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19956963-DS-16
19,956,963
21,623,051
DS
16
2131-08-30 00:00:00
2131-08-30 18:41:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Lithium / Synvisc Attending: ___ Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: ___ year old woman with history of ESRD from lithium s/p living related donor transplant ___, chronic leukopenia/hyponatremia, renal osteodystrophy, hypertension, bipolar disorder, GERD and recent total right knee replacement who presents with fevers. The patient states she had undergone total knee replacement last ___ and was discharged to rehab ___, ___ on ___. She developed fevers/chills, sweats on a daily basis at rehab and her temperatures peaked at 100.5 while there. She denies nausea/vomiting but had decreased appetite. She was concerned that the physicians at the rehab were not informed about her fevers and that the RNs stated her Bactrim SS would cover any infection she could have. She understands that post-operatively one could have low-grade fevers but decided to sign out AMA on ___ night. After returning home, she developed dysuria and worsened fevers to 101. She called her orthopedist who set her up with ___. When the ___ evaluated her yesterday, they found her temperature to be 103.5 and sent her to the ___. There she was found to have a "florid UTI" and thus was treated with levofloxacin enroute to ___ where her nephrologist/transplant physicians are. In the ___, initial VS: T99.3, HR100, BP126/66, RR16, 95% on RA. Labs were not drawn as they had been done at ___ ~4pm. Urinalysis confirmed UTI. The patient was given acetaminophen for fever, oxycodone 10mg for right knee pain. 1L NS IVF was started. Upon transfer, T100.2, BP130/90, HR118, RR18, 99% on RA. Past Medical History: * ESRD due to lithium s/p living related donor kidney transplant (___) * Leukopenia, hyponatremia * Renal osteodystrophy * Pulmonary embolism * Total right knee replacement, one week ago at ___ (on Coumadin X1 month for this) * Bipolar disorder * Hypertension * GERD * Left foot trauma s/p fusion, other surgeries X 9 * Right torn ACL/PCL s/p surgery X2 (___) * Laparoscopic cholecystectomy (___) * Obesity Social History: ___ Family History: Father died of lung cancer, mother with diabetes ___. Physical Exam: Admission exam VS: Tc 102.7 Tm 102.7 135/68 (107-135/54-68) P ___ GENERAL: Well appearing in NAD. HEENT: Sclera anicteric. MMM. CARDIAC: Tachycardic, regular rhythm. no excess sounds appreciated LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: Soft, nondistended, non-tender to palpation. Dullness to percussion over dependent areas but tympanic anteriorly. No HSM or tenderness appreciated. EXTREMITIES: No pedal edema. Warm and well perfused, no clubbing or cyanosis. NEUROLOGY: AAOx3, moves all extremities Discharge exam VS 98.6/101 (yesterday AM) 149/91 (120s-180s/60s-90s) 102 (80s-100s) 20 100% ra GENERAL: Overweight female, NAD HEENT: Sclera anicteric. MMM. CARDIAC: Tachycardic, regular rhythm. no mrg LUNGS: CTA b/l with no wheezing, rales, or rhonchi. ABDOMEN: BS+, Soft, nondistended, non-tender to palpation. No HSM or tenderness appreciated. No flank tenderness EXTREMITIES: No pedal edema. Warm and well perfused, no clubbing or cyanosis. R knee wound is clean, dry, and intact. Minimal stable erythema surrounding it NEUROLOGY: AAOx3, moves all extremities PSYCHIATRIC: Tearful, tangental, patient remains somewhat confrontational today Pertinent Results: Admission labs ___:56AM BLOOD WBC-5.3# RBC-2.66*# Hgb-8.6*# Hct-25.1*# MCV-94# MCH-32.2*# MCHC-34.1 RDW-15.4 Plt ___ ___ 08:56AM BLOOD ___ PTT-34.5 ___ ___ 08:56AM BLOOD Glucose-163* UreaN-16 Creat-1.1 Na-133 K-3.8 Cl-98 HCO3-27 AnGap-12 ___ 08:56AM BLOOD Calcium-8.9 Phos-1.9* Mg-1.5* ___ 08:56AM BLOOD tacroFK-3.9* Discharge labs ___ 06:10AM BLOOD WBC-2.7* RBC-2.37* Hgb-7.6* Hct-22.4* MCV-94 MCH-32.0 MCHC-33.9 RDW-15.5 Plt ___ ___ 06:10AM BLOOD Neuts-81* Bands-0 Lymphs-10* Monos-9 Eos-0 Baso-0 ___ Myelos-0 ___ 06:10AM BLOOD ___ PTT-33.5 ___ ___ 06:10AM BLOOD Glucose-104* UreaN-7 Creat-0.7 Na-138 K-4.3 Cl-104 HCO3-27 AnGap-11 ___ 06:10AM BLOOD Calcium-9.0 Phos-2.8 Mg-2.0 ___ 06:10AM BLOOD tacroFK-3.7* MICRO: BCX ___: NEG BCX ___ PND CMV AB ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. >400 AU/ML. NEGATIVE FOR CMV IgM ANTIBODY BY EIA. CMV VL: PND PARVOVIRUS B-19 ANTIBODY IgG 2.13 H IgM: ___ BK VIRUS: PND UA ___: tr leuks, tr protein, 4 wbc Ucx ___: no growth Studies ___ urine culture: E coli ampicillin: R > 16 augmentin: R > 16 aztreonam: S cefazolin: R ceftazidime: S <=1 ceftriaxone S <=8 cefuoxime S < 4 nitrofurantoin S < 32 cipro S < 1 gentamicin S < 4 sensitive tetraccycline S < 4 zosyn S < 16 amikacin S < 16 meropenem S < 1 Renal u/s ___: IMPRESSION: 1. Normal color Doppler examination of the transplant kidney. 2. Urothelial thickening and debris in the collecting system, consistent with pyelitis, pyelonephritis cannot be excluded CXR ___: In comparison with the study of ___, there is little change and no evidence of acute cardiopulmonary disease. No pneumonia, vascular congestion, or pleural effusion. Extensive hypertrophic spurring in the thoracic spine and evidence of previous surgery in the right shoulder. Brief Hospital Course: Ms ___ is a ___ with h/o ESRD ___ lithium s/p living related donor transplant ___, chronic leukopenia/hyponatremia, renal osteodystrophy, bipolar disorder, and recent total right knee replacement, who presents fevers secondary to pyelonephritis. . # Pyelonephritis: Growing E coli at ___ lab (where she initally rpesented), w/ sensitivities in the "important results" section of this d/c summary. However, this data was not available for several days, so initially she was but on ceftriaxone, then transitioned to meropenem on ___. She spiked a fever on the morning of ___ to 101 while on meropenem, with infectious workup negative to date (CMV IgM negative, parvovirus IgM negative, Bcx NGTD, BK virus pending and CMV VL pending). She then remained afebrile for 24 hours and was transitioned to PO cipro 500mg BID for a total 14 day course from the beginning of meropenem treatment (to end ___. . # Right total knee replacement: Surgical incision site c/d/i without localizing signs of infection during this admission. She is on coumadin for 1 month s/p surgery, and INR remained therapeutic but dropped to 1.7 on the day of discharge. Decision was made to continue pre-hospitalization dosing of 3mg daily given the expected rise in the INR with initiation of Cipro. Her orthopedist Dr. ___ follow her INRs, with the next one to be drawn by ___ on ___. Pain controlled w/ oxycodone/tramadol. ___ was continued in house and will be continued as an outpatient . # ESRD s/p renal transplant in ___. Creatinine at baseline this admission. Continued home azathioprine and tacrolimus. Tacro level on ___ was low at 3.4 so tacro was increased to 7mg BID. She will have a tacro level rechecked on ___ with results to be sent to the transplant ___ clinic. She was continued on home Bactrim SS. She will follow up with her nephrologist Dr. ___ on ___ . # Anemia: Likely a combination of iron deficiency and anemia of chronic disease/kidney disease. She normally is in the 30's, but trended to the low ___ and was 22.4 on discharge. She received a dose of epogen 6000 Units prior to d/c with plan to follow up in ___ clinic. There was no evidence of hemolysis, and B12 was negative . # Chronic leukopenia/hyponatremia: stable this admission . # Renal osteodystrophy: Continued home cinacalcet, ascorbic acid, and vitamin D3 . # Hypertension: continued on home metoprolol and losartan. BPs were well controlled with the exception of when patient became agitated/emotionally distraught. . # Bipolar disorder: continued home gabapentin, seroquel, carbamazepine, lorazepam. Pt had labile mood and tangentality and was ofetn confrontational throughout admission. . # GERD: Stable: continued home pantoprazole . ============================= TRANSITIONAL ISSUES # INR check on ___ to be checked by ___. INR to be sent to Dr. ___ (her orthopedic surgeon). Will need close monitoring while on cipro # Tacro level check ___ by ___ with results to be sent to transplant ___ clinic # Pt received 1 dose of 6000 units of Epo on d/c. The transplant ___ clinic was contacted and will be in touch with her to coordinate this as an outpatient # F/u on ___ with Dr. ___ in ___ clinic # Final blood cultures, CMV VL, and BK virus which are pending on discharge Medications on Admission: * Coumadin 3mg daily * Azathioprine 50mg qAM * Carbamazepine 200mg twice daily * Cinacalcet 30mg daily * Bactrim SS daily * Gabapentin 800mg three times daily * Lorazepam 1mg qHS * Losartan 25mg daily * Metoprolol tartrate 100mg twice daily * Pantoprazole 40mg twice daily * Seroquel 50mg twice daily, 200mg qHS * Tacrolimus 6mg twice daily * Tramadol 100mg daily * Trazodone ___ qHS PRN * Ascorbic acid ___ daily * Cholecalciferol (Vitamin D3) 1000 units daily * Glucosamine daily * Melatonin 2mg qHS Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY 2. Azathioprine 50 mg PO DAILY 3. Carbamazepine 200 mg PO BID 4. Cinacalcet 30 mg PO DAILY 5. Ciprofloxacin HCl 500 mg PO Q12H Duration: 12 Days RX *Cipro 500 mg 1 Tablet(s) by mouth Twice daily Disp #*24 Tablet Refills:*0 6. Gabapentin 800 mg PO Q8H 7. Lorazepam 1 mg PO HS hold for sedation, RR<12 8. Metoprolol Tartrate 100 mg PO BID hold for sbp<100, HR<55 9. Pantoprazole 40 mg PO Q12H 10. Quetiapine Fumarate 50 mg PO BID qAM and q5pm 11. Quetiapine Fumarate 200 mg PO HS 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 13. Tacrolimus 7 mg PO Q12H 14. TraMADOL (Ultram) 100 mg PO DAILY hold for sedation, RR<12 15. traZODONE ___ mg PO HS:PRN insomnia 16. Vitamin D 1000 UNIT PO DAILY 17. Warfarin 3 mg PO DAILY16 18. Outpatient Lab Work please check INR on ___, and ___ and send results to Dr. ___: P: ___ F: ___. Please note that patient is on ciprofloxacin which may elevate INR 19. Outpatient Lab Work PLEASE CHECK: CBC; Sodium; Potassium; Chloride; Bicarbonate; BUN; Creatinine; Glucose; ALT; Calcium; AST; Total Bili; Phosphate; Albumin; Tacrolimus on ___ and weekly thereafter and fax results to office of transplant nephrology at ___ at ___ 20. Losartan Potassium 25 mg PO DAILY hold for SBP<100 Discharge Disposition: Home With Service Facility: ___ ___: Primary: Pyelonephritis Secondary: status post right knee replacement End stage renal disease Hypertension 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 kidney infection. We gave you intravenous antibiotics which were then changed to oral antibiotics (ciprofloxacin) once your fevers improved. You should continue to take the ciprofloxacin through ___. While you were here, we continued you on your coumadin for your recent knee replacement. Your INR levels will be checked by your ___ and sent to Dr. ___. You also have follow up with Dr. ___ on ___. You will also be started on Epogen for your blood counts. You will be contacted by the transplant nephrology office to have this set up for you. Please expect a call from them soon. Your tacrolimus levels will also be checked by ___ and will be sent to the transplant nephrology office. We increased the dose to 7mg twice daily we made the following changes to your medications: STARTED: Ciprofloxacin CHANGED: Tacrolimus to 7mg twice daily (your levels will be drawn at home) Followup Instructions: ___
19957285-DS-14
19,957,285
20,267,759
DS
14
2118-10-08 00:00:00
2118-10-08 13:53:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Cephalosporins / ciprofloxacin / clindamycin / codeine / droperidol / furosemide / glyburide / ketamine / latex / insulin glargine / Levemir / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / Penicillins / Sulfa (Sulfonamide Antibiotics) / acetaminophen / Compazine / Dilaudid / diphenhydramine / gabapentin Attending: ___. Chief Complaint: Subarachnoid hemorrhage Major Surgical or Invasive Procedure: ___: R EVD placement ___: AComm coiling History of Present Illness: Eu Critical, ___ is a ___ y/o female who was transferred via Medflight with a diffuse SAH. Reportedly the patient experienced a syncopal episode s/p passing a bowel movement. She was taken via ambulance to ___ and underwent a CT head which showed a diffuse SAH. She was intubated and transferred via medflight to ___ for further evaluation. Past Medical History: HTN GERD DM? Anxiety Glaucoma? s/p gastric bypass surgery Social History: ___ Family History: Brother and Father hx. of aneurysms Physical Exam: ============= ON ADMISSION ============= PHYSICAL EXAM: ___ and ___: [ ]Grade I: Asymptomatic, mild headache, slight nuchal rigidity [ ]Grade II: Moderate to severe headache, nuchal rigidity, no neurological deficit other than cranial nerve palsy. [ ]Grade III: Drowsiness/Confusion, mild focal neurological deficit. [ ]Grade IV: Stupor, moderate-severe hemiparesis. [x]Grade V: Coma, decerebrate posturing. Fisher Grade: [ ]1 No hemorrhage evident [ ]2 Subarachnoid hemorrhage less than 1mm thick [ ]3 Subarachnoid hemorrhage more than 1mm thick [x]4 Subarachnoid hemorrhage of any thickness with IVH or parenchymal extension ___ Grading Scale: [ ]Grade I: GCS 15, no motor deficit [ ]Grade II: GCS ___, no motor deficit [ ]Grade III: GCS ___, with motor deficit [ ]Grade IV: GCS ___, with or without motor deficit [x]Grade V: GCS ___, with or without motor deficit ___ Coma Scale: [x]Intubated [ ]Not intubated Eye Opening: [x]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [ ]4 Opens eyes spontaneously Verbal: [x]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [ ]4 Confused, disoriented [ ]5 Oriented Motor: [ ]1 No movement [x]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 [ ]6 Obeys commands GCS Total: 4 T: 97.3 BP: 109/57 HR: 92 RR: 18 O2Sats: 100% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-2mm, sluggish bilaterally. + cough No gag + corneal reflexes bilaterally BUE: Extensor posturing to noxious stimuli BLE: Triple flexes to noxious stimuli ============= ON DISCHARGE ============= Lethargic, but arousable Pertinent Results: ============= IMAGING ============= See OMR for pertinent imaging Brief Hospital Course: On ___, ___ (EuCritical ___ was transferred to ___ via Medflight with subarachnoid hemorrhage. #Subarachnoid Hemorrhage/AComm aneurysm Thepatient was transferred from ___ with ___/___ 4 subarachnoid hemorrhage. She was intubated at the OSH prior to transfer. On arrival, CTA was obtained which revealed diffuse SAH with AComm aneurysm. The patient was admitted to the Neuro ICU where EVD was placed emergently at the bedside. She was started on nimodipine for vasospasm prophylaxis, and on ___ she was enrolled in the Nimodipine trial. She was started on Keppra x7 days for seizure prophylaxis. She underwent angiogram on ___ which revealed AComm aneurysm and it was successfully coiled. She had TCDs done but bone window was poor so unable to assess for vasospasm. Concern for storming given tachycardia, fever and tachypnea, up titration of metoprolol. IV hydration was titrated to maintain euvolemia/hypervolemia. #Infarction MRI brain was performed on ___ due to abulia and left lower extremity weakness which showed punctate early subacute infarction in the left frontal centrum semiovale and resolving SAH. Nimodipine was stopped on ___ due to hypotension. Provigil was started on ___ for lethargy and increased on ___. #Respiratory The patient was successfully extubated on ___. On ___ tachypneic to 30's, CXR stable. She was again tachypneic on ___ this was felt to be neurogenic. The patient required reintubation on ___ after she became hypoxic and unresponsive. A large mucous plug was removed at that time. On ___ the patient remained intubated. She was extubated on ___. #CV Prior to angio, the patient's blood pressure was maintained less than 140. After the aneurysm was secured, BP liberalized to <180. On ___ H&H low but no transfusion needed. ___ A-line stopped working and d/c'd. On ___ EKG for chest pain, trop/CK negative. On ___ concern for storming given tachycardia, fever and tachypnea, up titration of metoprolol. She received an additional dose of metoprolol x 2 on ___ for tachycardia. #GI/FEN OGT was placed for feedings and medications. On ___ increased urine output, possibly fluid shift post extubation, bolus given. SLP were consulted. She was started on NPH for hyperglycemia. Dobhoff was changed to NGT on ___. #GU Foley catheter was placed on admission. #Electrolytes The patient was hyponatremic and hypokalemic on admission; electrolytes were repleted and he was bolused with hypertonic saline. Sodium normalized. On ___ started salt tabs for hyponatremia from possible fluid shift post extubation and consistently negative fluid balance despite fluid boluses. Restarted NS IVF in addition to 3% NS. PO salt tabs and hypertonic saline was adjusted to maintain normonatremia. 3% was weaned off and she was maintained on salt tabs. She became hypernatremic, which was managed with IVF boluses and free-water flushes. 3% was restarted on ___ given persistently low sodium and concern for possible cerebral salt wasting. Her serum Na was found to be in the low 120s on ___. A PICC line was placed and she was started on a 3% HTS gtt for a goal Na of normonatremia. #Fracture On ___, the patient was noted to have subacute fractures to her right foot; non-weight bearing was recommended. #Goals of Care On ___ family meeting was held with the patients son and other family members; ___ Care consulted. After a comprehensive conversation with the patient's son ___, the patient was made CMO and hospice care was pursued. On ___, the patient was discharged to a hospice care facility in ___. Medications on Admission: - folic acid daily 1mg - oxycodone 10mg - enalapril 20mg daily - diazepam 10mg as needed - HCTZ 25mg TID - potassium ER 10meq - omeprazole 40mg daily - Norvasc 5mg daily - butalbital/ASA - atenolol 25mg daily - Zofran 4mg as needed - nystatin - lantanprost .005% ___ drop q evening R eye Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 2. LORazepam 0.5-2 mg IV Q2H:PRN anxiety/distress 3. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory distress 4. Ondansetron ___ mg IV Q6H:PRN nausea/vomiting Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Subarachnoid hemorrhage AComm aneurysm Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Aneurysmal Subarachnoid Hemorrhage Surgery/ Procedures • You had a cerebral angiogram to coil the aneurysm. You may experience some mild tenderness and bruising at the puncture site (groin). 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. 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. Followup Instructions: ___
19957410-DS-11
19,957,410
23,037,934
DS
11
2168-10-30 00:00:00
2168-10-30 18:28:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: liver failure Major Surgical or Invasive Procedure: ___ Deceased donor liver transplant, backtable preparation of liver allograft, temporary abdominal closure ___ Left deceased donor kidney transplant into right iliac fossa with ureteral stent for neoureterocystostomy. ___ biliary anastomosis stricture s/p sphincterotomy and stent Plasmapheresis ___ History of Present Illness: Ms. ___ is a ___ with h/o decompensated HCV/EtOH cirrhosis (current MELD 40) c/b renal failure ___ presumed HRS now on HD, persistent LGIB requiring repeated transfusions currently being evaluated for liver transplantation. Briefly, patient has reportedly carried a diagnosis of cirrhosis for ___ years, though was recently admitted for decompensated cirrhosis in ___ and developed renal failure requiring CRRT with eventual transition to HD. She was declined transplant listing at that time and was discharged shortly thereafter. She subsequently came to ___ to establish care living visiting her daughter and has been admitted for liver transplant evaluation. Since admission, she has had persistent LGIB requiring repeated transfusions though has never been hemodynamically unstable or required pressor support. She underwent EGD and colonoscopy on ___ that only demonstrated evidence of portal hypertensive gastropathy and internal hemorrhoids, which are felt to be the source if her ongoing bleeding and transfusion needs. She has recently undergone CT imaging that demonstrated evidence of nononcclusive portal vein thrombus without and moderate ascites only. Transplant Surgery is now consulted for surgical evaluation for liver transplantation. On further review, the patient denies any previous history of bacterial peritonitis or significant GI bleeding. She currently endorses minor abdominal discomfort, but denies any significant pain and also reports decreasing frequency of bloody stools. She also denies fevers/chills, CP/SOB, nausea/vomiting. Past Medical History: PMH: - HCV and EtOH cirrhosis (s/p Harvoni) - CVA in ___, unclear if due to ?high altitude vs stroke (per daughter) - HTN - Gout PSH: - none Social History: ___ Family History: Mother: died at ___ yo Father: died at ___ Children: alive and healthy Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: ___ 0316 Temp: 97.5 AdultAxillary BP: 112/63 R Lying HR: 77 RR: 19 O2 sat: 99% O2 delivery: Ra GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera icteric. Dry MM. NECK: Supple No JVD. CARDIAC: RRR. No murmurs/rubs/gallops. LUNGS: Crackles b/l to mid lung No wheezes, rhonchi or rales. No increased work of breathing. BACK: No spinous process tenderness. No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: Warm. Cap refill <2s. No rash. NEUROLOGIC: CN2-12 intact. Moving all extremities spontaneously. +asterixis on exam, but AAOx3, DOWB WNL DISCHARGE PHYSICAL EXAM: VITALS: T98.8 PO BP117 / 70 HR90 RR 18 ___ 95RA GENERAL: AOX3, smiling, comfortable HEENT: MMM, mild scleral icterus CARDIAC: RRR LUNGS: breathing comfortably on RA ABD: soft, non-tender, non-distended, incisions clean dry and intact with steri strips in place. Prior drain sites sutured. EXTREMITIES: WWP, non-edematous Pertinent Results: ___ 05:56AM BLOOD WBC-2.8* RBC-2.56* Hgb-8.1* Hct-23.8* MCV-93 MCH-31.6 MCHC-34.0 RDW-18.7* RDWSD-64.0* Plt ___ ___ 05:00AM BLOOD WBC-2.4* RBC-2.48* Hgb-7.9* Hct-23.3* MCV-94 MCH-31.9 MCHC-33.9 RDW-18.9* RDWSD-64.8* Plt ___ ___ 06:30AM BLOOD WBC-2.0* RBC-2.37* Hgb-7.4* Hct-22.2* MCV-94 MCH-31.2 MCHC-33.3 RDW-19.1* RDWSD-64.1* Plt ___ ___ 06:45AM BLOOD WBC-2.1* RBC-2.58* Hgb-8.3* Hct-23.9* MCV-93 MCH-32.2* MCHC-34.7 RDW-19.1* RDWSD-63.7* Plt ___ ___ 06:30AM BLOOD Neuts-71.5* Lymphs-11.8* Monos-13.7* Eos-2.0 Baso-0.5 AbsNeut-1.46* AbsLymp-0.24* AbsMono-0.28 AbsEos-0.04 AbsBaso-0.01 ___ 05:56AM BLOOD Plt ___ ___ 05:56AM BLOOD Glucose-103* UreaN-16 Creat-0.7 Na-126* K-4.5 Cl-90* HCO3-25 AnGap-11 ___ 05:41PM BLOOD Na-125* K-4.9 ___ 05:00AM BLOOD Glucose-121* UreaN-13 Creat-0.7 Na-126* K-4.6 Cl-92* HCO3-26 AnGap-8* ___ 06:30AM BLOOD Glucose-180* UreaN-11 Creat-0.6 Na-128* K-4.7 Cl-94* HCO3-26 AnGap-8* ___ 09:11PM BLOOD Na-129* ___ 06:45AM BLOOD Glucose-116* UreaN-11 Creat-0.7 Na-128* K-4.2 Cl-93* HCO3-25 AnGap-10 ___ 06:19AM BLOOD Glucose-76 UreaN-8 Creat-0.7 Na-125* K-3.6 Cl-88* HCO3-24 AnGap-13 ___ 05:56AM BLOOD ALT-54* AST-37 AlkPhos-110* TotBili-1.7* ___ 05:00AM BLOOD ALT-59* AST-41* AlkPhos-116* TotBili-1.6* ___ 06:30AM BLOOD ALT-62* AST-45* AlkPhos-110* TotBili-1.6* ___ 06:45AM BLOOD ALT-71* AST-58* AlkPhos-122* TotBili-1.7* ___ 06:19AM BLOOD ALT-72* AST-66* AlkPhos-126* Amylase-57 TotBili-2.4* ___ 05:56AM BLOOD Albumin-3.4* Calcium-9.2 Phos-3.6 Mg-1.6 ___ 05:00AM BLOOD Albumin-3.4* Calcium-9.0 Phos-2.9 Mg-1.4* ___ 06:30AM BLOOD Albumin-3.2* Calcium-8.8 Phos-2.6* Mg-1.5* ___ 06:45AM BLOOD Albumin-3.4* Calcium-8.9 Phos-4.0 Mg-1.7 ___ 06:19AM BLOOD Albumin-3.3* Calcium-8.6 Phos-4.1 Mg-1.3* ___ 06:45AM BLOOD T4-7.0 calcTBG-0.95 TUptake-1.05 T4Index-7.4 Free T4-1.5 ___ 05:30AM BLOOD %HbA1c-5.1 eAG-100 ___ 01:04AM BLOOD HCV Ab-POS* ___ 02:51AM BLOOD HCV VL-NOT DETECT IMAGING MRI Brain ___ 1. White matter hyperintensities suggesting chronic small vessel ischemia. Otherwise normal brain MRI. CT CHEST ___ IMPRESSION: Evidence of cirrhosis with for portal hypertension and pneumobilia. 7 mm left lower lobe pulmonary nodule. Three-month follow-up is recommended. NG tube projects below the left hemidiaphragm. Moderate-sized hiatus hernia. CTA Abdomen Pelvis ___ IMPRESSION: 1. Simple appearing fluid collections adjacent to the right lower quadrant transplant kidney hilum and along the right pelvic sidewall measuring up to 4.3 cm likely reflect postoperative seromas or lymphoceles. 2. Debris is noted within the distal aspect of the CBD stent, though pneumobilia and lack of intrahepatic biliary dilation suggest stent patency. 3. Splenomegaly, small volume abdominopelvic ascites, and extensive paraesophageal and upper abdominal varices. Duplex ___ IMPRESSION: 1. Patent hepatic vasculature. 2. Pneumobilia predominantly within the left hepatic lobe, however no evidence of intrahepatic or extrahepatic biliary ductal dilatation. 3. Slightly echogenic and coarsened hepatic echotexture, similar in appearance to prior studies. 4. Moderate splenomegaly measuring up to 17.8 cm. 5. Bilateral echogenic kidneys consistent with medical renal disease. MRCP ___ IMPRESSION: 1. Focal severe stricture at the biliary anastomosis with moderate upstream intrahepatic and extrahepatic biliary ductal dilatation. 2. Evaluation of the portal venous and main hepatic arterial anastomoses are substantially limited by motion degradation. If there is concern for vascular anastomotic complication, multiphasic CT should be performed as it is less susceptible to motion artifact. 3. Extensive varices. Small volume ascites. Moderate splenomegaly. CT Head/C-spine ___ 1. No acute intracranial abnormality. 2. No evidence acute intracranial hemorrhage or fracture. 3. Bilateral posterior parietal and occipital subgaleal hematomas with left parietal probable laceration. 1. Dental amalgam streak artifact limits study. 2. Within limits of study, no definite evidence of acute fracture. 3. Probable multilevel cervical spondylosis as described. Please note MRI of the cervical spine is more sensitive for the evaluation of ligamentous injury. 4. Question pulmonary edema on limited imaging of lungs. Consider dedicated chest imaging for further evaluation. Brief Hospital Course: MEDICINE FLOOR COURSE: ============ Admitted to ___ Hepatology service for liver failure. Started on empiric antibiotics, blood cultures drawn, underwent paracenteses, and resuscitation. MICU COURSE: ============ Admitted to the MICU ___ for hypotension despite fluid resuscitation and encephalopathy. In the ICU, she received both a diagnostic paracentesis and later a therapeutic paracentesis which did not show evidence of SBP. She was continued on daptomycin for VRE bacteremia. A new dialysis catheter was placed and she was started on HD, which she tolerated. She briefly required norepinephrine to maintain her MAP goal, but this was quickly weaned. She also had episodes of bloody bowel movements with corresponding Hgb drop which was treated with blood transfusions and per the Hepatology team was not further investigated. She was then transferred back to the ___ service for further treatment of her VRE bacteremia and transplant work-up. ============= SICU COURSE: ============= The patient was transferred to the SICU for CRRT in the setting of inability to remove fluid at HD secondary to her blood pressure. She did not tolerate volume removal and had an increasing pressor requirement. Cultures were sent and empiric antibiotics were started for concern for infection with an increasing pressor requirement - cultures were negative. On ___, Ms. ___ diagnosed with adrenal insufficiency as she failed stim test. Started on hydrocortisone 25mg Q8H IV, subsequently increased to 50mg Q8H IV. On ___ she underwent a deceased donor liver transplant with sameday takeback for biliary anastomosis and renal transplant. Her donor was strep viridans positive ___ bottles, penicillin sensitive, she completed a week of ceftriaxone for this result. Initially her platelets were decreasing with transfusion and a HITT panel was sent and found to be negative. CRRT was stopped about 4 hours postop and she has had good urine output since. TFs were re-started POD2 and she tolerated them well. She was advanced to a regular diet without issue on ___. Because she had low flow T cell +ve cross match. In that setting she received plasmapheresis (PEX) #1 in between her liver and kidney transplant. She then received plasmapharesis and IVIG five times postop (every other day). Her FSBG were consistently high (280s) refractory to ISS, added insulin naive dosing of lantus, 13U @ dinner. All liver ultrasounds showed patent hepatic vasculature and her renal ultrasound also showed patent renal vasculature. She was subsequently transferred to the floor. ============= FLOOR COURSE: ============= Ms ___ was transferred to the floor on ___. The first night on the floor, she had a mechanical fall with headstrike and no loss of consciousness. A head CT was performed which showed no acute intracranial abnormalities. Her scalp laceration was stapled. While on the floor, she had slowly rising liver enzymes on her daily panel. An ultrasound was obtained on ___ which showed dilatation of biliary duct (from 5mm to 8mm) as well as intrahepatic biliary dilatation. ERCP was consulted. They recommended an MRCP which demonstrated a tight biliary anastomotic stricture. She was therefore taken to the GI suite for ERCP, sphincterotomy, and placement of CBD stent. She also complained of non-specific abdominal pain, mostly at night, awakening her from sleep. This was initially in the RUQ, then LLQ, then in the epigastrium. A thorough workup including a urinanalysis, KUB, CXR, and drain cell count (to rule out SBP) were all obtained and revealed no cause of the pain. Gabapentin was started on ___ and her oxycodone was titrated up ___. Psychiatry was consulted for a possible anxiety component to the abdominal pain and recommended continuing her home Celexa and Wellbutrin as well as delirium precautions. She became hyponatremic to 123 on ___. Urine and serum studies were consistent with SIADH. Based on Nephrology recommendations, she was free water restricted to 1L, her tube feeds were further concentrated, and her medications were adjusted. Oxycodone was switched to tramadol, her SSRI was held, and her gabapentin and Celexa were discontinued. Her sodium continued to hover in the low 120s for the next several days, nadiring at 122. This was treated with normal saline infusion, salt tabs, and intermittent IV Lasix. Her sodium stabilized in the mid to high 120s. An endocrinology consult was placed for concern for SIADH vs adrenal insufficiency. Pituitary panel was sent without evidence of concerning intracranial process. CT chest and MRI brain were unrevealing for additional causes of SIADH. She was started on daily fludrocortisone for suspected adrenal insufficiency, and her sodium stabilized. Her appetite improved throughout her floor course after her tube feeds were held. She was started on Marinol after which her oral intake improved significantly. Her Dobhoff was therefore removed prior to discharge. By day of discharge, she was tolerating a regular diet, ambulating independently, voiding spontaneously, with pain well controlled. Her staples and drains were all removed by this point. She received discharge teaching for medications, including insulin, and will follow up in the ___. # Immunosuppresion # - Received ATG 2 full doses (divided between 5 days due to low plts), last dose ___ - Received plasmapheresis ___ (with IVIG each time) - DSA repeated ___ - Received IVIG with plasmapheresis ___, ___ then IVIG alone on ___ for a total dose of 120grams - Tacrolimus - discharged on 2.5 BID for a level of 8. Goal tacrolimus ___ given DSA. - MMF - Steroid taper per liver protocol Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Pantoprazole 40 mg PO Q24H 2. Rifaximin 550 mg PO BID 3. Sumatriptan Succinate 50 mg PO DAILY:PRN migraine 4. Lactulose 30 mL PO TID 5. Midodrine 10 mg PO TID 6. Octreotide Acetate 100 mcg SC Q8H 7. Allopurinol ___ mg PO DAILY 8. Citalopram 20 mg PO DAILY 9. BuPROPion 75 mg PO BID 10. Furosemide 40 mg PO DAILY 11. Potassium Chloride 20 mEq PO DAILY 12. Vitamin E 400 UNIT PO BID 13. Thiamine 100 mg PO DAILY 14. Vitamin D ___ UNIT PO DAILY 15. Ascorbic Acid ___ mg PO DAILY 16. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild do not take more than 4 of the 500 mg tablets daily 2. Ciprofloxacin HCl 500 mg PO Q24H to prevent UTI Duration: 1 Dose take one hour prior to removal of the ureteral stent by urology 3. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line 4. Dronabinol 2.5 mg PO BID 5. Fluconazole 400 mg PO Q24H 6. Fludrocortisone Acetate 0.1 mg PO DAILY 7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate No driving if taking this medication. Taper use as tolerated 9. NPH 4 Units Breakfast NPH 3 Units Bedtime 10. Magnesium Oxide 400 mg PO DAILY 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Mycophenolate Mofetil 1000 mg PO BID 13. PredniSONE 12.5 mg PO DAILY Duration: 7 Doses Start ___ and then follow transplant clinic taper 14. Sodium Chloride 1 gm PO TID 15. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium take only when instructed by transplant coordinator 16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 17. Tacrolimus 2.5 mg PO Q12H 18. ValGANCIclovir 900 mg PO DAILY 19. Allopurinol ___ mg PO DAILY 20. BuPROPion 75 mg PO BID 21. Pantoprazole 40 mg PO DAILY 22. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: HCV/ETOH Cirrhosis ESRD/HRS ___ (ICD-10 Z76.82) VRE bacteremia Donor blood culture Viridin group streptococci s/p combined liver/kidney transplant ___ Biliary anastomosis stricture s/p stent Hyponatremia Medication induced hyperglycemia 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: Please call the transplant clinic at ___ for fever of 101 or higher, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day, pain/burning/urgency with urination, decreased urine output or any other concerning symptoms. . Bring your pill box and list of current medications to every clinic visit. . For this week only: please get labs drawn ___. Then You will have labwork drawn every ___ and ___ as arranged by the transplant clinic, with results to the transplant clinic (Fax ___ . CBC, Chem 10, AST, ALT, Alk Phos, T Bili, Trough Tacro level, Urinalysis. . *** On the days you have your labs drawn, do not take your Tacro until your labs are drawn. Bring your Tacro with you so you may take your medication as soon as your labwork has been drawn. . Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. . You may shower. Allow the water to run over your incision and pat area dry. No rubbing, no lotions or powder near the incision. You may leave the incision open to the air. No tub baths or swimming . No driving if taking narcotic pain medications . Avoid direct sun exposure. Wear protective clothing and a hat, and always wear sunscreen with SPF 30 or higher when you go outdoors. . Your appetite will return with time. Eat small frequent meals and snacks, and you may supplement with things like carnation instant breakfast or Ensure.Please try to limit fluid intake to 1 liter daily until your sodium improves. . Check your blood sugars and treat with insulin as directed. Report Blood sugars over 200 or less than 80. Check blood pressure daily and report readings above 160 systolic. . Do not increase, decrease, stop or start medications without consultation with the transplant clinic at ___. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant. . Consult transplant binder, and there is always someone on call at the transplant clinic with any questions that may arise Followup Instructions: ___
19957410-DS-12
19,957,410
24,629,182
DS
12
2168-11-22 00:00:00
2168-11-22 16:44:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: nausea/vomiting/headache Major Surgical or Invasive Procedure: ___- U/S guided liver biopsy History of Present Illness: Ms ___ is a ___ year old female history of HCV and EtOH cirrhosis c/b HRS now s/p DDRT and DDLT on ___, whose postop course was complicated by biliary anastomotic stricture s/p ERCP sphinc. and stenting on ___, hyponatremia and poor PO intake, all of which has resolved. Of note she underwent underwent IVIG and plasmapheresis on a scheduled basis from ___ through ___ with a total dose of 120 g of IVIG, and on a ___ specimen, there was no longer any donor specific antibody against her kidney, liver donor. She presents again today with headache, nausea, and vomiting of one day duration. she has been passing gas and having bowel movements. The patient received one mg of Ativan which helped with her nausea but made her very drowsy. She also underwent a CT head (for severe headache) which showed no intracranial abnormality. Her husband in the ___ was interviewed who also noted that the patient is drowsier that her usual self. however, he also mentioned that the patient could not get any sleep last night and that when she does not get enough rest she becomes very drowsy. her labs in the ___ were notable for wbc 4.7 with PMN 87%, Cr 0.9, and sodium of 134. her lactate was 1.0. Her serum and urine tox screen was negative except for opiates which she takes at home (dilaudid). her KUB and CXR were wnl. Past Medical History: PMH: - HCV and EtOH cirrhosis (s/p Harvoni) - CVA in ___, unclear if due to ?high altitude vs stroke (per daughter) - HTN - Gout PSH: - none Social History: ___ Family History: Mother: died at ___ yo Father: died at ___ Children: alive and healthy Physical Exam: Physical Exam Vitals T 97.8 HR 88 BP 118 / 74 RR 18 PO2 100% RA General: NAD, A/)x3 Lungs: CTAB, not in respiratory distress CV: RRR Abd: well healed incision, soft, nontender, non distended, biopsy dressing clean/dry/intact Ext: no peripheral edema Discharge PE: PHYSICAL EXAMINATION: 24 HR Data (last updated ___ @ 325) Temp: 98.2 (Tm 98.8), BP: 137/75 (102-137/63-84), HR: 88 (84-96), RR: 18, O2 sat: 99% (97-99), O2 delivery: Ra, Wt: 143.2 lb/64.96 kg Fluid Balance (last updated ___ @ 2245) Last 8 hours Total cumulative 260ml IN: Total 360ml, PO Amt 360ml OUT: Total 100ml, Urine Amt 100ml Last 24 hours Total cumulative 1791ml IN: Total 3416ml, PO Amt 2260ml, IV Amt Infused 1156ml OUT: Total 1625ml, Urine Amt 1625ml GENERAL: [x ]NAD [ x]A/O x 3 [ ]intubated/sedated [ ]abnormal CARDIAC: [x ]RRR [ x]no MRG [ x]Nl S1S2 [ ]abnormal LUNGS: [x ]CTA b/l [ x]no respiratory distress [ ]abnormal ABDOMEN: [ ]NBS [ x]soft [ x]Nontender [ ]appropriately tender [ ]nondistended [x ]no rebound/guarding [ ]abnormal WOUND: [x ]CD&I [x ]no erythema/induration [ ]JP [ ]abnormal EXTREMITIES: [x ]no CCE [x ]Pulse [ ]abnormal Pertinent Results: ___ 11:05AM BLOOD WBC-5.4 RBC-3.19* Hgb-10.4* Hct-30.9* MCV-97 MCH-32.6* MCHC-33.7 RDW-17.5* RDWSD-62.8* Plt ___ ___ 11:05AM BLOOD Neuts-81.4* Lymphs-9.4* Monos-5.7 Eos-2.0 Baso-0.4 Im ___ AbsNeut-4.40 AbsLymp-0.51* AbsMono-0.31 AbsEos-0.11 AbsBaso-0.02 ___ 02:32PM BLOOD ___ PTT-23.1* ___ ___ 06:25AM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-134* K-3.7 Cl-102 HCO3-20* AnGap-12 ___ 02:32PM BLOOD ALT-90* AST-56* AlkPhos-73 TotBili-1.7* ___ 05:20AM BLOOD WBC-3.0* RBC-2.92* Hgb-9.5* Hct-28.0* MCV-96 MCH-32.5* MCHC-33.9 RDW-16.8* RDWSD-59.2* Plt ___ ___ 05:20AM BLOOD Glucose-109* UreaN-14 Creat-0.8 Na-132* K-4.0 Cl-97 HCO3-24 AnGap-11 ___ 05:20AM BLOOD ALT-68* AST-36 AlkPhos-73 TotBili-1.3 MRI Head: FINDINGS: No evidence of acute territorial infarction, hemorrhage, masses or midline shift. Ventricles and sulci are slightly prominent, likely due to involutional changes. Periventricular and subcortical white matter T2/FLAIR hyperintensities are nonspecific but likely sequelae of chronic small vessel ischemic disease. The major flow voids are preserved. Mild maxillary sinus disease. IMPRESSION: 1. No acute infarction or hemorrhage. 2. Evidence of chronic ischemic vessel disease. ___ 4:00 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. Brief Hospital Course: Ms. ___ is a ___ female history of HCVC/ EtOH cirrhosis s/p deceased donor liver and kidney transplant on ___, who presented to the emergency department with nausea/vomiting and headache who was admitted to the transplant surgery service for further management. An infectious workup was performed, inluding stool studies which returned negative. She received IV hydration and Tylenol for her headaches She had a persistent headache, worse than her normal headaches, as well as was drowsy and difficult to arouse on exam. Neurology was consulted and an MRI head w/ contrast was performed. The MRI demonstrated no intracranial pathology. Due to her benign imaging findings and physical exam, with improvement in mentation and alertness as the day progressed, unlikely to represent a pathological process. Her headaches resolved with Tylenol, fioricet x2, and a one time dose of PO dilaudid. For her drowsiness, we discontinued the diluadid and Dronabinol, decreased her Welbutrin from 150 to 75mg BID, with improvement in her mental status On admission, her lab work remarkable for elevated LFTs, with an increased Total bilirubin to 1.7, and elevated Alk Phos, ALT and AST, with normal LFTs at discharge on ___. Therefore, an ultrasound guided liver biopsy was performed in radiology, and the pathology was rushed, with results demonstrated no rejection. She continued on her usual immunosuppression that consisted of prednisone 5mg daily, mycophenolate 1gram twice daily and tacrolimus. Tacrolimus dosing was adjusted per trough levels. ___ FK ___ (12.4) ___ FK 2.5/2.5(11.2) At the time of discharge, she was tolerating a regular diet, pain was resolved, she was voiding adequately and spontaneously, ambulating without assistance. She was discharged home with followup on ___. She will have labs drawn on ___. Of note, blood cultures were pending at time of discharge to home. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. BuPROPion 150 mg PO BID 3. Dronabinol 2.5 mg PO BID 4. Famotidine 20 mg PO BID 5. Fluconazole 400 mg PO Q24H last dose ___ 6. Fludrocortisone Acetate 0.1 mg PO DAILY 7. Glucagon 1 mg IM Q15MIN:PRN low blood sugar 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate 9. Mycophenolate Mofetil 1000 mg PO BID 10. PredniSONE 10 mg PO DAILY 11. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 13. Tacrolimus 2.5 mg PO Q12H 14. ValGANCIclovir 900 mg PO Q24H Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever Reason for PRN duplicate override: Alternating agents for similar severity do not take more than 2000mg per day 2. Docusate Sodium 100 mg PO BID 3. NPH 3 Units Breakfast NPH 3 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 4. Multivitamins 1 TAB PO DAILY 5. Senna 8.6 mg PO BID:PRN Constipation - First Line 6. BuPROPion 75 mg PO BID 7. PredniSONE 5 mg PO DAILY 8. Tacrolimus 2 mg PO Q12H 9. Allopurinol ___ mg PO DAILY 10. Famotidine 20 mg PO BID 11. Fluconazole 400 mg PO Q24H last dose ___ 12. Glucagon 1 mg IM Q15MIN:PRN low blood sugar 13. Mycophenolate Mofetil 1000 mg PO BID 14. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 15. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 16. ValGANCIclovir 900 mg PO Q24H Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Dehydration Migraine delirium r/t medications h/o liver/kidney transplant DM Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ___ of ___ will continue to follow you Please call the transplant clinic at ___ for fever of 101 or higher, chills, nausea, vomiting, diarrhea, constipation, inability to tolerate food, fluids or medications, yellowing of skin or eyes, increased abdominal pain, incisional redness, drainage or bleeding, dizziness or weakness, decreased urine output or dark, cloudy urine, swelling of abdomen or ankles, weight gain of 3 pounds in a day, pain/burning/urgency with urination, decreased urine output or any other concerning symptoms. Bring your pill box and list of current medications to every clinic visit. Please get labs drawn on ___ then twice weekly as previously arranged. *** On the days you have your labs drawn, do not take your Tacrolimus until your labs are drawn. Bring your Tacrolimus with you so you may take your medication as soon as your labwork has been drawn. Follow your medication card, keep it updated with any dosage changes, and always bring your card with you to any clinic or hospital visits. No driving if taking narcotic pain medications Avoid direct sun exposure. Wear protective clothing and a hat, and always wear sunscreen with SPF 30 or higher when you go outdoors. Check your blood sugars and treat with insulin as directed. Report Blood sugars over 200 or less than 80. Check blood pressure daily and report readings above 160 systolic. Do not increase, decrease, stop or start medications without consultation with the transplant clinic at ___. There are significant drug interactions with anti-rejection medications which must be considered in medication management following transplant. Followup Instructions: ___
19957410-DS-15
19,957,410
26,712,985
DS
15
2169-01-28 00:00:00
2169-01-28 09:21:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: headache, nausea, vomiting Major Surgical or Invasive Procedure: ___ ERCP: Plastic stent removed, new metal stent placed across CBD stricture. History of Present Illness: Ms ___ is a ___ year old woman w hx alcoholic cirrhosis with HRS now s/p ___ transplant (___) complicated by moderate liver rejection (liver bx ___ s/p ___ course of IV ATG (___), and anastomotic stricture requiring CBD stent placement (___) which was found to be inferiorly displaced, requiring subsequent repeat biliary stent (2 stents) placement (___), as well as h/o SIADH, migraines, depression/anxiety. She is presenting with headaches, nausea, multiple episodes of ___ emesis. PRIOR HOSPITALIZATION (___) ====================================== She was recently admitted to the Transplant Hepatology service (___) for influenza for which she completed a ___ course of Tamiflu and transaminitis ___ moderate rejection for which she received 5 days of IV ATG (___) + ductal stenosis for which she underwent ERCP (___) and had 2 stents placed. Given that the rejection occurred on prednisone 7.5mg qd, she was discharged on prednisone 20mg qd, and continued on other immunosuppressive meds: dapsone 100mg qd, fluconazole 400mg qd, Valcyte 900mg qd. She did not make it to her scheduled follow up apts with Renal Transplant, Liver Transplant, as she ___ to the ED shortly after discharge. ED PRESENTATION (___) ====================================== About ~1 day prior to presentation, she reports worsening headache similar to prior migraines, associated with nausea and RUQ pain. She had multiple ___ emesis throughout the day. She has not been tolerating po intake. She had her labs drawn at ___, and transplant coordinator directed her to ED for further evaluation. In the ED initial vitals: 98.0F, HR 106, BP 101/72, RR 18, SpO2 100% RA - Exam notable for: mild RUQ tenderness, otherwise benign exam. - Labs notable for: CBC: WBC 14.2/Hgb 10.5/Plt 131 Chem7 (grossly hemolyzed): Na 132, K 6.3 > whole blood 4.3, Cr 1.0, Mg 1.6 LFTs: ALt 106, AST 96, AP 123, Tbili 2.5, dbili 0.4. Alb 3.6. Lipase 18. Coags: INR 1.3 Flu: Negative. - Imaging notable for: 1) Liver/gallbladder U/S: 2 heterogenous rounded structures within liver parenchyma measuring up to 2.1cm (NEW since prior U/S) c/f hepatic abscesses. Patent hepatic vasculature with appropriate waveforms. Mild splenomegaly. 2) MR liver: Nonspecific liver lesions in hepatic segments 7 and 8 demonstrating slight heterogeneous hyperintense signal on T2, hypointensity on T1, and rim enhancement. Even though there is a lack of definite restricted diffusion,these lesions are suspicious for developing infection/abscess. 3) Renal Transplant U/S: Normal renal trnapslant U/S. 1. Normal renal transplant ultrasound. 2. Interval decrease of small seroma located superior to the transplanted kidney. - Consults: Hepatology who recommended admission to ___ ___ ___ for further management. - Patient was given: IV prochlorperazine 10mg, PO Zofran 4mg, 1L LR, started zosyn ON THE FLOOR (___) ====================================== She is having headaches, mild RUQ pain. Past Medical History: PMH: - HCV and EtOH cirrhosis (s/p Harvoni) - CVA in ___, unclear if due to ?high altitude vs stroke (per daughter) - HTN - Gout PSH: - deceased donor liver and kidney transplant on ___ Social History: ___ Family History: Mother: died at ___ yo Father: died at ___ Children: alive and healthy Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: 24 HR Data (last updated ___ @ 1417) Temp: 97.6 (Tm 97.6), BP: 134/84, HR: 89, RR: 18, O2 sat: 99%, O2 delivery: Ra, Wt: 138 lb/62.6 kg GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: Soft, +ttp in RUQ. EXTREMITIES: Warm, no ___. NEURO: A&Ox4, no focal neurologic deficits. SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAMINATION: 24 HR Data (last updated ___ @ 509) Temp: 98.1 (Tm 98.1), BP: 110/60 (___), HR: 81 (___), RR: 16 (___), O2 sat: 97% (___), O2 delivery: Ra GENERAL: NAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB ABDOMEN: Soft, nd, nt. EXTREMITIES: Warm, no ___. NEURO: A&Ox4, no focal neurologic deficits. ACCESS: RUE ___ Pertinent Results: ADMISSION LABS ___ 12:40PM BLOOD ___ ___ Plt ___ ___ 12:40PM BLOOD ___ ___ Im ___ ___ ___ 12:40PM BLOOD ___ ___ ___ 12:40PM BLOOD ___ ___ ___ 12:40PM BLOOD ___ ___ ___ 12:40PM BLOOD ___ ___ 04:47AM BLOOD ___ ___ 06:05AM BLOOD ___ ___ 12:55PM BLOOD ___ DISCHARGE LABS ___ 07:47AM BLOOD ___ ___ Plt ___ ___ 07:47AM BLOOD ___ ___ ___ 07:47AM BLOOD ___ ___ ___ 07:47AM BLOOD ___ LD(LDH)-173 ___ ___ ___ 07:47AM BLOOD ___ ___ 07:47AM BLOOD ___ TACROLIMUS: ___ 07:47AM BLOOD ___ ___ 09:45AM BLOOD ___ ___ 09:40AM BLOOD ___ ___ 08:53AM BLOOD ___ ___ 10:15AM BLOOD ___ ___ 10:20AM BLOOD ___ ___ 04:47AM BLOOD ___ ___ 06:05AM BLOOD ___ MICRODATA: ___ 12:40 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. FINAL SENSITIVITIES. Ertapenem REQUESTED BY ___. ___ (___) ON ___. Ertapenem = SUSCEPTIBLE test result performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFTAZIDIME----------- 16 I CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- 16 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R Anaerobic Bottle Gram Stain (Final ___: Reported to and read back by ___ @ 0420 ON ___ - ___. GRAM NEGATIVE ROD(S). Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___ 4:42 am BLOOD CULTURE Blood Culture, Routine (Preliminary): ESCHERICHIA COLI. Identification and susceptibility testing performed on culture # ___ ON ___. Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). ___ BCX: NGTD Time Taken Not Noted ___ Date/Time: ___ 6:50 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. REPORTS: ___ RUQUS: 1. 2 heterogeneous lesions within the liver parenchyma measuring up 2.1 cm, new since prior ultrasound, concerning for hepatic abscesses. 2. Patent hepatic vasculature with appropriate waveforms. 3. Mild splenomegaly. ___ LIVER MRI: 1. Nonspecific liver lesions in hepatic segments 7 and 8 demonstrating slight heterogeneous hyperintense signal on T2, hypointensity on T1, and rim enhancement. Even though there is a lack of definite restricted diffusion, these lesions are suspicious for developing infection/abscess. 2. Stable aspect of the focal narrowing of the inferior aspect of the main portal vein. ___ ERCP: SUCCESSFUL ERCP WITH STENT REMOVAL.PLASTIC BILIARY STENT WAS REMOVED. CBD WAS THEN CANNULATED AND CHOLANGIOGRAM SHOWED A 1CM BENIGN APPEARING ___ STRICTURE AT THE ANASTAMOSIS WHICH THE METAL STENT DID NOT TRAVERSE. THE METAL STENT WAS THEN REMOVED AND A NEW FCMS WAS PLACED SUCESFFULY ACROSS THE CBD STRICTURE. ___ TTE: LVEF >/=60%. NO VEGETATIONS. ___ CXR: ___ PICC line has been removed. ___ PICC line has been placed with its tip in the cavoatrial junction. There is moderate cardiomegaly. There is mild interstitial edema. There is no pleural effusion. No pneumothorax. Brief Hospital Course: Ms ___ is a ___ year old woman w hx alcoholic cirrhosis with HRS now s/p ___ transplant (___) complicated by moderate liver rejection (liver bx ___ s/p ___ course of IV ATG (___), and anastomotic stricture requiring CBD stent placement (___) which was found to be inferiorly displaced, requiring subsequent repeat biliary stent (2 stents) placement (___), as well as h/o SIADH, migraines, depression/anxiety. She ___ for worsening HA, nausea, RUQ pain found to have E. coli bacteremia and likely early hepatic abscesses on MRI. She is now s/p ERCP on ___ during which previous plastic stent was removed and new metal stent was placed across CBD stricture. She is now s/p RUE PICC placement on ___ for 4 week course of meropenem (___). She was discharged to rehab. ACUTE/ACTIVE ISSUES: ==================== # E. coli bacteremia # Hepatic Abscess On this admission, she was found to have new hepatic lesions in segments 7,9 which are not amenable to drainage by ___. Blood cultures were positive for ___ resistant E. coli. TTE showed no e/o endocarditis, repeat NCHCT (obtained iso recurrent HA) showed no acute intracranial abnormality. Per ID, she should continue IV meropenem 500mg q6h x 4 weeks (___). She will need repeat liver MRI in ___ weeks to evaluate abscesses (___) and ID will arrange for OPAT f/u. # Alcoholic cirrhosis s/p liver/renal transplant (___) # Transaminitis # S/P liver transplant, on immunosuppression, c/b acute moderate cellular rejection s/p ATG # Biliary stricture s/p stenting, most recently on ___, stent exchange ___ Patient underwent transplant and biliary stenting in ___. Her last MRCP showed good effect of biliary stent. She began developing rising LFTs in ___. MRCP showed stent migration on known stricture and new stricture, for which ERCP was done on ___ with two stents placed. Unfortunately, pt with worsening transamnitis and s/p liver biopsy on ___ showing acute moderate rejection for which she received ATG x5d (___). ___ ERCP was done for exchange of previous plastic stent with new metal stent due to 1 cm ___ stricture (___). IMMUNOSUPPRESSION: - Tacro was increased to 3mg bid (goal tacro level is ___ given active infection) - Prednisone 20mg qd (___), given rejection occurred on prednisone 7.5mgqd. PPX: - Dapsone 100mg qd for PCP ppx - ___ Ppx: Valcyte 900mg x 3months (___), though may ___ duration as pt had pancytopenia in the past. - Antifungal Ppx: Fluconazole 400mg qd x 3months (___) #Leukocytosis p/w WBC 14.2. Although pt is on prednisone 20mg qd since last hospitalization for liver/renal transplant immunosuppression, WBC has been largely been wnl. In this setting, likely iso hepatic abscesses. WBC at discharge: 4.0 # Hyponatremia # SIADH Hyponatremia due to unclear etiology, though likely ___ SIADH; notably, has LLL pulm nodule c/f growing neoplasm. Lytes during last admission c/w low salt intake. ___ urine osm 509, UNa 113. Na at discharge: 137 # Migraines Increased home bupropion to 150mg bid at last admission, continued home topiramate 25mg po daily. Gave prn IV compazine for headaches. Per Transplant Pharmacy, limited triptan use to 1x/week. # Pancytopenia Chronic secondary to valganciclovir. # Thrombocytopenia: p/w plt 131 during last admission down to ___ and now improving. 4T score: 3, c/f HIT as plt counts ___ after starting SQ hep. Last HIT Ab neg during ___id and had pt on pneumoboots instead. Platelets at discharge: 129 CHRONIC/STABLE ISSUES: ====================== # Lower Back pain: has chronic back pain with h/o laminectomy. Was continued on her home pain regimen. # LLL nodule: ___ chest CT shows LLL pulm nodule increased in size 7x5mm c/f growing neoplasm. Seen by outpatient Thoracic Surgery on ___ at which time decision was made to monitor with close surveillance ___ chest CT in 3 months), given pt is recovering from liver/renal transplant. Will need F/u with Dr. ___ with a repeat chest CT in 3 months (___) or new ___ MD in ___ if she moves. # New Osteoporosis Osteoporosis on ___ DXA; new diagnosis for pt. # Gout Continued home allopurinol ___ po daily # GERD Continued home famotidine 2mg po daily # Housing instability: Some difficulties with current housing situation with daughter. They are hoping to return to ___ ASAP. Seen by ___ during last admission. TRANSITIONAL ISSUES ==================== []CHECK TACROLIMUS LEVEL 30 minutes prior to am dose on ___ and then weekly and fax result to ___, Attn: Transplant hepatology []Obtain weekly: CBC with differential, BUN, Cr, AST, ALT, Total Bili, ALK PHOS, CRP. ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ []Continue meropenem 500mg q6h (___), end date to be determined by OPAT []Please obtain repeat liver MRI in ___ weeks to evaluate abscesses (___) []Repeat ERCP in ___ weeks (ERCP on ___ to assess stricture. []Will need Transplant ID f/u. []Per Transplant Pharmacy, limited triptan use to 1x/week. []F/u with Dr. ___ with a repeat chest CT in 3 months (___) or new ___ MD in ___ if she moves. # CODE: Full, presumed # CONTACT: HCP: ___, husband. Phone number: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. biotin 5 mg oral DAILY 2. Allopurinol ___ mg PO DAILY 3. BuPROPion 150 mg PO BID 4. Dapsone 100 mg PO DAILY 5. Docusate Sodium 100 mg PO DAILY 6. Famotidine 20 mg PO BID 7. Glucagon 1 mg IM Q15MIN:PRN low blood sugar 8. Multivitamins 1 TAB PO DAILY 9. Senna 8.6 mg PO QHS 10. Sodium Chloride 1 gm PO DAILY 11. Topiramate (Topamax) 25 mg PO QHS 12. Vitamin D ___ UNIT PO DAILY 13. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 14. Mycophenolate Sodium ___ 720 mg PO BID 15. PredniSONE 20 mg PO DAILY 16. Tacrolimus 2.5 mg PO Q12H 17. Fluconazole 400 mg PO Q24H 18. ValGANCIclovir 900 mg PO Q24H 19. Magnesium Oxide 400 mg PO TID Discharge Medications: 1. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck 2. Meropenem 500 mg IV Q6H 3. Tacrolimus 3 mg PO Q12H 4. Allopurinol ___ mg PO DAILY 5. biotin 5 mg oral DAILY 6. BuPROPion 150 mg PO BID 7. Dapsone 100 mg PO DAILY 8. Docusate Sodium 100 mg PO DAILY 9. Famotidine 20 mg PO BID 10. Fluconazole 400 mg PO Q24H 11. Glucagon 1 mg IM Q15MIN:PRN low blood sugar 12. Magnesium Oxide 400 mg PO TID 13. Multivitamins 1 TAB PO DAILY 14. Mycophenolate Sodium ___ 720 mg PO BID 15. PredniSONE 20 mg PO DAILY 16. Senna 8.6 mg PO QHS 17. Sodium Chloride 1 gm PO DAILY 18. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 19. Topiramate (Topamax) 25 mg PO QHS 20. ValGANCIclovir 900 mg PO Q24H 21. Vitamin D ___ UNIT PO DAILY 22.Outpatient Lab Work Please draw BUN, Cr, AST, ALT, Total Bili, ALK PHOS, CRP weekly starting ___. ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ ICD10: R78.81, Z79.2 23.Outpatient Lab Work please check tacrolimus level 30 min before AM dose on ___ and then weekly thereafter. Fax results to: ___, Attn: Transplant hepatology ICD 10: ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: E coli bacteremia Hepatic abscesses Secondary diagnoses: Transaminitis s/p liver transplant s/p renal transpalnt Hyponatremia Migraines Pancytopenia Thrombocytopenia 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 hospitalization at ___! WHY WERE YOU ADMITTED? - You were admitted to the hospital because you had bacteria in your blood and you had liver abscesses. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? - We gave you IV antibiotics to treat your infection. - We placed a special IV called a "PICC" so that you could continue getting IV antibiotics after leaving the hospital. - You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Take all of your medications as prescribed (listed below) - Keep your follow up appointments with your doctors - You will have repeat imaging study of your abdomen so the infectious disease doctors ___ determine ___ much longer you will need the antibiotics for. - 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. We wish you the best! Sincerely, - Your ___ Care Team Followup Instructions: ___
19957410-DS-16
19,957,410
23,304,523
DS
16
2169-03-11 00:00:00
2169-03-18 15:21:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Abdominal pain/weakness Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ PMH of hepatitis C and alcoholic cirrhosis with HRS now s/p liver-kidney transplant (___) complicated by moderate liver rejection (liver bx ___ s/p 5-day course of IV ATG (___), and anastomotic stricture requiring CBD stent placement (___) which was found to be inferiorly displaced, requiring subsequent repeat biliary stent (2 stents) placement (___) and replaced on ___, SIADH presents with 3 to 4 days of severe weakness and generalized fatigue as well as low back pain and lower abdominal pain. Patient was admitted ___ with pyogenic liver abscess and MDR E.coli with subsequent treatment with IV meropenem. She was seen at 4 week mark of abx in ___ clinic with subsequent MRI showing no drainable collection in the right hepatic lobe with wedge shaped areas of enhancements that were most compatible with resolving infection. Given these findings, she was continued for an additional 10 days of abx with Meropenem ending on ___. She was discharged from rehab at that point and has been at home with his daughter and husband. She also underwent an ERCP on ___BD stent was removed with residual mid-CBD stricture at the anastomosis with placement of a new stent. Plan for repeat ERCP in 8 weeks to reassess stricture. Patient notes that over the past 5 days, she has been feeling overall weakness with right lower quadrant abdominal pain. No nausea, vomiting, fever, RUQ pain, diarrhea, melena, hematochezia, cough, dyspnea, dysuria, headache/neck stiffness, changes in vision. Po intake remains same as usual. She intermittently falls asleep during the interview and states that this is similar to how she has been over the past 5 days. Notes that symptoms preceded stent replacement on ___ and has not changed since stopping antibiotics. In the ED initial vitals: T 97.1 HR 95 BP 153/78 RR 18 Sat 97% RA - Exam notable for: Lower abdominal tenderness - Labs notable for: WBC 4.1 H/H 10.8/31.4 Plt ___ -----------<255 4.9/19/1.2 CK 19 ALT 52 AST 45 AP 145 Tbili 1.2 Albumin 4.0 Lipase 21 INR 1.2 UA negative VBG 7.4/___ Lactate 1.4 Flu negative - Imaging notable for: CT abdomen/pelvis w/o contrast: 1. There is subtle hypo-attenuation of the periphery right hepatic lobe. Findings may represent known transplant rejection. Evaluation of the hepatic vasculature cannot be obtained on a noncontrast study. 2. Mild pneumobilia compatible with biliary stenting. 3. Moderate splenomegaly. 4. Small hiatal hernia. RUQUS w/ doppler 1. Patent hepatic vasculature with appropriate waveforms. 2. No focal liver lesions. 3. Mild pneumobilia. 4. Splenomegaly. Renal transplant u/s: Normal transplant u/s CXR: No acute findings EKG: NSR, rate 93, Q wave III-AVF, no changed from ___ - Consults: Transplant hepatology and renal consulted. - Patient was given: Tacro 3mg Mycophenolate 720mg 500ml LR REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS reviewed and negative. Past Medical History: PMH: - HCV and EtOH cirrhosis (s/p Harvoni) - CVA in ___, unclear if due to ?high altitude vs stroke (per daughter) - HTN - Gout PSH: - deceased donor liver and kidney transplant on ___ Social History: ___ Family History: Mother: died at ___ yo Father: died at ___ Children: alive and healthy Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 97.9 PO BP 143 / 89 HR 77 RR 16 ___ 95 RA GENERAL: NAD, lying in bed comfortably and dozing off intermittently through the interview, AOX3 and able to cite ___ backwards HEENT: EOMI, PERRL, anicteric sclera, MMM HEART: RRR, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably ABDOMEN: nondistended, well healed surgical scars, TTP in RLQ and suprapubic region no rebound/guarding EXTREMITIES: no ___ edema, warm/well perfused NEURO: A&Ox3, CN II- VII intact, ___ strength upper and Lower extremities, normal sensation, deferred gait assessment DISCHARGE EXAM: ___ 1203 Temp: 97.9 PO BP: 101/75 HR: 98 RR: 18 O2 sat: 96% O2 delivery: RA FSBG: 138 GENERAL: NAD, comfortable HEENT: EOMI, PERRL, anicteric sclera, MMM HEART: RRR, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably ABDOMEN: nondistended, well healed surgical scars EXTREMITIES: no ___ edema, warm/well perfused NEURO: A&Ox3, ___ strength upper and Lower extremities, normal sensation Pertinent Results: ADMISSION LABS: =============== ___ 06:15PM BLOOD WBC-4.1 RBC-3.29* Hgb-10.8* Hct-31.4* MCV-95 MCH-32.8* MCHC-34.4 RDW-13.5 RDWSD-47.1* Plt ___ ___ 06:15PM BLOOD Neuts-86.7* Lymphs-6.4* Monos-4.7* Eos-0.5* Baso-0.2 Im ___ AbsNeut-3.51 AbsLymp-0.26* AbsMono-0.19* AbsEos-0.02* AbsBaso-0.01 ___ 10:45AM BLOOD Poiklo-2+* Ovalocy-1+* Tear Dr-1+* RBC Mor-SLIDE REVI ___ 06:15PM BLOOD ___ PTT-22.6* ___ ___ 06:15PM BLOOD Plt ___ ___ 06:15PM BLOOD Glucose-255* UreaN-42* Creat-1.2* Na-136 K-4.9 Cl-103 HCO3-19* AnGap-14 ___ 06:15PM BLOOD ALT-52* AST-45* CK(CPK)-19* AlkPhos-145* TotBili-1.2 ___ 06:15PM BLOOD Lipase-21 ___ 06:15PM BLOOD Albumin-4.0 Calcium-9.8 Phos-3.0 Mg-1.6 ___ 10:45AM BLOOD Hapto-<10* ___ 06:56AM BLOOD %HbA1c-5.1 eAG-100 ___ 07:49AM BLOOD Osmolal-300 ___ 09:34AM BLOOD TSH-1.9 ___ 09:34AM BLOOD Free T4-1.0 ___ 06:02AM BLOOD Cortsol-<0.3* ___ 06:08AM BLOOD tacroFK-22.9* ___ 09:34AM BLOOD CMV VL-NOT DETECT ___ 08:25PM BLOOD ___ pO2-64* pCO2-36 pH-7.43 calTCO2-25 Base XS-0 ___ 06:25PM BLOOD Lactate-1.4 ___ 06:10PM URINE Color-Yellow Appear-Clear Sp ___ ___ 06:10PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-300* Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 06:10PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 ___ 09:29PM URINE Hours-RANDOM UreaN-634 Creat-45 Na-146 ___ 09:29PM URINE Osmolal-569 ___ 06:10PM URINE UCG-NEGATIVE ___ 08:10PM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE DISCHARGE LABS: =============== ___ 04:36AM BLOOD WBC-2.3* RBC-3.17* Hgb-10.3* Hct-29.5* MCV-93 MCH-32.5* MCHC-34.9 RDW-13.2 RDWSD-45.1 Plt Ct-99* ___ 04:36AM BLOOD Neuts-72.1* Lymphs-12.0* Monos-9.0 Eos-3.9 Baso-0.4 Im ___ AbsNeut-1.68 AbsLymp-0.28* AbsMono-0.21 AbsEos-0.09 AbsBaso-0.01 ___ 04:36AM BLOOD Plt Ct-99* ___ 04:36AM BLOOD Glucose-147* UreaN-18 Creat-0.8 Na-133* K-4.2 Cl-100 HCO3-19* AnGap-14 ___ 06:26AM BLOOD ALT-40 AST-34 AlkPhos-123* TotBili-0.8 ___ 04:36AM BLOOD Calcium-9.0 Phos-3.1 Mg-1.2* ___ 04:36AM BLOOD tacroFK-7.3 PERTINENT STUDIES: ================== Radiology Report CT ABD & PELVIS W/O CONTRAST Study Date of ___ 12:24 AM COMPARISON: CT abdomen and pelvis ___ FINDINGS: LOWER CHEST: There is mild bibasilar atelectasis. There is no evidence of pleural or pericardial effusion. ABDOMEN: HEPATOBILIARY: The transplant liver demonstrates subtle wedge-shaped hypoattenuation in the right hepatic lobe (02:20). There is no evidence of focal lesions within the limitations of an unenhanced scan. Re-demonstrated is mild pneumobilia likely secondary to biliary stent placement. There is no intrahepatic biliary ductal dilation. Cholecystectomy clips are noted. The gallbladder is within normal limits. PANCREAS: The pancreas has normal attenuation throughout, without evidence of focal lesions within the limitations of an unenhanced scan. There is no pancreatic ductal dilatation. There is no peripancreatic stranding. SPLEEN: The spleen is enlarged measuring 17.1 cm ADRENALS: The right and left adrenal glands are normal in size and shape. URINARY: The native kidneys are atrophic. The transplant kidney in the right lower quadrant appears unremarkable within the limits of a noncontrast study. There is no evidence of focal renal lesions within the limitations of an unenhanced scan. There is no hydronephrosis. There is no nephrolithiasis. There is no perinephric abnormality. GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops demonstrate normal caliber and wall thickness throughout. The colon and rectum are within normal limits. The appendix is normal. PELVIS: The urinary bladder and distal ureters are unremarkable. There is no free fluid in the pelvis. REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable. LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. VASCULAR: Extensive varices are again noted. There is no abdominal aortic aneurysm. Mild atherosclerotic disease is noted. BONES: Chronic left-sided rib fractures are noted. 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 subtle peripheral wedge-shaped hypoattenuation areas in the right hepatic lobe. Findings may represent transplant rejection. Correlation with liver function tests recommended. 2. Mild pneumobilia compatible with biliary stenting. 3. Moderate splenomegaly. 4. Small hiatal hernia. Radiology Report LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___ 11:46 ___ COMPARISON: None. FINDINGS: Liver echotexture: There is an ill-defined hypoechoic region in the right hepatic lobe also seen on CT from ___. There is no evidence of focal liver lesions or biliary dilatation. There is mild pneumobilia. CHD: 3 mm There is no ascites, right pleural effusion, or sub- or ___ fluid collections/hematomas. The spleen has normal echotexture. Spleen length: 15.4 cm DOPPLER: The main hepatic arterial waveform is within normal limits, with prompt systolic upstrokes and continuous antegrade diastolic flow. Peak systolic velocity in the main hepatic artery is 43.9 centimeters/second. Appropriate arterial waveforms are seen in the right hepatic artery and the left hepatic artery with resistive indices of 0.7, and 0.7, respectively. The main portal vein and the right and left portal veins are patent with hepatopetal flow and normal waveform. Appropriate flow is seen in the hepatic veins and the IVC. IMPRESSION: 1. Patent hepatic vasculature with appropriate waveforms. 2. Ill-defined hypoechoic region in the right hepatic lobe also seen on CT from ___. Correlation with liver function tests recommended. 3. Mild pneumobilia. 4. Splenomegaly. Radiology Report CHEST (PA & LAT) Study Date of ___ 8:18 ___ COMPARISON: Chest radiograph ___, CT chest ___ FINDINGS: Heart size is normal. The mediastinal and hilar contours are unchanged with a small hiatal hernia again noted. The pulmonary vasculature is normal. Lungs are clear. No pleural effusion or pneumothorax is seen. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary abnormality. Radiology Report RENAL TRANSPLANT U.S. Study Date of ___ 5:20 ___ COMPARISON: Renal transplant ultrasound from ___. FINDINGS: The right iliac fossa transplant renal morphology is normal. Specifically, the cortex is of normal thickness and echogenicity, pyramids are normal, there is no urothelial thickening, and renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of intrarenal arteries ranges from 0.5 to 0.7, within the normal range. The main renal artery shows a normal waveform, with prompt systolic upstroke and continuous antegrade diastolic flow, with peak systolic velocity of 67.3 cm per second. Vascularity is symmetric throughout transplant. The transplant renal vein is patent and shows normal waveform. IMPRESSION: Normal renal transplant ultrasound. MICROBIOLOGY: ============= __________________________________________________________ ___ 2:30 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 4:50 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 3:10 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. __________________________________________________________ ___ 10:12 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. Brief Hospital Course: ___ w/ PMH of hepatitis C and alcoholic cirrhosis with HRS now s/p liver-kidney transplant (___) complicated by moderate liver rejection (liver bx ___, presented with 5 days of generalized fatigue and RLQ abdominal pain, found to have supratherapeutic tacrolimus levels. ACTIVE ISSUES: ================ #Tacrolimus toxicity #Generalized fatigue #RLQ abdominal pain Presenting symptoms ultimately suspected ___ tacrolimus toxicity. Found to be supratherapeutic to 22.9. Infectious workup negative. Tacro was initially held then restarted at reduced dosing of 1.5mg Q12H. #Alcoholic cirrhosis s/p kidney-liver transplant #c/b acute moderate cellular rejection s/p ATG #CBD stricture s/p stent (most recent ___ #High level of DSA Continued home immunosuppressives and prophylaxis with adjustment of tacro dose as above, and discontinuation of fluconazole (had adequate course + reduce drug-drug interactions). Continued prednisone taper, decreased from 10mg to 7.5mg per schedule while inpatient. Will remain on 7.5mg until ___, then 5mg from ___ onward. ___ Likely related to tacro vs poor PO (pt was concerned about effects of tap water and didn't drink much), improved to baseline with dose reduction and IVF + bottled water. CHRONIC/STABLE ISSUES: ====================== #SIADH: Previously on salt tablets though appears plan was to hold at last admission. Na remained within normal during this admission, did not restart salt tablets. #Migraines: Continued home buproprion 150mg BID and home topiramate 25mg qhs. # Lower Back pain: Chronic back pain with h/o laminectomy. Continued tylenol PRN and lidocaine patch. # New Osteoporosis Osteoporosis on ___ DXA; new diagnosis for pt. Continued calcium and vitamin D 2000U daily. # Gout Continued home allopurinol ___ po daily. # GERD Continued home famotidine 2mg po daily # LLL nodule: ___ chest CT shows LLL pulm nodule increased in size 7x5mm c/f growing neoplasm. Seen by outpatient Thoracic Surgery on ___ at which time decision was made to monitor with close surveillance (non-con chest CT in 3 months), given pt is recovering from liver/renal transplant. Has f/u with Dr. ___ with a repeat chest CT in 3 months (___). If moving to ___ before then, will need new ___ MD. CORE MEASURES: ============== # CODE: Presumed FULL # CONTACT: ___ ___ TRANSITIONAL ISSUES: ==================== [ ] Tacrolimus dose now 1.5mg Q12H. [ ] Repeat ERCP in 8 weeks (from ___ when new stent was placed) to reassess stricture. [ ] Fluconazole discontinued as she had an adequate course and to reduce drug-drug interactions. [ ] Kayexalate held on admission, potassium levels remained normal, held on discharge, restart PRN. [ ] Start prednisone 5mg QD on ___ [ ] Chest CT on ___ for follow-up of growing LLL lung nodule noted on ___ CT. If moving to ___ before then, will need new ___ MD. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. BuPROPion 150 mg PO BID 3. Dapsone 100 mg PO DAILY 4. Docusate Sodium 100 mg PO DAILY 5. Famotidine 20 mg PO BID 6. Magnesium Oxide 400 mg PO TID 7. Mycophenolate Sodium ___ 720 mg PO BID 8. PredniSONE 20 mg PO DAILY 9. Senna 8.6 mg PO QHS 10. Sodium Chloride 1 gm PO DAILY 11. Topiramate (Topamax) 25 mg PO QHS 12. ValGANCIclovir 900 mg PO Q24H 13. biotin 5 mg oral DAILY 14. Multivitamins 1 TAB PO DAILY 15. Fluconazole 400 mg PO Q24H 16. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 17. Vitamin D ___ UNIT PO DAILY 18. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck 19. Tacrolimus 3 mg PO Q12H 20. TraZODone 50 mg PO QHS Discharge Medications: 1. PredniSONE 5 mg PO DAILY RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Tacrolimus 1.5 mg PO Q12H 3. Allopurinol ___ mg PO DAILY 4. biotin 5 mg oral DAILY 5. BuPROPion 150 mg PO BID 6. Dapsone 100 mg PO DAILY 7. Docusate Sodium 100 mg PO DAILY 8. Famotidine 20 mg PO BID 9. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck 10. Magnesium Oxide 400 mg PO TID 11. Multivitamins 1 TAB PO DAILY 12. Mycophenolate Sodium ___ 720 mg PO BID 13. Senna 8.6 mg PO QHS 14. Topiramate (Topamax) 25 mg PO QHS 15. TraZODone 50 mg PO QHS 16. ValGANCIclovir 900 mg PO Q24H 17. Vitamin D ___ UNIT PO DAILY 18. HELD- Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium This medication was held. Do not restart Sodium Polystyrene Sulfonate until you discuss with your doctor. Discharge Disposition: Home Discharge Diagnosis: Tacrolimus toxicity Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, It was a pleasure taking care of you at ___. Why you were in the hospital: -You felt abnormally tired and had abdominal pain. What was done for you in the hospital: -Your tacrolimus blood level was found to be too high and was likely the cause of your symptoms. We adjusted your tacrolimus dose. What you should do after you leave the hospital: - Please take your medications as detailed in the discharge papers. Important changes include a decrease of your tacrolimus to 1.5mg twice a day, and starting prednisone 5mg starting tomorrow (___). 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: ___
19957410-DS-17
19,957,410
24,167,166
DS
17
2169-03-17 00:00:00
2169-03-18 13:56:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Headache Major Surgical or Invasive Procedure: Cerebral angiogram ___ History of Present Illness: ___ is a ___ female with medical history notable for orthotopic liver transplant ___ and deceased donor renal transplant ___, c/b by moderate liver rejection status post 5-day course of IV ATG, and anastomotic stricture requiring CBD stent placement which was found to be inferiorly displaced, requiring subsequent repeat biliary stents x2 placement with replacement on ___. Patient had recent admission for fatigue and abdominal pain thought to be due to supratherapeutic tacrolimus, discharged ___, now being readmitted for headache, nausea, vomiting. Her headache has reportedly been ongoing for approximately 24 hours, worsening the last 12 hours. Is associated with nausea and vomiting. She did vomit her transfer medications 1 hour after taking them, although there were no noted pill fragments. She additionally in the last 12 hours has noted constant dizziness, with absence of visual symptoms. She has had a prior history of headaches, however this is substantially worse than any of her prior ones. Per family collateral, she has had headaches triggered by large meals. On arrival to the ED, her vitals were: T 96.6, HR 94, BP 125/81, RR 20, 100% room air ED exam notable for left torsional nystagmus on upward gaze. She initially had trouble keeping her eyes open for extraocular movements. Rest of her exam, including neuro exam was normal. Her labs are notable for tacrolimus level 7.1, serum sodium 130, negative urine and serum tox. CMV VL and serologies, HCV VL were drawn and pending at time of admission. In this setting, neurology, renal, transplant hepatology were consulted. Imaging was notable for: -CTA head and neck (prelim) without evidence of acute intracranial hemorrhage or large vascular territorial infarction. Distal right ACA 4 mm aneurysm is seen. -MRI head without contrast showing absence of acute infarction, hemorrhage, mass. Scattered white matter changes consistent with chronic micro-angiopathy. -PA and lateral chest x-ray without evidence of acute intrathoracic process -Right upper quadrant ultrasound with Dopplers demonstrating patent hepatic vasculature, as well as stable splenomegaly and mild pneumobilia. While in the ED patient received: -IV Zofran 4 mg x 1 -IV Reglan 10 mg x 1 -500 mL LR bolus followed by mIVF at 100cc/hr -IV Ativan 1mg x1 -Tacrolimus 1.5mg x2 -Mycophenolate sodium 720mg x2 -Valgancyclovir 900mg -Dapsone 100mg -Prednisone 5mg -Sumatriptan 25mg PO x1 10 point review of systems otherwise negative On arrival to the floor, patient states her HA has returned. Says it feels similar to prior with no clear trigger for her recurrence as she did not eat anything aside from cheerios in the ED. Associated with dizziness and nausea, has not vomited but feels like she might. She denied any recent f/c, cp, palpitations, SOB. No abdominal pain. Past Medical History: - HCV and EtOH cirrhosis (s/p Harvoni) c/b HRS s/p liver- kidney tx ___ - Liver transplant rejection (bx ___ s/p IV ATG - Liver anastomotic stricture s/p multiple stent (last ___ - Pyogenic liver abscess - SIADH - CVA in ___, unclear if due to ?high altitude vs stroke (per daughter) - HTN - Gout Social History: ___ Family History: Mother: died at ___ yo Father: died at ___ Children: alive and healthy Physical Exam: PHYSICAL EXAM: VS: 97.6 | 144/83 | 99 | 18, 100%ra GEN: Uncomfortable appearing, somewhat tearful. HEENT: PERRL, EOMI. Very mild scleral icterus. MMM. CV: RRR, +systolic murmur. no rubs or gallops. PULSES: 2+ in upper/lower extremities b/l RESP: CTAB, no w/r/r, no increased WOB ABD: S, NT, ND, BS+. well healed surgical scar in RUQ. EXT: No cyanosis, clubbing, edema. SKIN: WWP. No rashes. NEURO: AOx3. CN II-XII grossly intact. Face symmetric, speech non-dysarthric. Moving all four extremities with purpose. DISCHARGE PHYSICAL EXAM: GEN: NAD, appears comfortable HEENT: PERRL, EOMI. MMM. CV: RRR, +systolic murmur. no rubs or gallops. RESP: CTAB, no w/r/r, no increased WOB ABD: S, NT, ND, BS+. well healed surgical scar in RUQ. EXT: No cyanosis, clubbing, edema. SKIN: WWP. No rashes. NEURO: AOx3. CN II-XII grossly intact. Face symmetric, speech non-dysarthric. Moving all four extremities with purpose. Pertinent Results: ADMISSION LABS: ___ 06:00PM BLOOD WBC-3.3* RBC-3.61* Hgb-11.7 Hct-33.0* MCV-91 MCH-32.4* MCHC-35.5 RDW-13.4 RDWSD-44.4 Plt ___ ___ 06:00PM BLOOD Neuts-80.3* Lymphs-7.3* Monos-7.9 Eos-2.1 Baso-0.3 Im ___ AbsNeut-2.63 AbsLymp-0.24* AbsMono-0.26 AbsEos-0.07 AbsBaso-0.01 ___ 06:00PM BLOOD ___ PTT-25.0 ___ ___ 06:00PM BLOOD Glucose-128* UreaN-21* Creat-1.0 Na-130* K-4.0 Cl-97 HCO3-20* AnGap-13 ___ 06:00PM BLOOD ALT-73* AST-63* AlkPhos-114* TotBili-2.0* DirBili-0.4* IndBili-1.6 ___ 06:29AM BLOOD Albumin-3.8 Calcium-9.2 Phos-3.4 Mg-1.4* ___ 06:27AM BLOOD calTIBC-261 Hapto-<10* Ferritn-358* TRF-201 ___ 06:27AM BLOOD Osmolal-276 ___ 06:29AM BLOOD CMV IgG-POS* CMV IgM-NEG CMVI-Generally ___ 06:27AM BLOOD tacroFK-4.5* ___ 06:29AM BLOOD CMV VL-NOT DETECT DISCHARGE LABS: ___ 06:00AM BLOOD WBC-1.6* RBC-2.36* Hgb-7.6* Hct-22.0* MCV-93 MCH-32.2* MCHC-34.5 RDW-13.8 RDWSD-46.1 Plt Ct-89* ___ 06:00AM BLOOD Neuts-65.2 Lymphs-15.9* Monos-12.4 Eos-3.5 Baso-0.6 AbsNeut-1.11* AbsLymp-0.27* AbsMono-0.21 AbsEos-0.06 AbsBaso-0.01 ___ 06:00AM BLOOD Ret Aut-5.8* Abs Ret-0.15* ___ 06:00AM BLOOD Glucose-159* UreaN-12 Creat-0.9 Na-134* K-3.8 Cl-101 HCO3-24 AnGap-9* CTA HEAD NECK ___: 1. No evidence of infarction, hemorrhage or intracranial mass. 2. 4 mm left pericallosal artery aneurysm. 3. Otherwise patent cervical intracranial vasculature without evidence of dissection, stenosis or vessel occlusion. MR HEAD ___. No evidence of acute infarction, hemorrhage or intracranial mass. 2. Scattered white matter changes in the cerebral hemispheres bilaterally, likely sequela of chronic microangiopathy. ABD U/S ___. Patent hepatic vasculature with appropriate waveforms. 2. Stable splenomegaly and mild pneumobilia. MRCP ___. No liver abscess. 2. No new intrahepatic biliary duct dilatation in this patient with a metallic CBD stent. 3. Wedge shaped area of enhancement in the right liver lobe are unchanged. 4. Moderate splenomegaly and multiple varices are unchanged. MICRO: bcx, ucx: No growth to date Brief Hospital Course: ___ with PMHx hepatitis C and alcoholic cirrhosis complicated by hepatic nephropathy, ascites, esophageal varices, and acute renal failure s/p OLT ___ and DDRT ___ who presented to ED with migraine. ============= ACUTE ISSUES: ============= #Migraine Headache #Nausea/Vomiting Patient presented with acute, severe headache x24h associated with nausea and vomiting. CTA found 4mm ACA aneurysm, MRI imaging negative. Likely c/w migraine as she endorsed similar headaches in the past which were aborted with sumatriptan, stereotyped trigger (protein-rich meal), unilateral, debilitating, photophobia. Her HA was initially aborted by sumatriptan 25mg in the ED. This also resolved her nausea and she is tolerating po diet without vomiting. Her headache and nausea reoccurred on arrival to the floor but was aborted by IV benadryl and compazine. Increased Topamax to 50mg qhs for migraine ppx. While sumatriptan has a theoretical risk of cerebral aneurysm instability via it's vasoconstrictive effects, there is no great evidence behind this. Discussed with neurosurgery, who felt that it was safe to use sumatriptan as an abortive migraine medication. #4mm ACA aneurysm Seen on CTA head/neck. Seen by neurosurgery, who did diagnostic angiogram, which revealed similar aneurysm. No need for any intervention, plan for monitoring and follow up with neurosurgery. # Elevated LFTs, improved Patient had recent CBD stent displacement and subsequent replacement on ___, and recent admission for abdominal pain and fatigue. This prompted RUQUS which was performed in ED showing patent hepatic vasculature with appropriate waveforms, stable splenomegaly, and mild pneumobilia. No signs of congestion. No recent hypotensive episodes so unlikely ___ ischemia. Notably bilirubin elevation is primarily indirect. CMV VL neg. Had repeat MRCP which did revealed no liver abscess, no new intrahepatic biliary dilation, and ongoing wedge shaped area of enhancement in R liver lobe. #HCV, EtoH Cirrhosis s/p kidney-liver transplant #c/b acute moderate cellular rejection s/p ATG #CBD stricture s/p stent (most recent ___ #High level of DSA Adjusted tacrolimus dosing while inpatient. Tacro trough was low initially in the setting of vomiting up her immunosuppressive agents. Ultimately discharged on tacrolimus 2mg BID. Continued home mycophenolate 750mg BID, prednisone 5mg, dapsone, valganciclovir. #Concern for Hemolysis Hemolysis labs positive, though seem to have been so in a subacute manner. G6DP checked in ___ was normal. Smear reviewed by heme/onc. No schistocytes. Hgb is stable. Bilirubin improved without intervention. # Pancytopenia Presented with hgb 10.6 which is at baseline. Repeat iron studies consistent with inflammatory block. Likely also contribution from MMF and valganciclovir side effect. =============== CHRONIC ISSUES: =============== # Lower Back pain: - Continued Tylenol, lidocaine patch PRN #Hypomagnesemia - Continued Mg Oxide #Osteoporosis - Continued calcium and vitamin D # Gout - Continued home allopurinol ___ po daily. # GERD - Continued home famotidine 2mg po daily TRANSITIONAL ISSUES []discharge tacrolimus: 2mg BID []Increased Topiramate to 50mg qhs to help prevent migraines. []If issues with migraines, consider neurology headache referral. []Repeat ERCP on ___ (8 weeks from ___ when new stent was placed) to reassess stricture. [ ] Kayexalate held on admission, potassium levels remained normal, held on discharge, restart PRN. [ ] Chest CT on ___ for follow-up of growing LLL lung nodule noted on ___ CT. If moving to ___ before then, will need new ___ MD. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. BuPROPion 150 mg PO BID 3. Dapsone 100 mg PO DAILY 4. Docusate Sodium 100 mg PO DAILY 5. Famotidine 20 mg PO BID 6. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck 7. Magnesium Oxide 400 mg PO TID 8. Multivitamins 1 TAB PO DAILY 9. Mycophenolate Sodium ___ 720 mg PO BID 10. Senna 8.6 mg PO QHS 11. Topiramate (Topamax) 25 mg PO QHS 12. TraZODone 50 mg PO QHS 13. ValGANCIclovir 900 mg PO Q24H 14. Vitamin D ___ UNIT PO DAILY 15. biotin 5 mg oral DAILY 16. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 17. Tacrolimus 1.5 mg PO Q12H 18. PredniSONE 5 mg PO DAILY Discharge Medications: 1. Sumatriptan Succinate 25 mg PO DAILY:PRN migraine, take at first onset Please do not take more than ___ times a week. RX *sumatriptan succinate 25 mg 1 tablet(s) by mouth once a day Disp #*20 Tablet Refills:*0 2. Tacrolimus 2 mg PO Q12H 3. Topiramate (Topamax) 50 mg PO QHS RX *topiramate 50 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 4. Allopurinol ___ mg PO DAILY 5. biotin 5 mg oral DAILY 6. BuPROPion 150 mg PO BID 7. Dapsone 100 mg PO DAILY 8. Docusate Sodium 100 mg PO DAILY 9. Famotidine 20 mg PO BID 10. Lidocaine 5% Patch 1 PTCH TD QPM to L posterior neck 11. Magnesium Oxide 400 mg PO TID 12. Multivitamins 1 TAB PO DAILY 13. Mycophenolate Sodium ___ 720 mg PO BID 14. PredniSONE 5 mg PO DAILY 15. Senna 8.6 mg PO QHS 16. Sodium Polystyrene Sulfonate 15 gm PO DAILY:PRN elevated potassium 17. TraZODone 50 mg PO QHS RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 18. ValGANCIclovir 900 mg PO Q24H 19. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left pericallosal artery aneurysm Migraine 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 ___. Why ___ were admitted? - ___ were admitted because ___ were having a bad migraine. What we did for ___? - We gave ___ medication to treat your migraines - We adjusted some of your medications, which are detailed in your paperwork. - ___ were found to have a small aneurysm in a vessel in your brain. The neurosurgeons saw ___ and performed an angiogram. They will just continue to monitor this. What should ___ do when ___ leave the hospital? - Please take your medications as detailed in the discharge papers. If ___ 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 ___ do not hear from their office in ___ business days, please contact the office to schedule an appointment. - Please monitor for worsening symptoms. If ___ do not feel like ___ are getting better or have any other concerns, please call your doctor to discuss or return to the emergency room. Activity Instructions - ___ may gradually return to your normal activities, but we recommend ___ take it easy for the next ___ hours to avoid bleeding after your procedure - Heavy lifting, running, climbing, or other strenuous exercise should be avoided for ten (10) days. This is to prevent bleeding. - ___ 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. - ___ make take a shower. Post-Care of the Puncture Site - ___ 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. - ___ may use a band-aid if ___ wish. What ___ ___ Experience: - Mild tenderness and bruising at the puncture site - Soreness in your arms from the intravenous lines. - Mild to moderate headaches that last several days to a few weeks. - Fatigue is very normal We wish ___ the best, Your ___ team Followup Instructions: ___
19957626-DS-10
19,957,626
29,473,900
DS
10
2203-03-01 00:00:00
2203-03-02 08:37:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: nortriptyline / Percocet / Vicodin Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: UGI swallow study: WNL History of Present Illness: Ms ___ is a ___ s/p placement laparoscopic adjustable gastric band in ___, s/p lap cholecystectomy ___ presenting with severe epigastric abd pain twice in the past 72 hours. Patient reports that for the past 6 months she has had this abdominal pain in the epigastric region. It is a nearly constant ___ pain that radiates to her back and behind her sternum. At times it feels as though food is stuck behind her sternum, which is related to the pain previously. Nothing else makes it worse, but she induces vomiting to make it better. The pain was not associated with eating and awoke her from sleep. She has no odynophagia. She called ___, went to ___ and had negative cardiac and abd pain workup, which did not include CT scan but did include abdominal ultrasound, diagnosed with epigastric abd pain and discharged with Ativan. Patient went home, but woke up with same squeezing epigastric pain. The pains go into her back between her shoulder blades and behind her sternum. She took 3 tums and 2 tablets of Valium and fell back to sleep. It is associated with nausea, but no change in bowel function. Past Medical History: 1. hypertension 2. gastroesophageal reflux/chemical gastritis and ___ esophagus (EGD ___ was negative for ___ 3. asthma 4. sleep-disordered breathing (since ___, on CPAP) 5. osteoarthritis 6. back pain 7. hyperlipidemia 8. nephrolithiasis 9. fatty liver (on ultrasound) 10. hip bursitis 11. migraine headaches 12. fibroids Past Surgical History: 1. spinal fusion of cervical vertebrae (___) lower vertebrae (___) 2. right elbow surgery (___) 3. left shoulder surgery (___) Social History: ___ Family History: Father (deceased, ___) - tuberculosis Mother (living, ___) - cancer, arthritis and diabetes Sister (living) - obesity Another sister (living, ___) - arthritis Son (living, ___) - asthma, obesity and hyperlipidemia Daughter - obesity s/p lap band and lap band removal Physical Exam: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft, nondistended, mild tenderness on deep palpation over the epigastrium, no rebound or guarding, no palpable masses, no CVA tenderness Ext: No ___ edema, ___ warm and well perfused, 2+ DP pulses Pertinent Results: ___ 03:30PM GLUCOSE-85 UREA N-15 CREAT-0.8 SODIUM-140 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-28 ANION GAP-15 ___ 03:30PM ALT(SGPT)-23 AST(SGOT)-23 ALK PHOS-103 TOT BILI-0.4 ___ 03:30PM cTropnT-<0.01 Brief Hospital Course: Patient presented with the complaint of worsening epigastric pain. On admission, a cardiac ischemia was ruled out, in addition to an intrabdominal process with a Abc CT with Contrast. An UGI swallow study was performed to evaluate the esopagus, GE junction, and stomach given the patient's previous band procedure. The patient had experienced a significant symptomatic improvement on IV Protonix, and after throughly discussing with the patient her lab and imaging results, she was comfortable being discharged home. We explained the importance of presenting to the ER if Danger signs occur, such as fever, N/V or recurrence of her pain. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Amiloride-hydrochlorothiazide, atorvastatin, Diltiazem, Prozac, Vitamin D, Multivitamin Discharge Medications: 1. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Gastritis, acid reflux Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call your surgeon or return to the emergency department if you develop a fever greater than 101.5, chest pain, shortness of breath, severe abdominal pain, pain unrelieved by your pain medication, severe nausea or vomiting, severe abdominal bloating, inability to eat or drink, foul smelling or colorful drainage from your incisions, redness or swelling around your incisions, or any other symptoms which are concerning to you. You will be taking protonix. This medicine prevents gastric reflux. Followup Instructions: ___
19957675-DS-9
19,957,675
25,518,836
DS
9
2123-10-08 00:00:00
2123-10-08 18:04:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fevers Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a pleasant ___ w/ HTN, DL and newly dx Mantle Cell Lymphoma s/p 6 cycles of R-bendamustine [C6 ___ who p/w fever and malaise. His symptoms started after receiving his last dose of Rituximab on ___ and Bendamustine ___. He felt a bit more tired than usual after this chemo, taking taking more naps more often. He had a second opinion at ___ four days ago and his VS were WNL there. Yesterday his temp at home rose from 98 to 100.6 to 102.0F. Apart from generalized malaise, he does not have any localizing symptoms. He had some URI symptoms but those resolved and were attributed to be more allergic. He had some transient irregularity of his bowel movements but this was not entirely unexpected from the chemo and today he had a "swell" movement, describing it as "nice and compact." What he did notice 4 days ago was that he couldn't get his watch on because of a "hot bulge." He spoke with his outpatient providers several times and agreed to present to the ED. In ED, T ___, HR 84, 121/49, 98% RA. US revealed superficial clot of left cephalic vein. CXR neg for infection. Was empirically started on Vanc and Cefepime. Past Medical History: - HTN - HLD - Eczema - partial colonic resection for pre-malignant polyps - nonmelenoma skin cancer of the forehead Social History: ___ Family History: - Father died of MI at age ___. - Mother died at age ___. Had Parkinsons and bladder cancer. - Brother with lymphoma at age ___. Physical Exam: ADMISSION PHYSICAL EXAM: General: NAD, Resting in bed comfortably VITAL SIGNS: ___ 149/78 98 18 9% RA HEENT: MM dry, no OP lesions, no cervical/supraclavicular adenopathy CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND LIMBS: WWP, no ___, no tremors, slight bulge of left wrist SKIN: No rashes on the extremities, dry skin NEURO: Grossly normal DISCHARGE PHYSICAL EXAM: VITAL SIGNS: 97.6 (Tmax 99.7 at 11:30 on ___ 122/58 97 18 98% RA General: NAD, sitting in chair, comfortable HEENT: MMM, some petechaie on palate and buccal mucosa, no active bleeding CV: RR, NL S1S2 no S3S4 No MRG PULM: CTAB, No C/W/R, No respiratory distress ABD: BS+, soft, NTND LIMBS: WWP, no ___, slight bulge of left wrist, not warm or erythematous SKIN: No rashes on the extremities NEURO: Grossly normal Pertinent Results: ADMISSION LABS: ___ 10:20PM BLOOD WBC-2.1* RBC-2.71* Hgb-8.7* Hct-24.5* MCV-90 MCH-32.1* MCHC-35.5 RDW-15.5 RDWSD-50.2* Plt Ct-66* ___ 10:20PM BLOOD Neuts-71.5* Lymphs-18.4* Monos-7.2 Eos-1.4 Baso-0.5 Im ___ AbsNeut-1.48* AbsLymp-0.38* AbsMono-0.15* AbsEos-0.03* AbsBaso-0.01 ___ 10:20PM BLOOD Glucose-124* UreaN-13 Creat-1.1 Na-132* K-4.0 Cl-100 HCO3-20* AnGap-16 ___ 10:20PM BLOOD Albumin-3.6 Calcium-8.3* Phos-1.9* Mg-1.8 ___ 10:20PM BLOOD ALT-47* AST-49* AlkPhos-152* TotBili-0.8 ___ 10:23PM BLOOD Lactate-1.3 DISCHARGE LABS: ___ 08:05AM BLOOD WBC-5.2# RBC-2.83* Hgb-9.1* Hct-25.9* MCV-92 MCH-32.2* MCHC-35.1 RDW-15.5 RDWSD-51.4* Plt Ct-62* ___ 08:05AM BLOOD Neuts-80* Bands-9* Lymphs-9* Monos-2* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-4.63 AbsLymp-0.47* AbsMono-0.10* AbsEos-0.00* AbsBaso-0.00* ___ 03:05PM BLOOD Glucose-117* UreaN-14 Creat-1.1 Na-128* K-4.0 Cl-99 HCO3-23 AnGap-10 ___ 03:05PM BLOOD Calcium-8.2* Phos-1.8* Mg-1.9 ___ 08:05AM BLOOD ALT-43* AST-31 LD(LDH)-272* AlkPhos-152* TotBili-1.0 IMAGING: Forearm Xray (___): FINDINGS: No fracture is detected in the radius or ulna. The proximal or distal radioulnar joints are congruent. Mild degenerative changes at the first MTP identified. There is soft tissue swelling. Limited assessment of the elbow and wrist joint is grossly unremarkable. IMPRESSION: No evidence of fracture. Soft tissue swelling Chest X ray PA and Lat (___): FINDINGS: Lung volumes are low, but lungs are otherwise clear without focal consolidation, pleural effusion, or pneumothorax. Cardiomediastinal and hilar contours are unremarkable. IMPRESSION: No acute cardiopulmonary process. Unilateral Lft upper ext US ___: IMPRESSION: 1. Occlusive thrombus in the left cephalic vein from the level of the wrist, extending proximally to the level of the elbow. The cephalic vein was not identified proximally in the upper arm. 2. No evidence of deep venous thrombosis in the left internal jugular, left brachial, and left basilic veins. MICROBIOLOGY: URINE CULTURE (Final ___: <10,000 organisms/ml. BLOOD CULTURE ___ x2: NGTD Brief Hospital Course: ___ is a ___ year old man with HTN, HLD and Mantle Cell Lymphoma who presented C6 D19 of R-bendamustine with fever. #Fever. Mr. ___ reported a temperature measured at home on ___ of 102. He was not neutropenic (WBC 2.1, ANC 1.48) and had no localizing symptoms except for rhinorrhea that he attributed to allergies (improved with cetirizine). His UA was bland and UC was negative. He had a chest X ray that was negative for infiltrates. Blood cultures showed no growth for 72 hours. He has aluminum staples in his gut from a prior partial colon resection, but otherwise has no foreign bodies. He also has a history of EBV viremia but < 200 copies EBV detected in blood. He was given vancomycin and cefepime on admission, but the vancomycin was discontinued the morning after admission as he had been afebrile had no lines. Cefepime was continued for 24 hours and then transitioned to PO ciprofloxacin for 24 hours. Cipro was discontinued on discharge. He was afebrile for the entirety of his hospital stay. #Cephalic Vein Thrombus. Mr. ___ reported a tender swelling in his left wrist and was found to have a superficial vein thrombus of the left cephalic vein by ultrasound. This was treated with warm compresses and was improving at discharge. #Mantle Cell Lymphoma. On admission, Mr. ___ was C6 D19 of R-Bendamustine. He was receiving acyclovir prophylaxis. #Anemia and thrombocytopenia. Chemotherapy induced, continued to downtrend as expected during admission. #Transaminitis. Mr. ___ had a mildly elevated ALT/AST on admission. Simvastatin was held and repeat liver enzymes in the morning had normalized so simvastatin was restarted with no further abnormality in liver enzymes. Transitional issues: -Mr. ___ was hyponatremic during this admission (Na 128 on the day of discharge). This was thought to be hypovolemic, due to poor PO intake. He was given 500 cc NS. Please check electrolytes at his next appointment. -Mr. ___ received 1 dose of 480 mcg Filgrastim on ___ due to ANC 1.04 (WBC 1.4). He had a robust response with ANC 4.63 (WBC 5.2) so was not given an additional dose. Please follow his CBC/diff and assess his need for additional doses of Filgrastim. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Cetirizine 10 mg PO DAILY Allergies 2. Acyclovir 400 mg PO Q8H Shingles ppx 3. Enalapril Maleate 5 mg PO QHS HTN 4. simvastatin 20 mg oral QHS HLD Discharge Medications: 1. Acyclovir 400 mg PO Q8H Shingles ppx 2. Cetirizine 10 mg PO DAILY Allergies 3. Enalapril Maleate 5 mg PO QHS HTN 4. simvastatin 20 mg oral QHS HLD Discharge Disposition: Home Discharge Diagnosis: Fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you while you were in the hospital at ___. You came in because you were having fevers. Due to the chemotherapy you are receiving for your lymphoma, your body has more difficulty fighting off infections so we gave you antibiotics and tested you for common sources of infection. We did not find a source of infection. We stopped the very broad IV antibiotics and switched you to an antibiotic that comes in pill form (called ciprofloxacin). You did not have any fevers for 24 hours after this change was made and were generally feeling better and more energetic, so you were discharged. You do not need to take antibiotics once you leave the hospital. You should continue to take the medications you were taking at home. You also had a swelling in your left wrist. We did an ultrasound of your arm and found that you have a blood clot in one of the superficial veins of your arm. This was improving by applying hot compresses. You should continue to do this at home as long as the swelling bothers you. You should follow up at all appointments as scheduled. We wish you all the best in the future. Sincerely, Your ___ team Followup Instructions: ___
19957730-DS-10
19,957,730
23,135,742
DS
10
2135-10-03 00:00:00
2135-10-03 17:03:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Back pain Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ with extensive cardiac history including nonischemic cardiomyopathy (EF 20% in ___, severe MR, Afib on coumadin, Stage III-IV CKD, DERD, lupus who presents today with ongoing back pain and acute on chronic renal failure. . Patient reports having back pain over last 3 weeks. While she denies recent trauma or falls, she was recently admitted for falls. Describes pain in lower back involving her right buttock. Denies any radiation to her legs. While denies any urinary retention or bowel incontinence, patinet has experienced urinary incontinence which she attributes to diuretic use. Denies numbness/weakness in ___. No fevers, chills, or night sweats. Has had lower back pain in past however this is far worse. Was prescribed tramadol for pain however caused her be nauseous so stopped taking it. Denies NSAID use. Given ongoing pain, patient presented initially to OSH for evaluation. . With regards to renal failure, patient has known about her kidney disease for several years. Denies confusion or changes in sleep cycle. Has had nausea however attributed to tramadol use. Also having generalized pruritis. Denies any dysuria/hematuria. No change in urine color or quantity. No NSAID use. No diarrhea or vomiting. Of note patient reports a dry weight in 110s (lbs). . At OSH, patient was noted to have acute on chronic renal failure and was sent to ___ for further treatment. In ___ ED, initial VS were 97.6 86 105/60 16 97%RA. Initial evaluation showed Cr 2.7, BUN 115, INR 4.1, and WBC 3.5. CXR showed enlarged heart with mild pleural effusion on right with increased vascular markings (similar to prior study). Cardiology was notified who felt that she was compensated from a cardiac perspective and advised medicine admission. While in ED, patient had episode of subjected SOB and was placed on 2L NC. There was no evidence of hypoxia. VS prior to transfer were 80, RR: 18, BP: 104/67, Rhythm: Paced Rhythm, O2Sat: 97, O2Flow: 2l, Pain: ___. . Currently, patient appeared comfortable and in no acute distress. She stated that her pain had completely resolved after receiving tylenol #3 at OSH. . REVIEW OF SYSTEMS: 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: PACING/ICD: S/P BiV AICD for nonsustained V-tach in ___ Nonischemic Cardiomyopathy (EF 20% ___ Severe MR- Severe Pulmonary HTN, PA pressure 60mm Hg Chronic Afib on coumadin CKD Stage III-IV, baseline creatinine 1.6 to 1.8 Discoid Lupus GERD Osteoarthritis Macular Degeneration S/P Tubal Ligation Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM VS - Temp 98.3F, BP 98/64, HR 84, R 20, O2-sat 100% 2LNC 85% RA, Wt 53.5kg GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, dry MM, OP clear NECK - Supple, no thyromegaly, distended neck veins, no carotid bruits HEART - PMI non-displaced, RRR, nl S1-S2, II/VI systolic mumur LUNGS - CTAB, decreased breath sounds at right base with overlying crackles to ___ up posterior lung fields, resp unlabored, no accessory muscle use ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no edema, 2+ peripheral pulses BACK: no CVAT, no paraspinal muscle tenderness, skin excoriated SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, no asterixis DISCHARGE PHYSICAL EXAM VS - Tc 97.3F, Tm 98.3F, BP 123/71 (89-123/54-71), HR 88 (77-88), R 18, O2-sat 98% 2LNC GENERAL - Alert, interactive, well-appearing in NAD HEENT - PERRLA, EOMI, sclerae anicteric, dry MM, OP clear NECK - JVD to the angle of the mandible HEART - Irreg, irreg, S3+, no murmurs auscultated LUNGS - Decreased breath sounds at bilateral bases, R>L, no rales, wheezes ABDOMEN - NABS, soft/NT/ND, no masses or HSM EXTREMITIES - WWP, no edema, 2+ peripheral pulses BACK: Multiple ecchymoses along her back that are non-tender, non-blanching, no paraspinal muscle tenderness, and no bony tenderness NEURO - awake, alert, appropriately interactive, asterixis noted. Pertinent Results: ADMISSION LABS ___ 08:05PM BLOOD WBC-3.6* RBC-4.20 Hgb-12.7 Hct-40.7 MCV-97 MCH-30.3 MCHC-31.3 RDW-17.1* Plt ___ ___ 08:05PM BLOOD Neuts-75.7* Lymphs-17.5* Monos-5.0 Eos-0.6 Baso-1.2 ___ 08:05PM BLOOD ___ PTT-40.0* ___ ___ 08:05PM BLOOD Glucose-107* UreaN-115* Creat-2.7* Na-134 K-4.2 Cl-95* HCO3-23 AnGap-20 ___ 08:05PM BLOOD ALT-30 AST-47* CK(CPK)-98 AlkPhos-145* TotBili-1.2 ___ 05:45AM BLOOD Calcium-8.6 Phos-5.3* Mg-2.4 ___ 05:45AM BLOOD Osmolal-314* ___ 08:05PM BLOOD Digoxin-1.1 DISCHARGE LABS ___ 05:45AM BLOOD WBC-4.3 RBC-4.15* Hgb-13.1 Hct-41.8 MCV-101* MCH-31.6 MCHC-31.3 RDW-18.0* Plt ___ ___ 05:45AM BLOOD ___ PTT-38.6* ___ ___ 05:45AM BLOOD Glucose-100 UreaN-90* Creat-1.9* Na-138 K-3.9 Cl-98 HCO3-29 AnGap-15 ___ 05:45AM BLOOD ALT-33 AST-44* AlkPhos-136* TotBili-1.5 ___ 05:45AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.4 ___ 05:45AM BLOOD Digoxin-0.9 IMAGING ___ ECG: Localized baseline artifact. Prolonged Q-T interval. A-V sequential pacing with two non-paced QRS complexes of different morphology. Paced QRS complexes have an unusual right axis deviation and right bundle-branch block pattern suggesting biventricular pacing. Compared to the previous tracing of ___, ventricular ectopy is of one similar and one different morphology. Configuration of the paced QRS complexes is unchanged after accounting for differences in left precordial electrode placement. ___ CHEST (PA & LAT): The cardiomediastinal and hilar contours are stable, with mild cardiomegaly. Again seen are moderate-sized pleural effusions bilaterally, with associated bibasilar atelectasis, unchanged since the prior study. No evidence of pulmonary edema. No pneumothorax is detected. A left-sided AICD device is seen with the leads in the expected position of the right atrium and right ventricle. Moderate bibasilar effusions, not significantly changed since the earlier study of ___. ___ RENAL U.S.: The right kidney measures approximately 8.8 cm. The left kidney measures approximately 8.9 cm. Cortical echogenicity appears mildly echogenic. There is no hydronephrosis or nephrolithiasis. There are bilateral simple renal cysts. In the superior pole of the right kidney, a 2-cm simple cyst is present, predominantly exophytic. In the interpolar region of the left kidney, there is an 8-mm exophytic simple cyst. The bladder is incompletely distended but grossly unremarkable. Incidental note is made of bilateral right greater than left pleural effusions, seen on recent chest x-ray. Brief Hospital Course: ___ with extensive cardiac history including nonischemic cardiomyopathy (EF 20% in ___, severe MR, Afib on coumadin, Stage III-IV CKD, DERD, lupus who presents today with ongoing back pain and acute on chronic renal failure. ACUTE ISSUES # Acute on chronic renal failure: Likely pre-renal in etiology, as metolazone was added 6 weeks ago (despite stable creatinine up until now - may have had some inciting event such as decreased PO intake though pt does not report this), since she is clinically appeared dry, and so the metolazone was held during the hospitalization and discontinued upon discharge. Of note, pt received 700cc ___ at the OSH and BUN/Cr ratio also suggests pre-renal physiology, though FeUrea is > 35%. However, unclear if there could be a contribution of cardiorenal syndrome (given EF of 20%) as pt made good urine in response to the diuretics, indicating a possible role of congestive nephropathy. Renal ultrasound was without hydronephrosis, though showed small kidneys with mildly echogenic cortices. Pt's losartan was also held during the admission, given the increased creatinine. Pt's creatinine decreased down to 1.9, which is near pt's baseline, and was discharged on her home torsemide dose of 60mg daily and her home spironolactone dose of 25mg daily (though pt did not receive spironolactone on the day of day of discharge as this medication was held at the time) as her only diuretics. She will follow-up in the heart failure clinic on ___ with ___ ___. Her BUN/creatinine will be checked tomorrow, ___, by her ___ service, with the results faxed to Dr. ___ ___. # Chronic Systolic Heart Failure: Pt is followed closely by ___ clinic at ___, and her last EF was 20% in ___. She had a recent addition of metolazone in late ___ (see above) which may have contributed to her hypovolemic picture upon admission. Her metolazone was held, though her torsemide was continued. Pt did not receive spironolactone on the day of day of discharge as this medication was held at the time, but was restarted upon discharge. Digoxin levels were adequate. She was also continued on her home digoxin, lopressor, simvastatin, but her losartan was held, given the increase in creatinine. Her losartan was continued upon discharge. Her weight was 53.5kg upon admission, though not documented upon discharge. # Back pain: Unclear in etiology, though likely muscular. Hip and spine films done at the OSH were negative for fracture. Pt reports a history of a fall preceding the back pain (though at times her story shifts to falling after the back pain started). Pain significantly improved after tylenol #3 administration at the OSH. Pt had no neuro deficits, and her CK was normal. She worked with physical therapy succesfully and had good pain relief by the time of discharge. She was sent home with a hard-copy prescription of a one-week supply of Tylenol #3 to take as needed for pain relief. ___ pharmacy was called with this new prescription and a copy of it was faxed to them. They were verbally instructed to discontinue the Ultracet prescription the pt had on file, as the Tylenol #3 prescription will replace that one. The pt was educated that should she need more pain medication after one week's time, to get in touch with her PCP for further evaluation. # Hypoxia: Likely related to fluid in her lungs. She worked with physical therapy early and had good urine output to the administered diuretics. She weaned off oxygen without incident and was 97% on RA upon discharge. CHRONIC ISSUES # Afib: On coumadin 1.5mg daily at home, but was supratherapeutic to 4.1 upon admission, and so her coumadin was held throughout the hospitalization. On the day of discharge (___), her INR was 2.8, and so her home dose of coumadin 1.5mg daily was resumed and she was given a dose in the hospital prior to discharge. She will have her INR checked by her ___ services tomorrow, ___, with the results faxed to Dr. ___ who follows her INR. She was also continued on rate control with her home Lopressor. # Discoid Lupus: Pt takes Plaquenil at home, but this was held during the hospitalization, as the pt reports she can only take the brand name which ___ does not carry. The pt will resume this medication upon discharge. # Insomnia: The pt was continued on her home temazepam, and slept well throughout the hospitalization. # GERD: The pt was continued on zantac, but at 300mg once daily (renally dosed), but given that her creatinine came down to near her baseline, she was continued on her home dose 300mg twice daily upon discharge. TRANSITIONAL ISSUES # Recommend re-checking pt's INR and BUN/Cr at her follow-up visits with appropriate adjustments in her Coumadin and diuretic dosing, respectively. # Recommend follow-up of patient's back pain. Medications on Admission: - Potassium chloride 20mEq daily - Melatonin - Zinc plus protein - Metolazone 2.5mg ___ and ___ - Spironolactone 25mg daily - Lopressor 25mg daily - Digoxin 0.0625mg daily - Simvastatin 10mg HS - Coumadin - Plaquenil 200mg daily - Calcium/vitamin D - Losartan 25mg daily - Synthroid 25mcg daily - Zantac 300mg BID - Torsemide 60mg daily - Folic acid 1mg daily - Colace 100mg BID - Temazepam 7.5mg daily Discharge Medications: 1. potassium chloride 20 mEq Packet Sig: One (1) Packet PO once a day. 2. Lopressor 50 mg Tablet Sig: 0.5 Tablet PO once a day. 3. digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. simvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 5. Plaquenil 200 mg Tablet Sig: One (1) Tablet PO once a day. 6. losartan 25 mg Tablet Sig: One (1) Tablet PO once a day. 7. levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO twice a day. 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. temazepam 15 mg Capsule Sig: 0.5 Capsule PO HS (at bedtime). 12. melatonin Oral 13. Tylenol-Codeine #3 300-30 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*28 Tablet(s)* Refills:*0* 14. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 15. warfarin 1 mg Tablet Sig: 1.5 Tablets PO Once Daily at 4 ___. 16. spironolactone 25 mg Tablet Sig: One (1) Tablet PO once a day. 17. Zinc plus protein 18. Calcium/vitamin D Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis Acute on chronic kidney injury Secondary Diagnosis Chronic systolic heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospital stay at ___. You were admitted because you were found to have kidney dysfunction when being evaluated for your back pain. X-rays were done at the outside hospital of your hip and lower back, which were not concerning for fracture. Your pain was relieved with pain medication. However, it was found that your kidneys were not functioning at their baseline. You may have been too dry, and so your metolazone was held during this admission, and your kidney function improved. Please note the following changes to your medications. Please START taking: 1. Tylenol with Codeine (Tylenol #3) as needed for your back pain Please STOP taking: 1. Metolazone Weigh yourself every morning, and call your MD if your weight goes up more than 3 lbs. Followup Instructions: ___
19957730-DS-11
19,957,730
26,550,638
DS
11
2135-10-14 00:00:00
2135-10-14 19:21:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Tetracycline / Sulfa (Sulfonamide Antibiotics) Attending: ___ Chief Complaint: Weight Gain, Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ with extensive cardiac history including nonischemic cardiomyopathy (EF 20% in ___, severe MR, Afib on coumadin, Stage III-IV CKD, GERD, lupus who presents with shorntess of breath. . Of note she was recently admitted for back pain and acute on chronic renal insufficiency. The etiology of her acute kidney injury was felt to be be in the setting of recent initiation of metolazone for managment of her heart failure. A renal ultrasound did not demonstrated evidence of hydronephrosis. Her ___ was briefly held and she was discharged on her home dose of torsemide and spironolactone w/ heart failure clinic f/u. The etiology of her back pain remained unclear on discharge. Hip and spine films done at the OSH were negative for fracture. She was discharged w/ a 1 week supply of tylenol #3. . Since discharge, she has felt progressively short of breath w/ gradual onset. Her ___ spoke w/ cardiology clinic and reported increase in weight from 119 to 123 lbs. She was given a single dose of metolazone on ___ in addition to her torsemide. She reports using 2 pillow per night at baseline w/out increase. She walks w/ a walker and lives in assisted living w/ her husband. She uses O2 as needed at home. She denies associated chest pain, in her chest, neck, arm, jaw or back. She ___ cough, fevers, chills, nausea, emesis, abdominal pain or diarrhea. She reports her symptoms are similar to prior episodes of CHF. She further denies lower extremity swelling. . In the ED, initial vitals were 98.8 90 105/69 18 99% 4L. Inital labs were significant for creatinine 2.0 (baseline), troponin 0.05 (baseline), BNP 7626, Ddimer < 150, lactate 2.2 and INR of 3.3. A chest xray demonstrated a slight increase in bibasilar effusions, left greater than right when compared to more recent film on ___. The patient was not given any medications. She was admitted to the ___ team for management of an acute exacerbation of CHF. Vitals on transfer were 97.3, 84, 95/71, 22, on 3L nasal cannula. . . On arrival to the floor, patient 97.7 100/63 84 22 97RA. She is comortable and accompanied by her husband and son. . REVIEW OF SYSTEMS On review of systems, she denies any prior history of myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She 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, paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: Severe MR Nonischemic Cardiomyopathy (EF 20% ___ Chronic Afib on coumadin -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: S/P BiV AICD for nonsustained V-tach in ___ 3. OTHER PAST MEDICAL HISTORY: Severe Pulmonary HTN, PA pressure 60mm Hg CKD Stage III-IV, baseline creatinine 1.6 to 1.8 Discoid Lupus GERD Osteoarthritis Macular Degeneration S/P Tubal Ligation Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: 97.7 100/63 84 22 97RA GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: irregular normal S1, S2. systolic murmur right sternal border, faint heart sounds LUNGS: Poor air movement, w/ crackles up bilateral lung fields and decreased at the bilateral lung bases. Significant bruising on her back which she reports is ___ to pruritis that is a chronic issues. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: 1+ pitting edema to the knee caps, faint DPs SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. DISCHARGE EXAM: BP 100s/50-60s, HR 80-90, not hypoxic on room air Gen: somewhat tired, but AOx3, responds to questions appropriately, NAD Heart: irregular, ___ holosystolic murmur at apex with radiation to axilla Lungs: crackles L>R, mild dullness at bases Ext: trace edema Pertinent Results: ADMISSION LABS: ___ 03:00PM BLOOD WBC-3.5* RBC-4.31 Hgb-13.4 Hct-42.4 MCV-99* MCH-31.2 MCHC-31.7 RDW-17.1* Plt ___ ___ 03:00PM BLOOD Neuts-72.0* ___ Monos-6.4 Eos-0.7 Baso-1.0 ___ 03:00PM BLOOD ___ PTT-40.3* ___ ___ 03:00PM BLOOD Glucose-106* UreaN-73* Creat-2.0* Na-137 K-4.0 Cl-95* HCO3-30 AnGap-16 ___ 03:00PM BLOOD CK-MB-8 proBNP-7626* ___ 06:25AM BLOOD Calcium-9.6 Phos-5.3*# Mg-2.3 ___ 06:00AM BLOOD Digoxin-1.0 ___ 04:16PM BLOOD D-Dimer-<150 ___ 03:11PM BLOOD Lactate-2.1* DISCHARGE LABS ___ 07:38AM BLOOD WBC-4.2 RBC-4.41 Hgb-13.7 Hct-43.8 MCV-99* MCH-31.1 MCHC-31.3 RDW-17.2* Plt ___ ___ 04:42PM BLOOD ___ ___ 07:38AM BLOOD Glucose-88 UreaN-97* Creat-2.3* Na-136 K-4.5 Cl-94* HCO3-28 AnGap-19 =============== EKG: A-V sequentially paced rhythm with capture, as well as frequent ventricular ectopy. Compared to the previous tracing of ___ no diagnostic interim change. =============== CXR: IMPRESSION: Slight increase in bibasilar effusions, left greater than right, compared to study on ___. =============== TTE: The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (LVEF = ___ %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. The right ventricular cavity is dilated with severe global free wall hypokinesis. There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of ___, no clear change. Brief Hospital Course: This is a ___ yo F with an extensive cardiac history including nonischemic cardiomyopathy (EF ___ in ___ with ICD for Vtach, severe MR/TR, A-fib on coumadin, Stage III-IV CKD, GERD, and lupus who presents with shortness of breath and weight gain. . 1. Acute Decompensation of Systolic Congestive Heart Failure: On TTE, the patient has severe global left ventricular hypokinesis (LVEF = 10%) with moderate to severe MR ___ TR. ___ is s/p BiV AICD for nonsustained V-tach in ___. She is managed closely in the outpatient setting by ___, NP, w/ frequent teleheath and infusions of furosemide. The patient presented with subjective dyspnea, however, she only had mild crackles on exam and was never hypoxic. Her BNP was not significantly elevated from her baseline and her weight was slightly increased. The patient was given IV lasix in addition to her torsemide. She did not diurese to this and her creatinine began to rise. Her case was discussed with her outpatient cardiologist, Dr. ___ thought that home hospice was the best option. The patient had her ICD switched off prior to discharge. She will continue her torsemide 40mg Qday for comfort with PRN dosing based on her symptoms. She will also continue her metoprolol to prevent palpitations. . 2. Goals of Care: The patient was DNR/DNI in the hospital. After discussions with the patient and the family, the goals of care changed to comfort after multiple recent hospitalizations without much improvement. The patient had her ICD turned off. She was discharged on medications that the patient and her family wanted to continue. She will not continue coumadin. Hospice will assume care on discharge. Medications on Admission: - Potassium chloride 20 mEq daily - Lopressor 25 mg daily - Digoxin 62.5 mcg daily - Simvastatin 10 mg HS - Plaquenil 200 mg daily - Losartan 25 mg daily - Levothyroxine 25 mcg daily - Ranitidine HCl 300 mg BID - Folic acid 1 mg daily - Docusate sodium 100 mg BID - Temazepam 7.5 mg HS - Melatonin Oral - Tylenol-Codeine #3 300-30 mg Q6H:PRN pain - Torsemide 60 mg daily - Warfarin 1.5 mg daily - Spironolactone 25 mg daily - Zinc plus protein - Calcium/vitamin D Discharge Medications: 1. torsemide 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*2* 2. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. torsemide 20 mg Tablet Sig: ___ Tablets PO once a day as needed for SOB, weight gain. 4. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 5. clonazepam 0.25 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO twice a day. Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*2* 7. melatonin 1 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 9. Zinc-15 66 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: NYHA class IV heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with shortness of breath and weight gain concerning for an exacerbation of your heart failure. While you were here, we gave you some extra diuretics, but their effects were minimal and limited by your kidney function. After discussion with you, your family, and Dr. ___, ___ decided that the best place for you to be was at home with services to keep you comfortable. You will be discharged with home hospice care. Your updated medication list will be given to the hospice agency prior to your discharge. Followup Instructions: ___
19957847-DS-20
19,957,847
25,782,996
DS
20
2146-04-08 00:00:00
2146-04-08 16:44:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Status epilepticus Major Surgical or Invasive Procedure: None History of Present Illness: Per Dr. ___ is a ___ man with seizure with self stopped AED (unknown) and heavy alcohol use, TBI, cerebral aneurysm s/p intervention with residual cognitive dysfunction who presents for status epilepticus. Per OSH records, pt has been drinking every day and last drink was 2 days ago. He has a history of prior alcohol withdrawal seizures. He is also supposed to be on an AED (unknown) for a seizure disorder. Last known well was in the morning, daughter reported that he was feeling symptoms of withdrawal and went to the store to get him some soup. A neighbor later found him outside on the porch seizing with unclear duration. EMS was called and arrived about 10 minutes later, FSBG 166. Received 10mg valium without effect. On arrival to OSH, BP 141/80, HR 174, RR 48, T 105.5F rectal, 98% RA. Had an abrasion to the left forehead and right gaze deviation, pupils dilated and minimally reactive. Lactate was greater than 20, Na 153, Cr 1.62, AST 155 ALT 90. Ethanol level 11, trop normal. There, he received total of 24mg Ativan and 1g keppra and was intubated with rocuronium and etomidate and started on propofol. Temperature improved to normothermia with cooling blankets and NS. Started on empiric antibiotics for meningitis given elevated temperature and seizure. He continued to seizure despite the Ativan and keppra so was loaded with phenobarb (20mg/kg). He then stopped seizing." Past Medical History: PMH/PSH: TBI, seizure disorder, ETOH use/withdrawal seizures Social History: ___ Family History: FAMILY HISTORY: unknown Physical Exam: Admission Exam: PHYSICAL EXAMINATION General: intubated, sedated, examined off propofol HEENT: abrasion on forehead, intubated ___: RRR, no M/R/G Pulmonary: coarse breath sounds Abdomen: Soft, NT, ND, +BS, no guarding Extremities: Warm, no edema Neurologic Examination: - Mental status: intubated, examined off propofol, does not follow commands - Cranial Nerves: pinpoint pupils that are minimally reactive, difficult to assess facial symmetry given placement of ETT - Sensorimotor: Normal bulk, decreased tone. Does not withdraw to noxious in all 4 extremities - Reflexes: 2+ in bilateral biceps and brachioradialis, 0 in bilateral quads, toes mute bilaterally - Coordination: unable to assess - Gait: unable to assess Discharge Exam: Neurologic: -Mental Status: Alert, oriented x ___. Able to name ___ backward with 1 mistake. Language is fluent. Normal prosody. Pt was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes with prompt. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 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: mild intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. wide-based. Unable to walk in tandem. Pertinent Results: OSH LP (___) WBC 21-->3 (tube 1 --> tube 3) RBC 8850 -->113 -> 8850 PMN 93% --> 3% Lymph 4% --> 0% Protein 62 Glc 100 Imaging: EEG ___ IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of abundant left frontotemporal and frequent independent right frontotemporal epileptiform discharges. These findings are indicative of potentially epileptogenic foci independently in both frontal regions. Background activity is slow and disorganized, indicative of moderate to severe diffuse cerebral dysfunction, which is nonspecific as to etiology. No electrographic seizures are present. Compared to the prior day's recording, there is no significant change. MRI C spine ___ IMPRESSION: No evidence of ligamentous or bony injury. Mild degenerative changes without high-grade spinal stenosis or foraminal narrowing. MRI head ___ IMPRESSION: 1.No evidence of acute hemorrhage or infarction. No mass or mass effect. 2.Scattered foci of increased susceptibility artifact on gradient echo images in the cerebrum, cerebellum, right thalamus, and pons are consistent with micro hemorrhages likely from hypertension. 3.Moderate white matter microvascular ischemic change including scattered chronic lacunar infarcts in the basal ganglia and thalami. 4.Global atrophy is advanced for age. Brief Hospital Course: #Status Epilepticus: Patient was transferred from OSH following status epilepticus in setting of stopping drinking alcohol 2 days prior to onset of seizure. Patient arrived to ___ intubated and sedated. She was hemodynamically stable, vitals ___ showed multiple white matter hypodensities that was nonspecific. Etiology was likely EtOH withdrawal given history of recently stopping drinking and time course, versus primary seizure disorder (though patient had not been compliant with taking medications). LP was performed at OSH (WBC 21>3, RBC 8850>113; lymph 4%>0%; protein 62; glucose 100). CSF culture was followed and remained negative, HSV-1 CSF PCR negative. Patient was started on continuous EEG monitoring on arrival. As patient received Keppra 1g at OSH, he was continued on Keppra 1g BID (dosed for renal function). Patient was started on Phenobarbital protocol for alcohol withdrawal. He was also started initially on Vancomycin, Ceftriaxone, Ampicillin and Acyclovir for meningoencephalitis empiric treatment. These were discontinued once culture data and HSV-1 PCR returned negative. Patient was maintained goal SBP <160 and monitored with q2h neuro checks. Upon discharge his keppra was increased to 1250mg with outpatient follow up to monitor his keppra level and serum creatinine. On EEG monitoring, he did have frequent epileptiform activity, but no electrographic seizures. EEG was discontinued on ___. Patient was maintained on Keppra 100omg BID while in house and transferred to floor. #Acute Kidney Injury: Patient presented with Cr elevation to 1.8, with no known history of CKD. This was likely secondary to rhabdomyolysis versus ATN in setting of status epilepticus. Creatinine peak was 3.1, but patient maintained adequate urine output throughout ICU course. Patient was given aggressive IVF (normal saline and daily IV folic acid/MV/thiamine), medications were renally dosed, and creatinine was trended daily. Creatinine was gradually downtrending after these interventions. # Rhabdomyolysis: Presented with elevated CPK, peak of 4,900, likely secondary to seizure and immobility post-ictally. Patient was given aggressive IVF as above and creatinine gradually downtrended to 1100 on ___, at which point CK checks were discontinued. #Agitation:Patient noted to be intermittently agitated thorughout admission. Started on pyridoxine to ameliorate the effect that keppra might contirbute to his labile mood. In additon patient was started on seroquel 12.5mg BID. Patient was evaluated by Physical Therapy who recommended home with services. Pt was discharged in stable condition with neurology clinic outpatient follow up and instructions to make an appointment with his PCP for ___ hospital follow up. *Of note, patient was discharged with the following labs pending:Send Outs ___ 16:15 ANAPLASMA PHAGOCYTOPHILUM (HUMAN GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Rosuvastatin Calcium 40 mg PO QPM 4. Donepezil 10 mg PO QHS 5. Hydrochlorothiazide 25 mg PO DAILY 6. LevETIRAcetam 1500 mg PO BID 7. Vitamin D 1000 UNIT PO DAILY Discharge Medications: 1. CloNIDine 0.1 mg PO TID RX *clonidine HCl [Catapres] 0.1 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*1 2. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 4. Labetalol 400 mg PO TID RX *labetalol 200 mg 2 tablet(s) by mouth three times a day Disp #*180 Tablet Refills:*1 5. LevETIRAcetam 250 mg PO BID RX *levetiracetam 250 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 6. Multivitamins 1 TAB PO DAILY RX *multivitamin [Chewable-Vite] 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*1 7. Pyridoxine 100 mg PO BID RX *pyridoxine (vitamin B6) 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 8. QUEtiapine Fumarate 12.5 mg PO BID RX *quetiapine 25 mg 1 tablet(s) by mouth daily Disp #*60 Tablet Refills:*1 9. Senna 8.6 mg PO BID RX *sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tab by mouth daily Disp #*30 Tablet Refills:*0 10. Thiamine 100 mg PO DAILY RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*2 11. LevETIRAcetam 1250 mg PO BID RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 12. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 13. Vitamin D 1000 UNIT PO DAILY RX *ergocalciferol (vitamin D2) 2,000 unit 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 14. HELD- Donepezil 10 mg PO QHS This medication was held. Do not restart Donepezil until until patient has follow up with PCP 15. HELD- Hydrochlorothiazide 25 mg PO DAILY This medication was held. Do not restart Hydrochlorothiazide until until sCr normalized 16. HELD- Rosuvastatin Calcium 40 mg PO QPM This medication was held. Do not restart Rosuvastatin Calcium until patient had outpatient follow up and CK normalized Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Status Epilepticus secondary to medication non compliance and abrupt etoh cessation. 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. ___ you were admitted to ___ for status epilepticus which was most likely triggered by recent abrupt etoh cessation and not taking Keppra. Your EEG did show epileptiform discharges but no seizure activity. You received Keppra 1000 mg BID while at ___ which is still lower than your regular home dose, because of transient kidney injury that is the result of your prolonged seizure. Your kidney injury improved and ****** You also received phenobarbital to reduce the effects of alcohol withdrawal. You improved clinically and were deemed stable for discharge to a rehab facility. Followup Instructions: ___
19957862-DS-20
19,957,862
23,350,408
DS
20
2208-11-17 00:00:00
2208-11-20 19:35:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain, nausea, vomiting, diarrhea Major Surgical or Invasive Procedure: ___: Exploratory Laparotomy, small bowel resection History of Present Illness: ___ w/ no significant PMH who p/w abd pain, n/v, and diarrhea for 1 day. She describes sudden onset of sharp abd pain around 4 ___ yesterday coupled with nausea and nonbloody, nonbilious emesis and nonbloody diarrhea. Ms. ___ reports that had some tomatoes and vegetables but does not believe she ate anything to cause these symptoms. She has never had any abdominal pain of this intensity before. At bedside, Ms. ___ is uncomfortable. She reports diffuse abd pain that radiates to her right shoulder and lower abdomen. Notably, she is also febrile in the ED to 101.2. The patient denies SOB, chest pain, hematochezia, or any neurological Sx Past Medical History: PMH: osteoporosis PSH: none Social History: ___ Family History: Mother with diverticulitis Physical Exam: Admission Physical Exam: T 101.2 HR 84 BP 110/55 RR14 93% RA Gen: Alert, oriented, in moderate distress HEENT: EOMI, no palpable LAD CV: RRR Resp: CTAB, no inc WOB Abd: Firm, mildly distended, diffusely tender. Rebound tenderness and guarding. peritonitic. Extrem: no c/c/e Neuro: Grossly intact Psyc: Appropriate mood/affect Discharge Physical Exam: VS: GEN: HEENT: CV: PULM: ABD: EXT: Pertinent Results: IMAGING: ___: CXR: Minimal ground-glass opacification at the left lower lung base is likely compatible with atelectasis, however infection cannot be excluded in the appropriate clinical setting. ___: CT Abdomen/Pelvis: 1. Findings are compatible with perforated small bowel diverticulitis. 2. Bilateral renal cysts and additional hypodense lesions that are indeterminate or too small to characterize. 3. Moderate-sized hiatal hernia. 4. Colonic diverticulosis without evidence of diverticulitis. LABS: ___ 05:41PM POTASSIUM-3.5 ___ 05:41PM MAGNESIUM-1.3* ___ 05:41PM HCT-31.7* ___ 11:20AM LACTATE-2.0 ___ 11:12AM ___ PTT-27.5 ___ ___ 06:23AM LACTATE-2.2* ___ 03:45AM LACTATE-2.6* ___ 10:50PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 10:50PM URINE RBC-2 WBC-2 BACTERIA-FEW* YEAST-NONE EPI-3 ___ 10:50PM URINE MUCOUS-FEW* ___ 10:46PM LACTATE-1.5 ___ 10:40PM GLUCOSE-181* UREA N-10 CREAT-0.6 SODIUM-143 POTASSIUM-3.8 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15 ___ 10:40PM ALT(SGPT)-11 AST(SGOT)-16 ALK PHOS-75 TOT BILI-0.6 ___ 10:40PM LIPASE-16 ___ 10:40PM cTropnT-<0.01 ___ 10:40PM ALBUMIN-4.0 CALCIUM-9.0 PHOSPHATE-3.8 MAGNESIUM-1.6 ___ 10:40PM WBC-11.2* RBC-4.92 HGB-11.7 HCT-38.0 MCV-77* MCH-23.8* MCHC-30.8* RDW-14.9 RDWSD-41.2 ___ 10:40PM NEUTS-91.5* LYMPHS-3.9* MONOS-4.0* EOS-0.0* BASOS-0.2 IM ___ AbsNeut-10.21* AbsLymp-0.43* AbsMono-0.45 AbsEos-0.00* AbsBaso-0.02 ___ 10:40PM PLT COUNT-232 Brief Hospital Course: Ms. ___ is a ___ w/ no significant PMH who presented to ___ with abdominal pain, n/v/d, febrile in the ED to 101.2. CT Abdomen/Pelvis revealed perforated small bowel diverticulitis, with multiple nearby locules of free intraperitoneal air. The patient was consented for surgery and she underwent exploratory laparotomy and small bowel resection. This procedure went well (reader, please refer to operative note for further details). In the PACU, she received a fluid bolus for soft blood pressure and low urine output. After remaining hemodynamically stable, she was transferred to the surgical floor. She was NPO, on IVF and received IV acetaminophen and morphine for pain control. The nasal cannula oxygen was titrated down with time until she was stable on room air and autodiuresing. On POD #4, the patient had flatus and loose bowel movements and she was advanced to a clear liquid diet. On POD #5, she was advanced to a regular diet which she tolerated. 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: ALENDRONATE - alendronate 70 mg tablet. TAKE 1 TAB BY MOUTH WEEKLY IN THE MORNING, DO NOT EAT,DRINK,OR LIE DOWN FOR ___ MINS AFTER TAKING CITALOPRAM - citalopram 20 mg tablet. 1 tablet(s) by mouth once a day ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000 unit capsule. TAKE 1 CAPSULE BY MOUTH MONTHLY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Citalopram 20 mg PO DAILY 3. Ibuprofen 400 mg PO Q8H:PRN back pain Take with food. 4. Vitamin D ___ UNIT PO 2X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: Perforated distal ileum perforation 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 a perforation of a diverticulum (intestinal wall pouch) in your small bowel. You were taken to the operating room and underwent exploratory laparotomy and removal of the affected portion of your small bowel. This procedure went well. The affected portion of intestine was submitted to the Pathology department and the results, at this time, are still pending and will be discussed with you at your Acute Care Surgery clinic follow-up appointment. Followup Instructions: ___
19958279-DS-13
19,958,279
27,775,101
DS
13
2177-12-08 00:00:00
2177-12-08 19:42:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: codeine / Lipitor Attending: ___ Chief Complaint: Subdural hematoma Major Surgical or Invasive Procedure: ___ - Left mini craniotomy for evacuation of Subdural Hematoma. History of Present Illness: ___ is a ___ year old female s/p fall on ___ and ___ with head strike and no LOC. Since then she has felt "off". She c/o RLE weakness and unsteady gait. She presented to ___ where ___ MRI revealed left mixed density SDH with 7mm shift. She denies HA, N/V, dizziness, or visual changes. The patient was admitted to the ___ for close monitoring. Past Medical History: PMHx: high cholesterol Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: O: T: 98.2 BP: 137/77 HR:66 R:16 O2Sats:98 RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___ EOMs: intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Proximal RLE IP/Ham/Quad 4+/5, otherwise ___ throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right ___ 2 2 Left ___ 2 2 Toes downgoing bilaterally. Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin. PHYSICAL EXAMINATION ON DISCHARGE: The patient is awake, alert, and cooperative with the exam. She is oriented to self, location, and date. PERRL ___, EOMI. ___, no pronator drift. She moves all extremities with ___ strength and sensation is intact to light touch. Incision is clean, dry, and intact with staples and sutures. Pertinent Results: Please see OMR for pertinent lab and imaging results. Brief Hospital Course: #Left Subdural Hematoma: The patient was admitted to the ___ from the ED with a left mixed density subdural hematoma on ___. She was taken to the operating room later that day for a left craniotomy for evacuation of the subdural. A subdural drain was in place. She tolerated the procedure well. For further procedure details, please see separately dictated operative report by Dr. ___. She was extubated in the OR and transported to the PACU for recovery and later returned to the ___ for close neurological monitoring. On ___, she was neurologically intact and underwent a routine post-operative head CT which showed expected post-operative changes. On ___, subdural drain was removed without difficulty. On ___, she remained neurologically intact. Her pain was well controlled on oral medications. She was tolerating a diet and ambulating independently. Her vital signs were stable and she was afebrile. She was discharged home with outpatient physical therapy. #Urinary tract infection The patient was febrile to 101.2 and urinalysis was concerning for UTI. She was started on a 7 day course of ciprofloxacin. Medications on Admission: Medications prior to admission: simvastatin 20 mg tablet oral 1 tablet(s) Once Daily ranitidine 150 mg tablet oral 1 tablet(s) Twice Daily Claritin 10 mg tablet oral 1 tablet(s) Once Daily Children's Flonase Allergy Relief 50 mcg/actuation nasal spray,susp nasal 1 spray,suspension(s) Once Daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN fever or pain 2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days Take until prescription is gone RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth two times daily Disp #*10 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. LevETIRAcetam 1000 mg PO Q12H RX *levetiracetam 1,000 mg 1 tablet(s) by mouth two times daily Disp #*9 Tablet Refills:*0 6. Senna 17.2 mg PO QHS 7. Simvastatin 20 mg PO QPM 8.Outpatient Physical Therapy Diagnosis: Subdural hematoma Prognosis: Good Length of need: 13 months Discharge Disposition: Home Discharge Diagnosis: Subdural Hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Brain Hemorrhage with Surgery Surgery •You underwent a surgery called a craniotomy to have blood removed from your brain. •Please keep your sutures and staples along your incision dry until they are removed. •It is best to keep your incision open to air but it is ok to cover it when outside. •Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you are NOT allowed to drive by law. •No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •You may have difficulty paying attention, concentrating, and remembering new information. •Emotional and/or behavioral difficulties are common. •Feeling more tired, restlessness, irritability, and mood swings are also common. •You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. •You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: •Headache is one of the most common symptoms after a brain bleed. •Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. •Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. •There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit. •Nausea and/or vomiting. •Extreme sleepiness and not being able to stay awake. •Severe headaches not relieved by pain relievers. •Seizures. •Any new problems with your vision or ability to speak. •Weakness or changes in sensation in your face, arms, or leg. Call ___ and go to the nearest Emergency Room if you experience any of the following: •Sudden numbness or weakness in the face, arm, or leg. •Sudden confusion or trouble speaking or understanding. •Sudden trouble walking, dizziness, or loss of balance or coordination. •Sudden severe headaches with no known reason. Followup Instructions: ___
19958337-DS-15
19,958,337
24,150,470
DS
15
2152-10-31 00:00:00
2152-11-02 16:29:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: adhesive tape Attending: ___ Chief Complaint: fever Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p Cesarean total abdominal hysterectomy for placenta percreta complicated by massive hemorrhage, cystotomy, and left ureteral transection on ___, post operative course notable for ICU stay, placement of left percutaneous nephrostomy tube, and diagnosis of multiple pulmonary emboli and pulmonary infarction. Patient is presenting to ED with fever of 102 at home this morning. She has some left flank discomfort associated with PCN that is unchanged over the past 1 week. She has some abdominal discomfort with bowel movements associated with constipation but otherwise has no abdominal pain. The urine in her PCN bag has looked more cloudy than usual. Denies nausea/vomiting/vaginal bleeding/vaginal discharge. Past Medical History: PMH:multiple pulmonary emboli/pulmonary infarct diagnosed post operatively, placenta percreta PSH: (1) Cesarean total abdominal hysterectomy, ligation of right hypogastric artery, complex cystorrhaphy, ligation of left ureter, placement of L ureteral catheter, abdominal packing (2) Placement of left PCN tube (3) Exploratory laparotomy, unpacking of abdomen, exploration and ligation of left ureter, removal of left ureteral catheter. C/S x 2. POBHx: -LTCS for breech -repeat LTCS for arrest of dilation -SAB x2 -ceserean-hysterectomy as above Social History: ___ Family History: noncontributory Physical Exam: On day of discharge: afebrile, vital signs stable Gen: NAD Abd: soft, NT, ND, well healed inc. No R/G Back: PCN site c/d/i, non tender ___: nontender, no edema Pertinent Results: ___ 05:15AM BLOOD WBC-4.9 RBC-3.42* Hgb-11.0* Hct-32.9* MCV-96 MCH-32.2* MCHC-33.5 RDW-14.2 Plt ___ ___ 07:12AM BLOOD WBC-7.0 RBC-3.19* Hgb-10.2* Hct-30.6* MCV-96 MCH-31.9 MCHC-33.2 RDW-14.3 Plt ___ ___ 07:35AM BLOOD WBC-6.4 RBC-3.18* Hgb-10.1* Hct-30.4* MCV-96 MCH-31.6 MCHC-33.0 RDW-14.9 Plt ___ ___ 12:30PM BLOOD WBC-9.2 RBC-3.81*# Hgb-12.1# Hct-35.6* MCV-94 MCH-31.7 MCHC-33.9 RDW-13.9 Plt ___ ___ 05:15AM BLOOD Neuts-53.6 ___ Monos-8.5 Eos-2.3 Baso-0.5 ___ 07:12AM BLOOD Neuts-66.0 ___ Monos-9.2 Eos-1.2 Baso-0.8 ___ 07:35AM BLOOD Neuts-73.7* ___ Monos-7.3 Eos-0.5 Baso-0.3 ___ 12:30PM BLOOD Neuts-80.6* Lymphs-13.9* Monos-4.6 Eos-0.2 Baso-0.6 ___ 07:35AM BLOOD ___ PTT-40.0* ___ ___ 09:30PM BLOOD ___ PTT-47.1* ___ ___ 07:35AM BLOOD ___ 09:30PM BLOOD ___:15AM BLOOD Glucose-85 UreaN-9 Creat-0.5 Na-142 K-3.5 Cl-105 HCO3-26 AnGap-15 ___ 07:12AM BLOOD Glucose-97 UreaN-5* Creat-0.6 Na-137 K-3.0* Cl-103 HCO3-26 AnGap-11 ___ 07:35AM BLOOD Glucose-108* UreaN-7 Creat-0.6 Na-140 K-3.2* Cl-107 HCO3-27 AnGap-9 ___ 12:30PM BLOOD Glucose-92 UreaN-10 Creat-0.6 Na-139 K-3.6 Cl-101 HCO3-26 AnGap-16 ___ 12:30PM BLOOD Lipase-23 ___ 05:15AM BLOOD Calcium-8.9 Phos-4.2 Mg-2.2 ___ 07:12AM BLOOD Calcium-8.3* Phos-3.4 Mg-1.7 ___ 07:35AM BLOOD Calcium-8.1* Phos-2.6*# Mg-1.6 ___ 12:30PM BLOOD Calcium-8.9 Phos-4.2 Mg-2.0 ___ 01:46PM BLOOD Lactate-1.5 ___ 01:02PM BLOOD Lactate-1.3 Brief Hospital Course: Ms. ___ was readmitted with fever secondary to complicated pyelonephritis in the setting of indwelling percutaneous nephrostomy tubes. There was initially concern for possible pelvic abscess on CT scan, however on ultrasound the pelvic collection was consistent with post-operative changes and pelvic abscess was ruled out. She given IV cipro/flagyl until 24 hours afebrile. Urine culture was consistent with enterococcus from the clean voidspecimen and gram negative rods from the percutaneous nephrostomy tube. ID was consulted for choice of oral antibiotics who recommended po ciprofloxacin and amoxicillin. Throughout the course of her hospital stay she was continued on therapeutic lovenox for her previously diagnosed bialteral pulmonary embolisms. On HD#4 she was felt to be safe for discharge to home and was discharged with a course of oral antibiotics and outpatient follow up scheduled. Medications on Admission: lovenox Discharge Medications: 1. Amoxicillin 500 mg PO TID RX *amoxicillin 500 mg 1 tablet(s) by mouth three times a day Disp #*63 Capsule Refills:*0 2. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*42 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID 4. Acetaminophen ___ mg PO Q6H:PRN pain 5. Enoxaparin Sodium 80 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 6. Polysaccharide Iron (polysaccharide iron complex) 150 mg iron ORAL BID 7. Lorazepam 0.5 mg PO ONCE MR1 anxiety Duration: 1 Dose Take 30 min prior to ultrasound. RX *lorazepam 0.5 mg ___ tablet(s) by mouth once Disp #*2 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: urinary tract infection, likely pyelonephritis 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 oncology with fever and found to have an infection of your urine. You have recovered well and are stable for discharge home. Please follow the instructions below. * 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. * You may eat a regular diet. To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
19958492-DS-9
19,958,492
24,369,516
DS
9
2134-11-16 00:00:00
2134-11-16 17:13:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Macrodantin Attending: ___. Chief Complaint: weakness and gait instability Major Surgical or Invasive Procedure: Liver biopsy ___ with interventional radiology History of Present Illness: ___ with a history of hemorrhagic stroke (right parieto-temporal ___, hypertension, and obesity who presents with progressively worsening generalized weakness. On ___, she was in a motor vehicle accident. The airbag did not deploy. She did not go to the hospital for evaluation. On ___, she went to ___ and was noted to be talking in a nonsensical fashion and fall in her hotel room. She was taken to the emergency department where she was diagnosed with dehydration and was given IV fluids. A CT scan was negative. Upon return to the ___ on ___, she felt unwell but attributed this to jetlag. Since then, the patient has had worsening weakness, increased sleep, shakiness, and problems with balance. She now requires assistance from her husband to ambulate. Her bilateral hand tremors have also worsened to the point where her writing is illegible this week. She endorses decreased intake of both food and water, stating that food just does not taste good to her anymore. She denies myalgias, nausea, vomiting, odynophagia, diarrhea, dysuria, chest pain. She denies shortness of breath but states that she is so weak she needs to rest in between activities. She has also had a nonproductive cough that is new as of this week. No incontinence or urinary retention. - In the ED, initial vitals were: T 96.7F HR 79 BP 114/52 RR 18 O2 100% RA - Exam was notable for: "Heart: Systolic murmur, chronic Neuro: Mild tongue protrusion to right, other cranial nerves intact, sensation intact, strength 5 out of 5 in upper extremities bilaterally, strength 4 out of 5 in lower extremities bilaterally, left ankle unable to plantarflex due to ankle fusion, truncal weakness, unsteady gait, no pronator drift" - Labs were notable for: WBC 9.6 Hgb 12 with MCV of 100* Plt 246 BMP unremarkable ALT 19 AST 77* Alk phos 670* T bili 1.5 Alb 3.4 Trop <0.01 Lactate 2.0 UA normal - Studies were notable for: CT head without contrast 1. No acute intracranial abnormality. 2. Sinus disease and chronic changes as above. Liver US 1. Innumerable, rounded lesions scattered throughout the liver measuring up to 2.8 cm, new from prior study dated ___ and suspicious for metastatic disease. Correlate for history of primary malignancy. 2. Splenomegaly measuring 13.9 cm. 3. Heterogeneous lesion at the splenic hilum measuring 3.3 cm is incompletely characterized but may represent an accessory spleen. - The patient was given: 1L NS - Neurology were consulted: Felt most likely recrudescence of prior stroke in setting of toxic/metabolic derangements. Trend exam. No further neuroimaging. Neurology consult team to follow. On arrival to the floor, the patient reports not feeling normal since returning from ___. By far the worse symptom is her leg weakness, which makes it difficult for her to stand. At baseline, she was fully independent. She also notes a bilateral tremor. She notes some abdominal fullness and a lack of appetite. She denies any headaches, vision changes, nausea/vomiting, abdominal pain, chest pain, shortness of breath, changes in the caliber in her stool, diarrhea, or bloody stools. REVIEW OF SYSTEMS: ================== Per HPI, otherwise, 10-point review of systems was within normal limits. Past Medical History: Depression Hypertension Hypertriglyceridemia Interstitial cystitis Mitral regurgitation Obesity Seasonal allergies Vaginal prolapse Cervicalgia BPPV GERD Adrenal angiomyolipoma Social History: ___ Family History: Mother with breast cancer. Father with myocardial infarction. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 98.9F BP 148/83 RR 18 GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. Soft systolic murmur. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. ABDOMEN: Normal bowels sounds, non distended, mildly tender in RUQ and LUQ. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. Strength ___ apart from interphalangeals, which are ___. Stands with narrow gait, unbalanced. Action tremor. No dysdiadochokinesis. DISCHARGE PHYSICAL EXAM: ======================== VITALS: 24 HR Data (last updated ___ @ 732) Temp: 98.2 (Tm 98.5), BP: 123/72 (101-133/59-80), HR: 76 (66-82), RR: 16 (___), O2 sat: 91% (91-97), O2 delivery: Ra GENERAL: awake and alert, in no acute distress HEENT: SC/AT, sclera anicteric and without injection PATIENT DECLINED REMAINDER OF EXAM Pertinent Results: ADMISSION LABS ========================== ___ 08:55AM GLUCOSE-111* UREA N-18 CREAT-1.0 SODIUM-144 POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-25 ANION GAP-12 ___ 08:55AM ALT(SGPT)-18 AST(SGOT)-76* LD(LDH)-458* ALK PHOS-618* TOT BILI-1.4 ___ 08:55AM CALCIUM-9.8 PHOSPHATE-2.3* MAGNESIUM-2.0 URIC ACID-2.8 ___ 08:55AM WBC-9.8 RBC-3.45* HGB-11.4 HCT-34.8 MCV-101* MCH-33.0* MCHC-32.8 RDW-14.2 RDWSD-52.5* ___ 08:55AM PLT COUNT-227 ___ 08:55AM ___ PTT-26.1 ___ ___ 08:55AM ___ 02:29PM URINE HOURS-RANDOM ___ 02:29PM URINE UHOLD-HOLD ___ 02:29PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:29PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-MOD* ___ 02:29PM URINE RBC-0 WBC-2 BACTERIA-FEW* YEAST-NONE EPI-2 RENAL EPI-<1 ___ 02:29PM URINE MUCOUS-RARE* ___ 01:13PM LACTATE-2.0 ___ 12:48PM GLUCOSE-90 UREA N-22* CREAT-1.0 SODIUM-140 POTASSIUM-4.4 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14 ___ 12:48PM estGFR-Using this ___ 12:48PM ALT(SGPT)-19 AST(SGOT)-77* ALK PHOS-670* TOT BILI-1.5 ___ 12:48PM GGT-896* ___ 12:48PM cTropnT-<0.01 ___ 12:48PM ALBUMIN-3.4* CALCIUM-10.1 PHOSPHATE-2.7 MAGNESIUM-2.0 ___ 12:48PM TSH-2.1 ___ 12:48PM WBC-9.6 RBC-3.59* HGB-12.0 HCT-35.8 MCV-100* MCH-33.4* MCHC-33.5 RDW-13.7 RDWSD-50.4* ___ 12:48PM NEUTS-76.6* LYMPHS-9.1* MONOS-9.5 EOS-3.8 BASOS-0.6 IM ___ AbsNeut-7.32* AbsLymp-0.87* AbsMono-0.91* AbsEos-0.36 AbsBaso-0.06 ___ 12:48PM PLT COUNT-246 ====================== MOST RECENT LABS ===================== ___ 06:32AM BLOOD WBC-9.3 RBC-3.41* Hgb-11.3 Hct-34.7 MCV-102* MCH-33.1* MCHC-32.6 RDW-15.1 RDWSD-56.8* Plt ___ ___ 06:32AM BLOOD Glucose-96 UreaN-26* Creat-0.9 Na-141 K-4.2 Cl-103 HCO3-28 AnGap-10 ___ 06:32AM BLOOD ALT-25 AST-92* AlkPhos-591* TotBili-1.4 ___ 06:32AM BLOOD Calcium-10.5* Phos-1.9* Mg-2.3 ====================== OTHER PERTINENT LABS ===================== ___ CA ___ : ___ H ___ 05:54AM BLOOD CEA-25.4* AFP-2.0 ___ 12:48PM BLOOD TSH-2.1 Test Result Reference Range/Units LAMOTRIGINE 17.9 4.0-18.0 mcg/mL ==================================== MICROBIOLOGY ================================== ___ 2:29 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ 7:35 pm BLOOD CULTURE 1 OF 2. Blood Culture, Routine (Pending): No growth to date. ============== PATHOLOGY ================== LIVER BX PATH ___ PATHOLOGIC DIAGNOSIS: Liver, targeted needle core biopsy: - Metastatic adenocarcinoma. See note. Note: By immunohistochemistry, the tumor cells are positive for CK7, CK19 and focally positive for CDX-2 and GATA-3 (nonspecific) and are negative for CK20, mammaglobin, GCDFP, TTF-1, Napsin and PAX-8. While not entirely specific, this immunophenotype is supportive of a pancreatic or biliary origin, including metastatic pancreatic adenocarcinoma in the reported clinical and radiographic context. Other differential includes upper GI tract origin. Clinical and imaging correlation recommended. Preliminary pathology results were notified to Dr. ___ email by ___ by Dr. ___. ============================= IMAGING ============================= CT HEAD: ___ IMPRESSION: No acute intracranial process. Specifically, no evidence of acute infarction or intracranial hemorrhage. CT CHEST: ___ IMPRESSION: No evidence of intrathoracic malignancy. LIVER BX ___: IMPRESSION: Uncomplicated 18-gauge targeted liver biopsy x 3, with specimen sent to pathology. MR BRAIN ___ IMPRESSION: 1. Study is severely degraded by motion. 2. No definite evidence of acute infarct. 3. Grossly stable approximately 4 mm left cerebellar enhancing mass. While finding may represent artifact, or dural-based mass such as meningioma, metastatic disease is not excluded on the basis of this examination. Again, recommend three-month follow-up evaluation for stability or comparison with outside contrast brain MRI if available for comparison. 4. Right parieto-occipital remote hemorrhage related encephalomalacia. 5. Grossly stable right frontal punctate chronic blood products versus mineralization. CT A/P ___ IMPRESSION: 1. Hypoattenuating mass within the pancreatic tail measuring up to 3.4 cm in size with associated adjacent splenic vein thrombosis is concerning for a primary pancreatic tail malignancy. No main pancreatic duct dilation. 2. There are innumerable hypoattenuating lesions throughout the liver compatible with metastases. Left adrenal nodule measuring 1.5 cm is also concerning for a metastatic lesion. RUQUS ___ IMPRESSION: 1. Innumerable, rounded lesions scattered throughout the liver measuring up to 2.8 cm, new from prior study dated ___ and suspicious for hepatic metastases. Oncology consult, targeted liver biopsy, and CT torso is recommended for further evaluation. 2. Splenomegaly measuring 13.9 cm. 3. Heterogeneous lesion at the splenic hilum measuring 3.3 cm is incompletely characterized but may represent an accessory spleen or an additional site of malignancy. Brief Hospital Course: ==================== PATIENT SUMMARY: ==================== Ms. ___ is a ___ with a history of hemorrhagic stroke (right parieto-temporal ___, depression, hypertension, and obesity who presented with progressively worsening generalized weakness. On admission labs she was noted to have elevated liver enzymes, and right upper quadrant concerning for liver lesions. CT abdomen pelvis showed liver lesions and pancreatic tail lesion. She underwent uncomplicated biopsy of liver lesion ___ which showed metastatic adenocarcinoma of likely pancreaticobiliary origin. She had an elevated CA ___. CT chest for staging unremarkable. Brain MRI for staging with questionable 4 mm density however too much motion artifact. Repeat brain MR still with motion artifact. Palliative care was consulted. Course complicated by gait instability on admission, worsening confusion, and on ___ delirium with psychosis requiring legal consult and mechanical and physical restraints. Paraneoplastic blood work was sent. Neuro oncology consulted and thought AMS could be secondary to lamotrigine toxicity so lamotrigine was stopped. On ___ patient's mental status was improved and she was oriented x3 and able to participate in a family meeting on ___ with palliative care, social work, nursing staff, and primary team. She will go home with hospice services. She will follow-up with hematology oncology as an outpatient regarding final path and plan for possible palliative care. ==================== TRANSITIONAL ISSUES: ==================== [ ] Continue to take eliquis (Apixaban) 10mg BID through ___. She should thereafter transition to 5 mg twice daily indefinitely. [ ] Follow-up with hematology oncology on ___ regarding final pathology report of liver biopsy. [ ] Follow-up with cognitive neurology on ___ regarding new neurologic symptoms this admission including confusion and gait instability. [ ] Continue to have goals of care discussion regarding palliative treatment versus cancer treatment. [ ] Paraneoplastic blood work was sent this admission given new cancer diagnosis with neurologic symptoms. Please follow-up on paraneoplastic blood work and consider intervention within patient's goals of care. [ ] Lamotrigine was stopped because it was thought to cause psychosis in the setting of worsening liver function and supratherapeutic levels. It should likely be avoided in the future. ==================== ACUTE ISSUES: ==================== # Metastatic cancer to liver, suspected pancreatic primary On admission she had an alk phos elevated to 670 from baseline normal along with elevated AST to 77 and GGT elevated to 896. RUQ US revealed multiple lesions most concerning for metastases. In terms of her cancer screening, she had a normal mammogram in ___, colonoscopy in ___ demonstrated tubular adenomas with recommended repeat in ___, and pap smear in ___ was negative for intraepithelial malignancy. She reported yearly skin exams with dermatology and denies h/o melanoma. Family hx sig for mother with breast cancer. CT abd/pelvis ___ this admission demonstrated multiple liver lesions that were non-enhancing, as well as pancreatic tail mass concerning for pancreatic primary. She underwent a liver bx on ___ which showed metastatic adenocarcinoma of likely pancreaticobiliary origin. Her CEA was elevated to 25.4, and her ___ was elevated to ___ suggesting a pancreatic primary. Palliative care was consulted to assist with new diagnosis and goals of care discussion. Oncology was consulted to assist with outpatient follow-up. She had an MRI brain with questionable 4mm density concerning for met, however, unclear if this truly represented mass given motion artifact. She had a repeat MRI that continue to have motion artifact. For staging she had a CT chest ___ that showed no sign of malignancy. On ___ when her mental status had improved, she had a family meeting with her primary team, ___ care, and husband and daughter and her nurse to discuss goals of care. She again stated that her goal is to go home. She confirmed that she would not want an LP for further work-up. She would not want aggressive treatment for her cancer although she would consider meeting with oncology in clinic to discuss final diagnosis and palliative options. She has a home that is handicap accessible, and will go home with hospice services. Her MOLST was completed on ___ prior to discharge. #Splenic vein thrombosis She was noted to have splenic vein thrombosis on CT abdomen/pelvis on ___. Per hematology oncology recommendations she was started on 7-day course of apixaban 10 mg twice a day for 7 days (end date ___. She will then transition to apixaban 5 mg twice a day indefinitely. This was felt to be a palliative measure given potential for abdominal pain should this progress. #Delirium with psychosis, improving #Weakness and gait disturbance She presented with 4 to 6 weeks of weakness and gait disturbance however was alert and oriented x3 on admission. Had recently traveled to ___ and fallen over multiple times went to the ED and was given IV fluids for what was thought to be dehydration. On admission she had elevated alk phos and RUQ US concerning for multiple liver mets. The differential included brain metastases versus suspicion for cord compression but this was lower given no changes in bowel habits. Less likely recrudescence of her CVA symptoms. She had a brain MRI as part of staging in the setting of new cancer diagnosis, which showed 4 mm density however too much motion artifact to further specify. Neuro oncology was consulted given focus seen on brain MR but thought the pattern would not typical for causing gait disturbance. Neuro oncology was concerned for lamotrigine toxicity so lamotrigine level was drawn and found to be therapeutic however in the setting of worsening liver function was thought to be accumulating. Starting on ___ she became noticeably more confused. On ___ AM she had a code purple for agitation, delirium, paranoia, aggression toward staff and family. Her lamotrigine was stopped on ___. She was seen by psychiatry for pervasive paranoid delusions c/b verbal and physical aggression toward family and staff. The differential included infectious vs paraneoplatic process vs leptomeningial carinomatosis versus lamotrigine toxicity. TSH wnl. Infectious workup was negative. She had a NCHCT with no acute abnormality. Legal was consulted regarding need for mechanical and chemical restraints. She required PRN Haldol and 4 point restraints for aggression. Per neuro oncology recommendations a serum paraneoplastic panel was sent. However, on ___ her mental status was remarkably improved and she was oriented x 3, for first time in days. Given the timeframe of her recovery her acutely altered mental status was attributed to lamotrigine toxicity. She remained fatigued but oriented x3 the rest of her admission. She was able to participate in goals of care discussion as above. ==================== CHRONIC ISSUES: ==================== # Depression: Continued home sertraline. Stopped home lamotrigine as above # Hypertension; Continued home amlodipine. Continued home carvedilol #Allergic rhinitis: Held home ceterizine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amoxicillin ___ mg PO PREOP 2. Phenazopyridine 100 mg PO TID:PRN bladder pain 3. LORazepam 0.5-1 mg PO Q6H:PRN flight anxiety 4. CARVedilol 6.25 mg PO BID 5. amLODIPine 5 mg PO DAILY 6. lifitegrast 5 % ophthalmic (eye) BID 7. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK 8. Cetirizine 10 mg PO DAILY 9. Sertraline 100 mg PO DAILY 10. meloxicam 7.5 mg oral DAILY 11. LamoTRIgine 300 mg PO DAILY Discharge Medications: 1. Apixaban 5 mg PO BID Take two tabs (10mg) twice per day through ___. Then take 1 tab (5mg) twice per day. RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day Disp #*142 Tablet Refills:*0 2. amLODIPine 5 mg PO DAILY 3. CARVedilol 6.25 mg PO BID 4. Cetirizine 10 mg PO DAILY 5. estradiol 0.01 % (0.1 mg/gram) vaginal 2X/WEEK 6. lifitegrast 5 % ophthalmic (eye) BID 7. LORazepam 0.5-1 mg PO Q6H:PRN flight anxiety 8. meloxicam 7.5 mg oral DAILY 9. Phenazopyridine 100 mg PO TID:PRN bladder pain 10. Sertraline 100 mg PO DAILY Discharge Disposition: Home with Service Discharge Diagnosis: Primary diagnosis -Metastatic cancer likely pancreatic -Altered mental status -Lamotrigine toxicity Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had weakness for the last few weeks WHAT HAPPENED IN THE HOSPITAL? ============================== -You had a liver ultrasound and CT scan of your abdomen that showed new liver lesions and a lesion in your pancreas. -You had a biopsy of a 1 of the lesions in your liver that showed metastatic adenocarcinoma (cancer). Given your blood work this cancer is most likely from your pancreas. -He was seen by the palliative care team to discuss her goals of care. -You had a CT scan of your chest that showed no sign of cancer. -You had an MRI of your brain that was not clear because of movement during the test. -He became very confused and agitated. We needed to use restraints for your own safety and for the safety of staff. - You were seen by the neuro oncology team who thought you could have toxicity from your lamotrigine. Your lamotrigine was stopped. -Your confusion improved and you were closer to your normal self. You were able to participate in a goals of care discussion with the palliative team and primary team. You decided that he wanted to go home with hospice care. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Team Followup Instructions: ___
19958502-DS-3
19,958,502
20,046,734
DS
3
2131-10-21 00:00:00
2131-10-24 17:19:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: vancomycin / Percocet Attending: ___ Chief Complaint: Nausea, Vomiting. Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMHx SLE, ESRD s/p cadaveric kidney transplant ___, on tacro, MMF), HTN, anemia (baseline Hgb 9.6). Recently discharged from ___ 5 days prior to presentation for diarrhea with negative evaluation, by report. Since her discharge from ___, the patient's diarrhea has continued to improved; however, she notes decreased PO intake throughout the week. On the night before her presentation to ___, she endorses nausea, vomiting (nonbloody, nonbilious), and an inability to tolerate PO intake. On the day prior to presentation, her Cr was 7.0, up from 1.3 on discharge from ___ 4 days prior. ROS(+): chills, dysgeusia, ROS(-): chest pressure, abdominal pain, lower extremity edema, dyspnea, sick contacts. In the ED, initial vital signs were 97.8 73 93/44 18 100%. Labs were notable for Na 134, bicarb 12, BUN 46, creatinine 8.6, calcium 10.6, Phos 6.8, Hct 35.0. Urine lytes were also collected. She was given metoclopromide, viscous lidocaine, Aluminum-Magnesium Hydrox.-Simethicone, Elixir 5mL Oral. She underwent went renal transplant ultrasound that showed on prelim read: 1. No evidence of hydronephrosis. 2. Questionable area of venous stenosis within the main renal vein, probably artifactual. Per report transplant surgery also evaluated the patient. Vitals prior to transfer: 98.4 79 97/52 18 100% RA. Upon arrival to the floor, her VS were 98.6 102/555 78 18 100/RA. Bicarbonate IVF was continued. Past Medical History: Systemic lupus erythematosus ESRD ___ SLE nephritis s/p cadaveric kidney transplant ___ at ___, on tacro, MMF) Kidney disease, chronic, stage II (mild, EGFR 60+ ml/min) Hypercholesterolemia Anemia- HCT at ___ 30.1 (___) Hypertension, essential LSIL on Pap smear- LEEP done ___ History of hyperparathyroidism History of Splenectomy- done for history of thrombocytopenia. Social History: ___ Family History: Paternal grandfather - ESRD. Physical Exam: ADMISSION PHYSICAL EXAMINATION: ------- VS- 98.6 102/55 78 18 100/RA General- AAOx3. NAD HEENT- MMD. Neck- JVP<8cm. CV- Normal S1, S2. No m/r/g. Lungs- CTAB. No w/r/r. Abdomen- Soft. NTND. No Ext- WWP. No c/c/e. Neuro- Strength and sensation ___ symmetric, upper and lower extremities Skin- R brachial fistula with palpable thrill. DISCHARGE PHYSICAL EXAM: ---------- vitals 98.5 122/59 86 18 96% on RA stool output: BMx2 i/o 1500/1000 weight 65.9 <-- 64.2 General- AAOx3. NAD HEENT- MMD. Neck- JVP<8cm. CV- Normal S1, S2. No m/r/g. Lungs- CTAB. No w/r/r. Abdomen- Soft. NTND. No Ext- WWP. No c/c/e. Neuro- Strength and sensation ___ symmetric, upper and lower extremities Skin- R brachial fistula with palpable thrill. Pertinent Results: ADMISSION LABS: --------- ___ 02:57PM BLOOD WBC-6.2 RBC-3.79* Hgb-10.4* Hct-35.0* MCV-92 MCH-27.6 MCHC-29.8* RDW-14.5 Plt ___ ___ 02:57PM BLOOD Neuts-73.7* Lymphs-17.4* Monos-7.7 Eos-0.5 Baso-0.6 ___ 02:57PM BLOOD Glucose-101* UreaN-46* Creat-8.6* Na-134 K-4.0 Cl-100 HCO3-12* AnGap-26* ___ 02:57PM BLOOD Calcium-10.6* Phos-6.8* Mg-2.1 ___ 02:57PM BLOOD tacroFK-15.4 MICRO: ------ CMV Viral Load (Final ___: CMV DNA not detected. Performed by Cobas Ampliprep / Cobas Taqman CMV Test. Linear range of quantification: 137 IU/mL - 9,100,000 IU/mL. Limit of detection 91 IU/mL. MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM SEEN. CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN. 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. Cryptosporidium/Giardia (DFA) (Final ___: NO CRYPTOSPORIDIUM OR GIARDIA SEEN. GI biopsy: PATHOLOGIC DIAGNOSIS: Gastrointestinal mucosal biopsies, seven: 1. Upper esophagus: - Squamous mucosa with active, predominantly neutrophilic esophagitis, and organisms morphologically compatible with ___. 2. Mid esophagus: - Squamous mucosa with active, predominantly neutrophilic esophagitis, and organisms morphologically compatible with ___. 3. Gastroesophageal junction: - Squamous mucosa with marked active esophagitis and ulceration. - No glandular mucosa present. 4. Antrum: - Antral mucosa, within normal limits. 5. Pylorus, polyp: - Gastric foveolar hyperplastic polyp. 6. Duodenum: - Chronic active duodenitis. 7. Colon, random: - Colonic mucosa with numerous degenerating crypts, crypt abscesses, and scattered epithelial apoptosis (see note). Note: No diagnostic features of chronic colitis are identified. The findings raise the possibility of MMF-induced colitis in the reported clinical context. An infectious etiology is also possible; graft versus host disease is less likely given the history of solid organ transplantation. Further clinical correlation is needed. IMAGING: ----- TRANSPLANT RENAL ULTRASOUND ___ The renal morphology is normal. Specifically the cortex is of normal thickness and echogenicity, pyramids are normal, there is no pelvi-infundibular thickening and the renal sinus fat is normal. There is no hydronephrosis and no perinephric fluid collection. The resistive index of the intrarenal arteries ranges from 0.71-0.86. Acceleration times and peak systolic velocities of the main renal artery are normal. Vascularity is symmetric throughout transplants. There is a focal area of aliasing within the main renal vein. The renal vein is patent. The bladder is decompressed and cannot be evaluated. A large fibroid is partially visualized. IMPRESSION: 1. No evidence of hydronephrosis. 2. Questionable area of venous stenosis within the main renal vein, probably artifactual. EGD ___: Abnormal mucosa in the esophagus consistent with esophagitis and evidence for possible ___. (biopsy, biopsy, biopsy) Abnormal mucosa in the stomach consistent with gastritis. (biopsy) Polyp in the pylorus that appeared to be inflammatory. (biopsy) Abnormal mucosa in the duodenum (biopsy) Otherwise normal EGD to third part of the duodenum FLEX SIG ___: Abnormal mucosa in the colon (biopsy) Stool in the colon Otherwise normal sigmoidoscopy to splenic flexure Brief Hospital Course: ___ PMHx SLE, ESRD s/p cadaveric kidney transplant ___, on tacro, MMF), HTN, anemia (baseline Hgb 9.6) who presents with ___ and diarrhea. ACUTE ISSUES: # ACUTE ON CHRONIC KIDNEY INJURY: Baseline Cr 1.3, presenting with Cr 8.6 on admission. Most likely due to pre-renal azotemia, evidenced by her volume exam, history of decreased PO intake, significant diarrhea, and urinary Na <10. Additional contributors include iatrogenisis due to ongoing lisinopril use in the setting of pre-renal state. Held lisinopril and atenolol throughout hospital course in the setting of hypotension, ___, and ongoing diarrhea. Creatinine trended down to 2.1 with adequate volume repletion. # METABOLIC ACIDOSIS: Most likely due to combination of large volume diarrhea and ___. Pt was treated with 150 mEq Sodium Bicarbonate/ 1000 mL D5W multiple times for bicarb < 15. She was also started on sodium bicarbonate 1300mg tid until bicarb improved and diarrhea as well as ___ resolved. She was also fluid resuscitated with LR. # DIARRHEA: Due to MMF colitis based on biopsy. Pt had large volume diarrhea ___. She underwent EGD and flex sig. She was found to have ___ as well as colitis c/w MMF. MMF was discontinued and she was started on azathioprine 75mg daily. She was volume resuscitated with LR aggressively to keep fluid balance even. # ___ esophagitis: Pt was found to have ___ esophagitis on EGD. She was started on fluconazole 200mg x1 followed by 100mg daily for total of 14 days, last dose on ___. She was also started on protonix 40mg daily x2 weeks and sucralfate 2gm bid x2 weeks. Follow up was arranged with GI for further management. # S/P RENAL TRANSPLANT ___, ___): Initially tacrolimus was supratherapeutic in the setting ___ and diarrhea. Tacrolimus dose was adjusted to 3mg bid. Azathioprine was started in place of MMF at 75mg daily. MMF was discontinued. CHRONIC ISSUES: # ANEMIA: Overall remained stable but down trended in the setting of aggressive volume resuscitation and frequent blood draws. Never required transfusions. Baseline Hgb 9.6. # SLE: STABLE. - Diagnosed in ___. - Not on any SLE-specific immunosuppression. # HISTORY OF SPLENECTOMY: Per ___ records, done for thrombocytopenia. Patient has received PCV 13 ___, Meningoc IM ___, and H. influenza B ___. TRANSITIONAL ISSUES: - Code status: Full code. - Studies pending on discharge: Cathartic laxative screen, pancreatic elastase. - Emergency contact: ___ ___ - Patient should have labs done ___, faxed to Nephrology office - please monitor tacrolimus level as diarrhea improving and pt is on fluconazole. Can likely increase tacrolimus back to 5mg BID roughyl 2 weeks after discharge. - Please re-start lisinopril and atenolol once creatinine has improved as an outpatient (labs will be checked ___ - Normotensive on discharge. - Please trend hematocrit (likely minimal GI blood loss in setting of diffuse inflammation, as well as anemia in setting of volume shifts). Did not transfuse while inpatient (iron studies normal in ___. - Continue fluconazole (14 day course total), last day ___. - Continue sucralfate and omeprazole x 2 weeks, after that can STOP if symptoms have improved. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tacrolimus 5 mg PO Q12H 2. Mycophenolate Mofetil 1000 mg PO BID 3. Atenolol 75 mg PO DAILY 4. Lisinopril 10 mg PO MWF 5. Calcitriol 0.25 mcg PO DAILY 6. Magnesium Oxide 400 mg PO DAILY 7. Vitamin D 3000 UNIT PO DAILY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES: ------------ ACUTE KIDNEY INJURY NONANION GAP METABOLIC ACIDOSIS RENAL TRANSPLANT (___) DIARRHEA 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 ___. You were admitted with dehydration and kidney injury due to your ongoing diarrhea which was found to be due the medication MMF . We have discontinued this medication, and started you on azathioprine. You underwent EGD and flexible sigmoidoscopy to further assess your diarrhea. You received fluids to fix your dehydration and your kidney injury, from the dehydration, slowly improved. You were also found to have fungal infection of your esophagus and you are being treated with antibiotics for total of two weeks. Please followup with your transplant nephrologist and other doctors, as outlined below. Followup Instructions: ___
19958540-DS-15
19,958,540
21,189,178
DS
15
2174-09-13 00:00:00
2174-09-13 13:05:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: chlorhexidine Attending: ___. Chief Complaint: Right prior TMA site infection Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old male who has peripheral neuropathy of unclear etiology hx of infected ulcer and osteomyilits requiring IV anitbiotic treatment and TMA on ___ who was last discharge from ___ on ___ to rehab. Since that time has noted erythema of the R foot. Seen by Dr. ___ 3 weeks ago and completed a 2 week course of bactrim 6 days ago. Started on levaquin 3 days ago per podiatry after a culture of open wound grew pseudomonas. For the last ___ days has noted purulent drainage from the dorsal incision site. Today he presents with an open ulcerated TMA wound with purulent drainage with minimal pain at site. He states he does have pain along the right posterior knee and calf. Currently, he denies any fevers, chills, nausea, vomiting, diarrhea or new rash. He denies pain at the ulcer site secondary to his baseline neuropathy. Past Medical History: Past Medical History: HTN, hyperlipidemia, history of osteomyelitis as above, peripheral neuropathy with unknown etiology - followed at ___ by neurologist Past Surgical History: includes left ___ toe and metatarsal amputation, multiple I+D of right foot plantar ulcer, Right ankle surgery Social History: ___ Family History: CAD, no diabetes or family history of neuropathy Physical Exam: Admission Physical PE V.S. 98.6 95 129/71 18 97% General AAOx3 Cardiac RRR CTAB Abd ND NT soft Ext Right +2 pitting edema and erythema extending to mid calf. TMA wound that is open and ulcerated with yellow purulent discharge. Left +1pitting edema left ___ toe previous amputation with incision scar visible. No lesions. Pulses R:p/d/d/d L:p/p/p/d Discharge physical PE V.S. 98.5, 98.1, 61, 92/50, 18, 96RA General AAOx3 Cardiac RRR CTAB Abd ND NT soft Ext Minimal swelling, No drainage from TMA site. Left +1pitting edema left ___ toe previous amputation with incision scar visible. No lesions. Pulses R:p/d/d/d L:p/p/p/d Pertinent Results: ___ 05:46PM LACTATE-2.5* ___ 05:30PM GLUCOSE-88 UREA N-16 CREAT-0.9 SODIUM-137 POTASSIUM-3.7 CHLORIDE-97 TOTAL CO2-28 ANION GAP-16 ___ 05:30PM estGFR-Using this ___ 05:30PM CALCIUM-9.2 PHOSPHATE-3.8 MAGNESIUM-2.3 ___ 05:30PM WBC-11.9* RBC-4.96 HGB-13.8* HCT-42.9 MCV-86 MCH-27.8 MCHC-32.2 RDW-15.9* ___ 05:30PM NEUTS-75.1* LYMPHS-15.2* MONOS-7.2 EOS-1.9 BASOS-0.6 ___ 05:30PM ___ PTT-23.9* ___ ___ 05:30PM PLT COUNT-287 ___ 3:18 am SWAB Source: R TMA site. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. 2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). WOUND CULTURE (Final ___: MIXED BACTERIAL FLORA. This culture contains mixed bacterial types (>=3) so an abbreviated workup is performed. Any growth of P.aeruginosa, S.aureus and beta hemolytic streptococci will be reported. IF THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT PRESENT in this culture.. STAPH AUREUS COAG +. MODERATE 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. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | PSEUDOMONAS AERUGINOSA | | CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- =>4 R CLINDAMYCIN----------- R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S 2 S LEVOFLOXACIN---------- =>8 R MEROPENEM------------- <=0.25 S OXACILLIN------------- =>4 R PIPERACILLIN/TAZO----- 16 S RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Preliminary): RESULTS PENDING. ___ IMPRESSION: No evidence of deep vein thrombosis in the right lower extremity. Brief Hospital Course: Mr. ___ was admitted on ___ due to the last ___ days has noted purulent drainage from the dorsal incision site. Today he presents with an open ulcerated TMA wound with purulent drainage with minimal pain at site. He states he does have pain along the right posterior knee and calf. He was admitted for IV antibiotics vancomycin and cefepime. On ___ patient recieved PICC. Continued on a regular diet. Podiatry was consulted in regards to an achilles tendon lengthening procedure that the patient declined and the fitting of a short shoe which he will follow up with podiatry as an out patient. ID consulted with final recommendations of daptomycin and cefepime for 6 weeks. On ___ patient foot dry with dry dead skin that was debrided at bedside. Patient ready for discharge on IV antibiotics. Medications on Admission: 1. Aspirin 81 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. CefePIME 2 g IV Q8H RX *cefepime [Maxipime] 2 gram 1 dose IV every eight (8) hours Disp #*42 Vial Refills:*0 5. Daptomycin 840 mg IV Q24H RX *daptomycin [Cubicin] 500 mg 840 mg IV q24h Disp #*28 Vial Refills:*0 6. Docusate Sodium 100 mg PO BID 7. Furosemide 20 mg PO DAILY 8. Hydrochlorothiazide 25 mg PO DAILY 9. Losartan Potassium 100 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Nortriptyline ___ mg PO HS 12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 13. Pregabalin 300 mg PO BID 14. Senna 8.6 mg PO BID:PRN constipation Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Atorvastatin 10 mg PO DAILY 4. CefePIME 2 g IV Q8H RX *cefepime [Maxipime] 2 gram 1 dose IV every eight (8) hours Disp #*42 Vial Refills:*0 5. Daptomycin 840 mg IV Q24H RX *daptomycin [Cubicin] 500 mg 840 mg IV q24h Disp #*28 Vial Refills:*0 6. Docusate Sodium 100 mg PO BID 7. Furosemide 20 mg PO DAILY 8. Hydrochlorothiazide 25 mg PO DAILY 9. Losartan Potassium 100 mg PO DAILY 10. Multivitamins 1 TAB PO DAILY 11. Nortriptyline ___ mg PO HS 12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours Disp #*20 Tablet Refills:*0 13. Pregabalin 300 mg PO BID 14. Senna 8.6 mg PO BID:PRN constipation Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Surgical Wound infection at prior TMA sight RLE 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 TRANSMETATARSAL AMPUTATION DISHCARGE INSTRUCTIONS MEDICATIONS: •Take your medications as prescribed in your discharge •Take pain medication as needed / as prescribed •Remember that narcotic pain medication can be constipating. Increase your fiber intake ACTIVITY: •You should be non weight bearing on the side of the transmetatarsal amputation for ___ weeks. •You should keep this amputation site elevated when ever possible. •You may use the heel of your effected foot for transfer and pivots, but it is best to try to avoid this •No driving until cleared by your Surgeon. •No heavy lifting greater than 20 pounds for the next ___ days. BATHING/SHOWERING: •You may shower when you get home •No tub baths or pools / do not soak your foot for 4 weeks from your date of surgery WOUND CARE: • Please keep wound dry and clean. Continue dressing changes. CAUTIONS: •If you smoke, please make every attempt to quit. Your primary care physician can help with this. Smoking causes narrowing of your blood vessels which in turn decreases circulation. DIET: •Low fat, low cholesterol / if you are diabetic – follow your dietary restrictions as before CALL THE OFFICE FOR: ___ •Bleeding, redness of, or drainage from your foot wound •New pain, numbness or discoloration of the skin on the effected foot •Fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. Followup Instructions: ___
19958808-DS-12
19,958,808
29,990,340
DS
12
2123-07-17 00:00:00
2123-07-20 03:08:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RUQ abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ woman with a history of depression and alcohol use disorder, who presents as an outside hospital transfer from ___ with 1 day of right-sided abdominal pain, with imaging findings concerning for possible appendicitis, as well as LFT abnormalities. The patient states the pain started several hours prior to arrival at the OSH. She describes it as right upper quadrant/epigastric, 8 out of 10, aching, and worse with standing and walking. The pain is associated with 2 episodes of nausea with vomiting. She has no associated fever, chills, diarrhea, black or bloody stool, headache, neck pain, chest pain, difficulty breathing, and vaginal bleeding or discharge. She states that she has never experienced these symptoms before. The patient typically drinks 10 alcoholic drinks per day, but over the past ___ days has significantly increased her alcohol intake (up to 1 handle daily). She does not report any other ingestion aside from alcohol. She denies a history of liver disease. Her abdominal pain is not clearly associated with eating. She states she has depression with no suicidal or homicidal ideation. On arrival to the ___, the patient was found to be tachycardic to the 130s. Lab work was notable for a sodium of 126, potassium of 3.0, magnesium of 0.8, anion gap of 27 with a lactate of 8.0. White count was normal. LFTs and T bili were elevated. CT imaging of the abdomen was obtained given the patient's tenderness and showed concern for acute appendicitis. Surgery evaluated the patient and recommended transfer to a tertiary care center given concern for acute appendicitis and high risk for surgery given LFT abnormalities and alcohol history. The patient was covered with Zosyn and vancomycin. Blood cultures were sent. The patient was then transferred to ___. ED Course notable for: Initial vital signs: T 99.9 (Tmax 102.6), HR 130, BP 105/82, RR 17, O2 sat 97% RA Exam notable for: Abdomen: Soft, nondistended. Mild diffuse ttp without peritoneal signs. Pilonidal abscess with signs of I+D Labs notable for: WBC 6.2, Hgb 10.6, platelets 104, AST 107, ALT 71, alk phos 126, Tbili 2.2, Dbili 1.0, Na 127, Cl 85, HCO3 14, lactate 7.6-->5.5, K 3.0 VBG: 7.40/33 Imaging notable for: RUQUS- 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. No cholelithiasis or evidence of cholecystitis. In the ED, the patient was given 2L IVF. For her fever she was given 1g for Tylenol. She was given thiamine, folate, MVI, Zofran for nausea, and magnesium repletion. Vital signs on transfer: T 98.1, HR 121. BP 126/94, RR 21, O2 sat 99% RA On arrival to the MICU, the patient confirmed the above history. In addition to the above, the patient notes significant R ankle pain. This began about 2 weeks ago after she dropped a garbage can on it. Since then, her R ankle has become quite tender to touch and red. The patient also reports drainage from a cyst just above her buttock. She states that this has happened in the past and is a bit painful. Does not report chills, chest pain, shortness of breath, nausea, vomiting, and changes in bowel or bladder habits. REVIEW OF SYSTEMS: 10-point review of systems negative, except as above. Past Medical History: Alcohol use disorder Depression Social History: ___ Family History: Biological mother w/ hx of schizophrenia, mental health struggles Physical Exam: ADMISSION PHYSICAL EXAM: 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: Tachycardic, normal S1 S2, no murmurs, rubs, gallops ABD: soft, tenderness in the epigastrium and RUQ, non-distended, bowel sounds present, (+) ___ sign, hepatomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: R ankle with overlying erythema and warmth, tender to palpation, no crepitus or blistering; sacral open tract to draining cyst with surrounding erythema and discoloration NEURO: A&Ox3, moving all 4 extremities DISCHARGE PHYSICAL EXAM: 24 HR Data (last updated ___ @ 551) Temp: 98.3 (Tm 99.0), BP: 103/71 (103-127/71-81), HR: 98 (98-116), RR: 18 (___), O2 sat: 97% (95-97), O2 delivery: RA, Wt: 302.25 lb/137.1 kg GENERAL: well developed female in NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: tachycardic, S1/S2, no murmurs, gallops, or rubs PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles GI: abdomen soft, distended, mild tenderness to palpation in RUQ, with possible hepatomegaly, though difficulty to assess due to body habitus. Large ecchymosis across abdomen. BACK: lesion above gluteal cleft covered with dressing, dry and clean EXTREMITIES: minimal erythema and edema around right ankle, mildly edematous feet PULSES: 2+ radial pulses bilaterally NEURO: Alert, moving all 4 extremities with purpose, face symmetric Pertinent Results: ADMISSION LABS: ================ ___ 11:02PM ___ PO2-39* PCO2-33* PH-7.40 TOTAL CO2-21 BASE XS--2 ___ 11:02PM GLUCOSE-101 LACTATE-5.5* NA+-128* K+-3.0* CL--92* TCO2-20* ___ 07:07PM LACTATE-7.6* ___ 07:04PM GLUCOSE-103* UREA N-8 CREAT-0.9 SODIUM-127* POTASSIUM-4.1 CHLORIDE-85* TOTAL CO2-14* ANION GAP-28* ___ 07:04PM estGFR-Using this ___ 07:04PM ALT(SGPT)-71* AST(SGOT)-107* ALK PHOS-126* TOT BILI-2.2* DIR BILI-1.0* INDIR BIL-1.2 ___ 07:04PM LIPASE-39 ___ 07:04PM ALBUMIN-3.5 ___ 07:04PM WBC-6.2 RBC-3.33* HGB-10.6* HCT-31.5* MCV-95 MCH-31.8 MCHC-33.7 RDW-17.5* RDWSD-55.3* ___ 07:04PM NEUTS-79.9* LYMPHS-9.4* MONOS-9.4 EOS-0.0* BASOS-0.2 NUC RBCS-0.5* IM ___ AbsNeut-4.91 AbsLymp-0.58* AbsMono-0.58 AbsEos-0.00* AbsBaso-0.01 ___ 07:04PM PLT COUNT-104* DISCHARGE LABS: ================ ___ 07:25AM BLOOD WBC-7.1 RBC-2.61* Hgb-8.4* Hct-26.9* MCV-103* MCH-32.2* MCHC-31.2* RDW-22.3* RDWSD-64.5* Plt ___ ___ 04:45AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 07:25AM BLOOD Plt ___ ___ 07:25AM BLOOD ___ PTT-28.0 ___ ___ 07:25AM BLOOD Glucose-87 UreaN-2* Creat-0.6 Na-137 K-4.0 Cl-97 HCO3-26 AnGap-14 ___ 07:25AM BLOOD ALT-71* AST-154* AlkPhos-197* TotBili-1.4 ___ 07:25AM BLOOD Albumin-3.0* Calcium-8.2* Phos-2.3* Mg-1.5* ___ 04:40AM BLOOD calTIBC-203* Ferritn-848* TRF-156* ___ 01:42AM BLOOD VitB12-226* Folate-5 ___ 01:04PM BLOOD TSH-9.6* ___ 01:04PM BLOOD T4-5.3 T3-70* ___ 01:42AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG IMAGING: ============ RUQ US IMPRESSION ___: 1. Echogenic liver consistent with steatosis. Other forms of liver disease including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded on the basis of this examination. 2. No cholelithiasis or evidence of acute cholecystitis. ___ Imaging FOOT AP,LAT & OBL RIGHT IMPRESSION: 1. No fracture of the right foot. 2. No radiographic findings of osteomyelitis, noting that MRI is more sensitive for early osteomyelitis. MICROBIOLOGY: ============== Microbiology Results(last 7 days) ___ __________________________________________________________ ___ 4:58 pm SEROLOGY/BLOOD **FINAL REPORT ___ MONOSPOT (Final ___: NEGATIVE by Latex Agglutination. (Reference Range-Negative). __________________________________________________________ ___ 7:14 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 7:04 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: Ms. ___ is a ___ year old female with past medical history significant for depression and EtOH abuse who was admitted for alcoholic hepatitis and treated for alcohol withdrawal. ACTIVE ISSUES: #Alcohol use disorder The patient presented with a history of significant alcohol use beginning at approximately age ___, recently increased, up to 1 handle daily. She continued to have persistent tachycardia and nausea/vomiting, and as such was started on phenobarbital protocol for alcohol withdrawal with improvement in symptoms. She did not have any seizures, alcoholic hallucinosis, or other worrisome components of her hospital stay related to her alcohol withdrawal. She was continued on folate, multivitamin, and thiamine in the setting of her alcohol use. Addiction nursing and psychiatry were consulted and saw the patient to discuss options of treatment and management, resulting in the recommendation to a dual diagnosis rehabilitation facility. #Electrolyte abnormalities (K, Mg, PO4) #Concerns for refeeding syndrome The patient presented with significantly low potassium, magnesium, phosphate, which were downtrending following initiation of diet, which was felt to be likely in the setting of malnutrition and significant alcohol intake. Her electrolytes stabilized with aggressive repletion without complications. #Alcoholic hepatitis #RUQ pain The patient's RUQ pain and elevated transaminases are consistent with alcoholic hepatitis in setting of significant alcohol use disorder. Hepatitis serologies negative. RUQUS with evidence of steatosis. Deferred steroids given low ___ score. Recommend HBV vaccine during follow up. #Tachycardia Etiology likely multifactorial, including alcohol withdrawal, pain, infection, and dehydration. Improved overall with IVF. Patient noted her baseline HR is in 100s. EKG performed indicated sinus tachycardia but no other abnormalities. TSH was also checked, which showed elevated levels (9.6) with follow up T4/T3 levels normal (5.3) and low(70) respectively. #Cellulitis #Pilonidal Cyst The patient has two possible niduses of infection, namely the R ankle and her likely pilonidal cyst. Both areas are concerning for underlying cellulitis. Started on cephalexin for 5 days (D1 - ___ and seen by wound care and surgery who recommended non-surgical management. Both areas improved during her hospitalization. She also had an X-Ray of the right foot, which showed no signs of osteomyelitis or fracture. #Concerns for alcoholic gastritis Patient with abdominal pain and difficulty keeping down pills while in MICU. Transitioned po PPI to IV, though she was transitioned back to PO prior to discharge. #Anemia: Unclear baseline, but appears hemodynamically stable and no evidence of bleeding. Most likely related to alcohol-induced marrow suppression with component of B12 deficiency. She was started on Vitamin B12 while inpatient. In addition, iron studies were also ordered. Iron 50, TIBC 203, Ferritin 848, Transferrin 156. CHRONIC/RESOLVED ISSUES: #Hyponatremia: Likely hypovolemic in the setting of poor PO intake and significant alcohol use. Improved with IVF to normal levels. Discharge Na of 137. #Acidemia/lactatemia: Given the patient's significant alcohol use and ketones in her urine at ___, most likely etiology is due to a combination of alcoholic ketosis and starvation ketoacidosis. Lactate improved with IV fluids and was discharged without any active intervention. TRANSITIONAL ISSUES [] Recommend outpatient social work follow up for significant alcohol abuse [] Hepatology f/u for hepatic steatosis [] Recommend HBV vaccine during follow up. [] Started on Vitamin B12, follow up hemoglobin [] Concern for alcoholic gastritis - follow up abdominal pain, adjust PPI accordingly [] Ensure resolution of cellulitis and pilonidal cyst [] Repeat TSH, T4/T3 levels outpatient. Hypothyroidism vs sick euthyroid syndrome, the latter more likely [] Repeat LFTs outpatient and follow up accordingly [] Please set up an outpatient Psychiatry appointment for Ms. ___. She does not currently have a psychiatrist. Medications on Admission: NexIUM (esomeprazole magnesium) ___ mg oral prn Discharge Medications: 1. Citalopram 20 mg PO DAILY 2. Cyanocobalamin 1000 mcg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Pantoprazole 40 mg PO Q24H 6. Phosphorus 500 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Alcohol Use Disorder Anemia Cellulitis Alcoholic Hepatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted because you had right sided abdominal pain, electrolyte abnormalities, an ankle infection, and alcohol withdrawal. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were initially admitted to the MICU, at which time they helped with several conditions. You were given phenobarbital to help with symptoms of alcohol withdrawal. At this time, bloodwork showed your liver tests showed that your liver was enflamed but was still functioning well. You were given IV fluids which helped some of your other electrolyte abnormalities, as well. - You were also found to have a possible infection of your ankle and a chronic cyst on your back that we started antibiotics (cephalexin) for. We recommend your last dose to be on ___. - You had a fast heart beat while you were in the hospital, we monitored this with an EKG that did not show any concerning arrhythmias. - You were seen by our social workers, addiction specialists, and psychiatrists, as well, to help develop a plan for an inpatient psychiatric and addiction ___ rehabilitation center. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medicines and keep your appointments. - Refrain from using alcohol. This is very dangerous while phenobarbital is still in your system for the next week. - Please contact ___ Emergency Services Team (BEST) ___ or return to the ED if you feel unsafe, have thoughts about hurting yourself or someone else, or have symptoms that concern you. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19958882-DS-20
19,958,882
24,100,077
DS
20
2171-08-05 00:00:00
2171-08-15 11:09:00
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 pain Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ male w/PMHx metastatic squamous cell lung cancer on ___ line chemotherapy (last dose ___, presenting with sudden onset of worsened chest pain and shortness of breath at 2am today. He has been feeling fairly poorly overall given his advanced cancer, and has intermittent chest pains and shortness of breath at baseline, but early this morning, the symptoms were worse and so when he was at his Psychiatrist's office earlier today he described this history and was referred to the ___ ED. He notes he has had worsening lower extremity edema and 2d ago went from 10mg furosemide daily to 20mg daily. Denies F/C, N/V, constipation, urinary sx, dark urine. Endorses chronic slightly productive cough with no recent change, worsening appetite (only eats ___ of one meal a day), and anxiety and pain which keep him from sleeping. His pain is currently ___, at worst is ___, at best is entirely gone. By the time of triaging him to the ED from the outpatient clinic, his symptoms had return to baseline for him. In the ED he was found to be in afib w/RVR, rates up to 158, no O2 req (always >94% on RA), RR up to 22, SBP 97-113. Was given IVF. CTA chest done to rule out clot -- none seen. Bedside echo showed "compression of the R ventricle." Cardiac surgery saw patient -- "no intervention needed currently." Also noted to have elevated WBC, but no concerns for infection, BCx drawn anyways. ROS: [x] As per above HPI, otherwise reviewed and negative in all systems Past Medical History: Stage IV (metastatic) squamous cell lung cancer -- dx ___, received ___ line chemo --> with progression of disease, so enrolled in a clinical trial but randomized to doxetacel only arm, s/p 2 cycles (last ___ Alcoholic pancreatitis Mild COPD PSHx: Surgical repair of perforated eardrum Tonsillectomy/adenoidectomy Social History: ___ Family History: As per Dr. ___ note: brother with colon CA in ___, mother with liver dz or carcinoma, father died at ___ of COPD, parents were heavy drinkers. Sisters are well. Physical Exam: Admission: VS: T 97.5, HR 94, BP 107/78, O2 sat 100% on RA Lines/tubes: PIV Gen: very thin bald man standing and moving without assistance, alert, cooperative, NAD HEENT: anicteric, PERRL, MMM Neck: no ___, supple Chest: R upper chest wall port, not accessed, and equal chest rise, very thin/bony, good air movement, CTAB posteriorly Cardiovasc: RRR, nl S1, S2, no m/r/g, 3+ pitting edema in his legs, JVP visible when he is standing upright, probably ~12cm Abd: NABS, soft, NTND, no obvious organomegaly GU: no CVAT Extr: WWP, edema as noted in legs only Skin: no rashes seen Neuro: CN II-XII intact (IX and X not specifically tested), strength ___ throughout, sensation to light touch intact throughout, reflexes symmetric Psych: normal affect Discharge: no distress cachectic HR 110, regular Pertinent Results: ___ 10:55AM BLOOD WBC-24.6* RBC-4.11* Hgb-11.2* Hct-34.3* MCV-83 MCH-27.2 MCHC-32.6 RDW-15.8* Plt ___ ___ 10:55AM BLOOD Neuts-88.7* Lymphs-7.4* Monos-3.7 Eos-0 Baso-0.2 ___ 10:55AM BLOOD ___ PTT-30.5 ___ ___ 10:55AM BLOOD Glucose-111* UreaN-11 Creat-0.5 Na-130* K-4.6 Cl-92* HCO3-25 AnGap-18 ___ 05:34AM BLOOD ALT-34 AST-34 AlkPhos-163* TotBili-0.6 ___ 10:55AM BLOOD Calcium-11.3* Phos-3.2 Mg-1.7 ___ 11:10AM BLOOD Lactate-2.5* ___ 12:49PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Blood cx x2 pending CXR: Single AP view of the chest was obtained for review. A right chest port is noted with tip near the cavoatrial junction. Cardiomediastinal and hilar contours are unchanged. There are small bilateral pleural effusions, right greater than left. There is no pneumothorax. Multiple masses are seen within both lungs, better assessed by concurrent chest CTA. CTA: IMPRESSION: prelim: 1. No pulmonary embolism or evidence of acute aortic syndrome. 2. Increase in multiple pulmonary and hepatic lesions. Enlarging right infrahilar mass with worsening compressive effect on the pulmonary veins and the left atrium. Brief Hospital Course: ___ with advanced metastatic NSCLC who failed second line of chemotherapy and presents with AFIB with increased tumor burden on CT. After discussion with family and oncologist, he was made CMO and was discharged with home hospice. # Lung neoplasms: # Metastatic to liver: He has failed multiple courses chemotherapy. No further treatment options per oncologist. After discussion with oncologist and patient, he decided to focus on comfort and maximize his time at home with his wife. He was discharged with home hospice. # Atrial fibrillation with rapid ventricular rate: # Sinus tachycardia: Given some IV fluids with improvement. He was in NSR with tachycardia at the time of discharge. He was started on low dose beta blocker but with permissive tachycardia given cardiac and pulmonary vein compression by tumor. He was asymptomatic from the rate at the time of discharge. # Coagulopathy: He was given vitamin K. # Leukocytosis, normocytic anemia: Likely secondary to cancer. No clear evidence of infection. Possibly secondary to steroids from chemo regimen. No further work up given goals of care. # Hyponatremia: Likely secondary to nutrition, cancer and lasix. Will continue lasix at discharge as he may have some dyspnea benefit. If he get dehydrated this medication should be discontinued. # Hypercalcemia: Likely secondary to cancer. Hold evaluation or treatment given goals of care. # Nutrition: # Depression: He was treated with mirtazapine which was recently started. Given goals of care this will be continued. # Pain control: He was discharged on his home pain regimen. He will be seen by hospice for consideration of further uptitration of pain regimen. He was continued on bowel regimen for patient comfort. The hospice care medication bundle for was signed for potential upcoming hospice needs. He is comfort focused care. Hospice will continue to follow him at home and assess for further home services. Dr. ___ ___ the primary oncologist. The PCP was also notified. Transitional issues: Patient comfort and home supports Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dronabinol 5 mg PO BID:PRN poor appetite 2. Prochlorperazine Dose is Unknown PO Q6H:PRN nausea 3. Lorazepam 1 mg PO HS:PRN insomnia, anxiety 4. Docusate Sodium 100 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY 6. Furosemide 20 mg PO DAILY 7. Senna 1 TAB PO DAILY 8. morphine 45 mg Oral TID 9. oxyCODONE-acetaminophen ___ mg Oral Q4HR:PRN pain 10. budesonide-formoterol 160-4.5 mcg/actuation Inhalation BID *Research Pharmacy Approval Required* Research protocol ___ Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Dronabinol 5 mg PO BID:PRN poor appetite 3. Lorazepam 1 mg PO HS:PRN insomnia, anxiety 4. Polyethylene Glycol 17 g PO DAILY 5. Senna 1 TAB PO DAILY 6. Mirtazapine 7.5 mg PO HS RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 7. Furosemide 20 mg PO DAILY *Research Pharmacy Approval Required* Research protocol ___ 8. morphine 45 mg Oral TID *Research Pharmacy Approval Required* Research protocol ___ 9. oxyCODONE-acetaminophen ___ mg Oral Q4HR:PRN pain *Research Pharmacy Approval Required* Research protocol ___ 10. Prochlorperazine 5 mg PO Q6H:PRN nausea *Research Pharmacy Approval Required* Research protocol ___ 11. Metoprolol Succinate XL 25 mg PO DAILY *Research Pharmacy Approval Required* Research protocol ___ RX *metoprolol succinate 25 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Lung cancer Atrial fibrillation with rapid ventricular response Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted with a rapid heart rate. You were given a medication to slow the rate down. You felt better with this. You had a CT scan of your chest which showed progression of your cancer. After discussion with your oncologist, it was decided to focus on comfort and discharge you with hospice follow up at home. Followup Instructions: ___
19958954-DS-22
19,958,954
28,456,141
DS
22
2139-12-29 00:00:00
2139-12-29 17:30:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypoglycemia, Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old gentleman with PMHx NSTEMI, DMII with numerous falls due to hypoglycemia, alcohol abuse, HTN, HFrEF, brought in by ambulance after falling earlier today. He stated his blood sugar was in the 180s when he took fast acting insulin (had not eaten breakfast). He then went to the grocery store. On the way home from the grocery store he noticed his legs were getting weaker. At home he sat down due to weakness and subsequently passed out. He does not remember falling but noted large amount of blood coming from above his left eye. Prior to the episode and when he was walking he denied chest pain, chest pressure, chest palpitations, shortness of breath. He did experience minimal lightheadedness. Denied tongue bite, urinary or stool incontinence. He called his neighbor who called EMS. ___ by EMS 43, received 15 grams oral glucose and put in C collar for C-spine precautions. On arrival to ED, patient ___ was 43 and received additional amp. Of note, patient states he has brittle diabets and can see his blood sugar drop from mid ___ to below ___ after low dose of insulin. He has been hospitalized numerous times due to hypoglycemia and resultant falls. In ___ seen in ED because of seizure likely secondary to hypoglycemia. Many of these records at the ___ where he obtains his medical care. In the ED, initial vitals were: pain 8, HR 76, BP 107/62, RR 18, Pulse Ox 100% on RA. - Labs were significant for ___ 43. WBC 14.8, H/H 12.8/37.4. LFT's within normal limits, serum toxicology screen negative. Creatinine 1.5. Troponin x 1 0.02. - Imaging revealed: No acute process with CXR, CT C-Spine, CT L-spine, CT sinus/mandible/maxilofcaial, CT head. - The patient was given 1 amp as described above, ondansetron 4 mg IV x 1, Morphine sulfate 2 mg IV x 1, morphine sulfate 5 mg IV x 1, Tetanus shot, 1000 cc NS, diazepam 5 mg x 1. For laceration patient had sutures placed. Vitals prior to transfer were: 98.1, 75, 125/58, 16, 99% on RA. Upon arrival to the floor, patient states he is feeling well. Feels hungry but denies any chest pain, chest pressure, chest palpitations. Past Medical History: - Diabetes type 2 on insulin - Alcohol abuse - Asthma/COPD - Hypertension - Chronic Pancreatitis - HFrEF (TTE ___: 40-45%) - NSTEMI (___) - possible prior infract based on EKG findings. - Episode of atrial fibrillation ___ Social History: ___ Family History: Father has coronary artery disease. Brother with drug addiction. Mother alive and healthy. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 97.4, 93/63, 77, 18, 100% on RA. General: Resting in bed, ecchymoses under left eye, bandage over left eye with blood noted on bandage. HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Expiratory wheezes appreciated, no crackles. Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Ext: Warm, well perfused, no lower extremity edema. Bandage over the left forearm, clean, dry, intact. Neuro: CNII-XII intact, ___ strength upper/lower extremities. DISCHARGE PHYSICAL EXAM: Vitals: 98.1 129-137/56-58 ___ 18 99% RA General: Resting comfortably in bed, no acute distress HEENT: Improving ecchymosis under left eye, sutured laceration at left eyebrow. Edema improving. CV: Regular rate and rhythm, no murmurs Pulm: Poor air movement throughout without wheezes/crackles Abdomen: Soft, NTND, normoactive bowel sounds Ext: Ecchymosis and continued decreased swelling of R arm/forearm. Moderate tenderness over R biceps. Neuro: AOx3, strength/sensation grossly intact Pertinent Results: ADMISSION LABS ___ 04:05PM BLOOD WBC-14.8* RBC-3.92* Hgb-12.8* Hct-37.4* MCV-95 MCH-32.7* MCHC-34.2 RDW-13.8 RDWSD-48.7* Plt ___ ___ 04:05PM BLOOD Neuts-81.7* Lymphs-9.7* Monos-6.9 Eos-0.4* Baso-0.7 Im ___ AbsNeut-12.09* AbsLymp-1.43 AbsMono-1.02* AbsEos-0.06 AbsBaso-0.11* ___ 04:05PM BLOOD ___ PTT-31.7 ___ ___ 04:05PM BLOOD Glucose-62* UreaN-11 Creat-1.5* Na-137 K-4.2 Cl-100 HCO3-23 AnGap-18 ___ 04:05PM BLOOD ALT-33 AST-33 CK(CPK)-85 AlkPhos-105 TotBili-0.6 ___ 04:05PM BLOOD cTropnT-0.02* PERTINENT LABS ___ 12:20AM BLOOD cTropnT-0.01 ___ 04:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 07:10AM BLOOD LD(LDH)-150 ___ 07:10AM BLOOD Hapto-253* ___ ECG Normal sinus rhythm. Non-specific ST segment abnormalities in the inferolateral leads. Compared to the previous tracing of ___ there is resolution or pseudonormalization of the previously noted T wave inversions in the inferior leads. DISCHARGE LABS ___ 12:50PM BLOOD WBC-8.5 RBC-2.79* Hgb-9.2* Hct-26.8* MCV-96 MCH-33.0* MCHC-34.3 RDW-13.8 RDWSD-48.9* Plt ___ ___ 07:10AM BLOOD Ret Aut-3.6* Abs Ret-0.09 ___ 12:50PM BLOOD Glucose-348* UreaN-16 Creat-1.3* Na-129* K-4.9 Cl-97 HCO3-23 AnGap-14 ___ 12:50PM BLOOD Calcium-7.9* Phos-2.6* Mg-2.0 IMAGING ___ CXR: A portable frontal chest radiograph demonstrates a normal cardiomediastinal silhouette and hyperinflated lungs compatible with emphysema. No focal consolidation, pleural effusion, or pneumothorax. No displaced rib fracture is identified. The visualized upper abdomen is unremarkable. ___ CT C-spine: No acute fracture, malalignment, or prevertebral soft tissue abnormality. ___ CT head: 1. No acute intracranial abnormality. Soft tissue swelling and hematoma in the extracranial soft tissues about the left orbit. Globes intact. 2. Age-related involutional changes and mild sequela of chronic small vessel ischemic disease. ___ CT L-spine: No acute fracture, malalignment, or prevertebral soft tissue abnormality. ___ CT sinus/mandible/maxillofacial: Left periorbital soft tissue swelling without underlying fracture. ___ XR R humerus: No fracture. ___ Venous doppler R arm: No evidence of deep vein thrombosis in the right upper extremity. Moderate subcutaneous edema within the right upper extremity. MICROBIOLOGY ___ Blood culture: No growth to date. ___ Urine culture: Negative. ___ Sputum: MSSA and rare GNRs. Brief Hospital Course: ___ year old gentleman with PMHx NSTEMI, DMII with numerous falls due to hypoglycemia, alcohol abuse, HTN, HFrEF, brought in by ambulance after falling after syncope and hypoglycemia. # Syncope: Patient had blood glucose in ___ in field and again on presentation to the ED. Syncope thought likely due to hypoglycemia secondary to taking fast acting insulin without eating. ECG was unchanged and trops negative on admission, telemetry unremarkable. He had laceration to left forehead that was sutured in emergency room. He also complained of pain, bruising, swelling to right arm but imaging did not reveal clot or fracture. No further injuries identified on imaging. Sutures will need to be removed ___. # Brittle DM II: Patient with history of numerous falls due to hypoglycemia and reports he lets his BGs "ride high" because of concern for hypoglycemia. He reported very irregular eating habits. Given high concern that the danger of hypoglycemia in this patient outweighs the risks of hyperglycemia, team recommended that he stop using his fast-acting insulin on discharge. He was continued on lantus in house and on discharge. # Hospital acquired pneumonia: During stay patient developed chest pain with negative cardiac workup, productive cough. He had low grade temps to 100 and leukocytosis. He was started on levofloxacin for ___ acquired pneumonia with good improvement. Sputum culture grew MSSA. He will continue levofloxacin for ___gitation: On admission patient was very hostile and aggressive with staff. He refused most medical care and threatened to harm one of the physicians. He was seen by psychiatry who suspected underlying personality disorder, did not recommend inpatient hospitalization or ___. Per discussion with physicians at ___ patient has history of anger management issues although is not aggressive at baseline. Agitation improved somewhat during hospitalization. Suspect there may have been component of concussion superimposed on underlying anger issues. # ___: Presented with ___ to 1.4 from baseline 1.0 on admission. This improved throughout stay. Thought likely prerenal given syncopal episode and ___ BPs on admission. Recommend outpatient follow up. # Anemia: Drop on admission in setting of volume resuscitation and recent trauma. He had no further s/s bleeding during admission, VS remained stable and H/H remained stable. LDH and haptoglobin were wnl. # History EtOH Abuse: Patient with prior history of alcohol abuse though reports he has not had a drink in past ___ months. He was placed on CIWA initially but did not require this. Given MVI, thiamine, folic acid in house. # Tobacco abuse: Patient smokes ___ ppd at home. He was offered nicotine patch in house but declined. # H/o Atrial Fibrillation: Had episode of atrial fibrillation during hosptialization ___. Remained in sinus rhythm this admission. Anticoagulation was held given fall risk. # H/o CAD: Reportedly had catheterization at ___. He was continued on ASA, plavix, atorvastatin. Metoprolol was continued in house at ___ home dose for initial ___ BPs. Lisinopril and amlodipine were held given ___ and ___ BPs. Recommend considering restarting outpatient. # Asthma/COPD: Continued on symbicort, spiriva, albuterol nebs, ipratropium nebs, guaifenisin prn. # CODE STATUS: Full Code (confirmed) # CONTACT: No additional contact information. # TRANSITIONAL ISSUES: []Sutures to be removed ___, or at f/u appt on ___. []Recommend outpatient vs home ___ through ___ if possible. []Recommend stop all short acting insulin given danger of hypoglycemia - plan reviewed with patient and provider covering for PCP, all in agreement with this paln. []Recommend continued management of outpatient insulin regimen with PCP. []Evaluate when to restart antihypertensives as held for ___ BPs and in setting of syncope. []Consider anticoagulation for afib when/if patient has lower fall risk. []Recommend outpatient PFTs if patient has not had them. []Recommend f/u cardiology regarding whether patient is able to stop dual antiplatelet therapy. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen w/Codeine ___ TAB PO TID:PRN pain 2. Aspirin 81 mg PO DAILY 3. Tiotropium Bromide 1 CAP IH DAILY 4. Atorvastatin 80 mg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Multivitamins W/minerals 1 TAB PO DAILY 7. Metoprolol Succinate XL 100 mg PO DAILY 8. Glargine 18 Units Bedtime 9. Clopidogrel 75 mg PO DAILY 10. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of breath 11. zoledronic acid-mannitol-water 5 mg/100 mL injection every year ___. Amlodipine 5 mg PO DAILY 13. Furosemide 20 mg PO BID 14. Gabapentin 600 mg PO DAILY 15. Guaifenesin ER 1200 mg PO BID:PRN cough 16. Sildenafil Dose is Unknown PO PRN sexual activity 17. Lisinopril 40 mg PO DAILY 18. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Clopidogrel 75 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Multivitamins W/minerals 1 TAB PO DAILY 6. Tiotropium Bromide 1 CAP IH DAILY 7. Acetaminophen w/Codeine ___ TAB PO TID:PRN pain 8. Albuterol Inhaler 2 PUFF IH QID:PRN shortness of breath 9. Amlodipine 5 mg PO DAILY 10. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID 11. Furosemide 20 mg PO BID 12. Gabapentin 600 mg PO DAILY 13. Guaifenesin ER 1200 mg PO BID:PRN cough 14. Sildenafil 20 mg PO PRN sexual activity 15. zoledronic acid-mannitol-water 5 mg/100 mL INJECTION EVERY YEAR ___. Glargine 12 Units Breakfast 17. Levofloxacin 750 mg PO DAILY RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4 Tablet Refills:*0 18. Metoprolol Succinate XL 50 mg PO DAILY RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary ___ acquired pneumonia Secondary Diabetes mellitus, type 2 Acute kidney injury Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you had a fall due to very low blood sugar. As this has happened to you multiple times in the past, and this is very dangerous to you, we recommend you stop using short-acting insulin. Please continue using your long-acting insulin as usual. While you were in the hospital, you also developed a pneumonia. We started you on treatment for pneumonia with an antibiotic called levofloxacin. You will need to take this antibiotic for 4 more days. It is very important that you finish this. Please follow up with Dr. ___ at your scheduled appointment at the ___. It was a pleasure taking care of you in the hospital. - Your ___ Care Team Followup Instructions: ___
19958954-DS-24
19,958,954
29,040,322
DS
24
2141-11-23 00:00:00
2141-11-29 17:02:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Confusion, hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: In brief this is a ___ y/o man with history of DM, COPD (not on home O2), CAD s/p stent placement, and alcohol abuse brought in with confusion and hypoglycemia. Per admission note, Mr. ___ was found down by EMS. His fingerstick in the field was <20. He was completely altered and not responding to any commands. He was maintaining an airway. Upon arrival to the ED repeat fingerstick again <20. He was given 2A of dextrose and his fingersticks improved to 100. He subsequently became more alert, active and awake. He denied any chest pain, shortness of breath, recent illnesses, or medication adjustments. ED Course: Vitals: T: 97 HR: 116 BP: 173/97 RR: 22 SO2: 94% RA Labs were significant for: no leukocytosis (7.5) Na: 132 K: 3.6 HC03: 27 Crt: 1.1 Lactate 1.3 Serum/urine toxicology negative CT HEAD: No acute intracranial process or hemorrhage. CXR: No definite focal consolidation. Hyperinflation. He received: ___ 12:48 IV Dextrose 50% ___ 12:50 IV Dextrose 50% ___ 14:40 IV Dextrose 50% ___ 18:17 IVF D5LR ( 1000 mL ordered) ___ 18:27 IV Dextrose 50% 25 gm ___ 18:27 IV CefTRIAXone (1 g ordered) ___ 18:45 SC Insulin Not Given per Sliding Scale ___ 19:56 IM Haloperidol 5 mg ___ 19:56 IM LORazepam 2 mg ___ 20:00 IVF D5LR ___ 21:09 IV Azithromycin (500 mg ordered) Reportedly wanted to leave AMA after CT head had been completed, the dashboard documentation states "Hr 130s, not engaging in a rational decision making process about the risks of leaving AMA. Lacks capacity. Will give Haldol/Ativan for sedation if needed. Security at bedside." Vitals prior to transfer: T: 98.2 HR: 65 BP: 120/82 RR: 18 SO2: 100% RA Upon arrival to the floor, patient remained drowsy but arousable after Haldol 5mg, lorazepam 2mg given in ED. Was able to confirm his name, last 4 digits of SS in order to call ___. He states he was taking 15U glargine daily, does not frequently check his blood sugars. Does not believe he could have injected himself twice. Notably, he has had several ED evaluations and admission for similar epsiodes including: - ___ ED evaluation for hypoglycemia by ___ recommending: patient check BG ___, continue Metformin 500mg daily, reduce lantus to 10 units once daily - ___ p/w confusion, hypoglycemia, Lantus decreased to 10U qAM and started on metformin 500 mg every morning - ___: after a syncopal event and he was found to be hypoglycemic. At discharge, he was recommended to stop his short acting insulin and his glargine was reduced from 18U qAM to 12U qAM. Past Medical History: - Diabetes type 2 on insulin - Alcohol abuse - Asthma/COPD - Hypertension - Chronic Pancreatitis - HFrEF (TTE ___: 40-45%) - NSTEMI (___) - Episode of atrial fibrillation ___ Social History: ___ Family History: Father has coronary artery disease. Brother with drug addiction. Mother alive and healthy. Physical Exam: VITALS: 97.5 PO 124/66L Lying 84 18 96% RA GENERAL: Alert, NAD, does not know why he is in hospital and unable to complete capacity assessment HEENT: Sclerae anicteric CARDIOVASCULAR: normal rate, irregular rhythm, normal S1 + S2, no murmurs, rubs, gallops LUNGS: CTAB without wheezes, rales, rhonchi GU: No foley EXTREMITIES: WWP NEURO: Face grossly symmetric. Moving all limbs with purpose against gravity. Pertinent Results: ============== ADMISSION LABS ============== ___ 12:50PM PLT COUNT-320 ___ 12:50PM NEUTS-51.3 ___ MONOS-8.8 EOS-7.4* BASOS-1.5* IM ___ AbsNeut-3.87 AbsLymp-2.31 AbsMono-0.66 AbsEos-0.56* AbsBaso-0.11* ___ 12:50PM WBC-7.5 RBC-4.26* HGB-13.6* HCT-39.2* MCV-92 MCH-31.9 MCHC-34.7 RDW-13.6 RDWSD-46.3 ___ 12:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:50PM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-1.7 ___ 12:50PM proBNP-898* ___ 12:50PM estGFR-Using this ___ 12:50PM GLUCOSE-10* UREA N-10 CREAT-1.1 SODIUM-132* POTASSIUM-3.6 CHLORIDE-91* TOTAL CO2-27 ANION GAP-14 ___ 02:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 02:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 02:50PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POSITIVE* cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 02:50PM URINE HOURS-RANDOM ___ 06:09PM GLUCOSE-51* LACTATE-1.3 ============== DISCHARGE LABS ============== ___ 06:07AM BLOOD WBC-8.7 RBC-3.60* Hgb-11.8* Hct-32.9* MCV-91 MCH-32.8* MCHC-35.9 RDW-13.5 RDWSD-45.8 Plt ___ ___ 06:07AM BLOOD Plt ___ ___ 06:07AM BLOOD Glucose-80 UreaN-7 Creat-0.8 Na-136 K-4.1 Cl-100 HCO3-25 AnGap-11 ___ 06:07AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.6 ___ 05:00AM BLOOD %HbA1c-7.4* eAG-166* ============== IMAGING ============== ___ CHEST (PA & LAT) -Mildly increased interstitial prominence and hyperinflation may be related to chronic obstructive pulmonary disease. There is no pleural effusion or pneumothorax. There are atherosclerotic calcifications and tortuosity of the aorta. Coronary artery stent is also noted. Cardiomediastinal silhouette is within normal limits. - IMPRESSION: No definite focal consolidation. Hyperinflation. ___ CT HEAD W/O CONTRAST - There is no evidence of acute intracranial hemorrhage, mass, mass effect or shifting of the normally midline structures. The ventricles and sulci are prominent suggesting cortical volume loss for the patient's age. Confluent areas of low attenuation are demonstrated in the subcortical and periventricular white matter, which are nonspecific and may reflect areas of small vessel disease, which is also unusual in this age group, please correlate. Dense vascular arteriosclerotic calcifications are present the carotid siphons bilaterally as well as the left vertebral artery. No fractures are identified. The soft tissues and bony structures are unremarkable, the mastoid air cells are clear. - IMPRESSION: There is no evidence of acute intracranial process, however the ventricles and sulci are prominent for the patient's age. Areas of low attenuation in the subcortical and periventricular white matter are nonspecific and may reflect changes due to small vessel disease, which is also unusual in this age group, please correlate. ============== MICRO ============== ___ Blood culture x2: NGTD ___ Urine culture: NGTD Brief Hospital Course: ======================= BRIEF SUMMARY ======================= Mr. ___ is a ___ year old male veteran with history of DM (HbA1c 7.4%), COPD (not on home O2), CAD s/p stent placement, and alcohol abuse brought in by EMS after being found down with confusion and hypoglycemia (FSBG <20) likely secondary to iatrogenic insulin. In the ED, he received 2A dextrose and subsequently became more alert and active. CXR and CT head were negative for cause of his symptoms. He received mIVF with ___ until he was able to take good PO. Pt refused to engage in care at ___, requesting transfer to ___ for further management. Patient unable to engage in conversation around capacity or why he is hospitalized due to agitation. Of note, Mr. ___ reportedly has had 3 prior ED evaluations and admissions for similar episodes of hypoglycemia and AMS, with recommendations to decrease basal insulin from 15U to 10U or discontinue. Insulin seems to be unsafe for this gentleman with suboptimal use of oral agents. Insulin was stopped on admission and metformin increased from 500 to 1000mg ER. He was ultimately transferred to the ___ for further treatment, per pt request. ======================== TRANSITIONAL ISSUES: ======================== - Carefully monitor blood glucose. Insulin was discontinued and metformin dose increased from 500mg to 1000mg. - He will need close follow-up with his providers at the ___ for optimal DM management. Oral agents are likely safer for Mr. ___ than insulin, although it is unknown to us whether he has tried these in the past. Consider initiating sulfonylurea at low dose DPP-4 inhibitors, GLP-1 receptor agonists or a thiazolidinedione. Although the thiazolidinedione class is beleieved to increase HF exacerbation risk, there is some alternate trial data to support use (PIRAMID trial). - Will also need follow up at the ___ for anticoagulation for atrial fibrillation management as he is not currently on any and history of fall is not necessarily a contraindication. - Receives care at ___ ___ ___ (last 4 are 1544). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. TraZODone 25 mg PO QHS:PRN insomnia 2. Sildenafil 100 mg PO ASDIR 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Tiotropium Bromide 1 CAP IH DAILY 5. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 6. Lisinopril 40 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Glargine 13 Units Breakfast 9. GuaiFENesin ER 1200 mg PO Q12H 10. Gabapentin 600 mg PO DAILY 11. Furosemide 60 mg PO DAILY 12. Codeine Sulfate ___ mg PO TID:PRN pain 13. Vitamin D ___ UNIT PO DAILY 14. Calcium Carbonate 500 mg PO BID 15. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY 16. Atorvastatin 80 mg PO QPM 17. Aspirin 81 mg PO DAILY 18. amLODIPine 5 mg PO DAILY 19. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob Discharge Medications: 1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY Diabetes 2. Albuterol Inhaler 1 PUFF IH Q6H:PRN sob 3. amLODIPine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO QPM 6. Budesonide Nasal Inhaler 180 mcg/actuation nasal DAILY 7. Calcium Carbonate 500 mg PO BID 8. Codeine Sulfate ___ mg PO TID:PRN pain 9. Furosemide 60 mg PO DAILY 10. Gabapentin 600 mg PO DAILY 11. GuaiFENesin ER 1200 mg PO Q12H 12. Lisinopril 40 mg PO DAILY 13. Metoprolol Succinate XL 100 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. Sildenafil 100 mg PO ASDIR 16. Tiotropium Bromide 1 CAP IH DAILY 17. TraZODone 25 mg PO QHS:PRN insomnia 18. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: ================== PRIMARY DIAGNOSIS ================== HYPOGLYCEMIA ENCEPHALOPATHY DIABETES MELLITUS ================== SECONDARY DIAGNOSES ================== Heart failure Hypertension Atrial fibrillation COPD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___. Please see below for information on your time in the hospital. ================================ WHY WAS I IN THE HOSPITAL? ================================ - You were brought to ___ because you were found down, unable to respond, by emergency medical services (EMS) who found your blood sugar to be dangerously low. ================================ WHAT HAPPENED IN THE HOSPITAL? ================================ - You received sugar to bring your blood sugar levels up and you became more responsive and awake. - We ruled out infection as a possible cause for your symptoms and found that you were likely getting too much insulin. - We stopped your insulin and increased your metformin dose and kept a close eye on your blood sugar. ================================ WHAT SHOULD I DO WHEN I GO HOME? ================================ - Take your medications are prescribed. - Do not take any more insulin. Please take your metformin at your new dose (1000mg). - Follow up with your doctors at the ___ for better management of your diabetes. We wish you the best! -Your Care Team at ___ Followup Instructions: ___
19959499-DS-18
19,959,499
29,332,991
DS
18
2174-07-15 00:00:00
2174-07-16 14:21:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Dyspnea, Orthopnea and Weight Gain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: ___ hx of CAD, AS ___ 1.0-1.2cm2), CHF (EF~25% ECHO ___ s/p ICD placement presents with recurrent dyspnea and significant weight gain. Patient reports that he was having difficulty sleeping last night and awoke several times due to coughing. He describes the episode as feeling as though he was gasping for air, unable to breathe or cough up phlem. He attempted to use cough medicine and his advair, which did not help him. He typically sleeps on two pillows a night, but sitting up even more did not help. He also reports attempting to urinate many times without success and also had some light headedness. In the morning, his wife noted his distress and urged him to take his weight. With this, he reports having gained ___ lbs over the last two days when he last checked. He denies chest pain, fevers, nausea, vomiting and chills. He denies salty meals as of late and reports taking his furosemide as prescribed. In the ED, his initial vitals were: 99.0 70 141/52 18 97% RA. Interventions included a CXR that showed chronic disease at the RLL with evidence of overload, an U/S that was negative for heart effusions, an EKG that was consistent with prior EKGs, a WBC that was normal, a digoxin level that was therapeutic, and he was given IV lasix 40mg and CTX/Axithro for concern of PNA. He subsequently urinated and had BMx2 before being admitted to the SIRS. Of note, he was recently admitted (___) for dyspnea and chest pain, found to be in acute decompensated systolic heart failure. He described chest pain and cough, which were felt to be secondary to bronchitis. He was diuresed from admission weight of 115.2 kg down to 112.9 kg upon discharge and continued on losartan, carvedilol, furosemide 80mg BID, spironolactone, and digoxin. Currently, he is feeling well and has no complaints. Denies CP, SOB, dizziness, headaches, vision changes, nausea and vomiting. ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - CAD - s/p MI treated with CABG in ___. LVEF 20% at the time. - s/p Metronic ICD - single chamber, due to to inducible VT not suppressed by procainamide - Chronic sCHF LVEF 44% on ___ ___ cath, LVEF 25% ___ by echo - Hypertension - Hyperlipidemia with hypertryglceridemia - Type 2 diabetes on insulin for ___ years c/b nephropathy. No retinopathy - Peripheral vascular disease - AAA - s/p three stent grafts - Former smoker ___ years ago - ___ years of age, quit ___ - ___ arterial clots - on coumadin - Hx of cataract surgery - Hx of pneumonia - Obesity - Hypothyroidism - GERD - Gout Social History: ___ Family History: Mother- ___ years old, still alive, HTN Father- Died at age ___ of MI Brother- Had an MI at age ___ Sister- ___ years old, healthy Physical Exam: Admission: ================== VS - 98.0 145/75 70 18 92%RA ___ 117 General: NAD, sitting in bed, pleasant to conversation HEENT: AT/NC. Small dry skin/rash on right side of scalp, PEERL, EOMI, MMM, hearing intact to normal conversation Neck: Supple, no thyromegaly, no JVD appreciated CV: IV/VI systolic ejection murmur that radiates to the carotids Lungs: CTA-in left lung and upper right lung. Wheezes and crackles noted in the right lower lung base. Abdomen: SNTND, no organomegaly GU: Deferred Ext: WWP, no cyanosis, 2+ edema up to knees bilaterally Neuro: A&Ox3 Discharge: ================ VS: 97.6 119/52-166/88 55-67 18 97% RA Wt: 108.1kg-->108.1kg Gen: well appearing, NAD, comfortable HEENT: NCAT, clear OP Neck: JVP 2cm above clavicle at 45 degrees, no cervical LAD CV: nls1s2 RRR II/VI systolic murmur radiating to carotids Pulm: faint end expiratory wheeze diffusely Abd: soft, NT ND +BS Ext: wwp, 2+ DP, ___ and radial pulses Neuro: AAOx3, CNII-XII grossly intact. Pertinent Results: CBC: ___ 11:30AM BLOOD WBC-5.4 RBC-3.33* Hgb-11.9* Hct-33.4* MCV-100* MCH-35.7* MCHC-35.6* RDW-13.4 Plt ___ ___ 06:45AM BLOOD WBC-5.3 RBC-3.30* Hgb-11.6* Hct-33.5* MCV-101* MCH-35.1* MCHC-34.6 RDW-13.6 Plt ___ ___ 06:45AM BLOOD WBC-6.4 RBC-3.88* Hgb-13.5* Hct-39.3* MCV-101* MCH-34.7* MCHC-34.3 RDW-13.1 Plt ___ Chem 7: ___ 11:30AM BLOOD Glucose-186* UreaN-22* Creat-1.2 Na-139 K-4.3 Cl-107 HCO3-23 AnGap-13 ___ 06:45AM BLOOD Glucose-133* UreaN-21* Creat-1.3* Na-140 K-3.8 Cl-104 HCO3-26 AnGap-14 Other: ___ 11:30AM BLOOD proBNP-1432* ___ 11:30AM BLOOD Digoxin-0.4* ___ 11:30AM BLOOD cTropnT-<0.01 Imaging: CXR ___: IMPRESSION: Mild interstitial pulmonary edema. Relative increase in opacity at the right lung base could be due to underlying infection/pneumonia or relate to assymetric fluid overload. Cardiac Cath: 1. Native 2 vessel totally occlusive CAD, with mild diffuse atherosclerosis in the native ungrafted RCA. 2. Occluded SVG-ramus intermedius. 3. Patent SVG-OM with disease in the retrogradely perfused proximal portion of the grafted OM. 4. Patent LIMA-LAD with mid graft tortuousity. 5. Normal to slightly elevated PCW. 6. Mild pulmonary hypertension. 7. Moderate left ventricular diastolic heart failure. 8. Mild-moderate aortic stenosis. 9. Decreased cardiac index in setting of known chronic left ventricular systolic heart failure (likely non-ischemic). Given cardiac output >4 L/min, dobutamine not administered (after telephone consultation with Dr. ___ attending of record and Heart Failure Service attending). 10. Peripheral arterial disease, with 50 mm Hg gradient from left radial arterial pressure to left thigh NIBP. 11. Routine TR Band care. 12. Right antecubital venous sheath to be removed. 13. Heparin infusion may be resumed without bolus 2 hours after arterial hemostasis. 14. Reinforce secondary preventative measures against CAD and left ventricular systolic and diastolic heart failure. 15. F/U with Dr. ___ Dr. ___. Stress Echo: The patient received intravenous dobutamine in 5 min (low dose 5mcg/kg/min) and 3 minute stages (>5mcg/kg/min) to a maximum of 10 mcg/kg/min. The test was stopped because of increasingly frequent ventricular ectopy (see exercise report for details). Intravenous metoprolol was administered in early recovery. In response to stress, the ECG showed no diagnostic ST-T wave changes (see exercise report for details). The blood pressure response to exercise was normal. There was a blunted heart rate response to stress [beta blockade]. . Resting images were acquired at a heart rate of 60 bpm and a blood pressure of 118/56 mmHg. These demonstrated regional left ventricular systolic dysfunction with hypokinesis of the mid ventricle, akinesis of the distal ventricle, and dyskinesis of the apex. The remaining segments contracted well (LVEF = ___ %). Right ventricular free wall motion is normal. There is no pericardial effusion. Doppler demonstrated no aortic regurgitation and mild mitral regurgitation without significant resting LVOT gradient. The resting LVOT VTI was 26 cm and the AoV VTI was 60 cm with a calculated aortic valve area of 1.8 cm2. At low dose dobutamine [5mcg/kg/min; heart rate 60 bpm, blood pressure 134/60 mmHg], there was mild augmentation of all left ventricular segments; the apex remained dyskinetic. The LVOT VTI was 26 cm and the AoV VTI was 63 for a calculated aortic valve area of 1.6 cm2. At peak dobutamine stress [10 mcg/kg/min; heart rate 71 bpm, blood pressure 152/64 mmHg), no new regional wall motion abnormalities were identified. Baseline abnormalities persist. The peak LVOT VTI was 35 cm and the peak AoV VTI was 90 cm for a calculated AoV area of 1.6 cm2. IMPRESSION: No significant ECG changes with 2D echocardiographic evidence of prior myocardial infarction (multivessel coronary artery disease) without inducible ischemia to achieved workload. Mild mitral regurgitation at rest. Mild aortic stenosis ___ 1.8 cm2 at rest; 1.6 cm2 at peak infusion of dobutamine). Frequent ventricular ectopy. Test terminated secondary to increasing ventricular irritability. No anginal symptoms or ischemic ST segment changes. Appropriate blood pressure response to the Dobutamine infusion. Echo report sent separately. Brief Hospital Course: ___ hx of CAD, AS ___ 1.0-1.2cm2), CHF (EF~25% ECHO ___ s/p ICD placement who presented with dyspnea, orthopnea, and significant weight gain found to have a CHF exacerbation in the setting of worsening valvular disease, transferred to cardiology for further evaluation for aortic stenosis ACTIVE ISSUES: ==================== # Acute on CHF Exacerbation: The etiology of these symptoms are likely secondary to a CHF exacerbation in the setting of eating a salty meal and worsening aortic stenosis. Admission wt 116kg. Diuresed with lasix 80mg IV BID. Became euvolemic with wt down to 108kg. Started back on lasix 80mg PO BID (discharge weight). Patient was continued on spironolactone, carvedilol, and losartan. Further work-up for aortic stenosis below. # Aortic Stenosis: Patient arrived with CHF symptoms that were thought to be ___ worsening valve function. Patient had cardiac catheterization (pre-op for AVR) which showed a valve area of 1.5cm2. He then underwent a dobutamine stress test which showed a functional severe aortic stenosis. He was referred to cardiac surgery who recommended carotid ultrasound and chest CT. He was then would be contacted by csurge after discharge for AVR. # ___: Patient has baseline Cr of 1.2. With diuresis, he had a Cr of 1.4, which then trended back to normal. PAtient again developed ___ with Cr to 1.6, which then trended downwards to 1.3 at the time of discharge. # CAD: Patient underwent cardiac catheterization in the setting of pre-op evaluation for AVR. This revealed an occluded SVG to Ramus; the other grafts were patent. He was continued on his home regimen and ASA was added. # History of Arterial Clot: Patient had a history of arterial clot in LLE in the setting of AAA repair and likely LV thrombus ___ chf). In anticipation for procedures, coumadin was held and patient was bridged on to IV heparin. At discharge his INR remained subtherapeutic and he was sent home with SC lovenox bridge. INACTIVE ISSUES =================== #) HL: Continued on Atorvostatin. #) HTN: Continued lasix, losartan, carvediol. #) DMII: Continued 70/30 with HISS. #) Hypothyroid: Continued levothyroxine #) GERD: Continued omeprazole #) GOUT: Continued allopurinol #) COPD: Continued nebs #) Fe Deficiency: Continued iron supplementation. #) B12 Def: Continued B12 #) Arthritis: 1300mg/Day Acetaminophen Transitional Issues: ====================== # Full Code # INR and CHEM 7 check two days after discharge to be faxed to PCP # AVR: csurge to contact patient after discharge. he was provided with the number if the patient wasn't contact in a few days. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN Pain 2. Allopurinol ___ mg PO DAILY 3. Carvedilol 12.5 mg PO BID 4. Digoxin 0.125 mg PO QPM 5. DiphenhydrAMINE 25 mg PO HS:PRN Niacin pretreatment 6. Docusate Sodium 100 mg PO BID 7. Ferrous Sulfate 65 mg PO TID W/MEALS 8. Fish Oil (Omega 3) 1000 mg PO BID 9. Furosemide 80 mg PO BID 10. Levothyroxine Sodium 50 mcg PO DAILY 11. Losartan Potassium 50 mg PO DAILY 12. Multivitamins 1 TAB PO DAILY 13. Omeprazole 20 mg PO BID 14. Spironolactone 25 mg PO DAILY 15. Vitamin D ___ UNIT PO DAILY 16. Warfarin 5 mg PO DAILY16 17. Atorvastatin 40 mg PO DAILY 18. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN Cough 19. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 20. Cyanocobalamin 1000 mcg PO DAILY 21. fenofibrate *NF* 160 mg Oral daily 22. Flovent Diskus *NF* (fluticasone) 100 mcg/actuation Inhalation BID 23. Niaspan Extended-Release *NF* (niacin) 500 mg Oral QHS 24. NovoLIN 70/30 *NF* (insulin NPH & regular human) 100 unit/mL (70-30) Subcutaneous BID Discharge Medications: 1. Acetaminophen 1300 mg PO Q8H:PRN Pain 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea 3. Allopurinol ___ mg PO DAILY 4. Atorvastatin 40 mg PO DAILY 5. Carvedilol 12.5 mg PO BID 6. Cyanocobalamin 1000 mcg PO DAILY 7. Digoxin 0.125 mg PO QPM Systolic HF 8. DiphenhydrAMINE 25 mg PO HS:PRN Niacin pretreatment 9. Docusate Sodium 100 mg PO BID 10. Ferrous Sulfate 65 mg PO TID W/MEALS 11. Fish Oil (Omega 3) 1000 mg PO BID 12. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN Cough 13. Levothyroxine Sodium 50 mcg PO DAILY Hypothyroid 14. Losartan Potassium 50 mg PO DAILY 15. Multivitamins 1 TAB PO DAILY 16. Omeprazole 20 mg PO BID 17. Spironolactone 25 mg PO DAILY Systolic HF 18. Vitamin D ___ UNIT PO DAILY 19. Warfarin 4 mg PO DAILY H/o Arterial Thrombosis 20. fenofibrate *NF* 160 mg Oral daily 21. Flovent Diskus *NF* (fluticasone) 100 mcg/actuation Inhalation BID 22. Furosemide 80 mg PO BID Hold if SBP<100, HR<90 23. Niaspan Extended-Release *NF* (niacin) 500 mg Oral QHS 24. NovoLIN 70/30 *NF* (insulin NPH & regular human) 100 unit/mL (70-30) Subcutaneous BID 25. Enoxaparin Sodium 110 mg SC BID RX *enoxaparin 120 mg/0.8 mL 0.8 mL SC twice a day Disp #*30 Syringe Refills:*0 26. Aspirin 81 mg PO DAILY 27. Outpatient Lab Work INR CHEM7 to be faxed to Dr. ___ ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY:CHF Exacerbation, Acute on chronic renal failure, Diabetes Mellutis, Aortic Stenosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you here at ___ ___. You were admitted to the ___ for shortness breath, likely from a CHF exacerbation. While here, you were given increased doses of your lasix to remove the fluid from you lungs. This was maintained until your weight reduced to that of your previous discharge weight. We think that your CHF exacerbation was from your heart valve that is not functional well. We had the cardiac surgeons come see you who recommended surgery. Dr. ___ will call you tomorrow to schedule an appointment. If they have not called you his number is ___. You should continue to weigh yourself every morning, and call your MD if your weight goes up more than 3 lbs. You should also follow up with your cardiologist immediately. It was a pleasure to care for you at the ___. Followup Instructions: ___
19959691-DS-13
19,959,691
20,297,285
DS
13
2117-03-20 00:00:00
2117-03-20 16:29:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: headache Major Surgical or Invasive Procedure: Cerebral angiogram History of Present Illness: ___ who was in his usual state of health today and reports while working he experienced the worse headache he has felt. This occurred at about 4pm. He works as a ___ for a hotel. He describes the headache as very strong and intense, originating in the occipital region then radiating down his neck and down the left side of his body. He reports blurry vision during the headache and nausea. Denies vomiting. Denies any fevers. He was seen at an OSH where a head CT was negative, per ER reports an LP was performed which was positive. He was transferred to ___ for further management. PMHx: -Diabetes -HTN in past / currently off meds -? Head trauma in ___ in the ___- MVA that left large laceration but denies any intracranial surgery. -Left knee surgery for cyst removal All: NKDA Medications prior to admission: Metformin twice daily Ibuprofen prn Social Hx: ___ Family Hx: Colon cancer, denies cardiac or neurological history. No known familial hx of aneurysms ROS: pain ___ l neck PHYSICAL EXAM: O: T: 98.0 BP: 118/79 HR: 85 R 16 O2Sats 100% Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, no visible sign of trauma Neck: no nuchal rigidity Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: R pupil 3-2mm, L pupil slightly smaller 2.5-2mm. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger Handedness: Right CTA Head/Neck: Question of 1 mm left supraclinoid ICA aneurysm vs. outpouching (Recons pending) Labs: LP results from OSH CSF Tube 4: WBC 44, RBC 6667, Gluc 122, Prot 50 Positive xanthochromia per ER to ER report Assessment/Plan: ___ who reports experiencing the WHOL at 4pm, was taken to an OSH where a head CT was negative, LP positive, and transferred to ___. A CTA head/neck performed at ___ showed a question of a tiny L supraclinoid ICA aneurysm. Given that this possible tiny aneurysm correlates to patient's symptoms, ICU admission is recommended Past Medical History: -Diabetes -HTN in past / currently off meds -? Head trauma in ___ in the ___- MVA that left large laceration but denies any intracranial surgery. -Left knee surgery for cyst removal Social History: ___ Family History: Colon cancer, denies cardiac or neurological history. No known familial hx of aneurysms Physical Exam: O: T: 98.0 BP: 118/79 HR: 85 R 16 O2Sats 100% Gen: WD/WN, comfortable, NAD. HEENT: normocephalic, no visible sign of trauma Neck: no nuchal rigidity Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: R pupil 3-2mm, L pupil slightly smaller 2.5-2mm. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift Sensation: Intact to light touch Toes downgoing bilaterally Coordination: normal on finger-nose-finger Handedness: Right Pertinent Results: CTA Head/Neck: Question of 1 mm left supraclinoid ICA aneurysm vs. outpouching Labs: LP results from OSH CSF Tube 4: WBC 44, RBC 6667, Gluc 122, Prot 50 Positive xanthochromia per ER to ER report ___ Angiogram: small infundibulm anterior choridal, no aneurysm Brief Hospital Course: Pt was admitted to neurosurgery and monitored closely in the ICU. He remained neurologically intact throughout his hospital stay. He underwent angigram on ___ AM which showed no aneursym. His headache lessened. He was stable post-angiogram. His metformin was held secondary to dye-load from angiogram. He was kept flat for 6 hours post-angio and then diet and activity advanced. He was discharged to home with followup with PCP ___ 2 days to check renal function. Medications on Admission: Metformin twice daily Ibuprofen prn Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain/ fever. 2. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): do not take and ___ not resume until blood work done by PCP and kidney function is confirmed normal. 3. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 4. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while on pain med. Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Headache traumatic lumbar puncture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: No heavy lifting for one week. Remain out of work for one week. Do not take your metformin until bloodwork done by your PCP. Followup Instructions: ___
19959697-DS-12
19,959,697
22,344,558
DS
12
2157-05-10 00:00:00
2157-05-10 23:00:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: latex / aloe ___ ___. Chief Complaint: R Side Weakness Major Surgical or Invasive Procedure: right carotid endarterectomy History of Present Illness: Mr. ___ is a ___ yo man with significant vascular risk factors, R ICA 80%+ stenosis, and left pontine stroke in ___ with mild residual weakness who presented with worsened right weakness and dysarthria. The patient states that on ___ he started tripping and felt his R leg to be wobbly. Then on ___ his weakness was worse and he was unable to sweep the floor or make his bed, which he can usually do. He developed chest pain around 11:30 pm on ___ and took SL NG. The pain only lasted ___ min and did not feel like his prior MIs. His ex-wife made him come to the emergency room at that time. The history per the son is slightly different. He has had a headache for 2 weeks. He has had trouble walking for 1 week with a limp, his son thinks possibly due to pain or dysequilibrium. He gets tired easily, with shortness of breath. Climbing stairs is particularly challenging. He has had drenching sweats occasionally when sleeping for the past 2 weeks, although his room is kept really cold by the AC. He fell twice a few days ago. The patient was tired today. He slept most of the day. He seemed "out of it". Today around 11 pm the patient was mumbling and could not move his right side at all. He could not feel his right arm being touched. This is similar to his prior stroke presentation. He has been home since ___. At his new baseline, he can do chores, cook dinner, bathes, dresses. His speech is normal speed except when he is tired. At ___, CT ___ was negative for hemorrhage. Glucose was 300. The patient was transferred to ___ for consideration of intra-arterial intervention (initially he was thought to have been last normal at 10 pm on ___. The patient denies problems with vision, hearing. No recent illness, fevers, cough, flu, diarrhea, stomach pain, blood in urine/stool. Past Medical History: R ICA stenosis 80% L pontine stroke ___ - R arm and leg weakness, etiology unknown, glucose at that time 750, ASA increased to 325 DM c/b by osteomylitis of R ___ toe s/p amputation, peripheral neuropathy, repeated skin infections HTN CAD MI x2, no cardiac stents but known RCA 60% stenosis CKD Depression Social History: ___ Family History: - no strokes, seizures, brain tumors - brother - MI Physical ___: Admission Physical Exam: Vitals: BP= 161/82, HR= 86, RR= 11, SaO2= 97% General: Awake, cooperative, NAD. HEENT: NC/AT, dry mucous membranes Neck: Supple, R carotid bruit, No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: multiple scars on legs. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history but with difficulty. Language is fluent with intact repetition and comprehension. Slow prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. Attentive, able to name ___ backward but slowly. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch in all distributions VII: No facial droop, facial musculature symmetric and ___ strength in upper and lower distributions, bilaterally VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. R pronator drift. 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 R ___ ___ ___ 2 3 3 4 -DTRs: Bi Tri ___ Pat Ach L 1 1 1 0 0 R 1 1 1 0 0 - Plantar response was mute bilaterally. - Pectoralis Jerk was absent, and Crossed Adductors are absent. -Sensory: Diminished light touch, pinprick, and proprioception in BLE in stocking distribution, to level of knees. -Coordination: No dysmetria on FNF or HKS bilaterally. Unable to perform R HKS due to weakness. -Gait: Not tested. = = = ================================================================ Discharge Physical Exam T:99; Pulse:84; BP:138/75; Sats:97% General: awake and alert, NAD Neuro: A/Ox3, CNII-XII grossly intact HEENT: neck incision CDI, no erythema Cards: RRR Pulm: CTAB Abd: no tenderness, no distension, no rebound/guarding Pertinent Results: IMaging: MR ___ (___): FINDINGS: There is no evidence of hemorrhage, edema, masses, mass effect, midline shift or infarction. The ventricles and sulci are prominent for the patient's age, suggesting cortical volume loss. No diffusion abnormalities are detected. The major vascular flow voids are present and demonstrate normal distribution. The paranasal sinuses and mastoid air cells are clear, the orbits are unremarkable. IMPRESSION: 1. No acute intracranial abnormality. TTE (___): The left atrium is normal in size. No thrombus/mass is seen in the body of the left atrium. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. 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. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CT and CTA ___ (___): CT noncontrast ___: There is no acute intracranial hemorrhage, infarction, mass, mass effect, or midline shift. The ventricles and sulci are normal in size and configuration. CTA ___: The vessels of the circle of ___ and their principal intracranial branches are patent without stenosis, occlusion or aneurysm formation. The right A1 segment is absent or hypoplastic. Irregularity and narrowing of the right ophthalmic segment of the internal carotid arteries are related to atherosclerotic calcifications. The dural venous sinuses are patent. CTA NECK: There is a short segment of near occlusion of the right proximal internal carotid artery at the carotid bifurcation on 5:149 related to soft and calcified plaque. A lumen of the right proximal internal carotid artery measures less than 0.5 mm. The remainder of the distal right internal carotid artery measures 5 mm. The remainder of the cervical and intracranial segments of the right internal carotid artery are diminutive in caliber relative to the left internal carotid artery. There is no evidence of stenosis or occlusion of the left internal carotid artery by NASCET criteria. There are atherosclerotic calcifications at the origins of the vertebral artery, which remain patent. OTHER: Subsegmental atelectasis is noted in the left upper lobe. A 3 mm solid nodule in the right upper lobe is noted on 05:53. The visualized portion of the thyroid gland is within normal limits. There is no lymphadenopathy by CT size criteria. IMPRESSION: 1. Short-segment, near occlusion with greater than 90% estimated stenosis of the right proximal internal carotid artery by NASCET criteria. 2. Patent circle of ___. 3. No evidence of left internal carotid artery stenosis by NASCET criteria. 4. There is a 3 mm right upper lobe nodule. If the patient is at low risk for malignancy, no further follow-up is necessary. If the patient is at high risk for malignancy, CT follow-up is recommended in 12 months. These guidelines are based on ___ criteria. RECOMMENDATION(S): Three mm right upper lobe nodule. If the patient is at low risk for malignancy, no further follow-up is necessary. If the patient is at high risk for malignancy, CT follow-up is recommended in 12 months. These guidelines are based on ___ criteria. Brief Hospital Course: Mr. ___ is a ___ yo man with prior left pontine stroke with R weakness at that time, and multiple vascular risk factors including R ICA critical stenosis who presented with subacute decline over 2 weeks with lethargy, drenching sweats, worsening R weakness. He was admitted to neurology at ___ ___ to these symptoms where he received a workup for possible stroke/TIA. MRI was negative for stroke as was subsequent infectious workup and he remained afebrile without leukocytosis. He was then transferred to vascular surgery for his planned CEA on ___. On that day he underwent the procedure, which he tolerated well. He was extubated in the OR and sent to the PACU. He was started on a dextan drip. In the PACU, his blood pressures were labile in the 80/60's. He was given 1L LR bolus, which he was not responsive to, so neo drip was started. His BP went to 140's systolic on 0.2 neo so it was discontinued and he was given another 1L LR bolus. His blood pressure then stabilized after fluid resuscitation to 100s systolic before being transferred to the floor. On ___, his dextran drip was stopped, his foley was pulled and his blood pressure remained stable in the 130s systolic. He was seen by ___ later that day and cleared to go home (receives home ___ already and has outpatient visits at ___. He was discharged home ___ in good condition. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Gabapentin 1200 mg PO BREAKFAST 2. Gabapentin 1800 mg PO NOON 3. Sertraline 100 mg PO BID 4. Simvastatin 10 mg PO DAILY 5. Glargine 40 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner 6. Morphine SR (MS ___ 30 mg PO DAILY 7. Multiple Vitamins Liq. Dose is Unknown PO DAILY 8. Aspirin 325 mg PO DAILY 9. Fish Oil (Omega 3) Dose is Unknown PO DAILY 10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 11. Nitroglycerin SL 0.4 mg SL DAILY 12. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Gabapentin 1200 mg PO BREAKFAST 2. Gabapentin 1800 mg PO NOON 3. Aspirin 325 mg PO DAILY 4. Sertraline 100 mg PO BID 5. Simvastatin 10 mg PO DAILY 6. Metoprolol Succinate XL 25 mg PO DAILY 7. Nitroglycerin SL 0.4 mg SL DAILY 8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 9. Acetaminophen 325-650 mg PO Q6H:PRN pain RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every 6 hours Disp #*45 Tablet Refills:*0 10. Morphine SR (MS ___ 30 mg PO DAILY 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every 4 hours Disp #*60 Tablet Refills:*0 13. Multivitamins 1 TAB PO DAILY 14. Glargine 46 Units Bedtime Humalog 6 Units Breakfast Humalog 6 Units Lunch Humalog 6 Units Dinner Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Right carotid stenosis 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 right carotid endarterectomy. You have now recovered from surgery and are ready to be discharged. Please follow the instructions below to continue your recovery: WHAT TO EXPECT: 1. Surgical Incision: • It is normal to have some swelling and feel a firm ridge along the incision • Your incision may be slightly red and raised, it may feel irritated from the staples 2. You may have a sore throat and/or mild hoarseness • Try warm tea, throat lozenges or cool/cold beverages 3. You may have a mild headache, especially on the side of your surgery • Try ibuprofen, acetaminophen, or your discharge pain medication • If headache worsens, is associated with visual changes or lasts longer than 2 hours- call vascular surgeon’s office 4. It is normal to feel tired, this will last for ___ weeks • You should get up out of bed every day and gradually increase your activity each day • You may walk and you may go up and down stairs • Increase your activities as you can tolerate- do not do too much right away! 5. It is normal to have a decreased appetite, your appetite will return with time • You will probably lose your taste for food and lose some weight • 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 MEDICATION: • Take all of your medications as prescribed in your discharge ACTIVITIES: • No driving until post-op visit and you are no longer taking pain medications • No excessive ___ turning, lifting, pushing or pulling (greater than 5 lbs) until your post op visit • You may shower (no direct spray on incision, 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 over the area CALL THE OFFICE FOR: ___ • Changes in vision (loss of vision, blurring, double vision, half vision) • Slurring of speech or difficulty finding correct words to use • Severe headache or worsening headache not controlled by pain medication • A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg • Trouble swallowing, breathing, or talking • Temperature greater than 101.5F for 24 hours • Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: ___
19959697-DS-14
19,959,697
24,526,526
DS
14
2158-05-05 00:00:00
2158-05-06 13:04:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: latex / aloe ___ / penicillin G Attending: ___. Chief Complaint: Chronic infected left malleolar ulcer. Major Surgical or Invasive Procedure: Left below knee amputation (___) History of Present Illness: This patient is a ___ male who was admitted to the vascular surgery service for non-healing left lateral malleolus arterial wound drainage-referred from Dr. ___ clinic. Patient states that the wound has been refractory to antibiotic therapy (carbapenem-resistant Enterobacteriaceae). Of note, the patient has a history of left ankle osteomyelitis, post fracture requiring external fixation in ___. He has no fevers, chills, or night sweats. Dr. ___ a skin graft to cover the wound or a below knee amputation and the patient elected for the ___ and was admitted to vascular surgery for the procedure. VASCULAR ROS: Carotid: WNL. Mesenteric Ischema: WNL. Claudication: WNL. Ischemic Pain: WNL. AAA: WNL. DVT: WNL. Varicose Veins: WNL. Arterial Ulcers: ABNL: Left lateral malleolus ulcer. Venous Stasis Ulcer: WNL. Phlebitis: No. REVIEW OF SYSTEMS: General/skin/sleep: WNL. Respiratory: WNL. Musculoskeletal: ABNL: Graft pulse is palpable and area around the ulcer is viable. Endocrine: WNL. HEENT Eye: WNL. Ears: WNL. Nose: WNL. Mouth: WNL. Throat: WNL. Cardiovascular: WNL. Neuro/psych: WNL. GI: WNL. GU: WNL. Past Medical History: Hypertension, IDDM, Diabetic neuropathy, CKD, depression, anxiety, renal insufficiency, obesity, OSA, CAD (MI x2, no cardiac stents but known RCA 60% stenosis), PVD s/p stents x2 RLE, Left pontine stroke ___ (R arm and leg weakness, etiology unknown), COPD, recurrent aspiration PAST SURGICAL HISTORY: Right ___ ray amputation, R SFA stent x2 ___ ___), R CEA ___ ___, Umbilical hernia repair, excision of neck cyst Social History: ___ Family History: - No strokes, seizures, brain tumors - Brother - MI Physical ___: ADMISSION PHYSICAL EXAM ======================== Vital Signs: Temp: 98.1 RR: 18 Pulse: 84 BP: 147/72 Neuro/Psych: Oriented x3, Affect Normal, NAD. Neck: No masses, Trachea midline, Thyroid normal size, non-tender, no masses or nodules, No right carotid bruit, No left carotid bruit. Nodes: No clavicular/cervical adenopathy, no inguinal adenopathy. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, No masses, Guarding or rebound,No hepatosplenomegally, No hernia, No AAA. Extremities: Abnormal: Left lateral malleolar ulcer. Pulse Exam (P=Palpation, D=Dopplerable, N=None) RLE Femoral: P. Popiteal: P. DP: P. ___: P. LLE Femoral: P. DP: D. ___: D. DESCRIPTION OF WOUND: Side: Left. Lateral malleolar ulcer with clean edges and bleeding. DISCHARGE PHYSICAL EXAM: ======================== Vitals: 98 159/79 86 16 97%RA I/O: -1000cc overnight General: AAOx3, NAD, lying comfortably sleeping in bed HEENT: NC, AT Lymph: Not examined CV: normal R&R, no M/R/G Lungs: minimal crackles at bilateral bases, no wheezes/rhonchi/rales Abdomen: soft, non-tender, non-distended, no rebound or guarding, normoactive bowel sounds Ext: moving all extremities spontaneously, left BKA, right pinky toe amputation, warm and well perfused, dorsal pedal and medial tibial pulses palpable Neuro: CN2-12 grossly intact, voluntary purposeful movements of extremities, decreased sensation over right foot to knee Skin: confluent maculopapular rash diffusely on back (improving); chronic seborrheic dermatitis on scalp Pertinent Results: ADMISSION LABS: =============== ___ 11:04AM LACTATE-0.9 ___ 10:45AM GLUCOSE-148* UREA N-53* CREAT-3.5*# SODIUM-137 POTASSIUM-4.4 CHLORIDE-105 TOTAL CO2-17* ANION GAP-19 ___ 10:45AM WBC-7.4 RBC-3.06* HGB-8.1* HCT-26.4* MCV-86# MCH-26.5# MCHC-30.7* RDW-15.7* RDWSD-49.0* ___ 10:45AM NEUTS-72.9* LYMPHS-17.0* MONOS-5.7 EOS-2.2 BASOS-0.8 IM ___ AbsNeut-5.37 AbsLymp-1.25 AbsMono-0.42 AbsEos-0.16 AbsBaso-0.06 ___ 10:45AM PLT COUNT-329 DISCHARGE/OTHER PERTINENT LABS: =============== ___ 06:07AM BLOOD WBC-8.6 RBC-2.85* Hgb-7.8* Hct-25.5* MCV-90 MCH-27.4 MCHC-30.6* RDW-14.3 RDWSD-46.4* Plt ___ ___ 06:07AM BLOOD Plt ___ ___ 06:07AM BLOOD Glucose-142* UreaN-45* Creat-3.3* Na-137 K-4.3 Cl-99 HCO3-26 AnGap-16 ___ 06:07AM BLOOD Calcium-8.5 Phos-5.0* Mg-2.3 ___ 05:59AM BLOOD PTH-106* ___ 05:35AM BLOOD 25VitD-18* IMAGING: ======== - Chest CT w/out Contrast: (___) Small bilateral pleural effusions. Diffuse and severe parenchymal opacities, with a dominating ground-glass and a mild interstitial component. The distribution, the gradient, and the combination of the different components strongly favor multifocal pneumonia or pulmonary edema. Mild accompanying mediastinal lymphadenopathy. - Chest X-Ray: (___): substantial interval improvement (___): pulmonary opacifications decreased, cardiac silhouette at upper limit of normal or mildly enlarged (___): some improvement noted (___): some improvement noted (___): slightly worse extensive airspace opacities since ___, progressively worsening since ___, concerning for multifocal infection or severe pulmonary edema (___): pre-existing pulmonary edema has minimally decreased in severity but is still moderate to severe, mild cardiomegaly (___): severe, predominantly centralized pulmonary edema, edema shows a mild interstitial component, no pleural effusions seen, borderline size of the cardiac silhouette (___): Right PICC tip in low SVC, mild vascular congestion ECG: (___): Sinus tachycardia, unchanged since ___: Sinus rhythm with slowing of the rate as compared with prior ECG ___. The previously recorded ST segment depression has improved. (___): Sinus tachycardia. Inferolateral ST segment depression in the context of tachycardia. Consider ischemia. Gross Specimen Left BKA Pathology: 1. Gangrenous necrosis and ulceration of skin and subcutaneous tissue. 2. Atherosclerosis with focal recanalized thrombi. 3. Skeletal muscle atrophy. 4. Bone remodeling. 5. Viable bone and soft tissue at margins. Ankle (AP, Mortise, La) Left: Osteomyelitis calcaneus, talar neck, lateral malleolar soft tissue swelling MICRO: ___ Rapid Respiratory Viral Screen & Culture Respiratory Viral Culture- Respiratory Viral Culture (Final ___: No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at ___ within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final ___: Negative for Respiratory Viral Antigen. Specimen screened for: Adeno, Parainfluenza 1, 2, 3, Influenza A, B, and RSV by immunofluorescence. Refer to respiratory viral culture and/or Influenza PCR (results listed under "OTHER" tab) for further information. ___ URINE Legionella Urinary Antigen Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. Test Result Reference Range/Units SOURCE URINE S.PNEUMONIAE AG DETECT.LA NOT DETECTED ___ MRSA SCREEN MRSA SCREEN MRSA SCREEN (Final ___: No MRSA isolated. ___ SWAB GRAM STAIN-FINAL; WOUND CULTURE- GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: NO GROWTH. ___ BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY WARD - NO GROWTH ___ BLOOD CULTURE - NO GROWTH ___ 13:49 FLU PCR nasal swab Influenza A by PCR NEGATIVE Influenza B by PCR NEGATIVE ___ 04:00PM URINE Osmolal-432 ___ 04:27PM URINE bnzodzp-NEG barbitr-NEG opiates-POS* cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG ___ 04:47AM BLOOD ___ ___ 05:30AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0 Iron-22* ___ 05:30AM BLOOD calTIBC-150* VitB12-337 Folate-5.4 Ferritn-1080* TRF-115* ___ 05:30AM BLOOD %HbA1c-5.5 eAG-111 ___ 05:59AM BLOOD PTH-106* ___ 05:35AM BLOOD 25VitD-18* ___ 03:27AM BLOOD HIV Ab-Negative ___ 08:19PM BLOOD Vanco-17.0 ___ 03:27AM BLOOD Vanco-11.6 ___ 05:58AM BLOOD Vanco-19.2 ___ 05:35AM BLOOD VITAMIN D ___ DIHYDROXY-PND Brief Hospital Course: Mr. ___ is a ___ man who was directly admitted to the vascular service on ___ for a below knee amputation due to a non-healing lateral malleolar arterial ulcer s/p prior revascularization attempts. The patient consented for the procedure and the BKA was performed on ___. His hospital course was complicated by acute kidney injury and a multifocal pneumonia. # Peripheral arterial disease/Left malleolar ulcer s/p BKA: Patient was admitted for an elective BKA for a non-healing infected left lateral malleolar ulcer w/ suspicion of osteomyelitis. The wound is healing well, is clear, dry and non-infected. Patient requires rehabilitation at discharge. Pain has been managed with oxycodone and gabapentin. Patient reports pain well controlled. He is being discharged with a 5 day course of oxycodone to be weaned as able. # Hypoxia: During admission patient developed SOB following his procedure on ___ and desatted with new O2 requirement. A CXR was done which showed pulmonary edema, and he was managed with Lasix. Following another incident of hypoxia a CXR was obtained that showed extensive airspace opacities, concerning for multifocal infection or severe pulmonary edema. The patient was subsequently transferred to the medicine service, and required up to 5L of oxygen. He was managed with Lasix and co-administration of cefepime and vancomycin. Patient improved significantly, and has not required oxygen for >5 days. He reports breathing comfortably on room air and lungs are clear to auscultation bilaterally. A series of subsequent CXRs have shown gradual but substantial interval improvement. The patient received an 8-day course of antibiotics for a presumed healthcare-acquired pneumonia. Oral pharyngeal video swallow ordered to evaluate for aspiration showed significant interval improvement but continued aspiration of liquids. # Acute on Chronic Kidney Injury: Patient's baseline Cr 1.5-1.7 in ___ found to have a Cr 3.5 on admission, unknown if acute or new baseline. Likely to be multifactorial. Patient has a history of CKD. FeUrea 48.7% with examination of urine showing muddy brown casts consistent with ATN, may be ___ ischemia, medication side effects, and/or infection. Recent worsening can also be a result of hypotension or hemodynamic instability during his recent surgery. Patient found to have elevated urine protein/Cr and albumin/Cr ratios. Nephrology was consulted for recommendations. Patient received EPO ___ unit x2. Blood pressure and diabetes control was optimized. Parathyroid hormone was found to be elevated but currently within goal for Stage 4 CKD. Received EPO ___ unit x2 on ___ and ___, and oral iron supplementation (see anemia). # DM II: Patient has a significant history of DMII with end organ complications. Patient was found to have poorly controlled blood glucose. His course was complicated by an incident of hypoglycemia, in which the patient received insulin but did not consume food. Patient was not amenable to diet restrictions. ___ was consulted for optimization of insulin regimen. The patient was placed on Humalog 7U TID, Lantus 20 QHS, and ISS with good control. Hgb A1c not indicative of patient's BG control i/s/o multiple transfusions. # Anemia: History of chronic anemia previously worked-up and determined to be related to renal failure. No evidence of ongoing blood loss, and stool guaiac was negative. s/p 5U of PRBCs since admission. On 10000U/week of EPO at home. Received EPO ___ unit x2 on ___ and ___, and oral iron supplementation. #HTN: Patient was found to have elevated blood pressures. His CKD proteinuria and right carotid artery stenosis to 70-79% were considered when managing medications. He was treated with isosorbide monotitrate , amlodipine, carvedilol, and lisinopril. # Rash: Patient has diffuse pruritic maculopapular rash on his back. Likely dermatitis due to distribution. Patient reports rash improved on diphenhydramine and miconzaole cream. # CAD: CAD with MI x2, no cardiac stents but known RCA stenosis. Continued home aspirin, Plavix, statin. Started carvedilol. # Depression: Patient was continued on home Sertraline 50 mg PO/NG DAILY. ***TRANSITIONAL ISSUES*** # Please check CBC and Chem10 to evaluate CKD and anemia on ___. # Discharge Cr 3.3 # Discharge H/H 7.8/25.5 # Patient is s/p BKA and requires follow-up with Dr. ___ at ___ on ___ at 10:15 am for staple removal. # Patient has significant homogeneous atherosclerotic plaque in the right ICA resulting in 70-79% stenosis despite prior endarterectomy. Requires follow-up with vascular surgery as scheduled above # Patient should be on lifelong aspirin and should continue Plavix for a total of 30 days after the procedure (Last day ___. # Patient is diabetic and requires the following insulin regimen: - Humalog to 9 units with breakfast, 7 units with lunch, 7 with dinner - Glargine: 20U QHS - Insulin scale: 2U for every 50 g/dL BG>150 g/dL - Patient was advised to avoid ___ cups but if patient is non-compliant with require Humalog ___ units with every ___ cup. # Patient has a history of aspiration. He was evaluated with a video swallow study that showed he still has risk of aspiration with non-thickened liquids, but that improved with a chin-tuck maneuver. He does not aspirate solid food. He was advised to use a chin-tuck maneuver when drinking liquids, and advised to take his medications with thickened liquids such as apple sauce. # Patient has chronic kidney disease and requires follow-up with out-patient nephrologist Dr. ___ # ___ VITAMIN D ___ DIHYDROXY level pending at discharge # Patient was restarted on 10000U/week of EPO. # Patient started on 50,000U vit D qWeek, should continue for 8 weeks and then transition to 800U daily and recheck level. # Patient discharged with 5 days of oxycodone 5mg PO q6H PRN and should be weaned as able for post-operative pain. # Communication: Patient, no HCP listed # Code: DNR, okay to temporarily intubate Medications on Admission: ASA 325 Plavix 75mg qd, Heparin 5000 q12 Lantus 8u qAM/30 qPM Insulin sliding scale epogen ___ weekly Imdur 30mg qd Metoprolol 50mg bid amlodipine 2.5mg qd Gabapentin 1200 qAM/1800 qPM, sertraline 100mg bid Colace 100mg bid nitroglycerin SL prn Doripenem 240 q8 for 6 weeks daptomycin 600 qd for 6 weeks vancomycin 1250mg qd Tylenol ___ q4H prn senokot qd fish oil MTV Discharge Medications: 1. amLODIPine 5 mg PO BID RX *amlodipine 5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. Atorvastatin 20 mg PO DAILY RX *atorvastatin 20 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 3. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 4. Glargine 20 Units Bedtime Humalog 9 Units Breakfast Humalog 7 Units Lunch Humalog 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin 5. Lisinopril 5 mg PO QHS RX *lisinopril 5 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 6. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg 1 capsule(s) by mouth every six (6) hours Disp #*20 Capsule Refills:*0 7. Vitamin D ___ UNIT PO 1X/WEEK (MO) RX *ergocalciferol (vitamin D2) [___] 50,000 unit 1 capsule(s) by mouth 1X WEEK Disp #*8 Capsule Refills:*0 8. Ketoconazole 2% 1 Appl TP BID 9. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 10. Aspirin 325 mg PO DAILY 11. Clopidogrel 75 mg PO DAILY Total of 30 days since surgery. Last Day (___) 12. Epoetin Alfa 4000 UNIT SC QMOWEFR 13. Gabapentin 400 mg PO TID 14. Heparin 5000 UNIT SC BID 15. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 16. Metoprolol Succinate XL 25 mg PO DAILY 17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN angina 18. Pantoprazole 40 mg PO Q24H 19. Sertraline 200 mg PO DAILY 20. Simvastatin 10 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES Left lateral malleolar non-healing ulcer s/p below knee amputation Multifocal healthcare-acquired pneumonia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. During your hospitalization, you had surgery to remove unhealthy tissue on your lower extremity. You tolerated the procedure well and your leg is healing properly. Unfortunately, your stay was complicated by a lung infection that required treatment with antibiotics. Your breathing improved with treatment and you finished a full course of antibiotics before discharge. Regarding your leg surgery, please follow the recommendations below to ensure a speedy and uneventful recovery. DISCHARGE INSTRUCTIONS ACTIVITY - You should keep your amputation site elevated and straight whenever possible. This will prevent swelling of the stump and maintain flexibility in your joint. - It is very important that you put no weight or pressure on your stump with activity or at rest to allow the wound to heal properly. - You may use the opposite foot for transfers and pivots, if applicable. It will take time to learn to use a walker and learn to transfer into and out of a wheelchair. BATHING/SHOWERING: - You may shower when you feel strong enough but no tub baths or pools until you have permission from your surgeon and the incision is fully healed. - After your shower, gently dry the incision well. Do not rub the area. WOUND CARE: - Please keep the wound clean and dry. It is very important that there is no pressure on the stump. If there is no drainage, you may leave the incision open to air. - Your staples/sutures will remain in for at least 4 weeks. At your followup appointment, we will see if the incision has healed enough to remove the staples. - Before you can be fitted for prosthesis (a man-made limb to replace the limb that was removed) your incision needs to be fully healed. CALL THE OFFICE FOR: ___ - Opening, bleeding or drainage or odor from your stump incision - Redness, swelling or warmth in your stump. - Fever greater than 101 degrees, chills, or worsening incisional/stump pain NO OTHER PROVIDER, EXCEPT YOUR VASCULAR SURGEON, SHOULD DETERMINE IF YOUR STAPLES ARE READY TO BE REMOVED FROM YOUR STUMP! IF THERE ARE ANY QUESTIONS, THE PROVIDER SHOULD CALL THE VASCULAR SURGERY OFFICE AT ___ TO DISCUSS. THE STAPLES WILL BE REMOVED IN THE OFFICE AT YOUR FOLLOWUP APPOINTMENT WHEN IT IS DETERMINED BY THE VASCULAR SURGEON THAT THE WOUND HAS SUFFICIENTLY HEALED. We wish you a speedy recovery, Your ___ Care Team Followup Instructions: ___
19960115-DS-4
19,960,115
22,370,556
DS
4
2114-01-10 00:00:00
2114-01-09 14:58:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Tylenol-Codeine / lisinopril Attending: ___. Chief Complaint: Pancreatic cancer Returns for replacement of feeding tube Major Surgical or Invasive Procedure: ___: Successful CT-guided placement of an ___ pigtail catheter into the intraabdominal fluid collection. History of Present Illness: ___ medical interpreter (___) here at ___ for over ___ years who recently ___ ___ started to have worsening diabetes and abdominal pain. He ultimately developed biliary symptomatology and the long and short of it is that he went on to have identified and biopsied a small mass ___ the head of the pancreas causing biliary stenosis. Ultimately, combined procedures by Dr. ___ Dr. ___ a ___ diagnosis of malignant adenocarcinoma of the pancreatic head. Mr. ___ hospital course on prior admission was complicated by pneumonia necessitating ICU care tracheostomy placement, feeding tube placement, and discharge to a rehabilitation facility for further care. See prior discharge summary for details. Past Medical History: venous stasis, DM, GERD, prior pancreatitis, ampullary mass Social History: ___ Family History: No malignancy Physical Exam: Prior to Discharge: VS: 98.6, low 100s, 130/70, 18, 99% RA GEN: Pleasant with NAD HEENT: NJ tube ___ place CV: RRR, no m/r/g PULM; CTAB, tracheostomy site healing well ABD; Subcostal incision with wound VAC ___ place. EXTR: Warm Pertinent Results: LAST LABS: ___ 06:46AM BLOOD WBC-6.5 RBC-3.06* Hgb-9.0* Hct-29.0* MCV-95 MCH-29.4 MCHC-31.0* RDW-16.2* RDWSD-55.4* Plt ___ ___ 06:46AM BLOOD Glucose-197* UreaN-18 Creat-1.0 Na-134 K-4.3 Cl-94* HCO3-33* AnGap-11 ___ 06:46AM BLOOD Calcium-8.5 Phos-3.2 Mg-1.7 ___ 05:01AM BLOOD Amylase-32 MICRO: ___ 11:29 am SPUTUM Source: Endotracheal. **FINAL REPORT ___ GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ CLUSTERS. RESPIRATORY CULTURE (Final ___: SPARSE GROWTH Commensal Respiratory Flora. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. ___ MORPHOLOGY. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. BLOOD AND URINE CULTURES: Negative RADIOLOGY: ___ CXR: IMPRESSION: Feeding tube was advanced just beyond the duodenojejunostomy but could not be further advanced into the jejunum. ___ DOPPLER ___: IMPRESSION: No evidence of deep venous thrombosis ___ the bilateral lower extremity veins. ___ CT ABD: IMPRESSION: 1. Irregular intraperitoneal fluid collection primarily seen anterior to the stomach and spleen, and layering dependently just superior to the transverse colon. While there has been an overall decrease ___ the amount of intraperitoneal fluid, the collections now appear more loculated, with more apparent surrounding inflammatory change, a thin but enhancing wall, and an area of more focal possible phlegmonous change adjacent to the transverse colon. Superimposed infection cannot be excluded by CT. 2. Small fluid collection anterior to the biliary limb may represent a small lymphocele. 3. Status post Whipple procedure. Normal biliary limb. No evidence of obstruction. Normal pancreatic remnant. 4. Diffuse mild mesenteric haziness and subcutaneous soft tissue edema, compatible with a generalized edematous state. ___ CT CHEST: Tracheostomy tube is midline. Esophageal drainage tube passes into the stomach and out of view. There is no associated fluid collection or other complication. Supraclavicular and axillary nodes are not enlarged and there is no soft tissue abnormality ___ the chest wall suspicious for malignancy or infection. Thyroid is unremarkable. Atherosclerotic calcification is not apparent ___ the head and neck vessels and only mild ___ the coronaries, at least ___ the LAD. Pericardium is physiologic. The attenuation characteristics of small layering bilateral pleural effusions, roughly stable ___ volume since ___ all, are disturbed by artifact. Mediastinal and hilar lymph nodes are not pathologically enlarged, ranging ___ diameter up to 8 mm ___ the left lower paraesophageal mediastinal station, and 8 mm ___ the left hilus. The a 20 x 30 mm well-circumscribed right, paraesophageal fluid collection ___ the posterior mediastinum just above the diaphragm, 4:154, with a mildly enhancing rim, was 26 x 35 mm on ___, 6:60. It is either a seroma or an abscess, but not hematoma. New centrilobular micro nodularity ___ the upper lobe, most prominent at the right apex, 04:53, is probably bronchiolitis. What was previously a uniformly consolidated and possibly collapsed right lower lobe on ___, and now looks more like a large pneumonia, with a somewhat smaller component ___ the left lower lobe. There are no bone lesions ___ the chest cage suspicious for malignancy or infection. The severe kyphosis is due to moderate loss of height anteriorly ___ 3 contiguous thoracic vertebrae. ___ CT CHEST: IMPRESSION: 1. No evidence of tracheal fistula. 2. Bilateral lower lobe pneumonia is improved. Followup CT is recommended ___ 3 months to ensure resolution and rule out underlying malignancy. 3. Right paraesophageal fluid collection is similar to prior. Brief Hospital Course: Mr. ___ was admitted the evening of ___ for replacement of his Dobhoff tube, which was removed ___ the rehabilitation facility. He was directly admitted to the ICU for his ventilation requirements while he awaited DHT replacement under ___. ICU COURSE: ___: Difficult placement ___ by ___ d/t luminal narrowing & tortuosity - tip just beyond GJ anastomosis; bridled. Resumed TFs with higher free water flushes. PICC unclogged. ___: Fever w Tm 101.4 at ~ 9P, WBC to 10. Tylenol given. Per ID, no abx until culture results. BLE Doppler wnl. Placed on contact precautions for MRSA. No antibiotics started. ___: 101.8 (8am), per ID cdiff (negative), repeat sputum culture. ___ sputum culture positive for GNRs, ___ repeat 3+ GNR, 1+GPCs. Per ID, no antibiotics. 1 unit of PRBC for Hct 20, appropriate response to 23. CT Torso. CT A/P significant for loculated inflammatory thin enhancing wall phlegmonous change. CT Chest bilateral loculated collection likely pneumonia. Per ID, no antibiotics until speciation. ___: Awaiting ___ drainage of anterior intra-abdominal fluid collection. Lovenox held. Hct 21.5, no transfusion per ___. C diff negative. Continue to hold antibiotics per ID. Wound was debrided, VAC discontinued, moist-to-dry dressing placed. ___: ___ drainage done ___ AM, fluid sent for gram stain and culture. Pt. had episode of hypotension during drainage, required fluid bolus. Hct 21.2, d/w Surgery, agreed to transfuse pt 2 units pRBC. post transfusion HCT 27.4, appropriate response. Started on Fe PO. ___: Stable on trach mask. Plan to transfer out of ICU. FLOOR COURSE: ___: Trach downsized to # 6. Stable respiratory status on 40& O2 mask. ___: Decannulated secondary to unavailable to pass suction catheter through the trach. Patient tolerated capped trach prior decannulation. IP consulted for flex bronc. Wound VAC placed. ___: IP recommended CT chest. CT chest was negative for tracheal fistula or mediastinal gas. ___: Passed bedside swallowing evaluation. Diet advanced to regular ground with nectar thick liquids, tolerated well. Wound VAC changed. BY THE SYSTEMS: Neuro: The patient received Tylenol and Oxycodone via NJ tube with good effect and adequate pain control. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Patient having intermittent sinus tachycardia without any ectopy. Pulmonary: During admission patient was able to wean off the vent. His trach was downsized to #6 Portex. On ___ patient was decannulated. His respiratory status stable on room air. Sputum cultures were positive for Pseudomonal, but ID advised against antibiotics, thought patient colonized since prior infection. GI: Patient was continued on TF at goal. Patient passed swallowing test after decannulation and diet was advanced as recommended. ID: Patient's wound was debrided from fibrinous tissue, and wound was packed with moist-to-dry dressing. On ___ wound VAC was applied. Next VAC change ___. Endocrine: The patient's blood sugar was monitored throughout his stay; insulin dosing was adjusted accordingly. Hematology: The patient's complete blood count was examined routinely; he received total 3 units of pRBC during admission. He was started on PO Fe. HCT remained stable prior to discharge. Prophylaxis: The patient received subcutaneous Lovenox and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible. Medications on Admission: 1. Bisacodyl 10 mg PR QHS:PRN constipation 2. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 3. Docusate Sodium (Liquid) 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC Q12H Start: Today - ___, First Dose: Next Routine Administration Time 5. Famotidine 20 mg PO BID 6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 7. Glucose Gel 15 g PO PRN hypoglycemia protocol 8. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 9. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q4H:PRN pain 10. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 11. Ondansetron 4 mg IV Q8H:PRN nausea 12. OxycoDONE Liquid ___ mg PO Q4H:PRN pain 13. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush Discharge Medications: 1. Bisacodyl 10 mg PR QHS:PRN constipation 2. Docusate Sodium (Liquid) 100 mg PO BID 3. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 4. Glucose Gel 15 g PO PRN hypoglycemia protocol 5. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 6. Ondansetron 4 mg IV Q8H:PRN nausea 7. OxycoDONE Liquid ___ mg PO Q4H:PRN pain 8. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 9. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN pain 10. Ferrous Sulfate (Liquid) 300 mg PO DAILY 11. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time 12. Pantoprazole 40 mg PO Q24H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Locally advanced pancreatic adenocarcinoma 2. Anemia of chronic disease 3. Dislodged feeding tube 4. Intraabdominal fluid collection 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: You were admitted to the surgery service at ___ for incision care and replacement of a feeding tube. You were found to have intaabdominal fluid collection and underwent ___ drainage. Your tracheostomy was decannulated and you passed swallowing test. You are now safe to be discharge ___ rehab to continue recovery. . Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than ___ lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . Incision Care: Wound VAC with black sponge at 125 mmHg pressure. Dressing will be changed Q___. Next dreesing change due ___. Tracheostomy dressing change daily. . General Drain Care: *Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). *If the drain is connected to a collection container, please note color, consistency, and amount of fluid ___ the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes ___ character. Be sure to empty the drain frequently. Record the output, if instructed to do so. *Wash the area gently with warm, soapy water or ___ strength hydrogen peroxide followed by saline rinse, pat dry, and place a drain sponge. Change daily and as needed. *Keep the insertion site clean and dry otherwise. *Avoid swimming, baths, hot tubs; do not submerge yourself ___ water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. . What to watch out for when you have a Dobhoff Feeding Tube: 1. Blocked tube: If the tube won't flush, try using 15 mL carbonated cola or warm water. If it still will not flush, call your nurse or doctor. Always be sure to flush the tube with at least 60 mL water after giving medicine or feedings. 2.Vomiting: *Call doctor if vomiting persists. Vomiting causes the loss of body fluids, salts and nutrients. *Give the feeding ___ an upright position. *Try smaller, more frequent feedings. Be sure the total amount for the day is the same though. *Infection may cause vomiting. Clean and rinse equipment well between feedings. *Do not let formula ___ the feeding bag hang longer than 6 hours unrefrigerated. After the formula can is opened, it should be stored ___ refrigerator until used. 3. Diarrhea: *This is frequent loose, watery stools. *Can be caused by: giving too much feeding at once or running it too quickly, decreased fiber ___ diet, impacted stool or infection. Some medicines also cause diarrhea. *Avoid hanging formula for longer than 6 hours. *Give more water after each feeding to replace water lost ___ diarrhea. *Call doctor if diarrhea does not stop after ___ days. 4. Dehydration: *Due to diarrhea, vomiting, fever, sweating. (Loss of water and fluids) *Signs include: decreased or concentrated (dark) urine, crying with no tears, dry skin, fatigue, irritability, dizziness, dry mouth, weight loss, or headache. *Give more water after each feeding to replace the water lost. *Call your doctor. 5. Constipation: ___ be caused by too little fiber ___ diet, not enough water or side effects of some medicines. Followup Instructions: ___
19960115-DS-7
19,960,115
29,779,881
DS
7
2114-09-27 00:00:00
2114-09-27 19:23:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tylenol-Codeine / lisinopril / adhesive tape Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: ___ Permanent dual chamber pacemaker placement History of Present Illness: ___ male with history of diabetes and pancreatic cancer diagnosed in ___ s/p resection and Whipple ___, with recurrent hepatic and pulmonary mets on palliative FOLFOX (C1D1 ___ presenting with one day history of chest pain. The chest pain woke him up from sleep. He reports it is substernal without radiation. He reports associated shortness of breath. He also endorses cough productive of sputum. He denies any hemoptysis or leg swelling. Patient went to his oncologist for his symptoms two days ago. During that visit he was noted to be in 2:1 AV block, and an outpatient cardiology appointment was made. He received a unit of pRBCs due to anemia and in an attempt to improve his symptoms. However his symptoms have progressed, prompting visit to the ED. Of note, he was worked up for shortness of breath about 3 weeks ago with a CTA which was negative for pulmonary embolism but did demonstrate a right sided pleural effusion. The patient denies any history of heart disease. Patient reports he received 4 baby ASA and nitro spray from EMS with some improvement in pain. In the ED initial vitals were: T=97.9 BP=127/48 HR=43 RR=16 SpO2= 98%RA EKG: Rate 36. Predominant 3:1 AV block. RBBB and LAFB. QTc 434/369. No STEMI. - Labs/studies notable for: Albumin 2.3, H/H=8.5/28.2, Plt=84, BNP = 4998, lactate 2.0, Cr 0.9, BUN 21. Troponin WNL. LFTs, lipase WNL. ___: 11.8, PTT: 26.2, INR: 1.1. - Blood cx pending - CTA chest showed no evidence of pulmonary embolism or aortic abnormality. Progressively increased size of sclerotic lesion in the vertebral body of T5 not present on CT scan from ___, concerning for metastasis. Similar sclerotic focus at the superior end plate of T9 also concerning. Interval removal of right sided chest tube and resolution of small right pneumothorax. - CXR showed low lung volumes and probable bilateral effusions, left larger than right. Superimposed mild edema is also possible. Patient was given: 1L NS, then taken to cath lab for ___ implantation On the floor patient feels tired with some pain. He states that he has had progressive SOB and that his legs feel more swollen than usual. Past Medical History: PAST ONCOLOGIC HISTORY: per OMR Pancreatic cancer stage IIB (T3N1M0) - ___ Had a ___ years with history of DM-II but developed worsening glycemic control plus gallstone pancreatitis. - ___ MRCP showed moderate intra and extrahepatic biliary dilatation. The distal CBD is dilated to 12 mm and demonstrates smooth cut off immediately proximal to the ampulla on all sequences. - ___ ERCP showed that CBD was dilated to 13mm in diameter. No definite filling defects consistent with stones were identified in the CBD and CHD. The left and right hepatic ducts and all intrahepatic branches were moderately dilated. The intra-ampullary region appeared prominent and fleshy. Biopsies were taken for pathology, and returned as atypical but nondiagnostic. - ___ ERCP and biopsy again nondiagnostic - ___ Repeat EUS showed a 1.37cm x 1.15cm ill-defined mass was noted in the head of the pancreas and biopsy confirmed adenocarcinoma - ___ CA ___ 192 - ___ CT torso showed no identifiable mass in the pancreatic head, despite the biopsy-proven diagnosis of adenocarcinoma. Mesenteric arterial and venous vasculature is normal with no evidence of tumoral involvement. Note is made of a replaced right hepatic artery off the SMA. No enlarged porta hepatis, peripancreatic, or mesenteric lymph nodes. No evidence of distant metastasis in the abdomen or pelvis. No evidence of disease in the chest. - ___ Whipple resection revealed pancreatic adenocarcinoma, poorly differentiated, pT3 pN1 with ___ LN involved with cancer, LVI+, PNI+, margins negative. - ___ Discharged after a prolonged admission for biliary leak, sepsis, and Psuedomonas pneumonia - ___ Discussed adjuvant therapy recommendations including APACT (gem v NAB gem) - ___ Signed informed consent for the APACT trial of gemcitabine versus gemcitabine NAB paclitaxel in the adjuvant setting. ___ return at 143, so not eligible for trial - ___ CT torso showed no obvious recurrent disease - ___ C1D1 gemcitabine 1000 mg/m2 D1,8,15 - ___ C1D15 dose reduced to 750 mg/m2 for thrombocytopenia - ___ Start chemoradiotherapy with capecitabine 1500 mg PO BID on treatment days - ___ Completed XRT with 50.4 Gy to the tumor bed - ___ C2D1 gemcitabine 750 mg/m2 D1,8,15 - ___ Chemo held for thrombocytopenia - ___ Reduced gemcitabine to 500 mg/m2 for thrombocytopenia - ___ C3D1 gemcitabine to 500 mg/m2 D1,8,15, ___ rising - ___ CT torso showed new liver and lung mets - ___ Reviewed ___ ___ DVT prophylaxis trial for metastatic cancer - ___ Liver biopsy confirmed metastatic pancreatic cancer - ___ Thoracentesis showed malignant effusion s/p thoracentessis -___ C1D1 FOLFOX Past Medical History: venous stasis, DM, GERD, prior pancreatitis Social History: ___ Family History: No significant history of coronary artery disease or sudden cardiac death Physical Exam: ON ADMISSION: VS: 146/74 92 20 95%2L GENERAL: Tired but in NAD HEENT: Sclera anicteric, PERRL, oropharynx clear NECK: Supple with JVP of 9-10cm, brisk carotid pulsations CARDIAC: RRR no m/r/g. R side of chest wrapped in bandage, arm in sling LUNGS: Clear anteriorly, no increased work of breathing ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: WWP, 2+ pitting edema to knees bilaterally SKIN: No rash or venous stasis changes PULSES: Distal pulses palpable and symmetric ON DISCHARGE: Vitals: 98.2 100s-140s/50s-60s ___ 94-96%2L I/O: 200/600; 400/875 GENERAL: AAOx3, in NAD HEENT: Sclera anicteric, PERRL, oropharynx clear NECK: Supple with JVP of 9-10cm, brisk carotid pulsations CARDIAC: RRR no m/r/g. R side of chest wrapped in bandage, arm in sling LUNGS: Clear anteriorly, no increased work of breathing ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: WWP, trace pitting edema to knees bilaterally SKIN: No rash or venous stasis changes PULSES: Distal pulses palpable and symmetric Pertinent Results: ON ADMISSION: ___ 07:49AM BLOOD WBC-7.2 RBC-2.80* Hgb-8.5* Hct-28.2* MCV-101* MCH-30.4 MCHC-30.1* RDW-20.5* RDWSD-72.5* Plt Ct-84* ___ 07:49AM BLOOD Neuts-79.4* Lymphs-13.0* Monos-6.5 Eos-0.3* Baso-0.1 Im ___ AbsNeut-5.75 AbsLymp-0.94* AbsMono-0.47 AbsEos-0.02* AbsBaso-0.01 ___ 07:49AM BLOOD ___ PTT-26.2 ___ ___ 07:49AM BLOOD Glucose-129* UreaN-21* Creat-0.9 Na-135 K-4.4 Cl-101 HCO3-27 AnGap-11 ___ 07:49AM BLOOD ALT-10 AST-17 AlkPhos-126 TotBili-0.2 ___ 07:49AM BLOOD Lipase-9 ___ 07:49AM BLOOD cTropnT-<0.01 proBNP-4998* ___ 01:48PM BLOOD cTropnT-<0.01 ___ 09:33AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9 ___ 07:49AM BLOOD Albumin-2.3* ___ 07:59AM BLOOD Lactate-2.0 ON DISCHARGE: ___ 01:27PM BLOOD WBC-7.6 RBC-2.88* Hgb-8.7* Hct-28.9* MCV-100* MCH-30.2 MCHC-30.1* RDW-20.5* RDWSD-73.9* Plt ___ ___ 09:33AM BLOOD Glucose-102* UreaN-18 Creat-0.8 Na-138 K-4.3 Cl-101 HCO3-31 AnGap-10 ___ 09:33AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9 OTHER STUDIES: ___ Ventricular rate of 47 beats per minute Sinus rate is about 110 beats per minute, 2:1 AV conduction ___ Ventricular rate of 36 beats per minute sinus rate is about 140 beats per minute 3:1 AV conduction ___ CXR: Low lung volumes and probable bilateral effusions, left larger than right. Superimposed mild edema is also possible. ___ CTA CHEST: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Interval removal of right sided chest tube and resolution of small right pneumothorax. Unchanged bilateral loculated pleural effusions. 3. Unchanged appearance of hepatic and pulmonary metastatic disease burden notable for pleural based pulmonary consolidation, nodular interlobular septal thickening and pleural thickening. 4. Progressively increased size of sclerotic lesion in the vertebral body of T5 not present on CT scan from ___, concerning for metastasis. Smaller sclerotic focus at the superior end plate of T9 is also concerning. ___ CXR: Moderately severe pulmonary edema has worsened, moderate left pleural effusion is larger and cardiomediastinal silhouette is substantially larger. This could be due to cardiac decompensation, but since new transvenous right atrial and right ventricular pacer leads have been inserted, it raises concern for bleeding in the mediastinum and possibly pericardium.. There is no pneumothorax. Brief Hospital Course: ___ male with history of diabetes and pancreatic cancer diagnosed in ___ s/p resection and Whipple ___, with recurrent hepatic and pulmonary mets on palliative FOLFOX (C1D1 ___ who presented with one day history of chest pain and dyspnea. ACS was ruled out given neg troponin x2 and EKG without ischemic changes. However, patient was bradycardic in the ___ and EKG showed 3:1 AV block. Electrophysiology was consulted and she was admitted for permanent dual chamber pacemaker placement. The procedure went well without complications. He received cefazolin 1g q8h IV while in-house and was discharged on Keflex for a complete 3-day course. Post-PPM CXR did not show pneumothorax but did show pulmonary edema with increased cardiomediastinal silhouette concerning for bleeding in mediastinum and possibly pericardium. However, patient was stable from respiratory perspective. Additionally bedside TTE performed by the EP fellow revealed no evidence of bleeding. H/H remained stable at 8.7/28.9. CHRONIC ISSUES: #Anemia due to Inflammation/cytotoxic therapy: Baseline of ~9. Patient was on iron supplementation but denies taking currently. #Metastatic Pancreatic cancer: Recurrent to liver and lungs including pleura, R cavitary mass and malignant effusions. His CTA on admission shows no change in metastatic disease burden. Currently on C1D8 FOLFOX, managed by Dr. ___ #DM II: On ISS. On metformin at ___, has been more hyperglycemic since starting FOLFOX. #GERD: Continued ___ omeprazole TRANSITIONAL ISSUES: # Patient will be contacted regarding device clinic appointment in 1 week. # Patient discharged on Keflex ___ mg q6h for a total 3-day course to end on ___. # Please consider repeat CXR as an outpatient to evaluate findings on CXR though low suspicion for mediastinal bleeding from pacemaker. # CODE: Full # CONTACT: ___ (wife, HCP) ___ Son - ___ ___ (cell phone) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Omeprazole 20 mg PO BID 2. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain 3. Ascorbic Acid ___ mg PO DAILY 4. Cyanocobalamin 1000 mcg PO DAILY 5. MetFORMIN (Glucophage) 500 mg PO BID 6. Acetaminophen 650 mg PO Q6H Discharge Medications: 1. MetFORMIN (Glucophage) 500 mg PO BID 2. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain 3. Omeprazole 20 mg PO BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. Ascorbic Acid ___ mg PO DAILY 6. Acetaminophen 650 mg PO Q6H 7. Cephalexin 500 mg PO Q6H Duration: 2 Days RX *cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp #*10 Capsule Refills:*0 Discharge Disposition: ___ With Service Facility: ___ Discharge Diagnosis: PRIMARY: 3:1 AV block SECONDARY: Metastatic pancreatic cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ because you were experiencing chest discomfort and were found to have abnormal conduction of your heart. You therefore had a permanent pacemaker placed. The procedure went well without complications. Your pacemaker was tested and is functioning properly. You were given IV antibiotics to prevent infection. You will need to complete 3 more days (including today) of oral antibiotic treatment. Your last day of antibiotics will be ___. Your appointments with your oncologist have been scheduled for you, see below. The device clinic will call you regarding your follow-up appointment. We wish you the best, Your ___ Cardiology Team Followup Instructions: ___
19960203-DS-3
19,960,203
23,598,678
DS
3
2140-11-25 00:00:00
2140-11-25 14:46:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: PO intolerance, nausea, vomiting Major Surgical or Invasive Procedure: ___: EGD . ___: Exchange of a gastrostomy for an 18 ___ MIC gastrojejunostomy tube. History of Present Illness: We had the pleasure of seeing Mr. ___ in the ___ Pancreas and Liver Institute today. As you know, he is a ___ year old man with a history of longstanding iron deficiency anemia and B12 deficiency with a 2.5cm mass in D2 with poorly differentiated adenocarcinoma. He underwent a pylorus sparing radical pancreaticoduodenectomy with en bloc resection of the transverse mesocolon and placement of fiducials on ___ and presents today for follow up. He had a protracted ___ operative course secondary to oral intolerance and delayed gastric emptying that required a PEG tube placement for nausea control purposes. He was also discharged home on total parenteral nutrition (discharged on ___. He had an upper GI study completed yesterday which reveals very slow and minimal passage of contrast through the pylorus with no dilation of the stomach. They have been venting his g-tube each night since he was discharged from the hospital and each night it puts out anywhere between 400-600cc of green appearing fluid. He keeps his G tube clamped during the day but still has episodes of emesis. In terms of his nutrition he was not able to get TPN on ___ or ___ night due to ___ issues. He was able to get TPN on ___. Then on ___ his PICC line was not functioning. He feels dehydrated and reports worsening nausea and dry heaving afer the study was completed. He denies fevers, chills, or shortness of breath. He denies leg swelling. Past Medical History: HTN/HLD, paroxysmal atrial fibrillation on Coumadin, pre-diabetes, BPH, GERD, lower back pain with R-sided sciatica, colonic adenomas, s/p appendectomy (___) and removal of testis ___, he says this was in ___ for a testicle that got out of position and may have not been necessary) Social History: ___ Family History: Mother had CLL which transformed, she died in her ___. Father, 4 brothers, 1 sister, and 3 children all without any history of cancer. Physical Exam: DISCHARGE PHYSICAL EXAM: VS: 98.2, 78, 110/67, 18, 95% RA GEN: Pleasant with NAD HEENT: NC/AT, PERRL, EOMI, no scleral icterus CV: Irregular rhythm with normal rate. PULM: CTAB ABD: Subcostal incision healed well. Midline G/J-tube capped, site with drain sponge and c/d/I. EXTR: Warm, no c/c/e Pertinent Results: RECCENT LABS: ___ 09:45AM BLOOD WBC-4.9 RBC-3.03* Hgb-8.1* Hct-26.6* MCV-88 MCH-26.7 MCHC-30.5* RDW-16.1* RDWSD-50.7* Plt ___ ___ 09:45AM BLOOD Glucose-103* UreaN-14 Creat-0.9 Na-138 K-5.3 Cl-101 HCO3-26 AnGap-11 ___ 05:07AM BLOOD ALT-30 AST-25 AlkPhos-193* TotBili-0.2 ___ 09:45AM BLOOD Calcium-9.1 Phos-4.4 Mg-2.2 MICRO: ___ 10:59 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: ESCHERICHIA COLI. FINAL SENSITIVITIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 4 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Anaerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE ROD(S). Reported to and read back by ___ (___), ___ @ 13:33. RADIOLOGY: ___ CT ABD: IMPRESSION: 1. Small low-density lesion in the hepatic dome seem slightly larger measures 0.7 cm, previously 0.5 cm. This is incompletely characterized on this exam. 2. Interval improvement of subsegmental left lower lobe atelectasis with few areas focal hypoenhancing which could be due to retained secretions or small areas of infection. 3. Interval resolution of small right pleural effusion. Brief Hospital Course: Mr. ___ was sent to the ED from clinic on ___ with dehydration in the setting of not being able to get his TPN due to a nonfunctioning PICC line. Upon arrival to our ED his PICC was able to be accessed and he was given fluids. Gastroenterology was consulted for EGD and possible GJ tube exchange. Per GI they would want to wait 6 weeks from PEG tube placement so EGD was deferred to as an outpatient. ___ was consulted on ___ for placement of a GJ tube. This was successfully accomplished on ___ and he was transitioned off TPN to tube feeds. After starting tube feeds, he developed an episode of hypotension and was febrile to 100.2. Broad spectrum antibiotics including vancomycin, cefepime and flagyl were started. His PICC line was discontinued. Blood cultures eventually grew sensitive E. coli. Infectious disease was consulted and recommended a 2 week course of Bactrim from last negative blood cultures. Blood cultures were with no growth since ___. His vitals remained stable throughout his remainder hospitalization and he has been afebrile. His tube feeds were cycled on ___. Hpwever, the morning of ___, his G tube was unclamped due to nausea and 600cc of tube feeds had come out of the G tube. A drain study verified that the J tube had been dislodged and was no in the stomach. Per interventional radiology, a new site would have to be used. The patient was given a subsequent trial of PO. He was started on fulls on ___ and advanced to a soft mechanical diet on ___ with good results. However he was not taking in enough to nutritionally sustain himself and he eventually tube feeds was restarted overning to provide 50% daily calories. He continued to tolerate PO around the feeds. He was eventually discharged home on ___ with plans for outpatient follow up. The patient and family verbalized understanding and were agreeable with the plan moving forward. All questions were answered to their satisfaction. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Finasteride 5 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Acetaminophen 650 mg PO TID 4. Enoxaparin Sodium 60 mg SC Q12H 5. Lidocaine 5% Patch 1 PTCH TD QPM back pain 6. Metoclopramide 5 mg PO QID 7. Metoprolol Succinate XL 25 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 10. Pantoprazole 40 mg PO Q12H 11. Blood Glucose Monitoring (blood-glucose meter) 1 kit miscellaneous Q6H 12. GenStrip Test Strip (blood sugar diagnostic) 1 strip miscellaneous Q6H 13. lancets 28 gauge miscellaneous Q6H 14. Montelukast 10 mg PO DAILY 15. Rosuvastatin Calcium 5 mg PO QPM 16. Insulin SC Sliding Scale Insulin SC Sliding Scale using REG Insulin Discharge Medications: 1. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit oral TID W/MEALS 2. Creon (lipase-protease-amylase) 24,000-76,000 -120,000 unit oral TID W/MEALS RX *lipase-protease-amylase [Creon] 24,000 unit-76,000 unit-120,000 unit 3 capsule(s) by mouth TID W/MEALS Disp #*300 Capsule Refills:*3 3. Sulfameth/Trimethoprim DS 2 TAB PO/NG BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever 5. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line 6. Pantoprazole 40 mg PO Q24H 7. Enoxaparin Sodium 60 mg SC Q12H RX *enoxaparin 60 mg/0.6 mL 60 mg SC every twelve (12) hours Disp #*60 Syringe Refills:*1 8. Finasteride 5 mg PO DAILY 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Montelukast 10 mg PO DAILY 11. Multivitamins 1 TAB PO DAILY 12. Rosuvastatin Calcium 5 mg PO QPM 13. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Adenocarcinoma, intestinal type 2. Delayed gastric emptying 3. Bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, you were readmitted from clinic with symptoms of dehydration and with non working PICC line. In ED your PICC was accessed and you were started on IV hydration. Gastroenterology team was consulted for EGD, and ___ team was consulted for PEG tube exchange to G/J-tube. You were continued on TPN during admission. On ___ you underwent EGD and PEG tube exchange to gastrojejunostomy tube. ___ procedure you were started on tube feeding. When you tolerate TF at goal, TPN was discontinued and PICC was removed. Unfortunately your J-tube migrated to your stomach, which required holding tube feeding. Your diet was advanced to regular and you were able to tolerate small meals. TF was restarted via J-tube and was well tolerated. During admission you was found to have blood infection and was treated with antibiotics. You are now safe to be discharged home with following instruction. . G/J Tube care: Please keep G-tube capped. J-tube with tube feeding overnight. Flush J-tube with 30 cc of tap water Q6H. Change dressing daily and prn. Keep tube securely attached to prevent dislocation. Monitor for signs and symptoms of infection. Followup Instructions: ___
19960274-DS-27
19,960,274
28,286,271
DS
27
2199-08-20 00:00:00
2199-08-20 14:29:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: ___: endoscopy History of Present Illness: Per admitting resident: Mrs. ___ is a ___ with a PMH of RNYGB s/p jeujunojejeunal revision and LOA presenting with 4 weeks of abdominal pain. She states the pain is dull, starts in the epigastrium and radiates towards the bilateral lower quadrants. It is exacerbated by PO intake, and gets worse in the afternoon and evenings. In the last month her pain has been associated at times with lightheadedness, fever >101 x2, emesis x2, melena x2, steatorrhea, and bloating. She denies constipation, SOB, chest pain, BRBPR, dysuria, hematuria and paresthesias. She has tried Mylanta and APAP without improvement. She has also been taking Advil, ~2 pills/wk. She has not taken a PPI. She has not had an upper endoscopy since ___. She had a similar episode of pain in ___ that lasted 2 weeks and self-resolved. She is passing flatus. Past Medical History: Morbid obesity Cholelithiasis PAST SURGICAL HISTORY: Open RNYGB, Cholecystectomy ___ ___ Ex lap, Revision of jejeunojejeunal anastamosis ___ ___ Panniculectomy, repair of epigastric hernia ___ ___ Diagnostic laparoscopy, LOA ___ ___ BLE Bunionectomy (___) Social History: ___ Family History: Father - CAD, obesity Mother - ___ pancreatic mass, DM ___ panc resection, arthritis Physical Exam: T 97.8 BP 113/78 P 64 RR ___ RA GEN: no acute distress CARDIAC: regular rate and rhythm, NL S1,S2 RESP: clear to auscultation, bilaterally ABDOMEN: soft, non-tender, non-distended, no rebound tenderness/guarding EXT: no lower extremity edema or tenderness, bilaterally Pertinent Results: ___ 04:37AM BLOOD WBC-4.9 RBC-3.86* Hgb-10.4* Hct-32.9* MCV-85 MCH-26.9 MCHC-31.6* RDW-13.6 RDWSD-42.5 Plt ___ Glucose-89 UreaN-5* Creat-0.5 Na-139 K-3.7 Cl-105 HCO3-25 AnGap-9* ___ 10:24AM BLOOD Iron-89 ___ 04:37AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.8 ___ 10:24AM BLOOD calTIBC-439 VitB12-294 Folate-15 Ferritn-14 TRF-338 ___ 10:24AM BLOOD PTH-58 ___ 10:24AM BLOOD 25VitD-6* ___ 08:30PM BLOOD Glucose-85 UreaN-8 Creat-0.6 Na-142 K-4.2 Cl-106 HCO3-24 AnGap-12 ALT-8 AST-17 AlkPhos-152* TotBili-0.2 Lipase-27 WBC-8.1 RBC-4.32 Hgb-11.7 Hct-37.5 MCV-87 MCH-27.1 MCHC-31.2* RDW-13.9 RDWSD-44.6 Plt ___ Brief Hospital Course: Ms. ___ is ___ with a history of RNY gastric bypass who presented to the Emergency Department with abdominal pain. Upon arrival, an abdominal/pelvic CT scan which showed thickening of the jejunum just distal to the gastrojejunal ulcer concerning for enteritis. Given the CT scan findings and recent history of NSAID intake, gastroenterology was consulted for evaluation via EGD. The patient was also given intravenous antacid medication. On HD2, the patient underwent the EGD, which was negative for ulcers. Post-procedure, the patient's pain had resolved and she remained hemodynamically stable. She was able to tolerate a diet and was thus discharged to home on ongoing antacid treatment. Additionally, given a low-normal vitamin B12, she was given an IM injection prior to discharge. She was also found to have vitamin D and iron deficiencies and was counseled regarding the need to take supplements and follow-up with her PCP for further management. She will also follow-up with Dr. ___ in clinic. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Multivitamins W/minerals 1 TAB PO DAILY Discharge Medications: 1. calcium citrate-vitamin D3 315-200 mg-unit oral BID 2. cyanocobalamin (vitamin B-12) 500 mcg sublingual DAILY RX *cyanocobalamin (vitamin B-12) 500 mcg 1 tablet(s) sublingually once a day Disp #*30 Tablet Refills:*5 3. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*3 4. Vitamin D ___ UNIT PO 1X/WEEK (TH) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth 1X/Week Disp #*8 Capsule Refills:*0 5. Vitron-C (iron,carbonyl-vitamin C) 65 mg iron- 125 mg oral DAILY 6. Multivitamins W/minerals 1 TAB PO BID Discharge Disposition: Home Discharge Diagnosis: Abdominal pain Enteritis Vitamin D deficiency Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You presented to the hospital with abdominal pain and were found to have intestinal inflammation. You underwent a endoscopy to evaluate for evidence of ulcer as a source for the ulcer, however, you were treated with intravenous antacid medication which you should continue upon discharge. You are now preparing for discharge with the following additional instructions: Please return to the Emergency Department immediately if you develop fevers, chills, return of abdominal pain, nausea, vomiting, abdominal bloating, vomiting blood, blood or dark bowel movements or any other signs that are concerning to you. Followup Instructions: ___
19960353-DS-13
19,960,353
20,782,216
DS
13
2145-01-12 00:00:00
2145-01-12 14:32:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: pollen extracts / sunflower seed Attending: ___ Chief Complaint: Bactermia, Left Foot Infection Major Surgical or Invasive Procedure: ___ line placement History of Present Illness: ___ presents to emergency room with concern of redness surrounding left foot surgical site. Patient had a left third interspace neuroma excision on ___. Patient was seen ___ clinic ___ was found to be doing well. He was given clearance to return showering, with sutures are removed approximately 2 weeks after. Patient states ___ the last 48 hours he noticed surrounding redness around the incision site. He also noticed increased pain and swelling. Patient has been very active postoperatively ___ particular the last few days patient has been on his feet a moderate amount. He admits that he may have overdone it the last few days. Patient states he has been wearing a clean bandage at all times. Other than the pain and swelling, patient denies any fevers, chills, nausea, vomiting. Wife is a ___ at ___, he has taken a few doses of Keflex. Past Medical History: Diverticulosis, asthma, gastritis Left third interspace neuroma excision ___ Multiple orthopedic surgeries Social History: ___ Family History: Non-contributory Physical Exam: Admission: GEN: A&Ox3, NAD, Pleasant HEART: RRR LUNGS: CTAB, No resp distress ABD: Soft, non tender non distended EXTREMITIES: Puleses palpable, edema improved. Erythema surrounding the surgical site is improving. No signs of drainage or purulence. Discharge: Physical Exam: Vitals: AVSS GEN: A&Ox3, NAD, Pleasant HEART: RRR LUNGS: CTAB, No resp distress ABD: Soft, non tender non distended EXTREMITIES: Puleses palpable, edema improved. Erythema surrounding the surgical site completely resolved. No signs of drainage or purulence. Remaining sutures intact. Wound appear well coapted. Pertinent Results: ___ 11:40AM GLUCOSE-93 UREA N-12 CREAT-1.0 SODIUM-141 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-13 ___ 11:40AM estGFR-Using this ___ 11:40AM WBC-7.9 RBC-5.36 HGB-16.1 HCT-47.7 MCV-89 MCH-30.0 MCHC-33.8 RDW-13.5 RDWSD-43.8 ___ 11:40AM NEUTS-57.5 ___ MONOS-7.0 EOS-10.4* BASOS-1.3* IM ___ AbsNeut-4.51 AbsLymp-1.86 AbsMono-0.55 AbsEos-0.82* AbsBaso-0.10* ___ 11:40AM PLT COUNT-197 ___ 11:23 am SWAB Source: Left Foot Surgical Site. **FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CLUSTERS. WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. 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 ___ MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 1 S TRIMETHOPRIM/SULFA---- <=0.5 S Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI ___ CLUSTERS. Reported to and read back by ___ AT 05:12 ON ___. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI ___ CLUSTERS. ___ 11:45 am BLOOD CULTURE #2. Blood Culture, Routine (Preliminary): STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. Susceptibility testing performed on culture # ___ (___). Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI ___ CLUSTERS. Reported to and read back by ___ AT 07:01 ON ___. ___ 5:05 pm BLOOD CULTURE 1 OF 2. Blood Culture, Routine (Pending): No growth to date. ___ 7:15 pm BLOOD CULTURE 2 OF 2. Blood Culture, Routine (Pending): No growth to date. ___ 6:27 am BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. Brief Hospital Course: Patient was initially seen and evaluated ___ the emergency department on ___ found to have a cellulitis at his left neuroma third interspace surgical site. There was no signs of deep involvement. Patient was found to have stable vitals and without leukocytosis. Patient did have positive blood cultures ×2, Gram stain showed GPC's on 2 sets. Given the positive blood cultures, patient was admitted to podiatric surgery for IV antibiotics. 4 stitches ___ total were removed from the surgical site, remaining sutures were left intact. There is no signs of any deep involvement or drainage or purulence. Once admitted to the floor infectious disease was consulted for antibiotic management and duration. Patient also received a TTE, which was negative for any vegetations. Over the course of the hospital stay, cellulitis completely resolved. Pain also improved. Cultures grew staph aureus, infectious disease recommended a 2 week course of IV antibiotics. Given the need for long-term IV antibiotics, PICC line was placed without incident. Daily dressing changes were performed on the surgical site patient was given subcu heparin and pneumatic boots for DVT prophylaxis. Patient remained stable from a cardio vascular and respiratory point of view his labs remained completely stable during the entirety of the admission. He initially received broad-spectrum antibiotics, eventually narrowed down to Ancef per infectious disease recommendations. Once infectious disease recommendations were final, patient was not discharged from the hospital with left foot cellulitis resolved, and a planned two-week course of IV antibiotics, Ancef, 2 g every 8 IV. Patient is scheduled follow-up ___ clinic 1 week after discharge. Medications on Admission: ACYCLOVIR - acyclovir 400 mg tablet. TAKE 1 TABLET 3 TIMES DAILY FOR FIVE DAYS ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 inhalations(s) inhaled qid prn AZELASTINE - azelastine 137 mcg (0.1 %) nasal spray aerosol. ___ spray ___ each nostril x2/day BUDESONIDE-FORMOTEROL [SYMBICORT] - Symbicort 160 mcg-4.5 mcg/actuation HFA aerosol inhaler. 2 puffs inhaled twice a day use with spacer and rinse mouth after use CEPHALEXIN - cephalexin 500 mg capsule. 1 capsule(s) by mouth four times a day EPINEPHRINE [EPIPEN 2-PAK] - EpiPen 2-Pak 0.3 mg/0.3 mL injection, auto-injector. Use as directed; allergic reaction- once. FEXOFENADINE - fexofenadine 180 mg tablet. 1 tablet(s) by mouth once a day as needed for allergy symptoms FLUTICASONE - fluticasone 50 mcg/actuation nasal spray,suspension. 2 sprays ___ each nostril daily FLUTICASONE [FLOVENT HFA] - Flovent HFA 110 mcg/actuation aerosol inhaler. 2 puff bid daily OLOPATADINE [PATADAY] - Pataday 0.2 % eye drops. 1 drop ___ each eye once a day as needed for prn allergies OXYCODONE - oxycodone 5 mg tablet. ___ tablet(s) by mouth ___ hours as needed for pain RANITIDINE HCL - ranitidine 150 mg tablet. 1 tablet(s) by mouth twice a day Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. CeFAZolin 2 g IV Q8H RX *cefazolin ___ dextrose (iso-os) 2 gram/50 mL 1 vial IV every eight (8) hours Disp #*42 Intravenous Bag Refills:*0 3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 4. Fluticasone Propionate 110mcg 2 PUFF IH BID 5. Ranitidine 150 mg PO BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Bacteremia, Left foot cellulitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, It was a pleasure taking care of you at ___. You were admitted to the Podiatric Surgery service for your Left foot infection and bacteremia. You were given IV antibiotics while here. You are being discharged home with the following instructions: ACTIVITY: There are some restrictions to your activity. Weight bearing as tolerated to your L foot until your follow up appointment ___ a surgical shoe. You should keep this site elevated when ever possible (above the level of the heart!) You are able to drive. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness ___ or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity until the sutures are removed and wound has healed No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking ___ a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods ___ your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___
19960598-DS-4
19,960,598
21,729,823
DS
4
2152-08-05 00:00:00
2152-08-05 18:03:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: right sided weakness, difficulty speaking Major Surgical or Invasive Procedure: transesophageal echocardiogram History of Present Illness: The pt is a ___ year-old R-handed woman with PMHx of HTN and HL who presents with R sided weakness and difficulty speaking. She missed a 4pm hairdressing appointment, and her hairdresser called the patient's family, who went to check on her and found her "half-dressed" on the floor. It was unclear how long she had been there as no one had heard from her that day. She wasn't able to speak more than the words "yes" or "no" and so 911 was called. When EMS arrived they noticed that she wasn't moving her R side. She was brought to an OSH, where a ___ showed a L MCA infarct. She was given a 300mg PR ASA and sent to ___ for further evaluation. In the ED her CK was noted to be elevated to 1250, presumably from being on the floor for a prolonged period of time. Otherwise, her labs were unremarkable. She had a CTA head and neck that showed an M1 segment occlusion/cut-off and she was admitted to the stroke service for further evaluation. The patient is unable to complete ROS because of difficulty speaking. She can say "yes" or "no" intermittently to questions and denies pain. Past Medical History: - HTN, which per pt's family was high enough to almost prevent pt from getting a bunion repair surgery a year ago - HL, previously on lipitor, but stopped because of muscle aches Medications: patient takes no medications and prefers an "herbal approach" Social History: ___ Family History: father had a stroke at age ___, paternal aunt had a stroke at ___. Mother died of bladder cancer (was a smoker). Physical Exam: Physical Exam on Admission: Vitals: T: 98.2 P: 104 R: 18 BP: 137/77 SaO2: 99% on 2L NC General: Awake, cooperative, intermittently appears somewhat tearful. 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: Only able to say "yes" or "no" when asked questions. When asked to name, she shrugs and looks frustrated. She can follow commands. She is unable to read and again shrugs. She appears to be neglecting the R side. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation, pt unable to cooperate with finger wiggling or pin view as she keeps looking at the object not the examiner's nose. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus, but looks more frequently to the L. Normal saccades. V: Facial sensation intact to light touch. VII: R 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. -Motor: Normal bulk, tone throughout. RUE too weak to test pronator drift. No drift in LUE. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L ___ 5 5 R 0 0 0 0 1 0 0 0 0 0 0 0 0 0 -Sensory: Says no when asked if she feels pinprick, cold, vibration or light touch on her RUE and RLE, but when vibration is put on her big toe on the R or when noxious is given, she triple flexes her RLE. Unable to test extinction as she does not admit to sensation in her R-side. -DTRs: Bi Tri ___ Pat Ach L ___ 2 1 R ___ 1 1 Plantar response was flexor on the L and extensor on the R. -Coordination: No intention tremor, no dysdiadochokinesia noted on the L, but unable to test on the R ___ weakness. No dysmetria on FNF on L, unable to test on R. -Gait: Deferred given RLE plegia Physical Exam on Discharge: Vitals: T 98.2 BP 139/88 HR 70 RR 18 95 RA Mental status: awake, alert, unable to repeat words such as pen, dog; cannot repeat simple phrases; follows midline commands inconsistently (sticks out tongue), cannot follow appendicular commands (show me your thumb) Cranial nerves: right sided facial droop, the rest intact Motor: full strength on left upper/lower extremities, ___ in all muscle groups in RUE, ___ in right quad and TA, ___ in other groups Pertinent Results: Labs on Admission: ___ 11:05PM WBC-8.8 RBC-4.78 HGB-13.8 HCT-41.2 MCV-86 MCH-28.9 MCHC-33.5 RDW-13.6 ___ 11:05PM NEUTS-74.6* LYMPHS-17.2* MONOS-7.0 EOS-0.5 BASOS-0.8 ___ 11:05PM ___ PTT-33.1 ___ ___ 11:05PM GLUCOSE-117* UREA N-15 CREAT-0.7 SODIUM-143 POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-27 ANION GAP-17 ___ 11:05PM CALCIUM-10.0 PHOSPHATE-3.9 MAGNESIUM-2.0 ___ 11:05PM CALCIUM-10.0 PHOSPHATE-3.9 MAGNESIUM-2.0 ___ 11:05PM CK(CPK)-1250* ___ 11:14PM LACTATE-1.4 ___ 01:25AM URINE HOURS-RANDOM ___ 01:25AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 01:25AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 01:25AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 01:25AM URINE RBC-0 WBC-3 BACTERIA-FEW YEAST-NONE EPI-0 ___ 04:00PM CK-MB-5 cTropnT-<0.01 ___ 04:00PM ALT(SGPT)-33 AST(SGOT)-55* LD(LDH)-232 CK(CPK)-1531* ALK PHOS-76 TOT BILI-0.4 Relevant Labs: ___ 03:40PM BLOOD Lupus-NEG ___ 04:00PM BLOOD %HbA1c-6.2* ___ 04:00PM BLOOD Triglyc-137 HDL-53 CHOL/HD-5.1 LDLcalc-192* ___ 04:00PM BLOOD TSH-2.7 Imaging: CTA head/neck 1. Occlusion of the distal M1 segment of the left middle cerebral artery with associated acute/subacute infarct of the left frontal lobe extending into the insula and temporal lobe. 2. Mild atherosclerotic calcification of the carotid bulbs without significant stenosis. MRI head w/o contrast Left opercular acute/subacute infarction, previously demonstrated by CT of the head in ___. There is no evidence of significant mass effect or hemorrhagic transformation, extension of the ischemic changes is visualized at the left caudate nucleus and posterior limb of the left internal capsule. TTE ___ The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The estimated cardiac index is normal (>=2.5L/min/m2). Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. No mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal study. No definite structural cardiac source of embolism identified. TEE ___ The left atrium and right atrium are normal in cavity size. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. Trace aortic regurgitation is seen. 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. Chest x-ray Cardiomediastinal contours are normal. Aside from minimal atelectasis in the left lower lobe, the lungs are grossly clear. There is no pleural effusion. IMPRESSION: No evidence of acute cardiopulmonary abnormalities. Labs on Discharge: ___ 05:10AM BLOOD WBC-6.3 RBC-4.47 Hgb-12.8 Hct-37.8 MCV-85 MCH-28.7 MCHC-33.9 RDW-13.3 Plt ___ ___ 05:10AM BLOOD Glucose-108* UreaN-12 Creat-0.6 Na-140 K-3.7 Cl-107 HCO3-26 AnGap-11 ___ 07:43AM BLOOD CK(CPK)-499* ___ 05:10AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.1 Brief Hospital Course: Ms. ___ is a ___ year-old R-handed woman with PMHx of HTN and HL who presents with R sided weakness and difficulty speaking, found to have a L MCA stroke. # NEURO: As the time of onset was unknown and her L MCA stroke was already very apparent on the OSH NCHCT, no intervention with clot retreival was considered. She was not given tPA at the OSH for this same reason. Her exam on admission was notable for difficulty with language output, R-facial droop, R-sided weakness and R-sided neglect, all consistent with her known L MCA stroke. She was admitted to the stroke service for further workup. TTE did not show thrombus or PFO. As stroke appeared embolic, went ahead with TEE for better image quality which also did not show PFO or thrombus. In regards to stroke work up, HbA1c 6.2, LDL 192. She was started on atorvastatin 80mg PO qd as well as aspirin 325mg PO qd. Will follow up in stroke clinic on discharge. # CARDS: TTE and TEE as above. Monitored on telemetry, no aberrant rhythms were observed. # ID: U/A neg. CXR from OSH showed no acute process per their read, but our CTA showed ? small vessel disease in lungs. Patient was afebrile and no leukocytosis, so did not repeat chest x-ray. TRANSITIONS OF CARE: - will follow up in stroke clinic - anti-cardiolipin antibodies pending at time of discharge Medications on Admission: patient takes no medications and prefers an "herbal approach" Discharge Medications: 1. Aspirin 325 mg PO DAILY 2. Atorvastatin 80 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Senna 1 TAB PO BID:PRN constipation Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Ischemic Left Middle Cerebral Artery Stroke Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent but aphasic Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with difficulty speaking and weakness on your right side. You were found on an MRI to have an ischemic stroke in the left middle cerbral artery territory which causes speech problems and weakness. A workup for stroke risk factors was performed and showed a high-normal HgA1c (6.2) - a measure of blood sugar and you were not started on diabetes medications. Your LDL was 192 (elevated) and you were started on Atorvastatin at 80 mg to control this. A transthoracic and transesophageal echocardiogram were performed which showed no cardiac source for stroke and no septal defects. We looked at your blood vessels and saw mild atheroslerotic disease and an occlusion of the left MCA. You were started on a 325 mg dose of aspirin for secondary stroke prevention. You should follow up with Dr. ___ in clinic regarding additional care. 1. Start aspirin 325 mg daily 2. Start atorvastatin 80 mg daily 3. Follow-up with Dr. ___ in clinic ___ was a pleasure taking care of you, we wish you all the best! Followup Instructions: ___
19960665-DS-18
19,960,665
22,734,875
DS
18
2156-01-26 00:00:00
2156-01-26 18:09:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Fever 100.6 at home Major Surgical or Invasive Procedure: None History of Present Illness: ___ is a ___ year old woman who recently completed C6 R-CHOP + Lenolidamide for DLBCL who is admitted from the ED with fever. Patient developed subjective fevers starting ___ evening. T at that time ~99. She tracked her temperature throughout the day on ___, and it increased up to 100.6 around 2pm. She had no focal symptoms. She called her oncologist and was directed into the ED. In the ED, initial VS were pain 0, T 98.3, HR 126, BP 151/82, RR 18 O2 100%RA. Initial labs notable for WBC 1.9 (ANC 1620), HCT 26.7, PLT 278, Na 135, K 3.6, HCO3 23, Cr 1.2, Ca 9.3, Mg 1.8, P 4.0, lactate 1.1, UA negative. CXR without acute process. EKG with sinus tach and no ischemic changes. Patient was given 1LNS along with IV cefepime. VS prior to transfer wer T 98.5, HR 104, BP 121/81, RR 16, O2 96%RA. Past Medical History: PAST ONCOLOGIC HISTORY: - ___ CT torso performed as patient developed generalized lymphadenopathy; imaging revealed diffuse lymphadenopathy, also report of subcentimeter hepatic hypodensities and two 6 mm pulmonary nodules - ___ excisional lymph node biopsy with DLBCL, non-germinal center type; CD20+, CD10-, BCL6 (dim), MUM1+, negative for CD30 and 138, kappa restricted, Ki 67% 40-60%; cytogenetics revealed an abnormal karyotype, trisomy 3, 7 and 18, no evidence of IgH/BCL2 rearrangement, MYC rearrangement or tP53 deletion. There is BCL6 gene rearrangement. Gain of BCL2. - ___ C1D1 R-CHOP - ___ C2D1 R-CHOP - ___ C3D1 R2-CHOP (added revlimid) - ___ C4D1 R2-CHOP - ___ C5D1 R2-CHOP - ___ C6D1 R2-CHOP PAST MEDICAL HISTORY: - DLBCL, as above - ?Rhematoid arthritis, previously on prednisone and MTX - HTN - HLD - Osteoporosis - Pseudogout Social History: ___ Family History: No FH of hematologic malignancy. Positive for CAD Physical Exam: ADMISSION EXAM: VS: T 98.3, HR 126, BP 151/82, RR18 O2 100%RA GENERAL: Pleasant, well appearing woman in NAD. EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: Regular rate and rhythm, no murmurs, rubs, or gallops; 2+ radial pulses RESPIRATORY: Appears in no respiratory distress, clear to auscultation bilaterally, no crackles, wheezes, or rhonchi GASTROINTESTINAL: Normal bowel sounds; nondistended; soft, nontender without rebound or guarding; no hepatomegaly, no splenomegaly MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema; Normal bulk NEURO: Alert, oriented, CN II-XII intact, motor and sensory function grossly intact SKIN: No significant rashes LYMPHATIC: No cervical, supraclavicular, submandibular lymphadenopathy. No significant ecchymoses DISCHARGE EXAM: VS:T 98.2 BP:120/64 HR:86 RR:18 O2:96 RA GENERAL: Pleasant, well appearing woman in NAD. EYES: Anicteric sclerea, PERLL, EOMI; ENT: Oropharynx clear without lesion, JVD not elevated CARDIOVASCULAR: RRR, no murmurs, rubs, or gallops RESPIRATORY: No respiratory distress, CTAB, no crackles, wheezes, or rhonchi GASTROINTESTINAL: BS+; soft/nontender/nondistended MUSKULOSKELATAL: Warm, well perfused extremities without lower extremity edema NEURO: AAOx3 SKIN: No significant rashes, petechiae, ecchymoses LYMPHATIC: No lymphadenopathy LINE: R portocath site clean, dry, and intact. No drainage. Pertinent Results: ADMISSION LABS: ___ 07:05PM BLOOD WBC-1.9* RBC-2.67* Hgb-9.3* Hct-26.7* MCV-100* MCH-34.8* MCHC-34.8 RDW-13.6 RDWSD-49.1* Plt ___ ___ 07:05PM BLOOD Neuts-85* Bands-0 Lymphs-5* Monos-7 Eos-2 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-1.62 AbsLymp-0.11* AbsMono-0.13* AbsEos-0.04 AbsBaso-0.00* ___ 07:05PM BLOOD Glucose-102* UreaN-11 Creat-1.2* Na-135 K-3.6 Cl-99 HCO3-23 AnGap-17 ___ 07:05PM BLOOD ALT-14 AST-19 AlkPhos-77 TotBili-0.3 ___ 07:05PM BLOOD Albumin-4.1 Calcium-9.3 Phos-4.0 Mg-1.8 ___ 07:37PM BLOOD Lactate-1.1 ___ 06:48PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG DISCHARGE LABS: ___ 03:48PM BLOOD WBC-2.0* RBC-2.46* Hgb-8.7* Hct-24.5* MCV-100* MCH-35.4* MCHC-35.5 RDW-13.8 RDWSD-50.4* Plt ___ ___ 04:22AM BLOOD Neuts-62 Bands-0 ___ Monos-16* Eos-0 Baso-0 ___ 04:22AM BLOOD Glucose-97 UreaN-9 Creat-0.8 Na-138 K-3.7 Cl-104 HCO3-24 AnGap-14 ___ 04:22AM BLOOD Calcium-8.6 Phos-3.8 Mg-1.9 IMAGING: CXR (___): No acute cardiopulmonary abnormality. = MICRO: Blood and urine cultures pending Brief Hospital Course: ___ is a ___ year old woman who recently completed C6 R-CHOP + Lenolidamide for DLBCL who is admitted from the ED with neutropenic fever (___ 870). She reported temperature of 100.6 at home, but did not have any recorded fevers in the ED or during her admission. She has denied any localizing symptoms and CXR as well as UA are negative for infectious etiology. Urine and blood cultures pending. Originally given fluids and IV Vanc/Cefepime in ED. Antibiotics have since been discontinued as she continued to be afebrile during her stay. One dose of Neupogen was given to increase neutrophil count. TRANSITIONAL ISSUES: []Blood and urine cultures pending ___, resolved, discharge Cr (0.8) []Losartan held during admission and upon discharge, discuss restarting with PCP []F/U with ___ clinic for CBC check on ___ or ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Enoxaparin Sodium 90 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time 3. LORazepam 0.5-1 mg PO Q8H:PRN nausea/anxiety 4. FoLIC Acid 1 mg PO DAILY 5. Losartan Potassium 100 mg PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea 7. Oxybutynin 5 mg PO TID:PRN bladder urgency 8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 9. Calcium Carbonate 500 mg PO DAILY 10. Vitamin D ___ UNIT PO DAILY 11. Senna 8.6 mg PO DAILY:PRN constipation 12. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Calcium Carbonate 500 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 90 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time 5. FoLIC Acid 1 mg PO DAILY 6. LORazepam 0.5-1 mg PO Q8H:PRN nausea/anxiety 7. Ondansetron 8 mg PO Q8H:PRN nausea 8. Oxybutynin 5 mg PO TID:PRN bladder urgency 9. Senna 8.6 mg PO DAILY:PRN constipation 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Vitamin D ___ UNIT PO DAILY 12. HELD- Losartan Potassium 100 mg PO DAILY This medication was held. Do not restart Losartan Potassium until discussing with PCP ___: Home Discharge Diagnosis: Primary diagnosis: Neutropenic Fever Secondary diagnosis: ___, DLBCL Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your stay. You came into ___ because you had a fever at home. We did not find any infection causing the fever. We feel it is safe for you to return home at this time. If you continue to have fevers at home, please call your ___ clinic or go to the emergency room. Follow up as scheduled with your regular oncologist. Sincerely, Your ___ Care Team Followup Instructions: ___
19960731-DS-11
19,960,731
20,752,309
DS
11
2120-06-14 00:00:00
2120-06-14 17:58:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Ambien Attending: ___. Major Surgical or Invasive Procedure: None attach Pertinent Results: ADMISSION LABS ============== ___ 04:30PM BLOOD WBC-7.5 RBC-3.59* Hgb-11.9 Hct-35.8 MCV-100* MCH-33.1* MCHC-33.2 RDW-13.6 RDWSD-50.7* Plt ___ ___ 04:30PM BLOOD ___ ___ 04:30PM BLOOD UreaN-33* Creat-1.3* Na-132* K-7.5* Cl-102 HCO3-21* AnGap-9* ___ 04:30PM BLOOD ALT-27 AST-64* AlkPhos-150* TotBili-1.1 DirBili-0.6* IndBili-0.5 ___ 04:30PM BLOOD AFP-8.2 INTERIM LABS ============ ___ 11:54AM BLOOD K-5.7* ___ 03:57PM BLOOD K-5.6* ___ 12:39AM BLOOD K-4.8 DISCHARGE LABS ============== ___ 05:28AM BLOOD WBC-6.5 RBC-2.64* Hgb-8.8* Hct-25.8* MCV-98 MCH-33.3* MCHC-34.1 RDW-13.6 RDWSD-48.6* Plt ___ ___ 05:28AM BLOOD ___ PTT-36.0 ___ ___ 05:28AM BLOOD Glucose-79 UreaN-23* Creat-1.0 Na-139 K-4.9 Cl-111* HCO3-21* AnGap-7* ___ 05:28AM BLOOD ALT-22 AST-53* LD(LDH)-213 AlkPhos-95 TotBili-1.4 ___ 05:28AM BLOOD Calcium-7.8* Phos-4.1 Mg-1.8 REPORTS ======= ___ RUQUS IMPRESSION: 1. Patent portal vein with reversal of flow in the main, left, and right portal veins, unchanged. 2. Cirrhotic liver with mild ascites and portosystemic varices. 3. Cholelithiasis without evidence of acute cholecystitis. ___ CXR IMPRESSION: Cardiomediastinal silhouette is within normal limits. Lungs are clear. There are no pneumothoraces. There are degenerative changes thoracic spine. Brief Hospital Course: PATIENT SUMMARY: ================ This is a ___ ___ woman with a history of decompensated NASH cirrhosis complicated by portal hypertension, variceal bleeding and hepatic encephalopathy, poorly controlled insulin-dependent diabetes, IBS constipation, colon adenoma, reflux, obesity, and iron deficiency anemia who presented with hyperkalemia (> 7 on outpt labs) and a mild ___. Her potassium was managed with insulin and Lasix, and normalized. An infectious workup was performed, and was negative for any infectious source. Her kidney function returned to her recent baseline, and she was ready to leave the hospital. Surveillance labs will be obtained in ___ days, with follow-up from her hepatologist. TRANSITIONAL ISSUES =================== []In the hospital, the idea of palliative care in order to limit hospitalizations was discussed with the family. This has been discussed in the outpatient setting as well, and may be something she would benefit from. Her outpatient providers should continue to have this discussion with her and her family, as it pertains to her goals of care. []It is unclear exactly why her potassium was elevated, but there is likely a contribution from her medications. These were adjusted in-hospital: -Her losartan was reduced from 50mg daily to 25mg daily. -Her spironolactone was reduced from 200mg daily to 100mg daily. -Her Lasix will remain at 40mg daily. []She should have a lab check on ___ or ___ of next week: -CBC, CMP, AST/ALT, ALP, TBili, INR -Last potassium: 4.9 -Last creatinine: 1.0 []She has been endorsing distal leg numbness and tingling, likely secondary to diabetic neuropathy. Her outpatient providers should continue to adjust her medications to target optimum glucose control. []Patient will need EGD as outpatient (last EGD in system from ___ for variceal screening. []The patient has lost 25 pounds over the course of roughly 1 month. Her outpatient provider stopped her home diuretics due to concern for overdiuresis. Her weight should continue to be checked daily, and she should call her PCP or hepatologist if her weight fluctuates by more than 3 pounds. # CODE: FULL, limited - Discussions ongoing regarding transition to DNR/DNI. # CONTACT: Health Care Proxy: ___ ACTIVE ISSUES ============= #Hyperkalemia Patient presented with outpatient labs ___ notable for K 7.5. The most likely etiology is use of home ACE inhibitor, spironolactone use, and component of ___. After last hospitalization, she was discharged on 20mg Lasix and 100mg spironolactone; this was increased by her hepatologist to 80mg Lasix and 200mg spironolactone. However, her PCP noted some worsening renal function, and planned to cut down her Lasix to 40mg, which did not occur, per the patient's daughter. In-hospital, she was treated with IV Lasix and insulin/dextrose, which normalized her potassium to 4.9. She was monitored on continuous telemetry with no events. Discharge K: 4.9. #Decompensated NASH cirrhosis. MELD-Na 17 Was seen in ___ ___ ___ discussion re: connecting with palliative care to consider use of abdominal catheter for ascites, was started. Of note, ___ phone call with daughter, who stated that goals of care may be palliative. She is on lactulose and rifaximin for history of hepatic encephalopathy. A RUQUS showed patent haptic vasculature. She does not have a history of SBP, and ultrasound in-hospital showed small volume ascites. Last EGD ___ with varices and portal hypertensive gastropathy, with plan to repeat EGD in ___, although it is unclear of this has been performed. Regarding her diuretics, they have been downtitrated over the last several visits, with last day of diuretics being ___. She was previously on 80mg Lasix PO daily and 200mg spironolactone daily. She will be discharged on a reduced dose of 40mg Lasix daily and 100mg spironolactone daily. #Weight Loss # NUTRITION: Per patient and family, unchanged PO intake. Daughter states that she is a primary caregiver, and her only dietary restriction is low-salt. Per review of logs provided by daughter, the patient has lost roughly 25 pounds since last hospital discharge. She weighed 171 pounds on ___, and weight in-hospital was 147 pounds. # ___ Admission Cr 1.3 from ___ Discharge Cr 1.1. Hepatology appt ___ noted worsening Cr, with decision to taper diuretics. It appears the lasix was tapered, however, spironolactone was not, likely contributing to her hyperkalemia. She was given IV lasix in ED, as well as 1g/kg 25% albumin. Her creatinine improved to 1.0 upon discharge. #Goals of care Was documented as full code at last admission; however, daughter states that she believes her mother had expressed DO NOT INTUBATE wishes to a doctor, but she has not had this formal discussion with her mother. There has been no previous paperwork documented per daughter. We discussed that chest compressions could be accompanied by a brief period with a breathing tube, which the daughter translated to the patient. Her mother expressed that she would not want to be "a veggie" or in a "coma". Given this, she was kept full code, limited trial. CHRONIC ISSUES ============== # Insulin-dependent diabetes # left eye affected by severe nonproliferative retinopathy without macular edema HBA1c 7.1% (___). She was continued on 20 units glargine a.m., with insulin sliding scale. She experienced low morning BG levels, as reported at home, so her bedtime sliding scale was reduced. She will be discharged on her home insulin regimen of 20U glargine in the morning, Repaglinide 0.5 mg PO daily with her lunchtime (largest meal), Trulicity 1.5 mg/0.5 mL once per week (___). #HTN: -Continued home amLODIPine 2.5 mg PO DAILY -Her Losartan Potassium 100 mg PO DAILY was initially held given hyperK; will restart at reduced dose of 50mg daily upon discharge. #Insomnia #Depression -Continue home Sertraline 50 mg PO DAILY and TraZODone 100 mg PO QHS:PRN Insomnia Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 2.5 mg PO DAILY 2. Lactulose 30 mL PO TID 3. Losartan Potassium 50 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. rifAXIMin 550 mg PO BID 6. Sertraline 50 mg PO DAILY 7. TraZODone 50 mg PO QHS:PRN Insomina 8. Spironolactone 200 mg PO DAILY 9. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK 10. Nadolol 40 mg PO DAILY 11. Furosemide 80 mg PO DAILY 12. Magnesium Oxide 400 mg PO BID 13. Repaglinide 0.5 mg PO DAILY with largest meal of the day 14. Glargine 20 Units Breakfast Discharge Medications: 1. Furosemide 40 mg PO DAILY RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Losartan Potassium 25 mg PO DAILY RX *losartan 25 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 3. Spironolactone 100 mg PO DAILY RX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. amLODIPine 2.5 mg PO DAILY 5. dulaglutide 1.5 mg/0.5 mL subcutaneous 1X/WEEK 6. Glargine 20 Units Breakfast 7. Lactulose 30 mL PO TID 8. Magnesium Oxide 400 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. Nadolol 40 mg PO DAILY 11. Repaglinide 0.5 mg PO DAILY with largest meal of the day 12. rifAXIMin 550 mg PO BID 13. Sertraline 50 mg PO DAILY 14. TraZODone 50 mg PO QHS:PRN Insomina 15.Outpatient Lab Work ICD10: ___ Cirrhosis of the Liver Labs: CMP, CBC, AST, ALT, ALP, Tbili, INR Please fax to Dr. ___ fax: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: FINAL DIAGOSIS ============== Hyperkalemia Decompensated Cirrhosis Insulin-Dependent Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You came to the hospital because your labs showed an elevated potassium level. WHAT HAPPENED TO ME IN THE HOSPITAL? - You were given medications to reduce the potassium in your blood. - Your potassium levels were monitored closely, and they returned to normal. - Images of your lungs and liver showed that there was no infection. - You were feeling better and ready to return home. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. -Please weigh yourself daily in the morning. If you notice an increase or a decrease in your weight by 3 lbs or more, please call your doctor to adjust your ___ and spironolactone. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19960743-DS-20
19,960,743
23,680,914
DS
20
2141-08-06 00:00:00
2141-08-06 15:58:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PLASTIC Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: continued malaise, fevers to 101, and worsening abdominal surgical site erythema Major Surgical or Invasive Procedure: ___ Bedside procedure: L and central portions of the abdominal wound were anesthetized with 10cc of plain 1% lidocaine. An 11 blade was used to open the incision which yielded copious amounts of foul smelling pus and small amount of old clot. this was cultured. the wound was copiously irrigated, mechanically debrided with gauze, and then packed with ___ strength Dakin's moistened kerlex. History of Present Illness: ___ year-old female with a history of hodgkins's with mantel cell radiation, sternotomy x 2 for MV repair x2 (last one was several months ago) and triple neg L breast cancer who had a bilateral mastectomy and ___ flap breast reconstruction on ___ complicated by left ___ flap loss and PE. Patient was recently admitted following revision of left ___ tissue and discharged home on ___. Following discharge, patient reports continued malaise, fevers to 101, and worsening abdominal surgical site erythema. Patient seen in plastic surgery clinic earlier today with left breast wound dehiscence with necrotic/purulent appearing fat coming from the wound. Patient transferred to ER for admission to plastic surgery service. Past Medical History: Rheumatic fever as child Cocaine abuse Hodgkin's Lymphoma with radiation and chemo-1980s Anxiety Emphysema Left lung hemothorax Alcohol abuse Mitral Valve repair with 38mm annuloplasty band Skinning vulvectomy ___ Vocal cord polyp removal Triple negative left breast cancer Social History: ___ Family History: Father: ___ ___, MI, CABG. Mother: ___ ___, lymphoma. Brothers and sisters: All deceased, heart disease, stroke, suicide Physical Exam: physical exam from ___ plastic surgery consult note: General: NAD, reports feeling malaise CV: Mildy tachycardic Pulm: Breathing comfortably on RA Breast: Left breast with wound dehiscence and necrotic/purulent tissue. Tenderness around wound site. Wound very malodorous. Abdomen: Surgical site with mild erythema at midline, pain and edema. No palpable fluid collections. Ext: WWP Pertinent Results: ADMISSION LABS: ___ 10:20PM URINE HOURS-RANDOM ___ 10:20PM URINE UHOLD-HOLD ___ 10:20PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 10:20PM URINE RBC-0 WBC-1 BACTERIA-FEW* YEAST-NONE EPI-0 ___ 10:07PM LACTATE-1.1 ___ 09:50PM GLUCOSE-128* UREA N-20 CREAT-0.8 SODIUM-132* POTASSIUM-4.9 CHLORIDE-95* TOTAL CO2-22 ANION GAP-15 ___ 09:50PM WBC-13.2* RBC-2.61* HGB-7.4* HCT-23.3* MCV-89 MCH-28.4 MCHC-31.8* RDW-14.5 RDWSD-47.1* ___ 09:50PM NEUTS-79.8* LYMPHS-10.1* MONOS-9.1 EOS-0.2* BASOS-0.2 IM ___ AbsNeut-10.58*# AbsLymp-1.33 AbsMono-1.20* AbsEos-0.02* AbsBaso-0.02 ___ 09:50PM PLT COUNT-287 ___ 09:50PM ___ PTT-33.0 ___ . DISCHARGE LABS: ___ 07:08AM BLOOD WBC-9.6 RBC-2.81* Hgb-7.9* Hct-25.1* MCV-89 MCH-28.1 MCHC-31.5* RDW-15.3 RDWSD-50.1* Plt ___ ___ 07:08AM BLOOD Glucose-115* UreaN-11 Creat-0.8 Na-140 K-4.0 Cl-104 HCO3-23 AnGap-13 ___ 07:08AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.9 ___ 05:23AM BLOOD ___ . NUTRITION LAB: PREALBUMIN Test Result Reference Range/Units PREALBUMIN 6 L ___ mg/dL . IMAGING: Radiology Report VENOUS DUP UPPER EXT UNILATERAL Study Date of ___ 9:21 AM IMPRESSION: Unchanged appearance of nonocclusive deep venous thrombosis of the left internal jugular vein with persistent moderate left upper extremity edema. No evidence of propagation into any other left upper extremity vein. . MICROBIOLOGY: ___ 8:10 pm SWAB **FINAL REPORT ___ WOUND CULTURE (Final ___: PROTEUS MIRABILIS. MODERATE GROWTH. ESCHERICHIA COLI. MODERATE GROWTH. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S . ___ 10:00 am ABSCESS Source: abdominal wound. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: PROTEUS MIRABILIS. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ESCHERICHIA COLI. SPARSE GROWTH. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # ___ ___. ANAEROBIC CULTURE (Preliminary): ANAEROBIC GRAM NEGATIVE ROD(S). MODERATE GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Brief Hospital Course: The patient was admitted to the plastic surgery service on ___ for observation and treatment of purulent drainage from incisions, malaise, and fevers. A bedside debridement and drainage was performed on the abdominal incision and cultures were sent. Dakins packing BID was placed to the abdominal and left breast wounds x 3 days and then changed to normal saline wet to dry dressings. The patient tolerated these dressing changes well. . Neuro: The patient received oxycodone for pain with adequate pain relief reported. She received valium PRN for anxiety with good relief reported. . CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. . Pulmonary: The patient was stable from a pulmonary standpoint; vital signs were routinely monitored. . GI/GU: Patient was maintained on a regular diet. Her albumin was noted to be low at 2.6 so a prealbumin was sent off and returned low at 6. Patient was started on Ensure shakes TID and was compliant with this. She was maintained on a bowel regimen to encourage bowel movement. Patient voiding large amounts of urine without difficulty. Intake and output were closely monitored. . ID: The patient was initially started on vancomycin and zosyn in the ED and then switched to vanco/ceftaz/flagyl on the floor. Culture data revealed proteus mirabilis and E. Coli. ID then recommended discontinuing triple antibiotic therapy in favor of an extended course of IV unasyn. A PICC line could not be placed in the RUE at the bedside by IV team so patient was sent to ___ for PICC line placement on ___. The patient's temperature was closely watched for signs of infection. . Prophylaxis: The patient was continued on her regular Coumadin dosing and an INR of ___ was maintained until ___ when INR returned at 4.3 so warfarin was held. She was encouraged to get up and ambulate as early as possible. On HD#5, patient's left arm was noted to be increasingly swollen and she was sent for LUE and LIJ U/S which revealed no change in the LIJ thrombus visualized by in ___. . At the time of discharge on HD#7, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, Ensure shakes, ambulating, voiding without assistance, and pain was well controlled. Her left breast and abdominal wounds were clean and without odor or drainage. They were packed with wet to dry dressings which will be converted to wound vac dressings at rehab facility. Medications on Admission: ALBUTEROL SULFATE - albuterol sulfate 2.5 mg/3 mL (0.083 %) solution for nebulization. as directed - (Prescribed by Other Provider) ALBUTEROL SULFATE [PROAIR HFA] - ProAir HFA 90 mcg/actuation aerosol inhaler. 2 puffs every 4 hours as needed - (Prescribed by Other Provider) CEFADROXIL - cefadroxil 500 mg capsule. 1 capsule(s) by mouth every 12 hours DIAZEPAM - diazepam 5 mg tablet. 1 tablet(s) by mouth twice a day as needed - (Prescribed by Other Provider) ENOXAPARIN - enoxaparin 60 mg/0.6 mL subcutaneous syringe. 1 SC q12hrs Continue through ___ - (Prescribed by Other Provider) ESTRADIOL [ESTRACE] - Estrace 0.01% (0.1 mg/gram) vaginal cream. apply twice weekly - (Prescribed by Other Provider) FLUCONAZOLE [DIFLUCAN] - Diflucan 150 mg tablet. 1 tablet(s) by mouth twice a day PRN - (Prescribed by Other Provider) FLUTICASONE - fluticasone 50 mcg/actuation nasal spray,suspension. 1 spray in each nostril daily - (Prescribed by Other Provider) FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - Advair Diskus 500 mcg-50 mcg/dose powder for inhalation. 1 INH twice daily - (Prescribed by Other Provider) FUROSEMIDE - furosemide 20 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) IBUPROFEN - ibuprofen 800 mg tablet. tablet(s) by mouth 3times daily as needed Hold for 5 days, may resume on ___ - (Prescribed by Other Provider) LEVOTHYROXINE [LEVO-T] - Levo-T 137 mcg tablet. tablet(s) by mouth daily - (Prescribed by Other Provider) METOPROLOL TARTRATE - metoprolol tartrate 25 mg tablet. 0.5 (One half) tablet(s) by mouth twice a day - (Prescribed by Other Provider) OMEPRAZOLE - omeprazole 20 mg capsule,delayed release. 1 capsule(s) by mouth twice a day - (Prescribed by Other Provider) OXAZEPAM - oxazepam 15 mg capsule. 1 capsule(s) by mouth ___ times a day as needed - (Prescribed by Other Provider) OXYCODONE - oxycodone 5 mg tablet. 1 tablet(s) by mouth every six (6) hours as needed for post op pain POTASSIUM CHLORIDE - potassium chloride ER 20 mEq tablet,extended release. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) SIMVASTATIN - simvastatin 20 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) WARFARIN [COUMADIN] - Coumadin 5 mg tablet. 1 tablet(s) by mouth once a day ___ - (Prescribed by Other Provider) WARFARIN [COUMADIN] - Coumadin 2.5 mg tablet. 1 tablet(s) by mouth once a day ___ and ___ - (Prescribed by Other Provider) . Medications - OTC ASPIRIN [ADULT LOW DOSE ASPIRIN] - Adult Low Dose Aspirin 81 mg tablet,delayed release. 1.5 tablet(s) by mouth daily - (Prescribed by Other Provider) DOCUSATE SODIUM [COLACE] - Colace 100 mg capsule. 1 capsule(s) by mouth daily - (Prescribed by Other Provider) FERROUS SULFATE, DRIED [IRON (DRIED)] - Iron (dried) 160 mg (50 mg iron) tablet,extended release. tablet(s) by mouth 325 mg daily - (Prescribed by Other Provider) POLYETHYLENE GLYCOL 3350 [MIRALAX] - Dosage uncertain - (Prescribed by Other Provider) SENNOSIDES [SENEXON] - Senexon 8.6 mg tablet. 1 tablet(s) by mouth once a day - (Prescribed by Other Provider) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Ampicillin-Sulbactam 3 g IV Q6H 3. Ascorbic Acid ___ mg PO BID Duration: 14 Days 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Ondansetron ODT 4 mg PO Q8H:PRN nausea 7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*50 Tablet Refills:*0 8. Warfarin 2.5 mg PO ___ AND ___ 9. Warfarin 5 mg PO 5X/WEEK (___) 10. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 11. Diazepam 5 mg PO Q6H:PRN anxiety RX *diazepam 5 mg 5 mg by mouth every six (6) hours Disp #*14 Tablet Refills:*0 12. Fluticasone Propionate NASAL 1 SPRY NU DAILY 13. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 14. Furosemide 20 mg PO DAILY 15. Levothyroxine Sodium 137 mcg PO DAILY 16. Metoprolol Tartrate 12.5 mg PO BID 17. Multivitamins 1 TAB PO DAILY 18. Omeprazole 20 mg PO DAILY 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation 20. Potassium Chloride 20 mEq PO DAILY 21. Senna 8.6 mg PO BID:PRN constipation 22. Simvastatin 20 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1) left breast wound 2) dehiscence of the abdominal incision 3) Infection left breast wound and abdominal incision 4) poor nutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. . Personal Care: 1. You will have a wound VAC dressing with a wound vac machine in place for discharge. This dressing will be changed every three days. 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. In addition, you should bring a VAC dressing kit to your follow up appointments with your doctor so that he/she may remove your VAC dressing, evaluate your wound and then apply fresh VAC dressing. Your VAC drain will be removed as soon as possible and when it is determined that the wound is healthy enough to be surgically closed. 4. You may shower daily with assistance as needed. You should do this with wound vac apparatus disconnected from you. Once you have showered you will need to reconnect your dressing to the wound vac apparatus and make sure it is functioning properly. 5. No baths until after directed by your surgeon. . Activity: 1. Avoid strenuous activity with wound vac in place. . Medications: 1. Resume your regular medications unless instructed otherwise and take any new meds as ordered. 2. You may take your prescribed pain medication for moderate to severe pain. You may switch to Tylenol or Extra Strength Tylenol for mild pain as directed on the packaging. Please note that Percocet and Vicodin have Tylenol as an active ingredient so do not take these meds with additional Tylenol. 3. Take prescription pain medications for pain not relieved by tylenol. 4. You will continue your antibiotic therapy until advised otherwise by Infectious Disease. 5. Take Colace, 100 mg by mouth 2 times per day, while taking the prescription pain medication. You may use a different over-the-counter stool softener if you wish. 6. Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. . Call the office IMMEDIATELY if you have any of the following: 1. Signs of infection: fever with chills, increased redness, swelling, warmth or tenderness at the surgical site, or unusual drainage from the incision(s). 2. A large amount of bleeding from the incision(s) or drain(s). 3. Fever greater than 101.5 oF 4. Severe pain NOT relieved by your medication. . Return to the ER if: * If you are vomiting and cannot keep in fluids or your medications. * If you have shaking chills, fever greater than 101.5 (F) degrees or 38 (C) degrees, increased redness, swelling or discharge from incision, chest pain, shortness of breath, or anything else that is troubling you. * Any serious change in your symptoms, or any new symptoms that concern you. Followup Instructions: ___
19960743-DS-21
19,960,743
28,131,106
DS
21
2141-08-21 00:00:00
2141-08-23 07:13:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: chest pain, anxiety, tachycardia, WOB Major Surgical or Invasive Procedure: ___- intubation ___ Central line placement History of Present Illness: ___ with history of recent necrotic breast flap currently on Unasyn therapy, PE, and recent mitral valve repair ___ who presents from rehab with increased work of breathing and agitation, found to have septic shock and hypoxic respiratory failure. Patient with a complicated recent medical/surgical history. She was diagnosed with triple negative breast cancer ___. Subsequently underwent the following procedures: -B/L mastectomy and ___ (deep inferior epigastric perforator) flap breast reconstruction on ___. Hospitalization complicated by PE diagnosed by CTA ___, started on heparin bridge to Coumadin. -Revision of the ___ tissue with deep irrigation as well as irrigation of the abdominal wound, with full debridement down to healthy tissue ___ No tissue samples/cultures obtained, she was discharged ___ on po cefpodoxime -___ seen in plastics clinic and admitted, necrotic flap with pus noted, debrided at bedside on admission with purulence; swab grew pan-sensitive E coli and Proteus -___ abdominal wound was also debrided at bedside w/ copious amounts of foul smelling pus and old clot was drained and sent for culture; no growth -Discharged ___ to The ___ on IV Unasyn via ___ projected end date ___, anticipated switch to po Augmentin at that time with ID follow up. Per discussion with The ___ staff, when she arrived wound vacs were placed to abdomen and L chest and patient started complaining of chest pain and anxiety. She was tachycardic to 130s and had increased work of breathing. Subsequently sent to ___ ED. Arrival to ___ to 150s, sats ___ on NC (unknown how much), so patient placed on Bipap instead. Labs: VBG ___ Lactate 5.0, WBC 22 BNP 14632 Trop-T 0.05 Given Vanc/Zosyn, 60 IV Lasix, Foley placed. 2 hrs later SBP dropped to ___, given 500cc with improvement to 100s systolic. Started transfer to ___ ED. In ED initial VS: 97.0 130 130/89 27 96% bipap Exam: Labs significant for: 24.7 > 10.3/33.6 < 463 INR 2.7 Trop 0.22 Phos 5.3, otherwise lytes normal Lactate 1.7 Patient was satting well on Bipap but per ED resident had increased working of breathing/anxiety and decision was made to intubate. ABG 7.33/51/159 on 100% FiO2 after intubation Patient was given: Fent gtt Midaz gtt Imaging notable for: CXR ___ 1. Moderate to severe bilateral pulmonary edema and moderate cardiomegaly, progressed compared to the prior exam from ___. 2. Bilateral layering pleural effusions given supine acquisition of images. Consults: Plastics Wound vacs over breast and abdomen removed. No evidence of infection. Replaced by saline WTD dressings. Breast/abdominal wound unlikely to be cause of white count. Please do full infectious workup. Pt with fluid overloaded lungs on CXR, ?pna. Hx CHF and PE, has known L IJ thrombus (u/s ___ without propogation of clot). Appropriately anti-coagulated on discharge. Has received 60mg IV Lasix. Pt very Lasix sensitive. CTA chest ordered to r/o PE as cause of respiratory decompensation. Please transfer to MICU. Plastics will continue to follow and see her on floor. VS prior to transfer: 97.0 108 105/70 20 100% on 60% FiO2 On arrival to the MICU, patient able to follow commands but otherwise unable to participate in interview. REVIEW OF SYSTEMS: Unable to obtain ___ mental status Past Medical History: Rheumatic fever as child Cocaine abuse Hodgkin's Lymphoma with radiation and chemo-1980s Anxiety Emphysema Left lung hemothorax Alcohol abuse Mitral Valve repair with 38mm annuloplasty band Skinning vulvectomy ___ Vocal cord polyp removal Triple negative left breast cancer Social History: ___ Family History: Father: ___ ___, MI, CABG. Mother: ___ ___, lymphoma. Brothers and sisters: All deceased, heart disease, stroke, suicide Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: 98.5 ___ 24 100% FiO2 60% GENERAL: intubated, sedated HEENT: pinpoint pupils bilaterally NECK: supple, JVP appears elevated LUNGS: rhonchi bilaterally 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: 2+ edema up to hips SKIN: dressings over L chest wound + abdominal wound; R chest wound appears CDI NEURO: able to follow commands DISCHARGE PHYSICAL: GENERAL: Well appearing woman sitting up on bed HEENT: AT/NC, EOMI, no JVD, neck supple LUNGS: Bilateral LL crackles improved relative to prior, no wheezing appreciated, no accessory muscle usage HEART: RRR, s1+s2 normal, no m/g/r appreciated ABDOMEN: +BS, non-tender, non-distended EXTREMITIES: Pulses present, no edema Pertinent Results: ADMISSION LABS: ============== ___ 06:24AM BLOOD WBC-24.7*# RBC-3.67*# Hgb-10.3*# Hct-33.6*# MCV-92 MCH-28.1 MCHC-30.7* RDW-16.2* RDWSD-54.2* Plt ___ ___ 06:24AM BLOOD Neuts-90.4* Lymphs-3.8* Monos-4.5* Eos-0.0* Baso-0.3 Im ___ AbsNeut-22.34*# AbsLymp-0.93* AbsMono-1.10* AbsEos-0.00* AbsBaso-0.07 ___ 05:23AM BLOOD ___ ___ 06:24AM BLOOD ___ PTT-44.4* ___ ___ 06:24AM BLOOD Glucose-233* UreaN-16 Creat-1.0 Na-140 K-4.1 Cl-99 HCO3-24 AnGap-17 ___ 06:24AM BLOOD CK-MB-9 cTropnT-0.22* ___ 06:24AM BLOOD Calcium-8.8 Phos-5.3* Mg-1.8 ___ 07:52AM BLOOD Type-ART Rates-20/ Tidal V-400 PEEP-10 FiO2-100 pO2-159* pCO2-51* pH-7.33* calTCO2-28 Base XS-0 AADO2-499 REQ O2-84 Intubat-INTUBATED DISCHARGE LABS: ___ 05:28AM BLOOD WBC-9.3 RBC-3.52* Hgb-9.6* Hct-32.0* MCV-91 MCH-27.3 MCHC-30.0* RDW-17.8* RDWSD-57.1* Plt ___ ___ 05:28AM BLOOD Plt ___ ___ 05:28AM BLOOD Glucose-114* UreaN-22* Creat-0.9 Na-143 K-4.6 Cl-104 HCO3-25 AnGap-14 ___ 05:28AM BLOOD Calcium-9.7 Phos-4.4 Mg-2.2 MICROBIOLOGY: ============= ___ 2:20 pm SWAB Source: Vaginal. SMEAR FOR BACTERIAL VAGINOSIS (Final ___: Indeterminate. YEAST VAGINITIS CULTURE (Preliminary): PND ___ blood cultures with NGTD ___ urine cultures - negative ___ - sputum culture with yeast RELEVANT IMAGING: ================= ___ Upper extremity US IMPRESSION: Unchanged appearance of nonocclusive deep venous thrombosis of the left internal jugular vein with persistent moderate left upper extremity edema. No evidence of propagation into any other left upper extremity vein. ___ PICC placement IMPRESSION: Successful placement of a right 40 cm brachial approach single lumen PowerPICC with tip in the distal SVC. The line is ready to use. ___ ECHO The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is severely depressed (LVEF = 25 %) secondary to extensive severe concentric, circumferential, symmetric apical hypokinesis/akinesis with focal dyskinesis. The right ventricular free wall thickness is normal. Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. A bioprosthetic mitral valve prosthesis is present. The gradients are higher than expected for this type of prosthesis. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: severe left ventricular systolic dysfunction: Takotsubo cardiomyopathy vs myocardial infarction ___ CTA chest IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. Diminished lung volumes with enlarged bilateral nonhemorrhagic pleural effusions, large on the right and moderate sized on the left. There is adjacent compressive atelectasis in both lower lobes. 3. Prominent main pulmonary artery, suggesting pulmonary arterial hypertension. ___ ECHO There is moderate regional left ventricular systolic dysfunction with near akinesis of the distal half of the ventricle and mild apical dyskinesis. Though none is seen, a left ventricular mass/thrombus cannot be fully excluded due to suboptimal image quality.. Right ventricular chamber size is normal with moderate global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present.Mild aortic stenosis is suggested. Mild (1+) aortic regurgitation is seen. A well-seated bioprosthetic mitral valve prosthesis is present. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. A left pleural effusion is present. A left pleural effusion is present. IMPRESSION: Suboptimal image quality. Normal left ventricular cavity size with extensive regional systolic dysfunction in a pattern most c/w Takotsubo cardiomyopathy or proximal lad disease. Right ventricular free wall hypokinesis. Well seated mitral bioprosthesis. Large left pleural effusion. Compared with the prior study (images reviewed) of ___, the findings are similar (aortic regurgitation was also present on review of the prior study). ___ Central line CXR IMPRESSION: Compared to the earlier same day examination, there has been placement of a right internal jugular approach central venous catheter terminating in the high right atrium, satisfactory, without pneumothorax. No other significant interval changes seen. The remainder of the support devices are unchanged. The cardiomediastinal silhouette is unchanged. Bilateral effusions, vascular congestion, and moderate edema appears unchanged. No new consolidation is seen, though infection remains difficult to exclude. ___ CT Abn/pelvis: IMPRESSION: 1. No clear source of infection identified in the abdomen and pelvis. 2. Heterogeneous enhancement of the liver is nonspecific and may be secondary to mild congestion. 3. Mild biliary duct dilatation with no obstructive cause. 4. Small bilateral pleural effusions and bibasilar atelectasis. ___ Dominance: Right * Left Main Coronary Artery The LMCA is without significant disease. * Left Anterior Descending The LAD is without significant disease. * Circumflex The Circumflex is without significant disease. * Right Coronary Artery The RCA is without significant disease. The Right PDA is without significant disease. ___ ECHO: There is moderate regional left ventricular systolic dysfunction with akinesis of the distal ___ of the left ventricle. The remaining segments contract normally (LVEF = 30%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. There is no pericardial effusion. Bilateral pleural effusions are present. IMPRESSION: Moderate regional left ventricular systolic dysfunction, most c/w takotsubo cardimoyopathy. Normally-seated mitral valve bioprosthesis without significant regurgitation. Compared with the prior study (images reviewed) of ___, right ventricular function has improved. Left ventricular systolic function is relatively similar. Brief Hospital Course: In brief, Ms. ___ is a ___ y/o F with history of triple negative breast cancer, recent necrotic breast flap discharged most recently ___, s/p B/L mastectomy and flap breast reconstruction on ___omplicated by b/l PE on warfarin, and recent mitral valve repair ___ who presented from rehab on ___ with increased work of breathing and agitation, found to have septic shock and hypoxic respiratory failure, requiring intubation and pressors. She was originally admitted to the MICU, and then transferred to the CCU after she was found on be in heart failure with echo showing apical ballooning consistant with Takosubos and rising troponin. She underwent cath w/ no disease and diuresis with IV Lasix. Concern for VAP on initial presentation so underwent 8 day antibiotic course. She was extubated and weaned off pressors in CCU and transferred to floor ___. On ___, was planned for Dobhoff for TFs given NPO per recommendation of SS. During Dobhoff placement aspirated, developed HTN, tachypneic, and pulmonary edema. Was placed on BIPAP in CCU and diagnosed with flash pulmonary edema. S/P Diuresis and nitro, off O2, became euvolemic and transferred to floor. On the floor, she was retained on Unasyn for the breast flap necrosis and infection until ___, when cleared by ID and plastics to no longer need Abx. She was switched to Ativan 1mg PO q6:PRN for better anxiety control. She was medically optimized for her Takotsubo cardiomyopathy with metoprolol, lisinopril, ASA, Lasix and simvastatin. She received continuous ___ on the floor and will be following in the outpatient setting with a walker and cane at first. Potential vaginal candidiasis was swabbed with cultures pending, but treated empirically with fluconazole. ACTIVE ISSUES: ================================= # Takotsubo Cardiomyopathy Suspect that cardiomyopathy is stress induced in setting of significant infection and echocardiographic findings consistent with Takotsubo. Improved with diuresis, patient appeared euvolemic (last CVP in CCU was 8, with current plan to transition to PO Lasix, but without enteric access). Flash pulmonary edema on ___, s/p diuresis. Stable since transfer from MICU on ___, with goals towards optimization of medication regimen. Originally on metop 6.25mg PO, which was escalated to 12.5mg then 25mg subsequently. It was consolidate to metoprolol succinate 200mg daily on ___. Given Lasix 40mg IV daily one time doses for pulm edema, held on ___ for Cr bump. Otherwise, continued ASA 81mg daily, Lisinopril 2.5 mg, and Simvastatin 20 mg QPM. #Breast Flap Necrosis Unasyn was continued until ___ per ID, without further need for any antibiotics. PICC line to be removed prior to d/c. Cleared from wound perspective by plastics. OK to shower soapy water over wounds without scrubbing. Will f/u with plastics Dr. ___ in clinic. # Anxiety Patient notes significant anxiety and has been on high doses of benzos at home. Restarted home nebs for reassurance if dyspnea precipitates. Continued LORazepam at 1 mg q6h:PRN. ___ require outpatient psych for long-term optimization. #Physical Therapy and Disposition: Doesn't want to go to rehab, wants to go home. ___ has been working with her. Sister in law is involved in care, willing to go to her house with services. Cleared from cardiac/wound perspectives. Will d/c with rolling walker and cane, allowing home with ___ services. #Potential Vaginal Candidiasis: Complaining to nurse regarding potential yeast infection. S/p empiric fluconazole 150mg PO once. Cultures pending, gram stain for BV indeterminate. CHRONIC/STABLE ISSUES: =============================== # Recent PE: no PE on admission CTA, but seen in ___. Continued on warfarin with goal INR ___ # Triple negative breast cancer: follow up with Dr. ___ ___ anticipated ___ mos chemotherapy once wounds are healed. # Hypothyroid: Continued levothyroxine # HLD: Continued simvastatin TRANSITIONAL ISSUES: []No further abx needed per infectious disease []PCP appointment within next ___ days []Plastics appointment with Dr. ___ in upcoming 2 weeks []Place appointment with Dr. ___ within upcoming 2 weeks []Home ___ with walker and cane at sister-in-law's home first, then potential transfer home []Outpatient psych for long-term optimization []Monitor heart rate and adjust metoprolol as needed []Repeat TTE per outpatient cardiology provider []Please check INR on ___ []Adjust Lasix if patient gaining weight on current Lasix dose #Discharge weight = 59.6 kg (131.39 lb) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 3. Ampicillin-Sulbactam 3 g IV Q6H 4. Ascorbic Acid ___ mg PO BID 5. Diazepam 5 mg PO Q6H:PRN anxiety 6. Docusate Sodium 100 mg PO BID 7. Ferrous Sulfate 325 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU DAILY 9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 10. Furosemide 20 mg PO DAILY 11. Levothyroxine Sodium 137 mcg PO DAILY 12. Metoprolol Tartrate 12.5 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. Omeprazole 20 mg PO DAILY 15. Ondansetron ODT 4 mg PO Q8H:PRN nausea 16. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 17. Polyethylene Glycol 17 g PO DAILY:PRN constipation 18. Potassium Chloride 20 mEq PO DAILY 19. Senna 8.6 mg PO BID:PRN constipation 20. Simvastatin 20 mg PO QPM 21. Warfarin 2.5 mg PO ___ AND ___ 22. Warfarin 5 mg PO 5X/WEEK (___) Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Ascorbic Acid ___ mg PO BID 3. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Lisinopril 2.5 mg PO DAILY RX *lisinopril 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 7. LORazepam 1 mg PO BID:PRN anxiety RX *lorazepam 1 mg 1 tablet by mouth up to two times a day Disp #*14 Tablet Refills:*0 8. Metoprolol Succinate XL 200 mg PO DAILY RX *metoprolol succinate 200 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. Ondansetron ODT 4 mg PO Q8H:PRN nausea 10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 11. Warfarin 2.5 mg PO ___ AND ___ 12. Warfarin 5 mg PO 5X/WEEK (___) 13. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 14. Diazepam 5 mg PO Q6H:PRN anxiety 15. Fluticasone Propionate NASAL 1 SPRY NU DAILY 16. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 17. Furosemide 20 mg PO DAILY 18. Levothyroxine Sodium 137 mcg PO DAILY 19. Multivitamins 1 TAB PO DAILY 20. Omeprazole 20 mg PO DAILY 21. Polyethylene Glycol 17 g PO DAILY:PRN constipation 22. Potassium Chloride 20 mEq PO DAILY Hold for K >5 23. Senna 8.6 mg PO BID:PRN constipation 24. Simvastatin 20 mg PO QPM 25.Outpatient Physical Therapy Diagnosis: Takotsubo Cardiomyopathy I51.81 What: Rolling walker and cane Why: ___ for diagnosis When: Follow up with home ___ and PCP (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== - Sepsis from cellulitis - Takotsubo cardiomyopathy - Acute on chronic reduced ejection heart failure SECONDARY DIANGOSIS =================== - Mixed cardiogenic and distributive shock - Hypoxic respiratory failure requiring intubation - Recent pulmonary emboli - Triple negative breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to ___ because you were feeling unwell with chest pain and increased work of breathing. WHAT DID WE DO WHILE YOU WERE HERE? - We used a breathing machine and a tube in your throat to support your breathing - We treated you with medications to increase your blood pressure - We treated you with IV antibiotics and had assistance from our infectious disease team. - We provided you with wound care with assistance from the plastic surgery team. - Your heart was not working as well as it can so we gave you medicine to help you pee out extra fluid and increase the strength of your heart. WHAT SHOULD YOU DO WHEN YOU GO HOME? - Take all of your medicines as prescribed. - Follow up with your outpatient doctor, ___, plastic surgeon, and oncologist. It was a pleasure taking care of you! ~ Your ___ team Followup Instructions: ___
19960879-DS-15
19,960,879
29,288,546
DS
15
2169-05-11 00:00:00
2169-05-11 10:50:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: No Allergies/ADRs on File Attending: ___. Chief Complaint: s/p fall, TBI Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o F with history of Alzheimer's presents s/p fall today. Patient was transferred from OSH after head CT revealed L ICH. She is amnestic to events. She reports headache, but denies any n/v/d, or change in vision. Past Medical History: Alzheimer's osteoporosis Vit D deficiency Social History: ___ Family History: Unknown Physical Exam: On admission: PHYSICAL EXAM: Gen: patient is agitated and slightly combative HEENT: atraumatic, normocephalic Pupils: 2.5-2mm bilaterally EOMs: intact Neck: in hard collar Alert to self Follows commands MAE with good strength Upon discharge: Awake, alert, oriented to self only. MAE spont without deficit. PERRL. Patient appears more interactive in the AM, has gotten agitated in the evening and overnights. Pertinent Results: Head CT ___: IMPRESSION: Nondepressed occipital fracture with scattered extra-axial hemorrhage (SDH and SAH) as detailed above, and focal parenchymal contusion in the left inferior temporal lobe and left cerebellum. Head CT ___: FINDINGS: Compared with prior exam, there is a general progression of intracranial hemorrhage. The left temporal and left posterior cerebellar hemisphere hemorrhagic contusions have increased in size. New bilateral inferior frontal contusions are now seen. Bilateral sulcal subarachnoid hemorrhage has increased in extent, left greater than right. There has been a mild increase in size of subdural hematoma along the left anterior cerebellum. There is unchanged extraaxial blood in the midline posterior fossa, adjacent to the nondisplaced left occipital bone fracture. The amount of blood in the occipital horn of the left lateral ventricle has increased, and there is new blood in the occipital horn of the right lateral ventricle. The ventricles are stable in size, prominent due to cerebral atrophy, and proportionate to prominent sulci. A cavum septum pellucidum is again noted. Periventricular white matter hypodensities are likely sequela of chronic small vessel ischemic disease. The basal cisterns are not compressed. Secretions are seen in the inferior frontal sinus. Brief Hospital Course: Ms. ___ was seen in the ER and admitted to the step down unit for monitoring. A repeat head CT on HD 1 did show expected progression of her bleed. Her exam remained unchanged. Patient is typically awake and alert, only oriented to self, MAE with good strength. During her hospital stay she did become agitated at times in the evening and overnight. She was noted to have urinary retention and required a foley to be placed. She remained unchanged in her exam and was discharged back to her facility on ___. Medications on Admission: Donepezil 10 mg PO QAM Lorazepam 0.25 mg PO HS:PRN anxiety Vitamin D 5000 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain 2. Donepezil 10 mg PO QAM 3. Lorazepam 0.25 mg PO HS:PRN anxiety 4. Phenytoin Sodium Extended 100 mg PO TID 5. Vitamin D 5000 UNIT PO DAILY 6. Docusate Sodium 100 mg PO BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Traumatic brain injury Bilateral contusions Bilateral traumatic subarachnoid hemorrhage IVH Nondisplaced left occipital bone fracture Urinary retention Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Nonsurgical Brain Hemorrhage •Take your pain medicine as prescribed. •Exercise should be limited to walking; no lifting, straining, or excessive bending. •Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. •Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. •If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you may safely resume taking this when cleared by the neurosurgeon. •You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP’s office, but please have the results faxed to ___. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion, lethargy or change in mental status. •Any numbness, tingling, weakness in your extremities. •Pain or headache that is continually increasing, or not relieved by pain medication. •New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ___
19961152-DS-17
19,961,152
25,444,212
DS
17
2148-06-06 00:00:00
2148-06-06 15:38:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Dilantin / morphine Attending: ___. Chief Complaint: s/p mechanical fall with left hand degloving injury Major Surgical or Invasive Procedure: ___ 1. Wide debridement circumferential left forearm wrist and hand. 2. Full thickness skin graft dorsum of the hand (25.0 x 12.0 cm) using partial thickness avulsed skin from elsewhere in the forearm. 3. Application of very complex dressing left forearm, wrist and hand. ___: Right and left chest tube placements. ___: Dressing change under anesthesia. Debridement left forearm ___: Dressing change under anesthesia, left upper extremity ___: Dressing change under anesthesia, left upper extremity History of Present Illness: Mr. ___ is an ___ man with a past medical history of CAD s/p CABG x3, CHF, PPM, T2DM, HTN, hx of prostate cancer who presents with injuries from a mechanical fall. From talking with his son, it seems that Mr. ___ fallen with increasing frequency over the past ___ years, regularly being hospitalized and set to rehab facilities for his injuries. Most of his falls happen at night in the bathroom, as he gets up very frequently to urinate. While two months ago he could work with a walker, 3 months ago the rehab facility determined he needed a wheelchair, and on his past discharge on ___ he was sent home with wheelchair and oxygen. After returning to his living facility he was having difficulty ambulating to the bathroom and soiling himself, so the facility sent an aid to help him during the day. His son is not sure of what happened on the evening of ___ as they have heard two stories - either that the aid was not present during the fall or that his father tripped over the aid. He reportedly did not lose consciousness nor was any seizure activity witnessed and ___ did not become incontinent of stool or urine. With this fall, he sustained multiple injuries, including L posterior ___ rib fractures, two scalp lacerations repaired in ED, and a degloving injury of L arm. On the L lower arm plastic surgery performed a washout and full thickness skin graft. Past Medical History: 1. CAD with CABG x 3 in ___ and CABG x 4 in ___, 2 cardiac stents placed in ___ 2. Atrial fibrillation, SVT s/p ablation and pacer placement ___ (dual chamber ___ 3. T2DM (HbA1C in ___ 8.3%); hand paresthesia 4. Chronic kidney disease ___ Creatinine 1.24) 5. HTN 6. Chronic low back pain 7. Polymyalgia rheumatica 8. History of prostate cancer 9. Meningioma resection in ___ 10. Diastolic CHF (echo in ___ shows LVEF 50-55%; mild aortic and mitral regurgitation, moderate tricuspid regurgitation, PASP 29.79 mmHg) 11. Anxiety 12. Gout 13. Anemia and thrombocytopenia 14. Glaucoma 15. Chronic leg edema - moderate to severe, worse in the L leg 16. Restless leg syndrome 17. Generalized osteoarthritis 18. HLD 19. Surgical evacuation of right calf hematoma ___ 20. Fall with hospitalization at ___ ___ bilateral lower extremity cellulitis, T7 compression fracture, rib fracture, left arm hematoma - followed by rehab for ___ weeks. 21. Fall with ED evaluation at ___ ___ - Repair of skin tears and sent to rehab -Fall requiring hospitalization with left degloving injury -Hospitalization at ___ ___ Fall with left arm degloving injury s/p wide debridement circumferential left forearm wrist and hand/Full thickness skin graft dorsum of the hand (25.0 x 12.0 cm) using partial thickness avulsed skin from elsewhere in the forearm. -Hospitalization at ___: ___: Bilateral chest tube placements for bilateral pleural effusions. Social History: ___ Family History: Brother died of ___ Disease in ___ Physical Exam: ADMISSION PHYSICAL EXAM ======================= Vital Signs: T 97.5 BP 120/64 HR 73 RR 18 100% on 4 L General: Alert, oriented to place and date, no acute distress. Labored breathing with nasal cannula in place. HEENT: Sclera anicteric, MMM, oropharynx clear, JVP elevated to ear. Indented area of right forehead due to past operation Lungs: Tachypneic and taking shallow breaths. Crackles in posterior lung fields CV: Regular rate and rhythm, normal S1 + S2. ___ systolic murmur best heard over the left lower sternal border Abdomen: Soft, non-distended, bowel sounds present, mildly tender in LUQ without rebound tenderness or guarding. Pitting edema in lower abdomen. Ext: Cool with thick dry skin. Pulses not palpable. 1+ pitting edema up to thighs. Skin: Multiple ecchymoses, especially on left upper arm, right chest Neuro: Intermittent myoclonus in right hand. DISCHARGE PHYSICAL EXAM ======================= Vitals: 98.4, 147/50, 72, 16, 95% on 1L to 97% on 3L. General: Laying in bed, appears well rested, alert and oriented to person, hospital, and year. HEENT: Sclera anicteric, dry mucous membranes. Lungs: Nasal cannula in place. Breathing non-labored, minimal crackles at bases throughout anterior auscultation. No wheezes appreciated. CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur best heard over LLSB Abdomen: soft, non-tender, non-distended, no rebound or guarding. Ext: Sacral edema appreciated. LUE in ACE bandage with edematous fingers. Sensation maintained in left fingers and pulsation maintained in fingers. Skin: Deep bruising/ecchymoses on right upper extremity, although improving from prior in hospitalization. Ecchymoses of the face are improved, chronic venous stasis changes ___ bilaterally MS: Alert and oriented x 3. Pertinent Results: ADMISSION LABS ============== ___ 06:15AM BLOOD WBC-6.6 RBC-2.53* Hgb-7.4* Hct-26.7* MCV-106* MCH-29.2 MCHC-27.7* RDW-18.5* RDWSD-70.4* Plt Ct-91* ___ 06:15AM BLOOD Neuts-70.1 Lymphs-15.5* Monos-11.1 Eos-2.0 Baso-0.8 Im ___ AbsNeut-4.60 AbsLymp-1.02* AbsMono-0.73 AbsEos-0.13 AbsBaso-0.05 ___ 06:15AM BLOOD ___ PTT-30.4 ___ ___ 06:15AM BLOOD Glucose-120* UreaN-21* Creat-1.2 Na-142 K-4.1 Cl-102 HCO3-31 AnGap-13 ___ 05:25AM BLOOD Calcium-8.0* Phos-4.1 Mg-1.8 DISCHARGE LABS ============== ___ 04:11AM BLOOD WBC-4.8 RBC-2.56* Hgb-7.6* Hct-27.3* MCV-107* MCH-29.7 MCHC-27.8* RDW-21.3* RDWSD-80.5* Plt Ct-74* ___ 04:11AM BLOOD Plt Ct-74* ___ 04:11AM BLOOD Glucose-143* UreaN-29* Creat-1.1 Na-144 K-4.0 Cl-103 HCO3-35* AnGap-10 ___ 04:11AM BLOOD Calcium-8.2* Phos-2.8 Mg-2.2 WORKUP OF MACROCYTOSIS ====================== ___ 06:50AM BLOOD Ret Man-3.2* Abs Ret-0.09 ___ 06:50AM BLOOD ALT-2 AST-30 AlkPhos-73 TotBili-0.6 ___ 05:35PM BLOOD ALT-6 AST-21 LD(LDH)-175 AlkPhos-78 TotBili-0.5 ___ 05:36AM BLOOD calTIBC-196* VitB12-1759* Folate-14.4 Ferritn-102 TRF-151* ___ 06:50AM BLOOD TSH-9.5* ___ 06:50AM BLOOD T4-6.1 ___ 07:15AM BLOOD Cortsol-2.9 PLEURAL FLUID RESULTS ===================== ___ 12:14PM PLEURAL WBC-120* RBC-1350* Polys-11* Lymphs-78* ___ Meso-3* Macro-8* ___ 12:14PM PLEURAL TotProt-0.9 Glucose-152 Creat-0.8 LD(LDH)-51 Albumin-LESS THAN ___ Misc-PRO BNP = pH: 7.40 ___ 12:16PM PLEURAL WBC-111* RBC-3389* Polys-7* Lymphs-88* ___ Meso-1* Macro-4* ___ 12:16PM PLEURAL TotProt-1.0 Glucose-164 Creat-0.8 LD(LDH)-61 Albumin-LESS THAN ___ Misc-PRO BNP = pH: 7.43 MICROBIOLOGY ============ ___ 12:16 pm PLEURAL FLUID PLEURAL FLUID LEFT SIDE. **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. ___ 12:14 pm PLEURAL FLUID PLEURAL FLUID ( RIGHT SIDE). **FINAL REPORT ___ 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 (Final ___: NO GROWTH. IMAGING/REPORTS =============== ___: FOREARM (AP AND LATERAL) LEFT IMPRESSION: 1. No definite fractures however study is limited due to technique and the severe degenerative changes of the radiocarpal joint. 2. Lucent lesion involving distal ulna likely a subchondral cyst related to the distal radial ulnar joint osteoarthritis. 3. There is some subluxation at the distal radioulnar joint. ___: LEFT, AP AND LATERAL VIEWS LEFT IMPRESSION: No evidence of fracture or dislocation of the left elbow. ___: FOOT AP, LATERAL AND OBLIQUE BILATERAL FINDINGS: Right: There is no fracture or focal osseous abnormality. Joint spaces are grossly preserved. Diffuse soft tissue swelling seen. There is no subcutaneous gas or radiopaque foreign body. Left: There is no acute fracture. Small plantar calcaneal spur is identified. There is diffuse soft tissue swelling. Surgical clip projects over the ankle. No other radiopaque foreign body identified. IMPRESSION: No fracture. ___: ANKLE (AP, MORTISE AND LATERAL) BILATERAL FINDINGS: Left: There is no fracture or acute osseous abnormality. Small plantar calcaneal spur is identified. Ankle mortise is preserved on these nonstress views. Small vessel atherosclerotic calcifications are noted. Surgical clip projects within the tissues overlying the distal left tibia. Soft tissue swelling seen overlying the medial malleolus. Right: There is no acute fracture. Well corticated osseous fragment seen adjacent to the tip of the medial malleolus. Ankle mortise are preserved on these nonstress views. Atherosclerotic calcifications are noted. Diffuse soft tissue swelling is noted without radiopaque foreign body. IMPRESSION: Soft tissue swelling bilaterally, right greater than left. No acute fracture. ___: WRIST (3+ VIEWS) RIGHT FINDINGS: Right hand: No fracture or dislocation seen. There are mild degenerative changes at the interphalangeal joint and metacarpophalangeal joint of the thumb. Radiocarpal degenerative changes are better evaluated on the wrist radiograph. Right wrist: There are moderate degenerative changes at the radio carpal articulation. There is widening of the scapholunate interval, consistent with injury to the scapholunate ligament. The ulnar styloid is not visualized, this likely relates to a remote fracture as there is no bony fragment seen. Extensive vascular calcification noted. Right forearm: Degenerative changes are noted at the wrist joint. No fracture or dislocation seen. An IV cannula is noted at the antecubital fossa. IMPRESSION: Degenerative changes as described. No acute fracture seen. ___: CHEST X-RAY (PORTABLE) There are no prior chest radiographs available for review, but the study is read in conjunction with chest CT on ___ which showed large dependent, non trans UT 80 of, but nonhemorrhagic bilateral pleural effusion, and asbestos related pleural plaques, largely calcified. Heart is moderately enlarged. Pulmonary edema is mild if any. Most of the abnormalities due to persistence of the pleural effusions and new left lower lobe atelectasis. There is no pneumothorax. Atrioventricular pacer leads follow their expected courses, continuous from the left pectoral generator. No pneumothorax. Although no acute fracture or other chest wall lesion is seen, conventional chest radiographs are not sufficient for detection or characterization of most such abnormalities. If the demonstration of trauma to the chest wall is clinically warranted, the location of any referrable focal findings should be clearly marked and imaged with either bone detail radiographs or Chest CT scanning. There is a healed fracture deformity of the proximal right humerus with severe degenerative changes at the shoulder. ___: UNILATERAL LOWER EXTREMITY ULTRASOUND LEFT FINDINGS: There is normal compressibility, flow, and augmentation of the left common femoral, femoral, and popliteal veins. Normal color flow and compressibility are demonstrated in the posterior tibial veins. The peroneal veins were not well seen. Subcutaneous edema is noted in the calf. There is normal respiratory variation in the common femoral veins bilaterally. No evidence of medial popliteal fossa (___) cyst. IMPRESSION: No evidence of deep venous thrombosis in the left lower extremity veins, though the peroneal veins were not well seen. Subcutaneous edema in the calf. ___: TRANSTHORACIC ECHOCARDIOGRAM The left atrium is markedly elongated. The right atrium is markedly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Global systolic function is low normal (LVEF 50%). (Intrinsic function may be depressed given the severity of mitral regurgitation.] The right ventricular cavity is dilated with normal free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] There is abnormal diastolic septal motion/position consistent with right ventricular volume overload. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. IMPRESSION: Moderate to severe tricuspid regurgitation. Moderate mitral regurgitation. Low normal left ventricular systolic function . Right ventricular cavity dilation. Moderate pulmonary artery systolic hypertension. Mildly dilated ascending aorta. ___: CTA CHEST WTIH AND WITHOUT CONTRAST IMPRESSION: 1. No evidence of pulmonary embolism. 2. Large bilateral pleural effusions and bilateral dependent atelectasis. 3. Diffuse pleural calcifications. 4. Compression fracture of the T7 vertebral body which is age-indeterminate but likely to be more acute than chronic based on imaging findings. 5. Fractures of the posterior left ___ and 7th ribs. ___: PLEURAL FLUID CYTOLOGY: RIGHT PLEURAL EFFUSION DIAGNOSIS: Pleural Fluid, Right: Negative for malignant cells. Mesothelial cells and small lymphocytes. ___: PLEURAL FLUID CYTOLOGY: LEFT PLEURAL EFFUSION: DIAGNOSIS: Pleural Fluid, Left: Negative for malignant cells. Mesothelial cells, many small lymphocytes, and rate multinucleated giant cells. ___: CHEST (PORTABLE AP) FINDINGS: Interval insertion of bilateral chest tubes, appear low. Heart is moderately enlarged. Mild pulmonary edema unchanged. Most of the abnormalities due to persistence of the pleural effusions and left lower lobe atelectasis. There is no pneumothorax. Atrioventricular pacer leads follow their expected courses, continuous from the left pectoral generator. No pneumothorax. IMPRESSION: No pneumothorax. No substantial change in bilateral moderate effusions. Bilateral chest tubes appear low. ___: CHEST (PORTABLE AP) IMPRESSION: Bilateral pigtail catheters are seen projecting over the lower chest/upper abdomen, stable. Heart size upper limits of normal. There is a dual lead left-sided pacemaker. There is persistent mild pulmonary edema and a left retrocardiac opacity. There are no pneumothoraces. Irregularity of the right proximal humerus may be related to prior old trauma. There is elevation of the left humeral head likely due to rotator cuff rupture. ___: CHEST (PORTABLE AP) IMPRESSION: In comparison with the study of ___, there is little overall change. Bilateral pigtail catheters remain in place and there is no evidence of pneumothorax. Continued enlargement of the cardiac silhouette with pulmonary vascular congestion. Monitoring and support devices are unchanged. ___: CHEST (PORTABLE AP) IMPRESSION: Left pigtail catheter is in place. Cardiomediastinal silhouette is stable. Pacemaker leads are unremarkable. Parenchymal opacities are unchanged as well as pleural calcifications. No pneumothorax seen. ___: CHEST X-RAY (PORTABLE AP) IMPRESSION: Heart size is top-normal. Mediastinum is normal. Pacemaker leads are unremarkable. Vascular congestion has substantially improved. No interval increase in pleural effusion demonstrated. ___: PICC PLACEMENT/PROCEDURE FINDINGS: 1. Existing right arm approach PICC with tip in the axillary vein replaced with a new double lumen PIC line with tip in the low SVC. IMPRESSION: Successful placement of a 37 cm right arm approach double lumen PowerPICC with tip in the low SVC. The line is ready to use. PROCEDURES ========== ___ PREOPERATIVE DIAGNOSES: 1. Circumferential avulsion of skin, left arm, elbow, forearm and dorsum of the hand. 2. Polymyalgia rheumatica with long-standing steroid medication. 3. Coronary artery disease. 4. Diabetes. POSTOPERATIVE DIAGNOSES: 1. Circumferential avulsion of skin, left arm, elbow, forearm and dorsum of the hand. 2. Polymyalgia rheumatica with long-standing steroid medication. 3. Coronary artery disease. 4. Diabetes. OPERATION PERFORMED: 1. Wide debridement circumferential left forearm wrist and hand. 2. Full thickness skin graft dorsum of the hand (25.0 x 12.0 cm) using partial thickness avulsed skin from elsewhere in the forearm. 3. Application of very complex dressing left forearm, wrist and hand. ANESTHESIA: General. HISTORICAL NOTE: Earlier last evening, this man was admitted to the emergency room after he had fallen locally. He lives in an assisted care facility with his wife. This man is ___ years old and takes care of his wife who has advanced ___ disease. He fell down and sustained a very significant avulsion to the entire forearm and dorsum of the hand circumferentially. He is brought to the OR for appropriate dressing change, evaluation and treatment. DESCRIPTION OF PROCEDURE: With the ___ on the operating table in supine position with the head elevated 10 degrees, general endotracheal anesthetic was induced without difficulty. The dressing which was on the arm was very carefully removed. The avulsed skin flaps were all inspected and the they were all turned back on themselves, and all of the clots adherent to these skin flaps which were essentially partial-thickness or full-thickness skin grafts at this point in time, were removed. The clots were removed from the native wound. More serious injury is on the dorsum of the hand where he had some huge clots attendant to large dorsal draining veins which had bled significantly. Extensor tendons over metacarpals 2, 3, 4 and 5 were all exposed. Skin was a avulsed, full-thickness plus subcutaneous fat. The veins were tied off. Potential bleeders were cauterized with bipolar cautery. We cannot use a regular cautery because he has a pacemaker. Wound was appropriately irrigated. Looking at the forearm, the entire forearm had been avulsed circumferentially, partial thickness skin over the entire flexor pronator mass in the forearm came off, but this actually looked quite good because there was good bleeding dermis with deep dermal appendages including hair follicles and sweat glands. Under normal circumstances, this should epithelialize spontaneously. There were many conduit flaps on the dorsum of the hand, particularly at the distal metacarpal level extending into the web spaces 2, 3 and 4. These flaps were all sorted out and clots removed. The arm was then elevated, very carefully exsanguinated over many layers of moist gauze over the form circumferentially. Tourniquet was then inflated and the wounds were very carefully inspected. On the dorsum of the hand, many local flaps were sutured back into place as local flaps or as full- thickness skin grafts with 5 and ___ catgut chromic sutures. There was 1 large avulsed skin segment which we prepared as a thick split-thickness skin graft, or in full-thickness skin grafts in several areas. This was sutured directly over the big defect of the dorsum of the hand which was prepared first by cauterizing potential bleeding areas and trimming off what appeared to be nonviable or marginally viable tissue. This graft was sutured into place. Many other avulsed partially avulsed flaps were all sutured back into place. Dressing was placed. This was a complex burn type dressing consisting of Xeroform and bacitracin as the first layer, and this included the interdigital web spaces, the digits, the hand, dorsum of the hand, and the entire forearm circumferentially. Next was a layer of moist gauze, followed by a layer of moist cotton, followed by more layers of moist gauze, followed by dry cotton followed by Kerlix wraps. A snug compression dressing was placed throughout including the dorsum of the hand, the digits and the interdigital web spaces. This very bulky dressing was then kept on with ACE wraps. The tourniquet was released. Fortunately there was no avulsed skin in the tourniquet area. This will be a very difficult wound healing problem as the skin from the chronic steroid use was essentially like a youngster with epidermolysis bullosa. Can be avulsed very easily anywhere on his body. ___: OPERATION PERFORMED 1. Dressing change under anesthesia. 2. Debridement left forearm. ___: OPERATION PERFORMED -Dressing change under anesthesia, left upper extremity. Brief Hospital Course: Mr. ___ is an ___ man with a past medical history of CAD s/p CABG x3, CHF, PPM, T2DM, HTN, prostate cancer, and multiple falls who presents with degloving injury of the left arm s/p skin graft of the left upper extremity, c/b bilateral pleural effusions s/p bilateral pigtail catheters. Plastic Surgery Hospital Course =============================== ___ presented to ___ on ___ after a mechanical fall from standing. The ___ was pan-scanned including head CT/Cspine/CT torso/as well as plain films of his left arm/hand. His injuries include, left sided posterior ___ and 7th rib fractures, significant degloving injury of left arm, with exposed tendon and displaced ulnar. Plastic and hand surgery were consulted for the degloving injury and repaired the injury in the OR with a skin graft. Plastic recommends continuing Cefazolin for 7 days. He was extubated, taken to PACU then transferred to the surgical floor for management. On POD1 he was sleepy but arousable, hemodynamically stable, tolerating a regular diet, incontinent of urine, and pain is controlled on PO medications. He had xrays of the right upper extremity which were negative for fracture. He was transferred to medicine for further management. Medicine Hospital Course ======================== # Left Upper Extremity Degloving Injury: ___ had left posterior ___ rib fractures, two scalp lacerations repaired in ED, and a degloving injury of left arm. ___ underwent left arm repair and skin graft with plastic surgery on ___ and was continued on 7 day course of Cefazolin. His pain was controlled initially with acetaminophen and oxycodone PRN, but ___ reported persistent discomfort, so home dose MS ___ was resumed (30 mg PO QAM and 15 mg PO QHS). ___ somnolent on BID dosing, so only morning 30mg MS contin continued, with good pain control. ___ went back to the OR on ___ for dressing change and again on ___ for debridement. Per plastics, wound had appearance consistent with pseudomonal infection on ___. He was transitioned from Cefazolin to Cefepime/Flagyl per their recs with last day on ___. ___ underwent final dressing change on ___ at which point they believed wound appeared to be healing with recommendation to discontinue antibiotics. He was discharged to rehab on ___. He will follow up with plastic surgery within one week of discharge with Dr. ___ see "Transitional Issues" regarding scheduling an appointment with Dr. ___. He will likely need further dressing change in the OR in 2 weeks following discharge from the hospital. This can be arranged after discussion with Dr. ___. # History of Falls: ___ and family reported history of falls from standing with increasing frequency over past ___ years. Etiology of recurrent falls is not known. OSH ECG showed no ST changes and troponins on arrival were negative. ___ pacemaker was interrogated by EP and showed no events. Other possible causes include orthostatic hypotension due to the numerous medications that can lead to orthostasis (as he was on furosemide 120 mg daily, gabapentin 300 mg daily, metoprolol tartrate 25 mg BID, Morphine SR 30 mg daily, Morphine SR 15 mg QHS, oxycodone 10 mg Q4H:PRN, tamsulosin 0.4 mg daily, and trazadone 12.5 mg PO BID:PRN). Additional etiologies included autonomic dysfunction from aging; hypoglycemia from glipizide; syncope from structural defect (although echocardiogram did not show evidence of aortic stenosis, but did show moderate to severe tricuspid regurgitation, moderate mitral regurgitation, low normal left ventricular systolic function) and peripheral neuropathy. Micturition syncope also considered, as most of the falls he experienced in the past occurred in the bathroom. ___ monitored on telemetry during admission with no significant events. His electrolytes remained within normal limits as did his blood sugars. Orthostatic hypotension in the setting of multiple medications and poor PO intake was thought to be most likely cause of ___ falls. Unfortunately, ___ unable to stand for any significant period of time given his diffuse weakness, so orthostatic vital signs unable to be obtained. ___ was evaluated by ___ and OT who determined that he was significantly deconditioned and should be discharged to rehab. To prevent further orthostasis and falls, ___ trazadone, gabapentin, and bedtime morphine SR were discontinued. This should be re-evaluated as outpatient. # Pain Management: ___ has history of chronic lower back pain as well as acute pain from injuries and surgery. Pain was initially controlled with Acetaminophen 650mg Q6H and Oxycodone 5mg q4h PRN. ___ home pain regimen included Morphine SR, 30mg in the mornings and 15mg in the evenings. Home dose was resumed due to poor pain control. However, due to extreme drowsiness, evening MS ___ dose was subsequently held. His pain regimen at the time of discharge included Morphine SR 30 mg PO QAM, oxycodone 5 mg PO Q4H:PRN (although he did not require breakthrough oxycodone for pain during most of hospitalization). He was on gabapentin 300 mg PO daily, but this caused increased confusion and was discontinued at the time of discharge. Resumption of gabapentin should be discussed at rehab. # Acute on Chronic Diastolic Heart Failure Complicated by Bilateral Pleural Effusions: ___ reported persistent dyspnea on ___ NC supplemental oxygen. On exam ___ had elevated JVP (difficult to interpret with severe TR) and pitting edema in his lower and upper extremities bilaterally. On transfer to medicine, ___ reported subjective dyspnea and was satting in low 90's on ___ O2 NC. Per his son, oxygen requirement is new as most recent rehab stay. To further investigate cause of the dyspnea/oxygen requirement, a CTA was performed. CTA revealed large bilateral pleural effusions and atelectasis, but no PE. Interventional Pulmonary was consulted who placed pigtail catheter in both right and left lung on ___ that drained >1 L per lung. Pleural effusions negative for malignancy by cytology and felt to be secondary to CHF. Atelectasis likely due to prolonged immobility and inability to take a deep breath with broken ribs Chest tubes were removed on ___ and ___ continued to do well. At time of discharge, ___ satting high 90's on 3L although when nasal cannula was removed, his O2 saturation remained in high ___. ___ preferred to have nasal cannula in place for comfort. He was discharged on his home dose of furosemide 120 mg PO daily. His weight at time of discharge was 173 pounds. He should have daily weights. If weight ___, MD should be informed and his furosemide should be uptitrated as needed. # Delirium: At times during hospitalization, ___ was alert and oriented x 3. He had fluctuating mentation and mental status. This was thought to be secondary to prolonged hospital course, chronic illness, and medication effects. His Morphine SR was decreased from 30 mg PO QAM and 15 mg PO QPM to just 30 mg PO QAM (the nighttime dose was stopped). His gabapentin was also discontinued due to concern that this was leading to delirium. During hospitalization, attempted to re-orient, keep shades open, have him near a window, and avoid tethers. At the time of discharge he still had waxing and waning of mental status but was alert and oriented to person, hospital, and year. # Poor wound healing: Pain's skin was very thin, tender to palpation and with diffuse ecchymoses throughout. Poor wound healing and bruising likely secondary to a combination of daily prednisone, thrombocytopenia and malnutrition. The ___ initially had high INR (peak of 3.7) responsive to vitamin K supplementation. Nutrition was consulted who recommended supplementing ___ with Multivitamin and Glucerna shake TID. Per plastics, ___ left upper extremity wound graft healing well. Wound care was consulted for the remainder of the ___ wounds. He was discharged to rehab where he will continue to receive wound care and be followed closely by Plastic Surgery as outpatient. # Anemia: ___ has history of chronic anemia with increased MCV and increased RDW, suggesting multiple etiologies. For macrocytosis, there was no evidence of folate def or B12 deficiency by labs; LFTs were within normal limits. Normal T4 with high TSH suggested subclinical hypothyroidism. MDS was considered a significant possibility, given ___ age and persistent thrombocytopenia in addition to macrocytic anema. ___ also found to have low serum iron, low TIBC, and low transferrin. Ferritin was normal but was considered low given his inflammatory state. This pattern therefore suggested anemia of chronic disease with iron deficiency. Low reticulocyte production index of 1.4% evidence of inadequate marrow response to anemia possibly due to old age or underlying bone marrow pathology, such as MDS. ___ continued on iron supplementation during admission and Hemoglobin remained stable. Further evaluation of anemia should be addressed as outpatient. # PMR: ___ on 10 mg prednisone daily for PMR, which was continued during admission. His measured morning cortisol was low at 2.9 ug/dL indicating that his HPA likely suppressed. ___ received stress dosed steroids perioperatively on ___ and ___ for wound debridement and dressing change and he did well. ___ showed no evidence of adrenal insufficiency during admission. # Living situation: With progressive decline, current home at assisted living facility may not provide sufficient support for ___. Social work and case management were consulted and a family meeting was held to discuss the situation. ___ discharged to rehab to continue recovery from his significant injuries and deconditioning. Decisions about placement beyond rehab were deferred, pending ___ improvement during rehab stay. CHRONIC ============ # CAD s/p CABG: continued Aspirin 81, Pravastatin 40mg. # Hypertension: continued Metoprolol Tartrate TID # Diabetes mellitus complicated by neuropathy: ___ on Insulin sliding scale. Continued Gabapentin initially but mental status fluctuated while on medication. This was discontinued at the time of discharge and should be re-addressed at rehab. # BPH: continued Tamsulosin. # GERD: continued Omeprazole. # Anxiety: continued Citalopram. # PMR: continued Prednisone 10mg daily, with stress-dose steroids ___ for wound debridement. # Chronic low back pain: continued Acetaminophen and Oxycodone PRN. ___ MS ___ reduced from 30mg in the morning, 15mg at night to only 30mg QAM. Transitional Issues =================== #Discharge weight: approximately 173 pounds, although difficult to be accurate given that this was a bed weight (as ___ has diffuse weakness and difficulty with standing). #Please obtain a weight on admission to rehab. #At time of discharge from rehab, please obtain a discharge weight for outpatient providers. #Please weigh ___ daily. If weight is up-trending please contact MD and consider increasing furosemide. His current dose is 120 mg PO daily. #Please remove sutures from his prior chest tubes (had bilateral chest tubes in place) on ___. ___ will require follow up appointment with Dr. ___ ___ of ___ Surgery within one week following discharge from the hospital. The number to contact Dr. ___. The number to Dr. ___ office is ___. ___ will require a dressing change in 2 weeks following discharge from the hospital. This should be coordination with Dr. ___. Number to his office is as above. #When able to stand please obtain orthostatic vital signs. #Please obtain CBC and chemistry every other day. Please obtain ___ weekly to assess for nutritional deficiency (as INR was increased during hospitalization due to poor nutrition and reversed with vitamin K). ___ was noted to have atrial fibrillation during hospitalization. Please obtain repeat ECG as outpatient and discuss with ___ pros versus cons of anticoagulation if within goals of care. #Please obtain repeat CBC as outpatient and consider further workup of his macrocytosis (TSH was elevated with normal T4 during hospitalization). #Please not that ___ has adrenal insufficiency likely secondary to his chronic steroid use. An AM cortisol was low consistent with adrenal insufficiency. #Please repeat CXR as outpatient to assess for resolution of bilateral pleural effusions/parenchymal opacities. #Please obtain speech and swallow evaluation at rehabilitation to assess ___ ability to swallow. #Prior CT Chest showed calcified pleural plaques possibly related to sequel of asbestos exposure. # CT Abdomen and Pelvis from ___: There are bilateral renal cystic lesions including lesions that are too small to characterize including a 1.4 cm indeterminate cystic lesion interpolar right kidney which may be more fully characterized with dedicated CT or MRI renal mass protocol. #Per Plastic Surgery: Please keep left arm dressing clean and dry. #Please discuss medication changes with PCP, as he is on numerous medications that can lead to orthostatic hypotension and subsequent falls. Discontinuing oxycodone should be considered as he did not receive oxycodone during most of hospitalization. #CODE: DNR/DNI #CONTACT: ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN (Glucophage) 500 mg PO BID 2. MetFORMIN (Glucophage) 1000 mg PO DAILY 3. PredniSONE 10 mg PO DAILY 4. Ferrous Sulfate 325 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 7. Magnesium Oxide 400 mg PO BID 8. Docusate Sodium 100 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. Senna 8.6 mg PO BID 12. Tamsulosin 0.4 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Citalopram 10 mg PO DAILY 15. GlipiZIDE XL 10 mg PO DAILY 16. Potassium Chloride 20 mEq PO DAILY 17. Vitamin D ___ UNIT PO DAILY 18. Travatan Z (travoprost) 0.004 % ophthalmic QHS 19. Acidophilus (Lactobacillus acidophilus) 1 cap oral BID 20. Furosemide 120 mg PO DAILY 21. Metoprolol Tartrate 25 mg PO BID 22. Pravastatin 40 mg PO QPM 23. TraZODone 12.5 mg PO BID:PRN anxiety 24. Acetaminophen 1000 mg PO Q8H:PRN pain 25. Gabapentin 300 mg PO DAILY 26. Insulin SC Sliding Scale Insulin SC Sliding Scale using Novolog Insulin 27. Morphine SR (MS ___ 30 mg PO DAILY 28. Morphine SR (MS ___ 15 mg PO QHS 29. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Citalopram 10 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO BID 6. Furosemide 120 mg PO DAILY 7. Insulin SC Sliding Scale Insulin SC Sliding Scale using Novolog Insulin 8. Metoprolol Tartrate 12.5 mg PO TID 9. Morphine SR (MS ___ 30 mg PO QAM RX *morphine [MS ___ 30 mg 1 tablet(s) by mouth daily Disp #*5 Tablet Refills:*0 10. Omeprazole 20 mg PO DAILY 11. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain RX *oxycodone 5 mg 1 tablet(s) by mouth Q4H:PRN Disp #*10 Tablet Refills:*0 12. Polyethylene Glycol 17 g PO DAILY:PRN constipation 13. Pravastatin 40 mg PO QPM 14. PredniSONE 10 mg PO DAILY 15. Senna 8.6 mg PO BID 16. Tamsulosin 0.4 mg PO DAILY 17. Heparin 5000 UNIT SC BID 18. Acidophilus (Lactobacillus acidophilus) 1 cap oral BID 19. GlipiZIDE XL 10 mg PO DAILY 20. Magnesium Oxide 400 mg PO BID 21. MetFORMIN (Glucophage) 500 mg PO BID 22. MetFORMIN (Glucophage) 1000 mg PO DAILY 23. Multivitamins 1 TAB PO DAILY 24. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 25. Potassium Chloride 20 mEq PO DAILY 26. Travatan Z (travoprost) 0.004 % ophthalmic QHS 27. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= -Left Degloving Injury -Syncope/Fall thought to be secondary to orthostatic hypotension in setting of medications. -Acute on Chronic Diastolic Heart Failure c/b bilateral pleural effusions s/p bilateral pigtail catheters by interventional pulmonary -Left posterior ___ rib fractures -Scalp lacerations repaired in ED -Macrocytic Anemia -Thrombocytopenia Secondary Diagnosis =================== -CAD -Hypertension -Type II Diabetes Mellitus -Hypertension -BPH -GERD 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 admitted to ___ after a fall at your assisted living. You sustained a degloving injury to your left arm. Plastic surgery and hand surgery was consulted and repaired your arm with a skin graft. You also have left rib fractures. These will continue to heal over time and do not require surgery at this time. You have a laceration to the left side of your forehead which was repaired in the Emergency Department. You also were very short of breath when you came to the hospital. You underwent an imaging study of your lungs which showed pleural effusions in each of the lungs (fluid within each of the lungs). In order to treat this, you were seen by the lung doctors who placed two chest tubes to drain the fluid. This helped improve your breathing. The cause of your fall was thought to be related to some of the medications you were on. Your nighttime morphine was stopped. Your trazadone and gabapentin were also stopped. It will be important to follow up with your primary care physician to determine the necessary medications you are on. When you are at home, please weigh yourself everyday. If your weight increases more than 3 pounds in any given day, please call your primary care physician to adjust your furosemide (water pill). Please call Dr. ___ Plastic ___ to schedule an appointment within one week following discharge from the hospital. The number to his office is ___. It was a pleasure taking care of you during your hospitalization. We wish you all the best! Sincerely, Your ___ Care Team Please note the following discharge instruction: Rib Fractures: * 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). Followup Instructions: ___
19961180-DS-6
19,961,180
20,189,169
DS
6
2118-07-27 00:00:00
2118-07-27 18:28:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___ Chief Complaint: Monitoring after variceal banding Major Surgical or Invasive Procedure: ___ - EGD with banding (prior to admission) History of Present Illness: Ms. ___ is a ___ woman with a history of ___ Class B NASH cirrhosis decompensated with HE, admitted for monitoring after outpatient EGD/banding with post-procedural ooze. Patient underwent EGD today demonstrating 1 cord of medium sized varices with friable mucosa in the lower third of the esophagus. 1 band was successfully placed with hemocystic spot following band placement and oozing just proximal to the banded varix. Oozing stopped prior to completion of case. Given post-procedure oozing, patient was referred in for observation. Of note, patient's blood sugar was 100 @ 1145 and 64 upon arival to procedure. She has a history of hypoglycemia but not diabetes. In the ED, initial vitals were 10 79 153/53 18 100%. Patient reported intermittent, diffuse abdominal pain that felt "like gas" and was the same as her chronic pain. She also reported "darker" stools this morning, but no bloody or frankly black stools, no hematemisis, no n/v/d, no fever. She reported mild increase in abdominal distention x 2 weeks. She has no h/o prior paracentesis. Labs in the ED were notable for WBC 3.2, H/H 14.4/41.1, plt 52 (baseline), INR 1.6 (baseline), AST 50 (baseline), AP 117 (baseline), Tbil 2.4 (1.3 in ___ and 2.1 in ___. ___ as trace guaiac positive. The Liver Fellow was called who advised RUQ ultrasound was not needed. She received IVF at 75 ml/hr, protonix and octreotide infusion. Vitals prior to transfer were 0 98.3 82 139/55 18 99% RA. On floor, she notes chronic dizziness and chronic abdominal pain, both of which are near baseline. She got up to bathroom and notes room spinning, but says this is normal for her intermittently at home. Has been passing stool with black material in them, new for her. Regarding history of HE, has been diagnosed with this in past, denotes some intermittent episodes of confusion and forgetfulness, not compliant with rifaximin. Stopped citalopram. Not compliant with nadolol because was told by Dr. ___ to stop for her liver disease. Does not take acetaminophen for chronic pain because was told to stop. Takes oxycodone for chronic back pain and hip pain. Reports itchiness throughout her skin, scratching draws blood x 2weeks. No numbness/tingling. No chest pain, no SOB. Reports headache x 3 weeks which she cannot describe. She feels like her veins at front of head will burst, but pain is worse in posterior. No change in vision, causes difficulty sleeping. Oxycodone helps. ROS: per HPI, denies fever/chills, otherwise please see above. Past Medical History: - ___ Cirrhosis decompensated with HE. Also has non-bleeding varices. - Portal hypertension. - Endoscopic band ligation therapy for treatment of esophageal varices - Migraines - Osteoporosis - Chronic low back pain, hip pain - Enchondroma of the hip (benign) - Pancreatic cysts compatible with side branch IPMNs - Chronic abdominal pain - Renal cysts: Not felt to have a cystic kidney syndrome Social History: ___ Family History: Mother with lung cancer, COPD. Father with COPD, throat cancer. No liver disease or autoimmune disease in the family. Physical Exam: ADMISSION PHYSICAL EXAM ================================= VS: 98.7 - 172/74 - 90 0 18 - 99RA fs 93 General: pleasant obese lady sitting in bed, no distress HEENT: sclera anicteric, mucous membranes are moist Neck: supple w/o elevated JVP CV: regular rate and rhythm, soft systolic murmur heard throughout precordium, best at ___, NOT louder with inspiration Lungs: CTA bilaterally Abdomen: soft, mildly TTP throughout without rebound or guarding, bowel sounds present Ext: no pedal edema. skin: left upper medial arm with non raised long thing erythematous lines (pt says from BP cuff). no excoriations. no jaundice Neuro: face symmetric, gait slow but steady. moves all extremities. no asterixis DISCHARGE PHYSICAL EXAM ================================= VS: 97.8 - 125/74 - 59 - 18 - 95RA General: pleasant obese lady sitting in bed, no distress HEENT: sclera anicteric, mucous membranes are moist Neck: supple w/o elevated JVP CV: regular rate and rhythm, soft systolic murmur heard throughout precordium, best at ___ Lungs: CTA bilaterally Abdomen: soft, mildly TTP in upper quadrants without rebound or guarding, bowel sounds present Ext: no pedal edema. skin: left upper medial arm with non raised long thing erythematous lines (in distribution of BP cuff). no excoriations. no jaundice Neuro: face symmetric. moves all extremities. no asterixis Pertinent Results: ADMISSION LABS ===================== ___ 05:00PM BLOOD WBC-3.2* RBC-4.53 Hgb-14.4 Hct-41.1 MCV-91 MCH-31.9 MCHC-35.1* RDW-15.2 Plt Ct-52* ___ 05:00PM BLOOD Neuts-74.1* Lymphs-15.7* Monos-6.0 Eos-3.7 Baso-0.5 ___ 05:00PM BLOOD ___ PTT-43.4* ___ ___ 05:00PM BLOOD Glucose-92 UreaN-6 Creat-0.5 Na-142 K-3.7 Cl-108 HCO3-26 AnGap-12 ___ 05:00PM BLOOD ALT-38 AST-50* AlkPhos-117* TotBili-2.4* ___ 05:00PM BLOOD Lipase-32 ___ 05:00PM BLOOD Albumin-3.5 ___ 05:07PM BLOOD Lactate-1.4 PERTINENT LABS ===================== ___ 05:28AM BLOOD AFP-4.9 ___ 05:28AM BLOOD WBC-3.3* RBC-4.17* Hgb-13.4 Hct-37.8 MCV-91 MCH-32.2* MCHC-35.5* RDW-14.7 Plt Ct-44* ___ 01:00PM BLOOD Hgb-14.2 Hct-40.5 ___ 05:28AM BLOOD ALT-34 AST-48* AlkPhos-108* TotBili-3.0* ___ 01:00PM BLOOD ALT-37 AST-53* AlkPhos-117* TotBili-3.5* ___ 04:53AM BLOOD ALT-32 AST-48* AlkPhos-105 TotBili-2.8* DISCHARGE LABS ===================== ___ 04:53AM BLOOD WBC-3.0* RBC-4.07* Hgb-13.1 Hct-37.1 MCV-91 MCH-32.1* MCHC-35.2* RDW-14.8 Plt Ct-47* ___ 01:07PM BLOOD ___ PTT-45.5* ___ ___ 04:53AM BLOOD Glucose-96 UreaN-11 Creat-0.7 Na-142 K-4.4 Cl-107 HCO3-29 AnGap-10 ___ 01:07PM BLOOD ALT-34 AST-54* AlkPhos-114* TotBili-2.7* ___ 04:53AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.1 MICROBIOLOGY ====================== Blood culture NGTD x 1 at discharge RADIOLOGY ====================== ___ ___ US FINDINGS: LIVER: The hepatic architecture is coarsened and nodular in appearance. There is no focal liver mass. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CBD is again noted to be dilated measuring 1.2 cm. This is unchanged from the MRI of ___ GALLBLADDER: The patient is status post cholecystectomy. PANCREAS: The head and body of the pancreas are within normal limits. The tail of the pancreas is not visualized due to overlying bowel gas. SPLEEN: The spleen is enlarged measuring 18.4 cm. KIDNEYS: No hydronephrosis is seen in either kidney. The right kidney measures 10.4 cm and the left kidney measures 11.2 cm. A simple cyst is again seen in the right kidney measuring 7.2 x 5.5 x 6.1 cm. DOPPLER EXAMINATION: The main, right and left portal veins are patent with hepatopetal flow. There is a patent umbilical vein. Appropriate arterial waveforms are seen in the main, right and left hepatic arteries. The hepatic veins are patent. Hepatopetal flow is seen in the splenic vein and SMV in the midline. IMPRESSION: 1. Coarsened nodular hepatic architecture. No concerning liver lesion identified. 2. No intrahepatic biliary dilatation. The common bile duct is again noted to be dilated measuring 1.2 cm but is unchanged from the abdomen MRI ___. 3. Patent hepatic vasculature. A patent umbilical vein is noted. 4. Splenomegaly. 5. Simple right renal cyst stable from prior imaging. Brief Hospital Course: Ms. ___ is a ___ woman with a history of Child's B ___ cirrhosis who was referred in for observation after variceal banding with post-procedure oozing and was found to have an uptrending bilirubin above her baseline . # Esophageal Varices s/p banding: She underwent EGD on ___ whic showed 1 cord of medium sized varices with friable mucosa in the lower third of the esophagus. A band was successfully placed with hemocystic spot following band placement and oozing just proximal to the banded varix. Oozing stopped prior to completion of case. Given post-procedure oozing, patient was referred in for observation. Her H&H remained stable, she had no signs/symptoms of ongoing bleeding. Started on omeprazole 40mg daily x 2 weeks, and sucralfate was increase from 1g TID to QID x 2 weeks. Was changed from soft diet to regular on discharge (2 days post-procedure). It was clarified with her that she SHOULD be taking nadolol. # Hypoglycemia: Has a history of hypoglycemia, including upon presentation to the ___ on day of EGD. Unclear etiology, likely poor hepatic function. Has not been hypoglycemic during this admission. Blood culture was NGTD, no urinary or pulmonary symptoms, no fevers. # Child ___ Class B NASH Cirrhosis, decompensated with HE: Initially she was noted to have an increasing bilirubin abover her baseline. It peaked at 3.5 the day after proceduer, then downtrended to 2.7. She reports she takes lactulose once per daily, has 3 BMs, does note confusion at times. Not compliant with rifaximin or nadolol. A RUQ US with dopplerwas performed and showed no change in biliary duct size or evidence of vascular thrombosis. Restarted rifaximin 550mg BID, Nadolol 20mg daily. # Abdominal Pain: At chronic baseline pain in intensity and characteristics, has been worked-up extensively in the past. RUQ US with no changes or ascites. Continued home narcotics with holding parameters, added <2g acetaminophen. #CODE: OK to resuscitate, DO NOT INTUBATE #CONTACT: Does not have a HCP. Emergency contact is son ___, ___ ===================================== TRANSITIONAL ISSUES ===================================== - Has slip for outpatient lab draw on ___ for CBC, Chem10, LFTs - Continue to emphasize medication compliance with nadolol, rifaximin, and lactulose - Increased sucralfate to QID for 2 weeks (until ___ - Take omeprazole for 2 weeks (until ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 15 mL PO DAILY 2. Nadolol 20 mg PO DAILY 3. Rifaximin 550 mg PO BID 4. Sucralfate 1 gm PO TID 5. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY 6. OxycoDONE (Immediate Release) 10 mg PO QHS:PRN pain 7. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN pain Discharge Medications: 1. Lactulose 15 mL PO DAILY Titrate to ___ BMs daily. ___ MD if change in mental status. RX *lactulose [Generlac] 10 gram/15 mL 15 mL by mouth daily Refills:*1 2. OxycoDONE (Immediate Release) 10 mg PO QHS:PRN pain 3. OxycoDONE (Immediate Release) 5 mg PO DAILY:PRN pain 4. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 5. Sucralfate 1 gm PO QID Mix into slurry consistency. Take QID for 2 weeks ___, then return to TID. RX *sucralfate 1 gram/10 mL 1 gm by mouth four times a day Refills:*1 6. Omeprazole 40 mg PO DAILY Take for 2 weeks ___, then stop. RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*14 Capsule Refills:*0 7. Nadolol 20 mg PO DAILY RX *nadolol 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 8. Caltrate 600 (calcium carbonate) 600 mg (1,500 mg) oral DAILY 9. Outpatient Lab Work Please obtain LFTs (including ALT, AST, Alk Phos, Bilirubin), CBC, and Chem10 and fax to Dr. ___ at the ___ (fax: ___, phone ___ ICD9 code ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS - Esophageal varices SECONDARY DIAGNOSIS - ___ cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure being a part of your care at the ___ ___. You were admitted for close observation after an endoscopy procedure, to ensure that you didn't experience bleeding. Your blood counts remained stable and you did not require any further intervention. You should take omeprazole 40mg daily for the next to weeks (through ___, and you should take a sucralfate slurry four times a day for the next two weeks and then decrease it to your pre-admission schedule of three times a day. It was noted that some of your liver tests increased initially, so an ultrasound was performed. There was no evidence of bile duct or blood flow problems, and your tests started to decrease the next day. It will be important to follow up with Dr. ___ 2 weeks at the ___. It is also important to take your nadalol (to prevent bleeding), rifaximin (to prevent confusion), and lactulose (to prevent confusion). Please use the provided laboratory slip to have your labs drawn on ___ or ___ or ___ next week and faxed to Dr. ___ office to monitor your counts and liver function. Sincerely, Your ___ Team Followup Instructions: ___
19961180-DS-8
19,961,180
27,821,728
DS
8
2120-04-16 00:00:00
2120-04-17 13:40:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: abdominal swelling, leg edema Major Surgical or Invasive Procedure: ___ paracentesis History of Present Illness: ___ w/PMHx NASH Cirrhosis c/b HE, varicies and ascites presents to ___ with decompensated cirrhosis. Pt reports progressive abdominal distension over the past several months. In this setting, she has also developed diffuse abdominal pain for which she takes oxycodone at home. She denies at fevers, chills. She does note some increased DOE and some ___ swelling. Otherwise, no melena/hematochezia, diarrhea, urinary changes. Pt saw Dr. ___ ___ who recommended admission. In the ED, initial vitals: 99.8; 82; 138/58; 17; 100% RA - Labs notable for: CBC: 5.1>13.4/38.4<63 Na: 140 Cr: 0.6 Lactate: 2.8 ALT: 22 AST: 50 AP: 145 Tbili: 4.4 Alb: 2.9 PTT: 45.8 INR: 2.1 Pt has a dx paracentesis shosing ascites fluid with 109 WBCs - Imaging notable for: None - Patient given: PO OxyCODONE (Immediate Release) 5 mg PO Lorazepam 1 mg - Vitals prior to transfer: 98; 81; 100/40; 16; 100% RA On arrival to the floor, pt reports... REVIEW OF SYSTEMS: No fevers, chills, night sweats, or weight changes. No changes in vision or hearing, no changes in balance. No cough, no shortness of breath, no dyspnea on exertion. No chest pain or palpitations. No nausea or vomiting. No diarrhea or constipation. No dysuria or hematuria. No hematochezia, no melena. No numbness or weakness, no focal deficits. Past Medical History: - ___ Cirrhosis decompensated with HE. Also has non-bleeding varices. - Portal hypertension. - Endoscopic band ligation therapy for treatment of esophageal varices - Migraines - Osteoporosis - Chronic low back pain, hip pain - Enchondroma of the hip (benign) - Pancreatic cysts compatible with side branch IPMNs - Chronic abdominal pain - Renal cysts: Not felt to have a cystic kidney syndrome Social History: ___ Family History: Mother with lung cancer, COPD. Father with COPD, throat cancer. No liver disease or autoimmune disease in the family. Physical Exam: ADMISSION EXAM: Vitals: 97.9; 134/65; 82; 18; 98 RA General: Alert, oriented, no acute distress HEENT: Mild conjunctival injection, but to scleral icterus, MMM, oropharynx clear, neck supple, 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, mildly tender, distended, +fluid wave, bowel sounds present, no rebound tenderness or guarding Ext: Warm, well perfused, 1+ pitting edema to mid shin bilaterally Skin: Mild jaundice. Without rashes or lesions Neuro: Mild asterixis. A&Ox3. Grossly intact. DISCHARGE EXAM: Vitals:98.1 PO 93 / 54 78 16 97 RA General: Alert, oriented, no acute distress HEENT: Mild conjunctival injection, but to scleral icterus, MMM, oropharynx clear, neck supple, 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, bowel sounds present, obese, no fluid shift, no rebound tenderness or guarding, Ext: Warm, well perfused, trace pedal edema Skin: Mild jaundice. Without rashes or lesions Neuro: Mild asterixis. A&Ox3. Grossly intact. Pertinent Results: ADMISSION LABS: ___ 08:00PM BLOOD WBC-5.1 RBC-3.88* Hgb-13.4 Hct-38.4 MCV-99* MCH-34.5* MCHC-34.9 RDW-14.8 RDWSD-54.0* Plt Ct-63* ___ 08:00PM BLOOD Neuts-72.9* Lymphs-14.0* Monos-9.4 Eos-2.7 Baso-0.6 Im ___ AbsNeut-3.74 AbsLymp-0.72* AbsMono-0.48 AbsEos-0.14 AbsBaso-0.03 ___ 08:00PM BLOOD ___ PTT-45.8* ___ ___ 08:00PM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-140 K-4.0 Cl-105 HCO3-26 AnGap-13 ___ 08:00PM BLOOD ALT-22 AST-50* AlkPhos-145* TotBili-4.4* ___ 08:00PM BLOOD Lipase-28 ___ 08:00PM BLOOD Albumin-2.9* ___ 09:37AM BLOOD Calcium-8.4 Phos-2.7 Mg-2.1 ___ 08:30PM BLOOD Lactate-2.8* PERITONEAL FLUID STUDIES: ___ 09:00PM ASCITES WBC-109* RBC-540* Polys-12* Lymphs-42* Monos-19* Eos-1* Mesothe-1* Macroph-25* ___ 09:00PM ASCITES TotPro-0.6 Glucose-127 Albumin-0.4 ___ 05:58PM ASCITES WBC-131* RBC-148* Polys-12* Lymphs-44* Monos-15* Eos-1* Mesothe-4* Macroph-24* DISCHARGE LABS: ___ 07:30AM BLOOD WBC-3.1* RBC-3.39* Hgb-11.1* Hct-33.5* MCV-99* MCH-32.7* MCHC-33.1 RDW-14.6 RDWSD-53.8* Plt Ct-48* ___ 07:30AM BLOOD Glucose-93 UreaN-8 Creat-0.5 Na-140 K-4.4 Cl-106 HCO3-27 AnGap-11 ___ 07:30AM BLOOD ALT-15 AST-36 AlkPhos-117* TotBili-3.8* MICROBIOLOGY: ___ BLOOD CULTURE: NO GROWTH TO DATE ___ PERITONEAL FLUID CULTURES: NO GROWTH TO DATE STUDIES: ___ RUQUS 1. Patent portal veins with patent umbilical vein again noted. 2. Coarse and nodular hepatic architecture consistent with the patient's known cirrhosis. Splenomegaly. 3. Moderate ascites. 4. No hydronephrosis. A simple cyst is again noted in the right kidney. Brief Hospital Course: ___ w/PMHx ___ Cirrhosis c/b HE, varicies and ascites presents to ___ with decompensated cirrhosis - moderate ascites and bilateral lower extremity edema. Most likely diuretic refractoriness/non-compliance. Renal US without hydronephrosis. RUQUS without portal vein thrombosis. Peritoneal fluid without SBP. She underwent 3L therapeutic paracentesis and was discharged on double her home diuretic dose. TRANSITIONAL ISSUES: ===================== -Needs chem-7 checked at her next PCP ___ appointment in ___ days -Discharge weight 80.5 kg Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 15 mL PO Q8H:PRN 3 bowel movements/day 2. Furosemide 40 mg PO DAILY 3. Spironolactone 50 mg PO DAILY 4. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate 5. Rifaximin 550 mg PO BID 6. OxyCODONE (Immediate Release) 10 mg PO QHS:PRN Pain - Moderate Discharge Medications: 1. Furosemide 80 mg PO DAILY RX *furosemide 40 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 2. Spironolactone 100 mg PO DAILY RX *spironolactone 50 mg 2 tablet(s) by mouth daily Disp #*60 Tablet Refills:*0 3. Lactulose 15 mL PO Q8H:PRN 3 bowel movements/day 4. OxyCODONE (Immediate Release) 10 mg PO BID:PRN Pain - Moderate 5. OxyCODONE (Immediate Release) 10 mg PO QHS:PRN Pain - Moderate 6. Rifaximin 550 mg PO BID 7.Outpatient Lab Work ICD10: ___.81 By ___ ___ Fax to Attn: ___. @ ___ Discharge Disposition: Home Discharge Diagnosis: Primary: Decompensated non-alcoholic steaohepatitis cirrhosis Secondary: Thrombocytopenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure taking care of you at the ___ ___. Why were you here: -You had swelling in your abdomen/legs What was done: -We removed 3 liters of fluid from your abdomen and restarted your home water pills What to do next: -Take your water pills every day. Note the doses of these have been doubled. You need to get your kidney function checked at your PCP ___. -Weight yourself daily. Call Dr. ___ your weight goes up by 5 pounds. -Call your doctor if you feel lightheaded We wish you all the best, Your ___ team Followup Instructions: ___
19961282-DS-3
19,961,282
28,809,895
DS
3
2115-02-21 00:00:00
2115-02-22 01:18:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Acute Left Lower Extremity Ischemia Major Surgical or Invasive Procedure: ___: Left groin cutdown, ___ dist thrombectomy, left iliac stent, left CFA interposition graft History of Present Illness: ___ w/ CAD s/p CABG x3, who presented to an OSH this AM after acute onset pain and difficulty moving his left foot which started around 3PM yesterday. Upon arrival to the OSH he wasnoted to have no distal pulses. He was given 5000U bolus of heparin and transferred for further care. He is currently having difficult moving his lower extremity below the knee and has very diminished sensation up to the midcalf. He has never had a similar episode in the past though he does endorse a history of claudication in the left calf with short distances. He denies any history of afib and denies any chest pain, SOB or palpitations. Past Medical History: Past Medical History: CAD PVD HTN HLD chronic low back pain Past Surgical History: CABG ___ Social History: ___ Family History: non-contributory Physical Exam: Vitals: T 98.1 BP 120/82 HR 70 Resp 18 96% RA GEN: NAD CV: RRR Resp: Lungs CTAB ABD: Soft, NT/ND Ext: Both lower extremities warm and well-perfused. ___ signals dopplerable bilaterally. Groin incision clean and dry with mild surrounding erythema, improving upon discharge. LLE slightly swollen compared to right. Pertinent Results: Sleep Study: DIAGNOSTIC IMPRESSIONS: 1.Severe complex sleep apnea with severe desaturations and periodic breathing. In this patient autotitrating CPAP is contraindicated. Baseline data recording was aborted due to recurrent apneas and patient's recent arrest. 2. Titration was complicated by persistent periodic breathing resulting in persistent desaturations despite adequate positive pressure. Breathing was most stabilized with a combination of Adapt SV EEP min 5, max 9/ IPAP min 3/max 9, non-vented mask, supplemental oxygen, and acetazolamide 250mg. ECHO: Left ventricular cavity size is normal. Mild symmetric left ventricular hypertrophy. There is mild regional left ventricular systolic dysfunction with hypokinesis/near-akinesis (?scar) of the inferior and inferolateral segments. In the setting of suboptimal image quality additional wall motion abnormalities cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mild symmetric left ventricular hypertrophy with regional wall motion abnormalities consistent with prior inferior infarct. Additional wall motion abnormalities cannot be excluded. Clinically significant valvular stenosis and/or regurgitation cannot be assessed. CTA: The aorta and pulmonary arteries are well opacified. There is no evidence of pulmonary embolism. The aorta maintains a normal contour or without any evidence of aneurysm. The celiac, SMA, bilateral renal arteries, and ___ are patent. Atherosclerotic disease with hard and soft plaque is noted throughout. Atherosclerotic disease is also noted at the aortic bifurcation. Soon after the bifurcation of the left common iliac artery, the left external iliac artery is completely occluded for a short segment than partly reconstitutes. The common femoral arteries patent. At the knee, the popliteal artery becomes occluded for a long segment (series 404, image 21). In the mid calf for a short time there is a normal 3 vessel runoff, but for the majority of the left calf there is no arterial opacification. Slightly more of the normal 3 vessel runoff on the left is noted on the delayed phase scan. The right lower extremity vasculature is patent with a normal 3 vessel runoff. The lung bases are clear. Assessment of intraabdominal organs is limited in the arterial phase. However, the liver, gallbladder, spleen, pancreas, and adrenal glands are unremarkable. The kidneys present symmetric nephrograms. Several hypodensities are present within the right kidney, some too small to characterize and others consistent with simple cysts. The largest is in the right interpolar region and measures 4.6 cm. The stomach, small bowel, and large bowel are unremarkable without any evidence of wall thickening or obstruction. There is no abdominal free air or free fluid. There is no mesenteric or retroperitoneal lymphadenopathy. IMPRESSION: 1. Occlusion of a large segment of the left popliteal artery without any arterial supply distally into the left foot. 2. Short segment occlusion of the left external iliac artery with partial reconstitution. 3. Diffuse atherosclerotic disease of the abdominal aorta. Brief Hospital Course: The patient was admitted to the vascular service for emergent treatment of his acute left lower extremity. Upon admission, the patient underwent CTA which revealed the following: 1. Occlusion of a large segment of the left popliteal artery without any arterial supply distally into the left foot. 2. Short segment occlusion of the left external iliac artery with partial reconstitution. 3. Diffuse atherosclerotic disease of the abdominal aorta. The patient was taken emergently to the operating room where he underwent left groin cut, proximal and distal thrombectomy, left iliac stent and common femoral interposition graft. Following this procedure, the patient had restored blood flow to his left leg. The patient tolerated the procedure well, however following extubation, the patient rapidly desaturated and lost a pulse. CPR was started and after approximately one minute of CPR following the ACLS algorithm, he had return of spontaneous circulation. The patient was taken intubated to the ICU. Cardiology was consulted in the ICU to rule-out an acute cardiac event as the cause of his arrest. The patient's cardiac enzymes transiently were elevated but rapidly returned to baseline. ECHO did not reveal any evidence of acute coronary event. After discussions with cardiology, it was determined that this arrest was likely respiratory in nature. The patient quickly stabilized in the ICU and was later extubated on POD0. In regards to his vascular disease, the patient was started on a heparin drip, aspirin, and coumadin in addition to his home medications. On POD0 the patient experienced significant pain in his left lower extremity, especially in the calf. Despite his pain, his compartments remained soft and his CK quickly plateaued at 2400 and began to decline and thus the decision was made to forgo fasciotomy. On POD1 he was transferred from the ICU to the floor. He was started on diet and began to ambulate. The patient was started on ciprofloxacin on POD2 for a UTI, however his antibiotics were broadened to vanc/cirpo/flagyl due to wound erythema. He remained on these antibiotics for the remainder for his hospital stay and his erythema resolved. However, given the presence of a graft, to prevent deep infection he will be discharged on a two week course of Augmentin. On POD4, the patient's INR was therapeutic and the heparin drip was discontinued. At this point, the patient was stable for discharge from a vascular perspective. Due to the patient's respiratory arrest, sleep medicine was consulted to assess for sleep apnea. Given the patient's body habitus, sleep medicine thought OSA was extremely likely in this patient and likely contributed to his arrest. On POD5, the patient underwent a sleep study that revealed severe complex sleep apnea - mixed obstructive and central with severe desaturations. He was started on BiPAP with oxygen at night. Upon presentation, the patient did not have health insurance in ___. During his admission, he was enrolled in ___ ___. Once the patient had active insurance, he was able to arrange PCP ___. He was also able to obtain all his medications and a SV BiPAP machine to adequately treat his sleep apnea. He will be discharged with close PCP ___ for coumadin management and ___ with Dr. ___ in 2 weeks. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 40 mg PO DAILY 2. HYDROcodone-acetaminophen ___ mg oral q6H PRN Pain 3. Losartan Potassium 50 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Gabapentin 600 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Enalapril Maleate 5 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:*2 2. Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 3. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 4. Gabapentin 600 mg PO DAILY RX *gabapentin 600 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 5. Losartan Potassium 50 mg PO DAILY RX *losartan 50 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*2 6. AcetaZOLamide 250 mg PO QHS RX *acetazolamide 250 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*2 7. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*2 8. Warfarin 2.5 mg PO ONCE Duration: 1 Dose RX *warfarin 2.5 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 9. HYDROcodone-acetaminophen ___ mg ORAL Q6H PRN Pain RX *hydrocodone-acetaminophen 10 mg-325 mg 1 tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 10. Oxygen 2L NC Continuous O2 to maintain O2sat >92%. Patient frequently desaturates as low as 79% while sleeping without supplemental oxygen. 11. Amoxicillin-Clavulanic Acid ___ mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth every twelve (12) hours Disp #*28 Tablet Refills:*0 12. BiPAP SV Length of need: 99 months. For home use. Therapeutic Objectives: Rate - auto rate. EEP: min 5/max 9. IPAP min 3/max 9. Back-up rate: 12. Please titrate 2L O2 into BiPAP. Dx: OSA Discharge Disposition: Home Discharge Diagnosis: Acute Left Lower Extremity Ischemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: WHAT TO EXPECT: It is normal to have slight swelling of the effected leg: • Elevate your leg with pillows every ___ hours throughout the day and at 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 What activities you can and cannot do: • You may shower (let the soapy water run over the arm 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 that is draining, as needed • No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week • 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 MEDICATION: • Take Aspirin 81mg (enteric coated) once daily • If instructed, take Plavix (Clopidogrel) 75mg once daily • Continue all other medications you were taking before surgery, unless otherwise directed • You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort CALL THE OFFICE FOR: ___ • Numbness, coldness or pain in the effected extremity • Temperature greater than 101.5F for 24 hours • New or increased drainage from incision or white, yellow or green drainage from incisions • Bleeding from incision site SUDDEN, SEVERE BLEEDING OR SWELLING in the effected arm • Sit down 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. While admitted you were diagnosed with Obstructive Sleep Apnea. This is a serious condition that causes you to intermittently stop breathing at night. Please you the BiPAP machine every night while you are sleeping as directed. Followup Instructions: ___
19961925-DS-10
19,961,925
20,139,648
DS
10
2196-12-15 00:00:00
2196-12-16 15:17:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Vicodin Attending: ___. Chief Complaint: Epidural Abscess Major Surgical or Invasive Procedure: ___ Guided Bone Biopsy: ___ Lumbar puncture: ___ History of Present Illness: Patient seen and examined, agree with house officer admission note by Dr. ___ ___ with additions below: ___ year old Male with HIV/AIDS (CD4 140, not on HAART) trasnferred from an OSH with concern for epidural abscess on MRI. The patient notes that for 3 weeks prior to admission he experienced marked low back pain, night sweats, bilateral leg pain; he also notes progressive forgetfullness, some ataxia/dysequilibrium including a fall getting off the T last week, and falling in the snow. In the CHA ED, he was afebrile, had negative U/A, an unremarkable CT head, and an MRI was done that showed enhancing 6mm collection at L4-L5 with inflammation of the sacrum and adjacent psoas consistent with epidural abscess so he was transferred to ___ ED for neurosurgical evaluation. In the ___ ED he was afebrile, labs were unremarkable, neurosurgical evaluation recommended empiric antibiotics and re-imaging in ___ weeks. The patient received ceftriaxone 2 g IV, vancomycin 1000mg IV Flagyl 500 mg IV and morphine 2 mg IV. Currently the patient reports being fairly comfortable lying in bed on his back. But movement is uncomfortable. Past Medical History: HIV: Likely transmitted in the 1980s, diagnosed ___ nadir cd4 85, and started AZT/3TC/EFV then transitioned to Atripla, and did well until ___ when he had personal issues and dropped out of care. Re-entered care in ___ when he had urosepsis (___) and restarted Atripla, but again fell out of care and ___ found to have K103N and CD4 around 100. Started Complera/Norvir ___ but then did not return to care until ___. ID Doctor is ___ at ___ PFO Left sided CVA with residual right-sided numbness Psych: ADHD, MDD, PTSD, generalized anxiety disorder Kidney stones Syphilis treated ___ (3 PCN injections and follow up titres became NR) Social History: ___ Family History: Adopted at ___ mo of age. Physical Exam: On admission: Vitals- 98, 140/94, 78, 18, 98% RA General- alert, NAD HEENT- MMM, PERRLA Neck- supple, no JVD Lungs- CTAB no rales, wheezes, rhonchi CV-RRR no MRG Abdomen- soft, NT, ND GU- no foley Ext- WWP, 2+DP Neuro- alert, oriented x3, CN II-XII intact, finger to nose abnormal with difficulty following directions and off target, heal to shin with R leg normal, heal to shin with left leg abnormal, Romberg test abn- grabbed for poll for balance, unsteady gait, normal strength and sensation b/l extremities On discharge: Vitals- 98.2 123/83 64 18 97% RA General- alert, NAD HEENT- MMM, PERRLA Neck- supple, no JVD Lungs- CTAB no rales, wheezes, rhonchi CV-RRR no MRG Abdomen- soft, NT, ND GU- no foley Ext- WWP, no edema Neuro- alert, oriented x3, CN II-XII intact, difficulty following commands for strength testing, strength ___ in extremities bl, sensation to light touch intact in extremities bl, abnormal finger nose finger (R>L) and heel to shin (R>L) Pertinent Results: ================== Labs ================== ___ 07:00AM BLOOD WBC-5.0 RBC-4.16* Hgb-13.5* Hct-40.9 MCV-98 MCH-32.5* MCHC-33.1 RDW-12.2 Plt ___ ___ 06:52PM BLOOD WBC-4.2 RBC-4.55* Hgb-14.6 Hct-44.3 MCV-98# MCH-32.2*# MCHC-33.0 RDW-12.7 Plt ___ ___ 06:52PM BLOOD Neuts-42.5* Lymphs-46.7* Monos-7.3 Eos-2.2 Baso-1.3 ___ 06:52PM BLOOD ___ PTT-27.7 ___ ___ 06:52PM BLOOD ESR-19* ___ 07:00AM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND CD4/CD8-PND ___ 07:00AM BLOOD Glucose-94 UreaN-11 Creat-0.5 Na-136 K-3.9 Cl-103 HCO3-25 AnGap-12 ___ 06:52PM BLOOD Glucose-84 UreaN-11 Creat-0.5 Na-136 K-3.9 Cl-101 HCO3-24 AnGap-15 ___ 06:52PM BLOOD ALT-22 AST-27 AlkPhos-64 TotBili-0.5 ___ 07:00AM BLOOD Mg-2.1 ___ 06:52PM BLOOD Albumin-3.8 ___ 06:52PM BLOOD VitB12-263 Folate-8.1 ___ 06:52PM BLOOD TSH-1.6 ___ 06:52PM BLOOD CRP-1.3 ___ 07:00AM BLOOD WBC-5.1# RBC-4.46* Hgb-14.3 Hct-43.9 MCV-98 MCH-31.9 MCHC-32.5 RDW-12.5 Plt ___ ___ 07:00AM BLOOD Glucose-90 UreaN-12 Creat-0.6 Na-137 K-3.9 Cl-105 HCO3-26 AnGap-10 ___ 06:15AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.3 ___ 10:37PM URINE Color-Yellow Appear-Clear Sp ___ ___ 10:37PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 10:37PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE Epi-<1 ================== Micro ================== ___ 6:50 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 10:30 pm URINE URINE CULTURE (Final ___: <10,000 organisms/ml. ___ 7:00 pm SEROLOGY/BLOOD ADDED TO CHEM ___. **FINAL REPORT ___ RAPID PLASMA REAGIN TEST (Final ___: NONREACTIVE. Reference Range: Non-Reactive ___ 7:00 am SEROLOGY/BLOOD CHEM # ___ ___. **FINAL REPORT ___ CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). ___ 4:30 pm TISSUE SPINE BIOPSY SPECIMEN. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ___ 6:15 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 6:45 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ 7:00 am BLOOD CULTURE #1. Blood Culture, Routine (Pending): ___ 1:28 pm BLOOD CULTURE Blood Culture, Routine (Pending): ___ 5:00 pm CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). ___ 5:00 pm CSF;SPINAL FLUID Source: LP. HIV-1 Viral Load/Ultrasensitive (Pending): ___ 5:00 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take ___ weeks to grow.. VIRAL CULTURE (Preliminary): ================== Imaging ================== MR HEAD W & W/O CONTRAST Study Date of ___ 1:56 AM IMPRESSION: Small nodular enhancement within the right frontoparietal lobe near the vertex. Differential considerations would include subacute infarct, vascular malformation (such as capillary telangectasia), infection, or neoplasm. Recommend repeat examination in ___ days for further characterization. MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 4:57 ___ IMPRESSION: No abnormal enhancement identified. Multilevel cervical spondylosis with moderate/severe bilateral C3-4, severe left C4-5, and severe bilateral C5-6 neural foraminal narrowing; moderate C5-C6 canal narrowing. Portable TTE (Complete) Done ___ at 1:00:00 ___ FINAL The left atrial volume is normal. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/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). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. IMPRESSION: No echocardiographic evidence of endocarditis seen. Normal biventricular regional/global systolic function. Normal left ventricular diastolic function. No clinically significant valvulopathies seen. Brief Hospital Course: ___ yo M with PMH HIV recent CD4 140 transferred from OSH with possible epidural abscess on imaging, confusion and gait disturbance. # AMS: Pt. presenting with complaint of being forgetful and having difficulty with balance. Currently patient is oriented x3, but has poor attention span and requires repeat explanations to follow simple commands. MRI head w small frontal lesion but not felt to be explanatory of his symptoms. Metabolic w/u unrevealing. RPR and Crypto antigen negative. Initial LP results not consistent for infection with 1 WBC and negative gram stain. CSF micro studies pending at discharge (CSF cultures as well as HIV, VDRL, toxo, TB, ___ virus, HSV pending; cryptococcal antigen negative). Pt to have repeat MRI as outpatient (___), and follow up with ID and neuro. # ?EPIDURAL ABSCESS: At OSH MRI lumbar spine showed L4-L5 6mm epidural abscess. Transferred for neurosurgery evaluation, which felt procedure was not indicated. Inflammatory markers negative (although pt immunosuppressed) and pt remained afebrile, so was maintained off all antibiotics including fluconazole. ___ performed bone bx to look for osteo/abscess; gram stain was negative--universal PCR for bacteria, AFB, fungi pending at discharge. TTE negative. Pt has follow up with ID. # NECK PAIN: Per neuro had some cervical tenderness. MRI showed multilevel cervical spondylosis. Pt to follow up with neuro. # HIV: Most recent CD4 of 140, not on anti-retrovirals as patient self-discontinued. ID recommended waiting to start HAART until outpatient. Pt was continued on dapsone prophylaxis. Transitional issues: # MRI head and L spine in 2 weeks to assess for change in lumbar lesion # f/u unversal PCR for bacteria/AFB/fungi # f/u LP results: bacterial culture, viral culture, fungal culture, TB culture, HIV, VDRL, toxo, TB, ___ virus, HSV Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Fluconazole 100 mg PO Q24H 2. Dapsone 100 mg PO DAILY Discharge Medications: 1. Dapsone 100 mg PO DAILY 2. Aspirin 81 mg PO DAILY RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth daily Disp #*30 Tablet Refills:*6 3. FoLIC Acid 1 mg PO DAILY RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*8 4. Thiamine 100 mg PO DAILY RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*8 5. Lidocaine 5% Patch 1 PTCH TD QAM RX *lidocaine 5 % (700 mg/patch) 1 patch daily Disp #*30 Transdermal Patch Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ataxia Possible Epidural Abscess HIV infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for choosing us for your care. You were transferred to ___ for confusion and poor coordination as well as back pain. We noted that your HIV was not under control. An MRI of your back had findings concerning for an infection. We performed a biopsy of your spinal column. Some of these results are still pending, so it will be very important to follow up with our infectious disease clinic. The scheduling information is below. You also had a lumbar puncture performed to evaluate for infection in the fluid around your brain and spinal cord. The initial results were normal, but the tests for specific infections are still pending. Please follow up at your neurology and infectious diseases appointments, listed below. You have a repeat MRI scheduled on ___ at 06:15p. It will be on the ___ floor of the ___ on the ___. It is very important that you go to this appointment. Followup Instructions: ___
19961925-DS-11
19,961,925
25,038,426
DS
11
2197-03-01 00:00:00
2197-03-01 22:02:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Vicodin / codeine Attending: ___ Chief Complaint: AMS Major Surgical or Invasive Procedure: Lumbar Puncture ___ History of Present Illness: ___ with h/o HIV with neurocognitive disorder, was feeling confused and was hallucinating, seeing mice that werent there at home. Also reported photophobia for 1 week in addition to headache that is longstanding x2 months, unsure if worse now. Hasnt felt febrile, ___ took temp but wasnt having a fever. CD4 237 on ___, HIV VL 139 on ___. He Has h/o CVA with R hand numbness, endorses this currently. He also reported drinking large amount of alcohol the night prior to admission, unsure of exact amount. Says he is not a daily drinker, used to be heavy drinker and seems to continue to drink heavily off and on. No h/o withdrawal seizures. Has unsteady gait at baseline, uses a walker, feels more unsteady on day of admission (has home ___, ___. Denies cough, SOB, abd pain, N/V/D, other systemic symptoms. Of note he was admitted in ___ for confusion, LP showed high CNS VL which was suggestive of HIV associated neurocognitive disorder (HAND), otherwise negative work up and RPRP negative. In the ED it was noted that he was very difficult to get history from. Pt says he has been taking his HAART. Per outpt ID provider cryptococcal antigen was recently checked and was negative. ROS: As above In the ED intial vitals were: 98 96 138/101 16 97% RA. Exam was notable for confusion with breath smelling of alcohol, no oral lesions or thrush, no signs of meningismus. Lung, heart and abdomen exam were normal. He was AO to self, with intact CN ___ and pronator drift on the right. Labs were significant for Lactate 4.4, blood etoh 223. Na 137, K 4.1, Cr 0.6, BUN 14, AG of 15. Urine and serum tox were negative. LFT was normal. UA was not suggestive of UTI, CXR was not suggestive of PNA. CBC was normal with WBC 6.6, N:41.9, L:54.3. Patient was given 1 L D5NS, and 2 L NS. LP was performed which showed TP of 65, Gluc of 70, 1 WBC. IV acyclovir 900 mg q 8 hr is initiated. Vitals prior to transfer were: 98.2 88 158/99 16 98% RA. Repeat lactate prior to transfer was 3.2. On the floor pt does not complain of pain and was asking if he can go home. Review of Systems: (+) per HPI Past Medical History: HIV Left sided CVA with residual right-sided numbness (has PFO) Psych: ADHD, MDD, PTSD, generalized anxiety disorder Kidney stones Syphilis treated ___ (3 PCN injections and follow up titres became NR) HIV neurocognitive disoder Social History: ___ Family History: ___ Physical ___: ADMISSION PHYSICAL EXAM ======================== VS: 98.4 132/68 78 20 97% on RA GENERAL: no acute distress HEENT: NCAT NECK: JVP not elevated LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops BACK: diffuse tenderness to spinal palpation, no overlying erythema or edema ABD: normoactive bowel sounds, soft, mild diffuse tenderness to palpation GU: rectal tone intact EXT: warm, no edema NEURO: AAOx2, strength ___ in the lower extremities bilaterally DISCHARGE PHYSICAL EXAM ======================== 97.3 113/72 61 18 93% RA GENERAL: Awake/alert, oriented, squinting throughout interview, NAD. HEENT: Unable to perform pupillary exam bc of photophobia, slight conjunctival erythema CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: Soft, NT, ND. EXTREMITIES: WWP, no edema. NEURO: CN ___ grossly intact, Moves all extremities symmetrically Pertinent Results: ADMISSION LABS ============== ___ 03:00PM BLOOD WBC-6.6 RBC-5.01 Hgb-16.2 Hct-48.1 MCV-96 MCH-32.4* MCHC-33.8 RDW-13.0 Plt ___ ___ 03:00PM BLOOD Neuts-41.9* Lymphs-54.3* Monos-2.5 Eos-0.9 Baso-0.4 ___ 03:00PM BLOOD Glucose-76 UreaN-14 Creat-0.6 Na-137 K-4.1 Cl-104 HCO3-18* AnGap-19 ___ 03:00PM BLOOD ALT-19 AST-27 AlkPhos-66 TotBili-0.2 OTHER LABS =========== ___ 03:00PM BLOOD ASA-NEG ___ Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:20PM BLOOD Lactate-4.4* MICROBIOLOGY ============= URINALYSIS ___ 04:40PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:40PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 04:40PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 ___ 04:40PM URINE Mucous-RARE ___ 7:20 am IMMUNOLOGY **FINAL REPORT ___ HIV-1 Viral Load/Ultrasensitive (Final ___: 6,870 copies/ml. CSF ___ 06:00PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-1* Polys-0 ___ ___ 06:00PM CEREBROSPINAL FLUID (CSF) TotProt-65* Glucose-70 ___ 6:00 pm CSF;SPINAL FLUID Source: LP #3. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. ___ 18:00 HERPES SIMPLEX VIRUS PCR Test Name Flag Results Unit Reference Value --------- ---- ------- ---- --------------- Herpes Simplex Virus PCR Specimen Source CSF HSV 1, PCR Negative Negative An inadequate volume of specimen was received, and therefore, the sample was diluted to the appropriate volume for testing. A negative result may not rule out infection. HSV 2, PCR Negative Negative An inadequate volume of specimen was received, and therefore, the sample was diluted to the appropriate volume for testing. A negative result may not rule out infection. ___ 6:00 pm CSF;SPINAL FLUID Source: LP. **FINAL REPORT ___ CRYPTOCOCCAL ANTIGEN (Final ___: CRYPTOCOCCAL ANTIGEN NOT DETECTED. IMAGING: CT HEAD non con ___: IMPRESSION: No evidence of acute intracranial process. Chronic sinus disease. CXR ___: IMPRESSION: No acute cardiopulmonary process. MR head ___: IMPRESSION: No MR evidence of ___ or PML. No acute infarct or intracranial hemorrhage. Mild cerebral atrophy, unchanged. Brief Hospital Course: ___ man with h/o HIV associated neurocognitive disorder, residual right sided weakness from left sided CVA, history of syphilis s/p treatment, ADHD, anxiety disorder presents with altered mental status, s/p EtOH intoxication. ACTIVE ISSUES ============== # AMS Pt has h/o HIV neurocognitive disorder at baseline, who was confirmed to be intoxicated on admission with high blood EtOH level. AMS most likely from EtOH intoxication. LP and brain MRI were negative. Mental status returned to baseline, which seems to be A+Ox3 (with some difficulty), some word finding and recall difficulties. Was seen by ID who did not feel that his presentation was concerning for meningitis and felt it was most likely due to his intoxication. At the same time, he appears to have a severe and possibly progressive dementia/neurocognitive disorder, with evidence of worsening ataxia, and requires extensive ___ and close neuro-ID ___. # ETOH use: Patient reported drinking a large amount of alcohol the night prior to admission, unsure of exact amount, alcohol level elevated upon admission. Friends and sister ___, HCP, were concerned that the patient is actually drinking more than he states. Discussed with PCP who said that he has not been endorsing recent heavy drinking. He did not show any evidence of withdrawal. He was seen by social work. Continued home dose thiamine, folate and multivitamin. He will ___ w/ his PCP regarding this issue. # Photophobia Patient states he has had photophobia and blurry vision for the past couple weeks, unclear cause. He did have a dilated eye exam with his opthalmologist about two weeks prior to admission, note seen through ___, diagnosed with ocular hypertension on the L, given eyedrops. These were continued. His symptoms were unchanged from prior. Optho re-eval was negative during this admission, except for attributing his blurry vision to need for refraction. MRI brain was negative for ___. Patient to followup as outpatient with optho. Improving slightly at discharge. CHRONIC ======== # HIV + HAND: CD4>400, though VL at 6,000 (rising from prior). Continued home dose HIV medications and dapsone. There was not enough LP sample to run HIV VL CNS assay. Per recs from PCP/ID, sent HIV genotype out of concern for occult resistance (pending at d/c) # PTSD/ADHD/MMD/anxiety: Continued home dose citalopram. TRANSITIONAL ISSUES ==================== - Pt requires extensive ___ and gait training - opthalmology and neuro-virology followup for photophobia - Outpt PCP ___ should be arranged after d/c from rehab - Outpt neuro-ID ___ - ___ possible ETOH abuse as outpt - ___ pending CSF studies - ___ pending HIV genotyping (requested by PCP, who will ___ result) - Pls work with patient on insurance coverage issues Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 5 mg PO DAILY 2. RiTONAvir 100 mg PO BID 3. Darunavir 600 mg PO BID 4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 5. Raltegravir 400 mg PO BID 6. Dapsone 100 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Citalopram 10 mg PO DAILY 10. Lidocaine 5% Patch 1 PTCH TD QAM 11. Thiamine 100 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Ondansetron 4 mg PO Q8H:PRN nausea 14. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Citalopram 10 mg PO DAILY 3. Dapsone 100 mg PO DAILY 4. Darunavir 600 mg PO BID 5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Multivitamins 1 TAB PO DAILY 9. Raltegravir 400 mg PO BID 10. RiTONAvir 100 mg PO BID 11. Thiamine 100 mg PO DAILY 12. Ondansetron 4 mg PO Q8H:PRN nausea 13. Lisinopril 5 mg PO DAILY 14. Latanoprost 0.005% Ophth. Soln. 1 DROP LEFT EYE HS 15. Artificial Tears ___ DROP BOTH EYES PRN eye pain, photophobia This medication can be purchased over the counter Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY Altered Mental Status HIV SECONDARY h/o CVA ADHD PTSD Generalized anxiety disorder 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 due to confusion. You had a spinal tap which was not concerning for infection. Most likely your initial confusion was due to your recent alcohol use. Please avoid drinking large amounts of alcohol in the future, as it has a negative effect on your health. We still do not know why your eyes hurt in the light. We did a brain MRI and had the ophthalmologists see you, without an explanation. Please find your medications and appointments below. Followup Instructions: ___
19961925-DS-12
19,961,925
21,099,120
DS
12
2198-05-11 00:00:00
2198-05-11 13:01:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Bactrim / Vicodin / codeine Attending: ___. Chief Complaint: HMED Admission Note ___ cc: fever, chills Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo M with HIV on HAART (CD4 312, VL < 20 in ___ admitted here due to recurrent fevers, chills, sweats and chest pain. Pt admitted to ___ twice in the past month with similar symptoms. He underwent extensive testing which revealed sinusitis, pleural and pericardial effusions. ___ 2 showed mildly exudative fluid. Klebsiella was initially obtained from culture and pt treated with broad spectrum antibiotics on both admissions. Pericardial effusion, not sampled as it was quite small. Pt had other testing with negative serial AFB, negative urine histo, negative cryptococcal antigen. Pt sent home on augmentin, colchicine/ibuprofen. Antibiotics completed on ___eveloped shaking chills and fever to 101-102. Pt saw his PCP who is also his ID physician who recommended he come to ___ for evaluation given that he may be able to have pericardial fluid sampled here. Aside from fevers and chills, pts only other localizing symptom is pleuritic L chest pain radiating to L scapula and interscapular region. No worsening with exertion. No cough. No headache. In the ER, pt had cultures sent and had an LP which was unremarkable. CXR showed mild L pleural effusion but no significant infiltrates. Pt admitted for further care. ROS: negative except as above Past Medical History: HIV Left sided CVA with residual right-sided numbness (has PFO) Psych: ADHD, MDD, PTSD, generalized anxiety disorder Kidney stones Syphilis treated ___ (3 PCN injections and follow up titres became NR) HIV neurocognitive disoder Gout Shingles Social History: ___ Family History: Mother with DM. No family history of immunosuppression. Physical Exam: Vitals: T 98.1 116/77 80 17 96%RA Gen: NAD HEENT: NCAT, no sinus tenderness CV: faint heart sounds, regular, no r/m/g Pulm: clear b/l, mild decrease BS at L base Abd: soft, nt/nd, +bs Ext: no edema, no joint inflammation Neuro: alert and oriented x 3, some cognitive slowing Pertinent Results: ___ 08:05AM BLOOD WBC-5.2 RBC-3.14* Hgb-9.3* Hct-27.8* MCV-89 MCH-29.7 MCHC-33.6 RDW-15.1 Plt ___ ___ 08:05AM BLOOD WBC-5.9 RBC-3.15* Hgb-9.4* Hct-28.2* MCV-90 MCH-30.0 MCHC-33.5 RDW-15.3 Plt ___ ___ 03:00PM BLOOD Hct-29.1* ___ 07:09AM BLOOD WBC-7.6 RBC-3.11* Hgb-9.6* Hct-27.7* MCV-89 MCH-30.8 MCHC-34.6 RDW-15.4 Plt ___ ___ 04:05PM BLOOD WBC-11.4*# RBC-3.64* Hgb-11.0*# Hct-32.1*# MCV-88# MCH-30.2 MCHC-34.2 RDW-16.0* Plt ___ ___ 04:05PM BLOOD Neuts-71.8* ___ Monos-4.1 Eos-0.9 Baso-0.3 ___ 07:09AM BLOOD ___ PTT-30.7 ___ ___ 04:05PM BLOOD ___ PTT-30.9 ___ ___ 08:05AM BLOOD Glucose-91 UreaN-10 Creat-0.8 Na-137 K-3.7 Cl-103 HCO3-28 AnGap-10 ___ 07:09AM BLOOD Glucose-98 UreaN-6 Creat-0.7 Na-138 K-3.2* Cl-102 HCO3-27 AnGap-12 ___ 04:05PM BLOOD Glucose-90 UreaN-8 Creat-0.7 Na-132* K-6.3* Cl-100 HCO3-22 AnGap-16 ___ 04:05PM BLOOD ALT-10 AST-34 CK(CPK)-120 AlkPhos-66 TotBili-0.4 ___ 04:05PM BLOOD Lipase-26 ___ 09:10PM BLOOD cTropnT-<0.01 ___ 04:05PM BLOOD CK-MB-<1 cTropnT-<0.01 ___ 04:05PM BLOOD Lactate-1.1 K-4.2. . Date 6 Lab # Specimen Tests Ordered By All ___ ___ ___ All BLOOD CULTURE BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) CSF;SPINAL FLUID CSF;SPINAL FLUID NOT PROCESSED IMMUNOLOGY SEROLOGY/BLOOD STOOL TISSUE URINE All EMERGENCY WARD INPATIENT ___. ___ BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING INPATIENT ___ STOOL C. difficile DNA amplification assay-FINAL; FECAL CULTURE-PENDING; CAMPYLOBACTER CULTURE-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ___ URINE URINE CULTURE-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE} INPATIENT ___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL; FUNGAL CULTURE-PRELIMINARY; ACID FAST CULTURE-FINAL; VIRAL CULTURE-FINAL EMERGENCY WARD ___ CSF;SPINAL FLUID CRYPTOCOCCAL ANTIGEN-FINAL EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY WARD ___ BLOOD CULTURE Blood Culture, Routine-PENDING . ___ CXR: FINDINGS: AP upright and lateral views of the chest provided. Low lung volumes limits the evaluation. The patient's chin also obscures the superior mediastinum and portions of the lung apices. There are bibasilar opacities which may reflect atelectasis and small effusions. There is hilar engorgement and mild congestion noted. Heart size appears mildly enlarged. The mediastinal contour is stable. The imaged bony structures appear intact. IMPRESSION: As above. . echo: There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. The effusion is echo dense, consistent with blood, inflammation or other cellular elements. There are no echocardiographic signs of tamponade. Pericardial constriction cannot be excluded. Compared with the prior study (images reviewed) of ___, a small circumerential pericardial effusion and septal bounce are now present. . CT torso: IMPRESSION: 1. No evidence of acute intra-abdominal process. Nonvisualized appendix. 2. Cholelithiasis without evidence of acute cholecystitis. 3. Scattered nonenlarged lymph nodes. Cluster of nonenlarged lymph nodes is noted near the GE junction. If clinically indicated, consider endoscopy. IMPRESSION: 1. Small bilateral pleural effusions with adjacent atelectasis. 2. Small hyperdense pericardial effusion. 3. Moderate biapical paraseptal emphysema. . CT head: IMPRESSION: No acute intracranial process. Brief Hospital Course: This is a ___ with history of HIV/AIDS, history of HAND, CVA with PFO who presented with fever, rigors and with chest pain with concerns for persistent pericarditis. #Recurrent fevers #Continued pericarditis/pericardial effusion Pt with CD4 level that did not put him at risk for opportunistic infections. HAART was recently reinitated. Pt underwent CXR that was not concerning for PNA, EKG and Troponins were not concerning for ACS. ECHO did reveal a small pericardial effusion but no signs of tamponade. Pt had a CT of this torso which showed a small pericardial effusion and small pleural effusions. Pt remained afebrile for at least 48 hours prior to discharge. Bcx x5 were NGTD, mycolytic culture pending, CSF NGTD, cryptococcal AG negative, c.diff negative. HSV CSF negative, urine with 10,000-100,000 colonies of coag negative staph, not treated as infection as no symptoms. The infectious disease service followed along and recommended the studies as above. Given that nothing new was found on labs/imaging and pt remained afebrile and stable decision to discharge pt home with plans to continue treatment for known pericarditis with colchicine, asa, tylenol for pain and to f/u with his PCP ___ for ongoing care. It was not felt that he had an infected pericarditis given his stability and afebrile without antibiotics. (on hold during admission). Pt aware that there are some studies still PENDING at discharge. ** will need to f/u HISTOPLASMA AG EBV VL CSF FINAL MYCOLYTIC AND BLOOD CULTURES . # HIV-continued outpt HAART regimen. Did not need PCP ppx given CD4 count. . #anemia-guaiac stools x3. Trend HCT. Remained stable. Will need outpt f/u. #HTN -resumed lisinopril on discharge #Paroxysmal atrial fibrillation Per ___ notes, had afib during previous hospitalization. Continued ASA. Currently rate controlled. . #h.o CVA-aspirin. Does not appear to be on anticoagulation at baseline. However would have CHADS2 score of 2 given prior CVA. . Transitional care 1. please f/u pending histoplasma AG, blood cultures and mycolytic cx, ebv from CSF Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 2. Dolutegravir 50 mg PO DAILY 3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 4. Darunavir 800 mg PO DAILY 5. Pantoprazole 20 mg PO Q24H 6. RiTONAvir 100 mg PO DAILY 7. Lisinopril 10 mg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Aspirin 81 mg PO DAILY 10. Colchicine 0.6 mg PO DAILY 11. Citalopram 40 mg PO DAILY 12. Amitriptyline 25 mg PO QHS Discharge Medications: 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze 2. Amitriptyline 25 mg PO QHS 3. Aspirin 81 mg PO DAILY 4. Citalopram 40 mg PO DAILY 5. Colchicine 0.6 mg PO DAILY 6. Darunavir 800 mg PO DAILY 7. Dolutegravir 50 mg PO DAILY 8. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD QAM 10. Lisinopril 10 mg PO DAILY 11. Pantoprazole 20 mg PO Q24H 12. RiTONAvir 100 mg PO DAILY 13. Acetaminophen 650 mg PO Q6H:PRN pain or fever you may purchase over the counter. Max daily dose 4gm Discharge Disposition: Home Discharge Diagnosis: pericarditis h.o HIV, afib Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for evaluation of chest pain with diarrhea. You were evaluated by the infectious disease service and had laboratory studies and a CT scan for further evaluation. At this time, it seems as though your symptoms are related to continued viral infection that caused pericarditis. You should continue your pericarditis regimen as prior to admission to the hospital. There are a few studies that are PENDING at discharge including some viral and fungal studies that will need to be followed up after discharge. Please be sure to contact Dr. ___ at ___ on ___ to schedule a follow up appointment. Followup Instructions: ___
19962126-DS-19
19,962,126
21,472,938
DS
19
2145-03-06 00:00:00
2145-03-06 14:24:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cardiac arrest Major Surgical or Invasive Procedure: intubation arterial line placement History of Present Illness: The patient is a ___ year old man with COPD, alcohol dependence, and schizophrenia on risperidone BIBA after he was found down without a pulse by a bystander. FD arrived and performed CPR with ROSC. When EMS arrived, EKG revealed atrial fibrillation w/ RVR. Patient was alert during transport and reported chest discomfort and SOB 2 hours prior to LOC. The event was preceded by dizziness and lightheadedness. Patient denies prior cardiac history. ___ the ED, EKG showed sinus rhythm, STE ___ V3 that does not meet the criteria for STEMI ___ an isolated lead. Also inverted t-waves noted ___ V3. Bedside echo showed dilated RV with HK and normal LV function and wall motion. The patient was placed on bipap followed by elective intubation. Initial settings consisted of CMV with VT:500 RR:16 PEEP:8(air trapping present, inc to 10) and FiO2 100%. On transfer, vitals were: T: 95.7F BP: 101/75 P: 66 CMV TV: 450, RR 18, PEEP 12, FiO2 50% On arrival to the MICU, the patient was sedated and intubated and unable to provide additional history. Review of systems: Per HPI. Past Medical History: COPD (clinical diagnosis, no formal PFTs) Tobacco abuse Alcohol abuse History of colon cancer status post partial colectomy Schizophrenia Social History: ___ Family History: (per OMR): Pt denies family history of lung disease. Mother died of breast cancer. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 95.7F BP: 101/75 P: 66 Vent settings: CMV TV: 450, RR 18, PEEP 12, FiO2 50% GENERAL: Intubated and sedated, RASS -5 HEENT: Sclera anicteric, PERRLA, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD LUNGS: CTAB, no wheezes or rhonchi CV: Distant heart sounds, normal rate, regular rhythm, normal S1/S2, no murmurs ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly, scar ___ midline EXT: Cold upper and lower extremities, 1+ radial and pedal pulses, no edema, poor pedal hygene SKIN: IO ___ the left tibia NEURO: RASS -5 Pertinent Results: ADMISSION LABS: ================= ___ 11:02AM BLOOD WBC-14.1* RBC-4.12* Hgb-13.7 Hct-44.0 MCV-107* MCH-33.3* MCHC-31.1* RDW-13.6 RDWSD-54.0* Plt ___ ___ 04:58PM BLOOD Neuts-95* Bands-0 Lymphs-3* Monos-2* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-13.21* AbsLymp-0.42* AbsMono-0.28 AbsEos-0.00* AbsBaso-0.00* ___ 04:58PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-NORMAL ___ 11:02AM BLOOD ___ PTT-29.2 ___ ___ 11:02AM BLOOD ___ ___ 11:02AM BLOOD UreaN-41* Creat-1.8* ___ 04:58PM BLOOD Glucose-168* UreaN-38* Creat-1.4* Na-142 K-5.0 Cl-109* HCO3-19* AnGap-19 ___ 11:02AM BLOOD CK(CPK)-119 ___ 04:58PM BLOOD ALT-23 AST-39 LD(LDH)-278* CK(CPK)-429* AlkPhos-58 TotBili-0.3 ___ 11:02AM BLOOD Lipase-28 ___ 11:02AM BLOOD cTropnT-0.05* ___ 11:02AM BLOOD CK-MB-4 proBNP-6805* ___ 04:58PM BLOOD CK-MB-17* MB Indx-4.0 cTropnT-0.02* ___ 04:58PM BLOOD Albumin-3.2* Calcium-7.8* Phos-3.6 Mg-1.5* ___ 02:24AM BLOOD Triglyc-65 ___ 04:58PM BLOOD TSH-0.30 ___ 11:02AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 05:01PM BLOOD Type-ART pO2-100 pCO2-46* pH-7.28* calTCO2-23 Base XS--4 ___ 11:09AM BLOOD Glucose-218* Lactate-8.1* Na-138 K-4.7 Cl-98 calHCO3-25 ___ 11:09AM BLOOD Hgb-13.9* calcHCT-42 O2 Sat-61 COHgb-2 MetHgb-0 ___ 11:09AM BLOOD freeCa-1.23 ___ 03:21PM URINE Color-Yellow Appear-Hazy Sp ___ ___ 03:21PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 03:21PM URINE RBC-15* WBC-16* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 ___ 03:21PM URINE CastGr-3* CastHy-24* ___ 03:21PM URINE WBC Clm-RARE Mucous-RARE OTHER PERTINENT/DISCHARGE LABS: ================= ___ 11:02AM BLOOD Lipase-28 ___ 02:24AM BLOOD Lipase-89* ___ 03:55AM BLOOD Lipase-27 ___ 11:02AM BLOOD cTropnT-0.05* ___ 11:02AM BLOOD CK-MB-4 proBNP-6805* ___ 04:58PM BLOOD CK-MB-17* MB Indx-4.0 cTropnT-0.02* ___ 12:16AM BLOOD cTropnT-0.02* ___ 04:22AM BLOOD CK-MB-12* cTropnT-0.07* ___ 10:53AM BLOOD cTropnT-0.12* ___ 05:46PM BLOOD cTropnT-0.09* ___ 02:24AM BLOOD CK-MB-6 cTropnT-0.06* ___ 05:48PM BLOOD Type-ART pO2-110* pCO2-49* pH-7.31* calTCO2-26 Base XS--2 IMAGING: ================= ___ - CT C-spine w/o contrast 1. No acute fracture or subluxation ___ the cervical spine. 2. Moderate multilevel degenerative changes, particularly at the C3-C6 vertebral levels. 3. Emphysematous changes ___ the lung apices. ___ CXR Emphysema and probable underlying pulmonary arterial hypertension. Patchy opacities within the right mid lung and both lung bases, potentially atelectasis and/or infection. Multiple bilateral rib fractures which may be related to recent resuscitation, without large pneumothorax identified. ___ CT Head w/o contrast No acute intracranial process. ___ CT Chest w/o contrast 1. Bilateral anterolateral rib fractures, notably the ___ ribs on the right, and ___ and 7th ribs on the left. Additionally, there is a sternal fracture with a small anterior mediastinal hematoma. 2. Diffuse airway wall thickening with extensive areas of mucosal plugging, most notably ___ the right lower lobe, compatible with diffuse airway inflammation or infection. Patchy opacities ___ the dependent aspect of the right upper and lower lobes may reflect a combination of aspiration and atelectasis. 3. Probable right hilar lymphadenopathy, likely reactive. 4. Ill-defined small nodular opacities are noted ___ the lungs bilaterally, possibly related to small airways disease, but should be reassessed on follow up CT exam. 5. Severe centrilobular emphysema. ___ bilateral LENIs No evidence of deep venous thrombosis ___ the right or left lower extremity veins. ___ TTE The left atrium is normal ___ size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed (LVEF = 20%). No masses or thrombi are seen ___ the left ventricle. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with severe global free wall hypokinesis. The ascending aorta is mildly dilated. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The presence/absence of mitral valve prolapse cannot be determined. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal left ventricular wall thickness and cavity size with severe left ventricular systolic dysfunction. Mild right ventricular dilation and severe free wall hypokinesis. Mild tricupsid regurgitation ___ CTA w&w/o contrast No evidence of pulmonary embolism or aortic dissection. Increasing consolidation within the bilateral lower lobes and inferior portion of the right upper lobe suggests infection or aspiration, increased from the prior examination on ___. Material within airways may reflect aspiration as detailed above. Small right pleural effusion and trace left pleural effusion also minimally increased. Minimal intra-abdominal ascites, slightly increased from the prior examination. . ___ echo: The left atrium is normal ___ size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF = 70%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, left and right ventricular contractile function is now normal. . CXR: ___: IMPRESSION: ___ comparison with the study of ___, the nasogastric tube is been removed. PICC line is unchanged. The cardiac silhouette is within normal limits and there is mild indistinctness of pulmonary vessels consistent with elevation of pulmonary venous pressure. Continued hyperexpansion of the lungs is consistent with chronic obstructive pulmonary disease. Bilateral basilar opacifications reflects pleural effusions and underlying compressive atelectasis. MICROBIOLOGY: ================= ___ 3:08 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final ___: >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ PAIRS AND CHAINS. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final ___: Commensal Respiratory Flora Absent. STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH. PRESUMPTIVELY PENICILLIN SENSITIVE BY OXACILLIN SCREEN. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. MODERATE GROWTH. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested ___ cases of treatment failure ___ life-threatening infections.. MORAXELLA CATARRHALIS. SPARSE GROWTH. SENSITIVITIES: MIC expressed ___ MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | PENICILLIN G---------- S FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STREPTOCOCCUS PNEUMONIAE, HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE, MORAXELLA CATARRHALIS}; FUNGAL CULTURE-PRELIMINARY INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT ___ URINE URINE CULTURE-FINAL INPATIENT ___ MRSA SCREEN MRSA SCREEN-FINAL Brief Hospital Course: ___ year old man with COPD, alcohol dependence, and schizophrenia on risperidone BIBA after he was found down without a pulse. #LOC/PEA: Unclear etiology for cardiac arrest. Most likely breath stacking by patient due to underlying COPD/emphysema with subsequent decompression with CPR allowing for ROSC vs. tachyarrhythmia (Afib with RVR) causing absence of palpable pulse. LENIs were negative and CTA was negative. Trops peaked at 0.07, which was felt to be due to demand ischemia. Cardiology did not feel it was necessary to cath the patient at that time. TTE showed ___ EF which was felt to be due to myocardial stunning ___ setting of acute stress. Repeat echo with normal EF prior to discharge. # Respiratory distress/hypoxia/CAP/COPD: Patient intubated ___ the ED for respiratory distress. Most likely due to his COPD and aspiration pneumonia. He was extubated without incident. He was given 10 day burst of steroids for COPD exacerbation. He was also treated for CAP/aspiration with vanc/cefepime/levofloxacin because he was noted to have thick, purulent secretions. He was then narrowed to ceftriaxone to complete an ___fter sputum cx's returned. See above. Patient had some episodes post-extubation of hypoxia and tachypnea which were felt to be due to his COPD with wheezing on exams. Patient improved with duonebs and oxygen NC. There was also some concern that patient aspirated ___ setting of vomiting (see below) but patient was able to maintain O2Sats on NC after extubation and was weaned down to ___. CXR on ___ did not show PNA but did show atelectasis. Would continue incentive spirometry and bronchodilators. He will need a REPEAT CT of the chest to evaluate for interval change. #Alcohol Dependence: Patient with a history of alcohol dependence. Negative for alcohol per ED toxicology screen. Concern for risk of withdrawal based on history. He was started on a phenobarbital protocol which was eventually d/c'ed as he did not appear to be withdrawing. He received high dose thiamine x 3 days and then 100 mg daily along with folate and MVI. #Ileus/gastritis: Patient had copious vomiting the night after extubation. An NGT was placed. KUB showed distended loops of bowel consistent with ileus, but no signs of volvulus or SBO. Patient was not passing gas. He was given a suppository and other aggressive bowel regimen meds and he started to have bowel movements. On day of transfer from the unit, pt was draining dark reddish fluid from NGT, felt to be due to gastritis. Pt was placed on a PPI IV BID which was then increased ___ dose when fluid from NGT returned guaiac positive. AXR on ___ showed resolving ileus, pt was passing gas. NGT clamped on ___, pt denied pain or nausea. No residual. Was reexamined by speech and swallow on ___ and allowed a nectar thickened and soft diet. NGT removed. Stools guaiac negative. Continued on PPI. #Cardiomyopathy, EF 20%: Initially diuresed due to feeling that patient was fluid overloaded and his respiratory status improved. Creatinine eventually bumped and diuresis was stopped. Given his NPO status, patient eventually became hypernatremic and was given free water flushes as well as IV D5 free water. Repeat TTE showed normal EF. He will follow up with cardiology after discharge. #Atrial Fibrillation: Patient found to have afib with RVR shortly after ROSC. Felt to be new onset. Subsequently ___ sinus rhythm. Patient was started on aspirin for CHADS 1. #Schizophrenia: Existing diagnosis. Risperdal was held during admission and can consider restarting at discharge. #Social situation: Mr. ___ lives at the ___ and has no HCP. His brother confirmed that he "is his own guardian". After extubation, the patient stated that he did not want the medical team to contact anyone ___ particular. He had difficulty comprehending the reasons behind his admission, however, and an ICU consent and code status could not be obtained. He was full code. . #anemia, acute renal failure and alkalosis improved. . #nutrition-on nectar thickened, soft diet. Please adat and continue swallow therapy. RECOMMENDATIONS: 1. PO diet: Soft solids with nectar thick liquids 2. PO meds: whole ___ puree 3. oral care TID 4. Aspiration precautions - ___ tuck with nectar liquids - slow rate - upright for all PO intake 5. Service to f/u for training of supraglottic swallow, compliance of ___ tuck strategy and potential introduction of free water protocol. TRANSITIONAL ISSUES: 1.HCP: Per OMR, HCP is brother ___ (___) but upon contacting him, he stated the patient is his own guardian. 2.Code: Full 3.Pt will need repeat CT of the chest to evaluate opacities noted on prior exam "Ill-defined small nodular opacities are noted ___ the lungs bilaterally, possibly related to small airways disease, but should be reassessed on follow up CT exam.. RECOMMENDATION(S): Recommend attention on follow up imaging for the multiple ill-defined nodular opacities ___ the lungs." 4.Pt will need cardiology follow up 5.wean oxygen 6.consider restarting risperdol. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. RISperidone 1 mg PO DAILY 2. Guaifenesin ER 600 mg PO Q12H 3. Multivitamins 1 TAB PO DAILY 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. FoLIC Acid 1 mg PO DAILY 6. Thiamine 100 mg PO DAILY 7. umeclidinium 62.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 2. FoLIC Acid 1 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Thiamine 100 mg PO DAILY 5. umeclidinium 62.5 mcg/actuation inhalation DAILY 6. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob 7. Aspirin 81 mg PO DAILY 8. Docusate Sodium (Liquid) 100 mg PO BID 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 10. Pantoprazole 40 mg PO Q12H Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: - hypercarbic and hypoxemic respiratory failure - cardiopulmonary arrest, either due to hypercarbia or tachyarrhthmias - aspiration pneumonia - ileus - EtOH dependence - schizophrenia - vocal cord partial paralysis s/p intubation - acute heart failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, ___ were admitted to ___ after being found without a pulse. ___ were successfully resuscitated and were transfered to ___ where ___ required intubation to maintain your oxygen and carbon dioxide levels. The reason we think that ___ might have had a cardiopulmonary arrest is due to a severe COPD exacerbation causing retention of carbon dioxide, or an abnormal rhythm of your heart causing it to beat too fast. ___ were also treated for a pneumonia with antibiotics and for your COPD with steroids. Your breathing improved and the breathing tube was removed. ___ developed a slowing of your intestines causing vomiting. There seemed to also be slow bleeding from your stomach. ___ were put on medication for the bleeding and a tube was placed ___ your nose to your stomach to relieve the fluid and air buildup. Your intestines recovered and the tube was removed and your diet was started. ___ still had trouble swallowing thin liquids which can happen to people who require intubation. This usually recovers over time, but ___ need to be careful to use the techniques taught to ___ by the swallowing experts to avoid choking and aspirating on food and liquids. ___ were discharged to a rehab facility. Followup Instructions: ___
19962126-DS-20
19,962,126
23,209,050
DS
20
2145-04-15 00:00:00
2145-04-16 23:27:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: Intubation ___ PICC placement ___ History of Present Illness: ___ M with hx of COPD on 3L home O2, schizophrenia previously on risperidone, and h/o EtOH abuse sober since ___ presenting for respiratory distress from assisted living facility. Of note, patient had hospitalization in ___ after cardiac arrest of unclear etiology. That hospitalization was c/b CAP / Aspiration pna, afib with rvr, ileus, and cardiomyopathy with EF 20% with subsequent normalization of cardiac function. Per nursing staff at patient's living facility, he was noted to be altered, non-communicative, and hypoxic this morning (VS BP 165/85, P 61, RR 24, O2 sat 88% on 4L NC, FSBS 143). Staff subsequently called EMS. On presentation to ED, pt was unresponsive. In the ED, initial vitals: -Exam: Coarse breath sounds bilaterally. Poor air movement, unresponsive. Intubated with ETT position confirmed on x-ray. -initial vitals (post-intubation): 31.8 °C (89.2 °F) (Rectal), Pulse: 66, RR: 24, BP: 98/36, MAP: 56.7 mm Hg, O2 sat: 100. -Labs notable for: WBC 6.6, Hgb 11.4/39.0, Plt 279, Na 142, K 6.8--->5.9, BUN/Cr 34/1.0, HCO3 37, Glucose 125, lactate 1.1, INR 0.8 - patient was given 125 IV methylpred, vanc/cefepime/azithro, 1L NS - Imaging: diaphragmatic flattening, no clear consolidation On arrival to the MICU, patient was unresponsive with pinpoint pupils. VS were T93.9, HR 77, BP 107/34, RR 19, SaO2 100% on CMV. Past Medical History: COPD (clinical diagnosis, no formal PFTs, on 3L home O2) Tobacco abuse Alcohol abuse History of colon cancer status post partial colectomy Schizophrenia h/o cardiac arrest ___ afib (chads =1, on ASA) Social History: ___ Family History: Pt denies family history of lung disease. Mother died of breast cancer. Physical Exam: ADMISSION PHYSICAL =================== Vitals: T93.9, HR 77, BP 107/34, RR 19, SaO2 100% on CMV GENERAL: intubated / sedated HEENT: NC/AT, sclera anicteric, pinpoint pupils, +corneal reflex, ET tube in place NECK: supple, JVP not elevated, no LAD LUNGS: Diffuse expiratory wheezes, no rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No rashes or excoriations NEURO: Pinpoint pupils, +corneal reflex, +withdrawal to noxious stimuli Discharge Exam ================== Vital Signs: T 99.8 P 75 BP 126/55 RR 18 O2 94-96% on 2L General: Alert, oriented, no acute distress HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple, JVP not elevated, no LAD Lungs: Poor air movement throughout with diffuse expiratory wheezing. No rales or 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: Without rashes or lesions Neuro: No focal deficits. Pertinent Results: ADMISSION LABS ___ 12:15AM BLOOD WBC-6.6 RBC-3.68* Hgb-11.4* Hct-39.0* MCV-106* MCH-31.0 MCHC-29.2* RDW-14.6 RDWSD-56.5* Plt ___ ___ 12:15AM BLOOD ___ PTT-31.4 ___ ___ 12:15AM BLOOD Glucose-141* UreaN-34* Creat-1.0 Na-142 K-6.8* Cl-98 HCO3-37* AnGap-14 ___ 05:00AM BLOOD Glucose-117* UreaN-38* Creat-1.1 Na-138 K-9.4* Cl-98 HCO3-32 AnGap-17 ___ 07:00AM BLOOD Na-146* K-5.7* Cl-103 ___ 12:15AM BLOOD CK-MB-5 cTropnT-<0.01 ___ 05:00AM BLOOD CK-MB-4 cTropnT-<0.01 ___ 01:19PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 05:00AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.6 ___ 12:28AM BLOOD Glucose-125* Lactate-1.1 Na-146* K-5.9* Cl-93* calHCO3-39* Lactate Trend ============= ___ 07:11PM BLOOD Lactate-2.3* ___ 01:30PM BLOOD Lactate-3.3* ___ 05:34AM BLOOD K-4.8 ___ 03:24AM BLOOD Lactate-2.5* ___ 01:52AM BLOOD Lactate-1.9 K-5.3* ___ 12:28AM BLOOD Glucose-125* Lactate-1.1 Na-146* K-5.9* Cl-93* calHCO3-39* Discharge Labs =============== ___ 06:04AM BLOOD WBC-8.0 RBC-2.59* Hgb-7.8* Hct-25.3* MCV-98 MCH-30.1 MCHC-30.8* RDW-15.4 RDWSD-54.9* Plt ___ ___ 06:04AM BLOOD Plt ___ ___ 06:04AM BLOOD Glucose-89 UreaN-34* Creat-1.0 Na-140 K-4.0 Cl-99 HCO3-36* AnGap-9 ___ 03:16AM BLOOD ALT-32 AST-26 AlkPhos-153* TotBili-0.3 ___ 06:04AM BLOOD Calcium-8.7 Phos-3.5 Mg-1.8 Imaging ========= ___ CXR IMPRESSION: 1. Endotracheal tube terminates 6.6 cm above the carina. Recommend advancement of both the endotracheal and enteric tubes. 2. Moderate to severe emphysema. 3. Ill-defined opacities in the right upper and left lower lung, of unclear clinical significance. Close interval follow-up is recommended, with consideration for a repeat PA and lateral chest radiograph if appropriate. ___ CXR IMPRESSION: Compared to chest radiographs ___. Lung volumes are lower but there is clearly progression of consolidation in the axillary and basal regions of the right chest, probably due to developing pneumonia. Left lung is essentially clear. The heart is normal size and there is no appreciable vascular engorgement in either the lungs or mediastinum. ET tube is in standard placement, at new esophageal drainage tube passes into the stomach and out of view, and the apparent advance of the right PIC line from the superior cavoatrial junction into the upper right atrium is probably a function of lower lung volumes. ___ CXR IMPRESSION: In comparison to ___ chest radiograph, worsening, poorly defined areas of consolidation in the right mid and both lower lungs are concerning for developing multifocal pneumonia. Small bilateral pleural effusions are also demonstrated. Brief Hospital Course: ___ M with hx of COPD on 3L home O2, schizophrenia, and h/o EtOH abuse with recent admission for cardiac arrest c/b pneumonia, afib with rvr, and cardiomyopathy with EF 20% with subsequent normalization of cardiac function who was admitted with hypoxic respiratory failure requiring intubation ___ COPD exacerbation and HCAP. # Hypoxic respiratory failure: this was attributed to COPD exacerbation and HCAP. Patient was intubated in the ICU. He received steroids and broad spectrum antibiotics with vanc/cefepime (day 1: ___. He was weaned off of the vent and extubated on ___. He maintained O2 sats in mid 90's on 2L NC for the remainder of hospitalization. Patient was evaluated by speech and swallow out of concern for aspiration who recommended soft dysphagia diet, thin liquids and S&S follow up as outpatient. # Sepsis ___ HCAP: patient presented with SIRS criteria and chest imaging was concerning for pneumonia. Patient was started on vanc/cefepime (day 1: ___ and PICC was placed. Lactate was noted to be elevated, but improved with IVF. Sputum culture and respiratory viral panel were negative. Patient's MRSA swab returned negative and blood cultures revealed no growth, so Vancomycin was discontinued on ___. Patient discharged on Cefepime with plans to complete 8 day course (last day ___. Patient to follow up with PCP as outpatient. # COPD: on home O2 (3L). On Advair, Albuterol, Incruse Ellipta at home. He was started on standing/PRN nebs, steroids and azithromycin on ___. On arrival to the floor on ___ he was transitioned to PO prednisone and continued on Azithromycin. He improved as above and was discharged with plans to complete 5 day course of steroids/Azithromycin, ending on ___. #Anemia: Patient's Hb ~8 throughout admission, stable. No evidence of active bleeding. Patient has history of chronic, macrocytic anemia, likely due to chronic alcohol abuse. Patient instructed to follow up with PCP. #Atrial Fibrillation: diagnosed during previous admission. Noted after cardiac arrest / ROSC subsequently in sinus rhythm. On aspirin for CHADS 1. He was in sinus rhythm during hospitalization. #Schizophrenia: previously on Risperidone. Was held during previous admission. Not currently on it per rehab medication list. Will need to discuss restarting prior to discharge from the hospital. Transitional Issues =================== [ ] Patient should complete 8 day course of cefepime for pneumonia (last day ___. [ ] Patient should complete 5 day course of azithromycin and prednisone for COPD exacerbation (last day ___. [ ] Patient has R sided PICC in place. Should be removed after completion of IV antbiotics. [ ] There is concern that patient is aspirating, which may have contributed to his initial respiratory distress. He was evaluated by speech and swallow who recommended dysphagia diet w/thin liquiids. He should follow up with speech and swallow as outpatient for further evaluations. [ ] Patient previously on risperidone for schizophrenia but it was discontinued during last hospitalization. Outpatient PCP/psychiatrist may consider resuming this medication as outpatient. QTc 408. [ ] Patient should be counseled to stop smoking because he is on O2. [ ] Consider outpatient CT chest given nodules seen on imaging during last hospitalization. Communication: HCP: ___ (brother) ___. Code: Full, confirmed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY 4. Multivitamins 1 TAB PO DAILY 5. Thiamine 100 mg PO DAILY 6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 7. Docusate Sodium 100 mg PO BID 8. Pantoprazole 40 mg PO Q12H 9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 10. Heparin 5000 UNIT SC BID 11. Ondansetron 4 mg PO Q8H:PRN nausea 12. Atorvastatin 40 mg PO QPM 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob Discharge Medications: 1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 5. FoLIC Acid 1 mg PO DAILY 6. Heparin 5000 UNIT SC BID 7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H 8. Multivitamins 1 TAB PO DAILY 9. Ondansetron 4 mg PO Q8H:PRN nausea 10. Pantoprazole 40 mg PO Q12H 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Thiamine 100 mg PO DAILY 13. Docusate Sodium 100 mg PO BID 14. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY 15. Azithromycin 250 mg PO Q24H Duration: 1 Dose 16. CefePIME 2 g IV Q24H 17. PredniSONE 40 mg PO DAILY Duration: 1 Dose Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary Diagnosis =================== Pneumonia Acute Exacerbation of Chronic Obstructive Pulmonary Disease Secondary Diagnosis ==================== Anemia Schizophrenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted with difficulty breathing. You had a tube placed down your throat with a machine to help you breathe and were admitted to the Intensive Care Unit. In the ICU your chest x ray showed evidence of pneumonia and you were thought to have an exacerbation of your COPD. You were started on antibiotics, steroids and standing nebulizer treatments and you improved. You were able to have the tube removed on ___ and you were transferred to the medicine floor on ___. You continued to improve and were discharged with close primary care follow up. You had a PICC line placed on ___, a special IV that will be used to administer antibiotics as outpatient. This will be removed once you complete your course of antibiotics. During admission you were evaluated by swallowing experts, because there was concern that you may be aspirating (food accidentally going into your lungs while you are eating). You should continue to eat soft food and be careful to chew and swallow slowly. You should also sit up during all meals. You should NOT smoke cigarettes because you are on oxygen, which is extremely flammable. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
19962242-DS-8
19,962,242
25,769,651
DS
8
2133-09-25 00:00:00
2133-09-25 10:19:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: diltiazem / Verapamil Attending: ___. Chief Complaint: "I fell" Major Surgical or Invasive Procedure: none Pertinent Results: ECHO ___: Conclusions The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. 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. 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) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. CT HEAD W/O CONTRAST ___: IMPRESSION: Stable right parietal subdural hematoma. No new hemorrhage or mass effect. CAROTID U/S ___: IMPRESSION: No significant stenosis in either internal carotid artery. Brief Hospital Course: ___: Pt admitted for ___ after syncopizing (likely vagal). Started keppra 500 BID x10 days. ___ stable. Patient had syncopal work-up and medicine was consulted. They agreed with current management and orthostatics were obtain. SHe had no evidence of orthostatic hypotension. She is set for discharge home in stable condtion. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 2. Atorvastatin 20 mg PO DAILY 3. Nitroglycerin SL 0.4 mg SL PRN chest pain 4. Lisinopril 5 mg PO DAILY 5. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN pain ok to take OT ES tylenol RX *acetaminophen 650 mg 1 tablet(s) by mouth every six (6) hours Disp #*60 Tablet Refills:*0 2. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 3. LeVETiracetam 500 mg PO BID Duration: 10 Days RX *levetiracetam 500 mg 1 tablet(s) by mouth twice a day Disp #*20 Tablet Refills:*0 4. Levothyroxine Sodium 50 mcg PO DAILY 5. Omeprazole 20 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: syncopal episode TBI right subdural hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had a syncopal episode prior to your admission. Your work-up was essentially negative. It is important that prior to standing that you sit for ___ prior to standing and walking. It is imperative that you follow-up with your PCP upon discharge from hospital. You were diagnosed with a small right subdural hematoma for which you suffered after you fell striking your head. This is a traumatic head injury. You may experience different severity of headaches. Please take tylenol Extra strength as needed. - You should hold your Aspirin for 1 week from your injury. Restart ASA on ___ •You have been prescribed Keppra for anti-seizure medicine and you should take it for 10 days. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING •New onset of tremors or seizures. •Any confusion, lethargy or change in mental status. •Any numbness, tingling, weakness in your extremities. •Pain or headache that is continually increasing, or not relieved by pain medication. •New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: ___
19962724-DS-4
19,962,724
29,247,919
DS
4
2203-10-30 00:00:00
2203-10-30 13:13:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Lower abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ M with a history of HTN presenting with five days of intermittent left lower abdominal pain refered by his PCP. In the ED, initial vitals were: 97.1 66 136/86 16 100% RA. In the ED, labs were notable for normal CBC, chemistry, and lactate of 1.6. U/A was negative. CT scan showed sigmoid diverticulitis. He was given Cipro IV and admitted to medicine for further management. On the floor, the patient notes that he has left lower quadrant pain that began 5 days ago. He describes the pain as an intermittent sharp pain that comes and goes. He notes that this morning the pain became so severe that he was unable to walk. He denies any nausea, vomiting, diarrhea, or constipation. He notes he has been eating and drinking normally without difficulty. He has tried ibuprofen with codeine for the pain intermittently. He denies fever, chills, dysuria, cough, chest pain, or headaches. He does note that about 1 month ago he was evaluated for similar abdominal pain in the right lower qudrant that was attributed to a possible nephrolithiasis. He was given tylenol with codeine at that time. He currently denies any right lower quadrant pain. Of note he does mention hematuria in the past thought to be due to UTI for which he was given amoxicillin with resolution of his symptoms. He has since stopped taking 81 mg aspirin daily. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: HTN Colonscopy ___ with diverticulitis and multiple polyps plan for repeat in ___ years Hematuria resolved with amoxicillin per patient's report and cessation of aspirin GERD High cholesterol Social History: ___ Family History: No known family history of colon cancer. Father with hypertension and diabetes. Physical Exam: EXAM ON ADMISSION: ================== Vitals: T: 98.2 BP: 113/81 P: 64 R:18 O2: 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, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to palpation in mid lower quadrant and left lower quadrant with guarding though no rebound. Non-tender to palpation in RLQ. Negative rovsig sign. Negative psoas sign. No evidence of hernia Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rash Neuro: CN II-XII intact, ___ strength in upper and lower extremities. EXAM ON DISCHARGE: ================== Vitals: T: 98.1, BP 115/71, HR 68,RR 18, 97% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender to palpation in left lower quadrant with guarding though no rebound. Non-tender to palpation in RLQ. Negative rovsig sign. Negative psoas sign. No evidence of hernia Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: no rash Neuro: CN II-XII intact, ___ strength in upper and lower extremities. Pertinent Results: LABS ON ADMISSION: ================== ___ 01:50PM BLOOD WBC-7.6 RBC-4.97 Hgb-15.6 Hct-44.2 MCV-89 MCH-31.3 MCHC-35.2* RDW-12.8 Plt ___ ___ 01:50PM BLOOD Glucose-107* UreaN-16 Creat-1.2 Na-136 K-4.1 Cl-99 HCO3-27 AnGap-14 ___ 01:54PM BLOOD Lactate-1.6 STUDIES: ======== CT ABD ___: IMPRESSION: 1. Acute sigmoid diverticulitis. Extensive surrounding fat stranding and phlegmonous changes without evidence of macroperforation or drainable abscess formation. 2. Cholelithiasis without evidence of acute cholecystitis. EKG: ==== QTc of 418 PRIOR Colonscopy ___: ========================== Findings: Protruding Lesions A single sessile 5 mm polyp of benign appearance was found in the transverse colon. A single-piece polypectomy was performed using a cold snare in the transverse colon. The polyp was completely removed. A single sessile 4 mm polyp of benign appearance was found in the hepatic flexure. A single-piece polypectomy was performed using a cold snare in the hepatic flexure. The polyp was completely removed. Three sessile polyps of benign appearance and ranging in size from 4 mm to 5 mm were found in the splenic flexure, descending colon and rectum. Single-piece polypectomies were performed using a cold snare in the splenic flexure, descending colon and rectum. The polyps were completely removed. Excavated Lesions A few diverticula were seen in the right and left colon. Diverticulosis appeared to be of mild severity. Impression: Polyp in the transverse colon (polypectomy) Polyp in the hepatic flexure (polypectomy) Polyps in the splenic flexure, descending colon and rectum (polypectomy) Diverticulosis of the right and left colon Otherwise normal colonoscopy to cecum Recommendations: We will follow up polyp pathology Repeat screening colonoscopy in ___ years pending polyp pathology Additional notes: The procedure was performed by the attending and the GI fellow. The attending was personally present during the entire procedure and collaborated with the Fellow on the findings of this report. The patient's reconciled home medication list is appended to this report. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. Specimens were taken for pathology as listed above. Brief Hospital Course: ___ M with a history of HTN presenting with five days of intermittent lower abdominal pain found to have uncomplicated sigmoid diverticulitis. # Uncomplicated Diverticulitis: Mr. ___ presented to the hospital with left lower quadrant pain found to have uncomplicated diverticulitis with CT abdomen showing localized localized diverticular inflammation and is without evidence of abscess, obstruction, or perforation. He is also without evidence of leukocytosis though exam was notable for left lower quadrant tenderness with guarding though no rebound. Patient's last colonscopy in ___ showed evidence of sigmoid diverticulitis with polyps with need for repeat in ___ years. Mr. ___ was admitted to the hospital placed on clear liquid diet, started on PO ciprofloxacin/flagyl with improvement of his abdominal pain and ability to ambulate easily prior to discharge. He was discharged with 10 day course of PO cipro/flagyl, tylenol for pain, and zofran for nausea (Qtc of 418). He was instructed to continue clear liquid diet for ___ days and if tolerating without issue could transition to regular diet. # HTN: Blood pressure remained well controlled and he was continued on atenolol. # BPH: Continued on home tamsulosin QHS #History of hematuria Patient with prior history of hematuria that per his report had resolved after treatement with amoxicillin possible secondary to nephrolithiasis vs. hemorrhagic UTI. UA currently without evidence of blood. Follow up with primary care doctor #Cholelithiasis without cholecystitis CT abdomen showing diverticulitis above noted cholelithiasis though no cholecystitis TRANSITIONAL ISSUES: ==================== -ciprofloxacin and flagyl started this hospital course for 10 day treatment of uncomplicated diverticulitis -naprosyn and tylenol with codeine were stopped this hospital course -tylenol was recommended for pain management not to exceed more than 3 grams in 1 day -zofran initiated as antiemetic and continued for short course on discharge (___ 418) -follow up patient's abdominal pain/resolution of diverticulitis -screening colonscopies as per prior schedule (last completed in ___ with plan for repeat in ___ years) -CT abdomen showed cholelithiasis though no cholecystitis Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Naproxen 250 mg PO Q8H:PRN pain 2. Atenolol 25 mg PO DAILY 3. Tamsulosin 0.4 mg PO QHS 4. Acetaminophen w/Codeine ___ TAB PO Frequency is Unknown Discharge Medications: 1. Atenolol 25 mg PO DAILY 2. Tamsulosin 0.4 mg PO QHS 3. Acetaminophen 325-650 mg PO Q6H:PRN pain RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0 4. Ciprofloxacin HCl 500 mg PO Q12H RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every 12 hours Disp #*19 Tablet Refills:*0 5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every eight (8) hours Disp #*28 Tablet Refills:*0 6. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting Duration: 5 Days RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours Disp #*15 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Uncomplicated diverticulitis Cholelithiasis without evidence of acute cholecystitis Secondary: Hypertension Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because of lower abdominal pain. You were found to have a condition called diverticulitis that is caused by inflammation in the outpouchings in the large intestine. You were given antibiotics for this that you will continue for a full 10 day treatment course. Please continue with a clear liquid diet within the next ___ days and transition to a normal diet if you are tolerating fluids without difficulty. It was a pleasure being involved in your care. Sincerely, Your ___ Team Followup Instructions: ___
19963038-DS-15
19,963,038
23,414,579
DS
15
2159-10-05 00:00:00
2159-10-06 10:30:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Metformin / Glyburide / Simvastatin / Tricor / Januvia / Cardizem / trazodone / Tetanus&Diphtheria Toxoid / adhesive Attending: ___. Chief Complaint: abnormal labs Major Surgical or Invasive Procedure: EBUS and lymph node biopsy performed by interventional pulmonology on ___ History of Present Illness: ___ ___ F PMHx including recurrent diverticulitis, hematochezia, hx C. diff colitis, hx Constipation, type 2 DM c/b gastroparesis and neuropathy, severe AS, presents for reports of abnormal labs. Was seen by PCP ___ ___ after recent discharge for diverticulitis on cipro/flagyl. Was unable to tolerate flagyl ___ to N/V and was switched to moxifloxacin. Patient was instructed to come into the ED for neutropenia. In the ED on ___ WBC was 2.1 with 24% neutrophils ANC of 504. Patient was completely asymptomatic in the ED. Of note she reports that abdominal pain and diverticular symptoms have completely resolved and she has had no fevers. She reported to nursing in the ED (according to the dash) that she was particularly concerned about getting C dif colitis as she has had this in the past. She was given 1 G IV Vancomycin and admitted to medicine. Notably her most recent admission (___) she was treated for c-dif colitis admission CT torso at that time revealed: Sigmoid diverticulitis in the mid sigmoid colon with moderate surrounding inflammatory change and a small intramural abscess, but no drainable fluid collection. Recommend endoscopic evaluation after resolution of acute symptoms. 2. New, significant retroperitoneal, periportal, and portacaval lymphadenopathy is indeterminate although potentially concerning for lymphoproliferative disease or other malignancy, versus inflammatory change. Complete imaging of the chest is recommended to fully evaluate the partially imaged thoracic lymphadenopathy. Multiple prominent and enlarged mediastinal lymph nodes as well as a prominent left hilar lymph node conglomerate are noted. A 1.2 cm subcarinal node is seen in may be amenable to transbronchial biopsy. Trace bibasilar atelectasis. ERCP and IP services were consulted at that time to biopsy one of these lymph nodes and both felt that bipsy would be defered until after the acute episode of diverticulitis had resolved. Labs in the ED were remarkable for CBC 2.1 12.1 173 37.0 CHEM7 137 104 23 -------------<132 4.0 23 1.2 Vitals prior to transfer were: 0 98.0 77 119/70 16 100% RA Upon arrival to the floor, Patient had no complaints REVIEW OF SYSTEMS: (+) Per HPI 1 episode of loose stool (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: Recurrent Diverticulitis Hematochezia Hx C. diff colitis Hx Constipation Hx TIA Type 2 Diabetes c/b Gastroparesis, Neuropathy Severe Aortic Stenosis Hypertension Lipid Disorder Asthma Pancreatic Cysts GERD OA Sciatica Macular Degeneration (Wet and Senile) Pruritis Tongue Leukoplacia TAH/BSO Cataract Surgery Chronically Low MCV and MCH Social History: ___ Family History: Mother with h/o appendicitis and CAD. Father with h/o MI. Brother with CAD. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.9 116/69 p 81 R 16 98% on RA General:elderly female NAD sitting quietly on side of bed HEENT: OP clear NECK: supple, no JVD Heart:RRR ___ SEM with radiation to carotids Lungs: CTAB Abdomen:soft, normoactive bowel sounds nonttp Extremities: WWP, brace on LUE Neurological: A+Ox3 per family who interpreted DISCHARGE PHYSICAL EXAM: VS: 98.4 98.4 79 117/58 18 98% ra General:elderly female NAD, resting in bed HEENT: OP clear NECK: supple, no JVD Heart: RRR ___ SEM with radiation to carotids Lungs: CTAB Abdomen:soft, normoactive bowel sounds, slight tenderness in lower quadrants, no rebound or guarding Extremities: WWP, brace on LUE Neurological: fluent speech, steady gait, grossly intact Pertinent Results: LABS ON ADMISSION: ___ 05:35PM BLOOD WBC-1.6* RBC-4.75 Hgb-11.8* Hct-35.4* MCV-75* MCH-24.7* MCHC-33.2 RDW-13.8 Plt ___ ___ 05:35PM BLOOD Neuts-32* Bands-0 ___ Monos-24 Eos-1 Baso-0 ___ Myelos-0 ___ 05:35PM BLOOD Plt ___ ___ 05:35PM BLOOD UreaN-21* Creat-1.0 Na-138 K-4.3 Cl-103 HCO3-19* AnGap-20 ___ 05:35PM BLOOD TotProt-6.1* Albumin-3.9 Globuln-2.2 Phos-2.9 Mg-2.2 LABS ON DISCHARGE: ___ 08:10AM BLOOD WBC-1.4* RBC-4.61 Hgb-11.4* Hct-35.0* MCV-76* MCH-24.7* MCHC-32.5 RDW-14.3 Plt ___ ___ 06:02PM BLOOD WBC-2.1* RBC-4.87 Hgb-12.1 Hct-37.0 MCV-76* MCH-24.9* MCHC-32.8 RDW-13.9 Plt ___ ___ 06:02PM BLOOD Neuts-24* Bands-4 ___ Monos-29* Eos-1 Baso-1 Atyps-2* ___ Myelos-0 ___ 08:10AM BLOOD Plt ___ ___ 06:02PM BLOOD Plt Smr-NORMAL Plt ___ ___ 08:10AM BLOOD Glucose-120* UreaN-21* Creat-1.1 Na-139 K-4.0 Cl-105 HCO3-25 AnGap-13 ___ 06:02PM BLOOD Glucose-132* UreaN-23* Creat-1.2* Na-137 K-4.0 Cl-104 HCO3-23 AnGap-14 ___ 08:10AM BLOOD LD(LDH)-226 ___ 06:02PM BLOOD ALT-19 AST-26 LD(LDH)-262* AlkPhos-50 TotBili-0.2 ___ 06:02PM BLOOD Lipase-212* ___ 08:10AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.1 ___ 06:02PM BLOOD Albumin-3.9 ___ 06:10PM BLOOD Lactate-1.2 ___ 06:30PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 06:30PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR ___ 06:30PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-2 TransE-<1 ___ 06:30PM URINE Uric AX-FEW ___ 06:30PM URINE Mucous-FEW MICROBIOLOGY: Blood and urine cultures pending IMAGING: CXR ___: The patient is status post median sternotomy and aortic valve replacement. Mild enlargement of the cardiac silhouette is again noted. Mediastinal lymphadenopathy s again noted, most pronounced within the region of the AP window. Pulmonary vasculature is normal. Increased interstitial markings are seen within the periphery of the lung bases compatible with chronic lung disease, better characterized on the recent CT. Lungs are hyperinflated. No focal consolidation, pleural effusion or pneumothorax is present. There are mild degenerative changes noted within the thoracic spine. IMPRESSION: No acute cardiopulmonary abnormality. Unchanged mediastinal lymphadenopathy and mild chronic interstitial abnormality. Brief Hospital Course: Hospital course: ___ y/o ___ F PMHx including recurrent diverticulitis, hx C. diff colitis, weight loss, retroperitoneal and mediastinal lymphadenopathy and neutropenia presents after outpatient follow up for recent diverticulitis revealed neutropenia. She was neutropenic during previous admission, which is new over the past few months. Given that her other cell lines have been stable, this may be from a medication although unlikely to be her antibiotics given time course. An enlarged lymph node was biopsied, and she will have clinic follow up for the results. Active issues: #Neutropenia: ANC 504 on admission. The cause of the neutropenia is likely multifactorial, all three agents, ciprofloxacin, flagyl and moxifloxacin have been rarely implicated in neutropenia all though this effect is relatively rare, for moxifloxacin ___ on patients and a simmilar number of patient have an increase in ANC on therapy. Additionaly her ANC is not substantially decreased from her recent discharge 640 vs 504. Fenofibrate may also have contributed, and was discontinued on discharge. A malignancy is also a possible cause of neutropenia given her diffuse lymphadoopathy on imaging. Reassuringly she is asymptomatic. Her ANC and temperature were trended, and she was not febrile. LDH wnl. She was discharged with outpatient IP, heme/onc, and PCP follow up after an enlarged lymph node was biopsied. #Diverticulitis: Patient with resolved abdominal discomfort; afebrile during this hospitalization, and tolerated meals. Given that she was unable to tolerate flagyl due to nausea, and she has known allergies to beta-lactams, cephalosporins and bactrim, moxifloxicin, which had been started on an outpatient basis, was continued during this hospitalization and at the time of discharge. #Acute Kidney injury: Cr returned to 1.2 from 1.0 on d/c and she appears dry. Her creatinine improved with encouragement of PO intake by the time of discharge. #Diffuse lymphadenopathy: In the setting of neutropenia a malignancy is high on the differential. She was discharged with outpatient IP, heme/onc, and PCP follow up after an enlarged lymph node was biopsied. Chronic issues: # Diabetes: Her most recent A1c was 6.7% in ___. She was continued on a diabetic diet. #Macular degeneration: As she missed an an outpatient eye appointment due to her hospitalization, she noted that she would re-schedule this appointment. # Hypertension: Well controlled on home medications # Hyperlipidemia: She was continued on her home atorvastatin in-house and at discharge. Fenofibrate was discontinued as above. # GERD: She was continued on her home omeprazole in-house and at discharge. Transitional issues: -IP follow up scheduled, for follow up of biopsy results; hematology/oncology follow up pending at discharge -fenofibrate was discontinued as it was noted that this medication can rarely be associated with neutropenia - full code - contact: Patient, daughter ___ (___) ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. Docusate Sodium 100 mg PO BID 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Omeprazole 20 mg PO DAILY 6. Zolpidem Tartrate ___ mg PO QHS 7. Lovaza (omega-3 acid ethyl esters) 1 gram oral DAILY 8. methylcellulose (laxative) 500 mg oral DAILY 9. Moxifloxacin 400 mg OTHER DAILY 10. Eye Health Formula (vits A,C,E-lutein-zeax-zn-copp) 9,650 unit-195 mg-95 unit oral daily 11. Fenofibrate 48 mg PO DAILY 12. Lisinopril 5 mg PO DAILY 13. Metoprolol Succinate XL 50 mg PO DAILY 14. Mirtazapine 15 mg PO QHS 15. Prochlorperazine 5 mg PO Q8H:PRN nausea Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. Docusate Sodium 100 mg PO BID 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Moxifloxacin 400 mg OTHER DAILY 7. Omeprazole 20 mg PO DAILY 8. Zolpidem Tartrate ___ mg PO QHS 9. Eye Health Formula (vits A,C,E-lutein-zeax-zn-copp) 9,650 unit-195 mg-95 unit oral daily 10. Lisinopril 5 mg PO DAILY 11. Lovaza (omega-3 acid ethyl esters) 1 gram oral DAILY 12. methylcellulose (laxative) 500 mg oral DAILY 13. Mirtazapine 15 mg PO QHS 14. Prochlorperazine 5 mg PO Q8H:PRN nausea Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSES ================= 1. Neutropenia 2. Retroperitoneal and mediastinal lymphadenopathy 3. Recent history of diverticulitis; now improving on moxifloxacin SECONDARY DIAGNOSES =================== 1. History of aortic stenosis 2. Microcytic Anemia 3. Diabetes 4. Hypertension 5. Hyperlipidemia 6. GERD 7. macular degeneration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure taking care of you at ___. You were admitted after your white blood cell count was noted to be low during a follow up visit for your recent episode of diverticulitis. In the hospital, you were feeling well and did not have a fever. We recommend that you follow up with the interventional pulmonology specialists for a biopsy of the enlarged lymph nodes previously noted in your chest and abdomen. We sent your stool to test for c diff infection and will let you know if this returns positive. If you should develop fevers, have worsening diarrhea, or not be able to eat food, please let your doctor know. Best wishes, Your ___ Medicine Team Followup Instructions: ___
19963038-DS-23
19,963,038
26,480,413
DS
23
2163-09-20 00:00:00
2163-09-21 09:16:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Metformin / Glyburide / Simvastatin / Tricor / Januvia / Cardizem / trazodone / Tetanus&Diphtheria Toxoid / adhesive / vancomycin / Flagyl / cefepime Attending: ___. Chief Complaint: cough, fever Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with asthma, DMII, NSIP, HTN, and history of Hodgkin's presenting with cough and fever x 2 weeks. Patient has had dry cough, becoming more productive recently as well as fevers at home. Has also had associated dyspnea with exertion. Notes post-tussive emesis as well. She spoke with her pulmonologist on ___ and was prescribed a 7 day course of levofloxacin (___). Symptoms have persisted since then. Temperature about two weeks ago of 38.2, since then has been ~37.5 ("normal" for her, per daughter/HCP, is around 36.0). She subsequently saw her pulmonologist on ___, per notes she was finishing a course of prednisone for acute bronchitis. CXR at that time did not show any evidence of pneumonia. Saw heme/onc on ___ who recommended she come to the ED for likely admission and IV antibiotics, though she wanted to wait a few days so she could see her dying husband in rehab. She presented to the ED today for further evaluation. Patient previously underwent incomplete ABVD therapy for her Hodgkin's that was stopped secondary to side effects. She was disease free for many years, though FDG PET on ___ showed "multifocal areas of abnormal FDG avidity involving both lungs with a 3.3 x 1.6 cm lesion in the left lower lobe [that] could be secondary to multifocal infectious/inflammatory disease, however underlying malignancy cannot be excluded." - In the ED, initial vitals were: T 98.9, HR 98, BP 107/67, RR 22, SpO2 96% RA - Exam was notable for: Afebrile RRR, III/VI systolic murmur appreciated throughout precordium Diffuse bibasilar crackles though worse and more coarse at right base - Labs were notable for BUN 24, Cr 1.1, WBC 7.4, Flu negative - Studies were notable for: ECG -- sinus tach with poor R wave progression CXR -- Low lung volumes. Subtle increased opacity in the left lateral lung could reflect an area of infection or inflammation, somewhat more pronounced than on ___. Redemonstration of chronic fibrosing interstitial lung disease better characterized on prior chest CT. CT CHEST -- 1. Ground-glass opacities in both upper lobes suggest infectious or inflammatory etiology, new from ___. 2. Redemonstrated fibrotic changes with lower lobe predominance overall similar to ___. 3. Slightly grown mediastinal lymph nodes may be reactive. - The patient was given vancomycin, cefepime, and IV benadryl On arrival to the floor, history is obtained from the patient and her daughter who assists in translation. Patient endorses the story outlined above. Continues to endorse cough, minimally productive which is new. Does endorse some dyspnea, particularly with coughing. No fever currently but has had them intermittently over the past two weeks. Past Medical History: Interstitial pneumonitis H/o Hodgkin's disease Asthma GERD Hypertension Hyperlipidemia AS s/p QVR in ___ TIA Headaches Sciatica Macular degeneration Social History: ___ Family History: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: ___ 2234 Temp: 98.2 PO BP: 159/84 L Sitting HR: 104 RR: 18 O2 sat: 96% O2 delivery: RA Dyspnea: 8 RASS: 0 Pain Score: ___ GENERAL: ___ speaking. Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Nonlabored respirations. Bases in right lung base. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: No clubbing, cyanosis, or edema. SKIN: Warm. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE PHYSICAL EXAM: ======================== ___ 1113 Temp: 98.4 PO BP: 110/67 R Lying HR: 99 RR: 18 O2 sat: 93% O2 delivery: ra General: ___ speaking. Appears well, lying in bed, in no acute distress. Occasional cough Heart: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs. Audible S4 Lungs: Coarse bilateral crackles from bases to mid lung fields bilaterally, stable from previous exam Abd: non-distended, minimal suprapubic ttp, midline scar from hysterectomy Extremities: warm and well-perfused, no cyanosis, clubbing or edema Pertinent Results: ADMISSION LABS ============== ___ 02:47PM BLOOD WBC-7.4 RBC-4.54 Hgb-11.4 Hct-37.7 MCV-83 MCH-25.1* MCHC-30.2* RDW-13.7 RDWSD-41.1 Plt ___ ___ 02:47PM BLOOD Neuts-81.9* Lymphs-6.9* Monos-6.9 Eos-3.4 Baso-0.5 Im ___ AbsNeut-6.10 AbsLymp-0.51* AbsMono-0.51 AbsEos-0.25 AbsBaso-0.04 ___ 02:47PM BLOOD Glucose-143* UreaN-24* Creat-1.1 Na-137 K-4.7 Cl-104 HCO3-23 AnGap-10 ___ 06:55AM BLOOD ALT-9 AST-13 LD(LDH)-233 AlkPhos-67 TotBili-0.3 ___ 06:55AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.4 DISCHARGE LABS ============== ___ 04:55AM BLOOD WBC-8.4 RBC-4.37 Hgb-11.1* Hct-36.6 MCV-84 MCH-25.4* MCHC-30.3* RDW-13.3 RDWSD-40.6 Plt ___ ___ 04:55AM BLOOD Glucose-122* UreaN-19 Creat-0.9 Na-138 K-4.8 Cl-101 HCO3-26 AnGap-11 ___ 04:55AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3 IMAGING ======= CT CHEST ___. Slight interval worsening ground-glass opacities in both upper lobes when compared to ___, a nonspecific finding which could be due to an infectious or inflammatory etiology, including exacerbation of underlying known chronic interstitial lung disease. 2. Redemonstration of chronic fibrotic interstitial lung disease with lower lobe predominance, minimally worse in the peripheral aspect of the left upper lobe. 3. Stable enlarged mediastinal lymph nodes may be reactive. 4. Stable dilation of the main pulmonary artery may be reflective of underlying pulmonary arterial hypertension. Brief Hospital Course: BRIEF HOSPITAL COURSE ================================= Presented to the ED with 2 weeks of dry cough and subjective fever that had persisted despite treatment with trial of Doxycycline and 7-day course of Levofloxacin outpatient. She had a CT chest which identified mild upper lobe ground glass opacities of unclear significance. Pulmonology was consulted who felt they were most consistent with resolving infection from her prior outpatient treatment. They did not feel it represented an untreated infection or flare of her interstitial lung disease. Recommended no further antibiotics, continuing outpatient prednisone, and supportive treatment for cough symptoms. Also treated for UTI. ==================== ACUTE ISSUES: ==================== #Cough #Fever #GGO on CT chest Patient underwent CT identifying GGO likely representing inflammatory process vs. infection. The patient was afebrile during this admission and her DOE and cough seemed to be resolving. Imaging was not consistent with acute bacterial process, although atypicals could not be ruled out. Pulmonology consulted and felt findings were consistent with a post-infectious cough. She was treated initially with Vanc/cefepime in the ED but this was discontinued after recommendations from pulmonology. Additionally, she was continued on outpatient prednisone 5mg daily. Azithromycin 250mg daily prophylaxis was resumed as this had been discontinued during outpatient antibiotics therapy. Patient also treated with fluticasone, and atrovent. Given PET/CT was performed during suspected pulmonary infection, results are difficult to interpret, and we recommend repeat in 3 months. Urinary strep pneumo and legionella were negative. Her ambulatory oxygenation improved during her hospital course. #UTI Patient reported dysuria, suprapubic tenderness and red-tinged urine. A UA was positive for pyuria with cultures showing no growth. Patient was treated briefly with Cefepime and then Ceftriaxone but symptoms persisted. Repeat UA with no pyuria but positive for nitrites. Antibiotics were discontinued and repeat urine culture results pending. If the culture is positive, will contact patient about initiating treatment. If sx persist, please consider further workup #___ Patient reported one incident of a small amount of bright red blood with wiping. She has a history of constipation and her symptoms were thought to be ___ anal fissure or hemorrhoid. She was put on a bowel regimen to prevent constipation and her BMs were monitored with no subsequent bleeding. Outpatient follow-up recommended if this recurs. ==================== CHRONIC ISSUES: ==================== #Interstitial pneumonia CT scan demonstrated stable fibrotic changes but with evidence of GGOs, consistent with inflammatory vs. infectious process. Given her underlying NSIP, follow-up with Dr. ___ is recommended as an outpatient. #Hodgkin's lymphoma Incomplete ABVD therapy due to side effects. Recent PET scan with multifocal areas of increased FDG avidity bilaterally, could be ___ infectious/inflammatory process as described above. Cannot rule out malignancy. Recommend repeat PET/CT in 3 months as outpatient. Follow up with Dr. ___ ==================== TRANSITIONAL ISSUES: ==================== [] Patient had several episodes of BRBPR on admission which then stopped. Unclear etiology although suspect hemorrhoids, would consider further workup if this is ongoing [] Patient had an episode of loose stools with no infectious symptoms. If continuing to have these, would consider C. Diff testing [] Recommend repeat PET/CT in 3 months as recent PET scan with multifocal areas of increased FDG avidity [] Patient on home acyclovir as prescribed by ___ ___, NP (Hematology/Oncology). It was unclear to the inpatient team whether this is needed indefinitely, please discuss with heme/onc. [] Treated for UTI given pyuria and dysuria though culture was negative, repeat UA without pyuria. If sx persist please workup further. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Vitamin D ___ UNIT PO 1X/WEEK (MO) 2. PredniSONE 5 mg PO DAILY 3. Atorvastatin 10 mg PO QPM 4. Docusate Sodium 100 mg PO BID 5. Senna 8.6 mg PO BID 6. Omeprazole 20 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Polyethylene Glycol 17 g PO DAILY 9. Zolpidem Tartrate 5 mg PO QHS 10. Acyclovir 400 mg PO Q12H Discharge Medications: 1. Azithromycin 250 mg PO/NG Q24H RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 2. Benzonatate 200 mg PO TID:PRN cough RX *benzonatate 200 mg 1 capsule(s) by mouth three times a day Disp #*20 Capsule Refills:*0 3. Fluticasone Propionate 110mcg 2 PUFF IH BID RX *fluticasone propionate [Flovent HFA] 110 mcg/actuation 2 puff twice a day Disp #*1 Inhaler Refills:*0 4. GuaiFENesin ER 1200 mg PO Q12H RX *guaifenesin 1,200 mg 1 tablet(s) by mouth every twelve (12) hours Disp #*20 Tablet Refills:*0 5. Phenazopyridine 100 mg PO TID Duration: 3 Days RX *phenazopyridine [Pyridium] 100 mg 1 tablet(s) by mouth three times a day Disp #*60 Tablet Refills:*0 6. Acyclovir 400 mg PO Q12H 7. Atorvastatin 10 mg PO QPM 8. Docusate Sodium 100 mg PO BID 9. Metoprolol Succinate XL 50 mg PO DAILY 10. Omeprazole 20 mg PO DAILY 11. Polyethylene Glycol 17 g PO DAILY 12. PredniSONE 5 mg PO DAILY 13. Senna 8.6 mg PO BID 14. Vitamin D ___ UNIT PO 1X/WEEK (MO) 15. Zolpidem Tartrate 5 mg PO QHS Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Post-infectious cough Urinary tract infection SECONDARY DIAGNOSIS Hodgkin's Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ================================================ MEDICINE Discharge Worksheet ================================================ Dear ___, ___ was a pleasure taking part in your care here at ___! Why was I admitted to the hospital? - You were admitted for a cough and reported fevers. Given your history of lung disease, lymphoma, and the fact that your symptoms seemed to not be resolving with treatment with antibiotics and steroids as an outpatient, your hematologist/oncologist felt that admission to the hospital was appropriate for further investigating the cause of your symptoms and optimizing your treatment. During your time in the hospital, it was discovered that you were also suffering from a urinary tract infection which required antibiotic treatment. What was done for me while I was in the hospital? - You underwent imaging studies including a chest X-Ray and CT scan, as well as various laboratory tests. - The pulmonary (lung) doctors saw ___, and felt your sx are likely ongoing irritation from the pneumonia you were treated for outpatient. They did not feel this was a flare of your lung disease or that steroids would be beneficial. You were with medications to help improve your cough and shortness of breath. - You received antibiotics for a urinary infection What should I do when I leave the hospital? Follow up with your primary care provider as well as specialists, including your hematologist/oncologist and pulmonologist. Call or return to the hospital if your symptoms return or worsen. Make sure to take all of your medications as prescribed. Sincerely, Your ___ Care Team Followup Instructions: ___
19963038-DS-24
19,963,038
23,433,058
DS
24
2163-10-02 00:00:00
2163-10-02 12:23:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Cephalosporins / Metformin / Glyburide / Simvastatin / Tricor / Januvia / Cardizem / trazodone / Tetanus&Diphtheria Toxoid / adhesive / vancomycin / Flagyl / cefepime Attending: ___ Chief Complaint: Shortness of Breath, Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ ___ female with Hodgkin's disease, ILD, asthma, AS s/p TAVR, and DMII who presents with persistent dyspnea and hypoxia. The patient has had a 2 week history of productive cough and fevers with progressive dyspnea on exertion. She was initially prescribed a 7-day course of levofloxacin on ___ and prednisone with some improvement of her symptoms per her follow-up with pulmonology on ___. However, she was then seen by her oncologist on ___ and given her persistent cough and fevers was admitted to ___ from ___. During that admission she underwent a CT chest that demonstrated upper lobe GGOs. Pulmonology was consulted and felt that this was likely due to a resolving infection. After initial treatment with vancomycin/cefepime this was discontinued and the patient remained on her outpatient prednisone 5mg and azithromycin prophylaxis. She was also discharged on fluticasone inhaler. Since discharge, the patient continued to have persistent dry cough and dyspnea with exertion. She called her outpatient pulmonologist, Dr. ___ recommended increasing her prednisone to 10mg daily, stopping inhalers, and obtaining ambulatory oxygen. Ambulatory O2 sats were done the day prior to admission and notable for: At Rest 02 sat 93% RA, HR 88; Exercise O2 sat 83% RA, HR 111. Her daughter reports that she has been monitoring her temperature closely which she checks under her armpit. She notes her normal temperature is 35.9 to 36.6 C and anything above 37 C is concerning. She notes that over the past week or so her temperatures have been 36.6 to 37.5C. On arrival to the ED, initial vitals were 97.4 94 113/69 24 96% RA. Exam was notable for bilateral diffuse inspiratory and expiratory crackles. Labs were unremarkable. Flu negative. CXR was stable from prior. She was given cefepime 2g IV. Prior to transfer vitals were 98.3 77 117/74 17 96% 1L. On arrival to the floor, patient reports feeling better after using oxygen in the ED. She notes some occasional dizziness and intermittent pelvic pain. She denies headache, vision changes, weakness/numbness, hemoptysis, chest pain, palpitations, abdominal pain, nausea/vomiting, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: Interstitial pneumonitis H/o Hodgkin's disease Asthma GERD Hypertension Hyperlipidemia AS s/p QVR in ___ TIA Headaches Sciatica Macular degeneration Social History: ___ Family History: Non-contributory. Physical Exam: ADMISISON: VS: Temp 97.6, BP 135/84, HR 79, RR 20, O2 sat 94% RA. GENERAL: Very pleasant woman, in no distress, lying in bed comfortably, intermittent coughing. HEENT: Anicteric, PERLL, OP clear. CARDIAC: RRR, no murmurs. LUNG: Coarse bilateral crackles from bases to mid lung fields. ABD: Soft, non-tender, non-distended, normal 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. VITAL SIGNS: 97.9 PO 150 / 81 63 18 96 RA ambulating General: NAD HEENT: MMM CV: RR, NL S1S2 no S3S4, III/VI SEM PULM: respirations unlabored no wheezing, fine crackles at b/l bases ABD: BS+ SNT/ND LIMBS: No ___, WWP SKIN: No rashes on extremities NEURO: Speech fluent, strength grossly intact PSYCH: thought process logical, linear, future oriented ACCESS: PIV Pertinent Results: ___ 06:27AM BLOOD WBC-8.4 RBC-4.72 Hgb-12.0 Hct-39.2 MCV-83 MCH-25.4* MCHC-30.6* RDW-13.8 RDWSD-41.2 Plt ___ ___ 06:27AM BLOOD Glucose-98 UreaN-31* Creat-1.1 Na-140 K-4.5 Cl-100 HCO3-27 AnGap-13 ___ 03:34PM BLOOD ALT-18 AST-18 LD(LDH)-294* AlkPhos-65 TotBili-0.2 ___ 03:34PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-666* ___ 06:27AM BLOOD Calcium-9.8 Phos-3.9 Mg-2.5 ___ 08:04AM BLOOD %HbA1c-6.9* eAG-151* ___ 03:40PM BLOOD Lactate-1.6 ___ 06:11AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-Test ___ 03:34PM BLOOD B-GLUCAN-Test Brief Hospital Course: ___ with Hodgkin's disease, ILD, asthma and AS s/p TAVR presented with persistent dyspnea and hypoxia after recent admission for similar symptoms. #ACUTE HYPOXIC RESPIRATORY FAILURE #DYSPNEA ON EXERTION #COUGH #INTERSTITIAL LUNG DISEASE: Patient presented with progressive dyspnea and cough in the setting of low grade fevers and documented hypoxia with ambulation. Infectious work up on recent admission was unrevealing and CT scan demonstrated GGOs which were thought to be from a resolving prior pulmonary infection per pulmonology. Given her sudden progressive symptoms and negative infectious work up in addition to recent imaging findings, her symptoms were attributed to an ILD flair. Patient was seen by pulmonology who recommended increasing steroids to 60mg daily, but patient wanted to try a lower dose to avoid side effects so she was given 30mg daily. In addition, the patient was treated with broad spectrum antibiotics to rule out an infectious process. She was on vanc from ___ to ___ (d/c'd after negative MRSA swab). She was also treated with cefepime x7 days (___). She was able to ambulate on the floor without hypoxia. B-Glucan was elevated, but this was thought to be due to her prior cefepime rather than PJP or fungal infection. Patient to follow up with her pulmonologist for prednisone tapering. She was started on Bactrim for PJP ppx in addition to Calcium (on VitD at home). Her omeprazole was increased to 40mg daily. [ ] repeat B-glucan ~3 weeks after d/c of cefepime (last dose ___ [ ] pulm to titrate her prednisone (currently 30 mg) and repeat chest CT in ___ wks #STEROID INDUCED HYPERGLYCEMIA: Patient with modest increase in her glucose after starting prednisone which was well controlled with NPH. Although the patient's hyperglycemia would likely be well controlled with an oral agent, the patient and daughter preferred insulin given prior intolerances to medication. She was seen by ___ and their educator. She was discharged on the following regimen: [ ] 12U NPH before every breakfast, no sliding scale needed at this time #HODKGIN'S LYMPHOMA: Patient is s/p partial treatment with ABVD due to toxicity with recent PET CT demonstrating bilateral multifocal areas of increased FDG avidity in the chest that may be due to her underlying inflammatory pulmonary process. She continues to have night sweats concerning for possible relapse [ ] Follow-up with Dr. ___ [ ] Will need repeat PET-CT once these symptoms resolve #HTN: #AORTIC STENOSIS S/P TAVR (___): No chest pain or signs of heart failure. However, repeat TTE demonstrates moderate MR and reduced effective orifice area index, though it is unclear if this is changed from prior echos and this finding is an expected finding given her valve in valve replacement. Continued home metoprolol and aspirin. #GERD: cont home omeprazole #INSOMNIA: cont home ambien PRN #Moderate malnutrition: nutrition consulted; appreciate recs DISPO: Home w/ services BILLING: >30 min spent coordinating care for discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q12H 2. Atorvastatin 10 mg PO QPM 3. Docusate Sodium 100 mg PO BID 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. PredniSONE 10 mg PO DAILY 8. Senna 8.6 mg PO BID:PRN constipation 9. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia 10. Azithromycin 250 mg PO/NG Q24H 11. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO) 12. Aspirin 81 mg PO DAILY Discharge Medications: 1. Calcium Carbonate 500 mg PO BID RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 2. NPH 12 Units Breakfast Insulin SC Sliding Scale using HUM Insulin RX *insulin NPH isoph U-100 human [Humulin N NPH Insulin KwikPen] 100 unit/mL (3 mL) AS DIR 12 Units before BKFT; Disp #*2 Syringe Refills:*2 3. Pen Needle (pen needle, diabetic) 32 gauge x ___ miscellaneous as dir RX *pen needle, diabetic [BD Ultra-Fine Nano Pen Needle] 32 gauge X ___ use to inject insulin up to 5 times daily Disp #*150 Each Refills:*2 4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tab-cap by mouth once a day Disp #*30 Tablet Refills:*0 5. Omeprazole 40 mg PO DAILY RX *omeprazole 40 mg 1 capsule(s) by mouth once a day Disp #*30 Capsule Refills:*0 6. PredniSONE 30 mg PO DAILY RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 7. Acyclovir 400 mg PO Q12H 8. Aspirin 81 mg PO DAILY 9. Atorvastatin 10 mg PO QPM 10. Azithromycin 250 mg PO Q24H 11. Docusate Sodium 100 mg PO BID 12. Metoprolol Succinate XL 50 mg PO DAILY 13. Polyethylene Glycol 17 g PO DAILY 14. Senna 8.6 mg PO BID:PRN constipation 15. Vitamin D ___ UNIT PO EVERY 2 WEEKS (MO) 16. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute Hypoxic Respiratory Failure Interstitial Lung Disease Steroid induced hyperglycemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, You were admitted for shortness of breath. You were seen by the lung doctors who ___ this is most likely an infection or a flare of your interstitial lung disease. You improved on antibiotics and steroids. You were seen by the diabetes experts who helped formulate an insulin regimen to help keep your sugars under good control while on steroids. Regarding your prednisone, this was increased to 30 mg. Your lung doctor ___ see you on ___ and will decrease the dose to 20 mg if you are doing well and likely continue that dose for a few weeks. In addition, we started you on calcium to help keep your bones strong while on high dose steroids. We increased your omeprazole dose to help prevent ulcers while on the higher dose of prednisone and this can be decreased after some time. Your outpatient team will recheck your fungal cultures in ___ weeks and repeat a chest CT in ___ weeks. Followup Instructions: ___
19963063-DS-12
19,963,063
24,560,750
DS
12
2138-09-09 00:00:00
2138-09-13 08:20:00
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: ruptured ectopic pregnancy; mild post-operative colonic ileus Major Surgical or Invasive Procedure: laparoscopic left salpingo-oophorectomy, evacuation of hemoperitoneum, and cystoscopy; blood transfusion History of Present Illness: Ms. ___ is a ___ yo G1P0 at 7w4d by LMP who presents with abdominal pain. Last night she developed vaginal bleeding without pain. This morning she awoke around 5 AM with sudden lower abdominal pain with continued vaginal bleeding, though unchanged. Denies feeling light headed or dizzy. Had a positive pregnancy test at ___ with family medicine, though intra-uterine pregnancy had not yet been confirmed; was scheduled for PNV this week with ultrasound. Last ate last night around 6 ___. Had sips of water this AM around 5:30 AM, nothing else. This was a desired and planned pregnancy. Past Medical History: OB: G1P0 - G1: Current, 7w4d GYN: - LMP: ___ - Sexually active: yes, with husband who is present - STIs: denies - Contraception: n/a PMH: Denies PSH: Denies Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION Vitals: 94.8 91/53, 99/46, 98/52, 73/45, 66-74, 18, 100%RA General: NAD, uncomfortable, mildly pale, pain with movement CV: RRR Resp: CTAB Abd: distended, soft, moderate tenderness with palpation on LLQ, no rebound, voluntary guarding throughout Ext: non-tender, no edema Pelvic: deferred DISCHARGE Vital signs stable within normal limits General: NAD, comfortable Abdomen: softly distended, incisions clean/dry/intact, faint ecchymosis surrounding umbilical port site, no erythema or drainage, appropriately tender to palpation over incisions without rebound or guarding Extremities: no TTP, no edema Pertinent Results: ================ ADMISSION LABS ================ ___ 06:37AM BLOOD WBC-14.0* RBC-3.35* Hgb-10.4* Hct-30.8* MCV-92 MCH-31.0 MCHC-33.8 RDW-12.6 RDWSD-41.8 Plt ___ ___ 06:37AM BLOOD Neuts-78.1* Lymphs-17.2* Monos-3.5* Eos-0.4* Baso-0.3 Im ___ AbsNeut-10.94* AbsLymp-2.41 AbsMono-0.49 AbsEos-0.06 AbsBaso-0.04 ___ 06:37AM BLOOD ___ PTT-26.8 ___ ___ 06:37AM BLOOD Glucose-166* UreaN-9 Creat-0.7 Na-138 K-3.7 Cl-100 HCO3-22 AnGap-16 ___ 06:37AM BLOOD ___ ================ OTHER LABS ================ ___ 10:15PM BLOOD WBC-14.3* RBC-3.62* Hgb-10.6* Hct-30.6* MCV-85# MCH-29.3 MCHC-34.6 RDW-15.0 RDWSD-46.4* Plt ___ ___ 07:16AM BLOOD WBC-12.3* RBC-3.35* Hgb-9.8* Hct-29.7* MCV-89 MCH-29.3 MCHC-33.0 RDW-15.3 RDWSD-49.7* Plt ___ ___ 07:16AM BLOOD Neuts-75.3* Lymphs-17.7* Monos-5.4 Eos-0.6* Baso-0.3 Im ___ AbsNeut-9.27* AbsLymp-2.18 AbsMono-0.66 AbsEos-0.07 AbsBaso-0.04 ___ 08:11AM BLOOD Lactate-2.5* ================ IMAGING ================ Early OB Ultrasound ___: There is no intrauterine gestational sac. The right ovary is unremarkable. There is a corpus luteal cyst noted in the right ovary. The left ovary demonstrates a corpus luteal cyst and also demonstrates normal color Doppler vascularity. In the left adnexa, there is a gestational sac that contains an embryo with cardiac activity compatible with a tubal ectopic pregnancy. Heterogeneous complex fluid surrounding the gestational sac is consistent with hemorrhage, extending into the right adnexa. Abdominal X Ray ___: Multiple loops of large bowel filled with predominantly air, but also stool, are mildly dilated. There is no free intraperitoneal air. The lung bases appear clear. IMPRESSION: Multiple dilated loops of large bowel, most consistent with ileus. Brief Hospital Course: Ms. ___ is a ___ year old G1P0 who presented to the Emergency Department with abdominal pain and vaginal bleeding and was found to have a ruptured left tubal ectopic pregnancy. She underwent urgent laparoscopic left salpingo-oophorectomy, evacuation of hemoperitoneum, and cystoscopy, and was subsequently admitted to the Gynecology service for observation. Please see the operative report for further details. Intra-operative findings were notable for approximately 2.5 L of hemoperitoneum. The patient received a total of 4 units of packed red blood cells at the time of and immediately following surgery. Her hematocrit on presentation was 30.8 and was 30.6 post-transfusion. Immediately post-op, her pain was controlled with IV hydromorphone and ketorolac. Her diet was advanced, and she was transitioned to oral acetaminophen, ibuprofen, and oxycodone. On post-operative day 1, her urine output was adequate, so her foley was removed, and she voided spontaneously. On post-operative day 2, the patient complained of ongoing abdominal distention without passing flatus. She had no nausea or emesis, and was self-moderating her diet. Her exam showed moderate distention, appropriate diffuse tenderness without peritoneal signs, and with active bowel sounds. Labs were notable for stable hematocrit, WBC of 12.3 (thought to be appropriate for post-operative state), and lactate of 2.5. Abdominal plain films showed mild colonic distention consistent with a colonic ileus. The patient then passed flatus and was symptomatically improved. She continued to tolerate a regular diet without nausea or vomiting. By post-operative day 2, she was tolerating a regular diet, voiding spontaneously, ambulating independently, and pain was controlled with oral medications. She was then discharged home in stable condition with outpatient follow-up scheduled. Medications on Admission: Prenatal vitamins Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*0 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity take with food RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours Disp #*50 Tablet Refills:*1 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe do not drive or drink alcohol while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: ruptured ectopic pregnancy acute blood loss anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after your procedure. You have recovered well and the team believes you are ready to be discharged home. Please call Dr. ___ office 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. * No strenuous activity until your post-op appointment. * No heavy lifting of objects >10 lbs for 6 weeks. * You may eat a regular diet. * You may walk up and down stairs. Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No tub baths for 6 weeks. * You have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. 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 * significant dizziness, chest pain or trouble breathing To reach medical records to get the records from this hospitalization sent to your doctor at home, call ___. Followup Instructions: ___
19963242-DS-20
19,963,242
26,363,470
DS
20
2178-10-24 00:00:00
2178-11-03 09:18:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Left flank/abd pain. Major Surgical or Invasive Procedure: CYSTOSCOPY,URETERAL STENT PLACEMENT,LEFT History of Present Illness: Patient is a ___ female who with a history of multiple medical problems including diabetes, who presented to ER overnight for Left flank/abd pain. PAtient states she has had intermittent sharp left sided pains for a while, but they acutely became worse 4 days ago. She had nausea and vomiting yesterday. Chills as well, did not take temperature. Patient also notes foul smelling urine. Patient was found to have a 4mm mid ureteral stone with hydronephrosis. Her pain and nausea is much improved, but her UA is suggestive of infection so Urology was called. Has never seen a urologist previously. First UA had evidence of contamination, therefore a repeat UA was requested via straight cath. There is still evidence of infection in this UA, her WBC is ildly elevated. Patient is afebrile and hemodynmically stable, buy given the concern for infection, we recommended ureteral stent placement. Past Medical History: S/P TUBAL LIGATION BIPOLAR DISORDER BREAST CYST s/p removal CHILDHOOD SEIZURES DIABETES MELLITUS DIVERTICULOSIS CHOLELITHIASIS HYPERLIPIDEMIA HYPERTENSION LIVER MASS PALPITATIONS RECTAL BLEEDING URINARY TRACT INFECTION Social History: ___ Family History: Mother - DM, still alive at ___+ years of age (as ___ No history of skin infections Pertinent Results: ___ 05:07AM BLOOD WBC-11.3*# RBC-5.02 Hgb-12.4 Hct-40.1 MCV-80* MCH-24.7* MCHC-30.9* RDW-14.2 RDWSD-41.1 Plt ___ ___ 05:07AM BLOOD Neuts-79.3* Lymphs-12.3* Monos-7.8 Eos-0.0* Baso-0.2 Im ___ AbsNeut-8.94*# AbsLymp-1.39 AbsMono-0.88* AbsEos-0.00* AbsBaso-0.02 ___ 05:07AM BLOOD Glucose-156* UreaN-21* Creat-1.2* Na-140 K-4.0 Cl-106 HCO3-23 AnGap-15 ___ 5:30 am URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. OF TWO COLONIAL MORPHOLOGIES. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ 8 S AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: Ms. ___ was admitted to the urology service with concern for a UTI and nephrolithiasis, flank pain, abdominal pain. She was optimized for urgent intervention and underwent cystoscopy, left ureteral stent placement. Ms. ___ tolerated the procedure well and was recovered in the PACU before transfer back to the general surgical floor . See the dictated operative note for full details. Diet was advanced and she was converted to oral pain medications. Perioperative antibiotics were completed and she was subsequently discharged home. At discharge on POD0, her pain was controlled with oral pain medications, she was tolerating regular diet, ambulating without assistance, and voiding without difficulty. Ms. ___ was explicitly advised to follow up as directed as the indwelling ureteral stent must be removed and or exchanged and additional procedures for definitive stone treatment may follow. She was given explicit instructions to return in ___ weeks for KUB before follow up with Dr. ___. She will continue with the oral antibiotics prescribed, until finished. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. MetFORMIN (Glucophage) 500 mg PO BID 4. Rosuvastatin Calcium 20 mg PO QPM 5. Senna 8.6 mg PO BID:PRN constipation 6. Aspirin EC 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days Concurrent use of CIPRO and antidiabetic agents may result in severe hypoglycemia. RX *ciprofloxacin HCl 500 mg ONE tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 3. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg one capsule(s) by mouth twice a day Disp #*60 Capsule Refills:*0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate RX *oxycodone 5 mg ONE tablet(s) by mouth Q4HRS Disp #*25 Tablet Refills:*0 5. Phenazopyridine 100 mg PO TID Duration: 3 Days RX *phenazopyridine 100 mg ONE tablet(s) by mouth Q8HRS Disp #*9 Tablet Refills:*0 6. Senna 8.6 mg PO DAILY Duration: 2 Doses 7. Tamsulosin 0.4 mg PO DAILY PROMOTES RELAXATION OF URETER AND PASSAGE OF STONE RX *tamsulosin 0.4 mg ONE capsule(s) by mouth daily Disp #*30 Capsule Refills:*1 8. Aspirin EC 81 mg PO DAILY 9. lisinopril-hydrochlorothiazide ___ mg oral DAILY 10. MetFORMIN (Glucophage) 500 mg PO BID 11. Rosuvastatin Calcium 20 mg PO QPM Discharge Disposition: Home Discharge Diagnosis: NEPHROLITHIASIS, URINARY TRACT INFECTION, DIABETES MELLITIS, ACUTE KIDNEY INJURY (CREAT BUMP TO 1.2 FROM BASELINE) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed ___ there may fragments/others still in the process of passing. STRAIN ALL THE URINE FOR STONES/FRAGMENTS -You may experience some pain associated with spasm of your ureter.; This is normal. Take the narcotic pain medication as prescribed if additional pain relief is needed. -Ureteral stents MUST be removed or exchanged and therefore it is IMPERATIVE that you follow-up as directed. -Do not lift anything heavier than a phone book (10 pounds) -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume your pre-admission/home medications EXCEPT as noted. You should ALWAYS call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor. -IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken even though you may also be taking Tylenol/Acetaminophen. You may alternate these medications for pain control. For pain control, try TYLENOL FIRST, then ibuprofen, and then take the narcotic pain medication as prescribed if additional pain relief is needed. -Ibuprofen should always be taken with food. Please discontinue taking and notify your doctor should you develop blood in your stool (dark, tarry stools) -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative, and available over the counter. The generic name is DOCUSATE SODIUM. It is recommended that you use this medication. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while Foley catheter is in place. Followup Instructions: ___
19963323-DS-12
19,963,323
21,312,275
DS
12
2171-05-15 00:00:00
2171-05-15 16:12:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / sulfamethoxazole-trimethoprim / Ciprofloxacin / Iodine / Lipitor / Codeine / Darvon-N / Demerol / morphine / Sulfa (Sulfonamide Antibiotics) / Lopressor / lisinopril / Shellfish / Sesame Oil / Fish derived / Milk / Sunflower Oil / Melon / Artificial orange Attending: ___. Chief Complaint: visual changes Major Surgical or Invasive Procedure: ___ Left temporal artery biopsy History of Present Illness: ___ s/p CABG x 2 with Dr. ___ on ___. Post-op course significant for atrial fibrillation- started on coumadin. Intolerant of beta-blockers, rate controlled with amio and dilt. She was discharged to rehab on POD 9. She developed visual changes this morning described as "twinkling" and "pulsing" vision, as well as strobe light effect. This was associated with left temporal headache/pressure and temporal region tenderness. She presented to the ED where she was evaluated by Neurology and Ophthalmology. She does have a history of retinopathy and cataracts. Ophthalmology recs are pending at this time, however there is suspicion for Giant Cell Arteritis in the setting of ESR of 76. Head CT was negative for acute process. Neurology findings include right sided sensory loss and weakness, likely resulting from C6 radidulopathy, which could be further evaluated by MRI (however, this is not urgent, as it may not change management at this point). Neurology recommends a heparin bridge, as she is not therapeutic on coumadin. Suspicion remains high for GCA and steroids are being considerred. Past Medical History: Temporal Arteritis PMH: coronary artery disease s/p coronary artery bypass grafts Hypertension Hyperlipidemia noninsulin dependent Diabetes Mellitus coroanry artery disease s/p ___ BMS to LAD Diabetic retinopathy s/p stroke ___ mild left leg "dragging" when fatigued gastroesophageal reflux Asthma s/p Hysterectomy & Ovarian surgery s/p Cholecystectomy s/p Bilateral cataract surgery paroxysmal atrial fibrillation Social History: ___ Family History: Premature coronary artery disease- Paternal family with multiple members with CAD Physical Exam: Pulse: 42 sinus w PVCs Resp: 18 O2 sat: 97%RA B/P Right: Left: 159/71 Height: Weight: General: NAD Skin: Dry [x] intact [x] HEENT: PERRLA []lens implants and dilated s/p ophth. exam, 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 [xx] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] _none__ Varicosities: None [] Neuro: Grossly intact [x] Pulses: Femoral Right: Left: DP Right: 2+ Left:2+ ___ Right: 2+ Left:2+ Radial Right: Left: Pertinent Results: ___ Lower Extremity Ultrasound Final Report STUDY: Duplex sonogram of the left lower extremity. INDICATION: ___ female with left leg aching and tenderness. Evaluate for deep vein thrombosis. FINDINGS: There is normal flow, compression and augmentation involving deep veins of the left lower extremity. IMPRESSION: Negative study for deep vein thrombosis in the left lower extremity. The study and the report were reviewed by the staff radiologist. . ___ Head CT IMPRESSION: 1. No acute intracranial process. 2. Subcortical white matter hypodensity, likely sequela of chronic small vessel ischemic disease. 3. Focal hypodense lesion in the left cerebellar hemisphere, likely old infarct. ___ 06:13AM BLOOD WBC-18.4* RBC-3.29* Hgb-9.3* Hct-28.3* MCV-86 MCH-28.3 MCHC-32.9 RDW-13.4 Plt ___ ___ 06:12AM BLOOD WBC-21.6* RBC-3.20* Hgb-9.1* Hct-27.3* MCV-85 MCH-28.4 MCHC-33.3 RDW-13.1 Plt ___ ___ 06:25AM BLOOD WBC-30.5*# RBC-3.47* Hgb-9.7* Hct-29.7* MCV-85 MCH-28.0 MCHC-32.7 RDW-13.0 Plt ___ ___ 05:35AM BLOOD WBC-13.5* RBC-3.51* Hgb-10.2* Hct-30.6* MCV-87 MCH-29.1 MCHC-33.4 RDW-12.9 Plt ___ ___ 06:13AM BLOOD ___ PTT-65.6* ___ ___ 06:12AM BLOOD ___ PTT-71.2* ___ ___ 06:25AM BLOOD ___ PTT-44.5* ___ ___ 05:35AM BLOOD ___ ___ 05:34AM BLOOD ___ PTT-25.4 ___ ___ 05:35AM BLOOD ESR-86* ___ 06:13AM BLOOD Glucose-125* UreaN-29* Creat-0.9 Na-141 K-4.5 Cl-108 HCO3-25 AnGap-13 ___ 06:12AM BLOOD Glucose-144* UreaN-36* Creat-1.0 Na-141 K-4.6 Cl-108 HCO3-24 AnGap-14 ___ 06:25AM BLOOD Glucose-185* UreaN-37* Creat-1.2* Na-139 K-4.5 Cl-104 HCO3-23 AnGap-17 ___ 05:34AM BLOOD CRP-11.7* Brief Hospital Course: The patient was admitted for further work-up. Suspicion remained high for temporal arteritis, and the patient was started on high dose IV steroids. She was transitioned to PO steroids for concern of compromised wound healing of the sternum (agreeable with Rheumatology). She saw ___ and temporal artery biopsy was recommended. Vascular surgery consulted and performed temporal artery biopsy on ___. Overall the patient tolerated the procedure well and post-operatively was transferred back to the floor for further recovery. Results are pending at the time of discharge and are expected to be available on ___. The patient was on Coumadin for post-op AFib. This was held for the biopsy, and Heparin bridge was initiated. She remained in Sinus Rhythm throughout her admission. She has an allergy to beta blockers and was maintained on Diltiazem and Amiodarone. Blood glucose remained high on steroids, and Insulin scale was adjusted accordingly, as well as Lantus BID. She developed a leukocytosis on steroids. Urine culture was clean and the sternal wound continued to heal without signs of infection. The patient was discharged home on Hospital day 4 with extensive follow-up instructions. Dr. ___ will follow INR/Coumadin dosing. The patient will follow up with Rheumatology, Neurology, Neuro-opthalmology and her Retinologist, Dr. ___ ___ the temporal arteritis. She will remain on Prednisone 60mg daily until further instructed by Rheumatology. Further treatment may be affected by results of temporal artery biopsy. She will also remain on PCP prophylaxis with ___ until further instructed by Rheumatology. Medications on Admission: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 4. valsartan 320 mg Tablet Sig: One (1) Tablet PO once a day. 5. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: as directed Subcutaneous once a day: 10Units at HS daily. 8. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 9. amiodarone 200 mg Tablet Sig: as directed Tablet PO as directed: 200mg twice daily for 4 weeks, then 200mg daily until instructed to stop. 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. glipizide 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): TAPER 400 MG BID X 7 DAYS, THEN 400 MG PO QD, THEN 200 MG PO QD UNTILL F/U WITH PCP. 14. diltiazem HCl 30 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). 15. warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): INR GOAL IS ___. 16. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pravastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 7. amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): decrease to 200mg daily on ___. Disp:*60 Tablet(s)* Refills:*2* 8. atovaquone 750 mg/5 mL Suspension Sig: Two (2) PO DAILY (Daily): 1500mg daily until directed to stop by Rheumatology. Disp:*60 * Refills:*5* 9. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 11. insulin glargine 100 unit/mL Solution Sig: One (1) Subcutaneous twice a day: 20 Units am, 30 Units pm. Disp:*qs * Refills:*2* 12. Insulin Regular Insulin per attached Sliding Scale disp: qs 2 refills 13. sodium chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal QID (4 times a day) as needed for dry nares . Disp:*qs * Refills:*0* 14. warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: Dr. ___ to dose for goal INR ___, dx: afib. Disp:*60 Tablet(s)* Refills:*2* 15. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Temporal Arteritis PMH: coronary artery disease s/p coronary artery bypass grafts Hypertension Hyperlipidemia noninsulin dependent Diabetes Mellitus coroanry artery disease s/p ___ BMS to LAD Diabetic retinopathy s/p stroke ___ mild left leg "dragging" when fatigued gastroesophageal reflux Asthma s/p Hysterectomy & Ovarian surgery s/p Cholecystectomy s/p Bilateral cataract surgery paroxysmal atrial fibrillation Discharge Condition: Alert and oriented x3, nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Edema none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns ___ Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns ___. Answering service will contact on call person during off hours** Followup Instructions: ___
19963844-DS-3
19,963,844
29,666,518
DS
3
2122-12-16 00:00:00
2122-12-18 15:58:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: iodine IV contrast, omnipaque / iodine IV contrast, omnipaque Attending: ___. Chief Complaint: abdominal bloating, fevers Major Surgical or Invasive Procedure: none History of Present Illness: ___ yoF with h/o ulcerative colitis presenting with 3d of fever and bloating for several days. Fever usually occurs in the ___. She reports tmax to 102-103. She denies abdominal pain, diarrhea, n/v, dysuria. Last BM was small BM this AM She says that her current symptoms are not as severe as her past ulcerative colitis exacerbations. Denies bloody BMs. Reports heavy menstrual cycles although states they only last two days. Recently finished menstrual cycle. Denies any other sources of bleeding. No known sick contacts. She reports taking tylenol for her symptoms. Did not take any imodium or zofran. In the ED, initial vitals were: 98.4 86 129/77 18 100% - Labs were significant for CRP: 138.9, wbc ct 10.6, h/h 8.5/28.8, and unremarkable chem-7. - Exam significant for guiac neg stool - Imaging revealed KUB with Similar bowel gas pattern compared to the prior radiograph from ___. No evidence of small-bowel obstruction, free air or pneumatosis - The patient was given nothing Vitals prior to transfer were: 98.2 84 122/79 16 100% RA Past Medical History: Ulcerative Colitis Acne Social History: ___ Family History: +FH of IBD in paternal aunts and cousins Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.7, 112/72, 92, 16, 97% on RA General: Alert, oriented, no acute distress, well appearing HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple CV: flow mumur at ___ Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, +BS, mildly diffusely TTP but without rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema DISHCARGE PHYSICAL EXAM: VS: 98.2, afeb 115/74 83 16 98%RA General: A+Ox3, NAD, appears comfortable HEENT: MMM, ___ Neck: Supple CV: RRR, no murmurs appreciated Lungs: CTAB Abdomen: soft, +BS, non-tender throughout, no distention GU: No foley Ext: WWP, no edema Pertinent Results: ADMISSION LABS: ================= ___ 02:10PM BLOOD WBC-9.6# RBC-3.81* Hgb-8.5*# Hct-28.2* MCV-74*# MCH-22.3*# MCHC-30.1* RDW-15.4 RDWSD-41.9 Plt ___ ___ 02:10PM BLOOD Neuts-63.0 ___ Monos-11.1 Eos-0.7* Baso-0.6 Im ___ AbsNeut-6.02 AbsLymp-2.31 AbsMono-1.06* AbsEos-0.07 AbsBaso-0.06 ___ 02:10PM BLOOD Plt ___ ___ 02:10PM BLOOD Glucose-86 UreaN-10 Creat-0.9 Na-138 K-4.1 Cl-102 HCO3-26 AnGap-14 ___ 02:10PM BLOOD CRP-138.9* DISCHARGE LABS: ================ ___ 10:00AM BLOOD WBC-9.1 RBC-3.90 Hgb-8.4* Hct-28.9* MCV-74* MCH-21.5* MCHC-29.1* RDW-15.6* RDWSD-41.6 Plt ___ ___ 10:00AM BLOOD Glucose-81 UreaN-10 Creat-0.9 Na-140 K-4.4 Cl-103 HCO3-25 AnGap-16 ___ 10:00AM BLOOD CRP-96.8* ___ 10:00AM BLOOD calTIBC-343 Ferritn-50 TRF-264 IMAGING: ========= ABDOMEN (SUPINE & ERECT) Study Date of ___ IMPRESSION: Similar bowel gas pattern compared to the prior radiograph from ___. No evidence of small-bowel obstruction, free air or pneumatosis. MICRO: ====== **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. 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. Brief Hospital Course: ___ y F with newly diagnosed ulcerative colitis presenting with 3d of fever and bloating. No diarrhea, no bloody stool, no nausea, no abdominal pain. Guiac negative stool on exam. KUB without evidence of obstruction or perforation. Stool studies sent, GI was consulted. However patient felt well and declined to stay for further work-up. She undesrtoond the risks of leaving against medical advice, including risk of serious infection, hemodynamic instability, organ damage. She will follow-up with GI as an outpatient. TRANSITIONAL ISSUES: # will follow-up with GI for further work-up including possible flex-sig Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 8 mg PO BID PRN nausea 2. Mesalamine ___ 800 mg PO TID 3. loperamide-simethicone ___ mg oral daily PRN gas Discharge Medications: 1. Mesalamine ___ 800 mg PO TID 2. loperamide-simethicone ___ mg oral daily PRN gas 3. Ondansetron 8 mg PO BID PRN nausea Discharge Disposition: Home Discharge Diagnosis: ulcerative colitis flare Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You came to the hospital after several days of fevers and bloating. Although your symptoms improved, we were very concerned about an ulcerative colitis flare given the elevated markers of inflammation in your blood. We recommended you stay in the hospital for further work-up, including a flexible-sigmoidoscopy. However you chose to leave: you understand the risks of leaving against medical advise, including risk of serious infection and organ damage. Please take your medications as directed and follow-up with your doctors as ___ below. We recommend you call ___ to reschedule a sooner appointment with Dr. ___. Sincerely, Your ___ Care Team Followup Instructions: ___
19963970-DS-14
19,963,970
21,016,234
DS
14
2168-06-25 00:00:00
2168-06-26 12:52:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: lisinopril Attending: ___. Chief Complaint: code stroke Major Surgical or Invasive Procedure: None History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 7 minutes Time (and date) the patient was last known well: 2330 ___ Stroke Scale Score: 2 t-PA given: No Reason t-PA was not given or considered: low NIHSS, resolving symptoms ___ Stroke Scale score was 2: 1a. Level of Consciousness: 0 1b. LOC Question: 2 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: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. Reason for consult: CODE STROKE for left arm numbness HPI: Mr. ___ is a ___ yo RH AAM with h/o HTN, HLD, recent admission (___) for multiple small right-sided embolic strokes and ?dementia pugilistica who presents as CODE STROKE for transient left arm numbness and difficulty making a fist with the left hand. He is known to have quite severe amnesia in the context of prior boxing. His fiancee needed to remind him of the presenting symptom and told much of the history. Patient initially was admitted to Stroke service on ___ with left arm numbness and weakness, found to have multiple small right-sided strokes that appeared embolic. As he also had a history of LEFT eye amaurosis fugax in ___, source was postulated to be most likely cardioembolic (given bilateral symptoms). Carotid embolus also considered. His home ASA was uptitrated from 81mg to 325mg daily. Stroke risk factors showed LDL 86, A1C 6.0%. He was discharged home on ___ with plans for outpatient TTE. Since discharge he has been doing well until now, except for feeling "run down" with a dry cough for the past few days. Last night around 11:30pm, while typing on the computer, he told his fiancee that his left hand and arm felt numb. She immediately drove him to the ED. In the car he complained that he was having difficulty closing his left hand into a fist as well. No difficulties with speech or gait. By 12:20 am, his symptoms had resolved completely. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness or parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt endorses recent dry cough and fatigue. Denies recent fever or chills. No night sweats or recent weight loss or gain. Denies shortness of breath. Denies chest pain or tightness, palpitations. Denies 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: - Right-sided embolic strokes ___, per above) - Dementia, perhaps pugilistica, followed by Drs. ___. at ___ and ___ for this. Many times briefly knocked-out, but not for the 'ten count'. - Prostate cancer - scheduled for brachytherapy in ___ - Hypertension - Hypercholesterolemia - Clear colonscopy with polyp removed, about ___ years ago Social History: ___ Family History: No family history of cerebrovascular disease, stroke, hemorrhage, seizure, dementia or other neurologic disorders. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.2 100 148/66 18 100% General: elderly AAM, WDWN, awake, cooperative, NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: soft, nontender, nondistended Extremities: no edema, pulses palpated Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x person but not place or date (even with choices). Nearly amnestic to all recent events including the symptoms which brought him to ED, but able to relate older parts of history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm and brisk. VFF to finger counting. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5- ___- ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: decreased cold sensation in left forearm and hand. Otherwise intact to light touch, pinprick,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: not tested DISCHARGE PHYSICAL EXAM: Gen: NAD HEENT: nc/at, mucosa moist and pink, oropharynx clear CV: rrr, no m/r/g Pulm: ctab Abd: BS+, soft, nt, nd MSK: no c/c/e Neuro: Oriented to person but not place or date. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm and brisk. VFF to finger counting. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 Pertinent Results: LABS: ___ 12:05AM BLOOD WBC-12.0* RBC-4.88 Hgb-15.6 Hct-45.8 MCV-94 MCH-32.0 MCHC-34.1 RDW-12.9 Plt ___ ___ 12:05AM BLOOD ___ PTT-30.5 ___ ___ 12:45PM BLOOD Glucose-99 UreaN-8 Creat-1.1 Na-141 K-3.7 Cl-103 HCO3-28 AnGap-14 ___ 12:05AM BLOOD cTropnT-<0.01 ___ 12:45PM BLOOD Calcium-8.9 Phos-2.8 Mg-2.2 IMAGING: CTA HEAD AND NECK ___: IMPRESSION: 1. No evidence of acute intracranial abnormalities. MRI would be more sensitive for an acute infarction, if clinically indicated. 2. Mild short-segment narrowing of the proximal M1 segment of the right middle cerebral artery, which appears more prominent than on ___. No evidence of distal occlusion. 3. Atherosclerosis in the proximal right and left internal carotid arteries without evidence of a hemodynamically significant stenosis, unchanged since ___. Atherosclerosis at the origin of the right vertebral artery with moderate narrowing, unchanged. 4. Left thyroid nodule. Recommend further evaluation by sonography, if not previously performed elsewhere. The study and the report were reviewed by the staff radiologist. MRI HEAD ___: IMPRESSION: 1. Small subacute infarction in the right superior posterior frontal lobe, new since ___. 2. Evaluation of the superior frontal lobes is otherwise limited by artifacts bilaterally. TTE ___: Conclusions The left atrium is normal in size. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. 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) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: ___ w hx of HTN, HLD, recent admission (___) for multiple small right-sided emoblic strokes, and hx of dementia puglistica who presented w transient left arm and hand numbness/weakness. MRI shortly after arrival demonstated small subacute infarction in the right superior posterior frontal lobe. Hospital course, by system, as follows: 1) Neuro - Presented with small subacute infarction in the right superior posterior frontal lobe. Symptoms completely resolved by HD1. It was felt that his infarct was related to artery-to-artery embolism due to atherosclerotic carotid disease. Modifiable risk factors, including A1c and cholesterol levels were evaluated. HbA1c equal to 6.0 and LDL equal to 86. Given patient's new infarction while previously taking aspirin 325mg and simvastatin 10mg, he was switched to clopidogrel 75mg daily and atorvastatin 40mg daily. TTE performed on ___ failed to identify PFO. ___ evaluated, determined patient safe for discharge home. Patient was discharged home, where he is cared for by his girlfriend, Ms. ___ ___, who agreed for continuous supervision. 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 = 86, checked on ___ - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) (x) Yes - () No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? (x) Yes - () No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A 2) CV: Hx of HTN and HLD. As above, switched to atorvastatin. 3) GI: Passed bedside swallow exam prior to initiating regular diet. Tolerating regular diet without clinical signs of aspiration. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY Hold for sBP <130, HR <60 2. Doxazosin 2 mg PO HS Hold for sBP <130, HR <60 3. Hydrochlorothiazide 25 mg PO DAILY Hold for sBP <130, HR <60 4. Memantine 10 mg PO DAILY 5. Aspirin 325 mg PO DAILY 6. Simvastatin 10 mg PO DAILY Discharge Medications: 1. Memantine 10 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 3. Amlodipine 10 mg PO DAILY 4. Doxazosin 2 mg PO HS 5. Hydrochlorothiazide 25 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*90 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: - Cerebral embolism with infarction - dementia puglistica SECONDARY: - hyperlipidemia - hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for choosing ___ for your medical care. You were admitted with left arm numbness and weakness of the left hand. You had brain imaging performed, which revealed 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: hyperlipidemia (high cholesterol). We will be switching your simvastatin to atorvastatin for improved control of your cholesterol levels. Your medications have changed: STOP aspirin - we have replaced this with Plavix (clopidogrel) Please take your other medications as prescribed: Ensure that you take amlodipine and HCTZ in the morning, and doxazosin at night. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization. Followup Instructions: ___
19963970-DS-15
19,963,970
23,399,468
DS
15
2168-07-17 00:00:00
2168-07-18 00:07:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: lisinopril Attending: ___. Chief Complaint: Left eye blurriness Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a ___ year-old right-handed man with a history of multiple embolic infarcts and dementia who presents with transient left eye blurriness. The patient is unable to provide much detail about the event and refers frequently to his girlfriend, who is at bedside. Per her report, at approximately 1:30pm he complained to her that the vision in his left eye was blurry and that he saw a shade come down over the top of the vision. The episode seemed to last about ___ hours before resolving. No other symptoms at the time. She called his ___ nurse and later spoke with Dr. ___ outpatient neurologist, who instructed them to come in. He was discharged from the stroke service last month after presenting with left arm tingling. At that time he was switched from aspirin to clopidogrel, which he continues on now. He was thought to have a cardioembolic source as he has had bilateral events, although he has no clear risk factors for this. Recently his blood pressure medicines have been decreased as he was having orthostasis symptoms. On neuro ROS, the pt denies headache, diplopia, dysarthria, dysphagia, lightheadedness, vertigo. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. 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: - Right-sided embolic strokes (___) - history of recurrent stroke/TIA with left arm numbness and weakness as well (___) and left eye amaurosis fugax in ___ - Dementia, perhaps pugilistica, followed by Drs. ___ at ___ and ___ at ___ for this. - Prostate cancer - scheduled for brachytherapy in ___ - Hypertension - Hypercholesterolemia - Clear colonscopy with polyp removed, about ___ years ago Social History: ___ Family History: No family history of cerebrovascular disease, stroke, hemorrhage, seizure, dementia or other neurologic disorders. Physical Exam: ADMISSION EXAMINATION: Vitals: T: 98.4 P: 70 BP: 129/59 --> 160/81 RR: 16 SaO2: 98% RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus, MMM, clear oropharynx Neck: Supple, no nuchal rigidity. Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions Neurologic: ___ Stroke Scale score was: 0 1a. Level of Consciousness: 0 1b. LOC Question: 0 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: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 -Mental Status: Alert, oriented x 3. Attentive, able to name ___ backward without difficulty. Unable to relate history of recent events and asked girlfriend frequently about details. Language is fluent with intact repetition and comprehension. Normal prosody. There were occasional semantic paraphasic errors during naming. Pt. was able to name both high frequency objects but needed prompting for low. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and has symmetric strength. -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 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No dysmetria on FNF or HKS bilaterally. UE RAMs symmetric. -Gait: deferred =========================== DISCHARGE EXAMINATION: GEN: unremarkable MS: Poor memory, recognizes few of the team members but not all. Pleasant, seems to have good long term memory re: his nickname. Speech fluent without no paraphasic errors. Follows midline and appendicular commands. CN: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline and has symmetric strength. -Motor: Normal bulk, tone throughout. No pronator drift but does have some orbiting around left forearm. No adventitious movements. No asterixis. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick. 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 dysmetria on FNF or HKS bilaterally. UE RAMs symmetric. -Gait: deferred Pertinent Results: ADMISSION LABS: ___ 06:38PM BLOOD WBC-9.9 RBC-4.88 Hgb-15.7 Hct-46.0 MCV-94 MCH-32.1* MCHC-34.1 RDW-13.1 Plt ___ ___ 06:38PM BLOOD ___ PTT-32.9 ___ ___ 07:00AM BLOOD Glucose-89 UreaN-13 Creat-0.9 Na-144 K-3.5 Cl-105 HCO3-29 AnGap-14 ___ 06:38PM BLOOD ALT-18 AST-21 AlkPhos-67 TotBili-0.4 ___ 07:00AM BLOOD Calcium-8.4 Phos-3.4 Mg-2.2 CARDIAC ENZYMES: ___ 06:38PM BLOOD cTropnT-<0.01 ___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01 ================== IMAGING: CTA ___ IMPRESSION: 1. No acute intracranial abnormalities. 2. Major intracranial vessels remain patent. No evidence of aneurysm, dissection, or occlusion. Unchanged focal stenosis at the proximal right M1 segment. 3. 22% right and 11% left proximal ICA stenosis by NASCET criteria. Unchanged focal stenosis at the origin of the right vertebral artery. Major cervical vessels remain patent. 4. Dental disease as described above. MRI ___ 1. No acute intracranial abnormalities, including no acute hemorrhage or infarct. 2. Mild global atrophy. Mild-to-moderate medial temporal atrophy. 3. Mild chronic microangiopathy. Brief Hospital Course: Mr. ___ is a ___ yo RH man with history of multiple embolic infarcts and dementia (possibly pugilistica) who presented with left eye blurriness. As patient had multiple events including left amaurosis fugax and right embolic infarcts (___), anticoagulation was increased to coumadin with lovenox bridge. However, after discussion with his PCP, he was changed back to Plavix for several reasons as detailed below. # Neuro: 1. Left eye vision change: history was difficult to obtain, though his girlfriend reported that he described vision change similar to his prior amaurosis fugax. Later on, he was only able to say it was "blurry." Given his history of recurrent strokes, repeat MRI was done and did not show any acute stroke at this time. His neurologic exam continued to be normal throughout his stay, except for very subtle weakness on his left side (had orbiting around left forearm on exam, no pronator drift/detectable weakness). On HD2 he was switched from clopidogrel to warfarin with lovenox bridge given continued events on current regimen. CTA showed stable, mild narrowing of carotid arteries bilaterally (___), stable right vertebral artery narrowing and stable right proximal M1 segment narrowing. On discussion with Dr. ___ PCP, the concern was raised that given his imminent brachytherapy treatment scheduled for his prostate cancer and possible cataract surgery as well, this was not an ideal time to start coumadin. In addition, questions about the ability of his girlfriend to help him successfully comply with medication administration was also raised. As a result, the decision was made to discharge the patient on Plavix and obtain ___ services to help with medication administration at home. Given that he had well controlled risk factors during the last hospitalization, he was continued on home atorvastatin 20mg only. His antihypertensives were held during his stay and he was placed on Hydralazine PRN which he did not require. He was monitored on telemetry throughout his stay which did not reveal atrial fibrillation. 2. Dementia, alzheimer's vs. pugilistica - though he has significant history of boxing, he did present with significant memory problem first and does not show significant rigidity or cogwheeling. Patient with baseline dementia and difficulty with short term memory. He was continued on home Namenda 10mg BID and Seroquel prn for agitation. # CV: HTN MI ruled out with negative CE x2. His antihypertensives were held as above and he was monitored on telemetry. His doxazosin was continued for BPH. # ENDO: He was started on finger sticks QID and insulin sliding scale with a goal of normoglycemia # OPHTHO: On HD3 he was seen by ophthalmology who felt that he had visually significant cataracts and he will need surgery. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Memantine 10 mg PO BID 2. Atorvastatin 20 mg PO DAILY 3. Amlodipine 5 mg PO DAILY 4. Doxazosin 2 mg PO HS 5. Hydrochlorothiazide 25 mg PO DAILY 6. Clopidogrel 75 mg PO DAILY 7. Quetiapine Fumarate 25 mg PO DAILY:PRN agitation Discharge Medications: 1. Atorvastatin 20 mg PO DAILY 2. Clopidogrel 75 mg PO DAILY 3. Doxazosin 2 mg PO HS 4. Memantine 10 mg PO BID 5. Quetiapine Fumarate 25 mg PO DAILY:PRN agitation 6. Amlodipine 5 mg PO DAILY 7. Hydrochlorothiazide 25 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ ___: Primary Diagnosis: left visual obscuration, dementia, possibly pugilistica Secondary Diagnosis: hypertension, hyperlipidemia, recurrent strokes/TIAs, prostate cancer Discharge Condition: Mental Status: Confused - sometimes. Patient is conversant but has memory difficulties. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, you were admitted to the hospital for the left eye blurriness and there was concern that this could be a stroke. You had an MRI of your brain that did not show any new stroke. You also had an evaluation by the ophthamologist (eye doctor) who said you had significant cataracts bilaterally. Please continue taking medications as prescribed. Followup Instructions: ___
19964059-DS-23
19,964,059
23,234,986
DS
23
2188-04-02 00:00:00
2188-04-03 07:06:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of PAF (s/p ablations X2), CAD s/p CABG, HTN who is admitted for syncope. . Patient is independent at baseline with active life-style. Drinks ___ drinks per day at baseline usually beer (11 ounces) X2 + Scotch ___ ounces), today had 1 beer + one scotch. Also took some Zyrtec for a runny nose. Was feeling as his usual state of health this evening around 17:00 when while standing in the kitchen taling to his wife he suddenly lost consciousness, he recalls no preceeding symptoms. He hit the back of his head. Family rushed in attempted CPR but patient woke up during CPR unclear for how long he was out, but not more than a few minutes. EMS arrived and said the patient was perseverating but otherwise alert and oriented. Patient denies incontinence, tongue ___. No limb paralysis noted after episode. He does not however recall episode. He denies any chest pain or shortness of breath prior to the events or currently. He has been having some runny nose and soar throat for the past 2 weeks, but has had no fevers and has otherwise been feeling well. His PCP obtained throat swab which was neg. Did not recieve any Abx. No recent med changes. He has had one prior episode of syncope in his life ___ years ago, was seen in the ___ ED for this and was told it was benign and ___ to dehydration. He currently denies any pain except at the back of his head where he hit his head. Past Medical History: - CAD s/p 2 vessel CABG ___ - Paroxysmal atrial fibrillation s/p ablation ___, recurrence ___, s/p ___ ablations ___ performed at ___ - Hyperlipidemia - Hypertension - BPH s/p transurerthral resection of prostate ___ - GERD - Peripheral neuropathy - B12 deficiency - Osteoporosis - Chronic LBP - Gallstones s/p cholecystectomy - Patient recalls having another abdominal surgery, but does not know what it was Social History: ___ Family History: Non-contributory. No family history of seizures. Physical Exam: ADMISSION: VS - Temp 98.4F, BP 170/79 , HR 65 , R 18, O2-sat 100% RA GENERAL - well-appearing man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, mild erythema and tenderness in right occipital area, small 1mm shiny white round lesion in right pharynx. NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait DISCHARGE: VS T 97.8, BP 148/77, P 63, R 18, 97% on RA GEN Alert, oriented, no acute distress HEENT: Stable contusion over right occipital bone. Swelling is decreased, still tender to palpation. Small, white lesion in oropharynx on right tonsils. Moist mucus membranes. Sclera anicteric. EOMI with no pain, nystagmus, or double vision. NECK: no carotid bruits, supple, no JVD, intact hepatojugular reflex PULM: CTAB with no wheezes, rales, ronchi. CV: Generally RRR, with occasional irregular beats, that may be PACs. Normal S1/S2, no murmurs, rubs or gallops. ABD: Normoactive bowel sounds. Soft, non-distended, non-tender to palpation. No hepatosplenomagly or masses palpable. EXT: No edema. Feet are warm and well perfused with 2+ ___ pulses bilaterally. NEURO: CNs2-12 intact, motor function grossly normal SKIN: Small bruise on left forearm. No rashes or ulcers noted. Pertinent Results: ADMISSION ___ 06:18PM BLOOD WBC-5.7 RBC-3.92* Hgb-12.3* Hct-36.8* MCV-94 MCH-31.5 MCHC-33.6 RDW-13.2 Plt ___ ___ 06:18PM BLOOD Glucose-81 UreaN-20 Creat-1.1 Na-138 K-4.5 Cl-106 HCO3-22 AnGap-15 ___ 06:10AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.0 ___ 06:18PM BLOOD ASA-NEG Ethanol-93* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 06:18PM BLOOD D-Dimer-360 ___ 06:10AM BLOOD ALT-16 AST-15 LD(LDH)-198 AlkPhos-67 TotBili-0.2 ___ 06:18PM BLOOD cTropnT-<0.01 ___ 06:10AM BLOOD CK-MB-2 cTropnT-<0.01 IMAGING CT Head ___: No acute intracranial process. Soft tissue swelling noted overlying the right frontoparietal bones. Ventricles and sulci are prominent, consistent with age-related parenchymal involution. CT Neck ___: No acute fracture or malalignment. Degenerative change with Grade 1 anterolisthesis of C3 on C4. CXR ___: No acute traumatic injury seen. The heart is normal in size. Mediastinal contour is normal. Lungs are clear. No pneumothorax or pleural effusion. Bones appear intact. TELEMETRY ___ OVERNIGHT: ___ episodes of pauses. No discernable heart block. No episodes of bradycardia lasting >3 seconds. DISCHARGE LABS ___ 06:00AM BLOOD WBC-5.8 RBC-4.01* Hgb-12.6* Hct-37.1* MCV-93 MCH-31.4 MCHC-33.9 RDW-13.4 Plt ___ ___ 06:00AM BLOOD Glucose-102* UreaN-24* Creat-1.2 Na-140 K-4.2 Cl-105 HCO3-25 AnGap-14 . ___/ EKG: Baseline artifact. Sinus rhythm with a single atrial premature beat. Low limb lead voltage. Right bundle-branch block. Since the previous tracing of ___ atrial premature beat is new. Differences in the precordial T waves to some degree may be related to lead position. Clinical correlation is suggested. Brief Hospital Course: HOSPITAL COURSE ___ PMH of PAF (s/p ablations X2), CAD s/p CABG, HTN who is admitted for syncope in the context of concomittant use of alcohol and anti-histamine. Previous records from ___ obtained showed a normal cardiac stress test in ___, pumlmonary vein isolation ablation ___ and repeat on ___, and a TEE after his second ablation on that showed no left atrial thrombus and LVEF of 65%. During admission, he had an episode of asymptomatic bradycardia on ___ to the ___ after administration of 100 mg metoprolol succinate ER. The episode resolved without treatment. Overnight on ___ he had two more episodes of brady to ___ however on review of telemetry strips there were skipped atrial beats that showed as a rate in the ___, but no true bradycardia. The pauses between atrial contractions were all less than 2.3 seconds, were not sustained, and were not concerning for heart block. ACTIVE ISSUES # Syncope: Appears to be due to alcohol + antihistamine use. Given his history of atrial fibrillation, there was concern for cardiogenic syncope due to arrhythmia. Nothing to suggest seizure. Reduced Metoprolol XL dosing to 50 BID. ___ records showed no imaging suggestive of embolic or arrhythmic etiology for syncope. Telemetry strips overnight from ___ showed skipped atrial beats reading as rate in the ___, but on review telemetry showed no true bradycardia. The pauses between atrial contractions were all less than 2.3 seconds, were not sustained, and were not concerning for heart block. Can consider carotid duplex to complete syncope workup. . # Head trauma: When syncopal, the patient struck the back of his head. He has a contusion approximately 2 cm in diameter over his right occipital bone that is tender to palpation. He had a CT head that showed no fracture, or acute intracranial process. CT C-spine showed no fractures. . INACTIVE ISSUES . # posterior pharynx lesion: Out patient ENT followup arranged. . # PAfib: maintained sinus in-house. Continued pradaxa + metoprolol. Metoprolol dosing was decreased by ___ to 50mg BID. . # CAD: Continued aspirin, BB, statin . # ETOH: Readressed drinking habit and availability of services for quitting. Pt stated he knew what to do. LFTs normal. No signs of withdrawal during admission. TRANSITIONAL ISSUES # f/u Dr. ___, electrophysiology at ___ # f/u pharyngeal cyst/tonsillith with ENT # consider carotid duplex to complete syncope workup although very low suspicion of embolic phenomena Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Metoprolol Succinate XL 100 mg PO BID hold for SBP < 100 or HR < 55 2. carisoprodol *NF* 250 mg Oral BID:PRN pain 3. Dabigatran Etexilate 150 mg PO BID 4. Lisinopril 20 mg PO DAILY Start: In am hold for SBP < 100 5. Niacin SR 1000 mg PO QHS 6. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain 7. PrimiDONE 50 mg PO HS 8. Rosuvastatin Calcium 10 mg PO DAILY Start: In am 9. Aspirin 81 mg PO DAILY Start: In am 10. Calcium Carbonate 1500 mg PO QDAY 11. Vitamin D 1000 UNIT PO DAILY 12. Cyanocobalamin ___ mcg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Calcium Carbonate 1500 mg PO QDAY 3. carisoprodol *NF* 250 mg Oral BID:PRN pain 4. Cyanocobalamin ___ mcg PO DAILY 5. Dabigatran Etexilate 150 mg PO BID 6. Lisinopril 20 mg PO DAILY hold for SBP < 100 7. Niacin SR 1000 mg PO QHS 8. PrimiDONE 50 mg PO HS 9. Rosuvastatin Calcium 10 mg PO DAILY 10. Vitamin D 1000 UNIT PO DAILY 11. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain 12. 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 Discharge Disposition: Home Discharge Diagnosis: Syncope due to alcohol and cetirazine co-administration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, Thank you for choosing us for your care. You were admitted after you lost consciousness and fell and struck your head. We did a CT scan to make sure there was no trauma to your brain, and it was normal. We currently believe your episode of passing out was due to a combination of alcohol use and use of antihistamines. You had one episode of few seconds of very slow heart rate down to around 30 beats per minute. You did not report symptoms at that time and your rhythm returned to normal shortly afterwards. We have monitored you on telemetry (continuous heart rhythm monitoring) and found no dangerous heart rhythms otherwise. There were a few instances of dropped beats, but you did not have any symptoms, and we have made a follow appointment with your cardiologist to discuss this further. Nonetheless, we decreased your dose of the beta blocker Metoprolol as a precaution. Please continue to take metoprolol at the new dose of Metoprolol XL 50mg twice a day. In the future, there are several classes of medicine that are important for you to use with caution as they may cause you to become sleepy or pass out. In particular they must not be mixed with alcohol. These include anti-allergy medicines (such as Zyrtec, Benadryl and Claritin), anti-cholinergic medicines (Benadryl which as these effects as well, Advil ___ and benzodiazepines (Ativan, Xanax, Klonopin). If you feel that your alcohol use if adversely affecting your life, there are great support systems that can help you reduce your use. Please follow this up with your primary care physician. We have scheduled an appointment with an ENT to evaluated your throat as listed below. We have made the following medication changes during this admission: DECREASE Metoprolol ER 100 mg BID to Metoprolol ER 50 mg BID It was a pleasure taking care of you, and we wish you the best of health. Followup Instructions: ___
19964512-DS-2
19,964,512
24,111,883
DS
2
2167-05-20 00:00:00
2167-05-20 20:32:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: Penicillins / Lipitor / atenolol / doxycycline / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Left leg pain Major Surgical or Invasive Procedure: Open reduction and internal fixation of left tibial ___ History of Present Illness: ___ h/o DM2, HTN, HLD who presents as OSH transfer with closed L tibia fx s/p Segue accident. Patient was on a Segue tour in ___ with his wife earlier today. As he slowed to cross a dirt road the Segue flipped, somehow catching his left leg in one of the wheels. He says the Segue then ran over him 3 times. +HS/-LOC. Taken to local hospital where CT head was negative. X-rays showed tibia fracture and told that he needed an ankle specialist. No orthopedist available, transferred to ___ where x-rays were reviewed, he was again told he needed an ankle specialist but there was none available. Transferred to ___. Past Medical History: Diabetes mellitus type 2 Hypertension Hyperlipidemia Social History: - Occupation: ___ - Assistive device: none - Tobacco: former smoker (quit ___ - Alcohol: 1 drink daily with dinner - Illicits: denies Physical Exam: Exam on Admission: Vitals: AVSS General: NAD, A&Ox3 Psych: appropriate mood and affect Musculoskeletal: Right Lower Extremity: Skin clean - no abrasions, induration, ecchymosis Thigh and leg compartments soft and compressible Fires ___ Sensation intact to light touch sural, saphenous, tibial, superficial and deep peroneal nerve distributions 1+ dorsal pedis and posterior tibial pulses Left Lower extremity Skin clean - no abrasions, induration, ecchymosis, no skin at risk +swelling and tender about the ankle and lower leg Thigh and leg compartments soft and compressible Fires ___ Sensation intact to light touch sural, saphenous, tibial, superficial and deep peroneal nerve distributions 1+ dorsal pedis and posterior tibial pulses Exam on Discharge: General: No acute distress Left lower extremity: Firing ___, FHL in splint Sensation intact SP, DP nerve distribution Warm and well-perfused Pertinent Results: ___ 05:20AM BLOOD WBC-8.0 RBC-4.05* Hgb-12.2* Hct-35.6* MCV-88 MCH-30.2 MCHC-34.4 RDW-13.9 Plt ___ Brief Hospital Course: Mr. ___ presented to the ___ emergency department on ___ and was evaluated by the orthopedic surgery team. The patient was found to have a left distal tibia fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for open reduction and internal fixation of the left distal tibia fracture, which the patient tolerated well (for full details please see the separately dictated operative report). The patient was taken from the OR to the PACU in stable condition and after recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given perioperative antibiotics and anticoagulation per routine. The patients 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 was afebrile with stable vital signs that were within normal limits, pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is touch-down weight-bearing in the left lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up in two weeks per routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course, and all questions were answered prior to discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem Extended-Release 240 mg PO DAILY 2. Vitamin D ___ UNIT PO DAILY 3. olmesartan 40 mg oral daily 4. MetFORMIN (Glucophage) 1000 mg PO BID 5. Enalapril Maleate 20 mg PO BID 6. fenofibrate 135 mg oral daily 7. Methyldopa 500 mg PO Q12H 8. Acetaminophen ___ mg PO Q8H:PRN pain Discharge Medications: 1. Acetaminophen ___ mg PO Q8H:PRN pain 2. Diltiazem Extended-Release 240 mg PO DAILY 3. Enalapril Maleate 20 mg PO BID 4. fenofibrate 135 mg oral daily 5. Methyldopa 500 mg PO Q12H 6. olmesartan 40 mg oral daily 7. Vitamin D ___ UNIT PO DAILY 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Docusate Sodium 100 mg PO BID RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a daily Disp #*60 Tablet Refills:*0 10. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg SC every night Disp #*14 Syringe Refills:*0 11. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain Do not drink alcohol or drive while taking this medication. RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp #*80 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Closed left tibia fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take lovenox 40mg daily for 2 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet ACTIVITY AND WEIGHT BEARING: - Touchdown weight-bearing left lower extremity Followup Instructions: ___
19964656-DS-5
19,964,656
25,807,699
DS
5
2131-02-28 00:00:00
2131-02-28 21:14:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: vertigo Major Surgical or Invasive Procedure: None History of Present Illness: Dr. ___ is a ___ right-handed man with history notable for atrial fibrillation (on apixiban), polycythemia ___ (on hydroxyurea), hypertension, and peripheral neuropathy (ascribed to spinal stenosis) presenting with dizziness. On waking up this morning at 07:00, Dr. ___ a "strong dizziness" upon rising to use the restroom. He describes the sensation as the "room spinning" with a component of disequilibrium but without lightheadedness. He walked to the restroom, leaning on the wall for support along the way, and proceeded to have a normal bowel movement; subsequently, he developed profuse diaphoresis, without lightheadedness, palpitations, or chest discomfort. He was able to rise and return to his bedroom, again relying on the wall for assistance. he notified his son of his symptoms by phone, who activated EMS; no speech changes were noted at that time. Dr. ___ did not notice any headache, vision change, hearing change, focal weakness, or sensory disturbance. He did note nausea and one episode of small-volume emesis. He denies recent neck trauma or manipulation, but does report canoeing vigorously for the first time after a protracted break from the sport last week; he did not notice ensuing neck pain. Past Medical History: Atrial fibrillation (on apixiban) Polycythemia ___ (on hydroxyurea) Hypertension Peripheral neuropathy (ascribed to spinal stenosis) OA Social History: ___ Family History: FAMILY HISTORY: Non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM: PHYSICAL EXAMINATION Vitals: T: 96.8 HR: 67 BP: 168/82 RR: 16 SpO2: 100% RA General: NAD HEENT: NCAT, no oropharyngeal lesions, neck supple ___: irregularly irregular Pulmonary: no tachypnea or increased WOB Abdomen: soft, ND Extremities: warm, no edema Neurologic Examination: - Mental status: Awake, alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Speech is fluent with intact naming, comprehension, and repetition. No dysarthria. Able to follow both midline and appendicular commands. No hemineglect. - Cranial Nerves: PERRL (3 to 2 mm ___. VF full to number counting. EOMI, no nystagmus. Slight ?lid dehiscence OD. No skew deviation. V1-V3 without deficits to light touch bilaterally. No facial movement asymmetry. Hearing intact to conversation. Negative HIT and ___ test. Negative Unterberger within significant gait limitations. Palate elevation symmetric. Trapezius strength ___ bilaterally. Tongue midline. - Motor: Normal bulk. No drift. [Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA] L 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 - Reflexes: [Bic] [Tri] [___] [Quad] [Gastroc] L 0 0 0 0 0 R 1 1 1 0 0 - Sensory: No deficits to light touch or pinprick in proximal extremities. No extinction to DSS. Positive Romberg. - Coordination: Subtle action tremor without dysmetria on finger-to-nose testing bilaterally; no dysmetria on HKS. No dysdiadochokinesia. - Gait: Requires assistance to rise due to severe dizziness, able to maintain weight and take a few steps; wide-based gait. On the floor, able to sit up and stand up with mild dizziness but without assistance. Able to walk improved from ED per patient. Negative romberg, maintained balance with marching in place DISCHARGE PHYSICAL EXAMINATION: Same as above except gait is markedly improved: On the floor, able to sit up and stand up without assitance. Able to walk improved from ED per patient. Negative romberg, maintained balance with marching in place. Pertinent Results: Laboratory Values: ___ 04:15AM BLOOD WBC-12.7* RBC-4.56* Hgb-11.2* Hct-40.3 MCV-88 MCH-24.6* MCHC-27.8* RDW-23.4* RDWSD-74.6* Plt ___ ___ 09:07AM BLOOD WBC-13.4* RBC-4.90 Hgb-11.8* Hct-43.1 MCV-88 MCH-24.1* MCHC-27.4* RDW-23.4* RDWSD-75.4* Plt ___ ___ 09:07AM BLOOD Neuts-92.6* Lymphs-3.0* Monos-2.3* Eos-0.4* Baso-0.8 Im ___ AbsNeut-12.42* AbsLymp-0.40* AbsMono-0.31 AbsEos-0.06 AbsBaso-0.11* ___ 09:07AM BLOOD ___ PTT-30.8 ___ ___ 04:15AM BLOOD Glucose-77 UreaN-22* Creat-1.2 Na-142 K-4.2 Cl-106 HCO3-24 AnGap-12 ___ 09:07AM BLOOD ALT-15 AST-27 AlkPhos-90 Amylase-95 TotBili-0.9 ___ 09:07AM BLOOD Lipase-43 ___ 09:07AM BLOOD cTropnT-<0.01 ___ 09:07AM BLOOD Albumin-4.2 Calcium-9.6 Phos-2.7 Mg-2.0 ___ 04:15AM BLOOD Triglyc-94 HDL-31* CHOL/HD-4.2 LDLcalc-79 IMAGING: CTA head and neck: 1. No evidence of acute intracranial process. 2. Moderate narrowing of the left intracranial vertebral artery. No evidence of carotid or vertebral occlusion or dissection. MRI brain/ MR C-spine: No acute infarct Brief Hospital Course: Dr. ___ is a ___ right-handed man with history notable for atrial fibrillation (on apixiban), polycythemia ___ (on hydroxyurea), hypertension, and peripheral neuropathy (ascribed to spinal stenosis) presenting with vertigo, diaphoresis and gait instability. He was admitted to the stroke team to rule out posterior circulation stroke. #Vertigo: By the time the patient arrived to the floor from the ER his symptoms had largely resolved. He was feeling slightly vertiginous with position changes but was able to ambulate on his own. His BP was not elevated on the floor. He was given IVF. -MRI brain was done and negative for acute infarct -His eliquis/apixaban was continued #Gait Instability: -Patient was very unstable during his acute vertigo spell. After his vertigo subsided he had a slightly wide based gait but was stable. He had evidence of neuropathy with decreased pin prick and dropped reflexes in his ___ which is chronic. MRI Cspine was done and showed significant degenerative changes/ spondylosis without cord compression. We recommended patient to wear soft collar, outpatient ___, and to f/u with his outpatient neurologist Dr. ___. We encouraged the patient to continue all of his home medications including his eliquis and hypertensive medications. _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ ________________________________________________________________ Transitional Issues: 1. Please wear a soft collar nightly 2. Please attend outpatient physical therapy for gait balance training 3. Please follow-up with your outpatient neurologist Dr. ___. We have contacted her office to schedule you for an appointment 4. Please call your PCP office and see them within ___ weeks 5 . Please take all of your medications as prescribed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 2.5 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Hydrochlorothiazide 25 mg PO DAILY 4. Hydroxyurea 500 mg PO BID 5. Lisinopril 10 mg PO DAILY 6. Sildenafil 20 mg PO DAILY:PRN activity Discharge Medications: 1. amLODIPine 2.5 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Hydrochlorothiazide 25 mg PO DAILY 4. Hydroxyurea 500 mg PO BID 5. Lisinopril 10 mg PO DAILY 6. Sildenafil 20 mg PO DAILY:PRN activity Discharge Disposition: Home Discharge Diagnosis: Vertigo Cervical spondylosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at the ___ ___. You came to the hospital because you developed dizziness and inability to walk at home. These symptoms were concerning for a stroke however an MRI of your brain looking for stroke was NEGATIVE. We did find that you have significant arthritis in your neck. We recommend that you continue all of your medications including your eliquis as prescribed. Please do not miss any doses of your medications. Please follow up with your primary care physician ___ ___ weeks. We have contacted your neurologist office with Dr. ___ to set you up with an appointment in the next few months. If you do not hear from them to tell you when your appointment please call her office within 1 week. 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: ___
19964963-DS-12
19,964,963
25,939,306
DS
12
2129-09-26 00:00:00
2129-09-27 18:25:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: doxycycline / Tetanus Vaccines and Toxoid Attending: ___. Chief Complaint: increased bowel frequency, intermittent diarrhea, hematochezia Major Surgical or Invasive Procedure: EGD, colonoscopy ___ History of Present Illness: Ms. ___ is a ___ year old woman with a history of stage ___ lung adenocarcinoma (to lymph nodes) currently on C3 carboplatin/Pemetrexed/Pembrolizumab, presenting with diarrhea and hematochezia. Patient describes 2 weeks of loose stools, occurring ___ times a day, with associated abdominal cramping. It was initially brown but for the past 2 days has been mixed with bright red blood. She presented to ___ clinic on ___ where her outpatient oncologist, Dr. ___ evaluation for suspected pembrolizumab induced colitis. Past Medical History: Metastatic lung cancer (as above) GERD c/b Barrets, Allergic rhinitis OA (low back, R-leg, L hip) Raynaud's disease Social History: ___ Family History: Mother: cancer bladder (age ___, mouth (___) Maternal aunt: cancer unknown type (___) Maternal uncles: ?spinal cancer (___), brain cancer (___) Maternal grandparents: - Father: lung cancer (___, big smoker) Paternal side: lung, bladder Paternal grandparents: - Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: GEN: In NAD. HEENT: PERRL, moist mucous membranes, oropharynx clear without exudates. NECK: No JVD, no cervical lymphadenopathy. CV: RRR, no murmurs/gallops/rubs. PULM: CTAB, no wheezing/crackles/rhonchi. ABD: Soft, non tender, non distended. EXTREM: No ___ edema. Pulses +2 ___P, ___ bilaterally. SKIN: No rashes. NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly intact. DISCHARGE PHYSICAL EXAM: Vitals: 24 HR Data (last updated ___ @ 2328) Temp: 97.3 (Tm 98.1), BP: 127/82 (114-139/75-82), HR: 76 (76-101), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery: RA, Wt: 143.2 lb/64.96 kg GENERAL: pleasant woman sitting in chair, NAD EYES: PERRL, anicteric sclera, EOMI HEENT: OP clear, MMM NECK: Supple, normal range of motion LUNGS: not in respiratory distress, CTAB, no wheezing/crackles/rhonchi CV: RRR, normal S1/S2, no m/r/g ABD: abdomen soft, NT, ND, no organomegaly EXT: No deformity, normal muscle bulk, no edema SKIN: Warm dry, no rash NEURO: Alert and oriented x3, fluent speech ACCESS: Peripheral IV Pertinent Results: ADMISSION LABS: ___ 04:35PM BLOOD WBC-4.7 RBC-3.74* Hgb-11.0* Hct-34.3 MCV-92 MCH-29.4 MCHC-32.1 RDW-18.1* RDWSD-57.1* Plt ___ ___ 04:35PM BLOOD Neuts-32.8* ___ Monos-17.8* Eos-1.3 Baso-0.4 Im ___ AbsNeut-1.53* AbsLymp-2.21 AbsMono-0.83* AbsEos-0.06 AbsBaso-0.02 ___ 04:35PM BLOOD Plt ___ ___ 04:35PM BLOOD Glucose-109* UreaN-10 Creat-0.6 Na-142 K-4.6 Cl-105 HCO3-25 AnGap-12 ___ 04:35PM BLOOD CRP-5.2* DISCHARGE LABS: ___ 06:10AM BLOOD WBC-5.2 RBC-4.12 Hgb-12.2 Hct-38.2 MCV-93 MCH-29.6 MCHC-31.9* RDW-18.1* RDWSD-60.0* Plt ___ ___ 06:45AM BLOOD Neuts-36.4 ___ Monos-16.4* Eos-1.5 Baso-0.8 AbsNeut-1.44* AbsLymp-1.74 AbsMono-0.65 AbsEos-0.06 AbsBaso-0.03 ___ 06:10AM BLOOD Plt ___ ___ 06:10AM BLOOD ___ PTT-33.9 ___ ___ 06:05AM BLOOD Glucose-81 UreaN-6 Creat-0.7 Na-145 K-4.6 Cl-107 HCO3-22 AnGap-16 ___ 06:45AM BLOOD ALT-15 AST-19 AlkPhos-114* TotBili-0.2 ___ 06:05AM BLOOD Calcium-8.9 Phos-4.5 Mg-2.1 IMAGING: CT ABD & PELVIS WITH CO IMPRESSION: 1. No findings of bowel ischemia or colitis. 2. Bilateral heterogeneously enhancing adrenal nodules for which nonemergent follow-up imaging can be obtained, if not previously characterized. MICRO: ___ 2:50 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. ___ 10:02 am 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. FEW POLYMORPHONUCLEAR LEUKOCYTES. FEW RBC'S. 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. Brief Hospital Course: ___ with metastatic lung adenocarcinoma (s/p VATS w/ left lower lobectomy ___, s/p 3 cycles Carboplatin, Pemetrexed and Pembrolizumab) presented with increased bowel frequency, intermittent diarrhea, hematochezia c/f checkpoint inhibitor colitis. TRANSITIONAL ISSUES ==================== [] Started on budesonide 9 mg pending final path from her colonoscopy biopsies. If checkpoint inhibitor colitis is the diagnosis, recommend consulting with GI final treatment recs. [] On CT A/P, bilateral heterogeneously enhancing adrenal nodules for which nonemergent follow-up imaging can be obtained, if not previously characterized. ACUTE ISSUES ============= #Diarrhea, hematochezia Patient presented with subacute loose stools with new small volume hematochezia with clots. Her labwork was unremarkable, her stool studies including C. diff were normal. She had a CT A/P that didn't identify any pathology. She was evaluated by GI who recommended EGD and colonoscopy evaluation on ___, which found congestion, decreased vascularity, edema, erythema, and exudate in the distal sigmoid colon and rectum. She was started on budesonide on discharge pending the final biopsy path. CHRONIC ISSUES ================ #Metastatic Lung Adenocarcinoma (s/p VATS w/ left lower lobectomy ___, s/p 3 cycles Carboplatin, Pemetrexed and Pembrolizumab) Her next cycle of chemotherapy was postponed ___ hospitalization, will be resumed as an outpatient. #Chronic Neoplasm Pain Continued home amitriptyline, gabapentin, tramadol #HCP/Contact: Husband ___ is her HCP ___ but is chronically ill so her secondary is daughter ___ ___ #Code: Full presumed Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amitriptyline 10 mg PO QHS 2. Dexamethasone 8 mg PO ASDIR 3. Fluticasone Propionate NASAL 1 SPRY NU DAILY 4. FoLIC Acid 1 mg PO DAILY 5. Gabapentin 600 mg PO TID 6. Omeprazole 20 mg PO DAILY 7. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 8. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second Line 9. TraMADol 100 mg PO Q4H:PRN Pain - Moderate 10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever Discharge Medications: 1. Budesonide 9 mg PO DAILY RX *budesonide 3 mg 3 capsule(s) by mouth Every morning Disp #*24 Capsule Refills:*1 2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 3. Amitriptyline 10 mg PO QHS 4. Dexamethasone 8 mg PO ASDIR 5. Fluticasone Propionate NASAL 1 SPRY NU DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 600 mg PO TID 8. Omeprazole 20 mg PO DAILY 9. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line 10. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second Line 11. TraMADol 100 mg PO Q4H:PRN Pain - Moderate Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Inflammatory colitis SECONDARY DIAGNOSIS ==================== Lung adenocarcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, You came to the hospital because you were having diarrhea with blood in it. WHAT HAPPENED IN THE HOSPITAL? You were monitored with a clear diet and had labwork that showed you weren't losing blood. You had a colonoscopy with the GI doctors that showed ___ of inflammation in your rectum. WHAT ARE THE NEXT STEPS? - You will start taking a new medication, budesonide, which may help with your diarrhea. - Please follow up with Dr. ___ in clinic ___ was a pleasure taking care of you! Your ___ Care Team Followup Instructions: ___
19964998-DS-3
19,964,998
21,387,214
DS
3
2130-04-10 00:00:00
2130-04-10 17:04:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: aspirin / caffeine Attending: ___. Chief Complaint: Abdominal Pain, Nausea/Vomiting Major Surgical or Invasive Procedure: C1D1 ___ ___ History of Present Illness: Mr. ___ is an ___ male with history of metastatic neuroendocrine tumor of the pancreas with liver metastases on Sandostatin who presents from ___ with abdominal pain and nausea/vomiting found to have bowel obstruction. Patient reports developing RUQ abdominal pain about a week ago, where it began relatively mild and has not radiated anywhere. At about 4AM on ___ morning the pain increased in severity to ___ and was very sharp. He then vomited brown liquid. The pain is worse with movement. He has had a total of 3 episodes of non-bloody brown material. Since then he has lost his appetite and has not eaten. He continues to have regular BMs and to pass gas. He denies BRBPR and melena. He denies any fevers or chills. He has never had pain like this before. He initially presented to ___. Vitals were Temp 98.2, BP 114/80, HR 88, RR 20, O2 sat 97% RA. Labs were notable for WBC 3.3, H/H 12.9/37.8, Plt 263, Na 130, BUN/Cr ___, lipase 14, and negative UA. Blood cultures were drawn. CT abdomen showed interval worsening metastatic disease with large pancreatic mass with new extent to the left splenic flexure with associated dilatation of the descending and transverse colon as well as the terminal ilium, likely representing partial obstruction. Patient was evaluated by Surgery who recommended transfer to ___ for possible subtotal colectomy with end ileostomy versus palliative stent. Patient was given morphine 5mg IV x 2, Zofran 4mg IV x 2, and 1L NS. On arrival to the ED, initial vitals were 98.0 96 125/70 16 96% RA. Labs were notable for WBC 3.6, H/H 12.7/37.4, Plt 260, Na 132, BUN/Cr ___, LFTs wnl, and lactate 1.3. Patient was given morphine 4mg IV, reglan 10mg IV, and 1L NS. Surgery was consulted and recommended NG tube, IVF, and no role for surgical intervention. NG tube was placed in the ED. Prior to transfer vitals were 98.0 84 133/80 20 95% RA. On arrival to the floor, patient reports generalized weakness. The abdominal pain and nausea has improved. He denies fevers/chills, night sweats, headache, vision changes, dizziness/lightheadedness, shortness of breath, cough, hemoptysis, chest pain, palpitations, diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria, and new rashes. Past Medical History: PAST ONCOLOGIC HISTORY: He states that due to his asthma he recently had a chest CT. This incidentally revealed a mass in the pancreas, as well as multiple lesions within the liver. He had a subsequent CT of the abdomen and pelvis completed on ___, which revealed an 8 x 5 x 4.7 x 3.1 cm mass occupying the body and tail of the pancreas, with occlusion of the SMV, with extension to the portal vein. There were innumerable lesions seen in the liver, which were radiographically consistent with metastasis. He was seen at ___ in ___ and a biopsy was recommended. He elected to have additional oncologic care closer to his home. A liver biopsy was arranged and completed on ___. This revealed neuroendocrine tumor of the pancreas. He had an octreotide scan which showed large ill-defined octreoscan avid pancreatic tail mass and numerous avid hepatic metastasis. He was started on Sandostatin. PAST MEDICAL HISTORY: - Well-differentiated neuroendocrine tumor of the pancreas with liver metastases. - Type II Diabetes - Glaucoma - Asthma - Arthritis - Hypertension - BPH s/p TURP - s/p open cholecystectomy done in ___ Social History: ___ Family History: The patient's mother died in her ___. His father died in his ___ with cirrhosis. He has one sister alive with glaucoma and asthma. Physical Exam: ADMISSION PHYSICAL EXAM ======================= VS: Temp 98.0, BP 144/64, HR 96, RR 20, O2 sat 93% RA. GENERAL: Pleasant man, in no distress, lying in bed comfortably. HEENT: Anicteric, PERLL, OP clear. NG tube in place draining brown liquid. 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, diffusely tender to palpation worse in the RUQ without rebound or guarding, mildly distended, diminished bowel sounds. EXT: Warm, well perfused, no lower extremity edema, erythema or tenderness. NEURO: A&Ox3, good attention and linear thought, CN II-XII intact. Strength full throughout. Sensation to light touch intact. SKIN: No significant rashes. DISCHARGE PHYSICAL EXAM ======================= 97.6 112 / 71 95 18 90 Ra Weight 78.84 kg GENERAL: Pleasant, lying in bed HEENT: Anicteric, EOMI, NG in place CARDIAC: RRR, normal s1/s2, no m/r/g. LUNG: CTAB, no r/r/wh. ABD: Soft, nontender, distended. NEURO: A&Ox3, CN II-XII grossly intact. SKIN: No significant rashes. Pertinent Results: ADMISSION LABS ============== ___ 08:11PM BLOOD WBC-3.6* RBC-3.96* Hgb-12.7* Hct-37.4* MCV-94 MCH-32.1* MCHC-34.0 RDW-14.8 RDWSD-51.8* Plt ___ ___ 08:11PM BLOOD Neuts-33* Bands-43* Lymphs-11* Monos-13 Eos-0 Baso-0 ___ Myelos-0 AbsNeut-2.74 AbsLymp-0.40* AbsMono-0.47 AbsEos-0.00* AbsBaso-0.00* ___ 08:11PM BLOOD ___ PTT-25.5 ___ ___ 08:11PM BLOOD Glucose-147* UreaN-15 Creat-0.7 Na-132* K-4.2 Cl-98 HCO3-19* AnGap-19 ___ 08:11PM BLOOD ALT-29 AST-24 AlkPhos-215* TotBili-0.6 ___ 08:11PM BLOOD Lipase-8 ___ 08:11PM BLOOD Albumin-3.3* Calcium-9.4 Phos-3.0 Mg-1.8 ___ 08:20PM BLOOD Lactate-1.3 MICROBIOLOGY ============ __________________________________________________________ ___ 6:50 pm BLOOD CULTURE **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 5:30 pm URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. __________________________________________________________ ___ 5:05 pm BLOOD CULTURE 1 OF 2. **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. __________________________________________________________ ___ 2:57 am URINE Source: ___. **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ BLOOD CULTURE No growth ___ URINE URINE CULTURE < 10,000 CFU/mL. ___ BLOOD CULTURE No growth ___ URINE URINE CULTURE MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ___ BLOOD CULTURE No growth ___ BLOOD CULTURE No growth IMAGING ======= ___ CT Abd/Pelvis with Contrast 1. Large mass replacing the body and tail of the pancreas demonstrates new hypoattenuation, consistent with tumor necrosis. 2. Intravascular tumor within the proximal portion of the main portal vein and superior aspect of the SMV also demonstrates new hypodensity but not significantly changed in size. Stable thrombosis of the splenic vein. 3. Innumerable hepatic metastases are not significantly changed in size. Several lesions demonstrate new hypodensity, consistent with necrosis. 4. No evidence of bowel obstruction. 5. Moderate volume ascites. 6. Please refer to separate report of CT chest performed the same day for description of the thoracic findings. ___ CT Chest with Contrast 1. Small to moderate simple bilateral pleural effusions with compressive atelectasis. 2. No evidence of pneumonia ___ Portable Abdomen Nonobstructive bowel gas pattern. Decreased distention of the small bowel and increased gas in the colon compared to ___. ___ Imaging CHEST (PORTABLE AP) The tip of the nasogastric tube projects over the stomach. ___ Imaging CHEST (PORTABLE AP) In comparison with the study of ___, the nasogastric tube is difficult to see beyond the mid stomach. An abdomen study could be obtained if the precise position of the tube is of clinical importance. Bibasilar opacifications again could merely reflect atelectasis and small pleural effusions. However, in the appropriate clinical setting, more coalescent opacification at the left base would be worrisome for aspiration/pneumonia. ___ Portable Abdomen Improved colonic distension compared to CT dated ___. Nonobstructive bowel gas pattern. ___ Imaging CHEST (PORTABLE AP) Enteric tube is coiled within esophageal hiatal hernia or near GE junction, should be advanced. Dilated proximal upper abdominal bowel loops, partially seen. Bibasilar opacities, may represent atelectasis or pneumonia/aspiration. Trace right pleural effusion is likely. DISCHARGE LABS ============= ___ 07:40AM BLOOD WBC-30.9* RBC-3.71* Hgb-11.7* Hct-34.8* MCV-94 MCH-31.5 MCHC-33.6 RDW-15.5 RDWSD-51.3* Plt ___ ___ 07:40AM BLOOD Neuts-75* Bands-7* Lymphs-6* Monos-4* Eos-0 Baso-0 ___ Metas-6* Myelos-2* AbsNeut-25.34* AbsLymp-1.85 AbsMono-1.24* AbsEos-0.00* AbsBaso-0.00* ___ 07:40AM BLOOD Glucose-135* UreaN-18 Creat-0.9 Na-135 K-4.3 Cl-102 HCO3-23 AnGap-14 ___ 07:40AM BLOOD Calcium-8.4 Phos-3.1 Mg-2.3 ___ 07:50AM BLOOD ALT-25 AST-54* LD(LDH)-432* AlkPhos-268* TotBili-0.4 Brief Hospital Course: Mr. ___ is an ___ male with history of metastatic neuroendocrine tumor of the pancreas with liver metastases on Sandostatin who presents from ___ with abdominal pain and nausea/vomiting found to have bowel obstruction. Bowel obstruction did not resolve with conservative measures, and patient ultimately opted for treatment with chemotherapy. Received C1 of ___ while hospitalized on ___. Bowel obstruction resolved prior to discharge with patient tolerating a regular diet. # Malignant Bowel Obstruction: # Abdominal Pain: # Nausea/Vomiting: Patient presented with symptoms and imaging consistent with large and small bowel obstruction. Likely secondary to progression of malignancy causing multiple areas of bowel obstruction. No role for surgical intervention. Patient was managed conservatively with bowel rest, IVF, and NG tube to suction. Pain control with IV morphine prn, and Zofran prn for nausea. Patient was also treated with octreotide 200mg SC TID for both SBO and also for episodic carcinoid syndrome (hot flashes, flushing). Surgical consult noted that patient would be a candidate for venting G-tube, if within goals of care. Patient ultimately elected to trial chemotherapy in the hopes that the obstruction would resolve. Patient received C1D1 carboplatin/etoposide on ___. Small bowel obstruction resolved following chemotherapy, and with conservative management with NGT. NGT was pulled, and patient was able to tolerate a regular diet by the time of discharge. He is being discharged on aggressive bowel regimen with docusate, senna, and miralax, and ondansetron prn for nausea. Octreotide was discontinued with resolution of SBO and carcinoid syndrome. # Metastatic Neuroendocrine Tumor of the Pancreas: Metastatic to liver. Patient previously receiving Sandostatin at ___. Patient had started Sutent on the week prior to admission, but discontinued after one day due to fatigue. Imaging demonstrated progression of metastatic disease. Ki-67(MIB-1) (on biopsy from ___ demonstrates an increased proliferative index of ~20%. In consultation with outpatient oncologist, patient was started on ___ ___, with resolution of small bowel obstruction as above. Patient's WBC started to nadir on ___ and he was started on daily neupogen and ciprofloxacin prophylaxis. Counts recovered to 4.7 and neupogen was discontinued (last dose ___. Leukocytosis developed following neupogen d/c, as described below. Patient will need C2D1 carboplatin/etoposide ___. Of note, patient had received depot injection of sandostatin on ___, and as above, short course of received octreotide 200mg TID for episode of carcinoid and small bowel obstruction. Patient may resume depot injections of octreotide with chemotherapy per outpatient oncologist. #Leukocytosis: After receiving neupogen, pt developed a new leukocytosis to 15.9. This continued to rise to a maximum of 30 on d/c. This was most likely ___ filgrastrim. CT Chest/Abd/Pelvis showed no PNA or acute abd/pelvis findings and cx data was negative (two cultures still pending at d/c). # Hypervolemia. Dry weight: 70.31kg. Patient became hypervolemic during hospitalization, likely secondary to IVF given with chemotherapy and in the setting of being NPO during small bowel obstruction. He was diuresed with boluses of IV lasix, with improvement in volume status. Weight 78.8 kg at d/c, Cr 0.9 at d/c # SVT: Patient went into periods of HR with 140's with an SVT in setting of SBO. This resolved with initiation of 25 mg metoprolol succinate. RESOLVED ISSUES # C/f Urinary Tract Infection: Resolved. Patient experienced dysuria on ___ and had urinalysis with 69 WBC, although negative nitrites and leukesterase. Patient was started on IV ceftriaxone (___) and then switched to cefepime (___) to replace the cipro BID ppx for neutropenia. He completed a five day course. # Hypoxia: Pt became hypoxic overnight ___, likely ___ atelectasis in setting of distended abdomen. There was also likely a component of hypervolemia, given patient received large amount of IVF with IV abx. CT chest on ___ was unremarkable. He improved with IV lasix and was weaned back to RA from a brief initial O2 requirement of 5 L. #Neutropenia/thrombocytopenia s/p etoposide/carboplatin ___: Resolved. Platelet nadir was 20, nadir ANC 40. His cipro BID ppx was switched to cefepime for the UTI as above. He will need neulasta with next chemo. # Hyponatremia. Resolved. Likely hypovolemic due to poor PO intake. Resolved with IVF. # Asthma. Advair prescribed in hospital due to formulary interchange for home Symbicort. Symbicort resumed for discharge. # Glaucoma. Continued home eye drops. TRANSITIONAL ISSUES: ===================== - Discharge weight: 78.8 kg Discharge Cr: 0.9 - Patient discharged on aggressive bowel regimen with docusate, senna, and miralax, and ondansetron prn for nausea (last small bowel movement ___ - Patient started on C1D1 carboplatin/etoposide ___. He is scheduled for C2D1 on ___ with Dr. ___. Consider giving concurrent somatostatin depot injecxtion as well -Will need neulasta with next chemo, given neutropenia and thrombocytopenia this admission -Consider dcing metoprolol; this was started in relation to SBO induced SVT; patient SR on discharge and normotensive -Patient home metformin and insulin dced due to blood sugars largely being wnl in house -Patient with reactive leukoctyolsis on discharge due to filgrastim injections. Patient had scans and infectious workup that was negative prior to D/C. D.C WBC 30. Expected to plateau before WBC of 40. Please check next CBC on ___. Please check next Chem-10 on ___. -Patient dced with 5 mg oxycodone standing and prn order. Due to ongoing constipation consider dcing standing order if patient amenable. # CODE: DNR/DNI # EMERGENCY CONTACT HCP: ___ (niece) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY 2. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 4. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 5. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Chloraseptic Throat Spray 1 SPRY PO Q6H:PRN sore throat 2. Docusate Sodium 100 mg PO BID 3. Heparin 5000 UNIT SC BID 4. Maalox/Diphenhydramine/Lidocaine 30 mL PO QID:PRN heartburn 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Ondansetron 8 mg PO Q8H:PRN nausea 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 5 mg ___ capsule(s) by mouth As needed for breakthrough pain Disp #*6 Capsule Refills:*0 8. OxyCODONE (Immediate Release) 5 mg PO BID RX *oxycodone 5 mg 1 capsule(s) by mouth Twice a day Disp #*6 Capsule Refills:*0 9. Polyethylene Glycol 17 g PO DAILY:PRN constipation 10. Prochlorperazine 10 mg PO Q6H:PRN nausea and vomiting 11. Senna 8.6 mg PO BID 12. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE BID 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 14. Multivitamins 1 TAB PO DAILY 15. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: malignant bowel obstruction Secondary Diagnoses: Metastatic Neuroendocrine Tumor of the Pancreas hyponatremia asthma 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! You were admitted to ___ ___ because you were nauseated and vomiting. While you were here, we found that your intestines were blocked up, which we believe was caused by the cancer cells in your abdomen. We started you on treatment for your cancer, and you were feeling better by the time you were discharged. We have scheduled outpatient oncology follow-up for you. It was a pleasure caring for you! Your ___ Care Team Followup Instructions: ___
19965408-DS-7
19,965,408
21,767,071
DS
7
2132-07-24 00:00:00
2132-07-25 08:43:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: syncopal episode and left nasolabial fold flattening Major Surgical or Invasive Procedure: None History of Present Illness: Historical info obtained from patient. Pt is a ___ yr F w/ hx of anxiety and early Alzheimer's Dementia who presented to hospital due to presyncopal event while at home this morning. Per pt and husband at bedside, she had been fasting for religious purposes and began to feel lightheaded while walking in her home. She called out to her husband who came to her and grabbed her as she fell. She sustained no head trauma and her dizziness slowly improved. She denies any preceding headache, chest pain, palpitations or other presyncopal symptoms and had no LOC. No immediate sequelae to event. She was brought to ___ by husband. While in ___, she was noted to have new L sided facial droop and Code Stroke was called. Of note, upon evaluation, pt's husband reported that he wasn't sure if facial droop had been a chronic issue and recalls that pt had sustained head trauma 1.5 weeks ago when falling out of bed with no neurologic complications at that time. Past Medical History: Anxiety Alzheimer's Dementia Iron deficiency Social History: ___ Family History: Family Hx: Father-CHF ___ Dementia Physical Exam: ADMISSION PHYSICAL EXAM: Physical Exam: Vitals: T: 98.7 P: 82 R: 14 BP: 139/74 SaO2: 100% RA General: Awake, cooperative, NAD. Elderly Caucasian female. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to person, place, and month and year. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. Pt was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: Mild L facial droop, L NLFF. 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 ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, vibratory sense, proprioception throughout. -DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -Gait: Deferred. DISCHARGE PHYSICAL EXAM: Vitals: T current 97.9, BP 130-151/72-85. HR: 70-89. RR: 16. 02% 94-95% on RA. Gen: Lying in bed, NAD. HEENT: L nasolabial fold elevation Pulm: Breathing comfortably on room air Extremities: WWP, no edema NEUROLOGICAL EXAM: MSE: Alert, oriented to place and self. CN: EOMI, face activates symmetrically, tongue midline, very mild droop on noted on left side at rest, intact hearing, sensation. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FE IP Quad ___ ___ ___ L 5 ___ ___ 5 5 4 R 5 ___ ___ 5 5 4 Reflexes: Negative Babinski, bilaterally Sensory: Intact bilaterally to light touch and temperature Pertinent Results: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 04:19AM 4.3 3.94 11.5 35.8 91 29.2 32.1 12.6 41.5 167 Import Result ___ 11:40AM 4.5 4.05 12.0 37.3 92 29.6 32.2 12.6 42.5 171 Import Result DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im ___ AbsLymp AbsMono AbsEos AbsBaso ___ 04:19AM 74.8* 17.4* 7.3 0.0* 0.0 0.5 3.18 0.74* 0.31 0.00* 0.00* Import Result BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___ ___ 04:19AM 167 Import Result ___ 04:19AM 11.9 26.6 1.1 Import Result ___ 11:40AM 171 Import Result ___ 11:40AM 11.5 22.3* 1.1 Import Result Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 04:19AM 108* 18 0.8 141 3.8 102 31 12 Import Result ___ 11:48AM 1.1 Import Result ___ 11:40AM 148* 20 1.0 139 4.5 98 26 20 Import Result ESTIMATED GFR (MDRD CALCULATION) estGFR ___ 11:48AM Using this Import Result ___ 11:40AM Using this Import Result ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili ___ 04:19AM 15 17 202 69 0.4 Import Result ___ 11:40AM 18 25 74 0.3 Import Result CPK ISOENZYMES cTropnT ___ 04:19AM <0.01 Import Result CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron Cholest ___ 04:19AM 4.2 195 Import Result ___ 11:40AM 4.6 Import Result DIABETES MONITORING %HbA1c eAG ___ 04:19AM 5.8 120 Import Result LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc LDLmeas ___ 04:19AM 53 86 2.3 98 104 Import Result PITUITARY TSH ___ 04:19AM 1.9 Import Result LAB USE ONLY LtGrnHD ___ 11:40AM HOLD Import Result LAB USE ONLY ___ 04:19AM Import Result ___ 11:40AM Import Result Blood Gas WHOLE BLOOD, MISCELLANEOUS CHEMISTRY Glucose Na K Cl calHCO3 ___ 11:46AM 136* 141 4.4 98 32* Import Result HEAD CT NON CONTRAST: 1. No hemorrhage or evidence of acute infarct. Please note that MR is more sensitive for the detection of early stroke. HEAD MRA/MRI NON CONTRAST: 1. Global atrophy, chronic small vessel ischemic change, and chronic cerebellar infarcts. No acute infarction. 2. Susceptibility changes in the basal ganglia and may represent changes due to mineralization. No intra or extra-axial hemorrhage otherwise. 3. Unremarkable brain MRA. 4. Unremarkable neck MRA. Brief Hospital Course: Ms. ___ is an ___ who presented to the ___ Emergency Department on ___ after a syncopal episode at home. Patient was fasting for religious holidays, and started to feel lightheaded while walking around. She shouted to her husband, and when he got to her she fainted in his arms. She sustained no head trauma, and denies any headache, chest pain, palpitations, or LOC. A code stroke was called in the ___ due to a reported L sided facial droop. Husband was not sure if it was chronic or not, but he reported that the patient had head trauma about 1.5 weeks prior when she feel out of bed. Other than this finding, the physical exam was notable for normal mental status, cranial nerves, motor exam, reflexes, sensation and coordination. A ___ showed no abnormal findings. Patient was admitted to the stroke service and placed on stroke precautions. MI was ruled out with CEs. She was made NPO prior to passing bedside swallow evaluation, and then progressed to Kosher Diet. Patient was also resuscitated with IV fluids, started on ASA 81mg, HbA1c drawn, ___ consulted, and continued on home medications. MRI/MRA was unremarkable, revealing global atrophy with chronic small vessel ischemic changes, as well as chronic cerebellar infarcts but no acute findings. Patient was kept overnight, and reevaluated the next morning. At this time, she was not having any residual symptoms and her husband felt that she was at her baseline. She was advised to drink water if she continues to fast in order to avoid future recurrences. Patient will be discharged home with home ___ Transitions of Care Issues: 1. Echocardiogram: Ordered for outpatient. Please call ___ to schedule this test. 2. Follow up with Stroke Service on ___. 3. Please start taking aspirin 81mg daily. Follow up with primary care provider. 4. Follow up lipid panel results and start statin if necessary. 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 = ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if LDL >100, reason not given: ] 6. Smoking cessation counseling given? () Yes - (x) No [reason (x) non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given (verbally or written)? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No 9. Discharged on statin therapy? () Yes - (x) No [if LDL >100, reason not given: ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - () No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - (x) N/A *Patient did not have acute stroke but a code stroke was activated on admission due to chronic left facial droop. Medications on Admission: Effexor XR 150mg, 1 capsule daily Donepezil 5mg, 1 tablet daily QHS Brimonidine 0.2%, 1 drop both eyes BID Latanoprost 0.005%, 1 drop both eyes daily Discharge Medications: Effexor XR 150mg, 1 capsule daily Donepezil 5mg, 1 tablet daily QHS Brimonidine 0.2%, 1 drop both eyes BID Latanoprost 0.005%, 1 drop both eyes daily Aspirin 81mg, daily Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Vasovagal syncope Discharge Condition: Stable condition MS: Intact to person, orientation. Difficulty with ADL's. Ambulatory status with assistance and walker. Discharge Instructions: Dear Ms. ___, You were hospitalized due to symptoms of fainting that occurred after you were fasting with little water intake. You also were noted to have a left facial droop and a stroke code was activated however no stroke was seen on evaluation or brain MRI. Likely you fainted form vasovagal syncope, which means you were dehydrated. We are changing your medications as follows: Start taking aspirin 81mg 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 Followup Instructions: ___
19965408-DS-9
19,965,408
23,688,028
DS
9
2134-03-25 00:00:00
2134-04-16 17:40:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: L wrist pain Major Surgical or Invasive Procedure: I&D, ORIF L distal radius fracture History of Present Illness: ___ RHD w/ Alzheimer's Dementia presents to ___ ED with L wrist pain s/p mechanical fall at 7:30 pm after tripping while walking up stone steps. No HS or LOC. Mechanical fall. Noted immediate pain, deformity, swelling, and deep laceration with ?visible bone. Denies numbness, tingling, weakness distally. States otherwise has been healthy with no recent fevers/chills. When arrived in ED, patient reported up to date on Tdap, and received abx per ED. Denies other injuries. Past Medical History: Past Medical History: Anxiety Alzheimer's Dementia Past Surgical History: BSO Social History: ___ Family History: Family Hx: Father-CHF ___ Dementia Physical Exam: Gen: healthy appearing female in NAD LUE: splint in place fires EPL/FPL/DIO fingers warm and well perfused Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have an open L distal radius fx and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for I&D, ORIF L distal radius fx, 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 SNF 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 nonweight bearing in the left upper extremity, and will be discharged on no medication 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 DAILY 2. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN pain RX *oxycodone 5 mg ___ tablet(s) by mouth every three to six hours Disp #*20 Tablet Refills:*0 3. Senna 17.2 mg PO HS RX *sennosides 8.6 mg 1 tablet by mouth nightly Disp #*20 Tablet Refills:*0 4. Aspirin 81 mg PO DAILY 5. Donepezil 10 mg PO QHS 6. QUEtiapine Fumarate 75 mg PO QHS 7. Venlafaxine XR 150 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: open L distal radius fx Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - non weight bearing left upper extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - none needed WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - Splint must be left on until follow up appointment unless otherwise instructed - Do NOT get splint wet 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 FOLLOW UP: Please follow up with your Orthopaedic Surgeon, Dr. ___. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: non weight bearing left upper extremity ok for platform bearing walker 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: ___
19965802-DS-4
19,965,802
28,373,590
DS
4
2122-02-05 00:00:00
2122-02-05 11:48:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Codeine / Levaquin / Accupril / lidocaine Attending: ___. Chief Complaint: Nausea, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ F w/ extensive ICU course following ex-lap/repair of parastomal hernia, now returns w/ ~24 hrs nausea/vomiting. The patient was recently discharged to rehab, and was noted to have decreasing urostomy output starting yesterday. She felt as though she became more distended, and was nauseated & vomiting. An NGT was placed at rehab w/ ~1 L of bilious output. She also underwent CT of her abdomen and pelvis that demonstrated a loop of bowel contained in her parastomal hernia as well as proximal dilitation and distal decompression of her small bowel. She has not been febrile, and her abdominal pain has been crampy and intermittent. Past Medical History: PMH: Transitional cell bladder Ca, GERD, DM, CAD (not stented), HTN, parastomal hernia, L ureteral stricture with chronic stent changed Q3mos PSH: ex lap/ repair of parastomal hernia ___, laparoscopic CCY, hysterectomy, umbilical hernia repair, radical cystectomy/ileal conduit with urostomy ___ Social History: ___ Family History: Non-contributory Physical Exam: On admission: GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: Soft. Minimally distended. Tender in bilateral lower quadrants with no guarding or rebound. Parastomal hernia is easily reducible at bedside. Wound: Multiple areas of wound breakdown, no evid of acute infection Ext: No ___ edema, ___ warm and well perfused On discharge: VS: GEN: CV: PULM: ABD: EXT: Pertinent Results: ___: ABDOMEN (SUPINE & ERECT): IMPRESSION: Nonobstructive bowel gas pattern that is not significantly changed from previous study. ___: chest x-ray: A horizontal interface just above the right hemidiaphragm has been visible intermittently over the past several weeks. Viewed in coordination with the abdomen CT on ___ I think this is a small-to-moderate right pleural effusion and the lung is largely clear aside from associated atelectasis. Left lung is entirely clear. The heart is mildly enlarged, a chronic finding. Upper mediastinum is widened by tortuous head and neck vessels displacing the trachea slightly to the left. Dual-channel catheter ends in the right heart. No pneumothorax. ___ 05:25AM BLOOD WBC-10.7 RBC-2.86* Hgb-8.8* Hct-26.5* MCV-93 MCH-30.9 MCHC-33.4 RDW-16.7* Plt ___ ___ 08:04AM BLOOD WBC-12.6* RBC-2.90* Hgb-8.9* Hct-26.5* MCV-91 MCH-30.6 MCHC-33.5 RDW-17.0* Plt ___ ___ 11:00AM BLOOD WBC-14.9* RBC-3.04* Hgb-9.3* Hct-27.4* MCV-90 MCH-30.6 MCHC-34.0 RDW-16.5* Plt ___ ___ 10:15PM BLOOD WBC-11.5*# RBC-3.15* Hgb-9.5* Hct-28.5* MCV-91 MCH-30.2 MCHC-33.3 RDW-16.4* Plt ___ ___ 10:15PM BLOOD Neuts-77* Bands-0 Lymphs-11* Monos-6 Eos-2 Baso-0 ___ Myelos-4* ___ 05:25AM BLOOD Plt ___ ___ 10:15PM BLOOD ___ PTT-26.5 ___ ___ 05:25AM BLOOD Glucose-95 UreaN-21* Creat-2.7*# Na-141 K-3.8 Cl-102 HCO3-32 AnGap-11 ___ 08:04AM BLOOD Glucose-90 UreaN-38* Creat-4.4* Na-139 K-4.0 Cl-99 HCO3-28 AnGap-16 ___ 10:15PM BLOOD Glucose-97 UreaN-32* Creat-4.0* Na-140 K-4.3 Cl-99 HCO3-27 AnGap-18 ___ 05:30AM BLOOD CK(CPK)-39 ___ 10:20PM BLOOD CK(CPK)-40 ___ 05:30AM BLOOD CK-MB-6 ___ 11:50AM BLOOD CK-MB-6 cTropnT-0.24* ___ 04:24AM BLOOD CK-MB-6 cTropnT-0.21* ___ 10:15PM BLOOD cTropnT-0.21* ___ 05:25AM BLOOD Calcium-8.2* Phos-3.1# Mg-1.8 ___ 10:25PM BLOOD Lactate-0.9 Brief Hospital Course: Ms. ___ developed abdominal pain, distension and vomiting at her rehabilitation facility on ___. A CT scan done showed parastomal hernia and small bowel obstruction, therefore, an NG tube was placed with 1 liter immediate drainage with improvement in patients symptoms. She was then transferred to the ___ Emergency Department where intravenous pain medication was administered and she was admitted to the Acute Care Surgical service for further observation. NEURO: The patient remained alert and oriented throughout her admission. Pain was well controlled throughout the admission with oral acetaminophen and tramadol prn. CV: The patient remained in atrial fibrillation with intermittent RVR. The patient continued on digoxin for rate control with a digoxin level of 1.7. ECG were routinely monitored with initiation of droperidol for bouts of nausea. Additionally, cardiac enzymes were cycled due to previous ST-T changes with troponin elevation during previous admission. She continued to have mild elevation in her troponin level. RESP: The patient experienced shortness of breath and acute desaturations. O2 sats improved immediately with administration of 3L 02 via nasal cannula. Last chest x-ray showed a small to moderate pleural effusion. She has maintained an oxygen saturation of 97% on 1 liter. GI: On HD#1, a KUB suggested resolution of obstruction, therefore, the ___ tube was discontinued; diet was advanced to a renal diet on HD2 which the patient tolerated without abdominal pain. She experienced a bout of diarrhea but c.diff reported as normal. The patient did experience intermittent nausea, which was managed with droperidol and ondansetron. Renal: Given acute kidney injury imposed upon chronic kidney disease, which occurred prior to this admission, hemodialysis was resumed on HD2; Nephrology felt meaningful recovery of kidney function was unlikely necesitating indefinite HD treatment, which she continued 3x per week while hospitalized and tolerated well; nephrocaps were administered and a renal diet was provided. Urine output via urostomy remained marginal. Electrolytes were closely monitored during the hospitalization. Heme: On prior admission, patient reported to have GIB., anticoagulants were held. With continuation of atrial fibrillation, decision made to resume coumadin. The patient was started on 2 mg of coumadin on ___. Her hematocrit has remained stable 26.5. SKIN: A wound vac was applied to the abdominal wound. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a low protein, renal diet, ambulating and was without pain. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. At the time of discharge, no surgical date had been established for repair of para-stomal hernia. Dr. ___ making arrangements for return operation. Since a date has not been established, Dr. ___ secretary to inform rehabilitation facility about date/time surgery. Pt will need to hold coumadin for 7 days prior to the procedure. Blood work, including CBC, electrolytes, and coags to be repeated 24 hours prior to surgery. Medications on Admission: . 1. fenofibric acid *NF* 105 mg Oral daily 2. Omeprazole 20 mg PO DAILY 3. Simvastatin 40 mg PO DAILY 4. Acetaminophen 650 mg PO Q6H:PRN pain 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN nebulizing solution 6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 7. Digoxin 0.125 mg PO EVERY OTHER DAY 8. Heparin Dwell (1000 Units/mL) ___ UNIT DWELL PRN dialysis Dwell to CATH Volume 9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN nebulizing solution 10. Metoprolol Tartrate 37.5 mg PO Q8H 11. Nephrocaps 1 CAP PO DAILY 12. Ondansetron 4 mg IV Q8H:PRN nausea 13. Senna 1 TAB PO BID:PRN constipation 14. traZODONE 25 mg PO HS:PRN insomnia 15. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin Discharge Medications: 1. Nephrocaps 1 CAP PO DAILY 2. Omeprazole 20 mg PO DAILY 3. Acetaminophen 650 mg PO Q6H:PRN pain 4. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN nebulizing solution 5. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 6. Digoxin 0.125 mg PO EVERY OTHER DAY 7. fenofibric acid *NF* 105 mg Oral daily 8. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using REG Insulin 9. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN nebulizing solution 10. Ondansetron 4 mg IV Q8H:PRN nausea 11. Senna 1 TAB PO BID:PRN constipation 12. Simvastatin 40 mg PO DAILY 13. traZODONE 25 mg PO HS:PRN insomnia 14. Warfarin 2 mg PO DAILY16 please monitor ___ daily 15. Heparin 5000 UNIT SC TID 16. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain patient on coumadin, please closely monitor coags. 17. Heparin Dwell (1000 Units/mL) ___ UNIT DWELL PRN dialysis Dwell to CATH Volume 18. Metoprolol Tartrate 37.5 mg PO Q6H hold for systolic blood pressure <110, hr <60 Discharge Disposition: Extended Care Facility: ___ ___) Discharge Diagnosis: Small bowel obstruction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: You were admitted to the hospital with nausea and vomiting related to a bowel obstruction from your hernia. You were placed on bowel rest with placement of a ___ tube at an outside hospital for decomrpession. Your obstruction has resolved and you were able to tolerate a diet, therefore, you are preparing for discharge to rehab. You will need to return to the hospital for repair of the hernia around your stoma to prevent recurrence of the bowel obstruction. Followup Instructions: ___
19966115-DS-11
19,966,115
27,409,352
DS
11
2184-09-23 00:00:00
2184-09-27 17:29:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness and fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M with h/o ___, afib on coumadin, HTN, DM, prostate cancer s/p resection, who presents with fall at home. Patient had ___ days of weakness prior to presentation along with 2 days of non-bloody, watery diarrhea. On day of presentation (___) pt was moving out of bed to wheelchair at 7 AM. He felt unable to support himself and fell slowly to the floor. He felt diaphoretic with some "room spinning." He denies chest pain, SOB, nausea/vomiting, or lightheadedness. He did not hit his head, lose consciousness, have tonic-clonic movements or tongue biting. He denies any recent fevers, dysuria. Patient called EMS and presented to the ED. ED Course (labs, imaging, interventions, consults): In the ED, his initial vitals were: T 98.3 HR 91 BP 92/46 RR 16 O2 95% RA Given unclear history, patient received a CT head which did not show any intracranial hemorrhage. EKG demonstrated multiple PACs but no ischemic changes. He received a UA with many bacteria and >182 WBC and was started on empiric threapy with vanc 1g, CTX 1g. His vitals prior to transfer were HR 73 BP 136/72 RR 19 O2 98% RA. He was transferred to the medicine floor for further management. Past Medical History: ___ DISEASE ___ ESOPHAGUS with adenocarcinoma treated with radiation therapy DIABETES MELLITUS HYPERTENSION SLEEP APNEA CPAP OSTEOARTHRITIS SPINAL STENOSIS s/p laminectomy/decompression/diskectomy FALLS H/O PAROTID DUCT STONES H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency H/O POSSIBLE CONCUSSION REMOVAL INDWELLING PORT, RIGHT CHEST ___ 1. RIGHT SINGLE PORT-A-CATH 2. LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT ___ BIL TKR Social History: ___ Family History: History of cirrhosis in father/brother (alcohol use). History of DM, HTN. Physical Exam: ADMISSION PHYSICAL EXAM: T: 98.3 HR: 91 BP: 92/46 RR: 16 O2: 95% ra GENERAL: Alert, oriented, no acute distress HEENT: ? Sclerae icteric, MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD RESP: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, systolic murmur LSB ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or guarding EXT: R knee with minor abrasion and TTP; no other evidence of trauma 2+ pitting edema RLE to knee. 2+ pitting edema LLE to mid calf. NEURO: CNs2-12 intact, motor function grossly normal. ___ strength in all major muscle groups. SKIN: No rash. DISCHARGE PHYSICAL EXAM: VS: T:98.5 HR: 84 BP: 154/58 RR: 20 O2: 96RA GENERAL: Alert, oriented, no acute distress HEENT: MMM, oropharynx clear NECK: supple, JVP not elevated, no LAD RESP: CTAB no wheezes, rales, rhonchi CV: RRR, Nl S1, S2, systolic murmur LSB ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or guarding EXT: 2+ pitting edema RLE to knee. 2+ pitting edema LLE to mid calf. Pertinent Results: ADMISSION LABS: ___ 11:25AM URINE RBC-16* WBC->182* BACTERIA-MANY YEAST-NONE EPI-3 TRANS EPI-2 ___ 11:25AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG ___ 01:08PM LACTATE-1.1 ___ 08:35PM CK-MB-8 cTropnT-0.03* ___ 09:00AM cTropnT-0.03* ___ 09:00AM WBC-8.3 RBC-3.62* HGB-10.5* HCT-32.3* MCV-89 MCH-29.0 MCHC-32.5 RDW-14.2 RDWSD-46.1 DISCHARGE LABS: ___ 05:52AM BLOOD WBC-6.7 RBC-3.39* Hgb-9.6* Hct-30.5* MCV-90 MCH-28.3 MCHC-31.5* RDW-14.3 RDWSD-46.8* Plt ___ ___ 05:52AM BLOOD Glucose-120* UreaN-18 Creat-1.2 Na-142 K-3.9 Cl-110* HCO3-23 ___ CT HEAD NONCON IMPRESSION: No acute intracranial abnormalities. ___ CXR IMPRESSION: No acute intrathoracic process. ___ R Knee XR FINDINGS: Patient is status post right knee arthroplasty with prosthesis in anatomic alignment without findings to suggest hardware complication. The patella is fragmented, likely old, no prior available for comparison. There is a small suprapatellar joint effusion. No dislocation is seen. No definite acute fracture. Vascular calcifications are seen. Brief Hospital Course: ___ yo M with h/o ___, afib on coumadin, HTN, DM, prostate cancer s/p resection, and recurrent UTIs who presents with fall and generalized weakness, found to have UTI. # UTI: Patient presented to ED with generalized weakness for ___ days and recent fall on ___. In the ED he received an infectious workup with urinalysis which showed WBC>182 with many bacteria. His blood cultures were unrevealing. Patient was started on empiric tx with vanc, ceftriaxone in the ED. Patient was then transferred to the floor where his UTI was treated with ampicillin and ceftriaxone 1000 mg Q24H based on prior urine cultures growing serratia and enterococcus. His urine cultures returned with GNRs and he was narrowed to ciprofloxacin PO with plan to continue for 4 days. He received 3 days of inpatient antibiotic therapy prior to discharge. His urine ultimately grew 2 strains of klebsiella that were sensitive to ciprofloxacin. # Fall: His fall was initially concerning for pre-syncope/syncope but was then thought to be mechanical in the setting of his weakness ___ UTI as above. We considered orthostasis and vagal etiologies and thought that seizure was unlikely. Patient also received an EKG with showed his known atrial fibrillation but no ischemic changes. He received a CT head without evidence of intracranial hemorrhage. CXR did not have e/o pneumonia. # Diarrhea: His hospital stay was complicated by ongoing diarrhea that had reportedly started several days prior to admission. He received a C. difficile stool test which was negative. This was thus thought to be viral gastroenteritis or excessive bowel regimen, improved by time of discharge. # ___: Patient had ___ with an elevation in his creatinine from 1.3 at baseline to 1.6 on presentation. This was thought to be of prerenal etiology ___ dehydration in the setting of his diarrhea. His ___ resolved with IV fluids with creatinine that returned to 1.2 at discharge. His lisinopril was held during admission and restarted on the day of his discharge. # Somnolence: During his admission, he was thought to have increased somnolence that was slightly increased from baseline per reports from family. Patient was oriented x3 throughout his admission and was thought to be ___ his known infection. # DM: Stable on his home lantus 6 QAM, 10 QPM. #TRANSITIONAL ISSUES: -Cont ciprofloxacin for 4 more days finishing ___ -Will need 24 hour care given inability to transfer to wheelchair -Please verify seroquel dosing with neurologist (most recent note from neurologist does not correspond with patient understanding of dose, was discharged with neurologist recommended-dosing) -Will need to continue to monitor his blood sugar and insulin dosing, considering transition to long acting insulin if needed -Will need to follow up with PCP (Dr. ___ regarding care and coumadin therapy # CODE STATUS: Full (Confirmed) # CONTACT: HCP ___ (Daughter): ___ ___ (Wife): ___ Medications on Admission: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO EVERY OTHER DAY 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Cyanocobalamin 500 mcg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Lidocaine 5% Patch 1 PTCH TD QAM R knee pain 7. Lisinopril 20 mg PO DAILY 8. Omeprazole 20 mg PO BID 9. pramipexole 0.5 mg oral tid 10. Tamsulosin 0.4 mg PO QHS 11. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral daily 12. Warfarin 5 mg PO ONCE 13. Humalog 10 Units Breakfast Humalog 6 Units Dinner 14. Simvastatin 10 mg PO QPM 15. Seroquel 15 mg QAM, 25 mg QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO EVERY OTHER DAY 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Cyanocobalamin 500 mcg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Humalog 10 Units Breakfast Humalog 6 Units Dinner RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR 10 Units before BKFT; 6 Units before DINR; Disp #*3 Syringe Refills:*0 7. Lidocaine 5% Patch 1 PTCH TD QAM R knee pain 8. Lisinopril 20 mg PO DAILY 9. Omeprazole 20 mg PO BID 10. pramipexole 0.5 mg ORAL DAILY 11. Simvastatin 10 mg PO QPM 12. Tamsulosin 0.4 mg PO QHS 13. Warfarin 5 mg PO DAILY16 14. QUEtiapine Fumarate 12.5 mg PO DAILY 15. QUEtiapine Fumarate 25 mg PO QHS 16. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500 mg(1,250mg) -125 unit oral daily 17. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*8 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: Urinary tract infection Secondary: Diabetes, Atrial fibrillation, ___ disease Discharge Condition: Level of Consciousness: Alert Mental Status: Oriented x3 and cooperative. Intermittently somnolent. Talkative, coherent without confusion. Activity Status: Non-ambulatory. Requires assistance transferring to wheelchair. Discharge Instructions: Dear Mr. ___, You came to ___ because of weakness and a fall at home. In the ED we found your urine to have a bacterial infection. We think your weakness was due to the infection in your urinary tract. You also received a CT scan of your head that did not show any bleeding and an x-ray of your chest that did not show pneumonia. We checked your cardiac enzymes and EKG, and we do not think you had a heart attack. You had diarrhea prior to admission that continued while you were in the hospital. We checked for a bacterial intestinal infection (C. difficile) and that was negative. You had a slight amount of damage to your kidneys, which was likely caused by dehydration due to diarrhea. Your kidneys recovered with IV fluids. We started you on antibiotics here in the hospital but you should continue to take your discharge antibiotics (ciprofloxacin) for 4 more days. We recommend you closely monitor your blood sugar and continue to take Coumadin for your atrial fibrillation. You should have close follow up with your primary care physician after discharge. We wish you all the best, Your ___ Team. Followup Instructions: ___
19966115-DS-12
19,966,115
24,831,979
DS
12
2184-12-04 00:00:00
2184-12-04 18:09:00
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 pain Major Surgical or Invasive Procedure: none History of Present Illness: ___ yo M with h/o ___, afib on coumadin, HTN, DM, prostate cancer s/p resection, esophageal cancer s/p radiation and recurrent UTIs who presents with chest pain. The history was taken from the patient (poor historian) and confirmed with his wife. This morning he went for a stroll in his wheelchair. When he returned, he c/o substernal chest pain radiating to the back and both shoulders. He dozed off, and when he awoke about an hour later he again complained of CP. It was constant, nothing made it better or worse, and not associated with SOB, diaphoresis, abdominal pain, N/V. No weakness, numbness, tingling, fever, chills, cough. The wife noticed he ate less of his soup than normal today, but previously had been eating/drinking well. No diarrhea/constipation/dysuria. Of note, the patient had a stress test in ___ which was negative for inducible ischemia. In the ED, initial vitals were: 97.5 80 72/29 16 98% RA - Labs were notable for: WBC 3.2 w/ 78% PMNs, creatinine 2 (baseline 1.3), lactate 2.2, troponon 0.03 (baseline), dirty UA, INR 2.4. - CXR showed bibasilar atelectasis and MRA chest/abd was negative for aortic dissection but showed a 1.6cm hilar mass/LN. - EKG showed sinus rhythm, rate 77, normal axis/intervals, no TWI or ST changes, similar to prior Patient was given: ___ 15:39 IVF 1000 mL NS 500 mL ___ 17:05 IVF 1000 mL NS 500 mL ___ 17:39 IV Morphine Sulfate 2 mg ___ 19:56 PO/NG Carbidopa-Levodopa (___) 1 TAB ___ 19:56 PO/NG Cephalexin 500 mg ___ 19:56 PO/NG Sulfameth/Trimethoprim DS 1 TAB ___ 19:56 PO Omeprazole 40 mg ___ 19:56 PO/NG QUEtiapine Fumarate 12.5 mg On the floor, the patient complains of itchy arms b/l but no chest, arm, or back pain. He c/o pain in his R knee, chronic, ___bout 5 months ago. Review of systems: as above, otherwise negative in 6 systems. Past Medical History: ___ DISEASE ___ ESOPHAGUS with adenocarcinoma treated with radiation therapy; follows with Dr. ___ at ___ DIABETES MELLITUS HYPERTENSION SLEEP APNEA CPAP OSTEOARTHRITIS SPINAL STENOSIS s/p laminectomy/decompression/diskectomy H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT Bilateral TKR Kidney stones Recurrent UTIs Social History: ___ Family History: History of cirrhosis in father/brother (alcohol use). History of DM, HTN. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.8 124/52 78 20 98% RA wt 86.7kg General: Oriented x3 but somnolent, masked facies, rigid movements HEENT: PERRL, MMM Neck: Supple, JVP not elevated CV: Regular rate and rhythm, SEM at RUSB Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present GU: No foley Skin: rash in armpits, groin Ext: Increased tone in all extremities. He has decreased strength in the bilateral lower extremities which is baseline. Has healing wounds on left shin surrounded by mild erythema. Right leg with mild erythema. No edema b/l DISCHARGE PHYSICAL EXAM: Vitals: T:98.2 BP:145/56 P:71 R:18 O2:99RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi. Chronic junky cough. CV: RRR, ___ systolic crescendo-decrescendo murmur best heard at RU sternal borders, heard throughout precordium. No radiation to the carotids. Abdomen: Soft, non-tender, protruberent. Ventral hernia at the site of previous j-tube. Ext: Warm, well perfused. Left shin has healing wound, 5cm, with mild surrounding erythema. ___ mildly erythematous bilaterally below the knee. Neuro: CN II-XII intact and symmetric. Some difficulty tracking with eyes (saccadic movements, but range is intact). Masked facies. Pseudobulbar affect. Increased tone in all extremities. Right hand pill rolling tremor. Strength 4+/5 throughout. Sensation to light touch intact distally. Pertinent Results: ADMISSION LABS: ___ 03:10PM BLOOD WBC-3.2* RBC-3.85* Hgb-10.8* Hct-33.7* MCV-88 MCH-28.1 MCHC-32.0 RDW-16.7* RDWSD-53.0* Plt ___ ___ 03:10PM BLOOD Neuts-78.3* Lymphs-11.5* Monos-9.3 Eos-0.3* Baso-0.3 Im ___ AbsNeut-2.53# AbsLymp-0.37* AbsMono-0.30 AbsEos-0.01* AbsBaso-0.01 ___ 03:10PM BLOOD Glucose-102* UreaN-38* Creat-2.0* Na-133 K-6.5* Cl-103 HCO3-19* AnGap-18 ___ 03:10PM BLOOD ALT-11 AST-42* AlkPhos-80 TotBili-0.2 ___ 03:10PM BLOOD cTropnT-0.03 PERTINENT LABS: ___ 03:10PM BLOOD cTropnT-0.03* ___ 12:39AM BLOOD CK-MB-16* MB Indx-1.5 cTropnT-0.04* ___ 06:25AM BLOOD CK-MB-13* MB Indx-1.2 cTropnT-0.04* ___ 06:25AM BLOOD CK(CPK)-1112* DISCHARGE LABS: ___ 06:25AM BLOOD WBC-3.4* RBC-3.40* Hgb-9.4* Hct-29.2* MCV-86 MCH-27.6 MCHC-32.2 RDW-16.5* RDWSD-51.6* Plt ___ ___ 06:25AM BLOOD Glucose-95 UreaN-32* Creat-1.7* Na-139 K-4.8 Cl-109* HCO3-21* AnGap-14 STUDIES: ___ MR ANGIOGRAM: No evidence of aortic dissection. The aorta and great vessels are grossly patent. There is a background of mild to moderate atherosclerosis. Measurements of the aorta include: Aortic root: 2.5 cm Proximal ascending: 3.6 cm Distal ascending: 3.8 cm Proximal arch: 3.1 cm Distal arch: 2.8 cm Mid descending: 2.7 cm Distal descending: 2.5 cm LUNGS: There is a 1.6 x 1.3 cm nodule in the right hilum, which may represent an enlarged lymph node versus mass. This is incompletely assessed in the current study. Additionally, there is mild bilateral dependent subsegmental atelectasis particularly involving the bases. No pleural effusion. Trace pericardial fluid. HEART AND MEDIASTINUM: Moderate cardiomegaly. No mediastinal lymphadenopathy. UPPER ABDOMEN: Small hiatal hernia. The imaged portion of the liver, spleen, and bilateral adrenals are unremarkable. The imaged pancreas is also within normal limits. The main pancreatic duct is not dilated. No evidence of intrahepatic or extrahepatic biliary ductal dilatation. The gallbladder is unremarkable. OSSEOUS STRUCTURES AND SOFT TISSUES: No worrisome osseous findings. IMPRESSION: 1. No evidence of aortic dissection. 2. Right hilar mass measuring up to 1.6 cm. Further evaluation with dedicated CT chest recommended. RECOMMENDATION(S): Right hilar mass measuring up to 1.6 cm. Further evaluation with dedicated CT chest recommended. ___ CXR FINDINGS: Cardiac silhouette size is mildly enlarged but unchanged. The mediastinal and hilar contours are similar. Pulmonary vasculature is normal. Streaky atelectasis is seen in the lung bases without focal consolidation. No pleural effusion or pneumothorax is the benefit. Degenerative changes are noted involving both acromioclavicular joints. IMPRESSION: Mild bibasilar atelectasis. MICROBIOLOGY: Urine cx pending Brief Hospital Course: Mr. ___ is an ___ year-old male with a past medical history significant for ___ Disease, Atrial Fibrillation on Coumadin, Esophageal Cancer, and Prostate Cancer. He presented with chest pain with a negative cardiac workup # Chest pain: Pain began after spending time outside in his wheelchair, was sub-sternal and radiated to his shoulders, posterior neck, and head. He denied shortness of breath, nausea, vomiting, diaphoresis, weakness, fever, or chills. We performed a chest X-ray, MRI-MRA, and EKG, all of which showed no signs of acute coronary syndrome, acute pulmonary, or aortic disection. Cardiac enzymes trended x3. The etiology of his chest pain remains unclear, though ACS, PE (not pleuritic, no other symptoms), and aortic dissection are unlikely. Possibly muscle spasms vs esophageal spasm. His symptoms resolved within ___ hours without intervention. No changes in medications were made. Mr. ___ should follow up with his Primary Care Physician. # Right hilar mass vs enlarged lymph node: New finding seen on CT Chest/Abd in ED ___. Given his history of esophageal cancer and prostate cancer, should rule out malignancy/metastatic disease. He had a recent CT scan done by his outpatient oncologist that is not in our system. Should follow up with outpatient oncologist. # Elevated CK: Noticed while trending cardiac biomarkers. Unclear etiology. Potentially secondary to recent decreased physical activity and increased tremor. Please follow up. # Leukopenia: Found to have new leukopenia of 3.2 on admission. Most likely due to his recent Sulfameth/Trimethoprim use. Another possibility is UTI, especially given his history of recurrent UTIs, however he is currently asymptomatic. Urine culture is pending. He has been leukopenic in the past in the setting of UTIs. Please repeat CBC and consider discontinuing Sulfameth/Trimethoprim if indicated. # CKD: Creatinine chronically elevated per OMR. Was 2.0 on admission, now 1.7 after fluids. This mild elevation from his baseline is likely due to poor PO intake on day of admission. It is also unclear if he received contrast during his recent outpatient CT scan, in which case this elevation could be due to contrast induced nephropathy. Chronic issues: # ___ disease: Follows with neurology here. Continued home regimen of Carbidoba-levodopa and Seroquel. # Afib on coumadin: Currently in sinus; not on a nodal agent or antiarrhythmic. Continue home regimen of Warfarin 5 mg PO daily # DM: Continued humalog 10 units Breakfast and 6 Units Dinner, + SSI # GERD: Continued omeprazole 20 mg PO BID # HTN: Continued lisinopril # HLD: Continued simvastatin 10 mg PO QPM # BPH: Continued tamsulosin Transitional issues: - 1.6 cm hilar mass found incidentally on MRI. Family reports recent CT scan, which is not in our system. Please follow up and compare results. - Increased tremors, immobility, and falls since discontinuing pramipexole. Follow-up with Neurologist. - Patient reporting new abdominal discomfort associated with ventral hernia at LUQ, follow up with Primary Care Physician ___ on ___: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO EVERY OTHER DAY 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Cyanocobalamin 1000 mcg PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Humalog 10 Units Breakfast Humalog 6 Units Dinner 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. Lisinopril 20 mg PO DAILY 9. Omeprazole 20 mg PO BID 10. Simvastatin 10 mg PO QPM 11. Tamsulosin 0.4 mg PO QHS 12. Warfarin 5 mg PO DAILY16 13. QUEtiapine Fumarate 12.5 mg PO BID 14. calcium carbonate-vitamin D3 500 mg(1,250mg) -125 unit oral DAILY 15. Sulfameth/Trimethoprim DS 1 TAB PO BID 16. Cephalexin 500 mg PO Q6H Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Aspirin 81 mg PO EVERY OTHER DAY 3. Carbidopa-Levodopa (___) 1 TAB PO TID 4. Cephalexin 500 mg PO Q6H 5. Cyanocobalamin 1000 mcg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Humalog 10 Units Breakfast Humalog 6 Units Dinner 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. Omeprazole 20 mg PO BID 10. QUEtiapine Fumarate 12.5 mg PO BID 11. Simvastatin 10 mg PO QPM 12. Sulfameth/Trimethoprim DS 1 TAB PO BID 13. Tamsulosin 0.4 mg PO QHS 14. Warfarin 5 mg PO DAILY16 15. calcium carbonate-vitamin D3 500 mg(1,250mg) -125 unit oral DAILY 16. Lisinopril 20 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Chest Pain Secondary: ___ disease Atrial fibrillation 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 admitted to ___ for an episode of chest pain. You had an MRI of your chest, an ECG of your heart and lab tests that were all reassuring and suggested that you did not have a heart attack. Unfortunately, we are unsure about what caused this episode of pain. However, we are reassured by the fact that it went away on its own and didn't come back. Please follow up with your primary doctor. If these symtoms come back, please seek medical care. As part of your workup, we got an MRI of your chest and abdomen. We found a small mass near the ___ your chest. We are unsure about the significance of this mass since we do not have other recent images. We will let your oncologist know about these images and you can follow up with him. Thank you for allowing us to be a part of your care. Sincerely, Your ___ team Followup Instructions: ___
19966115-DS-17
19,966,115
26,417,465
DS
17
2186-04-09 00:00:00
2186-04-09 23:37:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness, lethargy Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ year old with a complex medical history, relevant for history of lung and esophageal cancer, on palliative care, ___ disease, atrial fibrillation on warfarin, recurrent UTI's with an indwelling Foley ___ urinary retention, who presented with weakness, found to have evidence of a UTI, admitted for inpatient antibiotic treatment and consideration of hospice options. Patient has had a complex oncologic history, including esophageal cancer s/p chemoradiation in ___, with a repeat hospitalization here at ___ ___ and found to have an enlarging lung mass. This was presumed to be lung cancer, though esophageal origin could not be excluded without biopsy. He was treated with palliative XRT during his stay by Dr. ___. Given his multiple medical problems including severe aortic stenosis the patient and his family opted for not pursuing aggressive or invasive therapeutic options at that time. He did not have a biopsy because it was thought to be too high risk. In ___ he was set up with hospice and other services at home, and started working with palliative care. He indicated in ___ at his Onc follow-up that he would like to be DNR/DNI and would not like any aggressive life sustaining measures including dialysis, IV fluids, artificial respiration or anything that would be uncomfortable. If he needed to be transferred to the hospital for comfort then that would be acceptable. A MOLST form was filled out at that time. Patient's family notes that he experienced a change of thought and signed a FULL CODE version of his MOLST on ___. They brought that version with them, which is scanned and in the chart on this admission. He therefore has been full code on hospice since ___. Per family patient has had a progressive but slow decline in functional status. Has been at home with his wife, with private assistants helping in the morning and the evening, and hospice workers visiting once in the afternoon. Patient's wife says he has had an indwelling Foley catheter for urinary incontinence (also ? retention contributing to frequent UTIs), and this has only been changed twice in the past year. Per family, patient had urine tested several weeks ago, with UA demonstrating concern regarding UTI. Patient had been on fosfomycin ppx regularly, but this finding prompted administration of ciprofloxacin 250 q12h. Another antibiotic was also prescribed when interval UA also appeared dirty, though the family does not recall what this was. Family notes his urine was dark, but only started to become purulent a few days ago. They note with the onset of purulent drainage from the catheter. In the ED, initial vitals were: - Exam notable for: Oriented to person place and time, no focal neuro deficits - Labs notable for: WBC 4.8 (78% neutrophils), H/H 10.8/34.9, Na 141, Cr 1.2, lactate 1.9, UA -> leuk, mod blood, > 182 WBCs, 38 RBCs. - EKG showed 1st degree AV block PR 221, HR 77 - Imaging was notable for: CXR -> New elevation of the right hemidiaphragm which obscures the right hilar mass. Patchy opacities in lung bases may reflect atelectasis but infection or aspiration cannot be excluded. - Patient was given: a new Foley Catheter, Ceftriaxone, Azithromycin (500 mg ordered) Upon arrival to the floor, patient is responsive to questions, resting comfortably, requires redirecting to participate in conversation. Answers with words that are hard to distinguish. Feels comfortable. 12-point ROS notable for family also being concerned regarding ongoing possibility of aspiration. They note he has had increased sputum and mucus production over the past week, with a more prominent cough (has a chronic cough at baseline). No new fevers or chills. They do not note a definite aspiration event. No abdominal pain. No nausea or vomiting. ROS otherwise negative unless indicated above. Past Medical History: Chronic UTIs (w/ indwelling Foley catheter for ___ year, on Fosfomycin ppx) CHF ___ Aortic Stenosis ___ DISEASE ___ ESOPHAGUS with adenocarcinoma treated with radiation therapy; follows with Dr. ___ at ___ DIABETES MELLITUS HYPERTENSION SLEEP APNEA CPAP OSTEOARTHRITIS SPINAL STENOSIS s/p laminectomy/decompression/diskectomy H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT Bilateral TKR Kidney stones Hilar MASS, presumed lung CA s/p palliative XRT, not on active chemo ___, MD is ___ Social History: ___ Family History: History of cirrhosis in father/brother (alcohol use). History of DM, HTN. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 98.3 PO 120/69 70 18 97 RA General: alert, oriented to self and hospital, no acute distress. HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, some left side cervical LAD. Lungs: Slight rales at R base. Prominent xiphoid process. CV: RRR, ___ systolic ejection murmur at RUSB. Abdomen: soft, slight distension, slight epigastric tenderness to palpation. bowel sounds present, no rebound tenderness or guarding. GU: exchanged Foley catheter in place draining clear urine. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: moving all extremities. eyes track to examiner. responsive to questions in a soft voice. Limited ability to give medical history. DISCHARGE PHYSICAL EXAM: Vitals: 98.3 143/82 L ___ ___ General: alert, oriented to self, hospital, year, no acute distress. Speaking slowly in weak voice with some word finding difficulty, difficult to discern certain words. HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated. Lungs: CTAB. CV: RRR, ___ systolic ejection murmur at RUSB. Abdomen: soft, nontender, nondistended. bowel sounds present, no rebound tenderness or guarding. GU: has foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis, 1+ edema b/l ___ ___: moving all extremities. eyes track to examiner. responsive to questions in a soft voice. Pertinent Results: ADMISSION LABS: ___ 12:00PM BLOOD WBC-4.8 RBC-4.32* Hgb-10.8* Hct-34.9* MCV-81* MCH-25.0* MCHC-30.9* RDW-20.3* RDWSD-59.2* Plt ___ ___ 12:00PM BLOOD Neuts-78.4* Lymphs-10.6* Monos-9.8 Eos-0.4* Baso-0.4 Im ___ AbsNeut-3.77 AbsLymp-0.51* AbsMono-0.47 AbsEos-0.02* AbsBaso-0.02 ___ 12:00PM BLOOD Plt ___ ___ 07:41PM BLOOD ___ PTT-40.4* ___ ___ 12:00PM BLOOD Glucose-140* UreaN-32* Creat-1.2 Na-141 K-4.3 Cl-104 HCO3-24 AnGap-17 ___ 12:00PM BLOOD Calcium-9.1 Phos-3.6 Mg-2.2 ___ 12:17PM BLOOD Lactate-1.9 ___ 12:30PM URINE Color-Yellow Appear-Cloudy Sp ___ ___ 12:30PM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 12:30PM URINE RBC-38* WBC->182* Bacteri-MANY Yeast-RARE Epi-0 ___ 12:30PM URINE CastHy-13* DISCHARGE LABS: ___ 07:35AM BLOOD WBC-5.4 RBC-4.34* Hgb-10.9* Hct-34.8* MCV-80* MCH-25.1* MCHC-31.3* RDW-19.9* RDWSD-58.4* Plt ___ ___ 07:35AM BLOOD Plt ___ ___ 07:35AM BLOOD ___ PTT-42.8* ___ ___ 07:35AM BLOOD Glucose-145* UreaN-20 Creat-1.1 Na-143 K-4.3 Cl-105 HCO3-26 AnGap-16 ___ 07:35AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.3 MICROBIOLOGY ___ CULTUREBlood Culture, Routine-PENDING ___ CULTUREBlood Culture, Routine-PENDING ___ CULTURE-FINAL {ESCHERICHIA COLI} 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. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- =>64 R CEFEPIME-------------- 16 R CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S CXR ___ FINDINGS: Cardiac silhouette size remains mildly enlarged. The mediastinal contours appear unremarkable. Pulmonary vasculature is not engorged. Elevation of the right hemidiaphragm appears new, and obscures the known right hilar mass. Patchy opacities in lung bases may reflect areas of atelectasis, though infection or aspiration cannot be excluded. No large pleural effusion or pneumothorax is detected. There are no acute osseous abnormalities. IMPRESSION: New elevation of the right hemidiaphragm which obscures the right hilar mass.Patchy opacities in lung bases may reflect atelectasis but infection or aspiration cannot be excluded. Brief Hospital Course: This is an ___ year old male with chronic atrial fibrillation, ___ Disease, dementia, systolic CHF, prostate cancer with urinary retention and chronic indwelling Foley catheter admitted with bacterial urinary tract infection, culture showing Ecoli sensitive to Bactrim, foley changed and initiated on antibiotics, showing clinical improvement able to be discharged home. # Catheter-associated bacterial UTI: Patient presented with progressive weakness and confusion, with purulent drainage from foley on initial exam. His foley catheter was exchanged and cultures growing >100k cfu E coli, resistant to ceftazidime, sensitive to meropenem and bactrim. Patient transitioned to Bactrim and was able to be discharged (last day bactrim planned for ___ # Atelectasis - Patient admission chest xray raising concern for RLL process pneumonitis vs. atelectasis vs. pneumonia. On admission exam, lungs clear, no hypoxia or other respiratory findings. Pneumonia or atelectasis were felt to be unlikely given his reassuring clinical picture. He was monitored without development of respirator findings. # R hilar lung cancer # Goals of care: Patient presented about ___ year after his initial evaluation regarding a right lung mass, for which he been seen by oncology, declined biopsy or additional procedures, and had received empiric radiation therapy. Per prior documentation he had been DNR/DNI and was currently receiving hospice care. On this admission, family and patient reported wanting to be full code, although they were open to further discussions, but only in the context of requested oncology follow-up. Per discussion with family, there was no other long-term provider who they felt comfortable having this discussion with. Patient family's goal was to help him regain some strength and return home. He was set up with an oncology follow-up appointment at time of discharge. He was continued on Acetaminophen 650 mg PO BID and Naproxen 250 mg PO Q12H for pain. # Systolic CHF - Continued home Lasix # Chronic Atrial fibrillation - INR 3.3 on day of discharge; per discussion with pharmacy, Coumadin dose adjusted to 3mg daily; continued metoprolll # ___ - Continued Carbidopa-Levodopa # Diabetes type 2 - Continued home Humalog 75/25, but at reduced dose (as below) due to low-normal fingersticks. # GERD - Continued PPI # Dementia - Continued QUEtiapine; patient on this longitudinally, but given history of ___ would consider weaning in long-term to reduce risk of worsening ___ symptoms # BPH - continued Tamsulosin # Dysphagia : continued Prethickened liquids TRANSITIONAL ISSUES: - patient is being discharged on Bactrim DS 1 tab bid for E. coli cystitis to complete a course through ___ evening. Patient should restart his fosfomycin prophylaxis therafter; if consistent with goals of care, would consider outpatient urology follow-up for scheduled foley catheter changes (to decrease future infections) - Patient has still established himself as a "Full Code" on MOLST during this admission; family are open to further discussions regarding this status, specifically at oncology follow-up - warfarin was continued for patient's atrial fibrillation. Should it be within patient's goals of care, would consider transitioning to ___ given data regarding improved outcomes in the setting of cancer. His dose was reduced from 5mg to 3mg due to supratherapeutic INR and concern for interaction with Bactrim. Recommend repeat INR on ___. - reduced Humalog ___ to 2 units at breakfast and 2 units at bedtime # CODE: Full Code # CONTACT: ___ (daughter, nurse, HCP) ___ ___ (wife) ___, ___ (daughter) ___ # DISPO: ___ pending above Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO BID 2. Carbidopa-Levodopa (___) 1.5 TAB PO BID 3. Docusate Sodium 100 mg PO BID 4. Furosemide 20 mg PO DAILY 5. Metoprolol Succinate XL 25 mg PO DAILY 6. Omeprazole 20 mg PO BID 7. QUEtiapine Fumarate 12.5 mg PO BID 8. Senna 17.2 mg PO DAILY 9. Tamsulosin 0.4 mg PO QHS 10. Warfarin 5 mg PO DAILY16 11. Carbidopa-Levodopa (___) 1 TAB PO QPM 12. Naproxen 220 mg PO Q12H 13. Ciprofloxacin HCl 250 mg PO Q12H 14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 15. Humalog ___ 7 Units Breakfast Humalog ___ 7 Units Bedtime Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*10 Tablet Refills:*0 2. Naproxen 250 mg PO Q12H 3. Warfarin 3 mg PO DAILY16 RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Acetaminophen 650 mg PO BID 5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of breath 6. Carbidopa-Levodopa (___) 1.5 TAB PO BID 7. Carbidopa-Levodopa (___) 1 TAB PO QPM 8. Docusate Sodium 100 mg PO BID 9. Furosemide 20 mg PO DAILY 10. Humalog ___ 2 Units Breakfast Humalog ___ 2 Units Bedtime 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Omeprazole 20 mg PO BID 13. QUEtiapine Fumarate 12.5 mg PO BID 14. Senna 17.2 mg PO DAILY 15. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Home with Service Discharge Diagnosis: # Acute bacterial UTI secondary to Ecoli # Right hilar lung cancer # Chronic Atrial fibrillation # Aortic Stenosis # ___ Disease # Dementia # Chronic Urinary Retention Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after you experienced a few weeks of worsening confusion and weakness at home. It was noticed that you had purulent drainage from your Foley catheter, so your Foley was changed. Your urine was tested and it appeared you had evidence of another urinary tract infection (bacteria growing in your bladder). Because of this we have treated you with an antibiotic course (this will continue through evening of ___ As you know, your cancer is ongoing, and in the year since your last oncology appointment, it is likely that your cancer has progressed and will eventually cause you more symptoms and continue to contribute to a decline in your health. There was ongoing discussion with your family about the importance of clarifying your wishes regarding what you would want done in the event of a health care emergency. It is likely that as your cancer gets worse, you will move more toward end of life care. As you have stated your wishes, you elected to have "everything done" in the event that your heart should give way or your lungs have difficulty breathing. The last thing we would want to do would be to expose you to a traumatic experience, like a cardiac resuscitation (with the possibility of broken ribs) or intubation, if the experience were not something you would wish and there were little chance of meaningful recovery. There is a decent chance that as your cancer gets worse, there may be a medical emergency from which there can be no definitive or meaningful recovery. Should you wish to focus on your comfort in such a scenario, it would be very helpful to clarify this with your family and your outpatient oncologist before any medical emergencies happen. Your sugars appeared to be fairly well controlled while you were in the hospital. We have resumed your Humalog insulin at a reduced number of units. Please monitor your blood sugar throughout the day and ask the hospice program for assistance should you have concerns about your sugar being too high or too low. We have written you for an antibiotic that we recommend you take through ___ evening. It was a pleasure to be involved with your care at ___! - Your ___ Care Team Followup Instructions: ___
19966115-DS-6
19,966,115
29,707,865
DS
6
2183-08-26 00:00:00
2183-08-26 15:56:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Dyskinesias Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo RH man with history of ___ disease and multiple other medical problems who present with significant worsening of his dyskinesia. The patient and his family report that he does have some dyskinesia (orofacial/tongue thrusting and some movements of hand/arms) at baseline but it is much milder. In the last ___ days it worsened significantly and the wife reports that it was noted to be much worse this morning and stayed about the same. Patient thinks it might be a little bit better than this morning, but it is unclear. There has been no change in his PD medications (sinemet, mirapex and comtan) and he denies taking extra medications. No other new medications either prescription or over the counter. Because of the movements, he slid down and landed on his buttocks today from his walker when he was leaning/sitting on it this morning. So the family brought him to ED. On neuro ROS, the pt denies headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. + ring-like scattered rash on abdomen, more noticeable after shower per wife. Past Medical History: DM2 Hypertension Prostate cancer status post TURP c/b urinary retention and frequency ___ disease Obstructive sleep apnea (CPAP setting: 4 cm H20, no oxygen) Parotid duct stones Osteoarthritis s/p bilateral TKRs Spinal stenosis s/p laminectomy/decompression/diskectomy Insulin dependent T2 DM OA Lumbar stenosis s/p surgery ___ disease - diagnosed in ___ and has been on sinemet, mirapex and comtan for number of years without change. Sees ?Dr. ___ as outpatient, family would like to change care to ___. Esophageal cancer s/p radiation, in remission per family s/p R hip replacement (___) squamous cell carcinoma s/p resection (on scalp, done couple days ago) Social History: ___ Family History: History of cirrhosis in father/brother (alcohol use). History of DM, HTN. Cousin with ?PD vs. Wegener's. Physical Exam: ========================== ADMISSION PHYSICAL EXAM ========================== Vitals: 99.7 HR 100 BP 130/palp RR 19 95% RA General: Awake, cooperative, near continuous dyskinetic movement, in mild distress. HEENT: NC/AT Neck: Supple. No nuchal rigidity Pulmonary: CTABL Cardiac: RRR, no murmurs Abdomen: somewhat distended, but soft, nontender Extremities: no edema, warm to touch Skin: pinkish ring-like rashes on abdomen with some scaling Neurologic: -Mental Status: Alert, awake. Speech is fluent but has occasional dysphonia. Hypophonic. Able to relate history with some prompting. Inattentive, able to say ___ forward but not backwards. Intact comprehension, follows commands for rest of the examination without difficulty. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1 mm and brisk. VF difficult to test due to frequent forced eye closures but does see fingers on both side. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XII: Tongue protrudes in midline. -Motor: Normal bulk, mild rigidity throughout. Able to participate somewhat in the motor examination, mild weakness in bilateral deltoids (past rotator cuff injuries), but good strength in biceps/triceps and wrist extensors. Mild hip weakness bilaterally but good quadriceps and hamstring strength when he is able to participate. Patient has frequent movements of bilateral arms and neck/face. Frequent head turning to right with tongue thrusting, as well as eye closure/blepharospasms. Bilateral jerky arm movements. No significant movements of legs. -Sensory: No deficits to light touch throughout. -DTRs: Bi Tri ___ Pat Ach L 1+ 1+ 1+ 0 0 R 1+ 1+ 1+ 0 0 Plantar response was mute bilaterally. -Coordination: unable to participate due to frequent movements. -Gait: deferred in the ED. =============================== DISCHARGE PHYSICAL EXAM =============================== General physical exam at discharge was unchanged. Neurologic exam at discharge was unchanged apart from motor. At time of discharge, pt did not exhibit any dyskinesia (no tongue thrusting or bilateral jerky movements). He did exhibit bradykinesia and cogwheeling ridigity in the bilateral upper extremities; however, this was minimal. Pertinent Results: ================= MICROBIOLOGY ================= URINE CULTURE (Final ___: SERRATIA MARCESCENS >100,000 ORGANISMS/ML. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ SERRATIA MARCESCENS | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 256 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S ___ 05:50PM URINE RBC-8* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 ___ 05:50PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 05:50PM URINE Color-Yellow Appear-Hazy Sp ___ ============= IMAGING ============= - MRI L-spine (___): ~0.8 x 0.5 cm structure at left L4-5 neural foramen, either a swollen nerve root or less likely disc material, focal signal abnormality within the L1 vertebral body, possibly a metastasis, abnormal signal within the L2-3 endplates, either due to degenerative disease, compression fractures, or metastasis - CT L-spine (___): Degenerative and postoperative changes in the lumbar spine. Sclerosis adjacent to the inferior endplate of L1 and endplates adjacent to the L2-L3 intervertebral disc. While metastatic disease is not entirely excluded, degenerative changes is considered more likely. - CT Chest with Contrast (___): Bilateral paravertebral fibrosis, overall mild in distribution. Moderate-to-severe coronary calcifications, moderate valvular calcifications. No lymphadenopathy. No evidence of malignant lung nodules. No masses, no pleural effusions. - CT Abdomen and Pelvis with and without Contrast (___): 1. 8mm left ureteral stone without discrete signs of obstruction. 2. Small hiatal hernia 3. Extensive degenerative changes as outlined in CT L-spine dated ___. Brief Hospital Course: Mr. ___ is a ___ year old right handed man with a past medical history notable for ___ disease and spinal stenosis status post laminectomy, decompression, and discectomy who presented to ___ ___ due to worsening of his baseline dyskinesias. On presentation, urinalysis was positive for moderate bacteria, large amount of leukocytes and a WBC of 182. Pt was admitted to the general neurology service for further management. # NEUROLOGIC As pt presented with worsening of his baseline dyskinesia, his ___ medications were adjusted during hospital stay. His sinemet dosing was decreased from 2 tablets QID (8am, 11am, 2pm and 5pm) to 1 tablet five times a day (8am, 11am, 2pm, 5pm and 8pm). Comtan was also increased to five times a day to correlate with sinemet dosing. Mr. ___ tolerated this change in dosage without increase in ridigity or bradykinesia. He also had a decrease in his dyskinesias. He was continued on his home Mirapex with unchanged dosing. Physical therapy worked with Mr. ___ and recommended home with physical therapy at time of discharge. He was also continued on his home bowel regimen. An appointment was scheduled with ___ Disorders ___ at time of discharge. # INFECTIOUS DISEASE Mr. ___ was initially started on IV ceftriaxone to treat a complicated urinary tract infection. Urine culture grew back SERRATIA MARCESCENS sensitive to ciprofloxacin so, on hospital day 3, pt was transitioned to ciprofloxacin 500 PO BID. Pt will complete a 14 day course of this medication. # MUSCULOSKELETAL Mr. ___ complained of severe left greater than right radicular pain during hospital stay. As he had a history of spinal stenosis status post laminectomy, decompression, and discectomy and esophageal and prostate cancer (both in remission), he was evaluated for any spinal disease with lumbar spine CT and MRI. While the MRI was concerning for a possible lesion, CT scan showed degenerative and postoperative changes in the lumbar spine more consistent with degenerative changes than metastatic disease. Mr. ___ underwent a CT torso which was negative for any malignancy. Thus, results were compatible more with degenerative changes. Mr. ___ was started on tramadol as needed and gabapentin for radicular pain. He should follow-up with his primary care doctor for further evaluation and management. # CARDIOVASCULAR Mr. ___ was continued on his home aspirin, simvastatin, and anti-hypertensives while in the hospital. Blood pressure remained stable. Mr. ___ was placed on a cardiac diet in the hospital. # GASTROINTESTINAL Mr. ___ was continued on omeprazole for GERD while in the hospital. # GENITOURINARY Mr. ___ creatinine remained at baseline of 1.4-1.6 while in the hospital. Nephrotoxic medications were avoided. Mr. ___ was also continue on home tamsulosin for history of benign prostatic hypertrophy. # ENDOCRINE Mr. ___ was continued on home dosing of insulin while in the hospital. He also had a diabetic diet. # INTEGUMENTARY Mr. ___ has a chronic erythematous rash. He was placed on miconazole cream while in the hospital with minimal improvement. This medication was discontinued at time of discharge. Mr. ___ should follow-up with his primary care doctor for further management; this rash was stable during hospitalization. # GLOBAL Mr. ___ was placed on heparin for DVT prophylaxis while in the hospital. =========================== TRANSITIONS OF CARE =========================== Sinemet was changed during hospitalization from 2 tablets QID (8am, 11am, 2pm and 5pm) to 1 tablet five times a day (8am, 11am, 2pm, 5pm and 8pm) with improvement in dyskinesias. Mr. ___ was treated for a complicated UTI during hospitalization and will complete a 2 week course of ciprofloxacin at time of discharge. For his bilateral lower extremity radicular pain, Mr. ___ was started on gabapentin and tramadol PRN. Imaging showed this was likely due to degenerative lumbar spine disease, although there was an initial concern for a spinal lesion and metastatic disease (as he has a history of esophageal and prostate cancer). Please see discharge summary for additional details. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Carbidopa-Levodopa (___) 2 TAB PO QID 2. entacapone 200 mg oral QID 3. pramipexole 0.5 mg oral TID 4. FoLIC Acid 1 mg PO DAILY 5. Cyanocobalamin 500 mcg PO DAILY 6. Thiamine 100 mg PO DAILY 7. Omeprazole 40 mg PO DAILY 8. Klor-Con (potassium chloride) 10 mEq oral daily 9. Simvastatin 10 mg PO DAILY 10. Tamsulosin 0.4 mg PO HS 11. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 12. Amlodipine 5 mg PO DAILY 13. Humalog ___ 10 Units Breakfast Humalog ___ 6 Units Dinner 14. Furosemide 20 mg PO DAILY:PRN leg swelling 15. HydrOXYzine 25 mg PO Q6H:PRN itching 16. Docusate Sodium 100 mg PO DAILY:PRN constipation 17. Aspirin 81 mg PO DAILY 18. Polyethylene Glycol 17 g PO DAILY:PRN constipation Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Docusate Sodium 100 mg PO DAILY:PRN constipation 4. FoLIC Acid 1 mg PO DAILY 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Omeprazole 40 mg PO DAILY 7. pramipexole 0.5 mg oral TID 8. Simvastatin 10 mg PO DAILY 9. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 10. Thiamine 100 mg PO DAILY 11. Tamsulosin 0.4 mg PO HS 12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain RX *tramadol 50 mg 1 tablet(s) by mouth Q6HR Disp #*30 Tablet Refills:*0 13. Cyanocobalamin 500 mcg PO DAILY 14. Furosemide 20 mg PO DAILY:PRN leg swelling 15. Klor-Con (potassium chloride) 10 mEq oral daily 16. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY 17. entacapone 200 mg oral 5 times/day with Sinemet 18. Gabapentin 300 mg PO DAILY 1 tab daily for 2 days, then take 1 tab every 12 hours for 2 days, then 1 tab every 8 hours RX *gabapentin 300 mg 1 capsule(s) by mouth DAILY Disp #*60 Capsule Refills:*1 19. Humalog ___ 10 Units Breakfast Humalog ___ 6 Units Dinner 20. Ciprofloxacin HCl 500 mg PO Q12H Duration: 8 Days RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #*16 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Parkinsons Disease with dyskinesias Secondary Diagnosis: Urinary Tract Infection Degenerative Disease of the Lumbar Spine 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 hospitalized for concern about increasing dyskinesias. You were also found to have a urinary tract infection. For your increasing dyskinesias, we decreased your dosing of Sinemet from 2 tablets four times a day (8am, 11am, 2pm and 5pm) to 1 tablet five times a day (8am, 11am, 2pm, 5pm and 8pm). Comtan was also increased to five times a day to match with with your sinemet dosing. This has improved your dyskinesias. For your urinary tract infection, we started you on antibiotics. Please take ciprofloxacin as prescribe at home to complete a course of antibiotics. You also described lower back and leg pain during your hospitalization. We did a CT scan and MRI of your back to further explore this issue. These studies showed abnormalities consistent with degenerative changes. Please follow-up with your primary care doctor for further management. We also started you on two new medications for your leg pain, gabapentin and tramadol. When starting the gabapentin, you may feel sleepy at first. Please continue to take this medication for one week and if you continue to feel sleepy, please speak with your primary care doctor about discontinuing the medication. The tramadol is a medication that you only need to take as needed for pain. We hope you all the best. Followup Instructions: ___
19966115-DS-8
19,966,115
23,669,560
DS
8
2184-02-10 00:00:00
2184-02-10 20:07:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: ___ Edema Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ yo M with a PMH of ___ disease, HTN, DM, Spinal stenosis, and bilateral TKR's who presents with leg swelling and pain. Of note, the patient is a poor historian and sedated during interview. His wife and daughter were unavailable. The patient presents with one week of lower extremity edema, R>L. He also complains of bilateral knee pain. The patient is seen by Dr. ___ at ___. His Lt knee had been found to have evidence of periprosthetic joint loosening, but per the patient, he was told he was not an operative candidate. One week ago, he stepped on his R leg wrong and felt a twinge in the R knee. He has been experiencing significant pain even since. He saw Dr. ___ on the day of presentation, who reportedly is considering doing another cortisone shot in his knee in the future. She also reportedly recommended using a lidocaine patch but did not give the patient a prescription. No X-rays have been done recently. Per the patient, Dr. ___ was concerned that the patient has been more fatigued recently and recommended that he go to the ED to get a UA and blood work to check for a urinary tract infection (he has chronic urinary leakage and infections). In addition, patient reports worsening cough with yellow sputum. He denied fevers, chills, nausesa, vomiting, sick contacts. In the ED initial vitals were: 98.2 78 143/60 20 98%. Labs were notable for H/H 11.7/34.4, Cr 1.6. CXR showed LLL opacity. Knee XR showed fragmented appearance of patella with soft tissue prominence. The patient was given lidocaine patch, tramadol, tylenol, and ceftriaxone. On the floor, the patient reported a chronic cough which he attributes to h/o esophageal cancer. His cough has recently gotten more frequent with sputum. He denies dyspnea, orthopnea, PND, and weight gain. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: ___ DISEASE ___ ESOPHAGUS with adenocarcinoma treated with radiation therapy DIABETES MELLITUS HYPERTENSION SLEEP APNEA CPAP OSTEOARTHRITIS SPINAL STENOSIS s/p laminectomy/decompression/diskectomy FALLS H/O PAROTID DUCT STONES H/O PROSTATE CANCER s/p TURP c/b urinary retention & frequency H/O POSSIBLE CONCUSSION REMOVAL INDWELLING PORT, RIGHT CHEST ___ 1. RIGHT SINGLE PORT-A-CATH 2. LAPAROSCOPIC JEJUNOSTOMY TUBE PLACEMENT ___ LAMINECTOMY/DECOMPRESSION/DISKECTOMY TRANSURETHRAL PROSTATECTOMY BIL TKR Social History: ___ Family History: History of cirrhosis in father/brother (alcohol use). History of DM, HTN. Physical Exam: EXAM ON ADMISSION: ================== Vitals: T 97.8 BP 128/58 P71 RR 20 95 RA GENERAL: Drowsy and falls asleep during interview. No acute distress. HEENT: AT/NC, EOMI, PERRL, anicteric sclera, dry mucous membranes. NECK: nontender supple neck, no LAD, no JVD. CARDIAC: RRR, S1/S2, ___ systolic murmur loudest at ULSB. LUNG: Decreased breath sounds with crackles at the Lt base. ABDOMEN: Nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Warm and well perfused. Pulses 2+. 2+ pitting edema bilaterally up to knees. Knees not edematous, erythematous. Normal ROM, without pain. NEURO: CN II-XII intact, strength intact. EXAM ON DISCHARGE: =================== Vitals: Temp. 98.1, BP 126/66, HR 64, RR 20, 96% RA GENERAL: No acute distress. HEENT: AT/NC, EOMI, PERRL, anicteric sclera. NECK: nontender supple neck, no LAD, no JVD. CARDIAC: RRR, S1/S2, ___ systolic murmur loudest at LUSB. LUNG: crackles in lower bases, otherwise clear to auscultation bilaterally ABDOMEN: Nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: Warm and well perfused. Pulses 2+. 1+ pitting edema bilaterally up to knees, erythematous. Knees normal ROM, non-tender to palpation NEURO: CN II-XII intact. Pertinent Results: LABS ON ADMISSION: ================== ___ 06:32PM BLOOD WBC-4.1# RBC-4.06* Hgb-11.7* Hct-34.4* MCV-85 MCH-28.8 MCHC-34.0 RDW-15.6* Plt ___ ___ 06:32PM BLOOD ___ PTT-32.8 ___ ___ 06:32PM BLOOD Glucose-216* UreaN-37* Creat-1.6* Na-135 K-3.6 Cl-97 HCO3-26 AnGap-16 ___ 06:30AM BLOOD Ferritn-25* ___ 06:32PM BLOOD proBNP-718 LABS ON DISCHARGE: ================== ___ 07:25AM BLOOD Glucose-161* UreaN-28* Creat-1.4* Na-139 K-4.4 Cl-107 HCO3-24 AnGap-12 STUDIES: ========= ___ Knee AP/Lat/Oblique: IMPRESSION: Thinning of expected patellar line and attenuated fragmented appearance of patella with apparent overlying soft tissue prominence. Small joint effusion. To assess for the significance clinically, if any, of the appearance of the patella, direct correlation to prior radiographs would be helpful, if available. CXR ___: IMPRESSION: Left lower lobe opacity, which could be seen with atelectasis, although an infectious process is not excluded and results should be correlated with clinical presentation. No evidence of congestive heart failure. Echocardiogram ___: The left atrium is mildly dilated. The right atrium is moderately dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are indeterminate for left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis (valve area 1.0-1.2cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Moderate aortic stenosis. Normal biventricular cavity size with preserved regional and global biventricular systolic function. Borderline pulmonary hypertension. Brief Hospital Course: ___ yo M with a PMH of ___ disease, HTN, DM, Spinal stenosis, and bilateral TKR's who presents with bilateral ___ edema with erythema consistent with stasis dermatitis. # Lower extremity edema likely secondary to stasis dermatitis: Mr. ___ was noted to have lower extremity edema that was symmetric and erythematous to the midshins. BNP was obtained that was within normal limits to assess the likelihood of heart failure exacerbation as contributor to patient's symptoms though no prior history of CHF was noted. Mr. ___ had echocardiogram on day of discharge to evaluate his cardiac function in the setting of known OSA and predisposition to right sided heart failure. Echocardiogram showed moderate aortic stenosis with preserved global biventricular systolic function and borderline pulmonary hypertension in the setting of known OSA. It was felt that his lower extremity edema was from stasis dermatitis from venous insufficiency. He was treated with leg elevation and compression stockings. Lasix was discontinued Amlodipine was also discontinued given that it was felt that it could be contributing to lower extremity edema. His lower extremity edema improved with leg elevation and compression stockings. # URI symptoms: Mr. ___ presented with chronic cough, but inconsistent with reporting if cough is worse at this time. He remained with oxygen requirement, leukocytosis, and CXR was without evidence of pneumonia. On hospital day 2 Mr. ___ developed congestion, rhinorrhea, and sore throat. He was tested for influenza that was negative. He was treated symptomatically with tylenol and lozenges. His congestive symptoms improved prior to discharge. #Dysuria Mr. ___ endorsed dysuria prior to admission. He was noted to be on bactrim chronically for UTI precention. UA at time of admission was negative for infection. Bactrim was continued per prophylactic home dose. Mr. ___ has upcoming urology appointment with Dr. ___ on ___. # Acute on chronic renal failure (baseline creatinine of 1.4-1.6) Mr. ___ presented with creatinine of 1.6 BUN/Cr > 20 and consistent with pre-renal process and FENa 1.85% more consistent with intrinsic process and is likely to be mixed process given underlying CKD with acute insult. Patient noted to take 20 mg daily lasix which likely contributed to some degree of pre-renal insult. Creatine improved to 1.4 with fluid challenge and cessation of lasix and hydrochlorothiazide. #Hypertension Mr. ___ had systolic SBP of 140-160. Initially HCTZ-triamterene and amlodipine were held given ___ and ___ extremity edema. It was felt that given his comorbidities including hypertension, diabetes, and CKD lisinopril was started at 20 mg and HCTZ-triamterene and amlodipine were stopped. His blood pressure goal would be 130/80 given his age and comorbities include CKD and diabtes. # Knee pain s/p bilateral TKR: Mr. ___ presented with worsening knee pain. He had right knee pain at time of admission though prior to admission had been seen by his orthopedist who felt there was no indication for surgical intervention and had recommended pain management and outpatient physical therapy. X-ray of right knee at time of admission did not indicate any new injury and knee on exam does not appear to have evidence of infection. He was evaluated by physical therapy who felt he would benefit from rehabilitation. His pain was controlled with tylenol and tramadol. #Normocytic Anemia Chronic and stable. Mr. ___ ferritin was noted to be 25 and consistent with iron deficiency anemia. Should consider outpatient colonoscopy. He was started on daily ferrous sulfate with bowel regimen. #OSA Continued on bipap. Echocardiogram showed borderline pulmonary hypertension likely secondary to OSA. # DM II complicated by neuropathy: ISS continued. gabapentin continued for neuropathy # ___: Continued carbidopa-levodopa, entacapone, pramipexole # HLD: Contued simvastatin. # BPH: Continued tamsulosin. # Code: DNR, ok to intubate # Emergency Contact: ___ (Dtr) ___, ___ (Wife) ___ TRANSITIONAL ISSUES: ===================== -lasix, amlodipine, and triamterene-HCTZ was discontinued this hospital course -potassium supplementation was also stopped -lisinopril 20 mg daily was started for blood pressure control -ferrous sulfate 325 mg daily was started for iron deficiency -Echocardiogram showed moderate aortic stenosis with preserved global biventricular systolic function and borderline pulmonary hypertension. -consider colonscopy given iron deficiency anemia and low ferritin levels this hospital course -chem-7 should be checked on ___ to evaluate renal function Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY 4. Cyanocobalamin 500 mcg PO DAILY 5. Docusate Sodium 100 mg PO DAILY:PRN constipation 6. FoLIC Acid 1 mg PO DAILY 7. Omeprazole 20 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY constipation 9. Simvastatin 10 mg PO DAILY 10. Tamsulosin 0.4 mg PO BID 11. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 12. Oyster Shell Calcium-Vit D3 (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral bid 13. Furosemide 20 mg PO DAILY PRN leg swelling 14. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral daily 15. Humalog 10 Units Breakfast Humalog 0 Units Lunch Humalog 8 Units Dinner Humalog 0 Units Bedtime 16. Acetaminophen 650 mg PO Q6H:PRN pain 17. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 18. Gabapentin 300 mg PO TID 19. Klor-Con 10 (potassium chloride) 10 mEq oral daily 20. Sarna Lotion 1 Appl TP QID:PRN itching 21. Sildenafil 100 mg PO PRN sexual activity 22. Sulfameth/Trimethoprim DS 1 TAB PO DAILY daily 23. Thiamine 100 mg PO DAILY 24. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 25. Clotrimazole Cream 1 Appl TP BID 26. pramipexole 0.5 mg oral TID daily 27. entacapone 200 mg oral 5X's daily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY 3. Docusate Sodium 100 mg PO DAILY:PRN constipation 4. entacapone 200 mg oral 5X's daily 5. FoLIC Acid 1 mg PO DAILY 6. Gabapentin 300 mg PO TID 7. Omeprazole 20 mg PO BID 8. Polyethylene Glycol 17 g PO DAILY constipation 9. pramipexole 0.5 mg oral TID daily 10. Simvastatin 10 mg PO DAILY 11. Sulfameth/Trimethoprim DS 1 TAB PO DAILY daily 12. Tamsulosin 0.4 mg PO BID 13. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath 14. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral daily 15. Clotrimazole Cream 1 Appl TP BID 16. Cyanocobalamin 500 mcg PO DAILY 17. Oyster Shell Calcium-Vit D3 (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral bid 18. Sarna Lotion 1 Appl TP QID:PRN itching 19. Sildenafil 100 mg PO PRN sexual activity 20. Thiamine 100 mg PO DAILY 21. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain 22. Lisinopril 20 mg PO DAILY RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 23. Compression Stalkings Stasis Dermatitis ICD-9 code ___.1 4 pairs please wear compression stockings one on each leg daily 24. 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 25. Senna 8.6 mg PO BID:PRN constipation RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60 Capsule Refills:*0 26. Aspirin 81 mg PO DAILY 27. Humalog 10 Units Breakfast Humalog 0 Units Lunch Humalog 8 Units Dinner Humalog 0 Units Bedtime Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Stasis Dermatitis Acute on chronic kidney injury Hypertension Secondary: Osteoarthritis s/p bilateral TKR ___ disease ___ Esophagus with adenocarcinoma treated with radiation therapy Diabetes Mellitus Hypertension Sleep apnea on CPAP 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 of swelling in your legs. It was felt that the swelling in your legs was not because of your heart. Your leg swelling was thought to be from "stasis dermatitis" a condition where swelling in your leg results from decreased flow of fluid back to the heart. It is treated with compression stockings and leg elevation. Your kidney function was also slighltly diminished due to dehydration and we have you IV fluids and it improved before discharge. You had a sore throat, cough, and congestion. You were tested for the flu and this test was negative. Your symptoms improved prior to discharge. You were assessed by physical therapy who felt that you would benefit from rehabilitation. Sincerely, Your ___ Team Followup Instructions: ___
19966322-DS-5
19,966,322
27,308,251
DS
5
2140-11-09 00:00:00
2140-11-10 14:41:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo F with hypothyroidism who p/w acute onset substernal chest pain radiating to the back. She was at a warm and crowded art exhibit, standing for quite some time, when she suddenly felt nauseated. She then noticed palpitations that turned into ___ pain in the ___ her chest. She sat down, but the pain persisted. She called EMS after going home and was given baby aspirin and nitro x2, which provided relief of pain to ___. She then came to the ED. . In the ED, initial VS 98.2 90 156/82 18 91%RA, 97%2L. CXR showed widened mediastinum without pleural effusion. Chest CT was obtained and neg for aortic dissection and PE. D-dimer also neg. Pt was given morphine, O2 (though not subjectively short of breath), IVF, and a dose of cipro for leukocytosis and ?UTI. Pt then admitted to Cardiology service for further management. VS on transfer, 98.4 80 15 115/53 97% 2L NC. . On arrival to the floor, VS. 97.7 119/62 82 16 98% 2L. Chest pain remains pleuritic especially on deep inspiration, and continues to radiate to upper back, but has decreased to ___. Nausea resolved. No dyspnea. . Pt has never had this pain before. She denies any recent illness. She just returned from ___ 2 weeks ago and felt well at the time. Of note, she also takes amoxicillin for dental procedures (last taken 5 weeks ago), but had a root canal 1 week ago and had forgotten to take her antibiotic. . Past Medical History: Hypothyroidism Osteoporosis Asthma Social History: ___ Family History: Mother was long time smoker who had COPD and died of MI. Father died young of ?colon cancer Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.7 119/62 82 16 98% 2L Gen: WDWN, sitting upright in bed, NAD. A&Ox3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Mucous membranes dry. Neck: Supple with JVP of 8 cm. Kussmaul's sign neg. CV: RRR, nl S1, S2, no murmurs, no rub, no gallops. Heart sounds not muffled. Pulm: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. B/l inspiratory crackles ___ up. Abd: Soft, NT,ND. No HSM or TTP. +BS Extr: wwp, no ___ edema. Dark nail ___. Neuro: A&Ox3, CNII-XII intact. Sensation to LT intact. PULSES: 2+ radial and ___ pulses b/l . DISCHARGE PHYSICAL EXAM VS: 97.4 115/55 (104-120/55-63) 82 (72-91) 18 94%RA Gen: WDWN, sitting upright in bed, NAD. A&Ox3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI, MMM. Neck: Supple with JVP of 8 cm. Kussmaul's sign neg. CV: RRR, nl S1, S2, no murmurs, no rub, no gallops. Heart sounds not muffled. Pulm: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. R-sided inspiratory crackles ___ up. Abd: Soft, NT,ND. No HSM or TTP. +BS Extr: wwp, no ___ edema. Dark nail ___. Neuro: A&Ox3, CNII-XII intact. Sensation to LT intact. PULSES: 2+ radial and ___ pulses b/l Pertinent Results: CBC ___ WBC-16.9* RBC-3.65* Hgb-12.1 Hct-34.7* MCV-95 MCH-33.1* MCHC-34.8 RDW-12.8 Plt ___ ___ Neuts-81.7* Lymphs-13.4* Monos-3.0 Eos-1.4 Baso-0.5 ___ WBC-8.5 RBC-3.34* Hgb-11.1* Hct-31.8* MCV-95 MCH-33.2* MCHC-34.8 RDW-12.8 Plt ___ . CHEMISTRY ___ Glucose-113* UreaN-38* Creat-1.0 Na-143 K-4.0 Cl-104 HCO3-29 ___ Glucose-107* UreaN-20 Creat-0.9 Na-142 K-4.1 Cl-111* HCO3-26 ___ Calcium-8.8 Phos-2.2* Mg-2.2 . CARDIAC ENZYMES ___ 03:55PM CK(CPK)-92 ___ 11:15PM cTropnT-<0.01 ___ 06:00AM cTropnT-<0.01 ___ 03:55PM CK-MB-3 cTropnT-<0.01 ___ 06:45AM CK-MB-3 cTropnT-0.01 CK(CPK)-85 ___ 06:45AM CK(CPK)-85 . COAGS ___ ___ PTT-22.5* ___ . OTHER ___ D-Dimer-194 Urine Culture ___ Pending . CXR ___: FINDINGS: Portable chest radiograph demonstrates apparent widening of mediastinum this is due to patient rotation. Cardiomediastinal and hilar contours are unremarkable. Low lung volumes with vascular crowding. Lungs are clear. No pleural effusion or pneumothorax. IMPRESSION: No acute intrathoracic process. . CTA CHEST ___: FINDINGS: Chest CTA: The aorta is of normal caliber throughout and without evidence of dissection. The pulmonary vasculature is well opacified and without filling defect to suggest pulmonary embolism. Heart size is normal and without pericardial effusion. CT Chest: The thyroid gland is incompletely visualized, though demonstrated portions are unremarkable. Minimal dependent atelectasis identified bilaterally, otherwise, lungs are clear. Airways are normal to the subsegmental levels. No pleural effusion or pneumothorax identified. Though this exam is not tailored for subdiaphragmatic evaluation, the demonstrated portions of the liver are unremarkable. Though this exam is not tailored for subdiaphragmatic evaluation, the visualized aspects of the liver and adrenal glands are unremarkable. No suspicious lytic or blastic lesions are evident. IMPRESSION: No evidence of aortic dissection or pulmonary embolism. No acute process identified. . TTE ___: 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%). 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) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Physiologic mitral regurgitation is seen (within normal limits). The tricuspid valve leaflets are mildly thickened. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. There are no echocardiographic signs of tamponade. There is no evidence of pericardial constriction. IMPRESSION: Normal global and regional biventricular systolic function. No pericardial effusion, pulmonary hypertension or pathologic valvular abnormality seen. . Brief Hospital Course: ___ yo F with hypothyroidism who p/w acute onset chest pain with diffuse ST elevations and PR depressions on ECG consistent with acute pericarditis. . # Chest pain: Likely acute pericarditis given classic ECG findings. A normal CXR and Chest CTA with negative D-dimer effectively ruled out pulmonary embolism and aortic dissection. Ruled out for MI with cardiac enzymes negative x3. Pt started on indomethacin x2 weeks, colchicine x3 months, and omeprazole x2 weeks for prophylaxis. TTE was obtained given recent history of dental procedures and showed normal function, no evidence pericardial effusion, and no vegetations. . # ?Hypoxia: In ED pt was noted to have O2 sat of 91%, asymptomatic. On floor, noted that she had dark nail ___ this was removed and O2 sat improved to mid 90's. Pt was asymptomatic throughout admission. She had bilateral crackles on lung exam, but CXR and CTA Chest were remarkable only for atelectasis. She seemed to be taking shallow breaths at first, so pain from pericarditis may have caused shallow breathing and atelectasis. She is prescribed advair diskus for "asthma", but has never had PFTs and has used her advair ___ times in the last ___ years, so the diagnosis seems unlikely. . CHRONIC STABLE ISSUES: # Hypothyroidism: continued on home dose levothyroxine. . Medications on Admission: Levothyroxine 88 mcg daily Advair 250/50 mcg BID (only required 2x in last ___ yrs) multivitamins QD Calcium Vitamin D 1000 Units QD Discharge Medications: 1. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily): Do not take with levothyroxine. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily) for 2 weeks. Disp:*14 Capsule, Delayed Release(E.C.)(s)* Refills:*0* 6. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. indomethacin 50 mg Capsule Sig: One (1) Capsule PO three times a day for 1 weeks. Disp:*21 Capsule(s)* Refills:*0* 8. indomethacin 50 mg Capsule Sig: One (1) Capsule PO twice a day for 4 days: start after finishing 1 week of indomethacin 3 times weekly. Disp:*8 Capsule(s)* Refills:*0* 9. indomethacin 50 mg Capsule Sig: One (1) Capsule PO once a day for 3 days: start after finishing indomethicin 2 times daily. Disp:*3 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis acute pericarditis Secondary Diagnosis hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___. You were admitted with chest pain and found to have inflammation of the lining around the heart, called pericarditis. We treated you with NSAIDs and colchicine to calm the inflammation. You should continue these meds and follow up with your cardiologist and PCP. The following changes were made to your medication list: **START indomethacin [anti-inflammatory]. Take a 50mg pill THREE times daily for 1 week, then TWO times daily for four days, then ONCE daily for 3 days, then stop **START colchicine 0.6 mg ONCE daily for 3 months, or until told to stop by your PCP. [anti-inflammatory] **START omeprazole 20 mg ONCE daily, take for 2 weeks [stomach protection] Followup Instructions: ___
19966553-DS-9
19,966,553
27,576,329
DS
9
2135-06-04 00:00:00
2135-06-04 19:52:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: ___: Cardiac catheterization History of Present Illness: ___ w/hx of T2DM and HTN acutely started feeling intense chest pressure w/o radiation morning of ___ along with nausea and severe dyspnea. Daughter reports that she was also unable to answer questions coherently, had slurred speech and was profoundly diaphoretic. EMS was called and inferior ST elevations while en route. In the ED, found to have CHB with escape in ___, SBPs in the ___. Her chest pain improved by the time she went to the cath lab. A temp pacer wire was placed and she was paced at 60 beats per minute prior to coronary cath. Right shot first showing occluded and recanalized RCA with distal embolization. BMS x 2 placed and patient started conducting intrinsically. Left coronaries found to have 90% mid LAD obstruction and 100% obstruction of LCA (felt to be chronic). Swan showed elevated filling pressures. PCWP ___, RAP ___. RVDP up as well. MVO2 40's with calculated CO about 4 and CI 2.6. Echo showed EF 40-50% with inferior hypokinesis and moderate to severe MR without ruptured papillary muscle. During the procedure, she received bivalrudin, heparin gtt, and she was loaded with clopidogrel 600mg and ASA 325mg. She received 2L of NS in the cathlab. Hct was found to be 20% then 18%, blood was hung. She denies hx of red or black stools. After cath, lactate was trending down. Most recent gas was 7.30/___/132/14. CBC significant for normal WBC and platelets with Hgb 6.8. Chem-7 145/4.4/118/___/1.0/309 EKG post-cath with ST resolution. SBPs 140. Has the following catheters: ___ in R Femoral Art and ___ in R Femoral Vein . She received furosemide 40mg IV and a nitro gtt to help with post-cath diuresis. Upon arrival to the floor, the patient was pleasant and comfortable, feeling cold, difficult to get precise answers. She denied any chest pain and admitted to some dyspnea. Her vitals were 34.4C | 68 | 166/72 | 21 | SpO2 100% on 4L/min. The bear hugger device was placed to rewarm the patient. Of note, patient reports having fatigue and generally not feeling well for the past ___ weeks. She was recently diagnosed with iron deficiency anemia in ___ when found to have hgb 9 from 13. She reports she may have had pink stools over the past few days but she is unsure. Past Medical History: HTN DMII Diverticulosis, diverticulitis in ___ s/p partial colectomy?? Anemia during last ___ ? Chronic cognitive decline ?Angina(uses nitropatch for last ___ years) Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM ======================== VS: T=35.2C BP=168/86 HR=87 RR= 19 O2 sat=100% on 4L/min General: Pale and thin elderly lady in no acute distress. Lying flat comfortably. HEENT: Anicteric sclera, conjunctival pallor, dry oral mucosa, smooth tongue Neck: Supple, JVD to the mid neck, no HJR CV: RRR, Normal S1 and S2apical holosystolic murmur, no rubs or gallops Lungs: Good breath sounds, scant bibasilary crackles Abdomen: Non-distended, BS+ ___ quadrants, soft, non-tender Rectal: Dark brown stool with some red specs. Not melenic Ext: Cold proximally and distally, good capillary filling, no pitting edema Neuro: AOx3. Tangential and circumstancial thought process. Can move all 4 extremities at will. Skin: Dry, cold, pale, no lesions PULSES: DP and ___ present ++/+++ DISCHARGE PHYSICAL EXAM ======================== General: Pale and thin elderly lady in no acute distress. Lying flat comfortably. HEENT: Anicteric sclera, conjunctival pallor, dry oral mucosa, smooth tongue Neck: Supple, no JVD, no HJR CV: RRR, Normal S1 and S2apical holosystolic murmur, no rubs or gallops Lungs: Good breath sounds, CTAB Abdomen: Non-distended, normoactive BS, soft, non-tender Ext: Warm and well perfused, 1+ pitting edema on the R>L. Resolving right groin hematoma. Neuro: AOx3. Tangential and circumstancial thought process. Can move all 4 extremities at will. Skin: Dry, cold, pale, no lesions PULSES: DP and ___ present ++/+++ Pertinent Results: ADMISSION LABS =============== ___ 10:08AM BLOOD WBC-10.1 RBC-2.58* Hgb-6.7* Hct-22.8* MCV-89 MCH-25.9* MCHC-29.2* RDW-15.3 Plt ___ ___ 10:08AM BLOOD Neuts-41.9* Lymphs-53.4* Monos-3.0 Eos-1.1 Baso-0.6 ___ 02:17PM BLOOD WBC-9.4 RBC-2.97* Hgb-8.0* Hct-25.9* MCV-87 MCH-26.8* MCHC-30.8* RDW-15.2 Plt ___ ___ 08:10PM BLOOD Hgb-8.3* Hct-26.6* ___ 02:17PM BLOOD ___ PTT-150* ___ ___ 10:08AM BLOOD Glucose-309* UreaN-32* Creat-1.0 Na-145 K-4.4 Cl-118* HCO3-9* AnGap-22* ___ 02:17PM BLOOD Glucose-289* UreaN-31* Creat-1.0 Na-139 K-4.6 Cl-115* HCO3-15* AnGap-14 ___ 02:17PM BLOOD Albumin-2.8* Calcium-7.5* Phos-4.3 Mg-1.6 ___ 10:08AM BLOOD CK-MB-5 cTropnT-0.43* ___ 10:08AM BLOOD ALT-30 AST-54* LD(LDH)-269* CK(CPK)-51 AlkPhos-116* TotBili-0.1 ___ 10:08AM BLOOD calTIBC-250* Hapto-359* Ferritn-69 TRF-192* ___ 11:03AM BLOOD Type-ART pO2-106* pCO2-27* pH-7.23* calTCO2-12* Base XS--14 ___ 11:47AM BLOOD Type-ART pO2-132* pCO2-27* pH-7.30* calTCO2-14* Base XS--11 ___ 11:03AM BLOOD Glucose-323* Lactate-5.1* Na-132* K-4.0 Cl-110* ___ 11:47AM BLOOD Lactate-3.9* ___ 02:40PM BLOOD Lactate-1.4 PERTINENT LABS =============== ___ 03:25PM BLOOD WBC-8.8 RBC-3.59* Hgb-9.9*# Hct-30.0* MCV-84 MCH-27.6 MCHC-33.0 RDW-15.0 Plt ___ ___ 05:15AM BLOOD ___ PTT-27.1 ___ ___ 05:15AM BLOOD Ret Aut-2.3 ___ 05:15AM BLOOD Glucose-94 UreaN-30* Creat-1.2* Na-141 K-4.1 Cl-112* HCO3-18* AnGap-15 ___ 05:15AM BLOOD CK(CPK)-553* ___ 05:15AM BLOOD CK-MB-62* MB Indx-11.2* cTropnT-3.00* ___ 05:15AM BLOOD Calcium-7.7* Phos-3.9 Mg-2.1 ___ 03:15PM BLOOD WBC-9.2 RBC-3.00* Hgb-8.2* Hct-25.7* MCV-86 MCH-27.5 MCHC-32.0 RDW-15.1 Plt ___ ___ 10:44AM BLOOD Glucose-211* UreaN-28* Creat-1.0 Na-140 K-4.9 Cl-112* HCO3-20* AnGap-13 ___ 06:25AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.9 ___ 05:45AM BLOOD WBC-7.8 RBC-2.50* Hgb-7.0* Hct-21.5* MCV-86 MCH-27.8 MCHC-32.4 RDW-15.4 Plt ___ ___ 05:45AM BLOOD Glucose-215* UreaN-27* Creat-1.0 Na-139 K-4.0 Cl-112* HCO3-20* AnGap-11 ___ 08:30AM BLOOD LD(LDH)-268* ___ 05:45AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.8 ___ 05:00AM BLOOD WBC-9.7 RBC-2.98* Hgb-8.3* Hct-25.4* MCV-85 MCH-27.9 MCHC-32.7 RDW-16.5* Plt ___ ___ 05:00AM BLOOD Glucose-137* UreaN-25* Creat-0.9 Na-142 K-4.1 Cl-113* HCO3-22 AnGap-11 ___ 05:00AM BLOOD Calcium-7.6* Phos-2.5* Mg-1.7 ___ 06:45AM BLOOD WBC-8.6 RBC-2.99* Hgb-8.5* Hct-25.8* MCV-86 MCH-28.3 MCHC-32.9 RDW-16.4* Plt ___ ___ 06:45AM BLOOD Glucose-138* UreaN-20 Creat-0.8 Na-139 K-4.1 Cl-112* HCO3-19* AnGap-12 ___ 06:45AM BLOOD Calcium-7.7* Phos-2.6* Mg-1.6 ___ 07:20AM BLOOD WBC-9.1 RBC-2.96* Hgb-8.3* Hct-25.6* MCV-87 MCH-27.9 MCHC-32.3 RDW-16.2* Plt ___ ___ 07:20AM BLOOD Glucose-252* UreaN-24* Creat-0.8 Na-138 K-4.1 Cl-109* HCO3-20* AnGap-13 ___ 07:20AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.6 DISCHARGE LABS =============== ___ 07:55AM BLOOD WBC-8.5 RBC-2.85* Hgb-7.8* Hct-25.2* MCV-89 MCH-27.6 MCHC-31.1 RDW-15.5 Plt ___ ___ 07:55AM BLOOD Glucose-140* UreaN-25* Creat-0.9 Na-140 K-4.8 Cl-110* HCO3-24 AnGap-11 ___ 07:55AM BLOOD Calcium-8.0* Phos-3.1 Mg-1.7 REPORTS ======== LENIS ___ No lower extremity DVT Persistent right groin hematoma. Correlate clinically for signs of enlargement. ___ CHEST X-RAY Focal opacity in the right medial lung base with associated air bronchograms and corresponding to the right middle lobe location on the lateral view. These findings are more suggestive of bronchiectasis in a patient with a history of recurrent pneumonia, although an acute infectious process cannot be excluded. Comparison to prior studies and clinical correlation is advised. The remaining lungs are clear. Overall cardiac and mediastinal contours are within normal limits. No pneumothorax or pulmonary edema. Blunting of both posterior costophrenic angles may reflect small effusions or chronic pleural thickening. No acute bony abnormality. Followup imaging should be based on the clinical assessment. ___ CHEST X-RAY IMPRESSION: No significant appreciable change in size of right groin hematoma. ___ Small right groin hematoma. No evidence of pseudoaneurysm or other vascular abnormality. ___ TTE There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior, inferoseptal, and inferolateral segments, as well as mid inferoseptal and inferolateral segments. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). The mitral valve leaflets are mildly thickened. An eccentric, posteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Moderate [2+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Mildly depressed left ventricular systolic function with extensive regional wall motion abnormalities as decribed above consistent with coronary artery disease, likely involving the RCA/LCx territories. Moderate to severe mitral regurgitation. Moderate tricuspid regurgitation. ___ Cardiac Cath RCA: Initial limited angiography showed an eccentric 90% proximal-mid RCA lesion with TIMI 2 flow in a calcified vessel. There was a 50% mid RCA lesion with mild diffuse plaquing in the distal RCA before the RPDA. The RPDA had a 60% mid stenosis. The distal AV groove RCA after the RPDA had a ~70% stenosis. The RPL system was large and hyperdominant. The major RPL (RPL5) had anorigin 60% stenosis with post-stenotic dilata tion. Three vessel coronary artery disease, with ? chronic occlusion of the distal CX vs. more likely anatomic variant with the entire lateral LV supplied by the large distal RCA and RPL system. Successful deployment of 2 bare metal stents in the RCA. Brief Hospital Course: ___ with diabetes and HTN with 3 weeks of fatigue and dyspnea who p/w acute chest pressure/N/V found to have inferior STEMI # Inferior STEMI: She was taken to the cath lab on presentation, with findings of occluded and recanalized RCA with distal embolization. BMSx2 was placed. Left coronaries found to have 90% mid LAD obstruction and 100% obstruction of LCA (felt to be chronic). ECHO revealed EF 40-50% with inferior hypokinesis and moderate to severe MR without ruptured papillary muscles. During the procedure, she received bivalirudin, heparin gtt, and she was loaded with clopidogrel 600 mg and ASA 325 mg. She received 2L of NS in the cathlab. Chest pain subsided, with improvement of dyspnea as well. She was placed on aspirin, Clopidogrel, atorvastatin and metoprolol. # Anion gap metabolic acidosis: Anion gap 18 with lactate 5.1->3.9 with IVF/transfusions. Patient appeared to be perfusing well with a normal CI and lactate likely related to poor O2 carrying capacity and hypotension in setting of CHB. She was transfused with PRBC's in Cath lab. Hct was monitored and lactate trended to normal. # Acute-on-chronic normocytic anemia: Appears to be subacute in nature as Hgb was 13 in ___ and 9 in ___ when she was diagnosed with iron deficiency at that time. Her most recent colonoscopy was ___ years ago. Initial rectal exam was without melena or gross blood but she had guiaic + stool, though later in her hospitalization she was noted to have melanotic stool. Iron studies revealed ferritin 69 and normal/low TIBC, elevated haptoglobin and normal T. bili, ruling out hemolysis. Concern for GI malignancy. GI was consulted who recommended EGD/Colonoscopy as an outpatient. She received a total of 4 units of pRBCs since admission with appropriate hematocrit bump. She should continue Pantoprazole 40 mg daily. # Right groin hematoma: Patient developed acute rapid enlargement of R groin hematoma (at site of line placement for cath) upon sitting up and moving to the edge of the bed on ___. Pressure was held with STAT U/S revealing small hematoma and no pseudoaneurysm. Hematoma remained stable during the rest of her hospital stay, confirmed by repeat ultrasound on ___. She did have evidence of right lower extremity edema>left on ___, though LENIs were negative for DVT. At the time of discharge, Hct was 25.2. # Acute on chronic congestive heart failure with systolic dysfunction: LVEF 40-50%. Received fluids intraprocedure and diuresed with furosemide. Echocardiogram showed LVEF of 50% with mild regional left ventricular systolic dysfunction with hypokinesis of the basal inferior, inferoseptal, and inferolateral segments, 3+MR and 2+TR. Fluid balance monitored closely and she appeared euvolemic throughout the rest of the hospital stay. # Cough: Ms. ___ had a mild cough throughout during her hospital stay. She had no fevers or leukocytosis. CXR was not definitive for acute infectious process, but could not rule it out. Repeat CXR showed stable infiltrate. Given no clinical signs of a pneumonia she was not started on antibiotics. However, she was started on Tessalon Perles, dextromethorphan, and albuterol MDI and her lisinopril was switched to losartan. # Diabetes Melitus: placed on HISS ========================== TRANSITIONAL ISSUES ========================== - Patient has scheduled Cardiology follow-up with Dr. ___ ___ - Patient was found to have low-grade GI bleeding. She will require outpatient colonoscopy and EGD for guiac (+) stools and normocytic anemia work-up Medications on Admission: The Preadmission Medication list is accurate and complete. 1. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 2. benazepril 20 mg oral daily 3. Nitroglycerin Patch 0.4 mg/hr TD Q24H 4. GlipiZIDE 2.5 mg PO TID 5. Pantoprazole 40 mg PO Q24H 6. FoLIC Acid 1 mg PO DAILY 7. Ferrous Sulfate 325 mg PO DAILY Discharge Medications: 1. Ferrous Sulfate 325 mg PO DAILY 2. FoLIC Acid 1 mg PO DAILY 3. Pantoprazole 40 mg PO Q24H 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 80 mg PO HS 6. Losartan Potassium 25 mg PO DAILY 7. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY 8. GlipiZIDE 2.5 mg PO TID 9. Clopidogrel 75 mg PO DAILY Do not stop taking this medicine or miss any doses unless Dr. ___ that it is OK to do so. 10. Metoprolol Succinate XL 37.5 mg PO DAILY 11. Nitroglycerin SL 0.4 mg SL PRN chest pain Take 1 tab, wait 5 min, then take 1 more tab. Call ___ if you still have chest pain after 2 tabs. 12. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN sore throat 13. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough Discharge Disposition: Home Discharge Diagnosis: PRIMARY Inferior STEMI Acute on chronic CHF SECONDARY GI bleed Anemia Right groin hematoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because of chest discomfort and were found to have a heart attack. You underwent a procedure where a stent was placed in the arteries of your heart that were blocked to open them back up. You felt better after this procedure. We will send you home with medications to help prevent this from occuring again in the future. You were also seen by the gastroenterology team because of your low red blood cell counts. It is likely that you are slowly losing blood from your GI tract. The cause of this is unclear at this time but we recommend that you follow up with a gastroenterologist after your are discharged from ___. Followup Instructions: ___
19966756-DS-25
19,966,756
21,700,620
DS
25
2153-06-20 00:00:00
2153-06-21 07:55:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Enalapril Attending: ___. Chief Complaint: bleeding Major Surgical or Invasive Procedure: EGD Colonoscopy PICC placement History of Present Illness: ___ with history of dCHF, HTN, PE, DM2, CKD who presents with shortness of breath, bilateral leg swelling, CP and headache. The patient reports 2 days of shortness of breath and ___ weeks of increasing leg swelling. He reports that he had a bitemporal headache early yesterday without blurred vision, neck pain, paresthesias, that has since resolved. He also reports a 5 min episode of chest pressure early yesterday am that has since resolved. He denies palpitations but does report SOB x a few days, but not orthopnea. He reports increased leg swelling x 2 weeks and thinks he likely has gained some weight. He reports cough since dx of PE. He reports a few episodes of vomiting yesterday. He denies fever, chills, abdominal pain, nausea, diarrhea, constipation, melena, brbpr, dysuria, changes in appetite or weight. . In the ED, he was noted to have brown, trace guaiac positive stool. EKG with SR, left axis, normal intervals, similar to prior. CXR with pulm vascular congestion similar to prior. He was ordered for 1 unit of blood. . 10 ___ ROS Reviewed and otherwise negative. Past Medical History: HTN dCHF DVT/PE *S/P COLON CANCER - reports colonic resection for cancer at age ~ ___ ? CHOLELITHIASIS DIABETES, TYPE II GOUT HYPERTENSION RENAL INSUFFICIENCY S/P CATARACTS INGUINAL HERNIA PAST SURGICAL HISTORY: - Pars plana vitrectomy, right eye; endolaser, right eye (___) - Umbilical hernia repair - Colectomy (side unspecified, for colon cancer) Social History: ___ Family History: Father ___ CIRRHOSIS Sister ___ ___ STROKE Physical Exam: ADMISSION GEN: tired appearing, NAD vitals:T 99.3 BP 172/74 HR 75 RR 20 sat 100% on 3L HEENT: ncat eomi anicteric dry MM neck: supple chest: b/l ae, bibasilar crackles, decreased bs heart: s1s2 rr no m/r/g abd: +bs, soft, NT, ND, no guarding or rebound ext: no c/c 3+ pitting edema to the thighs b/l neuro: face symmetric, speech fluent, moves all extremities psych: calm, cooperative Pertinent Results: ___ 02:11AM ___ PO2-47* PCO2-42 PH-7.42 TOTAL CO2-28 BASE XS-2 ___ 01:47AM LACTATE-1.3 ___ 01:40AM GLUCOSE-287* UREA N-97* CREAT-4.4* SODIUM-137 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-23 ANION GAP-21* ___ 01:40AM cTropnT-0.06* proBNP-8025* ___ 01:40AM CALCIUM-9.3 PHOSPHATE-5.9*# MAGNESIUM-2.6 ___ 01:40AM WBC-8.5 RBC-2.66* HGB-5.6*# HCT-18.7*# MCV-70*# MCH-21.1*# MCHC-29.9*# RDW-19.4* RDWSD-47.6* ___ 01:40AM NEUTS-83.8* LYMPHS-6.0* MONOS-8.9 EOS-0.2* BASOS-0.4 NUC RBCS-0.4* IM ___ AbsNeut-7.16* AbsLymp-0.51* AbsMono-0.76 AbsEos-0.02* AbsBaso-0.03 ___ 01:40AM PLT COUNT-171 ___ 01:40AM ___ PTT-31.5 ___ . CXR: pulm edema . CT head: IMPRESSION: 1. No acute intracranial process. 2. Parenchymal atrophy and chronic small vessel ischemic disease. 3. Paranasal sinus disease as described above . EKG: overall similar to prior ___ Colon biopsy: adenoma ECHO: The left atrial volume index is mildly increased. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF = 65%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular free wall is hypertrophied. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___ the tricuspid regurgitation is worse; the pulmonary artery pressure is higher. DC LABS: ___ 06:44AM BLOOD WBC-5.2 RBC-3.03* Hgb-7.5* Hct-23.4* MCV-77* MCH-24.8* MCHC-32.1 RDW-19.8* RDWSD-54.6* Plt ___ ___ 06:09AM BLOOD ___ ___ 06:09AM BLOOD Glucose-128* UreaN-56* Creat-3.0* Na-139 K-4.0 Cl-100 HCO3-29 AnGap-14 ___ 06:30AM BLOOD ALT-14 AST-21 AlkPhos-68 TotBili-0.3 Brief Hospital Course: This is a ___ year old male with past medical history of diastolic CHF, DM type 2 with diabetic nephropathy, CKD stage 4, recent ___ acute DVT/PE admitted ___ with acute diastolic CHF, ___, and acute blood loss anemia, s/p ___ and polypectomy, course otherwise complicated by anemia of chronic kidney disease # Acute and Chronic Diastolic CHF - Patient admitted with lower extremity edema and hypoxia, with exam concerning for decompensated heart failure. No clear exacerbating factor was identified. Patient was treated with BID IV lasix with slow clinical improvement complicated by his underlying severe CKD (see below) as well as need for transfusions for his anemia (see below). Discharge weight was 70.6kg. He was transitioned to Torsemide 60mg daily and close monitoring is recommended. Chem 7 and fluid status follow up is recommended at next appointment. Consider cardiology referral. # Chronic Blood Loss Anemia / Acute Blood Loss Anemia / Anemia of Chronic Kidney Disease / Iron deficiency anemia - patient admitted with progression of anemia; found to be iron deficient and had guaiac positive brown stools. Thought to have had acute worsening of a chronic anemia, with likely lower GI source. Patient required several transfusions through the course of his hospitalization that were complicated by his heart failure. Patient underwent ___ that showed cecal polyps, status post polypectomies. Hemostasis was complex, given his recent diagnosis of DVT/PE ___ (anticoagulation described below). Following ___, patient remained quite anemic, requiring additional transfusions, attributed to iron and CKD. There was no role for Epo at this time after discussion with nephrology. He was maintained on iron and had received several transfusions. Ultimately his Hct remained stable. He will require further GI work up to include capsule endoscopy, and GI follow up was arranged. Would repeat CBC on follow up - He will also need repeat colonoscopy in 6 months given adenoma which was found this hospitalization # Acute GI Bleed NOS / Cecal Polyp - as above, patient felt to have acute on chronic bleed leading up to admission; ___ with cecal polyps for which he underwent polypectomies. Continued home PPI. 6 month C scope is recommended. # Chronic DVT/PE / Chronic Respiratory Failure - DVT/PE diagnosed during admission ___. Since that time he has been treated with coumadin and supplemental O2 (___). Coumadin held at time of EGD/colonoscopy and was subsequently restarted after waiting 48 hours after polypectomy. He was given warfarin 3mg daily and INR was 2.4 on discharge. # ___ on CKD stage 4 - patient with cardiorenal syndrome on admission; with creatinine improving to baseline with diuresis. Discharge Cr was 3 # Diabetes type 2 - continued lantus + humalog # GERD - continued PPI # Gout - continued allopurinol # Hypertension - continued amlodipine, clonidine, minoxidil # Hyperlipidemia - continued statin Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 2 mg PO DAILY16 2. Torsemide 20 mg PO DAILY 3. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 4. ZEMplar (paricalcitol) 4 mcg oral DAILY 5. Allopurinol ___ mg PO DAILY 6. Amlodipine 10 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 20 mg PO QPM 9. CloniDINE 0.3 mg PO BID 10. Docusate Sodium 100 mg PO BID 11. Metoprolol Tartrate 100 mg PO BID 12. Minoxidil 10 mg PO BID 13. Senna 8.6 mg PO BID:PRN c Discharge Medications: 1. Allopurinol ___ mg PO DAILY 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. CloniDINE 0.3 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Glargine 10 Units Breakfast Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 1 Units Dinner Insulin SC Sliding Scale using HUM Insulin 7. Metoprolol Tartrate 100 mg PO BID 8. Minoxidil 10 mg PO BID 9. Senna 8.6 mg PO BID:PRN c 10. Warfarin 3 mg PO DAILY16 RX *warfarin [Coumadin] 1 mg 3 tablet(s) by mouth once a day Disp #*180 Tablet Refills:*0 11. Torsemide 60 mg PO DAILY RX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*90 Tablet Refills:*0 12. ZEMplar (paricalcitol) 4 mcg oral DAILY 13. Ferrous Sulfate 325 mg PO DAILY RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0 14. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute blood loss anemia GI bleeding Iron deficiency anemia Chronic kidney disease stage IV Type 2 diabetes mellitus h/p PE/DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted due to anemia caused by GI bleeding, iron deficiency, and your kidney disease. It is very important that you follow up closely with your gastroenterologist for ongoing care. You also had a flare of your heart failure. Please take all medications as prescribed. Please take your warfarin and have your INR checked in ___ days. Weigh yourself every morning, call MD if weight goes up more than 3 lbs. Followup Instructions: ___
19966756-DS-26
19,966,756
25,743,475
DS
26
2153-08-26 00:00:00
2153-08-26 16:47:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: None History of Present Illness: ___ with history of HTN, DM2, HFpEF, presents with 1 day history of nausea/vomiting. Pt reports 1 day history of NBNB vomiting (approx. 5 episodes) and feeling generally unwell. He does endorse blurry vision but denies other symptoms, including chest pain or pressure, shortness of breath, headache, weakness or numbness. He reports that he has been taking his medications as prescribed. Of note, pt has a history of diastolic CHF, but his weight has been decreasing recently, prompting his PCP to decrease his dose of torsemide to 20mg po daily. He denies diarrhea, abdominla pain, dysuria, cough, or fevers. In the ED, initial vitals: 98.2 ___ 20 97% RA Pt was given: 1L IVF, Zofran 4mg, labetalol 10mg IV x 2, 20mg IV x 2, and then started on labetalol gtt. On arrival to the MICU, pt endorses history above. He is sleepy but able to answer questions mostly appropriately in a quiet voice. He does not subjectively feel confused. Review of systems: As per above otherwise negative. Past Medical History: HTN dCHF DVT/PE *S/P COLON CANCER - reports colonic resection for cancer at age ~ ___ ? CHOLELITHIASIS DIABETES, TYPE II GOUT HYPERTENSION RENAL INSUFFICIENCY S/P CATARACTS INGUINAL HERNIA PAST SURGICAL HISTORY: - Pars plana vitrectomy, right eye; endolaser, right eye (___) - Umbilical hernia repair - Colectomy (side unspecified, for colon cancer) Social History: ___ Family History: Father ___ CIRRHOSIS Sister ___ ___ STROKE Physical Exam: ADMISSION EXAM: ================ Vitals: T: 98.9 BP:198/94 P:85 R:18 O2:92% GENERAL: Confused, oriented to person and place, NAD HEENT: Sclera anicteric, Dry MM, oropharynx clear NECK: Supple, JVP not elevated LUNGS: Bibasilar crackles, otherwise clear to auscultation bilaterally CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: Soft, mild tenderness around umbilicus, non-distended, bowel sounds present EXT: Warm, 2+ pulses, no clubbing, cyanosis or edema SKIN: Dry, no rashes or lesions NEURO: No focal neurological deficits, generalized tremors, CN2-12 intact, strength ___ upper extremities, ___ lower extremities, and sensation intact bilaterally. Able to do days of the week backwards with pauses. DISCHARGE EXAM: ================ Vitals: T 98.2, HR 92, BP 130/66, RR 18, SaO2 99% RA, I/O 1080/1100 GENERAL: Well appearing, comfortable in NAD, sitting up in chair. Oriented to self, ___ and date. HEENT: Sclera anicteric, MMM, poor dentition NECK: JVP elevated to tragus LUNGS: CTAB, breathing comfortably. CV: Regular rate and rhythm, normal S1 S2 ABD: Soft, nontender, non-distended, bowel sounds present EXT: Warm, 2+ pulses, no clubbing, cyanosis or edema SKIN: Dry, no rashes or lesions. NEURO: No focal deficits. Pertinent Results: ============== ADMISSION LABS ============== ___ 01:00AM BLOOD WBC-8.8# RBC-4.94# Hgb-12.2*# Hct-39.3*# MCV-80* MCH-24.7* MCHC-31.0* RDW-21.2* RDWSD-58.4* Plt ___ ___ 01:00AM BLOOD Neuts-90.5* Lymphs-5.6* Monos-3.5* Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.92*# AbsLymp-0.49* AbsMono-0.31 AbsEos-0.00* AbsBaso-0.01 ___ 01:00AM BLOOD ___ PTT-26.7 ___ ___ 01:00AM BLOOD Glucose-306* UreaN-42* Creat-2.9* Na-143 K-5.8* Cl-101 HCO3-28 AnGap-20 ___ 01:00AM BLOOD ALT-36 AST-50* AlkPhos-121 TotBili-0.5 ___ 01:00AM BLOOD proBNP-9922* ___ 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 03:49PM BLOOD ___ pO2-99 pCO2-51* pH-7.38 calTCO2-31* Base XS-3 ============== PERTINENT LABS ============== ___ 01:06AM BLOOD Lactate-3.4* K-4.6 ___ 01:06PM BLOOD Lactate-3.3* ___ 03:49PM BLOOD Lactate-2.7* ___ 01:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 01:00AM BLOOD cTropnT-0.04* ___ 12:52PM BLOOD CK-MB-57* MB Indx-8.4* cTropnT-1.48* ___ 03:20PM BLOOD CK-MB-61* cTropnT-2.09* ___ 08:29PM BLOOD CK-MB-53* cTropnT-2.54* ___ 03:10AM BLOOD CK-MB-25* cTropnT-1.89* ============ MICROBIOLOGY ============ - Blood culture: negative - Urine culture: negative ======= IMAGING ======= EEG ___ IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of a slow and disorganized background. The clinical events identified had significant muscle artifact, but no epileptiform changes seen. Interval results were conveyed to the treating team intermittently during this recording period to assist with ___ medical decision-making. CXR ___. No evidence of pneumonia. CT A/P ___ 1. No acute intra-abdominal process within the limitations of an unenhanced scan. 2. Extensive severe calcified atherosclerotic disease involving all of the intra-abdominal artery is and the partially visualized coronary arteries. 3. 8 mm left lower lobe pulmonary nodule for which nonemergent completion chest CT is recommended. RECOMMENDATION(S): Nonemergent completion chest CT is recommended to evaluate for additional pulmonary nodules in the setting of an 8 mm left lower lobe pulmonary nodule and a history of colon cancer. ___ ___ 1. No acute intracranial process. 2. Unchanged left frontal encephalomalacia, age related involutional changes, and sequelae of chronic small vessel ischemic disease. 3. Of note, MRI is more sensitive for the detection of intracranial masses. ___ ___ There is no acute hemorrhage mass effect or midline shift. Left frontal encephalomalacia again seen. Mild to moderate brain atrophy and small vessel disease noted. Extensive soft tissue vascular calcifications are seen. EEG ___ IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of a slow and disorganized background. No epileptiform findings were identified. Interval results were conveyed to the treating team intermittently during this recording period to assist with ___ medical decision-making. ECHO ___ The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is hypokinesis of the mid to distal inferior walls and inferoseptal segments. Tissue Doppler imaging suggests an increased left ventricular filling pressure. (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Globally preserved biventricular systolic function with hypokinesis of the mid to distal inferior and inferoseptal segments. Moderate symmetric left ventricular hypertrophy. Increased left ventricular filling pressure. No clinically significant valvular disease. Borderline pulmonary artery systolic pressure. Compared with the prior study (images reviewed) of ___, the wall motion abnormalities are new. The severity of mitral and tricuspid regurgitation has decreased. The pulmonary artery systolic pressure is lower. ============== DISCHARGE LABS ============== ___ 06:00AM BLOOD WBC-4.5 RBC-3.83* Hgb-9.4* Hct-30.7* MCV-80* MCH-24.5* MCHC-30.6* RDW-21.2* RDWSD-60.0* Plt ___ ___ 06:00AM BLOOD Glucose-152* UreaN-42* Creat-2.8* Na-145 K-3.5 Cl-106 HCO3-28 AnGap-15 ___ 06:00AM BLOOD Calcium-9.2 Phos-2.9 Mg-1.8 Brief Hospital Course: Mr. ___ is a ___ male with a history of HFpEF, DM type 2 with diabetic nephropathy, and CKD stage 4 who presented with nausea/vomiting and was admitted for hypertensive emergency requiring ICU stay. His course was complicated by toxic metabolic encephalopathy and NSTEMI. # Hypertensive emergency: Patient presented to the ED with SBPs to the 240s. Unclear cause of hypertensive emergency but may possibly have been medication non-adherence. He was admitted to the ICU and started on a labetalol drip with goal reduction of SBP of approximately 20% in the first day. He was initiated on metoprolol and amlodipine as his labetalol gtt was weaned off. Home clonidine was slowly downtitrated and discontinued after transfer to the floor. He was switched from metoprolol to carvedilol and home minoxidil was restarted. Blood pressures on the floor were well-controlled. # NSTEMI: Patient presented with a several day history of nausea/vomiting, which may represent his anginal equivalent. He remained chest pain free throughout this event. Troponins peaked at 2.54, EKG with T-wave flattening in II, III, aVF. Elevated troponins were initially attributed to demand ischemia in the setting of hypertensive emergency. However, a TTE revealed new WMA concerning for true ACS and cardiology was consulted. He was initiated on heparin gtt, ASA, Plavix, and atorvastatin. Cardiac catheterization was considered, but after discussion with the patient and family about the risk of progression of his CKD to ESRD with the significant contrast load, this was ultimately deferred. Per cardiology, he should continue Plavix for one year. # Acute toxic metabolic encephalopathy: During his MICU course, patient had multiple episodes of waxing and waning mental status with episodes of diminished responsiveness to verbal or painful stimuli. In the setting of his hypertensive emergency and underlying comorbidities, these events were highly concerning for acute infarction. Neurology was consulted during these episodes. Non-contrast CT head x 2 were obtained without evidence of acute change. On ___, episodes of high amplitude shaking were noted on exam and patient was initated on Keppra for presumed seizure. EEG during this episode did not show evidence of seizure activity and Keppra was discontinued. Infectious work up was unrevealing for possible infectious etiology. Encephalopathy was attributed to relative hypotension while on labetalol gtt. His mental status returned to baseline. # Acute on chronic diastolic congestive heart failure with preserved ejection fraction: Patient has a history of congestive heart failure with normal EF (>55%). Weight on recent discharge was 70.6 kg and he presented at 61.3 kg. BNP 9000 on admission with elevated JVP, so home torsemide was continued. He received an extra dose of 20 mg on ___ and became hypotensive with SBP 100. He was discharged on torsemide 20 mg daily. # Chronic stage IV CKD: Creatinine remained at baseline (2.8). Electrolytes were normal. # Diabetes: Type 2 DM, poorly controlled, insulin requiring and complicated by nephropathy. Home glargine 10 units qAM was continued. He was also placed on a Humalog sliding scale. # Chronic anemia: This is thought to be due to anemia of chronic kidney disease and possible chronic GI bleeding. He had ___ on recent hospitalization which showed only cecal polyps. He was due to get capsule endoscopy at some point. His Hb ranged from 8 to 9 (above recent baseline of 7). >30 minutes were spent on discharge planning. Transitional Issues ==================== -Patient presented with hypertensive emergency. He should have his blood pressure monitored closely by PCP and medications adjusted PRN. Medications on discharge include amlodipine 10 mg daily, carvedilol 12.5 mg bid (switched from metoprolol), minoxidil 10 mg bid, and torsemide 20 mg daily. Clonidine was stopped due to the risk of reflex hypertension. -Patient had NSTEMI during admission. Patient declined catheterization and was treated medically. He was started on aspirin and Plavix (he should continue Plavix for one year). Atorvastatin dose was increased to 80 mg daily. PCP may consider referral to cardiology as outpatient if it is within patient's goals of care. -Patient had 8 mm left lower lobe pulmonary nodule identified on CT A/P during admission. Follow up chest CT is as outpatient is recommended. This was discussed with patient prior to discharge and a letter sent to ___ office as ___ reminder as well. Communication: ___: ___ ___ (wife), ___ ___, cell ___ home ___ Code: DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Amlodipine 10 mg PO DAILY 3. Atorvastatin 20 mg PO QPM 4. CloniDINE 0.3 mg PO BID 5. Docusate Sodium 100 mg PO BID 6. Metoprolol Tartrate 100 mg PO BID 7. Minoxidil 10 mg PO BID 8. Senna 8.6 mg PO BID:PRN c 9. Torsemide 20 mg PO DAILY 10. ZEMplar (paricalcitol) 4 mcg oral DAILY 11. Ferrous Sulfate 325 mg PO DAILY 12. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. Amlodipine 10 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. Docusate Sodium 100 mg PO BID 5. Ferrous Sulfate 325 mg PO DAILY 6. Minoxidil 10 mg PO BID 7. Senna 8.6 mg PO BID:PRN c 8. Torsemide 20 mg PO DAILY 9. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 10. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 11. ZEMplar (paricalcitol) 4 mcg oral DAILY 12. Carvedilol 12.5 mg PO BID RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 13. Glargine 10 Units Breakfast Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnoses ================== Hypertensive Emergency NSTEMI Secondary Diagnoses ==================== Chronic Stage IV Kidney Disease Heart Failure with Preserved Ejection Fraction Type 2 Diabetes Anemia 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 very high blood pressure and were briefly in the Intensive Care Unit (ICU). While in the ICU you were confused and there was evidence of damage to your heart, likely caused by your elevated blood pressures. Your blood pressure improved with medications and your symptoms resolved. You were placed on two new medications for your heart (aspirin and Plavix). You should continue taking these medications unless told to stop by your doctor. Your blood pressure medications were changed during this hospitalization. You should take all medications as instructed and follow up with your primary care doctor as scheduled to have your blood pressure rechecked. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
19966756-DS-28
19,966,756
20,726,020
DS
28
2155-12-13 00:00:00
2155-12-15 21:33:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___. Chief Complaint: Hyperglycemia Major Surgical or Invasive Procedure: ___ - Tunneled Dialysis Line (Right Internal Jugular) History of Present Illness: ___ year old male with IDDM, CKD IV, hypertension, hyperlipidemia, HFrEF (last EF in ___ was 36%), and CAD s/p NSTEMI with DES to LAD in ___ who presented to the ED with elevated blood glucose levels and was found to have a CXR concerning for pneumonia. Patient reports checking his blood sugar yesterday afternoon and noting it to be over 300, despite taking his insulin as prescribed. He endorses nausea and one episode of vomiting yesterday morning but denied fevers, abdominal pain, diarrhea, chest pain, and shortness of breath. He endorsed a dry cough that is chronic. He says the only reason he came in was because of the elevated blood glucose reading. ED course: Exam in the ED was notable for glucose 261, hypertension with systolics in the high 180s and 2+ pitting ___ edema. A CXR was officially read as "increased opacities in the right greater than left lower lobes concerning for pneumonia". Also of note, his ECG showed ST depressions in the lateral leads. Labs were remarkable for troponin 0.12, CK-MB 5, and BNP 18617. He was given ceftriaxone and azithromycin for CAP, as well as 500cc IVF. Several hours later, he became tachypneic with RR in the ___ in the setting of blood pressures of 196/110. A repeat CXR showed "increased opacities involving the bilateral mid to lower lung field with obscuration of the bilateral costophrenic angles suggest progression of mild pulmonary edema with probable layering bilateral pleural effusion." He was given 0.4mg of SL nitroglycerin with resolution of his symptoms. His BP decreased to 144/86 and his RR decreased to 25. He never desaturated but was still tachypneic so he was placed on BIPAP and a request was changed to an ICU bed. On arrival to the MICU, patient reports that he is feeling good. He denies any shortness of breath, chest pain. He endorses a dry cough but states that this is chronic and unchanged from his baseline. Past Medical History: Hypertension CAD s/p NSTEMI with DES to LAD (___) HFrEF DVT/PE CKD Stage IV T2DM Gout Anemia Colon Cancer s/p colonic resection for cancer at age ~___ (per patient) s/p Cataracts Inguinal Hernia Social History: ___ Family History: Father ___ CIRRHOSIS Sister ___ ___ STROKE No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Family history of hypertension. Physical Exam: PHYSICAL EXAM ON ADMISSION: =========================== VS: T 98.3F, BP 158/77, HR 61, RR 18, O2 sat 96% on 2L GENERAL: NAD HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no LAD CV: normal S1, S2 without murmurs, rubs, or gallops PULM: coarse breath sounds, but otherwise no wheezes, rhonchi, or crackles GI: abdomen soft, non-distended, and non-tender to palpation EXTREMITIES: 1+ pretibial edema bilaterally PULSES: 2+ radial pulses bilaterally NEURO: Alert and oriented to person, place, and date. Moving all 4 extremities with purpose, face symmetric DERM: warm and well perfused, no excoriations or lesions, no rashes PHYSICAL EXAM ON DISCHARGE: =========================== VS: T 99.1F, BP 138/63, HR 71, RR 18, O2 sat 95% on RA General: NAD, sitting comfortably in chair MSK: No muscle spasm observed. HD catheter site's has dried blood around it. Cardiac: RRR, S1, S2, systolic ejection murmur ___ in RUSB and LUSB. JVD 10-11 cm. Lung: CTAB Abdomen: Soft, non-tender, non-distended ___: No swelling or edema ___ Pertinent Results: =============== ADMISSION LABS: =============== ___ 11:40PM GLUCOSE-135* UREA N-59* CREAT-3.8* SODIUM-143 POTASSIUM-6.1* CHLORIDE-112* TOTAL CO2-18* ANION GAP-13 ___ 11:40PM CK-MB-7 cTropnT-0.14* ___ 11:40PM CALCIUM-8.2* PHOSPHATE-4.7* MAGNESIUM-2.0 ___ 11:40PM WBC-4.4 RBC-3.51* HGB-9.0* HCT-28.6* MCV-82 MCH-25.6* MCHC-31.5* RDW-16.9* RDWSD-49.3* ___ 11:40PM PLT COUNT-106* ___ 11:40PM ___ PTT-23.5* ___ ___ 11:00PM GLUCOSE-137* UREA N-63* CREAT-3.7* SODIUM-143 POTASSIUM-5.3 CHLORIDE-111* TOTAL CO2-19* ANION GAP-13 ___ 10:07AM ___ PO2-185* PCO2-34* PH-7.33* TOTAL CO2-19* BASE XS--6 COMMENTS-GREEN TOP ___ 10:07AM LACTATE-1.8 ___ 10:07AM freeCa-1.03* ___ 09:54AM GLUCOSE-126* UREA N-59* CREAT-3.7* SODIUM-144 POTASSIUM-4.9 CHLORIDE-113* TOTAL CO2-14* ANION GAP-17 ___ 09:54AM cTropnT-0.14* ___ 09:54AM CALCIUM-8.3* PHOSPHATE-4.0 MAGNESIUM-2.0 ___ 08:26AM GLUCOSE-126* UREA N-58* CREAT-3.5* SODIUM-145 POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-19* ANION GAP-14 ___ 08:26AM CK-MB-5 cTropnT-0.14* ___ 08:26AM CALCIUM-8.1* PHOSPHATE-4.0 MAGNESIUM-2.0 ___ 08:26AM WBC-4.2 RBC-3.41* HGB-8.7* HCT-28.5* MCV-84 MCH-25.5* MCHC-30.5* RDW-16.7* RDWSD-49.9* ___ 08:26AM NEUTS-74.3* LYMPHS-12.5* MONOS-10.8 EOS-1.0 BASOS-0.7 IM ___ AbsNeut-3.08 AbsLymp-0.52* AbsMono-0.45 AbsEos-0.04 AbsBaso-0.03 ___ 08:26AM PLT COUNT-144* ___ 08:26AM ___ PTT-25.4 ___ ___ 02:42AM ___ PO2-23* PCO2-40 PH-7.32* TOTAL CO2-22 BASE XS--6 ___ 01:56AM LACTATE-1.2 ___ 01:48AM GLUCOSE-261* UREA N-59* CREAT-3.4* SODIUM-142 POTASSIUM-4.4 CHLORIDE-109* TOTAL CO2-21* ANION GAP-12 ___ 01:48AM estGFR-Using this ___ 01:48AM LIPASE-35 ___ 01:48AM LIPASE-35 ___ 01:48AM cTropnT-0.12* ___ 01:48AM CK-MB-5 ___ ___ 01:48AM ALBUMIN-3.4* CALCIUM-8.7 PHOSPHATE-3.8 MAGNESIUM-2.0 ___ 01:48AM URINE HOURS-RANDOM ___ 01:48AM URINE UHOLD-HOLD ___ 01:48AM WBC-3.4* RBC-3.90* HGB-10.0* HCT-31.7* MCV-81* MCH-25.6* MCHC-31.5* RDW-16.6* RDWSD-49.1* ___ 01:48AM PLT COUNT-136* ___ 01:48AM NEUTS-70.3 LYMPHS-14.0* MONOS-11.3 EOS-3.5 BASOS-0.6 IM ___ AbsNeut-2.42 AbsLymp-0.48* AbsMono-0.39 AbsEos-0.12 AbsBaso-0.02 ___ 01:48AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:48AM URINE BLOOD-SM* NITRITE-NEG PROTEIN-600* GLUCOSE-100* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:48AM URINE RBC-6* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 ___ 01:48AM URINE HYALINE-6* ___ 01:48AM URINE MUCOUS-RARE* =================== DISCHARGE LABS: =================== ___ 08:10AM BLOOD WBC-5.1 RBC-2.83* Hgb-7.2* Hct-23.2* MCV-82 MCH-25.4* MCHC-31.0* RDW-17.3* RDWSD-51.0* Plt ___ ___ 08:10AM BLOOD Glucose-227* UreaN-42* Creat-3.7* Na-141 K-3.7 Cl-100 HCO3-27 AnGap-14 ___ 08:10AM BLOOD Albumin-3.1* Calcium-7.6* Phos-1.7* Mg-1.9 ==================== IMAGING STUDIES: ==================== ___ EXAMINATION: VENOUS MAPPING FOR DIALYSIS ACCESS IMPRESSION: Patent bilateral basilic and cephalic veins with measurements as above. Mild to moderate calcifications of the bilateral brachial and, moderate calcification of the left radial artery normal peak systolic velocities. ___ Radiology ___ ___ TUNNELED W/O PORT IMPRESSION: Successful placement of a 19 cm tip-to-cuff length tunneled dialysis line. The tip of the catheter terminates in the right atrium. The catheter is ready for use. ___ CXR FINDINGS: Low lung volumes are unchanged, contributing to crowding of bronchovascular markings. There is tortuosity of the descending thoracic aorta. Moderate cardiomegaly is unchanged. Mild pulmonary edema is slightly improved compared to prior study. No focal consolidations. No pleural effusion or pneumothorax is seen. IMPRESSION: 1. Slight interval improvement of mild pulmonary edema and moderate cardiomegaly. 2. Persistent low lung volumes. ___ CXR (Portable) IMPRESSION: Comparison to ___. Stable low lung volumes persist. Moderate cardiomegaly is unchanged. Mild pulmonary edema is present on today's radiograph. No pleural effusions. No pneumonia. EKG (___): NSR at rate of 108 BPM with normal axis and intervals. ST depressions appreciated V4-5. TWI noted in I, aVL, and V6. ___ Renal US IMPRESSION: 1. No hydronephrosis. 2. Bilateral simple renal cysts. 3. Slightly echogenic appearance of the renal cortices may reflect known medical renal disease. ___ CXR (Portable) IMPRESSION: Comparison to ___, 04:38. No relevant change is noted. Low lung volumes. Moderate cardiomegaly with retrocardiac atelectasis that has minimally increased in extent. Mild pulmonary edema. No pleural effusions. No pneumonia. ___ CXR (Portable) IMPRESSION: 1. Increased opacities involving the bilateral mid to lower lung field with obscuration of the bilateral costophrenic angles suggest progression of mild pulmonary edema with probable layering bilateral pleural effusion. ___ CXR (PA & Lat) IMPRESSION: 1. Increased opacities in the right greater than left lower lobes is concerning for pneumonia, atelectasis can have a similar appearance. ECHO (___): The left atrial volume index is SEVERELY increased. The right atrium is mildly enlarged. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is >15mmHg. There is normal left ventricular wall thickness with a mildly increased/dilated cavity. There is mild regional left ventricular systolic dysfunction with basal inferior and basal to mid inferolateral akinesis (see schematic) and severe global hypokinesis of the remaining segments. No thrombus or mass is seen in the left ventricle. The visually estimated left ventricular ejection fraction is 15%. Left ventricular cardiac index is depressed (less than 2.0 L/min/m2). There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. Tissue Doppler suggests an increased left ventricular filling pressure (PCWP greater than 18mmHg). Mildly dilated right ventricular cavity with SEVERE global free wall hypokinesis. 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. Aortic valve stenosis cannot be excluded (planimetered valve area 1.4cm2, but cardiac output severely compramised. The appearance of the valve leaflets suggests this is all pseudo-aortic stenosis). There is no aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Mr. ___ is a ___ gentleman with ___ IDDM, CKD IV, hypertension, hyperlipidemia, HFrEF (EF 15%), and CAD s/p NSTEMI with DES to LAD in ___ who was admitted for hyperglycemia and hypertensive emergency. Patient had a PEA arrest in MICU on ___ while being transferred to the commode. Regained ROSC with one round of chest compression and one epi. He was subsequently transfered to the cardiology service for ongoing management of HFrEF exacerbation and NSTEMI, course complicated by ___ w/ ATN. Patient developed oliguria after ATN and became significantly overloaded. He is producing minimal amount of urine with IV/PO Bumex and now requires ongoing hemodialysis. ============= ACUTE ISSUES: ============= # ___ on CKD (Baseline 3.2): The patient had CKD with a Cr of 3.1-3.2 at his baseline. He developed a superimposed ___ in the setting of a PEA arrest in the MICU, with Cr trending up to ___ and BUN up to 120 while being diuresed for HFrEF exacerbation. He initially tolerated aggressive diuresis with IV diuretics. Medication was held in the setting of uptrending Cr. He subsequently developed oliguria despite resuming IV diurectics in the hopes that restoring euvolemia would improve his renal function by relieving congestive nephropathy ___ decompensated HF. Renal consult service was involved in the patient's care. Patient had tunneled dialysis line placed on ___ and received 4 rounds of dialysis during his stay. He will require ongoing dialysis three times a week as an outpatient (___). # HFrEF exacerbation: At presentation, patient demonstrated tachypnea and on CXR was found to have significant bilateral opacities consistent with pulmonary edema. BNP at presentation was elevated >18,000. Unclear dry weight. Additionally, TTE was performed while patient was in the MICU and demonstrated worsened EF from 36% to 15% with global hypokinesis and inferoseptal akinesis. Unclear precipitant for exacerbation, but possibly secondary to hypertensive crisis or to myocardial ischemia, given the regionality of akinesis. Patient initially tolerated aggressive diuresis with IV diuretics. Medication was held in the setting of uptrending Cr. He subsequently developed oliguria despite resuming IV diurectics in the hopes that restoring euvolemia would improve renal function by relieving congestive nephropathy ___ decompensated HF. He now requires dialysis to remove excess fluid as he had been only producing minimal amount of urine. For afterload reduction, he was given hydralazine 100mg PO TID, and amlodipine 5mg daily, and his home Isosorbide was continued. For neurohormonal blockade, he was given his home carvedilol. # Type II NSTEMI: Patient's troponin was elevated at presentation to 0.14. Lateral ST depressions appreciated on EKG with TWI in lateral and inferior leads, consistent with NSTEMI. Felt to be secondary to demand ischemia in the setting of patient's hypertension. Continued home ASA, atorvastatin, carvedilol, and Plavix. # Hypertensive emergency: Presented with BPs in the 180s-190s/100s, resulting in type II NSTEMI. Patient was started on standing hydralazine 100mg TID and continued on his home amlodipine and isosorbide to good effect. =============== CHRONIC ISSUES: =============== # DM: Continued insulin glargine 7U qAM and ISS ==================== TRANSITIONAL ISSUES: ==================== MEDICATIONS CHANGED: ==================== New Medication: - Clopidogrel 75mg PO Q Daily - Hydralazine 100mg PO TID - Nephrocaps PO Q Daily - Tamsulosin 0.4 mg PO QHS - Vitamin D ___ U Q Weekly for 10 weeks Changed Medication: - Torsemide 80mg PO daily changed to Bumex 4mg PO one dose after discharge - Changed Amlodipine 10mg PO QHS to 5mg QHS - Changed allopurinol ___ every other day to 100mg every other day Stopped Medication: - Ferrous Sulfate 325 mg PO DAILY Discharge Cr: 3.7 Discharge Hgb: 7.2 Discharge Weight: 66.0kg (145.5 lb) [] Close renal f/u with Dr. ___ [] Ensure stable weights on dialysis [] Hemodialysis three times a week - ___ Dialysis Center (___) at 4PM [] CBC and Chem-10 with dialysis [] Transfuse if Hgb < 7 [] Ferrlecit, Zemplar 2mcg with hemodialysis [] Must adhere to low K, low Phos diet [] Close f/u with cardiology for HFrEF (EF 15%) [] Home with ___ [] HBV IMMUNIZATION: received first dose of HBV series on ___ [] DIURESIS: will be discharged with one dose of bumetanide on ___, then volume management per HD =========================================== CONTACT: Wife, ___, ___ CODE STATUS: FULL (Presumed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO EVERY OTHER DAY 2. amLODIPine 10 mg PO HS 3. Atorvastatin 80 mg PO QPM 4. Carvedilol 25 mg PO BID 5. Doxazosin 2 mg PO HS 6. Glargine 13 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 7. Isosorbide Dinitrate 20 mg PO BID 8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 9. Torsemide 80 mg PO DAILY 10. Aspirin 81 mg PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Ferrous Sulfate 325 mg PO DAILY 13. Senna 8.6 mg PO BID:PRN Constipation - Second Line Discharge Medications: 1. Bumetanide 4 mg PO ONCE Duration: 1 Dose Please take Bumetanide on ___ RX *bumetanide 2 mg 2 tablet(s) by mouth Once Disp #*2 Tablet Refills:*0 2. Clopidogrel 75 mg PO DAILY RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 3. HydrALAZINE 100 mg PO Q8H RX *hydralazine 100 mg 1 tablet(s) by mouth every eight (8) hours Disp #*90 Tablet Refills:*0 4. Nephrocaps 1 CAP PO DAILY RX *B complex with C#20-folic acid [Nephrocaps] 1 mg 1 capsule(s) by mouth Daily Disp #*30 Capsule Refills:*0 5. Tamsulosin 0.4 mg PO QHS RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*30 Capsule Refills:*0 6. Vitamin D ___ UNIT PO 1X/WEEK (FR) RX *ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth WEEKLY (___) Disp #*10 Capsule Refills:*0 7. Allopurinol ___ mg PO EVERY OTHER DAY RX *allopurinol ___ mg 1 tablet(s) by mouth Daily Disp #*30 Tablet Refills:*0 8. amLODIPine 5 mg PO HS RX *amlodipine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30 Tablet Refills:*0 9. Glargine 7 Units Breakfast Insulin SC Sliding Scale using HUM Insulin 10. Aspirin 81 mg PO DAILY 11. Atorvastatin 80 mg PO QPM 12. Carvedilol 25 mg PO BID 13. Docusate Sodium 100 mg PO BID 14. Doxazosin 2 mg PO HS 15. Isosorbide Dinitrate 20 mg PO BID 16. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 17. Senna 8.6 mg PO BID:PRN Constipation - Second Line Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= Acute on chronic systolic heart failure Pulseless electrical activity cardiac arrest Secondary Diagnosis =================== Acute kidney injury Non-ST segment elevation myocardial infarction Hypertensive emergency Type II diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had high blood sugar levels and high blood pressure. WHAT HAPPENED IN THE HOSPITAL? ============================== - You had a cardiac arrest in the hospital. You received a round of CPR and you regained consciousness. - You had an injury to your kidneys, and they stopped making normal amount of urine. - You were seen by the kidney doctors who made ___ for treatment. You agreed to dialysis. You received dialysis in the hospital to help remove fluid and other waste products normally removed by your kidneys. - We had been giving you a medicine called Bumex through an IV to see if your kidneys would start producing urine again. Your kidneys had been producing reduced amount of urine. - We transitioned you to the oral version of Bumex before you left the hospital. - You were given the first dose of Hepatitis B Vaccine before you were discharged. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Please take all of your medications as prescribed. - Please weigh yourself daily and let you cardiologist know if you gain more than ___ so that the doses of your medications can be adjusted or dialysis schedule should be increased. - Follow up with your kidney doctor and cardiologist. - Please attend all your dialysis sessions as scheduled. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
19966826-DS-22
19,966,826
22,744,040
DS
22
2145-02-01 00:00:00
2145-02-01 18:52:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Catapres-TTS-1 Attending: ___. Chief Complaint: Urinary incontinence/urgency, malodorous urine, confusion Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo with Type II diabetes, HTN, hx UTI, complaining of foul-smelling urine, urinary frequency urgency/incontinence, dizziness x2-3 days and ___ days of delirium per son. Today, the son noticed that the patient was seeing things and thought she was standing out of bed but was laying flat, and thought there was a hole in the floor. She has had this before with urinary tract infection. Per her son, no fevers/chills but was diaphoretic before ambulance. Patient denies any belly pain, dysuria. Reports liquid stools last week. Has not been able to walk since last admission for UTI, from which she went to rehab. In the ED, initial VS were: 97.8 81 148/93 20 97% RA Past Medical History: - DM2 - HTN - HL - Allergic rhinitis - OA - Cervical spondylosis - Chronic LBP on narcotics contract - S/p DVT ___ - S/p TAH/BSO Social History: ___ Family History: Mother ___ ___ DIABETES MELLITUS, HYPERTENSION Father ___ ___ANCER Sister ___ ___ BREAST CANCER dies from vzv during chemotherapy. Sister Living ___ ARTHRITIS Brother Living ___ Brother Living ___ BACK PAIN Physical Exam: ======================== ADMISSION PHYSICAL EXAM: ======================== GEN - incontinent, comfortable, diaphoretic HEENT - dry mucous membranes, poor dentition CV - RRR, no murmurs RESP - CTAB LEGS - 1+ pitting edema b/l EXT - warm, well-perfused ABD - soft, nontender, nondistended. 2x2mm Healing wound in pannus under umbilicus. NEURO - oriented to ___, year, date. Not attentive to days of the week backwards. Can supply history with reasonable accuracy (per son). Can say months of year forwards. ======================== DISCHARGE PHYSICAL EXAM: ======================== VS: 98.2, 114/84, 69, 18, 97% RA GEN: comfortable, no apparent distress HEENT: dry mucous membranes, poor dentition CV: RRR, no murmurs RESP: CTAB LEGS: No cyanosis, edema, clubbing EXT: warm, well-perfused, 1+ pitting edema bilaterally to shins ABD: soft, nontender, nondistended. 2x2mm Healing wound in pannus under umbilicus. NEURO: Oriented to person, ___, year, date. Not attentive to days of the week backwards. Pertinent Results: =============== ADMISSION LABS: ___ ___ 08:07PM BLOOD WBC-6.5 RBC-5.08 Hgb-13.7 Hct-41.2 MCV-81* MCH-27.0 MCHC-33.3 RDW-14.8 RDWSD-43.5 Plt ___ ___ 08:07PM BLOOD Neuts-63.8 ___ Monos-7.5 Eos-2.6 Baso-1.2* Im ___ AbsNeut-4.15# AbsLymp-1.60 AbsMono-0.49 AbsEos-0.17 AbsBaso-0.08 ___ 08:07PM BLOOD Glucose-203* UreaN-15 Creat-1.0 Na-143 K-4.0 Cl-100 HCO3-26 AnGap-17 ___ 05:00PM BLOOD ALT-15 AST-26 CK(CPK)-1052* AlkPhos-50 TotBili-0.5 ___ 06:35AM BLOOD CK(CPK)-423* ___ 05:11AM BLOOD Calcium-9.7 Phos-2.5* Mg-1.3* ======================== PERTINENT INTERVAL LABS: ======================== ___ 08:24PM BLOOD Lactate-4.0* ___ 06:33AM BLOOD Lactate-3.9* ___ 05:16PM BLOOD Lactate-3.8* ___ 12:14AM BLOOD Lactate-2.0 ___ 05:00PM BLOOD VitB12-1146* ___ 05:00PM BLOOD Prolact-13 TSH-2.0 ___ 05:00PM BLOOD Free T4-1.5 ___ 05:00PM BLOOD CK-MB-12* MB Indx-1.1 cTropnT-<0.01 ___ 11:58PM BLOOD proBNP-771* =============== DISCHARGE LABS: =============== ___ 06:35AM BLOOD WBC-6.6 RBC-4.91 Hgb-13.1 Hct-39.3 MCV-80* MCH-26.7 MCHC-33.3 RDW-15.0 RDWSD-43.2 Plt ___ ___ 06:35AM BLOOD Glucose-280* UreaN-11 Creat-0.8 Na-139 K-4.1 Cl-97 HCO3-27 AnGap-15 ___ 06:35AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.8 ================ IMAGING STUDIES: ================ - CXR (___): No focal lung consolidation - CT Head (___): There is no evidence of acute territorial infarction, hemorrhage, edema, or mass. The ventricles and sulci are prominent compatible with involutional changes, stable from prior examinations. Periventricular and subcortical white matter hypodensities are nonspecific and may suggest chronic small vessel ischemic changes. A right cerebellar hypodensity is also present in ___ suggestive of a chronic infarct (2:9). No acute fracture seen. Mucous retention cyst is noted in the sphenoid sinus. The remaining paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The orbits are unremarkable. IMPRESSION: No intracranial hemorrhage or CT evidence of acute infarct. -CT ABD/PELVIS (___): 1. No acute intra-abdominal or pelvic process. 2. Cholelithiasis. 3. Moderate to severe degenerative changes of the lumbar spine, unchanged from ___. 4. Chronic right ischial bursitis. - Bilateral lower extremity U/S (___): No evidence of deep venous thrombosis in the right or left lower extremity veins. ============= MICROBIOLOGY: ============= __________________________________________________________ ___ 1:00 am BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 11:58 pm BLOOD CULTURE Source: Venipuncture. Blood Culture, Routine (Pending): __________________________________________________________ ___ 8:50 pm BLOOD CULTURE Blood Culture, Routine (Pending): __________________________________________________________ ___ 8:54 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S __________________________________________________________ ___ 8:01 pm BLOOD CULTURE Blood Culture, Routine (Pending): Brief Hospital Course: ___ year old female with Type II diabetes, HTN, history of recurrent UTIs, complaining of foul-smelling urine, urinary frequency urgency/incontinence, dizziness x ___ days and ___ days of delirium who was found to have a urinary tract infection. ============= ACUTE ISSUES: ============= #UTI: Patient presented with urinary incontinence, malodorous urine, and confusion for ___ days with a UA showing WBC >182, few bacteria. Urine cultures positive for Klebsiella Pneumonia. Patient was initially treated empirically with IV Cefriaxone (first dose ___, then narrowed per sensitivities to PO Bactrim DS BID. Of note, she has a history of recurrent UTIs (most recently ___ growing E.Coli and Klebsiella. Plan to continue treatment with PO Bactrim DS BID for 3 more days following discharge (total 7 day course of abx). #Altered Mental Status: Patient presented with confusion for the last ___ days per son. She is alert but inattentive on exam. No focal neurologic deficits, able to follow commands, moving all extremities with purpose. CT head negative. CXR, VBG, BUN/Cr, LFTs, TSH, B12 all within normal limits. Neurology consulted, unlikely new infarct or seizure. Most likely that confusion was toxic metabolic in etiology ___ current UTI. She has had similar confusion with past UTIs per son, and baseline dementia. On discharge, she is AAOx3, but slow to answer questions. This is her baseline mental status per son. # Lower extremity ankle/calf pain: Patient complaining of lower extremity pain. Ultrasound was negative for DVT bilaterally. Pain controlled with Tylenol. Likely related to underlying arthritis/deconditioning. =============== CHRONIC ISSUES: =============== #Central vestibular dysfunction Patient endorsed dizziness during her admission, which is chronic for her, and ongoing for > 6 months. She says when she turns her head quickly to the side (especially to the right) she feels like the room is spinning. This typically lasts ___ minutes and then resolves spontaneously, but can last up to ___ where she feels like she is "falling". She says she has episodes like this daily. No fevers, headache, N/V, or focal neurologic deficits. Orthostatics also negative. Unlikely vestibular infarct because test of skew was negative. ___ consider BPPV, vestibular migraine (although no associated headache or history of migraines), or vestibular paroxysmia. Plan for follow up with PCP for further workup and treatment of chronic dizziness as an outpatient. #T2DM: Most recent ___ HbA1c 8.8%. Patient on Metformin and Glipizide at home. Oral anti-hyperglycemics were held on admission, and patient treated with insulin sliding scale. Plan to restart home glipizide on discharge. Home Metformin held in the setting of lactate elevation on admission to 4.3, and the concern for lactic acidosis in the setting of acute infection. Lactate normalized during her hospital admission with fluids and antibiotics. Plan to discharge patient on home glipizide as above, and insulin sliding scale while at rehab. Would likely benefit from resuming Metformin upon discharge from rehab, after acute infection has resolved. #HTN: Continued home Metoprolol Succinate XL 50 mg PO daily, Lisinopril 40 mg PO/NG daily, and Amlodipine 10 mg PO/NG daily. ==================== TRANSITIONAL ISSUES: ==================== [ ] Continue Bactrim DS PO daily for 3 more days for cystitis/UTI [ ] Patient discharged on home glipizide, while holding home metformin in the setting of lactic acid elevation on admission. Will instead discharge on insulin sliding scale while at rehab. Would likely benefit from resuming Metformin upon discharge from rehab, after acute infection has resolved. [ ] In terms of her dizziness, most likely BPPV, but may also consider vestibular migraine (although no associated headache or history of migraines) and/or vestibular paroxysmia. Consider anti- magnetic resonance imaging (MRI) for evidence of neurovascular compression if concern for vestibular paroxysmia. Please continue workup and treatment of chronic dizziness as an outpatient. [ ]Follow up with primary care provider ___ 1 week of discharge #CONTACT: Health care proxy: ___ Phone number: ___ Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Acetaminophen 650 mg PO TID 7. GlipiZIDE 10 mg PO BID 8. MetFORMIN (Glucophage) 1000 mg PO BID 9. Sertraline 50 mg PO DAILY Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice a day Disp #*6 Tablet Refills:*0 2. Acetaminophen 650 mg PO TID 3. amLODIPine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. GlipiZIDE 10 mg PO BID 6. Lisinopril 40 mg PO DAILY 7. Metoprolol Succinate XL 50 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Sertraline 50 mg PO DAILY 10. HELD- MetFORMIN (Glucophage) 1000 mg PO BID This medication was held. Do not restart MetFORMIN (Glucophage) until speaking with your primary care doctor 11. Insulin sliding scale Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: #Uncomplicated UTI #Altered Mental Status Secondary Diagnosis: #Benign Paroxysmal Positional Vertigo #T2DM #HTN Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! Why was I admitted to the hospital? -You were admitted because you had confusion and a urinary tract infection. What happened while I was in the hospital? - You were treated with antibiotics for your urinary tract infection. You will need to continue taking these antibiotics twice daily when you go to rehab. - You also had some confusion on admission. We did a CT scan of your head while you were admitted which looked normal. It is likely that your confusion was related to your urinary tract infection. What should I do after leaving the hospital? - Please take your medications as listed in discharge summary and follow up at the listed appointments. Thank you for allowing us to be involved in your care, we wish you all the best! Sincerely, Your ___ Healthcare Team Followup Instructions: ___
19966826-DS-25
19,966,826
27,596,355
DS
25
2145-10-15 00:00:00
2145-10-15 16:09:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Catapres-TTS-1 / Bactrim / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Dysuria, abdominal and back pain Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ female with the past medical history of Insulin dependent Type II diabetes, HTN, and hx of recurrent UTI, who presents complaining of foul-smelling urine, urinary frequency urgency, dizziness x2-3 days and ___ days of delirium per son. Today, the son noticed that the patient was confused and thought she was standing out of bed but was laying flat. She has had this before with urinary tract infection. Per her son, who cares for the patient, UTIs may be recurring due to the patient soiling herself in her depends. ROS: no fevers/chills but was diaphoretic before ambulance. Patient also notes occasional suprapubic pain. Past Medical History: - DM2 - HTN - HL - Allergic rhinitis - OA - Cervical spondylosis - Chronic pain due to degenerative arthritis - S/p DVT ___ - S/p TAH/BSO - recurrent UTIs Social History: ___ Family History: Mother ___ ___ DIABETES MELLITUS, HYPERTENSION Father ___ ___ANCER Sister ___ ___ BREAST CANCER died from vzv during chemotherapy. Physical 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: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. No HSM GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert but inattentive, oriented to person and place only, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: ___ 03:25PM WBC-7.1 RBC-4.66 HGB-11.8 HCT-36.3 MCV-78* MCH-25.3* MCHC-32.5 RDW-15.1 RDWSD-42.4 ___ 03:25PM MAGNESIUM-1.5* ___ 03:25PM GLUCOSE-172* UREA N-13 CREAT-0.8 SODIUM-143 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15 Urine Culture: ecoli ___ 01:44AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-100* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD* ___ 01:44AM URINE RBC-1 WBC-22* BACTERIA-MOD* YEAST-NONE EPI-<1 Brief Hospital Course: #Recurrent UTIs - slightly more confused than her baseline, noting dizziness, dysuria and suprapubic pain over the past few days as well. This is similar to her past episodes of early UTI. No leukocytosis or fevers. UA positive, growing e coli - f/u sensies - treat with IV CTX but will ultimately send out on Bactrim, augmentin or levaquin to complete ___ day course - taking adequate po fluids #Increased needs at home - son may need increased help at home as pt is stooling into depends which may be leading to recurrent UTIs - ___ is interested in expanding elder service coverage so that pt receives care twice daily (once in the morning, once in the evening) M-F. ___ made plan to ___ with ___ during next shift (___) when ___ is able to obtain program names; ___ available ___. #DM2 - d/c metformin, start lantus 12 units nightly and SSI #HTN - c/t lisinopril and amlodipine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Fluticasone Propionate NASAL 2 SPRY NU BID 4. Lisinopril 40 mg PO DAILY 5. Metoprolol Succinate XL 50 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Sertraline 50 mg PO DAILY 8. trospium 20 mg oral BID 9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate Discharge Medications: 1. Sulfameth/Trimethoprim DS 1 TAB PO BID UTI Duration: 4 Days RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1 tablet(s) by mouth twice daily Disp #*8 Tablet Refills:*0 2. amLODIPine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Fluticasone Propionate NASAL 2 SPRY NU BID 5. Lisinopril 40 mg PO DAILY 6. Metoprolol Succinate XL 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Sertraline 50 mg PO DAILY 9. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 10. trospium 20 mg oral BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: E coli UTI Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted with a urinary tract infection. We treated you with an IV antibiotic called ceftriaxone. Your urine culture showed a bacteria called E. coli. We would like you to complete a course of oral antibiotics (Bactrim) when you go home. It is important that you change your depends frequently and avoid getting bacteria from stool into your urinary tract. Please follow up with your PCP. Followup Instructions: ___
19966826-DS-28
19,966,826
22,560,858
DS
28
2146-03-08 00:00:00
2146-03-08 17:44:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Catapres-TTS-1 / Bactrim / Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Confusion, pain with urination Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with history of DM2, HTN, chronic low back pain, and recurrent UTI, who presents with a recurrent episode of altered mental status. The patient was most recently admitted to the hospital from ___ after presenting with worsening confusion, disregulated sleep, and hallucinations in the setting of her husband's recent death. She was found to have UTI with UCx growing Klebsiella and E.Coli, both sensitive to CFTX. She was initially treated with IV CFTX and subsequently transitioned to PO cefpodoxine for a total 7d course. While her cognition reportedly improved with treatment of her underlying UTI, the medical record also indicates that her mental status waxed and waned throughout the admission with medication effect (ie chronic opioids, BZD) and possible adjustment disorder in setting of husband's recent death also on the differential. Additionally, work up for AMS in the past has included normal TSH, B12, and multiple cross-sectional images of the head, including a CTA head/neck earlier this year. She has also previously been seen by Neurology for question of postictal state following possible seizure event. Per neurology evaluation in ___, etiology of her AMS at that time was suspected TME in setting of UTI. From discussion with the patient's son, ___, her mental status has not fully recovered ever since she was discharged in ___. While she does not have a formal diagnosis of dementia, she has experienced a cognitive decline over the past several years that has significantly limited her ability to perform ADLS including cooking and even dressing herself. At baseline she is usually oriented to person and place, but has difficulty with the date. The acute change in mental status noted by her son over the past week has been worsening hallucinations and delusions. These include thinking people in the television are speaking to her as well as seeing and having conversations with people that aren't present. Over this time, the son has noted very foul smelling urine that the patient herself has commented on. In the ED, inital vitals: T97.0. HR 76, BP 124/80, RR 16, 99% RA. MSE notable for orientation x2 (name, ___. She knew the name of the president and day of the week as well as the fact that it was ___, however, she did not know the year. Exam notable for + suprapubic tenderness. Labs notable for WBC 6.2, Cr of 0.9, lactate 1.6. UA with > 182 WBCs and many bacteria. She was given 4.5mg IV Piperacillin-Tazobactam for recurrent UTI. Vitals stable upon transfer. Upon arrival to the floor, patient is interactive but perseverating on feeling as though she is up too high. She is intermittently tearful in regards to her dead husband. Although limited by mental status, she is able to state that she has a headache that has improved since admission without associated photophobia or neck stiffness. She endorses stomach pain but denies worsening of her chronic back pain, dysuria, or increased frequency (though incontinent at baseline). ROS: Pertinent positives and negatives as noted in the HPI. All other systems were reviewed and are negative (as best as determined in setting of AMS). Past Medical History: Diabetes mellitus Essential hypertension Hyperlipidemia Allergic rhinitis GERD Depression Overactive bladder Osteoarthritis Cervical spondylosis Chronic pain due to degenerative arthritis (back/shoulders) S/p DVT ___ S/p TAH/BSO Recurrent UTIs Social History: ___ Family History: Mother ___ ___, (unknown cause; hx of DM2 and HTN) Father ___ ___, died of Head and Neck Cancer Sister ___ ___, breast Ca, died from systemic vzv during chemotherapy. Physical Exam: ADMISSION: ========== T 98.6, BP 130/92 HR 71 RR18 94% RA. GENERAL: older woman laying in bed intermittently tearful but answering questions appropriately in NAD. EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, tender to palpation in suprapubic region without rebound. No CVA tenderness. MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Answering questions appropriately but intermittently inattentive and tangential (easily re-directable), oriented x2 (name and location, believes date is ___, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout. No resting tremor observed. Gait analysis deferred. PSYCH: pleasant, appropriate affect DISCHARGE: ========== VITALS:97.9 BP:159 / 93 67 18 97 RA GENERAL: older woman laying in bed awake and interactive, eating lunch EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate CV: Heart regular, no murmur, no S3, no S4. No JVD. RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, non- tender to palpation. No CVA tenderness. MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Answering questions appropriately, oriented x2-3 (name and location, month not date) face symmetric PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION: ========== ___ 02:00PM BLOOD WBC-6.2 RBC-5.05 Hgb-12.5 Hct-39.5 MCV-78* MCH-24.8* MCHC-31.6* RDW-16.1* RDWSD-45.5 Plt ___ ___ 02:00PM BLOOD Glucose-136* UreaN-17 Creat-0.9 Na-143 K-4.0 Cl-104 HCO3-24 AnGap-15 ___ 07:20AM BLOOD ALT-15 AST-17 AlkPhos-41 TotBili-0.3 ___ 06:33AM BLOOD Mg-1.1* ___ 08:50AM BLOOD Type-ART pO2-89 pCO2-37 pH-7.46* calTCO2-27 Base XS-2 Intubat-NOT INTUBA ___ 02:04PM BLOOD Lactate-1.6 DISCHARGE: ========== ___ 07:20AM BLOOD WBC-6.5 RBC-4.75 Hgb-11.7 Hct-36.5 MCV-77* MCH-24.6* MCHC-32.1 RDW-16.1* RDWSD-45.1 Plt ___ ___ 07:50AM BLOOD Glucose-173* UreaN-10 Creat-0.8 Na-141 K-4.1 Cl-104 HCO3-25 AnGap-12 ABG ___ on RA ABG: ___: 7.38/45/144/28 Lact 1.1 UA (___): sm blood, neg nit, lg ___, 2 RBCs, >182 WBCs, many bact C.diff (___): PCR +, Antigen - BCx (___): pending x 2 UCX (___): Klebisella pneumoniae and E.coli _________________________________________________________ KLEBSIELLA PNEUMONIAE | ESCHERICHIA COLI | | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S =>32 R CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S =>4 R GENTAMICIN------------ <=1 S =>16 R MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I <=16 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S 8 I TRIMETHOPRIM/SULFA---- <=1 S <=1 S Prior micro: UCx (___): _________________________________________________________ ESCHERICHIA COLI | KLEBSIELLA PNEUMONIAE | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I 16 I CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN--------- =>4 R <=0.25 S GENTAMICIN------------ =>16 R <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S 64 I PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ 4 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S UCX (___): _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S IMAGING: ======== Renal U/S (___): No hydronephrosis. No sonographic evidence of renal abscess. EKG (___): NSR at 91 bpm, LAD, PR 204 (1st degree AV block), QRS 98, QTC 451, poor R wave transition (similar to ___ CXR (___): Comparison to ___. Stable low lung volumes. Stable moderate cardiomegaly. Potential hiatal hernia. Newly appeared bilateral parenchymal opacities at the medial right lung bases and at the peripheral left lung basis, highly suggestive of pneumonia in the appropriate clinical setting. No pulmonary edema. No pleural effusions. NCHCT (___): There is no evidence of large territory infarction, hemorrhage, or edema. The ventricles and sulci are prominent, as seen previously, likely consistent with involutional changes. Periventricular and subcortical white matter hypodensities are nonspecific but likely secondary to moderate chronic microvascular ischemic disease. Unchanged encephalomalacia in the right cerebellum. Brief Hospital Course: ___ female with history of DM2, HTN, chronic low back pain, and recurrent UTI with multiple recent admissions (last ___ presenting with altered mental status and delusions, likely toxic metabolic encephalopathy secondary to UTI vs PNA in setting of suspected underlying dementia. # Acute Toxic Metabolic Encephalopathy: # Acute delirium: # E.coli/Klebsiella UTI vs CAP: # Suspected Dementia: Ms. ___ has had multiple recent admissions for acute on chronic encephalopathy and delusions ___, ___, dating back to ___ usually attributed to recurrent UTIs. During each of these admissions she improved with antibiotic therapy. Prior imaging, including CTA head/neck ___ and NCHCT during last admission ___ in setting of similar presentation showed no acute abnormality and revealed prominent ventricles and sulci suggestive of underlying dementia, as well as non-specific periventricular and subcortical white matter hypodensities that suggest chronic small vessel ischemia. She has been evaluated by neurology on multiple occasions, last ___, at which time no further neurologic ___ was recommended (EEG last performed and negative in ___. Her current presentation with confusion and delusions in setting of more chronic and progressive cognitive impairment was thought most consistent with a toxic metabolic encephalopathy superimposed on what is likely underlying, undiagnosed progressive dementia. Likely etiology is recurrent UTI given dysuria and growth of E.coli/Klebsiella in urine vs PNA (given what sounds like an aspiration event two days prior to admission and radiographic evidence of b/l infiltrates). No e/o aspiration on bedside swallow exam ___, and renal U/S without perinephric abscess. TSH, B12, RPR nl on prior admissions. No fever, leukocytosis, or meningismus to suggest CNS infection (and chronicity and waxing/waning nature argues strongly against meningitis). She was treated initially with CTX/azithromycin for UTI vs PNA. On ___ AM she triggered for unresponsiveness (in absence of deliriogenic medications or hypoglycemia) and antibx were broadened to include Vancomycin (given hx of Enteroccous ___ although, of note, no microbiologic confirmation of VRE despite reference to this organism in prior notes). On re-evaluation that afternoon was AOx2-3, appropriately conversant, and without evidence of obvious delusions (approximately her baseline). On the morning of ___ she was again borderline obtunded with normal vital signs and blood glucose; mental status returned to baseline within hours and without intervention, similar to her prior trajectories and suggestive of component of delirium superimposed on dementia. Lower suspicion for seizure, although has not been evaluated with EEG since ___ neurology was not consulted this admission. Given UCx with Klebsiella/E.coli, Vancomycin was discontinued on ___, and she completed 3d of azithromycin for CAP. ID was consulted for consideration of prophylactic suppressive therapy for recurrent UTIs and recommended against suppression therapy given c/f resistance induction (Fosfomycin sensis were requested should ppx be considered going forward). At ID's recommendations, she was transitioned to cefpodoxime 200mg BID on ___ to complete a 10d course through ___. She was started on Vit C to acidify the urine and will be referred to urology for consideration of urogyn testing for recurrent UTIs. Dysuria and flank tenderness have resolved and urinary incontinence is baseline. With regards to her suspected underlying dementia, etiology is likely vascular vs Alzheimers, but ___ body dementia is aconsideration given given visual hallucinations (but no Parkinsonism on exam). Of note, per review of prior notes and discussion with patient's son ___, patient has significant cognitive impairment and is largely dependent in her ADLs. She is wheelchair bound given fear of falling, although ___ reports that no organic cause of weakness has been uncovered. She uses a ___ lift at home. She requires assistance with bathing, hygiene, preparing meals, administering medication and finances. She can typically feed herself independently. She lives with two of her sons, one of which lives in her apartment and the other lives in a different space within the same home. She has a home health aid who comes during the week for 2h daily; otherwise ___ is her primary caretaker at home. She has been referred to neurology on discharge for further ___ of possible dementia. Mental status on discharge was close to recent baseline. Discussed with son ___ importance of neurology evaluation. # Diarrhea: # C.diff colonization: Developed diarrhea ___ AM, likely from antibiotics. C.diff PCR positive, toxin negative, suggestive of colonization rather than active infection (particularly in absence of fever/leukocytosis/abdominal pain). She was isolated (per protocol) and received PO vancomycin BID prophylaxis while hospitalized, while will not be continued on discharge after discussion with ID. Diarrhea had improved at discharge. She was discharged on loperamide PRN. # Headache: Ms. ___ complained of frontal headaches for the last 6 months- ___ year, likely tension headaches. No fevers/leukocytosis or meningismus to suggest CNS infection (chronicity also argues strongly against). No jaw claudication or temporal artery tenderness to suggest GCA. Recent NCHCT ___ and CTA head/neck ___ without acute pathology in setting of similar symptoms. Will plan to discharge on Tylenol PRN with instructions to ___ with her PCP for further ___ and management. # Diabetes mellitus: # Hypoglycemia: Per son, had recently been taking 18u lantus QHS. No documented low FSBGs at home, but did develop asymptomatic hypoglycemia to 60 on ___ on reduced lantus dose of 10u QHS. Lantus was further reduced to 7u with mild hyperglycemia and no recurrent hypoglycemia. She will be discharged on lantus 8 units QHS and resumption of home metformin, with instructions to ___ with her PCP for further adjustment. # Sinus Bradycardia: # 1st degree AV block: Telemetry was notable for sinus brady to ___, not clearly symptomatic. EKG with 1st degree AV block with no evidence of higher grade block. Given c/f hypoperfusion contributing to fluctuating mental status, home metoprolol dose was reduced to 25mg daily (from 50mg daily) with resolution of bradycardia. # Essential hypertension: Continued on her home regimen on amlodipine and lisinopril. Home metoprolol was decreased as above. # Hypomagnesemia: Mg 1.1 on admission. Chronic issue looking back at prior admissions. Etiology unclear in absence of ETOH abuse, clear malabsorption, diarrhea/emesis, or renal dysfunction on admission. Improved with repletion. Would consider magnesium oxide supplementation as outpatient (not initiated while hospitalized to avoid confounding diarrhea picture). # Osteoarthritis: Chronic back and neck pain thought secondary to degenerative disease. Continued home tylenol and discharged with lidocaine patch prescription. # GERD: Continued home omeprazole. # Depression: Continued home sertraline. # Contacts: ___ (son/HCP) ___ # Code Status/Advance Care Planning: FULL confirmed with son ** TRANSITIONAL ** [ ] cefpodoxime course through ___ [ ] ___ glucose control; discharged on reduced dose of lantus given morning hypoglycemia this admission [ ] ___ final UCx with fosfomycin sensitivities should UTI prophylaxis be deemed appropriate in the future [ ] urology ___ for recurrent UTIs (scheduled) [ ] neuropsych ___ for ___ of possible dementia (appointment pending) [ ] would check BMP + Mg at PCP ___ and consider magnesium supplementation Patient seen and examined on day of discharge. Discharge plan reviewed with the patient's son/HCP ___. >30 minutes on complex discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Metoprolol Succinate XL 50 mg PO DAILY 5. Omeprazole 20 mg PO DAILY 6. Sertraline 50 mg PO DAILY 7. Glargine 18 Units Bedtime 8. MetFORMIN (Glucophage) 1000 mg PO BID Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 2. Ascorbic Acid ___ mg PO BID 3. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 5 Days Through ___ 4. Lidocaine 5% Patch 1 PTCH TD QAM 5. LOPERamide 2 mg PO QID:PRN diarrhea 6. Glargine 8 Units Bedtime 7. Metoprolol Succinate XL 25 mg PO DAILY 8. amLODIPine 10 mg PO DAILY 9. Aspirin 81 mg PO DAILY 10. Lisinopril 40 mg PO DAILY 11. MetFORMIN (Glucophage) 1000 mg PO BID 12. Omeprazole 20 mg PO DAILY 13. Sertraline 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary: UTI Pneumonia Delirium Dementia Secondary: Diabetes mellitus Hypertension Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital with confusion, likely due to a pneumonia and a urinary tract infection. You were treated with antibiotics and improved. You are being discharged home to complete a course of antibiotics. It will be important for you to follow-up with your primary care doctor. In addition you are being referred to a urologist who can help investigate the cause of your recurrent urinary tract infections, as well as a neurologist for workup of your headaches and memory loss. If you continue to have difficulty sleeping, you can try taking melatonin at bedtime. Please continue to take your medications as prescribed and follow-up with your doctors. With best wishes for a speedy recovery, ___ Medicine Team Followup Instructions: ___
19966826-DS-30
19,966,826
23,373,567
DS
30
2146-12-29 00:00:00
2147-01-01 13:48:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Catapres-TTS-1 / Bactrim Attending: ___ Chief Complaint: UTI Major Surgical or Invasive Procedure: none History of Present Illness: ___ female with history of several UTIs pending due to approximately 2 days of worsening confusion with hallucinations. Per ED documentation of convo with her son, she commonly has hallucinations when she has a urinary tract infection. Patient denies any fever chills. He does have foul-smelling urine. She also is endorsing some abdominal pain. He denies any cough, chest pain, shortness of breath. No nausea or vomiting. No diarrhea. Patient denies any recent falls. According to her son, patient has been seeing cats in the house but they do not have cats as well as other visual hallucinations. Recent admission ___ for similar presentation, Her U/A was infectious appearing and her UCx grew E.Coli as well as Klebsiella (both sensitive to Ceftriaxone). Completed a 5d course of IV Ceftriaxone while hospitalized. Past Medical History: Diabetes mellitus Essential hypertension Hyperlipidemia Allergic rhinitis GERD Depression Overactive bladder Osteoarthritis Cervical spondylosis Chronic pain due to degenerative arthritis (back/shoulders) S/p DVT ___ S/p TAH/BSO Recurrent UTIs Social History: ___ Family History: Mother ___ ___, (unknown cause; hx of DM2 and HTN) Father ___ ___, died of Head and Neck Cancer Sister ___ ___, breast Ca, died from systemic vzv during chemotherapy. Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: POE Constitutional: Comfortable, pleasant Head/eyes: NCAT, PERRLA, EOMI. ENT/neck: OP WNL Chest/Resp: CTAB. Cardiovascular: RRR, Normal S1/S2. Abdomen: Soft, nondistended, tender to palp in suprapubic Musc/Extr/Back: ___. No edema. Skin: No rash. Warm and dry. Neuro: confused, speech fluent. no focal deficits. moving all 4 extremities. AAOx1 DISCHARGE EXAM: Constitutional: VS reviewed, NAD, pleasant HEENT: eyes anicteric, normal hearing, nose unremarkable, MMM without exudate, poor dentition CV: RRR no mrg, no JVD Resp: CTAB GI: sntnd, NABS GU: no foley, neg CVAT MSK: no obvious synovitis, B shoulders w/o warmth/erythema, + painful arc, pain with resisted external rotation but rest of shoulder exam limited by positioning and pain, no tenderness over acromion/clavicle Ext: ___, neg edema in BLEs Skin: no rash grossly visible Neuro: A&Ox3, cannot do DOWB, ___ BUE/BLE, SILT BUE/BLE, EOMI, PERRL, no droop, FTN wnl Psych: normal affect, pleasant Pertinent Results: ADMISSION LABS ___ 04:00PM BLOOD WBC-9.5 RBC-4.88 Hgb-13.1 Hct-40.5 MCV-83 MCH-26.8 MCHC-32.3 RDW-15.7* RDWSD-47.0* Plt ___ ___ 04:00PM BLOOD Neuts-49.1 ___ Monos-8.1 Eos-4.3 Baso-1.2* Im ___ AbsNeut-4.67 AbsLymp-3.52 AbsMono-0.77 AbsEos-0.41 AbsBaso-0.11* ___ 04:00PM BLOOD ___ PTT-31.6 ___ ___ 04:00PM BLOOD Plt ___ ___ 04:00PM BLOOD Glucose-171* UreaN-26* Creat-1.3* Na-140 K-4.0 Cl-106 HCO3-20* AnGap-14 ___ 04:00PM BLOOD ALT-12 AST-17 AlkPhos-52 TotBili-0.3 ___ 04:00PM BLOOD Lipase-42 ___ 04:00PM BLOOD cTropnT-<0.01 ___ 04:00PM BLOOD Albumin-4.3 ___ 07:11PM BLOOD Lactate-1.5 ___ 05:10PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 05:10PM URINE Blood-TR* Nitrite-NEG Protein-100* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG* ___ 05:10PM URINE RBC-1 WBC->182* Bacteri-MOD* Yeast-NONE Epi-0 ___ 05:10PM URINE Mucous-RARE* ___ 5:10 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. FOSFOMYCIN REQUESTED BY ___. ___ (___) ON ___. FOSFOMYCIN SUSCEPTIBLE test result performed by ___ ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- 16 R 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 DISCHARGE LABS ___ 07:11AM BLOOD WBC-6.1 RBC-4.34 Hgb-11.6 Hct-35.4 MCV-82 MCH-26.7 MCHC-32.8 RDW-15.7* RDWSD-46.6* Plt ___ ___ 07:11AM BLOOD Plt ___ ___ 07:44AM BLOOD Glucose-142* UreaN-14 Creat-1.0 Na-140 K-3.9 Cl-106 HCO3-21* AnGap-13 ___ 07:11AM BLOOD Calcium-9.5 Phos-2.7 Mg-1.8 ___ 07:50AM BLOOD %HbA1c-8.1* eAG-186* Brief Hospital Course: PATIENT SUMMARY ================== Ms. ___ is an ___ yo F with recurrent UTI's presenting with visual hallucinations and abdominal pain. She was found to have a UTI and was started on IV Ceftriaxone per her last urine culture showing E Coli and Klebsiella that were sensitive to CTX. She also had a mild ___ that improved with IV fluids. Urine culture resulted as pansensitive E Coli. She finished CTX on ___. She was started on vaginal estrogen given her recurrent UTI history. She was discharged after completion of the ___nd improvement in her creatinine. TRANSITIONAL ISSUES ==================== [] Due to her frequent UTIs, we added fosfomycin sensitivities to her E coli (sensitive). Could consider this as an option for long-term ppx in the future. [] Discharged patient on vaginal estrogen as atrophy may have increased risk of UTI's. [] Received IV Ceftriaxone course ___ for uncomplicated cystitis [] Pt reports right shoulder pain that has been long standing but intermittently worsens. ___ be due to rotator cuff injury vs arthritic changes. Consider shoulder xray and increased physical therapy. [] Pt reports hallucinations as well as blurry vision. ___ have diplopia (poor historian) or true dementia. Would benefit from consideration of workup for vascular dementia and addition of statin if so. ACUTE ISSUES ============= #Acute simple cystitis, E coli Has history of recurrent UTIs with AMS as presenting symptoms, typically with E. Coli and Klebsiella. CT head negative. Of note, prior cultures sensitive to Ceftriaxone. Previously seen by Urology (___) with cystoscopy and urodynamics suggestive of incomplete emptying as the underlying nidus. Presenting with recurrent UTI, UCx showed pansensitive E. Coli. No CVAT so no concern for pyelonephritis. Patient afebrile. CXR not concerning for PNA.. Received ceftriaxone from ___. #AMS Pt reports "seeing things" that other people cannot see. Prior to admission she remarked seeing cats. During her admission she remarked having blurry vision. Unclear if she has diplopia chronically (eg from vascular dementia). ___ require further workup outpatient. ___ Baseline Creatinine ~0.8-1.0, found to have Cr 1.3 on admission. Thought to be prerenal. Resolved to baseline with IVF and treatment of UTI. Held lisinopril at admission and restarted once creatinine resolved. #Shoulder pain No history of trauma, unlikely to represent acute fracture of dislocation. Pt subsequently reports that this pain is long standing but occasionally flares up. ___ be due to chronic rotator cuff injury. Managed with lidocaine patches and Tylenol. CHRONIC ISSUES: ================ #Diabetes mellitus Well controlled in the outpatient setting. Dose reduced home glargine while inpatient due to reduced PO intake. #Hypertension Continued on home, on amlodipine, metoprolol. Held lisinopril briefly in setting of ___, restarted after improvement in Cr. #Osteoarthritis Continued home APAP #Depression Continued home sertraline #Dementia Continued home memantine >30 minutes spent on patient care and coordination on day of discharge. Medications on Admission: The Preadmission Medication list may be inaccurate and requires further investigation. 1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 2. amLODIPine 10 mg PO DAILY 3. Ascorbic Acid ___ mg PO BID 4. Aspirin 81 mg PO DAILY 5. Memantine 10 mg PO BID 6. Sertraline 50 mg PO DAILY 7. MetFORMIN (Glucophage) 1000 mg PO BID 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Lisinopril 40 mg PO DAILY 10. Glargine 23 Units Bedtime Discharge Medications: 1. Estrogens Conjugated 1 gm VG DAILY Duration: 3 Weeks 2. Glargine 23 Units Bedtime 3. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever 4. amLODIPine 10 mg PO DAILY 5. Ascorbic Acid ___ mg PO BID 6. Aspirin 81 mg PO DAILY 7. Ibuprofen 400-600 mg PO Q8H:PRN Pain - Mild 8. Lisinopril 40 mg PO DAILY 9. Memantine 10 mg PO BID 10. MetFORMIN (Glucophage) 1000 mg PO BID 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Sertraline 50 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS ================== Acute simple cystitis SECONDARY DIAGNOSIS ==================== Type II diabetes mellitus Acute toxic metabolic encephalopathy Dementia 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 part in your care here at ___! Why was I admitted to the hospital? - You were admitted for a urinary tract infection What was done for me while I was in the hospital? - You were given antibiotics to treat the infection What should I do when I leave the hospital? Take all of your medications as prescribed Go to all of your follow up appointments Sincerely, Your ___ Care Team Followup Instructions: ___
19967846-DS-17
19,967,846
21,070,823
DS
17
2126-07-17 00:00:00
2126-07-17 15:03:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: trauma Major Surgical or Invasive Procedure: none History of Present Illness: This is a ___ year-old woman who was in her USOH until the day of presentation when the patient was struck by a vehicle at low speed. Reported LOC. Found to have left 4-5mm SDH, multiple facial fractures and rib fractures. Past Medical History: hypertension Social History: ___ Family History: Noncontributory Physical Exam: Discharge Physical Exam VS: 98.9 84 124/63 18 99%ra Gen- alert and oriented, NAD. Ecchymoses around left eye CV- RRR Pulm- CTAB Abd- soft, NT ND Ext- WWP,RUE in sling Pertinent Results: ___ CT Head 1. No change to left temporal lobe contusion. No change to small left subdural hematoma. There is new small amount hyperdensity along the left tentorium and in the left occiptal lobe which also likely represents subdural blood. The subarachnoid hemorrhage is now more superior likely representing redistribution. There is no associated shift of midline structures. 2. Again seen are right medial and posterior maxillary sinus fractures and right lateral orbital wall fracture. The other known facial fractures are better visualized on outside hospital facial bone CT. Brief Hospital Course: Ms. ___ was admitted to the T-SICU for observation, given her subdural hematoma. She was transferred to the floor on HD 2. Her hospital course is outlined by systems below. Neuro: Neurosurgery was consutled for her small subdural hematoma. Repeat NCHCT was obtained and was unchanged. She was started on keppra for seizure prophylaxis, and is discharged on day 9 of a 10 day course which she will finish at rehab. She did have some issues with delirium but these have resolved on discharge. Geriatrics was consulted to help with delirium and pain management. At discharge she is on ultram and small doses of oxycodone for pain, which is well controlled and slowly improving. Cardiopulm: She was initially started on intermittent IV hydralazine for blood pressure control, however she was not hypertensive and remained stable for the majority of her stay. She was weaned to room air quickly and remained stable. Pain from the rib fractures were well controlled, and she used the incentive spirometer well. FEN/GI: She was initially taking very little PO and was started on marrinol for appetite. Her intake did increase and she was able to take Ensure supplements as well. She was evaluated by speech/swallow while she was having waxing and waning mental status. GU: She is voiding without difficulty. Heme: She has been on SQH for DVT prophylaxis. MSK: Orthopedic trauma was consulted and evaluated the clavicle fracture. They provided a sling and recommended non weight bearing x2 weeks or until follow up in clinic with them. She has been working with physical therapy and will continue to do so at rehab. She is discharged to rehab on hospital day ___ and will follow up with ACS, orthopedic surgery, and plastic surgery (for nonoperative facial fractures) within the next 2 weeks. Medications on Admission: Lisinopril Discharge Medications: 1. Dronabinol 5 mg PO BID 2. Heparin 5000 UNIT SC TID Can stop this medication at rehab once she is ambulating more frequently 3. Insulin SC Sliding Scale 4. LeVETiracetam 500 mg PO BID Last dose should be in the evening on ___. Docusate Sodium 100 mg PO BID 6. Senna 1 TAB PO BID:PRN constipation 7. TraMADOL (Ultram) 50 mg PO Q 8H 8. TraZODone 50 mg PO HS:PRN sleep 9. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN breakthru pain RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every four (4) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 5mm left subdural hematoma Right clavicle fracture Right ribs ___ fractures Facial fractures including orbit, nose, and maxilla Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. ___, You were admitted to the Acute Care Surgery service after your accident. You had several injuries, including bleeding in your head, fractures to your face, ribs, and clavicle. You have done well and are now ready to go to rehab to continue your recovery. Please resume all of your regular home medications. You will also also have a small amount of narcotic pain medication to take as necessary for pain. Please continue to try and increase the amount you are eating. You have been taking Ensure nutritional supplements while you were here, and should continue with that in rehab. Followup Instructions: ___
19968039-DS-12
19,968,039
21,464,016
DS
12
2132-05-23 00:00:00
2132-05-23 16:49:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: CARDIOTHORACIC Allergies: thorazine / Motrin Attending: ___. Chief Complaint: left groin abscess Major Surgical or Invasive Procedure: ___ Incision and drainage of left groin abscess ___ Incision and drainage of left groin abscess and ___ drain placement History of Present Illness: ___ history of stage 3 left lung adenocarcinoma s/p L VATS wedge resection with completion open left upper lobectomy requiring pulmonary artery primary repair with left groin cutdown (but without femoral access) on ___ who presents with complaint of left groin drainage. His postoperative course was uncomplicated except for the development of pericarditis, for which he was started on a 3-month course of colchicine. He was discharged to ___ House on ___ and most recently saw Dr. ___ in clinic on ___. At that time, there were no left groin abnormalities noted and CXR was stable from time of discharge. Since, the patient reports three days of left groin pain with purulent drainage progressing to large volume outputs. Past Medical History: PMH: stage 3 lung adenocarcinoma Bipolar disorder GERD COPD Chronic alcohol abuse PSH: L VATS wedge resection with completion open left upper lobectomy requiring pulmonary artery primary repair with left groin cutdown (no femoral access) on ___ Mediastinoscopy, bronchoscopy, left VATS umbilical hernia repair Social History: ___ Family History: Unknown, pt grew up in foster care Physical Exam: VS: Temp: 98.1 (Tm 98.4), BP: 108/75 (108-131/65-90), HR: 81 (69-81), RR: 16 (___), O2 sat: 99% (95-99), O2 delivery: Ra Gen: [x] NAD, [x] AAOx3 CV: [x] RRR, [] murmur Resp: [x] breaths unlabored, [x] CTAB, [] wheezing, [] rales Abdomen: [x] soft, [x] non distended, [x] non tender, [] rebound/guarding Wound: inguinal wound open with dressing covering it and with sanguenous output staining the dressing. Thigh wound with same characteristics to inguinal wound. there is a ___ drain connecting both wounds Ext: [x] warm, [] tender, [x] no edema Pertinent Results: ___ 11:51AM LACTATE-0.8 ___ 11:35AM GLUCOSE-88 UREA N-19 CREAT-1.0 SODIUM-136 POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-25 ANION GAP-13 ___ 11:35AM estGFR-Using this ___ 11:35AM WBC-9.8 RBC-3.73* HGB-10.8* HCT-33.7* MCV-90 MCH-29.0 MCHC-32.0 RDW-16.4* RDWSD-54.0* ___ 11:35AM NEUTS-74.3* LYMPHS-13.3* MONOS-11.5 EOS-0.3* BASOS-0.2 IM ___ AbsNeut-7.31* AbsLymp-1.31 AbsMono-1.13* AbsEos-0.03* AbsBaso-0.02 ___ 11:35AM PLT COUNT-333 ___ 05:19AM BLOOD WBC-4.0 RBC-3.35* Hgb-9.5* Hct-30.0* MCV-90 MCH-28.4 MCHC-31.7* RDW-16.4* RDWSD-53.6* Plt ___ ___ 05:19AM BLOOD Neuts-42.9 ___ Monos-9.8 Eos-7.1* Baso-0.5 Im ___ AbsNeut-1.70 AbsLymp-1.56 AbsMono-0.39 AbsEos-0.28 AbsBaso-0.02 ___ 05:19AM BLOOD Plt ___ ___ 05:19AM BLOOD Glucose-94 UreaN-12 Creat-1.0 Na-139 K-4.4 Cl-104 HCO3-26 AnGap-9* ___ 05:19AM BLOOD Calcium-8.6 Phos-4.4 Mg-1.8 Vanco trough ___ 16:30 13.5 ___ 00:12 15.5 ___ 15:44 19.1 ___ CT abd: 1. Fluid collection centered in the left inguinal region measures up to 9.3 cm craniocaudally. This demonstrates ring enhancement and is concerning for abscess 2. No acute intra-abdominal process. Brief Hospital Course: Mr. ___ was admitted to the hospital for management of his left groin wound infection. He had an abdominal CT which showed a fluid collection centered in the left inguinal region measures up to 9.3 cm which demonstrated ring enhancement, concerning for abscess. He underwent an I & D at the bedside and a large amount of purulent fluid was drained. He had wound cultures sent and was placed on IV Vancomycin and Zosyn. He is evaluated the following day and had some reaccumulation of fluid and had another I & D with placement of a ___ drain. He subsequently underwent BID dressing changes. He remained afebrile and had a normal WBC. The Infectious Disease service evaluated him and recommended placement of a PICC line as they felt he would need minimally 2 weeks of IV antibiotics as his wound cultures were positive for MRSA. On ___ a right PICC line was placed. His antibiotics were narrowed to just Vancomycin once the cultures were finalized and his most recent dosing is 750 mg every 8 hours thru ___. The ID service will follow him in their ___ ___ and no more Vanco levels are needed. His last trough was 13. His left groin is cleaning up nicely and the ___ drain was removed on ___. He is getting saline damp to dry dressings BID to continue the debridement process. He is having some pain at the groin site which is relieved with Tylenol and occasional Oxycodone. He is up and walking independently and tolerating a regular diet. He was discharged to rehab on ___ to complete his antibiotic course and will follow up with Dr. ___ in a few weeks as well as the Infectious Disease service. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ARIPiprazole 30 mg PO DAILY 2. FLUoxetine 10 mg PO DAILY 3. Colchicine 0.6 mg PO BID 4. Senna 8.6 mg PO BID:PRN Constipation - First Line 5. TraZODone 50 mg PO QHS:PRN Insomnia 6. Atorvastatin 80 mg PO QPM 7. Aspirin 81 mg PO DAILY 8. Omeprazole 20 mg PO DAILY 9. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain - Moderate RX *oxycodone 5 mg ___ tablet(s) by mouth Q ___ hrs Disp #*20 Tablet Refills:*0 3. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line flush 4. Vancomycin 750 mg IV Q 8H 5. ARIPiprazole 30 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 80 mg PO QPM 8. Colchicine 0.6 mg PO BID 9. FLUoxetine 10 mg PO DAILY 10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation DAILY 11. Omeprazole 20 mg PO DAILY 12. Senna 8.6 mg PO BID:PRN Constipation - First Line 13. TraZODone 50 mg PO QHS:PRN Insomnia Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: MRSA abscess left groin 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 an infection in your left groin which needed to be cleaned out in the Operating Room. The wound is healing well with dressing changes twice a day and antibiotics. You will need to continue the antibiotics through ___ and will be followed closely by Dr. ___ the ___ Disease service. * You had a PICC line placed for antibiotic therapy which will be able to be removed after the treatment is complete. * Check your incisions daily and report any increased redness or drainage or any fevers of > 101. * your groin wound will continue with dressing changes daily as it heals from inside out. * You nay shower daily. Take the groin dressing off and let the water flow over your incision to help clean it out. * Continue to stay well hydrated and eat well to help heal your wounds. * Call Dr. ___ at ___ with any questions or concerns. Followup Instructions: ___
19968619-DS-15
19,968,619
25,230,239
DS
15
2116-02-28 00:00:00
2116-02-28 16:50:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: codeine Attending: ___. Chief Complaint: left tibial plateau fracture Major Surgical or Invasive Procedure: left leg external fixation History of Present Illness: ___ female presents with a left tibial plateau s/p mechanical fall. This is a closed, isolated injury and the patient is NVI. Past Medical History: none Social History: ___ Family History: nc Physical Exam: Vitals: AVSS General: laying comfortably in bed, in no acute distress LLE: ex fix in place. fires TA, gastroc, FHL, ___. SILT spn/dpn/s/s/tibial nerve distributions. soft compartments. foot WWP. Brief Hospital Course: Hospitalization Summary (ED Admit) The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a left tibial plateau fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for external fixation, 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. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: 1. Cimetidine 400 mg PO TID 2. Simvastatin 20 mg PO QPM Discharge Medications: 1. Acetaminophen 650 mg PO Q6H RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by mouth every 6 hours as needed Disp #*100 Tablet Refills:*0 2. 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 #*60 Tablet Refills:*0 3. Enoxaparin Sodium 40 mg SC QHS Start: ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 1 syringe subc daily at night Disp #*28 Syringe Refills:*0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain dont drink/drive while taking RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as needed Disp #*80 Tablet Refills:*0 5. Senna 8.6 mg PO BID hold for loose stools RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily while taking narcotics Disp #*100 Tablet Refills:*0 6. Cimetidine 400 mg PO TID 7. Simvastatin 20 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: left tibial plateau fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - nonweightbearing on the left lower extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take 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: nonweightbearing on the LLE 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. -elevate the LLE Followup Instructions: ___
19969031-DS-25
19,969,031
21,704,732
DS
25
2181-04-22 00:00:00
2181-04-22 14:54:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: s/p fall with subsequent RUE weakness Major Surgical or Invasive Procedure: None History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 5 minutes Time (and date) the patient was last known well: 10:45 AM was time of fall, unclear when deficits started (24h clock) ___ Stroke Scale Score: 2 t-PA given: No Reason t-PA was not given or considered: Unclear symptom onset endovascular intervention: []Yes [x]No I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. ___ Stroke Scale score was 0: 1a. Level of Consciousness: 0 1b. LOC Question: 0 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: 2 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 0 11. Extinction and Neglect: 0 HPI: ___ man with a past medical history significant for non-small cell lung cancer with brain metastases removed in ___ who presented after a fall with head strike. He states that he was at home in the bathroom when he felt as if his legs gave out underneath him. He uses a walker or wheelchair at baseline. When he fell, he hit the right side of his face on the bathtub. He denies any loss of consciousness. He activated his lifeline and EMS arrived within 10 minutes. He states that he has old right sided arm weakness but that his arm is more weak than it has been in the past. He also describes new numbness in the arm. A code stroke was called for his new right arm paresthesias. On neuro ROS, chronic difficulty with gait generally requiring a walker or wheelchair. He currently denies headache despite the head strike. Chronic right arm weakness, he thinks this is worse after the fall. He denies changes in vision, dysarthria, difficulties producing or comprehending speech. On general review of systems, denies recent illnesses, shortness of breath, chest pain. Past Medical History: - a craniotomy on ___ ___ for the removal of a poorly differentiated non-small cell lung metastasis from the left parietal brain, - whole brain cranial irradiation from ___ to ___ to 4000 cGyd - pancoast tumor resection ___ hypertension depression paranoia Social History: ___ Family History: Mother died of lung cancer at ___ Paternal uncle died of lung cancer Father died at ___ due to complications of peptic ulcer diseease Brother died of MI at ___ Physical Exam: Admission Exam: - Vitals: Temperature 97.8 67 138/66 16 98% on room air blood glucose 84 - General: Awake, cooperative, very hard of hearing - HEENT: In c-collar, no obvious ecchymosis or hematoma - Pulmonary: no increased WOB - Abdomen: soft - Extremities: no edema NEURO EXAM: - Mental Status: Awake, alert, oriented x 3. Able to relate history with some difficulty with details. mixes up dates. Unable to describe his baseline right arm and hand weakness in a coherent manner. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name all the objects on the stroke card. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. - Cranial Nerves: Anisocoria more prominent in the dark. Right ___, left ___, right ptosis, he says that he has been told in the past his right eye is smaller than his left. He says that this is not the pupil, just the eye. VFF to confrontation. EOMI. Facial sensation equal to pinprick. No facial droop. Hearing intact to loud voice only. Palate elevates symmetrically. Tongue protrudes in midline and to either side with no evidence of atrophy or weakness. - Motor: Decreased bulk throughout. Marked weakness in the right arm, unable to extend this. no adventitious movements such as tremor or asterixis noted. Markedly decreased range of motion at the right shoulder Delt Bic Tri WrE WrF FE FF IP Quad Ham TA ___ L 4 ___ ___ 4 5 5 5 5 4 R 4- 4 0 3 3 0 5 4 5 5 5 5 4 - Sensory: Reports sensory loss to pinprick in the right upper extremity. This is very hard to delineate as the exam is inconsistent. But the sensory deficits appear most prominent, 25% sensation compared to the left, in the C8 through T2 dermatomes. No extinction to DSS. No dysmetria on FNF - Gait: Deferred as the patient is in a c-collar and normally ambulates with a walker only Discharge exam: General exam unremarkable. Mental status normal, oriented x3, speech fluent without paraphasic errors. CN: R pupil 3->2, L pupil 5->3. subtle L facial droop. No dysarthria. Motor: Spasticity RUE, RLE. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 4+ ___ 5 4+ 5 5 5 5 5 R 5 4+ 4- ___ 4 4 4 4+ 5 DTRs: Bi Tri ___ Pat Ach L 2+ 2+ 2+ 2 R 2+ 2+ 2+ 2 Pertinent Results: ___ 03:08PM URINE HOURS-RANDOM ___ 03:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG ___ 03:08PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 03:08PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 02:16PM ALT(SGPT)-9 AST(SGOT)-20 ALK PHOS-90 TOT BILI-0.3 ___ 02:16PM ALBUMIN-3.8 ___ 02:16PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:21PM CREAT-0.9 ___ 12:21PM estGFR-Using this ___ 12:16PM ___ PH-7.40 COMMENTS-GREEN TOP ___ 12:16PM GLUCOSE-91 LACTATE-1.4 NA+-139 K+-4.7 CL--100 TCO2-28 ___ 12:16PM freeCa-1.11* ___ 12:00PM UREA N-23* ___ 12:00PM ALT(SGPT)-12 AST(SGOT)-38 ALK PHOS-82 TOT BILI-0.3 ___ 12:00PM ALBUMIN-3.9 CALCIUM-9.5 PHOSPHATE-3.2 MAGNESIUM-2.0 ___ 12:00PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:00PM WBC-6.6 RBC-4.07* HGB-12.1* HCT-37.1* MCV-91 MCH-29.7 MCHC-32.6 RDW-14.1 RDWSD-47.1* ___ 12:00PM NEUTS-71.1* LYMPHS-16.8* MONOS-10.0 EOS-0.8* BASOS-0.8 IM ___ AbsNeut-4.69 AbsLymp-1.11* AbsMono-0.66 AbsEos-0.05 AbsBaso-0.05 ___ 12:00PM PLT COUNT-195 ___ 12:00PM ___ PTT-22.5* ___ CTA head and neck IMPRESSION: 1. No evidence of acute infarction, hemorrhage, or edema. Status post left frontal craniotomy with stable left frontoparietal and right precentral encephalomalacia. 2. Right posterior communicating artery aneurysm measuring 4 x 3 mm. 3. Otherwise, patency of the intracranial vasculature without stenosis or occlusion. 4. Mild atherosclerotic disease at the right carotid bifurcation without internal carotid artery stenosis per NASCET criteria. 5. Severe centrilobular emphysema. CT c spine IMPRESSION: 1. No acute fracture or dislocation. Multilevel degenerative changes including left greater than right neural foraminal narrowing and mild central canal narrowing, at least at C5/C6. MRI head with con IMPRESSION: 1. There is no evidence of new or recurrent mass. 2. There are no acute intracranial changes. 3. Stable posttreatment changes. MRI c spine IMPRESSION: 1. Multilevel advanced degenerative changes in the cervical spine. 2. Multilevel central canal narrowing, most prominent and moderate to severe at C5-C6 level. 3. There is multilevel significant foraminal narrowing. 4. No evidence of metastases. CXR IMPRESSION: No acute cardiopulmonary abnormality Brief Hospital Course: SUMMARY: ___ right-handed man with past medical history significant for non-small cell lung cancer with brain metastases resected in ___ who presented after a fall with head strike without loss of consciousness, and concern for acute on chronic right arm weakness. #Weakness following fall: Patient was admitted due to concern for worsened weakenss of his baseline weak RUE. Timeline was unclear, but there was concern for stroke given possible acute onset (details unclear in ED). Given fall, he underwent CT C-spine which was negative for acute process, and prominent and moderate to severe narrowing at C5-C6 level. CT head and CTA was negative for acute process, including no evidence of vessel occlusion. MRI brain w/ and without contrast was stable from prior with no stroke; he did have evidence of left frontoparietal craniotomy with stable postsurgical changes. MRI c-spine w/wo showed moderate canal stenosis most prominent at C5/C6, but no acute findings to explain new weakness. Stroke risk factors included LDL 57, A1c 5.6 which did not require intervention. Overall, and with later clarification of patient history, he consistently endorsed that his RUE weakness was actually at baseline. Most likely this was felt to be due to a combination of prior left hemispheric brain met and cervical spondylosis with mild myelopathy. ___ recommended rehab. Patient was arranged for follow up with Neurology. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Levothyroxine Sodium 25 mcg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. Lisinopril 10 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 10 mg PO QPM 3. Levothyroxine Sodium 25 mcg PO DAILY 4. Lisinopril 10 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: cervical myelopathy 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 ___ were admitted to ___ for symptoms of chronic right sided arm weakness which we think is due to your cervical arthritis. ___ underwent MRI brain which showed no new abnormality. As well as MRI c spine which showed moderate narrowing in certain areas in your spine consistent with degenerative disease of the spine. ___ reported that ___ felt back at your baseline during admission. ___ were seen by physical therapy who recommended rehab. We are changing your medications as follows: -START ASA 81 mg daily Please take the rest of your medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If ___ experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to ___ - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
19969031-DS-27
19,969,031
26,728,965
DS
27
2182-02-24 00:00:00
2182-02-24 11:38:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Lethargy and cough Major Surgical or Invasive Procedure: None History of Present Illness: ___ h/o non-small cell cancer with brain metastases, seizures, hypertension, hyperlipidemia, and hypothyroidism who presented to the emergency department with lethargy, weakness, and hypoxia. The patient was reportedly in their usual state of health and then morning the patient was noted at his ___ rehab to be lethargic, weak, with diminished breath sounds. At that time his vital signs were temperature with 100.4, BP of 129/76, respiratory rate 20, heart rate 92, and O2 saturation was 85% on room air. The patient was placed on 2.5 L and was transferred to the hospital for further evaluation. In the emergency department the patient was seen and evaluated. He underwent a CTA of the chest which was negative for pulmonary embolism but did show a bilateral infiltrate concerning for pneumonia.. He had a flu swab which was negative. His labs were notable for a white blood cell count of 14.6, lactate of 1.9, a negative UA. He was given ceftriaxone 1 g IV, azithromycin 500 mg IV ×1, and his home Keppra in IV form and was admitted to the medical service for further evaluation and management. On arrival to the floor the patient reports that he lives at home. He knows he is at ___ in the hospital. He thinks that he is there because he had a fall. He reports that he has had an ongoing cough for the last several weeks. He reports that it is mostly dry but occasionally will bring up clear sputum. He denies any GI symptoms. Does not feel like his breathing is particular short of breath. Otherwise no complaints. ROS: as above otherwise 10point ROS negative Past Medical History: - a craniotomy on ___ ___ for the removal of a poorly differentiated non-small cell lung metastasis from the left parietal brain, - whole brain cranial irradiation from ___ to ___ to 4000 cGyd - pancoast tumor resection ___ -HTN, depression, paranoia Social History: ___ Family History: Mother died of lung cancer at ___ Paternal uncle died of lung cancer Father died at ___ due to complications of peptic ulcer diseease Brother died of MI at ___ Physical Exam: -Vitals: reviewed -General: NAD, resting comfortably in bed, appears older than stated age -HENT: atraumatic, normocephalic, moist mucus membranes -Eyes: PERRL, EOMi -Cardiovascular: RRR, no murmur -Pulmonary: clear b/l, no wheeze -GI: Soft, nontender, nondistended, bowel sounds present -GU: no foley, no CVA/suprapubic tenderness -MSK: No pedal edema, no joint swelling -Skin: No rashes, ulcerations, or jaundice -Neuro: no focal neurological deficits, CN ___ grossly intact -Psychiatric: appropriate mood and affect Pertinent Results: ADMISSION LABS ___ 09:45AM BLOOD WBC-14.6* RBC-4.16* Hgb-11.8* Hct-37.0* MCV-89 MCH-28.4 MCHC-31.9* RDW-15.8* RDWSD-51.6* Plt ___ ___ 10:52AM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-136 K-5.2* Cl-96 HCO3-22 AnGap-18 ___ 10:52AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.0 ___ 09:55AM BLOOD ___ pO2-34* pCO2-47* pH-7.39 calTCO2-30 Base XS-2 DISCHARGE LABS *** IMAGING -CXR ___: Subtle right retrocardiac opacification may be secondary to an infectious etiology versus atelectasis. -CTA CHEST ___: 1. No evidence of pulmonary embolism to the segmental level. Subsegmental pulmonary arteries are limited in evaluation, due to respiratory motion artifact. 2. Multifocal bilateral areas of ground-glass and nodular opacification in the lungs, concerning for developing bronchopneumonia and/or aspiration, given the clinical history. Associated right lower lobe are bronchial opacification, compatible with mucous plugging and secretions. 3. Postoperative changes after right upper lobectomy and chest wall resection. Persistent severe centrilobular emphysema. Bibasilar atelectasis. 4. Increased diameter of the right and left main pulmonary artery, as can be seen in pulmonary arterial hypertension. Brief Hospital Course: ___ h/o non-small cell cancer with brain metastases, seizures, dementia, HTN, and hypothyroidism who presents w/ lethargy, weakness, and hypoxia found to have pneumonia. 1. Acute hypoxic respiratory failure and sepsis due to pneumonia -SIRS (fever, leukocytosis, tachypnea) found to have b/l opacities on imaging concerning for pneumonia vs aspiration pneumonia started on ceftriaxone + azithromycin (day ___ deescalted to augmentin + azithromycin ___ which was completed on ___ (5d course). Flu negative. SLP recommendations noted. Continue supplemental O2 to maintain SpO2 90-92%, duonebs, guaifenesin. 2. Aspiration, dysphagia -Appreciate SLP recommendations okay to advance to ground solids with thin liquids. He does not have his teeth, so it may be difficult for him to eat. 1:1 supervision, aspiration precautions, small sips & bites, frequent oral care. CHRONIC MEDICAL PROBLEMS 1. HTN: resume home lisinopril with improvement in blood pressure 2. HLD: Continue pravastatin 3. Hypothyroidism: Continue levothyroxine 4. NSCLC w/ brain mets: Locally advanced nonsmall cell lung carcinoma /sulperior sulcus (Pancoast) tumor clinical ___ s/p resection ___ w/ single central nervous system (brain metastasis) relapse in ___. Surveillance since ___ with no evidence of recurrent disease up to current (last CT Scan chest ___ and last MRI brain ___. Continue to monitor 5. Normocytic anemia: stable, monitor >30 minutes spent on discharge planning Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 500 mg PO BID 2. Acetaminophen 500 mg PO BID:PRN Pain - Mild 3. Aspirin 81 mg PO DAILY 4. GuaiFENesin ___ mL PO Q6H:PRN cough 5. Levothyroxine Sodium 25 mcg PO DAILY 6. Lidocaine 5% Ointment 1 Appl TP TID:PRN Pain 7. Lisinopril 20 mg PO DAILY 8. Naproxen 375 mg PO Q12H:PRN Pain - Moderate 9. Pravastatin 40 mg PO QPM 10. Mirtazapine 7.5 mg PO QHS:PRN anxiety/insomnia 11. Cyanocobalamin 250 mcg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO BID 2. Acetaminophen 500 mg PO BID:PRN Pain - Mild 3. Aspirin 81 mg PO DAILY 4. Cyanocobalamin 250 mcg PO DAILY 5. GuaiFENesin ___ mL PO Q6H:PRN cough 6. Levothyroxine Sodium 25 mcg PO DAILY 7. Lidocaine 5% Ointment 1 Appl TP TID:PRN Pain 8. Lisinopril 20 mg PO DAILY 9. Mirtazapine 7.5 mg PO QHS:PRN anxiety/insomnia 10. Naproxen 375 mg PO Q12H:PRN Pain - Moderate 11. Pravastatin 40 mg PO QPM Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: -Acute hypoxic respiratory failure with pneumonia -Dysphagia, aspiration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. ___, You were admitted shortness of breath found to have pneumonia treated with antibiotics, oxygen, breathing treatments, and cough medicine with improvement. You are at a high risk for aspirating and getting food into your lungs that can cause pneumonia; please be very careful when you eat. It was a pleasure taking care of you. -Your ___ team Followup Instructions: ___
19969118-DS-21
19,969,118
27,973,799
DS
21
2144-01-03 00:00:00
2144-01-04 18:11:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Paxil / Penicillins / Neomycin Attending: ___ Chief Complaint: Confusion, Weakness, Suicidal ideation Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old female with history of MS previously controlled on ___ (stopped in ___, presents with confusion and lower extremity pain. She reports that she has felt as though she was in a "mental fog" for months, described as forgetfulness, feeling disoriented, sometimes difficulty finishing a sentence. This is in the setting of an overall health decline that started 15 months ago. In this time she has had chronic fatigue, night sweats, and leg cramps. worse since ___. She reports that the possibility of Lyme disease was raised in ___, though a prior Lyme titer was equivocal (no record of a positive titer). She is presenting to the ED after speaking with her hematologist Dr. ___ the phone, reported her ongoing complaints along with suicidal thoughts, and she was referred to ED for LP/MRI to rule out Lyme meningitis. She had a Hematology consult as an outpatient in ___ for eosinophilia following an upper respiratory infection, thought to be reactive to either bacterial or viral infection. She had an equivocal Lyme test, which has reportedly become negative, and Lyme disease was felt to be unlikely. The eosinophil percentage has decreased. She was noted to have a low ferritin level, for which she will be undergoing further evaluation in the outpatient setting. In the ED, initial VS were: 97.7 66 144/108 16 97% RA. Patient reports that she is not actively suicidal (no plan), but does say that she would be better off dead given her multiple medical problems. She denies fevers or meningismus. Her lower extremity pain and weakness is described as being consistent with her prior MS flares. Has been ambulating with a cane at times. Neurology was consulted and patient was admitted to medicine. 1:1 sitter was provided given suicidal ideation. She refused LP by the ED staff as she preferred neurology to do it. On arrival to the floor, VS were T 98.4, BP119/72, HR77, RR18, O2sat 100%RA. She endorses SI but states that she has no plans. REVIEW OF SYSTEMS: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, nausea, vomiting, constipation, melena, hematochezia, dysuria, hematuria. Past Medical History: -DM type II/ ___ (latent autoimmune diabetes mellitus in adults) -multiple sclerosis, on ___ until ___ -depression -osteopenia -iron deficiency anemia of undetermined etiology -gastroesophageal reflux -s/p oophorectomy in ___ (prophylactic due to strong FH of ovarian cancer); patient reports she tested negative for BRCA1 and BRCA2 mutations -s/p cesarean section in ___ and ___ -gestational diabetes in ___ Social History: ___ Family History: Significant for breast cancer in a maternal grandmother, great-grandmother and maternal aunt, ovarian cancer in mother and a cousin. ___ grandfather died of colon cancer and maternal grandfather died of pancreatic cancer. Physical Exam: ADMISSION: VS: T 98.4, BP119/72, HR77, RR18, O2sat 100%RA GENERAL: NAD HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox3, CNs II-XII grossly intact DISCHARGE: VS: T 98.7, BP 117-125/51-81, HR77-92, RR18, O2 sat 100%RA ___: 108-123 GENERAL: NAD.Comfortable in bed HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK: supple. Non elevated JVP LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART: RRR, no MRG, nl S1-S2 ABDOMEN: normal bowel sounds, soft, non-tender, non-distended, no rebound or guarding, no masses EXTREMITIES: no edema, 2+ pulses radial and dp NEURO: awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: ___ 10:40PM URINE HOURS-RANDOM ___ 10:40PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 10:40PM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG ___ 08:58PM LACTATE-0.9 ___ 08:55PM GLUCOSE-118* UREA N-19 CREAT-0.6 SODIUM-139 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-31 ANION GAP-11 ___ 08:55PM estGFR-Using this ___ 08:55PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 08:55PM WBC-7.4 RBC-4.67 HGB-14.8 HCT-44.4 MCV-95 MCH-31.8 MCHC-33.4 RDW-12.6 ___ 08:55PM NEUTS-49.9* ___ MONOS-6.1 EOS-3.3 BASOS-1.9 ___ 08:55PM PLT COUNT-323 MRI HEAD: ___ 1. Multiple periventricular FLAIR signal abnormalities are compatible with known history of multiple sclerosis. 2. No enhancing lesion or acute intracranial process. Brief Hospital Course: ___ female with PMH ___, MS, and depression, admitted for gradual decompensation with complaints of increased mental "fogginess", fatigue, leg cramps, and increased depression ___ suicidal ideation. Patient states that these complaints have been present since ___, ultimately leading to her passive suicidal thoughts. Patient was evaluated by Neurology who confirmed a nonfocal neuro exam and recommended MRI, which showed no acute intracranial findings. Presentation was not consistent with MS flare. Patient with depression and anxiety, evaluated by Psychiatry and started on lexapro. ___ hospital course is summarized by problems below: #Suicidal ideation/depression: Patient reported to her hematologist that she was experiencing suicidal thoughts. She did contract for safety as an outpatient. On admission, she endorsed ongoing thoughts of suicide in the recent months with no suicidal plan. Prior to admission she had started to see a therapist as outpatient. Psychiatry evaluated patient and determined that patient had no concerns about being discharged home. Patient was started on lexapro daily. Recommended that patient continue following up with outpatient therapist and for neuropsych/psychological testing as outpatient. #subjective confusion: Patient's sense of confusion, not being "as sharp" as baseline, has been worsening over a period of months. She maintains the ability to work but reports increased mental fogginess. Mutliple etiologies were considered including: MS flare, chronic Lyme disease given patient's reported positive testing, and depression. Neurology evaluated patient and recommended MRI to rule out acute flare as explanation. MRI head showed no acute intracranial findings. Neurology believed that current presentation was not consistent with MS flare and was likely secondary to patient's depression. Patient had positive antibodies to lyme disease from outside records and ID was consulted. Review of her outside lyme records showed positive IgM immunoblot and negative IgG immunoblot. ID believed that positive IgM is useful in the immediate weeks after infection and should not be relied on afterwards given high false negatives. The patient had two negative IgG results indicating that the isolated IgM result is inconclusive. Repeat Lyme serologies were sent here and will need to be followed up. Chronic Issues: #Night sweats: Patient reports a history of night sweats for the past 15 months. She has been evaluated in the context of a transient eosinophilia that developed and initial eval was negative. Potential etiologies could include infection or other inflammatory process. Otherwise potential hot flashes of menopause. ESR/ CRP normal during this hospitalization. Recent TSH was normal. Will need contineud monitoring as outpatient. #Diabetes mellitus II/ ___: Pt followed at ___ by Dr ___. HbA1c as of ___ is 5.1. She has never had a glucose >118 nor an HbA1c>5.4 in our or the ___ system. Patient insists she has type I diabetes and tells all her doctors she ___ type I diabetes. She has not been on insulin. Patient had blood sugars in low 100's during this admission with no insulin requirements. Oral hypoglycemic agents were held. Transitional Issues: -Recommend outpatient f/up with therapist to treat depression -Referral to Cognitive Neurology for neuropsych/psychological testing. -Lyme Serology was pending at time of discharge, please followup Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lorazepam 0.5 mg PO BEDTIME 2. Glumetza *NF* (metFORMIN) 1,000 mg Oral BID 3. Aspirin 81 mg PO DAILY 4. Tolterodine Dose is Unknown PO BID 5. Gabapentin Dose is Unknown PO TID Discharge Medications: 1. Escitalopram Oxalate 10 mg PO DAILY RX *escitalopram 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Lorazepam 0.5 mg PO HS:PRN insomnia 3. Multivitamins 1 TAB PO DAILY 4. Aspirin 81 mg PO DAILY 5. Gabapentin 300 mg PO TID 6. Tolterodine 1 mg PO BID Discharge Disposition: Home Discharge Diagnosis: Primary: major depression with suicidal ideation Secondary: multiple sclerosis, relapsing-remitting cognitive impairment NOS: needs neuropsychiatric testing possible chronic Lyme disease: evaluation in progress Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure taking care of you during your most recent hospitalization. You were admitted for increased depression, fatigue, and mental haziness. You were evaluated by neurology and psychiatry in house. You were felt safe for discharge. MRI of head showed no acute intracranial process. Please take of your medications as prescribed. Please followup with your physician ___. Followup Instructions: ___
19969137-DS-15
19,969,137
20,917,922
DS
15
2143-03-31 00:00:00
2143-04-02 13:46:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: ___ Intubated/sedated for MRA Head and Neck and Linq cardiac loop recorder placement, extubated same day History of Present Illness: Patient is a ___ y/o non-verbal female with a hx of autism, intellectual disability, seizures who lives at a group home who presented to ___ with lethargy. Per reports, the patient presents with three weeks of lethargy, shortness of breath, and an inability to lie flat. She then had an event of unresponsiveness at the group home on ___. Reportedly, her eyes rolled back and her body went limp without any associated seizure activity/shaking. She was transferred to ___. Work up revealed hypothermia, Cr 1.4, lactate 3.2, negative UA. Additionally, CT head was negative. She was given Vancomycin, Zosyn and 1.7L IVF. While lying flat in the CT scanner, she had another episode of shortness of breath, cyanosis and brief apnea. She also may have had a witnessed tonic clonic seizure per reports though this is unclear. During the apnea, the patient was bagged and then PEA arrested. She received CPR and was given epinephrine x1 and atropine with subsequent ROSC. There was concern for seizure vs arrest. A code was called and she briefly received compressions before she was noted to have a pulse with borderline low BPs. She was given keppra 1g, intubated, and then transferred to our ED. Per chart review: "the patient is completely dependent in her ADLs and IADLs except for feeding herself. She is incontinent of bowel and bladder. At her baseline she screams and grabs at things as a means of communication. She was noted to be more lethargic" Of note, the patient was admitted to ___ from ___ for AMS and hypothermia (temp 32), found to be hypotensive to ___. She also displayed symmetric upper extremity myoclonic movements concerning for seizures. She was admitted to the ___ for septic shock and respiratory failure. She was treated with six days of broad spectrum antibiotics for UTI, possible urosepsis. She was initially given IVF for rescucitation and then required daily diuretics to improve volume/respiratory status and wean the nasal cannula. Additionally, EEG showed no seizure activity and phenytoin level was elevated. Her movements were felt to be toxic metabolic encephalopathy. Neurology recommended continuing fosphenytoin. In ED initial VS: T 92.9 HR 62 BP 97/50 HR 16 Labs significant for: Na 148, K 5.2, Cr 1.1, WBC 4.2 H/H ___ platelets 68, Troponin 0.03 Patient was given: 1L NS Imaging notable for: CXR showed severe right pulmonary edema and chronic severe elevation of left diaphragm Consults: Neurology recommended cEEG and continue home phenytoin VS prior to transfer: Temp 35.3 BP 101/49 HR 68 RR 16 100% on ventilator On arrival to the MICU, patient was intubated and sedated, unable to obtain further history. Past Medical History: Autism Seizure Disorder Developmental delay of unknown etiology Urinary incontinence Venous insufficiency Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: Temp 35.3 BP 101/49 HR 68 RR 16 100% on ventilator 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, dry. No rashes. NEURO: Sedated/intubated. DISCHARGE PHYSICAL EXAM: ========================= VITALS: ___ 0416 Temp: 98 Axillary BP: 121/68 HR: 8 0 RR: 18 O2 sat: 94% O2 delivery: RA GENERAL: Awake and alert in the ___, sitting upright in bed in wrist restraints, no mittens. Joined by visitor, ___, from group home. HEENT: Sclera anicteric, EOMI, MMM NECK: supple LUNGS: CTA on R, Decreased sounds on L side, though poor effort. No crackles or wheezes. CV: RRR, no m/r/g ABD: soft, non-tender, non-distended, no rebound tenderness or guarding, no organomegaly EXT: Warm, well perfused, 2+ DP pulses bilaterally. BLE 1+ edema in both feet and lower legs. SKIN: Warmer than previous, dry. No rashes. Mild erythema, non-purulent, non-edematous around incision site for Linq placement. NEURO: Alert, interactive, EOMI and frequent eye contact. Disconjugate eyes (baseline per family). Smiles at visitor. No facial droop. Spontaneous movement in four extremities. Pertinent Results: ADMISSION LABS ============== ___ 09:45PM BLOOD WBC-4.2 RBC-2.60* Hgb-8.4* Hct-28.0* MCV-108* MCH-32.3* MCHC-30.0* RDW-16.8* RDWSD-65.9* Plt Ct-68* ___ 09:45PM BLOOD Plt Smr-VERY LOW* Plt Ct-68* ___ 09:45PM BLOOD ___ PTT-34.9 ___ ___ 09:45PM BLOOD ___ 09:45PM BLOOD Glucose-128* UreaN-45* Creat-1.1 Na-148* K-5.2* Cl-110* HCO3-27 AnGap-11 ___ 09:45PM BLOOD cTropnT-0.03* ___ 09:45PM BLOOD Lipase-54 ___ 09:45PM BLOOD Albumin-3.3* Calcium-8.8 Phos-3.0 Mg-2.2 ___ 09:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 09:50PM BLOOD pO2-75* pCO2-52* pH-7.34* calTCO2-29 Base XS-0 ___ 09:50PM BLOOD Glucose-123* Lactate-1.4 Na-145 K-5.0 Cl-112* ___ 09:50PM BLOOD Hgb-8.9* calcHCT-27 O2 Sat-92 COHgb-2 MetHgb-0 ___ 09:50PM BLOOD freeCa-1.11* INTERVAL LABS: ============== ___ 06:35AM BLOOD TSH-6.6* ___ 07:20AM BLOOD Free T4-1.2 ___ 06:35AM BLOOD Cortsol-16.8 ___ 05:08PM BLOOD Phenyto-12.7 DISCHARGE LABS: =============== ___ 07:10AM BLOOD WBC-4.9 RBC-3.05* Hgb-10.0* Hct-32.7* MCV-107* MCH-32.8* MCHC-30.6* RDW-16.1* RDWSD-62.7* Plt ___ ___ 07:10AM BLOOD Glucose-91 UreaN-15 Creat-0.8 Na-144 K-4.4 Cl-102 HCO3-32 AnGap-10 ___ 07:10AM BLOOD Calcium-9.8 Phos-4.3 Mg-2.2 IMAGES/STUDIES =============== CXR (___): 1. The endotracheal tube terminate approximately 3.4 cm above the carina. 2. Severe right pulmonary edema. 3. Chronic severe elevation of the left hemidiaphragm. CXR (___): Compared to ___. Previous moderate right pleural effusion or mild, unilateral pulmonary edema has resolved. Left hemidiaphragm is either markedly elevated or effectively bypassed by contents of the left upper abdomen filling most of the left hemithorax and displacing the lower mediastinum to the right. Heart is somewhat enlarged, but generally obscured by the abdominal contents. Nasogastric tube is curled just below the level of the carina, possibly in the elevated stomach. No pneumothorax. ET tube in standard placement. EEG (___): IMPRESSION: This is an abnormal continuous ICU EEG monitoring study because of overall background slowing. This finding is suggestive of a nonspecific encephalopathy. The most common causes include, but are not limited to, medication effect, metabolic derangement and/or infection. Frontally predominant delta activity can be seen in midline lesions, hydrocephalus or metabolic derangements. Intermittent slowing in the right temporal region may represent subcortical dysfunction in that region. Superimposed faster activity is often seen as a medication effect. No epileptiform discharges or electrographic seizures are captured. Compared to the previous days' recording, there is no significant change. MRA Head and Neck (___): 1. Technically limited evaluation of the great vessel origins and vertebral artery origins. Otherwise, unremarkable neck MRA. 2. Unremarkable brain MRA allowing for mild motion artifact. CXR (___): No evidence of pneumonia, or pleural effusion. Mild pulmonary edema. MICROBIOLOGY: ================ Blood culture (___): negative x 2 Urine culture (___): negative Sputum culture (___): negative MRSA screen (___): negative ___ 9:28 pm URINE Source: Catheter. **FINAL REPORT ___ URINE CULTURE (Final ___: GRAM NEGATIVE ROD(S). ~1000 CFU/mL. Brief Hospital Course: Ms. ___ is a ___ year old non-verbal woman with a history of autism, intellectual disability, and seizure disorder who lives at a group home, and presented to presented to ___ with lethargy with hypoxia. Her course there was complicated by PEA arrest and she was intubated and then transferred to ___ MICU. MICU COURSE: The patient was started empirically on broad spectrum antibiotics for sepsis of unknown source. She was easily weaned off of the ventilator and successfully extubated on ___. The patient was continued on home antiepileptics with out evidence of any seizure activity. She was transferred to the medicine floor for further management. ACTIVE ISSUES ============ #Hypothermia #Sepsis The patient was hypothermic on admission to ___ ~33-34C. Review of chart reveals she had a similar presentation in ___ that was believed to be due to urosepsis. Endocrine dysfunction was ruled out with normal cortisol and borderline high TSH/normal T4. Highest on the differential was sepsis secondary to pneumonia given the presentation with hypoxia, however there was no clear evidence to suggest localized infection. Urine studies were unremarkable, MRSA was negative, and an induced sputum culture was devoid of organisms. She was treated empirically with vancomycin and ceftazidime, which eventually narrowed to augmentin for a total of an 8 day course. Neurology did not find any cause for hypothermia or signs to suggest a hypothalamic cause. #Hypoxic respiratory failure #S/p Cardiac Arrest Per reports, the patient had a PEA arrest in the setting of hypoxia that occurred when lying flat and required intubation. She received CPR and epinephrine with return of ROSC. She arrived to ___ intubated and was initially treated in the MICU, but was able to be extubated and then transferred to the floor. After arriving on the medicine floor, the patient was very quickly weaned off of supplemental O2 and was satting well on room air. The differential for the cause of this event was broad and an extensive work up was conducted. She has a known diaphragmatic hernia in addition to a CXR with pulmonary edema and reports of increasing difficulty in lying flat. Given the large size of the diaphragmatic hernia it was postulated that the hypoxia may occur as a result of positional compression of mediastinal structures while laying flat, so thoracics surgery was consulted to advise. They did not feel that this was likely but did recommend outpatient follow up for possible surgery. Electrolytes and glucose and oxygen levels were initially appropriate at OSH around time of arrest, making these causes less likely. For further work up, an MRA head and neck was done, which was unremarkable and showed no abnormalities in the great vessels. In consideration of a possible cardiac etiology, a TTE was obtained that was poor quality, but ruled out major structural abnormalities or obstructive etiologies. She did not appear to be in heart failure. Cardiology and EP were consulted. The patient also had a cardiac loop recorder implanted for further long term monitoring in case of arrhythmia. Finally, as discussed above, there was concern for sepsis due to a possible pulmonary source, so the patient was also treated empirically for pneumonia. She had no further events or hypoxia during her hospital stay. She appeared euvolemic throughout so home Lasix was held. In the end, it seems most likely that the cause of her arrest was hypothermia. #Seizure-like Activity Outside records describe tonic-clonic seizure like activity prior to arrest, which may have been seizure or alternatively convulsive syncope. Her phenytoin level was found to be therapeutic (potentially ___ hypothermia). Continuous EEG monitoring was done which showed no seizure. Neurology was consulted and felt that it was unlikely that the patient had a seizure during the arrest. It was recommended that she continue her home phenytoin dosing. #AMS Per the patient's brother, she was initially less interactive than her baseline after extubation. The etiology was felt to be multifactorial with contribution from likely sepsis as well as toxic metabolic encephalopathy. Her mental status continued to improve over the course of her admission and she was felt to be at her baseline on discharge. #Hypernatremia The patient was hypernatremic throughout her hospital stay. She was given D5W to correct her free water deficit and Na was trended daily. Wnl prior to discharge. #Thrombocytopenia The patient was thrombocytopenic on admission. She was also noted to have platelets as low as 28 during last hospitalization for sepsis. The cause was felt to be due to sepsis. There were no signs of consumption, hemolysis, DIC or TTP, and the timing with heparin was not suggestive of HIT. She was monitored with daily CBCs and her platelet count normalized. #Macrocytic Anemia Hgb was found to be 8.4 on admission. There were no signs of an active bleed. Etiology could be vitamin deficiency vs macrocytic from increased production. Her Hbg was trended daily. #Fever #GNRs in Urine The pt spiked a low grade fever on ___, along with relative hypotension, and slightly higher WBC however neither outside of normal limits. A CXR was unremarkable and a U/A was not suggestive of infection. The urine culture drawn on this day did result with very small growth of gram negative rods (~1000 CFU/mL.). Unclear of the significance of this as the patient appeared to improve without intervention as antibiotics were deferred. Given that she is non verbal, it is difficult to assess for symptoms. Reassuringly, she developed no further fevers or hypotension and her WBC was trending down at time of admission. Would recommend close monitoring as an outpatient. # Facility concern for CHF: facility reported patient had been retaining fluid and resisting lying flat prior to admission. It is possible that this represents symptomatic CHF. Though initially had pulmonary edema in setting of arrest, she was fairly euvolemic throughout and has only minimal foot edema without any furosemide. TTE suboptimal but without clear CHF. Advised facility to monitor weights, and she will follow up with cardiology. CHRONIC PROBLEMS ======================== #Developmental Delay The was continued on home risperidone and buspirone. #Seizure Disorder: She was continued on home phenytoin. The level was checked and found to be therapeutic. TRANSITIONAL ISSUES =================== For family and care givers: [] We recommend daily weights for further monitoring of fluid status. Please call the patient's PCP or cardiologist if her weight increased by more than 3lbs in 1 day or more than 5lbs in a week. [] We also recommend seeking medical attention if the patient has a temperature that is greater than 101 degrees F, or less than 95 degrees F. [] The patient has a large diaphragmatic hernia that was evaluated by Thoracic Surgery. Recommend continued discussions regarding elective repair of hernia. A thoracics follow up appointment has been made. For providers: [] Recommend repeat TSH and T4 testing as an outpatient. TSH was found to be borderline high however free T4 was within normal limits, so thyroid supplementation was not indicated this admission. [] Given the urine culture that resulted above, we recommend checking a CBC and monitoring the patient for a possible infection at the patient's follow up PCP ___. [] While admitted, the patient had a Linq cardiac loop recorder placed in subcutaneous tissue over L chest. At PCP follow up visit, recommend checking the site of insertion to ensure no infection or bleeding has developed. [] The patient was not given home Lasix because there was concern for infection as noted above and because the patient was euvolemic appearing. Further, it was felt that she likely had decreased PO intake while in the hospital. As she transitions back to her regular diet at home, consider restarting the patient on her home 20mg PO Lasix and titrate as needed. NEW MEDICATIONS: None HELD MEDICATIONS: Furosemide (Lasix 20mg PO daily) - Communication: HCP: ___ ___ - Code: Full Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Loratadine 10 mg PO DAILY:PRN allergy 2. Ferrous Sulfate 325 mg PO DAILY 3. Vitamin D 1000 UNIT PO DAILY 4. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 5. Furosemide 20 mg PO DAILY 6. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 7. Phenytoin (Suspension) 160 mg PO Q24H 8. BusPIRone 7.5 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. RisperiDONE 0.25 mg PO DAILY 11. Milk of Magnesia 30 mL PO PRN constipation 12. GuaiFENesin ___ mL PO Q6H:PRN cough 13. Polyethylene Glycol 17 g PO DAILY:PRN constipation 14. RisperiDONE 0.5 mg PO QHS Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN Pain - Mild 2. BusPIRone 7.5 mg PO DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. FoLIC Acid 1 mg PO DAILY 5. GuaiFENesin ___ mL PO Q6H:PRN cough 6. Ibuprofen 400 mg PO Q8H:PRN Pain - Mild 7. Loratadine 10 mg PO DAILY:PRN allergy 8. Milk of Magnesia 30 mL PO PRN constipation 9. Phenytoin (Suspension) 160 mg PO Q24H 10. Polyethylene Glycol 17 g PO DAILY:PRN constipation 11. RisperiDONE 0.25 mg PO DAILY 12. RisperiDONE 0.5 mg PO QHS 13. Vitamin D 1000 UNIT PO DAILY 14. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until your PCP instructs you to restart Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY ======== Hypothermia Sepsis Hypoxic Respiratory Failure Hypernatremia SECONDARY ========== Diaphragmatic Hernia Seizure Disorder 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. ___ and ___, It was a pleasure taking care of you at ___ ___. Why were you admitted to the hospital? - You had episodes of unresponsiveness and then had trouble breathing. - Your heart stopped working correctly and you needed chest compressions and CPR. You also needed to have a breathing tube put in to help you breath. - Your body temperature was found to be really cold. What was done while you were in the hospital? - Imaging of your heart was done which was normal. - An MRI of your head and neck was done, which also did not show any abnormalities. - A cardiac loop recorder, called a Linq, was implanted to monitor the rhythm of your heart when you go home. What should you do when you go home? - Continue taking all your medications as directed. Wishing you all the best! Your ___ Care Team Followup Instructions: ___
19969326-DS-9
19,969,326
20,407,284
DS
9
2136-11-02 00:00:00
2136-11-03 18:12:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Erythromycin Base Attending: ___. Chief Complaint: Chest pressure Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with PMHx obestiy, HTN, HLD who presents with chest pain. She as awoken from sleep the morning prior to admission at 1:00am wtih substernal, dull chest aching. The pain became more prominent with activity throughout the day, although it was intermittent. She denied assoicated N/V, dizziness, SOB, palpitations. It did not radiate. She notes intermittent left hand numbness for the past month. She was seen urgently at her PCP's office the day prior to admission. In the office, she was asymptomatic, exam notable for BP 163/84, HR 112, II/VI SEM at ___, EKG interpreted by physician as sinus tachycardia, normal axis, and possible J-point elevation in V3 compared to EKG ___. There was a concern for unstable angina versus PE, and was sent to the ED for further evaluation. In the ED, initial vitals were T 99.2, HR 108, BP 178/75, RR 20, 98% on 2L. Received 325mg ASA. Troponin negative x 2. ___ in ED for observation. She was scheudled for a stress MIBI on the morning of ___, but was found to be in new AFib with RVR in the 150s, BP noted to be normal and patient asymptomatic, rate controlled wtih 30mg IV diltiazem and 30mg PO diltiazem. She remained in AFib with rates in 100s-110s. On review of systems, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: (-) Diabetes, (+) Dyslipidemia, (+) Hypertension 2. CARDIAC HISTORY: none 3. OTHER PAST MEDICAL HISTORY: - Morbid obesity - Cataract - H/o breast cancer - H/o colorectal polyps - Subtotal hysterectomy ___, still has cervical cuff - Excision of ovarian cyst ___ Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.9 161/70 106 18 93% on RA General: NAD, pleasant female, sitting comfortably in bed HEENT: NC/AT, no scleral icterus, no conjunctival injection, MMM, oropharynx clear Neck: supple, no LAD, no JVP elevation, no thyromegaly CV: irregularly irregular, nl s1/s2, no m/r/g Lungs: good effort, clear to auscultation bilaterally Abdomen: obese, soft, nontender, nondistended, normoactive bowel sounds, no masses or organomegaly GU: no foley Ext: warm, no clubbing or cyanosis, 1+ b/l ___ pitting edema to ankles Neuro: alert, oriented x 3, moves all 5 extermities Skin: dry, no rash Pulses: 2+ ___ bilaterally DISCHARGE PHYSICAL EXAM Pertinent Results: ADMISSION LABS ===================== ___ 08:30PM BLOOD WBC-10.6 RBC-4.49 Hgb-13.4 Hct-41.1 MCV-92 MCH-29.9 MCHC-32.7 RDW-13.9 Plt ___ ___ 08:30PM BLOOD Neuts-76.8* Lymphs-16.8* Monos-4.1 Eos-1.6 Baso-0.6 ___ 08:30PM BLOOD ___ PTT-30.4 ___ ___ 08:30PM BLOOD Glucose-114* UreaN-13 Creat-0.6 Na-137 K-3.7 Cl-96 HCO3-31 AnGap-14 PERTINENT LABS ==================== ___ 08:30PM BLOOD cTropnT-<0.01 ___ 02:33AM BLOOD cTropnT-<0.01 ___ 03:33PM BLOOD cTropnT-<0.01 ___ 08:46PM BLOOD D-Dimer-155 ___ 03:33PM BLOOD TSH-1.6 STUDIES/IMAGING =================== ___ CXR PA AND LAT FINDINGS: Frontal and lateral radiographs show clear lungs. The lung fields are slightly obscured by overlying soft tissue attenuation. ThE heart size is top normal. The mediastinum is normal. No pleural effusion or pneumothorax is seen. IMPRESSION: Mild cardiomegaly. ___ TTE Poor image quality.The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. ECG =================== ___: Narrow complex tachycardia with a single P wave preceding each QRS complex which is upright consistent with sinus tachycardia. Slight P-R interval prolongation. Q waves in leads II, III, and aVF. The one in lead III is wide and pathologic, the others are not. This raises a question of an old inferior wall myocardial infarction. No previous tracing available for comparison. ___: Atrial fibrillation with a rapid ventricular response. compared to the previous tracing of ___ the rate and rhythm have changed. ___: Atrial fibrillation. Compared to the previous tracing the ventricular response rate is slower. ___: Sinus rhythm. Occasional premature atrial contractions. Compared to the previous tracing the rhythm has changed. DISCHARGE LABS =================== ___ 05:30AM BLOOD WBC-8.3 RBC-4.31 Hgb-13.1 Hct-39.5 MCV-92 MCH-30.4 MCHC-33.1 RDW-13.9 Plt ___ ___ 05:30AM BLOOD Glucose-110* UreaN-12 Creat-0.6 Na-141 K-3.8 Cl-99 HCO3-32 AnGap-14 ___ 05:30AM BLOOD Calcium-9.3 Phos-3.4 Mg-2.2 Brief Hospital Course: Mrs. ___ was admitted with new substernal chest discomfrot and increased dyspnea on exertion, was ruled-out for ACS with negative ECG and troponins, but found to have new-onset atrial fibrillation with rapid ventricular rate. Ventricular rate was controlled with nodal blockade, and she spontaneously converted back into sinus rhythm. Echocardiogram was negative for valvular abnormalities, and she was discharged on PO metoprolol and rivaroxaban for anticoagulation. ACTIVE ISSUES # Atrial fibrillation New onset, asymptomatic and hemodynamically stable on admission. She self-converted back to sinus rhythm about 6 hours after the first noted atrial fibrillation on ECG. Given her history of at least several months of dyspnea on exertion and occasional fatigue, it is likely that she has paroxysmal Afib and this is not completely new. CHADS2 = 1, but CHADS2-VASC=3. TSH normal and echo without structural causes to suggest atrial fibrillation. She was started on metoprolol for rate control if/when she converts back into atrial fibrillation. She was started on rivaroxaban for long-term anticoagulation. She was discharged asymptomatic and in normal sinus rhythm. # Chest discomfort Not typical chest pain as it was not always brought on by exertion or relieved by rest. Troponins negative x 2, no EKG changes. Was observed initially in the ED for stress MIBI but this was cancelled when noted to be in atrial fibrillation on pre-stress ECG. Did not need further inpatient workup. Will likely have outpatient stress MIBI v PET. Has follow-up with cardiologist at discharge. CHRONIC ISSUES # Hypertension Continued HCTZ # Hyperlipidemia LDL goal < 130, last lipid profile LDL within goal. TRANSITIONAL ISSUES - Should monitor blood pressure given the initiation of metoprolol - Stress MIBI needs to be 2-day given obesity Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Multivitamins 1 TAB PO DAILY 4. Metoprolol Succinate XL 25 mg PO DAILY RX *metoprolol succinate 25 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #*14 Tablet Refills:*0 5. Rivaroxaban 20 mg PO DAILY RX *rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth daily Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: atrial fibrillation with rapid ventricular response Secondary: hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because of an irregular heart beat, called afib. You were started on a medication called metoprolol which will help control your heart rate. Your heart is going in and out of afib, which is common. Because of this, it is possible to develop a blood clot which causes a stroke. To try to reduce the risk of stroke, we have started you on a blood thinning medication. You should still have the 2-day stress test performed as an outpatient. We scheduled you for an appointment with a cardiologist at ___ who can arrange this stress test. It was a pleasure taking care of you in the hospital! Followup Instructions: ___
19969737-DS-6
19,969,737
22,907,047
DS
6
2140-05-16 00:00:00
2140-05-17 10:11:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / codeine / Dilaudid / cyclobenzaprine / gabapentin / pregabalin / oxycodone / Soma / nortriptyline Attending: ___. Chief Complaint: acute on chronic lower back pain, nausea, inability to tolerate PO Major Surgical or Invasive Procedure: None History of Present Illness: ___ w PMH of lumbar degenerative disease, chronic lower back pain, and chronic pelvic/genital pain, presenting with worsening pain, nausea x2 days. She has been followed by ___ Pain ___. She was weaned off fentanyl ___, and vicodin was stopped on ___. Tramadol was started recently. She had a plan for followup with pain clinic for bilateral SIJ joints in 2 weeks. She was also supposed to go to neurology clinic visit in 2 weeks. She came to the hospital today because she had worsening of her pain and nausea with inability to tolerate PO. Pain radiates down her back and into her R buttocks and leg. She also has abdominal pain that has been present for awhile. Per family, no one has been able to figure out why she has abdominal pain or genital burning pain or back/leg pain. The neurosurgeon has turned her down for surgery based on the fact that spinal disease is not severe and does not explain severity of symptoms. Denies f/c, vomiting, diarrhea. Patient has 1 BM every other day with bowel regimen medications. In the ED, initial VS were 97.8, 70, 154/83, 20, 99% RA Exam notable for: Thin, frail appearing PERRLA CV, pulm, abd benign Lower lumbar spine pain, Right paraspinal pain, positive L straight leg raise Labs showed no abnormalities No imaging done. Received Zofran 4 mg, Ketorolac 30 mg IV, 1L NS, 4 mg morphine IV Transfer VS were T97.5 HR70 BP138/79 RR16 O2Sat 100% RA Decision was made to admit to medicine for further management. On arrival to the floor, patient reports that she is miserable in pain with nausea. She has not been able to eat much but she can drink liquids more easily than eating food. Past Medical History: HTN - off meds GERD Osteoporosis Lung infiltrate - s/p XRT (never biopsied and confirmed to be cancer) Fall in ___ - fractured ribs and scapula Anxiety Lumbar spinal stenosis Common bile duct abnormality - work up with MRCP and ERCP negative Cataracts Dental infection - on penicillin Hemorrhoids Social History: ___ Family History: Patient's mother and sister had arthritis. Physical Exam: ADMISSION PHYSICAL EXAM: VS - T97.5 HR70 BP150s/80s RR16 O2Sat 100% RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: non distended, hyperactive bowel sounds, tender to palpation over mid-abdomen EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally Back: tenderness to palpation over spinous processes, +L straight leg test NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM VS - AF, 147/87, 70, 16, 99% on RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: non distended, hyperactive bowel sounds, tender to palpation over mid-abdomen EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally Back: tenderness to palpation over spinous processes, +L straight leg test NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 11:29AM BLOOD WBC-4.5 RBC-4.73 Hgb-12.0 Hct-38.7 MCV-82 MCH-25.4* MCHC-31.0* RDW-15.3 RDWSD-45.3 Plt ___ ___ 11:29AM BLOOD Neuts-73.1* Lymphs-17.5* Monos-8.4 Eos-0.4* Baso-0.2 Im ___ AbsNeut-3.29 AbsLymp-0.79* AbsMono-0.38 AbsEos-0.02* AbsBaso-0.01 ___ 11:29AM BLOOD Glucose-89 UreaN-15 Creat-0.9 Na-139 K-4.2 Cl-102 HCO3-28 AnGap-13 DISCHARGE LABS: ___ 07:40AM BLOOD Glucose-86 UreaN-23* Creat-0.9 Na-141 K-4.1 Cl-105 HCO3-26 AnGap-14 ___ 12:40PM BLOOD WBC-7.5 RBC-4.36 Hgb-11.0* Hct-36.1 MCV-83 MCH-25.2* MCHC-30.5* RDW-15.2 RDWSD-46.1 Plt ___ CXR: There is volume loss in the right upper lobe with faint opacity at the right apex likely correlating to an area in the right upper lobe seen on ___ which most likely reflects post radiation change. Clinical correlation is recommended. Lungs are otherwise clear. No pleural effusions or pulmonary edema. No focal airspace consolidation to suggest pneumonia. No pneumothorax. Heart is upper limits of normal in size given portable technique. Mediastinal contours are within normal limits. The aorta is somewhat unfolded and tortuous. Old left-sided posterior lateral rib fractures. Brief Hospital Course: ___ w PMH of lumbar degenerative disease, chronic lower back pain, and chronic pelvic/genital pain, who presented with worsening pain, nausea x2 days and inability to tolerate PO. She has had extensive work up for back pain as an outpatient. Neurosurgery has seen her as outpatient and declined surgical intervention for her. She was started inpatient on IV morphine which improved her pain. Chronic pain was consulted who recommended pudendal nerve block at next pain clinic visit, in addition to starting her on nortriptyline 25 mg QHS and naproxen 500 mg PO BID x 7 days for arthritic component of pain. TRANSITIONAL ISSUES: - Patient discharged on Nortriptyline 10 mg QHS to be up titrated as outpatient. - Ativan and tramadol were stopped due to interaction - She was also prescribed low dose morphine to assist with acute pain (14 tabs) - Consider pudendal nerve block at next pain clinic visit - Consider referral for biofeedback - Patient will have follow up with Physical therapy, neurology, and pain clinic. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Fentanyl Patch 12 mcg/h TD Q72H 2. TraMADOL (Ultram) 25 mg PO Q3H PRN Pain 3. Gabapentin 100 mg PO QHS 4. Lidocaine 5% Patch 1 PTCH TD BID 5. polycarbophil 1 tsp vaginal DAILY 6. Ranitidine 150 mg PO BID 7. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN gas, GI upset 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Docusate Sodium 100 mg PO BID 10. Senna 17.2 mg PO BID 11. Milk of Magnesia 45 mL PO QHS 12. Vitamin D 1000 UNIT PO DAILY 13. Calcium Carbonate 1000 mg PO DAILY 14. Lorazepam 0.5 mg PO Q8H:PRN anxiety, pain Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN gas, GI upset 2. Calcium Carbonate 1000 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Fentanyl Patch 12 mcg/h TD Q72H 5. Gabapentin 100 mg PO QHS 6. Lidocaine 5% Patch 1 PTCH TD BID 7. Milk of Magnesia 45 mL PO QHS 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. polycarbophil 1 tsp vaginal DAILY 10. Ranitidine 150 mg PO BID 11. Senna 17.2 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Nortriptyline 10 mg PO QHS RX *nortriptyline 25 mg 1 QHS by mouth at bedtime Disp #*21 Capsule Refills:*0 RX *nortriptyline 10 mg 1 tab by mouth at bedtime Disp #*30 Capsule Refills:*0 14. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain RX *morphine 15 mg 1 tablet(s) by mouth every eight (8) hours Disp #*14 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Acute on chronic lower back pain Vulvodynia 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 worsening back pain with nausea and inability to eat. You were given IV morphine to help with the pain which improved your back pain. You were seen by the chronic pain doctors ___ were in the hospital. - You will start a new medicine called Nortriptyline 10 mg. This medicine dose can be increased by your outpatient team. Please take this medicine every night. - You should not take Ativan while taking this medicine - You should not take tramadol while taking this medicine. - We also prescribed morphine. You should take this medicine only for severe pain. Please do not drive or operate heavy machinery while on this medicine. It has been a pleasure taking care of you. Sincerely, Your ___ Team Followup Instructions: ___
19969737-DS-7
19,969,737
24,259,455
DS
7
2140-06-11 00:00:00
2140-06-11 13:03:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: aspirin / codeine / Dilaudid / cyclobenzaprine / gabapentin / pregabalin / oxycodone / Soma / nortriptyline Attending: ___. Chief Complaint: confusion Major Surgical or Invasive Procedure: Head CT History of Present Illness: Ms. ___ is an ___ woman with history of HTN, GERD, anxiety, lumbar spinal stenosis with chronic back pain (followed by pain management on chronic opioids, self described as "pudendal neuropathy", recently admitted ___ for acute on chronic back pain), who presented with an episode of altered mental status (resolved), chronic back pain, and headache in the ED and grossly positive UA, admitted for UTI (? pyelo given CVA tenderness). Ms. ___ was interviewed with her daughter at beside to provide collateral info. They believe that her presenting symptoms of headache and ab pain and altered mental status all relate to being switched from morphine sulfate ___ to tramadol by her outpatient providers which happened on ___ and she states she started having headaches on ___ per the daughter. Notes ongoing bilateral back pain that radiates to her groin which is unchanged recently. Pt's daughter stated that that patient was not coherent and had difficulty with memory briefly and then slowly her mental state improved with redirection after talking with her daughter. The daughter states that her mental status is currently at her baseline. ROS: (+) mild ab discomfort, frontal headache x several days. (-)nausea vomiting, neck stiffness, diarrhea. the patient reportedly had not focal weakness or sensory deficits. Remainder of comprehensive 10 point ROS it otherwise negative. Past Medical History: HTN - off meds GERD Osteoporosis Lung infiltrate - s/p XRT (never biopsied and confirmed to be cancer) Fall in ___ - fractured ribs and scapula Anxiety Lumbar spinal stenosis Common bile duct abnormality - work up with MRCP and ERCP negative Cataracts Dental infection - on penicillin Hemorrhoids Social History: ___ Family History: Patient's mother and sister had arthritis. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 97.3 153/89 P71 R18 100% on RA GEN: Alert, frail, elderly woman walking around the floor (because she says it makes her back feel better), conversant, when asked what year this is she looked at the calendar and misread ___ as ___. She read the calendar for the date. She knew she was in the hospital but couldn't recall which one (this is all normal for her mother per the patients daughter) ___, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS, there is positive CVA tenderness but the patient is quick to note that her back would always feel painful with any light pounding on her back and this is unchanged. EXTREM: Warm, no edema NEURO: CN II-XII grossly intact, ambulating the hallways slowly but no problems walking, motor function grossly normal DISCHARGE PHYSICAL EXAM: VS: T97.5 134/91 P70 R18 99% on RA GEN: Alert, frail, elderly woman in no apparent distress ___, anicteric sclera, no conjunctival pallor NECK: Supple without LAD PULM: Clear, no wheeze, rales, or rhonchi COR: RRR, normal S1/S2, no murmurs ABD: Soft, NT ND, normal BS EXTREM: Warm, no edema NEURO: CN II-XII grossly intact, ambulating the hallways slowly but no problems walking, motor function grossly normal Pertinent Results: ___ 06:10AM LACTATE-1.1 ___ 04:23AM GLUCOSE-81 UREA N-23* CREAT-1.0 SODIUM-139 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-26 ANION GAP-17 ___ 04:23AM estGFR-Using this ___ 04:23AM URINE HOURS-RANDOM ___:23AM URINE HOURS-RANDOM ___ 04:23AM URINE UHOLD-HOLD ___ 04:23AM URINE GR HOLD-HOLD ___ 04:23AM WBC-5.7 RBC-4.42 HGB-11.2 HCT-36.5 MCV-83 MCH-25.3* MCHC-30.7* RDW-14.8 RDWSD-45.1 ___ 04:23AM NEUTS-72.7* LYMPHS-16.2* MONOS-10.3 EOS-0.3* BASOS-0.2 IM ___ AbsNeut-4.16 AbsLymp-0.93* AbsMono-0.59 AbsEos-0.02* AbsBaso-0.01 ___ 04:23AM PLT COUNT-257 ___ 04:23AM ___ PTT-29.3 ___ ___ 04:23AM URINE COLOR-Straw APPEAR-Hazy SP ___ ___ 04:23AM URINE BLOOD-NEG NITRITE-POS PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-LG ___ 04:23AM URINE RBC-1 WBC->182* BACTERIA-MOD YEAST-MOD EPI-<1 CXR on ___: "Again seen is mild volume loss in the right upper lobe with peribronchial consolidation in the right upper lobe which may correspond to consolidation and cavitation seen on prior CT. The cardiomediastinal silhouette is stable since the prior examination. The aorta is tortuous. There is no pleural effusion or pneumothorax. No focal consolidation is identified. There is evidence of healed left rib fractures. IMPRESSION: 1. No acute intrathoracic abnormality. 2. CT of the chest is recommended on a non-emergent basis to evaluate right upper lobe abnormality. " Head CT on ___: FINDINGS: "No evidence of infarction, hemorrhage, edema, or mass. Periventricular white matter hypodensities are nonspecific and likely reflects sequela of chronic small vessel ischemic disease. Bilateral, symmetric prominence of the ventricles and sulci likely age-related involutional change. Choroid plexus calcifications are noted. No evidence of fracture. The visualized portion of the paranasal sinuses, mastoid air cells, and middle ear cavities are clear. The visualized portion of the orbits are unremarkable other than lens replacement. IMPRESSION: 1. No evidence of hemorrhage. 2. Age-related involutional change. 3. Sequelae of chronic small vessel ischemic disease. " As of ___: URINE CULTURE (Preliminary): GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. GRAM NEGATIVE ROD #2. >100,000 ORGANISMS/ML.. Brief Hospital Course: Ms. ___ is an ___ woman with history of HTN, GERD, anxiety, lumbar spinal stenosis with chronic back pain (followed by pain management on chronic opioids, self described as "pudendal neuropathy", recently admitted ___ for acute on chronic back pain - followed by outpatient pain management, who presented with a brief episode of altered mental status (resolved), acute on chronic back pain, and headache in the ED found to have a grossly positive UA, admitted for UTI. Her mentation was normal throughout this hospitalization and was explained by her infection. Her back pain appeared worsened in the context of her UTI however pyelo was felt unlikely given CVA tenderness was not worse than her usual pain and lack of high fevers, and relative clinical stability, we opted to treat her for cystitis. Urine cultures grew two different strains of >10,000 GNRs however the patient quickly felt better after just one dose of ceftriaxone. She received a second dose of ceftriaxone and will be discharged home to complete a total 5 day course of ciprofloxacin orally. Her final urine cultures will need to be followed up. Her daughter was concerned that perhaps her tramadol may have played a role in her presentation and regardless the patient felt that it was not treating her pain so pain management was consulted who recommended switching her back to MSIR which she had been on just about a week prior to admission (before she was switched to tramadol) and she will follow up with pain management as an outpatient to address her chronic pain issues. She was scheduled to see her PCP to follow up her urine culture data on ___. I suspect the urine culture will be mixed flora but in the case that sensitivities are available at that time, I want to ensure that she is on the proper antibiotic. Rest of hospital course/plan are outlined below by issue: Pyelo is unlikely and her back pain is chronic. Uncomplicated UTI most likely explains her symptoms but given possible altered mental status and #UTI: UA >182 WBCs and + Ni -ceftriaxone started (___) --> changed to PO cipro on after noon of ___, given ceftriaxone was started late on ___ - I count the first day of abx as ___. For uncomplicated UTI in this patient, I favor 5 days of treatment given frailty, last day will be ___. #Altered mental status: most likely due to apparent infection. Now improved to baseline per her daughter. She probably has some underlying cognitive impairement (no prior dx of dementia) which puts her at risk for toxic metabolic encephalopathy in the context of infection. -Head CT showed chronic changes consistent with old age #Headaches: Given persistent headaches over the past week, I ordered non contrast head CT to rule out bleeding (in an elderly woman at risk for subdural due to bridging veins) which was negative for any bleeding. The patient attributed her headache to taking tramadol which I doubt but regardless her headache was stable to improved during the hospitalization and may have simply been a symptom of her UTI. #Chronic Pain: Including chronic back pain and headache x 1 week. She has been followed by ___ Pain ___. She was weaned down on her dose of fentanyl to 12mcg as of ___, and vicodin was stopped on ___, switched to oxycodone and then subsequently to tramadol on ___ but developed headache after this change. She had a back injection reportedly about a week before admission. -will continue home fentanyl patch at 12mcg (which was recently decreased per the patient. -note the patient was previously taking MSIR 7.5mg q4h PRN for pain before she was taking tramadol. Since she had a poor "response" (ie. headache and altered mental status) and the patient's daughter was anxious about restarting this medications, I will put her back on her previous MSIR at her old dose until she can follow up with her pain specialist. -she was prescribed enough MSIR to last her until her next pain management appointment. #Transitional: -PCP ___ arranged ___ to ___ UTI and cultures - rescheduled appointment with pain management Dr. ___ ___ discharge. -FYI to PCP: ___ CXR ___: per radiology "CT of the chest is recommended on a non-emergent basis to evaluate right upper lobe abnormality." Note that the patient had a known lung infiltrate - s/p prior XRT (never biopsied or confirmed to be cancer). However given age would likely not change management but will inform PCP. # CONTACT: I discussed the plan with the patient's daughter and healthcare proxy at bedside on ___ and answered all questions. I discussed the plan with both the patient and her daughter again on the day of discharge. Spent > 30 minutes seeing patient and organizing discharge. ___, MD ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN gas, GI upset 2. Calcium Carbonate 1000 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Fentanyl Patch 12 mcg/h TD Q72H 5. Gabapentin 100 mg PO QHS 6. Lidocaine 5% Patch 1 PTCH TD BID 7. Milk of Magnesia 45 mL PO QHS 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. polycarbophil 1 tsp vaginal DAILY 10. Ranitidine 150 mg PO BID 11. Senna 17.2 mg PO BID 12. Vitamin D 1000 UNIT PO DAILY 13. Nortriptyline 10 mg PO QHS 14. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain Discharge Medications: 1. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN gas, GI upset 2. Calcium Carbonate 1000 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. Fentanyl Patch 12 mcg/h TD Q72H 5. Gabapentin 100 mg PO QHS 6. Lidocaine 5% Patch 1 PTCH TD BID 7. Milk of Magnesia 45 mL PO QHS 8. Ondansetron 4 mg PO Q8H:PRN nausea 9. Ranitidine 150 mg PO BID 10. Senna 17.2 mg PO BID 11. Vitamin D 1000 UNIT PO DAILY 12. polycarbophil 1 tsp vaginal DAILY 13. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days last day of antibiotics is ___ RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth two times a day Disp #*6 Tablet Refills:*0 14. Morphine Sulfate ___ 7.5 mg PO Q4H:PRN pain RX *morphine 15 mg 0.5 (One half) tablet(s) by mouth every 4 hours Disp #*28 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Urinary tract infection Chronic Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear. Ms. ___, You were admitted for a urinary tract infection and exacerbation of your chronic pain. You were switched from tramadol back to morphine sulfate immediate release per the pain management doctors ___. You will be discharged on an antibiotic called ciprofloxacin to complete a total of 5 days of treatment (last day being ___. On ___, you should follow up with your PCP to review the results of the final urine cultures (which are pending currently) and change your antibiotic if needed. You should follow up with your other outpatient providers as below. Followup Instructions: ___
19969918-DS-18
19,969,918
26,790,284
DS
18
2186-05-24 00:00:00
2186-05-24 13:35:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Darvocet-N 100 Attending: ___. Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: Mr. ___ is a ___ gentleman w/ multiple sclerosis ___ tracheostomy and PEG tube who was recently admitted ___ for trach replacement and is readmitted due to fever at rehab. . Please see notes from prior admission for details. He had a recent ESBL PNA and had been admitted to an OSH for hypoxia and increased trach secretions and had been transferred to ___ for trach replacement which was successful. He recently completed a course of ertopenem [1g daily] for ESBL pneumonia [last day of Ertapenem was ___. ___ records demonstrated patient growing pan-sensitive pseudomonus from sputum culture on ___. This was felt to be a chronic colonizer rather than infectious agent as patient had clear CXR, normal WBC, afebrile and had baseline oxygen requirements. . Upon discharge he arrived at rehab and immediately reportedly had a temp 103.1, accompanied by a rhonchorous cough. Patient reports that he had a worsened chesty cough that has now resolved. Here, patient's cough continues with suctioning for thick, yellow secretions. Son, ___, reports that he was called about the fever earlier but knows no other information. . In the ED, initial VS: 98.6 89 162/68 20 100% 10L NRB. Labs were similar to his d/c labs, with WBC 5.6 (45% neutrophils). CXR showed possible trace left pleural effusion with overlying atelectasis. He was given Vancomycin and was admitted to Medicine for fever workup. VS prior to transfer included rectal temp 100.2, POx 100% on 35% trach collar. . On the floor, he is comfortable. When asked if he felt feverish/chills today he says no. Denies any worsened cough, suprapubic/flank pain, rash. Past Medical History: - Multiple sclerosis with Parkinsonian elements (followed by Dr. ___ at ___) - Anemia - Coronary artery disease status post multiple PCI. - cath ___ showed progression of diffuse disease: Mid LAD: 40 %, ___ Diagonal: focal 80 %, ___ diagonal: 95% proximal, Proximal Circumflex: focal 100 % in distal third, ___ Marginal: focal 70 % in proximal third, Ramus: Occluded at site of prior stenting, Mid RCA: long and irregular 30 % stenosis, PDA: irregular 80 % mid-vessel stenosis, overall no intervention - Heart failure with preserved systolic function. - Hyperlipidemia. - Hypertension. - Chemosis with left eyelid swelling, followed at ___. - Osteoarthritis, right knee. - ___ total knee replacement R ___ - History of UTI. - neurogenic bladder Social History: ___ Family History: Patient unable to provide. Physical Exam: ON ADMISSION: VS - Temp 97.7F, BP 130/80, HR 82, R 24, O2-sat 99% on 35%TC General: NAD HEENT: Sclera anicteric, oropharynx clear, PERRL Neck: Supple, no JVD CV: RRR, normal S1/S2, II/VI SEM loudest over LLS border Lungs: Loud upper airway sounds, no focal wheezes/rales Abdomen: soft, non-tender, non-distended GU: foley in place Ext: WWP, 2+ ___, trace pedal edema, no cyanosis Neuro: LUE contracture, CN II-XII wnl ON DISCHARGE: VS 96.1, 148/68, 68, 18, 99RA General: NAD HEENT: Sclera anicteric, oropharynx clear, PERRL Neck: Supple, no JVD CV: RRR, normal S1/S2, II/VI SEM loudest over LLS border Lungs: Loud upper airway sounds, no focal wheezes/rales Abdomen: soft, non-tender, non-distended GU: foley in place Ext: WWP, 2+ ___, trace pedal edema, no cyanosis Neuro: LUE contracture, CN II-XII wnl Pertinent Results: ADMISSION LABS: ___ 06:46AM BLOOD WBC-4.6 RBC-3.30* Hgb-9.9* Hct-29.5* MCV-90 MCH-30.0 MCHC-33.6 RDW-13.2 Plt ___ ___ 08:15PM BLOOD Neuts-45.2* Lymphs-46.2* Monos-6.5 Eos-1.8 Baso-0.3 ___ 06:46AM BLOOD Glucose-79 UreaN-15 Creat-0.7 Na-137 K-4.0 Cl-107 HCO3-22 AnGap-12 ___ 08:15PM BLOOD ALT-16 AST-29 AlkPhos-64 TotBili-0.4 ___ 06:46AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.7 DISCHARGE LABS: ___ 08:35AM BLOOD WBC-6.6 RBC-3.52* Hgb-10.5* Hct-30.9* MCV-88 MCH-29.8 MCHC-34.0 RDW-12.8 Plt ___ ___ 08:35AM BLOOD Glucose-119* UreaN-11 Creat-0.7 Na-136 K-3.6 Cl-98 HCO3-32 AnGap-10 ___ 08:35AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.7 ___ 12:23AM BLOOD Lactate-1.3 URINALYSIS: ___ 09:12PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-TR ___ 09:12PM URINE RBC-2 WBC-7* Bacteri-NONE Yeast-NONE Epi-1 IMAGING: IMPRESSION: PA and lateral chest compared to ___ through ___ Small region of consolidation at the medial aspect of both lung bases has been present to varying degrees since ___. The left is more persistent and therefore more likely atelectasis. On the right, there may be a region of consolidation that was not present on ___. Small bilateral pleural effusions are decreasing. Upper lungs are clear and the heart is normal size. Tracheostomy tube above the left wall of the trachea. No evidence of central adenopathy. No pneumothorax. Brief Hospital Course: ___ M PMhx MS ___ trach and G-tube placement for recurrent aspirations, recent ESBL PNA, now ___ trach replacement. Was discharged afebrile to ___ and was immediately transfered back after febrile to 103 per report. Patient afebrile over hospital course with no localizing signs of infection. Patient transfered back to ___. . # Fever: Patient had just finished course of ertapenem for ESBL pneumonia. Was discharged afebrile to ___ on ___ and was immediately transfered back after he was found to be febrile to 103 per report. Patient afebrile over entire hospital course at ___ with no localizing signs of infection: negative CXR, negative UA, no elevations in LFTs, no increase in the WBC or differential, and no change clinically. Patient did not receive any antibiotics (after a dose in the ED) and was watched for 48 hours with no return of fevers. . # Conjuctivitis/Blethitis: patient found to have crusting of his left eye, given erythromycin 0.005 % opthalmic solution for a 4 day course to be given QID to both eyes. . # Tube feeds: stable, at full rate with no residules. . # Chronic Anemia: stable with stable hematocrit . # MS: Stable. Followed by Dr. ___ in neurology. Continued on home baclofen and siminet. # CAD: Stable, continued on home aspirin and beta-blocker. . # DM: stable, continued on home insulin regmin. # Depression: stable, continued on home citalopram. . TRANSITIONAL ISSUES: -blood and sputum cultures were no growth to date at the time of transfer. Medications on Admission: Aspirin 81 mg daily Clopidogrel 75 mg daily Metoprolol tartrate 12.5 mg BID Carbidopa-levodopa ___ mg TID Baclofen 10 mg BID Citalopram 20 mg daily Albuterol sulfate 2.5 mg /3 mL (0.083 %) neb Q6H Ipratropium bromide 0.02 % neb Q6H Bisacodyl 10mg daily PRN Senna 8.6 mg BID PRN Docusate sodium 50 mg/5 mL Liquid BID Carbamide peroxide 6.5 % Drops: 5 drops BID Nystatin 100,000 unit/g Cream BID Folic acid 1 mg daily Insulin regular Heparin (porcine) 5,000u SC TID Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 3. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 7. carbidopa-levodopa ___ mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 9. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 13. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 14. insulin lispro 100 unit/mL Solution Sig: One (1) Subcutaneous ASDIR (AS DIRECTED). 15. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical BID (2 times a day). 16. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1) Ophthalmic QID (4 times a day) for 3 days: apply to both eyes. 18. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 19. carbamide peroxide 6.5 % Drops Sig: Five (5) Drop Otic BID (2 times a day) for 4 days. Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary: Fever Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Mr. ___, As always, it was a pleasure taking care of you while you were in the hospital. You were admitted out of concern that you might have an infection, the work up at our hospital indicated that ___ did not and you were observed for 24 hours without any recurrance of fevers. You were discharged back to your extended care facility to continue with physical therapy. Followup Instructions: ___
19969918-DS-19
19,969,918
25,664,596
DS
19
2186-06-13 00:00:00
2186-06-13 15:44:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Darvocet-N 100 Attending: ___ ___ Complaint: Increased secretions and work of breathing Major Surgical or Invasive Procedure: None History of Present Illness: ___ y/o M with ___ progressive MS ___ trach and G-tube placement for recurrent aspirations, recent ESBL E. coli PNA transferred from an OSH with hypoxia and hypotension. The patient presented to ___ on the day prior to admission after his trach tube had fallen out. His trach was replaced in the ___, and he was subsequently discharged. He returned to the ___ with increased work of breathing, increased secretions from his trach, hypoxia (74% unclear O2 delivery), and BP 69/59. Per report, his trach was suctioned aggressively. A L femoral central line was placed, and after 4L IVF his BP improved to 110/65 and HR improved to 100. At the time of transfer, he was satting 98% on 12L humidified air via trach mask. CXR demonstrated R-sided infiltrate/pneumonitis and his UA was positive. Initial troponin was 0.2 and lactate 9.3. He was given vancomycin, ceftazadime (h/o pseudomonas sensitive) and gentamycin. History of E. coli in urine (___) resistent to bactrim and flouroquinolones. Patient admitted in ___ with hypoxic respiratory failure and RLL aspiration PNA. Due to deterioration of MS in the acute setting as well as difficulty extubation ___ recurrent aspiration, PEG and trach were placed. Sputum culture grew Enterobacter resistent to ceftriaxone and ceftazidime. Treated initially with Vanc/Zosyn, then narrowed to PO cipro. In ___, admitted to OSH with LLL PNA, ESBL E. coli and treated with Ertapenem. In the ___ inital vitals were, 98 116 90/60 20 100% 15L. Lactate 3.1. He was given 1L NS, then transferred to the ICU. On arrival to the ICU, VS: 96.2; 126; 110/84; 22; 95% trach mask 15L; 40%. Patient has diminished mental status though unclear whether this is close to his baseline. Patient is unable to describe any further symtpoms, including chest pain and shortness of breath. Review of systems: (+) Per HPI, son added chronic b/l ___ weakness and right facial droop (-) Per son, HCP, denies fever, chills, cough, chest pain. Past Medical History: - Multiple sclerosis with Parkinsonian elements (followed by Dr. ___ at ___) - Anemia ___, h/o guaiac + stools, but no colonoscopy or known source of GIB - Coronary artery disease status post multiple PCI. - cath ___ showed progression of diffuse disease: Mid LAD: 40 %, ___ Diagonal: focal 80 %, ___ diagonal: 95% proximal, Proximal Circumflex: focal 100 % in distal third, ___ Marginal: focal 70 % in proximal third, Ramus: Occluded at site of prior stenting, Mid RCA: long and irregular 30 % stenosis, PDA: irregular 80 % mid-vessel stenosis, overall no intervention - Heart failure with EF 40-45% - Hyperlipidemia. - Hypertension. - Chemosis with left eyelid swelling, followed at MEEI. - Osteoarthritis, right knee. - ___ total knee replacement R ___ - History of UTI. - neurogenic bladder Social History: ___ Family History: Unable to obtain Physical Exam: Admission exam: VS: 96.2; 126; 110/84; 22; 95% trach mask 15L; 40%. General: Alert, awake, follows command, can nod yes to questions HEENT: Sclera anicteric, dry MM Neck: supple, JVP not elevated Lungs: Trach in place, tachypneic, rhonchorous transmitted upper airway sounds throughout CV: Tachycardic, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: PEG tube in place, soft, non-tender, non-distended, bowel sounds present GU: Foley in place, draining clear urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: WBC-5.9 RBC-3.09* Hgb-9.5* Hct-29.1* MCV-94 MCH-30.7 MCHC-32.6 RDW-13.9 Plt ___ Neuts-30* Bands-51* Lymphs-15* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-4* Myelos-0 Glucose-94 UreaN-43* Creat-1.1 Na-146* K-4.2 Cl-114* HCO3-23 AnGap-13 ALT-17 AST-22 LD(LDH)-162 CK(CPK)-115 AlkPhos-40 TotBili-0.3 CK-MB-4 cTropnT-0.03* Albumin-2.5* Calcium-7.7* Phos-2.9 Mg-1.8 Lactate-3.7* . Imaging: CXR ___- Large scale consolidation in the right lower lung, predominantly lower lobe, was new earlier today compared to ___. It has grown slightly more radiodense over the past eight hours, probably active pneumonia. Small right pleural effusion is presumed and should be monitored in order to detect any development of empyema. Left lung is clear. Cardiomediastinal silhouette is normal. The patient has a tracheostomy tube in standard placement. No pneumothorax. . CXR ___ (following PICC placement)- Right PIC line has been repositioned, tip is approximately 2 cm below the estimated location of the superior cavoatrial junction. Extensive consolidation right mid and lower lung zone stable since ___, increased at the left base since ___ consistent with worsening pneumonia. There is no pulmonary edema. Heart size is normal. Tracheostomy tube in standard placement. . Microbiology: . **FINAL REPORT ___ URINE CULTURE (Final ___: IDENTIFICATION AND SENSITIVITY TESTING REQUESTED BY ___ ___ ___. ENTEROCOCCUS SP.. ~3000/ML. ESCHERICHIA COLI. ~1000/ML. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- =>64 R CEFTRIAXONE----------- 8 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S LINEZOLID------------- 2 S MEROPENEM------------- <=0.25 S NITROFURANTOIN-------- 128 R <=16 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ =>32 R . **FINAL REPORT ___ . GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions.. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. . RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal Respiratory Flora. WORK UP ALL PATHOGENS PER ___. ___ ___. ESCHERICHIA COLI. SPARSE GROWTH. Piperacillin/tazobactam sensitivity testing available on request. BETA STREPTOCOCCI, NOT GROUP A. SPARSE GROWTH. PSEUDOMONAS AERUGINOSA. RARE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by ___ ___. . SENSITIVITIES: MIC expressed in MCG/ML . _________________________________________________________ ESCHERICHIA COLI | PSEUDOMONAS AERUGINOSA | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S 8 S CEFTAZIDIME----------- 16 R 16 I CEFTRIAXONE----------- 2 I CIPROFLOXACIN--------- =>4 R 1 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S 0.5 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: HOSPITAL COURSE ___ y/o M with PMH progressive multiple sclerosis ___ trach and G-tube placement for recurrent aspiration PNA, recent Enterobacter and ___ transferred from an OSH with hypoxia, hypotension and focal consolidation on CXR. He was treated for a pneumonia with IV antibiotics and transferred to an LTAC for further care. His hospital course was complicated by tachycardia and volume overload. . ACTIVE ISSUES # Septic Shock: At outside hospital, patient met SIRS criteria with tachycardia, bandemia and tachypnea. He was afebrile, but hypotensive and not responsive to fluid boluses, and had a lactate of >9. CXR at outside hospital, and confirmed at ___ showed new right lower lobe opacity. In addition, he had a positive urinalysis. Patient was started on broad spectrum antibiotics with vancomycin, levofloxacin and meropenem to cover hospital acquired pneumonia and urinary tract infection, with history of ESBL e.coli UTIs. Lactate trended down, was 3 on arrival to ___, and was normal by HD1. Patient required a total of 6L NS in fluids, and then was placed on phenylephrine for blood pressure support. Pressors were weaned on HD1. Patient had a PICC line placed on HD1 for antibiotic administration, with plan to continue broad spectrum antibiotics for 14 days, day 1= ___. At the time of discharge, urine culture was positive for both enterococcus and ecoli, which were speciated to VRE however < 3000 colonies so therfore not treated. Sputum cultures were contaminated but speciated to pseudomonas and ecoli. Blood cultures were still pending or negative at the time of transfer. At the time of transfer he was day ___ of meropenem for esbl pneumonia. He completed 7 days of vancomycin which was discontinued prior to transfer given absence of culture driven data. - Continue IV Meropenem for 6 additional days to complete 14 day course . # Hypoxic respiratory distress: Thought to be due to recurrent pneumonia, likely aspiration despite tube feeds through PEG. On arrival to ICU, sat's were in the ___ on tach mask at FiO2 35%. ABG 7.44/___. Patient was treated with broad spectrum antibiotics as above, with plan to treat for 14 days. Patient was at his baseline at the time of discharge. Interventional pulmonology saw patient while in-house and were concerned about recurrent aspirations and recommended that G-tube be changed to J-tube. Head of bed was elevated to prevent aspirations in addition to frequent suctioning of oral secretions. He was diuresed prior to transfer given total fluid balance during his hospital stay was over 10 liters. He was placed on a lasix drip prior to transfer in an effort to achieve relative ___. - He should be continued on bolus lasix 20 IV for goal net negative 1 liter per day. - At the time of discharge he was 7 liters up total length of stay. . # Tachycardia: Documented initially as sinus, with rates in the 120s. He went into atrial fibrillation with short bursts into the 190s that were felt to be supraventricular. As blood pressure was stable, home metoprolol was restarted on the evening of admission and was titrated up for improved heart rate control. Tachycardia coincided with aggressive diuresis. He flipped back into sinus rhythm and his metoprolol was ultimately down-titrated to tid dosing. - Increase metoprolol to 12.5 mg tid . Chronic issues: # CAD ___ stent- Unknown when stents were placed, but at higher risk of cardiac event in the setting of sepsis, hypoperfusion, and tachycardia. Aspirin and plavix were continued. Cardiac enzymes were flat. . # Anemia- patient with chronic anemia and history of guaiac positive stools. No signs of bleeding from recent EGD prior to PEG placement in ___. No colonoscopy records. Baseline Hct ___. Was 29 on arrival. Noted to have coffee grounds in oral suction. He was started on IV protonix for ___ week course. - Start IV protonix for ___ week course. . # HTN - Continued home metoprolol as above. . # sCHF - EF in ___ 40-45% with focal WMA. . # DM - Started on humalog insulin sliding scale while an inpatient. . # MS - History of progressive MS, also recently developed Parkinsonian symptoms and started on carbidopa-levodopa. Continued all home medications includeing baclofen and sinement. . # Transitional issues: - blood cultures pending - code status: full (Discussed at length with patient and health care proxy while hospitalized. Patient was able to express understanding regarding discussion and wish for continued full code status) Medications on Admission: #. heparin (porcine) 5,000 unit/mL One (1) Injection TID #. Carbidopa-Levodopa ___ mg, 1 tab TID #. bisacodyl 5 mg Two (2) Tablet PO DAILY (Daily) prn constipation #. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID #. senna 8.6 mg Tablet One (1) Tablet PO BID prn constipation. #. albuterol sulfate 2.5 mg /3 mL (0.083 %) One (1) Inhalation Q6H #. ipratropium bromide 0.02 % Solution One (1) Inhalation Q6H #. aspirin 81 mg One (1) Tablet, Chewable PO DAILY (Daily). #. baclofen 10 mg One (1) Tablet PO TID (3 times a day). #. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY #. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). #. metoprolol tartrate 25 mg 0.5 Tablet PO BID (2 times a day). #. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: 1. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. baclofen 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. Mucinex ___ mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day. 11. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. carbidopa-levodopa ___ mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: ___ Tablet, Delayed Release (E.C.)s PO DAILY (Daily) as needed for constipation. 14. bisacodyl 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 15. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO at bedtime as needed for constipation. 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 17. heparin, porcine (PF) 10 unit/mL Syringe Sig: Five (5) ML Intravenous PRN (as needed) as needed for line flush. 18. meropenem 500 mg Recon Soln Sig: One (1) injection Intravenous every six (6) hours for 6 days. 19. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 20. furosemide 10 mg/mL Solution Sig: ___ mL Injection twice a day as needed for volume overload: titrated as directed by supervising MD for goal urine output . Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Pneumonia, Paroxysmal Atrial Fibrillation 2. Multiple Sclerosis status post tracheostomy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert Activity Status: Bedbound. Discharge Instructions: You were admitted for increased oxygen requirement, low blood pressure and increased respiratory secretions that were secondary to a pneumonia. You were treated with strong antibiotics initially to cover for urinary and respiratory sources. Ultimately, bacteria was isolated from your respiratory secretions and you will require a total of fourteen days of antibiotic therapy. Your hospitalization was complicated by a fast heart rate which was treated with increased doses of your metoprolol. You also developed volume overload, which was treated with a diuretic, furosemide. Lastly you were noted to have blood in your stomach so you were started on 6 weeks of anti-acid medication. The following changes were made to your medication list: 1. CONTINUE Lasix (furosmide): 10mg-20mg IV for goal urine out put 1 liter per day for several days 2. CONTINUE Meropenem 500 mg IV every 6 hours for 6 more days 3. INCREASE Metoprolol to 12.5mg three times a day 4. START Pantoprazole 40mg IV twice a day for four additional weeks Followup Instructions: ___
19969973-DS-21
19,969,973
27,702,430
DS
21
2145-09-24 00:00:00
2145-09-24 13:46:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Ativan / lisinopril Attending: ___. Chief Complaint: Periprosthetic Femur fracture Major Surgical or Invasive Procedure: Right distal femur Open Reduction and Internal Fixation of Periprosthetic fracture History of Present Illness: ___ s/p mechanical fall on ___ when she was taken to ___ ___ in ___. The patient had been having R radicular leg pain due to a reported synovial cyst in her back. She was out walking her dog when the pain in her leg caused her to fall. She called ___ and was brought to ___. Patient did not strike her head or lose consciousness, but does note some R shoulder pain. She was found to have a periprosthetic distal femur fracture and transferred to ___. She was then transferred here for eventual surgery with Dr. ___. Past Medical History: Bipolar depression, anxiety, chronic pain in shoulders/legs/hands/feet, rheumatoid arthritis. Right TKA and revision as above, R knee arthroscopy ___ years ago multiple times, Shoulder arthroscopy R and L ~ ___ years ago. Carpal tunnel x2L x1R, tonsillectomy, c-section. Social History: ___ Family History: NC Physical Exam: PHYSICAL EXAMINATION: AVSS NAD, A&Ox3 Right lower extremity: - Skin intact - Slight visual deformity of left thigh with lateral prominence distally. - Soft but very tender to palpation in the thigh. Knee with mild to moderate effusion. No erythema. Not warm to the touch. - ROM not attempted at the knee, full ROM at the ankle - No pain with palpation and gentle log roll of the hip. - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused Exam on Discharge: AVSS NAD, A&Ox3 RLE Incision well approximated. Fires ___. SITLT s/s/dp/sp/tibial distributions. 1+ DP pulse, wwp distally. Pertinent Results: IMAGING: Distal femur periprosthetic fracture at the level of the knee prosthesis stem. Apex lateral, no diplacement. Brief Hospital Course: The patient presented as a same day admission for surgery. The patient was taken to the operating room on ___ for Right distal femur Open Reduction and Internal Fixation of Periprosthetic fracture, 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 Touch Down Weight Bearing in the hinged knee brace in right lower extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. ClonazePAM 1 mg PO QID 2. Amlodipine 5 mg PO DAILY 3. Docusate Sodium 100 mg PO BID 4. FoLIC Acid 0.8 mg PO DAILY 5. Gabapentin 700 mg PO TID 6. Morphine SR (MS ___ 60 mg PO Q12H 7. LaMOTrigine 100 mg PO BID 8. Nicotine Patch 21 mg TD DAILY 9. TraZODone 50 mg PO QHS:PRN sleep 10. Senna 8.6 mg PO BID 11. Beclomethasone Dipro. AQ (Nasal) 1 spray Other BID 12. Patanol (olopatadine) 0.1 % ophthalmic BID 13. diflunisal 500 mg oral BID Discharge Medications: 1. Amlodipine 5 mg PO DAILY 2. Beclomethasone Dipro. AQ (Nasal) 1 spray Other BID 3. ClonazePAM 1 mg PO QID 4. Docusate Sodium 100 mg PO BID 5. FoLIC Acid 0.8 mg PO DAILY 6. Gabapentin 700 mg PO TID 7. LaMOTrigine 100 mg PO BID 8. Morphine SR (MS ___ 60 mg PO Q12H RX *morphine [MS ___ 60 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 9. Nicotine Patch 21 mg TD DAILY 10. Senna 8.6 mg PO BID 11. TraZODone 50 mg PO QHS:PRN sleep 12. Acetaminophen 1000 mg PO Q6H pain, fever 13. Artificial Tears ___ DROP BOTH EYES PRN dry eyes 14. Enoxaparin Sodium 40 mg SC DAILY Start: Today - ___, First Dose: Next Routine Administration Time RX *enoxaparin 40 mg/0.4 mL 40 mg sc once a day Disp #*28 Syringe Refills:*0 15. Fluticasone Propionate 110mcg 2 PUFF IH BID 16. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 17. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN severe pain RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 3 hours Disp #*150 Tablet Refills:*0 18. Patanol (olopatadine) 0.1 % ophthalmic BID 19. diflunisal 500 mg oral BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Periprosthetic Right Femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Touch Down Weight Bearing on Right Lower Extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox 40mg daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - Keep your hinged knee brace on till your follow up at clinic and do not get it wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your surgeon's team (Dr. ___, with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: -TDWB RLE in unlocked ___ Treatments Frequency: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - No dressing is needed if wound continues to be non-draining. - hinged knee brace must be left on until follow up appointment unless otherwise instructed - Do NOT get brace wet Followup Instructions: ___
19969991-DS-3
19,969,991
22,950,880
DS
3
2177-08-12 00:00:00
2177-08-14 15:20:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ old woman with atrial fibrillation, hypothyroidism who presents with shortness of breath x 2 months and found to be in afib RVR and new pleural effusion. She was diagnosed with afib on routine physical in ___. She had worsening shortness of breath when walking up an incline, shoveling snow, going up stairs when carrying her 20 pound puppy. She has had a nonproductive cough, denies ___ swelling, chest discomfort, and palpitations. She has gained ___ pounds since ___, but attributes this to poor eating habits as she works as a ___. She denies lower extremity swelling, no PND or orthopnea. She denies any fevers, recent travels or contact with anyone ill. She had 30 lbs intentional weight loss with diet and exercises. she denies fever chills, sig. fatigue. She was seen in clinic and found to be in afib RVR with rate 130s and new inverted T waves from prior EKG. She was sent to ___. Chest x-ray showed a new pleural effusion and question of a right lobe mass which prompted transfer to ___. ___ ED Course (labs, imaging, interventions, consults): - Initial Vitals/Trigger: T 98.1 145 121/83 16 96% RA - EKG: rapid afib with rate 148, old RBBB no STEMI - CTA chest showed no pulmonary embolism but large nonhemorrhagic right pleural effusion without obvious associated pulmonary mass or obvious infection although there was compressive atelectasis leading to right lung base consolidation. - She was given diltiazem IV 20 mg once, followed by diltiazem PO 30mg x 2 and IV 10 mg with improvement in HR to 100s. Transfer vital signs: T 98.5 106 103/62 18 99% RA. On the floor, VS 97.6 118/75 52 recorded but on tele ___, 18 94% RA. She feels well at this time and is asymptomatic. She states she has no shortness of breath at rest or lying down flat. no acute events overnight, this am, pt denies CP, SOB, abd pain, d/c. no f/c. Past Medical History: -Hypothyroidism. TFT's wnl ___ -Lymphocytic colitis -Afib. Dx'd on routine physical ___, asymptomatic. She has had no recent CP, SOB, palps. Saw Dr. ___ ___ and has appt booked for ___ -Hyperlipidemia Social History: ___ Family History: Mother had breast ca, MI and hypertension. Father with DM and brain tumor possibly from melanoma mets. Sister died at ___ of unknown cause. Physical Exam: ADMISSION PHYSICAL EXAM Vitals - T97.6 118/75 52 (on tele is 100-120s) 18 94% RA GENERAL: NAD, lying in bed HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: Irregularly irreg rates variable in 100s, no murmurs, gallops, or rubs appreciated LUNG: Breathing comfortably without use of accessory muscles, dullness to percussion and decreased breath sounds over right lung fields up ___ and decreased. ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE PHYSICAL EXAM: Vitals: 98.4 115/80 52 18 94% RA Tele: afib with highest rate of 150s Last 24 hours I/O: -300 Today's weight: 72 GENERAL: NAD, sitting up in chair HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: Irregularly irreg, no murmurs, gallops, or rubs appreciated LUNG: Breathing comfortably without use of accessory muscles, dullness to percussion and decreased breath sounds over right lung fields up ___ and decreased. ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 05:16PM BLOOD WBC-6.7 RBC-5.23 Hgb-16.3* Hct-49.2* MCV-94 MCH-31.1 MCHC-33.1 RDW-14.1 Plt ___ ___ 05:16PM BLOOD ___ PTT-35.1 ___ ___ 05:16PM BLOOD Glucose-114* UreaN-13 Creat-0.6 Na-141 K-4.3 Cl-105 HCO3-21* AnGap-19 ___ 08:19AM BLOOD ALT-42* AST-37 LD(LDH)-192 AlkPhos-63 TotBili-1.4 ___ 05:16PM BLOOD Calcium-9.6 Phos-4.0 Mg-2.0 IMAGING: CXR ___: Previous moderate to large right pleural effusion is smaller but still substantial. There is no pneumothorax. Atelectasis in the medial aspect of the right middle and right lower lobe has improved, but not cleared. Left lung is clear. Heart is large. There is no pulmonary edema. CXR ___ FINDINGS: There is increased opacity at the right lung base with silhouetting of the right hemi diaphragm and right heart border. On the projection there is an apparent soft tissue density extending from the anterior chest wall. There is prominence of the interstitial lung markings bilaterally. There is also a high over consolidation seen at the right lower lobe. IMPRESSION: Appearances are concerning for a chest wall lesion with consolidation in the right lower lobe. Given the patient does not have symptoms of an acute infection, recommend CT chest to further evaluate. CTA CHEST ___: 1. No pulmonary embolism. 2. Large, nonhemorrhagic right pleural effusion with no obvious associated pulmonary mass. Consolidation at the right lung base is likely compressive atelectasis, however infection can be considered in the appropriate clinical setting. 3. Trace perisplenic and perihepatic ascites seen in the limited images of the abdomen. ECHO ___ The left atrium is elongated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No structural heart disease or pathologic flow identified. EKG: review of EKG shows afib 145, TWI in V4-V6 DISCHARGE LABS: ___ 06:05AM BLOOD WBC-5.6 RBC-5.43* Hgb-17.3* Hct-50.6* MCV-93 MCH-31.8 MCHC-34.1 RDW-13.9 Plt ___ ___ 06:05AM BLOOD Glucose-98 UreaN-14 Creat-0.6 Na-138 K-4.5 Cl-102 HCO3-25 AnGap-16 ___ 06:05AM BLOOD ALT-48* AST-50* AlkPhos-78 TotBili-0.7 ___ 06:05AM BLOOD Calcium-9.6 Phos-4.8* Mg-2.1 Brief Hospital Course: Ms. ___ is a ___ old woman with atrial fibrillation, hypothyroidism who presents with shortness of breath x 2 months and found to be in afib RVR and new pleural effusion. ACUTE ISSUES: # Afib RVR: Patient presented in afib with RVR with rates 130-150s. Rates were decreased diltizem, which was uptitrated to max dose of 90 q6h with rates in the ___. Patient was monitored on telemetry and remained in atrial fibrillation. She remained asymptomatic and hemodynamically stable during these episodes. Patient had attempted cardioversion on ___ but this was unsuccessful. She was started on Flecanide 150mg BID in addition to Diltizem with successful cardioversion on ___. Patient should remain on decreased doses of Flecanide and Diltizem as an outpatient will follow-up with her cardiologist. She was continued on home Apixaban. # R pleural effusion: Patient presented with new non-hemorrhagic right pleural effusion on imaging. Etiology was felt to be secondary to the atrial fibrillation but it is unusual to cause a unilateral effusion. Patient did not have constitutional symptoms and she is up to date on cancer screening including mammography and colonscopy so maligancy is less likely etiology. Patient was diuresed with Lasix and good urine output. She had a follow-up CXR on discharge which showed decreased size of the effusion. An appointment was made for the patient to have the effusion tapped for diagnosis and/or therapy with interventional pulmonology as an outpatient. # Transaminitis: AST/ALT 50/48 on discharge. This was felt to be possibly secondary to medication side effect. Patient will have follow-up labs with PCP as outpatient for monitoring. CHRONIC ISSUES: # Hypothyroidism: Patient was continued on home levothyroxine. # Hyperlipidemia: Patient continued on home simvastatin. TRANSITIONAL ISSUES f/u LFTs as outpatient: ?drug effect - f/u TSH as outpatient (TSH elevated at 8.8, w/o symptoms of hypothyroidism) - repeat CBC as outpatient as Hct elevated on discharge at 50.6 - pleural effusion will need to be followed up as an outpatient. We are working on getting an outpatient IP appointment. -There is a drug-drug interaction between simvastatin and diltiazem if the statin is increased over 10mg/day to cause rhabdomyolysis. Currently on 10mg, but monitor for signs of rhabdo. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Apixaban 5 mg PO BID 2. Atenolol 25 mg PO DAILY 3. Ketoconazole 2% 1 Appl TP DAILY 4. Levothyroxine Sodium 150 mcg PO 5X/WEEK (___) 5. Levothyroxine Sodium 175 mcg PO 2X/WEEK (___) 6. Simvastatin 10 mg PO QPM 7. Multivitamins 1 TAB PO DAILY 8. Calcium Citrate Plus (Vit B6) (calcium-mag-vit B6-D3-minerals) 250-40-5-125 mg-mg-mg-unit oral daily 9. Fish Oil (Omega 3) ___ mg PO DAILY Discharge Medications: 1. Apixaban 5 mg PO BID 2. Levothyroxine Sodium 150 mcg PO 5X/WEEK (___) 3. Levothyroxine Sodium 175 mcg PO 2X/WEEK (___) 4. Simvastatin 10 mg PO QPM 5. Flecainide Acetate 100 mg PO Q12H RX *flecainide 100 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*1 6. Calcium Citrate Plus (Vit B6) (calcium-mag-vit B6-D3-minerals) 250-40-5-125 mg-mg-mg-unit oral daily 7. Fish Oil (Omega 3) ___ mg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Diltiazem Extended-Release 180 mg PO DAILY RX *diltiazem HCl 180 mg 1 capsule(s) by mouth daily Disp #*30 Capsule Refills:*1 Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: atrial fibrillation Secondary diagnosis: pleural effusion 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 hospitalization. You came in because your heart rate was fast from your atrial fibrillation. We tried to control your heart rhythm and rate with medications but your heart rate was still fast. You underwent a procedure on ___ to reverse your rhythm but it was unsuccessful. You had the procedure again on ___ and your heart rhythm returned to normal. You will continue flecainide and diltiazem (new medications to help your heart rhythm) and the blood thinner. While you were here you also had a chest X-ray which showed fluid around your lung. We gave you a medication to remove the fluid, but still some remains. We are unclear about what is causing the fluid build-up. You have an appointment in the interventional pulmonary clinic to follow up the fluid. We wish you the best, Your ___ Team Followup Instructions: ___
19970078-DS-26
19,970,078
29,613,932
DS
26
2197-12-22 00:00:00
2197-12-22 15:49:00
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROSURGERY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Senna / Verapamil / peanut Attending: ___. Chief Complaint: Left facial droop Major Surgical or Invasive Procedure: ___: Right frontal craniotomy for mass resection History of Present Illness: ___ is a ___ year old female with pmhx of HTN, hypothyroid, glaucoma who presents to the ED with concern of left facial droop. Patient states that when she went to bed last night she did not notice the facial droop, but when she awoke and was brushing her teeth at about 0830 she noted the right side of her face was much higher than the left. Patient with no other symptoms and continued to go to work when her colleagues expressed concerns and instructed her to present to the ED. CTH on presentation to the ED with concern for a right frontal lesion for which neurosurgery was consulted. Past Medical History: - HTN - Spinal Stenosis of L4-L5 - Diverticulitis - Hyperthyroidism - Thyroid nodules - s/p hysterectomy for fibroids ___ - PPD positive CXR negative - Toxic nodular goiter Social History: ___ Family History: Parents with kidney disease Maternal cousins with lung cancer and colon cancer Physical Exam: ON ADMISSION: ___ =================== PHYSICAL EXAM: T: 98.4 BP: 171/92 HR: 56 R: 14 O2Sats: 100% Room air Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-2mm bilaterally EOMs: Intact Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength intact, left facial droop. 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 noted. Sensation: Intact to light touch Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin ON DISCHARGE: ================= Opens Eyes: [x]Spontaneous [ ]To voice [ ]To noxious [ ]None Orientation: [x]Person [x]Place [x]Time Follows Commands: [ ]Simple [x]Complex [ ]None Pupils: PERRL Extraocular Movements: [x]Full [ ]Restricted Face Symmetric: [ ]Yes [x]No - Left facial droop Tongue Midline: [x]Yes [ ]No Pronator Drift: [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No Comprehension Intact: [x]Yes [ ]No Motor: Trapezius Deltoid Biceps Triceps Grip Right 5 5 5 5 5 Left 5 5 5 5 5 IP Quadriceps Hamstring AT ___ Gastrocnemius Right 5 5 5 5 5 5 Left 5 5 5 5 5 5 Sensation: Intact to light touch bilaterally. Right Cranial Incision: - Clean, dry, intact, OTA. Pertinent Results: ___ 06:45AM BLOOD WBC-13.1* RBC-4.26 Hgb-12.3 Hct-37.7 MCV-89 MCH-28.9 MCHC-32.6 RDW-14.2 RDWSD-45.8 Plt ___ ___ 07:05AM BLOOD ___ PTT-26.6 ___ ___ 05:55AM BLOOD Na-135 ___ 12:56PM BLOOD Na-133* ___ 06:45AM BLOOD Glucose-95 UreaN-19 Creat-0.9 Na-132* K-4.7 Cl-95* HCO3-25 AnGap-12 ___ 11:12AM BLOOD ALT-32 AST-33 AlkPhos-94 TotBili-0.6 ___ 11:12AM BLOOD Lipase-28 ___ 12:07AM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:45AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 ___ 11:12AM BLOOD %HbA1c-5.9 eAG-123 ___ 11:12AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ Non contrast head CT IMPRESSION: 1. Status post right frontal craniotomy for resection right frontal lesion, with overall similar appearance of expected postsurgical changes. 2. Unchanged vasogenic edema involving the right frontal and parietal regions. 3. Unchanged 3 mm leftward midline shift. ___ MRI head with and without contrast IMPRESSION: 1. Expected postsurgical changes after subtotal resection of a right frontal lobe mass. 2. Residual nodular enhancement superiorly to the resection cavity, along its medial and posterior inferior border are consistent with residual tumor. 3. Unchanged extensive edema in the right frontal lobe surrounding the resection cavity and residual mass with stable 4 mm leftward midline shift and partial effacement of the right lateral ventricle. 4. Unchanged nonspecific additional patchy white matter changes in the cerebral hemispheres bilaterally, likely sequela of chronic microangiopathy. Brief Hospital Course: ___ awoke on ___ at 830AM and noted a left facial droop. Patient was feeling otherwise well and went to work when her colleagues stated she should present to the ED. On arrival to ED patient was CODE stroke and neurology consulted. CTH in ED revealing right frontal mass for which neurosurgery was consulted. Neuro Oncology and Radiation Oncology were also consulted. #Right frontal brain mass with cerebral edema Patient admitted to the floor under the neurosurgery service for this new diagnosis of brain mass. Patient underwent MRI brain with and without contrast revealing a cystic right frontal mass with intratumoral hemorrhage. Patient also underwent CT chest/abdomen and pelvis for malignancy workup which was negative for malignancy however did reveal small unchanged lung nodules. Patient was started on Keppra for seizure prophylaxis. Patient's vital signs remained stable throughout hospitalization. On ___ patient and her niece updated regarding findings and diagnostics. Patient agreed to surgical intervention and the risks and benefits were discussed with both patient and the niece and consent was signed by patient. On ___ ___ patient was noted by niece to have left eye twitching and an episode of aphasia which self resolved. Patient given stat dose of Keppra. Patient went to the OR on ___ for a right crani for tumor resection. Please see operative report by Dr. ___ full details. She was started on steroids postoperatively, which were tapered down to maintenance dosing of 2mg BID. MRI brain on POD 1 showed a subtotal resection of the lesion. Following the procedure, her exam slowly improved and she was made floor status on ___. She was transferred to the floor where she remained neurologically and hemodynamically stable. She was scheduled for radiation planning appointment on ___ with the intent to start radiation on ___ or ___. In the meantime she was seen by ___ and OT and screened for rehab. #Dysphagia Postoperatively patient had significant difficulty managing secretions (requiring frequent suctioning) and significant dysphagia/coughing with PO intake. The SLP service was consulted and assessed to be high risk for aspiration, she was therefore made NPO with all critical meds converted to IV and non-critical meds were held. NGT placement was attempted on the floor but was unsuccessful despite multiple attempts. On ___ the patient underwent successful NG tube placement under fluoroscopy, performed by the BI radiology service. She was subsequently started on tube feeds per nutrition recommendations and continued to work with the SLP service. She was restarted on home PO meds via NGT on ___. ACS was consulted for placement of a PEG as the patient was unable to progress with safe PO intake. PEG was placed on ___ and the patient tolerated titrating tube feeds to goal after 24hours. She had a video swallow on ___. She remained NPO with trials of puree, nectar with SLP only. #Hyponatremia Patients sodium trended down to 132, she was started on salt tabs 1G BID and her sodium was monitored daily. #Leukocytosis Although the patient was on decadron for her lesion a CXR was obtained to monitor for pneumonia given her high risk for aspiration. It showed a LLL opacity and she was monitored closely for fever. She remained afebrile without cough or other respiratory symptoms. #UTI The patient was started on Macrodantin on ___ for a UTI. Last dose to be given 1800 on ___. #Hypertension The patient's home oral hypertensive medications were initially held in the immediate post-operative period and prn Hydralazine IV was used to maintain SBP below 160, however they were both eventually restarted. She was noted to have ST elevation on telemetry, although was aymptomatic. EKG showed new worsening ST elevations on lateral leads. Cardiac enzymes were negative. Medicine was called to review EKG who felt the changes were likely repolarization and no further work-up was indicated. #Disposition While inpatient, ___ and OT evaluated the patient and recommended discharge to rehab with plan to begin radiation on ___ or ___. Medications on Admission: Labetalol 100mg BID, Synthroid 75mcg daily, Spironolactone 25mg daily, Latanoprost 0.005% one gtt bilat eyes QHS. Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 3. Dexamethasone 2 mg PO Q12H This is the maintenance dose to follow the last tapered dose 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg PO BID 6. Heparin 5000 UNIT SC BID 7. LevETIRAcetam 1000 mg PO BID 8. Milk of Magnesia 30 mL PO Q6H:PRN Constipation - Second Line Reason for PRN duplicate override: Alternating agents for similar severity 9. Nitrofurantoin (Macrodantin) 50 mg PO Q6H Duration: 1 Dose last dose: 1800 on ___ 10. Sodium Chloride 1 gm PO BID 11. Fluticasone Propionate NASAL 1 SPRY NU DAILY 12. Labetalol 100 mg PO BID 13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 14. Levothyroxine Sodium 75 mcg PO DAILY 15. Spironolactone 25 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right Frontal Brain Mass Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Discharge Instructions Brain Tumor Surgery •You underwent surgery to remove a brain lesion from your brain. •You may shower at this time. •It is best to keep your incision open to air but it is ok to cover it when outside. •Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity •We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. •You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. •No driving while taking any narcotic or sedating medication. •If you experienced a seizure while admitted, you are NOT allowed to drive by law. •No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications •Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. •You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. •You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: •You may experience headaches and incisional pain. •You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. •You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. •Feeling more tired or restlessness is also common. •Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. When to Call Your Doctor at ___ for: •Severe pain, swelling, redness or drainage from the incision site. •Fever greater than 101.5 degrees Fahrenheit •Nausea and/or vomiting •Extreme sleepiness and not being able to stay awake •Severe headaches not relieved by pain relievers •Seizures •Any new problems with your vision or ability to speak •Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: •Sudden numbness or weakness in the face, arm, or leg •Sudden confusion or trouble speaking or understanding •Sudden trouble walking, dizziness, or loss of balance or coordination •Sudden severe headaches with no known reason Followup Instructions: ___
19970078-DS-27
19,970,078
22,135,897
DS
27
2198-04-12 00:00:00
2198-04-13 09:51:00
Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Senna / Verapamil / peanut Attending: ___. Major Surgical or Invasive Procedure: G-J tube replacement ___ Colonoscopy ___ ACUTE PROBLEMS: # Hyponatremia-improved Labs suggestive of SIADH previously. Resolved. attach Pertinent Results: =============== Admission labs =============== ___ 05:00PM BLOOD WBC-0.6* RBC-3.38* Hgb-10.5* Hct-32.5* MCV-96 MCH-31.1 MCHC-32.3 RDW-17.2* RDWSD-60.1* Plt Ct-6* ___ 05:00PM BLOOD Neuts-10* Lymphs-86* Monos-2* Eos-0* Baso-0 Atyps-2* AbsNeut-0.06* AbsLymp-0.53* AbsMono-0.01* AbsEos-0.00* AbsBaso-0.00* ___ 02:00AM BLOOD ___ PTT-24.1* ___ ___ 05:00PM BLOOD Glucose-132* UreaN-28* Creat-1.0 Na-143 K-3.8 Cl-104 HCO3-23 AnGap-16 ___ 05:00PM BLOOD ALT-44* AST-27 AlkPhos-119* TotBili-1.2 ___ 05:00PM BLOOD Calcium-9.6 Phos-3.8 Mg-2.3 ___ 05:26AM BLOOD Neuts-22* Bands-4 Lymphs-64* Monos-8 Eos-0* Baso-0 =============== Pertinent labs =============== Atyps-2* AbsNeut-0.13* AbsLymp-0.33* AbsMono-0.04* AbsEos-0.00* AbsBaso-0.00* ___ 04:55AM BLOOD ALT-145* AST-88* AlkPhos-307* TotBili-3.8* ___ 05:32AM BLOOD cTropnT-<0.01 ___ 02:41PM BLOOD cTropnT-<0.01 ___ 06:15AM BLOOD Triglyc-141 ___ 06:15AM BLOOD ___ ___ 06:15AM BLOOD CMV IgG-POS* CMV IgM-POS* CMVI-In the app EBV IgG-POS* EBNA-NEG EBV IgM-NEG EBVI-Infection ___ 08:47AM BLOOD HIV Ab-NEG ___ 05:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 08:47AM BLOOD HCV Ab-NEG ___ 05:26AM BLOOD CMV VL-PENDING ___ 08:47AM BLOOD B-GLUCAN-POSITIVE ___ 08:47AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-NEG =============== Discharge labs =============== =============== Studies =============== CT Head w/o contrast ___: IMPRESSION: 1. 3.6 x 2.5 cm oval hypodensity with surrounding vasogenic edema within the right front surgical bed is similar to ___. 2. Interval decrease of now 2 mm leftward midline shift, previously 4 mm. 3. The extensive vasogenic edema makes it difficult to exclude a superimposed ischemia. 4. No evidence of acute intracranial hemorrhage. MRI head ___: IMPRESSION: 1. Interval increase in size of the previously seen intra-axial enhancingmass lesion, with increased perilesional edema, and locoregional mass effect. Described findings suggests progression. For follow-up with advanced MR techniques (MR perfusion and spectroscopy) is recommended TTE ___: IMPRESSION: No definite 2D echocardiographic evidence for endocarditis. If clinically suggested, the absence of a discrete vegetation on echocardiography does not exclude the diagnosis of endocarditis. Suboptimal image quality. RUQUS ___: IMPRESSION: Normal abdominal ultrasound. No evidence of cholelithiasis or cholecystitis. MRI brain ___: IMPRESSION: -The peripherally enhancing lesion centered in the right frontal lobe is stable in size and appearance compared with the most recent MRI head dated ___, however has increased in size compared with the MR head dated ___. -No acute intracranial abnormality is identified. EEG ___: IMPRESSION: This continuous EEG monitoring study was abnormal due to: 1. Near continuous right frontal epileptiform discharges which frequently become lateralized periodic discharges with a broad field over the right hemisphere. This finding lies on the ictal-interictal continuum with increased risk for seizures. 2. Focal slowing over the right frontal region indicative of cerebral dysfunction in this region. 3. Generalized background slowing and disorganization is suggestive of a moderate to severe encephalopathy, non-specific as to etiology. Common causes include toxic metabolic-disturbances, medication effects and/or infection. CT abd/pelvis w/ contrast ___: IMPRESSION: 1. Large amount of stool within the rectum with associated perirectal stranding and fluid. Findings may reflect proctitis and possibly stercoral colitis. CT chest ___: IMPRESSION: 1. Ground-glass opacities in the bilateral posterior upper lobes and consolidative opacities at the lung bases are in a distribution most suggestive of a combination of atelectasis and aspiration given the patulous esophagus containing ingested material to the level of the upper thorax. 2. Few pulmonary nodules in the right lung are stable compared with ___, however there are at least 3 new pulmonary nodules in the right lung measuring up to 4-5 mm, may be infectious/inflammatory nature, however metastatic disease cannot be excluded. Recommend short-term interval follow-up with CT chest in 3 months. CTA abd/pelvis ___: IMPRESSION: 1. Due to the administration of positive oral contrast, assessment for lower GI bleed cannot be performed. 2. There is a large fecaloma in the rectum. Surrounding the fecaloma is rectal wall is thickened and significant perirectal fat stranding and edema. Constellation of findings is suggestive of stercoral colitis. 3. Pancolonic diverticulosis. There is a focal area of mural thickening at the level of the ascending colon, as above. Although this may reflect a diverticulum that has not been filled with oral contrast, this cannot be determined with certainty on today's CT. If clinically indicated, direct visualization with scope may be considered. 4. Small bilateral pleural effusions with passive atelectasis. CT CHEST W/CONTRAST ___ IMPRESSION: 1. Persistent posterior ground glass opacity in the left upper lobe. Patchy bronchovascular opacities in the superior segment of the left lower lobe. These are possible foci of infection. 2. Dilated esophagus with debris. Possible risk of aspiration based on this. More specifically possibility of developing achalasia could be considered or versus worsening dysmotility of less specific etiology. CT ABD & PELVIS WITH CONTRAST ___ IMPRESSION: 1. Interval increase in number and size of numerous hypodense splenic lesions, with more confluent lesions within the inferior pole, concerning for splenic microabscesses. 2. Interval evacuation of the rectal stool ball, with mild mucosal hyperenhancement and no substantial change in mild wall thickening and presacral edema, likely reflecting residual proctitis. 3. Please refer to the separate report of the chest CT performed on the same day for Intrathoracic characterization. CT CHEST W/CONTRAST ___ IMPRESSION Stable small right lung abscess, but growing left perihilar abscesses, infected lymph nodes or pneumonia. Moderate nonhemorrhagic non serous left pleural effusion has also ncreased. Growing splenomegaly due to worsening microabscesses. Stable severely dilated full length, esophagus, either functionally or anatomically obstructed. SPLEEN ULTRASOUND ___ 1. Numerous splenic lesions measuring up to 1.6 cm, which in the current clinical setting most likely represent abscesses (fungal or bacterial). Aspiration would likely need to be performed with CT and concurrent ultrasound guidance. 2. Small to moderate left pleural effusion. SELECTED Microbiology ===================== Blood Culture, Routine (Final ___: STREPTOCOCCUS ___. Isolated from only one set in the previous five days. IDENTIFICATION & SUSCEPTIBILITY TESTING INCLUDING LEVOFLOXACIN PER ___ (___) ___. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS ___ | CEFTRIAXONE-----------<=0.12 S CLINDAMYCIN----------- =>1 R ERYTHROMYCIN---------- 4 R LEVOFLOXACIN---------- 0.5 S PENICILLIN G----------<=0.06 S VANCOMYCIN------------ 0.5 S BLOOD CULTURE ___ **FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 3:20 pm ABSCESS Source: splenic microabcess. GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. POTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL ELEMENTS SEEN. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. FECAL CULTURE (Final ___: NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER FOUND. CYTOLOGY ___ "Splenic microabscess", aspiration: NEGATIVE FOR MALIGNANT CELLS. - Numerous neutrophils with necrotic debris, consistent with abscess. CYTOLOGY ___ Pleural fluid, left: NEGATIVE FOR MALIGNANT CELLS. - Reactive mesothelial cells, histiocytes, neutrophils, and lymphocytes. Brief Hospital Course: SUMMARY: =================== Ms. ___ is a ___ with history of glioblastoma (s/p resection ___ then external beam radiation with concomitant daily temozolomide, on hold since ___, who presented from home with encephalopathy, found to have febrile neutropenia secondary to S. viridans bacteremia, stercoral colitis, and hospital-acquired pneumonia, course further complicated by development of splenic abscesses, ultimately underwent biopsy of splenic abcessess with no pathogen identified, treated broadly with cipro/flagyl/voriconazole per the recommendation of ID, stabilized and discharged to LTAC with OPAT follow-up. ACUTE PROBLEMS: ================ # Strep viridans blood stream infection # Proctitis and possibly stercoral colitis Developed recurrent fevers while neutropenic and started on vanc/cefepime on admission. Initial blood cultures with S. viridans, then later found to have pneumonia (see below) and sterocoral colitis. Continued to spike fevers despite broad spectrum abx, broadened to vanc/meropenem and added on micafungin for +B-glucan, per ID recommendations. Patient temporarily improved and was de-escalated to ctx/flagyl, but then respiked fevers with CT abd/pelvis on ___ showing microabscess in spleen, c/f fungal infection. At this time, micafungin was restarted and then transitioned to voriconazole prior to discharge. Plan for 4 week course of cipro/flagyl/voriconazole with repeat CT torso prior to end-date with decision regarding discontinuation vs further antibiotics to be determined at that time based on imaging findings. Dates of antibiotic administration detailed below: - Transitioned to Flagyl, CTX [___] on ___ switched to flagyl/cipro (projected end date ___ - Transitioned to Voriconazole ___- projected end date ___ - s/p Micafungin [___] - s/p Meropenem [___] - s/p Vancomycin [___] # Hospital-acquired pneumonia # Pleural Effusion Initial CXR clear, then developed infiltrate c/f HAP. Found to also have L pleural effusion c/f parapneumonic effusion, s/p thoracentesis ___, fluid culture with no growth and pH not consistent with parapneumonic effusion. Ultimately treated with 7d course of antibiotics, as above. # LGIB ___ rectal ulceration Developed BRBPR concerning for LGIB. CTA non-diagnostic given retained oral contrast. Colonoscopy on ___ notable for bleeding rectal ulceration, s/p placement of 2 clips with subsequent stabilization of Hgb. Received a total of 9u pRBC throughout entire admission. # Pancytopenia Neutropenia Felt secondary to aplastic anemia secondary to recent chemotherapy administration. Also some concern for CMV viremia but treatment deferred after discussion with ID given that risks of treatment would likely outweight benefit. For neutropenia, received neupogen with improvement in ANC. # Toxic metabolic encephalopathy Felt to be multifactorial secondary to infection, radiation, steroids, delirium, and medications. Treated for infection, lacosamide switched to zonisamide, and kept on delirium precautions with improvement in mental status. # Transaminitis Hyperbilirubinemia Mild. RUQUS unremarkable. Felt secondary to drug reaction secondary to antifungals. Resolved prior to discharge. # Goals of care Unfortunately patient has a very aggressive cancer and was unable to receive treatment during period of prolonged pancytopenia and hospitalization complicated by multiple infections requiring prolonged broad spectrum antibiotics and antifungals. She was very functional at baseline and enjoyed a very rich life and stated many times she would not want to be hooked up to machines. Pt was DNR/DNI/OK to transfer to ICU during hospitalization. CHRONIC ISSUES: =============== # Glioblastoma S/p resection ___ then external beam radiation concomitant daily temozolomide, on hold since ___. Treatment complicated by pancytopenia. Treatment held given critical illness, family does not want to pursue any further radiation or chemo. # HTN Noted to be hypertensive during admission so home labetalol was increased from 100mg BID to ___ BID with subsequent improvement. Blood pressures on discharge 120-150s/70-90s. # Left upper extremity focal motor seizures Initially on steroids and lacosamide. Locasamide discontinued on ___ as it was not helping the LUE shaking at lower doses and was felt to be too sedating at higher doses. Started zonisamide ___ with improvement in shaking. # Malnutrition # Dysphagia S/p G-J tube placement ___. Nutrition followed and provided tube feed recs. # Hypothyroidism - Continued home levothyroxine TRANSITIONAL ISSUES: ==================== [] Needs repeat CT abdomen/pelvis on ___ prior to discontinuation of antibiotics/antifungals. Pending CT read, ID will determine final antibiotic/antifungal course at follow-up appointment. [] ID fellow to arrange follow-up on ___ - final antibiotic course TBD at this visit. Antibiotics/antifungals should NOT be discontinued prior to this appointment. [] Needs repeat CT chest in 3 months to follow up pulmonary nodules noted on CT chest [] Please check weekly CBCs and transfuse for Hgb > 7 and plts > 10 (or > 20 with active bleeding). Discharge WBC 14.7, Hgb 7.6, Plt 39. [] Please check Na and phos every 2 days until normalized. For hypernatremia, increase free water flushes/administer D5W PRN to correct Na to 140. Discharge Na 150 (received 1L D5W for free water deficit of 1.2L). For hypophosphatemia, replete PRN. [] F/u blood pressure and uptitrate labetalol PRN for goal SBP < 140. Was previously on spironolactone for unclear reasons; if a second agent is needed, would likely not choose spironolactone [] Please continue goals of care discussions in outpatient setting. At this time, there is no further plan for cancer-directed therapy; however, we suspect that Ms. ___ weakness should slowly improve and in the future, she may reconsider what treatment options she wants to pursue. #HCP/Contact: ___, ___ ___ (alternate HCP/son), ___ #Code: DNR/DNI Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 3. Dexamethasone 1 mg PO ASDIR This is the maintenance dose to follow the last tapered dose 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg PO BID 6. LevETIRAcetam 1000 mg PO BID 7. Nitrofurantoin (Macrodantin) 100 mg PO Q12H 8. Sodium Chloride 1 gm PO BID 9. Labetalol 100 mg PO BID 10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 11. Levothyroxine Sodium 75 mcg PO DAILY 12. Spironolactone 25 mg PO DAILY 13. Fluticasone Propionate NASAL 1 SPRY NU DAILY 14. Nystatin Oral Suspension 5 mL PO QID Discharge Medications: 1. Ciprofloxacin HCl 500 mg PO BID Duration: 4 Weeks RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day Disp #*42 Tablet Refills:*0 2. Lidocaine Jelly 2% 1 Appl TP TID:PRN abdominal pain RX *lidocaine 3 % 1 Application three times a day, as needed Refills:*0 3. MetroNIDAZOLE 500 mg PO TID Duration: 4 Weeks RX *metronidazole 500 mg 1 tablet by mouth three times a day Disp #*63 Tablet Refills:*0 4. Polyethylene Glycol 17 g PO BID RX *polyethylene glycol 3350 17 gram 1 dose by mouth twice a day Disp #*60 Packet Refills:*0 5. Voriconazole 150 mg PO BID Duration: 4 Weeks RX *voriconazole 50 mg 3 tablet(s) by mouth twice a day Disp #*126 Tablet Refills:*0 6. Acetaminophen (Liquid) 1000 mg PO Q8H:PRN Pain - Mild/Fever RX *acetaminophen 500 mg/15 mL 30 ml by mouth every eight (8) hours, as needed Disp #*2700 Milliliter Refills:*0 7. Labetalol 200 mg PO BID RX *labetalol 200 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0 8. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 9. Famotidine 20 mg PO BID 10. Fluticasone Propionate NASAL 1 SPRY NU DAILY 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Levothyroxine Sodium 75 mcg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: =================== Strep viridans blood stream infection Acute blood loss anemia ___ rectal ulceration Proctitis Splenic abscess Hospital-acquired pneumonia SECONDARY DIAGNOSIS: ==================== Pancytopenia Right frontal glioblastoma Hypertension Hypothyroidism Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - You were admitted to the hospital for confusion and fevers. WHAT HAPPENED TO ME IN THE HOSPITAL? - While you were in the hospital, you had labs and imaging studies that showed that you had several serious infections in your blood, colon, lungs, and spleen. You had a biopsy of your spleen so we could sample some of the infected fluid. You received antibiotics and antifungal medications to treat your infection, and the infectious disease doctors were called to help us manage your infections. - While you were here, you also had some bleeding from your gastrointestinal tract. You had a procedure called a colonoscopy to locate the source of your bleeding, and two small clips were placed over an ulcer that was causing your bleeding. - You developed some confusion which we think was partly due to one of your medications (lacosamide). This medication was stopped and you were switched to a different medication (zonisamide). - The feeding tube in your stomach was exchanged in order to help provide you with nutrition. - Your blood counts were low so you received blood products and medications to help increase your blood counts. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? - Continue to take all your medications as prescribed. You will be on antibiotics and antifungal medications for 4 more weeks. - The week of ___, you should get a cat scan of your abdomen and pelvis to ensure your infection is improving. The order for your cat scan has been placed, so please ensure you get this scan done! The infectious disease doctors ___ discuss the results of this cat scan with you at your appointment. - Please keep all of your follow up appointments (see below for appointment information). We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19970101-DS-16
19,970,101
22,502,365
DS
16
2187-05-24 00:00:00
2187-05-24 21:03:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo M PMHx of CAD s/p PCI (___) c/b in-stent thrombosis in ___ now on ASA and ticagrelor, Mobitz I, CVA without residual deficits, glaucoma, gout, and HLD who presented with progressive SOB, recently admitted for right-sided empyema with MSSA, s/p chest tube placement ___ c/b trapped lung transitioned to pleurX ___ who presented with chronic pleural effusion and progressive dyspnea. Pleural effusion first noted in ___, when patient presented to ___ with chest pain and shortness of breath, found to have a small right pleural effusion as well as a LLL PNA. Pt was discharged on azithromycin and improved. Patient was admitted to ___ (___) for shortness of breath, found to have R-sided empyema growing MSSA, s/p chest tube placement ___ with improvement in effusion but c/b trapped lung. Culture grew staph aureus; cytology negative for malignancy. He was seen by thoracic surgery, but patient and family declined thoracotomy with decortication as definitive management. He was treated with cefazolin/flagyl for planned ___ week course from date of chest tube insertion (___) with repeat imaging and OPAT f/u to determine the final course. Underwent transition to pleurX on ___ with plan for daily pleurX drainage (<1L to be drained per day) through at least IP f/u on ___. Lasix 20mg daily initiated ___. Weight on discharge was 156.7 lbs. On ___, patient was seen in ___ clinic for follow-up and reports that since discharge, he was alright for several days. However, in the past week, he has been having significant shortness of breath and fatigue. Today, patient reports dyspneic at rest. He denies cough, fevers, chills. His appetite has also been poor. CT Chest showed improved RLL lung re-expansion and small right pleural effusion. Labs showed improvement in CRP and WBC within normal limits, thus there was less concern about worsening pleural infection. However given his significant cardiac history and concern for cardiac component to breathlessness, he was sent to the ED for evaluation. In the ED, initial vitals were: temp 97.5, HR 56, BP 122/74, RR 19, O2 sat 100% RA Exam notable for: Chest: Decreased aeration throughout CV: Murmur appreciated Ext: LLE edema Labs notable for: Troponins and EKG are unrevealing. BNP 1344 WBC 5.9, Hgb 8.9, Cr 0.8, INR 1.3, LFTs wnl, CRP 4.4, lactate 0.9 Imaging was notable for: Left venous doppler with no evidence of DVT Patient was given: Cefazolin, ticagrelor, metronidazole, predisone 10mg, aspirin 81mg, allopurinol ___ Consults: IP - - Obtain TTE - Consider cardiology consult - Continue the antibioctics and diuretics for now - Three times weekly pleurX drainage (MWF) VS Prior to Transfer: HR 69, BP 116/54, RR 22, O2 sat 100% RA Upon arrival to the floor, patient reports that he has had worsening dyspnea over the past week, feeling like he had to "open window." Stable orthopnea, no new PND. No new palpitations. "Pinching sensation" in chest. No f/c/n/v. No cough. +ve swelling in his feet. ROS: Positive per HPI. Remaining 10 point ROS reviewed and negative Past Medical History: CAD as described below Glaucoma Gout Cataracts Skin cancer H/o CVA Hearing loss Cardiac history: The pt has a h/o PCI to RCA in ___ with 1st degree heart block. In ___, he came to ___ with chest pain. He was found to have ___levations in II, III, and AVF. Pt went for cath which showed RCA stent thrombosis. The stent was dilated and re-stented. The pt was started on ticagrelor. He had second degree heart block during the ischemia and intermittent complete heart block. His arrhythmia improved and he came out of complete heart block. Pt was discharged without a pacemaker. Echo showed a normal EF. PAST SURGICAL HISTORY: Appendectomy Tonsillectomy Cataract surgery Social History: ___ Family History: 7 siblings, all healthy Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VITAL SIGNS: 24 HR Data (last updated ___ @ 1515) Temp: 97.5 (Tm 97.5), BP: 104/62, HR: 76, RR: 17, O2 sat: 99%, O2 delivery: ra GENERAL: Cachectic HEENT: PERRLA, EOMI NECK: No JVD CARDIAC: rrr, ___ systolic crescendo decrescendo murmur early peaking, soft S2, no g/r, non-displaced PMI, soft heart sounds LUNGS: Decreased breath sounds over R, pleurex dressing CDI ABDOMEN: NTND, bowel sounds present EXTREMITIES: WWP, no edema NEUROLOGIC: CNII-XII intact, no focal deficits SKIN: no rashes, no lesions DISCHARGE PHYSICAL EXAM: ========================= 24 HR Data (last updated ___ @ 1129) Temp: 98.0 (Tm 98.5), BP: 92/46 (88-116/46-63), HR: 80 (65-80), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery: RA, Wt: 143.74 lb/65.2 kg GENERAL: Cachectic HEENT: PERRLA, EOMI NECK: No JVD CARDIAC: RRR, +systolic murmur LUNGS: Decreased breath sounds over R, pleurex dressing CDI. + tactile fremitus on R ABDOMEN: NTND, bowel sounds present EXTREMITIES: WWP, no edema +TTP R great toe NEUROLOGIC: CNII-XII intact, no focal deficits SKIN: no rashes Pertinent Results: ADMISSION LABS: ================ ___ 09:39PM BLOOD WBC-5.9 RBC-2.77* Hgb-8.9* Hct-28.6* MCV-103* MCH-32.1* MCHC-31.1* RDW-20.3* RDWSD-75.7* Plt ___ ___ 09:39PM BLOOD Neuts-73.1* Lymphs-17.1* Monos-8.5 Eos-0.0* Baso-0.5 Im ___ AbsNeut-4.30 AbsLymp-1.01* AbsMono-0.50 AbsEos-0.00* AbsBaso-0.03 ___ 09:39PM BLOOD Glucose-110* UreaN-14 Creat-0.8 Na-136 K-4.0 Cl-95* HCO3-31 AnGap-10 ___ 09:39PM BLOOD proBNP-1344* ___ 09:38PM BLOOD Lactate-0.9 PERTINENT LABS: =============== ___ 07:39AM BLOOD Glucose-72 UreaN-15 Creat-0.8 Na-139 K-4.4 Cl-94* HCO3-35* AnGap-10 ___ 05:32AM BLOOD Glucose-121* UreaN-17 Creat-0.8 Na-136 K-4.3 Cl-95* HCO3-34* AnGap-7* ___ 06:26AM BLOOD Glucose-85 UreaN-18 Creat-0.7 Na-138 K-4.1 Cl-97 HCO3-33* AnGap-8* ___ 04:23AM BLOOD Glucose-79 UreaN-15 Creat-0.6 Na-136 K-4.5 Cl-99 HCO3-33* AnGap-4* ___ 06:26AM BLOOD proBNP-936* ___ 10:50AM BLOOD CRP-4.4 ___ 07:39AM BLOOD Free T4-1.5 ___ 07:39AM BLOOD TSH-2.3 ___ 07:39AM BLOOD VitB12-467 DISCHARGE LABS: ================ ___ 04:45AM BLOOD WBC-6.4 RBC-2.50* Hgb-7.9* Hct-26.3* MCV-105* MCH-31.6 MCHC-30.0* RDW-20.3* RDWSD-78.4* Plt ___ ___ 04:45AM BLOOD Glucose-83 UreaN-17 Creat-0.7 Na-136 K-4.7 Cl-98 HCO3-32 AnGap-6* ___ 04:45AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.8 IMAGING: ======== CTA Chest ___: IMPRESSION: 1. No evidence of pulmonary embolism or aortic abnormality. 2. New nodular ground-glass opacities in the bilateral posterior lower lobes, in a distribution most suggestive of aspiration. 3. A pigtail catheter terminates in a small right pleural effusion which contains small foci of air, not significantly changed. 4. Cholelithiasis. TTE ___: IMPRESSION: Mild left ventricular regional dysfunction consistent with coronary artery disease. No clinically significant valvular regurgitation ot stenosis. Indeterminate pulmonary pressure. Compared with the prior TTE (images reviewed) of ___, there is no obvious change, but the suboptimal image quality of the studies precludes definitive comparison. UNILAT LOWER EXT VEINS ___: IMPRESSION: Limited evaluation of the calf vessels. Within these limitations, no evidence of deep venous thrombosis in the left lower extremity veins. CT CHEST W/CONTRAST ___: IMPRESSION: Small unilateral pleural collection is mildly decreased in volume in the interval, however, it is again noted fluid-filled with internal gas bubbles concerning most likely for empyema. Interval decrease in number and size of the multiple prominent mediastinal lymph nodes, most likely reactive. Redemonstrated ectatic ascending and descending thoracic aorta ectasia saved. Peripheral reticular opacities probably related to interstitial disease are unchanged. MICROBIOLOGY: ============== 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, if applicable. FLUID CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. GRAM STAIN (Final ___: <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final ___: TEST CANCELLED, PATIENT CREDITED. Brief Hospital Course: BRIEF HOSPITAL COURSE: ======================= ___ w/ CAD s/p PCI (___) c/b in-stent restenosis in ___ now on ASA and ticagrelor and recent admission for R-sided empyema c/b MSSA s/p chest tube placement ___ c/b trapped lung and pleurex placed ___, who presented this admission for progressive dyspnea, thought to be due to aspiration and possibly ticagrelor, which was thus discontinued. He was discharged to a physical rehabilitation program with interventional pulmonology and cardiology follow-up. TRANSITIONAL ISSUES: ==================== [] CT with ectatic ascending/descending thoracic aorta. F/u with vascular surgery as outpt [] Continue IV cefazolin/Flagyl until ___. He has outpatient follow-up scheduled with infectious disease. [] CXR did not assess for PICC placement (placed during prior admission). However, per primary team, we reviewed CXR and PICC line appears in correct position and ok to use. ACUTE ISSUES: ============= # Progressive dyspnea Most likely explanation for acute-onset dyspnea is aspiration given ground glass opacities seen on CT and previous history of aspiration. Ticagrelor may have also contributed to dyspnea and thus was discontinued. He had been on ticagrelor for a year since last cath in ___ and it was deemed unnecessary to continue per cards. The right-sided empyema per interventional pulmonology was not deemed a likely source of dyspnea given normal CRP, WBC, and reassuring CT scan. Heart failure was excluded given TTE unchanged from prior and he was not volume overloaded on exam. Ischemia was excluded as well given no troponin leak. For his aspiration, he was previously diagnosed with mild oral and moderate pharyngeal dysphagia via video swallow at his last admission. A bedside exam this admission confirmed he is at an elevated risk of aspiration given history of silent aspiration and his presentation in the setting of his overall respiratory compromise. He was continued on a diet of pureed solids/thin liquids with 1:1 supervision. # Small L pleural effusion # Right-sided empyema with MSSA # Trapped lung # Mild pulmonary vascular congestion He was admitted to ___ (___) for shortness of breath, found to have R-sided empyema growing MSSA, s/p chest tube placement ___ with improvement in effusion but c/b trapped lung. Culture grew methicillin sensitive staph aureus; cytology negative for malignancy. He was seen by thoracic surgery, but patient and family declined thoracotomy with decortication as definitive management. Lasix 20mg daily was discontinued as below. He continued to receive MWF pleurex drainages. He continued his treatment with cefazolin/flagyl for planned 6 week course from date of chest tube insertion (___) with repeat imaging and OPAT f/u. He will continue IV Cefazolin 2g IV q8 hours and Flagyl PO q8 hours through ___. #Primary metabolic alkalosis with respiratory compensation Per ABG ___ with HCO3 35. Urine chloride 2 days off Lasix was elevated at 20. Ddx for saline-resistant metabolic alkalosis is narrow, and most likely includes hypochloremic alkalosis vs contraction alkalosis. Lasix was discontinued. Urine pH was elevated as expected and the bicarb normalized. # Orthostatic hypotension He was orthostatic on exam, likely due to being volume down. He was given IVF as needed and Lasix was stopped as above # Sinus Bradycardia # Mobitz I Known hx of Mobitz I s/p MI with occasional 2:1 conduction at that time (documented during admission ___. Seen by Atrius cardiologist, Dr. ___, on ___, who was not concerned for higher-grade AV block and recommended against PPM at this time. Would avoid b-blockers indefinitely. Patient has a follow-up appointment with outpatient cardiologist, Dr. ___ for ___ which will be rescheduled due do hospitalization. # Macrocytic anemia Appears to be acute on chronic. ___ w/in normal limits. Iron studies c/w anemia of inflammation. Ddx would also include drug induced macrocytosis, nutritional deficiency. Likely some component of reticulocytosis in setting of chronic anemia. His Hgb remained stable during hospitalization. # Possible ILD # Chronic steroid use Patient started on prednisone by outpatient pulmonologist (Dr. ___ due to c/f ILD. He started 20 mg daily x 1 week in ___, and then switched to prednisone 10 mg daily since then (~8 mo). Based on imaging here as well as the results of the PFTs obtained by outpatient pulmonologist (normal DLCO), the diagnosis of ILD is in question. Due to increased dyspnea, he was started on stress dose steroids with prednisone 30mg x 3 days (___), and then resumed his home dose of prednisone 10mg daily. # CAD s/p PCI with in-stent restenosis Approx ___ year from in-stent restenosis, and taking on ASA and ticagrelor. - Continued home ASA and statin. - Discontinued ticagrelor as above #Gout: continued home allopurinol. continued to have flares on R hallux #CVA: continued home ASA, statin #Glaucoma: continued home eye drops. #Ectatic ascending/descending thoracic aorta: f/u w/ vascular sx as outpt # CODE: DNR, DNI # CONTACT: daughter ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. CeFAZolin 2 g IV Q8H 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 7. PredniSONE 10 mg PO DAILY 8. TiCAGRELOR 90 mg PO BID 9. Furosemide 20 mg PO DAILY 10. MetroNIDAZOLE 500 mg PO/NG Q8H 11. Multivitamins W/minerals 1 TAB PO DAILY 12. Docusate Sodium 100 mg PO BID Discharge Medications: 1. Thiamine 100 mg PO DAILY 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. CeFAZolin 2 g IV Q8H 6. Docusate Sodium 100 mg PO BID 7. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID 8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 9. MetroNIDAZOLE 500 mg PO Q8H 10. Multivitamins W/minerals 1 TAB PO DAILY 11. PredniSONE 10 mg PO DAILY 12. HELD- Furosemide 20 mg PO DAILY This medication was held. Do not restart Furosemide until you discuss with your pulmonologist 13. HELD- TiCAGRELOR 90 mg PO BID This medication was held. Do not restart TiCAGRELOR until you discuss with your cardiologist Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================== Silent aspiration Pleural effusion Contraction alkalosis Orthostatic hypotension Mild oral and moderate pharyngeal dysphagia SECONDARY DIAGNOSIS: ==================== Mobitz Type 1 Possible interstitial lung disease Coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a privilege caring for you at ___. WHY WAS I IN THE HOSPITAL? - You were admitted because you were having worsening shortness of breath. WHAT HAPPENED TO ME IN THE HOSPITAL? - You had a CT scan of your lungs and ultrasound of your heart, which showed that aspiration (or swallowing things down the wrong tube) could have caused your worsening shortness of breath. - You were also stopped on one of your heart medications called ticagrelor since it may have also contributed to your shortness of breath. - You were continued on antibiotics, prednisone, and ___, ___ pleurex drainages. - You were given fluids to help with your lightheadedness when you stand up. Lasix was discontinued, since it could have been contributing to your lightheadedness. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? -Please continue to take all of your medications and follow-up with your appointments as listed below. We wish you the best! Sincerely, Your ___ Team Followup Instructions: ___
19970466-DS-10
19,970,466
26,762,325
DS
10
2151-05-26 00:00:00
2151-05-27 06:51:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Phenergan / NSAIDS (Non-Steroidal Anti-Inflammatory Drug) Attending: ___ Major Surgical or Invasive Procedure: none attach Pertinent Results: ADMISSION LABS: =============== ___ 12:53PM BLOOD WBC-8.6 RBC-2.94* Hgb-8.7* Hct-29.1* MCV-99* MCH-29.6 MCHC-29.9* RDW-18.4* RDWSD-64.8* Plt ___ ___ 12:53PM BLOOD Neuts-81.6* Lymphs-8.6* Monos-8.5 Eos-0.5* Baso-0.2 Im ___ AbsNeut-7.00* AbsLymp-0.74* AbsMono-0.73 AbsEos-0.04 AbsBaso-0.02 ___ 12:53PM BLOOD ___ PTT-34.4 ___ ___ 12:53PM BLOOD Glucose-97 UreaN-13 Creat-0.9 Na-138 K-5.3 Cl-98 HCO3-27 AnGap-13 ___ 12:53PM BLOOD ALT-14 AST-58* AlkPhos-108* TotBili-0.5 ___ 12:53PM BLOOD ___ ___ 12:53PM BLOOD cTropnT-0.27* ___ 08:31PM BLOOD cTropnT-0.30* ___ 12:20AM BLOOD cTropnT-0.25* ___ 08:31PM BLOOD Calcium-9.5 Phos-3.5 Mg-2.1 ___ 12:53PM BLOOD Albumin-3.6 ___ 12:56PM BLOOD Lactate-1.3 DISCHARGE LABS: =============== ___ 06:13AM BLOOD Glucose-93 UreaN-22* Creat-0.9 Na-142 K-4.1 Cl-97 HCO3-31 AnGap-14 ___ 06:13AM BLOOD Calcium-9.4 Phos-2.6* Mg-1.8 OTHER PERTINENT LABS: ====================== ___ 06:35AM BLOOD calTIBC-334 Ferritn-136 TRF-257 IMAGING: ========= CXR ___: Small to moderate left pleural effusion. Otherwise, clear lungs. No pulmonary edema. CXR ___: Lungs are low volume with increasing pulmonary vascular congestion. Bilateral effusions left greater than right are unchanged. The aorta is tortuous. A stent is seen within the aorta. No pneumothorax. Stable cardiomediastinal silhouette. No evidence of pneumonia TTE ___: The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with a normal cavity size. There is normal regional and global left ventricular systolic function. Quantitative biplane left ventricular ejection fraction is 44 % (normal 54-73%). There is no resting left ventricular outflow tract gradient. Normal right ventricular cavity size with normal free wall motion. There is mild [1+] aortic regurgitation. The mitral valve leaflets are mildly thickened with no mitral valve prolapse. There is moderate [2+] mitral regurgitation. The pulmonic valve leaflets are normal. 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: 1) Mild regional LV systolic dysfunction c/w prior myocardial infarction in RCA territory vs multivessel CAD. 2) Moderate mitral regurgitation. Compared with the prior TTE (images reviewed) of ___ , the inferolateral myocardial segments are more contractile. The severity of mitral regurgitation has decreased. MICRO DATA: =========== ___ 6:20 am MRSA SCREEN NASAL SWAB. **FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ & ___ BCx: no growth to date DISCHARGE LABS: =============== ___ 06:13AM BLOOD Glucose-93 UreaN-22* Creat-0.9 Na-142 K-4.1 Cl-97 HCO3-31 AnGap-14 Brief Hospital Course: TRANSITIONAL ISSUES ==================== DISCHARGE WEIGHT: 157.41 lbs DISCHARGE Cr: 0.9 DISCHARGE DIURETIC: furosemide 80mg PO daily MEDICATION CHANGES: - NEW: ceftazidime (last day ___, polyethylene glycol, senna, isosorbide mononitrate - STOPPED: lisinopril - CHANGED: increased dose of furosemide, increased dose of sertraline, decreased dose of spironolactone FOR CARDIOLOGY: [] please follow-up volume status to determine if pt will require increased dose of furosemide [] please follow-up electrolytes, BUN, Cr in 1 week [] please follow-up blood pressures, and add lisinopril vs. increase spironolactone dose for goal SBP 110-120. [] please follow-up pt's anginal sx (dyspnea) and uptitrate anti-anginal agents prn FOR PCP: [] please follow-up on effect of increased dose of sertraline in ___ weeks. BRIEF HOSPITAL COURSE: ====================== Ms. ___ is a ___ woman with a history of triple vessel CAD s/p DES to RCA x2 (most recently ___ iso inferior STEMI with infarction), HFmrEF 42% (infarct mediated), moderate-severe MR, DM2, HTN, HLD, COPD on home O2 2L, and emergent endovascular repair of ruptured TAA (initial TEVAR ___, and repeat ___ who presented from rehab with SOB, orthopnea, and fatigue. Given elevated proBNP, most concerning for acute on chronic HF exacerbation, therefore was treated with several days of IV diuresis before she was transitioned to a higher dose PO furosemide (80mg daily). Given new productive cough, we also treated her empirically for HAP and COPD exacerbation. She will be discharged with ceftazidime to complete a 7d course (she additionally received 4d vanc + 5d azithro). She completed her 5d prednisone and will be discharged on her home inhaler regimen. Course was complicated by intermittent SOB, felt to be her anginal equivalent, for which we optimized her anti-anginal agents. Also complicated by brief episode of hypotension, for which her blood pressure agents were titrated. # CORONARIES: DES x2 to RCA (last ___ 50% left main, 50% ___ LAD, 70% ___ diag, 70% septal perforator, 80% LCx disease # PUMP: 42% with FWMA # RHYTHM: NSR ACTIVE ISSUES: ================ #Acute Decompensated HFmrEF (EF 44% - ___ BNP >12,000 at time of admission along with CXR showing small to moderate left pleural effusions, clinically appeared volume overloaded at admission with JVP elevated ___ to angle of jaw, and bilateral pitting edema. Treated w/ several days of IV diuresis and then once euvolemic, transitioned to higher dose of PO furosemide 80mg daily with goal net even. She tolerated this for several days prior to discharge. Her weight upon discharge is 157.41 lbs. For afterload reduction she will be discharged on imdur 30mg daily. For NHBK she will be discharged on carvedilol 25mg BID + spironolactone 12.5mg BID. We stopped her lisinopril in order to prioritize anti-angina medications. #Presumed hospital acquired pneumonia Felt this was less likely contributing to pt's initial presentation, but due to prolonged hospitalization, recent instrumentation, productive cough, and known COPD, opted to treat for HAP. Planned for 7d course of anti-pseudomonal coverage. Will be discharged on ceftazidime (D1 ___- D7 ___. She additionally received a 5d course of azithromycin and 4 days of vancomycin. #COPD exacerbation Similarly felt this was less likely contributing to pt's initial presentation, but due to known COPD, worsening hypoxia, and productive cough, treated empirically for COPD exacerbation with 5d of prednisone 40mg. Continued home tiotropium + ___ and provided prn duonebs. #Obstructed CAD with angina #Aborted STEMI s/p DES to RCA Intermittent SOB throughout admission felt to be most consistent with her anginal equivalent, often in the setting of stress and anxiety. At that time she had T wave inversions in V4,5,6 with negative troponins. Thus her anti-anginal agents were optimized and she will be discharged on carvedilol 25mg BID + isosorbide mononitrate 30mg daily. She was also continued on home ASA + clopidogrel + high intensity statin. #HTN During prior admission, BPs found to be elevated, goal was set 110-120/70-80. Initially held meds due to hypotension, but these were gradually restarted. She will be discharged on a regimen of : carvedilol 25mg BID + spironolactone 12.5mg daily + isosorbide mononitrate 30mg daily. Her home lisinopril was stopped in favor of up-titrating anti-angina agents. # Anxiety/Depression: Anxiety appears to be contributing to angina. Increased dose of sertraline from 100mg to 150mg daily. Continued prn lorazepam 0.5mg QHS for sleep/agitation. #At Risk for Delirium Pt noted to have periods of delirium during prior admission, but no apparent delirium this admission. CHRONIC ISSUES: ================ # DM2: - transitioned to Glargine 14 Units Bedtime, held home glipizide. okay to resume glipizide upon discharge. # HLD: - continued atorvastatin 80mg q HS # GERD: - continued Pantoprazole 40 mg PO Q24H Greater than 30 minutes spent on discharge planning. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. GlipiZIDE 10 mg PO DAILY 2. Pantoprazole 40 mg PO Q24H 3. albuterol sulfate 90 mcg/actuation inhalation 2 puffs q4 PRN SOB/wheezing - 4. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 80 mg PO QPM 7. Fluticasone Propionate NASAL 1 SPRY NU BID 8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 9. Lisinopril 40 mg PO DAILY 10. LORazepam 0.5 mg PO QHS:PRN agitation/sleep 11. Sertraline 100 mg PO DAILY 12. Tiotropium Bromide 1 CAP IH DAILY 13. CARVedilol 25 mg PO BID 14. Clopidogrel 75 mg PO DAILY 15. Furosemide 40 mg PO DAILY 16. Nitroglycerin SL 0.4 mg SL PRN chest pain 17. Spironolactone 25 mg PO DAILY 18. Lantus U-100 Insulin (insulin glargine) 16 U subcutaneous QHS Discharge Medications: 1. Bisacodyl 10 mg PO DAILY 2. CefTAZidime 1 g IV Q12H Last day is ___ 3. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line flush 4. Glargine 14 Units Bedtime 5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. Senna 8.6 mg PO BID:PRN Constipation - First Line 8. Sodium Chloride 0.9% Flush 10 mL IV DAILY and PRN, line flush 9. Furosemide 80 mg PO DAILY 10. Sertraline 150 mg PO DAILY 11. Spironolactone 12.5 mg PO DAILY 12. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild/Fever 13. albuterol sulfate 90 mcg/actuation inhalation 2 puffs q4 PRN SOB/wheezing - 14. Aspirin 81 mg PO DAILY 15. Atorvastatin 80 mg PO QPM 16. CARVedilol 25 mg PO BID 17. Clopidogrel 75 mg PO DAILY 18. Fluticasone Propionate NASAL 1 SPRY NU BID 19. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 20. GlipiZIDE 10 mg PO DAILY 21. LORazepam 0.5 mg PO QHS:PRN agitation/sleep 22. Nitroglycerin SL 0.4 mg SL PRN chest pain 23. Pantoprazole 40 mg PO Q24H 24. Tiotropium Bromide 1 CAP IH DAILY 25. HELD- Lisinopril 40 mg PO DAILY This medication was held. Do not restart Lisinopril until instructed by your physician ___: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: ======== heart failure with moderately reduced ejection fraction hospital acquired pneumonia COPD exacerbation SECONDARY: ========== coronary artery disease anxiety Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Confused - sometimes. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___! WHY WAS I IN THE HOSPITAL? ========================== - You were admitted because you had chest pain WHAT HAPPENED IN THE HOSPITAL? ============================== - Your chest pain was found to be due to a rupture of an aneurysm of your aorta, a large vessel. You underwent emergent surgery to repair this. - You also had a heart attack while recovering from this surgery. You had a catheterization procedure done which allowed us to visualize the arteries in your heart and place a stent to relieve blockages. WHAT SHOULD I DO WHEN I GO HOME? ================================ - Be sure to take all your medications and attend all of your appointments listed below. - It is very important to take your aspirin and clopidogrel (also known as Plavix) every day. - These two medications keep the stents in the vessels of the heart open and help reduce your risk of having a future heart attack. - If you stop these medications or miss ___ dose, you risk causing a blood clot forming in your heart stents and having another heart attack - Please do not stop taking either medication without taking to your heart doctor. - You are also on other medications to help your heart, such as a statin, metoprolol, and lisinopril. These medications are also very important to continue taking as prescribed. Thank you for allowing us to be involved in your care, we wish you all the best! Your ___ Healthcare Team Followup Instructions: ___
19970892-DS-21
19,970,892
25,899,573
DS
21
2116-06-20 00:00:00
2116-06-20 15:24:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Paraplegia Major Surgical or Invasive Procedure: LP ___ History of Present Illness: ___ M w/ hx of prior L zygomatic bone fracture, polysubstance abuse with hx of withdrawal w/ no seizure or ICU care presents today with flaccid paraplegia after overdose of Xanax. Per patient, once a month he takes "40-50" pills of Xanax all at once with muscle relaxers to get high to escape his depression and anxiety, he remains "high out of his mind" for ___ days after. In addition to using Xanax once a month, he drinks over a 6 pack of beer a day +/- a pint of hard liquor. He also "dabbles" in other drugs, mostly cocaine once a week and has snorted heroin in the past. Denies any IVDU. Per patient, he took up to 40 pills of Xanax over the course of three days. He woke up cross legged with his head between his legs on the floor and unable to move. He called his mother over to assist him and was BIBA to the ED. In the ED on general exam, he was mildly hypotensive to SBP in the ___, and diffusely tremulous. Neurologic examination notable for inattention (suggestive of mild toxic encephalopathy), peripheral left facial palsy, bilateral lower extremity plegia with areflexia of the knees and ankles, and absent sensation to pinprick and temperature below level of ~T5-6. He has preserved sensation to vibration and proprioception at the ankles. Lab abnormalities include a leukocytosis to 16.8 and ___ with Cr 2.2, CK ___, trop <.01. EKG was suggestive of lateral ischemia. Urine positive for benzos and positive for amphetamines. In the ED the differential of highest concern was an anterior spinal artery infarct in the upper thoracic cord, likely secondary to decreased perfusion in setting of benzodiazepine toxicity (with other toxicities not excluded). An acute compressive lesion, such as disc herniation, is possible but lower on the differential, as is an epidural abscess (pt denies history of IVDA but would still exclude this). MRI of cervical and thoracic spine: Signal abnormality in the anterior and posterior columns of the entire thoracic and lumbar spinal gray matter, concerning for cord infarction with differential considerations of transverse myelitis. Blood pressure was maintained <200/105 and >100 SBP or >70 MAP. Given 3.5 L. Admitted to ICU for : management of rhabdomyolysis, leukocytosis, cardiac ischemia, monitoring for autonomic instability, and supportive care for benzodiazepine toxicity. Neurology will follow as consult service. On transfer, vitals were: HR 120 96% on RA, 106/59 MAP 72, afebrile Past Medical History: - Facial injury in prison after being assaulted - Withdrawal from alcohol, benzo, opoids, cocaine, req hospitalization but no ICU care or siezures, DT Social History: ___ Family History: non contributory Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T:98.1 BP: 115/60 P: 131 R: 15 O2: 97% on RA GENERAL: Alert, oriented, no acute distress, drowsy 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 GU: Foley in place EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema SKIN: No lesions. NEURO: Intact sensation, strength, proprioception, vibration, pain stimuli, reflex up to T12-L1. Poor rectal tone, no intact sensation, proprioception, vibration, pain stimuli or reflexes past that point DISCHARGE PHYSICAL EXAM: Flaccid paraplegia in legs w/ mute plantar responses. Pt able to sense when foot being dorsiflexed or plantarflexed but unable to determine direction of movement. Otherwise, decreased sensation to light touch, proprioception, vibration, and temperature below L1. Pertinent Results: ADMISSION LABS: ================== ___ 08:41AM BLOOD WBC-16.8* RBC-5.61 Hgb-17.0 Hct-51.0 MCV-91 MCH-30.3 MCHC-33.3 RDW-12.9 RDWSD-42.2 Plt ___ ___ 08:41AM BLOOD ___ PTT-29.5 ___ ___ 08:41AM BLOOD Glucose-98 UreaN-22* Creat-2.2* Na-135 K-6.4* Cl-97 HCO3-20* AnGap-24* ___ 08:41AM BLOOD ALT-51* AST-196* LD(LDH)-439* ___ AlkPhos-66 TotBili-0.4 DirBili-<0.2 IndBili-0.4 ___ 04:37AM BLOOD WBC-15.8* RBC-4.99 Hgb-15.0 Hct-42.8 MCV-86 MCH-30.1 MCHC-35.0 RDW-12.1 RDWSD-37.3 Plt ___ ___ 05:16AM BLOOD ___ PTT-24.8* ___ ___ 10:35AM BLOOD Lupus-NEG AT-82 ___ 04:37AM BLOOD Glucose-112* UreaN-18 Creat-0.7 Na-136 K-4.1 Cl-99 HCO3-25 AnGap-16 ___ 04:37AM BLOOD CK(CPK)-695* ___ 04:35AM BLOOD ALT-104* AST-133* LD(LDH)-469* CK(CPK)-3337* AlkPhos-42 TotBili-<0.2 ___ 05:19AM BLOOD CK-MB-3 cTropnT-<0.01 ___ 04:37AM BLOOD Calcium-8.0* Phos-3.5 Mg-2.1 ___ 10:35AM BLOOD VitB12-379 ___ 04:37AM BLOOD %HbA1c-5.1 eAG-100 ___ 05:19AM BLOOD Triglyc-104 HDL-50 CHOL/HD-3.7 LDLcalc-113 ___ 10:35AM BLOOD TSH-0.41 ___ 10:35AM BLOOD T4-4.3* ___ 10:06AM BLOOD HBsAg-Negative HBsAb-Positive ___ 02:00AM BLOOD ANCA-NEGATIVE B ___ 02:00AM BLOOD dsDNA-NEGATIVE ___ 10:35AM BLOOD ___ ___ 10:35AM BLOOD RheuFac-<10 CRP-62.3* ___ 10:06AM BLOOD HIV Ab-Negative ___ 08:41AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 10:06AM BLOOD HCV Ab-Negative ___ neg, RPR neg, SS-A/SS-B neg ___, ACE neg CSF Studies: ___ Tuberculosis, ___, Enterovirus, VDRL, HSV PCR, CMV PCR, EBV PCR, negative ___ 3+ PMNs, Cx neg ___ C-Spine No fracture or traumatic malalignment. ___ 1. Small area of scalp stranding consistent with known forehead abrasion. 2. No hemorrhage or large territorial infarction identified. ___ C/T/L Spine w/o 1. Study is moderately degraded by motion, and further limited by nondiagnostic thoracic spine diffusion imaging. 2. Signal abnormality in the anterior and posterior columns of the entire thoracic and lumbar spinal gray matter, concerning for cord infarction with differential considerations of transverse myelitis. 3. Within limits of study, no definite evidence of fracture, epidural hemorrhage, or cervical spinal cord infarction. 4. Nonspecific lumbosacral soft tissue edema. ___ T Spine w/ and w/o 1. Progression of spinal cord swelling and signal intensity abnormality since the study of ___. The gray matter predominant pattern continues to suggest infarction as the most likely etiology. ___ Brain w/ and w/o 1. Normal brain MRI. ___ read pending Brief Hospital Course: ___ M w/ hx of prior L zygomatic bone fracture, polysubstance abuse with hx of withdrawal w/ no seizure or ICU care presents with flaccid paraplegia after overdose of Xanax, with MRI findings of signal abnormality in the anterior and posterior columns of the entire thoracic and lumbar spinal gray matter, concerning for cord infarction. #paraplegia: Pt w/MRI findings etiology includes cord infarct vs transverse myelitis, with the former likely being due to decreased perfusion secondary to benzodiazepine toxicity. Neuro was consulted and followed patient in ICU. LP was performed which showed elevated WBC count. Patient was initially started on antibiotics for meningitis coverage, which was stopped on ___ due to negative blood cultures. Pt was transferred to Neurology on ___. ID was also consulted due to CSF pleocytosis. Due to concern for inflammatory process of spine, pt received 5 days of steroid therapy. Pt had repeat MRI of his thoracic spine which showed continued enhancement of gray matter consistent with cord infarction. Pt was monitored on Neurology service and started on aspirin and atorvastatin. Echo was performed with results pending on discharge. ___: Patient found down with elevated CK to ___ and Cr 2.2 (unknown baseline) c/w rhabdomyolysis. Patient was aggressively treated with IVFs in ICU and CK downtrended. His ___ resolved during hospital course. # Polysubstance abuse/mental health: Pt w/hx EtOH, polysubstance abuse, no IVDU. Tox screen on admission positive for benzos and amphetamines, neg for others. Pt w/mild tachycardia to 110s which could be ___ withdrawal. Last ___. Patient was seen by SW and psychiatry. Psych was concerned about severe depression/anxiety vs bipolar disorder. Pt will need outpatient psych, maybe substance abuse counseling as well. Patient was treated with MVI, thiamine, folate. # Tachycardia: Pt in sinus tach to 110s on arrival, possibly secondary to dehydration (___), possibly withdrawal. Later in hospital course, pt seen to develop Afib with RVR. This resolved w/ acute beta blockade and pt was started on Metoprolol 25mg BID with appropriate rate control. Pt underwent Echo as noted above. TRANSITIONAL ISSUES: ==================== -Pt will need outpatient psych, maybe substance abuse counseling as well. -Pt will need to follow up with Cardiology for new onset Atrial Fibrillation -Pt will need to follow up with Neurology due to apparent spinal cord infarction -Pt will need to work with ___ at acute rehab -Pt will need to continue taking ASA, Atorvastatin, and Metoprolol for treatment -Pt will need to have Echo read followed up after discharge Medications on Admission: No current medications Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Bisacodyl 10 mg PO DAILY Constipation 5. Docusate Sodium 100 mg PO BID 6. FLUoxetine 20 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Metoprolol Tartrate 25 mg PO BID 9. Multivitamins 1 TAB PO DAILY 10. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate 11. Polyethylene Glycol 17 g PO DAILY Constipation 12. Senna 8.6 mg PO QHS Constipation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute ischemic stroke of thoracic and lumbar spinal cord Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, You were hospitalized at ___ and treated by Neurology as well as Medicine due to acute weakness and sensory loss in legs, seen upon further evaluation with MR imaging and lumbar puncture studies to be due to a spinal cord infarction. 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 Hyperlipidemia We are changing your medications as follows: Please start taking aspirin 81mg daily. Please start taking Atorvastatin 40mg daily. Please take Metoprolol 25mg twice daily. Please take Fluxoetine 20mg daily. Please take your other medications as prescribed. Please followup with Neurology, Cardiology, and your primary care physician as listed below. Please work with your primary care physician to have outpatient psychiatry services arranged. 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: ___
19970934-DS-3
19,970,934
28,543,557
DS
3
2113-06-14 00:00:00
2113-06-14 19:19:00
Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: weakness Major Surgical or Invasive Procedure: none History of Present Illness: ___ transferred from ___ with concern for CBD stone and choledocolithiasis versus cholangitis, admitted to ___ from ED with elevated lipase and acidemia. Per osh records, came in from home with generalized weakness, inability to care for herself, and wheezing. Per husband, did not get out of bed for 3 days. Patient has not taken any of her medications, just got back from rehab and "going through the same thing again", "doesn't even get out of bed to go to the bathroom." Patient states that she is too weak to do anything. Per pt, who is a poor historian, she endorses some mild RUQ abd pain over past several days as well as generalized weakness, decrease PO intake and loose stools over this time. She denies f/c, vomiting, nausea, dysuria, flank pain, confusion, cp, ___ swelling, ha, visual changes, rash, arthalgias myalgias. Lives at home with her husband. At OSH: PE: vitals: 96.9 (rectal) BP 125/60 HR 101 RR 28 O2 98% RA dry MM, mild respiratory distress, wheezing, abdomen nontender, ___ strength ___, A&Ox3 CBC WBC 8, H/H 11.___, MCV 100, plt 280 82% polys Tbili 0.6 albumin 3, alk phos 135, AST 109, ALT 38 lipase 2297 Na 129, K 4.2, Cl 102, CO2 9, BUN 11, Cr 1.2, gap 34 abdominal U/s - patient declined most of exam, too limited ABG 7.___/146/3.5 CXR: no acute process Received 1g vancomycin IV at ___, zosyn 4.5g at ___, levaquin 750mg, duonebs x 2, methylprednisolone 125mg IV, morphine In the ___ ED pt was afebrile, HR in the ___, normotensive, RR ___, saturating well on RA. She was afebrile, HRs ___ normotensive RR ___, didn't know why she was there. She was tremulous and had diffuse tenderness to palpation of abdomen. VBG in ED showed pH 7.17/ ___/ 8, anion gap acidosis 33, lactate 1.8. CXR - normal at OSH. CT A&P: unremarkable, fatty liver Her urine with 150 ketones, but otherwise negative. She received thiamine and folate. On arrival to ICU patient HD stable, afebrile, HR 94, BP 124/68, RR 20, O2 100%RA. Received further history when husband arrived: Patient has been drinking "too much vodka" everyday. Unable to clarify but about ___ quart everyday without any food or fluid intake. She was recently admitted to ICU in ___ with GI bleed, diverticulosis, discharged to rehab and has been home for a couple months, but unable to take care of herself with many falls Past Medical History: COPD OSA CKD Diverticulosis Recent GI bleed C diff on ___ Social History: ___ Family History: Unknown Physical Exam: ADMISSION EXAM: VS General: Alert, oriented x 2, year "1990s" HEENT: Sclera anicteric, dry MM, PEERL Lungs: wheezes, otherwise Clear to auscultation CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely 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: normal orthostatic vital signs 99% RA A and O x 2 (not always aware of correct date), forgetful at times HEENT: Sclera anicteric, MMM, PEERL Lungs: clear to auscultation CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: ___ 12:14AM BLOOD WBC-5.5 RBC-3.13* Hgb-10.2* Hct-34.0* MCV-109* MCH-32.7* MCHC-30.0* RDW-17.1* Plt ___ ___ 12:14AM BLOOD Neuts-84.3* Lymphs-11.6* Monos-3.5 Eos-0.5 Baso-0.1 ___ 12:14AM BLOOD Plt ___ ___ 12:14AM BLOOD Glucose-183* UreaN-10 Creat-0.7 Na-144 K-4.0 Cl-104 HCO3-7* AnGap-37* ___ 12:14AM BLOOD ALT-23 AST-54* AlkPhos-110* TotBili-0.3 ___ 12:14AM BLOOD Lipase-492* ___ 12:14AM BLOOD Albumin-3.3* Calcium-8.0* Phos-2.3* Mg-1.4* ___ 12:14AM BLOOD Osmolal-304 ___ 12:14AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:53AM BLOOD ___ pO2-24* pCO2-22* pH-7.17* calTCO2-8* Base XS--20 ___ 12:53AM BLOOD Lactate-1.8 MICRO: c. diff neg, blood cxs neg EKG ___ Sinus rhythm with baseline artifact. Diffuse low QRS voltage. Non-specific repolarization abnormalities. Cannot exclude inferior wall myocardial infarction of indeterminate age. Cannot exclude anterior wall myocardial infarction of indeterminate age. No previous tracing available for comparison. CT ABD/PELVIS ___. Diffuse hypoattenuation of the liver, consistent with hepatic steatosis, but hepatitis can present similarly. 2. There is no biliary obstruction or cholecystitis. 3. Normal CT appearance of the pancreas. DISCHARGE LABS: ___ RBC Hgb Hct MCV MCH MCHC RDW Plt Ct 4.61 2.81 9.1 28.3 101 32.2 31.9 17.1 241 UreaN Creat Na K Cl HCO3 7 0.6 137 3.8 105 22 ALT AST AlkPhos TotBili 60 113 105 0.2 albumin 3.4 cortisol 13.6 TSH- 0.15 free T4- 1.3 hepatitis B and C serologies negative SPEP negative UPEP negative Brief Hospital Course: ___ yo female with CKD, alcohol abuse admitted with acidemia and found to have elevated lipase due to EtOH and starvation ketoacidosis. # Acidemia - due to excessive alcohol use and lack of appetite, likely both resulting from depression due to deaths of recent close friends. She was fluid repleted and given bicarb with improvement in her symptoms and resolution of acidemia. # Pancreatitis - lipase 2200 at OSH and 400 here. BISAP score 2 for SIRS and age, indicating lower mortality. Likely due to alcohol intake given history per husband. Patient received maintenance fluids at 150cc/hr, titrated for urine output. She was started on clears and her diet was successfully advanced. She required minimal pain medications, and none needed on day of discharge, eating a regular diet. # Refeeding syndrome: patient developed hypokalemia, hypomagnesemia and hypophosphotemia with advancement of diet. She required agressive electolyte repletion for a few days, followed by resolution of refeeding syndrome. # Altered mental status - toxic metabolic due to the above. Resolved with treatment. Intermittently forgetful at times, and not always oriented to date. Counseled to continue to avoid alcohol use. # Anemia/thrombocytopenia: likely due to EtOH use, stable while in the hospital. Platelet count normalized at discharge, and anemia was mild, improving. # Hypothyroidism - TSH low on admission which woul indicate hyperthyroidism but more likely sick euthyroid. Free T4 was normal. Her home dose of levothyroxine was continued but should be monitored as an outpatient. # Transaminitis: likey due to chronic alcohol use. Hepatitis serologies were negative. Patient counseled to avoid further alcohol use. # EtOH abuse: she was started on a CIWA scale but did not score while in the hospital. # poor appetite: likely due to depression, unclear outpt w/u but pt reports nl ___ in last ___ yrs. Pt was started on mirtazipine with improvement in sleep and appetite. CHRONIC ISSUES # COPD - Symbicort *** TRANSITIONAL ISUUE *** - please repeat thyroid studies around ___ and adjust levothyroxine as needed - would recommend ongoing discussions with patient regarding depression and alcohol abuse Medications on Admission: Per ___ Records on transfer 1. Levothyroxine Sodium 100 mcg PO DAILY 2. Klor-Con M20 (potassium chloride) 20 mEq oral daily 3. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation inhalation BID 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Simvastatin 10 mg PO DAILY Discharge Medications: 1. Montelukast 10 mg PO DAILY 2. Simvastatin 10 mg PO DAILY 3. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation inhalation BID 4. Fluticasone Propionate NASAL 1 SPRY NU DAILY 5. Levothyroxine Sodium 100 mcg PO DAILY 6. FoLIC Acid 1 mg PO DAILY 7. Multivitamins 1 TAB PO DAILY 8. Thiamine 100 mg PO DAILY 9. Mirtazapine 7.5 mg PO HS 10. Cyanocobalamin 100 mcg PO DAILY 11. Nicotine Patch 14 mg TD DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: starvation/alcoholic ketoacidosis, pancreatitis, mild alcoholic hepatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital for acidemia (acidic blood) and weakness due to poor nutrition and alcohol use. Your symptoms improved with repletion of essential nutrients and increased food intake and IV fluids. You were started on a medication to help improve your appetite and your mood (Remeron). You were also found to have pancreatitis (inflammation of the pancreas) and liver inflammation due to alcohol use. This improved with conservative management and you were tolerating a regular diet prior to discharge from the hospital. Please see below for your medications and follow up appointments. Followup Instructions: ___
19970991-DS-18
19,970,991
23,925,038
DS
18
2145-04-21 00:00:00
2145-05-05 15:12:00
Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: lisinopril Attending: ___. Chief Complaint: R Leg Pain, R Leg Swelling Major Surgical or Invasive Procedure: ___ - Aspiration of right leg with debridement of subcutaneous tissue ___ - Washout of right leg incisions. Wound VAC placement over RLE wounds ___ - Removal and Placement of wound VAC to right lower extremity History of Present Illness: Mr. ___ is a ___ w ___ notable for DMII, L knee osteoarthritis, prior CVA, and current inmate who is presenting with RLE pain and swelling. Two to three weeks prior to this presentation, the patient reports that he developed pain in his RLE which eventually improved. Then three days prior to this presentation, he again developed significant pain in his RLE along with fevers. The patient was initially taken to ___. There, his course was notable for labs showing WBC 21.4, H/H 10.5/30.5, platelets 265, 91% neutrophils, sodium 132, potassium 3.7, bicarb 24, BUN 33, creatinine 1.3, glucose 176, calcium 9.4. RLE US negative for DVT. He was given vanc/zosyn and transferred due to concern for nec fasc. Per report, patient was seen confused in the ambulance by paramedics en route, but found to be clear upon arrival to the ED. Past Medical History: Type 2 diabetes hyperlipidemia left knee osteoarthritis history of CVA prior to incarceration Social History: ___ Family History: Non-contributory Physical Exam: ADMISSION EXAM =============== VITALS: 100.3, BP 131 / 69, HR 90, RR 18, O2 100 RA GENERAL: AOx3, NAD HEENT: Normocephalic, MMM, poor dentition NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. No JVD. LUNGS: CTAB, no adventitious sounds ABDOMEN: Soft, nontender, nondistended EXTREMITIES: There is a large area of confluent erythema and warmth on the anterior surface of the RLE (marked with skin marker on ___. There is significant tenderness to palpation throughout the antererior and medial portions of the RLE. There are no dopplerable DP pulses on the right leg, but there is a dopplerable ___ pulse on the right leg. Neither leg is cool. No crepitus or fluctuance. NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. DISCHARGE EXAM ================ VS: 97.9 PO 132 / 78 L Lying 62 20 98 Ra GEN: Awake, alert, following commands. Moving all extremities equal and strong. HEENT: PERRL. EOMI. Mucus membranes pink/moist. CV: RRR PULM: Clear bilaterally ABD: Soft, non-distended. Non-tender. EXT: Warm. RLE knee to ankle erythema. Vac dressing with black foam CDI, holding sucition. RLE > LLE swelling. Doppler pulses. Pertinent Results: ADMISSION LABS =============== ___ 07:30PM BLOOD WBC-14.8* RBC-3.52* Hgb-9.8* Hct-29.0* MCV-82 MCH-27.8 MCHC-33.8 RDW-13.7 RDWSD-40.6 Plt ___ ___ 07:30PM BLOOD Neuts-95* Bands-1 ___ Monos-4* Eos-0 Baso-0 ___ Myelos-0 AbsNeut-14.21* AbsLymp-0.00* AbsMono-0.59 AbsEos-0.00* AbsBaso-0.00* ___ 07:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-OCCASIONAL Burr-OCCASIONAL ___ 07:30PM BLOOD Glucose-146* UreaN-31* Creat-1.2 Na-136 K-4.1 Cl-98 HCO3-24 AnGap-14 ___ 07:30PM BLOOD Calcium-8.4 Phos-1.7* Mg-1.4* ___ 07:30PM BLOOD CRP-253.5* PERTINENT INTERVAL LABS ========================= ___ 06:03AM BLOOD Lactate-1.6 ___ 10:05AM BLOOD HIV Ab-NEG ___ 05:58AM BLOOD calTIBC-213* Ferritn-493* TRF-164* ___ 05:58AM BLOOD CK(CPK)-218 ___ 06:12AM BLOOD CK(CPK)-146 STUDIES/IMAGING =============== ___ CXR Slightly limited exam due to lordotic positioning. Patchy retrocardiac opacity could reflect atelectasis with infection not excluded in the correct clinical setting. ___ CTA ___ w/ Contrast 1. Extensive subcutaneous stranding and edema throughout the leg, especially of the right groin and calf region, without focal fluid collection or soft tissue gas. Right groin lymphadenopathy, presumably reactive. 2. Occlusion of the right anterior tibial artery just beyond its origin and dorsalis pedis artery. Otherwise, two vessel runoff to the right foot via the right peroneal and posterior tibial arteries. 3. Primarily single-vessel runoff to the left foot via the peroneal artery with occlusion of the left posterior tibial artery at the mid leg with distal reconstitution via the peroneal artery. Left anterior tibial artery is patent to the level of the distal leg, though with multifocal areas of high-grade narrowing and occlusion. Non opacification of the distal anterior tibial artery at the level of the ankle and the dorsalis pedis, suspicious for occlusion. 4. Severe (approximately 90%) focal narrowing of the distal left common iliac artery. 5. Distended bladder ___ Knee XRAY IMPRESSION: Severe tricompartmental degenerative change, most pronounced around the patellofemoral compartment. Patella baja. ___ MRI Calf IMPRESSION: 1. No evidence of drainable fluid collections or rim enhancing lesions. No MRI evidence of osteomyelitis. 2. Diffuse subcutaneous edema which likely represents cellulitis in the appropriate clinical setting. 3. Fascial and muscular edema, most prominent anterior compartment muscles, which is nonspecific but may represent myositis. 4. Heterogeneous enhancement of enlarged superficial gastrocnemius veins may represent thrombosis in the appropriate clinical setting. Lower extremity ultrasound is recommended if clinical concern is present. 5. Incidental tibiofibular intraosseous ganglion. ___ MRI pelvis IMPRESSION: 1. Moderate subcutaneous and fascial edema in the right lower extremity and scrotum and mild edema in the left lower extremity and the mid back is nonspecific, but can be seen with cellulitis. There is mild patchy nonspecific edema in the musculature. There is no evidence of a rim enhancing fluid collection to suggest abscess formation. 2. Mildly heterogeneous red bone marrow signal in the pelvis without suspicious focal lesions or evidence of osteomyelitis. ___ RLE US IMPRESSION: No evidence of deep venous thrombosis in the right lower extremity veins. MICROBIOLOGY ============= ___ Skin biopsy: Skin, right lateral shin: - Papillary dermal edema with red cell extravasation, perivascular lymphocytes and sparse predominantly subcutaneous neutrophils in the subcutaneous fat (see comment). - No bacterial organisms seen on a tissue Gram stain. - No fungal organisms seen on a PAS stain. - Multiple tissue levels examined. Comment. The histologic features are not specifically diagnostic and no bacterial organisms are identified on a tissue Gram stain. However, the presence of papillary dermal edema with sparse and predominantly subcutaneous neutrophils is compatible with cellulitis in the appropriate clinical setting. Although no organisms are identified on special stains this finding should be correlated with the results of microbiologic culture. A more deeply situated process may not be represented in the current biopsy material. Stains for mycobacteria are in process and will be reported in an addendum. Brief Hospital Course: Mr. ___ is a ___ man with a history of type 2 diabetes, hyperlipidemia, CVA who presented with right lower extremity pain and fevers concerning for deep space infection. Patient was admitted to ___ on ___. Patient was initially located on a medical service and was later transferred to the surgery service on ___. On the medical service the patient was seen by orthopedic surgery, dermatology, and vascular surgery. The patient underwent a punch biopsy with dermatology specimen sent for dermatopathology and fungal, bacterial, atypical culture. The patient was evaluated by vascular surgery, and given CTA lower extremity findings of 2 vessel runoff in the right lower extremity and dopplerable signals on exam of vascular etiology for his cellulitis was felt to be unlikely. Psychiatry (delirium): On ___, psychiatry was consulted to evaluate the patient's capacity to refuse surgery. The patient was found to be delirious, and therefore was not able to be capable of consent. The patient was taken for urgent debridement of the right lower extremity under assumed consent due to concern for necrotizing fasciitis. Given the patient's legal status is a prisoner, and lack of recorded healthcare proxy, legal services was contacted at ___. Based on a conversation between legal services and the ___ medical staff at the present it was decided that emergency guardianship should be obtained. Emergency guardianship was later obtained, and serial consent was obtained through the emergency guardian. Right lower extremity infection: The patient was taken to the operating room on ___, for exploration of subcutaneous tissue of the right leg with debridement. For details of the surgical procedure please see the surgeon's operative note. There was found to be a lateral tract of loose subcutaneous tissue with dishwasher fluid. Infectious disease was consulted, and on ___, the patient was recommended to continue on vancomycin, Zosyn, and clindamycin given concern for necrotizing infection. On ___, the patient was taken to the operating room for washout of right leg incisions and wound VAC placement over right lower extremity wounds. For details of the surgical procedure please see surgeon's operative note. On ___, infectious disease recommended continuing a course of vancomycin and Zosyn for 7 days starting on ___ and continuing through ___. On ___, the patient was taken to the operating room for removal and placement of wound VAC to the right lower extremity. Details of the surgical procedure please see surgeon's operative note. On ___, infectious disease recommended discontinuing vancomycin and Zosyn due to the fact of the patient was having likely drug fever. On ___, the right lower extremity wound VAC was changed at bedside with the patient tolerated procedure well. Disposition: On ___, the patient was evaluated by physical therapy, and was recommended that he be discharged back to his facility without any need for further physical therapy. Physical therapy recommended that he continue to use a rolling walker on discharge and may require rehabilitation pending other medical needs. The patient was not informed about discharge date as per policy given that he was returning to prison. Appropriate follow-up was arranged, all of the patient's questions were answered. Arrangements were made to have nursing services visit the patient for wound VAC change. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. amLODIPine 5 mg PO DAILY 2. Naproxen 500 mg PO Q12H 3. MetFORMIN (Glucophage) 1000 mg PO BID 4. Hydrochlorothiazide 25 mg PO DAILY 5. GlipiZIDE 5 mg PO DAILY 6. Vitamin D ___ UNIT PO QMONTH 7. Atorvastatin 40 mg PO QPM 8. Aspirin 325 mg PO DAILY 9. hyaluronic acid, hydrol (bulk) unknown mg miscellaneous q3 weeks Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID 3. Glucose Gel 15 g PO PRN hypoglycemia protocol 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate Take lowest effective dose. 5. Polyethylene Glycol 17 g PO DAILY 6. Senna 8.6 mg PO BID 7. amLODIPine 5 mg PO DAILY 8. Aspirin 325 mg PO DAILY 9. Atorvastatin 40 mg PO QPM 10. GlipiZIDE 5 mg PO DAILY 11. hyaluronic acid, hydrol (bulk) unknown miscellaneous Q3 WEEKS 12. Hydrochlorothiazide 25 mg PO DAILY 13. MetFORMIN (Glucophage) 1000 mg PO BID 14. Naproxen 500 mg PO Q12H 15. Vitamin D ___ UNIT PO QMONTH Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: 1. Necrotizing soft tissue infection right lower leg Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at ___ ___. Why were you admitted to the hospital? - You were brought to the hospital because you were having fevers and leg pain. What was done while you were in the hospital? - You were started on antibiotics for your leg infection. - A CT scan of your leg showed that some of the vessels in your legs were partially blocked, which was likely a long term problem - You were given fluids through an IV to keep you hydrated - An MRI showed inflammation. - Your leg did not improve so dermatology took a skin biopsy that showed a serious infection. - You began having fevers again thus the decision was made you needed emergent surgery to remove dead tissue from inside your leg. - You were confused at the time of surgery so you were taken emergently without consent - You were then transferred to the surgical service to have further debridement of the wounds of your right leg to prevent infection. You were taken back to the operating room several times for further debridement. Wound VAC was placed over the wounds to prevent infection and promote healing and you are discharged with a wound VAC in place with a plan for visiting nurses to change the wound VAC on a regular schedule. What should you do when you go home? - You should go to all your outpatient follow up appointments as listed below. - You should take all your medications as directed. Wishing you all the best, Your ___ Care Team Followup Instructions: ___