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19938391-DS-16 | 19,938,391 | 20,649,140 | DS | 16 | 2130-08-05 00:00:00 | 2130-08-05 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
Lumbar Puncture ___
History of Present Illness:
Mr. ___ is a ___ right-handed male with PMH of ADEM,
for which he was admitted in ___, with course complicated by
saddle PE and now on warfarin, who presents with a likely
seizure while driving.
The seizure occurred at approximately 11am on ___. The last
thing he recalls prior to the event on ___ is driving along the
road in ___; when he awoke, he was in the ambulance feeling
confused. He had urinated on himself and his tongue was sore.
Per bystander reports, he drove off the road into a ditch, where
he came to a stop and was seen shaking all over. By the time
EMS arrived, he was no longer seizing, but continued to be
confused for approximately 10 minutes. He was taken to ___
___, where a ___ was done and found to be negative for
hemorrhage. A ___ CT was also negative for fracture. Labs
were notable for an elevated WBC of 15.2 with 86% PMNs. His INR
was only 1.2, despite being on Coumadin. He was transferred to
___ for further evaluation.
The patient reports feeling fatigued on the day prior to the
event, but attributed this to increased physical activity over
the past several days. On the morning of the seizure, he
experienced a ___ dull frontal headache not associated with
nausea, photophobia, or phonophobia. He took 3 aspirin for the
headache. He did not notice any usually sensations or feelings
prior to losing consciousness. He does not use drugs or alcohol
and slept well the night before the event. He has not started
any new medications. He skipped breakfast the morning of the
seizure, but this is not very unusual for him. He denies recent
fevers, chills, cough, nausea, vomiting, diarrhea, dysuria, or
other symptoms of infection. His sister-in-law (whom he lives
with) had a cold earlier in the week, but he does not believe he
contracted similar symptoms. He has no recent history of head
trauma, although he has a prior history of head trauma. He lost
consciousness several times as a child (he reports his
stepfather was physically abusive). He was hit in the face ___
years ago with a hockey puck and ___ years ago when he was mugged,
but did not lose consciousness during these events.
Neuro ROS: Reports occasional sensation of vibrations shooting
down his body when he touches his chin to his chest. He has had
occasional tingling in his fingertips since his diagnosis of
ADEM. He thinks his hearing may have worsened since ___. Denies
loss of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus. Denies difficulties
producing or comprehending speech. Denies focal weakness or
numbness.No bowel or bladder incontinence or retention. Denies
difficulty with gait except for mild balance issues that are
improving.
General ROS: Lost 50 lbs with initial illness in ___ has now
gained back approximately 20 lbs of that weight. Denies recent
fever or chills. No night sweats. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
#Presumed ADEM:
-Diagnosed in ___. He has no recollection of the first three
weeks of hospitalization. Treated with 5 days of IV steroids and
five more days of IVIG. The patient's exam improved despite
repeat MRI imaging showing progression of the lesions, and no
further interventions were made. No definitive diagnosis was
reached, but ADEM was felt to be the most likely.
-Was initially seen at ___ before transfer to
___ studies showed WBC of 550, Diff: 15% PMNs, 69%
Lypmhs, 15% Monos, RBC of 3. Serology at ___ notable for
positive EBV IgG and Lyme IgM slightly increased at 1.3; this
finding is consistent with early Lyme infection vs. past
infection treated early in course vs. cross-reacting IgM
antibody such as EBV. Serology negative for babesia, anaplasma,
HIV, monospot. CSF negative for Lyme PCR, enterovirus PCR,
___, EEE IgM/IgG, WEE IgM/IgG, ___
meningoencephalitis IgG and IgM, ___ encephalitis IgG and
IgM, LCM IgG and IgM, Measles IgM/IgG, Mumps IgM/IgG, HSV
IgM/IgG, ___, Echovirus, CMV, ___ virus, VDRL.
Oligoclonal band assay of serum and CSF were also negative. CSF
gram stain negative, culture showed no growth. There was some
concern for ___ virus encephalitis at OSH, and patient
was given one dose of IV acyclovir before transfer to ___.
-After discharge from ___, he was in rehab for approximately
seven weeks, where he slowly regained his strength and ability
to walk. He continued outpatient ___ until recently. His only
current deficits are mild balance difficulties which cause him
to feel unstable, although he does not fall.
#Saddle pulmonary embolism: Occurred during hospitalization in
___. Started initially on heparin gtt, then transitioned to
lovenox/coumadin and then just coumadin. Most recently had INR
checked 2 weeks ago with therapeutic INR at that time per pt
report.
-Developed respiratory failure, felt to be multifactorial from
weaknesss from ADEM and PE. Patient underwent trach and PEG
placement in light of prolonged intubation, but this has since
been removed.
# Pericarditis in ___, where he was noted to have diffuse ST
elevations on ___. He had not chest pain. They resolved
with ibuprofen 600 mg TID.
Social History:
___
Family History:
No history of seizures. His biological father died of stroke at
age ___. No family history Multiple Sclerosis or other neurologic
conditions.
Physical Exam:
Admission Physical Exam:
Physical Exam:
Vitals: T: 97.2 P:61 R: 14 BP: 115/72 SaO2: 100% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Able to read without difficulty. Speech was not
dysarthric. Able to follow both midline and appendicular
commands. Pt. was able to register 3 objects and recall ___ at 5
minutes, but at 20 mins could get ___. The pt. had good
knowledge of current events. There was no evidence of apraxia
or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3.5 to 1.5mm and brisk. VFF to confrontation.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric except for
subtle L ptosis that pt reports is his baseline as does his
friend who is in the room.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
.
Pertinent Results:
Laboratory Evaluation:
___ 08:03PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:30PM URINE HOURS-RANDOM
___ 06:30PM URINE UHOLD-HOLD
___ 06:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 06:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 06:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:30PM URINE RBC-2 WBC-6* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 06:30PM URINE GRANULAR-2* HYALINE-7*
___ 06:30PM URINE MUCOUS-MANY
___ 06:30AM BLOOD WBC-6.2 RBC-4.47* Hgb-13.2* Hct-39.3*
MCV-88 MCH-29.4 MCHC-33.5 RDW-14.1 Plt ___
___ 06:30AM BLOOD ___
___ 05:05AM BLOOD ___
___ 06:30AM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-141
K-4.2 Cl-105 HCO3-30 AnGap-10
___ 02:18AM BLOOD calTIBC-235* Ferritn-116 TRF-181*
___ 05:20PM BLOOD PEP-PND
___ 05:20PM BLOOD ANGIOTENSIN 1 - CONVERTING ___
___ 03:00PM BLOOD NEUROMYELITIS OPTICA (___) EVALUATION
WITH REFLEX-PND
___ 03:00PM BLOOD MULTIPLE SCLEROSIS (MS) PROFILE-PND
___ 09:27PM URINE Hours-RANDOM TotProt-37
___ 09:27PM URINE U-PEP-PND
___ 02:17PM CEREBROSPINAL FLUID (CSF) WBC-24 RBC-1*
Polys-15 ___ ___ 02:17PM CEREBROSPINAL FLUID (CSF) WBC-21 RBC-4*
Polys-10 ___ ___ 02:17PM CEREBROSPINAL FLUID (CSF) TotProt-41 Glucose-46
___ 02:17PM CEREBROSPINAL FLUID (CSF) EBV-PCR-PND
___ 02:17PM CEREBROSPINAL FLUID (CSF) MULTIPLE SCLEROSIS
(MS) PROFILE-PND
.
MICROBIOLOGY:
CSF GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
CSF FLUID CULTURE (Preliminary): NO GROWTH.
.
Imaging:
#CHEST (PA & LAT) Study Date of ___ 9:26 ___
FINDINGS: Frontal and lateral views of the chest were obtained.
The lungs are clear without focal consolidation. No pleural
effusion or pneumothorax is seen. The lungs are relatively
hyperinflated. Cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION: No focal consolidation.
.
#MR HEAD W & W/O CONTRAST
FINDINGS: There is marked interval improvement in the previous
confluent
FLAIR signal hyperintensity in the white matter, only minimal
residual
hyperintensity persisting. There is no evidence of hemorrhage,
ischemia, and there is no abnormal enhancement. A developmental
venous anomaly is noted in the left cerebellar hemisphere. The
visualized paranasal sinuses reveal mucosal thickening in the
ethmoid air cells. There is mild increased fluid signal in the
mastoid air cells
bilaterally. The orbits are unremarkable.
IMPRESSION: Interval marked improvement in the previous diffuse
T2 FLAIR
signal hyperintensity in the white matter without new
abnormality identified.
.
#MR ___ W/O CONTR
FINDINGS: The vertebral bodies are normal in height, signal
intensity and alignment. Intervertebral discs are normal in
signal intensity. The
previously seen extensive confluent spinal cord signal
abnormality on the
prior examination has almost completely resolved. There is
minimal residual T2 signal hyperintensity in the in the dorsal
spinal cord. There is no abnormal enhancement. The paraspinal
soft tissues are unremarkable.
IMPRESSION: Minimal residual signal hyperintensity in the dorsal
spinal cord, nearly completely resolved, compared to the prior
examination. No abnormal enhancement.
Brief Hospital Course:
#Neurology- Seizure: From bystander reports, it seems most
likely the patient experienced a generalized tonic-clonic
seizure. No obvious cause for his seizure could be identified.
He was started on levetiracetam 1000mg BID. Initial leukocytosis
with PMN predominance resolved after transfer to ___, and can
likely be attributed to his seizure. EEG performed after
admission was normal. MRI Head showed marked improvement from
last MRI in ___ with no new lesions. Lumbar puncture performed
on ___ showed ___ WBC with lymphocyte predominance, 41 prot,
46 gluc. (On initial presentation to ___ in
___, his CSF had 550 WBCs.) The patient is afebrile without
meningismus. Extensive work-up during his ___ ___
showed no evidence of CSF infection. During this admisison, CSF
EBV PCR (patient has had positive serum EBV IgG in the past)and
MS ___ were sent. Serum ACE was also sent as sarcoid was on
the differential. It could be CSF pleocytosis is due to his
recent seizure. Alternatively, the patient could have MS, and
this might explain his seizure in addition to increased CSF WBC.
The patient had no oligoclonal bands on initial evaluation in
___.
.
#Neurology- ?cervical cord disease: The patient has Lhermitte's
sign (reports sensation of vibrations running down his body
during neck flexion). MR ___ spine showed minimal residual
hyperintensity in the dorsal spinal cord, nearly completely
resolved compared to prior exam, with no abnormal enhancement.
At this point, seems sensory symptoms are most consistent with
residual cervical cord disease due to ADEM. Multiple sclerosis
profile and neuromyelitis optica evaluation were sent.
.
#DVT PPx: Patient has history of saddle pulmonary embolism. INR
remained at 1.1-1.3 despite increasing warfarin to 7.5mg from
his previous home dose of 5mg. Warfarin dose was therefore
further increased to 10mg. There is some concern for a
hypercoagulable disorder as patient developed PE after only
several days of hospitalization in ___. SPEP and UPEP were
performed in ___ and were normal and were again checked during
this hospitalization. We will send Factor V Leiden and
prothrombin gene mutation (can't eval Protein C, Protein S or
ATIII as patient is on warfarin and enoxaparin). These results
will be reviewed with patient during his follow-up appointment
with Dr. ___. Patient also has follow-up appt with his
pulmonologist scheduled for ___ to evaluate need for further
anti-coagulation.
.
[]Transitional Issues
The following labs were pending on discharge: SPEP, UPEP, MS
___ evaluation, CSF EBV PCR, CSF final culture, ACE
level
-FVL, prothrombin sent. Will be discussed in follow-up
appointment with Dr. ___
-___ will be continued on enoxaparin bridge until he is seen
by his primary care physician as an outpatient and satisfactory
INR is achieved on warfarin.
-Patient understands he will be unable to drive for at least 6
months because of his seizure. He is aware Keppra can have some
side effects, especially mood changes.
-If anti-coagulation is ultimately discontinued, it may be wise
to check Protein C, Protien S, ATIII to make sure it is safe for
patient to stay off anti-coagulation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neurologic exam showed no focal deficits.
Discharge Instructions:
You were admitted for a seizure. You may have had a seizure
because your brain has a decreased seizure threshold after your
episode of ADEM. You were started on an anti-seizure medication
called Keppra (Levetiracetam). In addition, your INR was low so
your dose of Warfarin was increased.
We discussed the following seizure precautions with you:
- no driving by ___ law for 6 months
- avoid heights, ladders, swimming, and take showers instead of
baths
- avoid highly strenuous exercise
Followup Instructions:
___
|
19938958-DS-18 | 19,938,958 | 21,970,619 | DS | 18 | 2165-03-30 00:00:00 | 2165-03-30 13:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Levaquin / Celexa / Trazodone
Attending: ___
Chief Complaint:
Dizziness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old right-handed woman with HTN, HLD,
inflammatory bowel/diverticulitis s/p resection, strong family
history of hypercoagulability who presents with perisistent
vertigo, acute occipital HA, and episode of confusion.
The patient endorses 2 month history of transient episodes of
clockwise room spinning that are aggravated by head position
change (mostly to the right) consistent with likely peripheral
etiology. She notices that every time she kneels down to water
her plants at home, she turns her head to the right and has a
sudden onset with typical resolution within ___ minutes when she
sits down and rests. There are no other associated neurology
symptoms.
Yesterday she was in her usual state of health until she was
driving to pick up her grandson in her ___ of ___.
While driving she suddenly became disoriented and could not find
her way to the pickup location, even though she drives there
three times per week. She called her son-in-law and he thought
she seemed confused and was able to direct her with great
effort.
She was not aphasic or dysarthric on the phone. She eventually
felt better after about 20 minutes, but realized she forgot her
purse at home which was very unusual for her. She went to bed
feeling tired but awoke this morning again in her normal state
of
health. Around 7AM she was at her daughter's house cleaning
when
she knelt down and turned her head to the right provoking severe
vertigo. This episode was unusual in that it lasted for hours
and was associated with a new severe occipital ___ pounding
HA.
She has been nauseous but has not vomitted. There is associated
photo/phonophobia, but no vision change. Of note she does have
a
history of left ear hearing loss that is congenital, otherwise
no
tinnitus, ear fullness. No recent illness or trauma.
She was taken to ___ where urgent CT was negative for
acute stroke. Exam was significant for vertigo, bilateral
slight
dysmetria with FNF and gait instability. Labs showed no
metabolic abnormalities. She had LENIs due to swelling in the
LLE
but this was negative for DVT and she was transferred to ___
for further care. Here in our ___ SBP was 150-170 (slightly high
for her). She had prn valium, meclizine, and zofran with some
improvement in symptoms, but not complete resolution. There was
initial supposed ___ (left, aggrevated symptoms) per
___
and improvement with Epley but her symptoms recurred and Neuro
was consulted.
Important risk factors include family history notable for 2
sisters (ages ___, ___) with reported embolic strokes. Both of
those sisters also had miscarriages. Her mother had a large ___
DVT requiring blood thinners. She herself has endorses an
unusual history of head trauma while playing baseball when she
was age ___. Hospital workup revealed "a clot in her head"
(unclear if this was a hematoma or actual venous clot) and she
was hospitalized at ___ for 3 weeks, placed on prophylactic
dilantin for ___ years. The patient has also had 1 prior
miscarriage.
ROS: On neuro ROS, endorses intermittend L foot
dragging/weakness
(fluctuates) over past month. She denies loss of vision,
blurred
vision, diplopia, dysarthria, dysphagia, tinnitus. Denies
difficulties producing or comprehending speech. Denies focal
weakness, numbness, parasthesiae. No bowel or bladder
incontinence or retention.
On general review of systems: (+) Nausea, constipation
(chronic).
Denies recent fever or chills. No night sweats or recent weight
loss or gain. Denies cough, shortness of breath. Denies chest
pain or tightness, palpitations. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
- HLD
- HTN
- ashtma
- irritable bowel/diverticulitis s/p colon resection
- aortic insufficiency
- Hx of sexual assault with genital herpes on acyclovir
- OSA
- GERD
- Diverticulitis
- Arthritis of knee, left
- hx of head trauma as teenager. fell while trying to catch a
baseball, hit head, +LOC. Per report from patient hospitalized
3 weeks, likely hematoma.
Social History:
___
Family History:
Notable for 2 sisters (___, ___) with reported embolic
strokes "multiple clot strokes" per pt. Both of those sisters
also had miscarriages. Her mother had a large ___ DVT requiring
blood thinners. No family hx of seizures.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 97 70 170/82 14 95%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid or orbital bruits appreciated. No
nuchal
rigidity. Sigificant tenderness of paraspinal musculature
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: LLE slightly larger, asymmetric, appears slightly
erythematous. No pain dorsiflexion
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes. The pt had good
knowledge of current events. There was no evidence of apraxia or
neglect.
-Cranial Nerves:
II: VFF to confrontation. Visual acuity ___ bilaterally.
Fundoscopic exam revealed no papilledema.
III, IV, VI: PERRL 3 to 2mm and brisk. EOMI right beating
nystagmus in right gaze, subtle torsional componenet. Hypometric
saccades to right on testing.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 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. + Head impulse test to
the right, not left. ___ recreates symptoms in either
direction
-Gait: Able to stand but on taking a few steps, sways to the
right. Romberg + right
=======================================
DISCHARGE PHYSICAL EXAM
Vitals: T98, BP 108-145/40-50, HR 56-67, RR 18, O2 99% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid or orbital bruits appreciated. No
nuchal
rigidity. Sigificant tenderness of paraspinal musculature
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: LLE slightly larger, asymmetric, appears slightly
erythematous. No pain dorsiflexion
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive. Language is fluent with intact
repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Able to
follow both midline and appendicular commands. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II: VFF to confrontation.
III, IV, VI: PERRL 3 to 2mm and brisk. EOMI right beating (7
beats)
nystagmus in end gaze on the right.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch
-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. - Head impulse test
-Gait: Able to stand but on taking a few steps. Expresses
pain on left foot due to recent surgery. Able to tandem walk.
Pertinent Results:
___ 05:20AM BLOOD WBC-5.0 RBC-3.54* Hgb-11.7* Hct-34.1*
MCV-96 MCH-32.9* MCHC-34.2 RDW-13.2 Plt ___
___ 05:20AM BLOOD Neuts-43.4* Lymphs-42.8* Monos-9.3
Eos-3.9 Baso-0.6
___ 05:20AM BLOOD ___ PTT-26.9 ___
___ 05:20AM BLOOD ___ 05:20AM BLOOD Lupus-PND
___ 05:20AM BLOOD Glucose-101* UreaN-14 Creat-0.9 Na-144
K-3.9 Cl-109* HCO3-28 AnGap-11
___ 05:20AM BLOOD Calcium-8.7 Phos-4.8* Mg-2.0
MRI/MRV/MRA: No evidence of sinus venous thrombosis. No
evidence of stroke. Nonspecific T2/FLAIR hyperintensities.
Brief Hospital Course:
___ is a ___ year-old right-handed woman with HTN, HLD,
inflammatory bowel/diverticulitis s/p resection, strong family
history of hypercoagulability who presents with perisistent
vertigo, acute occipital HA, and episode of confusion.
Initially, her exam is with minimal abnormality-- there is right
torsional nystagmus
on right gaze, +head-impulse to R, and she is falling to R on
exam but has intact cerebellar exam, normal strength, vision,
and
fundi. Her dizziness improved with meclizine and zofran in the
Emergency Room. Her dizziness was resolved with the Epley
manuever in the Emergency Room. Although it appears she has
many symptoms consistent with peripheral vertigo, the acute
occipital HA, episode of confusion and severe vertigo in the
context of familial
hypercoagulability is concerning for possible sinus venous
thrombosis. Ms. ___ has a MRI/MRA/MRV which was showed no
sinus venous thrombosis or stroke. Ms. ___ symptoms
completely resolved. She is able to walk without assistance.
Thus, she was discharged home with meclizine prn and asked to
follow up with her primary care doctor in next few weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Magnesium Oxide 400 mg PO ONCE
2. Valsartan 160 mg PO DAILY
3. Hydrochlorothiazide 12.5 mg PO DAILY
4. ClonazePAM 0.5 mg PO QHS:PRN anxiety
5. Omeprazole 20 mg PO DAILY
6. Atorvastatin 10 mg PO QPM
7. Vitamin D 50,000 UNIT PO DAILY
8. Ascorbic Acid ___ mg PO DAILY
9. Fish Oil (Omega 3) 1000 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. ClonazePAM 0.5 mg PO QHS:PRN anxiety
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Valsartan 160 mg PO DAILY
7. Vitamin D 50,000 UNIT PO DAILY
8. Acyclovir 400 mg PO Q12H
9. Fish Oil (Omega 3) 1000 mg PO DAILY
10. Magnesium Oxide 400 mg PO ONCE
11. Meclizine 12.5 mg PO Q6H:PRN dizziness
RX *meclizine 25 mg 1 tablet(s) by mouth every 6 hours as needed
for dizziness Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1. Benign Paroxysmal Postional Vertigo
2. Hypertension
3. Hyperlipidemia
4. Diverticulitis s/p colon resection
5. Aortic insufficiency
6. Arthritis
7. Obstructive Sleep Apnea
8. History of head trauma as a teenager
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized for work up of vertigo or dizziness. There
are 2 main reasons for dizziness. One reason is due to the
peripheral nerves in the inner ear and the other reason is due
to the brain such as a stroke. Due to the fact that you have had
many short episodes of dizziness before, it was improved with a
maneuver to dislodge the calcium crystals in your inner ear and
now you do not have any more symptoms, we believe that most
likely the cause of your dizziness is because of a nerve problem
and not because of a stroke. Your MRI did not show a stroke or
blood clot in your head.
Followup Instructions:
___
|
19938968-DS-6 | 19,938,968 | 29,315,149 | DS | 6 | 2111-08-30 00:00:00 | 2111-08-30 14:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics) / Levaquin
Attending: ___.
Chief Complaint:
Distal femur osteomyelitis
Major Surgical or Invasive Procedure:
Distal Femur I&D (___)
History of Present Illness:
___ male with h/o pre-diabetes, T11 paraplegia ___ AV
malformation within spinal cord presents to ED from ___
___ with c/f LLE cellulitis vs. osteomyelitis. The patient
reportedly broke his femur approximately ___ years ago, had
hardware placed at ___ which became infected and
was removed approximately ___ year later. As the patient is
non-ambulatory, the leg was not repaired. He reports that he was
doing really well until the past 48-hours of fevers, subjective
chills, and redness around an area of skin break down on the
posterior knee from his compression stockings. A CT scan
identified a 2.9 x 8.3 x 3.1 soft tissue abscess. Imaging also
identified a fragmented femoral shaft with impaction into the
fragmented femoral condyles. An ultrasound was negative for DVT.
He was febrile (Tmax 103.2F) with WBC 11.2. He was started on
Vancomycin, Cefepime, and Clindamycin and transferred to ___
for further care.
Past Medical History:
- T11 paraplegia ___ AVM
- Hyperlipidemia
Social History:
___
Family History:
NC
Physical Exam:
NAD
Incisons c/d/i. Well approximated.
No evidence of hematoma or infection.
Moderate about of swelling from foot to mid-thigh, with much
improved mild erythema
No baseline sensation or motor function
Foot WWP
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have an infected ___ of the distal femur and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ and ___ for irrigation and
debridement, which the patient tolerated well. For full details
of the procedure please see the separately dictated operative
reports. 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 infectious disease
service was consulted during admission and recommended a course
of IV CTX therapy given cultures positive for GBS. The ___
hospital course was otherwise unremarkable.
At the time of discharge the patient's incisions were
clean/dry/intact. The patient is NWB in the operative extremity,
and will be discharged on Lovenox for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
See OMR
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV q24hr
Disp #*30 Intravenous Bag Refills:*2
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 40 mg SC twice a day Disp #*60
Syringe Refills:*0
4. Ascorbic Acid ___ mg PO BID
5. Atorvastatin 20 mg PO QPM
6. Baclofen 20 mg PO TID
7. DULoxetine ___ 90 mg PO DAILY
8. Furosemide 20 mg PO DAILY
9. Oxybutynin 5 mg PO TID
10. OxyCODONE SR (OxyCONTIN) 20 mg PO Q8H
11. Pregabalin 200 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Distal Femur osteomyelitis
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:
- Activity as tolerated
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Please take all medications as prescribed by your
physicians at discharge.
3) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
ANTIBIOTTICS:
- Take Ceftriaxone as prescribed unless otherwise directed by
Infectious Disease
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing 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:
No restrictions
Treatments Frequency:
Sutures to be removed at 2 week follow up in ___ trauma
clinic.
Followup Instructions:
___
|
19939036-DS-9 | 19,939,036 | 23,442,391 | DS | 9 | 2134-03-23 00:00:00 | 2134-03-29 08:23:00 |
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 sided weakness
Major Surgical or Invasive Procedure:
attempted embolectomy
History of Present Illness:
___ left handed male with history of hypertension,
hyperlipidemia, subdural hematoma ×2, multiple falls, alcohol
abuse, prior CVA in ___ with no residual deficits presented to
___ with left MCA syndrome transferred for possible
embolectomy.
Last known well at 9:30 AM ___ when his wife saw him before
she went to the gym. She gave him his computer to keep him
occupied while she was gone when she returned in the afternoon
she found him with right arm and leg weakness, confusion,
slurred
speech, right-sided neglect and visual deficit.
On arrival to ___ his ___ stroke scale was 8 scoring for
month and age, command, extraocular movements, right leg drift,
ataxia and one limb, aphasia, dysarthria, neglect. Initial
vital
signs were blood pressure 172/86, 90 8.3F, pulse is 70, satting
95%. EKG showed right bundle branch block with T-wave
inversions
in leads III, these findings are similar to the prior EKG.
Noncontrast head CT showed developing hypodensity in the left
parietal region in addition to left ICA occlusion from origin to
the petrous portion.
On arrival to the VI emergency department the patient was taken
directly to CT where perfusion imaging showed an ischemic core
of
39 cc and a mismatch of 5.4 signifying a large penumbra. He was
therefore taken directly from CT to the endovascular suite for
intervention on his L ICA occlusion.
In the ___ suite, multiple attempt to pass the catheter through
the ICA occlusion failed so the procure was aborted. Heparin gtt
started at goal 50-70 PTT.
Past Medical History:
Alcohol abuse, frequent and active
Hypertension
Hyperlipidemia
Recurrent falls
Right knee surgery
CVA in ___ details, no reported residual
Social History:
___
Family History:
Unknown
Physical Exam:
Vitals: Vital signs not performed prior to transfer to ___
suite.
Per EMS, SBP between 200-220 during transfer.
Neurologic Examination:
In order to expedite his care, only the NIHSS was performed by
the stroke fellow and attending - this is documented below.
- Mental status: Awake, alert, interactive. Stuttering effortful
Speech - nonfluent. Follows simple commands. Significant neglect
of his right side.
- Cranial Nerves: Horizontal gaze full. VFF to confrontation,
Face activates symmetrically. Speech is mildly dysarthric.
- Motor:
No drift in all four extremities
- Reflexes: Deferred
- Sensory: Decreased sensation to light touch on the right side
of his body
- Coordination: No dysmetria on finger/nose/finger
- Gait: deferred
The NIHSS was performed:
Date: ___
Time: 4:30p
(within 6 hours of patient presentation or neurology consult)
___ Stroke Scale score was : 6
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 0
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 1
10. Dysarthria: 1
11. Extinction and Neglect: 2
===============
DISCHARGE EXAM:
General: Awake, cooperative, NAD.
HEENT: NC/AT, No nuchal rigidity
Pulmonary: no increased WOB
Cardiac: warm, well perfused
Abdomen: soft, NT/ND
Extremities: No ___ edema.
Skin: no rashes.
Neurologic:
-Mental Status: Alert, Fluent speech. Able to follow simple
ommands.
-Cranial Nerves: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. R NLFF, activates slower. Palate elevates
symmetrically. Dense RHH.
-Motor:
RUE: ___ R delt. ___ R tri, ___ R finger flexion.
LUE: Full strength on left
RLE: ___ IP, ___ quad, ___ TA, ___ plantarflexion
LLE: ___ IP, ___ quad, ___ TA, ___ plantarflexion
-Coordination: no dysmetria
-Gait: deferred
Pertinent Results:
ADMISSION LABS:
___ 06:24PM BLOOD WBC-10.5* RBC-3.86* Hgb-12.9* Hct-36.5*
MCV-95 MCH-33.4* MCHC-35.3 RDW-12.2 RDWSD-42.5 Plt ___
___ 06:24PM BLOOD ___ PTT-29.7 ___
___ 06:24PM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-135
K-4.6 Cl-96 HCO3-23 AnGap-16
___ 06:24PM BLOOD ALT-18 AST-47* LD(LDH)-431* CK(CPK)-118
AlkPhos-50 TotBili-0.9
___ 06:24PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:24PM BLOOD Albumin-4.5 Calcium-9.0 Phos-3.5 Mg-1.7
Cholest-200*
___ 06:24PM BLOOD %HbA1c-4.6 eAG-85
___ 06:24PM BLOOD Triglyc-127 HDL-73 CHOL/HD-2.7
LDLcalc-102
___ 06:24PM BLOOD TSH-2.1
___ 06:24PM BLOOD CRP-1.2
___ 06:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-10.9* RBC-4.03* Hgb-13.4* Hct-37.8*
MCV-94 MCH-33.3* MCHC-35.4 RDW-12.1 RDWSD-41.9 Plt ___
___ 07:00AM BLOOD Glucose-101* UreaN-15 Creat-0.7 Na-139
K-3.7 Cl-102 HCO3-22 AnGap-15
DIAGNOSTIC STUDIES:
MR ___ ___:
1. Acute infarct within the left parieto-occipital and temporal
lobes.
2. Generalized parenchymal volume loss, likely age related.
CTA Head and Neck ___:
1. Findings consistent with acute left parietal infarct with
surrounding
ischemic penumbra in the left parieto-occipital region.
2. Severe stenosis (70-99%) is identified at bilateral internal
carotid artery
origins.
3. Left internal carotid artery is diminutive and is completely
occluded at
the petrous segment.
4. Right vertebral artery is completely occluded from the origin
to C7 level.
Second site of occlusion is at V3 segment, below C1 transverse
foramen. Focal
calcification in V4 segment limits evaluation of vessel patency
at that
location.
5. Left vertebral artery ends in posterior inferior cerebellar
artery.
6. There is a lack of distal MCA branches in the left parietal
region.
Otherwise, the vessels of the circle of ___ and their
principal
intracranial branches appear patent.
7. Right cerebellar encephalomalacia is likely an old infarct.
CT Head ___:
1. Interval evolution of recent left parietal infarct.
2. No intracranial hemorrhage is identified.
Echo ___:
The left atrial volume index is severely increased ___ of 49
mL/m2). 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%).
Global longitudinal strain is normal (-20.5%). Right ventricular
chamber size and free wall motion are normal. The diameters of
aorta at the sinus, ascending and arch levels are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION:
1) Normal biventricular regional/global systolic function.
2) No specific echocardiographic evidence of cardiac embolus
noted. However, there is biatrial enlargement with severe left
atrial enlargement in absence of significant mitral
regurgitation..
Brief Hospital Course:
___ (L handed) w/ HTN, HLD, subdural hematoma x2, h/o multiple
falls, alcohol abuse, prior CVA in ___ with no residual
deficits presented to ___ on ___ with left MCA
syndrome, L parietal hypodensity (possibly angular gyrus artery
territory), L ICA
occlusion (from neck to petrous portion) transferred to ___
___ for embolectomy. Interventional approach showed that the
left ICA in the neck was closed and heavily calcified, could not
be opened. He was started on heparin gtt (goal PTT 50-70), and
transitioned to dual antiplatelet therapy with aspirin and
plavix.
# Ischemic Stroke: Thrombectomy was unsuccessful due to fully
occluded and calcified left ICA. The patient did not receive tPA
as he was out of the window. Etiology was possibly artery to
artery, as there were calcifications in aorta and carotids.
Possibly stem embolus from
ICA occlusion vs afib, though no history of afib. He was
admitted and started on heparin drip and fluids with HOB flat.
In the ICU, he had an exam change, increased hand weakness and
facial droop, repeat head CT showed interval evolution of L
parietal stroke, without any hemorrhagic transformation. His
activity was liberalized and he was able to tolerate sitting up
without any further changes in exam. Heparin drip was stopped
after 4 days and changed to ASA/Plavix, with a plan to continue
that for 3 months before transitioning to aspirin only. A1c 4.6%
LDL 102. Atorvastatin 80 mg daily started. Echocardiogram was
done to evaluate for stroke risk factors was done, and was
normal. Patient was discharged with cardiac monitor to assess
for presence of atrial fibrillation.
# HTN: Initial blood pressures were allowed to auto regulate to
SBP <180, and home blood pressure regimen was held. He was
restarted on 6.25mg metoprolol XL (decreased from home dose),
with SBPs in the 130s-140s range at discharge.
=================
Transitional Issues:
Meds:
- please titrate blood pressure medications (increase
metoprolol to home dose and restart Lisinopril) as tolerated
- patient continues on ASA/Plavix started on ___. Please
transition to aspirin only in 3 months.
Diagnostics:
- Patient requires outpatient holter monitor
Appointments:
- patient to follow up with neurology ___ months after
discharge
- patient to follow up with PCP
=================
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 = 102) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) (x) Yes - () No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
35 minutes were spent on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Lovastatin 40 mg oral DAILY
3. Omeprazole 20 mg PO DAILY
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Thiamine 100 mg PO DAILY
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until blood pressure tolerates
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Ischemic Stroke
Left Carotid Artery Thrombosis
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. ___,
You were hospitalized due to symptoms of weakness resulting
from an ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the ___ is blocked by a
clot. The ___ is the part of your body that controls and
directs all the other parts of your body, so damage to the ___
from being deprived of its blood supply can result in a variety
of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
high blood pressure
elevated serum lipids
prior stroke
We are changing your medications as follows:
- we stopped lovastatin, and started atorvastatin instead for
hyperlipidemia
- your blood pressure medications (metoprolol and Lisinopril)
were reduced, and can be restarted as instructed by your doctor
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19939336-DS-9 | 19,939,336 | 29,130,518 | DS | 9 | 2141-09-17 00:00:00 | 2141-09-17 14:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
losartan / cephalexin / felodipine / quinine / triamterene
Attending: ___.
Chief Complaint:
L knee wound infection
Major Surgical or Invasive Procedure:
Irrigation and debridement of left patellar wound ___ ___
Wound closure and ex-fix placement (___)
History of Present Illness:
___ female with history of recent left open patella fracture
status post ORIF ___ ___, who now presents with
wound
infection and draining sinus.
Patient was last seen in clinic on ___. She had been
having some erythema as well as subjective fevers, but it was
thought to be mostly due to postoperative changes. However,
more
recently at rehab, she was noticed to have a open draining sinus
at her left knee. She presents to the ED today for further
evaluation and treatment.
Past Medical History:
PMH/PSH:
Problems (Last Verified - None on file):
Hypertension takes 30 mg lisinopril daily
Social History:
___
Family History:
Non Contributory
Physical Exam:
___ 0748 Temp: 99.1 PO BP: 169/90 L Lying HR: 80 RR: 18 O2
sat: 97% O2 delivery: Ra
General: Well-appearing, breathing comfortably
MSK:
Incision C/D/I, with ex-fix in position
WWP distally
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 knee I&D and closure and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ and ___ for irrigation and debridement,
followed by closure and ex-fix placement, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to rehab was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing in the left lower extremity, and will be
discharged on Lovenox 40 mg daily for 4 weeks for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge.
See below for infectious disease recommendations:
ASSESSMENT & PLAN:
___ yo woman w/ HTN who was living independently before traumatic
L open patella fracture ___ s/p ORIF ___ and d/c to rehab ->
home now p/w wound infection and draining sinus s/p L knee
washout ___.
Patient is presenting with erythema, swelling and drainage from
her left knee after ORIF ___. She is not having any systemic
symptoms. OR cultures ___ growing MRSA. Patient underwent
another incision and drainage of her left knee ___. While op
reports are not up at the time of this note, we would recommend
treating for an empiric septic joint/osteomyelitis course with 6
weeks of therapy, tentatively until ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
5. Lisinopril 30 mg PO DAILY
6. Metoprolol Tartrate 6.25 mg PO Q6H
7. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
8. Pantoprazole 40 mg PO Q24H
9. Senna 8.6 mg PO BID:PRN Constipation - Second Line
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcu once a day Disp #*28
Syringe Refills:*0
4. Ondansetron 4 mg IV Q8H:PRN Nausea/Vomiting - First Line
5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
6. Vancomycin 1250 mg IV Q 24H
7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every four
horus Disp #*15 Tablet Refills:*0
8. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
9. Atorvastatin 80 mg PO QPM
10. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
11. Lisinopril 30 mg PO DAILY
12. Metoprolol Tartrate 6.25 mg PO Q6H
13. Pantoprazole 40 mg PO Q24H
14. Senna 8.6 mg PO BID:PRN Constipation - Second Line
15. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until patient completes 4-weeks of lvx
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left patellar tendon wound status post irrigation and
debridement (___)
Discharge Condition:
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing left lower extremity with an external fixator
(will require ex-fix for ___ weeks as the wound heals) pin care
needed.
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 [] daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Activity: Left lower extremity: Non weight bearing
Treatments Frequency:
Pin Site Care Instructions for Patient and ___:
For patients discharged with external fixators in place, the
initial dressing may have Xeroform wrapped at the pin site with
surrounding gauze.
Often, the Xeroform is used in the immediate post-op phase to
allow for control of the bleeding. The Xeroform can be removed
___ days after surgery.
If the pin sites are clean and dry, keep them open to air. If
they are still draining slightly, cover with clean dry gauze
until draining stops.
If they need to be cleaned, use ___ strength Hydrogen Peroxide
with a Q-tip to the site.
Call your surgeon's office with any questions.
Followup Instructions:
___
|
19939579-DS-7 | 19,939,579 | 25,525,274 | DS | 7 | 2180-02-07 00:00:00 | 2180-03-15 14:53:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, po intolerance
Major Surgical or Invasive Procedure:
___: ERCP
History of Present Illness:
Per admitting resident: ___ with PMHx for cholecystitis who
underwent lap converted to
open cholecystectomy on ___ due to inability to visualize
gallbladder. Patient had wound vac placed and was discharged on
___ with a JP drain and wound vac to midline of the abdomen.
Patient returned to ___ on ___ with emesis, diarrhea, and
abdominal pain and infection of drain site. Patient was
discharged on ___. Patient again presented to the ED on ___
for RUQ pain and was managed by GI for gastroenteritis. Patient
was again seen in the ED on ___ for abdominal pain,
inability to tolerate PO, and nausea/vomiting. CT scan was WNL,
and labs were wnl. Patient was seen in clinic, tearful,
complaining of abdominal pain, and not tolerating any PO since
___. Patient states that she has been having cyclic
vomiting.
Past Medical History:
Past Medical History:
# HTN - off meds, previously on norvasc
# diverticulitis ___ yrs ago
# anxiety, depression
Past Surgical History:
# umbilical hernia repair with mesh
# CCY as above
Social History:
___
Family History:
Father died of amyloidosis, mother died of CHF.
Physical Exam:
Per team note day of discharge:
VS T 98.8 P 73 BP 143/57 RR 18 02 100%RA
Neuro: alert and oriented x 3, NAD
Cardiac: regular rate and rhythm
Resp: no respiratory distress
Abdomen: soft, nondistended, nontender, no rebound
tenderness/guarding
Ext: +pulses
Pertinent Results:
LABS:
___ 06:00AM BLOOD ALT-199* AST-50* AlkPhos-151* TotBili-0.5
Lipase-48
___ 07:15AM BLOOD ALT-298* AST-94* AlkPhos-183* Amylase-37
TotBili-0.7 WBC-4.3# RBC-4.71 Hgb-13.2 Hct-40.0 MCV-85 MCH-28.1
MCHC-33.1 RDW-16.7* Plt ___ ALT-298* AST-94* AlkPhos-183*
Amylase-37 TotBili-0.7 ALT-298* AST-94* AlkPhos-183* Amylase-37
TotBili-0.7 BLOOD Lipase-37
___ 07:35AM BLOOD WBC-9.7 RBC-4.91 Hgb-13.5 Hct-40.7 MCV-83
MCH-27.5 MCHC-33.2 RDW-16.4* Plt ___ ALT-486* AST-268*
AlkPhos-225* TotBili-1.1
Lipase-23
___ 11:00AM BLOOD ALT-544* AST-437* AlkPhos-233*
TotBili-3.0* Lipase-20
___ 07:10PM BLOOD WBC-10.2 RBC-5.84* Hgb-15.8 Hct-47.3
MCV-81* MCH-27.0 MCHC-33.4 RDW-16.3* Plt ___ Neuts-72.6*
___ Monos-5.3 Eos-1.2 Baso-0.3
___ 07:16PM BLOOD Lactate-1.5
IMAGING:
___
MRCP (MR ABD ___: 1. 1 cm obstructing distal CBD stone with
mild intra and extrahepatic bile duct dilatation, mild
cholangitis, and delayed excretion of hepatobiliary contrast. 2.
No hepatic fluid collection. 3. Moderate hepatic steatosis.
ERCP: During difficult CBD cannulation, the pancreatic duct was
partially filled with contrast and visualized proximally. The
course and caliber of the duct was normal with no evidence of
filling defects, masses, chronic pancreatitis or other
abnormalities. A ___ single pigtail pancreatic duct was placed.
The bile duct was deeply cannulated with the sphincterotome.
Contrast was injected and there was brisk flow through the
ducts. Contrast extended to the entire biliary tree. The CBD was
12mm in diameter. A large filling defect consistent with a stone
was identified in the distal CBD. The left and right hepatic
ducts and all intrahepatic branches were normal. A biliary
sphincterotomy was made with a sphincterotome. There was no
post-sphincterotomy bleeding. The biliary tree was swept with a
12-15mm balloon starting at the bifurcation. A large amount of
viscous bile and pus was removed. Stone extraction was deferred
at this time given presence of cholangitis and likely need for
additional sphincteroplasty. A ___ x 8cm straight plastic stent
was placed into the CBD. Excellent bile and contrast drainage
was seen endoscopically and fluoroscopically. Otherwise normal
ercp to third part of the duodenum.
Brief Hospital Course:
Per In-patient Scanned Records: Ms ___ is a ___ year-old
female s/p laparoscopic converted to open cholecystectomy
performed in ___. Upon presentation to ___ clinic on
___, the patient reported intermittent pain since
surgery which had become acutely worsened over the previous
three week period and was now associated with nausea, vomiting
and po intolerance. She was thus transferred to the Emergency
Department where she placed on bowel rest and given intravenous
fluid resuscitation, anti-emetics and anti-nausea medication.
Once a bed became available, the patient was transferred to the
general surgical ward for ongoing work-up and observation.
On HD#2, the patient was noted to have a transaminitis (ALT 544,
AST 437, alk phos 233, T bili 3)and an obstructing CBD stone
with mild cholangitis seen on MRCP. Subsequently, she was
placed on Unasyn and underwent an ERCP during which a
sphincterotome and CBD stent placement was performed; the CBD
stone was seen, however, extraction was deferred due presence of
cholangitis. Post-procedure, the patient remained afebrile and
hemodynamically stable. Given improved abdominal pain and
downward trending LFTs, the patient's diet was advanced to clear
liquids. She did inititally experience some nausea with po
intake, but this resolved and she was able to progress to a
regular diet on HD#4. Intravenous antibiotics were discontinued
on HD#4.
Given steady improvement of symptoms and LFTs, the patient was
discharged to home on HD#5 with planned repeat ERCP for removal
of the CBD and PD stents with sphincertoplasty and stone
extraction on ___ and follow-up in the ___ clinic.
Medications on Admission:
amlodipine 5', zoloft 100', xanax 0.25'prn
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
do not drive or use machinery while taking this medication
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID constipation Duration: 2 Weeks
stop use if having loose stool
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
1: abdominal pain
2: vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital on ___ for a clinic appointment
complaining of abdominal pain, and not tolerating any PO since
___. You stated that you had been having cyclic
vomiting. You were admitted to the hospital from clinic for
further evaluation and ERCP which you had on ___.
You are feeling better and are ready to be discharged home.
Please adhere to the following instructions 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. 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:
___
|
19939579-DS-9 | 19,939,579 | 23,371,760 | DS | 9 | 2180-03-04 00:00:00 | 2180-03-04 16:40:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
cc: nausea/vomiting
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ yo F who presents with nausea/vomiting and inability to
tolerate regular diet. Pt with complicated history since ___ when she underwent lap to open cholecystectomy. This was
complicated by bile leak requiring JP drain and wound vac to
laparotomy site. She subsequently had another admission for an
infected R port site for which she completed a course of
antibiotics. Pt with ongoing symptoms of nausea and intermittent
abdominal pain, which led to an admission on ___ where she had
an MRCP which showed a stone in the distal CBD and evidence of
cholangitis. She underwent sphincterotomy and billiary stenting.
The stone was unable to be removed. Pt had repeat ERCP on ___
where the existing stents were removed and sphinceroplasty was
performed followed by removal of a large stone. Post procedure,
she had resolution of her RUQ and epigastric pain, but had
ongoing nausea. She was not able to be advanced past clears at
the time of discharge. Pt went home and continued to only
tolerate a clear liquid diet. She says that whenever she has
tried toast or broth, she has had recurrent nausea and vomiting.
Vomitus is nonbloody and nonbillious and consists of what she
ate. She has only been able to drink fluids such as gatorade.
She denies abdominal pain. She has been having bowel movements
and passing gas. No diarrhea.
ROS: otherwise negative
Past Medical History:
Past Medical History:
# HTN - off meds, previously on norvasc
# diverticulitis ___ yrs ago
# anxiety, depression
Past Surgical History:
# umbilical hernia repair with mesh
# CCY as above
Social History:
___
Family History:
Father died of amyloidosis, mother died of CHF.
Physical Exam:
Vitals: 98.4 128/64 68 18 98%RA
Gen: NAD
HEENT: moist mucous membranes
CV: rrr, no r/m/g
Pulm: clear b/l
Abd: no tenderness, healed midline and laproscopic scars, active
bowel sounds
Ext: no edema
Neuro: alert and oriented x 3, no focal deficits
Pertinent Results:
___ 03:15PM WBC-8.4 RBC-5.27 HGB-14.7 HCT-42.3 MCV-80*
MCH-27.8 MCHC-34.7 RDW-16.0*
___ 03:15PM PLT COUNT-181
___ 03:15PM GLUCOSE-85 UREA N-7 CREAT-0.9 SODIUM-138
POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
___ 03:15PM ALT(SGPT)-38 AST(SGOT)-34 ALK PHOS-68 TOT
BILI-0.6
___ 03:15PM ALBUMIN-4.3 CALCIUM-9.6 PHOSPHATE-3.7
MAGNESIUM-2.3
___ 03:15PM LIPASE-28
___ 03:15PM LACTATE-1.5
___ 03:15PM ___ PTT-31.2 ___
___ 04:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___
Normal mucosa in the esophagus
Erythema in the stomach compatible with gastritis (biopsy)
There was a large amount of bile seen in the stomach. Bile was
also seem refluxing into the stomach through the pylorus.
There was a soft area with a central dimple near the pylorus.
(biopsy)
Polyps in the duodenal bulb (biopsy)
There was a slight increase of bleeding noted with each biopsy.
Mild patchy erythema in the duodenal bulb compatible with
duodenitis
Otherwise normal EGD to third part of the duodenum
Recommendations:Follow up pathology results.
Further recommendations per inpatient team.
.
CT abd/pelvis:
IMPRESSION:
1. Pneumobilia, a normal finding after ERCP.
2. No evidence of acute intra-abdominal or intrapelvic process.
3. Large unchanged paraumbilical hernia.
4. Mild splenomegaly.
5. Diverticulosis.
6. Status post cholecystectomy
.
pathology"
PATHOLOGIC DIAGNOSIS:
1A. Body: Fundal mucosa, no diagnostic abnormalities recognized.
2A. Antrum: Changes suggestive of chemical gastropathy.
3A. Duodenum: Changes consistent with chronic duodenitis
Brief Hospital Course:
This is a ___ yo F s/p CCY complicated by bile leak and
woundinfection, retained stone s/p ERCP and extraction now with
ongoing nausea/vomiting and inability to tolerate diet.
#Nausea/Vomiting
The patient presented with nausea and vomiting following ERCP >1
week prior to presentation. She was seen by GI and underwent EGD
which showed gastritis with bile in the stomach as well as
duodenitis. It was thought her symptoms of nausea may be due to
bile acid gastritis. As such, she was started on carafate and
continued on a PPI with improvement in symptoms. She was
tolerating a regular diet prior to discharge. She was discharged
with a PPI, carafate, and oral antiemetics for symptomatic
relief. She will need outpatient GI follow up for consideration
of gastric emptying study. At the time of follow up, can
consider full course of therapy for her PPI, carafate and
antiemetics.
#Anxiety/Depression
continued home Xanax and sertraline
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.25 mg PO TID:PRN anxiety
2. Sertraline 100 mg PO DAILY
3. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
Discharge Medications:
1. ALPRAZolam 0.25 mg PO TID:PRN anxiety
2. Sertraline 100 mg PO DAILY
3. Vitamin D 50,000 UNIT PO 1X/WEEK (MO)
4. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*60 Tablet Refills:*0
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth q6 Disp
#*30 Tablet Refills:*0
7. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth q8 Disp #*15
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Bile acid gastritis
Nausea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
admission to ___. You were admitted with nausea and inability
to eat. You had an endoscopy which showed bile in your stomach
which may have been making you feel nauseated. You had some
evidence of irritation in your duodenum (small intestine) and
stomach (gastritis). You were started on a medication called
Carafate which improved your symptoms. You will need to follow
up with gastroenterology as an outpatient to discuss a gastric
emptying study.
Followup Instructions:
___
|
19939665-DS-2 | 19,939,665 | 28,666,537 | DS | 2 | 2187-01-12 00:00:00 | 2187-01-15 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine / aspirin / Vicodin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
___ is a ___ man with chronic hepatitis C
virus liver disease, genotype 1, complicated by decompensated
cirrhosis with a history of fluid retention and hepatic
encephalopathy presenting with AMS and abdominal pain x6 days.
Abd pain started on ___ but was mild and intermittent and today
it got more severe. He was instructed by hepatology fellow to
come to ED to r/o SBP. He has chronic abd pain, described as
"soreness". Abd pain is located in the RUQ, right flank, and
sometimes LLQ, sore in quality but gets intermittently sharp to
___. He also reports increased abdominal girth. On GI ROS, he
endorses diarrhea 2x/day on lactulose 30cc bid-tid, intermittent
BRBPR in stool (last episode last week attritubted to
hemorrhoids), denies N/V, constipation, poor appetitie, melana.
No fever, chills, URI symptoms, recent illness, chest pain, or
dyspnea. Has a chronic cough. Has been compliant with all his
medications. No recent medication changes. Pt does not have a
PCP ___.
Pt states that he has severe headaches ___ h/o TBI and his
headache has been very severe today. He also reports left
shoulder pain s/p fall and humurus fracture over a month ago.
On ROS, he reports ___ edema and knee pain.
In the ED initial vitals were: 97.2 64 134/96 16 97% on RA.
- Labs were significant for BUN/Cr ___ (baseline Cr 1.0), ALT
96, AST 108, T.bili 1.5, Alb 4.3, lipase 43, normal CBC, INR
1.0, lactate 1.3. UA w/ small leuks, WBC 4, few bacteria. CT A/P
notable for splenomegaly and varices but no ascites and
thickened esphagus c/f esophatitis.
- Patient was given percocet x2.
Vitals prior to transfer were: 97.6 60 109/67 18 99% RA.
On the floor, VS are: 97.7 131/65 57 20 96% on RA. Pt is in no
acute distress. When asked about abd pain, pt speaks mostly
about headache and left shoulder pain than abd pain. He says
that abd pain is chronic, "it is always sore" but it has been
worse x6-7 days and intermittently becomes sharp. He says that
he's been getting into arguments with his wife frequently daily
and that has been very stressful to him. He says that he felt
some chest pain before he was transferred to the floor.
Past Medical History:
HCV cirrhosis c/b hepatic encephalopathy and fluid retention
DMII
depression
BPH
insomnia
Hypertension
Head injury secondary to a car crash in ___ where he
sustained a subdural hematoma
epilepsy
kidney stones
Past Surgical History:
1. cholecystectomy
2. bilateral shoulder rotator cuff repair
3. kidney stones
Social History:
___
Family History:
Mother is deceased at age ___ from complications
of diabetes and coronary artery disease. Father deceased at age
___ from CVA, MI and heart failure. He has 1 sister who has MS
and no brothers.
Physical Exam:
ADMIT PHYSICAL EXAM:
Vitals - 97.7 131/65 57 20 96% on RA.
GENERAL: in mild stress, slow in response but A&Ox3, responding
appropriately to questions with good recall and cognition,
moderate asterixis
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, systolic murmur
LUNG: crackles bibasilar, breathing comfortably without use of
accessory muscles
ABDOMEN: soft, diffuse tenderness but more in RUQ, hypoactive
BS, splenomegaly, no fluid wave, no rebound or gaurding
EXTREMITIES: moving all extremities well, trace edema in b/l
feet
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, moderate asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Vitals - 97.8 61 127/67 20 96%
GENERAL: in mild distress, but alert and talkative.
appropriately to questions with good recall and cognition
HEENT: AT/NC anicteric sclera, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2 normal
LUNG: crackles bibasilar, breathing comfortably without use of
accessory muscles
ABDOMEN: soft, diffuse tenderness but more in RUQ, normal BS,
splenomegaly, no fluid wave, no rebound or gaurding
EXTREMITIES: moving all extremities well, trace edema in b/l
feet
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, very mild asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 04:35PM BLOOD WBC-8.6 RBC-5.03 Hgb-17.1 Hct-48.8 MCV-97
MCH-34.0* MCHC-35.0 RDW-12.6 Plt ___
___ 05:47AM BLOOD WBC-7.0 RBC-4.68 Hgb-15.9 Hct-45.6 MCV-98
MCH-34.0* MCHC-34.9 RDW-12.4 Plt ___
___ 06:48PM BLOOD ___ PTT-30.4 ___
___ 05:47AM BLOOD ___ PTT-29.2 ___
___ 04:35PM BLOOD Glucose-159* UreaN-23* Creat-1.1 Na-136
K-4.4 Cl-98 HCO3-30 AnGap-12
___ 05:47AM BLOOD Glucose-161* UreaN-21* Creat-1.1 Na-137
K-3.7 Cl-99 HCO3-32 AnGap-10
___ 04:35PM BLOOD ALT-96* AST-108* AlkPhos-84 TotBili-1.5
___ 05:47AM BLOOD ALT-84* AST-88* AlkPhos-72 TotBili-1.7*
CT Abdomen
1. Cirrhotic liver with splenomegaly and varices. No ascites.
2. Mildly thickened distal esophagus for which clinical
correlation is
advised for possible esophagitis.
3. Atherosclerosis of the abdominal aorta without aneurysm.
US Liver
1. Echogenic liver consistent with known history of cirrhosis.
2. Patient is status post cholecystectomy, without abnormality
evident in the
right upper quadrant.
3. No evidence of ascites.
EGD
There was scant yellow debris in the esophagus which washed off
completely with gentle irrigation. Otherwise, normal EGD.
Brief Hospital Course:
___ is a ___ man with chronic hepatitis C
virus liver disease, genotype 1, with cirrhosis with a history
of fluid retention and hepatic encephalopathy presenting with
abdominal pain.
# abdominal pain: Patient was admitted with acute on chronic
abdominal pain. He had no ascites, therefore SBP was not
suspected clinically. CT and US of the abdomen and EGD showed no
organic cause of his pain. On physical exam the patients abdomen
was tender to palpation with use of the hands, but nontender
when the abdomen was palpated with a stethoscope (stethoscope
test). patient had recently been discharge from his PCP. He was
also insistent on receiving pain medication on discharge. He was
discharged with a limited supply of percocet until he was able
to follow up with the pain clinic on ___.
# HCV cirrhosis: genotype 1, c/b hepatic encephalopathy and
fluid retention that are medically controlled. MELD score: 9
(baseline low ___. due to blood transfusion in ___. Atenol,
lasix, aldactone, choletyramine were continued.
#h/o HE; no confusion on admission, AOx3 and minimal asterixis.
Continued home lactulose and rifaximin.
# h/o seizure: chronic. s/p TBI due to a car accident many years
ago. home dose of Keppra was continued.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
2. Atenolol 50 mg PO DAILY
3. Rifaximin 550 mg PO BID
4. Spironolactone 100 mg PO DAILY
5. LeVETiracetam 1000 mg PO BID
6. Benzonatate 100 mg PO TID:PRN cough
7. Cholestyramine 4 gm PO DAILY
8. ClonazePAM 0.5 mg PO TID:PRN anxiety
9. Escitalopram Oxalate 40 mg PO DAILY
10. NexIUM (esomeprazole magnesium) 40 mg oral daily
11. Furosemide 40 mg PO DAILY
12. Lactulose 30 mL PO TID
13. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
14. TraZODone 200 mg PO HS:PRN insomnia
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
2. Atenolol 50 mg PO DAILY
3. Benzonatate 100 mg PO TID:PRN cough
4. Cholestyramine 4 gm PO DAILY
5. Escitalopram Oxalate 40 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Lactulose 30 mL PO TID
8. LeVETiracetam 1000 mg PO BID
9. Rifaximin 550 mg PO BID
10. Spironolactone 100 mg PO DAILY
11. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO BID:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
twice per day Disp #*15 Tablet Refills:*0
12. NexIUM (esomeprazole magnesium) 40 mg oral daily
13. ClonazePAM 0.5 mg PO TID:PRN anxiety
Discharge Disposition:
Home
Discharge Diagnosis:
cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___, you were admitted to the hospital because you
were having abdominal pain. We imaged your belly with a CT scan
and ultrasound and also did a procedure called an EGD to look
inside your stomach. All of these tests show that there is
nothing acutely wrong inside your belly. We are setting you up
with a new primary care doctor so that they can manage your pain
better.
Followup Instructions:
___
|
19940147-DS-26 | 19,940,147 | 25,969,058 | DS | 26 | 2127-12-30 00:00:00 | 2127-12-30 17:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cefepime / Aztreonam
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
Upper endoscopy (EGD)
Colonoscopy
History of Present Illness:
Ms. ___ is a ___ year old woman with accelerated CML s/p
allo-transplant ___ complicated by GVHD of the GI/liver/muscle
who has a trach due to respiratory failure from myositis related
to GVHD who presented to her outpatient hematologist today with
worsening diarrhea and was sent to the emergency room. She
reports that stool output varies throughout the day but has been
worsening in the past several days. She denies fevers, chills
or night sweats. She feels hungry currently but has no
abdominal pain.
.
In the emergency department, initial vitals: 98.6 96 135/75 24
100% 6L. Blood and urine cultures were sent. Stool was sent
for C. Diff. Labs were notable for slightly elevated LFTs
compared to her baseline.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough, shortness of breath. + secretions.
Denied chest pain or tightness, palpitations. Denied nausea,
vomiting, abdominal pain. No recent change in bowel or bladder
habits. No dysuria. Denied arthralgias or myalgias.
Past Medical History:
ONCOLOGIC HISTORY:
- ___: Asymptomatic abnormal CBC noted by PCP during routine
visit
- ___: Bone marrow biopsy showed myeloproliferative
disorder, likely chronic myelogenous leukemia. Per patient
report, began taking interferon three times weekly shortly after
diagnosis.
- ___: Started Gleevec 400 mg daily. At some point
thereafter, her dose was increased to 600 mg daily
- ___: Gleevec increased to 400 mg twice daily with
hydroxyurea and allopurinol
- ___: Seen at ___, found to be
in late chronic phase CML. Stem cell transplant was recommended,
but she did not wish to pursue this course.
- ___: ___ held due to worsening anemia and
thrombocytosis. Started on Nilotinib
- ___: Nilotinib held due to QTC prolongation, started on
Dasatinib
- ___: First seen at ___. Bone marrow biopsy showed
accelerated phase CML. began induction chemo with 7+3.
- ___: Admission for MRD SCT
- ___: Discharged on day +32. Transplant complicated by
mucositis with biopsy of the esophagus suggesting upper GI GVHD
which was treated with steroids.
- ___ colonoscopy showing lower GI GVHD
- ___ readmitted with recurrent aGVHD of the liver upper
and lower GI tract in the setting of reducing immunosuppression
- course complicated by myositis due to GVHD requiring
intubation, received IVIG on ___
.
.
PAST MEDICAL HISTORY:
- atherosclerotic coronary vascular disease
- status post CABG in ___
- hypertension
- hyperlipidemia
- Right ankle surgery in ___
- Total abdominal hysterectomy in ___
- Appendectomy at age ___
Social History:
___
Family History:
- father - died of MI, no other health problems
- mother - had heart problems, DM
Four siblings
- 2 bothers had CABG
- 1 brother prostate cancer
- Her sister ___ is her donor and is well
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 98.5 BP 153/70 HR 118, RR 22 93% 10L TM
GENERAL: appears fatigued, pale, no acute distress. Tach masck
in place.
HEENT: No scleral icterus. PERRLA/EOMI. MM dry. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: Diffuse bruising/ecchymosis of the right axilla
extending down left flank. Hands with black eschars on dorsal
surfaces bilaterally.
.
DISCHARGE PHYSICAL EXAM:
T 97.2 BP 116/70 P 81 RR 20 SaO2 99% RA
GENERAL: elderly F in NAD, lying in bed
HEENT: No scleral icterus. PERRLA/EOMI. MM dry. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: CTA B, good air movement bilaterally.
ABDOMEN: Normoactive bowel sounds. Soft, NT, ND. No HSM.
EXTREMITIES: 1+ pitting edema in LLE. Pulses 2+ bilaterally.
NEURO: strength ___ in RLE flexors, ___ in LLE flexors. Strength
___ in LLE and RLE extensors. Sensation grossly intact
bilaterally.
SKIN: Hands with black eschars on dorsal surfaces bilaterally.
Diffuse bruising on skin.
Pertinent Results:
ADMISSION LABS:
WBC-8.0 RBC-3.40* Hgb-11.5* Hct-34.0* MCV-100* MCH-33.8*
MCHC-33.7 RDW-20.0* Plt ___
Neuts-74* Bands-1 Lymphs-9* Monos-14* Eos-0 Baso-0 Atyps-0
Metas-2* Myelos-0 NRBC-1*
Glucose-93 UreaN-26* Creat-0.3* Na-136 K-4.6 Cl-101 HCO3-24
AnGap-16
Calcium-8.8 Phos-4.1 Mg-2.0
ALT-113* AST-51* AlkPhos-228* TotBili-0.8 BLOOD Lipase-21
.
DISCHARGE LABS:
WBC-3.1* RBC-2.70* Hgb-9.3* Hct-28.6* MCV-106* MCH-34.5*
MCHC-32.4 RDW-18.8* Plt ___
Neuts-63 Bands-0 Lymphs-13* Monos-13* Eos-0 Baso-0 Atyps-0
Metas-11* Myelos-0
Glucose-114* UreaN-20 Creat-0.4 Na-138 K-4.0 Cl-105 HCO3-29
AnGap-8
ALT-72* AST-59* AlkPhos-178* TotBili-0.5
Calcium-8.2* Phos-2.2* Mg-1.7
.
Urine Tests:
___ 06:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
.
MICROBIOLOGY:
Stool culture (___): NEGATIVE
Stool O&P (___): NEGATIVE
Stool C. diff toxin A/B (___): NEGATIVE
Blood cultures (___): NEGATIVE
CMV PCR (___): NEGATIVE
Stool C. diff toxin A/B (___): POSITIVE
.
COLONOSCOPY (___): Distal ileum and colon appeared normal with
the exception of two whitish 9 mm "nodules/plaques" in the
cecum. Random biopsies were taken from the distal ileum,
ascending colon, transverse colon, recto-sigmoid to assess for
GVHD. Separately the two cecal nodules which readily came off
completely with biopsy forceps, were submitted as "cecal
nodules". Cold forceps biopsies were performed for histology at
the ileum, ascending colon, transverse colon, recto-sigmoid
colon, cecal nodules.
.
EGD (___): Normal exam. Biopsies were taken from the ___
portion of the duodenum to assess for evidence of GVHD. Cold
forceps biopsies were performed for histology.
.
CT CHEST WITHOUT CONTRAST (___):
1. Diffuse narrowing of the airways without associated air
trapping or
peribronchial inflammation may represent early changes related
to
bronchiolitis obliterans. No air trapping or evidence of
infection.
2. Right approach PICC terminates within the right atrium.
3. Diffusely increased attenuation of the liver most compatible
with iron
deposition.
4. Pericardial calcification likely the residual of prior
pericarditis.
5. 3.0 fluid collection within the right breast is smaller since
___, likely related to a seroma or resolving hematoma, for
which clinical correlation is recommended.
6. Diffusely atrophied chest wall musculature.
.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with a history of
accelerated CML s/p allo-MRD SCT ___ complicated by GVHD of
the liver, gut, myositis necessitating intubation due to
respiratory muscle weakness. She presented with worsening
blood-streaked diarrhea and elevated LFTs, with hospitalization
complicated by multiple DVTs and resulting BRBPR caused by
heparin gtt, with BRBPR, and recurrent C. diff infection.
.
#. DIARRHEA: ___ GVHD and recurrent C diff. Patient has been
having blood-streaked diarrhea since admission likely secondary
to GVHD, which progressed to BRBPR with clots after starting
heparin gtt for DVTs (see below). Heparin was discontinued, but
patient with continued diarrhea. On ___ C. diff toxin was
found positive. Pt has had multiple episodes of C diff in past,
and prophylactic PO vanco had been discontinued on ___. She
was started on IV flagyl on ___ for her positive C diff), then
switched to vanco 500mg PO q6hrs per GI recs (used for recurrent
c diff: 250-500mg PO q6hrs x14 days, then taper). Diarrhea
progressively improved after this. Patient also has chronic gut
and liver GVHD. She had EGD and colonoscopy on ___, which
showed 2 whitish cecal plaques/nodules with biopsy showing focal
active ileitis, rare apoptotic crypt cells in
ileum/ascending/transverse colon consistent with (but not
specific for) GVHD. Also had ileocecal valve nodules composed of
"predominantly fibrinopurulent exudate consistent with ulcer and
a very minute strip of surface epithelium". EGD/colonoscopy
biopsies were found negative for AFB, fungi, CMV, viruses. For
her C diff, patient is discharged on Vancomycin 500mg PO q6
hours for 14 days (first day = ___, last day = ___. After
this, she should restart suppressive therapy: vancomycin 250mg
q6 hours chronically. For her GVHD, she is discharged on
prednisone 30mg by mouth daily, and cyclosporine 50mg by mouth
twice daily.
.
#. BRBPR: pt admitted with blood-streaked stools, found likely
secondary to GVHD (confirmed by colonoscopy on ___. When
heparin gtt was started for multiple ___ DVTs, patient developed
frank BRBPR with clots. This resolved after discontinuing
heparin gtt; patient guaiac negative afterward. She was started
on enoxaparin 40mg BID for DVT prophylaxis with no ensuing
complications.
.
#. ELEVATED LFTs: Patient has known GVHD of the liver. LFTs on
admission showed elevated AST, ALT and Alk Phosph, found likely
___s voriconazole, which she is taking for h/o
paelomyces (___). Her cyclosporine was uptitrated from 25
BID to 50mg qAM and 75mg qPM. When cyclosporine was decreased to
50BID, her LFTs rose again (AST 59, ALT 72, Alk Phosph 178).
**Cyclosporine was increased/decreased/not changed....***
.
#. GVHD: manifested as gut, liver, and muscle GVHD. During
hospitalization her cyclosporine was increased from 25mg BID to
50mg BID as it was felt that her diarrhea on presentation was
from GVHD. Her prednisone was decreased to 30mg by mouth daily.
Due to her muscle GVHD (diagnosed by rheumatology), patient is
extremely weak in her ___ flexor muscles. She will continue
physical therapy at rehab. She was also incidentally found to
have diffuse airway narrowing consistent with possible early
bronchiolitis obliterans on chest CT on ___, although no
clinical signs/symptoms and currently appropriately treated with
steroids and cyclosporine.
.
# MULTIPLE ___ DVTs: patient had left ___ swelling during
hospitalization. ___ on ___ showed multiple BLE DVTs
involving common femoral, superficial femoral, popliteal and
posterior tibial and peroneal veins on L>R. ___ swelling L>R. Pt
started on heparin gtt overnight ___, with a goal PTT of
60-80. She also has an IVC filter in place. Unfortunately, she
then had BRBPR overnight with a supratherapeutic PTT (150). The
heparin gtt was held. She was started on enoxaparin 40mg BID for
DVT prophylaxis, without further guaiac positive stools.
.
# DYSPHAGIA, REDUCED VOCAL CORD MOBILITY: patient has h/o
dysphagia secondary to muscle GVHD. She had repeat swallow study
on ___ which showed no aspiration, also noted reduced right
vocal cord mobility for which she should have outpatient ENT
followup with Dr. ___ # ___. Swallow eval
recs were soft solids, nectar thickened liquids, pills crushed
in puree.
.
#. PAECILOMYCES ON BRONCHIOALVEOLAR LAVAGE: pt found to have
paecilomyces growth on BAL on ___ (her last
hospitalization) in Legionella bottle. She was discharged at
that time on voriconazole with plan to follow up in 2 weeks.
Voriconazole was continued throughout hospitalization. She will
need outpatient ID follow-up in ___.
___ with repeat chest CT prior to appointment, where it will be
determined whether or not to continue Voriconazole. Beta glucan
was rechecked and found to be 52 (down from 92 on ___.
.
# CML s/p MRD AlloSCT: pt is s/p allogeneic SCT on ___. She
is currently in remission, with no evidence of leukemia at this
time. Her course has been complicated by GVHD. During
hospitalization her acyclovir and atovaquone prophylaxis were
continued.
.
# MACROCYTIC ANEMIA: normal B12, folate, TSH. Likely anemia of
chronic disease. B12 and folate supplementation were continued
during hospitalization.
.
# TRACHEOSTOMY: pt has h/o tracheostomy after intubation on last
hospitalization due to respiratory muscle weakness from GVHD.
Trach was decannulated on ___ by IP without incident.
Patient was not dyspneic throughout hospitalization.
.
# HYPERTENSION: home metoprolol and captopril were continued.
Amlodipine was decreased from 10mg daily to 5mg daily.
==================================
Medications on Admission:
MEDICATIONS, per rehab records:
Trazodone 50 mg PO qHS
Vancomycin 250 mg PO q6H
Jevity 1.2 cal 50 ml/hr
Water 120 ml q6H
Voriconazole 200mg PO q12
Combivent inhalation 3 ml q4H PRN
Nystatin 5ml PO QID
Amlodipine 10 mg daily
Atovaquone 1500 mg PO q12H
Colestyramine 1 packet q12
Acyclovir 400 mg PO q12
Calcium Carbonate 500 mg PO q8H
Alumina/magnesia/simethicone 30 ml PO q6H PRN
Cyclosproine 25 mg PO q12H
Lansoprazole 30 mg PO daily
Acetaminophen 650 mg PO q6H PRN
Fluticasone 2 puffs BID
Prednisone 30 mg PO BID
Metoprolol 100 mg PO q6H
Captopril 12.5 mg PO q8H
Diazeptam 2 mg PO qHS PRN
Lorazepam 1 mg IV q6H PRN
Cholecalciferol 400 units PO q12H
Heparin 5000 units SC q12
Lidocaine 2% 10ml PO q8H PRN
.
DIFFERENCES FROM PRIOR D/C SUMMARY:
- Atovaquone is listed as daily on d/c summary
- PO vanc is not on d/c summary
- immunosuppression was IV solumedrol 30 mg BID and IV
cyclosporine
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
1. GVHD of gut, liver and muscle
2. C. difficile diarrhea
Secondary diagnosis:
1. Accelerated CML
GVHD of gut, liver and muscle
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure participating in your care at ___
___. You were admitted to the hospital for
increasing diarrhea and elevations in your liver enzymes. We did
some tests, which showed that this was probably not due to an
infection. You also had an upper and lower endoscopy which
showed signs of GVHD. We will continued to treat this with
cyclosporin and prednisone. In addition, you had a recurrence of
diarrhea caused by C. difficile (which you have had several
times in the past). We are treating this with an antibiotic
called vancomycin.
Please attend the follow-up appointments listed below with your
oncologist Dr. ___ the voice specialist Dr. ___.
We made the following changes to your medications:
1. STARTED enoxaparin 400mg subcutaneous twice daily
2. STARTED alendronate sodium 5mg by mouth daily
3. STARTED ipratropium bromide MDI 2 puffs every 4 hours as
needed for wheezing/shortness of breath
4. STARTED clonazepam 1mg by mouth at bedtime as needed for
insomnia
5. INCREASED vancomycin to 500mg by mouth every 6 hours
6. INCREASED cyclosporin to 50mg by mouth twice daily
7. DECREASED prednisone to 30mg by mouth once daily
8. DECREASED atovaquone to 1500mg by mouth once daily
9. DECREASED amlodipine to 5mg by mouth once daily
10. DECREASED cholecalciferol to 400 units by mouth once daily
11. STOPPED trazodone
12. STOPPED Jevity (tube feeds)
13. STOPPED Combivent
14. STOPPED cholestyramine
15. STOPPED aluminum/magnesium/simethicone
16. STOPPED diazepam
17. STOPPED lorazepam
18. STOPPED heparin subcutaneous injections
19. STOPPED lidocaine 2%
20. STOPPED fluticasone
Followup Instructions:
___
|
19940468-DS-5 | 19,940,468 | 21,877,812 | DS | 5 | 2127-01-20 00:00:00 | 2127-01-20 09:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
left hip hemiarthroplasty ___
attach
Pertinent Results:
Admission Labs:
___ 03:15PM BLOOD WBC: 8.0 RBC: 4.39 Hgb: 11.5 Hct: 38.2
MCV: 87 MCH: 26.2 MCHC: 30.1* RDW: 14.6 RDWSD: 46.5* Plt Ct: 380
___ 03:15PM BLOOD Glucose: 107* UreaN: 11 Creat: 0.7 Na:
137
K: 5.4 Cl: 102 HCO3: 20* AnGap: 15
___ 04:47PM BLOOD ___: 12.7* PTT: 35.6 ___: 1.2*
___ 03:29PM BLOOD Lactate: 3.7* K: 3.1*
___ 10:02PM BLOOD Lactate: 1.7 K: 4.1
Micro:
- Blood culture (___): pending
Imaging:
- Left ___ (___): IMPRESSION: Deep venous thrombosis involving
the left common femoral vein, superficial femoral vein,
popliteal
vein with limited views of the calf veins, which are
also likely partially occluded.
- Left hip plain films (___):
IMPRESSION: Left femoral neck fracture line with transfixing
screws which do not appear to be well anchored in the femoral
head.
- EKG (___): Reviewed by me. NSR, Qtc 464, no acute ischemic
changes
___ 1:30 pm PROSTHETIC JOINT FLUID Source: hip.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
Reported to and read back by ___ (___)
___ 11:59
AM.
GRAM NEGATIVE ROD(S). 1 COLONY ON 1 PLATE.
Anaerobic culture, Prosthetic Joint Fluid (Preliminary):
NO ANAEROBES ISOLATED.
Brief Hospital Course:
SUMMARY/ASSESSMENT: Ms. ___ is a ___ woman with
history of rheumatoid arthritis, hyperthyroidism, left hip
fracture s/p repair now presenting with left leg pain.
ACUTE/ACTIVE PROBLEMS:
# Left hip fracture:
Patient with left hip fracture s/p operative repair four months
prior to admission in ___, now with imaging demonstrating
nonunion and hardware malpositioning. On admission, orthopedic
surgery team was consulted. Recommended ___ guided aspiration of
the hip to rule out infection as the cause of nonunion. Pt
underwent this on ___ and fluid studies showed ONE colony of
gram negative rods. We are awaiting speciation. However, on ___
she went to the OR for debridement and left hip
hemiarthroplasty. After discussing with ortho fellow, sounds
like source is controlled and no indication for antibiotics
after the OR. She has been afebrile without leukocytosis
throughout hospitalization.
She was transferred to the orthopedics service the morning after
her OR.
# Deep vein thrombosis:
Patient presenting with left leg pain, found to have provoked
DVT in setting of immobility relate to
recent surgery as above. Patient received dose of enoxaparin in
ED. Started on heparin gtt on admission. Hep drip was stopped
periop.
Medicine recommends a DOAC like apixaban on discharge for likely
3 months because this is provoked. Her primary care doctor can
follow this up.
# Hyperthyroidism:
Per review of the chart, the patient was seen here by
endocrinology in ___ for palpitations and weakness and found to
have hyperthyroidism. She underwent a radioactive iodine uptake
and scan that showed a hot nodule. Cytology was negative for
malignancy. At that time, the patient was planning to return to
___ so it was recommended that the patient undergo
surgery
(rather than radioactive iodine therapy). It appears that the
patient was subsequently lost to follow up here. The patient
reports that she takes propranolol for management of symptoms
due
to hyperthyroidism, and it does not appear that the patient
underwent definitive management of her hyperthyroidism.
Here, her TSH suppressed, T3 and T4 wnl consistent with
subclinical hyperthyroidism or euthyroid sick syndrome. Given
normal T3 and FT4 no additional work up required at this time.
Continued on home propranolol.
She can have her primary care physician refer her to endocrine.
Discharge Disposition:
Home
Discharge Diagnosis:
Left lower extremity acute provoked DVT
Left hip hardware malposition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Miss ___,
You were admitted with leg pain. You were found to have a clot
in your left leg which was treated with blood thinners. You were
also found to have a problem with the metal in your hip. You had
an operation to fix this.
It was a pleasure taking care of you.
Physical Therapy:
Followup Instructions:
___
|
19940534-DS-16 | 19,940,534 | 25,690,529 | DS | 16 | 2151-06-04 00:00:00 | 2151-06-04 10:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
a left terrible triad injury
Major Surgical or Invasive Procedure:
left radial head arthroplasty, coronoid ORIF, and LCL repair
History of Present Illness:
___ male with no significant past medical history who
presents with the above fracture status post fall from height.
Patient fell from 25 feet directly onto his bilateral heels. He
was evaluated at an outside hospital to have a left elbow
fracture dislocation. This was close reduced, and he was sent
here for further evaluation and possible surgical intervention.
He denies any numbness, tingling in the left upper extremity.
He
is complaining of bilateral heel pain. He denies head strike or
loss of consciousness.
Past Medical History:
denies
Social History:
___
Family History:
non-contributory
Physical Exam:
Temp: 99.6 PO BP: 107/64 HR: 96 RR: 16 O2
sat: 97% O2 delivery: RA
General: Well-appearing, breathing comfortably
MSK:
Left upper extremity:
- In posterior slab splint
- Fires EPL/FPL/DIO
- SILT radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
Pertinent Results:
___ 12:30AM GLUCOSE-105* UREA N-13 CREAT-0.8 SODIUM-143
POTASSIUM-4.2 CHLORIDE-109* TOTAL CO2-21* ANION GAP-13
___ 12:30AM estGFR-Using this
___ 12:30AM WBC-8.1 RBC-4.27* HGB-12.6* HCT-37.6* MCV-88
MCH-29.5 MCHC-33.5 RDW-13.2 RDWSD-42.8
___ 12:30AM NEUTS-76.9* LYMPHS-15.7* MONOS-6.7 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-6.19* AbsLymp-1.26 AbsMono-0.54
AbsEos-0.01* AbsBaso-0.01
___ 12:30AM PLT COUNT-196
___ 12:30AM ___ PTT-26.1 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left terrible triad injury and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left radial head arthroplasty,
coronoid ORIF, and LCL repair, 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
non-weight bearing in the left upper extremity, and will be
discharged on Aspirin 325mg 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.
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Aspirin 325 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate Duration: 10 Days
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
5. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
left terrible triad injury
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:
- non weight bearing in the left upper extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
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 Aspirin 325mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever > 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB
Physical Therapy:
non-weight bearing in the left upper extremity
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:
___
|
19940586-DS-20 | 19,940,586 | 24,061,735 | DS | 20 | 2138-10-09 00:00:00 | 2138-10-09 12:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R ankle pain
Major Surgical or Invasive Procedure:
R distal tibia/ankle ORIF
History of Present Illness:
___ s/p fall from bike sustaining angulating deformity to RLE.
No other injuries, no headstrike, no LOC, no change in vision,
no UE pain, no abd pain, no pelvis pain, no LLE pain. Eval at
OSH significant for RLE bi-mal fx, sent for ortho trauma here.
No paresthsia or weakness, only limited due to pain.
Past Medical History:
none
Social History:
___
Family History:
nc
Physical Exam:
PE: 98.5 102 158/80 16 100% RA
NAD, AOx3
BUE skin clean and intact
No tenderness, deformity, erythema, edema, induration or
ecchymosis
Arms and forearms are soft
No pain with passive motion
R M U ___
EPL FPL EIP EDC FDP FDI fire
2+ radial pulses
BLE skin clean and intact
No LLE tenderness, deformity, erythema, edema, induration or
ecchymosis.
RLE in splint; wwp wiggles toes,
Thighs and legs are soft
No pain with passive motion
Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire
1+ ___ and DP pulses
Pertinent Results:
___ 09:10PM GLUCOSE-101* UREA N-10 CREAT-0.8 SODIUM-141
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-28 ANION GAP-15
___ 09:10PM estGFR-Using this
___ 09:10PM CALCIUM-9.3 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 09:10PM ___ PTT-27.1 ___
___ 08:55PM URINE COLOR-Straw APPEAR-Clear SP ___
Brief Hospital Course:
The patient was admitted to the Orthopaedic Trauma Service for
repair of a R distal tibia/fibula fracture. The patient was
taken to the OR and underwent an uncomplicated ORIF R distal
tibia/fibula. The patient tolerated the procedure without
complications and was transferred to the PACU in stable
condition. Please see operative report for details. Post
operatively pain was controlled with a PCA with a transition to
PO pain meds once tolerating POs. The patient tolerated diet
advancement without difficulty and made steady progress with ___.
Weight bearing status: NWB RLE.
The patient received ___ antibiotics as well as
lovenox for DVT prophylaxis. The incision was clean, dry, and
intact without evidence of erythema or drainage; and the
extremity was NVI distally throughout. The patient was
discharged in stable condition with written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Calcium Carbonate 500 mg PO TID
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC HS
RX *enoxaparin 40 mg/0.4 mL inject into abdomen at bedtime Disp
#*12 Syringe Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Hold for sedation, RR<12 or altered mental status
RX *oxycodone 5 mg ___ Tablet(s) by mouth q4hrs Disp #*90 Tablet
Refills:*0
6. Senna 1 TAB PO BID
7. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
status post R distal tibia, lateral malleolus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
******SIGNS OF INFECTION**********
Please return to the emergency department or notify MD if you
should experience severe pain, increased swelling, decreased
sensation, difficulty with movement; fevers >101.5, chills,
redness or drainage at the incision site; chest pain, shortness
of breath or any other concerns.
-Wound Care: You can get the wound wet/take a shower starting
from 3 days post-op. No baths or swimming for at least 4 weeks.
Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment. No dressing is needed
if wound continued to be non-draining.
******WEIGHT-BEARING*******
non weight bearing R leg
******MEDICATIONS***********
- Resume your pre-hospital medications.
- You have been given medication for your pain control. Please
do not operate heavy machinery or drink alcohol when taking this
medication. As your pain improves please decrease the amount of
pain medication. This medication can cause constipation, so you
should drink ___ glasses of water daily and take a stool
softener (colace) to prevent this side effect.
-Medication refills cannot be written after 12 noon on ___.
*****ANTICOAGULATION******
- Take Lovenox for DVT prophylaxis for 2 weeks post-operatively
Followup Instructions:
___
|
19940725-DS-9 | 19,940,725 | 27,381,801 | DS | 9 | 2123-10-18 00:00:00 | 2123-10-18 19:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
___ Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic paracentesis ___
History of Present Illness:
Ms. ___ is a ___ female with obesity who presented to
the ___ ED on ___ with >2 months of progressive shifting
abdominal pain and bloating.
Ms. ___ notes she has no remarkable history of chronic
abdominal pain. She has been followed intermittently for low
back pain and radiating neuropathic pain to her legs, but this
has been well controlled.
Ms. ___ was feeling well and in her usual state of health
until ___ when she had a one-day GI illness characterized
by vomiting. At baseline, she has one bowel movement per day,
yet around the time following that illness, she began to
experience constipation, having several days without a BM. She
also experienced bloating. Her PCP recommended ___, which
caused her diarrhea. A KUB was unremarkable. She had a
colonoscopy in ___, which was normal. At that time, she
discontinued her ___ and began taking Benefiber, which
helped with the frequency and quality of her BMs, yet she still
experienced significant bloating, causing her pain in her back
and under her ribs. She notes, importantly, that this type of
pain seems completely new and distinct from the type of back
pain she has experienced before.
She also endorsed rectal pain, prominent when walking, as well
___ diffuse abdominal pain worse at night and in the LLQ. She
denied any blood in her stool at that time. Her rectal pain has
since resolved. She also endorsed new SOB with exertion over the
last month. Gas-X, as well as a dairy-free and gluten-free diet
did not help with her bloating, which became gradually worse.
She denied any weight loss over this time period, but she has
been experiencing significant fatigue over the last year; she
saw sleep specialists in neurology who attributed her fatigue to
OSA. Celiac labs were negative, and GI postulated that her
symptoms were due to post-infectious IBS; she took iberogast
(herbal), VSL#3 (probiotic), and dicyclomine without any relief
of her bloating. She also endorsed right lateral thigh numbness
that first began in her right toes over the last month. She
denied any other paresthesias. An abdominal and pelvic
ultrasound was obtained on ___, demonstrating, "Moderate
ascites, with larger volume visualized within the pelvis on same
day" and "Large volume ascites without separable concerning
abnormality within the uterus/adnexa." Her gastroenterologist
recommended admission to the ED for further evaluation.
On ___, she presented to the ED, where she denied fever, chills,
SOB, or changes in skin or urine color, with minimal nausea and
vomiting.
In the ED, initial vitals were: 97.2, 101, 143/83, 18, 100%RA
- Exam notable for: distended abd w/ diffuse TTP worse in LLQ, +
fluid wave
- Labs notable for: WBC6.9, plt ct ___, chem pl nl, LFTs
unremarkable, UA bland, lactate 2.6
- Imaging was notable for:
There is thickening and nodularity along the right peritoneum
(601:47, 52, 55, 61), thickening nodularity of the omentum
(02:52 and 602b:50), and thickening of the peritoneum along the
presacral space (602:46, 2:84) likely representing peritoneal
carcinomatosis.
2. Large volume ascites and intermediate density small
left-sided pleural effusion which are likely malignant.
- Patient was given: 1 L NS bolus, ibuprofen 600mg PO
Upon arrival to the floor, patient reports feeling hungry and
well apart from abdominal discomfort due to her ascites. She
denied any fevers, chills, SOB, CP, myalgias, n/v/d. She reports
she is aware about the concern regarding possible cancer. She
says she feels mainly reassured that a previous mysterious cause
of pain may now have a path toward diagnosis.
Past Medical History:
- chronic back pain (previous MRIs available extending as far
back as ___
- sleep apnea
- morbid obesity
Social History:
___
Family History:
brother - UC
father - "heart condition," COPD
mother - HLD, depression
paternal grandfather - MI, bladder ca, prostate ca
maternal grandmother - b/l breast ca, colon ca, ___
disease
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
Vitals: 97.9, 118/96, 90, 20, 96% RA
General: young female. 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
Abdomen: soft, mild diffuse TTP, distended, + fluid wave; bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals: 98.2 113/80 93 18 95% RA
General: Young lady lying in bed in no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, less distended compared to yesterday, + fluid
wave; dressing on L upper abdomen at paracentesis site, bowel
sounds present, no rebound tenderness or guarding, no
organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
LAB RESULTS ON ADMISSION:
=========================
___ 11:50AM BLOOD WBC-6.9 RBC-4.51 Hgb-11.5 Hct-36.9 MCV-82
MCH-25.5* MCHC-31.2* RDW-13.2 RDWSD-39.5 Plt ___
___ 11:50AM BLOOD Neuts-65.6 ___ Monos-9.5 Eos-0.6*
Baso-0.6 Im ___ AbsNeut-4.50 AbsLymp-1.60 AbsMono-0.65
AbsEos-0.04 AbsBaso-0.04
___ 11:50AM BLOOD ___ PTT-28.1 ___
___ 11:50AM BLOOD Glucose-97 UreaN-7 Creat-0.7 Na-137 K-4.3
Cl-100 HCO3-24 AnGap-17
___ 11:50AM BLOOD ALT-13 AST-17 LD(LDH)-217 AlkPhos-63
TotBili-0.3 DirBili-<0.2 IndBili-0.3
___ 11:50AM BLOOD Lipase-32
___ 11:50AM BLOOD Albumin-3.8 Calcium-9.5 Phos-4.4 Mg-2.1
PERTINENT INTERVAL LABS:
========================
___ 06:50AM BLOOD calTIBC-322 VitB12-222* Ferritn-112
TRF-248
___ 04:45PM ASCITES TNC-1186* RBC-2037* Polys-18*
Lymphs-30* ___ Macroph-5* Other-47*
___ 04:45PM ASCITES TotPro-5.9 Glucose-66 LD(___)-327
TotBili-0.2 Albumin-2.9
LAB RESULTS ON DISCHARGE:
=========================
___ 06:55AM BLOOD WBC-7.6 RBC-4.34 Hgb-11.0* Hct-35.2
MCV-81* MCH-25.3* MCHC-31.3* RDW-13.3 RDWSD-39.3 Plt ___
___ 06:55AM BLOOD Glucose-90 UreaN-4* Creat-0.6 Na-138
K-4.3 Cl-104 HCO3-25 AnGap-13
___ 06:55AM BLOOD Calcium-8.8 Phos-4.9* Mg-2.0
IMAGING:
========
CT ABDOMEN/PELVIS WITH CONTRAST ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is asmall intermediate density left-sided pleural
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepaticor extrahepatic biliary dilatation. The gallbladder
is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence offocal lesions or pancreatic ductal
dilatation. There is no peripancreaticstranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
withoutevidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is noperinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstratenormal caliber, wall thickness, and enhancement
throughout. The colon andrectum are within normal limits. The
appendix is normal. There is thickeningand nodularity of the
omentum (02:52 and 602b:50). There is also thickeningand
nodularity along the right superior peritoneum (601:47, 52, 55,
61) in thesubhepatic space. There is large volume ascites.
PELVIS: There is thickening of the peritoneum along the
presacral space(602:46, 2:84) The urinary bladder and distal
ureters are unremarkable. Thereis a large volume ascites in the
pelvis.
REPRODUCTIVE ORGANS: The uterus and ovaries are grossly
unremarkable.
LYMPH NODES: There is thickening and nodularity along the right
peritoneum(601:47, 52, 55, 61). There is thickening nodularity
of the omentum (02:52and 602b:50). There is thickening of the
peritoneum along the presacral space(602:46, 2:84)
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic diseaseis noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
1. There is thickening and nodularity along the right peritoneum
(601:47, 52,55, 61), thickening nodularity of the omentum
(02:52 and 602b:50), andthickening of the peritoneum along the
presacral space (602:46, 2:84) likelyrepresenting peritoneal
carcinomatosis.
2. Large volume ascites and intermediate density small
left-sided pleuraleffusion which are likely malignant.
Brief Hospital Course:
Ms. ___ is a ___ female who presents with >2 months of
constipation, bloating, abdominal pain, and L thigh numbness,
found to have ascites on ultrasound and CT demonstrating
concerning features for metastatic cancer, including signs of
peritoneal carcinomatosis and possible malignant pleural
effusion.
# Peritoneal Thickening c/f Metastatic Cancer
# Pleural Effusion
Ms. ___ presents with several weeks of constipation, bloating,
and abdominal pain. She was found to have ascites and CT
findings concerning for peritoneal carcinomatosis and malignant
pleural effusion. There is no obvious primary tumor on history
or exam, and her prior transvaginal ultrasound on ___ was
unremarkable. She underwent diagnostic and therapeutic
paracentesis with total of 6.7L of green ascetic fluid removed
on ___. SAAG was 0.9, T.bili was 0.2, and cell count was notable
for 1186 total nucleated cells with 47% atypicals. Fluid was
sent for cytology, which was pending at time of discharge.
She has follow up appointment scheduled for ___ with her
primary care physician, at which time we anticipate that
cytology results should be available. Pending results, she may
require hematology/oncology follow up and further work up such
as staging CT. We did not discharge her on a diuretic as her
ascetic fluid is thought to be exudative. Can consider
outpatient paracentesis for comfort should fluid reaccumulate.
We discussed a clear plan that ___ f/u with her PCP early
next week for results of this cytology evaluation. If she has
any worsening symptoms or concerns prior to then, Dr. ___
___ gave her and her mother his contact information to contact
him directly, though if any severe symptoms to go straight to
the ED. If any issues with her PCP visit as well, she knows to
contact him directly.
# Thrombocytosis: Most likely reactive in the setting of
inflammation; downtrended throughout stay and was 529 at
discharge.
# Sinus tachycardia: Patient noted to have sinus tachycardia
throughout stay with HR in 90-100s. Etiology not entirely clear,
suspect contribution of pain, anxiety, increased sympathetic
tone from underlying inflammatory state. She breathed
comfortably on room air throughout stay, at discharge SpO2 95%;
no evidence of DVT on exam.
TRANSITIONAL ISSUES:
====================
- Discharge weight: 87.3 kg
[] Please follow up pending cytology
[] Consider outpatient paracentesis for comfort should ascites
reaccumulate
[] Consider outpatient social work
[] Pending cytology results, please consider alternate
contraception methods (patient currently on OCP)
# CODE: Full
# CONTACT: ___ (partner; ___
Greater than 30 minutes were spent on this patient's discharge
day management.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20
mcg (21)/75 mg (7) oral ASDIR
2. DICYCLOMine 10 mg PO TID
3. Beneprotein (whey protein isolate) 6 gram-25 kcal/7 gram oral
DAILY
4. VSL#3 (Lactobac #2-Bifido #1-S. therm) 450 billion cell oral
ASDIR
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
3. ___ FE ___ (28) (norethindrone-e.estradiol-iron) 1 mg-20
mcg (21)/75 mg (7) oral ASDIR
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Concern for peritoneal carcinomatosis
New onset ascites
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 came to us with >2 months of progressive shifting abdominal
pain and bloating.
While you were here, we performed a CT scan, which discovered
that you had a large amount of fluid ("ascites") in your belly,
as well as thickening and nodularity of the tissue layer that
lines your belly cavity ("peritoneum", "omentum"). We performed
a procedure to drain the fluid from your belly ("paracentesis"),
and sent samples to be evaluated in the lab/under the
microscope, which will hopefully help us understand the exact
cause for your abdominal pain and abdominal fluid accumulation.
While we cannot tell you a precise diagnosis yet, based on the
imaging findings, we are worried that it might be from a serious
condition such as cancer.
We will be in contact with your primary care doctor to let her
know what has transpired during your stay, and have arranged for
a follow up appointment with her. The results of the tests that
we sent should be available at that time. Based on the results,
you will require further diagnostic testing.
We suspect that the abdominal fluid will likely re-accumulate
slowly over time. If this occurs, please contact your primary
care doctor. It may be possible to arrange for outpatient
drainage procedures to improve your symptoms.
Please take care, we wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19940836-DS-3 | 19,940,836 | 21,746,727 | DS | 3 | 2142-03-19 00:00:00 | 2142-03-19 12:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Citrus And Derivatives / apple skin / cabbage extract
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ woman with history of
fibromyalgia and migraines presenting with abdominal pain.
The patient reports that a migraine woke her from sleep about 4
days ago. She has a history of migraines and this is typical.
She
had an occipital headache associated with nausea. She has a poor
appetite, and did not eat much in the subsequent days. Then on
the day of admission, she felt like "the lining of [her] stomach
is on fire" and felt severe cramping in her right upper
quadrant,
radiating to her back. She felt the urge to defecate but could
not. She compared this pain to the pain of childbirth. She took
an Excedrin migraine, for both a persistent headache and for
this
pain, which did not help. She then developed diffuse pain all
over her abdomen. She denies an emesis. No fevers or chills. No
diarrhea or constipation. No dysuria. She presented initially to
Urgent Care, and then was referred to the ED.
In the ED, vitals: 10 97.6 55 124/80 18 100% RA
Exam: None documented
Labs: CBC, BMP, LFTs, lipase all normal; urinalysis negative
Imaging:
- CXR: No acute cardiopulmonary abnormality.
- CT A/P:
1. No nephroureterolithiasis.
2. Common bile duct is dilated up to 2.1 cm, with tapering seen
in the pancreas head. No obstructing stone or lesion identified.
MRCP is recommended for further evaluation.
Patient given:
___ 22:15 IV Morphine Sulfate 4 mg
___ 22:15 IV Ondansetron 4 mg
___ 01:49 IV Morphine Sulfate 4 mg
___ 01:49 IV Ondansetron 4 mg
On arrival to the floor, the patient reports that her abdominal
pain and nausea are improved. She denies a headache. Some
history
of mild constipation, but no change in bowel habits. No melena
or
hematochezia. She otherwise has no complaints.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
- Fibromyalgia
- Asthma
- Anxiety
- Migraines
- S/p bilateral salpingectomy
- S/p CCY
Social History:
___
Family History:
Mother with ___, anxiety/depression. No known family history of
gastrointestinal disease.
Physical Exam:
ADMISSION:
-------------
VITALS: 97.6 ___ 18 100 RA
GENERAL: Alert, mildly uncomfortable appearing
EYES: Anicteric, pupils equally round
ENT: Moist mucous membranes
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, mildly distended, diffusely tender to
palpation
in all quadrants without rebound or guarding
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: Pleasant, appropriate affect
DISCHARGE:
--------------
AVSS. Tenderness especially in epigastrum, lower quadrants of
abdomen tender, but less so. No rebound or guarding.
Pertinent Results:
ADMISSION:
-------------
___ 09:11PM BLOOD WBC-6.1 RBC-4.25 Hgb-13.0 Hct-38.4 MCV-90
MCH-30.6 MCHC-33.9 RDW-13.1 RDWSD-43.2 Plt ___
___ 07:53AM BLOOD ___ PTT-33.9 ___
___ 09:11PM BLOOD Glucose-94 UreaN-4* Creat-0.8 Na-143
K-4.2 Cl-106 HCO3-22 AnGap-15
___ 09:11PM BLOOD ALT-22 AST-23 AlkPhos-89 TotBili-0.4
___ 09:11PM BLOOD Lipase-38
___ 09:11PM BLOOD Albumin-4.4
___ 08:31AM BLOOD Lactate-1.1
DISCHARGE:
-------------
___ 06:40AM BLOOD WBC-5.9 RBC-3.96 Hgb-11.9 Hct-35.9 MCV-91
MCH-30.1 MCHC-33.1 RDW-12.9 RDWSD-42.9 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-105* UreaN-7 Creat-0.8 Na-141
K-4.5 Cl-106 HCO3-26 AnGap-9*
___ 06:40AM BLOOD ALT-25 AST-25 AlkPhos-77 TotBili-0.3
___ 06:40AM BLOOD Calcium-8.8 Phos-3.7 Mg-2.1
Dilatation of the CBD up to 2.1 cm, which tapers towards the
ampulla. There is equivocal sludge versus artifact in the distal
CBD. No obstructing mass or additional stricture. The sphincter
closed on all sequences and this may represent sphincter of Oddi
dysfunction. Please see the subsequent final dictation for non
urgent findings.
UA (___): neg blood, neg nit, sm ___, 2 RBCs, <1 WBC
UCG: neg
UCx (___): pending
IMAGING:
========
MRCP (___):
CTU w/o cont (___):
1. No nephroureterolithiasis.
2. Common bile duct is dilated up to 2.1 cm, with tapering seen
in the pancreas head. Subtle hyperdense material seen in the
distal CBD is nonspecific, may represent sludge/stones. MRCP is
recommended for further evaluation.
CXR (___):
No acute cardiopulmonary abnormality.
Brief Hospital Course:
___ with hx fibromyalgia, migraines, asthma, symptomatic
cholelithiasis s/p CCY, tubal ligation presenting with one day
of severe abdominal pain, found on imaging to have a dilated
CBD.
# Nausea:
# Abdominal pain:
Patient presented with diffuse abdominal pain and nausea. A
non-contrast CT A/P performed in the ED showed no evidence of
pancreatitis, nephroureterolithiasis, ovarian pathology, or
obstruction/perforation, but did reveal dilation of the CBD to
2.1 cm, with tapering seen in the pancreatic head without
obvious stones. WBC, lipase, lactate and LFTs all WNL. UA and
UCG negative. Patient s/p CCY for symptomatic cholelithiasis,
with low suspicion for cholangitis in the absence of
fevers/leukocytosis. Ms. ___ was initially treated with bowel
rest, IVFs, narcotics, and an IV PPI. She underwent an MRCP,
which showed no strictures or masses, and possible sphincter of
Oddi dysfunction. As nothing was concerning of MRCP and her
sphincter dysfunction is unlikely to have caused her acute pain,
the most likely diagnosis is peptic ulcer disease. Fortunately,
she had no signs of GI bleeding. As she improved with PPIs, she
will be discharged to finish at least a month of omeprazole. Her
PCP should follow up an H Pylori breath test (stool test was not
completed here). If her symptoms do not improve within several
weeks, she will follow up with a gastroenterologist for an upper
endoscopy.
# Migraines:
Patient reports weekly migraines, R-sided with neck pain,
photophobia, auras. Has been seen by outpatient neurology and
reports that "nothing works." She requested NSAIDs (specifically
toradol) for migraine while hospitalized, which were avoided in
the setting of her abdominal pain as above. She was treated with
IVFs and compazine PRN, with some improvement in her pain. She
was advised to follow up with her outpatient neurologist for
further consideration of non-NSAID pharmacologic therapies.
# Asthma:
Not on daily medications (only takes fluticasone during allergy
season).
> 35 minutes spent on discharge activities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Flovent Diskus (fluticasone) 100 mcg/actuation inhalation BID
2. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6h PRN
3. Ibuprofen 800 mg PO Q12H PRN Headache
4. Cetirizine 10 mg PO DAILY AS NEEDED allergies
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY AS NEEDED
allergies
Discharge Medications:
1. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
2. Cetirizine 10 mg PO DAILY AS NEEDED allergies
3. Flovent Diskus (fluticasone) 100 mcg/actuation inhalation
BID
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY AS NEEDED
allergies
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q6h PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Peptic ulcer disease
Secondary:
Migraines
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with abdominal pain. A CT scan
of your abdomen showed dilation of your main bile duct, and you
therefore underwent another imaging test called an MRCP for
further evaluation. This showed that you likely had sphincter of
Oddi dysfunction, but no other cause of blockage. The sphincter
of Oddi dysfunction is unlikely to be the cause of your pain. It
is most consistent with peptic ulcer disease (PUD). Therefore, I
am prescribing you a month-long course of an acid blocking
medication called omeprazole. If you are still having pain after
a month of taking this, you should follow up with the GI doctors
for ___ upper endoscopy to look inside your stomach.
Followup Instructions:
___
|
19940947-DS-10 | 19,940,947 | 28,526,241 | DS | 10 | 2134-09-06 00:00:00 | 2134-09-06 14:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
conventional angiography ___
History of Present Illness:
The patient is an ___ year old man with history of multiple
vascular risk factors including prior stroke who presents with
new right sided weakness and facial droop at 2am this morning
when he awoke. He was last known well at 12am when he went to
bed. Per family, he awoke at 2am and noticed right sided
weakness, however went back to sleep. He then awoke again at
4:30am, which was when family noticed that his face was
asymmetric and he was not moving his right side as well. Of
note, he experienced symptoms of left facial droop last ___
while the patient was in ___ but this was mild and resolved.
He was subsequently brought to ___ where he had NIHSS of
10. He underwent CT/CTA which showed L PCA occlusion. He was
transferred to ___ for further intervention. He did not
receive tpa. He went to angio to eval L PCA for thrombectomy,
however, no clot was seen in angio suite so no intervention
performed. He is admitted to Neuro ICU post angio.
Past Medical History:
HTN
HLD
DMII
CAD s/p LIMA to LAD, followed by PTCA and DES to RCA in
___, on aspirin long term
CVA in ___ without residual deficits, started on Plavix
after this in addition to aspirin
CHF, last TTE in ___ showing EF 45%, mildly dilated left atrium
Social History:
___
Family History:
Brother with stroke
Physical Exam:
ADMISSION EXAMINATION:
Vitals: T: 98 HR: 72 BP: 130/78 RR: 16 SaO2: 100% RA
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
-MS: Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive to examiner. Speech is fluent with full
sentences, intact repetition, and intact verbal comprehension.
Naming intact. No paraphasias. Mild dysarthria. Normal prosody.
No apraxia. No evidence of hemineglect. No left-right confusion.
Able to follow both midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 brisk. VF full to threat. EOMI, no
nystagmus. V1-V3 without deficits to light touch bilaterally. R
lower facial droop with decreased activation of R facies.
Hearing intact to finger rub bilaterally. Palate elevation
symmetric. SCM/Trapezius strength ___ bilaterally. Tongue
midline.
- Motor: Normal bulk and tone. Drift in RUE and RLE throughout.
No tremor or asterixis.
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 2+ 2+ 2+ 2+ 1
R 2+ 2+ 2+ 2+ 1
Plantar response flexor on L, extensor on R
- Sensory: Decreased sensation to LT and PP over RUE/RLE.
Proprioception intact at great toes b/l. Extinction noted to
sensory stimuli over R.
- Coordination: Dysmetria noted in RUE out of proportion to
weakness. None in LUE.
- Gait: Deferred
DISCHARGE PHYSICAL EXAM:
Tmax: 98.5
T current:
HR: 59-78 bpm
BP: 126/80 - 155/70 mmHg
RR: 16 insp/min
SPO2: 98%
General: elderly gentleman sitting comfortably in bed
HEENT: NC/AT, sclerae anicteric, no conjunctival injection
Neck: supple
CV: RRR, no M/R/G
Lungs: clear to auscultation b/l
Abdomen: soft, nontender, nondistended; R groin with dressing,
no pain or palpable hematoma, no ecchymosis, no strikethrough
bleeding
GU: no hernia
Ext: warm, well perfused, pulses intact. right proximal arm with
large area of ecchymosis in dependent areas
Skin: no rashes or cutaneous lesions
Neuro:
MS- awake, alert, oriented, fluent speech; per family slightly
dysarthric with some word finding difficulty
CN- R pupil pinpoint, L pupil surgical cataracts, visual fields
appear full, EOMI, mild right NLFF, tongue protrudes midline
Sensory/Motor- LUE and LLE ___ throughout. RUE ___ deltoid,
4+/5 bicep, ___ tricep; ___ wrist extensor, ___ finger
extensors. RLE internally rotated, right IP ___, ham ___ and
quad 4+/5, plantarflexion ___, dorsiflexion ___.
Sensation intact to light touch throughout but there is
extinction to DSS on the RUE and RLE.
Reflexes-L toe upgoing
Coordination- no ataxia on L, R incoordination in proportion to
weakness.
Pertinent Results:
ADMISSION LABS:
___ 10:01AM BLOOD WBC-7.8 RBC-3.57* Hgb-10.2* Hct-30.7*
MCV-86 MCH-28.6 MCHC-33.2 RDW-13.4 RDWSD-42.4 Plt ___
___ 10:01AM BLOOD Neuts-71.6* Lymphs-18.4* Monos-7.9
Eos-1.2 Baso-0.5 Im ___ AbsNeut-5.56 AbsLymp-1.43
AbsMono-0.61 AbsEos-0.09 AbsBaso-0.04
___ 10:01AM BLOOD ___ PTT-34.7 ___
___ 10:01AM BLOOD Glucose-127* UreaN-17 Creat-1.2 Na-136
K-3.8 Cl-101 HCO3-23 AnGap-16
___ 10:01AM BLOOD Calcium-9.0 Phos-4.2 Mg-1.7 Cholest-PND
___ 10:01AM BLOOD ALT-8 AST-12 CK(CPK)-50 AlkPhos-91
TotBili-0.3
___ 10:01AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:01AM BLOOD %HbA1c-7.9* eAG-180*
*************
IMAGING:
CT head ___
1. No intracranial hemorrhage.
2. Of note, there is a known occlusion of the left posterior
cerebral artery previous CTA head and neck ___.
However, there are no findings on CT suggestive of infarction.
This is likely because of the acuity of the occlusion.
Cerebral angiogram ___:
IMPRESSION:
Diagnostic cerebral angiogram did not demonstrate a tip of the
basilar
occlusion, both PCAs were patent.
Brief Hospital Course:
The patient was taken to ___ suite directly from ED. Cerebral
angiography did not reveal any occlusion of the basilar artery
or either of the PCAs. He was subsequently admitted to the neuro
ICU.
# Neuro
The patient's neurologic examination remained stable and notable
on admission for ___ weakness in the right deltoid, triceps,
and wrist extensors, 5- in the right biceps, and 3 in the finger
extensors. He also had ___ weakness of the ankle dorsiflexor,
with the proximal motor groups limited by groin splint. He had
intact sensation but with extinction to DSS on the right.
Given the findings on angiogram, it was felt that possibly
either the patient had a proximal clot that embolized distally
and/or dissolved prior to the study, or that the CTA findings
represented a congenital vascular anomaly and he had an
alternate vessel infarct. He underwent MRI which showed subacute
infarcts in the left posterior putamen/external capsule leading
to the left posterior frontal corona radiata, right splenium of
the corpus callosum, and right occipital lobe. Stroke risk
factors: A1c 7.9, LDL 73. The etiology was felt to be
cardioembolic in origin despite not having captured atrial
fibrillation (see CV section below). After discussion with his
outpatient cardiologist, he was started on apixaban/aspirin, and
plavix was discontinued.
# CV
Trop, EKG negative for acute ischemia. He was monitored on
telemetry and underwent TTE which showed mild regional LV
systolic dysfunction, c/w CAD and mild mitral regurgitation
(LVEF = 50%); normal LA size; no masses or thrombi. He was
initially continued on aspirin and Plavix. Metoprolol was
continued and the remainder of his antihypertensive were held
for permissive hypertension. Cardiology office visit notes were
also obtained and revealed that he had been on aspirin
monotherapy until his stroke in ___ in ___, when he
was started on Plavix in addition to aspirin. His cardiologist
had ordered a zio patch monitor x14 days in ___ which did not
reveal any evidence of atrial fibrillation. After discussion
with his cardiologist, he was started on apixaban and aspirin,
and plavix was discontinued. He will follow up with his
outpatient cardiologist for potentially long term implantable
loop recording.
# Hematology
He did have oozing through his groin catheter site which did not
respond to pressure and required injection of lidocaine and
epinephrine. Oozing of blood then stopped. CBC was stable.
# Diabetes
A1c 7.9 on admission. A ___ consult was obtained for poorly
controlled DM, and the patient was started on an increased
regimen.
# Right shoulder hematoma/ecchymosis
Incidentally noted several days into admission. No history of
trauma to the area. He underwent a shoulder plain film which was
unremarkable; no evidence of fracture.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed â () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 73) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL if LDL >70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL]
6. Smoking cessation counseling given? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ ] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - () Anticoagulation] - (x) No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A ***presumed
cardioembolic, no definite evidence of atrial fibrillation***
Transitional Issues
[ ] Follow up with Neurology
[ ] Follow up with Cardiology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Metoprolol Succinate XL 200 mg PO DAILY
4. Pravastatin 10 mg PO QPM
5. Valsartan 320 mg PO DAILY
6. amLODIPine 10 mg PO DAILY
7. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Glargine 16 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
3. Pravastatin 80 mg PO QPM
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Metoprolol Succinate XL 200 mg PO DAILY
8. Valsartan 320 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___
Discharge Diagnosis:
Multifocal infarcts, likely cardioembolic origin
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. ___,
You were hospitalized due to symptoms of right sided weakness
resulting from an ACUTE ISCHEMIC STROKE, a condition where a
blood vessel providing oxygen and nutrients to the brain is
blocked by a clot. The brain is the part of your body that
controls and directs all the other parts of your body, so damage
to the brain from being deprived of its blood supply can result
in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
DIABETES
HIGH BLOOD PRESSURE
HIGH CHOLESTEROL
We are changing your medications as follows:
INCREASE PRAVASTATIN TO 80MG DAILY
STOP PLAVIX 75MG DAILY
START APIXABAN 5MG TWICE DAILY
Please take your other medications as prescribed.
Please followup with Neurology and your primary care physician.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19941011-DS-18 | 19,941,011 | 22,616,408 | DS | 18 | 2143-10-09 00:00:00 | 2143-10-11 22:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers, malaise
Major Surgical or Invasive Procedure:
None, Left AMA
History of Present Illness:
Ms. ___ is a ___ with h/o depression, hep C, and
polysubstance abuse who presents with malaise, fever, and
feeling unsafe. She has been having feelings of being unsafe in
the context of increased drug use and self-injurious behavior,
and since her mother's death one year ago, she has been using
escalating amounts of cocaine, heroin, and benzodiazepines to a
level and amount she knows is unsafe. One week ago, patient
claims that she overdosed on both heroin and benozos in an
attempt to kill herself. Since that time, she has been having
subjective fevers and malaise.
She uses cocaine and heroin regularly, last use last night. She
thinks she is using drugs to hurt herself, and the other day
woke up on the roof of a building, thinking that she might have
gone there to jump off. She endorses vague auditory
hallucinations as well. She is currently living in a shelter.
In the ED, initial vitals were: 100.0 116 152/91 16 95%. Her
labs were significant for WBC of 14.9. UA showed no bacteria,
148 WBCs, with trance of nitrites. She was given cephalexin,
bactrim for cellulitis on her foot and for presumed UTI. CXR was
obtained, which did no show any acute process. When she was
re-evaluated in the AM, a faint murmur was auscultated on exam,
with temp of 100.0F and so blood cultures were drawn, she was
given vancomycin and admitted to medicine to evaluate for
endocarditis. She was also seen by psych in the ED, who felt
that she did not meet ___ criteria. It was felt, however,
that she would benefit from voluntary inpatient hospitalization,
specifically a dual diagnosis program that would address her
psychiatric and substance problems, allowing for detoxification,
diagnostic clarification, psychopharmacologic intervention, and
after-care planning.
Patient endorses weight loss of approximately 30lbs in last 90
days. New rash developed in past week in hands and lower
extremities b/l. Patient has been having subjective fevers over
last week and for this reason came to the ED for evaluation.
On the floor, patient is somnolent with stable vital signs,
responding appropriately to questions.
Past Medical History:
Hepatitis C diagnosed ___ years ago
Social History:
Currently homeless. Lives with a friend at times, on the
streets, or at a homeless shelter. Is unemployed. Born in
___ and raised in ___, ___. Raised by mother. Has ___
daughter, currently living with grandmother, whom she rarely
sees. Lost her housing when her mother passed away and has since
been staying in shelters and crack houses. History of sexual
assaults and domestic violence.
Drug use as follows:
Cocaine- use began at ___ and continued until early ___,
initially occasional then becoming more regular (weekly).
Started using again one year ago and is now using ___
daily.
Heroin- Used daily ___ years and then stopped. For last year,
she's used about 2g daily.
Benzos- for last year has used clonazepam/xanax daily, with the
goal of 2mg clonazepam per day.
Crystal Meth- uses weekly
Cigarettes- ___ since ___
Alcohol- regular use, last drink last night at 11PM.
Family History:
Mother- ~6 suicide attempts, depression
Brother- opioid addiction
Physical Exam:
Exam on Admission:
Vitals: 97.9, 59, 119/63, 18, 99% RA
General: somnolent, oriented, no acute distress, nodding off in
between questions
HEENT: Pupils dilatd to 5mm b/l which are ERRL
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: cachetic, soft, non-tender, non-distended
Ext: Several small erythematous markings present in hands b/l.
Also faint erythematous markings present down both legs b/l.
Neuro: Speech normal
Psych: Denies suicidal ideation.
Exam on Discharge:
Unable to obtain as pt left AMA.
Pertinent Results:
Labs on admission
==================
___ 01:25AM BLOOD WBC-14.9*# RBC-4.07* Hgb-12.3 Hct-34.6*
MCV-85 MCH-30.3 MCHC-35.6* RDW-12.4 Plt ___
___ 01:25AM BLOOD Neuts-79.3* Lymphs-13.8* Monos-5.9
Eos-0.5 Baso-0.5
___ 01:25AM BLOOD Glucose-178* UreaN-13 Creat-0.7 Na-135
K-3.3 Cl-96 HCO3-24 AnGap-18
___ 01:25AM BLOOD Albumin-4.6 Calcium-9.3 Phos-2.9 Mg-2.1
___ 08:14AM BLOOD Lactate-1.7
Labs on discharge
==================
___ 07:20AM BLOOD WBC-8.3 RBC-4.49 Hgb-13.5 Hct-38.6 MCV-86
MCH-30.1 MCHC-35.0 RDW-13.0 Plt ___
___ 07:20AM BLOOD Glucose-139* UreaN-11 Creat-0.7 Na-143
K-4.0 Cl-104 HCO3-28 AnGap-15
___ 07:20AM BLOOD Calcium-9.5 Phos-3.1 Mg-2.5
___ 07:20AM BLOOD HIV Ab-NEGATIVE
MICRO
___ Blood Culture, Routine (Pending):
___ Blood Culture, Routine (Pending):
___ BLOOD/FUNGAL CULTURE (Pending):
BLOOD/AFB CULTURE (Pending):
___ Blood Culture, Routine (Pending):
___ URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING
___ TTE: The left atrium is normal in size. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF 65%). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: no vegetations seen
___ CHEST (PA & LAT): Normal radiograph of the chest.
Brief Hospital Course:
___ with h/o depression, hep C, and polysubstance abuse who
presents with malaise and fevers, being evaluated for
endocarditis but left AMA.
**Of note, on the day that pt left against medical advice, she
was found in the room of another patient, going through the
other patient's purse. She had stolen a debit card and cash.
When confronted, she denied she stole the items, and claimed
them hers. However, it was confirmed that these items did not
belong to her (as the name on the debit card was not hers), and
they were returned to the owner. The ___ police department
was called, and the patient's whose debit card was stolen
decided not to press charges. She was ushered back to her room,
where she had a sitter, until she decided to leave against
medical advice. It was explained to her that she was being
evaluated for a potentially life-threatening infection, and she
was also explained the risks of leaving without the evaluation
being complete. The patient understood this and relayed the
risks back to the team.
Active Diagnoses:
==================
# Malaise and fevers: Ddx included infective endocarditis,
opiate withdrawal, cocaine withdrawal. Patient had blood
cultures drawn in the ED and on floor. Patient noted to have new
murmur on exam in ED however this thought to be a flow murmur
once patient arrived on floor (holosystolic murmur). Given
history concerning for IE, echo was performed which showed no
vegetations, and she had no clinical findings of endocarditis on
exam, despite the flow murmur. She was given vancomycin
initially and had 2 doses. Her blood cultures were pending when
she left, though was no growth to date. She left against medical
advice.
# Pyuria: She had significant pyuria, but no bacteria on UA. She
received Bactrim in ED. She was asymptomatic, so bactrim was not
continued.
# Polysubstance Abuse: pt with long history of IVDA. Has been in
and out of rehab. Patient without SI currently, however last
attempted suicide attempt was with Heroin and Benzos. Patient at
risk for ETOH and Benzo withdrawl, Heroin withdrawal. Psych was
consulted, who felt that pt was not sectionable. She was on
clonidine, tylenol, methocarbamol, dicyclomine, and lorazepam
for withdrawal symptoms. She left against medical advice prior
to the opportunity to seek placement at detoxification centers.
# Recent Weight Loss: pt states that she has lost 30lbs in last
90 days. HIV antibody is negative. Unclear if her weight loss is
related to her drug use.
Transitional Issues:
====================
- Blood cultures (___) x 2 pending
Medications on Admission:
None
Discharge Medications:
None, pt left AMA
Discharge Disposition:
Home
Discharge Diagnosis:
Substance abuse
Fevers
Discharge Condition:
Left AMA
Discharge Instructions:
Patient admitted with cachexia, fever and malaise. History of
IVDU. Demanded IV narcotics on floor. Found to be stealing from
other patients on floor. Echo performed with no e/o
endocarditis. Blood cultures negative to date. Patient demanded
to leave AMA. She understood the risks and left shortly
thereafter.
Followup Instructions:
___
|
19941474-DS-10 | 19,941,474 | 20,997,199 | DS | 10 | 2188-01-28 00:00:00 | 2188-01-30 17:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
L PleurX placement
History of Present Illness:
Mr. ___ is a ___ with h/o NSCLC complicated by malignant
pleural and pericardial effusions, atrial fibrillation, & COPD
presenting with syncopal event. He has had two recent
hospitalizations: ___ (for tx of cardiac tamponade and
pleural effusion) and ___ (for upper extremity DVT and
port placement). After being discharged yesterday (___), he
returned home. He became very dizzy when trying to urinate in
the middle of the night and had to sit down on the toilet. He
then found himself on the ground ground in the hallway and
states that he may have passed out for a few moments. He denies
fall or head strike. He returned to bed and was too dizzy to
even sit up and use the urinal in bed. He denies CP,
palpitations, SOB. He denies any changes in urination. He
presented to ___ where he was initially found to be
hypotensive, responded well to fluids. He was transferred back
to ___ for further management.In the ED, initial vitals: 98.1
74 110/66 16 92%RA, with a CXR showing a moderate L pleural
effusion. Oxygen saturation improved with 2L NC, and on transfer
to the floor he was HDS, comfortable, and mildly dyspneic
compared to baseline.
Past Medical History:
#Paroxysmal atrial fibrillation
#NSCLC
#Diverticulitis s/p colostomy reversal (___)
#H/o Small bowel obstruction
#Hypertension
#Hyperlipidemia
#COPD
#AAA (4.4 cm, ___
#Cholelithiasis
#OA
#Obesity
#s/p L TKR
#Glaucoma
Social History:
___
Family History:
No h/o premature ASCVD or cancer
Physical Exam:
Admission Exam
Vitals- 98.2 126/85 84 19 96%2L
Pulsus paradoxus <10
General- Alert, lying in bed, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB with decreased sounds at left base
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, large ventral hernia,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
=====
Discharge Exam
Vitals- 97.7 102/63 75 20 96 on RA
General- Alert, sitting up, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- mild L basilar inspiratory crackles s/p pleurx
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, large ventral hernia,
no rebound tenderness or guarding
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission
___ 05:26AM ___ PTT-75.3* ___
___ 05:26AM PLT COUNT-396
___ 05:26AM WBC-13.0* RBC-4.10* HGB-11.3* HCT-33.0*
MCV-81* MCH-27.6 MCHC-34.3 RDW-14.0
___ 05:26AM CALCIUM-8.5 PHOSPHATE-3.6 MAGNESIUM-1.9
___ 05:26AM ALT(SGPT)-29 AST(SGOT)-32 LD(LDH)-209 ALK
PHOS-89 TOT BILI-0.4
___ 05:26AM GLUCOSE-104* UREA N-11 CREAT-1.2 SODIUM-137
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
Pertinent Labs
___ 11:12AM proBNP-1087*
___ 11:12AM cTropnT-0.02*
___ 06:50PM cTropnT-<0.01
Imaging
CXR ___
Since prior, there has been a increased opacity at the left lung
base
compatible with a worsening effusion. Lingular opacity is also
increased. The mediastinal contour is unremarkable. The left
cardiac border is obscured. The right lung is hyperinflated but
grossly clear. There is no pneumothorax. A right chest wall port
a catheter ends in the proximal right atrium. Lymphangitic
spread better seen on prior CT.
CXR ___ (S/p pleurx)
In comparison with the study of ___, there may be slight
increase in the opacification at the left base, consistent with
prominent pleural effusion. There may be a curvilinear pleural
line in the left apex consistent with a small pneumothorax. The
right lung is essentially clear and there is little change in
the Port-A-Cath.
Brief Hospital Course:
___ with atrial fibrillation, NSCLC complicated by malignant
pleural and pericardial effusions, and COPD presenting with
syncopal event while urinating ___. He had just been discharged
from the second of two recent hospitalizations, for magement of
pericardial and pleural malignant effusions, and then for upper
extremity DVT and port placement.
#Syncope: This was thought to be secondary to a combination of
orthostatic hypotension and vagal tone while urinating. No
evidence of recurrent tamponade on exam and trop flat without
any new ECG changes, afib well rate controlled. He was initially
supported with fluids, his amlodipine was held, and his
metoprolol was halved. His pressures and orthostasis improved,
while maintaining rate control (HR ___. These medication
changes were continued after discharge, to be reassessed in
follow up by his PCP.
# Hypoxemia/Pleural effusion: Did not require oxygen during the
day, 2L at night with intermittent mild desaturations. Plerux
was placed ___ with improvement in respiratory status to recent
baseline. He was educated on Pleurx management, and will have
___ followup to assist and to monitor vitals
post-hospitalization. See following instructions:
1. Please drain Pleurx every other day (___)
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate catheter in any way.
5. Keep a daily log of drainage amount and color, have the
patient bring it with him to his appointment.
6. You may shower with an occlusive dressing
7. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
8. Please call office with any questions or concerns at
___.
Pleurex catheter sutures to be removed when seen in clinic ___
days post PleurX placement.
#DVT: Patient was started on anticoagulation during recent
admission, SC enoxaparin BID, which was maintained during
hospitalization except for ___ for pleurx placement.
# Atrial Fibrillation: Variably in NSR and afib. His home
diltiazem (240mg) was continued, and his metoprolol succinate
was halved to 50mg BID, with rate well controlled in the ___ and
better pressure control/ orthostatics.
# Metastatic Lung Adenocarcinoma: Patient to start chemotherapy
in follow-up with heme/onc on ___. Nothing acute during
admission.
Chronic Issues
#COPD: oxygen support 2L at night. no desaturations after
drainage of effusion.
#HTN: Amlodipine held given likely contribution of orthostatic
hypotension to syncopal event, continued to hold after
discharge.
#Glaucoma: Continued eye drops
#HLD: Continued his statin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO BID
5. Lumigan (bimatoprost) .03% ophthalmic QHS
6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
7. Enoxaparin Sodium 100 mg SC Q12H
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
4. Metoprolol Succinate XL 50 mg PO BID
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
5. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
6. Lumigan (bimatoprost) .03% ophthalmic QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==================
Syncope
Orthostatic hypotension
Pleural effusion
Atrial fibrillation
Secondary Diagnoses
=====================
Non-small cell lung cancer
COPD
HTN
HLD
Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were hospitalized after briefly losing consciousness,
associated with low blood pressure. We treated you with fluids
and changed some of your medications, decreasing your metoprolol
and your amlodipine. The interventional pulmonology team also
placed a PleurX tube to drain the fluid that had accumulated
around your left lung, and allow you to continue to drain it at
home. Both your blood pressure and your breathing improved
during your stay and you are ready for discharge.
Please continue to take your medications as prescribed, and
please call an MD if you become short of breath, develop chest
pains, lightheadedness, fever, chills, or any other symptoms
that concern you.
With regards to your PleurX,
1. Please drain Pleurx every other day (___)
2. Do not drain more than 1000 ml per drainage.
3. Stop draining for pain, chest tightness, or cough.
4. Do not manipulate catheter in any way.
5. Keep a daily log of drainage amount and color, have the
patient bring it with him to his appointment.
6. You may shower with an occlusive dressing
7. If the drainage is less than 50cc for three consecutive
drainages please call the office for further instructions.
8. Please call office with any questions or concerns at
___.
Pleurex catheter sutures to be removed when seen in clinic ___
days post PleurX placement.
We wish you all the best in the future,
Your ___ Care Team
Followup Instructions:
___
|
19941474-DS-11 | 19,941,474 | 23,188,619 | DS | 11 | 2188-05-22 00:00:00 | 2188-05-22 15:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Thigh Pain
Major Surgical or Invasive Procedure:
Thoracentesis ___
History of Present Illness:
Mr. ___ is a ___ year old male with stage IV lung
adenocarcincoma (malignant pleural and pericardial effusions)
status post 4 cycles of carboplatin and pemetrexed, now on
maintenance pemetrexed (first dose ___. Who is admitted
from the ED with presycnopal episode after several days of hip
and thigh pain.
Patient awoke ___ am with new onset left posterior thigh
pain; over the next several days the pain in his left hip and
thigh progressed. On the day of admission, he awoke with pain so
severe that he could not walk to the bathroom. His wife called
___, but patient declined transport to the hospital. Later this
morning, patient was attempting use a bedside urinal and had a
near syncopal event. His wife again called ___ and patient was
brought to ___. On arrival, his left thigh
was noted to be tense, firm, and indurated. Labs at OS___ were
notable for hct down to 21 (from 26.8 on ___. Xray of
left
hip was negative for fracture and ___ negative for DVT. LLE
CT
showed large 11.1 x 9cm intramuscular hematoma in left adductor
gluteus. Patient received IV pain medication was transported to
___ ED.
In the ED, initial VS were pain 7, T 96.3, HR 88, BP 117/78, RR
12, O2 98%. Initial labs were notable for WBC 20.0 (94%N) H/H
6.6/20.6, PLT 285, Na 142, K 4.1, HCO3 23, Cr 1.3, and normal
LFT's. INR was 1.2 and lactgate was 1.4. CT head was performed
and was unremarkable. Patient was given IV morphine x2 and 1
unit pRBC before being admitted to OMED for further management.
On arrival to the floor, patient is moaning in severe pain. He
reports ___ pain in his left posterior thigh. He denies any
trauma prior to the start of his pain ___ am. He denies any
hematochezia, melena, or BRBPR. No recent fevers or chills. No
SOB or cough. No N/V/abdominal pain. His appetite has been poor,
as usual after his chemo therapy. No diarrhea or difficulty
urinating. He is normally ambulatory at home. He does take
therapeutic lovenox, his last dose was ___ evening. Remainder
of ROS is unremarkable.
Past Medical History:
PAST ONCOLOGIC HISTORY
- ___: Developed progressive DOE.
- ___: Admitted to ___ with Afib/RVR and
large left pleural effusion and left lung mass c/f lung ca.
Underwent left ___ on ___ and transbronchial biopsy on ___.
Also found to have large pericardial effusion c/f tamponade.
- ___: Transferred to ___ for further management
of
pericardial effusion, pleural effusion, and new dx of lung ca.
- ___: Admitted Left upper extremity DVT and port
placement
- ___: Admitted with syncope
- ___: Left tunneled pleural catheter placed by IP
- ___: C1D1 Carboplatin/Pemetrexed
- ___: C2D1 ___
- ___: C3D1 ___
- ___: C4D1 ___
- ___: Left PleurX catheter removed per patient request
- ___: C5D1 Pemetrexed
PAST MEDICAL HISTORY:
- Stage IV NSCLC as above: c/b malignant pleural effusion,
pericardial effusion, and lymphangitic carcinomatosis
- Paroxysmal atrial fibrillation
- PICC-associated LUE DVT on LMWH
- Diverticulitis s/p colostomy reversal (___)
- Small bowel obstruction
- Hypertension
- Hyperlipidemia
- COPD (not on home O2)
- AAA (4.4 cm, ___
- Cholelithiasis
- OA s/p L TKR
- Obesity
- Glaucoma
Social History:
___
Family History:
No h/o cancer or bleeding diathesis
Physical Exam:
ADMISSION EXAM:
VITAL SIGNS: 98 tmax, HR 88 ___, 94% 2L
General: NAD, sitting upright in chair watching the ___
game w/ wife at bedside
___: MMM
CV: RRR, NL S1S2 no S3S4, no MRG
PULM: CTAB, respirations unlabored
ABD: BS+, soft, NTND
SKIN: No rashes on extremities
NEURO: Grossly WNL, oriented to person, ___,
day/month/year, and reason for admission and plan for discharge
EXT: Left thigh less tender and size stable today. No
discoloration and decreased in girth. Not tense nor indurated.
ext wwp b/l
DISCHARGE EXAM:
VITAL SIGNS: 98.5 120/50 94 20 94% 2L
General: NAD, sitting up in bed, chronically ill appearing
___: MMM, thrush improving, OP clear
CV: NL S1S2 no S3S4, no MRG
PULM: decreased at L to mid chest R base decreased no crackles
post thoracentesis later today L side clear
ABD: BS+, soft, NTND
SKIN: L inner and outer thigh w/ residual reddish purplish hue
from
hematoma prior erythema now resolved w/ some residual warmth at
site of hematoma, no areas of fluctuance, skin indurated,
evolving ecchymosis at superior L hip
EXT: L thigh skin as above, able to flex at hip and knee
nontender over joints. no ___ edema stockings in place
NEURO: ___, EOMI, face symmetric, no nystagmus, oriented to
person day/month/year, moves all ext against resistance, lifts
both legs off bed cannot sustain hip flex against resistance,
full bicep flex/shoulder abduct, sensation intact bilat to light
touch, no clonus
Pertinent Results:
ADMISSION LABS:
___ 06:15AM BLOOD WBC-1.6*# RBC-2.50* Hgb-7.5* Hct-22.4*
MCV-90 MCH-30.0 MCHC-33.5 RDW-15.8* RDWSD-51.3* Plt Ct-36*
___ 06:15AM BLOOD Neuts-89* Bands-0 Lymphs-10* Monos-1*
Eos-0 Baso-0 ___ Myelos-0 AbsNeut-1.42*
AbsLymp-0.16* AbsMono-0.02* AbsEos-0.00* AbsBaso-0.00*
___ 06:15AM BLOOD Glucose-110* UreaN-26* Creat-1.1 Na-134
K-3.6 Cl-101 HCO3-25 AnGap-12
___ 05:23AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 06:15AM BLOOD calTIBC-155* VitB12-435 Hapto-106
___ TRF-119*
DISCHARGE LABS:
___ 05:48AM BLOOD WBC-7.4 RBC-2.71* Hgb-8.3* Hct-25.3*
MCV-93 MCH-30.6 MCHC-32.8 RDW-16.0* RDWSD-53.6* Plt ___
___ 05:48AM BLOOD Glucose-174* UreaN-20 Creat-1.1 Na-146*
K-3.5 Cl-115* HCO3-21* AnGap-14
___ 05:48AM BLOOD ALT-82* AST-164* LD(LDH)-943* AlkPhos-83
TotBili-0.9
___ 05:48AM BLOOD Calcium-7.9* Phos-1.6* Mg-1.5*
___ 10:58AM PLEURAL TotProt-2.9 Glucose-133 LD(LDH)-248
Albumin-1.9 ___ Misc-PND
IMAGING:
CT head w/o contrast ___
IMPRESSION:
1. Stable left temporal meningioma from ___.
2. Limited exam due to excessive motion artifact without gross
abnormality.
If there is continued concern, repeat study when patient is able
to lay still.
CTA Lower ext ___
IMPRESSION:
1. No evidence of active arterial extravasation. Hematoma
within
predominantly the left adductor magnus and gluteus medius
muscles is minimally
increased in size from the prior examination on ___.
2. Extensive stranding in the subcutaneous fat of the left thigh
is increased
from the prior examination.
3. Infrarenal abdominal aortic aneurysm measuring up to 4.2 cm
with small
peripheral thrombus within the aneurysmal sac. Moderate focal
stenoses in the
distal 5 cm of the left superficial femoral artery.
CXR ___
IMPRESSION:
Moderate left pleural effusion has increased since ___.
Left lower obe is obscured, presumably atelectatic. Upper
lungs are grossly clear, hyperinflated, suggesting pneumonia.
Heart size hard to determine, but not significantly enlarged.
Central venous infusion catheter ends in the upper right atrium.
No
pneumothorax.
Liver U/S ___
IMPRESSION:
1. Unremarkable liver ultrasound.
2. Cholelithiasis.
3. Left pleural effusion.
CXR ___
IMPRESSION:
No pneumothorax, post left-sided chest tube placement with
decrease in left pleural effusion.
Brief Hospital Course:
___ w/ stage IV lung adenocarcincoma (malignant pleural and
pericardial effusions) s/p 4 cycles of carboplatin and
pemetrexed, now on maintenance pemetrexed (first dose ___
admitted for painful large left thigh hematoma, whose hospital
course c/b myelosuppression, frequent blood transfusions,
neutropenia, severe constipation, severe pain and AMS/delirium.
# Left thigh hematoma: Occurred spontaneously in setting of
anticoagulation use leading to severe pain. CTA revealed no
active arterial exsanguination and US neg for DVT. Stopped
lovenox on admisison. Leg exam, pain and mobility had been
improving. Now able to bear weight and ambulate w/ assistance
#Anemia: Acute Hgb drop (8.9 on ___ to 6.6 on admit ___ due to
blood loss from hematoma and also affected by marrow suppression
from recent chemo. received 8 PRBCs this admission, last ___
- ongoing gradual Hgb decline likely due to marrow
suppresion/nadir and phelbotomy
- LD/hapto abnormal but rate of Hgb drop slow bili nl, unlikley
intravasc hemolysis, more likely due to clearance of Hgb post
hematoma rather than true hemolysis, smear normal other than
anemia w/ without schistocytes or other signs of hemolysis
- hgb stable at time of discharge, continue CBC ___ weekly,
transfuse to maintain Hg >7, HCT>21
#Neutropenic fever w/ cellulitis - temp ___, HR/BP stable.
Source mostly likely superinfected hematoma/leg cellulitis as he
developed confluent erythem and hot leg at that time.
Blood/urine cultures remained negative
- leg exam improved w/ empiric vanco/cefepime no further fevers,
as WBC improved soon after narrowed to keflex ___ planned end
date ___
#C diff diarrhea - C diff PCR ___, diarrhea improving, did not
have abdominal pain or fevers. Pt tolerating oral intake and off
IVF. - continue oral vanco for at least ___ days after keflex
completed (___). in enteric isolation.
#Pancytopenia - ___ marrow suppresion from chemo although Plt
drop was more than would expect. coags not consistent w/ DIC and
now resolved w/o intervention
# Malignant pleural effusion: Previously had left pleurX which
was removed ___ per patient request. Respiratory status has
remained stable although effusion slowly re-accumulating. pt not
interested in repeat CT chest but eventually was agreeable to
repeat thoracentesis at this time. He continues to decline
replacement of pleurex.
- s/p thoracentesis ___ w/ drainage of 1700mL over 30 min,
chest tube removed, no pneumothorax, fluid studies not
suggestive of infection but remain pending at time of discharge
- uses ___ NC QHS at baseline
# Delirium - noted to have sundowning at night felt to be
multifactorial (narcotics, age, hospitalization, anemia,
pneumonia). No neurological deficits on exam to suggest CVA.
- improved once no longer needing pain medications
- head CT this admission stable and MS now improved
#Transaminitis - is listed side effect of premetrexed. no other
offending meds.
- liver U/S negative for GB or liver pathology, no mets
- now improving
# Hx DVT: LUE subclavian vein DVT in setting of PICC ___.
Completed 3.5 months of lovenox at time of admission for the
hematoma. Now held indefinitely given bleeding on admission
# Hx Atrial Fibrillation, paroxysmal: pt currently NSR continues
on home dose diltiazem for ongoing rate control. Now off
anticoagulation as above, if recurs in future could consider ASA
# Metastatic Lung Adenocarcinoma: S/p 4 cycles
carboplatin/pemetrexed. started maintenance pemetrexed, last
dose ___.
- struggling w/ pancytopenia and overall deconditioning, due to
further side effects pt reports he may elect to stop
chemotherapy in the future
- next appointment with Dr ___ on ___ at ___ but
at this time will hold off on further pemetrexed. Patient/family
will contact clinic early next week, if doing well may defer
next appointment for 2 weeks. will have restaging exams per Dr
___ at that time
#COPD: On ___ NC QHS. Respiratory status currently stable.
- Substitute Advair for home BUDESONIDE-FORMOTEROL while
hospitalized
#HTN:
- Cont dilt and metoprolol, BP in normal range
#Glaucoma: Continue home eye drops
#HLD: Continue home statin
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. bimatoprost 0.03 % ophthalmic QHS
3. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
4. Dexamethasone 4 mg PO ASDIR
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Metoprolol Succinate XL 50 mg PO BID
7. Enoxaparin Sodium 100 mg SC Q 12 HOURS
8. FoLIC Acid 1 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Atorvastatin 20 mg PO QPM
2. FoLIC Acid 1 mg PO DAILY
3. bimatoprost 0.03 % ophthalmic QHS
4. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
5. Metoprolol Succinate XL 50 mg PO DAILY
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Dexamethasone 4 mg PO ASDIR
8. Gabapentin 300 mg PO QHS
9. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB/Wheeze
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 17.2 mg PO BID constipation
13. Simethicone 40-80 mg PO QID:PRN gas pain or bloating
14. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth q4h prn Disp
#*14 Tablet Refills:*0
15. Diltiazem Extended-Release 240 mg PO DAILY
16. Cephalexin 500 mg PO Q6H Duration: 7 Days
end date ___
17. Nystatin Oral Suspension 5 mL PO QID Duration: 7 Days
end date ___
18. Phosphorus 250 mg PO DAILY Duration: 2 Doses
end date ___
19. Vancomycin Oral Liquid ___ mg PO Q6H
end date ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Spontaneous Intramuscular Left Thigh Hematoma
Stage IV lung adenocarcincoma c/b malignant pericardial and
pleural effusions
LUE Subclavian Vein DVT, provoked by PICC, s/p 3.5 months a/c
Atrial Fibrillation
Pancytopenia
COPD on ___ O2 QHS
HTN
Glaucoma
HLD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted for a spontaneous thigh hematoma. Your lovenox was
stopped, your pain controlled, and you were able to start moving
your leg again. You received blood transfusions and now have
graduated and going to a skilled nursing facility for rehab.
Followup Instructions:
___
|
19941474-DS-9 | 19,941,474 | 21,944,435 | DS | 9 | 2188-01-25 00:00:00 | 2188-01-26 07:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
DVT
Major Surgical or Invasive Procedure:
port placement
History of Present Illness:
___ year old male with recent diagnosis of NSCLC was seen by Dr
___ oncologist) for the first time a few days ago - in
clinic, he was noticed to have a swollen left arm - upper ext
DVT noted. Admitted for anticoagulation initiation and close
monitoring given recent tamponade.
Past Medical History:
#Paroxysmal atrial fibrillation
#Diverticulitis s/p colostomy reversal (___)
#H/o Small bowel obstruction
#Hypertension
#Hyperlipidemia
#COPD
#AAA (4.4 cm, ___
#Cholelithiasis
#OA
#Obesity
#s/p L TKR
#Glaucoma
Social History:
___
Family History:
No h/o premature ASCVD or cancer
Pertinent Results:
___ 05:26AM BLOOD WBC-13.0* RBC-4.10* Hgb-11.3* Hct-33.0*
MCV-81* MCH-27.6 MCHC-34.3 RDW-14.0 Plt ___
___ 05:26AM BLOOD ___ PTT-75.3* ___
___ 05:26AM BLOOD Plt ___
___ 05:26AM BLOOD Glucose-104* UreaN-11 Creat-1.2 Na-137
K-4.1 Cl-103 HCO3-25 AnGap-13
___ 05:26AM BLOOD ALT-29 AST-32 LD(LDH)-209 AlkPhos-89
TotBili-0.4
___ 07:25AM BLOOD proBNP-308
___ 05:26AM BLOOD Calcium-8.5 Phos-3.6 Mg-1.9
Brief Hospital Course:
He was started on IV heparin given his recent history of cardiac
tamponade. He was monitored on telemetry for 48hrs without any
events. Observed for 48hrs on heparin without any signs of
bleeding, Hgb stable. Transitioned to lovenox at discharge. Pt
also had port placed in anticipation of starting chemo.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Lumigan (bimatoprost) .03 % ophthalmic QHS
5. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
6. Amlodipine 10 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO BID
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Diltiazem Extended-Release 240 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO BID
5. Enoxaparin Sodium 100 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 100 mg sq twice a day Disp #*60 Syringe
Refills:*0
6. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
7. Lumigan (bimatoprost) .03 % ophthalmic QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
left upper extremity dvt
lung cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___, you were admitted due to a blood clot in your arm.
You were started on a blood thinner and monitored for signs of
bleeding. You tolerated the medication well without any side
effects. You will continue to take lovenox at home as a blood
thinner. Please follow up with your oncologist as previously
scheduled.
Followup Instructions:
___
|
19941834-DS-6 | 19,941,834 | 23,047,258 | DS | 6 | 2174-02-18 00:00:00 | 2174-02-22 18:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
confusion, L facial droop, concern that he may have taken a
whole bottle of tamsulosin
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is an ___ year old man w PMH HTN, liver disease, BPH,
anxiety, p/w confusion for several days, L facial droop, and
concern for possibly haven taken a bottle of tamsulosin.
He was prescribed Tamsulosin on ___ of this week for BPH,
and his prior medication doxazosin was DCed at that time. In the
next few days his children noted him to be more confused than
usual. He would recognize his children, but did not recognize
Burger ___ or other familiar places. On ___, he was over at
his daughter's house, and he stayed out later than he normally
does, seeming like he might have forgotten that he was supossed
to go home. When he went to leave, he tried to get into his
daughter's car instead of his own car. However, once he got into
his car he was able to drive himself home in 1 piece. On
___ morning, the patient's son who lives with him noted
that the bottle of tamsulosin which had been recently prescribed
was suddenly empty. The patient denied taking extra medication,
however, this prompted alarm amongst the children, so they came
to assess him. One of his daughters noted that his L face did
not seem to activate as quickly when he smiled as his R face,
which was new. They asked a pharmacist what to do in the case of
overdose of this medication, and the pharmacist recommended they
go to the ED.
The patient presented to an OSH ED, where a head CT showed a R
frontal hemorrhage. He was transfered to ___, where neuro surg
evaluated the patient and felt there was no acute intervention
needed at this time. Neurology was consulted for medical
management at this time.
Family and patient deny headache, althought the patient
occasionally takes aspirin for headache, and may have taken one
the day of presentation. Denies any visual changes, unsteady
gait, focal weakness or sensory changes. Family endorses some
slurred speech in the ED.
No recent fever, chills, night sweats, weight loss, cough, SOB,
CP, nausea, vomiting, abd pain. Has to urinate frequently at
baseline, so has been urinating in the hospital bed today since
he cannot get up to go to the bathroom. No rash.
Past Medical History:
- HTN
- liver disease, per family he had jaundice which was diagnosed
to be some sort of blockage
- h/o shingles in his L arm ___ years ago
- anxiety
- BPH
Social History:
___
Family History:
Daughter with ___ and a "white mass" in her brain, which
she has been told is a birth defect.
Physical Exam:
Physical Examination:
VS 99 53 127/61 15 99% RA
General: NAD, bed comfortably, intermittently confused and needs
to be reoriented by children at bedside. Has wet the bed.
Head: B/l eyelid droopiness, NC/AT, no conjunctival icterus, no
oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus, no carotid
bruits
Cardiovascular: RRR, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: obese, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable pulses
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status -
Awake, alert, poorly attentive. Says the month is ___. Knows
his age. Often looses attention during a task and just does not
respond. Keeps eyelids half closed. Can say days of the week
forwards but not backwards. Structure of speech demonstrates
fluency with full sentences, intact repetition, and intact
verbal comprehension. Naming intact for high frequency objects
"thumb" and "hand", but impaired for lower frequency objects
(watch = "you tell time with it").
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (3mm to ___. VF full to
confrontation.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus. Keeps looking to the R side over the L,
although there were lots of distractions in the room.
V. facial sensation was intact, muscles of mastication with full
strength
VII. + L facial musculature with delay in activation with smile
VIII. hearing was intact to finger snap bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
+ Finger curling and drift of the L arm.
Muscule bulk and tone were normal. No tremor or asterixis.
Delt Bic Tri ECR IO IP Quad Ham TA Gas ___
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch, pinprick throughout.
- DTRs -
Bic Tri ___ Quad Gastroc
L 3 2 3 2 no clonus
R 3 2 3 3 no clonus
Plantar response flexor on the R, withdrawl on the L.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. + end
point tremor. Good speed and intact cadence with rapid
alternating movements.
- Gait -
deferred
DISCHARGE EXAM:
Mild difficulty with L gaze, mild L hand pronator drift, mild L
facial droop. Intermittently sundowning, and somnolent after
medication effect.
Pertinent Results:
ADMISSION LABS
___ 02:00AM GLUCOSE-108* UREA N-23* CREAT-1.5* SODIUM-140
POTASSIUM-3.4 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
___ 02:00AM estGFR-Using this
___ 02:00AM ALT(SGPT)-15 AST(SGOT)-26 ALK PHOS-71 TOT
BILI-0.3
___ 02:00AM ALBUMIN-4.0 CALCIUM-8.9 PHOSPHATE-2.8
MAGNESIUM-2.0
___ 02:00AM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 02:00AM URINE HOURS-RANDOM
___ 02:00AM URINE HOURS-RANDOM
___ 02:00AM URINE GR HOLD-HOLD
___ 02:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:00AM WBC-6.7 RBC-3.92* HGB-12.2* HCT-34.9* MCV-89
MCH-31.1 MCHC-34.9 RDW-13.6
___ 02:00AM NEUTS-62.3 ___ MONOS-7.2 EOS-2.8
BASOS-0.5
___ 02:00AM PLT COUNT-158
___ 02:00AM ___ PTT-30.0 ___
___ 02:00AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
CT HEAD ___
Large right frontal intraparenchymal hemorrhage with adjacent
mass effect upon the sulci as well as the frontal horn of the
right lateral ventricle, overall stable in size from five hours
prior.
CXR ___
No evidence of acute cardiopulmonary process.
CT Head ___
Large right frontal intraparenchymal hemorrhage with adjacent
mass effect on the sulci and the frontal horn of the right
lateral ventricle which appears overall stable in size. No new
areas of hemorrhage.
EEG ___
This is an abnormal continuous ICU monitoring study because of
the presence of frequent and often long runs of lateralized
periodic
discharges distributed broadly over the right hemisphere
indicative of
underlying epileptogenic cortex. However, these discharges did
not evolve to suggest electrographic seizures. The background
over the left hemisphere reached a normal alpha frequency.
EEG ___
This is an abnormal continuous ICU monitoring study because of
the presence of asymmetric slowing over the right hemisphere
compatible with structural pathology. On this tracing, however,
there were no clear interictal epileptic discharges noted. This
record suggests an improving cerebral physiology.
MRI/MRA brain ___
Stable right frontal lobe hemorrhage with mass effect on the
anterior horn of the right lateral ventricle and minimal
leftward midline shift. Differential would include amyloid
angiopathy, even in the absence of other chronic
microhemorrhages on the gradient echo sequence. Also, an
underlying mass or vascular malformation can not be excluded.
Recommend follow up imaging.
Head MRA is unremarkable.
DISCHARGE LABS
___ 06:20AM BLOOD WBC-8.4 RBC-4.15* Hgb-13.1* Hct-37.7*
MCV-91 MCH-31.5 MCHC-34.7 RDW-13.6 Plt ___
___ 06:00AM BLOOD Glucose-100 UreaN-23* Creat-1.5* Na-138
K-4.0 Cl-99 HCO3-29 AnGap-14
___ 06:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
___ 06:00AM BLOOD Phenyto-9.9*
___ 06:20AM BLOOD Albumin-3.6 Calcium-8.6 Phos-2.5* Mg-1.9
UricAcd-8.0*
Brief Hospital Course:
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
___ w PMH HTN, unknown liver disorder, BPH, p/w confusion, L
facial droop, and concern for taking too much tamsulosin. On
exam, has L facial droop, and L pronator drift. Found to have a
R frontal IPH on head CT with 5 mm midline shift. He was
admitted to the ICU for monitoring. Etiology of bleed could be
amyloid angiopathy vs HTNsive bleed. MRI brain did not show
extensive evidence of amyloid, although the patient does have a
history of memory decline. His BP may have been in a different
range than normal considering that he had DCed his doxizosin the
week prior to his hemorrhage, (although he had also taken too
much tamsolsin). MRI did not show evidence of underlying mass,
but he should have a repeat MRI in 2 months once blood has
started to resolve to look for underlying structural lesion or
cavernoma. At rehab, the patient should avoid taking any
aspirin, NSAIDs, or blood thinning medication. His blood
pressure should be monitored and blood pressure medications
adjusted as needed, goal is normotension (SBP < 140).
The patient also had symptoms concerning for seizure, with some
R hand shaking followed by L hand shaking. This shaking was felt
to be due to tremor and likely not seizure since he was able to
follow commands with his arms while it persisted. However, he
was evaluated on the afternoon of ___ for decreased
responsiveness and found to have right gaze preference, worsened
perseveration, motor impersistence on the left, and increased
somnolence. Repeat NCHCT showed a stable hemorrhage. It was
thought that he was having seizures of right frontal origin
(with the IPH as a nidus) - totally independent of the
long-standing intermittent arm twitching which may well be
tremor. EEG showed PLEDs but no epileptic activity. The patient
was intitially started on keppra, which did not seem to be
effective, so he was transitioned off of keppra onto phenytoin
instead. He. Phenytoin level at discharged was 9.9, since the
goal is ___, the dose was not adjusted. He should have his
level rechecked on ___ and the dose adjusted as needed for a
goal adjusted level of ___ (need to adjust phenytoin level for
albumin of 3.6 with online calculator).
# Sundowning: the patient became intermittently confused at
night. He was started on seroquel at 8 pm, and PRN olanzipine
controlled his sx well.
- maintain good sleep-wake cycle and sleep hygeine, the patient
has been intermittently agitated at night which responded well
to olanzipine SL prn. If the patient is confused, would prefer
olanzipine prn instead of home benzodiazepine.
# Constipation: the patient had no sx of constipation, but was
noted to not have had a bowel movement during hospital stay, so
he was started on a bowel regimin
- monitor bowel movements, change bowel regimin as needed
INACTIVE ISSUES
# Autoimmune cholangitis: cont home ursodiol
# Gouty pain: No clear flare on physical exam, although the
patient had some mild L toe pain and L hip pain. He took black
cherry juice from home, which helped his pain considerably. He
also got tylenol as needed
# L arm post herpetic neuralgia: at baseline, gave tylenol as
needed
# CKD: Baseline renal function unclear, Cr stable around 1.5
during this admission
- F/U chem10 weekly, repelte lytes, monitor renal fuction
- and also check BUN/Cr on ___ (1 month prior to MRI scan)
# PVCs: the patient had frequent PVCs on telemetry monitoring
but no other arryhtmias. Electrolytes were repleted and were
stable at discharge
- check weekly chem10 and replete as needed
Code Status: Full, confirmed
Health Care Proxy Contact Information: No HCP chosen previously.
Son ___, daughter ___ ___
TRANSITIONAL ISSUES
- avoid any NSAIDS, aspirin, or any other blood thinning
medications
- monitor bowel movements, change bowel regimin as needed
- check phenytoin level on ___ at rehab, goal level ___,
adjust dose as needed (goal reflects correction for albumin
however, so for instance phenytoin level of 9.9 corrected for
albumin of 3.6 is about 12)
- check chem10 to monitor for stability of BUN/Cr and once per
week, and also check on ___ (1 month prior to MRI scan)
- replete lytes as needed
- monitor BP, goal normotension
- maintain good sleep-wake cycle and sleep hygeine, the patient
has been intermittently agitated at night which responded well
to olanzipine SL prn. If the patient is confused, would prefer
olanzipine prn instead of home benzodiazepine.
- Repeat MRI in 2 months and follow up with Stroke Neurology
- continue black cherry juice for gouty pain
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ursodiol 900 mg PO TID
2. Tamsulosin 0.8 mg PO HS
3. Metoprolol Tartrate 50 mg PO BID
4. ALPRAZolam 0.5 mg PO Q8H:PRN nervousness
5. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Metoprolol Tartrate 50 mg PO BID
3. Tamsulosin 0.8 mg PO HS
4. Ursodiol 900 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN pain, fever
6. OLANZapine (Disintegrating Tablet) 5 mg PO BID:PRN agitation
7. Phenytoin Infatab 100 mg PO BID
8. Phenytoin Infatab 200 mg PO HS
9. QUEtiapine Fumarate 50 mg PO NIGHTLY AT 8 ___
10. Sarna Lotion 1 Appl TP QID:PRN pruritis
11. ALPRAZolam 0.5 mg PO Q8H:PRN nervousness
RX *alprazolam 0.5 mg 1 tablet(s) by mouth q8h as needed Disp
#*10 Tablet Refills:*0
12. Docusate Sodium 100 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Bisacodyl 10 mg PR HS:PRN constipation
15. Senna 1 TAB PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
1. intraparenchymal hemorrhage
Secondary diagnosis
1. hypertension
2. cognitive decline
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted for a bleed in your brain,
which has remained stable. You are being discharged to rehab to
regain your strength. You will need a repeat MRI in 2 months and
follow up with Stroke Neurology.
It is important that you take all medications as prescribed, and
keep all follow up appointments. Avoid any NSAIDS, aspirin, or
any other blood thinning medications.
Followup Instructions:
___
|
19941834-DS-7 | 19,941,834 | 27,307,863 | DS | 7 | 2174-06-17 00:00:00 | 2174-06-17 15:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left face weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Reason for Consult: new brain hemorrhage
HPI:
The pt is a ___ yo man with hx of right frontal IPH in ___ who presents as a transfer from ___ for acute
ICH. Per the patient's family, they had called EMS this morning
as the patient was complaining of chest pain, although now the
patient reports it wasn't chest pain, it was gas pain. He denies
any headaches, nausea, or vomiting. His family reports that his
left facial droop had improved during his recovery from his
right
IPH, but this morning it is now more prominent. This is the only
change from baseline in his mental status/physically that
they've
noticed. The do mention some concern that over the past 1.5
months, since he has been home from rehab/nursing home, he has
been increasingly sedentary, not wanting to do things, as well
as
losing weight, approximately 15 pounds in 1.5 months. They
believe the decrease in activity may be due to some family
members allowing him to refuse activities, compared to the
persistence of others. They note that his vitals are checked
daily and he's been afebrile, with blood pressures on average
138-140/70s.
In regard to his follow up since his IPH discahrge, he has seen
Dr. ___ in clinic. He had a repeat MRI brain with contrast
in
___ that showed new leptomeningeal enhancement. He has no
personal history of malignancy. He is scheduled for a repeat MRI
brain in ___.
On neuro ROS, the pt reports chronic left hand/arm postherpetic
pain. He also has occasional urinary incontinence, primary when
he is unable to make it to the bathroom in time. He denies loss
of vision, blurred vision, diplopia, dysarthria, dysphagia,
lightheadedness, vertigo. Denies difficulties producing or
comprehending speech.
On general review of systems, the pt has lost 15 pounds in the
last 6 weeks. He also complains of "gas pains" today. He denies
recent fever or chills. Denies cough, shortness of breath.
Denies chest pain or tightness, palpitations. Denies nausea,
vomiting, diarrhea, constipation. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
- HTN
- liver disease, per family he had jaundice which was diagnosed
to be some sort of blockage
- h/o shingles in his L arm ___ years ago
- anxiety
- BPH
- right frontal intraparenchymal hemorrhage ___
Social History:
___
Family History:
Daughter with migraines and a "white mass" in her brain, which
she has been told is a birth defect.
Physical Exam:
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx
Neck: Supple, no nuchal rigidity. No carotid bruits
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally, pain on left medial forearm
and ___ digits
Skin: no rashes or lesions
Neurologic:
-Mental Status: Alert, oriented x 1. Could not identify hospital
even with multiple choices. Unable to identify season, but did
pick year from multiple choices. He has decreased spontaneous
language output. When asked questions, he tends to joke and talk
around the question, without answering. He is fluent. He has
difficulty following commands, often requires multiple
repetitions, and even with mimicry, he has difficulty. There is
some degree of perseverance as well. Inattentive, difficulty in
saying the days of the week forward, getting only half correct
after some delay. He has anomia for both high and low frequency
objects, although he is able to get some high frequency objects
with cueing. Gaze midline. No neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. Blinks to threat in all
quadrants.
Funduscopic exam revealed no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Left lower facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline and has symmetric strengh.
-Motor: Normal bulk, tone throughout. No pronator drift. No
adventitious movements. No asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4 5 - - 5 5
R 5 ___ ___ 5 5 - - 5 5
-Sensory: No deficits to light touch, pinprick throughout.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 - -
R 2 2 2 - -
Toe down on right, up on left.
-Coordination: No dysmetria on FNF bilaterally.
-Gait: deferred
Pertinent Results:
___ 11:30AM WBC-5.3 RBC-4.31* HGB-13.2* HCT-40.3 MCV-94
MCH-30.6 MCHC-32.7 RDW-13.9
___ 11:30AM PHENYTOIN-16.4
___ 11:30AM cTropnT-<0.01
Brief Hospital Course:
Mr. ___ had repeat head CT here on ___ that confirmed the
new small right frontal hemorrhage. He neurologically remeained
stable with improvement in his left facial droop. Given the past
concern about leptomeningeal enhancement around the site of the
earlier bleed, he had a CT torso to evaluate for possible masses
that may have metastasized to the brain. His CT chest identified
a solitary 6mm right lower lobe pulmonary nodule on unknown
significance. Recommended repeat chest CT in ___. His abdomen CT
scan showed evidence of external iliac vein thrombosis due to
extension from his DVT in the left common femoral vein. There
was no evidence of thrombosis. He had a repeat head CT with
contrast on ___ that was stable. He was seen by ___ that
recommended acute rehab.
Discharge Medications:
1. Metoprolol Tartrate 50 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Phenytoin Infatab 200 mg PO BID
4. Phenytoin Infatab 100 mg PO DAILY
patient should take 200mg qam and qpm and 100mg at noon
5. Tamsulosin 0.8 mg PO HS
6. Ursodiol 900 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal Hemorrhage
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were hospitalized due to symptoms of left facial weakness
resulting from an ACUTE CEREBRAL HEMORRHAGE, a condition where a
blood vessel ruptures and blood enters into the brain. 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 the bleeding can
result in a variety of symptoms. You had repeat head CT scans
that showed no changes in the sign of the bleed. Your
neurological exam remained stable. You had a CT scan of the
chest that showed a small pulmonary nodule that appears benign
and needs a follow up CT scan in 6 months. You had an abdominal
CT that showed evidence of a previous external iliac vein
thrombosis from the previous deep vein thrombosis. There was no
sign of any malignancy. We believe that the bleeding is likely
due to amyloid angiopathy.
Followup Instructions:
___
|
19941834-DS-8 | 19,941,834 | 25,455,160 | DS | 8 | 2174-07-01 00:00:00 | 2174-07-02 14:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___ swelling, fever
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ male with history of hemorrhagic
stroke ___ and ___, DVTs, IVC filter who presents with
worsening red right leg pain and swelling for the last 5 days,
from his rehabilitation facility.
It is difficult to communicate with the patient given post-ICH
status, so much of history obtained from his wife and two
offspring in the room. Per the family, this has been the
patient's mental status and ability to communicate since his
most recent hospitalization for ICH.
He was initially seen at ___ 3 days ago, per patient's
son he had a CAT scan which showed clot, however no
interventions were performed. He denies cough, vomiting,
abdominal pain. He did have a fever to 101.4 at his
rehabilitation facility ___ evening, resolved with Tylenol.
Of note he had a recent admission ___ for L sided weakness and
was found to have new right frontal hemorrhage. At that time CT
abdomen
showed evidence of external iliac vein thrombosis due to
extension from his DVT in the left common femoral vein.
In the ED, initial vital signs were: 98.5 63 106/51 16 99%
Labs were notable for INR 1.2 Cr 1.3 Ht 35
Exam notable for significant swelling of the right leg with some
overlying erythema
___: Occlusive thrombus of all interrogated deep veins
including the right superficial femoral, deep femoral, popliteal
and left common femoral and superficial femoral veins.
Examination was aborted prematurely due to patient's agitated
state.
Neurology was consulted and felt that anticoagulation would be
quite high risk for him given his recurrent intracranial
hemorrhages and strong possibility of underlying malignancy.
They agreed to continue to follow with stroke consult team and
will be happy to discuss further once his US results are
available and vascular surgery has had a chance to weigh in.
Vascular was consulted and commented on there being no
indication for surgical intervention from vascular surgery
perspective. No anticoagulation given recent hemorrhagic stroke.
Recommended RLE pressure stocking and elevation.
The patient's family notes that the patient periodically gets
agitated at night at rehab and was recently introduced seroquel,
which has improved this.
In the ED, patient was given vanc, lorazepam and quetiapine
Past Medical History:
- HTN
- liver disease? per family he had jaundice which was diagnosed
to be some sort of blockage?
- h/o shingles in his L arm ___ years ago
- anxiety
- BPH
- right frontal intraparenchymal hemorrhage ___
- right frontal hemorrhage ___
Social History:
___
Family History:
Daughter with migraines and a "mass" in her brain, which she has
been told is a birth defect.
Physical Exam:
ADMISSION EXAM:
===============
98.7 108/63 76 20 96%RA
General: NAD, lying in bed
HEENT: MMM
CV: RRR, no M/r/g
Lungs: CTAB
Abdomen: soft, NT/ND
GU: no foley
Ext: RLE > LLE, edema to thigh, no warmth but erythema of entire
upper leg, not indurated; pulses palpable but diminished R>L
Neuro: alert, oriented to name, not to place, date or season;
able to answer very simple one word questions
Skin: see leg above, otherwise no rashes
.
DISCHARGE EXAM:
===============
Physical Exam:
V: 98.7 134/69 76 18 100% RA
General: NAD, lying in bed
HEENT: MMM, pupils equal
CV: RRR, nl S1/S2, S3 no other appriciable murmurs
Lungs: CTAB
Abdomen: soft, NT/ND
GU: no foley
Ext: RLE > LLE, edema to thigh, no warmth but erythema of entire
upper leg, not indurated; pulses palpable but diminished R>L
Neuro: AO to self, follows simple commands, respons
appropriately to questions.
Skin: see leg above, a few small areas on folliculitis on chest
Pertinent Results:
ADMISSION LABS:
===============
___ 12:52PM LACTATE-1.5
___ 12:45PM GLUCOSE-105* UREA N-36* CREAT-1.3* SODIUM-140
POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13
___ 12:45PM WBC-9.3# RBC-3.71* HGB-11.3* HCT-35.2* MCV-95
MCH-30.5 MCHC-32.1 RDW-13.8
___ 12:45PM NEUTS-80.0* LYMPHS-10.9* MONOS-6.2 EOS-2.3
BASOS-0.6
___ 12:45PM PLT COUNT-174
___ 12:45PM ___ PTT-28.3 ___
.
IMAGING:
========
CXR ___
Limited exam given low lung volumes; however, no evidence of
large confluent consolidation
.
___ ___
Occlusive thrombus of all interrogated deep veins including the
right superficial femoral, deep femoral, popliteal and left
common femoral and superficial femoral veins. Examination was
aborted prematurely due to patient's agitated state.
DISCHARGE LABS:
===============
___ 07:30AM BLOOD WBC-6.8 RBC-3.79* Hgb-11.6* Hct-35.3*
MCV-93 MCH-30.7 MCHC-32.9 RDW-13.3 Plt ___
___ 07:30AM BLOOD Glucose-100 UreaN-28* Creat-1.3* Na-140
K-3.7 Cl-104 HCO3-26 AnGap-14
Brief Hospital Course:
PRINCIPLE REASON FOR ADMISSION:
Mr. ___ is a ___ w/ complicated past medical history
including recent (weeks ago) hemorrhagic strokes and also DVTs
with an IVC filter in place, who presents from his rehab
facility with right leg swelling, redness and pain, likely
representing progression of his clot.
ACTIVE PROBLEMS
# DVTs/swollen, erythematous leg: errythema, swelling and pain
in right upper leg all consistent with severe DVTs (progression
from prior) noted on ___. Has known DVTs from prior admissions,
and IVC filter already in place. Exam not consistent with
cellulitis, and though patient recieved 1 dose of vancomcyin in
ED initially, was not continued on antibiotics while inpatient.
Patient was evaluated by vascular surgery who did not feel
surgical management was warranted, and instead recommended
conservative management with elevation and wrapping. Neurology
was consulted in the ED for question of anticoagulation, but in
setting of ICH a few weeks ago (with likely underlying
malignancy), anticoagulation in contraindicated.
.
# FEVER: single fever observed at rehabe to 101.4, no further
fevers while inpatient. Most likely in setting of large clot
burden. Infectious work up was preformed; CXR showed no distinct
infiltrates, urine showed no leukocytosis/nitrates, and blood
cultures showed no growth while patient was in hospital. No
other clear source of infection.
.
# Recent ICH: Per family, mental status stable, has periodic
agitation at baseline. Neurology also felt exam was consistent
with prior. Continued on home phenytoin and seroquel, which was
increased to 25mg qhs.
# ___: Per records, recent ___ with Cr to 1.6. On this admission
Cr 1.3, which is baseline. Encouraged PO hydration with stable
Cr.
.
# Anemia: Normocytic anemia at baseline, hemaglobin normally 12,
11 on this admission. Patient hemodynamically stable. Rectal
exam revealed brown stool, so low suspcion for slow GI bleed;
did not start emperic PPI. Recommend that patient have H/H
followed up as outpatient.
.
TRANSITIONAL ISSUES:
====================
# Follow up anemia as outpatient; recommend checking CBC at
rehab facility in a week to ensure stablity
# Follow up pending blood cultures
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 50 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Phenytoin Infatab 200 mg PO BID
4. Phenytoin Infatab 100 mg PO DAILY
5. Tamsulosin 0.8 mg PO HS
6. Ursodiol 900 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Senna 17.2 mg PO DAILY
9. TraZODone 75 mg PO HS:PRN insomnia
10. QUEtiapine Fumarate 25 mg PO Frequency is Unknown
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Metoprolol Tartrate 50 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Phenytoin Infatab 200 mg PO BID
5. Phenytoin Infatab 100 mg PO DAILY
6. QUEtiapine Fumarate 12.5 mg PO QHS
7. Senna 17.2 mg PO DAILY
8. Tamsulosin 0.8 mg PO HS
9. Ursodiol 900 mg PO DAILY
10. TraZODone 75 mg PO HS:PRN insomnia
11. Acetaminophen 650 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# PRIMARY: deep vein thrombosis
# SECONDARY: strokes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a plesure taking care of you at the ___
___. You were admitted for right leg swelling and
redness. You had known clots in your legs, for which an inferior
vena cava (IVC) filter was previously placed. It seems these
clots have progressed further, accounting for the pain,
swelling, and even the fever. We do not think you have a skin
infection on your leg, and so are not giving you antibiotics. We
also found no other evidence of infection. Unfortunately, given
your history of brain bleeds, we can not anticoagulate you,
which is the traditional treatment for clots. Instead, we
recommend wrapping and elevating the leg to help reduce pain and
swelling.
Followup Instructions:
___
|
19942060-DS-17 | 19,942,060 | 26,995,122 | DS | 17 | 2161-02-10 00:00:00 | 2161-02-10 12:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
codeine
Attending: ___.
Chief Complaint:
SAH; aneurysm
Major Surgical or Invasive Procedure:
___: Cerebral angiogram with coiling of aneurysm
___: Right frontal EVD placement
___: VP shunt placement
History of Present Illness:
___ is a ___ female with 2 days of sudden onset
headache and nausea/vomiting. She presented to ___ with
persistent headache.
She states that she has a hx of an aneurysmal bleed in ___ -
___ known to Dr ___. At that time she was unable to have it
clipped or coiled. She has L sided hemiparesis since. In ___,
she was started on Coumadin for a PE. She had a mild re-bleed
SAH in ___. At the OSH she had a INR of 3.3, was given KCentra
and Vitamin K. She was hypertensive to 160's, started on
Nicardipine gtt. She was given 1g Keppra. CT head showed SAH, so
she was sent to ___ for further mngt.
History obtained from: patient and OSH records
Last seen well: c/o headache 2 days prior to presentation
Time of headache onset: ___
Past Medical History:
(obtained from patient and chart review)
Hemorrhagic stroke from ruptured aneurysm - resulting in left
sided hemiparesis in ___
Re-bleed SAH in ___
PE in ___, requiring long term Coumadin use
HTN
High Cholesterol
Hypothyroidism
Neuropathy
Shoulder fracture
L hip arthroplasty in ___
Social History:
Obtained from OSH
*Lives in assisted living facility
Denies tobacco use, alcohol use or illicit drug use
Tobacco Use:
[x]No
[ ]Yes
[ ]Current Smoker
Years: Packs per day:
[ ]Previous Smoker
Years: Packs per day:
Recreational Drug use:
[x]No
[ ]Yes
[ ]Substance: Frequency:
Alcohol Use:
[x]No
[ ]Yes
Frequency:
Number of drinks:
Family History:
Unknown
Physical Exam:
ON ADMISSION:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: R 4mm reactive L 3mm reactive EOMs intact
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect - sleepy but arousable
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 round and reactive to light, R 4mm to 2mm and L 3mm
to
2mm.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength appears symmetric - very mild
participation with this exam - sensation intact and symmetric.
VIII: Hearing intact to finger rub bilaterally.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor:
RUE ___ intact, RLE ___ intact
*L side hemiparesis from previous stroke.
LUE withdraws to noxious
LLE triple flexes to noxious
Sensation: Intact to light touch
Coordination: unable to assess d/t participation
ON DISCHARGE:
General:
VS:
___ 0831 Temp: 99.3 PO BP: 144/68 R Lying HR: 100 RR: 21 O2
sat: 92% O2 delivery: Ra FSBG: 204
Fluid Balance:
___ Total Intake: 2072ml PO Amt: 510ml TF/Flush Amt: 1308ml
IV Amt Infused: 254ml
___ Total Intake: 694ml TF/Flush Amt: 644ml IV Amt Infused:
50ml
Output Note recorded
Bowel Regimen: [x]Yes [ ]No Last BM: Flexiseal d/c'd ___
Exam:
Opens eyes: [ ]spontaneous [x]to voice [ ]to noxious
*Continues to be nonverbal today, facial grimaces when in the
room and try to get examination.
Follows commands: [x]None
Pupils: PERRL 3-2mm bilaterally with eyes held open
Facial grimacing to noxious stimuli
RUE spontaneous
LUE weak withdrawal to noxious
RLE spontaneous
LLE withdrawal to noxious
Wound:
[x]Clean, dry, intact
[x]Staples - removed ___
Pertinent Results:
Please refer to OMR for pertinent imaging and lab results
Brief Hospital Course:
#___
Patient was admitted to the neuro ICU. She refused to consent
for intervention and treatment of her SAH. She was given Keppra,
KCentra and Vitamin K. A judge approved to invoke the Health
Care Proxy. ___ was consulted and determined the patient did
not have capacity to make her own medical decisions. Blood
pressure was maintained <140 on nicardipine gtt. Patient became
lethargic on ___ and CT head was stable. Patient was intubated
for STAT EVD placement and opened at 15. CT was stable. Pt was
loaded with ASA 325mg and Brillinta. Patient went to the OR on
___ and underwent coiling of ACOMM aneurysm, unable to stent
the aneurysm. Patient continued on ASA 81mg indefinitely and
brillinta for 3 more doses. She was extubated in ICU. CTA
concerning for spasm especially R MCA compared to admission. BP
was driven up to 180 with pressors PRN. Plan was to repeat CT in
a few days. Home baclofen was slowly tapered to help improve her
mental status. A repeat NCHCT showed a right frontal 8mm
intraparenchymal focus of hemorrhage, compatible with
hemorrhagic transformation may have minimally increased or may
be more conspicuous due to slice selection. Milrinone was
initiated for spasm. and TCDs were ordered and negative for
vasospasm on ___. EVD was lowered to 10. Her free water flushes
were increased for hypernatremia. Her exam improved and on ___
she spoke to the ICU team. Her milrinone was d/c'd and her
nimodipine was changed to 60mg q4h. MRI brain was done and
showed multiple subacute infarcts in L basal ganglia and
subcortical, subacute to early chronic right MCA territory
infarction, and punctate probable chronic infarct of the right
cerebellar hemisphere. CTA head was ordered for concern of
vasospasm due to lack of responsiveness and was negative. She
was started on IVF and neo with goal SBP >120. Patients exam
improved and she was verbalizing and up in the chair. EVD was
raised to 15 and then 20 after stable neurological exam.
Patients exam became less brisk and EVD was lowered to 15. On
serial exams the patient became more lethargic and not following
commands and EVD was decreased to 10. Repeat CTA showed mild
narrowing of the right MCA but no significant change from prior.
A family team meeting was held with the neurosurgery attending
on ___ and it was decided to continue treating the patient to
maximum potential until the following week. She underwent VP
shunt placement on ___ and tolerated the procedure well. Please
see separately dictated operative report by Dr. ___
complete details of the procedure. Post-op CT was stable.
Post-operatively the patient's exam initially improved, but then
declined, and a NCHCT was obtained which demonstrated
ventriculomegaly. Patient's shunt setting was adjusted from 1.0
to 0.5, and a NCHCT was the next day to evaluate interval
changes. Ventriculomegaly remained stable, but exam began to
improve, therefore no plans for shunt revision were made at this
time. On ___, the patient underwent a CT of the head which
showed improvement in the degree of hydrocephalus. Patient has
remained stable since and was transferred to the floor for care.
She was medically ready for discharge to rehab on ___
#Seizure
On continuous EEG she appeared to be in NSCE. She was given 2mg
midaz for procedure and EEG improved, start fosphenytoin 1000mg
IV load with 100mg IV q8. EEG appeared to improve. The epilepsy
attending recommended loading with Keppra and increasing the
standing dose. After load doses the patient became somnolent
however respiratory efforts remained stable. EEG was negative
for seizures on ___. Her corrected phenytoin level was 21.4.
Push button was pressed for arm twitching and did not correlate
with seizure. EEG was d/c'd. Patient was less responsive on ___
with no movement of the RLE, with associated eye blinking
concerning for status. She was placed back on EEG without
evidence of seizures and improved encephalopathy when compared
to prior. IV fosphenytoin was changed to PO Dilantin. Keppra
taper was started on ___, Dilantin continued. She was switched
back to fosphenytoin IV. There was concern for seizure on ___ in
the setting of fever to 101.6. Phenytoin level was 7.1.
Neurology was consulted and EEG was placed. She was not in
status however had many discharges on EEG. She was loaded with
fosphenytoin 500mg x1 and increased standing dose to 125mg q8h.
Her afternoon exam was still concerning and she was given 500mg
Keppra x1 and increased standing dose to 1G BID. EEG button was
pushed for eye fluttering and did not correlate, EEG was much
improved and her exam was improved also. As of ___ patient EEG
demonstrated the patient remained seizure free for 24 hours, and
EEG was discontinued.
#Leukocytosis
Infectious work-up was sent for elevated WBC. Pan cultures were
sent and she was started on Vanc/cefepime. Vanc trough was
normal. Her foley was removed and flexiseal placed for diarrhea.
She had persistent fevers. LENIs were negative for DVT. Cdiff
was negative. Urine culture was negative. Cefepime was stopped
and she was started on meropenem. Blood cultures and CSF were
prelim negative so ID was consulted for assistance with
management of fevers and elevated WBCs. CT torso was negative
for PNA but was concerning for mild ascending colitis. Stool
was sent for cdiff per ID concern for e.Coli however was
negative. ID felt fevers and elevated WBC were related to
sterile fever and inflammatory response, and recommended
stopping all antibiotics. Vanco was stopped and she continued
Meropenem and Flagyl another day and then stopped. Patient was
switched to PO vanco for presumed cdiff colitis. IV flagyl was
resumed on ___ when the patients WBC reached 27 (up from 20)
for presumed cdiff. WBC trended down. Repeat cdiff was again
negative and PO vanco and IV flagyl were discontinued. She
became febrile again on ___ and was pan cultured. A repeat Cdiff
was again negative. Repeat urine analysis and cultures were sent
which were positive for E.Coli UTI, therefore patient was
started on ceftriaxone for seven days. Repeat urine cultures
showed resolution of UTI and patient remained afebrile as of
___. Patient again was febrile on ___ overnight. Fever workup
was initiated which was negative. She had fevers overnight again
on the ___, with no clear evidence of infection. Patient's
fever broke and she remained afebrile >24 hrs at the time of
discharge
#Anemia
Her H&H slowly downtrended during admission. Stool for guaiac
was negative
#Colitis
CTA torso suggestive of mild ascending colitis. Patient was
started on Flaygl 500mg q8h. She continued on Vancomycin with
therapeutic troughs.
#Pneumothorax
Pneumothorax was found on CXR after intubation, the patient
remained hemodynamically stable. IP was consulted for possible
chest tube in setting of ASA/Brillinta. Ultrasound was negative
for pneumothorax and repeat CXR was negative for pneumothorax.
She was noted to have ___ breathing on ___.
#Afib
Patient was tachycardic to 130's and tele alarmed for afib. EKG
confirmed Afib. IV metoprolol x1 was given. Patient was started
on double her home dose of metoprolol for high BP and
tachycardia. She was ordered TTE given murmur and bounding
venous pulsations. Post-operatively from her VP shunt placement
she had ST elevations on tele. Cardiac enzymes were cycles and
were negative x2.
#Iliac artery aneurysm/splenic artery aneurysm
CT torso for infectious work-up revealed incidental findings of
bilateral common iliac artery aneurysms up to 2 cm and 1-cm
calcified splenic artery aneurysm.
#Nutrition
Patient was given enteral nutrition while intubated. She was
dehydrated with hypotension likely due to large amounts of loose
stool output and given 500cc NS bolus. Tube feeds were held and
bowel movements lessened. On ___, the patient underwent
placement of a PEG. On ___, tube feeds were started. On ___,
tube feed formularies were changed to help decrease the amount
of diarrhea. Diarrhea resovled and patient's flexiseal was
removed overnight on ___.
#Genital herpes
Dermatology was consulted to evaluate vesicular lesion in the
gential/buttock area. She was started on acyclovir per their
recommendation for treatment of genital herpes.
#UTI
On ___, a urine culture was sent and found to be growing
enterococcus. She was started on a 7-day course of Macrobid.
#Fever
On ___, the patient spiked a fever to 101.2 and blood cultures
were sent. A chest x-ray urinalysis was performed which was
negative. She spiked a fever again early morning ___, LENIs
were performed , which were negative for DVT.
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
AMLODIPINE - amlodipine 10 mg tablet. 1 tablet(s) by mouth daily
ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth
daily
CLONIDINE HCL - clonidine HCl 0.2 mg tablet. 1 tablet(s) by
mouth
twice daily
FENOFIBRATE MICRONIZED - fenofibrate micronized 134 mg capsule.
1
capsule(s) by mouth daily
GABAPENTIN - gabapentin 300 mg capsule. 2 capsule(s) by mouth
three times daily
LAMOTRIGINE - lamotrigine 25 mg tablet. 1 tablet(s) by mouth
twice daily
LEVOTHYROXINE - levothyroxine 88 mcg tablet. 1 tablet(s) by
mouth
daily
LORAZEPAM - lorazepam 0.5 mg tablet. 1 tablet(s) by mouth daily
-
(Prescribed by Other Provider)
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr. 3 tablet(s) by mouth daily
WARFARIN - warfarin 1 mg tablet. 1 tablet by mouth daily as
directed by Coumadin nurse
Medications - OTC
DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s)
by
mouth daily
--------------- --------------- --------------- ---------------
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
4. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
5. FoLIC Acid 1 mg PO DAILY
6. Fosphenytoin 125 mg PE IV Q8H
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. Heparin 5000 UNIT SC BID
10. Insulin SC
Sliding Scale
Fingerstick q6
Insulin SC Sliding Scale using REG Insulin
11. LevETIRAcetam 1000 mg PO Q12H
12. LOPERamide 2 mg PO QID:PRN Diarrhea
13. Modafinil 100 mg PO DAILY
14. Multivitamins W/minerals 1 TAB PO DAILY
15. Nitrofurantoin (Macrodantin) 100 mg PO Q6H
Please continue through ___. Nystatin Oral Suspension 5 mL PO QID thrush
17. Thiamine 100 mg PO DAILY
18. Levothyroxine Sodium 88 mcg PO DAILY
19. Metoprolol Tartrate 37.5 mg PO Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cerebral aneurysm
Subarachnoid hemorrhage
Hydrocephalus
Urinary tract infection
Genital herpes
Atrial fibrillation
Diarrhea
Status Epileptics
Pneumothorax
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Surgery/ Procedures:
- You had a cerebral angiogram to coil the aneurysm. You may
experience some mild tenderness and bruising at the puncture
site (groin).
- You had a VP shunt placed for hydrocephalus. Your incision
should be kept dry until sutures or staples are removed.
- Your shunt is a ___ Strata Valve which is programmable.
This will need to be readjusted after all MRIs or exposure to
large magnets. Your shunt is programmed to 0.5..
Activity
- We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
- You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
- You make take a shower.
- No driving while taking any narcotic or sedating medication.
- If you experienced a seizure while admitted, you must refrain
from driving.
Medications
- Resume your normal medications and begin new medications as
directed.
- You may be instructed by your doctor to take one ___ a day
and/or Plavix. If so, do not take any other products that have
aspirin in them. If you are unsure of what products contain
Aspirin, as your pharmacist or call our office.
- You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication until follow-up. It is important that you take this
medication consistently and on time.
- You have been discharged on a medication called phosphenytoin
for seizures. Please make sure you are taking this medication on
time and you have weekly troughs by your PCP drawn to make sure
you are at a therapeutic level.
- You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
- You are currently on a 7 day course of Macrobid for UTI.
Please continue this medication through ___.
What You ___ Experience:
- Mild to moderate headaches that last several days to a few
weeks.
- Difficulty with short term memory.
- Fatigue is very normal
- Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
When to Call Your Doctor at ___ for:
- Severe pain, swelling, redness or drainage from the incision
site or puncture site.
- Fever greater than 101.5 degrees Fahrenheit
- Constipation
- Blood in your stool or urine
- 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:
___
|
19942382-DS-10 | 19,942,382 | 21,022,775 | DS | 10 | 2203-06-29 00:00:00 | 2203-06-29 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Effexor / lisinopril
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
Central venous catheter
History of Present Illness:
Ms. ___ is a ___ female with IDDM, hypertension, and
anxiety, hx of meningitis, alcoholic pancreatitis who presented
to the ED with 2 days of watery diarrhea and fever.
In early ___, she complained of fever, productive cough w/
blood flecks, as well as emesis. Throat culture was positive for
Strep but she ended up leaving the office prematurely. Unclear
if this was ever treated. She presented to the ED that day, and
was found to be febrile with a lactate of 3. She underwent LP
which was normal. She left the ED AMA. She then left for
___ for 2 weeks. Patient continued to be febrile while in
___, and she was taking antibiotics prescribed to her there
for hematuria. Upon her return, she called PCP on ___
with continued fever, cough and now emesis. For the past two
days she has had abdominal pain, constant watery diarrhea and
emesis. Denies hematochezia, melena, or hematemesis. She has
some pain with stooling, fevers, and malaise.
ED course notable for:
Initial vitals: 97.7 ___ 17 95% RA. PE notable for dry
mucous membranes, regular tachycardia. Labs notable for WBC 13.7
with neutrophilic predominance, negative parasite smear, Cr 2.0
from baseline 0.9 with HCO3 20 and AG 20. Initial lactate was
3.2 which downtrending to 1.7 with 2L IVF. Blood, urine, and
stool cultures were sent. CT abdomen pelvis showed no acute
process. Chest x-ray shows no consolidations. She had persistent
hypotension, so was started on a Levophed gtt. A L subclavian
line was placed. She was started on cefepime and Flagyl for
presumed intra-abdominal source.
On arrival to the MICU, patient is on levophed. She appears
well, is saturating well on room air and mentating
appropriately. She wishes to be brief in conversation. She is
not a great historian.
Past Medical History:
Pre-diabetic
Hypertension
Anxiety
Depression
Meningitis x2, HSV encephalitis
Asthma
History of etoh abuse (quit 6 months ago)
History of cocaine abuse (many years ago)
Active tobacco use
Hemorrhoids s/p hemorrhoidectomy ___
Left otitis externa
Seborrheic dermatitis
Social History:
___
Family History:
2 uncles with hemorrhoids but neither had hemorrhoidectomy. No
other significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VITALS: T 103, HR 116 sinus, BP 108/71 on levophed, RR 26,
saturating 87% on room air improved to 95% on 2 liters nasal
cannula
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: warm and dry no rashes or lesions
NEURO: alert and oriented
DISCHARGE PHYSICAL EXAM:
======================
VITALS: ___ 0819 Temp: 98.6 PO BP: 121/80 HR: 90 RR: 18 O2
sat: 95% O2 delivery: RA
GENERAL: NAD. sitting comfortably in bed
HEENT: NC/AT. EOMI. Sclera anicteric and without injection. MMM.
No evidence of lice.
CARDIAC: RRR. Audible S1 and S2. No murmurs/rubs/gallops.
LUNGS: CTABL. No wheezes, rhonchi or rales. Breathing
comfortably
on RA.
ABDOMEN: NABS. Soft, nondistended, nontender. No organomegaly.
EXTREMITIES: A&Ox3. No focal neurologic deficits. Moving all
extremities.
SKIN: facial erythema with dry skin noted
Pertinent Results:
ADMISSION LABS:
=============
___ 06:47PM BLOOD WBC-13.7* RBC-4.61 Hgb-13.6 Hct-42.5
MCV-92 MCH-29.5 MCHC-32.0 RDW-12.6 RDWSD-42.5 Plt ___
___ 06:47PM BLOOD Neuts-89.3* Lymphs-6.0* Monos-4.2*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-12.25* AbsLymp-0.82*
AbsMono-0.58 AbsEos-0.00* AbsBaso-0.03
___ 03:53AM BLOOD ___ PTT-24.9* ___
___ 06:51PM BLOOD Glucose-177* UreaN-26* Creat-2.0*# Na-136
K-3.7 Cl-94* HCO3-20* AnGap-22*
___ 06:51PM BLOOD ALT-39 AST-30 AlkPhos-104 TotBili-0.9
___ 03:53AM BLOOD Albumin-3.6 Calcium-7.7* Phos-4.1 Mg-0.6*
___ 10:01AM BLOOD HAV Ab-POS* IgM HAV-NEG
___ 10:01AM BLOOD HIV Ab-NEG
___ 01:23AM BLOOD ___ pO2-33* pCO2-46* pH-7.34*
calTCO2-26 Base XS--1 Intubat-NOT INTUBA
___ 06:49PM BLOOD Lactate-2.7*
PERTINENT LABS:
=============
___ 06:47PM BLOOD Parst S-NEGATIVE
___ 10:01AM BLOOD HAV Ab-POS* IgM HAV-NEG
___ 10:01AM BLOOD HIV Ab-NEG
___ 01:14PM BLOOD LEPTOSPIRA ANTIBODY-PND
___ 10:01AM BLOOD DENGUE FEVER ANTIBODIES (IGG, IGM)-PND
___ 05:42AM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE
MICROBIOLOGY:
=============
___ 1:14 pm BLOOD CULTURE Source: Line-TLCL #2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 5:50 am BLOOD CULTURE Source: Line-TLCL.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 3:30 pm THROAT FOR STREP
**FINAL REPORT ___
R/O Beta Strep Group A (Final ___:
NO BETA STREPTOCOCCUS GROUP A FOUND.
__________________________________________________________
___ 11:05 am Blood (Malaria)
**FINAL REPORT ___
Malaria Antigen Test (Final ___:
Negative for Plasmodium antigen.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
Note, Malaria antigen may be below the detection limit of
this test
in a small percentage of patients. Therefore, malaria
infection can
not be ruled out. Negative results should be confirmed by
thin/thick
smear with testing recommended approximately every ___
hours for 3
consecutive days for optimal sensitivity.
__________________________________________________________
___ 5:42 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
ADD ON CRYTPTO/GIARDIA BY ___ ON ___ AT 0318.
CYCLOSPORA ADDED ON PER ___ ___ 15:10
# ___.
CYCLOSPORA STAIN (Pending):
OVA + PARASITES (Pending):
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
__________________________________________________________
___ 11:35 pm URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 10:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
ADD ON E.COLI 0157 VIBRIO AND YERSINIA REQUESTED BY ___,
___
___ AT 0318.
FECAL CULTURE (Preliminary):
Reported to and read back by ___ MD (___)
___
@14:56.
Susceptibility testing requested per ___ ___ ___.
SALMONELLA SPECIES.
Presumptive identification pending confirmation by
___
Laboratory.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
SALMONELLA SPECIES
|
AMPICILLIN------------ <=2 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
LEVOFLOXACIN---------- 1 I
TRIMETHOPRIM/SULFA---- =>16 R
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
__________________________________________________________
___ 10:30 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
__________________________________________________________
___ 6:52 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 6:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
IMAGING:
=======
CXR ___: The lungs are well expanded and clear. There is
no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. There is
no acute osseous abnormality or free intraperitoneal air.
CT ABD/PEL ___:
1. Mild colitis without significant soft tissue stranding or
bowel
obstruction.
2. Moderate hepatic steatosis and likely fibroid uterus, as on
prior.
CXR ___: Interval placement of left-sided central venous
line, with tip terminating at the mid SVC. No pneumothorax is
seen.
DISCHARGE LABS:
===============
___ 05:52AM BLOOD WBC-5.2 RBC-3.99 Hgb-12.0 Hct-36.2 MCV-91
MCH-30.1 MCHC-33.1 RDW-12.6 RDWSD-41.3 Plt ___
___ 05:52AM BLOOD Plt ___
___ 05:52AM BLOOD Glucose-105* UreaN-12 Creat-0.7 Na-146
K-3.6 Cl-107 HCO3-23 AnGap-16
___ 05:52AM BLOOD ALT-34 AST-34 LD(LDH)-194 AlkPhos-77
TotBili-0.2
___ 05:52AM BLOOD Albumin-3.9 Calcium-8.9 Phos-3.9 Mg-1.5*
Brief Hospital Course:
Information for Outpatient Providers: BRIEF HOSPITAL SUMMARY:
=====================
Ms. ___ is a ___ yo woman with hx of IDDM, HTN,
alcohol/cocaine use who presented with fevers, abdominal pain
and diarrhea c/f GI infection which progressed to sepsis,
requiring admission to MICU. Her hypotension improved after
fluid resuscitation. Was ultimately found to have Salmonella
gastroenteritis, potentially from food vs water ingestion either
here in ___ or on recent trip to ___. Infectious disease
was consulted. Patient received empiric ceftriaxone and flagyl
for while inpatient, and was transitioned to Ciprofloxacin x14
days total.
TRANSITIONAL ISSUES:
==================
[ ] Pending tests: stool O&P, cyclospora, dengue, leptospirosis
[ ] Stool culture from ___ grew Salmonella. Sent to state lab
for further speciation and sensitivities. Patient was discharged
on cipro 500mg BID for 10 days (for a total 14-day course of
antibiotics). Please follow up further culture data at PCP
appointment and adjust antibiotic if Cipro-resistant.
[ ] Patient reports having OSA and requests CPAP machine at home
for nighttime. Please discuss at PCP ___.
[ ] Patient presented with ___ felt to be pre-renal in setting
of sepsis. Creatinine improved with fluid resuscitation.
Creatinine on day of discharge was 0.7. Please recheck at PCP
___.
[ ] Holding home anti-hypertensives: losartan, HCTZ, amlodipine
and metoprolol given normotensive at discharge and recent
sepsis. Please consider restarting at next PCP appointment if
hypertensive.
ACUTE/ACTIVE ISSUES:
==================
# Sepsis, resolved
# Diarrhea/colitis
Patient presented with fever to 103, tachycardia, and
hypotension concerning for sepsis. She had a leukocytosis of 13
and elevated lactate. Source was thought likely abdominal given
diarrhea, nausea, and vomiting, as well as lack of evidence on
infection on CXR or urine studies. CT A/P showed mild colitis.
In the MICU, she briefly required Norepinephrine, but was weaned
off pressers after she received 5L fluid resuscitation with
improvement in blood pressures and lactate. Infectious disease
was consulted and she was started on empiric cefepime and flagyl
which was then transitioned to ceftriaxone and flagyl.
Leukocytosis downtrended to normal range. Differential diagnosis
included many possible infectious causes of diarrhea considering
her recent travel to ___ and recent ingestion of unwashed
produce, including typhoid fever, listeria, dengue,
leptospirosis, hepatitis A, cryptosporidium, cyclospora and
giardiasis. C diff test was negative. Hepatitis A IgM was
negative and IgG was positive, indicating past exposure but not
current active infection. HIV test was negative. Malaria antigen
was negative. Blood cultures had no growth to date. Urine
culture was negative. Additional negative tests included
cryptosporidium, giardia, campylobacter, E coli, vibrio and
yersenia. Stool culture was eventually positive for Salmonella
with further speciation at the state lab pending. Diet was
advanced to regular as tolerated and patient received IV fluids
as needed. She was discharged on ciprofloxacin 500 BID for an
additional 10 days (end date ___, for a total antibiotic
course of 14 days. Patient will follow up at PCP and make any
appropriate changes in antibiotics.
# History of alcohol use
Patient drinks 1 pint of vodka every ___ days and has achieved
sobriety once in past through a Detox center. She was maintained
on CIWA protocol while inpatient but did not require any
benzodiazepines. She received a multivitamin, thiamine and
folate supplementations. Social work was consulted to offer
resources for substance use disorder.
# ___, resolved
Patient presented with Cr of 2.0, above baseline of <1. Etiology
was likely pre-renal in setting of ongoing diarrhea and
decreased PO intake secondary to nausea/vomiting. Creatinine
improved with fluid resuscitation and downtrended to normal
range. Nephrotoxins were avoided and she received fluids as
needed. Creatinine was monitored during admission and was 0.7 on
day of discharge.
# Dermatitis, resolving
Patient reported history of dermatitis on face and uses
triamcinolone cream at home. During hospitalization, she had
facial erythema which was consistent with her typical dermatitis
flares. She received triamcinolone 0.05% cream and rash was
resolving at time of discharge.
CHRONIC ISSUES:
===============
# DM:
Patient on Trulicity at home but was not sure of the dose on
admission. She received sliding scale insulin during admission
with qACHS fingerstick blood glucose. She was discharged on her
home regimen of insulin.
# Hypertension
Patient is on losartan, HCTZ, metoprolol, amlodipine at home.
Anti-hypertensive medications were held on admission in the
setting of hypotension and ___. Given she was normotensive at
discharge, her home blood pressure medications were held and are
to be reevaluated at her next PCP ___.
#CODE: Full
#CONTACT: ___
Relationship: Daughter
Phone number: ___
___ on Admission:
1. Losartan Potassium 100 mg PO DAILY
2. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
3. Ketoconazole 2% 1 Appl TP BID face
4. Ketoconazole Shampoo 1 Appl TP 3X/WEEK (___)
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. Diazepam 5 mg PO Q12H:PRN flying
7. Metoprolol Succinate XL 50 mg PO DAILY
8. amLODIPine 5 mg PO DAILY
9. Lidocaine Viscous 2% 15 mL PO Q6H:PRN sore throat
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
12. Omeprazole 40 mg PO BID
13. Citalopram 20 mg PO DAILY
14. tacrolimus 0.1 % topical QHS
15. Hydrochlorothiazide 25 mg PO DAILY
16. Thiamine 100 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H Duration: 10 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*20 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Ondansetron ODT 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*9
Tablet Refills:*0
4. Citalopram 20 mg PO DAILY
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. Diazepam 5 mg PO Q12H:PRN flying
7. Guaifenesin-Dextromethorphan 10 mL PO Q6H:PRN cough
8. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
9. Ketoconazole 2% 1 Appl TP BID face
10. Ketoconazole Shampoo 1 Appl TP 3X/WEEK (___)
11. Lidocaine Viscous 2% 15 mL PO Q6H:PRN sore throat
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Omeprazole 40 mg PO BID
14. Tacrolimus 0.1 % topical QHS
15. Thiamine 100 mg PO DAILY
16. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until you see your PCP to discuss
17. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until you see your
PCP to discuss
18. HELD- Losartan Potassium 100 mg PO DAILY This medication
was held. Do not restart Losartan Potassium until you see your
PCP to discuss
19. HELD- Metoprolol Succinate XL 50 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until you see your PCP to discuss
___ Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Salmonella gastroenteritis/colitis
Sepsis from GI source
Secondary diagnoses:
___
History of alcohol use
DM
HTN
Dermatitis
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 the ___
___.
Why did you come to the hospital?
- You came to the hospital because you were having diarrhea,
nausea and fevers.
What did you receive in the hospital?
- You received fluids because your blood pressure was low.
- You had many tests sent on your blood and stool. One of the
tests on your stool was positive for salmonella, a bacteria
which can cause severe diarrhea.
- You received antibiotics to treat the bacterial infection.
What should you do once you leave the hospital?
- You should continue to eat and drink a lot of fluids to stay
hydrated.
- You should attend all of your follow up appointments as
scheduled.
- You should take all of your medications as prescribed.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19942382-DS-9 | 19,942,382 | 21,399,644 | DS | 9 | 2202-06-22 00:00:00 | 2202-06-22 20:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Effexor / lisinopril
Attending: ___.
Chief Complaint:
Rectal pain, Fever, Called by ___ regarding positive
blood culture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history significant for hemorrhoidectomy
___ done electively at ___, who was briefly admitted
to ___ ___ with urinary retention and fevers, who now
presents to ___ after being called about a positive blood
culture.
The patient was in her usual state of health and had elective
surgery on ___ of last week. On ___ she began
having fevers and could not sleep, so she went to the ED. She
was
admitted to ___ found to have urinary retention and fevers; a
foley catheter was placed and removed without difficulty. There
was no clear source of her fevers and she was discharged without
antibiotics as her cultures were negative.
On ___ she had a temp of 101 at night, and ___
morning she was called by covering MD to inform her that her
blood cultures were positive (gram+ cocci in clusters). She felt
okay and was managing rectal pain at home so she did not go to
the hospital. Today ___ she called an ambulance and was brought
to ___ for further care.
She currently complains of severe rectal pain (___), worse
after having a bowel movement. Also complains of feeling sweaty
and warm, but her last temp was ___ on ___. Also reports
nausea, cough productive of green sputum, vaginal
burning/itching, rectal bleeding, chills and headache.
Rest ROS negative unless stated above.
ED course:
Oxycodone ___ po x1
Metronidazole 500mg iv x1
Cipro 400mg iv x1
LR 1000ml x2
Vancomycin 1g iv x1
Initially recommended to receive cipro/flagyl by colorectal team
for possible infection/abscess, later felt that presentation was
more consistent with UTI.
Past Medical History:
Pre-diabetic
Hypertension
Anxiety
Depression
Meningitis x2, HSV encephalitis
Asthma
History of etoh abuse (quit 6 months ago)
History of cocaine abuse (many years ago)
Active tobacco use
Hemorrhoids s/p hemorrhoidectomy ___
Left otitis externa
Seborrheic dermatitis
Social History:
___
Family History:
2 uncles with hemorrhoids but neither had hemorrhoidectomy
No other significant family history
Physical Exam:
ADMISSION PHYSICAL EXAM:
T 99.6, BP 142/95, HR 77, RR 20, O2 95% RA
Gen - moderate distress, very uncomfortable and wincing in pain
HEENT - nc/at, moist oral mucosa, no oropharyngeal exudate or
erythema
Eyes - anicteric, perrl
Neck - supple, no LAD
___ - RRR, s1/2, no m/r/g
Lungs - CTA b/l, no w/r/r, breathing unlabored and symmetric
Abd - soft, NT, ND, +bowel sounds
Ext - no edema or cyanosis
Skin - warm, dry, no rashes
Psych - calm, cooperative
Neuro - motor ___ all extremities
Rectal - +small protruding hemorrhoid with dried blood around
perianal area
Vaginal - no lesion or discharge noted
DISCHARGE PHYSICAL EXAM:
VS: 98.3 PO 139 / 87 59 18 96 RA
Gen: WDWN, well appearing.
HEENT: NCAT grossly nl OP, anicteric
Neck - supple, no LAD
___ - RRR, s1/2, no m/r/g
Lungs - CTA b/l, no w/r/r, breathing unlabored and symmetric
Abd - soft, NT, ND, +bowel sounds
Ext - no edema or cyanosis
Skin - warm, dry, no rashes
Psych - calm, cooperative
Neuro - motor ___ all extremities
Pertinent Results:
ADMISSION LABS:
___ 09:44AM BLOOD WBC-6.4 RBC-4.57 Hgb-13.6 Hct-41.4 MCV-91
MCH-29.8 MCHC-32.9 RDW-12.6 RDWSD-41.4 Plt ___
___ 09:44AM BLOOD Neuts-62.7 ___ Monos-6.3 Eos-8.9*
Baso-0.9 Im ___ AbsNeut-4.01 AbsLymp-1.32 AbsMono-0.40
AbsEos-0.57* AbsBaso-0.06
___ 09:44AM BLOOD Plt ___
___ 09:44AM BLOOD Glucose-150* UreaN-14 Creat-0.6 Na-142
K-3.4 Cl-100 HCO3-27 AnGap-15
___ 06:50AM BLOOD Calcium-9.2
___ 06:50AM BLOOD %HbA1c-7.2* eAG-160*
___ 09:50AM BLOOD Lactate-1.3
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-6.2 RBC-4.40 Hgb-13.0 Hct-40.1 MCV-91
MCH-29.5 MCHC-32.4 RDW-12.5 RDWSD-41.3 Plt ___
___ 06:50AM BLOOD Glucose-159* UreaN-15 Creat-0.6 Na-140
K-3.5 Cl-97 HCO3-29 AnGap-14
MICRO:
-Ucx ___ ___, results in careweb)
>100k enterococcus faecalis
Ampicillin S
Cipro S
Levaquin S
Linezolid S
Nitrofurantoin S
Benzylpenicillin S
Tetracycline R
Vancomycin S
- Bcx ___ ___, results in careweb)
Preliminary ___ bottles
BLOOD CULTURE Preliminary
___
Aerobic bottle: MICROCOCCUS LUTEUS
Anaerobic bottle: No growth
Ucx ___ ___ - pending, ngtd
Bcx ___ ___ - pending, ngtd
CXR ___: The lungs remain clear. There is no effusion or
consolidation. Linear right
mid to lower lung opacity is likely atelectasis versus scarring.
Cardiomediastinal silhouette is within normal limits. No acute
osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
___ with history significant for hemorrhoidectomy ___ done
electively at ___, who was briefly admitted to ___
___ with urinary retention and fevers, who now presents to
___ after being called about a positive blood culture.
# Positive blood culture: Blood cultures at ___-N grew
Micrococcu Leuteum 9no sensitivities) from ___: Patient had not
had a fever in greater than 72 hours. Discussed with ID.
MIcrococcus is usually a contaminant. Did not match enterococcus
in the urine. Patient was well appearing and non-toxic. BCx
drawn in ID were negative. Discussed with patient, would prefer
to go home, as feeling
well, no fevers, and well appearing. PLanned to treat UTI with
augmentin, as Micrococcus is usually b-lactam sensitive in case
abx course needs to be extended. Will follow-up blood cultures
and call back at ___. Pt understands to answer
incoming phone calls in case hospital needs to call.
# UTI: +dysuria, +hematuria (mild). No e/o ascending or systemic
infection. Started on augmentin x 3 days BID at time of
discharge
# Rectal pain
# Rectal Bleeding: Colorectal saw them for this issues in the
ED. Per their evaluation, NTD. Follow-up at planned outpatient
visit. Patient was treated with lidocaine topical and ice packs.
Bowel regimen ordered. pt reports her stool is soft but
exquisitely painful so bowel/pain regimen adjusted PRN
# Urinary retention: )(Not present this admission) Now able to
void on own wihout issue. Likely related to prior pain
medications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. amLODIPine 5 mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. ClonazePAM 1 mg PO BID:PRN anxiety
6. FoLIC Acid 1 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY:PRN
9. Losartan Potassium 100 mg PO DAILY
10. Omeprazole 40 mg PO BID
11. Potassium Chloride 20 mEq PO DAILY
12. Sertraline 150 mg PO DAILY
13. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe
14. Senna 8.6 mg PO BID:PRN constipation
15. Docusate Sodium 100 mg PO BID
16. lidocaine 4 % topical Q6H:PRN
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 6 Doses
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice a day Disp #*6 Tablet Refills:*0
2. GuaiFENesin ER 600 mg PO Q12H cough
RX *guaifenesin 600 mg 1 tablet(s) by mouth twice a day Disp
#*20 Tablet Refills:*1
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
4. amLODIPine 5 mg PO DAILY
5. Atenolol 100 mg PO DAILY
6. ClonazePAM 1 mg PO BID:PRN anxiety
7. Docusate Sodium 100 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Hydrochlorothiazide 25 mg PO DAILY
10. Ibuprofen 800 mg PO Q8H:PRN Pain - Severe
11. lidocaine 4 % topical Q6H:PRN
12. Losartan Potassium 100 mg PO DAILY
13. Omeprazole 40 mg PO BID
14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth Q6H PRN Disp #*8 Tablet
Refills:*0
15. Potassium Chloride 20 mEq PO DAILY
16. Senna 8.6 mg PO BID:PRN constipation
17. Sertraline 150 mg PO DAILY
18. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL)
subcutaneous DAILY:PRN
Discharge Disposition:
Home
Discharge Diagnosis:
Positive Blood Cultures
UTI
Hemorrhoid
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 because your blood cultures
were found to be positive at ___. We believe that
this is actually a contaminant, and does not represent a true
infection. ___ will be discharged home and we will continue to
watch your blood cultures. If they turn positive, we will
contact ___ and ___ may have to return to the hospital. Please
be attentive and answer any unknown phone calls.
Take your medication (augmentin) for the next 3 days, twice a
day.
Please make an appointment with your PCP with one week of
discharge.
Please take all medications as prescribed and keep all scheduled
doctor's appointments. Seek medical attention if ___ develop a
worsening or recurrence of the same symptoms that originally
brought ___ to the hospital, experience any of the warning signs
listed below, or have any other symptoms that concern ___.
It was a pleasure taking care of ___!
Your ___ Care Team
Followup Instructions:
___
|
19942499-DS-21 | 19,942,499 | 28,649,090 | DS | 21 | 2192-10-01 00:00:00 | 2192-10-06 14:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
PRIMARY DIAGNOSIS:
-Urinary retention
SECONDARY DIAGNOSIS:
PRIMARY DIAGNOSIS:
- Urinary Retention
SECONDARY DIAGNOSIS:
-CKD stage V, possibly secondary to diabetes ___ type 2
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ woman with T2DM, HTN, CKD, now s/o
peritoneal dialysis catheter placement on ___ who now
presents with inability to void and abdominal pain.
She underwent PD placement on ___. That evening she did not
void, but attributed it to decreased fluid intake. On ___ she
woke up with abdominal pain, which she describes as sharp and
heavy, which increased with walking, requiring her to take very
small steps. The pain was originally located in the upper
abdomen, but is now more pronounced in the lower abdomen. She
also noted increasing abdominal distension. That day she voided
a very small amt of urine 2x, but was only able to void when
lifting her abdominal pannus.
In the ED her vital signs were notable for high BP to 175/73.
Labs were significant for BUN/Cr of 88/10.6, Na 132, K 5.2,
Bicarb 19, Phos 8.0, Glucose 255, and UA with 100 protein. A
foley was placed, with 1.1L of UOP.
She was seen by Nephrology and Transplant surgery. She was given
100mg IV Lasix x1 and Kayexalate.
KUB showed PD catheter in left pelvis and coiling to right of
midline.
Also notes light headedness with standing. Chills since
___. No fevers. No N/V. No leakage around catheter. Normal
eating. Appetite OK. Denies fevers, dizziness, dysuria. She
notes that her last BM was on ___.
On the floor, she noted abdominal cramping which started today
after foley placement in the ED. Otherwise the pain and urge to
urinate have improved.
Past Medical History:
CKD stage V, possibly secondary to diabetes ___ type 2
Hypertension
Asthma
Diabetes ___ type 2 with retinopathy
Morbid obesity
Depression and anxiety
Cholecystectomy
Tubal ligation
Vaginal bleeding with possibly negative endometrial biopsy
Anemia
Vitamin D deficiency
Right ankle fracture in ___
Eye surgery
?CHF, although the current ejection fraction is not known
Social History:
___
Family History:
Mother ___ with diabetes ___, hypertension, dyslipidemia.
One sister with diabetes ___ and hypertension. One sister
with cancer, possible lymphoma, but not clear.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
PHYSICAL EXAM:
Vital Signs: T 98, BP 124/50, HR 71, RR 20, O2 99 on RA, Wt 145
kg
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, obese, tenderness to RUQ palpation,
non-distended, bowel sounds diminished, no rebound or guarding,
PD catheter site covered with C/D/I bandage, right upper abdomen
port site with some surrounding erythema but non-tender, no
warmth or induration
GU: Foley in place
Ext: Warm, well perfused, 2+ pulses, L > R ___ edema (chronic)
PHYSICAL EXAM UPON DISCHARGE:
=============================
Vitals: Tm 98.5 HR 65-70 BP ___ RR 18 SaO2 97%RA
General: Alert, oriented, no acute distress, lying in bed.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, ___ systolic murmur at LUSB(known)
normal S1 + S2, no murmurs, rubs, gallops.
Abdomen: Soft, obese, bowel sounds present. TTP and mild
erythema around port site in Right upper abdomen. Mild TTP to
right of umbilicus. No rebound tenderness or guarding, no
organomegaly. PD catheter dressing is c/d/I just left of
umbilicus.
GU: Foley in place. Clear, yellow urine.
Ext: warm, well perfused, 2+ pulses. 1+ edema to calf, L>R. Dry
skin with hyperpigmented scales on LEFT toes.
Pertinent Results:
ADMISSION LABS:
==============
___ 03:31PM BLOOD WBC-6.3 RBC-2.63* Hgb-8.3* Hct-26.6*
MCV-101* MCH-31.6 MCHC-31.2* RDW-13.2 RDWSD-49.3* Plt ___
___ 03:31PM BLOOD Plt ___
___ 03:31PM BLOOD Glucose-255* UreaN-88* Creat-10.6*#
Na-132* K-5.2* Cl-96 HCO3-19* AnGap-22*
___ 07:49PM BLOOD Glucose-300* UreaN-87* Creat-10.5*
Na-130* K-4.7 Cl-96 HCO3-18* AnGap-21*
___ 07:49PM BLOOD ALT-11 AST-27 AlkPhos-429* TotBili-0.5
___ 07:49PM BLOOD GGT-526*
___ 07:49PM BLOOD Calcium-8.0* Phos-8.0* Mg-1.8
___ 07:50PM BLOOD Glucose-276* Na-130* K-4.6 Cl-100
calHCO3-17*
INTERVAL LABS:
==============
___ 03:00PM BLOOD WBC-6.1 RBC-2.63* Hgb-8.5* Hct-26.4*
MCV-100* MCH-32.3* MCHC-32.2 RDW-13.3 RDWSD-48.7* Plt ___
___ 05:32AM BLOOD Glucose-311* UreaN-93* Creat-10.6*
Na-131* K-4.9 Cl-96 HCO3-19* AnGap-21*
___ 05:32AM BLOOD ALT-7 AST-21 AlkPhos-410* TotBili-0.4
___ 05:32AM BLOOD Calcium-7.9* Phos-8.4* Mg-1.9
DISCHARGE LABS:
===============
___ 05:31AM BLOOD WBC-5.5 RBC-2.43* Hgb-7.8* Hct-24.6*
MCV-101* MCH-32.1* MCHC-31.7* RDW-13.5 RDWSD-50.3* Plt ___
___ 05:31AM BLOOD Glucose-211* UreaN-94* Creat-10.7*#
Na-133 K-4.2 Cl-96 HCO3-17* AnGap-24*
___ 05:31AM BLOOD ALT-8 AST-22 AlkPhos-448* TotBili-0.4
___ 05:31AM BLOOD Calcium-8.0* Phos-7.9* Mg-1.7
___ 05:31AM BLOOD ___ PTT-34.1 ___
IMAGING:
=========
___ Abdominal X-ray:
IMPRESSION: Peritoneal dialysis catheter is seen entering the
left pelvis and coiling just to the right of midline.
Nonobstructive bowel gas pattern.
___ RUQ U/S:
IMPRESSION: 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. No biliary tree dilatation.
Brief Hospital Course:
Patient is a ___ with CKD, T2DM, HTN, s/p PD catheter placement
on ___, who presents with inability to void and abdominal
pain.
#Urinary retention: New urinary retention after PD placement.
Most-likely opioid-induced, as she was started on Oxycodone
after PD placement, which is renally cleared. Could also be due
to constipation (no BM for 3days). Upon arrival to the ED, she
was seen by Transplant Surgery and Nephrology, a foley was
placed and she was given 100mg IV Lasix. KUB showed correct
placement of PD catheter and non-obstructive bowel gas pattern.
She had good UOP after foley was placed and she passed voiding
trial with Flomax. She was also started on a bowel regimen for
constipation. UA was NEG. Renal U/S showed no evidence of
hydronephrosis. Pt did not start peritoneal dialysis during
admission.
# RUQ pain/ Elevated Alk-Phos: On physical exam on admission pt
had tenderness to palpation in RUQ and elevated Alk-Phos(429)
and GGT (526). Pt is s/p CCY. RUQ U/S did not showed no biliary
tree obstruction. AMA test was negative.
#Anemia: Pt has chronic anemia at baseline. Most likely due to
ESRD-induced decreased EPO production. Recommend re-checking at
next PCP ___.
# ESRD not on PD: S/p PD catheter placement. See by Nephrology
during admission, and decided to hold off on starting PD for
now. Renal dialysis is following. Hold off on starting PD for
now. Home Vitamin D and Calcitriol was held due to
hyperphosphatemia. Started on Sodium Bicarb.
# T2DM on insulin: At home, takes Levemir 12U qHS and Insulin
Sliding scale with HUM insulin. Glucose finger sticks were ___
labile during admission- 100's to high 300's throughout the day.
She also had a few episodes of symptomatic hypoglycemia during
admission, which is most likely due to pt not being able to eat
scheduled meals/snacks. Pt should continue home Insulin regimen
upon discharge.
# Hypertension: Continued home clorthalidone and labetalol.
TRANSITIONAL ISSUES:
[] Please follow-up recheck alk-Phos, GGT as outpatient. of
note, Anti-Mitochondrial Ab was negative
[] caltriol and vit D was discontinued per renal rec. sodium
bicarb was started.
[] Please continue to follow and trend Hb/Hct. Consider stool
guiac to look for possible GI bleed.
[] please follow up pt's BS and adjust insulin further as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 1 mcg PO DAILY
2. Chlorthalidone 25 mg PO DAILY
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
4. Labetalol 400 mg PO TID
5. Polyethylene Glycol 17 g PO DAILY
6. Senna 17.2 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Vitamin D ___ UNIT PO EVERY MONTH
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
10. Torsemide 60 mg PO DAILY
11. Torsemide 20 mg PO QPM
12. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection
EVERY 4 WEEKS
13. Levemir 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Lactulose 30 mL PO DAILY:PRN constipation
15. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN pain
16. sevelamer CARBONATE 2400 mg PO TID W/MEALS
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
2. Chlorthalidone 25 mg PO DAILY
3. Levemir 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
5. Labetalol 400 mg PO TID
6. Torsemide 20 mg PO QPM
7. Torsemide 60 mg PO DAILY
8. Lactulose 30 mL PO DAILY:PRN constipation
9. Polyethylene Glycol 17 g PO DAILY
10. Senna 17.2 mg PO DAILY
11. sevelamer CARBONATE 2400 mg PO TID W/MEALS
12. Simethicone 40-80 mg PO QID:PRN gas pain
RX *simethicone 80 mg 1 tablet by mouth up to four times a day
Disp #*50 Tablet Refills:*0
13. Sodium Bicarbonate 1300 mg PO TID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth three times a
day Disp #*84 Tablet Refills:*0
14. darbepoetin alfa in polysorbat 100 mcg/0.5 mL injection
EVERY 4 WEEKS
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Urinary Retention
SECONDARY DIAGNOSIS:
-CKD stage V, possibly secondary to diabetes ___ type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were not able to
urinate after your Peritoneal Dialysis catheter was placed. We
placed a urinary catheter to remove the urine from your bladder
and gave you medication to help you urinate. When we removed the
catheter from your bladder you were able to urinate on your own.
We think that you were not able to urinate because of a side
effect of the pain medication Oxycodone. We discontinued this
medication while you were in the hospital and we advise that you
do not take it when you leave the hospital.
When you leave the hospital, it is important that you follow-up
with your outpatient providers at your scheduled appointments.
It has been a pleasure taking care of you.
Sincerely,
You ___ Team
Followup Instructions:
___
|
19943130-DS-12 | 19,943,130 | 28,328,726 | DS | 12 | 2149-10-24 00:00:00 | 2149-10-24 11:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC:back pain radiating down R leg
Major Surgical or Invasive Procedure:
L2-5 laminectomy
History of Present Illness:
HPI: ___ year old male with a history of kyphoplasty presents
with
acute onset of lumbar paraspinal pain radiating down his right
leg. The patient has had a long history of back pain and been
evaluated and treated at the ___ as well as ___. At ___, he was seen by Dr. ___ he was planning on performing back surgery for spinal
stenosis. He had tried steriod injections, as well as multiple
rounds of physical therapy. A week and half ago, he was having
a
bowel movement and stood up and felt a sudden knife like
stabbing
sensation which radiated down the back of his right leg. The
has
been in ___ pain since onset of acute pain a couple weeks ago.
ROS: Denies urinary or rectal incontience
Past Medical History:
PMHx:
HL
HTN
Depression
Social History:
___
Family History:
noncontributory
Physical Exam:
PHYSICAL EXAM on admission:
O: T: 99 BP: 157/89 HR:110 R 27 99%O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, patient
in
obvious pain.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 5 5 5 5 4 5
L 5 5 5 5 5 5 5 5 5 4 5
Sensation: Intact to light touch.
Reflexes: B T Br Pa Ac
Right ___ 2 2
Left ___ 2 2
Propioception intact
Toes downgoing bilaterally
Negative ___ and negative clonus.
+ ___ sign on R side.
On discharge
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light,3 to 2
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: full strength throughout w/ exception of L ___, 4+/5.
Sensation: Intact to light touch thoughout w exception of
decreased senstation to light touch in left S1 distribution.
Toes downgoing bilaterally
Pertinent Results:
___ 07:41PM URINE HOURS-RANDOM
___ 07:41PM URINE GR HOLD-HOLD
___ 07:41PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:41PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-LG
___ 07:41PM URINE RBC-8* WBC-128* BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:41PM URINE CA OXAL-OCC
___ 07:41PM URINE MUCOUS-RARE
___ 03:45PM GLUCOSE-208* UREA N-23* CREAT-1.2 SODIUM-139
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-21* ANION GAP-18
___ 03:45PM ALT(SGPT)-44* AST(SGOT)-27 ALK PHOS-68 TOT
BILI-0.4
___ 03:45PM LIPASE-68*
___ 03:45PM ALBUMIN-4.1
___ 03:45PM WBC-12.4* RBC-4.77 HGB-15.5 HCT-46.3 MCV-97
MCH-32.5* MCHC-33.5 RDW-12.3
___ 03:45PM NEUTS-82.7* LYMPHS-11.5* MONOS-4.9 EOS-0.4
BASOS-0.5
___ 03:45PM PLT COUNT-340
___ 03:45PM ___ PTT-25.1 ___
Brief Hospital Course:
Fr ___ was admitted on ___ for pain control and for
surgical intervention. He underwent a pre-operative work-up and
it was determined he would undergo a L3-L4 laminectomy with
questionable laminectomy at adjacent levels on ___. On___
he developed a UTI and was started on a 10 day course of
bactrim. He was taken to the OR on ___ where a L2-L5
laminectomy was preformed. During the case a dural tear was
encountered and it was repaired w/ stitches & seal
intraoperatively. Thep patient was extubated and sent to the
PACU where he was stable and transfered to the floor. On POD 1
the patient was Okay to raise HOB by 10 degrees every hour until
he reached 45 degrees. Then patient remained on bedrest at 45
degrees for the day and did well without any evidence of
headaches. on ___ the patient was OOB with ___ and was stable
without headaches. Experienced 1 episode of tachycardia up to
120s. Ordered EKG which showed sinus rhythm. on ___ the
patients exam was stable and he was medically cleared for
discharge to rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
2. Amlodipine 2.5 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Simvastatin 10 mg PO DAILY
5. Venlafaxine XR 75 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN pain
8. Piroxicam 20 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Lisinopril 5 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Simvastatin 10 mg PO DAILY
7. Tamsulosin 0.4 mg PO HS
8. Venlafaxine XR 75 mg PO DAILY
9. Acetaminophen 325-650 mg PO Q6H:PRN fever; pain
10. Diazepam 5 mg PO Q6H:PRN muscle spams
11. Lorazepam 0.5 mg PO Q6H:PRN anxiety
12. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
13. Senna 1 TAB PO HS
14. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 10 Days
15. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
lumbar stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Spine Surgery
Do not smoke.
Keep your wound(s) clean and dry / No tub baths or pool
swimming for two weeks from your date of surgery.
If you have steri-strips in place, you must keep them dry for
72 hours. Do not pull them off. They will fall off on their own
or be taken off in the office. You may trim the edges if they
begin to curl.
No pulling up, lifting more than 10 lbs., or excessive bending
or twisting for at least 6 weeks
Limit your use of stairs to ___ times per day.
Have a friend or family member check your incision daily for
signs of infection.
Take your pain medication as instructed; you may find it best
if taken in the morning when you wake-up for morning stiffness,
and before bed for sleeping discomfort.
Do not take any anti-inflammatory medications such as Motrin,
Advil, Aspirin, and Ibuprofen etc. unless directed by your
doctor.
Increase your intake of fluids and fiber, as pain medicine
(narcotics) can cause constipation. We recommend taking an over
the counter stool softener, such as Docusate (Colace) while
taking narcotic pain medication.
Clearance to drive and return to work will be addressed at
your post-operative office visit.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING:
Pain that is continually increasing or not relieved by pain
medicine.
Any weakness, numbness, tingling in your extremities.
Any signs of infection at the wound site: redness, swelling,
tenderness, and drainage.
Fever greater than or equal to 10.5° F.
Any change in your bowel or bladder habits (such as loss of
bowl or urine control).
Followup Instructions:
___
|
19943165-DS-5 | 19,943,165 | 25,794,810 | DS | 5 | 2174-10-23 00:00:00 | 2174-10-27 00:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
codeine
Attending: ___.
Chief Complaint:
Progressive dysphagia
Major Surgical or Invasive Procedure:
___ - G-tube placement
___ - Bronchoscopy and biopsy
___ - endoscopy
___ - endoscopy
History of Present Illness:
Primary Care Physician: Dr. ___ (In ___
___ with history of familial visceral myopathy affecting the
bladder and ___ years of dysphagia presents with subacute
worsening of his dysphagia. He had gradually been losing more
and more weight and has progressed to only being able to swallow
liquids. Can only swallow ensure or milk. He has seen a GI doc
once in his second home in ___, who recommended a
barium swallow. He was unable to swallow the barium and did not
have the test performed. He has lost 20 lbs in the last couple
of months. When his family picked him up from the airport
yesterday they felt he looked "bad" and much thinner. They
noticed he is unable to swallow his saliva and constantly spits
it out. Although he has an appt here with GI (Dr. ___ on
___, they brought him to the ED for expedited work up.
Denies fever, chills, abdominal pain, diarrhea, night sweats.
ROS(+): +constipation. +voice change over last couple months.
In the ED intial vitals were: 98.5 97 149/76 16 100%. Labs were
notable for leukocytosis (WBC 14.2k), thrombocytosis (604k). GI
was consulted and the patient transferred to the medicine floor.
Upon arrival to the floor, 98.1 116/74 76 18 99/RA
Past Medical History:
Visceral myopathy of the bladder - self-straight cath TID
(started ___ years ago)
Gastric ulcers
Alcoholism with w/d seizures - quit ___ yrs ago.
Social History:
___
Family History:
Per patient report, 90 family members are positive for the same
autosomal dominant genetic disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
---------
Vitals: 98.1 116/74 76 18 99/RA
General: Alert, oriented, emaciated, no acute distress. Tobacco
smoke odor.
HEENT: Sclera anicteric, MM dry, oropharynx clear
Neck: JVP<8cm, no LAD , no thyromegaly.
Lungs: Decreased breath sounds 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
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
---------
Vitals: 98.7 106/59 93 16 95/RA
General: alert, oriented, emaciated, no acute distress.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: no LAD , no thyromegaly.
Lungs: Few crackles lower lung bases b/l. 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
Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
---------
___ 02:32PM WBC-14.2* RBC-4.61 HGB-13.5* HCT-42.0 MCV-91
MCH-29.3 MCHC-32.2 RDW-11.8
___ 02:32PM NEUTS-81.1* LYMPHS-12.8* MONOS-4.2 EOS-1.2
BASOS-0.6
___ 02:32PM GLUCOSE-108* UREA N-18 CREAT-0.7 SODIUM-138
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-28 ANION GAP-15
___ 02:32PM ALT(SGPT)-18 AST(SGOT)-19 ALK PHOS-130 TOT
BILI-0.3
___ 04:07PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:07PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 04:07PM URINE RBC-<1 WBC-10* BACTERIA-FEW YEAST-NONE
EPI-<1
IMAGING:
----------
___ CT NECK (I+)
FINDINGS:
Evaluation of the aerodigestive tract demonstrates diffuse
thickening of the
upper esophagus and a large retrocricoid esophageal mass, which
erodes the
posterior trachea. A tracheo-esophageal fistula is best seen on
series 2:76
and 602b:33. This likely represents esophageal cancer with
secondary invasion
of the trachea. There is also significant edema of the
supraglottic larynx,
and asymmetry suggestive of a left hypopharyngeal mass (2:12).
Prominent
pre-tracheal lymph nodes measure up to 1.4 cm (2:91).
The salivary and thyroid glands are unremarkable. The neck
vessels enhance
bilaterally without flow-limiting stenosis or occlusion. For
detailed
evaluation of the lungs, please see the CT chest report from the
same day.
IMPRESSION:
1. Large retrocricoid esophageal mass, which erodes the
posterior trachea,
creating a tracheo-esophageal fistula, likely secondary to
esophageal cancer
with secondary invasin of the trachea. These are better
evaluated on CT chest
from the same day.
2. Edema of the supraglottic larynx with assymmetry suggestive
of a left
hypopharyngeal mass.
3. Prominent pretracheal lymph nodes, measuring up to 1.4 cm.
___ CT CHEST (I+)
FINDINGS: There is a poorly defined mass extending along the
upper to mid
aspect of the thoracic esophagus, measuring up to 4.5 x 3.2 cm
in its greatest
axial ___ and extending over a craniocaudal length of
approximately 9
cm (___). Superiorly, the mass reaches the level of the
thoracic inlet.
Anteriorly, the mass appears to invade the posterior wall of the
trachea,
although tracheal patency is preserved. There is a probable
fistulous
communication between the anterior aspect of the esophagus and
left
posterolateral aspect of the trachea at the level of the
clavicular heads
(4:37). Inferiorly, the mass extends to the level of the
carina. There are
multiple prominent mediastinal lymph nodes, measuring up to 8 mm
along the
right upper paratracheal region, 10 mm in the lower right
paratracheal region,
8 mm in the prevascular space, and 25 x 16 mm in the subcarinal
region (2:17,
22, 24, 28). An enlarged left hilar nodal conglomerate measures
14 x 13 mm
(2:30). There are no pathologically enlarged right hilar lymph
nodes or
enlarged axillary lymph nodes. The thoracic aorta is normal in
caliber.
Scattered aortic calcifications are seen. There are also
scattered coronary
artery calcifications. The right ventricular outflow tract and
its central
branches are normal in caliber and patent. The heart is normal
in size.
There is no pericardial effusion.
Scattered foci of high density within the right middle lobe are
likely related
to prior aspiration of barium. There is mild-to-moderate
centrilobular
emphysema. A 7-mm right middle lobe opacity is seen along the
minor fissure,
likely a lymphoid aggregate (4:132). A similar-appearing 9-mm
opacity is seen
within the right lower lobe adjacent to the major fissure, also
likely
lymphoid aggregate (4:127). Additional high-density foci are
seen medially
within the right lower lobe, also likely related to prior
aspiration. There
are no pleural effusions. No pneumothorax is seen.
This study was not tailored for evaluation of the
subdiaphragmatic contents.
Note is made of a 4-mm lymph node along the gastrohepatic
ligament (2:56).
Multiple gallstones are seen layering within the gallbladder.
There is no
associated gallbladder wall thickening or pericholecystic fluid.
High-density
material within the colon likely relates to prior oral contrast
administration.
BONE WINDOW: There is diffuse demineralization. No suspicious
lytic or
blastic lesions are identified. Multilevel degenerative changes
of the
thoracolumbar spine are noted.
IMPRESSION:
1. Large mass extending along the proximal to mid portion of
the thoracic
esophagus, correlating to the finding seen on prior endoscopy.
Anteriorly,
the mass appears to invade the posterior wall of the trachea.
There is a
probable fistulous tract connecting the anterior aspect of the
esophagus to
the left posterolateral aspect of the trachea at the level of
the clavicular
heads. Aspirated barium within the right middle and lower lobes
likely
relates to passage of orally administered contrast through this
fistulous
communication during a prior radiologic study.
2. Mediastinal lymphadenopathy, as described above. 4-mm
nonspecific node
along the gastrohepatic ligament. PET-CT may be of value in
further assessing
for subdiaphragmatic pathologic lymphadenopathy.
3. Cholelithiasis.
___ CTAP
FINDINGS:
LUNG BASES: Scattered foci of high density within the right
lower lobe are
likely related to prior aspiration of barium. There small
bilateral pleural
effusions with adjacent atelectasis, right greater than left.
The visualized
portion of the heart and pericardium are normal. There is no
pericardial
effusion.
ABDOMEN: The liver is normal in size and homogeneous in
enhancement. There
are no concerning mass lesions in the liver. The portal and
hepatic veins are
patent.
The gallbladder is distended and contains numerous radiopaque
gallstones. The
common bile duct is not dilated.
The spleen is normal in size and homogeneous in enhancement.
The pancreas enhances homogeneously without peripancreatic fat
stranding. The
pancreatic duct is prominent but not enlarged.
The adrenal glands are normal in size and shape.
The kidneys are normal in size and display symmetric nephrograms
and contrast
excretion. There are no concerning mass lesions seen in the
kidneys. The
ureters are normal in caliber along their course the bladder.
There is no
perinephric abnormality seen.
The distal esophagus is normal appearing with no hiatal hernia.
The stomach
is under distended, but grossly normal. The small bowel does
not show
abnormal dilatation or focal wall thickening. The large bowel
contains feces
and does not show obstructive mass lesions, wall thickening, or
diverticulosis. There is no intraperitoneal free air or free
fluid.
There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes
by CT size criteria.
There is no aneurysmal dilatation of the abdominal aorta. The
aorta and its
major branches are patent. There is minimal calcified
atherosclerotic disease
seen in these vessels.
PELVIS: The bladder is relatively underdistended. There is
diffuse bladder
wall thickening, likely related to familial visceral myopathy.
Prostate gland
is unremarkable. The rectum and sigmoid are unremarkable.
There is no pelvic
free fluid. There are no pathologically enlarged pelvic
sidewall or inguinal
lymph nodes by CT size criteria.
OSSEOUS STRUCTURES AND SOFT TISSUES: There are no hernias seen.
There are no
concerning lytic or sclerotic lesions seen.
IMPRESSION:
1. No evidence of metastatic disease in the abdomen or pelvis.
2. Gallbladder is distended with multiple radiopaque
gallstones.
----
PATHOLOGY: ___
CYTOLOGY REPORT - Final
Specimen(s) Submitted: FINE NEEDLE ASPIRATION, TBNA tracheal
mass
Diagnosis
FNA, tracheal mass:
POSITIVE FOR MALIGNANT CELLS.
Squamous cell carcinoma.
Brief Hospital Course:
___ with prominent family history of familial visceral myopathy
affecting the bladder and ___ years of progressive dysphagia now
unable to tolerate solids or liquids, EGD unable to pass
esophagus, CT neck/chest shows large esophageal mass with LAD
concerning for esophageal cancer, s/p tracheal stent placement.
------
ACUTE ISSUES:
# SQUAMOUS CELL CARCINOMA: STABLE. FNA evidences squamous cell
carcinoma of as yet undelineated primary. Most likely primary
esophageal cancer given location and history of tobacco and
ethanol use.
- Bronchoscopy performed ___ and biopsy taken revealing
SCC. Trachea stented.
- Seen by oncology, will f/u with oncology/rad onc here and get
PET scan outpatient.
- WILL NEED INDEFINITE albutgerol/hypertonic
saline/Acetylcysteine nebs per IP to maintain tracheal stent
patency q6h
-___ bedside for choking hazard.
-peridex bid for halitosis
# TRACHEOESOPHAGEAL FISTULA CAUSING ASPIRATION: PERSISTENT.
Leading to aspiration events, evidenced by CT chest which
demonstrates oral radio contrast within the lung bases.
#MALNUTRIITON DUE TO MECHANICAL, OBSTRUCTIVE DYSPHAGIA:
ONGOING. Due to large esophageal mass. Strict NPO. At home will
get 1.5 cans jevity bolused TID, infusion company is ___,
contact: ___ ___.
# BACTERURIA: Due to chronic colonization in the setting of
long-term self-catheterization.
- No action.
# TOBACCO ABUSE:
- SBIRT
- Nicotine patch 14mg DAILY
# THROMBOCYTOSIS/LEUKOCYTOSIS: Elevated acute phase reactants.
- Repeat CBC in AM.
CHRONIC ISSUES:
-------
# HISTORY OF ALCOHOL WITHDRAWL SEIZURES: STABLE. Patient states
he has quit alcohol for ___ years.
- Monitored without signs of withdrawal.
# FAMILIAL VISCERAL MYOPATHY WITH BLADDER INVOVLEMENT: STABLE. A
rare, autosomal dominant hereditary myopathic degeneration of
both urinary and gastrointestinal tracts that causes chronic
intestinal pseudo-obstruction. It often presents with
megaduodenum, megacystitis, and symptoms such as abdominal
distention, pain, vomiting, constipation, diarrhea, dysphagia,
and urinary tract infection.
- Patient's whole family has been evaluated at ___
including genetic screening which revealed extent of genetic
penetrance.
- Patient to continue self-catheterization tid.
TRANSITIONAL ISSUES:
-------
#SQUAMOUS CELL CARCINOMA:
-f/u bx results
-reconsult GI for esophageal stenting if mass can be debulked
via radiation
-Total NPO, Yankauer suction for home.
-will followup here with onc and rad-onc, with PET scan prior to
appointments
# TOBACCO ABUSE:
# TRACHEAL STENT: INDEFINITE albutgerol/hypertonic
saline/Acetylcysteine nebs per IP to maintain tracheal stent
patency q6h. Contact by patient's sister on the day after
discharge - confirmed with interventional pulmonary that the
patient can miss ___ hours of NAc due to difficulty obtaining
this product as an outpatient. Sister has a plan to obtain the
necessary medications and will present to ED if any signs of
stridor.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ranitidine (Liquid) 150 mg PO DAILY
Discharge Medications:
1. Acetylcysteine 20% ___ mL NEB Q12H stent
RX *acetylcysteine 200 mg/mL (20 %) Please nebulize 3mL (600mg)
Every 12 hours Disp ___ Milliliter Refills:*1
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H stent
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 2.5 mg INH 4 TIMES A
DAY Disp #*300 Milligram Refills:*1
3. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour Apply 1 patch DAILY Disp #*7
Transdermal Patch Refills:*0
4. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H stent
RX *sodium chloride 3 % 15 mL INH FOUR TIMES A DAY Disp #*1800
Milliliter Refills:*1
5. Jevity 1.5 Cal (lactose-free food with fiber) 1.5 cans oral
TID
as directed, with water flushes as directed
RX *lactose-free food with fiber [Jevity 1.5 Cal] 0.06 gram-1.5
kcal/mL 1.5 CANS by tube THREE TIMES A DAY Disp #*60 Bottle
Refills:*1
6. Suction
Yankuer suction catheter and portable suction machine since
patient is not to swallow secretions.
Diagnosis: Esophageal squamous cell carcinoma
7. Nebulizer
150.3 Malignant Neoplasm of the Esophagus.
31.93 Placement of tracheal stent
Please dispense 1 nebulizer for lifelong inhalation of
acetylcysteine.
8. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
ESOPHAGEAL SQUAMOUS CELL CARCINOMA
TRACHEOESOPHAGEAL FISTULA
DYSPHAGIA
MALNUTRITION
SECONDARY DIAGNOSES:
FAMILIAL VISCERAL MYOPATHY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for difficulty swallowing. We
found a large mass which appears to be cancer which was
compressing your esophagus and trachea. We were able to stent
open your trachea (breathing tube) - to maintain this stent and
keep it open so that you can breathe it is very important that
you continue to use the nebulizers every 6 hours for the rest of
your life (hypertonic saline, albuterol, and acetylcysteine).
Because you can't swallow, we placed a gastric tube so that food
can go directly into your stomach. You will take one and half
cans of Jevity 1.5 three times daily as directed. A feeding
company will help you with this.
For your mass, you will followup here with the cancer doctors
and ___. Before your appointments with them you
with have a PET scan.
Followup Instructions:
___
|
19943634-DS-2 | 19,943,634 | 22,300,726 | DS | 2 | 2193-03-11 00:00:00 | 2193-03-11 21:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Keflex / morphine / fentanyl / nicotine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
___ lumbar puncture
Trans-sphenoidal EEG
History of Present Illness:
___ w/ past medical history significant for domestic violence
and PTSD presenting with worsening mental status over the last
few months. She was diagnosed with dementia a year ago and has
been slowly deteriorating but now has started rapidly
deteriorating over the last month. According the admission note
and her daughter, she has deteriorated rapidly during the past 6
weeks. At baseline, she was able to carry out all daily
activities. Since ___, she has become very paranoid about
people stealing from her trash or getting abandoned by her
family. She has become unable to care for herself and has become
increasingly confused. She would try to run away from house, had
a couple of "accidents" of urinary and fecal incontinence. Has
lost interest in usual activities. Has been found wandering on
the street. She often does not eat or speak to family. She
sleeps little. She has lost approximately ___ lbs in one
month. She is not able to follow what is going on on TV. She
does not exhibit aggressive features except when sundowning at
night.
Of note, she takes oxycodone as much as 75mg TID. There has not
be any significant medication chages. She has had recent
mammogram and pap smears, but has refused colonoscopy in the
past. Her daughter's boyfriend recently passed away from MI at
age ___. Per daughter, both the ___ and daughter were trying
to resuscitate him and were left shaken by this experience.
Denies h/o cancer or seizure disorder. Denies psychiatric or
neurologic disorders.
.
OSH Neurlogy Workup Summary (Obtained via fax)
___
___
- MRI Brain ___: Moderately severe generalized atrophy and
scattered foci of high snial on the T2 weighted images
compatbile with small vessel ischemic changes.
- MRA ___: Mild decreased caliber of intrasylvian branches
of R-MCA
- Cardiac echo ___: (Limited quality) EF 55-60%. Possible
mild hypokinessi of the apical anterior wall. Abnomral LV
diastolic filling c/w I/IV diastolic dysfunction. Trivial
pericardial effusion.
- Carotid Duplex ___: 1. Heterogenous plaque formation in
the both proximal internal carotid arteires associated with
___ nonhemodynamically sig stenosis bilaterally. 2. Antegrade
flow in bilateral vert a.
- Holter monitor ___: NSR dominant. 1 run of SVT 13 beats,
irregular possible AFib at 5am.
OSH Labs
___
B12 418
Folate 7.2
TSH 2.58
ESR 41
CRP < 0.4
.
Per the note from the patient's PCP he is concerned about her
rapid deterioration of neurologic status without clear cause,
wants patient admitted for an expedited neurologic evaluation.
She is appearing more demented and wandering outside.
.
From OMR it appears she has been sent to cognitive neurology
several times but has missed so many first appointments that
they are no longer willing to see her.
.
In the ED, initial VS were 97.6 94 109/62 16 97%. On exam she
was noted to be aox2, flat affect, intermittently confused. A UA
was positive and she was started on cipro. She is admitted for
further declining mental status.
.
On arrival to the the floor she seems comfortable and in no
acute distress. She is complaining of lower back pain which she
has had for a long time. She also reports having had some
dysuria for the past few days. No frequency. Also reports a
chronic cough which is not worse than baseline. No hemoptysis.
Patient is afraid that her family will abandon her and reports
feeling depressed. She became tearful while discusing her
difficult social history.
.
REVIEW OF SYSTEMS:
+ per HPI
Denies fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
COPD/emphysema
aortic aneurism
diverticulosis
depression
Social History:
___
Family History:
Family history of diabetes, uncle with leukemia. No known family
history of early dementia or neurologic disease.
Physical Exam:
ADMISSION:
PHYSICAL EXAM:
VS: 98.9 123/70 88 22 94RA 800/100 since admission
GENERAL - sleeping, difficult to arouse, drowsy, not cooperative
HEENT - Normal pupil size, PERRLA, EOMI, sclerae anicteric, MMM,
OP clear
NECK - Supple
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - diffuse rhonchi, no wheeze, moderate air movement
ABDOMEN - obese, soft, nontender, + BS, + B/L CVA tenderness
BACK - no rashes or lesions
EXTREMITIES - WWP, 2+ peripheral pulses
SKIN - no rashes or lesions
NEURO - awake, A&Ox2, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, plantar
reflex equivocal; DTRs 1+ throughout, cerebellar exam intact
Pertinent Results:
___ 08:43PM WBC-8.7# RBC-5.13 HGB-16.6* HCT-45.5 MCV-89#
MCH-32.4* MCHC-36.6* RDW-12.1
___ 08:43PM NEUTS-71.8* ___ MONOS-5.9 EOS-1.1
BASOS-3.2*
___ 08:43PM GLUCOSE-116* UREA N-10 CREAT-0.7 SODIUM-144
POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-28 ANION GAP-14
___ 09:26PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:26PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-15 BILIRUBIN-MOD UROBILNGN-0.2 PH-5.5 LEUK-SM
___ 09:26PM URINE RBC-1 WBC-11* BACTERIA-FEW YEAST-NONE
EPI-2
___ 09:26PM URINE MUCOUS-RARE
___ 10:25PM LACTATE-1.3
___ 07:52AM BLOOD ALT-34 AST-28 LD(LDH)-165 CK(CPK)-41
AlkPhos-56 TotBili-0.8
___ 04:00PM BLOOD CK(CPK)-52
___ 11:12AM BLOOD CK(CPK)-131
___ 09:55AM BLOOD AlkPhos-63
___ 07:52AM BLOOD CK-MB-2 cTropnT-<0.01
___ 04:00PM BLOOD CK-MB-2
___ 04:00PM BLOOD cTropnT-<0.01
___ 11:12AM BLOOD CK-MB-2 cTropnT-<0.01
___ 11:09AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:52AM BLOOD Albumin-3.4* Calcium-9.8 Phos-2.3* Mg-1.9
___ 11:09AM BLOOD Albumin-4.7 Calcium-10.8* Phos-2.5*
Mg-2.4
___ 01:00PM BLOOD Calcium-10.5* Phos-2.1* Mg-2.1
___ 03:45PM BLOOD Albumin-4.1 Calcium-10.6* Phos-2.8 Mg-2.1
___ 03:45PM BLOOD PTH-217*
___ 07:52AM BLOOD TSH-2.0
___ 04:00PM BLOOD Cortsol-18.6
___ 02:50PM BLOOD HIV Ab-NEGATIVE
___ 04:00PM BLOOD ASA-NEG Acetmnp-20 Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 07:52AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 06:50AM BLOOD WBC-5.7 RBC-5.09 Hgb-15.5 Hct-48.6*
MCV-96 MCH-30.5 MCHC-32.0 RDW-12.9 Plt ___
___ 06:50AM BLOOD Glucose-106* UreaN-6 Creat-0.6 Na-143
K-4.3 Cl-105 HCO3-27 AnGap-15
___ 06:50AM BLOOD Calcium-10.3 Phos-2.3* Mg-2.1
___ 11:44PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-INTERFEREN mthdone-NEG
___ 12:00AM URINE AMPHETAMINES, GC/MS-Test Name
___ 10:38AM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-0 Polys-0
___ ___ 10:38AM CEREBROSPINAL FLUID (CSF) TotProt-43 Glucose-71
___ 10:38AM CEREBROSPINAL FLUID (CSF) CSF-PEP-NO OLIGOCL
___ 10:38AM CEREBROSPINAL FLUID (CSF) CSF HOLD-PND
___ 10:38AM CEREBROSPINAL FLUID (CSF) BETA 2
MICROGLOBULIN-PND
___ 10:38 am CSF;SPINAL FLUID Source: LP TUBE #3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
___ 11:32 am STOOL CONSISTENCY: WATERY Source:
Stool.
**FINAL REPORT ___
CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final ___:
Feces negative for C.difficile toxin A & B by EIA.
(Reference Range-Negative).
___ 1:08 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
RAPID PLASMA REAGIN TEST (Final ___:
NONREACTIVE.
LYME SEROLOGY (Final ___:
NO ANTIBODY TO B. BURG___ DETECTED BY EIA.
Blood Culture, Routine (Final ___: NO GROWTH.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN
AND/OR GENITAL CONTAMINATION.
CHEST (PA & LAT)Study Date of ___ 9:57 ___
Hyperinflation without acute cardiopulmonary process.
EEGStudy Date of ___
This is a normal waking EEG. No focal abnormalities or
epileptiform discharges were present.
MRA BRAIN W/O CONTRASTStudy Date of ___ 12:09 ___
FINDINGS:
MRI: There is no evidence of hemorrhage, edema, mass, mass
effect, or
infarction. There is no diffusion abnormality to suggest acute
ischemia. The
ventricles and sulci are mildly prominent, consistent with
global atrophy,
likely related to the patient's age. There is no evidence of
preferential
central, or medial or other temporal lobar atrophy. There is
fluid-opacification of the mastoid air cells, bilaterally. The
visualized
paranasal sinuses are well-aerated.
MRA: Incidental note is made of a small left posterior
communicating artery
and the right PCom is not definitely seen. The major vessels of
the
intracranial anterior and posterior circulation are patent
without evidence of
stenosis, occlusion, vascular malformation, or aneurysm larger
than 3 mm.
IMPRESSION:
1. No acute intracranial abnormality.
2. Mild global atrophy, likely related to patient's age.
3. Unremarkable cranial MRA.
TRANSPHENOIDALEEGStudy Date of ___
FINDINGS:
ROUTINE SAMPLING: The background activity showed a symmetric
8.5-9.0 Hz
alpha rhythm which attenuated with eye opening.
SPIKE DETECTION PROGRAMS: There were numerous automated spike
detections predominantly for electrode and movement artifact.
There
were no epileptiform discharges.
SEIZURE DETECTION PROGRAMS: There were no automated seizure
detections
predominantly for electrode and movement artifact. There were no
electrographic seizures.
PUSHBUTTON ACTIVATIONS: There were no pushbutton activations.
SLEEP: The patient progressed from wakefulness to stage II, then
slow
wave sleep at appropriate times with no additional findings.
CARDIAC MONITOR: Showed a generally regular rhythm with an
average rate
of 60-80 bpm.
IMPRESSION: This is a normal video EEG monitoring session.
Background
activity was normal. There were no epileptiform discharges or
electrographic seizures. None of the patient's typical events
were
recorded.
TRANSPHENOIDALEEGStudy Date of ___
FINDINGS:
BACKGROUND: Included a well-formed 10 Hz alpha frequency
posteriorly in
wakefulness.
SPIKE DETECTION PROGRAMS: Were not functioning in the session.
SEIZURE DETECTION PROGRAMS: Captured no events.
PUSHBUTTON ACTIVATIONS: There were none.
SLEEP: The patient became drowsy and had some early sleep also
without
new findings.
CARDIAC MONITOR: Showed a generally regular rhythm.
IMPRESSION: This telemetry captured no pushbutton activations.
The
recording was that of a normal background in wakefulness and
drowsiness.
There were no prominent focal abnormalities or any clearly
epileptiform
features.
CT CHEST W/CONTRAST; CT ABD & PELVIS WITH CONTRASTStudy Date of
___ 3:40 ___
1. 4-cm infrarenal abdominal aortic aneurysm without CT evidence
for acute
intra-abdominal or pelvic process.
2. Ground-glass opacity in the anterior right lower lobe, which
is a
non-specific finding but could represent early infection.
SPECT-CT images of the brain ___
No focal temporal lobe perfusion abnormalities
DISCHARGE LABS:
___ 01:00PM BLOOD WBC-7.4 RBC-5.28 Hgb-15.9 Hct-51.6*
MCV-98 MCH-30.2 MCHC-30.9* RDW-12.6 Plt ___
___ 01:00PM BLOOD Glucose-126* UreaN-8 Creat-0.6 Na-141
K-4.2 Cl-104 HCO3-25 AnGap-16
___ 01:00PM BLOOD Albumin-4.2 Calcium-11.0* Phos-2.7 Mg-2.1
PURKINJE CELL (YO) ANTIBODIES
Test Result Reference
Range/Units
YO AB SCREEN, IFA, SERUM NEGATIVE NEGATIVE
Purkinje cells cytoplasmic antibody (Yo) can be found in
approximately 50% of patients with paraneoplastic cerebellar
degeneration (PCD). The presence of Yo antibody strongly
suggests underlying gynecological cancer primarily of
ovarian or breast origin. A negative assay for Yo antibody
does not exclude the possibility of a malignant tumor.
This test was developed and its performance characteristics
have been determined by ___,
___. It has not been cleared or approved by
the ___. Food and Drug Administration. The FDA has
determined that such clearance or approval is not necessary.
Performance characteristics refer to the analytical
performance of the test.
THIS TEST WAS PERFORMED AT:
___
___ ___, ___
___, MD PHD
Test Result Reference
Range/Units
___ AB SCREEN, IFA, SERUM NEGATIVE NEGATIVE
Neuronal nuclear (___) antibody is present in patients with
various neurological symptoms including two paraneoplastic
syndromes: sensory neuropathy (PSN) and encephalomyelitis
(PEM). The presence ___ antibody strongly suggests
underlying small cell lung carcinoma (SCLC). ___ antibody is
identified by IFA and confirmed by Western Blot. A negative
result does not exclude the possibility of a SCLC or other
malignant tumor.
This test was developed and its performance characteristics
have been determined by ___,
___. It has not been cleared or approved by
the ___. Food ___ Drug Administration. The FDA has
determined that such clearance or approval is not necessary.
Performance characteristics refer to the analytical
performance of the test.
THIS TEST WAS PERFORMED AT:
___
___ ___, ___
___, MD PHD
Brief Hospital Course:
___ w/ past medical history significant for domestic violence
and PTSD diagnosed with dementia a year at OSH ago p/w 2 month
h/o rapidly deteriorating mental status.
.
# ACUTE DETERIORATION OF MENTAL STATUS/ PSEUDODEMENTIA
Patient was found to be withdrawn, minimally interactive,
confused, agitated, and paranoid. She also endorsed some CVA
tenderness with positive UA, which resolved with 3 day course of
ciprofloxacin. She eloped on HD 1 and was found wandering around
1 mile away from the hospital by police. She was readmitted and
was observed by 24h 1:1 sitter throughout the remaining hospital
course. Patient reported feeling depressed and paranoid about
"getting kicked out" and her medical teams being impostors.
Patient's home dose oxycodone, trazodone, clonazepam, ranitidine
were held. There was no evidence of withdrawal. Patient
frequently refused vitals, medications, and the diagnostic
tests. Neurology, psychiatry, and social worker were involved.
She underwent extensive neurologic and medical work up as
follows. Pseudodementia with catatonic and paranoid features was
thought to be the most likely diagnosis at discharge.
Repeat MRI/MRA showed no structural or vascular abnormalities.
BTox/UTox were pan-negative. Folate/B12/LFTs/BUN-Cr/initial
Ca/TSH/cortisol/anti-TPO were all within normal limitations.
Lyme/RPR/HIV were neg. BCx was negative. UCx grew no dominant
organisms and appeared to be contaminated. UTI was unlikely to
have been the cause as there was no improvement in mental status
after three days of ciprofloxacin. CT torso demonstrates
possible ground-glass opacities but no overt evidence for any
malignancy. Her hallucinations about bad smells led to
EEG/Sphenoidal EEG/MRI SPECT for temporal lobe seizure, and they
were all negative. ___ guided LP was performed without any
complications. CSF cell counts, protein, glucose were within
normal limitations. CSF culture was negative. Paraneoplastic
work-up including multiple CSF and serum antibodies are pending
at the time of discharge. This includes CSF PEP, VKGC Antibody;
___ Antibody; anti-NMDA antibody, LGI1 antibody, CRMP1
antibody, CASPR2 antibody, CSF cytologic exam; as well as ___
serum paraneoplastic panel.
Patient had an isolated "good day" after getting 2mg of ativan
given prior to her MRI. She became more interactive with
spontaneous speech and good insight into her illness. Patient
went back to her confused and withdrawn presentation after a
day. Additional dose of ativan given for another diagnostic
procedure had a similar effect. Per psychiatry recommendations,
she was put on ativan 1mg BID. Her improved mental status was
sustained for 2 days. Per daughter's request and psychiatry's
approval, ativan was increased to 2mg BID on ___.
On the day of discharge, patient's mental status was improved
from admission though not to the level of initial improvement
seen with first dose of Ativan, she was less withdrawn, making
good eye contact, would occasionally smile and become tearful at
thought of not leaving the hospital. She was fixated on the
medical team continuing to keep her as a "prisoner" in the
hospital but unlike prior episodes, she did not have delusions
or feel paranoid about people evacuating the hospital or her
doctors being ___. Her thought process was linear and
appropriate at time of discharge and she was able to state in
her own words the risks of her calcium increasing as an
outpatient and what would have to be done (she would be brought
to the ED) if her mental status or calcium became worse.
Follow-up for depression was planned with ___ and a
consult with ___. The patient and
daughter are aware of both.
Patient was discharged with the arrangemenets to follow up with
multiple outpatient psychaitrists. PCP was notified of all
pending tests via email.
# EKG Changes:
Upon admission, ECG on ___ was notable for new ST-T wave changes
in leads V3-V6, raising possibility of ___ ischemia of
unknown age when compared to ___. Patient was asymptomatic
and cardiac enzymes were negative. Patient had a brief episode
of chest pain, which patient did not wish to elaborate, on ___.
ECG x 2 on ___ and ___ were unchanged from previous ECGs.
Cardiac enzymes were negative. Patient had no recurrent chest
pain.
# Hypercalcemia
Patient's Ca was wnl upon admission. She however was found to be
hypercalcemic on ___ at 10.8 and phos 2.5 in the setting of
poor PO intake. PTH was 217. This was most consistent with
primary hyperparathyroidism. Parathyroid glands were not
palpable. Hypercalcemia itself was unlikely to be contributing
to patient's mental status given her initial Ca was wnl and the
best mental status observed with a near peak calcium of 10.8.
Patient remained mostly asymptomatic except for transient
episodes of abdominal pain. Patient was treated with IV fluid
with good effect and was encouraged PO intake. Ca level at the
time of discharge was 11. As her hematocrit had also risen and
her depression had been worse the day before, it was thought
most likely that this was due to hypovolemia and decreased oral
intake. Endocrinology was consulted who felt that it was an
option to send patient home as long as she continued to drink
lots of fluids and had a follow-up calcium check. The patient
and PCP are aware that she should have her calcium checked on
___ and return to the hospital if it is still elevated >11.
Endocrine also felt this was most likely not a PTH secreting
tumor given their rarity. Plan is for outpatient endocrine
follow-up with consideration of treatment options including
surgery and radioablation. Outpatient workup recommendations
were communicated with PCP.
.
# Chronic back pain:
Remained stable on oxycodone-Acetaminophen (5mg-325mg) ___
tablet q6h PRN. Home oxycodone was held as above.
.
# Asthma:
Remained stable on home regimen.
.
# GERD:
Remained stable on home omeprazole.
.
TRANSITIONAL ISSUES
# Neuro w/u: The following tests are pending at the time of
discharge.
- VKGC Antibody ; ___ Antibody; anti-NMDA antibody, LGI1
antibody, CRMP1 antibody, CASPR2 antibody
- ___ serum paraneoplastic panel
- CSF Cytologic exam; Protein Electrophoresis
.
# Hypercalcemia/hyperparathyrodism:
- Repeat Ca, albumin by PCP to ensure taking in enough orally
___
- F/u Parathyroid Hormone Related Protein
- Endocrine appointment needs to be scheduled and consideration
of Sestamibi scanning for Parathyroid tumors and adenomas
.
# depression:
- consideration of alternative medication management options and
tapering of ativan
.
# FULL CODE
# HCP ___ ___
Medications on Admission:
Oxycodone 75mg TID prn pain (225mg per day total)
Albuterol 90mcg HFA 2 puffs Q4H prn
Albuterol nebs
Wellbutrin 150mg BID (for last year)
Betamethasone 0.05% CREAM bid PRN itching
Clonazepam 2mg QHS
Flonase 50mcg 1 each nostril once a day
Flovent 110mcg 2 puffs BID
Ibuprofen 800mg TID for pain
Nicotine cartridge
Omeprazole 20mg BID
ranitidine 150mg daily
spiriva 18 mcg daily
Trazadone 50mg QHS
nasal saline drops
O2 at night
Discharge Medications:
1. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Inhalation every four (4) hours as needed for shortness
of breath or wheezing.
2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO BID (2 times a day).
3. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1)
Spray Nasal once a day.
4. Flovent HFA 110 mcg/actuation Aerosol Sig: Two (2)
Inhalation twice a day.
5. omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
7. lorazepam 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a
day).
Disp:*18 Tablet(s)* Refills:*0*
8. Saline Nasal 0.65 % Aerosol, Spray Sig: One (1) Nasal once a
day.
9. oxycodone-acetaminophen ___ mg Tablet Sig: One (1) Tablet
PO every six (6) hours as needed for pain.
Disp:*18 Tablet(s)* Refills:*0*
10. ibuprofen 800 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain.
11. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2)
Tablet PO DAILY (Daily).
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Altered mental status
Depression
SECONDARY DIAGNOSIS
COPD
emphysema
aortic aneurism
diverticulosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized at the ___ for worsening confusion and
change in mental status. Your brain MRI, EEG, MRI SPECT, lumbar
puncture, and blood tests were all negative. You still have some
labs pending, which will be followed by your PCP. You were also
treated for urinary tract infection with antibiotics.
We have made the following changes to your medications:
- STOPPED oxycodone
- STOPPED clonazepam
- STOPPED Trazodone
- ADDED oxycodone-acetaminophen (percocet) ___ mg Tablet
Sig: One (1) Tablet PO every six (6) hours as needed for pain
- ADDED ativan (lorazepam) 2mg twice a day
- ADDED vitamin D daily
Please only use the Percocet when you are in severe pain as it
can make you sleepy or drowsy.
On the day of your discharge, we recommended that you stay
longer to treat you hypercalcemia and arrange a better treatment
plan however you decided to leave. You were able to tell us
about the risks of high calcium including confusion, heart
arrthymias which may cause death. You and ___ decided that
you would be able to drink at least 8 glasses of fluid a day and
would have your calcium checked by your primary care doctor on
___. If it is elevated more than 11, you will have to come
back to the hospital.
On ___, you should call the endocrine (calcium) doctor for
an appointment at ___.
Followup Instructions:
___
|
19943951-DS-2 | 19,943,951 | 20,275,108 | DS | 2 | 2152-09-16 00:00:00 | 2152-09-17 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol-Codeine / Phenergan
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
Ms. ___ is a ___ year old female with a history of NASH
cirrhosis, and CAD who p/w 1 week of worsening abdominal pain
and
distention, N/V, poor PO intake, confusion, dizziness, and
fatigue/malaise.
The patient says that she had about 1 weeks of acute on chronic
abdominal pain. She says that she has had ongoing abdominal pain
for the past ___ years but in the past week it was getting worse.
From the patient report she had a large volume ___ L
paracentesis at her outside facility. Along with abdominal pain
she started having fevers and chills at home with a Tmax at home
recorded of ___.
She also says that she has been more confused over the past few
days but states that she stopped taking her lactulose about ___
days ago because it was making her feel sick. She then had a
fall
at home. She thinks that she lost consciousness and fell but is
unsure what happened. She was getting out of her bed and walking
in her room when she says she lost her balance and fell to the
floor. The patient says she lost consciousness but is able to
recall most of the events of her fall.
Patient was referred here by her PCP in ___ with concerning for
decompensation of her cirrhosis. She denies any BRBPR or melena,
hematemesis or coffee ground emesis.
Past Medical History:
- unclear past medical history since the patient is confused at
the time of our interview and she did not come with any records
from an OSH. She reports a history of:
- NASH cirrhosis
- Diabetes type (not currently on treatment)
- Vitiligo
- Outside Hospital cardiac arrest requiring ED CPR/INTUBATINO 3
weeks ago
- cholecystectomy
- tubal ligation
Social History:
___
Family History:
Mother with a history of ovarian cancer and Father with a
history
of etoh use disorder and cirrhosis.
Physical Exam:
ADMISSION PHYSICAL EXAM
======================
VITALS: Tenp 98.8 BP 130/75 HR 87 RR ___ Ra
GENERAL: chronically ill appearing jaundiced female lying in bed
slightly confused
HEENT: icteric sclera, moist mucous membranes
NECK: No JVD.
CARDIAC: Regular rhythm, rapid rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: trace crackles at the bases, no rhonchi or wheezes
BACK: No CVA tenderness.
ABDOMEN: largely distended but soft, well dressed clean and
intact paracentesis bandaged area on lower left quadrant,
non-tender to deep palpation in all four quadrants.
EXTREMITIES: No lower extremity pitting edma. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. jaundiced with vitiligous appearing hypopigmented
skin changed on face, chest, back abdomen and lower extremities,
erythematous upper chest area, spide nevi
NEUROLOGIC: able to count from 10 to 0 but very slowly, slight
asterixis on exam
DISCHARGE PHYSICAL EXAM
=======================
VITALS: ___ 0735 Temp: 98.6 PO BP: 132/91 L Sitting HR: 105
RR: 18 O2 sat: 96% O2 delivery: Ra
GENERAL: laying in bed, appears comfortable
HEENT: icteric sclera, moist mucous membranes
NECK: No JVD.
CARDIAC: Regular rhythm, rapid rate, no murmur
LUNGS: CTAB
BACK: No CVA tenderness.
ABDOMEN: minimally distended, soft, non distended, minimally
tender with no localization
EXTREMITIES: No lower extremity pitting edema. Pulses DP/Radial
2+ bilaterally.
SKIN: minimally jaundiced
NEUROLOGIC: slowed cognition but follows commands, no focal
deficits
Pertinent Results:
ADMISSION LAB RESULTS
===================
___ 04:49PM BLOOD WBC-2.5* RBC-3.12* Hgb-9.9* Hct-29.7*
MCV-95 MCH-31.7 MCHC-33.3 RDW-13.8 RDWSD-48.1* Plt Ct-58*
___ 04:49PM BLOOD ___ PTT-39.0* ___
___ 04:49PM BLOOD Glucose-105* UreaN-6 Creat-0.5 Na-135
K-3.8 Cl-103 HCO3-22 AnGap-10
___ 04:49PM BLOOD ALT-35 AST-73* LD(___)-250 AlkPhos-181*
TotBili-6.5*
___ 04:49PM BLOOD Albumin-2.6* Calcium-8.2* Phos-2.9 Mg-1.8
Iron-180* Cholest-149
___ 04:49PM BLOOD Triglyc-84 HDL-42 CHOL/HD-3.5 LDLcalc-90
LDLmeas-107
DISCHARGE LAB RESULTS
====================
___ 06:30AM BLOOD WBC-8.0 RBC-4.26 Hgb-13.4 Hct-38.7 MCV-91
MCH-31.5 MCHC-34.6 RDW-14.9 RDWSD-48.6* Plt ___
___ 06:30AM BLOOD ___ PTT-36.3 ___
___ 06:30AM BLOOD Glucose-137* UreaN-10 Creat-0.6 Na-134*
K-4.1 Cl-94* HCO3-24 AnGap-16
___ 06:30AM BLOOD ALT-48* AST-93* LD(___)-240 AlkPhos-175*
TotBili-6.4*
___ 06:30AM BLOOD Calcium-9.8 Phos-4.5 Mg-2.1
IMAGING
=======
RUQ US: ___
--------------
1. Cirrhotic liver morphology without concerning liver lesion.
Main portal vein is patent.
2. Splenomegaly measuring up to 16.7 cm.
3. Moderate volume ascites in the right greater than left lower
quadrants as well as in the right upper quadrant.
___ CT HEAD w/o contrast:
No acute intracranial process.
___ CXR
------------
IMPRESSION:
Medial right basilar opacity, atelectasis versus pneumonia.
Re-evaluation with short-term follow-up standard PA and lateral
radiographs may be helpful to reassess.
___ CXR PA/LATERAL:
1. On the lateral image, there is increased retrocardiac
opacification that cannot be lateralized on the AP view. The
aforementioned finding may
represent pneumonia in the appropriate clinical setting however
atelectasis cannot be excluded.
___ TTE:
Mild symmetric left ventricular hypertrophy with normal cavity
size and regional/global biventricular systolic function. No
valvular pathology or pathologic flow identified. High normal
estimated pulmonary artery systolic pressure.
___ EGD: No evidence of varices
___ KUB:
1. No evidence of bowel obstruction or ileus.
MICROBIOLOGY:
==============
___ 5:50 pm PERITONEAL FLUID PERITONEAL FLUID.
**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.
___ 7:43 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH
___ 2:21 pm PERITONEAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
INTERVAL LABS:
================
___ 06:25AM BLOOD ALT-19 AST-50* LD(___)-182 AlkPhos-142*
TotBili-2.6*
___ 06:40AM BLOOD ALT-27 AST-63* LD(___)-242 AlkPhos-139*
TotBili-4.6*
___ 07:20AM BLOOD ALT-35 AST-72* LD(LDH)-222 AlkPhos-158*
TotBili-5.5*
Brief Hospital Course:
Patient Summary for Admission:
==============================
Ms. ___ is a ___ year old female with a history of NASH
cirrhosis, and CAD who p/w 1 week of worsening abdominal pain
treated for SBP while inpatient and managed for hepatic
encephalopathy. She underwent screening EGD and once her IV
antibiotic course was completed felt safe for discharge home.
ACUTE ISSUES:
=============
# Acute SBP: Ms. ___ presented with abdominal pain and
initial diagnostic paracentesis notable for PMNs >250 consistent
with diagnosis of SBP. She received albumin supplemenation on
Day 1 and Day 3 of hospitalization and diuretics initially held.
She was treated with a 5 day course of Ceftriaxone 2grams Q24H
and transitioned to Ciprofloxacin 500mg daily on ___ for
prophylaxis and Bactrim 1 Tab DS in the setting of prolonged
QTc. Repeat paractenesis ___ was negative for SBP and 4L
removed.
# Hepatic Encephalopathy: On presentation patient notably AO1-2
with slowed cognition. Worsening HE likely in setting of SBP as
above. However her home alprazolam and amitriptyline were held
while inpatient to ensure medication effects did not worsen her
mental status. Lactulose was titrated to ___ BM per day and Ms.
___ was started on Rifaximin 550mg BID while inpatient.
# ___ Cirrhosis: MELD-NA 24 | ___ Class: C
# Hepatitis C positive: Has not established with ___ as
of yet. Concern for NASH vs HCV Cirrhosis (HCV positive but
negative viral load). Her volume status was managed with a large
volume paracentesis on ___ and with diuretics, 40mg Furosemide
and 100mg Spironolactone which was restarted ___ with stable
renal function. EGD completed ___ without evidence of varices
but portal hypertensive gastropathy noted. She was evaluated by
Transplant Social work while inpatient and will followup in the
___ following discharge. Nutrition evaluated by consult
team and Ensure supplementation recommended. Her tbili was 6.4
at time of discharge, however no other clinical changes
appreciated. As a result, she will have close follow up
scheduled in the ___.
# Nausea/Vomiting: Following EGD on ___, Ms. ___ noted to
have significant nausea/vomiting. Lipase WNL, and KUB was
negative for ileus or obstruction. On EGD, patient noted to have
retained food contents which raised concern for gastroparesis.
Her symptoms were managed with zofran and reglan and improved
prior to discharge.
# Pancytopenia: likely from her above cirrhosis history. Her
differential was unrevealing and her smear was reassuring. WBC
stabilized prior to discharge.
# Mild Hyponatremia: Na 134 at time of discharge likely in
setting of poor PO intake.
CHRONIC ISSUES:
===============
# CAD: ECHO completed ___ and notable for mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified. High normal estimated
pulmonary artery systolic pressure.
# Hypothyroidism: Continued home levothyroxine 100mcg daily
# Anxiety/depression: Floxetine continue while inpatient and
amitriptyline restarted prior to discharge.
TRANSITIONAL ISSUES:
Pending labs at discharge:
___ 18:03 BLOOD CULTURE Blood Culture, Routine
___ 15:08 PERITONEAL FLUID ANAEROBIC CULTURE
[] Recommend repeat chemistry, LFTs at PCP visit on ___ with
Dr. ___
[] Patient without insurance, will need to apply in ___
for insurance. This was directly communicated to Dr. ___
[] Liver clinic follow up scheduled and would consider need for
outpatient LVP
[] Discharged on Bactrim for SBP prophylaxis given prolonged QTc
[] Patient will have close Liver Clinic follow up to be
scheduled by inpatient team
[] Home ___ was recommended for Ms. ___ however given her
insurance situation, this was deferred.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Amitriptyline 10 mg PO QHS
4. ALPRAZolam 0.25 mg PO TID:PRN anxiety
5. Rifaximin 550 mg PO BID
6. Lactulose 15 mL PO TID
7. Vitamin D ___ UNIT PO 1X/WEEK (___)
8. Spironolactone 100 mg PO DAILY
9. Digestive Probiotic (B infan-B long-L acid-L
rhamn;<br>Bifidobacterium
i
n
f
a
n
t
i
s
;
<
b
r
>
L
.___
1.5 billion cell oral DAILY
10. FLUoxetine 10 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Metoclopramide 5 mg PO TID
RX *metoclopramide HCl 5 mg 1 tablet by mouth three times a day
Disp #*9 Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
4. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
5. Digestive Probiotic (B infan-B long-L acid-L
rhamn;<br>Bifidobacterium
i
n
f
a
n
t
i
s
;
<
b
r
>
L
.___
1.5 billion cell oral DAILY
6. FLUoxetine 10 mg PO DAILY
7. Furosemide 40 mg PO DAILY
8. Lactulose 15 mL PO TID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Rifaximin 550 mg PO BID
11. Spironolactone 100 mg PO DAILY
12. Vitamin D ___ UNIT PO 1X/WEEK (___)
13. HELD- ALPRAZolam 0.25 mg PO TID:PRN anxiety This medication
was held. Do not restart ALPRAZolam until instructed to do so by
PCP
14. HELD- Amitriptyline 10 mg PO QHS This medication was held.
Do not restart Amitriptyline until instructed to do so by PCP
___:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
___ Cirrhosis
Spontaneous Bacterial Peritonitis
Hepatic Encephalopathy
Secondary Diagnosis:
====================
Anxiety
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for choosing ___ as your site of care!
Why was I admitted to the hospital?
- You were admitted because of abdominal pain and confusion.
What was done for me while I was in the hospital?
- You had a sample take of the fluid in your abdomen. This was
notable for an infection.
- We treated this infection with antibiotics and drained
additional fluid from your abdomen.
- We stopped some of your medications to reduce your confusion.
What should I do when I leave the hospital?
- Please continue all of your medications and your new
medication, Bactrim to prevent future infections.
- If you notice fevers at home, worsening abdominal pain it is
very important that you call the ___ at ___.
- Please follow up in the ___ as detailed below.
We wish you the best!
Followup Instructions:
___
|
19944215-DS-4 | 19,944,215 | 20,267,911 | DS | 4 | 2177-08-28 00:00:00 | 2177-08-28 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
Morphine
Attending: ___
Chief Complaint:
chronic subdural hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ male who presents to ___ with
2.5cm subacute SDH with 7mm midline shift. The patient has
fallen
multiple times since ___. His daughter contacted his PCP
concerned about confusion and increased lethargy. His MRI/MRA is
also notable for a 9mm partially calcified aneurysm along the
left distal vertebral artery.
He has been experiencing multiple falls in which he loses his
balance or trips; during the first fall he lost his balance and
fell backwards in his kitchen striking his posterior head, the
second he tripped on a curb and struck his face. He denies any
preceding cardiopulmonary symptoms. He denies any dizziness or
lightheadedness. He denies any pain following his falls. He
denies any unilateral weakness. He ambulates with the use of a
rolling walker. He takes Aspirin 81mg and Plavix daily for
cardiac stents placed in ___.
He lives in an apartment attached to his daughter's house. He
is
independent with all ADL, continues to drive and works
20hrs/week
at the police station. He manages his own medications. His
daughter and coworkers have noticed increased confusion,
difficulty using the computer and lethargy over the past several
weeks. His daughter is concerned about him falling asleep after
driving.
Past Medical History:
CAD s/p LAD stent (___)
PVC
Thrombocytosis
Pulmonary Hypertension
Social History:
___
Family History:
non-contributory
Physical Exam:
Exam on Admission
T: 97.2 BP: 172/89 HR: 65 RR: 17 O2 Sat: 95% RA
GCS upon Neurosurgery Evaluation: 15 Time of evaluation: 1700
Airway: [ ]Intubated [x]Not intubated
Eye Opening:
[ ]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[x]4 Opens eyes spontaneously
Verbal:
[ ]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[x]5 Oriented
Motor:
[ ]1 No movement
[ ]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[x]6 Obeys commands
Exam on Discharge:
Patient alert and oriented to person, place and time.
Face symmetrical, tongue midline.
MAE ___ with exception of Left Deltoid and Left Tricepts are
4+/5. Left pronator drift.
Pertinent Results:
Please see OMR for relevant issues
Brief Hospital Course:
#SDH
The patient was admitted from the ED to the ___ for observation
after a repeat NCHCT demonstrated a stable right SDH. His
Aspirin and Plavix were held in anticipation of upcoming surgery
for evacuation. Given that the patient looked clinically well
and that he had recent Plavix/ASA use, the decision was made to
have the patient screened for rehab with planned return for burr
hole evacuation.
Medications on Admission:
omeprazole 20 mg capsule,delayed release oral
1 capsule,delayed ___ Once Daily
folic acid 1 mg tablet oral
1 tablet(s) Once Daily
oxybutynin chloride ER 15 mg tablet,extended release 24 hr oral
1 tablet extended release 24hr(s) Once Daily
niacin ER 500 mg tablet,extended release 24 hr oral
1 tablet extended release 24 hr(s) Once Daily
bumetanide 0.5 mg tablet oral
1 tablet(s) Once Daily
Acidophilus capsule oral
1 capsule(s) Once Daily
metoprolol succinate ER 50 mg capsule,extended release 24 hr
oral
1 capsule,extended release 24hr(s) Once Daily
Aspir-81 81 mg tablet,delayed release oral
1 tablet,delayed release (___) Once Daily
B complex-vitamin C-folic acid -- Unknown Strength
Unknown # of dose(s) Once Daily
hydroxyurea 500 mg capsule oral
1 capsule(s) Twice Daily
magnesium oxide 400 mg capsule oral
1 capsule(s) Once Daily
simvastatin 40 mg tablet oral
1 tablet(s) Once Daily
amlodipine 5 mg tablet oral
1 tablet(s) Once Daily
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
Do not exceed 4G in 24 hours.
2. LevETIRAcetam 500 mg PO BID
3. amLODIPine 5 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Hydroxyurea 500 mg PO BID
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Simvastatin 40 mg PO QPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Chronic Subdural hematoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
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.
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 were taking Aspirin and Plavix, but they have been
discontinued in anticipation of your upcoming surgery.
***You have been discharged on Keppra (Levetiracetam). This
medication helps to prevent seizures. Please continue this
medication as indicated on your discharge instruction. It is
important that you take this medication consistently and on
time.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
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:
___
|
19944416-DS-10 | 19,944,416 | 29,235,727 | DS | 10 | 2150-01-17 00:00:00 | 2150-01-20 11:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Depo-Provera
Attending: ___.
Chief Complaint:
fever
gum swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with iron
deficiency anemia and endometriosis presented to the ED with 3
days of fevers and malaise with one day of gum swelling, found
to
be leukopenic.
Patient was seen as an epi visit at ___ on ___ complaining of
two days of lightheadedness, weakness, dizziness, and fatigue
which she attributed to her anemia. At that time, she was
afebrile. She was diagnosed with a presumed viral infection.
Labs
were also drawn at that visit that were notable for WBC 2.4 and
baseline anemia (hgb 8.1). On ___, she called her PCP to report
fevers to 102-103 and persistent constitutional symptoms with
new
onset gum swelling (no bleeding). She was instructed to come to
the ___ ED.
Of note she has never traveled outside country, has no sick
contacts ___ year old son has eczema rash only), no pets, no
outdoor hobbies, does not consume unpasteurized foods and does
not have a restricted diet. She has no h/o autoimmune disorder,
denies abdominal pain, denies early satiety. No weight loss, no
adenopathy. No new sexual partners. No needle exposure. No
antibiotics in last six months.
In the ED, vital signs were notable for Tmax 100.9 with HR 103.
Labs were drawn that show WBC 1.4 with absolute neutrophil count
of 610 and absolute lymphocyte count of 480. No other cell
lineages were abnormal. LFTs and BMP were unremarkable. Lactate
1.5. A UA was contaminated with 7 epis, but otherwise showed
small blood, 6RBC, 29 WBC, and few bacteria. A CXR was without
acute cardiopulmonary abnormality.
A peripheral smear was performed and hematology-oncology was
consulted.
The patient received 2g IV cefepime in addition to IVF and PO
acetaminophen.
On arrival to the floor, patient confirms history of above has
mild frontal headache, aware that Tylenol or ibuprofen would ask
fevers, defers trial of opioid.
Past Medical History:
iron deficiency anemia
endometriosis
Social History:
___
Family History:
Mother - ___, HLD, HTN
Father - Kidney ___, colon cancer diagnosed in late ___
MGM - Lung cancer
PGM - Schizophrenia
PGF - DM, cancer
Uncle - ESRD
Physical ___:
=================
ADMISSION EXAM:
=================
VS: 98.0PO 128 / 78 R Lying 80 18 100 Ra
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no adenopathy, no gingival bleeding
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
=================
DISCHARGE EXAM:
=================
Temp: 98.7 BP: 95 / 66 R Sitting HR: 77 RR: 17 O2
sat: 100% O2 delivery: Ra
GENERAL: NAD, resting comfortably in bed
HEENT: AT/NC, anicteric sclera, MMM, no gingival bleeding,
oropharynx clear; PERRLA, with no periorbital swelling
appreciated. No facial tenderness to palpation. No gum swelling
visualized.
NECK: supple, no adenopathy
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or appreciable edema
PULSES: 2+ radial pulses bilaterally
NEURO: CN ___ intact; Alert, moving all 4 extremities with
purpose, face symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
___ 10:44PM BLOOD WBC-1.4* RBC-4.62 Hgb-8.5* Hct-29.7*
MCV-64* MCH-18.4* MCHC-28.6* RDW-19.8* RDWSD-44.1 Plt ___
___ 10:44PM BLOOD Neuts-44.9 ___ Monos-14.7*
Eos-4.4 Baso-0.7 AbsNeut-0.61* AbsLymp-0.48* AbsMono-0.20
AbsEos-0.06 AbsBaso-0.01
___ 11:30AM BLOOD ___ 09:00AM BLOOD Ret Aut-0.1* Abs Ret-0.01*
___ 10:44PM BLOOD Glucose-89 UreaN-11 Creat-0.7 Na-137
K-3.8 Cl-102 HCO3-23 AnGap-12
___ 10:44PM BLOOD ALT-15 AST-16 LD(LDH)-223 AlkPhos-67
TotBili-<0.2 DirBili-<0.2
___ 10:44PM BLOOD CRP-1.3
___ 09:00AM BLOOD HIV Ab-NEG
___ 12:09AM BLOOD Lactate-1.5
Discharge Labs:
___ 07:10AM BLOOD WBC-2.7* RBC-4.11 Hgb-7.6* Hct-26.2*
MCV-64* MCH-18.5* MCHC-29.0* RDW-20.2* RDWSD-43.8 Plt ___
___ 07:10AM BLOOD Neuts-62 Bands-1 ___ Monos-2* Eos-4
Baso-1 Atyps-1* Metas-1* Myelos-0 AbsNeut-1.70 AbsLymp-0.78*
AbsMono-0.05* AbsEos-0.11 AbsBaso-0.03
___ 07:10AM BLOOD Hypochr-OCCASIONAL Anisocy-2+* Poiklo-1+*
Macrocy-NORMAL Microcy-1+* Polychr-NORMAL Ovalocy-OCCASIONAL
Tear Dr-OCCASIONAL
___ 09:00AM BLOOD Ret Aut-0.1* Abs Ret-0.01*
___ 07:10AM BLOOD Glucose-102* UreaN-17 Creat-0.7 Na-139
K-4.0 Cl-104 HCO3-22 AnGap-13
___ 10:44PM BLOOD ALT-15 AST-16 LD(LDH)-223 AlkPhos-67
TotBili-<0.2 DirBili-<0.2
___ 10:44PM BLOOD calTIBC-456 VitB12-710 Folate-10
___ Ferritn-48 TRF-351
___ 09:00AM BLOOD CMV VL-NOT DETECT
___ 09:00AM BLOOD HIV Ab-NEG
PARVOVIRUS DNA PCR: POSITIVE
Brief Hospital Course:
ASSESSMENT & PLAN: ___ year old female with iron deficiency
anemia presents with 4 days of constitutional symptoms and now
fevers to 102-103, found in ED to be neutropenic.
ACUTE ISSUES:
===============
# Infection of unknown etiology
Patient with fevers for 3 days to 102-103 and found to be
leukopenic to 1.4 (moderately neutropenic with ANC 610).
Notably,
patient does not truly meet criteria for neutropenic fever with
ANC > 500 in the absence of ongoing cytoreductive chemotherapy.
MASCC 23, low risk Regardless, patient started on Cefepime. With
the exception of gum swelling and broken tooth, and
retro-orbital fullness and pain, there were no overt signs of
focal infection on exam or preliminary imaging. Etiology was
suspected to be viral ,with extensive workup sent. HIV, CMV were
negative. Her neutropenia resolved on ___ an abx were
discontinued, after which she remained afebrile and
asymptomatic. On ___ Her Parvovirus DNA PCR returned
positive, and this is suspected to be the underlying cause of
her acute onset neutropenia.
# Leukopenia
WBC 1.4 on presentation with ANC 610 and abs lymphocyte count of
480. No other cell lineages are abnormal. LDH, LFTs, and lactate
are also notably normal. No reports of gum bleeding (just gum
swelling) or easy bruising lately. Exam without lymphadenopathy.
Overall, suspect her leukopenia is likely secondary to marrow
suppression from her infection. Initially trended downward and
recovered on ___. Thought to be due to parvovirus infection.
CHRONIC ISSUES:
===============
# Iron deficiency anemia: profound with ferritin of 4, iron
infusion held as inpatient due to infection and workup of
neutropenia. Baseline Hgb ___ since ___. Will f/u with a
repeat
CBC and PCP appointment in ___ weeks, and will undergo iron
infusion
therapy as outpt.
==============================
TRANSITIONAL ISSUES:
==============================
[] new-onset neutropenia due to parvovirus, will need repeat CBC
___.
[] iron deficiency anemia, chronic, needs to be on outpatient
iron supplementation (rx'd but not taking)
[] broken upper left molar - chronic for past 2 months; pt has
outpatient dentist and will need to follow up
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ferrous Sulfate 325 mg PO DAILY (questionable if taking
regularly)
3. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ferrous Sulfate 325 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Naproxen 500 mg PO Q12H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Neutropenia
Anemia
Parvovirus infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- you had fevers and gum swelling
- your white blood cell count was found to be very low
WHAT HAPPENED TO ME IN THE HOSPITAL?
- blood tests were performed to identify the source of infection
and low white cell count
- you were given antibiotics for a suspected infection
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19944585-DS-8 | 19,944,585 | 20,765,421 | DS | 8 | 2159-05-28 00:00:00 | 2159-06-02 11:57:00 |
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:
abdominal pain
Major Surgical or Invasive Procedure:
laparoscopic cyst drainage and right salpingoophorectomy
History of Present Illness:
Ms. ___ is an ___ year old who had nausea and vomiting x 1
day 7 days ago
as well as onset of abdominal pain. She finds it difficult to
describe, but her daughter notes it seems worse with movement.
Her daughter was visiting ___ and ___ that, while she has
had an enlarged lower abomen for months, it now felt hard and
was tender. She was seen at ___, got IVF and had a CT which
showed a large cystic mass and wsa sent to ___ ED.
Past Medical History:
PGynHx: Menopause age ___ or ___, denies ever having PMBx. Denies
any GYN issues such as ovarian cysts, abnormal Paps.
PObHx: SVD x 2, term no comps
PMHx: osteoporosis
shoulder fracture age ___
?cerebellar tumor
peripheral neuropathy and ataxic gait of uncelar etiology
spinal compression fractures
PSHx: skin cancer resection ( unsure if melanoma or basal cell
carcinoma)
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam on admission:
PE: 99.6 65 141/79 20 95%
General: cachetic, papery skin, multiple brusies on ___
Cardiac: RRR
Pulm: fine crackles at bases
Abdomen: soft, large firm smooth mass 2cm above umbilicus. mildy
TTP, no rebound, no guarding.
GU: atrophic external anatomy, smooth vaginal mucosa, smooth
cervix, no nodularity. Large smooth mass, high in pelvis,
mobile.
Rectal: no nodularity
Pertinent Results:
___ 08:45AM BLOOD WBC-7.8 RBC-3.74* Hgb-11.0* Hct-34.8*
MCV-93 MCH-29.5 MCHC-31.7 RDW-12.6 Plt ___
___ 05:35AM BLOOD WBC-8.4 RBC-3.31* Hgb-9.8* Hct-31.3*
MCV-95 MCH-29.6 MCHC-31.4 RDW-12.6 Plt ___
___ 09:03PM BLOOD WBC-7.9# RBC-3.87* Hgb-11.0* Hct-35.3*
MCV-91 MCH-28.5 MCHC-31.2 RDW-12.9 Plt ___
___ 08:45AM BLOOD Glucose-161* UreaN-9 Creat-0.6 Na-138
K-4.0 Cl-104 HCO3-26 AnGap-12
___ 05:35AM BLOOD Glucose-44* UreaN-12 Creat-0.5 Na-140
K-3.5 Cl-106 HCO3-22 AnGap-16
___ 09:03PM BLOOD Glucose-92 UreaN-18 Creat-0.7 Na-135
K-4.2 Cl-98 HCO3-28 AnGap-13
___ 08:45AM BLOOD Calcium-8.4 Phos-2.2* Mg-1.8
___ 05:35AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.8
___ 09:03PM BLOOD Calcium-8.6 Phos-3.3 Mg-2.1
___ 09:03PM BLOOD CEA-2.5 CA125-32
___ 09:03PM BLOOD CA ___
Brief Hospital Course:
Ms. ___ was admitted to the gynecology oncology service
after presenting to the ED with a large abdominal mass. She was
noted to have a urinary tract infection in the ED and started on
macrobid for treatment. The following day she underwent an
uncomplicated operative laparoscopy, right
salpingo-oophorectomy. Please see the operative report for full
details.
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with IV dilaudid. Her
diet was advanced without difficulty and she was transitioned to
APAP and oxycodone. On post-operative day #1, her urine output
was adequate so her Foley catheter was removed and she voided
spontaneously. Physical therapy was consulted to assist with
ambulation.
By post-operative day 2, she was tolerating a regular diet,
voiding spontaneously, ambulating with the assistance of
physical therapy, and pain was controlled with oral medications.
She was then discharged home in stable condition with outpatient
follow-up scheduled.
Medications on Admission:
denied
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*1
2. Acetaminophen 650 mg PO TID
do not take more than 4000mg of acetaminophen in 24 hrs
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet
extended release(s) by mouth every 8 hrs Disp #*45 Tablet
Refills:*0
3. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
do not drink or drive on this med
RX *oxycodone 5 mg 0.5 (One half) capsule(s) by mouth every 4
hrs Disp #*20 Tablet Refills:*0
4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
twice a day Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Large Cystic Mass, urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted to the gynecologic oncology service after
undergoing the procedures listed below. ___ have recovered well
after your operation, and the team feels that ___ are safe to be
discharged home. After physical therapy evaluated ___, they had
recommended a rehabilitation facility. However, given that your
family would prefer to take ___ home, we have set up home ___ for
___ instead. They will contact ___ directly to establish the
care. ___ were also started on antibiotics for a urinary tract
infection. Please follow these instructions:
.
Laparoscopic instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 12
weeks.
* No heavy lifting of objects >10lbs for 4 weeks.
* ___ may eat a regular diet.
* It is safe to walk up stairs.
Incision care:
* ___ may shower and allow soapy water to run over incision; no
scrubbing of incision. No bath tubs for 6 weeks.
* Please leave the steri-strips on and let them fall off on
their own. If they are still on after ___ days from surgery,
___ may remove them.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Followup Instructions:
___
|
19945152-DS-10 | 19,945,152 | 29,187,537 | DS | 10 | 2145-06-21 00:00:00 | 2145-06-21 15:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
baclofen / oxybutynin
Attending: ___.
Chief Complaint:
Back pain and dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
This is a ___ year old female with past medical history of
pulmonary hypertension secondary to pulmonary ___
disease on home oxygen ___, CREST/scleroderma, hypertension,
obesity, admitted with several weeks of worsening dyspnea as
well
as acute onset lower back pain.
Patient reports recently notice increased dyspnea. Initially
she
attributed it to "head cold" she had, but it did not improve
with
treatment for this. On the day of her admission, she saw her
outpatient pulmonologist Dr. ___ a scheduled visit. Dr. ___ felt her symptoms related to inadequate
diuresis--the
patient has been noncompliant with the recommended dosing (is
taking lower dose of spironolactone than ordered) and frequency
(is not taking her torsemide twice daily as ordered).
Following her outpatient visit, patient reported worsening back
pain, which she had first noticed that morning prior to her
visit. She reported onset was while she was sitting on the
toilet, was sudden, sharp and nonradiating, located over her
lower back. Denies any preceding trauma or lifting. Reported
some temporary tingling in her feet bilaterally at the time, but
denied any shooting radicular pain. Denies any new bowel
incontinence. Reports chronic urinary incontinence whenever she
takes her diuretic. Given worsening pain over the course of the
day following her pulm visit, patient presented to the ED.
In the ED, initial VS were 96.6 96 127/51 20 96% 4L NC. In the
ED, she underwent CT T/L spine with wet read "1. No fracture is
identified. 2. Chronic compression fractures at L3, L4, L5
vertebral bodies are unchanged compared to ___.
Patient
received lidocaine patch, Tylenol. ED course notable for
worsening respiratory status. CXR did not show radiographic
evidence pneumonia. Patient was admitted to medicine for
further
management. Vitals prior to transfer: 98.0 95 102/53 23
97% 4L NC .
On arrival to the floor, patient confirmed above, and also
reported recent initiation of course of augmentin for possible
sinus infection. She reported noncompliance with medications as
I detailed above. Full 10 point review of systems positive
where
noted, otherwise negative.
Past Medical History:
Pulmonary hypertension with pulmonary ___ disease
(see
below for details)
Chronic hypoxic respiratory failure (4L at home)
CREST/Scleroderma, limited
Esophageal dysmotility
Telangiectasia
Hypertension
stress Urinary incontinence
Pulmonary nodule/lesion, solitary
Pericardial effusion
Obesity, morbid
Lichen simplex chronicus
Lumbago
Colon adenomas
Hypoxia
Obstructive sleep apnea
Squamous cell carcinoma in situ of skin of left upper arm
Sjogren's disease
Insomnia
Squamous cell carcinoma of right upper extremity
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
Vitamin D insufficiency
Hyponatremia
Osteoporosis without current pathological fracture
Past Pulmonary History:
- Pulmonary arterial hypertension, secondary to SSc/CREST.
Diagnosed by RHC ___ (mPAP 33, PVR 3.7). Also with RHC ___
consistent with PAH (mPAP 28, PVR 3.4). Hemodynamics worsening
on
___ RHC (mPAP 46, PVR 6.2 ___ with good response to therapy
augmentation. In ___ symptoms progressed with addition of
selexipag despite improvement in hemodynamics, and imaging
concerning for PVOD.
- Limited scleroderma/CREST with Sjogren's overlap.
Manifestations include Raynauds, GERD, sicca symptoms. Positive
___ with centromere pattern per old notes
- OSA previously on CPAP, now O2 alone
- Multiple pulmonary nodules
- Mediastinal adenopathy. On chest CT imaging at least since
___, found to be PET avid ___, s/p mediastinoscopy and LN
biopsy (2R, 4R) ___, c/w reactive follicular hyperplasia.
Path
also with pigment laden histiocytes, no evidence of lymphoma.
- Community acquired pneumonia ___, and post-op pneumonia
___
Social History:
___
Family History:
FAMILY HISTORY
Brother - Liver Cancer
Father - COPD
Physical ___:
VS: 98.8 PO 104 / 59 85 24 97 5 LNC
Gen: sitting up in bed, uncomfortable appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally, no crackles, ronchi or wheezing;
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 12:00AM BLOOD WBC-5.5 RBC-3.06* Hgb-9.7* Hct-30.0*
MCV-98 MCH-31.7 MCHC-32.3 RDW-14.9 RDWSD-53.5* Plt ___
___ 12:00AM BLOOD Glucose-110* UreaN-21* Creat-1.0 Na-137
K-3.6 Cl-97 HCO3-23 AnGap-17
___ 12:00AM BLOOD proBNP-298
___ 07:32AM BLOOD WBC-4.6 RBC-3.21* Hgb-10.3* Hct-31.5*
MCV-98 MCH-32.1* MCHC-32.7 RDW-14.5 RDWSD-52.2* Plt ___
___ 07:38AM BLOOD WBC-4.9 RBC-2.97* Hgb-9.2* Hct-28.7*
MCV-97 MCH-31.0 MCHC-32.1 RDW-14.6 RDWSD-51.7* Plt ___
___ 07:32AM BLOOD ___
___ 07:32AM BLOOD Glucose-102* UreaN-21* Creat-0.9 Na-134*
K-4.3 Cl-92* HCO3-28 AnGap-14
___ 07:38AM BLOOD Glucose-89 UreaN-21* Creat-0.9 Na-133*
K-4.3 Cl-96 HCO3-23 AnGap-14
___ 07:32AM BLOOD ALT-25 AST-20 AlkPhos-80 TotBili-0.4
___ 07:32AM BLOOD Albumin-3.9 Mg-2.1
___ 07:38AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.8
MRI spine ___
IMPRESSION:
1. Probable acute to subacute compression fracture of the
superior endplate of L1, with minimal loss of height.
2. Mild cervical degenerative disc disease, without spinal canal
narrowing or definite nerve root impingement.
3. Chronic compression deformities of the L5 and S1 vertebral
bodies. Please note that there is transitional anatomy at the
lumbosacral junction. The lowest well-formed intervertebral
disc is designated as S1-2.
Brief Hospital Course:
This is a ___ year old female with past medical history of
pulmonary hypertension secondary to pulmonary ___
disease on home oxygen ___, CREST / scleroderma, hypertension,
obesity, admitted with several weeks of worsening dyspnea as
well as acute onset lower back pain.
# Lower back pain - initially thought to represent acute on
chronic back pain due to muscle strain related to frequent
coughing and chronic compression fractures of spine secondary to
osteoporosis. She was started on standing Tylenol, lidocaine
patches, tramadol prn and trial of flexeril but continues to
have pain prompting MRI spine. MRI spine performed on ___
showed chronic spinal compression fractures in addition to
likely acute to subacute compression fracture in thoracic spine
without loss of height. She was seen by spine surgery service
who recommended no surgical intervention. She was discharge with
spinal corset for comfort but does not have spinal instability
and is without activity restrictions. She does not require
formal follow up in spine clinic and can follow up with her PCP
for continued management of her pain and osteoporosis. She was
provided with a short script for tramadol to use on discharge
from rehab.
# Acute on chronic hypoxic respiratory failure
# Pulmonary hypertension with pulmonary ___ disease
Volume status appears to be driving her suboptimally controlled
symptoms; no signs infection; Discussed with primary
pulmonologist on admission and the next day and she was
continued on her chronic PHTN medications with uptitration of
her diuretic regimen with goal fluid off. Her uncontrolled
respiratory symptoms have been attributed to volume overload
even when seen in clinic, due in part to erratic compliance
with her diuretics due to concern for cramping. While here, her
doses were increased to spironolactone 100mg daily and torsemide
50mg QAM and 10mg QPM. She was effectively diuresed over the
course of this admission with 5kg off by the time she was
discharged, with discharge weight 78.9 kg (173.94 lb) down from
Admission Weight: 85 kg (___). Of note, she did not
require any addiotional electrolyte repletion after ___
despite increased diuretic dosing. No changes were made to her
Opsumit, tadalafil, or her immunosuppression and prophylaxis
with prednisone, Mycophenolate, atovaquone, calcium/vitamin. She
will need to follow up with Dr. ___ than next scheduled
followup. I will contact her myself to schedule this.
# Acute bacterial sinusitis - Was recently started on an
outpatient antibiotic course for sinusitis. She was continue on
augmentin 875 BID with planned end date ___. She was also
started on Flonase and saline spray for nasal congestion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye) BID
2. Doxazosin 2 mg PO BID
3. Opsumit (macitentan) 10 mg oral DAILY
4. Mycophenolate Mofetil 1500 mg PO BID
5. Pantoprazole 40 mg PO Q12H
6. pilocarpine HCl 5 mg oral QID
7. Potassium Chloride (Powder) 20 mEq PO DAILY
8. PredniSONE 10 mg PO DAILY
9. Spironolactone 75 mg PO DAILY
10. tadalafil 20 mg oral BID
11. Detrol LA (tolterodine) 4 mg oral DAILY
12. Torsemide 40 mg PO DAILY
13. Multivitamins W/minerals 1 TAB PO DAILY
14. Atovaquone Suspension 750 mg PO BID
15. Calcitrate (calcium citrate) 200 mg (950 mg) oral DAILY
16. Vitamin D ___ UNIT PO ASDIR
17. Torsemide 10 mg PO DAILY
18. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Capsaicin 0.025% 1 Appl TP TID affected area over back
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Lidocaine 5% Patch 3 PTCH TD QAM low back pain
RX *lidocaine 5 % 3 patches QAM Disp #*90 Patch Refills:*0
7. Miconazole Powder 2% 1 Appl TP QID:PRN rash
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID
10. Sodium Chloride Nasal 2 SPRY NU TID
11. TraMADol ___ mg PO Q6H:PRN Pain - Severe
RX *tramadol 50 mg 0.5 to 1 tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
12. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
13. Torsemide 50 mg PO DAILY
RX *torsemide 100 mg 0.5 (One half) tablet(s) by mouth Daily
Disp #*15 Tablet Refills:*0
14. Torsemide 10 mg PO QPM
RX *torsemide 10 mg 1 tablet(s) by mouth QPM Disp #*30 Tablet
Refills:*0
15. Vitamin D ___ UNIT PO 1X/WEEK (MO)
16. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Last dose on ___.
17. Atovaquone Suspension 750 mg PO BID
RX *atovaquone 750 mg/5 mL 750 mg by mouth twice a day
Refills:*0
18. Calcitrate (calcium citrate) 200 mg (950 mg) oral DAILY
19. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic (eye)
BID
20. Detrol LA (tolterodine) 4 mg oral DAILY
RX *tolterodine 4 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
21. Doxazosin 2 mg PO BID
22. Multivitamins W/minerals 1 TAB PO DAILY
23. Mycophenolate Mofetil 1500 mg PO BID
RX *mycophenolate mofetil 500 mg 3 tablet(s) by mouth twice a
day Disp #*180 Tablet Refills:*0
24. Opsumit (macitentan) 10 mg oral DAILY
RX *macitentan [Opsumit] 10 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
25. Pantoprazole 40 mg PO Q12H
26. pilocarpine HCl 5 mg oral QID
27. Potassium Chloride (Powder) 20 mEq PO DAILY
Hold for K > 4
28. PredniSONE 10 mg PO DAILY
29. tadalafil 20 mg oral BID
RX *tadalafil [Cialis] 20 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on Chronic hypoxic respiratory failure due to:
#Pulmonary hypertension with pulmonary ___ disease
#Acute bacterial rhinosinusitis
Acute on chronic low back pain due to:
#Acute to subacute and chronic compression fractures
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:
For rehab:
[ ] please repeat chemistry panel including potassium and
magnesium within 3 days of discharge to ensure electrolyte
stability on new diuretic regimen.
[ ] please perform daily weights including on admission, goal
I/O is net even with weight on discharge of 78.9 kg (173.94 lb).
For patient:
Dear Ms. ___,
It was a pleasure to participate in your care.
WHY WAS I ADMITTED TO THE HOSPITAL?
You were admitted to the hospital for shortness of breath and
back pain. Your shortness of breath was likely due to multiple
reasons including your infection but the biggest factor was the
extra fluid on board.
WHAT HAPPENED WHILE I WAS HERE?
For your shortness of breath, we continued your antibiotics and
breathing treatments. We also increased the dose of your
torsemide and spironolactone and were able to get 5Kg of fluid
off while you were with us.
For your back pain, we increased your pain medications including
Tylenol, lidocaine patches, muscle relaxant and tramadol. Your
initial CAT scan of the spine showed only old fractures in the
spine related to your osteoporosis. Because you continued to
have pain we also got an MRI of the spine which did show a more
recent fracture in the spine similar to your old fractures. This
is usually managed with supportive care and does not require
surgery. The spine surgeons saw you and recommended continued
management with pain medications and physical therapy and adding
a spinal corset for your comfort. The fracture itself is not
unstable and should heal slowly over time. You do not need to
see the surgeons in clinic after discharge unless you have a
change in symptoms such as worsening pain or weakness.
WHAT SHOULD I DO WHEN I GET HOME?
You should continue to weigh your self every morning including
the first day you arrive home after discharge from rehab. Please
call Dr. ___ you gain 3 or more pounds in 1 day or 5 or more
pounds in 3 days. Please continue with your low salt / sodium
diet (no more than 2g daily).
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19945152-DS-4 | 19,945,152 | 26,352,487 | DS | 4 | 2139-12-10 00:00:00 | 2139-12-14 23:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
esophageal dysphagia
Major Surgical or Invasive Procedure:
Upper endoscopy under conscious sedation
Upper endoscopy under general anesthesia with intubation
History of Present Illness:
___ year old woman with a history of scleroderma with chronic
esophageal dysmotility who presents with inability to tolerate
PO x 2 days. Patient states that symptoms began acutely this
past ___. She attempted to eat, but had near-immediate
regurgitation of intact food. She has had continued
regurgitation of food since that time. The patient notes that on
___, liquids also began to come back up. She endorses
dysphagia with a sensation of food sticking in her esophagus
(points substernal) prior to regurgitation. No nausea, vomiting,
or diarrhea. No fevers, chills or other systemic symptoms. Able
to handle secretions without difficulty. She presented to her
PCP who referred her to the ED for GI eval.
.
Of note, the patient has had chronic esophageal dysmotility.
Last EGD ___. She has had issues of occassional difficulty
with completely swallowing her secretions, however she has never
had issues with regurgitation. She denies any odynophagia.
.
In the ED, initial Vitals 98.1 88 147/73 18 98%/RA. She was
started on IV fluids (NS) and given glucagon with persistent
epigastric pain. GI was consulted and recommended evaluation
with barium swallow. Barium swallow showed significant
obstruction, and the patient was admitted to medicine. Vitals
prior to transfer 98.1, 70, 16 128/60 100%RA.
.
Currently, she appears well and is comfortable. She is concerned
about this new issue, but feels well otherwise. She denies any
recent changes in her urine output. She always has dry mouth due
to her rheum conditions.
Past Medical History:
Scleroderma
CREST syndrome
Sjogrens Syndrome
Raynauds
Osteoarthritis
GERD
Esophagus Motility Dysfunction
chronic pericardial effusion, s/p cath ___
Social History:
___
Family History:
No family history of rheumatic disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - Temp 98.1F, BP 143/78, HR 90, R 16, O2-sat 97% RA
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, non-tender thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat with some decreased air movement, no r/rh/wh,
resp unlabored, no accessory muscle use
HEART - PMI non-displaced, somewhat distant heart sounds, normal
rate RR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, pedal edema, 2+ peripheral pulses (radials,
DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, steady gait
.
DISCHARGE PHYSICAL EXAM:
VS - Temp 98.1F, BP 115/65, HR 74, R 18, O2-sat 94% RA
GENERAL - well-appearing woman in NAD, sitting comfortably in
bed, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, non-tender thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat with some decreased air movement, no r/rh/wh,
resp unlabored, no accessory muscle use
HEART - PMI non-displaced, normal rate RR, no MRG, nl S1-S2,
slightly distant heart sounds
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, pedal edema, 2+ peripheral pulses (radials,
DPs)
SKIN - thickened skin on hands; telangectasias on hands and face
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, steady gait
Pertinent Results:
Admission Labs ___ 04:07PM:
WBC-7.1 RBC-4.12* Hgb-12.5 Hct-37.0 MCV-90 MCH-30.4 MCHC-33.8
RDW-13.4 Plt ___
Neuts-80.3* Lymphs-13.1* Monos-5.1 Eos-1.2 Baso-0.4
___ PTT-34.2 ___
Glucose-109* UreaN-15 Creat-0.6 Na-139 K-3.6 Cl-103 HCO3-24
AnGap-16
.
Discharge Labs ___ 08:20AM:
WBC-4.5 RBC-3.90* Hgb-11.8* Hct-35.3* MCV-90 MCH-30.2 MCHC-33.4
RDW-13.8 Plt ___
Glucose-91 UreaN-11 Creat-0.8 Na-138 K-4.2 Cl-108 HCO3-22
AnGap-12
ALT-30 AST-36 AlkPhos-71 TotBili-0.4
Calcium-8.5 Phos-2.8 Mg-1.9
.
Barium swallow ___: Dilated esophagus with debris and large
filling defects as well as slow passage of contrast to the GE
junction. Findings could support functional or anatomical
obstruction. Not much changed from prior ___.
.
EGD ___: A large amount of food was found in the whole
Esophagus. Due to risk of aspiration, we quickly passed through
the food debris and were able to push a lot of food debris into
the stomach. Due to large amount of food, the whole esophagus
could not be visualised completely. Esophageal candidiasis.
Normal mucosa in the stomach. Normal mucosa in the duodenum.
The patient aspirated some food toeards the end of procedure and
the procedure had to be terminated. Otherwise normal EGD to
third part of the duodenum
.
EGD ___ (under general anesthesia): Patulous esophagus.
Thick secretions lining the esophagus were suctioned. There was
no food found in the esophagus. Polyps in the stomach body.
The stomach was empty with no food in it. Normal mucosa in the
duodenum. Otherwise normal EGD to third part of the duodenum
Brief Hospital Course:
___ year old woman with CREST and Sjogren's syndrome who presents
with two days of dysphagia to liquids and solids with
regurgitation of food; found to have retained food without
evidence of stricture and esophageal candidiasis on EGD.
.
# Dysphagia/Esophageal Candidiasis: The patient was admitted
with sudden onset dysphagia to solids and liquids, with
regurgitation of food. She has a history of chronic esophageal
dysmotility, but had never experienced these symptoms in the
past. She was able to handle her secretions. The patient was
made NPO, and was started on an IV PPI. She underwent EGD that
showed a large volume of retained food in the esophagus, and
esophageal candidiasis. Food was advanced to the stomach with
the endoscope. The patient's diet was advanced to clears. She
was started on fluconazole for esophageal candidiasis. The
following day, the patient underwent repeat endoscopy under
general anesthesia to evaluate for mass or evidence of
malignancy, as the esophagus was not visible on previous
endoscopy secondary to retained food. No evidence of mass or
stricture was noted and esophageal candidiasis had improved.
The patient was discharged on a 2 week course of fluconazole.
She will follow up with her gastroenterologist in 2 weeks.
.
# Sjo___'s syndrome: The patient has chronic sicca symptoms.
Stable on admission. The patient was continued on home regimen
of oral mouth rinses for dry mouth as well as cyclosporine eye
drops.
.
# HTN: Chronic. On lisinopril 10mg daily. On admission, the
patient was mildly hypertensive, as she was unable to tolerate
her home medications for 2 days. Lisinopril was resumed when the
patient was able to tolerate PO medications. Hypertension
improved.
.
# GERD: Chronic in the setting of lower esophageal dysfunction
from CREST syndrome. The patient was started on IV pantoprazole
as an inpatient in the setting of dysphagia. She was
transitioned to PO pantoprazole BID at discharge.
.
# Limited Scleroderma/CREST syndrome: Complicated by Raynaud's
phenomenon, esophageal dysmotility, chronic pericardial effusion
and pulmonary manifestations. Patient with sclerodactyly and
telangiectasias on exam. She was continued on home albuterol.
Doxazosin was held on admission, and was resumed when the
patient was able to tolerate PO medications.
.
# CODE: Full Code (confirmed)
.
# CONTACT: Daughter ___ (cell) ___
==================================================
TRANSITIONAL ISSUES:
# Patient to complete 2 week course of fluconazole (day 1 -
___. LFTs at beginning of course within normal limits.
# CT scan from prior hospitalization showed small lung nodules.
Patient should undergo repeat CT scan in 1 month
Medications on Admission:
Furosemide 20 mg Oral Tablet take one tablet daily
Albuterol Sulfate (VENTOLIN HFA) INH 2 puffs up to 4 times a day
for Tolterodine (DETROL LA) 4 mg PO; 1 CAP DAILY (No
substitution)
ESTRADIOL (VAGIFEM VAGL) Take twice a week
PREVACID 30 mg Capsule; 1 TAB ___ MINS PRIOR to MEAL BID
Doxazosin 2 mg Tab; 1 tab daily for Raynaud's or as directed
Lisinopril 10 mg Oral Tablet; 1 TABLET PO DAILY
SPRAY B NASAL ___, MENTHOL/CAMPHOR, ___ sprays ___ times a day
Pilocarpine HCl (SALAGEN) 5 mg Tab; 1 tab four times per day
RESTASIS 0.05 % EYE DROPPERETTE (CYCLOSPORINE)
Genteal eye drops
Oral Balance
Discharge Medications:
1. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day.
2. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB,
wheeze.
3. tolterodine 4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
4. estradiol 0.01 % (0.1 mg/g) Cream Sig: One (1) application
Vaginal twice a week.
5. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO twice a day: take 30 min prior
to meal.
6. doxazosin 2 mg Tablet Sig: One (1) Tablet PO once a day.
7. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day.
8. pilocarpine HCl 5 mg Tablet Sig: One (1) Tablet PO four times
a day.
9. cyclosporine 0.05 % Dropperette Sig: One (1) Drop Ophthalmic
DAILY (Daily).
10. fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day
for 12 days.
Disp:*24 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Esophageal dysmotility, esophageal
candidiasis
SECONDARY DIAGNOSIS: Scleroderma, Sjogren's syndrome
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 with difficulty swallowing
solids and liquids. You had an upper endoscopy that showed a
fungal infection in your esophagus, as well as retained food due
to your known esophageal dysmotility. The food was pushed into
your stomach. The next day, you underwent another upper
endoscopy under general anesthesia, in which you had biopsies
performed. The gastroenterologists will contact you as an
outpatient with biopsy results.
.
You were started on an antifungal medication during your
admission. Your diet was advanced and you tolerated it well.
Please be sure to chew your food thoroughly and to eat multiple
small meals daily.
.
Please follow up with your PCP and gastroenterologist as below.
A CT scan from your last hospitalization showed small lung
nodules. You should have a repeat CT scan in 1 month.
.
MEDICATIONS CHANGED THIS ADMISSION:
START fluconazole 400 mg daily for 12 days
Followup Instructions:
___
|
19945152-DS-6 | 19,945,152 | 23,400,410 | DS | 6 | 2142-05-30 00:00:00 | 2142-05-31 11:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of limited scleroderma and CREST syndrome, Sjogren's
syndrome, OSA on nocturnal CPAP and pulmonary hypertension, who
presents with acute exacerbation of her chronic dyspnea.
The patient began feeling shortness of breath for the last year,
which significantly worsened in ___, at which point she was
diagnosed with pHTN. The patient's dyspnea had slowly been
worsening, but last night, it became significantly worse. She
felt accompanying dizziness and productive cough "felt in her
chest". The cough was green (with small amounts of blood), and
associated with nonradiating chest pressure felt across the
middle of the chest. During this time, the patient also felt
chills, but did not take her temperature. She also felt neck
soreness in the back of her neck last night, though this
improved by late morning.
The patient's daughter (whom she visits regularly) had a minor
URI recently, but no sick contacts otherwise. No recent travel
history. No prolonged periods of immobility in the preceding
days. She states her legs have been swollen at baseline,
especially since starting macitentan for her PAH.
In the ED, initial vitals: 99.6 93 106/55 24 97% 2L Nasal
Cannula.
- Labs: WBC=8.9 (88.2% N), proBNP=270, Trop-T < 0.01,
Lactate=1.4
- UA negative
- Given 1 g Vanc, 4.5 g Zosyn, 0.5 mg Ativan
Past Medical History:
- Pulmonary arterial hypertension, secondary to SSc/CREST.
Diagnosed by RHC ___ (mPAP 33, PVR 3.7). Also with RHC ___
consistent with PAH (mPAP 28, PVR 3.4)
- Limited scleroderma/CREST with Sjogren's overlap.
Manifestations include Raynauds, GERD, esophageal dysmotility,
sicca symptoms. Positive ___ with centromere pattern per old
notes
- OSA on CPAP
- Multiple pulmonary nodules
- Obesity
- Osteoarthritis
- GERD/esophageal dysmotility
- Chronic pericardial effusion, unclear etiology, s/p cath
___
Social History:
___
Family History:
No family history of rheumatic disease. Brother with DM, son is
pre-diabetic. Mother died of CHF at age ___, father with a
pacemaker placed in his ___, no heart attacks/strokes that she
knows of, had COPD and died of COPD at age ___. Father also with
skin cancer (unclear if melanoma), and prostate cancer, brother
with skin cancer (unclear if melanoma), brother with liver
disease, sister with OA. Asthma and allergies in siblings.
Physical Exam:
MICU ADMISSION PHYSICAL EXAM
===============================
Vitals: 99.1 94 109/53 19 95% 4L NC
GENERAL: alert, oriented x 3, no acute distress
NECK: JVD at level of clavicle at 90 degrees, hard R cervical LN
tender to palption
LUNGS: bibasilar inspiratory crackles, scattered wheezing
throughout lungspace
CV: RRR, normal s1/s2, no m/r/g
ABD: soft, nondistended, nontender to palpation
EXT: Warm, well perfused, 2+ ___ pulses, 1+ pitting in BLE
NEURO: motor grossly intact
HOSPITAL DISCHARGE PHYSICAL EXAM:
===============================
Vitals: Tm 99.1 Tc 97.8, HR 85 (70-100), BP ___
(91-120/47-79), RR ___, O2 93-97% on 4L (on tele with numerous
dips to below 90%) on 4L
Orthostatics on ___: sitting BP 120/62, HR 79, standing BP
117/79, HR 88, with sats dipping to mid-high ___.
GENERAL: alert, no acute distress, sitting in bed eating
breakfast
HEENT: dry mouth/lips, dry eyes, PERRL, EOMI, MMM, equal palate
elevation, tongue protrusion midline
NECK: Unable to appreciate any JVD this morning. Soft, supple,
nontender neck, no LAD noted.
CV: RRR, distant s1/s2, no m/r/g
LUNGS: Inspiratory crackles in the L mid-lower lung fields,
improved from yesterday, minimal basilar crackles on R, apices
clear
ABD: obese, soft, nondistended, nontender to palpation, +BS
EXT: Warm, well perfused, 2+ ___ pulses, radial pulses, 2+
pitting in BLE to mid-shin
NEURO: alert and interactive, answering questions appropriately
SKIN: warm, dry, no obvious lesions/excoriations/rashes
Pertinent Results:
ADMISSION LABS:
==================
___ 10:00AM BLOOD WBC-8.9# RBC-4.14* Hgb-13.0 Hct-37.0
MCV-90 MCH-31.5 MCHC-35.2* RDW-14.4 Plt ___
___ 10:00AM BLOOD Neuts-88.2* Lymphs-5.3* Monos-5.8 Eos-0.4
Baso-0.3
___ 10:00AM BLOOD ___ PTT-30.2 ___
___ 10:00AM BLOOD Glucose-112* UreaN-18 Creat-0.7 Na-135
K-4.0 Cl-102 HCO3-22 AnGap-15
___ 10:00AM BLOOD proBNP-270
___ 10:00AM BLOOD cTropnT-<0.01
___ 10:20AM BLOOD Lactate-1.4
___ 05:18PM BLOOD ___ Temp-37.3 Rates-/20 O2 Flow-4
pO2-49* pCO2-30* pH-7.48* calTCO2-23 Base XS-0 Intubat-NOT
INTUBA Comment-NASAL ___
___ 03:45PM URINE Color-Straw Appear-Clear Sp ___
___ 03:45PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
DISCHARGE LABS:
=================
___ 07:30AM BLOOD WBC-4.3 RBC-3.95* Hgb-12.2 Hct-35.1*
MCV-89 MCH-30.9 MCHC-34.8 RDW-14.3 Plt ___
___ 07:30AM BLOOD Glucose-96 UreaN-27* Creat-0.9 Na-138
K-3.6 Cl-102 HCO3-26 AnGap-14
___ 07:30AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.1
MICROBIOLOGY:
=================
___ URINE CULTURES: No growth
___ BLOOD CULTURES: Pending at time of discharge, NGTD
IMAGING:
=================
___ EKG:
Sinus tachycardia. Non-diagnostic Q waves inferiorly. Low
voltage. Non-specific ST segment changes. Compared to the
previous tracing of ___ the ventricular rate is faster.
___ CXR (PORTABLE)
Consolidation within the lingula of the left upper lobe thought
reflective of infectious process in the correct clinical
setting.
Brief Hospital Course:
Ms. ___ is a ___ with hx of limited scleroderma and CREST
syndrome, Sjogren's syndrome, OSA on nocturnal CPAP and
pulmonary artery hypertension, who presents with acute
exacerbation of her chronic dyspnea with productive cough, found
to have a left lingular PNA on imaging.
ACTIVE ISSUES:
=================
# Lingular Bacterial pneumonia:
Patient admitted with acute on chronic dyspnea with chills and
productive cough, mild leukocytosis, with lingular pneumonia
noted on CXR. Initially admitted to the medical ICU for close
monitoring on 4L NC, and started on CAP treatment with
ceftriaxone/azithromycin. Given patient remained stable,
transferred to the floor, and transitioned to PO levofloxacin
750mg PO for 5 day course (last day of abx ___. Patient
remaiend afebrile, with stable vital signs, and her cough
resolved. Blood and urine cultures were sent, which were no
growth to date by time of discharge. Given some described chest
pressure, BNP and troponin levels were sent, which were
negative. Possible contribution of scleroderma effect given
chronic inflammatory small airway disease seen on last CT in
___, as well as worsening pHTN, however less likely etiology
of acute presentation (likely contributes to patient's poor lung
substrate).
Patient continued on oxygen supplementation this admission,
given exacerbation of underlying lung disease with new
infection. Patient has had difficulty setting up home oxygen
(prescribed recently given diagnosis of underlying pulmonary
HTN), so this was arranged while in hospital. On ambulatory
saturations, noted to drop to mid ___ off O2, with acceptable
oxygen saturations in the mid ___ on 4L via nasal cannula. At
rest, she was also noted to have occasional desturations to high
___ off O2 with talking or moving, so will require 4L O2 with
movement and at rest, at least until her infection clears.
Patient has planned follow up with outpatient pulmonologist Dr.
___, as well as with her PCP, in early ___, to
determine ongoing oxygen requirements. Will likely need follow
up CT chest to evaluate interval change since last CT scan in
___, once infection clears.
CHRONIC ISSUES:
# pulmonary HTN:
Patient recently started treatment in ___ with Dr. ___.
Stable this admission, continued on home medications of
macitentan 10mg daily (brought in from home), as well as home
torsemide and potassium supplementation for ___ edema, and was
stable on this regimen. Dr. ___ visited the patient
during this hospitalization.
# GERD:
Stable, continued home lansoprazole.
# Sjogrens syndrome:
Stable, continued home pilocarpine, restasis and artificial
tears for dry eyes (no Gen-Teal, her home med, on formulary
here). Biotene oral balance not on formulary (not FDA approved),
supplied with artificial saliva (caphosol) while inpatient for
symptomatic treatment.
# Osteoarthritis:
Stable this admission, held home Glucosamine Chondroitin MaxStr
(glucosamine-chondroit-vit C-Mn) given not on our formulary as
not FDA approved.
# Urinary incontinence:
Stable, continued Detrol (tolterodine) while inpatient, 2mg BID
(patient on 4mg daily long acting at home).
# Raynaud's phenomenon:
Stable, continued home doxazosin 2mg BID.
TRANSITIONAL ISSUES:
======================
# Levofloxacin 750mg daily for 3 more doses (last day ___,
for a total 5d course.
# Started on home O2, 4L via nasal cannula with activity and at
rest, set up with new O2 vendor Apria to supply patient with
5lbs portable O2 tank in the future.
# Plan for follow up with Dr. ___ on ___, consider
repeat chest CT once pneumonia resolves to evaluate interval
change in pulmonary HTN since last scan ___.
# Follow up with outpatient PCP on ___ for acute
hospitalization.
# Communication: ___ (daughter, HCP) - ___
# Code: Full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Doxazosin 2 mg PO BID
2. macitentan 10 mg oral daily
3. Detrol LA (tolterodine) 4 mg oral daily
4. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
5. bifidobacterium infantis 1.5 billion cell oral daily
6. pilocarpine HCl 5 mg oral QID:PRN dry mouth
7. Multivitamins 1 TAB PO DAILY
8. Glucosamine Chondroitin MaxStr (glucosamine-chondroit-vit
C-Mn) 500-400 mg oral daily
9. Torsemide 40 mg PO DAILY
10. Potassium Chloride 20 mEq PO DAILY
11. Restasis (cycloSPORINE) 0.05 % ophthalmic twice daily
12. Tylenol Extra Strength (acetaminophen) 500 mg oral PRN pain
13. GenTeal Mild to Moderate (artificial tears(hypromellose))
0.3 % ophthalmic qhs
Discharge Medications:
1. Doxazosin 2 mg PO BID
2. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. pilocarpine HCl 5 mg oral QID:PRN dry mouth
5. Potassium Chloride 20 mEq PO DAILY
6. Restasis (cycloSPORINE) 0.05 % ophthalmic twice daily
7. Torsemide 40 mg PO DAILY
8. bifidobacterium infantis 1.5 billion cell oral daily
9. Detrol LA (tolterodine) 4 mg oral daily
10. fiber 2 gram oral Daily
11. GenTeal Mild to Moderate (artificial tears(hypromellose))
0.3 % ophthalmic qhs
12. Glucosamine Chondroitin MaxStr (glucosamine-chondroit-vit
C-Mn) 500-400 mg oral daily
13. macitentan 10 mg oral daily
14. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic
QID:PRN dry eyes
15. Tylenol Extra Strength (acetaminophen) 500 mg oral PRN pain
16. Levofloxacin 750 mg PO DAILY Duration: 5 Doses
This is a new medication to treat your pneumonia, or lung
infection.
RX *levofloxacin 750 mg 1 tablet(s) by mouth Daily Disp #*3
Tablet Refills:*0
17. Biotene Oralbalance (lactoperoxi-gluc oxid-pot
thio;<br>saliva stimulant agents comb.2) ___ oz mucous
membrane PRN dry mouth
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
-Community Acquired Pneumonia
Secondary Diagnoses:
-Sjogren's Disease
-Limited Scleroderma with CREST Syndrome
-Pulmonary Artery Hypertension
-Obstructive Sleep Apnea
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 recent hospital
stay at the ___. You came in
with acute worsening of your shortness of breath, with chills at
home, dizziness, and a productive cough. A chest x-ray showed a
new pneumonia in your left lung. You were initially cared for in
the intensive care unit, however you were quickly moved to the
regular medicine floor as you improved greatly. You were started
on intravenous antibiotics, and later switched to oral
antibiotics as you continued to improve. You were also given
oxygen, both because of your pulmonary disease called pulmonary
hypertension, and because of your lung infection. We have now
set up oxygen therapy for you at home, to be used at all times
while you are recovering from your lung infection.
You are scheduled to see Dr. ___ in clinic for your lung
disease in ___, and at that time you will check how you are
doing with your infection and with your oxygen status, to
determine how much oxygen you will continue to need. It is very
important that you keep this follow up appointment, and that you
continue to the use our oxygen to ensure your oxygen levels
don't get too low.
Your medications, including any new medications, and your future
appointments are listed below.
We wish you all the best with your health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19945152-DS-9 | 19,945,152 | 22,721,016 | DS | 9 | 2144-12-08 00:00:00 | 2144-12-09 20:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
baclofen
Attending: ___.
Chief Complaint:
Shortness of breath, dyspnea on exertion
Major Surgical or Invasive Procedure:
Right heart catheterization ___
History of Present Illness:
___ is a ___ year old woman with scleroderma/moderate
pre-capillary PAH (on tadalafil, macitentan, ___ (most
recent RHC in ___ with mPAP 46, PVR 6.2 ___ also on chronic
O2, with progressive dyspnea more acutely over last few days,
now with significant worsening of CT chest at ___ today. She
was referred by her pulmonologist for admission for further
evaluation of worsening DOE, hypoxia, chest CT findings.
Per pulmonary, recommend infectious workup, attempts at
diuresis, pulm consult, and plan for likely RHC this admission,
as well as possible empiric steroids for ?PVOD.
CT showed more prominent ground glass opacities w/ basilar
predominance w/ increase in size of lymph nodes, no effusion but
adenopathy and opacities is concerning for development of
pulmonary vaso-occlusive disease.
In ED initial VS: 98.5 126/66 82 17 92% 6L NC.
Exam: none documented
Patient was given: 80mg PO torsemide, in consultation with
pulmonary.
Decision was made to admit to ICU for hypoxemia and concern for
volume overload and development of pulmonary vaso-occlusive
disease.
Labs notable for:
CBC with 3.9>11.6/34.9<160
VBG 7.42/39
Lactate 1.3
Chemistries WNL
pro-BNP 746; trop T <0.01
bland UA
Imaging notable for:
CXR PA/LAT
Mild interstitial pulmonary edema. Persistent mild enlargement
of the cardiac silhouette.
Consults: none in ED, patient discussed with ___.
VS prior to transfer: 98.0 118/60 88 22 94% 6L NC.
Past Medical History:
- Pulmonary arterial hypertension, secondary to SSc/CREST.
Diagnosed by RHC ___ (mPAP 33, PVR 3.7). Also with RHC ___
consistent with PAH (mPAP 28, PVR 3.4)
- Limited scleroderma/CREST with Sjogren's overlap.
Manifestations include Raynauds, GERD, sicca symptoms. Positive
___ with centromere pattern per old notes
- OSA previously on CPAP, now O2 alone
- Multiple pulmonary nodules
- Mediastinal adenopathy. On chest CT imaging at least since
___, found to be PET avid ___, s/p mediastinoscopy and LN
biopsy (2R, 4R) ___, c/w reactive follicular hyperplasia.
Path also with pigment laden histiocytes, no evidence of
lymphoma.
- Community acquired pneumonia ___, and post-op pneumonia
___
- Obesity
- Osteoarthritis
- GERD/esophageal dysmotility
- Chronic pericardial effusion, unclear etiology
- Smoking history: never
___ treatment history:
* Sildenafil 20 mg TID since ___
* Macitentan 10 mg daily since ___
Specialty pharmacy: Humana
Social History:
___
Family History:
Her father had COPD and died at ___. Her mother died of
congestive heart failure at ___. Her sister and brother have
asthma and allergies.
Physical Exam:
ADMISSION EXAM
VITALS: 98.6, HR ___, BP 118/60s, O2 sat 94% 6L NC
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
DISCHARGE EXAM
Vitals: 97.9 105/69 76 20 93% 5L
24hr I/Os: ___
GENERAL: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated to ~7cm
LUNGS: Clear to auscultation b/l
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: WWP. No c/c/e
SKIN: + chronic venous stasis changes ___ noted bilaterally
NEURO: CN II-XII grossly intact, moving all extremities
Pertinent Results:
PERTINENT LABS
================
___ 04:37PM BLOOD WBC-3.9* RBC-3.76* Hgb-11.6 Hct-34.9
MCV-93 MCH-30.9 MCHC-33.2 RDW-14.2 RDWSD-48.4* Plt ___
___ 04:25AM BLOOD WBC-4.4 RBC-3.62* Hgb-11.0* Hct-33.2*
MCV-92 MCH-30.4 MCHC-33.1 RDW-14.3 RDWSD-48.0* Plt ___
___ 06:18AM BLOOD WBC-5.1 RBC-3.60* Hgb-11.0* Hct-33.1*
MCV-92 MCH-30.6 MCHC-33.2 RDW-14.1 RDWSD-47.9* Plt ___
___ 05:45AM BLOOD WBC-4.7 RBC-3.67* Hgb-11.1* Hct-33.8*
MCV-92 MCH-30.2 MCHC-32.8 RDW-14.3 RDWSD-48.2* Plt ___
___ 05:50AM BLOOD WBC-4.0 RBC-3.76* Hgb-11.4 Hct-34.4
MCV-92 MCH-30.3 MCHC-33.1 RDW-14.3 RDWSD-48.4* Plt ___
___ 04:37PM BLOOD Glucose-105* UreaN-17 Creat-0.9 Na-138
K-3.5 Cl-101 HCO3-22 AnGap-19
___ 04:25AM BLOOD Glucose-90 UreaN-19 Creat-1.0 Na-138
K-4.1 Cl-102 HCO3-23 AnGap-17
___ 02:59PM BLOOD Glucose-99 UreaN-20 Creat-1.0 Na-133
K-4.2 Cl-98 HCO3-22 AnGap-17
___ 06:18AM BLOOD Glucose-87 UreaN-29* Creat-1.0 Na-135
K-4.3 Cl-99 HCO3-24 AnGap-16
___ 05:45AM BLOOD Glucose-84 UreaN-24* Creat-0.9 Na-136
K-4.1 Cl-100 HCO3-22 AnGap-18
___ 02:53PM BLOOD Glucose-129* UreaN-21* Creat-0.9 Na-134
K-4.1 Cl-100 HCO3-21* AnGap-17
___ 05:50AM BLOOD Glucose-92 UreaN-26* Creat-1.0 Na-136
K-4.2 Cl-98 HCO3-22 AnGap-20
___ 04:25AM BLOOD ALT-8 AST-12 LD(LDH)-166 AlkPhos-73
TotBili-0.3
___ 04:43PM BLOOD Lactate-1.3
___ 04:48PM BLOOD ___ pO2-21* pCO2-39 pH-7.42
calTCO2-26 Base XS-0
PERTINENT IMAGING
==================
CXR ___
Mild interstitial pulmonary edema. Persistent mild enlargement
of the cardiac silhouette.
CXR ___
Heart size is enlarged, unchanged. Mediastinum is stable.
Surgical changes in the right mid and lower lung are present.
There is no appreciable pleural effusion. There is no
pneumothorax.
Cardiac cath ___
1. Precapillary pulmonary hypertension (mPAP 31, PVR 4.3 ___.
2. Normal RA and PCW pressures.
3. Normal cardiac output and index.
4. In comparison to prior RHC from ___, mPAP, PVR, and RA
pressures are all lower.
Plain film R foot ___
No acute fractures or dislocations are seen. The fifth
metatarsal appears
intact. Joint spaces are preserved without significant
degenerative changes. There is mild demineralization. Lisfranc
interval appears preserved.There are no bony erosions. There are
calcaneal spurs.
Brief Hospital Course:
___ with scleroderma/moderate pre-capillary PAH (on tadalafil,
macitentan, ___ (most recent RHC in ___ with mPAP 46,
PVR 6.2 ___ also on chronic O2, with progressive dyspnea
referred by her pulmonologist for admission for further
evaluation of worsening DOE, hypoxemia, chest CT findings.
ACTIVE ISSUES:
=================
# hypoxemia respiratory failure
# Pulmonary artery hypertension (PAH) ___ scleroderma
Patient with long history of scleroderma-related PAH, presenting
with worsening dyspnea and hypoxia and progressive findings on
chest imaging. Her initial exam (showing evidence of volume
overload) and elevated pro-BNP were suggestive of volume
overload. She was diuresed with PO Torsemide in the MICU with
good response in UOP and improvement of her O2 requirement.
Patient reported improvement in breathing however still noted
SOB with desaturation with movement/activity; her O2 sats
improved with gentle diuresis in the MICU and on the floor.
Right heart cath showed lower PA pressures than prior;
suggesting that her worsening respiratory status may be due in
part to PVOD, likely from scleroderma. Therefore, in
consultation with her Pulmonologist Dr. ___
was weaned to 800mg BID. Otherwise continued her home tadalafil,
macitentan, and spironolactone 50 mg daily. Torsemide was
decreased to alternating doses of 20mg and 40mg daily.
Rheumatology was consulted for discussion of steroid initiation,
to hopefully improve her PVOD. Plans were made to start this as
an outpatient, this will be done in consultation with her
outpatient Rheumatologist Dr ___.
# Foot pain
Noted on ___ to have focal tenderness at distal ___
metatarsal concerning for fracture, although she denies
trauma/injury. Plain film R foot showed no fracture. Given
recent diuresis, symptoms may be consistent with gout. She would
likely benefit from steroid initation, as planned for PVOD as
above.
#Sjo___'s Syndrome
#Scleroderma
Patient followed by ___ @ ___ for management of her
scleroderma; per ___ records has dry eye, dry mouth, advanced
pulm HTN and esophageal dysmotility. Continued pilocarpine HCl 5
mg oral QID
# Sinusitis
Patient with recent diagnosis of sinusitis (diagnosed and
treatment initiated at ___ ___ antibiotics discontinued on
___ after ___ompleted.
- continued Oxymetazoline 1 SPRY NU BID ear fullness
- continued Fluticasone Propionate NASAL ___ SPRY NU DAILY
CHRONIC ISSUES:
===============
# GERD:
- continued home PPI
# Ophtho:
- continued home eye drops:
CYCLOSPORINE 0.05% OPHTH EMULSION 0.05 % ophthalmic BID
Artificial Tears ___ DROP BOTH EYES PRN dry eyes
# urinary Incontinence:
- continued home tolterodine
TRANSITIONAL ISSUES:
====================
TRANSITIONAL ISSUES:
- dry weight: Her outpatient dry weights were documented as
___ Kg (___). Weight at discharge: 90kg
- diuretic regimen: Changed to: Torsemide 20mg and 40mg PO
alternating each day
-Follow up with Dr ___ in ___ for further med
adjustment. Dr. ___ will contact the patient on discharge
>30 minutes spent coordinating discharge to home
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
2. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
3. Doxazosin 2 mg PO BID
4. Opsumit (macitentan) 10 mg oral daily
5. Pantoprazole 40 mg PO Q12H
6. Spironolactone 50 mg PO DAILY
7. tadalafil 40 mg oral DAILY
8. Tolterodine 4 mg PO DAILY
9. Torsemide 50 mg PO DAILY
10. Oxymetazoline 1 SPRY NU BID ear fullness
11. pilocarpine HCl 5 mg oral QID
12. Fluticasone Propionate NASAL 1 SPRY NU Frequency is Unknown
13. Augmentin XR (amoxicillin-pot clavulanate) 2,000-125 oral
Q12H
14. ___ 1,600 mcg oral Q12H
15. macitentan 10 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO/NG Q8H:PRN Pain - Mild
2. Torsemide 20 mg PO DAILY
Take 20mg every other day. Take 40mg on days in between.
3. Fluticasone Propionate NASAL ___ SPRY NU DAILY
4. ___ 800 mcg oral Q12H
5. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
6. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
7. Doxazosin 2 mg PO BID
8. macitentan 10 mg oral DAILY
9. Opsumit (macitentan) 10 mg oral daily
10. Oxymetazoline 1 SPRY NU BID ear fullness
11. Pantoprazole 40 mg PO Q12H
12. pilocarpine HCl 5 mg oral QID
13. pilocarpine HCl 5 mg oral QID
Start: Upon Arrival Reason for Ordering: Wish to maintain
preadmission medication while hospitalized, as there is no
acceptable substitute drug product available on formulary.
14. Spironolactone 50 mg PO DAILY
15. tadalafil 40 mg oral DAILY
16. Tolterodine 4 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute hypoxic respiratory failure
Pulmonary arterial hypertension
Pulmonary ___ disease
Scleroderma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms ___,
It was a pleasure taking care of you at ___
___.
You were in the hospital because you were having trouble
breathing. You were initially in the ICU then on the medical
floor. We made some adjustments to your medications. You also
stayed in the hospital to complete physical therapy.
When you leave the hospital, you should continue taking your
medications as prescribed. Dr ___ with follow you closely
and adjust your medicines as necessary. If your breathing
worsens, you should call Dr ___ return to the Emergency
Department immediately.
Please weigh yourself every day. We changed your Torsemide to 20
mg/ 40 mg every other day. If your weight goes up more than
3lbs, call Dr ___.
Best wishes,
Your ___ team
Followup Instructions:
___
|
19945476-DS-3 | 19,945,476 | 29,656,680 | DS | 3 | 2175-11-15 00:00:00 | 2175-11-17 14:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache and right-sided weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Ms. ___ is a ___ woman, postpartum 20 days,
with a significant past medical history for recurrent blood
clots
and gestational hypertension during her prior pregnancy ___ years
prior), which required treatment with Lovenox. The patient
presents today from an outside hospital ___)
The patient states she was in her usual state of health the
night
before. She went to bed and slept throughout the night.
Hospital) after she woke up early this morning with a headache
and right-sided weakness arm greater than leg. On ___
morning, the patient awoke and noted that she had a dull
headache
that wrapped around her head but was more concentrated in the
back. She attempted to reach for her cell phone to check with
time it was but noticed that her arm felt incredibly heavy and
very weak. She had a difficult time lifting it up to grab her
phone but is able to do so. She then noted that she was not
able
to dial her passcode to look at her phone. The patient's
headache then began to increase in severity. She called her
husband who then stood her up and noted that she was able to
walk
but felt a little unsteady. They decided to go to the hospital
to be evaluated. At ___, the patient stated that
she was noted to be hypertensive to above 140s. At ___ they performed imaging of the brain including
noncontrast CT of the head, CTA head and neck, and CTV which
were
unremarkable. The patient was then transferred to ___ for
further evaluation and management.
After she presented to the hospital and was given medications
her headache improved dramatically. The headache never worsened
in severity and she did not experience any visual symptoms, neck
pain, nor any difficulties with language, speech, nor left-sided
symptoms along with a headache. The patient states that her
right-sided feeling of heaviness and weakness persisted
throughout the day but did not acutely worsen or improve. She
denies any other symptoms such as infectious, back pain, seizure
activity, confusion. Patient states that ___ years ago when she
was pregnant with her first child she was found to have multiple
blood clots in her legs and was required to stay on Lovenox for
a
few months after pregnancy. Currently, the patient states that
she did not have issues with blood clots during her pregnancy
however she notes that her legs are slightly swollen since
delivering her second child just over 20 days ago. The patient
does have a history of having migraine headaches, however these
are typically are not associated with any neurologic symptoms
such as today. Currently at the time of encounter, the
patient's
headache has resolved however the numbness in the right arm and
weakness is still present.
On neurologic review of systems, the patient denies
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or
dysphagia. Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
PMH/PSH:
1. DVTs in the setting of pregnancy ___ years ago, treated on
Lovenox
2. Gestational hypertension
3. Overweight
4. Migraine headaches
Social History:
___
Family History:
FAMILY HISTORY:
1. Grandmother with stroke (maternal)
Physical Exam:
DSICHARGE PHYSICAL EXAM:
=========================
Vitals: Tm 98.7 Tc98.2 BP: 106-125/67-86 HR: ___ RR: ___
SaO2: 96-97%
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: Breathing comfortably, no tachypnea nor increased WOB
Cardiac: skin warm, well-perfused.
Abdomen: soft, ND
Extremities: bilateral ___ edema
Neurologic:
-Mental Status: Awake, alert, oriented x 3. Able to relate
history without difficulty. Attentive, able to name ___ backward
without difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. Naming intact. No
paraphasias. No dysarthria. Normal prosody. Able to register 3
objects and recall ___ at 5 minutes. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline
and appendicular commands.
-Cranial Nerves: PERRL 3->2 brisk. Bilateral blink to threat
intact. EOMI without nystagmus. Face appears slightly asymmetric
with left side weakness. Intact facial sensation. Facial
sensation intact to light touch.
Hearing intact to conversation. Palate elevates
symmetrically. SCM/Trapezius strength ___ bilaterally. Tongue
midline. Tongue protrudes slightly towards right.
-Motor: +Right pronotar drift present. +Orbiting around Right
arm. Normal bulk, tone throughout. o adventitious movements,
such
as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA Gastroc
L 5 5 5 5 5 5 5 5 5 5 5
R 4+ 4+ 4+ 4+ 5 4 5 5 5 5 5
-Sensory: Intact to LT throughout. Intact proprioception and
vibratory sensation.
-DTRs:
Bi Tri ___ Pat Ach Pec jerk Crossed Abductors
L 2+ 2+ 2+ 2 - -
R 2+ 2+ 2+ 2 - -
Plantar response was flexor bilaterally.
Coordination - patient very slow with finger-nose-finger on
right, no dysmetria. Slow and clumsy rapid alternating movements
in the right upper extremity likely limited by weakness.
Gait -deferred at this time given patient's headache, however
has been endorses she was able to walk earlier without any
complications.
Pertinent Results:
ADMISSION LABS:
================
___ 09:55PM BLOOD WBC-7.0 RBC-4.23 Hgb-11.8 Hct-36.5 MCV-86
MCH-27.9 MCHC-32.3 RDW-12.9 RDWSD-40.6 Plt ___
___ 09:55PM BLOOD Neuts-52.3 ___ Monos-6.3 Eos-2.7
Baso-0.9 Im ___ AbsNeut-3.64 AbsLymp-2.60 AbsMono-0.44
AbsEos-0.19 AbsBaso-0.06
___ 09:55PM BLOOD ___ PTT-32.3 ___
___ 09:55PM BLOOD Plt ___
___ 09:55PM BLOOD Glucose-84 UreaN-16 Creat-0.6 Na-135
K-3.8 Cl-100 HCO3-23 AnGap-16
___ 09:55PM BLOOD ALT-23 AST-18 AlkPhos-107* TotBili-0.3
___ 09:55PM BLOOD cTropnT-<0.01
___ 09:55PM BLOOD Albumin-4.0 Calcium-9.5 Phos-4.0 Mg-2.0
___ 09:55PM BLOOD LDLmeas-131*
___ 09:55PM BLOOD TSH-1.0
DISCHARGE LABS:
================
___ 05:30AM BLOOD WBC-6.3 RBC-4.17 Hgb-11.6 Hct-36.2 MCV-87
MCH-27.8 MCHC-32.0 RDW-12.9 RDWSD-40.8 Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD ___ PTT-30.5 ___
___ 05:05PM BLOOD FacVIII-139
___ 05:05PM BLOOD AT-114 ProtCFn-129 ProtSFn-101
___ 05:05PM BLOOD Lupus-NEG
___ 05:30AM BLOOD Glucose-99 UreaN-27* Creat-0.9 Na-140
K-4.2 Cl-104 HCO3-23 AnGap-17
___ 05:30AM BLOOD Calcium-9.3 Phos-5.1* Mg-2.0
___ 05:05PM BLOOD VitB12-1093*
___ 03:16AM BLOOD %HbA1c-5.1 eAG-100
___ 05:25AM BLOOD Homocys-9.2
___ 01:38PM BLOOD Triglyc-126 HDL-53 CHOL/HD-3.7
LDLcalc-118
___ 09:55PM BLOOD LDLmeas-131*
PERTINENT IMAGING:
==================
___: Imaging MR HEAD W/O CONTRAST
1. Left parietal white matter lesion likely subacute infarction.
2. Multiple deep and subcortical lesions most likely epresenting
chronic infarction.
___ Imaging MR CERVICAL SPINE W/O C
Mild multilevel degenerative changes, with a midline disc
protrusion slightly indenting the spinal cord at C3-4. No other
neural foraminal or spinal canal stenosis.
___: TEE
Intact intra-atrial septum with Doppler and saline with
maneuvers. Mildly thickened trileaflet aortic valve with
moderate
aortic regurgitation.
___ Imaging BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
___ MRV Pelvis: IMPRESSION:
1. No evidence of pelvic DVT.
2. Heterogeneous endometrium toward the left fundus. Correlate
with history of postpartum bleeding as retained fetal products
cannot be entirely excluded.
Images at outside ___ ___) include CT head
without
contrast, CTA head and neck, CTV. No acute intracranial
abnormalities.
Brief Hospital Course:
Ms. ___ is a ___ female 20 days postpartum with
a history of migraine headaches and recurrent DVTs in her prior
pregnancy ___ years prior, treated with Lovenox) who presents
from an outside hospital after she awoke earlier in the day with
right arm greater than right leg weakness and a persistent
posterior headache.
NEURO:
#Ischemic stroke
#c/f DVT/paradoxical embolus vs cardiac source vs postpartum
angiopathy vs hypercoagulable state:
At the time of initial presentation to ___
___), CT imaging at the OSH was negative for
hemorrhage/venous clot and showed patent vasculature. However
patient had continued right upper extremity weakness and was
transferred to ___ for further stroke workup. At ___,
patient was admitted to the stroke Neurology service and was
noted to have persistent right upper extremity weakness with
pronator drift, orbiting, and delayed finger tapping. An MRI was
obtained which showed evidence of a left parietal white matter
lesion representing an acute to subacute infarction. Patient
further had evidence of multiple deep and subcortical
right-sided lesions which likely represent chronic infarction,
on FLAIR imaging. Patient was ___ postpartum, and patients
ischemic stroke was worrisome for a paradoxical embolism from
DVT due to patients prior known history of DVTs during pregnancy
___ years prior requiring therapeutic Lovenox) vs cardiac
etiology for patients likely thromboembolic stroke. However, TEE
to assess for PFO was negative with no evidence of PFO or ASD,
as well as no evidence of a left atrial appendage clot or LV
thrombus. Furthermore, lower extremity ultrasound was negative
for DVT. Due to the unclear nature of patients stroke etiology,
further workup for venous thromboembolism was carried out with
MRV pelvis which was negative, as well as a hypercoagulable
workup as noted below, which was pending at the time of
discharge. Patients workup for the etiology of patients stroke
has thus far been largely unremarkable, with only elevated LDL
of 131 but otherwise normal TSH, A1c, lipid panel, negative TEE
with no evidence of PFO or left atrial appendage/LV thrombus,
negative lower extremity ultrasound and negative MRV of the
pelvis. Thus, patient had a cryptogenic stroke of unclear
etiology, and was started on on Aspirin 81mg which she will
continue after discharge while her hypercoagulable workup is
completed. Furthermore, she was started on atorvastatin 40mg qhs
for elevated LDL. Patient was instructed to continue Aspirin 81
mg daily given her fixed neurologic deficits and likely
diagnosis of cryptogenic stroke, as no clear etiology for
patients stroke could be identified. Patient may require further
systemic anticoagulation if outpatient hypercoagulable workup is
notable for an underlying etiology. At the time of discharge
patient had pending hypercoagulable workup including
Homocysteine, B12, Protein C, Protein S, Factor VIII,
Anti-phospholipid, anti-cardiolipin, B-2 glycoprotein, Lupus
anticoagulant, Antithrombin III. Furthermore, patient will have
outpatient genetic testing including prothrombin, Factor V
___ and ___ testing. Patient will take part in
outpatient OT to progress her RUE weakness, and will followup in
Neurology clinic in ___ weeks.
#Cardiology: patient's TEE was negative for a PFO/ASD or
intracardiac clot. However,
pts TEE on this admission showed slightly reduced LVEF of 50%
and thickened trileaflet Aortic valve with moderate Aortic
Regurgitation. Patient was advised to followup with cardiology
due to her mildly decreased EF and findings on her ECHO. During
this admission, patient was otherwise hemodynamically stable
with well controlled HR and blood pressures.
#GI: on this admission, no acute GI issues were identified
#Renal: on this admission, patient had normal BUN/Cr, and no
acute renal issues were identified.
#FEN: patient was maintained on a regular diet on this
admission, with no difficulties swallowing on this admission.
# Heme: patient was started on ASA 81 mg for anticoagulation for
presumed cyrpotgenic stroke as her hypercoagulable workup is
completed. Furthermore, patient was maintained on subcutaneous
heparin and pneumatic boots for DVT prophylaxis while admitted
as an inpatient.
#Endo: patient had no acute endocrine issues at this time, with
normal AM serum blood glucose levels during this admission
#MSK: patient was evaluated by OT on this admission, who
recommended outpatient OT to progress RUE strength. Patient was
provided instructions and a prescription for outpatient OT, and
will followup in neurology clinic to assess his RUE weakness.
=
=
================================================================
Transitional issues:
=
=
================================================================
[ ] Please follow up patients right upper and right lower
extremity weakness which was appreciated during this admission
after patients reassumed L parietal stroke. Patient was
discharged on Aspirin 81 daily as noted below as well as
outpatient OT.
[ ] Please monitor patients anticoagulation. Put had a
cryptogenic stroke, thus was discharged on aspirin 81mg daily.
Patient may warrant further systemic anticoagulation if patients
hypercoagulable work up is positive.
[] Please arrange an outpatient cardiology clinic visit due to
pts TEE findings of a slightly reduced LVEF of 50% and thickened
trileaflet Aortic valve with moderate Aortic Regurgitation
[ ] Please follow up patients hypercoagulable genetic work up:
factor V Leiden, prothrombin and ___ testing, which
will be obtained as an outpatient.
[ ] Please follow up patients inpatient hypercoagulable work up
which was pending at the time of discharge, including
Antithrombin III, protein C/S, Lupus anticoagulant, Homocystein,
Cardiolipin antibiodies, beta-2-glycoprotein antibodies
=
=
=
=
================================================================
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 (aspirin 81mg daily) - () No
4. LDL documented? (x) Yes (LDL = 131) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - Aspirin 81mg daily () 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. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth every night Disp
#*60 Tablet Refills:*0
3.Outpatient Occupational Therapy
OT evaluation and treatment for right upper weakness after L
ischemic stroke. Please evaluate and treat to progress right
upper extremity strength and coordination
Discharge Disposition:
Home
Discharge Diagnosis:
- Ischemic stroke: Left parietal acute/subacute infarction.
- Multiple deep and subcortical right-sided lesions representing
chronic infarcts
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted to the Neurology service after presenting to
the ED with right arm and right leg weakness resulting from an
ACUTE ISCHEMIC STROKE, a condition where a blood vessel
providing oxygen and nutrients to the brain is blocked by a
clot. The brain is the part of your body that controls and
directs all the other parts of your body, so damage to the brain
from being deprived of its blood supply can result in a variety
of symptoms.
While your initial CT imaging showed no evidence of a bleed or
clot in the brain, an MRI of the brain showed a new left sided
stroke. Furthermore, you had evidence of several older strokes
on the right side. Stroke can have many different causes, so we
assessed you for medical conditions that might raise your risk
of having stroke. You were assessed with an echocardiogram of
your heart, Ultrasound of your legs, an MRI of your pelvis and
several lab studies. All of the tests have been negative thus
far, except for a slightly elevated LDL cholesterol. At this
time, we do not know why you have had strokes. Due to the
concern for future strokes, you were started on Aspirin and
atorvastatin to reduce the likelihood of a future stroke.
Furthermore, you had several labarotary tests that were taken
while you were admitted in the hospital to look for why you
might be more prone to developing clots. You will followup in
Neurology clinic with Dr. ___ as indicated below, at which
time the results of these studies will be discussed.
Please followup at the appointment that has been arranged on
your behalf. Please also continue to take the medications as
prescribed below unless you are directed to discontinue them by
your physician.
We are changing your medications as follows:
- Please start Aspirin 81mg daily
- Please start Atorvastatin 40mg daily at night
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
It was a pleasure being involved in your care.
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19945500-DS-7 | 19,945,500 | 21,615,940 | DS | 7 | 2195-08-22 00:00:00 | 2195-08-23 07:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Keflex / ACE Inhibitors
Attending: ___.
Chief Complaint:
Pyelonephritis with E. coli bacteremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o bladder cancer s/p radical cystectomy with neobladder
presenting with fevers, leukocytosis, and urinary retention.
While traveling from ___, he noted urinary retention on
___ and ___. He has had intermittent episodes of
urinary retention in the past and treated his urinary retention
with self-caths. During his second self-cath, he also noticed
the onset of abdominal pain and R-sided flank pain.
On ___ he woke in the morning with a fever of 101.5 with
severe chills. At presentation to his PCP he was febrile to
102.9, tachycardic with a HR of 126. Labs showed WBC 18.7 and
grossly positive UA. He was started on PO ciprofloxacin 500mg
and took three doses.
On repeat CBC on ___ his WBC had risen to 26.4 from 18.7
previously. Urine culture from ___ grew E. Coli
(sensitivities pending) and one of the blood cultures grew GNRs.
At that time he presented to the ED for further evaluation given
worsening leukocytosis.
In the ED, initial vital signs were: T101 P90 BP159/75 R18
O2sat:97/RA. Labs notable for leukocytosis with WBC 23.4, BUN
28/Cr 1.2, positive UA with >182 WBC positive leuks positive
nitrites. Received IV cipro, zosyn and 1 L NS bolus. Urology
placed foley catheter via urethra into neobladder.
Today he endorses feeling significantly improved from
previously. He is no longer having chills or flank pain. The
remainder of his review of systems is negative. He denies any
nausea, vomiting, chest pain, SOB, abdominal pain.
Past Medical History:
- Bladder cancer s/p radical cystectomy with ileal neobladder in
___
- Urethral recurrences treated with local resection and BCG
alpha interferon gel at 6 month intervals
- Hypertension
- Rosacea
- OSA
- Vasovagal syncope
- B12 deficiency
- UTI in ___, cultures grew pan-sensitive E.coli
- Pyelonephritis in ___, cultures grew pan-sensitive E. coli
and was treated with levaquin
Social History:
___
Family History:
Brother deceased at age ___ (early cardiac death), father has
history of cancer, CAD. Mother passed away of melanoma in ___,
also had lymphoma.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.1 113/54 HR 72 r 18 98 RA
General: Lying comfortably in bed, NAD, mildly diaphoretic
HEENT: MMM
CV:RRR no murmurs
Lungs: CTAB
Abdomen: SNTND Normal BS, no CVA TTP
GU: Foley in place draining clear yellow urine
WWP: 2+ DP and ___ pulses
Skin: no visible rashes
==========
DISCHARGE EXAM:
Vitals: Tm/Tc:102.1/99.5 BP:105-124/56-63 HR:72(63-90) O2:99/RA
General: Lying comfortably in bed, NAD
HEENT: MMMs
CV:RRR no murmurs
Lungs: CTAB
Abdomen: soft, NT/ND, +BS, no CVA tenderness to palpation
bilaterally
Ext: wwp, 2+ DP and ___ pulses
Skin: no visible rashes
GU: No foley, no suprapubic discomfort or tenderness
Pertinent Results:
ADMISSION LABS:
=================
___ 03:55PM BLOOD WBC-23.4*# RBC-4.27* Hgb-14.3 Hct-41.4
MCV-97 MCH-33.6*# MCHC-34.6 RDW-14.0 Plt ___
___ 03:55PM BLOOD Neuts-92.2* Lymphs-3.1* Monos-4.1 Eos-0.3
Baso-0.2
___ 07:00AM BLOOD ___
___ 03:55PM BLOOD Glucose-112* UreaN-28* Creat-1.2 Na-135
K-4.2 Cl-100 HCO3-23 AnGap-16
___ 04:08PM BLOOD Lactate-2.4*
___ 07:00AM BLOOD Calcium-9.7 Phos-1.6* Mg-2.0
DISCHARGE LABS:
==================
___ 07:00AM BLOOD WBC-7.3 RBC-3.79* Hgb-12.2* Hct-36.3*
MCV-96 MCH-32.3* MCHC-33.7 RDW-14.1 Plt ___
___ 07:00AM BLOOD Glucose-88 UreaN-24* Creat-0.9 Na-135
K-4.1 Cl-103 HCO3-24 AnGap-12
___ 07:00AM BLOOD Calcium-9.2 Phos-1.8* Mg-2.2
MICROBIOLOGY:
================
___ Urine Culture from PCP ___: E. Coli (pan-sensitive)
___ Urine Culture: <10,000 organisms
___ Blood Culture from PCP ___ x2: E. Coli
(pan-sensitive), pending.
___ Blood Culture x2: NGTD.
IMAGING:
==================
CT Cystogram w/ Delayed Contrast ___:
No evidence of contrast extravasation from the neobladder. Note
is made of calcified debris within the neobladder.
Brief Hospital Course:
___ h/o bladder cancer s/p radical cystectomy presenting with
probable pyelonephritis with E. coli bacteremia. Developed
urinary retention post-CT cystogram. Improved during admission
and was discharged on PO ciprofloxacin with plan to self-cath at
home for urinary retention.
ACUTE ISSUES:
#Pyelonephritis with Bacteremia: Patient presenting with
probable pyelonephritis with fevers, back pain, urinary
retention, grossly positive UA, leukocytosis to 23.2, and
positive urine and blood cultures. He was initially treated at
___ with 2 days of IV zosyn. After culture sensitivities from
___ showed pan-sensitive E. Coli in both urine and blood, he
was transitioned to PO ciprofloxacin on ___. He intermittently
spiked fevers on ___, resolved with antipyretics. He had a CT
cystogram on ___ with delayed contrast which showed an intact
neobladder with no extravasation of contrast. He rapidly
improved with antibiotic treatment, with his WBC dropping from
23 on admission to 7.3 on discharge. He was discharged in stable
condition on PO ciprofloxacin with a plan to complete a 14-day
course.
# Urinary retention: Patient developed mild incontinence and
difficulty voiding after foley was placed and d/c'd for CT
cystogram on ___. Bladder scan showed 560cc PVR. Patient does
have a history of intermittent urinary retention treated at home
with self-cath. Urology evaluated patient and recommended
self-treatment with straight cath at home TID until followup in
___ clinic, with expected resolution within few days.
CHRONIC ISSUES:
# HTN: Losartan-HCTZ was held during admission given infection.
BP stable throughout admission. Patient will restart as
outpatient.
# B12 deficiency: Continued home cyanocobalamin 1000mcg PO every
other day.
TRANSLATIONAL ISSUES:
- Complete 14-day course of PO ciprofloxacin (ending ___.
- Will followup as outpatient with Dr. ___ Urology in
clinic next week.
- Will straight cath TID at home until follow up with urology.
# Code: Full code (confirmed with patient)
# Emergency Contact: ___ wife cell ___, home ___
Medications on Admission:
1. losartan-hydrochlorothiazide 100-25 mg oral daily
2. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral every
other day
3. Ciprofloxacin HCl 500 mg PO Q12H
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*22 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain/fever
3. B-12 DOTS (cyanocobalamin (vitamin B-12)) 1000 mcg oral every
other day
4. losartan-hydrochlorothiazide 100-25 mg oral daily
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Pyelonephritis with E. coli bacteremia
Secondary diagnosis:
Hypertension
Bladder cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you during your stay at the
___. You had initially been admitted with pyelonephritis
(infection of the kidney), after your white blood cell count had
increased even when taking oral antibiotics. While you were here
in the hospital, we started you on stronger IV antibiotics and
you rapidly improved. We performed a CT scan which showed your
neobladder had no sign of leakage or damage. After the CT scan
you had some difficulty urinating. Our urology team recommended
that you self-cath three times a day at home, with this expected
to resolve within a few days. You were discharged from the
hospital on ciprofloxacin.
Note the following:
1. Please complete 14-day course of antibiotics (ciprofloxacin),
ending ___.
2. Please call Dr. ___ office to schedule a follow-up
appointment next week.
3. Please self-cath three times a day (morning, afternoon,
evening) until your followup with urology.
4. Please resume taking all your regular medications as
prescribed.
Again, it was a pleasure taking care of you. We all wish you the
very best!
- Your ___ care team
Followup Instructions:
___
|
19945642-DS-13 | 19,945,642 | 22,576,776 | DS | 13 | 2184-01-28 00:00:00 | 2184-01-31 08:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Mechanical and chemical thrombolysis and TIPS placement with ___
on ___.
History of Present Illness:
___ presenting with abdominal pain x 6 days. On ___ night
(___), patient developed pain in the lower abdomen, which he
described as dull and constant, localized posterior to the
umbilicus, and deep below the skin. The pain was associated with
decrease in appetite, weight loss (3 lbs over past week), and
constipation (no BMs since ___), though no associated
jaundice, pruritis, early satiety, nausea, diarrhea, vomiting,
or difficulty passing gas. After eating, patient's pain
increases in magnitude, becomes more sharp and shooting, and
spreads over a larger region of his abdomen. Patient took zantac
without relief.
Abdominal pain has worsened over the past few days. On ___
(___), patient presented to Urgent Care at ___
___. At Urgent Care, initial VS were 97.4, 98, 16, 144/90,
95%/RA. Exam notable for moderately tender abdomen in suprapubic
region. Labs showed TBili 1.8 (other LFTs not elevated), WBCs
13.6 (77% PMNs), troponin not elevated, lipase not elevated. UA
showed many bacteria but leukesterase and nitrite negative; UCx
showed no growth. EKG showed rate 92, NSR, LBBB, no ST changes.
CT abdomen revealed liver mass and pancreatic lesion. Patient
received 1L NS and was connected to a PCP for ___ appt the
next day.
Patient visited PCP on ___ to review labs and establish
plan of care. Patient again presented to PCP on ___ with
continually worsening abdominal pain. Decision made to send
patient to ___ ED.
In ED, initial VS were 98.0 108 145/96 20 98% RA. Exam notable
for non-tender abdomen. Labs notable for WBC 14.7 (PMNs 76.4%),
bicarb 19, anion gap 18, INR 1.3, AST 57, Tbili 1.4, lactate
2.5. EKG showed NSR. BCx ordered. Patient received 1L LR and 1L
NS in ED. Patient refused morphine for pain.
Transfer VS were 98.1 96 138/88 20 98% RA. Decision was made to
admit to medicine for further management.
On the floor, patient reports continued abdominal pain. He
states that pain is ___. Patient provided additional hx. He has
a history of "not reacting well to food" (burping, feeling
generally ill) intermittently over the past ___ yrs, with no
definitive dx. ___ yrs ago, patient noticed bright red bloody
stools, although colonoscopy and endoscopy performed with no
significant findings. Bloody stools stopped ___ years ago. For
past ___ years, patient has experienced loose BMs every ~2
hours and an urgent need to go to the bathroom after eating.
ROS:
(+) - per HPI. Also endorses some chills but denies fever.
(-) - denies n/v/d, fatigue, night sweats, fevers, dysuria,
hematuria, flank pain, testicular pain, swelling, CP, SOB,
cough, congestion, myalgias, arthralgias, rash, BRBPR, pale
stools.
Past Medical History:
- HTN
- Bilateral knee surgery
Social History:
___
Family History:
Mother - ___ (age ___, METASTATIC BREAST CANCER
Father - ___ (age ___, BRAIN STEM STROKE
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VS: 99.6 PO 164/77 79 18 96 RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
moist mucus membranes
NECK: supple neck, no JVD
HEART: RRR, S1/S2, systolic murmur appreciated
LUNGS: CTAB
ABDOMEN: distended, soft, +BS, non-tender to superficial and
deep palpations in all quadrants
EXTREMITIES: no cyanosis, clubbing or edema. Skin warm and
well-perfused.
NEURO: grossly intact
DISCHARGE PHYSICAL EXAM:
===========================
VS: Tmax 98.7 Tcurrent 98.7 | ___ | 96-112 | 18 |
95/RA
I/O: ___ yesterday, about even
GENERAL: NAD
NECK: supple neck, no JVD
HEART: irregular rhythm, S1/S2, systolic murmur appreciated
diffusely
LUNGS: CTAB
ABDOMEN: Distended, soft, +BS, NTTP
SKIN: Large bruise on R flank extending to upper portion of R
leg; appears stable
EXTREMITIES: No cyanosis, clubbing or edema. Skin warm and
well-perfused.
Pertinent Results:
=============================
ADMISSION/IMPORTANT LABS
=============================
___ 12:16PM BLOOD WBC-14.7* RBC-5.06 Hgb-16.8 Hct-50.1
MCV-99* MCH-33.2* MCHC-33.5 RDW-12.6 RDWSD-45.8 Plt ___
___ 12:16PM BLOOD Neuts-76.4* Lymphs-8.8* Monos-14.0*
Eos-0.1* Baso-0.3 Im ___ AbsNeut-11.25* AbsLymp-1.30
AbsMono-2.06* AbsEos-0.02* AbsBaso-0.04
___ 12:16PM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-1+ Burr-1+
___ 12:16PM BLOOD ___ PTT-30.0 ___
___ 12:16PM BLOOD Glucose-90 UreaN-11 Creat-1.0 Na-135
K-5.9* Cl-98 HCO3-19* AnGap-24*
___ 12:16PM BLOOD ALT-22 AST-57* AlkPhos-58 TotBili-1.4
___ 12:16PM BLOOD Albumin-3.8
___ 07:00AM BLOOD Albumin-3.0* Calcium-8.3* Phos-2.9 Mg-2.1
___ 07:30AM BLOOD Triglyc-48
___ 12:16PM BLOOD HBsAg-Negative HBsAb-Negative
HBcAb-Negative HAV Ab-Negative
___ 12:16PM BLOOD CEA-0.4 AFP-0.7
___ 12:16PM BLOOD HCV Ab-Negative
___ 12:28PM BLOOD Lactate-2.5* K-3.9
___ 10:14PM BLOOD Lactate-1.7
___ 07:00AM BLOOD CA ___ -PND
============================
DISCHARGE LABS
============================
___ 05:46AM BLOOD WBC-11.8* RBC-2.94* Hgb-9.7* Hct-29.9*
MCV-102* MCH-33.0* MCHC-32.4 RDW-16.6* RDWSD-59.4* Plt ___
___ 05:32AM BLOOD Neuts-81.8* Lymphs-5.6* Monos-11.5
Eos-0.3* Baso-0.2 Im ___ AbsNeut-10.26* AbsLymp-0.70*
AbsMono-1.44* AbsEos-0.04 AbsBaso-0.03
___ 05:46AM BLOOD ___
___ 05:46AM BLOOD Glucose-113* UreaN-14 Creat-0.7 Na-136
K-4.9 Cl-103 HCO3-19* AnGap-19
___ 05:46AM BLOOD ALT-31 AST-41* AlkPhos-118 TotBili-1.1
___ 05:46AM BLOOD Calcium-7.5* Phos-2.6* Mg-2.1
=============================
MICROBIOLOGY
=============================
___ 1:05 am BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
URINE CULTURE (Final ___: NO GROWTH.
___ 10:03 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
___ 7:25 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM POSITIVE RODS.
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE ROD(S).
Reported to and read back by ___ ___
22:00.
___ 11:20 am URINE
URINE CULTURE (Final ___: NO GROWTH.
MICRO:
___ 7:25 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS).
Isolated from only one set in the previous five days.
___ 12:10 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 1:05 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:46 am URINE Site: CATHETER CATH.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
IMAGING:
EKGs from ___ at ~23:00, and ___ at ~11:00 show PACs.
___BD & PELVIS WITH CO
IMPRESSION:
1. Hypodense lesion in the hilar region of the liver with
biliary dilatation concerning for a hilar mass and potential
cholangiocarcinoma. Recommend MRI for further workup and
correlation with LFTs.
2. Hypodense lesions the pancreas, likely side branch IPMN can
also be further evaluated on the MRI.
3. Diverticulosis without acute diverticulitis
RECOMMENDATION(S): MRI of the abdomen with contrast for further
evaluation.
MRCP (___):
IMPRESSION:
1. Extensive acute likely bland thrombus involving the superior
mesenteric vein, inferior mesenteric vein, splenic vein and the
main, right and left portal veins.
2. Focal area of hypoperfusion at the hepatic hilum involving
segments IV; V and the caudate lobe - without a discrete focal
mass lesion.
3. No intrahepatic or extrahepatic biliary duct dilatation. No
biliary duct mass to suggest cholangiocarcinoma.
4. No suspicious solid pancreatic mass lesion. There are
scattered T2
hyperintense cystic lesions throughout the pancreas, most likely
side-branch IPMNs. Per departmental protocol, this does not
need further follow-up.
___ (SUPINE & ERECT)
FINDINGS:
While there are air-fluid levels in the ascending colon there is
gas within the rest of the colon and in the rectum, most likely
related to ileus. There are no abnormally dilated loops of
large or small bowel. There is no free intraperitoneal air.
Osseous structures are unremarkable.There are no unexplained
soft tissue calcifications or radiopaque foreign bodies.
___ Imaging TIPS
IMPRESSION:
Unsuccessful transjugular intrahepatic portal vein and trans
splenic vein access despite multiple attempts. The procedure
was terminated due to multiple failed attempts and extended
procedure time.
RECOMMENDATION(S): The patient should restart the heparin drip
in 12 hours. A repeat attempt will be performed the next ___
days.
___BD & PELVIS W/O CON
IMPRESSION:
1. Small amount of intraperitoneal nonhemorrhagic free fluid is
identified without evidence of hematoma.
2. Known portal vein thrombosis is not well demonstrated on this
unenhanced exam.
___ Imaging UNILAT UP EXT VEINS US
IMPRESSION:
1. Nonocclusive thrombus within the left basilic vein, distal to
the
antecubital fossa.
2. No deep venous thrombosis otherwise demonstrated within the
left upper extremity.
___ Imaging TIPS
IMPRESSION:
Successful placement of an infusion catheter via right internal
jugular TIPS approach into the ___. This catheter will be
infused with tPA. The 10 ___ TIPS sheath was left in placed
an the side arm will be infused with heparin. Successful
placement of a triple-lumen temporary central line via right
internal jugular vein access.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
There there are no prior chest radiographs available for review.
Lung volumes are low. Left infrahilar opacification is probably
atelectasis. Small left pleural effusion may be present. Right
lung is clear. Heart size normal.
2 right transjugular central venous lines end in the right
atrium. No mediastinal widening. No pneumothorax.
___ Imaging PORTAL VENOGRAPHY
IMPRESSION:
Successful TIPS and main portal vein stent placement.
Successful chemical and mechanical thrombectomy SMV, splenic and
portal veins.
RECOMMENDATION(S): The patient should be bridged from heparin
to Coumadin. He will need a 2 week ___ ___ clinic
appointment.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Compared to chest radiographs ___.
No pulmonary edema. Improved moderate left basal atelectasis.
Probable small left pleural effusion, chronicity indeterminate.
No pneumothorax. Heart size normal, exaggerated by low lung
volumes.
Right jugular line ends in the right atrium.
EGD ___:
Esophagus: Circular rings and linear furrows consistent with
eosinophilic esophagitis were seen. Given the indication for the
procedure is bleeding, biopsies were not taken.
Stomach: Melena was seen in the whole stomach. No fresh blood,
active bleeding or potential sites of bleeding were seen. Many
non-bleeding polyps and ranging in size from 2 mm to 3 mm were
found in the stomach body. Given the indication for the
procedure is bleeding, biopsies were not taken.
Duodenum: Many non-bleeding polyps and ranging in size from 2
mm to 5 mm were found in the duodenal bulb, consistent with
Brunner's gland hyperplasia.
___ Imaging LIVER OR GALLBLADDER US
IMPRESSION:
1. Study limited by overlying bowel gas.
2. The gallbladder is distended with echogenic stones and
sludge, but without thickening of the gallbladder wall.
3. The liver parenchyma cannot be adequately assessed.
4. Too early to assess TIPS patency.
___ Imaging US RENAL ARTERY DOPPLER
IMPRESSION:
Normal renal ultrasound. No evidence of renal artery stenosis.
___ Imaging CHEST PORT LINE/TUBE PL
IMPRESSION:
Compared to chest radiographs ___ and ___ at
05:59.
New endotracheal tube ends at the upper margin of the clavicles,
with the chin elevated. Care should be taken not to withdraw it
any further.
Lungs are low in volume exaggerating heart size, probably
normal. Supine positioning contributes to vascular engorgement
in mediastinal widening, probably unchanged. Atelectasis at the
lung bases is mild. No pneumothorax or pleural effusion.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Comparison to ___. The patient has been extubated.
Lung volumes continue to be low. Areas of atelectasis are seen
at the left and the right lung basis. The position of the right
internal jugular vein catheter is unchanged. No new focal
parenchymal opacities. No pleural effusions.
___BD & PELVIS W & W/O
IMPRESSION:
1. Patent TIPS, with residual nonocclusive clot at the portal
confluence. The SMV is patent, however there is occlusive
thrombosis of its distal branches. The proximal splenic vein is
patent, with residual thrombosis in the distal portion of the
splenic vein.
2. Trace bilateral pleural effusions and adjacent atelectasis.
3. Trace perihepatic and perisplenic ascites, and small amount
of free fluid in the pelvis.
___ 4:38 AM # ___ CHEST (PORTABLE AP)
IMPRESSION:
Heart size and mediastinum are stable in appearance. Left basal
linear
opacities are most likely representing atelectasis in
combination of small
amount of pleural effusion.
Right internal jugular line tip is at the level of cavoatrial
junction or
proximal right atrium and might be pulled back 1 cm. No
pneumothorax. No
pulmonary edema.
___ CHEST
IMPRESSION:
1. Slightly limited study by breathing artifacts. No evidence
of pulmonary
embolism to the segmental levels bilaterally.
2. Bibasilar atelectasis and trace right pleural effusion.
Component of
infiltrate in the left lower lobe is unlikely, cannot be
excluded.
___ EKG - Sinus tachycardia. No ST changes. Rate 109; QTc
431.
Brief Hospital Course:
___ who presented with acute abdominal pain x 6d and was found
to have extensive mesenteric, portal, splenic vein thrombosis of
unclear etiology, s/p catheter directed mechanical/chemical
thrombectomy of clot with ___ on ___. Patient started on
warfarin with heparin bridge. Course complicated by GI bleed
with unremarkable EGD concerning for mesenteric ischemia, which
has now resolved.
# SUPERIOR MESENTERIC/INFERIOR MESENTERIC/SPLENIC/PORTAL
THROMBOSIS
Patient had extensive mesenteric thrombosis involving the SMV,
IMV, splenic vein, and main, right, and left portal veins. S/p
mechanical and chemical thrombolysis and TIPS placement with ___
on ___. Etiology of thrombosis remains unclear (differential
includes myeloproliferative disorders, intra-abdominal
malignancy, thrombophilia, and intra-abdominal causes).
Initially with transaminitis now downtrending. Course
complicated by upper GI bleed with unremarkable EGD as well as
melena/bright red blood per rectum attributed to mesenteric
ischemia/ischemic colitis in setting of multiple thrombi.
Associated abdominal pain initially controlled with Oxycodone,
now resolved. Patient is now tolerating PO intake.
Patient started on Warfarin with heparin bridge. Patient
supratherapeutic at the time of discharge and Warfarin was held
on ___. Patient will require INR check on ___. Primary care
physician agreed to manage patient's warfarin. Patient will
follow up with hematology for hypercoaguability workup. PNH,
Beta-2 glycoprotein, anti-cardiolipin, Erythropoetin, ___ all
within normal limits. Deferred testing of JAK2 V617, lupus
anti-coagulant, Protein C, Protein S, anti-thrombin III,
prothrombin G20210A gene mutation, and Factor V Leiden to
outpatient setting.
# DECONDITIONING
During hospitalization patient became deconditioned. He has
worked with physical therapy and has been cleared for discharge
with home physical therapy. Patient becomes tachycardic with
exertion. Patient worked with ___ who recommended home with ___.
# COAGULOPATHY
INR was elevated 1.3-1.6 prior to initiation of warfarin. This
could include hepatic dysfunction given thrombosis discussed
above, versus vitamin K deficiency as a result of malnutrition.
# NUTRITION
Patient has had poor PO intake for > 7 days, and nutrition was
consulted. Recommendations included advance diet as able,
encourage and monitor intake with consideration for TPN. Patient
was able to adavance diet and was tolerating PO without
abdominal pain at the time of discharge.
# HTN:
Home Lisinopril-HCTZ was held in setting of acute illness. Can
be restarted as an outpatient as needed.
# Surrogate/emergency contact: ___ (ex-wife) -
___
# Code Status: Full
TRANSITIONAL ISSUES:
====================
- Patient started on Warfarin during admission. INR
supratherapeutic at 3.7 on ___. Will hold Warfarin on ___ and
resume at 3mg on ___. Patient will need INR checked on ___.
Dr. ___ has agreed to monitor Warfarin.
- Patient will need to follow up with hematology as an
outpatient. Deferred JAK2 V617, lupus anti-coagulant, Protein C,
Protein S, anti-thrombin III, prothrombin G___ gene mutation,
and Factor V Leiden.
- Patient's home lisinopril and HCTZ were held during
hospitalization and not restarted (BPs were 120s without these
medications). Please assess need to restart these medications as
an outpatient.
- PPI started in the setting of upper GIB; please monitor need
for continued use.
- Ensure patient is up to date on age appropriate cancer
screening including colonoscopy.
- Patient deconditioned, will need to continue physical therapy
at home.
- Patient will need to follow up with Interventional radiology
in 3 weeks.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth Daily Disp #*30 Capsule
Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 1 tab by mouth Daily:PRN Disp #*30
Tablet Refills:*0
4. Warfarin 3 mg PO DAILY16
RX *warfarin 1 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*0
5. HELD- Hydrochlorothiazide 12.5 mg PO DAILY This medication
was held. Do not restart Hydrochlorothiazide until You follow up
with your PCP
6. HELD- Lisinopril 20 mg PO DAILY This medication was held. Do
not restart Lisinopril until You follow up with your PCP
___:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Thrombosis of R and L portal, superior
mesenteric, inferior mesenteric, and splenic veins.
Secondary diagnosis: Mesenteric ischemia, deconditioning
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 of abdominal pain.
We found that you had blood clots in some of the large veins in
your abdomen. You had a procedure with the interventional
radiologists to remove the blood clots. After the procedure you
had some abdominal pain and blood in your stool. This was a
result of the poor blood flow to your intestine because of the
blood clots. The pain has now improved and you are able to eat
food.
We started you on a new medication called Warfarin (Coumadin),
which thins your blood. You will need to have frequent labs
drawn to monitor the levels in your blood. Your primary care
doctor, ___ will help manage this medication and you
will follow up with him. You should get your blood drawn on
___ at your PCP's office. This order is already placed at
the lab.
We recommend that you follow up with the Hematology (blood)
doctors. ___ are going to run additional tests to see if there
is a reason why you formed extensive blood clots.
You will also need to follow up with the radiologists.
All of your appointments and medications are below.
It was a pleasure taking care of you!
Your ___ Team
Followup Instructions:
___
|
19945711-DS-13 | 19,945,711 | 22,120,331 | DS | 13 | 2160-01-30 00:00:00 | 2160-01-30 19:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with no significant medical history presenting
with substernal chest pressure starting the night prior to
admission. He rates it a ___ and was unable to get to sleep
from 12am to 6am when the pain started. Pain was persistent this
morning, but mildly improved to ___ and has continued to
improve throughout the day. The pain worsens at night when he is
lying flat, deep breathing, and coughing. He has not found a
position that provides relief but states the pain is better
during the day when he is not lying down. Not relieved by
leaning forward. His counselor at school told him to report to
the ED to get checked when his chest pain continued into today.
He does note that 2 days ago, he had a sore throat but had felt
well up until that point. He had a headache that accompanied his
chest pain. No recent travel. He denies recent drug use,
including cocaine.
In the ED, initial VS: 100.6 87 120/62 16 100%. Fever in ED to
100.6. Bedside U/S did not show an effusion and CXR showed no
evidence of PTX or PNA. Peak flow was 600. Orthostatic vitals
normal. He was reported to desat to 88% with ambulation in the
ED but this is inaccurate, pt reports sat was low before he
started walking. Repeat ambulatory sat on the floor was 99%.
Labs were notable for an initial troponin 0.03, which then
trended to 0.09. He was given Ketorolac 30mg IV x1 and Ibuprofen
600mg. CTA chest was performed to rule out PE and it was
negative. Consultation with cardiology attending was called and
he recommended to admit for TTE and possible cardiac MR in AM
given inconsistent symptoms for pericarditis. He notes that his
pain resolved after receiving toradol in the ED. Vitals on
transfer: 98.4F, 72, 122/52, 18, 96%ra
On the floor, he is more comfortable, saying that the pain
medications and rest have been extremely helpful. He is
wondering how long he needs to stay in the hospital. As above,
ambulatory sat was 99% upon arrival to the floor.
Past Medical History:
-Mild asthma (recently asymptomatic, no medication use)
Social History:
___
Family History:
No family history of premature coronary artery disease or sudden
death. Both parents are living and healthy.
Physical Exam:
Admission exam:
S - Temp 97.8F, BP 100/58, HR not recorded (but not
tachycardic), RR 22, O2-sat 98% RA
GENERAL - Alert, interactive, well-appearing in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
SKIN - no rashes or lesions, mild bruising on left lower leg
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Discharge exam - unchanged from above
Pertinent Results:
Admission labs:
___ 03:55PM BLOOD WBC-10.5 RBC-4.89 Hgb-15.1 Hct-45.0
MCV-92 MCH-30.8 MCHC-33.5 RDW-12.5 Plt ___
___ 07:20AM BLOOD ___ PTT-28.9 ___
___ 03:55PM BLOOD Glucose-97 UreaN-10 Creat-0.9 Na-137
K-3.9 Cl-101 HCO3-26 AnGap-14
___ 07:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
Cardiac enzymes:
___ 03:55PM BLOOD cTropnT-0.03*
___ 10:10PM BLOOD cTropnT-0.09*
___ 07:20AM BLOOD CK-MB-11* MB Indx-8.0 cTropnT-0.19*
___ 01:13PM BLOOD CK-MB-11* MB Indx-7.9* cTropnT-0.16*
___ 03:55PM BLOOD CK(CPK)-106
___ 07:20AM BLOOD CK(CPK)-137
___ 01:13PM BLOOD CK(CPK)-140
Imaging:
-CXR (___): No acute cardiopulmonary process.
-CTA Chest (___): No acute intrathoracic process. No
evidence of pulmonary embolism.
-TTE (___):
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size, and global systolic
function are normal (LVEF>55%). Transmitral and tissue Doppler
imaging suggests normal diastolic function, and a normal left
ventricular filling pressure (PCWP<12mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no mitral valve prolapse. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Normal regional and global biventricular systolic
function. Normal diastolic function. No pathologic valvular
abnormalities. No pericardial effusion.
Brief Hospital Course:
___ with no PMH who presents with 2 days of substernal chest
pain/pressure which is worse when lying flat
#Myopericarditis: The etiology of his chest pain was thought to
be from myopericarditis. His troponin elevation, EKG changes
(J-point elevation in V3-V6, high T-wave amplitude in V3-V6, and
subtle P-R depression in scattered leads), and symptoms of chest
pain worse when lying flat are all consistent with this
diagnosis. The elevated biomarkers are likely from the
myocarditis component. This is further supported by the
complete resolution of his pain with toradol in the ED. He is
extremely low risk for ischemia or ACS and his TTE showed no
focal wall abnormalities. We also considered coronary vasospasm
given his demographics and that his chest pain started at night
while he was sleeping. However, his pain was persistent all day
and night for 2 days. He also denies any drug use which could
be associated with vasospasm. His symptoms were not consistent
with PE, regardless he had a CTA chest in the ED was negative.
He had a TTE this admission which was entirely normal, there
were no focal WMAs and he had no pericardial effusion. His
troponins peaked 0.19 with CK-MB of 11 and were trending down
prior to discharge. He remained chest pain/pressure free since
leaving the ED and was started on ibuprofen 600mg q8h. He will
continue this for one week and will follow-up with a physician
here at ___ after discharge (his PCP is in his home ___
___ as well as a cardiologist. During the admission, he
tolerated this dose of NSAIDs with no GI side effects.
#Code status this admission: FULL
#Emergency contact: ___ (father): ___
#Transitional issues:
-Will continue ibuprofen 600mg tid for 7 days after discharge
-Chest pain/pressure should be re-evaluated after this ___y his cardiology and ___ follow-up
Medications on Admission:
None
Discharge Medications:
1. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Myopericarditis
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 admission to
___ for chest pain and pressure. We think the cause of your
chest discomfort was something called pericarditis and
myocarditis, which is inflammation of the heart muscle and the
sack around the heart. This is usually caused by a viral
infection. You had an echocardiogram which was completely
normal. You will follow-up with a primary care doctor and ___
cardiologist after leaving the hospital.
We started you on ibuprofen every 8 hours for the next 7 days to
help reduce the inflammation around your heart. You should take
this medication on a full stomach and avoid excessive alcohol
use. If the pain comes back after you stop the ibuprofen,
please call the cardiologist we have scheduled you to see or
return to the emergency room.
The following changes were made to your medications:
START ibuprofen 600mg by mouth every 8 hours for the next 7 days
Followup Instructions:
___
|
19945904-DS-3 | 19,945,904 | 26,472,679 | DS | 3 | 2151-11-10 00:00:00 | 2151-11-11 08:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
___: multiple laceration repairs
History of Present Illness:
___ PMH osteoporosis p/w mechanical fall.
Patient is at an assisted living facility, was reaching for
something on the floor and fell forward, hitting head. Did not
pass out. Was alone at the time. No precipitating
CP/SOB/palpitations. No significant DOE but spends most of her
time in a wheelchair. No f/c. Positive difficulty urinating and
possibly dysuria.
Last fall over ___ years ago. Per discussion with her daughters,
decision was made to continue warfarin despite bleeding risks as
she had a presumed embolic stroke with gradual return of
function, and they felt she would take the bleeding risk to not
suffer another stroke.
In the ED, initial vitals were: 97.5 80 161/75 16 95% RA
- Exam notable for: AAOx3, lacerations overlying b/l knees,
right proximal forearm and dorsum of hand, punctate lac on left
arm
- Labs notable for: WBC 10.4 with left shift, INR 1.8, u/a with
70 wbc, +nitr
- Imaging was notable for: Ct head, C-spine negative for
bleed/fracture, with plain films also negative for fracture
- Patient was given: tetanus shot x 1, Tylenol ___ mg, CTX 1g
IV x 1
- Laceration repair performed: of arms and forehead, otherwise
steri strips on other areas
- Vitals prior to transfer: 85 142/60 16 95% RA
Upon arrival to the floor, patient reports Tylenol helped her
pain. She denies numbness/tingling/weakness. She does report
feeling depressed and bored with life, with every day the same
at her facility. She denies thoughts of self harm.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) 10 point ROS reviewed and negative unless stated above in
HPI
Past Medical History:
- Osteoarthritis
- Osteoporosis
- Hypertension
- Left occipital stroke, thought to be cardioembolic, on
coumadin
- Hx of DVT
- History of GI bleed at age ___
- Gerd
- COPD
- Depression
- Status post D&C in the ___.
- Status post tonsillectomy in the ___.
Social History:
___
Family History:
Noncontributory
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM:
=========================
Vital Signs: 97.3 130/78 81 20 92 RA
General: Alert, oriented, no acute distress
HEENT: With bruising across face and laceration s/p repair on
forehead. Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheeze
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, multiple echymoses and
areas of laceration repair over forehead and arms, bru
Neuro: CNII-XII intact, grossly intact strength in b/l upper and
lower extremities
=========================
DISCHARGE PHYSICAL EXAM:
=========================
Vital Signs: 97.8 128/59 73 18 95 Ra
General: Alert, oriented, no acute distress
HEENT: Extensive bruising across face and under eyes. Laceration
s/p repair on forehead. Sclerae anicteric, MMM, oropharynx
clear, EOMI.
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally anteriorly
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, multiple echymoses and
areas of laceration repair over arms
Neuro: CNII-XII intact, grossly intact strength in b/l upper and
lower extremities. Gait deferred, patient is wheelchair bound at
baseline.
Pertinent Results:
===================
ADMISSION LABS:
===================
___ 05:55PM ___ PTT-32.2 ___
___ 05:55PM NEUTS-71.9* LYMPHS-12.8* MONOS-7.8 EOS-5.6
BASOS-1.4* IM ___ AbsNeut-7.51* AbsLymp-1.34 AbsMono-0.81*
AbsEos-0.58* AbsBaso-0.15*
___ 05:55PM WBC-10.4* RBC-4.05 HGB-11.8 HCT-36.7 MCV-91
MCH-29.1 MCHC-32.2 RDW-14.2 RDWSD-47.3*
___ 05:55PM GLUCOSE-93 UREA N-21* CREAT-0.7 SODIUM-142
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-21* ANION GAP-18
___ 06:52PM URINE MUCOUS-RARE
___ 06:52PM URINE RBC-14* WBC-70* BACTERIA-FEW YEAST-NONE
EPI-0
___ 06:52PM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 06:52PM URINE COLOR-Straw APPEAR-Hazy SP ___
===================
PERTINENT LABS:
===================
___ 07:18PM BLOOD CK-MB-3 cTropnT-0.01
___ 06:45AM BLOOD CK-MB-4 cTropnT-0.02*
===================
MICROBIOLOGY:
===================
__________________________________________________________
___ 9:20 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:19 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:52 pm URINE
URINE CULTURE (Preliminary):
Culture workup discontinued. Further incubation showed
contamination with mixed skin/genital flora. Clinical
significance of isolate(s)uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION.
PROTEUS MIRABILIS. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION.
===================
IMAGING/STUDIES:
===================
___ CHEST (SINGLE VIEW)
FINDINGS:
Given semi supine positioning and rotation, the lungs are
grossly clear. Cardiac silhouette is enlarged but grossly
unchanged. Atherosclerotic
calcifications are noted at the aortic arch. Old healed right
lateral rib
fractures and proximal right humerus fractures are noted.
IMPRESSION:
No definite acute cardiopulmonary process.
===
___ PELVIS (AP ONLY)
FINDINGS:
The bones are diffusely demineralized limiting detailed
evaluation. Orthopedic hardware transfixing old chronic
appearing right femoral neck fracture is noted. No definite
acute fracture. Pubic symphysis and SI joints are grossly
preserved. Lumbar dextroscoliosis and degenerative changes are
noted.
IMPRESSION:
Limited exam due to demineralization with chronic changes of the
proximal right femur. No visualized acute fracture.
===
___ CT HEAD W/O CONTRAST
1. Scalp hematoma and laceration overlying the frontal bone, but
no evidence of underlying fracture or intracranial hemorrhage.
2. Sequela of extensive chronic microangiopathy with an
unchanged regions of encephalomalacia within the left frontal
and temporal lobes as well as the bilateral cerebellar
hemispheres.
3. Paranasal sinus disease with an air-fluid level, slightly
improved compared to prior. Please correlate with any clinical
signs of acute sinusitis.
===
___ CT C-SPINE W/O CONTRAST
1. No evidence of fracture or traumatic subluxation.
2. Extensive multilevel multifactorial degenerative changes.
3. Unchanged hypodense nodule arising from the right lobe of the
thyroid
measuring up to 3.0 cm.
===================
DISCHARGE LABS:
===================
___ 06:45AM BLOOD ___ PTT-30.9 ___
___ 06:45AM BLOOD Glucose-83 UreaN-16 Creat-0.7 Na-142
K-3.7 Cl-106 HCO3-25 AnGap-15
___ 06:45AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.9
___ 01:10PM BLOOD WBC-9.2 RBC-3.26* Hgb-9.5* Hct-29.5*
MCV-91 MCH-29.1 MCHC-32.2 RDW-14.2 RDWSD-47.0* Plt ___
Brief Hospital Course:
Ms. ___ is a ___ y/o woman with history of DVT and embolic
CVA on warfarin, osteoporosis, presented after a mechanical fall
from her wheelchair at her rehab facility, complicated by facial
hematomas and lacerations. Lacerations on the forehead and arms
were repaired in the Emergency Department. CT Head and neck, and
plain films of the chest and pelvis were negative for fracture.
The patient also reported dysuria, and was found to have
positive urinalysis with urine culture growing E. coli and
Proteus. The patient received three days of ceftriaxone.
====================
ACTIVE ISSUES:
====================
# Urinary tract infection: Patient presented with dysuria, found
to have leukocytosis and positive urinalysis. Urine culture grew
E. coli and Proteus, but was also contaminatd by genital flora.
The patient received 3 days of ceftriaxone (Last day: ___.
# S/p mechanical fall
# Facial hematomas, lacerations: Patient presented after fall
from her wheelchair at rehab. CT Head and Neck were negative for
fracture. Plain films of the chest and pelvis were also negative
for fracture. H/H on discharge ___.5.
# Hx of DVT
# Hx of CVA: Patient has history of left occipital stroke that
is thought to be cardioembolic in nature, despite overall
negative work-up including echo and
hypercoagulability panel with neurology. On warfarin with goal
INR ___. During this admission, INR found to be slightly
subtherapeutic and warfarin dose was increased from 2.5 mg daily
to 3 mg daily. INR on day of discharge was 2.2. Patient should
have next INR checked on ___. Please monitor INR closely.
Patient was continued on home statin.
# Osteoporosis: Consider calcium and Vitamin D as an outpatient.
# Depression: Patient reports low mood despite antidepressant
therapy. Patient denied any SI/HI. Continued sertraline;
consider uptitration as an outpatient.
=====================
CHRONIC ISSUES:
=====================
# COPD: Patient does not appear to be on home medications for
this; in the past she appears to have been on Spiriva.
# HTN: Continued home amlodipine.
# GERD: Continued home omeprazole.
# HLD: Continued home statin.
=======================
TRANSITIONAL ISSUES
=======================
- Sutures placed to right arm and forehead on ___.
-- Please remove sutures from forehead in 5 days (___).
-- Please remove sutures from right arm in 7 days (___).
- INR was subtherapeutic during this admission. Warfarin dose
increased from 2.5 mg daily to 3 mg daily. INR on day of
discharge: 2.2. Check next INR on ___. Please continue to
monitor INR closely.
- Consider initiating calcium/vitamin D for osteoporosis
- Patient reported low mood without SI/HI; consider uptitrating
antidepressant
- Code: DNR/DNI
- Communication: ___, Daughter Phone number:
___
Greater than 30mins was spent on care coordination and
counseling by the attending physician on the day of discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 5 mg PO DAILY
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
3. Acetaminophen 650 mg PO BID:PRN Pain - Mild
4. Atorvastatin 20 mg PO EVERY OTHER DAY
5. Ibuprofen 400 mg PO BID:PRN Pain - Mild
6. Omeprazole 20 mg PO BID
7. Artificial Tears 1 DROP BOTH EYES DAILY
8. Calcium Carbonate 500 mg PO BID:PRN GI distress
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Docusate Sodium 100 mg PO 3X/WEEK (___)
11. Senna 8.6 mg PO QHS
12. Sertraline 50 mg PO DAILY
13. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild
2. amLODIPine 5 mg PO DAILY
3. Artificial Tears 1 DROP BOTH EYES DAILY
4. Atorvastatin 20 mg PO EVERY OTHER DAY
5. Calcium Carbonate 500 mg PO BID:PRN GI distress
6. Docusate Sodium 100 mg PO 3X/WEEK (___)
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Ibuprofen 400 mg PO BID:PRN Pain - Mild
9. Omeprazole 20 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO QHS
12. Sertraline 50 mg PO DAILY
13. Warfarin 2.5 mg PO DAILY16
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Urinary tract infection
- Mechanical fall
SECONDARY:
- History of deep vein thrombosis
- History of cerebral vascular accident
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you. You came to the hospital
because you had a fall from your wheelchair and had some
bruising and cuts on your face. We repaired these cuts.
We also found that you had a urinary tract infection, and we
gave you antibiotics to treat this.
We wish you the best of health.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19946380-DS-12 | 19,946,380 | 23,690,922 | DS | 12 | 2182-07-06 00:00:00 | 2182-07-07 00:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia/ Hyperkalemia
Major Surgical or Invasive Procedure:
Upper endoscopy
Colonoscopy
History of Present Illness:
___ yo F DM2, COPD, CKD, called in by outpatient provider due to
hyperkalemia and anemia. Initially complained of dyspnea at ___
office. Patient reported a few weeks of progressive dyspnea,
severe over past 3 days limiting her to only a few steps.
Patient reports no recent sputum production, f/c but does
endorse a runny nose. No med non-compliance, no orthopnea/ PND,
no chest pain. Patient also does not report changes in her
bowel habits (no melanotic stools). PCP diagnosed with COPD
exacerbation, had labs drawn, gave prednisone taper and sent
home. PCP then called patient into the ED from home when labs
came back with Hct 19.7 and K of 6.9.
Upon arrivival to the ED, initial vitals at 1845: T 98.7, BP
162/53, HR 96, RR 22 97% on 2L NC. Exam was remarkable for
coarse breath sounds. CXR negative. EKG shows TWI in V3-V6, STD
in I, II, AVF, V3-V6. Guaiac negative rectal exam. Patient got
10 units regular insulin, 25gm IV dextrose, 2g IV calcium
gluconate and kayexalate.
On arrival to the ICU, initial vitals T 100.2, HR 93, BP 129/30,
RR 20 sat 90% on RA, up to 100% on nebulizer. Patient had bowel
movement upon arrivival which was guiac positive. She was
speaking in full sentences and not using accessory muscles to
breath.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight changes.
Denies headache, sinus tenderness or congestion. Denies cough,
shortness of breath, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria, frequency, or urgency. Denies
arthralgias or myalgias. Denies rashes or skin changes.
Past Medical History:
#1 COPD - last PFTs ___ FVC/FEV1 68, FVC 82% pred, FEV1 81%
pred. stage I, mild COPD. She reports being on Home O2 for a
period of ___ months in the past. Her last COPD flare requiring
steroids and admission was ___ years ago.
#2 current tobacco use although cutting back
#3 DM II - hgb A1c 7.9, on insulin
#4 Obesity
#5 Hyperlipidemia
#6 Diverticulosis
#7 h/o adrenal adenoma
#8 herpes simplex
#9 hx PE in setting of OCPs 30+ years ago
#10 Chronic kidney diease - baseline Cr 2.0-3.0
Social History:
___
Family History:
father died in ___ - EtOH
mother died @ ___ - MI. obese, smoked
sister - DM, renal failure
brother - mentally retarded, recently passed away.
had 4 children, 1 son died @ ___ - EtOH, hemochromatosis, seizure
Physical Exam:
Admission:
Vitals: T 100.2, HR 93, BP 129/30, RR 20 sat 90% on RA, up to
100% on nebulizer
General: Alert, oriented, no acute distress, no accessory muscle
use.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Diffuse inspiratory and expiratory wheezes overlaid with
rhonci.
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic flow
murmur. No rubs or gallops
Abdomen: obese, soft, non-tender, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
GU: ___
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Discharge:
VS: Tm Afebrile Tc HR ___ BP 130-140s/50s-70s RR ___ SaO2
91% RA -> 96% 1L NC I/O
GENERAL: [x] NAD [] Uncomfortable
Eyes: [x] anicteric [] PERRL
ENT: [x] MMM [] Oropharynx clear [] Hard of hearing
NECK: [] No LAD [] JVP:
___: [x] RRR [x] nl s1 s2 [x] no MRG [x] no edema
LUNGS: [x] No rales [x] No wheeze [x] comfortable
ABDOMEN: [x] Soft [x]nontender []bowel sounds present []No
hepatosplenomegaly
SKIN: []No rashes []warm []dry [] decubitus ulcers:
LYMPH: [] No cervical LAD []No axillary LAD [] No inguinal LAD
NEURO: [] Oriented x3 [x] Fluent speech
Psych: [x] Alert [x] Calm [] Mood/Affect:
Pertinent Results:
Admission Labs:
___ 07:20PM BLOOD Neuts-94* Bands-0 Lymphs-5* Monos-0 Eos-0
Baso-0 ___ Myelos-1*
___ 08:36AM BLOOD WBC-8.3 RBC-2.38*# Hgb-6.0*# Hct-19.7*#
MCV-83# MCH-25.4*# MCHC-30.7* RDW-15.9* Plt ___
___ 07:20PM BLOOD WBC-6.7 RBC-2.27* Hgb-5.9* Hct-19.1*
MCV-84 MCH-26.1* MCHC-31.1 RDW-15.5 Plt ___
___ 07:20PM BLOOD Hypochr-3+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-OCCASIONAL
Target-OCCASIONAL
___ 07:20PM BLOOD ___ PTT-25.4 ___
___ 08:36AM BLOOD UreaN-65* Creat-2.9* Na-143 K-6.9*
Cl-112* HCO3-21* AnGap-17
___ 07:20PM BLOOD Glucose-299* UreaN-63* Creat-2.7* Na-136
K-6.7* Cl-106 HCO3-18* AnGap-19
___ 08:36AM BLOOD ALT-15 AST-16
___ 07:20PM BLOOD cTropnT-0.04*
___ 07:20PM BLOOD Calcium-8.6 Phos-4.1 Mg-2.0
___ 08:36AM BLOOD %HbA1c-7.9* eAG-180*
___ 08:36AM BLOOD Triglyc-61 HDL-47 CHOL/HD-2.4 LDLcalc-56
___ 09:00PM URINE Color-Straw Appear-Clear Sp ___
___ 09:00PM URINE Blood-SM Nitrite-NEG Protein-100
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 09:00PM URINE RBC-4* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
Imaging:
CHEST (PA & LAT) Study Date of ___ 10:33 AM
FINDINGS: Chest PA and lateral radiograph demonstrates
unremarkable
mediastinal, hilar and cardiac contours. Lungs are clear. No
pleural
effusion or pneumothorax evident. Stable mild kyphosis of the
thoracic spine with anterior osteophyte formation.
IMPRESSION: No acute cardiopulmonary process
___ CXR: IMPRESSION: Small effusions and left-sided
atelectasis/scarring, unchanged
compared with ___. UZRD without other evidence of CHF. COPD
and suspected pulmonary hypertension.
Pathology:
sophageal and intestinal mucosal biopsies, four:
1. Distal esophagus (A):
Mild neutrophilic esophagitis.
2. Duodenum (B):
Small intestinal mucosa, no diagnostic abnormalities
recognized.
3. Cecum, polyp, polypectomy (C):
Fragments of adenoma.
4. Ascending colon, polyp, polypectomy (D):
Adenoma.
Discharge/Notable Labs:
___ 06:55AM BLOOD WBC-7.2 RBC-3.36* Hgb-9.3* Hct-28.2*
MCV-84 MCH-27.7 MCHC-33.0 RDW-15.4 Plt ___
___ 06:45AM BLOOD Glucose-118* UreaN-71* Creat-2.4* Na-141
K-4.1 Cl-107 HCO3-25 AnGap-13
___ 07:20PM BLOOD cTropnT-0.04*
___ 11:33PM BLOOD CK-MB-5 cTropnT-0.04*
___ 04:53AM BLOOD CK-MB-5 cTropnT-0.04*
___ 05:25AM BLOOD CK-MB-6 cTropnT-0.04*
___ 06:45AM BLOOD Phos-4.1
___ 04:53AM BLOOD calTIBC-345 VitB12-279 Folate-12.8
Ferritn-8.1* TRF-265
___ 11:33PM BLOOD Hapto-361*
___ 08:36AM BLOOD %HbA1c-7.9* eAG-180*
___ 08:36AM BLOOD Triglyc-61 HDL-47 CHOL/HD-2.4 LDLcalc-56
___ 04:53AM BLOOD PEP-NO SPECIFI
Studies pending at discharge:
None
Brief Hospital Course:
___ yo F with type 2 Diabetes mellitus, chronic obstructive
pulmonary disease, hypertension, and hyperlipidemia admitted
with iron deficiency anemia, hyperkalemia, and COPD exacerbation
#Chronic obstructive pulmonary disease exacerbation:
Patient was found to have a COPD exacerbation at PCP ___. She
was started on prednisone and bronchodilators and continued on
these inpatient. She improved and was able to ambulate without
desaturation prior to discharge. She was discharged on a
prednisone taper along with prior home medications.
#Iron deficiency anemia due most probably to chronic
gastrointestinal bleeding:
Patient was found to have a hematocrit of 17 and was noted to
have ST depression on EKG that resolved with transfusion of 3
units of packed red blood cells. Labs were notable for iron
deficiency. Patient remained hemodynamically stable and anemia
remained stable after red cell transfusions. The patient was
seen by GI and had an upper endoscopy and colonscopy which could
not identify a source of bleeding, but colonoscopy had poor
prep. Therefore, the patient was discharged to follow up for a
repeat scope in 3 weeks.
#Hyperkalemia/Stage IV, Chronic kidney disease:
Patient was admitted with K of 6.7 which improved over
admission. She has had trouble with hyperkalemia in the past and
lisinopril has been reduced in the past. Her lisinopril was held
and her lasix was continued. She was discharged off lisinopril
pending follow up with her PCP and ___.
#Probable CAD:
Patient had ST depressions with hematocrit of 17 that resolved
with transfusion of red cells to hematocrit of 27. She was on
aspirin and statin at home per report, but aspirin was held in
the setting of chronic blood loss anemia. This was not restarted
on discharge, but could be restarted in the outpatient setting
if hematocrit remains stable. Additionally, stress testing was
deferred, but this could be considered in the outpatient setting
as a positive test may reduce threshold for addition of a
betablocker to the patient's hypertension regimen.
#Atrial fibrillation:
Patient was noted to have asymptomatic atrial fibrillation,
paroxysmal, up to rate of 150s-160s without hemodynamic effect.
These episodes usually occured after ambulation or after
bronchodilators. Therefore, patient was started on low dose
Diltiazem in place of nifedipine. This can be followed and
adjusted at PCP and ___ outpatient visits.
#Type 2 diabetes mellitus complicated by hypoglycemia:
Patient recently had NPH reduced for hypoglycemia. However, on
regimen of NPH 20 units BID the patient had consistent morning
hypoglycemia. Therefore, NPH was reduced to 14 units in the AM
and 10 in the ___. Given the patient's most likely underlying
dementia, the patient was discharged on 10 units NPH BID for
ease of administration.
#Congitive impairment/Social:
Patient was noted to have significant cognitive impairment and
the patient's daughter noted that there was often discrepancy
between the patient's glucometer readings and her log.
Therefore, the patient was discharged with home services.
However, if her cognition continues to decline she may require
more intensive services or 24 hour care in the near future.
#CODE: Full
#Disposition:
Patient was discharged on prednisone taper to follow up with PCP
and outpatient GI for repeat colonscopy. Patient did not have a
follow up with Renal on discharge, but patient was encouraged to
make this appointment given her CKD and medication changes. She
may also benefit from outpatient cardiac ischemia workup.
Medications on Admission:
-albuterol sulfate 90 mcg HFA Aerosol Inhaler 2 puffs(s)
inhalation q4-6 hours as needed for cough/wheeze
-atorvastatin 40 mg qd
-calcitriol 0.25 mcg qod
-fluticasone-salmeterol [Advair Diskus] 500 mcg-50 mcg/Dose Disk
with Device 1 puffs(s) inhaled twice a day \
-furosemide 20 mg bid
-lisinopril 5 mg qd
-nifedipine [Nifedical XL] 30 mg Tablet Extended Rel 24 hr qd
-aspirin 81 mg qd
-carbamide peroxide [Debrox] 6.5 % Drops 4 gtt R ear at bedtime
-NPH insulin human recomb [Humulin N Pen] 24 units via pen twice
a day (Dose adjustment - ___: up from 20 units daily
while on steroids)
Just started today ___:
-prednisone 10 mg Tablet 6 Tablet(s) by mouth once a day Taper
as directed ___
Discharge Medications:
1. diltiazem HCl 120 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
Disp:*30 Capsule, Ext Release 24 hr(s)* Refills:*2*
2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2*
3. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. carbamide peroxide 6.5 % Drops Sig: Four (4) Drop Otic HS (at
bedtime).
5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY
OTHER DAY (Every Other Day).
7. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
8. NPH insulin human recomb 100 unit/mL (3 mL) Insulin Pen Sig:
Ten (10) units Subcutaneous twice a day.
9. Medication Changes
The following medications have been ADDED:
-Prednisone taper
-Diltiazem 120mg po daily
-Pantoprazole 40mg po BID
The following medications have been STOPPED:
Please stop taking the above medications until you have had your
follow up appointment with Dr. ___.
-Lisinopril
-Nifedipine
-Aspirin
The following medications have been CHANGED:
NPH insulin has been reduced from 20 units twice a day to NPH
insulin 10 units twice a day.
Please start taking your NPH insulin at 10 units before
breakfast and before dinner.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Anemia, Iron deficiency, chronic blood loss
Coronary Artery Disease
COPD exacerbation
Diabetes Mellitus, type 2
Chronic Kidney Disease, stage IV
Hyperkalemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were referred to the hospital for evaluation of anemia and
hyperkalemia in addition to treatment of your COPD. You were
initially admitted to the ICU and were transfused 3 units of red
blood cells. Your lisinopril was held. You were seen by the
Gastroenterology team and had an upper endoscopy and a
colonoscopy to evaluate for cause of GI bleeding. Your upper
endoscopy did not show evidence of bleeding but did show
abnormalities. These were biopsied and the GI team will inform
you of these results when they return.
Additionally, your colonoscopy did not show evidence of bleeding
but you had a poor prep. Therefore, you are scheduled to have
another colonoscopy as listed below. It is very important that
you keep this appointment so that any cause of bleeding can be
identified.
Additionally, when your blood counts were low you had EKG
changes which suggest possible underlying coronary artery
disease. You were continued on a statin medication and may
benefit from increasing your dose depending on a recheck of your
lipid levels. Additionally, you were not continued on an aspirin
since you may have GI bleeding. However, your PCP ___ follow
you and decide if an aspirin should be started at a later date.
She will also likely order you for a stress test once your
bleeding is worked up completely.
With regards to your COPD, you were treated with inhalers and
steroids and should continue to take prednisone taper as
prescribed.
Lastly, your blood sugars were noted to be low during this
admission. Therefore, your insulin has been reduced. Please
remember to take the NEW amount of NPH rather than your previous
prescription until you have had time to follow up with your PCP.
Followup Instructions:
___
|
19946593-DS-9 | 19,946,593 | 28,829,753 | DS | 9 | 2196-08-05 00:00:00 | 2196-08-07 18:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
fever, nausea/vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with a PMH significant for
CAD currently undergoing work-up for CABG, T1DM, chronic
sinusitis (recently finished doxycycline, currently on Bactrim),
and ongoing work-up for small-volume hemoptysis who presents
with fever, n/v.
With regards to the patient's recent work-up, she first
developed hemoptysis in ___. She had one episode of small
amount BRB with very small clots in a tissue. She then had a
second episode ___ days later with larger volume, ___ cup with
dime sized clots. She presented to ___ ED ___ where CTA
was negative for PE but showed bilateral peripheral nodularity.
Since then, she has no further episodes of hemoptysis. She has
not traveled outside the country. The patient was referred to
___ clinic, with first visit ___ at which time VS HR 79
BP 132/57 O2 Sat 100%. At that time, pt denied SOB but reported
having to walk reduced pace. She also reported stomach pain and
belching that also improved after abx and Prilosec. 60lb weight
loss with dieting over ___ year. +F/C with sinus infection but
improved with doxycycline. Etiology of hemoptysis thought most
likely secondary to atypical infection, but given chronic
sinusitis and T1DM also considering ABPA vs. aspergillous vs.
mucormycosis.
The patient subsequently underwent transbronchail biopsy and
outpatient BAL yesterday ___, results of which currently
notable for "acid-fast rod-shaped mycobacterial forms and
Fragments of airway tissue and alveolated lung parenchyma with
chronic inflammation and focally necrotizing granulomatous
inflammation."
Since the procedure, the patient reported nausea, clear emesis.
She also c/o fever, weakness, diffuse muscle aches. She reports
intermittent cough with some production. She also reports
lightheadedness when she stands up quickly at times. no CP SOB.
No diarrhea/dysuria. She has not had BM in the past 2 days. no
recent sick contact.
Upon arrival to ___ ED, initial VS 100.7 83 143/57 18 98% RA.
Labs notable for Chem-7 with Na 128 K 6.3 (hemolyzed) BUN/Cr
___ Glu 337, CBC with WBC 15.0 with 95%P H/H 10.2/30.7 Plt
170, lactate 2.1, VBG 7.42/45 and K 4.0. BCx x1 sent and
pending. CXR with "opacities within the lingula and right lung
base medially are more conspicuous relative to prior examination
performed ___. Nodular opacities within the with
right upper lobe are additionally noted as well. Findings
together likely reflect bronchocentric abnormality, infectious
or inflammatory, more conspicuous compared to yesterday's exam."
ID consulted with preliminary recommendation that "Unlikely to
be TB given no risk factors, holding off on treating for active
TB. Avoid macrolide or quinolones to prevent resistance." The
patient is now admitted to Medicine for further treatment and
management. VS prior to transfer 98.1 87 142/51 25 98% RA.
Past Medical History:
DM I with retinopathy. On insulin
Glaucoma
LBP-lumbar disc disease
HTN
HL
Vertigo-benign
Chronic sinusitis currently on doxycycline and Flonase (followed
by ENT)
Social History:
___
Family History:
Brother: 3V CABG, ___ cancer
Brother: killed in ___.
Mother: HTN, HL
Father: ___ cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 99.9 150/53 79 18 99RA
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
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: non-focal
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 99.3 142/54(140-170/54-70) 87 (74-87) 16 94RA
General: NAD
HEENT: MMM, PERRL.
Lungs: CTAB
CV: RRR, no murmurs rubs or gallops
Abdomen: normal BS, non-distended, soft, non-tender
Ext: WWP, pedal edema +1
Neuro: CN2-12 grossly intact. Grossly moving upper and lower
extremities appropriately.
Pertinent Results:
LABS ON ADMISSION
=================
___ 04:46PM BLOOD WBC-15.0*# RBC-3.49* Hgb-10.2* Hct-30.7*
MCV-88 MCH-29.2 MCHC-33.2 RDW-13.0 RDWSD-41.5 Plt ___
___ 04:46PM BLOOD Neuts-95.4* Lymphs-1.7* Monos-2.1*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-14.26*# AbsLymp-0.25*
AbsMono-0.32 AbsEos-0.00* AbsBaso-0.02
___ 04:46PM BLOOD Plt ___
___ 04:46PM BLOOD Glucose-337* UreaN-16 Creat-1.1 Na-128*
K-6.3* Cl-93* HCO3-24 AnGap-17
___ 05:26PM BLOOD ___ pO2-31* pCO2-45 pH-7.42
calTCO2-30 Base XS-2 Comment-PERIPHERAL
___ 04:59PM BLOOD Lactate-2.1*
___ 05:26PM BLOOD Glucose-331* K-4.0
___ 05:26PM BLOOD O2 Sat-60
___ 10:59PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 10:59PM URINE Color-Yellow Appear-Clear Sp ___
OTHER PERTINENT RESULTS
=======================
___ 07:20AM BLOOD ALT-14 AST-17 AlkPhos-80 TotBili-0.3
___ 07:20AM BLOOD CK-MB-1 cTropnT-<0.01
___ 07:52AM BLOOD CK-MB-1 cTropnT-<0.01
___ 01:45PM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:20AM BLOOD HBsAb-NEGATIVE HBcAb-NEGATIVE HAV
Ab-NEGATIVE
___ 03:19PM BLOOD ANCA-NEGATIVE B
___ 05:45PM BLOOD HIV Ab-Negative
___ 07:20AM BLOOD HCV Ab-NEGATIVE
LABS ON DISCHARGE
=================
___ 07:57AM BLOOD WBC-6.4 RBC-3.45* Hgb-10.0* Hct-30.6*
MCV-89 MCH-29.0 MCHC-32.7 RDW-12.8 RDWSD-41.2 Plt ___
___ 07:57AM BLOOD Plt ___
___ 02:50PM BLOOD Glucose-184* UreaN-15 Creat-1.0 Na-133
K-5.1 Cl-93* HCO3-29 AnGap-16
___ 02:50PM BLOOD Calcium-9.7 Phos-4.2 Mg-1.8
MICROBIOLOGY:
=============
___ 11:40 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 8:23 am SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 4:41 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 5:45 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 11:50 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
TEST CANCELLED, PATIENT CREDITED.
Inadequate specimen for respiratory viral culture.
PLEASE SUBMIT ANOTHER SPECIMEN.
Respiratory Viral Antigen Screen (Final ___:
Less than 60 columnar epithelial cells;.
Inadequate specimen for DFA detection of respiratory
viruses..
Interpret all negative DFA and/or culture results from
this specimen
with caution..
Negative results should not be used to discontinue
precautions.
Recommend new sample be submitted for confirmation..
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
Reported to and read back by ___ ___ AT
1259.
___ 7:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 4:46 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:30 am TISSUE TBBX LINGULAR.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). RARE GROWTH.
VIRIDANS STREPTOCOCCI.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Reported to and read back by ___. ___
___
___ 14:29.
AFB GROWN IN CULTURE; ADDITIONAL INFORMATION TO FOLLOW.
SENT TO STATE LAB FOR FURTHER IDENTIFICATION ___.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
NO FUNGAL ELEMENTS SEEN.
___ 8:00 am BRONCHOALVEOLAR LAVAGE BAL LINGULAR.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
ACID FAST SMEAR (Final ___:
Reported to and read back by ___ @ 15:00,
___.
REPORTED BY E-MAIL TO ___ ___.
Reported to and read back by ___ (RESOURCES RN IN ED) @
15;30,
___.
ACIDFAST BACILLI. NUMEROUS seen on concentrated smear.
ACID FAST CULTURE (Preliminary):
Reported to and read back by ___
___ @
15:00, ___.
MYCOBACTERIUM AVIUM COMPLEX.
Identified by ___ Laboratory REPORT DATE ___.
Susceptibility testing requested by ___
___.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
MTB Direct Amplification (Final ___:
M. TUBERCULOSIS DNA NOT DETECTED BY NAAT: Infection is
most likely
caused by mycobacteria other than M. tuberculosis.
.
NAAT results will be followed by confirmatory testing with
conventional culture and DST methods. This TB NAAT method
has not
been approved by FDA for clinical diagnostic purposes.
However, ___
Laboratory Institute (___) has established assay
performance by
in-house validation in accordance with CLIA standards.
IMAGING:
========
ECG Study Date of ___ 5:38:47 ___
Sinus rhythm. Non-diagnostic inferior Q waves. Compared to the
previous
tracing of ___ no significant change.
Rate 80 PR165 QRS93 QT356 QTc391/411
CHEST (PA & LAT) Study Date of ___ 5:23 ___
Opacities within the lingula and right lung base medially are
more conspicuous relative to prior examination performed ___. Nodular opacities within the with right upper
lobe are additionally noted as well. Findings together likely
reflect bronchocentric abnormality, infectious or inflammatory,
more conspicuous compared to yesterday's exam.
ECG Study Date of ___ 8:45:20 AM
Sinus rhythm. Within normal limits.
Rate 81 PR162 QRS78 QT360 QTc396
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of CAD, T1DM,
chronic sinusitis (s/p doxycycline, on Bactrim), and hemoptysis
(currently undergoing outpatient workup) who presented with
fever, nausea, and vomiting 1 day s/p transbronchial biopsy/BAL.
ACUTE ISSUES:
=============
# Fever:
Ms. ___ had a low fever of 1 day duration s/p
transbronchial biopsy/BA with a WBC of 15 with neutrophilic
predominance. She was started on ceftriaxone and doxycycline in
the ED for HCAP. Tm 100.3 subsequently, generally afebrile with
Tm ~99. Was felt to be secondary to post-operative inflammation
however given rare strep viridans on tissue pathology, ID
recommended CTX for 6day course. Afebrile at time of discharge.
# Nausea/Vomiting:
Patient presented with nausea and vomiting, without diarrhea or
abdominal pain, after her biopsy/BAL. Was felt to be secondary
to anesthesia and her procedure and resolved during her hospital
stay.
# Hemoptysis:
Patient with multiple episodes of hemoptysis since ___ and
was undergoing workup in the outpatient setting. Non-infectious
etiologies such as GPA considered but ANCA negative. Recent
biopsy demonstrated focally necrotizing granulomatous
inflammation, positive acid fast rod-shaped mycobacterial forms,
concerning for MAC versus TB. Patient ruled out for TB with
three negative sputum AFB smears. MAC growing on preliminary
acid fast culture from BAL. Patient with ID follow up for
initiation of MAC treatment after sensitivities return.
# T1DM:
Patient on a regimen of NPH and regular insulin as outpatient.
___ was consulted after patient with poorly controlled blood
sugars in house. ___ recommended changing outpatient regimen
to glargine 20 units prior to dinner and Humalog sliding scale.
# CAD:
Undergoing outpatient consideration for CABG. Patient with no
chest pain during hospital stay but with one episode of dyspnea
and dizziness ultimately felt to be vasovagal in etiology after
EKG negative and troponins negative. Was continued on
Atorvastatin 20 mg PO QPM, Lisinopril 10 mg PO DAILY, Metoprolol
Succinate XL 25 mg PO QHS, Aspirin 81 mg PO DAILY
# ___:
Creatinine slightly increased to 1.3 on admission that was felt
to be prerenal in etiology. Resolved with improved po intake.
# Pseudohyponatremia:
Hyponatremic but normo-natremia when calculated for glucose
levels. Glucose was controlled per above.
CHRONIC ISSUES
==============
# Glaucoma:
Patient was continued on home, Latanoprost 0.005% Ophth. Soln. 1
DROP BOTH EYES QHS, Pilocarpine 2% 1 DROP BOTH EYES Q8H but with
Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID broken
into individual components as combigan is NF
TRANSITIONAL ISSUES
===================
1. Will need follow-up in ___ clinic in 6 weeks time once
cultures and sensitivities have returned, as we suspect
hemoptysis is secondary to atypical mycobacteria (MAC) and she
would qualify for treatment
2. Will need follow-up with ___ for T1DM control. Insulin
regimen changed to glargine 20 units prior to dinner and Humalog
sliding scale.
3. Patient has not had mammogram or colonoscopy. Given reported
60lb weight loss in last year and presence of MAC infection in
otherwise non-immunosuppressed individual, she should undergo
age-appropriate cancer screening as an outpatient.
4. Patient reports that she was to have started Bactrim for
chronic sinusitis. Was not taking at time of admission and was
asymptomatic with regards to sinusitus so bactrim was not
started. Please follow up appropriate treatment course.
# CONTACT: husband ___ ___
# CODE: full (confirmed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID
3. Furosemide 20 mg PO DAILY:PRN leg swelling
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Lisinopril 10 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO QHS
7. Pilocarpine 2% 1 DROP BOTH EYES Q8H
8. Aspirin 81 mg PO DAILY
9. NPH 20 Units Breakfast
NPH 4 Units Bedtime
Insulin SC Sliding Scale using REG Insulin
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO QPM
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. Lisinopril 10 mg PO DAILY
5. Metoprolol Succinate XL 25 mg PO QHS
6. Pilocarpine 2% 1 DROP BOTH EYES Q8H
7. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic TID
8. Furosemide 20 mg PO DAILY:PRN leg swelling
9. Glargine 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL AS DIR 20 Units before
DINR; Disp #*3 Vial Refills:*0
RX *insulin lispro [Humalog] 100 unit/mL AS DIR Up to 16 Units
QID per sliding scale Disp #*3 Vial Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
--Hemoptysis
--Pneumonia
--Atypical mycobacterial infection, mycobacterial avium complex
--Type one diabetes
--Acute kidney injury
Secondary:
-- Coronary artery disease
-- Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ for fever, nausea, and vomiting after
your lung biopsy. While you were here, you received fluids and
your nausea and vomiting improved. Your fever may have been due
to inflammation caused by the procedure or due to a pneumonia.
We treated you with antibiotics for pneumonia and you were no
longer having fevers at the time of discharge.
Your lung biopsy showed evidence of an infection with an
organism called mycobacterium. One type of mycobacterium can be
seen in a tuberculosis (TB) infection. We therefore performed a
series of tests to check for TB and found that you did not have
tuberculosis.
You will still need to undergo treatment for this mycobacterium
infection as an outpatient. You will follow up with the
infectious disease doctors after ___ leave the hospital and they
will pick which medications you will need to take at that time.
While you were in the hospital, you also had many elevated blood
sugars. We had the ___ diabetes team help us with your
insulin schedule. They recommended changing your insulin regimen
to glargine 20 units before dinner and using a Humalog sliding
scale. Please make sure to follow-up with Dr. ___ at the
___ (appointment information is below).
We wish you the best!
- Your ___ Care Team
Followup Instructions:
___
|
19947284-DS-23 | 19,947,284 | 21,863,330 | DS | 23 | 2134-11-09 00:00:00 | 2134-11-07 14:22:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___
Emergent coronary artery bypass grafting x4 with
left internal mammary artery to left anterior descending
artery and reverse saphenous vein graft to the posterior
descending artery and sequential reverse saphenous vein graft
to the obtuse marginal artery and the left posterior left
ventricular branch artery.
History of Present Illness:
___ woke at 3am with chest pain. Took one sub-lingual Nitro and
pain subsided. Pain recurred at 8:30 am and subsided again with
one sub-lingual Nitro. He presented to the ED, where EKG showed
evidence of acute MI. He was brought emergently to the cath lab
and found to have left main and severe 3 vessel coronary artery
disease. Balloon Pump was inserted and Cardiac Surgery called
for emergency surgical bypass. The patient has had intermittent
chest pain for several months. Stress test was abnormal in
___,
but cath was deferred at the time in the setting of worsening
renal failure. He is currently on HD.
Past Medical History:
Coronary Artery Disease, acute Myocardial Infarction
End Stage Renal Disease
Spinal Stenosis
Prostatic Hyperplasia (scheduled for prostate biopsy in ___
Hypertension
Gout
Social History:
___
Family History:
No family history of sudden cardiac death or heart disease;
otherwise non-contributory.
Physical Exam:
Pulse: 120 Resp: 21 O2 sat: 88% nc
B/P Right: 104/58 Left:
Height: 6'5" Weight: 250lb
General: NAD, supine on cath table
Skin: Dry [x] intact [x] no rash on chest
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ [x]
Extremities: Warm [x], well-perfused [x] Edema [] _none__
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: Left:
DP Right: 2+ Left:2+
___ Right: 2+ Left:2+
Radial Right: 2+ Left: AV fistula, +thrill
Carotid Bruit Right: Left:
Pertinent Results:
___ TEE:
PRE-BYPASS:
1. No spontaneous echo contrast is seen in the body of the left
atrium or left atrial appendage.
2. No atrial septal defect is seen by 2D or color Doppler.
3. There is mild symmetric left ventricular hypertrophy. The
left ventricular cavity size is top normal/borderline dilated.
There is mild regional left ventricular systolic dysfunction
with hypokinesis of the basal to distal anterior and
anteroseptal walls. Overall left ventricular systolic function
is mildly depressed (LVEF= 40 %).
4. Right ventricular chamber size and free wall motion are
normal.
5. The aortic root is mildly dilated at the sinus level. The
ascending aorta is mildly dilated. The aortic arch is mildly
dilated. There are simple atheroma in the aortic arch. The
descending thoracic aorta is mildly dilated. There are simple
atheroma in the descending thoracic aorta.
6. There are three aortic valve leaflets. There is no aortic
valve stenosis. No aortic regurgitation is seen.
7. The mitral valve leaflets are moderately thickened. Moderate
(2+) mitral regurgitation is seen.
8. There is a trivial/physiologic pericardial effusion.
9. There is an intraaortic balloon pump with the tip 3 cm distal
to the left subclavian artery.
Dr. ___ was notified in person of the results at time of
surgery.
.
POST-BYPASS:
1. The patient is in sinus rhythm.
2. The patient is on a norepinephrine infusion.
3. Biventricular function is unchanged. Regional wall motion
abnormalities are unchanged.
4. Mitral regurgitation is unchanged.
5. The aorta is intact post-decannulation.
.
___ 02:36AM BLOOD WBC-7.5 RBC-3.11* Hgb-9.6* Hct-28.9*
MCV-93 MCH-31.0 MCHC-33.3 RDW-14.7 Plt ___
___ 03:31AM BLOOD WBC-7.7 RBC-2.77* Hgb-8.5* Hct-25.7*
MCV-93 MCH-30.7 MCHC-33.1 RDW-14.7 Plt ___
___ 02:36AM BLOOD ___
___ 06:14AM BLOOD ___ PTT-32.4 ___
___ 03:06AM BLOOD ___ PTT-30.6 ___
___ 04:00AM BLOOD ___ PTT-28.0 ___
___ 05:45PM BLOOD ___ PTT-26.4 ___
___ 02:36AM BLOOD Glucose-84 UreaN-44* Creat-6.1*# Na-134
K-4.0 Cl-92* HCO3-30 AnGap-16
___ 03:31AM BLOOD Glucose-85 UreaN-27* Creat-4.4*# Na-136
K-3.7 Cl-96 HCO3-33* AnGap-11
Brief Hospital Course:
The patient was brought emergently to the Operating Room on
___, after receiving an IABP in the cath lab, where the
patient underwent CABG x 4 with Dr. ___. Overall the patient
tolerated the procedure well and post-operatively was
transferred to the CVICU in stable condition for recovery and
invasive monitoring. The patient is on dialysis and renal was
consulted for appropriate recommendations. He was dialyzed on
POD 1.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. IABP was discontinued. He remained on Neo
as his blood pressure was labile with dialysis. Midodrine was
started. He developed rapid atrial fibrillation. Coumadin was
started. The patient did not tolerate the AFib well and he was
cardioverted to Sinus Rhythm. The patient was transferred to
the telemetry floor for further recovery. Chest tubes and
pacing wires were discontinued without complication. He had
been on Plavix pre-op. This was for his Coronary disease and
therefore will not be resumed post-op. The patient was
evaluated by the physical therapy service for assistance with
strength and mobility. By the time of discharge on POD 7 the
patient was ambulating freely, the wound was healing and pain
was controlled with oral analgesics. The patient was discharged
to ___ in good condition with appropriate follow up
instructions.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Calcium Acetate ___ mg PO TID W/MEALS
2. Cinacalcet 60 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Metoprolol Tartrate 50 mg PO BID
6. Pantoprazole 40 mg PO Q24H
7. Simvastatin 40 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
2. Calcium Acetate ___ mg PO TID W/MEALS
3. Cinacalcet 60 mg PO DAILY
4. Acetaminophen 650 mg PO Q4H:PRN pain, fever
5. Amiodarone 400 mg PO BID
___ bid x 1 week, then 400 daily x 1 week, then 200 daily
6. Bisacodyl ___AILY:PRN constipation
7. Docusate Sodium 100 mg PO BID
8. Heparin 5000 UNIT SC TID
9. Midodrine 10 mg PO TID
10. Nephrocaps 1 CAP PO DAILY
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 Tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
12. Pantoprazole 40 mg PO Q24H
13. Simvastatin 40 mg PO DAILY
14. Tamsulosin 0.4 mg PO HS
15. ___ MD to order daily dose PO DAILY AFib
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease, acute Myocardial Infarction
End Stage Renal Disease
Spinal Stenosis
Prostatic Hyperplasia (scheduled for prostate biopsy in ___
Hypertension
Gout
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, deconditioned
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
trace edema
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19947284-DS-24 | 19,947,284 | 24,252,083 | DS | 24 | 2136-08-30 00:00:00 | 2136-09-02 22:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
First time seizure and abnormal CT
Major Surgical or Invasive Procedure:
- None
History of Present Illness:
This is a ___ year old right handed man with a history of CAD s/p
MI and CABG, ESRD on HD and lumbar stenosis who presents with
left arm and leg shaking this morning.
The patient reports feeling well last night. He woke as usual
to
go to the bathroom at 4:30am and once he was back in bed his
left
arm suddenly started shaking. It was rhythmic and not
suppressible as demonstrated by his wife who witnessed it. After
less than a minute it spread to his left leg. The shaking lasted
about 5 minutes. During this time he was fully awake,
conversant.
His daughter immediately called EMS. When they arrived the
patient was able to walk downstairs. He did note that his arm
was
"hanging limp" and had lost it's power. This lasted ___ minutes.
His family confirmed that strength had returned by his arrival
at
___.
At ___ he had basic labs and a head CT that was read as an
old
right frontal infarct. The patient does not report ever having a
stroke and does not recall any symptoms affecting the left side
previously. He has no seizure history.
The patient does reports a few pounds (dry) weightloss in the
past few months despite good appetite. He has trouble with
balance at baseline and walks with a cane.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. No new numbness (has baseline
left finger numbness) No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
Coronary Artery Disease, acute Myocardial Infarction
End Stage Renal Disease
Spinal Stenosis
Prostatic Hyperplasia (scheduled for prostate biopsy in ___
Hypertension
Gout
Social History:
___
Family History:
No family history of sudden cardiac death or heart disease;
otherwise non-contributory.
Pertinent Results:
___ 01:10PM GLUCOSE-117* UREA N-37* CREAT-7.8* SODIUM-143
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-27 ANION GAP-18
___ 01:10PM estGFR-Using this
___ 01:10PM CALCIUM-9.5 PHOSPHATE-5.1* MAGNESIUM-2.3
___ 01:10PM WBC-6.7 RBC-3.59* HGB-10.9* HCT-32.9* MCV-92
MCH-30.3 MCHC-33.1 RDW-14.4
___ 01:10PM PLT COUNT-166
___ 01:10PM ___ PTT-29.4 ___
MRI of the brain:
Limited study due to lack of intravenous contrast. There is an
intrinsically
T1 hyperintense lesion in the right frontal lobe with chronic
blood products
within it. There is associated surrounding edema. Findings are
concerning
for metastatic lesion( versus a primary subacute hematoma).
Recommend
post-gadolinium imaging when clinically able, depending on the
patient's
dialysis schedule.
Brief Hospital Course:
___ year-old man with hx of CHF, ESRD ON HD, CAD, CABG admitted
to neurology service after he presented with shaking in his left
arm and leg concerning for seizure, Performed CT showed a
hypodensity suspicious for edema related to a brain tumor.
He was started on keppra 500mg daily and 500 mg after
hemodialysis. He did not have further seizures in the hospital.
MRI with contrast was recommended; the Nephrology service was
consulted and indicated that contrast could be administered if
immediately followed by HD for 2 consecutive days. However, the
patient refuse to receive contrast.
MRI without contrast was performed, and showed a right frontal
lobe lesion with chronic blood products in it, most likely a
metastatic tumor; a subacute primary hemorrhage was considered
much less likely.
At his request, the patient was discharged home, with further
workup and ___ as an outpatient.
Regarding his hemodialysis nephrology service visited the
patient and he had 2 episodes of hemodialysis while he was in
house.
We continued all of his home medication.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Tamsulosin 0.4 mg PO HS
3. Cinacalcet 30 mg PO DAILY
4. Enalapril Maleate 2.5 mg PO BID
5. Metoprolol Tartrate 75 mg PO BID
6. Simvastatin 20 mg PO DAILY
7. PhosLo (calcium acetate) 2,001 mg oral TID
Discharge Medications:
1. Cinacalcet 30 mg PO DAILY
2. Enalapril Maleate 2.5 mg PO BID
3. Metoprolol Tartrate 75 mg PO BID
4. Simvastatin 20 mg PO DAILY
5. Tamsulosin 0.4 mg PO HS
6. PhosLo (calcium acetate) 2,001 mg oral TID
7. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every 6 hours Disp
#*90 Tablet Refills:*3
8. LeVETiracetam 500 mg PO DAILY
RX *levetiracetam 500 mg 1 tablet(s) by mouth every morning with
an extra tab IMMEDIATELY after dialysis Disp #*30 Tablet
Refills:*3
9. LeVETiracetam 500 mg PO AFTER HEMODYALISIS
10. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
- Epilepsy
- Possible brain tumor
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted because of a seizure due to what may be a
tumor in your brain. This will be further investigated by doing
a CAT scan of your chest and abdomen; your nephrologist Dr.
___ will arrange for this (you will make a time for an
appointment when you see him on ___ for dialysis).
Your medication list has changed
START
------
1. Keppra 500mg (1 pill) EVERY MORNING AS SOON AS YOU WAKE UP
with an extra pill AS SOON AS YOU ARE FINISHED WITH EACH
DIALYSIS SESSION
2. Dexamethasone 4mg (1 pill) every 6 hours for the next 2 days
___ after that take 1 pill every 8 hours
3. Vitamin D 800 IU (1 pill) per day
STOP
------
1. Aspirin until ___. At that time, resume taking one
81mg pill per day
Follow up with Dr. ___ as scheduled for dialysis on ___.
Follow up with Dr. ___ in neurology this coming ___,
as below. Call Dr. ___ a ___ appointment within
the next several weeks as he acts as your primary care
physician.
Followup Instructions:
___
|
19947284-DS-27 | 19,947,284 | 25,682,552 | DS | 27 | 2137-09-11 00:00:00 | 2137-09-11 17:36:00 |
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 sided weakness and shaking
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of ESRD on HD, CAD, CHF and renal cell Ca who
presents with worsening Right sided weakness. Pt referred in to
ED by Dr. ___. Pt reports rhythmic shaking of his R leg at
rehab ___ night. He has had persistent RUE and RLE weakness
since episode which is not resolving. Patient also discharged
from rehab yesterday.
Patient recently admitted ___ for similar symptoms and at
that time felt to be ___ to bleed at sight of prior met and
intervention. Patient initially on dexamehtasone and startd on
Keppra. At time of discharge to rehab, dexamethasone was stopped
and Keppra was continued post HD days.
No CP, HA, blurry vision, SOB, abdominal pain, fecal
incontinance. Pt makes minimal urine ___ ESRD.
In the ED, initial VS were: 97.9 78 162/93 16 98% RA
Labs were notable for: H/H stable, WBC count wnl, INR 1.2
Imaging included: NCHCT revealing new hemorrhage around known
brain met new since earlier this month
Treatments received: Levitirecetam
On arrival to the floor, patient reports that he was doing well
at rehab prior to his seizure like event during which he
experienced RLE jerking overnight ___ lasting approximately 10
minutes. When he arrived at HD ___, he noticed he was having
weakness of the RUE and RLE and hasn't been able to ambulate
with his walker which he had been able to do at rehab. He denies
any infectious symptoms including
fevers/chills/nausea/vomiting/abd pain/diarrhea/CP/SOB/cough.
Past Medical History:
1. Renal cancer with mets to brain
2. Anemia
3. End-stage renal disease, on hemodialysis (TTS)
4. Gout
5. Atrial fibrillation
6. CHF -- EF 25% in ___. Prostatism
8. NSTEMI, ARF ___
9. CABG ___
10. Spinal stenosis
11. Nephrolithiasis
12. Hypertension
13. Claustrophobia
Social History:
___
Family History:
No h/o cancer
Physical Exam:
Admission physical exam:
VS: 97.7 183/72 83 18 100% on RA
Gen: NAD, AAOx3
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
Resp: CTAB, breathing comfortably without use of accessory
muscles
CV: S1, S2, RRR, no m/r/g
Abd: Soft, NT/ND
Ext: wwp, no c/c/e, fistula in LUE forearm with palpable thrill
Skin: No rashes or lesions noted
Neuro: ___ strength left upper and lower extremeties, RUE with
___ strength, RLE ___ strength, no tremors noted, ___, TM, CN
II-XII grossly intact
Discharge physical exam:
Pertinent Results:
ADMISSION LABS:
___ 12:25PM BLOOD WBC-5.8 RBC-3.72* Hgb-11.1* Hct-33.4*
MCV-90 MCH-29.7 MCHC-33.1 RDW-16.2* Plt ___
___ 12:25PM BLOOD Neuts-70.8* Lymphs-16.5* Monos-8.3
Eos-3.6 Baso-0.7
___ 12:25PM BLOOD ___ PTT-27.5 ___
___ 12:25PM BLOOD Glucose-83 UreaN-30* Creat-5.2*# Na-142
K-4.5 Cl-100 HCO3-28 AnGap-19
___ 06:45AM BLOOD Calcium-9.5 Phos-5.0*# Mg-1.9
DISCHARGE LABS:
MICRO:
Blood cx ___ pending
C.diff ___ negative
STUDIES:
CT head w/o contrast ___:
1. New hemorrhage since CT of ___ within left posterior
parietal lobe metastatic lesion and left parafalcine metastatic
lesion which are similar in size to MRI of ___, and
better characterized on previous MR.
2. Multiple intracranial metastatic lesion as described above.
No signs of herniation.
3. Acute on chronic sinus disease.
EEG ___:
IMPRESSION: This is an abnormal continuous video EEG monitoring
study because of occasional independent bursts of focal slowing
in the temporal regions bilaterally indicative of mild focal
subcortical dysfunction in these regions. There is very mild
diffuse background slowing indicative of a very mild
encephalopathy which is non-specific as to etiology. There are
no pushbutton activations, epileptiform discharges, or
electrographic seizures.
EEG ___:
IMPRESSION: This is an abnormal continuous video EEG monitoring
study because of occasional independent bursts of focal slowing
in both temporal regions indicative of mild focal subcortical
dysfunction in these regions. There is diffuse background
slowing, indicative of a very mild encephalopathy, which is
non-specific as to etiology. There are no pushbutton
activations, epileptiform discharges, or electrographic
seizures. There is no significant change compared to the
previous day.
CXR ___:
As compared to ___ radiograph, increasing linear
opacity at the left lung base is attributed to worsening
atelectasis. Additionally, a nonspecific patchy opacity is
developed at the right lung base, which could be due to focal
aspiration, atelectasis, or developing pneumonia. No other
relevant changes.
CT Head w/o contrast ___:
1. New punctate hemorrhages in the superficial left parietal
lobe (4:22) are of unclear etiology, as no underlying metastatic
lesions were seen on the recent brain MRI.
2. The small hemorrhagic metastasis in the medial right
occipital lobe (04:17) is stable in size with slightly decreased
density of blood products.
3. Hemorrhagic metastases in the left parafalcine, left anterior
parietal, and left frontal operculum regions are unchanged.
Additional metastases demonstrated on the recent MRI are not
adequately assessed on the present noncontrast CT.
4. Multi focal edema in the cerebral hemispheres is unchanged.
No edema is seen in the posterior fossa.
Brief Hospital Course:
___ M with hx of sCHF (EF 25%), CAD s/p CABG, ESRD on HD, RCC c/b
brain mets s/p cyberknife (last ___ who presented w/ right
sided shaking, concerning for seizure, and worsened right sided
weakness.
# Right-sided weakness: ___ on admission showed new
hemorrhage since CT of ___ within left posterior parietal
lobe metastatic lesion and left parafalcine metastatic lesion.
The bleeding and associated cerebral edema were likely the cause
of the patient's new motor weakness. The patient's aspirin was
stopped to help prevent further bleeding episodes. There were no
new metastatic lesions, and the lesions were stable, and thus
rad/onc did not think further radiation would be helpful. The
patient was discharged to rehab.
# Seizure-like episodes: The patient had a shaking episode at
rehab, and again during admission. EEG was negative for
seizures. His keppra was continued, and by discharge he had not
had any events for several days.
INACTIVE ISSUES
# ESRD on HD: Pt continued HD while inpatient. No acute issues.
# ___ with LVEF 25%: Stable, euvolemic on exam. Continued on
home metoprolol. Continued HD for volume management. Aspirin was
stopped given recurrent intraparencymal cerebral hemorrhages.
# Anemia: Stable H/H, normocytic, normochromic, most likely ___
ESRD, anemia of chronic disease.
TRANSITIONAL ISSUES:
- Aspirin was stopped given recurrent brain bleeds with
neurologic deficits
- HCP: ___ (Wife) ___
- DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Cinacalcet 30 mg PO DAILY
4. LeVETiracetam 1000 mg PO DAILY:PRN dialysis
5. Metoprolol Tartrate 75 mg PO BID
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
7. sevelamer CARBONATE 2400 mg PO TID W/MEALS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal brain hemorrhage
Renal cell carcinoma with brain metastases
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay. You were
admitted for worsening right sided weakness and shaking. On
arrival, CT scan of your head showed a new bleed around one of
the metastatic brain lesions, which is causing your symptoms.
There were no new metastatic lesions. Repeat head CT 3 days
later showed stable findings, thus the bleed did not progress
while you were here. We stopped your aspirin in an attempt to
prevent further bleeds in the future. EEG did not reveal any
seizure-like activity. We are hopeful that as the blood in your
head resorbs you will regain some motor function. You were
discharged to rehab to regain your strength. We wish you the
best!
Your ___ care team
Followup Instructions:
___
|
19947298-DS-30 | 19,947,298 | 22,844,443 | DS | 30 | 2146-12-17 00:00:00 | 2146-12-18 10:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Shellfish
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with hx of type 1 DM, HTN, CAD s/p CABG, CVA
c/b right eye blindness/RUE weakness and CHF who is presenting
with confusion and sudden onset garbled speech.
He was fatigued this morning, but otherwise at his baseline.
Wife noticed that he started having garbled speech and was not
making sense around 8:30 AM, he was scheduled for an ultrasound
of his legs for PCP ___ (gets ultrasound every 6 weeks for
PAD/PVD ___ and due to confusion, wife decided to take
him to ED instead. She also noted that he had difficulty
ambulating to car (almost like he did not know how to walk),
which was new. This resolved prior to ED arrival. He triggered
on arrival to ED due to concerns that he was unable to ambulate.
He has difficulty walking on the right side at baseline due to
amputation surgery for peripheral vascular disease and also has
chronic right-sided sensory deficits in the setting of history
of CVA.
He denies new numbness, weakness, tingling, difficulty walking,
chest pain, shortness of breath, cough, URI symptoms, nausea,
vomiting, diarrhea or abdominal pain. He has multiple recent
admissions for CHF. He reports an 11lb weight gain over the last
week.
Neurology was consulted in the ED, noted that patient's global
encephalopathy was likely from CHF with acute on chronic renal
failure and unlikely to be a TIA. He was admitted for
encephalopathy presumed to be related to CHF. He was complaining
of abdominal swelling and was noted to have abd, sacral, and
bilateral lower extremity edema. His hands also were noted to be
swollen and stiff.
Per recent discharge summary from ___ (patient
discharged ___, patient had shortness of breath and was found
to have elevated Cr 1.9, BNP of 592, CXR showing possible
congestion and bilateral pleural effusions. He has a mild dry
cough at baseline. He got Lasix IV 40BID and then was discharged
on torsemide 60mg daily. It has since been uptitrated to 70mg
daily per his outpatient cardiologist, as of 2 days ago.
Otherwise his discharge weight had been around 193 lbs. A repeat
TTE was 50-55%. He was noted to have a troponin bump of 0.36
thought related to demand ischemia. Discharge Cr 1.6. TSH was
3.96 on ___.
Note that patient was recently discharged in ___ from
cardiology service. At the time, he had presented to ___
___ on ___ with CHF (SOB, BLE edema, > 15 lbs) and
subsequent elevated
troponins to 0.09. Due to an abnormal stress test, he was
transferred to ___ for coronary angiogram. Here, on ___,
his coronary angiogram revealed occluded native RCA, and
occluded SVG to PDA. RCA fills via L to R collaterals, patent
LIMA and SVG to OM1/OM2 and elevated filling pressure of 30. He
was managed medically and started Metoprolol tartrate 25mg twice
daily and Isosoribide ER 30mg daily. If patient should continue
to have anginal symptoms, a CTO PCI of RCA could be considered.
For his heart failure, he was diuresed with IV Lasix for about
one week, then transitioned to Furosemide 40mg po Lasix once
daily at discharge. Discharge weight was 192.7 lbs (87.4kg).
Discharge Cr was 1.6.
Of note, patient had presented back to ED on ___ (2 days
after discharge) with lethargy, patient was nodding off in the
middle of conversation. However, patient wanted to leave before
further work-up was done and subsequently eloped.
On the floor, patient reports no shortness of breath, his wife
had just noted progressive gradual increase in swelling as well
as weight gain since recent discharge. He is able to lie flat
and denies any PND or orthopnea. He reports adherence to low
salt diet (normally eats same thing every day-- breakfast muffin
with jelly and fruit in AM, sandwich with ___ for lunch and
chicken salad, no-salt canned vegetables and variations for
dinner) and drinks 1.2-1.5L fluids daily. He has a normal
appetite, has had regular BM without constipation (though he
does use Colace every other day). He does feel some cold
intolerance. He is medication compliant.
Past Medical History:
PMH/PSH:
HTN
HLD
AMI ___
CAD s/p CABG ___ with LIMA-LAD, SVG-PDA, sequential SVG to OM1
and OM2
Type 1 DM c/b neuropathy
CKD stage III
CVA
Left carotid disease
OSA
PVD s/p right BK/pop to distal peroneal with SVG, left fem/pop
bypass, s/p right TMA (currently covered with mepilex), LLE
stenting
Perineal and buttock necrotizing soft tissue infection s/p
debridement ___
Social History:
___
Family History:
Patient with strong family history of DM-I with his father and
siblings affected at age < ___, most with chronic sequelae of
disease. Father passed away from MI.
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
T 97.8 HR 61 BP 148/57 RR 18 O2 Sat 95% RA
Gen: pleasant man sitting up in a chair, in NAD
Neuro: alert and oriented x 4, MAE, speech clear
Neck/JVP: large supple neck with JVP difficult to assess d/t
body habitus
CV: distant heart sounds, RRR. No M/R/G
Chest: Lungs CTA. breathing regular and unlabored
ABD: large soft, NT
Extr: BLE warm, pulses by Doppler, BLE with trace edema to shin
PVD skin changes
Skin: Dry skin in legs. Right foot with dressing c/d/I. No
drainage or odor noted.
Access sites: right wrist soft and flat w/o drainage or hematoma
DISCHARGE PHYSICAL EXAM:
==========================
___ 0802 Temp: 97.8 PO BP: 107/47 L Sitting HR: 83 RR: 18
O2
sat: 95% O2 delivery: Ra FSBG: 500
I/Os: 1470/3025 , -2.140 L
Weight: 83.8kg -> 84.5; reported dry weight = 190 lb
Gen: pleasant man sitting in chair, no acute distress
Neuro: alert and oriented x3, speech clear, PERRL with decreased
peripheral vision on OD
Neck/JVP: JVP no seen at ___istant heart sounds, RRR. No M/R/G
Chest: Lungs CTA. breathing regular and unlabored
ABD: large, distended, NT
Extr: trace to 1+ edema to midshin bilaterally
Skin: Dry skin in legs. Right foot with dressing c/d/I. No
drainage or odor noted.
Pertinent Results:
ADMISSION/PERTINENT LABS:
========================
___ 09:49AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 09:49AM TSH-11*
___ 09:49AM FREE T4-1.2
___ 09:49AM cTropnT-0.01 proBNP-3432*
___ 09:49AM GLUCOSE-199* UREA N-60* CREAT-2.1* SODIUM-135
POTASSIUM-4.9 CHLORIDE-91* TOTAL CO2-32 ANION GAP-12
___ 09:49AM ALBUMIN-3.7 CALCIUM-8.6 PHOSPHATE-5.0*
MAGNESIUM-2.0
___ 09:49AM ALT(SGPT)-15 AST(SGOT)-26 ALK PHOS-76 TOT
BILI-0.4
___ 09:49AM LIPASE-9
___ 12:37PM LACTATE-1.3
___ 09:49AM WBC-5.4 RBC-3.38* HGB-10.5* HCT-31.9* MCV-94
MCH-31.1 MCHC-32.9 RDW-13.2 RDWSD-45.4
___ 09:49AM ___ PTT-27.3 ___
___ 09:49AM BLOOD cTropnT-0.01 proBNP-3432*
DISCHARGE LABS:
================
___ 06:35AM BLOOD WBC-4.9 RBC-3.89* Hgb-11.9* Hct-35.5*
MCV-91 MCH-30.6 MCHC-33.5 RDW-13.2 RDWSD-43.7 Plt ___
___ 06:35AM BLOOD Glucose-404* UreaN-55* Creat-1.6* Na-134*
K-4.2 Cl-89* HCO3-30 AnGap-15
STUDIES/IMAGING:
================
___ CXR
No acute cardiopulmonary process.
___ CT Head
No acute intracranial process.
Brief Hospital Course:
Mr. ___ is a ___ with hx of HFpEF, type 1 DM, HTN, CAD s/p
CABG, and CVA who presented with AMS secondary to polypharmacy
and was subsequently found to have an acute CHF exacerbation.
===============
ACTIVE ISSUES:
===============
# Altered mental status:
# Hx of CVA with R sided deficits:
His altered mental status was related to multiple medications
with sedating effects in setting of poor renal function.
Neurology was consulted and did not feel presentation was
consistent with stroke. Infectious workup was negative. Several
medication changes were made: gabapentin was decreased to 300mg
TID (from 700mg TID) and nortriptyline and oxycodone were
discontinued. He was at his baseline mental status at discharge
without any issues with pain control.
# Acute HFpEF exacerbation:
Patient presented with elevated BNP 3400 and 11 lb weight gain
over preceding week. Exam notable for marked ___ edema and
elevated JVP. Recent ___ TTE with EF of 50-55% without valvular
dysfunction. Likely etiology was underdosed torsemide following
recent discharge. He was diuresed with 120 IV Lasix BID to a dry
weight if 186 lb (84.5 kg) and transitioned to 80mg PO torsemide
daily.
# Type 1 diabetes:
Followed by ___. Recent A1c in ___ of 8.3%, however,
extremely difficult to control throughout admission with
multiple FSBG > 500. No DKA. Followed by ___ inpatient with
multiple adjustments to insulin regimen and patient ultimately
transitioned from NPH to lantus 22u qAM and 12u qPM with
standing Humalog 14u with meals in addition to sliding scale.
Some improvement in glycemic control on discharge but will need
close monitoring after discharge with next ___ appointment
booked for ___.
# HTN:
Poorly controlled with SBPs in the 160s. Imdur discontinued as
this agent has poor efficacy without hydralazine. Losartan 50mg
was resumed (held on recent DC in setting of ___. Metop tart
was replaced with carvedilol 6.25mg BID with SBPs in 130s-140s
at time of discharge.
# Elevated TSH: Patient had TSH of 11 with no prior history of
hypothyroidism, normal TSH in ___. This was attributed to
nonthyroidal illness (negative anti-TPO and normal cortisol).
Patient will need TSH rechecked as outpatient with PCP to
determine if hypothyroidism is present. His free T4 was 1.2 on
this admission.
# Hx of CAD s/p CABG ___:
He was maintained on aspirin but his statin was switched from
simvastatin to atorvastatin.
# ___ on CKD:
baseline Cr around 1.6-1.7. Suspected cardiorenal as improved
with baseline with diuresis.
# Urinary Retention:
Patient had a short period of urinary retention that required
foley placement and we initiated tamsulosin 0.4mg once daily.
His retention was likely related to BPH. We passed a foley
urinary trial.
# Depression:
Continued Citalopram 60 mg. TCA stopped due to suspected
contribution to AMS.
TRANSITIONAL ISSUES:
======================
Discharge weight: 186 lb (84.5 kg)
Discharge Cr. 1.6
Discharge Hgb: 11.9
Medications:
New: Losartan 50mg once daily; Tamsulosin 0.4mg daily;
carvedilol 6.25 BID.
Stopped: Isosorbide moninitrate, nortriptyline, oxycodone, metop
tartrate;
Changed: Increased torsemide dose to 80mg, decreased gabapentin
dose; insulin as above
[ ] Blood sugars were very elevated on this admission and
required adjustment of his insulin regimen. He will need close
follow up to ensure safe regimen as an outpatient.
[ ] Monitor BP
[ ] F/u Creatinine and lytes at next visit
[ ] new urinary retention likely BPH; monitor for improvement on
tamsulosin
[ ] Continue to follow weights and ensure adequate diuretic
regimen
[ ] TSH re-check at ___ visit. TSH was elevated at 11 in
hospital concerning for nonthyroidal illness.
[] Recommend ongoing wean of deliorogenic medications (ie
temazepam and gabapentin) as clinically indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nortriptyline 10 mg PO DAILY
2. Torsemide 70 mg PO DAILY
3. OxyCODONE (Immediate Release) 10 mg PO Q12H:PRN BREAKTHROUGH
PAIN
4. Citalopram 60 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. gabapentin 700 mg oral TID W/MEALS
8. NPH 10 Units Breakfast
NPH 7 Units Lunch
Insulin SC Sliding Scale using HUM Insulin
9. Magnesium Oxide 400 mg PO DAILY
10. Temazepam 15 mg PO QHS
11. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth every evening Disp
#*30 Tablet Refills:*1
3. Carvedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
4. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth once daily Disp #*30
Tablet Refills:*1
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once daily Disp #*30
Capsule Refills:*1
6. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once daily Disp #*30
Capsule Refills:*1
7. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*1
8. Glargine 22 Units Breakfast
Glargine 12 Units Bedtime
Humalog 14 Units Breakfast
Humalog 14 Units Lunch
Humalog 14 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar U-100 Insulin] 100 unit/mL
(3 mL) AS DIR 22 Units before BKFT; 12 Units before BED; Disp
#*5 Syringe Refills:*0
9. Temazepam 15 mg PO QHS:PRN insomnia
10. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth once daily Disp #*120
Tablet Refills:*1
11. Citalopram 60 mg PO DAILY
12. Magnesium Oxide 400 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Drug-related encephalopathy
Acute on chronic ischemic heart failure
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
Thank you for coming to ___!
Why were you admitted?
- You came with altered mental status that was caused by some of
your medications.
- You also had worsening leg swelling and weight gain.
What happened while you were in the hospital?
- The neurology team evaluated you and did not feel that you had
a stroke.
- We were concerned that you had too many sedating medications.
We reduced your dose of gabapentin and stopped your
nortriptyline and oxycodone.
- Your sugar levels fluctuated a lot while in the hospital, so
we had our ___ diabetes specialists help with your insulin
regimen.
- We used IV medications to help remove excess fluid. You will
now be taking an increased dose of torsemide daily.
What should you do when you leave the hospital?
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
- Your discharge weight is 186 lb (84.5 kg).
- It is very important that you limit your salt/fluid intake and
watch your blood sugar very closely.
- It is extremely important that you follow up with the
appointments listed below for ongoing care.
It was a pleasure taking care of you! We wish you all the best.
- Your ___ Team
Followup Instructions:
___
|
19947350-DS-14 | 19,947,350 | 29,340,802 | DS | 14 | 2182-09-07 00:00:00 | 2182-09-07 18:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Zomig / Percocet / Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o with pmh of pseudotumor cerebri s/p VP shunt who presents
with LLQ abd pain. Described as a gradual worsening of left
lower quadrant abdominal pain over the past several days
associated with a fever of ___ last night. Also associated with
nausea, nonbloody diarrhea. States that she has a hx of
diverticulitis ___ and current presentation is similar. Denies
any hematemesis, melena or hematochezia. Denies HAs. LMP approx
one week ago with no current vaginal pain, bleeding or
discharge. She was seen in a epi visit on ___ with the above
complaints, where there was suspision for diverticulitis,
started on PO abx (Cipro/Falgyl) and a CT scan was ordered. Pt
continued to have worsening pain and nausea which was preventing
her from taking her antibiotics and thus decided to come to the
ED.
In the ED intial vitals were: 99.1 107 155/73 18 100%
- Labs were significant for H/H of 11.6/35.9 (at baseline), chem
and lactate were normal. UA was unremarkable and blood cultures
were sent.
- Imaging: CT abd/pelvis (w/o contrast) was notable for
uncomplicated acute diverticulitis in the proximal sigmoid.
- Patient was given: Cipro/Flagyl IV, and pain/nausea control
was attempted with Lorazepam, Zofran, and Dilaudid. 2L NS in ED.
- Being admitted due to inability to tolerate PO and pain
control.
Vitals prior to transfer were: 98.4 89 126/70 16 94% RA
On the floor, feeling better, rates pain as ___. Still has
nausea, seems to be most significant complaint.
Past Medical History:
depression
mild asthma
Social History:
___
Family History:
Mother: GASTRIC BYPASS, OBESITY
Cousin: GASTRIC SLEEVE
2 other cousins and an aunt have also had gastric sleeves
Additionally she notes osteoarthritis in her father
Physical ___:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.9 98/51 84 18 98%RA
GENERAL: NAD, comfortable
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness to palpation in LLQ
with radiation to the back, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=========================
VS - Tm 98.1 97.9 98/51 84 18 98/RA
General: Pleasant, obese female lying in bed in NAD
HEENT: NC/AT, anicteric sclera, MMM
Neck: Supple
CV: RRR, no m/r/g
Lungs: CBAT
Abdomen: Soft, obese, non-distended, moderate tenderness to
palpation in the LLQ with some radiation to the L flank but no
rebound/guarding
GU: No foley
Ext: No c/c/e
Neuro: CNII-XII grossly intact
Skin: No rash
Pertinent Results:
LABS:
======
___ 08:00AM BLOOD WBC-7.2 RBC-3.90* Hgb-11.1* Hct-34.7*
MCV-89 MCH-28.6 MCHC-32.1 RDW-13.3 Plt ___
___ 03:40PM BLOOD WBC-10.0# RBC-4.02* Hgb-11.6* Hct-35.9*
MCV-89 MCH-28.8 MCHC-32.3 RDW-13.2 Plt ___
___ 03:40PM BLOOD Glucose-103* UreaN-11 Creat-1.0 Na-138
K-3.9 Cl-101 HCO3-23 AnGap-18
___ 03:40PM BLOOD ALT-18 AST-16 AlkPhos-63 TotBili-0.2
___ 08:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.1
___ 03:51PM BLOOD Lactate-1.5
MICRO:
=======
BCx (___): Pending
UCx (___): Pending
IMAGING:
========
CT ABDOMEN: Assessment of the abdominal viscera is lmited in
this
non-enhanced examination. Allowing for this limitation:
The liver is homogeneous. The gallbladder is unremarkable. The
pancreas, spleen, adrenal glands are within normal limits. The
kidneys do not show hydronephrosis or focal lesions bilaterally,
although assessment is limited due to the lack of IV contrast.
No evidence of nephrolithiasis.
There is a focus of mild pericolonic stranding in the descending
colon
proximal to the region of prior diverticulitis. There is no
fluid collection or extraluminal gas. There is no bowel
dilatation to suggest obstruction. The appendix is seen and is
not inflamed. The aorta is nonaneurysmal. There is no
mesenteric or retroperitoneal lymph node enlargement by CT size
criteria. There is no ascites, abdominal free air or abdominal
wall hernia. Ventriculoperitoneal shunt seen in the left upper
quadrant.
CT PELVIS: The urinary bladder and ureters are unremarkable.
The uterus is within normal limits. There is no pelvic wall or
inguinal lymphadenopathy. No pelvic free fluid is observed.
OSSEOUS STRUCTURES: There are no lytic or blastic lesions
concerning for
malignancy.
IMPRESSION:
Acute uncomplicated diverticulitis in the descending colon.
Brief Hospital Course:
___ y/o with PMH of pseudotumor cerebri s/p VP shunt, migraines
and prior diverticulitis in ___ who presents with LLQ abd pain
found to have another episode of acute uncomplicated descending
colon diverticulitis.
ACTIVE ISSUES:
==============
# Acute Uncomplicated Diverticulitis
C/w LLQ abd pain and CT findings. No e/o abscess, perforation or
fistulization. No e/o acute abdomen requiring immediate
intervention. Resolved fevers here. Normal WBC. This was her
second episode with last in ___. Started on IV cipro/flagyl,
fluids, pain and nausea medications with improvement noted
during hospitalization. Transitioned to PO medications with
cipro/flagyl for a 14 day course (stop ___. Given second
episode, recommended follow-up with general surgery for
consideration of partial colectomy with appointment previously
scheduled with general surgery. Recomended also continued bland
diet until symptoms resolved and to stay well hydrated. Can take
tylenol for pain control and zofran for nausea with sx expected
to improve within the week. On discharge, patient able to take
normal PO and passing gas with improvement of pain.
Hemodynamicallys stable throughout.
CHRONIC ISSUES:
================
# DM:
Initially held Metformin, put on ISS, but restart home meds on
dispo.
# Migraines:
Continue Verapamil.
# GERD:
Continue Ranitidine.
TRANSITIONAL ISSUES:
====================
- F/u pending cultures
- F/u with general surgery on whether surgical interventions
warranted in the future
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
2. Gabapentin 300 mg PO TID
3. Lorazepam 1 mg PO DAILY:PRN vertigo
4. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
5. norethindrone (contraceptive) 0.35 mg oral daily
6. Ranitidine 150 mg PO BID
7. Verapamil SR 120 mg PO Q24H
Discharge Medications:
1. Gabapentin 300 mg PO TID
2. Ranitidine 150 mg PO BID
3. Verapamil SR 120 mg PO Q24H
4. Acetaminophen 1000 mg PO Q6H Duration: 3 Days
RX *acetaminophen [Tylophen] 500 mg 2 capsule(s) by mouth Every
6 hours as needed Disp #*30 Tablet Refills:*0
5. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Twice a day Disp
#*26 Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth Twice a day
Disp #*30 Capsule Refills:*0
7. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth Three times a day
Disp #*39 Tablet Refills:*0
8. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
9. Lorazepam 1 mg PO DAILY:PRN vertigo
10. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
Do Not Crush
11. norethindrone (contraceptive) 0.35 mg oral daily
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN Breakthrough pain
RX *tramadol 50 mg 1 tablet(s) by mouth Every 6 hours as needed
Disp #*20 Tablet Refills:*0
13. Ondansetron 8 mg PO Q8H:PRN Nausea, vomiting
RX *ondansetron 4 mg ___ tablet,disintegrating(s) by mouth Every
8 hours as needed Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Uncomplicated Diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital as you had another episode of
diverticulitis (inflammation of your colon). You improved after
starting IV antibiotics, which you will need to continue to take
by mouth for a total 14 days (last dose on ___. Your
abdominal pain and nausea should improve over the next week.
Please stay well hydrated. Also it will be important for you to
eat a bland diet in small portions initially to minimize your
discomfort.
You should also follow-up with your primary care doctor within ___
week after leaving the hospital who will make sure you are doing
better.
You should also continue to follow-up with General Surgeon Dr.
___ to discuss further treatment options for your
diverticulitis.
Take care.
- Your ___ Team
Followup Instructions:
___
|
19947673-DS-8 | 19,947,673 | 26,532,892 | DS | 8 | 2182-02-19 00:00:00 | 2182-02-21 09:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain/poor PO intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ woman with a history of Crohn's disease (not on any
medications currently) who presents with 3 months of
postprandial
abdominal pain, nausea and poor PO intake. She was triggered in
the ED for hypotension which resolved with IVF. Per daughter
___ and paperwork from ___, she was diagnosed with
Crohn's
around ___ years ago and initially was well maintained on
prednisolone and sulfasalazine. Given improvement in symptoms,
these medications were discontinued 3 months ago. Since then,
she
has been having periumbilical abdominal pain, decreased
appetite,
poor PO intake, and intermittent emesis after eating. She
presented to a doctor in ___ on ___ and was treated for
presumed gastroenteritis with ~10 day course of ciprofloxacin,
omeprazole, and magnesium. She came to the ___ from ___
seven days ago. Patient denies chest pain, difficulty
breathing,
dysuria, fever, melena, hematochezia. She has had regular bowel
movements with about 3 every 2 days. They are normally well
formed but occasionally watery. She has never had an EGD or
colonoscopy and has never had abdominal surgery.
In the ED:
Initial VS: Temp 97.1, HR 73, BP ___ RR 16, 100% RA
Exam:
Pertinent labs/imaging studies:
- Ma 143, K 4.4, Cl 107, Bicarb 24, BUN 7, Cr 0.5
- WBC 9.7, Hgb 11.6, Hct 36.7, Plt 334
- ALT 7, AST 11, Alk phos 80, Tbili 0.5
EKG with QTc of 419 and normal sinus rhythm.
She had a CT A/P showing:
Acute on chronic Crohn's disease with long segment acute
terminal
ileitis.
Patient received:
- 4L LR
Transfer VS: Temp 97.8, BP 102/66, HR 62, RR 16, SpO2 100% on RA
Past Medical History:
Crohn's disease
Recurrent UTIs
Social History:
___
Family History:
No family history of GI issues or autoimmune diseases.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: Reviewed in ___
General: no acute distress
HEENT: Dry mucous membranes, no exudates/erythema
Cardiac: RRR , no chest tenderness
Pulmonary: Clear to auscultation bilaterally with good aeration,
no crackles/wheezes
Abdominal/GI: Periumbilical tenderness to palpation
Rectal: Guaiac negative, brown stool
Renal: No CVA tenderness
MSK: No deformities or signs of trauma, no focal deficits noted
Neuro: Sensation intact upper and lower extremities, strength
___
upper and lower, no focal deficits noted, moving all extremities
DISCHARGE PHYSICAL EXAM:
========================
Vitals: Temp 98, BP 95/53, HR 60, SpO2 100% RA
General: no acute distress
HEENT: EOMI, no exudates/erythema
Cardiac: Normal rate and regular rhythm, normal S1 and S2
Pulmonary: Clear to auscultation bilaterally
Abdominal/GI: Soft, nondistended, mildly tender to palpation
diffusely
Extremities: warm and well perfused
Neuro: Awake and fully conversant, no asymmetries noted, moving
all extremities
Pertinent Results:
ADMISSION LABS
==============
___ 06:10AM BLOOD WBC-9.7 RBC-4.08 Hgb-11.6 Hct-36.7 MCV-90
MCH-28.4 MCHC-31.6* RDW-14.3 RDWSD-46.9* Plt ___
___ 06:10AM BLOOD Neuts-67.5 ___ Monos-4.3* Eos-3.8
Baso-0.2 Im ___ AbsNeut-6.52* AbsLymp-2.31 AbsMono-0.42
AbsEos-0.37 AbsBaso-0.02
___ 05:30PM BLOOD ___ PTT-27.1 ___
___ 06:10AM BLOOD Glucose-102* UreaN-7 Creat-0.5 Na-143
K-4.4 Cl-107 HCO3-24 AnGap-12
___ 06:10AM BLOOD ALT-7 AST-11 AlkPhos-80 TotBili-0.5
___ 06:10AM BLOOD Lipase-26
___ 06:10AM BLOOD Albumin-3.4*
___ 05:30PM BLOOD Iron-55
___ 05:30PM BLOOD calTIBC-190* VitB12-284 Ferritn-249*
TRF-146*
___ 05:30PM BLOOD 25VitD-5*
___ 05:30PM BLOOD CRP-36.3*
___ 06:20AM BLOOD Lactate-0.9 Creat-0.5
INTERVAL LABS
=============
___ 07:27AM BLOOD WBC-5.5 RBC-4.08 Hgb-11.4 Hct-37.0 MCV-91
MCH-27.9 MCHC-30.8* RDW-14.3 RDWSD-47.9* Plt ___
___ 07:27AM BLOOD ___ PTT-28.2 ___
___ 07:27AM BLOOD Glucose-93 UreaN-4* Creat-0.4 Na-144
K-4.6 Cl-109* HCO3-26 AnGap-9*
___ 07:27AM BLOOD Albumin-2.9* Calcium-8.6 Phos-3.9 Mg-1.9
___ 08:10AM BLOOD %HbA1c-5.9 eAG-123
___ 09:48AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG
___ 07:05AM BLOOD CRP-7.1*
___ 07:06AM BLOOD CRP-3.3
DISCHARGE LABS
==============
___ 07:29AM BLOOD Glucose-93 UreaN-7 Creat-0.5 Na-144 K-4.5
Cl-106 HCO3-26 AnGap-12
___ 07:29AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1
___ 07:29AM BLOOD CRP-1.9
MICRO
=====
Stool ova/parasites ___: NO OVA AND PARASITES SEEN.
Stool cultures ___:
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
IMAGING
========
CT Abdomen/pelvis ___:
Acute on chronic Crohn's disease with long segment acute
distal/terminal
ileitis. No resultant bowel obstruction.
Chest X-ray ___:
No acute cardiopulmonary abnormality.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] Discharged on prednisone taper with plan for further
evaluation of Crohn's regimen at GI ___
[] Although this was most likely a Crohn's flare, there could
have been a component of dyspepsia/GERD. She was started on
esomeprazole in ___. Could consider a trial of holding PPI
and completing stool test for H. pylori
[] Re-check vitamin D in 8 weeks to confirm repletion
[] F/u pending stool studies
[] Had a B12 of 284, so ordered a methylmalonic acid which is
pending. Based on the results, consider B12 supplementation in
outpatient setting.
[] F/u quantiferon gold, obtained in case anti-TNF therapy
appropriate
[] Patient is recently arrived in ___ and does not
have insurance. Temporary supply of medications was provided on
discharge. Please consider CRS and/or social work involvement at
___ ___ for further assistance with resources
[] A1C 5.9. Consider further discussion of lifestyle
modifications, referral to nutrition for reduction of risk of
progression to diabetes.
NEW MEDICATIONS:
Prednisone with the following taper: 4 pills a day (40 mg) for 7
days (___), then 3 pills a day (30 mg) for 7 days
(___), then 2 pills a day (20 mg).
Vitamin D 50,000 units PO/week for ___ weeks
Multivitamin with minerals 1 daily
CONTINUED MEDICATIONS:
Esomeprazole 40 mg
PATIENT SUMMARY:
================
___ Amharic-speaking woman, recently arrived from ___ with
a history of Crohn's disease (not on any medications) and recent
treatment for gastroenteritis (s/p cipro) who presented with 3
months of postprandial abdominal pain, nausea and poor PO
intake.
ACUTE/ACTIVE ISSUES:
====================
#Crohn's disease flare
#Terminal Ileitis
She presented with significant epigastric/periumbilical
abdominal pain and emesis with eating, as well as poor
appetite/PO intake ever since discontinuing sulfasalazine and
prednisolone. Her only notable medical history is Crohn's
disease and CT A/P showed evidence ofterminal ileitis. The most
likely etiology of her symptoms was a
flare of her Crohn's disease. Although her stools were
relatively normal, her intense pain/emesis and poor PO put her
in the moderate category. We assessed for nutritional
deficiencies in the setting of months of poor appetite and IBD
and found that she was Vitamin D deficient (5). We began
supplementation with 50,000 U each week for ___ weeks and
consulted nutrition who recommended ensure enlive
supplementation. She initially was only tolerating clears. GI
was consulted. Significant improvement after initiating IV
methylprednisolone per GI recommendations, with reduced
abdominal pain. Her CRP downtrended from 36.3 on admission ___
to 1.9 on ___. ESR on admission was 45. On day of discharge,
she was transitioned to 40 mg of PO prednisone with a plan to go
home on a prednisone taper. She is tolerating a regular diet at
discharge. Hepatitis serologies were negative and she was
hepatitis B immune. Other data included: HgbA1C 5.9%, c. diff
negative, stool studies negative for salmonella, shigella,
campylobacter, vibrio, Yersinia, E. Coli O157:H7, and giardia
with other studies pending, Tsat 29%, B12 284. We gave
omeprazole 40 daily while she was here.
#Vitamin D Deficiency
Serum level 5 in setting of terminal ileitis. Started repletion
with weekly 50,000U and calcium in MVI with minerals.
#Pre-Diabetes
Given plan to initiate steroids, A1C was checked while
inpatient. Returned 5.9 consistent with pre-diabetes. Consider
further discussion of lifestyle modifications, referral to
nutrition for reduction of risk of progression to diabetes.
Greater than 30 minutes spent on discharge planning and
coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Esomeprazole 40 MG Other DAILY
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. PredniSONE 10 mg PO DAILY
4 pills a day for 7 days (___), then 3 pills a day for 7
days (___), then 2 pills a day
Tapered dose - DOWN
3. Vitamin D ___ UNIT PO 1X/WEEK (___)
4. Esomeprazole 40 MG Other DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Crohn's disease flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- Abdominal pain/decreased appetite
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You received imaging of your abdomen which showed a flare of
your Crohn's disease in your small intestine. You were seen by
the gastrointestinal doctors who recommended several tests to
make sure nothing else was going on and who recommended starting
steroids. For the first 48 hours, you got intravenous steroids
and meanwhile, you began to feel better. Your pain improved and
your diet was advanced. Your inflammatory markers resolved. You
were also seen by the nutritionists who recommended vitamins and
supplemental shakes. At the end of your hospitalization, you
were switched to steroids by mouth which you will taper after
leaving the hospital.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19947761-DS-18 | 19,947,761 | 26,726,803 | DS | 18 | 2133-07-15 00:00:00 | 2133-07-15 12:33:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Self-inflicted stab wound to abdomen x2.
Major Surgical or Invasive Procedure:
Exploratory laparoscopy.
History of Present Illness:
Patient woke up on morning of ___, went to smoke outside
his house and stabbed himself with a pocket-knife twice in the
RLQ of his abdomen causing a 1 cm and a 0.5 cm wounds.
Immediately afterwards he was brought by ambulance to this
institution.
Past Medical History:
Depression
Anxiety
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY:
Reports multiple family members "have issues"
Oldest brother is "bipolar, hands down"
Physical Exam:
HEENT: Normocephalic, atraumatic, no visible or palpable
masses, depressions, or scaring.
NECK: Supple without lymphadenopathy.
HEART: Regular rate and rhythm.
LUNGS: Revealed decreased breath sounds at the bases. No
crackles or wheezes are heard.
ABDOMEN: TwoSoft, nontender, nondistended with good bowel
sounds heard. Inguinal area is normal.
EXTREMITIES: Without cyanosis, clubbing or edema.
NEUROLOGICAL: Gross nonfocal. Skin: Warm and dry without any
rash. There is no costovertebral angle tenderness.
Brief Hospital Course:
Patient arrived to the ED after self-inflicting two stab wounds
in RLQ of his abdomen. The patient was taken for CT scan of
abdomen and pelvis demonstrating two small puncture wounds in
the right lower quadrant abdominal wall with a small 2.4 cm
subcutaneous hematoma and no definite rectus abdominus
abnormality. He was offered a diagnostic laparoscopy to confirm
the small knife had not penetrated into the abdominal cavity.
The patient underwent diagnostic laparoscopy and the findings
were nonexpanding right rectus sheath hematoma without violation
of peritoneum. The patient was taken to floor afterwards and is
ready for discharge to psychiatry unit.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Prazosin 1 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Stab wound to the abdomen x 2 and right rectus sheath hematoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*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:
___
|
19948103-DS-2 | 19,948,103 | 21,009,849 | DS | 2 | 2165-03-11 00:00:00 | 2165-03-11 16:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Amoxicillin
Attending: ___.
Chief Complaint:
Gastroenteritis, Transaminitis, Hemolysis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old Male who presents with 8 days of fevers to 102,
nausea/vomitting, hemolysis and transaminitis. The patient is at
baseline healthy, when 8 days prior to admission he notes
lethargy, nasuea and vomitting. He was at college, and went to
the ___ health ___, who performed a liver scan which
was reportedly normal. He continued with his symptoms, after
returning home for ___. He denies knowing others with
the same symptoms. He also describes headaches, palpitations and
sore throat along with the other symptoms. He notes that several
days prior to admission his urine became darkly colored.
He came to the ___ ED on ___ where he was noted with
splenomegally on imaging and transaminitis. An LP was negative
and a rapid strep test was also negative. He was discharged with
a presumed diagnosis of mononucleosis. He returned on ___
with continue nausea and vomitting and fevers. He was noted in
the ED with fevers to 102. He was agressively hydrated, along
with IV antiemetics with good result. He reports some
improvement in his symptoms.
Past Medical History:
Kidney surgery as child for repair of congenital defect in the
collecting system
Social History:
___
Family History:
No liver or hematologic diseases
Physical Exam:
ROS:
GEN: + fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding, + Sore Throat
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, + Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 102.9, 106/55, 107, 18, 97%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, Kissing Tonsils
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3, Non-Focal
Pertinent Results:
___ 05:38AM BLOOD WBC-5.1 RBC-3.74* Hgb-11.8* Hct-32.5*
MCV-87 MCH-31.5 MCHC-36.3* RDW-13.5 Plt ___
___ 06:45AM BLOOD WBC-5.4 RBC-4.06* Hgb-12.5* Hct-35.1*
MCV-86 MCH-30.7 MCHC-35.5* RDW-13.4 Plt ___
___ 05:40AM BLOOD WBC-6.5 RBC-4.18* Hgb-12.9* Hct-35.9*
MCV-86 MCH-30.8 MCHC-35.8* RDW-13.2 Plt ___
___ 05:38AM BLOOD Neuts-34* Bands-0 ___ Monos-13*
Eos-0 Baso-0 Atyps-14* ___ Myelos-0
___ 06:45AM BLOOD Neuts-62 Bands-0 ___ Monos-7 Eos-1
Baso-0 ___ Myelos-0
___:40AM BLOOD Neuts-53 Bands-3 ___ Monos-10 Eos-0
Baso-0 Atyps-10* Metas-1* Myelos-0
___ 05:38AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-1+
___ 06:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:40AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 05:38AM BLOOD ___ PTT-39.2* ___
___ 06:00AM BLOOD ___ PTT-38.1* ___
___ 05:38AM BLOOD ___ 06:45AM BLOOD Parst S-NEGATIVE
___ 05:38AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-135 K-3.5
Cl-102 HCO3-22 AnGap-15
___ 06:45AM BLOOD Glucose-102* UreaN-10 Creat-0.9 Na-135
K-3.5 Cl-99 HCO3-25 AnGap-15
___ 05:38AM BLOOD ALT-244* AST-254* LD(LDH)-805* AlkPhos-51
TotBili-3.3*
___ 06:45AM BLOOD ALT-180* AST-170* LD(___)-708* AlkPhos-50
TotBili-2.6* DirBili-1.3* IndBili-1.3
___ 05:40AM BLOOD ALT-121* AST-145* AlkPhos-48 TotBili-1.7*
___ 05:38AM BLOOD Albumin-3.5 Calcium-8.0* Phos-1.7* Mg-1.9
___ 06:45AM BLOOD Albumin-3.9
___ 05:40AM BLOOD Albumin-4.3 Calcium-9.0 Phos-2.9 Mg-1.9
___ 06:45AM BLOOD Hapto-<5*
___ 06:45AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND HAV Ab-PND
IgM HAV-PND
___ 07:06AM BLOOD Lactate-1.3
___ 05:10PM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ 02:23PM BLOOD HERPES SIMPLEX VIRUS 1 AND 2 ANTIBODY
IGM-PND
___ 02:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
___ 02:00PM URINE RBC-0 WBC-3 Bacteri-NONE Yeast-NONE Epi-0
___ 07:18AM CEREBROSPINAL FLUID (CSF) WBC-2 RBC-0 Polys-0
___ Macroph-40
___ 07:18AM CEREBROSPINAL FLUID (CSF) TotProt-25 Glucose-58
Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm
Blood (EBV)
___ VIRUS VCA-IgG AB (Pending):
___ VIRUS EBNA IgG AB (Pending):
___ VIRUS VCA-IgM AB (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm
Blood (CMV AB)
CMV IgG ANTIBODY (Pending):
CMV IgM ANTIBODY (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm
SEROLOGY/BLOOD
RAPID PLASMA REAGIN TEST (Pending):
Time Taken Not Noted Log-In Date/Time: ___ 2:24 pm
SEROLOGY/BLOOD
LYME SEROLOGY (Pending):
___ 2:00 pm URINE
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
___ 5:57 am SEROLOGY/BLOOD
ADDED FROM ___ ON ___ AT 09:02.
**FINAL REPORT ___
MONOSPOT (Final ___:
NEGATIVE by Latex Agglutination.
(Reference Range-Negative).
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
7:27 AM
IMPRESSION:
1. Trace sludge within an otherwise unremarkable gallbladder
without evidence of cholecystitis.
2. Prominent splenomegaly of unclear etiology.
Brief Hospital Course:
___ yo M w/ no significant PMH who presents with fevers, n/v,
splenomegaly, transaminitis, elev direct bili and is EBV IgM pos
and influenza A positive.
#EBV Mononucleosis, Transaminitis: He initially presented with
GI symotoms (nausea and vomitting) most likely related to
hepatitis but over hosp course dev pharyngitisn exam with
enlarged tonsils. EBV IgM positive with ___, smear with
atypical lymphs. CMV Ab neg. Pt had transaminitis (AST ALT
300s), elev bili (up to 3), splenomegaly and also had low grade
DIC (slightly elevated INR and PTT) all related to EBV. Initial
concern for autoimmune hemoltic anemia in setting of low hapto
and elev LDH and elev bili (though direct higher than indirect)
and coombs and agglutinin were somewhat inconclusive and most
likely there was a low grade hemolytic anemia. EBV can cause an
autoimmune hemolytic anemia (anti-i). Ferritin in the 2000s
making HLH (EBV can cause HLH) unlikely. Heme/onc and ID
involved in his care. He was given zofran, IVF as supportive
measures. He was told to avoid contact sports bc of splenomegaly
and risk of splenic rupture.
#Influenza A:
He was started on tamiflu day ___ w/ plan to treat for 5 d
#Coagulopathy, Diseminated Intravascular Coagulation, Hemolysis:
slightly elev INR and PTT but stable, this was likely a low
grade DIC (elev D dimer, FDP, though fibrinogen normal) combined
w/ acute hepatitis. Hematology was consulted. He never required
transfusions
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. OSELTAMivir 75 mg PO Q12H Duration: 5 Days
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*6 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: EBV mono, low grade DIC, hepatitis, flu
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
It has been a pleasure taking care of you in the hospital. You
were admitted for fevers, nausea, and vomiting. You had a workup
and were found to have EBV mono (EBV is a common virus that
causes mono) and the flu. You were treated with intravenous
fluids and anti-emetics. You had hepatitis which means
inflammation of the liver from the virus. You were seen by
infectious disease doctors and ___ team as well. You
continued to improve. It is important you not play contact
sports for 3 months so you dont get a splenic rupture because
you have an enlarged spleen from the mono. You were also started
on tamiflu for the flu.
Followup Instructions:
___
|
19949052-DS-17 | 19,949,052 | 24,019,823 | DS | 17 | 2160-06-28 00:00:00 | 2160-06-28 13:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Posterior neck pain
Major Surgical or Invasive Procedure:
Right Frontal External Ventricular Drain
History of Present Illness:
This is a ___ year old male with a past medical history
significant for
hypertension, enlarged prostate, hyperlipidemia and chronic
renal
failure presented from ___ with a subarachnoid
hemorrhage. When he went to bed on ___, he was experiencing
some posterior neck pain which was increasing in intensity
through the night. At 1am on ___, he began to feel week, was
diaphoretic and started to have a headache. Head CT scan showed
CT
Hemorrhage ___ ventricle. He had an MRA/MRI completed that
revealed no evidence of obvious aneurysm and angio was deferred.
He was transferred to the SICU for monitoring overnight.
Past Medical History:
HTN
BPH
Dyslipidemia
Chronic renal failure
Social History:
___
Family History:
NC
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
___ and ___: 2 Fisher: 4 GCS 15
O: T: 97.8 BP: 168/94 HR:57 16 O2Sats99 RA
Gen: WD/WN, comfortable, NAD.
HEENT: PERRLA
Neck: Supple.
Extrem: Warm and well-perfused. No C/C/E.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2
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.
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.
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger.
On Discharge
Intact
Pertinent Results:
___ head CT
Stable intraventricular hemorrhage in the ___ ventricle. Small
amount of
hemorrhage in the bilateral occipital horns likely represents
redistribution of blood products.
___: MRA
IMPRESSION: Although evaluation for aneurysm on an MRA in
presence of
subarachnoid hemorrhage would be somewhat limited, no obvious
aneurysm is
identified in the arteries of anterior or posterior circulation.
If there is continued concern, CTA would be a better
examination for evaluation of an aneurysm.
CT HEAD W/O CONTRAST ___
Stable degree of ventricular hemorrhage within the bilateral
lateral and fourth ventricle with increasing size of lateral and
third
ventricles concerning for developing obstruction.
CT HEAD W/O CONTRAST ___ s/p EVD placement
IMPRESSION: Interval placement of right-sided ventriculostomy
catheter with mild interval decrease in ventricular size.
Increased intraventricular or new intraparenchymal hemorrhage
identified.
___ HEAD W/O CONTRAST:
IMPRESSION: No evidence of venous thrombosis. Normal MRV of the
head.
___ CT head : A right frontal drain ends in the anterior horn
of the right lateral ventricle. There is no hydrocephalus. No
new hemorrhage is seen.
___ CT head: In comparison to ___ exam, there is no
significant interval change in either the amount of
intraventricular hemorrhage or the ventricular size, with no new
intracranial hemorrhage.
___ CT head: Stable, no signs of hydrocephalus
Brief Hospital Course:
The patient was admitted to the neurosurgery service on ___
with a SAH. Neuro exam was stable. Patient was admitted to ___.
The patient had an MRA/MRI that showed no aneurysm, occlusion or
stenosis. The patient had an a-line placed for blood pressure
monitoring. He was started on a nicardipine drip. He recieved
Nimodipine. SBP goal was less than 140.
On ___ the patient remained neurologically intact. Repeat
head CT showed stable interventricular hemorrhage in the ___
ventricle with small amount of hemorrhage in the bilateral
occipital horns. The patient was started on SQH for DVT
prophylaxis.
On ___, patient became confused in AM. Head CT was ordered
which revealed ventriculomegaly. An EVD was placed in ICU at
bedside and leveled at 10cmH2O. Patient's exam improved with
draining of CSF. Repeat head CT showed good placement of
catheter in R lateral ventricle with no acute hemorrhage and
stable IVH. Neuro stroke recommended an MRI head to rule out
venous sinus thrombosis. The patient was seen by Neuology. They
recommend MRI looking for amyloid angiopathy or hemorrhageic
mass lesion, due to the patient's renal function he is unable to
get CTA.
On ___, the patient remained hypertensive. He was started on
Clonidine. He remained neurologically stable.
On ___ EVD was raised to 20. EVD was clamped. The patient
tolerated clamp trial.
On ___ EVD remained clamped, head CT was stable. There was no
evidence of hydrocephalus. Neuro exam was stable. The patient
was transferred to the step down unit.
On ___ he was transferred to the floor from the step down unit.
His neuro exam was stable and he worked with ___ and OT. Social
work was consulted for evaluation. Medicine continued to follow
the pt for BP with final recommendations on ___ of Clonidine
0.3mg Daily, Lisinopril 20mg daily, and Amlodipine 10mg Daily.
On ___ the day of discharge a Head CT was repeated for baseline
status and showed no signs of hydrocephalus.
At the time of discharge he was tolerating a regular diet,
ambulating with assist, afebrile with stable vital signs.
Medications on Admission:
none regularly
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN HA
RX *butalbital-acetaminophen-caff 50 mg-325 mg-40 mg ___
tablet(s) by mouth Q4 hrs Disp #*90 Tablet Refills:*0
2. Amlodipine 10 mg PO DAILY
3. Bisacodyl 10 mg PO/PR DAILY
4. CloniDINE 0.3 mg PO BID
5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
6. Docusate Sodium 100 mg PO BID
7. FoLIC Acid 1 mg PO DAILY
8. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
9. Heparin 5000 UNIT SC TID
10. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
11. Lisinopril 20 mg PO DAILY
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
13. Multivitamins W/minerals 1 TAB PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN HA
RX *oxycodone 5 mg 1 tablet(s) by mouth Q4 hours Disp #*60
Tablet Refills:*0
15. Senna ___ TAB PO BID
16. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush
17. Tamsulosin 0.4 mg PO HS
18. Thiamine 100 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
for Rehabilitation and Sub-Acute Care)
Discharge Diagnosis:
Intraventricular Hemorrhage
Hydrocephalus
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:
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.
Followup Instructions:
___
|
19949052-DS-19 | 19,949,052 | 26,305,563 | DS | 19 | 2162-04-17 00:00:00 | 2162-04-20 10:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
baclofen
Attending: ___.
Chief Complaint:
Symptomtic uremia
Major Surgical or Invasive Procedure:
Dialysis
History of Present Illness:
Mr. ___ is a ___ with a PMH of ESRD secondary to chronic HTN
and obstructive uropathy who presents with increased fatigue,
morning nausea, and increased tremulousness in the setting of
worsening kidney function. Discovered in ___'s office to have
symptomatic uremia with asterixis and rapidly declining kidney
function as evidenced by a GFR of 6 (GFR of 11 two weeks prior),
BUN of 89, Cr of 8.7 and phosphate of 6.7.
Past Medical History:
PAST MEDICAL HISTORY:
-HTN (reports that his SBP ranges up to 160s as outpatient)
-HLD
-BPH, has been straight cathing himself for ___ years
-recurrent UTI
-CKD thought to be from obstructive uropathy (per patient)
-no recollected history of MI, CHF, CVA
Social History:
___
Family History:
Father: HTN, died of an MI
Mother: dementia
Physical ___:
Vitals:
VS - 98.0 HR 78 BP 155/98 98% RA
General: well appearing, AOx3, NAD
HEENT: MMM, EOMI, PERRL, anicteric sclerae
Neck: no JVD, no LAD
CV: irregularly irregular, S1/S2 present, no m/r/g
Lungs: CTAB, breathing comfortably
Abdomen: soft, nontender, nondistended, no HSM appreciated
GU: deferred
Ext: 2+ pitting edema RLE to upper shin, 1+ pitting edema LLE to
upper shin. RUE AV fistula with audible bruit and palpable
thrill. WWP, PPP
Neuro: CNII-XII intact
Discharge
AVSS,
less tremulous. otherwise no change in exam.
Pertinent Results:
ADMISSION LABS
___ 08:25PM BLOOD WBC-5.3 RBC-3.22* Hgb-10.0* Hct-29.8*
MCV-93 MCH-30.9 MCHC-33.4 RDW-15.3 Plt ___
___ 08:25PM BLOOD Neuts-73.6* Lymphs-15.8* Monos-7.0
Eos-3.0 Baso-0.6
___ 08:25PM BLOOD Plt ___
___ 08:25PM BLOOD Glucose-129* UreaN-90* Creat-8.4*# Na-140
K-4.0 Cl-104 HCO3-22 AnGap-18
___ 08:25PM BLOOD Calcium-8.1* Phos-6.1* Mg-2.2
IMAGING
U/S Unilateral RLE Veins ___
No evidence of deep venous thrombosis in the right lower
extremity veins.
EKG ___
Atrial fibrillation. Poor R wave progression. No significant
change compared to the previous tracing of ___.
DISCHARGE LABS
___ 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 06:00AM BLOOD HCV Ab-NEGATIVE
___ 06:45AM BLOOD WBC-5.9 RBC-3.27* Hgb-10.3* Hct-29.8*
MCV-91 MCH-31.5 MCHC-34.5 RDW-14.8 Plt ___
___ 06:45AM BLOOD Glucose-124* UreaN-58* Creat-5.9* Na-140
K-3.9 Cl-101 HCO3-25 AnGap-18
Brief Hospital Course:
Mr. ___ is a ___ with a PMH of ESRD ___ chronic HTN and
obstructive uropathy who presents with increased fatigue,
morning nausea, and increased tremulousness in the setting of
worsening kidney function.
ACUTE ISSUES:
#ESRD. Progressive decline in renal function. GFR of 6 on
admission, BUN 89 with Cr 8.7, presents with fatigue, nausea,
and asterixis. Patient has a kidney donor who is beginning the
medical evaluation process at ___. Three inpatient dialysis
treatments. Torsemide continued during hospitalization on
non-dialysis days. Negative hepatitis labs. PPD placed. Started
sevelamer 800 mg TID, nephrocaps daily and low K/P/Na diet.
Outpatient dialysis treatment set up. Hepatitis labs negative,
PPD placed and to be read as an outpatient.
#Bilateral Pitting Edema. Asymmetric R>L ___ swelling and pitting
edema observed on presentation. DVT ruled out with ___ U/S.
Continue home torsemide, likely on non-dialysis days.
CHRONIC ISSUES:
#Hypertension. Blood pressures well controlled on admission.
Amlodipine and torsemide continued during hospitalization,
though torsemide only on non-dialysis days.
#Anemia. Chronic anemia, likely secondary to ESRD. Continue iron
supplementation as outpatient.
#Atrial fibrillation. CHADS score of 1. Not on anticoagulation,
especially given history of subarachnoid hemorrhage. Continue
home aspirin.
#BPH. S/P TURP. Continue tamsulosin.
Transitional:
- Continue diuretics on non-HD days.
- Patient will need to have his PPD read on ___ or ___
(placed ___ and bring a signed letter verifying negtaive
result to his outpatient dialysis center
- Patient will need to received the second and third injections
in the hepatitis B vaccination series (first shot received on
___ as an outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Tamsulosin 0.4 mg PO HS
3. Vitamin D 1000 UNIT PO DAILY
4. Amlodipine 5 mg PO BID
5. Aspirin EC 81 mg PO DAILY
6. Atorvastatin 80 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Torsemide 10 mg PO DAILY
10. Cialis (tadalafil) 20 mg oral prn sexual acitivty
Discharge Medications:
1. Amlodipine 5 mg PO BID
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Ferrous Sulfate 325 mg PO DAILY
6. Tamsulosin 0.4 mg PO HS
7. Vitamin D 1000 UNIT PO DAILY
8. Nephrocaps 1 CAP PO DAILY
RX *B complex with C#20-folic acid [Mynephrocaps] 1 mg 1
capsule(s) by mouth daily Disp #*30 Capsule Refills:*0
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
RX *sevelamer carbonate [Renvela] 800 mg 1 tablet(s) by mouth
three times a day Disp #*90 Tablet Refills:*0
10. Cialis (tadalafil) 20 mg oral prn sexual acitivty
11. Multivitamins 1 TAB PO DAILY
12. Torsemide 10 mg PO 4X/WEEK (___)
take on non-dialysis days
13. Lidocaine-Prilocaine 1 Appl TP ONCE Duration: 1 Dose
RX *lidocaine-prilocaine 2.5 %-2.5 % apply pre dialysis once a
day Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
End Stage Renal Disease from obstructive uropathy
Secondary:
hypertension/hyperlipidemia
benign prostatic hypertrophy
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Mr. ___,
Thank you for allowing us to be part of your care at ___. You
were admitted to the hospital after your primary care physician
discovered that your kidney function was progressively
deteriorating and was no longer effectively filtering your
blood. We have started you on dialysis. You will continue your
dialysis as an outpatient at the ___ Dialysis ___
every ___ and ___. You tested negative for
hepatitis. We gave you a dose of the hepatits B vaccine here;
you will need to receive 2 more doses as an outpatient. A PPD
test (a test for tuberculosis) was placed on your left forearm
on ___. You should have this read in an urgent care clinic on
___ or ___ at the latest. You must bring documentation of a
negative result to your dialysis center.
It been a pleasure taking care of you at the ___
-your ___ care team
Followup Instructions:
___
|
19949061-DS-10 | 19,949,061 | 27,658,829 | DS | 10 | 2189-06-05 00:00:00 | 2189-06-07 08:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope, difficulty swallowing and coughing with eating
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ y/o male with a hx of poorly controlled IDDM,
HTN, recent diagnosis of FTD-ALS, who presented with syncope. On
the morning of ___, the patient's son was preparing him to
go to his ___ and noted that his BS was elevated >200. He was
given 58 units of NPH. He then proceeded to taking a shower
without eating. After his shower, his son noticed that he was
clammy, drowsy, became unresponsive, fell backwards and was
helped by his son to the ground. There was no trauma to his
head. He remained unresponsive for 1 minute, regained
consciousness, and returned to his baseline. He was given orange
juice and a banana. EMS was called and they checked his BS which
was >200. His son reports that EMS noted his BP to be "low" and
was taken to the ED. Patient does not remember any of the events
that occurred but does remember the ambulance ride.
Initial VS in the ED: 97.0, 60, 130/70, 97RA. Chest x-ray showed
no consolidation but mild pulmomary edema. EKG was sinus without
concerning ischemic changes. Head CT showed no acute
intracranial process. He was admitted to internal medicine
service.
Past Medical History:
Insulin Dependent Diabetes Mellitus
Likely Frontotemporal Dementia and ___
Hyperlipidemia
Gastroesophageal Reflux Disease
Benign Prostatic Hyperplasia
Social History:
___
Family History:
Father had HTN and DM.
Mother passed away after delivery.
Children are all healthy.
Physical Exam:
Admission Physical Exam:
Vitals: T: 97.7 BP: 120/78 P: 60 O2: 96RA
General: Alert, oriented to self and place but not time, NAD,
voice is very raspy.
HEENT: PEARL, EOMI with limited vertical gaze, Sclera anicteric,
MMM, oropharynx clear.
Neck: supple, JVP not elevated, no LAD
Lungs: Decreased but equal breath sounds, no crackles or rhonchi
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: Normal tone without rigidity or cogwheeling. No gross
motor or sensory deficits. Very dysarthric speech with very
low, grumbling tone and almost impossible to understand anything
but single words of ___ (per interpreter)
Discharge Physical Exam:
VS: Tm 98.9 Tc 98.4 HR 55(55-66) BP 118/52(112-122/52-64) RR
___ O2 94-97% RA
Orthostatic BP:
Lying 113/56 Sitting 111/66 Standing 114/52
Gen: NAD, sleeping in hospital bed, easily arousable
HEENT: PEARL, oral pharynx clear
CV: RRR, S1, S2, no m/r/g
Pulm: Equal and good air entry bilateral, no
rales/rhonchi/wheezes
Abd: Soft, ND, NT, +BS
Ext: WWP, no edema, no ulcers, skin discoloration over shins,
but no open wounds or ulcers on ___
Pertinent Results:
Admission Labs:
___ 09:20AM BLOOD WBC-4.4 RBC-4.48* Hgb-13.3* Hct-42.2
MCV-94 MCH-29.8 MCHC-31.6 RDW-13.1 Plt Ct-95*
___ 09:20AM BLOOD Neuts-54 Bands-1 ___ Monos-12*
Eos-3 Baso-0 Atyps-1* ___ Myelos-0
___ 09:20AM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 09:20AM BLOOD ___ PTT-27.0 ___
___ 09:20AM BLOOD Glucose-304* UreaN-29* Creat-1.0 Na-133
K-4.2 Cl-102 HCO3-25 AnGap-10
___ 09:20AM BLOOD cTropnT-<0.01
___ 10:35PM BLOOD cTropnT-<0.01
___ 09:32AM BLOOD Lactate-2.0
Microbiology Data:
___ 11:30 am URINE Site: CLEAN CATCH CLEAN CATCH.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
Radiological Studies:
Head CT
FINDINGS: There is no evidence of hemorrhage, edema, mass
effect, or infarction. The ventricles and sulci are mildly
prominent, suggesting mild age-related volume loss. The basal
cisterns are patent. Minimal periventricular confluent
hypodensities are stable and consistent with chronic small
vessel ischemic disease. A small intraparenchymal calcification
adjacent to the left lateral ventricle is unchanged from prior
studies. This is of unclear etiology, but given its stability,
this is likely benign. No fracture is identified. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
1. No acute intracranial process.
2. Stable mild age-related volume loss and mild chronic small
vessel ischemic
disease.
Chest X-Ray
FINDINGS: The lung volumes are low. There is interstitial
prominence consistent with mild pulmonary edema. No pleural
effusion is present. The cardiac silhouette is moderately
enlarged. There is no consolidation or
pneumothorax.
IMPRESSION:
1. Mild pulmonary edema.
2. Moderate cardiomegaly.
ECHO
Findings
This study was compared to the report of the prior study (images
not available) of ___.
LEFT ATRIUM: Mild ___.
.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Moderately dilated RA.
.
LEFT VENTRICLE: Normal LV wall thickness. Normal LV cavity size.
Overall normal LVEF (>55%). TDI E/e' < 8, suggesting normal PCWP
(<12mmHg). No resting LVOT gradient.
.
RIGHT VENTRICLE: Normal RV chamber size. TASPE depressed
(<1.6cm)
.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter. Normal aortic arch diameter.
.
AORTIC VALVE: Mildly thickened aortic valve leaflets (3).
.
MITRAL VALVE: Normal mitral valve leaflets with trivial MR.
.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Borderline PA systolic hypertension.
.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
.
PERICARDIUM: Trivial/physiologic pericardial effusion.
Conclusions
The left atrium is mildly dilated. The right atrium is
moderately dilated. Left ventricular wall thicknesses are
normal. The left ventricular cavity size is normal. Overall left
ventricular systolic function is normal (LVEF>55%). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size is
normal. Tricuspid annular plane systolic excursion is depressed
(1.5 cm) consistent with borderline/mild right ventricular
systolic dysfunction. The aortic valve leaflets (3) are mildly
thickened. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is borderline pulmonary
artery systolic hypertension. There is a trivial/physiologic
pericardial effusion.
Compared with the report of the prior study (images unavailable
for review) of ___, findings are similar.
.
Video Oropharyngeal Swallow Study
SWALLOWING VIDEO FLUROSCOPY: Oropharyngeal swallowing video
fluoroscopy was performed in conjunction with the speech and
swallow division. Multiple consistencies of barium were
administered. Barium passed freely through the oropharynx
without evidence of obstruction. There was silent aspiration
with thin and nectar-thick liquids. Delayed initiation of oral
phase of swallowing was observed. There was also mild
oropharyngeal residue during the exam.
IMPRESSION: Aspiraiton with thin and nectar-thick liquids. For
details,
please refer to speech and swallow note in OMR.
.
Discharge Labs:
___ 05:28AM BLOOD WBC-5.6 RBC-4.50* Hgb-13.5* Hct-42.4
MCV-94 MCH-30.0 MCHC-31.8 RDW-13.2 Plt ___
___ 05:28AM BLOOD Glucose-58* UreaN-20 Creat-1.0 Na-141
K-4.4 Cl-103 HCO3-32 AnGap-10
___ 05:28AM BLOOD Calcium-9.6 Phos-4.2 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ y/o male with a history of poorly controlled
DM, HTN, recent frontotemporal dementia/ALS, who presented with
syncope and coughs with eating.
# Syncope: The patient presented to the hospital after a
witnessed episode of syncope. The differential diagnosis for
syncope includes cardiac (arrhythmia, structural heart disease,
acute MI), vasovagal, orthostasis, or neurological conditions
(seizures, CVA), and metabolic causes (hypoglycemia). Given the
clinical picture, concern for seizure was low. Chest xray
revealed mild pulmonary edema and moderate cardiomegaly;
therefore, an echocardiogram was obtained which basically showed
no significant change from prior exam. Head CT was negative for
an acute intracranial process. It was decided that the patient
should be admitted to the hospital for overnight monitoring.
The patient was placed on cardiac telemetry and no abnormalities
were noted. In addition, EKG and two sets of troponins ruled
out an acute MI. Since the patient has poorly controlled IDDM,
BPH treated with tamsulosin, had come out of a shower prior to
the syncope, seemed clammy and progressively became
unresponsive, it is most likely that he had orthostasis or
vasovagal episode. He also may have been hypoglycemic at the
time as he did not have anything to eat for a while after
getting his 58 units of NPH. IV fluid bolus was not given
because he seemed euvolemic on exam and showed mild pulmonary
edema on chest xray. Orthostatic blood pressures in the hospital
was normal and he had no further syncope or presyncope.
# Frontotemporal dementia / ALS: Patient has been experiencing
rapid and profound deterioration in cognitive function, mood,
and speech over the past 6 months. Decline in cognitive
function dates as far back as ___ years. He was recently seen by
Dr. ___ in ___ Neurology Unit on ___ his
care will be transferred to Dr. ___ as Dr. ___ is leaving
the practice. He has been completely dependent for ADLs and
IADLs and is minimally verbal. Patient and family members have
been reporting that he has difficulty swallowing in general and
especially liquids. In the hospital, we obtained a neurology,
physical therapy, speech and swallow service consult. A video
oropharyngeal swallow study was obtained which showed silent
aspiration to thin liquid and nectar consistency. After
discussion with patient and his family, the value they placed on
his comfort and desire to eat outweighed potential dangers and
they agreed to allow him to continue a diet with safety
modifications understanding the risks of aspiration.
Recommendations are to pre-thicken all liquids and foods prior
to eating and to crush medications and mix in apple cause or
puree. He will followup in ALS and Cognitive Neurology clinic
as scheduled for further evaluation and discussion for
nutritional plan going forward. Topic of feeding tube was
broached but family is not yet ready to pursue this step. Family
did see neurology and all members were made aware of likely ALS
diagnosis.
# Insulin dependent diabetes mellitus: Patient has poorly
controlled insulin dependent diabetes mellitus with last HgbA1c
of 10.5 on ___. A hypoglycemic episode may have been a
possible contributing factor in causing his syncope leading to
this hospitalization. Patient did not eat anything after
receiving his morning insulin dose until the episode of syncope.
However, given that he returned to baseline soon within a minute
after lying on the floor is not consistent with hypoglycemia.
While in the hospital, patient was given 54 units of NPH QAM and
a sliding scale of insulin QID. Patient and family members were
educated on hypoglycemia and not to have the patient go without
eating for long after receiving his insulin.
# Thrombocytopenia: On initial CBC, patient's platelet count
was 95,000. In the past year, patient's platelet count has been
ranging between 74,000 and 108,000. This was viewed to be a
chronic problem and given no evidence nor concern for active
bleeding, we did not pursue further workup during this
hospitalization. Outpatient work up can be considered depending
on patient's overall picture and multiple competing, life
threatening medical problems.
# Hypertension: Patient's blood pressure has been WNL and
stable throughout hospitalization. We continued his home
antihypertensive medications which included atenolol,
lisinopril, and hydrochlorothiazide.
# BPH: Patient has history of BPH. This was not an active
issue during this hospitalization and tamsulosin was continued
throughout the hospital course.
.
TRANSITIONAL ISSUES:
1. Discuss nutritional plan and other medical concerns as
patient's neurological disease progress at followup.
2. Follow up with ___ clinic in ___ with possible rescheduling
if there is a cancellation
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from ___.
1. Acetaminophen Dose is Unknown PO Frequency is Unknown
2. Lisinopril-Hydrochlorothiazide ___ mg Oral daily
4. Atenolol 25 mg PO DAILY
5. Ranitidine 300 mg PO QPM
6. Atorvastatin 10 mg PO DAILY
7. NPH insulin human recomb 58 Units Subcutaneous qAM
8. Omeprazole 40 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
Patient ran out of the following medications and has not been
taking them recently.
11. Albuterol sulfate 90 mcg/actuation Inhalation q6h
SOB/Wheezing
12. Sertraline 100 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 12.5 mg PO daily
2. Lisinopril 20mg PO daily
3. Aspirin 81mg PO daily
4. Atorvastatin 10mg PO daily
5. Omeprazole 40mg PO daily
6. Ranitidine 300mg PO QPM
7. Sertraline 100mg PO daily
8. Tamsulosin 0.4mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
1. Syncope secondary to orthostasis and hypoglycemia
2. Insulin dependent diabetes mellitus
3. Likely frontotemporal dementia
4. Likely amyotrophic lateral sclerosis
.
Secondary Diagnoses:
1. Hypertension
2. Thrombocytopenia
3. Gastroesophageal reflux disease
4. Benign prostatic hyperplasia
5. Hyperlipidemia
Discharge Condition:
Stable. Alert and oriented to time (with multiple choice),
place, and person. Unable to ambulate independently.
Discharge Instructions:
You were admitted to the hospital after an episode of syncope at
home. Laboratory, imaging, and EKG studies showed that you did
not have a heart attack, bleeding or stroke in the brain,
infection of the lungs or urine, abnormal heart rhythm (while
you were under monitoring during hospitalization). You likely
had a transient drop in blood pressure in combination with low
blood sugar that made you feel dizzy after standing up and/or
coming out the restroom. While in the hospital, your blood
pressure going from lying to sitting and then standing was
normal. When changing positions, please take time and rest in
between positions for few minutes to allow your body to
accomodate the changes it is experiencing. Also, always receive
help from another family member when you need to ambulate and
change position for your safety.
.
As discussed above, another contributing factor to your fall may
have been a low blood sugar. It is recommended that you eat
your breakfast soon after getting your morning insulin shot to
prevent profound drop in your blood sugar.
.
Due to concerns about your coughing and choking when swallowing,
we asked the speech and swallow service evaluate you and
obtained a video oropharyngeal swallow study. This showed silent
aspirations to thin liquid and nectar thick consistency. Please
do not eat thin liquids and nectar thick foods to avoid an
aspiration event. Any food that is thicker in consistency than
thin liquids minimizes the risk of aspiration. Please crush
medications and mix with apple sauce; you can easily purchase a
motar and pestle from a local pharmacy or online. For example,
you can get a set for $5.49 on ___. If you cannot crush
a medication, you can put the pill into apple sauce and swallow.
.
You were found to have low platelet count in your blood. It
seems to have been low, but stable for a while. As you did not
show any obvious signs of bleeding during this hospitalization,
we just watched the platelet count throughout the
hospitalization and it has remained stable. Please follow up
with your primary care physician regarding this issue to find
out what is causing a low platelet count.
.
You also have diagnoses of hypertension, gastroesophageal reflux
disease, benign prostatic hyperplasia, and hyperlipidemia. You
are doing well in terms of managing these diseases. Please
continue to take your medications as you have been doing so.
.
Below are lists of your medications at the time of discharge and
followup appointments with your primary care physician and
specialists. Please bring the list of medications to all of
your doctor visits.
.
Followup Instructions:
___
|
19949061-DS-11 | 19,949,061 | 27,655,157 | DS | 11 | 2189-10-04 00:00:00 | 2189-10-06 22:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness and fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o non-verbal M w/ALS presenting w/increased fatigue and
weakness per wife. Patient lives at home with wife who provides
all of his care. Today she was lifting him from bed when he
"flopped" from her arms and she called an ambulance for
assistance. Wife notes some complaints of cough with eating and
R shoulder pain (for about two months) but otherwise denies
fevers, chills, chest pain, SOB, cough, abdominal pain, nausea,
vomiting, blood in stools, melena, dysuria, or hematuria. Pt
minimally interactive. Will follow simple commands in ___.
In the ED, initial vitals were 98.2 75 95/66 16 96%. Labs were
stable. UA showed no evidence of infection. CXR showed no
definite acute cardiopulmonary process given relatively low lung
volumes. Rt. shoulder Xray showed no fracture or dislocation.
Vitals prior to transfer were: 98.2 66 111/64 16 95% RA. He is
being admitted for progressive ALS and placement at long term
care facility vs home hospice.
Past Medical History:
Frontotemporal Dementia
Amyotrophic Lateral Sclerosis
Diabetes Mellitus: ___ HbA1c 10.1
Thrombocytopenia
Hypertension
Hyperlipidemia
Gastroesophageal Reflux Disease
Benign Prostatic Hyperplasia
Social History:
___
Family History:
Father had HTN and DM.
Mother passed away after delivery.
Children are all healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.5, 107/67, 65, 20, 96% RA
GEN Non-verbal. Somnolent but rousable, minimally responsive.
HEENT NCAT MMM EOMI sclera anicteric, OP clear. Intermittent
wet-sounding cough, but non-productive.
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft NT ND normoactive bowel sounds, no hsm
EXT WWP 2+ pulses palpable bilaterally, scarring on shins
bilaterally.
NEURO CNs2-12 intact, motor function grossly normal. Rt shoulder
range of motion intact.
SKIN no ulcers or lesions
LABS: reviewed, see below
DISCHARGE PHYSICAL EXAM
VSS
physical exam unchanged
Pertinent Results:
ADMISSION LABS
___ 07:00PM BLOOD WBC-5.9 RBC-4.43* Hgb-13.5* Hct-39.3*
MCV-89 MCH-30.5 MCHC-34.4 RDW-12.4 Plt ___
___ 07:00PM BLOOD Neuts-69 Bands-0 Lymphs-17* Monos-12*
Eos-2 Baso-0 ___ Myelos-0
___ 07:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:00PM BLOOD Plt Smr-LOW Plt ___
___ 07:00PM BLOOD Glucose-74 UreaN-23* Creat-0.9 Na-136
K-4.4 Cl-97 HCO3-31 AnGap-12
___ 07:00PM BLOOD ALT-17 AST-30 AlkPhos-53 TotBili-0.4
___ 07:00PM BLOOD Albumin-4.3
___ 01:00PM BLOOD %HbA1c-10.1* eAG-243*
___ 07:13PM BLOOD Glucose-71 K-3.8
DISCHARGE LABS
___ 06:00AM BLOOD WBC-5.7 RBC-4.47* Hgb-13.5* Hct-39.9*
MCV-89 MCH-30.3 MCHC-33.9 RDW-12.5 Plt ___
___ 06:00AM BLOOD Glucose-93 UreaN-20 Creat-1.0 Na-140
K-3.5 Cl-98 HCO3-35* AnGap-11
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Calcium-10.1 Phos-4.0 Mg-2.0
URINE
___ 09:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:30PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
PERTINENT STUDIES
THREE VIEWS OF THE RIGHT SHOULDER ___: There is no
fracture or dislocation. There is moderate sclerosis of the
glenohumeral joint. Included views of the right upper chest are
clear. No rib fractures are detected. IMPRESSION: No fracture
or dislocation.
CXR ___
AP and lateral views of the chest. The lungs are clear given
low lung volumes with secondary crowding of the bronchovascular
markings. There is no consolidation or effusion.
Cardiomediastinal silhouette is stable as are the osseous and
soft tissue structures.
IMPRESSION:
No definite acute cardiopulmonary process given relatively low
lung volumes.
Brief Hospital Course:
Mr. ___ is a ___ y/o male with advanced ALS, frontotemproal
dementia, poorly controlled DM, HTN, presenting with increasing
care requirements at home, cough and right shoulder pain.
ACTIVE ISSUES
# Frontotemporal dementia / ALS: Profound, non-verbal,
progressive. Pt's current presentation is unchanged from his
based line per discussion with pt's wife and son. There was a
concern of right arm pain from the family. A shoulder/arm X-ray
was performed, which did not reveal fractures.
# GOAL OF CARE DISCUSSION: When last seen by neuro, family
discussion was held regarding patient's increasing needs and
possible transition to care in a SNF. At the time, patient's
family were reluctant to pursue SNF placement, but care needs
have increased even more. Also, during last hospital stay,
patient underwent speech and swallow eval, and was found to be
aspirating thin fluids and nectar consistency. After discussion
with patient and his family, they agreed to allow him to
continue a diet with safety modifications understanding the
risks of aspiration. Recommendations are to pre-thicken all
liquids and foods prior to eating and to crush medications and
mix in apple cause or puree. Feeding tube was broached, but
family declined at the time. We contacted his cognitive
neurologist Dr. ___ and PCP ___, to discuss
their views on his longterm prognosis and they had recommended
to the family on multiple occasions that he be placed in a
nursing facility. Long term care goals were discussed with
ex-wife and son ___ ( the HCP ___ but they would
like to keep caring for him at home at this time.
During this admission, a family meeting was held with pt's wife,
son, attending (___) and RN. A concensus decision by
the family was made that pt should be DNR/DNI.
CHORNIC ISSUES
# Depression: Sertraline was continued
# Insulin dependent diabetes mellitus: ___ HbA1c 10.1.
Poorly controlled diabetes. Continued NPH and monitor on humulin
sliding scale.
# Thrombocytopenia: Chronic. Baseline in 120s, 128 on admission.
# Hypertension: Continued atenolol, HCTZ, lisinopril
# BPH: Continued tamsulosin.
TRANSITIONAL ISUSE
# CODE STATUS: DNR/DNI
# PENDING STUDIES: blood cultures (will follow up)
# MEDICATION CHANGES: none
# FOLLOWUP PLAN:
- PCP and neurology
- We recommended ___ Lift at home. Pt's son was instructed
to discuss with ALS outreach coordinator (___) for that.
- Family confirmed that pt will STOP day program and resume
home ___, ___ services.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from webOMR.
1. Acetaminophen 325-650 mg PO PRN pain or fever
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
Hold for SBP<90, HR<50
4. Atorvastatin 10 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Ranitidine 300 mg PO QPM
7. Sertraline 100 mg PO DAILY
8. Tamsulosin 0.4 mg PO HS
Hold for SBP<90
9. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL DAILY
10. NPH 56 Units Breakfast
Insulin SC Sliding Scale using Humulin R Insulin
11. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h
SOB/Wheezing
12. Glycopyrrolate 1 mg PO Q4H:PRN secretions
Discharge Medications:
1. Acetaminophen 325-650 mg PO PRN pain or fever
2. Aspirin 81 mg PO DAILY
3. Atenolol 25 mg PO DAILY
Hold for SBP<90, HR<50
4. Atorvastatin 10 mg PO DAILY
5. Glycopyrrolate 1 mg PO Q4H:PRN secretions
6. Omeprazole 40 mg PO DAILY
7. NPH 56 Units Breakfast
Insulin SC Sliding Scale using Humulin R Insulin
8. Ranitidine 300 mg PO QPM
9. Sertraline 100 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
Hold for SBP<90
11. lisinopril-hydrochlorothiazide *NF* ___ mg ORAL DAILY
12. albuterol sulfate *NF* 90 mcg/actuation Inhalation q6h
SOB/Wheezing
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
ALS
Secondary Diagnoses:
Hypertension
Diabetes
Cough
Depression
BPH
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Nonverbal at baseline.
Mental Status: Awake.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the ___
for weakness and fatigue. Our Neurology colleagues evaluated you
and felt this was due to progression of your ALS. We have
scheduled follow-up appointments with your neurologist and
primary care doctor. We discussed the long term goals of your
care with your family and the palliative care team. We recommend
that you discuss with ___ and the visiting physical therapist
about obtaining a ___ lift to assist transition in and out of
bed.
You should continue taking all of your medications as directed.
The following appointments were made (see below).
Followup Instructions:
___
|
19949164-DS-9 | 19,949,164 | 25,420,009 | DS | 9 | 2136-12-14 00:00:00 | 2136-12-14 22:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath with exertion
Major Surgical or Invasive Procedure:
___: Therapeutic thoracentesis (left)
History of Present Illness:
___ with PMHx of ___'s macroglobulinemia/Lymphoma (on
monthly maintenance chemotherapy), HTN, T2DM who presented to
___ with new onset SOB and DOE for several weeks.
Per ___ documentation, patient presented reporting
increased pedal edema and dyspnea for 1 week, without chest
pain. Upon arrival O2 sat was 76% on RA, which improved to 95%
on 3L NC. CXR demonstrated left pleural effusion and pulmonary
congestion concerning for CHF. CTA did not show PE. BNP was
1495, Trp <0.01, Cr 1, K 4, LFTs wnl. She was given 60mg IV
Lasix with improvement in symptoms, 800cc urine out. She was
transferred to ___ for further care.
In the ED initial vitals were: 97, 81, 109/63, 20, 96% Nasal
Cannula
EKG: Sinus, RBBB (new from ___
Exam: No ED exam documented
Labs/studies notable for:
- CBC: 5.1/7.2/___.2/185
- Chem 7: K 4, Cr 0.9
- Trp <0.01
- Lactate 0.8
Patient was given: Nothing in ED
Vitals on transfer: 97.6, 81, 101/51, 15, 99% RA
On the floor, patient reports that she first noticed the ankle
swelling about 1 week ago. No chest pain at the time. No fevers,
chills. No new medications. She then noticed over the past
several days increasing DOE and SOB. She uses a walker at
baseline and does not have much mobility but even little
distances walking were problematic. She recently saw her
oncologist Dr. ___, who now works in ___, for her
___'s macroglobulinemia. She reports that her cancer is
"doing fine," and that she had recent lab work on ___ which was
stable. She received 1x month injections at home of her
maintenance chemotherapy Velcade, last on ___. Her daughter,
who is her HCP, administers these.
Currently, the patient reports feeling tired. Denies SOB at
rest, chest pain or other symptoms.
Past Medical History:
___'s macroglobulinemia
Type II diabetes mellitus
Hypertension
Anxiety
B12 deficiency
s/p cholecystectomy ___
Social History:
___
Family History:
Father died of pancreatic cancer at age ___. Mother died of a
stroke in her ___. Brother with hemachromatosis. Brother with
anxiety. She has five children who are generally in good health.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===================================
VS: 97.5, 103/61, 79 18 100 4L
Weight: 80.7kg
GENERAL: Tired appearing. NAD, speaking in short sentences,
winded
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
L>R proptosis, dry mucus membranes
NECK: Supple. JVP of 12cm
CARDIAC: Loud crescendo murmurs USB, RRR.
LUNGS: Poor effort, diffuse crackles, decreased breath sounds at
left base compared with right.
ABDOMEN: Soft, non-tender, non-distended. +BS, No palpable
splenomegaly.
EXTREMITIES: WWP, 1+ pitting pedal edema
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
===================================
Vitals: T 98.9 BPs 107-123/50-60s HR 80-90s RR 18 SaO2 94-95% 2L
NC
Weight: 75.2kg <-- 76.8kg
I/O total: -17.4
GENERAL: NAD, having a difficult time hearing, nasal cannula in
place, very sleepy likely due to restarting home BZD
HEENT: Pale, left eye proptosis, Sclera anicteric. PERRL. EOMI.
Moist mucus membranes
NECK: Supple. No JVD
CARDIAC: RRR. Loud crescendo murmurs USB, mid-peaking, S2
audible.
LUNGS: Improved air movement bilaterally but still decreased
breath sounds, no crackles wheezes or rhonchi
ABDOMEN: Soft, non-tender, non-distended. +BS, No palpable
splenomegaly.
EXTREMITIES: WWP, mild dependent pedal edema
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: CN II-XII in tact. AOx4
Pertinent Results:
ADMISSION/EARLY LABS:
=======================
___ 10:35PM BLOOD WBC-5.1 RBC-2.63* Hgb-7.2* Hct-26.2*
MCV-100*# MCH-27.4 MCHC-27.5*# RDW-21.7* RDWSD-77.2* Plt ___
___ 07:10AM BLOOD Neuts-60 Bands-0 ___ Monos-17*
Eos-1 Baso-0 ___ Metas-1* Myelos-0 NRBC-3* AbsNeut-2.64
AbsLymp-0.92* AbsMono-0.75 AbsEos-0.04 AbsBaso-0.00*
___ 10:35PM BLOOD ___ PTT-33.2 ___
___ 01:16PM BLOOD Ret Aut-5.0* Abs Ret-0.11*
___ 07:40PM BLOOD SerVisc-2.5*
___ Glucose-101* UreaN-19 Creat-0.9 Na-145 K-4.0 Cl-100
HCO3-34* AnGap-11
___ CK-MB-2 proBNP-1625*
___ Calcium-9.9 Phos-3.7 Mg-2.1
___ Albumin-2.7* Calcium-9.2 Phos-4.2 Mg-2.0 Iron-33
___ calTIBC-267 Ferritn-128 TRF-205
___ VitB12-861 Hapto-176
___ TSH-7.7*
___ Free T4-0.9*
___ PEP-ABNORMAL B IgG-476* IgA-9* IgM-4549*
___ U-PEP Albumin
___ Lactate-0.8
___ Hypochr-1+* Anisocy-OCCASIONAL Poiklo-OCCASIONAL
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL Tear
Dr-OCCASIONAL
___ freeCa-1.25
___ LD(LDH)-358*
___ WBC-4.8 RBC-2.53* Hgb-7.1* Hct-24.6* MCV-97 MCH-28.1
MCHC-28.9* RDW-20.3* RDWSD-72.5* Plt ___
DISCHARGE LABS:
=======================
___ Glucose-67* UreaN-26* Creat-1.0 Na-140 K-4.7 Cl-91*
HCO3-38* AnGap-11
___ Glucose-67* UreaN-26* Creat-1.0 Na-140 K-4.7 Cl-91*
HCO3-38* AnGap-11
___ Calcium-10.0 Phos-4.3 Mg-2.1
MICROBIOLOGY/CYTOLOGY:
=======================
___: Blood Culture - no growth
___: Urine culture: GRAM POSITIVE BACTERIA.
>100,000 CFU/mL OF TWO COLONIAL MORPHOLOGIES.
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___: Pleural fluid cultures:
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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary): PENDING
___: Pleural fluid studies (#/ul)
TNC: 1040* RBC: ___ POLYS 3%* BANDS 0% LYMPHS 45%* MONOS 0%
MESO 1%* MACRO: 32%* OTHER 19*%
TotProt 3.7 Glucose 210 LDH 62 Albumin 1.8 Cholest 33 Triglyc 33
Misc 14
CYTOLOGY: NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, macrophages and rare degenerated cells and
multilobated cell likely megakaryocyte.
SERUM STUDIES: TOTAL PROTEIN 7.5 GLUCOSE 191 LDH 107
IMAGING/STUDIES:
=======================
___ CXR:
There are bilateral effusions. Small on the right side and
moderate to large on the left side. There is also prominent
pulmonary edema. There are no pneumothoraces
___ TTE:
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. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. LVEF >
70%. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. There are three aortic valve leaflets. The aortic valve
leaflets are moderately thickened. There is moderate to severe
aortic valve stenosis by indexed valve area (valve area =1.0cm2
using peak velocity, 1.1cm2 using VTI in continuity equation and
0.55cm2/m2 using 1.05cm2 as valve area). No aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. No mitral regurgitation is seen.
[Due to acoustic shadowing, the severity of mitral regurgitation
may be significantly UNDERestimated.] The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
normal cavity size and dynamic systolic function. Moderate to
severe aortic stenosis (severe by indexed valve area). Left
pleural effusion.
___ CXR (obtained following diuresis):
There has been interval improvement in the bilateral pleural
effusions, most prominently on the right, there is persistent
bibasilar atelectasis and moderate pleural effusion on the left
lower lung still remaining. Pulmonary edema is unchanged from
previous. Cardiomediastinal silhouette is stable from previous.
No new focal consolidations.
IMPRESSION:
Interval improvement in the bilateral pleural effusions.
Moderate pleural
effusion remaining on the left. Persistent bibasilar
atelectasis and
pulmonary edema.
___ CXR (obtained following left lung thoracentesis)
IMPRESSION:
In comparison with the study of ___, there is been a left
thoracentesis with removal of a relatively small amount of
pleural fluid, but no evidence of pneumothorax. Curvilinear
line overlying the upper portion of the right hemithorax and
mimicking a pneumothorax is seen to represent merely a skin
fold. Otherwise, there is little overall change, and the study
is limited by a substantial obliquity of the patient.
___ CXR - REPEAT
IMPRESSION:
Compared to the examination from 3 hours prior, there has been
resolution of the curvilinear line overlying the right
hemithorax, likely having represented a skin fold. No
pneumothorax is seen. Moderate left-greater-than-right pleural
effusions appear slightly increased, though this may be due to
lower lung volumes. There is also adjacent bibasilar
compressive atelectasis. No other significant interval change
identified.
Brief Hospital Course:
SUMMARY (___)
========================
___ lady with PMHx of Waldenstrom's macroglobulinemia/lymphoma
(on bimonthly maintenance chemotherapy), HTN, T2DM who presented
to ___ with new onset SOB and DOE for several weeks.
Per ___ documentation, patient presented reporting
increased pedal edema and dyspnea for 1 week, without chest
pain. Upon arrival O2 sat was 76% on RA, which improved to 95%
on 3L NC. CXR demonstrated left pleural effusion and pulmonary
congestion concerning for CHF. CTA did not show PE. BNP was
1495, Trp <0.01, Cr 1, K 4, LFTs wnl. She was given 60mg IV
Lasix with improvement in symptoms, 800cc urine out. She was
transferred to ___ for further care. Admitted ___.
ACTIVE ISSUES:
========================
#Acute diastolic heart failure:
Admission proBNP 1625, troponins negative. Echo with no regional
wall motion abnormalities, hyperdynamic LV function, LVEF > 70%
and moderate-severe aortic stenosis. Etiology unclear. Suspect
mixed process: hypothyroidism, anemia, moderate-severe AS,
hypertension, possible underlying CAD, malignancy may all be
contributing. Underwent diuresis with IV Lasix 60mg BID and
transitioned to PO Torsemide. She also had a thoracentesis per
below. Of note, despite diuresis, repeat CXR did not show marked
improvement of pulmonary edema or bilateral pleural effusions.
The patient continues to require 2L O2 NC to maintain O2
saturations > 90%. On the day of discharge the patient was
euvolemic.
- PRELOAD: Torsemide 20 mg daily
- AFTERLOAD: continue home amlodipine 5mg once daily
#Moderate Aortic Stenosis: Exam with mid III/VI systolic murmur
and audible S2. Echocardiogram showed moderate-severe aortic
stenosis. Patient was diuresed cautiously as aortic stenosis is
a pre-load dependent condition.
#___ Macroglobulinemia/Lymphoma: Diagnosed in ___ with
signs/symptoms of hyperviscocity. CT-A obtained at that time was
notable for extensive mediastinal, retroperitoneal and abdominal
lymphadenopathy and splenomegaly, consistent with lymphoma. She
is followed outpatient at ___ in
___ by Dr. ___. Trialed on Rituximab as an
outpatient but did not tolerate the side effects. Recently has
been taking Bortezomib every month. On admission, the patient's
labs were significant for a hemoglobin of 7.2. On day 2 of
admission, her H/H was 6.3/22.7 for which she required 1unit of
pRBCs and responded accordingly. Her platelets were also mildly
low at 144. Per discussion with her oncologist, it appears that
the Bortezomib was ineffective. Hematology/Oncology was
consulted during her admission and did not recommend inpatient
chemotherapy. Significant labs include IgM 4549 and a serum
viscosity of 2.5. Further discussions with her outpatient
oncologist regarding therapeutic options will occur once she has
regained functional capacity through rehabilitation and medical
management.
#Anemia: Anemia lower than baseline, requiring 1 unit of pRBCs.
Thought to be secondary to her Waldenstrom's Macroglobulinemia.
Iron studies were normal and there were no signs suggestive of
hemolysis. The anemia may have contributed to her heart failure
exacerbation.
#Bilateral pleural effusions: Moderate left pleural effusions,
mild right pleural effusion. Noted to be loculated. Minor
decrease in severity following several days of diuresis.
Underwent diagnostic and therapeutic thoracentesis of roughly
600cc of fluid. Results were inconclusive in determining
exudative vs. transudative effusion. Pleural fluid was
significant for elevated RBC > 18,000/uL and WBC > 1000/uL with
45% lymphocytes. Cultures (bacterial, fungal, AFB) and gram
stain were negative for infection and no malignant cells were
seen on cytology. Despite removal of fluid, the patient
continued to require 2L O2 NC; post-thoracentesis CXR did not
show marked improvement following the procedure.
#Hypothyroidism: TSH on admission found to be elevated at 7.7,
low free T4 0.9. Given unclear precipitant of acute heart
failure, decided to treat with low dose levothyroxine 25mcg
daily given that she is elderly and has heart failure.
CHRONIC ISSUES:
========================
#Anxiety/Insomnia: The patient takes 10mg Valium QHS at home.
Held during admission given long half life and risks in elderly
population. Patient had some persistent anxiety and insomnia.
Trialed on Seroquel 12.5 QHS which was ineffective. Upon further
discussion with the family and patient regarding the risks and
benefits, the patient was given one dose of 10mg Valium the
night prior to discharge. The family and patient were warned of
the risks with benzodiazepines in the elderly, but still felt
they wanted her to take it.
#Diabetes Mellitus II: Home glyburide 5mg held. Maintained on
sliding scale and diabetic diet.
#Hypertension: maintained on home amlodipine 5mg to effect.
TRANSITIONAL ISSUES:
========================
MEDICATIONS ADDED:
Torsemide 20mg by mouth once daily
Levothyroxine 25mcg by mouth once daily
DISCHARGE WEIGHT: 75.2 kg
DISCHARGE CREATININE: 1.0
DISCHARGE CBC: WBC 4.8 Hb 7.1, Hct 24.6 Plt 124
DISCHARGE CODE STATUS: FULL
Cardiology:
[ ] Please weigh the patient daily. If her weight increases by
more than 3 pounds in 2 days, or more than 5 pounds over 1 week,
then please increase her Torsemide dose to 40mg daily until she
is back at her discharge weight of 75.2kg. Once she is back at
her dry weight, can resume Torsemide 20mg daily.
[ ] Consider AVR if patient amenable/within goals of care
Thyroid:
[ ] Please check TSH as an outpatient sometime between ___ and
___ to assess if on appropriate dose of Levothyroxine
Hypoxia:
[ ] Please continue supplemental O2 for goal O2 sat > 93%
Insomnia:
[ ] Would encourage not to use benzodiazepines in elderly
patient. Family and patient would like her to continue Valium,
but would continue to encourage alternatives such as Seroquel,
Melatonin.
Mood:
[ ] Patient's daughter worried that the patient is depressed and
would like her on an anti-depressant, patient does not feel
depressed and does not want to take anti-depressant. Daughter
requested we put in discharge paperwork that this discussion was
had so that future providers know there has been talk of an
anti-depressant.
Oncology:
[ ] Potential therapies for treatment or symptom control to be
discusssed with outpatient oncologist once the patient is
cleared from rehabilitation and functional status has improved
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 5 mg PO DAILY
2. GlyBURIDE 5 mg PO BID
3. Vitamin D 800 UNIT PO DAILY
4. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) ___ mg-mcg oral
DAILY
5. Bortezomib Dose is Unknown SC TWICE MONTHLY
Discharge Medications:
1. Levothyroxine Sodium 25 mcg PO DAILY
2. Torsemide 20 mg PO DAILY
3. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous
gluconat;<br>multivitamin-iron-folic acid) ___ mg oral QHS
Please do not take within 2 hours of the Levothyroxine
4. amLODIPine 5 mg PO DAILY
5. GlyBURIDE 5 mg PO BID
6. Vitamin D 800 UNIT PO DAILY
7. HELD- Bortezomib Dose is Unknown SC TWICE MONTHLY This
medication was held. Do not restart Bortezomib until speaking
with your oncologist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
==============
Acute diastolic heart failure
Moderate Aortic Stenosis
___ Macroglobulinemia/Lymphoma
SECONDARY:
==============
Anemia
Bilateral pleural effusions
Hypothyroidism
Diabetes Mellitus II
Hypertension
Anxiety/Insomnia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because you were short of breath and were found to have fluid in
your lungs. We obtained an ultrasound of your heart which showed
that your aortic valve is tight, causing fluid to back up into
your lungs. You were given a medication through an IV called
Lasix to help remove the fluid from your body. You also
underwent a procedure to drain some of the fluid in your lungs.
The fluid was not infected and did not show signs of cancer.
Additionally, you were very tired when you first arrived, and
your red blood cells were low. Therefore, we gave you 1 unit of
blood which helped increased your red blood cell count.
Lastly, you were found to have a urinary tract infection. We
treated you with an antibiotic for 5 days.
When you leave the hospital, you will still need to use the
oxygen because there is still some fluid in your lungs. We have
started you on a medication called Torsemide, which will need to
take once a day to help keep fluid off of your body. This
medication is a diuretic. Please do not drink more than 2 liters
a day and adhere to a low sodium (2grams/day) diet. It is also
important that you weight yourself every morning. If you notice
your weight increasing by 3 or more pounds in 2 days, or 5 or
more pounds in 1 week, please call your doctor, as this might
mean you need an extra dose of a diuretic. Weigh yourself every
morning, call MD if weight goes up more than 3 lbs.
Because you are going to a rehabilitation center, you will not
need to follow up with your primary care doctor immediately and
will instead be seen by the doctor at the facility. You have an
appointment on ___ at 10:30AM at the heart failure clinic
___ CLINIC) on the ___ floor of the ___ building here at
___. After that, you will have a new cardiologist
closer to home at ___ and should see them 4 weeks after
discharge. Finally, you have an appointment with your
oncologist's office on ___.
It was a pleasure taking part in your care. We wish you all the
best with your health.
Sincerely,
The medical team at ___
Followup Instructions:
___
|
19949258-DS-20 | 19,949,258 | 29,119,619 | DS | 20 | 2172-02-03 00:00:00 | 2172-02-04 07:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
atenolol / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Fall, pelvic fractures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with history of atrial
fibrillation on rivaroxban, hypertension, small-vessel strokes,
transferred from ___ for pelvic fractures after an unwitnessed
fall two days ago. History was obtained directly from the
patient, who recalls the fall.
The patient tells me she stood up from sitting in a chair,
immediately felt dizzy, and then fell to the ground, striking
her
right hip and elbow. She does not believe she lost consciousness
and did not strike her head. She denies any chest pain or
pressure, dyspnea, or diaphoresis. She had been feeling well
previously and denies any fevers, chills, cough, N/V/D/abdominal
pain, dysuria, or rashes. After falling, she complained of
severe
left hip pain. X-rays were ordered which showed superior and
inferior pubic ramus fractures, and she was transferred to ___
ED for evaluation.
In the ED, the patient was afebrile and HDS. Workup was notable
for:
- Leukocytosis, dirty UA
- CT head with e/o old infarcts, no acute process
- CT neck with degenerative changes but no acute injury
- Hip XR confirmed keft superior and inferior pubic rami
fractures.
- L Knee XR worrisome for patellar tendon rupture
- CXR and elbow XR unremarkable
Ortho was consulted and recommended CT A/P to better evaluate
fractures (not done in ED), non-operative management for now.
Patient received: IV morphine 2mg x2, IV ceftriaxone 1g
On arrival to the floor, patient reports her pain is now under
control. No ongoing dizziness or lightheadedness. No chest
pain/pressure or dyspnea.
Past Medical History:
- Atrial fibrillation on rivaroxaban
- Small-vessel strokes (possibly a new diagnosis - not
documented
in outpatient records)
- Hypertension
- Rheumatoid arthritis
- Anxiety
- Unstageable sacral pressure injury
- Lumbar compression fracture
- Diarrhea
- Seborrheic Dermatitis
- h/o endometrial cancer
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: Reviewed, afebrile and stable
GENERAL: Frail elderly woman in NAD.
HEENT: NC/AT. No icterus or injection. Poor dentition. MM dry.
CV: Irregularly irregular, normal rate, no audible murmurs.
RESP: Normal work of breathing, CTAB.
GI: Soft, NDNT.
GU: No suprapubic tenderness. Unable to assess for CVA
tenderness
due to positioning.
MSK: Hematomas on left hip and left elbow. Bilateral hand
deformities with ulnar deviation. Sacrum with erythema
consistent
with pressure injury, no fluctuance or purulence.
NEURO:
MS: Alert, oriented to person, place, month (not year),
president. +Inattention (could not ___ backwards).
CN: Pupils pinpoint, EOMI, no nystagmus. CN intact (could not
assess V).
Strength: assessment limited due to fractures and injuries;
bilateral deltoids, biceps, triceps, and handgrip symmetric and
at least ___.
Coordination & gait: unable to assess
DISCHARGE PHYSICAL EXAM:
VS: 98.4 137 / 81 84 16 96 Ra
GENERAL: Frail elderly woman in NAD.
HEENT: NC/AT. No icterus or injection. Poor dentition. MM dry.
CV: Irregularly irregular, normal rate, no audible murmurs.
RESP: Normal work of breathing, CTAB.
ABD: Soft, non-tender, non-distended.
GU: No suprapubic tenderness. No ecchymoses on back.
MSK: Hematomas on left hip and left elbow. Bilateral hand
deformities with ulnar deviation, R>L. Sacrum with erythema
consistent with pressure injury, no fluctuance or purulence.
NEURO:
MS: Alert, oriented to person, place, month (not year),
president. +Inattention (could not ___ backwards).
CN: Pupils pinpoint, EOMI, no nystagmus. CN intact (could not
assess V).
Strength: assessment limited due to fractures and injuries;
bilateral deltoids, biceps, triceps, and handgrip symmetric and
at least ___.
Coordination & gait: unable to assess
Pertinent Results:
===============
ADMISSION LABS
===============
___ 06:33PM BLOOD WBC-18.1* RBC-2.74* Hgb-9.1* Hct-28.0*
MCV-102* MCH-33.2* MCHC-32.5 RDW-14.7 RDWSD-54.6* Plt ___
___ 06:33PM BLOOD Neuts-76.9* Lymphs-11.4* Monos-10.2
Eos-0.5* Baso-0.2 Im ___ AbsNeut-13.89* AbsLymp-2.05
AbsMono-1.84* AbsEos-0.09 AbsBaso-0.04
___ 06:33PM BLOOD Plt ___
___ 06:33PM BLOOD Glucose-108* UreaN-26* Creat-1.0 Na-138
K-5.5* Cl-102 HCO3-23 AnGap-13
___ 07:50PM BLOOD K-4.5
==============
DISCHARGE LABS
==============
___ 01:12PM BLOOD WBC-16.4* RBC-2.31* Hgb-7.7* Hct-23.9*
MCV-104* MCH-33.3* MCHC-32.2 RDW-15.0 RDWSD-56.2* Plt ___
___ 01:12PM BLOOD Plt ___
___ 01:12PM BLOOD Glucose-127* UreaN-16 Creat-0.5 Na-137
K-4.5 Cl-102 HCO3-25 AnGap-10
___ 01:12PM BLOOD Calcium-8.7 Phos-2.6* Mg-2.0
==================
IMAGING/PROCEDURES
==================
___: CT C-spine
1. No acute fracture or prevertebral soft tissue swelling.
2. Moderate to severe degenerative changes including fusion of
the C1 and C2
vertebral bodies and facets bilaterally and marked degenerative
changes of the
atlanto-occipital joints bilaterally.
3. Mild multilevel anterolisthesis is likely degenerative in
etiology.
___ CT head w/o contrast
1. No acute intracranial hemorrhage or mass effect.
2. Remote right basal ganglia infarct. Chronic small right
thalamic lacunar
infarct.
3. Chronic microvascular infarction and moderate global atrophy.
___ Hip x-ray
IMPRESSION:
Left superior and inferior pubic rami fractures.
___ Knee x-ray
Marked patella ___ worrisome for patellar tendon rupture. No
acute fracture. Status post total knee arthroplasty without
definite hardware complication.
___ CXR
No acute cardiopulmonary abnormality. No displaced fractures
identified, but please note that the sensitivity of chest
radiographs for the detection of a rib fracture is limited.
___ CT pelvis ortho w/o c
1. Comminuted fractures of the left superior and inferior pubic
rami. Mildly displaced left sacral fracture along the left mid
sacroiliac joint.
2. Adjacent hematomas are seen just superior to the left pubic
symphysis and lateral to the left greater trochanter.
___ CT A/P w/o contrast
Stable small left pelvic and subcutaneous proximal thigh
hematomas. No new intra-abdominal or worsening pelvic hematoma
to account for hemoglobin drop.
Redemonstration of left-sided pelvic fractures. Age
indeterminate compression deformities of L1 and L3. Clinical
correlation is recommended.
Brief Hospital Course:
P - Patient summary statement for admission
====================================
___ y/o female nursing home resident with h/o AF on apixaban and
small-vessel strokes, admitted with pelvic fractures, hematomas,
and patellar injury after unwitnessed fall, course complicated
by UTI.
A - Acute medical/surgical issues addressed
====================================
# Unwitnessed fall:
History strongly suggests pre-syncope ___ orthostasis - patient
reports feeling dizzy immediately after standing from chair.
Orthostatic BPs while working with ___ on ___, improved with
IVF. Repeat orthostatic VS were negative after IV fluids. On
several meds that could be contributing (lisinopril, amlodipine,
citalopram, tramadol, trazodone). Tramadol, trazodone,
lisinopril, and amlodipine held this admission. Monitored on
tele given known persistent afib, no RVR or other arrhythmias
throughout this admission. No murmurs to suggest valvular
disease, TTE deferred at this time. Pt also found to have UTI,
as below, which could have contributed to pre-syncope. CT head
with chronic strokes but no acute process. Tramadol, trazodone,
lisinopril, and amlodipine held on discharge, could consider
restarting antihypertensives if BP persistently elevated at
rehab.
# Pelvic fractures:
Pt presented after unwitnessed fall with CT demonstrating
comminuted fractures of the left superior and inferior pubic
rami and mildly displaced left sacral fracture along the left
mid sacroiliac joint. Injuries are closed and pt is
neurovascularly intact. Conservative management per Ortho.
Weight bearing as tolerated, rolling walker for support, LLE in
knee immobilizer for left patella ___, as below. Pain control
with standing acetaminophen, oxycodone 2.5-5mg q4h prn. Vit D
wnl this admission. Continued home calcium carbonate. ___ and OT
recommended rehab to continue to address impairments and
maximize functional
independence.
# L patella ___:
Patient sustained trauma to left knee during unwitnessed fall,
with resulting pain and ecchymoses. Knee XR demonstrated L
patella ___ concerning for patellar tendon rupture. Managed
non-operatively per Ortho. Weight bearing as tolerated, rolling
walker for support, LLE in knee immobilizer at all times.
Patient will follow-up with orthopedics for further management.
___ recommended rehab as above.
# Hematomas:
# Acute blood loss anemia:
Pt presented after unwitnessed fall with bilateral pelvic
fractures and adjacent hematomas superior to the left pubic
symphysis and lateral to the left greater trochanter on CT. No
baseline CBC available. No tachycardia and HDS, but Hgb drop the
day after admission that was most likely a delayed reflection of
hematoma. No bloody stools or abdominal pain to suggest GIB.
Abdominal exam reassuringly benign. ___ CT abd/pelvis
demonstrated stable small left pelvic and subcutaneous proximal
thigh hematomas, no new intra-abdominal or worsening pelvic
hematoma. Hemolysis labs negative. Iron studies consistent with
anemia of chronic disease. H/H stabilized, anticoagulation with
home rivaroxaban at a reduced dose given age and size (15
instead of 20mg QD) was restarted 1 day prior to discharge and
tolerated well. Hgb at time of discharge is 7.7 (stable around
7.3-7.7 range for 3 days).
# Permanent atrial fibrillation:
At home is on anticoagulation with rivaroxaban 20mg QD.
Monitored on tele. HR ___ without rate control, no rapid
rates during this admission, less likely that RVR contributed to
her unwitnessed fall prior to presentation. CHADS2Vasc=6, CHADS2
only 4. History notable for prior strokes. Anticoagulation
briefly held in setting of concern for ongoing bleed, as above.
Rivaroxaban restarted prior to discharge at lower dose given age
and weight.
# UTI:
Urine appeared turbid with gross pyuria and bacteriuria on UA,
no clear symptoms but pt endorsed mild suprapubic pain and she
was treated with ceftriaxone 1g q24h x3 days (___) given
frailty and possible orthopedic hardware implantation. Pt
remained hemodynamically stable and afebrile, no evidence for
pyelo or sepsis.
C - Chronic issues pertinent to admission
====================================
# Chronic strokes:
CT head shows remote right basal ganglia infarct, chronic small
right thalamic lacunar infarct, and chronic microvascular
infarctions but no new pathology. No clear focal deficits,
though exam limited by injuries from fall. This may be a new
diagnosis - not documented in outpatient APG notes, though she
is on high-dose aspirin and statin. Decreased home ASA from 325
to 81mg QD to reduce risk of bleeding. Continued home
atorvastatin.
# Hypertension:
Held home lisinopril and amlodipine in setting of orthostasis,
as above. Please consider restarting if persistently
hypertensive.
# Unstageable sacral pressure injury:
Present on admission, documented in outpatient notes. Does not
appear infected. Wound care consulted and recommended Commercial
wound cleanser or normal saline to cleanse wounds. Pat the
tissue dry with dry gauze. Apply Duoderm wound gel to yellow
bed. Cover with Mepilex Sacral Border dressing. Change dressing
daily
# Hypothyroidism:
TSH 1.5 this admission. Continued home levothyroxine 88mcg daily
# Anxiety:
Continued home citalopram 10mg daily.
# Rheumatoid arthritis:
Patient has markedly deformed hands with ulnar deviation but
does not appear to take any medication for RA.
T - Transitional Issues
====================================
#DISCHARGE HGB: 7.7
[] F/u pelvic fractures and L patella ___ with Dr. ___ in
___ clinic in 3 weeks, pt given phone number to schedule
appointment. Patient will need to have follow-up appointment
made ___ days following discharge from hospital. Please
contact the orthopedics office at ___ on ___
to schedule this appointment.
[] Pain control: Will discharge on oxycodone for acute pain from
fractures. On tramadol prior to admission and would recommend
transitioning back to prior dose of tramadol once acute pain has
improved.
[] Rivaroxaban dose decreased from 20mg to 15mg daily due to
patient's age and weight (likely dose not need full dose).
[] Please get a repeat CBC in 2 days to make sure hgb stable. If
acutely dropping > ___, would be concerned for bleeding in
pelvis in area of prior hematoma.
[] Hypertension: Lisinopril and amlodipine held on discharge,
could consider restarting antihypertensives if BP persistently
elevated at rehab.
[] Unstageable sacral pressure injury: Commercial wound cleanser
or normal saline to cleanse wounds. Pat the tissue dry with dry
gauze. Apply Duoderm wound gel to yellow bed. Cover with Mepilex
Sacral Border dressing. Change dressing daily
[] Hx of stroke: Was on ASA 325mg at home, transitioned to 81mg
here as high dose is not associated with any benefit in stroke
prevention and increases bleeding risk.
[] Please keep on an aggressive bowel regimen while patient is
on oxycodone to prevent constipation.
# Contacts/HCP: ___ (son) ___
# Advance Care Planning: DNR/DNI, no non-invasive ventilation
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fleet Enema (Saline) ___AILY:PRN constipation -
third line
2. GuaiFENesin ___ mL PO Q4H:PRN cough
3. LOPERamide 2 mg PO QID:PRN diarrhea
4. Milk of Magnesia 30 mL PO Q3H:PRN Constipation - First Line
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Senna 8.6 mg PO QHS:PRN Constipation - First Line
7. Lisinopril 7.5 mg PO DAILY
8. Salonpas (methyl salicylate-menthol) ___ % topical QAM
9. TraMADol 50 mg PO BID
10. TraZODone 50 mg PO QHS
11. Rivaroxaban 20 mg PO DAILY
12. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
13. amLODIPine 5 mg PO DAILY
14. Aspirin 325 mg PO DAILY
15. Atorvastatin 40 mg PO QPM
16. Calcium Carbonate Suspension 1250 mg PO QHS
17. Citalopram 10 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Levothyroxine Sodium 88 mcg PO DAILY
20. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ capsule(s) by mouth every four hours
Disp #*10 Capsule Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. Aspirin 81 mg PO DAILY
5. Rivaroxaban 15 mg PO DINNER
6. Senna 17.2 mg PO HS
7. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild
8. Atorvastatin 40 mg PO QPM
9. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
10. Calcium Carbonate Suspension 1250 mg PO QHS
11. Citalopram 10 mg PO DAILY
12. Fleet Enema (Saline) ___AILY:PRN constipation -
third line
13. GuaiFENesin ___ mL PO Q4H:PRN cough
14. Levothyroxine Sodium 88 mcg PO DAILY
15. LOPERamide 2 mg PO QID:PRN diarrhea
16. Milk of Magnesia 30 mL PO Q3H:PRN Constipation - First Line
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Salonpas (methyl salicylate-menthol) ___ % topical QAM
19. HELD- amLODIPine 5 mg PO DAILY This medication was held. Do
not restart amLODIPine until you follow-up with your doctor
20. HELD- Lisinopril 7.5 mg PO DAILY This medication was held.
Do not restart Lisinopril until you follow-up with your doctor
21. HELD- TraMADol 50 mg PO BID This medication was held. Do
not restart TraMADol until you no longer have acute pain from
the fractures. After pain improved, switch back to tramadol from
oxycodone
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
#Pelvic fractures
#Left patellar tendon rupture
#Hematomas
#Anemia
#Unwitnessed fall
#Urinary tract infection
SECONDARY DIAGNOSES
==================
#Permanent atrial fibrillation
#Chronic strokes
#Hypertension
#Unstageable sacral pressure injury
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because you had a fall at home and hurt your
left hip. X-rays showed that you had hip fractures and you were
transferred to ___ for further care.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Imaging including X-rays and CT scans showed that you had
fractures at your left hip, a displaced left patella and likely
left patellar tendon rupture, and hematomas around your pelvic
fracture. You do not have fracture or dislocation of the left
elbow.
- You were given medications to reduce your pain.
- You were evaluated by the Orthopedic Surgery team who
recommended that you be managed non-operatively (no surgery
needed).
- Your heart rhythm was monitored on telemetry. You were in
atrial fibrillation throughout this admission but no other
arrhythmias occurred. This is your known heart rhythm and is not
new.
- Your blood counts were monitored with regular lab checks. You
have anemia (low red blood cell counts) likely from the bleeding
from your fall. Fortunately, your bleeding stopped and you were
restarted on your blood thinning medication successfully.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please continue to take all of your medications and follow-up
with your PCP and ___ surgery in appointments as listed
below.
- You should continue to wear your knee immobilizer brace at all
times. You can walk and move around as tolerated, with the help
of a rolling walker. When you see the Orthopedic surgeons in 3
weeks they will give you updated recommendations about caring
for your fractures.
- You should have your blood counts checked in 2 days to make
sure this is stable and not getting lower.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19949313-DS-14 | 19,949,313 | 25,652,319 | DS | 14 | 2178-03-09 00:00:00 | 2178-03-09 15:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
worst headache of life
Major Surgical or Invasive Procedure:
___ Diagnostic Cerebral Angiogram - Negative
___ - Diagnostic Angiogram - negative
History of Present Illness:
___ tx from OSH with SAH. She awoke this AM with nausea, then
sudden onset thunderclap headache s/p vomiting. She presented to
OSH, found to have SAH and transferred to ___ for neurosurgery
evaluation.
Past Medical History:
asthma, depression, hepatitis C, back pain with narcotic
agreement, osteoarthritis, SIADH, shingles, constipation
Social History:
___
Family History:
sibling with aneurysm
Physical Exam:
On Admission:
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2 mm
bilaterally (although difficult to asses due to +photophobia).
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch bilaterally.
Coordination: normal on finger-nose-finger
On Discharge:
alert, oriented x3
PERRL. EMOI. ___. TML.
SAR ___. SILT. No pronator drift
Steady gait
Right groin c/d/I without hematoma
Pertinent Results:
___ SECOND OPINOIN CT READ
1. CTA image interpretation is limited due to lack of 3D
reformatted images.
2. Acute bilateral subarachnoid and subdural hemorrhages as
described. Please note underlying mass is not excluded on the
basis examination. Recommend contrast brain MRI for further
evaluation, and follow-up imaging to resolution.
3. Grossly patent circle of ___ without definite evidence of
aneurysm
greater than 3 mm.
___ CTA
1. CTA image interpretation is limited due to lack of 3D
reformatted images.
2. Acute bilateral subarachnoid and subdural hemorrhages as
described. Please note underlying mass is not excluded on the
basis examination. Recommend contrast brain MRI for further
evaluation, and follow-up imaging to resolution.
3. Grossly patent circle of ___ without definite evidence of
aneurysm
greater than 3 mm.
___ MRI BRAIN
1. Study is moderately degraded by motion.
2. Interval decrease and redistribution of previously noted
parasagittal
bifrontal subarachnoid hemorrhage.
3. Grossly unchanged subcentimeter bifrontal parafalcine
subdural hematomas.
4. Within limits of study, no definite new hemorrhage.
5. Within limits of study, no definite infarct or enhancing
mass.
6. Please note underlying mass is not excluded on the basis
examination.
Recommend follow-up imaging to resolution.
Brief Hospital Course:
Ms. ___ is a pleasant ___ female who presented to
OSH after thunderclap worst headache of her life. Imaging
revealed diffuse SAH and she was transferred to ___ for
further neurosurgical evaluation.
#___: CTA on arrival showed grossly patent circle of ___
without definite evidence of aneurysm greater than 3 mm. A
diagnostic cerebral angiogram was performed on ___ that was
negative for aneurysmal source. Plan to repeat angio in 7 days
(___). The procedure was uncomplicated and the patient was
transferred to the Neuro ICU for closer monitoring. The patient
remained neurologically and hemodynamically stable. Her blood
pressures were liberalized to less than 200 and she was
transferred to the neurosurgical intermediate care unit for
vasospasm watch. She underwent a MRI of the brain on ___ to
rule out an underlying lesion as etiology of the hemorrhage- no
lesion was seen, although study was limited by motion. She
underwent a second diagnostic angiogram ___ which was negative
for aneurysm but notable for an irregular ACOMM artery. She was
transferred from the ___ to the floor later in the day. She
continued to be neurologically intact and was deemed stable for
discharge home on ___. She will follow up in 2 weeks with a CTA.
At time of discharge pain was well controlled with PO
medications, she was tolerating a PO diet, and ambulating
independently.
#Hyponatremia: She was hyponatriemic to 130. She was started on
salt tabs with good effect. At discharge, sodium was stable at
136. She was instructed to follow up with her PCP within ___ week
for sodium recheck and salt tab wean as tolerated.
Medications on Admission:
-alprazolam 1 mg tablet
-bupropion HBr ER 522 mg tablet,extended release 24 hr oral
-vortioxetine 10 mg tablet Once Daily
-Flovent
-Metamucil
-Miralax
-Albuterol
-Vit D3
-Gabapentin 1200 tid
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain
2. Docusate Sodium 100 mg PO BID
3. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every 8 hous as
needed Disp #*15 Tablet Refills:*0
4. Senna 17.2 mg PO QHS
5. Sodium Chloride 2 gm PO TID
RX *sodium chloride 1 gram 2 tablet(s) by mouth three times a
day Disp #*60 Tablet Refills:*0
6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
RX *tramadol 50 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*30 Tablet Refills:*0
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
8. ALPRAZolam 1 mg PO BID:PRN anxiety
9. BuPROPion 150 mg PO TID
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Gabapentin 1200 mg PO TID
12. HydrOXYzine 25 mg PO DAILY:PRN itching
13. Polyethylene Glycol 17 g PO DAILY:PRN constipation
14. Vitamin D 1000 UNIT PO DAILY
15. vortioxetine 20 mg ORAL QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Subarachnoid Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Activity
· You may gradually return to your normal activities, but we
recommend you take it easy for the next ___ hours to avoid
bleeding from your groin.
· Heavy lifting, running, climbing, or other strenuous exercise
should be avoided for ten (10) days. This is to prevent bleeding
from your groin.
· You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
· Do not go swimming or submerge yourself in water for five (5)
days after your procedure.
· You make take a shower.
Medications
· Resume your normal medications and begin new medications as
directed.
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
· If you take Metformin (Glucophage) you may start it again
three (3) days after your procedure.
· You were started on Salt tablets for low sodium. Please
continue these and follow up with your PCP within the next week
and they can be weaned as tolerated.
Care of the Puncture Site
· You will have a small bandage over the site
· Remove the bandage in 24 hours by soaking it with water and
gently peeling it off.
· Keep the site clean with soap and water and dry it carefully.
· You may use a band-aid if you wish.
What You ___ Experience:
· Mild tenderness and bruising at the puncture site (groin).
· Soreness in your arms from the intravenous lines.
· Fatigue is very normal.
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 puncture
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:
___
|
19949313-DS-15 | 19,949,313 | 29,434,086 | DS | 15 | 2180-02-17 00:00:00 | 2180-02-17 16:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea/vomiting/diarrhea
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ y. o F with hepatitis C s/p treatment with sofosbuvir,
compensated cirrhosis, back pain, HTN, SAH, prior ___ who
presented to the ED with nausea, vomiting, and abdominal pain x
1 day. She reported that her symptoms started the day prior to
admission, with six episodes of emesis and an episode of loose
stools without blood. She also endorses a ___ headache that
started this morning.
In the ED, initial VS were 98. 96 145/104 18 96% RA.
On exam, the patient appeared uncomfortable, with an
unremarkable neuro exam. She had mild periumbilical pain with
palpation without rebound and a negative ___ sign.
Labs notable for CBC of 15.6, H/H of 15.8/44.4, Plt 315. BMP
notable for Na 126, BUN/Cr ___. Coags WNL. AST elevated to
104, LDH 962.
She underwent CT A/P which showed wall thickening and mucosal
hyperemia and edema from the mid discending colon to
rectosigmoid junction consistent with colitis.
She received IV Zofran, 1L NS, IV cipro/flagyl.
Upon arrival to the floor, the patient tells the story as
follows. She reports she was in her usual state of health, when
she began having concurrent vomiting and diarrhea beginning the
day prior to admission. She reports that she was vomiting
primarily water, noting that it was red to brown in color,
unsure if it was blood. She denies any bright red blood or not
the consistency is somewhat applied. She reports she vomited
approximately 6 times. She endorsed diarrhea without blood or
black tarry stools. She endorses very mild lower abdominal
pain, but none currently. She reports chills at home, unsure if
she had fevers. She otherwise denies recent travel, sick
contacts, unusual food exposures. She otherwise denies
long-term weight loss, dysuria, chest pain, shortness of breath.
She does endorse a sensation of "Crawling out of her skin" which
she associates with her missed doses of Xanax x 1 day.
The patient appears well. She reports she is hungry and thirsty.
Past Medical History:
asthma, depression, hepatitis C, back pain with narcotic
agreement, osteoarthritis, SIADH, shingles, constipation
Social History:
___
Family History:
sibling with aneurysm
Physical Exam:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
Mucous membranes moist
CV: Heart regular, no murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, speech fluent
PSYCH: pleasant, appropriate affect
Pertinent Results:
___ 01:40PM BLOOD WBC-15.6* RBC-5.21* Hgb-15.8* Hct-44.4
MCV-85 MCH-30.3 MCHC-35.6 RDW-12.1 RDWSD-37.4 Plt ___
___ 06:55AM BLOOD WBC-15.3* RBC-4.71 Hgb-14.7 Hct-40.3
MCV-86 MCH-31.2 MCHC-36.5 RDW-12.2 RDWSD-37.6 Plt ___
___ 01:40PM BLOOD Glucose-148* UreaN-9 Creat-0.8 Na-126*
K-3.7 Cl-84* HCO3-23 AnGap-19*
___ 06:55AM BLOOD Glucose-125* UreaN-8 Creat-0.7 Na-129*
K-3.1* Cl-89* HCO3-21* AnGap-19*
___ 01:44PM BLOOD Glucose-122* UreaN-8 Creat-0.7 Na-127*
K-3.1* Cl-89* HCO3-22 AnGap-16
___ 05:05PM BLOOD ALT-36 AST-104* LD(LDH)-962* AlkPhos-52
TotBili-1.0
___ 06:55AM BLOOD ALT-29 AST-70* LD(LDH)-290* AlkPhos-59
TotBili-0.8
___ 01:44PM BLOOD Phos-2.6* Mg-2.2
___ 05:05PM BLOOD Osmolal-264*
___ 05:17PM BLOOD Lactate-1.5
CT A/P
Wall thickening, mucosal hyperemia, and edema from the mid
descending colon to the rectosigmoid junction consistent with
colitis. Differential includes ischemic, inflammatory, or
infectious etiologies.
Brief Hospital Course:
# Nausea/Vomiting/Colitis
# Hypokalemia
# Hypophosphatemia: Patient presented with abdominal pain and
diarrhea, without blood, with CT A/P significant for wall
thickening, mucosal hyperemia, and edema from the descending
colon to the rectosigmoid junction. Given her mild symptoms,
suspect this represents a viral process and does not require
further treatment for bacterial etiologies as her symptoms were
already improving at the time of presentation and have resolved
without any further antibiotics after those initially given in
the ED. Ischemic seems less likely given absence of melena/BRBPR
and no other history of thrombotic disease. No history of
inflammatory bowel disease. Zofran prescribed for any remaining
nausea, QTC 415. Mild hypokalemia and hypophosphatemia treated
with oral replacement.
# Acute on chronic hyponatremia: Admission Na of 126, with
previous baseline of 130-133 in the setting of known SIADH.
Likely exacerbated by GI losses. Urine Na of 60, suggestive of
component of SIADH. She had previously been on salt tabs, but no
longer taking these in the outpatient setting. Her Na improved
to 129 with supportive care, resolution of GI losses, and
ability to tolerate oral intake.
# Elevated transaminases: Admission labs notable for AST>>ALT
and elevations in LDH, with normal alkaline phosphatase and
t.bili, however, these labs may been inaccurate as sample was
hemolyzed. While this could be suggestive of alcoholic liver
injury, this pattern may also occur in the setting of cirrhosis
secondary to viral hepatitis, as in this patient. INR normal
without evidence of liver failure.
# Cirrhosis: Diagnosed by fibroscan in ___, likely secondary to
HCV. Patient without adequate outpatient follow up with
hepatology.
[ ] Recommend outpatient follow up for HCV and cirrhosis
[ ] Recommend outpatient EGD and HCC screening
CHRONIC/STABLE PROBLEMS:
# Chronic back pain: Continue home Tramadol 50-100 mg every
other day as needed for pain, Gabapentin 800 mg TID
# HTN: Continue home amlodipine.
# Anxiety: Continue Vortioxetine 20 mg daily, Aplenzin
(buproprion HBR) 522 mg daily, Alprazolam 1 mg QID
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Trintellix (vortioxetine) 20 mg oral DAILY
2. Aplenzin (buPROPion HBr) 522 mg oral DAILY
3. amLODIPine 5 mg PO DAILY
4. ALPRAZolam 1 mg PO QID
5. HydrOXYzine 25 mg PO Q6H:PRN itch
6. TraMADol 50-100 mg PO EVERY OTHER DAY
7. Gabapentin 800 mg PO TID
8. Fluticasone Propionate 110mcg 2 PUFF IH BID
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN Nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #*8
Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough
3. ALPRAZolam 1 mg PO QID
4. amLODIPine 5 mg PO DAILY
5. Aplenzin (buPROPion HBr) 522 mg oral DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID
7. Gabapentin 800 mg PO TID
8. HydrOXYzine 25 mg PO Q6H:PRN itch
9. TraMADol 50-100 mg PO EVERY OTHER DAY
10. Trintellix (vortioxetine) 20 mg oral DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to ___ with vomiting and diarrhea which is
most likely from virus or bacteria causing problems in your gut.
This is usually self limited, and the fact the vomiting and
diarrhea has improved is a good sign.
Instructions:
- Take Zofran as needed for nausea. Do not take more frequently
than every 8 hours
Followup Instructions:
___
|
19949666-DS-6 | 19,949,666 | 24,428,051 | DS | 6 | 2119-10-19 00:00:00 | 2119-10-21 11:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Penicillins / lisinopril
Attending: ___.
Chief Complaint:
Nausea
Major Surgical or Invasive Procedure:
none this admit
History of Present Illness:
Mr. ___ is a ___ year old man who underwent a Coronary artery
bypass grafting x2, left internal mammary artery to left
anterior
descending and reverse saphenous vein graft obtuse marginal, 27
tissue Trifecta aortic valve replacement on ___. Since then
he states that he has been nauseated. He moved his bowels
yesterday. His only new medication since pre-op is ultram. His
exam is benign.
Social History:
___
Family History:
Premature coronary artery disease- Father died of CVA at age ___.
Mother had MS and ___ and died at age ___.
Physical Exam:
Admission PE:
Physical Exam:
Pulse:89 Resp:18 O2 sat:100/RA
B/P Right:139/62mmHg
___ Weight:296.2 pounds
General:
Skin: Dry [] intact [X]
HEENT: PERRLA [X] EOMI [X]
Neck: Supple [X] Full ROM [X]
Chest: Lungs clear bilaterally [X]
Heart: RRR [X] Irregular [] Murmur [] grade ______
Abdomen: Soft [X] non-distended [X] non-tender [X] Extremities:
Warm [X], well-perfused [X] Edema [x] 2+
Neuro: Grossly intact [X]
Pulses:
Femoral Right: PALP Left: PALP
DP Right: PALP Left: PALP
___ Right: PALP Left: PALP
Radial Right: PALP Left: PALP
Sternum stable, MSI C/D/I.
Left EVH C/D/I
Pertinent Results:
STUDIES:
___ PA/LAT CXR:
IMPRESSION:
Stable appearance of the chest from ___ with
persistent pleural effusions and left lower lobe opacification.
While this likely reflects combination of atelectasis and
effusion, superimposed infection is possible.
___ KUB:
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
A left total hip arthroplasty is partially visualized with no
evidence of
complication.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies. Left pleural effusion is better seen on same day chest
x-ray.
IMPRESSION: No evidence of obstruction
LABS:
___ 12:00PM BLOOD WBC-10.1* RBC-4.18* Hgb-12.2* Hct-36.9*
MCV-88 MCH-29.2 MCHC-33.1 RDW-11.8 RDWSD-37.9 Plt ___
___ 12:00PM BLOOD Neuts-75.7* Lymphs-6.5* Monos-16.5*
Eos-0.5* Baso-0.2 Im ___ AbsNeut-7.65* AbsLymp-0.66*
AbsMono-1.67* AbsEos-0.05 AbsBaso-0.02
___ 12:00PM BLOOD ___ PTT-27.9 ___
___ 12:00PM BLOOD Glucose-113* UreaN-35* Creat-1.2 Na-135
K-3.1* Cl-85* HCO3-33* AnGap-20
___ 12:00PM BLOOD Albumin-PND Calcium-10.0 Phos-4.7* Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ year old man who underwent a Coronary artery
bypass grafting x2, (left internal mammary artery to left
anterior descending and reverse saphenous vein graft obtuse
marginal) with 27 tissue Trifecta aortic valve replacement on
___ who was discharged home on POD 5. His postoperative
course was uncomplicated except for mild nausea despite formed
bowel movements. He had limited PO intake since discharge. He
denied abdominal pain or vomiting. He presented back to the ER
in rate controlled, asymptomatic atrial flutter with potassium
of 3.1. His CXR, KUB, and labs (including LFTs), were
unremarkable. He was started on standing reglan with PRN
zofran, and his nausea resolved. He was able to tolerate PO
diet. After correcting his potassium, he **converted back to
NSR. He was started on anticoagulation. He was discharged home
with ___ services on POD 8, with additional medication changes
of
Medications on Admission:
1. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
2. Aspirin EC 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*1
3. Losartan Potassium 100 mg PO DAILY
RX *losartan 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
4. Metoprolol Tartrate 50 mg PO Q8H
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth q 8 h Disp
#*90 Tablet Refills:*1
5. Rosuvastatin Calcium 40 mg PO QPM
RX *rosuvastatin [Crestor] 40 mg 1 tablet(s) by mouth QPM Disp
#*30 Tablet Refills:*1
6. Vitamin D 1000 UNIT PO DAILY
7. Acetaminophen 325-650 mg PO Q4H:PRN pain/temp
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
9. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol [Ultram] 50 mg 1 tablet(s) by mouth q 4 h prn Disp
#*50 Tablet Refills:*0
10. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
11. Furosemide 40 mg PO BID Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
12. HydrALAzine 25 mg PO Q6H
RX *hydralazine 25 mg 1 tablet(s) by mouth q 6h Disp #*120
Tablet Refills:*1
13. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth q 6 h prn Disp #*30
Tablet Refills:*1
14. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
RX *metformin 1,000 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
15. Potassium Chloride 20 mEq PO BID Duration: 7 Days
RX *potassium chloride 20 mEq 1 tablet(s) by mouth twice a day
Disp #*14 Tablet Refills:*0
Discharge Medications:
1. Rosuvastatin Calcium 40 mg PO QPM
2. Senna 17.2 mg PO HS
3. TraMADOL (Ultram) 50 mg PO Q8H:PRN severe pain
4. Outpatient Lab Work
___ INR daily prn
Please send results to Dr. ___: ___ Fax: ___
6. Warfarin 2 mg PO AS DIRECTED Aflutter
INR Goal 2.0-3.0
RX *warfarin 2 mg as directed tablet(s) by mouth daily Disp
#*100 Tablet Refills:*0
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. Acetaminophen 650 mg PO Q6H:PRN pain
9. Amlodipine 10 mg PO DAILY
10. Aspirin 81 mg PO DAILY
11. Metoprolol Tartrate 50 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Nausea
postoperative atrial flutter
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Left Leg Incision - healing well, no erythema or drainage
Edema - none
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
19950100-DS-10 | 19,950,100 | 22,727,730 | DS | 10 | 2184-09-03 00:00:00 | 2184-09-03 11:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
shortness of breath, cough, fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with past medical history of asthma (requiring
intubation, ___ presenting with 1 day of shortness of breath
as
well as productive cough and congestion. He has been using
albuterol every ___ minutes at home without relief.
Due to increased work of breathing, patient was placed on BiPAP
briefly in the ED for comfort. He was treated with IV
methylpred,
Mg+, and nebulizers in the ED. Per report from the ED, he was
not
hypoxic, and BiPAP was removed prior to ICU transfer. VBG on
BiPAP 7.44/37/26.
He otherwise denies any chest pain, abdominal pain,
nausea/vomiting. Patient denies any sick contacts that he can
remember. Denies any
recent foreign travel, immobilization, or lower extremity
swelling.
In the ED,
- Initial Vitals: Temp: 103.0 HR: 119 BP: 144/84 Resp: 28 O2
Sat:
96% RA, Peak Flow 200
- Exam:
GA: Comfortable
HEENT: No scleral icterus
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Diffuse wheezes bilaterally, able to speak in full
sentences
Abdominal: Soft, non-tender, non-distended
Extremities: No lower leg edema
Integumentary: No rashes noted
- Labs:
- WBC 6.5, HgB 13.2, Plt 192
- BUN/Cr, ___
- Na+ 134, K+ 3.3
- Flu A PCR positive, Flu B PCR negative
- Imaging:
CXR: No acute cardiopulmonary abnormality
- Consults: Respiratory therapy
- Interventions:
___ 19:33 IV MethylPREDNISolone Sodium Succ 80 mg
___ 19:33 IH Ipratropium-Albuterol Neb 1 NEB
___ 19:33 IV Magnesium Sulfate
___ 19:51 PO Acetaminophen 1000 mg
___ 20:37 IV Magnesium Sulfate 2 gm
___ 21:44 IH Albuterol 0.083% Neb Soln 1 NEB
On arrival to the floor, patient is wearing nasal cannula and
reports feeling significant improvement from arrival. He
endorses
that he had been feeling poorly for about two days and just
today
began feeling extremely fatigued. He believes he had the flu
shot
this year at a PCP ___. He has had care at ___ in the
past for his asthma including being on flovent in the past, but
has not been on anything other than albuterol for several years,
maybe since ___. He endorses that cold weather can be a trigger
for his asthma. When ill sometimes uses his albuterol inhaler
constantly, and other times only ___ times a week. Will use it
prior to physical activity such as playing basketball.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
Asthma
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T 98.3 HR 77 BP 159/106 RR 11 SpO2 100% 2L O2
GEN: alert, awake, well developed man appears stated age
sitting
upright in bed in no acute distress with nasal cannula
EYES: sclera anicteric, PERRLA, EOMI
HENNT: NC/AT, MMM
CV: regular rate/rhythm, no m/r/g
RESP: inspiratory and expiratory wheezes diffusely b/l
GI: soft nt/nd, normoactive BS, no HSM/masses
MSK: no peripheral edema, warm and well perfused
SKIN: no rashes
NEURO: grossly normal, oriented x3
Discharge exam
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Breathing is non-labored, no crackles, rare L-sided
expiratory wheezing
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS
___ 07:00PM BLOOD WBC-6.5 RBC-5.23 Hgb-13.2* Hct-39.7*
MCV-76* MCH-25.2* MCHC-33.2 RDW-15.1 RDWSD-41.0 Plt ___
___ 07:00PM BLOOD Neuts-67.2 Lymphs-18.4* Monos-13.0
Eos-0.2* Baso-0.9 Im ___ AbsNeut-4.34 AbsLymp-1.19*
AbsMono-0.84* AbsEos-0.01* AbsBaso-0.06
___ 07:00PM BLOOD Glucose-120* UreaN-5* Creat-1.0 Na-134*
K-3.3* Cl-96 HCO3-22 AnGap-16
___ 03:07AM BLOOD Iron-11*
___ 03:07AM BLOOD calTIBC-287 Ferritn-174 TRF-221
___ 12:27AM BLOOD ___ pO2-66* pCO2-37 pH-7.44
calTCO2-26 Base XS-0
PERTINENT STUDIES
CXR ___
IMPRESSION:
No acute cardiopulmonary abnormality.
Discharge labs
___ 03:07AM BLOOD WBC-4.6 RBC-4.95 Hgb-12.5* Hct-37.4*
MCV-76* MCH-25.3* MCHC-33.4 RDW-15.1 RDWSD-40.6 Plt ___
___ 03:07AM BLOOD Glucose-152* UreaN-7 Creat-0.8 Na-136
K-4.0 Cl-99 HCO3-22 AnGap-15
___ 03:07AM BLOOD Iron-11*
___ 03:07AM BLOOD calTIBC-287 Ferritn-174 TRF-221
___ 03:43AM BLOOD ___ pO2-52* pCO2-35 pH-7.46*
calTCO2-26 Base XS-1
Brief Hospital Course:
Mr. ___ is a ___ male w/ PMH asthma (requiring
intubation ___ who presents with 1 day of shortness of breath,
productive cough, congestion, c/w asthma exacerbation ___
influenza infection. Patient was briefly on BiPAP and admitted
to
ICU. He was started on steroids. BiPAP was weaned and patient
maintained on ___ L NC. He was monitored in the ICU briefly then
called out to the floors on ___.
#Asthma exacerbation
#Influenza A positive - Patient presented with SOB refractory
his albuterol inhaler at home. Due to increased work of
breathing, patient was placed on BiPAP briefly in the ED for
comfort. He was treated with IV methylpred, Mg+, and nebulizers
in the ED. Per report from the ED, he was not hypoxic, and BiPAP
was removed prior to ICU transfer. VBG on BiPAP 7.44/37/___. He
was briefly monitored in the ICU, started on tamiflu and called
out to the floors on ___. He was weaned to room air by ___. He
was continued on PO prednisone (EOT ___ and Tamiflu (EOT
___.
#Microcytic anemia with low iron levels, normal ferritin: may
need further outpatient work up, started on PO iron
supplementation
Transitional care issues
[ ] needs formal PFTs for asthma, consider referral to
pulmonologist
[ ] work up of mild anemia
Greater than 30 minutes were spent providing and coordinating
care for this patient on day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
2. OSELTAMivir 75 mg PO BID
RX *oseltamivir 75 mg 1 capsule(s) by mouth twice a day Disp #*5
Capsule Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 4 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*4 Tablet
Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
RX *albuterol sulfate [Proventil HFA] 90 mcg 1 puff INH every 4
hours Disp #*3 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Asthma exacerbation
Influenza a
SECONDARY DIAGNOSES:
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___
___ were admitted for an asthma exacerbation related to flu
infection. ___ were briefly on a BiPAP machine to help your
breathing. ___ were given steroids and breathing treatments with
improvement in your asthma symptoms. ___ were started on a
medication to help with the flu infection as well.
WHY WAS I ADMITTED TO THE HOSPITAL?
- ___ were admitted to the hospital because ___ had shortness of
breath.
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the hospital, it was determined that your shortness of
breath was due to an asthma exacerbation. Your flu swab was
positive, and this was the likely cause of your asthma
exacerbation.
- ___ were given supplemental oxygen.
- ___ were given medications including albuterol, steroids, and
magnesium to treat your asthma exacerbation. ___ were also
placed on antivirals for your flu.
WHAT SHOULD I DO WHEN I GO HOME?
- Please take all of your medications exactly as prescribed and
attend all of your follow-up appointments listed below.
-Make sure ___ receive her flu shot every year.
-___ should have regular follow-up with a pulmonologist for
management of your asthma.
We wish ___ the best!
Your ___ Care Team
Followup Instructions:
___
|
19950146-DS-18 | 19,950,146 | 20,459,046 | DS | 18 | 2182-02-23 00:00:00 | 2182-02-26 19:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
shellfish derived / peanut
Attending: ___.
Chief Complaint:
abdominal sepsis
Major Surgical or Invasive Procedure:
ex-laparotomy, washouts, flap advancement with surgimend closure
History of Present Illness:
Mr. ___ is a ___ man with history significant
for asymptomatic large cecal mass detected on screening
colonoscopy underwent lap-assisted R colectomy complicated by
leak that required ex-lap with washouts and vac placement
eventually underwent closure of the abdomen on ___,
patient
discharged home and came back today with high grade fever, pain,
foul smelling abdominal wound discharges. He denies any nausea
vomiting, shortness of breath, chest pain or any other
complaints.
Past Medical History:
PMH: HTN, clavicle fx, gout, HLD, BPH, asthma
PSH: Knee surgery, inguinal hernia repair, umbilical hernia
repair w/ mesh, c-scope at ___ showing large cecal
mass
Social History:
___
Family History:
Non-contributory
Physical Exam:
Discharge Physical Exam:
VS: 97.8 120/76 105 16 99%RA
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, non-distended.
Incisions: large midline open abdominal wound cover with wound
VAC.
EXTREMITIES: Warm, well perfused, pulses palpable, (-) edema
Pertinent Results:
___ 03:13PM PLT SMR-HIGH PLT COUNT-543*
___ 03:13PM HYPOCHROM-1+ ANISOCYT-OCCASIONAL
POIKILOCY-NORMAL MACROCYT-OCCASIONAL MICROCYT-NORMAL
POLYCHROM-1+
___ 03:13PM NEUTS-76* BANDS-9* LYMPHS-4* MONOS-11 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-21.85* AbsLymp-1.03*
AbsMono-2.83* AbsEos-0.00* AbsBaso-0.00*
___ 03:13PM WBC-25.7*# RBC-3.01* HGB-9.1* HCT-27.1*
MCV-90 MCH-30.2 MCHC-33.6 RDW-14.0 RDWSD-45.6
___ 03:13PM ALBUMIN-3.1*
___ 03:13PM ALT(SGPT)-49* AST(SGOT)-30 ALK PHOS-249* TOT
BILI-0.8
___ 03:13PM GLUCOSE-110* UREA N-25* CREAT-1.2 SODIUM-122*
POTASSIUM-3.8 CHLORIDE-87* TOTAL CO2-19* ANION GAP-20
___ 03:36PM LACTATE-2.3*
___ 04:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:03PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 04:03PM URINE GR HOLD-HOLD
___ 04:03PM URINE UHOLD-HOLD
___ 04:03PM URINE HOURS-RANDOM
___ 04:03PM URINE HOURS-RANDOM
___ 09:56PM HCT-22.6*
___ 09:56PM CALCIUM-7.1* PHOSPHATE-2.3* MAGNESIUM-1.8
___ 09:56PM GLUCOSE-133* UREA N-17 CREAT-0.9 SODIUM-127*
POTASSIUM-3.0* CHLORIDE-94* TOTAL CO2-19* ANION GAP-17
Brief Hospital Course:
The patient presented to pre-op/Emergency Department on ___
. Pt was evaluated by anaesthesia/ Upon arrival to ED. Given
findings, the patient was taken to the operating room for
ex-lap,washouts,flap advancement w/ surgimend and wound VAC
placement. 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 TSICU
for observation.
On POD1, patient has been persistently tachycardic up to 130's,
however urine output has been adequate. NG tube was removed.
Over night, he has agitated and delirious that required 1 dose
of IV Haldol. Patient started on broad spectrum IV antibiotics
to treat abdominal sepsis and pneumonia and IV fluconazole
prophylactically.
POD2, he has multiple loose bowel movement which was positive
for C.diff, IV flagyl and PR vancomycin has been started. He
also stayed delirious during the day. He has been taken to the
OR again for washout/VAC changes and went back to the TSICU and
this time he kept intubated and was HD stable over the night.
POD3, Patient was extubated but remained delirious. POD4, his
over all delirium issues has been improved, CT abdomen/Pelvis
done which was negative for any perforation or fluid
collections, he has taken back to the OR for wash out/VAC
changes.
POD5, his heart rate went high, up to 133 with irregular rhythm,
multiple 5mg metoprolol doses have been given that managed the
heart rate perfectly, IV 5mg metoprolol was started q6h standing
dose daily that stopped completely a few days later.
On ___, he has taken back to the OR for another wash out
and VAC changes and then transferred to the regular floor after.
During stay on regular floor the hospital course has been
described systematically as follow:
Neuro: The patient was alert and oriented on the floor; pain was
managed perfectly with IV pain medicine that transitioned to
oral once tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. Metoprolol has
been stopped and heart rate remain stable.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged.
GI/GU/FEN: Initially he was NPO and on TPN. The diet was
advanced sequentially to a Regular diet, which was well
tolerated, subsequently TPN has been stopped. Patient's intake
and output were closely monitored
ID: The patient's fever curves were closely watched of which he
was afebrile through out hospitalization. Patient switched to PO
Flagyl and kept on C.Diff treatment for 15 days after discharge
with PO Vancomycin as well.
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 received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
3. Allopurinol ___ mg PO DAILY
4. MetroNIDAZOLE 250 mg PO Q8H
RX *metronidazole [Flagyl] 250 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*45 Tablet Refills:*0
5. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every twelve (12)
hours Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Enter Cutaneous fistula
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 here at ___
___. You were admitted to our hospital
after undergoing ex-laparotomy, washouts, flap advancement with
surgimend closure on ___. You have recovered from surgery
and are now ready to be discharged 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 may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
- Don't lift more than 10 lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
- 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 6 weeks. You might want
to nap often. Simple tasks may exhaust you.
- You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
- You could have a poor appetite for a while. Food may seem
unappealing.
- All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR BOWELS:
- Constipation is a common side effect of medicine such as
Percocet or codeine. 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:
- 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 from your surgeon 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.
VAC instruction:
1. While wet-to-dry dressings are in place, please change ___
times a day or as needed for increased soiling.
2. While VAC is in place, please clean around the VAC site and
monitor for air leaks of the VAC
3. A written record of the daily output from the VAC drain
should be brought to every follow-up appointment. Your VAC drain
will be removed as soon as possible when the daily output tapers
off to an acceptable amount and the wound is no longer
concerning for ongoing infection
4. You may shower daily with assistance as needed.
5. Okay to shower, but no baths until after directed by your
surgeon
Followup Instructions:
___
|
19950352-DS-17 | 19,950,352 | 24,287,165 | DS | 17 | 2142-04-17 00:00:00 | 2142-04-17 18:53:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / lisinopril
Attending: ___
Chief Complaint:
Rectal Pain, Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with CAD, atrial
fibrillation, hypertension, DMII, and extensive stage small cell
lung cancer on carboplatin/etoposide and radiation who presents
with constipation and rectal pain.
Patient reports feeling constipated with no bowel movement for 5
days. She reports feeling impacted. She notes associated severe
rectal pain. She notes nausea without vomiting for which she
took
zofran. She is passing gas. She has been taking stool softener
and miralax for 1 week. She reports similar symptoms like this a
couple of week ago and eventually moved her bowels with a hard
stool. Has had impairment in urination as well due to
constipation.
She initially presented to ___ Urgent Care for evaluation where
exam was notable for hyperactive bowel sounds and abdominal
tenderness over hernia. KUB showed a nonobstructive bowel gas
pattern. Disimpaction was attempted but was not tolerated due to
pain. Also attempted fleet enema but again not tolerated. She
was
transferred to ___ ED.
On arrival to the ED, initial vitals were 97.3 73 149/60 18 99%
RA. Exam was notable for inspiratory wheezing, reducible hernia,
and LLQ/suprapubic tenderness to palpation. Labs were notable
for
WBC 12.1, H/H 9.5/30.9, Plt 299, Na 137, K 5.0, BUN/Cr 38/1.5,
LFTs wnl, lactate 0.9, and UA negative. Urine culture was sent.
Abdominal CT was notable for three nonobstructing
bowel-containing hernias and large stool burden from the distal
transverse colon to the rectum. Patient was given tylenol 1g IV,
Ativan 1mg IV, miralax, lactulose, and 1L LR. She had a large
bowel movement prior to transfer. Prior to transfer vitals were
98.2 58 127/45 18 98% RA.
On arrival to the floor, patient reports multiple bowel
movements. Her pain is improved. She denies fevers/chills, night
sweats, headache, vision changes, dizziness/lightheadedness,
weakness/numbnesss, shortness of breath, cough, hemoptysis,
chest
pain, palpitations, vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, hematuria, and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY:
She presented with persistent dry cough since about 2 months ago
and began to developed blood tinged sputum in mid ___.
She has noticed some increased shortness of breath. She has been
on Advair for emphysema which was no longer helpful. She has
more
dyspnea especially when she lies down. She has lost her appetite
and lost about 15 pounds over several months. Due to these
complaints, she underwent the following workup:
- ___: CXR - 1. Soft tissue opacity right hilar region.
Focal opacity superior segment right lower lobe which may
represent infiltrate, pneumonia or lung lesion. Follow-up
contrast enhanced CT scan of the chest is recommended to exclude
malignancy.
- ___: CT of chest - 1. Large right upper lobe mass and a
small mass superior segment right lower lobe. 2. Bulky right
hilar/suprahilar mass. Subcarinal adenopathy. Pretracheal
adenopathy. 3. Bilateral thyroid nodules. Correlate with
nonemergent thyroid ultrasound. Findings are highly suspicious
for malignancy. Tissue sampling and PET CT advised.
- ___: PET/CT - 1. FDG avid right perihilar mass measuring
up to 7 cm demonstrates a max SUV of 23.56, suspicious for
primary lung neoplasm. There is compression upon the bronchus to
the posterior segment of the right upper lobe and probable
associated atelectasis of the right upper lobe. 2. FDG avid
subcarinal lymphadenopathy, FDG avid right axillary
lymphadenopathy, and a FDG avid 1.5 cm lung nodule in the right
lower lobe with max SUVs of 11.33, 13.67, and 13.93,
respectively, likely representing metastatic disease. FDG avid
epicardial lymph node with a max SUV of 3.69, likely
representing
metastatic disease. 3. FDG avid left cervical chain level IV
lymph node with a max SUV of 6.01, likely representing
metastatic
disease. 4. Two FDG avid subcutaneous soft tissue nodules in the
left posterior upper back superficial to the deltoid muscle and
left gluteal region superficial to the gluteus maximus muscle
with max SUVs of 20.22 and 15.41, respectively, likely
representing metastatic disease.
- ___: Bronchoscopy, EBUS FNA positive for small cell lung
cancer of level 7, 10R, 11R lymph nodes.
- ___ - ___: C1 carboplatin and etoposide.
- ___: Seen by Dr. ___ recommends adding radiation
after 2 cycles of chemotherapy.
- ___: C2D1 carboplatin and etoposide.
- ___: Starting concurrent XRT, Dr. ___.
- ___: C3D1 carboplatin and etoposide.
Past Medical History:
- Latent TB s/p treatment
- CAD s/p LAD stent in ___
- Paroxysmal Afib on ASA, atrial tachycardia
- PVD
- DM
- Hypertension
- Hyperlipidemia
- CKD Stage IV
- COPD
- HLD
- Basal Cell Carcinoma
Social History:
___
Family History:
Her mother and sister died of lung cancer. Her
father had prostate cancer. Brother had stomach cancer.
Mother with MI
Three siblings with MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.1, BP 145/74, HR 68, RR 20, O2 sat 98% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, mildly tender over hernia, non-distended, positive
bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM:
VS: ___ 1543 Temp: 98.4 PO BP: 150/53 HR: 76 RR: 18 O2 sat:
99% O2 delivery: Ra
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, mildly tender over hernia, non-distended, positive
bowel sounds.
EXT: Warm, well perfused, no lower extremity edema.
NEURO: A&Ox3, good attention and linear thought, gross strength
and sensation intact.
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS:
___ 03:35PM BLOOD WBC-12.1* RBC-3.53* Hgb-9.5* Hct-30.9*
MCV-88 MCH-26.9 MCHC-30.7* RDW-18.9* RDWSD-58.7* Plt ___
___ 03:35PM BLOOD Neuts-89.4* Lymphs-5.9* Monos-2.2*
Eos-1.2 Baso-0.6 Im ___ AbsNeut-10.81* AbsLymp-0.71*
AbsMono-0.26 AbsEos-0.14 AbsBaso-0.07
___ 03:35PM BLOOD Plt ___
___:35PM BLOOD Glucose-69* UreaN-38* Creat-1.5* Na-137
K-5.0 Cl-102 HCO3-20* AnGap-15
___ 03:35PM BLOOD ALT-6 AST-14 AlkPhos-91 TotBili-0.3
___ 03:35PM BLOOD Lipase-27
___ 03:35PM BLOOD Albumin-4.2 Calcium-9.1 Phos-4.4 Mg-2.3
___ 03:35PM BLOOD Free T4-1.8*
___ 03:35PM BLOOD TSH-4.8*
___ 03:45PM BLOOD Lactate-0.9
DISCHARGE LABS:
___ 04:25PM BLOOD WBC-5.8 RBC-2.95* Hgb-8.1* Hct-25.2*
MCV-85 MCH-27.5 MCHC-32.1 RDW-18.6* RDWSD-57.3* Plt ___
___ 04:25PM BLOOD Plt ___
___ 05:56AM BLOOD Glucose-65* UreaN-29* Creat-1.4* Na-136
K-4.6 Cl-103 HCO3-20* AnGap-13
___ 05:56AM BLOOD Calcium-8.0* Phos-4.8* Mg-2.3
___ 03:39PM URINE Color-Straw Appear-Clear Sp ___
___ 03:39PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 03:39PM URINE RBC-1 WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT STUDIES:
Radiology Report CT ABD & PELVIS WITH CONTRAST Study Date of
___ 5:32 ___
COMPARISON: ___ F FDG PET-CT from ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
biliary dilatation. The gallbladder is not visualized. The CBD
is dilated to
1.2 cm and tapers down smoothly at the level of the ampulla.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of
focal lesions or pancreatic ductal dilatation. There is no
peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
Bilateral extrarenal pelvises are noted. A 2 cm simple renal
cyst arising
from the lower pole of the left kidney is noted. Additional
hypodensities in
the kidneys bilaterally too small to characterize but
statistically cysts.
Punctate nonobstructing right renal calculus is noted.
Alternatively, this
could represent a vascular calcification. Cortical thinning
compatible scar
noted at the upper pole the right kidney. There is no evidence
of focal
suspicious renal lesions or hydronephrosis. There is no
perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable besides a small
hiatal hernia.
Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement
throughout. No bowel obstruction. Oral contrast seen up to the
distal
transverse colon, distal to the a ventral hernia containing
loops of
nonobstructed transverse colon. There are two additional small
bowel
containing hernias inferior to this hernia without secondary
obstruction.
Large amount of stool is noted in the distal transverse colon,
descending
colon, sigmoid and rectum. Colonic diverticulosis without
diverticulitis.
The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal
abnormality is
seen.
LYMPH NODES/MESENTERY/OMENTUM: No abdominal or pelvic
lymphadenopathy. Again
seen 2.3 cm omental infarct is noted in the right lower
quadrant, similar to
___.
VASCULAR: There is no abdominal aortic aneurysm. Moderate
atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
SOFT TISSUES: Ventral hernia containing loops of the small bowel
and
transverse colon without causing bowel obstruction.
IMPRESSION:
1. Three nonobstructing bowel containing hernias along the
anterior abdominal
wall, the superior most hernia contains transverse colon. Two
more inferior
midline abdominal hernias contain nonobstructed small bowel.
2. Large amount of stool from the distal transverse colon to the
rectum. No
obstruction.
3. Diverticulosis without diverticulitis.
MICROBIOLOGY:
__________________________________________________________
___ 3:39 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Ms. ___ is a ___ female with CAD, atrial
fibrillation, hypertension, DMII, and extensive stage small cell
lung cancer on carboplatin/etoposide and radiation who
presents with constipation and rectal pain. Had large bowel
movements after treating with lactulose and miralax, feeling
much better.
TRANSITIONAL ISSUES:
====================
[] Uptitrated home bowel reg by increasing miralax dose + adding
Colace and PRN lactulose, as well as by instructing patient to
take senna, miralax, and colace on a scheduled rather than on an
as-needed basis. Educated patient that she can uptitrate her
miralax as needed.
[] Recheck thyroid function studies as outpatient, her TSH was
high normal even though her free T4 was normal, consider
relative hypothyroidism as a possible underlying cause for her
chronic constipation.
[] Home lantus dose was cut in half (24 units QHS to 12 units
QHS) on discharge given fingersticks in ___ in the ED and ___
the next morning iso no insulin. Patient states she checks her
sugars before bed and will only administer her lantus if above
150. However, given her low fingersticks while inpatient her
home dose was felt to be too high. She may have also had poor PO
during her 5 days of no BM, which could have exacerbated this.
Recommend retitrating her insulin as outpatient.
ACTIVE ISSUES:
==============
# Constipation
# Hx of Hypothyroidism
Acute on chronic issue for several years. Actively moving bowels
s/p lactulose and miralax. Patient had been taking senna 8.6mg
BID and miralax 17g QD at home, and hadn't tried uptitrating
this regimen. Educated patient that she can safely increase the
amount of miralax she takes as needed to prevent another episode
like this from occurring. Also added colace 100mg BID and PRN
lactulose to her home bowel reg on discharge. Is taking
levothyroixine for hx of hypothyroidism. Free T4 was
high-normal, however TSH was high-normal as well, suggesting
relative hypothyroidism even if her free T4 falls within the
population range. Recommend repeat TFTs as outpatient and
consider adjusting levothyroxine dose.
# Extensive Stage Small Cell Lung Cancer:
Patient was very upset as she was due for C3 oral etoposide and
did not take it yet. She does not have the medication with her
and pharmacy did not stock PO etoposide. Also was too late for
IV etoposide. Patient was discharged the day after admission and
should be able to take it at home on ___. Dr. ___ was made
aware.
# DMII:
Home lantus dose was cut in half (24 units QHS to 12 units QHS)
on discharge given fingersticks in ___ in the ED and ___ the
next morning iso no insulin. Patient states she checks her
sugars before bed and will only administer her lantus if above
150. However, given her low fingersticks while inpatient her
home dose was felt to be too high. She may have also had poor PO
during her 5 days of no BM, which could have exacerbated this.
Recommend retitrating her insulin as outpatient.
# Anemia:
Likely secondary to malignancy and chemotherapy. Had a mild Hb
drop the day after admission, however this was most likely
dilutional iso dehydration at home from poor PO and having
received IVF in ED, afternoon repeat Hb stable. No clinical
signs of bleed.
CHRONIC ISSUES:
===============
# COPD
Continued home advair and albuterol PRN.
# Atrial Fibrillation
Coontinued home ASA, not on anticoagulation. Continued home
amiodarone for rhythm control.
# Stage IV CKD:
Baseline Cr 1.9 per ___ record. No significant electrolyte
abnormalities or volume overload. Continue home torsemide and
amiloride.
CORE MEASURES:
==============
CODE: Full Code (presumed)
EMERGENCY CONTACT HCP: ___ (son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Torsemide 20 mg PO QAM
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. aMILoride 5 mg PO DAILY
6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
7. Torsemide 10 mg PO QPM
8. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
9. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
11. Senna 8.6 mg PO BID:PRN constipation
12. Glargine 24 Units Bedtime
13. Vitamin D ___ UNIT PO DAILY
14. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY
15. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Lactulose 30 mL PO Q6H:PRN constipation
3. Glargine 12 Units Bedtime
4. Polyethylene Glycol 34 g PO DAILY
5. Senna 8.6 mg PO BID
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
7. aMILoride 5 mg PO DAILY
8. Amiodarone 100 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY
12. LORazepam 0.5 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
13. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
14. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
15. Torsemide 20 mg PO QAM
16. Torsemide 10 mg PO QPM
17. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
It was a pleasure taking care of you at ___.
Why you were in the hospital:
-You were suffering from severe constipation.
What was done for you in the hospital:
-We gave you strong laxatives to help you move your bowels.
What you should do after you leave the hospital:
- Please take your medications as detailed in the discharge
papers. If you have questions about which medications to take,
please contact your regular doctor to discuss.
- Please go to your follow up appointments as scheduled in the
discharge papers. Most of them already have a specific date &
time set. If there is no specific time specified, and you do not
hear from their office in ___ business days, please contact the
office to schedule an appointment.
- Please monitor for worsening symptoms. If you do not feel like
you are getting better or have any other concerns, please call
your doctor to discuss or return to the emergency room.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19950352-DS-18 | 19,950,352 | 27,931,909 | DS | 18 | 2142-05-13 00:00:00 | 2142-05-13 14:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / lisinopril
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year old woman with extensive stage small
cell lung cancer currently on carboplatin and etoposide +
radiation who is admitted from the ED with profound weakness and
dyspnea.
Patient reports approximately two days of progressive weakness
and tremulousness. Her weaekness progressed to the point she
couldn't stand up without assistance, and felt like a 'piece of
spaghetti'. Additionally, when attempting to stand her entire
body would shake with tremors. She notes mild associated
dyspnea.
She has a chronic cough occasionally associated with white
sputum
and has some throat discomfort and odynophagia with radiation.
Her appetite has been very poor. She has no other focal
complaints. No headaches. No visual changes (chronic left eye
blurriness). She has no recent URTI symtpoms. No CP. No N/V or
abodminal pain. She has intermittent constipation, last BM was
yesterday. No dysuria. No myalgias. No leg pain or swelling. No
new rashes.
Patient was seen in radiation oncology today for fraction ___
of planned 3500 cGy. There she was noted to be very weak and
tremulous and requiring assistance with ambulation. She was
transported to the ED.
In the ED, initial VS were pain 0, T 98.6, HR 88, BP 148/49, RR
18, O2 99%RA. Initial labs were notable for Na 134, K 6.2
(hemolyzed, repeat 5.3 whole blood 5.3), HCO3 20, Cr 1.5, Ca
9.0,
Mg 2.2, P 4.3, WBC 7.1, HCT 26.2, PLT 176, UA negative. Rapid
flu
swab negative. CXR showed no evidence of pneumonia and interval
improvement in known RUL mass. Patient was given normal saline
and po lorazepam. VS prior to transfer were T 98.3, HR 79, BP
134/61, RR 16, O2 100%RA.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Ms. ___ is a ___ yrs. female who has a remote history of
cigarette smoking, quit about ___ years ago and a long-standing
history of emphysema. She presented with persistent dry cough
since about 2 months ago and began to developed blood tinged
sputum in mid ___. She has noticed some increased
shortness of breath. She has been on Advair for emphysema which
was no longer helpful. She has more dyspnea especially when she
lies down. She has lost her appetite and lost about 15 pounds
over several months. Due to these complaints, she underwent the
following workup:
___: CXR - 1. Soft tissue opacity right hilar region. Focal
opacity superior segment right lower lobe which may represent
infiltrate, pneumonia or lung lesion. Follow-up contrast
enhanced
CT scan of the chest is recommended to exclude malignancy.
___: CT of chest - 1. Large right upper lobe mass and a
small mass superior segment right lower lobe.
2. Bulky right hilar/suprahilar mass. Subcarinal adenopathy.
Pretracheal adenopathy.
3. Bilateral thyroid nodules. Correlate with nonemergent thyroid
ultrasound. Findings are highly suspicious for malignancy.
Tissue
sampling and PET CT advised.
___: PET/CT -
1. FDG avid right perihilar mass measuring up to 7 cm
demonstrates a max SUV of 23.56, suspicious for primary lung
neoplasm. There is compression upon the bronchus to the
posterior segment of the right upper lobe and probable
associated
atelectasis of the right upper lobe.
2. FDG avid subcarinal lymphadenopathy, FDG avid right axillary
lymphadenopathy, and a FDG avid 1.5 cm lung nodule in the right
lower lobe with max SUVs of 11.33, 13.67, and 13.93,
respectively, likely representing metastatic disease. FDG avid
epicardial lymph node with a max SUV of 3.69, likely
representing
metastatic disease.
3. FDG avid left cervical chain level IV lymph node with a max
SUV of 6.01, likely representing metastatic disease.
4. Two FDG avid subcutaneous soft tissue nodules in the left
posterior upper back superficial to the deltoid muscle and left
gluteal region superficial to the gluteus maximus muscle with
max
SUVs of 20.22 and 15.41, respectively, likely representing
metastatic disease.
- ___: bronchoscopy, EBUS FNA positive for small cell lung
cancer of level 7, 10R, 11R lymph nodes.
- ___ - ___: C1 carboplatin and etoposide.
- ___: seen by Dr. ___ recommends adding radiation
after 2 cycles of chemotherapy.
- ___: C2D1 carboplatin and etoposide.
- ___: starting concurrent XRT, Dr. ___.
- ___: C3D1 carboplatin and etoposide.
- ___: C4D1 carboplatin and etoposide.
PAST MEDICAL HISTORY:
- Latent TB s/p treatment
- CAD s/p LAD stent in ___
- Paroxysmal Afib on ASA, atrial tachycardia
- PVD
- DM
- Hypertension
- Hyperlipidemia
- CKD Stage IV
- COPD
- HLD
- Basal Cell Carcinoma
Social History:
___
Family History:
Her mother and sister died of lung cancer. Her father had
prostate cancer. And one brother had stomach cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.2 HR 84 BP 121/79 RR 22 SAT 100% O2 on RA
GENERAL: Fatigued elderly woman sitting up in bed
EYES: Anicteric sclerea, PERLL, EOMI;
ENT: MMM, Oropharynx clear without lesion, JVD not appreciated
CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or
gallops
RESPIRATORY: Appears mildly tachypneic and speakinig in short
sentences, soft inspiratory wheeze throughout. Fair air movement
GASTROINTESTINAL: Normal bowel sounds; nondistended; soft,
nontender without rebound or guarding; prominent ventral hernia;
no hepatomegaly, no splenomegaly
MUSKULOSKELATAL: Warm, well perfused extremities without lower
extremity edema; Decreased bulk.
NEURO: Alert, oriented, CN III-XII intact, Bilateral ___ strength
is ___ throughout. After exertion she developed rhythmic
fasiculations at about 3Hz in her RLE that persisted for several
minutes. Similar but less pronounced tremeors in LLE.
SKIN: No significant rashes
LYMPHATIC: No cervical, supraclavicular, submandibular
lymphadenopathy. No significant ecchymoses
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 823)
Temp: 98.5 (Tm 98.5), BP: 127/48 (112-135/48-59), HR: 84
(74-84), RR: 17 (___), O2 sat: 99% (97-100), O2 delivery: RA,
Wt: 100.8 lb/45.72 kg
GEN: laying in bed comfortably
HEENT: healing rash in V1 distribution, no further vesicles
CV: NR, RR. Nl S1, S2. No m/r/g.
CHEST: CTAB, redness over chest and back largely resolved
GI: Soft, nontender.
NEURO: Alert, oriented.
Pertinent Results:
ADMISSION LABS
==============
___ 06:00PM BLOOD WBC-7.1 RBC-3.02* Hgb-8.4* Hct-26.2*
MCV-87 MCH-27.8 MCHC-32.1 RDW-20.2* RDWSD-62.9* Plt ___
___ 06:00PM BLOOD Neuts-86.1* Lymphs-8.4* Monos-3.2*
Eos-1.1 Baso-0.6 Im ___ AbsNeut-6.13* AbsLymp-0.60*
AbsMono-0.23 AbsEos-0.08 AbsBaso-0.04
___ 06:50AM BLOOD ___ PTT-22.8* ___
___ 06:00PM BLOOD Glucose-95 UreaN-43* Creat-1.5* Na-134*
K-6.2* Cl-100 HCO3-20* AnGap-14
___ 06:50AM BLOOD ALT-<5 AST-11 LD(LDH)-125 CK(CPK)-18*
AlkPhos-69 TotBili-0.2
___ 06:00PM BLOOD Calcium-9.0 Phos-4.3 Mg-2.2
___ 06:50AM BLOOD ___ 06:50AM BLOOD TSH-1.1
___ 06:50AM BLOOD Cortsol-21.1*
DISCHARGE LABS
==============
___ 06:18AM BLOOD WBC-5.3 RBC-3.08* Hgb-8.8* Hct-26.6*
MCV-86 MCH-28.6 MCHC-33.1 RDW-17.5* RDWSD-55.2* Plt Ct-83*
___ 06:18AM BLOOD Neuts-85* Lymphs-6* Monos-4* Eos-5 Baso-0
AbsNeut-4.51 AbsLymp-0.32* AbsMono-0.21 AbsEos-0.27
AbsBaso-0.00*
___ 06:18AM BLOOD Plt Smr-LOW* Plt Ct-83*
STUDIES
=======
___ CXR: No radiographic findings to suggest pneumonia.
Interval decrease in size of right upper lobe lung mass
compatible with known malignancy.
Brief Hospital Course:
___ is a ___ year-old woman with extensive stage small
cell lung cancer on carboplatin and etoposide with concurrent
radiation who presented from Radiation Oncology with weakness
and dyspnea, most likely I/s/o chemoradiation, subsequently
found to have Herpes Zoster.
# Herpes Zoster
While inpatient, developed pain of L forehead, and subsequent
vesicles in V1 distribution. Slight redness and pruritis of
chest and back. ID & Derm consulted and felt these represented
radiation changes and not disseminated zoster. Started
valacyclovir for planned 14 day course given immunosuppression
(through ___. Consulted ophthalmology for evaluation given V1
distribution and complaint of fuzzy vision in L eye; no evidence
of zoster retinitis, and normal visual acuity, however noted
incidental lesion as below.
# Subretinal Lesion
___ disk-diameter subretinal lesion noted at 5 o'clock next to L
optic nerve during ophthalmologic evaluation which was thought
consistent with choroidal metastasis v. granuloma v. other
inflammatory lesion. Recommended neuroimaging if possible with
thin orbital cuts with contrast; however, given patient is
declining recommended follow-up with Atrius ophthalmology within
1 week of discharge with OCT, visual field and ultrasound.
# Weakness
# Debility
# Tremor
Presented with weakness I/s/o chemoradiation. Infectious
findings negative apart from VZV as above. Intention tremor
noted which has been present for some time. TSH & cortisol
normal. Patient declined all CNS imaging. Evaluated by ___ and
deemed to be below baseline, but likely primarily due to
fatigue; recommended home with home ___ but patient declined home
services.
CHRONIC ISSUES
==============
# COPD
Dyspnea likely due to known COPD. Improved with standing duonebs
and continuation of home inhalers.
# Extensive-Stage SCLC
Followed by Dr. ___ at ___. Currently on treatment break after
3 cycles and conclusion of radiation; will repeat PET in 1
month.
>30 min were spent in discharge coordination and counseling
TRANSITIONAL ISSUES
===================
[ ] Needs ophthalmology f/u within 1 week of discharge to
evaluate heaped-up lesion near L optic disk.
[ ] Should continue valacyclovir for 14 day total course
(through ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
2. aMILoride 5 mg PO DAILY
3. Amiodarone 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY
7. LORazepam 0.5 mg PO Q6H:PRN nausea/vomiting/anxiety/insomnia
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
9. Senna 8.6 mg PO BID
10. Torsemide 20 mg PO QAM
11. Torsemide 10 mg PO QPM
12. Vitamin D ___ UNIT PO DAILY
13. Lactulose 30 mL PO Q6H:PRN constipation
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. Glargine 12 Units Bedtime
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Betamethasone Dipro 0.05% Oint 1 Appl TP BID Duration: 14
Days
DO NOT APPLY TO FACE
3. Sarna Lotion 1 Appl TP TID:PRN pruritis
4. ValACYclovir 1000 mg PO DAILY Duration: 9 Days
5. Glargine 12 Units Bedtime
6. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of
breath/wheezing
7. aMILoride 5 mg PO DAILY
8. Amiodarone 100 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. Lactulose 30 mL PO Q6H:PRN constipation
12. Levothyroxine Sodium 100 mcg PO EVERY OTHER DAY
13. LORazepam 0.5 mg PO Q6H:PRN
nausea/vomiting/anxiety/insomnia
14. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
16. Senna 8.6 mg PO BID
17. Torsemide 20 mg PO QAM
18. Torsemide 10 mg PO QPM
19. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
#Localized Herpes Zoster
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because of weakness and difficulty
breathing. We didn't find any signs of infection. We talked
about doing an MRI of your head but you declined. You then
developed some pain on your forehead and we found a rash there,
consistent with shingles and started you on an antiviral.
We asked the ophthalmology doctor ___ doctor) to evaluate you
because of the shingles and she noted that there was an
abnormality on the back of your eye. It's unclear if this is
something that has been there before or something new. It could
potentially be related to your cancer or an infection. It is
very important for you to see your eye doctor within ___ week of
leaving the hospital.
When you get home, continue your medications.
It was a pleasure caring for you, and we wish you the best.
Sincerely,
Your ___ Oncology Team
Followup Instructions:
___
|
19950400-DS-11 | 19,950,400 | 28,725,883 | DS | 11 | 2167-08-14 00:00:00 | 2167-08-15 12:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
metformin / Lactose
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac catheterization without stenting -- ___
History of Present Illness:
___ with CAD s/p CABG, known occluded SVG to RCA, chronic DOE,
HTN, dyslipidemia and diabetes presents with new onset chest
pain. This morning he was in his usual state of health. His
chest pain began while patient was walking from his car to a
pulmonary appointment this afternoon. His chest pain was in
___ chest and in his left arm, felt like pressure with a
sharp component. He had some dyspnea, but denies nausea or
diaphoresis. It did not radiate to the back. He stopped
walking and took a nitroglycerin, after which his pain resolved.
He was given a full-dose aspirin and EMS was called to
transport him to this facility. Of note he has had chest
pressure/ DOE for ___ years, but this new chest pain is different
and his DOE has gotten progressively worse.
He states that he has been getting chest pain with exertion
frequently. He was in fact scheduled for outpatient
catheterization on ___ following concerning pMIBI.
In the ED, initial vitals were 98.7 75 135/93 14 98% RA. At the
time of presentation he was pain free. Denies fevers,
dizziness, N/V, abdominal pain.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: CABG ___
- PERCUTANEOUS CORONARY INTERVENTIONS: ___, Left main and
3 vessel coronary artery disease. Two of three bypass grafts are
patent. 100% occlusion of RCA.
3. OTHER PAST MEDICAL HISTORY:
- Erectile dysfunction
- Hypercholesterolemia
- HEARING LOSS - SENSORINEURAL, UNSPEC
- Peripheral vascular disease
- Overweight
- Cranial nerve VI palsy
- Neuropathy, diabetic
- T2DM
- DUPUYTREN'S CONTRACTURE
- Lumbosacral radiculopathy
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
T2DM grandmother
___ father
___ cancer paternal aunt, 2 cousins
Physical Exam:
VS: 98.2, 141/76, 69, 18, 96%RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Discharge Exam:
VS: 95.2kg yesterday, 98.8, 122/59-136/61, 61-78, 18, 97-100%RA
I/O. ___, 990/not recorded
GENERAL: ___ man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Crackles at L base, no
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
___ 02:30PM BLOOD WBC-5.3 RBC-4.02* Hgb-12.9* Hct-37.5*
MCV-93 MCH-32.1* MCHC-34.4 RDW-13.2 Plt ___
___ 02:30PM BLOOD Glucose-236* UreaN-20 Creat-0.9 Na-136
K-4.8 Cl-102 HCO3-22 AnGap-17
___ 07:31AM BLOOD UreaN-19 Creat-1.0 Na-139 K-4.5 Cl-102
___ 07:05AM BLOOD ALT-6 AST-17 AlkPhos-71 TotBili-0.4
___ 02:30PM BLOOD cTropnT-<0.01
___ 12:15AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:05AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:31AM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1
CXR
Pleural thickening of the left lateral pleura could represent a
loculated effusion or prominent extrapleural fat. Stable
enlarged cardiac
silhouette.
EKG ___
Sinus rhythm with borderline first degree A-V conduction delay.
Non-specific intraventricular conduction delay. Poor R wave
progression. Non-specific T wave flattening in the limb leads
and lead V6. Compared to the previous tracing of ___ no
significant change.
Cath ___ prelim report
1. Selective coronary angiography of this right dominant system
demonstrated severe native three vessel disease. The LMCA was
diffusely
diseased with a 99% angulated stenosis in the proximal segment.
The LAD
had a 50% ostial lesion and 100% mid-vessel lesion. The LCx had
a 100%
stenosis in OM1. The RCA had a 100% mid-stenosis. The distal
RCA fills
via right-to-right and left-to-right collaterals.
2. Venous graft angiography of the SVG-OM1 was widely patent.
The
SVG-PDA was known to be occluded and thus no attempts were made
to
re-visualize.
3. Arterial conduit angiography of the ___-LAD demonstrated it
to be
widely patent except for a 90% stenosis in the distal segment
which is
small in caliber (1.5mm vessel).
4.
5. Limited resting hemodynamics revealed normal systemic
systolic
arterial pressures, with a central aortic pressure of 119/56,
mean 78
mmHg.
FINAL DIAGNOSIS:
1. Severe left main and native three vessel coronary artery
disease.
2. 2 of 3 bypass grafts are patent.
3.
4. Systemic systolic arterial normotension.
Brief Hospital Course:
___ with CAD s/p CABG, known occluded SVG to RCA, chronic DOE,
HTN, dyslipidemia and diabetes presents with new onset chest
pain concerning for ischemia, s/p cath.
# CORONARIES: CAD s/p CABG in ___. Known ___ occlusion of
RCA. Recent pMIBI showed small area of moderate stress induced
myocardial ischemia in the distribution of a septal artery.
Cath this admission showed the LMCA was diffusely diseased with
a 99% angulated stenosis in the proximal segment. The LAD had a
50% ostial lesion and 100% mid-vessel lesion. The LCx had a
100% stenosis. There was an unsuccessful attempt at PCI to the
left main due to 99% highly eccentric and angulated lesion. He
continued home Isosorbide Mononitrate 30 mg DAILY, Rosuvastatin
(CRESTOR) 20 mg, ASPIRIN 81 MG daily
# PUMP: Grade I diastolic dysfunction per most recent TTE with
preserved LVEF. Continued home Enalapril Maleate 1.25mg qd.
Continued home Atenolol 25 mg daily
# RHYTHM: No known Hx arrhythmia, no events on tele.
# T2DM: c/b peripheral neuropathy, maintained on ISS and
glargine
Transitional Issues:
Coronaries - will followup with Dr. ___ to consider
referral for cardiac surgery in the future.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 72 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
2. Omeprazole 20 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Gabapentin 200 mg PO QID
5. Rosuvastatin Calcium 20 mg PO DAILY
6. Enalapril Maleate 1.25 mg PO BID
hold for SBP<100
7. Atenolol 25 mg PO DAILY
hold for SBP<100 or HR< 55
8. Aspirin 81 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
10. Multivitamins 1 TAB PO DAILY
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 25 mg PO DAILY
hold for SBP<100 or HR< 55
3. Enalapril Maleate 1.25 mg PO BID
hold for SBP<100
4. Fluoxetine 40 mg PO DAILY
5. Glargine 72 Units Bedtime
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Rosuvastatin Calcium 20 mg PO DAILY
10. Nitroglycerin SL 0.3 mg SL PRN chest pain
11. Ranexa *NF* (ranolazine) 1,000 mg Oral BID
RX *ranolazine [Ranexa] 1,000 mg 1 tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
12. Gabapentin 200 mg PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___
___. You came to the hospital after an episode of
chest pain. You underwent a cardiac catheterization to check
your bypass grafts. One of these showed a narrowing in one of
your coronary arteries that could not be stented. You should
continue to take medications to reduce your risk of blockage of
these arteries.
We have added a new medication, Ranexa. Please review your
medication list carefully.
Please follow-up with your physicians as listed below.
Followup Instructions:
___
|
19950425-DS-16 | 19,950,425 | 25,448,746 | DS | 16 | 2145-12-27 00:00:00 | 2145-12-28 11:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R Arm swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old ___ speaking male with history of CHF,
DM2, Alzheimers, CKD, CAD, chronic indwelling foley (secondary
to urinary retention) and HTN who was recently admitted to
___ with acute left frontal ischemic CVA on ___
found to subsequently have complicated UTI requiring PICC line
placement presenting today with right arm pain and swelling.
Patient has advanced dementia, some speech impediment secondary
to the stroke and speaks only ___.
History, per the son's translation given to ___, was that
he was discharged from ___ on ___ but had a urine culture
from that admission turn positive afterward. He was started on
macrobid and PCP did another UA ___ which showed persistant
infection despite pt being asymptomatic (no fever, chills,
urinary sx). Per chart, the urine did appear cloudy at that
time and he returned to ___ on ___ for placement of
peripheral line after the midline placement was unsuccessful; he
got one dose of cefepime at that time. He re-presented to
___ on ___ and had a PICC placed for daily cefepime.
However, ___ noticed on ___ that there was R arm swelling that
was worsening, so the pt was sent to ___.
In the ___, initial VS: 97.6 84 156/75 16 100%. No labs
were drawn. Patient underwent a RUE ultrasound which
demonstrated a DVT and was started on heparin gtt. Patient was
then admitted to ___ for further management. Vitals prior to
transfer were: 98.4, 15, 126/66, 88, 97 RA
On the floor, he has been a little confused and disoriented but
appears to be comfortable and in no acute distress. With the
aid of his son and interpreter, he stated that he didn't think
his arm was swollen and that there was no pain. He did complain
of rectal pain, which his son stated that he has had hemorrhoids
for several years. He had some difficult with speech (L sided
CVA three weeks ago) and seemed to be searching for words with
little success. His son states that he has been seeing a speech
therapist and that he has improved quite a bit.
Past Medical History:
-Dementia
-HTN
-CKD
-CAD
-dCHF
-CVA
-Type 2 DM
-2nd degree heart block
-MRSA UTI
Social History:
___
Family History:
Has an identical twin brother with difficulty walking.
Physical Exam:
Physical Exam:
Vitals: T: 97.7 BP: 161/77 P: 75 R: 18 O2: 97% (RA)
Last finger stick: 194
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
Ext: Warm, well perfused, 2+ pulses, no edema. Has some
erythema along the upper R arm and some swelling. PICC site
identifiable near the swelling.
Exam at discharge:
VS: stable, afebrile, normotensive, 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding,
Ext: Warm, well perfused, 2+ pulses, no edema. Has some
erythema along the upper R arm and some swelling. PICC site
identifiable near the swelling.
Pertinent Results:
Admission Labs:
___ 01:58 WBC 6.5/RBC 3.55*/Hgb 10.7*/Hct 34.4*
___ 09:15 PTT 147*/Plt Ct ___
___ 01:58 ___ 13.0*/PTT 150*/INR 1.2*
___ 01:58 Glu 326/BUN 34*/Cr 1.8*/Na 139/K 4.0/Cl
106/HCO3 27
___ 01:58 Ca 9.3/P 2.9/Mg 2.0
___ 11:31 Urine Color: Yellow/Appear: Hazy/Sp ___: 1.013
DIPSTICK URINALYSIS Blood Nitrite Protein Glucose Ketone Bilirub
Urobiln pH Leuks
___ 11:31 UA Blood: MOD/Nit: NEG/Prot: 100/Glu: TR/Ket:
NEG/Bili: NEG/ Urobili: NEG/pH 5.5/Leuk LG
___ 11:31 Urine RBC 31*/WBC 150*/Bact FEW/Yeast MOD/Epi 0
Discharge Labs:
___ 06:30 WBC 7.3/RBC 3.55*/Hgb 10.4*/Hct 33.3*
___ 06:30 Plt 217 Source: Line-PICC
___ 06:30 ___ 12.9*/PTT 93.5*/INR 1.2*
___ 06:30 Glu 145*/BUN 27*/Cr 1.3*/Na 143/K 4.2/Cl
106/HCO3 27
___ 06:30 Ca 9.4/P 3.3/Mg 2.4
Imaging:
UNILAT UP EXT VEINS US RIGHT ___ 9:26 ___ "Occlusive DVT
involving the right subclavian, axillary, and brachial veins."
Microbiology:
___: Urine culture pending (Prelim: yeast growth)
Brief Hospital Course:
This is an ___ year old man presenting with RUE DVT in the
setting of a PICC for treatment of pseudomonal UTI and recent hx
of CVA.
#1. DVT: Patient presented with RUE DVT provoked by ___. He
has no previous history of DVT. He will require another ___ to
continue IV antibiotic dosage. He was begun on Enoxaparin 80 mg
BID as a bridge to three months of coumadin therapy.
#2. Pseudomonal UTI: Pt has a chronic indwelling foley secondary
to urinary retention (BPH) and a history of several UTI. He
culture positive for Pseudomonas at an OSH that was sensitive to
Cefepime. Catheter was changed during this hospital visit and a
new urine culture with sensitivities was sent out. Pt was
discharged continuing his Cefepime (discharged on day ___ of 14).
The issue of a suprapublic catheter becoming potentially
necessary was communicated to his urologist, Dr. ___ the
family. Urine cultures showed Candidal growth (which was
treated with replacing catheter) and not a significant bacterial
infection.
#3. CVA: Patient had a L sided CVA three weeks ago resulting in
no muscular deficits but some speech impairment. He is improving
with the help of speech therapy.
#4. Chronic Kidney Disease: Most likely diabetic nephropathy.
Per chart review, Stage III disease. His creatinine was slightly
elevated upon admission (1.8) but on day of discharge, it
trended down to 1.3.
#5. Dementia: Pt has Alzheimers disease with significant
sundowning at home. There is some question of whether his
seroquel dosage is sufficient and the family stated they would
follow this issue up with Dr. ___.
#6. Type 2 Diabetes: Per chart review, complicated by
nephropathy and neuropathy. Was well controlled with home
medications during his stay.
#7. CAD/CHF: Patient was euvolemic throughout admission and was
on home medications during his stay.
Transitional Issues:
-F/U with Dr. ___ in ___ days to confirm UTI resolved and
discuss seroquel dosages
-F/U with ___ ___ to monitor INR (to be drawn
by ___ coordinated by Dr. ___ with Dr. ___ suprapubic catheter placement
-F/U Urine culture sensitivities here at ___ and communicate
any new resistances to Dr. ___.
Medications on Admission:
Calcium 600 + VitD 200 PO BID
Vitamin D 1000 units PO Daily
Prozac (Fluoxetine) 20mg PO Daily
Metoprolol ER 50mg PO BID
Furosemide (Lasix) 40 mg PO qAM daily; qPM prn
Omeprazole (Prilosec) 20 mg PO Daily
Seoquel 25 mg PO half-tab at lunch, half-tab at dinner, full tab
qHS
Gabapentin (Neurontin) 100 mg PO BID (qAM, qHS)
Terazosin (Hytrin) 10 mg PO Daily qHS
Trazodone 100 mg PO Daily qHS
Aspirin 325 mg PO Daily
Colace 100 mg PO Daily
Lantus (insulin) 300 mg 18 units daily
Pravastatin 20 mg PO Daily QHS
Hydralazine 20 mg PO TID (Lunch, Dinner, HS)
Lisinopril 5 mg PO Daily ---- held for current admission
Diltiazem HCl (Cardizem CD) 360 PO Daily
Isosorbide 30 mg PO Daily
Acetaminophen 325 mg Daily PRN:pain
Discharge Medications:
1. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
2. gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at
bedtime).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
Disp:*30 Tablet(s)* Refills:*2*
6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
7. gabapentin 100 mg Capsule Sig: One (1) Capsule PO QAM (once a
day (in the morning)).
8. hydralazine 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times
a day).
9. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
10. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) Subcutaneous
Q12H (every 12 hours) for 4 days.
Disp:*8 syringes* Refills:*0*
11. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
12. terazosin 5 mg Capsule Sig: Two (2) Capsule PO HS (at
bedtime).
13. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO BID (2 times a
day).
14. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
15. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H
(every 6 hours) as needed for Rectal Pain (hemorrhoidal).
16. quetiapine 25 mg Tablet Sig: One half tablet Tablet PO
QLUNCH AND QDINNER ().
17. quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
18. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2)
Capsule, Extended Release PO DAILY (Daily).
19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once
a day.
20. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
21. Insulin
Please continue taking your home dose of Lantus as usual (18
units daily).
22. cefepime 1 gram Recon Soln Sig: One (1) Recon Soln Injection
Q12H (every 12 hours) for 5 days.
Disp:*10 Recon Soln(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Upper Extremity DVT
2. Pseudomonal Urinary Tract Infection
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted to ___ with a
blood clot in your right arm and a urinary tract infection.
While you were here, you had your foley catheter replaced and a
repeat urine culture sent which showed some yeast in your urine.
You were given blood thinners to help treat the clot in your arm
and IV antibiotics for the urinary tract infection.
You were STARTED on Coumadin 5 mg by mouth daily
You were STARTED on Enoxaparin 80 mg injection twice a day for 4
days
You were CONTINUED on Cefepime 1 gram twice a day by IV
Please resume all other home medications at the same dose and
frequency as prior to hospitalization.
Followup Instructions:
___
|
19950555-DS-3 | 19,950,555 | 20,460,004 | DS | 3 | 2153-07-23 00:00:00 | 2153-07-24 10:59:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Naproxen / Serax / Xanax / Tetanus / Oyster Shell /
Benzodiazepines
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: Cardiac catheterization
History of Present Illness:
___ y/o M with hx of CAD s/p CABG ___ complicated by ___,
found to have all grafts down, s/p PCI to LAD, stent thrombosis
LAD, delayed revascularization resulting in ___
cardiomyopathy, EF 35%, plavix resistance, HLD, hx of DVT (from
prior ___) presenting with progressively worsening chest pain.
Since ___ prolonged cardiac hospitalizations in ___ has been in cardiac rehab and his been able to
walk ___ miles per day. Yesterday ___ noticed after a 5
minute warmup that he had chest pain, which passed quickly
despite continued exercise, but he then developed chest pain
after 15 minutes on treadmill that persisted today. He worked
today without pain, but developed recurrence walking across
parking lot carrying only a briefcase. Dr. ___ earlier
arranged for him to have stress echo this ___, but given his
discomfort with minimal effort he was advised to come the ED for
further evaluation.
In the ED intial vitals were:98.8 64 121/67 18 99%. ___ had
troponin x 1 which was negative. EKG was consistent with prior
(RBBB, LAFB, anterior Q waves). ___ was given ASA 162 and
admitted to ___.
Vitals on transfer: 66 97/66 15 98% RA
On the floor ___ has no complaints. States his pain is more
pressure like over his chest, relieved with rest. Only present
with exertion. Denies nausea, dyspnea, vision changes.
ROS: On review of systems, s/he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. S/he denies recent
fevers, chills or rigors. S/he denies exertional buttock or calf
pain. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
CARDIOVASCULAR PROBLEMS:
1. CAD, status post all vein bypass (___), SVG to LAD, OM1, D1.
Inability to use LIMA because of poor graft quality. All grafts
subsequently occluded.
2. Status post ___. All grafts down,
PCI of LCX and mid LAD. Acute occlusion of LAD distal to the
stent immediately following the procedure through the second LAD
stent.
3. Status post stent thrombosis LAD, delayed revascularization
at ___ in ___, resulting in ___
cardiomyopathy, EF 35%.
4. Presumed clopidogrel resistance.
5. Ascending aortic ectasia 4cm
6. Remote history of hypertension, now hypotensive in context to
cardiomyopathy.
7. Mixed dyslipidemia ___ -- TC 127, ___ 303, HDL 33, LDL 33,
VLDL 61 and atorvastatin 40).
8. Mediastinitis, post CABG.
9. Questionable history of PE. Briefly on Xarelto. Resolution
of thrombus on subsequent scan three days later.
Social History:
___
Family History:
Brother with history of CHF, died in ___ (thought to be
congenital), mother with CABG in ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.9 102/67 65 10 99RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of 2 cm above clavicle at 45 degrees.
CARDIAC: RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3
or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 98.3, ___, 18, 98% RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric.
NECK: Supple with JVP of 8 cm above level of sternal angle.
CARDIAC: Bradycardic on exam to 56, prounounced S1, with soft
S2. No m/r/g. No thrills, lifts. No S3 or S4. Right femoral
catheter site covered in bandage that is clean/dry/intact
___, no bruits. Radial pulses 1+, distal pulses (femoral
2+, DP, ___ all 2+).
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
===============
___ 07:45PM BLOOD ___
___ Plt ___
___ 07:45PM BLOOD ___
___
PERTINENT LABS DURING HOSPITALIZATION:
======================================
___ 05:12AM BLOOD ___
___ Plt ___
___ 05:20AM BLOOD ___
___ Plt ___
___ 05:12AM BLOOD ___
___
___ 05:20AM BLOOD ___
___
___ 07:45PM BLOOD cTropnT-<0.01
___ 05:12AM BLOOD ___ cTropnT-<0.01
___ 07:30PM BLOOD cTropnT-<0.01
___ 05:20AM BLOOD cTropnT-<0.01
___ 05:20AM BLOOD ___
___ 05:20AM BLOOD ___
IMAGING/CATHETERIZATION:
========================
___ ECHOCARDIOGRAM:
The left atrium is mildly dilated. Left ventricular wall
thicknesses and cavity size are normal. There is mild to
moderate regional left ventricular systolic dysfunction with
hypokinesis of the septum, ___ anterior walls, and true
apex. The basal inferior wall is also hypokinetic. Overall left
ventricular systolic function is mildly depressed (LVEF= 40 %).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. Mild (1+) aortic regurgitation is seen.
The mitral valve leaflets are structurally normal. No mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Normal left ventricular size. Mild to moderate
regional left ventricular systolic dysfunction consistent with
coronary artery disease involving the left anterior descending
artery. Mild aortic regurgitation. No pericardial effusion.
___ CARDIAC CATHETERIZATION:
Coronary angiography: right dominant
LMCA: normal
LAD: subtotal occlusion after proximal stents followed by long
segment of severe diffuse disease and then total occlusion at
the
origin of the more distal stent(s). No distal collateral
filling.
LCX: focal eccentric ___ instent lesion in OM 1
RCA: 60% focal lesion after PDA; otherwise minor disease
Interventional details
Plan was to attempt to reperfuse LAD beyond prior stents to
assess size of distal vessel to determine whether further
intervention would be feasible. Changed for ___ Fr sheath and
XBLAD
3.5 guide. All lesions were crossed with first a Prowater and
then a Pilot 50 wire into the distal vessel. All were dilated
with sequential inflations with 2.0 balloon with improvement in
the long mid segment but without distal flow. Distal contrast
injection showed short small distal vessel with 90% apical
lesion. This was dilated with the 2.0 balloon and ic NTG given
without change in the caliber of the distal vessel, It was then
clear that there would be no significant distal runoff with
further stenting and the procedure was terminated. Final distal
injection showed small localized perforation; however injection
from the guiding catheter showed persistent total occlusion of
the distal vessel making extension of perforation unlikely.
Angioseal femoral closure.
Assessment & Recommendations
1. Unsuccessful PCI of occluded LAD
2. No further intervention possible and known large anterior
wall
motion abnormality, making medical therapy only option.
Brief Hospital Course:
___ yo M with hx of CAD s/p CABG ___ complicated by ___,
found to have all grafts down, s/p PCI to LAD, stent thrombosis
LAD, delayed revascularization resulting in ___
cardiomyopathy, EF 35%, plavix resistance, HLD, hx of DVT (from
prior ___) presenting with progressively worsening chest pain,
likely secondary to angina pectoris. Chest pain now improved
with rest, and ___ is s/p catheterization.
# CHEST PAIN:
Chest pain most likely angina given that it increases with
exertion, "substernal chest tightness" and decreases with rest.
No associated dyspnea, nausea, diaphoresis. ___ previously
tolerating cardiac rehab well. During hospitalization he
remained pain free, and did not require nitroglycerin gtt or
heparin gtt. Troponins x 4 <0.01, not an ___. He is on a
plant based low cholesterol diet at home, and his LDL was 34.
Despite this, cardiac catheterization
showed progression of his cardiac disease, and was amenable to
angioplasty in the LAD, but not to further stenting. He was
asked to follow up with Dr. ___ further management. He was
discharged on his home medication regimen as below, with Aspirin
raised to 325mg PO qdaily.
HOME REGIMEN:
1. Lisinopril 5 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Prasugrel 10 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Aspirin 162 mg PO DAILY --> 325mg PO qdaily on discharge
6. Furosemide 20 mg PO PRN leg swelling, weight gain
#CAD:
See "chest pain."
- management as above
#___ with EF 40%:
___ was euvolemic, no crackles in lungs or lower extremity
edema. Required no lasix during this hospitalization. CHF is
chronic, and has previously been EF <40%. During this
hospitalization we followed his fluid status, monitored
electrolytes, but did not need to diurese.
- DISCHARGE weight was 161.9 lbs
- ___ require PO lasix after discharge, should discuss with PCP
if signs of volume overload.
- Low salt diet, <4 grams, with daily weights.
#Anema:
Hemoglobin stable at 12.4 on discharge. ___ was offered PPI
this hospitalization and declined.
TRANSITIONAL ISSUES:
- Needs daily weights and follow up with cardiology/primary care
physician
- ___ has plavix resistant disease and is on prasugrel
- Only medication change on this hospitalization was ASA 162mg
daily --> ASA 325 mg daily, and Nitroglycerin sublingual prn
chest pain, other management as per outpatient cardiologist
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 5 mg PO BID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Prasugrel 10 mg PO DAILY
4. Atorvastatin 40 mg PO DAILY
5. Aspirin 162 mg PO DAILY
6. Furosemide 20 mg PO PRN leg swelling, weight gain
7. Multivitamins 1 TAB PO DAILY
8. Cyanocobalamin 200 mcg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Lisinopril 5 mg PO BID
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Prasugrel 10 mg PO DAILY
5. Cyanocobalamin 200 mcg PO DAILY
6. Furosemide 20 mg PO PRN leg swelling, weight gain
7. Multivitamins 1 TAB PO DAILY
8. Aspirin 325 mg PO DAILY
9. Nitroglycerin SL 0.3 mg SL PRN chest pain
PRN anginal symptoms. if no relief after 5 minutes, take
additional nitro tab. ___ repeat x 3 tabs.
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
prn chest pain Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Unstable Angina
Secondary:
Plavix Resistance
Coronary artery disease
Chronic Cardiac Heart Failure (EF<40%)
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to ___ because you
began experiencing chest pain on exertion over the past week.
The chest pain resolved with rest. Given your extensive coronary
artery disease history, you were admitted to the hospital for
further evaluation of your coronary arteries. You were chest
pain free in the hospital, and received a cardiac
catheterization on ___ where it was found that your left
main coronary artery was normal, your LAD had some stenosis
after the proximal stent, then an area of severe stenosis and
occlusion of your more distal LAD stent. Your left circumflex
coronary artery was ___ stenotic, and your RCA had a 60%
stenotic lesion. We were unable to stent the LAD, but were able
to open parts of the vessel via angioplasty, which may relieve
some of your chest discomfort. During the procedure, a small
leak of dye was seen at the very end of your LAD, representative
of a small perforation. You received an echocardiogram that
showed no evidence of that perforation causing any bleeding
around the lining of your heart.
After discharge, it will be important to follow up with your
cardiologist to optimize your medical management. Keep a diary
of the activities that bring on your chest pain. Changes to your
medication regimen in the future may be able to reduce these
periods of chest pain, and you should discuss this further with
your cardiologist.
As we discussed, your hospital studies are available to you via
request to medical records.
It has been a real pleasure caring for you during this
hospitalization, we wish you all the best in your recovery!
Kind Regards,
___ Cardiology
Followup Instructions:
___
|
19950628-DS-11 | 19,950,628 | 26,188,891 | DS | 11 | 2120-09-14 00:00:00 | 2120-09-15 05:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Joint pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female recently started on steroids for severe joint
pain, who presents for worsening pain.
She reports several months of diffuse pain and aches in her
hips, shoulders, hands, and dorsum of feet. There has been no
redness, but there was swelling, and she said her fingers looked
like "sausages" and her toes and dorsum of feet were swollen.
There was also intermittent numbness of her hands. She had been
using Tylenol and ibuprofen with limited relief.
She went for an episodic visit at ___ on ___, where exam was
negative for synovitis per note, and bloodwork and X-rays were
done. X-rays were negative for erosive changes, and bloodwork
was notable for elevated CRP of 9.0, but otherwise a
negative/normal RF, CCP, ___, TSH, Hep B, Hep C, TSH,
LFT's, and Parvo IgM. On ___, 3 days after the visit, a
Prednisone taper was prescribed, starting at 60mg. She took
60mg on ___, 40mg on ___, and 40mg on ___. She had no relief
of her pain. However, she says the swelling improved (although
joint swelling was not documented at last note).
She states that ___ her pain was so bad that she had
difficulty getting to the bathroom, and she wet herself. She has
been in too much pain to walk. She has felt very warm all over
(though no fever), she feels like her skin is flushed, and she
feels a burning sensation in her eyes. She also has one week of
dry eyes. She feels very fatigued, sleeping 20 hours per day,
non-restorative sleep.
No fever or chills, no diarrhea or constipation, no bleeding, no
conjunctivitis, no rash. She had started phenteramine for weight
loss in ___, and had previously taken phenteramine/topiramate in
___.
In the ED
-initial VS were: 97.9, HR 110, BP 170/88, RR 18, 100% RA
-pt received: IV Morphine x2, Toradol, Zofran, 1L IVF, Tylenol
On arrival to the floor, patient reports above story. Also
discussed with her sister at bedside.
Past Medical History:
PTSD
PCOS
Right Kidney Mass, with surveillance reportedly benign per pt
Gestational diabetes
Salivary gland stone
Breast lumpectomy (Right sided, benign)
Seasonal allergies
Social History:
___
Family History:
Sister- ___
Other sister x2- RA (on MTX she thinks)
Cousin- SLE (with kidney disease on HD)
Mother- drug abuse
Father- HTN, alcoholism
GM- DM
Daughter- DM type I, ___'s
Physical Exam:
DISCHARGE:
Temp: 98.9 PO BP: 112/77 L Sitting HR: 80 RR: 18 O2 sat: 98% O2
delivery: Ra
General: Lying in bed, Appears in NAD
HEENT: AT/NC
Neck: Supple
Lungs: CTAB
CV: RRR, Normal S1/S2, no m/r/g
GI: Normal bowel sounds; no pain/tenderness on light or deep
palpation
Ext: Erythematous reticular non-raised blanching rash on
forearms
bilaterally, no excoriations or exudate
Neuro: Aox3, CNs diffusely in tact
Pertinent Results:
ADMISSION:
___ 01:18AM WBC-14.9* RBC-4.08 HGB-13.4 HCT-39.2 MCV-96
MCH-32.8* MCHC-34.2 RDW-13.3 RDWSD-47.2*
___ 01:35AM LACTATE-2.1*
___ 03:03AM GLUCOSE-106* UREA N-11 CREAT-0.5 SODIUM-139
POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-18* ANION GAP-16
PERTINENT:
___ 03:03AM CRP-2.1
___ 03:03AM ALT(SGPT)-15 AST(SGOT)-17 CK(CPK)-39
___ 10:35AM 25OH VitD-20*
___ 10:35AM HIV Ab-NEG
___ 07:57AM BLOOD Calcium-9.7 Phos-3.3 Mg-1.9 Iron-168*
___ 07:57AM BLOOD calTIBC-348 Ferritn-93 TRF-268
___ 07:57AM BLOOD %HbA1c-5.5 eAG-111
IMAGING:
-Hand ultrasound:
IMPRESSION:
No evidence of generalized subcutaneous edema in the hands.
-CT Chest:
IMPRESSION:
1. Subtle ground-glass opacity in the right middle lobe may
represent early
pneumonia. Lungs are otherwise clear except for mild bibasilar
atelectasis.
2. No mediastinal or hilar lymphadenopathy.
3. Mass like areas in the right breast should be further
evaluated with
mammography if not recently performed.
Brief Hospital Course:
___ woman history of PCOS, sialoadenitis admitted with
refractory symmetric polyarthralgias without documented evidence
of synovitis prior to prednisone initiation on ___ status post
extensive rheumatologic work-up without clear etiology.
#Refractory polyarthralgias
Patient presented with 5 months of worsening joint pains in the
hips, shoulders, elbows, and wrists bilaterally with associated
symptoms of dry eyes, finger swelling, and rash. She had been
started on prednisone, however due to refractory pain she was
referred to the hospital for more emergent management. On
admission, Rheumatology was consulted. DDx was broad and
included CTD, sarcoidosis, seronegative RA, vasculitis,
polymyalgia rheumatica, polymyositis, fibromyalgia. Negative
work-up was notable for ___, HbA1C, TSH, hep serologies, CRP,
ESR, RF, HIV, Sjogren's Ab, sed rate, parvovirus, Chikungunya,
CCP, ___, CXR. Other work-up showed low vitamin D, slightly
elevated iron level, normal ferritin, CT chest with question of
breast mass, ophthalmologic exam with dry eye. She was started
on cymbalata for pain along with Tylenol/tramadol, vitamin D
repletion, and her prednisone was discontinued. Her pain
improved from a ___ on admission to a ___ by her third day.
She declined tramadol on discharge for pain, and was discharged
on a regimen of Tylenol/naproxen. She should follow up closely
with her PCP and ___.
TRANSITIONAL ISSUES:
[] Please refer for fibromyalgia ___
[] Started on high dose vitamin D repletion ___ - should
continue weekly x8 weeks and then switch to daily dosing
[] Avoid Qsymia and phentermine given association with
arthalgias
[] CT finding ___:
-Mass like areas in the right breast should be further evaluated
with
mammography if not recently performed
-Question of pneumonia, please reimage in ___ months to ensure
resolution
[] Recommend full outpatient eye exam
#Contact: Name of health care proxy: ___, Phone
number: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 40 mg PO DAILY
2. Loratadine 10 mg PO DAILY
3. Naproxen 660 mg PO Q12H
4. Acetaminophen 1000 mg PO Q6H
Discharge Medications:
1. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN dry
eyes
RX *white petrolatum-mineral oil [Artificial Tears ___
15 %-83 % ___ drops eye PRN Refills:*3
2. Docusate Sodium 100 mg PO BID
3. DULoxetine 30 mg PO DAILY
RX *duloxetine 30 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Vitamin D ___ UNIT PO 1X/WEEK (___)
RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by
mouth qweek Disp #*7 Capsule Refills:*0
5. Acetaminophen 1000 mg PO Q6H
6. Loratadine 10 mg PO DAILY
7. Naproxen 660 mg PO Q12H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Symmetric polyarthralgias
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I ADMITTED TO THE HOSPITAL?
You had severe pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
You were started on medications to help treat your pain
You were evaluated by the Rheumatology team, and an extensive
work-up for a systemic inflammatory disease did not show any
positive results
WHAT SHOULD I DO WHEN I GO HOME?
Take your medications as prescribed
Keep your follow up appointments with your care team
Thank you for letting us be a part of your care!
Your ___ Team
Followup Instructions:
___
|
19950864-DS-10 | 19,950,864 | 22,572,134 | DS | 10 | 2130-07-16 00:00:00 | 2130-07-16 16:46:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dizziness and SOB
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
___ ___ speaking) with history of COPD, latent TB,
and diabetes, AAA, dementia, presents with dizziness. yesterday
he experienced increasing SOB and dizziness with chest
discomfort similar to prior episodes. No fevers. Intermittent
cough. Since waking this morning, has been feeling like he's
going to fall over when he walks with chronic intermittent
headaches.
In the ED, initial vital signs were: 99.0 66 132/78 16 100% RA.
- Exam was notable for: mild dyspnea with speaking, poor air
entry with expiratory wheeze, baseline red eyes, nonfocal neuro
exam
- Labs were notable for: all labs were completely normal.
- Imaging: CTA with multiple pulmonary emboli in the lobar and
distal pulmonary arteries supplying the right middle and right
lower lobes, and left upper lobe segmental pulmonary artery. No
evidence of right heart strain.
- The patient was given: albuterol/ ipratropium nebs and started
on heparin gtt.
- Consults: none.
- Pt was admitted to medicine for: IV heparin.
Vitals prior to transfer were: 99.0 66 132/78 16 100% RA.
Upon arrival to the floor, the patient was interviewed with an
interpreter. He states that his dizziness has resolved. He
intermittently has episodes of vertigo in which the room is
spinning, worse with changes in position. He states that in the
past he has had similar dizzy spells when standing for too long.
He says his breathing is fine and he denies any shortness of
breath or hemoptysis. He denies previous history of blood clots
or family history of blood clots or cancer.
Overnight, he was continued on a heparin drip. He reports
feeling well this morning with none of the dizziness he came in
with. He reports that he still feels somewhat short of breath,
but that he has had respiratory issues for years. He seems to
think that his current SOB is from COPD.
Past Medical History:
Seropositive rheumatoid arthritis
Latent TB
Hepatitis B, continues on lamivudine
Diabetes
COPD continues the inhaler therapy
Medication compliance issues
Social History:
___
Family History:
No h/o autoimmune disease, denies family history of DVT/PE
Physical Exam:
ON ADMISSION:
===============
VITALS: 97.8 F, BP 120-150/50-70, HR ___, RR 20, 98% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, conjunctiva red and injected,
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, moderate air movement.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly. + soft umbilical hernia. Reducible.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema. No tenderness to palpation.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
ON DISCHARGE:
==============
VITALS: 98.8 F, BP 120/690, HR ___, RR 18, 97% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, conjunctiva red and injected,
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, wheezes in the
upper lobes b/l without crackles
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly. + soft umbilical hernia. Reducible.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema. No tenderness to palpation.
SKIN: Without rash.
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ON ADMISSION:
==============
___ 02:15PM BLOOD WBC-5.1 RBC-4.20* Hgb-11.8* Hct-37.1*
MCV-88 MCH-28.1 MCHC-31.8* RDW-14.4 RDWSD-46.2 Plt ___
___ 02:15PM BLOOD Neuts-54.4 ___ Monos-10.3 Eos-1.6
Baso-1.0 Im ___ AbsNeut-2.75 AbsLymp-1.63 AbsMono-0.52
AbsEos-0.08 AbsBaso-0.05
___ 02:15PM BLOOD Plt ___
___ 02:15PM BLOOD Glucose-100 UreaN-17 Creat-0.8 Na-138
K-4.8 Cl-99 HCO3-31 AnGap-13
___ 02:15PM BLOOD ALT-11 AST-19 AlkPhos-60 TotBili-0.4
___ 02:15PM BLOOD cTropnT-<0.01 proBNP-102
___ 02:15PM BLOOD Albumin-3.8 Calcium-9.3 Phos-3.8 Mg-2.0
INTERVAL LABS:
===============
___ 07:35AM BLOOD WBC-5.4 RBC-3.94* Hgb-11.1* Hct-34.6*
MCV-88 MCH-28.2 MCHC-32.1 RDW-14.5 RDWSD-46.5* Plt ___
___ 08:32AM BLOOD WBC-4.8 RBC-4.43* Hgb-12.2* Hct-39.0*
MCV-88 MCH-27.5 MCHC-31.3* RDW-14.4 RDWSD-46.4* Plt ___
___ 07:35AM BLOOD ___ PTT-129.1* ___
IMAGING:
===========
CTA CHEST ___:
1. Pulmonary emboli in the lobar and distal pulmonary artery
supplying the
right middle and right lower lobes, and left upper lobe
segmental pulmonary
artery. No evidence of right heart strain.
2. No acute intra-abdominal process.
3. Multiple thyroid nodules, the largest of which measures 2 cm
on the right.
PA/LAT CXR ___:
Emphysema with mild congestion and edema. Bibasal atelectasis,
mild
cardiomegaly.
DISCHARGE LABS:
=================
no labs on day of discharge
Brief Hospital Course:
___ with seropositive RA, COPD, diabetes, hep B, and latent TB
presenting with dizziness and shortness of breath, with PE noted
on CT-A.
# Pulmonary embolism: Patient no known provoking factors (no
recent surgery/trauma, cancer diagnosis, known thrombophilic
mutations). He does have inflammatory disease such as diabetes
and RA but these are unlikely to be a primary cause of PE. He
was started on a heparin drip. On ___ this was transitioned to
rivaroxaban 15 mg BID.
# Dizziness: based on history, his dizziness seems to be chronic
and intermittent. He did not have any further dizziness
in-house.
# Latent TB: continued isoniazid and pyridoxine
# Rheumatoid Arthritis: continued prednisone. Patient did not
receive MTX in-house.
# COPD: continued home inhalers.
# Hep B: continued lamivudine
***Transitional issues***:
- Appears to be an unprovoked DVT, started on Xarelto ___. Will
need 3 weeks of 15 mg BID before being transitioned to 20 mg
daily. He is approved for 2 weeks of Xarelto but will need a
prior authorization to continue his course after meeting with
his PCP at follow up appointment.
- per PACT team, patient is out of his home dose of prednisone
and folic acid. He will be given a 30-day supply for this with
no refills and should follow up with rheumatology.
- Should receive at least 6 months of anticoagulation. Patient
should be up to date on cancer screening.
- Thyroid nodules noted on CTA, the largest of which measures 2
cm. Thyroid u/s in the outpatient setting recommended.
FULL CODE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
2. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
3. FoLIC Acid 1 mg PO DAILY
4. HydrOXYzine 25 mg PO Q6H:PRN allergies
5. Isoniazid ___ mg PO DAILY
6. LaMIVudine 100 mg PO DAILY
7. Methotrexate 7.5 mg PO 1X/WEEK (___)
8. Omeprazole 20 mg PO DAILY
9. PredniSONE 5 mg PO DAILY
10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. TraMADol 50 mg PO Q6H:PRN pain
13. Acetaminophen 500 mg PO Q8H:PRN pain
14. Pyridoxine 100 mg PO DAILY
15. bimatoprost 0.01 % ophthalmic daily
Discharge Medications:
1. Rivaroxaban 15 mg PO BID Duration: 21 Days
with food
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice daily
Disp #*30 Tablet Refills:*0
2. Acetaminophen 500 mg PO Q8H:PRN pain
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN wheeze
4. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Isoniazid ___ mg PO DAILY
7. LaMIVudine 100 mg PO DAILY
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Omeprazole 20 mg PO DAILY
10. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Pyridoxine 100 mg PO DAILY
12. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
13. Tiotropium Bromide 1 CAP IH DAILY
14. TraMADol 50 mg PO Q6H:PRN pain
15. HydrOXYzine 25 mg PO Q6H:PRN allergies
16. Vitamin D ___ UNIT PO 1X/WEEK (___)
17. Methotrexate 7.5 mg PO 1X/WEEK (___)
18. bimatoprost 0.01 % ophthalmic daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Pulmonary embolism
Dizziness
Secondary diagnosis:
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were dizzy and
short of breath. You were found to have blood clots in your
lungs, called pulmonary embolisms. You were given an IV blood
thinner and started on an oral blood thinner called Xarelto, or
rivaroxaban. Please discuss this new medication with your
doctors.
It was a pleasure taking care of you and we wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
19950864-DS-11 | 19,950,864 | 28,064,275 | DS | 11 | 2130-12-28 00:00:00 | 2130-12-29 10:24:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of glaucoma, ? dementia, COPD, Rheumatoid arthritis,
DVT/PE, who presents after being confused about his PCP
___. Pt reports that yesterday AM, he was notified that
he had an appointment for the next day. He took a nap, woke up
in the afternoon, but thought it was the next morning, and
proceeded to go to ___ for his PCP ___. At ___, given that
he was confused, he was told to go to the ED. He was then
admitted for concern for poor self care.
A community nurse helps patient fills his medication box. He
lives alone as his wife is currently sick and is at nursing
home. He walks with a cane. Reports having good appetite.
Per previous note with community resource nurse: Pt takes the
bus or a taxi to ___ ___ and/or social activities:
such as visiting his wife in the nursing home. He does not have
a lifeline. He says if he does not feel well, he knocks on his
neighbor's door and asks for help. Pt was asked what he would
do if he was alone, not able to get OOB to ask for help. ___ did
not know.
Past Medical History:
Seropositive rheumatoid arthritis
Latent TB
Hepatitis B, continues on lamivudine
Diabetes
COPD continues the inhaler therapy
Medication compliance issues
Social History:
___
Family History:
No h/o autoimmune disease, denies family history of DVT/PE
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
Vital Signs: 98.1 142/71 61 18 98% RA
General: Alert, oriented, no acute distress
HEENT: Erythematous sclera. EOMI. Clear oropharynx.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
============================
Vital Signs: 98.9 120-137/57-71 59-68 ___ 93-98% RA
General: Alert, oriented, no acute distress
HEENT: Erythematous sclera. EOMI. No tonsillar exudates.
Neck: No cervical lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Umblilical hernia,
non-tender, reducible.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
ADMISSION LABS
===================
___ 01:22AM BLOOD WBC-5.9 RBC-4.23* Hgb-11.8* Hct-38.1*
MCV-90 MCH-27.9 MCHC-31.0* RDW-13.8 RDWSD-44.9 Plt ___
___ 01:22AM BLOOD Neuts-60.4 ___ Monos-7.4 Eos-2.4
Baso-0.8 Im ___ AbsNeut-3.59 AbsLymp-1.69 AbsMono-0.44
AbsEos-0.14 AbsBaso-0.05
___ 01:22AM BLOOD Glucose-123* UreaN-13 Creat-1.0 Na-139
K-5.0 Cl-96 HCO3-31 AnGap-17
___ 01:22AM BLOOD ALT-7 AST-14 AlkPhos-70 TotBili-0.4
___ 01:22AM BLOOD Albumin-3.9
___ 01:22AM BLOOD VitB12-230* Folate->20
___ 01:22AM BLOOD ___
METHYLMALONIC ACID (___): 543 H Normal range: 87-318 nmol/L
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final ___:
REACTIVE AT A TITER OF 1:4.
DISCHARGE LABS
==================
___ 12:51PM BLOOD WBC-5.8 RBC-4.46* Hgb-12.6* Hct-40.5
MCV-91 MCH-28.3 MCHC-31.1* RDW-13.9 RDWSD-45.8 Plt ___
___ 12:51PM BLOOD Neuts-61.7 ___ Monos-9.1 Eos-3.1
Baso-0.9 Im ___ AbsNeut-3.59 AbsLymp-1.44 AbsMono-0.53
AbsEos-0.18 AbsBaso-0.05
___ 12:51PM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-137
K-4.9 Cl-99 HCO3-29 AnGap-14
___ 12:51PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2
MICRO:
R/O Beta Strep Group A (Pending) ___:
URINE culture (___): No growth
CXR (___)
Mild interstitial edema. Left basilar opacity may reflect
atelectasis though infection can be considered in the
appropriate clinical setting.
Brief Hospital Course:
Mr. ___ is an ___ y/o ___ speaking man
presenting after mistakenly going to the hospital for an
unscheduled appointment. TSH within normal limits, RPR with
stable titer in the setting of known latent syphilis. Patient
was found to be B12 deficiency with elevated methylmalonic acid.
Supplementation with vitamin B12 was started. Physical therapy,
occupational therapy evaluated patient and recommended initially
that he be discharged to a rehabilitation facility, subsequently
revised their suggestion to home with ___ supervision. It was
determined that safest discharge would be to with his sister
with services, to which both he and she were agreeable.
#Self care:
Patient lives alone. In light of gait instability observed by ___
and concern by OT that he sometimes forgets to turn off the
stove, ___ supervision was advised. Much has been done in the
past to try to assist the patient. He has frequent follow-up
with his PCP, ___ extensive resources through HCA.
Following extensive discussion with case management, it was
determined that he did not qualify for ___
rehabilitation, and other placement options were financially
prohibitive. Following extensive discussion with his PCP and
case management, it was determined that safest discharge would
be to live with his sister, to which both the patient and his
sister were agreeable. A multidisciplinary family meeting,
including both inpatient and outpatient providers, was held on
the day of discharge, with emphasis to the patient and his
sister on the importance of his new living arrangements for his
optimal safety.
#Confusion/dementia
Patient appears back at baseline. TSH within normal limits. RPR
titer stable; in discussion with his ID provider, Dr. ___,
___ stable titer, recent rule-out for neurosyphilis, and
recent treatment for latent syphilis, no further work-up or
treatment needed at this time. Patient may be b12 deficient as
discussed below.
#B12 deficiency
Patient with low B12 level with elevated methylmalonic acid. ___
be secondary to PPI use and poor absorption. Started B12
supplementation with 1000mcg daily.
#Glaucoma:
Continues to have bilateral eye pain and erythematous sclerae.
Patient has appt with ophthalmologist on ___. Per
ophthalmology, his glaucoma has been difficult to control. His
conjunctival hyperemia is secondary to his eye drops which helps
to control his pressures. Continued home eye drops:
dorzolamide/timolol.
#Sore throat
___ be viral pharyngitis. Centor score of 1, therefore unlikely
strep pharyngitis. Was given lozenges for symptomatic relief.
Patient continued to have persistent sore throat. Swab for strep
pharyngitis pending at discharge and subsequently returned
negative.
#Weight loss: Outpatient PCP performing occult malignancy
work-up. Weight appears back up at 200lb on this admission.
Continue outpatient workup. Patient was seen eating well while
hospitalized. ___ be due to poor access to food.
#Pulmonary Embolism
Continued xarelto for 6 months of treatment (last dose ___.
#History of hepatitis B.
Continued lamivudine.
#Seropositive rheumatoid arthritis.
Continued prednisone 5 mg daily and methotrexate 25 weekly
#COPD
Continued home tiotroprium, and albuterol prn
#Gerd:
Continued omeprazole 20mg BID.
# Chronic Back Pain:
Continued home tramadol
***TRANSITIONAL ISSUES***
- Pt has chronic glaucoma, pain in eye, and conjunctival
hyperemia. Has an appointment with ophthalmologist on ___.
- Patient with B12 deficiency, persistent sore throat, weight
loss, consider workup of possible malignancy, as has been
ongoing in the outpatient setting.
- Consider further work-up of etiology of vitamin B12
deficiency, including IF Ab and EGD.
- Continue to monitor vitamin B12 level and MMA; oral
supplementation was chosen for patient convenience, but may
consider IM injections if deficiency does not improve with oral
supplementation or concern for malabsorption.
New medications: Vitamin B12 1000mcg
# CODE: full
# CONTACT:
Name of health care proxy: ___
___: sister
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. FoLIC Acid 1 mg PO DAILY
5. LaMIVudine 100 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. PredniSONE 5 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. TraMADol 50 mg PO Q6H:PRN pain
10. Vitamin D ___ UNIT PO 1X/WEEK (___)
11. Methotrexate 7.5 mg PO 1X/WEEK (___)
12. Rivaroxaban 20 mg PO DAILY
13. Loratadine 10 mg PO DAILY
Discharge Medications:
1. Cepacol (Sore Throat Lozenge) 1 LOZ PO TID sore throat
RX *dextromethorphan-benzocaine [Sore Throat and Cough] 5 mg-7.5
mg 1 lozenge(s) by mouth twice a day Disp #*1 Package Refills:*0
2. Cyanocobalamin 1000 mcg PO DAILY
RX *cyanocobalamin (vitamin B-12) 1,000 mcg 1 tablet(s) by mouth
daily Disp #*90 Tablet Refills:*3
3. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*90
Capsule Refills:*0
4. Acetaminophen 500 mg PO Q8H:PRN pain
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puffs inhaled four
times a day Disp #*1 Inhaler Refills:*0
6. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
RX *dorzolamide-timolol (PF) [Cosopt (PF)] 2 %-0.5 % 1 drop
topical twice a day Disp #*60 Package Refills:*3
7. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
8. LaMIVudine 100 mg PO DAILY
RX *lamivudine 100 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*3
9. Loratadine 10 mg PO DAILY
10. Methotrexate 7.5 mg PO 1X/WEEK (___)
11. PredniSONE 5 mg PO DAILY
12. Rivaroxaban 20 mg PO DAILY
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*90 Tablet Refills:*0
13. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
inhaled daily Disp #*1 Capsule Refills:*0
14. TraMADol 50 mg PO Q6H:PRN pain
15. Vitamin D ___ UNIT PO 1X/WEEK (___)
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth weekly Disp #*12 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Poor health literacy
B12 deficiency
SECONDARY:
Glaucoma
Chronic Obstructive Pulmonary Disease
History of Pulmonary Embolism
History of hepatitis B
Rheumatoid Arthritis
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 caring for you
Why you were admitted?
- You were admitted because there was concern about your safety
at home.
What we did for you?
- Physical therapy evaluated you and recommended that you go to
a rehab facility, but unfortunately due to financial
constraints, this could not be rearranged. It was determined
that it was safest for you to be discharged to your sister's
house.
What you should do when you go home?
- Continue taking all your medications as prescribed and go to
the appointments that we have arranged.
We wish you the best,
Your ___ team
Followup Instructions:
___
|
19951068-DS-15 | 19,951,068 | 23,671,976 | DS | 15 | 2113-03-04 00:00:00 | 2113-03-04 22:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
s/p fall off bicycle
Major Surgical or Invasive Procedure:
Paraverterbral catheters placed at T3 and T6 for pain control.
History of Present Illness:
___ yo male who was in his usual state of health then
while he was riding his bike hit a patch of sand and crashed his
bike. This resulted in head strike and LOC. He was transferred
to ___ from ___ with scans demonstrating sylvian
fissure/frontal sucus SAH, rib fractures, and a right clavicular
fracture. He c/o
back pain. He denied any HA/N/V, dizziness, or visual changes.
Past Medical History:
migraines
Social History:
___
Family History:
N/C
Physical Exam:
Vitals: Temp 98.8 PO, BP 113/81, HR 88, RR 16, SaO2 98% RA
Gen: A&Ox3, NAD.
HEENT: PERRLA, EOMI
Neck: Supple.
Pulm: CTAB, normal WOB
CV: RRR, WWWP
GI: soft, NT/ND
Extrem: Warm and well-perfused. Right arm in sling, abrasions
over right posterior shoulder. Chest wall TTP.
Neuro: CN II-XII grossly intact
Pertinent Results:
___ 02:09AM BLOOD WBC-6.8 RBC-4.69 Hgb-14.4 Hct-43.5 MCV-93
MCH-30.7 MCHC-33.1 RDW-12.9 RDWSD-43.3 Plt ___
___ 04:43PM BLOOD Neuts-69.6 Lymphs-16.7* Monos-10.6
Eos-2.2 Baso-0.4 Im ___ AbsNeut-5.74 AbsLymp-1.38
AbsMono-0.87* AbsEos-0.18 AbsBaso-0.03
___ 02:09AM BLOOD Plt ___
___ 04:43PM BLOOD ___ PTT-29.8 ___
___ 02:09AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.0
___ 11:12AM BLOOD pH-7.42 Comment-GREEN TOP
___ 11:12AM BLOOD Glucose-127* Lactate-1.0 Na-134 K-4.2
Cl-95* calHCO3-27
___ 11:12AM BLOOD Hgb-15.8 calcHCT-47
___ 11:12AM BLOOD freeCa-1.11*
CHEST (PORTABLE AP)Study Date of ___ 5:06 PMIMPRESSION:
Since the prior radiograph of 1 day earlier, a tiny right apical
pneumothorax
has slightly decreased in size. Cardiomediastinal contours are
normal.
Patchy bibasilar opacities may reflect atelectasis or
aspiration. Acute right clavicular fracture is again
demonstrated.
CT HEAD W/O CONTRASTStudy Date of ___ 9:33 AM Expected
evolution of the subarachnoid hemorrhage seen on ___ and
interval improvement in the right posterior scalp hematoma
without evidence of new hemorrhage.
Brief Hospital Course:
The patient transferred to ___ from ___ after a bicycle
accident. He presented to the the Emergency Department on
___. Pt was evaluated upon arrival to ED by ACS and
neurosurgery. Given findings of significant pulmonary contusion
in addition to his rib ractures, the patient was admitted under
ACS to the ICU for observation and monitoring. Bilateral pain
catheters were placed by the acute pain service with good
effect. The following day he remained stable and was transferred
to the floor, maintaining his oxygen saturations and breathing
comfortably on room air. However the patient remained in house
for several more days for pain control and observation.
Neuro: The patient was alert and oriented throughout
hospitalization. Pain management regimen was as per the
recommendations of APS and CPS at the time of discharge.
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 given 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, 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 diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*40 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
do not take if you are having diarrhea
RX *bisacodyl 5 mg 1 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
3. Senna 8.6 mg PO DAILY
do not take if you are having diarrhea
RX *sennosides [senna] 8.6 mg 1 tab by mouth once a day Disp
#*20 Tablet Refills:*0
4. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour apply 1 patch to skin once a day Disp
#*14 Patch Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QPM
RX *lidocaine 5 % apply over ribs once a day Disp #*7 Patch
Refills:*0
6. Gabapentin 900 mg PO TID
RX *gabapentin 300 mg 3 capsule(s) by mouth three times a day
Disp #*60 Capsule Refills:*0
7. Docusate Sodium (Liquid) 100 mg PO BID
do not take if you are having diarrhea
RX *docusate sodium 100 mg 1 tab by mouth twice a day Disp #*30
Capsule Refills:*0
8. Diazepam 5 mg PO Q6H:PRN spasm, pain, insomnia
do not drive or drink alcohol while taking this medication
RX *diazepam 5 mg 1 tablet by mouth twice a day Disp #*10 Tablet
Refills:*0
9. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*40 Tablet Refills:*0
10. LevETIRAcetam 1000 mg PO BID Duration: 6 Days
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*5 Tablet Refills:*0
11. Morphine SR (MS ___ 30 mg PO Q8H pain
do not drive or drink alcohol while taking this medication
RX *morphine 30 mg 1 capsule(s) by mouth every eight (8) hours
Disp #*40 Capsule Refills:*0
12. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive or drink alcohol while taking this medication
RX *oxycodone 10 mg ___ tablet(s) by mouth every four (4) hours
Disp #*70 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
subarachnoid hemorrhage
right posterior scalp hematoma
right clavicular fracture
right ___ rib fractures
right upper lobe pulmonary contusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ and
underwent observation and management for your injuries and rib
fractures after your bicycle accident. You are recovering well
and are now ready for discharge. Please follow the instructions
below to continue your recovery:
* Your injury caused ___ rib fractures which can cause severe
pain and subsequently cause you to take shallow breaths because
of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Take all medications a prescribed including Keppra until ___.
Please begin to wean your narcotic dosage.
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
Followup Instructions:
___
|
19951079-DS-7 | 19,951,079 | 25,030,566 | DS | 7 | 2165-12-07 00:00:00 | 2165-12-06 11:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
brain mass found on OSH MRI
Major Surgical or Invasive Procedure:
___ Left craniotomy and biopsy of Left temporal lesion
History of Present Illness:
___ RHD male with 6 months of increasing headaches,
confusion, episodes of weakness, and with recent fall. Was seen
at ___ (___) where a head CT and MRI showed a left sided
brain mass with midline shift so pt was transferred to ___ for
further treatment
Past Medical History:
denies
Social History:
___
Family History:
NC
Physical Exam:
PE: VS 99.2 76 140/91 98% RA
NAD
A&Ox2
PERRL
EOMI
CN's ___ intact
Right sided pronator drift
No deficit on finger-nose-finger
Significant expressive aphasia
Motor: ___ throughout both UE's and ___
Sensation intact throughout both UE's and ___
On Discharge:
Alert and attentive
Right hemiparesis
significant aphasia, unable to follow commands
Pertinent Results:
CT head ___:
Large L temporal lesion with vasogenic edema and cytic or
necrotic regions within lesion
MRI head ___:
Large left frontal temporoparietal complex enhancing lesion
causing mass
effect over the left lateral ventricle, midline shift to the
right, and
dilatation of the right lateral ventricle due to obstruction at
foramen of
___. Two other satellite lesions are noted in the left
frontal lobe as well as in the left cingulate gyrus extending to
the corpus callosum. Differential diagnosis may represent
glioblastoma multiforme or other high-grade glioma. Metastatic
disease is less likely but also in the differential diagnosis.
Stable left tentorial herniation, stable since ___.
CT Head ___:
IMPRESSION: Expected post-surgical changes status post left
frontal
craniotomy, with subcutaneous emphysema, small amount of
pneumocephalus, and possible small hemorrhage in the biopsy bed.
The presence of hemorrhage is difficult to assess, given the
intrinsically hyperattenuating character of large portions of
the tumor, as seen on the OSH CT.
Otherwise, there is little change in comparison to the recent
MRI, which
demonstrated a large, complex left frontotemporoparietal
enhancing lesion and two satellite nodules. There is unchanged
mass effect with 13 mm rightward shift of midline structures,
dilatation of the right lateral ventricle due to obstruction at
the foramen of ___, and left uncal and transtentorial
herniation.
CT Head ___:
IMPRESSION:
1. Stable mass effect from frontotemporoparietal brain mass,
when compared to previous study obtained roughly 13.5 hours
earlier. No evidence of new large hemorrhage or infarction.
2. Stable and expected post-operative changes related to left
frontotemporal craniotomy.
CXR ___: Left PICC line was inserted in the interim with its
tip in the right atrium and should be pulled back for about 5
cm. Heart size and mediastinum are unremarkable. Lungs are
essentially clear with no pleural effusion or pneumothorax.
CXR ___: The left PICC line now is at the level of mid SVC.
Heart size and mediastinum are unremarkable. Lungs are clear.
Brief Hospital Course:
___ y/o M with 6 months or worsening headaches, change in MS,
presents from OSH with large L temporal lesion. He was placed on
20mg of decadon and admitted to the neurosurgery service for
monitoring and treatment. He was admitted to the ICU for q1h
neuro checks. On exam, patient had expressive aphasia and R
pronator drift, but was otherwise stable. On ___, surgery was
discussed with patient and his family. His exam remained stable.
He was continued on decadron 6mg Q6H and left in ICU for close
monitoring. On ___, he was taken to the OR for L craniotomy.
___ Patient's mental status declined marked by increased
lethargy and confusion. A CT of the head was obtained that
showed increased cerebral edema and midline shift. He was
started on hypertonic saline and mannitol to attempt to and
serial Na and Osm were monitered.
His mental status did not improve and on ___ a discussion was
undertaken with the family who did not want to pursue further
aggressive care given patient's clinical status and diagnosis of
malignant glioma. The hypertonic saline and mannitol were
discontinued. Palliative care was consulted to provide support
and transition for the patient and family to hospice and he was
transferred to the regular floor.
He was without complaints of pain on the weekend ___ to
___. The patient was started on a regular diet per his
request.
He remained stable while hospice planning was discussed with the
family.
On ___ he developed a mild fever that was managed with
acetaminophen. A bed was available on ___ for hospice and he
was cleared for discharge.
At the time of discharge he was tolerating a regular diet with
stable vital signs.
Medications on Admission:
none
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Left temporal lesion
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
Have a friend/family member check your incision daily for
signs of infection.
Take your pain medicine as prescribed.
Exercise should be limited to walking; no lifting, straining,
or excessive bending.
You may wash your hair only after sutures have been removed.
You may shower before this time using a shower cap to cover
your head.
Increase your intake of fluids and fiber, as narcotic pain
medicine can cause constipation. We generally recommend taking
an over the counter stool softener, such as Docusate (Colace)
while taking narcotic pain medication.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion or change in mental status.
Any numbness, tingling, weakness in your extremities.
Pain or headache that is continually increasing, or not
relieved by pain medication.
Any signs of infection at the wound site: redness, swelling,
tenderness, or drainage.
Fever greater than or equal to 101° F.
Followup Instructions:
___
|
19951664-DS-20 | 19,951,664 | 25,366,197 | DS | 20 | 2159-10-09 00:00:00 | 2159-10-11 21:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M h/o EtOH abuse, HTN, and probable depression who
presented to the ED s/p fall of uncertain etiology.
The patient reports taht he woke up on ___ feeling unwell. He
states that he was tired and depressed (he has been depressed
since his wife died from GYN ca last year). He went back to
sleep from 8am - 1pm, when he awoke and drank an uncertain
quantity of vodka (usually goes through a handle every ___
days). He woke at 5pm and left his house when he ran into a
___ trooper who had been sent to check on him (he works as a
___ for the ___). While talking to the trooper, the patient
states that his "legs gave out" and it was uncertain whether or
not he lost consciousness. He denies any nausea, vomiting,
tunnel vision, light-headedness, dizziness, vertigo, chest pain,
or shortness of breath prior to the episode. He does not
describe any post-ictal state. He did not strike his head, but
he did scrape his knee and at the insistence of the trooper he
came to the hospital for evaluation.
In the ED, his vital signs were 97.7 79 119/74 18 99% RA. At
that time, he described a squeezing sensation in his chest that
was intermittent (lasting seconds only) and non-exertional.
There were no associated palpitations, nausea, or shortness of
breath. His exam was unremarkable. His EtOH level was 324, a
troponin negative, CXR without acute process, and EKG remarkable
for LVH and mild <1mm ST changes. He was admitted to medicine
for workup with stable vitals.
On arrival to the floor, he was reportedly comfortable and ate
well. His CIWA overnight peaked at 11 and he refused
benzodiazepines. On interview this morning, he endorsed
depression but denied any chest pain, shortness of breath,
diaphoresis. He states that his exercise tolerance is unchanged
but that he does get rather sweaty walking whereas he previously
did not.
Past Medical History:
- No other prior hospitalizations, has not seen PCP in over ___
years
- tongue polyps: discovered about ___ years ago when he was a
test patient at ___. States has somewhat
decreased in size since first noticed and are intermittently
painful.
Social History:
___
Family History:
- Dad, died of cancer (?in chest or blood vessels)
- Mom, age ___. no known cancers or hypertension
- 2 daughters, healthy
Physical ___:
Admission exam:
VS 98.9 169/93 93 18 96 RA LS 960 (IVF)/ BR
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, ___ murmur best heard at the aortic
position, early peaking without radiation to the carotid
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP, no c/c/e
NEURO CNs2-12 intact, left eye ptosis aside, motor function
grossly normal. He was tremulous at the time.
SKIN no ulcers or lesions
Discharge exam:
VS 98.4 159/88 (SBPs 152-179) 66 (60s-70s) 18 99% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, ___ murmur best heard at the aortic
position, early peaking without radiation to the carotid
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP, no c/c/e
NEURO alert, fluent, linear, prompt, mild left eye ptosis, motor
function grossly normal. He was tremulous at the time.
SKIN no ulcers or lesions
Pertinent Results:
Admission labs:
___ 08:00PM BLOOD WBC-5.5 RBC-4.87 Hgb-16.5 Hct-48.5
MCV-100* MCH-33.8* MCHC-34.0 RDW-13.3 Plt ___
___ 08:00PM BLOOD Neuts-62.7 ___ Monos-5.7 Eos-0.9
Baso-0.7
___ 08:00PM BLOOD ___ PTT-23.9* ___
___ 08:00PM BLOOD Plt ___
___ 08:00PM BLOOD Glucose-85 UreaN-13 Creat-0.8 Na-140
K-4.4 Cl-101 HCO3-23 AnGap-20
___ 08:00PM BLOOD ALT-147* AST-290* AlkPhos-61 TotBili-0.4
___ 08:00PM BLOOD proBNP-65
___ 08:00PM BLOOD Calcium-8.9 Phos-3.5 Mg-2.3
Discharge labs:
___ 06:00AM BLOOD WBC-7.7 RBC-4.68 Hgb-15.8 Hct-47.2
MCV-101* MCH-33.8* MCHC-33.5 RDW-13.1 Plt ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD Glucose-106* UreaN-14 Creat-0.7 Na-142
K-4.4 Cl-104 HCO3-29 AnGap-13
___ 06:00AM BLOOD Calcium-9.6 Phos-4.5 Mg-2.1
Other pertinent labs:
___ 08:00PM BLOOD ALT-147* AST-290* AlkPhos-61 TotBili-0.4
___:39PM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:25PM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:00PM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD proBNP-65
___ 06:00AM BLOOD VitB12-576 Folate-14.0
___ 06:00AM BLOOD %HbA1c-5.6 eAG-114
___ 06:00AM BLOOD TSH-2.2
___ 08:00PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
EKG ___:
Sinus tachycardia with marked increase in rate as compared with
previous
tracing of ___. Delayed precordial R wave transition.
Consider prior
anterior myocardial infarction. Left ventricular hypertrophy.
Compared to the previous tracing of ___ no diagnostic interim
change.
ECHO ___:
Conclusions
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). There is no left
ventricular outflow obstruction at rest or with Valsalva. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Mild (1+) aortic regurgitation is seen. The mitral
valve appears structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. Mild aortic regurgitation
CXR ___:
FINDINGS: PA and lateral views of the chest provided
demonstrating no focal consolidation, effusion, or pneumothorax.
The heart size is normal.
Mediastinal contour is unremarkable. The imaged osseous
structures are
intact. There is no free air below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
Brief Hospital Course:
___ yo M h/o EtOH abuse, depression, presyncope vs. instability
(thought by neuro alcoholic neuropathy) now presenting with fall
mechanical vs. syncopal.
ACTIVE ISSUES:
# Question Syncope: Likely intoxication (please see EtOH level
on admission) with possible peripheral neuropathy diathesis and
orthostasis as contributing factor. The patient was ruled out
for MI, monitored on telemetry without event, had TTE showing a
largely structurally normal heart, and an EKG not suggestive of
acute processes. CXR was similarly unrevealing. The patient
denied being intoxicated and was surprised at his blood alcohol
level.
# EtOH dependence: No history of seizures. The patient initially
reported drinking a rather modest amount of alcohol, but
eventually He was extremely unreceptive to any suggestion that
diminishing or cessation of alcohol could be beneficial. He
scored on the CIWA the first morning after admission and
psychiatry recommended adding a standing diazepam dose. The
patient refused severeal benzodiazepine doses and was
extraordinarily inquisitive as to the exact pharmacologic
properties of diazepam. Though he was tremulous and diaphoretic
through part of the hospital course, he did not seize. Thiamine,
folate, and MVI were continued. Please see a full description of
LFTs below.
# Transaminitis: The patient's LFTs showed a mild transaminitis
with 2:1 AST:ALT ratio strongly suggestive of alcoholic
hepatitis. He had a low ___. He was extremely unreceptive
to any suggestion that diminishing or cessation of alcohol could
be beneficial.
# Depression: The patient endorsed depression, but denied
suicidal ideation; he stated this was longstanding and related
to the death of his wife. Psychiatry recommended coordination
with a grief counselor (see transitional issues below).
# HTN: The patient's blood pressure was initially normal, but as
his CIWA increased, he did become persistently hypertensive,
though he was asymptomatic. He told us that he has taken his
pressure at home many times and that his high systolic seems to
be in the 150s with a mean that sounds like it is in the 130s.
His regimen was not intensified due to concern that acute HTN
was secondary to alcohol withdrawal and that an
anti-hypertensive regimen titrated to goal in house could induce
hypotension once the patient resumes alcohol at home.
INACTIVE ISSUES:
none
TRANSITIONAL ISSUES:
# Alcohol abuse: He will likely benefit from outpatient
counseling and was given the psychiatry department's number for
an intake appointment to coordinate with the most appropriate
therapist.
# Transaminitis: the patient's liver function should be followed
to ensure that there is no progression.
# HTN: regimen not intensified due to concern that acute HTN was
secondary to alcohol withdrawal and that an anti-hypertensive
regimen titrated to goal in house could induce hypotension once
the patient resumes alcohol at home.
Medications on Admission:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Thiamine 100 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis: mechanical fall
secondary diagnosis: alcoholic hepatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you while you were hospitalized at
the ___. As you know, you were admitted after
a fall after you had been drinking. Our workup did not reveal
any cardiac cause for your fall. Your blood sugar was normal. An
ultrasound of your heart showed a normally sized left ventricle
and left atrium without tightening of your aortic valve.
Psychiatry spoke to you about your depression and the usefulness
of following up with an outside therapist for grief counseling.
Your liver function tests were elevated in a pattern that is
suggestive of alcohol-induced damage. It is important that you
stop drinking to avoid further damage (such as cirrhosis) to
your liver. You have two follow-up appointments scheduled for
you below. It is important that you keep this appointment so
that your blood pressure can be properly assessed and treated if
it is high. There are also several lab tests pending that need
to be reviewed at this appointment, including a diabetes test
and vitamin levels.
No changes were made to your medication regimen.
Followup Instructions:
___
|
19951879-DS-18 | 19,951,879 | 21,109,516 | DS | 18 | 2168-11-29 00:00:00 | 2168-11-30 09:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
tunneled line placement for dialysis
History of Present Illness:
___ yo F with T2DM, CKD 5 (plan for dialysis soon), presenting
with worsening shortness of breath. Reports that she gets short
of breath with just a few steps, and sometimes at rest. This has
been present for 2 months. She also admits to ___ edema and
cough. Denies fevers, chest pain, abd pain, n/v/d, or dysuria.
She does admit to constipation, last BM 1 week ago. She reports
being treated for a bilateral ___ cellulitis for 2 weeks with
Bactrim.
ED Course notable for:
Patient given 40mg Lasix and started on insulin gtt. Foley was
placed.
Labs and imaging notable for:
VBG: ___
Lactate: 1.1
K 5.7; BUN 91; Cr 5.8; glucose 317
Trop 0.10; CK 60; MB 3
___ 36147
H/H 8.0/25.4
CXR: Moderate pulmonary edema with small bilateral pleural
effusions, right greater than left.
EKG: NSR, ST depression in V5.
On arrival to the MICU, patient is mildly tachypneic but
speaking in full sentences. She reports improved SOB. She is
experiencing leg cramps.
Past Medical History:
Type II diabetes
right carotid endarterectomy
high grade stenosis of the left carotid artery
HTN
HLD
Glaucoma
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 97.8; HR 73; BP 144/58; RR 22; SpO2 97% nasal cannula
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP at the mandibular angle at 30 degrees
LUNGS: Bibasilar rales, no rhonchi.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, mildly distended. Bowel sounds present,
no rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 1+ pulses, no clubbing, or cyanosis.
1+ edema and mild erythema in bilateral distal ___.
SKIN: warm and dry
NEURO: Moves all extremities.
DISCHARGE PHYSICAL EXAM:
VS: ___ 0423 Temp: 98.3 PO BP: 158/62 R Lying HR: 64 RR: 18
O2 sat: 95% O2 delivery: RA
GEN: Sleeping in bed, comfortable
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB
GI: abdomen soft, nondistended, nontender
EXTREMITIES: Trace pitting edema in lower extremities up to the
knee bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused
Pertinent Results:
ADMISSION LABS:
___ 11:10PM BLOOD WBC-8.3 RBC-2.50* Hgb-8.0* Hct-25.4*
MCV-102* MCH-32.0 MCHC-31.5* RDW-14.9 RDWSD-56.0* Plt ___
___ 11:10PM BLOOD Glucose-317* UreaN-91* Creat-5.8*#
Na-132* K-5.7* Cl-100 HCO3-13* AnGap-19*
___ 11:10PM BLOOD ALT-52* AST-30 CK(CPK)-60 AlkPhos-188*
TotBili-0.2
___ 11:10PM BLOOD CK-MB-3 cTropnT-0.10* ___
___ 11:10PM BLOOD Albumin-4.0 Calcium-8.1* Phos-5.6* Mg-2.6
___ 04:13AM BLOOD calTIBC-294 Ferritn-161* TRF-226
MICRO:
Urine culture ___: PND
Blood culture ___ x2: PND
Imaging:
CXR ___
Moderate pulmonary edema with small bilateral pleural effusions,
right greater than left.
TTE ___
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a normal
cavity size. There is mild regional left ventricular systolic
dysfunction with focal severe hypkinesis to akinesis
of the entire inferior wall and imid to apical nferoseptum (see
schematic) and preserved/normal contractility of
the remaining segments. The visually estimated left ventricular
ejection fraction is 40-45%. There is no
resting left ventricular outflow tract gradient. Diastolic
function could not be assessed. Normal right ventricular
cavity size with normal free wall motion. The aortic sinus
diameter is normal for gender with normal ascending
aorta diameter for gender. The aortic arch diameter is normal.
The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are
moderately thickened with no mitral valve prolapse. There is
severe mitral annular calcification. There is
minimal functional mitral stenosis from the prominent mitral
annular calcification. There is trivial mitral
regurgitation. The tricuspid valve leaflets appear structurally
normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Mild concentric left ventricular hypertrophy with
normal left ventricular cavity size and mild
regional systolic dysfunction most consistent with single vessel
coronary artery disease (PDA distribution).
Minimal mitral stenosis from severe annular calcification.
RENAL US ___. The right kidney is asymmetrically smaller than the left
kidney with
diffuse cortical thinning, suggestive of renal atrophy. No
hydronephrosis
identified.
2. Markedly distended bladder with volume of 1697 cc is
concerning for a
malpositioned Foley catheter.
VENOUS DUP UPPER EXT ___
Clotted right cephalic Vein in the proximal forearm, with thick
wall at the antecubital fossa.
Left upper extremity venous system is patent.
Heavily calcified bilateral brachial a bilateral radial
arteries.
TUNNELED LINE ___
Successful placement of a 23cm tip-to-cuff length tunneled
dialysis line. The tip of the catheter terminates in the right
atrium. The catheter is ready for use.
DISCHARGE LABS
---------------
___ 06:30AM BLOOD WBC-9.5 RBC-2.45* Hgb-7.8* Hct-24.6*
MCV-100* MCH-31.8 MCHC-31.7* RDW-14.9 RDWSD-54.6* Plt ___
___ 06:30AM BLOOD Glucose-102* UreaN-29* Creat-4.1* Na-137
K-3.8 Cl-96 HCO3-28 AnGap-13
___ 06:30AM BLOOD Calcium-8.3* Phos-3.9 Mg-2.0
Brief Hospital Course:
Ms. ___ is an ___ with PMH T2DM and CKD Stage V, who
presented with volume overload, hyperglycemia and metabolic
acidosis in the setting of renal dysfunction, admitted to the
MICU for insulin gtt, then transferred to the floor on a lasix
gtt with resolution of dyspnea and initiation on dialysis ___
after tunneled line placement.
ACTIVE ISSUES:
=============
# End stage renal disease:
# Volume overload:
# Anion gap metabolic acidosis:
Creatinine elevated to 5.8 on admission from 4.3 in ___. She
initially presented with elevated blood glucose in 370s, pH of
7.23, and bicarb of 18, however no urine ketones. Most likely
etiology of acidemia is renal failure. She received 1 amp of
Bicarb. Received Lasix boluses and was started on a Lasix gtt
with good response. Recent records from ___ showed
she was admitted with a similar presentation, however, she
declined initiation of HD at that point. Here at ___, she
eventually agreed to HD initiation. She underwent right tunneled
line placement by ___ on ___ and started on HD the same day. Per
renal team, she was started on Lasix 80mg PO on non-HD days and
continued Sevelamer 800 mg tid with low phos meals. Venous
mapping showed patent left upper extremities. She will need
follow up as outpatient with transplant surgery for AVF
placement. She had negative hepatitis serologies and PPD.
# Enterococcus urinary tract infection:
# Urinary retention:
Patient spiked fever overnight ___. Urine culture grew
enterococcus sensitive to ampicillin. She had initially been
started on Vancomycin, but switched to ampicillin after culture
sensitivities returned. She should continue ampicillin ___ to
___ to complete a 10 day course. She had a failed void trial on
___ a second void trial on ___ patient was able to urinate on
her own.
# Shortness of breath:
# Heart failure with reduced ejection fraction:
Patient presented with shortness of breath with chest X ray
showing moderate pulmonary edema. BNP elevated to 36,147. She
was started on a Lasix drip with good urine output. Likely cause
of shortness of breath was a combination of ESRD and heart
failure. Renal US showed no hydronephrosis or stones. TTE showed
EF 40-45% with regional systolic dysfunction consistent with
single-vessel CAD. Hypoxemic resolved with diuresis and she
received Lasix 80mg PO on non-HD days.
# hyperglycemia:
Initially on insulin gtt, transitioned to subq insulin. ___
was consulted and made recommendations regarding insulin regimen
as reflected in her discharge medications.
# Acute on chronic anemia:
Thought to be anemia ___ CKD. Required no transfusions. Iron
studies within normal limits with only slightly elevated
ferritin. She received iron supplementation and EPO 5000 units
IV q HD.
#Superficial thrombophlebitis
She developed tenderness on the dorsum of her R hand where a
previous IV was attempted. Pain was treated with warm
compresses, Tylenol, and tramadol.
#Glaucoma / dry eye
Continued home timolol and brimonidine eye drops
- Home lotemax NF so continued prednisolone-acetate drops BID
- Continued home systane
#HTN
Continued home amlodipine.
#HLD
Continued simvastatin 20 mg PO daily
TRANSITIONAL ISSUES:
==================
[] Metoprolol 25mg qd was started for heart failure.
[] please continue Lasix 80mg PO on non-HD days
[] All lab draws, IV lines should be on the RIGHT side to save
the left side for fistula placement
[] Consider outpatient cardiology follow-up for likely
underlying CAD
[] Will need f/u with transplant surgery outpatient with Dr. ___
to discuss fistula placement for dialysis
[] Consider hepatitis B vaccine as patient was non-immune during
this hospitalization.
[] please continue ampicillin 500mg PO q12h ___ to ___ to
complete a 10 day course
[] please check hemoglobin in 1 week to ensure anemia is stable
[] please monitor for urinary retention and straight cath/place
foley as needed
[] please monitor blood sugars and adjust insulin accordingly
# Communication: HCP: ___ (___)
# Code: Full, presumed
Billing: Greater than 30 minutes spent on discharge counseling
and coordination of care.
Medications on Admission:
1. amLODIPine 10 mg PO DAILY
2. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID
3. U-100 Levemir 26 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye) DAILY
5. Simvastatin 20 mg PO QPM
6. Nephrocaps 1 CAP PO DAILY
7. Systane Gel (artificial tears(hypromellose);<br>peg
400-propylene glycol) 0.4-0.3 % ophthalmic (eye) Q4H:PRN
8. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
9. Doxazosin 1 mg PO DAILY
Discharge Medications:
1. Ampicillin 500 mg PO Q12H
2. Furosemide 80 mg PO 4X/WEEK (___) volume overload
3. Metoprolol Succinate XL 25 mg PO DAILY
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
5. Vitamin D 1000 UNIT PO DAILY
6. Glargine 12 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
7. amLODIPine 10 mg PO DAILY
8. brimonidine-timolol 0.2-0.5 % ophthalmic (eye) BID
9. Doxazosin 1 mg PO DAILY
10. Lotemax (loteprednol etabonate) 0.5 % ophthalmic (eye)
DAILY
11. Nephrocaps 1 CAP PO DAILY
12. Simvastatin 20 mg PO QPM
13. Systane Gel (artificial tears(hypromellose);<br>peg
400-propylene glycol) 0.4-0.3 % ophthalmic (eye) Q4H:PRN
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
--------
end stage chronic kidney disease
anion gap metabolic acidosis
enterococcus urinary tract infection
urinary retention
volume overload
dyspnea
heart failure with reduced ejection fraction
superficial thrombophlebitis
hyperglycemia
SECONDARY
------------
acute on chronic anemia
type II diabetes mellitus
hypertension
constipation
hyperlipidemia
glaucoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You presented to ___ because you were feeling
short of breath.
-While in the hospital, your blood sugar was found to be high.
You were treated with insulin.
-You had too much fluid in your body and you received medication
to remove this fluid.
-You had an ultrasound of your heart, which showed that it is
not pumping as well as it should.
-You had a catheter line placed and you started dialysis due to
your kidney disease.
After you leave the hospital, it is important that you take your
medications as prescribed and follow up with your doctors in
___.
We wish you the best,
Your ___ medicine team
Followup Instructions:
___
|
19952329-DS-12 | 19,952,329 | 27,949,032 | DS | 12 | 2181-05-29 00:00:00 | 2181-05-29 17:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Chantix / Vicodin
Attending: ___.
Chief Complaint:
Acute hypoxic respiratory failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old female with locally advanced
endometrial cancer on chemotherapy (C5 carboplatin on ___,
asthma, COPD, hypertension, anemia, presenting with shortness of
breath and wheezing.
Patient has had upper respiratory symptoms for the last 2 days
with worsening shortness of breath. Significant wheezing
currently. One nebulizer treatment on route by EMS. No fevers or
chills. Occasional nausea w/o vomiting. No shortness of breath.
Productive of yellow/green sputum. No hemoptysis. No change in
bowel or bladder function. Occasional abdominal pain, none
currently.
In the ED, she was given nebulizers, magnesium, PO prednisone,
and was appearing better clinically. She then had increased work
of breathing, tachypnea, tachycardia, and was put on BiPAP. She
became more tachycardic with diffuse rhonchi on exam and
hypertension with SBPs in 190s. Given additional nebs, c/f
developing flash pulmonary edema so started on nitro gtt, given
Lasix and IV steroids and transferred to ICU for further
management.
Upon arrival to the ICU, patient endorses above history. She has
had a week of respiratory symptoms - cough productive of
yellow-green phlegm and increasing work of breathing. Denies
fevers/chills. Yesterday afternoon she had increased tachypnea,
dyspnea and was brought into ED by her husband ___. He reports
that he walked with her to the bathroom, when she saw her
reflection in the mirror she was distressed and panicked, and it
was subsequent to returning from the bathroom that she became
more acutely tachypneic and required BiPAP. She reports problems
with anxiety in the past esp as related to her chemo and cancer
treatment.
Also reports orthopnea, dysuria, but no hematuria. No leg
swelling, no chest pain. She has not had any problems with
respiration in the past.
Past Medical History:
- COPD with emphysema
- chronic gastritis
- hypertension
- spinal stenosis with neurogenic claudication
- nicotine dependence
- diverticulosis
- serous endometrial cancer
Social History:
___
Family History:
The patient has a family history of no malignancies.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.7F 131 153/93 23 98% BiPAP
GEN: Labored breathing, BiPAP mask on. ___
HEENT: NCAT. No rhinorrhea
NECK: Supple
CV: Tachycardic, regular rhythm. No murmurs rubs gallops
RESP: Labored work of breathing. Diffusely rhonchorous and
wheezing.
GI: Abdomen soft, NTND.
MSK: Moving all extremities.
EXT: No lower extremity edema. DPs palpable bilaterally
SKIN: Appears flushed. Warm, dry. No rashes.
NEURO: AA0x3. No focal deficits.
PSYCH: Appropriate affect and demeanor
DISCHARGE PHYSICAL EXAM:
===========================
Vitals:98.4 BP:103 / 69HR:108R18O2:95RA
General: appears calm, no major resp distress at this time
HEENT: Anicteric, eyes conjugate, MM dry, no JVD
Cardiovascular: tachy RRR no MRG, nl. S1 and S2
Pulmonary: clear b/l on ausculation no crackles
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: No rashes or ulcerations evident
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
Admission labs:
===============
___ 04:15PM BLOOD WBC-12.0* RBC-3.65* Hgb-11.8 Hct-37.0
MCV-101* MCH-32.3* MCHC-31.9* RDW-20.4* RDWSD-74.4* Plt ___
___ 04:15PM BLOOD Neuts-81* Lymphs-5* Monos-9 Eos-0* Baso-0
Metas-1* Myelos-4* NRBC-0.3* AbsNeut-9.72* AbsLymp-0.60*
AbsMono-1.08* AbsEos-0.00* AbsBaso-0.00*
___ 05:24PM BLOOD ___
___ 05:24PM BLOOD D-Dimer-617*
___ 04:15PM BLOOD Glucose-132* UreaN-21* Creat-0.5 Na-137
K-4.5 Cl-101 HCO3-18* AnGap-18
___ 04:30AM BLOOD ALT-16 AST-13 AlkPhos-84 TotBili-0.3
___ 04:30AM BLOOD proBNP-648*
___ 04:30AM BLOOD Calcium-9.6 Phos-5.3* Mg-2.7*
___ 05:46AM BLOOD Lactate-2.9*
___ 04:32PM BLOOD ___ pO2-72* pCO2-40 pH-7.41
calTCO2-26 Base XS-0
CXR ___:
Hyperexpanded lungs, could be secondary to COPD. No focal areas
of
consolidation concerning for infection.
CTA ___. Pulmonary embolus at a branch point between a left lower lobe
segmental and subsegmental vessel. No signs of right heart
strain or infarcted parenchyma 2. Moderate centrilobular
emphysema with increased prominence of diffuse centrilobular
nodules throughout the bilateral lungs which can be seen in
respiratory bronchiolitis or hypersensitivity pneumonitis. No
focal consolidation.
3. Persistent mild bronchial wall inflammation which is likely
chronic.
B/l LENIs ___
Partially occlusive DVT within the proximal left femoral vein is
likely acute.
No DVT within the right lower extremity.
PA/Lat CXR ___
In comparison with the study of ___, there is little
change and no
evidence of acute cardiopulmonary disease. Hyperexpansion of
the lungs with flattening hemidiaphragms is consistent with the
known COPD. No acute focal pneumonia, vascular congestion, or
pleural effusion.
Port-A-Cath tip again extends to the mid to lower SVC.
Discharge labs:
================
___ 04:19AM BLOOD WBC-10.4* RBC-3.47* Hgb-11.0* Hct-34.9
MCV-101* MCH-31.7 MCHC-31.5* RDW-17.7* RDWSD-66.4* Plt ___
___ 03:38AM BLOOD Glucose-111* UreaN-19 Creat-0.5 Na-142
K-4.0 Cl-105 HCO3-26 AnGap-11
MICRO:
___ 9:50 am URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 5:21 pm URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
___ year-old female with locally advanced endometrial cancer on
chemotherapy (C5 carboplatin on ___, asthma/COPD,
hypertension, anemia, presenting with shortness of breath and
wheezing consistent with COPD exacerbation treated initally in
ICU then transferred out of MICU for ongoing management.
# Hypoxic respiratory failure:
# COPD exacerbation:
# Acute PE:
Initially presented with wheezing and hypoxia requiring BiPAP
and high-flow NC and ICU admission. Respiratory viral panel
positive only for rhinovirus, the possible precipitant of her
exacerbation. Flu negative. No consolidation on imaging to
suggest superimposed pneumonia, nonetheless she received a five
day course of azithromycin/CFTX. Her respiratory distress
persisted for several days prompting treatment with prolonged
taper. She will continue slow taper at discharge and has follow
up scheduled with pulmonology for chronic management of her
COPD, which seems to be quite advanced on the basis of imaging.
Additionally, due to ongoing poor respiratory status, CTA was
obtained to investigate other contributing etiologies and
discovered a segmental/subsegmental PE. She was started on
lovenox with plan to discuss possibility of DOAC with her
oncologist on follow up.
#Tachycardia:
#Hypertension:
Patient with known high HRs with baseline the low 100s. Acute
episode of hypertensive urgency and tachycardia in the ED likely
___ in setting of respiratory distress,
steroids, anxiety and multiple nebulizers. BP has improved but
with persistent sinus tachycardia that began to plateau in the
110s. This was initially improving, but again worsened a few
days prior to discharge possibly in the setting of worsening
anxiety around leaving. However, infectious causes and
hypovolemia were also considered due to mildly increasing WBC
despite ongoing wean of steroids. CXR without new consolidation
and blood culture was without growth at time of discharge. She
did have a positive UA from ___ that grew resistant E.coli
though repeat growing mixed flora, albeit RBCs and pyuria
persisted on the UA. After discussion with urology, and given
improving WBC in urine, the patient was discharged off
antibiotics,
# Hematuria:
#History of Hydronephrosis with Stent insitu
Hematuria could be due to initiation of ___ in addition,
patient has stent in place. Discussed with urology who reviewed
chart, patient with no clear evidence of infection and dysuria
is baseline symptom. Creatinine also at baseline. Patinet will
follow up with her urologist Dr. ___ management of
ureteral stent.
# Constipation:
In setting of opioids. Developed loose stool after bowel regimen
thus further medication was held.
#Stage IIIC2 high-grade serous carcinoma of the endometrium.
Diagnosed in ___, C5 Carboplatin / doxil on ___. Was
supposed to get C6 ___ on ___ but held ___
thrombocytopenia (plts 67K) - given overall worsening functional
status, fatigue, weakness, it is unclear if she is still a
candidate for forther chemotherapy, but this can be addressed at
follow up with her oncologist. She did undergo radiation mapping
with plan for first fraction ___.
#Low back pain:
Pt c/o low back pain, reports this is chronic issue and recently
flared. No pain down legs, neuropathy, leg weakness, recent
falls. MRI L spine done ___ without evidence of cord
compression or injury. - continued home pain regimen.
#History of depression: continued home duloxetine. received
occasional Ativan for steroid-related anxiety.
Transitional Issues:
=====================
[] Monitor respiratory as steroids are tapered; ensure she makes
her outpatient pulmonary visit.
[] Transitioning from ___ to DOAC to be discussed at follow
up with her outpatient oncologist.
[] Please ensure patient follows up with her urologist after
discharge.
Code: Full
HCP: ___ (husband) ___
I have seen and examined Ms. ___ on the day of discharge and
reviewed discharge plan with the patient and husband with
___ interpreter. The patient is stable for discharge home
today. >30 minutes on discharge and coordination of care.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB
2. Senna 8.6 mg PO BID:PRN Constipation - First Line
3. DULoxetine ___ 30 mg PO DAILY
4. Gabapentin 300 mg PO TID
5. Acetaminophen 650 mg PO QID
6. Morphine Sulfate ___ 7.5 mg PO TID
7. Oxybutynin 15 mg PO TID
8. Verapamil SR 180 mg PO Q24H
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Asthma/COPD exacerbation ___ infectious trigger
Acute pulmonary embolus
Sinus tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital with shortness of breath and
found to have an asthma/COPD exacerbation likely caused by the
common cold. You were treated with antibiotics, steroids, and
breathing treatments and your symptoms gradually improved over
time. You will still need to complete a few days of steroids and
continue taking an inhaler medication at home.
Additionally, you were also found to have a clot in your lungs
and were started on a blood thinner medication. This will be
given as a shot for now but you can discuss with Dr. ___
___ a pill to take by mouth is an option instead.
In the last few days of your hospitalization, your white count
began to rise and then improved. This may be due to an infection
but after discussion with urology, the decision was made to
discontinue antibiotics. It is important that you follow up with
your urologist for ongoing management of you stent.
Please take all medications as prescribed and follow up with all
appointments as detailed below.
It was a pleasure taking care of you,
Your ___ Care Team
Followup Instructions:
___
|
19953009-DS-6 | 19,953,009 | 27,614,034 | DS | 6 | 2167-06-15 00:00:00 | 2167-06-16 04:16:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bilateral tibial plateau fractures
Major Surgical or Invasive Procedure:
R tibial plateau ORIF ___ ___
History of Present Illness:
___ male presents with the above fracture s/p mechanical
fall. Patient states that he was working when he fell from his
truck and struck the rear bumper. Patient has not been able to
___ and says he cannot bear weight on his bilateral knees. He
presented to the emergency department with plain films were
notable for bilateral tibial plateau fractures.
Past Medical History:
No past medical history
Social History:
___
Family History:
NC
Physical Exam:
Exam:
Vitals: AVSS
General: Well-appearing male in no acute distress. Wearing
unlocked bledsoes.
MSK: RLE: Appropriately painful to palpation with moderate
edema.
Fires gastroc, ta, fhl/fhl, edl/fdl.
SILT in s, s, dp, sp, t nerve distributions.
WWP. Soft compartments.
LLE: Appropriately painful to palpation with moderate edema.
Fires gastroc, ta, fhl/fhl, edl/fdl.
SILT in s, s, dp, sp, t nerve distributions.
WWP. Soft compartments.
Brief Hospital Course:
Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have bilateral tibial plateau fractures and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for right tibial plateau 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. The patient was given ___ antibiotics
and anticoagulation per routine. The patient's home medications
were continued throughout this hospitalization. The patient
worked with ___ who determined that discharge to home with
services was appropriate. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
Gabapentin 100 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six hours as
needed Disp #*100 Tablet Refills:*1
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
hold for loose stools
RX *bisacodyl [Correctol] 5 mg 2 tablet(s) by mouth daily as
needed Disp #*60 Tablet Refills:*0
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 100 mg PO BID
hold for loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily
while taking narcotics Disp #*100 Tablet Refills:*0
5. Enoxaparin Sodium 40 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe subc daily at night Disp
#*28 Syringe Refills:*0
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
don't drink/drive/operate heavy machinery while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*74 Tablet Refills:*0
7. Vitamin D 400 UNIT PO DAILY
8. Gabapentin 100 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
bilateral tibial plateau fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- touch down weight bearing on bilateral lower extremities in
unlocked bledsoes
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
Activity: Activity: Activity as tolerated
Right lower extremity: Touchdown weight bearing
Left lower extremity: Touchdown weight bearing
BLE in unlocked ___ at all times, can come out for skin
checks
Treatments Frequency:
-incisions to be managed at f/u appt
Followup Instructions:
___
|
19953167-DS-13 | 19,953,167 | 29,504,301 | DS | 13 | 2151-03-11 00:00:00 | 2151-03-11 17:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS:
===============
___ 09:00AM BLOOD WBC-8.7 RBC-2.50* Hgb-7.2* Hct-23.1*
MCV-92 MCH-28.8 MCHC-31.2* RDW-18.1* RDWSD-59.7* Plt ___
___ 09:00AM BLOOD Neuts-73.5* Lymphs-11.6* Monos-11.1
Eos-0.5* Baso-1.6* Im ___ AbsNeut-6.39* AbsLymp-1.01*
AbsMono-0.97* AbsEos-0.04 AbsBaso-0.14*
___ 09:00AM BLOOD ___ PTT-37.5* ___
___ 09:00AM BLOOD Glucose-85 UreaN-2* Creat-0.3* Na-138
K-4.3 Cl-99 HCO3-22 AnGap-17
___ 09:00AM BLOOD ALT-20 AST-110* AlkPhos-154* TotBili-3.5*
___ 09:00AM BLOOD Lipase-19
___ 09:00AM BLOOD Albumin-2.5* Calcium-7.6* Phos-4.1 Mg-1.8
___ 09:00AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS*
IgM HAV-NEG
___ 09:00AM BLOOD HCV Ab-NEG
PERTINENT LABS:
===============
___ 06:40AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE
___ 06:40AM BLOOD ___
___ 06:40AM BLOOD tTG-IgA-5
___ 06:40AM BLOOD 25VitD-17*
DISCHARGE LABS:
===============
___ 10:29AM BLOOD WBC-15.6* RBC-3.32* Hgb-9.7* Hct-30.8*
MCV-93 MCH-29.2 MCHC-31.5* RDW-18.6* RDWSD-58.4* Plt ___
___ 10:29AM BLOOD ___ PTT-34.4 ___
___ 10:29AM BLOOD Glucose-124* UreaN-2* Creat-0.3* Na-134*
K-4.1 Cl-101 HCO3-22 AnGap-11
___ 10:29AM BLOOD ALT-17 AST-108* AlkPhos-144* TotBili-4.3*
___ 10:29AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.7
IMAGING:
========
RUQUS ___:
1. Findings not suggestive of acute cholecystitis. Patient is
diffusely
tender, not suggestive of sonographic ___. Gallbladder
contains stones and sludge, but the gallbladder wall is not
distended or edematous.
Pericholecystic fluid is noted, however, patient also has small
volume
ascites.
2. Echogenic liver with nodular contour which is suggestive
cirrhosis or
chronic liver disease.
3. Patent main portal vein. Bidirectional flow in the right
anterior portal vein.
4. Splenomegaly.
5. Small to moderate volume ascites.
CXR ___:
Persistent right basilar atelectasis and small pleural effusion.
Low lung
volumes.
___ paracentesis ___:
1. Technically successful ultrasound guided diagnostic and
therapeutic
paracentesis.
2. 500 cc of fluid were removed and, and 20 cc were sent for
analysis.
MICROBIOLOGY:
=============
Blood cx ___ and ___: Negative
Bland UA ___
Peritoneal fluid: No growth
Brief Hospital Course:
BRIEF HOSPITAL COURSE:
========================
___ year old w/ hx of alcohol use disorder p/w abdominal
distension and pain and scleral icterus concerning for acute
alcoholic hepatitis with alcoholic cirrhosis. She received an
___ paracentesis with no evidence of SBP. She had an EGD
done at ___ ___ without evidence of varies. Her course
was complicated by low-grade fevers, leukocytosis, and RUQ
abdominal pain with normal lipase and OSH CT abdomen/pelvis. Her
pain was managed with Tylenol and oxycodone 5mg. She was
discharged in stable condition with short course of oxycodone
5mg with instructions to never drink any alcohol again.
TRANSITIONAL ISSUES
========================
[ ] Pain control: patient can take Tylenol but no more than 2g
per day. Also sent with prescription for 7 pills of oxycodone 5
mg. She should try and control her pain with acetaminophen
first.
[ ] Patient was counseled to never drink alcohol again given
alcoholic cirrhosis. Please continue to reinforce.
[ ] Vitamin D low. Was prescribed 8 weeks of ___ units
starting on ___. Please recheck level after
repletion.
[ ] Nutritional status is poor due to liver disease. She should
continue ensure shakes to supplement her caloric intake.
[ ] She received 1st dose of hepatitis B vaccine ___.
[ ] Started on new prescriptions given cirrhosis. Please check
labs at follow up with PCP (CMP given transaminitis and new
prescriptions of furosemide and spironolactone)
ACUTE ISSUES:
==============
#Cirrhosis
#Acute alcoholic hepatitis
Patient with abdominal distension, ascites, and jaundice. RUQUS
showing steatosis with nodular liver c/f cirrhosis with patent
main portal vain. Patient etoh history concerning for alcohol
liver disease with new onset of pain, leukocytosis, fever all
consistent with acute alcoholic hepatitis. She underwent
___ paracentesis with no evidence of SBP. She was Hep B
non-immune and received first dose of Hepatitis B vaccine.
Abdominal pain was controlled with Tylenol and intermittent
doses of oxycodone 5mg. Steroids were deferred given DF <32. She
did not undergo additional cross sectional imaging to
investigate the etiology of her abdominal pain since a CTAP from
___ on ___ was normal. Lipase was tested and
was normal.
- HE: AOx3, no asterixis on exam. No history of HE.
- GIB/Varices: EGD ___ without evidence of varies.
- VOLUME/ASCITES: Hypervolemic on exam. Started on
spirinolactone 100mg daily and furosemide 40mg daily
- SBP: No evidence of SBP.
- RENAL: No evidence of renal dysfunction
- COAGULOPATHY: INR continued to be elevated post-Vitamin K
challenge.
- NUTRITION: Advanced diet to 2gm sodium, ensures
#Anemia
Patient presenting with hemoglobin of 7 without known baseline.
No
evidence of overt GI bleeding. Patient does have history of
recent prior metomenorrhagia. She was placed on a PPI briefly
for suspicion of GI bleed, which was discontinued, as she had a
recent EGD earlier in ___ from ___ that was
completely normal without esophageal or gastric varices, ulcers,
or gastritis.
#C/f Etoh withdrawal
#Positive urine tox
Patient was positive for benzo and barb in her urine tox screen
so she may have already been treated for alcohol withdrawal at
___. She was placed on CIWA protocol and did not
require treatment for alcohol withdrawal. She received thiamine
500mg IV x3 days and continued on thiamine 100mg daily.
Nutrition and social work were consulted.
#CODE: presumed full
#CONTACT: ___ ___: Husband)
--- Discharge weight: 63.46 kg (139.9 lb)
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
None
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN Pain -
Severe Duration: 7 Doses
RX *oxycodone 5 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. Spironolactone 100 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. Vitamin D ___ UNIT PO 1X/WEEK (FR) Duration: 8 Weeks
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Acute alcoholic hepatitis
Alcoholic cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you were having
abdominal pain.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- It was discovered that you have scarring in your liver, likely
this is from drinking alcohol. This was giving you pain, fevers,
and making you feel very sick.
- You had fluid removed from your abdomen (called a
paracentesis) which did not show any signs of infection.
- You received the first dose of the hepatitis B vaccine.
- You were started on medications to help with your liver
disease.
- Your pain was controlled with Tylenol and oxycodone.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol again or you will die
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed (listed below). You
have a few new medications since you were diagnosed with liver
disease
- You can take Tylenol (acetaminophen), but you should only take
4 pills a day maximum (less than 2 grams per day). You should
try taking acetaminophen and using the ice or heat packs on your
belly to help with your pain. If you cannot control your pain
this way, it is ok to take a small amount of the oxycodone for
very severe pain. If your pain cannot be controlled this way, it
may be a sign that you are getting sicker and need to see the
doctor urgently.
- It is really important that you eat as much high calorie food
as you can, and that you avoid salty foods. You were seen by the
nutritionist who gave you a list of foods that are best for you.
You should also continue to drink supplements with beneprotein.
- Your vitamin D was low, so you should take high dose vitamin D
once a week for 8 weeks. You received your first dose on ___
___ and left with a prescription for this.
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
19953300-DS-5 | 19,953,300 | 29,165,479 | DS | 5 | 2152-01-06 00:00:00 | 2152-01-06 08:40:00 |
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/Right Lower Quadrant Abscess
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ with complicated history of Crohns
disease who underwent ileocecectomy for his disease on ___
at ___. His post-operative course was complicated by a RLQ
abscess that was drained by ___ at ___ 2 weeks post op. The
collection continued to drain and the drain itself was exchanged
and upsized 2 weeks prior to his presentation today. Over the
past 2 days he complains of worsening lower abdominal pain that
was more generalized than the RLQ pain focally related to his
drain site. He had a CT drain study at ___ on ___ that by his
report showed a fistula between the abscess cavity and the
bowel.
He had scheduled an appointment with Dr. ___ colorectal
surgery at ___ for evaluation for possible need for further
surgical management, but came to the ED due to his change in
symptoms. He has been followed at ___ for the majority of his
GI care. He denies fever, chills, emesis, or diarrhea. He has
continued to tolerate reasonable PO diet.
Past Medical History:
PMH: Crohns disease (dx'd at age ___, previously on azathioprine
and humira)
PSH: ileocectomy at ___ ___, ___ RLQ abscess drainage 2
weeks
post op
Social History:
___
Family History:
Noncontributory
Physical Exam:
Physical Exam at Discharge:
AFVSS
Gen: AAOx3, NAD, cachectic appearing
HEENT: Normocephalic/Atraumatic
CV: Regular rate and rhythm, no murmurs rubs or gallops
Resp: Clear to auscultation bilaterally
Abd: soft, tender to palpation at drain site, nondistended
Ext: +2 pulses bilaterally
Pertinent Results:
___ 03:30PM LACTATE-0.8
___ 03:02PM GLUCOSE-113* UREA N-8 CREAT-0.6 SODIUM-138
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-32 ANION GAP-12
___ 03:02PM estGFR-Using this
___ 03:02PM WBC-8.8 RBC-3.57* HGB-10.5*# HCT-32.1*#
MCV-90 MCH-29.3# MCHC-32.6 RDW-15.0
___ 03:02PM NEUTS-88.1* LYMPHS-6.0* MONOS-4.6 EOS-1.2
BASOS-0.2
___ 03:02PM PLT COUNT-390
CT A/P ___:
Postsurgical changes in the right lower quadrant reflect prior
ileocectomy.
Contrast does not pass beyond the mid ileum. Therefore,
contrast leak from
the anastomosis cannot be assessed. A right abdominal catheter
coils within a tiny collection along the right iliacus muscle.
The collection closely wraps around coiled catheter measuring
approximately 4.4 x 1.9 cm. The collection is smaller when
compared with CT ___ and grossly unchanged since ___. There is marked surrounding stranding and
inflammation of the adjacent soft tissues extending into the
enlarged right iliacus muslce . Communication with bowel cannot
be assessed with this study. Of note, several sideholes in the
drainage catheter are remain inside the abdomen but are outside
of the focal collection (2:47).
Brief Hospital Course:
Mr. ___ presented to ___ for further management of his
right lower quadrant abscess in conjunction with medical
treatment of his Crohn's Disease. After admission, his records
were obtained from ___ (where his
prior ileocectomy and drain placements were performed). His
records were reviewed, the acute pain service was consulted for
pain control, the GI service was consulted for continued
management while the patient was in house, and interventional
radiology was consulted for recommendations regarding placement
of his right lower quadrant drain that was not appropriately
draining.
Neuro: The acute pain service was consulted and recommended a
combination of tylenol, ultram, oxycodone, flexeril, and a
lidocaine patch to the drain site that resulted in significant
improvement in the patient's pain. He noted he was much more
functional and able to perform his activities of daily living
with this regimen.
CV/Pulm: The patient had no cardiopulmonary issues throughout
his hospitalization.
GI: Serial abdominal exams were performed throughout his
hospitalization and his drain was monitored. Gastroenterology
was consulted and the decision was made to give a dose of
Infliximab during his hospital stay and monitor for signs of
improvement in his abdominal exam. Over hospital days ___, the
patient's abdominal pain improved with pain only noted at the
drain site - this was controlled with the regimen described
above. A CT scan showed the drain in place though the side holes
from the drain were not in the abscess cavity. Interventional
radiology was consulted and evaluated the drain after it was
noted to diminished output on ___. The drain output picked
back up after flushing with saline, which the patient will
continue at home.
GU: The patient was voiding independently throughout this
hospitalization.
ID: The patient's fever curves were monitored for signs of
infection of which there none.
Heme: The patient was given subcutaneous heparin throughout his
hospitalization for deep venous thrombosis prophylaxis.
On ___, the patient was discharged to home. At discharge, he
was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. He will ___ in the
clinic in ___ weeks with Dr. ___ as well as Dr. ___ with GI.
___ information was communicated to the patient directly prior
to discharge.
Medications on Admission:
flagyl 500 TID, amoxicillin 875, colace BID, percocet prn
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth Every 8 hours Disp
#*40 Tablet Refills:*2
2. Cyclobenzaprine 5 mg PO TID:PRN abd pain r/t muscle spasm in
abdomen
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth Every 8 hours Disp
#*30 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
Daily Disp #*20 Capsule Refills:*0
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours Disp
#*60 Tablet Refills:*0
6. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth Every 6 hours Disp #*30
Tablet Refills:*0
7. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
8. MetRONIDAZOLE (FLagyl) 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Right lower quadrant abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for
further management of your right lower quadrant abscess/fistula
in conjunction with management of your Crohn's disease. You are
being discharged in stable condition after altering your drain.
You are being discharged on pain medications to help control the
pain associated with your drain. Please take this medications as
directed.
Please monitor your drain site for signs of infection such as
spreading redness and blistering. Please keep this site dressed
appropriately with gauze and tape. Continue to monitor the
output from this drain and record it daily - you should bring
this information to your follow up appointments.
You may resume your regular activities. Do not partake in
activities that may jeopardize the placement of your drain - you
otherwise have no other restrictions.
You may shower with a covered water tight dressing overlying the
drain site.
You are being discharged with antiobiotics. Please take them as
prescribed
Followup Instructions:
___
|
19953300-DS-9 | 19,953,300 | 28,477,924 | DS | 9 | 2153-03-16 00:00:00 | 2153-03-18 15:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Remicade
Attending: ___.
Chief Complaint:
Fever, diarrhea
Major Surgical or Invasive Procedure:
Paracolic abscess drainage
Perirectal abscess drainage
History of Present Illness:
___ with history of Crohn's, perforating ileo-cecal CD s/p
ileo-cecal resection in ___ c/b anastomotic leak s/p resection
and re-anastomosis, who presents w/ persistent fever.
He has had diarrhea x3 per day despite being on steroid taper
that was completed 4 days prior to presentation, occasionally
bloody for months. He also has fever with perirectal pain x 1
week. He was seen ___ in the ED, perirectal abscess was seen
on CT and was drained. He was discharged on percocet for pain
control. He continued to have fever of 102 at home despite
tylenol, and diarrhea. No abdominal pain at rest, only when
___ region and RLQ are palpated. He reports nausea.
Of note, has required anti-TNF but had reaction in infliximab
and had progressive disease on certolizumab. Recently on
prednisone taper for progressive ileal disease on MRI ___.
He completed prednisone taper ___ days prior to presentation and
continues to have diarrhea 3x per day, not nocturnal.
He called Dr ___ ___ and it was noted that he has had
quinolone resistance bacteria in the past, but given failure of
multiple TNFs, lack of insurance coverage for tofacitinib and
recently completing prednisone taper, to start metronidazole and
ciprofloxacin for two week course.
In the ED initial vitals were: 101.3 120 94/54 18 97%. Labs were
notable for WBC 13.3, PMN 82%, normal LFT, K 3.4 and Cr 0.8,
normal UA, lactate 1.3, Hgb 10.3 (baseline), MCV 71, CRP 190.9,
ESR pending at time of admission. Patient was given cipro 400 mg
IV x1, flagyl IV 500 mg x1, ibuprofen PO for fever. CXR showed
no acute process. Pt was seen by colorectal surgery who
recommended admission to GI service. Vitals prior to transfer
were: 100.2 108 108/69 16 100% RA
On the floor, pt has no complaints. He was not aware to avoid
NSAIDS so was advised to avoid NSAIDS.
Review of Systems:
(+) per HPI
Past Medical History:
PMH: Crohns disease (dx'd at age ___, previously on azathioprine
and humira)
PSH: ileocectomy at ___ ___, ___ RLQ abscess drainage 2
weeks post-op
re-do and SBR in ___
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 97.7 101/67 80 18 99RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, 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, tender ___ and RLQ
regions, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals - Tm 99.6, Tc 98.5, 101/62, 85, 18, 97% on RA
GENERAL: NAD
HEENT: clear OP
CARDIAC: NR, RR, no murmurs
LUNG: CTAB, nonlabored
ABDOMEN: nondistended, +BS, minimally tender, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION:
___ 09:20PM BLOOD WBC-13.0* RBC-4.52* Hgb-10.3* Hct-32.1*
MCV-71* MCH-22.7* MCHC-32.0 RDW-16.1* Plt ___
___ 09:20PM BLOOD Neuts-81.7* Lymphs-6.7* Monos-9.9 Eos-0.9
Baso-0.8
___ 05:10AM BLOOD ___ PTT-35.9 ___
___ 09:20PM BLOOD ESR-37*
___ 09:20PM BLOOD Glucose-128* UreaN-8 Creat-0.8 Na-134
K-3.4 Cl-96 HCO3-26 AnGap-15
___ 09:20PM BLOOD ALT-14 AST-15 AlkPhos-82 TotBili-1.0
___ 09:20PM BLOOD Lipase-20
___ 09:20PM BLOOD Albumin-3.7 Calcium-8.5 Phos-2.9 Mg-1.8
___ 09:20PM BLOOD CRP-190.9*
___ 09:50PM BLOOD Lactate-1.3
___ 12:10AM URINE Color-Straw Appear-Clear Sp ___
___ 12:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:10AM URINE
DISCHARGE:
___ 06:35AM BLOOD WBC-6.0 RBC-4.47* Hgb-10.1* Hct-32.4*
MCV-73* MCH-22.5* MCHC-31.0 RDW-16.5* Plt ___
___ 06:35AM BLOOD Neuts-70.9* ___ Monos-5.2
Eos-4.9* Baso-0.4
___ 06:35AM BLOOD ___ PTT-32.4 ___
___ 06:35AM BLOOD Glucose-87 UreaN-10 Creat-0.9 Na-137
K-3.9 Cl-100 HCO3-30 AnGap-11
___ 06:35AM BLOOD Calcium-8.7 Phos-3.9 Mg-2.1
MICROBIOLOGY:
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
MANY POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
___ 2:23 pm ABSCESS Site: PERIRECTAL
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- 1 S
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S 2 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 5:30 pm ABSCESS Site: ABDOMEN
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): BUDDING YEAST.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
BLOOD CULTURES ___: NO GROWTH
IMAGING:
MRI pelvis ___:
IMPRESSION:
1. 19 x 20 x 13 mm intersphincteric abscess arising from a 6
o'clock
(posterior, lithotomy) track from the lower anus, with a tract
extending from the inferior aspect of the collection to the
right perineum.
2. Moderate lower/mid rectal active inflammation, and mild
sigmoid chronic inflammation, reflecting known history of
Crohn's disease.
Drainage of paracolic fluid collection ___:
IMPRESSION:
Successful CT-guided drainage of right pericolic gutter abscess.
1 cc purulent fluid sample was sent for microbiology
evaluation.
CT abd-pelvis with contrast ___
1. 28 mm posterior periabscess abscess, new from the prior exam.
2. Persistent fluid collection with surrounding stranding along
the right paracolic gutter with evidence of a fistulous tract in
the mid pelvis. This is slightly larger in size was a new
lobulated component of the collection xtending superiorly. It is
difficult to determine if it is definitely contiguous. It may be
discrete and immediately adjacent to this existing collection.
3. Soft tissue thickening in the presacral region may be
phelgmonous changes or collapsed rectum.
4. Cholelithiasis without acute cholecystitis.
Brief Hospital Course:
___ year old male with complicated Crohn's disease, recent
perirectal abscess drain, presents with persistent diarrhea and
fever prompting concern for infection vs. Crohn's flare.
# Crohn's disease: perforating ileocecal Crohn's disease s/p
ileocecal resection in ___ c/b anastomotic leak s/p resection
and re-anastomosis, s/p pelvic abscess drain ___, s/p
___ abscess drain ___, presents with persistent
diarrhea and fever concerning for Crohn's flare vs infectious
etiology (including perirectal abscess vs right paracolic
abscess). Stool cultures and C. difficile PCR was negative. MRI
pelvis revealed persistent perirectal abscess, now s/p drainage
on ___ which grew coagulase negative staphylococcus and
enterococcus. Patient also had an ___ aspiration of right
paracolic fluid collection on ___ with fluid culture growing
yeast. ID was consulted and recommended piperacillin/tazobactam
and micafungin in house, switched to ertapenem and micafungin on
discharge (to be continued through ___. GI followed patient
and recommended methotrexate 25 mg IM x 1 which patient received
on ___ and should repeat in 1 week as an outpatient.
TRANSITIONAL ISSUES:
# IV ertapenem and micafungin through ___ via ___
# Follow up with ID in 1 week, prior to end of antibiotic course
# Methotrexate 2nd dose on ___, will be delivered to his home.
# Code: Full - confirmed
# Emergency Contact: HCP/wife ___, ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Micafungin 100 mg IV Q24H
RX *micafungin [Mycamine] 100 mg 100 mg IV daily Disp #*1 Gram
Refills:*0
2. ertapenem 1 gram injection daily
RX *ertapenem [___] 1 gram 1 gram IV daily Disp #*10 Gram
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY: Crohns disease, perirectal abscess, paracolic abscess
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. You were admitted with
fever and diarrhea and you were found to have a fluid collection
by your colon and a perirectal abscess. You were started on an
IV antibiotic and an IV antifungal.
Please keep your follow-up appointments as below. Please return
to the emergency room if you experience fevers, chills, chest
pain, shortness of breath, abdominal pain, worsening diarrhea or
any other new or concerning symptoms.
Additionally, your next dose of methotrexate should be delivered
to you within the week. You should call the GI office if you
have any problems obtaining the medication.
We wish you the best
Followup Instructions:
___
|
19953567-DS-15 | 19,953,567 | 28,931,076 | DS | 15 | 2150-08-11 00:00:00 | 2150-08-11 19:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right arm pain, Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ y/o male with a history of IVDU, now on suboxone
who presented with R arm pain and fever. Patient stated that two
weeks prior to admission, he melted his own buprenorphine and
injected it into his right AC fossa "in order to hit me quicker"
but that he "missed the vein". Subsequently, he had 5 days of
pain, swelling, and redness at the injection site. He also
developed a fever to ___ the day prior to admission, which had
persisted upon arrival. He denied upward streaking or drainage
from the site. He denied chest pain, cough, shortness of breath,
worsening headaches, weakness, or joint pain.
The patient had a history of IV heroine use, reported his last
injection was ___ years ago. Recently, he had been living at a
recovery house and had been on suboxone. He denied other recent
drug or alcohol use.
In the ED, initial vitals: 102.5 113 148/77 18 95% RA
- Exam notable for: systolic murmur; 1cm induration and erythema
in flexural surface of R proximal forearm
- Labs notable for: WBC 9.8
- Imaging notable for: CXR and forearm XR unremarkable
- Pt given:
___ 00:46 IV CefTRIAXone 1 gm
___ 00:46 IVF NS 1000 mL
___ 00:46 PO Ibuprofen 600 mg
___ 03:40 IV Vancomycin 1500 mg
___ 11:14 PO Lorazepam .5 mg
___ 12:18 SL Buprenorphine-Naloxone (8mg-2mg) 1 TAB
- Vitals on the floor: 97.4F BP 124/74 HR 87 RR 18 99% on RA
On the floor, Mr. ___ reported continued pain and redness
over his right forearm. Also describeed ongoing fatigue.
Otherwise, no chest pain, SOB, cough, or joint pain.
REVIEW OF SYSTEMS:
General: Positive for fevers.
Cardiac: no chest pain or palpitations.
Resp: no shortness of breath or cough.
GI: no nausea, vomiting, diarrhea.
GU: no dysuria, frequency, urgency.
Neuro: Occasional headaches. No weakness.
MSK: no arthralgia.
Heme: no bleeding or easy bruising.
Lymph: no swollen lymph nodes.
Integumentary: no new skin rashes or lesions.
Psych: no mood changes.
Past Medical History:
- Depression w/ history of cutting
- Hx of IV heroine use on suboxone
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 97.4F BP 124/74 HR 87 RR 18 99% on RA
General: Alert, oriented, no acute distress. Lying comfortably
in bed.
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple.
CV: Regular rate and rhythm with normal S1 + S2. II/VI SEM heard
over RUSB, LUSB, LLSB. No rubs or gallops.
Lungs: Normal respiratory effort. Clear to auscultation
bilaterally, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no guarding.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. 2x2cm area of erythema, warmth, induration, and
tenderness over right AC. No ___ nodes ___ lesions.
Skin: Warm, dry, erythema over right AC, otherwise no rashes.
Previous cutting scars over left forearm. Multiple tattoos.
Neuro: A&Ox3. CNII-XII grossly intact. Normal strength
throughout.
Mood: Normal mood and affect.
DISCHARGE PHYSICAL EXAM:
=======================
VITALS: T 97.6, BP 93/50, P 64, R 16, O2 sat 98% RA
General: Alert, NAD, lying comfortably in bed.
HEENT: Sclerae anicteric, MMM, neck supple.
CV: Regular rate and rhythm with normal S1/S2. II/VI SEM heard
over LLSB. No rubs or gallops.
Lungs: Normal respiratory effort. Clear to auscultation
bilaterally, no wheezes, rales, rhonchi.
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no guarding.
Ext: Warm, well perfused, 2+ pulses, no cyanosis or edema. 2x2cm
area of erythema, warmth, induration, and very little tenderness
over right AC; erythema slightly improved, induration slightly
worse today.
Skin: Warm, dry, mild erythema over right AC, otherwise no
rashes. Previous cutting scars over left forearm. Multiple
tattoos.
Neuro: A&Ox3. CNII-XII grossly intact. Normal strength
throughout.
Mood: Normal mood and affect.
Pertinent Results:
ADMISSION PHYSICAL EXAM:
======================
___ 11:00PM BLOOD WBC-9.8 RBC-4.69 Hgb-13.6* Hct-41.0
MCV-87 MCH-29.0 MCHC-33.2 RDW-12.2 RDWSD-39.2 Plt ___
___ 11:00PM BLOOD Neuts-63.1 ___ Monos-12.6 Eos-2.0
Baso-0.5 Im ___ AbsNeut-6.20* AbsLymp-2.11 AbsMono-1.24*
AbsEos-0.20 AbsBaso-0.05
___ 11:00PM BLOOD Glucose-128* UreaN-16 Creat-1.0 Na-141
K-4.0 Cl-101 HCO3-25 AnGap-15
___ 11:21PM BLOOD Lactate-1.5
PERTINENT LABS/MICRO:
====================
___ 06:23AM BLOOD HBsAg-NEG HBsAb-Borderline HBcAb-NEG
___ 06:23AM BLOOD HIV Ab-NEG
___ 11:00PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 01:00AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 01:00AM URINE Color-Straw Appear-Clear Sp ___
___ 01:00AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ Blood cultures: NGTD
___ Urine culture: No growth
DISCHARGE LABS:
==============
___ 06:32AM BLOOD WBC-6.2 RBC-4.93 Hgb-14.4 Hct-42.6 MCV-86
MCH-29.2 MCHC-33.8 RDW-12.2 RDWSD-38.5 Plt ___
___ 06:32AM BLOOD Glucose-90 UreaN-16 Creat-0.8 Na-142
K-4.6 Cl-102 HCO3-28 AnGap-12
___ 06:32AM BLOOD Calcium-9.7 Phos-5.1* Mg-2.0
PERTINENT IMAGING:
=================
___ Right Forearm Xray:
No radiopaque foreign bodies are noted.
___ Chest Xray:
No acute cardiopulmonary process.
___ TTE:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). 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. No
masses or vegetations are seen on the aortic valve. The mitral
valve appears structurally normal with trivial mitral
regurgitation. No mass or vegetation is seen on the mitral
valve. There is no pericardial effusion.
___ MSK US RIGHT ELBOW (Preliminary Read):
Superficial thrombophlebitis at the right antecubital fossa. No
sonographic
evidence of abscess.
IMPRESSION: No valvular vegetations or abscesses appreciated.
Brief Hospital Course:
This is a ___ year old male with past medical history of IVDU on
suboxone admitted ___ with R antecubital fossa cellulitis
at the site of an injection drug attempt, status post
initiation of antibiotics with subsequent improvement, imaging
without signs of retained foreign body or abscess, able to be
discharged home on PO antibiotics
# Sepsis secondary to R arm cellulitis
# R arm superficial thrombophlebitis
Patient presented with fever, erythema, pain at right
antecubital fossa following an attempted IV injection of ground
up suboxone. He was found to be tachycardic. Patient was
initially treated broadly with vancomycin given concern for
bacteremia (given history of recent injection). The cellulitis
improved and his blood cultures remained negative for > 72
hours, with a TTE negative for any vegetations. Patient was
transitioned to PO doxycycline with continued clinical
improvement. The erythema resolved, but given persistent
induration at the R antecubitum, he underwent ultrasound to
rule out fluid collection--this showed a superficial
thrombophlebitis. Educated patient on local conservative
management including hot compresses and elevation.
# Opioid Use Disorder
Patient has a history of opioid use disorder and had been
maintained on suboxone via ___ Faster Paths Program. He
presented after trying to inject suboxone two weeks prior to
arrival. He was continued on suboxone here without issues.
Details of his admission were communicated to his ___
clinic.
TRANSIITONAL ISSUES:
===================
[ ] Continue doxycycline 100 mg BID x 5 days (end date ___
[ ] Pt with superficial thrombophlebitis at the right
antecubital fossa. No sonographic evidence of abscess. Monitor
for resolution.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
Discharge Medications:
1. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*7 Tablet Refills:*0
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Sepsis secondary to R arm cellulitis
# R arm superficial thrombophlebitis
# Opioid Dependence
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
Why you were admitted to the hospital:
- You presented with pain and redness in your right arm as well
as a fever, concerning for an infection in your skin and
possibly in your blood stream.
What happened while you were here:
- You were started on intravenous antibiotics to fight the
infection
- An ultrasound of your heart did not show any problems with the
valves in your heart
- You were eventually switched from intravenous antibiotics to
oral antibiotics
- An ultrasound of your arm did not show any obvious signs of
infection, but did show a small clot in a small superficial
vein.
What you should do once you get home:
- Please continue taking the antibiotic (doxycycline)twice
daily, as prescribed
- Please keep all of your appointments, details below
- Put warm packs on the clot, and this will eventually go away
on its own.
We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19953778-DS-9 | 19,953,778 | 28,745,198 | DS | 9 | 2117-01-15 00:00:00 | 2117-01-15 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with unclear medical history admitted for abdominal
pain. Pt reports that he has had constant, sharp left lower
quadrant abdominal pain radiating to the back and left leg which
has been present for last two weeks, worsened yesterday.
Associated with occasional left leg tingling. Exacerbated by
defecation, no relieving factors. No nausea/vomiting, fever. No
hx gallstones or right upper quadrant pain, no hx heavy alcohol
use.
Pt also reports that for the last two months he has had change
in stool pattern: stools formerly tan and solid, now dark,
loosely formed, ___ bowel movements a day. No recent weight
loss. Pt reports being diagnosed with enlarged spleen and
elevated D-Dimer at another hospital workup.
Pt further reports that 1.5 months ago he collapsed at a
friend's house and required three minutes of CPR, recovered
before defibrillator needed. Was worked up in hospital, pt
reports workup normal but notes not available. Since then pt
endorses persistent poor exercise tolerance, dyspnea, night
sweats and frequent chills.
In the ED, initial vitals: Pain: 7 Temp: 98.5 Pulse: 68 BP:
116/60 RR: 18 O2: 97% . Labs were significant for lipase 224,
normal WBC with lymphocyte predominance at 47.4%. Alk phos 36.
All other labs, UA, EKG within normal limits (note D-dimer wnl).
Normal mental status throughout. Vitals prior to transfer:
Pain: 9 Temp: 97.8 Pulse: 57 BP: 111/64 RR: 16 O2: 97% RA
Pt admitted to floor in stable condition. Continues to report
abdominal pain.
Past Medical History:
-Recent collapse in setting of alcohol intoxication (he was
given several minutes of CPR apparently)
-Bipolar Disorder
-Depression, recent hospitalization ___ for suicide attempt
Social History:
___
Family History:
No family history as he is adopted
Physical Exam:
Admission Exam:
Vitals- T: 98.1 BP 126/86 P: 54 RR: 18 O2:97% ___ Wt: 177
lb
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, very tender to mild palpation in left lower
quadrant especially; tender to deeper palpation in LUQ. No
tenderness in epigastric or right upper quadrants. Mildly tender
in right lower. Rebound tenderness in LUQ, LLQ. No organomegaly.
Normal bowel sounds present.
Back: Diffuse left sided tenderness to palpation.
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- grossly assessed to be normal, motor function grossly
normal, AOx3
Discharge Exam:
Vitals: Tm: 98.5 BP: ___ P: ___ R: 18 O2 Sat: 97-100
Pain: ___ I/O: ___
GENERAL - Alert, interactive, tired appearing but in NAD
HEENT - EOMI, sclerae anicteric, MMM
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB
ABDOMEN - Normal Bowel sounds. LUQ, LLQ tenderness to moderate
palpation without rebound or guarding present
Back: diffusely tender throughout left back
EXTREMITIES - WWP, no c/c, no edema
NEURO - awake, grossly assessed to be intact
Pertinent Results:
ADMISSION LABS:
___ 04:42AM BLOOD WBC-5.3 RBC-4.20* Hgb-13.1* Hct-40.0
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.2 Plt ___
___ 04:42AM BLOOD Neuts-40.9* Lymphs-47.4* Monos-8.1
Eos-2.9 Baso-0.7
___ 04:42AM BLOOD Glucose-93 UreaN-14 Creat-1.0 Na-139
K-4.1 Cl-105 HCO3-27 AnGap-11
___ 04:42AM BLOOD ALT-18 AST-15 AlkPhos-36* TotBili-0.5
___ 04:42AM BLOOD Lipase-224*
___ 04:42AM BLOOD Albumin-4.0 Calcium-8.6 Phos-4.6* Mg-2.0
___ 04:42AM BLOOD D-Dimer-<150
___ 04:42AM URINE Color-Straw Appear-Clear Sp ___
___ 04:42AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ ECG
Sinus rhythm. Normal ECG. No previous tracing available for
comparison.
___ CXR
No acute cardiopulmonary process.
___ CT ABD PELVIS W CONTRAST
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout. There is no evidence of focal lesions. There is no
evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is within normal limits, without stones or
gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation
throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of stones, focal renal
lesions or hydronephrosis. There are no urothelial lesions in
the kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber,
wall
thickness and enhancement throughout. Colon and rectum are
within normal
limits. The appendix is surgically absent.
RETROPERITONEUM: There is no evidence of retroperitoneal and
mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no
calcium burden in the abdominal aorta and great abdominal
arteries.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There
is no evidence of pelvic or inguinal lymphadenopathy. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Reproductive organs are within normal
limits
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic
wall is within normal limits.
IMPRESSION:
No findings to explain patient's symptoms.
___ MRCP
1. No evidence of cholelithiasis or choledocholithiasis.
2. Normal appearing pancreas.
3. Small bilateral pleural effusions and minimal amount of
ascites.
___ MR CERVICAL SPINE W/O CONTRAST
No evidence of bony or ligamentous injury. Degenerative disc
disease bulging and mild to moderate foraminal changes from C3-4
through C5-6 levels.
DISCHARGE LABS:
___ 06:50AM BLOOD WBC-3.9* RBC-4.46* Hgb-14.6 Hct-41.0
MCV-92 MCH-32.8* MCHC-35.7* RDW-12.4 Plt ___
___ 06:50AM BLOOD Glucose-76 UreaN-8 Creat-1.1 Na-140 K-3.7
Cl-101 HCO3-28 AnGap-15
___ 06:45AM BLOOD ALT-18 AST-21 AlkPhos-32* TotBili-0.6
___ 06:45AM BLOOD Lipase-23
___ 06:00AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:50AM BLOOD Calcium-9.2 Phos-4.8* Mg-2.0
___ 06:00AM BLOOD VitB12-418
___ 04:42AM BLOOD D-Dimer-<150
___ 04:42AM BLOOD Triglyc-62
URINE:
___ 08:54PM URINE Color-Straw Appear-Clear Sp ___
___ 04:42AM URINE Color-Straw Appear-Clear Sp ___
___ 08:54PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 04:42AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
Brief Hospital Course:
___ with bipolar disorder, depression, recent syncope from
?alcohol intoxication, presented with left abdominal pain for 2
weeks found to have acute pancreatitis, suspect alcohol-induced.
# ACUTE PANCREATITIS. He presented to OSH with 2 weeks of
abdominal pain. He acutely worsened overnight and requested
transfer to ___. His lipase was found to be elevated to 220s.
CT showed no intrabdominal findings consistent with the
patient's signs/symptoms. MRCP was negative for gallstones in
the ducts or gallbladder and no signs of acute infection. The pt
denied a history of alcohol abuse; however ___ records
indicate pt recently presented with alcohol intoxication.
Triglycerides and calcium were normal. Etiology of pancreatitis
suspected to be alcohol induced. He was treated with IVF, pain
management with PO acetaminophen and morphine. Diet was slowly
advanced. On day of discharge, he tolerated regular diet, had
tolerable abdominal pain, and was discharged with acetaminophen
PO PRN. He was counseled to abstain from alcohol.
# Bipolar Disorder. No active SI or HI. Note that outside
records indicate he had been hospitalized recently for recurrent
depression with suicide attempt. Pt was maintained on home
regimen of lamotrigine.
# Bilateral hand tingling. On ___ pt endorsed bilateral hand
tingling. B12 normal, HIV and HepC negative recently at OSH. MR
cervical spine showed no evidence of bony or ligamentous injury,
but did reveal degenerative disc disease bulging and mild to
moderate foraminal changes from C3-4 through C5-6 levels.
Symptoms were stable, exam reassuring with no evidence of upper
motor neuron signs. Etiology of tingling unclear, possibly
carpal tunnel syndrome.
# Full Code
TRANSITIONAL ISSUES:
-Pain control with acetaminophen PRN
-Abstain from alcohol
-Follow up with PCP
-___ follow up of degenerative disk disease of C3-4, C5-6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMOTrigine 25 mg PO DAILY
Discharge Medications:
1. LaMOTrigine 25 mg PO DAILY
2. Acetaminophen 500 mg PO Q4H:PRN Pain / Fever
Discharge Disposition:
Home
Discharge Diagnosis:
-Acute Pancreatitis
-Abdominal pain
-Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
with abdominal pain and change of stool pattern which was most
likely due to acute pancreatitis. You had an elevated lipase
level although no findings on CT scan. You were treated with IV
fluids and pain medicines. Your diet was slowly advanced and you
tolerated a regular diet on discharge. Your pain was well
controlled.
Please do not drink alcohol as it may cause further problems
with your health.
Followup Instructions:
___
|
19954423-DS-21 | 19,954,423 | 26,434,264 | DS | 21 | 2141-12-04 00:00:00 | 2141-12-04 18:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH of FAP (s/p colectomy ___, Recently Diagnosed
Intrabdominal Desmoid Tumor (initially resected in ___ in ___
when smaller, now recurrent and much larger), who was referred
by
soon to be oncologist Dr ___ in advance of her
initial
appointment for rapid workup and improved control of abdominal
pain.
As per review of records from ___, ___ has
been
seen from ___ to ___ in the emergency department where
she has been noted to have increased in size of abdominal tumor,
for which a ultrasound-guided core needle biopsy was performed
whose pathology revealed desmoid fibramatosis. She was seen by
colorectal surgery at ___ who declined to offer
therapy as they felt her abdominal tumors were too large and too
complicated to be operated on at a community ___. She has
not yet established care with an outpatient oncologist but was
due to see Dr ___, who referred her to the emergency
department for pain control and further workup.
Pt reports that she has had left lower quadrant mass for many
years and was initially resected in ___ when it was much
smaller. After resection it recurred and has grown since. She
noted that she has persistent abdominal pain that is typically
left-sided and also occasionally in the right lower quadrant,
which is sharp/stabbing, and aggravated by long periods in the
same position (sitting/standing). She noted that with taking
Percocet temporarily gets better but never is fully resolved.
She notes that it interferes with her daily life and she is
unable to tolerate a normal diet as result. She notes that she
frequently has diarrhea, that is nonbloody. She noted that she
has fevers and chills at night. Noted that she presented on this
admission to initiate care with oncologist for surgical
evaluation as she would like the mass removed.
She otherwise noted that she was without sore throat, cough,
headache, shortness of breath, dysuria, rash
In the ED, initial vitals: 97.8 100 132/99 18 98% RA. WBC 9.5,
Hgb 14.3, plt 251, LFTs/CEHM/Lactate wnl. UA with 10WBC +
ketones, ___ prot, mod bld, mod ___, then was repeated and had 3
WBC, +keton, Tr prot, sm bld, tr ___.
CTH revealed:
No acute intracranial process. Please note that MRI is more
sensitive in detecting small intracranial lesions.
CXR revealed:
No definite focal consolidation to suggest pneumonia. 2 mm left
apical punctate opacity may represent vessel on end, calcified
granuloma, or a tiny pulmonary nodule. Please note that CT is
more sensitive in assessing for small pulmonary nodules.
___ was given dilaudid, Tylenol, IVF and admitted to
oncology
for further care.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
******************OSH IMAGING & PATHOLOGY*****************
CT A/P ___ from ___:
Compared to prior CT of the abdomen and pelvis dated ___
1. There is a large persistent soft tissue mass involving the
left rectus musculature.
2. Additional spiculated peritoneal masses are noted.
Possibilities again include desmoid tumor or GI stromal tumor
3. There is a persistent lobulated left adnexal cyst measuring
up to 2 cm there is a stable 1.5 subcentimeter area of subtle
enhancement within the inferior right hepatic lobe. If
clinically indicated, this may be evaluated with MRI.
4. Mild intrahepatic and extrahepatic biliary duct dilatation,
possibly due to chronic postcholecystectomy change, although
intrahepatic ductal prominence appears slightly more evident
than
on prior study
CT A/P ___ from ___:
Since previous CT scan of abdomen and pelvis performed on
___
1. Persistent large left suprapubic abdominal wall mass lesion
with interval increase in size, could be due to postbiopsy
hemorrhage.
2. Persistent right lateral abdominal possibly mesenteric
tumor,
with no significant interval change in size.
3. Persistent possible slight interval increase in size of a
hyperenhancing subscapular right hepatic lobe segment 6 mass
lesion
4. Unchanged status post cholecystectomy
MRI Abdomen ___:
8.2 x 8.0 x 10.1 cm markedly heterogeneous enhancing mass in the
left lower abdominal wall. Differential diagnostic
considerations include desmoid tumor, soft tissue sarcoma,
endometriosis, and others. 3 nonspecific enhancing lesions in
the liver possibly focal nodular hyperplasia or less likely
flash
filling hemangiomas. Other etiologies cannot be excluded.
Follow-up MRI abdomen in 3 months without and with contrast is
suggested to document stability
Pathology ___
Left lower quadrant abdominal mass, ultrasound-guided core
needle
biopsy: Desmoid fibramatosis. Specimen shows a cytologically
uniform fibroblastic/myofibroblastic proliferation with an
orderly fascicular architecture and a collagenous stroma. There
is no atypia or pleomorphism. The lesional cells are
multifocally positive for SMA and show multifocal nuclear
positivity for beta-catenin. The appearances indeed fit very
well for a desmoid fibromatosis. There is no evidence of
malignancy
Past Medical History:
PAST MEDICAL HISTORY:
s/p CCY
FAP s/p colon resection ___
Recently Diagnosed Intrabdominal Desmoid Tumor (initially
resected in ___ in ___ when smaller, now recurrent and much
larger)
Social History:
___
Family History:
Both of ___ brothers died of colon cancer 1 at ___ and the
other at ___ years old
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 98.0 117/82 71 16 100 ra
GENERAL: Laying in bed, no acute distress, pleasant, smiling
EYES: Anicteric, pupils equally round reactive to light
HEENT: Oropharynx clear, moist mucous membranes, braces on upper
teeth
NECK: Supple
LUNGS: Clear to auscultation bilaterally without any wheezes
rales or rhonchi, normal respiratory rate, speaks in full
sentences
CV: Regular rate and rhythm, normal distal perfusion without any
edema
ABD: Soft, as grapefruit size soft tissue lesion in left lower
quadrant which is solid and firm to the touch which is very
tender with palpation, she has smaller abdominal mass noted in
the right upper quadrant which is also tender but less so, no
rebound or guarding, no peritoneal signs, hypoactive bowel
sounds, large old surgical scar in midline
GENITOURINARY: No Foley
EXT: No deformity, normal muscle bulk
SKIN: Warm dry, no rash, abdominal scar noted as above
NEURO: Alert and oriented ×3, fluent speech
ACCESS: Peripheral IV
DISCHARGE EXAM:
===============
VS: ___ 0736 Temp: 98.1 PO BP: 115/71 HR: 88 RR: 18 O2 sat:
99% O2 delivery: RA
Gen: NAD, sitting up in chair
HEENT: EOMI, PERRL, anicteric sclera, MMM; no resting nystagmus,
braces on upper and lower teeth
Cards: RR, no peripheral edema, 2+ DP and radial pulses b/l
Chest: CTAB, normal WOB
Abd: inspection reveals large (baseball sized) mass in the LLQ,
remainder of abdominal inspection reveals only a small
hyperpigmented area at the level of the umbilicus on the right
side of the abdomen; the LLQ mass is severely tender to
palpation; the remainder of the abdomen is soft, not distended,
and without significant tenderness to palpation
MSK: thin, stable gait, grossly normal strength
Neuro: AAOx4, clear speech, conversant, no tremor
Psych: calm, cooperative
Pertinent Results:
ADMISSION LABS
===============
___ 04:24PM BLOOD WBC-9.5 RBC-5.41* Hgb-14.3 Hct-45.2*
MCV-84 MCH-26.4 MCHC-31.6* RDW-13.1 RDWSD-39.7 Plt ___
___ 04:24PM BLOOD Neuts-68.0 ___ Monos-4.7*
Eos-0.4* Baso-0.2 Im ___ AbsNeut-6.46* AbsLymp-2.50
AbsMono-0.45 AbsEos-0.04 AbsBaso-0.02
___ 04:24PM BLOOD ___ PTT-27.0 ___
___ 04:24PM BLOOD Glucose-82 UreaN-6 Creat-0.6 Na-142 K-4.0
Cl-103 HCO3-26 AnGap-13
___ 04:24PM BLOOD ALT-7 AST-17 LD(LDH)-176 AlkPhos-63
TotBili-0.9
___ 04:24PM BLOOD Lipase-29
___ 04:24PM BLOOD Albumin-4.8 Calcium-9.7 Phos-3.6 Mg-2.0
UricAcd-2.8
___ 04:30PM BLOOD Lactate-1.5
.
.
DISCHARGE LABS
===============
___ 05:51AM BLOOD WBC-6.8 RBC-5.09 Hgb-13.4 Hct-42.3 MCV-83
MCH-26.3 MCHC-31.7* RDW-12.8 RDWSD-38.6 Plt ___
___ 05:51AM BLOOD Glucose-91 UreaN-5* Creat-0.5 Na-140
K-4.2 Cl-103 HCO3-22 AnGap-15
___ 05:51AM BLOOD Calcium-9.5 Phos-4.4 Mg-1.8
.
.
MICRO
======
-___ Stool C. diff: negative
-___ UCx: mixed bacterial flora (final)
-___ UCx: mixed bacterial flora (final)
-___ BCx: pending
-___ BCx: pending
___ 7:19 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Preliminary):
OVA + PARASITES (Final ___:
CANCELLED. QUANTITY NOT SUFFICIENT FOR TESTING.
REPEAT SPECIMEN REQUESTED.
FECAL CULTURE - R/O VIBRIO (Preliminary):
FECAL CULTURE - R/O YERSINIA (Preliminary):
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
CANCELLED. QUANTITY NOT SUFFICIENT FOR TESTING.
REPEAT SPECIMEN REQUESTED.
___ 1:21 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
___ 9:46 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
.
.
.
.
IMAGING
========
___ CT head w/o contrast:
CT HEAD W/O CONTRAST
INDICATION: History: ___ with headache, abdominal malignancy//
eval for
intracranial mass, hemorrhage eval for intracranial mass,
hemorrhage
TECHNIQUE: Noncontrast enhanced MDCT images of the head were
obtained.
Reformatted coronal and sagittal images were also obtained.
DOSE Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy
(Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute intracranial hemorrhage, midline
shift, mass
effect, or acute large vascular territory infarct. Gray-white
matter
differentiation is preserved. There is no hydrocephalus. The
partially
imaged paranasal sinuses demonstrate opacification of a right
ethmoid air cell
and minimal mucosal thickening of the right frontal sinus. The
mastoid air
cells are clear. No acute fracture seen.
IMPRESSION:
No acute intracranial process. Please note that MRI is more
sensitive in
detecting small intracranial lesions.
.
.
___ CXR (PA & lat)
Final Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with abdominal pain and mass// ?mass,
pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
No focal consolidation is seen. There is no pleural effusion or
pneumothorax.
The cardiac and mediastinal silhouettes are unremarkable. 2 mm
left apical
punctate opacity may represent vessel on end, calcified
granuloma, or a tiny
pulmonary nodule.
IMPRESSION:
No definite focal consolidation to suggest pneumonia.
2 mm left apical punctate opacity may represent vessel on end,
calcified
granuloma, or a tiny pulmonary nodule. Please note that CT is
more sensitive
in assessing for small pulmonary nodules.
Brief Hospital Course:
# LLQ pain: due to large, growing, pathology-confirmed desmoid
tumor
# Intra-abdominal desmoid tumor
- Dr. ___, of ___ Oncology, evaluated the ___
and advised starting sulindac w/ PPI for GI ppx and outpatient
surgery f/u w/ Dr. ___
- ___ is scheduled for f/u appointment with both Dr.
___ on ___.
- Appointment w/ Dr. ___ is in the process of being scheduled.
- She was afebrile, with normal VS, ambulatory, and tolerating a
regular diet at the time of discharge.
# 2 mm lung opacity
- non-urgent re-imaging can be performed as outpatient
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
3. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*3
3. Sulindac 150 mg PO BID
RX *sulindac 150 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
4. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
LLQ abdominal pain
Desmoid tumor of the abdomen
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 with a painful mass in the
left lower quadrant of your abdomen. You were evaluated by the
Oncology doctor (___) who recommended starting 2
new medications and following up in ___ clinic with him and
in Surgery clinic with Dr. ___.
We wish you the best.
Sincerely,
The ___ Medicine Team
Followup Instructions:
___
|
19954460-DS-8 | 19,954,460 | 25,451,646 | DS | 8 | 2156-05-30 00:00:00 | 2156-05-30 17:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
2 days of
word finding difficulty and intermittent right sided weakness.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Pt is an ___ with HTN, GERD, legal blindness, left sided
acute-on-chronic ___ s/p left MMAE on ___, and atrial
fibrillation not on anticoagulation who presents with 2 days of
word finding difficulty and intermittent right sided weakness.
Patient reports that she began noticing word finding
difficulties
2 days prior as well as intermittently feeling weak on the right
side. She came to the ED when her son came to visit her and
noted
her difficulty with speech. She has no other new neurologic
concerns, but states "I think i probably had a stroke". Recently
diagnosed with afib but not on anticoagulation ___ to ___. She
has difficulty with long sentences and naming, but follows both
midline and appendicular commands. Evaluated by NSG in ED who
recommended neurology consult for possible stroke.
NIHSS of 8. CTH/ CTP with 20cc left hemispheric penumbra and
proximal M3 cutoff. Also of note left vertebral artery with
decreased flow, unclear chronicity. Not tPA or thrombectomy
candidate as out of time frame.
Past Medical History:
HTN
Legal blindness
Depression
GERD
Afib with RVR
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals:
T 96.5 HR 96 BP 106/72 RR 18 97% on RA
General: Awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple,No nuchal rigidity.
Pulmonary: Normal work of breathing.
Cardiac: irregular rhythm
Abdomen: Soft, non-distended.
Extremities: No ___ edema.
Skin: No rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history.
Attentive. Language with intact comprehension, unable to repeat
"No ifs and or buts". Halting speech. There were paraphasic
errors. Difficulty naming high and low frequency objects. No
dysarthria. Able to follow both midline and appendicular
commands. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: Left pupil clouded over. Right pupil 3mm NR
EOMI without nystagmus - cannot track but looks in all
directions
to command. Reports very faint light perception.
V: Facial sensation intact to light touch.
VII: Right facial droop
VIII: Hearing intact to finger-rub bilaterally. Hearing aid in
place
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii bilaterally.
XII: Tongue protrudes in midline with good excursions. Strength
full with tongue-in-cheek testing.
-Motor: Normal bulk and tone throughout. Right pronator drift.
No
adventitious movements, such as tremor or asterixis noted.
[Delt][Bic][Tri][ECR][FEx][IO][IP][Quad][Ham][TA][Gas]
L 4 5 4+ 5 ___ 5 5 5 5
R 4 5 4+ 4+ 4+ 4 4+ 5 5 4+ 5
-Sensory: No deficits to light touch throughout. No extinction
to
DSS.
-Reflexes:
[Bic] [Tri] [Pat] [Ach]
L 3 3 2 1
R 3 3 2 1
Right flexor, left extensor
-Coordination: No intention tremor. Normal finger-tap
bilaterally. Unable to test FNK due to blindness, patient had
difficulty following instruction for HKS but did not appear to
have dysmetria
DISCHARGE
No acute distress, breathing comfortably on room air,
extremities
warm and well-perfused, non-edematous.
Awake, alert, oriented to date and location. Attentive
throughout exam. Language fluent without errors.
Right pupil is surgical; left pupil with significant cataract.
EOM full range and conjugate. Mild RNLFF.
She has flexor > extensor ___ weakness in her right leg.
Pertinent Results:
___ 03:44AM BLOOD WBC-8.4 RBC-3.48* Hgb-8.9* Hct-29.9*
MCV-86 MCH-25.6* MCHC-29.8* RDW-17.0* RDWSD-54.0* Plt ___
___ 03:44AM BLOOD Neuts-63.4 ___ Monos-8.8 Eos-2.6
Baso-0.2 Im ___ AbsNeut-5.32 AbsLymp-2.08 AbsMono-0.74
AbsEos-0.22 AbsBaso-0.02
___ 03:44AM BLOOD ___ PTT-29.0 ___
___ 12:37PM BLOOD Glucose-94 UreaN-9 Creat-0.7 Na-142 K-4.6
Cl-104 HCO3-22 AnGap-16
___ 03:44AM BLOOD ALT-10 AST-23 CK(CPK)-46 AlkPhos-68
TotBili-0.3
___ 03:44AM BLOOD cTropnT-<0.01
___ 12:37PM BLOOD Albumin-3.7 Calcium-9.1 Phos-3.9 Mg-1.5*
Cholest-120
___ 12:37PM BLOOD %HbA1c-5.9 eAG-123
___ 12:37PM BLOOD Triglyc-73 HDL-56 CHOL/HD-2.1 LDLcalc-49
___ 12:37PM BLOOD TSH-2.0
___ 03:44AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ Echo Repor
IMPRESSION: Normal left ventricular wall thickness and
biventricular cavity sizes and regional/
global biventricular systolic function. Mild aortic
regurgitation. Mild mitral regurgitation. Moderate
tricuspid regurgitation. Moderate pulmonary hypertension.
___ HEAD W/O CONTRAST
1. Multiple small foci of slow diffusion in left parietal
region, which may
reflect small cortical infarctions or small amounts of
subarachnoid
hemorrhage..
2. Redemonstration of left cerebral convexity different ages
subdural hematoma
with underlying mass effect on opposing brain parenchyma with no
midline
shift. Unchanged in size since ___.
___ HEAD AND NECK WITH
1. Multiple small foci of slow diffusion in left parietal
region, which may
reflect small cortical infarctions or small amounts of
subarachnoid
hemorrhage..
2. Redemonstration of left cerebral convexity different ages
subdural hematoma
with underlying mass effect on opposing brain parenchyma with no
midline
shift. Unchanged in size since ___.
Brief Hospital Course:
___ with HTN, legal blindness, left sided acute-on-chronic SDH
s/p left MMAE on ___, and atrial fibrillation (not on
anticoagulation) who presented with 2 days of word finding
difficulty and intermittent right sided weakness.
CT perfusion showed with L hemispheric area of decreased
perfusion. CTA showed 60% stenosis of origin of R ICA, R vert
stenosis, and reconstitution of the L vert from the basilar. MRI
showing multiple small L parietal ischemic strokes. A1c 5.9, LDL
49, ECHO did not reveal a cardiac source for embolism. Most
likely etiology is cardioembolic given atrial fibrillation.
Started aspirin 81 mg daily. CT scan already schduled for ___.
Will consider transition to apixaban if that CT scan is stable.
Patient was noted to AF with RVR during this admission. Treated
with IV mteoprolol PRN. Increased diltiazem to 240 mg daily.
TRANSITIONAL ISSUES
- Stroke follow up after CT scan on ___. Will make decision
regarding transition from ASA to apixaban at that time
- Please continue to monitor heart rates and increase rate
control as needed with goal < 110.
- Follow up with neurosurgery regarding subdural hemorrhage.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? (x) Yes, confirmed
done - () Not confirmed () No. If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(I.e. bleeding risk, hemorrhage, etc.)
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No. If not, why not? (I.e. bleeding risk,
hemorrhage, etc.)
4. LDL documented? (x) Yes (LDL = 49)
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL
>70, reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[x ] LDL-c less than 70 mg/dL
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No. If no, why not? (I.e. patient at baseline
functional status)
9. Discharged on statin therapy? () Yes - (x) No [if LDL >70,
reason not given:
[ ] Statin medication allergy
[ ] Other reasons documented by physician/advanced practice
nurse/physician ___ (physician/APN/PA) or pharmacist
[ x] LDL-c less than 70 mg/dL
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - (x) No - If no, why not (bleedign
risk with subdural hemorrhage)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
2. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Ondansetron 4 mg PO DAILY
7. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES DAILY
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
9. Rosuvastatin Calcium 20 mg PO QPM
10. Sertraline 50 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*5
2. Diltiazem Extended-Release 240 mg PO DAILY
RX *diltiazem HCl [Cartia XT] 240 mg 1 capsule(s) by mouth once
a day Disp #*30 Capsule Refills:*5
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. Furosemide 20 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Ondansetron 4 mg PO DAILY
7. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES DAILY
8. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP BOTH EYES BID
9. Rosuvastatin Calcium 20 mg PO QPM
10. Sertraline 50 mg PO DAILY
11. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute ischemic stroke (left parietal)
Atrial fibrillation with rapid ventricular
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were hospitalized due to symptoms of word finding difficulty
and intermittent right sided weakness resulting from an ACUTE
ISCHEMIC STROKE, a condition where a blood vessel providing
oxygen and nutrients to the brain is blocked by a clot. The
brain is the part of your body that controls and directs all the
other parts of your body, so damage to the brain from being
deprived of its blood supply can result in a variety of
symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
- atrial fibrillation
- high blood pressure
We are changing your medications as follows:
- Started aspirin 81 mg daily
- Increased diltiazem to 240 mg daily
Please take your other medications as prescribed.
Please follow up with Neurology and your primary care physician
as listed below.
If you experience any of the symptoms below, please seek
emergency medical attention by calling Emergency Medical
Services (dialing 911). In particular, since stroke can recur,
please pay attention to the sudden onset and persistence of
these symptoms:
- Sudden partial or complete loss of vision
- Sudden loss of the ability to speak words from your mouth
- Sudden loss of the ability to understand others speaking to
you
- Sudden weakness of one side of the body
- Sudden drooping of one side of the face
- Sudden loss of sensation of one side of the body
Sincerely,
Your ___ Neurology Team
Followup Instructions:
___
|
19954715-DS-4 | 19,954,715 | 20,242,622 | DS | 4 | 2129-07-26 00:00:00 | 2129-07-29 13:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath and weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
___ w/ hx of several adm for PNA over last several months,
Parksinson, shy ___, and recurrent UTIs presents after she
was found to have possible pneumothorax on CRX at rehab
facility. Pt states she is having shortness of breath
intermittently, denies any pain. Per family she had a fever this
past weekend with a cough and sputum production. Family also
notes that patient continues to have diarrhea depsite finishing
a course of flagyl last week for C.Diff. She was recently
admitted to ___ for a UTI and hydration. She was
treated with a course of amoxacillin. Does not drink fluids per
family who states the patient has been on a 'downward spiral' in
recent months. Pt incredibly poor historian due to hx of
dementia, parkinsons.
.
ED Course (labs, imaging, interventions, consults):
CXR shows no ptx per radiology
Past Medical History:
___ disease
neurogenic bladder with bladder stimulator
urinary incontinence
orthostatic hypotension
hypertension
hyperlipidemia,
___ disease.
anxiety/depression.
Social History:
___
Family History:
Noncontributory
Physical Exam:
Admission:
VS: T:99.3 127/68 P81 R24 98% on 2L
GENERAL: AOx1, NAD
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: Poor entry. No rales or wheezing appreciated. Poor exam.
ABDOMEN: soft, moderately distended, tender in periumbilical
region. no guarding or rebound, neg HSM. neg ___ sign.
RECTAL: ___ skin excoriation
EXT: b/l lower ext 2+ pitting edema . DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: extensive sacral ulcers and ___ anal region ulcers
NEURO/PSYCH: CNs II-XII intact. Patient midly communicative. B/l
foot drop. Masked face with cog wheel rigidity b.l ue.
Discharge:
VS: T:97.5 102/56 P75 R18 99% on 1L
GENERAL: AOx1, NAD
HEENT: MMM. no LAD. no JVD. neck supple.
HEART: RRR S1/S2 heard. no murmurs/gallops/rubs.
LUNGS: Poor entry. No rales or wheezing appreciated.
ABDOMEN: soft, moderately distended but improved from previous
exams, non-tender. no guarding or rebound, neg HSM. neg
___ sign.
RECTAL: ___ skin excoriation
EXT: b/l trace pedal edema . DPs, PTs 2+.
LYMPH: no cervical, axillary, or inguinal LAD
SKIN: extensive sacral ulcers and ___ anal region ulcers
NEURO/PSYCH: CNs II-XII intact. B/l foot drop. Masked faced. B/l
ue cogwheel rigidiy, improved from admission
Pertinent Results:
___ 04:40PM BLOOD WBC-11.1* RBC-3.49* Hgb-10.1* Hct-31.9*
MCV-91 MCH-28.9 MCHC-31.6 RDW-14.5 Plt ___
___ 08:05AM BLOOD WBC-15.3* RBC-3.51* Hgb-9.8* Hct-31.0*
MCV-88 MCH-28.0 MCHC-31.7 RDW-14.4 Plt ___
___ 06:50AM BLOOD WBC-9.5 RBC-3.63* Hgb-10.2* Hct-33.1*
MCV-91 MCH-28.2 MCHC-30.9* RDW-15.1 Plt ___
IMPRESSION: No evidence of pneumothorax. Bilateral pleural
effusions and
congestion
IMPRESSION: Suboptimal image quality due to body habitus. Left
ventricular systolic function is probably normal, a focal wall
motion abnormality cannot be excluded. The right ventricle is
not well seen but is probably normal No significant valvular
abnormality. Indeterminate indices to assess diastolic function.
Moderate elevation of pulmonary artery systolic pressure.
FINDINGS: As compared to the previous radiograph, the lung
volumes have
increased, likely reflecting improved ventilation. However,
extent of the
pre-existing bilateral pleural effusion is constant. Moderate
areas of
atelectasis, left more than right. No newly appeared
parenchymal opacities.
Unchanged size of the cardiac silhouette
IMPRESSION: Nonspecific bowel gas pattern with no evidence of
ileus,
megacolon, or perforation.
In comparison with the study of ___, there are continued low
lung
volumes. There is mild enlargement of the cardiac silhouette
with left
ventricular configuration. Bilateral pleural effusions with
compressive
atelectasis persist. Poor definition of the left hemidiaphragm
suggests
substantial volume loss in the left lower lobe.
Brief Hospital Course:
___ w/ hx of several admissions for PNA over last several
months, Parksinson, Shy ___, and recurrent UTIs presents with
SOB and weakness.
#Diarrhea: Soon after admission, patient was found to have
perfuse diarrhea. She had been treated for C.diff in early ___
at ___ with PO flagyl but it is unclear the length
of course the pt completed as an outpatienet. A stool PCR for
c.diff was positive on ___ and she was started on PO
vancomycin. After several days of worsening symptoms, and
elevated WBC, and abdmoninal distention, IV flagyl was added to
her regimen. A KUB was obtained which was negative for toxic
colon. Pt received IV fluid to compensate for volume lose
secondary to diarrhea. Her electrolytes were monitored and
repleted. Her diarrhea slowed down after 6 days and she is now
making formed stool. The patient spiked a fever to 101.2 on ___
and there as concern for infection of known ___ ulcer. The
area continues to be clean and the patient had no subsequent
fevers. She will continue on PO vancomycin for a 10 day course
following discharge from the hospital.
#SOB: The patient presented for a chief complaint of SOB. While
AF on admission, her family notes she had a cough and was
febrile at nursing facilty the prior day. A CXR showed PNA vs.
pleural edema. She was orginally started on Vanc/Zosyn to cover
HCAP but considering she was afrebrile and CXR appeared more
cosistent with fluid overload vs PNA abx were d/c after the
first dose. She was given 20mg of lasix IV for the first 3 days
of admission and urine output monitored with foley. She
responded well and SOB improved. Pt was originally on NC 2L on
admission and was weaned off.
#___ Disease: The patient remained stable on her home
regimen throughout hospital stay. On admission, she was very
somulent and had severe cogwheel rigidity in her b/l UE. Her
somulence and rigidity improved toward the end of admission most
likely ___ improved infection.
#Shy ___: DX in addition to PD and kept on home med
midodrine. Per family, pt has been told that peripheral edema is
secondary to condition. Her b/l 2+ pitting edema improved
greatly with lasix and compression wraps. She currently has no
peripheral edema. Nursing did express concern for dysphagia and
a speech and swallow study showed she had difficulty with solids
and liquids. The Speech and Swallow team found overt signs of
aspiration at the bedside. Further evaluation by video swallow
was limited, but this is still a high risk of aspiration.
Discussion with the family informed them of this risk and she
should continue on a strict diet of nectar thickened liquids and
pureed solids with close supervision.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/Caregiver.
1. Fludrocortisone Acetate 0.05 mg PO BID
2. Simvastatin 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5
5. Aspirin 81 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Mirtazapine 7.5 mg PO HS
8. Carbidopa-Levodopa (___) 1 TAB PO QID
9. Quetiapine Fumarate 25 mg PO DAILY
10. Diltiazem 30 mg PO TID
11. Midodrine 2.5 mg PO BID
12. Heparin 5000 UNIT SC TID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO QID
3. Diltiazem 30 mg PO TID
4. Ferrous Sulfate 325 mg PO DAILY
5. Fludrocortisone Acetate 0.05 mg PO BID
6. Heparin 5000 UNIT SC TID
7. Midodrine 2.5 mg PO BID
8. Mirtazapine 7.5 mg PO HS
9. Multivitamins 1 TAB PO DAILY
10. Simvastatin 20 mg PO DAILY
11. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours
Hold for K >5
12. Quetiapine Fumarate 25 mg PO DAILY
13. Vancomycin Oral Liquid ___ mg PO Q6H Duration: 10 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Clostridium difficile colitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you during your stay at ___.
You came in due to SOB and weakness. You were found to have
fluid in your lungs and we gave you medication to remove it.
Your shortness of breath improved with treatment. You also had
diarrhea from a bacteria called C.difficile. We gave you
antibiotics and your diarrhea resolved. You will continue to
take antibiotics.
Followup Instructions:
___
|
19954807-DS-20 | 19,954,807 | 27,989,967 | DS | 20 | 2193-02-04 00:00:00 | 2193-02-06 06:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right leg swelling and pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with recurrent platinum-sensitive high-grade serous
ovarian carcinoma most recently on carboplatin and liposomal
doxorubicin, awaiting receipt of olaparib (not yet initiated)
referred in for RLE swelling and pain. She states it has been
developing over ~2 weeks, gradually. She has pain by her shin
and
in her thigh. She has swelling and edema. She reports occasional
parasthesias at night. Is anticoagulated for incidentally found
segmental PE. Has known lymphadenopathy in groin and flank,
which
is where she complains of pain. Denies CP, SOB, n/v.
She reports for the last ___ weeks she has had right sided leg
swelling, erythema at times, and pain. The entire leg is
diffusely painful. NO fevers, nausea/vomiting, no chest pain or
dyspnea. Does note dysuria and suprapubic pain worsening over
the
past few weeks also. She is having difficulty walking due to the
pain as even touching the foot feels very tender. All other 10
point ROS neg.
ED COURSE:
97.2 HR 103 --> 80. BP 119/72. Chem reassuring K 3.5 creat 0.7.
LFTs reassuring. UA suggestive of infection. CBC WNL. She
received 2L IVF and 4mg IV morphine. CT a/p shows necrotic
aortocaval node resulting in compression on distal IVC, may
explain patients symptoms of venous obstruction, overall
worsening lymphadenopathy. Right ___ without DVT.
On arrival to the floor she appears fairly comfortable at rest.
Past Medical History:
ONCOLOGIC AND TREATMENT HISTORY:
Patient developed abdominal pain and vaginal discharge ___.
Pelvic ultrasound showed a complex right adnexal mass and CA-125
was 555. MRI pelvis showed a large right adnexal lesion with
heterogeneously enhancing solid and cystic components. CT scan
at
___ in ___ showed the mass as well as retroperitoneal
inter-caval and left pelvic lymphadenopathy. There was a
nodular,
thickened appearance of the omentum and two adjacent small
nodules in the left lower lobe, as well as a possible
___ lymph node.
On ___, patient underwent exploratory laparotomy, TAH/BSO,
radical resection of pelvic mass, appendectomy, and gastrocolic
omentectomy. Debulking was suboptimal; patient had residual
disease along the right hemi-diaphragm, nodal disease involving
the aorta, vena cava, and left internal iliac artery, as well as
disease within the rectosigmoid colon. Lymphovascular invasion
was noted in the hilum of the left ovary.
Patient received adjuvant carboplatin and paclitaxel from
___ to ___.
On ___, patient reported back pain, abdominal pain,
constipation, and intermittent nausea with abdominal distention.
CA-125 had decreased slightly; however, it had not normalized.
Imaging on ___ revealed evidence of disease recurrence.
Patient received carboplatin, gemcitabine, and bevacizumab from
___ to ___. Genetic testing showed BRCA1 mutation
___.
On ___, patient reported abdominal pain. CT abdomen/pelvis
on ___ showed a decrease in retroperitoneal lymphadenopathy
and
size of known soft tissue nodules in the para-colic gutter
bilaterally and the sigmoid mesentery. Two nodules had
completely
resolved and there were no new lesions.
On ___, CA-125 increased to 72. CT torso on ___ showed new
bulky mediastinal, left supraclavicular, and retroperitoneal
lymphadenopathy consistent with recurrent metastatic disease.
Patient received carboplatin and liposomal doxorubicin from ___
to ___. She received 3 cycles of carboplatin and liposomal
doxorubicin and 1 additional cycle of single-agent carboplatin,
doxorubicin dropped due to diffuse myalgias/arthralgias, though
unclear if it was truly related. CA-125 initially decreased from
113 to 67, but it subsequently increased during cycles 4 and 5.
CT torso on ___ showed overall decreased burden of disease
compared to scans from ___. Given the myalgias and the slight
increase/plateauing of her CA-125, additional chemotherapy was
deferred. CT torso also showed an incidental left segmental
pulmonary embolus, and she was started on enoxaparin.
PAST MEDICAL HISTORY:
- Ovarian carcinoma, as above
- Low back pain
- Osteoarthritis
SURGICAL HISTORY:
- TAH/BSO
- Radical resection of pelvic mass
- Appendectomy
- Gastrocolic omentectomy
- Sinus surgery
Social History:
___
Family History:
No known family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VITAL SIGNS: 99.2 104/70 90 18 100% RA
General: NAD
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
GI: BS+, soft, tender to palpation over suprapubic area
LIMBS: RLE with slightly larger than left and diffuse mild
erythema, but no pitting edema, pulses and sensation intact,
neuro function WNL and symmetric
NEURO: Oriented x3. Cranial nerves II-XII are within normal
limits excluding visual acuity which was not assessed, no
nystagmus; strength is ___ of the proximal and distal upper and
lower extremities; reflexes are 2+ of the biceps, triceps,
patellar, and Achilles tendons, toes are down bilaterally; gait
is normal, coordination is intact.
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.8, 98-100/60-80, 80-98, ___, 97-100% RA
I/O: 8h 400/500, 24h ___
Wt: 71.62kg
GEN: Well-appearing female in NAD, lying comfortably in bed
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RRR, nl S1/S2, no MRG
PULM: CTAB, no wheezes/rales/rhonchi
ABD: Soft, ND, normoactive bowel sounds, tenderness to deep
palpation to epigastric area, also with suprapubic tenderness
EXT: Right ankle with maculopapular circumferential rash with
associated tenderness, tenderness to dorsum of right foot,
warmth, rash not raised, mild edema, no right calf tenderness,
distal pulses intact. Left leg with no edema, rash, or
tenderness.
NEURO: AAOx3, CN II-XII grossly intact
Pertinent Results:
ADMISSION LABS:
===============
___ 02:40PM ___ PTT-38.6* ___
___ 02:40PM PLT COUNT-204
___ 02:40PM NEUTS-61.7 ___ MONOS-9.1 EOS-2.5
BASOS-0.4 IM ___ AbsNeut-2.97 AbsLymp-1.24 AbsMono-0.44
AbsEos-0.12 AbsBaso-0.02
___ 02:40PM WBC-4.8 RBC-3.69* HGB-11.2 HCT-36.0 MCV-98
MCH-30.4 MCHC-31.1* RDW-14.2 RDWSD-50.9*
___ 02:40PM K+-3.5
___ 02:40PM ALBUMIN-4.3
___ 02:40PM ALT(SGPT)-24 AST(SGOT)-59* ALK PHOS-62 TOT
BILI-0.2
___ 02:40PM GLUCOSE-94 UREA N-11 CREAT-0.7 SODIUM-137
POTASSIUM-8.8* CHLORIDE-103 TOTAL CO2-25 ANION GAP-18
___ 04:10PM URINE RBC-1 WBC-17* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 04:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-MOD
___ 04:10PM URINE COLOR-Straw APPEAR-Hazy SP ___
DISCHARGE LABS:
================
___ 05:40AM BLOOD WBC-3.7* RBC-3.81* Hgb-11.4 Hct-35.8
MCV-94 MCH-29.9 MCHC-31.8* RDW-13.8 RDWSD-46.5* Plt ___
___ 05:40AM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-139
K-4.0 Cl-101 HCO3-25 AnGap-17
___ 05:40AM BLOOD CK(CPK)-54
___ 05:40AM BLOOD Calcium-9.4 Phos-5.2* Mg-2.1
STUDIES:
=========
UNILAT LOWER EXT VEINS ___
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
CT ABD & PELVIS W & W/O ___
IMPRESSION:
1. 18 x 14 mm necrotic aortocaval node causing anterior
compression on the
inferior IVC, without associated occlusion/ thrombosis.
2. Worsening intra-abdominal/pelvic lymphadenopathy in the short
3 weeks
interval.
3. New 8 x 6mm enhancing nodule in the left inferior hemipelvis,
may represent an additional metastatic focus. Recommend
attention on follow-up studies.
4. Unchanged 7 mm left lower lobe pulmonary nodule. Short
interval follow-up in 3 months is advised, as previously
recommended.
MR CALF ___ CONTRAST ___
IMPRESSION:
1. Nonspecific, non enhancing subcutaneous soft tissue edema
overlying the
anteromedial aspect of both legs, right more than left. This is
not fully
characterized, but could be due to third spacing. (The patient
underwent
right lower extremity ultrasound examination which reported no
evidence of
DVT.)
2. Mildly enhancing soft tissue edema in the posterolateral
aspect of the
right leg that is also nonspecific. This is also non-specific
in appearance, but if there are corresponding skin findings then
this could represent cellulitis.
3. Focal abnormal marrow signal in the distal right fibula
spanning about 3cm in length with mild enhancement. Further
evaluation with right tib/fib
radiograph is recommended. The MR appearance is non-specific
include and
includes an intraosseous vessel versus multiple stress fractures
versus a
lesion in the marrow. The post-contrast images suggest a vessel
going into
the marrow space. Radiographs may be helpful in further
characterization.
This finding lies remote from the areas of edema in the
subcutaneous fat and is not clearly related to them.
RECOMMENDATION(S): Right tibia-fibula radiographs recommended
to further
assess area of abnormal marrow signal in the distal fibula.
Brief Hospital Course:
___ with recurrent platinum-sensitive high-grade serous ovarian
carcinoma most recently on carboplatin and liposomal
doxorubicin, now admitted with RLE swelling and pain.
# RLE swelling and pain:
Concerning for possible post-phlebitis syndrome in the setting
of her recent pulmonary embolus. ___ negative for current DVT.
CT abdomen/pelvis showed necrotic aortocaval node compressing
distal IVC, though this was felt likely inadequate to explain
her presentation. She is on dalteparin for anticoagulation
currently. RLE exam with edema and pain to shin and ankle. She
initially had some erythema to the ankle which subsequently
improved. MRI of the lower extremity showed non-specific edema
and inflammation. Pain was controlled with PRN morphine PO,
Tylenol, and Toradol IV/PO. Home gabapentin was continued. She
was encouraged to use ACE wraps / compression stockings to RLE
to control swelling.
# Ovarian cancer:
She has recurrent high-grade serous ovarian carcinoma, now
likely platinum resistant, with bulky mediastinal, left
supraclavicular, and retroperitoneal lymphadenopathy now s/p 3
cycles of carboplatin and liposomal doxorubicin and 1 additional
cycle of single-agent carboplatin. Now with platinum resistant
ovarian cancer. She will continue followup with outpatient
oncologist; planned for olaparib as outpatient.
# Recent pulmonary embolism:
Discovered incidentally on restaging CT chest. Currently
enrolled in ___ ___, "A phase III randomized open-label
trial of dalteparin vs. edoxaban in cancer patients with VTE."
Patient has been randomized to dalteparin which was continued
during her admission.
# UTI:
She presented with suprapubic pain and dysuria for weeks, no
fever or
nausea/vomiting. UA concerning for UTI. She was treated with 5
day course of Macrobid, last day ___.
TRANSITIONAL ISSUES:
- She was discharged with plan for compression stockings/ACE
wraps for empiric treatment of possible post-phlebitis syndrome
of RLE. She should have continued followup for her RLE edema and
pain to assess for continued improvement.
- Last day of Macrobid for UTI is ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Gabapentin 400 mg PO QAM
4. Gabapentin 300 mg PO BID
5. Metoclopramide 10 mg PO QID:PRN nausea
6. olaparib 200 mg oral BID
7. Omeprazole 40 mg PO DAILY
8. dalteparin (porcine) unkonwn subcutaneous DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Pain Relief] 500 mg 2 tablet(s)
by mouth Every 8 hours Disp #*30 Tablet Refills:*0
2. ketorolac 10 mg oral Q4H:PRN pain
RX *ketorolac 10 mg 1 tablet(s) by mouth Every 4 hours Disp #*28
Tablet Refills:*0
3. Morphine Sulfate ___ 15 mg PO Q6H:PRN Pain - Severe
RX *morphine 15 mg 1 tablet(s) by mouth Every 6 hours Disp #*5
Tablet Refills:*0
4. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H Duration: 3
Doses
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
Twice a day Disp #*3 Capsule Refills:*0
5. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia
6. dalteparin (porcine) 12,500 anti-Xa unit/0.5 mL subcutaneous
QHS
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Gabapentin 400 mg PO QAM
9. Gabapentin 300 mg PO BID
10. Metoclopramide 10 mg PO QID:PRN nausea
11. olaparib 200 mg oral BID
12. Omeprazole 40 mg PO DAILY
13.ACE wrap
Please provide ACE wrap for right lower extremity.
___ substitute compression stockings if desired.
ICD 10: ___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Right lower extremity pain and edema
SECONDARY DIAGNOSIS:
Serous ovarian carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure being part of your care at ___. You were
admitted to the hospital due to right leg pain and swelling. You
had an MRI which showed swelling and inflammation of the right
leg. There was no evidence of any tumors or active infection
inside the leg, though a CT scan did show an enlarged lymph node
next to one of your central veins. It is possible that your
symptoms are due to a recent blood clot in one of your leg veins
which has since been dislodged.
After discharge, please follow up with your doctors as described
below.
It was a pleasure being part of your care,
Your ___ team
Followup Instructions:
___
|
19954807-DS-21 | 19,954,807 | 20,496,916 | DS | 21 | 2193-09-07 00:00:00 | 2193-09-10 21:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of BRCA1
___ mutation and recurrent platinum-resistant serous
ovarian carcinoma with bulky mediastinal, left supraclavicular,
and retroperitoneal lymphadenopathy s/p multiple lines of
chemotherapy and now s/p 4 cycles of paclitaxel and bevacizumab
(discontinued for disease progression) who presents with
seizure.
She was in her usual state of health the morning of admission.
This afternoon she was eating soup for lunch and suddenly her
right hand cramped up and began to twist. She then lost
consciousness. Her friend ___ mother was at the home and
witnessed the event. She described it as whole body shaking as
well as eyes rolling up. The mother called ___ who was nearby
and came to the house. ___ found the patient on the floor
with
some drool in her mouth. She seemed confused and did not
recognize her friend. She was looking around the room, pushed
away her friend, and started screaming. This lasted for about 30
minutes before she returned to baseline. She denies any tongue
biting and urinary/fecal incontinence. Her friend then brought
her to the ED for further evaluation.
On arrival to the ED, initial vitals were 98.5 ___ 18
97%
RA. Labs were notable for WBC 11.0, H/H 13.2/42.2, Plt 197, Na
137, K 3.5, BUN/Cr ___, LFTs wnl, trop < 0.01, lactate 11.9,
UA negative. CXR negative for pneumonia. Head CT showed multiple
brain metastases with vasogenic edema. While in the ED, had
another seizure where her left hand cramped up, started
screaming, and then had tonic clonic movements of whole body
with
LOC which terminated with IM Ativan after 2 minutes. Patient was
given Ativan 2mg IM, Ativan 1mg IV, keppra 1g IV, dextamethasone
10mg IV, Tylenol 1g PO, and 1L NS. Neurology was consulted and
recommended brain MRI, keppra 1g BID, dexamethasone 10mg IV
followed by 4mg q6h. Prior to transfer vitals were 98.3 104
125/74 18 98% RA.
On arrival to the floor, patient reports cough for which she was
started on antibiotics. She also reports headache for the past
month but she forgot to tell her Oncologist at the appointment
yesterday. She also notes some dizziness. She denies
fevers/chills, night sweats, headache, vision changes,
weakness/numbnesss, shortness of breath, hemoptysis, chest pain,
palpitations, abdominal pain, nausea/vomiting, diarrhea,
hematemesis, hematochezia/melena, dysuria, hematuria, and new
rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Patient developed abdominal pain and vaginal discharge ___.
Pelvic ultrasound showed a complex right adnexal mass and CA-125
was 555. MRI pelvis showed a large right adnexal lesion with
heterogeneously enhancing solid and cystic components. CT scan
at
___ in ___ showed the mass as well as retroperitoneal
intercaval and left pelvic lymphadenopathy. There was a nodular,
thickened appearance of the omentum and two adjacent small
nodules in the left lower lobe, as well as a possible ___
cardiophrenic lymph node.
On ___, patient underwent exploratory laparotomy, TAH/BSO,
radical resection of pelvic mass, appendectomy, and gastrocolic
omentectomy. Debulking was suboptimal; patient had residual
disease along the right hemi-diaphragm, nodal disease involving
the aorta, vena cava, and left internal iliac artery, as well as
disease within the rectosigmoid colon. Lymphovascular invasion
was noted in the hilum of the left ovary.
Patient received adjuvant carboplatin and paclitaxel from
___ to ___.
On ___, patient reported back pain, abdominal pain,
constipation, and intermittent nausea with abdominal distention.
CA-125 had decreased slightly; however, it had not normalized.
Imaging on ___ revealed evidence of disease recurrence.
Patient received carboplatin, gemcitabine, and bevacizumab from
___ to ___. Genetic testing showed BRCA1 mutation
___.
On ___, patient reported abdominal pain. CT abdomen/pelvis
on ___ showed a decrease in retroperitoneal lymphadenopathy
and
size of known soft tissue nodules in the para-colic gutter
bilaterally and the sigmoid mesentery. Two nodules had
completely
resolved and there were no new lesions.
On ___, CA-125 increased to 72. CT torso on ___ showed new
bulky mediastinal, left supraclavicular, and retroperitoneal
lymphadenopathy consistent with recurrent metastatic disease.
Patient received carboplatin and liposomal doxorubicin from ___
to ___. She received 3 cycles of carboplatin and liposomal
doxorubicin and 1 additional cycle of single-agent carboplatin,
doxorubicin dropped due to diffuse myalgias/arthralgias, though
unclear if it was truly related. CA-125 initially decreased from
113 to 67, but it subsequently increased during cycles 4 and 5.
CT torso on ___ showed overall decreased burden of disease
compared to scans from ___. Given the myalgias and the slight
increase/plateauing of her CA-125, additional chemotherapy was
deferred. CT torso also showed an incidental left segmental
pulmonary embolus, and she was started on enoxaparin.
On ___, CT torso with progressive disease in the chest,
abdomen, and pelvis. Because of platinum-resistance, the patient
started olaparib in late ___. Evidence of continued
progression on scans in ___, for which she was switched to
Taxol and bevacizumab
- ___: C1D1 ___
- ___: C2D1 ___
- ___: C3D1 ___
- ___: C4D1 ___
- ___: stopped ___ given disease progression with
left lower lobe and lingular lymphangitic carcinomatosis seen on
CT
-___: Admitted for new onset seizures, found to have
innumerable brain metastases, one of which was hemorrhagic.
Stopped dalteparin trial. Started on steroid taper and
levetiracetam. Got ___ fractions of WBXRT.
PAST MEDICAL HISTORY:
- Ovarian carcinoma, as above
- Low back pain
- Osteoarthritis
- s/p TAH/BSO
- s/p radical resection of pelvic mass
- s/p appendectomy
- s/p gastrocolic omentectomy
- s/p sinus surgery
Social History:
___
Family History:
No known family history of cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: Temp 98.3, BP 142/92, HR 98, RR 16, O2 sat 95% RA.
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably, cooperative with exam.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact. FTS and HTS intact bilaterally. Able to state ___
backwards.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
DISCHARGE PHYSICAL EXAM:
VS: 98.0 125/85 88 18 99%RA
GENERAL: Pleasant woman, in no distress, lying in bed
comfortably, cooperative with exam.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact. FTS intact bilaterally.
SKIN: No significant rashes.
ACCESS: Right chest wall port without erythema.
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-6.5# RBC-4.08 Hgb-12.5 Hct-39.6
MCV-97 MCH-30.6 MCHC-31.6* RDW-15.9* RDWSD-56.6* Plt ___
___ 01:00PM BLOOD Neuts-62.4 ___ Monos-7.7 Eos-2.6
Baso-0.5 Im ___ AbsNeut-4.05# AbsLymp-1.71 AbsMono-0.50
AbsEos-0.17 AbsBaso-0.03
___ 01:00PM BLOOD UreaN-15 Creat-0.7 Na-138 K-3.9 Cl-100
HCO3-26 AnGap-16
___ 01:00PM BLOOD ALT-31 AST-20 AlkPhos-73 TotBili-0.2
___ 05:28PM BLOOD cTropnT-<0.01
___ 01:00PM BLOOD Calcium-9.4 Phos-4.8* Mg-1.9
___ 01:00PM BLOOD CA125-119*
___:48PM BLOOD Lactate-11.9*
IMAGING:
___ HEAD W & W/O CONTRAS
1. Innumerable enhancing supra and infratentorial metastatic
lesions, as
described, additionally with involvement of the midbrain and
pons. Many of these lesions demonstrate vasogenic edema with
associated localized mass effect. Of these, a single left
occipital lesion appears hemorrhagic.
2. 11 x 10 mm lesion abutting the inferior endplate of the C2
vertebral body is suspicious for osseous metastasis. This can
be further evaluated with contrast-enhanced dedicated cervical
spine MR, if indicated.
3. Paranasal sinus disease, as described, with postsurgical
changes from FESS.
___ HEAD W/O CONTRAST
1. Multiple hyperdense lesions in the right and left cerebral
hemispheres, many at the gray-white matter junction, with
surrounding vasogenic edema,compatible with metastatic disease.
2. Vasogenic edema in the left cerebellar hemisphere is also
suspicious for an underlying mass lesion, though none is
discretely identified. No evidence of intracranial hemorrhage
or acute infarct.
3. Please note that MRI is more sensitive for detection of
smaller
metastases.
___ (PORTABLE AP)
1. Interval development of mild pulmonary edema and patchy
opacities in the lung bases, likely atelectasis, but aspiration
cannot be excluded.
2. Known lymphangitic carcinomatosis in the left lung base,
pulmonary
nodules, and sclerotic osseous metastases are better assessed on
the previous CT.
DISCHARGE LABS:
___ 05:12AM BLOOD WBC-8.4 RBC-4.20 Hgb-12.8 Hct-40.2 MCV-96
MCH-30.5 MCHC-31.8* RDW-15.5 RDWSD-54.0* Plt ___
___ 05:12AM BLOOD Glucose-109* UreaN-18 Creat-0.7 Na-143
K-4.1 Cl-105 HCO3-21* AnGap-21*
___ 05:12AM BLOOD Calcium-9.3 Phos-4.1 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ female with history of BRCA1
___ mutation and recurrent platinum-resistant serous
ovarian carcinoma with bulky
mediastinal, left supraclavicular, and retroperitoneal
lymphadenopathy s/p multiple lines of chemotherapy and now s/p 4
cycles of paclitaxel and bevacizumab (discontinued for disease
progression) who presents with first known seizure and found to
have innumerable brain metastases including a hemorrhagic mass.
# Multiple Brain Metastases / Seizure:
Patient presented with 2 seizures (R focal onset and L focal
onset), found to have multiple lesions with vasogenic edema
concerning for brain mets on CT. MRI confirmed these findings
and found one of the lesions to be hemorrhagic. She received
10mg iv x1 of dexamethasone and 1g iv x1 of levetiracetam.
Admitted to oncology floor, continued on dexamethasone with slow
taper and levetiracetam 1g bid. Evaluated by neuro-oncology and
radiation oncology who recommended WBXRT. Received simulation
and ___ fractions in house.
#Hemorrhagic brain metastasis: As one of the brain metastasis
was hemorrhagic, dalteparin was held and then was stopped from
trial ___ due to severe adverse event.
# Elevated lactate: Up to 11.9 on admission. Likely secondary to
seizure, now
returned to 2.8.
# Metastatic Platinum-Resistant Ovarian Cancer: Progressive on
multiple lines of therapy. Considering cyclophosphamide vs.
topotecan/avastin vs. clinical trial with a phase I agent.
Metastatic to lung with lymphangitic carcinomatosis, bone, lymph
nodes, and now brain as above.
# Pulmonary Embolism: Discovered incidentally on ___. On
clinical trial ___ ___, "A phase III randomized open-label
trial of dalteparin vs. edoxaban in cancer patients with VTE."
She was randomized to dalteparin arm. Anticoagulation was held
given hemorrhagic brain met and now off study..
# Pneumonia: Recent diagnosis in setting of URI symptoms.
Started
on azithromycin ___. Continued azithromycin x5 days through
___
TRANSITIONAL ISSUES:
#Off dalteparin: Given presence of one hemorrhagic metastasis,
dalteparin was discontinued and patient was terminated from
___ due to severe adverse event. Given intracranial
hemorrhage and asymptomatic PE incidentally found on scans the
risk of long term anticoagulation vastly outweighs its benefits.
#Dexamethasone taper: Discharged on dexamethasone 4mg q12h
(___), 4mg qAM (___), 2mg qAM (___).
#Initiation of levetiracetam: started on levetiracetam 1g bid
for secondary prophylaxis for seizures. Likely to need for
foreseeable future.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. dalteparin (porcine) 12,500 anti-Xa unit/0.5 mL subcutaneous
QHS
2. Fluticasone Propionate NASAL 1 SPRY NU DAILY
3. Omeprazole 40 mg PO DAILY
4. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia
5. Furosemide 20 mg PO BID
6. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
7. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
8. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
9. Calcium Carbonate 500 mg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6)
hours Disp #*28 Tablet Refills:*0
2. Dexamethasone 4 mg PO Q12H Duration: 2 Days
Tapered dose - DOWN
RX *dexamethasone 2 mg ASDIR tablet(s) by mouth ASDIR Disp #*20
Tablet Refills:*0
3. Dexamethasone 4 mg PO DAILY Duration: 4 Days
Tapered dose - DOWN
4. Dexamethasone 2 mg PO DAILY Duration: 4 Days
Tapered dose - DOWN
5. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
6. Calcium Carbonate 500 mg PO DAILY
7. Cyclobenzaprine 5 mg PO HS:PRN spasm/insomnia
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Furosemide 20 mg PO BID
10. Omeprazole 40 mg PO DAILY
11. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
12. OxyCODONE (Immediate Release) 10 mg PO Q8H:PRN Pain -
Moderate
13. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
-Seizure
-Secondary neoplasm of the brain
-Intracranial hemorrhage
-Metastatic ovarian cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had a seizure. A
head CT and MRI unfortunately showed that the cancer has spread
to your brain. We treated you with dexamethasone (to reduce
swelling in the brain) and levetiracetam (Keppra, to prevent
seizures). You will need to continue these medications. You were
also started on whole brain radiation and will need to complete
your 5 treatment sessions.
It was a pleasure to take care of you,
Your ___ Team
Followup Instructions:
___
|
19955235-DS-5 | 19,955,235 | 21,025,811 | DS | 5 | 2167-08-06 00:00:00 | 2167-08-05 14:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RUQ pain
Major Surgical or Invasive Procedure:
laparoscopic cholecystectomy
History of Present Illness:
___ presents with 5 day history of RUQ pain and fevers.
___ evening she began to experience cramps, diarrhea and
vomiting. Since then she has felt fatigued and generally unwell.
She was not eating on ___ or ___ and had a fever of
102. Yesterday she felt better and started eating again, but
after lunch the cramps returned, and her temperature was 101.
She
called a doctor who told her to come to the ER today. The pain
is
cramping in nature and is intermittent, and worse with meals.
Upon presentation she feels no pain unless one presses on her
RUQ. ROS positive for fever, loss of appetite, chills, and
bloating. She does not have nausea, recent diarrhea, bloodly
bowel movements, urinary symptoms or vomting. She has not
recently passed flatus but has been having one bowel movement
per
day.
Past Medical History:
PMH: Hypothyroidism
PSH: None
Social History:
___
Family History:
FH: Father had heart problems and had gall bladder removed.
Mother had diabetes. Brothers died of colon cancer, lung cancer,
brain cancer. Sister died of stroke.
Physical Exam:
Vitals: T 97.6, HR 72, BP 151/70, RR 12, sat 96%/RA
Gen: NAD A&Ox 3, pleasant and cooperative
CV:RRR
Pulm: CTA b/l , no labored breathing
Abd: soft, mildly distended, NT, lap port site incisions are
without signs of infection, no hematoma or bleeding, no rebound
or guarding.
Ext: warm and well perfused.
Pertinent Results:
___ 01:30PM URINE HOURS-RANDOM
___ 01:30PM URINE HOURS-RANDOM CREAT-37 SODIUM-43
POTASSIUM-10 CHLORIDE-34
___ 01:30PM URINE HOURS-RANDOM
___ 01:30PM URINE UCG-NEGATIVE
___ 01:30PM URINE OSMOLAL-230
___ 01:30PM URINE GR HOLD-HOLD
___ 01:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
___ 01:30PM URINE RBC-0 WBC-6* BACTERIA-NONE YEAST-NONE
EPI-2
___ 10:52AM LACTATE-1.7 NA+-141 K+-5.0
___ 10:40AM GLUCOSE-96 UREA N-11 CREAT-0.9 SODIUM-129*
POTASSIUM-9.1* CHLORIDE-99 TOTAL CO2-24 ANION GAP-15
___ 10:40AM estGFR-Using this
___ 10:40AM ALT(SGPT)-34 AST(SGOT)-99* ALK PHOS-68 TOT
BILI-0.7
___ 10:40AM LIPASE-39
___ 10:40AM ALBUMIN-4.1
___ 10:40AM WBC-5.8 RBC-5.13 HGB-13.9 HCT-39.6 MCV-77*
MCH-27.1 MCHC-35.2* RDW-13.5
___ 10:40AM NEUTS-59.7 ___ MONOS-7.5 EOS-4.2*
BASOS-0.2
___ 10:40AM PLT COUNT-204
Brief Hospital Course:
The patient was admitted to the Acute Care Surgery Service on
___ for evaluation and treatment of RUQ pain and found to
have acute cholecystitis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
fro observation.
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:
Levothyroxine 50 mcg daily,
MTV
vit D3 ___ units daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
Please do not take more than 3 grams per day
RX *acetaminophen 650 mg 1 (One) tablet(s) by mouth every six
(6) hours Disp #*30 Tablet Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drive or drink alcohol while taking this
medication
RX *oxycodone 5 mg 1 to 2 capsule(s) by mouth every four (4)
hours Disp #*30 Capsule Refills:*0
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
acute cholecystitis, s/p laparoscopic cholecystectomy
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 cholecystitis. You
were taken to the operating room and had your gallbladder
removed laparoscopically. You tolerated the procedure well and
are now being discharged home to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19955371-DS-3 | 19,955,371 | 26,497,119 | DS | 3 | 2144-08-10 00:00:00 | 2144-08-10 13:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / morphine / Iodinated Contrast Media
Attending: ___.
Major Surgical or Invasive Procedure:
___ central line placed
___ intubated
___ EGD
___ ___ GDA embolization
___ OMFS bedside washout
attach
Pertinent Results:
ADMISSION LAB
=========================
___ 11:58AM BLOOD WBC-16.8* RBC-4.08 Hgb-12.5 Hct-36.5
MCV-90 MCH-30.6 MCHC-34.2 RDW-13.1 RDWSD-42.9 Plt ___
___ 11:58AM BLOOD Neuts-83.9* Lymphs-5.4* Monos-9.4
Eos-0.1* Baso-0.2 Im ___ AbsNeut-14.04* AbsLymp-0.91*
AbsMono-1.58* AbsEos-0.02* AbsBaso-0.04
___ 11:58AM BLOOD Glucose-281* UreaN-5* Creat-0.7 Na-128*
K-5.3 Cl-90* HCO3-23 AnGap-15
___ 11:58AM BLOOD cTropnT-<0.01
___ 11:58AM BLOOD Albumin-3.8
___ 10:15AM BLOOD %HbA1c-7.9* eAG-180*
___ 08:14AM BLOOD Osmolal-282
___ 02:18PM BLOOD Prolact-27*
___ 07:45AM BLOOD CRP->300*
___ 12:04PM BLOOD Lactate-1.3
DISCHARGE LAB:
================
IMAGING:
==========
ABD XR ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
Mild colonic
stool burden
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or
radiopaque foreign
bodies. Surgical clips from prior cholecystectomy are seen.
There is a CGM
device seen in the right flank.
IMPRESSION:
Nonobstructive bowel gas pattern with mild colonic stool burden.
CT Neck without contrast ___
FINDINGS:
Maxillofacial:
A drain is in place adjacent to the right maxilla, with
surrounding fat
stranding and without discrete fluid collection. Diffuse, right
periorbital/preseptal soft tissue swelling and fat stranding has
not
substantially changed. There is diffuse right malar soft tissue
swelling and fat stranding, with new, interval small locules of
air with adjacent stranding spanning approximately 2.3 x 0.9 cm
(2:36). Diffuse fat stranding extends inferiorly into the right
submandibular space and posteriorly into the masticator and
parotid spaces. No drainable fluid collection.
There is no facial bone fracture. Pterygoid plates are intact.
There is no
mandibular fracture and the temporomandibular joints are
anatomically aligned. The orbits are intact. Aside from the
aforementioned findings, the globes and extra-ocular muscles are
unremarkable.
Included paranasal sinuses are clear.
Neck:
Evaluation of the aerodigestive tract demonstrates no mass and
no areas of
focal mass effect. Focal calcifications are seen within the
inferior aspect of the right parotid gland (2:50), which most
likely represents sialoliths. The other salivary glands are
grossly without mass or adjacent fat stranding. Multiple
prominent to enlarged right-sided cervical nodes measure up to
1.1 cm (2:52).
Mild mosaic attenuation of the lung apices is nonspecific. A
hypodense right thyroid nodule measures 1.5 cm. No worrisome
osseous lesions or acute fracture.
IMPRESSION:
1. Diffuse right malar soft tissue swelling and fat stranding
following
drainage of a right maxillary abscess, with a drain in situ.
Small locules of air within the right malar soft tissues may
reflect postprocedural changes. No evidence of drainable fluid
collection.
2. No substantial change in diffuse right periorbital/preseptal
soft tissue swelling.
3. Right-sided cervical lymphadenopathy, likely reactive.
4. Hypodense right thyroid nodule, measuring up to 1.5 cm.
Further evaluation is recommended with thyroid ultrasound as an
outpatient, if this has not been previously worked up.
___ EGD
- normal esophageal mucosa
- gastritis
- multiple ulcers in duodenal bulb; largest 2 cm with clotting
to suggest recent bleeding injected with epinephrine but further
intervention unable to be pursued due to size
___ ___ GDA embolization
IMPRESSION:
Successful right common femoral artery approach GDA coil
embolization.
CT HEAD ___
IMPRESSION:
1. There is partial visualization of known right facial
infection.
2. Otherwise normal head CT.
CT W/ contrast
1. Interval improvement of right malar soft tissue swelling and
fat stranding, with no evidence of drainable fluid collection.
2. Redemonstrated irregularity and erosion in the second and
third right molar regions. Gas in the region of the soft tissues
overlying the area has coalesced.
___ 06:00AM BLOOD WBC-9.3 RBC-2.46* Hgb-7.4* Hct-24.1*
MCV-98 MCH-30.1 MCHC-30.7* RDW-14.7 RDWSD-51.0* Plt ___
___ 05:49AM BLOOD WBC-10.8* RBC-2.61* Hgb-7.8* Hct-25.7*
MCV-99* MCH-29.9 MCHC-30.4* RDW-15.1 RDWSD-51.1* Plt ___
___ 05:49AM BLOOD Glucose-293* UreaN-14 Creat-1.1 Na-138
K-5.1 Cl-100 HCO3-22 AnGap-16
___ 05:49AM BLOOD CRP-12.8*
Brief Hospital Course:
PATIENT SUMMARY:
=====================
___ y/o F with T1DM, pseudoseizures, anxiety, and depression
presented with right-sided facial pain and swelling after
multi-tooth extraction ___ found to have cellulitis c/b
polymicrobial maxillary abscess causing profound facial edema
leading to dysphagia and dyspnea, transferred to the FICU for GI
bleeding with episode of unresponsiveness, Unasyn-challenge and
high-risk airway. S/p GDA embolization ___.
TRANSITIONAL ISSUES:
========================
[ ] R Thyroid nodule seen on CT, recommended thyroid ultrasound
as outpatient
ACUTE ISSUES:
=======================
# Right facial cellulitis
# Right maxillary abscess
Presented with tender and indurated right cheek after teeth
extraction, CT c/f deep tissue infection. Underwent I&D with
OMFS ___ and ___, with improvement. For antibiotics,
initially treated with clinda, which was broadened to include
vancomycin and cipro with assistance of ID. Now s/p graded
unasyn challenge in the ICU without reaction. She continued to
have some drainage from a skin opening in the malar region. With
this and a WBC that was still higher than her baseline, CT w/o
contrast was obtained to look for a drainable fluid collection.
This was equivocal, so after clarifying the patient's prior
reaction to IV contrast and discussing the risks and benefits,
CT w/ contrast with premedication was obtained. She did not
experience a reaction to the contrast, and the study showed
overall improvement with no drainable abscess. WBC was elevated,
but this was after administration of several doses of IV
solumedrol for premedication. The patient felt better overall
and requested strongly to return home, so in light of her exam,
overall clinical picture, and imaging findings, antibiotics were
changed to Augmentin 875 BID for 7 more days. The patient will
follow up with her PCP. Return precautions were
# Restricted right-sided upward gaze
Evaluated on ophthalmology ___ with low concern for
subperiosteal abscess or orbital cellulitis. She was monitored
clinically with overall improvement.
# Hypotension
# Intubated
Intubated ___ electively for airway protection in anticipation
of EGD and further intervention for GI bleeding.. Became
hypotensive after initiating Propofol and continued GI bleed
(discussed below) and fentanyl requiring norepinephrine. After
her procedures, her sedation was weaned and she was successfully
extubated on ___. Her hypotension also resolved as sedation
was weaned.
# GI Bleed
# Duodenal ulcer
Patient had moderate-large volume melanotic stools. She was on
IV PPI twice daily. A large duodenal ulcer found on EGD which
was injected with epinephrine; GDA embolized by ___ on ___
without further bleeding. Her ulcer was suspected to be related
to NSAID use due to her opioid allergy. She required 3 units of
PRBC. She was discharged on Protonix 40 mg daily for a total of
8 weeks
# Coagulopathy
INR initially 1.6, she received 3 days of 5 mg IV Vitamin K in
the setting of coagulopathy + GI bleeding.
# ___
Cr up to 1.5 with baseline 0.7. Thought to be related to
pre-renal and/or ATN. Her Cr stabilized at 1.1
# Possible seizure:
# Hx of non-epileptiform seizures:
Pt reports almost daily seizures, usually preceded by an aura of
facial numbness. Confirmed to be non-epileptiform on admission
to ___ ___. She is followed by Dr. ___
neurology), who has been trying to refer her to neuropsychiatry.
On lamotrigine and oxcarbazepine for bipolar disorder (not
epilepsy). Had questionable seizure episode on ___ ___ and
again ___ with rhythmic R-sided shaking and unresponsiveness,
resolved spontaneously after ~30s. Seen by neurology, who have
recommended against further diagnostics and suggest continuation
of her home mood stabilizers.
CHRONIC/STABLE ISSUES
=======================
# Hypertension
Her home lisinopril was held iso hypotension/GI bleeding.
Restarted on discharge.
# Anxiety # Depression # PTSD
Her home medicines were continued.
# Type 1 Diabetes
A1c 7.9% this admission. Her home lantus dose was slightly
increased during her admission. Her meal-time Humalog was
initially held as patient was NPO but restarted when she was
eating. Her metformin was held and restarted on discharge.
The patient was seen and examined on the day of discharge. The
total time spent preparing discharge, coordinating, and
counseling was greater than 30 minutes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 150 mg PO DAILY
2. LamoTRIgine 100 mg PO DAILY
3. OXcarbazepine 300 mg PO QAM
4. QUEtiapine Fumarate 100 mg PO Q4H PRN anxiety
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Prazosin 1 mg PO QHS
7. TraZODone 150 mg PO QHS insomnia
8. Glargine 22 Units Bedtime
Humalog 10 Units Breakfast
Humalog 8 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
10. Ibuprofen 800 mg PO Q8H:PRN Pain - Mild
11. OXcarbazepine 600 mg PO QHS
12. Lidocaine Viscous 2% 5 mL PO EVERY 15 MINUTES
13. QUEtiapine Fumarate 50 mg PO Q4H PRN anxiety
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY AS NEEDED
allergies
15. HydrOXYzine 50 mg PO Q4H:PRN anxiety
16. Melatin (melatonin) 3 mg oral QHS PRN insomnia
17. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*49
Tablet Refills:*0
3. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY AS NEEDED
allergies
6. HydrOXYzine 50 mg PO Q4H:PRN anxiety
7. Glargine 22 Units Bedtime
Humalog 10 Units Breakfast
Humalog 8 Units Lunch
Humalog 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
8. LamoTRIgine 100 mg PO DAILY
9. Lisinopril 10 mg PO DAILY
10. Melatin (melatonin) 3 mg oral QHS PRN insomnia
11. MetFORMIN (Glucophage) 500 mg PO BID
12. OXcarbazepine 300 mg PO QAM
13. OXcarbazepine 600 mg PO QHS
14. Prazosin 1 mg PO QHS
15. QUEtiapine Fumarate 100 mg PO Q4H PRN anxiety
16. QUEtiapine Fumarate 50 mg PO Q4H PRN anxiety
17. Sertraline 150 mg PO DAILY
18. TraZODone 150 mg PO QHS insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Facial abscess
Odontogenic infection
GI bleed
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were treated at ___ for a facial abscess. After drainage
and antibiotics, the infection is improving. Please continue the
full course of antibiotics at home. If you notice any concerning
changes, please seek medical attention immediately.
Followup Instructions:
___
|
19955582-DS-6 | 19,955,582 | 26,593,491 | DS | 6 | 2139-10-18 00:00:00 | 2139-10-18 19:25:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Appendicitis
Major Surgical or Invasive Procedure:
Laparoscopic appendectomy
History of Present Illness:
___ year old otherwise healthy woman who presents with
periumbilical -> RLQ pain. The patient was in her usual state of
health until 10pm the night prior to presentation when she
developed worsening periumbilical pain. She developed worsening
nausea and NBNB vomiting. She presented to the ED for further
evaluation. On ED presentation, she noted RLQ > periumbilical
pain. She continued to have nausea but denied fevers, chills,
diarrhea, sweats, recent weight loss, BRBPR, melena, chest pain,
and SOB. Her last meal was the prior evening and her last drink
of water was 5am the morning of presentation.
Past Medical History:
None
Social History:
___
Family History:
NC
Physical Exam:
Exam on Admission
Vitals: T 98.7 HR 76 BP 126/64 RR19 SpO2 100%RA
GEN: A&O, lethargic but easily arousable, resting in stretcher
HEENT: No scleral icterus, mucus membranes dry
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended. Tenderness to palpation in RLQ
>periumbilical. No rebound or guarding. Negative ___ sign.
No palpable masses.
Ext: No ___ edema, ___ warm and well perfused.
Exam on discharge:
99.3 98.6 79 ___ 97RA
Gen: NAD
CV: RR
Resp: NRD
Abd: Soft, NT/ND w/o R/G. Incisions c/d/I w/o e/o erythema or
induration.
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 and was admitted to the Acute Care Surgery
service. The patient was taken to the operating room on ___
for laparoscopic appendectomy, 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. On ___ the patient was noted to be hypotensive
to SBP of 85-90 with a hct drop to 19.9. She was transfused 2U
PRBC with an appropriate Hct rise to 26. At the time of
discharge the patients Hct was stable at 25.8. 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
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:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hrs Disp #*30 Tablet
Refills:*0
3. Docusate Sodium 100 BID while taking narcotic pain
medications.
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 to continue your recovery with the
following instructions.
Please follow up in the Acute Care Surgery clinic at the
appointment listed below.
Department: GENERAL ___
When: ___ at 1:20 ___
With: ___
Building: ___
Campus: ___ Best Parking: ___
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in
your throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before
your pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
19955908-DS-17 | 19,955,908 | 23,511,709 | DS | 17 | 2176-03-20 00:00:00 | 2176-03-20 22:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Benzodiazepines / lisinopril / vicryl stitching
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Lumber puncture ___
History of Present Illness:
History of Present Illness: ___ male with history of
hypertension, IVDU (clean ___ years, on suboxone), and hepatitis C
presenting with acute headache. Patient states his symptoms
started with neck pain and stiffness on ___. His
headache started on ___. The pain was gradual in
onset, starting upon awakening at 5 AM on ___ and increasing
throughout the day until the pain reached a ___ in intensity
by mid-day. The spouse reports that the patient had symptoms
suggestive of an upper respiratory infection or sinusitis in the
days leading up to his presentation at ___.
Patient endorses fevers, chills, photophobia, nausea, vomiting,
and neck stiffness. Denies chest pain, SOB, paresthesias, recent
travel, sick contacts, or animal/pet contacts.
Notably, Mr. ___ has a history of illicit drug abuse but has
been clean for last ___ years on Suboxone (managed by Dr. ___
___
in ___ at ___.
In the ED, initial vital signs were: T: 100.3 HR: 113 BP:
137/70 RR: 16 O2%: 100 RA
Exam notable for: No nuchal rigidity.
Labs were notable for: WBC 14.0, Lactate:1.5
Imaging were notable for:
(___) CT HEAD W/O CONTRAST
IMPRESSION:
1. No orbital cellulitis or acute intracranial process.
2. Mucosal thickening in the bilateral maxillary sinuses,
frontal sinuses and ethmoid air cells. Correlate clinically for
sinusitis.
(___) CHEST (PA & LAT)
IMPRESSION:
No acute cardiopulmonary process.
In the ED patient was given 1L NS, vancomycin 1000 mg,
ceftriaxone 2 gm, Lorazepam 2 mg, hydromorphone 1 mg, morphine
mulfate 4 mg, acetaminophen 1000 mg.
Vitals on transfer: T: 98.3 HR: 71 BP: 153/80 RR: 14 O2%: 97
RA
Upon arrival to the floor, the patient was in acute distress,
crying in severe ___ pain. He was inattentive at times through
the interview and physical exam and had some difficulty
following commands.
Past Medical History:
IVDU
Asthma
Back pain
hypertension
Obesity
Hepatitis c
Migraine headaches
Hallux rigidus
GERD
Osteoporosis
Arthritis
Social History:
___
Family History:
He has two healthy siblings. His mother is ___ with gallstones
and his father has hypertension.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals- Tc: 98.1 BP: 110s-140s/60s HR: 80s-100s RR: ___ O2%:
98 RA
GENERAL: AAOx1, in acute distress intermittently and crying but
then minutes later falls asleep, snoring
HEENT: PERRLA. EOMI. Oropharynx is clear. Pupils constricted but
reactive bilaterally.
CARDIAC: RRR. No m/r/g. No JVD.
LUNGS: CTAB.
ABDOMEN: NT/ND
EXTREMITIES: No edema, 2+ pulses bilaterally
SKIN: No rashes, petechiae
NEUROLOGIC: Unable to state his location or time. Inattentive,
keeps falling asleep after being asked questions but rousable.
CN II-XII intact, has some left eyelid droop but seems related
to photosensitivity and improves with dark room. Strength ___
bilaterally in upper and lower extremities. Sensation intact
throughout except notes slightly different sensation to light
tough in left lower extremity.
DISCHARGE PHYSICAL EXAM
=======================
Vitals- 98.1 128/74 99 20 100%RA
GENERAL: AAOx3, resting in bed with fiance in room, no acute
distress.
HEENT: Left eye swelling and erythema improved. Able to read
card without propping eye open. PERRL. Intact visual fields and
visual acuity to finger number bilaterally. Left eye acuity is
___ OD and ___ OS bilaterally. EOMI, restricted on left with
mild pain with left eye movement.
CRDIAC: RRR. No m/r/g.
LUNGS: CTAB, normal work of breathing.
ABDOMEN: NT/ND, +BS
EXTREMITIES: 1+ pitting edema to shins bilaterally isimproved,
2+ pulses DP/Radial.
SKIN: No rashes, petechiae over left upper arm under shirt from
prior iv attempts.
NEUROLOGIC: Alert and oriented x3. Has difficulty opening his
left eyelid but is improving and ophthalmology is happy with
progress. Strength ___ bilaterally in upper and lower
extremities. Sensation intact throughout except as noted above.
LINES: R PICC c/d/i
Pertinent Results:
ADMISSION LABS
==============
___ 06:55AM BLOOD WBC-14.0*# RBC-4.30* Hgb-13.5* Hct-40.8
MCV-95 MCH-31.4 MCHC-33.1 RDW-13.2 RDWSD-45.1 Plt ___
___ 06:55AM BLOOD Neuts-81.3* Lymphs-7.6* Monos-9.6
Eos-0.6* Baso-0.3 Im ___ AbsNeut-11.40*# AbsLymp-1.06*
AbsMono-1.34* AbsEos-0.08 AbsBaso-0.04
___ 06:55AM BLOOD ___ PTT-29.6 ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD Glucose-127* UreaN-7 Creat-0.7 Na-136
K-3.7 Cl-96 HCO3-28 AnGap-16
NOTABLE LABS
==============
___ 07:00AM BLOOD ___
___ 03:53PM BLOOD Iron-26*
___ 03:53PM BLOOD calTIBC-224* Hapto-281* Ferritn-300
TRF-172*
___ 06:10AM BLOOD IgG-1404 IgA-216 IgM-61
MICROBIOLOGY
==============
___ 7:00 pm ASPIRATE Site: SINUS
SINUS, LEFT OSTEROMEATAL COMPLEX 1. C1.
**FINAL REPORT ___
RESPIRATORY CULTURE (Final ___:
RARE GROWTH Commensal Respiratory Flora.
STAPH AUREUS COAG +. SPARSE GROWTH.
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
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.5 S
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ 7:15 pm ASPIRATE Site: SINUS
SINUS LEFT OSTEOMEATAL COMPLEX 1.
**FINAL REPORT ___
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ SINUS
FROM
___.
ESCHERICHIA COLI. RARE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 4:45 pm ASPIRATE Source: Sinus.
**FINAL REPORT ___
RESPIRATORY CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ SINUS
ASPIRATE FROM
___.
YEAST. RARE GROWTH.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Blood cultures, CSF cultures, Lyme all negative
IMAGING
==============
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. No orbital cellulitis or acute intracranial process.
2. Mucosal thickening in the bilateral maxillary sinuses,
frontal sinuses and
ethmoid air cells. Correlate clinically for sinusitis.
___ MR MRV HEAD W/O CONTRAST
Left orbital cellulitis with significant sinus disease. No
abscess found at this time. Adjacent left frontal meningitis
suggests intracranial extension of infection without evidence of
abscess or empyema. No evidence of cavernous sinus thrombosis.
___ CT HEAD W/O CONTRAST
IMPRESSION:
1. There is no evidence of acute large territorial infarction,
hemorrhage, edema nor mass effect.
2. Interval increased left periorbital inflammatory stranding
compatible with cellulitis. Please refer to dedicated
concurrent CT orbits for further details.
3. Stable paranasal sinuses disease as described above.
___ CT ORBITS, SELLA & IAC
IMPRESSION:
1. Left preseptal and postseptal orbital cellulitis, not seen on
prior
examination. The postseptal orbital inflammation/phlegmon is
predominantly
localized to the superior-medial-lateral extraconal regions with
mass effect
and inferior displacement of the underlying extraocular muscles,
with
extension to the medial orbital wall. However, there is faint
stranding seen
within the left intraconal region that is concerning for
intraconal spread.
There is no evidence of left globe involvement.
2. No definite confluent collection to suggest abscess. These
findings could
be better evaluated with dedicated MRI of the orbits.
3. There is moderate to severe sinus mucosal thickening most
prominent in the
left ethmoid sinus that appears to have worsened when compared
to the ___ study. Although there is no obvious evidence of sinus wall
bony defect
visible on the this CT, extension of sinusitis to the left orbit
cannot be
excluded. In the the appropriate clinical setting, may consider
the
possibility of paranasal sinusitis as a potential source of
infection and
orbital cellulitis.
___ CT SINUS/MANDIBLE/MAXIL
IMPRESSION:
1. Increased prominence of the left ethmoid, frontal, and
maxillary sinus sinusitis without definite bony dehiscence
identified. This likely represents an infectious source.
2. Persistent left orbital cellulitis with increased
retrobulbar, preseptal, and left facial inflammation, stable
mass effect on the superior and lateral rectus muscles, and no
evidence of retrobulbar or periosteal abscess.
3. Meningeal enhancement seen on previous MRI is not well
demonstrated on this study. There is no evidence of
intracranial abscess or empyema.
4. Left superior ophthalmic vein is normal in size and there is
symmetric appearance of cavernous sinuses.
MRI Orbit With and Without Contrast ___
IMPRESSION:
1. Progressive left orbital cellulitis with worsening proptosis
and
periorbital extension with involvement of the extraocular
musculature and left
optic nerve, as described.
2. Progressive left frontal pachymeningeal thickening and
enhancement
consistent with meningitis from direct extension of orbital
cellulitis with
interval development of an 8 x 6 mm epidural abscess.
3. Progressive extensive paranasal sinus disease, the likely
infectious
source.
4. No evidence of cavernous sinus thrombosis.
DISCHARGE LABS
==============
___ 05:20AM BLOOD WBC-12.6* RBC-4.20* Hgb-13.3* Hct-39.6*
MCV-94 MCH-31.7 MCHC-33.6 RDW-13.3 RDWSD-45.9 Plt ___
___ 05:20AM BLOOD Glucose-104* UreaN-16 Creat-0.6 Na-136
K-4.5 Cl-95* HCO3-26 AnGap-20
___ 05:20AM BLOOD CK(CPK)-35*
___ 05:20AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.6
Brief Hospital Course:
Mr. ___ is a ___ male with history of hypertension,
IVDU (clean ___ years, on suboxone), and hepatitis C who presented
with acute headache and fever, treated initially for meningitis
but found to have orbital cellulitis ___ direct spread from
sinusitis.
ACTIVE ISSUES
=============
# Bacterial sinusitis/orbital cellulitis/meningitis/epidural
abscess
Mr. ___ presented to ___ for evaluation of acute headache
of ___ intensity with neck stiffness and photophobia, worked
up for meningitis with relatively bland CSF. Morning of ___
developed pronounced left orbital swelling with a headache ___
in intensity. Urgent MRI/MRV and CT head/orbit showing worsening
sinusitis and orbital cellulitis; no venous sinus thrombosis. In
ED on ___ prior to LP patient received vancomycin and
ceftriaxone, acyclovir added night of admission. Due to concern
for eye swelling on ___, metronidazole added that AM. ID
consulted, evening of ___ d/ced metronidazole and ceftriaxone,
added clindamycin and meropenem.
Ophthalmology and ENT were consulted for possible surgical
interventions, none needed during admission but followed closely
by both services. Unifying etiology determined to be bacterial
sinusitis with spread to orbit and meninges, likely secondary to
MRSA which grew from sinus cultures. Patient started on broad
spectrum antibiotics (vancomycin starting ___, meropenem
starting ___, clindamycin starting ___, stormy clinical
course with both opthomology and ENT considering surgery.
Patient received a three-dose pulse of Dexamethasone 10 mg on
___, and underwent extensive sinus irrigation with normal
saline. An attempt was made to transition to oral antibiotics on
___ following clinical improvement, but on the night of ___
interval imaging found a small intracranial epidural abscess
with worsening of eye findings on imaging as well as worsening
clinical condition the next morning. He was restarted on IV
antibiotics (vancomycin and meropenem). Neurosurgery was
consulted and did not want to operate as the abscess was very
small and there was no compromise of the barrier between the
sinus and intracranial space. ID decided to switch him to
Daptomycin and Ceftriaxone IV with metronidazole PO and was
discharged with OPAT and close follow up. He is having close
follow up with ID, ENT, and Ophthalmology who will be monitoring
his clinical condition, labs and imaging.
# Acute pain: Patient with significant headache and eye pain
during admission. Suboxone was discontinued on admission, and
pain regimen titrated uo in conjuction with chronic pain
service. During peak of pain patient on dilaudid PCA, which was
weaned off and discontinued on ___. Restarted on Suboxone ___
BID per home regiment for chronic pain on ___ with Tylenol and
NSAIDs PRN. Nortriptyline 25 mg PO/NG QHS started per recs from
chronic pain, and on discharge was stable on his suboxone in
minimal pain.
# Opioid Use Disorder: Sober for ___ years. On Suboxone therapy
for several years. Suboxone managed by Dr. ___ in
___ at ___. Held on admission,
restarted suboxone ___ BID on ___ and discharged on home dose
with follow-up.
# Diarrhea - Resolved - ___. Watery diarrhea starting ___,
likely secondary to multiple antibiotics but concern for c.
diff. PCR negative, and diarrhea resolved by time of discharge.
CHRONIC ISSUES
==============
# Chronic back and right foot pain: Continued home gabapentin
800 mg PO QD.
# Hepatitis C: Seen in ___ clinic ___ for
possible treatment with dalatasvir/ sofosbuvir but unable to
start for insurance reasons, patient early stage and does not
require inpatient treatment.
# Hypertension: Restarted home hydrochlorothiazide 12.5 mg
daily.
# Attention Deficit Disorder: Initially held
amphetamine-dextroamphetamine 30 mg PO while in hospital, and
plan to restart as outpatient.
# Asthma: Home inhaler held initially, on the morning of ___ he
was found to be wheezing and was given nebulizer treatments. He
was restarted on his home inhaler without further incident.
# GERD: Continued home omeprazole 20 mg PO QD.
# BPH: Continued home tamsulosin 0.4 mg PO QD.
TRANSITIONAL ISSUES:
[] Will need weekly CBC with differential, BUN, Cr, AST, ALT,
TB, ALK PHOS, and CK faxed to ___ ___
[] Follow-up with infectious disease ___, MD on ___
___ at 11:00 AM
[] Continue taking MetroNIDAZOLE 500 mg PO/NG TID until cleared
by ID
[] Continue taking Daptomycin 750mg IV daily until cleared by
ID
[] Continue taking ceftriaxone 2g BID until cleared by ID.
[] Will need follow up MRI orbit imaging ___ for monitoring of
intracranial infection and improvement in orbital infection
[] Will need outpatient sinus surgery after resolution of acute
infection
# Code Status: FULL
# Emergency Contact/HCP: Spouse (___) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
2. Gabapentin 800 mg PO QID
3. Omeprazole 20 mg PO DAILY
4. Hydrochlorothiazide 12.5 mg PO DAILY
5. Amphetamine-Dextroamphetamine 30 mg PO DAILY
6. Tamsulosin 0.4 mg PO QHS
7. Albuterol Inhaler 2 PUFF IH PRN Asthma
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH DAILY:PRN
Asthma
Discharge Medications:
1. CefTRIAXone 2 gm IV BID
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 50 mL IV twice a
day Disp #*28 Intravenous Bag Refills:*1
2. Daptomycin 750 mg IV Q24H
RX *daptomycin [Cubicin RF] 500 mg 1.5 vials Daily Disp #*28
Vial Refills:*1
3. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth Three Times a Day
Disp #*52 Tablet Refills:*1
4. sodium bicarb-sodium chloride 1 PKT NU TID
This is an over the counter medication available at the
pharmacy.
5. sodium bicarb-sodium chloride 1 PKT NU TID
6. Albuterol Inhaler 2 PUFF IH PRN Asthma
7. Amphetamine-Dextroamphetamine 30 mg PO DAILY
8. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID
9. Gabapentin 800 mg PO QID
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH DAILY:PRN
Asthma
12. Omeprazole 20 mg PO DAILY
13. Tamsulosin 0.4 mg PO QHS
14.Outpatient Lab Work
ICD10: ___
Weekly CBC with differential, BUN, Cr, AST, ALT,
TB, ALK PHOS, and CK faxed to ___ ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
-Sinusitis
-Left orbital cellulitis
-Meningitis
Secondary diagnosis
-Opioid Use Disorder
-Hypertension, essential
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were having a
severe headache and neck pain. In the hospital you developed
severe eye left eye swelling. We determined that you had a sinus
infection that had spread to your eye (orbital cellulitis) and
lining of your brain (meningitis) and developed a small abscess
outside the lining of your brain.
You were placed on very strong IV antibiotics, and over time
your infection improved. You will need to stay on these IV
medications and be followed closely in clinic until your abscess
resolves.
You will need to follow up Ear Nose and Throat, Oculoplastics
(eye doctors), and infectious disease doctors after ___.
It was a privilege to help care for you in the hospital.
Sincerely,
Your ___ Health Team
Followup Instructions:
___
|
19956148-DS-10 | 19,956,148 | 22,450,853 | DS | 10 | 2146-07-18 00:00:00 | 2146-07-18 16:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Left finger pain and discoloration
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: ___ w/ h/o R subclavian artery stent & axillary angioplasty
who presents with 1 day of R hand ___ & ___ finger discoloration
and pain. She was evaluated at an OSH where CTA showed partial
occlusion of her R subclavian stent as well as R vertebral
artery stenosis. She was
started on a hep gtt and transferred to ___ for further
evaluation.
Past Medical History:
PMH: HL, HTN, morbid obesity, hypothyroid, bipolar, chronic knee
pain, migraines, Hep C, Vit D deficiency, tobacco use, h/o
opiate dependence on methadone, PTSD, panic disorder
PSH: ___ R subclavian artery stent and R axillary
angioplasty
Physical Exam:
Alert and oriented x 3
VS:BP 138/62 HR 68 RR 16
Resp: Lungs clear
Abd: Soft, non tender
Ext: Pulses: Bilateral upper extremity: 2+ Palpable ulnar and
radial pulses. Finger warms, well perfused, color pink with
temperature equal both hands.
Pertinent Results:
___ 08:20PM BLOOD Neuts-48.9 ___ Monos-4.6* Eos-1.9
Baso-0.5 Im ___ AbsNeut-5.06 AbsLymp-4.53* AbsMono-0.48
AbsEos-0.20 AbsBaso-0.05
___ 08:20PM BLOOD WBC-10.4* RBC-4.42 Hgb-12.7 Hct-39.3
MCV-89 MCH-28.7 MCHC-32.3 RDW-13.8 RDWSD-44.7 Plt ___
___ 07:25AM BLOOD ___
___ 07:45AM BLOOD Glucose-92 UreaN-9 Creat-0.7 Na-137 K-4.6
Cl-100 HCO3-24 AnGap-18
___ 07:45AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.1
Brief Hospital Course:
HPI: ___ w/ h/o R subclavian artery stent & axillary angioplasty
presents to OSH with 1 day of R hand ___ & ___ finger
discoloration and pain. CTA was concernin g for occlusion of
her R subclavian stent as well as R vertebral artery stenosis.
She was started on a hep gtt and transferred to ___ for
further evaluation.
Her finger discoloration and pain improved on heparin. After
review of the CTA we felt that the right subclavian artery had
focal stenosis or partial thrombosis of the subclavian artery
just distal to the stent but the stent was patent. There was
good distal flow to the axillary artery which also had
multifocal stenoses. There is also evidence of high-grade
stenosis of the proximal right vertebral artery.
Digit pressures and waveforms were excellent. Her antiplatelet
was changed to plavix from aspirin. We felt an intervent was
not warrented and would increase the risk of thromboembolic
events.
As her symptoms resolved, we discharged her to home on coumadin
with lovenox bridge
and plavix. She will follow up her INR check on ___ with her
PCP. We will also follow her closely in the clinic. She is
instructed to call for any changes in her hand or arm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pravastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Levothyroxine Sodium 275 mcg PO DAILY
6. ClonazePAM 2 mg PO TID:PRN Anxiety
7. Gabapentin 800 mg PO TID
8. Paroxetine 40 mg PO QAM
9. Methadone 100 mg PO DAILY
10. Warfarin 5 mg PO DAILY16 arterial thrmboembolism
Discharge Medications:
1. ClonazePAM 2 mg PO TID:PRN Anxiety
2. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth DAILY Disp #*30
Tablet Refills:*11
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 800 mg PO TID
5. Levothyroxine Sodium 275 mcg PO DAILY
6. Methadone 100 mg PO DAILY
7. Paroxetine 40 mg PO QAM
8. Pravastatin 80 mg PO QPM
9. Amitriptyline 25 mg PO QHS
10. Enoxaparin Sodium 120 mg SC TWICE DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
INJECT TWICE DAILY UNTIL INSTRUCTED TO STOP BY ___ CLINIC
RX *enoxaparin 120 mg/0.8 mL 1 INJECTION TWICE DAILY Disp #*14
Syringe Refills:*0
11. Acetaminophen 650 mg PO Q6H:PRN pain
12. Warfarin 5 mg PO DAILY16 arterial thrmboembolism
Discharge Disposition:
Home
Discharge Diagnosis:
Peripheral Arterial Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you here at ___
___. You were admitted to our hospital with
discoloration in the fingers on your right hand. The CTA showed
that the stent in your chest was open with good blood flow but
the artery after the stent was narrowed. Blood pressure tests
showed the blood flow to your fingers was very good. We found
that your INR was low so we started IV blood thinners and your
symptoms improved. We added a new medication called plavix to
help with the blood flow through the narrowed artery. This will
replace the aspirin you were taking. You are now ready to be
discharged to home. We will continue to follow you closely in
the office. Please follow the recommendations below to ensure a
speedy and uneventful recovery.
Followup Instructions:
___
|
19956148-DS-11 | 19,956,148 | 25,462,122 | DS | 11 | 2146-11-27 00:00:00 | 2146-11-28 12:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
vaginal bleeding, abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old G1P1 female with a history of right subclavian
artery stenosis s/p stent and carotid arty filter placement who
presents with a month of abnormal vaginal bleeding. She is
post-menopausal and had not had vaginal bleeding
for ___ years, until bleeding started in ___. She
underwent a hysteroscopy/D&C on ___ for the bleeding, and
pathology demonstrated the following: "Disordered proliferative
endometrium with extensive tubal metaplasia and focal glandular
crowding, fragments suggestive of endocervical polyp, no
definite hyperplasia."
Since that time, she has been maintained on 20mg of provera BID
with intermittent improvement in bleeding pattern. Since last
week, she has continued to have bleeding, changing a pad every
hour. Her hemoglobin has been followed by her outpatient
treaters and has been essentially stable (Hgb 10.9 on ___,
10.8 on ___, but today, in the setting of feeling dizzy, she
was sent to the ED for further evaluation.
She reports cramping abdominal pain that is diffuse. This tends
to be present when her bleeding starts up again. She denies
fever/chills. No abnormal vaginal discharge. No chest pain,
shortness of breath.
Of note, in the work-up of AUB, she had a pelvic ultrasound that
demonstrated a large cystic finding with low-level echoes int eh
right adnexa measuring 8.8 x 7.8 x 8.1 cm, representing a large
right para-ovarian cyst versus hydrosalpinx.
Her medical history is notable for peripheral vascular disease
and right subclavian artery stenosis. In the setting of her
subclavian stenosis, she underwent treatment with stent and
carotid artery filter placement
She also has a history of narcotic dependence and chronic Hep C,
as well as anxiety, depression, and PTSD. Finally, she is obese
with a BMI 46. On exam, she overall appears well. Abdominal exam
is soft, diffusely tender but no peritoneal signs.
Past Medical History:
POBHx: G1P1 SVD x1, uncomplicated
PGynHx: LMP ___ yrs ago. Denies STIs. Hx of ASCUS Pap/HPV neg in
___ w/neg Pap/HPV in ___. No sexual activity ___ years.
PMH: morbid obesity (BMI 46), peripheral vascular disease, R
subclavian artery stenosis, buerger's disease, hx of narcotic
dependence, chronic Hep C, anxiety, depression, PTSD,
hypothyroidism, shoulder dislocation
PSH: ___ right subclavian stenosis treatement with stent and
carotid artery filter placement
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission physical exam
PE: 98.1 112/56 73 99%RA 16
Gen: NAD
Abd: soft, obese, mod TTP in bilateral lower quadrants, no
rebound or guarding, palpable tender 8cm mass slightly right of
midline in lower quadrant; erythema and scattered papules on
upper left thigh and inguinal area under pannus
Pelvic: NEFG, atrophic vaginal mucosa, 2 cc of bld in vaginal
vault and one spot on pad, no active bleeding from cervix, no
CMT, unable to palpate uterus due to habitus but has midline TTP
as well as bilateral TTP of adnexa.
Rectovaginal: no palpable masses, normal tone
Discharge physical exam
Vitals: VSS
Gen: NAD, A&O x 3
CV: RRR
Resp: no acute respiratory distress
Abd: soft, non-tender, no rebound/guarding
Ext: no TTP
Pertinent Results:
___ 10:50AM LACTATE-1.6
___ 10:30AM URINE UCG-NEGATIVE
___ 10:30AM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 10:30AM URINE RBC->182* WBC-18* BACTERIA-FEW
YEAST-NONE EPI-1 TRANS EPI-<1
___ 10:30AM URINE MUCOUS-RARE
___ 10:30AM URINE MUCOUS-RARE
___ 09:30AM CALCIUM-9.4 PHOSPHATE-3.0 MAGNESIUM-2.2
___ 09:30AM CEA-2.6 CA125-27
___ 09:30AM CEA-2.6 CA125-27
___ 09:30AM NEUTS-63.2 ___ MONOS-4.2* EOS-1.0
BASOS-0.4 IM ___ AbsNeut-9.76*# AbsLymp-4.70* AbsMono-0.65
AbsEos-0.16 AbsBaso-0.06
___ 09:30AM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL
___ 09:30AM PLT SMR-HIGH PLT COUNT-473*#
___ 09:30AM ___ PTT-48.6* ___
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
in the setting of vaginal bleeding and abdominal pain of unclear
etiology. She underwent a continued diagnostic workup as an
inpatient, which included a pelvic ultrasound that demonstrated
a 6.5 x 7.0 x 7.4 cm cystic structure with no appreciable
internal flow on color Doppler, most likely consistent with a
hydrosalpinx. A urine sample was sent, along with a urine
culture, and cultures for gonorrhea and chlamydia. These
cultures were negative. She also underwent an MRI of the
abdomen/pelvis to further characterize the nature of the
findings on ultrasound. The MRI was notable for an 8cm benign
appearing simple cyst of the right ovary.
The patient remained hemodynamically stable throughout
admission. The bleeding was monitored with pad counts, which
were appropriate, and serial Hct which remained stable and
appropriate. She was continued on Provera. The dose of Provera
was decreased to 10mg BID on hospital day 2. Her INR was
monitored daily and she was given her confirmed dose of Coumadin
on HD2. This dose was increased from 7.5mg to 8mg in the setting
of a subtherapeutic range INR. She was scheduled an appointment
at the Anticoagulation Management Clinic in ___ to be seen on
the day of discharge for a repeat INR and dose adjustment.
Vascular Surgery was consulted given the patient's history of a
RUE arterial thrombosis, currently on ASA, Plavix and Coumadin.
The patient was continued on her anticoagulation regimen, given
that there was no plan to take her to the operating room this
admission. Her Coumadin dose was confirmed with her PCP's office
(Dr. ___ with ___). She underwent a
duplex arterial scan of the right subclavian and PVRs of
bilateral upper extremities to further assess her vasculature
and clot burden, per Vascular Surgery recommendations. They was
no need for vascular intervention and they recommended follow up
as planned with Dr. ___ as outpatient.
She tolerated a regular diet throughout admission, was voiding
without issue and ambulating independently. She was continued on
her home dose of methadone (confirmed with her ___ clinic
as 100mg QD), as well as her other home medications.
On hospital day 3, she was tolerating a regular diet, voiding
spontaneously, ambulating independently, and pain was controlled
with her home regimen of oral medications. She was then
discharged home in stable condition with outpatient follow-up
scheduled at ___.
~~~~~~~~~~~~~~~~~~~~~~~~
Note (___ ___: Discharge dose of Provera was 10mg bid.
Given pain & initial leukocytosis it was felt that some of her
sx could be due to post-procedureal endometritis, hence decision
to treat with abx. Some bleeding might also be attributable to
the relatively high dosage of Provera she was on.
It was felt that she did not have an acute process requiring
emergent operative treatment . Based on her overall stability
and her need for anticoagulation, we felt that further
procedures (if any) to address her bleeding and adnexal cyst
were best performed on a planned basis after coordination with
her vascular surgery & other providers. Options discussed for
management of her bleeding included Mirena and hysterectomy.
Medications on Admission:
provera 20mg BID, clonazepam, synthroid, warfarin 7.5mg
daily (goal INR ___, paxil, aspirin, nystatin, vit D, Plavix,
gabapentin, pravastatin, methadone, ammonium lactate, Tylenol
prn
All: codeine (N/V)
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H:PRN pain
RX *acetaminophen 500 mg 1 tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. ClonazePAM 2 mg PO BID
4. Clopidogrel 75 mg PO DAILY
5. Gabapentin 800 mg PO TID
6. Levothyroxine Sodium 275 mcg PO DAILY
7. MedroxyPROGESTERone Acetate 20 mg PO BID
8. Methadone 100 mg PO DAILY
9. Nystatin Cream 1 Appl TP BID
10. Paroxetine 40 mg PO DAILY
11. Pravastatin 80 mg PO QPM
12. Vitamin D ___ UNIT PO 1X/WEEK (___)
13. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*20 Capsule Refills:*0
14. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*24 Capsule Refills:*0
15. MetRONIDAZOLE (FLagyl) 500 mg PO BID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth twice a
day Disp #*24 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
right ovarian cyst, vaginal bleeding on anticoagulation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology service in the setting of
vaginal bleeding and abdominal pain. Your diagnostic workup has
been reassuring and you have remained stable. The team believes
you are ready to be discharged home. Please call the ___
clinic at ___ with any questions or concerns. Please
follow the instructions below.
General instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Take a stool softener such as colace while taking narcotics to
prevent constipation.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* You may eat a regular diet.
* You may walk up and down stairs.
Call your doctor for:
* fever > 100.4F
* 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:
___
|
19956148-DS-13 | 19,956,148 | 26,535,791 | DS | 13 | 2148-02-11 00:00:00 | 2148-02-12 08:23:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
left ___ finger cyanosis and segmental PE
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with history of
thromboembolic syndrome, prior occlusion of right subclav artery
s/p right subclavian stent and axillary ___. She was
transferred from ___ where she presented to ED with
bilateral hand pain for 2 days, dusky fingers, also sob for two
hours.
She just stopped warfarin and Plavix 75mg daily one month ago.
Past Medical History:
PMH:
Hep C, HLD, HTN, morbid obesity, hypothyroidism, bipolar
disease,
anxiety, chronic knee pain, migraines, vit D deficiency
PSH:
right subclavian stenting, right axillary artery angioplasty
___ ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
98.5po, 132/76, 66, 18, 95%RA
General: Ms. ___ is an obese Caucasian female in no acute
distress. She is ambulating ad lib and tolerating activity
well.
HEENT: Head is atraumatic, normocephlaic. Mucous membranes are
moist. Sclerae is anicteric. Neck is supple. There is no JVD.
Trachea is midline. Carotid pulses difficult to appreciate.
HEART: Normal S1, S2. No clicks, murmurs or rubs appreciated
LUNGS: Clear to auscultation
ABDOMEN: Protuberant, soft, non tender
UPPER EXTREMITIES: Warm with brisk capillary refill. There is
no cyanosis. Skin is intact. Sensory and motor exam grossly
intact. I cannot palpable brachial, radial or ulnar pulses.
LOWER EXTREMITIES: Bilateral lower extremities are warm. There
is no cyanosis or edema. The skin is intact. I cannot easily
appreciate popliteal or ___ pulses. DP pulses palpable
bilaterally.
Pertinent Results:
___ 06:20AM BLOOD WBC-8.6 RBC-4.26 Hgb-11.5 Hct-36.6 MCV-86
MCH-27.0 MCHC-31.4* RDW-16.8* RDWSD-52.7* Plt ___
___ 06:20AM BLOOD Glucose-112* UreaN-14 Creat-0.8 Na-136
K-4.2 Cl-100 HCO3-25 AnGap-15
Brief Hospital Course:
Ms. ___ was started on a heparin drip and once she became
therapeutic, her finger paresthesias and pain resolved. She
underwent bilateral upper extremity duplexes which demonstrated
severe bilateral subclavian artery stenosis and absent waveform
at the left second digit. Her sensory motor exam remained
stable. She complained on intermittent shortness of breath.
She underwent bedside echo which did not reveal any obvious
source of embolism. She underwent lower extremity duplexes which
were negative for DVTs.
The team discussed restarting warfarin with her PCP. The PCP
had to stop warfarin because the patient had not been adherent
with INR checks. After discussion with the PCP and the patient,
the patient was started on Xarelto 15mg BID which she tolerated
well. Teaching was provided and she demonstrated a good
understanding.
At the time of discharge, she denied finger pain. Her sensory
motor exam was stable. She denies shortness of breath and was
able to ambulate while maintaining an O2 saturation of >88% with
activity. She was denying pain and voiding sufficient amounts
of clear yellow urine. Her vital signs remained stable.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Methadone 94 mg PO DAILY
2. PARoxetine 40 mg PO DAILY
3. LamoTRIgine 25 mg PO DAILY
4. CloNIDine 0.1 mg PO BID
5. ClonazePAM 2 mg PO QHS
6. ClonazePAM 1 mg PO BID
7. Levothyroxine Sodium 288 mcg PO DAILY
8. Gabapentin 800 mg PO TID
9. Nystatin Cream 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Rivaroxaban 15 mg PO BID Duration: 21 Days
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) ___ tablets(s)
by mouth per instructions Disp #*1 Dose Pack Refills:*0
6. Rivaroxaban 20 mg PO DAILY
to be started after the 15mg twice daily dosing has finished
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
7. ClonazePAM 2 mg PO QHS
8. ClonazePAM 1 mg PO BID
9. CloNIDine 0.1 mg PO BID
10. Gabapentin 800 mg PO TID
11. LamoTRIgine 25 mg PO DAILY
12. Levothyroxine Sodium 288 mcg PO DAILY
13. Methadone 94 mg PO DAILY
14. Nystatin Cream 1 Appl TP BID
15. PARoxetine 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right segmental pulmonary embolism ( on prelim CT)
gastrohepatic nodes
Bilateral upper extremity ischemia likely secondary to
atherosclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
It was a pleasure taking care of you. You were admitted because
of a blood clot in your lungs and pain in your fingers. You
were restarted on blood thinners. It is very important that you
remain on your blood thinners to prevent this from happening
again. For the next ___ days, you will take Xarelto 15mg twice
daily. Starting ___, you will take 20mg once daily. Your
Plavix 75mg daily was also restarted. Even though both plavix
and aspirin are antiplatelets and you are on a blood thinner, it
is important for you to remain on all 3. You are started on a
medication called Atorvastatin, to slow down the hardening of
your arteries. Your shortness of breath is resolving. If it
worsens, you should go to an emergency room right away. If you
have any questions or concerns, call the office at ___.
Followup Instructions:
___
|
19956148-DS-19 | 19,956,148 | 20,176,110 | DS | 19 | 2149-01-26 00:00:00 | 2149-01-26 15:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Codeine
Attending: ___.
Chief Complaint:
left index finger numbness, tingling, and discoloration
Major Surgical or Invasive Procedure:
___ angioplasty and stent of the left brachial artery
History of Present Illness:
___ w/ h/o upper extremity thromboembolism, including R
subclavian thrombosis s/p angioplasty and stenting in ___ and L
subclavian ___ in ___, now p/w dusky Left index
finger over the past few days. Patient reports that she has
noticed duskiness and coolness of her left index finger, as well
some numbness and tingling throughout the entire hand over the
past three days. She denies any motor weakness or dysfunction.
Past Medical History:
PMH: thromboembolic syndrome, Hep C, HLD, HTN, morbid obesity,
hypothyroidism, bipolar disease, anxiety, chronic knee pain,
migraines, vit D deficiency
PSH: R subclavian stenting, right axillary artery angioplasty
___ ___
Social History:
___
Family History:
Non-contributory
Physical Exam:
GEN: NAD
HEENT: NC/AT, EOMI
Pulm: no increased work of breathing, nonlabored respirations
CV: RRR
Abd: soft, nontender, nondistended
Ext: bilateral upper extremities with palpable radial pulses,
bilateral dopplerable DPs, fingers non-cyanotic, sensorimotor
intact
Pertinent Results:
Admission labs:
___ 04:47PM WBC-12.5* RBC-4.24 HGB-6.9* HCT-25.6* MCV-60*
MCH-16.3* MCHC-27.0* RDW-20.0* RDWSD-42.9
___ 04:47PM GLUCOSE-105* UREA N-13 CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-26 ANION GAP-12
___ 10:06PM LACTATE-1.6
___ 04:47PM ___ PTT-36.5 ___
LUE CTA ___:
IMPRESSION:
1. Acute thrombus in the left distal subclavian artery extending
to the left axillary artery over a 2.7 cm segment with distal
reconstitution of flow and patent distal arteries.
2. Prominent left axillary lymph nodes are noted, likely
reactive.
Brief Hospital Course:
Ms ___ was admitted to the Vascular surgery service with
left hand and finger numbness and tingling. CTA of the upper
extremity showed acute thrombus in the L SCA extending to the
left axillary artery. She was started on a heparin drip and
pain management. She also had complained of LLE pain at rest,
for which LLE ABI/PVR studies were obtained. These revealed
monophasic signals in the legs with L toe pressure of 17. She
was continued on the heparin drip and then taken to the OR on
___ for an angiogram and axillary artery stent. Please see
the operative note for details. At the end of the procedure,
the radial artery pulse was palpable. The heparin drip was
then resumed. She was maintained on a heparin drip for POD 1,
Plavix was started and the left radial artery was once again
palpable. On POD 2, xarelto was restarted, the heparin drip was
stopped, and the patient was started on cilostazol. At the time
of discharge, the patient was tolerating a diet, her pain was
well controlled, she had palpable radial pulses bilaterally, and
was able to ambulate. She will follow up with Dr. ___ in
clinic.
Medications on Admission:
AMMONIUM LACTATE PRN
atorvastatin 80 mg tablet'
clonazepam 2 mg tablet''' prn
clonidine HCl 0.1 mg tablet''
Vitamin D2 50,000 unit capsule weekly
gabapentin 800 mg tablet'''
levothyroxine 200 mcg tablet'
methadone 92 mg daily
nystatin 100,000 unit/gram topical cream prn
oxycodone 5 mg tablet prn
paroxetine 40 mg tablet'
Xarelto 20 mg tablet'
verapamil ER (___) 100 mg capsule'
aspirin 81 mg tablet'
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Cilostazol 100 mg PO BID
RX *cilostazol 100 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*1
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
4. Verapamil 20 mg PO Q8H
We decreased the dose of this medication due to your low blood
pressure. Follow up with your PCP
5. Atorvastatin 80 mg PO QPM
6. ClonazePAM 2 mg PO TID:PRN anxiety
7. CloNIDine 0.1 mg PO BID
8. Gabapentin 800 mg PO TID
9. Levothyroxine Sodium 200 mcg PO DAILY
10. Methadone 90 mg PO DAILY
11. PARoxetine 40 mg PO DAILY
12. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Left subclavian thromboembolism
Left lower extremity rest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Division of Vascular and Endovascular Surgery
Angioplasty/Stent Discharge Instructions
MEDICATION:
Take Plavix (Clopidogrel) 75mg once daily for 30 days. After
you are finished with the 30 days of this medication, you may
either keep taking the Plavix or you may stop it and start
taking Aspirin. This will be at the discretion of your surgeon.
Keep taking your xarelto
Continue all other medications you were taking before surgery,
unless otherwise directed
You make take Tylenol or prescribed pain medications for any
post procedure pain or discomfort
WHAT TO EXPECT:
It is normal to have slight swelling of the arm:
Elevate your arm above the level of your heart with pillows
every ___ hours throughout the day and night
It is normal to feel tired and have a decreased appetite, your
appetite will return with time
Drink plenty of fluids and eat small frequent meals
It is important to eat nutritious food options (high fiber,
lean meats, vegetables/fruits, low fat, low cholesterol) to
maintain your strength and assist in wound healing
To avoid constipation: eat a high fiber diet and use stool
softener while taking pain medication
ACTIVITIES:
When you go home, you may walk and use stairs
You may shower (let the soapy water run over incision, rinse
and pat dry)
Your incision may be left uncovered, unless you have small
amounts of drainage from the wound, then place a dry dressing or
band aid over the area
No heavy lifting, pushing or pulling (greater than 5 lbs) for
1 week (to allow groin puncture to heal)
After 1 week, you may resume sexual activity
After 1 week, gradually increase your activities and distance
walked as you can tolerate
No driving until you are no longer taking pain medications
CALL THE OFFICE FOR: ___
Numbness, coldness or pain in lower extremities
Temperature greater than 101.5F for 24 hours
New or increased drainage from incision or white, yellow or
green drainage from incisions
Bleeding from puncture site
SUDDEN, SEVERE BLEEDING OR SWELLING (puncture site)
Lie down, keep arm 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:
___
|
19956204-DS-14 | 19,956,204 | 25,990,857 | DS | 14 | 2118-03-16 00:00:00 | 2118-03-17 13:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tylenol-Codeine
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ F with PMH HTN, COPD, afib not on AC, HLD and LLL lobectomy
in ___ for stage IA lung cancer who presents for shortness of
breath.
Patient reports that last ___ night she was having
dinner(hamburger rice) when she began to have nausea. She
reports that she spit up dinner but did not vomit. After that
she did not feel well in the next day she continued to not feel
well. She reports that she did dress up and have cereal for
breakfast but continued to be nauseous and was unable to
tolerate dinner. On ___ she continued to have weakness and
was unable
to get out of bed. Around this time she began to have chills
and sweats. She does not remember when she began to have
shortness of breath but reports that she was unable to smoke as
many cigarettes as she normally does. She reports that she
typically smokes 1 pack a day but was only able to tolerate
about 4
cigarettes on ___ and even less on subsequent days. She does
not recall any abdominal symptoms or urinary symptoms.
Of note she has not been taking her most recently prescribed
inhalers which per Dr. ___ recent note to our Incruse
and Brio Ellipta. She also reports she is not quite sure why
she is not on anticoagulation for her atrial fibrillation. She
says that she was unable to pick up her prescription for
apixaban.
And per her last PCP note she was to continue on it per her
cardiologist, Dr. ___.
Patient initially presented to be ___ where she received
1g ceftriaxone, 500 mg of azithromycin and 1 L normal saline.
- In the ED, initial vitals were: T 98.1 HR 112 BP 94/48 RR 20
O2
93% RA
- Exam was notable for: awake and alert, cachectic, breathing
comfortably on nasal cannula. She has diffuse coarse rhonchi.
Abdomen is soft and nontender.
- Labs were notable for: Bandemia, troponin less than 0.01
- Patient was given: 1L IVF
On arrival to the floor patient reports fatigue and would like
to go to sleep. She does not feel like her symptoms have
improved arriving to the hospital.
Past Medical History:
LLL lobectomy ___ with Dr ___ poorly differentiate large
cell neuroendocrine carcinoma (stage IA)
Coronary artery disease
COPD
Hypertension
Hyperlipidemia
Peripheral vascular disease
History of TIA/CVA with no residual deficits
Anxiety
Social History:
___
Family History:
The patient's father died at age ___ from heart disease and her
mother died at age ___ from pulmonary embolism.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 24 HR Data (last updated ___ @ 234)
Temp: 98.0 (Tm 98.0), BP: 116/62, HR: 85, RR: 20, O2 sat:
93%, O2 delivery: 4L
GENERAL: Alert and interactive, cachectic
HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Grade
___ systolic murmur best appreciated at RUSB
LUNGS: moderate expiratory and inspiratory wheezing bilaterally,
decreased breath sounds and rhonchi over left lower lung field
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously.
DISCHARGE PHYSICAL EXAM
========================
VITALS: 24 HR Data (last updated ___ @ 1535)
Temp: 97.8 (Tm 98.8), RR: 18 (___)
GENERAL: resting comfortably, cachectic appearing
HEENT: temporal wasting
RESP: tachypneic to low ___
Pertinent Results:
ADMISSION LABS
=============
___ 12:20AM BLOOD WBC-16.1* RBC-2.90* Hgb-9.4* Hct-29.4*
MCV-101* MCH-32.4* MCHC-32.0 RDW-13.8 RDWSD-51.0* Plt ___
___ 12:20AM BLOOD Neuts-93.6* Lymphs-2.2* Monos-2.9*
Eos-0.0* Baso-0.2 Im ___ AbsNeut-15.07* AbsLymp-0.36*
AbsMono-0.47 AbsEos-0.00* AbsBaso-0.04
___ 05:40AM BLOOD ___ PTT-24.0* ___
___ 12:20AM BLOOD Glucose-136* UreaN-17 Creat-0.4 Na-136
K-3.8 Cl-103 HCO3-19* AnGap-14
___ 05:40AM BLOOD ALT-78* AST-91* AlkPhos-98 TotBili-0.5
___ 12:20AM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8 Iron-14*
___ 05:40AM BLOOD calTIBC-181* ___ Folate-9
Ferritn-278* TRF-139*
___ 05:40AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:40AM BLOOD HCV Ab-NEG
___ 10:55PM BLOOD ___ pO2-48* pCO2-37 pH-7.43
calTCO2-25 Base XS-0 Intubat-NOT INTUBA
___ 10:55PM BLOOD Lactate-2.2*
___ 11:50PM BLOOD Lactate-2.1*
REPORTS
=======
CT CHEST W/O CONTRASTStudy Date of ___
1. Extensive airspace opacity of the remaining left upper lobe
following left lower lobectomy, likely a combination of
postobstructive consolidation and postobstructive atelectasis
due to mucus plugging within the left lobe bronchus.
2. Patchy areas of airspace opacity on the right likely
represent additional sites of infection, associated with
reactive mediastinal lymphadenopathy.
3. Mucous impaction within the right middle lobe causing a small
amount of subsegmental collapse, overall substantially better
aerated when compared with the prior study.
4. Areas of smooth interlobular septal thickening suggesting
concurrent volume overload.
5. Severe centrilobular emphysema.
CHEST (PORTABLE AP)Study Date of ___
There is a new extensive subtotal atelectasis of the left lung,
with leftward cardiac and mediastinal shift. No change in
appearance of the slightly overinflated right lung.
CTA CHESTStudy Date of ___
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral aspiration pneumonia,, particularly worsened on the
left, where there is further volume loss of the left upper lobe
by obstructing material in the distal left main bronchus and
left upper lobe bronchus.
3. Bilateral small pleural effusions, greater on the right.
4. Two hyperdensity areas within the mucosa of the stomach. This
could represent ingested hyperdense material or bleed into the
stomach. No other areas suspicious for active extravasation.
Aspiration of gastric contents is recommended to correlate with
hematemesis. If hematemesis is present, EGD is recommended.
DISCHARGE LABS: n/a
Brief Hospital Course:
This is a ___ year old female with past medical history of
hypertension, COPD, atrial fibrillation, admitted with sepsis
and acute hypoxic respiratory failure secondary to acute
bacterial pneumonia and COPD with acute exacerbation, initially
treated with anitbiotics and steroids, but with worsening
clinical status including acute metabolic encephalopathy
prompting family and patient decision to pursue comfort
measures care, able to be discharged home with hospice
# Sepsis
# Acute hypoxic respiratory failure
# Acute bacterial pneumonia
# COPD with acute exacerbation
# Acute metabolic encephalopathy
Patient presented with shortness of breath, found to have
sepsis secondary to CAP and acute COPD exacerbation. She
received treatment for CAP with antibiotics and COPD with
steroids. Her hospital course was complicated by worsening
hypoxemia. Repeat CT chest showed worsening bilateral
pneumonia, suspected to have been aspiration in etiology based
on appearance, as well as atelectasis and mucus plugging versus
other obstructing material in
the distal left mainstem bronchus and left upper lobe bronchus.
Patient and family decided that pursuing invasive treatment or
additional workup were not within her wishes, and that they
wanted to pursue comfort focused measures. She was transitioned
to comfort measures only and all unnecessary medications were
discontinued. Team coordinated with case management to arrange
for home support including hospice and supplies. Patient was
able to be discharged home with hospice care.
#CMO: All unnecessary medications were discontinued. Patient
was continued on Tylenol PRN for pain/fever, glycopyrrolate and
hyoscyamine PRN for secretions, haloperidol IV and lorazepam
PO/IV PRN for delirium/anxiety and morphine PO/IV PRN for
pain/respiratory distress.
# CODE: DNR/DNI/CMO
# CONTACT: ___ (daughter/HCP) ___
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Losartan Potassium 25 mg PO DAILY
3. Breo Ellipta (fluticasone furoate-vilanterol) 200-25 mcg/dose
inhalation DAILY
4. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN mild pain,tactile fever
2. Glycopyrrolate 0.1-0.2 mg IV Q4H:PRN excess secretions
3. Haloperidol 0.5-2 mg IV Q4H:PRN delirium
4. Hyoscyamine 0.125-0.25 mg SL Q4H:PRN excess secretions
5. LORazepam 0.5-2 mg PO Q2H:PRN anxiety
6. LORazepam 0.5-2 mg IV Q2H:PRN anxiety
7. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL ___
mg PO Q1H:PRN moderate-severe pain or respiratory distress
8. Morphine Sulfate ___ mg IV Q15MIN:PRN moderate-severe pain
or respiratory distress
9. Scopolamine Patch 1 PTCH TD Q72H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Sepsis
Acute hypoxic respiratory failure
Acute bacterial pneumonia
COPD with acute exacerbation
Atrial fibrillation
Chronic severe protein calorie malnutrition
Discharge Condition:
N/A
Discharge Instructions:
Dear Ms. ___,
It was a privilege taking care of you at ___
___.
You were admitted to the hospital because you were having
trouble breathing. You received antibiotics for an infection in
your lungs. You received steroids for a flare of your COPD.
Unfortunately your respiratory status continued to worsen
despite these interventions. You ultimately decided to pursue
more comfort-focused measures to ensure that you were not
suffering. We hope that you continue to spend time with your
family and remain comfortable.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19956599-DS-19 | 19,956,599 | 26,733,373 | DS | 19 | 2124-09-22 00:00:00 | 2124-09-22 15:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Chief Complaint: Hypoxia
Reason for MICU transfer: Respiratory Failure; Hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is an ___ female with a PMHx of COPD, CHF,
and recurrent pneumonia presents with hypoxia and dyspnea.
History obtained from pt's family (daughter ___ is HCP and at
bedside with pt, as well as pt's niece ___ and ___
___. At baseline, pt has severe dementia and is A+Ox1. She
recognizes faces but incorrectly names family members. She is
bed/chair bound. Over the past year, she has had multiple
hospitalization for PNA and UTI and has had episodes of hypoxia.
She previously required O2 only at night but now requires it
continuously at ___. Recently, given ___ medical problems, she
has been seen by home hospice. Per daughter, this was actually
initiated by ___ after she expressed disatisfaction with her
mother's care at ___, as a means of providing improved care.
Pt was in her usual state of health when she was found to have
O2 of 65% at ___/ She presented to ___. There pt was
found to be hypoxic to ___ (per ___ sign-out). CXR showed a right
lower lobe infiltrate. There, she received vancomycin, cefepime.
Previously, patient's goals of care were reported as being
"DNR/DNI and no CPAP" but CPAP was not fully explained to the
family/HCP. On clarification with ___ providers, pt was placed on
CPAP for persistent hypoxia, as this was felt to be in
accordance with her wishes.
In the ___, VS: T 98.4, P 93-110, BP 95-113/40-61. Labs
were significant for WBC 22.6, HCT 31.8 (baseline), TnI 0.08
(734AM), Cr 1.3
In the ___ ___, VS: T 99, P 78-82, BP 98-107/40-49; RR ___,
O2 Sat 100% on NRB. She was reportedly wheezing on exam. Labs
were significant for VBG 7.30/___/21. Lactate 2.3. TnT 0.08. Cr
1.3. WBC 11.9. CXR showed evidence of RLL PNA with hazy
interstitial markings. EKG showed sinus rhythm at 80bpm, Q in
V1-4, LAD/iLBBB, TWI in AVL and STD in I. ___ staff addressed
goals of care with family and it was decided that pt was to
remain DNR/I, would not want central lines/pressors but would be
OK with non-invasive ventilation. She received nebs given
wheezing. She arrived on CPAP but was taken off CPAP and placed
on a nonrebreather shortly after her arrival. On a nonrebreather
mask she maintained her oxygen saturation at 100% with a
respiratory rate low ___.
On arrival to the MICU, pt was noted to be comfortable with an
O2 Sat of 100% on NRB. She was transitioned to RA with no
concerns. She reports that she feels well without pain.
Review of systems (per family):
No recent fever, chills, night sweats, recent weight loss or
gain. cough, wheezing, complaints of pain, vomiting, diarrhea,
or other changes. 10-point ROS negative.
Past Medical History:
- HTN
- HLD
- NIDDM 2
- Recurrent PNA (including aspiration PNA)
- Severe Alzheimer's Dementia
- COPD (on home O2 intermittently 2L)
- Allergic Rhinitis
- CHF
- Lung nodule
- SP cateract repair
- ?Atrial fibrillation - pt's daughter recall discussing
___ with PCP in setting of occasional irregular rhythm
Social History:
___
Family History:
No significant family history of pulmonary disease.
Physical Exam:
ICU ADMISSION EXAM
------------------
Vitals: T: 98.8, 88, 106/47, 19, 100% on RA
General: Pale, somnolent, opens eyes to voice. Comofrtable
HEENT: Sclera anicteric, Dry MM, oropharynx clear, anisocoria
L>R; +L cateract
Neck: Supple, JVP not elevated, no LAD
Lungs: Dry rhales at bases bl, no wheezes, or ronchi
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
GU: + foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A+Ox1. Motor function grossly normal. No focal defecits
Pertinent Results:
ADMISSION EXAM
--------------
___ 11:07AM BLOOD WBC-11.9* RBC-3.50* Hgb-10.3* Hct-32.9*
MCV-94 MCH-29.3 MCHC-31.2 RDW-12.8 Plt ___
___ 11:07AM BLOOD Neuts-87.7* Lymphs-7.0* Monos-5.0 Eos-0.1
Baso-0.1
___ 11:07AM BLOOD ___ PTT-27.1 ___
___ 11:07AM BLOOD Glucose-135* UreaN-23* Creat-1.3* Na-139
K-4.5 Cl-101 HCO3-27 AnGap-16
___ 11:07AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9
___ 11:07AM BLOOD cTropnT-0.08*
___ 08:26PM BLOOD CK-MB-4 cTropnT-0.06*
___ 11:14AM BLOOD ___ pO2-29* pCO2-65* pH-7.30*
calTCO2-33* Base XS-2
___ 11:14AM BLOOD Lactate-2.3*
MICRO
-----
BLOOD CX: ___
URINE CX: ___
IMAGING
-------
CXR ___
PORTABLE UPRIGHT FRONTAL VIEW OF THE CHEST: There are diffuse
reticulonodular opacities concerning for pulmonary edema. A
component of underlying fibrosis is possible. The costophrenic
angles are blunted suggestive of small bilateral pleural
effusions. The cardiac and mediastinal contours are normal.
There is no pneumothorax. There is no free air beneath the right
hemidiaphragm. There is no acute osseous abnormality.
CXR ___:
IMPRESSION:
Interval development of moderate pulmonary edema.
CXR ___:
IMPRESSION:
Improved pulmonary edema with stable mild cardiomegaly.
Brief Hospital Course:
Ms. ___ is an ___ female with a PMHx of COPD, CHF,
and prior pneumonia presents with hypoxia and dyspnea.
# Hypoxemic/Hypercarbic Respiratory Failure
Likely multifactorial from ? aspiration on top of COPD and acute
on chronic CHF exacerbation -- serial CXR showed improvement of
pulmonary ___. DDx included PE but was felt to be less likely
given Well's 1.5. Pt's respiratory status currently appears to
be at her baseline. On 1L NC on admission despite 2L NC home O2.
Pt had hypoxia and met SIRS criteria (tachypnea, WBC ~12) and
with elevated lactate and therefore there was initial concern
for sepsis criteria on admission, especially in light of
reported RLL infiltrate. She improved with BIPAP. After 24 hrs
leukocytosis resolved and respiration was significantly
improved. She was never febrile, and so antibiotics were
discontinued ___ with the thought that she may have aspirated.
Urine culture was negative and blood cultures were NGTD. Stopped
antibiotics given low concern for PNA, no fevers, rapid
improvement of symptoms. On ___ she had acute onset tachypnea
and hypoxemia to ___ requiring high flow mask. ABG was
7.06/116/>200. She was placed on BiPAP ___ and diuresed
overnight with improvement of symptoms and return to 1L NC O2
requirement by morning. She had no clear tachyarrhythmia or
other precipitant such as aspiration to explain her dyspnea. CXR
showed worsening bilateral opacities concerning for worsened
edema, without volume loss to suggest mucus plugging. Cardiac
enzymes were CK: 31 MB: 3 Trop-T: 0.07, the morning after her
acute onset hypoxemic/hypercarbic respiratory failure,
suggesting she did not have myocardial ischemia/infarction
underlying her decompensation. This resolved with re-initiation
of her diuretics. She was off O2 prior to DC with RA SpO2 >93%.
# ___: Likely pre-renal in setting of CHF exacerbation --
pulmonary edema seen on pulmonary eval without other evidence of
significant volume overload on exam. She had 1L IVF on admission
with improved Cr. She then had diuresis without Cr increase.
# CHF: LVEF 30%. She was warm, dry, compensated while here on
medical floor out of ICU. Home meds include
ACEI/BB/ASA/statin/furosemide 40mg BID. She received diuresis
___ given acute onset hypercarbic/hypoxemic respiratory
failure with subsequent improvement. She appeared euvolemic
___ and ___. Her home lisinopril, metoprolol, aspirin,
statin, and diuretic were continued. Metoprolol tartrate 25mg
BID was changed to succinate 50mg daily. Her Lasix was decreased
to 40mg AM and 20mg ___ given development of mild alkalosis.
# Elevated TnT: Likely demand ischemia in setting of CHF
exacerbation on arrival. EKG changes not specific for ischemia
(LBBB is old). She had mild TnT elevation ___ the morning
after her acute respiratory decompensation, but always <0.10.
# GOC: Discussed goal of care in detail with family. They
expressed interest in continuing to treat reversible causes and
are trying to transition to hospitc oreiented comfort-focused
care. The code status was DNR/DNI, not pressors or invasive
lines, but CPAP OK. They have started arranging hospice to come
to ___ SNF that the patient lives in. Case management
communicated family's hospice request to ___. DNH status
was not discussed.
# Anemia: Chronic. Likely in setting of chronic disease and poor
po intake. There were no findings of acute blood loss anemia.
# HTN: Well-controlled. Home lisinopril and metoprolol were
continued. Lasix dose was adjusted to 40mg QAM and 20mg QPM.
# HLD: Holding statin
# Nutrition: Aspiration risk. Patient on HONEY THICKENED
LIQUIDS/PUREED SOLIDS at her SNF. Speech and swallow saw the
patient and did not recommend any further changes to this diet
order, especially in light of family's desire for no tube
feedings. Care should be taken with feedings in upright
position as she is still at aspiration risk.
# Access: PIVs
# Communication: ___ (daughter/HCP)
___. Is agreeable to transfer back to ___. We
have no MD name on file, and ___ did not know the name of
MD provider at ___ (has never met/spoke with ___
MD).
# Code: DNR/I; no lines/pressors; OK for non-invasive
ventilation
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Furosemide 40 mg PO DAILY vs BID (multiple entries in ___
MAR)
3. Lisinopril 2.5 mg PO DAILY
4. Metoprolol Tartrate 25 mg PO BID
5. MetFORMIN (Glucophage) 500 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation bid
9. Tiotropium Bromide 1 CAP IH DAILY
10. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation qid
11. TraZODone 50 mg PO HS:PRN insomnia
12. Bisacodyl 10 mg PR HS:PRN constipation
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
14. Vitamin D 1000 UNIT PO DAILY
15. Citalopram 20 mg PO DAILY
16. Acetaminophen 650 mg PO BID:PRN pain
17. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Citalopram 20 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lisinopril 2.5 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. TraZODone 50 mg PO HS:PRN insomnia
9. Vitamin D 1000 UNIT PO DAILY
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Simvastatin 20 mg PO DAILY
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
13. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation qid
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Tiotropium Bromide 1 CAP IH DAILY
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION BID
17. Furosemide 40 mg PO BID
40mg PO qAM
20mg PO qPM
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Respiratory distress - required BIPAP (no intubation)
CHF exacerbation
Aspiration risk
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Patient admitted with respiratory distress -- likely due to CHF
exacerbation. ___ have been brought on by aspiration event, but
leukocytosis and SIRS criteria resolved, empiric antibiotics
were discontinued in absence of pulmonary infiltration.
Pulmonary edema resolved with diuresis.
Followup Instructions:
___
|
19956654-DS-14 | 19,956,654 | 27,367,095 | DS | 14 | 2138-01-26 00:00:00 | 2138-02-11 14:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
difficulty breathing
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with h/o CAD (s/p NSTEMI s/p DES in ___, DM, small cell
lung cancer s/p chemo, renal cell carcinoma s/p partial
nephrectomy presented with acute worsening of dyspnea. He has
had shortness of breath for months, but it recently became much
more noticeable. He only gets short of breath when he is
exerting himself. He reports being able to walk close to ___
yards without being dyspnic, and being able to easily climb 10
steps. His shortness of breath became more noticeable recently
in the setting of having to plow snow. He reports chronic sharp
chest pain when lying down, which gets better with NTG. He
coughs small amount of clear to dark phlegm (less than a
teaspoonful) after meal. He denies blood in phlegm. He denies
fever, diarrhea, or recent travel.
Patient have had intermittent problem with memory and mentation
since his prophylactic brain radiation couple of years ago. He
forgets things temporarily, and he remembers them in a day or
two. He denies cofusion or acute change in mental status.
Upon arrival, his VS were 97.8 88 146/91 18 97%. Bedside
ultrasound showed ~0.5cm circumferential pericardial effusion
without collapse of RA, LV>RV. Head CT was negative for bleed or
obvious metastasis. Cr was 1.8, mildly elevated from his
baseline. Troponin was negative, but d-dimer was positive.
Cardiology admission was considered given his cardiac history
and dyspnea, however in the ED there was significant concern for
altered mental status and therefore ___ Medicine admission
was favored.
Currently, he reports feeling well, with no dyspnea, no chest
pain, and reports to be at his baseline.
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No palpitations. No
nausea or vomiting. No diarrhea or constipation. No dysuria or
hematuria. No hematochezia, no melena. No numbness or weakness,
no focal deficits.
Past Medical History:
1. COPD- no oxygen at home
2. Hypertension
3. Hyperlipidemia
4. CAD s/p MI. s/p Cx stenting in ___ and LAD stenting
in ___
5. Diabetes type 2 with neuropathy of feet
6. Remote Left eye embolus with mild loss of vision
7. GERD, esophageal stricture x 2. Patient reports that he
continues with a mild difficulty with swallowing.
8. Frequent UTI's
9. Hx of renal cancer in ___ s/p left partial nephrectomy
10. ___: Left lung cancer s/p XRT and chemo, s/p
prophylactic brain radiation in ___ at ___
11. s/p cholecystectomy
___. Umbilical hernia repair
13. ___ colovesicular fistula repair complicated by
post-operative NSTEMI and LAD DES
14. s/p cystoscopy, bilateral ureteral stent placement and
sigmoid colectomy on ___
15. CKD
16. Gout
17. BPH
Discharge Summary Past Medical History Signed ___
___ 3:45 ___
PAST ONCOLOGIC HISTORY:
-___ presented with worsening DOE and worsening
productive cough.
- In ___ hemoptysis for 2 weeks
- ___ hospitalization for colovesicular fistula repair
c/b
NSTEMI and need for revascularization with primary cathether
reopening of his LAD on ___ CT Chest w/ 4.1 x 3.7 cm mass at the upper pole of the
left hilus which was entirely within the left upper lobe with
slight retraction of the fissure. Linear opacity distal to the
mass with pleural thickening was noted. The mass narrowed the
apical posterior segment bronchus and invadedthe underside of
the anterior segment bronchus. Ipsilateralmediastinal
lymphadenopathy with a necrotic lymph node was noted.Other
incidental findings included aneurysmal dilation of the
descending thoracic aorta to 4.4cm.
-___ PET/CT Scan disclosed a 42 x 36 mm FDG-avid left upper
lobe juxtahilar mass had a SUVmax of 8.9. An enlarged FDG-avid
prevascular lymph node measured 35 x 22 mm
(SUVmax = 9.8). An FDG-avid left hilar lymph node conglomerate
measured 36 x 30 mm (SUVmax = 10.3). A low level FDG-avid right
paratracheal lymph node measured 9 mm in short axis (SUVmax =
3.0). Mild FDG-avid mesenteric fat stranding in the left lower
quadrant may be postoperative is etiology (image 151, SUVmax =
3.5). No abnormal FDG-avid osseous lesion is identified.
Physiologic uptake is seen in the brain, myocardium, salivary
glands, GI and GU tracts, liver and spleen.
- ___ Bronchoscopy showed left upper lobe nonobstructing
endobronchial mass seen. Biopsies w/ small cell
carcinoma. The tumor was markedly hypercellular. Tumor cells had
high nuclear/cytoplasmic ratio with minimal cytoplasm and showed
prominent nuclear molding. There were numerous mitoses and
apoptotic cells. The tumor cells were positive for TTF-1,
synaptophysin and chromogranin and were negative for CD7, CK20,
CD3 and CD20. The level 4L lymph node FNA positive for
malignant cells, c/w metastatic small cell carcinoma.
Social History:
___
Family History:
Father died of attack when he was ___. Brother died from attack
when he was ___.
Physical Exam:
ON ADMISSION:
VS: 97.3 150/65 61 18 99%RA
___: Alert, oriented, no acute distress. breathing
comfortably on RA. fully oriented and normally conversive, no
confusion
HEENT: Sclerae anicteric, MMM, oropharynx clear, dentures in
place
NECK: supple, JVP not elevated though possible jugular
distention with RUQ pressure but habitus makes exam difficult.
no LAD
RESP: minimal bibasilar crackles, otherwise CTAB
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly.
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
trace pitting edema bilaterally. mild healing excoriation on R
shin
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No rash.
ON DISCHARGE:
VS: 97.3 150/65 61 18 99%RA
___: Alert, oriented, no acute distress. breathing
comfortably on RA. fully oriented and normally conversive, no
confusion
HEENT: Sclerae anicteric, MMM, oropharynx clear, dentures in
place
NECK: supple, JVP not elevated. no LAD.
RESP: minimal bibasilar crackles, otherwise CTAB
CV: RRR, Nl S1, S2, No MRG
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly.
GU: no foley
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis.
trace pitting edema bilaterally. mild healing excoriation on R
shin
NEURO: CNs2-12 intact, motor function grossly normal
MENTAL STATUS: alert and fully oriented, but tangential at times
SKIN: No rash.
Pertinent Results:
ON ADMISSION:
___ 02:40PM K+-4.4
___ 02:16PM K+-6.9*
___ 01:53PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:53PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:53PM URINE RBC-0 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 01:53PM URINE MUCOUS-FEW
___ 01:28PM D-DIMER-1556*
___ 01:00PM GLUCOSE-104* UREA N-30* CREAT-1.8* SODIUM-137
POTASSIUM-7.4* CHLORIDE-102 TOTAL CO2-25 ANION GAP-17
___ 01:00PM estGFR-Using this
___ 01:00PM ALT(SGPT)-13 AST(SGOT)-40 ALK PHOS-106 TOT
BILI-0.4
___ 01:00PM LIPASE-41
___ 01:00PM cTropnT-<0.01
___ 01:00PM proBNP-1153*
___ 01:00PM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-3.7
MAGNESIUM-2.3
___ 01:00PM WBC-6.8 RBC-3.45* HGB-10.6* HCT-32.0* MCV-93#
MCH-30.8 MCHC-33.2 RDW-14.8
___ 01:00PM NEUTS-70.6* LYMPHS-16.0* MONOS-9.5 EOS-3.3
BASOS-0.5
___ 01:00PM PLT COUNT-197
___ 01:00PM ___ PTT-31.3 ___
ON DISCHARGE:
___ 06:55AM BLOOD WBC-5.2 RBC-3.64* Hgb-11.1* Hct-33.3*
MCV-91 MCH-30.4 MCHC-33.3 RDW-14.9 Plt ___
___ 06:55AM BLOOD Glucose-102* UreaN-30* Creat-1.7* Na-140
K-3.8 Cl-103 HCO3-25 AnGap-16
___ 07:18AM BLOOD ___ pO2-75* pCO2-43 pH-7.38
calTCO2-26 Base XS-0
MICRO:
none
EKG:
ECGStudy Date of ___ 12:31:30 ___
Sinus bradycardia. Normal ECG. Compared to the previous tracing
of ___ the A-V interval has normalized. Otherwise, no
diagnostic interim change.
___
___
EEG:
EEGStudy Date of ___
This is a mildly abnormal EEG due to the presence of a slower
than normal background rate. While this may have been related to
an excessively drowsy state, other possibilities include the
presence of widespread areas of bilateral subcortical or deeper
midline lesions. No focal
or epileptiform abnormalities were evident. The posterior
dominant rhythm was otherwise well-formed.
IMAGING:
CT HEAD W/O CONTRASTStudy Date of ___ 1:21 ___
No acute intracranial process. Of note, MRI is more sensitive
for the detection of small intracranial lesions.
CHEST (PA & LAT)Study Date of ___ 1:33 ___
No acute cardiopulmonary process.
Portable TTE (Complete) Done ___ at 1:58:06 ___ FINAL
Suboptimal image quality. Normal biventricular regional/global
systolic function. Small to moderate pericardial effusion
without echocardiographic evidence of tamponade. Compared with
the prior study (images reviewed) of ___, the pericardial
effusion is new.
LUNG SCANStudy Date of ___
Low likelihood ratio of acute pulmonary embolism.
MR HEAD W & W/O CONTRASTStudy Date of ___ 5:16 ___
1. No evidence of intracranial metastatic disease.
2. No intracranial hemorrhage or infarct. White matter changes
compatible
with small vessel ischemic disease.
3. Bilateral cerebellar hemisphere encephalomalacia.
4. Essentially unremarkable MRA of the head.
5. On MPRAGE in T1 sagittal sequences, there is a large left
paracentral disc
protrusion at C3-4 which results in moderate spinal canal
narrowing and
effacement of the ventral aspect of the cord. This may be
further evaluated
with dedicated MRI of the cervical spine as clinically
indicated.
Brief Hospital Course:
___ with h/o CAD (s/p NSTEMI s/p DES in ___, DM, small cell
lung cancer s/p chemoradiation, remote renal cell carcinoma s/p
partial nephrectomy presented with acute worsening of dyspnea
and subtle cognitive changes.
ACTIVE ISSUES:
# Exertional Dyspnea: Given his 100+ pack-year history of
smoking, and productive cough, COPD was thought to be the most
likely etiology. Prior imaging was also consistent with
emphasematous changes, though he has never been formally tested
for COPD. Given his cardivascular risk factors (including prior
MI), multiple first degree relatives with MI, and elevated
proBNP, CHF was considered as well however his exam did not
support this and his TTE was normal. V/Q scan was negative for
PE. Speech and swallow study was negative for aspiration. He was
started on albuterol and tiotropium, and his breathing remained
comfortable and stable. Recommend outpatient evaluation with
PFTs.
# Confusion: Patient has had intermittent slow mentation and
memory lapses for couple of years with its onset following whole
brain irradiation. According to his wife, his mental status was
subacutely worsened on admission. On exam he remained alert and
fully oriented though often tangential. He also appears to have
word finding difficulty at times. Brain metastasis, stroke, and
seizure were considered, so he underwent brain MRI and EEG. MRI
ruled out mets or stroke, though it did show small vessel
ischemic disease along with encephalomalacia. EEG was negative
for seizure but showed diffuse slowing. No evidence of infection
on basic work-up. His confusion was therefore attributed to
several home sedating medications in the setting of prior
radiation therapy, so his gabapentin dose was decreased and his
triazolam qhs was switched to trazodone.
# Chest pain: This was thought to be non cardiac in nature given
its nature and chronicity. Patient had pain when lying down, and
he described it as sharp-well localized small area of pain.
Patient reported pain getting better with NTG. EKG remained
non-ischemic and cardiac enzymes remained negative. Esophageal
spasm or GERD was thought to be the most likely cause. His
recent (___) nuclear stress test was negative. We continued
his home PPI. We recommend further outpatient work-up.
CHRONIC ISSUES:
#CAD: s/p NSTEMI s/p DES in ___: continued home atorvastatin,
metoprolol, isosorbide mononitrate, nitroglycerin SL,
clopidogrel, and aspirin
#GERD: continued home Pantoprazole 40 mg PO Q12H
#BPH: continued Tamsulosin 0.4 mg PO QHS
#Gout: continued home Febuxostat 40 mg PO DAILY
#Diabetes: well controlled off medicine. HISS while in-house.
#Diabetic peripheral neuropathy: continued Gabapentin but
decreased from 300 mg PO TID to ___ po BID.
TRANSITIONAL ISSUES:
- Neurologic evaluation for cerivical disc protrusion with canal
narrowing and cord effacement (asymptomatic and incidental)
along with follow-up for his cognitive decline
- Follow up regarding cognitive changes (word-finding
difficulty, memory deficits). We decreased his gabapentin and
switched triazolam to trazodone.
- recommend outpatient PFTs to further evaluate for COPD
- HTN follow up. We started him on lisinopril, follow renal
function and K+
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Febuxostat 40 mg PO DAILY
3. TRIAzolam 0.25 mg PO ONCE
4. Metoprolol Succinate XL 150 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Clopidogrel 75 mg PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Aspirin 325 mg PO DAILY
11. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
4. Febuxostat 40 mg PO DAILY
5. Gabapentin 100 mg PO BID
RX *gabapentin 100 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
6. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
7. Metoprolol Succinate XL 150 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Pantoprazole 40 mg PO Q12H
10. Tamsulosin 0.4 mg PO QHS
11. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth Once a day Disp #*30
Tablet Refills:*0
12. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 PUFF
INHALED Once a day Disp #*30 Capsule Refills:*1
13. TraZODone 25 mg PO QHS:PRN sleep
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
14. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
RX *albuterol sulfate 90 mcg ___ PUFFS INHALED q4-6h Disp #*1
Inhaler Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
COPD/emphysema
Altered mental status
SEONDARY DIAGNOSES:
Cervical disc disease with canal narrowing and cord effacement
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted for shortness of breath and
recent change in your mental status. For your shortness of
breath, you were started on inhalers to improve your breathing.
Your chest x-ray was normal, and so was the echo of your heart.
We also did a nuclear study called V/Q scan to look at the
vessels of your lung, and it was normal too (no blood clot in
the lung). Given your long smoking history and previous images
consistent with COPD/emphysema, we started you on albuterol and
tiotropium inhalers. However, you should follow-up with your
doctor regarding emphysema for more testing.
Given your change in your mental status, we were concerned about
damage in your brain. We took a picture of the brain in a study
called MRI. This showed changes consistent with your prior
radiation treatment, but fortunately no mass or other worrisome
findings. A disc in your neck was protruded and narrowing your
spinal cord. You should follow up with your doctor regarding
this. We also looked at brain waves in a study called EEG, and
it was normal too without seizures.
It is important to try to decrease your gabapentin and to stop
your triazolam, as these can cause confusion and also some
dizziness that you are experiencing. Given that your blood
pressure was slightly high, we also started you on lisinopril.
We are glad that you are feeling better, and we wish you the
best of luck!
Regards,
___ Team
Followup Instructions:
___
|
19956723-DS-22 | 19,956,723 | 27,397,573 | DS | 22 | 2194-12-07 00:00:00 | 2194-12-09 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Allegra / Tylenol #3
Attending: ___.
Chief Complaint:
Stridor
Major Surgical or Invasive Procedure:
Bronchoscopy and laryngoscopy ___
Tracheostomy placement by ENT ___
Tracheostomy replacement by ENT ___
Laryngeal Electromyogram by ENT and Neurology ___
History of Present Illness:
Mr ___ is a ___ h/o with COPD on continuous O2 at 2L who
presented to the ED with c/o 2 days of not feeling and trouble
breathing. Of note, pt was here recently for same presentation
and had ENT scope that was unrevealing. On that occasion, he
was admitted to the ICU and required intubation, was evaluated
by ENT who visulaized a small amount of tissue overlying the
vocal cords with no evidence of obstruction to level of
epiglottis, however not able to view larynx.
.
In the ED, initial vs were not recorded, however pt was reported
to be hypoxic. Patient was given heliox, albuterol, ipratroprium
and 125 mg methylprednisolone. Initially he was anxious and
very stridorous but subesequently relaxed and was breathing more
comfortably, although still with insp stridor. Labs were
notable for hyponatremia to the 120s, mild anemia. CT neck was
attempted but was unable to be completed because the patient was
unable to lie down. Chest xray showed no acute CP process. EKG
showed NSR with occ PACs. Vitals on transfer were 108/70 94 24
100% on non-rebreather.
.
On the floor, pt continues to be stridorous and is difficulty to
understand due to mask/heliox. Stridor improved throughout the
H&P.
.
Review of sytems:
(+) Per HPI, also endorses wt loss, last BM last night
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied cough. Denied chest pain or tightness,
palpitations. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
-COPD: evaluated in pulmonary clinic (Dr. ___ prior
to surgery in ___, spirometry at the time revealed FEV1
of 1.41L (59% predicted) and FVC of 2.25L (60% predicted), with
ration 0.63 suggesting moderate mixed obstructive and
restrictive deficit (little change since ___ previously
followed by Dr. ___ from ___ to ___ intermittent
adherance to therapy; emphysema with right lower lobe
atelectasis seen on CT from ___
-Pulmonary HTN: mean pulmonary artery pressure of 27 (on cath in
___
-Paroxysmal a.fib in setting of knee surgery: post-op course
complicated by abif and dyspnea, with negative PE-CT; CHADS
score 4, anticoag with lovenox and ASA
-Hyperglycemia: HbA1c 6.1%
-Hyperlipidemia
-Coronary artery disease s/p PCI in ___
-Diastolic heart dysfunction: echo from ___ shows LVEF 75%,
increased left ventricular pressure, moderate calcific aortic
stenosis
-Osteoarthritis causing chronic knee pain: R-knee replacemetn on
___, ambulating with walker
-Lumbar disc disease and spinal stenosis cervical spine
degeneration of C3 through C7 with neck pain
-Sleep apnea on home oxygen
-Benign essential tremor
-Restless leg syndrome
-h/o bladder cancer status post resection, followed by Dr. ___,
___ last resection was in ___ for recurrence
-h/o stroke with residual right ___ nerve palsy
-h/o hiatal hernia: dx in setting of dysphagia in ___ via
double contrast barium esophogram
Social History:
___
Family History:
non-contributory
Physical Exam:
Vitals: T:97.3 BP:135/79 P:106 R:32 O2:91%
General: Alert, aao to day, "___", no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: R-sided rhonchi, stridorous, no wheezes, rales
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, mild ttp throughout, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: A&Ox3, CNII-XII intact, sensation and strength grossly
intact in all extremities
Discharge:
T: 98, P: 74, BP: 91/ 64, RR: 25, 97% on TM
General: Awake, alert and oriented xt3, NAD
HEENT: continues to have minimal trach secretions, trach in
place, strong voice, minimal stridor on capping
Neck: supple, minimal secretions around trach, no LAD
Lungs: loud upper airway sounds, minimal scattered rhonchi
ant/lat
CV: Regular rate and rhythm, normal S1 + S2 shifted to the
right, ___ SEM radiating to carotids
Abdomen: soft, non-tender, slightly distended in upper portion,
no peritoneal signs
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
Admission labs:
___ 10:45AM GLUCOSE-134* UREA N-14 CREAT-0.6 SODIUM-120*
POTASSIUM-4.5 CHLORIDE-82* TOTAL CO2-31 ANION GAP-12
___ 10:45AM estGFR-Using this
___ 10:45AM TSH-0.44
___ 10:45AM WBC-4.7 RBC-4.13* HGB-10.8* HCT-32.5*
MCV-79*# MCH-26.0* MCHC-33.1 RDW-13.1
___ 10:45AM NEUTS-59.5 ___ MONOS-5.4 EOS-1.4
BASOS-0.7
___ 10:45AM PLT COUNT-278
___ 10:45AM ___ PTT-30.4 ___
___ 10:54AM LACTATE-0.7
Discharge Labs:
___ 03:55AM BLOOD WBC-4.1 RBC-3.93* Hgb-10.4* Hct-31.4*
MCV-80* MCH-26.4* MCHC-33.0 RDW-13.9 Plt ___
___ 04:52AM BLOOD Neuts-67.2 ___ Monos-7.3 Eos-0.1
Baso-0.1
___ 03:55AM BLOOD ___ PTT-34.2 ___
___ 04:48AM BLOOD Glucose-147* UreaN-15 Creat-0.6 Na-133
K-4.0 Cl-91* HCO3-36* AnGap-10
___ 04:48AM BLOOD Calcium-9.5 Phos-4.1 Mg-2.2
OTHER:
___ 03:52AM BLOOD %HbA1c-5.8 eAG-120
___ 10:45AM BLOOD TSH-0.44
___ 04:29AM BLOOD Cortsol-9.9
___ 06:42AM BLOOD Vanco-13.9
EKG: NSR, no acute ST tw changes
CT Neck ___:
IMPRESSION:
1. Simple fluid lining the posterior ___-, oro-, and
laryngopharynx, and
anterior laryngopharynx, findings likely secondary to recent
intubation. No compressive extrinsic enhancing mass lesion to
explain patient's stridor. However, assessment for endoluminal
lesions or abnormalities is limited due to intubation. Follwoup
as clinically indicated.
3. Endotracheal tube in standard position, 3.3 cm above the
carina.
4. Mild paraseptal emphysema in the lung apices.
5. Stable degenerative changes of the cervical spine.
Brief Hospital Course:
___ yo gentleman with hx of MICU admission for stridor with no
evidence of obstruction, now presenting with recurrent stridor.
.
#. Stridor: Initially unclear cause of his stridor given normal
laryngoscope on last visit. Pt intubated on admission and
stabilized on vent. CT scan of the neck did not show any
extraluminal masses compressing. ___ an attempt was made to
extubate him, but he afterwards developed stridor and had to be
re-intubated. During the brief extubation, a laryngoscopy was
done that was concerning for at least partial paralysis of the
vocal cords. He was treated with 24 hours of IV solumedrol in
case there was a contribution of airway swelling. ___ he had a
tracheostomy placed by the ENT service with some difficulty
because of his severe scoliosis and altered anatomy. Afterwards
he was quickly weaned to a trach collar. With the concomitant
dysphagia, there was concern for neuromuscular weakness, so
neurology was consulted. Their work-up consisted of MRI, which
failed to demonstrate a lesion that would explain the pathology
found. The next test Neurology recommended was an EMG, this
demonstrated a pattern consistent with a myopathy. The
neuromuscular service was consulted to evaluate the LEMG and
guide further diagnostic studies. LEMG was EMG suggestive of
neuromuscular junction disorder. He was discharged with
follow-up with the ___ clinic and ENT.
#. Dysphagia: patient had been having several weeks of worsening
dysphagia prior to admission, including weight loss. He had an
EGD ___ for similar symptoms that did not show a cause for
dysphagia. Patient declined video swallow study.
#. Hyponatremia: Most likely hypovolemic as this improved with
IV fluids. Likely from poor ___ intake ___ dysphagia. This
resolved with tube feeds.
#. Anemia: at baseline, no evidence of active bleeding, with low
iron ___, nl ferritin, iron/TIBC<18 concerning for iron
deficiency. Likely from poor ___ intake.
#. Tachycardia: sinus, likely due to resp distress.
Transitional Issues:
There are several tests requested by Neurology that were sent
off by pathology to outside facility that are pending prior to
discharge. Patient should follow up with outpatient Neurology
regarding these tests.
Medications on Admission:
1. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk
with Device Inhalation Q12H (every 12 hours).
2. Lipitor 20 mg Tablet Sig: One (1) Tablet ___ once a day.
3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) ___ once a day.
4. citalopram 20 mg Tablet Sig: 0.5 Tablet ___.
5. Clotrimazole Foot 1 % Cream Sig: One (1) application Topical
twice a day: apply to feet.
6. acetaminophen 500 mg Tablet Sig: ___ Tablets ___ Q 8H (Every 8
Hours) as needed for fever or pain.
7. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet
Sublingual as needed as needed for chest pain: Take one tablet
under tonque every 5 inutes up to 3 pills, if pain persists call
doctor.
8. aspirin 325 mg Tablet Sig: One (1) Tablet ___ once a day.
9. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: ___
puffs Inhalation every four (4) hours as needed for wheeze.
10. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device
Sig: One (1) puff Inhalation twice a day.
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet ___ once a day.
2. citalopram 20 mg Tablet Sig: One (1) Tablet ___.
3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2)
Tablet, Delayed Release (E.C.) ___ as needed for
constipation.
4. trazodone 50 mg Tablet Sig: 0.5 Tablet ___ HS (at bedtime) as
needed for insomnia.
5. aspirin 325 mg Tablet Sig: One (1) Tablet ___ once a day.
6. lansoprazole 30 mg Tablet,Rapid Dissolve, ___ Sig: One (1)
Tablet,Rapid Dissolve, ___ ___.
7. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) ___ Q6H
(every 6 hours) as needed for pain.
8. docusate sodium 50 mg/5 mL Liquid Sig: One (1) ___ BID (2
times a day).
9. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation
Q2H (every 2 hours) as needed for SOB.
10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as
needed for SOB.
11. senna 8.6 mg Tablet Sig: One (1) Tablet ___ BID (2 times a
day).
12. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1)Vocal Chord dysfunction
2)Dysphagia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to our hospital with shortness of breath. We
have determined that you needed a tracheostomy. We have placed a
tube in your neck to help you with breathing. To help you with
eating, we placed a feeding tube into your stomach through your
nose.
Your were also evaluated by our neurologists and our ear, nose
and throat doctors. ___ cause of your trouble swallowing and
vocal cord dysfunction is not clear. You will follow-up with the
neurologists regarding these issues.
The following changes were made to your medications:
- STOPPED Spiriva, pantoprazole
- STARTED ipratroprium, advair, lansoprazole
- STARTED colace, biscodyl and senna as needed for constipation
- INCREASED Citalopram from 10 mg to 20 mg ___
Followup Instructions:
___
|
19956777-DS-10 | 19,956,777 | 27,157,149 | DS | 10 | 2118-11-11 00:00:00 | 2118-11-11 16:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Labetalol / Benzonatate
Attending: ___.
Chief Complaint:
Diarrhea, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of Dementia AAOx2 at baseline, PAF on coumadin and dig,
who was sent in from ___ for vomiting and diarrhea.
Started this morning when she was found to be vomiting and had a
bout of "explosive diarrhea." Her blood pressure at the time was
160 systolic and they gave her an oral antiemetic. She then had
another bout of vomiting and diarrhea and her blood pressure was
noted to be 90's systolic with a HR in the 120's. According to
___ there is C. diff and a viral gastro going
around. The patient is unable to offer any history but is awake
and alert. Son states she was at baseline yesterday (eating,
walking around). She denied having any pain or discomfort. She
was noted to be tachycardic in the 120s.
.
In ED VS were 99.1 126 147/91 18 96%. Labs were remarkable for
WBC 19.7, lactate 2.7 --> 2.3 upon repeat, UA negative, trops x1
negative; Flagyl 500mg IV x1 given. Metoprolol 5mg IV x1 and
metoprolol 25mg PO x2 given. Guaiac positive in the ED.
Tachycardia thought to be partly due to dehydration and 3L NS
given in the ED. Vitals on transfer were 97.2, 94 157/84 24
98%RA.
On arrival to the floor, vitals were T 100.0, 140/90, 104, 20,
97%RA. Patient was without complaints, not able to answer
questions, does not remember what happened this morning and is
A&Ox1.
.
Review of systems:
patient unable to answer
Past Medical History:
- Paroxysmal Atrial Fibrillation on warfarin
- Syncope in ___ thought possibly secondary to rapid
afib
- GI Bleed (hematochezia) ___ felt ___ gastritis, at ___
- RP bleed, self resolved, while on coumadin ___
- h/o Right popliteal tibial artery embolus s/p embolectomy
(was not on AC at that time due to her prior RP/GI bleed),
coumadin restarted ___
- h/o TIAs/CVA
- Hypertension.
- Hypercholesterolemia.
- Dementia, likely mixed vascular and Alzheimer's type.
- Hearing loss, left ear.
- History of fractured sternum.
- ?Diabetes Mellitus, Type 2
PAST SURGICAL HISTORY:
1. Bilateral cataract surgery in ___.
2. Left carotid endarterectomy in ___.
Social History:
___
Family History:
Her father died at age ___ of either cancer or heart attack-- she
notes that he had collapsed at work and died a couple of days
later. Her mother at ___ from cardiac disease.
Physical Exam:
Admission Exam:
VS: T 100.0, 140/90, 104, 20, 97%RA
GA: AOx1, NAD, resting in bed
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple.
Cards: tachycardic, irreg irreg, S1/S2 heard. no
murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes appreciated, poor inspiratory
effort
Abd: soft, NT, +BS. no g/rt. neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or other lesions noted. some old ecchymoses on
extremities
Neuro/Psych: CNs II-XII grossly intact. unable to coorperate
with neuro exam.
Discharge Exam:
VS: 98.2, 124/66, 92 (92-128), 95%RA
GA: AOx1, NAD, resting in bed comfortably
HEENT: PERRLA. MMM. no LAD. no JVD.
Cards: tachycardic, irreg irreg, S1/S2 heard. no
murmurs/gallops/rubs.
Pulm: CTAB, no crackles or wheezes appreciated, poor inspiratory
effort
Abd: soft, minimally tender in lower quadrants, +BS. no g/rt.
neg HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or other lesions noted. some old ecchymoses on
extremities
Neuro/Psych: CNs II-XII grossly intact. unable to coorperate
with neuro exam.
Pertinent Results:
Admission Labs:
___ 07:50AM BLOOD WBC-19.7*# RBC-4.43# Hgb-12.1# Hct-38.3#
MCV-86 MCH-27.3# MCHC-31.6 RDW-14.3 Plt ___ (***all spurious
values compared to past and present lab values***)
___ 07:50AM BLOOD Neuts-93.6* Lymphs-2.9* Monos-2.8 Eos-0.6
Baso-0.1
___ 07:50AM BLOOD ___ PTT-36.1 ___
___ 07:50AM BLOOD Glucose-238* UreaN-27* Creat-1.0 Na-139
K-5.2* Cl-101 HCO3-27 AnGap-16
___ 07:50AM BLOOD ALT-13 AST-14 CK(CPK)-35 AlkPhos-92
TotBili-0.3
___ 07:50AM BLOOD Lipase-63*
___ 07:50AM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD Albumin-3.9
___ 07:50AM BLOOD Digoxin-1.1
___ 08:00AM BLOOD Lactate-2.7*
___ 10:58AM BLOOD Glucose-181* Lactate-2.3* K-4.4
Discharge Labs:
___ 06:05AM BLOOD WBC-9.6 RBC-3.43* Hgb-9.5* Hct-29.3*
MCV-85 MCH-27.6 MCHC-32.3 RDW-14.7 Plt ___
___ 06:05AM BLOOD ___ PTT-35.8 ___
___ 06:05AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-138
K-3.7 Cl-106 HCO3-24 AnGap-12
___ 06:05AM BLOOD Calcium-7.8* Phos-2.0* Mg-1.6
Microbiology:
___ c. diff negative
___ blood cultures NGTD
Urine Analysis:
___ 08:30AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:30AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 08:30AM URINE RBC-<1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:30AM URINE CastHy-6*
___ 08:30AM URINE Mucous-RARE
Imaging:
___ ECG Rate 125, Probable atrial flutter with 2:1
conduction. Flutter waves are more apparent in lead V1 and lead
II. ST segment depression in the inferior and anterolateral
leads which may be related to myocardial ischemia. Compared to
the previous tracing of ___ the rhythm is now atrial flutter
and ST segment depression is more pronounced.
___ CT abd/pelvis w/ contrast: 1. Normal-appearing small
and large bowel. Early colitis cannot be excluded with this
technique.
2. Small hiatal hernia.
3. Multiple renal cysts.
4. Mild interval enlargement of a right adnexal mature teratoma.
Brief Hospital Course:
___ with a PMH of dementia (AAOx2 at baseline), paroxysmal
atrial fibrillation on coumadin and digoxin, who was sent in
from ___ for vomiting and diarrhea.
.
Active Issues:
# Diarrhea: The patient's stool tested c. diff negative (test
with >90% sensitivity). On admission, patient with diarrhea (4x
in 8 hours) and a WBC of 19.7. A WBC that high is usually
suggestive of c. diff, however the CBC on admission appears to
be spurious lab values given that all CBC quantities (WBC, hct,
plts) dropped excessively on repeat and remained stable there
after. Patient was empirically started on flagyl 500mg IV TID
for a day, prior to c. diff coming back negative. It was then
discontinued. Patient's repeat WBCs were within normal range
(8.1 on day 2) and patient remained with occasionally low grade
fevers (to 100.4). Within 2 days, patient's diarrheal output
decreased and even ceased by the time of discharge. Of note
___ reports an outbreak of viral gastroenteritis, as
well as an outbreak of c.diff, per report. The patient most
likely has a viral gastroenteritis and this has resolved. She
was given IVFs to rehydrate and returned to her nursing home
once the diarrhea had resolved.
.
# Nausea: Patient was nauseous prior to arrival to the
hospital, however once in the hospital, patient denies any
nausea and was without episodes of vomiting. Symptoms were
likely related to her gastrointestinal infection. Initially
patient was maintained on sips, however diet was advanced to
full once it was clear she had resolution of her symptoms.
.
# Tachycardia: Patient with paroxysmal afib on coumadin,
metoprolol and digoxin (recently increased to 0.25mg daily). She
was given extra metoprolol in the ED for an increased heart rate
(120s). HR remained in the 100s-110s, but decreased initially
with IVFs. Patient was monitored on telemetry and home
metoprolol (25 TID), digoxin (0.25 daily) and warfarin 2.5mg
daily were administered. INR ranged from 1.8-1.9 over admission.
Patient sees cardiology as an outpatient and last recorded note
mentions considering cardioversion if this continues 6wks out
from her appointment. Heart rate was relatively well controlled
(SBP 100s), so not further action was taken.
.
Chronic Issues:
# DM: No recent HgbA1c in the system. Patient's metformin was
held, glargine 10units Qhs was given and patient was covered
with an HISS. ASA was also continued.
.
# HTN: continued home metoprolol and lisinopril. Patient
remained normotensive on regimen.
.
# HL: continued home simvastatin.
.
#FEN: continued iron, Vit D and folate supplementation. Patient
tolerating a diet currently.
.
Transitional Issues:
Patient will resume her care at ___.
Medications on Admission:
- acetaminophen 650 mg Rectal Suppository Rectal 1
Suppository(s) Every 4 hrs, as needed
- Dulcolax 10 mg Rectal Suppository Rectal 1 Suppository(s) Once
Daily, as needed
- Fleet Enema 19 gram-7 gram/118 mL Rectal 1 Enema(s) q 3 days ,
as needed
- ___ of Magnesia 400 mg/5 mL Oral Susp Oral 1
Suspension(s) 30 ml po daily as needed
- Tylenol ___ mg Tab Oral 1 Tablet(s) Every 4 hrs , as needed
- digoxin 0.25 mg a day
- metoprolol tartrate 25 mg Tab Oral 1 Tablet(s) Three times
daily
- quinapril 20 mg Tab Oral 1 Tablet(s) , at bedtime
- simvastatin 40 mg Tab Oral 1 Tablet(s) , at bedtime
- aspirin 81 mg Tab Oral 1 Tablet(s) Once Daily
- Vitamin D-3 1,000 unit Chewable Tab Oral 1 Tablet, Chewable(s)
Once Daily
- pantoprazole 40 mg Tab, Delayed Release Oral 1 Tablet, Delayed
Release (E.C.)(s) Twice Daily
- ferrous sulfate 325 mg (65 mg iron) Tab Oral 1 Tablet(s) Once
Daily
- Colace 100 mg Cap Oral 1 Capsule(s) Twice Daily
- senna 8.6 mg Cap Oral 2 Capsule(s) , at bedtime
- Novolin R 100 unit/mL Injection Injection 1 Solution(s)
sliding scale 4x/day
- metformin 500 mg Tab Oral 0.5 Tablet(s) Twice Daily
- Lantus 100 unit/mL Sub-Q Subcutaneous 1 Solution(s) 10 units
sq , at bedtime
- prochlorperazine maleate 10 mg Tab Oral 1 Tablet(s) Every ___
hrs:PRN
- folic acid 1 mg Tab Oral 1 Tablet(s) Once Daily
- Coumadin 2.5 mg Tab Oral 1 Tablet(s) at 5 pm daily
Discharge Medications:
1. acetaminophen
acetaminophen 650 mg Rectal Suppository Rectal 1 Suppository(s)
Every 4 hrs, as needed
2. Dulcolax 10 mg Suppository Sig: One (1) tablet Rectal once a
day as needed for constipation: hold until diarrhea resolves
completely.
3. ___ of Magnesia 400 mg/5 mL Suspension Sig: Thirty
(30) ml PO once a day as needed for constipation: hold until
diarrhea resolves completely.
4. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO every four
(4) hours as needed for pain.
5. digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID
(3 times a day).
7. quinapril 20 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
9. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
10. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
12. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day:
Hold for diarrhea.
13. senna 8.6 mg Tablet Sig: Two (2) Tablet PO at bedtime: hold
for diarrhea.
14. metformin 500 mg Tablet Sig: 0.5 Tablet PO twice a day.
15. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
every ___ hours as needed for nausea.
16. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day.
17. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at
4 ___: Regular INR checks.
18. Novolin R 100 unit/mL Solution Sig: Per sliding scale
Injection four times a day.
19. Fleet Enema ___ gram/118 mL Enema Sig: One (1) enema Rectal
Q3days as needed for constipation.
20. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous at bedtime.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis: viral gastroenteritis
.
Secondary Diagnosis:
- Paroxysmal Atrial Fibrillation on warfarin
- Syncope in ___ thought possibly secondary to rapid
afib
- GI Bleed (hematochezia) ___ felt ___ gastritis, at ___
- RP bleed, self resolved, while on coumadin ___
- h/o Right popliteal tibial artery embolus s/p embolectomy
(was not on AC at that time due to her prior RP/GI bleed),
coumadin restarted ___
- h/o TIAs/CVA
- Hypertension.
- Hypercholesterolemia.
- Dementia, likely mixed vascular and Alzheimer's type.
- Hearing loss, left ear.
- History of fractured sternum.
- ?Diabetes Mellitus, Type 2
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were admitted for nausea, vomitting, and
diarrhea. While you were here, you were rehydrated with
intravenous fluids. We determined that your diarrhea was not
cause by a bacterial infection. It is likely a viral
gastroenteritis that will resolve on its own. You should treat
yourself symptomatically and make sure to stay hydrated by
drinking a lot of water. While you were here, your diarrhea
improved on its own. You are safe for discharge back to ___
Institute.
The following medication was STOPPED:
Ferrous sulfate
.
Please continue your other medications as prescribed.
Followup Instructions:
___
|
Subsets and Splits