clinically the to decide on the need for further
workup or followup.
CXR ___: The heart is mildly enlarged, slightly increased in
size since ___. There is increased central
pulmonary vascular congestion, without overt edema. There is no
pneumothorax, focal consolidation, or pleural effusion. Moderate
degenerative changes throughout the thoracic spine appear
stable.
Brief Hospital Course:
This is a ___ year old female with past medical history of
dementia, atrial fibrillation on coumadin, chronic diastolic
heart failure, recent OSH stay for pneumonia, with
post-discharge period complicated by acute metabolic
encephalopathy, admitted ___ and found to have constipation
and ___, volume resuscitated and bowel regimen enhanced,
symptoms resolved, discharged to rehab.
#) Acute Metabolic Encephalopathy - patient with dementia, with
baseline several months prior independent of most ADLs, but over
recent ___ months has had significant decline, presenting with
acute worsening, including agitation and confusion; workup
notable for ___ and constipation (see below); with treatment of
these issues her mental status improved to recent baseline per
family (see below)
#) ___: Cr peaked at 1.9 on admission, secondary to dehydration;
improved with IV hydration, Cr at 1.1 at time of discharge.
ACEi, which was held, was restarted at discharge.
# Constipation - admitted without moving bowels x 1 week; was
passing flatus and no concern for obstruction; CT showed
extensive fecal loading; she received augmented bowel regimen as
well as bisacodyl per rectum followed by manual disimpaction.
Bowel regimen was continued, with regular stooling.
#) ATRIAL FIBRILLATION: CHADS2 = 5. Course was complicated by
INR 4.1, prompting holding of Coumadin on day of discharge.
#) DIASTOLIC CHF: Lasix held in setting of ___ restarted once
patient was taking reliable PO.
TRANSITIONAL ISSUES:
====================
[] Warfarin was held in the setting of antibiotics and
supratherapeutic INR. A repeat INR should be obtained tomorrow.
If the INR < 2.5, please start on 2.5mg QD warfarin and repeat
INR in 3 days. Continue to increase dose to home dose (2.5mg
QMWF, 5mg QTThSaSu) as long as INR remains at goal ___
[] Lasix was originally held due to concern for volume depletion
on admission, and was restarted to 40mg PO QD (half of her home
dose) prior to discharge to rehab. Daily weights should be
followed at rehab, and her dose should be adjusted accordingly.
Stopped potassium supplement given reinitiation of lasix at half
dose.
[] Baseline mental status on this admission was oriented to
name, and variably to date, with fair to poor attention and
tangential thought. She was always interactive.
[] She was started on olanzapine 2.5mg PO QHS as a sleep aid the
night prior to discharge, which helped her sleep. This may be
necessary in the future if she develops irregular sleeping
habits.
-Full Code confirmed w/ HCP
#Emergency Contact: ___ (son) - ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Klor-Con M20 (potassium chloride) 20 mEq oral daily
2. Lisinopril 5 mg PO DAILY
3. Warfarin 2.5 mg PO QMWF
4. Furosemide 40 mg PO BID
5. Warfarin 5 mg PO QTRSASU
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
4. Docusate Sodium 100 mg PO BID
5. OLANZapine (Disintegrating Tablet) 2.5 mg PO QHS
6. Polyethylene Glycol 17 g PO TID
7. Senna 8.6 mg PO BID
8. Klor-Con M20 (potassium chloride) 20 mEq oral daily
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Altered mental status of unclear etiology
Constipation
Acute kidney injury
Secondary diagnoses:
Atrial fibrillation
Diastolic congestive heart failure
Dementia
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 admitted to ___ on ___ for concerns about confusion,
weakness, decreased food intake, and abdominal pain. We ruled
out infection, including pneumonia or urinary tract infection,
electrolyte imbalances, medication-related changes, or possible
bleeding in your head after your fall a few days prior. Your
abdominal discomfort was likely due to constipation, which
resolved. Your kidney function was decreased when you arrived
but has since returned to normal. You have remained confused
since your admission, but we have ruled out important reversible
or life-threatening causes of your mental status changes. It is
possible that given the reported onset of these changes since
your admission for pneumonia at ___, it will take
significant time to return to baseline. We had to hold your
warfarin during the admission, and we will restart it at rehab.
Thank you for allowing us to take part in your care.
___ MDs
Followup Instructions:
___
|
19927180-DS-16 | 19,927,180 | 26,488,138 | DS | 16 | 2178-03-22 00:00:00 | 2178-03-23 10:59:00 |
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:
Menorrhagia
Major Surgical or Invasive Procedure:
2 units of packed red blood cell transfusion
History of Present Illness:
this is a ___ y/o G2P1 who has had heavy vaginal bleeding since
___. She has been using up to 1 pad an hr, and passing grape
sized blood clots. She denies LOC, no syncope, some light
headedness when she stands up too fast, but no SOB. She had some
palpitations which resolved today. She was stable at the triage
with nl VS, and using only 1 pad in 4 hrs.
However, after leaving she was symptomatic and briefly lost
consciousness after a prodrome of "tunnel vision",
lightheadedness. In gyn triage hct had been 30 (last hct ___
was 40). At this time feels lightheaded/dizzy with ambulation.
No abd pain, N/V, F/C.
Past Medical History:
PMH: Fe-def anemia, fibroids
PSH: D&C, lumpectomy in ___ (benign)
OBHx:
G1: SAB -> D&C
G2: SVD, daughter ___: dD&C x ___ SAB, nl pap
SH: ___
Family History:
non-contributory
Physical Exam:
On Admission:
Vitals:
115/73 P88 RR16 T98.2 100% on RA
Gen: A&O, NAD
CV: RRR
Resp: CTAB
Abd: +BS, soft, NT/ND, no rebound or guarding
Ext: calves nontender bilaterally, no c/c/e
On discharge:
AF, VSS
GEn: A&O, NAD
CV: RRR
Resp: CTAB
Abd: +BS, soft, NT/ND, no rebound or guarding
Ext: calves nontender bilaterally, no c/c/e
Pertinent Results:
___ 07:20PM WBC-8.8 RBC-2.79* HGB-8.8* HCT-26.2* MCV-94
MCH-31.6 MCHC-33.6 RDW-12.1
___ 07:20PM NEUTS-79.0* LYMPHS-14.6* MONOS-5.0 EOS-1.1
BASOS-0.2
___ 07:20PM PLT COUNT-267
___ 06:35PM URINE HOURS-RANDOM
___ 06:35PM URINE UCG-NEGATIVE
___ 06:35PM URINE COLOR-Red APPEAR-Clear SP ___
___ 06:35PM URINE BLOOD-LG NITRITE-POS PROTEIN->300
GLUCOSE-250 KETONE-150 BILIRUBIN-LG UROBILNGN->8 PH-8.5* LEUK-LG
___ 06:35PM URINE RBC->182* WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
___ 05:42PM GLUCOSE-100 UREA N-14 CREAT-1.0 SODIUM-141
POTASSIUM-4.0 CHLORIDE-108 TOTAL CO2-27 ANION GAP-10
___ 05:42PM estGFR-Using this
___ 10:56AM WBC-7.4 RBC-3.28*# HGB-10.3*# HCT-30.2*#
MCV-92 MCH-31.4 MCHC-34.1 RDW-12.4
___ 10:56AM PLT COUNT-282
Brief Hospital Course:
This is a ___ G2P1 who presented with menorrhagia in the
setting of known fibroid uterus. At triage, her Hct was
initially 30, which decreased to 26 in the ED, which ultimately
led to her admission for observation.
A repeat Hct was performed on ___ evening, and she had a hct
of 21.6. She was given provera 20 in the ED at that time. Given
that she was symptomatic with some dizziness while ambulating
though her vitals signs remained stable with her heart rate in
the ___, the decision was made to transfuse 2 units of PRBC
after the patient's consent. Her post-transfusion hct was 27.5.
We closely observed Mrs. ___ with strict Is&Os and pad
counts, and she remained clinically stable throughout her stay.
She tolerated a normal diet, ambulated independently, minimal
pain reported and urinated spontaneously. She was in stable
condition, so we discharged her to home with a schedule
follow-up, as well as prescribed medication including
norenthindrone 15mg QD and her home Fe-Sulfate.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Ibuprofen 400 mg PO Q8H:PRN pain
4. norethindrone acetate 5 mg Oral daily
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Ibuprofen 400 mg PO Q8H:PRN pain
3. Multivitamins 1 TAB PO DAILY
4. norethindrone acetate 15 mg Oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Menorrhagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You have been admitted to the Gynecology service for symptomatic
anemia due to heavy vaginal bleeding. You have been transfused
with 2 units of blood, and have had a follow-up hematocrit of
27.5. You are in stable condition, as you are eating a regular
diet, urinating spontaneously, walking without assistance with
minimal bleeding. We have deteremined that you are in good
condition for discharge, and you have a scheduled follow-up with
Dr. ___ a preliminary surgery date in ___ for a
hysterectomy. Your prescription for norenthindrone has already
been routed to your pharmacy, and a receipt has been given to
you.
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 appointment.
* 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:
___
|
19927870-DS-7 | 19,927,870 | 23,539,302 | DS | 7 | 2124-09-01 00:00:00 | 2124-09-01 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
altered mental status, failure to thrive
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with history of CKDIII,
prostate CA, HTN, glaucoma, multiple admissions for FTT who
presents from PCP's office with altered mental status and
failure to thrive.
Per ___ daughter she was bringing her father to his PCP
today for evaluation of R leg pain and R ischial pressure ulcer.
Patient has had R leg pain and weakness x months. The R ischial
pressure ulcer was noted by one of ___ homemakers.
Additionally, patient has had intermittent altered mental status
for the past month. Per homemaker patient was axox3 this
morning, no change in mental status. When daughter arrived to
take patient to PCP ___ voice had low tone and she had
difficulty understanding what he was saying. When they arrived
to the doctor's office, within ___ minutes patient became
silent and minimally responsive in his wheelchair. According to
PCP chart vitals 97.5 HR 125 B 126/82 O2 sat 96% on RA. Patient
was then taken by ambulance to ___ ED.
In the ED, initial vital signs were: 97.4 ___ 16 98% on RA
Exam notable for lethargy, minimal responsiveness, L hip
pain/pressure ulcer, Stage 2 pressure ulcer to R ischium,
cracked R heel.
Labs notable for WBC 5.3, Cr 1.1, Ca ___ (with albumin 3.5,
corrected calcium 11.1). UA with 50 RBC >182 WBC many bacteria 8
epi. CXR without infiltrate.
Given initial hypotension, patient given vancomycin, zosyn, and
1L IVF. After fluids BP improved, patient mental status
improved. Patient was then admitted for further work up of
failure to thrive.
On Transfer Vitals were: 97.4 98 121/83 18 99% on RA
On arrival to the floor the patient is axox3. He reports R leg
pain with decreased sensation and weakness x "months". He has
not noted any incontinence of bowel or bladder. Additionally he
complains of R hip pain, painful wound on R ischium, pain at
bottom of R heel. He has not had any recent falls.
Patient denies fevers, chills. Reports he has had a "cold" for
past month with rhinorrhea, sore throat. He has not had any
cough, shortness of breath, wheeze. He denies abdominal pain,
n/v/d/constipation, reports he eats 3 meals/day and has good
appetite. However, ___ daughter reports he intermittently
refuses meals, is very picky about what he will eat. Daughter
___ states patient has had multiple admissions for failure
to thrive and patient has refused to go to a rehabilitation
facility.
Review of ___ past medical records notable for admission
___ for back pain and R leg weakness, found to have CT C3-4
spinal stenosis, no additional findings on imaging to explain
pain. Given pain, elevated calcium, SPEP/UPEP checked which were
normal.
Past Medical History:
- CKD III
- prostate cancer s/p external beam radiation ___ [high
recurrence risk / ___ 4+4, signs of biochemical recurrence
by ASTRO criteria, PSA-DT ___ year, PSA 1.1 ___
- HTN
- glaucoma
- legally blind
- recurrent falls, Poor balance, Failure to thrive (scheduled
for brain MRI)
- Anemia
- Vit D deficiency
- right hip bursitis s/p steroid injection ___
- benign renal mass/oncocytoma
Social History:
___
Family History:
Mother died after broken hip, father had hypertension
Physical Exam:
Physical Exam on Admission:
Vitals:97.4 100 138/91 16 100% on RA
General: very thin older ___ gentleman with
temporal wasting, with eyes closed lying in bed, speaking in
full sentences, NAD
HEENT: PERRL, no conjunctival pallor, no scleral icterus, moist
mucous membranes, oropharynx without erythema or exudate,
minimal dentition
Lymph: no anterior cervical lymphadenopathy
CV: tachycardic, S1, S2 without m/r/g, JVP flat
Lungs: CTAB, no wheezes, crackles, rhonchi
Abdomen: very thin, non distended, non tender to deep palpation,
+BS
GU: foley in place with clear urine
Ext: warm, well perfused, dry skin on bilateral feet without
open wound, erythema. no lower extremity edema. strength ___
LLE, ___ RLE
Neuro: axox3, CN II-XII grossly intact, decreased sensation to
light touch R lower extremity
Skin: warm, well perfused, R ischium with stage II ulcer without
erythema or induration
Physical Exam on Discharge:
Vitals: 98.9/98.9 96 (80-100) 111/77 (90-100/50-30) 18 100% on
RA
General: Frail, elderly gentleman lying in bed with eyes closed,
responds slowly to questions with full answers, no acute
distress
HEENT: PERRL, dry MM, oropharynx without erythema, exudate,
thrush
Lymph: no anterior cervical lymphadenopathy
Lungs: CTAB, no crackles, wheezes, rhonchi
CV: regular rate and rhythm, s1/s2 without m/r/g
Abdomen: very thin and cachectic non distended, non tender to
deep palpation, +BS
Ext: warm, well perfused, dry skin on bilateral heels, boots in
place
Neuro: axox3, able to move all four extremities, decreased grip
strength and ___ grip strength LUE; ___
strength LLE, ___ strength RLE, able to move bilateral lower
extremities with sensation to light touch intact
Skin: dry bilateral heels, stage II pressure ulcer R ischium
with dressing in place that is c/d/i
Pertinent Results:
Labs on Admission:
___ 12:23PM BLOOD WBC-5.3 RBC-4.07*# Hgb-12.6*# Hct-37.9*#
MCV-93 MCH-31.0 MCHC-33.3 RDW-14.8 Plt ___
___ 12:23PM BLOOD Neuts-70.1* ___ Monos-4.6 Eos-0.7
Baso-0.2
___ 12:23PM BLOOD ___ PTT-28.9 ___
___ 12:23PM BLOOD Glucose-91 UreaN-20 Creat-1.1 Na-140
K-4.8 Cl-103 HCO3-22 AnGap-20
___ 12:23PM BLOOD ALT-15 AST-35 AlkPhos-79 TotBili-0.4
___ 12:23PM BLOOD Lipase-41
___ 12:23PM BLOOD Albumin-3.5 Calcium-10.7* Phos-2.9 Mg-1.7
___ 06:29AM BLOOD pH-7.39 Comment-GREEN TOP
___ 12:43PM BLOOD Lactate-2.3*
___ 06:29AM BLOOD freeCa-1.23
PERTINENT LABS:
___ 05:53AM BLOOD VitB12-934*
___ 05:53AM BLOOD TSH-0.98
___ 05:53AM BLOOD PTH-42
LABS ON DISCHARGE:
___ 07:00AM BLOOD WBC-4.8 RBC-3.22* Hgb-10.0* Hct-30.6*
MCV-95 MCH-31.1 MCHC-32.8 RDW-15.2 Plt ___
___ 07:00AM BLOOD Glucose-90 UreaN-15 Creat-0.9 Na-136
K-4.8 Cl-103 HCO3-29 AnGap-9
___ 07:00AM BLOOD Calcium-9.3 Phos-2.6* Mg-2.0
MICRO:
___ 12:50 pm URINE
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Blood cultures- NGTD
IMAGING:
CXR ___:
IMPRESSION:
Hyperinflated lungs suggesting COPD. No focal consolidation.
MRI Brain ___:
IMPRESSION:
1. No evidence of acute infarction or acute hemorrhage.
2. Generalized parenchymal volume loss.
3. Confluent T2/FLAIR signal hyperintensity in the white matter
of the
bilateral cerebral hemispheres which is nonspecific but likely
on the basis of
chronic small vessel ischemic disease.
4. Multiple small foci of susceptibility artifact in the
bilateral cerebral
hemispheres and pons as detailed above. Findings may represent
chronic
microhemorrhage or amyloid angiography.
5. Slightly prominent empty sella versus arachnoid cyst. If
clinical concern
over this finding warrants, a dedicated MR of the pituitary
gland could be
obtained for further evaluation.
Brief Hospital Course:
Mr. ___ is a ___ year old gentleman with history of CKDIII,
prostate CA, HTN, glaucoma, multiple admissions for FTT who
presents from PCP's office with altered mental status, weakness,
brief hypotension that resolved with IVF. MRI brain negative for
acute process. Patient found to have E. coli UTI treated with
ciprofloxacin. Patient was found to be malnourished with poor PO
intake. Nutrition recommended g tube placement but this was not
within patient or ___ daughter's goals of care. Physical
therapy evaluated patient and recommended acute rehabilitation
but patient adamantly refused rehabilitation and requested to go
home. Met with patient, daughter, and palliative care team and
patient decided to return to home with home hospice. Patient
decided that he would want resuscitation (FULL CODE) but would
not want to be hospitalized. Patient completed a MOLST form
prior to discharge to reflect this and was discharged to home
with home hospice.
#Weakness: Patient with generalized weakness requiring
assistance for all transfers, R>L sided weakness on exam. No
evidence of acute infarct or stroke on MRI brain, only signs of
chronic small vessel disease. ___ weakness most likely
secondary to poor PO intake given cachectic appearance, low body
weight, dehydration. Patient and his daughter would not be
interested in g tube or artificial feeding at this time. ___ has
recommended acute rehab though patient has declined at this
time, ___ lift ordered per ___ recommendations to help with
home transfers.
#Altered Mental Status: Patient with intermittent altered mental
status, has appeared dry and improved with IVF x2 consistent
with poor PO intake and dehydration. He has evidence of chronic
small vessel changes on MRI but no new stroke to explain mental
status changes. Also consider component of delirium given waxing
and waning nature. ___ be component of infectious etiology given
Ecoli UTI which we treated as below.
#UTI: Patient with +UA, urine cultures with E.coli. Given
___ altered mental status on admission, treating for male
UTI with cipro 500mg PO q12 x 7 d1= ___, last dose ___.
#Goals of Care: Patient with multiple admission for failure to
thrive, weakness, and has refused acute rehabilitation. During
this admission patient evaluated by physical therapy who again
recommended acute rehabilitation, which patient declined.
Patient consistently expressed a desire to return home. He
indicated that he is very happy at home with his home care,
enjoys their food. He expressed that he would not want to be
hospitalized in the future. He would, however, like to be full
code with CPR and intubation. In-patient medicine team me with
patient, his daughter ___, and palliative care team to
discuss goals of care. We determined together that patient will
return home with home hospice. Conversation discussed with
primary care physician ___. Additionally we
completed a MOLST form that indicated patient would like to be
full code, but does not want hospitalization unless for comfort.
This will need to be readderessed in the outpatient setting.
MOLST form specifics: Yes to CPR and intubation, no to re-
hospitalization, no to artificial feeding, yes to IVF, undecided
re dialysis. Patient was discharged to home with home hospice.
#R Ischial Pressure Ulcer: Appears to be stage 2 without
superimposed infection. Monitored closely by nursing with daily
wound care and dressing changes. Please continue upon discharge.
#Poor nutrition: Patient appears cachectic with poor PO intake
per daughter's report. Nutrition recommended strawberry
scandishake once daily, Ensure Plus BID, Ensure Pudding & Magic
Cup once daily each. Nutrition recommended PEG tube placement,
however patient refused and daughter agreed that this was not
within ___ goals of care.
#Hypercalcemia: Resolved. Patient presented with elevated Ca
___ (corrected) which improved to 9.5 with IVF, i cal 1.23.
SPEP/UPEP negative ___, PTH within normal limits.
CHRONIC MEDICAL ISSUES:
#Hypertension: Continued home amlodipine with holding
parameters.
#Glaucoma and blindness: Continued home latanoprost eye drops,
blind precautions for patient room.
=====================
TRANSITIONAL ISSUES:
=====================
[]UTI- E.coli UTI, please continue Cipro 500mg PO q12 x 7 d1=
___, last dose ___.
[] R ischial stage II pressure ulcer- please continue to monitor
closely with daily dressing changes and wound care.
[] Goals Of Care-MOLST form completed prior to discharge: Yes to
CPR and intubation, no to re- hospitalization, no to artificial
feeding, yes to IVF, undecided re dialysis. Please continue to
address with patient.
# Code: FULL confirmed with patient, but patient does not want
to return to hospital
# Emergency Contact: daughter ___
Phone number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Omeprazole 40 mg PO DAILY
3. Amlodipine 10 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
5. Vitamin D 1000 UNIT PO DAILY
6. Acetaminophen 325-650 mg PO Q6H:PRN pain
Discharge Medications:
1. ___ Lift
Diagnosis: Malnutrition induced myopathy with muscle wasting.
Need: Lifetime
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*8 Tablet Refills:*0
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
4. Amlodipine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP RIGHT EYE QHS
7. Omeprazole 40 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Cystitis
Malnutrition
Dehydration
Secondary Diagnosis: Stage II Pressure Ulcer R Ischium
Hypertension
Glaucoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and minimally interactive.
Activity Status: Out of Bed requiring significant assistance to
chair or wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your recent
admission to ___. You came into
the hospital because you were very weak and had altered mental
status. We found that you had a urinary tract infection and
started you on antibiotics which you will continue on discharge.
You had an MRI of your brain that showed that you did not have a
stroke. Your altered mental status and weakness was likely due
to your poor oral intake and malnutrition, as your mental status
improved with IV fluids. Our physical therapists worked with you
and recommended that you go to acute rehabilitation. You
determined that you did not want to go to rehabilitation and
that you wanted to go home. You met with our palliative care
services and a hospice team and determined that you would prefer
to go home with home hospice and would not like to remain in the
hospital. You will establish care with ___ hospice on your
discharge today. You requested that you not be brought back to
the hospital if you were to get more ill and inidcated that you
would prefer to stay at home and continue to receive medical
therapy there.
Be well and take care.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19928034-DS-10 | 19,928,034 | 29,255,503 | DS | 10 | 2148-08-27 00:00:00 | 2148-08-29 07:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient followed by ___ oncology for high-grade B cell lymphoma
and on chemo Patient seemed warm to touch to her husband and
checked temp with 101.8 12:40 am
Has hx UC and recently hospitalized with neutropenic fever
last week Discharged home with occasional fevers attributed to
colitis flare but temps were lower at 99-100 Also discharged
home on prednisone Now temp tonight 101.8 Advised by oncologist
on-call Dr. ___ to go to ED for further eval
In the ED, initial vitals: 100.3 93/52 94 16 98%RA
- Exam notable for Unremarkable, benign abd
- Labs were notable for:
7.2>8.2/24.1<450 MCV 100 76%N 2 bands 1 meta 2 myelo
repeat 10 hours later: 6.4>7.4/23.7<456 MCV 101 with 87%N 2%
bands
___
---------<196
4.7/24/0.6
repeat 10 hours later
137/101/15
----------<161
3.7/24/0.7
lactate 1.7->2.0
haptoglobin 550
fibrinogen 533
___ 14.0/1.3
PTT 28.8
UA unremarkable aside from 30 protein
- Imaging:
CXR PA/LAT: Consolidation in the left lower lobe, concerning for
pneumonia.
- Patient was given:
1000mg acetaminophen x2 (11 hours apart)
1000mg vancomycin
2g cefepime
4L NS
RIJ placed
- Consults: none
On arrival to the MICU, she reports feeling mostly in her usual
state of health. She reports a mild tickle/cough today, but is
otherwise feeling well aside from her current UC flare. She
continues to have ___ loose stools daily with a small amount of
blood. She believes she is still in the midst of a flare. She is
currently on 30mg prednisone daily (20AM and 10PM) but did not
take anything today prior to coming to the ED.
Past Medical History:
Ulcerative colitis
Rhinitis, allergic
Eczema
Headache, common migraine. *MRI performed ___ due to
complaints of headache, and was unremarkable.
Hyperlipidemia
Fatty liver
Fibroids
Osteoarthritis
Adrenal nodule
Pancreatic cyst
Hypercalcemia
Diffuse large B-cell lymphoma of extranodal site excluding
spleen and other solid organs
Social History:
___
Family History:
pat aunt- breast CA. Sister with breast CA in her ___.
Physical Exam:
==============
ADMISSION EXAM
==============
VITALS: 102.4 124/60 99 21 100%2L NC
GENERAL: thin, no acute distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: crackles in bilateral lung bases, 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 III-XII intact
==============
DISCHARGE EXAM
==============
General: NAD, AOx3
VITAL SIGNS: 97.9PO 107 / 66R Lying 77 18 96 RA
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
==============
ADMISSION LABS
==============
___ 03:40AM BLOOD WBC-7.2# RBC-2.41* Hgb-8.2* Hct-24.1*
MCV-100* MCH-34.0* MCHC-34.0 RDW-18.2* RDWSD-65.2* Plt ___
___ 03:40AM BLOOD Neuts-76* Bands-2 Lymphs-7* Monos-12
Eos-0 Baso-0 ___ Metas-1* Myelos-2* NRBC-2* AbsNeut-5.62
AbsLymp-0.50* AbsMono-0.86* AbsEos-0.00* AbsBaso-0.00*
___ 03:40AM BLOOD Hypochr-NORMAL Anisocy-1+
Poiklo-OCCASIONAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL
Ovalocy-OCCASIONAL Tear Dr-OCCASIONAL
___ 03:40AM BLOOD Plt Smr-HIGH Plt ___
___ 02:10PM BLOOD ___
___ 03:40AM BLOOD Glucose-196* UreaN-21* Creat-0.6 Na-135
K-4.7 Cl-99 HCO3-24 AnGap-17
___ 02:10PM BLOOD Hapto-550*
___ 03:54AM BLOOD Lactate-1.7
=================
PERTINENT IMAGING
=================
CXR (___): Consolidation in the left lower lobe, concerning
for pneumonia.
==========
MICRO DATA
==========
C. DIFF (___): Negative
==============
DISCHARGE LABS
==============
___ 07:30AM BLOOD WBC-7.0 RBC-2.56* Hgb-8.2* Hct-25.5*
MCV-100* MCH-32.0 MCHC-32.2 RDW-18.5* RDWSD-66.2* Plt ___
___ 07:30AM BLOOD Neuts-71 Bands-0 Lymphs-16* Monos-7 Eos-1
Baso-1 Atyps-1* Metas-3* Myelos-0 NRBC-3* AbsNeut-4.97
AbsLymp-1.19* AbsMono-0.49 AbsEos-0.07 AbsBaso-0.07
___ 07:30AM BLOOD Plt Smr-VERY HIGH Plt ___
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of recently
diagnosed DLBCL, s/p 1 cycle R-CHOP with split dose Rituxan, who
presented with complaints of fever after recent hospitalization
for febrile neutropenia.
=============
ACTIVE ISSUES
=============
# Concern for HCAP: Pt with only mild symptoms of throat tickle
and cough. Had evidence of small LLL consolidation concerning
for PNA. Given recent hospitalization and antibiotic exposure,
treated empirically for HCAP with vanc/cefepime.
# Hypotension: To SBP in the 80's to low 90's. Lactates
negative. Minimal, typically lives in low 100's per review of
Atrius records. Repleted with 5L IVF, to improvement of
pressures. Possibly in setting of hypovolemia from HCAP vs.
?ongoing UC flair.
# Hypoxia: Initially required up to 3L NC by oxygen when
formerly on RA. Weaned prior to discharge.
# Ulcerative colitis: Was taking 30mg daily prednisone as a
taper per her outpatient GI. Continued with *** instructions to
follow her prior weekly taper (30 mg/day for 1 week, then 20
mg/day for 1 week, then 15 mg/day for 1 week, then 10 mg/day for
1 week, then 5 mg/day for 1 week, and then stop).
# High grade B-cell lymphoma: In between cycles, next
originally planned Rit/CHOP on ___.
===================
TRANSITIONAL ISSUES
===================
# Communication: Husband, ___ (___)
# Code: full, confirmed
[ ] High-grade B cell lymphoma:
- Touch base with oncology re: when to start next cycle
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. LOPERamide 4 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. diclofenac sodium 1 % topical Q6H:PRN pain
6. Halobetasol Propionate 0.05 % topical Q12H:PRN rash
7. Mesalamine (Rectal) ___AILY
8. Mesalamine Enema 4 gm PR QHS
9. PredniSONE 20 mg PO DAILY
10. PredniSONE 10 mg PO QHS
Discharge Medications:
1. Levofloxacin 750 mg PO DAILY
last day ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
2. Vancomycin Oral Liquid ___ mg PO Q6H
last day ___
RX *vancomycin (bulk) 900 mcg/mg (not less than, USP) 125 mg PO
every six (6) hours Refills:*0
3. PredniSONE 30 mg PO DAILY Duration: 6 Doses
This is dose # 1 of 6 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth per taper Disp #*25
Tablet Refills:*0
4. PredniSONE 15 mg PO DAILY Duration: 7 Doses
This is dose # 3 of 6 tapered doses
5. PredniSONE 5 mg PO DAILY Duration: 7 Doses
This is dose # 5 of 6 tapered doses
6. PredniSONE 5 mg PO EVERY OTHER DAY Duration: 4 Doses
This is dose # 6 of 6 tapered doses
RX *prednisone 5 mg 1 tablet(s) by mouth per taper Disp #*18
Tablet Refills:*0
7. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H
8. diclofenac sodium 1 % topical Q6H:PRN pain
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Halobetasol Propionate 0.05 % topical Q12H:PRN rash
11. Mesalamine (Rectal) ___AILY
12. Mesalamine Enema 4 gm PR QHS
13. Simvastatin 40 mg PO QPM
14. HELD- LOPERamide 4 mg PO DAILY This medication was held. Do
not restart LOPERamide until speaking with our primary care
physician
___:
Home
Discharge Diagnosis:
PRIMARY
- Pneumonia
- Sepsis
- Clostridium difficile infection
SECONDARY
- Diffuse large b-cell lymphoma
- Ulcerative colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___. You were admitted for
fevers and low blood pressure, which required a brief stay in
the ICU. You were found to have pneumonia and a gastrointestinal
infection call clostridium difficile. You were treated with
antibiotics which you should continue as below.
Antibiotic course:
--- levofloxacin for completion of a 5 day course (___)
--- vancomycin (oral) for completion of a ___fter
completion of levofloxacin (last day ___
Prednisone taper:
--- ___ - ___ prednisone 30 mg daily
--- ___ prednisone 20 mg daily
--- ___ prednisone 15 mg daily
--- ___ prednisone 10 mg daily
--- ___ - ___ prednisone 5 mg daily
--- ___ - ___ prednisone 5 mg ever other day
Please note, your steroid course may change depending on your
chemotherapy plan. Please discuss with your oncologist about any
possible changes to your steroids.
Please follow up with your physicians as below.
Wishing you well,
Your ___ Care Team
Followup Instructions:
___
|
19928034-DS-12 | 19,928,034 | 28,270,387 | DS | 12 | 2148-10-03 00:00:00 | 2148-10-03 20:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman, with past history of
Diffuse High Grade B-Cell Lymphoma (diagnosed ___,
currently on active chemotherapy with R-CHOP (last received on
___, Cycle 3D#1), and history of Ulcerative Colitis
currently on steroids, who is presenting with fever. Patient to
be admitted to OMED service for further evaluation and workup.
Patient reports that she had new onset of fever to 101 on the
morning of admission. She had been feeling at her usual state of
health until yesterday night, where she started to feel a
post-nasal drip, but no cough, pleuritic chest pains, or
pharyngitis type symptoms. No URI symptoms. Patient's daughter
has been having a viral URI these past few days. No increased
diarrhea, or abdominal pain per her UC. Patient then called her
___ clinic, and was referred to the ED.
In the ED, patient's lungs were clear, abdomen was benign. She
underwent chest radiograph which was negative for pneumonia. She
was given Vancomycin + Cefepime given concern for fever in the
setting of current chemotherapy. She also underwent blood
culture x 2, urine culture.
Labs were significant for WBC 22, Hgb 7.3, Hct 23.4, Platelet
106. PMN 58, Band 9. ANC 1460.
Influenza negative.
Sodium 133, K 3.8, Cl 97, Bicarb 24, BUN 14, Cr 0.4, Glucose
175
ALT 13, AST 17, AP 83, Lipase 37. Albumin 3.4. T-bili 0.5.
Urinalysis: Spec ___ 1006, Epi < 1.
Patient was given
___ 08:44 IV CefePIME 2 g
___ 09:19 IV Vancomycin
___ 09:19 PO Acetaminophen 1000 mg
___ 10:19 IVF NS ( 1000 mL ordered)
___ 10:20 IV Vancomycin 1 mg
Vitals upon arrival: 101.4 122 110/70 16 100% RA
Vitals upon transfer: 98.6 92 91/52 16 100% RA
On arrival to the floor, pt reports feeling her normal state
of health - only came to hospital because she had been
instructed to come in with the fever. Not feeling
feverish/chills. No cough, no N/V/D. No urinary symptoms.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: Referred to Dr ___ in our dept for
probable malignancy. 30 pound wt loss over the past year and 8
pound drop over the fall. Developed worsening confusion and
unsteadiness in early ___ and found to be hypercalcemic (Ca
___.
Admitted to ___ where she was given iv fluids,
Calcitonin and Pamidronate. Low PTH and normal PTHrp. Her CBC
showed early myeloid forms and some nuc rbc and her LDH was
elevated at 656. CT scans of chest, abd, pelvis did not show
any
adenopathy or splenomegaly. There was a 5mm low attenuation
lesion in the panc head and a 1.3 cm lesion in the right
adrenal
gland. There was a large 8.7x7.7x6.5 mass inseparable from the
uterus where a fibroid had been noted previously. Subsequent
MRI
showed diffused dilatation of the panc duct raising concern for
IPM of the main panc duct and endoscopic ultrasound was
suggested as well as a dedicated adrenal washout CT for the
small adrenal lesion.
-Dr. ___ a BM asp and Bx that day which did not
show any abnormal lymphocytes in the aspirate and the
cytogenetics and FISH were normal. However, the biopsy showed a
multifocal infiltrate of malignant lymphocytes with Ki67 of
50-60%, felt to be an aggressive B cell lymphoma of germinal
center origin.
-___: Upper endoscopy showed mult gastric ulcers - bx
showed lymphoma, cytogenetics showed BCL6, no myc or BCL2
translocations.
-___: First cycle Rit/CHOP with split dose Rituxan.
-___ for febrile neutropenia despite neulasta
then ulc colitis flare. Restarted Pred.
-___: Fever, diarrhea due to C.dif. Rx'd po vanco
and pneumonia, rx'd Levoflox.
-___: cycle 2 Rit/CHOP.
PAST MEDICAL HISTORY:
- Ulcerative Colitis
- Rhinitis, allergic
- Eczema
- Headache, common migraine. *MRI performed ___ due to
complaints of headache, and was unremarkable.
- Hyperlipidemia
- Fatty Liver
- Fibroids
- Osteoarthritis
- Adrenal Nodule
- Pancreatic Cyst
Social History:
___
Family History:
Paternal aunt with breast CA. Sister with breast CA in her ___.
Physical Exam:
ADMISSION EXAM
==============
Vitals: T 98.3, BP 116/72, HR 95, RR 18, SpO2 95/RA
GENERAL: well-appearing female, wearing cap, sitting up in
bed, NAD
HEENT: Without hair on head. PERRL. MMM, OP clear.
NECK: No cervical LAD. Supple.
LUNGS: CTAB, no W/R/C
CV: RRR, S1+S2, II/VI SEM heard throughout
ABD: non-distended. Soft, non-tender. Normoactive bowel sound.
No masses.
EXT: WWP, no edema. No inguinal or axillary LAD
SKIN: no rashes or lesions
NEURO: alert, oriented x3. Moving all 4 extremities.
DISCHARGE EXAM
==============
VS: T 99.0, BP 90-103/56-65, HR 102-108, RR 18, SpO2 99/RA
GENERAL: well-appearing female, sitting up in bed, NAD
HEENT: Without hair on head. PERRL. MMM, OP clear.
NECK: No cervical LAD. Supple.
LUNGS: CTAB, no W/R/C
CV: RRR, S1+S2, II/VI SEM heard throughout
ABD: non-distended. Soft, non-tender. Normoactive bowel sound.
No masses.
EXT: WWP, no edema. No inguinal or axillary LAD
SKIN: no rashes or lesions
NEURO: alert, oriented x3. Moving all 4 extremities.
Pertinent Results:
ADMISSION LABS
==============
___ 08:29PM CRP-27.5*
___ 09:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 09:10AM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 09:10AM URINE HYALINE-1*
___ 09:00AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 08:49AM LACTATE-1.2
___ 08:00AM GLUCOSE-175* UREA N-14 CREAT-0.4 SODIUM-133
POTASSIUM-3.8 CHLORIDE-97 TOTAL CO2-24 ANION GAP-16
___ 08:00AM ALT(SGPT)-13 AST(SGOT)-17 ALK PHOS-83 TOT
BILI-0.5
___ 08:00AM LIPASE-37
___ 08:00AM ALBUMIN-3.4*
___ 08:00AM WBC-22.0*# RBC-2.21* HGB-7.3* HCT-23.4*
MCV-106* MCH-33.0* MCHC-31.2* RDW-19.4* RDWSD-75.5*
___ 08:00AM NEUTS-59 BANDS-9* LYMPHS-4* MONOS-11 EOS-0
BASOS-0 ATYPS-2* METAS-5* MYELOS-6* PROMYELO-4* NUC RBCS-2*
AbsNeut-14.96* AbsLymp-1.32 AbsMono-2.42* AbsEos-0.00*
AbsBaso-0.00*
___ 08:00AM HYPOCHROM-OCCASIONAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ OVALOCYT-1+
SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
___ 08:00AM PLT SMR-LOW PLT COUNT-106*#
MICRO
=====
__________________________________________________________
___ 11:21 am Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 8:29 pm BLOOD CULTURE Source: Line-port.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:15 am BLOOD CULTURE #2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 8:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
DISCHARGE LABS
==============
___ 06:33AM BLOOD WBC-12.6* RBC-2.47* Hgb-8.3* Hct-25.9*
MCV-105* MCH-33.6* MCHC-32.0 RDW-19.0* RDWSD-72.5* Plt ___
___ 06:33AM BLOOD Neuts-65 Bands-6* Lymphs-7* Monos-8 Eos-0
Baso-0 ___ Metas-4* Myelos-9* Promyel-1* AbsNeut-8.95*
AbsLymp-0.88* AbsMono-1.01* AbsEos-0.00* AbsBaso-0.00*
___ 06:33AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-NORMAL Polychr-1+
___ 06:33AM BLOOD Plt Smr-NORMAL Plt ___
___ 06:33AM BLOOD Glucose-149* UreaN-11 Creat-0.6 Na-135
K-3.7 Cl-97 HCO3-27 AnGap-15
___ 06:33AM BLOOD Calcium-8.4 Phos-3.9 Mg-2.1
IMAGING
=======
___ (PA & LAT)
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Ms. ___ is a ___ year old woman, with past history of High
Grade B-Cell lymphoma currently receiving chemotherapy with
R-CHOP (Cycle 3 on ___, and ulcerative colitis, now
presenting with acute fever.
#LEUKOCYTOSIS:
#FEVER: Suspect infectious process given known sick contact,
elevated leukocytosis and recent chemotherapy and relative
immunosuppression with lymphoma, chemotherapy, and high dose
steroids. U/A bland, CXR without frank pneumonia, and given PORT
placement recently in ___, would also cover for potential
line infection. WBC could certainly also be from neulasta (last
dose on ___, as well as high dose steroids (prednisone 100 mg
with chemotherapy). CRP elevated to 27.5 on admission, likely
related to ulcerative colitis. Last febrile 0300 on ___
initial blood cx from ___ at 0800 NGTD. Respiratory viral panel,
flu negative. Viral culture pending at time of discharge.
Vancomycin and cefepime discontinued on ___ in AM; pt remained
afebrile until the time of discharge. High suspicion that the
fever was the result of viral infection.
#HIGH GRADE B-CELL LYMPHOMA: Currently receiving chemotherapy
with Rituximab-CHOP, with last dose of chemotherapy given on
___. She has been given high dose MTX on ___, with mild
increase in LFTs, and then administered Rit CHOP on ___. Held
outpatient sodium bicarb as MTX is on hold. Continued home
acyclovir 400 mg BID.
#ULCERATIVE COLITIS: Recent flare in ___, during admission
thought to be related to first chemotherapy cycle (R-CHOP on
___, at which point was started on prednisone taper -
currently on 5mg daily. CRP elevated to 27.5 on admission,
likely related to ulcerative colitis. Continued prednisone 5 mg
daily.
#ANEMIA: appears worsened from baseline Hgb 9 (7.3 on
admission). Normocytic/macrocytic. No e/o bleeding.
#ELEVATED A1c: Last hemoglobin a1c 7.6% on ___. Pt reports
never having been diagnosed with diabetes. Likely has elevated
A1c and hyperglycemia in the setting of current prednisone
taper. Managed with insulin sliding scale. ___ need more glucose
management as an outpatient, if she remains on steroids.
#HYPERLIPIDEMIA: continued simvastatin
#ALLERGIC RHINITIS: continued fluticasone nasal spray daily
TRANSITIONAL ISSUES
#PET SCAN: will go to scheduled scan on ___ immediately
following discharge
#GLYCEMIC CONTROL: pt with elevated A2c to 7.6 and FSG in high
100s during admission, likely in the setting of ongoing
prednisone taper. If persistent, may need medical management
with Dr ___ in oncology, Dr ___ in endocrinology, or
Dr. ___ (PCP).
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Headache
2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. PredniSONE 5 mg PO DAILY
This is dose # 3 of 3 tapered doses
Tapered dose - DOWN
5. Simvastatin 40 mg PO QPM
Discharge Medications:
1. Capsaicin 0.025% 1 Appl TP TID
RX *capsaicin 0.025 % Apply to shins Three times a day
Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN Headache
3. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. PredniSONE 5 mg PO DAILY
This is dose # 3 of 3 tapered doses
Tapered dose - DOWN
6. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
- viral upper respiratory infection
- diffuse large B cell lymphoma
SECONDARY DIAGNOSES
- elevated A1c
- ulcerative colitis
- anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to ___ from
___ - ___ for a fever.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had blood and urine work done to look for infection. While
you were in the hospital, all of these tests were negative,
meaning there was no sign of bacterial infection or common
viruses causing a respiratory infection.
- You were given antibiotics while you were here to cover for
bacterial infection. These were stopped the day before you were
discharged, and you did not develop a fever off antibiotics.
- We suspect that your fever was the result of a virus. Viruses
do not require antibiotics for treatment, so we sent you home
without antibiotics.
WHAT WILL HAPPEN WHEN YOU LEAVE THE HOSPITAL?
- You will have your PET scan as soon as you leave the hospital.
You may call Dr ___ on ___ to discuss the results.
- You will follow-up with Dr ___ as scheduled on ___,
unless she instructs you otherwise.
We wish you the best with your health in the future.
Your ___ Oncology Team
Followup Instructions:
___
|
19928034-DS-18 | 19,928,034 | 28,000,352 | DS | 18 | 2149-02-26 00:00:00 | 2149-02-26 18:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
word finding difficulty
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ woman with a history of high-grade diffuse large
B-cell lymphoma(primary bone marrow lymphoma)diagnosed in
___
with noted CNS involvement on TEDDI-R who is admitted from the
ED
with word finding difficulty and headache.
Of note, patient recently admitted ___ with similar
word finding difficulties. MRI showed overall mixed response of
her CNS lymphoma. Although EEG was negative, keppra was started
for possibly seizures. She did not have any significant headache
during this admission and she completed C3 TEDDI-R.
Since discharge, she never entirely returned to her baseline,
although she was doing a bit better. ___ she went to
___ for her son's graduation. During the trip her husband
noted she had increasing difficulty finding the right words. He
describes forgetfulness, substitution errors, and 'jumbled' text
messages. ___ morning she was noted to be very quiet and on
the drive home she was having significant difficulty with every
sentence. She reported a new ___ bifrontal headache while en
route to the ED.
In the ED, initial VS were pain 7, T 98.6, HR 90, BP 142/69, RR
16, O2 100%RA. Labs were notable for Na 139, K 3.8, HCO3 24, Cr
0.5, WBC 2.3 (ANC 920), HCT 26.9, PLT 331, lactate 2.6. CT head
showed no ICH, stable CNS lymphoma but some increased edema.
Patient was given 1LNS along with 1000mg po Tylenol. VS prior to
transfer were pain 5, T 98.2, HR 72, BP 129/61, RR 16, O2
100%RA.
On arrival to the floor, patient reports her headache has
resolved. She notes word finding difficulties as above. No
fevers
or chills. No URTI symptoms. No SOB or cough. No N/V. Appetite
is
OK. Nl BM prior to admission and no diarrhea. Denies dysuria. No
frank seizure activity. No new leg swelling or rashes.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___ Diagnosed
-___, Cycle 1 Rituxan/CHOP, Cycle 1. Complicated by
admission for febrile neutropenia despite receiving Neulasta;
then ulcerative colitis flare.
-___, Cycle 2 Rituxan/CHOP
-___, Cycle 3 Rituxan-CHOP.
-___, PET imaging showed decreased uptake in the left
parotid gland with resolution of multiple focal FDG avid osseous
lesions as well as resolution of FDG avidity within the left
adrenal gland, gastric fundus, right breast and subcutaneous
tissues.
-___, Admitted with diplopia, right sided ptosis,
headache, and RLE weakness. MRI of the orbit revealed
thickening and enhancement of the left ocular motor nerve from
the interpeduncular cistern to the cavernous sinus, as well as
mild enhancement of the right ocular motor nerve near the
cavernous sinus. Lumbar puncture was performed which showed
involvement by CNS lymphoma.
-___, Rituxan and high-dose methotrexate at 8 gm/m2.
Discharged to home on ___
-___, Rituxan.
-___, Rituxan. Double vision better but not gone with
development of some thigh numbness and leg weakness and back
pain
-___, Admitted for treatment with high dose Methotrexate,
Ifosfamide and IT Ara-C(Depocyt).
-___, Rituxan Neurological symptoms had markedly improved
with this treatment.
-___, 2nd dose of IT Ara-C(Depocyt).
-___, admitted for planned ___ cycle of treatment but
developed new headache with vomiting. MRI of the head showed
significant progression of her CNS disease.
-___, HD Methotrexate @ 4 gm/m2, then 12 gm/m2 on
___. Discharged on ___.
-___, Rituxan. Started on Ibrutinib at 140 mg daily.
Increased slowly to 420 mg per day as of ___.
-___, Admitted with increasing fever, somnolence,
headache, nausea with concern for CNS progression vs. infection.
No progression noted on imaging.
-___, C1D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,
Dexamethasone, Ibrutinib, Rituximab).
-___, C2D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,
Dexamethasone, Ibrutinib, Rituximab) with IT Cytarabine.
-___, C3D1 of TEDDI-R (Temozolomide, Etoposide, Doxil,
Dexamethasone, Ibrutinib, Rituximab) with IT Cytarabine
PAST MEDICAL/SURGICAL HISTORY:
1. Diffuse large B-cell lymphoma(Primary bone marrow lymphoma)
as noted above with CNS involvement.
2. Ulcerative colitis, last flare in ___ with fever and
neutropenia admission. Previously treated with ___ for about
one and a half years as well as prednisone during flares.
3. Sjogren's with dry eyes, uses Restasis.
4. Osteoarthritis.
5. Eczema.
6. Hypercholesterolemia.
7. Fatty liver.
8. Diabetes.
9. Pancreatic cyst
10. Allergic rhinitis.
Social History:
___
Family History:
A paternal aunt with breast cancer. Sister with breast cancer in
her ___ but died from other medical issues.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 98.2 HR 74 BP 117/73 RR 18 SAT 98% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, dry MM, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented to person and place. Has marked word
finding difficulty with occaisional substitution errors. No
motor
aphasia. She can identify high-frequency objects but not
low-frequency. She registers ___ objects and recalls 0 at 5
minutes. She cannot spontaneously name words starting with a
particular letter and she cannot name ___ forward or backward.
She repeats sentences with occasional error. Cranial nerves
III-XII are intact. She has symmetric and full strength
throughout. Cerebellar fxn is intact to FTN bilaterally.
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM
Vitals: 98.0 95 / 62 76 18 100 Ra
GENERAL: Pleasant, lying in bed comfortably
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: Oropharynx clear without lesion, dry MM, JVD not elevated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops; 2+ radial pulses
RESPIRATORY: Appears in no respiratory distress, clear to
auscultation bilaterally, no crackles, wheezes, or rhonchi
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; no hepatomegaly, no
splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Normal bulk
NEURO: Alert, oriented to person and place. full sentences with
low frequency objects today; no difficulty moving mouth and can
identify objects although parts of objects are more difficult,
Cranial nerves III-XII are intact. She has symmetric and full
strength
throughout. Cerebellar fxn is intact to FTN bilaterally.
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
Pertinent Results:
ADMISSION LABS
___ 09:06PM WBC-2.3*# RBC-2.74* HGB-8.4* HCT-26.9* MCV-98
MCH-30.7 MCHC-31.2* RDW-19.3* RDWSD-68.9*
___ 09:06PM NEUTS-35 BANDS-5 ___ MONOS-25* EOS-3
BASOS-0 ATYPS-1* ___ MYELOS-1* AbsNeut-0.92* AbsLymp-0.71*
AbsMono-0.58 AbsEos-0.07 AbsBaso-0.00*
___ 09:06PM HYPOCHROM-OCCASIONAL ANISOCYT-3+ POIKILOCY-2+
MACROCYT-2+ MICROCYT-1+ POLYCHROM-NORMAL SCHISTOCY-1+
STIPPLED-OCCASIONAL TEARDROP-1+
___ 09:06PM GLUCOSE-186* UREA N-10 CREAT-0.5 SODIUM-139
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15
___ 09:18PM LACTATE-2.6*
DISCHARGE LABS
___ 12:00AM BLOOD WBC-2.8* RBC-2.70* Hgb-8.1* Hct-24.9*
MCV-92 MCH-30.0 MCHC-32.5 RDW-20.2* RDWSD-62.8* Plt Ct-96*
___ 12:00AM BLOOD Neuts-48 Bands-1 ___ Monos-12 Eos-0
Baso-0 ___ Metas-6* Myelos-2* NRBC-24* AbsNeut-1.37*
AbsLymp-0.87* AbsMono-0.34 AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Plt Smr-LOW Plt Ct-96*
___ 12:00AM BLOOD Glucose-135* UreaN-20 Creat-0.3* Na-138
K-4.0 Cl-104 HCO3-20* AnGap-18
___ 12:00AM BLOOD TotProt-4.3* Albumin-2.8* Globuln-1.5*
Calcium-7.8* Phos-3.8 Mg-2.0
IMAGING
___ CT CHEST
IMPRESSION:
No acute hemorrhage. The extent of edema in bilateral splenium
of the corpus callosum and left cerebral hemisphere is similar
to the ___ CT.
___ CT HEAD
IMPRESSION:
1. No evidence of intracranial hemorrhage.
2. Changes of parenchymal lymphoma are better evaluated on MRI
examination
from ___. Allowing for differences in technique, there
appears to be no
progression over this short time interval. However, in
comparison to the
prior head CT from ___, there is significant increase in
associated
vasogenic edema.
___ MR HEAD W & W/O CONTRAS
IMPRESSION:
1. Overall, compared to the most recent prior exam from ___, there
appears to be slight interval progression of the heterogeneous
multiple
enhancing periventricular lesions, with interval increase in
heterogeneity and
surrounding FLAIR signal abnormality. Although this could be
secondary to
sequelae of post treatment changes, given the interval increased
signal on the
diffusion weighted images of many of these lesions, progression
of disease
remains of concern.
2. Focal area of nodular enhancement within the left internal
auditory canal,
appears new compared to the prior exam, may represent a venous
structure.
Close attention on followup is recommended.
3. Stable 0.4 cm enhancing lesion adjacent to the tectum.
4. Additional findings as described above.
Brief Hospital Course:
___ with a history of high-grade diffuse large
B-cell lymphoma(primary bone marrow lymphoma)diagnosed in
___
with noted CNS involvement on TEDDI-R who is admitted for word
finding difficulties which has been persistent on prior recent
hospitalization.
# Aphasia: Concern for worsening since last hospitalization,
while not completely resolved at discharge, pt notes being
markedly worse. possibly component of superimposed infection,
dehydration, active process worsening aphasia, outpatient MRI
finalized to read possible interval change with disease; started
on fourth cycle of TEDDI-R chemotherapy, discuss with patient
and husband that will need to discuss more seriously with
outpatient oncologist regarding golas of care given concern for
lack of improvement. Completed TEDDI-R without complications.
Given headache, also started on po dex (start ___, decreased
to 8mg bid (___), decreased to 4mg bid (___), decreased to 4mg
daily (___). At discharge will continue on 2mg dex ___ -
ongoing).
No headache after day 2 of admission. ___ evaluated and
recommended home with 24 hour supervision.
#urinary incontinence: Pt's urinary incontinence is worsening
per nursing staff, pt says it does not bother her, no dysuria,
UA unrevealing, UCx however grew enterococcus that is vanc
resistant, has had prior UTis with klebs. Pt was s/p ceftriaxone
x 3 days prior to speciation. Did have recent UTI S/p tx.
Diagnosed with klebsiella UTI last admission. No
dysuria/suprapubic pain. UA clean. However worsening urinary
urgency per RN last evening. Pt with enterococcus in urine but
without symptoms. s/p ctx x 3 days (start ___. Pt started on
doxycycline bid x 5 days given resistance patterns. Completed 5
days of doxycycline with some improvement in urinary
incontinence. Some incontinence is reported to be baseline.
Will continue doxy until ___.
# headache: Pt was noted to have mild headache in the ED but has
since resolved on the floors, CT without new hemorrhage although
possible increase in edema; concern for possible intracranial
pressures that can lead to seizures per prior hospitalization
and started on prophylactic anti-epileptics. Pt was continued on
keppra, and started on po dexamethasone per above. Pt also
started on pantoprazole with steroids. ___ was consulted
given elevated sugars with dexamethasone.
# High-grade primary bone marrow lymphoma with CNS involvement:
Recent admission for neuro symptoms thought due to disease vs
possibly seizure. MRI shows mixed response to current regimen.
Repeat MRI done as outpatient pending. Completed cycle 4 of
___ complications. CT head showed stable brain edema
and started on dex. Markedly improved aphasia per above -
unclear if dex ___ dex to 2mg daily.
Con't acyclovir, atovaquone, voriconazole ppx and con't keppra
500mg po q12 hours.
# Neutropenia: No fever or obvious source of infection. Did get
neupogen after last cycle of chemotherapy. Will continue
neupogen outpatient - despite increasing WBCs, still neutropenic
on differential.
# Type II DM: Known to become hyperglycemic while taking
dexamethasone. On HISS while inpatient. ___ evaluated and
will start NPH outpatient in addition to restarting metformin
500. Will have insulin teaching per RN and husband. ___
recommended follow up but will favor follow up while inpatient
for next ___.
# Sjogren's Syndrome: Eye drops prn
TRANSITIONAL
=============
-Pt will continue doxycycline until ___ for presumed UTI.
-Refills for keppra, acyclovir, atovaquone written. Pt with
enough neupogen, voriconazole until next follow up.
-___ apt recommended in 1 week ___ will call with
appointment) given new NPH prescription and sliding scale.
Insulin teaching explained to husband and patient.
-Next cycle ___ for week after discharge
-Vori level pending at discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Atovaquone Suspension 1500 mg PO DAILY
3. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN
headache
4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/insomnia/anxiety
7. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
9. Pyridoxine 100 mg PO DAILY
10. Voriconazole 200 mg PO Q12H
11. MetFORMIN XR (Glucophage XR) 500 mg PO BID type 2 diabetes
12. LevETIRAcetam 500 mg PO Q12H
Discharge Medications:
1. Dexamethasone 2 mg PO DAILY
RX *dexamethasone 2 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*6 Capsule Refills:*0
3. Filgrastim 300 mcg SC Q24H
4. ibrutinib 560 mg ORAL DAILY
5. NPH 10 Units Breakfast
NPH 0 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [FreeStyle Lite Strips] with every
glucose check Disp #*100 Strip Refills:*2
RX *blood-glucose meter [FreeStyle Freedom Lite] three times a
day Disp #*100 Kit Refills:*3
RX *lancets 33 gauge use four times daily Disp #*100 Each
Refills:*2
RX *insulin NPH human recomb [Humulin N KwikPen] 100 unit/mL (3
mL) AS DIR 10 Units before BKFT; 0 Units before DINR; Disp #*2
Syringe Refills:*2
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine]
31 gauge X ___ with insulin Disp #*100 Syringe Refills:*2
6. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
10. Acyclovir 400 mg PO Q8H
RX *acyclovir 400 mg 1 tablet(s) by mouth three times a day Disp
#*30 Tablet Refills:*0
11. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 10 mL by mouth daily Refills:*0
12. butalbital-acetaminophen-caff 50-300-40 mg oral Q8H:PRN
headache
13. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. LevETIRAcetam 500 mg PO Q12H
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*0
16. LORazepam 0.5 mg PO Q6H:PRN
nausea/vomiting/insomnia/anxiety
17. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
18. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
19. Pyridoxine 100 mg PO DAILY
20. Voriconazole 200 mg PO Q12H
21.Outpatient Physical Therapy
Rolling walker
Dx: 202.8 (malignant lymphoma)
PX: Good
Length of need: 13 mon
22.commode
ICD-9: 202.80
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
======================
high-grade diffuse large B cell lymphoma (with CNS involvement)
SECONDARY DIAGNOSIS
======================
bacteriuria
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 for your word finding difficulty. You had
imaging of your head which showed swelling in your brain and
concern for areas of good to no response from prior
chemotherapy. You were started on steroids to help with the
swelling in your brain. You also were on your fourth cycle of
chemotherapy.
You improved at discharge and occupational and physical therapy
evaluated you. They recommended that you are safe to go home but
will require extensive supervision (24 hour).
If you have worsening symptoms of headache, word finding
difficulty, pain, or new symptoms, please return for further
evaluation. It was a pleasure taking care of you at ___!
Your ___ Team
Followup Instructions:
___
|
19928034-DS-9 | 19,928,034 | 23,557,338 | DS | 9 | 2148-08-21 00:00:00 | 2148-08-24 15:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with a history of
recently diagnosed DLBCL, s/p 1 cycle R-CHOP with split dose
Rituxan, who presents with complaints of fever this morning.
Notably, she was seen by her oncologist Dr ___ in clinic on
___ after completion of cycle 1 R-CHOP. At that time she
stated that she had been feeling well after chemo, up until the
___, at which point she began to feel "somewhat tired and very
achy", and also complained of a mild headache. She had just
completed a taper of Prednisone (100mg daily, last day ___,
and her symptoms were attributed to discontinuation of the
steroid. Plans were made to start back on 20 mg Prednisone that
day, then 10 mg the day after, and 5 mg the day after that. She
completed this and felt well in the interim.
However, she awoke this morning feeling very fatigued. She also
noted a headache focused behind her left eye. She took her
temperature and found it to be 100.8. She subsequently presented
to ___ Urgent Care, where her temperature was 99.5.
She was then referred to the ___ ED.
In the ED, initial vitals: T 101.2, BP 99/62, P ___, RR 14, O2
99% RA
- Exam unremarkable.
- Labs were notable for: WBC 300 with ANC 10, chemistry
unremarkable, lactate 1.2, UA without infection. BCx, UCx sent.
- Imaging: CXR obtained
- Patient was given: Tylenol 1g (11:30), Vancomycin 1g (12:50)
- Decision was made to admit to ___ for neutropenic fever
- Vitals prior to transfer were T 99.6, BP 93/52, P ___, RR 18,
O2 100% RA.
On arrival to the floor, she reports feeling better than this
morning, although still somewhat fatigued. She states her
headache is ___ in severity, much improved from earlier. She
denies visual changes, stiff neck, congestion, sore throat,
sinus tenderness, cough, dyspnea, chest pain, palpitations,
abdominal pain, nausea/vomiting, diarrhea, constipation, rash,
muscle/joint ache. No sick contacts at home or work. No recent
travel.
Past Medical History:
Ulcerative colitis
Rhinitis, allergic
Eczema
Headache, common migraine. *MRI performed ___ due to
complaints of headache, and was unremarkable.
Hyperlipidemia
Fatty liver
Fibroids
Osteoarthritis
Adrenal nodule
Pancreatic cyst
Hypercalcemia
Diffuse large B-cell lymphoma of extranodal site excluding
spleen and other solid organs
Social History:
___
Family History:
pat aunt- breast CA. Sister with breast CA in her ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.7 HR 96 BP 99/59 RR 16 SAT 99% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: EOMI, PERRL, oropharynx without lesions/ulcers
CARDIAC: Regular rate and rhythm, II/VI late peaking systolic
murmur at ___, no rubs or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM:
VS: 98.4PO 115 / 60 109 16 98 RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: EOMI, PERRL, oropharynx without lesions/ulcers
CARDIAC: Regular rate and rhythm, II/VI late peaking systolic
murmur at ___, no rubs or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
================
___ 11:48AM BLOOD WBC-0.3*# RBC-2.47*# Hgb-8.2*# Hct-26.1*#
MCV-106*# MCH-33.2*# MCHC-31.4* RDW-16.5* RDWSD-64.4* Plt
___
___ 11:48AM BLOOD Neuts-3* Bands-0 Lymphs-85* Monos-6 Eos-5
Baso-1 ___ Myelos-0 AbsNeut-0.01* AbsLymp-0.26*
AbsMono-0.02* AbsEos-0.02* AbsBaso-0.00*
___ 11:48AM BLOOD Glucose-197* UreaN-11 Creat-0.5 Na-133
K-4.4 Cl-94* HCO3-28 AnGap-15
___ 12:06PM BLOOD Lactate-1.2
MICROBIOLOGY
================
ASPERGILLUS GALACTOMANNAN ANTIGEN
Test Result Reference
Range/Units
INDEX VALUE 0.09 <0.50
ASPERGILLUS AG,EIA,SERUM Not Detected Not Detected
URINE CULTURE (Final ___: NO GROWTH.
MRSA SCREEN (Final ___: No MRSA isolated.
BLOOD CX X2 ___: PENDING, NEGATIVE AT TIME OF D/C
___ 1:30 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
IMAGING
================
CXR ___:
Heart size is normal. Mediastinum is normal. Lungs are clear
within the
limitations of chest radiograph technique. There is no pleural
effusion.
There is no pneumothorax.
If clinically warranted, correlation with chest CT to exclude
the possibility of radiographically occult neutropenic pneumonia
is to be considered.
PERTINENT RESULTS
================
___ 07:30AM BLOOD WBC-3.0*# RBC-2.80* Hgb-8.8* Hct-27.7*
MCV-99* MCH-31.4 MCHC-31.8* RDW-18.2* RDWSD-66.7* Plt ___
___ 07:30AM BLOOD Neuts-79* Bands-5 Lymphs-8* Monos-8 Eos-0
Baso-0 ___ Myelos-0 NRBC-1* AbsNeut-2.52
AbsLymp-0.24* AbsMono-0.24 AbsEos-0.00* AbsBaso-0.00*
___ 07:35AM BLOOD Hapto-523*
___ 07:35AM BLOOD Ret Aut-0.2* Abs Ret-0.00*
DISCHARGE LABS
================
___ 07:40AM BLOOD WBC-4.6# RBC-2.80* Hgb-9.1* Hct-27.7*
MCV-99* MCH-32.5* MCHC-32.9 RDW-17.7* RDWSD-64.9* Plt ___
___ 07:40AM BLOOD Neuts-81* Bands-6* Lymphs-5* Monos-7
Eos-0 Baso-0 ___ Myelos-0 Other-1* AbsNeut-4.00
AbsLymp-0.23* AbsMono-0.32 AbsEos-0.00* AbsBaso-0.00*
___ 07:40AM BLOOD Plt Smr-NORMAL Plt ___
___ 07:40AM BLOOD Glucose-154* UreaN-8 Creat-0.6 Na-134
K-4.5 Cl-96 HCO3-28 AnGap-15
___ 07:40AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of recently
diagnosed DLBCL, s/p 1 cycle R-CHOP with split dose Rituxan, who
presented with complaints of fever I/s/o ANC 10.
#Febrile neutropenia: Pt with fever 101.5 on morning of ___ at
home as well as in ED. Unclear source as pt with no localizing
symptoms other than headache. No stiff neck/meningismus to
suggest meningitis. Most likely cause was thought to be viral
source, possibly URI, given complaints of general
fatigue/malaise and headache, although resp panel negative.
Received 1g Vancomycin in ED as well as 1g Tylenol. This was
discontinued on admission as she did not have a central line and
had no signs of skin breakdown. She was instead started on
Cefepime 2g q8h but this was discontinued once ___ recovered (>
4000 at time of d/c) and no s/s infection developed. Urine cx
negative, MRSA swab negative, blood cx's still pending at time
of d/c. Patient did spike a fever on day of discharge to 101.5,
however had symptoms of ulcerative colitis flare (see below). In
setting of UC flare symptoms and lack of other signs/symptoms of
infection throughout a five day hospital course, patient was
discharged with close follow up with Oncology and GI.
#Headache: Resolved quickly after admission. As above, low
concern for meningitis. Recent MRI brain without signs of
metastases.
#Ulcerative colitis: Symptoms had been absent during first few
days of hospitalization. Patient denied any recent flares.
Patient on Loperamide/Mesalamine/Mercaptopurine as outpatient,
however mesalamine (rectal/enema) and mercaptopurine held on
admission in setting of neutropenia. Patient did complain of
flare symptoms (crampy abdominal pain and clots in stool) on
___ AM, and then had pink stools on ___ and worsening
abdominal pain. Patient's infectious work up remained stable
after 5 days in hospital, and patient noted her usual UC flares
usually are accompanied by fevers. Therefore, patient was deemed
safe for discharge given she appeared clinically well and had
strong desire to be home. The fevers she continued to spike even
while on Cefepime were thought to be from her UC flare. She was
discharged home with close follow up appointment with Dr. ___
on ___.
#Anemia/macrocytosis: Likely anemic from bone marrow crowding vs
effect of chemo. MCV gradually rising over past weeks to 106 on
admission. CBC was monitored daily. Hemolysis labs (LDH,
haptoglobin, reticulocyte count) were checked and were
unremarkable. Received 1U pRBC for Hgb 6.9 on ___, Hgb
responded appropriately and remained stable throughout
admission.
CHRONIC ISSUES:
#Osteoarthritis: pt reports she does not need Diclofenac gel
currently.
#Eczema: pt reports she does not need topical steroid cream
currently.
#Dry eyes: Continued cyclosporine drops.
#Anxiety: Continued home Lorazepam.
TRANSITIONAL ISSUES
===================
NEUTROPENIA
[ ] ANC 4000 at time of d/c, consider rechecking as outpatient.
INFECTION R/O
[ ] F/u pending blood cx, urine cx to ensure negative.
ULCERATIVE COLITIS
[ ] Pt to follow up with Dr. ___ on ___.
[ ] Prednisone 20mg QAM and Prednisone 10mg QPM for UC flare,
taper to be determined by outpatient GI.
[ ] Restarted Mesalamine rectal enema and suppository.
[ ] Holding Mercaptopurine, plan to restart per outpatient GI.
SINUS TACHYCARDIA
[ ] Patient with sinus tachycardia in 100s-110s. Asymptomatic.
Likely from fevers, malignancy. Should continue work up as
outpatient.
# HCP/Contact: Husband, ___ (___)
# Code: Full, confirmed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Prochlorperazine 10 mg PO Q6H:PRN nausea
3. LORazepam 0.5 mg PO BID
4. Halobetasol Propionate 0.05 % topical Q12H:PRN rash
5. LOPERamide 4 mg PO DAILY
6. Mesalamine (Rectal) ___AILY
7. Mesalamine Enema 4 gm PR QHS
8. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H
9. Mercaptopurine 100 mg PO DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. diclofenac sodium 1 % topical Q6H:PRN pain
Discharge Medications:
1. PredniSONE 20 mg PO DAILY
RX *prednisone 10 mg 2 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
2. PredniSONE 10 mg PO QHS
RX *prednisone 10 mg 1 tablet(s) by mouth QPM Disp #*15 Tablet
Refills:*0
3. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic Q12H
4. diclofenac sodium 1 % topical Q6H:PRN pain
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Halobetasol Propionate 0.05 % topical Q12H:PRN rash
7. LOPERamide 4 mg PO DAILY
8. LORazepam 0.5 mg PO BID
9. Mesalamine (Rectal) ___AILY
10. Mesalamine Enema 4 gm PR QHS
11. Ondansetron 8 mg PO Q8H:PRN nausea
12. Prochlorperazine 10 mg PO Q6H:PRN nausea
13. Simvastatin 40 mg PO QPM
14. HELD- Mercaptopurine 100 mg PO DAILY Duration: 1 Dose This
medication was held. Do not restart Mercaptopurine until you see
your GI doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
============
Neutropenic fever
Ulcerative colitis flare
SECONDARY
============
Headache
Anemia
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 in the hospital because you had a fever and your white
blood cell count was very low. We gave you with antibiotics to
treat you for any possible infection. All of your studies
returned normal, without evidence of infection, which does
happen at times. You likely had a viral illness which went away
on its own.
However toward the end of your hospitalization you continued to
spike fevers to 101.5. Given that your vitals remained stable,
and that you did not have any new symptoms EXCEPT for symptoms
which you describe as your typical Ulcerative colitis flare
symptoms, it is likely that these fevers are due to a UC flare.
We started you on steroids and your mesalamine at your home
dose.
Please make sure to seek medical attention if you develop NEW
symptoms or WORSENING symptoms such as new pain, rashes, cough,
headache, changes in balance, changes in vision, neck pain, or
worsening abdominal pain.
Please follow up with your specialists, see below.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19928152-DS-12 | 19,928,152 | 22,631,194 | DS | 12 | 2149-07-06 00:00:00 | 2149-07-07 10:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
methotrexate / pantoprazole / niacin / doxazosin / lidocaine
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
Bronchoscopy ___
Renal biopsy ___
History of Present Illness:
Mr ___ is a ___ man with a history of hypertension,
hyperlipidemia, and rheumatoid arthritis, who presents with lung
lesions and acute kidney injury.
2 weeks ago, he developed a persistent cough and worsening
shortness of breath. He had no fevers, nasal congestions, or
other signs of infection, and no sick contacts. His cough and
dyspnea got severe, so he presented to his PCP, who ordered a
CXR. CXR showed a consolidation, but PCP was concerned about
degree of dyspnea, so he ordered a CTA chest. This showed no PE,
but was concerning for infiltrative process. At this point, his
dyspnea continued to worsen, and PCP checked labs, which were
notable for new Cr 3.4, up from baseline of normal. During this
time, the patient had no chest pain, flank pain, dysuria,
hematuria, or frothy urine. He has had 3 episodes of vomiting,
but no diarrhea.
His PCP instructed him to come to the ED, and was referred to
___ for urgent Nephrology consultation.
- In the ED, initial vitals were: 98.1 72 200/55 18 97% RA
- Exam notable for: no CVAT, 1+ pitting edema to knees
bilaterally
- Labs notable for: Cr 3.1
- Imaging was notable for: renal U/S with no hydro
- Patient was given:
___ 05:35 IVF NS ___ Started
___ 09:29 SC Insulin 2 Units ___
- Vitals on transfer: 97.9 64 171/97 16 96% RA
Upon arrival to the floor, patient reports feeling well. He does
not have headache, and is breathing comfortably at rest. He is
still coughing a dry cough. He notes that his legs have gotten
more swollen today. Otherwise, no complaints.
ROS: Positive per HPI. Remaining 10 point ROS reviewed and
negative
Past Medical History:
- Rheumatoid arthritis
- HTN
- HLD
- TIA (on Plavix)
- Myocardial infarction ___ viral process, but clean coronaries
- T2DM on insulin
Social History:
___
Family History:
No family history of kidney disease. 1 sister with
hypothyroidism
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITAL SIGNS: 97.0 AdultAxillary 201 / 86 L Lying 67 20 96 Ra
GENERAL: Sitting comfortably in bed, NAD
HEENT: no scleral icterus, mmm
NECK: no JVD, supple
CARDIAC: rrr, ___ systolic murmur at ___
LUNGS: clear bilaterally with faint expiratory wheezing at
bases
ABDOMEN: soft, NT/ND, +bs, no suprapubic pain
EXTREMITIES: warm, 1+ pitting edema to shins bilaterally
NEUROLOGIC: A&Ox3, CN intact, moving all 4 extremities w/
purpose
SKIN: no rashes or jaundice
BACK; no CVA tenderness
DISCHARGE PHYSICAL EXAM:
===========================
VITAL SIGNS: 98.5 PO 161 / 54L Lying 57 18 97 Ra
GENERAL: Sitting comfortably in chair, NAD
HEENT: no scleral icterus, mmm
NECK: supple
CARDIAC: rrr, ___ systolic murmur at ___
LUNGS: CTAB
ABDOMEN: soft, NT/ND, +bs
EXTREMITIES: warm, trace pitting edema to shins bilaterally
NEUROLOGIC: A&Ox3, CN intact, moving all 4 extremities w/
purpose
SKIN: There are scattered erythematous, non-blanching, ~purpuric
lesions on the bilateral UEs on forearms and left side of back
Pertinent Results:
ADMISSION LABS:
===========================
___ 10:50PM BLOOD WBC-4.9 RBC-2.65* Hgb-8.3* Hct-24.6*
MCV-93 MCH-31.3 MCHC-33.7 RDW-13.0 RDWSD-44.1 Plt ___
___ 10:50PM BLOOD Neuts-78.2* Lymphs-8.2* Monos-10.6
Eos-2.2 Baso-0.4 Im ___ AbsNeut-3.83 AbsLymp-0.40*
AbsMono-0.52 AbsEos-0.11 AbsBaso-0.02
___ 10:50PM BLOOD ___ PTT-34.9 ___
___ 10:50PM BLOOD Glucose-228* UreaN-54* Creat-3.1*# Na-138
K-4.3 Cl-97 HCO3-25 AnGap-16
___ 10:50PM BLOOD Calcium-9.6 Phos-5.1* Mg-2.4
___ 10:50PM BLOOD CRP-59.0*
IMAGING/STUDIES:
===========================
___ RENAL U/S:
1. No hydronephrosis. Both ureteral jets are visualized.
2. Nonobstructive nephrolithiasis of the left kidney.
___ronchus centric opacities in the right upper lobe and both
lower lobes
concerning for multifocal pneumonia.
Small bilateral effusions and mild interstitial edema.
Small mediastinal lymph nodes could be reactive.
DISCHARGE LABS:
===========================
___ 07:40AM BLOOD WBC-6.6 RBC-2.46* Hgb-7.7* Hct-23.4*
MCV-95 MCH-31.3 MCHC-32.9 RDW-13.2 RDWSD-45.1 Plt ___
___ 07:40AM BLOOD ___ PTT-33.1 ___
___ 07:40AM BLOOD Glucose-120* UreaN-41* Creat-1.8* Na-145
K-4.3 Cl-110* HCO3-23 AnGap-12
___ 07:40AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.2
OTHER PERTINENT LABS
===========================
___ 06:38AM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-1+*
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL
Ovalocy-1+* Tear Dr-OCCASIONAL
___ 06:38AM BLOOD Ret Aut-2.2* Abs Ret-0.05
___ 06:38AM BLOOD ALT-19 AST-20 LD(LDH)-166 AlkPhos-35*
TotBili-<0.2
___ 01:20PM BLOOD CK(CPK)-414*
___ 10:48PM BLOOD CK(CPK)-464*
___ 06:30AM BLOOD CK-MB-5 cTropnT-0.05*
___ 01:20PM BLOOD CK-MB-7 cTropnT-0.07*
___ 10:48PM BLOOD CK-MB-7 cTropnT-0.04*
___ 05:28AM BLOOD CK-MB-6 cTropnT-0.06*
___ 06:38AM BLOOD calTIBC-268 Ferritn-68 TRF-206
___ 06:20AM BLOOD TSH-5.7*
___ 06:20AM BLOOD Free T4-0.9*
___ 05:00PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:00PM BLOOD ANCA-NEGATIVE B
___ 10:50PM BLOOD CRP-59.0*
___ 05:00PM BLOOD ___
___ 06:38AM BLOOD CRP-16.7*
___ 05:30PM BLOOD PEP-NO SPECIFI
___ 05:00PM BLOOD C3-164 C4-28
___ 06:30AM BLOOD HIV Ab-NEG
___ 05:00PM BLOOD HCV Ab-NEG
___ 09:35AM BLOOD SM ANTIBODY-Test
___ 09:35AM BLOOD RO & ___
___ 09:35AM BLOOD RNP ANTIBODY-Test
___ 09:35AM BLOOD ALDOLASE-Test
___ 06:38AM BLOOD SED RATE-Test
___ 05:00PM BLOOD ANTI-GBM-Test
___ 06:12AM BLOOD SED RATE-Test Name
Brief Hospital Course:
PATIENT SUMMARY
===============
___ w/ HTN, HL, RA, DM, TIA presenting after recent episode
likely community-acquired pneumonia s/p azithromycin with
improvement who presented with persistent cough and dyspnea and
found to have bilateral lung opacities and acute kidney injury
with nephrotic-range proteinuria.
ACTIVE ISSUES
=============
#) ACUTE KIDNEY INJURY
On admission, patient noted to have acute kidney injury with a
creatinine of 3.1 (baseline normal, 0.5). Renal ultrasound
normal. Nephrology consulted. Urine sediment showed few
cellular casts. Urine protein/creatinine ratio 10.3. CRP 59
and ESR 119. Other workup remained unrevealing (negative ___
and ANCA, normal C3, C4). During admission, creatinine
improved. The etiology of the acute kidney injury remained
unclear. It is possible that the proteinuria is secondary to
diabetes, and that he developed acute kidney injury secondary
to post-streptococcal glomerulonephritis, or pre-renal
azotemia, and that the cellular casts were related to the
hypertension. Very low suspicion for pulmonary-renal syndrome.
Underwent kidney biopsy on ___. The patient was discharge
while awaiting pathology results because it was felt that his
kidney function had stabilized and he was appearing clinically
well without symptoms. Needs outpatient follow up with
nephrology.
#) PULMONARY INFILTRATES
Patient was recently diagnosed with community-acquired
pneumonia and completed a course of azithromycin and presented
with persistent dyspnea and productive cough. Imaging was
notable for nodular pulmonary consolidations with associated
ground-glass opacities. Repeat CT scan showed persistent
radiographic evidence of multifocal nodular opacities in RUL
and LLL, which prompted bronchoscopy for further evaluation.
BAL was only notable for diffusely edematous airways without
focal lesions or hemorrhage. BAL cell count showed atypical
cells but cytology was negative for malignancy. The patient
symptomatically improved during admission and did not receive
antibiotics. The symptoms and infiltrates were thought to be
related to community acquired pneumonia. Patient will need
repeat outpatient CT chest to evaluate the infiltrates in ___
weeks, and outpatient follow up with pulmonology.
#) HYPERTENSIVE URGENCY:
During admission, patient was found to have hypertensive
urgency with systolic blood pressure up to 200 but the patient
remained asymptomatic without evidence of end organ damage.
Per the patient, he has longstanding hypertension, and rarely
had blood pressure readings less than 150. During admission,
anti-hypertensives were adjusted given the setting of acute
kidney injury. Lisinopril was held. Received home furosemide,
amlodipine and spironolactone. Metoprolol was transitioned to
labetalol for better blood pressure control. Also started on
hydralazine. There was aggressive blood pressure management to
reduce the bleeding complication risk of the renal biopsy.
Patient should have further outpatient workup of resistant
hypertension, and should have monitoring of blood pressure and
adjustment of anti-hypertensives as appropriate.
#) CHEST PAIN
During admission, patient reported intermittent pleuritic chest
discomfort. EKG showed stable ST elevations that were
attributed to repolarization in anterior leads. Cardiac
enzymes showed only slight elevation of troponin and normal
CK-MB. Per the patient's report, cardiac catheterization one
year previously showed no evidence of CAD. The
characterization of the pain, and the clinical picture was not
felt to be consistent with ACS. Could consider further
outpatient workup with stress test and TTE.
#) ANEMIA
Patient found to have new hypoproliferative anemia with
hemoglobin ___. No evidence of bleeding. Iron studies were
normal. The etiology remained unclear during admission but
patient remained hemodynamically stable, with stable hemoglobin
and did not require a transfusion so it was felt that further
workup could be pursued in the outpatient setting.
#) CONCERN FOR MYOSITIS
Noted during admission patient had evidence of myositis
(elevated CK, mildly elevated troponin T, and elevated
CRP/ESR). No associated myalgias or weakness. Differential
includes hypothyroidism (TSH elevated and FT4 low, needs repeat
thyroid studies as outpatient), drug-induced (was on
gemfibrozil and rosuvastatin (which were both held during
admission) or autoimmune. Patient needs further workup as an
outpatient.
CHRONIC STABLE ISSUES:
========================
#) DM: glargine and ISS while inpatient
#) HLD: held gemfibrozil and rosuvastatin in setting of
possible myositis
#) h/o TIA: held clopidogrel in setting of renal biopsy. Needs
to wait at least until ___ to resume plavix.
TRANSITIONAL ISSUES:
========================
#) Monitor labs as an outpatient: CBC, BUN/Cr, CK, troponin.
Next lab check will be on ___ while seeing PCP.
#) Continue to hold Plavix for at least one week post-renal
biopsy (okay to resume on ___
#) Needs outpatient follow up with nephrology. Kidney biopsy
pathology pending on discharge
#) Needs outpatient workup of resistant hypertension. Need to
follow up blood pressure, and adjust anti-hypertensives.
Lisinopril was held given ___, but can be resumed as
appropriate.
#) Patient needs repeat thyroid studies checked as an
outpatient
#) Rosuvastatin and gemfibrozil were held in the setting of
concern for myositis.
#) Patient will need repeat outpatient CT chest to evaluate the
infiltrates in ___ weeks, and outpatient follow up with
pulmonology (Dr. ___.
#) Consider outpatient workup of chest pain, including TTE and
stress test
#) Patient needs further workup of hypoproliferative anemia as
an outpatient
#) Needs further workup of suspected myositis as an outpatient.
Monitor for symptom improvement after cessation of gemfibrozil
and statin. Also recheck CK, troponin as an outpatient. Could
assess for vitamin D deficiency.
#CONTACT: ___, wife, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 100 mg PO BID
2. Metoprolol Succinate XL 75 mg PO DAILY
3. Gemfibrozil 600 mg PO BID
4. Furosemide 40 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Lisinopril 40 mg PO DAILY
8. Glargine 30 Units Bedtime
9. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. HydrALAZINE 25 mg PO Q6H
RX *hydralazine 25 mg 1 tablet(s) by mouth every six (6) hours
Disp #*120 Tablet Refills:*0
2. Labetalol 300 mg PO TID
RX *labetalol 300 mg 1 tablet(s) by mouth three times a day Disp
#*90 Tablet Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Furosemide 40 mg PO BID
5. Glargine 30 Units Bedtime
6. Spironolactone 100 mg PO BID
7. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until at least one week after kidney
biopsy. Do not resume until after discussing with kidney doctor
8. HELD- Gemfibrozil 600 mg PO BID This medication was held. Do
not restart Gemfibrozil until instructed to resume by your
doctor. This medication may have caused muscle inflammation
9. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do
not restart Lisinopril until instructed to resume by your
doctor. This medication cannot be restarted right away because
it can cause kidney injury
10. HELD- Rosuvastatin Calcium 40 mg PO QPM This medication was
held. Do not restart Rosuvastatin Calcium until instructed to
resume by your doctor. This medication may have caused muscle
inflammation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
- Acute kidney injury
- bilateral pulmonary infiltrates
SECONDARY DIAGNOSES
- Hypertensive urgency
- Dyspnea on exertion
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 ___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- ___ had shortness of breath
- Your kidney function was getting worse
WHAT HAPPENED WHILE I WAS HERE?
- ___ saw the kidney doctors and ___ had a kidney biopsy done.
It is important for ___ to not take your plavix for at least one
week after the kidney biopsy. Do not resume plavix until
discussing with your kidney doctor.
- ___ saw the lung doctors and have follow up scheduled with the
lung doctors. ___ will need another CT scan of your lungs in 6
to 8 weeks
WHAT SHOULD I DO WHEN I GO HOME?
- Please call your doctors ___ away ___ return if ___ develop
blood in your urine or back pain
- Take all of your medicines as prescribed
- Go to all of your follow-up appointments, which are listed
below
- Call your doctor if ___ have any fevers, shortness of breath,
weight gain >3 lbs in 3 days, leg swelling, or decreased urine
We wish ___ all the best in the future!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19928285-DS-4 | 19,928,285 | 24,197,782 | DS | 4 | 2152-01-13 00:00:00 | 2152-01-13 15:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Liver hematoma
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of end stage renal disease (not
yet on dialysis) and Hepatitis C, currently being evaluated for
possible kidney transplant who presents after a pre-syncopal
event at home. As part of his transplant work up, patient
underwent liver biopsy on ___ to assess extent of liver
disease from Hepatitis C before consideration of
immunosuppression for transplant. The procedure was without
incident and patient was recovering well at home. Per patient's
wife, the patient appeared weak and tired since procedure but
otherwise like himself. This AM, patient felt increasinly weak
and almost collapsed from standing. He did not lose conciousness
or hit his head. EMS found him hypotensive with SBP 70's which
increased to 120s with 500cc NS. Since arrival in the ED,
patient has felt well and been hemodynamically stable. He
deniesabdominal pain, dizziness, nausea, vomiting, weakness, and
malaise.
Past Medical History:
Past Medical History:
Chronic alcoholic pancreatitis, Chronic kidney disease,
Hepatitis C, Gout, Hypertension
Past Surgical History:
Tonsillectomy and removal of laryngeal polyps.
Social History:
___
Family History:
Father with hypertension on hemodialysis. Maternal aunt with
diabetes on dialysis. Brother with coronary artery disease.
Physical Exam:
Vitals: T 99.3, HR 68, BP 132/80, RR 18, O2 98% RA
Gen: A&O, NAD
CV: RRR
Pulm: CTAB
Abd: soft, mild TTP in RUQ, no rebound/guarding
Ext: w/d
Pertinent Results:
___ 03:43AM BLOOD ___ PTT-27.5 ___
___ 03:43AM BLOOD ALT-21 AST-23 AlkPhos-51 TotBili-0.7
___ 12:17AM BLOOD Lipase-13
___ 03:43AM BLOOD Albumin-2.9* Calcium-8.2* Phos-4.2 Mg-1.8
___ 09:33AM BLOOD Lactate-1.7
___ 09:36AM BLOOD WBC-9.1# RBC-2.85*# Hgb-7.8*# Hct-26.0*#
MCV-91 MCH-27.6 MCHC-30.2* RDW-14.2 Plt ___
___ 01:07PM BLOOD Hct-26.2*
___ 03:08PM BLOOD WBC-7.8 RBC-2.82* Hgb-8.0* Hct-25.5*
MCV-91 MCH-28.4 MCHC-31.3 RDW-14.7 Plt ___
___ 08:00PM BLOOD Hct-27.1*
___ 12:17AM BLOOD WBC-7.7 RBC-2.61* Hgb-7.5* Hct-23.9*
MCV-91 MCH-28.7 MCHC-31.4 RDW-15.0 Plt ___
___ 06:07AM BLOOD Hct-29.9*#
___ 09:58AM BLOOD Hct-32.7*
___ 09:58AM BLOOD Hct-33.6*
___ 10:48PM BLOOD Hct-31.5*
___ 02:50AM BLOOD WBC-8.8 RBC-3.60*# Hgb-10.3*# Hct-32.6*
MCV-91 MCH-28.6 MCHC-31.6 RDW-15.5 Plt ___
___ 01:13PM BLOOD Hct-30.1*
___ 03:43AM BLOOD WBC-7.1 RBC-3.12* Hgb-9.3* Hct-28.0*
MCV-90 MCH-30.0 MCHC-33.4 RDW-14.9 Plt ___
Brief Hospital Course:
The patient was admitted to the ICU for monitoring. CT scan
revealed a moderate sized subcapsular hematoma and moderate to
large amount of hemoperitoneum. The hematocrit on admission was
26 and INR was 1.2. He was transfused 2 units of blood HD 1 and
the hematocrit increased to 27 before trending down to 23.9 and
he was transfused an additional 2 units of blood and 1 unit of
FFP. The hematocrit increased to 29 and then slowly trended
upwards. He remained hemodynamically stable.
On the floor, his hematocrit continued to be stable. His pain
was well controlled on PO pain meds. He was ambulating as with
his baseline. During his hospital stay, he underwent vein
mapping in prepation for future dialysis access. On day of
discharge, he still had some abdominal pain, but it was
controlled on po pain meds, and was tolerating a regular diet.
Medications on Admission:
1. Vitamin D 50,000 unit once week
2. furosemide 20 mg daily
3. amlodipine 10 mg daily
4. Colcrys 0.6 mg prn gout
Discharge Medications:
1. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4
hours) as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
2. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain/fever.
5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
Discharge Disposition:
Home
Discharge Diagnosis:
hepatic subcapsular hematoma with hemoperitoneum
chronic kidney disease
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 bleeding from the liver.
You were treated with blood products to keep your blood levels
elevated. You have done well and are ready for dicharge. You had
an ultrasound of your arms to assess the veins in preparation
for creation of a fistula for dialysis access. You will be
called by the transplant office with further instructions about
your upcoming surgery. Avoid needle sticks, blood pressures, lab
draws, or IV's in the left arm.
Followup Instructions:
___
|
19928285-DS-7 | 19,928,285 | 20,462,480 | DS | 7 | 2152-12-07 00:00:00 | 2152-12-08 19:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with history of hypertensive nephropathy
status post kidney transplantation on ___ with cadaveric
transplant from an at-risk donor who presents with fever. He
reports right knee pain, but no recent injury, warmth, or
redness. He denies night sweats, weight loss, cough, colds,
myalgias, nausea/vomiting/diarrhea, abdominal pain, dysuria,
rash, calf pain, rectal pain, or any other new symptoms.
He denies new medications, recent antibiotics, or recent travel,
though his daughter experienced gastrointestinal upset not long
ago. He reports prior travel overseas to ___ and the ___. He reports a prior negative PPD. He has had Zostavax and
Pneumovax. He has been taking tacrolimus and mycophenolate
mofetil since his transplant in ___, though tacrolimus dose
was reduced recently.
In the ED, initial vital signs were as follows: 102.1 156/69 64
18 97% on RA. Admission labs were notable for white blood cell
count of 3.5, including 2 bands, 20 monos, and 5 atypicals. He
was given ceftriaxone after blood cultures were obtained. Vital
signs prior to transfer were: 102.1 130/83 76 18 97% on RA.
Past Medical History:
-Stage V Chronic kidney disease (thought secondary to HTN,
unable to undergo biopsy due to bilateral cysts)
-Hepatitis C, genotype 1, no history of treatment
-Chronic alcoholic pancreatitis
-Gout
-Hypertension
-Diverticulosis
-Colonic polyps
-Tonsillectomy and removal of laryngeal polyps
-LUE AVF ___, superficialized ___
Social History:
___
Family History:
Father with hypertension on hemodialysis. Maternal aunt with
diabetes on dialysis. Brother with coronary artery disease.
Physical Exam:
On admission:
VS: 99.0 127/80 67 18 99% on RA 64kg
GENERAL: Well appearing male in NAD
HEENT: Sclera anicteric. PERRL, EOMI. MMM without lesions
NECK: Supple with low JVP
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RRR, S1 S2 clear with ___ systolic and diastolic murmurs
heard throughout the precordium
LUNGS: CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: +BS, soft, NT, ND, no HSM
EXTREMITIES: wwp, no ___ edema or asymmetry
NEURO: A&Ox3, CN ___ intact, ___ strength throughout
SKIN: no rashes
At discharge:
Afebrile/AVSS. Otherwise unchanged.
Pertinent Results:
On admission:
___ 09:50PM BLOOD WBC-3.5* RBC-4.67 Hgb-13.7* Hct-43.2
MCV-92 MCH-29.3 MCHC-31.7 RDW-12.7 Plt ___
___ 09:50PM BLOOD Neuts-63 Bands-2 Lymphs-10* Monos-20*
Eos-0 Baso-0 Atyps-5* ___ Myelos-0
___ 09:50PM BLOOD Glucose-121* UreaN-14 Creat-1.6* Na-139
K-4.1 Cl-102 HCO3-25 AnGap-16
___ 09:50PM BLOOD ALT-30 AST-44* LD(LDH)-230 AlkPhos-48
TotBili-0.6
___ 06:28AM BLOOD Calcium-9.2 Phos-3.4 Mg-1.4*
___ 10:04PM BLOOD Lactate-0.9
___ 09:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:50PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 09:50PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
At discharge:
___ 06:00AM BLOOD WBC-2.3* RBC-4.65 Hgb-13.5* Hct-42.9
MCV-92 MCH-29.0 MCHC-31.4 RDW-12.6 Plt ___
___ 06:00AM BLOOD ___ PTT-30.0 ___
___ 06:00AM BLOOD Glucose-112* UreaN-14 Creat-1.5* Na-139
K-4.5 Cl-105 HCO3-25 AnGap-14
___ 06:00AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.8
___ 06:00AM BLOOD tacroFK-6.6
In the interim:
___ 09:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 09:00AM BLOOD HIV Ab-NEGATIVE
___ 06:00AM BLOOD BK VIRUS BY PCR, BLOOD-PND
Microbiology:
Urine culture ___ and ___: NG
Blood cultures x2 (___), x3 (___): NGTD
CMV viral load (___): Undetectable
HIV viral load (___): Undetectable
EBV panel (___): Pending
Imaging:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
Mr. ___ is a ___ with history of hypertensive nephropathy
with end stage renal disease status post cadaveric renal
transplant from an at-risk donor in ___ who presented with
fever.
Active Issues:
(1)Fever: There were no clear localizing signs/symptoms of
infection; murmur had been documented previously, hence deemed
unlikely to reflect endocarditis/new valvulopathy. CXR and urine
culture were unremarkable/negative, and blood cultures showed no
growth to date by the time of discharge. HIV antibody and viral
load, CMV viral load, and hepatitis B antibody panel were
without evidence of infection. EBV antibody panel and BK PCR
remained pending at discharge. He remained hemodynamically
stable without SIRS/sepsis physiology throughout admission and
had defervesced by the time of discharge, with fevers likely
attributable to nonspecific viral syndrome.
(2)End stage renal disease status post cadaveric renal
transplant: Creatinine remained stable at 1.5 to 1.6 throughout
admission, consistent with recent baseline. Home tacrolimus and
mycophenolate mofetil were continued, with therapeutic levels
throughout admission. Home trimethoprim/sulfamethoxazole also
was continued.
Inactive Issues:
(1)Leukopenia: Baseline leukopenia (2.3 to 3.5) in the setting
of multiple immunosuppressants with marrow suppression persisted
throughout admission.
Transitional Issues:
- Pending studies: Blood cultures x2 (___), x3 ___ EBV
panel ___ BK PCR (___).
- Code status: Full.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mycophenolate Mofetil 1000 mg PO BID
2. Tacrolimus 3 mg PO Q12H
3. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) unknown Oral daily
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
6. Pancrelipase 5000 Dose is Unknown PO Frequency is Unknown
Discharge Medications:
1. Mycophenolate Mofetil 1000 mg PO BID
2. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
3. Tacrolimus 3 mg PO Q12H
4. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
5. Outpatient Lab Work
Please check labs on ___ and fax to Dr. ___,
___ at ___ ___: CBC,
Sodium; Potassium; Chloride; Bicarbonate; BUN; Creatinine;
Glucose; ALT; Calcium; AST; Total Bili; Phosphate; Albumin;
Tacrolimus, BK virus pcr.
ICD-9 V42.0
6. Pancrelipase 5000 ___ CAP PO TID W/MEALS
7. Calcarb 600 With Vitamin D *NF* (calcium carbonate-vitamin
D3) 500 mg ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Viral URI
Fever
Renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care during your admission
to ___. As you know, you were
admitted for fever, which was attributed to likely a viral upper
respiratory illness. Your fever resolved and we believe that it
is safe for you to go home.
Followup Instructions:
___
|
19928323-DS-9 | 19,928,323 | 23,697,420 | DS | 9 | 2163-12-03 00:00:00 | 2163-12-06 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
Endoscopic ultrasound
History of Present Illness:
Ms ___ presented to ___ after a fall that was presumed to be
a seizure. We performed a repeat MRI that demonstrated meningeal
enhancement over the left hemisphere but worsening edema in that
area. The gastroenterology team performed an endoscopic
ultrasound that did not demonstrate the presence of a mass, and
on repeat examination of the prior CT, radiology was less
concerned about a discrete mass near the duodenum. Given the
negative malignancy workup, we discussed the possibility of a
brain biopsy to characterize the lesion. However, this was not
felt to be consistent with Ms ___ goals of care. Therefore,
we decided to presumptively treat for amyloid angiitis, which is
a disorder that can appear like the lesion seen on MRI. We
treated her with five days of high dose steroids, and she did
regain significant strength on the right arm, although her right
leg did not improve. She did have elevated blood pressures on
steroids, and we increased the dose of her losartan. In
addition, she had high blood sugars, and we consulted the
diabetes team, who recommended that she start nightly insulin
plus a sliding scale insulin before meals. We would recommend
continuing this dose of prednisone for one month and then
tapering the prednisone over one month.
Past Medical History:
mechanical valve (aortic) on coumadin; goal INR 2.5-3.5
HTN
HLD
arthritis
diabetes
Social History:
___
Family History:
Father with CAD and DM.
Physical Exam:
Vitals:
97.8 74 163/82 18 98% RA
GEN: Awake, cooperative, NAD.
HEENT: NC/AT, anicteric, MMM, no lesions noted in oropharynx
NECK: Supple
RESP: CTAB
CV: RRR
ABD: soft, NT/ND
EXT: No edema, no cyanosis
SKIN: no rashes or lesions noted.
NEURO EXAM:
MS:
Alert, oriented to self, hospital (does not know which
hospital),month and day, but not year.
Unable to related details of history. She states that she went
directly to home after her prior hospitalization, but when told
she actually went to a ___, she then states that she was there
for 2 months. She cannot reliably tell if she has followed up at
___.
Inattentive
Language is fluent with intact repetition and comprehension.
Normal prosody.
There were no paraphasic errors.
Speech is dysarthric with difficulty with primarily palatal
sounds (baseline)
Able to follow both midline and appendicular commands.
Good knowledge of current events.
Uses hand as tool bilaterally on apraxia testing.
Possible L/R confusion vs. extinction (see sensory exam)
CN:
II:
PERRLA 3 to 2mm and brisk.
VFF to confrontation.
III, IV, VI: EOMI, no nystagmus. Normal saccades.
V: Sensation intact to LT.
VII: Facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate rise symmetric.
XI: Trapezius and SCM ___ bilaterally.
XII: Tongue protrudes midline.
Motor:
Normal bulk, increased tone in RLE. There is downward drift with
pronation on right.
No adventitious movements. No asterixis.
Motor exam is limited by patient effort. There is clear
asymmetry
however, with the right arm and leg weaker than the left, all
groups in the 4 range.
Sensory: Sensory exam is limited by inattention, but patient
reports light touch on RLE when touched on RLE, LLE or both
simultaneously.
Reflexes:
Bi Tri ___ Pat Ach
L ___ 2 1
R ___ 2 1
Right toe up, left toe down
Coordination:
No intention tremor, no dysdiadochokinesia noted. No dysmetria
on
FNF.
Discharge exam:
Motor: Right deltoid 3, biceps 4, triceps 4, wrist extensor 4+,
finger extension 4+, finger flexion 5-, Right leg plegic, Left
arm and leg full strength
Pertinent Results:
___ 04:48AM BLOOD WBC-7.8 RBC-3.37* Hgb-10.1* Hct-30.0*
MCV-89 MCH-30.0 MCHC-33.7 RDW-13.1 RDWSD-42.4 Plt ___
___ 08:00AM BLOOD Neuts-82.1* Lymphs-11.1* Monos-5.7
Eos-1.0 Baso-0
___ 10:55AM BLOOD ___ PTT-75.4* ___
___ 10:55AM BLOOD Glucose-86 UreaN-23* Na-143 K-3.4 Cl-110*
HCO3-26 AnGap-10
___ 05:16AM BLOOD ALT-46* AST-27 AlkPhos-107* TotBili-0.5
___ 04:49AM BLOOD Calcium-10.0 Phos-2.4* Mg-2.1
___ 05:16AM BLOOD CEA-1.1
MRI: Persistent left cerebral hemisphere sulcal effacement with
interval
increase and left frontal and left parietal lobe edema,
subarachnoid blood products, and areas of more chronic
micro-hemorrhage within the bilateral cerebral hemispheres,
including a new focus within left parietal lobe. The overall
findings may represent metastatic disease versus amyloid
angiopathy related inflammation, less likely sarcoid or
lymphoma.
Brief Hospital Course:
Ms ___ presented to ___ after a fall that was presumed to be
a seizure. We performed a repeat MRI that demonstrated meningeal
enhancement over the left hemisphere but worsening edema in that
area. The gastroenterology team performed an endoscopic
ultrasound that did not demonstrate the presence of a mass, and
on repeat examination of the prior CT, radiology was less
concerned about a discrete mass near the duodenum. Given the
negative malignancy workup, we discussed the possibility of a
brain biopsy to characterize the lesion. However, this was not
felt to be consistent with Ms ___ goals of care. Therefore,
we decided to presumptively treat for amyloid angiopathy, which
is a disorder that can appear like the lesion seen on MRI. We
treated her with five days of high dose steroids, and she did
regain significant strength on the right arm, although her right
leg did not improve. She did have elevated blood pressures on
steroids, and we increased the dose of her losartan. In
addition, she had high blood sugars, and we consulted the
diabetes team, who recommended that she start nightly insulin
plus a sliding scale insulin before meals. We would recommend
continuing this dose of prednisone for one month and then
tapering the prednisone over one month.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO BID:PRN pain
2. Docusate Sodium 100 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Rosuvastatin Calcium 40 mg PO QPM
9. TraZODone 150 mg PO QHS:PRN insomnia
10. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -400 unit oral DAILY
11. diclofenac epolamine 1.3 % transdermal BID
12. Mirtazapine 15 mg PO QHS
13. Polyethylene Glycol 17 g PO DAILY
14. Warfarin 3.5 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO BID:PRN pain
2. Docusate Sodium 100 mg PO DAILY
3. Ezetimibe 10 mg PO DAILY
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Losartan Potassium 100 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Omeprazole 20 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY
10. Rosuvastatin Calcium 40 mg PO QPM
11. TraZODone 150 mg PO QHS:PRN insomnia
12. Warfarin 4 mg PO DAILY16
13. Calcium Carbonate 500 mg PO DAILY
14. NPH 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
15. LeVETiracetam 1000 mg PO BID
16. PredniSONE 60 mg PO DAILY
Take 60mg daily x1 month; then decrease 10mg every five days
until off
17. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Amyloid angiopathy
Discharge Condition:
Mental Status:
Level of Consciousness: Alert and interactive
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted with right sided weakness after a fall. We
suspected that this was caused by a seizure. You were found to
have more inflammation around the covering of the brain on the
left side, which likely caused the seizure and your weakness. We
put you on a medication that prevents seizures. We performed
multiple tests but without performing surgery we were not able
to find out exactly what was causing the inflammation. One
possibility for the inflammation was a disorder called amyloid
angiitis, and we decided to presumptively treat you for this
condition. You received five days of high dose steroids and will
continue on steroids for another two months.
Followup Instructions:
___
|
19928728-DS-11 | 19,928,728 | 21,394,753 | DS | 11 | 2177-10-14 00:00:00 | 2177-10-14 13:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa(Sulfonamide Antibiotics) / Arava / Keflex /
Septra / Suprax / Plaquenil / Erythromycin Base
Attending: ___
Chief Complaint:
Status-post fall
Major Surgical or Invasive Procedure:
___: 1. Open treatment of fracture instability of T10 and
T11 with posterior fixation and arthrodesis. 2. Posterior
instrumentation T9 to T12 with pedicle screw segmental
construct. 3. Arthrodesis T9 to T12 posteriorly. 4. Application
of allograft and demineralized bone matrix.
___: Percutaneous tracheostomy and placement
of IVC filter.
___: Percutaneous endoscopic gastrostomy.
History of Present Illness:
___ with hx of RA, DVT on coumadin, visiting from ___, woke
up to go to bathroom and fell down 10 carpeted stairs, + LOC.
Seen at OSH, panscanned, and found to have bilat SAH in the
setting of an elevated INR (2.0). Pt received vit K prior to
transfer from OSH. Patient also found to have T11 burst fx, C4
transverse process fx with displacement into the left transverse
foramen, T10 end plate fx, R posterior 1st rib fx. No urinary or
bowel incontinence. No lower extremity weakness or numbness.
Pt transferred to ___ for further evaluation. In the ED pt
received 1 OF 2 units of FFP. She was seen by ortho-spine and
neurosurgery. The pt was admitted to the TSICU. Now s/p
posterior fusion for thoracic spine fractures. Re-intubated for
respiratory distress on ___.
Past Medical History:
Rheumatoid arthritis; arthritis; cervical spinal stenosis;
spondylosis; occipital neuralgia; DVT, Sjogrens syndrome
Social History:
___
Family History:
Non-contributory
Physical Exam:
On discharge:
VS: Tm 99.1 Tc 98.3 HR 83 BP 143/52 RR 22 98%Fi02 35% trach
collar
General: in no acute distress
HEENT: mucus membranes moist, nares clear, ___ J collar in
place
CV: regular rate, rhythm
Pulm: clear to auscultation anteriorly, slightly diminished at
bases
Abd: soft, nontender, nondistended. PEG in position without
evidence of infection.
MSK: warm, well perfused with venodyne boots on b/l. Chronic
rheumatoid changes to hands bilaterally. Able to move from bed
to commode with assistance.
Neuro: alert, oriented. Slightly withdrawn but appropriate.
Moves all extremities appropriately.
Pertinent Results:
___ 05:00AM BLOOD WBC-10.8 RBC-3.73* Hgb-10.9* Hct-33.9*
MCV-91 MCH-29.2 MCHC-32.1 RDW-15.1 Plt ___
___ 05:00AM BLOOD ___ PTT-32.1 ___
___ 08:03AM BLOOD Glucose-139* UreaN-22* Creat-0.6 Na-139
K-3.7 Cl-100 HCO3-28 AnGap-15
___ 01:24AM BLOOD ALT-19 AST-31 LD(LDH)-312* AlkPhos-92
TotBili-0.5
___ 01:24AM BLOOD WBC-15.3* RBC-2.44* Hgb-7.1* Hct-22.4*
MCV-92 MCH-29.2 MCHC-31.8 RDW-14.4 Plt ___
___ 04:40AM BLOOD WBC-7.7 RBC-2.49* Hgb-7.3* Hct-23.1*
MCV-93 MCH-29.2 MCHC-31.5 RDW-14.3 Plt ___
___ 06:40AM BLOOD ___ PTT-47.1* ___
___ 01:26AM BLOOD Glucose-145* UreaN-24* Creat-0.7 Na-136
K-3.6 Cl-100 HCO3-24 AnGap-16
___ 04:40AM BLOOD Glucose-114* UreaN-19 Creat-0.6 Na-135
K-3.7 Cl-97 HCO3-32 AnGap-10
___ 02:09AM BLOOD ALT-61* AST-58* AlkPhos-205* TotBili-0.4
___ 07:49AM BLOOD Vanco-11.3
___ 05:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
CT Head:
1. Increase in size of now 2.8 cm left inferior frontotemporal
hemorrhagic contusion with surrounding edema, with resultant
mass effect leading to partial effacement of the suprasellar
cistern and concern for developing downward transtentorial
herniation.
2. Unchanged to minimally increased left greater than right
multifocal
subarachnoid hemorrhage with extension in the occipital horn of
the right
lateral ventricle without evidence of hydrocephalus or shift of
midline
structures.
3. Left occipital subgaleal hematoma.
CTA Neck:
1. Acute fracture of the left transverse foramen of C4 without
evidence of vascular injury.
2. Right first rib fracture.
3. Probable Paget's disease of the bone involving the left
humerus,
incompletely imaged.
CTA Head:
1. Enlarging subarachnoid hemorrhage centered at the left
operculum, with minimal mass effect, and new extension into the
intraventricular space.
2. No evidence of vascular malformation, aneurysm, or mass.
3. Paranasal sinus disease featuring mucosal thickening and
air-fluid levels.
MRI Cervical and Thoracic Spine:
1. The cervical spine demonstrates irregularity and abnormal
signal of C4, C5, and C6 vertebral bodies which may be
degenerative in nature. The fracture described at the left
transverse foramen of C4 cannot be appreciated in this MRI.
There is a fluid collection in the prevertebral soft tissues
measuring 2.4 x 0.25 cm anterior to C3 and C4. This may
represent edema or fluid collection related to the recent
history of trauma. The cerebellar tonsils are displaced 1 cm
inferiorly through the foramen magnum which may be due to Chiari
1 malformation or due to increased intracranial pressure related
to the intracranial hemorrhage.
2. The thoracic spine demonstrates a compression fracture of
T11 vertebral body with 7.5-mm retropulsion, causing deformity
of the anterior aspect of the spinal cord and mild abnormal
signal in the spinal cord. Additionally, there are nondisplaced
fractures of T4 and T5 vertebral bodies. There is no evidence
of epidural hematoma.
3. Bilateral pleural effusion and atelectasis.
___: CT head:
Overall, the parenchymal and subarachnoid blood is unchanged
compared to the most recent examination, with minimal
intraventricular blood, also unchanged, and no evidence of
hydrocephalus or central herniation.
___: EEG:
This is an abnormal continuous ICU monitoring study because
of severe diffuse encephalopathy manifest by reversal of the
anterior-
posterior gradient and the presence of diffuse slowing with a
frontal
central predominance. There are also features suggesting
slightly
greater left hemisphere pathology. While there are numerous
potential
epileptic discharges in the form of sharp slow waves, no clear
spike and
wave discharges were seen and no seizures were identified.
___: Bilateral lower extremity non-invasive studies:
Grayscale, color Doppler images were obtained of bilateral
common femoral, femoral, popliteal and tibial veins. Normal
flow, compression and augmentation is seen in all of the
vessels.
___: CT head:
1. No acute hemorrhage. Resolving left frontal intraparenchymal
and left
frontal subarachnoid hemorrhage.
2. New non-hemorrhagic fluid in the left maxillary sinus,
ethmoidal sinus, sphenoidal sinus and both mastoid air cells.
3. Low lying cerebellar tonsils- ? Chiari 1 malformation
___: Right wrist/forearm:
Severe chronic-appearing degenerative changes superimposed on a
prior inflammatory process involving the wrist, but with no
definite
superimposed injury. Bony demineralization
___: Portable chest:
Tracheostomy tube is in a standard position. NG tube tip is out
of view,
below the diaphragm. Left PICC tip is in the mid SVC. There is
no
pneumothorax. If any, there is a small left pleural effusion.
Mild
cardiomegaly is stable. Right lower lobe opacities have
increased, worrisome for aspiration. There is mild vascular
congestion. Spinal hardware is again noted.
Brief Hospital Course:
Ms. ___ was admitted to the trauma ICU on ___ with the
following injuries:
Bilateral subarachnoid hemorrhage
R. posterior 1st rib fx
C4 transverse process fx
T11 burst fx
T10 end-plate fx
Her course is described below by system:
Neuro: Patient was followed by neurosurgery through out her
stay. Due to the extent of hemorrhage, a CTA was obtained to
determine if an aneurysm was present, but none were visualized.
Her neurologic status gradually improved and she was weaned from
sedation. Her GCS was 15, though intermittently agitated. Repeat
Head CTA showed expected evolution of the SAH with no evidence
of vasospasm or mass effect or midline shift. She also had
unstable fractures of T10 and T11 confirmed by MRI. She was
taken to the OR and underwent posterior fusion on ___
without event. Additionally, she had a C4 transverse process
fracture with possible ligamentous injury; she had a ___
collar which was to be remain in place until follow-up or
re-evaluation by Spine surgery, which will be in 6 weeks after
discharge on ___. She was also evaluated by neurosurgery for
her SAH with recommendations to continue Keppra until at least
follow-up. She did not demonstrate seizure activity during her
hospitalization.
CV: Patient had severe hypertension to SBP 200s during her stay
requiring a nicardipine drip for control. Her home medication
doses were increased until nicardipine could be weaned. Patient
was also diuresed with lasix to assist with volume reduction and
hypertension. Eventually she was stabilized on her home regimen
which included lisinopril, labetalol and lasix. She remained
hemodynamically stable. Her blood pressure was stable at
systolic 140s prior to discharge, and her heart rate in sinus
rhythm in the ___.
Resp: She was extubated on POD#1. On ___, patient had an
episode of respiratory distress with tachypnea, inability to
clear secretions, and hypoxia. She was reintubated without
difficulty. There was a prolonged vent wean complicated by the
fact that she developed a MRSA pneumonia that was treated with a
14 day course of vancomycin to was completed on ___. She
returned to the OR, therefore, for a tracheostomy and IVC filter
on ___. She ultimately tolerated trach wean trials on trach
mask and was stable enough for a Passy-Muir valve on ___. She
was attaining oxygen saturations at 98% on trach-collar at 35%
Fi02 and was monitored on continuous oxygen monitoring
throughout her stay.
GU/GI/FEN: Patient was started on tube feedings through a
dobhoff tube which she tolerated without event. When had a PEG
placed on ___. Tube feeds were started soon thereafter, which
she did tolerate at 30cc/hr goal to 45cc/hr. Her electrolytes
were drawn routinely and repleted appropriately; these were
within normal limits upon discharge. She was voiding adequately
via foley catheter prior to discharge.
Heme: Received one unit of blood each on ___ and ___.
This was not due to concern for acute bleed but rather due to a
slow drift downward. She had an IVC filter placed on ___ as
well. She has a history of DVT on coumadin, which was
discontinued after filter placement. Her hematocrit remained
stable between ___ for several days prior to discharge and did
not require additional transfusions beyond ___. The patient
has a PICC line in place with good placement confirmed on CXR.
ID: Patient spiked a fever on ___. Cultures were sent and
due to thick purulent secretions, she was started on a
vent-associated pneumonia protocol with initiation of vancomycin
and ciprofloxacin. Her WBC count normalized and fevers resolved
therafter.Due to history of PCP pneumonia, she was started on
pentamidine prophylaxis until PCP cultures came back negative.
She completed a 14 day course of vancomycin, dc'd on ___. She
was continued on ciprofloxacin for her history of a septic elbow
and as recommended by ID. She was afebrile prior to discharge
without any evidence of infection or leukocytosis.
MSK: the patient has rheumatoid arthritis with particular focus
in the wrist and fingers bilaterally. She was continued on her
oral predisone dose without issue. Films were taken on ___
with no evidence of acute injury or fracture.
Prophylaxis: the patient underwent IVC filter for her history of
DVT and wore venodyne compression boots for prophylaxis. She
also continues to receive famotidine for stress ulcer
prophylaxis. She was continued on Keppra for seizure prophylaxis
given her subarachnoid hemorrhage.
Upon discharge, the patient was afebrile, hemodynamically
stable, tolerating her tube feeds near goal and maintaining good
urine output via foley catheter prior to discharge. Her
follow-up was discussed with her family with understanding of
the discharge instructions.
Medications on Admission:
ctonel 35mg weekly; Atenolol 50mg daily; Crestor 10mg daily
Diovan 320mg daily; folic acid 1mg daily; lasix 20mg BID;
abatacept qmonth; nexium 40mg daily; norvasc 5mg daily;
calcium-vit D; singulair 10mg daily; tenazopam 30mg qhs daily;
multivitamin; xanex 0.25mg daily; zoloft 50mg daily; albuterol
BID; cipro 500mg BID (elbow infection); vicodin qhs; Coumadin
1.5mg daily; tramodol QID; mobic 1 tab daily; prednisone 5mg
daily; vit C
Discharge Medications:
1. insulin regular human 100 unit/mL Solution Sig: One (1) per
sliding scale Injection ASDIR (AS DIRECTED).
2. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1)
Recon Soln Injection Q15MIN () as needed for hypoglycemia
protocol.
3. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. levetiracetam 100 mg/mL Solution Sig: One (1) PO BID (2
times a day).
6. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
7. ipratropium-albuterol ___ mcg/actuation Aerosol Sig: ___
Puffs Inhalation Q6H (every 6 hours).
8. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
9. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette
Ophthalmic TID (3 times a day).
10. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
11. sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for Pain.
Disp:*60 Tablet(s)* Refills:*0*
13. temazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime) as needed for Insomnia: to continue until follow-up
with Neurosurgeon.
14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for fever, pain.
15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours): continue indefinitely for history of septic
elbow.
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as
needed for wheeze.
17. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
18. labetalol 200 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
19. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every
12 hours).
20. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2
times a day).
21. dextrose 50% in water (D50W) Syringe Sig: One (1) per
protocol Intravenous PRN (as needed) as needed for hypoglycemia
protocol.
22. sodium chloride 0.9 % 0.9 % Syringe Sig: One (1) ML
Injection PRN (as needed) as needed for line flush: 10ml flush
for PICC daily and PRN.
23. sodium chloride 0.9 % 0.9 % Syringe Sig: One (1) ML
Injection Q8H (every 8 hours) as needed for line flush.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid Hemorhage
C4 ligamentous injury
T11/T10 fracture post fusion
Right posterior 1st rib fracture
Discharge Condition:
Mental Status: slightly withdrawn, but alert and oriented.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
General Instructions
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
You were on Coumadin (Warfarin) before your injury, but you
now have a filter in place to help prevent clots from returning
to your heart. You will not have to continue your coumadin at
this point.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Due to prolonged bedrest and the risk of developing a blood
clot, you received an 'IVC filter' to prevent clots from
returning to your heart.
Due to weakened respiratory muscles secondary to prolonged
ventilation and failure to adequately oxygenate without
assistance, you underwent a tracheostomy.
Due to weakened swallowing ability and difficulty feeding with a
tracheostomy in place, you underwent PEG placement for tube
feeds, which you have tolerated well. These will be continued
until you get stronger to have the tracheostomy removed and
undergo speech and swallow therapy to assess your ability to
eat.
Followup Instructions:
___
|
19929060-DS-18 | 19,929,060 | 28,158,118 | DS | 18 | 2138-10-19 00:00:00 | 2138-10-19 19:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Iodinated Contrast Media - IV Dye / bee venom (honey bee)
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Appendectomy
History of Present Illness:
___ presenting with 1 day of worsening abdominal pain, nausea,
vomiting x1. She was in her normal state of health until
yesterday morning when she started to have ___ generalized
abdominal pain. The pain subsequently localized to the right
abdomen this morning. She initially presented to her PCP this
morning and underwent an abdominal CT. CT showed acute
appendicitis and possible appendiceal mucocele. She subsequently
had a anaphylactic reaction to IV contrast with difficulty
breathing and facial swelling. She was treated with fluids,
EpiPen, Benadryl, and transferred to ___ for further care.
Past Medical History:
Pectus excavatum
Social History:
___
Family History:
No family history of inflammatory bowel disease, aunt with
pancreatic cancer, mother with HTN, relatives with CAD
Physical Exam:
Physical Exam on admission:
Vitals: 97.9 70 151/84 16 100%RA
GEN: AOx3, 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: RLQ tenderness to palpation, soft, no rebound, negative
Rovsing's and psoas signs
Ext: No ___ edema, ___ warm and well perfused
Exam on Discharge:
Pertinent Results:
___ 06:00AM BLOOD WBC-10.1* RBC-2.98*# Hgb-9.5*# Hct-29.3*#
MCV-98 MCH-31.9 MCHC-32.4 RDW-12.2 RDWSD-43.9 Plt ___
___ 01:00PM BLOOD WBC-16.4* RBC-4.48 Hgb-14.4 Hct-42.5
MCV-95 MCH-32.1* MCHC-33.9 RDW-11.9 RDWSD-41.3 Plt ___
___ 01:00PM BLOOD Neuts-80.3* Lymphs-16.4* Monos-2.3*
Eos-0.4* Baso-0.1 Im ___ AbsNeut-13.15* AbsLymp-2.68
AbsMono-0.37 AbsEos-0.07 AbsBaso-0.02
___ 01:00PM BLOOD ___ PTT-23.0* ___
___ 06:00AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-134
K-4.5 Cl-102 HCO3-26 AnGap-11
___ 01:00PM BLOOD Glucose-160* UreaN-15 Creat-0.8 Na-138
K-3.2* Cl-103 HCO3-20* AnGap-18
___ 06:00AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.7
___ 01:20PM BLOOD Lactate-2.8*
___ OSH CT scan
Mid to distal aspect of the appendix is dilated to 13 mm and
contains
intraluminal hypodensity. The more proximal appendix (the base)
is collapsed. It is difficult to discern whether maybe subtle
minimal periappendiceal inflammation. Differential diagnosis
includes appendiceal mucocele vs appendicitis.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the Acute Care Surgery Team. The patient was found
to have appendicitis with possible mucocele and was admitted to
the Acute Care Surgery Service. The patient was taken to the
operating room on ___ for a laprascopic appendectomy, which
the patient tolerated well. Please see operative report for
details. The patients appendix was sent to pathology for
assessment of the appendix for a possible mucocele. 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 of pre-natal vitamins were continued throughout this
hospitalization. The ___ hospital course was remarkable
for anaphylaxis secondary to IV iodine contrast prior to her CT
scan in the Emergency Department. She was treated with an
Epi-Pen and her symptoms promptly resolved. She continued to
have orthostatic hypotension on POD1. Her hct down trended from
42.1 pre-op to 27.4 by POD1. Her Hct stabilized at 25.4 and her
orthostatic symptoms resolved
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, and tolerating a regular diet. The patient
will follow up with Dr. ___ in two weeks. 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. Pre-natal Vitamins
Discharge Medications:
1. Prenatal Vitamins 1 TAB PO DAILY
2. Acetaminophen 650 mg PO Q6H pain
3. Docusate Sodium 100 mg PO BID
4. EPINEPHrine (EpiPEN) 0.3 mg IM X2 PRN Anaphylaxis reaction
RX *epinephrine HCl (PF) 1 mg/mL (1 mL) 1 Epipen IM prn
anaphylaxis Disp #*3 Ampule Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #*20 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Anaphylaxis secondary to contrast iodine
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dr. ___,
___ were admitted to the Acute Care Surgery Service at BICMD on
___ with acute appendicitis. ___ were taken to the
operating room and had your appendix removed laparoscopically.
Samples of the appendix were sent to pathology. The results of
this test will be reviewed with ___ at your follow up
appointment. ___ tolerated the procedure well and are now being
discharged home to continue your recovery with the following
instructions.
___ had a CT scan with IV contrast and had an anaphylactic
reaction to the contrast media. ___ were treated with
epinephrine. Please update your primary care provider with this
information. ___ should alert future health care providers of
this allergy.
ACTIVITY:
o Do not drive until ___ have stopped taking pain medicine and
feel ___ could respond in an emergency.
o ___ may climb stairs.
o ___ may go outside, but avoid traveling long distances until
___ 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 ___ may start some light exercise when ___ feel comfortable.
o ___ will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when ___
can resume tub baths or swimming.
HOW ___ MAY FEEL:
o ___ may feel weak or "washed out" for a couple of weeks. ___
might want to nap often. Simple tasks may exhaust ___.
o ___ may have a sore throat because of a tube that was in your
throat during surgery.
o ___ might have trouble concentrating or difficulty sleeping.
___ might feel somewhat depressed.
o ___ 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 ___ may shower and remove the gauzes over your
incisions. Under these dressing ___ 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 ___ 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 ___ were told
otherwise.
o ___ 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 ___ may shower. As noted above, ask your doctor when ___ may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, ___ may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. ___ can get both of these
medicines without a prescription.
o If ___ 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 ___ find the pain
is getting worse instead of better, please contact your surgeon.
o ___ 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 ___ take it before
your pain gets too severe.
o Talk with your surgeon about how long ___ will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If ___ are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when ___
cough or when ___ are doing your deep breathing exercises.
If ___ 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 ___ were on before the operation just as
___ did before, unless ___ have been told differently.
If ___ have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19929203-DS-22 | 19,929,203 | 26,994,637 | DS | 22 | 2159-12-03 00:00:00 | 2159-12-03 15:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa(Sulfonamide Antibiotics) / atenolol
Attending: ___
Chief Complaint:
Fever and confusion
Major Surgical or Invasive Procedure:
ERCP
History of Present Illness:
CC: fever and confusion
HPI(4): Mr. ___ is a ___ man with a long history of
hypertension, with bilateral renal artery stenosis, history of
lacunar stroke ___ years, ?Afib on chronic warfarin, with a
recent L4-L5 discectomy at ___ who presented
with
acute onset of confusion, fevers, and chills, found to have GNR
bacteremia. ___ had his discectomy about one month ago; his
course was complicated by delirium attributed to alprazolam
withdrawal. He was discharged to ___, and progressed
well, discharging home last ___. His course there was
complicated by diarrhea; a C Diff was sent and vancomycin
started
with improvement in the diarrhea, but the PCR was negative. When
vancomycin was stopped, diarrhea worsened so he was treated
empirically. After discharging home, he continued to improve --
walking at his baseline with a cane and eating well. He
continued
to be at his normal state of health until ___ at lunch
time.
At that point he started to complain of feeling hot; by 2 ___ he
had a temperature of 102.4, and was completely altered. His
brother ___ (who is a retired emergency room ___) took his
BP and noted he was hypotensive and brought him to ___
emergency room. ___ denies any localizing symptoms -- no
abdominal pain, no urinary symptoms, no meningismus, no
headache.
In the ED, TMax 101.8 with SBPs in the ___, oxygen was 88% on
RA,
requiring 4 liters to have spO2 in the mid ___. Out of concern
for meningitis he was started on IV acyclovir, IV vancomycin, IV
ampicillin, and IV CefePIME. The ED considered performing a
lumbar puncture, but deferred in the setting of anticoagulation.
His blood cultures came back with both bottles growing GNRs.
Out of concern for a spine infection, ortho spine was consulted,
and an MRI of his spine was performed.
1. No evidence of epidural collection, cord compression or
severe
spinal canal stenosis.
2. Postsurgical changes after right L3-L4 hemilaminectomy with
expected postsurgical changes.
3. Small fluid collection in the subcutaneous soft tissues
subjacent to the incision site with minimal surrounding
enhancement most likely represents a
postoperative seroma. However, an early phlegmon or abscess
formation is not entirely excluded and clinical correlation is
suggested.
4. Mild multilevel degenerative changes throughout the cervical
spine partially with mild remodeling of the ventral cord
secondary to small disc herniations but without cord signal
abnormality.
5. Degenerative changes of the lumbar spine are most pronounced
at L2-L3 where there is moderate spinal canal stenosis and
compression of the traversing L3 nerve roots as well as at L4-L5
and L5-S1 where there is compression of the exiting nerve roots
within the neuroforamen.
Per ortho, this fluid collection likely represented a seroma and
not an infected collection.
A CT abdomen was performed which showed:
1. Mild intrahepatic biliary dilatation. Linear hypodensities
surrounding the bile ducts within the right lobe of the liver
may
represent the sequela of cholangitis, however there are no
priors
for comparison. No focal fluid collections.
2. Incidental findings include a large periampullary duodenal
diverticulum and severe atherosclerosis.
CT head was performed since:
1. No acute intracranial abnormalities.
2. Severe chronic microvascular ischemic and age-related
involutional changes.
EKG showed ventricular bigeminy.
Patient was started on a heparin gtt because on INR 1.8 and high
CHADS2Vasc and then admitted to medicine.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
PAST MEDICAL/SURGICAL HISTORY:
1. HTN
2. GERD
3. PMR, previously on prednisone
4. PVD with claudication
5. pAF
6. Anxiety
7. Carotid stenosis
8. BPH
9. CVA
___. Celiac artery stenosis
11. CKD
12. Anemia
13. AS
SOCIAL HISTORY: ___
FAMILY HISTORY: Heart disease
Past Medical History:
See HPI
Social History:
___
Family History:
See HPI
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
CV: Heart regular at present, sys m, 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 at
present. Bowel sounds present.
GU: No suprapubic fullness or tenderness to palpation
MSK: No edema or cyanosis
SKIN: No rashes or ulcerations noted
NEURO: Alert, memory deficits, grossly intact. AAOx3 today
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 05:45AM BLOOD WBC-7.6 RBC-3.25* Hgb-10.0* Hct-28.9*
MCV-89 MCH-30.8 MCHC-34.6 RDW-12.9 RDWSD-41.9 Plt ___
___ 05:45AM BLOOD Neuts-67.9 Lymphs-18.0* Monos-8.6 Eos-3.8
Baso-0.8 Im ___ AbsNeut-5.14 AbsLymp-1.36 AbsMono-0.65
AbsEos-0.29 AbsBaso-0.06
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD ___ PTT-34.8 ___
___ 05:45AM BLOOD Glucose-90 UreaN-7 Creat-0.6 Na-139 K-3.6
Cl-105 HCO3-23 AnGap-11
___ 05:45AM BLOOD ALT-76* AST-34 AlkPhos-472* TotBili-0.3
___ 05:50AM BLOOD ALT-111* AST-89* AlkPhos-583* TotBili-0.4
___ 05:45AM BLOOD Albumin-2.9* Calcium-8.3* Mg-1.3*
Brief Hospital Course:
___ y//o patient who presented w/ sepsis secondary to cholangitis
associated with Klebsiella bacteremia.
He underwent ERCP w/ sludge and stone extraction. Clinically
improved. All sepsis parameters have resolved. Bcx +ve for
Klebsiella pneumoniae >> covered w/ Rocephin and transitioned to
Levaquin at discharge. LFTs improving. F/u blood Cx negative.
Will need 5 more days of Abx.
Diarrhea has resolved. Although appetite is poor -- able to
tolerate diet well. Quite weak -- rehab was discussed. Pt and
family preferred to go home w/ services.
Warfarin was briefly held for ERCP. Resumed now. INR 2.4 today.
Recc INR check on ___ and f/u w/ PCP. F/u CMP; CBC w/ PCP
in ___ week
Initially was hypotensive -- req IVF. BP stable now but still
off HTN meds (on Terazosin for BPH). Recc check BP at home over
next week and show log to PCP at next visit.
___ plan d/w patient; his wife and brother. All agree w/
the plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 20 mg PO Q12H
2. Spironolactone 50 mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Citalopram 10 mg PO DAILY
5. Losartan Potassium 50 mg PO DAILY
6. Chlorthalidone 25 mg PO DAILY
7. Terazosin 1 mg PO QHS
8. Warfarin 2.5 mg PO 3X/WEEK (___)
9. Warfarin 5 mg PO 4X/WEEK (___)
10. Atorvastatin 80 mg PO QPM
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Gabapentin 300 mg PO QHS
13. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Medications:
1. LevoFLOXacin 750 mg PO Q24H Duration: 5 Days
RX *levofloxacin [Levaquin] 750 mg 1 tablet(s) by mouth once a
day Disp #*5 Tablet Refills:*0
2. Citalopram 10 mg PO DAILY
3. Gabapentin 300 mg PO QHS
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
5. Pantoprazole 20 mg PO Q12H
6. Terazosin 1 mg PO QHS
7. Warfarin 2.5 mg PO 3X/WEEK (___)
8. Warfarin 5 mg PO 4X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sepsis secondary to Cholangitis w/ Klebsiella pneumonia
bacteremia
Discharge Condition:
Stable
No distress; Currently AAOx3; Quite frail though
Discharge Instructions:
Follow up w/ PCP in ___ week
CBC; CMP check w/ PCP in ___ week
INR check on MON ___ and send results to PCP. Warfarin dose
adjustment per MD accordingly. Target INR ___
Check BP twice/day and show records to PCP at next visit
Followup Instructions:
___
|
19929207-DS-5 | 19,929,207 | 22,677,634 | DS | 5 | 2160-08-05 00:00:00 | 2160-08-05 16:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ female with h/o HTN who presents
with RUQ abdominal pain for the past 6 months.
She reports RUQ pain since ___. Pt reports pain is
constant and does not change with eating, but substantially
worsens with movement or walking. Pain radiates to her back. It
is associated with leg pain as well, and she feels that her legs
have become weak so that she has to walk slowly. Denies any
nausea, vomiting, diarrhea, constipation or blood in her stool.
She does report chest pressure ("like a weight") that worsens
when she presses on her chest. It is not associated with SOB or
diaphoresis. Denies fevers. The chest pressure is also worse
with movement, but also occurs when she is lying flat. Does not
seem to worsen with exercise. She was seen by her PCP yesterday
for ___ BP check, but complained of this RUQ pain and chest pain
so was sent to the ED for evaluation.
Notably, she has been intermittently followed by GI for
epigastric pain here at ___, and has had elevated
transaminases at her PCP's office of unclear etiology (full
records not available).
In the ED, initial vitals were 98.5 84 ___ 99%RA. ECG
showed NSR with rate 71, normal axis, with TWI in V3, aVF, c/w
prior. Labs notable for mild transaminitis. RUQ showed
cholelithiasis without cholecystitis. Surgery was consulted who
recommended no acute surgical intervention and admission to
medicine for leukocytosis.
Currently, she continues to complain of RUQ and right upper back
pain, as well as leg pain. She still can feel her chest
pressure, but states that does not concern her as much as the
RUQ pain.
ROS: Denies fever, chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, cough, shortness
of breath, nausea, vomiting, diarrhea, constipation, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
Hypertension
Positive PPD treated with INH in ___
Benign hyperplastic gastric polyp in ___
H/o epigastric pain, seen in our GI clinic and elevated LFTs
Social History:
___
Family History:
Mother with hypertension. Father expired at age ___ in an
accident involving alcohol. She has two brothers, all are
healthy. No history of colon cancer, inflammatory bowel disease,
peptic ulcer disease. Denies FH of MI.
Physical Exam:
Admission:
Vitals: 98.2 100/69 91 18 96%RA 83.5kg
GENERAL: Pleasant, well appearing female in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___. Chest pain/pressure reproducible on palpation.
LUNGS: CTAB, good air movement bilaterally.
ABDOMEN: NABS. Soft, tender to palpation in RUQ and right upper
back without distention. No HSM.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Does have pain with straight leg raise on the
right. Slightly decreased hip flexor strength on right but feel
limited due to effort/pain. Gait assessed and relatively steady
but some giveway weakness/leg buckling when walking
NEURO: A&Ox3. Appropriate.
PSYCH: Listens and responds to questions appropriately, pleasant
Discharge:
Notable for less tenderness over the right chest wall. Patient
also ambulating without issue with normal lower extremity
strength exam.
Pertinent Results:
___ 08:08PM BLOOD WBC-11.9* RBC-4.93 Hgb-14.9 Hct-44.4
MCV-90 MCH-30.2 MCHC-33.5 RDW-13.5 Plt ___
___ 06:45AM BLOOD WBC-11.0 RBC-4.82 Hgb-15.2 Hct-43.5
MCV-90 MCH-31.5 MCHC-34.9 RDW-13.2 Plt ___
___ 08:08PM BLOOD Neuts-58.8 ___ Monos-3.6 Eos-1.7
Baso-0.8
___ 06:45AM BLOOD Neuts-61.0 ___ Monos-3.9 Eos-0.9
Baso-0.8
___ 06:45AM BLOOD ___ PTT-28.3 ___
___ 06:45AM BLOOD ESR-25*
___ 08:08PM BLOOD Glucose-103* UreaN-20 Creat-0.9 Na-135
K-3.9 Cl-103 HCO3-24 AnGap-12
___ 06:45AM BLOOD Glucose-96 UreaN-23* Creat-0.6 Na-134
K-3.7 Cl-102 HCO3-21* AnGap-15
___ 08:08PM BLOOD ALT-76* AST-43* AlkPhos-133* TotBili-0.3
___ 06:45AM BLOOD ALT-78* AST-48* CK(CPK)-107 AlkPhos-139*
TotBili-0.5
___ 08:08PM BLOOD Lipase-181*
___ 06:45AM BLOOD CK-MB-1 cTropnT-<0.01
___ 08:08PM BLOOD cTropnT-<0.01
___ 08:08PM BLOOD Albumin-4.3
___ 06:45AM BLOOD TotProt-7.2 Calcium-9.3 Phos-2.2* Mg-2.3
___ 06:45AM BLOOD VitB12-336
___ 06:45AM BLOOD TSH-3.5
___ 06:45AM BLOOD CRP-7.6*
___ 01:25PM BLOOD LEAD (BLOOD)-PND
___ 11:23PM URINE Color-Straw Appear-Clear Sp ___
___ 11:23PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 11:23PM URINE UCG-NEGATIVE
STUDIES:
ECG Study Date of ___ 7:56:30 ___
Sinus rhythm. Anterior T wave changes, cannot rule out
myocardial ischemia. Compared to previous tracing of ___,
anterior ST-T wave changes are persistent. Clinical correlation
is suggested.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
10:30 ___
FINDINGS:
Evaluation is limited due to body habitus.
There are no focal hepatic lesions. Liver is normal in
echotexture. Portal vein is patent with no hepatopetal flow.
Gallstones are seen within the gallbladder, but there are no
signs of
cholecystitis including no evidence of gallbladder distention,
edema, or
pericholecystic fluid. ___ sign is negative.
There is no intra- or extra-hepatic biliary dilatation with the
common bile duct measuring 2.5 mm.
There is no free fluid.
IMPRESSION:
Gallstones but no evidence of acute cholecystitis.
CHEST (PA & LAT) Study Date of ___ 11:02 ___
FINDINGS: The lungs are clear, the cardiomediastinal silhouette
and hila are normal. There is no pleural effusion and no
pneumothorax.
IMPRESSION: No acute cardiothoracic process.
RIB UNILAT, W/ AP CHEST RIGHT Study Date of ___ 11:15 AM
CHEST, TWO VIEWS. RIBS, THREE VIEWS.
CHEST: There are low inspiratory volumes and lordotic
positioning. This
likely accounts for prominence of the cardiomediastinal
silhouette. There is slight prominence of the vascular
markings. No frank consolidation, effusion, or pneumothorax is
identified.
RIBS: Three views of the right ribs were obtained. A marker
was placed and overlies the mid abdomen, slightly lower than the
twelfth rib. No lucent or sclerotic fracture line. No
displaced fracture is detected involving the right-sided ribs.
IMPRESSION: Low inspiratory volumes. No rib fracture and no
acute pulmonary process identified.
Brief Hospital Course:
___ year old female with h/o HTN who presents with RUQ abdominal/
rib pain for the past 6 months.
# Back/ Abdominal pain: Patient with chronic pain, no clear
precipitant, no trauma. Constant and unchanging. LFTs
chronically elevated. Patient also denies previous rash in the
area. By exam, ? rib pathology due to tenderness to palpation
along ribs specifically although x-ray without fracture/
pathology. Also possible is pancreatitis (although no
radiation) given lipase of 181. Also ? zoster versus possible
multiple myeloma/ lead poisoning, but again, no fracture,
lucency. Patient started on gabapentin 30mg BID with some
resolution of her symptoms. Physical therapy did not believe
that patient met criteria to be evaluated as she was quite
mobile. We appreciated consultation with surgical colleagues
who recommended
HIDA with CCK for ? biliary dyskinesia though this was not felt
to be urgent as she had no ___ sign and pain very localized
to chest wall, NOT ABDOMEN. Patient will follow up with the
___ consideration of this test.
# Elevated LFTs: Upon review of OMR (including OSH labs), LFTs
not that far off baseline and RUQ read is similar to prior.
Unclear etiology, but it appears as though she has had a partial
workup at an OSH. ? fatty liver. Despite numerous attempts, we
were unable to confirm outside labs. Patient will follow up in
liver clinic.
# Leg weakness: Has subjective leg weakness with some mild
weakness on exam felt to be due to effort. Unclear etiology but
strange in this young patient. Neuro exam unremarkable. ?
possible multiple myeloma contributing to combined rib pain,
neuropathy but this was felt unlikely given her aged,
demographics, and normal protein gap with lack of anemia. ESR
and CRP were mildly elevated. As above, ___ consult not
necessary as patient mobile without difficulty. TSH 3.5, B12
336.
# Initial presentation of chest pain: Reports chronic
reproducible chest pressure. ECG not remarkably different than
baseline. Feel unlikely to be cardiac and most likely
musculoskeletal, although duration of symptoms is strange. CXR
unremarkable. Troponins negative x2. No further intervention.
# Leukocytosis: Denies recent fevers. UA unremarkable. No other
localizing symptoms of infection other than RUQ pain. Could
consider epidural abscess but she appears quite well on exam and
has no neutrophilia on differential. Resolved
# HTN: Home lisinopril and HCTZ
# Transitional:
- Lead levels pending.
- Hepatitis B non-immune.
Medications on Admission:
Lisinopril-HCTZ 40mg-25mg po daily
Oral OCPs per surgery note, although was not in patient's list
when I asked
Discharge Medications:
1. lisinopril-hydrochlorothiazide ___ mg Tablet Sig: Two (2)
Tablet PO once a day.
2. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Neuropathic pain, flank pain.
Secondary:
Hypertension, history of latent tuberculosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was our pleasure to care for you at ___. We believe that
your abdominal pain is secondary to neuropathic causes, or
dysfunction in the nerves around your ribs. We started you on a
medication, Gabapentin, to help control this pain.
Senora ___,
Fue nuestra placer ___. Pensamos ___
dolor ___ a ___ de sus costillas.
Hicimos unos estudios ___ no demonstraron una fractura en las
costillas. Empezamos una nueva medicacion para usted para
controlar las simptomas de dolor, ___ se llama gabapentin.
Porfavor, atiende a las citas describidas debajo.
We made the following changes to your medications.
Please START gabapentin 300mg BID
Followup Instructions:
___
|
19929286-DS-20 | 19,929,286 | 22,584,344 | DS | 20 | 2193-01-10 00:00:00 | 2193-01-11 08:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Midazolam / Demerol / Tegaderm Frame Style / Red Dye / Iodinated
Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Subtotal colectomy, rigid sigmoidoscopy, lysis of
adhesions, ABThera placement.
___: Resection of rectum, left oophorectomy, ileostomy
___: Interventional Radiology paracentesis
___: EGD: 2x clips applied over AVM
___: EGD
___: Interventional Radiology JP drains placed x2
History of Present Illness:
Ms ___ is a ___ year old lady with history of CAD, MI,
ischemic colitis, pacemaker, bioprostetic AVR ___ years ago and
TAVR last year, and diverticulosis, who has been having
abdominal
discomfort mostly in the LLQ for the past ___ months, treated
intermittently as diverticulitis in ___ and here with
antibiotic course, last course of which has been two weeks ago
which was completed 3days ago. She states that the overall
course
has been worsening but that the antibiotics helped sometimes.
Patient states that after completion of this last course of
cipro
and flagyl 3 days ago, she became progressively and severely
nauseous with frequent vomiting, had abdominal pain and
diarrhea.
the patient went to ___ initially where her lactate was
found to be 2.3, and her WBC was ___ with left shift.
A CT scan without IV contrast was notable for colonic dilation
up
to the level of the sigmoid colon, and a complex cystic mass in
the left adnexa.
The patient was transferred to ___ for further workup after 1L
fluid resuscitation and one dose of meropenem. On presentation
to
___ her lactate had increased to 5, her pressures were soft
and
her mental status was deteriorated.
Surgery is consulted regarding the need for surgical
intervention.
at the time of this consult the patient is still nauseous, and
complains of severe abdominal pain. her last bowel movement had
been the day prior to this presentation, which she describes as
black and soft. From a mental status standpoint she was very
drowsy, however, she responded appropriately to a few questions
when verbally reoriented. She denies fever, chills, SOB, CP,
palpitations, lightheadedness.
Cardiac enzymes were negative for acute MI, and cardiology
service did not recommend further cardiac output.
Past Medical History:
Past Medical History:
MI
CAD
ischemic colitis
diverticulosis
Past Surgical History:
cholecystectomy
C-section
open bioprosthetic AVR ___ years ago
TAVR one year ago
Social History:
___
Family History:
brother s/p OLT for hep C, passed away
Physical Exam:
Admission Physical Exam:
Vitals: HR:70 BP: 95/60 RR:28 Sat: 92%RA T:97.8
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: tachypneic on RA, no use of accessory muscles, no central
cyanosis
ABD: Soft, TTP diffusely, no rebound/guarding
Ext: No ___ edema, no cyanosis.
Discharge Physical Exam:
VS: T: 98.3 PO BP: 109/71 HR: 70 RR: 18 O2: 100% Ra
GEN A+Ox3, NAD
CV: RRR
PULM: no respiratory distress, breathing comfortably on room air
ABD: soft, non-distended, non-tender to palpation. Surgical
wound with wet-to-dry dressing. Wound base red overall with
minimal fibrinous debris in inferior portion of the wound, no
s/s infection. Right ileostomy with stool in bag.
Extremity: wwp, no edema b/l
Pertinent Results:
Pathology: ___:
1- Ileocecal resection:
- Partially autolyzed viable small and large intestine; margins
viable.
- Tubular adenomas, up to 0.4cm
- Unremarkable vermiform appendix
2- Ascending colon, partial colectomy:
- Diverticular disease; no significant peridiverticular
inflammation seen.
- Viable colon with partial autolysis including viable specimen
margins
3- Transverse colon, partial colectomy:
- Colon with subtotal transmural infarction; margins viable
4- Ileum, partial resection:
- Small intestine with mucosal and submucosal ischemia involving
specimen margins
5- Descending colon, partial colectomy:
- Diverticular disease; with associated stricture, patchy mural
chronic inflammation, and foreign body
giant cell reaction.
LABS:
___ 09:46PM TYPE-ART PO2-139* PCO2-41 PH-7.33* TOTAL
CO2-23 BASE XS--4
___ 09:46PM LACTATE-2.0
___ 09:46PM freeCa-1.08*
___ 09:39PM GLUCOSE-103* UREA N-33* CREAT-1.5* SODIUM-146
POTASSIUM-4.4 CHLORIDE-112* TOTAL CO2-20* ANION GAP-14
___ 09:39PM CALCIUM-7.4* PHOSPHATE-4.2 MAGNESIUM-2.6
___ 09:39PM HGB-10.7* HCT-33.5*
___ 08:07PM TYPE-ART PO2-174* PCO2-40 PH-7.33* TOTAL
CO2-22 BASE XS--4
___ 08:07PM LACTATE-2.1*
___ 08:07PM freeCa-1.07*
___ 04:01PM TYPE-ART PO2-178* PCO2-45 PH-7.28* TOTAL
CO2-22 BASE XS--5
___ 04:01PM LACTATE-2.6*
___ 04:01PM freeCa-1.11*
___ 03:54PM GLUCOSE-110* UREA N-33* CREAT-1.5* SODIUM-146
POTASSIUM-4.6 CHLORIDE-112* TOTAL CO2-19* ANION GAP-15
___ 03:54PM CALCIUM-7.6* PHOSPHATE-4.8* MAGNESIUM-2.8*
___ 03:54PM WBC-8.1 RBC-4.14 HGB-11.6 HCT-35.7 MCV-86
MCH-28.0 MCHC-32.5 RDW-15.3 RDWSD-48.1*
___ 03:54PM PLT COUNT-187
___ 01:34PM TYPE-ART PO2-151* PCO2-45 PH-7.25* TOTAL
CO2-21 BASE XS--7
___ 01:34PM LACTATE-2.7*
___ 11:51AM TYPE-ART PO2-171* PCO2-50* PH-7.20* TOTAL
CO2-20* BASE XS--8
___ 11:51AM LACTATE-3.8*
___ 09:06AM TYPE-ART PO2-450* PCO2-44 PH-7.24* TOTAL
CO2-20* BASE XS--8
___ 08:50AM GLUCOSE-92 UREA N-35* CREAT-1.4* SODIUM-145
POTASSIUM-3.4* CHLORIDE-109* TOTAL CO2-18* ANION GAP-18
___ 08:50AM CALCIUM-8.5 PHOSPHATE-5.1* MAGNESIUM-1.6
___ 08:50AM CEA-10.6*
___ 08:50AM WBC-11.4* RBC-4.22 HGB-11.9 HCT-36.5 MCV-87
MCH-28.2 MCHC-32.6 RDW-15.1 RDWSD-47.7*
___ 08:50AM PLT COUNT-221
___ 08:50AM ___ PTT-32.8 ___
___ 07:54AM TYPE-ART PO2-318* PCO2-48* PH-7.20* TOTAL
CO2-20* BASE XS--9 INTUBATED-INTUBATED VENT-CONTROLLED
___ 07:54AM GLUCOSE-78 LACTATE-5.4* NA+-138 K+-3.4
CL--110*
___ 07:54AM HGB-10.3* calcHCT-31
___ 07:54AM freeCa-1.22
___ 06:14AM TYPE-ART O2-80 PO2-272* PCO2-50* PH-7.09*
TOTAL CO2-16* BASE XS--14 AADO2-244 REQ O2-49
INTUBATED-INTUBATED VENT-CONTROLLED
___ 06:14AM GLUCOSE-102 LACTATE-4.4* NA+-137 K+-3.7
CL--113*
___ 06:14AM HGB-12.0 calcHCT-36 O2 SAT-98
___ 06:14AM freeCa-1.12
___ 01:58AM ___ PO2-50* PCO2-26* PH-7.23* TOTAL
CO2-11* BASE XS--15
___ 01:58AM LACTATE-6.1* K+-3.6
___ 01:58AM O2 SAT-77
___ 12:08AM LACTATE-5.0*
___ 11:53PM GLUCOSE-158* UREA N-35* CREAT-1.6* SODIUM-136
POTASSIUM-7.0* CHLORIDE-116* TOTAL CO2-9* ANION GAP-11
___ 11:53PM ALT(SGPT)-9 AST(SGOT)-52* ALK PHOS-81 TOT
BILI-0.5
___ 11:53PM LIPASE-17
___ 11:53PM cTropnT-<0.01
___ 11:53PM CK-MB-2
___ 11:53PM ALBUMIN-3.2*
___ 11:53PM WBC-29.1* RBC-5.54* HGB-15.3 HCT-47.6* MCV-86
MCH-27.6 MCHC-32.1 RDW-15.2 RDWSD-47.3*
___ 11:53PM NEUTS-82* BANDS-13* LYMPHS-3* MONOS-2* EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-27.65* AbsLymp-0.87*
AbsMono-0.58 AbsEos-0.00* AbsBaso-0.00*
___ 11:53PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-1+* MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL
BURR-1+* ELLIPTOCY-OCCASIONAL
___ 11:53PM PLT SMR-NORMAL PLT COUNT-321
___ 11:53PM ___ PTT-29.0 ___
Microbiology:
___ 9:30 am PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ (___) AT
3:15 ___
___.
ENTEROCOCCUS SP.. SPARSE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
PENICILLIN G---------- =>64 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 11:55 am PERITONEAL FLUID PERITONEAL FLUID LLQ.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ 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 (Final ___: NO GROWTH.
___ 11:40 am ABSCESS
ABCESS DRAINAGE RUQ PER HANDWRITTEN ON SYRINGE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 11:40 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Brief Hospital Course:
**Rehab stay expected to be less than 30 days.**
Ms ___ was admitted to the ACS service after emergent
subtotal colectomy for necrotic cecum and obstructing sigmoid
mass. She underwent her initial surgery and was admitted to the
Trauma ICU for resuscitation, intubated and sedated with an open
abdomen. She was taken back to the operating room the following
day for resection of the remainder of her sigmoid colon as well
as her left ovary and fallopian tube. An ileostomy was created.
She was treated with 4 days of zosyn postoperatively.
She was readmitted to the trauma ICU postoperatively for
monitoring. Her hospital course, by systems, is as follows:
Neuro: The patient was initially sedated and intubated
postoperatively. After she was extubated, she was acutely
delirious for two days, after which her mental status improved.
After transfer to the floor, she was intermittently delirious
and geriatrics was consulted for any medical recommendations to
reduce delirium.
CV: The patient was initially requiring vasopressors
postoperatively but they were soon weaned; vital signs were
routinely monitored. Cardiology was consulted for a 30 minute
episode of tachycardia (underlying rhythm consistent with RV
pacing). Pacemaker was interrogated and was normal. Cardiology
also assisted with anticoagulation recommendations and
recommended stopping Plavix.
Pulmonary: The patient was extubated on POD #1 from her second
operation and was weaned successfully to room air. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. Postoperatively,
the NGT was dc'ed once she had good ostomy output. She received
anti-diarrheal medication as she initially had high ostomy
output. Once her output was controlled, the antidiarrheal
medication was discontinued. Her diet was advanced sequentially
to a Regular diet. The patient had episodes of nausea and
emesis and had a CT scan which showed a large volume of ascites
which was removed via paracentesis. She had an episode of
hematemesis and underwent EGD which was normal. The patient
received medication, such as reglan, erythromycin and Marinol,
to stimulate her appetite. She had a dobhoff feeding tube
placed and tube feeds were initiated, however, she self-removed
the dobhoff and refused any enteral access. POs were encouraged
and nutritional supplements were provided. All appetite
stimulants were later stopped, as the patient felt that all the
medication she was receiving may be contributing to her nausea.
ID: peritoneal fluid collection grew enterococcus sp and she
received a course of linezolid which finished. She also grew
e.coli from her urine culture and she received ceftazedime which
finished. The patient later had two JP drains placed by
Interventional Radiology for simple fluid seen within the
abdomen. These JP drains were later removed.
HEME: The patient's blood counts were closely watched for signs
of bleeding and she required intermittent blood transfusions to
maintain adequate hematocrit/hemoglobin.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
Wound Care: The patient had her scheduled bedside wound vac
changes which she tolerated well.
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:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO BID:PRN anxiety
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Anastrozole 1 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Aspirin 325 mg PO DAILY
6. Lisinopril 5 mg PO DAILY
7. Clopidogrel 75 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Citalopram 20 mg PO DAILY
Discharge Medications:
1. Heparin 5000 UNIT SC BID
2. Metoprolol Tartrate 25 mg PO BID
3. Miconazole Powder 2% 1 Appl TP QID:PRN excoration perineum
4. Pantoprazole 40 mg PO Q24H
5. Aspirin 81 mg PO DAILY
6. LORazepam 0.25 mg PO BID:PRN sleep/anxiety
RX *lorazepam 0.5 mg 0.5 (One half) mg by mouth twice a day Disp
#*5 Tablet Refills:*0
7. Anastrozole 1 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. Citalopram 20 mg PO DAILY
10. Levothyroxine Sodium 100 mcg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Large bowel obstruction with ischemic colon, with malignant
versus diverticular sigmoid stricture
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 an obstruction of your
colon and decreased blood flow to your bowel. You were taken to
the operating room and underwent removal of the colon, rectum,
and the left ovary and a diverting ileostomy was created.
Following surgery, you had an infected intra-abdominal fluid
collection as well as a urinary tract infection and you
completed a course of antibiotic therapy. You had a wound vac
sponge dressing placed to help close your surgical wound. You
now have return of bowel function and are tolerating a regular
diet. It is important to keep eating a nutritious, high-calorie
diet while at rehab to regain your strength and promote healing.
You are now ready to be discharged to rehab to continue your
recovery. Please note the following discharge instructions:
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
19929286-DS-22 | 19,929,286 | 24,868,766 | DS | 22 | 2193-11-17 00:00:00 | 2193-11-17 08:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Midazolam / Demerol / Tegaderm Frame Style / Red Dye / Iodinated
Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Septic shock
Major Surgical or Invasive Procedure:
Central venous catheter placement on ___
History of Present Illness:
Ms. ___ is a ___ woman with multiple cardiovascular
comorbidities including several ischemic/embolic events (to the
colon and to bilateral legs), s/p CABG, s/p pacemaker placement
for complete heart block, s/p AVR then a TAVR, who initially
presented to an OSH complaining of nausea and vomiting, fever
and chills. At OSH she had temp of 100.8, SBP ___, WBC 19, CXR
with possible PNA. She was treated with azithromycin, cefepime,
acetaminophen, and 4L NS prior to transfer to the ___ ED.
History is notable for a recent ___ admission for
Enterococcus faecalis pneumonia/bacteremia, during which her TEE
was negative, VAD was removed, PICC was placed, and she was
treated with a 6-week course of IV antibiotics.
Past Medical History:
Notable for:
- colonic ischemia s/p subtotal colectomy and ileostomy
- CAD s/p CABG
- CHB s/p pacemaker
- AVR
- subsequent TAVR
- peripheral artery disease s/p embolectomy
- Enterococcus faecalis bacteremia in ___
- HTN/HLD
- C section
- cholecystectomy
- recurrent diverticulitis
- Invasive ductal carcinoma s/p lumpectoy, SNLB, radiation,
anastrozole
- RLL speculated pulmonary nodule suspicious for BAC
- hyoothyroidism
- anxiety
Social History:
___
Family History:
Brother s/p OLT for hep C, passed away
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: HR 81, BP 151/66, RR 24, O2 88% RA
GENERAL: Alert and pleasantly conversant. Shivering.
HEENT: NCAT. Dry mucus membranes.
CARDIAC: Regular rate and rhythm. Normal S1 and S2. ___ SEM best
heard at RUSB
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. Normal work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
palpation. Ostomy bag with thin green liquid.
EXTREMITIES: No edema. Radial pulses palpable. PICC line in
right
arm without drainage. Some erythema from bandage surrounding the
PICC.
NEUROLOGIC: Moving all extremities spontaneously. AOx3.
DISCHARGE PHYSICAL EXAM
GENERAL: Alert, in NAD, eating pudding with her sister
EYES: ___, pupils equally round
PSYCH: pleasant, appropriate affect
Remainder of exam deferred given CMO
Pertinent Results:
ADMISSION LABS
___ 09:53PM WBC-15.8* RBC-3.02* HGB-9.0* HCT-28.6* MCV-95
MCH-29.8 MCHC-31.5* RDW-16.8* RDWSD-57.5*
___ 09:53PM NEUTS-93.8* LYMPHS-2.5* MONOS-2.5* EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-14.84* AbsLymp-0.39* AbsMono-0.40
AbsEos-0.00* AbsBaso-0.02
___ 09:53PM ___ PTT-26.4 ___
___ 09:53PM GLUCOSE-80 UREA N-23* CREAT-2.1* SODIUM-142
POTASSIUM-4.0 CHLORIDE-122* TOTAL CO2-8* ANION GAP-12
___ 09:53PM ALBUMIN-2.7* CALCIUM-7.1* PHOSPHATE-2.2*
MAGNESIUM-0.9*
___ 09:53PM ALT(SGPT)-8 AST(SGOT)-21 ALK PHOS-48
___:53PM LIPASE-9
___ 09:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:55PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 09:55PM URINE RBC-9* WBC-5 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:04PM LACTATE-1.4 CREAT-2.0*
PERTINENT LABS
MICRO
DISCHARGE LABS
IMAGING/STUDIES
CXR ___- PICC line in expected position and unchanged. Early
pulmonary edema suspected, with patchy airspace opacities of the
lung bases, could represent alveolar edema, or superimposed
infection.
CT A/P ___- 1. Post subtotal colectomy and proctectomy, with
right lower quadrant diverting ileostomy with a small amount of
ascites. No acute intra-abdominal process.
2. Small bilateral pleural effusion, with bibasal atelectasis
and superimposed aspiration/pneumonia in the RLL.
NCHCT ___- 1. Right occipital parietal subacute infarction
without edema.
2. MR may be helpful for further characterization to investigate
the
possibility of infection as well as any evidence for mycotic
aneurysm.
3. Evidence of chronic infarct in the right frontal lobe.
TTE ___- There is normal regional and global left ventricular
systolic function. The visually estimated left ventricular
ejection fraction is >=55%. There is no resting left ventricular
outflow tract gradient. Normal
right ventricular cavity size with normal free wall motion. An
aortic valve bioprosthesis is present. The prosthesis is well
seated with leaflets not well seen. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
with no mitral valve prolapse. There is mild to moderate [___]
mitral regurgitation. The pulmonic valve leaflets are not well
seen. The tricuspid valve is not well seen. There is mild to
moderate [___] tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Focused study.Suboptimal image quality. Overall LV
systolic function. Bioprosthetic AVR is present, gradients not
obtained on this focused study. Thickening around aortic valve
short axis and aorto-mitral continuity appears similar to prior
study, however image quality is poor. Mild to moderate mitral
regurgitation. Mild to moderate tricuspid regurgitation.
Compared with the prior TTE (images reviewed) of ___,
there is no obvious change, but the suboptimal image quality of
the studies precludes definitive comparison.
___ 05:50AM BLOOD WBC: 23.3* RBC: 3.49* Hgb: 10.1* Hct:
31.6* MCV: 91 MCH: 28.9 MCHC: 32.0 RDW: 16.6* RDWSD: 55.2* Plt
Ct: 86*
___ 01:07AM BLOOD WBC: 10.1* RBC: 3.49* Hgb: 10.1* Hct:
31.4* MCV: 90 MCH: 28.9 MCHC: 32.2 RDW: 16.6* RDWSD: 55.0* Plt
Ct: 93*
___ 03:02AM BLOOD WBC: 15.2* RBC: 3.35* Hgb: 9.8* Hct:
29.5*
MCV: 88 MCH: 29.3 MCHC: 33.2 RDW: 16.4* RDWSD: 53.1* Plt Ct:
123*
___ 01:07AM BLOOD Glucose: 124* UreaN: 22* Creat: 1.5* Na:
134* K: 3.5 Cl: 106 HCO3: 16* AnGap: 12
___ 03:02AM BLOOD Glucose: 112* UreaN: 24* Creat: 1.7* Na:
138 K: 4.2 Cl: 110* HCO3: 13* AnGap: 15
___ 03:42PM BLOOD Trep Ab: NEG
___ Blood culture: +GPC
___ Blood culture: MRSA ___ Blood culture: MRSA ___ Blood culture: MRSA ___ Blood culture: MRSA ___
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
Other micro:
___ Legionella urine Ag: negative
___ Urine culture: No growth final
___ Stool culture: Campylobacter negative, otherwise pending
Cultures from prior admissions:
___ Blood culture - enterococcus faecalis
E faecalis
M.I.C. Inter
------ -----
Ampicillin <=2 S
Beta Lactamase -
Ciprofloxacin <=0.5 S
Daptomycin 0.5 S
Erythromycin 2 I
Gentamicin Syn S
Levofloxacin 1 S
Minocycline <=0.5 S
Norfloxacin 4 S
Penicillin 2 S
Streptomycin ___ S
___ CT Head:
1. Right occipital parietal subacute infarction without edema.
2. Evidence of chronic infarct in the right frontal lobe.
Upper extremity ultrasound ___- No evidence of deep venous
thrombosis in the left lower extremity veins.
Brief Hospital Course:
SUMMARY STATEMENT
Ms. ___ is a ___ with multiple cardiovascular
comorbidities(pacemaker, aortic valve replacement, peripheral
artery disease), initially presenting with altered mental status
and hypotension, found to have high-grade MRSA bacteremia with
presumed bacterial endocarditis and imaging findings of a
sub-acute brain infarct
concerning for a septic embolus.
ACUTE ISSUES
# Septic shock
Pt presented to ___ ED in shock briefly requiring levophed.
Etiology of shock most likely secondary to MRSA sepsis and
hypovolemia. MAP was maintained >60 initially with levophed,
then with fluid resuscitation. Serial blood cultures grew MRSA.
Chest x-ray had scant opacities that could not rule out
pneumonia. Given source control, her PICC line was removed.
Family refused pacemaker extraction.
Pt found to fulfill Duke Criteria for endocarditis: 1) MRSA+
blood cultures, 2) fever, 3) history of aortic valve
replacement, 4) imaging evidence of endocarditis complications
(subacute infarct in brain). Infectious Disease team was
consulted, and recommended a 6 week course of vancomycin +
gentamycin, with rifampin to follow. TTE demonstrated normal
cardiac function but was unable to visualize aortic valve. TEE
was deferred as it was not consistent with patient's goals of
care.
# Endocarditis
Definitive treatment for endocarditis is cardiac surgery. Workup
of surgery would necessitate (among other things) 1) extraction
of pacemaker, 2) TEE. Family was consulted and determined that
surgery and other invasive interventions are not within their
goals of care. Therefore, we decided to treat pt's endocarditis
with antibiosis alone.
# Brain infarct
Given persistent altered mental status including inattentiveness
and echolalia, a head CT without contrast was performed,
revealing a left-sided subacute infarct in the parietal and
occipital region consistent with an embolic event. No edema was
noted, though an MRI/MRA would be required to further determine
etiology of stroke. Family refused MRI/MRA as they determined it
was not within goals of care.
There was a question of whether pt's home antithrombotic regimen
(plavix + apixaban) would be appropriate. Ultimately given pt's
declining platelet count and risk of hemorrhagic transformation
of septic emboli, anticoagulation regimen was held.
# Altered mental status
Considered most likely delirium given waxing and waning course,
though probably complicated by worsening vascular dementia.
# ___ on CKD
Most consistent with a pre-renal etiology given patient's
presenting hypovolemia. Creatinine trending to normal after
fluid resuscitation.
#CMO
After thorough discussion with
the patient and her HCP/daughter ___, plan was not to pursue a
TEE or any surgical interventional for source control and to
return home with hospice on ___ (when her daughter is off from
work)
TRANSITIONAL ISSUES
[] Palliation with home hospice
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Escitalopram Oxalate 20 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Anastrozole 1 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. FoLIC Acid 1 mg PO BID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. loperamide-simethicone ___ mg oral TID
10. Octreotide Acetate 50 mcg SC Q8H
11. TraZODone 25 mg PO QHS
12. Atorvastatin 80 mg PO QPM
13. Apixaban 2.5 mg PO BID
14. OLANZapine 5 mg PO QHS:PRN agitation
15. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
16. sodium chloride 0.9 % intravenous 3X/WEEK
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever
2. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose
3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
4. Phenazopyridine 100 mg PO TID Duration: 3 Days
5. Levothyroxine Sodium 100 mcg PO DAILY
6. TraZODone 25 mg PO QHS
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Persistent MRSA bacteremia likely ___ infective endocarditis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
For any discomfort at home, please consult your hospice nurse.
We want to honor your wishes to have you return home and stay
home.
Followup Instructions:
___
|
19929373-DS-2 | 19,929,373 | 29,613,563 | DS | 2 | 2160-05-04 00:00:00 | 2160-05-12 18:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___- Paracentesis
___- Exploratory laparoscopy with washout of bilious
ascites, Right abdominal JP drain placement.
___- Ultrasound and fluoroscopic guided right percutaneous
transhepatic bile duct tube placement.
___- ___ for exchange and reposition of R PTBD
History of Present Illness:
HPI: ___ s/p laparoscopic cholecystectomy here with increasing
abdominal pain and concern for bile leak. She reports having a
lap chole at an OSH 9 days ago having increasing episodes of
biliary colic. The procedure was reportedly uncomplicated and
she went home that day. She then developed left shoulder pain
and LUQ abdominal pain that have been steadily increasing. She
reports some low grade fevers and chills. She denies any
nausea/vomiting. She had some initially diarrhea however this
resolved. She was seen in the ED at an OSH 3 times for this
pain. An initial CT scan demonstrated colitis and she was
started on flagyl 6 days
ago. A second CT scan today however demonstrated a large bile
leak for which she was transferred here for further care.
Past Medical History:
PMH: Obesity
PSH: Lap roux-en-y gastric bypass, abdominoplasty ___ years ago,
breast augmentation ___ years ago, wisdom teeth out
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission PE:
99.3 127 122/76 24 96%/RA
NAD but appears uncomfortable, A&Ox3
Sinus tachy
Unlabored respirations
Abd soft, non-distended, tender to palpation mostly in RUQ and
epigastrium, no rebound or gaurding, well healed surgical
incisions
Ext wwp no edema
Discharge PE:
VS: T: 98.6, HR: 82, BP: 106/64, RR: 18, O2: 97% RA
General: NAD, A+Ox3
Cardiovascular: RRR
Pulmonary: CTA b/l
Abdominal: soft, non-distended, PTBD intact, surrounding skin
without erythema
Extremeties: no edema
Pertinent Results:
___ 06:30AM GLUCOSE-91 UREA N-9 CREAT-0.5 SODIUM-136
POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
___ 06:30AM ALT(SGPT)-42* AST(SGOT)-23 ALK PHOS-261* TOT
BILI-1.0
___ 06:30AM ALBUMIN-3.0* CALCIUM-8.2* PHOSPHATE-2.6*
MAGNESIUM-1.6
___ 06:30AM WBC-8.5 RBC-3.87* HGB-10.9* HCT-31.6* MCV-82
MCH-28.3 MCHC-34.7 RDW-13.2
___ 06:30AM PLT COUNT-224
___ 06:30AM ___ PTT-25.9 ___
___ 11:01PM LACTATE-0.9
___ 11:00PM GLUCOSE-94 UREA N-9 CREAT-0.5 SODIUM-135
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-20* ANION GAP-18
___ 11:00PM WBC-11.0 RBC-4.47 HGB-12.7 HCT-37.0 MCV-83
MCH-28.5 MCHC-34.4 RDW-13.4
___ 11:00PM NEUTS-82.0* LYMPHS-11.2* MONOS-5.5 EOS-1.1
BASOS-0.3
___ 11:00PM PLT COUNT-260
Imaging:
___: PARACENTESIS DIAG/THERAP W IMAGING GUIDE:
IMPRESSION: Successful ultrasound-guided diagnostic and
therapeutic paracentesis with removal of approximately 1 L of
bilious fluid.
___: MRCP (MR ABD ___: Large, loculated, continuous,
upper abdominal collection, involving the gallbladder fossa,
surrounding the left hepatic lobe and extending around the
spleen.
___: Successful placement of a right anterior 10 ___
internal-external biliary drain.
___: Abd supine only: A PTBD is in unchanged position from
the previous PTBD procedure images.
___: Biliary Cath Replacement: Successful exchange of
existing percutaneous transhepatic biliary drainage catheters
with new 10 ___ percutaneous transhepatic biliary catheter.
Brief Hospital Course:
___ year-old female who presented to ___ on ___ with
increasing abdominal pain, s/p laparoscopic cholecystectomy at
an outside hospital 9 days ago. She had an abdominal CT at an
outside hospital which was concerning for a large bile leak. The
patient was made NPO, started on IV fluids and antibiotics and
was admitted to the Acute Care Surgery team. She was
transferred to the surgery floor for hydration, pain control,
hemodynamic monitoring and serial abdominal exams.
On HD1, the patient underwent an ultrasound-guided paracentesis
with removal of approximately 1 L of bilious fluid. She also
had a MRCP which could not directly visualize a biliary leak due
to lack of contrast, but was concerning for an aberrant bile
duct. On HD3, she was taken to the OR for a exploratory
laparoscopy with washout of bilious ascites and had a JP drain
placed.
On POD2, the patient underwent a percutaneous transhepatic
biliary drainage (PTDB) tube placement by interventional
radiology to help further drain her bile collection. On POD3,
the PTDB was capped, however, her abdominal pain increased and
the bag was placed back to drainage. On POD4, the patient had
increasing abdominal pain and became newly febrile. On POD5,
She underwent a repositioning of her PTDB tube by Interventional
Radiology which she tolerated well. On POD6, her PTDB tube was
capped which she tolerated well.
During this hospitalization, the patient's blood counts were
closely watched for signs of bleeding, of which there were none.
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. The patient was alert and
oriented throughout hospitalization; pain was initially managed
with IV pain medicine and then transitioned to oral pain
medicine once tolerating a diet. The patient remained stable
from a cardiovascular standpoint; vital signs were routinely
monitored.
The patient remained stable from a pulmonary standpoint. Good
pulmonary toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
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. The patient was discharged
to home with Visiting Nurse services to help with PTBD and JP
drain care. A follow-up appointment was scheduled with the Acute
Care Surgery clinic.
Medications on Admission:
OCP
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H pain
do NOT exceed 3gm in 24 hours
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
please hold for loose stools
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*40 Capsule Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
apply patch for 12 hours and then remove and leave off for 12
hours.
RX *lidocaine-methyl sal-menthol [LidoPro Patch] 4 %-4 %-5 %
apply to skin over painful area every twelve (12) hours Disp
#*30 Patch Refills:*0
4. Milk of Magnesia 30 mL PO Q6H:PRN constipation
5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
do NOT drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every three (3) hours
Disp #*40 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bile leak.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented to ___ on ___ with increasing abdominal pain
after having your gallbladder removed about 1 week prior at an
outside hospital. You had a CT scan of your abdomen at the
outside hospital which was concerning for a bile leak. You were
admitted to the Acute Care Surgery team and were transferred to
the surgery floor for further management.
You were started on IV fluids and antibiotics. On ___, you
underwent a paracentesis to drain the bile collection which you
tolerated well.
On ___, you went to the OR and underwent an exploratory
laparoscopy with a washout of the bilious fluid collection. You
had a drain placed to help drain any further fluid collection.
On ___, you had a percutaneous transhepatic biliary drainage
(PTDB) tube placed by interventional radiology to help further
drain your bile collection.
On ___, your PTDB was capped, however, your abdominal pain
increased and the bag was placed back to drainage.
On ___, you had increasing abdominal pain and a new fever and
repositioning of your PTDB tube was required. You tolerated
this procedure well. On ___, your PTDB tube was capped and
you reported no new or increasing pain.
You have been tolerating a regular diet, have ambulated, and
your pain is now controlled with oral pain medication. You are
now medically cleared to be discharged to home. You have
received drain care teaching from the nurse and will have a
visiting nurse come to your your home to assist you with your
drain management. You are scheduled for follow-up appointments
with the Acute Care Surgery clinic. Please note the following
discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
JP Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
General Drain Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*If you have an increase in abdominal pain, you can uncap your
drain and attach it to the drainage collection bag. Please call
the ___ clinic if your abdominal pain increases.
*If the drain is connected to a collection container, please
note color, consistency, and amount of fluid in the drain. Call
the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character. Be sure to
empty the drain frequently. Record the output, if instructed to
do so.
*Wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
19929625-DS-20 | 19,929,625 | 20,538,997 | DS | 20 | 2153-06-07 00:00:00 | 2153-06-07 15:03:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Biaxin / Tamiflu / bee venom (honey bee)
Attending: ___.
Chief Complaint:
Nausea/ vomiting
Major Surgical or Invasive Procedure:
ERCP with NJ tube placed on ___
History of Present Illness:
___ F h/o obesity and multiple episodes of pancreatitis in the
past with recent diagnosis of pancreatic mass s/p ERCP on ___
with gandular cells highly suspicious for adenocarcinoma and PCT
biliary drain presents with 3 days of nausea, vomiting. Started
on ___, vomits within 10 minutes of eating food or drinking
liquid, unable to keep anything down. PTC drain has been capped
this entire time. Also endorses epigastric pain.
- In the ED, initial VS were:9 97.0 100 115/94 18 97% 2L . Exam
was notable for TTP in RUQ and epigastric area, no jaundice.
- Labs were notable for liapse of 1829 (up from 138), otherwise
downtrending LFTs and other labs at baseline.
- Imaging included a CT A/P which showed bo small bowel
obstruction, no pneumoperitoneum, a 5.9 x 6.5 cm heterogeneous
fluid collection in the body of the pancreas (2:27), an
appearance suggestive of walled off necrosis and a second
homogeneous 6.5 x 7.9cm fluid collection was seen in the
pancreatic tail (2:18), which creates mass effect on the
adjacent stomach, compatible with pseudocyst. Known pancreatic
head mass was grossly unchanged.
- Pt given zofran, 1L NS, oxycodone and morphine.
- Admitted to OMED for further workup.
- VS prior to transfer 0 98.3 98 124/69 16 99% Nasal Cannula.
On arrival to the floor, patient was VSS.
REVIEW OF SYSTEMS: +ve per HPI
Past Medical History:
PAST ONCOLOGIC HISTORY
none
PAST MEDICAL HISTORY:
- Scleroderma on 2L home oxygen x ___ yrs
- Morbid obesity
- Hyperglycemia when receives steroids
- Hx recurrent pancreatitis
- Cholecystectomy ___
- Osteoporosis
- Grave's disease
Social History:
___
Family History:
mother - DM
Brother - DM
father - "thyroid issues"
Physical Exam:
Physical exam on admission:
=====================================
VS: 98.2 96 112/74 98% 2L Wt: 195.4lbs, Ht: 60.5 inches
GENERAL: NAD, obese
HEENT: NC/AT, EOMI, significant proptosis, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: decreased lung sounds throughout, no significant wheezing,
crackles
ABD: significantly distended, soft, tenderness to moderate
palpation throughout but mostly in epigastric area and on R side
around site of drain. biliary drain without erythema, swelling,
warmth.
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact, upper and lower extremity strength and
sensation is intact
SKIN: Warm and dry, vitiligo of hands/wrist area. No rashes
Physical exam on discharge:
=====================================
VS: 98.6 114/62 94 18 96% on 2L
GENERAL: NAD, obese
HEENT: NC/AT, EOMI, significant proptosis, MMM, NJ tube in place
CARDIAC: RRR, normal S1 & S2, without murmurs, S3 or S4
LUNG: decreased lung sounds throughout, no significant wheezing,
crackles
ABD: significantly distended, soft, tenderness to moderate
palpation throughout but mostly in epigastric area
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact, motor function is grossly intact
SKIN: Warm and dry, vitiligo of hands/wrist area. No rashes
Pertinent Results:
Labs on admission:
==========================
___ 12:15PM BLOOD WBC-7.1 RBC-3.63* Hgb-10.9* Hct-32.8*
MCV-90 MCH-29.9 MCHC-33.1 RDW-16.0* Plt ___
___ 12:15PM BLOOD Neuts-63.8 ___ Monos-5.3 Eos-2.7
Baso-0.3
___ 12:15PM BLOOD ___ PTT-23.7* ___
___ 12:15PM BLOOD Plt ___
___ 12:15PM BLOOD Glucose-106* UreaN-7 Creat-0.6 Na-141
K-3.5 Cl-98 HCO3-31 AnGap-16
___ 12:15PM BLOOD ALT-23 AST-42* AlkPhos-83 TotBili-0.4
___ 12:15PM BLOOD Albumin-3.3*
___ 06:40AM BLOOD Albumin-3.2* Calcium-8.4 Phos-3.8 Mg-1.8
___ 09:31PM BLOOD pO2-71* pCO2-42 pH-7.46* calTCO2-31* Base
XS-5 Comment-GREEN TOP
___ 09:31PM BLOOD Lactate-0.8
___ 09:31PM BLOOD freeCa-1.01*
Reports:
==========================
___ CT Abd and Pelvis with contrast:
IMPRESSION:
1. No small bowel obstruction. No pneumoperitoneum.
2. A complex fluid collection involving the body of the
pancreas is
compatible with walled off necrosis. A second homogeneous fluid
collection adjacent to with secondary mass effect on the
stomach, is likely a pseudocyst.
Given short interval development of these findings and recent
episode of acute pancreatitis, these findings are most likely
complications of acute
pancreatitis and less likely due to tumor progression.
3. A 2.2 x 0.7 cm low-density soft tissue structure adjacent to
the SMA, new since ___, is also most likely inflammatory,
although followup will be necessary as metastatic involvement
cannot be excluded.
4. Known pancreatic head mass grossly unchanged.
5. A portion of the splenic vein appears attenuated due to mass
effect
from adjacent changes of pancreatitis.
___: ERCP:
Impression: Inflamatory stricture in the second part of the
duodenum.
NJ tube placed successfully.
Otherwise normal EGD to second part of the duodenum
___ Upper EUS:
EUS : Mass: A 3.4 cm mass was noted in the head of the
pancreas. FNA was performed of the mass.
The pancreas parenchyma in the body and tail showed multiple
patchy hyperechoic areas c/w inflammation and edema likely from
recent acute pancreatitis.
A > 5 cm cyst was noted adjacent to the stomach in the region of
the body / tail of the pancreas. The walls of the cysts were
irregular. Moderate amout of debris were noted within the cyst.
Microbiology:
==========================
None
Labs on discharge:
==========================
___ 07:20AM BLOOD WBC-11.0# RBC-4.00* Hgb-11.6* Hct-37.1
MCV-93 MCH-29.0 MCHC-31.3 RDW-16.0* Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-123* UreaN-7 Creat-0.7 Na-136
K-4.2 Cl-97 HCO3-24 AnGap-19
___ 07:20AM BLOOD ALT-22 AST-46* LD(LDH)-413* AlkPhos-92
TotBili-0.3
___ 07:20AM BLOOD Calcium-8.7 Phos-3.6 Mg-1.9
CEA - 1.5
Test Result Reference
Range/Units
CA ___ 1141 H <34 U/mL
Brief Hospital Course:
___ y/o female with h/o morbid obesity and recurrent pancreatitis
and head of pancreatic mass with cytology suspicious for
malignancy presents with nausea, vomiting and inability to
tolerate PO c/w pancreatitis. Patient with ERCP showing
obstruction likely from pancreatitis, not the pancreatic mass.
They suspect the swelling to go down from obstruction in a few
weeks they also suspect the NJ tube (placed on ___ - see
below for tubefeeding recs) can be in place for a couple months.
Unfortunately, definitive management of the mass cannot happen
until resolution of pancreatitis, though patient to have follow
up on ___ ___. Patient was discharged with tube
feeds, and clear liquids as tolerated.
TRANSITIONAL ISSUES:
- patient undergoing evaluation for suspected malignancy in head
of pancreas - to follow up with surgery on ___ as outpatient
- patient to go home with tube feeds, to follow up with GI
within the next two weeks
- patient with biliary PCT in place and capped - please evaluate
whether this can be pulled
- code during hospitalization - full code
- emergency contact/HCP: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
2. Levothyroxine Sodium 200 mcg PO DAILY
3. PredniSONE 5 mg PO DAILY
4. Docusate Sodium 100 mg PO DAILY:PRN constipation
5. Alendronate Sodium 70 mg PO QWEEK
6. Cyanocobalamin 500 mcg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 300 mg PO BID-TID
9. Loratadine 10 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. TraZODone 75 mg PO QHS
13. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
14. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN severe pain
15. Senna 8.6 mg PO DAILY:PRN constipation
Discharge Medications:
1. tube feed order
Tubefeeding: Promote with Fiber Full strength;
Starting rate: 10 ml/hr; Advance rate by 10 ml q6h Goal rate: 60
ml/hr
Residual Check: q4h Hold feeding for residual >= : 200 ml
Flush w/ 150 ml water q4h
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/wheeze
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 300 mg PO BID-TID
5. Levothyroxine Sodium 200 mcg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN severe pain
8. PredniSONE 5 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
11. TraZODone 75 mg PO QHS
12. Senna 8.6 mg PO DAILY:PRN constipation
13. Loratadine 10 mg PO DAILY
14. Docusate Sodium 100 mg PO DAILY:PRN constipation
15. Cyanocobalamin 500 mcg PO BID
16. Alendronate Sodium 70 mg PO QWEEK
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Acute pancreatitis, mass at head of pancreas
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure taking part in your care during your
hospitalization at ___. You
were admitted for abdominal pain, and you were found to be
having an episode of pancreatitis. In order to prevent further
pain and worsening of the pancreatitis, a feeding tube was
placed. Your pain, nausea, and vomiting improved.
Please continue to only drink clear liquids as tolerated, and
take your medications as listed below. Additionally, please
follow up with your appointments as listed below.
We wish you the best
- Your ___ care team
Followup Instructions:
___
|
19929769-DS-25 | 19,929,769 | 27,411,511 | DS | 25 | 2121-06-11 00:00:00 | 2121-06-12 13:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o male with a past medical history of
CKD stage 5, MGUS, DM2 and glaucoma who presented to the ED with
DOE.
Patient reports that for the past 4 days he has had increasing
SOB when walking and improves with rest. At baseline walks
approximately 30 minutes per day, but now gets SOB with walking
50-60 feet. He denies fevers, chills, lower extremity swelling.
During episodes of dyspnea, denies chest pain, dizziness,
palpitations, nausea, diaphoresis. Sleeps propped up in easy
chair for years, denies new/worsening orthopnea.
Patient recently had short URI ~3 weeks prior.
In the ED, initial vital signs were: T 97.4, HR 66, BP 166/84 RR
20, 100% RA.
- Labs were notable for: WBC 11.4, Hb 10.4, PLT 167, HCO3 21,
BUN 57, Cr 3.9 (baseline around 4), glucose 226. Coags were wnl.
Trop 0.14 (CK MB added on). BNP >11,000
- Imaging: CXR Patchy basilar opacity could be due to
atelectasis, aspiration, and/or pneumonia. Cardiac silhouette is
top-normal to mildly enlarged. Mediastinal contours are
unremarkable
- EKG showed mobitz ___ I
Upon arrival to the floor, patient feels well, without any
symptoms at rest.
Past Medical History:
- depression with prior suicide attempts
- MGUS, IgG-L
- CKD stage 5 (baseline creatinine ~4.0)
- DMII c/b retinopathy and neuropathy
- HTN
- HLD
- glaucoma
- anemia of chronic disease
Social History:
___
Family History:
mother: drank heavily. Uncle with depression and alcoholic.
Another unlce that is described as "inexpressive; couldn't come
out of his shell."
Physical Exam:
PHYSICAL EXAM ON ADMISSION
===========================
VITALS: T 97.8, BP 186/91, HR 73, RR 22, SPO2 98RA
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, no thyromegaly, JVP 7cm
CARDIAC: irregularly irregular rhythm with occasional dropped
beat, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Babasilar rales. No wheezing or rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis. 1+ pitting to mid
shins
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
PHYSICAL EXAM ON DISCHARGE
===========================
VITALS: T 98.0, BP 124-194/59-82, HR 35-80, RR ___, SPO2 97RA
I/O: 84.6<-85.0<-87.9; ___
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, no thyromegaly, JVP flat
CARDIAC: irregularly irregular rhythm with occasional dropped
beat, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Babasilar rales. No wheezing or rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis. 2+ pitting edema
on left lower extremity to above the ankle. no edema on right.
SKIN: Without rash. Some venous stasis findings bilaterally on
lower extremities L worse than right.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
LABS ON ADMISSION
==================
___ 09:35PM BLOOD WBC-11.4* RBC-3.35* Hgb-10.4* Hct-32.5*
MCV-97# MCH-31.0 MCHC-32.0 RDW-13.7 RDWSD-48.1* Plt ___
___ 09:35PM BLOOD Neuts-82.7* Lymphs-7.6* Monos-6.1 Eos-2.3
Baso-0.5 Im ___ AbsNeut-9.41* AbsLymp-0.87* AbsMono-0.69
AbsEos-0.26 AbsBaso-0.06
___ 09:35PM BLOOD ___ PTT-30.2 ___
___ 09:35PM BLOOD Glucose-226* UreaN-57* Creat-3.9*# Na-138
K-4.6 Cl-103 HCO3-21* AnGap-19
___ 09:35PM BLOOD cTropnT-0.14*
___ 09:35PM BLOOD CK-MB-5 ___
___ 09:35PM BLOOD Calcium-9.9 Phos-3.8 Mg-2.1
___ 09:35PM BLOOD TSH-5.3*
___ 06:34AM BLOOD FreeKap-57.4* ___ Fr K/L-2.19*
LABS ON DISCHARGE
==================
___ 07:20AM BLOOD WBC-10.4* RBC-4.19* Hgb-12.6* Hct-40.0
MCV-96 MCH-30.1 MCHC-31.5* RDW-13.9 RDWSD-47.3* Plt ___
___ 07:23AM BLOOD ___ PTT-33.0 ___
___ 12:40PM BLOOD Glucose-185* UreaN-66* Creat-4.2* Na-136
K-4.4 Cl-99 HCO3-24 AnGap-17
___ 06:34AM BLOOD CK-MB-8 cTropnT-0.24*
___ 12:40PM BLOOD Calcium-9.5 Phos-4.5 Mg-2.0
___ 07:23AM BLOOD IgG-1531 IgM-61
IMAGING
========
ECG ___
Sinus bradycardia with premature atrial contractions. Right
bundle-branch
block with left anterior fascicular block. Left ventricular
hypertrophy with secondary repolarization abnormalities.
Compared to the previous tracing the findings are similar.
CXR ___
IMPRESSION:
Patchy basilar opacity could be due to atelectasis, aspiration,
and/or
pneumonia.
ECHO ___
The left atrial volume index is severely increased. There is
mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global systolic function (LVEF>55%). There is
no ventricular septal defect. Right ventricle is not well seen.
The aortic valve leaflets (?#) appear structurally normal with
good leaflet excursion. There is no aortic valve stenosis. Trace
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. Mild to
moderate (___) mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Biatrial enlargement. Normal biventricular function
and cavity size. Mild symmetric left ventricular hypertrophy.
Mild to moderate mitral regurgitation.
Brief Hospital Course:
___ y/o male with a past medical history of CKD stage 5, MGUS,
DM2 and glaucoma who presented to the ED with DOE and found to
have HFpEF, and Mobitz Type I.
#Heart failure with preserved ejection fraction:
Likely DOE secondary to new onset heart failure. Patient
presented with ___ days of exertional dyspnea. Initial
evaluation notable for hypertension and EKG that showed Mobitz
type 1 second degree heart block. Also, pt presented with BNP
>11,000 with crackles on exam, lower extremity edema and
elevated JVP all c/w HF. Etiology of HF unclear, but may be due
to chronic HTN and DMII. Ischemic CM less likely, as patient has
no history of CAD although he does have risk factors with
advanced CKD and diabetes. Trop elevated in setting of stage V
CKD, but MB was flat. ECHO done and showed: Biatrial
enlargement, normal biventricular function and cavity size. Mild
symmetric left ventricular hypertrophy. Mild to moderate mitral
regurgitation and what could be early grade I diastolic heart
failure. BP control initiated with captopril(switched to
lisinopril on discharge) and diuresis was done with IV diuretics
and then he was transitioned to PO Lasix.
#Second Degree Heart Block Mobitz Type I: Unclear etiology, but
not likely due to ischemia, medication effects, or amyloid.
Thyroid disease is a possibility as TSH slightly elevated, but
there are no other associated symptoms that suggest thyroid
disease. ECHO does not support a diagnosis of amyloid, and he is
not taking any medications that would cause bradycardia or an
atypical rhythm. TSH should be rechecked at outpatient
appointment.
#Hypertension:
BP elevated to 180s on arrival to floor; patient denies
headache, chest pain, dyspnea at rest. New diagnosis per
patient. Review of ___ records show SBP 100-180. In ___ he
had documented blood pressures on discharges of SBP 170-180.
Started on short acting ACEi and discharged on lisnopril.
# ___: Cr up from admission 3.9 to 4.6, and 4.2 on discharge
though very minimal if any difference in real GFR, thus
discharged on lasix 20mg PO and lisinopril 10mg QD, for heart
failure and HTN, respectively.
#Diabetes mellitus
Hgb A1C 6.7 in ___. Continued glipizide.
#Glaucoma:
Continued home eye drops
TRANSITIONAL ISSUES
===================
[ ] Patient needs a referral for a ___ cardiologist for new onset
heart failure and monitoring of second degree heart block, type
I
[]Patient was diuresed as inpatient, and subsequently had a rise
in BUN/Cr. His baseline is around 4.0 and ___ in setting of over
diuresis bumped to 4.6-which translates to a minimal change in
his GFR. He will be discharged on 20mg dose of Lasix, and 10mg
lisinopril.
[]patient will have Chem 10 checked by ___ on ___ while on
new PO Lasix dose and lisinopril for ?___ and/or hyperkalemia.
___ will check and send labs to ___'s office.
[]NaHCO3 which was probably previously prescribed for CKD
discontinued given new onset heart failure. Adjust as needed.
[ ] DW: 84.6kg
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. GlipiZIDE 2.5 mg PO BID
2. Sodium Bicarbonate 1300 mg PO TID
3. Calcitriol 0.25 mcg PO DAILY
4. calcium carbonate-vitamin D3 250-125 mg-unit oral BID
5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Calcitriol 0.25 mcg PO DAILY
3. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
4. GlipiZIDE 2.5 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Heart failure with preserved ejection fraction
Hypertension
second degree heart block mobitz Type I
SECONDARY DIAGNOSIS
===================
Diabetes mellitus type II
Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
shortness of breath. You were found to have high blood pressures
and new onset heart failure. This means that your heart does not
relax normally. This can lead to fluid accumulation in your body
and this can cause you to become short of breath.
While you were here, we also noted that you had an abnormal
heart rhythm. This should be monitored, but at this time, it was
determined you do not need a pacemaker.
Please ensure that you follow up with your primary care
physician who can follow your kidney function and your blood
pressures on your new medications.
Please take your new blood pressure medication, lisinopril, as
directed and please take your fluid pill, Lasix, so you do not
accumulate more fluid in your body.
It was a pleasure taking part in your care!
Your ___ Team
It will be important to weigh yourself every morning, and call
your physician if your weight increases more than 3 lbs.
Followup Instructions:
___
|
19930063-DS-8 | 19,930,063 | 28,032,041 | DS | 8 | 2137-11-26 00:00:00 | 2137-11-27 10:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left foot Calcaneal fracture, Right ankle fracture
Major Surgical or Invasive Procedure:
ORIF Right pilon fracture
splinting of left calcaneus fracture
History of Present Illness:
___ y/o M climbing up a ladder around midnight and foot got
caught fell off landing on feet L ankle pain with displaced
calcaneous fx. Pt states he fell from about ___ feet. Pt was
transferred from ___ where he was worked up and has head CT,
spine imaging ruled out for any fractures. He states that he is
in significant pain in he left foot and is also endorsing R foot
pain. Pt denies any N/V/F/C/SOB/CP. He states the last time he
had anything to eat was yesterday afternoon.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
Physical Exam on admission:
Gen: A+Ox3, NAD
AVSS
CV: RRR
Resp: No respiratory distress
Abd: Soft, NT, ND
Focused left lower extremity exam:
In splint, overwrapped with fiberglass. Exposed toes wwp,
wiggling toes. SILT to exposed toes.
Focused right lower extremity exam:
- ___ fire
- Sensation intact to light touch in
SPN/DPN/Tibial/saphenous/Sural distributions
- 1+ ___ pulses, foot warm and well perfused\
- RLE in air cast boot.
Pertinent Results:
___ 06:25AM GLUCOSE-112* UREA N-13 CREAT-0.8 SODIUM-136
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-17
___ 06:25AM estGFR-Using this
___ 06:25AM CALCIUM-9.0 PHOSPHATE-3.1 MAGNESIUM-1.8
___ 06:25AM WBC-13.3* RBC-4.64 HGB-13.6* HCT-40.2 MCV-87
MCH-29.3 MCHC-33.8 RDW-12.5 RDWSD-39.4
___ 06:25AM PLT COUNT-179
___ 06:25AM NEUTS-76.1* LYMPHS-16.2* MONOS-6.4 EOS-0.2*
BASOS-0.5 IM ___ AbsNeut-10.08* AbsLymp-2.15 AbsMono-0.85*
AbsEos-0.03* AbsBaso-0.06
___ 06:25AM ___ PTT-23.4* ___
Pertinent Imaging:
Left foot CT ___ and impacted fracture of the
calcaneus with intra-articular extension to all three
articulations of the talocalcaneal joint. There is associated
soft tissue swelling overlying the fracture.
Right foot/ankle Xrays (___): 1. Depressed,
intra-articular fracture of the anterior/medial aspect of the
distal tibia. 2. No evidence of fracture in the foot.
Brief Hospital Course:
The patient was transferred from an OSH following a 10 foot fall
for a left foot calcaneal fracture. He was admitted to the
podiatric surgery service for pain control. After initial
evaluation it was determined that his injuries would be best
served on the orthopaedic service so his care was transferred.
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left calcaneus fracture and a right ankle fracture and
was admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF of the right
ankle and splinting of the left calcaneus, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the LLE and WBAT in an air cast boot in the RLE, and will
be discharged on lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN Constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice per day
Disp #*30 Capsule Refills:*0
2. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe sc every evening Disp #*28
Syringe Refills:*0
3. Gabapentin 300 mg PO DAILY
RX *gabapentin 300 mg 1 capsule(s) by mouth once per day Disp
#*30 Capsule Refills:*1
4. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour apply to skin once every 24h Disp
#*30 Patch Refills:*1
5. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
please wean as your pain improves
RX *oxycodone 5 mg ___ tablet(s) by mouth every three hours Disp
#*80 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice per day
Disp #*30 Capsule Refills:*0
7. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Left foot calcaneal fracture, Right Ankle Fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- NWB LLE in splint, WBAT RLE in ACB
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
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
INSTRUCTIONS FROM SOCIAL WORK
SW addressed several resource needs for this very low income
patient without health insurance.
Health Insurance:
Along with pt today we called RI Medicaid. After 60 mins hold
time ___ worked with a representative to activate pt's insurance.
Pt was able to be activated and enrolled in Neighborhood Health
Plan of ___. The rep noted that he will not be active in the
system for ___ days, and will have to wait ___ weeks for his
card. Until that time ___ weeks), the only way he can have
access to ___ medical care is in an emergency using
his social security number for ID.
This insurance plan will pay for past medical bills incurred
since ___, including this hospital ___ if pt submits it
to
them.
Primary Care:
We spoke about the pt's need for primary care. ___ recommends
setting pt up with PCP at the following ___ clinic,
noting with intake there that he has/will have Neighborhood
Health Plan:
___ at ___.
___, ___
Phone: ___
Fax: ___
This clinic is accepting new patients but is booking into the
end
of ___. They can offer the pt a sliding scale if his
insurance is not active by then. Pt feels that this clinic is
close enough to his home that he should not have difficulty
getting there.
Durable medical equipment:
Pt was given contact information for the ___ in ___ who has free durable medical equipment, as well as
getatstuff.com, where individuals who have unused medical
equipment can post it online. Most of the equipment is free,
but
pt would need to pick it up from the individual. Pt did not
wish
for additional SW assistance to identify and organize the
procurement of equipment.
A/P
Although pt now has health insurance, he will not be able to
access it for some weeks. Any discharge meds will need to be
under free care; please communicate with nurse case management
for any medication needs upon discharge. He will also have to
procure a walker and/or wheelchair. He has the ability to do
this and does not wish for further SW assistance for this. A
local sliding-scale PCP office has been identified if pt needs
follow-up.
Followup Instructions:
___
|
19930120-DS-17 | 19,930,120 | 23,731,549 | DS | 17 | 2179-09-17 00:00:00 | 2179-09-18 12:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
aspirin / phenylephrine / doxylamine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ G-tube placement by ___
___ EGD with attempted G-tube placement by GI
History of Present Illness:
___ year-old right-handed woman with primary central nervous
system lymphoma in the left basal ganglia (C5D1 Bevacizumab,
pemetrexed and rituximab) who presents from ___ clinic via
ED for altered mental status.
The NeuroOnc team was asked to evaluate Mrs. ___ on ___
9
treatment area for change in mental status. Husband reports
progressively more lethargic since the last visit (over past 3
weeks). She also has had decrease in appetite and energy level,
as well as worsening symptoms of aspiration. She was able to
take a few bites. She has steady weight drop. She is requiring
max assistance with care. Her husband is her sole caretaker.
Husband brought urine from home. Today, she endorsed abdominal
pain for the first time to her husband. Over the past three
weeks, she has been increasingly incontinent--she used to let
her husband know when she needed to use the restroom.
At baseline, she is able to state her full name and social
security number. She speaks in ~2 word sentences, and often
verbalizes incomplete thoughts. She is, however, able to attend
to stimuli, follow instructions, and communicate her needs to
her husband. She is not able to transfer or ambulate.
On initial evaluation in clinic, Mrs. ___ was not oriented
to person, place or time. She was only able to follow simple
direction with repeated prompts. She was given 250 cc NS &
became more alert, but remained disoriented. She was referred to
ED for further eval.
In the ED, initial vitals: 96.1 81 144/107 16 99% RA
- Labs were notable for:
WBC 6.6, K 3.1, lactate 1.0, UA with large leuks, many bacteria,
TSH 2.5, free T4 1.4
- Imaging:
ECG Sinus rhythm @ 74 bpm. Possible old inferior wall myocardial
infarction. QTc 483. Similar to prior.
CT HEAD: IMPRESSION: No acute intracranial hemorrhage. Chronic
changes. No midline shift.
CXR: No acute process
- Patient was given: 1 gm IV CTX
Of note, clinic note on ___ notable for decreased PO intake,
difficulty swallowing, waxing/waning mental status.
On arrival to the floor, per report of patient's husband, she
looks much better than earlier today. She is speaking more, and
responding appropriately to questions. He notes that when she
has presented in the past with a new mass, she has been
significantly more confused than she is today.
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:
She is s/p:
1. Non-diagnostic brain biopsy on ___ by Dr. ___ at ___
2. Brain biopsy on ___ by Dr. ___ CNS lymphoma
3. High-dose methotrexate started on ___,
4. Rituximab + high-dose methotrexate for progression
5. WBXRT ___ - ___ to 3,600 cGy for progression
6. Admission ___ for UTI
7. Admission ___ for DVT and PE
8. Admission ___ for purulent discharge Portacath
9. Adm x 2 in ___ for septic shock
10. Monthly Temozolomide started ___ to ___.
11. Adm ___ for confusion related to cold medication
12. Rituximab started ___
13. SRS to right parieto-occipital lesion ___ to 1600 cGy
14. Metronomic TMZ ___. SRS to left periventricular lesion ___ to 2200 cGy
16. Port placed ___
17. Bevacizumab, pemetrexed and rituximab started ___
18. SRS to right frontal lesion ___ to ___ cGy
PAST MEDICAL HISTORY: DVT, s/p IVC filter, HTN COPD,
hypercholesterolemia, oophorectomy. Renal calculi lithotripsy
___.
Social History:
___
Family History:
Her father with diabetes and status post coronary artery stent
placement. Her mother history of CVA. Sister is healthy. She
has 2 children but her daughter has cognitive impairment.
No family history of GU malignancies.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.3, 159 / ___ 99 Ra
GENERAL: Chronically ill appearing, awake, NAD
HEENT: Dry MM. No scleral icterus. EOMI.
NECK: Supple, no JVD, no LAD
LUNGS: CTAB, decreased at bases
CV: RRR, no r/m/g
ABD: Soft, non-distended, NABS, mildly tender in suprapubic area
EXT: Extremities contracted ___, trace ___ edema
SKIN: Warm, dry, no visible rash
NEURO: AO x 1. CNII-XII grossly intact. Alert, following
commands.
ACCESS: Port non-tender, no erythema
DISCHARGE EXAM:
VS: 97.2 162/88 67 18 100
GENERAL: Chronically ill appearing, sleeping, but easily
arousable, NAD
HEENT: Dry MM. No scleral icterus. EOMI.
NECK: Supple, no JVD, no LAD
LUNGS: CTAB, decreased at bases
CV: RRR, no r/m/g
ABD: Soft, non-distended, NABS, non-tender. PEG tube in place in
R abdomen, dressing c/d/i
EXT: Extremities contracted ___, trace ___ edema. Increased muscle
tone throughout.
SKIN: Warm, dry, no visible rash.
NEURO: Alert, cannot assess orientation. CNII-XII grossly
intact.
Alert, following commands.
ACCESS: Port non-tender, no erythema
Pertinent Results:
ADMISSION LABS:
___ 11:59AM BLOOD WBC-6.6 RBC-3.70* Hgb-12.0 Hct-38.6
MCV-104* MCH-32.4* MCHC-31.1* RDW-16.7* RDWSD-63.3* Plt ___
___ 11:59AM BLOOD Neuts-85* Bands-0 Lymphs-4* Monos-10
Eos-1 Baso-0 ___ Myelos-0 AbsNeut-5.61 AbsLymp-0.26*
AbsMono-0.66 AbsEos-0.07 AbsBaso-0.00*
___ 11:59AM BLOOD WBC-6.6 Lymph-4* Abs ___ CD3%-88 Abs
CD3-232* CD4%-53 Abs CD4-140* CD8%-33 Abs CD8-87* CD4/CD8-1.60
___ 11:59AM BLOOD CD3 %-90.10 CD3Abs-237.86 ___ 11:59AM BLOOD UreaN-11 Creat-0.7 Na-140 K-3.1* Cl-99
HCO3-28 AnGap-16
___ 11:59AM BLOOD ALT-11 AST-17 LD(LDH)-291* AlkPhos-69
TotBili-0.6
___ 11:59AM BLOOD TotProt-5.6* Calcium-9.0 Phos-2.9 Mg-1.9
___ 11:59AM BLOOD TSH-2.5
___ 11:59AM BLOOD Free T4-1.4
___ 11:59AM BLOOD PEP-HYPOGAMMAG b2micro-3.2* IgG-353*
IgA-72 IgM-15* IFE-NO MONOCLO
___ 02:02PM BLOOD Lactate-1.0
___ 11:30AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 11:30AM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-2* pH-6.0 Leuks-LG
___ 11:30AM URINE RBC-19* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
___ 11:30AM URINE CaOxalX-MOD
MICROBIOLOGY:
___ URINE CULTURE (Final ___:
KLEBSIELLA OXYTOCA. >100,000 CFU/mL.
___ BLOOD CULTURE: NEGATIVE, FINAL
DISCHARGE LABS:
___ 05:33AM BLOOD WBC-5.5 RBC-3.14* Hgb-10.1* Hct-32.6*
MCV-104* MCH-32.2* MCHC-31.0* RDW-16.3* RDWSD-62.4* Plt ___
___ 05:00AM BLOOD Glucose-105* UreaN-8 Creat-0.4 Na-138
K-4.0 Cl-103 HCO3-27 AnGap-12
___ 05:00AM BLOOD Calcium-8.9 Phos-2.4* Mg-2.0
IMAGING:
___ CXR: No acute cardiopulmonary process.
___ CT HEAD: No acute intracranial hemorrhage. Chronic
changes including prominence of the ventricular system, ex vacuo
dilatation of the left frontal horn with left frontal lobe
encephalomalacia, and confluent bilateral periventricular and
subcortical white matter hypodensity, similar in distribution
compared to prior MRI. If concern for acute ischemia, MRI would
be more sensitive. No midline shift.
Brief Hospital Course:
___ year-old right-handed woman with primary central nervous
system lymphoma in the left basal ganglia (C5D1 Bevacizumab,
pemetrexed and rituximab) who presents with altered mental
status, possibly due to UTI. Mental status improved with IV
ceftriaxone & IVF. She was treated for 7 days. She was evaluated
for dysphagia and recommended to be NPO. As such, G-tube was
placed for medications/nutrition. Repeat video swallow after
improvement of mental status showed continued aspiration with
all liquids/solids. This, and the risk of aspiration, even
respiratory arrest, with any food/liquid by mouth was explained
to patient and her husband, who expressed understanding. Once
continuous tube feeds were tolerated, she was switched to bolus
feeds, which she tolerated prior to discharge.
#UTI
#Subacute toxic metabolic encephalopathy: Likely multifactorial,
from UTI, dehydration related to poor PO, lastly, CNS lymphoma
may also contributing. Calcium, TSH WNL. NCHCT with no active
bleeding. Treated with IVF and 7 day course of ceftriaxone with
improvement in her mental status to baseline.
#Primary CNS lymphoma: Day of admission would have been C5D1 of
Bevacizumab, pemetrexed and rituximab. She has history of
seizure as well. Repeat brain MRI showed stable to improved
disease. She was continued on her home keppra and
methylphenidate. Dexamethasone was increased to 4mg daily.
#Swallowing dysfunction: Seen by S&S after resolution of
encephalopathy, who recommended strict NPO. Underwent PEG tube
placement with ___ on ___.
CHRONIC:
#Depression: Continued citalopram (held while NPO)
#Constipation: Continued home bowel regimen with lactulose,
husband brought in home linzess (which is NF).
#Hypokalemia: Chronic hypokalemia, ?due to bowel regimen.
#HLD: Continued atorvastatin
#Misc: Continued home folate
#Full code, confirmed
#HCP/Contact: Husband, ______)
TRANSITIONAL ISSUES:
===================
-Pt persistently hypokalemic; Needs to continue repletion
-MRI brain showed no progression/improvement of previous
abnormal findings
-Dexamethasone increased to 4 mg qd
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO Q8H:PRN constipation
2. Linzess (linaclotide) 290 mcg oral DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. potassium chloride 20 mEq/15 mL oral BID
8. LevETIRAcetam 500 mg PO BID
9. MethylPHENIDATE (Ritalin) 10 mg PO BID
10. Dexamethasone 0.5 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO QHS
RX *docusate sodium 50 mg/5 mL ___ mL Gtube at bedtime
Refills:*0
2. Senna 8.6 mg PO QHS
RX *sennosides [senna] 8.8 mg/5 mL ___ mL by mouth at bedtime
Refills:*0
3. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
once a day Disp #*60 Tablet Refills:*0
4. Dexamethasone 4 mg PO DAILY
RX *dexamethasone 4 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. MethylPHENIDATE (Ritalin) 10 mg PO Q9AM
6. Atorvastatin 10 mg PO QPM
7. Citalopram 20 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Lactulose 15 mL PO Q8H:PRN constipation
10. LevETIRAcetam 500 mg PO BID
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Linzess (linaclotide) 290 mcg oral DAILY
13. potassium chloride 20 mEq/15 mL oral BID
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY:
Urinary tract infection, complicated
Dysphagia
SECONDARY:
CNS lymphoma
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at the ___
___.
You were admitted for confusion, dehydration.
We found that you had a urinary tract infection and gave you
antibiotics and fluids.
Your mental status improved.
Given you difficulty swallowing food/pills, a G-tube was placed
to help give you nutrition and your medications.
We evaluated your swallowing with a special video test and it
appears unsafe for you to have any medications or food,
including ice chips by mouth. We explained this to you and your
husband.
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
19930170-DS-12 | 19,930,170 | 28,627,767 | DS | 12 | 2167-04-02 00:00:00 | 2167-04-02 16:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / prochlorperazine
Attending: ___.
Chief Complaint:
___ abd pain
Major Surgical or Invasive Procedure:
Laparoscopic Cholecystectomy
History of Present Illness:
Pt is a ___ yo woman who normally lives in ___ and was
visiting a friend in ___ on ___. She states
she went to her nl daily visit to her ___ clinic in ___ and then drove to her friend's house. She spent the night
and on ___ am, awoke with nausea. She states she had multiple
bouts of emesis throughout the day on sat. By the end of the day
on sat, nausea was improving. Yesterday, ___, she awoke with
right upper quad pain which at its worst was ___. Currently abd
pain is ___. Pt denies current nausea. She states that she last
took her methadone on sat. She normally has to go to this clinic
in ___ daily for her methadone. She has not gone given
the fact she has been nauseas with abd pain. She presented this
am to ___ in ___, ___ which is near
___. She was evaluated in the ED and found to have
increased abnl transaminases as well as dilated common bile duct
on u/s and CT. She was sent down to ___ ED for further
evaluation and possible ERCP.
Past Medical History:
1) left hand injury in ___ s/p bite by her sibling - she states
that she got addicted to oxycodone after this injury with
surgery at ___. For this reason, she receives daily oral
methadone at ___ in ___. Clinic was closed so I was unable to confirm but
records from ___ in ___ suggests they gave her 90mg methadone
daily by mouth.
2) She's had 2 nl vaginal deliveries - her 2 children are
teenagers
3) ___ she states she presented to ___ with
epigastric to right sided abd pain. WAs seen in their ED and
then transferred to ___ where she was hospitalized for 2 days.
Per pt the w/u was unrevealing but per records from ___, at
___ she had u/s with CBD to 10mm. She had MRCP
which demon extrahepatic biliary ductal dilatation and mild
intrahepatic biliary ductal dilatation thought to c/w type 4
choledochal cyst. At ___, she had ERCP which revelaed moderate
dilation of biliary tree to 13 mm with distal tapering.
Sphinterotomy was performed and stent was placed. Dilated
pancreatic duct was found and a pancreatic sphincterotomy and
stent placement was also performed. GI felt findings were more
consistent with benighn papillary stenosis rather than
choledochal cyst.
4) depression, anxiety disorder, PTSD - pt states she is
followed by Dr. ___ (psychiatrist) but ___ records
says she is followed by ___ NP who prescribes her
psychiatric meds. ___ records say she was victim of physical
abuse as child.
5) records from ___ says that she tested positive for HCV at
___ in ___
6) dental abscess in past
7) hx of laparoscopy x 2 in her ___ - no documented hx of
endometriosis.
Social History:
___
Family History:
Pt denies any family hx of abd pain
Physical Exam:
T=98.3 65 110/64 18 100RA
Pt appears very comfortable and in no distress
Pt able to get out of bed easily and ambulate without any
difficulty
Pt has multiple tattos over right shoulder, left ankle and lower
back
Pt has erthryoderma over face c/w sun exposure
Pt is alert and oriented in all spheres
Pt is missing multiple teeth
PERRL, EOMI
neck is soft and supple with full ROM
CV - RRR without any murmurs
Lungs - CTA in all fields
Abd - soft, nondistended, mild tenderness to palpation in RUQ,
No guarding or rebound, surgical insicions covered with dry
dressings
Ext - no c/c/e
Neuro - CN ___ intact; nl gait; nl strength and sensory exam;
nl attention; pt answers ques appropriately
Pertinent Results:
On admission, labs from ___ earlier in the
day:
AST 65 ALT 71
nl CBC and chem 7
Abd u/s and CT abd both with dilation of CBD. No intrahepatic
dilatation.
___ 02:05AM BLOOD WBC-5.2 RBC-3.51* Hgb-10.9* Hct-32.7*
MCV-93 MCH-31.1 MCHC-33.3 RDW-12.5 Plt ___
___ 07:30AM BLOOD WBC-6.0 RBC-3.65* Hgb-12.1 Hct-34.5*
MCV-95 MCH-33.1* MCHC-35.0 RDW-12.5 Plt ___
___ 08:00AM BLOOD WBC-6.9 RBC-3.85* Hgb-12.7 Hct-36.4
MCV-94 MCH-32.9* MCHC-34.8 RDW-12.4 Plt ___
___ 07:40AM BLOOD WBC-6.5 RBC-3.79* Hgb-11.7* Hct-35.4*
MCV-93 MCH-30.8 MCHC-32.9 RDW-12.7 Plt ___
___ 07:50AM BLOOD WBC-7.9 RBC-3.99* Hgb-12.5 Hct-37.5
MCV-94 MCH-31.4 MCHC-33.5 RDW-12.4 Plt ___
___ 07:50AM BLOOD Neuts-70.8* ___ Monos-5.3 Eos-2.5
Baso-0.3
___ 02:05AM BLOOD Plt ___
___ 08:00PM BLOOD ___ PTT-27.6 ___
___ 07:30AM BLOOD Plt ___
___ 08:00AM BLOOD Plt ___
___ 10:50AM BLOOD ___ PTT-28.1 ___
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD ___ PTT-UNABLE TO ___
___ 02:05AM BLOOD Glucose-88 UreaN-3* Creat-0.6 Na-143
K-3.7 Cl-106 HCO3-30 AnGap-11
___ 07:30AM BLOOD Glucose-86 UreaN-4* Creat-0.7 Na-142
K-3.6 Cl-106 HCO3-30 AnGap-10
___ 08:00AM BLOOD Glucose-82 UreaN-4* Creat-0.6 Na-142
K-4.6 Cl-103 HCO3-30 AnGap-14
___ 07:40AM BLOOD Glucose-85 UreaN-6 Creat-0.5 Na-141 K-3.5
Cl-108 HCO3-25 AnGap-12
___ 07:50AM BLOOD Glucose-101* UreaN-10 Creat-0.5 Na-139
K-3.8 Cl-106 HCO3-24 AnGap-13
___ 02:05AM BLOOD ALT-95* AST-66* AlkPhos-68 TotBili-0.2
___ 07:30AM BLOOD ALT-105* AST-88* LD(LDH)-137 AlkPhos-76
TotBili-0.2
___ 08:00AM BLOOD ALT-102* AST-90* AlkPhos-65 TotBili-0.5
___ 07:40AM BLOOD ALT-72* AST-64* LD(LDH)-124 AlkPhos-47
TotBili-0.5
___ 07:50AM BLOOD ALT-68* AST-65* LD(LDH)-150 AlkPhos-53
Amylase-44 TotBili-0.6
___ 02:05AM BLOOD Lipase-32
___ 08:00AM BLOOD Lipase-42
___ 07:50AM BLOOD Lipase-53
___ 02:05AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.9
___ 08:00AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8
___ 07:40AM BLOOD Calcium-8.5 Phos-4.0 Mg-2.0
___ 07:50AM BLOOD Albumin-3.8 Calcium-9.0 Phos-3.2 Mg-2.1
___ 07:50AM BLOOD RedHold-HOLD
Brief Hospital Course:
1) RUQ abd pain, abnormal transaminases and dilated CBD
Make pt NPO for now and place on maintenance IVF's. Consult
GI/ERCP team in am. Given the fact that the pt did not come with
discs with imaging studies, will repeat RUQ u/s to eval CBD.
Continue to monitor pt's sxs and abd exam.
2) Chronic methadone use
___ is currently closed. Will need to call in am to
confirm that she receives daily methadone. ___ records from ___
says she was recieving 90mg methadone daily then. Pt currently
without any withdrawal sxs despite not receiving any methadone
since sat - suspect likely due to long halflife of methadone.
Will treat with prn morphine overnight for now. Discussed plan
with pt who was agreeable.
3) Low grade fever of ___ on admission
- will continue to monitor pt's temp and sxs. Will plan on blood
and urine cultures if Temp 100 or higher. For now, no need for
empiric abx as pt looks well.
4) Anxiety disorder/PTSD/depression - continue home dose of
xanax
5) Pt reports being raped by multiple men in ___. I
asked if she felt safe currently and wanted to speak with anyone
now - she said no. Will ask social work to see her in am.
6) Hx of prior alcohol abuse
Pt did not reveal this to me but was seen on ___ records.
Will also provide MVI, thiamine and folate for time being.
Assess for any withdrawal sxs.
7) Prophlaxis
pt is ambulatory so no current need for pharmacologic
prophylaxis. Will check urine preg test. Pt states she is not
sexually active. Plan discussed with nurse ___.
Acute Care Surgery was consulted on ___ for further
evaluation and treatment. Patient had already undergone liver
ultrasound and MRCP on ___ with the following findings
US:
No evidence of cholelithiasis. Dilated common bile duct up to 8
mm without
obstructing stone or mass identified, without intrahepatic
biliar dilatation.
Further evaluation with MRCP for cause of obstruction should be
considered.
MRCP:
1. Mild intrahepatic and extrahepatic bile duct dilation.
Prominent main
pancreatic duct with many slightly dilated side-branches. Mild
gallbladder
wall hyperemia associated with trace perihepatic and
pericholecystic fluid.
The above findings could relate to a recently passed gallstone
or are
secondary to sphincter of Oddi dysfunction or ampullary
stenosis. No
obstructing gallstones are seen in the CBD or cystic duct.
2. Mild hepatic steatosis.
The patient underwent HIDA scan on the ___ with findings
consistant with chronic cholecystitis.
Patient was pre oped and consented for laparoscopic
cholecystectomy. 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 we
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 POD0 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 in two weeks.
Medications on Admission:
per pt
methadone 110mg po daily
xanax 1mg bid po
gabapentin 800mg TID
Discharge Medications:
1. ALPRAZolam 1 mg PO BID
2. DiphenhydrAMINE 75 mg PO HS
3. Gabapentin 600 mg PO TID
4. Methadone 110 mg PO DAILY
5. Prazosin 4 mg PO QHS
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
7. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
8. Multivitamins 1 CAP PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*60
Capsule Refills:*0
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl [Vitamin B-1] 100 mg 1 tablet(s) by mouth once
a day Disp #*60 Tablet Refills:*0
10. Acamprosate 666 mg PO TID
11. BuPROPion (Sustained Release) 100 mg PO QAM
12. Lunesta (eszopiclone) 3 mg oral HS
13. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute-on-chronic cholecystitis
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 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:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 4 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19930293-DS-11 | 19,930,293 | 21,037,600 | DS | 11 | 2133-06-22 00:00:00 | 2133-06-22 20:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Chills, fever, worsening cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of DLBCL on
R-CHOP, ESRD on HD (MWF), diastolic heart failure, and newly
diagnosed atrial fibrillation (on rate control, not on
anticoagulation ___ recent GI bleed) who presents with fever
during HD session early in the day.
He was doing HD today ___ and alternate SAT). Patient notes
that during HD he began shaking uncontrollably. States "the
fluid was colder than my body and I told them not to keep giving
it to me but they did!" Notes a fever there of unknown
temperature but "they kept putting warm packs on me so naturally
I had a fever!"
Began shaking uncontrollably. Incredibly uncomfortable with
chills. Fever there of unknown temp. His feet were throbbing and
aching. As soon as HD stopped (continued to finish of session),
he began feeling much better. Then steadily got worse, and was
asking for extra blankets. Cough is at baseline.
Past Medical History:
-heart failure w/preserved EF
-ESRD
-DM2
-htn
-obesity
-OSA on CPAP
-Seasonal allergy.
-History of pneumonia in ___ leading to ESRD in setting of
long-standing DM2
-CAD
-diffuse large B cell lymphoma
PAST ONCOLOGIC HISTORY:
- ___ by Dr ___ management of his newly
diagnosed B cell diffuse large cell lymphoma, dx'd by a core
biopsy 5 d ago of a large pelvic mass. He noted RLE swelling in
early ___. LENIs were negative for clot but did show an
enlarged groin node. The picture was felt to be from a prior
cellulitis of his foot and he was followed. His swelling
continued and repeat LENIs in early ___ showed suggestion of
an
obstruction higher up and he underwent a CT of his abdomen and
pelvis that showed a large pelvic mass with splenomegaly and
mediastinal and portacaval adenopathy and lytic lesions in the
right pubic symphysis and inferior pubic ramus. A subsequent
PET
scan delineated those areas as well as moderate disease in his
chest. He underwent a core bx in ___ last week which showed B
cell
diffuse large cell lymphoma, germinal center origin (better
prognosis) with a high proliferative index of 80-90%.
Cytogenetics showed bcl 6 rearrangement but no worrisome
mutations. Interestingly, his LDH is normal. He continues to
have
RLE edema but denies any abdominal pain or pelvic pain. His wt
is
stable. He denies any fevers, night sweats or pruritis. He has
multiple medical problems with DM since adolescence and has been
on dialysis for the past ___ years. He denies any cardiac disease
but did have mild dysfunction on a cardiac PET test a year ago.
He is complaining of left elbow pain, having fallen at dialysis
several days ago, striking his left elbow and leg. Xrays at the
___ were negative. Sent home without a sling or any advice. Exam
showed obesity, 3 fb splenomegaly, pain, swelling left elbow and
2+ RLE edema Labs: Hct 32, LDH- 171, protein elec-normal. Hep
serologies normal.
A: Stage IIIA large cell lymphoma. High intermediate risk given
age, performance status and multiple sites of disease with CR
estimated at 56%, ___ year OS of 37%. Recommended Rit/CHOP chemo.
- ___: Started chemo with Rit/CHOP. Split dose Rituxan with
50
mg/m2 given on day 1. The rest to be given day 6. Under mistaken
impression that he was to take his prednisone indefinitely so
stayed on it until subsequent GI bleed.
- ___/: Rituxan given.
- ___: Hosp FH for acute GI bleed. Upper endoscopy showed
duodenal ulcers. Missed chemo ___ due to miscommunication.
- ___: Hosp ___ for ___ cellulitis LLE and epistaxis. Also
had paroxysmal atrial fib.
- ___: Cycle 2 Rit/CHOP given. Neulasta given on day 2.
Treatment delayed 2 wks due to gi bleed and LLE cellulitis.
- ___: CT showed near resolution of soft tissue masses in
right iliopsoas and obturator internus muscles, persistence of
splenomegaly and bone lytic lesions
- ___: Resumed chemo with rituxin and bendamustine
- ___: Received day 2 of rituxin and bendamustine
Social History:
___
Family History:
He denies any family history of kidney disease. His father with
diabetes ___ and hypertension died at age ___ due to heart
attack. His mother with diabetes ___ is in her ___.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VITALS: T 99.6 HR 105 BP 90/51 RR 24 SpO2 94% 5L NC
GENERAL: Alert, oriented, no acute distress. Lying flat in bed
with no dyspnea.
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: Supple, unable to assess JVP given neck size, no LAD
LUNGS: Crackles in the lung bases bilaterally but L>R
CV: Irregularly irregular, 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. 2+ pitting edema to knees
bilaterally
SKIN: Unstagable ulcer on right heal, 3-4cm wound on right calf
without erythema or induration.
NEURO: CNII-XII grossly intact. No focal deficits. Moving all 4
extremities
========================
DISCHARGE PHYSICAL EXAM
========================
VS: T98.1 BP121/67 HR98 RR20 99%RA
GENERAL: Pleasant man, very talkative, NAD, lying in bed
comfortably receiving HD.
HEENT: Anicteric sclerae, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Bibasilar crackles similar to prior, no wheezes or
rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds.
EXT: Warm, well perfused, LEs 2+ pitting edema past knees
NEURO: grossly intact
SKIN: Unstagable ulcer on right heal, 3-4cm wound on right calf
without erythema or induration, front of left leg diffusely
erythematous, multiple small linear breaks in the skin of the
legs with overlying crust. L leg erythema continues to recede
from ___ markings.
Pertinent Results:
ADMISSION LABS:
=================
___ 07:02PM WBC-11.3* RBC-2.95* HGB-8.8* HCT-28.9* MCV-98
MCH-29.8 MCHC-30.4* RDW-22.7* RDWSD-81.5*
___ 07:02PM NEUTS-83* BANDS-3 LYMPHS-6* MONOS-5 EOS-3
BASOS-0 ___ MYELOS-0 NUC RBCS-2* AbsNeut-9.72*
AbsLymp-0.68* AbsMono-0.57 AbsEos-0.34 AbsBaso-0.00*
___ 07:02PM GLUCOSE-112* UREA N-24* CREAT-3.5*#
SODIUM-137 POTASSIUM-3.8 CHLORIDE-90* TOTAL CO2-31 ANION GAP-16
___ 07:02PM ALT(SGPT)-21 AST(SGOT)-23 CK(CPK)-63 ALK
PHOS-176* TOT BILI-1.0
___ 08:57PM ___ PO2-54* PCO2-40 PH-7.54* TOTAL
CO2-35* BASE XS-10
___ 08:57PM LACTATE-1.6
___ 07:42PM LACTATE-2.5*
___ 07:40PM ___ PO2-34* PCO2-45 PH-7.52* TOTAL
CO2-38* BASE XS-11
DISCHARGE LABS:
================
___ 07:15AM BLOOD WBC-8.6 RBC-2.46* Hgb-7.5* Hct-24.2*
MCV-98 MCH-30.5 MCHC-31.0* RDW-22.7* RDWSD-82.2* Plt Ct-73*
___ 07:15AM BLOOD Neuts-85.1* Lymphs-6.2* Monos-4.6*
Eos-2.6 Baso-0.4 Im ___ AbsNeut-7.30* AbsLymp-0.53*
AbsMono-0.39 AbsEos-0.22 AbsBaso-0.03
___ 07:15AM BLOOD Glucose-230* UreaN-28* Creat-4.1* Na-136
K-4.6 Cl-92* HCO3-28 AnGap-16
___ 07:15AM BLOOD Glucose-267* UreaN-42* Creat-5.1* Na-132*
K-4.8 Cl-89* HCO3-28 AnGap-15
___ 07:15AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0
MICROBIOLOGY:
==============
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ 6:30 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
___ MRSA SCREEN MRSA SCREEN-FINAL negative
___ BLOOD CULTURE Blood Culture, Routine-FINAL
negative
___ BLOOD CULTURE Blood Culture, Routine-FINAL
negative
IMAGING:
==========
___ CXR:
IMPRESSION:
Pulmonary vascular congestion without definite focal
consolidation.
___ TTE:
There is moderate symmetric left ventricular hypertrophy. The
left ventricular cavity size is normal. There is mild to
moderate global left ventricular hypokinesis (LVEF = 35 %). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. The right ventricular cavity is
moderately dilated with mild global free wall hypokinesis. The
aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. Trivial mitral regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
clear change.
Brief Hospital Course:
Mr. ___ is a ___ male with history of DLBCL on
R-CHOP, ESRD on HD (MWF, ___, systolic/diastolic heart
failure LVEF 35%, and newly diagnosed atrial fibrillation (on
rate control, not on anticoagulation ___ recent GI bleed) who
presented with new hypoxia and fever, concerning for pneumonia,
ultimately found to have beta-hemolytic gp G strep bacteremia,
likely ___ skin source.
===ACUTE ISSUES===
#Sepsis ___ LLE Cellulitis:
#Streptococcal bacteremia:
Pt presented to HD, had fevers/chills, BP ___, BCx obtained
___ at HD ultimately grew Beta-hemolytic gp G Strep. No further
positive cultures. Initially presumed respiratory source (see
below) however ultimately narrowed to cefepime with HD for 14d
course (___). He was noted to have erythema, swelling,
several linear skin breaks, and warmth on the LLE c/f
cellulitis, improving with antibiotics. D/c on cefepime with HD,
per the following schedule: Weeks of MWFSa: 2g/HD. Weeks of MWF:
2g/MW, 3g/F. ID f/u scheduled ___.
#AF w/ RVR: Mr. ___ has history of paroxysmal AF, however is
not on AC due to recent GI bleed from duodenal ulcers. Required
esmolol gtt in ICU, was quickly weaned off and transitioned to
metoprolol tartrate with no further episodes, transitioned to
home succinate upon discharge.
#Acute Hypoxic Respiratory Failure:
On BiPAP in ED due to respiratory distress, transitioned to NC
quickly upon arrival to ICU. VBG showing metabolic alkalosis.
Started on Vancomycin and Cefepime for presumed HCAP, which was
narrowed to cefepime upon improvement in his volume status via
HD and greater suspicion that the cause of his sepsis was due to
cellulitis.
#Open Wound RLE
#Chronic venous stasis changes:
#Unstagable ulcer on right heel: On exam, his RLE wound did not
appear infected. Wound consult obtained, continued current
management.
# DLBCL: Stage IIIA large cell lymphoma. High-intermediate risk
given age, performance status and multiple sites of disease.
During recent admission patient transitioned to
rituxan/bendamustine and received doses on ___ and ___. Has
outpatient onc appointment ___/, planned for chemo.
===CHRONIC ISSUES===
#Systolic and Diastolic Heart Failure: Recent TTE that showed
decreased EF concerning for doxorubicin-induced cardiomyopathy.
ECHO obtained to assess for bacterial vegetation. None noted.
LVF remains 35%.
#End Stage Renal Disease on Hemodialysis:
#Hypophosphatemia:
Received dialysis per his usual schedule MWF,QO-Sa. Phos level
noted to be low, sevelamer and calcium carbonate were held.
Please trend levels at HD.
#T2DM: Continued home regimen of lantus 20 u with breakfast, 15u
qHS. Started a Humalog SS.
# Anemia: Likely multifactorial. Likely due to malignancy,
chemotherapy, and ESRD. Not on epo presumed due to malignancy.
Remained hemodynamically stable. Required no blood transfusions.
# Thrombocytopenia: Likely secondary to chemotherapy. Discharge
plt 73, no signs of bleeding during hospitalization.
# CAD: Continue home metoprolol and atorvastatin
# Hypertension: Continued home metoprolol (briefly on esmolol as
above) and irbesartan
# Gout: Continued home allopurinol
===TRANSITIONAL ISSUES===
#Antibiotics course (14 days, ___: Cefepime following HD.
If patient is on a week where he dialyzes MWFSa, then dose 2g
following each session. If patient is on a week where he
dialyzes only MWF, then dose 2g following the MW sessions and 3g
following the F session.
#Hypophosphatemia: sevelamer and calcium carbonate were held on
discharge. Discharge phos 2.1. Please trend at HD.
#Amenic/thrombocytopenic during hospitalization, please obtain
CBC within 1 week of discharge. Discharge Hb 7.5, plt 73.
#Follow-up for resolution of LLE cellulitis, improving on
discharge.
#Continue wound care for RLE open wound: adaptic to wound gel
and dry gauze daily.
CODE: Full Code (confirmed)
COMMUNICATION: Patient
EMERGENCY CONTACT HCP: ___ (sister/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 20 Units Breakfast Glargine 15 Units Bedtime Insulin
SC Sliding Scale using HUM Insulin
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Atorvastatin 80 mg PO QPM
4. Loratadine 10 mg PO DAILY:PRN allergies
5. sevelamer CARBONATE 2400 mg PO TID W/MEALS
6. irbesartan 300 mg oral DAILY
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. Calcium Carbonate 1250 mg PO TID W/MEALS with each meal
9. Cinacalcet 60 mg PO 5X/WEEK (___)
10. Benzonatate 100 mg PO TID
11. Pantoprazole 40 mg PO Q24H
12. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. CefePIME 2 g IV M, W AFTER HD
2g ___ and ___ after HD
2. CefePIME 2 g IV F, SAT AFTER HD ON WEEKS GETTING ___ HD
___ on weeks with ___ HD
3. CefePIME 3 g IV F WEEKS NOT GETTING ___ HD
___ after HD on weeks not getting ___ HD
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
5. Allopurinol ___ mg PO EVERY OTHER DAY
6. Atorvastatin 80 mg PO QPM
7. Benzonatate 100 mg PO TID
8. Cinacalcet 60 mg PO 5X/WEEK (___)
9. Glargine 20 Units Breakfast
Glargine 15 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. irbesartan 300 mg oral DAILY
11. Loratadine 10 mg PO DAILY:PRN allergies
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. HELD- Calcium Carbonate 1250 mg PO TID W/MEALS with each
meal This medication was held. Do not restart Calcium Carbonate
until cleared by your dialysis doctor
15. HELD- sevelamer CARBONATE 2400 mg PO TID W/MEALS This
medication was held bc phosphate levels were too low. Do not
restart sevelamer CARBONATE until cleared by dialysis.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Sepsis
Bacteremia
Acute Hypoxic Respiratory Failure
Atrial Fibrillation with Rapid Ventricular Response
Cellulitis
Open Wound on Right Lower Extremity
Systolic and Diastolic Heart Failure
End Stage Renal Disease on Hemodialysis
Diffuse Large B Cell Lymphoma
Anemia
Thrombocytopenia
Coronary Artery Disease
Type II Diabetes
Hypertension
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to take care of you during your stay here at
___.
You came to the hospital because of fever and shaking during
dialysis. You went to the intensive care unit because we were
worried that you had a serious infection and also because your
heart was beating very quickly from Atrial Fibrillation. You
then came to the oncology floor where we continued to treat your
blood infection.
You most likely got your blood infection from a skin infection
in your leg, which we are treating. You are now doing much
better and we have not detected any bacteria in your blood for
many days.
You are safe to return to ___ to continue your
antibiotics, which will be given to you after your dialysis. We
hope you continue to feel better.
Please see below for your follow-up appointments and changes in
your medicines.
Sincerely,
___ Oncology Team
Followup Instructions:
___
|
19930293-DS-14 | 19,930,293 | 27,917,243 | DS | 14 | 2134-02-11 00:00:00 | 2134-02-11 22:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L ___ Metatarsal Osteomyelitis
Major Surgical or Invasive Procedure:
___: Left foot ___ metatarsal head resection, excision of
base of ___ proximal phalanx
History of Present Illness:
___ y/o M with PMHx of DLBCL, HFrEF, atrial fibrillation, ESRD on
HD MWF, DM2, recurrent lower extremity ulcerations and
cellulitis, who presents with complaint of foot ulcer now found
to have L ___ Metatarsal Osteomyelitis and admitted per podiatry
for ongoing antibiotic therapy and surgical planning.
Per patient, was seen by outpatient podiatrist this AM who noted
a foot XRAY from 1 wk ago with evidence of osteomyelitis of the
L ___ metatarsal bone. Given clinical concern for spread of
infection and need for surgical planning, patient was sent to ED
for further evaluation and planned admission for ongoing
antibiotic therapy. Of note, patient was notified about
osteomyelitis 1 week ago at time of foot XRAY, but was unwilling
to go to the hospital at this time.
On arrival ___ the ED, patient was HDS with initial vitals 98.0
84 143/80 16 98% RA. Denied fevers or chills or other systemic
complains. Also denied sensation of pain, but has baseline
neuropathy. Exam notable for pale-appearing and overweight
elderly gentleman, with quarter-size open ulceration over
lateral aspect of the L foot along the plantar surface. Small
area of
exudative tissue noted at ulcer site, and ED provider able to
probe bone but with no obvious cellulitis surrounding
ulceration. Otherwise CTAB, NTND and soft abdomen, and with
dopplerable DP pulse of the L foot. Labs significant for CRP
12.4, WBC 5, Lactate 1.9. Imaging showing no significant change
compared to most recent prior, but with concern for
osteomyelitis of the L
___ metatarsal. Patient given Levofloxacin 750mg, Insulin 8
Units. Vitals prior to transfer: 97.8 82 129/79 16 96% RA.
Currently, patient stable on floor and continuing to deny
fevers, chills, or pain ___ L foot (c/w known underlying
neuropathy). Amenable to continued treatment with antibiotics,
and looking
forward to definitive surgical management.
Past Medical History:
- Diastolic Heart Failure
- ESRD on HD (MWF)
- Type II Diabetes complicated by Diabetic Rentinopathy and
Peripheral Neuropathy
- Hypertension
- Obesity
- OSA not on CPAP
- CAD
- Atrial Fibrillation
- GI Bleed ___ Multiple Duodenal Ulcers ___ ___
- Hyperlipidemia
- Erectile Dysfunction
- Colonic Adenoma
- Hyperparathyroidism
- Coagulopathy
Social History:
___
Family History:
Father with diabetes and hypertension died at age ___ due to
MI. Mother with diabetes ___ is ___ her ___. Maternal
grandfather possibly died of lymphoma age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.6PO 153 / 96R Sitting 76 18 97 RA
GEN: Alert, lying ___ bed, no acute distress
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 with harsh systolic ejection murmur, likely
from fistula
ABD: Soft, non-tender, non-distended
EXTREM: There is moderate peripheral edema noted to the
left lower extremity. 2cm by 2cm ulceration on lateral aspect
of
fifth metatarsal head. Fibrinous wound bed with minimal
surrounding erythema. T
NEURO: CN II-XII grossly intact, motor function grossly normal
PHYSICAL EXAM:
VITALS: 98.1 PO___ R Lying___
GEN: Alert, sitting up on the edge of the bed, no acute
distress, energetic and pleasant.
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: CTA b/l without wheeze, rales, rhonchi
COR: RRR (+)S1/S2 with harsh systolic ejection murmur
ABD: Soft, non-tender, non-distended
EXTREM: Left foot is bandaged, post-operatively, with wound vac.
warm and well perfused.
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
============
___ 10:36AM BLOOD WBC-5.0 RBC-3.67* Hgb-12.3* Hct-37.4*
MCV-102* MCH-33.5* MCHC-32.9 RDW-18.0* RDWSD-67.5* Plt Ct-90*
___ 10:36AM BLOOD Neuts-76.0* Lymphs-11.0* Monos-9.4
Eos-2.8 Baso-0.6 Im ___ AbsNeut-3.78 AbsLymp-0.55*
AbsMono-0.47 AbsEos-0.14 AbsBaso-0.03
___ 10:36AM BLOOD ___ PTT-34.7 ___
___ 10:36AM BLOOD Glucose-403* UreaN-41* Creat-4.9*#
Na-130* K-7.1* Cl-90* HCO3-25 AnGap-15
___ 01:12PM BLOOD Glucose-377* UreaN-44* Creat-5.2* Na-131*
K-7.6* Cl-88* HCO3-22 AnGap-21*
___ 03:41PM BLOOD Glucose-330* UreaN-45* Creat-5.1* Na-134*
K-5.9* Cl-89* HCO3-28 AnGap-17
___ 01:12PM BLOOD Calcium-9.3 Phos-4.7* Mg-1.9
___ 05:55AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 10:36AM BLOOD CRP-12.4*
___ 05:55AM BLOOD HCV Ab-NEG
___ 03:39PM BLOOD ___ pO2-37* pCO2-47* pH-7.42
calTCO2-32* Base XS-4
___ 10:44AM BLOOD Lactate-1.9 K-6.0*
___ SED RATE BY MODIFIED - TEST NOT PERFORMED
___ 06:15AM BLOOD CRP-61.4*
DISCHARGE LABS:
============
___ 07:05AM BLOOD WBC-4.7 RBC-3.14* Hgb-10.6* Hct-31.4*
MCV-100* MCH-33.8* MCHC-33.8 RDW-17.3* RDWSD-63.1* Plt Ct-90*
___ 07:05AM BLOOD Glucose-126* UreaN-65* Creat-8.0*#
Na-133* K-4.8 Cl-89* HCO3-27 AnGap-17
___ 07:05AM BLOOD Calcium-8.5 Phos-6.4* Mg-1.8
MICROBIOLOGY:
===========
___ BLOOD CX X2: NGTD
___ 8:00 am TISSUE ___ METATARSAL HEAD,LEFT.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Time Taken Not Noted ___ Date/Time: ___ 9:28 am
TISSUE ___ TOE,LEFT FOOT.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
This isolate is presumed to be resistant to clindamycin
based on
the detection of inducible 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
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
IMAGING:
========
FOOT AP,LAT & OBL LEFTStudy Date of ___
1. No significant change compared to most recent prior. Large
erosion of the head of the fifth metatarsal and smaller erosion
at the lateral base of the proximal phalanx of the fifth toe is
concerning for osteomyelitis ___ the setting of infection.
2. Previously described fracture of the base of the fifth
metatarsal is unchanged compared to most recent prior.
Brief Hospital Course:
___ M with PmHx notable for T2DM (c/b multiple poorly healing
foot ulcers), HTN, and ESRD, who presents with complaint of foot
ulcer, found to have L ___ Metatarsal MSSA Osteomyelitis, now
s/p debridement and L ___ metatarsal head resection.
ACTIVE ISSUES:
================
#L ___ Metatarsal Osteomyelitis
Patient with T2DM c/b neuropathy and with history of recurrent
non-healing lower extremity ulcers. Demonstrated evidence of
osteomyelitis of the L ___ metatarsal on foot XRAY, had been on
levofloxacin as an outpatient, which was stopped upon admission
for continued antibiotic therapy and surgical planning per
podiatry, and then went to the OR (___) where ___ metatarsal
head was resected, left open and packed, and ultimately a vac
was placed. Prelim tissue cultures grew MSRA, planned for 6 week
course of Vancomycin with HD, expected end date ___. Final
cultures and pathology on the bone fragment pending at
discharge. Should have outpatient ID followup. Wound vac
transitioned to wet-to-dry on discharge, plan for ___ to replace
vac at home on ___, continue pending podiatry f/u ___.
#Hyperkalemia: EKG's continue to have no changes, and remains
asymptomatic throughout his stay. Electrolytes managed at
dialysis. Low K diet.
CHRONIC ISSUES:
==================
#ESRD on ___ dialysis schedule
#T2DM (c/b neuropathy and ESRD): Takes lantus 60 AM and 40 ___
with HISS at home. Put on lower long acting regimen here given
NPO for procedure and reduced PO intake, continued on 40 AM and
20 ___ of lantus on discharge and instructed to check FSG TID.
#Anemia
#Thrombocytopenia: Appears at or above baseline for platelets
and Hgb. Pt is status post nine months of CHOP chemotherapy, and
likely has some degree of bone marrow suppression which fits his
macrocytosis. Iron studies c/w AIC.
#HTN: Well controlled with Irbesartan, transitioned to
Lisinopril ___ house as irbesartan nonformulary.
#HFpEF: Volume managed at dialysis. Continued on home
metoprolol.
#DLBCL: S/p CHOP chemo. Not on active chemo during this
admission (last round of chemo one month prior to admission)
#CAD: Continue home atorvastatin, metoprolol
#Hyperparathyroidism: Patient states he is no longer on
cinacalcet, would confirm
#GERD: Continued home pantoprazole
#AFib: Not on anticoagulation ___ setting of history of GIB.
Rates well controlled with Metoprolol as above.
#Gout: Dose reduced allopurinol for renal dosing.
====================
Transitional Issues
====================
[ ] Wound vac: ___ has been coordinated to come to Mr. ___
home to manage his wound vac, will place ___, letter
provided with ___ will have vac until podiatry followup
___
[ ] Final wound cultures pending at discharge, please f/u
[ ] Pathology on the bone fragment pending at discharge, please
f/u
[ ] Monitor insulin dosing carefully, reduced to 40 AM, 20 ___
lantus and blood sugar was well controlled
[ ] Discharged with Home Physical Therapy.
[ ] Vanc will be dosed by level at outpatient HD, confirmed
[ ] Allopurinol dosing reduced to QOD
[ ] Patient states he took Calcium carbonate 1000 mg TID with
meals, would clarify at followup
CODE: Full Code (confirmed)
EMERGENCY CONTACT HCP: ___ (sister/HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Levofloxacin 250 mg PO Q48H
3. irbesartan 300 mg oral DAILY
4. Loratadine 10 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Atorvastatin 80 mg PO QPM
7. Glargine 60 Units Breakfast
Glargine 40 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. sevelamer CARBONATE 1600 mg PO TID W/MEALS
9. Calcium Carbonate 1000 mg PO TID W/MEALS
10. Allopurinol ___ mg PO DAILY
11. Gabapentin 100 mg PO DAILY:PRN pain
Discharge Medications:
1. ___ MD to order daily dose IV HD PROTOCOL Sliding
Scale
Start: Today - ___, First Dose: Next Routine Administration
Time
continue through ___
RX *vancomycin 1 gram 1 g IV three times a week during HD Disp
#*1 Vial Refills:*0
2. Allopurinol ___ mg PO EVERY OTHER DAY
3. Glargine 40 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
4. Atorvastatin 80 mg PO QPM
5. Calcium Carbonate 1000 mg PO TID W/MEALS
6. Gabapentin 100 mg PO DAILY:PRN pain
7. irbesartan 300 mg oral DAILY
8. Loratadine 10 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Pantoprazole 40 mg PO Q24H
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Osteomyelitis
Secondary Diagnoses: End Stage Renal Disease, Type 2 Diabetes
___, Peripheral Neuropathy, Hypertension, Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
You came into the hospital for management of the ulcer on your
left pinky toe, which was found to have an infection ___ the bone
(osteomyelitis). You had surgery to clean out the wound and
remove the infected part of the bone on your pinky toe. After
surgery you remained ___ the hospital and were given antibiotics
to help fight any lingering infection, while you continued
dialysis.
Sometimes the bone infection can persist ___ your body for a
weeks without any visible sign of it, therefore even after you
leave the hospital, you will continue to receive antibiotics
through ___, even if you feel fine.
When you leave the hospital:
- Please see podiatry ___
- Please have wound vac placed by ___ on ___
- Call your primary care doctor to schedule an appointment
- Call infectious disease clinic to schedule an appointment
- Monitor your blood sugar 3 times per day. You were given a
lower dose of insulin than you normally have
- If you feel feverish or weak, or notice a significant negative
change ___ the appearance of your wound, such as more fluid, a
bad color, or a bad smell it will be important to call your
podiatrist.
- You can only place weight on the heel of your left foot.
Thank you for coming to ___, and we wish you a speedy
recovery.
Your ___ Team
Followup Instructions:
___
|
19930554-DS-24 | 19,930,554 | 27,090,024 | DS | 24 | 2197-10-27 00:00:00 | 2197-10-27 17:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose
Attending: ___.
Chief Complaint:
Left arm pain and swelling
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ w/ hx of hx of breast cancer with left node disection
(chemo/xrt in ___) who presents w/ left arm pain and swelling.
She reports that the pain began several weeks ago, and she
expresses frustration that her pain was not taken seriously. Per
chart review, there was concern for DVT and an ultrasound appt
w/ transportation was arranged but the patient did not go. The
picture is complicated by the fact that the patient has had
chronic left axila pain since her partial masectomy, and there
has been concern for narcotics misuse. She has also missed
several appointments, citing that she is a single mother with
three children.
The pain is in her left axila extending to the deltoid area. It
is sharp and comes and goes, ranging in severity from ___,
on top of her baseline post-surgical pain in this area.
Oxycodone and motrin are not effective, she reports, but the
tramadol she takes at home and the morphine she received in the
ED are effective.
In the ED, she received 5 mg morphine. She was found to have an
extensive LUE DVT, and was given a heparin bolus and started on
a heparin drip.
Denies hx of blood clots or having a line in the left arm. Chart
review shows that chemo was previously administered by a
portacath in the right chest.
ROS: As above in HPI. Upon questioning, she endorses ___ days of
subjective fevers/chills, ___ days of headache, and ___ days of
left-sided chest pain and shortness of breath. The cp/sob only
comes on when she is talking, and immediately resolves when she
stops. She has not had this while in the hospital. Does not come
on with walking, stairs, or lifting her children. Denies
abdominal pain, nausea/vomiting, diarrhea/constipation, vision
changes, weakness or tingling on arms or legs. No recent
surgeries.
Past Medical History:
Past Medical History:
- T1DM (HbA1c of 11.7 in ___
- Gastroparesis
- HTN
- Asthma
- Anemia
- Depression and anxiety
- Insomnia
- Chlamydia, syphillis
PAST ONCOLOGIC HISTORY:
Left breast cancer stage IIA (pT1c pN1 M0), grade 3 IDC,
triple-negative
- ___ pt palpated a painful left breast mass
- ___ visit to PNP, abnormal CBE with palpable mass
- ___ diagnostic breast imaging was notable for 3.3 cm mass
in left breast, also a 1.6 cm abnormal left axillary LN.
- ___ left breast core biopsy diagnostic of 0.8 cm grade 3
IDC, ER/PR neg, HER2 neg (FISH 0.7); FNA of LN positive for
malignant cells.
- ___ full radiographic staging with CT torso, bone scan,
brain MRI all negative for MBC. MRI brain notable for possible
demyelinating disease
- ___ left partial mastectomy/axillary LN dissection; 1.7 cm
grade 3 invasive ductal carcinoma with DCIS, negative margins,
+ALND ___ positive nodes)
- ___ C1D1 dd-AC (adriamycin reduced by 20% given emesis
associated with gastroparesis)
- ___ C2D1 dd-AC (adriamycin increased to full dose)
- ___ C3 postponed
- ___ C3D1 dd-AC
- ___ C4D1 dd-AC
- ___ dd-taxol x 3, ___ cycle was held due to
neuropathy
- ___ Radiation treatment
- ___ Negative BRCA1/2 comprehensive sequencing and ___
genetic test results.
Social History:
___
Family History:
Reports multiple family members with DM and HTN. No known
history of cancer.
Physical Exam:
ADMISSION EXAM:
VITALS: 97.6 95 157/95 15 98%RA
General: Lying in bed, no apparent distress. Tearful at times,
describing being a single mother
___, EOMI, MMM.
Neck: supple. No LAD.
CV: RRR. No m/r/g.
Lungs: CTAB.
Abdomen: Soft, ntnd, +BS.
Ext: Lower extremities and RUE are warm and well perfused,
without edema. LUE has pitting edema to elbow, grossly larger
than RUE, tender to palpation in axila. Axila is diffusely
indurated with post-surgical changes. Some erythema on inner
arm, not warm to touch.
Neuro: CNs II-XII grossly normal. Moving all extremities
equally.
DISCHARGE EXAM:
VITALS: 98.8 81 158/94 16 98%RA
General: Lying in bed, no apparent distress.
___: MMM.
CV: RRR. No m/r/g.
Lungs: CTAB.
Abdomen: Soft, ntnd, +BS.
Ext: Lower extremities and RUE are warm and well perfused,
without edema. LUE edema has largely resolved, no pitting edema.
Also much less tender.
Pertinent Results:
ADMISSION LABS:
___ 05:00AM GLUCOSE-251* UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-29 ANION GAP-13
___ 05:00AM estGFR-Using this
___ 05:00AM WBC-7.3 RBC-3.68* HGB-11.6* HCT-34.0* MCV-92
MCH-31.5 MCHC-34.1 RDW-14.5
___ 05:00AM NEUTS-71.9* ___ MONOS-5.7 EOS-2.0
BASOS-0.6
___ 05:00AM PLT COUNT-297
___ 05:00AM ___ PTT-30.3 ___
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-6.8 RBC-3.92* Hgb-12.2 Hct-36.6
MCV-94 MCH-31.0 MCHC-33.2 RDW-14.0 Plt ___
___ 06:15AM BLOOD Glucose-125* UreaN-11 Creat-0.6 Na-138
K-3.7 Cl-99 HCO3-27 AnGap-16
___ 06:15AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.8
IMAGING: ___ Left Upper Extremity Ultrasound:
1. Deep venous thrombosis in the left subclavian, axillary and
basilic veins.
2. Enlarged abnormal lymph nodes in the left axilla. While
possibly reactive, these require short term follow-up US after
resolution of the acute findings given the history of breast
cancer.
Brief Hospital Course:
___ w/ hx of L breast cancer s/p partial masectomy, chemo,
radiation, who presents w/ LUE DVT.
HOSPITAL ISSUES:
# LUE DVT: Previous surgery w/ lymph node dissection and
radiation to this area. Denies any IVDU or instrumentation to
the LUE. The patient was bolused iv heparin in the ED and
started on a heparin drip. She was transitioned to SC Lovenox
60mg bid on ___. Her pain was well controlled with ibuprofen
and tramadol.
# Left breast cancer stage IIA (pT1c pN1 M0), grade 3 IDC,
triple-negative: Enlarged lymph nodes seen in left axilla and
new DVT raise question of reccurence.
She will follow up with her oncologist, Dr. ___,
who is aware.
# Chest pain/shortness of breath: Has not been an issue in
house. History is not suggestive of cardiac cause. Vitals all
within normal limits. EKG normal.
CHRONIC ISSUES:
#DM: continue home glargine and sliding scale humalog.
#Depression: continue home celexa.
TRANSITIONAL ISSUES:
#Follow up is recommended for the enlarged abnormal lymph nodes
seen on her ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Ibuprofen 600 mg PO Q6H:PRN pain
3. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using novalog Insulin
4. TraMADOL (Ultram) 50 mg PO HS pain
5. Gabapentin 300 mg PO TID
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Enoxaparin Sodium 60 mg SC Q12H Start: ___, First Dose:
Next Routine Administration Time
RX *enoxaparin 60 mg/0.6 mL 60 mg SC Twice daily Disp #*28
Syringe Refills:*0
2. Citalopram 20 mg PO DAILY
3. Ibuprofen 600 mg PO Q6H:PRN pain
4. TraMADOL (Ultram) 50 mg PO HS pain
5. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using novalog Insulin
6. Gabapentin 300 mg PO TID
7. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Deep venous thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It has been a pleasure taking care of you in the hospital. You
were found to have a blood clot in your left arm. You were
started on anticoagulant medication. You should continue to
inject this medication twice a day, as prescribed. You should
follow-up with your primary care and oncologist (see
appointments below).
Followup Instructions:
___
|
19930554-DS-25 | 19,930,554 | 21,205,318 | DS | 25 | 2197-12-03 00:00:00 | 2197-12-07 21:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose
Attending: ___.
Chief Complaint:
nausea, vomiting, diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of triple negative metastatic breast cancer
treated with palliative chemo (eribulin C1D8 as of ___,
DM1 c/b gastroparesis presenting with acute onset abdominal
pain,
subjective fevers, chills, vomiting >20x, diarrhea ___. These
symptoms started one day after receiving chemotherapy on ___.
She has not noted any blood in vomit or stool. Her pain is
___,
periumbilical, without any alleviating factors.
She had some nausea after her first round of chemo, but did not
have symptoms like this. No sick contacts, new foods, or travel.
She denies any h/o DKA or requiring hospitalization for her type
I diabetes. She denies any CP, SOB, leg swelling, urinary
symptoms, or weakness.
ED course:
O: 97.9 110 169/99 20 99%
meds
23:14 Lovenox 60 mg SC
20:20 Morphine Sulfate 5 mg IV
19:00 Ondansetron 4 mg IV
19:00 Morphine Sulfate 5 mg IV
rads
20:36 CT ABD & PELVIS WITH CONTRAST
iv
20:20 40 mEq Potassium Chloride / 1000 mL NS Continuous at
250 ml/hr for 1000 ml
Review of Systems: As per HPI. All other systems negative.
Past Medical History:
ONCOLOGIC HISTORY:
Left breast cancer stage IIA (pT1c pN1 M0), grade 3 IDC,
triple-negative on palliative chemo (eribulin C1D8 as of
___
-please see OMR for full onc history details
PMH:
- T1DM (hemoglobin A1c ___ was 10.2%) complicated by
gastroparesis
- LUE DVT on lovenox
- Left lymphedema
- HTN
- Asthma
- Anemia
- Depression and anxiety
- Insomnia
- Chlamydia, syphilis
Social History:
___
Family History:
Diabetes and hypertension, both run in the
family, but there is no known family history of breast cancer.
Physical Exam:
ON ADMISSION:
98.9, 164/92, 102, 16, 95%RA
GEN: NAD, reclined in bed
HEENT: PERRL, EOMI, slightly dry mucosal membranes, oropharynx
clear, no cervical ___: CTAB, no wheezes, rales or rhonchi.
CV: RRR with II/VI SEM, nl S1 S2. JVP<7cm
Chest: R sided port without surrounding erythema, swelling, TTP
ABD: normal bowel sounds, soft, not distended. +mild TTP in
epigastric area.
EXTR: Warm, well perfused. left UE lymphedema. 2+ radial and DP
pulses.
NEURO: alert and orientedx3, motor grossly intact
ON DISCHARGE:
Still with Left upper extremity edema, improving per patient.
Pertinent Results:
___ 08:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-150 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 08:50PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:05PM LACTATE-1.5
___ 06:52PM GLUCOSE-256* UREA N-11 CREAT-0.6 SODIUM-140
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-29 ANION GAP-17
___ 06:52PM ALT(SGPT)-14 AST(SGOT)-21 ALK PHOS-91 TOT
BILI-0.2
___ 06:52PM LIPASE-24
___ 06:52PM ALBUMIN-3.9
___ 06:52PM WBC-9.2# RBC-3.46* HGB-10.2* HCT-32.3*#
MCV-93 MCH-29.6 MCHC-31.7 RDW-13.0
___ 06:52PM PLT COUNT-448*
ON DISCHARGE:
___ 09:43AM BLOOD Neuts-50.8 Lymphs-44.5* Monos-4.2 Eos-0.4
Baso-0.1
___ 09:43AM BLOOD Glucose-186* UreaN-11 Creat-0.6 Na-140
K-4.1 Cl-100 HCO3-33* AnGap-11
MICRO:
___ BLOOD CULTURE Blood Culture,
Routine-FINAL neg EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-FINAL negEMERGENCY WARD
___ URINE URINE CULTURE-FINAL negEMERGENCY
WARD
CT ABD/PELVIS ___
The visualized lung bases again demonstrate innumerable
pulmonary nodules as well as necrotic left breast mass. The
patient is status post right mastectomy. The liver, gallbladder,
spleen, bilateral adrenal glands, pancreas, stomach, and
visualized loops of small large bowel are within normal limits.
Bilateral kidneys are normal with no evidence of hydronephrosis
or stones. The appendix is not clearly visualized but there are
no secondary signs of appendicitis. There is no free fluid or
free air. There is no mesenteric or retroperitoneal
lymphadenopathy. Abdominal aorta is normal in caliber. There is
no free air or free fluid. CT PELVIS WITH IV CONTRAST: The
uterus appears within normal limits with an IUD in place. The
rectum, sigmoid colon, and bladder appear unremarkable. There is
a small amount of free fluid, likely physiologic. OSSEOUS
STRUCTURES: There are no lytic or sclerotic osseous lesions
suspicious for malignancy. Mild diffuse body anasarca is again
noted. Subcutaneous gas is noted in the anterior subcutaneous
tissues, likely from injections. IMPRESSION:
1. No acute abdominal or pelvic process.
2. Visualized lung bases again demonstrate innumerable pulmonary
nodules as well as a necrotic left breast mass.
Brief Hospital Course:
___ with history of triple negative metastatic breast cancer
treated with palliative chemo (eribulin C1D8 as of ___,
DM1 c/b gastroparesis presenting with acute onset abdominal
pain, subjective fevers/ chills, vomiting and diarrhea. Abd CT
scan
was unremarkable for acute intraabdominal process. She did
initially have hypokalemia which improved with supplementation.
She was also given intravenous fluids and her glucosuria and
ketonuria also resolved. Her symptoms of nausea, vomiting and
diarrhea as well as abdominal pain had resolved as of the
morning after her adssion.
She was able to tolerate a diet and felt improved however, she
was unable to have a bowel movement. As a result, her bowel
regimen was advanced and she responded to miralax which she was
given at time of discharge.
Otherwise, she was continued on her home medication regimen
including her insulin, enoxaparin.
She was confirmed full code at admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enoxaparin Sodium 60 mg SC Q12H
2. Citalopram 20 mg PO DAILY
3. Ibuprofen 600 mg PO Q6H:PRN pain
4. TraMADOL (Ultram) 50 mg PO HS pain
5. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using novalog Insulin
6. Gabapentin 300 mg PO TID
7. Omeprazole 20 mg PO DAILY
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Acetaminophen 1000 mg PO Q8H
10. Hydrocortisone Oint 2.5% 1 Appl TP BID
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Prochlorperazine 5 mg PO Q6H:PRN nausea
13. Morphine SR (MS ___ 15 mg PO Q12H
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis
15. Senna 2 TAB PO BID
16. Docusate Sodium 100 mg PO BID
17. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QAC
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 60 mg SC Q12H
5. Gabapentin 300 mg PO TID
6. Hydrocortisone Oint 2.5% 1 Appl TP BID
7. Ibuprofen 600 mg PO Q6H:PRN pain
8. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using novalog Insulin
9. Morphine SR (MS ___ 15 mg PO Q12H
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Prochlorperazine 5 mg PO Q6H:PRN nausea
13. Senna 2 TAB PO BID
14. TraMADOL (Ultram) 50 mg PO HS pain
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis
16. Polyethylene Glycol 17 g PO Q12H constipation
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth once
to twice daily Disp #*600 Gram Refills:*3
17. NovoLOG (insulin aspart) 100 unit/mL subcutaneous QAC
18. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
chemotherapy-induced vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ with
abdominal pain, nausea and vomiting. This improved and you then
developed constipation which improved with constipation
medications including miralax.
Call your doctor if you have been constipated for more than 2
days or if you develop any abdominal pain or vomiting, any fever
more than 100.4 or with any other concerns.
Followup Instructions:
___
|
19930554-DS-26 | 19,930,554 | 24,162,042 | DS | 26 | 2197-12-10 00:00:00 | 2197-12-10 20:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with hx. stage IIA breast cancer (grade 3
IDC), triple negative, on palliative chemo (eribulin), T1DM, LUE
DVT on lovenox, HTN, asthma, depression/anxiety, presenting with
chest pain.
Patient reports onset of ___ substernal CP that woke her from
sleep this AM. Describes it 'like a ton of bricks' on her chest,
radiating to back, with associated SOB. Worsens with
inspiration, no relation to position. Denies n/v, no dizziness
or lightheadedness. Never had this pain before but does report
chronic left sided axilla/CP in relation to her breast cancer
diagnosis. Pain was severe enough to cause patient to report to
ED.
In the ED intial vitals were: 10 98.6 90 141/77 20 97% RA. Labs
were notable for CBC with WBC 3.2 with 43%N, H/H 8.2/26.1, plt
416, chem-7 unremarkable. u/a unconcerning for infection, ucg
negative, lactate normal, tropt negative x2. Patient was given
morphine 5mg IV x3, toradol 15mg x1, oxycodone 5mg PO x1,
aspirin 81. CT head was negative for acute change. CTA chest
showed no PE but numerous pulmonary nodules, some increased in
size since last CT ___, as well as left axillary mass.
Discussion was had with outpatient oncologist with decision made
to admit for pain control. As no beds were available on OMED
service she was admitted West to ___.
On the floor patient reports chest pain now improved, currently
___. She reports morphine 'took the edge off' but toradol
really seemed to help. She does report ongoing left sided axilla
pain, about ___, related to her breast cancer. Denies
fevers/chills. No headaches or visual changes.
Review of Systems:
(+) as above
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, abdominal pain,
nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
ONCOLOGIC HISTORY:
Left breast cancer stage IIA (pT1c pN1 M0), grade 3 IDC,
triple-negative on palliative chemo (eribulin C1D8 as of
___
-please see OMR for full onc history details
PMH:
- T1DM (hemoglobin A1c ___ was 10.2%) complicated by
gastroparesis
- LUE DVT on lovenox
- Left lymphedema
- HTN
- Asthma
- Anemia
- Depression and anxiety
- Insomnia
- Chlamydia, syphilis
Social History:
___
Family History:
Diabetes and hypertension, both run in the family, but there is
no known family history of breast cancer.
Physical Exam:
Admission exam:
Vitals- 97.8 143/82 hr 94 18 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Chest - right sided port in place, dressing c/d/i, excoriations
overlying left breast/axilla, no erythema, purulence, or
drainage
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- +lymphedema involving LUE, other WPP
Neuro- CNs2-12 intact, motor function grossly normal
Discharge exam:
Vitals: 98.3 133/73 (113-133/65-76) 87 18 99% RA
General- Alert and oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear, neck is supple
CV- r/r/r, normal S1 + S2, no murmurs, rubs, gallops
Lungs- Clear to auscultation bilaterally
Abdomen- soft, non-tender, non-distended, bowel sounds present
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Chest- decreased tenderness to palpation along left breast,
lidocaine patch in place. Left breast is nodular and firm with
overlying skin changes. Left axillar is also tender to touch
with multiple hard lymph nodes appreciated. No draining sinus
tracts noted. No overlying erythema of the skin
Pertinent Results:
Admission labs:
___ 07:30AM BLOOD WBC-3.2*# RBC-2.79* Hgb-8.2* Hct-26.1*
MCV-93 MCH-29.4 MCHC-31.5 RDW-14.0 Plt ___
___ 07:30AM BLOOD ___ PTT-44.5* ___
___ 07:30AM BLOOD Glucose-184* UreaN-9 Creat-0.6 Na-138
K-3.8 Cl-101 HCO3-30 AnGap-11
___ 07:30AM BLOOD ALT-21 AST-15 AlkPhos-81 TotBili-0.1
___ 07:30AM BLOOD Lipase-25
___ 07:30AM BLOOD cTropnT-<0.01
___ 02:13PM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD Albumin-3.5
___ 05:51AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.7
___ 07:47AM BLOOD Lactate-1.1
Discharge labs:
___ 06:44AM BLOOD WBC-3.0* RBC-2.82* Hgb-8.1* Hct-26.1*
MCV-92 MCH-28.6 MCHC-31.0 RDW-14.1 Plt ___
Urine:
___ 12:44PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 05:37PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 12:44PM URINE RBC-5* WBC-1 Bacteri-NONE Yeast-NONE
Epi-1
___ 05:37PM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-1
Urine culture negative
Blood cultures: NGTD, pending final results
IMAGING:
CXR ___:
IMPRESSION:
1. No acute findings.
2. Nodular opacity adjacent to the left heart border, compatible
with known
history of pulmonary nodules.
3. No clear sign of effusion or pneumonia, although assessment
is limited by rotation.
CTA ___:
IMPRESSION:
1. No pulmonary embolus.
2. Increased tumor burden with increase in size of the left
axillary mass,
multiple left breast masses, and pulmonary nodules.
CT head ___:
IMPRESSION:
No acute intracranial abnormality. Please note that MR is more
sensitive ___ detection of intracranial metastatic lesions.
Brief Hospital Course:
Impression: ___ year old female with recurrent triple negative
breast cancer, now metastatic on palliative chemo (eribulin),
T1DM, LUE DVT on lovenox, HTN, asthma, depression/anxiety,
presenting with chest pain, most likely related to increased
tumor burden.
**ACUTE ISSUES**
# Chest Pain: Initial workup excluded ACS with negative
troponins x2 and no concerning EKG changes. CTA excluded both PE
and aortic dissection. CT revealed increased tumor burden with
increased left axillary mass as well as increases in multiple
pulmonary nodules. Pain resolved with toradol. Chest pain was
thought to be secondary to tumor burden. Palliative care was
consulted to aid in pain management. Patient was discharged on
lidocaine patch, MS contin 30mg BID, ___ morphine 15mg q6h
prn:pain, ibuprofen 600 mg TID prn:pain, and gabapenin 300mg
TID. She experienced good pain control during hospitalization.
**CHRONIC ISSUES**
# Recurrent breast cancer: Patient currently on palliative
chemotherapy with Eribulin. Dr. ___ was notified of admission
on day of presentation. Patient is to follow-up with palliative
care in clinic on ___.
# History of LUE DVT: CTA ruled out PE, home lovenox was
continued.
# Anemia: Patient's hb and hct remained at baseline during
hospitalization. She also remained asymptomatic without any
complaints of light-headedness or dizziness.
# TIDM: continued home insulin regimen.
# Depression: continued home Celexa.
# GERD: continued home omeprazole.
**TRANSITIONAL ISSUES**
- Patient expressed concern her son, her primary caregiver, did
not want her to take opioids for pain control out of concern for
their addictive potential. Further conversations with the son
about pain-control education would be warranted.
- Patient currently has no health care proxy but expressed
interest in having her son serve this role. She was provided
with HCP information and forms.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
5. Gabapentin 300 mg PO TID
6. Hydrocortisone Cream 2.5% 1 Appl TP BID
7. Ibuprofen 600 mg PO Q6H:PRN pain
8. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using Novolog Insulin
9. Morphine SR (MS ___ 15 mg PO Q12H
10. Omeprazole 20 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
12. Prochlorperazine 5 mg PO Q6H:PRN nausea
13. Senna 2 TAB PO BID
14. TraMADOL (Ultram) 50 mg PO HS:PRN pain
15. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis
16. Polyethylene Glycol 17 g PO Q12H
17. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 50 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
5. Gabapentin 300 mg PO TID
6. Hydrocortisone Cream 2.5% 1 Appl TP BID
7. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Polyethylene Glycol 17 g PO Q12H
11. Senna 2 TAB PO BID
12. TraMADOL (Ultram) 50 mg PO HS:PRN pain
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID pruritis
14. Ibuprofen 600 mg PO Q6H:PRN pain
15. Prochlorperazine 5 mg PO Q6H:PRN nausea
16. Morphine SR (MS ___ 30 mg PO Q12H
RX *morphine [MS ___ 30 mg 1 tablet extended release(s) by
mouth twice a day Disp #*30 Tablet Refills:*0
17. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
RX *morphine 15 mg ___ tablet(s) by mouth Q6:prn Disp #*30
Tablet Refills:*0
18. Lidocaine 5% Patch 1 PTCH TD DAILY
RX *lidocaine [Lidoderm] 5 % (700 mg/patch) One patch to left
chest Daily Disp #*30 Transdermal Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
metastatic Breast Cancer
Chest pain secondary to metastatic cancer
Secondary diagnosis:
Type 1 diabetes mellitus
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___
___. You were admitted for chest
pain. We believe this is due to your cancer. We consulted the
palliative care doctors to help with pain management.
Please use the following pain regimen at home:
- lidocaine patch: please use for 12 hours and then remove it
for 12 hours
- MS contin: 30mg every morning and evening
- IS morphine: take as needed every 6 hours
- Ibuprofen: 600mg take as needed up to 4 times a day
- gabapentin: take 3 times a day
We have helped make an appointment in the palliative care
clinic. Please follow-up with them next ___ at 9am as noted
below.
Thank you for allowing us to participate in your care.
Followup Instructions:
___
|
19930554-DS-31 | 19,930,554 | 22,024,416 | DS | 31 | 2198-03-27 00:00:00 | 2198-03-27 14:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lactose
Attending: ___.
Chief Complaint:
breast pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with metastatic breast cancer (see recent onc notes for past
events and current chemo regimen) who chronic but worsening L
breast, L shoulder and L arm pain. She was told to increase MS
contin to 45mg BID from 30mg but she did not receive new Rx for
higher dose and she ran out of narcotics at home 2d ago and her
pain was uncontrolled at home. She also noted increased pain in
this area despite higher dose of opiate. She lives with her
three children (age ___. A good day for her is when she can
cook and spend time with her kids and not be fully incapacitated
by her pain. She has approx 3 good days a week. Her son helps
take care of her and the house and drives her to appts.
No fevers, headache, diarrhea, vomitting, or bleeding.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-___: The patient palpated a painful left breast mass.
-___. Visited primary care provider, abnormal
clinical
breast exam with palpable mass.
-___: Diagnostic breast imaging was notable for 3.3
cm
mass in the left breast, also a 1.6 cm abnormal left axillary
lymph node.
-___: Left breast core biopsy revealed grade 3
invasive
ductal carcinoma, ER/PR/HER2 negative. FNA of lymph node was
positive for malignant cells.
-___. CT torso, bone scan and brain MRI were negative for
metastatic disease.
-___: Left partial mastectomy and axillary node
dissection. Pathology revealed a 1.7 cm grade 3 invasive ductal
carcinoma with DCIS, negative margins, ___ positive lymph
nodes.
-___: C1 D1 ddAC (Adriamycin reduced by 20%
given
emesis associated with gastroparesis).
-___: C2D1 ddAC (Adriamycin full dose)
-___: C3D1 ddAC (cycle 3 was postponed by one week
as
patient had been unable to receive her Neulasta shot).
-___: D4D1 ddAC
-___ to ___: ddT x3, C4 held due to
neuropathy.
-___ - ___: Radiation.
-___: Negative BRCA1 and 2 testing, negative ___
genetic testing results.
-___: Diagnostic mammography showed expected
posttreatment changes with no evidence of malignancy.
___ to ___: Admission for left
upper extremity DVT. She was discharged on subq Lovenox. Left
upper extremity ultrasound showed enlarged abnormal lymph nodes
in the left axilla for which followup was recommended.
-___: Hyperpigmentation of L breast noted on exam. Skin
biopsy performed by derm and showed invasive carcinoma
consistent
with metastatic breast carcinoma (ER/PR/HER2 negative)
-___: Bone scan was without evidence of bony metastatic
disease. CT showed interval development of 38 x 31 mm
rim-enhancing necrotic left axillary lymph node, as well as
numerous other enhancing foci in the left axilla and left
breast,
concerning for metastatic disease in this patient with history
of
left breast cancer. Mediastinal and bilateral hilar
lymphadenopathy as well as innumerable subscentimeter bilateral
pulmonary and subpleural metastases.
-___: Consented for ___ protocol ___, Eribulin
for HER2 Negative Metastatic Breast Cancer
-___: C1D1 eribulin
-___ start weekly cisplatin/irinotecan
PAST MEDICAL HISTORY:
- Type I DM (hemoglobin A1c ___ was 10.2%)
- Gastroparesis
- LUE DVT on enoxaparin
- Left upper extremity lymphedema
- Hypertension
- Asthma
- Anemia
- Depression and anxiety
- Insomnia
- Chlamydia
- Syphilis
Social History:
___
Family History:
(per OMR, confirmed with patient)
No history of breast cancer, but + history of DM.
Physical Exam:
99.2 88 160/90s
tired but pleasant, lying in bed
aox3, facial features symmetric
L breast with significant swelling, hyperpigmentation, firm,
nodular texture, distorted with some superficial nodules and
large, indurated/firm axilla. L arm is swollen but not pitting
clear breath sounds
soft abdomen
Pertinent Results:
___ 04:40AM BLOOD WBC-4.2 RBC-3.17* Hgb-9.7* Hct-30.2*
MCV-95 MCH-30.6 MCHC-32.2 RDW-17.0* Plt Ct-35*
___ 04:40AM BLOOD Glucose-568* UreaN-20 Creat-0.9 Na-135
K-5.1 Cl-101 HCO3-28 AnGap-11
L arm duplex venous ultrasound
Markedly diminutive color Doppler flow within the left
subclavian vein with
Preliminary Reportmultiple adjacent collateral veins suggestive
of chronic occlusive thrombosis.
Preliminary ReportConglomerate ill-defined nodal masses are
identified adjacent to the left
Preliminary Reportsubclavian vein, in keeping with breast
carcinoma nodal metastases.
Preliminary Report2. Patent left axillary vein.
Preliminary Report3. Chronic nonocclusive thrombosis of the left
brachial vein and basilic vein.
Preliminary Report4. Left cephalic vein demonstrates almost
complete compressibility, however
Preliminary Reportdoes not demonstrate wall to wall flow,
suggestive of chronic nonocclusive
Preliminary Reportthrombosis.
Brief Hospital Course:
___ with advanced metastatic breast cancer with L upper arm
chronic DVT on LMWH now with worsened cancer related pain in L
breast and thrombocytopenia (developed following
cisplatin/gemcitabine administered on ___
I spoke with her oncologist, Dr. ___ and the
Palliative care attending, Dr. ___.
CANCER PAIN:
She was able to have improved pain control after we used
escalating doses of IV morphine to rapidly determine an
effective dose of morphine. After approximaetly 160mg of PO
morphine equivalant given over 5hrs, we calculated that her
basal dose of morphine with MS contin should be 100mg BID.
Breakthrough dose of PO morphine ___ was calculated to be 45mg to
be used up to q1-3 hr as needed for pain. She received these
new doses and her pain was substantially improved before
discharge and she had better control of pain (rated as ___ and
tolerable.
She was given Rx for MS contin 100mg BID 30 tab no refills and
Morphine ___ 45mg (30mg tabs) with 40 tabs supplied 0 refills.
This should last at least until her appt with Dr. ___
___.
Metastatic Breast Cancer:
Increased soft tissue disease despite ongoing therapy. Last
week chemo was held for thrombocytopenia. Dr. ___ she
has poor prognostic features including advanced stage cancer
that seems refractory to chemotherapy and patient says that
quality of life is important to her including better symptom
management, thus Dr. ___ work with patient to involve
home hospice and have patient maintain closer ties to palliative
care
Chronic UE DVT: despite thrombocytopenia, Dr. ___ I
___ to continue LMWH since she was not having bleeding and
repeat duplex ultrasound of LUE showed significant chronic upper
extremity clot. Her plts are expected to recover.
FULL code during admission since Dr. ___ has not yet
discussed this with patient yet.
Patient's ___ year old daughter's birthday (with plans to see
___ on Ice) was on day of discharge and since patient's pain
was controlled she was discharged in the AM in order to attend
this event.
TRANSITIONAL ISSUES
[]OPTIMIZE PAIN CONTROL DOSING
[]TREND PLATELET COUNT
[]CHEMOTHERAPY PER ___. ___
[]SHE WOULD BENEFIT FROM HOME HOSPICE FOR SUPPORT TO MANAGE
SYMPTOMS AND AVOID UNCONTROLLED PAIN AND AVOID HOSPITALIATIONS
[]SHE SHOULD COMPLETE HER HEALTH CARE PROXY: SHE INDICATES THAT
SON WILL BE HCP
[]CODE STATUS ?
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 1000 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Enoxaparin Sodium 50 mg SC Q12H
4. Gabapentin 300 mg PO TID
5. Hydrocortisone Cream 2.5% 1 Appl TP BID
6. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. Lidocaine 5% Patch 2 PTCH TD DAILY
8. LOPERamide 2 mg PO QID:PRN diarrhea
9. Lorazepam 0.25-5 mg PO Q6H:PRN nausea
10. Morphine SR (MS ___ 45 mg PO Q12H
11. Morphine Sulfate ___ ___ mg PO Q6H:PRN pain
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. Senna 2 TAB PO BID
14. TraMADOL (Ultram) 50 mg PO HS:PRN pain
15. Docusate Sodium 100 mg PO BID
16. Ibuprofen 600 mg PO Q6H:PRN pain
17. Prochlorperazine 5 mg PO Q6H:PRN nausea
18. Polyethylene Glycol 17 g PO Q12H
19. Dronabinol 5 mg PO Q8H:PRN nausea
20. NexIUM (esomeprazole magnesium) 40 mg oral qd
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Dronabinol 5 mg PO Q8H:PRN nausea
5. Enoxaparin Sodium 50 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
6. Gabapentin 300 mg PO TID
7. Hydrocortisone Cream 2.5% 1 Appl TP BID
8. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
9. Lidocaine 5% Patch 2 PTCH TD DAILY
10. LOPERamide 2 mg PO QID:PRN diarrhea
11. Lorazepam 0.25-5 mg PO Q6H:PRN nausea
12. Morphine SR (MS ___ 100 mg PO Q12H
RX *morphine 100 mg 1 tablet extended release(s) by mouth twice
a day Disp #*30 Tablet Refills:*0
13. Morphine Sulfate ___ 45 mg PO Q1H:PRN pain
RX *morphine 30 mg 1 and a half tablet(s) by mouth q1-3h Disp
#*40 Tablet Refills:*0
14. Ondansetron 8 mg PO Q8H:PRN nausea
15. Polyethylene Glycol 17 g PO Q12H
16. Prochlorperazine 5 mg PO Q6H:PRN nausea
17. Senna 2 TAB PO BID
18. Ibuprofen 600 mg PO Q6H:PRN pain
19. NexIUM (esomeprazole magnesium) 40 mg ORAL QD
Discharge Disposition:
Home
Discharge Diagnosis:
metastatic breast cancer
cancer related pain
chronic LUE DVT
thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
you were admitted with pain in your left breast from your
cancer. we greatly increased your pain medications to reduce
the level of your pain. take the pain medications as instructed
but don't drink alcohol or take sleeping medications such as
ativan if they are not precibed to you. you can add tylenol and
ibuprofen to the morphine. you may be constipated on your
morphine so you can buy senna, colace or miralax from the
pharmacy over the counter.
please contact Dr. ___ (Palliative Care) via the
operator to have him paged if in any way your pain remains not
controlled
you have low platelet counts and are on blood thinners so report
any injuries to your doctors ___ immediate medical attention
if you have a serious fall or head injury.
Followup Instructions:
___
|
19930655-DS-5 | 19,930,655 | 21,445,420 | DS | 5 | 2160-06-06 00:00:00 | 2160-06-07 12:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
latex / bananas, apples, pears
Attending: ___.
Chief Complaint:
Nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx DM1 and seasonal allergies presenting with nausea
and vomiting x3 days. Vomiting started ___ evening.
Patient symptoms may have been due to eating ground ___ from
___. Denies sick contacts. He reports almost hourly
n/v since that time. He has had limited PO intake since then
due to the ongoing n/v. Did try to drink some ___. Denies
bloody emesis. Due to being unable to take POs, he self dc'd
his long-acting insulin. Patient reports taking 4U novolog
yesterday due to elevated FSBS and 6U when ambulance picked him
up today when FSBS was 336. Denies fevers, cough, shortness of
breath, URI symptoms, diarrhea, dysuria.
In the ED, initial vitals: T99.7 HR85 BP110/50 RR18 SaO2100%
RA
--initial labs: WBC 18.4, Hgb/Hct 14.7 / 44.3, Plt 276, Na/K
131/4.9, BUN/Cr 34/1.2, VBG: 7.24 | 31 | 43, lactate 3.2, u/a
with ketones.
--CXR without acute cardiopulmonary process
--ECG NSR, early repolarization
--patient was given: 4L NS, 4 mg Zofran, and started on insulin
gtt @ 4U per hour
On arrival to the MICU, T98.8, HR 94, BP 112/45, RR 22, SaO2
100% RA. Patient reported feeling thirsty and hungry, but
otherwise was without complaints.
Past Medical History:
-DM1
-seasonal allergies
-h/o eosinophilic esophagitis
Social History:
___
Family History:
-Mother with DMI, MGM Type 2; "stomach issues" on father's side
of family, MGF with CAD
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
Vitals: T98.8, HR 94, BP 112/45, RR 22, SaO2 100% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, dry MM, 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, no clubbing, cyanosis or
edema
SKIN: No rashes or excoriations
NEURO: Moving all extremities, speech fluent
DISCHARGE PHYSICAL EXAM:
===============================
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
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 rashes or excoriations
NEURO: Moving all extremities, speech fluent
Pertinent Results:
LABS:
=======================
___ 09:00PM BLOOD WBC-18.4* RBC-4.93 Hgb-14.7 Hct-44.3
MCV-90 MCH-29.8 MCHC-33.2 RDW-12.0 RDWSD-39.5 Plt ___
___ 12:05AM BLOOD WBC-15.0* RBC-4.19* Hgb-12.5* Hct-37.5*
MCV-90 MCH-29.8 MCHC-33.3 RDW-12.1 RDWSD-39.5 Plt ___
___ 05:15AM BLOOD WBC-12.7* RBC-3.85* Hgb-11.5* Hct-34.0*
MCV-88 MCH-29.9 MCHC-33.8 RDW-12.2 RDWSD-39.3 Plt ___
___ 09:00PM BLOOD Glucose-425* UreaN-34* Creat-1.2 Na-131*
K-4.9 Cl-95* HCO3-12* AnGap-29*
___ 12:05AM BLOOD Glucose-234* UreaN-29* Creat-1.0 Na-133
K-6.8* Cl-104 HCO3-15* AnGap-21*
___ 02:10AM BLOOD Glucose-168* UreaN-25* Creat-0.9 Na-136
K-4.2 Cl-108 HCO3-18* AnGap-14
___ 05:15AM BLOOD Glucose-190* UreaN-22* Creat-0.9 Na-136
K-3.8 Cl-107 HCO3-21* AnGap-12
___ 12:54PM BLOOD Glucose-278* UreaN-17 Creat-0.9 Na-133
K-3.8 Cl-104 HCO3-21* AnGap-12
___ 05:56PM BLOOD Glucose-234* UreaN-16 Creat-0.8 Na-136
K-3.1* Cl-103 HCO3-23 AnGap-13
___ 12:05AM BLOOD Calcium-8.5 Phos-3.4 Mg-2.2
___ 05:56PM BLOOD Calcium-8.8 Phos-1.8* Mg-1.8
___ 02:55AM BLOOD %HbA1c-6.6* eAG-143*
___ 09:10PM BLOOD ___ pO2-43* pCO2-31* pH-7.24*
calTCO2-14* Base XS--12
___ 12:22AM BLOOD ___ pO2-30* pCO2-32* pH-7.28*
calTCO2-16* Base XS--11
___ 02:19AM BLOOD ___ pO2-72* pCO2-33* pH-7.37
calTCO2-20* Base XS--4
___ 05:34AM BLOOD ___ pO2-69* pCO2-37 pH-7.36
calTCO2-22 Base XS--3
___ 09:10PM BLOOD Lactate-3.2* K-4.8
___ 12:22AM BLOOD Lactate-2.4* K-4.5
___ 02:19AM BLOOD Lactate-1.2 K-4.1
___ 05:34AM BLOOD Lactate-1.1 K-3.6
___ 10:30PM URINE Color-Straw Appear-Clear Sp ___
___ 10:30PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-1000 Ketone-150 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:30PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
MICRO:
==============
BLOOD CULTURES FROM ___ NEGATIVE AS OF DISCHARGE DATE
IMAGING:
================
CXR ___:
FINDINGS:
PA and lateral views the chest provided demonstrate no focal
consolidation, large effusion or pneumothorax.
Cardiomediastinal silhouette is normal. Bony structures are
intact. No free air below the right hemidiaphragm.
IMPRESSION:
No acute intrathoracic process.
Brief Hospital Course:
___ with h/o Type 1 Diabetes admitted with nausea/vomiting x3
days found to have DKA.
# DKA: likely secondary to stopping long-acting insulin after
developing gastroenteritis. Patient reported limited PO intake
x3 days and was severely dehydrated on exam. Initial labs showed
anion-gap metabolic acidosis, hyperglycemia, and ketones in
urine. Patient was given IV fluids and started on insulin drip
and his electrolytes were closely monitored. Anion gap closed
and patient's nausea/vomiting resolved. Patient was
subsequently started on his home lantus and was tolerating meals
on day of discharge. Patient's A1c was 6.6%. He was seen by
___ team who felt patient was safe to be discharged
on home regimen of lantus/novolog and was given information and
encouraged to follow up with ___ for continued management of
his diabetes while he lives in ___ (from ___, living in
___ as student).
# Gastritis: likely viral gastritis after eating out on
___. No diarrhea, and lack of sick contacts, thus
norovirus is less likely. N/v resolved with treatment of his
DKA as above (IVF + insulin gtt).
# Leukocytosis: likely stress response in setting of DKA. CXR
and U/A negative. Improved with treatment of his DKA as noted
above.
TRANSITIONAL ISSUES
=================================
[] blood cultures pending at the time of discharge
[] patient does not have a primary care doctor in the ___
area.
[] patient given contact info to establish care at ___ for
continued management of his Type 1 Diabetes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lantus (insulin glargine) 32 units subcutaneous DAILY
2. Novolog 6 Units Breakfast
Novolog 8 Units Lunch
Novolog 8 Units Dinner
Novolog 4 Units Bedtime
3. Glucagon 1 mg SUBCUT ONCE hypoglycemia
Discharge Medications:
1. Glucagon 1 mg SUBCUT ONCE hypoglycemia Duration: 1 Dose
RX *glucagon (human recombinant) [Glucagon Emergency Kit
(human)] 1 mg 1 mg IM once Disp #*1 Kit Refills:*1
2. Novolog 6 Units Breakfast
Novolog 8 Units Lunch
Novolog 8 Units Dinner
Novolog 4 Units Bedtime
3. Lantus (insulin glargine) 32 units subcutaneous DAILY
4. Ketone Urine Test (acetone (urine) test) 1 strip
miscellaneous ONCE:PRN hyperglycemia
RX *acetone (urine) test as needed for hyperglycemia Disp #*30
Strip Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: diabetic ketoacidosis
Secondary diagnosis: gastroenteritis
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. You were admitted with
diabetic ketoacidosis (DKA) which means that your blood sugar
was elevated and you had ketones in your body. You were
monitored in the intensive care unit and you received insulin
and fluids. Your labs improved and you were started on novolog.
You were seen by the diabetes doctors and ___. It is
very important that you continue to monitor your blood sugars
and drink plenty of fluids. Please return to the hospital if
your blood sugars remain elevated or if you are unable to eat or
drink anything.
Please continue taking lantus 32 units every morning and novolog
6 u with breakfast; 8 u with lunch; 8u with dinner; ___ with
supper (28u
total scheduled).
Your ___ Team
Followup Instructions:
___
|
19930660-DS-14 | 19,930,660 | 26,058,756 | DS | 14 | 2141-09-06 00:00:00 | 2141-09-11 18:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, lysis of adhesions, small
bowel resection.
History of Present Illness:
___ w HBV, hx GSW to abdomen s/p ex lap, SB ___, SBO
managed non-operatively (___) p/w nausea, vomiting, abdominal
pain x 3 days. Patient in usual state of health until three days
prior to presentation when she noted onset of nausea and
recurrent bilious, non-bloody emesis. This was accompanied by
severe abdominal pain described as diffuse, constant and located
primarily in lower abdomen. Describes pain as similar to prior
SBO but more severe. Minimal po intake over this time. No flatus
or BM for 3 days. +Chills. Presented to ED for evaluation given
severity and persistent symptoms.
On surgery eval patient relays hx as above. Denies fever, chest
pain, shortness of breath, blood per rectum,
dysurea,bruising/bleeding.
Past Medical History:
PMH: HBV, Hx GSW (accidentally shot by family member) to abdomen
s/p trauma laparotomy (___), non-operative SBO (___)
PSH: Trauma ex lap, small bowel resection (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
VS: 98.7 77 123/83 16 100% RA
GEN: WD, WN in NAD
HEENT: NCAT, anicteric
CV: RRR
PULM: non-labored, no respiratory distress
ABD: soft, +tender lower abdomen, +rebound/guarding, +distended,
well healed midline laparotomy w no evidence hernia
PELVIS: deferred
EXT: WWP, no CCE
NEURO: A&Ox3, no focal neurologic deficits
Discharge Physical Exam:
VS: Temp: 97.9, BP: 107/65, HR: 85, RR: 18, O2: 100% RA
General: A+Ox3, NAD
CV: RRR
Pulm: CTA b/l
ABD: soft, non-distended, non-tender. Erythema around surgical
site within marked borders, mild induration around upper aspect
of surgical incision site without drainage. Staples along
midline incision intact.
EXT: no edema
Pertinent Results:
___ 06:39AM GLUCOSE-112* UREA N-15 CREAT-0.6 SODIUM-137
POTASSIUM-3.4 CHLORIDE-104 TOTAL CO2-25 ANION GAP-11
___ 06:39AM CALCIUM-7.8* PHOSPHATE-2.4* MAGNESIUM-1.5*
___ 06:39AM WBC-4.6# RBC-4.06 HGB-12.6 HCT-37.9 MCV-93
MCH-31.0 MCHC-33.2 RDW-11.8 RDWSD-40.6
___ 06:39AM PLT COUNT-178
___ 07:20PM URINE UCG-NEGATIVE
___ 07:20PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 07:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-40 BILIRUBIN-SM UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:20PM URINE RBC-0 WBC-5 BACTERIA-NONE YEAST-NONE
EPI-18
___ 07:20PM URINE AMORPH-RARE
___ 06:36PM ___
___ 06:32PM GLUCOSE-121* UREA N-21* CREAT-0.8 SODIUM-138
POTASSIUM-3.5 CHLORIDE-96 TOTAL CO2-29 ANION GAP-17
___ 06:32PM WBC-11.7*# RBC-4.91 HGB-15.3 HCT-45.6* MCV-93
MCH-31.2 MCHC-33.6 RDW-11.7 RDWSD-39.8
___ 06:32PM NEUTS-79.6* LYMPHS-11.1* MONOS-8.7 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-9.30* AbsLymp-1.30 AbsMono-1.01*
AbsEos-0.02* AbsBaso-0.02
___ 06:32PM PLT COUNT-253
Imaging:
___: CT ABD/PEL:
Dilated small bowel loops are consistent with small bowel
obstruction, as seen on prior CT.
Brief Hospital Course:
___ year-old female with a history of GSW to abdomen s/p ex lap,
SB resection
(___), SBO managed non-operatively (___) who presented to
___ on ___ with nausea, vomiting and abdominal pain x 3
days. On HD1, she had a CT abd/pelvis which revealed a
high-grade small bowel obstruction with a moderate amount of
free fluid within the pelvis. She was admitted to the Acute
Care Surgery/Trauma service for further medical management.
On HD1, she was made NPO, was started on IV fluids and taken to
the Operating Room on ___ where she underwent an
exploratory laparotomy, lysis of adhesions and small bowel
resection. There were no adverse events in the operating room;
please see the operative note for details. Pt was extubated,
taken to the PACU until stable, then transferred to the ward for
observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medicine and she was then transitioned to oral Dilaudid once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. The NGT was d/c
once the patient started to have bowel sounds and pass flatus.
Therefore, the diet was advanced sequentially to a Regular diet,
which was well tolerated. Patient's intake and output were
closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection. The patient was noted to have erythema and
induration around her surgical incision and she was started on
IV cefazolin. The area of erythema was marked with a surgical
pen and this erythema continued to improve with cefazolin. The
patient was transitioned to 5 day course of PO keflex which she
was discharged with.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged with her abdominal
staples in place which were to be removed at her ___ follow-up
appointment. 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. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
do NOT exceed 3gm in 24 hours
3. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN Sore throat
4. Docusate Sodium 100 mg PO BID
please hold for loose stool
5. Senna 8.6 mg PO BID:PRN constipation
6. Ibuprofen 400 mg PO Q6H:PRN pain
please take with food, alternate q3hr with acetaminophen
7. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain
do NOT drive while taking this medication
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
High Grade Small Bowel Obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented to ___ on ___
with complaints of abdominal pain. You were found to have a
small bowel obstruction and were admitted to the Acute Care
Surgery team.
On ___, you were taken to the Operating Room and underwent
surgery to treat your bowel obstruction. You were started on an
IV antibiotic to treat a post-surgical skin infection and it is
recommended that you continue to take an oral antibiotic for 5
more days for treatment.
You are now tolerating a regular diet and your pain is
controlled on oral pain medicine. You are now medically cleared
to be discharged to home.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Followup Instructions:
___
|
19930769-DS-12 | 19,930,769 | 29,077,714 | DS | 12 | 2164-10-07 00:00:00 | 2164-11-03 09:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
N/V, abdominal pain
Major Surgical or Invasive Procedure:
EUS
ERCP
EGD
History of Present Illness:
This is a ___ woman with history of duodenal ulcer, hiatal
hernia, and retinal vasculitis leading to legal blindness, who
presents with three days of abdominal pain and bilious vomiting.
She reports that she has been suffering from abdominal pain for
months now, however that pain is mild to moderate and usually
improved with PPI. She has been evaluated in the outpatient
setting and found to have gastric ulcerations and a hiatal
hernia, she is being evaluated for surgical correction of the
hernia to treat her symptoms. More recently, on ___ she
started having severe pain which is worse in intensity and more
persistent than her subacute-chronic abdominal pain. The pain
started ___ and is described as severe, very intense and
crampy in nature. The pain has been associated with severe
nausea
and vomiting and the pain is worse with food intake, in fact she
hasn't eaten in several days as a result. She has not had a BM
for ___ days. Due to her vision loss, she is not able to say
whether there was any blood in emesis or stools or melena. She
has not have any fevers or chills.
In the ED, initial vitals were: ___ pain 97.4 77 152/112 18
96%
RA. Exam was notable for active vomiting, with bilious emesis in
bag, significant abdominal tenderness across upper quadrants, no
lower quandrant tenderness, rectal- Guaiac negative, formed
stool
in the rectal vault, no frank blood. Labs revealed leukocytosis
but otherwise were unremarkable. CT A/P was performed which
revealed dilatated biliary ducts and possible impacted stone.
She
reeived IV Morphine, Zofran, 1L IVFs, NGT was placed for
decompression and 400cc of dark bilious fluid however patient
indicates to this provider that decompression did not improve
her
symptoms. She was then admitted to medicine.
On the floor, she reports her pain and nausea are in good
control. When asked what helped the most she responds "morphine"
and denies that NGT with decompression alleviated her symptoms.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. No dysuria. Denies arthralgias or
myalgias. Otherwise ROS is negative.
Past Medical History:
- HTN
- Hiatal Hernia
- Duodenal Ulcer
- Retinal Vasculitis leading to blindness
- Depression
Social History:
___
Family History:
Multiple family members with gallstones, both parents recently
had CCY
Parents in assisted living with Alzheimers/dementia
Father with MI age ___, CAD
Family history of DM, stomach cancer
Physical Exam:
Admission PHYSICAL EXAM:
Vitals: 97.4 82 145/92 18 96% RA
Pain Scale: ___
General: Patient appears uncomfortable, she moves little in bed
careful to not move her abdomen specifically. Otherwise,
however,
she is alert, oriented and not in extremis. She is legally blind
and does not make eye contact
HEENT: Legally blind, dry mucous membranes, pink nasal mucosa
Neck: supple, JVP low, no LAD appreciated
Lungs: Clear to auscultation bilaterally, moving air well and
symmetrically, no wheezes, rales or rhonchi appreciated
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality,
no murmurs, rubs or gallops appreciated
Abdomen: Tender to palpation over epigastrium but otherwise
soft,
non-distended, no rebound or guarding, normoactive bowel sounds
throughout, no peritoneal signs
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: CN2-12 grossly in tact, motor and sensory function
grossly
intact in bilateral UE and ___, symmetric
Discharge physical exam:
Pertinent Results:
Admission Labs:
___ 04:45PM BLOOD WBC-11.7* RBC-5.02 Hgb-16.5* Hct-47.9*
MCV-95 MCH-32.9* MCHC-34.4 RDW-13.8 RDWSD-48.1* Plt ___
___ 04:45PM BLOOD Neuts-66.0 ___ Monos-6.7 Eos-1.9
Baso-0.5 Im ___ AbsNeut-7.70* AbsLymp-2.85 AbsMono-0.78
AbsEos-0.22 AbsBaso-0.06
___ 04:45PM BLOOD Plt ___
___ 04:45PM BLOOD Glucose-112* UreaN-15 Creat-0.9 Na-143
K-4.1 Cl-97 HCO3-24 AnGap-22*
___ 04:45PM BLOOD ALT-26 AST-19 AlkPhos-100 TotBili-0.9
___ 04:45PM BLOOD Lipase-31
___ 04:45PM BLOOD Albumin-4.4
___ 04:56PM BLOOD Lactate-2.5*
___ 08:57PM BLOOD Lactate-1.6
Discharge Labs:
Imaging:
KUB ___- Large hiatal hernia, with tip of NG tube likely
terminating within the stomach. No definite signs of bowel
obstruction, paucity of bowel gas limits evaluation however.
CT abd/pelvis ___. Increased intrahepatic and extrahepatic
biliary ductal dilation extending to the distal most portion of
the common bile duct with a possible obstructing stone or
lesion. Recommend further evaluation with ERCP.
2. Probably subacute or chronic L1 burst fracture with 5 mm
osseous
retropulsion into the spinal canal.
MRCP:
IMPRESSION:
1. Mild central intrahepatic and extrahepatic biliary ductal
dilatation, with the common bile duct measuring up to 11 mm in
diameter. Transient opening of the common bile duct into the
ampulla is demonstrated. Findings are most compatible with
sphincter of Oddi dysfunction.
EUS:
large hiatal hernia, question of subacute volvulus, not able to
do EUS; recommend surgical consultation and then reconsult for
EUS +/- ERCP after surgical completion
KUB:
Nonspecific nonobstructive bowel gas pattern.
Brief Hospital Course:
___ woman with history of duodenal ulcer, hiatal hernia, and
retinal vasculitis leading to legal blindness, who presents with
three days of abdominal pain and bilious vomiting.
# Nausea with vomiting
# r/o choledocholithiasis
# sphincter of oddi dysfunction
# hiatal hernia
Patient has abdominal pain worse with PO intake, colicky in
nature located over epigastrium and RUQ, with associated nausea
and vomiting as well as CT findings demonstrating dilated
intrahepatic and extrahepatic bile ducts and possible impacted
bile stone in the proximal common bile duct all consistent with
choledocholithiasis and obstruction as etiology to symptoms.
However LFTs did not support this, MRCP without obstruction
(just sphincter of oddi dysfunction). EUS non-diagnostic as
unable to bypass hiatal hernia; EUS was also concerning for
subacute volvulus. Failed NGT removal and PO challenge. Was
evaluated by surgery and GI. She was gradually able to
introduce PO intake, without any vomiting or abdominal pain.
The bulk of her symptoms thought related to her hiatal hernia.
She is safe for discharge today, now that she has tolerated PO
intake, and has not vomited. To complete workup before surgery,
she will need esophageal manometry, to conclusively rule in/or
out, any dysmotility issues.
# Duodenal Ulcer: had some red emesis at times, but this has
fully resolved., continued PPI. Hgb stable.
# Retinal Vasculitis: held MTX/pred while NPO and gave IV
steroids in the interim. Transitioned back to PO once able to
take.
# Depression: held lexapro/trazodone/buprion while NPO
Patient seen and discharged on ___. This note was entered
late on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Escitalopram Oxalate 40 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. PredniSONE 4 mg PO DAILY
4. BuPROPion XL (Once Daily) 450 mg PO DAILY
5. Methotrexate 15 mg PO 1X/WEEK (TH)
6. TraZODone ___ mg PO QHS:PRN insomnia
7. Omeprazole 20 mg PO DAILY
8. InFLIXimab x mg IV Q6WEEKS
9. Alendronate Sodium 70 mg PO QMON
10. Metoprolol Tartrate 25 mg PO DAILY
Discharge Medications:
1. InFLIXimab determined by physician ___ -- IV Q6WEEKS
2. Alendronate Sodium 70 mg PO QMON
3. BuPROPion XL (Once Daily) 450 mg PO DAILY
4. Escitalopram Oxalate 40 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Methotrexate 15 mg PO 1X/WEEK (TH)
7. Metoprolol Tartrate 25 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 4 mg PO DAILY
10. TraZODone ___ mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
symptomatic hiatal hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Dear ___ were admitted with nausea and worsening abdominal pain. ___
were found to have a large hiatal hernia. The surgical team
evaluated ___ and felt that your symptoms were related to this
hernia. No operations done during this hospitalization. ___
have outpatient follow up scheduled.
Best of luck in your recovery.
Your ___ care team
Followup Instructions:
___
|
19930769-DS-13 | 19,930,769 | 29,856,553 | DS | 13 | 2164-10-17 00:00:00 | 2164-10-17 18:51:00 |
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, N/V
Major Surgical or Invasive Procedure:
Esophageal Manometry ___
Laparoscopic paraesophageal hernia repair with Nissen
Fundoplication ___ ___
___ of Present Illness:
Patient is a ___ with history of duodenal ulcer, hiatal
hernia, depression, and retinal vasculitis leading to legal
blindness (on prednisone, MTX, infliximab) who presents with
acute on chronic abdominal pain and nausea/vomiting.
Of note, patient was admitted to ___ ___ after
presenting
with abdominal pain and bilious vomiting. Her abdominal pain
had
been ongoing for months, responsive to PPI, though acutely
became
severe and crampy. It was associated with severe nausea and
vomiting, worse with food intake. CT A/P showed dilated
intrahepatic and extrahepatic bile ducts and possible impacted
bile stone in the proximal common bile duct, concern for
choledocholithiasis (though LFTs were wnl). ERCP team was
consulted, abx were deferred as patient did not appear
systemically sick. ERCP was non-diagnostic ___, MRCP showed
likely sphincter of Oddi dysfunction with mild central
intrahepatic and extrahepatic biliary ductal dilatation. EGD
performed ___ had shown hiatal hernia and esophagitis. Her
symptoms were ultimately thought to be related to her hiatal
hernia, surgery was consulted (large paraesophageal hernia type
3), no acute surgical intervention. Once patient's were under
better control with supportive measures, decision was made to
discharge her home with outpatient surgical follow-up.
After discharge, patient states that she has been unable to
tolerate POs consistently. Multiple episodes of recurrent
bilious emesis starting ___ evening with severe nausea.
Unclear if there is any blood given patient's legal blindness.
No fevers/chills. She also continues to have crampy abdominal
pain ___ in severity, waxing and waning, worse with food
intake. Her last BM earlier this AM was quite loose, again
unsure if bloody. Given her worsening symptoms, patient decided
to represent to the ___ ED.
In the ED, initial VS were: 97 80 133/98 20 99% RA
Exam notable for: TTP in epigastric region. No guarding or
rebound.
ECG: NSR (87bpm), normal intervals, normal intervals, difficult
to interpret baseline, no ischemic changes.
Labs showed:
CBC 12.9>15.3/44.2<376
BMP ___ (AG 27)
ALT 62
AST 25
ALP 95
Tbili 1.0
Albumin 4.4
Lipase 22
Lactate 2.0
Consults: NONE
Patient received:
___ 20:15 IVF NS
___ 20:39 IV Morphine Sulfate 2 mg
___ 21:04 IV Potassium Chloride (40 mEq ordered)
___ 21:04 IV LORazepam 1 mg
___ 22:31 IV Morphine Sulfate 2 mg
___ 22:31 IV LORazepam .5 mg
Transfer VS were:
99.0 96 162/103 18 99% RA
On arrival to the floor, patient recounts the history as above.
She is visibly uncomfortable, intermittently having small
volumes
of bilious emesis. Abdominal pain is intermittently severe,
paroxysms ___ and crampy, predominantly epigastric. One
episode of loose stools AM ___. No palpitations. No
lightheadedness/dizziness. No fevers/chills.
Past Medical History:
Retinal vasculitis
Hypertension
Depression
Diverticulitis
Social History:
___
Family History:
Parents in assisted living with Alzheimers/dementia
Father with MI age ___, CAD
Family history of DM, stomach cancer
Physical Exam:
ADMISSION EXAM
==========================
VS: 98.3 ___ 95
GENERAL: Uncomfortable appearing.
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, dry MMM.
NECK: No appreciable JVP.
HEART: RRR, S1/S2, no murmurs, gallops, or rubs.
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles.
ABDOMEN: +BS, nondistended, mild diffuse tenderness, guarding
with palpation over epigastrum, no rebounding, no
hepatosplenomegaly.
EXTREMITIES: No cyanosis, clubbing, or edema.
PULSES: 2+ radial pulses bilaterally.
NEURO: A&Ox3, moving all 4 extremities with purpose.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
DISCHARGE EXAM
==========================
Pertinent Results:
___ 05:40AM BLOOD WBC-11.3* RBC-3.23* Hgb-10.4* Hct-32.3*
MCV-100* MCH-32.2* MCHC-32.2 RDW-14.6 RDWSD-53.4* Plt ___
___ 05:20AM BLOOD WBC-12.6* RBC-3.72* Hgb-12.1 Hct-36.6
MCV-98 MCH-32.5* MCHC-33.1 RDW-14.5 RDWSD-52.2* Plt ___
___ 05:40AM BLOOD Glucose-135* UreaN-10 Creat-0.6 Na-140
K-4.3 Cl-104 HCO3-25 AnGap-11
Brief Hospital Course:
Ms. ___ is a ___ female with history of
large hiatal hernia, paraesophageal hernia, recently healed
duodenal ulcer, gastritis, esophagitis, and biliary dilation who
presented with abdominal pain, nausea, and vomiting.
ACUTE ISSUES:
=================================
# Nausea/vomiting
# Epigastric pain
# Hiatal hernia:
Patient had been recently hospitalized with similar symptoms
likely due to hiatal hernia. She was discharged on liquid diet
and outpatient surgical follow-up but did not tolerate liquids
at home. She was readmitted with abdominal pain, nausea, and
vomiting. She was made NPO and NGT was placed for decompression
given concern for obstruction. KUB did not show obstruction and
CMV was negative. Patient had ketonuria on admission suggesting
malnutrition. GI and General Surgery were consulted. She had
manometry which showed mild esophageal dysmotility.
The patient was then transferred to the ___ Surgical
Service for further management of her hiatal hernia. Ms. ___
received a laparoscopic repair of hiatal hernia with Nissen
fundoplication and ___ gastroplasty on ___ and
therefore transferred to the surgical service. Please see the
operative report for further details. The patient did experience
slight aspiration of gastric contents intra-operatively.
Post-operatively the patient was taken to the PACU until stable
and then transferred to the wards until stable to go home.
___ Course (___)
#NEURO: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA and was
then transitioned to PO pain meds. Pain was very well
controlled.
#CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
#PULMONARY: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
#GI/GU/FEN: The patient had a foley placed intra-operatively,
which was removed post-surgery on POD1 with autonomous return of
voiding. The patient's diet was then advanced slowly while she
was concurrently on TPN for nutritional support. The patient was
discharged without TPN. The patient was tolerating a regular
diet prior to discharge.
#ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
#HEME: Patient received BID SQH for DVT prophylaxis, in addition
to encouraging early ambulation and Venodyne compression
devices.
--------------------
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating diet as
above per oral, 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.
# Malnutrition: Patient had ketonuria on admission suggesting
malnutrition due to poor PO intake from hiatal hernia, nausea,
vomiting, chronic abdominal pain. Patient was NPO in
anticipation for surgery and nutrition was consulted for TPN
initiation. She was started on TPN which was continued until
___ and was discontinued on discharge.
# Anemia
Likely dilutional iso of IVF, but possible that pt is bleeding,
given hx of duodenal ulcer and GI irritation.
-Monitored throughout the patient's hospitalization.
# Transaminitis
Patient was just recently worked up for choledocholithiasis
during recent admission, MRCP showed Sphincter of Oddi
dysfunction and biliary duct dilation. ALT elevated only mildly
without any signs of obstruction.
- Continue to trend LFTs
CHRONIC ISSUES:
===============================
# Retinal vasculitis:
Patient is legally blind at baseline and takes prednisone, MTX
once weekly, and infliximab. Her outpatient Rheumatologist was
contacted and she had recently received Infliximab and did not
need dosing while inpatient. Per her Rheumatologist, she did not
need to receive PO MTX while remaining NPO for surgery. If she
were NPO for a prolonged period of time, he recommended
equivalent IM dosing of MTX. Her home prednisone was replaced
with IV methylprednisolone 4 mg daily.
# Depression
Held home wellbutrin, escitalopram iso NPO.
These medications were resumed on discharge.
# HTN
Held home metoprolol iso NPO.
These medications were resumed on discharge.
# L1 burst fracture
Noted on CT A/P during previous admission. Vitamin D level was
low this admission and during previous admission.
- Noted on CT A/P during her last admission.
Hypovitaminosis D on recent labs. Patient is at increased risk
of osteoporosis iso chronic steroids.
- Continue Vitamin D supplementation
TRANSITIONAL ISSUES
==============================
- Transitional issue: bisphosphonate (though patient has
esophagitis), DEXA scan
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. BuPROPion XL (Once Daily) 450 mg PO DAILY
2. Escitalopram Oxalate 40 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Methotrexate 15 mg PO 1X/WEEK (TH)
5. Metoprolol Tartrate 25 mg PO DAILY
6. PredniSONE 4 mg PO DAILY
7. TraZODone ___ mg PO QHS:PRN insomnia
8. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Metoprolol Tartrate 25 mg PO/NG DAILY
Start: Upon Arrival
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: dcing
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
PRN Disp #*20 Tablet Refills:*0
4. TraZODone 25 mg PO QHS:PRN insomnia
5. BuPROPion XL (Once Daily) 450 mg PO DAILY
6. Escitalopram Oxalate 40 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Methotrexate 15 mg PO 1X/WEEK (TH)
9. Omeprazole 20 mg PO DAILY
10. PredniSONE 4 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Paraesophageal hernia
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 here at ___
___. You were admitted to our hospital for
hiatal hernia. You had a hiatal hernia repair and Nissen
fundopliation on ___ ___. You tolerated the
procedure well and are ambulating, stooling, tolerating a
regular diet, and your pain is controlled by pain medications by
mouth. You are now ready to be discharged to home. Please follow
the recommendations below to ensure a speedy and uneventful
recovery.
ACTIVITY:
- Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
- You may climb stairs. You should continue to walk several
times a day.
- You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- You may start some light exercise when you feel comfortable.
Slowly increase your activity back to your baseline as
tolerated.
- Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
- No heavy lifting (10 pounds or more) until cleared by your
surgeon, usually about 6 weeks.
- You may resume sexual activity unless your doctor has told you
otherwise.
HOW YOU MAY FEEL:
- You may feel weak or "washed out" for 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You may have a sore throat because of a tube that was in your
throat during the surgery.
YOUR BOWELS:
- Constipation is a common side effect of narcotic pain medicine
such as oxycodone. If needed, you may take a stool softener
(such as Colace, one capsule) or gentle laxative (such as milk
of magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
- If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
- After some operations, diarrhea can occur. If you get
diarrhea, don't take anti-diarrhea medicines. Drink plenty of
fluids and see if it goes away. If it does not go away, or is
severe and you feel ill, please call your surgeon.
PAIN MANAGEMENT:
- You are being discharged with a prescription for oxycodone for
pain control. You may take Tylenol as directed, not to exceed
3500mg in 24 hours. Take regularly for a few days after surgery
but you may skip a dose or increase time between doses if you
are not having pain until you no longer need it. You may take
the oxycodone for moderate and severe pain not controlled by the
Tylenol. You may take a stool softener while on narcotics to
help prevent the constipation that they may cause. Slowly wean
off these medications as tolerated.
- Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- chest pain, pressure, squeezing, or tightness
- cough, shortness of breath, wheezing
- pain that is getting worse over time or pain with fever
- shaking chills, fever of more than 101
- a drastic change in nature or quality of your pain
- nausea and vomiting, inability to tolerate fluids, food, or
your medications
- if you are getting dehydrated (dry mouth, rapid heart beat,
feeling dizzy or faint especially while standing)
-any change in your symptoms or any symptoms that concern you
Additional:
- pain that is getting worse over time, or going to your chest
or back
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.
WOUND CARE:
-You may shower with any bandage strips that may be covering
your wound. Do not scrub and do not soak or swim, and pat the
incision dry. If you have steri strips, they will fall off by
themselves in ___ weeks. If any are still on in two weeks and
the edges are curling up, you may carefully peel them off. ***
Your staples will be removed by your surgeon at your follow up
appointment.
Do not take baths, soak, or swim for 6 weeks after surgery
unless told otherwise by your surgical team.
-Notify your surgeon is you notice abnormal (foul smelling,
bloody, pus, etc) or increased drainage from your incision site,
opening of your incision, or increased pain or bruising. Watch
for signs of infection such as redness, streaking of your skin,
swelling, increased pain, or increased drainage.
Please call with any questions or concerns. Thank you for
allowing us to participate in your care. We hope you have a
quick return to your usual life and activities.
-- Your ___ Care Team
Followup Instructions:
___
|
19930769-DS-14 | 19,930,769 | 29,566,994 | DS | 14 | 2165-10-23 00:00:00 | 2165-10-23 19:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
pain in her left thigh and left lateral chest wall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with a past medical history significant
for blindness who presents to the hospital with a chief
complaint
of pain in her left thigh and left lateral chest wall. She
reports that yesterday at 630pmm she experienced a mechanical
fall. She says that she fell down some stairs (she believes it
was four steps) because they were slippery. She denies any head
strike and remembers everything in detail. She reports that she
landed on her left side after the fall and then she subsequently
got up and went home. However, she started experiencing pain in
her left thigh and left lateral chest wall and for this reason
she presented to the hospital (Via ambulance) for further
management.
ROS:
(+) per HPI
(-) Denies fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
Retinal vasculitis
Hypertension
Depression
Diverticulitis
Social History:
___
Family History:
Parents in assisted living with Alzheimers/dementia
Father with MI age ___, CAD
Family history of DM, stomach cancer
Physical Exam:
Admission physical exam
===================
Vitals:
___, BP 125/77, HR 89, RR 15, 98% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l, mild tenderness to palpation on
left lateral chest wall
ABD: Soft, nondistended, nontender, no rebound or guarding,no
palpable masses
Ext: No ___ edema, ___ warm and well perfused. Pulse exam: ___
bilaterally palpable.
Scratches present throughout her entire extremities
Left posterior thigh with ecchymosis and a palpable hematoma
Neuro: Cranial nerves ___ intact (patient has blindness at
baseline)
Strength: ___ throughout upper and lower extremities
Sensation: Intact throughout upper and lower extremities
Pelvis: Stable
Spine: No tenderness to palpation
Discharge physical exam
==================
Gen: [x] NAD, [x] AAOx3
CV: [x] RRR, [] murmur
Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales
Abdomen: [x] soft, [] distended, [] tender, [] rebound/guarding
Ext: [x] warm, [x] tender L thigh, [] edema, L posterior thigh
with ecchymosis and a palpable hematoma now covered by dressing.
Tenderness on palpation on left chest wall.
Pertinent Results:
admission labs
===========
___ 04:05AM BLOOD WBC-9.0 RBC-3.87* Hgb-12.6 Hct-37.2
MCV-96 MCH-32.6* MCHC-33.9 RDW-13.8 RDWSD-47.5* Plt ___
___ 04:05AM BLOOD Neuts-75.2* Lymphs-17.9* Monos-5.0
Eos-1.1 Baso-0.4 Im ___ AbsNeut-6.79* AbsLymp-1.62
AbsMono-0.45 AbsEos-0.10 AbsBaso-0.04
___ 04:05AM BLOOD Glucose-182* UreaN-17 Creat-1.0 Na-136
K-4.8 Cl-102 HCO3-19* AnGap-15
Imaging
======
left femur x-ray ___
No acute fracture or dislocation.
NC chest CT ___
1. Mild ecchymosis along the left lateral upper chest. No
evidence of acute
fractures.
2. Chronic left-sided rib fractures and chronic mild L1
compression deformity.
3. Markedly dilated common bile duct, measuring up to 16 mm,
increased
compared to MRCP from ___. Correlation with LFTs is
recommended,
and repeat MRCP on an outpatient basis could be considered.
4. Severe coronary calcification.
CXR ___
No acute cardiopulmonary process. Multiple chronic left-sided
rib fractures
are better evaluated on same-day chest CT.
U/S LLE ___
8.0 x 1.8 x 3.7 cm complex fluid collection likely represents a
hematoma.
However, given recent trauma and its location near the greater
trochanter and
along the deep subcutaneous fat, Morel ___ lesion cannot be
excluded.
Clinical and/or ultrasound follow-up to resolution is
recommended.
MRI THIGH LEFT ___
1. Favored 5.3 x 3.3 x 9.3 cm subcutaneous hematoma in the
posterolateral
proximal left thigh, not fitting criteria for Morel ___
lesion.
Recommend follow-up to resolution. If the lesion enlarges or
persists after 3
months, recommend repeat ultrasound or MRI imaging.
2. Sequela of prior soft tissue injury seen in the proximal
left
thigh/gluteal region.
DISCHARGE LABS
==============
___ 05:25AM BLOOD WBC-6.6 RBC-3.16* Hgb-10.3* Hct-31.5*
MCV-100* MCH-32.6* MCHC-32.7 RDW-13.5 RDWSD-48.9* Plt ___
Brief Hospital Course:
P - Patient summary statement for admission
___ with blindness who presents s/p fall now with a left thigh
hematoma could not exclude Morel ___ lesion.
A - Acute medical/surgical issues addressed
She underwent an ultrasound of left thigh which showed 8.0 x 1.8
x 3.7 cm complex fluid collection likely represents a hematoma
and Morel ___ lesion couldn't be excluded. She underwent an
MRI of left thigh which showed hematoma. She was given
medication for pain control and she was monitored during the
hospitalization.
C - Chronic issues pertinent to admission (ex. HTN, held
Lisinopril for ___
She was continued on her home medication for depression and
hypertension during hospitalization.
T - Transitional Issues (ex. follow up Cr and restart
Lisinopril)
[]Please repeat imaging as follow up for left thigh hematoma
[]Please encourage incentive spirometer use for chronic
left-side rib fractures
[]Please repeat LFTs and MRCP as follow up for dilated common
bile duct as outpatient
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 ___
Medications on Admission:
Medications - Prescription
ALENDRONATE [FOSAMAX] - Dosage uncertain - (Prescribed by Other
Provider)
BUPROPION HCL [WELLBUTRIN SR] - Wellbutrin SR 150 mg tablet, 12
hr sustained-release. 1 tablet(s) by mouth once a day -
(Prescribed by Other Provider)
ESCITALOPRAM OXALATE [LEXAPRO] - Lexapro 20 mg tablet. 1
tablet(s) by mouth - (Prescribed by Other Provider)
METHOTREXATE SODIUM [TREXALL] - Trexall 15 mg tablet. tablet(s)
by mouth weekly - (Prescribed by Other Provider)
METOPROLOL SUCCINATE - Dosage uncertain - (Prescribed by Other
Provider)
PREDNISONE - Dosage uncertain - (Prescribed by Other Provider)
RYMADIL - Dosage uncertain - (Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*24 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*6 Capsule Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % Please apply to left side chest wall once a
day Disp #*3 Patch Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
5. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [ClearLax] 17 gram/dose 1 dose by
mouth once a day Disp #*3 Packet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
Please hold for loose stools
RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tablet(s) by
mouth twice a day Disp #*6 Tablet Refills:*0
7. BuPROPion (Sustained Release) 150 mg PO QAM
8. Escitalopram Oxalate 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left thigh hematoma
Chronic left rib fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You came to the hospital because you had a fall and you had a
hematoma on your left thigh. We obtained an MRI of your left leg
which showed
1. Favored 5.3 x 3.3 x 9.3 cm subcutaneous hematoma in the
posterolateral
proximal left thigh, not fitting criteria for Morel ___
lesion.
Recommend follow-up to resolution. If the lesion enlarges or
persists after 3
months, recommend repeat ultrasound or MRI imaging.
2. Sequela of prior soft tissue injury seen in the proximal
left
thigh/gluteal region.
You also underwent a CT chest which showed:
1. Mild ecchymosis along the left lateral upper chest. No
evidence of acute
fractures.
2. Chronic left-sided rib fractures and chronic mild L1
compression deformity.
3. Markedly dilated common bile duct, measuring up to 16 mm,
increased
compared to MRCP from ___. Correlation with LFTs is
recommended,
and repeat MRCP on an outpatient basis could be considered.
4. Severe coronary calcification.
You were monitored and given medication for pain control. Now
you are ready to be discharged home.
* You have chronic 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). Lap CCY: Please follow up in the
Acute Care Surgery clinic at the appointment listed below.
ACTIVITY: -Do not drive until you have stopped taking pain
medicine and feel you could respond in an emergency. -You may
climb stairs. -You may go outside, but avoid traveling long
distances until you see your surgeon at your next visit. -Don't
lift more than ___ lbs for 4 weeks. (This is about the weight
of a briefcase or a bag of groceries.) This applies to lifting
children, but they may sit on your lap. -You may start some
light exercise when you feel comfortable. -You will need to stay
out of bathtubs or swimming pools for a time while your incision
is healing. Ask your doctor when you can resume tub baths or
swimming. HOW YOU MAY FEEL: -You may feel weak or "washed out"
for a couple of weeks. You might want to nap often. Simple tasks
may exhaust you. -You may have a sore throat because of a tube
that was in your throat during surgery. -You might have trouble
concentrating or difficulty sleeping. You might feel somewhat
depressed. -You could have a poor appetite for a while. Food may
seem unappealing. -All of these feelings and reactions are
normal and should go away in a short time. If they do not, tell
your surgeon.
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:
___
|
19930907-DS-12 | 19,930,907 | 20,588,915 | DS | 12 | 2128-02-05 00:00:00 | 2128-02-06 17:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
R MCA syndrome s/p tPA
Major Surgical or Invasive Procedure:
status post tPA
right carotid stenting and thrombectomy ___
History of Present Illness:
Mr. ___ is a ___ right handed man with a past medical
history of Eosinophilic Esophagitis and Chronic Hepatitis B who
presents s/p tPA for sudden onset left hemiplegia and mild
neglect, with evidence of a hyperdense R MCA at OSH.
History is gathered from patient at bedside, but is limited.
In brief, Mr. ___ was at his baseline state of health this
morning when around roughly 8PM he was driving to ___ to
visit
a friend. He recalls smelling burning rubber (and thinking that
he blew a car tire). The next thing he recalled was being on
the
side of the road following a car accident. EMS arrived, and due
to concern for a facial droop he was taken to OSH.
There, there was concern for a stroke. ___ revealed a
possible
hyperdense Right MCA. NIHSS was at least 6 (exact details
unclear), with 1 point for Left facial palsy, 1 for dysarthria,
___nd 1 for leg and arm drift respectively.
He was given IV tPA roughly 2 hours following onset of symptoms
(roughly 10pm) He was transferred to ___ for endovascular
consideration.
Here, NIHSS was 9. CTA reconfirmed occlusion of the right
internal carotid artery distal to the bifurcation, with
re-cannulization exiting the cavernous sinus. He was taken
urgently for Neurovascular intervention. Groin puncture was at
00:15 with placement of 1 right ECA stent and 2 Right ICA stents
with carotid recanalization. Subsequent underwent stent
retrieval and suction catheterization. During this procedure he
received integrillin and IV heparin per endovascular team.
RoS unable to be fully gathered. Endorses mild headache.
Past Medical History:
Chronic Hepatitis B
Eosinophilic Esophagitis
Splenic Artery Aneurysm
Social History:
___
Family History:
Denies any family history of neurologic issues including stroke
or seizure.
Physical Exam:
ADMISSION EXAMINATION:
Vitals: 98.0 73 139/89 16 96% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: WWP.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person place and date. Able
to
relate history regarding car crash without difficulty. He is
not
aware of his left sided weakness or sensory deficits and
excluding a headache reports he otherwise feels well. Attentive
to examiner and tasks. In the setting of the left hemisensory
neglect as below, he does acknowledge providers on both sides.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors. Pt was able to
name both high and low frequency objects. Speech was mildly
dysarthric but easily understandable. Able to follow both
midline
and appendicular commands.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. Normal saccades. Visual fields with likely left
neglect versus left hemianopsia, but difficult to clarfiy.
V: Facial sensation intact to light touch, but with intermittent
left neglect.
VII: Clear left UMN pattern facial droop.
VIII: Hearing intact room voice.
IX, X: Palate midline.
XI: Turns head side to side w/o difficulty.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Left pronator drift
present. No adventitious movements, such as tremor, noted.
Limited
strength assessment. RUE and RLE appear grossly full to
contfronational strength testing. LUE was perhaps subtly weak
at
left deltoid and triceps. LLE with mild weakness of IP, perhaps
hamstring. unfortunately, due to urgency of intervention, full
exam unable to be performed.
-Sensory: Has left hemibody sensory extinction to DSS.
Inconsistent neglect to left hemisensory light touch. Otherwise
grossly intact to light touch and tickle.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2+ 2 2 3 1
- Pec jerk present on left, not present on right
- Plantar response was flexor bilaterally.
-Coordination: No intention tremor. Limited assessment of RAM.
Mild LUE ataxia in proportion to weakness.
-Gait: Unable to assess.
**********
DISCHARGE EXAMINATION:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl. S1S2
Abdomen: soft, NT/ND.
Extremities: WWP.
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. EOMI without
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: Mild L NLFF and decreased activation of left facial
muscles.
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. Mild cupping of left hand
with eyes closed. No adventitious movements, such as tremor,
noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, vibratory sense
throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: deferred.
Pertinent Results:
LABS:
___ 11:45PM BLOOD WBC-8.0 RBC-4.72 Hgb-14.4 Hct-42.1 MCV-89
MCH-30.5 MCHC-34.2 RDW-12.4 RDWSD-40.7 Plt ___
___ 11:45PM BLOOD Neuts-67.4 ___ Monos-7.0 Eos-3.6
Baso-0.5 Im ___ AbsNeut-5.38 AbsLymp-1.68 AbsMono-0.56
AbsEos-0.29 AbsBaso-0.04
___ 11:45PM BLOOD ___ PTT-29.6 ___
___ 11:45PM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-140
K-3.8 Cl-102 HCO3-26 AnGap-16
___ 03:31AM BLOOD Albumin-3.8 Calcium-8.3* Phos-3.2 Mg-2.1
Cholest-141
___ 03:31AM BLOOD ALT-20 AST-25
___ 03:31AM BLOOD %HbA1c-5.3 eAG-105
___ 03:31AM BLOOD Triglyc-79 HDL-31 CHOL/HD-4.5 LDLcalc-94
___ 03:32AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
******************
IMAGING:
CTA head and neck ___:
1. Complete occlusion R ICA bifurcation to cavernous sinus.
2. Abrupt right V3 caliber change, reflect dissection.
Cerebral angiographay ___:
IMPRESSION:
Presumed right internal carotid artery dissection causing
carotid occlusion and middle cerebral artery occlusion carotid
stenting and thrombectomy. TICI3 recanalization.
CT head noncontrast ___:
IMPRESSION:
Unchanged mild loss of gray-white matter differentiation in the
right frontal lobe, without evidence of new hemorrhage.
MRI Brain ___:
1. Acute infarction involving the right frontal operculum and
insular cortices corresponding to the middle cerebral artery.
2. Numerous punctate infarcts involving the right
temporo-occipital cortex. Punctate infarcts involving the right
anterior limb internal capsule and posterior external capsule.
No evidence of hemorrhagic conversion. The parietal infarcts
may be in watershed distribution.
3. Background sequela chronic microangiopathy.
Transthoracic echocardiogram ___:
IMPRESSION:
Mildly dilated aortic arch. Normal biventricular cavity sizes
with preserved regional and global biventricular systolic
function. No definite structural cardiac source of embolism
identified.
CLINICAL IMPLICATIONS:
The patient has a mildly dilated ascending aorta. Based on ___
ACCF/AHA Thoracic Aortic Guidelines, a follow-up echocardiogram
is suggested in ___ years.
Brief Hospital Course:
This is a ___ year old man with chronic Hep B, splenic art
aneurysm who presented acutely after new left-sided weakness and
neglect leading to MVA on ___. On arrival to OSH he was found
to have NIHSS of 6 and CT showed hyperdense R MCA, was given iv
tPA at 22:00 and transferred to ___.
# Neuro
At ___ was 8 (LUE went to 2 and sensory deficit noted
in addition to tactile extinction) and CT/CTA showed R
extracranial carotid occlusion, right vert dissection and distal
R M1/M2 occlusion. He was taken urgently for endovacular
intervention around midnight and had 3 stents placed
extracranially (1 in the ECA, two in series in the ICA), he had
clot retreival, and carotid was successfully recanalized at
01:10 (~5h). He was admitted to the neurology ICU for post-tPA
care and monitoring. He had an unremarkable course and was
subsequently transferred to the floor, where his neurologic
examination continued to improve. Suspected etiology R-ICA
dissection with R-MCA (M-2) occlusion. Echo and telemetry did
not suggest alternative cardioembolic source, although he had
mildly dilated aortic arch on echo without any other associated
abnormalities for which he needs a follow up study in ___ years
as recommended by Cardiology guidelines. Evaluation of stroke
risk factors revealed A1c of 5.3 and LDL of 94. He was started
ASA 81mg/Plavix 75mg for indefinite secondary stroke prevention.
SBP goals 120-160 and plan for DriveWise driving clearance as
outpatient.
Transitional issues:
[ ] continue aspirin 81mg + Plavix 75mg for secondary stroke
prevention in setting of carotid stent
[ ] patient needs a follow up echocardiogram in ___ years (___)
for mildly dilated aortic arch without any other signs of
valvular or functional impairment
[ ] recommend interval vascular imaging to evaluate for right
carotid artery and stent
[ ] patient was encouraged to obtain DriveWise evaluation prior
to resuming driving
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 = 94) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) 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? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - aspirin/plavix () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID:PRN SOB, wheeze
2. Omeprazole 20 mg PO BID
3. azelastine 137 mcg (0.1 %) nasal BID
Discharge Medications:
1. azelastine 137 mcg (0.1 %) nasal BID
2. Omeprazole 20 mg PO BID
3. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
QID:PRN SOB, wheeze
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
5. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Acute stroke
Right internal carotid occlusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of left-sided weakness
leading to a car accident 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 gave you the medication
for acute stroke (tPA) and took you for angiographic
intervention (with placement of right internal carotid artery
stents and clot retrieval).
We are changing your medications as follows:
- ADDING aspirin 81mg daily and Plavix 75mg daily which you
should remain on indefinitely.
YOU SHOULD REFRAIN FROM DRIVING until you are evaluated by the
___ DriveWise Team and are cleared to drive. We do not think
there is a serious contraindication for you traveling via plane
(you asked specifically about an upcoming trip to ___,
and we think this would be safe).
Your echocardiogram did not show any possible sources of stroke,
although there was one small unusual finding for which you
should receive a repeat echocardiogram in ___ years.
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 during this
hospitalization.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19931382-DS-39 | 19,931,382 | 29,381,057 | DS | 39 | 2149-08-29 00:00:00 | 2149-08-30 13:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending: ___.
Chief Complaint:
ETOH withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/history of paroxysmal Afib s/p TEE cardioversion,
tachycardia-induced myopathy that has since resolved (EF >55% on
echo ___, HBV, HCV, and EtOH abuse, who presented to the ED
last evening with report of chest pain radiating to left arm,
who is admitted to the MICU now for EtOH withdrawal. Patient is
homeless, and reports he was in his usual state of health last
evening before going to sleep outside. Awoke with ___ chest
pain, radiating to his left arm, with associated
numbness/tingling in his left hand. States the pain feels like
a squeezing sensation. Has had similar pain before. Pain
associated w/mild dyspnea. He has had abdominal pain, but no
N/V/D. Patient took SL nitro, but is not sure if it helped
relieve pain.
In the ED, initial VS were: 97.2 105 150/90 18 100%. Labs were
notable for hypokalemia (K 2.9), CO2 19, serum EtOH 167. Hct
30.9 with MCV 101. UA showed 40 ketones, 30 protein, and was
not c/w UTI. ECG showed sinus tachycardia, and no ischemic
changes. Trop was negative x2. He received 3L of NS, 40 mEq
potassium repletion.
While in ED, patient became agitated, and was physically and
verbally threatening towards staff. Has h/o EtOH abuse, and
appeared intoxicated. Was also tachycardic and hypertensive,
and was concern for EtOH withdrawal. He received 50mg diazepam,
and was transferred to MICU for further management. VS prior to
transfer Pulse: 120, RR: 20, BP: 152/81, O2Sat: 96 % on 2L NC.
On arrival to the MICU, patient drowsy but arousable. Reports
ongoing CP ___, radiating to left arm with associated mild
dyspnea.
Of note, he has had multiple recent admissions for atypical
chest pain and EtOH withdrawal - 7 admissions in past 6 months.
During these admissions, he has ruled out for MI with negative
enzymes and unchanged ECGs. He frequently leaves AMA and has
not followed-up with his PCP since his last admission in
___. Does report he has been taking his medications as
prescribed, which he gets from the ___.
Review of systems: Positive as per HPI. Occasional cough
productive of white phlegm. Chronic back pain, no
numbness/tingling in legs. Denies fevers, chills, headache,
dizziness, rhinorrhea, congestion, current abdominal pain,
nausea, vomiting, diarrhea, constipation, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
-Atrial fibrillation (paroxysmal, s/p TEE cardioversion)
-Tachycardia induced cardiomyopathy (since resolved)
-ETOH abuse with cirrhosis
-Prior cocaine abuse
-Hypertension
-2.5-cm cystic lesion in pancreatic tail (___)
-Colonic polyposis
-s/p knee replacement
-Hepatitis B/C/ETOH, grade 3 fibrosis
-reported hx of MI and stroke, although limited review of OMR
does not reveal documentation
Social History:
___
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
ADMISSION EXAM:
T: 99.8 BP: 165/96 P: 121 R: 10 O2: 95% RA
General: drowsy but arousabe, NAD
HEENT: sclera anicteric, slightly dry MM, oropharynx clear,
EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachycardic but regular, normal S1 + S2, no r/m/g
Lungs: diffuse wheezing throughout lung fields, no
rhonchi/rales, good air movement
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ edema
Neuro: oriented x3, CNII-XII intact
DISCHARGE EXAM:
VS - Temp F 97.9, BP 157/92, HR 88, RR 20, 98% RA
GENERAL - well-appearing man in NAD, comfortable,
HEENT - EOMI, sclerae anicteric, MMM
NECK - supple, no JVD,
LUNGS - lungs clear bilaterally, no dullness to percussion, good
breath sounds on both sides
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - abdomen is soft and nontender, no ___ sign, no
rebound/guarding, no spider angiomas, no kaput medusa
EXTREMITIES - WWP, no cyanosis or clubbing, 2+ peripheral pulses
(radials, DPs), no ankle edema is present
NEURO - awake, A&Ox3, Pt seems cooperative, asterixis lessened
today.
Pertinent Results:
LABS ON ADMISSION:
___ 11:05PM cTropnT-<0.01
___ 11:05PM WBC-5.3# RBC-3.07* HGB-10.4* HCT-30.9*
MCV-101* MCH-33.8* MCHC-33.5 RDW-15.7*
___ 11:05PM ASA-NEG ___ ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:05PM PLT COUNT-197#
___ 11:05PM GLUCOSE-69* UREA N-11 CREAT-0.6 SODIUM-145
POTASSIUM-2.9* CHLORIDE-105 TOTAL CO2-19* ANION GAP-24*
LABS ON DISCHARGE:
___ 07:05AM BLOOD WBC-3.9* RBC-3.05* Hgb-10.3* Hct-31.4*
MCV-103* MCH-33.8* MCHC-32.9 RDW-15.3 Plt ___
___ 07:05AM BLOOD Glucose-105* UreaN-10 Creat-0.4* Na-140
K-2.9* Cl-101 HCO3-27 AnGap-15
___ 07:05AM BLOOD ALT-46* AST-115* AlkPhos-113 TotBili-1.1
___ 07:05AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.4*
MICRO: NONE
CXR ___: Lungs appear grossly clear and well inflated
without evidence of pleural effusions, pulmonary edema or
pneumothorax. Overall, cardiac and mediastinal contours are
stable. No pneumothorax. Calcification of the aortic knob,
consistent with atherosclerosis.
Brief Hospital Course:
This is a ___ gentleman with a history of paroxysmal
atrial fibrillation s/p TEE cardioversion, tachycardia-induced
cardiomyopathy that has since resolved (EF >55% on echo ___,
HBV, HCV, and EtOH abuse, who presented with atypical chest pain
and was admitted for alcohol withdrawal.
# ETOH WITHDRAWAL: Patient has long history of EtOH abuse, and
multiple recent admissions for EtOH intoxication and withdrawal.
Serum EtOH was 167 in ED; patient reported last drink ___ days
ago. On admission, patient was tremulous, hypertensive,
tachycardic, but denied any hallucinations. He was given valium
in the ED and this was continued in the ICU and on the floor
until he was scoring a 0 on the CIWA scale.
# ATYPICAL CHEST PAIN: Patient's symptoms of chest pain
radiating to left arm were concerning for possible ACS, though
trop negative x2 and ECG not concerning for ischemia. In past,
chest pain has been attributed to costochondritis, and has
typically resolved on its own. Of note, during recent admission
for a similar presentation, CTA chest was negative for PE.
Patient was ruled out for MI. His EKGs did not show any acute
change. Chest pain resolved during treatment for alcohol
withdrawal
# WHEEZING: Patient was noted to have diffuse wheezing on exam.
He was given nebulizers during admission and had no evidence of
pulmonary edema. His symptoms resolved over course of
hospitalization.
# TRANSAMINITIS: Overall, improved from prior admissions. AST
elevated > ALT, c/w EtOH use. Patient also w/history of HBV,
HCV. Has had e/o grade 3 fibrosis in past. RUQ u/s ___
showed echogenic liver compatible with diffuse steatosis, and
more severe forms of liver fibrosis/cirrhosis could not be
excluded. Patient should recieve outpatient hepatology
follow-up.
# ANEMIA: Hct close to recent baseline. Macrocytosis of 102
suggestive of B12 or folate deficiency. Folate 15.6 in ___,
and B12 308 in ___. Iron 203 in ___. Patient's
hematocrit was trended and he was continued on folic acid.
#GERD: Omeprazole was continued.
# THROMBOCYTOPENIA: Stable. Platelets were monitored
throughout admission.
# HISTORY OF AFIB: On admission, patient was in sinus rhythm.
Metoprolol and diltiazem were continued during admission.
TANSITIONAL ISSUES: The patient was given a script for
metoprolol and was advised to follow up with his PCP. Pt had
earlier tried to leave AMA in this admission for unclear reasons
and was convinced otherwise. This time however, the pt remained
adamant.
Medications on Admission:
- metoprolol succinate 25mg daily (patient does not know if he
takes this or not, he claims to take several meds he doesn't
know the name of)
- hydrochlorothiazide 12.5 mg daily
- omeprazole 20 mg Capsule BID
- multivitamin daily
- folic acid 1 mg daily
- diltiazem HCl 120 mg Capsule, Extended Release daily
- thiamine HCl 100 mg Tablet daily
- furosemide 40 mg Tablet daily
Discharge Medications:
1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO once
a day.
Disp:*30 Tablet(s)* Refills:*0*
2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. hydrochlorothiazide 12.5 mg Tablet Sig: One (1) Tablet PO
once a day.
8. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1)
Capsule, Extended Release PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
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 stay at ___
___. You were admitted for chest pains and
alcohol withdrawal. You are no longer requiring medication for
withdrawal and are requesting to leave. We believe it is safe
for you to do so.
MEDICATIONS STARTED
1. You were started on metoprolol for your high blood pressure.
You were unsure of whether or not you have been prescribed this
in the past. You need to take one of these 25 mg pills each
day.
Followup Instructions:
___
|
19931382-DS-41 | 19,931,382 | 25,407,424 | DS | 41 | 2150-12-28 00:00:00 | 2150-12-29 07:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending: ___.
Chief Complaint:
alcohol withdrawl
pneumonia
Major Surgical or Invasive Procedure:
intubation
History of Present Illness:
___ hx hep C, etoh cirrhosis, bilateral uncoagulated DVTs, UGIB,
multiple admissions for alcohol withdrawal pw mtuliple
complaints in partiular cough, shaking, "not feeling well" some
nausea and andominal pain. Pt is a poor historian. States he has
chronic back, chest, and bilateral lower extremity pain, which
seems to have worsened over the last week. He endorses dry
cough, and subjective fevers. Denies hemoptysis. States he has
not take any medications in at least a week as they were stolen.
He is homeless, has been drinking alcohol heavily, and was
drinking listerine today, last drink 5 am. He states he feels
shaky. He has never had a seizure. No vomiting or bloody stools.
No changes in urinary habits. He was recently at ___
admitted for alcohol withdrawal, while he was there he would go
out and drink alcohol and he then left on ___,
In the ED, inital vitals were notable for 99.2 120 121/78 24 95%
RA. He subsequently had a episode of desaturation to the low ___
and was placed on 2L NC. Labs were notable for sodium of 132, K
of 2.9, CL 91 and bicarb of 19. CXR demonstrated a possible RLL
pneumonia. He was given levofloxacin, 2L NS. He was noted to be
tachycardic and tremulous felt to be due to ETOH withdrawal. He
recieved in total 4 mg IV ativan and 20 PO valium without
improvement in his tachycardia.
Past Medical History:
-Hepatitis C/ETOH cirrhosis with hx of grade 3 fibrosis, grade 2
inflammation, genotype was 1 and 3, with a viral load of
3,160,000 IU/mL in ___
-Hepatitis B (cleared by immune system)
-Hepatitis C (not on treatment)
-Atrial fibrillation (paroxysmal, s/p TEE cardioversion in ___
-Tachycardia-induced cardiomyopathy (since resolved)
-Hypertension
-2.5-cm cystic lesion in pancreatic tail (___)
-Colonic polyposis
-Chronic bilateral lower extremity DVT, not on anticoagulation
-Hx of upper GIB in ___ requiring hospitalization
-s/p knee replacement
-has reported hx of MI and stroke, although review of OMR does
not reveal documentation
-h/o C dif ___
-pancreatits ___
-Hepatitis C/ETOH cirrhosis with hx of grade 3 fibrosis, grade 2
inflammation, genotype was 1 and 3, with a viral load of
3,160,000 IU/mL in ___
-Hepatitis B (cleared by immune system)
-Hepatitis C (not on treatment)
-Atrial fibrillation (paroxysmal, s/p TEE cardioversion in ___
-Tachycardia-induced cardiomyopathy (since resolved)
-Hypertension
-2.5-cm cystic lesion in pancreatic tail (___)
-Colonic polyposis
-Chronic bilateral lower extremity DVT, not on anticoagulation
-Hx of upper GIB in ___ requiring hospitalization
-s/p knee replacement
-has reported hx of MI and stroke, although review of OMR does
not reveal documentation
Social History:
___
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
Admission Examination
99.2 120 121/78 24 95% RA.
General: Alert, oriented, tremulous, coughing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: tachy in the 140s, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, 1+ edema in lower ext
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred, finger-to-nose intact though with intentional tremor
Discharge Examination
Afebrile, vitals stable
General: no apparent distress
HEENT: moist
Lungs: bibasilar crackles, otherwise CTAB
CV: no edema
Abdomen: soft, nontender, nondistended
Back: low back pain
Neuro: CN intact, ___ strength bilateral lower extremities
(left worse than right), decreased sensation bilateral lower
extremities. Gait deferred.
Pertinent Results:
___ 03:42AM BLOOD WBC-6.1 RBC-2.80* Hgb-8.5* Hct-26.6*
MCV-95 MCH-30.3 MCHC-31.9 RDW-15.3 Plt ___
___ 03:42AM BLOOD Neuts-74.9* ___ Monos-5.1 Eos-0.8
Baso-0.3
___ 03:42AM BLOOD ___ PTT-31.3 ___
___ 05:46AM BLOOD Glucose-87 UreaN-17 Creat-0.7 Na-136
K-3.7 Cl-104 HCO3-23 AnGap-13
___ 03:58AM BLOOD ALT-41* AST-82* LD(LDH)-187 AlkPhos-104
TotBili-0.9
___ 03:42AM BLOOD Calcium-7.9* Phos-3.9 Mg-2.0
___ 10:00AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 12:30AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG
___ 12:30AM URINE RBC-23* WBC-3 Bacteri-FEW Yeast-NONE
Epi-0
CXR on admission: Right lower lobe consolidation, compatible
with pneumonia. Followup to resolution.
MRI T and L ___: 1. New diffuse bone marrow signal
abnormality with heterogeneous hypointensity on the T1 sequence.
This may be seen in the setting of red marrow reconversion with
chronic anemia or other marrow replacement processes such as
multiple myeloma or diffuse metastasis. Correlation with
laboratory values is recommended. 2. No evidence of epidural
abscess or discitis/osteomyelitis. No evidence of spinal cord
compression. 3. Mild lumbar ___ degenerative changes as
described above have mildly progressed from the prior
examination. 4. Moderate right pleural effusion.
Brief Hospital Course:
___ with long history of poor medical care, EtOH abuse,
alcoholic and hepatitis C cirrhosis presents with aspiration
pneumonia, septic shock, and alcohol withdrawal. He was
intubated and admitted to the medical ICU. He was treated with
antibiotics for 8 days with resolution of his respiratory
symptoms. He was monitored on a CIWA and required treatment for
alcohol withdrawal. While he was here he noted progressive
worsening of his lower extremity weakness (he states this has
been worsening over the last 2 months and has been a problem for
the last ___ years; of note he was discharged from a rehab with
similar complaints a few weeks prior to admission and was
ambulating with a walker at that time). Given he also has
chronic back pain and a recent infection an MRI T+L ___ was
done without radiographic disease that would explain his
symptoms. He was recommended to rehab and EtOH treatment.
# Septic shock
# Aspiration pneumonia
# Respiratory failure
He presented with septic shock from a pulmonary source. He was
intubated for respiratory failure. Imaging showed pneumonia. He
was treated for HCAP wtih vanc, zosyn and levofloxacin. He was
extubated without difficulty. He completed the course with
improvement in his respiratory symptoms. At the time of
discharge he was breathing comfortably on room air and was
without shortness of breath, cough, fevers or other symptoms.
# EtOH Dependence
# EtOH Withdrawal
He developed some EtOH withdrawal symptoms and was monitored on
a CIWA scale. He did require benzos for treatment but was
without seizures. Thiamine, folate and multivitamin were given.
# Weakness
He notes that he has been "crippled" for ___ years. He states the
last few months his lower extremity weakness has gotten much
worse. However, he was recently discharged (or left rehab) from
rehab on ___ and was able to walk with a walker. He is able to
walk and has good strength with the exception of his left ankle
which is weak. Given his back pain, "progression of symptoms"
and no imaging since ___ an MRI was done which showed chronic
degenerative changes, bone marrow signal abnormality. These
changes were told to the patient (including the possiblity of
cancer in the bone marrow and the need for additional follow
up). He stated "I am paralyzed, give me a motorized wheelchair".
We recommended rehab placement which he was initially agreeable.
However, he then demanded to leave the hospital, became agitated
and threatening towards staff. He was deemed to have capacity.
We were able to secure him a nonmotorized wheelchair and he was
allowed to leave the hospital. Of note, he did poorly on
transfers and was warned of the risks of leaving the hospital
and potential benefits of rehab (and repeated them back to me
with understanding). The likely diagnosis is a combination of
chronic ___ disease, baseline peripheral neuropathy, recent
ICU stay and immobilization with deconditioning and patient
effort.
# Social issues: He is homeless, abuses listerine and has a very
labile personality. Code purple was called and security
requested to bedside multiple times for concern of abusive
behavior. We worked with SW, CM and other services. He was not
interested in placement or EtOH treatment. He was agreeable with
rehab but left AMA prior to being accepted by any rehab.
Chronic Issues:
# Hepatitis C/alcoholic cirrhosis: On no treatment at this time.
No evidence of decompensation.
# Paroxismal Afib: CHADS score of 1. He has poor medical
compliance so anticoagulation is not an option. Aspirin would be
waranted.
# HTN, benign: he was on labetalol and diltiazem. He was not
discharged with medications as he left AMA and is not compliant
with medical care.
# Chronic neuropathy: Presumed to be secondary to EtOH.
# Anemia, chronic: Likely EtOH / nutritional related. Cannot
rule out MM given ___ imaging. This will need to be worked up
further if he decides to receive further medical evaluation.
# Hematuria: Microscopic. Likely related to foley trauma but
needs repeat UA.
He was not discharged with appointments with PCP or ___. He
has DNK or cancelled his last 14 appointments at ___. He was
given the number to schedule an appointment for a PCP or ___
physician. He was encouraged to re-enroll in the medical system.
He was notified of his ongoing medical conditions that need
follow up (he did not seem interested at this time).
Medications on Admission:
None
Discharge Medications:
He left AMA, he was not given prescriptions
Discharge Disposition:
Home
Discharge Diagnosis:
pneumonia
alcohol withdrawl
deconditioning with lower extremity weakness
Discharge Condition:
alert, interactive
wheelchair, able to stand with cane
Discharge Instructions:
You were admitted with alcohol abuse and pneumonia. While you
were here you became weak. An MRI was done of your back which
shows slight progression of your chronic disease. Your bones
looked abnormal which could be due to anemia or a cancer (this
finding is worse than prior exams). You should be followed by a
primary care physician. Please see below about setting up a
primary care appointment. You are weak and would benefit from
going to rehab for physical therapy. Based on the MRI, you would
be able to regain strength in your legs. You were willing to go
to rehab but were unwilling to stay in the hospital any longer.
We attempted to find a rehab and you decided to leave against
medical advice. You know the risks associated with leaving
against medical advice including risk of injury from falling,
which could be severe enough to cause death, lack of mobility or
to escape danger, difficulty with bathing or going to the
bathroom and other issues. You know that in our opinion rehab
could strengthen you and make you discharge significantly safer.
No medications were given because you do not have medical follow
up and are not compliant with your care. Once you have medical
follow up a number of medications are indicated to treat blood
pressure and other problems.
I recommend that you take thiamine and a multivitamin at the
very least.
Followup Instructions:
___
|
19931382-DS-42 | 19,931,382 | 24,728,221 | DS | 42 | 2150-12-30 00:00:00 | 2151-01-04 16:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
AMA
History of Present Illness:
___ with hx EtOH abuse recently hospitalized with EtOH withdrawl
and aspiration who also has extreme b/l ___ weakness requiring
wheelchair. Patient left hospital AMA today and refused to go to
rehab. He went across the street to buy cigarettes, smoked 3,
and became SOB. A pedestrian called EMS and he was brought back
into the ED.
In the ED, initial vitals 97.4 99 91/53 16 99% RA. On arrival he
stated he was no longer short of breath. He did complain of
chronic pain in his back and legs, as well as b/l ___ weakness
that prevents him from walking. He has been offered rehab, but
refuses to go, states that he will be fine if he has a
wheelchair. He denies any recent EtOH or drug use, no f/c, no
n/v/d, no chest pain, abdominal pain. CXR showed persistent RLL
pneumonia, therefore PO Levaquin was started. Blood cultures
were drawn. Serum tox screen negative, other labs within normal
limits. He also received tramadol / flexeril / lidoderm patch
for back pain
After discussion with CM and ED attending, the decision was made
to admit to medicine for workup of unresolved pneumonia. Patient
refuses to be transferred to ___, and is being refused from
rehab. He wants to leave AMA, but needs ___ medical
attention. Per Case Management, "Patient refusing rehab, stating
he will be discharged to streets once medically cleared." Prior
to leaving the ED, the patient became agitated.
On the floor, patient is yelling about how he will sue all of
the doctors involved is his care. Very agitated. States he is
short of breath at times, denies EtOH use and cigarette use
prior to this admission. Denies any other illicit drugs.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies shortness of breath, cough, dyspnea or
wheezing. Denies chest pain, chest pressure, palpitations.
Denies constipation, abdominal pain, diarrhea, dark or bloody
stools. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
- Hepatitis C/ETOH cirrhosis with hx of grade 3 fibrosis, grade
2 inflammation, genotype was 1 and 3, with a viral load of
3,160,000 IU/mL in ___
- Hepatitis B (cleared by immune system)
- Hepatitis C (not on treatment)
- Atrial fibrillation (paroxysmal, s/p TEE cardioversion in
___
- Tachycardia-induced cardiomyopathy (since resolved)
- Hypertension
- 2.5-cm cystic lesion in pancreatic tail (___)
- Colonic polyposis
- Chronic bilateral lower extremity DVT, not on anticoagulation
- Hx of upper GIB in ___ requiring hospitalization
- s/p knee replacement
- has reported hx of MI and stroke, although review of OMR does
not reveal documentation
- h/o C dif ___
- pancreatits ___
Social History:
___
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98 BP: /83 HR: 86 RR: 20 02 sat: 94%RA
GENERAL: NAD, awake and alert, tangential thoughts, yelling at
author, disheveled appearance
HEENT: AT/NC, anicteric sclera, pink conjunctiva, patent nares,
MMM, no teeth
NECK: nontender and supple, no LAD, no JVD
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: patient refused to turn or sit forward, clear and
symmetric to percussion, no accessory muscle use
ABDOMEN: +BS, obese, soft, non-tender, distended, no rebound or
guarding, no HSM, tympanic to percussion
EXT: warm and well-perfused, 1+ edema to ankles
PULSES: 2+ DP pulses bilaterally
NEURO: b/l ___ decreased sensation to light touch at feet, 2+
strength L foot, 3+ strength R foot, unable to test other muscle
groups
.
.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98 BP: /83 HR: 86 RR: 20 02 sat: 94%RA
GENERAL: NAD, awake and alert, tangential thoughts, yelling at
author, disheveled appearance
HEENT: AT/NC, anicteric sclera, pink conjunctiva, patent nares,
MMM, no teeth
NECK: nontender and supple, no LAD, no JVD
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: patient refused to turn or sit forward, clear and
symmetric to percussion, no accessory muscle use
ABDOMEN: +BS, obese, soft, non-tender, distended, no rebound or
guarding, no HSM, tympanic to percussion
EXT: warm and well-perfused, 1+ edema to ankles
PULSES: 2+ DP pulses bilaterally
NEURO: b/l ___ decreased sensation to light touch at feet, 2+
strength L foot, 3+ strength R foot, unable to test other muscle
groups
Pertinent Results:
Admission Labs:
___ 07:45PM BLOOD WBC-9.2# RBC-2.86* Hgb-8.9* Hct-28.2*
MCV-99* MCH-31.0 MCHC-31.4 RDW-15.3 Plt ___
___ 07:45PM BLOOD Neuts-75.9* ___ Monos-4.8 Eos-0.6
Baso-0.5
___ 07:00PM BLOOD Glucose-92 UreaN-18 Creat-0.9 Na-137
K-4.3 Cl-106 HCO3-16* AnGap-19
___ 07:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Discharge Labs:
___ 07:25AM BLOOD WBC-7.5 RBC-2.80* Hgb-8.8* Hct-27.2*
MCV-97 MCH-31.3 MCHC-32.3 RDW-15.2 Plt ___
___ 07:25AM BLOOD Glucose-96 UreaN-17 Creat-0.8 Na-141
K-3.7 Cl-107 HCO3-20* AnGap-18
___ 07:25AM BLOOD Calcium-8.9 Phos-4.4 Mg-1.7
___ 07:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
Microbiology:
___ BLOOD CULTURE Blood Culture, Routine-FINAL
.
Imaging:
___ CXR: IMPRESSION: Persistence of severe RLL consolidation
over at least 10 indicates inadequate treatment and merits an
explanation.
.
___ CXR: Two lateral views confirm a right lower lobe
pneumonia.
Brief Hospital Course:
___ with long history of poor medical care, EtOH abuse,
alcoholic and hepatitis C cirrhosis presents with shortness of
breath after leaving ___ AMA earlier today and going to buy
cigarettes.
.
.
# Aspiration pneumonia: The patient was recently discharged
after an 11 day stay for EtOH withdrawl and aspiration
pneumonia. During this admission he was intubated for
respiratory failure. Imaging showed pneumonia. He was treated
for HCAP wtih vanc, zosyn and levofloxacin. He was extubated
without difficulty. He completed the course with improvement in
his respiratory symptoms. At the time of discharge he was
breathing comfortably on room air and was without shortness of
breath, cough, fevers or other symptoms. Upon returning to the
hospital, CXR shows evidence of pneumonia; subjectively the
patient reports shortness of breath after he started smoking
cigarettes, no fevers, chills, sweats, or cough.
.
The patient had evidence of persistant infiltrate on repeat CXR
after 8 days IV ABX for HCAP treatment. He had no cough, no
fever, and no hypoxia. This clinical setting is not consistent
with active pneumonia. Radiographic evidence of consolidation
may be present despite resolution of infection.
- Recommend follow-up imaging with CXR or CT in ___ weeks to
ensure resolution.
.
.
# Social issues: He is homeless, abuses Listerine and has a very
labile personality. Code purples have been called in the past
for concern of abusive behavior. Social work, case management,
and other services have previously been involved. On his last
admission, he was not interested in placement or EtOH treatment.
He was agreeable with rehab but left AMA prior to being accepted
by any rehab.
.
On this admission, patient began yelling at staff that he wanted
to leave to get cigarettes. He called ___ who was unable to
verify call and so presented to his room at ___. He sent them
away, stating he wanted cigarettes. He declared his desire to
leave AMA. Risks of leaving the hospital were explained him and
was able to verbalized that he understood risks involved
including death and further weakness. He left the hospital AMA
in his wheelchair, he did not want paperwork or prescriptions.
See AMA discharge note from ___ ___ for
additional details.
.
.
Chronic Issues:
# Hepatitis C/alcoholic cirrhosis: On no treatment at this time.
No evidence of decompensation.
.
# Paroxismal Afib: CHADS score of 1. He has poor medical
compliance so anticoagulation is not an option. Aspirin given
while in the hospital. He was not discharged with aspirin
prescription as he left AMA.
.
# HTN, benign: He was given labetalol and diltiazem. He was not
discharged with medications as he left AMA. Similarly, he did
not want prescriptions and left AMA.
.
# Chronic neuropathy: Presumed to be secondary to EtOH. No
evaluation during this hospitalization as the patient left AMA.
.
# Anemia, chronic: Likely EtOH / nutritional related. Cannot
rule out MM given spine imaging. This will need to be worked up
further if he decides to receive further medical evaluation.
.
# Hematuria: Noted on previous admission. Microscopic. Likely
related to foley trauma but needs repeat UA. Unable to repeat
due to patient leaving AMA.
.
He was not discharged with appointments with PCP or spine. He
has DNK or cancelled his last 14 appointments at ___. He was
given the number to schedule an appointment for a PCP or spine
physician. He was encouraged to re-enroll in the medical system.
He was notified of his ongoing medical conditions that need
follow up (he displayed disinterest at this time).
.
It was recommended that he take folate and thiamine, and follow
up with a doctor. Rehab again was encouraged due to his
weakness. It was explained to him that leaving AMA included
risks such as injury from falling and worsening of his medical
conditions that could be severe enough to cause death.
.
He was not discharged with prescriptions stating he did not want
them. He continued to refuse follow up or interest in engaging
in his care.
.
Recommend follow-up imaging with CXR or CT in ___ weeks to
ensure resolution of lung infiltrate.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
.
Left AMA from last admission on day prior to admission, was not
given prescriptions as he refused. Recommended to take thiamine
and a multivitamin at the very least.
Discharge Medications:
Left AMA from this admission, was not given prescriptions as he
refused. Recommended to take thiamine and a multivitamin.
Discharge Disposition:
Home
Discharge Diagnosis:
AMA
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:
AMA please see discharge summary. patient did not want
paperwork.
Followup Instructions:
___
|
19931382-DS-43 | 19,931,382 | 28,486,659 | DS | 43 | 2151-03-28 00:00:00 | 2151-03-29 12:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Enalapril
Attending: ___.
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
Intubation
Mechanical Ventilation
Central Line Placement
Fiberoptic Bronchoscopy
History of Present Illness:
___ yo homeless M w/ long hx of EtOh abuse, many prior admissions
for same, EtOH/HepC cirrhosis, Afib not on coumadin, HTN,
chronic b/l ___ DVT, reported prior GI bleed, presented to ED
unconscious and intoxicated after being found down. On
presentation to the ED, pt was awake, endorsed drinking one
quart alcohol (likely listerine) that day. Initial vitals: 98.3
78 103/69 20 97%. C/o nausea, vomiting small amts clear liquid.
Labs initially not drawn. Head CT was neg. Given diazepam 10 mg
X 2, thiamine, MV, zofran, placed in obs.
At 4 am had episode of dark coffee-ground emesis, was noted to
be tachycardic to 120s, BP ___, lowest read low ___.
Mentating at ___ (still intoxicated), Tachypneic to ___, no
respiratory distress. #18 EJ placed, 80 mg ppi bolus given.
Resuscitated w/ 3L NS, then ___ NS at 250/hour; pt remained
tachy to 120 w/ pressures in low 100s. FSBG in ___, given amp of
D50. Guiac significantly positive but w/ brown stool, no melena.
Labs drawn, notable for ABG: 7.17|17|135, bicarb 6. Cr 2.1 from
___ 0.7, Na 140 Cl 92, K 3.0, AG 45. Hct 35.9 from ___ 27.
Pt transferred to MICU for further evaluation and treatment.
Vitals on arrival were HR 120-130, BP 125/81, RR 25, O2 Sat 94%
on 2L NC.
Of note, in ED patient reporting weakness in legs and difficulty
walking. Had similar complaints in ___ admission, which
included an T and L spine MRI showing bone marrow conversion but
no spinal cord compression, no epidural abscess and no
osteomyelitis. He was advised to go to rehab but declined. Left
AMA during each admission. Has history of abusive behavior.
On arrival to the MICU, the patient does appear tachypneic but
is yelling in complete sentences. He is demanding orange juice.
He is tremulous, and says ___! I'm withdrawing!"
Past Medical History:
- Hepatitis C/ETOH cirrhosis with hx of grade 3 fibrosis, grade
2 inflammation, genotype was 1 and 3, with a viral load of
3,160,000 IU/mL in ___
- Hepatitis B (cleared by immune system)
- Hepatitis C (not on treatment)
- Atrial fibrillation (paroxysmal, s/p TEE cardioversion in
___
- Tachycardia-induced cardiomyopathy (since resolved)
- Hypertension
- 2.5-cm cystic lesion in pancreatic tail (___)
- Colonic polyposis
- Chronic bilateral lower extremity DVT, not on anticoagulation
- Hx of upper GIB in ___ requiring hospitalization
- s/p knee replacement
- has reported hx of MI and stroke, although review of OMR does
not reveal documentation
- h/o C dif ___
- pancreatits ___
Social History:
___
Family History:
Positive for coronary artery disease (details unknown) and
hypertension. His father had an aortic aneurysm. There is a
history of cancer of the brain and the breast.
Physical Exam:
ADMISSION EXAM:
Vitals: T: BP: 125/81 P: 117 R: 24 O2: 92% 2L NC
General- Alert, oriented, tachypneic but speaking in complete
sentences.
HEENT- Sclera anicteric, MMM, oropharynx edentulous but without
lesions.
Neck- supple, JVP not elevated, no LAD. EJ in place.
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- tachycardia, 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- CNs2-12 intact, UE is ___ and equal bilaterally. Very
tremulous. ___ is only able to plantarflex L foot ___ and
dorsiflex bilaterally ___. Sensation intact. Tremor. Wiggles
left toes. Remainder of exam of lower extremities, patient says
"I"m trying!" and there is no flicker of muscle.
Discharge EXAM
Vitals: t98.0, 133/70, p86, R16, 99% on RA
General: sleeping in bed, calm today. no restraints
HEENT: oropharynx edentulous.
Neck: supple full ROM
Lungs: Clear bilaterally
CV: irregular rhythym with ___ systolic murmur at LUSB
Abdomen: soft, non tender non distended
Ext: +DP and Radial pulses,
Neuro/psych:Alert, not priented, but calm
Pertinent Results:
ADMISSION LABS:
___ 05:00AM BLOOD WBC-5.1 RBC-3.40* Hgb-11.8*# Hct-35.9*#
MCV-106*# MCH-34.8*# MCHC-32.9 RDW-17.0* Plt ___
___ 05:00AM BLOOD ___ PTT-26.2 ___
___ 05:00AM BLOOD Glucose-57* UreaN-27* Creat-2.1*# Na-140
K-3.0* Cl-92* HCO3-6* AnGap-45*
___ 01:20PM BLOOD ALT-59* AST-234* AlkPhos-177* TotBili-1.4
___ 05:00AM BLOOD Lipase-69*
___ 01:49AM BLOOD ___
___ 05:00AM BLOOD Calcium-7.2* Phos-6.7*# Mg-1.6
================================
MICROBIOLOGY:
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
-------------------
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 5:43 pm BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___: NO GROWTH, <1000
CFU/ml.
LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED.
================================
NCHCT:
IMPRESSION:
1. No acute intracranial process.
2. Fluid in the right mastoid air cells, is nonspecific but
could represent mastoiditis. Correlate clinically.
CXR ___:
The ET tube is in appropriate position, and the orogastric tube
ends in the stomach outside the view of this radiograph. A
right IJ central venous line ends at the cavoatrial junction.
Multifocal opacities in the mid and lower lungs persist. A
right middle lobe opacity has appeared comparison to the chest
radiograph from ___. The cardiac, mediastinal and
hilar contours are normal.
CT Abdomen and Pelvis
1. No acute intra-abdominal or pelvic process.
2. Hypodensity arising from the tail of the pancreas appears
likely to
communicate with the pancreatic duct and appears similar
compared to ___, may
represent intraductal papillary mucinous neoplasm (IMPN) or
possibly a
pseudocyst if the patient has history of prior pancreatitis. and
should be
further evaluated with MRCP or EUS.
3. Partially imaged multifocal pneumonia with small bilateral
pleural
effusions are stable from the recent chest radiograph.
4. Nodular and hypoattenuating liver concerning for underlying
cirrhosis and
fatty liver.
5. Hypodensities within the duodenum may represent ingested
material,
although, small lipomas are difficult to exclude without prior
imaging
CXR ___
FINDINGS: AP single view of the chest has been obtained with
patient in
semi-upright position. Comparison is made with the next
preceding similar
study of ___. During the interval, an NG tube has
been placed seen
to pass well below the diaphragm into the abdominal area. The
tip of the line
is too advanced to identify as it escapes the lower image field.
Comparison
of chest findings suggests some regression of the basal
infiltrates. It is
observed that a right internal jugular approach central venous
line has been
removed without occurrence of pneumothorax.
EKG
Sinus rhythm. Prolonged Q-T interval. Compared to the previous
tracing
of ___ the Q-T interval has increased
RUQ US
IMPRESSION:
1. Coarsened echotexture of the liver.
2. Probable tiny gallstones.
3. Of note, the known pancreatic tail cystic lesion is not seen
on ultrasound
due to early termination of the exam due to patient refusal.
Brief Hospital Course:
___ yo homeless M w/h/o EtOH abuse, EtOH cirrhosis, Afib not on
coumadin, GIB, presents intoxicated w/ AG acidosis and coffee
ground emesis concerning for upper GIB, pna, and EtOH
ketoacidosis, intoxication and delerium now with resolved septic
shock and ARDS and altered mental status.
# Respiratory failure: Pt demonstrated persistent bilateral
infiltrates on CXR and was notable for tachypnea on exam. Given
a concern for significant aspiration event in the setting of
worsening RLL infiltrate on CXR. Patient was transferred to the
unit reuiring intubation for hypoxic repiratory failure. He was
treated with HAP (see below) and successfully extubated ___.
On transferr to the floor on ___ he was satting 98% on 2L.
Patient was also ~10 L positive while in the unit and required
IV diuresis which improved the pulmonary edema observed on CXR.
On vanc/cefepime for HCAP coverage, started ___. Planned
treatment course was 7 days, but blood Cx grew e. coli and
patient was started on ceftriaxone. The last day of abx was
___. He remained afebrile after discontinuation of ABX and
subsequenct blood cultures were negative.
# E.coli bacteremia: Pt with e coli bacteremia, with one blood
cx growing cefepime-sensitive e.coli. Negative mini-BAL (___),
negative bronch (___), negative urine legionella and cultures.
On vanc/cefepime for HCAP coverage. Negative C-diff on ___,
but then developed loose stools repeat C diff on ___ was
negative. Given e.coli bacteremia, abdominal CT scan was
performed, but no clear source of infection was identified.
# EtOH withdrawal/ delirium: Pt was monitored for withdrawal
throughout the the first 2 weeks of his hospitalization using
the ___ scoring system. Additionally Pt had received large
amount of benzos so need to monitor for benzo withdrawal as
well. Pt was very Somnolent during the first 2 weeks of
hospitalization wand did not become vocal until ___. This was
thought ___ to be medication induced with component of benzo
intoxication. Pt more verbal after transfer to floor, but
continues to be intermittently agitated and significantly
delirious initially requiring physical restraints. Pt was on
seroquel in on transfer to the floor and it was insufficinetly
controlling his agitation. Psych was consulted and they
recommended standing haldol to control delerium with prn if
agresive. Patient responded well to this regimen and was able
to sit in bed without restraints applied. His delerium slowly
improved on haldol. He became calm, and psychiatry recommended
weaning haldol in the out patient setting and only giving prn
for agitation.
# Hypernatremia: Likely related to pt AMS resulting in no free
water intake. Na 140 on admission ___, peaked at 152 on ___.
3L free water deficit at discharge from MICU, which was
succesfully managed with free water flushes via NG tube. Pt
self discontinued his NG tube on the floor and Speech and
swallow evaluated him and cleared him for nectar thickend
liquids. As his mental status improved, Speech and swallow
reevaluated him and approved a soft mechanical diet. It is
unkilely his diet will advance further given his edentulous
state.
# Hypophosphatemia: His phosphate required frequent repletion
in the unit and on transfer to the floor, but as he tolerated PO
and his diarrhea resolved, the phosphate level normalized as
well.
# Anemia, thrombocytopenia: likely related to acute illness and
also some component of chronic EtOH abuse as well. Plts
uptrending. He did receive pRBCs during his admission (most
recently 2 units on the day of discharge). He did not have any
evidence of bleeding while on the floor. Hct should be monitored
while he is at rehab.
# ___: Cr downtrending after urine sediment showed signs of ATN.
This slowly improved to his baseline of 1.3-1.4
#elevated TSH: Given AMS, thyroid function was check and he was
found to have a TSH of 13, however Free T4 was normal at 1.2.
This should be further investigated as an outpatient.
Transitional Issues
-Hypodensity within the tail of the pancreas is unchanged from
___ and should be further evaluated with MRCP or EUS as an
outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. FoLIC Acid 1 mg PO DAILY
4. Guaifenesin ___ mL PO Q6H:PRN cough
5. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
6. Labetalol 200 mg PO BID
7. LOPERamide 4 mg PO QID:PRN diarrhea
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Thiamine 100 mg PO DAILY
12. TraZODone 12.5 mg PO HS:PRN insomnia
13. Haloperidol 2 mg PO BID
You should not need to contiue this medication outside the
hospital
14. Haloperidol 2 mg PO TID:PRN agitation
give only if agitated
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Encephalopathy, EColi Bacteremia, sepsis,
Atrial fibrillation not on coumadin, Acute respiratoy failure,
anemia, substanse abuse, transaminitis, acute renal failure
Secondary diagnosis: hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___, It was a pleasure taking care of you during
your recent admission to ___. You
were admitted intoxicated by alcohol, and you were treated for
alcohol withdrawal. During your hospital stay you developed a
respiratory infection and had difficulty breathing. You were
transferred to the Intensive care unit where your were treated
with antibiotics and placed on the ventilator to help you breath
and treat your infection. Your breathing improved, however you
remained agitated in the hospital and required physical
restraints because of your agitation. We treated you with a
medication to help your thinking and your mental status
improved. You should not need to continue this medication after
discharge from the hospital. Your blood count was also alow and
you were transfused with 3 units of blood during your stay.
Your doctors recommend that ___ avoid alcohol, tobacco and
illicit drugs and follow up with a primary care provider within
the next week.
Be Well.
Followup Instructions:
___
|
19931495-DS-16 | 19,931,495 | 25,870,551 | DS | 16 | 2114-04-27 00:00:00 | 2114-04-27 22:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
L groin hematoma
Major Surgical or Invasive Procedure:
L Groin Exploration and Evacuation of Hematoma
History of Present Illness:
Mrs. ___ is an ___ year old woman who underwent a RLE
angiogram on ___ with a R SFA stent placement x2 and a R ___
angioplasty, complicated by a L groin pseudoaneurysm repaired on
___, who re-presented with a L groin hematoma and
leukocystosis on ___.
Past Medical History:
PMH:
- Positive PPD
- Osteoporosis
- Sarcoidosis 135
- Colonic polyp
- Acute-angle glaucoma
- Bilateral pseudophakia
- Carpal tunnel syndrome
- Degenerative arthritis of cervical spine, mild
- Degenerative arthritis of lumbar spine, mild
- Trigger finger; R ring
- Trigger finger; R long
- Shoulder impingement
PSH:
- Colonoscopy ___, 2 mm cecal polyp bx'd. adenoma
- Excision pterygium, w/ graft ___ right eye
- Colonoscopy ___ ___ no polyps. tic's.
- Cataract extracaps extract, complex w intraocular lens
___
left
- Cataract extract - phacoemulsification ___ right
- Post capsulotomy - laser ___ od
- Incise finger tendon sheath Right ___ finger
- Hysterectomy
- Tonsillectomy
Social History:
___
Family History:
- Mother with breast cancer, diabetes
- Father with CAD
Physical Exam:
GEN: AOx3, NAD
CV: RRR no MRG, RLE pulses p/p/p/d, LLE pulses p/p/p/d
Resp: in no apparent distress
Abd: soft, non-tender, non-distended, palpable hematoma in her
LLQ underlying her groin incisioin, dressing c/d/i excepting two
spots of serosanguionous leakage
Ext: mild b/l generalized edema
Neuro: CN ___ grossly intact
Pertinent Results:
___ 06:55AM BLOOD WBC-10.7* RBC-3.00* Hgb-8.4* Hct-28.5*
MCV-95 MCH-28.0 MCHC-29.5* RDW-18.6* RDWSD-61.6* Plt ___
___ 07:00AM BLOOD WBC-12.9* RBC-3.20* Hgb-8.8* Hct-30.4*
MCV-95 MCH-27.5 MCHC-28.9* RDW-18.5* RDWSD-63.0* Plt ___
___ 08:40PM BLOOD WBC-14.5* RBC-3.24* Hgb-9.0* Hct-31.1*
MCV-96 MCH-27.8 MCHC-28.9* RDW-18.6* RDWSD-63.0* Plt ___
___ 01:10PM BLOOD WBC-12.3* RBC-3.07* Hgb-8.5* Hct-29.3*
MCV-95 MCH-27.7 MCHC-29.0* RDW-18.2* RDWSD-61.9* Plt ___
___ 07:19PM BLOOD WBC-13.4* RBC-3.23* Hgb-9.2* Hct-30.6*
MCV-95 MCH-28.5 MCHC-30.1* RDW-18.2* RDWSD-60.9* Plt ___
___ 06:55AM BLOOD ___ PTT-75.5* ___
___ 07:00AM BLOOD ___ PTT-43.0* ___
___ 06:05AM BLOOD Glucose-104* UreaN-14 Creat-0.7 Na-138
K-4.6 Cl-105 HCO3-23 AnGap-15
Bilateral Venous Duplex ___
FINDINGS:
There is normal compressibility, flow and augmentation of the
right common femoral, femoral, and popliteal veins. Normal color
flow and compressibility are demonstrated in the posterior
tibial and peroneal veins.
The left proximal CFV is not compressible, but flow is seen with
augmentation in this segment on color doppler. This is
consistent with a non-occlusive thrombus. This finding is new
compared to prior study on ___. There is normal
compressibility of the left distal CFV, popliteal, and peroneal
veins. There is normal respiratory variation in the common
femoral veins bilaterally.
Brief Hospital Course:
Patient presented on ___ with concern for infection of her L
groin hematoma due to leukocytosis, fever and pain at her prior
L groin puncture site. She was begun on Vancomycin and Zosyn
and consented with the aid of a ___ interpreter and taken
back to the OR for exploration of the wound and evacuation of
her hematoma. The procedure was uncomplicated and she tolerated
it well, returning to the floor from the PACU shortly
afterwards. A Provena wound vac was left overlying her incision
but had to be replaced on POD 0 for excessive drainage. Her
Vancomycin was discontinued following surgery, and her Zosyn was
continued for 7 days post operatively. Her Plavix was
discontinued following surgery due to her recurrences of
bleeding. A groin hemotoma recurred starting on ___. Her
Provena vac was discontinued after it had no significant
drainage for three days postoperatively, at which point her
wound had a continuous slow leak of serosanguinous fluid
eventually requiring three stitches to acheive hemostasis. She
developed melena and was treated empirically with omeprazole
before undergoing an esophogealduodenoscopy which revealed
duodenitis. A venous ultrasound on ___ found a DVT in her
L CFV, for which she was started on a heparin drip as a bridge
to Coumadin. At time of discharge she was no yet at therpeutic
levels of Coumadin, and so was discharged with a prescription
for a Lovenox bridge to rehab.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 10 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Multivitamins 1 TAB PO DAILY
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. Clopidogrel 75 mg PO DAILY
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
8. Tears Naturale II (dextran 70-hypromellose) 0 units
OPHTHALMIC DAILY
9. Atenolol 25 mg PO DAILY
10. fexofenadine-pseudoephedrine 180-240 mg oral daily
11. Atorvastatin 80 mg PO QPM
12. Acetaminophen 1000 mg PO Q8H
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN
rash/itch
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ capsule(s) by mouth every six (6) hours
Disp #*20 Capsule Refills:*0
5. Enoxaparin Sodium 50 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
Will discontinue once therapeutic on Coumadin
6. Omeprazole 40 mg PO DAILY
___ MD to order daily dose PO DAILY16
8. Acetaminophen 1000 mg PO Q8H
9. Amitriptyline 10 mg PO QHS
10. fexofenadine-pseudoephedrine 180-240 mg oral daily
11. Fluticasone Propionate NASAL 1 SPRY NU DAILY
12. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN SOB
13. Multivitamins 1 TAB PO DAILY
14. Tears Naturale II (dextran 70-hypromellose) 0 units
OPHTHALMIC DAILY
15. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
16. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN
rash/itch
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Deep Vein Thrombosis of the Left Common Femoral Vein
Left groin hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to ___ and
underwent a left groin exploration and evacuation of blood
clots. ___ have now recovered from surgery and are ready to be
discharged. Please follow the instructions below to continue
your recovery:
MEDICATION:
Continue Aspirin 81 mg once daily, lifelong.
Take Coumadin once per day. Your final dose will be
determined by the physicians at your rehab facility. ___ will
remain on Lovenox
until your INR is therapeutic.
Take Omeprazole once per day for your duodenitis
___ no longer require Plavix
Continue all other medications ___ were taking before surgery,
unless otherwise directed
___ 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 ___ go home, ___ may walk and use stairs
___ may shower (let the soapy water run over groin incision,
rinse and pat dry). Your foot ulcer will need to be covered
while showering. The ulcer should be kept clean and dry.
Your incision should be dressed with a dry dressing daily.
No heavy lifting, pushing or pulling greater than 5 lbs until
your follow up
After 1 week, gradually increase your activities and distance
walked as ___ can tolerate
No driving until ___ 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:
___
|
19932024-DS-13 | 19,932,024 | 29,514,568 | DS | 13 | 2146-03-01 00:00:00 | 2146-03-01 23:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Decompensated Cirrhosis
Major Surgical or Invasive Procedure:
___: Colonoscopy
___: CT Colonography
___: Extraction of teeth numbers 6, 8, 9, 11, 13, 14, 28.
___: EGD
___: Upper Endoscopic Ultrasound with ___
subcarinal mediastinum biopsy
___: Bone Marrow Biopsy
History of Present Illness:
Ms. ___ is a ___ woman with a PMH of hepatitis C/cirrhosis
genotype 1A (hx of encephalopathy, jaundice, ___ edema),
hypertension, ___, sent in from clinic for hyponatremia,
elevated Tbili, and elevated INR. Patient recently established
care with Dr. ___ evaluation of liver transplant. MELD at
that visit was 25. Was seen in clinic yesterday (___), and
labs showed Na 125, Bili of 10 INR 3.1. She was sent to the ED
for expedited workup transplant workup given new MELD of 28.
In the ED, Vitals 97.3 78 125/70 18 100% RA. Pt in ___ pain.
Labs significant for wbc 3.5, H/H 11.5/33.8, plt 20, Na 123, K
5, Cl 93, bicarb 23, BUN 9, Cr 0.3, Mg 1.6, AST/ALT 144/67, Alk
185, Tbili 9.3, Alb 2.3, INR 3.4. Serum tox negative, Urine tox
positive for opiates and oxycodone positive. RUQ US without
thormbosis, minimal ascites. CXR negative. Unable to do
diagnostic tap due to inadquate ascites. UA contaminated, but
unlikely infection. Given morphine 5mg IV x2, zofran 4mg x1,
lactulose 30mL. Evaluated by hepatology in the ED. Vital prior
to transfer, 98.6 81 123/73 16 99% RA.
On the floor, vitals 98.6, 129/63, 82, 18, 98%RA. Patient is
extremely upset about everything that is going on. She feels
down emotionally and scared about what her illness means for her
two daughters. She says that about a month ago she couldn't get
her rifaxamin or furosemide, but had been taking them for the
last few weeks. She has been feeling better emotionally, but
physically she is very weak, has poor appetite. She has chronic
back and shoulder pain. She has intermittent dizziness when
going from sitting to standing. She has chronic epigastric pain,
with no clear triggers. Denies chest pain, shortness of breath,
current diarrhea. Has ___ BM daily.
ROS: per HPI, denies fever, chills, night sweats, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
1. Hepatitis C/cirrhosis c/b hepatic encephalopathy,
gastric/esophageal varices, portal hypertensive gastropathy.
2. Portal hypertension and encephalopathy.
3. Portal hypertension/volume overload.
4. History of ___.
5. Hypertension.
6. Chronic back pain on and off is longstanding.
7. History of helicobacter gastritis.
8. Pancytopenia-being worked up by Heme/Onc ___
9. Mediastinal lymphadenopathy, being worked up by Heme/Onc
___.
PAST SURGICAL HISTORY:
1. Status post cholecystectomy back in ___.
2. Status post ruptured ectopic pregnancy in the ___.
3. Status post ex lap in ___.
4. Liposuction abdominoplasty in ___.
5. Dental extraction ___
Social History:
___
Family History:
Family history of coronary artery disease in her mother,
negative for hypertension, no diabetes, no stomach, breast, or
colon cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 98.6, 129/63, 82, 18, 98%RA
Weight: 76.7kg
General: middle aged woman, tearful throughout exam, lying
comfortably in bed
HEENT: PERRL, EOMI, sclera icteric, MMM, jaundice of mucosa,
poor dentition
Neck: supple, no LAD
CV: RRR, normal s1/s2, faint systolic ejection murmur heard
throughout precordium
Lungs: mild bibasilar crackles, clear to ascultation elsewhere,
no wheezes, ronchi
Abdomen: hyperactive bowel sounds, tender in epigastrum and RLQ,
no rebound, no guarding, soft, slightly distended, dullness at
sides, no HSM
GU: deferred
Ext: trace pitting edema up to shins, warm, well perfused
Neuro: AOx3, days of the week backwards, slight droop of left
eye and left lip, 4+ strength in all extremities, limited by
effort, no asterxisis
Skin: palmar erythema, few spiders on chest
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.0, 113-129/42-61, 60-72, 18, 97-99% on RA.
Weight: 81.5 kg
General: Middle aged woman, sitting up in bed, resting
comfortably, breathing non-labored, jaundiced.
HEENT: sclera icteric, no abscess noted, no pus from left
maxilla, non-tender to palpation, no submandibular or cervical
lymphadenopathy.
Neck: supple
CV: RRR, normal s1/s2, ___ systolic ejection murmur heard
throughout precordium
Lungs: Clear to auscultation bilaterally no w/r/r.
Abdomen: +bowel sounds, nontender, no rebound, no guarding,
soft, splenomegaly appreciated.
Ext: No lower extremity edema.
Back: Bone marrow biopsy on posterior aspect of left iliac
crest, mildly tender to palpation. Minimal bruising. No
discharge from biopsy site.
Neuro: AOx3, no asterixis, able to say days of the week
backwards. moving all extremities. Responding appropriately to
questions.
Skin: palmar erythema, few spiders on chest, jaundiced.
Pertinent Results:
ADMISSION LABS
==============
___ 03:40PM BLOOD WBC-4.7 RBC-3.63* Hgb-13.1 Hct-37.5
MCV-104* MCH-36.1* MCHC-34.8 RDW-17.4* Plt Ct-33*
___ 11:45AM BLOOD Neuts-75* Bands-0 Lymphs-5* Monos-14*
Eos-6* Baso-0 ___ Myelos-0
___ 03:40PM BLOOD ___
___ 03:40PM BLOOD UreaN-10 Creat-0.5 Na-125* K-4.3 Cl-93*
HCO3-25 AnGap-11
___ 03:40PM BLOOD ALT-73* AST-166* AlkPhos-195*
TotBili-10.3* DirBili-4.1* IndBili-6.2
___ 03:40PM BLOOD Albumin-2.7*
___ 11:45AM BLOOD Albumin-2.3* Calcium-8.0* Phos-3.1 Mg-1.6
DISCHARGE LABS
==============
___ 04:00AM BLOOD WBC-1.7* RBC-2.37* Hgb-8.9* Hct-25.5*
MCV-107* MCH-37.4* MCHC-34.8 RDW-19.7* Plt Ct-21*
___ 04:00AM BLOOD Neuts-61.2 ___ Monos-13.1*
Eos-6.0* Baso-0.9
___ 04:00AM BLOOD ___ PTT-67.0* ___
___ 04:00AM BLOOD Glucose-180* UreaN-10 Creat-0.4 Na-136
K-4.4 Cl-102 HCO3-26 AnGap-12
___ 04:00AM BLOOD ALT-30 AST-81* AlkPhos-146* TotBili-7.8*
___ 04:00AM BLOOD Calcium-9.2 Phos-4.1 Mg-1.5*
HEMATOLOGY LABS
===============
___ 04:45AM BLOOD Ret Aut-4.1*
___ 04:18AM BLOOD VitB12-GREATER TH Folate-15.0
___ 04:18AM BLOOD Cryoglb-NEGATIVE
___ 04:18AM BLOOD PEP-POLYCLONAL IgG-2259* IgA-629* IgM-104
___ 04:19AM BLOOD URIC ACID-4.8
___ 04:13AM BLOOD FreeKap-PND FreeLam-PND
___ 04:13AM BLOOD RheuFac-82*
___ 02:38PM URINE U-PEP: NO PROTEIN DETECTED, NEGATIVE FOR
___ PROTEIN.
FURTHER ANALYSIS OF PANCYTOPENIA
================================
___: PARVOVIRUS B19 DNA: NOT DETECTED.
___: EBV PCR, QUANTITATIVE, WHOLE BLOOD: <200 copies/mL
(Reference Range: <200 copies/mL)
___: ADENOVIRUS PCR: <500 copies/mL (Reference Range: <500
copies/mL)
___: HERPES SIMPLEX VIRUS, TYPE 1 AND 2 DNA, QUANTITATIVE
REAL TIME PCR: HSV-1; NOT DETECTED; HSV-2: NOT DETECTED.
___: CMV DNA PCR: <200 copies/mL (Reference Range: <200
copies/mL).
TOXICOLOGY TESTING
==================
___ 01:25PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG oxycodn-POS mthdone-NEG
___ 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
HCV VIRAL LOAD
==============
___: HCV VIRAL LOAD: 4,310 IU/mL.
MICROBIOLOGY
============
___: BLOOD CULTURE: NO GROWTH.
___: BLOOD CULTURE: NO GROWTH.
___: BLOOD CULTURE: NO GROWTH.
___: BLOOD CULTURE: NO GROWTH.
___: URINE CULTURE: <10,000 organisms/mL.
___: CMV VIRAL LOAD: PENDING.
___: R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (RECTAL SWAB):
VRE POSITIVE.
___: FECAL SWAB-FECAL CULTURE: No Stenotrophomonas
maltophilia or carbapenemase resistant Pseudomonas aeruginosa
isolated.
___: URINE CULTURE: Mixed bacterial flora (>=3 colony
types, consistent with skin and/or genital contamination.
___: BLOOD CULTURE: NO GROWTH.
___: BLOOD CULTURE: NO GROWTH.
___: C. DIFFICILE DNA AMPLIFICATION ASSAY: NEGATIVE.
IMAGING/REPORTS
===============
___: RIGHT UPPER QUADRANT ULTRASOUND
IMPRESSION:
1. Cirrhotic liver without focal lesion identified. Trace
perihepatic ascites.
2. Sequela of portal hypertension including splenomegaly.
3. Patent hepatic vasculature with reversal of flow in the left
portal vein.
___: CHEST (PA AND LATERAL)
IMPRESSION: No acute cardiopulmonary abnormality.
___: MRI LIVER WITH AND WITHOUT CONTRAST
IMPRESSION:
1. Limited exam due to motion. No arterially enhancing lesions
are identified.
2. Findings compatible with cirrhosis and portal hypertension
including a
recanalized paraumbilical vein, esophageal and gastric varices,
splenomegaly and trace perihepatic and perisplenic ascites.
3. Multiple periportal lymph nodes, likely reactive.
___: CT CHEST WITH CONTRAST
IMPRESSION:
1. No CT evidence of suspicious lung nodule or mass to suggest
a primary
non-small cell lung cancer as a cause of paraneoplastic
syndrome.
2. Diffuse mediastinal lymphadenopathy is a nonspecific finding
that could be due to inflammatory, infectious or neoplastic
etiology. If warranted
clinically, correlated PET-CT imaging could be performed.
3. Masslike appearance of lower thoracic esophagus, difficult to
assess in the absence of oral contrast. This may be secondary to
extensive paraesophageal varices, but correlative barium swallow
may be helpful to exclude an intrinsic esophageal abnormality if
warranted clinically.
4. Cirrhotic liver and sequela of portal hypertension, which
will be more
fully assessed on concurrent MRI of the abdomen, performed the
same date and dictated separately.
___: TRANSTHORACIC ECHOCARDIOGRAM
The left atrium is mildly dilated. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) 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 no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function.
___: PAP SMEAR CYTOLOGY: NEGATIVE FOR INTRAEPITHELIAL
LESION OR MALIGNANCY.
___: CHEST (PORTABLE AP)
IMPRESSION: Despite the low lung volumes. The increase in the
perihilar interstitial opacities and increase in the azygos vein
is consistent with interstitial pulmonary edema. Small bilateral
pleural effusions are most likely present.
___: CHEST (PORTABLE AP)
IMPRESSION: Low lung volumes with bibasilar atelectasis and/or
consolidation. Underlying mild pulmonary edema also noted.
___: CHEST (PORTABLE AP)
IMPRESSION: No change in mild to moderate pulmonary edema and
cardiomegaly. No lobar consolidation.
___: RIGHT UPPER QUADRANT ULTRASOUND
IMPRESSION: Patent hepatic vasculature. No evidence of portal
vein thrombus. Cirrhotic liver without focal lesion identified.
No ascites. Splenomegaly.
___: CT HEAD WITHOUT CONTRAST
IMPRESSION: No acute intracranial process.
___: TISSUE: IMMUNOPHENOTYPING-FNA LARGE LYMPH NODE
RESULTS:
Three color gating is performed (light scatter vs. CD45) to
optimize lymphocyte yield.
Due to paucicellular nature of the specimen, a limited panel is
performed to evaluate B-cells.
CD45-bright, low side-scatter gated lymphocytes comprise 37% of
total analyzed events.
B cells comprise ~ 60% of lymphoid-gated events, and do not
express aberrant antigens CD5 or CD10. By surface immunoglobulin
light chain staining, there appears to be a subpopulation of
kappa skewed cells in a polytypic background.
INTERPRETATION
Immunophenotyping findings demonstrate an atypical surface
immunoglobulin light chain staining profile of B-cells.
There appears to be a kappa skewed subpopulation of B-cells in a
polyclonal background; the findings raise the concern for, but
are not diagnostic of, a possible B-cell lymphoproliferative
disorder.
There is no remaining sample left for any additional workup.
Please correlate with clinical, radiologic and other laboratory
(e.g. SPEP etc) findings. If clinically indicated, a
re-biopsy/open biopsy may be considered for further assessment.
___: TISSUE: GASTROINTESTINAL MUCOSAL BIOPSY
FINAL PATHOLOGY READ PENDING AT THE TIME OF DISCHARGE.
___: FDG TUMOR IMAGING (PET-CT SCAN)
IMPRESSION:
1. Unchanged mediastinal lymphadenopathy with low level uptake.
These may be reactive in nature.
2. Scattered abdominal/ periportal lymphadenopathy with low
level uptake, likely the sequelae of cirrhosis and portal
hypertension.
3. Periapical lucency and focus of FDG uptake in the left
maxilla concerning for dental disease/abscess.
4. Splenomegaly, varices, periportal edema and ascites
___: TISSUE: BONE MARROW, BIOPSY, CORE
FINAL BONE MARROW BIOPSY READ PENDING AT THE TIME OF DISCHARGE.
GASTROENTEROLOGY STUDIES
========================
___: COLONOSCOPY
Findings: There was stool throughout the colon.
Protruding Lesions: Two sessile polyps of benign appearance and
ranging in size from 4 mm to 5 mm were found in the sigmoid
colon. Non-bleeding grade 1 internal hemorrhoids were noted.
Excavated Lesions: A few diverticula were seen in the sigmoid
colon. Diverticulosis appeared to be of mild severity.
Other Findings: INCOMPLETE COLONOSCOPY that reached ascending
colonoscopy.
Impression:
Diverticulosis of the sigmoid colon
Grade 1 internal hemorrhoids
Stool in the colon
Polyps in the sigmoid colon
INCOMPLETE COLONOSCOPY that reached ascending colonoscopy.
Otherwise normal colonoscopy to ascending colon
___: EGD
Esophagus Mucosa: Normal mucosa was noted. No varices seen.
Stomach Mucosa:Diffuse continuous erythema, congestion and
mosaic appearance of the mucosa with no bleeding were noted in
the stomach body and fundus. These findings are compatible with
Portal gastropathy.
Duodenum Mucosa: Normal mucosa was noted.
Impression:
Normal mucosa in the esophagus
Erythema, congestion and mosaic appearance in the stomach body
and fundus compatible with Portal gastropathy
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
___: CT COLONOGRAPHY
IMPRESSION:
1. No significant polyp or mass identified (greater than 1 cm).
The
sensitivity of CT colonography for polyps greater than 1 cm is
85-90%. The
sensitivity for polyps 6-9mm is about 60-70%. Flat lesions may
be missed with CT Colonography.
2. Cirrhotic liver with sequela of portal hypertension including
splenomegaly and esophageal and gastric varices.
___: UPPER EUS WITH BIOPSY OF ___ SUBCARINAL
MEDIASTINUM
Esophagus: Protruding Lesions: 1 cords of grade II varices were
seen in the lower third of the esophagus. The varices were not
bleeding.
Stomach Mucosa:Diffuse erythema, congestion and mosaic
appearance of the mucosa was noted in the fundus, stomach body
and antrum. These findings are compatible with portal
gastropathy.
Duodenum: Limited exam of the duodenum was normal with the
echoendoscope.
Other findings: EUS was performed using a linear and radial
echoendoscope at ___ MHz and ___ MHz frequency:
T staging: No mass or lesion was noted endoscopically or
sonographically.
N staging: A lymph node was noted in ___ subcarinal
mediastinum [ 35 cm from the incisors]. It measured 1.8 cm in
diameter. The lymph node was hypoechoic and homogenous in
echotexture. The borders were well-defined. No central
intra-nodal vessels were seen. A smaller 0.64cm lymph node was
identified, adjacent to the previous one, with identical
sonographic features. Multiple splenic collateral vessels were
noted sorrounding these two lymph nodes. FNA was performed of
the 1.8 cm lymph node. Color doppler was used to determine an
avascular path for needle aspiration. A 25-gauge needle with a
stylet was used to perform aspiration. Two passes were made
using a SharkCore needle for cytology. Two more passes were made
using a SharkCore needle for pathology.
A third lymph node was noted in ___ area [ 40 cm from
the incisors]. It measured 1.64 cm in diameter. The lymph node
was hypoechoic and homogenous in echotexture. The borders were
well-defined. No central intra-nodal vessels were seen. This
lymph node was not sampled as the aspirating needle would have
to first traverse the splenic vein.
Impression:
1 cords of grade II varices were seen in the lower third of the
esophagus. The varices were not bleeding.
Mosaic appearance in the fundus, stomach body and antrum
compatible with portal hypertension gastropathy
No esophageal mass or lesion was noted endoscopically or
sonographically.
A lymph node was noted in ___ subcarinal mediastinum
[ 35 cm from the incisors].
It measured 1.8 cm in diameter.
The lymph node was hypoechoic and homogenous in echotexture.
The borders were well-defined. No central intra-nodal vessels
were seen.
FNA was performed of the 1.8 cm lymph node.
Color doppler was used to determine an avascular path for needle
aspiration.
A 25-gauge needle with a stylet was used to perform aspiration.
Two passes were made using a SharkCore needle for cytology.
Two more passes were made using a SharkCore needle for
pathology.
Additional passes were not taken due to bleeding risk and
adjacent esophageal varices.
A smaller 0.64cm lymph node was identified, adjacent to the
previous one, with identical sonographic features.
Multiple splenic collateral vessels were noted sorrounding these
two lymph nodes.
A third lymph node was noted in ___ area [ 40 cm from
the incisors].
It measured 1.64 cm in diameter.
The lymph node was hypoechoic and homogenous in echotexture.
The borders were well-defined.
No central intra-nodal vessels were seen.
This lymph node was not sampled as the aspirating needle would
have to first traverse the splenic vein.
Otherwise normal upper eus to third part of the duodenum
Brief Hospital Course:
Ms. ___ is a ___ year old woman with Hep C genotype 1A
cirrhosis (c/b hepatic encephalopathy, grade I esophageal
varices, ___ edema) sent in from clinic for elevated INR, Tbili,
and hyponatremia and MELD of 29 presenting for expedited liver
transplantation work-up.
# HCV Cirrhosis/Expedited Transplant Workup: Pt has Hep C
cirrhosis, biopsy proven, genotype 1A, in an acute
decompensation (unclear exact cause as during hospitalization
there was no initial infectious process; decompensation may have
been secondary to progressive HCV). Complicated by lower
extremity edema, jaundice, hepatic encephalopathy. MELD on
admission 29, up from 25 in ___. MELD remained at this level
throughout hospitalization. Likely contracted Hep C from blood
transfusion in ___ during ectopic pregnancy. Underwent
expedited transplant workup due to progressive liver
disfunction. Had pre-transplant lab tests, endoscopy,
colonoscopy, pulmonary function tests, echocardiogram (normal
biventricular function), PAP smear (negative), abdominal and
chest imaging, and surgical tooth extractions (extraction of
teeth numbers 6, 8, 9, 11, 13, 14, 28). Mammogram obtained from
OSH. Accepted by transplant committee but not listed as she
developed severe pancytopenia with ANC <1000.
Hematology/oncology who believed pancytopenia was secondary to
antibiotics (as she was started on cefepime after tooth
extractions as she developed fever and likely transient
bacteremia in the setting of teeth extractions). Please see
"Pancytopenia" for further explanation of pancytopenia course.
As part of pre-transplantation, patient had a CT chest with
contrast. Results of the CT chest showed "diffuse mediastinal
lymphadenopathy...that could be due to inflammatory, infectious,
or neoplastic etiology." Also CT chest showed "masslike
appearance of lower thoracic esophagus." To further assess the
lymphadenopathy and ?esophageal mass, she underwent Upper EUS.
The Upper EUS did not reveal any esophageal mass. A biopsy of a
___ subcarinal mediastinum lymph node was performed.
immunophenotyping of the lymph node showed findings that "raise
the concern for, but are not diagnostic of a possible B-cell
lymphoproliferative disorder." A PET-Scan was performed which
showed "unchanged mediastinal lymphadenopathy with low level
uptake. These may be reactive in nature. Scattered
abdominal/periportal lymphadenopathy with low level uptake,
likely sequelae of cirrhosis and portal hypertension. Periapical
lucency and focus of FDG uptake in the left maxilla concerning
for dental disease/abscess." Dental was consulted and panorex
was ordered to asses ?left maxilla dental disease/abscess who
did not believe there was any infection present.
Given immunophenotyping concerning for a possible B-cell
lymphoproliferative disorder, Hematology/Oncology was
re-consulted. They believed the lymphadenopathy was most likely
reactive. However they performed a bone marrow biopsy on ___ as
was essential for her candidacy. Bone marrow biopsy results were
pending at the time of discharge. Additionally, final biopsy
results of the ___ subcarinal mediastinum lymph node
were pending at the time of discharge.
**MELD AT THE TIME OF DISCHARGE 28** Total bilirubin 7.8, INR
3.5, Cr 0.4.
# Volume Overload Secondary to Cirrhosis: Patient presented on
furosemide 20 mg PO every other day and spironolcatone 50 mg PO
daily. During hospitalization she did have episodes of volume
overload in the setting of receiving blood products for her
tooth extractions. Additionally, during hospitalization, patient
developed episodes of hyponatremia. Diuretics were titrated and
she appeared euvolemic on a diuretic regimen of 20 mg PO daily
and spironolactone 50 mg PO daily. Weight at the time of
discharge was 81.5 kilograms. Creatinine at discharge 0.4. She
is set to follow-up within the next week to obtain chemistry
panel and titrate diuretics as an outpatient.
# Grade II Esophageal Varices Secondary to Cirrhosis: Patient
underwent Upper EUS which revealed 1 cord o fgrade II varices in
the lower third of the esophagus. Patient was continued on
carvedilol 3.125 mg PO BID. Consideration for titrating the
carvedilol to lower HR and BP as an outpatient should be
discussed. She did not have episodes of variceal or any bleeding
during hospitalization.
# Hepatic Encephalopathy: On ___ Pt developed acute
encaphalopathy. Infectious workup (Urine, blood, c diff)
negative. CXR, CT head, RUQ US, UA unremarkable. No ascites for
tap. No evidence of purulence at extraction sites. Possibly
precipitated from increased PO oxycodone and IV dilaudid after
tooth extractions. Started empirically on PO vanc and then IV
___ while blood cultures and c diff pending. Given Q2h
lactulose, and mental status improved. IV vancomycin and
meropenem were discontinued after 48 hours of negative blood
cultures. Oxycodone was titrated to 10 mg PO Q4H:PRN pain. She
was continued on rifaximin 550 mg PO BID, and lactulose 30 mL PO
QID to titrate to ___ bowel movements daily. During rest of
hospitalization, she did not have further episodes of hepatic
encephalopathy.
# Pancytopenia: Pt developed worsening pancytopenia with ANC
nadir of 700. Hematology consulted, who initially thought most
likely due to cefepime or Flagyl after tooth extraction (please
see above). WBC improved after stopping antibiotics, however,
continued to downtrend again during hospitalization even after
antibiotics were stopped. Broad laboratory evaluation was
performed to assess pancytopenia. HCV viral load came back
positive at 4,310. EBV, CMV, Parvovirus, Adenovirus, HSV ___
came back negative. Vitamin B12 was greater than assay. Folate
was normal at 15. As noted above, patient underwent EUS with
biopsy of a ___ subcarinal lymph node with
immunophenotyping indicating a possible B-cell
lymphoproliferative disorder. Additionally, patient underwent a
PET-Scan which showed "unchanged mediastinal lymphadenopathy
with low level uptake. These may be reactive in nature.
Scattered abdominal/periportal lymphadenopathy with low level
uptake, likely the sequelae of cirrhosis and portal
hypertension." Given these findings, Hematology/Oncology was
re-consulted. After second consultation, they believed the
mediastinal lymphadenopathy was likely reactive lymphadenopathy.
UPEP was sent and was negative. Cryoglobulins were also
negative. SPEP showed polyclonal hypergammaglobulinemia with IgG
2,259, IgA 629, IgM 104. Although cryoglobulins were negative,
Rheumatoid Factor was obtained and was elevated at 82. Given
this finding, C3 and C4 were sent. These were pending at the
time of discharge. If both are low, consider CH50 testing.
Given question of B-cell lymphoproliferative disorder, patient
underwent a bone marrow biopsy performed by Hematology/Oncology.
# Mediastinal Lymphadenopathy. Please see "Pancytopenia" for
work-up of the mediastinal lymphadenopathy.
At the time of discharge, both ___ lymph node and
bone marrow biopsy were pending. Bone Marrow biopsy will be
followed by Hematology/Oncology and will schedule a follow-up
appointment with patient pending the results of the bone marrow
biopsy.
# Fever/hypoxia: Patient had fever to 101 on ___. Given
previous neutropenia, started on vanc/cefepime/flagyl. There was
concern about possible bibasilar consolidation, but most likely
fevers was due to transient bacteremia and hypoxia ___ volume
overload in setting of receiving platelets and FFP for dental
extraction procedure (please see above). Abx narrowed to
CTX/flagyl on ___, stopped completely on ___.
# Vulvar itching: completed fungal tx as outpatient. ? candidal
vanginitis vs HSV. S/p 5 day course of acyclovir. Itching
returned and used miconazole cream to labia at night x 7 days.
This improved vulvar itching.
# Coagulopathy: Pt not currently bleeding. Has history of UGIB,
but history unknown and patient unable to recount what the upper
GI bleed was related to (unsure if related to gastritis, ulcers,
or esophageal varices). During hospitalization, she had an INR
of 4. Platelets in ___. INR was likely in setting of poor PO
intake prior to presentation to ___ as well as underlying
liver disease. She received vitamin K 10 mg IV x 5 days
(___). Improved marginally. INR at the time of discharge
3.5. Platelet count at time of discharge 21.
# Chronic pain: Patient has history of chornic pain in
shoulders, back, and abdomen. Takes oxycodone 10mg q4h prn pain
at home. She was discharged on oxycodone 10 mg PO Q4H:PRN for
pain as noted above.
# Depression: patient has a history of depression. She was
continued on mirtazapine 15 mg PO QHs and ativan 0.5 mg PO daily
PRN anxiety.
TRANSITIONAL ISSUES
===================
-Discharge Weight: 81.5 kilograms (180 pounds).
-Creatinine at the time of discharge 0.4.
-MELD at time of discharge: 28.
-Diuretic Regimen: Furosemide 20 mg PO daily, spironolactone 50
mg PO daily.
-Rheuatmoid Factor was elevated. Cryoglobulins were negative.
Given these findings C3 and C4 were sent. They were pending at
the time of discharge. If C3-C4 low, consider CH50 testing.
-HCV Viral Load: 4,310.
-Please follow-up final biopsy results of ___
subcarinal mediastinum biopsy.
-Please follow-up final bone marrow biopsy results which were
pending at the time of discharge.
-Please obtain chemistry 10 at the next visit and adjust
diuretics.
-Patient noted to have eosinophilia at discharge from hospital
(WBC 1.7, eosinphils 6%). Please evaluate with strongyloides
and/or Churg ___ as outpatient if clinically indicated.
-Polyps located within sigmoid colon on colonoscopy. Please
consider follow-up of polyps.
-Patient had vitamin D level of 15 in ___. Consider vitamin D
supplemenation.
-Patient had negative HBsAb: consider vaccination series for
hepatitis B given
-Code: Full
-Contact: ___ (HCP, father) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 50 mg PO DAILY
2. Lorazepam 0.5 mg PO PRN anxiety
3. Furosemide 20 mg PO EVERY OTHER DAY
4. Rifaximin 550 mg PO BID
5. Carvedilol 6.25 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
8. Lactulose 30 mL PO QID titrate for ___ BM daily
9. HydrOXYzine 25 mg PO TID:PRN itching
10. Magnesium Oxide 400 mg PO DAILY
Discharge Medications:
1. Carvedilol 3.125 mg PO BID
RX *carvedilol 3.125 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Lactulose 30 mL PO QID titrate for ___ BM daily
RX *lactulose 10 gram/15 mL 30 mL by mouth four times a day Disp
#*500 Milliliter Milliliter Refills:*0
4. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Spironolactone 50 mg PO DAILY
RX *spironolactone 50 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. HydrOXYzine 25 mg PO TID:PRN itching
9. Lorazepam 0.5 mg PO PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth daily Disp #*10 Tablet
Refills:*0
10. Magnesium Oxide 400 mg PO DAILY
RX *magnesium oxide 400 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
11. Mirtazapine 15 mg PO QHS
RX *mirtazapine 15 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
12. Acetaminophen 650 mg PO Q8H:PRN pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*0
13. Outpatient Lab Work
Chemistry 10. Please call Dr. ___ ___ and fax to
___.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
=================
Decompensated Hepatitis C cirrhosis c/b portal
hypertension/encephalopathy
Pancytopenia
Lymphadenopathy
Surgical tooth extractions
Hepatic Encephalopathy
Secondary Diagnosis
===================
History of ___ Esophagus
Hypertension
Chronic Back Pain
History of Helicobacter Gastritis
s/p Cholecystectomy ___
s/p Ruptured ectopic pregnancy in 1980s.
s/p Ex Lap in ___
Liposuction abdominoplasty ___
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital due to a decompensation of your liver
failure and to be expedited on the transplant list. Your sodium
was low on admission and your diuretics were stopped initially.
___ underwent the transplant workup including lab tests,
endoscopy, colonoscopy, pulmonary function tests,
echocardiogram, PAP smear, abdominal and chest imaging, and
surgical tooth extractions.
___ were accepted to the transplant list but low white blood
cell counts and swollen lymph nodes in your chest needed to be
evaluated prior to being listed. ___ underwent a PET CT scan and
an endoscopic ultrasound. A biopsy of one of the lymph nodes was
performed during the Endoscopic Ultrasound.
Results of the biopsy required a Hematology/Oncology
consultation. ___ underwent a bone marrow biopsy on the day
prior to discharge. Results of the bone marrow biopsy were
pending at the time of discharge. These will be followed up
during one of your outpatient follow-up appointments. The
Hematology/Oncology doctors ___ let ___ know if a follow-up
appointment will be required regarding the bone marrow biopsy
results.
Your course was complicated by one episode of hepatic
enceophalopathy (confusion) that cleared with increased amounts
of lactulose. ___ had no signs of infection to trigger the
event. It was likely due to increased pain medications required
after surgical tooth extractions. Please be cautious of the
amount of pain medications ___ take in the future. Please also
continue to take the lactulose.
Your diuretic regimen was re-started prior to discharge. ___
were on furosemide 20 milligrams by mouth DAILY. ___ were also
on spironolactone 50 milligrams by mouth DAILY.
Please take your weight EVERY OTHER DAY. If ___ weight increases
or decreases by 2 pounds, please contact your MD to adjust your
lasix regimen. Your weight at the time of discharge was 81.5
kilograms (180 pounds).
It was a pleasure taking care of ___ during your
hospitalization. We wish ___ all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19932024-DS-14 | 19,932,024 | 24,609,514 | DS | 14 | 2146-03-18 00:00:00 | 2146-03-18 14:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Altered Mental Status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ F with pMHx significant for hep C
cirrhosis and HTN with recent admission for decompensated liver
failure and expedited transplant workup now returning from an
OSH with AMS.
Patient initially presented to an OSH with AMS by her husband.
Unfortunately she was unable to provide any history; however,
per report she has been medication compliant. She was treated
with one dose of lactulose at the ___ and transferred to the
___ ED.
-Addendum (after speaking with father @ ___-
Day before admission, patient came to ___ for heme/onc f/up with
her father. He noted she appeared drowsy and at times not as
alert during the visit. She also missed at least one dose of
lactulose during this time as it took so long to get to and from
the hospital. She has not been consuming EtOH and has had no
changes in her oxycodone or ativan dosages.
In the ED, initial vitals: 98.6 86 130/90 20 98%
Exam was significant for being guiac negative.
Labs were drawn and were significant for H/H (anemic but at
baseline), sodium of 124, transaminitis and Tbili of 13.
CT abd/pelvis and head CT were performed which were
unremarkable. There was no drainable ascites seen on CT scan.
She received a lactulose enema and was admitted to the MICU due
to concerns that she would require frequent monitoring given her
AMS.
On transfer, vitals were: 84 125/65 18 92% RA
On arrival to the MICU, the patient was hemodynamically stable
and appeared uncomfortable. She knows that she is in a hospital
but does not know she is in ___ and thinks she is in ___.
She is otherwise answering questions appropriately. She states
that her father, ___, is her HCP. She denies any
recent fevers, chills, cough, chest pain, abdominal pain,
nausea, vomiting. She does report feeling the need to urinate
frequently.
Past Medical History:
PAST MEDICAL HISTORY:
1. Hepatitis C/cirrhosis c/b hepatic encephalopathy,
gastric/esophageal varices, portal hypertensive gastropathy.
2. Portal hypertension and encephalopathy.
3. Portal hypertension/volume overload.
4. History of ___.
5. Hypertension.
6. Chronic back pain on and off is longstanding.
7. History of helicobacter gastritis.
8. Pancytopenia-being worked up by Heme/Onc ___
9. Mediastinal lymphadenopathy, being worked up by Heme/Onc
___.
PAST SURGICAL HISTORY:
1. Status post cholecystectomy back in ___.
2. Status post ruptured ectopic pregnancy in the ___.
3. Status post ex lap in ___.
4. Liposuction abdominoplasty in ___.
5. Dental extraction ___
Social History:
___
Family History:
Family history of coronary artery disease in her mother,
negative for hypertension, no diabetes, no stomach, breast, or
colon cancer.
Physical Exam:
ADMISSION
Vitals: BP:129/81 P:87 R:16 O2: 97 on RA
GENERAL: Largely alert and oriented but cannot name ___,
___ in ___, appears uncomfortable, follows commands
HEENT: Sclera icteric, NCAT, EOMI, PERRLA
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, systolic murmur
ABD: soft, non-tender, non-distended, no rebound tenderness or
guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Jaundiced, no obvious abrasions or other injuries.
NEURO: CN II-XII grossly intact, moving all extremities, speech
fluent
DISCHARGE
VS: 98.6 95/51 69 18 100/ra (stable)
GENERAL: NAD. Comfortable
Eyes: Mild icterus without conjunctival injection
ENT: MMM. No oral lesions
NECK: supple, no JVP
COR: RRR, NMRG
LUNGS: CTAB, no w/r/c
ABDOMEN: soft, ntnd. ascites greater than yesterday.
SKIN: Warm. Dry. Petechia on hands and feet
NEURO: AAOx3, no asterixis, ___ reverse, calm and appropriate
MSK: now with trc-1+ bilat symmetric ___ edema
Pertinent Results:
ADMISSION
___ 01:27PM ___
___ 01:27PM PLT COUNT-28*
___ 01:27PM WBC-4.1# RBC-3.11*# HGB-11.2*# HCT-32.8*#
MCV-106* MCH-36.1* MCHC-34.2 RDW-18.5*
___ 05:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 05:20AM ALT(SGPT)-63* AST(SGOT)-272* ALK PHOS-195*
TOT BILI-13.5* DIR BILI-3.7* INDIR BIL-9.8
___ 03:01PM ALT(SGPT)-52* AST(SGOT)-139* LD(LDH)-522* ALK
PHOS-212* TOT BILI-14.5*
DISCHARGE
___ 05:56AM BLOOD WBC-2.1* RBC-2.29* Hgb-8.7* Hct-25.0*
MCV-109* MCH-38.0* MCHC-34.7 RDW-18.8* Plt Ct-18*
___ 05:56AM BLOOD Neuts-66.3 Lymphs-16.1* Monos-13.0*
Eos-4.1* Baso-0.5
___ 05:56AM BLOOD ___ PTT-65.9* ___
___ 05:56AM BLOOD Glucose-114* UreaN-10 Creat-0.3* Na-126*
K-3.8 Cl-100 HCO3-24 AnGap-6*
___ 05:56AM BLOOD ALT-45* AST-112* LD(___)-339*
AlkPhos-169* TotBili-9.1*
___ 05:56AM BLOOD TotProt-6.4 Albumin-2.4* Globuln-4.0
Calcium-8.1* Phos-3.5 Mg-1.7
MICRO
___ STOOL C. difficile DNA amplification
assay-FINAL INPATIENT (NEGATIVE)
___ URINE URINE CULTURE-FINAL INPATIENT (NO
GROWTH)
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT (NO GROWTH)
___ URINE URINE CULTURE-FINAL {ESCHERICHIA
COLI, KLEBSIELLA PNEUMONIAE} INPATIENT (SEE OMR FOR
SUSCEPTIBILITIES)
___ URINE URINE CULTURE-FINAL INPATIENT (NO
GROWTH)
___ MRSA SCREEN MRSA SCREEN-FINAL INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-FINAL
INPATIENT
(NO GROWTH)
STUDIES
___ Cardiovascular ECHO ___ ___.
With bubbles. See OMR for full report
Conclusions
There is early appearance of agitated saline/microbubbles in the
left atrium/ventricle at rest most consistent with an atrial
septal defect or stretched patent foramen ovale (though a very
proximal intrapulmonary shunt cannot be fully excluded). Overall
left ventricular systolic function is normal (LVEF>55%). Right
ventricular chamber size and free wall motion are normal.
Compared with the report of the prior study (images
unavailable for review) of ___, saline microbubble
administration suggests an ASD or PFO (saline not given
previously).
___ Imaging CHEST (PA & LAT) ___.
Approved
Heart size is normal. Mediastinum is normal. Lungs are clear.
There is no pleural effusion or pneumothorax.
___ Imaging LIVER OR GALLBLADDER US ___.
1. Patent portal vein with normal direction of flow.
2. Cirrhosis and splenomegaly without ascites. No suspicious
hepatic lesion.
___ Imaging CT HEAD W/O CONTRAST ___.
Approved
No acute intracranial process.
___BD & PELVIS WITH CO ___.
1. Cirrhotic liver with sequela of portal hypertension including
splenomegaly and paraesophageal and intra-abdominal varices. No
ascites. Please note hepatocellular carcinoma cannot be
excluded on this single phase study.
2. Extensive porta hepatic lymphadenopathy, likely related to
chronic liver disease however, other neoplastic processes are
not excluded.
3. Moderate hiatal hernia.
Brief Hospital Course:
___ hep C cirrhosis (MELD ~30), previous negative workup for B
cell malignancy ___ mediastinal lymphadenopathy and
pancytopenia), recent admission for decompensated liver failure
and expedited transplant workup now returning from an OSH with
AMS, transferred on ___.
Initially in MICU here. Initially treated with vanc/zosyn,
increased lactulose frequency, and withholding sedating
medications. MS improved to baseline (AOx3, ___ backwards) with
above interventions. De escalated to Zosyn only, then to Cipro
500 bid. She was discharged home on a course of Cipro x10d abx
total for complicated UTI (d1 = ___, d10 = ___.
Of note, diffuse mediastinal and abdominal LAD noted on last
hospitalization's scans. Heme Onc previously consulted; LN bx
and BMBx showed noncaseating granulomas c/w sarcoidosis. This
admission, had Pulm consult; their recs were to monitor her
closely (see OMR for full recs). She will follow up for CT torso
with contrast and ID appointment as an outpatient.
TRANSITIONAL
- hyponatremia: developed in hospital. restricted to 1.5L fluid
diet. recheck at next visit
- fluid retention: re-started diuretics at furosemide
20/spironolactone 50 (eg, same lasix dose and decr
spironolactone dose) given hyponatremia. check potassium at next
visit and supplement as needed.
- liver transplant: patient still awaiting transplant listing
due to insurance issues, pls clarify in outpatient setting.
- Pulm consult: dx sarcoidosis, see OMR for complete recs.
- needs CT torso with contrast and ID followup as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 20 mL PO QID
2. Magnesium Oxide 400 mg PO ONCE
3. Mirtazapine 15 mg PO QHS
4. Lorazepam 0.5 mg PO QHS:PRN anxiety
5. Carvedilol 6.25 mg PO BID
6. Furosemide 20 mg PO EVERY OTHER DAY
7. Spironolactone 100 mg PO DAILY
8. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
9. Omeprazole 20 mg PO DAILY
10. Rifaximin 550 mg PO BID
Discharge Medications:
1. Carvedilol 3.125 mg PO BID
2. Furosemide 20 mg PO DAILY
3. Lactulose 20 mL PO QID
RX *lactulose 20 gram/30 mL 20 mL by mouth 4 times per day
Refills:*2
4. Lorazepam 0.5 mg PO QHS:PRN anxiety
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth at bedtime Disp
#*10 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp
#*20 Tablet Refills:*0
7. Rifaximin 550 mg PO BID
8. Spironolactone 50 mg PO DAILY
9. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*12 Tablet Refills:*0
10. Magnesium Oxide 400 mg PO ONCE Duration: 1 Dose
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
- hepatic encephalopathy
- cirrhosis, decompensated
- hepatitis C virus infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were seen at ___ for confusion, which we think is due to a
urine infection. You were treated for this and you improved.
Please see your appointments and medications below.
Followup Instructions:
___
|
19932242-DS-24 | 19,932,242 | 22,352,403 | DS | 24 | 2159-08-11 00:00:00 | 2159-08-11 15:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Latex / Plavix / Lipitor / Sulfa (Sulfonamide
Antibiotics) / Pollen/Seasonal
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with hx of multiple myeloma on
active chemotherapy (carfilzomib/dexamethasone), CAD (___ ___
s/p PCI to ___), ___ (EF 45%), and several syncopal episodes
over past few weeks now admitted for recurrent episode in clinic
resulting in significant facial trauma. On day of admission, Mr.
___ was in the ___ clinic for a platelet transfusion. He
reports having fallen asleep and he was told to stand up to get
a chest x ray. He got up suddenly and reportedly
felt-lightheaded and the feeling as though he would fall down -
he attempted to reach out his hand to brace himself on the wall
however he was not able to do so and fell on his face.
Of note, per the witnesses in the clinic, Mr. ___ walked
through the hallway in the clinic before he suffered the
syncope.
Of note the patient has had several prior episodes of falling.
He reports an episode about a month ago when he was walking to
clinic on the ___ of ___. He walked out of the
elevator and felt he was going to fall down and was not able to
reach the bench before he fell. There was another episode about
___ months ago which occurred again on the ___ of ___
and again in the setting of getting up suddenly. He had another
episode about ___ years ago however he does not remember the
events of that episode. The patient denies symptoms of
palpitations or shortness of breath associated with these
episodes. He believes they are due to changes in his blood
pressure. Of note the patient denies actually losing
consciousness during any of the episodes, however per the
witnesses he was found unconscious in the clinic on the day of
admission. He reports remembering everything before and
everything after the episode but does not remember the episodes
of actually falling through the air. He was transported to the
emergency department for further eval.
Of note, he was seen in clinic on ___ by his cardiologist Dr.
___ who ___ him for similar symptoms. He had
normal vitals signs and was clinically euvolemic so continued on
his lisinopril and metoprolol. The etiology for his pre-syncope
and falls was unclear so he was recommended to have a Holter
monitor and treadmill stress test.
In the ED, VS: 68 122/61 18 96% ra
- arrived with significant facial trauma, right sided anterior
packing, left side fell out but no longer bleeding
- Labs notable for platelets 26k and 15k on repeat, WBC 0.8k
(39% PMNs), Hgb 8.7, bicarb 20 otherwise normal chemistries
- CT revealed bilateral Lefort I fractures, comminuted nasal
bone fracture, and fractures of the nasal septum and
inferomedial wall of R orbit, diffuse facial soft tissue
swelling. No intracranial hemorrhage. acute blood in R maxillary
sinus, paranasal sinuses, frontal sinuses
- He recieved 1 bag of platelets with increas to 38k
- Plastics was consulted but pt reportedly refused to speak with
them or be examined
- Prior to transfer, VS: 98.7 75 153/72 18 99% RA
Onr arrival to the floor, VS: 98.6 168/86 80 18 98%RA
He was lying comfortably in bed in NAD.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ y/o h/o CAD s/p stent placement, PVD, HTN, DM with no
prior history of renal disease who was transferred from ___
(___) after presenting with acute renal failure (Cr 8.96
on presentation to ___, expedited work-up revealing new
diagnosis of multiple myeloma.
After initial response to Velcade and dexamethasone, his
IgA started to rise and at that point, Revlimid was added with
initial response; however, this was followed by both increase in
his IgA as well as symptoms concerning for heart failure.
Revlimid was stopped at that point and Mr. ___ received a cycle
of Velcade, cyclophosphamide, and dexamethasone. This was
followed by a pulse Cytoxan. On ___ patient enrolled in
___ protocol ___: A Phase ___ Open-label Study to Assess
the Safety, Tolerability and Preliminary Efficacy of TH-302, A
Hypoxia-Activated Prodrug, and Dexamethasone with or without
Bortezomib in Subjects with Relapsed/Refractory Multiple
Myeloma.
Patient was taken off study ___ due to disease progression
as
seen in UPEP. C1D1 Carfilzomib ___. ECHO ___ EF 40%. No
clear benefit from Carfilzomib. Switched to IV Pom/Dex.
PAST MEDICAL HISTORY:
- Hypertension.
- Hyperlipidemia.
- Coronary artery disease, status post drug-eluting stent to
patient's RCA ___ out of state.
- Diabetes mellitus? (patient denies)
- Chronic obstructive pulmonary disease.
- Peripheral vascular disease.
- History of colon polyps seen by Dr. ___.
- Resection of a polyp from his vocal cords.
- ? obstructive sleep apnea.
- Hand trauma with damage to his left hand, status post multiple
surgeries.
Social History:
___
Family History:
-Father died of MI age ___
-Mother died of blood clot in brain when pt was ___ years old.
Physical Exam:
ADMISSION EXAM:
================
VITALS: 98.6 168/86 80 18 98%RA
General: adult man lying in bed, significant facial trauma, no
acute distress
Eyes: edema and echymosis surrounding orbit bilaterally.
ENT: right nare packed with nasal trumpet
Neck: no jugular venous distention
Lungs: mostly CTAB though mild rhonchi intermittently
Heart: RRR, normal S1 and S2, no m/r/g,
Abd: Soft, NTND, NABS, no organomegaly, normal aorta without
bruit
Msk: Normal muscle strength and tone, normal gait and station,
no scoliosis or kyphosis
Ext: No c/c/e
Neuro: A and O to self, place and time, appropriate mood and
affect
DISCHARGE EXAM:
================
Vitals: Tm 98.8/Tc 98, HR 78, BP 128/76, RR 18, SaO2 99% RA
Gen: Alert, oriented, multiple facial traumas, in no acute
distress.
HEENT: Large ___ ecchymoses with mild edema, nontender.
No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, JVP not elevated.
CV: Normocardic, regular. Normal S1,S2. No MRG.
LUNGS: Breathing comfortably, scattered rhonchi that partially
cleared after coughing, no crackles.
ABD: +BS, soft, nondistended, nontender.
EXT: WWP. No ___ edema.
SKIN: ___ ecchymoses and small ecchymosis on right
inner cheek, ecchymosis across right shoulder.
NEURO: A&Ox3.
LINES: Port.
Pertinent Results:
ADMISSION LABS:
================
___ 09:30AM BLOOD WBC-0.8*# RBC-2.31* Hgb-8.7* Hct-25.1*
MCV-109* MCH-37.8* MCHC-34.7 RDW-21.7* Plt Ct-26*
___ 09:30AM BLOOD Neuts-39* Bands-0 Lymphs-55* Monos-1*
Eos-4 Baso-0 ___ Myelos-1* NRBC-2*
___ 04:40AM BLOOD ___ PTT-30.1 ___
___ 09:30AM BLOOD UreaN-24* Creat-1.1 Na-135 K-3.6 Cl-104
HCO3-20* AnGap-15
___ 09:30AM BLOOD ALT-17 AST-27 LD(LDH)-207 AlkPhos-47
TotBili-0.4
___ 09:30AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.3*
DISCHARGE LABS:
================
___ 12:24AM BLOOD WBC-2.7* RBC-1.94* Hgb-7.1* Hct-21.4*
MCV-110* MCH-36.6* MCHC-33.2 RDW-24.2* RDWSD-96.0* Plt Ct-31*
___ 12:24AM BLOOD Neuts-62 Bands-1 ___ Monos-15*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-1.70 AbsLymp-0.59
AbsMono-0.41 AbsEos-0.00 AbsBaso-0.00
___ 12:24AM BLOOD ___ PTT-34.5 ___
___ 12:24AM BLOOD Glucose-107* UreaN-21* Creat-1.0 Na-136
K-3.7 Cl-104 HCO3-22 AnGap-14
___ 12:24AM BLOOD Calcium-7.8* Phos-2.4* Mg-1.7
___ 12:24AM BLOOD ALT-14 AST-17 LD(LDH)-170 AlkPhos-45
TotBili-0.3
IMAGING:
=========
CT Sinus (___):
IMPRESSION:
1. Right Lefort I fracture. Fractures through the left
pterygoid plates and suspected maxillary sinus fracture
suspicious for left LeFort I. Additional fractures included
comminuted fracture of the nasal bone, fracture through the
nasal septum, and a fracture of the inferomedial wall of the
right orbital floor/lamina papyracea.
2. Significant erosion of the alveolar process of the maxilla
right greater the left, not due to trauma. Correlate clinically
with physical exam findings, as this may relate to pre-existing
peridontogenic disease, underlying malignancy, or chronic
inflammation.
3. Sequelae of trauma including diffuse soft tissue swelling of
the face centered on the nasal bone, as well as blood products
and small foci of air seen throughout the facial sinuses, as
above.
CT Head (___):
IMPRESSION:
1. No evidence of intracranial hemorrhage or acute infarction.
2. Multiple facial bone fractures, at least including the nasal
bone, the nasal septum, and likely the inferomedial wall of the
right bony orbit/lamina
papyracea. These are better evaluated on same-day CT facial
bones.
3. Chronic findings including white matter small vessel ischemic
changes and volume loss.
TTE (___):
No atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is at least 15 mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity is moderately dilated. There is mild regional left
ventricular systolic dysfunction with hypokinesis of the basal
inferior wall with mild global hypokinesis. There is
considerable beat-to-beat variability of the left ventricular
ejection fraction due to an irregular rhythm/premature beats
(LVEF = 40-50%). The estimated cardiac index is normal
(>=2.5L/min/m2). Doppler parameters are indeterminate for left
ventricular diastolic function. There is no left ventricular
outflow obstruction at rest or with Valsalva. There is no
ventricular septal defect. Right ventricular chamber size is
normal. with normal free wall contractility. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. Mild (1+) aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, LV wall thicknesses are normal and the
cavity is more dilated; other findings are similar.
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of multiple
myeloma on C3D21 of carfilzomib/pomalidomide, CAD (MI ___ s/p
PCI to RCA), sCHF (EF 45%), and several recurrent syncopal
episodes who was admitted after syncope resulting in significant
facial trauma.
# Syncope: Patient has been having recurrent syncopal events
and lack of prodrome is concerning for a cardiac etiology.
Orthostatics were negative. EKG was normal and patient was
monitored on telemetry with occasional PVCs but major events.
TTE was largely unchanged and showed no outflow obstruction.
Outpatient ___ of hearts showed no events, and he will continue
to wear this when he returns home. He has follow-up scheduled
with cardiology.
# Craniofacial trauma: CT scan showed multiple facial
fractures, including bilateral Lefort I fractures and a
comminuted fracture of the nasal bone. Patient declined
surgical intervention so these were managed conservatively. He
did require bilateral nasal packing for bleeding, but these
packings were removed quickly without any recurrent bleeding.
He was put on clindamycin while packing was in place. A bedside
speech and swallow evaluation was normal, though it was
recommended that he have an outpatient video swallow study to
evaluate for silent aspiration (given RLL opacities on previous
CXRs).
# Multiple myeloma: Diagnosed in ___, on cycle 3 of
carfilzomib/pomalidomide. Neupogen was continued while he was
here. He required one platelet transfusion in the setting of
bleeding and two blood transfusions. Acyclovir and allopurinol
were continued.
Chronic Issues:
# CAD: MI ___ s/p PCI to RCA at ___ in ___.
Catheterization at ___ performed in ___ for 8 month h/o
DOE and abnormal persantine MIBI showed proximal occlusion of
the RCA, not amenable to PCI; left to right collaterals to the
distal RCA were noted. Repeat coronary angiogram ___ with
stable findings.
# Systolic heart failure with EF 35% in ___ (previously
50-55% in ___ while undergoing chemotherapy for multiple
myeloma with Velcade and Revlimid, which improved to 45% with
medical management. Right heart catheterization reveled normal
right and left sided filling pressures, and endomyocardial
biopsy with no evidence of amyloid. Repeat TTE on this
admission showed EF 40-50%. He was continued on metoprolol and
lisinopril. There was no evidence of volume overload.
TRANSITIONAL ISSUES:
=====================
[ ] Patient was cleared by speech and swallow after bedside
swallowing evaluation, however they recommended outpatient video
swallow study to rule out silent aspiration. They will arrange
this appointment.
[ ] Patient will continue outpatient event monitor as directed
by cardiology.
[ ] Patient is scheduled for follow-up in ___ clinic next
week for Neupogen and CBC monitoring.
[ ] Patient does not need follow-up with Plastics unless he
decides to pursue surgical intervention.
[ ] Patient should NOT drive given ongoing recurrent syncopal
episodes. This was explained at length to him and he expressed
understanding.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q8H
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Allopurinol ___ mg PO DAILY
4. Escitalopram Oxalate 20 mg PO DAILY
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Gabapentin 300 mg PO QID
7. Montelukast 10 mg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Ranitidine 150-300 mg PO QHS:PRN heartburn
11. Simethicone 40-80 mg PO QID:PRN gas
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin B Complex 1 CAP PO DAILY
14. Omeprazole 40 mg PO DAILY
15. Fenofibrate 145 mg PO DAILY
16. Fish Oil (Omega 3) 1000 mg PO BID
17. Lovastatin 80 mg ORAL DAILY
18. melatonin 5 mg oral QPM
19. Metoprolol Succinate XL 12.5 mg PO QAM
20. Metoprolol Succinate XL 25 mg PO QHS
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Allopurinol ___ mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Fenofibrate 145 mg PO DAILY
5. Fluticasone Propionate 110mcg 1 PUFF IH BID
6. Gabapentin 300 mg PO QID
7. Lisinopril 5 mg PO DAILY
8. Metoprolol Succinate XL 12.5 mg PO QAM
9. Metoprolol Succinate XL 25 mg PO QHS
10. Montelukast 10 mg PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Tamsulosin 0.4 mg PO QHS
13. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
14. Fish Oil (Omega 3) 1000 mg PO BID
15. Lovastatin 80 mg ORAL DAILY
16. melatonin 5 mg oral QPM
17. Multivitamins 1 TAB PO DAILY
18. Ranitidine 150-300 mg PO QHS:PRN heartburn
19. Simethicone 40-80 mg PO QID:PRN gas
20. Vitamin B Complex 1 CAP PO DAILY
21. Acetaminophen 650 mg PO Q8H:PRN facial pain
RX *acetaminophen 325 mg 2 tablet(s) by mouth q8h prn Disp #*30
Tablet Refills:*0
22. Outpatient Speech/Swallowing Therapy
Video swallow study
ICD-9 code: ___
___ ___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
===================
Syncope
Facial fractures
SECONDARY DIAGNOSES:
=====================
Multiple myeloma
Pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you during your hospitalization at
___. You were admitted after
passing out in clinic. You sustained multiple fractures to your
facial bones and required nasal packing to prevent bleeding. It
is unclear why you have been passing out, but we are concerned
that it may be related to an abnormal heart rhythm in your heart
(though no abnormal rhythms were detected on our monitors here).
Please continue to wear the event monitor at home as directed
by cardiology.
Please continue your medications as prescribed and keep your
follow-up appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19932242-DS-27 | 19,932,242 | 20,351,538 | DS | 27 | 2159-11-28 00:00:00 | 2159-11-28 18:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Latex / Plavix / Lipitor / Sulfa (Sulfonamide
Antibiotics) / Pollen/Seasonal / lisinopril
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ male with PMH of CAD s/p DES to RCA ___, CHF
(EF ___ 40-50%), COPD, multiple myeloma who recently elected
not to pursue further chemotherapy presents with dyspnea. The
patient was at f/u appointment (requested ___ clinic
visits after last discharge and GOC discussion). During his
clinic f/u, the patient reported SOB for a few days which had
worsened overnight. Pt reports orthopnea, had to sleep upright.
He also reports wheeze and cough. He denied fevers, chills,
chest pain. In clinic, the patient was tachypneic with RR 28,
Sat 100% RA, HR 90 and BP 130/80. Lung exam revealed diffuse
wheeze w/o crackles. Pt had normal cardiac exam and trace ___
edema. Due to concern for CHF vs. PNA, the patient was treated
in clinic with albuterol x2, Lasix 40mg IV and transferred to
the ED. Of note, pt was scheduled to receive platelets and RBCs
in clinic today, however both were deferred ___ dyspnea.
In the ED, initial vitals were T 98.9, HR 87, BP 151/92, O2sat
100% on NC, Pt was evaluated with ABG which showed pH 7.41, pCO2
24, pO2 109, HCO3 16. Chem 7 remarkable for CL 110, HCO3 16, BUN
27, Cr 2.6; BNP 8604. WBC 1.9, Hgb 7.3, HCT 21.6, Platelets ___lood, protein, no ___
CXR showed mild-moderate pulmonary edema
Pt treated with albuterol and ipratropium neb and additional
20mg IV Lasix.
On the floor, pt reports persistent dyspnea and wheeze which has
somewhat improved with treatment in the ED. Reports
nonproductive cough.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ y/o h/o CAD s/p stent placement, PVD, HTN, DM with no
prior history of renal disease who was transferred from OSH
(___) after presenting with acute renal failure (Cr 8.96
on presentation to ___, expedited work-up revealing new
diagnosis of multiple myeloma.
After initial response to Velcade and dexamethasone, his
IgA started to rise and at that point, Revlimid was added with
initial response; however, this was followed by both increase in
his IgA as well as symptoms concerning for heart failure.
Revlimid was stopped at that point and Mr. ___ received a cycle
of Velcade, cyclophosphamide, and dexamethasone. This was
followed by a pulse Cytoxan. On ___ patient enrolled in
DF/___ protocol ___: A Phase ___ Open-label Study to Assess
the Safety, Tolerability and Preliminary Efficacy of TH-302, A
Hypoxia-Activated Prodrug, and Dexamethasone with or without
Bortezomib in Subjects with Relapsed/Refractory Multiple
Myeloma.
Patient was taken off study ___ due to disease progression
as
seen in UPEP. C1D1 Carfilzomib ___. ECHO ___ EF 40%. No
clear benefit from Carfilzomib. Switched to IV Pom/Dex.
PAST MEDICAL HISTORY:
- Hypertension.
- Hyperlipidemia.
- Coronary artery disease, status post drug-eluting stent to
patient's RCA ___ out of state.
- Diabetes mellitus? (patient denies)
- Chronic obstructive pulmonary disease.
- Peripheral vascular disease.
- History of colon polyps seen by Dr. ___.
- Resection of a polyp from his vocal cords.
- ? obstructive sleep apnea.
- Hand trauma with damage to his left hand, status post multiple
surgeries.
Social History:
___
Family History:
-Father died of MI age ___
-Mother died of blood clot in brain when pt was ___ years old.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97.7, 128/80, 90, 28, 100 on 3L
Gen: audible wheeze, speaking in short sentences, SOB after
conversion, belly breathing
HEENT: OP clear
NECK: JVP not visualized ___ body habitus
LYMPH: No cervical or supraclav LAD
CV: RRR, nl S1 S2, no murmurs/rubs/gallops though overall
decreased ___ wheezing
LUNGS: diffuse wheezing over all lung fields
ABD: NABS. Soft, NT, ND.
EXT: trace ___ edema
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3
LINES: POC
DISCHARGE PHYSICAL EXAM
Vitals: 97.5, 124/70, 76, 22, 98% on RA
Gen: no acute distress, speaking in full sentences without SOB
HEENT: OP clear
NECK: JVP not visualized ___ body habitus
LYMPH: No cervical or supraclav LAD
CV: RRR, nl S1 S2, no murmurs/rubs/gallops
LUNGS: decreased breath sounds at bases, minimal high pitched
expiratory wheeze in anterior lung fields
ABD: NABS, soft, NT, ND
EXT: trace ___ edema
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3
LINES: POC
Pertinent Results:
ADMISSION LABS:
___ 09:21AM BLOOD WBC-1.9* RBC-2.35* Hgb-7.3* Hct-21.6*
MCV-92 MCH-31.1 MCHC-33.8 RDW-17.5* RDWSD-56.7* Plt Ct-15*
___ 09:21AM BLOOD Neuts-58 Bands-0 ___ Monos-9 Eos-0
Baso-0 Atyps-1* ___ Myelos-1* Blasts-0 NRBC-1* AbsNeut-1.10*
AbsLymp-0.61* AbsMono-0.17* AbsEos-0.00* AbsBaso-0.00*
___ 09:21AM BLOOD Plt Smr-RARE Plt Ct-15*
___ 09:21AM BLOOD UreaN-27* Creat-2.6* Na-141 K-4.6 Cl-110*
HCO3-16* AnGap-20
___ 09:21AM BLOOD ALT-30 AST-41* LD(___)-230 AlkPhos-59
TotBili-1.1
___ 09:21AM BLOOD TotProt-9.1* Albumin-3.2* Globuln-5.9*
Calcium-7.9* Phos-2.5* Mg-1.7
___ 11:54AM BLOOD ___ pO2-109* pCO2-24* pH-7.41
calTCO2-16* Base XS--6
___ 11:54AM BLOOD Lactate-0.9
___ 09:21AM BLOOD proBNP-8604*
DISCHARGE LABS:
___ 09:10AM BLOOD WBC-2.0* RBC-2.37* Hgb-7.3* Hct-21.2*
MCV-90 MCH-30.8 MCHC-34.4 RDW-17.0* RDWSD-53.4* Plt Ct-27*
___ 01:06PM BLOOD Plt Ct-46*#
___ 12:00AM BLOOD Glucose-149* UreaN-45* Creat-2.8* Na-141
K-4.2 Cl-106 HCO3-19* AnGap-20
___ 12:00AM BLOOD ALT-27 AST-26 LD(___)-209 AlkPhos-52
TotBili-0.8
___ 12:00AM BLOOD Calcium-7.9* Phos-1.9*# Mg-1.8
UricAcd-2.3*
MICROBIOLOGY
___ BLOOD CULTURES PENDING
___ BLOOD CULTURE: STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
___ URINE CULTURE NG
___ C DIFF NEGATIVE
___ BLOOD CULTURE PENDING
IMAGING
CXR ___: As compared to the previous image, there is now
mild to moderate pulmonary edema. Moderate cardiomegaly. No
pleural effusions. No pneumonia.
ECG ___: Sinus rhythm with one inferanodal ventricular
premature beat. There is underlying left atrial abnormality and
left anterior hemiblock. There are non-specific mild T wave
abnormalities. Compared to the previous tracing of ___ there
is no significant change.
Brief Hospital Course:
Mr. ___ is a ___ male with PMH of CAD s/p DES to RCA ___, CHF
(EF ___ 40-50%), COPD, multiple myeloma who presents from
clinic with dyspnea concerning for CHF vs. COPD exacerbation.
# COPD vs. CHF exacerbation: Pt presented to ___ clinic
with dyspnea. He was found to have marked wheezing on physical
exam. The patient was evaluated with labs, which were remarkable
for elevated BNP greater than baseline. CXR showed mild to
moderate pulmonary edema. The patient was thought to have COPD
vs. CHF exacerbation. He was treated with BiPAP, quickly weaned
to room air. He was given duonebs, prednisone, levofloxacin and
IV furosemide with improvement in symptoms. The patient was
treated with a prednisone taper, which he will finish ___ (one
additional dose prednisone 20mg PO). He was treated with
levofloxacin 500mg PO q48hrs, which he will continue through
___. His home COPD regimen was adjusted, started on
Fluticasone-Salmeterol Diskus (100/50) 1 inhalation BID and
Tiotropium Bromide 1 cap inhaled daily. His Fluticasone
Propionate 110mcg 2puff inhaled BID was discontinued at
discharge. The patient was started on furosemide 40mg PO qday
for volume management and management of intermittent
hypercalcemia. The patient will f/u with his outpatient
oncologist for further evaluation. Furosemide and
fluticasone-salmeterol can be increased, if needed as
outpatient. ___ consider increased diuretic with platelet or RBC
transfusion.
# Coagulase negative staph positive blood culture x1: The
patient was found to have coag negative staph in ___ blood
cultures. Further blood cultures were pending at the time of
discharge. The patient was treated empirically with 1 dose of IV
vancomycin, which was discontinued as the positive blood culture
was thought to represent contamination.
# Diarrhea: The patient had some episodes of diarrhea on
admission. He was found to be C diff negative and his diarrhea
resolved.
# Multiple Myeloma: The patient has a history of multiple
myeloma for which has declined further treatment per family
meeting during the patient's last hospital admission. The
patient was continued on his home acyclovir, allopurinol,
multivitamin. The patient's calcitonin nasal spray was held, per
previous report from outpatient provider. The patient's calcium
remained within normal limits during admission. He was started
on furosemide as above. The patient should f/u with his
outpatient oncologist for further management.
# CAD: The patient was restarted on his home lovastatin on
discharge. The patient should f/u with outpatient providers to
consider discontinuing this medication given goals of care.
# Hypertriglyceridemia: The patient's fenofibrate was held at
discharge due to concern regarding the risk of rhabdomyolysis in
the setting of concurrent statin use and worsening kidney
disease.
# Acute on chronic kidney disease: The patient had Cr of 3.0
elevated from previously baseline 2.5-2.8 after IV diuresis. The
patient was evaluated with urine lytes which showed FENa 9.0% in
the setting of IV furosemide therapy. Cr trended down to 2.8
upon discharge. The patient was continued on his home sodium
bicarbonate.
# Anxiety, depression: continued home escitalopram, pt will
restart home lorazepam at discharge.
# Hypertension: continued home metoprolol
# Neuropathic pain: continued home gabapentin
# BPH: continued home tamsulosin
# GI: continued ranitidine, omeprazole, simethicone
Transitional Issues:
- Continue levofloxacin 500mg PO q48hrs through ___
- Continue prednisone taper, one additional dose 20mg PO x1
___
- Pt should f/u with heme/onc for further management of
intermittent hypercalcemia
- Pt should f/u for further management of Lasix dosing and
volume status. ___ titrate up Lasix as needed. Consider
increased doses vs. IV diuresis with blood/platelet transfusions
- continue to monitor COPD, consider uptitration of advair as
needed
# CODE: DNR/DNR (confirmed w/pt) okay with ICU and okay with
BiPAP
# EMERGENCY CONTACT: ___ (cousin) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Allopurinol ___ mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Fenofibrate 145 mg PO QHS
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Gabapentin 300 mg PO BID
7. Lorazepam 1 mg PO QHS:PRN anxiety
8. Metoprolol Succinate XL 25 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 40 mg PO DAILY
12. Ranitidine 150 mg PO QHS PRN heartburn
13. Simethicone 40-80 mg PO QID:PRN gas
14. Tamsulosin 0.4 mg PO QHS
15. Vitamin B Complex 1 CAP PO DAILY
16. Lovastatin 80 oral daily
17. magnesium gluconate 27 mg (500 mg) oral daily
18. Melatin (melatonin) 5 mg oral qHS
19. Acyclovir 400 mg PO Q12H
20. Calcitonin Salmon 200 UNIT NAS DAILY
21. Sodium Bicarbonate 650 mg PO QPM
22. Sodium Bicarbonate 1300 mg PO QAM
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Allopurinol ___ mg PO DAILY
3. Escitalopram Oxalate 20 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Montelukast 10 mg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Ranitidine 150 mg PO QHS PRN heartburn
8. Simethicone 40-80 mg PO QID:PRN gas
9. Sodium Bicarbonate 650 mg PO QPM
10. Sodium Bicarbonate 1300 mg PO QAM
11. Tamsulosin 0.4 mg PO QHS
12. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth every day Disp #*30
Tablet Refills:*0
13. Levofloxacin 500 mg PO Q48H
RX *levofloxacin 500 mg 1 tablet(s) by mouth every other day
Disp #*2 Tablet Refills:*0
14. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
inhaled every day Disp #*30 Capsule Refills:*0
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
16. PredniSONE 20 mg PO DAILY Duration: 1 Dose
This is dose # 2 of 2 tapered doses
RX *prednisone 20 mg 1 tablet(s) by mouth every day Disp #*1
Tablet Refills:*0
17. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL 5 mL by mouth at
bedtime as needed Refills:*0
18. Guaifenesin ___ mL PO Q6H:PRN cough
19. Lorazepam 1 mg PO QHS:PRN anxiety
20. Lovastatin 80 mg ORAL DAILY
21. magnesium gluconate 27 mg (500 mg) oral daily
22. Melatin (melatonin) 5 mg oral qHS
23. Multivitamins 1 TAB PO DAILY
24. Vitamin B Complex 1 CAP PO DAILY
25. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/Dose 1
puff inhaled twice a day Disp #*1 Disk Refills:*0
26. Gabapentin 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
primary: acute on chronic congestive heart failure, chronic
obstructive pulmonary disease, acute on chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
Thank you for allowing us to participate in your care at ___.
You were admitted to the hospital with shortness of breath. We
believe this was caused by your lung disease or your heart
disease. We treated you with steroids, antibiotics, and inhaled
medications, as well as some water pills to remove fluid from
your lungs. After these treatments, your symptoms improved.
After discharge, please continue to take your new inhalers as
prescribed. Please continue lasix, your water pill. Please
monitor your weight. You can weight yourself every morning and
call your doctor if your weight increases more than 3 pounds.
Please continue to take your antibiotics, levofloxacin through
___. Please take one additional dose of prednisone 20mg on
___. Please follow up with your oncologist for further
management of your breathing and multiple myeloma.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19932572-DS-10 | 19,932,572 | 24,050,017 | DS | 10 | 2180-11-09 00:00:00 | 2180-11-09 17:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
bacitracin / Anesthetics - Amide Type
Attending: ___.
Chief Complaint:
Obstructing left renal stone (transfer from ___.
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy
History of Present Illness:
___ transferred from ___ with left ureteral stone, left
hydronephrosis and left flank pain for 3 days.
stone. Has had 3 days of L flank pain, poor POs. Tmax 101.9.
CT demonstrates a 10mm x 5 mm in the proximal mid to left ureter
at the level of L4 with mild proximal ureteral dilation and mild
left hydronephrosis.
The patient is currently comfortable, reporting mild left flank
pain. She denies any nausea, vomiting, chest pain. She reports
fevers and chills.
Past Medical History:
Migraines
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM:
General: No apparent distress.
HEENT: MMM, sclera anicteric.
Neck: No lymphadenopathy, supple.
Pulmonary: CTAB, no rales or rhonchi.
Cardiovascular: RRR, normal S1/S2.
Abdomen: Soft, mild LLQ tenderness.
Extremities: No CCE.
Neurologic: Alert and oriented x3.
Skin: No rash, skin eruptions or erythema.
Vascular: Palpable bilateral femoral pulses. Palpable bilateral
brachial and radial pulses.
DISCHARGE PHYSICAL EXAM:
___ 0008 Temp: 98.9 PO BP: 128/76 R Lying HR: 90 RR: 18 O2
sat: 94% O2 delivery: Ra
General: Middle-aged woman in no acute distress. Resting in bed.
HEENT: Sclerae anicteric, MMM, oropharynx clear. Vesicular
lesions in cluster with surrounding erythema on mid lower lip.
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Sparse L basilar crackles but otherwise clear
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, +L nephrostomy w/
overlying bandages that are c/d/I. Nephrostomy tube draining
clear pale yellow urine.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. 1+
edema in LEs.
Pertinent Results:
ADMISSION LABS:
___ 07:29PM GLUCOSE-105* UREA N-20 CREAT-1.1 SODIUM-145
POTASSIUM-3.5 CHLORIDE-111* TOTAL CO2-18* ANION GAP-16
___ 07:29PM estGFR-Using this
___ 07:29PM CALCIUM-7.1* PHOSPHATE-1.7* MAGNESIUM-1.1*
___ 07:29PM WBC-4.2 RBC-3.97 HGB-12.0 HCT-36.6 MCV-92
MCH-30.2 MCHC-32.8 RDW-12.6 RDWSD-42.8
___ 07:29PM NEUTS-75* BANDS-17* LYMPHS-2* MONOS-1* EOS-0
BASOS-0 ___ METAS-4* MYELOS-1* AbsNeut-3.86 AbsLymp-0.08*
AbsMono-0.04* AbsEos-0.00* AbsBaso-0.00*
___ 07:29PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 07:29PM PLT SMR-VERY LOW* PLT COUNT-61*
___ 07:29PM ___ PTT-29.7 ___
OTHER PERTINENT LABS:
___ 03:50AM BLOOD WBC-17.7* RBC-3.61* Hgb-10.7* Hct-32.2*
MCV-89 MCH-29.6 MCHC-33.2 RDW-13.3 RDWSD-43.7 Plt Ct-48*
___ 03:30PM BLOOD WBC-22.1* RBC-3.59* Hgb-10.6* Hct-32.3*
MCV-90 MCH-29.5 MCHC-32.8 RDW-13.3 RDWSD-44.0 Plt Ct-57*
___ 06:28AM BLOOD WBC-25.0* RBC-3.39* Hgb-10.2* Hct-30.3*
MCV-89 MCH-30.1 MCHC-33.7 RDW-13.6 RDWSD-44.4 Plt Ct-66*
___ 03:15PM BLOOD WBC-27.0* RBC-3.62* Hgb-10.8* Hct-32.3*
MCV-89 MCH-29.8 MCHC-33.4 RDW-13.4 RDWSD-44.1 Plt Ct-82*
___ 04:23AM BLOOD WBC-21.3* RBC-3.38* Hgb-9.9* Hct-30.4*
MCV-90 MCH-29.3 MCHC-32.6 RDW-13.6 RDWSD-44.9 Plt Ct-86*
___ 04:45AM BLOOD WBC-15.9* RBC-3.48* Hgb-10.2* Hct-31.1*
MCV-89 MCH-29.3 MCHC-32.8 RDW-13.6 RDWSD-44.5 Plt ___
___ 04:55AM BLOOD WBC-15.6* RBC-3.48* Hgb-10.3* Hct-31.4*
MCV-90 MCH-29.6 MCHC-32.8 RDW-13.6 RDWSD-44.8 Plt ___
___ 03:30PM BLOOD Glucose-87 UreaN-12 Creat-0.4 Na-145
K-4.1 Cl-110* HCO3-26 AnGap-9*
___ 06:28AM BLOOD Glucose-97 UreaN-10 Creat-0.4 Na-147
K-3.5 Cl-109* HCO3-26 AnGap-12
___ 04:23AM BLOOD Glucose-117* UreaN-10 Creat-0.4 Na-145
K-3.0* Cl-104 HCO3-30 AnGap-11
___ 04:45AM BLOOD Glucose-107* UreaN-8 Creat-0.3* Na-148*
K-3.4 Cl-105 HCO3-29 AnGap-14
___ 04:55AM BLOOD Glucose-89 UreaN-7 Creat-0.3* Na-143
K-4.1 Cl-102 HCO3-29 AnGap-12
___ 06:28AM BLOOD Calcium-8.2* Phos-1.7* Mg-1.9
___ 04:23AM BLOOD Calcium-8.1* Phos-3.0 Mg-1.6
RADIOLOGY:
------------------
___ CXR
IMPRESSION:
1. Interval increase in pulmonary edema.
2. Interval increase in bibasilar opacification, which may
represent
atelectasis, although a superimposed pneumonia or aspiration
cannot be
excluded.
3. Small bilateral pleural effusions.
Brief Hospital Course:
Ms. ___ is a ___ woman with history of kidney stone s/p
lithotripsy in ___, stress and urge incontinence s/p fascial
sling in ___, melanoma ___, r. calf) and arthritis who
presented as a transfer from ___ after 3 day history of
fevers, chills, LLQ abdominal pain, and night sweats found to
have L ureter 10x5mm obstructing stone. She was transferred to
___ for urology evaluation of infected kidney stone. On ___
she underwent percutaneous nephrostomy placement by
Interventional Radiology. She was transferred from the Urology
service to the Medicine service on ___ for further
management and antibiotic treatment for this infection.
Active issues during this admission:
# Sepsis ___ UTI, resolved
# E coli Bacteremia
# UTI secondary to obstructing nephrolithiasis s/p percutaneous
nephrostomy tube
Baseline Cr 0.6. UCx at ___ notable for pan-sensitive E.
coli, with associated GNR bacteremia on BCx. S/p L percutaneous
nephrostomy tube on ___ by Interventional Radiology. Had brief
requirement of pressor support while in the ICU, was stabilized
and improved and transferred to medicine. Had a rising
leukocytosis that then resolved gradually. Urine and blood cx
from ___ grew pan-sensitive Proteus mirabilis and E. coli.
She was on antibiotics at ___, was continued on antibiotics
(ceftazidime and vancomycin, vanc was discontinued on ___ on
___ here at ___, was was transitioned to PO
ciproflocaxin on ___. On discharge, the plan is to continue for
a total of 2 weeks of coverage for E coli bacteremia (end date
will be ___. Pain was managed with acetaminophen and
oxycodone.
# hypoxia
For several days after the patient arrived to the medicine
service, she was requiring ___ supplemental oxygen. It was felt
that this was likely from excessive IV fluids causing a degree
of pulmonary edema. She did not have any symptoms of pneumonia.
She was weaned off of oxygen and was on room air on ___.
# Headache
Bilateral, at temples, lasting 5+ days. Only migraine like
feature is some nausea. Otherwise features most c/w tension
headache. Pt has had migraines in the past (including emesis,
photophobia) and feels this is more like a regular headache.
This was treated with various agents including Fiorcet,
acetaminophen, and metoclopramide.
# Thrombocytopenia: Platelets 61 on admission, down from
baseline of >200. No active signs of bleeding with nadir = 48.
4T score 3 indicating low risk of HIT. Increased gradually as
patient was improving clinically.
# Coagulopathy: Elevated INR up to 1.4. Normal baseline. Likely
i/s/o poor PO intake and recent sepsis. Resolved prior to
admission.. She was given PO Vitamin K 5mg x3 days (___).
CHRONIC ISSUES:
================
# Asthma: Continued home Albuterol nebs and inhaler PRN
# GERD: Continued home Omeprazole
# Arthritis: Held home Celecoxib i/s/o obstructing stone.
TRANSITIONAL ISSUES:
[]PLEASE RECHECK CBC AND CHEM 7 AT PCP ___
[]Plan for 2 week course of GNR coverage since PCN placement,
discharged on cipro, end date ___
[] outpatient urology follow up for outpatient lithotripsy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Celecoxib 100 mg oral Other
2. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN Headache
2. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*16 Tablet Refills:*0
4. Simethicone 80 mg PO QID
RX *simethicone 80 mg 1 tablet by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. HELD- Celecoxib 100 mg oral Other This medication was held.
Do not restart Celecoxib until talking with your PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Sepsis
Bacteremia
Obstructive nephrolithiasis
Nephrostomy
Tension Headache
Discharge Condition:
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___.
Why did you come to the hospital?
-You came to the hospital because you had an infected kidney
stone.
-It was causing you to be septic (very sick).
What was done for you while you were here?
-You got a nephrostomy tube through the skin to the L kidney to
drain the urine and releive the infection
-You were treated with strong antibiotics to treat the
infection.
-You were given other medications to help with other symptoms,
such as your headache.
What should you do when you go home?
-You should follow up with your PCP as well as the Urology team
at ___ (see below for appointment details).
We wish you the best.
Sincerely,
Your ___ Medicine Team
Followup Instructions:
___
|
19932649-DS-18 | 19,932,649 | 26,105,867 | DS | 18 | 2154-02-01 00:00:00 | 2154-02-01 14:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle fracture
Major Surgical or Invasive Procedure:
ORIF left bimalleolar ankle fracture
History of Present Illness:
___ female presents with the above fracture s/p mechanical
fall. She was transferring to a chair from her walker when she
lost balance and fell, noting left ankle pain and deformity.
Denies HS/LOC. Denies numbness or tingling distally in the foot.
Denies any other injuries. Denies any other active illness.
Past Medical History:
Prior CVA ___ years ago) w/ L-sided residual deficits
HLD
Bipolar disorder on Depakote (previously lithium)
Social History:
___
Family History:
Noncontributory
Physical Exam:
General: Well-appearing female in no acute distress.
left lower extremity:
- Skin intact, threatened medially prior to reduction
- clear deformity
- Soft, non-tender thigh and leg
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
___ 01:14PM K+-3.9
___ 01:05PM ___ PTT-27.7 ___
___ 10:49AM GLUCOSE-169* UREA N-19 CREAT-1.3* SODIUM-138
POTASSIUM-6.4* CHLORIDE-98 TOTAL CO2-24 ANION GAP-16
___ 10:49AM estGFR-Using this
___ 10:49AM WBC-9.2 RBC-3.98 HGB-13.5 HCT-41.4 MCV-104*
MCH-33.9* MCHC-32.6 RDW-13.3 RDWSD-51.0*
___ 10:49AM NEUTS-76.5* LYMPHS-11.8* MONOS-9.0 EOS-2.0
BASOS-0.4 IM ___ AbsNeut-7.04* AbsLymp-1.09* AbsMono-0.83*
AbsEos-0.18 AbsBaso-0.04
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left ankle fracture and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for ORIF, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to <<>> was appropriate. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the LLE extremity, and will be discharged on ASA 325 for
DVT prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Divalproex (EXTended Release) 250 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. Lithium Carbonate 150 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. rOPINIRole 0.5 mg PO QHS
7. Vitamin D ___ UNIT PO 1X/WEEK (SA)
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
Do not exceed 4000mg of acetaminophen (Tylenol) total, daily.
2. Aspirin 325 mg PO DAILY
Expected end date of this medication ___.
RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 100 mg PO BID
Take while using narcotic pain medications. Hold for loose
stools
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
Do not drink/drive on this medication. Beware sedation.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hrs Disp
#*24 Tablet Refills:*0
5. Atorvastatin 40 mg PO QPM
6. Divalproex (EXTended Release) 250 mg PO DAILY
7. Lithium Carbonate 150 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. rOPINIRole 0.5 mg PO QHS
10. Vitamin D ___ UNIT PO 1X/WEEK (SA)
11. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you follow-up
with your PCP and discuss restarting this medication
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing in the left lower extremity in a splint
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take 325 mg aspirin daily for 4 weeks total from the
date of her operation. The expected end date of this medication
is ___.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
Physical Therapy:
Nonweightbearing in the left lower extremity in a short leg
splint
Treatments Frequency:
Any staples or superficial sutures you have are to remain in
place for at least 2 weeks postoperatively. Incision may be
left open to air unless actively draining. If draining, you may
apply a gauze dressing secured with paper tape. You may shower
and allow water to run over the wound, but please refrain from
bathing for at least 4 weeks postoperatively.
Please remain in the splint until follow-up appointment. Please
keep your splint dry. If you have concerns regarding your
splint, please call the clinic at the number provided.
Followup Instructions:
___
|
19933011-DS-10 | 19,933,011 | 28,900,589 | DS | 10 | 2176-10-04 00:00:00 | 2176-10-05 20:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Ditropan / morphine / dicyclomine
Attending: ___.
Chief Complaint:
bladder spasm, lower back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with advanced CKD on HD (MWF, due for dialysis today,
makes urine), bladder cancer, L nephrectomy, chronic
hydronephrosis, and recurrent pyelonephritis presenting with
hematuria, vomiting, diarrhea. Two days prior to admission
patient began to have bladder "tightness" and bladder spasms
with dysuria and hematuria, which she has experienced before.
She then developed non-bloody non-bilious vomiting every half
hour and was unable to keep food or water down for the past two
days. She reports subjective fever, chills, suprapubic abdominal
pain that radiates to right flank and right back. Feels symptoms
also similar to prior urinary tract infection. Denies chest
pain, shortness of breath, cough, melena, hematochezia, recent
travel, recent antibiotics, or change in diet.
In the ED, initial vital signs were: T 97.5, HR 111, BP 150/78,
RR 16, O2 100% on RA. Exam notable for mild tenderness in the
RUQ and mild right CVA tenderness, no volume overload. Labs were
notable for Na 130, K6.4, bicarb 19, BUN 61, Cr 7.9, WBC 18.7
(89.3% N), and dirty UA with RBCs, nitrite neg. EKG showed sinus
tachycardia, no peaked T waves. Renal was consulted for
hyperkalemia (K 6.2 without EKG changes) and recommended medical
management and avoiding kayexelate for now given abdominal
symptoms. Patient was given 1.5 L NS, dilaudid 1.5 mg and
oxycodone 10 mg, ondansetron 4 mg, ceftriaxone, IV dextrose 50%,
insulin regular 10 units, IV furosemide 80 mg, belladonna &
opium suppository, magnesium sulfate 6 g. On transfer, vital
signs were T 98.0, HR 95, BP 108/69, RR 16, O2 100% on RA.
On the floor, patient continued to complain of periodic severe
abdominal pain and bladder spasms.
Past Medical History:
-___ dx with bladder cancer. Reports of 60+ bladder surgeries
for recurrence.
-___ left nephrectomy due to metastasis
-Recurrent pyelonephritis, previous urine cultures grew E. coli,
no previous bacteremia
-ESRD: HD on MWF, makes urine, baseline Cr ___. Thought to be
___ chronic hydronephrosis from scar tissue over ureteral site
and recurrent pyelonephritis
-___ hydronephrosis due to scarring of ureters from numerous
bladder surgeries, temporary nephrostomy tubes placed
-Hep C stage II fibrosis s/p treatment with interferon x2 not
completed due to poor tolerance, last viral load 458,000 IU/mL
in ___
-GERD with gastric ulcers
-h/o HTN: previously on amlodipine, has not required
anti-hypertensives since starting HD
Social History:
___
Family History:
Denies any family history of kidney disorders.
Family history of lung and colon cancer. Father died of colon
cancer age ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: T 98.5, BP 111/52, HR 98, RR 16, O2 98% on RA, BS 123,
wt 130 lb
General: No acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRLA
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Back: right CVA tenderness
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: Foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: alert, CN II-XII intact
Skin: erythematous rash with scale around the adhesive on her
left chest
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 98.7 (max), 150/89 (120s-150s/70s-100), 82 (70s-80s),
16, 100% on RA
General: Alert, no acute distress
HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear,
EOMI, PERRLA
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Back: right CVA tenderness
Abdomen: Soft, mild RUQ tenderness, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding
GU: Foley
Ext: Warm, well perfused, 2+ pulses, no edema
Pertinent Results:
ADMISSION LABS:
=================
___ 07:15PM BLOOD WBC-18.7*# RBC-4.55# Hgb-14.6# Hct-42.9#
MCV-94 MCH-32.1* MCHC-34.0 RDW-12.6 RDWSD-43.4 Plt ___
___ 07:15PM BLOOD Neuts-89.3* Lymphs-3.4* Monos-6.0
Eos-0.1* Baso-0.2 Im ___ AbsNeut-16.69*# AbsLymp-0.64*
AbsMono-1.13* AbsEos-0.01* AbsBaso-0.04
___ 07:15PM BLOOD Glucose-109* UreaN-61* Creat-7.9*#
Na-130* K-6.4* Cl-91* HCO3-19* AnGap-26*
___ 07:15PM BLOOD ALT-44* AST-46* AlkPhos-109* TotBili-0.8
___ 08:00PM BLOOD ALT-37 AST-27 AlkPhos-104 TotBili-0.9
___ 07:15PM BLOOD Albumin-4.5
___ 05:45AM BLOOD Calcium-8.7 Phos-5.1*# Mg-1.5*
___ 07:21PM BLOOD Lactate-2.7* K-7.1*
___ 07:15PM BLOOD Lipase-22
PERTINENT LABS:
======
___ 07:21PM BLOOD Lactate-2.7* K-7.1*
___ 05:49AM BLOOD Lactate-1.4
IMAGING:
=========
CTU ___
1. Severe right hydroureteronephrosis is unchanged in extent
since ___, with
no discrete obstructing mass identified on this noncontrast
examination.
2. Previously described right perinephric fat stranding on the
prior exam has
improved.
3. Postoperative changes related to prior left nephrectomy and
bladder mass
resection, as described above.
MICROBIOLOGY:
=============
Blood culture ___ - NGTD
___ 7:30 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
MICROCOCCUS/STOMATOCOCCUS SPECIES. PRESUMPTIVE
IDENTIFICATION.
Isolated from only one set in the previous five days.
ABIOTROPHIA/GRANULICATELLA SPECIES.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
___ 9:10 am BLOOD CULTURE Source: Line-dialysis.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
HCV-RNA NOT DETECTED.
Performed using Cobas Ampliprep / Cobas Taqman HCV v2.0
Test.
Linear range of quantification: 1.50E+01 IU/mL - 1.00E+08
IU/mL.
Limit of detection: 1.50E+01 IU/mL.
___ 08:40PM URINE Color-Amber Appear-Cloudy Sp ___
___ 08:40PM URINE Blood-LG Nitrite-NEG Protein->300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-8.0 Leuks-MOD
___ 08:40PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-NONE Epi-0
___ 08:40PM URINE WBC Clm-MANY
___ 8:40 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
DISCHARGE LABS:
==================
___ 06:17AM BLOOD WBC-6.4 RBC-3.27* Hgb-10.3* Hct-30.1*
MCV-92 MCH-31.5 MCHC-34.2 RDW-12.2 RDWSD-41.5 Plt ___
___ 06:17AM BLOOD Glucose-88 UreaN-48* Creat-7.3*# Na-134
K-3.8 Cl-94* HCO3-17* AnGap-27*
___ 06:17AM BLOOD Calcium-8.2* Phos-6.2* Mg-2.2
Brief Hospital Course:
SUMMARY
===========
This is a ___ year old female with past medical history of
bladder CA, chronic hydronephrosis with recurrent
pyelonephritis, ESRD on HD admitted ___ w Ecoli Urinary
Tract Infection, clinically improving on vancomycin and CTX,
course complicated by bladder spasm secondary to foley, resolved
after removal, able to be discharged home on course of PO
ciprofloxacin.
# Complicated Ecoli cystitis/pyelonephritis: Patient w a history
of recurrent pyelo with E. coli, who presented with Pyuria on
UA, hematuria, and urine culture growing E. coli concerning for
complicated UTI; upon speciation to pansensitive e. coli, pt was
transitioned to PO ciprofloxacin (total of 7 days, end:
___
# Bladder Spasm - given large amount of thick purulent urinary
output, patient initially had foley placed to aid clearance;
this resulted in intermittent lower abdominal pain thought to be
bladder spasms; pain control with belladonna suppositories,
acetaminophen, oxycodone; foley removed once purulence had
resolved and bladder spasms did not recur.
# Positive Blood Culture - admission cultures grew several
morphologies of Gram+ cocci, prompting initial treatment with
vancomycin; upon speciation, they were thought to be
contaminants and antibiotics were stopped.
# Anemia of Kidney Disease: History of normocytic anemia, likely
___ chronic kidney disease. ___ have a component of acute blood
loss from hematuria. Current Hgb. 11.3. Started Venofer (iron
sucrose) 100mg QHD (last dose: ___ per renal recs.
# Hyperkalemia: K on presentation 6.4, no EKG changes. Patient
treated medically with furosemide, dextrose, and insulin. K
normalized s/p HD on ___ and ___.
# Hyperphosphatemia: Resolved, phos decreased from 4.8 to 4.4.
- per renal recs, hold calcitriol and if phos becomes elevated,
consider adding phos binder - sevelmer 800mg tid with meals
after finishing ciprofloxacin
# ESRD: On hemodialysis (MWF, makes urine). Estimated GFR 5.5%.
Current weight 59.0 kg, 5 kg above estimated dry weight. Patient
appears euvolemic on exam. Renal to contact access surgery
regarding future plans for access. Continued on nephrocaps, low
K/Phos/Na diet.
# GERD with gastric ulcers- continued home omeprazole
# Depression: continue home fluoxetine and lorazepam
# Bladder cancer s/p L nephrectomy: Currently s/p numerous
surgeries and a L nephrectomy.
# HCV: s/p interferon x 2 without treatment completion.
TRANSITIONAL ISSUES:
- last day of ciprofloxacin ___
- Pt has mildly elevated phos while inpatient, may consider
adding sevelmer 800mg tid with meals once she is done with
ciprofloxacin course
- Patient still has HD catheter; will need f/u with transplant
nephrology re: maturation of AV fistula.
- Code: full (confirmed)
- Emergency Contact: husband ___ (___)
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Lorazepam 2 mg PO QHS:PRN anxiety
3. Fluoxetine 40 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Magnesium Oxide 400 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Fluoxetine 40 mg PO DAILY
2. Lorazepam 2 mg PO QHS:PRN anxiety
3. Magnesium Oxide 400 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Ciprofloxacin HCl 250 mg PO Q24H Duration: 2 Days
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth once daily
Disp #*2 Tablet Refills:*0
8. Amlodipine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Complicated Ecoli urinary tract infection
Bladder Spasm
End stage renal disease on hemodialysis
Anemia of CKD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at the ___
___. You were recently admitted for bladder spasms
and a urinary tract infection. You were treated with antibiotics
and you improved. You will continue these antibiotics as an
outpatient.
Please keep all of your follow-up appointments and take all of
your medications as prescribed.
It was a pleasure caring for you.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19933011-DS-11 | 19,933,011 | 25,749,618 | DS | 11 | 2176-12-14 00:00:00 | 2176-12-15 04:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Ditropan / morphine / dicyclomine
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old F with history of HTN, HCV, and ESRD on
HD, from chronic hydronephrosis and recurrent pyelonephritis who
presents to ___ "not feeling well." Her brother went to check
on her today as she hasn't been answering the phone. He drove
over to see her today "looked ok" at first but then was very
confused and looking for things. She states she has been
sleeping quite a lot the last 2 days, ___ hours a night. She
did not go to dialysis on ___ because her husband is
currently in the ICU at ___ and ___ was feeling
increasingly fatigued. Her last HD session was ___. She
does make some urine normally but has not made any urine for the
last 24 hours. She has also had associated dry heaves for the
last three days.
Review of systems is negative for any fevers, chills, chest
pain, shortness of breath.
Of note, patient was treated for complicated Ecoli
cystitis/pyelonephritis treated with po ciprofloxacin for which
she was hospitalized ___.
In the ED, initial vitals: 12:46 2 97.7 81 150/90 16 100% RA
Labs were significant for wbc 14.6 with 88.3%N, Na132, HCO317,
Creat 9.7, K6.5, improved to 6.1. EKG with no peaked T waves.
Imaging showed renal u/s notable for severe right
hydroureteronephrosis with cortical thinning. No debris seen
within the renal collecting system.
Seen by renal who recommended: repeat chem10, renal u/s given hx
recurrent pyelonephritis, and treatment of K if peaked t waves
with plans for dialysis within the next ___ hours
Patient was given alb neb X 1, 30g sodium polystyrene, 10U
regular insulin, D50% 12.5gm, and ceftriaxone 1g for u/a with lg
leuk, >182 wbc, few bacteria.
Vitals prior to transfer:
Today 18:40 0 97.8 72 135/81 18 100% RA
On the floor, patient notes that she had been having ongoing
nausea/vomiting over the last month which had worsened over the
last week - she also noted associated dysuria and increased
frequency. She notes these symptoms are typical of her UTIs. She
has also had associated night sweats over the same time period
and believes she lost about 15lbs over the last month. Of note,
she has been undergoing extensive stress in the setting of her
husband's recent hospitalization at ___ for biliary sepsis and
cirrhosis. Review of systems also positive for palpitations in
ED which improved after being treated for hyperkalemia and 1
episode of diarrhea with associated vomiting today after eating
an egg sandwich.
ROS:
No changes in vision or hearing, no changes in balance. No
cough, no shortness of breath, no dyspnea on exertion. No chest
pain. No hematochezia, no melena. No numbness or weakness, no
focal deficits.
Past Medical History:
-___ dx with bladder cancer. Reports of 60+ bladder surgeries
for recurrence.
-___ left nephrectomy due to metastasis
-Recurrent pyelonephritis, previous urine cultures grew E. coli,
no previous bacteremia
-ESRD: HD on MWF, makes urine, baseline Cr ___. Thought to be
___ chronic hydronephrosis from scar tissue over ureteral site
and recurrent pyelonephritis
-___ hydronephrosis due to scarring of ureters from numerous
bladder surgeries, temporary nephrostomy tubes placed
-Hep C stage II fibrosis s/p treatment with interferon x2 not
completed due to poor tolerance, last viral load 458,000 IU/mL
in ___
-GERD with gastric ulcers
-h/o HTN: previously on amlodipine, has not required
anti-hypertensives since starting HD
Social History:
___
Family History:
Denies any family history of kidney disorders.
Family history of lung and colon cancer. Father died of colon
cancer age ___.
Physical Exam:
ADMISSION LABS
VS: T98 BP139/78 HR79 RR18 100%RA
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: Clear, no wheeze, rales, or rhonchi
COR: RRR, normal S1/S2, no murmurs
CHEST: ___ chest dialysis cath
ABD: Soft, NT ND, normal BS
EXTREM: Warm, no edema; AV fistula in RUE (not currently being
used)
NEURO: CN II-XII grossly intact, motor function grossly normal
DISCHARGE EXAM
Vitals: T97.8 109/61 HR78 RR18 100%RA 52.7kg
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: Clear, no wheeze, rales, or rhonchi
COR: RRR, normal S1/S2, no murmurs
CHEST: ___ chest dialysis cath
ABD: Soft, NT ND, normal BS; no suprapubic pain on palpation
EXTREM: Warm, no edema; AV fistula in RUE (not currently being
used)
BACK: no flank pain
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
___ 01:45PM BLOOD WBC-14.6*# RBC-3.83* Hgb-11.3 Hct-34.2
MCV-89 MCH-29.5 MCHC-33.0 RDW-13.8 RDWSD-44.5 Plt ___
___ 01:45PM BLOOD Neuts-88.3* Lymphs-5.1* Monos-5.6
Eos-0.2* Baso-0.3 Im ___ AbsNeut-12.86* AbsLymp-0.74*
AbsMono-0.82* AbsEos-0.03* AbsBaso-0.05
___ 01:45PM BLOOD Glucose-89 UreaN-88* Creat-9.7*# Na-132*
K-8.3* Cl-93* HCO3-17* AnGap-30*
___ 01:45PM BLOOD Calcium-9.3 Phos-8.2*# Mg-2.0
___ 02:29PM BLOOD Lactate-2.0 Na-135 K-6.5* Cl-97
calHCO3-31*
___ 05:29PM BLOOD K-6.1* calHCO3-19*
MICROBIOLOGY
___ URINE CULTURE (Final ___: NO GROWTH.
___ BLOOD CX PENDING
___ BLOOD CX PENDING
IMAGING
___ CXR
No acute cardiopulmonary process. No pneumonia. No pulmonary
edema or pulmonary vascular congestion.
___ Renal u/s
1. Severe right hydroureteronephrosis with cortical thinning. No
debris seen within the renal collecting system.
2. A small nodular lesion is seen along the bladder wall.
Consider
cystoscopy to further assess.
RECOMMENDATION(S): A small nodular mass is seen within the
bladder, adherent to the bladder wall. This should be further
evaluated with cystoscopy, if not previously performed.
EKG: SR 82, no peaked t-waves or st-t wave changes
DISCHARGE LABS
___ 07:07AM BLOOD WBC-6.2 RBC-3.49* Hgb-10.4* Hct-30.7*
MCV-88 MCH-29.8 MCHC-33.9 RDW-13.5 RDWSD-43.4 Plt ___
___ 07:07AM BLOOD Glucose-81 UreaN-39* Creat-5.6* Na-134
K-3.7 Cl-93* HCO3-22 AnGap-23*
___ 07:07AM BLOOD Calcium-9.0 Phos-5.5* Mg-1.8
___ 06:20PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:20PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 06:20PM URINE RBC-24* WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
Brief Hospital Course:
This is a ___ year old female with past medical history of
bladder CA, chronic hydronephrosis with recurrent
pyelonephritis, ESRD on HD presenting with feelings of general
malaise found to have hyperkalemia in the setting of missing HD
session ___.
# Hyperkalemia, resolved: K on presentation 6.1, no EKG changes.
Patient treated medically with Insulin, D50, albuterol and
kayexelate in ED. Patient had complete resolution of
hyperkalemia after receiving 2 half day HD sessions on ___ and
___. Adherence to HD sessions was emphasized to prevent
recurrent hospitalizations for hyperkalemia and
hyperphosphatemia.
# Complicated UTI/General malaise, improved: Likely secondary to
hyperkalemia/hyperphos in the setting of missing HD session as
well as possible UTI in the setting of leukocytosis and positive
u/a, though urine culture negative. Of note, CXR wnl and R
hydronephrosis appears to be consistent with prior. Patient was
initially treated with ceftriaxone and subsequently transitioned
to ciprofloxacin to complete a 7 day course (___).
# ESRD: On hemodialysis (MWF, makes urine). Estimated GFR 5.5%.
Dry weight of 54kg with weight (54.7kg post HD). Patient
appeared evolemic on exam. She was restarted on nephrocaps and
continued on sevelamer. She was maintained on a low K/phos/Na
diet.
# Hyperphosphatemia: Phos 8.2. She underwent HD as above and was
continued on sevelamer.
CHRONIC ISSUES
# Anemia of Kidney Disease: History of normocytic anemia, likely
secondary chronic kidney disease. ___ have a component of acute
blood loss from hematuria.
# GERD with gastric ulcers: Continued home omeprazole.
# Depression: Continue home fluoxetine and lorazepam.
# Bladder cancer s/p L nephrectomy: Currently s/p numerous
surgeries and a L nephrectomy.
# HCV: s/p interferon x 2 without treatment completion.
# TRANSITIONAL ISSUES:
- A small nodular mass is seen within the bladder, adherent to
the bladder wall. This should be further evaluated with
cystoscopy, if not previously performed. These findings were
discussed with outpatient urologist Dr. ___ prior to
___ discharge. He asked that patient call to schedule an
appointment the first week of ___ since he would be on
vacation through ___. Patient was also notified of these
results with emphatic request that she follow-up with her
urologist the first week of ___.
- Patient still has HD catheter; will need f/u with transplant
nephrology re: maturation of AV fistula.
# CODE STATUS: FULL CODE
# CONTACT: Contact: ___ ___ and Son
___ ___. HCP husband ___ (___) -
currently hospitalized.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. sevelamer CARBONATE 800 mg PO BID
2. Magnesium Oxide 400 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Fluoxetine 40 mg PO DAILY
6. Lorazepam ___ mg PO BID:PRN anxiety
7. Omeprazole 20 mg PO DAILY
8. Amlodipine 2.5 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
RX *fluticasone 50 mcg/actuation 1 nasal spray daily Disp #*1
Spray Refills:*0
4. Lorazepam ___ mg PO BID:PRN anxiety
5. Omeprazole 20 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Renal Caps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
10. Ciprofloxacin HCl 250 mg PO Q24H
Last dose ___
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth daily Disp #*9
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Hyperkalemia/hyperphosphatemia
Secondary diagnosis: UTI
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 here at ___. You were
admitted for feelings of fatigue and found to have high
potassium and phosphate. This is most likely because you had
missed your dialysis session. You were also found to have a
urinary tract for which you were started on antibiotics (last
dose ___. Your dialysis sessions this week will be ___
___ and ___. We wish you all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19933011-DS-12 | 19,933,011 | 23,084,777 | DS | 12 | 2177-03-22 00:00:00 | 2177-03-23 16:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Ditropan / morphine / dicyclomine
Attending: ___.
Chief Complaint:
Right sided flank pain, nausea and vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of end-stage renal disease on HD secondary to
bladder cancer who presents with severe right-sided flank pain
which she states is similar to prior urinary tract infections.
She has felt nauseous and has had nonbloody, nonbilious emesis.
No fever but she has had chills. She has not been very compliant
with her dialysis recently as it makes her feel very unwell. She
was recently restarted on dialysis. She states she lies in the
bed sitting most of the day but denies bed sores.
In the ED, initial vital signs were: 97.8 ___ 16 99% RA
Exam showed R CVA tenderness.
- Labs were notable for: WBC 11.5, H/H 11.3/32.6, plts 133, Na
138, BUN/Cr 32/5.2, lactate 2.0 -> 1.1
- UA demonstrated >182 WBC, neg leuks and nitrites, >182 RBC, lg
blood, protein >300
- Imaging: CXR without acute cardiopulmonary process
- The patient was given:
___ 04:06 IV HYDROmorphone (Dilaudid) .5 mg
___ 04:06 IV Ondansetron 4 mg
___ 04:09 IVF 1000 mL NS
___ 05:26 IV CeftriaXONE 1 gm
- Consults:
Vitals prior to transfer were: 97.8 91 160/86 18 99% RA
Upon arrival to the floor, HDS and reports CVA pain has improved
after pain medication in ED.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, nasal congestion, cough, fevers,
chills, sweats, weight loss, dyspnea, chest pain, abdominal
pain, diarrhea, constipation, hematochezia, dysuria, rash,
paresthesias, and weakness.
Past Medical History:
-___ dx with bladder cancer. Reports of 60+ bladder surgeries
for recurrence.
-___ left nephrectomy due to metastasis
-Recurrent pyelonephritis, previous urine cultures grew E. coli,
no previous bacteremia
-ESRD: HD on MWF, makes urine, baseline Cr ___. Thought to be
___ chronic hydronephrosis from scar tissue over ureteral site
and recurrent pyelonephritis
-___ hydronephrosis due to scarring of ureters from numerous
bladder surgeries, temporary nephrostomy tubes placed
-Hep C stage II fibrosis s/p treatment with interferon x2 not
completed due to poor tolerance, last viral load 458,000 IU/mL
in ___
-GERD with gastric ulcers
-h/o HTN: previously on amlodipine, has not required
anti-hypertensives since starting HD
Social History:
___
Family History:
Denies any family history of kidney disorders.
Family history of lung and colon cancer. Father died of colon
cancer age ___.
Physical Exam:
Admission Physical Exam:
========================
VITALS: 98.2 152/73 82 18 100% 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, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema.
GU: R CVA tenderness.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Discharge Physical Exam:
========================
VS: 97.9 (98.5) 144/69 (106-144/62-79) ___ 20 100%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, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: R upper arm with well-developed AV fistula,
palpable thrill, bruit on auscultation; All extremities are
warm, well-perfused, no cyanosis, clubbing or edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
Admission Labs:
===============
___ 05:17AM BLOOD WBC-11.5*# RBC-3.79* Hgb-11.3 Hct-32.6*
MCV-86 MCH-29.8 MCHC-34.7 RDW-13.3 RDWSD-41.6 Plt ___
___ 05:17AM BLOOD Neuts-89.1* Lymphs-3.9* Monos-5.5
Eos-0.8* Baso-0.1 Im ___ AbsNeut-10.23* AbsLymp-0.45*
AbsMono-0.63 AbsEos-0.09 AbsBaso-0.01
___ 04:00AM BLOOD Glucose-115* UreaN-32* Creat-5.2* Na-138
K-4.0 Cl-96 HCO3-26 AnGap-20
___ 05:07AM BLOOD Lactate-2.0
___ 05:29AM BLOOD Lactate-1.1
Discharge Labs:
===============
___ 07:34AM BLOOD WBC-7.1 RBC-3.78* Hgb-11.1* Hct-33.1*
MCV-88 MCH-29.4 MCHC-33.5 RDW-13.5 RDWSD-43.4 Plt ___
___ 07:34AM BLOOD Neuts-60.9 ___ Monos-9.8 Eos-5.5
Baso-0.7 Im ___ AbsNeut-4.33# AbsLymp-1.62 AbsMono-0.70
AbsEos-0.39 AbsBaso-0.05
___ 07:34AM BLOOD Plt ___
___ 07:34AM BLOOD Glucose-83 UreaN-40* Creat-5.7*# Na-137
K-4.0 Cl-96 HCO3-26 AnGap-19
___ 07:34AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0
___ 05:29AM BLOOD Lactate-1.1
Micro:
======
Blood cx x 2 ___: Pending
Urine cx ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES),
CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Studies:
========
CTU ___:
1. Unchanged marked right-sided hydroureteronephrosis without
calculus formation. Superimposed pyelonephritis cannot be
excluded without the use of intravenous contrast.
2. Interval progression of right renal cortical thinning
compatible with longstanding partial or complete right-sided
obstruction.
3. Status post bladder mass resection and left nephrectomy with
expected postsurgical changes. Prominent para-aortic
lymphadenopathy is not significantly changed from ___.
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
EKG: NSR at ___
Brief Hospital Course:
This is a ___ year old female with past medical history of
bladder cancer, ESRD on HD, HCV, admitted ___ w acute
bacterial UTI and pyelonephritis, treated with antibiotics with
clinical improvement, discharged home
# Acute Right Pyelonephritis / UTI : Patient admitted with
chills, R flank pain, back pain, and dysuria consistent with
prior episodes of acute pyelonephritis. CTU showed stable
chronic R-sided obstruction but no e/o stone. Her urine culture
grew mixed bacterial flora. She was empirically treated with IV
ceftriaxone with improvement in symptoms. She was switched to PO
ciprofloxacin on day of discharge to complete a 10 day course.
She was instructed to seek medical attention immediately should
symptoms recur as this would be a sign of cipro-resistant
organism.
# ESRD on HD - She was continued on dialysis per outpatient
routine. Notably, she had self-discontinued dialysis for almost
2 weeks within the past month due to symptoms of severe
pruritis, nausea, and fatigue with outpatient dialysis. She did
not experience these symptoms while on dialysis as in-patient.
Her symptoms were felt secondary to the filter used in
outpatient setting, and this should be addressed with her
nephrologist. She will also follow-up with a ___ nephrologist
to discuss dialysis options.
# Bladder Cancer s/p Left Nephrectomy in ___ - She is followed
by Dr. ___ (urology). Patient had outpatient
cystoscopy which showed evidence of cancer recurrence, and she
was scheduled for outpatient surgery. CTU this admission
demonstrated unchanged marked right-sided hydroureteronephrosis
without culus formation and interval progression of right renal
cortical thinning compatible with longstanding partial or
complete right-sided obstruction. Patient will follow-up with
Dr. ___ to discuss scheduling of surgery.
# Hypertension: - Patient's amlodipine was increased to 5mg
daily due to systolic BP in 160s. Her SBP on discharge was 140s
TRANSITIONAL ISSUES:
# Continue ciprofloxacin 250mg daily (___)
# f/u with urologist Dr. ___ for concern of
recurrent bladder cancer and R hydroureteronephrosis
# Patient will schedule f/u with ___ nephrology for ___
opinion about dialysis options.
Code Status: Full Code
Contact: ___ (husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Lorazepam ___ mg PO BID:PRN anxiety
5. Omeprazole 20 mg PO DAILY
6. sevelamer CARBONATE 800 mg PO TID W/MEALS
7. Vitamin D ___ UNIT PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. NAC (acetylcysteine) 600 mg oral DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Fluoxetine 40 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Lorazepam ___ mg PO BID:PRN anxiety
5. Magnesium Oxide 400 mg PO DAILY
6. NAC (acetylcysteine) 600 mg oral DAILY
7. Omeprazole 20 mg PO DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Vitamin D ___ UNIT PO DAILY
10. Ciprofloxacin HCl 250 mg PO Q24H Duration: 6 Doses
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth daily Disp #*6
Tablet Refills:*0
11. HydrOXYzine 25 mg PO DAILY:PRN Itch
RX *hydroxyzine HCl 25 mg 1 by mouth daily Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute Right Pyelonephritis / UTI
# ESRD on HD
# Bladder Cancer s/p Left Nephrectomy
# Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented to ___ with an
infection in your right kidney, which improved after treatment
with antibiotics. You should continue taking Ciprofloxacin 250mg
daily thru ___. On days of your dialysis, please take
ciprofloxacin AFTER dialysis.
You should follow up with your outpatient urologist to discuss
rescheduling your surgery for recurrent bladder cancer.
IMPORANT INSTRUCTIONS
- Continue ciprofloxacin once daily thru ___. Take after
dialysis session on dialysis days.
- Please follow-up with ___ nephrologist and urologist (see
below)
- If you have fevers, back pain, burning with urine, vomiting,
this could be a recurrence of infection. Call your PCP
___.
- Increase amlodipine to 5mg daily for better blood pressure
control
- You may take hydroxyzine for itch once a day as needed
- Please discuss with your dialysis provider that your itch may
be due to the dialysis filter used, and they should be able to
correct this.
It was our pleasure caring for you. We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19933011-DS-14 | 19,933,011 | 27,437,666 | DS | 14 | 2177-12-23 00:00:00 | 2177-12-23 19:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Ditropan / morphine / dicyclomine / tolterodine /
phenazopyridine
Attending: ___.
Chief Complaint:
Found down by husband
Major ___ or Invasive Procedure:
___: Pericardiocentesis with drain placement
___: Drain removed
History of Present Illness:
___ year old female with h/o solitary right kidney, ESRD on HD (R
AVF), h/o low grade noninvasive bladder CA who initially
presented to ___ with dyspnea, found to have a pericardial
effusion on bedside ECHO and hypotension.
The patient reports that she has been fatigued for several
months, occasionally missing HD and other appointments due to
this. Several weeks ago, she started feeling mild sharp,
pleuritic chest pain along with thightness in her neck and L
scapula which has been progressive. Better sitting up or laying
flat, worse on her L side. She has not been able to exert
herself. Slight dry cough.
The patient was seen for this at outside hospital last week.
Admitted for chest pain evaluation and discharged on ___. 3
days of HD, last date of dialysis ___. Did not have her
dialysis session on ___ she was feeling too weak. This morning
was found on the ground by her husband. Does not remember how
she got there or getting up. Called the ambulance and found to
have systolic blood pressure in the ___.
At ___, she was found to have BP in the 70's, improved to the
___ with 3 L IVF. Large pericardial effusion on bedside echo.
Started on vanc/CTX for probable UTI, and was thought to have
?obstructive R pyelonephritis based on CT A/P. However UA with
TNTC WBCs but no bacteria or nitrites. She reported that she had
not had HD in 5 days (typically does 3x/week).
Medical history significant for chronically hydronephrotic,
poorly functional right kidney. Now transferred from ___ with
pericardial effusion.
In the ED, initial vitals were: 97.1 F, BP 105/69, HR 98, RR 18.
99% NC. Patient was A/Ox3 but sleepy on exam.
Labs showed: WBC 8.9, Hgb 7.4 (baseline ___ plts 166. No
bandemia. Lactate 1.3 from 1.0 at OSH. Trop <0.01. Cr 8.3.
Imaging showed:
EKG: HR ___, meets criteria for low voltage, no evidence of
segment prolongation, no evidence of ST segment changes
CXR- no evidence of PNA or pleural effusions, + cardiomegaly
CT chest/A/P- reportedly there is right hydronephrosis and
perinephric stranding, this may be a chronic finding
RUQ u/s- gallbladder wall edema, no acute pathology otherwise
Cards was consulted for concern for tamponade and bedside ECHO
showed mod-large effusion with borderline tamponade physiology
(RA collapse and respiratory variation). Pulsus at that time was
12.
Urology was consulted for prior h/o bladder CA. They reported,
"Imaging minimally changed from ___. Not obviously
obstructive pyelonephritis."
Decision to admit to CCU for pericardial effusion/tamponade.
Patient first went to cath lab for pericardiocentesis, draining
470cc of serosanguinous fluid. SBP>100; pericardial pressure
15-> 2;
Past Medical History:
RENAL HX:
-___ dx with low grade Ta bladder Ca. Reports of 60+ bladder
surgeries for recurrence.
-___ left nephrectomy due to metastasis
-TURBTs and left upper tract urothelial carcinoma s/p left
nephroureterectomy
-Most recent TURBT (transurethral resection of bladder tumor)
___
-Recurrent pyelonephritis, previous urine cultures grew E. coli,
no previous bacteremia
-ESRD: HD on MWF (right upper arm AV fistula), makes urine,
baseline Cr ___. Thought to be ___ chronic hydronephrosis from
scar tissue over ureteral site and recurrent pyelonephritis
-___ hydronephrosis due to scarring of ureters from numerous
bladder surgeries, temporary nephrostomy tubes placed
OTHER PAST MEDICAL HISTORY:
-Hep C stage II fibrosis s/p treatment with interferon x2 not
completed due to poor tolerance, last viral load 458,000 IU/mL
in ___
-GERD with gastric ulcers
-h/o HTN: previously on amlodipine, has not required
anti-hypertensives since starting HD
Social History:
___
Family History:
Denies any family history of kidney disorders.
Family history of lung and colon cancer. Father died of colon
cancer age ___.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
Vital Signs: 97, 114/64, 16, 96 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, soft rub,
incisional tenderness for pericardial drain - serosang to sang
drainage
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly tender in the RUQ w/ NEG ___ sign,
bowel sounds present, no organomegaly, no rebound or guarding
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, no ___ edema
Neuro: CNII-XII intact, grossly normal sensation, gait deferred.
========================
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.3 ___ ___ 18 96 RA
I/O: innacurate
PEx
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, soft rub,
incisional tenderness for pericardial drain, no drainage
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, mildly tender in the RUQ w/ NEG ___ sign,
tender in suprapubic region, bowel sounds present, no
organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no ___ edema
Neuro: CNII-XII intact, grossly normal sensation, gait deferred.
Pertinent Results:
================
ADMISSION LABS
================
___ 08:42AM BLOOD WBC-8.9 RBC-2.53*# Hgb-7.4*# Hct-23.3*#
MCV-92 MCH-29.2 MCHC-31.8* RDW-14.8 RDWSD-49.8* Plt ___
___ 08:42AM BLOOD Neuts-83.9* Lymphs-6.7* Monos-7.9
Eos-0.7* Baso-0.2 Im ___ AbsNeut-7.50*# AbsLymp-0.60*
AbsMono-0.71 AbsEos-0.06 AbsBaso-0.02
___ 08:42AM BLOOD ___ PTT-26.9 ___
___ 08:42AM BLOOD Glucose-106* UreaN-93* Creat-8.3* Na-132*
K-8.7* Cl-95* HCO3-10* AnGap-36*
___ 08:42AM BLOOD ALT-46* AST-49* AlkPhos-86 TotBili-0.5
___ 08:42AM BLOOD Lipase-66*
___ 08:42AM BLOOD cTropnT-<0.01
___ 08:42AM BLOOD Albumin-3.0* Calcium-7.0* Phos-8.4*
Mg-2.1
___ 10:00PM BLOOD calTIBC-166* ___ Ferritn-1254*
TRF-128*
___ 01:03PM BLOOD TSH-1.4
====================
HEPATITIS SEROLOGIES
====================
___ 09:34AM BLOOD HAV Ab-Positive
___ 01:03PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative
___ 01:03PM BLOOD HCV Ab-Positive*
___ 09:34AM BLOOD HCV VL-6.0*
=========================
PERTINENT STUDIES/IMAGING
=========================
CXR ___: no evidence of focal consolidation or pleural
effusions, cardiomegaly with some shift towards the center
CT A/P ___:
1) Mod-Severe R hydronephrosis and hydroureter, with associated
perinephric stranding and urothelial thickening suggesting
infection. Correlate with urinalysis.
2) Mod-Severe pericardial effusion and small bilateral pleural
effusions.
RUQ U/S ___:
1. Mildly distended gallbladder with gallbladder wall edema. In
the absence of calculi, these findings are equivocal. If there
is continued concern for acute cholecystitis, HIDA scan can be
obtained for further evaluation.
2. Severe right-sided hydronephrosis, comparable to the findings
seen on recent CT.
Shoulder XR ___:
FINDINGS: Widened left AC joint, stable since ___,
___, may be from prior trauma or surgery. Normal
glenohumeral joint alignment. No fractures. Remainder normal.
IMPRESSION: Stable widening left AC joint, may be from prior
trauma or surgery.
TTE ___:
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF>55%). There is no ventricular
septal defect. Right ventricular chamber size and free wall
motion are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is a small (1.0cm) echodense primarilyn
pericardial effusion primarilyn anterior to the right
atrium/right ventricle. There are no echocardiographic signs of
tamponade or constriction..
Compared with the prior study (images reviewed) of ___,
the effusion is now much smaller and primarily anterior.
Tamponade physiology is no longer suggested.
=============
MICROBIOLOGY
=============
___ Pericardial Fluid Culture: No Growth
WBC-6100* Hct,Fl-10.0* Polys-72* Lymphs-10* Monos-0 Eos-2*
Macro-16*
Cytology: No evidence of malignant cells
___ Urine Culture: No Growth
___ Urine Culture: Pending on discharge
==============
DISCHARGE LABS
==============
___ 06:55AM BLOOD WBC-5.9 RBC-2.88* Hgb-8.6* Hct-26.5*
MCV-92 MCH-29.9 MCHC-32.5 RDW-14.3 RDWSD-48.3* Plt ___
___ 06:55AM BLOOD Glucose-85 UreaN-41* Creat-5.3*# Na-136
K-4.7 Cl-93* HCO3-23 AnGap-25*
___ 06:55AM BLOOD Calcium-8.1* Phos-4.8* Mg-1.9
___ 11:52AM
Brief Hospital Course:
___ year old female with h/o solitary right kidney, ESRD on HD,
h/o low grade noninvasive bladder CA s/p multiple surgeries who
initially presented to ___ with dyspnea found to have a
pericardial effusion with tamponade physiology on bedside ECHO.
ACUTE ISSUES
============
#Pericardial effusion/Tamponade:
Likely secondary to uremic pericarditis given that pt missed
dialysis. Pericardiocentesis was performed with removal of 470cc
of serosanguinous fluid. Pericardial pressure 15->2. Drain
removed ___. No bacterial growth. Cytology negative for
malignancy. No further evidence of tamponade physiology over
course of admission.
#Urinary Tract Infection:
Pt was initially asymptomatic, and initial urine culture had no
growth. However, on ___ pt developed suprapubic tenderness and
dysuria, so she was started on cefpodoxime. Urine culture was
pending on discharge. The patient explained that her most recent
prophylactic cipro prescription was mistakenly for 150mg instead
of 500mg. She was instructed to finish a 7 day course of the
cefpodoxime, and resume her 500mg of cipro on ___ after HD.
#Anemia: Hemoglobin 7.4 from baseline of 11 with no evidence of
acute blood loss. In some individuals, uremic pericarditis may
be associated w/ worsening anemia ___ inflammation and EPO
resistance. Pt was transfused for Hgb<7, and received a total of
1 U PRBC over the course of her admission. Hemolysis labs were
wnl. Iron studies showed ferritin>1000.
Our nephrologists have contacted home dialysis unit to ensure
appropriate outpatient regimen.
#Transaminitis: Mild with no acute hepatic pathology on RUQ u/s.
___ have been due to volume overload/congestive hepatopathy.
Hepatitis serologies showed non-immunity to hep B, Hep C viral
load of 6, and Hep A Ab positive. Given Hep C viral load and
mild transaminitis there should be outpatient Liver/Hepatology
follow up.
CHRONIC ISSUES:
===============
#ESRD: Continued home sevelamer and vitamin D, and pt was
continued on her home ___ dialysis schedule.
#HTN: Held then restarted home amlodipine
#GERD: continued home PPI
#Anxiety: lorazepam qhs prn
#Depression: continued home fluoxetine
TRANSITIONAL ISSUES
===================
- Not immune to Hep B
- Positive Hep C Viral load (6) w/mild transaminitis. Will need
outpatient ___ follow up
- repeat TTE in 3 weeks
- pt was discharged with 7 day course of cefpodoxime for UTI,
scheduled to be taken after HD and to thus finish on ___. She
should resume her prophylactic cipro 500mg on ___ after HD.
However, she should discuss with her outpatient providers
whether cipro is the most appropriate prophylactic regimen given
its new blackbox warning. Additionally, pt claims that her most
recent cipro prescription was for 150mg instead of 500mg, which
could help explain why she developed a UTI. Please write a new
prescription if this is the case.
- Anemia - RENAL will speak directly w/ outpt HD to make sure
she is being treated appropriately and ask them to remind her to
present for dialysis
-Discharge Weight: 55.3kg (just post HD on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. FLUoxetine 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. sevelamer CARBONATE 1600 mg PO BID W/ MEALS
5. Vitamin D ___ UNIT PO DAILY
6. Magnesium Oxide 500 mg PO DAILY
7. LORazepam ___ mg PO BID PRN anxiety
8. Ciprofloxacin HCl 500 mg PO MWF
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO POST HD (___)
RX *cefpodoxime 200 mg 2 tablet(s) by mouth three times weekly
after HD (MWF) Disp #*6 Tablet Refills:*0
2. amLODIPine 2.5 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO MWF
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth three times
weekly after HD (MWF) Disp #*30 Tablet Refills:*1
4. FLUoxetine 20 mg PO DAILY
5. LORazepam ___ mg PO BID PRN anxiety
6. Magnesium Oxide 500 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. sevelamer CARBONATE 1600 mg PO BID W/ MEALS
RX *sevelamer carbonate [___] 800 mg 2 tablet(s) by mouth
twice daily with meals Disp #*60 Tablet Refills:*1
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
- Pericardial Effusion with tamponade
- Anemia
- Urinary Tract Infection
- Transaminitis; Hepatitis C
Secondary Diagnoses:
- ESRD
- HTN
- GERD
- Depression/Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___.
WHY DID YOU COME TO THE HOSPITAL?
Your husband found you on the ground and called an ambulance.
WHAT HAPPENED WHILE YOU WERE HERE?
- We discovered that you had fluid surrounding your heart, so we
placed a drain to help get rid of the fluid. We think that this
likely happened because you missed dialysis.
- Your blood counts were low so we gave you a blood transfusion
- You continued dialysis on your normal schedule
- We started you on antibiotics for a urinary tract infection
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL?
- Please be sure to take all of your medications as prescribed
- You will finish your Cefpodoxime (antibiotic) for your UTI on
___
- You should restart taking your Ciprofloxacin 500mg MWF on
___
- It is very important that you go to dialysis for all of your
sessions so that you do not develop fluid around the heart again
- Please follow up with all of your doctors
___, it was a pleasure taking care of you!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19933011-DS-15 | 19,933,011 | 20,782,858 | DS | 15 | 2178-05-12 00:00:00 | 2178-05-13 09:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Ditropan / morphine / dicyclomine / tolterodine /
phenazopyridine
Attending: ___.
Chief Complaint:
nausea, vomiting diarrhea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with h/o solitary right kidney, ESRD on HD (R
AVF), h/o low grade noninvasive bladder CA s/p multiple
surgeries, recent hospitalization at ___ 2 weeks ago for
nephrostomy tube placement ___ to obstruction from cancer, who
presents with nausea, vomiting, nonbloody diarrhea for 1 week.
Due to her symptoms, she has missed the last 3 sessions of HD.
The patient reports that 2 weeks ago she was at ___ for
nephrostomy tube placement to treat obstruction from bladder
cancer. Procedure was complicated by renal hemorrhage. Per
patient, she received antibiotics at ___. She thinks she was
admitted for 10 days. She has been changing nephrostomy tube at
home multiple times a day with 300cc output each time. Over the
past week she had diarrhea every time she ate and projective
vomiting. It was associated with cramping abdominal pain. Her
husband had similar symptoms, which resolved before hers did.
She thinks she had subjective fevers at home.
In ED initial VS: 98.3, 104, 185/94, 18, 100% RA.
- Labs: wbc 12.3, Hgb 10.5, plt 375, Na 138, K 7.2, Cl 102,
Bicarb 9, BUN 140, Cr 12.8. Trop 0.02, proBNP >70K, lactate 4.
VBG 7.12, CO2 38.
- Patient was initially here for nausea and vomiting and looked
well then developed worsening respiratory status and
hypertension with BP 204/113 and tachycardic to the 150s-170s.
She was placed on BiPAP.
- Patient was given: 1mg lorazepam, 650mg acetaminophen, 2g Ca
gluconate, started on nitro gtt, furosemide 20mg IV, 40mg IV,
sodium bicarb 50meq, furosemide 40mg, zosyn 4.5.
- Imaging notable for: CXR with moderate to severe pulmonary
edema
- Renal consulted for emergent HD, for indication of acidosis,
volume overload, and hyperkalemia
- Patient noted to have tachycardia to 160s. EKG with regular
wide complex tachycardia. Confirmed on multiple EKGs. Cardiology
was consulted in the ED, felt that she had wide complex
tachycardia that could be aflutter with abberency vs monomorphic
VT. Recommended doing serial EKGs and giving IV metoprolol.
- Patient given 2.5mg IV metoprolol and HR decreased to 120s.
Repeat EKG showed sinus tachycardia with narrow QRS. Plan for
aggressive electrolyte repletion.
- Repeat labs with lactate down to 2.3, K 5.1, VBG pH 7.25, CO2
36.
VS prior to transfer: 120, 150/85, 26, 96% bipap
On arrival to the MICU, she feels much better than when she was
in the ED. She would like her BiPAP taken off. She says that she
thought she was dying in the ED.
Past Medical History:
RENAL HX:
-___ dx with low grade Ta bladder Ca. Reports of 60+ bladder
surgeries for recurrence.
-___ left nephrectomy due to metastasis
-TURBTs and left upper tract urothelial carcinoma s/p left
nephroureterectomy
-Most recent TURBT (transurethral resection of bladder tumor)
___
-Recurrent pyelonephritis, previous urine cultures grew E. coli,
no previous bacteremia
-ESRD: HD on MWF (right upper arm AV fistula), makes urine,
baseline Cr ___. Thought to be ___ chronic hydronephrosis from
scar tissue over ureteral site and recurrent pyelonephritis
-___ hydronephrosis due to scarring of ureters from numerous
bladder surgeries, temporary nephrostomy tubes placed
OTHER PAST MEDICAL HISTORY:
-Hep C stage II fibrosis s/p treatment with interferon x2 not
completed due to poor tolerance, last viral load 458,000 IU/mL
in ___
-GERD with gastric ulcers
-h/o HTN: previously on amlodipine, has not required
anti-hypertensives since starting HD
Social History:
___
Family History:
Denies any family history of kidney disorders.
Family history of lung and colon cancer. Father died of colon
cancer age ___.
Physical Exam:
ADMISSION VITALS: 96.4 118 135/92 22 98%
GENERAL: Alert, oriented, lethargic, no respiratory distress
HEENT: PERRL, EOMI, Sclera anicteric, dry MM, oropharynx clear
NECK: supple
LUNGS: bibasilar crackles at the bases, no wheezes, rales,
rhonchi
CV: tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, hypoactive bowel sounds,
no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
BACK: nephrostomy tube dressing in tact, no erythema or
drainage, draining pink urine
SKIN: no rash
NEURO: CN II-XI intact, moving all extremities
ON DISCHARGE:
Pertinent Results:
Admission labs:
___ 01:33AM BLOOD WBC-12.3*# RBC-3.52* Hgb-10.5* Hct-32.8*
MCV-93 MCH-29.8 MCHC-32.0 RDW-15.9* RDWSD-53.9* Plt ___
___ 01:33AM BLOOD Neuts-55.4 ___ Monos-9.7 Eos-4.2
Baso-0.2 Im ___ AbsNeut-6.81* AbsLymp-3.68 AbsMono-1.19*
AbsEos-0.52 AbsBaso-0.03
___ 01:33AM BLOOD ___ PTT-29.9 ___
___ 01:33AM BLOOD Glucose-112* UreaN-140* Creat-12.8*
Na-138 K-7.2* Cl-102 HCO3-9* AnGap-34*
___ 01:33AM BLOOD ALT-49* AST-48* AlkPhos-146* TotBili-0.7
___ 01:33AM BLOOD proBNP->70000*
___ 01:33AM BLOOD cTropnT-0.02*
___ 08:50AM BLOOD Albumin-3.2* Phos-5.1* Mg-1.5*
___ 01:46AM BLOOD Lactate-4.0* K-6.7*
CXR ___
Moderate pulmonary edema. Trace left effusion.
Brief Hospital Course:
___ is a ___ female with history of solitary right
kidney, ARDS on HD, history of low-grade noninvasive bladder
cancer status post multiple surgeries, recent hospitalizations
at the ___ 2 weeks ago for nephrostomy tube
placement secondary to obstruction from cancer. She presented
with nausea vomiting nonbloody diarrhea for 1 week. Due to her
symptoms of nausea vomiting and diarrhea, she missed 3
consecutive sessions of hemodialysis resulting in shortness of
breath.
#Acute pulmonary edema
#Hypertensive emergency
#Wide complex tachcyardia
On presentation to the emergency room she was hypertensive to
180/94 and tachycardic to 104. Her labs were notable for
elevation of her potassium to 7.2, BUN of 140, creatinine of
12.8, troponin 0.02, proBNP greater than 70,000. She was in
respiratory distress and had an episode of tachycardia to 150
with wide complex morphology. Cardiology recommended IV
metoprolol due to the rhythm likely representing atrial flutter
with aberrant aberrancy versus monomorphic VT in the setting of
fluid overload and hyperkalemia. She was admitted to the MICU
for BiPAP and urgent dialysis which improved her respiratory
symptoms acidemia and hyperkalemia after 2 sessions with a total
of -3000 cc net fluid balance. After dialysis her oxygen
requirement was reduced to 2.5 nasal cannula. Due to
improvement she was transferred to the floor for further
monitoring. On the floor, she was seen by cardiology who
recommended no additional intervention for her tachycardia as it
had resolved. She will resume her dialysis as below. On the
floor the patient was asymptomatic denied shortness of breath
chest pain. No diarrhea nausea or vomiting. She underwent a
third session of dialysis with a total ultrafiltration volume of
-480 cc after stopping the session prematurely due to symptoms
of flushing which the patient associates with being dehydrated.
She was ambulating on room air without symptoms of shortness of
breath prior to discharge.
# ESRD on HD MWF:
# Anion gap acidosis:
# Hyperkalemia:
Ms. ___ missed 3 HD sessions in setting of feeling unwell.
Labs on admission significant for hyperkalemia to 7, Bicarb 9.
Underwent urgent HD on ___ with improvement in electrolytes.
She received HD in the MICU and HD was initiated on AM of ___,
however session terminated per patient request as she "wasn't
feeling well". She was followed closely by neprhology and was
thought to be below her dry weight. She continued sevelamer
carbonate, Vitamin D.
# Bladder Cancer
The patient has a reported history of transitional cell cancer
in her bladder. She also has a nephrostomy tube draining the
right kidney. She had recent biopsies at ___ which were
non-diagnostic as she had new/enlarging lymphadenopathy. The
patient has to follow-up with her outpatient urologist closely
for further management of this problem.
#Anemia, chronic inflammation
The patient's anemia of hemoglobin of 9.6 makes her below the
goal for her chronic kidney disease. We trended her hemoglobin
found to be relatively stable not requiring transfusions during
admission.
#Transaminitis
The patient had mild elevation of her LFTs on admission. ALT 49
AST 48 alk phos 146 T bili 0.7, of unclear cause. These were
trended during admission and found to be stable. Further workup
of these LFT abnormalities are required as an outpatient
Chronic issues:
# Hepatitis C
Patient reports she has a history of Hep C but denies having
taken Harvoni. Viral load was elevated when last checked at ___.
# Depression
- continued fluoxetine 20mg daily
# Anxiety:
- LORazepam 1 mg PO BID PRN anxiety
# GERD:
- Omeprazole 20 mg PO DAILY
TRANSITIONAL ISSUES
====================
[]patient will need follow up with her PCP and her urologist at
discharge
[] please follow up patient's adherence to hemodialysis and
ensure that she has close follow up if she is unable to make it
or decides not to go
[] please discuss Harvoni treatment with patient; at this time
she has prescription but has not taken treatment yet. she will
need GI follow up for this issue at discharge
[] please consider EPO for patient's low hemoglobin
[] on discharge her LFTs were mildly elevated. Please repeat
LFTs within one week.
[] given troponin elevation at this hospitalization consider
Echocardiogram on an outpatient basis to evaluate LV function
# Communication: HCP: Name of health care proxy: ___
Relationship: husband
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. FLUoxetine 20 mg PO DAILY
2. LORazepam 1 mg PO BID PRN anxiety
3. Omeprazole 20 mg PO DAILY
4. sevelamer CARBONATE 1600 mg PO BID W/ MEALS
5. Vitamin D ___ UNIT PO DAILY
6. amLODIPine 5 mg PO DAILY
7. Magnesium Oxide 500 mg PO DAILY
8. Ciprofloxacin HCl 500 mg PO MWF
9. Ramelteon 8 mg PO QHS:PRN insomnia
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Ciprofloxacin HCl 500 mg PO MWF
3. FLUoxetine 20 mg PO DAILY
4. LORazepam 1 mg PO BID PRN anxiety
5. Magnesium Oxide 400 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Ramelteon 8 mg PO QHS:PRN insomnia
8. sevelamer CARBONATE 1600 mg PO BID W/ MEALS
9. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
KYPERKALEMIA
SEVERE ACIDEMIA
PULMONARY EDEMA
CHRONIC KIDENY DISEASE ON DIALYSIS.
GASTROENTERITIS
NONINVASIVE BLADDER CANCER
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___ was a pleasure taking care of you at the ___
___.
You were admitted because you missed dialysis on 3 consecutive
sessions. This resulted in life-threatening severe accumulation
of acid and potassium in your blood levels and accumulation of
fluid leading to difficulty breathing and fluids on your lungs.
As a result, you were admitted to the intensive care unit where
you received urgent dialysis. During your ICU stay, you
received 2 sessions of dialysis which relieved your shortness of
breath, corrected your potassium, and reduced your acid levels
in the blood. Due to significant improvement, you were
transferred to the floor. On the floor, we continue to monitor
her vital signs which were stable. We also sent to for a
dialysis session to remove excess fluids. However, due to you
being symptomatic, the dialysis session was not continued.
Please follow-up with your outpatient nephrologist and your
dialysis ___ further dialysis needs.
It was a pleasure taking care of you at the ___
___. We wish you all the best.
Followup Instructions:
___
|
19933011-DS-18 | 19,933,011 | 25,570,323 | DS | 18 | 2178-11-09 00:00:00 | 2178-11-09 17:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Ditropan / morphine / dicyclomine / tolterodine /
phenazopyridine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Nephrostomy tube revision ___
History of Present Illness:
___ y/o female with CKD/ESRD on dialysis MWF via right tunneled
HD
line, long history of bladder cancer managed by Dr. ___
___ ___, L Nephroureterectomy, with an obstructed right
kidney (due to invading bladder cancer into the R ureter)
requiring a nephrostomy tube (placed in ___, last exchanged
on ___, presenting with 2 weeks of cramping right lower
quadrant pain. Patient says she woke up this morning feeling
more
bloated and puffy, with more abdominal cramping than normal. She
says she had a feeling "that something was off" and "her cancer
is growing".
Patient states that the nephrostomy tube has been putting out
well urine, as well as bright red blood with some clots (which
seems to be the baseline for her). She was supposed to have
surgery to remove her bladder and R ureter/kidney but things got
delayed due to her husband being hospitalized.
Patient reports constipation with minimal hard bowel movements
for the last 6 days but no vomiting, and is still passing
flatus.
She denies N/V, fever, chills. No SOB, or leg edema. Feels
abdomen is bigger and face is swollen. She has been doing
dialysis for about ___ years. Her right kidney is still producing
urine. She missed her dialysis today due to coming to the ER.
Renal was consulted for HD and hyperkalemia of 6.1. She was
given
insulin IV/dextrose for hyperkalemia. Repeat K was 5.5. She did
not have EKG changes for hyperkalemia.
In the ED, initial vitals: T 98.4, HR 86, BP 164/81, RR 18, POx
100%
- Exam notable for: anicteric, right-sided nephrostomy tube with
light pink urine, minimally tender in right lower quadrant
- Labs notable for:
13:57
133 91 70
----------<62
6.1 23 8.5
7.5>10.___<162
15:21 Repeat K=5.5
UA: trace leukocytes, moderate blood, neg nitrites, 100 Protein,
100 Glucose, neg ketones, >182 RBC, 13 WBC, few bacteria
- Imaging notable for:
CT A/P
1. Normal appendix.
2. Large heterogeneous, hypoattenuating mass in the region of
the
right renal pelvis with extension down the right proximal is
similar to mildly bigger than prior MR abdomen pelvis ___, lying for differences and study modality. This likely
represents a perinephric hematoma related to prior percutaneous
nephrostomy.
3. 4.5 cm segment of enhancing soft tissue mass involving the
distal right ureter is concerning for malignancy, similar to
prior.
4. Shrunken, dysmorphic appearance of the bladder is similar to
prior and also suspicious for malignancy.
5. Retroperitoneal lymphadenopathy with an enlarged right caval
lymph node measuring up to 2.2 cm is similar to prior.
Urin Cath Check - ordered 19:40
- ___ was consulted who recommended: PCN check/change in AM.
Please make NPO at midnight and contact the ___ service with any
acute changes in status.
- Renal was also consulted in the ED who recommended: as K is
coming down, will HD tomorrow first shift. Continue cardiac
monitoring.
- Pt given:
___ 15:17 IV Insulin (Regular) for Hyperkalemia 10 units
___
___ 15:17 IV Dextrose 50% 50 gm ___
___ 17:05 PO OxyCODONE (Immediate Release) 5 mg ___
___ 17:05 PO Acetaminophen 1000 mg
- Vitals prior to transfer: T 97.5, HR 71, BP 106/57, RR 18,
99%RA
On the floor, patient reports the cramping abdominal pain, she
is
worried about her tumor getting bigger and wants Dr ___ to be
informed about the results of her CT A/P. She is asking for help
with her constipation and also to make sure help for pain
control
(which she says it is a ___. Patient denies fever, chills,
shakes, nausea, vomiting, flank pain, or leakage around her
existing nephrostomy tube.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
-Hypertension
2. CARDIAC HISTORY
-Coronaries: unknown
-TTE ___ ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>55%).
3. OTHER PAST MEDICAL HISTORY
-ESRD ___ chronic hydronephrosis/pyelonephritis (E. coli), on HD
___
--s/p right brachiocephalic AV fistula (___)
--s/p tunneled HD line
-Urothelial carcinoma, low-grade (dx ___
--s/p right percuteanous nephrostomy placement (___)
--s/p numerous ___ (last ___
--Nephroureterectomy, left (___)
-pericardial effusion/tamponade (___) s/p pericardiocentesis
-HCV, stage II fibrosis s/p interferon (incomplete therapy)
-GERD
Social History:
___
Family History:
-Maternal hx DM, HTN
-Paternal hx DM, HTN
-No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: NAD, lying in bed
HEENT: PERRL/EOMI, MMM, poor dentition, no oropharyngeal lesions
NECK: supple, no JVD, no LAD
CARDIAC: RRR, S1/S2, no m/r/g
PULM: unlabored, CTAB
GI: soft, ND, NT, normoactive BS, no organomegaly. tenderness to
palpation in RLQ. Has nephrostomy tube coming out of R flank -
clean dressing with no leaking. it is draining pink urine.
EXT: warm, well perfused, without edema
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.3 135/76 85 18 100 Ra
GENERAL: NAD, alert, interactive
HEENT: Sclerae anicteric, MMM
LUNGS: Clear to auscultation bilaterally, no w/r/r
HEART: RRR no m/r/g
ABDOMEN: R nephrostomy tube draining red-pink colored fluid.
Dressing c/d/i. NT/ND, +BS
EXTREMITIES: L leg asymmetrically swollen, negative homans sign,
no tenderness to palpation
NEURO: awake, A&Ox3
Pertinent Results:
ADMISSION LABS
==============
___ 01:57PM BLOOD WBC-7.5 RBC-3.53* Hgb-10.8* Hct-32.0*
MCV-91 MCH-30.6 MCHC-33.8 RDW-13.8 RDWSD-45.5 Plt ___
___ 01:57PM BLOOD Neuts-71.8* Lymphs-16.4* Monos-8.2
Eos-2.8 Baso-0.4 Im ___ AbsNeut-5.37 AbsLymp-1.23
AbsMono-0.61 AbsEos-0.21 AbsBaso-0.03
___ 01:57PM BLOOD ___ PTT-30.0 ___
___ 01:57PM BLOOD Glucose-62* UreaN-70* Creat-8.5*# Na-133*
K-6.1* Cl-91* HCO3-23 AnGap-19*
___ 04:52AM BLOOD ALT-20 AST-30 LD(LDH)-205 AlkPhos-93
TotBili-0.3
___ 04:52AM BLOOD Albumin-3.4* Calcium-8.0* Phos-6.7*
Mg-2.6
___ 05:11PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 05:11PM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-100* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.5*
Leuks-TR*
___ 05:11PM URINE RBC->182* WBC-13* Bacteri-FEW* Yeast-NONE
Epi-0
MICRO
=====
___ 5:11 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM------------- 4 I
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
DISCHARGE LABS
==============
___ 04:35AM BLOOD WBC-5.1 RBC-3.45* Hgb-10.6* Hct-31.6*
MCV-92 MCH-30.7 MCHC-33.5 RDW-14.0 RDWSD-47.1* Plt ___
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD Glucose-90 UreaN-28* Creat-4.8*# Na-136
K-5.4* Cl-95* HCO3-31 AnGap-10
___ 04:35AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.4
IMAGING
=======
CT A/P W/ CONTRAST ___. Normal appendix.
2. Large heterogeneous, hypoattenuating mass in the region of
the right renal pelvis with extension down the right proximal is
similar to mildly bigger than prior MR abdomen pelvis ___, lying for differences and study modality. This
likely represents a perinephric hematoma related to prior
percutaneous nephrostomy.
3. 4.5 cm segment of enhancing soft tissue mass involving the
distal right
ureter is concerning for malignancy, similar to prior.
4. Shrunken, dysmorphic appearance of the bladder is similar to
prior and also suspicious for malignancy.
5. Retroperitoneal lymphadenopathy with an enlarged right caval
lymph node
measuring up to 2.2 cm is similar to prior.
B/L LOWER EXTREMITY U/S ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
URINE CATH CHECK ___. Right antegrade nephrostogram shows the right PCN slightly
retracted though still positioned within the collecting system.
2. Appropriate final position of right nephrostomy tube in the
renal pelvis.
IMPRESSION:
Technically successful right 8 ___ nephrostomy exchange.
RECOMMENDATION(S): Patient will return in 3 months for routine
exchange.
Brief Hospital Course:
___ y/o female with CKD/ESRD on dialysis MWF secondary to chronic
pyelonephritis, hydronephrosis, and scarring, long history of
bladder cancer, L Nephroureterectomy, with an obstructed right
kidney (due to invading bladder cancer into the R ureter) s/p
right PCN who presented with RLQ abdominal pain, hematuria, mild
hyperkalemia. She improved following evaluation and exchange of
the nephrostomy tube with ___. Hyperkalemia was treated
successfully with dialysis.
# Abdominal pain with hx of urothelial cancer s/p rt nephrostomy
# Obstructive uropathy on R kidney treated with PCN
# Pseudomonal UTI
Patient had PCN exchange on ___. Nephrostomy tube is working
well, draining urine as well as bright red blood and some clots,
which patient says it has been happening for a while. A repeat
CT
A/P showed large heterogeneous mass in the region of the right
renal pelvis
with extension down the right proximal, mildly bigger than prior
MR abdomen pelvis ___, which likely represents a
perinephric hematoma related to prior percutaneous nephrostomy.
Soft tissue mass involving the distal right ureter is concerning
for malignancy is similar to prior to study. ___ was consulted to
evaluate the nephrostomy tube placement as inadequate drainage
may have been contributing to her abdominal pain. She underwent
a successful nephrostomy tube exchange and adjustment with ___.
Her pain was adequately controlled with oxycodone 5mg Q4:PRN.
Her urine grew pseudomonas, and in the setting of her abdominal
pain, decided to treat w/ 14 day course of cipro (per
sensitivities) given her GU tract pathology and neph tube. She
will need outpatient follow up with her urologist Dr ___
___ the plan for future surgical interventions.
# Hyperkalemia - Her + was 6.1 on admission and came down to 5.5
after IV insulin/dextrose. This was likely in the setting of
missing a regularly scheduled dialysis appointment as well as
constipation per the patient. She was treated for K+ of 6.3 on
___ with insulin, dextrose, IV lasix 100mg and dialysis. Her
EKG was checked in the elevated setting without any concerning
changes or peaked T waves. She was monitored on telemetry
throughout her course.
# ESRD/HD MWF: She was dialyzed according to her regular
schedule. She received nephrocaps, sevelamer with meals,
magnesium oxide, and calicitriol.
# Hypertension: Continued amlodipine 5mg daily.
# Restless leg syndrome: Continued gabapentin 100mg QAM and
200mg QPM
# GERD: Continued Omeprazole 20 mg PO DAILY
# Anemia: - patient presents with H/H = 10.8/32 which is around
her baseline. Patient's hemoglobin is below the goal for
end-stage-renal-disease and should potentially have follow up
for potential initiation of EPO and IV iron.
# Nutrition: Low Na, Low K , Low P diet, water restriction to
1.5L per day. Nephrocaps 1 CAP daily
# Hepatitis C: Patient was previously on interferon therapy but
did not complete and has not gotten Harvoni treatment. She shoud
have GI follow up to discuss starting anti-viral therapy.
TRANSITIONAL ISSUES
=================
TRANSITIONAL ISSUES:
- It was noticed that she had asymmetric left leg swelling,
underwent ultrasound which did not show DVT in either lower
extremity. ___ require further investigation during outpatient
follow-up.
- ___ recommends follow-up in 3 months for nephrostomy evaluation
- Her hyperkalemia on this admission was consistent with her
baseline. She did not have any EKG changes, however, she will
need consistent hemodialysis on her follow-up to prevent
continued hyperkalemia.
- Her urine grew pseudomonas just prior to discharge. She will
be discharged with a 14 day course of ciprofloxacin 500mg once
daily (adjusted for renal function). Last day ___.
- Consider follow-up for epo and Iron studies
- She was previously on interferon therapy but did not complete
and has not gotten Harvoni treatment. She should have GI follow
up to discuss starting anti-viral therapy.
#CODE STATUS: Full (confirmed)
#CONTACT: Name of health care proxy: ___
Relationship: husband (currently in the hospital)
Phone number: ___
Son ___ ___
>30 minutes in patient care and coordination of discharge on
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. FLUoxetine 20 mg PO DAILY
3. LORazepam 1 mg PO BID PRN anxiety
4. Magnesium Oxide 400 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. Vitamin D ___ UNIT PO DAILY
8. Calcitriol 1 mcg PO 3X/WEEK (___)
9. Nephrocaps 1 CAP PO DAILY
10. Gabapentin 100 mg PO QAM
11. Gabapentin 200 mg PO QPM
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth once
daily Disp #*16 Tablet Refills:*0
2. amLODIPine 5 mg PO DAILY
3. Calcitriol 1 mcg PO 3X/WEEK (___)
4. FLUoxetine 20 mg PO DAILY
5. Gabapentin 200 mg PO QPM
6. Gabapentin 100 mg PO QAM
7. LORazepam 1 mg PO BID PRN anxiety
8. Magnesium Oxide 400 mg PO DAILY
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 20 mg PO DAILY
11. sevelamer CARBONATE 1600 mg PO TID W/MEALS
12. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSIS: Urothelial cancer
SECONDARY DIAGNOSIS: End Stage Renal Disease, Anemia,
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-Because you were having abdominal pain and high potassium.
WHAT HAPPENED IN THE HOSPITAL?
-You had your percutaneous nephrostomy tube evaluated with
Interventional Radiology. They adjusted the tube to allow for
better drainage.
-Your elevated potassium was lowered though dialysis
WHAT SHOULD YOU DO AT HOME?
-Please follow up with your primary care doctor ___ Dr. ___
___ your future surgical plans.
-Take all of your medications as prescribed.
-Take ciprofloxacin 500mg once per day for 14 days for an
infection in the urine.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
19933011-DS-8 | 19,933,011 | 23,790,955 | DS | 8 | 2175-12-26 00:00:00 | 2175-12-26 18:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex / Ditropan / morphine / dicyclomine
Attending: ___.
Chief Complaint:
Abnormal labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo female with CKD in planning stages for
dialysis, bladder cancer, L nephrectomy, chronic hydronephrosis,
and reurrent pyelonephritis with plans for ureterostomy who
presents with foul-smelling urine and chest heaviness. Since
surgery ___, reports 1 month of weakness, body aches, metallic
taste in mouth, weight loss. Last night developed foul-smelling
cloudy urine, small volume. Denies chest pain, fevers, chills,
shortness of breath. Reports heaviness in her chest like there
is "fluid" on it, worse when lying down. Reports "cloudy"
mentation.
In the ED, VS: 98.2 92 138/85 16 100% RA. Physical exam
significant for suprapubic tenderness and R CVA tenderness. She
was given ASA 325 for chest discomfort. Labs significant for a
Cr 7.7 (up from 4.9), K 5.2/BUN 93, bicarb 10, anion gap 18, Mg
1.3. UA significant for >182 WBC, positive leuk esterase,
moderate blood. Trops returned flat and EKG showed NSR with no
STE. Blood/urine cx pending. She was given an LR bolus in the ED
and was started on IV CTX out of concern for pyelonepritis. She
was admitted to medicine for management of pyelonephritis and
CKD. VS on transfer: 98.2 70 142/75 18 100% RA.
Upon interview on the floor, Ms. ___ said that she no longer
had pain or discomfort anywhere. She is fatigued, however, and
is ambivalent regarding plans for a ureterostomy. She would like
to speak with the renal team regarding this plan.
ROS:
+ per HPI, all other ROS negative
Past Medical History:
-___ dx with bladder cancer. Reports of 40+ bladder surgeries
for recurrence
-___ L.nephrectomy due to metastasis
-___ hydronephrosis due to scarring of ureters from numerous
bladder surgeries, temporary nephrostomy tubes placed
-Hep C stage II fibrosis
-Gerd with gastric ulcers
-HTN
Social History:
___
Family History:
Denies any family history and specifically any family history of
kidney disorders.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
VS: 98.5 140/68 70 18 100 ra
Gen: A fatigued woman lying in bed in no acute distress
HEENT: Normalocephalic/atraumatic
CV: RRR no M/G/R
Pulm: CTAB no wheezes/crackles
Abd: Soft, nontender, nondistended. No suprapubic or CVA
tenderness.
GU: no foley, wearing diaper due to occasional incontinence
Ext: 2+ radial pulse, no edema
Skin: No rashes or lesions
Neuro: Alert and conversing well, moving all extremities.
PHYSICAL EXAM ON DISCHARGE:
===========================
VS: 97.9, BP 101/53, HR 67, RR 18, 97% RA
Urine output 3900
Gen: A fatigued woman lying in bed, mild ___ edema
though improved
HEENT: Normalocephalic/atraumatic
CV: RRR no M/G/R
Pulm: CTAB no wheezes/crackles
Abd: Soft, nondistended. Tenderness to palpation in
mid-epigastric region. Positive right sided CVA tenderness.
GU: foley in place
Ext: 2+ radial pulse, no edema
Skin: No rashes or lesions
Neuro: Alert and conversing well, moving all extremities.
Pertinent Results:
LABS ON ADMISSION:
===================
___ 05:35PM BLOOD WBC-8.0 RBC-3.72* Hgb-11.1* Hct-31.5*
MCV-85 MCH-30.0 MCHC-35.4* RDW-13.4 Plt ___
___ 05:35PM BLOOD Neuts-73.5* Lymphs-15.8* Monos-5.0
Eos-5.3* Baso-0.4
___ 05:35PM BLOOD Glucose-89 UreaN-92* Creat-7.7*# Na-135
K-5.2* Cl-107 HCO3-10* AnGap-23*
LABS ON DISCHARGE:
==================
___ 06:00AM BLOOD WBC-6.5 RBC-3.08* Hgb-9.2* Hct-26.4*
MCV-86 MCH-30.0 MCHC-35.0 RDW-13.2 Plt ___
___ 06:00AM BLOOD Glucose-88 UreaN-45* Creat-4.4* Na-139
K-4.1 Cl-106 HCO3-23 AnGap-14
___ 06:00AM BLOOD Calcium-8.9 Phos-3.5 Mg-2.1
___ 5:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h.
ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. ___ MORPHOLOGY
Cefazolin interpretative criteria are based on a dosage regimen
of
2g every 8h.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 16 I =>32 R
CEFAZOLIN------------- <=4 S 16 R
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S 32 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ 4 S 8 I
TRIMETHOPRIM/SULFA---- =>16 R =>16 R
HCV viral load pending
IMAGING:
========
Renal US ___:
IMPRESSION:
Severe right hydroureteronephrosis, similar to prior MR exam
from ___.
CT ABD PELVIS ___:
IMPRESSION:
1. Right perinephric fat stranding is new since the MR
examination from ___ and may reflect
pyelonephritis. Multiple adjacent enlarged retroperitoneal lymph
nodes are likely reactive.
2. Severe right hydronephrosis and hydroureter extending to the
ureterovesical junction is unchanged since the previous MRI,
with no stone or obvious obstructing mass.
3. Diffuse mild bladder wall thickening with a stable known
anterior wall mass.
ART DUP EXT UP BILAT COMP ___:
IMPRESSION:
Patent central veins bilaterally. Patent cephalic and basilic
veins with
diameters as noted. The left upper arm cephalic vein is
diminutive.
VENOUS DUP UPPER EXT BILATERAL ___:
IMPRESSION:
Patent central veins bilaterally. Patent cephalic and basilic
veins with
diameters as noted. The left upper arm cephalic vein is
diminutive.
Brief Hospital Course:
Ms. ___ is a ___ yo female with CKD in planning stages for
dialysis, bladder cancer, L nephrectomy, chronic hydronephrosis,
and recurrent pyelonephritis who presents with pyelonephritis
and worsening CKD that improved with IVF and foley placement.
#Complicated Pyelonephritis (recurrent history) with chronic
right sided hydronephrosis and bladder cancer s/p left
nephrectomy with multiple surgeries:
Patient with CVA tenderness and pyuria on UA on presentation in
setting of known chronic hydronephrosis. Urine culture with
evidence of E. Coli sensitive to ceftriaxone though not
sensitive to PO antibiotics including ciprofloxacin or bactrim.
CT findings consistent with fat stranding supporting of
pyelonephritis. The patient had midline placed for full 14 day
course of IV ceftriaxone at time of discharge to be completed
___.
#Severe Right sided hydronephrosis chronic in nature thought to
be secondary to bladder spasms vs. scar tissue around ureteral
orifice in the past. CT pelvis non-contast obtained and ruled
out obstructive stone. Hydronephrosis appeared stable per
comparison to MR in ___ of this year though continues to be
severe in nature. Urology consulted with plan for decompression
with foley placement and consideration of perc nephrostomy tube
if patient does not show improvement though she did. Patient
also had one episode of bladder spasms and was given belladonna
suppository with resolution of symptoms. Of note patient did not
tolerate PO antispasmodics. She was provided with short term
supply of belladonna suppositories on discharge. In addition
plan for continued foley placement for decompression until
patient's follow up appointment with Dr. ___ on ___.
# Acute Renal Failure
# Chronic Kidney Disease - (baseline creatinine of ___
Patient with symptoms of CKD and uremia on admission including
general malaise/fatigue and dysguesia. On admission patient
noted to have creatinine of 7.7 significantly elevated compared
to her prior baseline. Patient's renal function improved with
IVF and foley placement to creatinine of 4.4 on day of
discharge.
Patient with initial metabolic acidosis in setting of renal
failure improved to normal range with sodium bicarbonate IVF.
The patient was without evidence of volume overload on exam or
other issue requiring urgent dialysis. Initial work up for
fistual formation was started with transplant surgery and upper
extremity vein mapping. The need for fistula creation in
anticipation of need for dialysis in the future was discussed
extensively with the patient and her hsuband. Multiple
discussions regarding this took place with the interdisciplinary
team and her outpatient urologist and nephrologist were also
updated regarding these discussions. Mrs. ___ ultimately
decided not to pursue fistula formation or dialysis and wanted
to discuss this matter further at time of her outpatient follow
ups both with Dr. ___ Dr. ___.
#Normocytic Anemia
Patient with normocytic anemia and elevated ferritin in the
setting of her chronic renal disease consistent with anemia of
chronic disease. Hg/Hct remained stable. The patient was without
evidence of active signs/symptoms of bleeding throughout
hospital course.
# GERD
# Dyspepsia
# Early satiety and weight loss in setting of questionable
hiatal hernia
Patient noted to have ongoing early satiety and heartburn
throughout the course of her hospitalization in the context of
weight loss in the month prior to admission. The patient noted
that she had a prior history of gastric ulcers approximately ___
years that warranted EGD at that time. The patient noted that H.
pylori was ruled out. In the setting of GERD/dyspepsis given her
age, weight loss, and early satiety, and lack of improvement of
her symptoms with prilosec and family history of gastric cancer
in her brother it was though she would greatly benefit from
repeat EGD upon follow up with Dr. ___ at ___
___.
#Constipation
Patient with constipation in setting of oxycodone use as well as
opium component in suppository. Constipation resolved prior to
discharge with bowel regimen including miralax, docusate, senna,
and dulcolax suppository. She was discharged with docusate and
senna.
#HCV
History of HCV with previous interferon treatment that was
stopped in setting of BCG treatment for bladder cancer. Patient
with normal LFT's and no evidence of synthetic dysfunction
throughout hospital course. HCV viral load was ordered during
this hospital stay and pending at time of discharge. Follow up
with patient's gastroenterologist Dr. ___.
#Headaches
Patient initially with tension headache that was bilateral in
nature not associated with photophobia nausea or vomiting that
improved prior to discharge.
#Hypertension
-Amlodipine was continued
#Depression/Anxiety:
Patient continued on fluoxetine and lorazepam QHS. A one time
dose of PRN ativan was given as patient was feeling overwhelmed
particularly during the initial part of her hospital course.
Social work was also consulted to help with coping.
#Electrolytes
Replete gently in the setting of CKD.
#Code Status/goals of care:
During this hospital course the patient was DNR/DNI.
# CONTACT: Husband ___ ___
TRANSITIONAL ISSUES:
==============
Outpatient EGD to follow up patient's symptoms of early satiety
and recent weight loss
-Consider treatment of patient's chronic HCV in the future,
viral load checked this hospitalization and pending at time of
discharge
-Follow up chem-7 and renal function at upcoming appointment
-Follow up discussion with patient regarding fistula and
dialysis
-Fax discharge summary to patient's Gastroenterologist Dr.
___ at ___ Fax: ___ Phone:
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Fluoxetine 40 mg PO DAILY
3. Lorazepam 2 mg PO QHS:PRN anxiety
4. Omeprazole 20 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. CeftriaXONE 1 gm IV Q24H
Last day will be ___
RX *ceftriaxone 1 gram 1 gram IV once a day Disp #*9 Vial
Refills:*0
2. Amlodipine 2.5 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Lorazepam 2 mg PO QHS:PRN anxiety
5. Omeprazole 20 mg PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Bisacodyl 10 mg PO DAILY:PRN constipation Duration: 1 Dose
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
9. Belladonna & Opium (16.2/30mg) 1 SUPP PR PRN bladder spasms
RX *___ alkaloids-opium [___-Opium] 30 mg-16.2 mg
1 suppository(s) rectally once a day Disp #*12 Suppository
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Complicated Pyelonephritis
Chronic hydronephrosis
Acute on chronic kidney injury
Secondary:
History of bladder cancer
Left nephrectomy
Hepatitic C
GERD with gastric ulcers
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure being involved in your care. You were admitted
to the hospital and found to have worsening kidney funcion and a
kidney infection. A foley catheter was placed and your kidney
function improved. In addition, you were started on an IV
antibioic called ceftriaxone to treat your kidney infection for
a 14 day course. Your foley catheter will stay in place until
you follow up with Dr. ___. You also noted that you felt
early fullness and have had some weight loss over the last
month. You have a history of gastric ulcers and should likely
have a repeat endoscopy with your outpatient gastroenterologist
Dr. ___. This should be discussed at your follow up
appointment.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19933117-DS-14 | 19,933,117 | 24,522,455 | DS | 14 | 2151-06-01 00:00:00 | 2151-06-01 08:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Second occurrence primary spontaneous pneumothorax.
Major Surgical or Invasive Procedure:
RIGHT VATS, BLEBECTOMY, PLEURODESIS, WEDGE RESECTION - Dr.
___
___ of Present Illness:
___ with recent history of spontaneous right pneumothorax
(in ___ treated with tube thoracostomy who is referred
to
the ED for finding of recurrent right pneumothorax on outpatient
CXR. Following initial hospitalization for first event, follow
up
CXR in clinic follow up on ___ showed right lung to remain fully
re-inflated. Patient reports that starting 1 week ago, he
noticed
a difference in his breathing (a mild dyspnea) when he laid down
to sleep at night. He did not have this sensation when he was
active and upright during the day. As the symptoms persisted, he
was concerned that his pneumothorax may have recurred and
presented to his PCP yesterday who obtained a CXR that in fact
showed a small-to-moderate size right pneumothorax. He was
notified about the findings today and was instructed to present
to the ED.
On evaluation, patient recounts history as above. He had some
chest tightness earlier but currently has no symptoms and denies
pain, dyspnea, and cough. He has been able to go to work as
usual.
Past Medical History:
None
Social History:
___
Family History:
Denies history of spontaneous pneumothorax.
Physical Exam:
Gen: WA/NAD
HEENT: NCAT, EOMI
Resp: Breathing comfortably on RA. Incisions c/d/I.
Cards: HDS
Ext: WWP
Pertinent Results:
___ 04:50AM BLOOD WBC-10.7* RBC-4.80 Hgb-14.8 Hct-43.1
MCV-90 MCH-30.8 MCHC-34.3 RDW-11.5 RDWSD-37.3 Plt ___
___ 04:00AM BLOOD WBC-15.3* RBC-4.81 Hgb-14.9 Hct-43.4
MCV-90 MCH-31.0 MCHC-34.3 RDW-11.6 RDWSD-38.1 Plt ___
___ 07:12PM BLOOD WBC-19.9* RBC-4.99 Hgb-15.3 Hct-45.0
MCV-90 MCH-30.7 MCHC-34.0 RDW-11.5 RDWSD-37.7 Plt ___
___ 07:57PM BLOOD WBC-6.2 RBC-4.96 Hgb-15.1 Hct-43.6 MCV-88
MCH-30.4 MCHC-34.6 RDW-11.6 RDWSD-36.8 Plt ___
___ 07:57PM BLOOD Neuts-47.8 ___ Monos-6.8 Eos-4.1
Baso-0.8 Im ___ AbsNeut-2.95 AbsLymp-2.46 AbsMono-0.42
AbsEos-0.25 AbsBaso-0.05
___ 04:50AM BLOOD Plt ___
___ 04:00AM BLOOD Plt ___
___ 04:00AM BLOOD ___ PTT-30.9 ___
___ 07:12PM BLOOD Plt ___
___ 07:57PM BLOOD Plt ___
___ 07:57PM BLOOD ___ PTT-35.8 ___
___ 04:50AM BLOOD Glucose-99 UreaN-17 Creat-1.1 Na-136
K-4.2 Cl-98 HCO3-28 AnGap-10
___ 04:00AM BLOOD Glucose-125* UreaN-14 Creat-1.1 Na-137
K-4.4 Cl-102 HCO3-25 AnGap-10
___ 04:50AM BLOOD Calcium-8.5 Phos-1.9* Mg-2.0
___ 04:00AM BLOOD Calcium-8.6 Phos-4.1 Mg-1.7
Brief Hospital Course:
Mr. ___ was admitted on ___ under the thoracic surgery
service for management a second occurrence of primary
pneumothorax . He was taken to the operating room and underwent
a R VATS wedge & pleurodesis (mechanical & doxycycline). Please
see operative report for details of this procedure. He tolerated
the procedure well and was extubated upon completion. He was
subsequently taken to the PACU for recovery. PACU CXR reports no
pneumothorax.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the morning of POD 1
___ to regular, which he tolerated without abdominal pain,
nausea, or vomiting. He was voiding adequate amounts of urine
without difficulty. His Foley was discontinued on POD 1. His CT
was discontinued on POD 2 and his post pull film showed a small
right apical pneumothorax not significantly changed from prior.
He was encouraged to mobilize out of bed and ambulate as
tolerated, which he was able to do independently. His pain level
was routinely assessed and well controlled at discharge with an
oral regimen as needed. On POD3 he was discharged home with
scheduled follow up in Thoracic surgery clinic on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q6H
Discharge Disposition:
Home
Discharge Diagnosis:
RECURRENT PNEUMOTHORAX
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
* You were admitted to the hospital for lung surgery and you've
recovered well. You are now ready for discharge.
* Continue to use your incentive spirometer 10 times an hour
while awake.
* Check your incisions daily and report any increased redness or
drainage. Cover the area with a gauze pad if it is draining.
* Your chest tube dressing may be removed in 48 hours if dry.
If it starts to drain, cover it with a clean dry dressing and
change it as needed to keep site clean and dry.
* You may need pain medication once you are home but you can
wean it over the next week as the discomfort resolves. Make
sure that you have regular bowel movements while on narcotic
pain medications as they are constipating which can cause more
problems. Use a stool softener or gentle laxative to stay
regular.
* No driving while taking narcotic pain medication.
* Take Tylenol on a standing basis to avoid more opiod use.
* Continue to stay well hydrated and eat well to heal your
incisions
* No heavy lifting > 10 lbs for 4 weeks.
* Shower daily. Wash incision with mild soap & water, rinse, pat
dry
* No tub bathing, swimming or hot tubs until incision healed
* No lotions or creams to incision site
* Walk ___ times a day and gradually increase your activity as
you can tolerate.
Call Dr. ___ ___ if you experience:
-Fevers > 101 or chills
-Increased shortness of breath, chest pain or any other
symptoms that concern you.
** If pathology specimens were sent at the time of surgery, the
reports will be reviewed with you in detail at your follow up
appointment. This will give both you and your doctor time to
understand the pathology, its implications and discuss options
going forward.**
Followup Instructions:
___
|
19933219-DS-5 | 19,933,219 | 24,660,278 | DS | 5 | 2148-11-13 00:00:00 | 2148-11-13 16:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / amoxicillin / levofloxacin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP with common bile duct stenting on ___
History of Present Illness:
Mr ___ is a ___ yo M who is 6 days out from his lap CCY. He
was sent home the day after surgery and had uneventful recovery
until this morning when he experienced sharp epigastric
abdominal
pain with no associated symptoms. No fever no chills. Denies
nausea or vomiting. Had a normal bowel movement yesterday.
His abdominal pain responded to oxycodone taken at home. He
arrived to the ED hemodynamically stable no respiratory issues
no
fever
Past Medical History:
PMH:
Asthma
History of atypical nevus: R thigh mild, L abd mod
Allergic rhinitis
Sleep pattern disturbance
Family history of retinal detachment
Refractive error
PSH:
Lap CCY ___
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam:
VS: afebrile. vital signs stable.
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: soft, appropriately tender, incision sites are c/d/i
covered with steri-strips
EXTREMITIES: Warm, well perfused, no edema
Pertinent Results:
___ 05:48PM BLOOD WBC-10.2* RBC-4.79 Hgb-14.0 Hct-40.3
MCV-84 MCH-29.2 MCHC-34.7 RDW-11.9 RDWSD-36.4 Plt ___
___ 08:48AM BLOOD Neuts-76.7* Lymphs-16.9* Monos-4.5*
Eos-1.2 Baso-0.3 Im ___ AbsNeut-9.___* AbsLymp-2.18
AbsMono-0.58 AbsEos-0.15 AbsBaso-0.04
___ 06:12AM BLOOD ___ PTT-31.6 ___
___ 05:48PM BLOOD Glucose-111* UreaN-20 Creat-0.9 Na-139
K-4.4 Cl-101 HCO3-26 AnGap-12
Brief Hospital Course:
HOSPITAL COURSE TEMPLATE:
The patient presented to the emergency department 5 days after
a laparoscopic cholecystectomy with acute onset right upper
quadrant pain radiating down into his groin. CT of the abdomen
and pelvis demonstrated a bile leak and small biloma. The
patient was taking for endoscopic retrograde
cholangiopancreatography and common bile duct stenting. The
patient tolerated the procedure well and his pain was
significantly improved after the stenting procedure. The patient
was then re-admitted to the surgical floor ward for monitoring,
pain control and careful diet advancement.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with intravenous
narcotic pain meicationa PCA. Pain was very well controlled. The
patient was then transitioned to oral pain medication after
ERCP.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. Afterwards, the
patient's diet was progressed slowly and the patient was was
started progressed to reqular which he was tolerating at the
time of discharge.
ID: The patient's fever curves were closely watched for signs
of infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 50 mg PO QHS:PRN insomnia
2. Fluticasone Propionate 110mcg 2 PUFF IH BID
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
4. Fexofenadine 180 mg PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen [8 Hour Pain Reliever] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*60 Tablet Refills:*0
2. Cholestyramine 4 gm PO TID:PRN lower abdominal pain
Duration: 7 Days
RX *cholestyramine (with sugar) 4 gram 1 powder(s) by mouth
three times daily as needed Refills:*0
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
OK to request partial fill. Wean as tolerated.
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours as
needed Disp #*15 Tablet Refills:*0
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
5. Fexofenadine 180 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Biloma secondary to bile leak from the Ducts of ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions: Please call your surgeon or return to
the Emergency Department if you develop a fever greater than 101
F, shaking chills, chest pain, difficulty breathing, pain with
breathing, cough, a rapid heartbeat, dizziness, severe abdominal
pain, pain unrelieved by your pain medication, a change in the
nature or severity of your pain, severe nausea, vomiting,
abdominal bloating, severe diarrhea, inability to eat or drink,
foul smelling or colorful drainage from your incisions, redness,
swelling from your incisions, or any other symptoms which are
concerning to you.
Diet: Stay on Stage III diet until your follow up appointment;
please refer to your work book for detailed instructions. Do not
self- advance your diet and avoid drinking with a straw or
chewing gum. To avoid dehydration, remember to sip small amounts
of fluid frequently throughout the day to reach a goal of
approximately ___ mL per day. Please note the following signs
of dehydration: dry mouth, rapid heartbeat, feeling dizzy or
faint, dark colored urine, infrequent urination.
Medication Instructions:
Please refer to the medication list provided with your discharge
paperwork for detailed instruction regarding your home and newly
prescribed medications.
Some of the new medications you will be taking include:
1. Pain medication: You will receive a prescription for
oxycodone, an opioid pain medication. This medication will make
you drowsy and impair your ability to drive a motor vehicle or
operate machinery safely. You MUST refrain from such activities
while taking these medications. You may also take acetaminophen
(Tylenol) for pain management; do not exceed 4000 mg per 24 hour
period.
2. Constipation: This is a common side effect of opioid pain
medication. If you experience constipation, please reduce or
eliminate opioid pain medication. You may trial 2 ounces of
light prune juice and/or a stool softener (i.e. crushed docusate
sodium tablets), twice daily until you resume a normal bowel
pattern. Please stop taking this medication if you develop
loose stools. Please do not begin taking laxatives including
until you have discussed it with your nurse or surgeon.
4. You will be given a prescription for cholestyramine. You
should take this medication if you have continued lower
abdominal pain.
Activity:
You should continue walking frequently throughout the day right
after surgery; you may climb stairs.
You may resume moderate exercise at your discretion, but avoid
performing abdominal exercises or lifting items greater than10
to 15 pounds for six weeks.
Wound Care:
You may remove any remaining gauze from over your incisions.
You will have thin paper strips (Steri-Strips) over your
incision; please, remove any remaining Steri-Strip seven to 10
days after surgery.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Please call the doctor if you have increased pain, swelling,
redness, cloudy, bloody or foul smelling drainage from the
incision sites.
Avoid direct sun exposure to the incision area for up to 24
months.
Do not use any ointments on the incision unless you were told
otherwise.
Followup Instructions:
___
|
19933258-DS-20 | 19,933,258 | 25,827,452 | DS | 20 | 2131-11-12 00:00:00 | 2131-11-12 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Aspartame / Prozac
Attending: ___.
Chief Complaint:
Nausea/ vomiting/ diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admitting resident: ___ hx of obesity s/p lap band ___
(___) presents with nausea, vomiting, diarrhea and
abdominal pain. Patient reports she has been having repeated
episodes of dry heaving and nonbilious emesis since her gastric
band placement with oral intake. She was last seen in clinic in
___ with similar symtpoms and 2ccs were aspirated from
her band. She has missed her next 2 subsequent yearly
appointments due to deaths in her family. Patient reports she
has been eating small bites of food as instructed with frequent
emesis as usual, however yesterday afternoon experienced an
aucte onset of crampy abdominal pain in LLQ and RLQ, clear
emesis x3 and multiple diarrhea. She has not been able to
tolerate any PO intake other than some soup since then. She
presented to the ___ where she was afebrile with normal
vital signs, WBC 14.7 w/left shift, normal BMP, LFTs and coags.
CT abdomen/pelvis with contrast showed multiple dialted loops of
small bowel with transition to decompressed small bowel in the
upper mid abdomen. She was subsequently transferred to ___.
Past Medical History:
PMH:
Obesity
OSA
Hypothyroidism
Depression
Migraine
PSH:
laparoscopic cholecystectomy ~ ___ yrs ago
laparoscopic gastric band ___ (___)
Social History:
___
Family History:
Non-contributory
Physical Exam:
VS: T 98.6 P 64 BP 106/40 RR 18
Constitutional: NAD
Neuro: Alert and oriented x 3
Cardiac: RRR, NL S1, S2
Resp: CTA B
Abd: Soft, non-tender, no rebound tenderness/guarding
Ext: No edema
Pertinent Results:
___ 07:17AM BLOOD WBC-10.4 RBC-4.49 Hgb-12.9 Hct-38.4
MCV-86 MCH-28.8 MCHC-33.6 RDW-13.9 Plt ___
___ 11:03PM BLOOD WBC-15.2*# RBC-4.82 Hgb-13.4 Hct-41.8
MCV-87 MCH-27.9 MCHC-32.1 RDW-13.8 Plt ___
___ 07:17AM BLOOD Glucose-82 UreaN-8 Creat-0.6 Na-139 K-3.8
Cl-103 HCO3-24 AnGap-16
___ 07:17AM BLOOD Calcium-8.6 Phos-4.7* Mg-2.1
___ 11:03PM BLOOD calTIBC-263 VitB12-435 Folate-7.1
Ferritn-171* TRF-202
___: ABDOMEN (SUPINE & ERECT):
IMPRESSION: Multiple dilated loops of small bowel with multiple
air-fluid levels consistent with small bowel obstruction as
described on earlier same day CT.
___: PORTABLE ABDOMEN:
Upper enteric drainage tube appears to enter the nondistended
stomach as
denoted by the band, ending in the mid portion. The
insufflation tubing
cannot be traced continuously, but is best evaluated empirically
by inflating the band if there is any doubt. Intestinal gas
pattern is essentially normal. Pneumoperitoneum is not assessed
by the supine imaging.
Brief Hospital Course:
Ms. ___ was transferred to ___ from an OSH due to concern
of small bowel obstruction seen on ABD/Pelvic CT scan. Upon
presentation to ___, she was afebrile with normal vitals. No
further labs were repeated other than a negative UA. She was
given 1L NS bolus and morphine x1 and was comfortable, and
passing gas, however, a KUB showed retained contrast prompting
complete unfilling of her band and placement of a ___
tube.
On HD3, given return of bowel function, the NGT was removed and
her diet advanced to stage 3. Given ongoing hemodynamic stabiliy
without fever and resolution of diarrhea, the patient was
discharged to home; of note, pt bradycardic which she reports is
baseline. She will continue a stage 3 diet at home gradually
advancing as tolerated and take a multivitamin and thiamine
supplementation. She follow-up with Dr. ___ in ___
as she undergoing a tonsillectomy in ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Topiramate (Topamax) 75 mg PO QAM
2. Topiramate (Topamax) 100 mg PO QPM
3. Buprenorphine HCl 100 mg PO DAILY
4. Buprenorphine HCl 100 mg PO Q NOON
5. Multivitamins W/minerals 1 TAB PO DAILY
6. meloxicam 15 mg oral Daily
7. Sumatriptan Succinate 50 mg PO PRN migraine
8. TraZODone 50 mg PO HS:PRN sleep
9. Levothyroxine Sodium 200 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 200 mcg PO DAILY
2. Topiramate (Topamax) 75 mg PO QAM
3. BuPROPion 100 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Thiamine 100 mg PO DAILY
6. Buprenorphine HCl 100 mg PO DAILY
7. Buprenorphine HCl 100 mg PO Q NOON
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Sumatriptan Succinate 50 mg PO PRN migraine
10. Topiramate (Topamax) 100 mg PO QPM
11. TraZODone 50 mg PO HS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
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.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___, You were admitted to the hospital due to nausea,
vomiting and diarrhea. An abdominal CT scan showed a possible
bowel obstruction, therefore, you band was entirely unfilled,
you were placed on bowel rest and had a ___ tube
placed. Your symptoms subsequently resolved without further
intervention and you were able to tolerate a stage 3 diet
without difficulty. You are now preparing for discharge to home
with the following instructions:
Followup Instructions:
___
|
19933418-DS-16 | 19,933,418 | 28,709,233 | DS | 16 | 2195-10-16 00:00:00 | 2195-10-17 14:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
metronidazole / levofloxacin / naltrexone / warfarin
Attending: ___
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ unknown past medical hx but suspected EtOH and IVDU s/p fall
from standing onto a brick found face down at a T stop with 3
min
LOC and Narcan found on person with reported GCS 9 and had
epistaxis. In ED was agitated and intubated for airway
protection, EtOH elevated to 350. CT face revealed left ZMC
fracture as well as minor orbital fractures for which plastic
surgery is consulted. CT head, c-spine, and chest/abdomen/pelvis
negative for traumatic injury aside from left
zygomaticomaxillary
complex (ZMC) fracture, mildly displaced right orbital roof
fracture with associated retrobulbar, extraconal orbital
hematoma, possible nondisplaced right lamina papyracea fracture,
and right frontal subgaleal hematoma. Ophthalmology evaluated
the
patient and found no elevated IOP and no concern for globe or
retina injury or entrapment.
Past Medical History:
-hepatitis C (___)
-basal cell carcinoma s/p resection ___ (left temple)
-L thigh fasciotomy for "overdose" w/ acute renal failure
___,
with residual deficits (weak toe flexion?)
Social History:
___
Family History:
Non-contributory. Father with history of "heart tumor" (still
alive)
Physical Exam:
Admission Physical Exam:
HEENT: + R frontal subgaleal hematoma, not expansile.
Superficial
abrasions of right forehead. R periorbital ecchymosis. Pupils
fixed/dilated from ophtho dilation. EOM unable to be performed,
intact by forced duction by ophtho. unable to assess visual
acuity. + Dried blood at nares. No nasal septal hematoma. No
rhinorrhea. Unable to assess cranial nerve function. Edentulous,
no obvious intraoral trauma, exam limited by presence of ETT.
Malar flattening on left side. No obvious stepoffs. Midface
stable.
Discharge Physical Exam:
VS: 97.8, 137/93, 73, 18, 98 Ra
Gen: A&O x3. c/o headache. ambulating in room steady gait
HEENT: Right periorbital/midface edema and eccymosis. abrasion
overlying
right frontal region.
right eye lid is swollen closed, manually able to open. pupils
equally round and reactive to light. EOMI with exception of
mild
limited upward gaze of right eye.
decreased light touch sensibility in the left V2 distribution.
nose is midline, no septal hematoma. tenderness along nasal
dorsum without stepoffs or deformity.
midface is stable
no intraoral lacerations, moist mucus membranes, edentulous,
normal mandibular excursion, TMJ stable
remainder of cranial nerve exam wnl
CV: HRR
Pulm: LS ctab
Abd: soft, NT/ND
Ext: Right shoulder TTP, pain with ROM. Right hand swollen,
x-ray negative for fracture.
Neuro: c/o dizziness, headache. + post concussive syndrome
Pertinent Results:
___ 05:53AM BLOOD WBC-3.0* RBC-3.63* Hgb-10.6* Hct-31.7*
MCV-87 MCH-29.2 MCHC-33.4 RDW-15.6* RDWSD-50.0* Plt Ct-91*
___ 04:21AM BLOOD WBC-3.1* RBC-3.52* Hgb-10.5* Hct-31.3*
MCV-89 MCH-29.8 MCHC-33.5 RDW-15.9* RDWSD-51.4* Plt Ct-83*
___ 02:10AM BLOOD WBC-6.7 RBC-4.47* Hgb-13.1* Hct-39.1*
MCV-88 MCH-29.3 MCHC-33.5 RDW-16.5* RDWSD-52.7* Plt ___
___ 09:44PM BLOOD WBC-4.8 RBC-4.69 Hgb-13.8 Hct-41.7 MCV-89
MCH-29.4 MCHC-33.1 RDW-16.6* RDWSD-54.4* Plt ___
___ 05:20PM BLOOD WBC-6.9 RBC-5.22 Hgb-15.2 Hct-46.3 MCV-89
MCH-29.1 MCHC-32.8 RDW-16.5* RDWSD-53.6* Plt ___
___ 05:53AM BLOOD Glucose-97 UreaN-10 Creat-0.6 Na-142
K-3.9 Cl-107 HCO3-26 AnGap-9*
___ 04:21AM BLOOD Glucose-99 UreaN-20 Creat-0.7 Na-142
K-3.7 Cl-105 HCO3-28 AnGap-9*
___ 02:10AM BLOOD Glucose-100 UreaN-13 Creat-0.6 Na-148*
K-3.9 Cl-110* HCO3-22 AnGap-16
___ 09:44PM BLOOD Glucose-108* UreaN-11 Creat-0.6 Na-147
K-4.3 Cl-111* HCO3-20* AnGap-16
___ 02:10AM BLOOD ALT-54* AST-74* AlkPhos-85 TotBili-0.9
___ 05:53AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.6
___ 04:21AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.8
___ 02:10AM BLOOD Albumin-3.6 Calcium-8.8 Phos-3.9 Mg-2.9*
___ 09:44PM BLOOD Calcium-8.9 Phos-4.5 Mg-1.6
___ 02:10AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-POS*
___ 05:20PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:10AM BLOOD HCV Ab-POS*
Imaging:
___ Hand X-ray: There is no evidence of fracture, dislocation,
lytic or sclerotic lesions demonstrated. No soft tissue
abnormalities seen.
___ Shoulder X-ray: There is no evidence of fracture,
dislocation, lytic or sclerotic lesion demonstrated. Image
portion of the lung parenchyma is unremarkable.
___ Chest X-ray: No significant interval change compared to
prior study. Mild vascular congestion remains with no overt
pulmonary edema. No superimposed consolidations. Stable and well
placed monitoring devices.
___ Sinus/Mandible/Maxillofacial CT: Left zygomaticomaxillary
complex (ZMC) fracture. Mildly displaced right orbital roof
fracture, in close proximity to the orbital apex with associated
retrobulbar, extraconal orbital hematoma. Possible nondisplaced
right lamina papyracea fracture. Large right frontal subgaleal
hematoma.
___ Chest CT: No evidence of fracture or soft tissue injury in
the torso. No free fluid in the abdomen pelvis. Diffuse wall
thickening the bladder which is nonspecific but can be seen in
cystitis or chronic bladder outlet obstruction. Cirrhotic
morphology of the liver and splenomegaly. There is a prominent
periportal lymph node which is nonspecific but can be seen in
chronic liver disease. Cholelithiasis without gallbladder wall
thickening.
___ Head CT: No intracranial hemorrhage. Large right-sided
subgaleal hematoma extending from the right frontal region to
the
right periorbital region. Multiple facial fractures, fully
outlined on concurrent maxillofacial CT.
___ C-spine CT: No fracture or malalignment of the cervical
spine. Left-sided facial fractures are better evaluated on same
day maxillofacial CT.
___ Chest X-ray: No acute intrathoracic abnormality.
Brief Hospital Course:
___ year old male found down with +LOC, found to have multiple
facial trauma and GCS of 9, +ETOH, intubated for airway
protection. CT imaging was significant for multiple facial
fractures including left zygomaticomaxillary complex (___)
fracture; Mildly displaced right orbital roof fracture, in close
proximity to the orbital apex with associated retrobulbar,
extraconal orbital hematoma. Possible nondisplaced right lamina
papyracea fracture; and large right frontal subgaleal hematoma.
Patient reports that ZMC fracture happened ~1 week ago at work
per PRS report on ___. Plastic surgery recommended
non-operative management at this time, with outpatient follow-up
to discuss surgical correction, and recommendation of soft diet
PRN for comfort and sinus precautions. Opthalmology consulted
and examined the patient, they recommend follow-up in ___ weeks
if any residual ocular symptoms after swelling resolves. The
patient was extubated and transferred to the floor in
hemodynamically stable condition.
Tertiary exam was negative for other injuries. ___ signed off on
the patient, as he was independently ambulatory in the room. OT
saw the patient for cognitive evaluation due to +LOC. They
recommended follow-up in the Concussion Clinic.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. FoLIC Acid 1 mg PO DAILY
4. Lidocaine 5% Patch 1 PTCH TD QAM right upper back pain
5. Nicotine Patch 14 mg/day TD DAILY
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Left zygomaticomaxillary complex (___) fracture.
2. Mildly displaced right orbital roof fracture, in close
proximity to the orbital apex with associated retrobulbar,
extraconal orbital hematoma.
3. Possible nondisplaced right lamina papyracea fracture.
4. Large right frontal subgaleal hematoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ after a fall. You were found to have
multiple facial fractures. You were seen by Plastic Surgery team
who recommended non-operative management at this time. You can
follow-up in Plastics clinic to discuss surgery in ___ weeks.
Their instructions for fracture and wound management are:
-Bacitracin twice a day and as needed to abrasions
-Can rinse with water, pat dry, re-apply ointment.
-Recommend sinus precautions x 1 week- elevate head on several
pillows, no smoking, no nose blowing, open mouth sneezing, no
drinking through straws.
-Soft diet for comfort
Ophthalmology was also consulted and examined you due to
fractures around your eye. The found no injuries. They recommend
outpatient follow-up.
You are now medically clear for discharge. Please call your
doctor or nurse practitioner or return to the Emergency
Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids
Followup Instructions:
___
|
19933622-DS-10 | 19,933,622 | 23,666,993 | DS | 10 | 2142-04-14 00:00:00 | 2142-04-14 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / tape
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Diagnostic laparoscopy, lysis of adhesions
History of Present Illness:
Ms. ___ is a ___ female s/p gastric bypass ___ years ago,
who presented to an outside hospital emergency room with
worsening abdominal pain. She had a CT scan that showed a
dilated loop of small bowel in her jejunojejunostomy. She was
transferred to our institution, admitted. Pt is s/p exploratory
laparoscopy, lysis of adhesions. Pt also with seizure hx. Pt
disc
in multi disciplinary rounds, ref'd to SW via POE. Chart/OMR
reviewed. Tox screen positive for cocaine, barbs, cocaine and
oxy.
Past Medical History:
PMH: heartburn, history of migraine headaches, left shoulder
pain, and kidney stones.
PSH: dental surgery
Social History:
___
Family History:
sister with morbid obesity, also had weight loss surgery
Physical Exam:
Discharge Physical Exam:
VS:98.4 69 110/57 18 100RA
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN:(+) BS x 4 quadrants, soft, non-tender, incision sites
are c/d/i covered with steri-strips
EXTREMITIES: Warm, well perfused, pulses palpable,(+) edema of
upper extremities bilaterally.
Pertinent Results:
___ 11:39PM URINE MUCOUS-RARE
___ 11:39PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-1
___ 11:39PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:39PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:39PM ___ PTT-29.8 ___
___ 11:39PM PLT COUNT-236
___ 11:39PM NEUTS-72.8* ___ MONOS-3.6 EOS-0.7
BASOS-0.7
___ 11:39PM WBC-7.8 RBC-4.29 HGB-11.7* HCT-36.4 MCV-85
MCH-27.2# MCHC-32.1# RDW-14.3
___ 11:39PM URINE bnzodzpn-NEG barbitrt-POS opiates-POS
cocaine-POS amphetmn-NEG oxycodn-POS mthdone-NEG
___ 11:39PM URINE GR HOLD-HOLD
___ 11:39PM URINE UCG-NEGATIVE
___ 11:39PM URINE HOURS-RANDOM
___ 11:39PM URINE HOURS-RANDOM
___ 11:39PM ETHANOL-NEG
___ 11:39PM ALBUMIN-4.2
___ 11:39PM LIPASE-21
___ 11:39PM ALT(SGPT)-14 AST(SGOT)-15 ALK PHOS-89 TOT
BILI-0.3
___ 11:39PM estGFR-Using this
___ 11:39PM GLUCOSE-112* UREA N-8 CREAT-0.9 SODIUM-141
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
___ 05:45AM PLT COUNT-222
___ 05:45AM WBC-8.0 RBC-4.08* HGB-11.2* HCT-34.4* MCV-84
MCH-27.4 MCHC-32.5 RDW-14.2
___ 05:45AM CALCIUM-8.4 PHOSPHATE-2.3* MAGNESIUM-1.8
___ 05:45AM GLUCOSE-116* UREA N-7 CREAT-0.9 SODIUM-141
POTASSIUM-3.7 CHLORIDE-110* TOTAL CO2-24 ANION GAP-11
___ 06:57AM LACTATE-1.5
___ 05:45AM calTIBC-365 VIT B12-365 FOLATE-10.3
FERRITIN-7.6* TRF-281
OHS CT: ?internal hernia
Brief Hospital Course:
The patient was transferred from ___ to the ___ ED on
___ for abdominal pain. Pt was evaluated by ___
bariatric surgery service.
The patient was made NPO, given intravenous fluids and pain
medication. An NG tube was inserted for decompression. The
patient had a CT scan with contrast done at ___ prior
to transfer, which was concerning for an inernal hernia.
The patient was taken to the operating room for a diagnostic
laparoscopy for abdominal pain, possible internal hernia. A
lysis of adhesions was done and there were no necrotic portions
of the bowel. There were no adverse events in the operating
room; please see the operative note for details.
Pt was extubated, taken to the PACU until stable, then
transferred to the ward for observation.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with IV pain
medications. Pain was very well controlled. The patient was then
transitioned to crushed oral pain medication once tolerating a
regular solid diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO and an NG tube was
inserted for decompression. Patient remained NPO with NGT
postoperatively POD 0. POD 1 she had her NGT removed, patient
had no N/V. Patient was started on clears with no issues. On POD
2, the patient was started on a bariatric stage 5 diet with no
issues. Patient resumed all home medications.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge ___, the patient was doing well,
afebrile and hemodynamically stable. The patient was tolerating
a bariatric stage 5 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:
Keppra 750mg BID
Gabapentin 900mg am, 600mg midday, 900mg pm
Celexa 40mg
Discharge Medications:
1. Citalopram 40 mg PO DAILY
2. 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
3. Gabapentin 900 mg PO DAILY
4. Gabapentin 600 mg PO NOON
5. Gabapentin 900 mg PO QPM
6. LeVETiracetam 750 mg PO BID
7. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
do not drink or drive while taking this medication
RX *oxycodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every 4 hours Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
s/p diagnostic laparoscopy, Lysis of adhesions
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were transferred from ___ to ___ for abdominal
pain. You were taken to the operating room for a diagnostic
laparoscopy. You were found to have adhesions which were taken
down. You tolerated the surgery well and had no complications.
You are stable now and ready to be discharged from the hospital.
It is imperative that you follow up with Dr. ___ in
clinic. Please read the following instructions carefully:
Resume your home medications, CRUSH ALL PILLS.
You will be starting some new medications:
1. You are being discharged on medications to treat the pain
from your operation. These medications will make you drowsy and
impair your ability to drive a motor vehicle or operate
machinery safely. You MUST refrain from such activities while
taking these medications.
2. You should begin taking a chewable complete multivitamin with
minerals. No gummy vitamins.
3. You should take a stool softener, Colace, twice daily for
constipation as needed, or until you resume a normal bowel
pattern.
4. You must not use NSAIDS (non-steroidal anti-inflammatory
drugs) Examples are Ibuprofen, Motrin, Aleve, Nuprin and
Naproxen. These agents will cause bleeding and ulcers in your
digestive system.
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.
If there is clear drainage from your incisions, cover with
clean, dry gauze.
Your steri-strips will fall off on their own. Please remove any
remaining strips ___ days after surgery.
Please call the doctor if you have increased pain, swelling,
redness, or drainage from the incision sites.
Sincerely,
___ Team
Followup Instructions:
___
|
19933692-DS-20 | 19,933,692 | 29,309,294 | DS | 20 | 2166-03-19 00:00:00 | 2166-03-19 14:54:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Valium
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic appendectomy
History of Present Illness:
Mr. ___ is a ___ who presents w/ one day of RLQ pain. He
endorses nausea that started yesterday evening, and awoke today
w/ ___ vague hypogastric pain that gradually increased to ___
RLQ pain. Denies chills, fevers, weight loss, or night sweats.
He last ate yesterday evening and w/ minimal appetite today.
Last
BM yesterday was normal.
Past Medical History:
hypertension
hypercholesterolemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
PE: 133/63, 74, 18, 92% RA
Gen: Patient is A&O x 3, and comfortable
Car: RRR, nl S1 and S2, non displaced PMI, no JVP appreciated.
Resp: Breath sounds CTA bilaterally
Abd: +BS, soft, non distended, mild tenderness over incisions
which are C/D/I
Extr: WWP, no edema.
Pertinent Results:
___ 04:30PM BLOOD WBC-19.3*# RBC-5.35 Hgb-16.0 Hct-46.6
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.4 Plt ___
___ 04:30PM BLOOD Neuts-88.8* Lymphs-6.0* Monos-4.2 Eos-0.3
Baso-0.7
___ 04:30PM BLOOD Plt ___
___ 04:30PM BLOOD ___ PTT-32.3 ___
___ 04:30PM BLOOD Glucose-112* UreaN-12 Creat-0.8 Na-138
K-3.8 Cl-101 HCO3-25 AnGap-16
___ 04:30PM BLOOD ALT-25 AST-26 AlkPhos-85 TotBili-0.8
___ 04:30PM BLOOD Lipase-21
___ 04:32PM BLOOD Lactate-1.2
CT Abdomen and Pelvis ___
FINDINGS:
Dependent regions of ground-glass in the lungs are most likely
due to
atelectasis. The lung bases are otherwise clear.
The liver, gallbladder, spleen, kidneys, adrenal glands, and
pancreas are
unremarkable. The stomach and small bowel are unremarkable
without evidence of obstruction. A few scattered diverticula
are noted in the colon without evidence of diverticulitis.
The appendix is dilated to 15 mm and is fluid-filled with
hyperemia of the
wall. There is surrounding fatty stranding. There is no
extraluminal air or drainable collection.
The bladder, prostate, and seminal vesicles are unremarkable.
There is no
free intraperitoneal fluid nor free air. There is no
intra-abdominal
adenopathy noting scattered subcentimeter retroperitoneal and
mesenteric
nodes. Partially calcified atherosclerotic plaque seen in the
abdominal aorta without evidence of aneurysm.
Degenerative changes are seen spine without suspicious osseous
lesion.
IMPRESSION:
Findings compatible with acute appendicitis.
Brief Hospital Course:
___ was admitted on ___ under the acute care surgery service
for management of his acute appendicitis. He was taken to the
operating room and underwent a laparoscopic appendectomy. Please
see operative report for details of this procedure. He tolerated
the procedure well and was extubated upon completion. He was
subsequently taken to the PACU for recovery.
He was transferred to the surgical floor hemodynamically stable.
His vital signs were routinely monitored and he remained
afebrile and hemodynamically stable. He was initially given IV
fluids postoperatively, which were discontinued when he was
tolerating PO's. His diet was advanced on the morning of ___
to regular, which he tolerated without abdominal pain, nausea,
or vomiting. He initially failed a voiding trial but thereafter
he was voiding adequate amounts of urine without difficulty. He
was encouraged to mobilize out of bed and ambulate as tolerated,
which he was able to do independently. His pain level was
routinely assessed and well controlled at discharge with an oral
regimen as needed.
On ___, he was discharged home with scheduled follow up in
___ clinic.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Atenolol 50 mg PO DAILY
3. Citalopram 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
Please follow up at the appointment in clinic listed below. We
also generally recommend that patients follow up with their
primary care provider after having surgery. We have scheduled an
appointment for you listed below.
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for ___ weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
You may feel weak or "washed out" a couple weeks. You might want
to nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You could have a poor appetite for a couple days. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay.
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19933827-DS-5 | 19,933,827 | 27,449,021 | DS | 5 | 2139-10-01 00:00:00 | 2139-10-17 19:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Singulair / vancomycin / ceftriaxone / cefepime
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ Guided LP
History of Present Illness:
Ms. ___ is a ___ y.o. F with a history of IDDM, HTN,
HLD, and steatosis who presents with altered mental status. She
was in her usual state of health until the morning of ___.
She went to work and was coughing all day. She has a chronic
non-productive cough, but she was coughing more on ___. She
was in a training session at work when she began to feel sick,
meaning she became tired and cold, so she went home and went to
bed. She can't remember anything after the training started,
like what she did at lunch or at home, and at home, she could
not remember how to inject herself with insulin. Her sister in
___ called her at home and found her to be confused, so she
called the patient's daughter who lives with the patient, and
the daughter called EMS. Per the daughter, the patient was last
normal on the morning of ___. EMS found the patient to be
tachypneic, tachycardic, and febrile with a FSBG en route in the
200s. She was brought to the ___ ED.
In the ED, initial vitals were: 103.7 122 197/88 35 100% Nasal
Cannula
- Labs were significant for: WBC 10.3, Cl 94, Ca ___, P 1.6,
AST/ALT 49/67, ALP 130 TBili 0.7
- Imaging: CXR: no acute intrathoracic process; NCHCT: Punctate,
1 mm density in the third ventricle could represent acute
hemorrhage.
- Consults: Neurosurgery: "Incidental finding of 1mm hyperdense
dot in the thalamus. M/P calcification (especially as seen in
coronal and sagital reconstructions). No need for special
monitoring. No need for repeat CT. No need for NSGY follow up."
- The patient was given:
___ 22:12 PO Acetaminophen 1000 mg
___ 22:13 IVF 1000 mL NS 1000 mL
___ 02:21 IVF 1000 mL NS 1000 mL
___ 04:03 IV CeftriaXONE 2 gm
___ 05:55 IV Vancomycin 1000 mg
and ordered for IV acyclovir
LP was attempted but unsuccessful. Patient admitted for further
work-up of AMS.
Vitals prior to transfer were: 98.3 98 164/65 20 97% RA
On the floor, the patient was afebrile with stable vital signs.
She was feeling OK but sweating and coughing. She denied sore
throat, chest pain, belly pain, n/v, diarrhea, constipation, and
chest pain. She endorses that her grandson who lives with her
has had a cold recently and endorses breathing faster for the
past few days.
Past Medical History:
-Diabetes since ___
-Overweight
-Hypertension
-Hyperlipidemia
-Colonoscopy ___
-Elevated LFTs likely from fatty liver ultrasound ___:
-Echogenic liver consistent with steatosis. Other forms of liver
disease including hepatic fibrosis or cirrhosis or
steatohepatitis cannot be excluded on the basis of this
examination. No concerning liver lesion identified.
Social History:
___
Family History:
-Father ___
-Mother ___
Physical Exam:
Exam on Admission ___
Vitals: 99.0, 134/67, 90, 22, 97RA
General: Lying in bed wearing mask, awake and alert, coughing,
sweating, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, no LAD, able to flex neck with no pain or limit in
ROM but unable to fully extend neck back (can only go to 90
degrees, unclear if this is her baseline)
Lungs: CTAB, no wheezes/rales/rhonchi
CV: RRR, normal S1/S2, no MRG
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, no cyanosis/clubbing/edema, 2+ pulses
Neuro: AAOx3, CN II-XII grossly intact, ___, equal strength
bilaterally in biceps, triceps, hamstrings, quadriceps, ___,
gastroc. Decreased strength in R IO.
Exam on Discharge
Pertinent Results:
IMAGING:
___ CXR
FINDINGS:
Low lung volumes are again noted. The lungs are grossly clear
without confluent consolidation or large effusion. The
cardiomediastinal silhouette is stable. No acute osseous
abnormalities.
IMPRESSION: No acute cardiopulmonary process.
___
Chest CT w and w/o contrast
FINDINGS:
The partially imaged thyroid is unremarkable. There is no
supraclavicular, axillary, hilar or mediastinal lymphadenopathy.
The esophagus is grossly normal. There is a small hiatal
hernia.
Heart is mildly enlarged without pericardial effusion. The
thoracic aorta and proximal great vessels are normal in caliber
and well opacified with a notable paucity of atherosclerotic
calcification. There is mild enlargement of the main pulmonary
artery to 3.3 cm.
Lung volumes are slightly low. There is no pleural effusion or
pneumothorax. Atelectasis at the lung bases is minimal. There
is a small peripheral ground-glass opacity in the right upper
lobe anteriorly (4a:49). 8 x 6 mm right middle lobe nodule
(4a:115). 3 mm right upper lobe nodule (4a:38). 4 mm granuloma
at the left base (4a:32) and a few other scattered small
granulomas.
IMPRESSION:
1. Small area of opacification in the right upper lobe could
reflect scarring or atelectasis.
2. Several pulmonary nodules, the largest 8 x 6 mm in the right
middle lobe require follow-up.
3. Mild cardiomegaly.
RECOMMENDATION(S): 8 x 6 mm right middle lobe nodule.
The ___ pulmonary nodule recommendations are
intended as guidelines for follow-up and management of newly
incidentally detected pulmonary nodules smaller than 8 mm, in
patients ___ years of age or older. Low risk patients have
minimal or absent history of smoking or other known risk factors
for primary lung neoplasm. High risk patients have a history of
smoking or other known risk factors for primary lung neoplasm.
For low risk patients, initial follow-up CT at ___ months and
then at ___ months if no change. For high risk patients -
initial follow-up CT at ___ months and then at ___ and 24
months if no change.
___
Abdominal and Pelvic CT w and w/o contrast
COMPARISON: Abdominal ultrasound ___
FINDINGS:
ABDOMEN:
HEPATOBILIARY: Hypoattenuation of the liver suggests fatty
deposition. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: Both kidneys enhance symmetrically without
hydronephrosis. In the interpolar region of the right kidney is
a 3.8 x 3.1 cm heterogeneous mass with solid and small cystic
components. There is minimal right perinephric stranding about
the mass.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. Diverticulosis of the sigmoid colon is
noted, without evidence of wall thickening and fat stranding.
The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: There both calcified and noncalcified
uterine fibroids.
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: Nonspecific 1.3 cm area of sclerosis in the left sacrum
(2:98) may be a bone island. Degenerative changes in the lumbar
spine are mild to moderate.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. Solid and cystic 3.8 cm mass in the right kidney was not seen
on abdominal ultrasound of ___ and is most suspicious
for developing renal abscess.
2. 1.3 cm area of sclerosis in the left sacrum is most likely a
bone island.
3. Diverticulosis without evidence of diverticulitis.
4. Fibroid uterus.
___
CT Head w/o contrast
IMPRESSION:
1. Punctate medial left basal ganglia punctate hyperdensity.
While finding may represent a punctate parenchymal calcification
or volume averaging of calcified choroid within adjacent third
ventricle, differential consideration of punctate hemorrhage is
not excluded on the basis of this examination. Recommend
clinical correlation. If available, consider comparison with
prior imaging. If clinically indicated, consider short-term
follow-up imaging further evaluation.
2. Please note MRI of the brain is more sensitive for the
detection of acute infarct.
RECOMMENDATION(S): Recommend clinical correlation. If
available, consider comparison with prior imaging. If
clinically indicated, consider short-term follow-up imaging
further evaluation.
MICROBIOLOGY:
___ 10:15 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
AMPICILLIN------------ R
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
MEROPENEM------------- S
PIPERACILLIN/TAZO----- S
TOBRAMYCIN------------ S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ 12:33 ___.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 10:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S).
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___ 12:33PM.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
LABORATORIES:
___ 11:05PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:05PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 11:05PM URINE RBC-2 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 11:05PM URINE HYALINE-1*
___ 11:05PM URINE MUCOUS-RARE
___ 10:15PM GLUCOSE-240* UREA N-10 CREAT-1.0 SODIUM-135
POTASSIUM-4.0 CHLORIDE-94* TOTAL CO2-24 ANION GAP-21*
___ 10:15PM estGFR-Using this
___ 10:15PM ALT(SGPT)-67* AST(SGOT)-49* ALK PHOS-130* TOT
BILI-0.7
___ 10:15PM LIPASE-35
___ 10:15PM ALBUMIN-4.7 CALCIUM-10.5* PHOSPHATE-1.6*
MAGNESIUM-1.6
___ 10:15PM ___ PO2-33* PCO2-39 PH-7.46* TOTAL
CO2-29 BASE XS-3
___ 10:15PM LACTATE-2.7*
___ 10:15PM O2 SAT-66
___ 10:15PM WBC-10.3*# RBC-5.05 HGB-14.3 HCT-42.5 MCV-84
MCH-28.3 MCHC-33.6 RDW-13.8 RDWSD-42.1
___ 10:15PM NEUTS-85.4* LYMPHS-9.8* MONOS-3.4* EOS-0.2*
BASOS-0.5 IM ___ AbsNeut-8.76*# AbsLymp-1.00* AbsMono-0.35
AbsEos-0.02* AbsBaso-0.05
___ 10:15PM PLT COUNT-178
DISCHARGE LABS
___ 05:54AM BLOOD WBC-7.8 RBC-4.57 Hgb-12.7 Hct-39.2 MCV-86
MCH-27.8 MCHC-32.4 RDW-14.2 RDWSD-43.8 Plt ___
___ 05:54AM BLOOD Glucose-221* UreaN-9 Creat-0.8 Na-138
K-3.7 Cl-100 HCO3-26 AnGap-16
___ 05:54AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8
Brief Hospital Course:
Ms. ___ is a ___ y.o. F with a history of IDDM, HTN,
HLD, and steatosis who presents with altered mental status now
resolved thought to be due to an infectious process.
ACUTE ISSUES
#GNR bacteremia c/b renal abscess:
Patient presented with altered mental status when relatives
found her to be confused over the phone after having not felt
well at work. In the ED, her AMS had resolved, but she was
febrile with a fever, increased LDH, and mildly elevated WBC
count indicating an infection. CXR and UA were negative, and
they were unable to obtain an LP. She was flu negative. Her
physical exam was unremarkable except for a noted worsening of
her chronic cough. She was started on vanc/ceftriaxone in the
ED. Her blood cultures grew GNR on ___, and her antibiotic
coverage was switched from vanc/ceftriaxone to vanc/cefepime to
cover pseudomonas. Chest, abdominal, and pelvic CTs were
performed to search for a source and revealed a mass in the
right kidney that was thought to be an abscess. ___ was
consulted and felt that it was too small to drain, and they
recommended antibiotic treatment with close imaging follow-up in
the next few weeks to follow resolution. Sensitivities returned
on ___ indicating ciprofloxacin sensitivity, and her antibiotic
coverage was switched to PO cipro/IV vanc on ___. Given all
of her findings, her infection was thought to be due to a missed
UTI that had ascended and resulted in her R renal abscess.
Blood cultures never grew any gram positive organisms, and
patient was discharged on ertapenem with out-patient ID follow
up. She should also undergo repeat renal u/s in ___ weeks to
evaluate for resolution of renal abscess. If inconclusive, the
patient should undergo CT scan to evaluate for resolution of
abscess.
#AMS: Patient presented after relatives found her to be confused
over the phone after having not felt well at work. Her AMS
resolved in the ED, and she had no more episodes during her
stay. She was found to have GNR bacteremia due to a R renal
abscess, and this was thought to be the cause of her AMS. She
was treated with vanc/cepepime and then vanc/cipro once
sensitivities returned. She never grew any gram positive
bacteria in her blood, and her vancomycin was stopped.
___ ISSUES
#IDDM: Patient has poorly controlled DM2 at baseline with a
recent HBA1C of 12.1. She is followed by ___ as an
outpatient, and per their reports she only checks her glucose
once or twice per day and misses more than half of her insulin
doses. She had FSBG QACHS and was continued on her home insulin
regimen with an ISS with good sugar control. She was maintained
on a carb consistent diet. She will follow up at ___ for
further care.
#HTN: Continued home Lisinopril 40 mg PO DAILY, Metoprolol
Tartrate 100 mg PO BID, Amlodipine 10 mg PO DAILY. Held home
HCTZ 25 mg PO DAILY during admission, but restarted prior to
discharge.
#HLD: Continued home atorvastatin 20 mg PO daily.
#Vitamin D deficiency: Continued home Vitamin D ___ UNIT PO
DAILY.
#GERD: Patient has EGD scheduled for ___ and reported
that she is supposed to hold her home Omeprazole for two weeks
prior to this procedure. Thus her home omeprazole 20mg DAILY
was held.
# FEN: IVF PRN / replete lytes PRN / carb consistent diet
# PPX: Heparin SQ
TRANSITIONAL ISSUES
[ ] Please obtain imaging of patients R kidney in ___ weeks to
follow resolution of her abscess. If u/s is inconclusive, would
proceed with CT scan
[ ] Please follow patients blood sugars and insulin regimen
adherence
[ ] Patient found to have pulmonary nodules on CT scan.
Recommend repeat CT scan in ___ months.
[ ] patient should have weekly CBC w/ diff, BUN, Cr, LFTs, and
CRP drawn in the setting of Ertapenem administration. ALL LAB
RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
# Code Status: Full
# Contact Info: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 1000 mg PO BID
2. Lisinopril 40 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Metoprolol Tartrate 100 mg PO BID
5. Atorvastatin 20 mg PO QPM
6. Amlodipine 10 mg PO DAILY
7. detemir 95 Units BedtimeMax Dose Override Reason: per PCP
___
8. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using UNK Insulin
9. Fluticasone Propionate NASAL Dose is Unknown NU Frequency is
Unknown
10. Omeprazole 20 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Ertapenem Sodium 1 g IV Q24H
RX *ertapenem [Invanz] 1 gram 1 gm IV once a day Disp #*26 Vial
Refills:*0
2. Outpatient Lab Work
ICD9: ___ (septicemia)
Pls draw weekly CBC w/ diff, BUN, Cr, AST, ALT, CRP
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 20 mg PO QPM
6. detemir 95 Units BedtimeMax Dose Override Reason: per PCP
___
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Tartrate 100 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Omeprazole 20 mg PO DAILY
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Fluticasone Propionate NASAL 0 SPRY NU Frequency is Unknown
13. Hydrochlorothiazide 25 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gram negative septicemia
Right renal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You presented to ___ with altered mental status and fever.
You were found to have bacteria growing in your blood because of
a bacterial collection called an abscess in your right kidney.
This collection of bacteria likely formed due to a urinary tract
infection that you may not have noticed. You were treated with
antibiotics and had resolution of your symptoms. You will need
to continue your antibiotic course for 26 days after your
discharge and follow up with an ultrasound imaging of your
kidney to make sure the bacterial collection in the kidney
resolves.
During your stay your blood sugars were high. This was very
likely due to the severe bacterial infection you had, but you
should plan to follow up with your ___ team to make sure you
are taking your blood sugar and dosing your insulin properly.
You should continue your regular home insulin regimen on
discharge.
You will need weekly labs drawn to monitor your blood counts and
liver enzymes while on IV antibiotics. You are being discharged
with a prescription for weekly lab checks.
It was our pleasure taking care of you. Thank you for choosing
___. We wish you the very best.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19934176-DS-17 | 19,934,176 | 23,386,744 | DS | 17 | 2190-10-05 00:00:00 | 2190-10-05 21:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
epinephrine / red dye
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ Y F with Hx of Stage IV NSCLC with brain
metastases who presents to the ER with encephalopathy. She
finished WBRT for metastatic NSCLC on ___ (37.5 Gyin 14 fx).
She was tapered from Decadron 0.5 mg BID to daily around the new
year, and as instructed stopped taking 0.5 mg daily on ___.
On the morning of ___, she had headaches and nausea, which
she had not had since midway through radiation. She was
restarted on Decadron 0.5mg PO daily. On ___, her husband
noted she was acting abnormally around 4:30pm. She was not
answering questions appropriately, had non-sensical, repetitive
speech, and repeated "it's ok" to all questions. She was taken
to the ER where vitals were 98.4 122/70, 73, 16, 100%2L. CT
head revealed Multi-focal areas of white matter edema in both
cerebral hemispheres, left midbrian, concerning for multifocal
mets. She was given a foley, Decadron 10mg IV, and transferred
to the floor for further management. On arrival, she is unable
to participate in the interview, but her husband and son are
present. They state that she complained of chills for the past
2 days and also had difficulty walking over the past 2 days.
They deny she had access or took an accidental overdose of
medications, had focal symptoms of infection, or fever.
ROS: unable to obtain secondary to altered mental status
Past Medical History:
Oncology History:
Mrs. ___ is a ___ white
woman with a prior 15-pack-year history of smoking, who
initially
present to medical care in mid ___ with periods of
confusion. It seems that in ___ the patient was been
evaluated by her Psychiatrist and developed a short period of
confusion. This was further evaluated with a brain MRI in
___ that disclosed the presence of multiple enhancing
lesions at the grey-white junction and deep white matter. Prior
to the reported symptoms, the patient denied new or subacute
neurological symptoms, confusion, problems with reasoning,
speech
or others.
Her only complaint over the last 3 months was related to an
upper
respiratory infection (runny nose and dry cough) a month or so
ago. During that period she lost some weight, but denies
significant weight loss. The patient was initially seen by
Neuro-Oncology on ___ and started on levetiracetam for
concern of seizure which improved her cognition.
Further work-up was undertaken and a CT Scan of chest and
abdomen
was obtained on ___. It showed the presence of a 12 x 6 mm
irregularly shaped nodule in the lingula of the left lung. There
were several enlarged paratracheal, subcarinal, and hilar lymph
nodes identified. There were several other subcentimeter but
prominent mediastinal lymph nodes. No blastic or lytic lesion
suspicious for malignancy were seen. Degenerative changes were
noted at T1-T2.
The patient was referred to Interventional Pulmonary and a
biopsy/fine needle aspiration with cell block of levels 4R and 7
were performed on ___. The preliminary pathology shows a
possible carcinoma. The tumor is KRAS wild-type, EGFR wild-type
and ALK FISH negative. She started WBRT for metastatic NSCLC on
___ (37.5 Gy in 14 fx) which was completed on ___.
PAST MEDICAL HISTORY:
1. Depression
2. Left leg weakness, thought to be back injury
3. Claustrophobia
4. Encephalitis ___ years ago
5. Endometrial polyp ___
6. Hypothyroidism
7. Basal cell carcinoma
8. Back pain
Social History:
___
Family History:
Her parents both deceased in their ___. Her sister had melanoma
___ years ago, now cancer-free.
Physical Exam:
Physical Exam on Admission:
VS: T 99.3 126/74 HR 80 RR 22 SaO2 95RA Wt 115.6 lbs
GEN: Elderly woman lying in bed, appears comfortable, eyes
closed, continually replies, "it's ok honey" when asked any
questions; cachectic
HEENT: Pupils equal at 5mm, sclera anicteric, conjunctivae
clear, OP moist and without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: No rash, warm skin
NEURO: Able to follow some commands "turn your head towards me"
but not "touch finger to nose." Can answer some yes or no
questions, and answers yes when asked if she is having a hard
time expressing herself. moving all 4 extremities; cannot
participate in a full neuro exam.
PSYCH: inappropriate, not anxious
.
Physical Exam on Discharge:
VS: Tc 96.8 Tm 97.9 BP 120/70 HR 74 RR 16 SaO2 100 RA
GEN: awake, sitting in bed, NAD, conversive, cachectic
HEENT: PERRL, sclera anicteric, conjunctivae clear, OP moist and
without lesion
NECK: Supple, no JVD
CV: Reg rate, normal S1, S2. No m/r/g.
CHEST: Resp unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABD: Soft, NT, ND, no HSM, bowel sounds present
MSK: normal muscle tone
EXT: No c/c/e, 2+ ___ bilaterally
SKIN: No rash, warm skin
NEURO:
MS: awake, alert, oriented to name, hospital, month, year, able
to say days of the week forward and backward, answers questions
appropriately, fluent speech, ___ object recall after 5 min
CN II-XII intact
Motor: ___ strength in UEs and ___
Cerebellar: finger to nose intact ___
Sensation grossly intactl ___ throughout
Pertinent Results:
Labs on Admission:
___ 09:29PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 09:29PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:29PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 09:29PM URINE RBC-2 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:05PM GLUCOSE-138* UREA N-14 CREAT-0.7 SODIUM-140
POTASSIUM-4.8 CHLORIDE-103 TOTAL CO2-30 ANION GAP-12
___ 09:05PM WBC-7.1 RBC-3.89* HGB-13.2 HCT-38.1 MCV-98
MCH-33.8* MCHC-34.6 RDW-13.2
___ 09:05PM NEUTS-73.3* ___ MONOS-4.3 EOS-2.5
BASOS-0.5
___ 09:05PM PLT COUNT-253
___ 09:05PM ___ PTT-29.4 ___
Urine Tox screen negative
.
Microbiology
Urine culture: neg
Blood culture: neg
.
Imaging
.
CT Head W/O Contrast ___:
1. Multifocal cortical, cerebral, midbrain and cerebellar edema,
consistent with underlying metastatic disease. Interval
progression of vasogenic edema since ___, indicating
worsening metastatic disease.
2. No evidence of herniation or hemorrhage.
.
CXR ___: Widened mediastinum which could reflect
lymphadenopathy in this patient with metastatic lung cancer. No
signs of pneumonia or CHF.
.
MRI ___:
Significant progression of widespread diffuse metastases
involving the supratentorial and infratentorial brain, some of
which are hemorrhagic. No major vascular territorial infarct or
evidence of herniation.
.
EEG (prelim report): diffuse slowing, L>R, no epileptiform
activity
.
Labs on Discharge:
.
___ 06:40AM BLOOD WBC-7.5 RBC-3.28* Hgb-11.1* Hct-32.1*
MCV-98 MCH-34.0* MCHC-34.7 RDW-13.5 Plt ___
___ 06:40AM BLOOD Glucose-113* UreaN-14 Creat-0.7 Na-144
K-4.4 Cl-111* HCO3-27 AnGap-10
___ 06:40AM BLOOD Calcium-7.6* Phos-2.5* Mg-2.4
Brief Hospital Course:
Patient is a ___ Y F with history of Stage IV NSCLC with brain
metastases s/p whole brain xrt completed ___ who presented to
the ER with altered mental status.
.
# Altered mental status: On admission, patient was minimally
responsive, not following commands, answering questions
inapropriately. Differential initially included infection,
electrolyte abnormality, med changes, metastatic disease.
Infection ruled out - U/A, chest x-ray unremarkable and patient
was afebrile. Only medication change was tapering off the
dexamethasone. Of note, Ms. ___ completed WBRT for
metastatic NSCLC on ___ (37.5 Gyin 14 fx). CT in the ER
showed cerebral edema secondary to metastatic disease. Thus,
edema was the cause of confusion. Patient was given Decadron
10mg IV given in ER and 4mg IV q6 on the floor. Patient's
mental status rapidly improved over 24 hours and she became
alert and oriented x3, following all commands, fluent speech,
good attention. On discharge, patient was on Dexamethasone 6mg
PO bid with instructions to continue this dose for 2 weeks and
then taper to 4mg PO bid. Also, Keppra was increased from 500mg
bid to ___ bid. She will follow up with Dr. ___
(___) after discharge for further management.
.
#Stage IV NSCLC with metastases to lymph nodes and brain:
Patient has not received chemotherapy, despite the fact that she
saw Dr. ___ at ___, family plans to have medical oncology
with Dr. ___ at ___, appointment scheduled for
the end of ___. MRI brain showed progression of disease
from last imaging.
.
#Depression: Continued home lexapro.
.
#Hyperthyroidism: Continued home synthroid.
.
#Anxiety: Held Ativan in setting of altered mental status, but
re-started on discharge.
.
#Steroid-induced gastritis: PPI for prevention.
.
TRANSITIONS OF CARE:
-FULL CODE: discussed this with her husband and daughter
-___ 6mg PO bid x2 weeks, then 4mg PO bid
-Will f/u with Dr. ___
Medications on Admission:
DEXAMETHASONE - 0.5 mg PO daily
ESCITALOPRAM [LEXAPRO] - (Prescribed by Other Provider; chart
conversion) - 20 mg Tablet - 1 Tablet(s) by mouth once daily
LEVETIRACETAM - 500 mg Tablet - 1 Tablet(s) by mouth twice a day
LEVOTHYROXINE - 50 mcg Tablet - 1 Tablet(s) by mouth once a day
LORAZEPAM - (Prescribed by Other Provider; chart conversion) -
0.5 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day as
needed for anxiety
Discharge Medications:
1. Lexapro 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. Ativan 0.5 mg Tablet Sig: 0.5 Tablet PO once a day as needed
for anxiety.
4. Keppra 1,000 mg Tablet Sig: One (1) Tablet PO twice a day.
Disp:*60 Tablet(s)* Refills:*2*
5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO once a day.
Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2*
6. dexamethasone 2 mg Tablet Sig: Three (3) Tablet PO twice a
day: -please take 3 tabs (6mg) twice per day for 2 weeks
-after 2 weeks, decrease to 2 tabs (4mg) twice per day.
Disp:*180 Tablet(s)* Refills:*2*
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary:
Cerebral edema
Non small cell lung cancer metastatic to the brain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
.
You were admitted to the hospital because you were very
confused. A CT of your brain showed that you had a lot of
swelling. We thought that the swelling was due to recent
discontinuation of Dexamethasone and started you on high dose
dexamethasone. You responded extremely well. You also had an
EEG which did not show any seizure activity. Thus, on discharge,
you will continue to take dexamethasone as per instructions
below.
.
We have made the following changes to your medications:
-START Dexamethasone 6mg twice per day for 2 weeks; after 2
weeks, please lower the dose to 4mg twice per day
-INCREASE Keppra from 500mg twice per day to 1000mg twice per
day
-START Omeprazole 20mg daily
.
On discharge, please follow up with your primary care physician
and Dr. ___ as scheduled below. Before your appointment
with Dr. ___ go to the radiology department to have
imaging as detailed below.
.
It was a pleasure taking care of you. We wish you all the best!
Followup Instructions:
___
|
19934547-DS-3 | 19,934,547 | 28,909,836 | DS | 3 | 2202-06-25 00:00:00 | 2202-06-28 19:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Hyperkalemia on pre-op evaluation
Major Surgical or Invasive Procedure:
___
1. Arthroplasty, left hallux.
2. Excisional debridement of left distal phalanx to bone with
ulcer and closure.
History of Present Illness:
This is a ___ year old male anti-coagulated on Coumadin with
history of a-fib, osteomyolitis of left great toe, s/p
pacemaker, ___ disease and DM who presents to the ED
after being told to ___ to the ED with an elevated creatinine
and hyperkalemia. Pt was to have a left great toe surgery today,
and pre-op labs demonstrated increased potassium levels of 6.2.
He was then referred to the ED for further evaluation. Pt denies
decreased urine output or any other symptoms such as chest pain
or shortness of breath. Pt was started on Bactrim and Keflex x1
month ago for infection of DM related foot ulcer. He has no
prior history of kidney disease. Pt notes he is unsure if he
took his furosemide today.
Pt says he underwent ablation procedures for his a fib that
failed. He was started on fleicanide many years ago and
experienced ___ conduction of a flutter that resulted in cardiac
arrest with ROSC after shock. Had another episode of cardiac
arrest, both not recent. Had demand dual-chamber pacemaker
placed but no ICD.
Pt says course of antibiotics from podiatry are completed and
not to continue them any longer. He is very concerned about
having the operation done in house.
In addition, he admitted to heavy alcohol usage, daily
consumption between 500 to 1000 mL vodka especially on this
holiday break away from being a ___.
In the ED, initial vital signs were: 96.5 89 154/85 16 100%
Exam notable for clear lungs, pitting edema trace to 1+, no SOB,
left great toe ulcer, b/l leg discoloration.
Labs were notable for hyperK up to 6.8, corrected down to 5.4 on
the floor, EKG with ?peaked T waves in the ED.
Patient was given -
___ 16:51 IV Insulin Regular 10 units ___
___ 16:51 IV Furosemide 40 mg ___
___ 16:51 IV Dextrose 50% 25 gm ___
___ 16:51 IV Calcium Gluconate 1 g ___
___ 16:51 IVF 1000 mL NS 1000 mL ___
___ 17:22 IVF 1000 mL NS 1000 mL ___
Review of Systems:
(+)
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
ATRIAL FIBRILLATION
Anticoagulant long-term use
CONGESTIVE HEART FAILURE, UNSPEC
HYPERTENSION - ESSENTIAL, BENIGN
ESOPHAGEAL REFLUX
PACEMAKER REPROGRAMMING / CHECK
ENROLLED - ANTICOAGULATION SVC (NOT DX, FOR PROB LIST ONLY)
HYPERLIPIDEMIA
COLONIC POLYP
ARTIFICIAL PACEMAKER
GOUT, UNSPEC
OBESITY - MORBID
Prostate Cancer
DM (diabetes mellitus), type 2 with renal complications
Plantar fasciitis
Colon adenomas
Social History:
___
Family History:
Positive for T2DM, bipolar disease
Physical Exam:
EXAM ON ADMISSION
Vitals: 98.7 144/77 66 18 99 on RA
General: NAD, morbidly obese very large man, comfortable
HEENT: PERRL, EOMI, NC/AT, MMM
Lymph: No LAD
CV: RRR, no MRG
Lungs: CTA b/l, no WRR
Abdomen: Protuberant, no TTP, BS+, no organomegaly appreciated
Ext: Grey/purple b/l discoloration of the lower legs, 1+ pitting
edema to the calves b/l, left great toe ulcer with granulation
tissue present, pulses ___ in the b/l ___ ___
Neuro: NFD, AOx3, CNs II-XII grossly intact
Skin: As above, no other lesions, rashes present
EXAM ON DISCHARGE
Vitals: 98.6, 147-162/88-92, 58-61, 18, 98 on RA, ___, 163.4 kg
(down 5 kgs since admission), FSBG 150, not scoring for meds on
___
General: NAD, morbidly obese very large man, comfortable
HEENT: PERRL, EOMI, NC/AT, MMM
Lymph: No LAD
CV: RRR, no MRG
Lungs: CTA b/l, no WRR
Abdomen: Protuberant, no TTP, BS+, no organomegaly appreciated
Ext: Grey/purple b/l discoloration of the lower legs, 1+ pitting
edema to the calves b/l, left foot with OR dressing intact; No
evidence of drainage
Skin: As above, no other lesions, rashes present
Pertinent Results:
ADMISSION LABS:
___ 10:30AM BLOOD WBC-7.0 RBC-3.82* Hgb-12.8*# Hct-38.5*
MCV-101* MCH-33.6* MCHC-33.3 RDW-16.6* Plt ___
___ 10:30AM BLOOD Neuts-68.9 ___ Monos-5.0 Eos-4.0
Baso-0.3
___ 03:00PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-1+ Microcy-OCCASIONAL Polychr-NORMAL
___ 10:30AM BLOOD ___ PTT-36.3 ___
___ 10:30AM BLOOD Plt ___
___ 03:00PM BLOOD Glucose-223* UreaN-47* Creat-2.3* Na-128*
K-6.8* Cl-99 HCO3-19* AnGap-17
___ 03:00PM BLOOD Calcium-10.5* Phos-2.9 Mg-1.4*
___ 03:03PM BLOOD K-6.8*
___ 06:16PM BLOOD K-5.4*
___ 06:14PM URINE Color-Yellow Appear-Hazy Sp ___
___ 06:14PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 06:14PM URINE RBC-1 WBC-8* Bacteri-NONE Yeast-NONE
Epi-2
___ 02:37PM URINE Hours-RANDOM UreaN-303 Creat-44 Na-31
K-12 Cl-26 TotProt-<6
___ 06:14PM URINE Hours-RANDOM UreaN-705 Creat-164 Na-56
K-47 Cl-29 TotProt-31 Prot/Cr-0.2
PERTINENT LABS:
___ 02:37PM URINE U-PEP-NO PROTEIN Osmolal-205
___ 05:41AM BLOOD PEP-NO SPECIFI
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-6.0 RBC-3.26* Hgb-11.2* Hct-33.5*
MCV-103* MCH-34.5* MCHC-33.6 RDW-15.7* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD ___ PTT-90.8* ___
___ 07:00AM BLOOD Glucose-212* UreaN-32* Creat-1.7* Na-127*
K-4.9 Cl-96 HCO3-23 AnGap-13
___ 07:00AM BLOOD Calcium-10.5* Phos-4.1 Mg-1.8
MICRO:
___ 8:35 am TISSUE LEFT HALLUX DISTAL PHALANX.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
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 in
this culture..
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
IMAGING/STUDIES:
___ FOOT AP,LAT & OBL LEFT IMPRESSION:
In comparison with the study of ___, there has been an
arthroplasty at the interphalangeal joint of the great toe with
debridement. There is soft tissue prominence, phone no definite
acute destructive changes at the operative site. However, there
is what appears to be gas within soft tissues about the distal
phalanx. It is difficult to assess spleen cortex of the distal
tip of the distal phalanx, though it does not appear as sharp as
on the previous study. If there is concern for osteomyelitis,
MRI could be considered for further evaluation.
PATHOLOGY:
___ LEFT TOE BONE FRAGMENTS
1. Bone, left hallux, resection: Fragments of unremarkable bone
and cartilage.
2. Distal phalanx, left hallux, resection: Skin and fragments of
bone with remodeling.
Brief Hospital Course:
___ with DM, with left toe ulcer, a fib after failed ablation
p/w hyperK and ___ with likely AIN secondary to Bactrim/keflex,
now s/p debridement of left toe ulcer on Augmentin for 2 week
course in a boot with outpatient podiatry follow up.
# ___ - Multi-factorial in nature; including component of
decreased Cr clearance from bactrim, AIN from bactrim, and
possible hypovolemia from diuretic regimen. Creatinine improved
to 1.5 to 1.7 on discharge.
- STOPPED atenolol, enalapril, furosemide, spironolactone (last
three with plan to reassess and restart as outpatient)
- REDUCED allopurinol from 300 mg PO QD to 100 mg PO QD (may be
uptitrated once creatinine improves)
# HYPERKALEMIA: ___. Improved with Ca, glucose, insulin, Lasix.
Downtrended while inpatient to 4.9 (at 7.0 in ED).
# ALCOHOL ABUSE c/f WITHDRAWAL - Last drink ___. 500 mL to
1 L vodka per day. Did not have evidence of withdrawal during
hospital stay. Started MVI, folate, thiamine. Social work
evaluated and patient pre-contemplative.
- STARTED folic acid 1 mg PO QD, multivitamins 1 TAB PO DAILY,
thiamine 100 mg PO DAILY
# HYPONATREMIA: Has had continued hyponatremia noted back in
___. Unclear cause. Could be hypovolemic hyponatremia on
presentation given infection, or hypervolemic in the setting of
CHF. Patient was euvolemic during hospital stay. ___ also be
SIADH from unclear cause. With elevated calcium, renal failure,
also concern about possible developing myeloma, with
paraproteins causing pseudohyponatremia with SPEP/UPEP WNL.
# LEFT GREAT TOE ULCER - Diabetic vs. alcoholic in nature, PCP
and podiatry aware, was presenting for surgery when found to be
hyperkalemic and with ___. Tolerated procedure well ___
with podiatry. Micro with mixed bacterial flora and path with
non-specific findings from bone chip.
- STARTED amoxicillin-clavulanic acid ___ mg PO Q12H, oxycoDONE
(Immediate Release) 5 mg PO Q6H:PRN pain
# CHF - Had nuclear stress test and echo several months ago, not
in our system. Euvolemic during hospital stay (no pronounced leg
edema off baseline or crackles/SOB). Continued labetalol 800 mg
PO TID at discharge.
- STOPPED atenolol, furosemide, enalapril, spironolactone (see
above)
# ATRIAL FIBRILLATION - H/o. Had ablation procedures with Dr.
___ ___ years ago that failed. Fleicanide usage
precipitated atrial flutter with 1:1 ventricular conduction that
resulted in cardiac arrest discrete episodes x 2. On atenolol,
warfarin (held ___. Has demand dual-chamber pacemaker,
no ICD. Restarted warfarin 5 mg PO QD post-op, used heparin gtt
___. INR 1.1 the three days prior to discharge, goal INR
___.
# CAD - Continue Aspirin 81 mg PO/NG DAILY & Pravastatin 5 mg PO
QOD
# DM - H/o. Uses metformin and glyburide at home. SSI while in
house. Diabetic and heart-healthy diet along with K, Phos
restrictions.
# GERD - Carries diagnosis. Continue omeprazole 40 mg PO BID
# GOUT - H/o. On 300 mg allopurinol QD at home. 100 mg
allopurinol QD for now to reduce nephrotoxin load, increase back
to home dosage as tolerated.
- REDUCED allopurinol from 300 mg PO QD to 100 mg PO QD (can
uptitrate when ___ completely resolves as outpt)
# TRANSITIONAL ISSUES:
- Podiatry follow up and complete Augmentin course
- Anti-coagulation, discharged on 5 mg warfarin, INR 1.1, goal
___
- PCP follow up for K and sCr (4.9 and 1.7 on discharge)
- Alcohol cessation if he wants (pre-contemplative)
- Code: FULL
- Emergency Contact: ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Spironolactone 50 mg PO DAILY
2. Sulfameth/Trimethoprim DS 1 TAB PO BID
3. Warfarin 5 mg PO DAILY16
4. Cephalexin 500 mg PO Q8H
5. Saline Wound Wash (benzethonium chloride;<br>sodium chloride)
0.13 % topical QD
6. Allopurinol ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Atenolol 100 mg PO DAILY
9. Enalapril Maleate 30 mg PO BID
10. Furosemide 80 mg PO DAILY
11. GlyBURIDE 5 mg PO BID
12. Labetalol 800 mg PO TID
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Omeprazole 40 mg PO BID
15. Pravastatin 5 mg PO QOD
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Labetalol 800 mg PO TID
4. Omeprazole 40 mg PO BID
5. Pravastatin 5 mg PO QOD
6. Warfarin 5 mg PO DAILY16
7. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*28 Tablet Refills:*0
8. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
9. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Daily Multi-Vitamin] 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*0
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg 1 capsule(s) by mouth Q6H:PRN Disp #*40
Capsule Refills:*0
11. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
12. GlyBURIDE 5 mg PO BID
13. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
- Acute kidney injury
- Hyperkalemia
- Left great toe ulcer s/p surgery
- Hyponatremia
- Hypercalcemia
Secondary:
- Atrial fibrillation
- Diabetes mellitus
- Hypertension
- Congestive heart failure, diastolic, chronic
- Alcohol abuse
- Gastroesophageal reflux disease
- Hyperlipidemia
- Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
It was our pleasure taking care of you at ___
___. You were admitted to the hospital for an acute
kidney injury and high potassium levels, most likely secondary
to Bactrim for one month in addition to your outpatient
medications. Your potassium levels and kidney function improved
while inpatient and your kidneys should continue to improve back
to your baseline, but this will take time. You underwent a toe
surgery with podiatry and will need to use the boot provided to
you. You are to continue Augmentin 875 mg by mouth twice a day
with food until you follow up with podiatry. In addition, you
were noted to have low sodium for which labs were sent for
evaluation, and this should improve as your kidney function
improves.
It is important to follow up with your outpatient regular
doctor, along with your podiatrist and cardiologist. Dr. ___
will decide when and how to restart several of your heart and
fluid medications.
You will need to have labs done at your next appointment to
determine your kidney function.
You were re-started on warfarin after your operation and will
need your INR checked in order to ensure proper anti-coagulation
as an outpatient through the ___ Anti-coagulation Service at
___.
Please weigh yourself every morning, call MD if weight goes up
more than 3 lbs.
Best wishes,
Your ___ Care Team
Followup Instructions:
___
|
19934566-DS-6 | 19,934,566 | 23,719,068 | DS | 6 | 2113-11-17 00:00:00 | 2113-11-18 18:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
c/f sepsis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male, history of marginal cell lymphoma,
hypertrophic obstructive cardiomyopathy, paroxysmal A. fib, last
infusion of rituximab was on ___ who presents with nausea,
diarrhea, vomiting, fever and rash.
During the infusion he started to feel burning in the ear and
face and then it passed. He then went home and felt somewhat
fatigued but of no concern. Went to work for a few days, and on
___ did not feel well. Went to ___ where he was found to be
in Afib where he converted with diltiazem. His dose of
metoprolol
succ was increased from 37.5 to 50mg. He was discharged on
___ and felt back to his baseline.
Over the next few days he began to feel increasingly weak and
tired. In addition, he developed chills, and then in the last 48
hours stopped taking po, felt nauseated, vomited and had
multiple episodes of non bloody, watery diarrhea. No foul odor,
just watery. Over the last 24 hours, he noted a new rash.
Started on his chest and spread peripherally. He did take
benadryl for it
but that did not help. He has never had a rash like this before.
In the ED,
- Initial Vitals:
98.6 71 104/46 22 96% RA
- Exam:
- Diffuse macular rash involving the forearms abdomen and
flanks. No sores on the inside of his mouth
- Abdomen is mildly tender in the right upper quadrant
- Generally appears unwell
- Labs:
wbc 5.0
hgb 13.7
hct 40.0
Na 137
K 4.8
Cl 97
HCO3 20
BUN 32
Cr 1.5
Glu 162
Trop-T: 0.08
pH 7.34 pCO2 39 pO2 45 HCO3 22
FluAPCR: Negative
FluBPCR: Negative
Trop-T: 0.08
CK: 35 MB: 2
ALT: 23 AP: 45 Tbili: 2.4 Alb: 3.6
AST: 35 LDH: 424 Dbili: TProt:
___: Lip: 12
UricA:6.6
___: ___
- Imaging:
EKG: T wave inversions, ST depressions in lateral leads
CT AP: pending
- Consults:
Cardiology
- Interventions:
vanc/cefepime
4 L fluids
steroids methylpred 125mg
on norepi
scan torso
Upon arrival to the FICU:
He feels exhausted. He has diffuse myalgias, most notably in his
large joints as well as his mandible making it very hard to talk
and to swallow. He endorses chills, abdominal pain, itchiness,
and myalgia. Denies sob, cp, dizziness.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
Marginal cell lymphoma
Hypertrophic obstructive cardiomyopathy
Paroxysmal atrial fibrillation
Hypertension
Vitamin D deficiency
Dumping syndrome
Cholecystectomy
Social History:
___
Family History:
Mother ___ ATRIAL FIBRILLATION
Father CORONARY ARTERY DISEASE
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS: 98.8 101/56 81 98%RA
GEN: very uncomfortable, tired appearing
EYES: right eye with conjunctival redness
HENNT: NCAT, PERRLA, supple, low LAD
CV: rrr, no m/r/g
RESP: ctab, no w/r/r
GI: nt, nd, +bs
MSK: ecchymosis on right ankle, strength ___, dtr 2+
SKIN: diffuse maculopapular rash, multiple size lesions varying
in size, some confluence on neck, ears. face, chest, abdomen,
trunk, back, arms and legs. sparing palms and soles
NEURO: CN II-XII in tact
PSYCH: affect appropriate
DISCHARGE PHYSICAL EXAM
=========================
24 HR Data (last updated ___ @ 1149)
Temp: 97.6 (Tm 97.9), BP: 117/57 (117-144/56-66), HR: 59
(54-64), RR: 18 (___), O2 sat: 94% (93-95), O2 delivery: RA,
Wt: 158.5 lb/71.9 kg
GEN: no acute distress, fatigued-appearing
EYES: EOMI, PERRL, sclerae not icteric
HEENT: clear OP, MMM
CV: RRR, diffuse systolic murmur II/VI
RESP: CTAB, no w/r/r
GI: nondistended, nontender
MSK: ecchymosis on right ankle
LYMPH: no palpable cervical, supraclavicular, axillary, or
femoral lymph nodes
SKIN: no rashes
NEURO: aaox3
Pertinent Results:
ADMISSION LABS
======================
___ 12:30PM BLOOD WBC-5.0 RBC-5.05 Hgb-13.7 Hct-40.0
MCV-79* MCH-27.1 MCHC-34.3 RDW-12.9 RDWSD-36.4 Plt Ct-31*
___ 12:30PM BLOOD Neuts-68 Bands-2 ___ Monos-7 Eos-1
Baso-1 Atyps-1* ___ Myelos-0 AbsNeut-3.50 AbsLymp-1.05*
AbsMono-0.35 AbsEos-0.05 AbsBaso-0.05
___ 12:30PM BLOOD ___ PTT-33.9 ___
___ 12:30PM BLOOD Glucose-162* UreaN-32* Creat-1.5* Na-137
K-4.8 Cl-97 HCO3-20* AnGap-20*
___ 12:30PM BLOOD ALT-23 AST-35 LD(LDH)-424* CK(CPK)-35*
AlkPhos-45 TotBili-2.4*
___ 12:30PM BLOOD CK-MB-2 ___
___ 12:30PM BLOOD cTropnT-0.08*
___ 04:49PM BLOOD CK-MB-2 cTropnT-0.05*
___ 12:30PM BLOOD Albumin-3.6 UricAcd-6.6
___ 12:30PM BLOOD Hapto-<10*
___ 04:49PM BLOOD ___ pO2-45* pCO2-39 pH-7.34*
calTCO2-22 Base XS--4 Intubat-NOT INTUBA
___ 12:49PM BLOOD Lactate-2.5*
RELEVANT LABS
======================
___ 01:21AM BLOOD WBC-6.3 RBC-4.46* Hgb-12.2* Hct-35.8*
MCV-80* MCH-27.4 MCHC-34.1 RDW-13.1 RDWSD-37.2 Plt Ct-33*
___ 07:30PM BLOOD WBC-6.5 RBC-3.81* Hgb-10.5* Hct-30.8*
MCV-81* MCH-27.6 MCHC-34.1 RDW-13.5 RDWSD-39.3 Plt Ct-52*
___ 05:48AM BLOOD WBC-5.0 RBC-3.39* Hgb-9.2* Hct-27.5*
MCV-81* MCH-27.1 MCHC-33.5 RDW-13.5 RDWSD-39.8 Plt Ct-55*
___ 02:45PM BLOOD WBC-4.1 RBC-3.22* Hgb-8.8* Hct-26.7*
MCV-83 MCH-27.3 MCHC-33.0 RDW-13.6 RDWSD-41.1 Plt Ct-61*
___ 12:00AM BLOOD WBC-4.2 RBC-3.19* Hgb-8.8* Hct-26.6*
MCV-83 MCH-27.6 MCHC-33.1 RDW-13.5 RDWSD-41.1 Plt Ct-74*
___ 12:00AM BLOOD WBC-3.9* RBC-3.22* Hgb-8.7* Hct-26.5*
MCV-82 MCH-27.0 MCHC-32.8 RDW-13.0 RDWSD-39.0 Plt Ct-94*
___ 12:00AM BLOOD WBC-5.7 RBC-3.56* Hgb-9.6* Hct-29.1*
MCV-82 MCH-27.0 MCHC-33.0 RDW-12.9 RDWSD-38.5 Plt ___
___ 12:00AM BLOOD WBC-7.0 RBC-3.94* Hgb-10.4* Hct-32.0*
MCV-81* MCH-26.4 MCHC-32.5 RDW-12.9 RDWSD-37.9 Plt ___
___ 01:21AM BLOOD Glucose-165* UreaN-26* Creat-1.3* Na-136
K-4.1 Cl-106 HCO3-18* AnGap-12
___ 07:30PM BLOOD Glucose-165* UreaN-27* Creat-1.4* Na-135
K-4.6 Cl-105 HCO3-22 AnGap-8*
___ 05:48AM BLOOD Glucose-110* UreaN-22* Creat-1.2 Na-140
K-4.7 Cl-110* HCO3-22 AnGap-8*
___ 02:45PM BLOOD Glucose-150* UreaN-18 Creat-1.1 Na-140
K-4.0 Cl-108 HCO3-23 AnGap-9*
___ 03:27PM BLOOD Glucose-140* UreaN-18 Creat-1.1 Na-138
K-3.9 Cl-105 HCO3-25 AnGap-8*
___ 12:00AM BLOOD Glucose-109* UreaN-19 Creat-1.1 Na-140
K-4.1 Cl-106 HCO3-24 AnGap-10
___ 12:00AM BLOOD Glucose-109* UreaN-17 Creat-1.0 Na-138
K-4.1 Cl-104 HCO3-24 AnGap-10
___ 01:21AM BLOOD ALT-14 AST-21 LD(___)-394* CK(CPK)-27*
AlkPhos-32* TotBili-1.4 DirBili-0.3 IndBili-1.1
___ 07:30PM BLOOD ALT-10 AST-13 LD(___)-331* CK(CPK)-37*
AlkPhos-34* TotBili-0.5
___ 05:48AM BLOOD ALT-9 AST-11 LD(___)-299* AlkPhos-28*
TotBili-0.4
___ 02:45PM BLOOD LD(LDH)-301* TotBili-0.3
___ 12:00AM BLOOD ALT-9 AST-13 LD(LDH)-294* CK(CPK)-26*
AlkPhos-32* TotBili-0.2
___ 12:00AM BLOOD ALT-8 AST-10 LD(LDH)-249 CK(CPK)-18*
AlkPhos-31* TotBili-0.2
___ 01:21AM BLOOD ___ PTT-34.2 ___
___ 12:08PM BLOOD ___ PTT-30.6 ___
___ 07:30PM BLOOD ___ PTT-28.1 ___
___ 07:30PM BLOOD Parst S-NEGATIVE
___ 01:21AM BLOOD Ret Aut-2.0 Abs Ret-0.09
___ 01:21AM BLOOD Calcium-7.6* Phos-2.6* Mg-1.4*
___ 07:30PM BLOOD Albumin-2.6* Calcium-7.6* Phos-1.8*
Mg-2.4 UricAcd-4.6
___ 07:30PM BLOOD ___ Ferritn-953*
___ 12:00AM BLOOD ___ IgA-201 IgM-13*
RELEVANT IMAGING
======================
___ CXR PA/LAT
Borderline to mildly enlarged cardiac silhouette size, likely
accentuated by AP technique.
___ CXR AP for line
There is no focal consolidation, pleural effusion or
pneumothorax identified. The size of the cardiomediastinal
silhouette is unchanged. There is a new right internal jugular
central line whose tip projects over the mid to distal SVC.
___ CT CHEST/ABD/PELVIS WITH CONTRAST
1. Multifocal small ground-glass opacities and bronchiolitis are
suspicious for pneumonia. Given that there are several nodular
opacities surrounded by a ground-glass halo, angioinvasive
aspergillosis or other fungal infection should be strongly
considered.
2. Mediastinal and axillary lymphadenopathy. Borderline
enlarged bilateral pelvic wall external iliac lymph nodes as
well as numerous retroperitoneal lymph nodes are present.
3. Splenomegaly.
___ BILATERAL LOWER EXTREMITY ULTRASOUND
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ CXR AP
No acute pulmonary disease.
RELEVANT MICRO
======================
___ BLOOD CULTURES X2: NO GROWTH
___ URINE CULUTRE: NO GROWTH
___ URINE CULTURES X2: FUNGAL AND AFB CULTURES PENDING
___ BLOOD
Lyme IgG (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Lyme IgM (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody.
___ URINE LEGIONELLA ANTIGEN: NEGATIVE
___ CRYPTOCOCCAL ANTIGEN: NEGATIVE
___ RPR: NEGATIVE
___ CMV
CMV IgG ANTIBODY (Final ___:
NEGATIVE FOR CMV IgG ANTIBODY BY EIA.
CMV IgM ANTIBODY (Final ___:
NEGATIVE FOR CMV IgM ANTIBODY BY EIA.
INTERPRETATION: NO ANTIBODY DETECTED.
Greatly elevated serum protein with IgG levels ___ mg/dl
may cause
interference with CMV IgM results.
___ EBV
___ VIRUS VCA-IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS EBNA IgG AB (Final ___: POSITIVE
BY EIA.
___ VIRUS VCA-IgM AB (Final ___:
NEGATIVE BY EIA.
INTERPRETATION: RESULTS INDICATIVE OF PAST EBV INFECTION.
In most populations, 90% of adults have been infected at
sometime
with EBV and will have measurable VCA IgG and EBNA
antibodies.
Antibodies to EBNA develop ___ weeks after primary
infection and
remain present for life. Presence of VCA IgM antibodies
indicates
recent primary infection.
___ RAPID RESPIRATORY VIRAL SCREEN & CULTURE
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
___ C. DIFFICILE PCR: NEGATIVE
___ STOOL CULTURE
MICROSPORIDIA STAIN (Preliminary):
CYCLOSPORA STAIN (Preliminary):
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
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.
MODERATE POLYMORPHONUCLEAR LEUKOCYTES.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ STOOL VIRAL CULTURE
VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED.
___ STOOL
O&P: PENDING
___ STOOL
O&P: PENDING
DISCHARGE LABS
======================
___ 12:00AM BLOOD WBC-7.0 RBC-3.94* Hgb-10.4* Hct-32.0*
MCV-81* MCH-26.4 MCHC-32.5 RDW-12.9 RDWSD-37.9 Plt ___
___ 12:00AM BLOOD Neuts-63.5 ___ Monos-8.4 Eos-2.0
Baso-0.3 Im ___ AbsNeut-4.44 AbsLymp-1.66 AbsMono-0.59
AbsEos-0.14 AbsBaso-0.02
___ 12:00AM BLOOD Glucose-124* UreaN-23* Creat-1.0 Na-139
K-4.3 Cl-103 HCO3-24 AnGap-12
___ 12:00AM BLOOD ALT-9 AST-10 LD(LDH)-238 CK(CPK)-14*
AlkPhos-34* TotBili-0.3
___ 12:00AM BLOOD Calcium-8.8 Phos-3.8 Mg-1.8
Brief Hospital Course:
===============
SUMMARY
===============
Dr. ___ is a ___ with h/o marginal zone lymphoma,
hypertrophic obstructive cardiomyopathy, paroxysmal atrial
fibrillation, last infusion of rituximab was on ___ and recent
trip to ___ who presented with nausea, vomiting, rash,
myalgia, arthralgia, and hypotension and was found to have CT
findings concerning for fungal infection vs. viral syndrome vs.
atypical bacterial pneumonia. He was treated initially with
vancomycin, cefepime, doxycycline, and fluconazole. Vancomycin
and cefepime were eventually stopped, and he was discharged to
finish a 10-day course of doxycycline and ongoing fluconazole
until fungal studies return, with plans to follow up in
Hematology/Oncology and Infectious Disease.
===============
ACUTE ISSUES
===============
#Shock
#Arthralgias, myalgias
#PNA
#Rash
#Diarrhea, vomiting
#Hemolytic anemia
#Thrombocytopenia
Presented with acute onset diarrhea, vomiting, myalgias,
arthralgias, and diffuse maculopapular rash. CT findings
suggestive of PNA. Found to have hgb below baseline, hapto<10,
Tbili 2.5 on admission, and elevated LDH, most consistent with
hemolytic anemia. Smear without significant amount of
schistocytes. Coombs negative. Also found to be thrombocytopenic
below baseline. Etiology of overall presentation was unclear but
felt to be most consistent with fungal pneumonia e.g.
coccidiodomycosis given recent travel to the ___,
though chronology (acute onset) not consistent. Histo, blasto
studies negative. Presentation did not feel c/w aspergillosis.
Also possible viral syndrome. Lastly possibly an atypical
bacterial pneumonia. Lives in ___ and at risk for
tick-borne illness, but parasite smear did not find this. Of
note, rash timing does not appear consistent with rituximab. He
was treated initially with vancomycin, cefepime, doxycycline,
and fluconazole. Vanc and cefepime were discontinued, and
patient was monitored to be improving on doxy and fluc alone. He
was discharged with a 10-day total course of doxycline, along
with ongoing fluconazole until coccidio studies return, with
plans to follow up with primary oncologist and infectious
disease as outpatient.
#AFib
On tele this admission. Was in sinus. Xarelto initially held
given high INR and ___, resumed home Xarelto 20mg once ___
resolved. Metoprolol initially held given hypotension, resumed
once normotensive.
#NSVT
#Elevated troponin
#Elevated BNP
#ST depression on EKG
#Hypertrophic obstructive cardiomyopathy
He is followed by Cardiology at ___. Has h/o systolic anterior
leaflet motion of the mitral valve, diastolic dysfunction, last
known ejection fraction 65% (___), trace mitral regurg,
bicuspid aortic valve without stenosis. Abnormalities on tele on
admission prompted ACS workup that was unrevealing (EKG
unchanged from prior, trops trending down, flat CKMB, patient
asymptomatic). ___ 135___ this admission. During this
hospitalization, was noted to have 1 run of 16 beats of likely
NSVT (less likely SVT with aberrant conduction given lack of
baseline visible conduction abnormality on EKG). Outpatient
cardiology Dr. ___ was made aware of this.
___
Baseline this admission appears to be 1.0. Presented at 1.4.
Likely pre-renal given volume losses. Resolved by discharge.
===============
CHRONIC ISSUES
===============
#Marginal zone lymphoma
Has history of splenic marginal zone lymphoma, s/p good response
to 4 doses of rituximab in ___. Re-presented in ___ with
asymptomatic palpable splenomegaly and painful adenoid
enlargement. Received 1 dose of rituxan on ___.
#HTN
See above for metoprolol.
#Chronic intermittent diarrhea
#?Dumping syndrome
Seen by GI previously. colonscopy wnl in ___. followed by GI
for wt loss and diarrhea. No evidence of celiac, biopsies
negative. thought to be dumping syndrome s/p cholecystectomy
though not on bile salt binders.
# Code Status: Full confirmed
# Emergency Contact: ___ ___ wife
TRANSITIONAL ISSUES
[] Patient was discharged with plans to complete doxycycline for
a 10-day course (___) and fluconazole ongoing (___-)
until coccidio studies return. Primary oncologist Dr. ___
___ ID physician ___ aware of this situation.
[] Patient should undergo repeat imaging of his chest in the
future. ID will help guide when this will occur.
[] Non-sustained ventricular tachycardia: the patient was noted
to have 1 run of 16 beats of likely NSVT on telemetry this
admission. Dr. ___ at ___ was made aware. He
may benefit from ICD placement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Rivaroxaban 20 mg PO DAILY
2. Escitalopram Oxalate 15 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 7 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every 12
hours Disp #*9 Tablet Refills:*0
2. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth every 24 hours Disp
#*60 Tablet Refills:*0
3. Rivaroxaban 20 mg PO DINNER
4. Escitalopram Oxalate 15 mg PO DAILY
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
#Shock
#Arthralgias
#Myalgias
#PNA
#Rash
#Diarrhea
#Vomiting
#AFib
#Non-sustained ventricular tachycardia
#Thrombocytopenia
#Hemolytic anemia
SECONDARY DIAGNOSES
___
#Hypertrophic cardiomyopathy
#HTN
#?Dumping syndrome
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Dr. ___,
___ was our pleasure taking care of you at the ___
___!
WHAT BROUGHT YOU TO THE HOSPITAL?
You came to the hospital with vomiting, diarrhea, rash,
arthralgia, and myalgia.
WHAT HAPPENED IN THE HOSPITAL?
- You were found to have a low blood pressure. As such, you were
transferred to the ICU briefly. Once your blood pressure
stabilized, you were transferred to the floor.
- You underwent a CT scan of the chest, which showed a
pneumonia.
- It was felt that your overall condition was due to a possible
fungal infection, atypical bacterial pneumonia, or viral
illness.
- You were started on broad-spectrum antibiotics (vancomycin,
cefepime, doxycycline) and antifungal (fluconazole) initially.
As you improved and test results came back, some of these
medications were stopped.
WHAT SHOULD YOU DO ONCE YOU LEAVE THE HOSPITAL?
- You were discharged on fluconazole and doxycycline. You should
take the fluconazole until you hear back from either your
oncologist or infectious disease doctor. You should complete the
doxycycline for a 10-day course.
- Please see the infectious disease physicians in clinic.
We wish you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
19934880-DS-17 | 19,934,880 | 28,186,624 | DS | 17 | 2161-10-17 00:00:00 | 2161-10-17 13:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back Pain, cough
Major Surgical or Invasive Procedure:
___: Anterior T1 Corpectomy and Abscess Drainage
___: Revision T1, C7, C6 corpectomy, Anterior arthrodesis
C5-T1l, Application of an interbody cage.
___: C5-T3 Posterior interbody fusion
___: Tracheostomy
History of Present Illness:
Ms. ___ is a ___ with history IVDU, epidural abscess status
post hardware placement in ___, asthma, and bipolar disorder
who presents with back pain and cough. History is obtained from
review of ED documentation as patient is intubated and sedated
on arrival to the MICU. She was reportedly in her usual state of
health until 4 days prior to admission, when she developed
subjective fevers and chills in association with nonproductive
cough. On the day of admission, she began to experience severe
low back pain accompanied by bilateral lower extremity weakness
with difficulty ambulating. It is unclear as to whether she
described urinary retention, with varying accounts available.
She denied fecal incontinence.
In the ED, initial vital signs were as follows: 97.6, 130,
105/71, 32, 90% 4L. Exam was notable for guaiac-positive brown
stool and "slight" rectal tone. Foley catheter was placed, with
1200cc urine output. Admission labs were notable for Wbc of 13.5
(82.8% PMNs), K of 3.1, INR of 1.2, normal LFTs and lipase, ABG
of 7.53/___, and lactate of 1.8. Urine hCG was negative,
and urinalysis was notable for gross and microscopic hematuria,
but no clear evidence of infection. Blood cultures x3 were
drawn. Portable CXR revealed streaky opacities concerning for
pneumonia or atelectasis, and she was given levofloxacin 750mg
IV x1, as well as hydromorphone 4mg IV. After she desaturated to
84% on 6L nasal cannula, she was placed on a nonrebreather,
followed by a ventimask. After subsequent CTA revealed extensive
bilateral pulmonary emboli without evidence of right heart
strain, left lower lobe collapse likely from mucous plugging,
mild diffuse bronchial wall thickening, and tiny clinically
insignificant pneumomediastinum, she received a heparin bolus
followed by drip, vancomycin 1g IV, and 40mEq KCl in 1L IV
normal saline. She received a total of 4L IV normal saline.
Given concern for epidural abscess, she was intubated for MRI,
with ABG of 7.28/55/414/27 on CMV with FiO2 of 100%, TV of 450,
rate of 12, and PEEP of 5. She was reportedly difficult to
sedate, requiring ketamine, propofol, midazolam, and fentanyl
drips, followed by multiple midazolam boluses. Blood pressure
nadired in the ___ systolic, felt to reflect propofol and
midazolam, with improvement to ___ systolic after propofol and
midazolam drips were weaned in favor of dexmedetomidine. She was
evaluated by the cardiology service, with bedside TTE
demonstrating signs of RV strain; nevertheless, in light of
relatively stable blood pressure, lysis was not advised.
Panspine MRI ultimately was deferred due to respiratory and
hemodynamic instability, and a right internal jugular central
venous line was placed. Vital signs at transfer were as follows:
98.3, 75, 95/65, CMV with FiO2 of 100%, TV of 450, rate of 16,
and PEEP of 10; oxygen saturation reportedly declined to 96%
after PEEP was weaned to 5.
On arrival to the MICU, she is intubated and sedated and unable
to provide a history.
Review of systems:
Unable to obtain.
Past Medical History:
(per ED documentation and ___ primary care note):
IVDU
Epidural abscess status post hardware placement in ___
Status post traumatic injury to left eye, now blind
Asthma
VSD status post repair in childhood
Hiatal hernia status post repair
Bipolar disorder
Social History:
___
Family History:
(adapted from ___ primary care note):
Mother with hypertension. Father with history of lung cancer.
Maternal grandmother and maternal cousin with breast cancer.
Maternal uncle with prostate cancer.
Physical Exam:
EXAM ON ADMISSION
Vitals: 98.3, 75, 95/65, CMV with FiO2 of 100%, TV of 450, rate
of 16, and PEEP of 10
GENERAL: Intubated, sedated
HEENT: Sclerae anicteric, pupils constricted (~2mm), but equally
reactive
NECK: Supple, JVP not elevated
LUNGS: Wheezy bilaterally
CV: Regular rate and rhythm, no murmurs appreciable
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no edema
SKIN: No cutaneous stigmata of IVDU or endocarditis
NEURO: Pupils constricted, but equally reactive, withdraws to
noxious stimuli, does not follow commands, rectal tone deferred
CURRENT EXAM:
100.8 87 100/58 97 A/C TV450 RR24 PEEP5 FiO2 50%
GENERAL: Pt with trach, Alert and oriented. Answering questions
appropriately
HEENT: Sclerae anicteric, MMM
NECK: Supple, JVP not elevated
LUNGS: coarse rhonchi bilaterally. Clear at apices
CV: Regular rate and rhythm, no murmurs appreciable
ABD: Soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no edema
SKIN: PEG site clean, no exudate, swelling or induration
NEURO: Movement of upper extremities. Some muscle fasciculations
of lower extremities, but no movement
Pertinent Results:
ADMISSION LABS:
___ 11:25AM WBC-13.5* RBC-5.00 HGB-14.1 HCT-42.4 MCV-85
MCH-28.2 MCHC-33.2 RDW-14.5
___ 11:25AM NEUTS-82.8* LYMPHS-10.0* MONOS-6.7 EOS-0.3
BASOS-0.2
___ 11:25AM PLT COUNT-321
___ 11:25AM ___ PTT-28.6 ___
___ 11:25AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 11:25AM ALBUMIN-3.4* CALCIUM-9.5 PHOSPHATE-2.5*
MAGNESIUM-2.1
___ 11:25AM cTropnT-<0.01 proBNP-355*
___ 11:25AM LIPASE-17
___ 11:25AM ALT(SGPT)-14 AST(SGOT)-22 ALK PHOS-87 TOT
BILI-0.7
___ 11:25AM GLUCOSE-122* UREA N-13 CREAT-0.6 SODIUM-135
POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-23 ANION GAP-14
___ 11:35AM O2 SAT-80
___ 11:35AM LACTATE-1.8
___ 11:35AM TYPE-ART PO2-43* PCO2-31* PH-7.53* TOTAL
CO2-27 BASE XS-3
___ 12:00PM URINE RBC-40* WBC-4 BACTERIA-NONE YEAST-NONE
EPI-0
___ 12:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
DISCHARGE LABS:
___ 04:09AM BLOOD WBC-3.7* RBC-3.23* Hgb-9.1* Hct-28.4*
MCV-88 MCH-28.2 MCHC-32.1 RDW-15.0 Plt ___
___ 03:32AM BLOOD Neuts-80.6* Lymphs-13.3* Monos-5.5
Eos-0.4 Baso-0.1
___ 04:09AM BLOOD Plt ___
___ 04:09AM BLOOD ___ PTT-41.8* ___
___ 04:09AM BLOOD Glucose-92 UreaN-9 Creat-0.3* Na-137
K-4.2 Cl-97 HCO3-33* AnGap-11
___ 03:57AM BLOOD ALT-12 AST-14 AlkPhos-85 TotBili-0.1
___ 04:09AM BLOOD Calcium-8.9 Phos-3.9 Mg-2.1
MICROBIOLOGY:
Blood cx ___ bottles positive for MRSA
Blood cx ___: no growth
Urine cx ___: no growth
Urine cx ___ and ___: growing yeast
Bronchealveolar lavage ___: YEAST. ~1000/ML.
Respiratory viral culture ___: negative
Wound spinal swab ___: MRSA
Spinal abscess culture ___: MRSA
Sputum cx ___: yeast
RELEVANT IMAGING:
CXR ___
IMPRESSION:
Streaky retrocardiac opacities may reflect atelectasis but
pneumonia is not excluded in the correct clinical setting. If
necessary, a lateral view could be obtained for further
evaluation.
CTA ___
IMPRESSION:
1. Extensive bilateral pulmonary emboli. No CT evidence for
right heart
strain.
2. Left lower lobe collapse, likely from mucous plugging. Mild,
diffuse
bronchial wall thickening.
3. Tiny amount of pneumomediastinum, clinically insignificant.
ECHO ___
Conclusions
The left atrium is normal in size. There is mild symmetric left
ventricular hypertrophy. Overall left ventricular systolic
function is normal (LVEF = 70%). The right ventricular free wall
thickness is normal. The right ventricular cavity is moderately
dilated There is abnormal septal motion/position consistent with
right ventricular pressure/volume overload. The basal free wall
of the right ventricle contracts normally. The apical free wall
of the right ventricle is severely hypokinetic. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion. The mitral valve leaflets are structurally normal.
Moderate [2+] tricuspid regurgitation is seen. There is moderate
pulmonary artery systolic hypertension. There is no pericardial
effusion.
ECHO ___
Conclusions
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF
>55%). There is no ventricular septal defect. The right
ventricular cavity is mildly dilated with mild global free wall
hypokinesis (more prominent RV apical hypokinesis). There is
abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is a very small pericardial effusion. There are no
echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___, no
major change.
CXR ___
IMPRESSION:
Persistent, dense left lower lobe retrocardiac opacity. No
relevant interval change.
MRI C/T/L Spine ___:
IMPRESSION:
Anterior Epidural abscess extending from C4-5 to T2 level with
compression of the spinal cord. Increased signal within the
spinal cord at C3 and C4 levels. Small paraspinal fluid
collection at T1 level most suggestive for paraspinal abscess.
Bilateral LENIs ___
IMPRESSION:
1. Nonocclusive, chronic appearing thrombus within one right
peroneal vein. The patient is already on heparin for pulmonary
embolism.
2. No evidence of deep venous thrombosis in the left lower
extremity veins.
CT C/T spine ___:
1. Anterior epidural fluid collection from C5 through T2 level
is better
evaluated on the same day MR and is not well characterized on
today's CT exam.
2. Anterior fusion of C5 through C7 without evidence for
hardware failure.
3. Multilevel degenerative changes as above.
4. A small ground-glass attenuation nodule in the right upper
lung measuring approximately 2 mm, there is also seen on the
prior CTA chest of ___.
MRI C-spine ___:
Persistent small anterior epidural fluid collection with
peripheral
enhancement at C6-7 level causing canal narrowing and deformity
on the cord. New anterior epidural fluid collection posterior to
T1 level with peripheral enhancement (where there is interval
corpectomy with body cage placement) moderate canal narrowing
and deformity on the cord.
Limited assessment for infection as immediate post-surgery with
post-surgical changes; however, cannot be excluded.
Diffuse Increased T2 signal in cervical and upper thoracic cord
from C4
downwards, lower limit not completely included - edema,
contusion, ischemia, infarction, inflammation, etc. Correlate
clinically and close followup
Limited assessment for anterior dural leak given the epidural
collections and deformity on thecal sac with decreased
conspicuity of dural outline.
Pathology of abscess, anterior neck, debridement ___:
- Acute osteomyelitis.
- Dense fibrous tissue with extensive acute and chronic
inflammation and associated reactive stromal changes.
CXR ___:
Persistent left retrocardiac opacity, likely atelectasis, though
underlying consolidation cannot be excluded. No new opacities.
Unchanged small left pleural effusion.
CXR ___:
Severe left lower lobe atelectasis persists, accompanied by any
indeterminate but not substantial volume of left pleural
effusion. Atelectasis at the right lung base medially is
relatively mild. The upper lungs are clear. The heart is normal
size since it is obscured KS it is obscured by combination
collapse and left pleural. Mediastinum is unremarkable. ET tube
and right internal jugular line are in standard placements
respectively and the nasogastric tube passes below the diaphragm
and out of view.
EKG ___: Sinus rhythm. Non-specific anterior T wave
changes. Compared to the previous tracing of ___ the Q-T
interval is shorter.
Cervical xray ___:
Status post fusion with laminectomy spanning C5 to an
indeterminate upper
thoracic vertebral body level. Please see the operative report
for further details.
Cervical spine xray ___:
There has been posterior cervical fusion extending from C5-T4.
There has been removal of the anterior plate at C5-C7 since the
prior study. No hardware related complications are seen. The
visualized lung apices are grossly clear. There is a right-sided
central venous line with its distal lead tip in the distal SVC.
CXR ___:
Left lower lobe is still collapsed, reflected in persistent
leftward
mediastinal shift and dense left infrahilar consolidation
obscuring the
diaphragmatic pleural interface. Small accompanying left
pleural effusion is unchanged. Right lung is clear,
hyperinflated in compensation. Right PIC line ends in the mid
SVC. Spinal stabilization hardware is not evaluated by this
slightly turned and should be evaluated clinically to see if it
is appropriately supported and positionned.
Brief Hospital Course:
___ with history IVDU, epidural abscess status post hardware
placement in ___, asthma, and bipolar disorder who presented
with back pain and cough found to have MRSA C4 epidural abscess
with cord compression and osteomyelitis s/p washout x3 and
spinal fusion, with her hospital course complicated by
submassive PE, ARDS, PNA, and delirium.
ACTIVE ISSUES:
# Epidural Abscess with cord compression: She presented with
back pain, lower extremity weakness and difficulty ambulating in
the setting of known IVDU (heroin per reports). Had hx of
epidural abscess status post repair at ___ in ___. Initial exam
concerning for poor rectal tone and urinary retention,
consistent with cord compression/cauda equina syndrome. Patient
had MRI C/T/L spine which confirmed an anterior epidural abscess
extending from C4-5 to T2 level with compression of the spinal
cord. She additionally had increased signal within the spinal
cord at C3 and C4 levels and a small paraspinal fluid collection
at T1 level most suggestive of a paraspinal abscess. Spine
surgery was consulted. She underwent three spinal surgeries. The
first was the night of ___ with successful anterior T1
corpectomy and abscess drainage. She returned to the OR on
___ for revision of the corpetomy, anterior arthrodesis
C5-T1l, and application of an interbody cage. She returned to
the OR On ___ for C5-T3 Posterior interbody fusion. Culture
of the abscess revealed MRSA complicated by osteomyelitis. ID
was consulted. She was given vancomycin with rifampin and will
continue this for AT LEAST 6 weeks, until ___ OR LONGER
PENDING CLINICAL IMPROVEMENT. She will also need to remain in a
cervical collar until ___ PENDING CLINICAL IMPROVEMENT. She
should follow up with orthopedic spine team after discharge.
# MRSA bacteremia/Epidural Abscess: Pt with ___ blood cultures
growing MRSA on admission on ___. Surveillance cultures
negative. Likely secondary to her IVDU; it is thought that she
was actively using on admission given her positive tox screen
for cocaine, opioids, and benzos. She was started on vancomycin
and remained on the antibiotic throughout admission. ID
consulted and added rifapmin. She likely seeded her spine with
epidural abscess. She had two trans-thoracic echocardiograms to
evaluate for endocarditis; they revealed thickened tricuspid
valve but no vegetiations. She was deemed too high-risk for a
trans-esophageal echocardiogram, given that it would not change
her antibiotic course. She required pressors throughout her
hospital stay and with the epidural abscess there was concern
for possible neurogenic component to her hypotension. Her
hypotension improved after starting midodrine. AM cortisol to
r/o adrenal insufficiency was normal.
# Respiratory distress/failure: She was found to be in
respiratory distress on arrival to the ED, with escalating
oxygen requirement requiring intubation. Likely multifactorial:
due to extensive pulmonary emboli, pneumonia, left lower lobe
collapse due to mucus plugging, and asthma. Bronchoscopy and BAL
on admission were unrevealing. The patient was unable to be
extubated due to persistently poor respiratory status, agitation
with weaning of sedation. She underwent tracheostomy on
___. She initially did well on trach collar, but then
required increased respiratory support with the vent with
increased suctioning requirements. Cefepime was started on
___ for VAP and was then switched to meropenem to complete
a 7 day course for VAP on ___. Given that she was very wheezy
on exam, she was treated was prednisone 40mg x 5 days with lat
day on ___. She underwent trach by ENT on ___ and was able to
be weaned off the vent to a trach collar. She has a passy muir
valve in place. She is discharged with a cuffed trach. If she is
ultimately eligible for decannulation she will need a cap trial.
She would need to be changed to an un-cuffed trach (6 or 7
uncuffed). She should follow up with Dr. ___ in clinic 2
weeks after discharge (appt scheduled and in discharge summary).
In the meantime she will need usual trach care (suction PRN,
humidification PRN if secretions thickened, cleaning around
edges of trach BID)
Given concern for aspiration she underwent video swallow on
___, which revealed evidence of aspiration and S&S
recommends she remains NPO. Currently with PEG tube in place.
OF NOTE SHE OCCASIONALLY DESATURATES TO MID-70S. SPONTANEOUSLY
RESOLVES AND LIKELY SECONDARY TO ASPIRATION. NO EVIDENCE OF
MUCOUS PLUGGING. ASYMPTOMATIC.
# Fever: The patient had low-grade fevers throughout her MICU
stay, thought to be due to poor source control from her epidural
abscess vs. endocarditis vs. post-operative. Her fever curve
increased on ___ with increase suctioning requirements,
likely due to ventilator-associated pneumonia. She completed a
course for VAP on ___.
# Submassive pulmonary emboli: Patient was found to have
extensive bilateral pulmonary emboli, with echocardiographic
evidence of right heart strain. There was no significant
hemodynamic compromise. Given need for surgery, lysis was
deferred. She had bilateral LENIs which demonstrated a
nonocclusive echogenic eccentric organized thrombus within one
of the right peroneal veins, compatible with chronic thrombus.
Given the overall appearance of the CTA findings and lack of
stigmata of endocarditis, PEs were thought to originate from DVT
rather than septic emboli. Patient was started on Heparin gtt
which was initially continued in the MICU. In light of urgent
indication for surgery, Interventional Cardiology was consulted
for consideration of IVC filter placement. Patient went to cath
lab on am of ___ for IVC filter placement. She continued on
anticoagulation throughout her MICU stay, with several breaks
for operations. At discharge she is on warfarin with a lovenox
bridge. Next INR to be drawn on ___. She should remain on
lovenox until her INR is therapeutic (___) x3 days.
PLEASE NOTE THAT WHEN SHE DISCONTINUES RIFAMPIN IN ___ HER
INR WILL LIKELY RISE AND HER WARFARIN DOSE WILL NEED TO BE
DECREASED
# Hypotension: Patient met SIRS criteria on admission on the
basis of leukocytosis, tachycardia, and fevers. Hypotension
likely due to pulmonary emboli, infection with MRSA
bacteremia/abscess and recurrent pneumonias. There was no
evidence of end organ hypoperfusion with persistently normal
lactate. She was initially started on broad spectrum antibiotics
with Vancomycin/Cefepime/Levofloxacin, which was weaned to
vancomycin after HCAP treatment. Surveillance cx negative. She
required Norepinephrine for blood pressure support in the
setting of large amounts of Fentanyl/Propofol required for
sedation and pain control. She was restarted on cefepime on
___ for VAP. She required norepinephrine throughout her stay
even with weaning of sedation. She was started on midodrine 10mg
TID given concern for neurogenic hypotension. Cortisol to r/o
adrenal insufficiency was normal.
BASELINE BLOOD PRESSURES ___ THOUGH THE PATIENT REMAINS
ASYMPTOMATIC. THIS IS THOUGHT SECONDARY TO NEUROGENIC ETIOLOGY
# Pain control: The patient required large amounts of fentanyl
and sedation during her MICU stay, in setting of multiple
operations. Pain control was consulted and recommended morphine
sulfate ___ 45IR Q3H, gabapentin 900mg TID, clonidine 0.1mg TID,
and Valium 5mg TID.
CHRONIC ISSUES:
# Polysubstance misuse: She reportedly continues to use heroin,
last on the day prior to admission, and toxicology screen is
positive for cocaine. It is not clear as to whether she misuses
alcohol. She was monitored for signs of withdrawal and started
on thiamine, folate and multivitamin.
# Bipolar disorder: Unable to obtain psychiatric history from
patient.
TRANSITIONAL ISSUES:
# Communication: Patient, sister ___ ___
Niece: ___ ___
# Code: Full (confirmed with next of kin)
# Disposition: ___
- discontinue lovenox when therapeutic INR for 3 days
-In 6 weeks can take IVC filter out (___). If not, within
6 months (___).
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Albuterol Inhaler 6 PUFF IH Q6H
3. Bisacodyl ___AILY
4. CefePIME 2 g IV Q8H
5. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
6. CloniDINE 0.1 mg PO TID
7. Diazepam 5 mg PO Q8H
8. Docusate Sodium 200 mg PO TID
9. Enoxaparin Sodium 70 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
10. Fluticasone Propionate 110mcg 8 PUFF IH BID
11. FoLIC Acid 1 mg PO DAILY
12. Gabapentin 900 mg PO Q8H
13. Ipratropium Bromide MDI 2 PUFF IH QID
14. Lidocaine 5% Patch 1 PTCH TD QPM
15. Morphine Sulfate ___ ___ mg PO Q3H:PRN pain
16. Multivitamins 1 TAB PO DAILY
17. Norepinephrine 0.03-0.25 mcg/kg/min IV DRIP TITRATE TO MAP
>65
18. Nystatin Oral Suspension 5 mL PO QID:PRN thrush, oral care
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
20. QUEtiapine Fumarate 200 mg PO QHS
21. QUEtiapine Fumarate 50 mg PO QAM
22. Rifampin 300 mg PO Q12H
23. QUEtiapine Fumarate 50 mg PO QPM
24. Senna 17.2 mg PO BID constipation
25. Thiamine 100 mg PO DAILY
26. Vancomycin 1250 mg IV Q 8H
27. Warfarin 3 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
MRSA bacteremia
Epidural abscess complicated by neurologic damage, s/p washout
Ventilator-associated pneumonia
Pulmonary embolism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with back pain and cough and
were found to have an abscess in your back. You underwent
surgeries to treat this infection and will be discharged on a
course of antibiotics.
While you were in the hospital you also suffered difficulty with
breathing and need to be intubated. You currently require a
tracheotomy to assist with your breathing, though this is
something that might be removed in the future. Your lung scans
revealed that you have clots in your lungs, and we are
discharging you on a blood thinner to help prevent further clots
from forming.
As you know, we are also concerned that you are inhaling some of
the food you have been eating into your lungs. You were
evaluated by the speech and swallow team and determined that you
are very high risk for aspiration. We recommend not eating or
drinking until you are stronger.
You will be discharged to ___, but will need to follow up
with Dr. ___ in 2 weeks to have your tracheomtomy checked.
Followup Instructions:
___
|
19934880-DS-18 | 19,934,880 | 24,811,153 | DS | 18 | 2163-03-04 00:00:00 | 2163-03-05 15:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / fish derived / green bell peppers / tramadol
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of C5
paraplegia, PE (current on SQ heparin), and MRSA epidural
abscess requiring multiple surgeries complicated by respiratory
failure who presents from nursing home with abdominal pain.
Patient reports ___ dull intermittent RLQ abdominal pain for
about the past one week. The pain radiates to her back. She was
given her methadone and oxycodone which helped her pain. She
also reports intermittent fevers to as high as 102 over the past
week. She notes intermittent nausea for the past week with one
episode of non-bloody vomiting. She notes her stool was normal
(usually has one bowel movement every morning) but she began to
have non-bloody diarrhea several days ago. She had several
episodes of loose stools, her last episode was two days ago. She
also notes decreased PO intake over the last several days. She
notes feeling increased urinary frequency for the past several
days but noticed decreased urine output in her chronic
indwelling foley. She also reports sinus congestion for the past
two to three days with dry cough for the past week.
She was recently started on ___ with Macrobid ___ twice
daily for a presumed urinary tract infection. Per patient, her
urine was not sent for urinalysis or culture. She was also given
a suppository prior to transfer to ___.
In the ED, initial vital signs were: 98.2 70 87/55 16 100% RA.
Exam was notable for RLQ abdominal tenderness to palpation. Labs
were notable for WBC 5.4, H/H 11.7/35.7, Plt 281, Na 141, K 3.8,
BUN/Cr ___ (baseline Cr 0.3-0.5), lactate 1.3, UA with large
leuks, moderate blood, negative nitrite, 65 WBCs, and few
bacteria. CT abdomen/contrast showed acute proctocolitis.
Bilateral lower extremity ultrasound showed no DVT. The patient
was given 2L NS, ceftriaxone 1g IV, methadone 20mg PO, oxycodone
15mg PO, gabapentin 800mg PO, Ativan 2mg PO, and flagyl 500mg
IV. She has a chronic foley that was changed. Vitals prior to
transfer were: 98.0 67 94/63 14 96% RA.
Upon arrival to the floor, she denies chest pain, palpitations,
and shortness of breath.
REVIEW OF SYSTEMS: Per HPI. Denies headache, visual changes,
pharyngitis, rhinorrhea, sweats, weight loss, dyspnea, chest
pain, constipation, hematochezia, dysuria, rash, paresthesias,
and weakness.
Past Medical History:
(per ED documentation and ___ primary care note):
IVDU
Epidural abscess status post hardware placement in ___
Status post traumatic injury to left eye, now blind
Asthma
VSD status post repair in childhood
Hiatal hernia status post repair
Bipolar disorder
Social History:
___
Family History:
(adapted from ___ primary care note):
Mother with hypertension. Father with history of lung cancer.
Maternal grandmother and maternal cousin with breast cancer.
Maternal uncle with prostate cancer.
Physical Exam:
ADMISSION EXAM
==============
VITALS: Temp 97.7, BP 95/48, HR 88, RR 18, O2 sat 98% 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, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, obese, soft, diffuse abdominal
tenderness to palpation without rebound or guarding,
non-distended, no organomegaly, well-healed previous PEG tube
site.
EXTREMITIES: Warm and well-perfused. Bilateral 2+ lower
extremity edema.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
DISCHARGE EXAM
==============
Vital Signs: 98, 81-88/46-52, 72, 20, 95 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, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: poor inspiratory effort, clear to auscultation
bilaterally, without wheezes or rhonchi.
ABDOMEN: Normal bowel sounds, obese, soft but thickened skin,
diffuse abdominal tenderness to palpation without rebound or
guarding, non-distended, no organomegaly, well-healed previous
PEG tube site, 2 midline scars thorax and upper abdomen.
EXTREMITIES: Warm and well-perfused. Bilateral 2+ pitting lower
extremity edema, fingers hyperextended at baseline, L leg
hyperflexed at baseline.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, decreased sensation
below umbilicus, ___ strength bilateral lower extremities (will
have occasional involuntary movements), ___ strength in thumb
abduction, inability to grip with hands otherwise given
hyperextension. Blind in L eye (positive pupil response on L
with efferent but not afferent)
Pertinent Results:
ADMISSION LABS
==============
___ 01:00PM PLT SMR-NORMAL PLT COUNT-281
___ 01:00PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-2+
MACROCYT-1+ MICROCYT-1+ POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL SCHISTOCY-OCCASIONAL TEARDROP-OCCASIONAL
BITE-OCCASIONAL
___ 01:00PM NEUTS-70 BANDS-1 LYMPHS-18* MONOS-7 EOS-3
BASOS-0 ATYPS-1* ___ MYELOS-0 AbsNeut-3.83 AbsLymp-1.03*
AbsMono-0.38 AbsEos-0.16 AbsBaso-0.00*
___ 01:00PM WBC-5.4 RBC-3.84* HGB-11.7# HCT-35.7# MCV-93
MCH-30.5 MCHC-32.8 RDW-12.5 RDWSD-42.1
___ 01:00PM CALCIUM-9.6 PHOSPHATE-3.9 MAGNESIUM-2.4
___ 01:00PM estGFR-Using this
___ 01:00PM GLUCOSE-92 UREA N-23* CREAT-1.1 SODIUM-141
POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-28 ANION GAP-16
___ 01:13PM LACTATE-1.3
___ 04:00PM URINE MUCOUS-RARE
___ 04:00PM URINE RBC-51* WBC-65* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
___ 04:00PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 04:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
DISCHARGE LABS
===============
___ 07:46AM BLOOD WBC-4.3 RBC-3.53* Hgb-10.7* Hct-33.1*
MCV-94 MCH-30.3 MCHC-32.3 RDW-12.7 RDWSD-43.2 Plt ___
___ 07:46AM BLOOD Plt ___
___ 07:46AM BLOOD Glucose-82 UreaN-14 Creat-0.7 Na-141
K-3.9 Cl-105 HCO3-26 AnGap-14
___ 07:46AM BLOOD Calcium-9.1 Phos-2.8 Mg-2.2
MICRO
=====
Urine Culture x2: Negative
Blood Culture x2: Pending
STUDIES
=======
Lower Extremity Doppler Ultrasound
No evidence of deep venous thrombosis in the visualized right or
left lower extremity veins. Nonvisualization of the peroneal
veins in either calf.
CT A/P w/contrast
1. Acute proctocolitis.
2. Indeterminate hepatic hypodense lesion within segment 8 for
which MRI is recommended on a nonemergent basis to further
assess.
3. Mild L1 superior endplate compression deformity, new from ___. Correlate for focal pain.
4. No evidence of pyelonephritis. Mild thickening of the
urinary bladder for which correlation with UA is advised to
exclude underlying infection.
RECOMMENDATION(S): MRI liver, nonemergent, to further assess
indeterminate liver lesion.
Brief Hospital Course:
Ms. ___ is a ___ female with history of C5
paraplegia, PE (current on SQ heparin), and MRSA epidural
abscess requiring multiple surgeries complicated by respiratory
failure who presented from long term care facility with
abdominal pain, found to have acute proctocolitis on CT A/P and
pyuria in setting of indwelling foley.
ACTIVE ISSUES
=========
# Proctocolitis. CT imaging on admission showed changes of the
distal sigmoid and rectum concerning for proctocolitis. She was
started on IV Ciprofloxacin and Flagyl. She was not febrile and
did not have a leukocytosis. Highest suspicion initially was for
infectious etiology in the setting of subjective diarrhea prior
to admission. However, she was unable to produce an adequate
stool sample during admission for testing. She was discharged
with PO Flagyl to complete a 7 day course of treatment.
Abdominal pain stabilized on discharge.
# Acute kidney injury. Cr was 1.1 on admission, above baseline
0.3-0.5. She received IVF and Cr downtrended to baseline 0.7 by
the time of discharge. Lisinopril was held in the setting ___
but restarted prior to discharge. Lasix were held.
# Pyuria in setting of chronic indwelling foley. She presented
with dysuria/urinary urgency and pyuria on UA suggestive of
infection. Foley was removed and replaced. She was treated with
Ciprofloxacin for 2 days, until urine cultures resulted
negative. Ciprofloxacin was discontinued. Given persistence of
urinary urgency, the benefits of starting an anti-spasmodic such
as oxybutynin were discussed and she may benefit from this
medication as an outpatient if symptoms persist after discharge.
# Hypotension. Her outpatient baseline blood pressures are
___. During admission she intermittently had SBP in the ___
and was asymptomatic.
# L1 Superior Endplate Compression Fracture: This was found
incidentally on CT imaging and appeared new since ___. She did
not endorse falls and is at high risk for bone disease in the
setting of tobacco use, chronic immobility.
CHRONIC ISSUES
==============
# Pulmonary Embolism: Extensive submassive bilateral pulmonary
emboli in ___ during previous admission, s/p IVC filter
placement. Discharged on Coumadin with Lovenox bridge. Unclear
duration of warfarin therapy. She presented this admission on
DVT ppx with SQ heparin without record of when warfarin was
discontinued. Her long term facility had no records of her ever
being on warfarin since her admission there in ___. We
were unable to obtain records from her prior stay at ___.
# Polysubstance Abuse/Chronic Pain. Continued home methadone and
oxycodone
# Bipolar Disorder. Continued home abilify, doxepin, Ativan, and
topiramate
# Neuropathy. Continued home gabapentin
TRANSITIONAL ISSUES
==============
# Hypotension
- SBPs at baseline 80-90s asymptomatic.
# Urinary urgency
- Urine Culture negative in setting of chronic indwelling foley.
Suspect if symptoms continue, may benefit from anti-spasmodic
medication such as oxybutynin. Would recommend monitoring for
any hypotension with this medication.
# Radiology Follow Up Imaging
- Indeterminate hepatic hypodense lesion within segment 8 for
which MRI is recommended on a nonemergent basis to further
assess.
# Medication Changes
- Held Lasix in setting of euvolemia and hypotension. Please
restart pending blood pressure and edema at rehab
- Held NSAIDs in setting ___
- Patient started on flagyl. Please continue through ___.
# CONTACT: ___ (sister) ___
# CODE STATUS: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. LORazepam 2 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Senna 17.2 mg PO BID
5. Topiramate (Topamax) 50 mg PO BID
6. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
7. Furosemide 40 mg PO BID
8. Ibuprofen 600 mg PO TID
9. Gabapentin 800 mg PO TID
10. Heparin 5000 UNIT SC TID
11. Ascorbic Acid ___ mg PO TID
12. ARIPiprazole 15 mg PO QHS
13. Doxepin HCl 75 mg PO QHS
14. Bisacodyl ___AILY:PRN constipation
15. levalbuterol tartrate 45 mcg/actuation inhalation Q4H:PRN
shortness of breath, wheezing
16. Acetaminophen 650 mg PO Q6H:PRN pain, fever
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
19. Simethicone 80 mg PO QID:PRN gas pain
20. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN pain
21. Methadone 20 mg PO Q6H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. ARIPiprazole 15 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Doxepin HCl 75 mg PO QHS
6. Gabapentin 800 mg PO TID
7. Heparin 5000 UNIT SC TID
8. LORazepam 2 mg PO BID
9. Maalox/Diphenhydramine/Lidocaine 5 mL PO QID:PRN pain
10. Methadone 20 mg PO Q6H
11. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 17.2 mg PO BID
14. Simethicone 80 mg PO QID:PRN gas pain
15. Topiramate (Topamax) 50 mg PO BID
16. MetroNIDAZOLE 500 mg PO Q8H
Please continue through ___
RX *metronidazole 500 mg 1 tablet(s) by mouth three times daily
Disp #*16 Tablet Refills:*0
17. Ascorbic Acid ___ mg PO TID
18. Bisacodyl ___AILY:PRN constipation
19. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
20. levalbuterol tartrate 45 mcg/actuation INHALATION Q4H:PRN
shortness of breath, wheezing
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Proctocolitis
Secondary Diagnosis
Pyuria
Acute Kidney Injury
L1 superior endplate compression fracture
Polysubstance abuse and chronic pain
bipolar disorder
neuropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your
hospitalization. Briefly, you were hospitalized with abdominal
pain and found to have inflammation in your intestine. You were
treated with antibiotics and improved. We replaced your foley
catheter.
We wish you the best,
Your ___ Treatment Team
Followup Instructions:
___
|
19934880-DS-19 | 19,934,880 | 27,116,021 | DS | 19 | 2163-03-28 00:00:00 | 2163-04-09 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / fish derived / green bell peppers / tramadol
Attending: ___.
Chief Complaint:
Hematuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of parapelegia ___ epidural abscess ___ IVDA, chronic
indwelling foley, who presents with hematuria since last night.
She also reports chills, fevers, nausea (no vomiting) and
generalized malaise. She also notes b/l shoulder spasms L>R
since yesterday with associated shob, denies chest pain. She
does note have similar spasms on the right in the past. She
states that she had a temperature of 100 last night and was
given Tylenol. Denies abdominal pain, diarrhea,
light-headedness/dizziness.
Of note, she was admitted to ___ from ___ for
proctocolitis which was treated with cipro/flagyl initially and
transitioned to PO flagyl. She completed a 7 day course of
treatment. Additionally she was noted to have pyuria, however
urine culture was negative thus was not treated for this.
In the ED, initial vitals: T98.9 HR93 BP124/91 RR16 SaO294% RA.
Patient became hypotensive to ___ while in the ED.
-initial labs: WBC 8.4, Hgb/Hct 11.6/35.7, Plt 199, Trop 0.11,
BUN/Cr ___, lactate 2.2, +u/a, LFTs wnl, INR 1.0
-Imaging: CXR: IMPRESSION: Streaky left basilar opacity, likely
reflective of left lower lobe atelectasis. Early infection is
not excluded in the correct setting.
-ECG - NSR, c/w prior
-bedside echo --> good contractility, no effusion
-patient was given: 3L NS, 20 mg methadone, 15 mg oxycodone, and
2 mg lorazepam and 2g cefepime
On arrival to the MICU, T98, HR 92, BP 77/54, RR 17 SaO2 94% 2L
NC. Patient reported left shoulder spasm but was otherwise
without complaints.
Past Medical History:
-IVDU
-Epidural abscess status post hardware placement in ___, repeat
epidural abscess ___ c/b c5 paraplegia
-H/o submassive PE ___ s/p IVC filter placement
-Status post traumatic injury to left eye, now blind
-Asthma
-VSD status post repair in childhood
-Hiatal hernia status post repair
-Bipolar disorder
Social History:
___
Family History:
Mother with hypertension and breast cancer. Father with history
of lung cancer. Maternal grandmother and maternal cousin with
breast cancer. Maternal uncle with prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===============================
Vitals: T98, HR 92, BP 77/54, RR 17 SaO2 94% 2L NC.
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, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally, without wheezes or
rhonchi.
ABDOMEN: Normal bowel sounds, obese, soft, no rebound or
guarding, normal active bowel sounds.
MSK: tenderness to palpation at anterior chest wall bilaterally
EXTREMITIES: Warm and well-perfused. Bilateral 2+ lower
extremity edema.
SKIN: No rashes or excoriations.
NEUROLOGIC: A&Ox3, CN II-XII grossly intact, absent sensation at
BLE, ___ strength at BLE, unable to to grip with hands
bilaterally. Blind in L eye.
DISCHARGE PHYSICAL EXAM:
===============================
Vital Signs: 98.8 101/61 78 18 96%RA
General: Pleasant woman, lying in bed, NAD
HEENT: MMM. JVP 8 cm
Lungs: Trace bibasilar crackles
CV: Regular rate and rhythm, II/VI systolic murmur loudest RUSB
Abdomen: Soft, mildly distended, nontender, NABS
Ext: WWP, soft brace on L leg, 2+ pitting dependent edema,
slightly improved from prior
Skin: Without rashes or lesions
Neuro: AOx3, strength ___ in UEs, ___ in ___
___ Results:
ADMISSION LABS:
==========================
___ 01:15PM BLOOD WBC-8.4# RBC-3.81* Hgb-11.6 Hct-35.7
MCV-94 MCH-30.4 MCHC-32.5 RDW-13.8 RDWSD-46.8* Plt ___
___ 01:15PM BLOOD ___ PTT-30.8 ___
___ 01:15PM BLOOD Glucose-118* UreaN-19 Creat-1.2* Na-140
K-4.4 Cl-106 HCO3-24 AnGap-14
___ 01:15PM BLOOD ALT-10 AST-13 AlkPhos-72 TotBili-0.3
___ 01:15PM BLOOD CK-MB-2 cTropnT-0.11*
___ 11:58PM BLOOD CK-MB-3 cTropnT-0.03*
___ 11:58PM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
___ 01:46PM BLOOD Lactate-2.2*
___ 01:45PM URINE Color-Red Appear-Cloudy Sp ___
___ 01:45PM URINE Blood-LG Nitrite-NEG Protein-300
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:45PM URINE RBC->182* WBC->182* Bacteri-FEW
Yeast-NONE Epi-0
___ 01:45PM URINE CastHy-35*
DISCHARGE LABS:
===========================
___ 06:53AM BLOOD WBC-3.6* RBC-3.81* Hgb-11.5 Hct-35.9
MCV-94 MCH-30.2 MCHC-32.0 RDW-13.2 RDWSD-45.2 Plt ___
IMAGING:
=======================
CXR ___:
IMPRESSION: Streaky left basilar opacity, likely reflective of
left lower lobe atelectasis. Early infection is not excluded in
the correct setting.
MICRO:
===================
URINE CULTURE ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
Brief Hospital Course:
___ female with history IVDA, MRSA epidural abscess ___
c/b of C5 paraplegia, h/o PE (current on SQ heparin), chronic
indwelling foley who presented from nursing home with hematuria
and fever.
# Urosepsis: Patient presented with positive UA in setting of
indwelling foley. She was admitted to MICU given hypotension.
Also noted to have ___ and elevated lactate. She was given
cefepime in ED and transitioned to CTX as well as fluid
resuscitation. Urine cultures returned contaminated however
given clinical improvement she will be discharged on
ciprofloxacin to complete 7 day course.
# Hypoxemia: In MICU patient developed hypoxemia in setting of
4L IVF for fluid resuscitation. She clinically appeared volume
overloaded. Given history of PE she was started empirically on
lovenox and underwent CTA which was negative for PE; lovenox was
stopped. She received Lasix 20 mg IV x1 however autodiuresed
even prior to receiving this and respiratory status returned to
normal with good sats on RA.
# Troponinemia: In setting of hypoxemia/volume overload patient
had elevated troponin to 0.11 without ECG changes and with
normal CK-MB. This was thought likely strain in setting of
pulmonary edema. She had repeat echocardiogram which did not
show any wall motion abnormalities or evidence of
systolic/diastolic dysfunction. Troponin downtrended.
# H/o pulmonary embolism: Submassive bilateral pulmonary emboli
in ___ during previous admission for epidural abscess s/p IVC
filter and warfarin treatment for unclear duration, continued on
prophylactic heparin SC as outpatient. She was briefly treated
with lovenox as above given concern for new PE however returned
to prophylactic heparin prior to discharge. She will need
outpatient removal of IVC filter which will be scheduled by
interventional cardiology. She should continue on SC heparin
until that time.
# Polysubstance abuse/chronic pain: Continued home methadone,
oxycodone, gabapentin.
# Bipolar disorder. Continued home abilify, doxepin, Ativan, and
topiramate
TRANSITIONAL ISSUES:
[ ] Patient to follow up with interventional cardiology for
elective removal of her IVC filter.
[ ] Discharged on prophylactic SC heparin, which can be stopped
once filter removed.
[ ] Lasix re-started at 40 mg daily. This should be increased to
40 mg bid if she has persistent ___ edema.
[ ] Mild nausea in setting of antibiotic use was treated with PO
Zofran.
[ ] Patient complaining of L shoulder spasm; this was not
treated with antispasmodics here given concern for oversedation
in combination with existing pain regimen. Consider changing
Ativan to valium.
# CONTACT: ___ (sister) ___
# CODE STATUS: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. ARIPiprazole 15 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Doxepin HCl 75 mg PO QHS
6. Gabapentin 800 mg PO TID
7. Heparin 5000 UNIT SC TID
8. LORazepam 2 mg PO BID
9. Methadone 20 mg PO Q6H
10. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 17.2 mg PO BID
13. Simethicone 80 mg PO QID:PRN gas pain
14. Topiramate (Topamax) 50 mg PO BID
15. Ascorbic Acid ___ mg PO TID
16. Bisacodyl ___AILY:PRN constipation
17. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
18. levalbuterol tartrate 45 mcg/actuation INHALATION Q4H:PRN
shortness of breath, wheezing
19. Ibuprofen 600 mg PO Q8H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. ARIPiprazole 15 mg PO QHS
3. Ascorbic Acid ___ mg PO TID
4. Aspirin 81 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Doxepin HCl 75 mg PO QHS
8. Gabapentin 800 mg PO TID
9. Heparin 5000 UNIT SC BID
10. LORazepam 2 mg PO BID
11. Methadone 20 mg PO Q6H
12. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Senna 17.2 mg PO BID
15. Simethicone 80 mg PO QID:PRN gas pain
16. Topiramate (Topamax) 50 mg PO BID
17. levalbuterol tartrate 45 mcg/actuation INHALATION Q4H:PRN
shortness of breath, wheezing
18. Ibuprofen 600 mg PO Q8H:PRN pain
19. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
First dose ___ in am
20. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 4 Days
21. Furosemide 40 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
Urosepsis
Secondary
Hypoxemia
History of DVT/PE
Paraplegia
Bipolar disorder
Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had fever, blood
in your urine, and very low blood pressure. You were found to
have urine studies concerning for a urinary tract infection. You
were treated with antibiotics and improved. Because you received
a lot of fluids, you also had some trouble breathing, but this
also improved with a low dose of Lasix. While you were here, we
noticed that your IVC filter, that had been placed in ___ when
you had blood clots in your legs, had never been removed. It is
important to remove this, so we are setting up an appointment
for you to do this after you leave the hospital.
It was a pleasure taking care of you during your stay in the
hospital.
- Your ___ Team
Followup Instructions:
___
|
19934880-DS-22 | 19,934,880 | 21,076,931 | DS | 22 | 2164-09-20 00:00:00 | 2164-09-23 21:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / fish derived / green bell peppers / tramadol /
codeine
Attending: ___.
Chief Complaint:
UTI, hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F w/ h/o epidural abscess iso IVDU s/p surgical
intervention c/b C5 paraplegia, asthma, bipolar disorder who
presents w/ acute on chronic R upper back pain, SOB, productive
cough, fever.
Pt states she has had R upper back pain for past few months,
acutely worsened last night. Sharp, radiates to neck, ___.
Tried home oxycodone, Ativan, no help.
Pt has had cough for past few days, worsening, productive w/
green sputum, SOB since yesterday, fevers, chills. Denies sick
contacts. Pt denies urinary symptoms, however is insensate below
ribs. One episode of vomiting, no persistent nausea.
Denies constipation/diarrhea/CP.
Pertinent ED course (including exam, labs, imaging, consults,
treatment):
In the ED, initial VS were: 97.2 91 87/49 16 97% RA
Labs showed: Lactate:2.1, UA w/ WBC>182, neg nitrites
Imaging showed:
CXR-
1. No focal consolidation concerning for pneumonia.
2. Pulmonary vascular congestion and low lung volumes.
Shoulder x-ray performed - no displaced fracture, degenerative
changes seen
Patient received: 2L NS, oxy, gabapentin, Diazepam 5 mg, nebs,
Tylenol, 1x dose CTX
Transfer VS were: Tm 100.6; 100 95/50 16 95% RA
Upon arrival to the floor, the patient reports persistent
shoulder pain as above, SOB, congestion, cough. Rest of history
as above.
Past Medical History:
-IVDU
-Epidural abscess status post hardware placement in ___, repeat
epidural abscess ___ c/b c5 paraplegia
-H/o submassive PE ___ s/p IVC filter placement
-Status post traumatic injury to left eye, now blind
-Asthma
-VSD status post repair in childhood
-Hiatal hernia status post repair
-Bipolar disorder
Social History:
___
Family History:
Mother with hypertension and breast cancer. Father with history
of lung cancer. Maternal grandmother and maternal cousin with
breast cancer. Maternal uncle with prostate cancer.
Physical Exam:
ADMISSION EXAM
==============
VITALS: Reviewed in POE.
GENERAL: tearful, NAD
EYES: blind in L eye, PERRLA, EOMI
ENT: oropharynx clear
CV: RRR, no m/r/g
RESP: no focal rales, diffuse expiratory rhonchi, no wheezes
GI: S, some distension, insensate
GU: foley in place
MSK: no ___ edema
SKIN: wwp
NEURO: CN2-12 intact, insensate below ribs, in hands, hands
cannot clench
DISCHARGE EXAM
==============
VITALS: T 98.3, BP 91 / 57, P89, RR18, PO2 95 Ra
GENERAL: NAD, AAOx3
ENT: oropharynx clear
CV: RRR, no m/r/g
RESP: no focal rales, diffuse expiratory rhonchi, no wheezes
GI: +BS, soft; some distension, insensate
GU: foley in place
MSK: no ___ edema
SKIN: wwp
NEURO: CN2-12 intact, insensate below ribs, in hands, hands
cannot clench
Pertinent Results:
ADMISSION LABS
==============
___ 12:50AM BLOOD WBC-7.6# RBC-4.40 Hgb-13.2 Hct-38.7
MCV-88 MCH-30.0 MCHC-34.1 RDW-13.2 RDWSD-42.4 Plt ___
___ 12:50AM BLOOD Neuts-72.6* Lymphs-17.6* Monos-5.9
Eos-2.2 Baso-0.5 Im ___ AbsNeut-5.52# AbsLymp-1.34
AbsMono-0.45 AbsEos-0.17 AbsBaso-0.04
___ 12:50AM BLOOD ___ PTT-26.3 ___
___ 12:50AM BLOOD Glucose-117* UreaN-9 Creat-0.6 Na-135
K-4.5 Cl-91* HCO3-31 AnGap-13
___ 12:50AM BLOOD ALT-15 AST-37 AlkPhos-104 TotBili-0.6
___ 12:50AM BLOOD Calcium-9.1 Phos-4.2 Mg-2.1
___ 01:10AM BLOOD Lactate-2.1*
MICRO/OTHER PERTINENT LABS
========================
___ 10:50AM BLOOD ___
___ 10:50AM BLOOD Cortsol-3.1
___ 06:20AM BLOOD Cortsol-10.7
___ 12:35PM BLOOD Cortsol-5.3
___ 01:05PM BLOOD Cortsol-16.1, 18.5 (cosyntropin
stimulation test)
___ 11:06AM BLOOD Lactate-1.6 (repeat)
___ 01:40AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.5 Leuks-LG*
___ 01:40AM URINE RBC-12* WBC->182* Bacteri-MANY*
Yeast-NONE Epi-0
___ 11:04 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
Blood cultures negative
Cdiff toxin negative
DISCHARGE LABS
==============
___ 08:05AM BLOOD WBC-7.3 RBC-4.70 Hgb-13.8 Hct-43.3 MCV-92
MCH-29.4 MCHC-31.9* RDW-13.7 RDWSD-47.0* Plt ___
___ 08:05AM BLOOD Glucose-106* UreaN-11 Creat-0.7 Na-142
K-4.8 Cl-101 HCO3-28 AnGap-13
___ 08:05AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.7*
IMAGING
========
Right shoulder X-ray ___
No fracture or dislocation. Degenerative changes as described.
CXR ___
1. No focal consolidation concerning for pneumonia.
2. Pulmonary vascular congestion and low lung volumes.
Brief Hospital Course:
___ F w/ h/o epidural abscess iso IVDU s/p surgical
intervention c/b C5 paraplegia, asthma, bipolar disorder who
presents w/ acute on chronic R upper back pain, UTI, and URI.
ACUTE/ACTIVE PROBLEMS:
========================
#UTI
Febrile, positive UA, left shift on differential. Foley
chronically in place, in for 2 weeks. Prior was left in for 10
weeks. No dysuria, but pt insensate. Replaced foley. Prior
cultures resistant only to ciprofloxacin. Hypotension likely
related to opioids rather than worsening infection. Urine
culture positive for enterococcus <100,000 cfu sensitive to
ampicillin. IV ceftriaxone initiated and transitioned to
augmentin for 7 day course with improved white count, afebrile.
Will take nitrofurantoin from ___.
#Hypotension
Pt triggered ___ for hypotension to ___. Pt asymptomatic
throughout event, mentating well. VBG essentially normal,
lactate 1.6, Hgb 13.0. EKG showed T wave inversions in V1-V4
with small ST depressions, unchanged from prior EKG. Labs w/o
any signs of hypoperfusion or anemia. Pt given 2L IVF w/ BP
improved to ___. Removed fentanyl patch and gave 3rd liter
of NS w/ SBP increasing to ___. Random cortisol checked which
was low normal, followed by cosyntropin test that was
unremarkable for adrenal insufficiency. Hypotension likely
related to high doses of narcotics rather than worsening
infection or endocrine abnormality. Fentanyl patch decreased to
62 mcg/hr as this was prior stable regimen at home. Of note,
patient reports her SBPs to be in the low ___.
#R upper back pain
Seemed c/w muscle spasm, although could be referred pain from
diaphragm. Liver, pancreatic pathologies possible, however
normal LFTs, lipase made pancreatitis, cholecystitis, hepatitis
very unlikely. Treated with heat packs, increased baclofen,
continued ativan, gabapentin, tizanidine. Decreased oxycodone,
fentanyl patch given hypotension, sedation as above.
#URI
URI symptoms. Negative CXR. Febrile in ED, although pt has other
localizing source in urine. CXR negative for pneumonia, physical
exam more c/w upper airway pathology, likely viral URI. Gave
guaifenisin, duonebs q6h.
CHRONIC/STABLE PROBLEMS:
=========================
#Bipolar disorder
Continued Topiramate (Topamax) 50 mg PO BID, Aripiprazole 10 mg
PO QHS, Doxepin HCl 75 mg PO HS
#Anxiety
Continued LORazepam 1 mg PO Q8H:PRN anxiety
#Bowel Regimen
Continued home bowel regimen
#Home meds
Continued Furosemide 40 mg PO BID, Aspirin 81 mg PO DAILY
#Nutrition
Continued Ascorbic Acid ___ mg PO TID, Ondansetron 4 mg PO
Q8H:PRN nausea
TRANSITIONAL ISSUES:
=========================
[ ] complete course of nitrofurantoin for total 7 days of
antibiotic treatment for CAUTI (end date: ___
[ ] regular exchange of indwelling foley catheter, last
exchanged ___
[ ] f/u PCP for pain control and managing her pain medication
regimen. Of note, fentanyl patch was reduced to 62 mcg/h TD q72H
and oxycodone was reduced to 20 mg q4H PRN given hypotension
[ ] revisit subQ heparin ppx as not shown to be effective in
such patients
[ ] confirm with PCP if patient has indeed been switched from
diazepam to lorazepam
>30 minutes spent coordinating discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Topiramate (Topamax) 50 mg PO BID
3. ARIPiprazole 10 mg PO QHS
4. LORazepam 1 mg PO Q8H:PRN anxiety
5. Docusate Sodium 100 mg PO BID
6. Senna 8.6 mg PO BID
7. Furosemide 40 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Doxepin HCl 75 mg PO HS
10. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
11. OxyCODONE (Immediate Release) 30 mg PO Q4H
12. Ascorbic Acid ___ mg PO TID
13. Baclofen 10 mg PO TID
14. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
15. Bisacodyl 5 mg PO DAILY:PRN constipation
16. Diazepam 5 mg PO Q8H
17. Fentanyl Patch 75 mcg/h TD Q72H
18. Heparin 5000 UNIT SC BID
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. Polyethylene Glycol 17 g PO DAILY
21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
22. Simethicone 80 mg PO QID:PRN gas
23. Tizanidine 2 mg PO QHS
24. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS
Discharge Medications:
1. Nitrofurantoin (Macrodantin) 100 mg PO BID UTI Duration: 3
Days
RX *nitrofurantoin macrocrystal 100 mg 1 capsule(s) by mouth
twice a day Disp #*6 Capsule Refills:*0
2. Baclofen 15 mg PO TID
3. Bisacodyl 10 mg PR QHS:PRN constipation
4. Fentanyl Patch 50 mcg/h TD Q72H
RX *fentanyl 50 mcg/hour 1 patch q72H Disp #*2 Patch Refills:*0
5. Fentanyl Patch 12 mcg/h TD Q72H
RX *fentanyl 12 mcg/hour apply to affected area q72H Disp #*2
Patch Refills:*0
6. OxyCODONE (Immediate Release) 20 mg PO Q4H:PRN Pain -
Moderate
7. ProAir HFA (albuterol sulfate) 1 puff inhalation Q4H:PRN SOB
8. ARIPiprazole 10 mg PO QHS
9. Ascorbic Acid ___ mg PO TID
10. Aspirin 81 mg PO DAILY
11. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
12. Docusate Sodium 100 mg PO BID
13. Doxepin HCl 75 mg PO HS
14. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QHS
15. Furosemide 40 mg PO BID
16. Gabapentin 800 mg PO TID
17. Heparin 5000 UNIT SC BID
18. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
19. LORazepam 1 mg PO Q8H:PRN anxiety
20. Ondansetron 4 mg PO Q8H:PRN nausea
21. Polyethylene Glycol 17 g PO DAILY
22. Senna 8.6 mg PO BID
23. Simethicone 80 mg PO QID:PRN gas
24. Tizanidine 2 mg PO QHS
25. Topiramate (Topamax) 50 mg PO BID
26. HELD- Diazepam 5 mg PO Q8H This medication was held. Do not
restart Diazepam until you talk to your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
UTI
HYPOTENSION
SECONDARY DIAGNOSES
====================
UPPER BACK PAIN
BIPOLAR DISORDER
ANXIETY
PARAPLEGIA
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 on this hospital stay at
___.
WHY YOU WERE ADMITTED:
You were admitted to the hospital for a urinary tract infection.
You had a fever, lower blood pressures, and bacteria in your
urine that we decided to treat with intravenous antibiotics. You
are at higher risk for urinary tract infections because you have
a foley catheter in place.
WHAT WE DID FOR YOU:
-You were treated with IV antibiotics for a few days and then
switched to an oral antibiotic called nitrofurantoin, for a
total 7 day course.
-You were having low blood pressures that were thought to be
because of your fentanyl and oxycodone, so we decreased your
fentanyl patch dose and oxycodone dose
WHEN YOU LEAVE THE HOSPITAL:
-You should finish taking the oral antibiotic for 3 days
(___) which you will be taking twice a day
-You should follow up with your primary care doctor to help
manage your back pain and to make sure your blood pressures are
stable
-You should come back to the hospital if you are feeling fevers,
chills, dizziness, nausea, vomiting, or any other symptoms that
concern you
We wish you the best,
Sincerely,
Your ___ Care Team!
Followup Instructions:
___
|
19935359-DS-21 | 19,935,359 | 23,033,564 | DS | 21 | 2205-03-23 00:00:00 | 2205-03-23 15:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/prior PE, esophageal cancer, presents w/SOB. Pt reports
dyspnea on exertion worsening over the last 3 weeks. Took
symbicort, flonase and albuterol w/out relief. Had similar
symptoms w/ prior PE ___ years ago. Also with dizziness and left
knee/calf pain w/radiation down L leg for 6 weeks of knee calf
pain. No falls.
Denies hematuria, no black/blood stool. No ___ swelling, no
recent weight gain.
In ED pt found to have ___ PE. Started on heparin gtt.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
PAST ONCOLOGIC HISTORY:
History of left-sided breast cancer (T1b, grade 2, ER/PR
positive, and HER-2/neu amplification
negative by FISH) s/p excision and partial breast radiation
followed by endocrine therapy.
___: pain with swallowing and noted pain along her
mid chest that radiated to her back with occasional gagging. New
pain along the lower aspect of her right breast. PMD started BID
dosing of PPI for acid reflux.
___: CT scan of the chest demonstrated right lower
lobe ground glass peribronchiolar opacities along with
midesophagus circumferential wall thickening.
___: Pt underwent an upper endoscopy on ___
that demonstrated an ulcerated lesion in the upper third of the
esophagus that was concerning for carcinoma. Biopsies of the
lesion were taken that demonstrated predominantly
fibrinopurulent
exudate and fungal forms of single tissue fragment with features
that were suspicious for squamous cell carcinoma. Upper
endoscopic ultrasound on ___ showed a large
esophageal
ulcer that measures approximately 5 cm and was stage T3 by
endoscopic ultrasound criteria. Furthermore, a 1.7 cm celiac
node was seen along with the 8-mm mediastinal node were noted,
both of which underwent FNA biopsies. ___, PET/CT showed
"Esophageal cancer metastatic to mediastinal, thoracic
paraspinal, celiac, and para-aortic nodes."
___: Port-a-cath placed on ___ however, feeding tube
could not be placed.
The patient started chemotherapy on ___ since it was
difficult to access the port, the patient was unable to start
treatment on ___ as origionally planned. The patient
started
radiation therapy on ___.
Cycle #: 1 Day 1: ___ Cycle end: ___
Fluorouracil/Carboplatin
Cycle #: 2 Day 1: ___ Cycle end: ___ Today is Day#: 12
PAST MEDICAL HISTORY:
1. Left-sided breast cancer diagnosed in ___, status post
excision and radiation therapy, previously on tamoxifen;
however,
now, the patient is on exemestane.
2. Bilateral PEs diagnosed in ___. The patient was on Lovenox
BID dosing for six months. (The patient PE is attributed to
possible tamoxifen use and thus the patient was switched from
tamoxifen therapy to exemestane after having PEs).
3. Right hiatal hernia.
4. Spinal injury with chronic low back pain.
5. GERD
Social History:
___
Family History:
Mother passed away in her ___ secondary to cancer. The patient
is unclear of which cancer, possibly abdominal or pelvic cancer.
Physical Exam:
Vitals: T:98.2 BP:122/92 P:86 R:18 O2:100%ra
PAIN: 6
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
MSK: no joint effusion
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 05:55PM GLUCOSE-123* UREA N-22* CREAT-1.4* SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 05:56PM LACTATE-2.2*
___ 05:55PM ALT(SGPT)-22 AST(SGOT)-19 ALK PHOS-80 TOT
BILI-0.2
___ 05:55PM LIPASE-17
___ 05:55PM ALBUMIN-4.1
___ 05:55PM WBC-8.3# RBC-3.77* HGB-11.3 HCT-36.8 MCV-98#
MCH-30.0 MCHC-30.7* RDW-17.2* RDWSD-61.7*
___ 05:55PM NEUTS-64.9 ___ MONOS-7.5 EOS-1.5
BASOS-0.4 IM ___ AbsNeut-5.36 AbsLymp-2.09 AbsMono-0.62
AbsEos-0.12 AbsBaso-0.03
___ 05:55PM PLT SMR-NORMAL PLT COUNT-150
# L ___ (___): No evidence of deep venous thrombosis in the
left lower extremity veins
# CXR (___): No acute cardiopulmonary process
# L knee x-ray (___): No evidence of acute fracture or
dislocation is seen. There is minimal to no suprapatellar joint
effusion is seen.
# Chest CTA (___): Extensive bilateral pulmonary emboli are
seen involving the right, and left main, lobar, segmental, and
subsegmental branches. No definite evidence of right heart
strain, however if there is further clinical concern, an
echocardiogram may be helpful for further evaluation.
# L knee MRI (___): 1. Horizontal tear of the body of the
lateral meniscus. 2. Intact medial meniscus, cruciate ligaments,
and collateral ligaments. 3. Mild degenerative changes of the
lateral compartment with partial thickness cartilage loss.
# Abd/pelvic CT (___): 1. No evidence of intra-abdominal or
intrapelvic malignancy or metastatic disease. Visualized
esophagus is unchanged appearance since ___.
Brief Hospital Course:
ASSESSMENT & PLAN: ___ h/o breast CA on hormone therapy,
esophageal CA s/p chemo/XRT, prior PE admitted w/SOB due to
acute PE.
# SOB/Dyspnea, cough: Ms. ___ was admitted with SOB and chest
CTA showed extensive bilateral pulmonary emboli with negative L
LENIs. During this stay, there was no O2 requirements: no
desaturations with ambulation, no hypotension or concern for RV
strain (based on CT scan). This episode represented her ___ PE
- as a result there was concern for a hypercoagulable state in
setting of adenoCA x2.
For this reason, she was treated with lovenox BID and will
likely need this medication indefinitely. To evaluate for a
possible recurrence of cancer as an etiology, an abd/pelvic CT
scan was performed. It showed no evidence of recurrence. She
may obtain a PET scan as an outpt to further delineate the need
for lovenox (if negative for recurrence then possibly
coumadin?).
She was seen by ___ and she was mildly orthostatic by pressure
(but asymptomatic). She was cleared for home with ___. There
was no drop in O2 with ambulation.
# L knee pain: Ms. ___ had L knee pain. LLENI and knee x-ray
revealed no dislocation, effusion or fracture. The exam was
suggestive of possible infrapatellar tenderness possibly ___
___ disease, infrapatellar bursitis/tendinitis. Ultimatley,
L MRI knee was obtained and this showed a tear in lateral
meniscus. It was otherwise unremarkable. She was treated with
NSAIDs, ice pack, vicodin PRN with good effect. Again, she
should continue with home ___
# Esophageal and Breast Cancers: no active treatment
- cont exemestane
- abd/pelvic CT scan without any signs of recurrence
# Chronic Back Pain: cont home meds
# OTHER ISSUES AS OUTLINED.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: on Lovenox
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: [X] Fall [] Aspiration []
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
#COMMUNICATION: pt
#CONSULTS: ___
#CODE STATUS: [X]full code []DNR/DNI
.
#DISPOSITION: d/c home with home ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. exemestane 25 mg Oral daily
4. Lorazepam 2 mg PO QHS:PRN insomnia
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
6. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Gabapentin 600 mg PO TID
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Ranitidine 300 mg PO QHS
12. Senna 8.6 mg PO BID:PRN constipation
13. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough
Discharge Medications:
1. Enoxaparin Sodium 110 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL ___very twelve (12) hours Disp
#*60 Syringe Refills:*5
2. Outpatient Physical Therapy
please evaluate and treat
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. exemestane 25 mg Oral daily
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Gabapentin 600 mg PO TID
9. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough
10. Lorazepam 2 mg PO QHS:PRN insomnia
11. Omeprazole 20 mg PO DAILY
12. Ranitidine 300 mg PO QHS
13. Senna 8.6 mg PO BID:PRN constipation
14. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
pain
RX *hydrocodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every six (6) hours Disp #*60 Tablet Refills:*0
15. Ibuprofen 400 mg PO Q8H:PRN knee pain Duration: 3 Days
Please use sparingly
16. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pulmonary embolism
Left lateral meniscus tear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure looking after you, Ms. ___. As you know, you
were admitted with shortness of breath and was found to have an
acute pulmonary embolus (clot in the lung). You were treated
with lovenox to help thin the blood and prevent progression of
old clot or development of new clot.
To identify a reason for why this clot developed, a lower
extremity ultrasound and abdominal CT scan was performed. It
did not show a clot in the legs - moreover, there was no sign of
recurrence of cancer which would potentially increase the risk
of developing a pulmonary embolus. You did not require oxygen
during this hospitalization.
You also had left knee pain. MRI of the knee revealed a tear
in the lateral meniscus - and this will be managed
conservatively (physical therapy). Please continue with home
physical therapy. You can continue to take ibuprofen as needed
for pain, but please use this sparingly as this can cause
stomach ulcers which would put you at risk of bleeding while you
are on Lovenox. You can also take vicodin as needed for pain.
Followup Instructions:
___
|
19935888-DS-15 | 19,935,888 | 21,178,042 | DS | 15 | 2143-11-14 00:00:00 | 2143-11-29 10:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
meloxicam
Attending: ___.
Chief Complaint:
Back pain, fecal incontinence
Major Surgical or Invasive Procedure:
revision laminectomy of L3, laminectomy of L2
fusion with instrumentation and autograft L2-L4
History of Present Illness:
Patient is a ___ year-old man with hx of trauma to his back years
ago, s/p extensive thoracic, lumbar and S1 surgery including
laminectomy and fusion and revision, presented to ED as a
transfer from ___ with worsening of back pain and 2
episodes of fecal incontinence which happened yesterday evening.
He noted that yesterday evening he started to cough so while he
was coughing he walked to kitchen to get some medicine, when his
wife noticed that he passed a large amount of loose brown stool,
he noted that he did not feel the stool coming out. An hour
later he had another episode while standing. Then he took
antidiarrheal medicine and it stopped. He noted that he never
had the same problem in the past. He denied any new weakness,
numbness, new bladder dysfunction or worsening of his walking.
He denied having any new trauma to his back and he does not have
any sign or symptom of infection. He was unable to undergo an
MRI because he has a nerve stimulator implanted. Because his
spine surgeon is at ___, he was transferred here for further
evaluation.
In the ED initial vitals were: 98.1 77 149/90 18 97% RA. On
exam, the patient was noted to have decreased rectal tone, and a
Code Cord was called. Neuro evaluated the patient and pt still
have some rectal tone on exam. Neuro recommended admission to
medicine for further management
- Labs were significant for platelets of 94 (chronic).
- Patient was given 1mg IV dilaudid x2 with little relief.
Vitals prior to transfer were: 60 151/82 18 95% RA.
On the floor, pt c/o chronic back pain. he was still able to
move his lower extremities. he has not had a BM since last
episode noted above.
Review of Systems:
Refer to HPI for pertinent positives and negatives. Remainder of
10 point ROS is negative.
After review of Mr. ___ history and physical examination,
as well as radiographic studies, it was determined that he would
be a good candidate for laminectomy L2-L3 and posterior lumbar
fusion L2-L4. The patient was in agreement with the plan and
consent was obtained and signed.
Past Medical History:
- Morbid obesity
- Diverticulitis (s/p colectomy ___
- L femoral nerve injury ___ years ago with resulting dysesthesia
and parasthesia and quad weakness
- S/p appendectomy
- Chronic low back pain s/p lumbar laminectomy and decompression
L3-S1, instrumented fusion L4-5, excision herniated disck L4-5
(___)
- Hypothyroid
- Hypertriglycerides (nl LDL)
- Lactose intolerance
Social History:
___
Family History:
Non-contributory.
Physical Exam:
=== ADMISSION PHYSICAL EXAM ===
Vitals - 97.8 160/96 62 18 96RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: 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 cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO:
- intact CN, and mental status.
- motor: full strength in the upper exts and right lower exts,
On the left side IP is ___ although the exam was painful, quad
is chronically weak., otherwise full.
- Reflexes 1+, allover except for left pattelar which is absent.
- Toes are going down.
- Rectal tone diminished, but he is able to squeeze and able to
sense finger
- He has diabetic neuropathy with gloves and stocking pattern
decreased sensation in all extremities: in the left leg to the
level of mid thigh and on the right side mid shin, and wrists in
the hands.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Physical Examination upon discharge:
On examination the patient is well developed, well nourished,
A&O x3 in NAD. AVSS.
Range of motion of the lumbar spine is somewhat limited on
flexion, extension and lateral bending due to pain.
Ambulating well with the assistance of a walker and ___, with
lumbar corset 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 midline lumbar incision is clean, dry and intact
without erythema, edema or drainage.
The patient is voiding well without a foley catheter.
Pertinent Results:
=== LABS ON ADMISSION ===
___ 06:20PM BLOOD WBC-3.9* RBC-4.28*# Hgb-14.0# Hct-41.0#
MCV-96 MCH-32.8* MCHC-34.2 RDW-15.6* Plt Ct-94*
___ 06:20PM BLOOD Neuts-52.2 ___ Monos-6.1 Eos-6.7*
Baso-0.4
___ 06:20PM BLOOD ___ PTT-33.7 ___
___ 06:20PM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-139 K-4.2
Cl-102 HCO3-28 AnGap-13
___ 06:20PM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7
=== IMAGING ===
CT L-Spine w/o contrast (___):
FINDINGS:
There are 5 non-rib-bearing lumbar type vertebral bodies. Fusion
hardware is
present at L3 and L4. Old screw tracts are noted in L5 where
there has been a
prior laminectomy. There mild degenerate changes moderate canal
stenosis
L2-L3. Evaluation of the intrathecal sac is limited by modality.
Evaluation of
cord compression is limited.
The paraspinal soft tissues are unremarkable.
IMPRESSION:
Lumbar spine hardware and moderate canal stenosis the L2-L3
stenosis.
Evaluation of the intrathecal sac is limited by modality.
CT Myelogram T- and L-Spine (___):
FINDINGS:
Thoracic spine: There is multilevel degenerative disc disease of
the thoracic
spine. There are multilevel small posterior disc protrusions
without evidence
of cord compression or neural impingement within the thoracic
spine. There is
also multilevel facet arthropathy.
The paraspinal and prevertebral soft tissues surrounding the
thoracic spine
are unremarkable. There is a nerve stimulator spanning the
T8-T10 levels.
Lumbar spine: There is multilevel degenerative disc disease of
the lumbar
spine. There are postoperative changes of a prior L3 through S1
laminectomies
with posterior stabilization hardware at the L3-L4 level.
At the T12-L1 level, the spinal canal and neural foramina appear
normal.
At the L1-L2 level, there is mild bilateral facet arthropathy.
The spinal
canal and neural foramina appear normal.
At the L2-L3 level, there is a disc bulge with posterior disc
protrusion and
bilateral facet arthropathy and ligamentum flavum thickening
which cause
severe spinal canal narrowing.
At the L3-L4 level, there are postoperative changes, as
described. The spinal
canal and neural foramina appear normal.
At the L4-L5 level, there are postoperative changes, as
described. The spinal
canal and neural foramina appear normal.
At the L5-S1 level, there are postoperative changes, as
described. The spinal
canal appears normal. There is probable mild bilateral neural
foraminal
narrowing, right greater than left.
IMPRESSION:
1. Postoperative changes, as described, including multilevel
laminectomies and
stabilization hardware at L3-L4.
2. Disc bulge, disc protrusion, bilateral facet arthropathy, and
ligamentum
flavum thickening at the L2-L3 level which causes severe spinal
canal
narrowing.
Brief Hospital Course:
___ year-old man with history of trauma to his back years ago,
s/p extensive thoracic, lumbar and S1 surgery including
laminectomy and fusion and revision, presented to ED as a
transfer from ___ with worsening of back pain and 2
episodes of fecal incontinence c/f spinal root impingement. CT
lumbar spine without contrast revealed disc bulge, disc
protrusion, bilateral facet arthropathy, igamentum flavum
thickening at the L2-L3 level (level above previous fusion),
causing severe spinal canal narrowing.
The patient was then admitted to the ___ Spine Surgery Service
and taken to the Operating Room on for a posterior spinal fusion
L2-L4. 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
continued for 24hrs postop per standard protocol. Initially,
postop pain was controlled with a dilaudid PCA and epidural.
The epidural was removed POD1. Diet was advanced as tolerated.
The patient was transitioned to oral pain medication when
tolerating PO diet. Foley was removed on POD#2 and the patient
was voiding well. Post-operative labs were grossly stable. A
hemovac drain that was placed at the time of surgery was also
removed on POD#2. Physical therapy was consulted for
mobilization OOB to ambulate. A lumbar corset brace was fitted
for the patient. Hospital course was otherwise unremarkable. On
the day of discharge the patient was afebrile with stable vital
signs, comfortable on oral pain control and tolerating a regular
diet.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Duloxetine 60 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO QAM
4. MetFORMIN (Glucophage) 1000 mg PO QPM
5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
6. Morphine SR (MS ___ 60 mg PO Q12H
7. Pregabalin 150 mg PO BID
8. Rivaroxaban 20 mg PO DAILY
9. Diazepam 5 mg PO Q8H:PRN muscle spasm
10. Glargine 24 Units Bedtime
11. Metoprolol Succinate XL 25 mg PO DAILY
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Duloxetine 60 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. MetFORMIN (Glucophage) 500 mg PO QAM
4. MetFORMIN (Glucophage) 1000 mg PO QPM
5. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
6. Morphine SR (MS ___ 60 mg PO Q12H
7. Pregabalin 150 mg PO BID
8. Rivaroxaban 20 mg PO DAILY
9. Diazepam 5 mg PO Q8H:PRN muscle spasm
10. Glargine 24 Units Bedtime
11. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
lumbar spondylosis and spinal stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
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.
Physical Therapy:
activity as tolerated; lumbar corset brace when OOB.
Treatments Frequency:
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 ___ Spine
Specialists, ___. 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:
___
|
19935891-DS-19 | 19,935,891 | 23,458,917 | DS | 19 | 2139-04-05 00:00:00 | 2139-04-05 18:01:00 |
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, abdominal aortic aneurysm
Major Surgical or Invasive Procedure:
Open Aortic Aneurysm Repair
History of Present Illness:
___ with known ___ transferred to ___ with back pain and
abdominal pain. Patient was attempting to have a bowel movement
at home and had sudden onset back and abdominal pain. He was
then
transferred to an OSH where they performed a noncontrast CT scan
as his Cr was 3.3. He was hemodynamically stable with no signs
of
rupture on the CT scan. He was then transferred for further
care.
Here the patient is hemodynamically stable and reports
improvement in his abdominal pain and back pain. He continues to
have some abdominal pain in the LLQ. He was previously scheduled
for a repair but had trouble with transportation.
The patient is nonambulatory at home because he broke his back,
he does have a non healing ulcer on the right lateral foot. He
also has chronic neck pain after a neck surgery where he
struggles to use his arms. Additionally, the patient reports he
has lost about 25 lbs. after his girlfriend was in the hospital.
Past Medical History:
- AAA (diagnosed in ___, ~6cm in ___
- CAD
- CHF
- C7 injury with spinal stenosis and subsequent functional
deficits, walks with b/l crutches
PSH:
- 3 vessel CABG ___) ~ ___
- C7 surgery (per patient, no hardware) - remote
- traumatic amputation R hand ___ digits - remote
Social History:
___
Family History:
father - heart disease
Physical Exam:
Vitals: 24 HR Data (last updated ___ @ 831)
Temp: 97.9 (Tm 98.8), BP: 124/67 (97-124/56-67), HR: 94
(88-102), RR: 16 (___), O2 sat: 95% (93-97), O2 delivery: RA
GENERAL: [x]NAD []A/O x 3 []intubated/sedated []abnormal
CV: [x]RRR [] irregularly irregular []no MRG []Nl S1S2
[]abnormal
PULM: []CTA b/l [x]no respiratory distress []abnormal
ABD: [x]soft []Nontender []appropriately tender
[x]nondistended []no rebound/guarding []abnormal
WOUND: [x]CD&I []no erythema/induration []abnormal
EXTREMITIES: [x]no CCE []abnormal
PULSES: L: p//d/d R: p//d/d
Pertinent Results:
___ 03:51AM BLOOD WBC-7.3 RBC-3.32* Hgb-10.2* Hct-32.0*
MCV-96 MCH-30.7 MCHC-31.9* RDW-13.5 RDWSD-47.5* Plt ___
___ 12:00AM BLOOD WBC-7.4 RBC-3.44* Hgb-10.5* Hct-33.0*
MCV-96 MCH-30.5 MCHC-31.8* RDW-13.2 RDWSD-46.7* Plt ___
___ 03:19AM BLOOD WBC-9.7 RBC-3.78* Hgb-11.6* Hct-35.7*
MCV-94 MCH-30.7 MCHC-32.5 RDW-14.3 RDWSD-49.5* Plt ___
___ 04:45AM BLOOD WBC-8.1 RBC-3.36* Hgb-10.2* Hct-31.5*
MCV-94 MCH-30.4 MCHC-32.4 RDW-14.1 RDWSD-48.5* Plt ___
___ 12:00AM BLOOD ___ PTT-28.2 ___
___ 03:02AM BLOOD ___ PTT-37.2* ___
___ 02:09AM BLOOD ___ PTT-22.4* ___
___ 12:00AM BLOOD Glucose-118* UreaN-73* Creat-3.3*# Na-144
K-4.7 Cl-104 HCO3-28 AnGap-12
___ 02:09AM BLOOD Glucose-97 UreaN-32* Creat-2.0* Na-144
K-5.1 Cl-114* HCO3-19* AnGap-11
___ 04:45AM BLOOD Glucose-77 UreaN-36* Creat-1.9* Na-143
K-4.3 Cl-106 HCO3-23 AnGap-14
___ 05:10AM BLOOD Glucose-91 UreaN-29* Creat-1.3* Na-146
K-3.1* Cl-104 HCO3-29 AnGap-13
___ 03:51AM BLOOD Glucose-99 UreaN-43* Creat-1.6* Na-142
K-4.6 Cl-98 HCO3-35* AnGap-9*
___ 04:24AM BLOOD Glucose-92 UreaN-44* Creat-1.7* Na-140
K-4.8 Cl-96 HCO3-34* AnGap-10
Brief Hospital Course:
Mr. ___ was admitted in the setting of his enlarging abdominal
aortic aneurysm. He was transferred promptly to the CVICU for
close blood pressure control with esmolol. He remained in the
CVICU and was evaluated by Cardiology and Nephrology to
medically optimize him before repair. Given the anatomy and size
of his aneurysm, it was apparent that no endovascular options
were suitable and the decision was made to proceed with an open
abdominal aortic aneurysm repair, which the patient underwent on
___. For full details, please refer to the operative report.
He tolerated the procedure well and was transferred immediately
back to the CVICU.
He recovered well postoperatively. His creatinine was closely
monitored and improved daily as did his urine output. On
postoperative day 2, he was able to get out of bed to chair and
his diet was advanced to sips and ice chips which he tolerated
well. He was followed closely be cardiology, and his home
medications were resumed on postoperative day 3. Upon return of
bowel function, his diet was advanced. On ___, his foley was
removed. He failed to void and was straight catheterized twice,
but ultimately a foley was placed with plans for a trial of
voiding in the outpatient setting or at his ___ nursing
facility. He was evaluated by ___ who recommended rehab
placement. The patient was then deemed appropriate for discharge
home. His medications were reconciled with input from his
cardiology team. He will follow up outpatient in the vascular
surgery and cardiology clinics appropriately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CARVedilol 12.5 mg PO BID
2. Amitriptyline 100 mg PO QHS
3. Spironolactone 25 mg PO DAILY
4. Naproxen 250 mg PO Q12H:PRN Pain - Moderate
5. Lisinopril 2.5 mg PO DAILY
6. Gabapentin 300 mg PO BID
7. Furosemide 40 mg PO DAILY
8. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First Line
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Bisacodyl ___AILY
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q8H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every eight (8)
hours Disp #*10 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. Tamsulosin 0.4 mg PO DAILY
7. CARVedilol 3.125 mg PO BID
8. Furosemide 40 mg PO DAILY:PRN Give if >3lb weight gain
Give only if patient gains 3lbs on daily weights
9. Amitriptyline 100 mg PO QHS
10. Docusate Sodium 100 mg PO DAILY:PRN Constipation - First
Line
11. Gabapentin 300 mg PO BID
12. Lisinopril 2.5 mg PO DAILY
13. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abdominal Aortic Aneurysm
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:
After open aortic repair, it is very important to have regular
appointments (every ___ months) for the rest of your life.
These appointments will include a CT (CAT) scan and/or
ultrasound of your graft. If you miss an appointment, please
call to reschedule.
WHAT TO EXPECT:
CARE OF THE INCSION:
Look at the area daily to see if there are any changes. Be
sure to report signs of infection. These include: increasing
redness; worsening pain; new or increasing drainage, or drainage
that is white, yellow, or green; or fever of 101.5 or more. (If
you have taken aspirin, Tylenol, or other fever reducing
medicine, wait at least ___ hours after taking it before you
check your temperature in order to get an accurate reading.)
Take aspirin daily. Aspirin helps prevent blood clots that
could form in your repaired artery.
It is very important that you never stop taking aspirin or
other blood thinning medicines-even for a short while- unless
the surgeon who repaired your aneurysm tells you it is okay to
stop. Do not stop taking them, even if another doctor or nurse
tells you to, without getting an okay from the surgeon who first
prescribed them.
You will be given prescriptions for any new medication started
during your hospital stay.
Before you go home, your nurse ___ give you information about
new medication and will review all the medications you should
take at home. Be sure to ask any questions you may have. If
something you normally take or may take is not on the list you
receive from the nurse, please ask if it is okay to take it.
PAIN MANAGEMENT
Most patients have incisional pain after this surgery. This
will improve daily. If it is getting worse, please let us know.
You will be given instructions about taking pain medicine if
you need it.
ACTIVITY
You must limit activity to protect the incision in your
abdomen. For ONE WEEK:
-Do not drive
-Do not swim, take a tub bath or go in a Jacuzzi or hot tub
FOR SIX WEEKS:
-Do not lift, push, pull or carry anything heavier than five
pounds
-Do not do any exercise or activity that causes you to hold your
breath or bear down with your abdominal muscles.
-Do not resume sexual activity
Discuss with your surgeon when you may return to other regular
activities, including work. If needed, we will give you a
letter for your workplace.
It is normal to feel weak and tired. This can last six-eight
weeks, but should get better day by day. You may want to have
help around the house during this time.
___ push yourself too hard during your recovery. Rest when
you feel tired. Gradually return to normal activities over the
next month.
We encourage you to walk regularly. Walking, especially
outdoors in good weather is the best exercise for circulation.
Walk short distances at first, even in the house, then do a
little more each day.
It is okay to climb stairs. You may need to climb them slowly
and pause after every few steps.
DIET
It is normal to have a decreased appetite. Your appetite will
return over time.
Follow a well balance, heart-healthy diet, with moderate
restriction of salt and fat.
Eat small, frequent meals with nutritious food options (high
fiber, lean meats, fruits, and vegetables) to maintain your
strength and to help with wound healing.
BOWEL AND BLADDER FUNCTION
You should be able to pass urine without difficulty. Call you
doctor if you have any problems urinating, such as burning,
pain, bleeding, going too often, or having trouble urinating or
starting the flow of urine. Call if you have a decrease in the
amount of urine.
You may experience some constipation after surgery because of
pain medicine and changes in activity. Increasing fluids and
fiber in your diet and staying active can help. To relief
constipation, you may talk a mild laxative. Please take to
your pharmacist for advice about what to take.
SMOKING
If you smoke, it is very important that you STOP. Research
shows smoking makes vascular disease worse. This could increase
the chance of a blockage in your new graft. Talk to your
primary care physician about ways to quit smoking.
CALLING FOR HELP/DANGER SIGNS
If you need help, please call us at ___. Remember,
your doctor, or someone covering for your doctor, is available
24 hours a day, seven days a week. If you call during
nonbusiness hours, you will reach someone who can help you reach
the vascular surgeon on call.
Call your surgeon right away for:
Pain in the groin area that is not relieved with medication,
or pain that is getting worse instead of better
Increased redness at the groin puncture sites
New or increased drainage from this incision, or white yellow,
or green drainage
Any new bleeding from the groin puncture sites. For sudden,
severe bleeding, apply pressure for ___ minutes. If the
bleeding stops, call your doctor right away to report what
happened. If it does not stop, call ___
Fever greater than 101.5 degrees
Nausea, vomiting, abdominal cramps, diarrhea or constipation
Any worsening pain in your abdomen
Problems with urination
Changes in color or sensation in your feet or legs
CALL ___ in an EMERGENCY, such as
Any sudden, severe pain in the back, abdomen, or chest
A sudden change in ability to move or use your legs
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19935894-DS-16 | 19,935,894 | 22,497,123 | DS | 16 | 2192-05-23 00:00:00 | 2192-06-05 11:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right VF cut
Major Surgical or Invasive Procedure:
na
History of Present Illness:
___ is a ___ right-handed man
w/PMH of AFib on dabigatran recent ___ Stroke admission ___
with embolic strokes of the left parietal, occipital, cerebellum
presents now with 30 min right hand clumsiness and right VF
loss.
The patient noted acute onset clumsiness of right-hand
clumsiness
while typing on the computer. He could not press the correct
buttons and was making mistakes. He feels like there was
weakness of the muscles of the hand, but symptoms did not
clearly
affect the whole arm. There was no involvement of the face or
right leg. A few minutes later he walked to a door that has a
latch on the right hand side and when he went to open it, he
realized he could not see the doorknob. He sat back down and
realized that he had poor vision on the right side of visual
field with either eye. He could not see the computer mouse at
his
desk and says "it was like it disappeared". There was no
headache, blurry vision, paresthesias, or speech difficulty.
The
whole episode lasted about 30 minutes in total. He lives with a
friend who alerted EMS and was taken to the ED. By the time he
arrived, deficits had resolved but was sent for an urgent CT
head
that showed a new area of hypodensity in the right
parieto-occipital region, consistent with an recent infarct.
During his recent Stroke Admission in ___ he had MRI/MRA and
the MRA was notable for irregularity towards the end of the M1
segment from prior embolic stroke or in-situ atherosclerotic
disease. The etiology of the strokes was believe due ischemia in
the setting of in situ atherosclerosis or recurrent embolism.
EEG was obtained which showed slowing but no frank seizures. The
patient unfortunately left the hospital AMA before echo could be
obtained.
He claims he has continued his home dabigatran and we
recommended
he start atorvastatin 20mg daily.
Past Medical History:
Afib
HTN
Hyperlipidemia
Chronic Kidney Disease
Anemia likely due to iron deficiency and chronic disease
Recent L parietal, occipital
hypothyroid
Social History:
___
Family History:
Brother died of lung cancer. No FH of CAD or Diabetes. Nil
neurological
Physical Exam:
Vitals: T: 98.0 P:58 R: 16 BP: 140/66 SaO2:100%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: irregular. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x self, hospital date= ___.
Able to relate history without difficulty. Attentive, but some
difficulty with ___ backward without difficulty. Language is
fluent with intact repetition and comprehension. Normal prosody.
There were no paraphasic errors. Pt was able to name both high
and low frequency objects. Able to read without difficulty.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. Pt was able to register 3 objects and
recall ___ at 5 minutes spontaneously.There was no evidence of
neglect.
-Cranial Nerves:
II: PERRL 3 to 2mm and brisk. VFF appears full to confrontation
to finger count and motion with a few mistakes on both sides.
There is not a right hemifield cut. Fundoscopic exam revealed no
papilledema, exudates, or hemorrhages.
Without glasses OS ___, OD ___
III, IV, VI: EOMI with ___ saccadic intrusions but no nystagmus.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___- 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 0 0
R 2 2 2 2 0
Plantar response was upgoing on left, equivocal right.
-Coordination: Slight intention tremor, some slowness with fine
motor movements bilaterally (right worse than left). No
dysmetria
on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
Pertinent Results:
admit labs
___ 08:46PM BLOOD WBC-5.3 RBC-3.86* Hgb-11.1* Hct-35.5*
MCV-92 MCH-28.7 MCHC-31.2 RDW-17.3* Plt ___
___ 08:46PM BLOOD Neuts-65.7 ___ Monos-5.3 Eos-1.0
Baso-0.3
___ 08:46PM BLOOD Plt ___
___ 09:15PM BLOOD PTT-74.6*
___ 08:46PM BLOOD Glucose-98 UreaN-27* Creat-1.7* Na-136
K-4.6 Cl-99 HCO3-29 AnGap-13
___ 08:46PM BLOOD ALT-31 AST-52* AlkPhos-65 TotBili-0.6
___ 05:10AM BLOOD Calcium-8.9 Phos-2.5* Mg-1.7
___ 08:46PM BLOOD Albumin-3.9
stroke labs
___ 08:46PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:40AM BLOOD T3-102 Free T4-1.1
___ 08:46PM BLOOD Ammonia-22
___ 06:40AM BLOOD Triglyc-89 HDL-39 CHOL/HD-3.5 LDLcalc-79
Studies:
___ ___
Acute infarct in the right parieto-occipital region without
acute hemorrhage. Old left parietal infarct.
MRI/MRA head/neck ___. New areas of slow diffusion within the bilateral parietal
lobes, right
greater than left, compatible with acute ischemia. Pattern, in
combination with prior findings, is suggestive of central
source.
2. No pathologic large vessel occlusion or vascular malformation
within the head or neck.
3. Distal intracranial vessels are not well visualized which is
potentially an artifactual basis although atheromatous narrowing
is possible.
ECHO ___
No atrial septal defect or patent foramen ovale. Normal
biventricular cavity sizes with preserved global and regional
biventricular systolic function. Mildly dilated aortic root with
mild aortic regurgitaion. Mild mitral regurgitation. Pulmonary
hypertension.
Brief Hospital Course:
___ is a ___ right-handed man w/ PMH
significant for AFib on dabigatran and a recent ___ Stroke
admission ___ with embolic strokes of the left parietal,
occipital and cerebellum who presented this time with 30 min
right hand clumsiness and right VF loss. His exam was notable
for left-right confusion, finger agnosia, dycalculia and
dysgraphia, in addition to his VF loss on the right and some
neglect on the left. MRI showed a new right inf MCA territory
acute infarct along with a small left post punctate infarct. The
etiology of the strokes were again thought to be cardioembolic
source. The patient was switched from dabigatran to warfarin
given his mulitple strokes on dabigatran. He was eventually DCed
home with services.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atenolol 50 mg PO BID
3. Dabigatran Etexilate 150 mg PO BID
4. Levothyroxine Sodium 37.5 mcg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
7. Ferrous Sulfate 150 mg PO DAILY
8. Citalopram 20 mg PO DAILY
9. Spironolactone 25 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO BID
2. Citalopram 20 mg PO DAILY
3. Ferrous Sulfate 150 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
6. Spironolactone 25 mg PO DAILY
7. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily at 4pm
Disp #*30 Tablet Refills:*1
9. Amlodipine 5 mg PO DAILY
10. Lisinopril 20 mg PO DAILY
11. Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine 88 mcg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Outpatient Lab Work
Please have INR drawn on ___ and ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ACUTE ISCHEMIC STROKE, atrial fibrilation, HTN, HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of right hand clumsiness
and vision loss resulting from an ACUTE ISCHEMIC STROKE, a
condition in which a blood vessel providing oxygen and nutrients
to the brain is blocked by a clot. 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:
- AFib
- hypertention
- high cholesterol
We are changing your medications as follows:
- STOP Dabigatran
- START Coumadin
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
you
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
- sudden difficulty pronouncing words (slurring of speech)
- sudden blurring or doubling of vision
- sudden onset of vertigo (sensation of your environment
spinning around you)
- sudden clumsiness of the arm and leg on one side or sudden
tendency to fall to one side (left or right)
- sudden severe headache accompanied by the inability to stay
awake
It was a pleasure providing you with care during this
hospitalization.
Followup Instructions:
___
|
19936081-DS-10 | 19,936,081 | 28,944,965 | DS | 10 | 2138-09-18 00:00:00 | 2138-09-18 13:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Gelatin / Yogurt
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo ex-premie with history of perinatal
encephalopathy secondary to R MCA stroke and intraventricular
hemorrhage with subsequent spastic quadriparesis, cortical
blindness, severe intellectual disability and epilepsy who
presents today with increased frequency in seizures.
Patient has had a long history of seizures with myoclonic jerks,
twitching, but also has longer lasting tonic-clonic movements.
In
___, he had increasing frequency of seizures, including daily
seizure in ___, one requiring Diastat. He was seen in
epilepsy clinic in ___ and lacosamide was increased to 200
mg BID. He had more seizures on ___ (1 minute), ___ (5 mins sz,
Diastat given) and ___ (90 seconds), prompting increase in dose
of phenobarbital by 16.2 mg starting on the night of ___.
Today had cluster of 5 seizures requiring Diastat use x2 so was
taken to ___ and ___ transferred here. Spoke with his
group home manager, ___ (___) who stated that
he had 5 seizures today -
9:50 am: sz lasting 1 minute, stopped on its own. 45 seconds
later, had another 1 minute seizure.
10:45 am: had a 5 min sz and was given Diastat for a cluster of
sz
3 pm: another seizure lasting >5 minutes, given Diastat again
and
sent to ED.
These episodes are described as his typical upper body jerks
with
occasional vocalization.
Patient nonverbal and unable to obtain ROS. Per manager, patient
has been at baseline, no fevers/chills, cough or diarrhea
(baseline soft stool but no change).
Past Medical History:
Cortical Blindness
Cerebral palsy- spastic quadiparesis
Dysphagia
IVH due to prematurity
Perinatal Encephalopathy
Perinatal RightMCA infarct
Seizure disorder
Intellectual Disability
Asthma
Sleep Apnea
Social History:
___
Family History:
noncontributory
No family history of seizures
Physical Exam:
Vitals: 97.7 66 125/84 18 100%
General: Awake, NAD
HEENT: microcephalic
Neck: Supple without nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: well healed surgical scars, soft, nontender,
nondistended
Extremities: no edema, cool to touch
Skin: no rashes or lesions noted.
Neurologic:
nonverbal at baseline. patient intermittently vocalizes but does
not seem to be in distress. blind at baseline, cornea cloudy. L
NLF. Does not move much spontaneously but does withdraw all
extremities from pain, right slightly more briskly than left.
Increased tone in LLE but otherwise fairly normal. Hyporeflexic
throughout, no clonus.
Discharge neurologic exam is unchanged from admission
Pertinent Results:
___ 10:10PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 09:23PM GLUCOSE-93 UREA N-14 CREAT-0.8 SODIUM-140
POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-23 ANION GAP-15
___ 09:23PM estGFR-Using this
___ 09:23PM ALT(SGPT)-23 AST(SGOT)-22 ALK PHOS-94 TOT
BILI-0.2
___ 09:23PM LIPASE-37
___ 09:23PM ALBUMIN-4.6 CALCIUM-9.3 PHOSPHATE-2.7
MAGNESIUM-2.1
___ 09:23PM PHENOBARB-26.1
___ 09:23PM WBC-5.6 RBC-4.84 HGB-15.7 HCT-45.0 MCV-93
MCH-32.5* MCHC-34.9 RDW-13.2
___ 09:23PM NEUTS-44.3* LYMPHS-46.9* MONOS-5.4 EOS-2.2
BASOS-1.1
___ 09:23PM PLT COUNT-167
___ 09:23PM ___ PTT-25.2 ___
___ 08:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
Patient was admitted to the epilepsy service. He was started on
keppra 500mg BID and monitored on EEG which showed generalized
slowing, multifocal
epileptiform discharges. No clear seizures. During the admission
he had an isolated fever to 100.6 F which prompted an infectious
work up. Chest Xray was clear, UA and urine culture were
negative. Blood cultures initially grew gram positive cocci in
___ bottles and the patient was started on vancomycin. The
culture eventually speciated to coag negative staph and
antibiotics were stopped. No further signs of infection. The
patient was discharged back to his group home with planned
follow up.
Medications on Admission:
Lacosamide 200 mg BID (increased on ___
Phenobarbital 113.4 mg QHS (increased on ___
Zonisamide 200 mg BID
Baclofen 10 mg TID
Gabapentin 300 mg QHS
Vitamin D/Oyster shell calcium
Omeprazole 20 mg daily
Colace 100 mg BID
Diastat 10 mg prn
Bisacodyl 5 mg prn
ibuprofen 100/5mL prn
hydramine 12.5/5mL prn
Vitamin A/D ointment prn
robitussin (guaifenasin) 100/5mL prn
Neosporin ointment prn
Tylenol ___ mg prn
Hydrogen peroxide prn
Albuterol 0.083% prn
Glycerin 2.1 gm prn
Discharge Medications:
1. Acetaminophen 325 mg PO ASDIR
2. Gabapentin 300 mg PO HS
3. Glycerin Supps 1 SUPP PR PRN constipation
4. Ibuprofen Suspension 100 mg PO Q8H:PRN pain
5. LACOSamide 200 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. PHENObarbital 113.4 mg PO HS
8. Zonisamide 200 mg PO BID
9. Albuterol 0.083% Neb Soln 1 NEB IH ASDIR
10. Baclofen 10 mg PO TID
11. Bisacodyl 5 mg PO DAILY:PRN constipation
12. Docusate Sodium 100 mg PO BID
13. Diastat *NF* (diazepam) 10 mg Other PRN seizure
14. DiphenhydrAMINE 12.5 mg PO Q8H:PRN as directed
15. Guaifenesin 5 mL PO Q6H:PRN cough
16. Neomycin-Polymyxin-Bacitracin 1 Appl TP PRN cut
17. Oyster Shell Calcium With D *NF* (calcium carbonate-vitamin
D2) 250 (625)-125 mg-unit Oral daily
18. LeVETiracetam 500 mg PO BID
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth two times
per day Disp #*60 Tablet Refills:*2
19. Vitamin A & D Diaper Rash *NF* (petrolatum, white-lanolin) 0
TOPICAL DAILY:PRN diaper rash
20. hydrogen peroxide *NF* 0 % TOPICAL AS DIRECTED
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Seizure
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused - always.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were hospitalized at
the ___. You were admitted for
evaluation of seizures. You did well in the hospital and no
sources of exacerbation could be identified. You had a blood
culture, which at first was concerning for infection, but turned
out to be a contaminated sample. You do not have a blood
infection.
The only change to your medication list was the addition of
Keppra 500mg (1 tablet) two times per day.
Please call your doctor or return to the emergency department
via ambulance/911 if you have any of the "danger signs" below.
We are working on a follow up appointment for you this week with
your primary care physician. You will be contacted with an
appointment.
Followup Instructions:
___
|
19936193-DS-22 | 19,936,193 | 29,898,007 | DS | 22 | 2189-10-19 00:00:00 | 2189-10-19 14:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMHx notable for seizures which are generally well
controlled on 3 agents was brought in for evaluation after being
found altered this morning by the ___. At that time he
was reportedly sitting in the sidewalk, was confused, and unable
to report how he got there. Upon arrival in ___ ED pt was
noted
to be HD normal and responsive although post-ictal. His mental
status improved. He was later noted to have repeat episode
wherein he was having sterotyped movements, pulling at hair,
with
rightward gaze. Pt had CT head which demonstrated new frontal
SAH
w/o e/o herniation. Also noted skull fracture extending from
left
frontal bone through saggital suture to along right occipital
bone.
Given these findings, neurosurgery was consulted for further
management. Upon evaluation, pt noted to be seizing again, with
sterotyped movements and minimal reponse to verbal stimuli. Pt
was given ativan x1 as well as fosphenytoin in ED prior to
transfer to ___.
Past Medical History:
Seizure disorder
Social History:
___
Family History:
No family history of seizures
Physical Exam:
Upon admission:
98.3 90 178/118 18 97% RA
Gen: confused, opens eyes to name, does not follow commands
Head: small bruising over L frontal skull, nontender throughout
face no other trauma seen
Neuro: pupils 2-->1 brisk, + nystagmus, is moving all
extremities
spontaneously but not to command, ___ strength, sensation not
able to be ascertained
CV: RRR
R: clear
Abd: soft, NT/ND
Ext: 2+ edema, no clubbing/cyanosis
Upon discharge:
AVSS
Gen: AO3, follows commands
Head: improved sm bruising over L frontal skull, nontender
throughout face
Neuro: Moving all ext to command, ___ strength, SILT
CV: No JVD
R: No inc resp effort
Abd: No guarding/rebound
Ext: No clubbing/cyanosis
Pertinent Results:
___ CT head
1. Subarachnoid hemorrhage involving both frontal lobes, left
temporal lobe, and likely right inferior temporal lobe with
hemorrhagic contusions involving the inferior frontal lobes
bilaterally as well as both inferior temporal lobes. No evidence
of herniation.
2. Small subacute to chronic subdural hematoma overlying the
left posterior parietal lobe.
3. Fracture extending along the left frontal bone through the
sagittal suture and along the right parietal bone with minimal
distraction. Small subgaleal hematoma along fracture path.
___ CXR
Chronically elevated right hemidiaphragm with chronic bibasilar
scarring. No focal consolidation.
___ CT head
1. Subarachnoid hemorrhage in the bilateral frontal, parietal
and temporal lobes. Bilateral inferior frontal hemorrhagic
contusions.
2. Slight increase in size of the left parietal extra-axial
hematoma measuring 4 mm.
3. New right posterior parieto-occipital extra-axillary
collection, likely epidural, measuring 7 mm.
4. Fracture of the right frontal bone into the sagittal suture
and right
parietal bone.
Brief Hospital Course:
___ w/ h/o complex partial seizure disorder found altered this
morning, likely having sustained traumatic skull fx and SAH.
Patient was admitted to neurosurgery. NEurology was consulted
for management of AEDs. HE was started on antibiotics for a UTI.
HE was placed on EEG
On ___ Mental status much improved. Medications changed to PO.
CT scan shows small stable SAH. Transfer orders to the floor. A
___ consult was placed.
On ___, the patient remained neurologically stable. He was
evaluated by physical therapy and occupational therapy.
On ___, the patient remained neurologically stable and it was
determined he would be discharged to home with a rolling walker.
Medications on Admission:
phenobarb 60mg BID
lamictal 300mg BID
phenytoin sodium extended 100 mg capsule 200mg in AM, 100mg in
___
ASA 81mg daily
Discharge Medications:
1. Rolling Walker
Diagnosis: Gait disturbance
Prognosis: Good
Length of Need: 13 months
2. Phenytoin Sodium Extended 200 mg PO QAM
3. Phenytoin Sodium Extended 100 mg PO QPM
4. PHENObarbital 64.8 mg PO BID
5. LaMOTrigine 300 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Seizure
Subarachnoid hemorrhage
Skull fracture
Discharge Condition:
Improved. AO3. WBAT w/rolling walker.
Discharge Instructions:
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. Use rolling walker when
ambulating.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
***Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
***You have been discharged on Lamictal. This medication helps
to prevent seizures. Please continue this medication as
indicated on your discharge instruction. It is important that
you take this medication consistently and on time.
***You have been discharged on Dilantin (Phenytoin) for
anti-seizure medicine, take it as prescribed and follow up with
laboratory blood drawing in one week. This can be drawn at your
PCPs office, but please have the results faxed to ___.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19936204-DS-14 | 19,936,204 | 23,249,562 | DS | 14 | 2143-12-02 00:00:00 | 2143-12-02 15:41:00 |
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
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a PMHx of cholangiocarcinoma (s/p 7 cycles
gemcitabine/cisplatin, cyberknife stereotactic radiotherapy
___, s/p multiple biliary stents), DM2, h/o LLE DVT (on
Coumadin), h/x of S. anginosis bacteremia and hepatic abscesses,
hx of E. coli bacteremia, h/o c. diff (___), and hx of
cholangitis ___ on minocycline), who presents with fever and
leukocytosis.
The patient was seen in follow-up by ID 1d prior to admission.
She reported a fever (102.6) 3d prior (___). All abx were
discontinued to better assess for sx. She was found to have WBC
24.6 and was instructed to present to the ED.
In the ED, initial VS were: T 97.8 P 77 BP 133/68 R 16 O2 Sat
96% on RA. Labs were notable for: UA with 41WBC (1 epi), 300
glucose, no ketones; INR 3.7, Cr 1.5->1.4, lactate 2.1, Na
126->136, AP 344 (~stable from prior), glucose 312. C. diff
assay neg. BCx and UCx were sent. RUQUS showed L hepatic
pneumobilia (cw stent patency), no intrahepatic biliary ductal
dilatation. CXR showed no PNA. Pt received Zosyn.
Of note, pt was recently admitted ___ for sepsis attributed
to biliary source. Pt was initially treated with Zosyn but abx
were narrowed to Cipro/Flagyl (last day planned ___
although as noted by ID, UA with ___ E coli which were
resistant to ciprofloxacin; and what cultures we do have in the
past generally show cipro-resistance).
Prior to this, pt was also admitted ___ for fever.
ERCP ___ showed biliary sludging and recurrence of likely
cholangiocarcinoma. ID was involved. Initially pt was on zosyn,
but discharged on ertapenem 1g IV Q24H for 14 day course (until
___.
On arrival to the floor, patient feels well without any
complaints. She reports that she had 1 episode of loose bm 1d
prior but has since had formed stools. She also reports
diaphoresis on day of fever but noted her fever as part of
routine daily temp checks.
Past Medical History:
# Unresectable Klatskin-type cholangiocarcinoma. Presented in
- ___ - painless jaundice; ERCP w hilar stricture, brushings
w atypical cells (post-ERCP course cb E. coli cholangitis)
- s/p percutaneous biliary stenting, transitioned to permanent
internal metal stent
- ___ BD bx w/ adenocarcinoma
- ___ LLE DVT
- ___ gemcitabine/cisplatin per ABC-2 regimen
- ___ Cyberknife stereotactic radiotherapy completed
- Not on chemotherapy since ___, plan to repeat CT in ___
and consider palliative chemotherapy
Past Medical History:
# h/o LLE DVT
# Fatty liver disease
# Morbid obesity
# HLD
# HTN
# DM2 (a1c 6.3)
# CKD ___ DM (baseline cr 0.9-1.1)
# Osteopenia
# Strep anginosis bacteremia
# MDR E coli bacteremia
# s/p TAH/BSO for Ovarian CA ___
Social History:
___
Family History:
mother - DM, ___ CVA
father - ___ brain tumor
other - Aunt with breast cancer
Physical Exam:
Admission:
VS: T 98, BP 127/80, P 57, R 18, O2 Sat 100% on RA
GENERAL: NAD, obese, pleasant female in NAD
HEENT: NC/AT, EOMI, PERRL, MMM
NECK: JVP at clavice with pt at 45 degrees
CARDIAC: RRR, normal S1 & S2, ___ soft HSM at RUSB
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft, ND, no rebound or guarding; mild RUQ ttp
EXT: No lower extremity pitting edema
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in UE and ___.
SKIN: Warm and dry, without rashes; port on R upper chest wall
without edema, erythema or ttp
Discharge: Same as above, remained afebrile with otherwise
normal vital signs
Pertinent Results:
___ 10:53AM BLOOD WBC-24.6*# RBC-3.55* Hgb-9.7* Hct-31.0*
MCV-87 MCH-27.3 MCHC-31.2 RDW-16.2* Plt ___
___ 12:15PM BLOOD WBC-9.2# RBC-3.31* Hgb-9.2* Hct-27.8*
MCV-84 MCH-27.9 MCHC-33.1 RDW-17.0* Plt ___
___ 06:30AM BLOOD WBC-5.9 RBC-3.01* Hgb-8.4* Hct-25.8*
MCV-86 MCH-27.9 MCHC-32.6 RDW-16.4* Plt ___
___ 10:53AM BLOOD Neuts-94.0* Lymphs-3.5* Monos-2.3 Eos-0.1
Baso-0.1
___ 12:15PM BLOOD Neuts-84* Bands-0 Lymphs-7* Monos-8 Eos-1
Baso-0 ___ Myelos-0
___ 06:30AM BLOOD Neuts-77.5* Lymphs-12.5* Monos-6.5
Eos-3.3 Baso-0.2
___ 12:15PM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL
___ 12:39PM BLOOD ___ PTT-45.7* ___
___ 06:30AM BLOOD ___ PTT-41.9* ___
___ 10:53AM BLOOD UreaN-32* Creat-1.8* Na-131* K-4.0 Cl-96
HCO3-19* AnGap-20
___ 12:15PM BLOOD Glucose-319* UreaN-34* Creat-1.5* Na-126*
K-GREATER TH Cl-101 HCO3-23
___ 01:00PM BLOOD Glucose-312* UreaN-34* Creat-1.4* Na-136
K-3.8 Cl-103 HCO3-25 AnGap-12
___ 06:30AM BLOOD Glucose-93 UreaN-25* Creat-1.1 Na-138
K-3.8 Cl-106 HCO3-24 AnGap-12
___ 10:53AM BLOOD ALT-19 AST-34 AlkPhos-399* TotBili-0.3
___ 12:15PM BLOOD ALT-18 AST-75* AlkPhos-344* TotBili-0.3
___ 01:00PM BLOOD Amylase-28
___ 06:30AM BLOOD ALT-15 AST-37 AlkPhos-328* TotBili-0.3
___ 12:15PM BLOOD Albumin-2.6* Calcium-7.6* Phos-3.1 Mg-1.8
___ 06:30AM BLOOD Calcium-8.1* Phos-2.8 Mg-1.6
___ 12:27PM BLOOD Lactate-2.1*
___ 06:36AM BLOOD Lactate-0.9
___ 11:20AM URINE Color-Dk Appear-Hazy Sp ___
___ 11:20AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD
___ 11:20AM URINE RBC-1 WBC-21* Bacteri-NONE Yeast-MANY
Epi-10
___ 11:20AM URINE Mucous-RARE
___ 12:15PM URINE Color-Red Appear-Hazy Sp ___
___ 12:15PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 12:15PM URINE RBC-7* WBC->182* Bacteri-FEW Yeast-MANY
Epi-13
___ 12:15PM URINE Mucous-RARE
___ 05:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 05:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 05:00PM URINE RBC-<1 WBC-41* Bacteri-FEW Yeast-FEW
Epi-1
Micro:
___ C. diff negative
___ BCx NGTD
___ UCx: mixed flora c/w contamination
___ UCx: pending
Imaging:
___ RUQUS:
1. Left hepatic pneumobilia suggests biliary stent patency.
2. No intrahepatic biliary ductal dilatation.
___ CXR:
The lungs are well inflated and clear. There is stable
elevation of the right hemidiaphragm. The cardiomediastinal
silhouette and hilar contours are stable. There is no pleural
effusion or pneumothorax. A right chest
Port-A-Cath terminates at the distal SVC, as before. A metallic
CBD stent is again noted projecting over the right upper
quadrant.
Brief Hospital Course:
___ with a PMHx of cholangiocarcinoma (s/p 7 cycles
gemcitabine/cisplatin, cyberknife stereotactic radiotherapy
___, s/p multiple biliary stents), DM2, h/o LLE DVT (on
Coumadin), h/x of S. anginosis bacteremia and hepatic abscesses,
hx of E. coli bacteremia, h/o c. diff (___), and hx of
cholangitis ___ on minocycline), who presents with fever and
leukocytosis.
# Fever, leukocytosis: Pt reported fever at home to 102.6 and
was noted to have
leukocytosis which resolved spontaneously prior to admission.
DDx includes UTI (given +UA; though asymptomatic), cholangitis
(of note, in past imaging benign and dx made with aid of ERCP,
had evolution of gallbladder on recent cross sectional imaging
but no RUQ tenderness now and RUQUS unchanged) and bacteremia
(port in place, BCx NGTD). C. diff was negative. Prior E. Coli
in urine was sensitive to Bactrim. Discussed with Dr. ___,
___ ID treater, who felt she looked much improved.
Lipase, lactate wnl. Afebrile throughout admission. Zosyn
continued during admission with minocycline held, transitioned
to Bactrim DS 1 tab BID x 7 days for presumed urinary source.
She will restart minocycline suppression upon completion of
Bactrim.
# Cholangiocarcinoma. Ongoing active neoplasm. Continued efforts
to maintain patent
biliary drainage system essential as part of preventing
infections. RUQUS showed patent stents, low suspicion for
biliary obstruction and nontender on exam. Per Dr. ___,
___ therapy being deferred given frequency of
hospitalizations recently with concern for infection.
# Anemia: Chronic, stable. Likely ___ chronic disease. No
transfusion required.
# ___: Likely ___ volume depletion, improved with IVF.
# LLE DVT: INR supratherapeutic at admission, likely related to
antibiotics (was on Cipro/Flagyl at home). Warfarin held ___
and ___, INR 3.7->3.3 on day of discharge. She has apppt for
INR check with PCP ___ AM and was instructed to hold coumadin
until told to restart by ___ clinic. She has home INR monitoring
and will coordinate with PCP's office.
# Hyperglycemia/DM: Glucosuria and glucose highly elevated.
Likely in setting of
stress/infection. Gave insulin sliding scale, held Actos,
restarted Actos at discharge.
# Elevated AST/AP: AST mildly elevated at admission, normalized
following day.
# HLD: Continued home statin.
TRANSITIONAL ISSUES:
1. Complete 7 days Bactrim DS 1 tab BID, then restart
minocycline 100mg PO BID.
2. Hold warfarin until INR check and INR <3.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO EVERY OTHER DAY
4. Senna 8.6 mg PO DAILY:PRN constipation
5. Simvastatin 40 mg PO QPM
6. Warfarin 5 mg PO 2X/WEEK (___)
7. Warfarin 2.5 mg PO 5X/WEEK (___)
8. Pioglitazone 45 mg PO DAILY
Discharge Medications:
1. Simvastatin 40 mg PO QPM
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. Pioglitazone 45 mg PO DAILY
5. Polyethylene Glycol 17 g PO EVERY OTHER DAY
6. Senna 8.6 mg PO DAILY:PRN constipation
7. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 7 Days
Take with food
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Urinary tract infection
2. Fevers
3. Cholangiogarcinoma
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 to the hospital with fevers
and a high white blood cell count (a marker for infection). You
may have a urinary tract infection. You did not have evidence of
problems with your stents or biliary tree. You did not have any
more fevers and were felt to be safe for discharge.
Medication Changes:
1. START Bactrim (trimethoprim/sulfamethoxazole) DS 1 tablet by
mouth twice a day (take with food).
2. STOP minocycline WHILE TAKING BACTRIM.
3. RESTART minocycline 100mg by mouth twice a day once the
course of Bactrim is completed.
Please be sure to follow up for an INR check on ___ and hold
your warfarin (coumadin) until you are told to restart by the
INR nurses.
___ be sure to keep all your follow up appointments.
Followup Instructions:
___
|
19936204-DS-15 | 19,936,204 | 23,910,112 | DS | 15 | 2144-01-13 00:00:00 | 2144-01-16 13:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
ERCP
Percutaneous abscess drainage
History of Present Illness:
Ms ___ is a ___ yo F with h/o cholangiocarcinoma, contained
gallbladder perforation treated non-surgically, t2DM, CKD, on
coumadin for LLE DVT, who is admitted from the ED with positive
blood cultures drawn at her ID appointment.
Patient with complicated ID history including Strep anginosus
bacteremia, hepatic abscesses, Cdiff colitis, on chronic
minocycline suppressive therapy. Her recent course includes
cholangitis admission in ___ treated initially with zosyn
and transitioned to ertapenem. Also had admissions in ___ for
apparent UTI treated initially with Cipro, and then bactrim.
She had been doing well until she developed low grade fevers
about 1 week ago. On ___ she developed a fever to ___ with
associated N/V and occaisional chills. She presented to ___
clinic
that same day and routine labs and blood cultures were obtained.
She returned home and felt generally better. However, on ___
her
blood culture returned positive for aeorbic bottle growng GNR
and
urine cx with >100K enterococcus and ___ e. coli. She was
directed to go to the ED.
In the ED, initial VS were T 97.9, HR 81, BP 91/40, RR 20, O2
97%RA. Initial labs were notable for WBC 12.1 (96%N), HCT 26.8,
PLT 200, Na 133, HCO3 20, Cr 1.1, lactate 3.0, ALT 45, AST 79,
TBili 0.6. CT a/p showed increased fluid collection around the
perforation of the gallbladder fundus (1.6x3.6cm) and unchanged
biliary dilation. Patient was given zosyn and 500cc NS. ERCP,
___,
and surgery were consulted. Surgery deferred surgical
intervention and ___ noted that the stents were patent. Patient
was given IV zosyn and 500cc NS. Labs prior to transfer to ___
were T 97.4, HR 65, BP 124/54, RR 15, O2 99%RA.
On arrival to the floor patient has no acute complaint. She had
a
mild headache yesterday. No ST or rhinitis. No CP, SOB, or
cough.
No abodminal pain, nausea or vomiting. No new rashes or joint
pains. Remainder of ROS is unremarkable.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ presented in ___ with painless
jaundice.
ERCP showed a hilar stricture, and brushings showed atypical
cells. Her post-ERCP course was complicated by E. coli
cholangitis and acute kidney injury. She underwent percutaneous
biliary stenting, which was then transitioned to a permanent
internal metal stent. Bile duct biopsy ___ showed
adenocarcinoma. She was diagnosed with a left lower extremity
DVT in ___. She initiated systemic chemotherapy with
gemcitabine/cisplatin per ABC-2 regimen ___. She was
treated with Cyberknife stereotactic radiotherapy completed
___. She was then hospitalized ___ with Strep
anginosis bacteremia and hepatic abscesses. No further
chemotherapy was administered. She was hospitalized again with
Ecoli bacteremia and C difficile colitis in ___, and with
cholangitis in ___.
PAST MEDICAL HISTORY:
1. left DVT diagnosed ___.
2. Chronic kidney disease.
3. Gout.
4. Obesity.
5. Hypercholesterolemia.
6. Type 2 diabetes mellitus.
7. History of endometrial cancer status post TAH-BSO in ___.
8. Status post cholecystectomy.
9. Osteoarthritis.
Social History:
___
Family History:
mother - DM, ___ CVA
father - ___ brain tumor
other - Aunt with breast cancer
Physical Exam:
DISCHARGE PHYSICAL EXAM:
Tmax 97.8 117/57 61 18 99%RA
General: NAD, obese
HEENT: NC/AT, left eye strabismus, MMM, OP clear
CV: RRR, nl s1/s2, no m/r/g appreciated
LUNGS: CTA ___
ABDOMEN: BS active, non distended, soft, nontender
EXTREMITIES: wwp, no edema
NEURO: A&OX3, strength is intact proximally and distally X 4
extremities
Pertinent Results:
ADMISSION LABS:
___ 10:20AM BLOOD WBC-12.1* RBC-3.16* Hgb-8.2* Hct-26.8*
MCV-85 MCH-25.9* MCHC-30.6* RDW-16.0* RDWSD-49.3* Plt ___
___ 10:20AM BLOOD Neuts-95.9* Lymphs-1.7* Monos-1.6*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.56* AbsLymp-0.21*
AbsMono-0.19* AbsEos-0.03* AbsBaso-0.02
___ 10:20AM BLOOD Glucose-204* UreaN-20 Creat-1.1 Na-133
K-3.8 Cl-100 HCO3-20* AnGap-17
___ 10:20AM BLOOD ALT-45* AST-79* AlkPhos-864* TotBili-0.6
___ 10:30AM BLOOD Lactate-3.0*
___ 10:20AM BLOOD Albumin-2.7*
DISCHARGE LABS:
___ 05:20AM BLOOD WBC-6.0 RBC-3.52* Hgb-9.4* Hct-30.0*
MCV-85 MCH-26.7 MCHC-31.3* RDW-16.2* RDWSD-50.2* Plt ___
___ 05:20AM BLOOD Glucose-92 UreaN-13 Creat-0.9 Na-137
K-3.6 Cl-106
___ 05:20AM BLOOD ALT-84* AST-99* AlkPhos-986* TotBili-0.9
MICRO:
___ 10:20 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Ertapenem SENITIVITY REQUESTED BY ___
___.
Ertapenem = SUSCEPTIBLE.
Ertapenem sensitivity testing performed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
IMAGING:
CT abdomen/pelvis w/ contrast ___
1. Increased size of a fluid collection adjacent to the
perforated gallbladder fundus, now measuring 1.6 x 3.6 cm in
axial plane, with increased thickening of the adjacent
peritoneal
wall.
2. Unchanged intrahepatic biliary duct dilation and pneumobilia,
with multiple biliary stents similar in position.
ERCP ___
The scout film revealed bilateral metal and plastic stents in
place. The bile duct was deeply cannulated with the balloon
through each stent. Contrast was injected and there was brisk
flow through the ducts. Given the concern for cholangitis,
contrast was not injected. The biliary tree was swept with a
balloon starting just proximal to the metal stents, bilaterally.
A large amount of sludge and debris was removed. Significant
oozing of blood was noted after balloon sweep of one of the
stents. Given the clinical picture of recurring bacteremia
likely from a biliary source, ___ x 5 cm double pigtail stents
were placed bilaterally, traversing the previously placed metal
stents. Excellent bile and contrast drainage was seen
endoscopically and fluoroscopically. I supervised the
acquisition and interpretation of the fluoroscopic images. The
quality of the fluoroscopic images was good.
Impression: 2 metal stents and 2 plastic stents through the
metal stents were found emerging from the major papilla. Both
plastic stents were removed using a snare.
The scout film revealed bilateral metal stents and plastic
stents in place.
The bile duct was deeply cannulated with the balloon.
Contrast was injected and there was brisk flow through the
ducts.
Given the concern for cholangitis, no contrast was injected
proximal to the metal stents.
The biliary tree was swept with a balloon starting just proximal
to the metal stents, bilaterally.
Oozing of blood was noted after sweeping the metal stent going
into the left system.
A large amount of sludge was removed.
Given the clinical picture of recurring bacteremia likely from a
biliary source, ___ x 5 cm double pigtail stents were placed
bilaterally, traversing the previously placed metal stents.
Excellent bile and contrast drainage was seen endoscopically and
fluoroscopically.
Otherwise normal ercp to third part of the duodenum
___ ___ guided abscess drainage
FINDINGS:
A small pericholecystic fluid collection is again identified,
corresponding to
the findings from the recent CT examination on ___.
This collection
was targeted for aspiration.
IMPRESSION:
Successful ultrasound-guided aspiration of a pericholecystic
fluid collection.
3 cc of purulent material aspirated and sent to the microbiology
lab.
Brief Hospital Course:
___ yo F with h/o cholangiocarcinoma with multiple biliary stents
in place, contained gallbladder perforation treated
non-surgically, t2DM, CKD, on coumadin for LLE DVT, admitted
___ with positive blood cultures (GNR) drawn at her ID
appointment on ___ after she reported fever to ___.
# Recurrent bacteremia (ESBL Ecoli) - Pt has had recurrent
bacteremia 6+ months with Strep anginosus, MDR/ESBL E. coli
bacteremia, recently on chronic minocycline suppressive therapy.
She presented w/ fever and again found to have ESBL E. coli on
blood cultures from ___, also + Ecoli and enterococcus UTI.
- pt currently clinically improved on IV meropenem, fevers
resolved.
- While UTI was possible source pt was asymptomatic and cannot
r/o chronic
infection of GB or other biliary source given her underlying
disease, known indwelling bile stents and persistent GB fluid
collection following prior GB performation
- CT a/p does show increase in fluid collection around
gallbladder, too small for drain but may be amenable to
aspiration per ___, unclear if is addnl reservoir of infection as
has been present for some time
- appreciate ID consult, pt was treated w/ meropenem while inpt
and transitioned to
ertapenem on discharge for both ESBL Ecoli and Enterococcus (amp
sensitive), planning for 2 week course
- she also underwent ERCP showing sludge but no pus thus unclear
if cholangitis contributing
- ultimately once INR downtrended she underwent GB aspiration of
sm amt pustular material and cultures pending to eval if
possible source
- surveillance blood cultures, thus far NGTD and pt clinically
improved so discharged on IV ertapenem w/ plan to f/u w/ Dr ___
___ week and consider suppressive bactrim on completion of IV
abx.
#Cholestasis - acute on chronic elevation of alkP, bili nl, mild
transaminitis.
- ERCP ___ for worsening LFTs, sludge removed and plastic
stents exchanged, enzymes improved post-procedure
- vitD also severely low which may contribute to her chronic
alkP
elevation, started ergocalciferol
#Microcytic disease - ___ vs ACD from malignancy, iron low,
ferritin low nl, TIBC nl. Pt on iron at home but Hgb slowly
downtrending. folate/b12 nl in ___
- transfusef 2U ___ for Hgb near 7 in anticipation of ERCP and
risk of possible bleeding, good bump
- of note pt found to have sm amt bleeding during ERCP from bile
ducts thus iron loss likely from chronic GI bleeding related to
malignancy
- was resumed iron on d/c and may require periodic pRBCs in
future
# Cholangiocarcinoma
- not currently on therapy for ___ year
- per Dr. ___ is on active surveillance given recent stable
disease, palliative nature of treatment and risk of worsening
infections w/ resumption of chemo, she will f/u in ___
# IDDM
- held oral hypoglycemis while inpt; recieved NPH and ISS
# hx LLE DVT (___)- has been on long-term coumadin held for
procedures as above, pt declines bridging w/ lovenox. ON review
of records U/S in ___ showed resolution of DVT and no hx
Afib thus given recent development of iron deficiency anemia
likely related to bleeding noted on ERCP, risk of bleeding may
outweigh risk of re-thrombosis and coumadin was not resumed on
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Acetaminophen 325-650 mg PO Q6H:PRN pain
3. Docusate Sodium 100 mg PO BID
4. Pioglitazone 45 mg PO DAILY
5. Polyethylene Glycol 17 g PO EVERY OTHER DAY
6. Senna 8.6 mg PO DAILY:PRN constipation
7. Minocycline 100 mg PO Q12H
8. Warfarin 5 mg PO 2X/WEEK (MO,FR)
9. Warfarin 2.5 mg PO 5X/WEEK (___)
10. 70/30 30 Units Breakfast
70/30 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Ertapenem Sodium 1 g IV DAILY Duration: 8 Doses
RX *ertapenem [___] 1 gram 1 g IV daily via port Disp #*8
Vial Refills:*0
2. Docusate Sodium 100 mg PO BID
3. 70/30 30 Units Breakfast
70/30 15 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
4. Senna 8.6 mg PO DAILY:PRN constipation
5. Simvastatin 40 mg PO QPM
6. Vitamin D 50,000 UNIT PO 1X/WEEK (TH)
please take once a week on ___
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth weekly Disp #*4 Capsule Refills:*0
7. Vitamin D ___ UNIT PO DAILY
start once the weekly ergocalciferol is completed, ___ can get
over the counter
8. Acetaminophen 325-650 mg PO Q6H:PRN pain
do not take more than twice daily as it can cause liver problems
9. Pioglitazone 45 mg PO DAILY
10. Polyethylene Glycol 17 g PO EVERY OTHER DAY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ESBL E coli bacteremia
Cholangitis
Hx of gallbladder perforation with chronic abscess
ESBL E coli and Enterococcus UTI
Cholangiocarcinoma
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the hospital with fevers and ___ were found
to have bacteria in your blood. ___ were treated with an
intravenous antibiotic and ___ will need to continue receiving
intravenous antibiotics at home as ___ have done in the past.
We are treating a resistant type of Ecoli thus ___ will receive
ertapenem. ___ also underwent drainage of a small collection of
pus near the gallbladder. ___ should follow-up with your
Oncologist, Dr. ___ and with your Infectious Disease
specialists, Drs. ___. Please also see Dr ___
as scheduled every 3 months.
Your ___ Care Team
Followup Instructions:
___
|
19936219-DS-17 | 19,936,219 | 21,435,770 | DS | 17 | 2167-11-27 00:00:00 | 2167-11-27 17:14:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ is a ___ year-old woman with no significant past
medical history. On ___, she was running and sliding onto a
"slip-and-slide" in her yard, when she sustained a fall,
striking
the back of her head. She had no loss of consciousness, but did
have a headache. She had an uneventful evening.
On the morning of ___, she continued to have a headache that
was
unrelieved by over-the-counter analgesics. She went to an
outside hospital for evaluation. A non-contrast head CT
revealed
a parafalcine subdural hematoma. There was no mid-line shift or
further effacement of intracranial structures. As a result, she
was transferred to ___ for Neurosurgical evaluation.
Mrs. ___ was neurologically intact on exam. She denied any
loss of consciousness, seizures, changes in hearing, dizziness,
gait instability or extremity weakness/paresthesias. She
endorsed headaches and subtle visual changes, as if her field of
vision became narrow.
Past Medical History:
None. Had two c-sections and a hysterectomy in the past.
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Physical Examination On Admission:
O: T 98.4 HR 72 BP 113/72 RR 18 O2 sat 98% on room air
Gen: WD/WN, comfortable, NAD.
HEENT: PERRL, EOMs intact.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift.
Sensation: Intact to light touch.
Physical Examination On Discharge:
Alert and oriented x3. Speech fluent and clear. Comprehension
intact.
CN II-XII grossly intact.
Motor Examination: ___ strength in the upper and lower
extremities bilaterally.
Pertinent Results:
CT Head without Contrast: ___
Stable bilateral parafalcine subdural hemorrhage since ___. No new intracranial hemorrhage.
Brief Hospital Course:
Ms. ___ was admitted to the neurosurgery service for frequent
neurochecks on the day of admission, ___.
On ___, the patient underwent a repeat head CT which showed a
stable parafalcine subdural hematoma. Ms. ___ pain was
ambulating independently, voiding without pain and tolerating a
diet. It was determined she would be discharged to home today.
Medications on Admission:
None.
Discharge Medications:
1. Ibuprofen 400 mg PO Q8H:PRN headache
RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp
#*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth BID. Disp #*30
Tablet Refills:*0
3. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
Do not exceed greater than 4g Acetaminophen in a 24-hour period.
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Hold for sedation, drowsiness or RR <12.
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Parafalcine Subdural Hematoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Nonsurgical Brain Hemorrhage:
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
Unless directed by your doctor, do not take any
anti-inflammatory medicines such as Motrin, Aspirin, Advil, or
Ibuprofen etc.
If you were on a medication such as Coumadin (Warfarin), or
Plavix (clopidogrel), or Aspirin prior to your injury, you may
not resume this medication until cleared by the outpatient
Neurosurgery office.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
19936782-DS-4 | 19,936,782 | 20,393,290 | DS | 4 | 2153-02-28 00:00:00 | 2153-03-01 13:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old woman with a past medical history of hypertension
not currently on any medications who presents after a syncopal
episode. She was in her normal state of health until she was
walking around her bedroom when she "blacked out." She did not
have any preceding symptoms of CP, palpitations, SOB. She has
felt quite well with no recent symptoms or illnesses. During the
fall, she hurt her hand, no other acute injuries. She has had
___ episodes where she has "blacked out" over the past few
years. Per her report she loses consciousness initially but
immediately regains consciousness. She denies head strike,
denies headache, neck pain, lightheadedness, dizziness, chest
pain, shortness of breath, nausea/vomiting, abdominal pain. Her
hand pain is now under control.
In the ED, initial VS: 97.8 120 77/58 18 98%. She was given a
tetanus booster and Cefazolin 1g. CT head/neck: parotid
enlargement. CXR: aortic calcification and interstitial changes.
Xray hand ___ metacarpal fracture, widening at ___ mcp joint.
EKG sinus at 79, 1st degree av block, LVH with Q in V1, V2, and
expected ST changes related to LVH. Labs were unremarkable with
a negative trop. Hand team relocated the fracture and repaired
the laceration. Splint was placed. Vitals on transfer: 98.5 88
18 169/96 95%RA.
Currently, feeling well. Would prefer to do as little as
possible. She currently has no pain or other symoptoms.
Past Medical History:
hypertension
Social History:
___
Family History:
non contributory
Physical Exam:
VS - Temp 98.5, BP 167/90, HR 90, R 18, O2-sat 98% RA
GENERAL - well-appearing elderly woman in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, Dry MM, OP clear
NECK - supple, no thyromegaly, JVD flat, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, normal rate, regular rhythm. S1
normal, S2 difficult to hear. ___ crescendo decrescendo murmur
at USB with radiation over the clavicle.
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, dry skin, no c/c/e
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, decreased hearing
Orthostatics:
SBP 180->150, DBP 80->90, HR remained in the 80's.
Pertinent Results:
Labs:
=====
___ 05:50PM BLOOD WBC-10.6 RBC-3.60* Hgb-11.5* Hct-34.7*
MCV-97 MCH-31.9 MCHC-33.1 RDW-12.5 Plt ___
___ 12:00PM BLOOD WBC-11.6* RBC-3.67* Hgb-11.5* Hct-37.0
MCV-101* MCH-31.3 MCHC-31.1 RDW-12.2 Plt ___
___ 05:50PM BLOOD Neuts-88.7* Lymphs-5.2* Monos-3.3 Eos-2.3
Baso-0.5
___ 12:00PM BLOOD Glucose-103* UreaN-22* Creat-0.9 Na-139
K-4.4 Cl-103 HCO3-22 AnGap-18
___ 12:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 05:50PM BLOOD cTropnT-<0.01
___ 12:00PM BLOOD CK(CPK)-43
___ 12:00PM BLOOD Cholest-190
___ 12:00PM BLOOD Triglyc-78 HDL-52 CHOL/HD-3.7 LDLcalc-122
EKG:
====
NSR @ 79 BPMs, 1st degree AV block with LVH.
IMAGING:
========
CT head without contrast ___:
IMPRESSION:
1. No acute intracranial process. Prominent ventricles, sulci
and extra-axial spaces consistent with atrophy, small vessel
ischemic disease.
2. Mass in the region the the right parotid gland, similar in
appearance to ___ may represent a parotid tumor.
Ultrasound is suggested to evaluate further when clinically
appropriate.
CT spine without contrast ___:
IMPRESSION:
1. No evidence of acute fracture or traumatic malalignment.
Degenerative changes at multiple levels, most prominent at C5-C6
levels. Stable grade I anterolisthesis of C4 on C5.
2. Ground-glass opacities in the lung apices may reflect volume
overload.
XRAY Hand (AP,LAT,Oblique) ___:
FINDINGS: A limited view shows that the fifth
metacarpophalangeal joint is still substantially subluxed
although difficult to compare to the prior study to
orientational differenes and new overlying splinting material.
Alignment appears probably improved somewhat, however. There is
also a mildly angulated fracture of the fourth metacarpal.
IMPRESSION: Fracture of the fourth metacarpal. Marked
subluxation at the fifth metacarpophalangeal joint.
Brief Hospital Course:
___ year old woman with past medical history significant for
hypertension not on medications currently and recent syncopal
episodes presented with a syncopal episode, most likely
multifactorial in the setting of aortic stenosis detected on
physical exam, dehydration and poor autonomic dysfunction. She
was discharged home in stable condition along with home with
physical therapy. Nieces will be around and will look for 24 hr
care.
# Syncope: Unclear etiology. Potentially cardiac (mechanical)
given the sudden onset during exertion without prodrome as well
as physical exam finding consistent with valvular disease
(likely AS) and EKG changes that signify mainly LVH. Telemetry
showed 1 episode of a tachy-arrhythmia which could be atrial
ectopy. Tpn x2 negative. She was orthostatic based on systolic
blood pressure on admission. She was evaluated by physical
therapy who recommended home with physical theraepy services. We
discussed with the patient and the niece about the aortic
stenosis work up and treatment options in terms of risks and
benefits. The patient clearly stated her unwillingness to pursue
any invasive procedures which seems a very reasonable decision
in her age.
# Right ___ metacarpal fracture: She had a fracture when she
fell down. This required relocation and laceration repair by
hand team in the ED. She is provided with the phone number for
hand clinic to call and schedule appointment for follow up on
___. She is instructed to raise the right upper
extremity, keep the splint on and take keflex ___ mg three times
day for a total of 7 days.
# Hypertension: Not currently on medications. Blood pressure was
in the 150-170's during her stay. Previously she was on
medications but these were gradually down-titrated and
discontinued given her previous falls. She eventually stopped
her medications and decided not to take them again.
# Goals of care discussion: Patient is ___ year old woman and
states "less is more."
# Incidental
Mass in the region the the right parotid gland, similar in
appearance to may represent a parotid tumor. US would be
recommended.
Medications on Admission:
None
Discharge Medications:
1. cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q8H (every
8 hours) for 7 days.
Disp:*21 Capsule(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope
Hypertension
Aortic stenosis
Right ___ metacarpal fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you. As you know you were
admitted because you fell down. We think this is a combination
of age, narrow aortic valve based on physical exam and low fluid
intake. You were evaluated by physical therapy who recommended
home with physical therapy as home service. You have decided
with your niece to get a 24 hour care. You also decided not to
pursue invasive procedures which seems a reasonable decision.
You had imaging of your head and neck which showed degenerative
changes per initial report. You also had xray of your right hand
which showed fracture of one of the bones. Hand doctors
___ and ___ the bone and placed a splint.
Please TAKE keflex ___ mg three times daily for total of 7 days
to treat possible infection at fracture site.
Please call hand clinic for further evaluation for your fracture
by hand doctors. Please ask for appointment on ___. Please keep your right upper arm elevated.
Please follow up with your primary care physician reachable at
___ within the next ___ days.
Please follow-up with PCP regarding parotid gland Mass in the
region the the right parotid gland.
Followup Instructions:
___
|
19936782-DS-5 | 19,936,782 | 28,486,132 | DS | 5 | 2154-02-16 00:00:00 | 2154-02-17 10:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p mechanical fall with polytrauma
Major Surgical or Invasive Procedure:
___ Closed reduction, pinning of right femoral neck fracture
History of Present Illness:
Mrs. ___ is a ___ who is s/p fall with unclear etiology who
reportedly ot up and attempted to use the bathroom and
subsequently fell with + head strike. She was found down by her
home health aide who lives downstairs. It is unclear if there
was syncope or any prodromal symptoms. She was brought in by
ambulance and in the ED bay was complaining only of right-sided
facial plain. The patient is at baseline blind in the right eye
with a known right parotid mass for which she has declined
work-up.
Past Medical History:
___: HTN, prior syncope with fall one year ago and metacarpal
fractures at that time managed conservatively, large necrotic R
parotid mass likely malignant patient did not want it worked up,
cataracts, R eye blindness at baseline
PS: cataracts, lower midline abdominal scar unknown surgery per
niece at bedside
Social History:
___
Family History:
non contributory
Physical Exam:
Upon discharge:
VS: 97.5, 84, 148/59, 20, 94%/RA
Gen: NAD, resting in bed.
Heent: EOMI, MMM
Cardiac: Normal S1, S2.
Pulm: Lungs CTAB No W/R/R
Abdomen: Soft/nontender/nondistended
Ext: + pedal pulses. No CCE
Neuro: AAOx3
Pertinent Results:
Labwork:
___
Diagnostics:
___: ECG:
Baseline artifact. Most likely sinus rhythm with slight
acceleration and
prolonged P-R interval. Left ventricular hypertrophy by voltage
criteria with T wave inversions in the lateral leads and poor
anterior R wave progression.
Non-specific ST segment flattening in the inferior leads.
Compared to the
previous tracing of ___ voltage criteria for left ventricular
hypertrophy are more pronounced. Repolarization abnormalities
are also more pronounced in the left precordial leads. These are
most likely due to left ventricular hypertrophy. However, an
ongoing lateral ischemic process cannot be excluded.
___: CT head:
1. Acute right subdural hematoma.
2. Multiple foci of hemorrhagic contusion within both frontal
lobes.
3. Multiple fractures of the walls of the right maxillary sinus,
including an orbital floor fracture, with air tracking into the
orbit.
4. Large preseptal hematoma lateral to the right orbit as well
as hemorrhage within the right globe.
5. Dense appearance of a sylvian branch of the right MCA within
the Sylvian fissure ("Sylvian dot" sign) may represent acute
thrombus. Alternatively, there may be layering surrounding
hemorrhage within the subarachnoid space within the fissure,
although this would be less likely given the focal nature of the
finding. There is no evidence of associated territorial
infarction, at this time.
6. Large right parotid mass, better-evaluated on the concurrent
cervical spine CT.
___: CT C-spine:
1. No evidence of acute fracture or alignment abnormality to the
cervical
spine. Stable multilevel severe degenerative changes.
2. Heterogeneous right parotid gland mass, with likey central
foci of
necrosis, slowly growing over the last ___ years. These findings
are highly suspicious for malignancy.
3. Non-hemorrhagic right pleural effusion may be substantially
larger than imaged, given that it extends to the right apex.
NOTE ADDED IN ATTENDING REVIEW: As above, the mass replacing
both the
superficial and deep lobes of the right parotid gland is highly
suspicious for malignancy. It appears to transgress both the
pre- and post-styloid parapharyngeal space. There is no evident
cervical lymphadenopathy.
There are right greater than left pleural effusions with smooth
interlobular septal thickening, likely CHF; these findings,
along with ground-glass opacity, likely alveolar edema, were
present on the study of ___
___: CXR/Pelvis:
AP supine radiograph of the chest: The lungs are hyperinflated
but grossly clear. There is a background of prominent
interstitial pulmonary markings and cardiomegaly, stable from
the prior examination, and likely secondary to chronic
congestive heart failure. There are right greater than left
pleural effusions as well as likely pleural thickening. No
obvious displaced fracture is seen. Degenerative changes of the
thoracic spine.
Single AP view of the pelvis: Again noted are the findings a
subcapital
femoral neck fracture on the right, described in detail in the
separate hip radiographs report. Right hip degenerative
changes. The left hip features severe degenerative changes with
near bone-on-bone joint space narrowing and sclerosis.
Degenerative changes of the lower lumbar spine, SI joints, and
pubic symphysis. There is diffuse osteopenia. No pelvic ring
fracture is identified. Soft tissues are unremarkable aside
from vascular calcifications and phleboliths.
___: CT Torso:
1. Minimally impacted acute fracture of the right femoral neck.
2. Cardiomegaly, interstitial pulmonary edema, moderate right
and small left nonhemorrhagic pleural effusions, consistent with
mild decompensated
congestive heart failure.
3. No evidence of clavicular dislocation as suspected on the
prior radiograph.
4. 3.4 cm infrarenal abdominal aortic aneurysm.
5. Cholelithiasis and diverticulosis without evidence of acute
inflammatory changes.
6. No other evidence of acute traumatic injury to the chest,
abdomen, or
pelvis.
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
No significant interval change in the subdural collections
intraparenchymal and subarachnoid and subdural blood compared to
the previous CT examination. No significant new interval
findings are seen.
Brief Hospital Course:
Mrs. ___ is a ___ who is s/p fall with unclear etiology on
___ who was found to have multiple facial fractures, a right
SDH, bi-frontal IPH as was a right femoral neck fracture who was
admitted to the ___ for closer monitoring given her age and
morbidity of her extremity fracture. She was evaluated by the
Neurosurgery service, with recommendations for conservative
management. On HD#2 she underwent a closed reduction and pinning
of her right femoral neck fracture, which she tolerated well.
She was extubated uneventfully post-procedure and was
transferred to the TSICU in good condition. She also underwent
interval head CT which showed mild worsening, although her
mental status was largely unchanged. Her U/A was mildly
positive, for which she received one day of ceftriaxone. She was
also evaluated by the Ophthalmology service for her right globe
hemorrhage and right pre-septal hematoma with preliminary
recommendations for serial eye exams and fundus exam to rule-out
vitreous hemorrhage. Overnight she was bolused ___ for
oliguria, with good response.
On HD#3 she underwent repeat head CT, which was unchanged. Her
mental status had improved somewhat after restful sleep, and her
pain regimen transitioned to oral medications. She was advanced
to a regular diet, which she tolerated well. Her blood pressure
remained largely in the 130-150s, which was treated
intermittently with IV hydralazine. Her pulmonary status
remained stable. Her foley was kept in place, and her UOP
remained adequate. She was evaluated by ___ and was cleared
for home with 24 hour supervision.
On HD#4 her foley catheter was removed, and she was able to
void. She was re-evaluated by the Ophthalomology service and
they recommended followup outpatient.
Upon discharge, the patient was tolerating a regular diet and
her pain was controlled with oral pain medications. She was
discharged home with followup instructions. Her vitals were
stable and she was afebrile. The patient will be discharged home
with nursing services for wound monitoring and 24 hour
supervision.
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Duration:
2 Weeks
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
2. Dispense One Wheelchair
Patient status-post traumatic fall with multiple injuries.
3. Senna 1 TAB PO BID:PRN constipation
4. Acetaminophen 325-650 mg PO Q6H:PRN pain
5. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
S/p fall with polytrauma
Injuries:
3.5mm Right SDH, small foci IPH
Right preseptal hematoma, globe hemorrhage
Right maxillary sinus fracture
Right orbital floor fracture
Right femoral neck fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You experienced a fall with subsequent injuries to your right
eye, head with small subdural hematoma and bilateral
intracranial bleeding. These were evaluated by the Ophthalmology
and Neurosurgery services, without the need for intervention.
You were found to have multiple right-sided facial fractures
which were reviewed by the Plastic surgery service without the
need for operation.
Among your other injuries includes a right femoral (right 'hip')
fracture for which you underwent pinning and closed reduction by
the Orthopedics service.
You were monitored closely in the ICU with good pain and blood
pressure control. You have recovered well and are ready to
continue this recovery outside the hospital.
For your head bleed: there are no interventions necessary.
Please follow-up with Neurosurgery with a routine head CT.
For your facial fractures: please follow-up with Dr. ___
(___) on ___. Please find contact information
below.
Followup Instructions:
___
|
19936782-DS-6 | 19,936,782 | 28,291,720 | DS | 6 | 2154-02-27 00:00:00 | 2154-03-02 11:25:00 |
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 verbal
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F w/ fall ___ suffering right facial fractures,
SDH, and s/p closed reduction of R fem neck frx (was admitted to
ortho service for these injuries) now w/ 2 days of poor po,
confusion, decreased mental status. Pt went home w/ ___ care,
but last 2 days have gone from interactive to nonconversational,
mostly mute, mostly limp when trying to move her. When she
originally came home ___, she was walking about 10 feet with
walker and talking, interested in talking to family and in
eating. Also scraped her left shin when being moved from
wheelchair to bed w/ no fall and no new head strike. Of note,
she has been on oxycodone for pain, but she has not been dosed
this today or yesterday for fear this was the cause of AMS.
She denies cough, fevers, chills, chest pain, palpitations,
diarrhea, vomiting, dysuria, incontinence worse than baseline.
In the ED, initial vitals were: 97.3 80 168/87 18 99% 2L Nasal
Cannula.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies cough, shortness of breath. Denies
chest pain or tightness, palpitations. Denies nausea, vomiting,
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denies arthralgias or
myalgias.
Past Medical History:
HTN
large necrotic R parotid mass likely malignant, patient did not
want it worked up
prior syncope with fall c/b metacarpal fx, managed
conservatively
cataracts
R eye blindness at baseline
lower midline abdominal scar unknown surgery per niece at
bedside
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION:
Vitals: 97.4, 130/82, 78, 20, 97% RA
General: asleep laying with HOB elevated 10 degrees
HEENT: large mass on right parotid gland, entire right side of
face covered in ecchymosis, PERRLA, dry mucus membranes
Neck: no JVD
CV: RRR, no m/r/g
Lungs: CTAB anteriorly, no w/r/r
Abdomen: soft, nontender, nondistended
Ext: no edema
Neuro: asleep, did not awaken per niece/HCP request
___: left leg with large skin lac, dressed.
DISCHARGE:
General: lying bed, moaning, localized to voice but does not
respond
HEENT: large mass on right parotid gland, entire right side of
face covered in ecchymosis
Neck: no JVD
CV: RRR, systolic ejection murmur ___
Lungs: CTAB anteriorly, no w/r/r
Abdomen: soft, nontender, nondistended
Ext: no edema
Skin: left leg with large skin lac, staples removed
Pertinent Results:
ADMISSION
___ 02:33PM BLOOD WBC-15.3* RBC-3.69* Hgb-12.2 Hct-39.7
MCV-108*# MCH-33.1* MCHC-30.8* RDW-14.6 Plt ___
___ 02:33PM BLOOD Glucose-112* UreaN-27* Creat-0.9 Na-135
K-5.4* Cl-104 HCO3-16* AnGap-20
___ 02:33PM BLOOD Calcium-9.3 Phos-4.2 Mg-2.4
___ 03:08PM BLOOD ___ pO2-158* pCO2-29* pH-7.41
calTCO2-19* Base XS--4 Comment-GREEN-TOP
___ 02:33PM BLOOD Lactate-2.1* K-5.0
___ 03:08PM BLOOD Lactate-1.9
IMAGING:
HIP:
CLINICAL HISTORY: ___ woman with hip fracture of the
femoral neck.
FINDINGS: There is a fracture at the subcapital portion of the
right femoral
neck. This is fixated by three cannulated screws and washers.
This is
unchanged from prior. There are no hardware-related
complications. There is
some foreshortening at the site of the femoral neck fracture.
Lateral
surgical skin staples are seen. The left hip demonstrates
there are severe
degenerative changes of the left hip with complete loss of joint
space and spurring. Degenerative changes of the lower lumbar
spine are also seen.
There is some generalized demineralization. Vascular
calcifications are
present.
CT HEAD:
IMPRESSION:
1. No significant change in bilateral frontal subdural
hematomas.
2. Expected evolution of bifrontal intraparenchymal contusions
with no new
hemorrhage.
3. Old right orbital and maxillary sinus fractures.
CT CHEST:
IMPRESSION:
1. Increase in moderate-to-large layering nonhemorrhagic
bilateral pleural
effusion with attendant atelectasis.
2. Atherosclerotic calcification heavy in the coronaries, left
subclavian
artery, and normal caliber thoracic and upper abdominal aorta.
Probable
calcific aortic stenosis.
3. No pneumonia.
TIB/FIB:
FINDINGS:
Frontal and lateral views of the left tibia and fibula. The
bones are
diffusely osteopenic. There is no displaced fracture
identified. No
subcutaneous gas or radiopaque foreign body.
IMPRESSION:
No visualized fracture. Diffuse osteopenia.
EKG:
Sinus rhythm. Borderline A-V conduction delay. Left
bundle-branch block.
Continued diminished limb lead voltage as recorded on ___
without diagnostic
interim change.
Brief Hospital Course:
___ yo F with undiagnosed nectrotic parotid gland mass, s/p fall
2 weeks ago with facial fractures and SDH, presents with
worsening confusion and lethargy, found to have leukocytosis and
bilateral moderate to large pleural effusions without evidence
of pneumonia on CT chest.
#Goals of Care: had long discussion with patient's nieces who
expressed that patient did not want overly aggressive
interventions and that she stated she wished that one day she
just didn't wake up from sleep. Stated that patient would not
like to undergo further evaluation and treatments. After
thorough discussion, patient was made comfort measures only and
transitioned to ___ with palliative care.
-Roxicet ___ PRN for pain, respiratory distress
-plan for DC to ___ with palliative care
# Toxic Metabolic Encephalopathy: Patient has active delirium
attributed to toxic metabolic encephalopathy as evidenced by
waxing andw aning mental status, inability to maintain attention
and limited interaction. Hypoactive delirium result of
multifactorial process from recent fall with significant injury
including subdural hematoma, new environment in the hospital.
Additionally, active pain from recent fall may be contributing
as well. Age and subdural hematoma puts her at significant risk.
Recent Head CT negative for acute change in intracranial bleeds
or contusions. Unlikely this is seizure related as she is
responsive to voice but with limited attention. Uremia may be
contributing. While her BUN is not within the range we would
normally expect to cause uremia, her body habitus and minimal
muscle mass may indicate that this level of BUN is a significant
elevation with a resulting halve in her GFR. Infection seems far
less likely given that patient has received 72 hours of
vanc/cefepime without any improvement (and instead worsening).
Antibiotics were discontinued on ___ and the patient was made
comfort measures only with plans to send to ___ with palliative
care and transition to hospice.
- Frequent reorientation
- Avoid sedating medications
#Anion gap metabolic acidosis: Likely component of renl
insufficiency. Acute renal failure likely now contributing given
Cr of 1.1 is probably a low GFR for this ___ emaciated female.
BUN of 30 is the highest it has been in years and may be
contributing as well.
# CKD: Labs appear dehydrated and patient not taking adequate PO
intake. Creatinine of 1.1 seems too elevated for her muscle mass
and hyper-kalemia is suggestive of renal failure as well.
# Parotid gland mass: Chronic, stable
- Patient does not want work up.
# Subdural hematoma: Acute from recent fall though improved per
CT ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Glucosamine 1500 Complex *NF* (glucosamine-chondroit-vit
C-Mn) 500-400 mg Oral daily
Discharge Medications:
1. OxycoDONE-Acetaminophen Elixir ___ mL PO Q4H:PRN pain,
respiratory distress
RX *oxycodone-acetaminophen [Roxicet] 5 mg-325 mg/5 mL ___ ml
by mouth q4 Disp #*300 Milliliter Refills:*0
2. Acetaminophen 650 mg PO TID
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Delirium
Encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for evaluation of confusion. While
you were here, it became evident that you had delirium, and that
your prognosis was poor. After discussion with your family, the
decision was made to make you comfortable and not pursue any
further aggressive care.
You will go to a skilled nursing facility with palliative care.
Followup Instructions:
___
|
19936849-DS-9 | 19,936,849 | 26,242,025 | DS | 9 | 2119-11-21 00:00:00 | 2119-11-21 13:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / amlodipine / codeine / levofloxacin /
lisinopril / fluticasone
Attending: ___
Chief Complaint:
Shortness of breath and palpitations, jaw pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief this is a ___ with a history of right jaw pain x
several months associated with ear drainage and not worsened
with exercise. Had a cath ___ and stent in ___ stenosis of
RCA that did not resolve these symptoms. She presents with
continued jaw pain, and separately, worsening exercise tolerance
and SOB associated with palpitations. The shortness of breath is
her most concerning symptom. On arrival at the outside hospital,
she had a troponin (I or T, not clear) of 0.04, and was started
on a heparin drip. Her pain resolved immediately, and her EKG
was unchanged. Troponin was <0.01, then 0.01, then <0.01.
Overnight in the hospital she had atrial fibrillation. During
this time, she with palpitations and shortness of breath, which
were similar to her primary complaint. She has no known history
of atrial fibrillation. She was started on metoprolol (home
diltiazem was held), heparin, aspirin and atorvastatin.
Past Medical History:
- BMS to RCA in ___
- atrial fibrillation, on Coumadin
- COPD/Asthma
- PE ___, provoked by surgery)
- Dysphagia (sp edophageal dilatations)
- Hyper-PTH
- DJD
- SP L THR
- SP ___ TKR
- SP Cateract repair
- SP L breast benign nodule excision
- SP rectal hemorrhoid banding in ___
Social History:
___
Family History:
Sibling - lung Ca
Physical Exam:
ADMISSION EXAM:
VS: T=97.5 BP=119-159/70-89 ___ RR=12 O2 sat= 96-98% RA
GENERAL: WDWN in NAD.
HEENT: NCAT. Left ear with wax, no focal signs of infection,
right ear with good reflex, minimal wax. Mild tenderness of the
jaw to palpation. Some cavities of teeth. Sclera anicteric.
PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the
oral mucosa. No xanthelasma.
NECK: Supple with JVP of 2 cm from sternal angle, nodule on
thyroid
CARDIAC: RR, normal S1, S2. Early systolic murmur. No thrills,
lifts. No S3 or S4.
LUNGS: Scoliosis of spine. Resp were unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: 1+ edema of calves bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Neuro: Oriented x4 without focal deficits
Psych: Mood, affect appropriate.
DISCHARGE EXAM:
VS: 98.5 130/65 HR 63 RR 12 96% RA
GENERAL: WDWN in NAD.
HEENT: NCAT. No tenderness of the jaw
NECK: Supple with JVP of 2 cm from sternal angle, nodule on
thyroid
CARDIAC: RR, normal S1, S2. No thrills, lifts. No S3 or S4.
LUNGS: Scoliosis of spine. Resp were unlabored, no accessory
muscle use. CTAB, no crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness
EXTREMITIES: trace edema of calves bilaterally
SKIN: Trace edema of legs. No stasis dermatitis, ulcers, scars,
or xanthomas.
Neuro: Oriented x4 without focal deficits
Psych: Mood, affect appropriate.
Pertinent Results:
Discharge ___ 07:00AM BLOOD WBC-6.5 RBC-3.41* Hgb-10.5*
Hct-33.2* MCV-98 MCH-30.8 MCHC-31.6 RDW-13.6 Plt ___
MCV-98 MCH-30.6 MCHC-31.4 RDW-13.3 Plt ___
Admission: ___ 08:20PM BLOOD WBC-6.3 RBC-3.97* Hgb-12.3
Hct-38.8 MCV-98 MCH-31.0 MCHC-31.7 RDW-13.4 Plt ___
Admission: ___ 08:00PM BLOOD Neuts-61.3 Lymphs-29.1
Monos-5.5 Eos-2.8 Baso-1.3
Discharge: ___ 07:00AM BLOOD ___ PTT-37.5*
___
___ 06:10AM BLOOD ___ PTT-31.0 ___
Prior to warfarin: ___ 06:53AM BLOOD ___ PTT-69.4*
___
Discharge: ___ 07:00AM BLOOD UreaN-12 Creat-0.7 Na-137
K-4.0 Cl-103 HCO3-27 AnGap-11
___ 07:00AM BLOOD Phos-1.9* Mg-2.2
Admission: ___ 08:00PM BLOOD Glucose-84 UreaN-19 Creat-0.7
Na-135 K-7.0* Cl-99 HCO3-26 AnGap-17
Admission: ___ 06:53AM BLOOD CK-MB-4 cTropnT-<0.01
___ 04:03AM BLOOD CK-MB-4 cTropnT-0.01
___ 08:20PM BLOOD CK-MB-4 cTropnT-<0.01
___ 06:10AM BLOOD Calcium-11.0* Phos-2.7 Mg-2.0
___ 04:03AM BLOOD TSH-2.3
___ 06:53AM BLOOD CRP-0.6
ECG ___:
Sinus rhythm. Left axis deviation. Minor lateral T wave
flattening. No
significant change compared with previous tracing of ___.
TRACING #1
ECG ___:
Atrial fibrillation. Minor inferolateral T wave abnormalities.
Compared to tracing #1 atrial fibrillation is new.
Echo ___:
The left atrial volume is moderately increased. No atrial septal
defect is seen by 2D or color Doppler. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Doppler parameters
are most consistent with Grade II (moderate) left ventricular
diastolic dysfunction. Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
are mildly thickened (?#). No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Trivial mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal cavity size and systolic function. Moderate left
ventricular diastolic dysfunction.
X-ray ___:
REASON FOR EXAM: Chest pain.
Comparison is made with prior study, ___.
Moderate-to-severe cardiomegaly is stable. Very tortuous aorta
is stable. The appearance of the mediastinum is unchanged.
Linear bibasilar atelectasis have increased on the right. There
is no pneumothorax or effusion. S-shaped scoliosis is again
noted.
Brief Hospital Course:
___ year old woman with jaw and neck pain that has been
consistent over the past three months which is likely
non-anginal, and recently increased shortness of breath and
palpitations coincident with atrial fibrillation.
# Jaw pain: In a patient with 80% stenosis of RCA recently,
concern is for in-stent thrombosis versus restenosis. However,
it does not appear from her symptoms that this was ever a true
anginal equivalent, as it did not occur with exercise and was
not relieved with the PCI. Abscess is unlikely by exam. Patient
does not take bisphosphanates, so osteonecrosis is also
unlikely. Temporal arteritis is possible, though pain is not
provoked by eating and her temporal artery is not tender. CRP
and ESR were both negative
-Had weakly positive biomarkers with troponin (I or T) of 0.04
at OSH, 0.01 and <0.01 here, without new EKG changes, may be
related to afib and does not have a characteristic ris and fall
consistent with ischemia.
# Atrial fibrillation: at separate times from her jaw pain, the
patient experiences palpitations, shortness of breath which are
her most distressing symptom. She has also noted increased
swelling of her legs. During her admission here, she has been
noted to be in atrial fibrillation twice. Her risk of stroke by
her CHADS score outweighs her risk of bleed by HAS BLED score,
therefore decision was made in conjunction with her PCP and
patient to start warfarin. Echocardiogram shows preserved
ejection fraction, dilated left atrium and moderate diastolic
dysfunction, so atrial fibrillation is likely not new
-Warfarin 2 mg daily, INR to be rechecked every two days. If
patient feels that increased bleeding is impacting her quality
of life, would discontinue this medication
-metoprolol 50 mg XL
-Amiodarone 200 mg BID until ___, then 200 mg daily ongoing
-will need repeat LFTs and TFTs in 6mo from onset of starting
amiodarone
-Stop plavix on ___
# Hypercalcemia: Patient has a history of hyperparathyroidism.
She has hypercalcemia here. There is some association with
atrial fibrillation and hypercalcemia, but unclear if it is
causative. Her home calcium channel blocker is likely less
effective in the setting of hypercalcemia.
-Management per PCP
#Constipation: No bowel movement for 4 days prior to
presentation, may be related to hypercalcemia. She was continued
on colace, and senna and miralax were added.
#Concern for deconditioning: Though her hospital stay was short,
the patient was concerned that she might be deconditioned and
not safe to return to independent living. We therefore consulted
physical therapy for an evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Hydrochlorothiazide 25 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Oxybutynin 15 mg PO DAILY
7. Docusate Sodium 200 mg PO DAILY constipation
8. Cetirizine 10 mg oral daily
9. mv-mn-vitC-asbNa-Glu-Lys-hc124 337 mg mucous membrane daily
prn cold symptoms
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Vitamin D ___ UNIT PO DAILY
12. Acetaminophen 325 mg PO Q4H:PRN pain
13. Atorvastatin 80 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325 mg PO Q4H:PRN pain
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Clopidogrel 75 mg PO DAILY
Stop on ___
5. Docusate Sodium 200 mg PO DAILY constipation
6. Nitroglycerin SL 0.4 mg SL PRN chest pain
7. Oxybutynin 15 mg PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Famotidine 20 mg PO Q24H
RX *famotidine 20 mg 1 tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*0
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
11. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*30 Tablet Refills:*0
12. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides 8.6 mg 1 tablet by mouth twice a day as needed
Disp #*60 Tablet Refills:*0
13. Warfarin 2 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
14. Cetirizine 10 mg oral daily
15. Hydrochlorothiazide 25 mg PO DAILY
16. mv-mn-vitC-asbNa-Glu-Lys-hc124 337 mg mucous membrane daily
prn cold symptoms
17. Amiodarone 200 mg PO BID atrial fibrillation
this will be downtitrated over the next couple of weeks
RX *amiodarone 200 mg 1 tablet(s) by mouth Twice a day for one
week then once a day Disp #*60 Tablet Refills:*0
18. Bisacodyl ___AILY:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally Daily as needed
Disp #*30 Suppository Refills:*0
19. Polyethylene Glycol 34 g PO DAILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___ Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Atrial fibrillation
Non-anginal jaw pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you in the hospital. You were
admitted because we were concerned that your jaw pain might be
caused by your heart. Because it has gone on many months and is
not different since your cath, is not worse with exercise, and
not associated with changes on your EKG, we think that it
probably is not coming from your heart and you do not need any
intervention at this time. You also had an abnormal rhythm here
called atrial fibrillation, which may have caused you to feel
more short of breath and palpitations. This rhythm puts people
at risk of clots that can cause stroke, so we started a drug
called warfarin to prevent you from having strokes.
Followup Instructions:
___
|
19937166-DS-10 | 19,937,166 | 20,549,473 | DS | 10 | 2172-11-04 00:00:00 | 2172-11-05 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bee Sting Kit
Attending: ___.
Chief Complaint:
2 falls with headstrike
Major Surgical or Invasive Procedure:
none.
History of Present Illness:
___ w/ PMH of L4-5 fusion ___ at ___ and diskectomy ___ years
prior for herniated disk, otherwise healthy, presents with 2
syncopal episodes this morning with headstrike. pt reports he
woke up with a very bad HA that was different from his others
___, mostly frontal. Walked to the bathroom, urinated and then
past out and hit his posterior head on the bathtub. Patient says
that he was feeling dizzy while urinating and remembers bringing
up a hand to try to steady himself. Next thing he remembers is
lying on ground, waking up to his wife screaming and noting that
he was having some rhythmic shaking movements. His wife, who
heard the loud sound from his head hitting bathtub found him on
the floor of the bathroom, seizing (upper body, upper
extremities, and neck but doesn't remember which side his head
was jerking towards), did not note any incontinence or tongue
biting or cyanosis. Patient noted HA, nausea but no vomiting,
CP, palpitations, SOB, or any other symptoms after first fall.
He was oriented, not confused. Eventually helped patient stand
up, walked 2 steps out of the bathroom, and patient passed out
again, hitting his head on the hallway wall. He denies any
presyncopal CP, SOB, diaphoresis, lightheadedness for the second
fall. Again, when he came to, he was nauseus, had cont'
posterior headache, but reports being oriented, with no
confusion.
.
Patient has no history of n/v prior to syncope event today, no
diarrhea, poor PO intake recently, no fevers, chills. No
medication changes. Previous syncopal episode prior to his back
surgery years ago. Had ___ concussions related to sports over ___
years ago, otherwise no head trauma in past. No seizures before.
Daughter at home is sick with pna and he wasn't feeling well
yesterday with cold symptoms.
.
In the ED, initial vs were: 97.3 64 121/69 16 98%RA. Patient
was given morphine and zofran for pain and nausea control.
cardiac enzymes neg x2. CT spine showed anterior osteophyte
fracture of C6-7, head CT with no acute processes. EKG shows NSR
with borderline PR prolongation and QRS widening and incomplete
RBBB. no ST changes. C-collar placed by neurosurgery, who said
that he will need for at least 2 wks and outpatient f/u. No
further imaging/surgery indicated at this time.
.
On the floor, patient continues to have pain, which responds to
IV morphine. Otherwise feeling okay. VSS.
.
Review of sytems: as above, otherwise negative.
Past Medical History:
-Hx of mononucleosis and chickenpox
-disk herniation in cervical spine, s/p diskectomy
-s/p c-spine fusion in ___
Social History:
___
Family History:
Brother with MI/?secondary to conduction abnormality at age ___,
survived.
Uncle with CAD in ___
Physical Exam:
Admission Physical Exam:
Vitals: 97.3 121/69 64 16 98%Ra
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: with c-collar on
Lungs: Clear to auscultation anteriorally and from the side
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended. + bowel sounds. no
rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema.
Neuro: CN II-XII intact. Strength ___ throughout. sensation
intact, symmetric, cerebellar fxn intact.
.
.
Discharge Physical Exam:
Vitals: 99.1/99.1 116/71 58 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Lungs: possible egophony at LLL, otherwise completely clear
CV: RRR, Split S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended. + bowel sounds. no
rebound or guarding.
Ext: warm, well-perfused. no cyanosis, clubbing, or edema.
Neuro: CN II-XII intact. Strength ___ throughout. sensation
intact, symmetric, cerebellar fxn intact.
Pertinent Results:
Labs on Admission:
___ 10:00AM BLOOD WBC-14.3* RBC-5.01# Hgb-15.6# Hct-45.5#
MCV-91 MCH-31.1 MCHC-34.2 RDW-11.9 Plt ___
___ 10:00AM BLOOD Neuts-81.5* Lymphs-12.0* Monos-5.3
Eos-0.8 Baso-0.3
___ 10:00AM BLOOD ___ PTT-22.3 ___
___ 10:00AM BLOOD Glucose-95 UreaN-19 Creat-1.0 Na-138
K-4.1 Cl-104 HCO3-22 AnGap-16
___ 05:40AM BLOOD Calcium-8.7 Phos-2.8# Mg-1.9
___ 10:00AM BLOOD CK(CPK)-175
___ 03:39PM BLOOD cTropnT-<0.01
___ 10:00AM BLOOD cTropnT-<0.01
___ 08:20PM BLOOD D-Dimer-540*
___ 06:30AM BLOOD Triglyc-141 HDL-38 CHOL/HD-3.6 LDLcalc-71
.
.
___ 5:35 pm SEROLOGY/BLOOD
**FINAL REPORT ___
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Reference Range: No antibody detected.
Negative results do not rule out B. burgdorferi infection.
Patients
in early stages of infection or on antibiotic therapy may
not produce
detectable levels of antibody. Patients with clinical
history and/or
symptoms suggestive of lyme disease should be retested in
___ weeks.
.
.
.
Labs on Discharge:
___ 06:30AM BLOOD WBC-7.6 RBC-4.83 Hgb-14.9 Hct-43.2 MCV-89
MCH-30.8 MCHC-34.5 RDW-12.2 Plt ___
___ 06:30AM BLOOD Glucose-90 UreaN-18 Creat-1.0 Na-138
K-4.3 Cl-100 HCO3-31 AnGap-11
___ 06:30AM BLOOD Calcium-9.5 Phos-4.8* Mg-2.0 Cholest-137
.
.
Imaging studies:
CXR ___: No acute process.
.
CXR (___): Large pneumonia in the lingula is demonstrated
in both PA and lateral views. The rest of the lungs are clear.
There is no appreciable pleural effusion or pneumothorax. The
heart size and cardiomediastinal silhouette are unremarkable.
.
EKG: Sinus rhythm. Leftward axis. RSR' pattern in lead V1 is
likely a normal variant. Compared to the previous tracing
findings are unchanged.
.
Head CT: 1. No acute intracranial process. 2. Right maxillary
sinus disease with layering fluid suggestive of acute component.
.
C-spine CT: 1. Oblique lucencies through the superior endplates
of C6 and C7 vertebral bodies on the left traversing disc spaces
may represent non-displaced fractures, age indeterminate.
Recommend clinical correlation with focal tenderness. ATTENDING
NOTE: The lucencies can also be due to incompletely ossified
osteophytes. Correlate with point tenderness or MRI if concern
persists.
.
ECHO: Normal left ventricular cavity size with very small
regional systolic dysfunction c/w possible focal myocarditis.
Patent foramen ovale. If clinically indicated, a cardiac MRI
(___) would be better able to confirm the focal wall
motion abnormality and to assess for possible myocarditis.
.
C-spine films: Degenerative changes of the mid to lower cervical
spine without signs for acute bony injury or abnormal motion.
.
CTA Chest ___: 1. No evidence of PE. 2. Pneumonia in the
left upper lobe with reactive bilateral hilar lymphadenopathy.
3. 3 mm noncalcified lung nodule. In a patient at low risk, no
further followup is necessary, in a patient at high-risk for
lung cancer, a one-year followup CT of the chest is recommended
to ensure stability.
.
Cardiac MRI: Impression:
1. Mildly increased left ventricular cavity size with focal wall
motion
abnormality (mid-to-distal lateral wall. The LVEF was mildly
decreased at
49%. The effective forward LVEF was normal at 47%. No CMR
evidence of prior myocardial scarring/infarction*.
2. Normal right ventricular cavity size and systolic function.
The RVEF was normal at 49%.
3. Mild mitral regurgitation.
4. The indexed diameters of the ascending and descending
thoracic aorta were normal. The main pulmonary artery diameter
index was normal.
5. Left upper lobe consolidation, which may represent
atelectasis, aspiration, or infection. Further assessment with
chest radiographs or CT may be considered, if clinically
indicated.
*While there is no evidence of myocardial fibrosis or
inflammation by late
gadolinium enhancement, the focal wall motion abnormality on
both CMR and
echocardiography is suspicious for underlying cardiac pathology.
Given the
patient's history of syncope with head trauma, a family history
of sudden
cardiac death (brother died of 'heart attack' at age ___, and
these abnormal cardiac findings on two non-invasive imaging
modalities, a formal cardiology consultation is recommended.
Brief Hospital Course:
___ w/ PMH of L4-5 fusion ___ at ___ and diskectomy ___ years
prior for herniated disk, otherwise healthy, presents with 2
syncopal episodes in morning with headstrike, admitted for
syncope workup, course complicated by pneumonia and also LV wall
motion abn seen on echo and MRI.
.
#Syncope: clinical pictures renders micturation syncope most
likely; vasovagal reaction led to first fall, head
trauma/concussion led to seizure and possibly second fall.
Patient was evaluated for orthostasis, which was negative.
Patient's med list included viagra, but patient says that he
hasn't taken any in the past year. Given family history of MI in
brother and uncle at early ages, cardiac enzymes were obtained,
and patient ruled out x2. EKG showed borderline PR prologation
and lyme was entertained given syncope presentation. Patient
doesn't recall ticks and lyme titers negative. Patient reported
an ASD and an echo was obtained to rule out any structural
abnormality, which showed a PFO (not ASD) as well as very small
LV wall motion abnormality with preserved ejection fraction.
Given unknown cause of LV wall motion abn and possible
contribution to clinical presentation, a cardiac MRI was
obtained and cardiology consulted. It was concluded that the
focal wall motion abnormality is subtle and that there is no
evidence of scarring or prior MI by cardiac MRI. Patient was
sent home with ___ of Hearts Monitor and will follow up with
cardiology (Dr. ___ and obtain a follow-up echo in ___
weeks. No medications or further treatment/study is warranted at
this point.
.
#Pneumonia: Patient presented with signs of URI, said that
daughter had pna at home. Initial CXR negative for any acute
process and symptoms were believed to be due to viral infection.
However, patient's cough worsened during hospitalization and
began to develop wheezing. Patient was re-imaged and found to
have a lingular pna and we put patient on CAP coverage
(azithromycin x5 days).
.
#Cervical Spine pain/Headache: Patient had severe neck pain and
headache following fall which improved with time. Head CT was
negative for any acute process and Spine imaging was not
concerning for any fracture or spinal cord compression.
Patient's pain was treated with tramadol and tylenol.
Neurosurgery had initally evaluated the patient and no further
outpatient follow up is needed at this time.
.
#Nausea/vomiting: Patient had nausea which improved with time,
sent home with zofran prn nausea. likely post-concussive
syndrome.
.
Code: Full (discussed with patient)
.
.
___ Issues:
--Patient to follow up with PCP/cardiology with appointments as
indicated below for recent episodes of syncope. Patient will be
leaving with ___ of Hearts.
Medications on Admission:
Epi pen prn
Viagra prn
ibuprofen prn
Discharge Medications:
1. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
Disp:*180 Tablet(s)* Refills:*0*
2. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*30 Tablet(s)* Refills:*0*
3. azithromycin 250 mg Tablet Sig: One (1) Tablet PO once a day
for 4 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___. You were admitted for an evaluation
and management of syncope and neck pain following 2 falls. You
were found to have what is most likely micturation syncope, in
which parasympathetic nerves may be stimulated when urinating,
which causes a drop and blood pressure and heart rate, causing
you to feel dizzy and to faint. We also noticed that your EKG
showed some borderline mild conduction abnormalities but did not
notice any concerning arrhythmias while you were monitored in
the hospital. We will send you home with a monitor which you can
wear for the next few weeks to help track your heart rhythms.
In evaluating your heart structure, we found that you have a
patent foramen ovale, which is a small channel between the two
atria that has little clinical significance. Your overall heart
function is normal with exception of a very small part of your
left ventricle, which may be consistent with myocarditis,
usually a sequelae of a viral infection and is self limited.
Please follow up with your primary care provider as an
outpatient next week.
You were discharged with a holter monitor and you will need
cardiology follow up within ___ weeks with an echo of your heart
prior to your appointment (or on the same day). No medications
or further treatment/study is warranted at this point.
Your headache and nausea have been well controlled with oral
medications, which we will send you home with.
You were also found to have a pneumonia and will need
antibiotics for a total 5 day course.
--Please take tramadol and tylenol as needed for pain
--Please take azithromycin to be taken for the next 4 days
Followup Instructions:
___
|
19937193-DS-11 | 19,937,193 | 27,795,852 | DS | 11 | 2137-11-03 00:00:00 | 2137-11-04 08:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / Oxycodone / Keppra / narcotics / Benadryl /
Zestril / Ativan
Attending: ___
Chief Complaint:
seizure
Major Surgical or Invasive Procedure:
pacemaker placement by EP cardiology
History of Present Illness:
___ is a ___ yo F with hx prior L occipital SDH (___) and mild
dementia who presented to ___ ED ___ following a fall with
headstrike; she was found to have an acute R SDH. Neurology was
consulted on ___ for management of new seizures. Neurology
re-consulted today for medication management after an episode of
bilateral arm shaking lasting 20 seconds with associated post
ictal period. Per her family at bedside. At about 1:30pm she was
watching TV, daughter noted she looked well but was somewhat
pale, then she turned her head forward, her hands came up to the
level of her chest, she stiffened and started jerking both of
her
arms. This lasted for ___ seconds at max. On further
questioning witnesses deny tongue biting, loss of bowel or
bladder control. After the event family reports she was
lethargic, "wiped out" for ___ minutes. Nursing staff checked
BP after the incident and found elevated to 170/90. Per the
daughter at the bedside and confirmed by her facility this event
happened in the context of missing her pm dose of lacosamide on
___ as this medication was not available when she arrived
there.
During her latest admission (___) it was concluded that
she
had new onset complex partial seizures, in the setting of an
acute SDH presumably irritating her cortex. She had 3 distinct
events while hospitalized. She was then seizure free since ___.
Her course was complicated by encephalopathy thought to be
medication related which eventually resolved. EEG was performed
and did not reveal any epileptiform discharges. Per previous
reports: "MRI showed slowed diffusion in the R frontal lobe in a
gyriform pattern, which may be post-ictal, and an area of
restricted diffusion in the R frontal lobe likely due to
subacute
ischemia. As pt did have transient afib in the TSICU, she likely
had a small embolic event." She was discharged on a PHT taper
(to
100 BID x 3 days, then 100 daily x 3 days, then 50 daily x 3
days
then OFF) as PHT is not a good long term agent in a pt with
CKD).
She was also sarted on Vimpat 100 BID (___) for long term AED
management.
Per previous notes her seizures were described as: "L eye and
head deviation accompanied by clonic activity of her L chin and
LUE that lasted ~60 seconds. This was accompanied by LOA and
followed by a period of 10 minutes of confusion".
On general ROS reports cough with clear sputum production.
Neurologic ROS remarkable for the above described symptoms.
Past Medical History:
HTN
elevated cholesterol
cardiac stent placed in ___ at ___
cataract surgery
cdiff
diverticulitis
RBBB
CKD
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 97.5, HR: 78, BP: 167/83, RR: 18, O2sat: 97% RA
General: NAD
HEENT: Dry oral mucosa
Neck: Supple
___: RRR
Pulmonary: Faint bibasilar crackles RT>LT
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Skin: multiple hematomas over bilateral upper extremities.
Neurologic Examination:
Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive, able to name ___ backward without
difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ with prompting at 5 minutes. No apraxia.
No evidence of hemineglect. No left-right confusion. Able to
follow both midline and appendicular commands.
- Cranial Nerves - LT pupil 3->2 brisk. R pupil ovid and with
minimal reactivity (s/p cataract surgery). EOMI, no nystagmus.
V1-V3 without deficits to light touch bilaterally. No facial
movement asymmetry. Hearing grossly diminished to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No asterixis. Low
frequency postural tremor of the hands.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___ ___ 4* 5 5 5 5 5
R 5- ___ ___ 5 5 5 5 5 5
*limited by pain as she reports this is the side she hurt when
she fell.
-Sensory - No deficits to light touch.
-DTRs:
Bi Tri ___ Pat Ach
L 2+ 2+ 2+ 1+ 1
R 2+ 2+ 2+ 1+ 1
Plantar response flexor bilaterally.
- Coordination - No dysmetria with finger to nose testing
bilaterally. However movement slow, and task limited as pt is
hard of hearing.
- Gait - Deferred.
================================
DISCHARGE PHYSICAL EXAMINATION
Vitals: 99.2 111-160/43-60 50 18 95% RA
General: NAD
HEENT: NC AT MMM
___: RRR
Abdomen: Soft, NT, ND
Extremities: WWP, no edema
Skin: multiple hematomas over bilateral upper extremities.
Neurologic Examination:
Awake, alert, oriented x 3. Speech is fluent with full
sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. No apraxia.
No evidence of hemineglect. No left-right confusion. Able to
follow both midline and appendicular commands.
- Cranial Nerves - LT pupil 3->2 brisk. R pupil ovid and with
minimal reactivity (s/p cataract surgery). EOMI, no nystagmus.
V1-V3 without deficits to light touch bilaterally. No facial
movement asymmetry. SCM/Trapezius strength ___ bilaterally.
Tongue midline.
- Motor - Normal bulk and tone. No drift. No asterixis. Low
frequency postural tremor of the hands.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5- ___ ___ 5- 5 5 5 5 5
R 5- ___ ___ 5- 5 5 5 5 5
-Sensory - No deficits to light touch.
- Gait - Deferred.
Pertinent Results:
___ 10:35AM BLOOD WBC-6.7 RBC-3.32* Hgb-9.6* Hct-31.4*
MCV-95 MCH-28.9 MCHC-30.6* RDW-14.5 RDWSD-49.6* Plt ___
___ 05:40AM BLOOD WBC-8.9# RBC-3.42* Hgb-9.9* Hct-31.6*
MCV-92 MCH-28.9 MCHC-31.3* RDW-14.4 RDWSD-48.7* Plt ___
___ 04:30AM BLOOD WBC-4.3 RBC-3.36* Hgb-9.8* Hct-31.1*
MCV-93 MCH-29.2 MCHC-31.5* RDW-14.1 RDWSD-47.8* Plt ___
___ 07:02AM BLOOD WBC-5.6 RBC-3.41* Hgb-9.9* Hct-32.4*
MCV-95 MCH-29.0 MCHC-30.6* RDW-14.6 RDWSD-50.1* Plt ___
___ 05:30PM BLOOD WBC-6.9 RBC-3.43* Hgb-10.2* Hct-32.2*
MCV-94 MCH-29.7 MCHC-31.7* RDW-14.6 RDWSD-50.0* Plt ___
___ 07:02AM BLOOD WBC-4.6 RBC-3.16* Hgb-9.1* Hct-30.0*
MCV-95 MCH-28.8 MCHC-30.3* RDW-14.4 RDWSD-50.4* Plt ___
___ 05:30PM BLOOD Neuts-63.9 ___ Monos-10.4 Eos-4.9
Baso-0.3 Im ___ AbsNeut-4.43 AbsLymp-1.40 AbsMono-0.72
AbsEos-0.34 AbsBaso-0.02
___ 10:35AM BLOOD Plt ___
___ 10:35AM BLOOD ___ PTT-25.2 ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD ___
___ 04:30AM BLOOD Plt ___
___ 04:30AM BLOOD ___ PTT-21.2* ___
___ 07:02AM BLOOD Plt ___
___ 05:30PM BLOOD Plt ___
___ 05:30PM BLOOD ___ PTT-25.5 ___
___ 07:02AM BLOOD Plt ___
___ 10:35AM BLOOD Glucose-148* UreaN-46* Creat-1.8* Na-135
K-4.6 Cl-102 HCO3-23 AnGap-15
___ 05:40AM BLOOD Glucose-110* UreaN-34* Creat-1.6* Na-136
K-4.6 Cl-102 HCO3-23 AnGap-16
___ 04:30AM BLOOD Glucose-121* UreaN-30* Creat-1.5* Na-136
K-5.0 Cl-104 HCO3-22 AnGap-15
___ 07:02AM BLOOD Glucose-95 UreaN-29* Creat-1.7* Na-137
K-4.9 Cl-105 HCO3-23 AnGap-14
___ 05:30PM BLOOD Glucose-91 UreaN-34* Creat-1.8* Na-136
K-5.2* Cl-104 HCO3-20* AnGap-17
___ 07:02AM BLOOD Glucose-78 UreaN-27* Creat-1.6* Na-139
K-4.5 Cl-107 HCO3-21* AnGap-16
___ 05:40AM BLOOD cTropnT-<0.01
___ 07:02AM BLOOD CK-MB-3 cTropnT-0.01
___ 10:35AM BLOOD Calcium-9.1 Phos-3.0 Mg-2.4
___ 05:40AM BLOOD Calcium-9.6 Phos-4.0 Mg-2.2
___ 04:30AM BLOOD Calcium-9.8 Phos-3.7 Mg-2.1
___ 07:02AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.0
___ 05:30PM BLOOD Calcium-9.4 Mg-2.1
___ 07:02AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8
___ 05:30PM BLOOD Phenyto-10.1
___ 05:39PM BLOOD Lactate-1.1
___ CHEST (PA & LAT)
AP upright and lateral views of the chest provided. Lung
volumes are low
limiting assessment. There is mild left basal atelectasis which
appears
unchanged. There is likely mild hilar congestion with mild
stable
cardiomegaly. The aorta is calcified and somewhat unfolded. No
convincing
evidence for pneumonia, large effusion or pneumothorax.
Visualized osseous structures appear intact.
___ CT HEAD W/O CONTRAST
1. Right cerebral subdural hematoma containing acute and
subacute hemorrhagic
components, measures up to 8 mm an causes 4 mm of leftward shift
of midline
structures. Minimal change from prior.
2. Expected evolution of the subacute infarct in the right
frontal cortex.
___ CHEST (PORTABLE AP)
In the setting of chronic moderate cardiomegaly and persistent
pulmonary
vascular congestion, new opacification at the lung bases should
be treated as possible edema. Alternatively this could
represent aspiration, particularly in the right lower lobe.
Small left pleural effusion is new. No pneumothorax.
___ CT HEAD W/O CONTRAST
1. Evolution of the subdural fluid collection on the right,
without evidence
of new hemorrhage.
2. Minimal right-to-left midline shift with effacement of the
sulci and right
lateral ventricle, unchanged from prior.
3. Evolving infarct involving the right frontal lobe, better
visualized on the
prior MRI.
___ CTA HEAD W&W/O C & RECONS
1. The mixed density right subdural hematoma is stable in size.
The small
focus of hyperdense blood within the anterior aspect of the
collection appears
slightly denser than on the prior CT, but this is most likely
artifactual
given the lack of enlargement. This may be reassessed on
follow-up
noncontrast CT.
2. Stable appearance of evolving subacute infarction in the
right frontal
lobe.
3. High-grade stenosis at origin of the left vertebral artery
4. Mild short-segment stenosis of the proximal V4 segment of the
left
vertebral artery.
5. At least mild narrowing of the proximal left subclavian
artery.
6. No evidence for carotid stenosis.
___ ECG
Sinus rhythm or ectopic atrial rhythm with one eposide of block
with a
consistent P-R complex before and after the block. Left axis
deviation. Left anterior fascicular block can also be considered
but the Q wave that is noticeable in leads I and aVL on this
tracing is quite diminutive. Clinical correlation is suggested.
___ CHEST (PA & LAT)
In comparison to study of ___, there is an placement of a
single lead pacer that extends to the apex of the right
ventricle. Lower lung volumes with continued enlargement of the
cardiac silhouette and persistent pulmonary vascular congestion.
Opacification at the left base is consistent with volume loss
in the lower lobe and pleural fluid.
Brief Hospital Course:
Ms. ___ is a ___ RH F w PMHx of prior left occipital
subdural hematoma in ___ and mild dementia who is readmitted to
___ currently in Neurology Stroke Service after presenting
with a breakthrough seizure at her rehab facility. Ms. ___
was recently admitted to the medicine service with neurology
consults following from ___ to ___, for new onset
complex partial seizures which was thought to be secondary to an
acute right subdural hematoma s/p fall.
Her seizure was most likely secondary to a missed dose of
lacosamide at the ___ center. We did not consider
this a failure of AEDs. While in the hospital, she was found to
have second degree heart block. We discontinued her lacosamide
and phenytoin for concerns that these medications could be
contributing to her heart block. She was seen by cardiology, who
introduced the possibility of placing a pacemaker. That evening,
the patient experienced an episode of asystole and was
transferred to the cardiac ICU. SHe underwent placement of a
pacemaker with EP cardiology. She tolerated the procedure well.
She was restarted on lacosamide, as the concerns for heart block
are resolved with the pacemaker in place. She will start on
lacosamide 100mg BID, to be advanced to 150mg BID in 7 days.
She was also noted to have evidence of cerebral edema on CT
head, for which she was started on dexamethasone. She will be
discharged to rehab with a taper schedule:
Please take 2mg (2 tabs) every 6 hours for 2 days,
then 1mg (1 tab) every 6 hours for 2 days,
then 1 mg twice a day for 2 days,
then 1mg daily for 1 day (your final dose).
She will be discharged to rehab for further care and
recuperation.
TRANSITIONAL ISSUES:
* dexamethasone taper for cerebral edema
* on lacosamide for seizures - will take 100mg BID x 7 days,
then 150mg BID ongoing
* s/p pacemaker placement by cardiology - will follow up with
cardiology
* follow up for CT head noncontrast and outpatient follow up
with neurology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO BID
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. Losartan Potassium 25 mg PO BID
6. Simvastatin 20 mg PO QPM
7. LACOSamide 100 mg PO BID
8. Phenytoin Sodium Extended 100 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Calcium Carbonate 500 mg PO BID
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Losartan Potassium 25 mg PO BID
5. Simvastatin 20 mg PO QPM
6. Aspirin 81 mg PO DAILY
7. Dexamethasone 2 mg PO Q6H Duration: 2 Days
Tapered dose - DOWN
RX *dexamethasone 1 mg 2 tablet(s) by mouth every 6 hours for 2
days Disp #*29 Tablet Refills:*0
8. Dexamethasone 1 mg PO Q6H Duration: 2 Days
Tapered dose - DOWN
9. Dexamethasone 1 mg PO Q12H Duration: 2 Days
Tapered dose - DOWN
10. Dexamethasone 1 mg PO DAILY Duration: 1 Day
Tapered dose - DOWN
11. LACOSamide 100 mg PO BID
Lacosamide 100mg twice a day for 7 days, then increase your dose
to Lacosamide 150mg twice a day.
RX *lacosamide [Vimpat] 100 mg 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
12. LACOSamide 150 mg PO BID
RX *lacosamide [Vimpat] 150 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
13. Famotidine 20 mg PO Q24H
RX *famotidine 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
seizures
heart block - second degree advancing to third degree
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ were hospitalized after experiencing a seizure in the
context of a recent head bleed. This can occur when blood from
the head bleed irritates the tissue.
While in the hospital, ___ were found to have a heart block,
which is a condition when the heart's electrical signaling does
not properly transmit. ___ were seen by cardiology and underwent
placement of a pacemaker to treat your heart block. ___
tolerated the procedure well.
We are changing your medications as follows:
* ___ are now taking lacosamide (vimpat) 100mg twice a day. ___
should continue this dosing for one week (7 days), and then
increase your dose to 150mg twice a day.
* ___ are also currently taking a steroid (dexamethasone) for
swelling around the brain. ___ will slowly decrease the dose of
the steroid over the course of 1 week.
Please take 2mg (2 tabs) every 6 hours for 2 days,
then 1mg (1 tab) every 6 hours for 2 days,
then 1 mg twice a day for 2 days,
then 1mg daily for 1 day (your final dose).
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
___ will have a CT of the head the morning before your neurology
follow up appointment.
If ___ experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- sudden partial or complete loss of vision
- sudden loss of the ability to speak words from your mouth
- sudden loss of the ability to understand others speaking to
___
- sudden weakness of one side of the body
- sudden drooping of one side of the face
- sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19937193-DS-8 | 19,937,193 | 28,366,652 | DS | 8 | 2135-06-03 00:00:00 | 2135-06-03 11:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
syncope and fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ year old female on 81 mg Aspirin a day who
states that she was standing at her kitchen counter when she
must
have fell. She is amnestic to the event and there was loss of
consciousness. The patient lives in her son's home. The
patient
denies tripping or mechanical fall. She does not report
dizziness or chest pain prior although she states that she
really
does not recall the event.
Currently she states that she has a slight headache and that she
feels "foggy". The patient denies weakness, numbness tingling
sensation or neck pain. She denies arm or leg pain. She denies
vision or hearing disturbance.
1 gram of Keppra was given as a loading dose prior to the
patient
arriving in the ___ ED.
Past Medical History:
HTN, elevated cholesterol, cardiac stent placed in ___ at
___, cataract surgery, cdiff, diverticulitis, LBBB
Social History:
___
Family History:
non contributory
Physical Exam:
PHYSICAL EXAM:
O: T:97.7 BP: 160/45 HR: 61 R: 19 O2Sats: 94 % r/a
Gen: WD/WN, comfortable, NAD.
HEENT:left head laceration- with one staple in place Pupils:
right irregular shape ( cataract surgery)reactive left 4->3mm
brisk reaction EOMs: intact
Neck: Supple.no point tenderness. no painful ROM noted
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils right irregular shape ( cataract surgery)reactive
left
4->3mm brisk reaction Visual fields are full to
confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing- patient has difficulty hearing at baseline
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Toes downgoing bilaterally
On the day of discharge:
Awake, alert, oriented x3, speech fluent, follows commands, MAE
full motor.
Pertinent Results:
Radiology Report CHEST (SINGLE VIEW) Study Date of ___ 2:58
___
Wet Read: ___ SAT ___ 5:31 ___
Widened mediastinum, which may be due to supine AP technique,
but if
clinically concerned for mediastinal or aortic injury, could
consider CT. WR communicated to Dr. ___ at 5:28 p.m. on
___hest ___:
IMPRESSION:
1. No evidence of aortic aneurysmal dilatation or other acute
findings. The finding of widened mediastinum on recent chest
radiograph appears to be attributable to a lateralized course of
the SVC.
2. Multiple very small peripheral pulmonary nodules bilaterally,
the largest measuring 4mm. In the absence of specific risk
factors for primary or secondary pulmonary malignancy, a
followup CT is recommended in 12 months. If risk factors are
known, followup in ___:
IMPRESSION:
1. New small amount of blood in the right collicular cistern.
No
hydrocephalus.
2. Unchanged subarachnoid hemorrhage involving the sylvian
fissures
bilaterally, parietal lobes bilaterally and left frontal lobe.
3. Unchanged left subdural hematoma.
4. No significant mass effect.
Echo:
The left atrium is elongated. Left ventricular cavity size and
regional/global systolic function are normal (LVEF >55%). There
is mild (non-obstructive) focal hypertrophy of the basal septum.
Right ventricular chamber size and free wall motion are normal.
The ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present.
Mild (1+) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. There is borderline
pulmonary artery systolic hypertension. There is no pericardial
effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic and mitral regurgitation. Borderline
pulmonary hypertension.
Carotid Ultrasound:
Findings: Duplex evaluation was performed of bilateral carotid
arteries. On the right there is no plaque in the ICA. On the
left there is no plaque in the ICA. Tortuous ICAs bilaterally.
On the right systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 63/13, 55/9, 66/8
cm/sec. CCA peak systolic velocity is 59 cm/sec. ECA peak
systolic velocity is 41 cm/sec. The ICA/CCA ratio is 1.4. These
findings are consistent with no stenosis.
On the left systolic/end diastolic velocities of the ICA
proximal, mid and distal respectively are 62/13, 80/20, 56/13
cm/sec. CCA peak systolic velocity is 70 cm/sec. ECA peak
systolic velocity is 74 cm/sec. The ICA/CCA ratio is 1.1. These
findings are consistent with no stenosis.
There is antegrade right vertebral artery flow.
There is antegrade left vertebral artery flow.
Impression: Right ICA with no stenosis.
Left ICA with no stenosis.
Brief Hospital Course:
This is a a ___ year old female on aspirin 81 mg status post fall
from standing at home. There was loss of consiousness and the
patient was amnestic to the event. The patient presented with a
___ from ___ that was consistent with SDH and
SAH. The patient had been loaded with Keppra 1 gram on the way
to the emergency department. The patient was given 1 pack of
platlets given daily aspirin. A CXR was performed on admission
and the prelimiary report was consistent with widened
mediastinum. A CT of the Chest was performed and nodules were
noted that will need a f/u CT in 12 months. The patient was
admitted to the ICU with q 1 hour neurological exam. The blood
pressure goal was systolic 100-160.
Patient was stable in the ICU. She was transferred to the floor
and underwent a syncope work up for her fall including an ECHO,
Cardiac enzymes which were flat and an EKG that showed a left
BBB and inferior wall MI. The patient's primary Cardiologist in
___ was contacted and we confirmed that the findings on her
EKG were not new. A carotid ultrasound was done and showed no
stenosis.
On ___ she was stable and doing well. She was cleared for d/c
to rehab and discharged.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Amlodipine 5 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Acetaminophen 325-650 mg PO Q12H:PRN headache
7. Bisacodyl 10 mg PO/PR DAILY
8. Docusate Sodium 100 mg PO BID
9. Heparin 5000 UNIT SC TID
10. LeVETiracetam 750 mg PO BID
11. Senna 2 TAB PO HS
12. Polyethylene Glycol 17 g PO DAILY
13. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN headache
14. Multivitamins 1 TAB PO DAILY
15. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
Subarachnoid hemorhage
Syncope
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 for Follow up for Subdural, Epidural or
Subarachnoid Hemorrhages
Non-Surgical
Dr. ___
Take your pain medicine as prescribed if needed. You do not
need to take it if you do not have pain.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
DO not take any anti-inflammatory medicines such as Motrin,
Aspirin, Advil, or Ibuprofen etc. until follow up.
You were on a medication Aspirin prior to your injury, you may
safely resume taking this when cleared by neurosurgery.
You have been discharged on Keppra (Levetiracetam) for
anti-seizure medicine, you will not require blood work
monitoring.
Do not drive until your follow up appointment.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
New onset of the loss of function, or decrease of function on
one whole side of your body.
Followup Instructions:
___
|
19937193-DS-9 | 19,937,193 | 29,759,889 | DS | 9 | 2135-06-10 00:00:00 | 2135-06-10 16:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Syncope and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with ___ HTN and HLD,
recently discharged on ___ s/p syncope complicated by ___
who presents from nursing home with a recurrent syncopal event.
She was having severe headaches earlier today. She was given 1
oxycodone and proceded to have a witnessed syncopal event which
was described as she become unresponsive while in bed, no apnea,
and she recovered. She was taken to ___ where she
was treated for headache. CT at OSH showed no new bleed. CXR
showed cardiomegaly and hypoinflated lungs. She also spiked a
rectal temp of 101.6 at OSH. Per family she has new cough today.
She has been given heparin this week for DVT prophylaxis.
In the ED, initial VS: 99.3 70 121/51 18 98%. Trop from ___
noted to be <0.02 and EKG without evidence of ischemia or
arrhythmia. The patient underwent CBC and chem 7 that were at
baseline. Urinalysis was negative. Blood cultures were drawn.
The patient was evaluted by neurosurgery, who felt the head CT
was improved from discharge. She was admitted to medicine for
evaluation of fever and syncope. VS prior to transfer: 99.5 68
129/65 18 95% RA.
On the floor patient reports she is feeling fine. She denies any
headache, lightheadedness, dizziness, chest pain, or SOB. She is
very tired and would like to sleep.
Review of sytems:
(+) Per HPI
(-) Denies chills, night sweats, recent weight loss or gain.
Denies sinus tenderness, rhinorrhea or congestion. Denies
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No dysuria. Denies arthralgias or myalgias. Ten
point review of systems is otherwise negative.
Past Medical History:
HTN
elevated cholesterol
cardiac stent placed in ___ at ___
cataract surgery
cdiff
diverticulitis
RBBB
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION:
Vitals- 99.1 152/52 90 22 91% RA
General- Alert, oriented x3, in no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1, S2, systolic murmur at
RUSB
Abdomen- soft, non-tender, non-distended, bowel sounds absent,
no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE:
VS: 98.1 149/62 71 22 97%RA
GEN: NAD, AOx3
HEENT: moist mucous membranes, oropharynx clear without erythema
or exudates, EOMI.
NECK: supple, JVP not elevated, no adenopathy or enlarged
thyroid.
CARDS: RRR, normal S1/S2, ___ systolic murmur at right upper
sternal border, no rubs or gallops
PULM: CTAB; no wheezes, rhonchi, rales, or increased work of
breathing
ABDOMEN: soft, NT/ND, +BS, no rebound/guarding
GU: no foley
EXT: warm and well perfused; 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rashes
NEURO: CN2-12 grossly intact, symmetrical muscle strength and
sensation. No focal neurologic deficits.
Pertinent Results:
ADMISSION:
___ 08:41PM BLOOD WBC-6.7 RBC-3.67* Hgb-11.2* Hct-32.8*
MCV-89 MCH-30.7 MCHC-34.3 RDW-13.0 Plt ___
___ 08:41PM BLOOD Neuts-72.0* ___ Monos-5.3 Eos-2.5
Baso-0.5
___ 08:41PM BLOOD ___ PTT-24.1* ___
___ 08:41PM BLOOD Glucose-92 UreaN-31* Creat-1.5* Na-140
K-4.0 Cl-106 HCO3-23 AnGap-15
___ 10:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:10PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 10:10PM URINE RBC-2 WBC-5 Bacteri-NONE Yeast-NONE Epi-5
DISCHARGE:
___ 06:35AM BLOOD WBC-5.6 RBC-3.75* Hgb-11.7* Hct-33.7*
MCV-90 MCH-31.3 MCHC-34.8 RDW-13.0 Plt ___
___ 06:35AM BLOOD ___ PTT-25.0 ___
___ 06:35AM BLOOD Glucose-106* UreaN-30* Creat-1.4* Na-137
K-4.0 Cl-101 HCO3-24 AnGap-16
___ 07:20AM BLOOD ALT-21 AST-34 AlkPhos-73 TotBili-0.5
___ 06:35AM BLOOD Calcium-9.4 Phos-3.4 Mg-2.2
MICROBIOLOGY:
- Blood cultures: no growth to date; final results pending.
STUDIES:
- Head CT ___:
1. No new areas of hemorrhage identified. Subarachnoid
hemorrhage involving the Sylvian fissures bilaterally has
resolved. Small amount of subarachnoid hemorrhage remains at the
left frontal lobe and parietal lobes bilaterally.
2. Interval decrease of left parietal subdural hematoma and
subgaleal hematoma.
- EEG: final report pending at time of discharge; no evidence of
seizures per neurology.
- EKG/telemetry: right bundle branch block at baseline, no new
evidence of ischemia or arrhythmias.
Brief Hospital Course:
Patient is a ___ year old female with hypertension,
hyperlipidemia, and recent admission for syncope complicated by
subdural hematoma/subarchnoid hemorrhage, who was admitted with
syncope and fever.
ACUTE:
# Recurrent syncope: No episodes since admission. Unclear
etiology, possibly orthostatics vs oxycodone-related. She was
discharged on ___ after syncope s/p fall with SAH/SDH. She was
orthostatic on admission and treated with IVF. Head CT showed no
new bleeds and improvement of a prior bleed. 24-hr EEG
monitoring showed no evidence of seizures. Syncopal work-up has
been negative to date (EKG/tele have not shown arrhythmic
events, ECHO and carotid duplexes were normal on last
admission). We suggest limiting pain medication to APAP + prn
tramadol.
# Persistent headaches: post-concussive vs. subdural
hematoma/subarachnoid hemorrhage. CT scan performed on ___
showed improvement in the bleed. The pateint was treated with
PO tylenol ___ TID for pain, with good effect.
# Confusion/mood lability/deconditioning: residual from SDH/___
vs. medication-related. As per family, the patient has not been
herself since suffering SDH/SAH; prior to that she was drving,
shopping, cooking and ambulating independently. At time of
SDH/SAH, she was presecibed keppra 750mg BID for seizure
prophylaxis and tylenol/fiorecet for headaches. On admission she
was intermittently confused, lethargic, moody, and with unsteady
gait. Geriatrics and neurology were consulted, and felt that
keppra was most likely the culprit. EEG monitoring showed no
evidence of seizures, so keppra was decreased to 500mg BID. She
will continue 500 mg BID for 1 week, then decrease to 250 mg BID
for 1 week, and then discontinue the keppra with planned
neurosurgery f/u. Her mental status and physical conditioning
markedly improved.
# Fever: unclear etiology. Early in admission she spiked to
101.6 and 101.1. Chest x-ray, urine analysis, blood cultures,
and WBC were normal. The patient was otherwise afebrile and not
treated with antibiotics.
# Constipation: the patient presented with 4-days of
constipation. She was treated with standing mirilax, senna and
colace, and PRN bisacodyl and was stooling daily at time of
discharge.
CHRONIC:
# CKD: Baseline creatinine 1.4-1.6; Cr during admission 1.4.
Medications were renally dosed and nephrotoxic agents were
avoided.
# Hypertension: continued amlodipine, atenolol, and losartan.
# CAD s/p IMI: continued atenolol, losartan, and simvastatin.
# GERD: continued lansoprazole.
TRANSITIONAL:
- removal of head staples at rehabilitation on ___
- follow-up with neurosurgery on ___ at 8:45 AM
- continue keppra taper per discharge medication list
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
4. Losartan Potassium 25 mg PO DAILY
5. Simvastatin 20 mg PO DAILY
6. Acetaminophen 325-650 mg PO Q12H:PRN headache
7. Bisacodyl 10 mg PO/PR DAILY
8. Docusate Sodium 100 mg PO BID
9. Heparin 5000 UNIT SC TID
10. LeVETiracetam 750 mg PO BID
11. Senna 2 TAB PO HS
12. Polyethylene Glycol 17 g PO DAILY
13. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN headache
14. Multivitamins 1 TAB PO DAILY
15. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN headache
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN headache
2. Amlodipine 5 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. LeVETiracetam 500 mg PO BID Duration: 6 Days
You will take 500 mg BID until ___ (for a total of 7 days).
6. LeVETiracetam 250 mg PO BID Duration: 7 Days
You will take 250 mg BID from ___ until ___, for a total
of 7-days.
RX *levetiracetam 250 mg 1 tablet(s) by mouth twice a day Disp
#*14 Tablet Refills:*0
7. Losartan Potassium 25 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 2 TAB PO HS
10. Simvastatin 20 mg PO DAILY
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
12. Docusate Sodium 100 mg PO BID
13. Heparin 5000 UNIT SC TID
14. Multivitamins 1 TAB PO DAILY
15. TraMADOL (Ultram) 25 mg PO BID:PRN headache
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: recurrent syncope, polypharmacy-induced confusion
Secondary: hypertension, hyperlipidemia
**The patient does not tolerate narcotics, benadryl, or
fiorecet**
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 ___,
It was a pleasure taking care of you during your admission at
___. You were admitting because you
fainted in bed and had a fever. A repeat image of your head
showed no new bleeds, and improvement of the bleed you sustained
during your previous admission. You were monitored for seizures,
which you did not have. Your heart function was also monitored
and showed no abnormalities. We managed your headaches with
tylenol. Your keppra was decreased from 750 mg BID to ___ mg BID
because we determined that you were not having seizures. You
will take 500 twice daily for 1 week. Then on ___, you
will decrease the keppra to 250 mg twice daily and continue this
for 1 week. On ___ you will stop take keppra. You will
then need to followup with neurosurgery in their clinic.
You are being discharged to rehabilitation; they will remove
your staples ___. You will follow-up with neurosurgery on
___. We also recommend that you make an appointment with
your podiatrist to follow-up regarding the skin lesion on your
right big toe.
Best wishes!
Followup Instructions:
___
|
19937419-DS-15 | 19,937,419 | 28,594,237 | DS | 15 | 2136-03-04 00:00:00 | 2136-03-04 20:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old M PMHx of myocardial infarction
s/p CABGx4 (___) complicated by anoxic brain injury with
aggressive behavior, CKD (stage IV) and chronic abdominal pain
presents from ___ with increased confusion and
abdominal pain. Patient was admitted to ___ 2 days ago where
he was being treated for bilateral lower extremity cellulitis
and RUL PNA and was discharged on ___. Patient arrived at
the rehabilitation facility in the afternoon and then developed
left upper quadrant abdominal pain, delirium, and tremors which
concerned him. At that time BG was 137. At that time is BP was
found to be 190/90. Per report his mental startus was waxing and
waning. Patient was transferred to ___ for further evaluation.
Patient has been unable to provide any other history due to his
anoxic brain injury.
Of note at ___ he was found to have WBC of 16.7 and was
found to have ___ cellulitis for which he was treated with broad
spectrum abx. He had negative Urine and blood Cx. He then was
found to have a RUL PNA. He was then discharged on keflex and
azithromycin but azithromycin was stopped due to an interaction
with zyprexa.
Of note patient had a recent admission to ___ from ___
and discharged on ___ for acute kidney injury, hypertension,
hypernatremia, elevated blood sugars from diabetes, and his
known anoxic encephalopathy. At that time he was discharged to
___
on the ___.
In the ED intial vitals were: 0 99.7 90 170/80 16 94% 2L Nasal
Cannula.
- Labs were significant for WBC 13.6 with PMNs 82.7%. H/H
10.6/34. K 5.4, Cr 3.1 (baseline of 2.5).
Patient had a negative CT scan abd/pelvis 2 days ago and has a
history of chronic abdominal pain so no further imaging
performed.
- Patient was given olanzapine 5mg x1
Vitals prior to transfer were:99.5 88 183/73 16 95% RA
On the floor patient reports he feels much better. He does not
feel confused. He stated he was sent in because the doctors were
concerned that he had abdominal pain. He states he continues to
have abdominal pain which is chronic. He states he has not had a
bowel movement in 4 days. No recent fevers. Reports some chills.
No nause, vomiting or diarrhea.
Past Medical History:
Urinary incontinence
chronic constipation
CKD stage IV with baseline cre 2.5
CAD s/p MI and 4V CABG complicated by anoxic brain injury
HTN
DM1
arthritis
HLD
Hypothyroidism
GERD
peripheral neuropathy
OSA
Social History:
___
Family History:
Mother with dementia (currently at ___).
Physical Exam:
=====================
ADMISSION
=====================
Vitals: T:98.2 BP:170/76 HR:82 RR:20 02 sat:98%RA
GENERAL: WD WN male comfortable in NAD
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, no LAD
CARDIAC: RRR, S1, S2, no murmurs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness in LUQ and RUQ, no
rebound/guarding
EXTREMITIES: moving all extremities well, no edema, erythema
overlying shins bilaterally which is tender to palpation
PULSES: 2+ DP pulses bilaterally
Neuro: sleepy but interactive Ox3, CNII-XII grossly inact, ___
forward but not backward, asterixis
======================
DISCHARGE
======================
Vitals: T:98.5 BP:150/71 HR:82 RR:20 02 sat:98%RA
GENERAL: WD WN male comfortable in NAD
HEENT: AT/NC, PERRL, anicteric sclera, pink conjunctiva, patent
nares, MMM, JVP mildly elevated
CARDIAC: RRR, S1, S2, no murmurs, rubs, or gallops
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness in LUQ and RUQ, no
rebound/guarding
EXTREMITIES: moving all extremities well, no edema, erythema
overlying shins bilaterally which is tender to palpation
PULSES: 2+ DP pulses bilaterally
Neuro: AAOx3, CNII-XII grossly inact, able to say ___ forward
and backward, no asterixis
Pertinent Results:
================
ADMISSION
================
___ 10:15PM WBC-13.6*# RBC-3.67* HGB-10.6* HCT-34.0*
MCV-93 MCH-28.9 MCHC-31.2 RDW-14.3
___ 10:15PM NEUTS-82.7* LYMPHS-9.6* MONOS-6.7 EOS-0.6
BASOS-0.3
___ 10:15PM ___ PTT-32.8 ___
___ 10:15PM GLUCOSE-153* UREA N-47* CREAT-3.1* SODIUM-141
POTASSIUM-5.4* CHLORIDE-105 TOTAL CO2-23 ANION GAP-18
___ 10:23PM LACTATE-1.9
___ 10:55PM URINE RBC-5* WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 10:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
===============
DISCHARGE
===============
___ 07:15AM BLOOD WBC-7.8 RBC-2.94* Hgb-8.5* Hct-27.5*
MCV-94 MCH-28.9 MCHC-30.9* RDW-14.3 Plt ___
___ 07:15AM BLOOD Glucose-234* UreaN-57* Creat-3.2* Na-140
K-5.2* Cl-105 HCO3-23 AnGap-17
___ 07:15AM BLOOD Calcium-7.9* Phos-4.0 Mg-2.1
===============
STUDIES
===============
___ CXR IMPRESSION: Relatively unchanged right upper lobe
pneumonia. New or increased left pleural effusion.
Brief Hospital Course:
___ year old M PMHx of myocardial infarction s/p CABGx4 (___)
complicated by anoxic brain injury with aggressive behavior, CKD
(stage IV) and chronic abdominal pain presents from
rehabilitation with increased confusion and abdominal pain.
# AMS: Reported to be confused but on arrival is alert and
oriented at this time. During his hospital stay the patient was
not significantly delerious, only sleepy. At times, he would
appear to fall asleep during conversation, sometimes with little
warning. It did not appear that his mental status was
significantly off his baseline when he was awake and talking.
Unlikely to be infectious in nature given his ___ exam is more
likely venous stasis and he had no symptoms of PNA such as
productive cough, fever, or new oxygen requirement. Would
consider the most etiology being a primary sleep disturbance
such as narcolepsy. Recommend repeated outpatient sleep study.
Patient has known diagnosis of sleep apnea which may be playing
a role and he should be consider for CPAP fitting. Would try to
normalize the patient's sleep and wake cycles.
# Cellulitis: On clinical exam, suspicion of cellulitis is much
less likely and this appears to be more likely venous stasis
given its appearance and bilateral nature. He will not need
further antibiotics to treat this.
# LUQ Abdominal pain: Pt with chronic abdomninal pain at
baseline. He presented to ___ on ___ with similar
complaints. He had a CT A&P which did not show any acute
pathology. No further imaging studies were repeated here. The
patient reported a history of significant constipation and his
bowel regimen was uptitrated until he had a large bowel
movement. THen he stated that he had similar abdominal pain for
years and that he felt that he was currently at his baseline.
# AoCKD: Pt with Cr of 3.1 up from baseline of 2.5-2.7 likely in
setting of diuresis. This reflects a minor change in GFR. UA
not consistent with infection. Had unremarkable renal US on
___. His diuretics were held while he was admitted and his
Cr remained stable. He should resume them upon discharge.
# DM:
- continue lantus and HISS
# HTN: ___ with BP of 190/90 at rehab now with SBP in 170s
- restart home BP regimen with exception of ACEI given
hyperkalemia
# Hyperkalemia: ECG without acute changes of hyperkalemia
TRANSITIONAL ISSUES:
- outpatient sleep study evaluation
- recommend rechecking chem10 in 1 week from discharge
- consider restarting lisinopril with repeat potassium
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Bacitracin Ointment 1 Appl TP QID
3. FoLIC Acid 1 mg PO DAILY
4. Venlafaxine 75 mg PO BID
5. Valproic Acid ___ mg PO QHS
6. Valproic Acid ___ mg PO QAM
7. Senna 2 TAB PO BID
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Omeprazole 20 mg PO DAILY
10. OLANZapine (Disintegrating Tablet) 5 mg PO QHS
11. Multivitamins 1 TAB PO DAILY
12. Metoprolol Succinate XL 125 mg PO DAILY
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY
15. Docusate Sodium 100 mg PO BID
16. Calcitriol 0.25 mcg PO 3X/WEEK (___)
17. Bisacodyl 10 mg PO DAILY:PRN constipation
18. Atorvastatin 80 mg PO DAILY
19. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indegestion
20. Acetaminophen 650 mg PO Q6H:PRN pain
21. Nitroglycerin SL 0.3 mg SL PRN chest pain
22. Lisinopril 20 mg PO DAILY
23. Amlodipine 5 mg PO HS
24. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
25. Furosemide 40 mg PO DAILY
26. Cephalexin Dose is Unknown PO Q8H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indegestion
3. Amlodipine 5 mg PO HS
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Bacitracin Ointment 1 Appl TP QID
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Calcitriol 0.25 mcg PO 3X/WEEK (___)
9. Docusate Sodium 100 mg PO BID
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Glargine 28 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
13. Levothyroxine Sodium 50 mcg PO DAILY
14. Metoprolol Succinate XL 125 mg PO DAILY
15. Multivitamins 1 TAB PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Polyethylene Glycol 17 g PO DAILY:PRN constipation
18. Senna 2 TAB PO BID
19. Valproic Acid ___ mg PO QHS
20. Valproic Acid ___ mg PO QAM
21. Venlafaxine 75 mg PO BID
22. Furosemide 40 mg PO DAILY
23. Nitroglycerin SL 0.3 mg SL PRN chest pain
24. OLANZapine (Disintegrating Tablet) 5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Obstructive sleep apnea
Chronic kidney disease, stave IV
Hyperkalemia
Chronic abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive, sometimes
lethargic but arousable
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear. Mr. ___,
You were admitted to ___ from rehab because there were
concerns about your abdominal pain and possible confusion. Upon
arrival here it was noted that you were not confused, but that
you were sleepy and would sometimes fall asleep during
conversation. There is concern that this may be related to
narcolepsy or sleep apnea and you should have another sleep
study and consider starting CPAP at night. You had a CAT scan
two days prior to admission for abdominal pain that did not find
any worrisome findings of the abdominal pain. While here, you
felt your abdominal pain was at baseline. We gave you multiple
laxitives so that you would have a bowel movement.
Followup Instructions:
___
|
19937419-DS-16 | 19,937,419 | 24,524,345 | DS | 16 | 2136-07-05 00:00:00 | 2136-07-05 16:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
agitation
Major Surgical or Invasive Procedure:
Midline placement ___
History of Present Illness:
Mr. ___ is a ___ with PMH anoxic brain injury due to
complications for MI s/p CABG x 4 (___), intermittent
aggressive behavior, IDDM, CKD (baseline cr around 3), HTN,
transferred from ___ today after sent from ___ on
___ with aggressive behavior. Per ___
staff, he threw a glass vase, punched and verbally abusive
towards staff. He does not remember anything about this. Prior
to the event, he has been taking his meds but refused insulin
during the day. He did have evening lantus dose on ___. He was
sent on ___ to ___ for further eval and management.
He has experienced several falls last week while raising from
bed and sustained scrapes on forehead and legs.
In the ___, labs were notable for Na 130, K+5.8, Bicarb
20, Glu 528, BUN/Cr 67/3.95. Ua with glucose but otherwise
unremarkable. Tox screen negative. EKG was sinus, old Q waves in
inferior leads, old ST depression in lateral leads with no
peaked t's. Received 1amp Ca gluconate, 10u insulin, 1 amp D5 by
___. He was planned for admit to ___ however
hospitalist there felt given psych comorbidities and aggressive
behavior would be better transferred to ___.
On arrival to the ___, vitals were 98.3 72 186/80 16 100% RA.
Labs notable for an improved k+ to 5.1, glucose 313. He received
an additional 8u insulin and 1L NS. He was also given 1g vanc
for possible b/l lower extremity cellulitis. Overnight, he was
not agitated. This morning, he complains of a sore throat and
some runny nose. Patient denies fever, CP/SOB, abdominal pain,
N/V/D. He does not remember his falls or his agitation episodes.
Past Medical History:
Urinary incontinence
chronic constipation
CKD stage IV with baseline cre 3
CAD s/p MI and 4V CABG complicated by anoxic brain injury c/b
agitation
HTN
DM1
arthritis
HLD
Hypothyroidism
GERD
peripheral neuropathy
OSA
Social History:
___
Family History:
Mother with dementia (currently at ___).
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 152/90 P89 22 100% RA
GENERAL: NAD, A&Ox2 (does not know place)
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, 2 superficial traumatic excoriations over left
forehead, near eyebrow, no surrounding erythema/edema, MMM, good
dentition, nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, b/l erythema over
shins with some blisters and superficial skin breakdown on left
leg.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, alert, oriented to person but not to
place or events, tangential, answers ROS questions
inconsistently, poor memory, poor historian
SKIN: warm and well perfused, lesions as noted above
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2/97.5 143/50 74 18 100% on RA
General: Sleeping, oriented to self but may be volitional that
he does not answer ROS questions, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear (no
erythema/exudate), no sinus tenderness, has 2 small scrapes over
left forehead near eyebrow (pt without pain or headache)
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Distant heart sounds, 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, has bilateral chronic
appearing redness and venous stasis changes, has 2 superficial
excoriations over left knee, no joint effusion or erythema. Has
bilateral stage I pressure ulcers on heels, now in waffle boots.
Skin: As above. Back without pressure ulcers.
Neuro: Waxing and waning alertness. Sometimes agitated but cools
down when left alone for a while. Has not displayed violent
behavior.
Pertinent Results:
ADMISSION LABS:
___ 08:00AM BLOOD WBC-8.5 RBC-3.36* Hgb-9.8* Hct-32.2*
MCV-96 MCH-29.2 MCHC-30.5* RDW-14.7 Plt ___
___ 12:15AM BLOOD Glucose-313* UreaN-59* Creat-3.7* Na-142
K-5.1 Cl-107 HCO3-21* AnGap-19
___ 08:00AM BLOOD Phos-3.5 Mg-2.0
DISCHARGE LABS:
___ 08:20AM BLOOD WBC-9.3 RBC-3.80* Hgb-11.0* Hct-36.8*
MCV-97 MCH-29.1 MCHC-30.0* RDW-14.6 Plt ___
___ 08:00AM BLOOD Glucose-160* UreaN-53* Creat-3.5* Na-144
K-5.1 Cl-111* HCO3-23 AnGap-15
___ 08:00AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.2
MICROBIOLOGY:
___ 11:38 am URINE Source: Catheter.
URINE CULTURE (Final ___:
PROTEUS MIRABILIS. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PROTEUS MIRABILIS
| ESCHERICHIA COLI
| |
AMPICILLIN------------ =>32 R 4 S
AMPICILLIN/SULBACTAM-- 8 S <=2 S
CEFAZOLIN------------- 8 R <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
IMAGING:
*************** ___ CT HEAD *****************
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Evaluate for subdural bleed
TECHNIQUE: Contiguous axial images MDCT images of the brain
were obtained
without intravenous contrast. Coronal and sagittal as well as
thin
bone-algorithm reconstructed images were obtained. The scan was
repeated due
to severe patient motion.
DLP: 1226 mGy-cm
COMPARISON: Head CT dated ___.
FINDINGS:
There is no hemorrhage, edema, mass effect, midline shift, or
mass. Prominence
of ventricles and sulci as indicative of age-advanced
involutional change.
Periventricular and subcortical white matter hypodensities are
nonspecific but
most likely due to chronic small vessel ischemia. Focal
hypodensity in the
left thalamus likely represents a prior lacunar infarct.
Encephalomalacia
adjacent to the occipital horns bilaterally are indicative of
chronic
infarcts. The basal cisterns are patent and there is normal
gray-white matter
differentiation.
No bony abnormalities seen. The paranasal sinuses, mastoid air
cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
Sequela of chronic small vessel ischemic disease and evidence of
prior
infarcts, but no evidence of subdural fluid collection.
*************** ___ CT HEAD *****************
ABNORMALITY #1: In the fully awake state, an evenly modulated
___ Hz theta
frequency background was seen.
BACKGROUND: As above.
HYPERVENTILATION: Was contraindicated due to the patient's
history of anoxic
brain injury.
INTERMITTENT PHOTIC STIMULATION: Could not be performed as the
test was
requested as a portable study.
SLEEP: The patient progressed from wakefulness through
drowsiness but failed
to achieve stage II sleep; no abnormalities were seen with this.
CARDIAC MONITOR: Revealed a generally regular rhythm with
average rate of 72
bpm.
IMPRESSION: This is a mildly abnormal EEG due to the presence of
a slower
than average background rhythm. This type of finding can be seen
in the
presence of a mild encephalopathy of toxic, metabolic, or anoxic
etiology.
It may also be seen in the context of significant bilateral or
deeper midline
subcortical lesions. No evidence of ongoing or potential
epileptogenesis was
seen at the time of this recording. No asymmetries of amplitude
or frequency
were present. If clinically warranted to assess intermittent
symptoms,
continuous EEG recording may provide additional diagnostic
information.
*************** ___ CXR *****************
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man poor historian, has anoxic brain
injury, now with
question of change in mental status. Need to rule out infection.
// Evaluate
for infection
TECHNIQUE: Portable chest
COMPARISON: ___
FINDINGS:
There is volume loss in both lower lungs. Early infiltrates in
these regions
cannot be excluded. Compared to the study from 4 months ago the
right upper
lobe process has resolved the heart continues to be mildly
enlarged. Sternal
wires are again seen. Mediastinal clips are again visualized.
There are tiny
bilateral pleural effusions
IMPRESSION:
Volume loss/early infiltrates in both bases.
Brief Hospital Course:
Mr. ___ is a ___ with PMH anoxic brain injury due to
complications for MI s/p CABG x 4 (___), intermittent
aggressive behavior, IDDM, CKD (baseline cr around 3), HTN,
transferred from ___ to ___ for further management of
agitation and hyperglycemia.
ACTIVE ISSUES:
# Agitation, waxing and waning delirium: Agitation was well
controlled on admission. He has waxing and waning mental status,
sometimes quite sleepy and sometimes awake and agitated, without
much of a pattern. Upon arrival, he had hyperglycemia to 500s
and ___, which may have contributed to his presenting symptoms
of agitation. Conversations with his sister and his care manager
___ suggested that his current mental status is at baseline.
Given that he had recent history of falls over the past week at
his nursing home, he underwent head CT, which was negative for
acute process. The patient had a few staring spells that were
observed, so EEG was done to rule out post-ictal confusion as a
cause of waxing and waning mental status. EEG shows slowing c/w
known anoxic brain injury and delirium, but does not show clear
epileptogenic foci. Psychiatry evaluated the patient and
suggested to continue with home valproate and olanzipine, and to
add haldol 1mg PO BID:prn agitation. Urine culture from ___ was
then positive, and so could have contributed to delirium.
Treatment of UTI is as below.
The patient is now being discharged to rehab with midline for IV
access.
# Urinary tract infection: Urine culture from ___ grew proteus
> 100,000 colonies and E coli 10,000-100,000 colonies. It was
sensitive to IV ceftriaxone. Treatment should be a total 7 day
course, which started ___. Last day of treatment is ___.
After finishing antibiotics, midline should be removed (in right
arm).
# Hyperglycemia/DM I: No evidence of DKA at this time with
closing AG and no ketones on UA. Most likely related to refusal
of insulin and additionally not being on an adequate dose. Per
last dc summary, he had been discharged on 26u lantus in the
evening. The ___ home transfer sheet only indicates he is on
6u. While inpatient, his sugars were quite difficult to control.
Initially he was well controlled with 20u lantus QHS and sliding
scale, but then due to waxing and waning mental status did not
have consistent PO intake, and fingersticks were ~40 for 2
mornings. He was discharged on his home insulin of 6u lantus and
sliding scale. Depending on his PO intake, this may require
titration by his outpatient and rehab providers.
# ___: On admission Cr was 3.7, and trended down to 3.2-3.5,
which is his baseline. Initial Cr elevation was most likely
related to osmotic diuresis secondary to hyperglycemia given
serum glucose over 500 at ___ and urine glucose over 300.
Insulin was uptitrated as above. The patient should be continued
on a low potassium diet (2gm per day). He is followed by Dr.
___ at ___ and has a left AV fistula for
possible initiation of hemodialysis in the future. No urgent
indication for dialysis this admission.
#Hyperkalemia: Now resolved to 5.1 with no ECG changes. Most
likely ___ ___ and hyperglycemia. The patient should continue on
a low potassium diet (2gm K) as above.
CHRONIC ISSUES:
# Question of bilateral cellulitis per ___: Appears to be chronic
changes related to PVD. Appears unchanged from prior based on DC
physical exam. Would favor holding further abx.
#CAD: No new ECG changes and pt denies any recent CP. Continued
home metoprolol, aspirin, atorvastatin. Not on ACE ___ hx of
hyperkalemia.
#HTN: Elevated on admission in setting of not receiving
antihypertensives this evening. Has been difficult to control in
past. SBP 150s while inpatient. Continued home amlodipine.
#Hypothyroidism: Continued home levothyroxine
#GERD: Continued home omeprazole
TRANSITIONAL ISSUES:
# Urinary tract infection: Urine culture from ___ grew proteus
> 100,000 colonies and E coli 10,000-100,000 colonies. Treatment
should be a total 7 day course of IV ceftriaxone, which started
___. Last day of treatment is ___. After finishing
antibiotics, midline should be removed (in right arm).
# Agitation: Although the patient displayed bouts of agitation,
in general these resolved by having staff leave the room and
letting the patient calm down by himself. He did received IV
haldol 0.5mg x 1 for agitation, but his psych meds were not
changed on discharge. Inpatient psychiatry suggested possibly
adding haldol 1mg PO BID:PRN agitation. This can be considered
based on mental status at rehab.
# Insulin: The patient is a type I diabetic with difficult to
control sugar due to waxing and waning mental status and
therefore inconsistent PO intake. He is being discharged on
insulin lantus 6u QHS and sliding scale but this may need
further titration as an outpatient.
# Renal failure: Per care manager ___, patient had fistula
created in left arm ___ weeks ago, so blood pressure should only
be done on the right arm. He should continue to follow up with
his outpatient nephrologist for his renal failure. No urgent
need for hemodialysis this admission.
# Code: DNR/DNI
# Emergency Contact: ___ (sister) Cell phone:
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indegestion
3. Amlodipine 7.5 mg PO HS
4. Aspirin 325 mg PO DAILY
5. Atorvastatin 80 mg PO DAILY
6. Bacitracin Ointment 1 Appl TP QID
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Calcitriol 0.25 mcg PO 3X/WEEK (___)
9. Docusate Sodium 100 mg PO BID
10. Fluticasone Propionate NASAL 1 SPRY NU DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Levothyroxine Sodium 75 mcg PO DAILY
13. Metoprolol Succinate XL 125 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Valproic Acid ___ mg PO QHS
18. Valproic Acid ___ mg PO QAM
19. Nitroglycerin SL 0.3 mg SL PRN chest pain
20. OLANZapine (Disintegrating Tablet) 15 mg PO QHS
21. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY
22. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Amlodipine 7.5 mg PO HS
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Bacitracin Ointment 1 Appl TP QID
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Calcitriol 0.25 mcg PO 3X/WEEK (___)
7. Docusate Sodium 100 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Metoprolol Succinate XL 125 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. Nitroglycerin SL 0.3 mg SL PRN chest pain
14. OLANZapine (Disintegrating Tablet) 15 mg PO QHS
15. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 8.6 mg PO BID
18. Valproic Acid ___ mg PO QHS
19. Valproic Acid ___ mg PO QAM
20. Milk of Magnesia 30 mL PO Q6H:PRN constipation
21. Acetaminophen 650 mg PO Q6H:PRN pain
22. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indegestion
23. CeftriaXONE 1 gm IV Q24H
24. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
25. Glargine 6 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
- Delirium
- Toxic-metabolic encephalopathy
- Hyperosmolar hyperglycemia
- Acute on chronic renal failure
- Hyperkalemia
- Urinary tract infection
SECONDARY DIAGNOSES
- Type I Diabetes Mellitus
- Bilateral stage I pressure ulcers, heels
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were agitated at
your nursing home. On arrival, we found that your blood sugars
were very high and this may have worsened your renal function.
You received better blood sugar control and fluids, which helped
improve your renal function back to baseline. You also had a
urinary tract infection, which is being treated by IV
antibiotics. You are now being discharged to rehab.
We wish you the best,
Your ___ Team
Followup Instructions:
___
|
19937419-DS-17 | 19,937,419 | 21,585,853 | DS | 17 | 2136-07-14 00:00:00 | 2136-07-15 06:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status, hypoxia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH anoxic brain injury due to complications for MI s/p
CABG x 4 (___), intermittent aggressive behavior, IDDM, CKD
(baseline cr around 3), HTN, and recent admission to ___ from
___ for delirium secondary to UTI and ___ now re-presents
from Radius rehab with worsening mental status and hypoxia. Per
report from rehab MD, he was initially interactive with staff
there. Then 2 days prior to presentation he became more altered
and developed new O2 requirement. WBC was also found to have
25,000 so they began treatment for HCAP with vancomycin and
zosyn. Yesterday he was progressively more altered/somnolent and
hypoxic to 86% on 2L, so he was referred to the ED for further
evaluation. His FSBS was 530 prior to transfer, so he was given
unknown dose of Humalog and transferred here for further
evaluation.
On arrival to the ER, initial VS were: 90, 138/72, 16, 99% 10L.
On arrival patient is somnolent but arousable to sternal rub,
withdraws and yells w/ IV insertion. Patient did not verbalize
complaints. Labs notable for WBC 19.6, Cr 4.0 (baseline 3.0), K
>10 (grossly hemolyzed), normal lactate 1.5, glucose 445. UA not
suggestive of infection. K was 4.8 once good non-hemolyzed
specimen was obtained. EKG was with out acute changes or peaked
T waves. CXR with small lung volumes but no obvious infiltrates,
however CT chest non-con showed bibasilar infiltrates R>L
concerning for pneumonia. CT head was without any acute
abnormalities, and bilateral LENIs given concern for possible PE
which were negative. O2 sats improved and he was able to wean
down to 6L this AM in the ER. He was continued on vancomycin and
zosyn for PNA. He was transferred to the ICU for further
management given poor mental status and high oxygen requirement.
On arrival in the ICU, the patient is not cooperative, unable to
answer questions.
Past Medical History:
Urinary incontinence
chronic constipation
CKD stage IV with baseline cre 3
CAD s/p MI and 4V CABG complicated by anoxic brain injury c/b
agitation
HTN
DM1
arthritis
HLD
Hypothyroidism
GERD
peripheral neuropathy
OSA
Social History:
___
Family History:
Mother with dementia (currently at ___).
Physical Exam:
ADMISSION EXAM:
Vitals- T: BP: P: R: 18 O2:
General: middle aged man lying in bed with eyes closed, agitated
with any interventions
HEENT: Will not open his eyes, dry MM with a lot of dried
secretions on his tongue
Neck: supple
Lungs: Taking small breaths so ascultation is limited but has
diminished breath sounds in bilateral bases with rhonchi, some
rales in right base.
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
GU: foley in place
Ext: cool, thin, multiple scabs and bruises especially on knees.
Neuro: not able to answer questions or follow commands, just
yelling out with care, difficult to redirect.
DISCHARGE EXAM:
Vitals: Tc98.4 156/96(116/68-156/96) 112 20 96% on RA
General: Middle-aged man lying in bed with eyes closed, snoring;
Tremulous; NAD
HEENT: PERRL; dry lips, unable to observe oral mucosa
Neck: Supple, no LAD
Lungs: Limited due to pts mental status; Diminished breath
sounds possibly due to somnolence; Improved rhonchi with
occasional expiratory wheeze in anterior lung fields; No
crackles; No evidence of increased WOB
CV: S1S2 auscultated, Tachycardic
Abdomen: Soft, non-distended; pt grimaces with palpation of RLQ;
+BS
Ext: Multiple excoriations with crust; Cool; Diminished distal
pulses b/l; No edema
Neuro: A+Ox0, drowsy; Grimaces with touch
Pertinent Results:
ADMISSION LABS:
___ 02:35AM BLOOD WBC-19.6*# RBC-3.23* Hgb-9.6* Hct-31.4*
MCV-97 MCH-29.8 MCHC-30.6* RDW-15.0 Plt ___
___ 02:35AM BLOOD Neuts-85* Bands-1 Lymphs-11* Monos-3
Eos-0 Baso-0 ___ Myelos-0
___ 02:35AM BLOOD ___ PTT-34.4 ___
___ 02:35AM BLOOD Glucose-447* UreaN-63* Creat-4.0* Na-139
K-GREATER TH Cl-108 HCO3-22
___ 06:45PM BLOOD Glucose-273* UreaN-63* Creat-4.0* Na-150*
K-5.0 Cl-116* HCO3-23 AnGap-16
___ 02:35AM BLOOD ALT-24 AST-131* AlkPhos-98 TotBili-0.3
___ 02:35AM BLOOD Lipase-15
___ 02:35AM BLOOD cTropnT-0.05*
___ 02:35AM BLOOD Albumin-2.8* Calcium-8.7 Phos-5.3*
Mg-2.7*
___ 03:51AM BLOOD D-Dimer-992*
___ 02:35AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:38AM BLOOD ___ pO2-65* pCO2-34* pH-7.44
calTCO2-24 Base XS-0 Comment-GREEN TOP
___ 09:19AM BLOOD Type-ART Temp-37.7 pO2-75* pCO2-37
pH-7.39 calTCO2-23 Base XS--1 Intubat-NOT INTUBA
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-6.8 RBC-2.79* Hgb-8.0* Hct-27.4*
MCV-98 MCH-28.6 MCHC-29.2* RDW-14.7 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD
___ 06:30AM BLOOD Glucose-338* UreaN-40* Creat-2.9* Na-145
K-4.2 Cl-114* HCO3-23 AnGap-12
___ 06:30AM BLOOD Calcium-8.3* Phos-3.2 Mg-2.2
___ 06:00AM BLOOD Valproa-35*
___ 06:06AM BLOOD Vanco-13.6
IMAGING:
Bilateral Lower Extremity Duplex (___): No evidence of DVT
in the right or left lower extremity veins.
CT Head w/o Contrast (___): 1. No acute intracranial
abnormality.
2. Global atrophy, sequelae of chronic small vessel ischemic
disease, and right more than left parieto-occipital
encephalomalacia, unchanged since ___, related to remote
infarction.
CXR Portable (___): 1. Possible left retrocardiac opacity
may reflect pneumonia in the right clinical setting. 2. Possible
fractured or minimally displaced superior median sternotomy
wire. Please correlate for site of pain, if any, on physical
exam.
CT Chest w/o contrast ___: 1. Right lower lobe opacity
with air bronchograms concerning for pneumonia. Bibasilar
atelectatic changes.
2. 6 mm left lower lobe nodule. In the absence of risk factors
or history of smoking, per ___ criteria, a followup chest
CT is recommended in 12 months, otherwise ___ month followup is
suggested.
MICROBIOLOGY:
___ 1:45 pm URINE Site: CATHETER Source: Catheter.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
__________________________________________________________
___ 1:55 pm MRSA SCREEN Site: NARIS (NARE)
Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
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 in
MCG/ML
_________________________________________________________
POSITIVE FOR METHICILLIN RESISTANT
STAPH AUREUS
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
__________________________________________________________
___ 2:45 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 2:45 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 2:35 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
___ y/o male with PMH anoxic brain injury due to complications
for MI s/p CABG x 4 (___), intermittent aggressive behavior,
IDDM, CKD (baseline cr around 3), HTN, and recent admission to
___ from ___ for delirium secondary to UTI and ___ now
re-presents from Radius rehab with worsening mental status and
hypoxia, currently day 6 of antibiotics on vanc/cefepime for
treatment of pneumonia.
ACTIVE ISSUES
# Pneumonia: Pt presented with worsening hypoxia from Radius
Rehab on vanc/zosyn (started ___ for the treatment of HCAP vs
aspiration pneumonia. On initial presentation to the Emergency
Department, the patient was hypoxic (80s) and somnolent,
requiring 100% O2 on facemask. Due to oxygen requirement and
altered mental status, he was transferred to the ICU. A CT scan
was obtained which showed a right lower lobe opacity with air
bronchograms concerning for pneumonia. Legionella urinary
antigen was negative. He was continued initially on vanc/zosyn
and levaquin was added to broaden coverage. In the ICU, his
respiratory status improved and he was weaned to 2L NC and
transferred to the floor. Prior to transfer, the patient's
antibiotics were changed to vanc/cefepime. On the floor patients
respiratory status continued to improve, and he was weaned to
room air. Throughout hospitalization also received standing
albuteral/ipratropium nebs. Had multiple speech and swallow
evaluations due to concern for aspiration and he was placed NPO
except for essential meds. At the time of discharge patient was
on day ___ of antibiotics.
# Leukocytosis: On presentation pt had leukocytosis to 19.6 with
85% PMNs. Secondary to PNA as it improved with HCAP coverage,
and at time of discharge was normal at 6.8. During
hospitaliation pt had negative urine culture, PICC site was
without erythema or exudate, and pt did not have watery stools
to suggest C diff.
# Altered mental status: Recent decline in MS over the past
month with frequent episodes of delirium and agitation. On
presentation to the Emergency Department, the patient was
somnolent, with response to sternal rub. An ABG was obtained
which did not show evidence of hypercarbia. Change in mental
status thought to be secondary to multiple factors including hx
of anoxic brain injury with infection, hyperglycemia,
hypernatremia, and medication affect. On transfer to the floor,
pt's mental status continued to fluctuate between somnolence and
agitation. His home zyprexa was held, and prescribed prn for
agitation, and valproate level was checked (subtherapeutic at
35). His mental status slightly improved, however patient
remained sleepy and disoriented throughout hospitalization.
# Hypernatremia: Throughout hospitalization, patient was
hypernatremic in the 150s. He was continued on D5W throughout
hospitalization, and at the time of discharge his sodium was
normal at 145.
# DM type I: Pt has hx of poorly controlled hyperglycemia in the
600-800s in the community. On admission, glucose was elevated in
the 400s, with no evidence of DKA. Glucose was difficult to
control during admission, likely secondary to D5W fluids as
above. Insulin regimen was adjusted, and at discharge pts sugars
ranging 200-300s on glargine 16 units qhs with insulin sliding
scale.
# Acute on CKD: Pt has hx of Stage IV CKD with newly placed
fistula in left arm (never used). On presentation, the patients
creatinine was elevated to 4 from his baseline (3). Prerenal
azotemia likely secondary to decreased po intake and infection.
Improved with fluids during admission and at time of discharge
creatinine was back to baseline at 2.9. Throuhgout admission pt
was continued on calcitriol, and medications were renally dosed.
# Nutrition: Throughout hospitalization, concern for aspiration
pneumonia as above. Speech and swallow evaluations occurred
throughout the hospitalization and patient was found to have
difficulty clearning secretions and was made NPO except for
essential medications crushed. At the time of discharge, pt had
to be transitioned to IV metoprolol, IV levothyroxine, and IV
valproate due to inability to tolerate meds PO. Pt will need
further speech and swallow evaluation and discussion of plan for
nutrition with family.
CHRONIC ISSUES
# Hypertension: Stable throughout admission on home doses of
amlodipine and metoprolol. One day prior to discharge pt could
not tolerate po meds, so amlodipine was not given and metoprolol
was changed to IV. Blood pressures remained stable in 150s.
# CAD: Stable on home doses of metoprolol, atorvastatin, and
aspirin throughout most of hospitalization until pt not able to
take po as above.
# Hypothyroidism: Stable throughout admission. Currently on IV
levothyroxine as above.
TRANSITIONAL ISSUES:
# Pneumonia: Presented from rehab with PNA on vanc/zosyn, and
transitioned to vanc/cefepime. Currently day ___ on antibiotics.
Will need to continue Abx until ___ with follow-up on
respiratory status. TID suctioning of oral secretions. PICC on
right upper extremity.
# Speech and swallow eval needed once mental status clears.
Could not take po metoprolol or levothyroxine so was switched to
equivalent IV doses.
# Please monitor sugars with new lantus dose of 16 units qhs
with ISS.
# Monitor chem10 for renal function and sodium levels; D5W as
needed for hypernatremia.
# Please monitor nutrition status
# Pulmonary nodule: On chest CT scan had a 7mm nodule that needs
to be followed up in ___ months given smoking history
# Valproate: Level was subtherapeutic at 35. Dose will need to
be readjusted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 7.5 mg PO HS
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 80 mg PO HS
4. Bacitracin Ointment 1 Appl TP QID
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Calcitriol 0.25 mcg PO 3X/WEEK (___)
7. Docusate Sodium 100 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Nitroglycerin SL 0.3 mg SL PRN chest pain
13. OLANZapine (Disintegrating Tablet) 5 mg PO QAM
14. Polyethylene Glycol 17 g PO DAILY
15. Senna 8.6 mg PO BID
16. Valproic Acid ___ mg PO QHS
17. Valproic Acid ___ mg PO QAM
18. Acetaminophen 650 mg PO Q4H:PRN pain
19. Vancomycin 1000 mg IV Q48H
20. Piperacillin-Tazobactam 2.25 g IV Q8H
21. Omeprazole 20 mg PO DAILY
22. Other 8 Units Breakfast
Other 8 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
23. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
24. Mupirocin Ointment 2% 1 Appl TP BID
25. Metoprolol Tartrate 50 mg PO BID
26. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
27. Heparin 5000 UNIT SC TID
Discharge Medications:
1. Amlodipine 7.5 mg PO HS
2. Acetaminophen 650 mg PO Q4H:PRN pain
3. Aspirin 325 mg PO DAILY
4. Atorvastatin 80 mg PO HS
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Calcitriol 0.25 mcg PO 3X/WEEK (___)
7. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
10. FoLIC Acid 1 mg PO DAILY
11. Heparin 5000 UNIT SC TID
12. Multivitamins 1 TAB PO DAILY
13. OLANZapine (Disintegrating Tablet) 5 mg PO QAM
14. Omeprazole 20 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. Senna 8.6 mg PO BID
17. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
18. Vancomycin 1000 mg IV Q48H
19. CefePIME 2 g IV Q24H
20. Bacitracin Ointment 1 Appl TP QID
21. Mupirocin Ointment 2% 1 Appl TP BID
22. Nitroglycerin SL 0.3 mg SL PRN chest pain
23. Glargine 16 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
24. Levothyroxine Sodium 37.5 mcg IV DAILY
25. Metoprolol Tartrate 5 mg IV Q6H
26. Valproate Sodium 750 mg IV Q8H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Healthcare associated pneumonia, aspiration
pneumonia, hypoxia, altered mental status, hypernatremia,
hyperglycemia
Secondary diagnosis: Diabetes mellitus type 1, acute on chronic
kidney disease, hypothyroidism
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ from ___
___ for altered mental status and for pneumonia. In the
Emergency Department, you required a lot of oxygen so you were
transferred to the ICU for further care and your antibiotics
from rehab were adjusted. Your pneumonia was possibly caused
from aspiration of food contents, therefore your swallowing was
evaluated. It was determined that you were at risk for
aspiration, so you were kept on IV fluids only.
It was also discovered that you had worsening kidney function
and high sodium, both which improved with fluids. You had high
blood sugars as well, so your insulin dose was adjusted. Your
oxygen requirement improved in the ICU so you were transferred
to the floor, and you eventually did not require oxygen. On
___, your sodium and sugars improved, so you were discharged
back to rehab on antibiotics.
It was a pleasure treating you,
Your ___ Team
Followup Instructions:
___
|
19937688-DS-16 | 19,937,688 | 20,981,455 | DS | 16 | 2142-02-22 00:00:00 | 2142-02-22 21:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
Chief Complaint: n/v/d weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year old legally blind gentleman w/ history
of CAD, hypertension, prostate cancer s/p surgery and
laminectomy with residual right foot drop, as well as recent
spinal surgery for L5-S1 disc herniation on ___ with n/v/d
and weakness, transferred from ___ for sepsis and a fib with
RVR.
He had a spinal surgery 1 week ago and has a Foley in place due
to failure to void. He has had two recent admissions to ___,
also originating at ___. He first presented with severe
lumbar spinal stenosis and neuroforaminal narrowing to ___
___ and was transferred to ___ for neurological
evaluation. Admitted from ___ to ___ on medicine service.
MRI L-spine on ___ confirmed severe degree of spinal stenosis
and neuroforaminal narrowing from disc bulge and facet
hypertrophy at the L5/S1 level. Neurosurgery was consulted and
recommended surgery in one week. Patient was then admitted to
the neurosurgery service from ___ for L5-S1 Laminectomy on
___. Upon review of previous admission, it appears
patient's PAML on neurosurgery admission did not include
diltiazem and as such he has not been on it for 3 weeks. He was
started on salt tabs for mild hyponatremia.
He was discharged to rehab on ___. Was doing well until ___
days ago when he started to develop malaise nausea, vomiting and
diarrhea. Multiple other patients with similar symtpoms. Legally
blind at baseline. Denies fall.
ED exam there showed Peaked Ts on monitor, Lungs clear,
Bilateral equal leg weakness. No abdominal TTP. Flu swab -
negative. significant leukocytosis. Cr elev to 1.7 from baseline
1.05. EKG - tachycardic, RBBB c/w prior. CT abdomen and pelvis -
midabdominal calcified mass. sclerosing mesenteritis (more
likely) v. carcinoid. hypodense linear lesion in spleen (limited
eval w.o contrast) could be splenic infarct. abdominal aorta is
tortuous and calcified. b/l iliac aneurysm 2.4 cm increased from
___.
He was given ceftriaxone, Repeat lactate improved to 3.0, Given
CT scan findings, ED consulted surgery, Repeat EKG Afib with
RVR. Continued RBBB, Hypertensive. Given diltiazem 10 mg IV x 1
with improvement in HR to 100s. Surgery recommended transfer to
___ for further evaluation given Afib with RVR despite
improvement with one dose of diltiazem and lack of hemodynamic
instability, as well as sepsis.
In the ED, initial vitals: (unable) 97.6 ___ 16 93%
Labs: WBC 19.5, thrombocytosis 546, INR 1.4, lactate 2.9, bun
24/ cre 1.5, albumin 3.2, urine cloduy with mild pyuria, some
bacteruria. Given IV dilt 15, 30, then started on dilt drip at
10mg/hour, up to 20mg/hour. Given vanc 1g and 500cc NS.
On transfer, vitals were: Today 04:22 0 98.9 103 134/90 18 95%
RA.
On arrival to the MICU, his mouth is so dry he is almost
dysarthric. He is initially confused and thinks I look like his
daughter ___ (patient is legally blind). He is however
quickly reoriented x3.
Review of systems:
(+) Per HPI
ROS: He denies recent cough, fever or chills, Denies chest pain,
shortness of breath, palpitations. Denies cough. has foley in
place but denies dysuria, hematuria. Denies abdominal pain.
Denies weakness, numbness or tingling.
Past Medical History:
HTN
BASAL CELL CARCINOMA
ACTINIC KERATOSIS
DERMATITIS, SEBORRHEIC
PROSTATE CANCER S/P SURGERY
S/P LAMINECTOMY
Severe lumbar spinal stenosis and neuroforaminal narrowing s/p
another L5-S1 Laminectomy at ___ ___
Coronary artery disease - sees Dr. ___ at ___
macular degeneration - legally blind
Mild depression
Peripheral neuropathy
Social History:
___
Family History:
arthritis in multiple family members
Physical ___:
ADMISSION PHYSICAL EXAM:
Vitals: 97.8 - 146/71 - 89 - 25 - 95% on 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, no clubbing, cyanosis or
edema
SKIN: lumbar incision erythematous w/o purulence
DISCHARGE PHYSICAL EXAM:
Vitals: 98.5, 140-170s/70-80s, HR 70-100s, RR ___, 94-98%RA
General- Alert, eyes mostly closed, lying in bed, no acute
distress
HEENT- Sclera anicteric, dry MM, oropharynx clear, poor
dentition
Neck- supple, JVP not elevated, no LAD
Lungs- decreased breath sounds at bilateral bases. Elsewhere
clear breath sounds, no wheezes, ronchi, crackles.
CV- irregular, intermittently tachycardic, normal S1 + S2, no
murmurs, rubs, gallops
Abdomen- soft, nontender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- feet appear equal temperatures. Trace ___ edema b/l.
Neuro- Minimal facial asymmetry at mouth on left, tounge
midline, Moving all extremities, able to pull himself up to
sitting position.
Pulses: 2+ DP right, 1+ DP left
Pertinent Results:
___ labs
WBC 28.4, 90% N's, no bands. HCT 50.6 (baseline 41-43),
platelets 657. INR 1.2. BUN 27, cre 1.7 (baseline 1.1), cl 95,
hco3 20. alb 3.9. CKMB 2.8, TnT 0.016 (high)
u/a- mild bacteriuria and pyuria, hematuria, + leuk est,
negative nit
ADMISSION LABS
================
___ 12:20AM BLOOD WBC-19.5* RBC-4.84 Hgb-14.7 Hct-43.4
MCV-90 MCH-30.5 MCHC-34.0 RDW-14.7 Plt ___
___ 12:20AM BLOOD Neuts-90.7* Lymphs-5.0* Monos-3.8 Eos-0.2
Baso-0.2
___ 12:20AM BLOOD ___ PTT-32.7 ___
___ 12:20AM BLOOD Glucose-151* UreaN-24* Creat-1.5* Na-134
K-4.8 Cl-100 HCO3-24 AnGap-15
___ 12:20AM BLOOD ALT-14 AST-17 AlkPhos-76 TotBili-0.5
___ 12:20AM BLOOD Albumin-3.2* Calcium-8.6 Phos-3.2 Mg-1.8
___ 09:43AM BLOOD ___ pO2-27* pCO2-36 pH-7.42
calTCO2-24 Base XS--1
___ 09:43AM BLOOD freeCa-1.07___ 09:43AM BLOOD O2 Sat-47
___ 12:28AM BLOOD Lactate-2.9*
___ 09:43AM BLOOD Lactate-1.8
OTHER PERTINENT LABS
=====================
___ 05:20PM BLOOD CK-MB-2 cTropnT-0.02*
___ 10:26PM BLOOD CK-MB-2 cTropnT-0.02*
___ 07:30AM BLOOD CK-MB-1 cTropnT-0.02*
___ 11:20AM BLOOD %HbA1c-6.6* eAG-143*
CA ___: normal
5'HIAA normal
DISCHARGE LABS
====================
___ 07:37AM BLOOD WBC-13.8* RBC-4.09* Hgb-12.2* Hct-35.5*
MCV-87 MCH-29.9 MCHC-34.4 RDW-14.6 Plt ___
___ 07:30AM BLOOD Neuts-82.7* Lymphs-8.7* Monos-7.8 Eos-0.5
Baso-0.2
___ 07:37AM BLOOD Glucose-129* UreaN-24* Creat-1.3* Na-127*
K-3.7 Cl-91* HCO3-22 AnGap-18
___ 07:30AM BLOOD ALT-15 AST-16 CK(CPK)-15* AlkPhos-81
TotBili-1.0
___ 07:37AM BLOOD Calcium-8.5 Phos-3.6 Mg-2.0
URINE
======
___ 12:20AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 12:20AM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___:20AM URINE RBC-41* WBC-2 Bacteri-FEW Yeast-NONE
Epi-0
MICROBIOLOGY
==============
___ STOOL C. difficile DNA amplification
assay-FINAL NEGATIVE; FECAL CULTURE-PENDING; CAMPYLOBACTER
CULTURE-PENDING INPATIENT
___ MRSA SCREEN MRSA SCREEN-PENDING INPATIENT
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ URINE URINE CULTURE-FINAL EMERGENCY WARD
STUDIES:
===============
CXR ___:
IMPRESSION:
Bilateral lung base opacity, in association with increase in
cardiac size, likely refecting pulmonary vascular congestion.
However, given clinical history, multifocal pneumonia is also a
possibility.
EKG ___:
Artifact is present. Atrial fibrillation with a rapid
ventricular response. Right bundle-branch block. Left anterior
fascicular block. Compared to the previous tracing of ___
the rhythm is now atrial fibrillation. The rate is increased.
Clinical correlation is suggested.
OSH imaging/reports: prelim read of CT: 1. There is a soft
tissue mass in the mesentery associated with coarse
calcifications, new compared to ___. This is non specific
and differentials include sclerosing mesenteritis, less likely
metastases from carcinoid syndrome. 2. A 1.6 x 1.8 cm
hypodensity within the posterior head of the pancreas ; enlarged
in size compared to the prior CT from ___. This is incompletely
characterized on today's exam given the lack of intravenous
contrast. 3. Bandlike hypodensity within a nonenlarged spleen,
that could represent an infarct versus sequela of trauma, in the
right clinical setting. 4. Cardiomegaly, dense coronary artery
calcification, extensive atherosclerotic calcification of the
abdominal aorta with bilateral common iliac artery aneurysms.
RECOMMENDATION(S): A nonemergent MRI of the abdomen to further
evaluate the pancreatic head lesion.
CXR ___: IMPRESSION: As compared to the previous
radiograph, there are now moderately increasing bilateral
pleural effusions and a increasing retrocardiac atelectasis. The
size of the cardiac silhouette continues to be enlarged. Mild
moderate pulmonary edema is present and has minimally increased
in severity since the
previous image. No evidence of pneumonia.
CT HEAD non contrast:
IMPRESSION: 1. No evidence of acute large territorial infarct or
hemorrhage. Please note, however, that MR is more sensitive in
the detection of acute stroke.
2. Atrophy, probable small vessel ischemic changes, and
atherosclerotic vascular disease as described.
MRI HEAD: Please note the study is degraded by motion. There is
prominence of the ventricles and sulci suggestive involutional
changes. Periventricular and subcortical T2 and FLAIR
hyperintensities are noted, which may represent small vessel
ischemic changes. There is a punctate focus of hemorrhage within
the
left frontal lobe (see series 7, image 15), that is new since
the ___ prior brain MRI.
There is an approximately 1.5 cm left parietal wedge-shaped area
of subacute infarct. Additional punctate acute infarcts are
noted within the left frontal, left occipital and right parietal
lobes.
There is no evidence of edema, masses, mass effect. There is a
chronic right cerebellar infarct again noted. There is a stable
right maxillary sinus mucous retention cyst versus polyp. The
visualized portion of the orbits are preserved. Small
nonspecific left mastoid fluid is present.
CTA ___: IMPRESSION:
1. No evidence of pulmonary embolism.
2. Moderate to severe mixed atherosclerotic disease of the
thoracic aorta. No intramural hematoma or dissection. Stable 3.4
cm ascending aortic aneurysmal dilation.
3. Large right and moderate left layering simple pleural
effusions. No evidence of focal or lobar lung consolidation.
4. Diffuse coronary artery and aortic and mitral valve
calcifications.
ECHO ___:
The left atrium is mildly dilated. The left atrium is elongated.
The right atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is at least 15 mmHg. Left ventricular wall thicknesses
and cavity size are normal. There is mild regional left
ventricular systolic dysfunction with focal hypokinesis of the
apex. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). Right ventricular
chamber size is normal. with normal free wall contractility. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. The mitral valve leaflets are
mildly 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.] There is moderate to severe pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
normal left ventricular cavity size and regional dysfunction c/w
CAD. Elevated PCWP. Moderate to severe pulmonary hypertension.
Mild mitral regurgitation. Mild to moderate tricuspid
regurgitaiton.
Compared with the prior study (images reviewed) of ___,
pulmonary pressures are higher and the tricuspid regurgitation
is new.
CHEST XRAY ___:
As compared to the previous radiograph, the radiographic
appearance is mildly improved. The right lung base has increased
in radiolucency, likely reflecting a decrease in pleural
effusion and pulmonary edema. The retrocardiac atelectasis is
unchanged, also unchanged is the small left pleural effusion but
overall, the signs of pulmonary edema have decreased in extent
and severity. No new focal parenchymal opacities. No
pneumothorax. Moderate cardiomegaly persists.
Brief Hospital Course:
Mr. ___ is a ___ legally blind M h/o CAD, hypertension,
prostate cancer s/p surgery and laminectomy with residual right
foot drop, as well as recent spinal surgery for L5-S1 disc
herniation on ___ transferred from ___ with
hypotension and Afib with RVR in setting of likely viral
gastroenteritis.
ACTIVE MEDICAL ISSUES
======================
# Severe sepsis. Pt presented to ___ with diarrhea,
nausea, vomiting. Multiple other people at rehab had similar
symptoms. Pt had severe sepsis with tachycardia and
leukocytosis, elevated lactate and ___. Given IVF, 1 dose of
ceftriaxone for questionable dirty urine. Transferred to ___,
went to ICU and started on vanc/cefepime/flagyl. No clinical
picture of pneumonia, cdif negative, urine and blood negative.
Transferred to floor. Abx stopped on day 2 and patient remained
stable. Lactate normalized and Cr trended down. Sepsis suspected
to be secondary to viral gastroenteritis.
# Atrial fibrillation with RVR. No history of Afib. Likely
triggered by sepsis. Started on diltiazem drip s/p several
boluses of dilt at BIN and in the ___ ED. Patient was
chronically on atenolol and diltiazem for blood pressure. CHADS2
= 2 (though splenic infarct noted on OSH CT concerning for
embolic event related to afib). Started on heparin gtt, and
transitioned to apixaban 5mg BID. Transitioned dilt gtt to po
diltiazem. HRs stabilized in 90-100s, remained in Afib.
Discharged on diltiazem ER 360MG daily.
# Leukocytosis: Wbc ~30 on admission to OSH. Had persistent
leukocytosis of unclear origin. No antibiotics given after
sepsis resolved. Wbc 13 at time of discharge.
# Ischemic stroke: Pt found to have wernicke's aphasia on
hospital day 5. MRI confirmed ischemic stroke, no hemorrahge.
Symptoms resolved. Suspect cardioembolic from AFib prior to
initiating anticoagulation. Started and discharged on apixaban.
# ARF:
Cr 1.7 on admission, up from baseline of 1.05. Improved with
IVFs
# New systolic heart failure with LVEF 45%. Not likely from
ischemic changes, potentially related to stress / tachycardia
cardiomypoathy given AFib wtih RVR and severe sepsis. EKG
unchanged, troponins neg x3. Patient was rate controlled on
diltiazem. Kidney function fluctuating. Did not start patient on
ACEi or Beta blocker as rate controlled on CCB so did not
switch, renal function was fluctuating limiting use of ___
and ultimately goals of care readdressed and patients preference
was to limit additional meds while transitioning to hospice
care.
# Goals of care: DNR/DNI. Signed MOLST indicating no further
hopspitalizations except for comfort. Will not persue
diagnositic or therapeutic measures for incidental findings on
imaging. Daughters/HCP in line with patient's wishes.
# Spinal stenosis s/p laminectomy: sp eval by neurosugery, in
the ED w/o any acute surgical issues.
# hyponatremia: Na 134 on admission. At points down to 127.
Likely hypovolemic hyponatremia as patient has poor access to
water given blindness. Na improved with normal saline boluses.
Worsened with lasix.
# Calcified abdominal/enlarging pancreatic head mass/?splenic
infarct: calcified abdominal mass concerning for sclerosing
mesenteritis vs. carcinoid based. CA ___ normal. 5'HIAA normal.
Per family and patient, will not persue diagnositic or
therapeutic measures for incidental findings on imaging.
# Left iliac and femoral thrombi: pt has isolated arterial
thrombi of left common and external iliac and left femoral
arteries. Has cooler left foot and decreased pulses. Possible
that it could have been caused by Atrial Fibrillation or clot
surrounding atherosclerotic disease. Heme consulted and do not
think it is a thrombophilia. 2+ DP pulse on right, 1+ pulse on
left. Stable through hospitalization. Patient and family opted
not to persue vascular surgery evaluation or intervention.
# HTN: Was on atenolol as outpatient which is not ideal drug in
patients prone to ___. Stopped atenolol and replaced with
diltiazem. Goal SBP >120 and <180.
# Chronic dyspnea: Has a long history of dyspnea. Having
increasing dyspnea, no hypoxia. Bilateral pleural effusions seen
on CTA. This morning, clinical exam consistent with increasing
pleural effusions. TTE showed new systolic heart failure. Given
one dose of lasix, no affect on dyspnea. Resolved on its own.
# CAD: Ranolazine is NF, continue aspirin and dilt as above.
# BPH: Continue tamsulosin
=======================
TRANSITIONAL ISSUES:
=======================
- NEW MEDICATIONS: Diltiazem ER 360mg daily, Apixaban 5mg BID
- Pt remained in afib, with HRs <110
- Should check CHEM on ___ to monitor Cr and Na. ___
MD if ___ > 1.6 or Na <129.
- Abdominal imaging found increasing pancreatic mass and
calcified mesenteric mass and thrombus of the left iliac and
femoral arteries. Patient and family decided not to persue
diagnostic or therapeutic measures at this time.
- Pt had ischemic stroke while inpatient. Had Wernicke's aphasia
that resolved.
- Pt had chest pain: EF mildly decreased, EKG unchanged, cardiac
enzymes negative. Resolved with morphine.
- New systolic heart failure (EF 45%). Likely secondary to
tachycardia. Rate controlled with diltiazem. Not started on ACEi
or B-blocker as underlying cause controlled and patient
transitioning to comfort focused care.
- Pt had dyspnea, evidence of elevated pulmonary pressures and
pulmonary edema. If pt shows evidence of fluid overload,
recommend trying diuresis. He responded to 10IV furosemide.
- Neurosurgery approved anticoagulation after spinal surgery
- Should have 1:1 supervision for meals as patient is legally
blind and needs assistance with intake.
- Passed speech and swallow
- please resume previous ___ services as tolerated
- DNR/DNI
- MOLST signed in chart
- Conact: ___ - younger daughter and HCP ___ ___-
Daughter ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Atenolol 25 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Heparin 5000 UNIT SC TID
5. Methocarbamol 500 mg PO TID
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
8. ranolazine 500 mg oral BID
9. Senna 17.2 mg PO HS
10. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
11. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
12. Sodium Chloride 1 gm PO BID
13. Tamsulosin 0.4 mg PO QHS
14. Simvastatin 20 mg PO QPM
15. Diltiazem 30 mg PO BID (pt not taking)
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Senna 17.2 mg PO HS
6. Tamsulosin 0.4 mg PO QHS
7. Methocarbamol 500 mg PO TID
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
9. ranolazine 500 mg ORAL BID
10. Simvastatin 20 mg PO QPM
11. Apixaban 5 mg PO BID
12. Morphine Sulfate ___ 15 mg PO Q6H:PRN pain
13. Diltiazem Extended-Release 360 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Viral gastroenteritis
Severe Sepsis
Atrial fibrillation
Acute kidney injury
Ischemic stroke
Acute systolic heart failure
SECONDARY DIAGNOSIS:
Spinal stenosis s/p laminectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of ___ at ___.
___ came to the hospital for diarrhea and weakness. Your heart
rate was found to be irregular and fast. ___ were treated with
IVF fluids, antibotics, and medicine to control your heart rate.
Your diarrhea was thought to be due to a viral illness and
antibiotics were stopped.
Your heart rate remained irregular but was no longer beating
fast. ___ were started on a blood thinner called Apixaban and
will follow up with your cardiologist. ___ were restarted on
your diltiazem, which had previously been stopped.
Imaging of your belly showed that the mass in your pancreas is
enlarging. It also noted a calcified mass in your intestines. An
MRI of your abdomen showed clots in the arteries in about
abdomen. We had a long discussion about what to do with these
findings, and since ___ and your family did not want any
invasive procedures or further workup, no diagnostic or
therapeutic measures were done.
On the ___ day of hospitalization, ___ were found to have
difficulty speaking. An MRI of your brain showed that ___ had a
stroke. Your speech returned to normal and no other effects of
the stroke were noticed.
At points of the hospitalization, ___ had chest pain and trouble
breathing. An extensive workup was done and showed no evidence
of new heart damage or pneumonia. The pain improved with
morphine and your symptoms resolved.
A MOLST form was signed before discharge. This form indicates
your wishes in types of treatments in the future. ___ decided to
only return to the hospital if it would improve your comfort.
We wish ___ all the best,
Your medical team at ___
Followup Instructions:
___
|
19938337-DS-18 | 19,938,337 | 28,021,083 | DS | 18 | 2174-11-05 00:00:00 | 2174-11-06 15:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hematemesis
Major Surgical or Invasive Procedure:
___ - Endotracheal intubation
___ - EGD, injection of glue in ___ ulcer, gastric and
esophageal varices
___ - TIPS
History of Present Illness:
Ms. ___ is a ___ woman with primary biliary cirrhosis
with progression to cirrhosis,complicated primarily by portal
hypertension in the form of multiple variceal bleeds, and
gastric ulcer bleeding, who initially presented to ___
with gross hematemesis one day prior to transfer. Despite 2u
pRBCs, Hct dropped from 36-->30. Patient also given 3L IVF, and
zofran for bloody vomit en route to ___ ED.
In the ED, initial vitals: T 98.1, HR 012, BP 89/42 (as low as
72/47), RR 18, O2 99%. Patient started on Octreotide gtt,
Pantoprazole IV. Given 2u pRBCs, 1u FFP, and 3L IVF. Continued
to have low SBP in ___ to ___.
On arrival to the MICU, HR 88, BP 81/34, RR 18, O2 97% on RA.
Past Medical History:
-Cirrhosis secondary to primary billiary cirrhosis,complicated
by portal hypertension in the form of esophageal varices and
ascites, splenomegaly and pancytopenia. Currently undergoing
transplant evaluation but is not yet listed.
-Multiple episodes of esophageal variceal bleeding, status post
band procedures. She required large volume paracentesis
following her bleed in ___. Last EGD ___ with one band
placed grade 2 varix, prior banding noted, on nadolol.
-Ascites, currently managed on Lasix and Aldactone.
-Mild malnutrition.
-History of gastric ulcer bleeding.
-h/o thrombocytopenia
-Status post cholecystectomy at age ___.
-History of left knee arthroscopy.
Social History:
___
Family History:
Per medical record, mother passed away from complications of
alcoholic cirrhosis; however, there is no liver disease or GI
illness in the family. Her sister was checked for PBC and that
was negative. There is no history of inflammatory bowel
disease, peptic ulcer disease or GI cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=============================
Vitals: HR 88, BP 81/34, RR 18, O2 97% on RA
GENERAL: Alert, oriented, in no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, 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
DISCHARGE PHYSICAL EXAM:
=============================
VITAL SIGNS: Tm 98.6, 85/39 -> manual recheck 90/46
(80-110's/40-80's), 79 (70-80's), 16, 100% RA
GEN: Sitting up comfortably, pleasant, in NAD; jaundiced
HEENT: NC/AT, EOMI, + scleral icterus
CV: Normal S1, S2 no m/r/g
PULM: CTAB, no wheezes or rhonchi
ABD: Soft, non-distended, NTTP, no rebound/guarding, NABS
EXTR: Warm, well-perfused, no edema
NEURO: Moving all extremities, speech fluent, A&Ox3, no
asterixis
Pertinent Results:
IMAGING / STUDIES:
============================
___ EGD:
Impression: 3 cords of grade II varices seen in distal
esophageal with high risk stigmata of red whale signs but no
active bleeding.
Esophageal diverticulum in distal esophagus.
3 cords of fundic gastric varices which appeared to be feeding
esophageal varices. In between 2 of the varices was a 1 cm clean
based non-bleeding ___ ulcer present in a hiatal hernia sac
which appeared to be the source of bleeding given it's proximity
to gastric varices. All 3 gastric varices were injected each
with 2 cc of Indermil glue with successful filling of the
varices. Following glue injection all of the grade II esophageal
varices were noted to decompress implicating successful variceal
obliteration via glue injection.
Portal hypertensive gastropathy was evident.
No fresh or old blood. Normal appearing duodenal mucosa.
Otherwise normal EGD to third part of the duodenum
___ CHEST X-RAY:
Normal lung volumes. The patient is intubated. The tip of the
endotracheal tube projects 2 cm above the carina. No pulmonary
edema. Mild fluid overload is present. Borderline size of the
cardiac silhouette. No pleural effusions. No pneumonia.
___:
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion and no aortic stenosis or
aortic regurgitation. The mitral valve leaflets are mildly
thickened. 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. No clinically-significant valvular disease seen.
Normal estimated pulmonary pressure.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
TIPS (___):
IMPRESSION:
1. Successful right internal jugular access with transjugular
intrahepatic portosystemic shunt placement with decrease in
porto-systemic pressure gradient from 19 mm Hg to 6 mm Hg.
2. 2 L of ascites drained.
ADMISSION LABS:
============================
___ 01:28AM BLOOD WBC-7.8# RBC-3.17* Hgb-10.4*# Hct-30.6*
MCV-97 MCH-32.8* MCHC-34.0 RDW-16.0* RDWSD-56.4* Plt ___
___ 01:28AM BLOOD Neuts-80.5* Lymphs-11.5* Monos-6.8
Eos-0.3* Baso-0.4 Im ___ AbsNeut-6.31* AbsLymp-0.90*
AbsMono-0.53 AbsEos-0.02* AbsBaso-0.03
___ 01:28AM BLOOD ___ PTT-21.9* ___
___ 01:28AM BLOOD Plt ___
___ 01:28AM BLOOD Glucose-198* UreaN-26* Creat-0.6 Na-141
K-5.6* Cl-112* HCO3-20* AnGap-15
___ 05:09AM BLOOD ALT-18 AST-26 LD(LDH)-158 AlkPhos-80
TotBili-1.7*
___ 01:28AM BLOOD Calcium-6.9* Phos-2.9 Mg-1.6
___ 01:31AM BLOOD Lactate-2.2*
DISCHARGE LABS:
============================
___ 04:46AM BLOOD WBC-4.9 RBC-3.46* Hgb-10.4* Hct-31.7*
MCV-92 MCH-30.1 MCHC-32.8 RDW-20.6* RDWSD-65.6* Plt Ct-82*
___ 04:46AM BLOOD ___ PTT-30.5 ___
___ 04:46AM BLOOD Glucose-119* UreaN-5* Creat-0.5 Na-140
K-4.0 Cl-109* HCO3-25 AnGap-10
___ 04:46AM BLOOD ALT-57* AST-68* AlkPhos-121* TotBili-7.0*
___ 04:46AM BLOOD Albumin-2.6* Calcium-8.0* Phos-1.2*
Mg-2.1
___ 12:16PM URINE Color-Yellow Appear-Hazy Sp ___
___ 12:16PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-150 Ketone-NEG Bilirub-LG Urobiln-4* pH-6.5 Leuks-NEG
___ 04:52PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-1
TransE-<1
MICRO:
===============
___ 12:16 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ yo female with PBC cirrhosis complicated by multiple upper GI
bleeds (due to varices and gastric ulcers), who presented as a
transfer from an outside hospital with hematemesis and was found
to have high risk varices and a bleeding ___ ulcer s/p glue
injection.
# UPPER GI BLEED: EGD ___ revealed 3 cords of grade II varices
with high risk stigmata, 3 cords of gastric varices, and a 1cm
clean-based non-bleeding ___ ulcer which appeared to be the
source of bleeding. All gastric and esophageal varices were
obliterated with glue. She received a total of 4U PRBCs, 1U
FFP, 1U PLTs, and 6L IVF with last transfusion being ___ at
2:30AM. She was placed on IV ceftriaxone for from ___ until
discharge. She was given octreotide gtt for 72 hours,
transitioned from IV PPI gtt to BID PO PPI. She was started on
sucralfate, which she should continue for at least 4 weeks from
___ EGD. She was given anti-emetics to minimize retching.
Patient underwent TIPS on ___. Procedure was without any
intra-op complications. Portosystemic gradient decreased from
19--->6. Post procedure patient had intermittent hypotension to
___ and had spiked fever to 100.7. Infectious workup was
unrevealing. Pt was asymptomatic with her lower BP. BPs
improved with 12.5g albumin. Softer BPs thought to be perhaps
related to fluid shifts associated with her TIPS and large
gradient change. Additionally, patient developed elevated Tbili
to 9.2 (direct fraction > 75%). Likely related to large shunt.
Downtrended after peak without specific intervention.
Additionally her nadalol was discontinued given she was s/p
TIPS.
# CIRRHOSIS: Due to primary biliary cirrhosis. Childs class B.
MELD 7 on admission. Rose to 16 post tips ___
hyperbilirubinemia post-TIPS. Patient was not encephalopathic
during admission. However post-TIPS was empirically started on
lactulose. For her PBC, she was continued on ursodiol
# MILD FLUID OVERLOAD: Due to cirrhosis and hypoalbuminemia.
Respiratory status was stable on room air. Home lasix /
spironolactone were briefly held given recent bleed, then
restarted on ___. Diuretics were intermittently held due to
transient episodes of hypotension post-TIPS as noted above. She
was discharged on spirinolactone 50 mg daily. Her lasix was not
restarted on discharge.
TRANSITIONAL ISSUES:
[] f/u with hepatology (Dr. ___ in 2 weeks
[]recommend trending of LFTs to ensure normalization of tbili
[]consider restarting lasix on follow up if clinically indicated
(dc'd on discharge)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO BID
2. Spironolactone 50 mg PO BID
3. Nadolol 40 mg PO DAILY
4. Ursodiol 500 mg PO BID
5. Ferrous Sulfate 325 mg PO BID
6. calcium carbonate-vitamin D3 1,000 mg(2,500 mg)-800 unit oral
DAILY
Discharge Medications:
1. Outpatient Lab Work
Diagnosis: 571 - cirrhosis
Weekly CBC
Send results to: ___ ___
2. Ferrous Sulfate 325 mg PO BID
3. Ursodiol 500 mg PO BID
4. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 capsule(s) by mouth Daily Disp
#*30 Capsule Refills:*0
5. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. calcium carbonate-vitamin D3 1,000 mg(2,500 mg)-800 unit oral
DAILY
7. Lactulose 15 mL PO TID
RX *lactulose 10 gram/15 mL 15 mL by mouth three times a day
Refills:*3
8. Spironolactone 50 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Upper GI bleed (varices and ulcers)
Cirrhosis due to PBC
Fluid overload
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted for gastrointestinal bleeding. This was due
to an ulcer as well as multiple varices (dilated arteries caused
by high pressures in your liver). You underwent endoscopy and
glue was injected into the ulcer as well as varices to stop the
bleeding. You received blood transfusions. Because you have
had multiple serious gastrointestinal bleeds, you underwent a
TIPS procedure. This should decrease your risk of future
bleeds. However, it does increase the risk of confusion from
your liver disease, so you were started on lactulose to help
prevent this. You no longer need to take nadalol becasue you've
had the TIPS. Do not take any lasix (furosemide) for now and
only take spironolactone once a day until you see Dr. ___
again in clinic.
Dr. ___ will call you with a follow up appointment.
Please call them at ___ if you have any concerns or
questions.
It was as pleasure being involved in your care,
Your ___ Team
Followup Instructions:
___
|
19938337-DS-20 | 19,938,337 | 26,615,463 | DS | 20 | 2178-09-06 00:00:00 | 2178-09-07 12:33:00 |
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: ___ distention
Major Surgical or Invasive Procedure:
___ - Therapeutic Large Volume Paracentesis
___ - Splenic Venogram with TIPS angioplasty
___ - Therapeutic Large Volume Paracentesis
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
===========================
___ yo woman w/ PBC cirrhosis c/b HE, EV, ascites, pancytopenia
s/p TIPS ___ w/ redo ___, who presented with abdominal
distention and lightheadedness.
She was recently admitted ___ for abdominal distention
and weakness. She underwent large volume paracentesis of 2.5L
with improvement in symptoms. Abdominal duplex ultrasound showed
potential slow flow through the left portal vein, follow up with
___ arranged for outpatient per patient preference. Lactulose was
added to her home medications. She reports that prior to this
she
had not required a paracentesis in ___ years.
She reports that ___ days later she started to develop recurrent
abdominal distention which has gradually worsened since that
time. She feels abdominal pain diffusely across her belly
worsening along with her distention. She has had mild nausea
that
lasts for ~2 minutes but no vomiting. She has been having ~2
bowel mvmts per day but recently had to decrease her lactulose
due to diarrhea. She has been feeling short of breath after
walking several steps over the past month. She has also felt
occasional lightheadedness when she stands up and walks as well
as bilateral lower extremity weakness. The lightheadedness
resolves gradually if she sits down. She denies fevers.
She has been taking her furosemide and spironolactone every day
and has been carefully watching her sodium intake by reading
nutritional labels. Her weight had been stable 128 lbs at home.
Past Medical History:
-Cirrhosis secondary to primary billiary cirrhosis,complicated
by portal hypertension in the form of esophageal varices and
ascites, splenomegaly and pancytopenia. Currently undergoing
transplant evaluation but is not yet listed.
-Multiple episodes of esophageal variceal bleeding, status post
band procedures. She required large volume paracentesis
following her bleed in ___. Last EGD ___ with one band
placed grade 2 varix, prior banding noted, on nadolol.
-Ascites, currently managed on Lasix and Aldactone.
-Mild malnutrition.
-History of gastric ulcer bleeding.
-h/o thrombocytopenia
-Status post cholecystectomy at age ___.
-History of left knee arthroscopy.
-Osteoporosis
Social History:
___
Family History:
Per patient, mother and great aunt had PBC but per medical
medical record, mother passed away from complications of
alcoholic cirrhosis. There is no history of inflammatory bowel
disease, peptic ulcer disease or GI cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: ___ Temp: 98.2 PO BP: 119/58 L Sitting HR: 97
RR: 20 O2 sat: 98% O2 delivery: Ra
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclerae anicteric. MMM.
NECK: No cervical lymphadenopathy. JVP ~9 cm.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. ___
systolic ejection murmur heard best at RUSB.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness. Tenderness to palpation in paraspinal
muscles to L of lumbar spine.
ABDOMEN: Distended, diffusely tender to palpation with no
guarding or rebound, + fluid wave. Normal bowel sounds.
EXTREMITIES: 1+ edema to knees bilaterally. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. +telangiectasias.
NEUROLOGIC: AOx3. Months of year backward intact. No asterixis.
CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength
throughout.
DISCHARGE PHYSICAL EXAM
Temp: 98.2 (Tm 98.7), BP: 91/52 (91-112/52-63), HR: 87 (84-93),
RR: 16 (___), O2 sat: 98% (97-100), O2 delivery: Ra, Wt:
121.03
lb/54.9 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclerae anicteric. MMM.
NECK: No cervical lymphadenopathy.
CARDIAC: RRR. Audible S1 and S2. ___ systolic ejection murmur
heard best at RUSB.
LUNGS: Clear to auscultation bilaterally. No increased work of
breathing.
ABDOMEN: Less distended than yesterday, soft, no guarding or
rebound, normal bowel sounds, para site c/d/i
EXTREMITIES: 1+ edema to knees bilaterally. Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. +telangiectasias.
NEUROLOGIC: AOx3. Moving all 4 limbs spontaneously. ___ strength
throughout. No asterixis.
Pertinent Results:
ADMISSION LABS:
___ 01:01PM BLOOD WBC-2.7* RBC-2.57* Hgb-9.3* Hct-28.7*
MCV-112* MCH-36.2* MCHC-32.4 RDW-19.9* RDWSD-79.7* Plt Ct-93*
___ 01:01PM BLOOD ___ PTT-30.2 ___
___ 01:01PM BLOOD Glucose-119* UreaN-12 Creat-0.5 Na-137
K-3.5 Cl-100 HCO3-27 AnGap-10
___ 01:01PM BLOOD ALT-35 AST-102* AlkPhos-134* TotBili-4.1*
DirBili-1.7* IndBili-2.4
___ 01:01PM BLOOD Albumin-2.1*
DISCHARGE LABS:
___ 06:51AM BLOOD WBC-2.7* RBC-2.44* Hgb-8.8* Hct-27.3*
MCV-112* MCH-36.1* MCHC-32.2 RDW-19.9* RDWSD-80.7* Plt Ct-96*
___ 06:51AM BLOOD Plt Ct-96*
___ 06:51AM BLOOD ___ PTT-31.4 ___
___ 06:51AM BLOOD Glucose-155* UreaN-12 Creat-0.5 Na-137
K-4.1 Cl-101 HCO3-28 AnGap-8*
___ 06:51AM BLOOD ALT-29 AST-76* LD(LDH)-341* AlkPhos-125*
TotBili-3.9*
___ 06:51AM BLOOD Calcium-7.8* Phos-2.4* Mg-2.2
MICRO:
- Peritoneal Fluid - ___- 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,
if applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
- Blood/Urine Culture - ___ - NO GROWTH
- Blood/Urine Culture - ___ - NGTD
- Blood Culture - ___ - NGTD
IMAGING:
Duplex Doppler - ___. Patent TIPS and main portal vein.
2. No demonstrable flow in the left or anterior right portal
veins. This could
be due to slow flow though thrombosis would be possible.
3. Cirrhotic morphology of the liver with findings of portal
hypertension
including ascites and splenomegaly.
Chest PA and Lateral - ___
No acute cardiopulmonary process.
Therapeutic Paracentesis - ___. Technically successful ultrasound guided diagnostic
paracentesis.
2. 3.9 L of straw-colored fluid were removed.
Splenic Venogram/TIPS Revision - ___. Pre angioplasty right atrial pressure of 7 and splenic
pressure measurement
of 27 resulting in portosystemic gradient of 20 mmHg.
2. Splenic venogram showing narrowing of the hepatic venous end
of the TIPS.
3. Post-angioplasty right atrial pressure of 10 and splenic
pressure of 17
resulting in portosystemic gradient of 7 mmHg.
4. 2.5 L clear yellow ascites drained
Brief Hospital Course:
___ year old woman with PBC cirrhosis complicated by HE, EV,
ascites, pancytopenia s/p TIPS ___ w/ redo ___, who was
admitted for lightheadedness and abdominal distention due to
recurrent ascites. Patient was admitted for large volume
paracentesis and for radiologic workup of suspected low flow
velocity through TIPS, ultimately underwent IV venogram and TIPS
revision on ___.
---------------
ACTIVE ISSUES
---------------
# Ascites:
# h/o TIPS ___ w/ redo ___:
Patient with significant abdominal distention and tenderness to
palpation. Previously had a large-volume paracentesis performed
on ___ despite years of not requiring a paracentesis. Prior to
presentation patient reported good adherence to medications and
NA restricted diet. Ascites due to impaired blood flow through
portal venous system confirmed by splenic venogram now,
corrected with TIPS angioplasty on ___ with portosystemic
gradient from 20 to 7mmHg after procedure. Large volume -4L and
-2.5L therapeutic paracenteses also performed on ___ and ___ by
___ with IV albumin administered post-procedurally. No signs of
SBP/infection throughout admission with reassuring diagnostic
para (___ 126) on ___.
#PBC Cirrhosis
Longstanding history of PBC cirrhosis, MELD 15 on admission,
Childs Class C. Patient continued on home ursodiol, lactulose,
and rixamin. Last EGD on ___, grade II varices observed s/p
banding. No hx of SPB, patient not started on prophylactic
antibiotics. Patient continued on low sodium diet with adequate
PO intake.
# Lightheadedness
Positional lightheadedness concerning for orthostasis due to
dehydration in setting of diuretic use and recent diarrhea.
Lightheadedness resolved with increased PO intake.
#Hypotension, resolved:
Transiently hypotensive morning of ___ to ___ but remained
asymptomatic. Resolved without intervention.
CHRONIC/STABLE ISSUES:
======================
#Pancytopenia
Chronic, consistent with baseline, likely due to PBC cirrhosis.
#Pancytopenia
Chronic, consistent with baseline, likely due to PBC cirrhosis.
Transitional Issues
======================
[ ] Please obtain weekly AST, ALT, total bilirubin, INR,
creatinine, and potassium and fax to Liver clinic fax number:
___
[ ] Please clarify driving status with patient given unclear
history of hepatic encephalopathy.
[ ] Repeat RUQUS within 1 week to assess flow through TIPS
[ ] ___ blood pressures in outpatient setting; briefly
hypotensive during admission, pressures improved thereafter
# CODE: Full
# CONTACT: Sister (___) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. rifAXIMin 550 mg PO BID
3. Spironolactone 100 mg PO DAILY
4. Ursodiol 500 mg PO BID
5. Lactulose 30 mL PO TID
Discharge Medications:
1. Furosemide 40 mg PO DAILY
2. Lactulose 30 mL PO TID
3. rifAXIMin 550 mg PO BID
4. Spironolactone 100 mg PO DAILY
5. Ursodiol 500 mg PO BID
6.Outpatient Lab Work
___.3
Obtain weekly AST, ALT, total bilirubin, INR, creatinine, and
potassium and fax to Liver clinic fax number: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Decompensated Cirrhosis
Secondary Diagnosis:
Primary Biliary Cirrhosis
Lightheadedness
Pancytopenia
Discharge Condition:
A&Ox3. Afebrile. HR ___, BP ___. Abdomen
distended, soft, mildly tender w/o rebound/guarding. No
asterixis. Lightheaded at times w/mild intermittent nausea. Able
to ambulate without difficulty.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I IN THE HOSPITAL?
You were in the hospital because you a build up of fluid in your
abdomen called ascites.
WHAT WAS DONE WHILE I WAS HERE?
You had a procedure to remove the fluid from your belly and some
imaging done to test the causes of the buildup of that fluid.
You also had a procedure to evaluate your TIPS and a revision of
your TIPS, which went well!
WHAT SHOULD I DO WHEN I GO HOME?
- You should adhere to a strict low sodium diet.
- You should take your medications as instructed. You should go
to your doctors ___ as below.
- Weigh yourself every morning, call your doctor if your weight
goes up or down more than 3 lbs in two days or more than 5 lbs
in one week.
We wish you the best!
-Your ___ Care Team
Followup Instructions:
___
|
19938337-DS-22 | 19,938,337 | 28,534,048 | DS | 22 | 2178-11-23 00:00:00 | 2178-11-23 17:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
Paracentesis ___ - 2.75 L removed
History of Present Illness:
Ms. ___ is ___ woman with primary biliary cirrhosis
complicated by HE, EV, ascites, pancytopenia s/p TIPS revision
___, who presented to OSH with slowly worsening
encephalopathy over the last 3 day and transferred here for
further management.
Per history obtained in the ED, Ms. ___ family reports that
patient has been doing unusual things at home (e.g. trying to
plug her TV remote into her phone charger)for several days
leading up to presentation. They feel that she is not safe to be
at home and brought her to ___ ___, where she was
found
to be mildly altered with a hemoglobin of 8.1, glucose 334, Na
127, K 3.0, ammonia of 50, and a borderline UA, with stable
LFTs.
She was transferred here for further GI work-up given her
history.
She reports she increased her Ensure intake from 1 to 3 per day
starting last week. Her furosemide was increased from 40mg to
60mg daily starting ___ but otherwise no medication changes.
She
said both her confusion and worsening abdominal extension
started
around ___. In addition, she was constipated for ___ days
this
week despite no change to her lactulose regimen with return of
her usual BM frequency on ___.
Per ___ records review, patient was admitted ___ for
management of HE and diuretic refractory ascities (4L drained
via
paracentesis). She was also treated with antibiotics for UTI
during admission.
In the ED, initial vitals were:
Temp 97.9-98.9F, HR 87-96, BP 90-122/42-62, RR ___, O2
94-98%RA
Exam was notable for:
HEENT: Scleral icterus, dry MMs
JVP: Elevated
CHEST: Few R basilar crackles
ABD: Soft, distended, non-tender; Light brown heme positive
stool
in the rectal vault
EXTREM: ___ BLE edema
NEURO: No asterixis. Mildly inattentive, able to complete DOWB
however unable to complete MOYB.
Labs were notable for: (use specific numbers)
Pancytopenia: WBC 3.7, Hgb 6.7, Platelets 107
Hgb 6.7 -> ___ s/p 1 unit PRBC transfusion -> 8.7
ALT: 31 AP: 186 Tbili: 4.0 Alb: 1.5
AST: 58 LDH: Dbili: 2.6
Na 137, Glucose 275
UA Leuk lg WBC 35 Bacteria Few
Studies were notable for:
-CXR: No acute cardiopulmonary process. No evidence of free
intraperitoneal air.
-ECG: Sinus rhythm, Low voltage in precordial leads compared to
previous ECG; no significant change
-U/S liver & gallbladder: Patent TIPS. Patent hepatic
vasculature. Cirrhotic liver morphology with moderate ascites
and
splenomegaly.
-Ultrasound guided paracentesis performed, removed 2.75L of
straw-colored fluid, well-tolerated. AF doesn't meet criteria
for
SBP by PMN count of 34.
The patient was given:
CTX 2g IV for presumed UTI
Pantoprazole 40mg IV given variceal hx
1U pRBC
x2 lactulose 30ml
1L NS
Consults:
GI-hepatology consulted and recommended admission to ET.
On arrival to the floor, patient is HDS (mildly tachycardic and
borderline hypotensive)and confirms the above history. She
reports improvement in her thinking. She denies fever, chills,
shortness of breath, chest pain, dizziness on rising from bed.
She denies hematemesis, melena, hematochezia.
Past Medical History:
-Cirrhosis secondary to primary billiary cirrhosis,complicated
by portal hypertension in the form of esophageal varices and
ascites, splenomegaly and pancytopenia. Currently undergoing
transplant evaluation but is not yet listed.
-Multiple episodes of esophageal variceal bleeding, status post
band procedures. She required large volume paracentesis
following her bleed in ___. Last EGD ___ with one band
placed grade 2 varix, prior banding noted, on nadolol.
-Ascites, currently managed on Lasix and Aldactone.
-Mild malnutrition.
-History of gastric ulcer bleeding.
-h/o thrombocytopenia
-Status post cholecystectomy at age ___.
-History of left knee arthroscopy.
-Osteoporosis
Social History:
___
Family History:
Per patient, mother and great aunt had PBC but per medical
medical record, mother passed away from complications of
alcoholic cirrhosis. There is no history of inflammatory bowel
disease, peptic ulcer disease or GI cancers.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS reviewed.
GENERAL: No distress, sitting in bed
HEAD: NC/AT, conjunctiva clear, icteric sclera
NECK: Supple
CARDIAC: PMI non-displaced, RRR, S1S2 w/o m/r/g.
RESPIRATORY: Normal work of breathing
ABDOMEN: soft, distended, +fluid wave, +BS, mildly tender around
site of paracentesis, no ecchymosis, C/D/I dressing over
paracentesis site
EXTREMITIES: Warm, trace edema around ankle
NEUROLOGIC: Grossly intact, face symmetric, speech fluent, no
asterixis, A/Ox3, able to do MOYB
PSYCHIATRIC: Pleasant, cooperative.
DISCHARGE PHYSICAL EXAM:
========================
VS: 98.1PO, 105 / 57, 92, 18, 97 Ra
GENERAL: No distress, sitting in bed
HEAD: NC/AT, conjunctiva clear, icteric sclera
NECK: Supple
CARDIAC: PMI non-displaced, RRR, ___ systolic murmur at RUSB
RESPIRATORY: CTAB, Normal work of breathing
ABDOMEN: soft, mildly distended, +BS, nontender, ecchymosis
around paracentesis site
EXTREMITIES: Warm, no ___
NEUROLOGIC: Grossly intact, face symmetric, speech fluent, no
asterixis. AAOX4.
PSYCHIATRIC: Pleasant, cooperative.
Pertinent Results:
ADMISSION LABS:
================
___ 01:00AM BLOOD WBC-3.7* RBC-1.87* Hgb-6.7* Hct-20.6*
MCV-110* MCH-35.8* MCHC-32.5 RDW-19.7* RDWSD-78.3* Plt ___
___ 01:00AM BLOOD Neuts-73.5* Lymphs-6.8* Monos-13.9*
Eos-4.4 Baso-0.3 Im ___ AbsNeut-2.69 AbsLymp-0.25*
AbsMono-0.51 AbsEos-0.16 AbsBaso-0.01
___ 01:00AM BLOOD ___ PTT-28.8 ___
___ 05:46PM BLOOD Glucose-275* UreaN-16 Creat-0.7 Na-137
K-3.5 Cl-99 HCO3-28 AnGap-10
___ 01:00AM BLOOD ALT-31 AST-58* AlkPhos-186* TotBili-4.0*
DirBili-2.6* IndBili-1.4
___ 01:00AM BLOOD Lipase-81*
___ 01:00AM BLOOD cTropnT-0.14*
___ 01:00AM BLOOD Albumin-1.5*
___ 02:19AM BLOOD Ammonia-<10
___ 01:10AM BLOOD Lactate-1.3
DISCHARGE LABS:
================
___ 05:36AM BLOOD WBC-3.0* RBC-2.27* Hgb-7.8* Hct-24.5*
MCV-108* MCH-34.4* MCHC-31.8* RDW-20.7* RDWSD-79.7* Plt Ct-94*
___ 05:36AM BLOOD ___ PTT-30.2 ___
___ 05:36AM BLOOD Glucose-207* UreaN-14 Creat-0.6 Na-134*
K-4.1 Cl-100 HCO3-28 AnGap-6*
___ 05:36AM BLOOD ALT-30 AST-54* AlkPhos-193* TotBili-4.5*
___ 05:36AM BLOOD Albumin-1.7* Calcium-7.5* Phos-2.6*
Mg-2.1
MICROBIOLOGY:
=============
___ 01:14AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 01:14AM URINE Blood-TR* Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-4* pH-6.0 Leuks-LG*
___ 01:14AM URINE RBC-9* WBC-35* Bacteri-FEW* Yeast-NONE
Epi-2 TransE-1
___ 01:14AM URINE CastHy-1*
___ 01:14AM URINE Mucous-RARE*
___ 02:50PM ASCITES TNC-695* RBC-263* Polys-33* Lymphs-2*
Monos-58* Mesothe-5* Macroph-2*
___ 02:50PM ASCITES TotPro-1.2 LD(LDH)-73 Albumin-0.2
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 2:51 pm
PERITONEAL FLUID
GRAM STAIN (Final ___:
1+ (<1 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, if
applicable.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 2:45 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 3:20 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 1:14 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
STUDIES:
===========
CHEST (PA & LAT) Study Date of ___
No acute cardiopulmonary process. No evidence of free
intraperitoneal air.
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
1. Patent TIPS. Slightly elevated proximal TIPS velocity
compared to prior,
which is likely due to technical differences. Attention on
follow-up imaging
is recommended.
2. Patent hepatic vasculature.
3. Cirrhotic liver morphology with moderate ascites and
splenomegaly.
Brief Hospital Course:
___ woman with primary biliary cirrhosis complicated by
HE, EV, ascites, s/p TIPS revision (___), who presented
with encephalopathy.
ACTIVE ISSUES:
====================
#Hepatic encephalopathy
Patient presented with confusion for the past 3 days. She
reports constipation, possibly related to downtitration of her
lactulose after a recent bout of diarrhea illness that has since
resolved. She has been compliant with home lactulose and
rifaximin. Hepatic encephalopathy likely triggered by
constipation, potentially also contribution from question of
UTI. Her mental status improved rapidly this admission. She was
continued on lactulose TID, rifaximin BID.
#UTI
UA on presentation showed large leuks and few bacteria. Urine
culture was contaminated. Patient denied any urinary symptoms.
She was treated with CTX for possible UTI for a total 3 day
course for uncomplicated UTI, given that her encephalopathy was
thought more related to HE with insufficient stooling rather
than systemic symptoms from infection.
#Anemia
Hgb 6.7 on presentation, for which she was transfused 1U pRBC
with appropriate response. Her recent baseline hgb in the last
few months has been in 7s-8s. She did not otherwise have
clinical evidence of active bleeding. Discharge hgb stable at
7.8.
#Cirrhosis ___ PBC
Cirrhosis ___ primary biliary cirrhosis s/p TIPS with recent
revision (___). She presented with HE as discussed above. RUQ
US with patent TIPS. Admission MELD 15. She received
diagnostic/therapeutic paracentesis on presentation with 2.75L
ascites removed; no SBP on cell counts. She was continued on
home furosemide/spironolactone. She has a prior history of
variceal bleeding now s/p TIPS. She had no clinical evidence of
active bleeding this admission though she had chronic anemia
requiring 1U pRBC with appropriate response. She was continued
on home ursodiol.
CHRONIC ISSUES:
======================
# Insomnia: Continued home trazadone prn
TRANSITIONAL ISSUES:
======================
[] Monitor mental status for recurrent HE; patient has been
counseled to titrate lactulose to ___ BMs daily.
[] Trend CBC for chronic anemia. She did received 1 pRBC
transfusion with appropriate response this admission.
[] Please continue to discuss question of code status with
patient, as she expressed uncertainty about this.
# CONTACT: ___ (HCP, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 15 mL PO TID
2. rifAXIMin 550 mg PO BID
3. Furosemide 60 mg PO DAILY
4. Spironolactone 150 mg PO DAILY
5. Ursodiol 500 mg PO BID PBC
6. TraZODone 50 mg PO QHS:PRN insomnia
7. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. Furosemide 60 mg PO DAILY
2. Lactulose 15 mL PO TID
3. rifAXIMin 550 mg PO BID
4. Spironolactone 150 mg PO DAILY
5. TraZODone 50 mg PO QHS:PRN insomnia
6. Ursodiol 500 mg PO BID PBC
7. Vitamin D ___ UNIT PO 1X/WEEK (MO)
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hepatic encephalopathy
Urinary tract infection
SECONDARY DIAGNOSIS:
Primary biliary cholangitis
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure to care for you at ___
___.
WHY WERE YOU ADMITTED?
- You were confused and likely had a urinary tract infection.
WHAT HAPPENED TO YOU IN THE HOSPITAL?
- You were treated with lactulose and your confusion improved.
- You were treated with antibiotics for a urinary tract
infection.
WHAT SHOULD YOU TO AT HOME?
- Take your medications as prescribed.
- Titrate your lactulose to reach ___ bowel movements daily.
- Please call your primary care doctor to make a follow up
appointment within 1 week of discharge.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19938358-DS-25 | 19,938,358 | 26,736,205 | DS | 25 | 2159-06-02 00:00:00 | 2159-06-06 08:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
angiogram dye
Attending: ___
Chief Complaint:
Epigastric/chest pain
Major Surgical or Invasive Procedure:
___: Cardiac catheterization, s/p DES to LAD for in-stent
re-thrombosis.
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ with history of CAD s/p stenting who presents with 1 week of
intermittent chest pain. He reports the pain is in the
epigastrium and describes it as a pressure, denies radiation of
the pain, and it is nonexertional and nonpleuritic. Denies
shortness of breath but has associated with nausea. He has
diaphoresis at baseline which he attributes to Lupron. Denies
cough, fever, back pain. Overall, pain has been going on for 2
weeks and worsened this morning. He is taking Prilosec with
minimal relief. Denies SOB, N/V/D. Tolerating POs, regular BMs.
He had a stress test in ___ which demonstrated lateral EKG
changes without corresponding echocardiographic changes. Seen in
urgent care and referred to ___. Given no stress testing
available in ED, he was recommended to be admitted to to
cardiology.
In the ED, initial vitals: 97.4 58 138/75 16 98% RA
- Labs notable for: H/H 11.7/33, BUN 33, Cr 1.4, Trop neg x1,
D-dimer 323, LFTs/lipase wnl
- Imaging notable for: normal chest xray
- Patient given:
On arrival to the floor, patient reports feeling better. He says
he has the above described epigastric band like dull discomfort,
that worsened ___ am, and thus he got scared and came to the
hospital. His last heart attack was ___ years ago, since then he
has had 3 stents in his LAD. He usually takes full dose ASA, but
was told to go down on that given addition of ibuprofen which he
was started on given his urinary pain (post radiation). He last
took full dose ASA also about 7 days ago, then did not take any
for about ___ days, then took baby aspirin and on ___ took
full dose aspirin again. He denies fevers, exposures, discomfort
is non exertion, non positional, non pleuritic. He says he
almost has no pain now.
Past Medical History:
-Chronic Anemia (thought to be iron deficiency + inflammatory)
-Prostate cancer diagnosed ___ with history as noted
above, now on
-Sepsis, attributed to urinary origin, for which he was admitted
on ___. He improved with antibiotics.
-Stage III CKD with recent creatinine levels as high as 1.6
-HTN managed with metoprolol.
-Hyperlipidemia managed with simvastatin.
-Rectal adenoma requiring low anterior resection, splenic
flexure
mobilization, and small bowel resection in ___.
-MI in ___, managed with coronary stenting
-Basal cell carcinoma; actinic keratosis managed with
cryotherapy.
-Chronic eosinophilia dating to at least ___, with eosinophilic
esophagitis; no history of steroid treatment.
-Duodenitis, with no prior duodenal biopsy apparent per our
records.
-R inguinal herniorrhaphy ___
-Bialteral cataract surgeries ___ and ___
Social History:
___
Family History:
He has a brother who similarly has CKD and anemia of uncertain
etiology. There was also another brother who died of renal
cancer at ___, also had hx of MI and CAD. Sister w hx MI and CAD,
osteoporosis. Father w emphysema.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.5 BP 146/64 HR 65 RR16 100RA
General: Pale gentleman, Alert, oriented, no acute distress,
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no rales or wheezes
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, no
chest tenderness
Abdomen: soft, non-tender, distended and tympanic, +hernia with
left abdomen bulging more than right (chronic), bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no edema
Pertinent Results:
======================================
Brief Hospital Course:
Outpatient Providers: ==================================
BRIEF HOSPITAL COURSE
==================================
Mr. ___ is a ___ y gentleman with prostate cancer s\p
brachytherapy
on Enzalutamide and Leuprolide, h/o MI (___) w/ 3 stents to
LAD, presents with anginal equivalent s/p cath revealing
in-stent restenosis, s/p DES to LAD.
#Angina ___ in-stent stenosis:
Epigastric pain is his anginal equivalent. He has prior CAD
history, with MI in ___ s/p stent to LAD c/b in-stent
thrombosis, requiring a total of 3 stents to LAD. The pain he
presented with was in the context of stopping aspirin (concern
for GI bleeding with NSAID use). Pain resolved with sublingual
nitroglycerin. His stress test in ___ was suboptimal, so
decision was made for cardiac catheterization. This revealed
in-stent restenosis and DES was placed within current LAD stent.
After the procedure, he had some epigastric pain overnight, but
this was different in character, associated with eating a large
meal, and resolved on its own. He was discharged in stable
condition on ASA 81 daily, Plavix 75mg daily, home metoprolol,
and atorvastatin 80mg daily (switched from home simvastatin 40).
[ ] New medications: Plavix, atorvastatin.
[ ] F/u with cardiology to monitor progression of CAD.
[ ] Re-check BMP in 1 week to assess for contrast nephropathy.
#Chronic anemia:
Has chronic anemia thought to be ___ iron deficiency vs anemia
of chornic disease vs a combination. Prior iron studies were
normal. Anemia remained at baseline.
[ ] Continue workup of anemia as an outpatient.
#Prostate Cancer on Enzalutamide: Patient brought this
medication from home.
#Urinary hesitancy: Continued home Tamsulosin 0.4 mg BID
#GERD: Continued home ranitidine, changed omeprazole to
pantoprazole given medication interaction.
#HTN: Continued home metoprolol 50 mg BID. BP stable
120s-140s/60s-70s.
========================
TRANSITIONAL ISSUES
========================
[ ] New medications: Plavix, atorvastatin, pantoprazole.
[ ] F/u with cardiology to monitor progression of CAD.
[ ] Continue workup of anemia as an outpatient.
[ ] Re-check BMP in 1 week to assess for contrast nephropathy.
[ ] Re-check CBC in 1 week, Hgb drop to 9.1 from admission 11.8
post-cath.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (ex wife) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Multivitamins 1 TAB PO DAILY
7. Omeprazole 20 mg PO DAILY
8. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
9. Simvastatin 40 mg PO QPM
10. Tamsulosin 0.4 mg PO BID
11. Vitamin D ___ UNIT PO DAILY
12. Ranitidine 150 mg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Senna 17.2 mg PO QHS
15. Ibuprofen 400 mg PO BID
16. enzalutamide 160 mg oral Q24H
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
RX *atorvastatin [Lipitor] 80 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually every 5
minutes Disp #*1 Package Refills:*0
4. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Ascorbic Acid ___ mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Cyanocobalamin 1000 mcg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. enzalutamide 160 mg oral Q24H
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Ibuprofen 400 mg PO BID
12. Metoprolol Tartrate 50 mg PO BID
13. Multivitamins 1 TAB PO DAILY
14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
15. Ranitidine 150 mg PO DAILY
16. Senna 17.2 mg PO QHS
17. Tamsulosin 0.4 mg PO BID
18. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Unstable angina
In-stent re-thrombosis, s/p re-stenting with DES
SECONDARY:
Normocytic anemia
Prostate cancer
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 ___ because you were having
chest/upper belly pain.
While you were here, you continued to have this pain. The pain
improved with nitroglycerin under the tongue. Your blood tests
and EKG showed no signs of heart attack. You had a cardiac
catheterization to look at the blood flow to the heart. They
found that the vessel with the stent in it had started to close
up. They placed two new stents to open up that vessel.
When you go home, it is important for you to take your aspirin
and Plavix. It is important to tell your doctor or call ___ if
you have chest pain.
Your medications and appointments are below.
It was a pleasure taking care of you!
Sincerely,
Your ___ Cardiology Team
Followup Instructions:
___
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Subsets and Splits