note_id
stringlengths 13
15
| subject_id
int64 10M
20M
| hadm_id
int64 20M
30M
| note_type
stringclasses 1
value | note_seq
int64 2
133
| charttime
stringlengths 19
19
| storetime
stringlengths 19
19
| text
stringlengths 1.56k
52.7k
|
|---|---|---|---|---|---|---|---|
19986589-DS-29 | 19,986,589 | 26,187,373 | DS | 29 | 2192-06-08 00:00:00 | 2192-06-08 20:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
From admitting H&P:
___ male with history of CAD s/p CABGx1 SVG-dRCA
(___), BMS to anomalous RCA ___, DES to OM ___, T2DM,
HTN and chronic knee pain from OA wheelchair-bound, multiple
recent admissions for chest pain, who presents with chest pain.
On day of admission, he reports waking up with ___ chest pain
from sleep at 7 am, no shortness of breath, nausea or vomiting.
He says the pain has been persistent over the day and has not
improved with sublingual nitro. He does not notice any change
with inspiration, position, or with exertion.
Of note, he's had 6 admissions over the last 6 months for chest
pain, and several additional ED visits. In ___ he presented
with unstable angina and underwent DES to OM ___. On the
subsequent admissions, chest pain was thought to be related to
either anxiety or microvascular disease, as he's had negative
troponins and no ischemic changes on EKG. He underwent
angiography again on ___ which showed stable nonobstructive
CAD with evidence of diffuse microvascular disease. He most
recently underwent a nuclear stress on ___ which was normal.
His recent admission was ___ to ___ with chest pain
thought to be related to anxiety.
After his last admission, he was discharged to a hotel rather
than to a skilled nursing facility. Per the note, "He states
that being in rehab has been very difficult. He notes that he is
there with many people who are much older than him, and this has
taken a mental toll. He has seen many things that have made him
uncomfortable and feel that the care he gets is often very poor.
He also struggles with the idea of being stuck in a wheelchair
at a rehab at such a young age."
He reports that he's very anxious regarding his ability to care
for himself. He feels he made a mistake by requesting discharge
to hotel and he has trouble getting in and out of bed and
getting to the bathroom. He has not been taking Ativan recently
but he reports that the Ativan appears to help his chest pain.
In the ED while he was getting an EKG, he suddenly became
confused and complained of sudden onset headache. Then had
weakness and inattentiveness. A code stroke called. CTA head
showed no hemorrhage or large vessel occlusion. Neurology
evaluated him and found no neurologic deficits, exam notable for
anxiety, and treated his headache with IVF and migraine
cocktail. He reports he's never had these types of symptoms
before.
- In the ED, initial vitals were: 97.8 90 135/71 18 96% RA
- Exam was notable for: Confused, in pain, unable to state
name, location, date, inattentive on the right. Weakness RUE >
LUE, weakness RLE > LLE, inattentive on right, not able to
follow exam commands for CN, able to wiggle toes.
- Labs were notable for: trop negative x2, negative serum
tox/urine tox, normal CBC, Cr, lytes, LFTs.
- Studies were notable for: 4 EKG's obtained showing NSR, normal
intervals, no ischemic changes
- The patient was given: SL nitro x 3, ASA 325, Tylenol,
prochlorperazine, 1L LR, plavix, atorvastatin 80 mg, tramadol 50
mg, insulin 4 U
- cardiology was consulted, recommended admission for medication
titration given his recurrent presentations to the ED for chest
pain.
On arrival to the cardiology service, he endorses history above.
He reports constant chest pain which is ___ and unchanged
from prior. He does appear comfortable and has been mostly
concerned with anxiety surrounding inability to complete ADLs."
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes (+)
- Hypertension (+)
- Dyslipidemia (+)
2. CARDIAC HISTORY
- CABGx1 SVG-dRCA (___)
- BMS to anomalous RCA ___, DES to OM ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY
- chronic knee pain from OA wheelchair-bound
- anxiety
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
On day of discharge:
Vitals: 24 HR Data (last updated ___ @ 800)
Temp: 98.3 (Tm 98.4), BP: 119/73 (108-143/64-89), HR: 74
(70-78), RR: 18 (___), O2 sat: 96% (96-99), O2 delivery: Ra
Weight: 113kg
Weight on admission: 110.3 kg
Telemetry: sinus rhythm
General: Well appearing, no apparent distress
HEENT: Normocephalic, atraumatic. EOMI.
Neck: Supple, trachea midline.
Lungs: Decreased breath sounds throughout, but otherwise clear
to auscultation bilaterally in all lung fields.
CV: RRR. Normal S1, S2. No murmurs, rubs or gallops.
Abdomen: Bowel sounds present throughout. Nontender to palpation
in 4 quadrants.
Ext: Warm, well perfused. No cyanosis
Neuro: CN II-XII intact. UE strength ___ bilaterally. ___
strength ___ bilaterally. Sensation intact and symmetric
throughout. Tone normal.
Pertinent Results:
At admission:
___ 01:10PM BLOOD WBC-5.9 RBC-4.43* Hgb-12.8* Hct-39.4*
MCV-89 MCH-28.9 MCHC-32.5 RDW-13.1 RDWSD-42.7 Plt ___
___ 01:10PM BLOOD ___ PTT-28.0 ___
___ 05:28AM BLOOD Glucose-153* UreaN-11 Creat-0.6 Na-141
K-3.9 Cl-101 HCO3-28 AnGap-12
___ 01:10PM BLOOD ALT-22 AST-19 AlkPhos-104 TotBili-0.3
___ 01:10PM BLOOD Lipase-18
___ 01:10PM BLOOD cTropnT-<0.01
___ 05:05PM BLOOD cTropnT-<0.01
___ 01:10PM BLOOD Albumin-3.7
Interim labs:
At discharge:
CTA head/neck:
1. No evidence of acute territorial infarction or intracranial
hemorrhage.
2. CT perfusion is nondiagnostic due to poor bolus timing.
3. No evidence of large vessel occlusion, stenosis, aneurysm, or
dissection.
MRI brain:
1. There is no evidence of hemorrhage, edema, mass, or
infarction. The ventricles and sulci are age-appropriate. There
is no mass effect or midline shift.
2. Scattered T2 and FLAIR hyperintense foci in the
periventricular and subcortical white matter are nonspecific,
but likely reflect chronic small
vessel ischemic changes.
3. There is mild mucosal thickening of the paranasal sinuses.
There is mild fluid signal in the left mastoid air cells. The
intraorbital contents are unremarkable.
Brief Hospital Course:
#Chest Pain
The patient presented with chest pain similar to previous
multiple admissions over the last 6 months. Patient has known
CAD and microvascular disease. Workup in the ED for ischemia was
negative. No pleurisy. Chest pain not responsive to sublingual
nitroglycerin and the pain persisted through 2 sets of negative
biomarkers and repeated EKGs. During his most recent admission,
___, his chest pain was thought to be related to
anxiety. He was given small dose Ativan to see if the chest pain
would improve on anxiolytics, and although the pain improved, it
did not go away. The cause of the chest pain remains unclear,
with anxiety vs microvasular disease both possible. Low
suspicion for ACS. Given his known CAD, he was continued on
Imdur, but the timing of the dose was changed to nightly for
improved antianginal effect in the morning.
#CAD
Patient is s/p CABGx1 SVG-dRCA (___), BMS to anomalous RCA
(___), and DES to OM (___). Additionally, coronary
angiography on ___ showed stable nonobstructive CAD with
evidence of diffuse microvascular disease. Nuclear stress on
___ was normal. Troponin negative x 2 this admission. EKG
without ischemic changes x4. Initially, it was thought that the
chest pain could be due to microvascular disease, but the pain
did not improve after nitroglycerin administration, making this
unlikely. He was continued on his aspirin and Plavix, as well as
Toprol XL. His Imdur was changed to nightly, as stated above.
#Anxiety
Patient has a hx of anxiety, however, he is not followed by a
therapist or a psychiatrist as an outpatient and is not on an
SSRI. His stress is worsened by his inability to perform his
ADLs. Pt denies anxiety specifically but endorses significant
worry and stress. He was trialed on Ativan 0.5mg prn on prior
admission and currently, with some relief, and discharged with
limited course. Recommend trial of longer acting anxiolytic,
SSRI or a TCA for anxiety symptoms. Social work was consulted
for assistance with discharge planning and coping. It was felt
that discharging the patient back to a hotel was unsafe given
failure of this strategy requiring rehospitalization. He was set
up with a complex case manager and discharged to a SNF.
#Code stroke in ED
While in the ED, the patient had an episode where he felt unable
to speak. A code stroke was called. NIHSS 0. The episode was
brief and the symptoms resolved by time the patient was
evaluated by neurology. CT head and CTA head/neck showed no
evidence of hemorrhage. The patient had no residual deficits or
recurrence of his symptoms. He was monitored on telemetry for
the duration of his hospital stay and no arrhythmias were
recorded. MRI brain was obtained with no evidence of bleed or
acute ischemia. The transient speech difficulty was felt highly
unlikely to represent TIA, and was not due to stroke given lack
of findings on imaging. His symptoms, given his underlying
psychiatric symptoms, are more consistent with a functional
neurologic symptom disorder. Neurology recommended 1 month of
outpatient heart monitoring, but this was deferred given lack of
MRI findings and no recorded arrhythmias on telemetry,
suggesting a low likelihood of arrhythmia leading to an embolic
event. This should be readdressed by the PCP.
#T2DM
Home ___ held while hospitalized, but restarted at discharge.
Patient covered with sliding scale insulin while in hospital.
#Osteoarthritis
Patient reports history of work injury and is s/p bilateral knee
replacement complicated by chronic knee pain. Patient is unable
to bear weight and is wheelchair-bound. Patient is reportedly
planning for surgery however, needs to be stable from cardiac
perspective. He was continued on his home analgesic regimen
without changes.
#Prior UTI
Patient was found to have Klebsiella UTI at last admission
___. He remained on ___ with plan to finish course ___.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. Clopidogrel 75 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. GlipiZIDE 10 mg PO BID diabetes
8. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. LORazepam 0.5 mg PO BID:PRN anxiety
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
16. Tamsulosin 0.4 mg PO QHS
17. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
18. melatonin 3 mg oral QHS
19. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second
Line
20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
21. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection
Discharge Medications:
1. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS
2. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
6. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
7. Ciprofloxacin HCl 750 mg PO Q12H urinary tract infection
Duration: 2 Doses
8. Clopidogrel 75 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. GlipiZIDE 10 mg PO BID diabetes
11. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. LORazepam 0.5 mg PO BID:PRN anxiety
14. melatonin 3 mg oral QHS
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. Metoprolol Succinate XL 50 mg PO DAILY
17. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second
Line
18. Multivitamins 1 TAB PO DAILY
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
20. Pantoprazole 40 mg PO Q24H
21. Tamsulosin 0.4 mg PO QHS
22. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Chest pain
Coronary artery disease
Transient aphasia
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of chest pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- In the emergency room, you had an episode where you were
unable to speak, so you were evaluated by the neurology team
- Your chest pain was evaluated with EKGs and lab work, all of
which was reassuring and not indicative of a cardiac cause of
your chest pain. Your pain was felt to be most likely related
to anxiety
- You were evaluated by the physical therapists who felt you
would benefit from a rehab facility. We agreed, so you were
discharged to a skilled nursing facility to help you with
self-care and medication administration
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Seek medical attention if you have new or concerning symptoms
or you develop swelling in your legs, abdominal distention, or
shortness of breath at night.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19986589-DS-30 | 19,986,589 | 21,882,677 | DS | 30 | 2192-06-14 00:00:00 | 2192-06-15 05:56:00 |
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:
Mr. ___ is a ___ year old M w/ hx of CAD s/p CABG x1 SVG-dRCA,
DES to OM, and BMS to RCA; HTN; DM; and anxiety who was recently
discharged from the hospital who presents from rehab with chest
pain. He was at ___ but left ___ after a dispute over
a
TV. He was supposed to be picked up by a family member but they
did not come. He then started to complain of chest pain and was
brought to ___. He was given aspirin in the ambulance.
In the ED, initial vitals were notable for tachycardia to 104
with BP 148/90. A code stroke was called as the patient was
non-verbal in the ED with lack of movement in his RUE. He was
evaluated by Neurology who felt his exam had many functional
features and he was noted to intermittently able to speak in
full
sentences and move LUE and LLE antigravity. CTA head/neck and
NCHCT were unremarkable. Further history was limited by minimal
patient participation regarding his chest pain. Troponin
negative
x1 and EKG showed sinus tachycardia. He was not given any
medications.
Of note, on his last admission, he also had a code stroke which
showed no evidence of TIA or stroke and were more consistent
with
a functional disorder. He also had chest pain felt to be
secondary to microvascular disease vs. anxiety. He has had
multiple admissions with complex care involved, as he is unable
to care for himself at home.
On arrival to the floor, the patient complains of right-sided
headache that he describes as similar to "someone sticking
needles" in his head. He denies nausea, vomiting,
lightheadedness, dizziness, blurry vision. He also complains of
chest pain which he said has been ongoing since his fight at
rehab on day prior to admission. He describes it as a squeezing,
pulling pain. He also notes that he intermittently "can hear but
can't respond or move as directed". He notes that when this
happens, he cannot move his RUE.
Past Medical History:
Diabetes
HTN
HLD
CABGx1 SVG-dRCA (___)
BMS to anomalous RCA ___, DES to OM ___
Chronic knee pain
Anxiety
Wheelchair bound
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 24 HR Data (last updated ___ @ 721)
Temp: 98.3 (Tm 98.3), BP: 118/77, HR: 90, RR: 18, O2 sat:
98%, O2 delivery: Ra, Wt: 253.31 lb/114.9 kg
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. mild TTP on left chest wall.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi
or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. did not participate in CN exam. Strength ___
in ___ upper extremities, ___ in LLE and ___ in RLE at the time
of
my exam. Normal sensation.
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert and interactive. In no acute distress.
HEENT: PERRL, EOMI. Sclera anicteric and without injection.
MMM.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops. mild TTP on left chest wall.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi
or
rales. No increased work of breathing.
BACK: No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to
deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+ bilaterally.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx3. did not participate in CN exam. Strength ___
in ___ upper extremities, ___ in LLE and ___ in RLE at the time
of
my exam. Normal sensation.
Pertinent Results:
ADMISSION LABS
==============
___ 03:07AM BLOOD WBC-6.7 RBC-4.71 Hgb-13.4* Hct-42.5
MCV-90 MCH-28.5 MCHC-31.5* RDW-14.0 RDWSD-45.4 Plt ___
___ 03:07AM BLOOD Neuts-58.8 ___ Monos-5.6 Eos-3.2
Baso-0.8 Im ___ AbsNeut-3.93 AbsLymp-2.07 AbsMono-0.37
AbsEos-0.21 AbsBaso-0.05
___ 03:25AM BLOOD ___ PTT-22.5* ___
___ 03:07AM BLOOD Glucose-161* UreaN-10 Creat-0.8 Na-138
K-4.5 Cl-101 HCO3-22 AnGap-15
___ 03:07AM BLOOD ALT-21 AST-23 AlkPhos-96 TotBili-0.4
___:07AM BLOOD cTropnT-<0.01
___ 03:07AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
___ 03:25AM BLOOD Glucose-160* Creat-0.7 Na-140 K-4.7
Cl-105 calHCO3-34*
STUDIES
=======
___ ___
No evidence of intracranial hemorrhage, acute large territorial
infarction, edema, or mass.
CTA HEAD AND NECK ___
No evidence of dissection, occlusion, high-grade stenosis, or
aneurysm greater than 3 mm within the great vessels of the head
or neck. The vessels of the circle of ___ and their principal
intracranial branches appear patent.
Brief Hospital Course:
Mr. ___ is a ___ year old M w/ hx of CAD s/p CABG x1 SVG-dRCA,
DES to OM, and BMS to RCA; HTN; DM; and anxiety who was recently
discharged from the hospital who presents from rehab with chest
pain and a code stroke in the ED with concern for functional
neurological disorder.
TRANSITIONAL ISSUES:
====================
[]Will need psychiatry outpatient follow up and consideration of
initiation of SSRI for anxiety
[]Patient will need ongoing management with social work and case
management as he has had numerous recent hospitalizations
[]He would benefit from ongoing outpatient workup for etiology
of headache
[]Please consider referral to Dr. ___ at ___ for suspect
functional neurological disorder
ACUTE/ACTIVE ISSUES:
====================
# Chest pain
While patient certainly has a history of CAD and risk factors,
trop negative x1 and EKG shows no signs of ischemia (although
could be microvascular disease). In addition, constant pain for
>24hrs with TTP on exam is not consistent with cardiac etiology.
Most likely Ddx at this point includes malingering given no
place to reside vs. anxiety. Patient was continued on home
aspirin, Plavix, atorvastatin, metoprolol and nitroglycerin prn
chest pain.
# Unresponsiveness
# Functional neurological deficit
Patient had a code stroke in the ED with inconsistent neurologic
exam, more consistent with functional neurological deficit. All
head imaging including NCHCT and CTA were negative for
intracranial etiology. In addition, exam changed between ED exam
and admission exam. Neurology was consulted and agree with
diagnosis of likely functional neurological deficit. He was
continued on home tramadol, gabapentin and lorazepam. Recommend
followup with Dr. ___ at ___ for further evaluation.
# Headache
All imaging was negative for intracranial etiology. He was seen
by neurology in the ED who felt that this was less likely a
complex migraine. More likely ___ medication overuse given
ongoing headache and numerous recent hospitalizations and rehab
stay. Tylenol was discontinued. He should be considered for
bridge therapy (with NSAIDS vs steroids vs DHE) if he continued
to experience severe headaches despite holding likely culprit.
Possibly also a component of left sided occipital neuralgia.
Recommend warm compresses to back of head, followup with
neurology if headache fails to improve.
CHRONIC/STABLE ISSUES:
======================
# Anxiety
Social work was consulted. He was continued on home lorazepam.
He should have outpatient f/u with psychiatry and should
consider initiation of an SSRI.
# Type II DM
Held home exanetide, placed on ISS while inpatient.
# Knee osteoarthritis
Continued home lidocaine patch, gabapentin and tramadol. Held
home Tylenol.
# BPH
Continued home Tamsulosin
# GERD
Continued home pantoprazole
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. Clopidogrel 75 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. LORazepam 0.5 mg PO BID:PRN anxiety
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second
Line
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q24H
14. Tamsulosin 0.4 mg PO QHS
15. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
16. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
17. GlipiZIDE 10 mg PO BID diabetes
18. melatonin 3 mg oral QHS
19. MetFORMIN (Glucophage) 1000 mg PO BID
20. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
21. Glargine 18 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 18 Units Bedtime
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. Byetta (exenatide) 10 mcg/dose(250 mcg/mL) 2.4 mL
subcutaneous BID
6. Clopidogrel 75 mg PO DAILY
7. Gabapentin 300 mg PO TID
8. GlipiZIDE 10 mg PO BID diabetes
9. Isosorbide Mononitrate (Extended Release) 30 mg PO QHS
10. Lidocaine 5% Patch 1 PTCH TD QAM
11. LORazepam 0.5 mg PO BID:PRN anxiety
12. melatonin 3 mg oral QHS
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Metoprolol Succinate XL 50 mg PO DAILY
15. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - Second
Line
16. Multivitamins 1 TAB PO DAILY
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
18. Pantoprazole 40 mg PO Q24H
19. Tamsulosin 0.4 mg PO QHS
20. TraMADol 75 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
Functional neurological deficit
SECONDARY DIAGNOSIS
Chest pain (non-cardiac)
Headache
Anxiety
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 part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for chest pain and a headache.
What was done for me while I was in the hospital?
- We did tests of your heart and your chest pain was determined
to not be coming from your heart
- You had trouble moving your arm and leg but we took images and
determined you did not have a stroke
- You complained of a headache which we think may be because you
take so many medications or an irritated nerve
What should I do when I leave the hospital?
- Take all of your medications as prescribed
- Go to all of your appointments
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19986715-DS-5 | 19,986,715 | 21,254,631 | DS | 5 | 2153-07-24 00:00:00 | 2153-07-25 16:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fatigue, decreased voice, globus sensation, drooling, diplopia:
Myasthenia ___ Flare
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ woman with medical history of MuSK
positive myasthenia ___ with predominantly bulbar symptoms
MGFA classification II-B followed in neurology clinic by Dr.
___ presents to the ED for evaluation of worsening
bulbar symptoms in the setting of a cold and medication
noncompliance.
She reports was in her usual state of health which includes
independence in all activities of daily living until ___. Of note she stopped taking her prednisone around ___ for the space of 2 weeks and felt well, so she discontinued
the use of her azathioprine (last filled in ___ as well). She
then developed an upper respiratory tract infection in ___ and has not been feeling like herself. Subsequently she
has been complaining of progressive fatigue which is especially
worse at the end of the day or when climbing up stairs. She has
also noted her voice has a different quality as she is somewhat
hypophonic and describes that her tongue is very slow. She has
to repeat what she wants to say several times as people have
trouble comprehending her. Additionally she has been
complaining of upper back pain like she is carrying camping bag.
She reports a sensation like something is caught in her throat
however denies choking. She does complain that her throat is
dry but has persistent drooling. She is concerned that the
sweating palms have returned. Her eyes are also tearing
excessively which is unusual for her and 2 days ago she
developed horizontal diplopia which resolves when covering
either eye. She denies any breathing difficulties, nausea
vomiting or diarrhea but reports poor appetite which has been a
problem in the past.
She initially presented in ___ with acute respiratory failure
requiring intubation and was found to have Musk antibody
positive myasthenia ___ with predominantly bulbar features.
Her initial symptoms were fluctuating diplopia, left eyelid
ptosis, dysphagia, dysarthria, lightheadedness and generalized
weakness. She was treated with 5 days of plasma exchange and
subsequently prednisone. She had also been prescribed a BiPAP
machine upon discharge for overnight respiratory support. She
has been managed in neurology clinic by Dr. ___
has slowly tapered her prednisone from 5060 mg p.o. daily down
to 5 mg p.o. daily and continued her on azathioprine 50 mg every
morning and 100 mg every afternoon.
Neurologic review of systems notable for the above-mentioned
symptoms otherwise unremarkable.
On general review of systems, the patient reports recent upper
respiratory tract infection. Otherwise denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
--------------- --------------- --------------- ---------------
ALLERGIES:
Allergies (Last Verified ___ by ___:
Patient recorded as having no known allergies to drugs
Past Medical History:
PMH/PSH:
Problems (Last Verified ___ by ___,
MD):
MYASTHENIA ___
OSTEOPENIA
PREDIABETES
VITAMIN D DEFICIENCY
HEADACHE
Social History:
___
Family History:
FAMILY HISTORY:
Reports no family history of neurologic conditions
Physical Exam:
ADMISSION EXAMINATION:
Vitals:
98.0
81
128/67
16
100% RA
NIF > -60
FVC 2.5L
General: NAD
HEENT: NCAT, LT proptosis without scleral irritation, no
oropharyngeal lesions
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive. Speech is fluent with full sentences, but
mildly hypophonic. Normal prosody. No evidence of hemineglect.
No left-right confusion. Able to follow both midline and
appendicular commands.
Cranial Nerves: PERRL 4->2 brisk. VF full to confrontation.
EOMI, but notable for saccadic pursuit. Horizontal diplopia
worse on LT gaze. Outer image disappears when covering her
right eye. V1-V3 without deficits to light touch bilaterally.
No facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline. There is mild upgaze
fatigability with frontalis activation, left greater than right
orbicularis oculi weakness on forced eye closure, full strength
in her orbicularis oris, jaw and tongue. Does exhibit some
weakness when trying to keep her cheeks puffed. Neck flexion
and extension full-strength.
Motor: Normal bulk and tone. No drift. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4+ 5 5 5 5 5
R 5 ___ ___ 4+ 5 5 5 5 5
Sensory: No deficits to light touch bilaterally. No extinction
to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
Coordination: No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
Gait: Normal initiation. Narrow base. Normal stride length and
arm swing. Stable without sway. Negative Romberg.
DISCHARGE EXAMINATION:
Vitals: T 98.6 BP 111 / 75 HR 71 RR 16 spO2 100 RA
General: thin ___ female, appears well, in no acute
distress
HEENT: NCAT, LT proptosis without scleral irritation, no
oropharyngeal lesions, mild soft tissue swelling in anterior
neck on left, no LAD
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes, breathing comfortably
without use of accessory respiratory muscles, counts to 30 in
one breath
Abdomen: soft, NT, ND, +BS, no guarding
Extremities: warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive. Speech is fluent with full sentences, but
mildly hypophonic. Normal prosody. Able to follow both midline
and appendicular commands.
Cranial Nerves: PERRL 6->4 brisk. VF full to confrontation.
EOMI, but notable for saccadic pursuit. There is subtle hyper
and exotropia on the left and exotropia on the right on
cover-uncover tests. Lower lid retraction bilaterally. No
reported diplopia on resting gaze and left gaze. Horizontal
diplopia on far right gaze with outside image disappearing with
covering right eye. Upgaze intact, with fatigability after 10
seconds. Mild bifacial weakness, left slightly greater than
right, with decreased forehead wrinkling and orbicularis oris
strength, orbicularis oculi is ___ bilaterally. Hearing intact
to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
Motor: Normal bulk and tone. No drift. No tremor or asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
Neck flexion and extension ___.
There is fatigability to 4+ on the right deltoid.
Sensory: No deficits to light touch bilaterally. No extinction
to DSS.
DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
Coordination: No dysmetria with finger to nose testing
bilaterally.
Gait: Good initiation, narrow based gait with normal arm swing.
Can ascend 2 flights of stairs with minimal dyspnea.
Pertinent Results:
IMAGING:
Noncontrast head CT with look at the orbits with No acute
intracranial process.
CXR without acute intrathoracic process
___ 07:10AM BLOOD WBC-4.9 RBC-3.89* Hgb-11.5 Hct-35.5
MCV-91 MCH-29.6 MCHC-32.4 RDW-12.4 RDWSD-41.1 Plt ___
___ 07:00PM BLOOD WBC-4.7 RBC-4.29 Hgb-12.7 Hct-39.6 MCV-92
MCH-29.6 MCHC-32.1 RDW-12.7 RDWSD-42.7 Plt ___
___ 07:10AM BLOOD Glucose-93 UreaN-13 Creat-0.7 Na-140
K-4.1 Cl-100 HCO3-23 AnGap-17
___ 07:00PM BLOOD Glucose-89 UreaN-15 Creat-0.6 Na-140
K-4.9 Cl-100 HCO3-26 AnGap-14
___ 07:00PM BLOOD ALT-11 AST-21 AlkPhos-68 TotBili-0.2
___ 07:00PM BLOOD Lipase-19
___ 07:00PM BLOOD TSH-2.2
___ 07:00PM BLOOD T4-7.8
___ 07:00PM BLOOD antiTPO-LESS THAN
Brief Hospital Course:
The patient is a ___ year old woman with history of MUSK-ab
positive myasthenia ___ who presents with a few weeks of
fatigue, blurred vision, and hypophonia in the setting of a
recent respiratory viral illness, and after self-tapering her
antimyasthenic medications several months ago. Her respiratory
status was stable and inspiratory force/vital capacity in the
normal ranges. She had mild anterior neck swelling that was Her
neurologic examination was notable for bilateral proptosis,
diplopia in horizontal endgaze and upgaze, mild bifacial
weakness, and full motor power in skeletal muscles (including
neck flexors/extensors) though with mild fatigability. An active
infection was excluded with negative CXR and UA. She was started
on prednisone 10mg daily and azathioprine 50mg BID and mestinon
30 mg TID. Her fatigue and neurologic examination improved with
these interventions, and her respiratory status remained stable,
with consistent ability to count to 30 in one breath and daily
respiratory mechanics Nif -60 and VC 2.75. For neck swelling,
TSH was negative, anti-TPO antibodies were also negative; she
will be ordered for outpatient thyroid ultrasound. Given her
good social supports with family to monitor her, she was deemed
safe to discharge with follow up in the ___ clinic
with her provider ___.
Transitional issues:
[ ] Consider uptitrating her prednisone to 20mg this week-
patient will contact Dr. ___ to discuss this.
[ ] Follow up with Dr. ___ on ___.
[ ] Follow up thyroid ultrasound to be performed outpatient.
Medications on Admission:
MEDICATIONS: See the prescribed medication list below, however
she reports has not been taking any medications since ___
___. As per pharmacy records she last filled her as a therapy
and prednisone in ___.
--------------- --------------- --------------- ---------------
Active Medication list as of ___:
Medications - Prescription
AZATHIOPRINE - azathioprine 50 mg tablet. 1 tablet(s) by mouth
twice daily
ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000
unit capsule. 1 (One) capsule(s) by mouth weekly for 12 weeks
FOLIC ACID - folic acid 1 mg tablet. 1 tablet(s) by mouth once a
day
Medications - OTC
ACETAMINOPHEN [TYLENOL] - Dosage uncertain - (OTC; as needed)
CALCIUM CITRATE-VITAMIN D3 - calcium citrate-vitamin D3 315
mg-250 unit tablet. 2 (Two) tablet(s) by mouth once a day
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000 unit capsule. 2 (Two) capsule(s) by mouth once a day
TOLNAFTATE [TINACTIN] - Tinactin 1 % topical spray. Apply to
affected areas twice a day
Discharge Medications:
1. AzaTHIOprine 50 mg PO BID
RX *azathioprine 50 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*1
2. PredniSONE 10 mg PO DAILY
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Pyridostigmine Bromide 30 mg PO TID
RX *pyridostigmine bromide [Mestinon] 60 mg/5 mL 2.5 mL by mouth
three times daily Refills:*1
4. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
MUSK myasthenia ___ flare
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted because of recent fatigue, blurred vision, and
voice changes, which we felt was likely symptoms of a myasthenia
flare, which probably resulted from a recent viral infection.
Because this is now your second presentation of myasthenia, we
restarted you on your medications, including Azathioprine at
50mg twice daily, and prednisone, at a low dose of 10mg daily.
You will need to remain on these medications for a prolonged
length of time in order to prevent another myasthenia flare. For
symptomatic relief, we also started on you a medication called
Mestinon (pyridostigmine), at a dose of 30mg, which you may take
three times a day.
Fortunately, you responded well to the above treatments. Your
respiratory status was monitored and you showed no sign of any
weakness in your breathing muscles. Your neurologic examination
was also improved. Therefore, we will discharge you home as long
as you remain well monitored by your family members and come
back to the Emergency Department for any signs of worsening or
development of difficulty breathing. You should call Dr.
___ and keep your follow up appointment with
her on ___ in order to address next steps.
It was a pleasure taking care of you. We wish you the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19986744-DS-22 | 19,986,744 | 29,239,682 | DS | 22 | 2132-04-04 00:00:00 | 2132-04-04 16:05:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Clindamycin Hcl
Attending: ___.
Chief Complaint:
fall
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with Hx recent carpal tunnel surgery, T2DM, osteoarthritis,
s/p PDA repair presents following fall this morning. Shortly
after waking this morning he went to the bathroom. After
standing up from the toilet he fell on his left side, striking
his ribs, shoulder, and head. He does not recall if he urinated
or not, but does recall standing up, feeling "funny" or drugged,
and then falling to the ground. He denies any prodrome, no
chest pain, no palpitations, no diaphoresis or tunnel vision, no
lightheadedness or vertigo. His wife heard a thud and went to
the bathroom. She attempted to convince him to stand up, but he
refused. She observed that he was lethargic and his speech was
slow. She did not see any asymmetry in his face, he was moving
all extremities, and his speech was not slurred. She was
concerned for hypoglycemia and gave him mango juice and sugar
packets. After a few minutes he improved and was speaking
normally, at which point he stood up. He denies history of
falls. Denies fever, chills, N/V/D/C, headache,
lightheadedness, vertigo, melena, BRBPR, CP, dyspnea,
palpitations. He is taking Tylenol #3 QHS following his surgery
___.
.
Of note, the patient notes that over the last 3 months he has
lost 20 pounds due to decreased appetite. He initially had a
chronic cough, typical for him in the ___, that reduced his
appetite. He then noted dyspepsia on eating meals, which he
addressed by eating several small meals over the course of the
day. His cough resolved a few weeks ago, but his appetite did
not improve and he has not returned to eating meals of the same
size as previous. A colonoscopy ___ was normal,
however he had prior polypectomy. PSA ___ 0.9.
.
In the ED, initial VS were: 97.3 86 103/56 16 100% RA. He had
an episode where his pressure dropped to 65/40 although he was
asymptomatic. Guaiac negative. Labs were remarkable for lactate
of 2.3, WBC count 8.3 with 90% PMN. CT head showed no acute
process. CXR and XR rib, shoulder were performed with no acute
injury shown. Thought to be dehydrated, provided 2L IVF.
.
On the floor he complains of his chronic left shoulder pain,
exacerbated due to missing his dose of ibuprofen. He also notes
pain of the left ribcage at approx the 7th rib in the
mid-axillary line. This is new since his fall. Finally he
notes pain behind his right ear, also new. He does not recall
falling on this ear.
Past Medical History:
PAST MEDICAL HISTORY:
- Carpal tunnel syndrome s/p bilateral release
- Left rotator cuff tears and impingement syndrome
- Cervical spondylosis
- Benign prostatic hypertrophy s/p TURP
- Diabetes mellitus type 2
- Osteoarthritis
- Erectile dysfunction
- Hearing loss
- Hyperlipidemia
- Calcified submandibular gland s/p resection
- Hemorrhoids
- Anemia
PAST SURGICAL HISTORY:
- Tonsillectomy
- TURP
- Arthroscopic knee surgery, ___ and ___
- Surgical resection of calcified submandibular gland,
complicated by infection, ___
- Carpal tunnel release (right ___, left ___
- PDA repair, ___
Social History:
___
Family History:
Notable for diabetes mellitus
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 97.6 90/58 112 16 99% RA
General: Alert, oriented, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP clear
Neck: supple, JVP not elevated, no LAD, no thyromegaly
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, 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: many brown SKs on back, no rash
Neuro: CN II-XII tested and intact, strength ___ throughout,
ROM limited in left shoulder ___ pain, gait not tested
.
DISCHARGE PHYSICAL EXAM:
Vitals: Tm/c 98.8 109-62 (90-108/50-62)
102 (86-112) 18 98%RA (96-99%RA)
FSBS: 171-329
General: Alert, oriented, no acute distress
HEENT: EOMI, PERRL, sclera anicteric, MMM, OP clear
Neck: supple, JVP not elevated, no LAD, no thyromegaly
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Back: No palpable muscle spasms, some TTP at ~T8 on the left,
jsut under scapula
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: many brown SKs on back, no rash
Neuro: CN II-XII tested and intact, strength ___ throughout,
ROM limited in left shoulder ___ pain, gait not tested
Pertinent Results:
Admission Labs:
___ 08:17AM BLOOD WBC-8.1 RBC-3.88* Hgb-10.4* Hct-33.7*
MCV-87 MCH-26.9* MCHC-30.9* RDW-14.2 Plt ___
___ 08:17AM BLOOD Neuts-90* Bands-2 Lymphs-7* Monos-0 Eos-1
Baso-0 ___ Myelos-0
___ 08:17AM BLOOD Hypochr-2+ Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-NORMAL
Acantho-OCCASIONAL
___ 08:17AM BLOOD Plt Smr-NORMAL Plt ___
___ 08:17AM BLOOD Glucose-193* UreaN-18 Creat-0.8 Na-137
K-4.1 Cl-103 HCO3-23 AnGap-15
___ 08:17AM BLOOD ALT-43* AST-38 AlkPhos-65 TotBili-0.7
___ 08:17AM BLOOD Lipase-42
___ 08:17AM BLOOD cTropnT-<0.01
___ 08:17AM BLOOD Albumin-3.5 Calcium-9.3 Phos-2.9 Mg-1.8
___ 08:24AM BLOOD Lactate-2.3*
.
Relevant Labs:
___ 01:10PM URINE Color-Straw Appear-Clear Sp ___
___ 01:10PM URINE Blood-TR Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-MOD
___ 01:10PM URINE RBC-2 WBC-78* Bacteri-NONE Yeast-NONE
Epi-<1
.
Discharge Labs:
___ 06:10AM BLOOD WBC-12.6*# RBC-3.52* Hgb-9.5* Hct-30.5*
MCV-87 MCH-27.2 MCHC-31.3 RDW-14.2 Plt ___
___ 06:10AM BLOOD Neuts-80.0* Lymphs-13.3* Monos-4.8
Eos-1.8 Baso-0
___ 06:10AM BLOOD Glucose-145* UreaN-10 Creat-0.8 Na-137
K-4.0 Cl-103 HCO3-24 AnGap-14
___ 06:10AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
___ 06:10AM BLOOD Cortsol-16.9
.
Microbiology:
___ Urine culture: pending at the time of discharge
.
Imaging:
CT Head ___: No acute intracranial process.
.
Left forearm and shoulder ___: (prelim)
No acute fracture or dislocation is seen. There are degenerative
changes at the acromioclavicular joint as well as spur formation
at the glenoid and in the region of the supraspinatus tendon.
IMPRESSION: No acute fracture or dislocation.
.
Left chest wall, rib and CXR ___: (prelim)
No focal opacity to suggest pneumonia is seen. No pleural
effusion, pulmonary edema or pneumothorax is present. The heart
size is top normal. There is tortuosity of the aorta and
calcification at the aortic arch. Adjacent to the marker along
the left lower hemithorax, there is a possible minimally
displaced fracture along the left lateral seventh rib.
Brief Hospital Course:
___ with Hx recent carpal tunnel surgery, T2DM, osteoarthritis,
s/p PDA repair presents following fall, possible syncope.
Admission complicated by transient hypotension and a
leukocytosis.
.
.
ACTIVE ISSUES:
# Syncope: The patient describes a fall, however it seems he
may have had LOC. The differential is broad, including
medication effect, hypoglycemia, orthostasis, vasovagal, and
mechanical fall. There is no evidence of seizure activity or
stroke. No chest pain or dyspnea, and troponin negative.
However, given his history of PDA repair, there is the
possibility of cardiac etiology. There is no sign of GIB, no
Hct drop, and he is guaiac negative. Medication effect is
possible, as he has been using Tylenol #3 QHS following his
recent surgery. As juice partially resolved his symptoms, and
given his use of a sulfonylurea, hypoglycemia is possible.
Micturition syncope is also possible, although largely a
diagnosis of exclusion. Patient was noted to be hypotensive on
admission. He was given IV fluids on arrival. Shortly
thereafter, orthostatic vital signs were negative. X-rays showed
possible minimally displaced fx of left 7th rib (will heal on
its own). Morning cortisol was within normal limits, ruling out
adrenal insufficiency. He was stabilized, and able to ambulate
around the floor without difficulty.
.
# Hypotension: He had an episode of asymptomatic hypotension in
the ED and was SBP 90 on admission to the floor. He was
clinically dehydrated on presentation and his BP did increase
with fluids, although not to baseline. He reports poor PO
intake recently, and per report his PCP thought he was
dehydrated at a recent visit. There was no sign of infection;
he was afebrile. No Hct drop or sign of GIB. Oral intake was
encouraged, and SBPs increased to low 100s.
.
# Leukocytosis: WBC 12.9 noted on day of discharge, with a
neutrophilic predominance. Patient was afebrile, with no
localizing symptoms of infection. leukocytosis may have been
secondary to possible rib fracture. ___ also be a component of
atelectasis, if not as mobile overnight. UA showed 72 WBC, so
patient began empiric treatment for uncomplicated cystitis with
ciprofloxacin. UCx was pending at the time of discharge.
.
.
CHRONIC ISSUES:
# T2DM: Currently well-controlled on oral regimen. He was
covered with a sliding scale while in house.
.
# Pain s/p carpal tunnel: Recently post-op on ___. Continues to
have pain post-op. Patient was treated with standing Tylenol,
along with home ibuprofen, and small doses of oxycodone.
.
# Hemorrhoids: Continued Anusol cream.
.
# Hyperlipidemia: Continued atorvastatin and ASA.
.
.
Transitional Issues:
- Would recommend TTE as outpatient to evaluate for cardiac
causes of syncope.
- Code: full
- Urine culture pending at the time of discharge.
Medications on Admission:
acetaminophen-codeine 300 mg-30 mg Tablet ___ Tablet(s) Q6H PRN
pain
atorvastatin 20 mg Tablet daily
glipizide 5 mg daily
hydrocortisone [Anusol-HC] 2.5 % Cream Apply rectally tid PRN
ibuprofen 600 mg TID
metformin 1500 mg daily
aspirin 81 mg daily
Discharge Medications:
1. acetaminophen-codeine 300-30 mg Tablet Sig: ___ Tablets PO
every six (6) hours as needed for pain.
2. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day.
4. Anusol-HC 2.5 % Cream Sig: One (1) application Rectal three
times a day.
5. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO three times a
day.
6. metformin 1,000 mg Tablet Sig: 1.5 Tablets PO once a day.
7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
8. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO twice a
day for 3 days: Through ___.
Disp:*6 Tablet(s)* Refills:*0*
9. oxycodone 5 mg Tablet Sig: ___ Tablet PO every six (6)
hours as needed for pain.
Disp:*20 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Syncope
Rib fracture
.
Secondary diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care here at ___
___. You were admitted after a fall.
We thought your fall may have been due to low blood pressures
from decreased intake of food and water. You improved after
getting some intravenous fluids. On chest x-ray, you were noted
to have a possible rib fracture. This will heal gradually over
time.
While you were here, we noted that you had some signs of
infection in your urine, so you were started on antibiotics for
treatment of a urinary tract infection.
Please note, the following changes have been made to your
medications:
- START ciprofloxacin 250 mg by mouth twice daily
- START oxycodone 5mg, ___ tablet by mouth every six hours as
needed for pain. DO NOT DRIVE WHILE TAKING THIS MEDICATION.
Please continue all of your other medications as you ad prior to
your hospitalization.
It is important that you follow up with your primary care doctor
this week. Please call Dr. ___ at ___ to make an
appointment.
Wishing you all the best!
Followup Instructions:
___
|
19987152-DS-10 | 19,987,152 | 21,958,012 | DS | 10 | 2147-03-26 00:00:00 | 2147-03-28 15:52:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Erythromycin Base / Demerol / Morphine Sulfate / Dilaudid (PF) /
fentanyl / medline brand surgical film (NOT tegederm brand) /
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
abdomino-pelvic pain
Major Surgical or Invasive Procedure:
Interventional Radiology procedure: pigtail drain removed.
please see operative report for full details
History of Present Illness:
___ yo ___ s/p exploratory laparotomy, removal J-pouch with end
ileostomy and perineal proctectomy (___) and and bilateral
ovarian cystectomy (both benign) on ___ complicated by
peritoneal inclusion cyst draining through vagina via uterus
requring ___ drainage and pigtail placement. First
drained ___ with 190cc output (cytology negative). Replaced
with sclerotherapy on ___, which had limited success and is
planned to be repeated under MAC "in the next couple weeks".
Reports lower abd pain started at time of ___ drain placement
and has been refractory to roxicet q4 hours. Cannot take NSAIDs
due to UC. Gets little reponse from pills as they "come out her
ostomy" without absorption.
Denies fever/chills, urinary sx, vaginal discharge or changes to
ostomy output, or other systemic malaise.
Past Medical History:
PMH: ulcerative colitis, alcohol use, chronic abdominal pain
panic attacks, depression anxiety
PSH:
___ total colectomy w/ diverting ileostomy
___ - j-pouch creation
___ - ileostomy takedown
___ - admitted with closed loop obstruction and had small
bowel resection (all surgeries done by Dr. ___ at ___
___)
C-Section x2
R Inguinal Hernia repair at ___ years old.
Social History:
Married, two small daughters, works in the home, history of
alcohol abuse as documented in PCP ___. Please see social work
note.
Physical Exam:
ED Consultation:
temp 99.6 HR 85 114/78 RR 15 97% RA
NAD, appears mildly uncomfortable
RRR
CTAB, no wheezes or increased work of breathing
abd soft throughout, mildly TTP, no rebound/guarding
LLQ drain without erythema/drainage, ~10cc serous fluid in bag
RLQ ostomy with gas & stool in bag
no peripheral edema
no hives or skin changes
Pertinent Results:
___ 06:33AM BLOOD WBC-9.3 RBC-4.21 Hgb-12.2 Hct-37.8 MCV-90
MCH-29.0 MCHC-32.4 RDW-12.4 Plt ___
___ 06:33AM BLOOD Glucose-111* UreaN-10 Creat-0.8 Na-140
K-3.8 Cl-105 HCO3-28 AnGap-11
___ 06:33AM BLOOD Calcium-9.2 Phos-2.6* Mg-1.9
Brief Hospital Course:
Ms. ___ was admitted to the gynecology oncology service
for pain management and further evaluation of her pelvic fluid
collections. She remained stable during her hospitalization. Of
note, after administration of IV contrast she experienced whole
body itching and hives. This was managed with Epipen and
benadryl. On hospital day #2 she was premedicated with
prednisone and IV benadryl for her ___ procedure. This procedure
was uncomplicated (see operative report for full details). Her
pain was managed with dilaudid and toradol. She recovered well
after her procedure and was stable to be dicharged home on
hospital day # 3.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE-Acetaminophen Elixir 5 mL PO Q6H:PRN pain
2. Lorazepam 0.5 mg PO BID:PRN anxiety
3. DiphenhydrAMINE 25 mg PO Q6H:PRN allergies
Discharge Medications:
1. Lorazepam 0.5 mg PO BID:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet by mouth TID:PRN Disp #*20 Tablet
Refills:*0
2. DiphenhydrAMINE 25 mg PO Q6H:PRN allergies
3. Acetaminophen (Liquid) 325-650 mg PO Q6H:PRN pain
do not take more than 4000mg in 24 hours
RX *acetaminophen 500 mg/5 mL ___ mL by mouth Q6H:PRN Disp
#*500 Milliliter Refills:*1
4. Dilaudid (HYDROmorphone) 1 mg/mL Oral TID pain
may take 2mL TID prn Pain. do not drive or combine with alcohol
or other narcotics. obtain refills from your PCP.
RX *hydromorphone [Dilaudid] 1 mg/mL 2 mL by mouth three times a
day Disp ___ Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
peritoneal inclusion cyst/ fluid collection
Discharge Condition:
stable
Discharge Instructions:
Dear Ms. ___,
You were admitted to the gynecology oncology service in order to
better manage your pain and to address your ongoing fluid
collection. You have remained stable during your stay and the
team believes that you are ready to be discharged home.
.
Please follow these instructions:
- take your medication as prescribed
- keep your follow up appointments
- please call if you have any concerning symptoms
Followup Instructions:
___
|
19987152-DS-11 | 19,987,152 | 24,973,631 | DS | 11 | 2147-04-02 00:00:00 | 2147-05-02 11:15:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Demerol / Morphine Sulfate / Dilaudid (PF) /
fentanyl / medline brand surgical film (NOT tegederm brand) /
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
EGD
History of Present Illness:
The patient is a ___ old female with a history of ulcerative
colitis s/p multiple abdominal surgeries previously admitted for
removal of pigtail draining pelvic fluid collection, and
presents with LLQ pain and weight loss.
Her hx of UC began with a J pouch that required multiple
revisions due to strictures and SBOs and was ultimately removed
and converted to an and ileostomy by Dr. ___ on ___. As
well, she has undergone bilateral ovarian cystectomies
complicated by multiple inclusion cysts requiring drainage and
sclerotherapy.
She was reently admitted to the GYN service with recurrent
pelvic pain ___. A CT scan was obtained and showed a new
loculated fluid collection in the presacral space with rim
enhancement felt to represent a peritoneal inclusion cyst,
adnexal cyst or abscess. Of note, she had a drain in place at
the time. She was scheduled for sclerotherapy on ___ but
injection of the area showed communication of peritoneal
inclusion cyst with peritoneum so sclerotherapy was not
performed and the percutaneous drainage catheter was removed.
She was discharged on Tylenol, Benadryl and dilaudid 2ml TID
prn.
Following this admission, she followed up with her
gastroenterologist, Dr. ___ complained of persistent
abdominal pain similar to previous SBOs. Dr. ___
going to the ED to r/o recurrent fluid collection vs new SOB or
stricture. However, upon further review of the imaging, Dr.
___ writes in her note that she is skeptical that her LLQ pain
is at all related to the fluid collection that was not drained
from the right pre-sacral space. Her note mentions concern for
drug seeking behavior, alcohol dependence and persistent request
for pain meds despite nearly falling asleep during interviews.
In the ED vITALS WERE: SPO2 of 100% on RA, Temp =98.8 Pulse=96
BP=121/85 RR=16.
Labs were unremarkable. Exam notable for tenderness near drain
site, ostomy intact, no surrounding erythema. M enterography
showed decreased fluid collection. She was given a litre of
normal saline,3 doses IV dilaudid with Benadryl, tramadol and
Lorazepam. She was admitted for pain control.
On the floor she reports of ___ abdominal and triggered by
eating and swallowing, weight loss of 8lbs in 2 weeks due to not
eating because of the pain.
Past Medical History:
PMH: ulcerative colitis, alcohol use, chronic abdominal pain
panic attacks, depression anxiety
PSH:
___ total colectomy w/ diverting ileostomy
___ - j-pouch creation
___ - ileostomy takedown
___ - admitted with closed loop obstruction and had small
bowel resection (all surgeries done by Dr. ___ at ___
___)
C-Section x2
R Inguinal Hernia repair at ___ years old.
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION:
Vitals: Temp = 98.9 BP=133/89 PULSE = 86 RR=18 SPO2 100%RA
General: alert and oriented x3. NAD Resting comfortably in bed
HEENT: Anicteric sclera. MMM . OP clear
Neck: supple. No JVD. No LAD.
LUNGS: CTAB
HEART:RRR. No murmurs, rubs or gallops
ABDOMEN: Soft, no tenderness when pressing on abdomen with
stethoscope but grimaces with manual palpation of periumblical
and LLQ areas without rebound or guarding. Hyperactive BS.
Colostomy c/d/I. When asked to sit up for lung ausculatation, pt
sits up quickly without grimacing and does not appear to be
limited by pain whatsoever.
GU: no foley
EXT: warm, well-perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO:CNs ___ intact. motor function grossly normal
DISCHARGE:
Vitals: Temp = 98.0 BP=100/64 PULSE =66 RR=18 SPO2 99%RA
General: alert and oriented x3. NAD Resting comfortably in bed
Neck: supple
LUNGS: CTAB. No wheezes, rales or rhonchi
HEART:RRR. No murmurs, rubs or gallops
ABDOMEN: normoactive BS. Mildly ttp, soft, no rebound or
guarding
GU: no foley
EXT: warm, well-perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
___ 12:20PM BLOOD WBC-5.4 RBC-4.69 Hgb-13.9 Hct-41.2 MCV-88
MCH-29.6 MCHC-33.7 RDW-12.5 Plt ___
___ 12:20PM BLOOD Neuts-59.8 ___ Monos-4.1 Eos-2.7
Baso-1.0
___ 07:00AM BLOOD WBC-5.7 RBC-4.07* Hgb-12.4 Hct-35.5*
MCV-87 MCH-30.4 MCHC-34.8 RDW-12.5 Plt ___
___ 07:00AM BLOOD ___ PTT-32.8 ___
___ 12:20PM BLOOD Glucose-93 UreaN-12 Creat-0.9 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
___ 12:20PM BLOOD ALT-11 AST-15 AlkPhos-38 TotBili-0.4
MR ENTEROGRAPHY ___
IMPRESSION:
1. Decreased size of lesion in the deep right pelvis, compatible
with a
hemorrhagic ovarian cyst.
2. Small adjacent fluid in the pre-sacral space with septations,
slightly
larger than on prior CT when the drainage catheter was in place.
3. Normal small bowel and ileostomy post proctocolectomy.
EGD ___
Impression: Normal mucosa in the whole esophagus
Normal mucosa in the whole stomach (biopsy)
Normal mucosa in the whole duodenum
Otherwise normal EGD to third part of the duodenum
Recommendations: -Patient can return to floor when recovered
from sedation
-Daily PPI
-Follow up biopsies and if positive treat for H. pylori
-Abdominal pain is not explained by the findings of this
endoscopy
Brief Hospital Course:
This is a ___ old female with PMH of UC requiring multiple
surgeries and an ___ guided drainage of pre-sacral fluid
collection improved on MR enterography, who presents with
persistent abdominal pain and inability to tolerate po intake.
#Abdominal pain: MR enterography showed improving fluid
collection. Decreasing fluid collection unlikely to be related
to current abdominal pain. No new obstruction or stricture was
seen on MR enterography. No evidence of infection at previous
drainage site. She underwent EGD with no remarkable findings.
Pain control with IV dilaudid was started in ED and continued on
the floor. Prn antiemetics were given. IVF were given to
rehydrate. No obvious etiology for abdominal pain was found.
Physical exam was not remarkable for an acute abdomen. After
bowel rest, IV pain medications and rehydration, she was more
comfortable at discharge and is to continue follow up with her
gastroenterologist and primary care physician for outpatient
work up and management of her abdominal pain.
#HX of Alcohol abuse: Consumes about 2drinks/night until the
past two months when she stopped drinking because of her
abdominal pain. She was placed on CIWA protocol because of
outpatient provider concerns for present alcohol abuse. Folate
and thiamine were supplemented.
TRANSITIONAL ISSUES:
Follow up biopsies from EGD and if positive treat for H. pylori
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO BID:PRN anxiety
2. DiphenhydrAMINE ___ mg PO Q6H:PRN itching
3. Dilaudid (HYDROmorphone) 2 mL Oral TID:PRN abdominal pain
Discharge Medications:
1. Lorazepam 0.5 mg PO BID:PRN anxiety
2. DiphenhydrAMINE ___ mg PO Q6H:PRN itching
3. HYDROmorphone (Dilaudid) (HYDROmorphone) 2 mL ORAL TID:PRN
abdominal pain
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain.
Secondary:
ulcerative colitis:
alcohol use
chronic abdominal pain
panic attacks
depression
anxiety
Discharge Condition:
alert and oriented x 3
NAD
AMBULATORY
Discharge Instructions:
Dear Ms. ___,
you came into the hospital due to worsening of your chronic
abdominal pain. An MRI showed that the fluid in your pelvis was
less than before. An EGD did not show any abnormalities.
You have received IV fluids for hydration and bowel rest. You
have been given pain medications as needed.
You are now ready to go home.
Followup Instructions:
___
|
19987152-DS-14 | 19,987,152 | 26,069,092 | DS | 14 | 2147-10-27 00:00:00 | 2147-10-27 20:22:00 |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / medline brand surgical film (NOT tegederm
brand) / Iodinated Contrast Media - IV Dye / thimerosal /
Neomycin
Attending: ___.
Chief Complaint:
Perineal pain
Major Surgical or Invasive Procedure:
Sclerotherapy ___ and ___
History of Present Illness:
___ yo F with a history of UC diagnosed in ___ s/p total
colectomy w/ diverting ileostomy, J-pouch s/p failure and take
down ___ with recurrent pelvic seromas who presents today
with ongoing perianal and perineal pain associated with JP drain
placed in early ___. The patient's JP drain was placed to
both drain the ceroma, and to infuse sclerotherapy for it on
___ with ___. The drain is supposed to be removed at that
time. Since the drain was placed, the patient has had severe
pelvic pain that prevents her from doing daily activities. She
was eating and drinking until yesterday, when the pain became so
severe that she was too nauseated to eat. The patient has been
followed by pain clinic, most recently on ___. She expresses
frustration with intolerable pain not be controlled with home
narcotics (Oxycontin 20mg PO BID, oxycodone liquid ___ q4-6
hours, ativan 0.5 PRN for anxiety), which she attributes to poor
absorption because of her ileostomy. No change in consistency of
her stool or increased transit of her bowel. No fevers, chills,
dysuria, urgency. Of note, the patient has tried fentanyl
patches for pain before, but is unable to tolerate them due to
hallucinations.
In the ED, initial VS: 99.0 118 126/96 16 99% ra. The patient
was found to be uncomfortable and tearing. Abdominal exam was
benign. Labs were within normal limits. She was evaluated by
surgery and ob/gyn regarding drain removal, but they recommended
keeping it in place until ___ follow-up. The patient was
initially placed on suicide watch because of statement that she
couldn't live like this with the pain. However, she denied
active plan and was not sectioned. She recieved hydromorphone 1
mg IV x 2 with 50 mg IV benadryl for pain and pruritus, in
addition to home lorazepam. She ate a sandwich in the ED, but
became nauseated afterwards (resolved without medication). She
was admitted to medicine for pain control and consultation with
___. VS prior to transfer: 98.3 63 ___ 98% RA.
On the floor, the patient complains of ongoing severe pain. She
is tearful when I address trying a sublingual narcotic pain
solution, as she specifically would like IV pain medication. She
denies fevers, chills. Nausea resolved.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
PMH:
Ulcerative colitis s/p J pouch (reversed), now with end
ileostomy
Chronic abdominal pain
Panic attacks/anxiety
Alcohol use
PSH:
___ total colectomy w/ diverting ileostomy
___ - j-pouch creation
___ - ileostomy takedown
___ - admitted with closed loop obstruction and had small
bowel resection (all surgeries done by Dr. ___ at ___
___)
C-Section x2
R Inguinal Hernia repair at ___ years old.
Social History:
___
Family History:
Mother had IBS.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - T: 98.3 BP: 109/70 HR: 78 RR: 18 02 sat: 99%RA
GENERAL: mildly uncomfortable appearing woman, tearful
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly, ileostomy in RLQ
draining brown stool, JP drain without surrounding erythema with
trace amount of serous fluid in bulb
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
Vitals: 98.0 89/53 80 16 100%
Tmax 98.4 89-110 ___
I/O (24hr): ___ PO, 180 IV /2250 +BRP
General: Awake, alert, calm but intermittently tearful or
agitated.
HEENT: NCAT. No scleral icterus. Face symmetric.
CV: RRR, no m/g/r.
Pulm: Non-labored breathing on room air. CTA bilaterally.
GI: Bowel sounds present. TTP LLQ. No rigidity/guarding.
Pertinent Results:
ADMISSION LABS
___ 01:00PM WBC-7.1 RBC-4.96 HGB-13.8 HCT-43.7 MCV-88
MCH-27.8 MCHC-31.6 RDW-12.5
___ 01:00PM NEUTS-61.7 ___ MONOS-4.1 EOS-3.2
BASOS-0.8
___ 01:00PM PLT COUNT-236
___ 01:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:00PM GLUCOSE-100 UREA N-11 CREAT-0.8 SODIUM-135
POTASSIUM-3.3 CHLORIDE-100 TOTAL CO2-21* ANION GAP-17
___ 02:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 02:56PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:56PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 02:56PM URINE UCG-NEGATIVE
___ 02:56PM URINE HOURS-RANDOM
PERTINENT INTERIM LABS
___ 06:05PM VAGINAL FLUID Hct,Fl-39*
LABS PRIOR TO DISCHARGE
___ 07:00AM BLOOD WBC-4.0 RBC-3.82* Hgb-11.6* Hct-35.0*
MCV-92 MCH-30.3 MCHC-33.1 RDW-13.2 Plt ___
MICROBIOLOGY
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING/STUDIES
Pelvis US ___
Small residual fluid collection in the posterior cul-de-sac
measuring 3.7 x
0.4 cm, with drainage catheter in situ
Pelvis US ___
Increased size of 8.4 cm fluid and debris containing collection
in the cul de
sac. The transgluteal drainage catheter courses within the
collection,
although the position of its tip is difficult to evaluate
sonographically.
Precise localization of the tip position would require
evaluation with CT.
MRI Pelvis w and wo contrast ___
Multiloculated pelvic peritoneal inclusion cyst larger since
___, now has
hyperenhancing walls, likely reflecting changes of recent
intervention and
presence of a drainage catheter.
Pelvis US ___
1. No large intrauterine fluid collection; small amount of
fluid in
endometrial cavity is nonspecific. No hydrosalpinx.
2. No uterine defect is sonographically evident other than the
cesarean
section scar.
3. Interval decrease in size of complex collection posterior to
the uterus.
MRI Pelvis w and wo contrast ___
Marked decrease in size of a peritoneal inclusion cyst since the
___
MRI reflecting reponse from recent sclerotherapy. A 3.9 x 2.1
cm presacral
multi-loculated collection remains, with a portion communicating
with a right
transgluteal drain. A small amount of gas within the collection
has increased
since the prior examination.
Pelvis US ___
1. Small pelvic fluid collection has decreased since ___.
2. Complex fluid in the vaginal canal.
3. Tiny amount of fluid within the endometrium. Otherwise,
normal uterus and
ovaries.
Pelvis US ___
Posterior to the cervix is again identified complex partially
solid and
partially cystic fluid collection which measures approximately
4.3 x 2.1 cm,
largely unchanged since most recent ultrasound dated ___. No new
fluid collection is identified.
The uterus is unremarkable measuring 8.9 x 4.7 x 5.5 cm. The
ovaries are
normal in size with a 1.5 cm anechoic physiologic cyst within
the left ovary
unchanged since prior examination. Complex fluid is present in
the vaginal
canal with an unremarkable cervix.
IMPRESSION:
1. Unchanged complex fluid collection posterior to the cervix,
stable in size
since ___, allowing for differences in imaging
modalities. No new
fluid collection is detected.
2. Normal appearing uterus and ovaries with small physiologic
cyst
redemonstrated within the left ovary.
Brief Hospital Course:
___ F h/o ulcerative colitis s/p total colectomy with
ileostomy, failed J-pouch s/p take-down, recurrent pelvic
peritoneal inclusion cysts s/p JP drain placement in ___ who
presented with intractable buttock/perineal pain due to
multiloculated peritoneal inclusion cyst and transgluteal drain,
now s/p two rounds of sclerotherapy.
ACTIVE ISSUES
# Pain of buttock, perineum and abdomen: Patient initially
presented with a chief complaint of perianal pain, described as
a scraping sensation in the ___ region, which she
attributed to the transgluteal drain in the left buttock. The
drain had been placed in ___ to drain the pelvic peritoneal
inclusion cyst. During the course of hospitalization she also
developed abdominal pain, which was possibly due to the
increased cyst size reflected by pelvis US on ___ and pelvis
MRI ___. There was low suspicion for abscess, cellulitis,
or intra-abdominal/pelvic infection based on physical exam and
lack of fever, tachycardia or leukocytosis. She underwent
sclerotherapy by Interventional Radiology on ___ and ___.
Cyst size appeared decreased on MRI ___ and reduced further on
US ___ repeat pelvis US on ___ was stable in comparison to
those studies, and no new fluid collection was detected.
Transgluteal drain was removed by ___ ___ once drain output had
become minimal. Of note, a multidisciplinary meeting with ___,
Colorectal surgery and Gynecology was held to discuss surgical
management options, and no surgical options were recommended or
offered (please see OMR note dated ___ for further details
about that discussion).
For pain control, pt initially had inadequate symptom relief
with hydromorphone IV boluses, and she largely declined PO meds
due to concern for poor oral absorption s/p colectomy. The Pain
service was consulted to provide recommendations. She was
started on a PCA. She had better pain control with the PCA with
basal rate. A fentanyl patch was initially avoided due to a
past history of hallucinations while on the patch (though this
was possibly in the setting of sepsis). Pt is able to tolerate
fentanyl IV for procedure purposes. A trial of a fentanyl patch
was attempted, but the patch was poorly tolerated due to
agitation. Agitation resolved as soon as patch was removed.
She was returned to the PCA. On ___ pt felt comfortable with
discontinuation of the basal rate, so the basal rate was DCed.
For adjunctive treatment, she was on gabapentin three times a
day. She initially declined standing PO acetaminophen due to
concern about side effects but later agreed to standing IV
acetaminophen. She declined initiation of duloxetine due to
concern about side effects in general and her impression that
pain would resolve after the cyst issue resolved. Initiation of
an NSAID was considered, though she was reluctant about this
option given her history of UC. In informal communication with
GI, it was determined that an NSAID would be safe since she
carries the diagnosis of UC and has had a colectomy. She
received a one-time dose of ketorolac with no obvious
improvement in symptoms. Pelvis ___ and acupuncture were
proposed, and she declined these modalities due to having acute
pain and said she would consider these in the future as
preventative measures, once the problem was under control.
On ___ Ms. ___ expressed a desire to wean off the PCA in
efforts toward getting discharged to home. She was
understandably frustrated with the lack of definitive treatment
options for her problem while hospitalized. On ___ she
requested transfer to a different hospital due to having pain
overnight which she did not think she could tolerate at home,
and so that she could seek management options elsewhere. Her
hospital of choice was contacted and declined the transfer. She
requested repeat imaging of the pelvis and stated that she would
want to be discharged if it was stable in order to explore other
options elsewhere. Pelvis US on ___ was stable in
comparison to imaging on ___ and ___, and no new fluid
collection was detected, as described above. She was amenable
to discharge. She was discharged ___ with prescriptions for
a 10-day supply of Oxycontin 20mg PO q 12 hrs and oxycodone
liquid ___ PO q 4 hrs PRN breakthrough pain, as well as PRN
ibuprofen, standing acetaminophen, gabapentin, ondansetron, and
lansoprazole. She has follow-up appointments scheduled with her
PCP ___ ___ and with Pain Clinic on ___.
# Anxiety: Pt was highly anxious and was treated with lorazepam
0.5mg IV TID PRN anxiety throughout most of hospitalization, and
often required additional doses. She declined using lorazepam
pills under the tongue but has lorazepam elixir at home. The
addition of duloxetine was strongly recommended to help with
anxiety and pain, but she declined duloxetine due to concern
about side effects in general and due to her impression that her
symptoms would improve upon resolution of medical problem. She
was offered consultation with Social Work and she declined.
# Cyst communication through fallopian tube: Peritoneal
inclusion cyst communicates with uterus/vagina through the left
fallopian tube according to ___. Pt was concerned that alcohol
from sclerotherapy was in contact with the uterus and vagina,
and in multidisciplinary meeting it was stated that alcohol
contacting the uterus/vagina after the procedure was not likely
but could not be ruled out. Also, the communication is not a
contraindication to future sclerotherapy if she does not wish to
preserve fertility, and Ms. ___ stated that she does not
wish to preserve fertility. She developed increased vaginal
drainage on ___, with the differential diagnosis being
menstrual flow versus drainage of fluid from pelvis via
fallopian tube. Vaginal fluid was collected and its Hct was 39,
suggestive of blood moreso than blood mixed with pelvic fluid.
Serum Hct was stable, indicating that blood was menstrual rather
than active extravasation. Patient was curious whether
hysteroscopy would be useful to identify the source of drainage
since vaginal drainage would present a major quality of life
problem. Gyn consultants stated hysteroscopy was not a
recommended option. One reason was that hysteroscopy requires
pressurized fluid, which could further distend the peritoneal
inclusion cysts that communicate with the fallopian tube. Tubal
ligation was not recommended.
# Bleeding from JP drain: Pt had temporary drainage of bloody
fluid via transgluteal drain. It could have been due to an
interval increase in cyst size, as seen on MRI. Serum Hct was
stable and bleeding via transgluteal drain ceased.
CHRONIC ISSUES
# Ulcerative colitis: Patient is s/p total colectomy. She had
complaints of rapid transit time and poor absorption of PO
medications. There was no clear explanation as to why she had
poor absorption of PO medications s/p colectomy.
# History of chronic abdominal pain: Management of acute on
chronic pain as described above.
# History of panic attacks/anxiety: Management of anxiety as
described above.
TRANSITIONAL ISSUES
[]Follow up with Pain Clinic on ___. Patient was discharged
with prescriptions for a 10-day supply of pain medications.
[]Follow up with PCP.
[]Obtain repeat MRI pelvis for monitoring of cyst size.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO BID:PRN anxiety
2. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis
3. OxycoDONE Liquid ___ mg PO Q6H:PRN breakthrough pain
4. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
Discharge Medications:
1. DiphenhydrAMINE 25 mg PO Q6H:PRN pruritis
2. Gabapentin 500 mg PO QAM
RX *gabapentin 250 mg/5 mL (5 mL) 10 ml by mouth q AM Disp #*100
Milliliter Refills:*0
3. Gabapentin 500 mg PO NOON
RX *gabapentin 250 mg/5 mL (5 mL) 10 ml by mouth q noon Disp
___ Milliliter Refills:*0
4. Gabapentin 750 mg PO HS
RX *gabapentin 250 mg/5 mL (5 mL) 15 ml by mouth q HS Disp #*150
Milliliter Refills:*0
5. Lorazepam 0.5 mg PO BID:PRN anxiety
6. OxycoDONE Liquid ___ mg PO Q4H:PRN breakthrough pain
RX *oxycodone 5 mg/5 mL ___ ml by mouth q 4 hrs Disp #*1200
Milliliter Refills:*0
7. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone [OxyContin] 20 mg 1 tablet extended release 12
hr(s) by mouth q 12 hrs Disp #*20 Tablet Refills:*0
8. Acetaminophen (Liquid) 1000 mg PO Q8H
RX *acetaminophen 500 mg/5 mL 10 ml by mouth q 8 hrs Disp #*300
Milliliter Refills:*0
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron [ZOFRAN ODT] 4 mg 1 tablet,disintegrating(s) by
mouth q 8 hrs Disp #*30 Tablet Refills:*0
10. Lansoprazole Oral Disintegrating Tab 15 mg PO DAILY
RX *lansoprazole [Prevacid SoluTab] 15 mg 1 tablet,disintegrat,
delay rel(s) by mouth daily Disp #*10 Tablet Refills:*0
11. Ibuprofen Suspension 600 mg PO Q6H:PRN pain
RX *ibuprofen 100 mg/5 mL 30 ml by mouth q 6 hrs Disp #*500
Milliliter Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Peritoneal inclusion cysts
Secondary: Ulcerative colitis s/p colectomy, end-ileostomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
Thank you for allowing us to take part in your care at ___
___. As you know, you came to the
hospital due to severe ___ pain in the setting of a
transgluteal catheter for peritoneal inclusions cysts, which was
not adequately controlled on your home medications. You were
evaluated by Interventional Radiology and had two rounds of
sclerotherapy. The cyst size has decreased on MRI and
ultrasound. You were evaluated by the Pain service, and you
were treated with a PCA and oral medications.
We wish you the very best in the recovery process.
Followup Instructions:
___
|
19987482-DS-5 | 19,987,482 | 25,440,790 | DS | 5 | 2147-12-17 00:00:00 | 2147-12-18 00:10:00 |
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:
prolonged menses, fever
Major Surgical or Invasive Procedure:
none
Physical Exam:
Discharge physical exam
Vitals: stable and within normal limits
Gen: no acute distress; alert and oriented to person, place, and
date
CV: regular rate and rhythm; no murmurs, rubs, or gallops
Resp: no acute respiratory distress, clear to auscultation
bilaterally
Abd: soft, appropriately tender, no rebound/guarding
Ext: no tenderness to palpation
Pertinent Results:
Labs on Admission:
___ 05:45PM BLOOD WBC-13.7* RBC-3.78* Hgb-8.9* Hct-29.8*
MCV-79* MCH-23.5* MCHC-29.9* RDW-15.3 RDWSD-43.8 Plt ___
___ 05:45PM BLOOD Neuts-77.7* Lymphs-15.1* Monos-6.1
Eos-0.2* Baso-0.4 Im ___ AbsNeut-10.61* AbsLymp-2.06
AbsMono-0.83* AbsEos-0.03* AbsBaso-0.05
___ 05:45PM BLOOD Glucose-103* UreaN-10 Creat-0.8 Na-140
K-4.1 Cl-97 HCO3-23 AnGap-20*
___ 05:45PM BLOOD ALT-6 AST-14 AlkPhos-62 TotBili-0.5
___ 05:45PM BLOOD Lipase-16
___ 05:45PM BLOOD Albumin-4.3
___ 05:45PM BLOOD HCG-<5
___ 11:04PM BLOOD Lactate-1.6
___ 10:41PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:41PM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-150* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 10:41PM URINE RBC-<1 WBC-3 Bacteri-FEW* Yeast-NONE
Epi-3
Relevant Labs:
___ 06:48AM BLOOD WBC-15.5* RBC-3.26* Hgb-7.7* Hct-25.7*
MCV-79* MCH-23.6* MCHC-30.0* RDW-15.2 RDWSD-43.7 Plt ___
___ 12:53PM BLOOD WBC-13.4* RBC-3.25* Hgb-7.8* Hct-25.4*
MCV-78* MCH-24.0* MCHC-30.7* RDW-15.3 RDWSD-42.9 Plt ___
___ 08:06PM BLOOD WBC-11.9* RBC-3.44* Hgb-8.2* Hct-27.0*
MCV-79* MCH-23.8* MCHC-30.4* RDW-15.5 RDWSD-43.8 Plt ___
___ 04:54AM BLOOD WBC-10.4* RBC-3.36* Hgb-8.0* Hct-26.4*
MCV-79* MCH-23.8* MCHC-30.3* RDW-15.3 RDWSD-43.7 Plt ___
___ 04:54AM BLOOD Neuts-61.4 ___ Monos-8.5 Eos-1.3
Baso-0.3 Im ___ AbsNeut-6.38* AbsLymp-2.93 AbsMono-0.88*
AbsEos-0.14 AbsBaso-0.03
___ 04:49AM BLOOD WBC-8.5 RBC-2.98* Hgb-7.0* Hct-23.4*
MCV-79* MCH-23.5* MCHC-29.9* RDW-15.2 RDWSD-43.3 Plt ___
___ 04:49AM BLOOD Neuts-57.0 ___ Monos-6.2 Eos-2.2
Baso-0.4 Im ___ AbsNeut-4.85 AbsLymp-2.87 AbsMono-0.53
AbsEos-0.19 AbsBaso-0.03
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service with
prolonged menses and pelvic pain. Transabdominal US showed
didelphys uterus, dilated tubular structure concerning for
hydrosalpinx and possibly blood within the endometrial cavity of
left horn. Patient spiked a fever to a Tmax of 102.9. CXR showed
no evidence of acute processes. WBC was 13.7. U/A was negative.
Flu swab was negative. She was given 1 dose of IV flagyl and
ciprofloxacin. Her fever resolved and further antibiotics were
deferred given no clear etiology of infection. She then had an
MRI pelvis that showed unicornuate uterus with left rudimentary
non-communicating horn containing blood products, pelvic
endometriosus with a large hematosalpinx, and non-visualized
left kidney. On ___, patient underwent diagnostic laparoscopy
under ultrasound guidance. Please see operative report for full
details. Her post-operative course was uncomplicated.
Immediately post-operatively her pain was controlled with PO
acetaminophen and ibuprofen. Her diet was advanced without
difficulty.
By hospital day 3, she was tolerating a regular diet, ambulating
independently, and pain was controlled with oral medications.
She was then discharged home in stable condition with outpatient
follow-up scheduled and prescription for continuous combined
oral contraceptives.
Medications on Admission:
none
Discharge Medications:
1. Apri (desogestrel-ethinyl estradiol) 0.15-0.03 mg oral daily
RX *desogestrel-ethinyl estradiol 0.15 mg-0.03 mg 1 tablet(s) by
mouth daily Disp #*90 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
unicornate uterus with left rudimentary non-communicating horn
containing blood products, left hematosalpinx
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 with prolonged
menses and fever. You were given IV antibiotics to treat a
possible pelvic infection. You had a pelvic ultrasound that
showed your previously diagnosed uterine abnormality. You then
had an MRI that showed that the left side of your uterus was a
separate entity that is closed off and does not connect with the
right side of your uterus or your vagina. Accordingly, there was
blood visualized within the left side of uterus that was found
to be spilling back through your fallopian tube on that side
into your pelvis. We recommended that you start continuous oral
contraceptive pills to prevent further menstrual blood from
collecting in the left side of your uterus. We also recommended
that you have surgery to remove the left side of your uterus.
The team believes you are now ready to be discharged home.
Please call our Ob/Gyn office at ___ with any
questions or concerns. Please follow the instructions below.
Call your doctor for:
* fever > 100.4F
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
Followup Instructions:
___
|
19987702-DS-9 | 19,987,702 | 27,149,559 | DS | 9 | 2131-06-09 00:00:00 | 2131-06-09 17:44:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
ibuprofen / NSAIDS (Non-Steroidal Anti-Inflammatory Drug)
Attending: ___.
Chief Complaint:
Abdominal wall abscess
Major Surgical or Invasive Procedure:
___: Ultrasound-guided drainage of superficial right
abdominal
collection
History of Present Illness:
We have been consulted on this patient known to Dr. ___
who is status post open cholecystectomy for choledocolothiasis
who presents to the ED with dehydration, leukocytosis and
clinical/radiological findings concerning for abdominal wall
abscess
He's a ___ year old very frail male with medical history
pertinent
for multifocal parieto-occipital CVA, carotid stenosis s/p
bilateral CEA, COPD, HTN, HLD, history of a Nissen
fundoplication
and a subsequent takedown, ___ esophagus that progressed
to
esophageal carcinoma.
As above, he is status post open cholecystectomy performed for
choledocholithiasis on ___ with uncomplicated postoperative
course and discharged home on POD#3.
Since discharge he endorses area of swelling, pain and
ecchymosis
at his incision. He was given Rx for Oxycodone post-op, used
these, but still in pain. He presented to PCP to follow on these
symptoms on ___. At that time he was found with area of
ecchymosis and distention at incision site, as well as tender to
palpation. A CT abdomen was performed which demonstrated
postsurgical changes as well as a postoperative seroma along the
right rectus musculature measuring approximately 2.2 cm. He
presents to the ED today with progression of symptoms, more
specifically he feels a "lump" at his incision. Denies any
fever,
nausea, chills, chest pain, shortness of breath, change in bowel
habits, GI bleeding. Of note, he endorses lack of appetite (but
this seems usual after each of the prior operations he has had)
as well as intermittent dysuria.
Upon arrival to the ED, VS: 98.8, 66, 108/66, 16, 97% RA. He is
no in acute distress but oral mucosa is dry. Abdominal exam
notable for area of swelling to subcostal incision with two
ecchymotic areas at the mid portion of the incision. I could not
express any purulent material of the incision. Slight tenderness
to palpation. Otherwise abdomen is soft. Outside hospital labs
remarkable for leukocytosis to 15 and hypokalemia. Liver
function
test unrevealing. Outside hospital CT abdomen performed today
demonstrating a 7cm walled off collection with some fat
stranding
at the right upper quadrant abdominal wall. This collection
seems
not to communicate with the abdominal wall cavity. I could not
appreciate any intraabdominal process.
ROS:
(+) per HPI
(-) Denies pain, fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, bleeding, easy bruising,
headache, dizziness, vertigo, syncope, weakness, paresthesias,
nausea, vomiting, hematemesis, bloating, cramping, melena,
BRBPR,
dysphagia, chest pain, shortness of breath, cough, edema,
urinary
frequency, urgency
Past Medical History:
Per HPI. Multifocal Parieto-occipital CVA (___) - (left
parieto-occipital area most affected, some left MCA involvement)
HTN, HLD, carotid stenosis s/p bilateral CEA
AAA without rupture (2.6 cm), Aortic dissection - not otherwise
specified, Esophageal adenocarcinoma, GERD, ___ Esophagus,
s/p Nissen fundoplication revision, Diverticulitis, Adrenal
Adenoma Asthma, COPD, Former smoker (40-pack yrs, Asbestos
exposure)Pneumonia, recurrent, Chronic pain - pain agreement,
potentially broken ___, Low back pain, Urinary frequency,
Inguinal hernia, ventral hernias, Prior alcohol abuse
Past Surgical History:
Per HPI.
Bilateral carotid endarterectomies
Inguinal and ventral hernia repair x4
Endoscopic mucosal resection of mass at ___ junction ___
___ and revision of ___ Fundoplication
Upper EUS (___)
ERCP and biliary stent placement (___)
Social History:
___
Family History:
Mother - CAD, PVD
Father - Liver ca
Other - Uncles - CVA, ___ cancer
Physical Exam:
Physical Exam on arrival:
Vitals: 98.8, 66, 108/66, 16, 97% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Physical Exam on arrival:
Vitals: Stable
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, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses; upper quadrant
wound packed with wick (healing appropriately)
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
Lab Results:
___ 05:22AM BLOOD WBC-8.1 RBC-3.63* Hgb-10.7* Hct-31.7*
MCV-87 MCH-29.5 MCHC-33.8 RDW-12.0 RDWSD-39.1 Plt ___
___ 06:00AM BLOOD WBC-9.2 RBC-3.68* Hgb-11.0* Hct-32.1*
MCV-87 MCH-29.9 MCHC-34.3 RDW-12.3 RDWSD-39.5 Plt ___
___ 05:42AM BLOOD WBC-9.7 RBC-3.70* Hgb-10.6* Hct-32.9*
MCV-89 MCH-28.6 MCHC-32.2 RDW-12.4 RDWSD-40.2 Plt ___
___ 06:45AM BLOOD WBC-12.0* RBC-3.83* Hgb-10.9* Hct-33.3*
MCV-87 MCH-28.5 MCHC-32.7 RDW-12.5 RDWSD-40.0 Plt ___
___ 08:18AM BLOOD WBC-11.6* RBC-3.65* Hgb-10.8* Hct-32.5*
MCV-89 MCH-29.6 MCHC-33.2 RDW-12.5 RDWSD-40.6 Plt ___
___ 04:35AM BLOOD WBC-14.5* RBC-3.84* Hgb-11.1* Hct-33.4*
MCV-87 MCH-28.9 MCHC-33.2 RDW-12.5 RDWSD-39.7 Plt ___
___ 05:22AM BLOOD Neuts-60.2 ___ Monos-12.5 Eos-5.2
Baso-0.5 Im ___ AbsNeut-4.88 AbsLymp-1.69 AbsMono-1.01*
AbsEos-0.42 AbsBaso-0.04
___ 08:18AM BLOOD Neuts-68.6 Lymphs-17.3* Monos-12.8
Eos-0.2* Baso-0.3 Im ___ AbsNeut-7.98* AbsLymp-2.01
AbsMono-1.49* AbsEos-0.02* AbsBaso-0.04
___ 04:35AM BLOOD Neuts-74.2* Lymphs-11.5* Monos-13.0
Eos-0.0* Baso-0.4 Im ___ AbsNeut-10.76* AbsLymp-1.67
AbsMono-1.88* AbsEos-0.00* AbsBaso-0.06
___ 05:22AM BLOOD Glucose-80 UreaN-6 Creat-1.2 Na-140 K-3.5
Cl-97 HCO3-31 AnGap-12
___ 06:00AM BLOOD Glucose-100 UreaN-5* Creat-1.1 Na-141
K-3.4 Cl-99 HCO3-29 AnGap-13
___ 05:42AM BLOOD Glucose-90 UreaN-9 Creat-1.3* Na-143
K-3.9 Cl-99 HCO3-29 AnGap-15
___ 06:45AM BLOOD Glucose-87 UreaN-6 Creat-0.8 Na-136 K-3.3
Cl-93* HCO3-29 AnGap-14
___ 08:18AM BLOOD Glucose-89 UreaN-14 Creat-0.8 Na-142
K-3.6 Cl-106 HCO3-26 AnGap-10
___ 04:35AM BLOOD Glucose-106* UreaN-17 Creat-0.9 Na-140
K-3.9 Cl-103 HCO3-25 AnGap-12
___ 05:22AM BLOOD Plt ___
___ 05:22AM BLOOD ___ PTT-37.7* ___
___ 09:50PM BLOOD PTT-36.3
___ 01:20PM BLOOD PTT-49.3*
Imaging:
PERC IMAGE GUID FLUID COLLECT DRAIN W CATH (___):
IMPRESSION: Successful US-guided placement of ___ pigtail
catheter into the right abdominal wall collection. Sample was
sent for microbiology evaluation.
Microbiology results from drain:
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): ANAEROBIC GRAM NEGATIVE ROD(S).
SPARSE GROWTH
Brief Hospital Course:
The patient presented to Emergency Department on ___.
Patient was found to have an abdominal wall abscess. For this
reason he was admitted to the ___ Surgery for further
management. On admission the patient's INR was 4.3 and for this
reason it was not possible to have the abscess drained on
presentation. For this reason he was admitted for further
management. His Coumadin was held and he was also given fresh
frozen plasma and vitamin K. The following day the patient went
to ___ and got the fluid drained and a drainage was placed. The
fluid collected from the peritoneal fluid collected it grew
sparse anaerobic gram negative rods (for full results please see
results section of discharge summary). The patient's creatinine
was elevated to 1.3 during the admission and for this reason he
was started on IV normal saline. Following the ___ procedure the
patient was restarted on a heparin drip. The heparin drip was
then stopped and the patient was placed on warfarin with lovenox
bridging. His creatinine function was downtrending. On discharge
his INR was therapeutic and his lovenox was discontinued.
Furthermore in summary during this hospital course review of
systems had as follow:
Neuro: The patient was alert and oriented throughout
hospitalization pain was well controlled with acetaminophen and
oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. He had two
episodes of asymptomatic high blood pressure that responded to
IV hydrazine.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was on a regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
He had two episodes of emesis during the hospital course that
did not require further work up at the time.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none. When the patient's
admission the ___ was 14 that was within normal limits on
discharge. The patient was placed on IV antibiotics (Vancomycin
and zosyn) that was transitioned to oral augmentin on discharge.
The patient needs to complete a two weeks course of augmentin
upon discharge.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none. The patient was bridged
back to Coumadin with lovenox. The INR level was appropriate at
the time of discharge.
Prophylaxis: ___ dyne boots were used during this stay and was
encouraged to get up and ambulate as early as possible.
Social work: During this hospital course the patient expressed
feelings of having difficulty coping. For this reason a social
work consult was obtained and coping strategies and resources
were put in place.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Atorvastatin 80 mg PO QPM
3. Zolpidem Tartrate 10 mg PO QHS
___ MD to order daily dose PO DAILY16
5. TraZODone 50 mg PO QHS:PRN insomnia
6. Sertraline 100 mg PO DAILY
7. Pantoprazole 40 mg PO Q12H
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. Metoprolol Succinate XL 100 mg PO DAILY
10. LORazepam 1 mg PO Q8H:PRN anxiety
11. LevETIRAcetam 1000 mg PO BID
12. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*30 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tab by mouth
twice a day Disp #*17 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Mild
RX *oxycodone 5 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*9 Tablet Refills:*0
RX *oxycodone 5 mg ___ tablet(s) by mouth every 8 hours Disp
#*25 Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
7. Atorvastatin 80 mg PO QPM
8. Enoxaparin Sodium 70 mg SC Q12H
If your INR is between ___ you can stop taking this medication.
RX *enoxaparin 80 mg/0.8 mL 70 mg SC every twelve (12) hours
Disp #*10 Syringe Refills:*0
9. LevETIRAcetam 1000 mg PO BID
10. LORazepam 1 mg PO Q8H:PRN anxiety
11. Metoprolol Succinate XL 100 mg PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. Pantoprazole 40 mg PO Q12H
14. Sertraline 100 mg PO DAILY
15. TraZODone 50 mg PO QHS:PRN insomnia
16. ___ MD to order daily dose PO DAILY16
17. Zolpidem Tartrate 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal wall abscess
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 ___ Surgery because you were
found to have an abdominal wall abscess. You were placed on
antibiotics and your anticoagulation was reversed. Then you had
the abdominal wall abscess drained and have recovered well. You
are now ready for discharge.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Coumadin: Please follow up with your PCP ___ ___ for an INR
check and instructions on dosing your warfarin.
Antibiotics: Please complete the full 9 day course(finish all
the pills)that you were prescribed at discharge.
Incision Care:
Your dressing was changed on the day of discharge. Please
continue to change it daily with clean dry gauze until it heals
or scabs over. Then you should keep it covered only as needed.
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
It has been a pleasure looking after you and we wish you a
speedy recovery.
___ Surgery
Followup Instructions:
___
|
19988077-DS-7 | 19,988,077 | 28,414,691 | DS | 7 | 2140-05-22 00:00:00 | 2140-05-23 09:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___.
Chief Complaint:
Dysphagia and odynophagia
Major Surgical or Invasive Procedure:
Direct laryngoscopy with biopsy, tracheostomy, PEG placement
___
History of Present Illness:
___ yo male with laryngeal cancer s/p xrt and cirrhosis who
presented with a 3 month history of dysphagia and odynophagia.
He first noticed coughing with liquids, but his dysphagia
progressed to complete intolerance of liquids. When drinking
even small quantities, he developed severe coughing. He noted
that he feels like he's "drowning". He has been able to tolerate
solid foods, but experience had developed a very sore throat. He
could only take liquids in very small amounts (ice and
popsicles) and so he also has been producing lots of thick
phlegm due to little hydration. His only other symptoms has been
an associated 15 lbs weight loss over the last 3 months. He
denied shortness of breath, nausea, vomiting, and abdominal
pain.
He had a barium study at ___ on ___ which showed
deep laryngeal penetration, esophageal dysmotility, and hiatal
hernia. He went to ___ ___ for an EGD and ? esophageal
dilitation. OSH records noted no esophageal stricture, distal
esophageal varices, and portal gastropathy. The records also
indicated a pre-operative diagnosis of posterior pharyngeal
tumor with dysphagia. He was then transferred to ___. Labs
from OSH were WBC 7.5, Hb 10.1, Hct 28.5, Plt 87, Na 140, K 4.3,
Cl 108, CO3 26, BUN 13, Cr 0.8, T Bili 2.2, AST/ALT 35/24, Alk
Phos 99, Alb 3.0. He also had a normal non-contrast head CT.
On arrival to ___, VSS and labs were notable for anemia,
thrombocytopenia, and elevated INR to 1.5. On further interview,
he revealed that he was lost to follow-up for chemotherapy after
he was diagnosed with and treated for vocal cord carcinoma by
ENT surgery and XRT in ___.
Past Medical History:
- vocal cord carcinoma, s/p ENT surgery and XRT in ___,
resolved as far as patient knows
- Distal esophageal stricture
- Abdominal abscess ___
- diverticulitis
- cirrhosis
- ETOH abuse
- anxiety
- OSA
- COPD
Social History:
___
Family History:
Prostate cancer in father. No hx of liver disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals - T: 98.1 BP: 132/80 HR: 82 RR: 20 02 sat: 97% RA
GENERAL: NAD, raspy voice, AAOx3, not jaundiced
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, 5mm
wound at LLQ draining minimal bloody discharge, no erythema,
warmth or purulence. Dilated veins apparent in midepigastrium
may represent mild caput madusae. No spider angiomata.
EXTREMITIES: moving all extremities well, no edema
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.5 107/56 72 18 97% on 40% blow by
General: NAD, sitting comfortably in bed
HEENT: MMM, EOMI
Neck: Trach in place, clean, no bleeding
CV: RRR, no m/r/g.
Lungs: CTAB, normal work of breathing.
Abdomen: Soft, nondistended, tender around G tube site. No
rebound tenderness, no guarding. G tube in place, dressing clean
and dry, left sided ecchymosis, enterocutaneous fistula in left
lower abd with colostomy bag (empty now).
Ext: Warm and well perfused, 2+ distal pulses, no peripheral
edema
Neuro: AAOx3, able to communicate by whispering words but exam
limited by trach. No asterixis.
Pertinent Results:
ADMISSION LABS
==============
___ 08:50PM BLOOD WBC-7.9 RBC-3.13* Hgb-10.2* Hct-31.3*
MCV-100* MCH-32.4* MCHC-32.4 RDW-14.7 Plt Ct-78*
___ 08:50PM BLOOD Neuts-77.9* Lymphs-11.8* Monos-6.6
Eos-3.3 Baso-0.3
___ 08:50PM BLOOD ___ PTT-39.7* ___
___ 08:50PM BLOOD Glucose-92 UreaN-14 Creat-0.8 Na-140
K-4.5 Cl-110* HCO3-24 AnGap-11
___ 08:50PM BLOOD ALT-27 AST-38 AlkPhos-105 TotBili-2.6*
___ 08:50PM BLOOD ALT-27 AST-38 AlkPhos-105 TotBili-2.6*
___ 08:50PM BLOOD Lipase-18
___ 08:50PM BLOOD Albumin-3.2* Calcium-8.7 Phos-3.1 Mg-1.6
============
NOTABLE LABS
============
___ 11:54AM URINE Color-Yellow Appear-Clear Sp ___
___ 11:54AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-4* pH-6.0 Leuks-NEG
___ 11:54AM URINE RBC-2 WBC-3 Bacteri-NONE Yeast-NONE Epi-2
___ 11:54AM URINE Mucous-RARE
==============
DISCHARGE LABS
==============
___ 05:48AM BLOOD WBC-5.0 RBC-2.29* Hgb-7.8* Hct-23.5*
MCV-103* MCH-34.2* MCHC-33.3 RDW-17.2* Plt Ct-93*
___ 05:48AM BLOOD Plt Ct-93*
___ 05:48AM BLOOD Glucose-109* UreaN-12 Creat-0.8 Na-136
K-3.8 Cl-100 HCO3-31 AnGap-9
___ 05:48AM BLOOD ALT-34 AST-30 AlkPhos-93 TotBili-1.3
___ 05:48AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.2
=====
MICRO
=====
BCX ___: ESCHERICHIA COLI. FINAL SENSITIVITIES.
ESCHERICHIA COLI. ___ MORPHOLOGY. FINAL SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| ESCHERICHIA COLI
| |
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- =>32 R =>32 R
CEFAZOLIN------------- =>64 R =>64 R
CEFEPIME-------------- 2 S 2 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- =>64 R =>64 R
CIPROFLOXACIN---------<=0.25 S =>4 R
GENTAMICIN------------ =>16 R =>16 R
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ 8 I <=1 S
TRIMETHOPRIM/SULFA---- <=1 S =>16 R
BCX ___: ESCHERICHIA COLI.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
ESCHERICHIA COLI. ___ MORPHOLOGY.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
CLOSTRIDIUM PERFRINGENS.
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0040.
GRAM NEGATIVE ROD(S).
GRAM POSITIVE ROD(S).
Peritoneal fluid ___: GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
=======
IMAGING
=======
CXR ___:
Heart size is normal. Mediastinum is normal. There is no
evidence of
pneumomediastinum or pneumothorax within the limitations of the
study
technique. Bibasal opacities are present and unclear if
represent atelectasis or aspiration. Some contribution to this
appearance is done by the low lung volumes, although they cannot
explain the entire extent of bibasal opacifications. There is
no appreciable pleural effusion noted.
CT Neck with contrast ___:
Supraglottic glottic and subglottic circumferential mass
consistent with known laryngeal cancer.
CT Chest with contrast ___:
Multifocal peribronchial, centrilobular and ___
opacities
in the right middle lobe, lingula and larger consolidation in
the left lower lobe are multifocal pneumonia, could be due to
aspiration. Followup is recommended. Other more focal irregular
soft tissue nodules described are of unclear etiology, could be
infectious, but metastases cannot be excluded. Coronary
calcification. Enlarged main pulmonary artery suggests pulmonary
hypertension. Findings in the abdomen in keeping with patient
known cirrhosis.
Video oropharyngeal swallow ___:
There was aspiration with liquids, nectar thick liquids, and
honey thick
liquids. Penetration with puree was demonstrated.
Abdominal U/S ___:
1. Nodular, heterogeneous echotexture liver that is consistent
with known
cirrhosis. No concerning liver lesions identified.
2. Trace ascites.
3. Stable splenomegaly.
4. Gallbladder sludge and/or gravel without evidence of
cholecystitis.
Brief Hospital Course:
___ yo male with laryngeal cancer s/p xrt and cirrhosis who
underwent attempted esophageal dilation at OSH for 3 month
history of dysphagia and odynophagia, with laryngeal SCC.
============
ICU COURSE
============
The pt was admitted directly to the ICU from the general
internal medicine floor. The pt presented from dysphagia and
odynophagia and a CT of the neck revealed a supraglottic,
glottic and subglottic circumferential mass concerning for
laryngeal cancer. On the evening of the ___, the pt developed
respiratory distress characterized by inspiratory stridor. He
was given racemic epinephrine and 10mg IV Dexamethasone with
improvement in his respiratory status and inspiratory stridor.
He spent 2 night in the MICU for intensive respiratory
monitoring. A surgical airway kit was placed by the bedside in
the event of acute respiratory compromise requiring emergent
surgical airway management. The patient was stable throughout
his entire admission and did not require any additional
therapies to manage his airway. He was transferred back to the
ENT team for further management.
============
ACUTE ISSUES
============
# Laryngeal SCC: The patient has a history of laryngeal cancer,
s/p ENT surgery (Dr. ___ in ___ and xrt in ___
with loss to follow-up for chemotherapy. As the patient
presented with dysphagia/odynophagia, CT neck revealed a
supraglottic, glottic, and subglottic circumferential mass
consistent with laryngeal cancer. A CT chest showed multifocal
peribronchial, centrilobular and ___ opacities c/w
aspiration pna as well as more focal irregular soft tissue
nodules that could not be ruled out as metastases. ENT was
consulted, performed bedside laryngoscopy that noted a mass on
the vocal cords. The patient was on Decadron ___ to reduce
swelling and was placed on telemetry for continuous O2
monitoring. Speech and swallow was consulted to obtain a
baseline video swallowing study, which showed aspiration with
all liquids and laryngeal penetration with puree. Nutrition and
general surgery were also consulted for the patient's
nutritional status. The patient was started on PPN and the
patient agreed to placement of a PEG by general surgery for more
long-term nutritional needs. Oncology was consulted on ___ and
recommended PET scan to clarify the extent of disease.
Palliative care was consulted on ___ for assistance with
symptom management as well as advanced care planning. On the
evening of ___, the patient developed significant stridor and
respiratory distress. He was given 10mg IV Dexamethasone and
Racemic epinephrine with subsequent improvement in his stridor
and respiratory status. He was monitored in the ICU where his
course was uneventful and he did not require emergent
intubation. He underwent biopsy and tracheostomy by ENT as well
as PEG placement by general surgery on ___. He was monitored in
the ICU for 24 hours post-op and transferred to the floor. The
biopsy showed ___ and subsequent PET scan showed no evidence of
metastasis. The patient was also seen by a social worker for
___, as he is the sole caretaker of his father.
# LLQ Fistula: Patient describes fistula after an abdominal
abscess in ___. Since that time it has been draining
serosanguinous fluid, requiring ___ dressing changes per day.
Surgery was consulted, but determined that there was no
operative action necessary. The medical team obtained outside
records from ___ in ___, which showed
that the fistula is from a ruptured diverticulum and tracts to
the colon. Surgery did not feel that additional imaging of the
fistula was needed prior to placement of PEG tube for nutrition,
as there is previous documentation of the fistula in OSH
records. The fistula leaked some clotted blood throughout the
hospitalization and wound care nurse saw patient and placed
colostomy bag over fistula. The patient stated that he would
continue to see his outpatient surgeon regarding the wound.
==============
CHRONIC ISSUES
==============
# Cirrhosis: The patient has a history of cirrhosis, presumably
from ETOH. His MELD was 15, with normal GFR, no hyponatremia,
INR 1.5, PLT 78, TBili 2.6. The patient was not encephalopathic.
The patient denied a history of varices, ascites, or
paracentesis, but had mild caput medusae on exam. An abdominal
ultrasound ___ showed a nodular, heterogeneous echotexture
liver consistent with cirrhosis and concerning liver lesions,
trace ascites, and stable splenomegaly. There was concern about
PEG placement in the setting of trace ascites so transplant
surgery was consulted on ___, who did not believe there was any
contraindication to PEG placement since the patient was not
decompensated. The patient was continued on lasix,
spironolactone, lactulose, and rifaximin while inpatient and
these medications were continued at discharge. His lasix was
increased to 40 mg PO daily.
# Anemia: On admission, the patient had macrocytic anemia,
likely due to alcoholic liver disease. He demonstrated no signs
or symptoms of active bleeding. He was typed and screened, and
cross-matched 2 units of blood for his surgery. His anemia was
stable during his hospitalization.
# Thrombocytopenia: On admission, the patient had
thrombocytopenia with platelets of 78. However, this is likely
due to alcoholic liver disease and perhaps some small
serosanguinous fluid draining from the LLQ wound. His platelet
count remained stable and uptrended a bit during his
hospitalization.
===================
TRANSITIONAL ISSUES
===================
# pt should follow-up with ENT
# The pt's LLQ fistula was evaluated by surgery at ___ and no
operative management was necessary. Pt should continue to see
his outpatient surgeon.
# Patient should continue IV zosyn from ___
# Code: Full
# Emergency Contact: ___ (girlfriend/HCP)
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Ipratropium Bromide MDI 2 PUFF IH TID
2. Spironolactone 50 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Rifaximin 550 mg PO BID
5. Potassium Chloride 10 mEq PO DAILY
6. Aspirin 81 mg PO DAILY
7. Lactulose 30 mL PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Rifaximin 550 mg PO BID
4. Spironolactone 50 mg PO DAILY
5. Acetaminophen (Liquid) 650 mg PO Q6H pain or fever
6. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
7. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
8. HYDROmorphone (Dilaudid) 0.25-0.5 mg IV Q2H:PRN pain
RX *hydromorphone 0.5 mg/0.5 mL 0.25-0.5 mg IV Q2H Disp #*36
Syringe Refills:*0
9. Ipratropium Bromide Neb 1 NEB IH TID
10. Piperacillin-Tazobactam 4.5 g IV Q8H
Last day of antibiotics to complete on ___
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8)
hours Disp #*21 Vial Refills:*0
11. Senna 8.6 mg PO BID:PRN Constipation
12. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
13. Lactulose 30 mL PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
1. Laryngeal cancer
2. Left lower quadrant abdominal fistula
SECONDARY DIAGNOSES
===================
1. Cirrhosis
2. Anemia
3. Thrombocytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were recently admitted for difficulty and pain when
swallowing liquids and solids. A CT scan and biopsy showed that
you had recurrence of laryngeal cancer. A tracheostomy was
placed to ensure you would be able to breathe and a PEG tube was
placed so that you can have adequate nutrition as you receive
further treatment for the cancer. It is very important that you
follow up with your ENT physician and oncologist, and we will
help to arrange this for you.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19988632-DS-4 | 19,988,632 | 21,153,934 | DS | 4 | 2182-05-27 00:00:00 | 2182-05-27 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
___ to R hand
Major Surgical or Invasive Procedure:
I&D x2
Bone graft to thumb MC and ring MC from iliac crest
History of Present Illness:
CC: ___ to right hand
HPI:
Mr. ___ is a ___ year old RHD man with PMH of smoking and heavy
EtOH use who presents with ___ to right hand. At baseline the
patient smokes 1PPD and drinks 1 liter of hard EtOH per day and
is currently unemployed. The patient was drinking EtOH overnight
when he was shot in the hand just a few feet away at
approximately 1:30am the morning of presentation. He initially
presented to an OSH who transferred him to ___ for evaluation
and treatment. He notes pain of his hand and swelling and
decreased sensation of his third webspace. He has two wounds,
one
at the site of his right dorsal radial thumb, and the other
between his ___ and ___ distal metacarpals on the dorsal aspect
of his hand. He does not recall his last tetanus shot. He last
ate around 6pm the prior evening and last drank EtOH at
approximately the time of the gun shot at 1:30am.
ROS:
(+) per HPI
(-) Denies fevers, chills, headache, dizziness, nausea,
vomiting,
chest pain, shortness of breath
Past Medical History:
___ to left thigh
Past Surgical History:
L thigh surgery for ___
Medications:
None
Allergies: NKDA
Social History:
Drinks 1 bottle hard liquor daily (tequila). Smokes 1PPD ___
years). Smokes occasional marijuana. Denies other illicit drugs
and IVDU. Not currently employed. Lives with sister.
Physical ___: T: 98.6, HR 69, BP 103/58, RR 16, SpO2 100% RA
GEN: A&O, NAD
HEENT: mucus membranes moist
CV: RRR
PULM: Breathing comfortably on room air
Ext: ___ on right hand dorsal radial base of thumb and ___ right
hand dorsal between ring and little finger distal metacarpals.
Doppler signal intact all digital arteries and palmar arch.
Radial pulse 2+ palpable. Decreased sensation ulnar aspect
middle
finger and radial aspect of ring finger. Motor and tendon exam
limited due to pain. Deficiency in right middle and index finger
extension from MCP, but exam difficult due to limitation of
pain.
Some extension and flexion of right thumb IP joint however
limited due to pain. Able to extend and flex wrist but limited
due to pain. Right hand with volar and dorsal swelling but
forearm and hand compartments currently soft.
Laboratory: pending
Imaging:
R hand x-ray: Severely comminuted and intraarticular fracture
right base of thumb metacarpal. Comminuted extraarticular
fractures of distal ___ and ___ metacarpals.
Assessment/Plan:
Mr. ___ is a ___ year old RHD man with PMH of smoking and heavy
EtOH use who presents with ___ to right hand. He is vascularly
intact without current signs of compartment syndrome. He has
extremely comminuted right proximal thumb metacarpal
intraarticular fractures and right distal ring and little finger
distal metacarpal extraarticular fractures, right ulnar middle
finger and radial ring finger decreased sensation suggesting
nerve injury, and inability to extend right middle and ring
fingers suggestive of possible tendon injury, although exam
limited due to pain. Plan for tetanus shot, IV antibiotics, and
likely OR today for right hand I+D, ORIF of right thumb, ring,
and little finger fractures, possible neurovascular repair,
possible tendon repair, and possible ex fix. Given history of
heavy EtOH use, will need to be monitored closely for withdrawal
signs and symptoms.
Past Medical History:
Asthma
Social History:
___
Family History:
Noncontributory
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended. ICBG site c/d/i.
RUE:
Incision clean/dry/intact with no erythema or discharge, minimal
ecchymosis.
Splint in place, clean, dry, and intact
Pertinent Results:
___ 06:15AM GLUCOSE-127* UREA N-17 CREAT-1.0 SODIUM-140
POTASSIUM-4.0 CHLORIDE-102 TOTAL CO2-21* ANION GAP-21*
___ 06:15AM estGFR-Using this
___ 06:15AM WBC-13.7* RBC-4.50* HGB-14.8 HCT-41.5 MCV-92
MCH-32.9* MCHC-35.7 RDW-12.2 RDWSD-41.1
___ 06:15AM NEUTS-85.9* LYMPHS-7.2* MONOS-6.2 EOS-0.0*
BASOS-0.2 IM ___ AbsNeut-11.73* AbsLymp-0.98* AbsMono-0.84*
AbsEos-0.00* AbsBaso-0.03
___ 06:15AM PLT COUNT-240
___ 06:15AM ___ PTT-27.6 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a gunshot wound to the right hand and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on for I&D x2 and bone graft to thumb MC and ring
MC from iliac crest, 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. He will be discharged on oral antibiotics for 7
days. The patient's home medications were continued throughout
this hospitalization. The patient worked with ___ who determined
that discharge to home was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NWB in the RUE, and will be discharged on Keflex for antibiotics
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:
N/a
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*28 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*30 Capsule Refills:*0
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q3H PRN Disp #*72
Tablet Refills:*0
5. Acetaminophen 1000 mg PO Q8H
Discharge Disposition:
Home
Discharge Diagnosis:
___ to R hand.
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:
- NWB RLE
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.
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
FOLLOW UP:
Please follow up with your surgeon Dr. ___ in 2 weeks. Please
call ___ to make an appointment.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for and any new
medications/refills.
Followup Instructions:
___
|
19988669-DS-9 | 19,988,669 | 28,672,431 | DS | 9 | 2156-07-29 00:00:00 | 2156-08-03 10:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Motrin
Attending: ___.
Chief Complaint:
bicycle accident
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male who complains of a bicycle
accident. The patient is transferred from OSH where he was an
intoxicated bicyclist struck by motor vehicle. Unknown speed,
whether helmeted, or whether LOC. he was reportedly
riding erratically prior to the event. He had pan-CT scan at OSH
which showed multiple facial fractures as well as a R PTX, chest
tube placed at the OSH. Patient was combative and received a
total of 6mg morphine and 3 mg ativan.
Past Medical History:
HIV - not on therapy. States he has been "fine" He has had HIV
since age ___
HCV
Social History:
___
Family History:
NC
Physical Exam:
Admission PHYSICAL EXAMINATION: ___
Constitutional: Altered, GCS 13
HEENT: Pupils equal, round and reactive to light,
Extraocular muscles intact grossly though patient poorly
compliant with exam. L sided periorbital ecchymosis.
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Psych: Normal mood
Discharge PE: ___
General: NAD
Lungs: LSCTAB, diminished at the bases
CV: RRR, no mumurs, rubs or gallops
Abd: Soft, nontender non distended
Extrm: warm well perfused, L knee abrasion without edema, full
ROM
Neuro: Alert and oriented X3, MAE to command, PERRL
Pertinent Results:
___ 08:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-POS amphetmn-NEG mthdone-NEG
___ 08:00AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:00AM URINE RBC-0 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 06:24AM GLUCOSE-103 LACTATE-1.5 NA+-142 K+-4.2
CL--101 TCO2-26
___ 06:15AM UREA N-9 CREAT-0.7
___ 06:15AM ASA-NEG ETHANOL-64* ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:15AM WBC-9.5 RBC-5.24 HGB-14.9 HCT-46.7 MCV-89
MCH-28.5 MCHC-31.9 RDW-13.9
___ 06:15AM PLT COUNT-226
___ 06:15AM ___ PTT-31.6 ___
___ 07:05AM BLOOD WBC-7.8 RBC-5.39 Hgb-15.0 Hct-47.8 MCV-89
MCH-27.9 MCHC-31.4 RDW-13.8 Plt ___
___ 07:05AM BLOOD ___ PTT-33.3 ___
___: CXR: 1. Chest tube in appropriate position with small
right-sided pneumothorax.
2. Increased opacities at the mid right lung is likely secondary
to
aspiration. Continued close interval follow up is recommended.
___: TIB/FIB XRAY: 1. Linear density along the posterior
margin of the tibia may be secondary to an old trauma. No
definite acute fracture is identified.
2. Irregularity along the lateral cortex of the distal tibia is
incompletely evaluated on this exam, however also likely
secondary to an old trauma
___: CXR: (CT to water seal) Stable small right pneumothorax
Increased bibasilar opacities could be due to atelectasis and or
aspiration
Brief Hospital Course:
Mr. ___ is a ___ year old man with a past medical history
significant for HIV, HCV, and polysubstance abuse who was
admitted to ___ from an OSH after he was hit by a car while
riding his bike intoxicated. At the ___ hospital he was found to
have a right pneumothorax for which a chest tube was placed,
facial fractures and he was transferred to ___. His injuries
include right sided tension pneumothorax, left lateral orbital
wall fracture, left zygomatic fracture, nasal bone fractures,
and a left maxillary sinus fracture. He was evaluated by
plastic surgery and it was decided that operative management was
would not be preformed on this admission. Opthalmology
evaluated patient and deemed no intervention needed. Tertiary
survey was negative for further injury.
He was admitted to the general care floor and remained
hemodynamically stable. He was placed on a CIWA scale for
alcohol withdrawal. He was placed on a soft diet and sinus
precautions. On ___, the right chest tube was placed to water
seal; subsequent Chest X-Ray revealed increased pneumothorax.
Thus, it was placed back to suction for 24 hours. Chest X-Ray on
___, showed small right pneumothorax and it placed back water
seal. On ___, the Chest X-Ray was stable and his Chest tube was
discontinued. A post pull film was stable small apical
pneumothorax.
He was discharged on ___ hemodynamically stable without an
oxygen requirement. His pain was well controlled with oral
Dilaudid. He was ambulating independently. He remained afebrile
with a normal WBC. He was evaluated by social work and given an
appointment for substance abuse follow up. Occupational Therapy
saw patient for cognitive evaluation and concussive symptom
education. He will see Plastic surgery and the ___ clinic as
listed below. The patient was educated on discharge instructions
and stated good understanding of the discharge care plan. ___
will evaluate him for medication review and home safety.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
Do not exceed 3 grams per day.
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Do not drive or drink alcohol while on this medication.
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*40 Tablet Refills:*0
3. Ibuprofen 400 mg PO Q8H
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
polytrauma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___ after a bike accident resulting in
facial fractures and a pneumothorax requiring a chest tube. Your
chest tube was removed and you are now ready to recover at home.
You will follow up with the plastic surgery clinic and the
general surgery clinic as listed below.
Please continue a soft diet until you see plastic surgery on
___. Please maintian sinus precautions as listed below.
1. Take the prescribed medications as directed.
2. Do not forcefully spit for several days.
3. Do not smoke for several days.
4. Do not use straws for several days.
5. Do not forcefully blow your nose for at least 2 weeks, even
though your sinus may feel stuffy or there may be some nasal
drainage.
6. Try not to sneeze; it will cause undesired sinus pressure. If
you must sneeze, keep your mouth open.
7. Eat only soft foods for several days, always trying to chew
on the opposite side of your mouth.
8. Do not rinse vigorously for several days. GENTLE salt water
swishes may be used. Slight bleeding from the nose is not
uncommon for several days after the surgery. Please keep our
office advised of any changes in your condition, especially if
drainage or pain increases. It is important that you keep all
future appointments until this condition has resolved.
Please come back to the emergency room with :
A fever of 101.5 or greater, chils
Nausea or vomitting
chest pain or shortness of breath
Dizziness or changes in vision
or any other concerning symptoms.
You are given narcotic pain medication to treat your pain. You
may also take Tylenol and Ibuprofen. Do not drive or drink
alcohol while on this medication. It may cause constipation so
continue to take a stool softener unless you start having loose
stool.
Followup Instructions:
___
|
19988951-DS-12 | 19,988,951 | 28,202,516 | DS | 12 | 2168-06-09 00:00:00 | 2168-06-09 22:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Epinephrine / Novocain
Attending: ___.
Major Surgical or Invasive Procedure:
Percutaneous coronary intervention with drug-eluting stent
placement
attach
Pertinent Results:
ADMISSION LABS:
==============
___ 10:27AM BLOOD WBC-6.6 RBC-3.89* Hgb-12.5* Hct-37.1*
MCV-95 MCH-32.1* MCHC-33.7 RDW-12.4 RDWSD-42.9 Plt ___
___ 10:27AM BLOOD ___ PTT-29.3 ___
___ 10:27AM BLOOD Glucose-381* UreaN-20 Creat-1.2 Na-129*
K-5.2 Cl-92* HCO3-23 AnGap-14
___ 10:27AM BLOOD cTropnT-<0.01
___ 01:55PM BLOOD cTropnT-<0.01
___ 07:40PM BLOOD cTropnT-<0.01
___ 10:27AM BLOOD Calcium-9.2 Phos-3.1 Mg-1.8
___ 10:57AM BLOOD pO2-60* pCO2-37 pH-7.43 calTCO2-25 Base
XS-0 Comment-GREEN TOP
___ 11:04AM BLOOD ___ pO2-76* pCO2-40 pH-7.40
calTCO2-26 Base XS-0
DISCHARGE LABS:
==============
___ 08:56AM BLOOD WBC-6.8 RBC-4.29* Hgb-13.8 Hct-40.8
MCV-95 MCH-32.2* MCHC-33.8 RDW-12.7 RDWSD-43.8 Plt ___
___ 08:56AM BLOOD Glucose-255* UreaN-17 Creat-1.0 Na-135
K-4.9 Cl-100 HCO3-21* AnGap-14
___ 08:56AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.0
IMAGING:
========
TTE - ___
The left atrial volume index is normal. The right atrial
pressure could not be estimated. There is normal left
ventricular wall thickness with a normal cavity size. There is a
small to moderate area of regional left ventricular systolic
dysfunction with hypo to akinesis of the basal inferior and
basal inferolateral walls, mid to apical anterior wall and
interventricualr septum (see schematic). The visually estimated
left ventricular ejection fraction is 35-40%. There is no
resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with uninterpretable free wall motion
assessment. The aortic sinus diameter is normal for gender with
a normal ascending aorta diameter for gender. There is a normal
descending aorta diameter. The aortic valve leaflets (?#) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve is not well seen. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. IMPRESSION: Suboptimal image quality. Mild to moderate
regional dysfunction c/w multiveselCAD/infarction. Cannot assess
right ventricular function due to poor image quality. No overt
valvular abnormalities. Compared with the prior TTE (images not
available for review) of ___, the findings are new.
CARDIAC CATHETERIZATION - ___
Coronary Description
LM:
The left main coronary artery is with eccentric 30% distal.
Circ:
The circumflex coronary artery is with widely patent stent and
90% hazy stenosis distal prior to bifurcation. L-L and L-R
collaterals are present.
RCA:
The right coronary artery is with multiple prior stents and mid
occlusion. A moderate branching AM is now with origin occlusion
and fills slowly via R-R collaterals.
LIMA-LAD:
A left internal mammary artery to the LAD is widely patent.
There is retrograde filling of a diagonal branch. L-L and L-R
collaterals are present.
SVGs:
Known occluded and not engaged.
RI:
The ramus intermedius is small caliber with diffuse 70-80%
proximal.
Complications:
There were no clinically significant complications.
Findings:
Three vessel coronary artery disease.
Successful PCI with drug-eluting stent of the circumflex
coronary artery.
Recommendations
ASA 81mg per day.
Plavix 75mg/day
Secondary prevention of CAD
Maximize medical therapy
Brief Hospital Course:
Mr. ___ is a ___ year old man with PMH of CAD s/p 4v CABG as
well as numerous PCIs, HTN, HLD, T1DM on insulin pump, who
presented with recurrent MI equivalent pain of jaw/L arm pain
with EKG negative for ischemia and troponins negative x2, most
concerning for unstable angina. The patient was admitted with
initial plan for nuclear stress test. Following admission the
patient had significant chest pain not relieved with sublingual
nitro, with no troponin elevation or EKG changes. He was started
on a nitro gtt and underwent PCI with coronary angiography, with
placement of one DES for 90% hazy stenosis distal prior to
bifurcation in the circumflex artery. The patient remained free
from chest pain following PCI and was discharged home in stable
condition with continuation of dual-antiplatelet therapy.
#CORONARIES: CABG ___ with LIMA to LAD, SVG to OM, Diagonal,
PDA
(___). Multiple PCI's on SVG's, the last in ___ PTCA to
ramus, PCI of mid LCX ___.
#PUMP: LVEF 45-50% (echo from ___
#RHYTHM: NSR
#CODE: Full Code (Presumed)
#CONTACT: No healthcare proxy selected
TRANSITIONAL ISSUES:
====================
[] Discharge weight: 182.98 lb (83 kg)
[] Discharge creatinine: 1.0
[] Discharge Hgb/Hct: 13.8/40.8
[] Please check Chem-7 at discharge to monitor electrolytes on
lisinopril
[] Consider increasing dose of lisinopril from 5mg to 10mg daily
[] Continue dual-antiplatelet therapy with ASA 81mg and Plavix
75mg daily indefinitely for coronary artery disease
[] Consider increasing atorvastatin from 40mg to 80mg daily if
patient tolerates.
[] Recommend repeating TTE within 5-weeks of discharge to
evaluate LVEF and regional wall motion abnormalities. Pre-cath
TTE revealed suboptimal image quality, mild to moderate regional
dysfunction c/w multiveselCAD/infarction and no overt valvular
abnormalities, with LVEF 35-40% (reduced from prior 45-50% in
___.
#ACTIVE ISSUES:
===============
# Unstable Angina
The patient presented with intermittent return of MI equivalent
pain represented as jaw/L arm pain at rest. Symptoms started
several weeks prior to admission and recurred, most recently
experiencing these symptoms a few days prior to admission, while
at rest. He had been using SL nitro with relief of his symptoms
as well as restarted Imdur per the advice of his RN sister. He
was free from chest pain upon arrival. EKG re-demonstrated LBBB.
Troponins were negative x2. His presentation is concerning for
UA. After discussion with patient, decision was originally to go
for cardiac nuclear stress test. However due to several episodes
of chest pain overnight ___ requiring nitro gtt, the patient
underwent PCI for unstable angina on ___. Pre-cath TTE
revealed suboptimal image quality, mild to moderate regional
dysfunction c/w multivesel CAD/infarction and no overt valvular
abnormalities, with LVEF 35-40%. Coronary angiography revealed
3-vessel CAD with 90% hazy stenosis distal prior to bifurcation
in the circumflex artery, for which 1 DES was placed without
complications.
- Continued optimal medical management for CAD with aspirin,
clopidogrel, atorvastatin, lisinopril and metoprolol succinate
#HTN
Continued home Lisinopril 5mg daily and home metoprolol
succinate 100mg daily.
- Consider increasing lisinopril from 5mg to 10mg daily if
tolerated.
#CHRONIC ISSUES:
================
#T1DM on insulin pump:
___ Diabetes was consulted for in-patient diabetes
management, who determined that the patient was fully capable of
operating his insulin pump. The patient managed his insulin
independently throughout the admission without complications.
#CAD s/p 4v CABG and numerous PCIs
#Ischemic cardiomyopathy without evidence of HF, EF 45-50%
(___)
Continued Atorvastatin, ASA, clopidogrel and metoprolol
- Consider increasing atorvastatin from 40mg to 80mg daily if
patient tolerates.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Lisinopril 5 mg PO QHS
4. Atorvastatin 40 mg PO QPM
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Neck/L arm pain
8. Terazosin 5 mg PO QHS
9. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
10. Vitamin D 1000 UNIT PO DAILY
11. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: ___
Fingersticks: QAC and HS
Discharge Medications:
1. Insulin Pump SC (Self Administering Medication)Insulin
Lispro (Humalog)
Target glucose: ___
Fingersticks: QAC and HS
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
5. Clopidogrel 75 mg PO DAILY
6. Lisinopril 5 mg PO QHS
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Neck/L arm pain
9. Terazosin 5 mg PO QHS
10. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Unstable angina
Coronary artery disease
SECONDARY DIAGNOSIS:
Type 1 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were having chest pain and there was concern for a
blockage in one of the arteries that supplies your heart.
WHAT WAS DONE IN THE HOSPITAL?
- The function of your heart and lungs was monitored. You were
given medications to treat your chest pain.
- You had a procedure called a cardiac catheterization and a
stent was placed to open a blockage in one of your coronary
arteries.
WHAT SHOULD I DO WHEN I GET HOME FROM THE HOSPITAL?
- Continue to take all of your medications as prescribed.
- Follow-up with your Cardiologist and your other doctors.
- If you experience chest pain, shortness of breath or generally
feel unwell, call your doctor or go to the nearest emergency
room.
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
19988997-DS-14 | 19,988,997 | 29,807,937 | DS | 14 | 2174-06-29 00:00:00 | 2174-06-29 14:05:00 |
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:
___ - Coronary angiogram with POBA
History of Present Illness:
___ year old male with no known PMH presents as a transfer from
___ with NSTEMI and ongoing CP at rest
concerning for ACS.
Patient developed severe chest pressure/pain around 9PM last
night. He tried to go to sleep but was unable to get
comfortable.
HE denied any associated shortness of breath, N/V, diaphoresis,
radiation, or lightheadedness. He denied any pleuritic or
positional component to the pain. Has not had recent infection.
He has no cardiac history, but does get occasional chest pain
lasting a few minutes relieved by drinking water. No exertional
chest pain.
In the ED initial vitals were: 98.4 60 144/80 20 96% RA
EKG: NSR, LVH, diffuse J-point elevation, Not particularly
ischemic.
Labs/studies notable for: CKmb 94, troponin 1.38
Patient was given: IV heparin. full dose ASA, 500 cc IV fluids.
Vitals on transfer: 50 127/69 12 95% RA
On the floor He was complaining of ___ typical chest pain,
refractory to SL nitro glycerine.
Past Medical History:
No known medical history. Denied HTN, HLD, DM.
Social History:
___
Family History:
Mother with cardiac disease in early ___. Divorced. Works in
___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 1701)
Temp: 98.3 (Tm 98.3), BP: 109/57 (109-152/57-83), HR: 63
(51-63), RR: 18, O2 sat: 97% (97-98), O2 delivery: RA, Wt:
159.83
lb/72.5 kg (159.83-161.82)
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP not elevated
CARDIAC: Regular rate and rhythm. Soft heart sounds, but nl S1,
S2. No murmurs, rubs, or gallops. no thrills or lifts.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: clammy, but 2+ DP's and radial pulses.
SKIN: clammy
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 1205)
Temp: 98.8 (Tm 98.8), BP: 104/64 (91-152/50-83), HR: 57
(47-67), RR: 16 (___), O2 sat: 95% (94-98), O2 delivery: RA,
Wt: 159.83 lb/72.5 kg (159.83-161.82)
Fluid Balance (last updated ___ @ 601)
Last 8 hours Total cumulative -470ml
IN: Total 130ml, IV Amt Infused 130ml
OUT: Total 600ml, Urine Amt 600ml
Last 24 hours Total cumulative -408ml
IN: Total 992ml, PO Amt 50ml, IV Amt Infused 942ml
OUT: Total 1400ml, Urine Amt 1400ml
GENERAL: Well developed, well nourished male in NAD. Oriented
x3.
Mood, affect appropriate.
HEENT: PERRLA. MMM.
NECK: Supple. JVP not elevated
CARDIAC: Regular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. no thrills or lifts.
LUNGS: Normal work of breathing on RA. No crackles, wheezes or
rhonchi.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 02:29PM BLOOD WBC-6.7 RBC-4.21* Hgb-13.3* Hct-39.0*
MCV-93 MCH-31.6 MCHC-34.1 RDW-11.5 RDWSD-38.8 Plt ___
___ 02:29PM BLOOD Glucose-112* UreaN-11 Creat-1.2 Na-139
K-4.4 Cl-100 HCO3-25 AnGap-14
___ 02:29PM BLOOD cTropnT-1.38*
___ 07:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-2.2 Cholest-157
PERTINENT LAB RESULTS
=====================
___ 02:29PM BLOOD cTropnT-1.38*
___ 07:36PM BLOOD CK-MB-96* cTropnT-1.68*
___ 03:00AM BLOOD CK-MB-64* cTropnT-2.22*
___ 07:00AM BLOOD CK-MB-45* cTropnT-1.96*
DISCHARGE LAB RESULTS
=====================
___ 07:00AM BLOOD WBC-7.2 RBC-3.64* Hgb-11.7* Hct-34.2*
MCV-94 MCH-32.1* MCHC-34.2 RDW-11.9 RDWSD-41.0 Plt ___
___ 07:00AM BLOOD Glucose-107* UreaN-11 Creat-1.2 Na-140
K-4.2 Cl-105 HCO3-21* AnGap-14
IMAGING
=======
___ CXR
No evidence of pulmonary edema. Mildly enlarged cardiac
silhouette when
compared to prior.
___ Coronary angiogram
A 6 ___ EBU3.5 guide provided adequate support. Crossed with
a Prowater wire into the distal LAD.Dilated with a 2.0 mm
balloon. Final angiography revealed normal flow, no dissection
and 40% residual
stenosis.
Findings
Two vessel and branch coronary artery disease.
Successful POBA of the diagonal coronary artery.
Possible culprits tiny OM not amenable to PCI or diseased
diagonal branch.
Brief Hospital Course:
TRANSITIONAL ISSUES:
====================
[] New medications on discharge: metoprolol-XL 25 mg daily,
atorvastatin 80 mg daily, clopidogrel 75 mg daily for one year,
imdur 30 mg, and aspirin 81 mg daily.
SUMMARY STATEMENT:
==================
___ year old male with no known past medical history transferred
from ___ with ongoing chest pain and troponin
elevations, concerning for NSTEMI. Patient was placed on a
heparin and nitro drip and noted to have troponins
1.38->1.68-2.22. Cardiac cath showed 90% stenosis of the first
diagonal branch of the LAD. PCTA was performed at the site.
Patient was Plavix loaded and discharged on statin, aspirin,
metoprolol, and Plavix for one year.
HOSPITAL COURSE:
================
# NSTEMI
Patient presented with typical cardiac chest pain at rest
without known cardiac risk factors except for family history of
heart disease. EKG non-ischemic, with likely LVH. Patient was
aspirin loaded, placed on a heparin drip, and nitro drip. Hb A1c
4.9% and lipids were within normal limits. Chest pain resolved
as of ___ AM after being on nitro drip. Troponin elevations
were noted 1.38->1.68-2.22 along with lactate elevations to 2.3.
He was taken to cath, which showed 90% stenosis of the ___
diagonal branch of the LAD. PCTA was performed at this site.
Patient was Plavix loaded and discharged on Plavix for one year,
asa 81, metoprolol-xl 25, imdur 30 mg, and atorvastatin 80. TTE
and ___ eval were performed prior to discharge.
Medications on Admission:
None
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
RX *isosorbide mononitrate 30 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet(s) by mouth Daily Disp
#*30 Tablet Refills:*0
6. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN Chest pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Q5MIN:PRN Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Non-ST elevation myocardial infarction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you at ___
___.
WHY WAS I ADMITTED TO THE HOSPITAL?
- You were admitted to the hospital because of chest pain
WHAT HAPPENED WHILE I WAS IN THE HOSPITAL?
- You were found to have a heart attack. You were started on
blood thinning medication and medication to help increase blood
flow in the heart. Your chest pain went away on this medication.
- A procedure was done to see the vessels around the heart. It
showed a significant blockage of one of the vessels. A procedure
was performed to open the blockage up with a balloon through the
vessel.
- When your chest pain improved, you were discharged home.
WHAT SHOULD I DO WHEN I GO HOME?
- You should continue to take your medications as prescribed.
- You should attend the appointments listed below.
- Please return to the emergency room if you have severe chest
pain, worsening shortness of breath, or loss of consciousness.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
19989126-DS-15 | 19,989,126 | 22,853,928 | DS | 15 | 2149-08-26 00:00:00 | 2149-08-26 14:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ Bilateral External Ventricular Drain placement
___ Diagnostic Cerebral Angiogram
History of Present Illness:
___ who was ___ her usual state of health until around 3pm this
afternoon when she c/o a severe headache, she than began
vomiting. She was taken to ___ where a head CT
showed IVH, she was intubated and medflighted to ___. Upon
arrival to the ER, her head CT was reviewed and bilateral EVDs
were placed given the significant IVH.
Past Medical History:
___: Thalamic bleed, admitted to ___ Stroke, angio showed
___ and 2 small aneurysms near the ventricles. Patient was seen
at ___ and underwent bypass surgery with Dr ___.
Depression- was on medication but discontinued secondary to side
effects.
Social History:
___
Family History:
Unknown hx of vascular anomalies
Physical Exam:
ADMISSION PHYSICAL EXAM:
Gen: Intubated, sedated for EVD placement
HEENT: Old R temporal crani scar
Neuro:
No ___ to stim, bringing torso off the bed, no commands,
PERRL but sluggish, + cough.
DISCHARGE PHYSICAL EXAM:
___: thin F ___ NAD, opens eyes to voice, speaks softly,
often tearful
HEENT: R and L EVD scars well-healed. Staples ___ place over R
EVD scar. PERRL, mild photophobia (significantly improved).
Negative Kernig/Brudzinski.
Neuro:
-Mental status: AAOx2 (person, place). Comprehension intact.
Follows simple commands, midline and appendicular.
-Cranial nerves: CN II-XII grossly intact. +mild photophobia,
significantly improved.
-Strength: ___ all extremities
-Sensation: intact throughout
Pertinent Results:
___ CT head:
Bilateral IVH, left ventricle fully casted, right ventricle
appears about 80% casted, blood noted ___ third and fourth
ventricle. No SAH can be appreciated ___ the OSH scan. Some edema
near the pons.
___ CT head: 1. No change ___ extensive intraventricular blood,
status post bilateral ventricular drain placements.
2. Effacement of the basal cisterns and sulci of the occipital
lobe. Low
lying cerebellar tonsils is concerning for herniation, unchanged
from prior study.
3. Diffuse subarachnoid hemorrhage, slightly increased from
prior.
___ Portable CXR:
IMPRESSION:
1. Nasogastric tube courses below the diaphragm with its tip
coiled likely within the stomach. An endotracheal tube remains
___ place ___ satisfactory position. The lungs are well inflated
without evidence of focal airspace consolidation, pleural
effusions, or pneumothorax. Overall, cardiac and mediastinal
contours are within normal limits.
___ CT head: IMPRESSION:
1. Interval improvement ___ hydrocephalus and intraventricular
hemorrhage. No new hemorrhage.
2. Unchanged position of bifrontal approach EVDs.
3. Subarachnoid hemorrhage is no longer visualized, compatible
with evolution of blood products.
___ head CT
IMPRESSION:
1. Interval evolution of blood products with improvement ___
intraventricular
hemorrhage and no significant change ___ size of ventricles.
2. Unchanged position of bifrontal approach EVDs.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
9:52 AM
IMPRESSION:
Interval removal of a left frontal approach EVD with
post-procedural small
amount of air ___ the right frontal horn and moderate amount of
air ___ the
right temporal horn.
1. Allowing for the new air ___ the ventricular system, the right
lateral
ventricle is unchanged and there is no evidence of hydrocephalus
or new mass effect.
2. Right frontoparietal subarachnoid hemorrhage is stable-more
conspicuous on prior exam from ___- attention on f/u.
CHEST (PORTABLE AP) Study Date of ___ 12:48 AM
FINDINGS: ___ comparison with the study of ___, there is no
change or evidence of acute cardiopulmonary disease.
Specifically, no pneumonia, vascular congestion, or pleural
effusion.
CHEST PORT. LINE PLACEMENT Study Date of ___ 8:56 AM
Right PICC line has been inserted with the tip at the level of
mid SVC. Heart size and mediastinum are unremarkable. Lungs
are essentially clear.
___ PORTABLE ABDOMEN: Air is seen throughout non-distended
loops of small and large bowel. There is moderate amount of
dense stool throughout colon, particularly at the cecum. No
evidence of pneumoperitoneum on this single supine film.
Osseous structures are unremarkable.
IMPRESSION: Non-obstructive bowel gas pattern.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
3:15 ___
CONCLUSION: Status post revision of EVD. Increased air ___
frontal horn of the lateral ventricle. Decreased air ___ the
temporal horn of the right
lateral ventricle. Small amount of blood seen ___ the bilateral
occipital
horns of the lateral ventricle is unchanged compared to prior
study. No
evidence of hydrocephalus. No evidence of new hemorrhage.
___ CT Head w/o Contrast: Decrease ___ right lateral
ventricular gas and decreased intraventricular blood. Unchanged
position of a right frontal approach ventriculostomy catheter ___
the parenchyma adjacent to the left side of third ventricle.
Correlate clinically if this is the desired position. No new
acute hemorrhage is detected
PORTABLE CHEST X-RAY (___): As compared to the previous
radiograph, there is no relevant change. Normal size of the
cardiac silhouette. No acute changes such as pneumonia or
pulmonary edema. No pleural effusions.
NONCONTRAST HEAD CT (___): Status post removal of VP shunt.
Normal postsurgical change. No evidence of acute hemorrhage or
findings to suggest hydrocephalus.
MICROBIOLOGY:
___ 11:36 am URINE Source: Catheter.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ 1:09 pm URINE Source: Catheter.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ 12:52 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE COCCUS(COCCI). ~8OOO/ML.
___ 9:55 am CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by ___. ___ ___, ___,
1:30PM.
FLUID CULTURE (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. MODERATE GROWTH.
SPECIATION REQUESTED BY ___. ___ ___ ___.
ENTEROCOCCUS SP.. SPARSE GROWTH.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
Sensitivity testing performed by Sensititre.
STAPH AUREUS COAG +. RARE GROWTH.
STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH.
SECOND MORPHOLOGY.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
| ENTEROCOCCUS SP.
| |
CORYNEBACTERIUM SPECIES (DI
| | |
STAPH AUREUS COA
| | | |
STAPH
| | | |
|
AMPICILLIN------------ <=2 S
GENTAMICIN------------ <=0.5 S <=2 S <=0.5 S
<=0.5 S
OXACILLIN-------------<=0.25 S 0.5 S
=>4 R
PENICILLIN G---------- 8 S 0.25 S
RIFAMPIN--------------
<=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=1 S 1 S <=1 S
1 S
___ 1:50 pm CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
CONSISTENT WITH
CORYNEBACTERIUM OR
PROPIONIBACTERIUM SPECIES.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
Reported to and read back by ___ @ 1645,
___.
FLUID CULTURE (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N ___.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N ___.
ENTEROCOCCUS SP.. RARE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # 350-3181N ___.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 2:08 pm FOREIGN BODY Site: CATHETER
EXTERNAL VENTRICULAR DRAIN CATHETER.
**FINAL REPORT ___
WOUND CULTURE (Final ___: NO GROWTH.
___ 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-PICC.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 4:42 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 5:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-PICC.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 5:00 pm BLOOD CULTURE Source: Line-PICC.
Blood Culture, Routine (Pending):
___ 11:17 am CSF;SPINAL FLUID Source: Shunt.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 5:30 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Brief Hospital Course:
On ___, Ms. ___ required urgent placement of bilateral
EVDs for obstructive hydrocephalus ___ the setting of bilateral
intraventricular hemorrhage. The EVDS were placed emergently ___
the ED and she was subsequently transferred to the Neuro-ICU
intubated.
The patient was extubated on ___, HD #2, without event. Her
total drain output was maintained at > 20 mL/hr. On ___, it
was noted that right EVD drained well with left EVD having
minimal output. Protocol drain trouble shooting efforts,
improved the left EVD output.
On HD #4, ___, bleeding from EVD site was observed on rounds.
PTT was elevated at 64.8. Patient's subcutaneous heparin was
temporarility discontinued. The head CT remained stable.
On HD #5, ___, patient's subcutaneous heparin was
re-initiated with a bid dosing schedule rather than tid. On
examination, patiet appeared delerious, which was attributed to
sleep deprivation.
On HD #6, ___, patient remained agiated on examination. We
continued to monitor her closely ___ the neuro-ICU.
On ___, PTT was elevated to 57.1, SQH was decreased to 2500
units. She was febrile to 101.1 overnight, urine culture was
sent. Patient reported significant headache and toradol was
added. Her L EVD was clamped ___ attempt to remove and R drain
remained open.
On ___, there were no issues with elevated ICPs while L EVD
clamped. A head CT was done which showed stable ventricle size
and L EVD was removed. R EVD was clamped ___ attempt to removed
as well. She was afebrile overnight. Patient reported pain and
aggitation, she was placed on standing toradol and prednisone.
On ___ patient was found to have an enterococcus UTI and was
started Vancomycin. The patients Intercranial pressures were
___ and the EVD was opened.
On ___, The External Ventricular Drain was open and the ICP was
10. The patient had complaints of severe headache and a Head Ct
was performed which was consistent with interval removal of a
left frontal approach EVD with post-procedural small
amount of air ___ the right frontal horn and moderate amount of
air ___ the
right temporal horn. Allowing for the new air ___ the ventricular
system, the right lateral ventricle is unchanged and there is no
evidence of hydrocephalus or new mass
effect. Right frontoparietal subarachnoid hemorrhage is stable.
Ampicillin was added by ICU for the UTI. On exam, the patient
opened eyes to command, exhibited signs of photophobia. The
patient was not answering questions secondary to pain, but did
follow commands ___ all 4 extremities.
On ___, The patient had a temperature of 101 overnight and
urine/blood/Cerebral SpinalFluid cultures were sent. The CSF
culture prelim findings were consistent with +3Gram Postive
Cocci and 2+Gram Negative Rods. There was a question that this
may have been a contaminant and a second CSF culture was sent.
The patient was more lethargic ___ am and this was thought to be
due to fever and lack of sleep. The neurological assessment was
changed to every four hours to allow for sleep. The patient
became more alert as the ___ progresses and followed command
more readily. The serum sodium was 129. Urine lytes were send
dueto urine output of 200cc /hr for repeated hours and were
consistent with Creatinine of 15, serum sodium 10, potassium 9,
chloride of 16, and Osmolality of 92. Due to poor nutritional
intake the patient was initiated on IVF at 75cc/hr. The
External ventricular drain was open and draining well. The EVD
was level at 10 above the tragus. A Infectious Disease consult
was called to recommend planning for laproscopic Ventricular
Peritoneal shunt and steroid therapy for headache given fevers
101-103 and infection. The White Blood Count was slightly
elevated at 11.1. The patient continued to complain of servere
headache and neck pain. Topiramate (Topamax) 25 mg PO/NG BID for
headache was initiated perthe ICU team. A KUB was performed
given temperature of 103 for abdominal tenderness. On exam, the
patient opened eyes to voice and followed intermitent commands.
The pupils were equal reactive. The patient briskly localized.
The patient moved the bilateral lower extremities to command
intermitently.
On ___, pt continued spiking fevers (Tmax 102.8). Her
antibiotics were switched to Vanc/Meropenam per ID recs for
empiric treatment of meningitis (Vanc also covering her
pan-sensitive UTI). Her EVD was replaced ___ the OR out of
concern that EVD contamination had caused the meningitis.
On ___, pt remained confused with persistent photophobia and
meningismus. Head CT assessing EVD position showed Status post
revision of EVD. Increased air ___ frontal horn of the lateral
ventricle. Decreased air ___ the temporal horn of the right
lateral ventricle. Small amount of blood seen ___ the bilateral
occipital
horns of the lateral ventricle is unchanged compared to prior
study. No
evidence of hydrocephalus. No evidence of new hemorrhage. The
Cerebral Spinal Fluid preliminary culture grew gram negative
staph, cornyebacterium (diptheroids), enterococcus (rare
growth). Per infectious disease recommendations antibiotics were
narrowed to Vancomycin 1g every 8 hrs for External Ventricular
Drain-associated meningitis. Severe headaches persist and
patient pain managed with fioricet/dilaudid/topomax.
On ___, The patient exam was slightly improved exam improved
and the patient was noted to have multiple loose stools. A urine
culture was sent which was negative.
On ___, The patient experienced fever to 101.8 overnight, The
external ventricular drain was clamped as a trial to see if the
patient would tolerate it. The Intercranial Pressures were low
___ ___ the morning. Intercranial pressures rose, prompting the
right EVD to be re-opened wtih 5 mL of drainage. Pysical
Therapy and Occupational Therapy orders were placed. The foley
catheter was discontinue. The patient has had poor po intake due
to pain and delerium and was initiated on intravenous fluid at a
rate of 75cc/hr.
On ___, the patient remained agitated during examination. As
her ICPs were ___, her EVD was reclamped. ICPs remained near 3.
Ms. ___ Foley was replaced per nursing request to optimize
care.
On ___, patient's examination was dramatically improved.
Agitation was substantially decreased and patient was able to
move all four extremities to command. The EVD remained clamped
with tolerable ICP. Repeat head CT revealed decrease ___ right
lateral ventricular air and decreased intraventricular blood.
___ the afternoon, the patient was febrile to 100.3, a fever
workup was institued and CSF cultures were obtained.
___, patient spiked to Tm 102.8. As per ID's recommendations we
change her antibiotics from Vancomycin to Linezolid to rule out
Vancomycin as the source of her fevers. Her EVD was removed and
a CSF sample was sent again. Patient no longer requires ICU
level care and is ready for transfer to a SD unit.
On ___, patient remained afebrile on the floor; photophobia
mildly improved but still confused and oriented only to self.
Her right EVD staples were removed. CSF cultures have shown no
growth to date since the positive cultures on ___.
On ___, Patient self-DC'd her PICC twice, so her Linezolid was
switched to PO (confirmed OK with ID).
On ___, patient spiked fever to 102.3. Blood cultures were sent
(no growth to date). Chest x-ray showed no infiltrate. Unable to
obtain urine culture as patient incontinent and refusing
straight cath.
On ___, patient was discharged to rehab.
=====================================
TRANSITION OF CARE:
-Studies pending on discharge: blood cx (___)
-If spikes fever, consider UTI (unable to obtain UCx after pt
spiked fever on ___
-Needs right-sided head staples removed on ___
-Needs follow-up appointment with Dr. ___ ___ 4 weeks
(phone # ___. Will need head CT prior to appointment.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q4H:PRN pain
max apap ___
2. Heparin 2500 UNIT SC BID
3. Linezolid ___ mg PO Q12H
Use while patient has no IV access instead of IV dosing
4. Topiramate (Topamax) 25 mg PO BID
5. DiphenhydrAMINE 25 mg PO Q6H:PRN Itch
6. Docusate Sodium 100 mg PO BID
7. Senna 1 TAB PO BID Constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraventricular hemorrhage
Cerebral AVM
UTI
EVD-associated meningitis
Chronic pain
Hypertention
Acute confusion/delerium
Altered mental status
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:
Ms. ___,
It was a pleasure participating ___ your care at ___
___. You were admitted to the hospital with
headache, nausea and vomiting. You were found to have
intraventricular hemorrhage (bleeding into the ventricles of
your brain), caused by your ___ disease. Extraventricular
drains (EVDs) were placed for monitoring and drainage, and you
were admitted to the ICU. ___ the ICU you developed meningitis -
infection of the fluid surrounding the brain. You were treated
with antibiotics and your meningitis resolved. Your EVDs were
then removed and you were transferred to the medical floor where
your symptoms continued improving. Because you are still too
weak to go home alone, you are being discharged to rehab.
We made the following changes to your medications:
1. STARTED Linezolid ___ by mouth every 12 hours for your
meningitis. (Last ___ = ___
2. STARTED Fioricet (acetaminophen-caffeine-butalbital) ___ tabs
every 4 hours as needed for headache
3. STARTED Topomax (topiramate) 25mg by mouth twice daily for
headache
4. STARTED Benadryl 25mg by mouth every 6 hours as needed for
itching
5. STARTED Heparin subcutaneous 2500mg twice daily to prevent
blood clots ___ the legs until you are able to walk independently
6. STARTED Colace (docusate) and Senna for constipation
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.
CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE
FOLLOWING
New onset of tremors or seizures.
Any confusion, lethargy or change ___ mental status.
Any numbness, tingling, weakness ___ 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:
___
|
19989126-DS-16 | 19,989,126 | 21,824,927 | DS | 16 | 2155-02-03 00:00:00 | 2155-02-03 14:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___: Diagnostic angiogram
History of Present Illness:
___ yo female with known ___ s/p right EDAS. She had
previous admission her since then in ___ with ___ that required
bilateral EVDs and TPA. She returns with 1 week of HA and
nausea. Head CT at the OSH shows left occipital IPH with ___.
She c/o continued HA and Nausea.
Past Medical History:
___: Thalamic bleed, admitted to ___ Stroke, angio showed
___ and 2 small aneurysms near the ventricles. Patient was seen
at ___ and underwent bypass surgery with Dr ___.
Depression- was on medication but discontinued secondary to side
effects.
Social History:
___
Family History:
Unknown hx of vascular anomalies
Physical Exam:
ON ADMISSION
============
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout. No pronator drift
Sensation: Intact to light touch, propioception, pinprick and
vibration bilaterally.
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
ON DISCHARGE
============
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: 2.5-2mm b/l PERRL
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
___
IPQuadHamATEHLGast
___
Left5 5 5 5 5 5
[x]Sensation intact to light touch throughout
Pertinent Results:
Please see OMR for pertinent imaging & labs
Brief Hospital Course:
___
On ___, Ms. ___ was admitted to the Neuro ICU. Arterial
line was placed for BP control with SBP goal <160. Diagnostic
angio on ___ re-demonstrated bilateral ___. U/S of right
groin was obtained on ___ for palpable nodule and was negative
for pseudoaneurysm. Medications were adjusted for headache
management. On ___ she was called out of the ICU to ___ where
she remained neurologically stable. She was mobilized and
encouraged POs. She was transferred to the neuro floor. NCHCT on
___ was stable to improved.
#Moyamoya
Neurology was consulted to assist with management of her
Moyamoya. It was recommended to avoid significant hypotension.
Patient was cleared to start ASA 81mg on ___. She should
follow-up with Dr. ___ discharge.
#Depression/anxiety
Psych was consulted for the patient stating "I want to die." It
was felt the patient did not require a 1:1 sitter. The valium
was discontinued and the patient was started on Seroquel per
Psych recommendation. The Seroquel was discontinued and low dose
Ativan was ordered BID PRN. Patient was started on mirtazepime
7.5mg qHS to help with sleep, mood, appetite, and nausea. Social
work was consulted to assist with setting up outpatient psych
for follow-up after discharge.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aspirin 81 mg PO DAILY
RX *aspirin [Aspir-81] 81 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*2
3. Docusate Sodium 100 mg PO BID
4. LORazepam 0.25 mg PO BID PRN anxiety
RX *lorazepam 0.5 mg 0.5 (One half) tab by mouth BID PRN Disp
#*7 Tablet Refills:*0
5. Mirtazapine 7.5 mg PO QHS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
6. Multivitamins W/minerals 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth Q4H PRN
Disp #*24 Tablet Refills:*0
8. Senna 17.2 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Brain Hemorrhage without Surgery
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace once you are symptom free at rest.
___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
If you experienced a seizure while admitted, you are NOT
allowed to drive by law.
No contact sports until cleared by your neurosurgeon. You
should avoid contact sports for 6 months.
Medications
Please do NOT take any blood thinning medication (Ibuprofen,
Plavix, Coumadin) until cleared by the neurosurgeon.
Your neurosurgeon is recommending starting aspirin 81mg daily
starting on ___.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
What You ___ Experience:
You may have difficulty paying attention, concentrating, and
remembering new information.
Emotional and/or behavioral difficulties are common.
Feeling more tired, restlessness, irritability, and mood
swings are also common.
Constipation is common. Be sure to drink plenty of fluids and
eat a high-fiber diet. If you are taking narcotics (prescription
pain medications), try an over-the-counter stool softener.
Headaches:
Headache is one of the most common symptom after a brain
bleed.
Most headaches are not dangerous but you should call your
doctor if the headache gets worse, develop arm or leg weakness,
increased sleepiness, and/or have nausea or vomiting with a
headache.
Mild pain medications may be helpful with these headaches but
avoid taking pain medications on a daily basis unless prescribed
by your doctor.
There are other things that can be done to help with your
headaches: avoid caffeine, get enough sleep, daily exercise,
relaxation/ meditation, massage, acupuncture, heat or ice packs.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
Nausea and/or vomiting
Extreme sleepiness and not being able to stay awake
Severe headaches not relieved by pain relievers
Seizures
Any new problems with your vision or ability to speak
Weakness or changes in sensation in your face, arms, or leg
Call ___ and go to the nearest Emergency Room if you experience
any of the following:
Sudden numbness or weakness in the face, arm, or leg
Sudden confusion or trouble speaking or understanding
Sudden trouble walking, dizziness, or loss of balance or
coordination
Sudden severe headaches with no known reason
Followup Instructions:
___
|
19989783-DS-21 | 19,989,783 | 22,784,678 | DS | 21 | 2128-06-21 00:00:00 | 2128-06-21 22:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / niacin
Attending: ___
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
___: EGD and Colonoscopy
History of Present Illness:
Mr. ___ is a ___ gentleman with PMH significant for
atrial fibrillation on warfarin, prostate cancer s/p radiation,
HFrEF (EF 40-45%), and history of lower GI bleed in ___ due to
rectal angioectasia in the setting of radiation proctitis who
presents with weakness found to have BRBPR and Hgb 4.4.
Per patient, he was at work earlier today when he developed
feelings of weakness, lightheadedness, and dizziness while
standing. He reports he sat down to take a break and, on
attempting to stand back up, became extremely dizzy again. He
reports a co-worker told him he looked really pale and ill, and
so called EMS. On EMS arrival, patient was noted to have 1 mm
STE in I and aVL. He received aspirin x4 and was transferred to
___.
Of note, patient reports x3 days of BRBPR; he reports seeing
bright red blood in the toilet bowl and mixed with his stool. He
also notes some maroon colored stools; he denies tarry or black
stools, diarrhea, increased frequency of BM. He denies N/V/abd
pain, f/c, CP/palp, SOB, dysuria, MSK/joint pain.
In the ED, initial vitals: HR 71, BP 90/64, RR 18, SAT 98% on
RA.
- Exam notable for gross blood in the rectum.
- Labs were notable for H/H 4.4/16.1, PLT 52, INR 3.1, Cr 2.2,
Trop-T 0.02.
- CXR showed "Cardiomegaly without evidence of pulmonary edema.
No evidence of pneumonia."
- Patient was given: 1L NS, 1 unit of uncrossmatched blood,
pantoprazole 40 mg IV x1, Kcentra 2490 units, vitamin K 10 mg
IV, 1u crossmatched blood.
- GI was consulted in the ED.
On arrival to the MICU, patient reports feeling "much better"
than this AM. He denies current dizziness, lightheadedness.
Past Medical History:
Atrial fibrillation
Systolic heart failure (LVEF of 40-45% in ___
Hypertension
Hyperlipidemia
Gout
Prostate cancer status post radiation therapy
Sarcoidosis
Sickle cell trait
Right total knee replacement in ___
Solitary pulmonary nodule followed since ___
Osteoarthritis
Peripheral neuropathy
Asthma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vitals: afebrile, 70 126/71 15 97% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, pale conjunctiva, 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: clear without ecchymoses/rash
NEURO: AAOx3, moves all extremities spontaneously
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM:
===========================
VS: 97.8, 74, 110/72, 18, 100%RA
GENERAL: NAD, pleasant
HEENT: PERRL, EOMI, poor dentition
NECK: no JVD
CARDIAC: Irregularly irregular, S1/S2, no MRG
LUNG: LCTA-bl, no w/r/r
ABDOMEN: Soft, NTND, no HSM
EXTREMITIES: FROM, no c/e/e
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact; strength and sensation symmetric and
intact bl
Pertinent Results:
ADMISSION LABS:
===================
___ 09:30AM BLOOD WBC-4.7 RBC-2.50*# Hgb-4.4*# Hct-16.1*#
MCV-64*# MCH-17.6*# MCHC-27.3*# RDW-23.7* RDWSD-53.5* Plt Ct-52*
___ 09:30AM BLOOD Neuts-70.5 Lymphs-13.8* Monos-11.0
Eos-3.9 Baso-0.2 NRBC-1.1* Im ___ AbsNeut-3.28
AbsLymp-0.64* AbsMono-0.51 AbsEos-0.18 AbsBaso-0.01
___ 09:30AM BLOOD ___ PTT-59.0* ___
___ 09:30AM BLOOD Glucose-137* UreaN-58* Creat-2.2* Na-138
K-4.9 Cl-104 HCO3-22 AnGap-17
___ 09:30AM BLOOD ALT-12 AST-21 AlkPhos-82 TotBili-0.4
___ 02:03PM BLOOD Ret Man-4.1* Abs Ret-0.12*
___ 09:30AM BLOOD proBNP-1654*
___ 09:30AM BLOOD cTropnT-0.02*
___ 09:30AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.6 Mg-2.2
Iron-46
___ 09:30AM BLOOD calTIBC-455 ___ Ferritn-5.8*
TRF-350
___ 09:36AM BLOOD Glucose-131* Lactate-1.9 Na-138 K-4.9
Cl-105 calHCO3-23
___ 09:36AM BLOOD Hgb-4.9* calcHCT-15
MICRO DATA:
===================
___ MRSA Screen: Negative
IMAGING/STUDIES:
===================
- CXR (___): IMPRESSION: Cardiomegaly without evidence of
pulmonary edema. No evidence of pneumonia
EKG ___:
Sinus rhythm. Left axis deviation with left anterior fascicular
block. Right
bundle-branch block. Occasional premature ventricular
contraction. Compared
to the previous tracing of ___ atrial flutter has now
converted to sinus
rhythm.
Abd US ___:
FINDINGS:
LIVER: The hepatic parenchyma appears coarsened. The contour of
the liver is
nodular. There is no focal liver mass. The main portal vein is
patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 7 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall
thickening.
PANCREAS: Imaged portion of the pancreas appears within normal
limits, without
masses or pancreatic ductal dilation, with portions of the
pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 12.1 cm.
KIDNEYS: The right kidney measures 11.3 cm. The left kidney
measures 10.9 cm.
2 parapelvic cysts are noted in the upper pole of the right
kidney. Several
cysts are that are identified in the left kidney. The largest
measures 3.6
cm. A 2.0 cm cyst is seen in the interpolar region on the left.
A 4 cm cyst
is seen in the lower pole a 2.8 cm cyst is seen in the upper
pole. Normal
cortical echogenicity and corticomedullary differentiation is
seen
bilaterally. There is no evidence of masses, stones, or
hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
1. Coarsened liver echotexture and nodular contour of the liver
are
concerning for cirrhosis.
2. Multiple bilateral renal cysts
3. Normal size of spleen
EGD ___:
Findings:
Esophagus:Normal esophagus.
Stomach:
Mucosa:Diffuse angioectasias of the antrum consistent with
GAVE. There were also more scattered angioectasias spreading up
into the body. Some of those in the body displayed mild ooze and
were treated with APC. Small areas in the antrum were also
treated with APC. An Argon-Plasma Coagulator was applied for
hemostasis and tissue destruction successfully.
Duodenum:Normal duodenum.
Impression:Diffuse angioectasias of the antrum, with scattered
in the stomach (thermal therapy)
Otherwise normal EGD to third part of the duodenum
Recommendations:GAVE likely a source of chronic blood loss, but
likely does not explain acute bleeding
BID PPI
Sucralfate QID for a week
Consider repeat EGD in 8 weeks
Proceed to colonoscopy
Colonoscopy ___:
Findings:
Contents:Dark red and clotted blood was seen only in the rectum
and the recto-sigmoid junction. Despite extensive washing, no
source of underlying mucosal abnormality was identified. Careful
exam in retroflexion also did not reveal any abnormalities.
Excavated LesionsMultiple non-bleeding diverticula were seen.
Diverticulosis appeared to be of mild severity.
Impression:Diverticulosis of the colon
Blood in the colon
Otherwise normal colonoscopy to cecum
Recommendations:Return to hospital ward
Source of bleeding likely from rectum or rectosigmoid given the
distribution of blood, however no specific source identified. A
rectal Dieulafoy is possible.
DISCHARGE LABS:
===================
___ 06:55AM BLOOD WBC-7.4 RBC-3.29* Hgb-7.3* Hct-24.0*
MCV-73* MCH-22.2* MCHC-30.4* RDW-28.2* RDWSD-72.5* Plt Ct-36*
___ 06:55AM BLOOD ___ PTT-31.9 ___
___ 06:55AM BLOOD Glucose-89 UreaN-30* Creat-2.0* Na-138
K-4.1 Cl-108 HCO3-24 AnGap-10
___ 06:55AM BLOOD ALT-10 AST-18 AlkPhos-73 TotBili-0.5
___ 06:55AM BLOOD ALT-10 AST-18 AlkPhos-73 TotBili-0.5
___ 06:55AM BLOOD Calcium-8.7 Phos-3.1 Mg-1.8
Other Relevant Labs:
___ 07:43PM BLOOD Hypochr-2+ Anisocy-3+ Poiklo-3+
Macrocy-NORMAL Microcy-2+ Polychr-OCCASIONAL Spheroc-OCCASIONAL
Ovalocy-OCCASIONAL Schisto-OCCASIONAL Pencil-OCCASIONAL Tear
___
___ 02:03PM BLOOD Ret Man-4.1* Abs Ret-0.12*
___ 09:30AM BLOOD proBNP-1654*
___ 09:30AM BLOOD cTropnT-0.02*
___ 07:43PM BLOOD cTropnT-0.01
___ 07:43PM BLOOD TotProt-6.7
___ 09:30AM BLOOD D-Dimer-167
___ 09:30AM BLOOD calTIBC-455 ___ Ferritn-5.8*
TRF-350
___ 07:43PM BLOOD PEP-TRACE ABNO IgG-1031 IgA-398 IgM-147
IFE-TRACE MONO
___ 09:36AM BLOOD Glucose-131* Lactate-1.9 Na-138 K-4.9
Cl-105 calHCO3-23
___ 09:36AM BLOOD Hgb-4.9* calcHCT-15
___ 07:42PM URINE Hours-RANDOM TotProt-7
___ 07:42PM URINE U-PEP-NO PROTEIN
Brief Hospital Course:
BRIEF SUMMARY STATEMENT:
==========================
Mr. ___ is a ___ man with atrial fibrillation on
warfarin, prostate cancer s/p radiation, HFrEF (EF 40-45%), and
history of lower GI bleed in ___ due to rectal angioectasia
likely secondary to radiation proctitis who presented with
weakness, found to have new profound anemia with gross rectal
bleeding, concerning for lower GI bleed. Pt was admitted to the
ICU but transferred to general medicine floor on ___.
# LOWER GI BLEED:
On admission, Hgb 4.4 with GI bleed was thought to be lower
given gross blood. He had a history of angioectasia in the
rectum secondary to radiation proctitis and had APC in ___.
He also had a coagulopathy with thrombocytopenia, and received
reversal with Kcentra, vitamin K, and platelets. On admission,
he was not tachycardic or hypotensive, but he was taking a beta
blocker at home. He received 4 units of pRBCs on ___ with
improvement in H/H. He also received 1U platelts. GI was
consulted, and patient received EGD/colonoscopy on ___, which
showed GAVE and mild diverticulosis. Colonoscopy showed likely
rectal bleeding but no clear lesion. Bleeding was thought to be
___ diverticulosis vs. rectal dieulafoy lesion. On discovery of
pt's cirrhosis, rectal varices vs. other ectopic varices were in
ddx but given pt's creatinine, further eval was limited. During
Colonoscopy, these were not noted. Pt GIB resolved during
hospitalization and HCT remained stable. Per GI, pt was felt to
be safe for discharge.
# ___ on CKD:
Baseline Cr ~1.5-1.7 c/w grade 3 CKD, based on previous labs
here in ___ and at ___ in ___. Here on admission 2.2, likely
pre-renal in the setting of poor renal perfusion from blood
loss. At time of discharge, creatinine was 2, which was
considered close to baseline. ___ was held at time of discharge.
# THROMBOCYTOPENIA:
Baseline low PLT ~100s. S/p 1u platelets in ED with
inappropriate response. LFTs were normal, haptoglobin and
fibrinogen were normal, SPEP showed non-specific abnormality and
UPEP wnl. Abd US showed cirrhosis.
# CHRONIC COMPENSATED SYSTOLIC HEART FAILURE: last TTE (___)
showed LVEF 45%. Euvolemic on exam. CV meds were held on initial
presentation given concern for instability. As he stabilized,
his Nifedipine was re-started. Metoprolol was re-started at
below home dose (Metoprolol 50mg/day as compared to 100mg per
day in outpatient setting). ___ was held prior to discharge
given Cr 2 and normotension. Lasix was also held in setting of
euvolemia.
# Atrial Fibrillation: CHADS2-VASc score of 3 for (C-H-A). Given
active bleeding, patient received kaycentra and vitamin K in ED.
In anticipation of GI intervention, patient's anticoagulation
was held. given cirrhosis/thrombocytopenia and recent GIB and
per conversation with pt's Cardiologist, decision was made to
hold anticoagulation pending outpatient re-assessment. Notably
pt was in sinus rhythm during admission.
# Anemia: concern for acute on chronic etiology given low MCV,
patient reported "weeks" of fatigue. Has known Sickle Cell
trait. Iron studies were notable for low ferritin.
# Cirrhosis: Given thrombocytopenia, pt underwent abd US which
showed evidence of cirrhosis. Dx discussed with pt and he
endorsed drinking a considerable amount of etoh use (several
beers/shots of liquor per day). He denied prior hx of withdrawal
sx. Folate and thiamine were prescribed after discharge and sent
to pt's pharmacy. DDx for cirrhosis included sarcoid. Per GI, pt
was felt to be safe for discharge with outpatient Hepatology
follow-up.
TRANSITIONAL ISSUES:
===========================
- Please start on iron supplementation given low ferritin
- Consider hematology CS
- Please ensure Sucralfate is continued for 1 week
- Per GI, f/u for repeat EGD in 8 weeks
- Please ensure follow-up with Hepatology for evaluation of new
dx of cirrhosis
- Please ensure follow-up with Cardiology for decision re
risk/benefit of resuming anticoagulation
- Please note, Lasix and Valsartan held; metoprolol re-started
at below home dose; consider switching to Carvedilol given lower
selectivity and possible advantage from Hepatology perspective
if pt were to develop varices.
- Please repeat CBC at follow-up
- Please note evidence of ?MGUS on SPEP, please consider repeat
SPEP
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO BID
2. Atorvastatin 40 mg PO QPM
3. NIFEdipine CR 60 mg PO DAILY
4. Tamsulosin 0.4 mg PO BID
5. Allopurinol ___ mg PO DAILY
6. Furosemide 40-80 mg PO ASDIR
7. Warfarin 2.5-5 mg PO DAILY16
8. Valsartan 160 mg PO DAILY
9. Aspirin EC 81 mg PO 3X/WEEK (___)
10. Vitamin D 1000 UNIT PO DAILY
11. Osteo Bi-Flex Triple Strength
(___) 750 mg-644 mg- 30 mg-1 mg oral
DAILY
12. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO 3X/WEEK (___)
2. NIFEdipine CR 60 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Allopurinol ___ mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Tamsulosin 0.4 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Osteo Bi-Flex Triple Strength
(___) 750 mg-644 mg- 30 mg-1 mg oral
DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
11. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
# Lower GI bleeding
# Cirrhosis
# GAVE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to participate in your care at ___. You were
admitted for gastric bleeding. You underwent blood transfusion,
platelet transfusion, EGD and Colonoscopy and your symptoms
resolved. You were found to have scarring of the liver. Your
blood-thinning medications were held because of your recent
bleeding though there is a slight increase in stroke risk as a
result. Please follow up with your Cardiologist to discuss if it
is safe to re-start Coumadin. Please follow up with a liver
specialist to discuss treatment plan for cirrhosis. Please note
that a repeat endoscopy was recommended in approximately 8
weeks. If you experience any recurrence in bleeding, please seek
medical attention.
Best Regards,
You ___ Medicine Team
Followup Instructions:
___
|
19989783-DS-24 | 19,989,783 | 24,282,820 | DS | 24 | 2130-08-07 00:00:00 | 2130-08-07 12:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lisinopril / niacin
Attending: ___.
Chief Complaint:
Leukocytosis, fever
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis ___
History of Present Illness:
___ with history of NICM (EF 25% ___, CKD Stage IV
(baseline Cr 4.4 from ___ presumed due to cardiorenal
origin, alcoholic cirrhosis who was discharge from ___ ___
to rehab who re-presents to the ED from rehab after being found
to have WBC of 17 and temp of 100.9 at rehab. Per report, he
was also extremely agitated and tried to remove his dialysis
line, and is now restrained. He was also found to have a
hematocrit of 22, which is in the range of his norm, and the ED
transfused 1 unit of pRBC. The patients labs reflect CHF
exacerbation as he has a BNP of >70000. No immediate source of
infection was found on initial ED workup. Of note, the patient
received a ketamine bolus and was started on a ketamine drip
prior to surgical consult, so no history or reliable physical
exam can be obtained.
Past Medical History:
Atrial fibrillation
Systolic heart failure (LVEF of 40-45% in ___
Hypertension
Hyperlipidemia
Gout
Prostate cancer status post radiation therapy
Sarcoidosis
Sickle cell trait
Right total knee replacement in ___
Solitary pulmonary nodule followed since ___
Osteoarthritis
Peripheral neuropathy
Asthma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
Admission
Vitals: 98.5, 82, 109/74, 17, 94% on 40%
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, mildly distended, nontender (on ketamine), no rebound
or guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Brief Hospital Course:
Mr. ___ was admitted to the Trauma ICU where he was known
given his recent hospital admission.
He was off pressors and off ketamine drip. His mental status
improved. His WBC was 17.3. He continued to produce copious
amounts of respiratory secretions and receive chest physical
therapy as before. He was on trach mask with intermittent vent
requirement for agitation. CT abd/pelvis showed ascites,
post-surgical changes in the splenic fossa and no drainable
collections. He had no abdominal pain. He was started on CTX.
Diagnostic paracentesis suggested spontaneous bacterial
peritonitis. A 10 day Ceftriaxone course was planned followed by
prophylactic Ciprofloxacin per Hepatology recommendation. He
received HD as scheduled.
The patient remained stable with normal vital signs. He was
discharged to ___ to continue his recovery.
Medications on Admission:
1. Acetaminophen (Liquid) 650 mg PO Q8H:PRN Pain - Moderate
RX *acetaminophen 325 mg/10.15 mL 20 cc by mouth Every 8 hours
Disp #*2 Bottle Refills:*0
2. Albuterol Inhaler ___ PUFF IH Q6H
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff Trach Every 6
hours Disp #*2 Inhaler 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. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % Mouth rinse with 15 cc three
times a day Refills:*0
5. Docusate Sodium (Liquid) 100 mg PO BID
RX *docusate sodium [Diocto] 50 mg/5 mL 100 mg by mouth twice a
day Disp ___ Milliliter Refills:*0
6. Heparin 5000 UNIT SC TID
RX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units
Subcutaneous three times a day Disp #*90 Cartridge Refills:*0
7. Ipratropium Bromide MDI 2 PUFF IH Q6H
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 2 PUFF
Trach every six (6) hours Disp #*2 Inhaler Refills:*0
8. Metoprolol Tartrate 12.5 mg PO BID
RX *metoprolol tartrate 25 mg Half tablet(s) by mouth twice a
day Disp #*30 Tablet Refills:*0
9. OLANZapine 2.5-5 mg PO QHS
RX *olanzapine 5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
10. OxycoDONE Liquid 2.5-5 mg PO Q8H:PRN Pain - Severe
RX *oxycodone 5 mg/5 mL 5 mg NG tube three times a day
Refills:*0
11. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 grams by mouth
Daily Refills:*0
12. Ramelteon 8 mg PO QHS:PRN insomnia
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth QHR Disp #*30
Tablet Refills:*0
13. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.8 mg/5 mL 8.8 mg by mouth twice a day
Disp ___ Milliliter Refills:*0
14. Sodium Chloride 3% Inhalation Soln 15 mL NEB Q6H:PRN resp
secretions
RX *sodium chloride 3 % 15 cc Trach Q6H PRN Disp #*100 Vial
Refills:*0
15. Vancomycin Oral Liquid ___ mg PO/NG Q6H
RX *vancomycin [Firvanq] 50 mg/mL 125 mg by mouth every six (6)
hours Refills:*0
Discharge Medications:
1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 160 mg/5 mL 650 mg by mouth Every 6 hours Disp
#*2 Bottle Refills:*0
2. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth every 12 hours Disp
#*60 Tablet Refills:*0
3. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 grams IV Daily
Disp #*7 Intravenous Bag Refills:*0
4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
RX *chlorhexidine gluconate 0.12 % 15 ml for mouth rinse twice a
day Refills:*0
5. Heparin 5000 UNIT SC TID
RX *heparin (porcine) 5,000 unit/mL (1 mL) 5000 units
Subcutaneous twice a day Disp #*30 Cartridge Refills:*0
6. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
RX *lansoprazole 30 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
7. OLANZapine 2.5-5 mg PO QHS
RX *olanzapine 5 mg ___ tablet(s) by mouth Every night Disp #*30
Tablet Refills:*0
8. Ramelteon 8 mg PO QHS
RX *ramelteon [Rozerem] 8 mg 1 tablet(s) by mouth Every night
Disp #*30 Tablet Refills:*0
9. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin [Firvanq] 25 mg/mL 125 mg by mouth Every 6 hours
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Spontaneous Bacterial Peritonitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were re-admitted to ___ for fevers and a high white blood
cell count suggestive of infection. You were found to have
Spontaneous Bacterial Peritonitis which was treated with
antibiotics. You are ready for discharge.
Follow these instructions
- You should continue to take your oral Vancomycin 125 mg Q6H
until ___.
- You should continue your antibiotic (Ceftriaxone 2gr/day)
until ___.
- On ___, you should start taking Ciprofloxacin 500 mg/day
to prevent recurrent infections. Keep taking this medication
until you see your Hepatologist in clinic.
Followup Instructions:
___
|
19989918-DS-25 | 19,989,918 | 26,554,786 | DS | 25 | 2179-09-16 00:00:00 | 2179-10-05 20:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
___ / Depakote / Tegretol / Codeine / Phenobarbital
/ Penicillins
Attending: ___
Chief Complaint:
Brought from epilepsy clinic for complex partial status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
from Dr. ___ note:
Mr. ___ is a ___ year old man who carries a diagnosis of
intractable complex partial epilepsy (affecting right arm & leg)
on 5 AEDs and s/p VNS, cortical sectioning who was brought to
the ED from epilepsy clinic for question complex partial status.
Mr. ___ is followed by ___. According to his wife,
who provided the history, he has only one spell type which
involves right sided twitching of the arm and leg (not the
face). During these spells, his eyes are closed and he is not
responsive, but reportedly can recall everything that happened
afterwards. She has been with him since ___ and is confident
that this is his only semiology. These are often protracted
spells (lasting > 30 minutes) and he often comes out of them
with the help of his wife saying soothing things about their
children, etc.
He had a recent admission in ___ (about 3 weeks ago) to
the epilepsy service when he had a similar spell. He was
actually on ___ 11 visiting his son, who was admitted to the
neurology service, when he had his incident. The semiology was
as above and lasted about 30 minutes. He got 9mg of lorazepam
(and has received similarly high doses without respiratory
compromise in the past). It was noted that the right arm would
drift slowly down if dropped and that passive movement of the
RUE would cause the shaking to abate. It was not obviously
clonic. EEG was deferred since it had been negative with similar
spells in the past. He had about 2 episodes per day of the above
semiology. Ativan did not curtail these spells, but he did get
2mg q5-10 minutes during spells. He was sent home on ___ (6 day
admission) with epilepsy clinic follow up.
In the interim, he had a similar spell for which he was seen at
a hospital in ___. He received about 10mg lorazepam and was
sent back home.
In epilepsy clinic today, he had a few staring spells (unusual
for him) and then towards the end of the appointment (3:40)
began to have right sided motor activity similar to prior. He
was brought to the ED where he received 10mg lorazepam without
change in spell. When I arrived, his spell had stopped and I was
able to conduct most of the MS examination before his spells
resumed. He got another 2mg but the spell continued. My
examination was similar to prior (frequency arm > leg, arm drops
slowly, mvmts stop with passive ROM). He was 3 minutes into a
gram of Keppra when I asked his wife to speak to him and over
the next ___ seconds, he stopped entirely and was somnolent.
ROS: Unable to obtain, but earlier today reported to ___
___:
"Triggers: many life changes/stresses in recent months (wife
lost job, son with poor health, insurance changes/worries, death
of close friend in past few weeks, off modified ketogenic diet
when hospitalized here
Other symptoms/problems:
- excessive fatigue, poor energy, malaise
- memory/concentration problems, can't keep track of time, poor
historian lately
- h/o depression, on antidepressant but not managed by
pyschiatrist recently
- sleep apnea, uses cpap
-c/o right sided headaches
- constipation major problem r/t diet
- blurry vision
- c/o breathing problems when magnet used- coughing witnessed
once today"
Past Medical History:
Per OMR as patient unable to provide in current state. Per Dr.
___ note in ___ and subsequent notes since:
"- Fell of slide at grade school, loss of consciousness,
withconcussion.
- Viral meningitis when ___ years old, but without seizures.
- Epilepsy: first seizure ___, mentions ___ and
referral to Dr. ___ initial ___ seems to have been in
___ in ___ - had been evaluated given funny spells
with headache, right temporal discharge on EEG (see ___
summary, ___, started on phenobarb. Essentially the same
semiology as now with aura: Aura consists of a one or more of a
'drunk' feeling, double vision, and numbness on his right side,
before right hand twitching - what he calls the seizure proper -
begins. Few true generalized seizures, but patient recalls
"Grand mal" initiated during intraoperative recording and then
shortly after that same craniotomy/intracranial recording. At
the end of this three week intracranial monitoring in ___, he
underwent subpial transection with Dr. ___ and Dr.
___, in the now-eponymously named ___ procedure,
which seemed to reduce seizure frequency for some time (see
___ Summary ___, and per Dr. ___. Of note he had
some pathological evidence of infection afterward and was
treated with gentamycin. Left VNS was placed in ___, then
replaced ___.
This was interrogated and adjusted today, by ___ (see
her note of today).
- Depression - he has been doing better from this point of view,
and he only has the occasional day with low mood presently - two
days this week without getting out of bed, but for pills. No
suicidal ideation. He has seen his psychiatrist in ___.
- Sleep apnea, on CPAP
- Prior myocarditis (details unclear), since on Toprol
- Hypercholesterolemia
- Gastroesophageal reflux
- Chronic headaches and prior sinusitis
- Low back surgery, L4-5 disc herniation s/p left L4-5
hemilaminectomy, median facetectomy and L4-5 diskectomy ___
(___)
- Tonsillectomy
- Vasectomy
- Benign hematuria, kidney stones (thought to be ___ topamax)
- Pulmonary Embolus in ___, ~6 months of Coumadin"
Social History:
___
Family History:
Mother living, age ___ with a history of MI and uterine cancer.
Father died at age ___ of a stroke and MI
Physical Exam:
ADMISSION EXAM:
___ 90 132/72 59 20 98 2L NC
General: Lying in bed
HEENT: NC/AT, no scleral icterus, MMM
Neck: Supple, no nuchal rigidity
Pulmonary: Moving air well bilaterally, upper airway sounds
Cardiac: RRR difficult to hear over upper airway sounds
Abdomen: soft, NT/ND, scant bowel sounds, no masses or
organomegaly.
Extremities: No C/C/E bilaterally.
Skin: no rashes or lesions
Neurologic:
-Mental Status: Prior to resumption of spells, was oriented to
self, place, and year (not month or date). Speech was quiet but
fluent with naming to high and low. Repetition and comprehension
were normal. There was no left/right confusion and he could
follow 2 step commands. He could not get through days of the
week ___ -> ___ -> ___ -> ___ -> ___. He then had a spell,
during which he was not responsive to commands (voice or motor).
-Cranial Nerves (examined during spell):
Pupils 4-3mm bilaterally without hippis. On testing
oculocephalics, eyes remained midline then corrected to primary
position or had disorganized saccades without nystagmus.
Corneals were strong bilaterally. Face was symmetric. There was
actually some mild resistance to eye opening bilaterally. Strong
gag.
-Motor/Sensory: Prior to spell, could lift all extremities at
least anti-gravity (during MS testing asking pt to follow
commands). No response to pain during spell. No Babinskis.
During the spell, the right arm twiched in flexion/extension
without convincing clonic activity at a rate of approximately 3
Hz. The leg extended at the knee at a rate of approximately 1.5
Hz. There was no facial activity. When the arm was raised and
dropped, it fell slowly. The movements could be distracted with
movement of the arm about the elbow.
-DTRs: ___ throughout.
DISCHARGE EXAM:
Unchanged.
Pertinent Results:
ADMISSION LABS (___)
8.1 > 11.9/37.2 < 267
Neuts-70.0 ___ Monos-6.4 Eos-0.4 Baso-0.3
141 | 106 | 17
--------------< 87
4.3 | 28 | 0.7
Lactate-1.6
IMAGING:
Chest XRay:
FINDINGS:
AP portable supine view of the chest. Vagal nerve stimulator
projects over the left chest wall with catheter extending to the
left neck soft tissues, unchanged. Heart size is mildly
enlarged. Lung volumes are low. No overt signs of pneumonia or
edema. No large effusion or pneumothorax. The mediastinal
contour is stable. No acute osseous injuries.
IMPRESSION:
No acute intrathoracic process
Brief Hospital Course:
___ was admitted to the epilepsy service in stable
condition. He had several more spells similar to his episodes on
admission: prolonged, associated with arm and leg twitching at
different frequencies, disctractable and responsive to his
wife's voice. A conservative workup was negative for any
infectious, toxic or metabolic trigger. His anti-epileptic
medication levels were sent on admission. His vagal nerve
stimulator was activated for spells and he received lorazepam 2
mg IV for spells lasting longer than thirty minutes. Since his
spells were similar in semiology and frequency to his home
events (multiple episodes a day), no further adjustments to his
antiepileptic medications were made. His modified ketogenic diet
was continued. An ictal SPECT study was discussed with the
patient and his wife but as this could not be obtained over the
weekend, they preferred to go home and follow up outpatient. He
was discharged in stable condition with close neurology
follow-up.
Medications on Admission:
1. Atorvastatin 40 mg PO DAILY
2. Clobazam 20 mg PO BID
3. Clobazam 10 mg PO DAILY
4. Ezetimibe 10 mg PO DAILY
5. felbamate 800 mg oral qAM
6. felbamate 1200 mg ORAL TWICE DAILY
7. LACOSamide 200 mg PO TID
8. LaMOTrigine 100 mg PO BID
9. LaMOTrigine 300 mg PO HS
10. LeVETiracetam 1000 mg PO TID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Ranitidine 300 mg PO DAILY
14. Venlafaxine XR 150 mg PO QHS
15. Aspirin 81 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Senna 8.6 mg PO BID:PRN constipation
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. Clobazam 20 mg PO BID
3. Clobazam 10 mg PO DAILY
4. Ezetimibe 10 mg PO DAILY
5. felbamate 800 mg oral qAM
6. felbamate 1200 mg ORAL TWICE DAILY
7. LACOSamide 200 mg PO TID
8. LaMOTrigine 100 mg PO BID
9. LaMOTrigine 300 mg PO HS
10. LeVETiracetam 1000 mg PO TID
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Ranitidine 300 mg PO DAILY
14. Venlafaxine XR 150 mg PO QHS
15. Aspirin 81 mg PO DAILY
16. Docusate Sodium 100 mg PO BID
17. Multivitamins 1 TAB PO DAILY
18. Senna 8.6 mg PO BID:PRN constipation
19. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
intractable complex partial epilepsy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you have been having
your typical spells frequently at home and in the clinic. Here
we saw that you were continuing to have these spells. We
continued your anti-epileptic medications without any changes.
We discussed performing a SPECT study, but since this could not
be completed this week, you do not need to stay in the hospital
just for this test. You will continue to work with Dr. ___
to discuss further testing for these spells.
It was a pleasure taking care of you.
- The ___ Neurology Team
Followup Instructions:
___
|
19990072-DS-16 | 19,990,072 | 22,632,312 | DS | 16 | 2180-07-27 00:00:00 | 2180-07-27 12:38:00 |
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:
LP
History of Present Illness:
___ year old F who comes in with headache, neck stiffness,
photophobia. Pt developed headache 8 days prior to admission.
Symptoms present and persistent so she saw an MD on ___ who
prescribed exedrin and zofran. ___ and ___ she developed
fevers to 102-103 which persisted despite tylenol. ___
afternoon, she started vomiting and had a syncopal event. Says
she felt like she was going to pass out beforehand and had no
confusion following event. Unwitnessed. Pt decided to come to
the ED for evaluation the following morning. Traveled 1.5 months
ago to ___, no travel since. No significant time outdoors. No
tick or insect bites. No outdoor pets.
In the ED pt had CT head which was negative. LP done which
showed elevated WBC with lymphocytic predominance. Urinalysis
showed pyuria. Pt given CTX and Vanc at meningitis dosing and
admitted for further management.
ROS: negative except as above
Past Medical History:
None
Social History:
___
Family History:
Parents generally healthy. Grandparents with diabetes.
Physical Exam:
Vitals: T 101 114/67 83 16 98%RA
Gen: NAD
HEENT: mild nuchal rigidity
CV: rrr, no r/m/g
Pulm: clear bl
Abd: soft, nt/nd, +bs
Ext: no edema
Neuro: alert and oriented x 3, CN ___ intact, strength ___ in
all extremities
Skin: no rash
Pertinent Results:
___ 01:30PM BLOOD WBC-6.7 RBC-3.91* Hgb-12.7 Hct-35.6*
MCV-91 MCH-32.5* MCHC-35.7* RDW-12.7 Plt ___
___ 07:20AM BLOOD WBC-5.7 RBC-3.77* Hgb-11.9* Hct-33.6*
MCV-89 MCH-31.6 MCHC-35.4* RDW-12.4 Plt ___
___ 12:55PM BLOOD WBC-5.9 RBC-3.78* Hgb-12.2 Hct-34.0*
MCV-90 MCH-32.2* MCHC-35.8* RDW-12.4 Plt ___
___ 01:00PM BLOOD WBC-10.7 RBC-4.57 Hgb-14.4 Hct-40.7
MCV-89 MCH-31.5 MCHC-35.3* RDW-12.7 Plt ___
___ 01:32PM BLOOD ___ PTT-24.5* ___
___ 01:30PM BLOOD Glucose-88 UreaN-4* Creat-0.7 Na-138
K-3.5 Cl-97 HCO3-32 AnGap-13
___ 12:55PM BLOOD Glucose-134* UreaN-7 Creat-0.6 Na-136
K-3.6 Cl-103 HCO3-23 AnGap-14
___ 01:00PM BLOOD Glucose-94 UreaN-9 Creat-0.8 Na-132*
K-3.8 Cl-93* HCO3-24 AnGap-19
___ 07:00AM BLOOD ALT-14 AST-12 AlkPhos-27* TotBili-0.1
___ 01:00PM BLOOD ALT-21 AST-23 AlkPhos-39 TotBili-0.3
___ 07:00AM BLOOD HIV Ab-NEGATIVE
___ 07:00AM BLOOD ANAPLASMA PHAGOCYTOPHILUM (HUMAN
GRANULOCYTIC EHRLICHIA AGENT) IGG/IGM-PND
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ (Malaria)Malaria Antigen
Test-FINALINPATIENT
___ Viral
Load/Ultrasensitive-FINALINPATIENT
___ CULTUREVIRAL
CULTURE-PRELIMINARYINPATIENT
___ CULTURE NOT PROCESSED INPATIENT
___ PLASMA REAGIN
TEST-FINALINPATIENT
___ SEROLOGY-FINALINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ CULTUREBlood Culture,
Routine-PENDINGINPATIENT
___ FLUIDGRAM STAIN-FINAL; FLUID
CULTURE-FINAL; Enterovirus Culture-PENDINGEMERGENCY WARD
___ CULTURE-FINALEMERGENCY WARD
___ CULTUREBlood Culture, Routine-PENDING
.
CT head:
IMPRESSION:
No acute intracranial process. Please note that MRI would be
more sensitive
for subtle intracranial lesions.
Brief Hospital Course:
Assessment/Plan:
___ y.o woman with no PMH who presents with headache and fever
found to have aseptic meningitis.
.
#aseptic meningitis
#headache (likely combination of post LP and meningitis) ?NSAID
related
#fever
Pt was treated for a presumed viral meningitis. CSF gram stain
and cx negative. She was given CTx and vancomycin in the ED
which were discontinued on the floor given negative CSF. She was
treated with acyclovir until HSV and VZV were negative. GIven
that she continued to spike fevers despite supportive care,
consulted ID who recommended a more intensive work up that was
unrevealing by the time of discharge. She did develop some
abdominal pain mostly in the ruq. LFTs were slightly elevated,
and multiple additional serologies were sent and were
unrevealing at the time of discharge. Transvaginal, abdominal,
and ruq ultrasounds were negative for pathology. Pt's continued
headache could have also been due to post LP headache and/or
NSAId induced. Symptoms improved. On the day of discharge pt.
had been afebrile for over 24 hours, and was strongly desirous
of going home. Her pain was controlled, she was tolerating po
intake, ambulatory, and voiding on her own. Her LFTs were
stable, with ALT of approx 100, without any elevation in
bilirubin. This was felt to be part of a likely viral syndrome.
Doxycycline was started emperically at ID's recommendation over
concern for possible anaplasmosis (test pending at discharge),
and this was well tolerated. The plan is for her to return home
and we will follow up on the results of multiple pending
serologies. She should see Dr. ___ this week for repeat
evaluation including a repeat test of LFTs, CBC, and Chemistry 7
(see below, and this was explained to patient).
.
#hyponatremia-likely hypovolemic in etiology. Improved with IVF.
.
#elevated lactate-improved with IVF
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN headache
do not drink any alcohol while using this
2. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN severe pain
RX *tramadol 50 mg 1 tablet(s) by mouth every four hours as
needed for pain Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
asceptic meningitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with fever, headache, and neck pain and found
to have a condition known as asceptic meningitis, which is
usually caused by a virus. The cause of your condition remains
unknown at this time, however, as we discussed. You underwent an
extensive work up and were evaluated by the infectious disease
team. Your symptoms improved, and as of the time of discharge,
we have multiple test results still pending, and will alert you
to the final results if they are positive.
You should NOT: take any ibuprofen or other NSAID as this may
worsen your headache (as can cause rebound headaches and also
asceptic meningitis), NOT take more than ___ mg of tylenol
(acetaminophen) in any one 24 hour period, NOT drink any
alcohol.
You SHOULD: Call Dr. ___ to arrange to be seen by her later
this week to be re-evaluated and to have your liver function
tests repeated, and to follow up on the results of the tests
that are pending. When you see Dr. ___ following should
be checked (blood tests): Complete blood count, ALT, AST, Alk
Phos, Total Bilirubin, and a 'Chemistry-7'
Followup Instructions:
___
|
19990106-DS-15 | 19,990,106 | 20,746,590 | DS | 15 | 2161-06-05 00:00:00 | 2161-06-05 20:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Cardiac cath with ___ 3.0x14 mm placed to LAD on ___
History of Present Illness:
___ yo M with CAD, s/p LAD and D1 ___ in ___ and ___
respectively, and restenosis of LAD stenit in ___ s/p
angioplasty, who presented to ED with chest pain. Started after
breakfast. Patient was sitting in kitchen drinking juice. Came
on suddenly, felt like heaviness in mid chest. Non-radiating, no
relation to inspiration. Associated with SOB. No diaphoresis,
palpitations, n/v. He took 1 nitro with minimal relief so took
another one, still w/o complete relief and called ___. By the
time he came to the ED his chest pain had mostly resolved but he
received nitro spray x 2. He had stable EKG abnormalities with
ST abnormalities in the inferolat leads. Enzymes were negative.
He was placed in obs and had an exercise nuclear test. He ex
___, no CP, but sig EKG changes with 1-2 mm of STD which
persisted through 15:00 of recovery. These changes are worse
compared to prior ETTs. Perfusion with TID.
In the ED intial vitals were: 97.8 80 127/83 20 97% 2L
Patient was given: Nitro x 2 and home meds
Vitals on transfer: 79 147/64 17 99% RA
On the floor, pt reports no current complaints. He relays the
above history.
ROS: On review of systems, he denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, joint pains, cough,
hemoptysis, black stools or red stools. He denies recent fevers,
chills or rigors. He denies exertional buttock or calf pain. All
of the other review of systems were negative.
Cardiac review of systems is notable for positive chest pain now
resolved, dyspnea on exertion (without chest pain), positive
paroxysmal nocturnal dyspnea, orthopnea ___ post-nasal drip,
negative for ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: S/P prior D1 Cypher
stenting on ___ at ___ and an Endeavor ___ to the LAD in
___. Had a50% D1 lesion at last cath. Had ___ cath at ___
with finding of 80% instent resten of the LAD, treated with
angioplasty. A 3-4 mm pseudoaneurysm was seen at the distal tip
of the patent ___ in the diag. Dr. ___ a 6 mos CT scan
of the chest for that. That was done in ___, and no FA was
noted.
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
HIV not on therapy
PUD w/ h/o GIB
CAD
DM with DIABETIC RETINOPATHY- am sugar 100-135
SLEEP APNEA
HTN
HLD
GERD
ED
BPH
RHINITIS
CLBP
OBESITY
DEPRESSION
ASTHMA
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=97.9 BP=156/80 HR=69 RR= 18 O2 sat= 98 RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple witwithout JVD
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ early peaking systolic murmur best
heard over RUSB. No thrills, lifts. No S3 or S4.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ radial and DP bilaterally
Discharge Physical Exam:
VS: T=98.4 SBP=126-162 (126/86) HR= ___ RR= ___ O2 sat=
___ RA
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple without JVD
CARDIAC: RRR, normal S1, S2. ___ early peaking systolic murmur
best heard over RUSB.
LUNGS: CTAB, no crackles, wheezes or rhonchi. Normal WOB
ABDOMEN: Soft, NTND.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: 2+ radial and DP bilaterally
Pertinent Results:
Admission Labs:
___ 12:15PM BLOOD WBC-5.6 RBC-4.93 Hgb-13.0* Hct-41.8
MCV-85 MCH-26.4* MCHC-31.2 RDW-14.6 Plt ___
___ 12:15PM BLOOD Neuts-58.1 ___ Monos-7.1 Eos-2.4
Baso-1.0
___ 12:15PM BLOOD Glucose-169* UreaN-13 Creat-1.3* Na-140
K-3.9 Cl-102 HCO3-29 AnGap-13
Pertinent Labs:
___ 12:15PM BLOOD cTropnT-<0.01
___ 06:34PM BLOOD cTropnT-<0.01
___ 11:30AM BLOOD cTropnT-<0.01
___ 07:30AM BLOOD cTropnT-<0.01
___ 08:22AM BLOOD HCV Ab-NEGATIVE
___ 08:22AM BLOOD HBsAg-NEGATIVE
___ 07:00PM BLOOD Calcium-10.1 Mg-1.7
Discharge Labs:
___ 07:30AM BLOOD WBC-6.3 RBC-5.04 Hgb-13.6* Hct-42.5
MCV-84 MCH-27.0 MCHC-32.1 RDW-14.7 Plt ___
___ 07:30AM BLOOD Glucose-184* UreaN-18 Creat-1.5* Na-138
K-4.3 Cl-100 HCO3-30 AnGap-12
___ 07:30AM BLOOD Calcium-9.8 Mg-2.2
Imaging:
EKG ___: Sinus rhythm. Left atrial abnormality. Delayed
anterior R wave progression.
Prior inferior wall myocardial infarction. Lateral ST segment
depression
consistent with possible ischemia. Compared to the previous
tracing of ___
no diagnostic interval change
EKG ___: Sinus rhythm. Delayed R wave progression. Lateral ST
segment abnormalities
consistent with ischemia. Possible left ventricular hypertrophy,
although
voltage criteria are not present. Compared to the previous
tracing there is
now only isolated Q wave in lead III, since diagnostic criteria
for inferior
wall myocardial infarction are not met on this tracing.
TRACING #2
Stress ___: Average exercise tolerance. Ischemic ECG changes
persisting
late post-exercise in the absence of anginal symptoms to
achieved
workload. Appropriate hemodynamic response to exercise. Nuclear
report
sent separately.
Nuclear ___: Pending
Cardiac Cath ___:
Technical
Anesthesia: Local
Specimens: None
Catheter placement via , 5 ___
Coronary angiography using 5 ___
Hemodynamic Measurements (mmHg)
Baseline
Site ___ ___ End Mean A Wave V Wave HR
___
Contrast Summary
Contrast Total (ml): Optiray (ioversol 320 mg/ml)173
Radiation Dosage
Effective Equivalent Dose Index (mGy) ___.52
Radiology Summary
Total Fluoro Time (minutes) 26.9
Medication Log
Start-StopMedicationAmountComment
10:00 AM Heparin in NS 2 units/ml (IA) IA0 ml
10:08 AM Versed IV1 mg
10:08 AM Fentanyl IV25 mcg
10:25 AM Lidocaine 1% Subcut3 ml
10:30 AM Lidocaine 1% Subcut2 ml
10:33 AM Nitroglycerine bolus (IA) IA200 mcg
10:34 AM Diltiazem bolus (IA) IA500 mcg
10:34 AM Heparin bolus (IV) IV5,000 units
11:23 AM Ticagrelor PO180 mg
11:27 AM Heparin bolus (IV) IV3,000 units
11:33 AM Versed IV0.5 mg
11:33 AM Fentanyl IV25 mcg
11:45 AM Nitroglycerine bolus (IC) IC200 mcg
Materials
ManufacturerItem Name ___ 320100ml
___ SCIENTIFICFL 3.5 DIAGNOSTIC5fr
___ SCIENTIFICFR 5 DIAGNOSTIC5fr
COOKJ WIRE 260cm.035in
___ SCIENTIFICMAGIC TORQUE .035 180cm.035in
NAVILYSTPRESSURE MONITORING LINE 12"
___ MEDICALLEFT HEART KIT
___ MEDICAL PROD & sCUSTOM STERILE KIT(STERILE
PACK)
TERUMOGLIDESHEATH SLENDER5Fr
TERUMOTR BAND (LARG)
___ 320100ml
___ SCIENTIFICAL 1 DIAGNOSTIC5fr
CORDISXBLAD 3.56fr
MALLINCKRODTCONRAY 60 50 ml
ABBOTTPROWATER WIRE180CM
ABBOTTP-PACKS ___ (INDEFLATORS)
___ SCIENTIFICAPEX RX 12mm2.5mm1st
___ SCIENTIFICAPEX RX 12mm2.5mm2nd
MEDTRONICRESOLUTE RX 15mm3.0mm
MEDTRONICNC SPRINTER RX 09mm3.0mm
Findings
ESTIMATED blood loss: Minimal
Hemodynamics (see above):
Access: Right radial
Coronary angiography: right dominant
LMCA: mild
LAD: Shelf-like ostial 50%, Ostial diag extending into the
stented segment 80-90% diffuse. There is a pseudo aneurysm in
the
mid diagonal beyond the stented segment that appears to be 4-5mm
in size.Hazy, eccentric 80% lesion in the proximal to mid LAD
treated with a 3.0 drug-eluting ___ post dilated with a 3.0 NC
balloon
LCX: mild ectasia, (no progression when compared to films from
___
RCA: mild disease (no significant progression when compared to
films from ___
Interventional details
A ___ XB LAD 3.5 guide provided adequate support (It was decided
to proceed with a PCI of the lesion in the proximal to mid LAD,
and not to intervene on the diagonal branch at this time due to
the ostial nature of the disease and the potential of
jeopardizing the proximal LAD)
ASA, Ticaegrelor and Heparin were used for thromboprophylaxis
The lesion in the proximal to mid LAD was crossed with a
Prowater
wire into the distal vessel with relative ease
___ dilation was performed with a 2.5 balloon
A 3.0 x 15 drug eluting ___ was deployed across the lesion and
post dilated with a 3.0 NC balloon at 16 ATM
Final angiography revealed no evidence of dissection,
embolization or thrombus. There was TIMI III flow in the distal
vessel.
Assessment & Recommendations
1. Severe single vessel and branch vessel disease of the LAD in
this right dominant coronary system
2. Successful PCI of the mid LAD with a 3.0 drug-eluting ___
3. Residual ostial Diagonal disease (with ___ restenosis
component and pseudo-anuerysm immediately distal to the stented
segment)
4. Re-load with Clopidogrel 300mg in 12 hours
5. Follow for angina symptoms
6. Aggressive secondary risk factor modification
7. * Post PCI the patient developed amnesia without any focal
motor or sensory deficits, stroke team assessed STAT and the
patient was transferred to the CT scanner for immediate imaging
CTA Neck ___: No evidence of infarct. No vascular abnormality.
Final read pending reformats.
CTA Head ___: No evidence of infarct. No vascular abnormality.
Final read pending reformats.
Brief Hospital Course:
___ yo M with h/o CAD, HIV, s/p stents to D1 and LAD, CKD,
admitted with chest pain and abnormal nuclear stress with
prolonged ST changes and transient ischemic dilation. S/p cath
___ with LAD ___ 3.0x14 mm. Pt with transient amnesia
post-op. CT head negative. Stroke team consulted and followed
and believed to be due to dye, no stroke. Pt returned to
baseline orientationx3, no neurological findings. Creatinine
with slight increase above baseline 1 day after cath. Deemed
safe for discharge with outpatient f/u. Home medications changed
to include high dose statin and plavix in addition to BB, ___,
aspirin.
Transitional Issues:
-Patient should have creatinine re-checked on ___ given slight
elevation during hospital stay; if it remains elevated, should
consider holding ___
-Medication changes: increased atorvastatin to 80 mg daily,
added plavix 75 mg daily (plavix to be taken for ___ year)
-Outpatient f/u with cardiologist, appt to be made
-Outpatient f/u with PCP
-___ orientation and changes in MS- may require MRI per
neurology
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxybutynin 5 mg PO DAILY
2. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain, SOB
3. Terazosin 10 mg PO HS
4. TraZODone 200 mg PO HS
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Gabapentin 300 mg PO TID
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Losartan Potassium 50 mg PO BID
9. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID
10. Amlodipine 5 mg PO DAILY
11. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous QAM
12. Pantoprazole 40 mg PO Q12H
13. Fluticasone Propionate NASAL 1 SPRY NU DAILY
14. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous
before meals
15. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4-6h: prn sob
16. Hydrochlorothiazide 37.5 mg PO DAILY
17. Atorvastatin 40 mg PO DAILY
18. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
4. Fluticasone Propionate NASAL 1 SPRY NU DAILY
5. Gabapentin 300 mg PO TID
6. Hydrochlorothiazide 37.5 mg PO DAILY
7. Losartan Potassium 50 mg PO BID
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain, SOB
10. Oxybutynin 5 mg PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Terazosin 10 mg PO HS
13. TraZODone 200 mg PO HS
14. Clopidogrel 75 mg PO DAILY Duration: 12 Months
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
15. exenatide 10 mcg/dose(250 mcg/mL) 2.4 mL subcutaneous BID
16. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous QAM
17. MetFORMIN (Glucophage) 1000 mg PO BID
18. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous
before meals
19. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
q4-6h: prn sob
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Narrowing of left anterior descending coronary artery
Secondary Diagnoses:
Coronary Artery Disease
Chronic Kidney Disease
Diabetes
HIV infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your stay at ___.
You were admitted for chest pain that started after breakfast
and responded to nitroglycerin. Work-up of your chest pain in
the ED showed an abnormality during stress testing that
warranted cardiac catheterization. This was performed ___ and
one ___ was placed. After the procedure, you were confused and
concern over a stroke prompted imaging of your head. The stroke
neurology team was called to see you as well. The scan of your
head was negative, and your memory returned, and the neurology
team did not think you had a stroke.
On the day of discharge, your kidney function slightly worsened.
This should be re-checked at ___ in 2 days (an
order has placed all you have to do is go to the lab to have
blood drawn) on ___.
You should follow up with your cardiologist Dr. ___ as an
outpatient. Her office will call you to make an appointment.
You have been started on a medication called Plavix
(clopidogrel). This is important to take everyday to prevent
clots in your new heart ___. Do NOT stop taking unless
directed by a physician.
Wishing you well,
Your ___ Cardiology Team
Followup Instructions:
___
|
19990141-DS-18 | 19,990,141 | 24,852,269 | DS | 18 | 2133-03-05 00:00:00 | 2133-03-05 21:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Hayfever / Keflex / filbert nuts
Attending: ___.
Chief Complaint:
pleuritic chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with a history of varicose
veins who presented to his PCP earlier today with ___ weeks of
R leg pain. The pain developed while he was on vacation in ___
but he did not mention the pain to his family until 3 days ago,
at which time he was brought to ___ in ___ and extensive
superficial venous thrombosis was noted and it was recommended
that he undergo f/u ultrasound in ___ days, which he underwent
this morning and was found to have worsening SVT and also DVT.
When he presented to his PCP this AM he denied dyspnea but did
endorse some pleuritic L sided chest pain and worsening ___
edema. He was referred from PCP to ___ for PE scan, which L
subsegmental pulmonary emboli involving the LLL with possible
early infarct.
Of note the patient reports ~50 lbs weight loss over
approximately ___ years. He reports mostly this has been gradual,
although potentially more rapid recently. He reports that to
some degree he feels he is less hungry but his wife also reports
that sometimes he "forgets to eat." He also notes that he is in
the process of evaluation for memory loss. He is still able to
do complex legal work (he is a retired ___) and manage
finances but has been somewhat slower at these jobs and repeats
things more often than he used to. He is awaiting brain MRI. He
has been taken off Lipitor for this reason. He has also been
taken off some of his antihypertensives recently (atenolol and
amlodipine). He reports that he is up to date on colonoscopy
screening. He also reports that he has an elevated PSA that has
been attributed to BPH and that he is followed closely by
urology who does not feel he has prostate cancer.
No recent prolonged immobility. Patient's daughter believes he
had superficial vein thrombosis remotely. His daughter also had
a DVT in her ___ with negative work-up for hypercoagulability.
She was on OCP and had been on long plane flight.
___ Course:
Afebrile, HRs ___, BPs 120s-150s/50s-80s, 99-100% on RA
Received 500 cc NS and 70 mg lovenox
Review of systems:
Const: no fevers, chills, dizziness, +weight change as above
HEENT: no HA, changes in vision or hearing
CV: +pleuritic chest pain
Pulm: no dyspnea, cough, or wheezing
GI: no abd pain, n/v, c/d, + increased eructation today
GU: no changes in urine or dysuria
MSK: no new myalgias/arthralgias
Neuro: no new focal weakness or numbness
Derm: no new rashes
Hem: no new bleeding/bruising
Endo: no hot/cold intolerance
Psych: no recent mood changes per patient, although his wife
feels he has been down at times
Past Medical History:
HL
HTN
BPH
Nasal plyps
Elevated PSA
Spinal stenosis
Varicose veins
History of remote spine surgery
History of hernia repair
Social History:
___
Family History:
History of provoked DVT in daughter in her ___ w/ neg coag w/u.
Physical Exam:
Admission Physical Exam:
Vital signs: 97.9 188/78 87 16 100% on RA
gen: pt in NAD
HEENT: nc/at, sclera anicteric, conjunctiva noninjected, PER,
EOMI, MMMs
CV: RRR no m/r/g
Pulm: CTAB No c/r/w (notes L sided lateral chest wall pain w/
deep inspiration)
Abd/GI: S NT ND BS+, no masses/HSM palpated
Extr: wwp, distal pulses intact, bilateral legs w/ varicose
veins, R medial thigh with hardened cords and tenderness, mild
edema R>L
GU: no CVA tenderness, no Foley
Neuro: alert and interactive, strength intact, sensation to
light touch slightly reduced over distal RLE
Skin: no rashes on limited skin exam
Psych/MS: normal range of affect'
DISCHARGE
VS: 97.8 124/64 62 16 100%RA
Gen: sitting up in bed, comfortable
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - chronic venous stasis changes bilaterally
Vasc - venous varicosities over R leg; 2+ ___ pulses
bilaterally
Neuro - AOx3, moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 02:40PM BLOOD WBC-7.6 RBC-4.38* Hgb-12.5* Hct-39.0*
MCV-89 MCH-28.5 MCHC-32.1 RDW-12.9 RDWSD-42.2 Plt ___
___ 02:40PM BLOOD ___ PTT-29.2 ___
___ 02:40PM BLOOD Glucose-125* UreaN-27* Creat-0.9 Na-142
K-3.8 Cl-107 HCO3-27 AnGap-12
DISCHARGE
___ 08:00AM BLOOD WBC-6.3 RBC-4.45* Hgb-12.6* Hct-38.9*
MCV-87 MCH-28.3 MCHC-32.4 RDW-12.5 RDWSD-40.2 Plt ___
___ 08:00AM BLOOD ___ PTT-38.1* ___
___ 08:00AM BLOOD Glucose-99 UreaN-19 Creat-0.7 Na-141
K-3.8 Cl-107 HCO3-27 AnGap-11
RLE Doppler
There is thrombosis of the majority of the greater saphenous
vein from its origin to the level of the distal calf with
extension into the common femoral vein at the greater saphenous
vein origin, compatible with superficial and deep venous
thrombosis.
CTA Chest
1. Subsegmental pulmonary emboli involving the left lower lobe
with probable left lower lobe infarct.
2. Filling defects within subsegmental pulmonary veins in the
right and left lower lobes.
3. Intermediate density small left pleural effusion.
Brief Hospital Course:
This is a ___ year old male with past medical history of
hypertension, BPH, varicose veins, who was referred for
admission from PCP's office after diagnosis of new DVT in the
setting of pleuritic chest pain, subsequently found to have
acute pulmonary embolism, with reassuring telemetry and EKG,
started on rivaroxaban and able to be discharged home
# Acute pulmonary embolism / Acute right Common Femoral DVT -
Patient with several days worsening leg swelling in setting of
recent diagnosis of superficial thromboembolism, found to have
acute R common femoral DVT--given ongoing pleuritic chest pain,
he was referred to ___ ___, where he was found to have acute
DVT. He was started on lovenox and admitted to medicine. Per
PESI score he was intermediate risk (based on age and gender, no
additional risk factors). EKG without signs of right heart
strain and patient was without any vital sign abnormalities or
symptoms (other than mild pleuritic L chest pain). Telemetry
was unremarkable. After discussion with patient and his PCP ___.
___ was prescribed rivaroxaban, delivered to bedside,
and instructed to begin taking 12 hours after last dose of
lovenox. At time of discharge patient was ambulating
comfortably. He and wife were educated on warning signs that
should prompt additional care, and verbalized their
understanding.
# Hypertension - continued lisinopril
# Mild Cognitive Impairment - continued donezpezil
TRANSITIONAL
- Discharged home with 21-day supply of rivaroxaban twice
daily--at follow-up visit he will need prescription for
maintenance daily dosing of rivaroxaban
- Defer to outpatient providers regarding utility of additional
workup for unprovoked venous thromboembolism
> 30 minutes spent on this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 40 mg PO DAILY
2. Donepezil 5 mg PO QHS
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Rivaroxaban 15 mg PO BID
with food; continue for 21 days
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day
Disp #*42 Tablet Refills:*0
2. Donepezil 5 mg PO QHS
3. Lisinopril 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
# Acute pulmonary embolism / Acute right Common Femoral DVT
# Hypertension
# Mild Cognitive Impairment
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___:
It was a pleasure caring for you at ___. You were admitted
with a new diagnosis of a deep vein thrombosis (blood clot) in
your leg, and a pulmonary embolism (blood clot) in your lung.
You were treated with a blood thinning medication. You
underwent cardiac testing that was reassuring.
We discussed the situation with your primary care doctor who
recommended the medication Xarelto (rivaroxaban).
Please take it twice a day for 21 days. After this you will be
able to take it once a day--please see your primary doctor who
will provide you with this once-a-day prescription.
Followup Instructions:
___
|
19990366-DS-18 | 19,990,366 | 24,092,667 | DS | 18 | 2133-08-13 00:00:00 | 2133-08-14 17:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of COPD, CHF, hypertension, TIA, osteoarthritis
and remote colon cancer, who presented with atraumatic back pain
that started when she was getting out of bed and found to have a
T-spine fracture. She developed atraumatic back pain 3 days
prior
to admission while walking to the bathroom. She states the pain
was ___ in severity and non-radiating. She states it is worse
with movement and pain medication helps with the pain.
She also reported some subjective left leg weakness. She
presented to the eye ___ where she was found to have urinary
retention and a Foley was placed. She states that she has been
having urinary retention for about a year but never sought
medical attention. She also states that she has not had a bowel
movement in 3 days and has good appetite. She denied any fever,
night sweats, chest pain, shortness of breath, lightheadedness,
abdominal pain, nausea, vomiting.
- In the ED, initial vitals were:
T 97.7 HR 94 BP 138/51 RR 16 O2 96% RA
- Exam was notable for:
"Midline low T-spine and ___ tenderness. Strength and
sensation intact in distal extremities although the right lower
extremity flexion is limited by pain. Normal rectal tone."
- Labs were notable for:
CBC unremarkable
BMP unremarkable
LFTs unremarkable
UA unremarkable
INR 1.0
- Studies were notable for:
MR ___ spine with and without contrast
Cord or cauda equina compression: No. Please note that imaging
can make the anatomic diagnosis of cauda equina COMPRESSION, but
that cauda equina SYNDROME is a clinical diagnosis based on the
patient examination. Imaging can never make a diagnosis of cauda
equina SYNDROME.
Cord signal abnormality: no
Epidural collection: no
Other: Increased fluid signal within the T12 and L1 vertebral
bodies at the site of known compression fractures. Multilevel
disc bulges, most prominent at L2-L3 causing moderate spinal
canal stenosis and bilateral neural foraminal stenosis.
- The patient was given:
IV morphine sulfate 2 mg x3
- Spine were consulted and recommended:
"TLSO ___ at edge of bed, no ___ restrictions,
follow
up with Dr. ___ in 1 month with lumbar spine AP/lateral
x-ray, pain management."
On arrival to the floor, She states her pain is ___ and her
pain
is adequately controlled. She also complains of constipation.
Past Medical History:
HTN
COPD
TIA
Osteoarthritis
Hypothyroidism
CHF (EF 60% in ___
Colon cancer
Sigmoid diverticulitis
Hysterectomy
Colectomy in ___
COPD
Squamous cell carcinoma
Social History:
___
Family History:
Not relevant to current presentation
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:
24 HR Data (last updated ___ @ 742)
Temp: 98.4 (Tm 98.4), BP: 172/70, HR: 86, RR: 20, O2 sat:
97%, O2 delivery: 2L
Fluid Balance (last updated ___ @ 756)
Last 8 hours Total cumulative 360ml
IN: Total 360ml, PO Amt 360ml
OUT: Total 0ml
Last 24 hours Total cumulative 360ml
IN: Total 360ml, PO Amt 360ml
OUT: Total 0ml
GENERAL: Alert and interactive. In no acute distress.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
crescendo-decrescendo murmur RUSB
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No CVA tenderness. Non-tender to palpation. Deferred
Sciatic exam given fracture.
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. multiple healed scars.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs
spontaneously. ___ strength throughout. Normal sensation.
DISCHARGE PHYSICAL EXAM
=======================
PHYSICAL EXAM:
VS:
___ 1115 Temp: 98.0 PO BP: 123/61 HR: 70 RR: 18 O2 sat: 94%
O2 delivery: Ra
Fluid Balance (last updated ___ @ 1200)
Last 8 hours Total cumulative 185mL
IN: Total 360 ml PO
OUT: Total 175ml, Urine Amt 175ml + inctx1
Last 24 hours Total cumulative 700ml
IN: Total 940ml, PO Amt 940ml
OUT: Total 285ml +inctx3
GENERAL: Alert and interactive. In no acute distress. Not
wearing
TLSO brace while in bed.
NECK: No cervical lymphadenopathy. No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2.
___ crescendo-decrescendo murmur appreciated throughout
precordium
LUNGS: Decrease breath sound in all lung fields anteriorly
BACK: Deferred Sciatic exam given fracture.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants.
EXTREMITIES: 1+ pitting edema in bilateral lower extremities.
Pulses DP/Radial 2+
bilaterally.
SKIN: Warm. Cap refill <2s. multiple healed scars.
NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs.
Pertinent Results:
ADMISSION LABS:
==============
___ 01:10PM WBC-9.4 RBC-3.79* HGB-11.7 HCT-35.6 MCV-94
MCH-30.9 MCHC-32.9 RDW-14.5 RDWSD-49.6*
___ 01:10PM NEUTS-78.7* LYMPHS-11.1* MONOS-7.2 EOS-2.1
BASOS-0.4 IM ___ AbsNeut-7.39* AbsLymp-1.04* AbsMono-0.68
AbsEos-0.20 AbsBaso-0.04
___ 01:10PM PLT COUNT-242
___ 01:10PM GLUCOSE-63* UREA N-25* CREAT-0.7 SODIUM-138
POTASSIUM-3.9 CHLORIDE-96 TOTAL CO2-24 ANION GAP-18
___ 01:10PM estGFR-Using this
IMAGING
=======
MR ___ & W/O CONTRAST ___. No evidence of cauda equina compression.
2. Compression fractures of L1 vertebral body (severe and with
mild
retropulsion) and L3 vertebral body (moderate). Superior
endplate fracture of
T12 vertebral body. The L1 and T12 fractures appear recent.
3. Moderate lumbar spondylosis, most marked at L2-L3, with
moderate spinal
canal narrowing, secondary to diffuse disc bulge and ligamentum
flavum
thickening. There is moderate bilateral neural foraminal
narrowing at L3-L4.
Chest radiograph ___. Mild pulmonary vascular congestion without frank pulmonary
edema.
2. Consolidation in the left lower lung field, consistent with
moderate left
pleural effusion alongside associated atelectasis. Remaining
left lung is
clear. Right lung is free of consolidation
3. Density projecting above the aortic arch is of unknown
etiology. Recommend
clinical correlation.
DISCHARGE LABS:
===============
___ 07:59AM BLOOD WBC-7.1 RBC-3.56* Hgb-11.1* Hct-34.6
MCV-97 MCH-31.2 MCHC-32.1 RDW-14.6 RDWSD-52.4* Plt ___
___ 07:59AM BLOOD Glucose-88 UreaN-27* Creat-0.8 Na-138
K-5.1 Cl-99 HCO3-31 AnGap-8*
___ 07:59AM BLOOD Calcium-9.2 Phos-3.6 Mg-2.8*
Brief Hospital Course:
___ with history of COPD, DMII, hypertension, and remote colon
cancer who presented with atraumatic back pain and found to have
T-spine fracture, urinary retention (for about a year) and
hypoxia which has improved. Currently has a TSLO brace for
support and HD and vitally stable. Discharged to rehab.
ACUTE/ACTIVE ISSUES:
====================
# Atraumatic T-spine fracture
Concerning for underlying osteoporosis. No cord compression by
imaging and urinary symptoms of unclear duration potentially. No
surgical intervention per spine surgery. Being treated with TLSO
brace when ambulating and pain medications. She also has an
appointment with Dr. ___ in 2 weeks. She should continue to
wear TLSO for duration when out of bed until f/u appointment.
She should continue to take calcium and vitamin D and f/u with
pcp for osteoporosis management. Pain control with Tylenol and
PRN oxycodone, pt at times not taking oxycodone. Encourage pt to
consider small dose in AM to help with mobilization/getting out
of bed to chair.
#Constipation - resolved
Patient complained of 5 days with no BM and recent indigestion.
She was started on multiple bowel regiments and had 2 bowel
movements on ___ and multiple BM on ___. Outpatient bowel
regimen can be PRN.
# Urinary retention - resolved
Concerning for cord compression, but no evidence on imaging and
rectal tone is normal, which is reassuring. Patient states that
she has been having an issue with urinary retention for about a
year. Perhaps secondary to severe pain. Foley in place and
removed on ___. She has been voiding without complaint.
# New Left pleural effusion- Resolved
# Hypoxemia
She was noted to be hypoxic to the low ___ on RA after receiving
multiple doses of IV morphine. CXR revealed left-sided pleural
effusion which was resolved after continuation of home lasix.
Subsequent CXR shows resolved effusion.
CHRONIC/STABLE ISSUES:
======================
# Hypertension
- Continue home amlodipine and losartan
# Hypothyroidism
- Continue home levothyroxine
TRANSITIONAL ISSUES:
===================
[] f/u appointment with Dr. ___ in 2 weeks ___
at 10:45 am at ___. She should
continue to wear TLSO brace when out of bed until this
appointment.
-- She will repeat Xray on same day as appt with Dr. ___
___: no HCP on file
Emergency ___: ___ (___ (DAUGHTER ___
___)
New medications
- oxycodone
- vitamin d
Changed medications
none
Stopped medications
none
CORE MEASURES:
==============
# CODE: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. amLODIPine 10 mg PO DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN wheezing
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*14 Tablet Refills:*0
3. Vitamin D 1000 UNIT PO DAILY
4. amLODIPine 10 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN wheezing
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
# Atraumatic T-spine fracture
# Constipation
# Urinary retention
# pleural effusion- Resolved
# Hypoxemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Ms. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were in the hospital because severe back pain.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- At the hospital we did imaging of your back that showed a
fracture in your lower back.
- We got a brace for you to stabilize your back.
- We also noted that you were having a hard time with passing
stool which we gave you some medication to help you have a bowel
movement.
- You were also having a hard time voiding so we place a foley
that we removed on ___. You were voiding with no issues
afterward.
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.
-You should wear your brace when out of bed until your follow up
appointment with Dr. ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19990545-DS-20 | 19,990,545 | 23,106,222 | DS | 20 | 2139-10-29 00:00:00 | 2139-10-29 17:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
ciprofloxacin / Unasyn
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: ERCP
.
___: CT-guided drainage of a retroperitoneal and pelvic
collections.
.
___: ___
.
___: CT-guided drainage of right perinephric collection.
History of Present Illness:
Mrs. ___ is a ___ w/ h/o chest/epigastric pain who presents
with 3 days of symptoms and U/S concerning for acute
cholecystitis. Patient reports that she has had a few of these
"attacks" over the past ___ years, occurring about every 6 months,
and described mostly as "twisting" chest pain, but usually
spontaneously resolves. For her current episode, she had
symptoms again mostly described as chest pain, and was worsened
with food intake. Her pain had not improved over the past few
days, thus she went to her PCP. There, she was noted to have RUQ
tenderness, and an U/S was obtained which was concerning for
acute cholecystitis. Patient underwent ERCP with sphincterotomy
on ___. Post ERCP patient developed abdominal pain,
distention, lipase was 1886 concerning for post ERCP
pancreatitis. Patient was admitted to the ___ surgery
service for evaluation, management of pancreatitis and possible
cholecystectomy.
Past Medical History:
None
Social History:
___
Family History:
Diabetes, h/o CAD
Physical Exam:
Prior to Discharge:
VS: 98.3, 61, 118/78, 18, 97% RA
GEN: Somewhat anxious without acute distress
HEENT: NC/AT, EIOM, PERRL, neck supple, no scleral icterus
SKIN: Trunk and thighs with multiple dark circular spots
CV: RRR, no m/r/g
PULM: CTAB
ABD: Soft non tender, non distended. Right flank with ___ drain
to bulb suction with minimal cloudy yellow output. Site with
drain sponge over and c/d/I.
EXTR: Warm, no c/c/e
Pertinent Results:
RECENT LABS:
___ 11:40AM BLOOD WBC-11.1* RBC-2.81* Hgb-7.8* Hct-24.1*
MCV-86 MCH-27.8 MCHC-32.4 RDW-13.8 RDWSD-43.8 Plt ___
___ 11:40AM BLOOD Glucose-124* UreaN-10 Creat-0.6 Na-132*
K-4.0 Cl-98 HCO3-24 AnGap-14
___ 06:01AM BLOOD ALT-156* AST-90* AlkPhos-289* TotBili-0.9
___ 11:40AM BLOOD Lipase-62*
___ 11:40AM BLOOD Calcium-7.7* Phos-3.5 Mg-2.3
MICROBIOLOGY:
___ 12:30 pm PERITONEAL FLUID
PERITONEAL FLUID ( FROM RETROPERITONEAL ABSCESS DRAIN ).
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
___ ALBICANS, PRESUMPTIVE IDENTIFICATION.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 4:40 pm FLUID,OTHER PERIPHERAL COLLECTION.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
___ ALBICANS. SPARSE GROWTH.
Yeast Susceptibility:.
Fluconazole MIC = 0.5 MCG/ML = SUSCEPTIBLE.
Results were read after 24 hours of incubation.
Sensitivity testing performed by Sensititre.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
RADIOLOGY:
___ LIVER US:
IMPRESSION:
1. Mobile gallstones and sludge within a moderately distended
gallbladder. No gallbladder wall edema or pericholecystic fluid
is seen at the present
time, although findings may represent early acute cholecystitis.
In addition there is note of choledocholithiasis, with at least
1 shadowing stone seen in the common bile duct.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study. Relative areas of hypo echogenicity
within the liver parenchyma are consistent with geographic
sparing from steatosis.
3. Trace right pleural effusion.
___ ERCP:
The scout film was normal.
Normal major papilla.
Cannulation of the biliary duct was successful and deep with a
sphincterotome using a free-hand technique.
Contrast medium was injected resulting in complete
opacification.
The common bile duct, common hepatic duct, right and left
hepatic ducts, biliary radicles and cystic duct were filled with
contrast and well visualized.
The course and caliber of the structures are normal with no
evidence of extrinsic compression, no ductal abnormalities, one
small stone was noted at the distal CBD
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome over an existing guidewire.
No evidence of post sphincterotomy bleeding was noted.
Balloon sweeps reveled small amount of sludge and one small
stone.
Occlusion cholangiogram showed no evidence of filling defects.
Post balloon sweeps good drainage of contrast and bile was
noted both endoscopically and fluoroscopically
Otherwise normal ercp to third part of the duodenum
___ KUB:
IMPRESSION:
No evidence of free intraperitoneal air.
___ CT ABD:
IMPRESSION:
1. Extraluminal retroperitoneal air is identified posterior to
the second
portion of duodenum. There is fluid extending from the duodenum
and to right perinephric space. Duodenal wall is thickened.
Findings are suspicious for duodenal perforation although no
oral contrast extravasation or discrete duodenal wall defect is
identified.
2. Cholelithiasis with gallbladder wall thickening.
Hyperenhancement of
gallbladder mucosa and extrahepatic bile ducts may be
inflammatory.
3. Peritoneal enhancement is consistent with peritonitis.
Omental nodularity may reflect edema.
4. Right colonic wall thickening may reflect secondary
inflammation.
5. Small to moderate ascites.
6. Bilateral pleural effusions are small.
___ CT ABD:
IMPRESSION:
1. Unchanged extraluminal retroperitoneal air and fluid
posterior to the
second portion of the duodenum and extending throughout the
right perirenal space, remaining suggestive of duodenum
perforation.
2. Moderate free fluid throughout the abdomen pelvis is slightly
increased
from prior with new rim enhancement suggestive of organizing
fluid
collections/ early abscess formation. New peritoneal
enhancement,
particularly in the pelvis, suggestive of peritonitis.
3. Mildly prominent small bowel loops with air-fluid levels are
suggestive of reactive ileus.
4. Probable reactive colonic mucosal thickening.
5. No definite CT evidence of acute cholecystitis.
___ ___ PROCEDURE:
1. Repositioning of wire placed under CT guidance from the
retroperitoneal
abscess into the retro duodenum region
2. Placement of 8 ___ biliary drain over wire with pigtail
formed in the retro duodenum region
3. Upper GI series through NG tube to evaluate for persistent
duodenum
perforation
___ CT ABD:
IMPRESSION:
1. Interval placement of a pigtail catheter, with resulting
decrease in size of the retroperitoneal fluid collection along
its course.
2. However, remainder of the small multiloculated perirenal
fluid collections on the right are unchanged in size.
3. Within the pelvis, a new 3.7 x 1.9 cm organized collection in
the region of the left adnexa could represent walled-off
ascites. Fluid collection along the posterior uterine wall has
decreased.
4. Fatty infiltration of the liver.
5. Trace pericardial effusion, grossly unchanged.
___ ___ PROCEDURE:
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
Brief Hospital Course:
The patient is a ___ female with acute cholecystitis
s/p ERCP. She was admitted to the HPB Surgical Service for
possible cholecystectomy. Overnight patient developed abdominal
pain and her lipase was 1886 with WBC 12. Surgery was postponed
and patient was started treatment for acute pancreatitis. She
was started on Unasyn, aggressive fluid resuscitation and made
NPO, pain was controlled with Dilaudid PCA. On HD 3, patient was
patient was noticed to have SOB, she was required supplemental
O2. Fluid rate was turned down, she was diuresed with Lasix x 2
and her respiratory status improved. On HD 6, patient's diet was
advanced to clear liquids. After taking clears, patient's
abdominal pain increased and she developed fever, she was made
NPO. On HD 7 (___) patient's WBC increased to 14K and CT scan
was obtained. Abdominal CT demonstrated extraluminal
retroperitoneal air, thickened duodenal wall, no active contrast
extravasation, peritoneal enhancement concerning for
peritonitis, ascites and acute cholecystitis. Patient's
antibiotics were changed to Cipro/Flagyl in the setting of
possible perforation. On HD 8 (___), patient's diet was
advanced to clears per GI recommendations. Patient spiked fever
to 103, vomited, and WBC increased to 16K, she was pan cultured
and ID was consulted. Cipro/Flagy was changed to meropenem per
ID recommendations. On HD 9 (___), patient remained febrile,
her blood, urine and stool cultures were negative. Patient
developed itchy rash, which start on her abdomen and spread.
Dermatology was consulted. Patient's WBC continued to climb and
was 18K. Patient was started on Allegra for itching and
Diprolene cream per Dermatology. On HD 10 (___) patient's WBC
continued to increase to 18.8, patient was afraid to have CT
scan secondary to her resent allergic reaction. On HD 11 (___),
WBC up to 19.6 and CT scan was obtained. CT demonstrated
unchanged extraluminal retroperitoneal air and fluid posterior
to the second portion of the duodenum and extending throughout
the right perirenal space, remaining suggestive of duodenum
perforation; moderate free fluid throughout the abdomen pelvis
is slightly increased from prior with new rim enhancement
suggestive of organizing fluid collections/ early abscess
formation; new peritoneal enhancement, particularly in the
pelvis, suggestive of peritonitis (please see Radiology report
for details). ___ was consulted for possible CT-guided drainage
of the fluid collections. On HD 12 (___) patient underwent
placement of two drains, one in retroperitoneal, and second into
pelvic fluid collections. Sample was sent for microbiology and
cell count. On HD 13 (___), patient underwent PICC line
placement and TPN was started for nutritional support. Abdominal
fluid cultures were positive for yeast and Mucafungin was added
per ID recommendations. On HD 14 (___) patient's diet was
advanced to clears and was well tolerated. On HD 15 (___)
micofungin was changed to Fluconazole as cultures growing
___. Patient's pelvic drain was discontinued. On HD 16
(___) patient's diet advanced to fulls. Patient's spiked a
fever to 101.7, WBC started to downward. Patient remained
febrile next four days with Tmax 102.1, WBC continued to
downtrend. On HD 19 (___) patient underwent CT scan, which
revealed decreased retroperitoneal fluid collection, small
multiloculated perirenal fluid collections and small walled off
ascites (please see Radiology report for details). On HD 20
(___) patient underwent CT-guided drainage of right
perinephric collection. After drainage diet was advanced to
regular. HD 21 (___), pain was well controlled, both
retroperitoneal and perinephric drain with minimal output, WBC
down tranding and patient remained afebrile. HD 22 (___), TPN
was discontinued. On HD 23 (___), perinephric drain fluid
positive for Candina, retroperitoneal drain was discontinued as
output was scant. HD 23 (___) patient discharged home in
stable condition with one drain remained in place and on
Fluconazole for 7 days total. Prior to discharge, patient
remained afebrile, pain was well controlled, PICC line was
removed, patient tolerated regular diet and ambulate without
assistance. Patient was discharged home with ___ services to
continue drain care. Follow up appointment with abdominal CT was
scheduled prior to discharge, patient instructed to call back if
fever or increased output from ___ drain.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
do not exceed more then 3000 mg/day
2. Betamethasone Dipro 0.05% Cream 1 Appl TP BID
RX *betamethasone, augmented 0.05 % aplly twice a day on
affected areas twice a day Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Fexofenadine 180 mg PO DAILY
5. Fluconazole 400 mg PO Q24H
RX *fluconazole 200 mg 2 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Acute cholecystitis
2. Post ERCP pancreatitis and small bowel perforation
3. Severe allergic reaction to antibiotics
(Unasyn/Ciprofloxacin) with skin rash
4. ___ peritonitis with intra abdominal abscesses
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the surgery service at ___ for management
acute pancreatitis and small bowel perforation after ERCP, which
was performed for acute cholecystitis. Your recovery was
complicated by severe allergic reaction to antibiotics and
___ peritonitis with intraabdominal abscesses, which
required ___ drainage. You required bowel rest and were placed on
TPN for nutritional support. Your diet is now advanced and TPN
was discontinued. You are now safe to return home to complete
your recovery with the following instructions:
.
Please call Dr. ___ office at ___ or ___
___, RN at ___. During off hours: Call pager
operator at ___ and ask to page ___ ___
___ team.
.
Please call back right away if you have fever > 100.5 or
increased abdominal pain. Call the numbers above if you drain
output significantly increase.
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.
.
___ drain care:
*Keep to bulb suction.
*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).
*Please note color, consistency, and amount of fluid in the
drain. Call the doctor, ___, or ___ nurse if the
amount increases significantly or changes in character. Be sure
to empty the drain frequently. Record the output, if instructed
to do so.
*Wash the area gently with warm, soapy water or ___ strength
hydrogen peroxide followed by saline rinse, pat dry, and place a
drain sponge. Change daily and as needed.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
Followup Instructions:
___
|
19990545-DS-22 | 19,990,545 | 28,670,614 | DS | 22 | 2140-03-04 00:00:00 | 2140-03-04 14:47:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin / Unasyn
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Patient is a ___ year old woman with history of
choledocholithiasis, cholecystitis in ___ s/p ERCP
decompression complicated by post-ERCP pancreatitis, duodenal
microperforation with RP and pelvic abscesses (s/p ___
drain placement) briefly requiring TPN, s/p cholecystectomy
___ now with episodic epigastric pain who presents with
worsening of her known abdominal pain.
Patient has had episodic epigastric pain for the past ___ year.
Prior to her cholecystitis episode in ___, she used to
experience the epigastric pain during ___ episodes per day,
characterized by sudden onset burning/throbbing pain that "feels
like spasms." The pain lasted 30 seconds to 1 minute and then
would go away.
She was admitted for abdominal pain and was diagnosed to have
cholecystitis. She underwent ERCP with stone extraction. However
subsequently had a complicated course with worsening
sxs/fever/leukocytosis, and eventually diagnosed with duodenal
perforation with RP/pelvic abscesses. SHe was treated with a
prolonged course of antibiotics
(unasyn-->cipro/flagyl-->meropenem) and ___ drainage of the fluid
collections. Abdominal fluid cultures were positive for yeast
and Mucafungin was also added per ID recommendations. SHe also
briefly required TPN. Her LFTs, WBC were trending down on day of
discharge. Her drains were removed at outpatient follow up and
she completed her course of abx. Her fluid collections improved
on post-dc CT scans.
SHe was then admitted in ___ for n/v, presumed to viral
gastroenteritis, improved with symptomatic therapy. SHe then
underwent CCY on ___.
For the past week she has been having ___ episodes of the
epigastric pain per day and also has a baseline ___ aching in
epigastrium for most of the day. Severe, cramping, non
radiating, worse when she does not eat for a long time, worst in
the morning. Also associated with several episodes of bilious
emesis over the past 2 days. Denies fevers, chills, recent
weight loss
In ED, VSS
On exam, tender in epigastrium to light palpation, voluntary
guarding in epigastrium.
Labs unremarkable
KUB did not show any free air under diaphragm, or any other
abnormality
Declined any pain medications
On arrival to floor, ROS negative except for as noted above.
During interview, noted to have one of the episodes of pain,
lasted 30 seconds, patient curled up clutching stomch, visibly
in significant distress, associated with retching.
Past Medical History:
- Choledocholithiasis and cholecystitis ___ s/p ERCP
decompression complicated by post-ERCP pancreatitis, duodenal
microperforation with RP and pelvic abscesses (s/p ___
drain placement) briefly requiring TPN
- S/p cholecystectomy ___
- Chronic abdominal pain
Social History:
___
Family History:
- No liver/gallbladder FH
- Dyslipidemia, HTN, diabetes, CAD
Physical Exam:
Gen: NAD, lying in bed
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
GI: soft, epigastric tenderness, guarding, ND
MSK: No significant kyphosis. No palpable synovitis.
Skin: No visible rash. No jaundice.
Neuro: AAOx3. No facial droop.
Psych: Full range of affect
Pertinent Results:
___ 01:14PM ___ PTT-31.0 ___
___ 12:37PM ___ COMMENTS-GREEN TOP
___ 12:37PM LACTATE-0.9
___ 12:34PM GLUCOSE-95 UREA N-15 CREAT-0.7 SODIUM-137
POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16
___ 12:34PM estGFR-Using this
___ 12:34PM ALT(SGPT)-20 AST(SGOT)-21 ALK PHOS-63 TOT
BILI-0.2
___ 12:34PM LIPASE-57
___ 12:34PM ALBUMIN-4.5 CALCIUM-9.2 PHOSPHATE-3.8
MAGNESIUM-2.0
___ 12:34PM WBC-9.9 RBC-4.87 HGB-13.2 HCT-40.0 MCV-82
MCH-27.1 MCHC-33.0 RDW-14.7 RDWSD-44.4
___ 12:34PM NEUTS-58.5 ___ MONOS-4.4* EOS-1.9
BASOS-0.6 IM ___ AbsNeut-5.78 AbsLymp-3.40 AbsMono-0.44
AbsEos-0.19 AbsBaso-0.06
___ 12:34PM PLT COUNT-292
___ 11:45AM URINE HOURS-RANDOM
___ 11:45AM URINE UCG-NEGATIVE
___ 11:45AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:45AM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-SM
___ 11:45AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
___ 11:45AM URINE MUCOUS-RARE
KUB: There is a nonobstructive bowel gas pattern. No large
air-fluid levels are seen. There is no evidence of free air.
Right upper quadrant surgical clips are from presumed
cholecystectomy. The lung bases are grossly clear.
MRCP: official read pending at time of discharge
Brief Hospital Course:
___ year old woman with history of choledocholithiasis,
cholecystitis in ___ s/p ERCP decompression complicated by
post-ERCP pancreatitis, duodenal microperforation with RP and
pelvic abscesses (s/p ___ drain placement) briefly
requiring TPN, s/p cholecystectomy ___ now with episodic
epigastric pain who presented with worsening of her chronic
abdominal pain. The cause of the acute increase of her chronic
abdominal pain remained unclear. She had no signs of perforation
or obstruction on KUB. MRCP was performed. GI team contacted
radiology who stated the wet read had no concerning findings.
Labs including lipase are unremarkable. She remained
hemodynamically stable with no systemic signs of toxicity. GI
and ERCP teams recommended discharge to home on PPI BID and
hyoscyamine prn abdominal cramping. They plan on performing an
outpatient EGD in the next ___ days.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY
3. Ranitidine 150 mg PO BID
4. Senna 8.6 mg PO BID
5. Multivitamins 1 TAB PO DAILY
6. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain - Moderate
Discharge Medications:
1. Hyoscyamine 0.125 mg SL Q4H:PRN abdominal cramping
RX *hyoscyamine sulfate 0.125 mg 1 tablet(s) sublingually every
four (4) hours Disp #*30 Tablet Refills:*0
2. Omeprazole 40 mg PO BID
RX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp
#*120 Capsule Refills:*0
3. Docusate Sodium 100 mg PO BID
4. Multivitamins 1 TAB PO DAILY
5. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 8.6 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
abdominal pain
Discharge Condition:
condition: good
mental status: intact at baseline
ambulatory status: independent
Discharge Instructions:
You were admitted to the hospital for abdominal pain and
expedited work-up. You had an MRCP that was unrevealing. You
were seen by GI who recommend an outpatient EGD be done early
this week. They will contact you with the specific date and
time. They have also recommended you start 2 new medications.
Omeprazole is to decrease gastric acid production and Levsin
(hyoscyamine) to treat abdominal cramping/muscle spasms.
Followup Instructions:
___
|
19990786-DS-23 | 19,990,786 | 20,124,902 | DS | 23 | 2154-11-04 00:00:00 | 2154-11-04 16:50:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Lovastatin
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history if CAD s/p ___ and POBA of the R-PDA in
___, hx TIAs in ___, HTN, HLD, DM, presenting as OSH transfer
___ for management of NSTEMI. The patient
noted that since ___ he had been experiencing "stoimach
upset" which was partially relieved by ___. He
continued to experience symptoms which he thought were
dyspepsia. The early ___ morning he was awoken from his
sleep by the onset of left sided chest pain/pressure
approximately 2am with some radiation to the upper back.
Associated with diaphoresis, nausea and vomiting. He called his
daughter who took him to the ED at ___. Found to have
elevated troponin and STDs V4-6. Given ASA. Started on heparin
PTA. Patient continuing to endorse chest pain on arrival to the
___ ED, though much improved. +d-dimer at ___.
In the ED, initial vitals were 97.8 66 184/103 18 96%, he was
started on a nitro gtt for ongoing chest pain. He continued on
Heparin gtt and received 1L NS. Labs remarkable for Troponin
0.02, CK 209, MB 5. Cr 1.3 (baseline ___. Had CTA
Chest given positive D dimer, which was negative for PE. He was
admitted to ___ for further management. Vitals on transfer: 63
186/92 13 98% RA. On arrival to the floor, patient reports that
his chest pain has resolved.
Past Medical History:
Past medical/surgical history:
- Hypercholesterolemia
- Hypertension
- CAD:
* ___, with circumflex cypher stent and right PDA POBA.
* ___: repeat cath: patent stent, diffuse disease in other
vessels
- Left hemiparesis after subdural hematoma
- Diabetes
- Gout
- Hernia repair
- Right below-knee amputation ___ years ago after a motor vehicle
accident and recent revision ___ has prosthesis; walks with
a cane
- Subdural hematoma s/p evacuation ___
- GERD
- h/o BPPV
- h/o TIA
Social History:
___
Family History:
father had hx of MIs and stroke, mother died of stomach cancer,
brother who needed CABG and died during CABG procedure.
Physical Exam:
On Admission:
--------------
Vitals:Temp 98, BP 122/74, HR 66, RR 16, O2 100% RA
General: well-appearing man in NAD
Neck: JVP flat, no carotid bruits
CV: RRR, S1, S2, S4, no murmurs or rubs
Lungs: clear to auscultation bilaterally
Abdomen: soft, nontender, nondistended, no evidence of masses or
organomegaly
GU: no foley
Extr: Right BKA, left with diminished ___ and DP pulses, feet
cool to touch
At Discharge:
--------------
Pertinent Results:
Labs on Admission:
-------------------
___ 07:41AM NEUTS-78.7* LYMPHS-16.3* MONOS-4.5 EOS-0.4
BASOS-0.2
___ 07:41AM PLT COUNT-217
___ 07:41AM NEUTS-78.7* LYMPHS-16.3* MONOS-4.5 EOS-0.4
BASOS-0.2
___ 07:41AM ___ PTT-96.7* ___
___ 07:41AM ALBUMIN-4.0 CALCIUM-8.7 PHOSPHATE-3.0
MAGNESIUM-1.4*
___ 07:41AM GLUCOSE-316* UREA N-33* CREAT-1.3* SODIUM-136
POTASSIUM-5.4* CHLORIDE-99 TOTAL CO2-22 ANION GAP-20
___ 07:41AM ALT(SGPT)-22 AST(SGOT)-41* CK(CPK)-209 ALK
PHOS-99 TOT BILI-0.4
___ 07:41AM LIPASE-29
___ 07:41AM cTropnT-0.02*
___ 01:45PM cTropnT-0.02*
___ 07:48PM CK-MB-3 cTropnT-0.01
REPORTS THIS ADMISSION:
Cardiac Perfusion Test ___:
There is mild fixed defect in the inferolateral wall in setting
of soft tissue attenuation. LV size and wall motion is normal.
EF is 60%.
Cardiac Stress Test ___: INTERPRETATION:
This ___ year old IDDM with a PMH of old MI, PCIs, 3VD and
traumatic LLL ambutation was referred to the lab for evaluation
of chest discomfort. The patient was infused with 0.142
mg/kg/min of dipyridamole over 4 minutes. No arm, neck, back or
chest discomfort was reported by the patient throughout the
study. There were no significant ST segment changes during the
infusion or in recovery. The rhythm was sinus with 1 apb.
Appropriate hemodynamic response to the infusion and recovery.
The dipyridamole was reversed with 125 mg of aminophylline IV.
IMPRESSION: No anginal type symptoms or ST segment changes.
Nuclear
report sent separately.
Brief Hospital Course:
___ PMH CAD, HTN, T2DM and HLD presenting with chest pain, HTN
and elevated troponin c/w NSTEMI.
# Unstable Angina with Troponin leak: patint with unstable
angina, and troponin leak, however troponin elevation <0.1, so
not true NSTEMI. Nitro gtt discontinued and patient remained
free of chest pain. Heparin gtt was discontinued, and he had no
recurrence of chest pain. He was medically optimized with
Atorvastatin 80, Beta-blocker, and ASA. He went for stress-mibi
to rule out reversible defects, and this study showed no new
reversible defects as well as no new irreversible defects and a
preserved ejection fraction. Please see "reports" section for
full details. He was discharged on his home medication regimen,
with the exception that his atorvastatin was increased to 80mg
PO daily from a dose of 40mg for CAD optimization.
# CAD: continued home atorvastatin at an increased dose of 80mg
as above; switched home atenolol to labetalol while in house but
transitioned back to home atenolol at discharge; continued home
ASA.
# DMT2: held home oral metformin and glipizide; ISS and QACHS ___
while in house
# HTN:continued home lisinopril and atenolol at discharge.
# Gout: continued home allopurinol.
# GERD: continued home omeprazole.
*****TRANSITIONAL ISSUES*****
- Atorvastatin was increased to 80mg qDaily.
- CPET without reversible defects.
- may consider switching atenolol to carvedilol as outpatient.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Lisinopril 10 mg PO DAILY
3. Chlorthalidone 12.5 mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. GlipiZIDE XL 10 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Omeprazole 20 mg PO DAILY
4. Atenolol 100 mg PO DAILY
5. Chlorthalidone 12.5 mg PO DAILY
6. GlipiZIDE XL 10 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
10. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet(s) sublingually
every 5 minutes as needed for Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
--------
Unstable Angina with Troponin Leak
Hypertensive Emergency
Secondary:
----------
Coronary Artery Disease
Diabetes Mellitus Type 2
HTN
HLD
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you during your hospital stay
at ___. You came in because you
were having chest pain. At the hospital we found that you had a
heart attack and your blood pressure was very high. We treated
you for the heart attack. You went for a stress test which
showed no evidence of worsening in your heart's function. It is
now safe for you to be discharged. Please be sure to take all of
your medications as prescribed and keep your follow-up
appointments. We wish you the very best !
Sincerely,
Your ___ Cadiology Team
Followup Instructions:
___
|
19991085-DS-19 | 19,991,085 | 28,178,930 | DS | 19 | 2125-01-10 00:00:00 | 2125-01-10 18:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abnormal PET scan
Major Surgical or Invasive Procedure:
Mediastinoscopy with lymph node biopsy
History of Present Illness:
___ year old female with history of spinal stenosis, cervical
radiculopathy, AV block s/p PPM (___), and morbid obesity
who was referred to the ED for abdnormal CT findings. The
patient is being followed by Neurology for spinal stenosis and
cervical radiculopathy. CT C-spine in ___ revealed enlarged
cervical and mediastinal lymph nodes. CT Chest on ___ showed
enlarged mediastinal and peripancreatic lymph nodes, up to 1.5x
2.3cm with mild splenomegaly. She was referred to Oncology, Dr.
___, and underwent a PET scan on ___, which returned
suspicious for lymphoma. There was also concern for cervical
cord/canal involvement by enlarged lymph nodes. The patient was
referred to the ED for further management.
In the ED, initial vitals were: 98.2 89 116/81 16 98% RA. Labs
were notable for WBC 7.1 (17.7L) and Cr 0.8. An MRI could not be
performed due to PPM. Radiology and neuoradiology felt there
would be no benefit to assess possible lymphoma involvement with
CT. Neurosurgery was consulted and there was low concern for
acute cord impingement or surgical lesion.
Upon arrival to the floor, the patient described stable numbness
in her arms, legs, and bottom of her feet. She describes
numbness at the lateral aspects as well as hands (Lt > Rt). The
numbness in her legs is prominent in her thighs above the knees
bilaterally. She describes intermittent weakness in her arms and
legs as well, that has been ongoing for years. She describes
having to sit after walking for long perioids. She also
describes difficulty with picking up objectss. The patient also
describes intentional 16 lb weight loss over 2 months. She has
night sweats at baseline, which has worsened as she is
___. Lastly, she describes feeling overwhelmed with
the new diagnosis of potential lymphoma. She denies any fevers,
chills, cough, shortness of breath, and abdominal pain. She has
stress incontinence at baseline, which has not changed.
Past Medical History:
- Morbid obesity
- Hypothyroidism
- 2nd degree AV block s/p PPM ___, Adapta L, implated
___
- Spinal stenosis
- Cerivical radiculopathy
- GERD
- Colon polyps, adenomatous
- Tinnitus
- Polycistic ovaries
- Stress urinary incontinence
- Genital herpes
- H/o wide complex tachycardia: VT versus SVT with aberrancy
- Depression
Social History:
___
Family History:
Brother: DM
Father: Died of lung cancer
MGF: Heart disease
MGM: Lung cancer
PGM: Aneurysm
PGF: Stomach cancer
Physical Exam:
Exam on Admission:
Vitals: 98.4 143/89 91 16 99RA
General: Alert, oriented, tearful, pleasant, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated. No lymphadenopathy.
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
at ___.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: +BS, soft, nondistended, nontender to palpation.
LYMPH NODES: No asxillary or inguinal lymph nodes palpated.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Exam on Transfer:
Vitals: Weight-92.3kg, Tc-98.4, Tm-98.4, BP-141/68
(141-143/68-89), HR-70 (70-91), RR-16 (16), O2-97% RA (97-99),
I/O since ___ admission: 120/not measured
General: AAOx3, comfortable appearing, in NAD, tearful when
discussing diagnosis and child care
HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink.
MMM. OP clear.
Neck: supple, no LAD, no JVP elevation
Lungs: CTAB, no w/r/r
CV: RRR, normal S1 and S2, no m/g/r
Abdomen: NABS, soft, nondistended, nontender. No HSM.
GU: no foley
Ext: WWP. 2+ peripheral pulses. No edema.
Neuro: CNs II-XII intact. Equal strenght in upper extremities
bilaterally. Decreased hamstring strength on L leg. Equal
proprioception, sensation to light touch and pin prick, and
vibratory sensation in upper and lower extremities bilaterally
Exam on Discharge:
VS: 97.6 134/64 52 18 98%RA
Wt: 196.6lbs (90kg)
GEN: Pleasant, NAD
HEENT: NCAT
Cards: Bradycardic, S1/S2 normal. Pacer site on left anterior
chest without induration, warmth or erythema.
Pulm: CTAB no crackles or wheezes
Abd: soft, NT, no rebound/guarding, no HSM. Nontender in RUQ
Extremities: wwp, no edema.
Skin: no rashes or bruising
Neuro: AOx3, CNs II-XII intact. ___ strength in U/L extremities.
sensation intact to LT, cerebellar fxn intact (RAM). Gait
grossly normal
Pertinent Results:
Imaging:
Pelvic US ___: No abnormality identified in the cervix.
Vaginal canal not well evaluated.
RECOMMENDATION(S): Pelvic MRI can be considered to better
evaluate the vaginal canal.
Hand Xray ___: Pending
ECHO ___:
IMPRESSION: Normal global and regional biventricular systolic
function.
CXR ___:
FINDINGS:
There is subsegmental atelectasis in both lower lungs. There is
no pneumothorax. The appearance of the dual lead pacemaker is
unchanged. The upper lungs are clear
Groin US ___:
IMPRESSION:
1. No abnormal right groin lymph node identified for marking.
2. Few normal-appearing right groin lymph nodes.
CXR ___:
Compared to the prior study there is no significant interval
change. There is a dual lead pacemaker with the leads
projecting over the expected location. No other radiopaque
foreign bodies are visualized.The cardiac and mediastinal
silhouettes are normal and are unchanged compared to prior.
MRI Head w/ and w/o contrast ___:
1. Study is limited by motion artifact, as described, limiting
the spatial resolution.
2. Diffuse nodular enhancing disease involving the
leptomeningeal and pachymeningeal extra-axial spaces, as
described, predominantly within the basal cisterns consistent
with intracranial lymphoma.
3. Mass like enhancing disease within the visualized upper
cervical canal from C1 through C3 levels, which may be
compressing or infiltrating the adjacent cervical cord.
4. Low signal within the cranial marrow which is nonspecific and
may be seen with hematopoetic marrow or infiltration.
MRI Cervical/Thoracic spine ___:
1. Motion artifact which limits space resolution of this study.
2. Diffuse total spine leptomeningeal carcinomatosis consistent
with lymphoma.
3. More focal areas of nodular masslike enhancing disease, as
described, with large 2 cm lesion at the C3 level severely
compressing the traversing cervical cord causing intrinsic cord
edema.
4. Enhancing lesion within the S2 vertebral body which may
represent
metastatic osseous disease.
5. Prominent bilateral iliac chain lymph nodes, as described.
___ FDG PET
IMPRESSION: 1. Widespread multifocal FDG adenopathy involving
the cervical, mediastinal, retroperitoneal, retrocrural, pelvic
side wall, and inguinal nodes consistent with neoplasm.
2. Focal uptake within the spinal canal within the cervical,
thoracic, and sacral levels consistent with intrathecal
involvement for which emergent MRI is advised.
3. Scattered foci of FDG avidity within the spleen consistent
with splenic involvement.
4. Foci of uptake involving the vagina and anterior cervix are
suspicious for
neoplasm for which pelvic ultrasound or MRI is additionally
warranted.
___ CXR
Compared to the prior study there is no significant interval
change. There is a dual lead pacemaker with the leads
projecting over the expected location. No other radiopaque
foreign bodies are visualized.The cardiac and mediastinal
silhouettes are normal and are unchanged compared to prior.
Admission Labs:
___ 06:25PM GLUCOSE-108* UREA N-13 CREAT-0.8 SODIUM-141
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 06:25PM TOT PROT-7.2 CALCIUM-9.3 URIC ACID-5.5
___ 06:25PM LD(LDH)-218
___ 06:25PM WBC-7.1 RBC-3.99 HGB-12.3 HCT-37.5 MCV-94
MCH-30.8 MCHC-32.8 RDW-13.2 RDWSD-45.5
___ 06:25PM NEUTS-70.1 LYMPHS-17.7* MONOS-8.0 EOS-3.5
BASOS-0.4 IM ___ AbsNeut-4.99 AbsLymp-1.26 AbsMono-0.57
AbsEos-0.25 AbsBaso-0.03
___ 06:25PM PLT COUNT-191
Discharge Labs:
___ 07:50AM BLOOD WBC-13.2* RBC-4.30 Hgb-13.5 Hct-39.2
MCV-91 MCH-31.4 MCHC-34.4 RDW-13.5 RDWSD-45.1 Plt ___
___ 08:35AM BLOOD ___ PTT-28.7 ___
___ 07:50AM BLOOD Glucose-105* UreaN-15 Creat-0.6 Na-137
K-4.2 Cl-102 HCO3-25 AnGap-14
___ 07:50AM BLOOD Calcium-9.9 Phos-3.9 Mg-2.3
___ 07:45AM BLOOD 25VitD-39
___ 09:53PM BLOOD b2micro-1.9
___ 06:25PM BLOOD PEP-NO SPECIFI
___ 08:35AM BLOOD HIV Ab-Negative
ACE level: 31 (normal
Brief Hospital Course:
Ms. ___ is a ___ y.o. woman with a history of spinal
stenosis, cervical radiculopathy, and obesity who presents for
workup after multiple CTs revealed cervical and mediastinal
lymphadenopathy and a PET scan on ___ was concerning for
lymphoma with possible cord involvment/compression. MRI ___
revealed significant brain and cord involvement with concern for
cord compression at C3 and T8 despite absence of clinical
findings. Lymph node biopsy consistent with sarcoidosis.
#Sarcoidosis: Patient found to have significant lymphadenopathy
on CT C spine done for progressive neuropathy and weakness now
with PET scan showing widspread lymphadenopathy concerning for
neoplasm with possible intrathecal involvement. MRI ___ showed
brain and cord involvement with possible compression of cord at
C3 and T8, for which patient was given steroids. In the mean
time, she underwent mediastinoscopy for biopsy and tissue
diagnosis on ___, with final pathology still pending but so far
consistent with sarcoidosis. HIV was negative. There was a low
suspicion for CNS lymphoma but it could not be ruled out because
LP was contraindicated given risk of cervical spine cord
compression. Rheumatology was consulted. She was treated with
methylprednisolone 1g qday x 3 days and will be discharged on
1mg/kg (IBW) prednisone (currently 50mg PO daily). She was
placed on PCP prophylaxis and ___ PPI that she will continue as an
outpatient. She will need a TB test as an outpatient. Lymph node
final pathology, ACE level, and hand xray reads are still
pending. She may need a cardiac-protocol PET to evaluate for
cardiac sarcoidosis.
#Gait abnormalities: The patient has had gait abnormalities
progressive over years, possibly related to stenosis but
concerning for worsening impingement on spinal cord. She was
managed with steroids and her gait problems have improved. She
should use a cane to ambulate per ___.
#Spinal stenosis: Patient has history of spinal stenosis for
which she takes gabapentin. She has no focal deficits on exam.
She should continue home gabapentin 300mg QD
#Cervical/vaginal lesion: PET showed uptake in cervix, which
would be atypical for sarcoid.Pelvic US revealed no lesions of
the cervix but MRI would better evaluate the vaginal canal.
#History of wide complex tachycardia: She has a pacer which
doesn't seem to be ICD. She was continued on metoprolol XL
100mg.
#Hypothryroidism: She was continued on levothyroxine 150mcg
daily
TRANSITIONAL ISSUES:
[] Started on 90mg PO prednisone daily, will need to continue
PPI and bactrim for PPX
[] Please obtain TB test as an outpatient
[] Follow-up ACE & 1,25 vitD levels
[] Consider cardiac-protocol PET to evaluate for cardiac
involvement of sarcoid
[] Follow-up final pathology of lymph node biopsy
[] Follow-up appointment with ___ Rhematology
[] Follow-up read of hand xray
[] Consider pelvic MRI for evaluation of vaginal canal
CODE STATUS: Full
CONTACT: ___ (Husband) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO PRN prior to PET scan
2. Gabapentin 300 mg PO DAILY
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Vitamin D 1000 UNIT PO DAILY
7. urea 40 % topical BID
Discharge Medications:
1. Gabapentin 300 mg PO DAILY
2. Levothyroxine Sodium 150 mcg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Vitamin D 1000 UNIT PO DAILY
6. urea 40 % topical BID
7. PredniSONE 50 mg PO DAILY
RX *prednisone 50 mg 1 tablet by mouth Daily Disp #*30 Tablet
Refills:*0
8. Senna 17.2 mg PO BID constipation
RX *sennosides [senna] 8.6 mg ___ Tablets by mouth BID prn Disp
#*30 Tablet Refills:*0
9. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet by mouth Daily Disp #*30 Tablet
Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Lymphadenopathy
Sarcoidosis
Spinal cord compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ after a PET scan revealed
lymphadenopathy concerning for malignancy and concerning for
spinal cord involvement. You underwent brain and spine MRI to
evaluate your spinal cord, and multiple brain and spine lesions
were detected. To better assess the nature of the lesions, you
subsequently underwent mediastinoscopy to obtain a lymph node
for histological analysis. The results of the biopsy showed that
you had sarcoidosis, not lymphoma. You were seen by rheumatology
and treated with high-dose steroids. You will need to continue
to take the prednisone steroid as well as your prophylactic
antibiotic.
Please report to an ED or your PCP with any worsening weakness,
numbness, cough, fevers, or chills. It was our pleasure taking
care of you,
Your ___ Team
Followup Instructions:
___
|
19991135-DS-18 | 19,991,135 | 29,872,770 | DS | 18 | 2133-07-11 00:00:00 | 2133-07-12 16:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tofu / moxifloxacin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yo F with medical history notable for atrial
fibrillation (not on Coumadin due to recurrent fall history, s/p
watchman ___, COPD on O2 (5L at rest), and frequent falls
who presented with shortness of breath and dizziness.
Per PCP notes patient was discharged from ___ ___
after being admitted 1 week previously with a severe flare of
her
advanced COPD. Unfortunately, no records available on BID
community link in OMR. She was recommended to go to rehab but
apparently did not want to do this. Per note PCP started her on
___ mg Lasix PO on ___ due to cocern for volume overload.
In the last few days since discharge from the hospital she has
had significant worsening of her baseline shortness of breath.
Normally when she gets up from lying down to sitting her
saturations will drop to mid ___ and then recover to low ___.
This week she has been dropping to the ___ with significant
shortness of breath. Today she became extremely dyspneic when
going to the bathroom, got dizzy, and fell down. Denies striking
her head. She crawled to her bedroom and was able to call for an
ambulance.
In the ED:
Initial vitals:
-98.6 90 115/82 26 92% 5L NC
- Labs notable for:
WBC 15.8, Hb 9.7, Cr 1.3, pBNP 3155, trop <0.1, INR 1.0, pH 7.51
- Imaging notable for: CTA with extensive segmental and
subsegmental PE, right ventricular prominence and pHTN noted
- Pt given:
___ 02:37 IH Albuterol 0.083% Neb Soln 1 NEB
___ 02:37 IH Ipratropium Bromide Neb 1 NEB
___ 02:51 IH Albuterol 0.083% Neb Soln 1 NEB
___ 02:51 IH Ipratropium Bromide Neb 1 Neb
___ 03:40 IH Albuterol 0.083% Neb Soln 1 Neb
___ 03:40 IH Ipratropium Bromide Neb 1 Neb
___ 06:52 IV Azithromycin
___ 06:52 IV CefTRIAXone
___ 06:52 IV Heparin 7000 UNIT
___ 06:52 IV Heparin
___ 07:03 IV CefTRIAXone 1 gm
___ 07:37 IV Azithromycin 500 mg
- Vitals prior to transfer:
HR 90 BP 105/65 RR 20 SPO2 87% 5L NC
Of note, patient was also admitted to ___ in ___ for Watchman
occlusion device, however the procedure was aborted due to
recurrent device dislodgements. During the procedure she had an
episode of severe hypotension and bradycardia requiring two
minutes of CPR until her condition stabilized. After This was
thought to be secondary to an air embolism. Dr. ___ was
consulted
for left atrial appendage ligation, went to operating Room on
___ where she underwent exclusion of left atrial appendage
via left mini thoracotomy with Dr. ___. She was on warfarin but
due to multiple falls and appendage surgery, this was stopped at
some point in ___.
Upon arrival to the floor, the patient denies chest pain or
dizziness. She reports mild shortness of breath.
Past Medical History:
1. HTN
2. Hypercholesterolemia
3. chronic back pain
4. COPD/emphysema
5. C spine disc disease
6. Depression
7. pneumonia ___. Right brachial plexus neuropathy
9. Right eye with decreased vision, ? macular degeneration
10. SLE (severe ophthalmopathy, diffuse arthropathy)
11. OSA/cpap
12. MVP
13. Fibromyalgia
PSH
1. S/P B/L cataracts
2. S/P C4-5 fusion
3. S/P multiple skin Ca exc both squamous and basal cell
Social History:
___
Family History:
No family history of premature coronary artery disease,
cardiomyopathy, congestive heart failure, or sudden death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
___ 1506 Temp: 97.8 PO BP: 117/67 R Lying HR: 87 RR:
20 O2 sat: 90% O2 delivery: 5 L
General: Lying in bed, on 5L NC
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, Right
pupil fixed 6mm, Left pupil 5-4mm
CV: Irregular, no murmurs, rubs, gallops
Lungs: Globally decreased breath sounds, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses; 1+ edema to the ankles b/l
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact (pupil exam as above), ___ strength
upper/lower extremities, grossly normal sensation,
DISCHARGE PHYSICAL EXAM:
VITALS: Afebrile, HR ___, BP 127/79, RR ___, satting 96%
on hi flow NC, 40L with 50% FiO2
GENERAL: Resting in bed, overall appears comfortable
HEENT: Sclera anicteric
CARDIAC: Tachycardic, distant heart sounds, no murmurs
PULMONARY: Significant diffuse wheezing w/ reduced breath sounds
ABDOMEN: Soft, nt, nd
EXTREMITIES: Warm with lower extremity ecchymoses, no ___ edema
SKIN: Warm and dry
NEURO: A&O x3
Pertinent Results:
___ 11:09PM BLOOD WBC-15.8* RBC-3.64* Hgb-9.7* Hct-32.4*
MCV-89 MCH-26.6 MCHC-29.9* RDW-14.7 RDWSD-48.0* Plt ___
___ 07:09AM BLOOD WBC-16.3* RBC-3.08* Hgb-8.3* Hct-28.3*
MCV-92 MCH-26.9 MCHC-29.3* RDW-15.7* RDWSD-51.7* Plt ___
___ 05:03AM BLOOD WBC-15.3* RBC-2.82* Hgb-7.7* Hct-25.9*
MCV-92 MCH-27.3 MCHC-29.7* RDW-15.6* RDWSD-51.1* Plt ___
___ 04:40AM BLOOD WBC-11.5* RBC-2.58* Hgb-7.0* Hct-23.3*
MCV-90 MCH-27.1 MCHC-30.0* RDW-15.4 RDWSD-49.4* Plt ___
___ 11:09PM BLOOD Glucose-277* UreaN-17 Creat-1.3* Na-143
K-4.4 Cl-95* HCO3-29 AnGap-19*
___ 05:10PM BLOOD Glucose-285* UreaN-18 Creat-1.0 Na-136
K-4.2 Cl-96 HCO3-25 AnGap-15
___ 04:40AM BLOOD Glucose-253* UreaN-30* Creat-1.0 Na-139
K-3.7 Cl-102 HCO3-27 AnGap-10
___ 07:09AM BLOOD cTropnT-<0.01 proBNP-2778*
___ 06:30PM BLOOD Digoxin-0.9
___ 06:09PM BLOOD ___ pO2-22* pCO2-43 pH-7.43
calTCO2-29 Base XS-2
CTA CHESTStudy Date of ___ 5:15 AM
1. Extensive filling defects in the pulmonary vascular tree
compatible with
pulmonary emboli. These are seen as proximal as the right
intralobar artery.
Emboli are seen at both the segmental and subsegmental level
involving nearly
every lobe, but predominantly in the lower lobes.
2. There is mild prominence of the right ventricle. Clinical
correlation for
right heart strain is recommended.
3. Dilation of the main pulmonary and right and left pulmonary
arteries
compatible with pulmonary hypertension.
4. Severe emphysematous changes. Ground-glass opacification is
seen
bilaterally which suggests interstitial pneumonitis. However,
in the superior
left upper lobe there is a more consolidative appearance favored
to represent
infection with atelectasis and infarction also considerations.
5. Trace left pleural effusion.
Transthoracic Echocardiogram Report
Name: ___ ___ MRN: ___ Date: ___ 09:45
The left atrium is mildly elongated. The estimated right atrial
pressure is ___ mmHg. The left ventricle has a
normal cavity size. Overall left ventricular systolic function
is normal. Mildly dilated right ventricular cavity
with moderate global free wall hypokinesis. Intrinsic right
ventricular systolic function is likely lower due to the
severity of tricuspid regurgitation. The mitral valve leaflets
appear structurally normal. There is trivial mitral
regurgitation. There is moderate to severe [3+] tricuspid
regurgitation. There is SEVERE pulmonary artery
systolic hypertension. In the setting of at least moderate to
severe tricuspid regurgitation, the pulmonary
artery systolic pressure may be UNDERestimated.
IMPRESSION: Right ventricular cavity dilation with free wall
hypokinesis. Severe pulmonary artery
systolic hypertension. Moderate to severe tricuspid
regurgitation.
Brief Hospital Course:
___ is a ___ year old woman a history of atrial
fibrillation s/p Watchman procedure in ___ (with prior
Watchman issues with device dislodgments and a cardiac arrest
___ possible air embolism in ___, not on home
anticoagulation due to frequent falls, COPD (5L O2 at home), who
was admitted to ___ on ___ for a submassive pulmonary
embolism. She was treated in the medical ICU until ___ for
this, along with pneumonia, copd exacerbation, and pulmonary
edema before being discharged directly to ___
___.
ACUTE ISSUES:
===================
#ACUTE RESPIRATORY FAILURE:
#SUBMASSIVE PULMONARY EMBOLISM:
#PULMONARY EDEMA:
#COPD WITH EXACERBATION
#HOSPITAL ACQUIRED PNEUMONIA:
Admitted to medicine initially, treated on the floor initially
with a heparin gtt, stable O2, transitioned to apixaban. She was
transferred to the MICU when she developed worsening hypoxemia
as well as tachcyardia and hemoptysis. She maintained that she
was DNR/DNI and was managed with non-invasive oxygenation
methods. Failure of anticoagulation was considered unlikely, but
she was transitioned to enoxaparin BID. Her acute respiratory
failure was felt to be from pulmonary edema, copd exacerbation,
and possible pneumonia. She improved with treatment of all three
and was weaned to <10 L/hr oxymizer, sats ok on NRB mask for
transfer to rehab.
- Discharged with azithromycin as well as a slow prednisone
taper, finishing vancomycin and cefepime (D7/last day =
___
- Restarted home furosemide at discharge
#GOALS OF CARE:
Spoke at length with the team and palliative care. She very
clearly wants to be in the hospital as little as possible.
Remains DNR/DNI. She was OK with a short stay at rehab to
maximize her chances of doing well at home, very important for
her to return there to be with her cats. Her mother does not
know that wants to be DNR/DNI and is even considering hospice
care, but her friend/sister-in-law/HCP ___ ___
is in the loop.
#STEROID INDUCED ANXIETY:
Prednisone taper significantly affecting the patient's anxiety,
well known issue for the patient. She was given large doses of
clonazepam here without respiratory drive depression, and it is
OK and actually preferable to continue controlling her anxiety
at rehab with this medication. Please call PCP if any concerns.
CHRONIC ISSUES:
=====================
#ATRIAL FIBRILLATION:
Now on anticoagulation, but for PEs. Continued metoprolol and
digoxin.
#DIABETES MELLITUS:
Continued insulin
#DEPRESSION/ANXIETY:
Continued home antidepressants and anxiety medications
#GERD:
Continued home PPI, sucralfate
#CHRONIC PAIN:
Continued home gabapentin, oxycodone
TRANSITIONAL ISSUES:
=====================
- Last day of vanc/cefepime is ___. OK to continue vancomycin
at 750 mg BID without checking levels.
- Last day of azithromycin is ___
- OK for patient to get significant doses of clonazepam,
especially while on prednisone taper. Please call PCP if any
concerns.
- Please consult palliative care and social work if available
- Prednisone taper, written out in discharge orders
- OK to use IV pain medication if needed, please avoid sending
patient back to hospital for pain management if possible
CODE STATUS: DNR/DNI
HCP: ___ (___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob
3. Cetirizine 10 mg PO DAILY
4. ClonazePAM 1.5 mg PO QHS:PRN insomnia and agitation
5. Digoxin 0.125 mg PO DAILY
6. DULoxetine 120 mg PO DAILY
7. Gabapentin 2400 mg PO QHS
8. Omeprazole 40 mg PO DAILY
9. PredniSONE 10 mg PO DAILY
Tapered dose - DOWN
10. Sucralfate 1 gm PO QID:PRN GI upset
11. Diazepam 5 mg PO Q12H:PRN m spasm
12. melatonin 10 mg oral QHS:PRN
13. MetFORMIN XR (Glucophage XR) 500 mg PO DAILY
14. nicotine (polacrilex) 4 mg buccal DAILY:PRN
15. Aspirin EC 81 mg PO DAILY
16. Furosemide 20 mg PO DAILY
17. ClonazePAM 0.5 mg PO DAILY:PRN anxiety
18. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of
breath/wheezing
19. Metoprolol Succinate XL 100 mg PO DAILY
20. GlipiZIDE XL 5 mg PO DAILY
21. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
22. ipratropium bromide 0.03 % nasal DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Azithromycin 250 mg PO DAILY Duration: 4 Doses
Last day ___. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line
4. CefePIME 2 g IV Q8H
Last day ___. Enoxaparin Sodium 80 mg SC Q12H
6. Glargine 8 Units Bedtime
Humalog 4 Units Breakfast
Humalog 4 Units Lunch
Humalog 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
7. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
8. Metoprolol Tartrate 25 mg PO Q6H
9. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*12 Tablet Refills:*0
10. PredniSONE 10 mg PO DAILY Duration: 3 Days
Start after the patient finishes 3 days of pred 20 mg Qd, and
then stop prednisone completely.
Tapered dose - DOWN
11. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
12. Senna 8.6 mg PO BID:PRN Constipation - First Line
13. Vancomycin 750 mg IV Q 12H
Last day ___. ClonazePAM 0.5 mg PO BID:PRN anxiety
RX *clonazepam 0.5 mg 1 tablet(s) by mouth twice a day Disp #*6
Tablet Refills:*0
15. PredniSONE 60 mg PO DAILY Duration: 2 Days
16. PredniSONE 50 mg PO DAILY Duration: 3 Doses
This is dose # 1 of 5 tapered doses
17. PredniSONE 40 mg PO DAILY Duration: 3 Doses
This is dose # 2 of 5 tapered doses
18. PredniSONE 30 mg PO DAILY Duration: 3 Doses
This is dose # 3 of 5 tapered doses
Tapered dose - DOWN
19. PredniSONE 20 mg PO DAILY Duration: 3 Doses
This is dose # 4 of 5 tapered doses
Tapered dose - DOWN
20. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob
21. Aspirin EC 81 mg PO DAILY
22. ClonazePAM 1.5 mg PO QHS:PRN insomnia and agitation
RX *clonazepam 1 mg 1.5 tablet(s) by mouth at bedtime Disp #*5
Tablet Refills:*0
23. Digoxin 0.125 mg PO DAILY
24. DULoxetine 120 mg PO DAILY
25. Furosemide 20 mg PO DAILY
26. Gabapentin 2400 mg PO QHS
27. nicotine (polacrilex) 4 mg buccal DAILY:PRN
28. Omeprazole 40 mg PO DAILY
29. Sucralfate 1 gm PO QID:PRN GI upset
30. HELD- Albuterol Inhaler 2 PUFF IH Q4H:PRN sob This
medication was held. Do not restart Albuterol Inhaler until you
go home
31. HELD- Cetirizine 10 mg PO DAILY This medication was held.
Do not restart Cetirizine until you need it
32. HELD- Diazepam 5 mg PO Q12H:PRN m spasm This medication was
held. Do not restart Diazepam until you need it
33. HELD- GlipiZIDE XL 5 mg PO DAILY This medication was held.
Do not restart GlipiZIDE XL until you go home
34. HELD- HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN
Pain - Moderate This medication was held. Do not restart
HYDROcodone-Acetaminophen (5mg-325mg) until you go home
35. HELD- Ipratropium Bromide Neb 1 NEB IH Q6H:PRN shortness of
breath/wheezing This medication was held. Do not restart
Ipratropium Bromide Neb until you go home
36. HELD- ipratropium bromide 0.03 % nasal DAILY This
medication was held. Do not restart ipratropium bromide until
you go home
37. HELD- melatonin 10 mg oral QHS:PRN This medication was
held. Do not restart melatonin until you go home
38. HELD- MetFORMIN XR (Glucophage XR) 500 mg PO DAILY This
medication was held. Do not restart MetFORMIN XR (Glucophage XR)
until you go home.
39. HELD- Metoprolol Succinate XL 100 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until you go home. Right now you are getting a short acting
version of this while in the hospital/rehab.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Submassive pulmonary embolism
COPD exacerbation
Pneumonia
Pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ because you were having trouble
breathing. You were diagnosed with a blood clot in your lungs
and given blood thinners to treat this, while being closely
monitored in the intensive care unit.
You were also treated for pneumonia, a COPD exacerbation, and
diuresed to get extra fluid out of your lungs.
Now that you are breathing with much less oxygen support, we are
able to discharge you to a rehabilitation center so that you can
get stronger before going home.
It was a pleasure caring for you,
Your ___ team
Followup Instructions:
___
|
19991805-DS-15 | 19,991,805 | 23,646,288 | DS | 15 | 2143-02-02 00:00:00 | 2143-02-02 18:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
theophylline / clarithromycin / quinidine
Attending: ___.
Chief Complaint:
hypoxia, shortness of breath, confusion
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Ms. ___ is an ___ with history of coronary artery disease s/p
CABG (___) and PCI (___), chronic diastolic heart failure (EF
55%), asthma/COPD, and CKD with baseline creatinine 2.1-2.5 who
presents for hypoxia.
Per EPOCH of ___ records: Was treated for bilateral
lobe pneumonia with 7 days of vantin (cefpodoxime) from
___. She looked better and was back to baseline on ___.
Today she desatted to ___ on 2L O2 with increase ___ O2 to 4L
NC with sats at 92-93%. They ordered CBC, BMP, and CXR which
revealed ?old consolidation of both lower lobes compatible with
pneuonia small right pleural effusion. Labs revealed worsening
hgb to 6, BUN 59, Na to 150. She received levoquin 500 mg x1, IV
___ NS 250 cc. Lasix 60 mg was held. Weights the past week have
been around 131, Tm 99, HRs ___, SBPs 130s.
Per daughter, states she thought she was getting better. Denied
fatigue, worsening cough. Has known aspiration risk and has been
on a diet of pureed food. States her mother normally does not
need oxygen at baseline. Has been at EPOCH since her last
discharge from ___ ___ ___. She says the doctors there say
she ___ lived alone due to early signs of dementia and a
weakened state.
___ the ED, initial vitals were: 97.9 67 137/68 22 99% 4L Nasal
Cannula which improved to 100% RA. UA positive for 180 WBC,
large lueks, 30 protein, few bact3eria, and <1 epis. Lactate
1.4, Na 149, BUN/Cr 59/2.4 and glucose 68, CBC with WBC 3.8, hgb
7.6. She was given ___ amp of D50 as well as 1L D5H20 for
hypernatremia. She desatted to ___ on RA, put back on 4L.
Upon arrival to the floor, patient was alert and oriented x 3.
She states her cough is slightly worse than before but overall
feels ok. She denies fevers, chills, nausea, vomiting abdominal
pain
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 ___ bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- CABG: s/p CABG ___
- PERCUTANEOUS CORONARY INTERVENTIONS: ___
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
CKD stage IV (Creatinine baseline ??, previously
Diastolic heart failure s/p multiple prior admits for CHF
exacerbation
Hx of DVT s/p IVD filter
Peripheral neuropathy
Anemia of iron deficiency
Asthma/COPD
Abdominal aortic aneurysm
Peripheral arterial disease
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
PHYSICAL EXAM ON ADMISSION
=========================================
Vitals: 97.8 110/48 68 22 100% 2L
Weight 59.4 kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, oropharynx dry, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Slight poor air movement, crackles sparingly throughout
both feels, small expiratory wheezes noted bilaterally
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
PHYSICAL EXAM ON DISCHARGE
=========================================
PHYSICAL EXAM:
Vitals: T 98.1 BP 118/57 HR 91 RR 18 O2 93 on RA
Weight 56kg
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, oropharynx dry, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Slight poor air movement, crackles throughout both fields
at bases
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally.
Pertinent Results:
ADMISSION LABS
=====================
___ 08:15PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 08:15PM URINE RBC-3* WBC-180* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 08:15PM URINE MUCOUS-RARE
___ 04:38PM LACTATE-1.4
___ 04:26PM GLUCOSE-68* UREA N-59* CREAT-2.4* SODIUM-146*
POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-28 ANION GAP-13
___ 04:26PM estGFR-Using this
___ 04:26PM proBNP-GREATER TH
___ 04:26PM WBC-3.8* RBC-2.39* HGB-7.6* HCT-23.5* MCV-98
MCH-31.8 MCHC-32.3 RDW-17.2*
___ 04:26PM NEUTS-54.4 ___ MONOS-6.2 EOS-5.2*
BASOS-0.4
___ 04:26PM PLT COUNT-181
MICROBIOLOGY
======================
___ 11:20 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
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 .
GRAM NEGATIVE ROD(S). RARE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 PND
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
___ 8:15 pm URINE Site: NOT SPECIFIED
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
STUDIES
================================
___ ___ F ___ ___
Cardiovascular Report ECG Study Date of ___ 5:18:58 ___
Sinus rhythm and frequent atrial ectopy. Non-specific ST-T wave
changes.
Delayed R wave transition, similar to that recorded on ___.
The rate has
slowed. There is variation ___ precordial lead placement. No
diagnostic
interim change.
Read by: ___
___ Axes
Rate PR QRS QT QTc (___) P QRS T
69 ___ 433 0 -27 -168
___ CXR (PORTABLE)
IMPRESSION:
Substantial opacities at both lung bases, raising concern for
pneumonia.
Findings also suggest mild coinciding vascular congestion and
possibly small pleural effusions.
DISCHARGE LABS
============================
___ 07:20AM BLOOD WBC-3.0* RBC-2.83* Hgb-9.2* Hct-29.6*#
MCV-105*# MCH-32.5* MCHC-31.1 RDW-17.9* Plt ___
___ 07:20AM BLOOD Plt ___
___ 07:20AM BLOOD Glucose-56* UreaN-40* Creat-2.0* Na-146*
K-3.9 Cl-109* HCO3-24 AnGap-17
___ 07:20AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
___ 08:02PM BLOOD Type-ART pO2-74* pCO2-42 pH-7.40
calTCO2-27 Base XS-0
Brief Hospital Course:
Ms. ___ is an ___ with history of coronary artery disease s/p
CABG and PCI, congestive heart failure, and COPD/asthma who
presents with new hypoxia, encephalopathy and hypernatremia.
Patient had recently received prior treatment for pneumonia at
her rehab facility with good affect. The patient was started on
Vanc/Cefepime empirically for treatment of HCAP. The patien had
UA/culture showing VRE ___ > 100,000 colonies that was sensitive
to doxycycline. The patient was transitioned from IV antibiotics
to oral doxycycline on day of discharge. The patient will
completed a 5 day course of antibiotics for treatment of her
pneumonia and a 3 day course for treatment of her UTI. The
patient's encephalopathy improved dramatically with antibiotics
and she was breathing comfortably and satting well on room air
on day of discharge (patient satting ___ 92-93 at rest). The
patient will be discharged on oxygen with ambulation. Her
hypernatremia resolved with increased free water intake. Her
lasix was held due to concern for dehydration on admission and
restarted during her hospitalization. The patient will return to
her rehabilitation facility for ongoing care.
ACUTE ISSUES
#Hypoxia: On arrival to the hospital the leading differential
was pneumonia s/p treatment failure vs. recurrent aspiration
with aspiration pneumonitis. Patient does have a history of MRSA
pneumonia during last admission. CHF less likely given she is
under her dry weight of 62.6 kgs and is dry on exam (and labs).
Other diagnoses such as PE were less likely. The patient was
started on Vanc/Cefepime empirically for treatment of HCAP.
Sputum culture grew coag + staph sensitive to doxycyline. It is
unclear whether true sputum sample versus contamination from
oral/nasal flora. The patient was rapidly weaned from 4LNC to
room air within one day on antibiotics making her presentation
of hypoxia more concerning for aspiration pneumonitis.
Vanc/Cefepime were discontinued after 48 hours of treatment.
She was continued on pureed diet/thickened liquids with
aspiration precautions ___ the hospital without further evidence
of aspiration and did not undergo speech/swallow evaluation. It
is possible that her aspiration occurred ___ the setting of
transient delerium from UTI/hypernatremia. Lasix was held
during admission and restarted at discharge. Her weight at time
of discharge was 56kg.
#VRE UTI was identified and treated with Vanc and then
transitioned to doxycycline once sensitivities returned. The
patient completed a 3 day course for doxycylcine per geriatric
team recommendations. It is possible that patient's confusion
was ___ to UTI after being treated for pneumonia as an
outpatient.
# Hypernatremia: 150 at Rehabilitation facility. Likely from
dehydration ___ setting of infection. Patient received 1L D5 H20
___ ED and encouraged free water intake with resolution of her
hypernatremia. Discharge sodium was 146 and followup sodiums
should be monitored.
# Metabolic Encephalopathy
Likely ___ the setting of infection, dehydration and
hypernatremia. The patient's mental status returned to baseline
within 24 hours after initiation of antibiotics. There is likely
an underlying dementia. We recommend evaluation with MOCA/MMSE
as outpatient for cognitive evaluation and trending.
Chronic Problems
# CKD: at baseline Cr. Patient had all meds renally dosed. Lasix
held on admission and restarted during hospitalization. .
# Anemia: Patient's reported hgb was ___ the 6s at her rehab but
is slightly more stable here at 7.6. She does not have any signs
of bleeding currently. No scopes ___ our system. CBC stable
throughout hospitalization. Guiac negative. Patient will need
close follow up ___ rehabilitation facility. Consider EPO given
chronic kidney disease. Patient should have follow up labs ___
the week after discharge.
# Systolic CHF: No signs of volume overload on admission and she
was below dry weight. Lasix was held on admission and restarted
during hospitalization.
#Neuropathy
Continue gabapentin at adjusted renal dose of 300 mg daily from
TID.
#Coronary artery disease s/p CABG, PCI:
-Continued aspirin, metoprolol, statin
#GERD: Continued omeprazole.
TRANSITIONAL ISSUES
=================================
-patient completed 3 day course of doxycyline for VRE UTI. If
patient febrile post discharge we recommend restarting
doxycycline with UA/culture; If patient remains febrile consider
oral linezolid based on sensitivities from culture
-patient should have repeat chest xray to evaluate for
resolution of disease ___ approximately 6 weeks
-patient should continue to be weighed and evaluated daily for
monitoring of fluid status for management of her heart failure
-patinet had stable low hgb ~ 7.5 during admission; patient
should have blood drawn on ___ to evaluate for stablity of
anemia; given CKD consider f/u with renal physician
___ on ___:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 81 mg PO DAILY
2. Calcitriol 0.25 mcg PO DAILY
3. Docusate Sodium 200 mg PO DAILY
4. Furosemide 60 mg PO DAILY
5. Gabapentin 300 mg PO BID
6. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
11. Bisacodyl ___AILY:PRN constipation
12. Fleet Enema ___AILY:PRN constipation
13. Guaifenesin ___ mL PO Q4H:PRN cough
14. Milk of Magnesia 30 mL PO DAILY;PRN constipation
15. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
16. Senna 8.6 mg PO DAILY:PRN constipation
17. Iron Polysaccharides Complex ___ mg PO DAILY
18. Omeprazole 20 mg PO DAILY
19. Senna 17.2 mg PO QHS
20. Simvastatin 20 mg PO QPM
21. TraMADOL (Ultram) 50 mg PO DAILY
22. Acetaminophen 650 mg PO Q6H:PRN pain, fever
23. QUEtiapine Fumarate 25 mg PO DAILY
24. TraZODone 50 mg PO QHS
25. Divalproex Sod. Sprinkles 250 mg PO TID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain, fever
2. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. Calcitriol 0.25 mcg PO EVERY OTHER DAY
6. Divalproex Sod. Sprinkles 250 mg PO TID
7. Docusate Sodium 200 mg PO DAILY
8. Fleet Enema ___AILY:PRN constipation
9. Furosemide 60 mg PO DAILY
10. Gabapentin 300 mg PO DAILY
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
12. Lidocaine 5% Patch 1 PTCH TD QAM
13. Metoprolol Succinate XL 50 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Omeprazole 20 mg PO DAILY
16. Senna 8.6 mg PO DAILY:PRN constipation
17. Senna 17.2 mg PO QHS
18. Simvastatin 20 mg PO QPM
19. TraMADOL (Ultram) 50 mg PO DAILY
20. Guaifenesin ___ mL PO Q4H:PRN cough
21. Iron Polysaccharides Complex ___ mg PO DAILY
22. Milk of Magnesia 30 mL PO DAILY;PRN constipation
23. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
24. QUEtiapine Fumarate 25 mg PO DAILY
25. TraZODone 50 mg PO QHS
26. Benzonatate 100 mg PO TID:PRN cough
27. Lactobacillus acidophilus 1 billion cell oral BID
28. Lactobacillus acidophilus 1 billion cell oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Pneumonia; Urinary Tract Infection; Metabolic Encephalopathy
2. CKD stage IV (Creatinine baseline ??, previously
Diastolic heart failure s/p multiple prior admits for CHF
exacerbation
Hx of DVT s/p IVC filter
Peripheral neuropathy ___ her feet
Anemia of iron deficiency
Asthma/COPD
Abdominal aortic aneurysm
Peripheral arterial disease
Recurrent UTIs
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 to take part ___ your care during your stay
here at ___. You were brought to the hospital from your
rehabilitation ___ facility for low oxygen levels ___
your blood, shortness of breath and confusion. You were found to
have an infection ___ both your lungs and ___ your urine. You were
initially started on intravenous antibiotics. You responded very
well and were transitioned to oral antibiotics. On the day of
leaving the hospital you were breathing comfortably off of
oxygen without fevers. You felt at your baseline.
You should continue to weigh yourself every morning, and your MD
should be notified if your weight goes up more than 3 lbs.
Thank you for allowing us to participate ___ your care during
your stay.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19992202-DS-10 | 19,992,202 | 20,329,411 | DS | 10 | 2153-03-02 00:00:00 | 2153-03-02 17:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet / lithium / codeine
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ w/ hx of CAD, stroke w/ residual cognitive
deficits, bipolar disorder w/ psychotic features, HTN, asthma,
hypothyroidism, multiple falls and other issues who presents
from ___ with altered mental status, fever,
leukocytosis, and an unwitnessed fall. On the evening of ___,
she began to complain of abdominal pain per her rehab, with some
nausea. She was noted to have T of 100.2 axillary on ___, with
tachypnea and tachycardia to 100 (repotedly normal on ___.
She had labs drawn at ___ showing WBC of 13.7 w/ 67% PMNs and
21% bands with a dirty UA. She also had an unwitnessed fall on
___, being found on floor around 4:30pm awake but confused,
grabbing at staff, nonverbal (At baseline is able to walk with a
rolling walker and is verbal, though combative with staff). She
was brought to the ED for further evaluation.
In the ED initial vitals were: 97.4 94 103/65 18 100%. Exam
notable for mental status initially quite altered, pt combative
with staff, but later improved and she was cooperative. She was
incontinent of a large amount of stool x4, and a foley catheter
was placed. Labs were significant for WBC 23.0 w/ 87.8% PMNs,
Hgb 12.7, plts 136, INR 1.1, ALT/AST ___, LFTs otherwise WNL,
CK 291, Trop 0.06, CK-MB 3, BUN/Cr 48/1.7 (baseline 0.6 in
___, K 8.5 on hemolyzed specimen (recheck 3.9), HCO3 22,
Lactate 3.0. UA with 150 WBCs, few bacteria, and positive
nitrites. ECG showed new RBBB but no ischemic changes. CT
Abd/pelvis showed multiple L-sided non-obstructive renal calculi
with perinephric and periureteral stranding. There was no
hydronephrosis. Also demonstrated were an L2 compression
fracture of uncertain chronicity and moderate cardiomegaly. CT
C-spine was unremarkable, CT head showed an 11 x 7 mm meningioma
abutting the R temporal bone, and evidence of chronic L inferior
frontal and temporal lobe infarctions. CXR was unremarkable.
Patient was given Ceftriaxone 1g, 1L NS, Acetaminophen 650 mg PO
x2, Quetiapine 50 mg PO x1 and was admitted. Vitals prior to
transfer were: 100.3 99 156/80 26 99% RA (Tmax in ED was 102.0).
Overnight, the patient was uncooperative with examiner and would
not answer questions, though awake (as evinced by forced eye
closure and swatting away examiner's hand in response to painful
stimuli).
This morning when I examined the patient, she was responsive to
voice, with coherent speech, asking me to go away and leave her
alone. Did say she had abdominal pain when I asked, but then
would not describe it to me at all, otherwise says she is fine.
Cannot answer where she is, won't tell me her name. Trying to
get out of bed, and swatting me away when I try to examine her.
Per rehab, baseline MS is combative and uncooperative,
frequently refusing medical examination in the past, refusing
medications at times, and refusin lab draws at times. Irascible
at times, not usually oriented, with deficits in memory and
executive function. Is usually verbal, and often yells at staff.
Per rehab documentation, is independent with feeding, requires
assistance to transfer from bed to chair, with walking,
bathing/dressing, and with commode/toilet/bedpan.
Review of Systems: Unable to obtain
Past Medical History:
-CAD
-Hx of CVA w/ residual cognitive deficits (L frontal MCA CVA
___
-RBBB, LAFB (Noted previously in ___ ECG)
-HLD
-HTN
-Asthma
-Bipolar disorder with psychotic manifestations
-Depression
-Anxiety
-Failure to thrive
-Hypothyroidism
-s/p parathyroidectomy ___
-OSA not on CPAP
-B12 deficiency without anemia, apparently repleted
-Meningioma resected in ___ (right frontal brain tumor)
-B/L Carotid endarterectomy in ___
-Insomnia
-Constipation
Social History:
___
Family History:
Per records, daughter with paranoid schizophrenia. Otherwise
unable to obtain.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===================
Vitals - 99.4 135/80 84 18 96% RA
GENERAL: NAD, sleeping but arousable
HEENT: AT/NC, MMM dry, fair dentition
NECK: nontender supple neck, no LAD, JVD not appreciable
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
BACK: No CVA tenderness bilaterally
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: Patient uncooperative with exam
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
===================
PHYSICAL EXAM:
VS: 98 175/63 93 98%RA
GENERAL: appears well
HEENT: Sclera anicteric
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Clear, no wheezes, rales, or rhonchi, no use of accessory
muscles
ABD: Soft, BS+, nontender, nondistended
EXT: no ___ edema, 1+ DP and ___ pulses
NEURO: Does not answer orienting questions
Pertinent Results:
==== ADMISSION LABS ====
___ 07:20PM BLOOD WBC-23.0*# RBC-4.78 Hgb-12.7 Hct-39.0
MCV-81* MCH-26.6* MCHC-32.6 RDW-14.7 Plt ___
___ 07:20PM BLOOD Neuts-87.8* Lymphs-7.4* Monos-4.4 Eos-0.1
Baso-0.2
___ 07:20PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:20PM BLOOD ___ PTT-22.9* ___
___ 07:20PM BLOOD Glucose-116* UreaN-48* Creat-1.7* Na-134
K-8.5* Cl-101 HCO3-22 AnGap-20
___ 07:20PM BLOOD ALT-20 AST-74* CK(CPK)-291* AlkPhos-67
TotBili-0.3
___ 07:20PM BLOOD CK-MB-3 cTropnT-0.06*
___ 07:20PM BLOOD Albumin-3.7 Calcium-10.3 Phos-3.3 Mg-2.4
___ 07:29PM BLOOD Lactate-3.0* K-6.5*
___ 09:04PM BLOOD K-3.9
___ 08:55PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:55PM URINE Blood-MOD Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 08:55PM URINE RBC-3* WBC-150* Bacteri-FEW Yeast-NONE
Epi-0
___ 08:55PM URINE CastHy-11*
___ 08:55PM URINE Mucous-RARE
==== INTERIM LABS OF NOTE ====
___ 10:55AM BLOOD ___
___ 10:55AM BLOOD Hapto-221*
TROPONINS:
___ 07:20PM BLOOD CK-MB-3 cTropnT-0.06*
___ 10:55AM BLOOD CK-MB-2 cTropnT-0.05*
BLOOD GASES:
___ 11:55AM BLOOD ___ pO2-68* pCO2-38 pH-7.40
calTCO2-24 Base XS-0
___ 12:11PM BLOOD Type-ART Rates-/40 pO2-96 pCO2-26*
pH-7.49* calTCO2-20* Base XS--1
___ 03:49PM BLOOD ___ pO2-36* pCO2-34* pH-7.46*
calTCO2-25 Base XS-0 Comment-LARGE GREE
___ 05:16PM BLOOD Type-ART Temp-37.2 Rates-/50 pO2-100
pCO2-25* pH-7.53* calTCO2-22 Base XS-0 Vent-SPONTANEOU
LACTATE:
___ 07:29PM BLOOD Lactate-3.0*
___ 11:55AM BLOOD Lactate-2.2*
___ 12:11PM BLOOD Lactate-2.6*
___ 03:49PM BLOOD Lactate-2.2*
___ 05:16PM BLOOD Lactate-1.2
==== DISCHARGE LABS ====
==== MICROBIOLOGY ====
___ 7:20 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY.
These preliminary susceptibility results are offered to
help guide
treatment; interpret with caution as final
susceptibilities may
change. Check for final susceptibility results in 24
hours.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
GRAM NEGATIVE ROD(S)
|
AMPICILLIN/SULBACTAM-- S
CEFEPIME-------------- S
CEFTAZIDIME----------- S
CEFTRIAXONE----------- S
CIPROFLOXACIN--------- S
GENTAMICIN------------ S
MEROPENEM------------- S
TOBRAMYCIN------------ S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Reported to and read back by ___ ___
9:26AM.
___ BLOOD CULTURES: pending
___ BLOOD CULTURES: pending
___ 8:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 1:51 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
==== IMAGING ====
___ ECG
Sinus rhythm with sinus arrhythmia. Right bundle-branch block.
Low precordial QRS voltages. No major change from the previous
tracing.
___ CXR (PORTABLE)
AP portable supine view of the chest. Underlying trauma board
is in place. Lungs appear clear. No supine evidence of effusion
or pneumothorax. The cardiomediastinal silhouette appears
grossly within normal limits. No acute bony injury.
IMPRESSION:
Limited, negative.
___ CT C-SPINE WO CONTRAST
No acute fracture. Degenerative changes with mild
anterolisthesis of C4. Lack of prior comparison studies limits
evaluation for stability of this alignment abnormality. Please
correlate clinically.
___ CT HEAD WO CONTRAST
1. No acute intracranial abnormality.
2. 11 x 7 mm calcified focus at the inner table of the right
temporal bone is compatible with a meningioma.
3. Evidence of chronic left inferior frontal and temporal lobe
infarction.
___ CT ABD/PELVIS WO CONTRAST
1. Multiple left-sided nephroureteral calculi, with
considerable perinephric and periureteral stranding compatible
with upper urinary tract infection. 4 mm left UPJ stone does not
appear obstructive, as there is no hydronephrosis.
Nonobstructive 5 mm lower pole left renal calculus is noted.
2. Compression deformity of the L2 vertebral body appears
chronic. Malalignment in lower lumbar spine as noted related to
spondylolysis.
3. Moderate cardiomegaly with a small amount of pericardial
fluid, and a small left pleural effusion.
4. Probable rectal fecal impaction
___ CXR (PORTABLE)
The patient is substantially rotated. No evidence of larger
pleural effusions. No pneumonia, no pulmonary edema. Moderate
cardiomegaly.
Brief Hospital Course:
___ with CAD, CVA, bipolar with psychotic features, admitted
with sepsis from Ecoli UTI and E-coli bacteremia
# Sepsis/E-coli Bacteremia/Pyelonephritis: Patient found to have
pan-sensitive Ecoli UTI and bacteremia. She had CT abd/pelvis
which showed non-obstructing stones in her left kidney. She was
initially started on cefepime and transitioned to Ceftriaxone
and finally to po cipro one day prior to discharge. Last
positive blood culture from ___. Her sepsis resolved. Lactate
and Cr normalized. She will continue po cipro until ___
# Diarrhea: She had copious amount of diarrhea during this
hospital stay. C-diff negative on ___. Repeat C-diff
negative from ___. Diarrhea most likely abx associated.
Patient started on loperamide with improvement.
# Hypertension: She was hypertensive during this hospital stay
and intermittent given IV hydralazine. She was continued on her
lisinopril and started on 5mg amlodipine on the day of
discharge. She will need further monitoring and uptitration of
her BP meds.
# Encephalopathy: Most likely toxic-metabolic encephalopathy in
setting of known sepsis vs underlying mood disorders versus
worsening dementia. Her encephalopathy improved wit antibiotics
however she intermittently refuses labs, exam and becomes
agitated.
# ___: presented with ___ with resolved initially with IVF.
# s/p fall: Likely occurred in the setting of AMS, but patient
with history of multiple falls. CT head/neck negative
CHRONIC ISSUES:
================
# Hypothyroidism: Continued home levothyroxine
# Bipolar disorder / psych: - Cont home venlafaxine of 150 mg
PO QD and 37.5 mg PO QD (total of 187.5mg daily, given all at
once). Cont home quetiapine 50 qhs
# Hx of stroke: Continued home Aspirin 81 mg PO QD
# Osteopenia: continue home Vitamin D (dosed q21 days)
TRANSITIONAL ISSUES:
=================
# Code: DNR/DNI (per HCP, son ___ ok for ICU, central line,
and pressors, per brief discussions with the son on ___ at
12:30pm
# Contact: son ___ (___) ___
- Continue po cipro until ___
- Patient having diarrhea likely antibiotic associated. C-diff
testing x 2 were negative. Her diarrhea improved with
loperamide.
- Patient hypertensive during this admission: sh was started on
amlodipine on ___. Continue to uptitrate amlodipine as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraZODone 25 mg PO QHS
2. Simethicone 40 mg PO TID GI upset
3. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO BID:PRN GI
upset
4. Venlafaxine 150 mg PO DAILY
5. TraMADOL (Ultram) 25 mg PO QHS:PRN pain
6. Acetaminophen 650 mg PO BID pain
7. QUEtiapine Fumarate 50 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Lisinopril 40 mg PO DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Vitamin D 50,000 UNIT PO EVERY 3 WEEKS
12. Venlafaxine 37.5 mg PO DAILY
13. Acetaminophen 650 mg PO BID:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO BID pain
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO BID:PRN GI
upset
3. Aspirin 81 mg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. QUEtiapine Fumarate 50 mg PO QHS
7. TraMADOL (Ultram) 25 mg PO QHS:PRN pain
8. TraZODone 25 mg PO QHS
9. Venlafaxine 150 mg PO DAILY
10. Venlafaxine 37.5 mg PO DAILY
11. Vitamin D 50,000 UNIT PO EVERY 3 WEEKS
12. Amlodipine 5 mg PO DAILY
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Ranitidine 150 mg PO BID
15. Ciprofloxacin HCl 500 mg PO Q12H
Last Day ___
16. Simethicone 40 mg PO TID GI upset
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Pyelonephritis
2. E-Coli bactermia
3. Diarrhea
4. Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___, it was a pleasure taking care of you during
you hospitalization at ___. You were admitted with urinary
tract infection and blood infection. You were treated with
antibiotics with improvement in your symptoms. Please continue
to take your antibiotics until ___.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs.
Followup Instructions:
___
|
19992365-DS-21 | 19,992,365 | 20,220,175 | DS | 21 | 2167-10-28 00:00:00 | 2167-10-28 15:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Augmentin / Clindamycin
Attending: ___
Chief Complaint:
Nystagmus, ataxia of gait and left arm
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 3 minutes
Time/Date the patient was last known well: 01:20 ___
___ Stroke Scale Score: 1
t-PA Administration
[] Yes - Time given:
[x] No - Reason t-PA was not given/considered: large left
cerebellar bleed vs mass
I was present during the CT scanning and reviewed the images
within 20 minutes of their completion.
___ Stroke Scale - Total [1]
1a. Level of Consciousness - 0
1b. LOC Questions - 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
HPI:
The patient is a ___ year old man with a history of anxiety,
COPD,
LVH with dystolic dysfunction, left cervical radiculopathy who
initially presented to the ED with tachypnea and dyspnea while
masturbating earlier today. Neurology evaluation is requested
as
part of a code stroke at 1:29am after he was found to be
lethargic with nystagmus, ataxia of gait and left arm.
The patient was last in his USOH this evening. He developed
acute
onset of tachypnea and dyspnea while masturbating at home. He
started gasping and and felt faint. At that point he described
brief sensation of room spinning. Also felt generally weak that
he had to crawl rather than walk. He called ___ and was taken
to
___ ED by ambulance.
The patient came to the ___ ED Triage at 1648 ___. Inital
exam was unremarkable. He had labs including leukocytosis with
left shift, ddimer 598. Cardiac enzymes were flat. Then CTA
chest was done which showed pulmonary nodules and absence of PE.
While in the ED, he developed acute anxiety again and was given
Ativan 1mg IV (double his home dose) at 930pm. Per resident
documentation, he was reevaluated at 1145pm and was sleepy able
to
use his phone. He walked with support around the bed. His gait
at
that time was characterized as unsteady but narrow based. At
0040 on ___, he had more trouble getting out of bed without
assistance and began to complain of nausea. He was ultimately
noted to have a change in his neuro exam and nausea.
Neurology was called to the bedside, and I ultimately activated
a
code stroke during my evaluation at 1:25am. The patient was
complaining of lethargy and his nausea had resolved. He also
was
having trouble walking. He denied room spinning, double vision
or other neurological deficits. As mentioned below, he had other
focal deficits, but was not aware of these: (nystagmus on left
gaze and left arm ataxia).
Prior to this ED visit, he did intermittently have double vision
and was evaluated by an opthalmologist for this. It was not
clear
that this was monocular vs binocular or occured at near vs far
vision. He does wear glasses as forgot to bring them to the ED
and felt that evaluation without his glasses was unfair. Also,
he alerts me that his left arm is weaker than his right arm at
baseline give cervical radiculopathy that is longstanding.
He denied other ROS as listed below:
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech. Denies loss of vision, blurred vision,
vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia.
Denies focal muscle weakness, numbness, parasthesia. Denies loss
of sensation. Denies bowel or bladder incontinence or retention.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough. Denies nausea, vomiting,
diarrhea, constipation, or abdominal pain. No recent change in
bowel or bladder habits. Denies dysuria or hematuria. Denies
myalgias, arthralgias, or rash.
Past Medical History:
ATTENTIONAL PROBLEMS
PSORIASIS
ERECTILE DYSFUNCTION
LVH WITH BORDERLINE LEFT VENTRICULAR OUTFLOW TRACT OBSTRUCTION
HYPERTENSION
OVERWEIGHT
SLEEP APNEA
SEBORRHEIC DERMATITIS
DEPRESSION
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
H/O LEFT CERVICAL RADICULITIS
Social History:
___
Family History:
No family history of strokes, seizures.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.0 82 147/87 22 100% RA
General: Tired appearing, dissheveled, NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental Status - Initially, he was lethargic appearing,
inattentive, preferred to keep eyes closed. But with
encouragement, he was oriented x3 and recalled a coherent
history. Did not fully recite months of year backwards. Speech
is
fluent without dysarthria. Repetition and comprehension and
naming intact. Normal prosody. No dysarthria. No apraxia. No
evidence of hemineglect. No left-right confusion.
- Cranial Nerves - PERRL 4->2 brisk. VF full to number counting.
EOMI, with left beating nystagmus on left gaze and only fine
nystagmus on right gaze that was fatigable. No nystagmus in up
or downgaze. V1-V3 without deficits to light touch bilaterally.
No facial movement asymmetry. Hearing intact to finger rub
bilaterally. Palate elevation symmetric. SCM/Trapezius strength
___ bilaterally. Tongue midline.
- Motor - Normal bulk and tone. No drift. No tremor or
asterixis.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 5 4+ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5
- Sensory - No deficits to light touch, pin bilaterally.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Coordination - There is marked dysmetria on left FNF, but with
encouragement he actually improves on multiple tasks. There is
no dysmetria on right FNF. HSH on left also clumsy compared to
right.
- Gait - No truncal ataxia when seated with arms crossed at edge
of bed. He requires 2 person assistance to stand. Gait is wide
based. Short stride length, grossly unstable.
DISCHARGE EXAM:
T 98.6, HR 60-90, BP 110/76, RR 18, O2 95% on RA
Gen: NAD, in bed
Neuro:
Awake, alert, ortiented x3.
PERRL 3->2, brisk. VF full. EOMI, eyes conjugate. Nystagmus in
primary gaze. Bilateral endgaze horizontal nystagmus L>R. +
vertical nystagmus. V1-V3 without deficits to light touch
bilaterally. Very mild R facial droop. Hearing intact to finger
rub bilaterally. Palate elevation symmetric. SCM/Trapezius
strength ___ bilaterally. Tongue midline.
Strength ___. Babinskis downgoing.
+ Left rebound, left dysmetria on FNF, left ataxia on HKS.
Pertinent Results:
___ 06:30PM BLOOD WBC-16.5*# RBC-4.92 Hgb-15.1 Hct-44.8
MCV-91 MCH-30.7 MCHC-33.7 RDW-13.6 Plt ___
___ 09:30AM BLOOD ___ PTT-24.4* ___
___ 06:30PM BLOOD Glucose-123* UreaN-16 Creat-0.8 Na-142
K-4.1 Cl-105 HCO3-23 AnGap-18
___ 06:30PM BLOOD cTropnT-<0.01 proBNP-192*
___ 03:15AM BLOOD CK-MB-6 cTropnT-0.30*
___ 11:45AM BLOOD CK-MB-4 cTropnT-0.16*
___ 03:15AM BLOOD Calcium-8.3* Phos-3.4 Mg-2.1
___ 06:30PM BLOOD D-Dimer-598*
___ 11:45AM BLOOD HIV Ab-NEGATIVE
___ 06:42PM BLOOD Lactate-1.5
___ 01:07AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 01:07AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
IMAGING:
EKG: NSR@80bpm. Q wave in I.
___ CXR
Vague opacity suggesting pneumonia or lower airway inflammation
or infection in the right upper lobe.
___ CTA Chest
1. No evidence of pulmonary embolism.
2. Centrilobular emphysema with multiple bilateral pulmonary
nodules better described on recent dedicated CT dated ___. Recommend imaging follow up in ___ months time.
3. Again identified are hepatic dome hypodensities incompletely
characterized on this single phase examination.
___ NCHCT
2.4 x 2.8 cm left cerebellar acute intraparenchymal hemorrhage
with mild mass effect and effacement of the fourth ventricle.
___ CTA
1. Stable 2.8x3.3cm left cerebellar acute hematoma, 2.8x3.3cm,
with mild surrounding edema and mass effect on the left side of
___ ventricle, similar to the prior study done 8 hr earlier.
2. No obvious aneurysm or AV malformation in the vicinity of the
left cerebellar hematoma. Minimally displaced nondilated
vascular structures adjacent. Correlate clinically for risk
factors. INR/NS consult to decide on further workup/mngt.
3. Atherosclerotic calcifications in the distal vertebral and
cavernous carotid segments with contour irregularity on both
sides. Patent major intracranial arteries as described above.
Right posterior inferior cerebellar and Left superior cerebellar
artery not well seen.
___ MRI
No significant interval change of a 26 x 24 mm acute left
cerebellar
intraparenchymal hematoma with associated mass effect and
effacement of the fourth ventricle. No definite underlying mass
with trace peripheral post gadolinium enhancement likely
secondary to bleed.
___ CT Head
Stable left cerebellar hematoma with mass effect on the left
side of the ___ ventricle; slightly increased mass effect on ___
ventricle. Limited assessment of position of cerebellar tonsils,
due to dental artifacts and lack of sagittal and coronal
reformations is performed as a portable study.
Brief Hospital Course:
Mr. ___ is a ___ year old man with a history of anxiety,
COPD, LVH with diastolic dysfunction, and left cervical
radiculopathy who initially presented to the ED with tachypnea
and dyspnea. During his time in the ED, he had intermittent
nausea and nystagmus and development of left arm ataxia and an
ataxic gait. A code stroke was called and NIHSS was 1 for ataxia
of 1 limb. ___ revealed a left cerebellar hyperdensity
indicative of IPH. CTA showed no underlying vascular
abnormality. MRI showed no enhancing mass. The etiology of his
hemorrhage is possibly HTN, occult AVM or occult mass, which is
why the patient will have follow up imaging (see below).
# Neuro:
- Left cerebellar intraparenchymal hemorrhage: etiology unknown,
possibly hypertension or occult lesion not seen on MRI
- He was admitted to the Neuro ICU for close monitoring for
change in exam which could indicate edema/obstructive
hydrocephalus. He was on Mannitol Q6 and his exam remained
stable, so mannitol was discontinued by hospital day 4.
- SBP goal < 140
- Avoid anti-platelets and anticoagulation
- repeat MRI/MRA in ___ months
- Neurology Stroke Clinic follow up
# Cardiopulmonary:
- trops 0.01->0.3->0.16, CT chest/EKG neg, no chest pain
- Goal SBP<140
- continue lisinopril 10, metoprolol 25 BID
- will need follow-up of pulmonary nodules seen on CT chest in
___ months
#Psych:
- history of anxiety - he had some nausea and vomiting the first
day in the ICU secondary to presumed anxiety which quickly
resolved when he was put on his home dose of alprazolam 0.25mg
BID prn.
- continue home lorazepam 0.5mg prn insomnia
- continue home alprazolam 0.25 mg BID prn
# Transitional Issues:
- needs outpatient colonoscopy
- needs follow up MRI/MRA Head with contrast in ___ months
- will need follow-up of pulmonary nodules seen on CT chest as
outpatient in ___ months
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes [performed
and documented by admitting resident] () No
2. DVT Prophylaxis administered by the end of hospital day 2?
(x) Yes - () No
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education given (written form in the discharge
worksheet)? (x) Yes - () No
(stroke education = personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup)
5. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No [if no, reason not assessed: ____ ]
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. modafinil 200 mg oral QAM and Qnoon
3. Lorazepam 0.5 mg PO HS:PRN insomnia
4. Meladox (melatonin) 3 mg oral QHS PRN insomnia
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
6. ALPRAZolam 0.25 mg PO PRN anxiety
7. Citalopram 20 mg PO DAILY
8. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN
Apply to ears
9. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QID
10. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN to face, to
penis
11. Patanol (olopatadine) 0.1 % ophthalmic 1 drop in both eyes
BID
12. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Metoprolol Tartrate 25 mg PO BID
3. Ondansetron 4 mg PO Q8H:PRN nausea
4. Citalopram 5 mg PO DAILY:PRN Bipolar symptoms
5. Lorazepam 0.5 mg PO HS:PRN insomnia
6. Meladox (melatonin) 3 mg oral QHS PRN insomnia
7. modafinil 200 mg oral QAM and Qnoon
8. ALPRAZolam 0.25 mg PO PRN anxiety
9. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
10. Fish Oil (Omega 3) 1000 mg PO BID
11. Fluocinolone Acetonide 0.01% Solution 1 Appl TP DAILY:PRN
Apply to ears
12. Fluorometholone 0.1% Ophth Susp. 1 DROP BOTH EYES QID
13. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN to face, to
penis
14. Patanol (olopatadine) 0.1 % ophthalmic 1 drop in both eyes
BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left cerebellar hemorrhage
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 due to symptoms of nausea resulting from
an ACUTE HEMORRHAGIC STROKE, a condition in which a blood vessel
providing oxygen and nutrients to the brain bleeds. 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 bleeding can
result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
In order to prevent future strokes, we plan to modify those risk
factors. Your risk factors are:
Hypertension
Please follow your medication list closely.
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:
___
|
19992418-DS-19 | 19,992,418 | 20,262,597 | DS | 19 | 2145-01-16 00:00:00 | 2145-01-22 04:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
lidocaine
Attending: ___.
Chief Complaint:
elevated BP
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ G3P3 POD4 from primary LTCS for arrrest of dilation and
fetal intolerance to augmentation of labor c/b gestational
hypertension now with severe BP at home. Reports assymetric calf
swelling (R>L) starting this morning. Has intermittent shortness
of breath, but none now. Endorse + chest pressure which started
on arrival to the ED, also comes and goes. Denies substernal
chest pain, arm pain, jaw pain, heart pain. Breast nt, feeding
and pumping well. incisional pain will controlled at home on
tylenol/oxy/ibuprofen with normal lochia. Infant is at home with
grandma.
Denies headache, vision changes, RUQ pain (subcostal cheat
discomfort as above). Remainder of ROS as per HPI.
Past Medical History:
OBHx:
- G1: SVD term, 5#15, pre eclampsia at 40 weeks
- G2: SVD term, 9#10oz, gHTN
- G3: pLTCS as above
GynHx:
- No h/o abnormal Pap, fibroids, Gyn surgery, STIs
PMH: none
PSH: wisdom teeth, cesarean delivery
Meds: PNV
All: lidocaine (difficulty breathing)
Social History:
SHx: denies T/E/D
Physical Exam:
General: NAD
CV: RRR
Lungs: Nonlabored breathing, CTAB
Abd: soft, fundus firm at umbilicus, appropriate fundal
tenderness
Incision: clean/dry/intact, no erythema/induration
Lochia: minimal
Extremities: no calf tenderness, 1+ edema
Pertinent Results:
___ 01:15PM cTropnT-<0.01
___ 11:04AM ___ PTT-33.7 ___
___ 10:10AM GLUCOSE-91 UREA N-9 CREAT-0.7 SODIUM-143
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-26 ANION GAP-12
___ 10:10AM ALT(SGPT)-45* AST(SGOT)-45* ALK PHOS-97 TOT
BILI-0.3
___ 10:10AM cTropnT-<0.01
___ 10:10AM proBNP-257*
___ 10:10AM ALBUMIN-3.5 CALCIUM-9.1 PHOSPHATE-3.6
MAGNESIUM-1.8
___ 10:10AM URINE HOURS-RANDOM
___ 10:10AM URINE UCG-POSITIVE*
___ 10:10AM URINE UHOLD-HOLD
___ 10:10AM WBC-11.0* RBC-3.67* HGB-10.0* HCT-31.3*
MCV-85 MCH-27.2 MCHC-31.9* RDW-16.7* RDWSD-50.5*
___ 10:10AM NEUTS-83.1* LYMPHS-11.7* MONOS-3.6* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-9.14* AbsLymp-1.29 AbsMono-0.40
AbsEos-0.01* AbsBaso-0.03
___ 10:10AM PLT COUNT-245
___ 10:10AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 10:10AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG*
___ 10:10AM URINE RBC-5* WBC-107* BACTERIA-MOD* YEAST-NONE
EPI-4 TRANS EPI-2
Brief Hospital Course:
Ms. ___ was readmitted on ___ with elevated blood
pressures, found to have pre-eclampsia severe by blood
pressures.
She presented to the ED on post-operative day 4 from primary low
transverse cesarean section. She received 20mg IV labetalol was
started on 24 hours of magnesium. Her home nifedipine was
continued and labetalol was added for better control of her
blood pressures.
In the ED, she also complained of chest pressure w/ bilateral
leg sweeling, bedside echocardiogram was within normal limit and
EKG demonstrated NSR. CTA demonstrated no evidence of pulmonary
embolism or aortic abnormalities, however ground-glass
opacities in dependent areas were noted, that may have
represented fluid overload.
During her hospital course, she continued to have persistent HA
(___). MRI/MRA obtained showed no evidence of ischemia,
hemorrhage, or edema. She received acetaminophen, ibuprofen,
fioricet, and Compazine. She had elevated liver enzymes which
downtrended prior to her discharge. Her anti-hypertensive
medications were uptitrated to labetalol 600 q8h and nifedipine
30 mg daily.
By hospital day 5, she was stable for discharge. Discussed
return precautions included severe range blood pressures and
persistent headache. She was discharged home with outpatient
follow-up.
Medications on Admission:
prenatal vitamins
Discharge Medications:
1. Labetalol 600 mg PO Q8H
RX *labetalol 300 mg 2 tablet(s) by mouth three times a day Disp
#*120 Tablet Refills:*1
2. NIFEdipine (Extended Release) 30 mg PO DAILY hypertension
hold if bp below 110/70
RX *nifedipine 30 mg 1 tablet(s) by mouth q day Disp #*20 Tablet
Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
post partum pre ecclampsia with headache symptoms
pulmonary edema
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
rest. take meds. no heavy lifting, exercise, for 4 weeks
Followup Instructions:
___
|
19992507-DS-19 | 19,992,507 | 28,877,211 | DS | 19 | 2175-06-30 00:00:00 | 2175-07-14 08:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Zofran
Attending: ___
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w hx remote colon cancer ___ s/p sigmoid resection c/b leak
requiring reoperation/diverting colostomy, s/p takedown, with
long-standing incisional hernia, who presents to the ED with 4
days of nausea and bilious emesis, found on CT to have recurrent
SBO. Patient reports 4 days ago she noticed cramping abdominal
pain associated with nausea, had several episodes of bilious
emesis. Did not have any bowel movements for 3 days/flatus x 2
days, however initially tried managing by increasing her stool
softeners and starting lactulose 2 days ago. However her
nausea/vomiting did not resolve prompting her to present today.
A
CT scan was done, results detailed below, demonstrating an
incarcerated ___ hernia for which we are consulted.
Only prior hospitalization for this issue was in ___, at which
time she was admitted to ___ service w obstructive symptoms -
ACS
was consulted several days into her hospital stay but at that
point her symptoms had already improved and CT demonstrated
partial SBO at most. Given her recurrent lymphoma and plans to
perform repeat aSCT she deferred definitive surgical repair -
her
symptoms resolved with non operative management, did not follow
up with surgery as outpatient. Successfully underwent repeat
aSCT
and has been in remission for ___ years, with last scans ___
showing no evidence of disease recurrence.
No recurrent SBO's in the subsequent ___ years until her
presentation today. Last colonoscopy ___ which noted several
adenomatous polyps, plans for repeat in ___.
ROS:
(+) per HPI
Past Medical History:
PAST ONCOLOGIC HISTORY
1. Recurrent marginal zone lymphoma, stage IIIA.
--Initially treated with R-CVP, completed in ___
--Relapsed in ___ with extensive adenopathy, treated with
total 6 cycles of Rituxan/Bendamustine, completed in ___
--Increasing left breast lesion and skin nodule. Biopsy on
___ showed diffuse large B-cell lymphoma and
transformation
in the background of a marginal zone lymphoma
--4 cycles of DA-EPOCH, followed by high dose Cytoxan and
autologous stem cell transplantation(D 0 ___.
2. Colon cancer, status post surgery in ___. She does not
remember the stage of her disease, but she did not receive any
adjuvant treatment. Colonoscopy needs to be repeated.
PAST MEDICAL HISTORY:
Osteoarthritis.
Adnexal cyst.
Hypertension
Chemotherapy induced pneumonitis, on steroids with taper.
Social History:
___
Family History:
Adopted. Family history unknown.
Physical Exam:
Admission physical exam
=======================
Vitals: T98 HR110 BP 130/80 RR 18 ___ 92RA
GEN: A&O, NAD, non-toxic appearing
HEENT: No scleral icterus, mucus membranes dry
CV: mild tachycardia, reg rhythm
PULM: unlabored respirations
ABD: Soft, morbidly obsese, nondistended, large palpable
incisional hernia just to the left of umbilicus with gas-filled
small bowel. Tender to palpation over hernia but no diffuse
abdominal tenderness, no rebound or guarding.
Ext: No ___ edema, ___ warm and well perfused
Discharge physical exam
========================
VS: 98.2, 135/75, 87, 20, 95 RA
Gen: A&O x3. Ambulatory. In NAD.
CV: HRR
Pulm: LS CTAB
Abd: soft, obese, + large hernia. nontender to palp.
Ext: WWP, trace edema
Pertinent Results:
Admission labs
==============
___ 10:00AM BLOOD WBC-10.5* RBC-5.57* Hgb-16.5* Hct-50.0*
MCV-90 MCH-29.6 MCHC-33.0 RDW-13.5 RDWSD-44.5 Plt ___
___ 10:00AM BLOOD Neuts-74.5* Lymphs-14.2* Monos-9.5
Eos-0.7* Baso-0.5 Im ___ AbsNeut-7.81* AbsLymp-1.49
AbsMono-0.99* AbsEos-0.07 AbsBaso-0.05
___ 10:00AM BLOOD ___ PTT-27.8 ___
___ 10:00AM BLOOD Plt ___
___ 10:00AM BLOOD Glucose-252* UreaN-17 Creat-0.9 Na-141
K-3.8 Cl-97 HCO3-26 AnGap-18
___ 10:00AM BLOOD Calcium-9.7 Phos-2.7 Mg-1.9
___ 11:03AM BLOOD Lactate-3.2*
___ 01:48AM BLOOD Lactate-1.2
___ 06:13AM BLOOD Lactate-1.5
Discharge labs:
___ 05:30AM BLOOD WBC-8.9 RBC-4.13 Hgb-12.4 Hct-40.0 MCV-97
MCH-30.0 MCHC-31.0* RDW-14.3 RDWSD-50.4* Plt ___
___ 04:50AM BLOOD WBC-10.4* RBC-4.48 Hgb-13.3 Hct-42.9
MCV-96 MCH-29.7 MCHC-31.0* RDW-14.5 RDWSD-50.2* Plt ___
___ 04:09AM BLOOD WBC-18.9* RBC-4.89 Hgb-14.7 Hct-46.4*
MCV-95 MCH-30.1 MCHC-31.7* RDW-14.1 RDWSD-48.9* Plt ___
___ 05:30AM BLOOD Glucose-124* UreaN-10 Creat-0.6 Na-143
K-3.7 Cl-105 HCO3-31 AnGap-7*
___ 04:50AM BLOOD Glucose-167* UreaN-12 Creat-0.6 Na-143
K-3.9 Cl-103 HCO3-30 AnGap-10
Imaging
========
CXR ___
PA and lateral views of the chest provided. Port-A-Cath resides
over the
right chest wall with catheter tip in the mid SVC region. The
lungs are clear bilaterally. There is no focal consolidation,
large effusion, pneumothorax or signs of edema.
Cardiomediastinal silhouette appears stable. Bony structures
are intact. No free air below the right hemidiaphragm.
CT A/P ___
1. Small-bowel obstruction due to a left periumbilical small
bowel containing hernia. Please correlate for reducibility. No
free fluid, free air or bowel wall thickening.
2. Multiple additional fat containing abdominal wall hernias.
3. Right adnexal cystic lesion, previously characterized as
hydrosalpinx.
4. Thickened endometrium, measuring up to 2.8 cm, consider
nonemergent pelvic ultrasound to further assess.
___ KUB: Multiple air-filled, mildly dilated loops of small
and large bowel, compatible with ileus.
___ KUB: Interval decrease in mildly dilated loops of small
and large bowel, compatible with improving ileus.
___ CHEST/ABD/PELVIS CT:
1. Left periumbilical incisional hernia with a 4.___ontaining loops of small bowel with interval slight
improvement of upstream small bowel dilatation. The oral
contrast material has passed through the trapped loops of
small-bowel in the incisional hernia, however, given the
continued upstream dilation, there appears to be an element of
persisting partial obstruction.
2. Thickened endometrium measures 0.9 cm as noted on pelvic
ultrasound dated ___. Please correlate with prior
endometrial biopsy.
3. Unchanged right hydrosalpinx.
4. Please refer to separate report of CT chest performed on the
same day for description of the thoracic findings.
Brief Hospital Course:
___ y/o F hx marginal zone lymphoma s/p alloSCT x 2, remote colon
cancer s/p resection with incisional hernia, admitted to the
General Surgical Service on ___ for evaluation and treatment of
abdominal pain, nausea and vomiting. Admission abdominal/pelvic
CT revealed a small-bowel obstruction due to a left
periumbilical small bowel containing hernia. The patient was
hemodynamically stable. She was treated non-operatively with
bowel rest, IV fluids, nasogastric tube for decompression, and
close monitoring or lab work and abdominal exam.
Serial abdominal x-rays showed gradual improvement. The patient
eventually began passing consistent flatus. On ___, a repeat CT
scan showed no bowel obstruction. NGT was removed and diet was
progressively advanced as tolerated to a regular diet with good
tolerability.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. She would follow-up as an outpatient to
discuss an elective hernia repair.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acyclovir 400 mg PO Q8H
2. Hydrochlorothiazide 25 mg PO DAILY
3. Vitamin D ___ UNIT PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Senna 8.6 mg PO BID
6. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Polyethylene Glycol 17 g PO DAILY
2. Acyclovir 400 mg PO Q8H
3. Docusate Sodium 100 mg PO BID
4. Hydrochlorothiazide 25 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
6. Senna 8.6 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Distal small-bowel obstruction due to a left periumbilical
hernia
containing multiple small bowel loops
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
You were admitted to the hospital because recurrent small bowel
obstruction and irreducible small-bowel containing incisional
hernia. You were managed non-operatively with bowel rest, IV
fluids, and nasogastric tube for stomach decompression. A repeat
CT scan was done which showed resolution of the obstruction, and
you also had begun to have reliable return of bowel function.
You have been tolerating a regular diet now, passing flatus and
having bowel movements. You are ready to be discharged home to
continue your recovery. You can follow-up in clinic to discuss
elective hernia repair.
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids
Followup Instructions:
___
|
19992581-DS-12 | 19,992,581 | 22,115,219 | DS | 12 | 2197-03-12 00:00:00 | 2197-03-12 11:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ laparoscopic appendectomy
History of Present Illness:
Mr. ___ is ___ year old male who presented to the ED on
___ with abdominal pain. He was in his usual state of
health until 24 hours prior to presentiation when he experienced
acute onset non-radiating RLQ pain. He has never experienced
this type of pain before and denies trauma to the area. Shortly
after the pain began, he had a loose bowel movement and is
passing flatus. He endorses subjective fevers, chills, nausea
and non-bilious emesis. He denies chest pain or shortness of
breath. CT scan in the ED indicated acute, nonperforated
appendicitis.
Past Medical History:
positive PPD, hypercholesterolemia, and chronic low back
Social History:
___
Family History:
non-contributory
Physical Exam:
On arrival to ___:
Vitals: 99.4 108 118/60 18 94 RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, focally tender to palpation in the RLQ, no rebound or
guarding, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ CT ABD & PELVIS WITH CONTRAST
Acute appendicitis. Appendix measures up to 8mm. No abscess,
drainable fluid collection or extra-luminal gas
___ 12:30PM WBC-12.5*# RBC-4.70 HGB-13.5* HCT-38.2*
MCV-81* MCH-28.8 MCHC-35.5* RDW-12.0
___ 12:30PM NEUTS-81* BANDS-13* LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ATYPS-1* ___ MYELOS-0
___ 12:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 12:30PM PLT SMR-NORMAL PLT COUNT-199
___ 12:30PM ALBUMIN-4.4
___ 12:30PM ALT(SGPT)-18 AST(SGOT)-24 ALK PHOS-42 TOT
BILI-1.5
___ 12:30PM LIPASE-19
___ 12:30PM GLUCOSE-136* UREA N-15 CREAT-1.2 SODIUM-135
POTASSIUM-3.6 CHLORIDE-101 TOTAL CO2-21* ANION GAP-17
___ 03:25PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
Brief Hospital Course:
Mr. ___ was admitted under the acute care surgery service for
management of his acute appendicitis. He was taken to the
operating room and underwent a laparoscopic appendectomy. See
operative report by Dr. ___ details of this procedure.
He was extubated after the procedure was completed and taken to
the PACU for recovery. He remained hemodynamically stable and
was transferred to the surgical floor postoperatively.
He remained alert and oriented throughout his postoperative
course. His pain level was routinely assessed and his pain level
was well controlled with oral narcotic pain medication and
tylenol as needed. His vital signs were routinely monitored in
the postoperative period and he remained hemodynamically stable.
Incentive spirometry and pulmonary toileting were encouraged. He
was voiding adequate amounts of urine without difficulty.
His diet was advanced to a regular diet in the morning of
postoperative day #1, which he tolerated well without
nausea/vomiting. His appendix was noted to be gangrenous during
the operation and so he was started on IV ciprofloxacin and
flagyl. On postoperative day #1, he became febrile to 102.
Blood and urine cultures were sent at this time and IV fluids
were continued. His antibiotics were changed to IV unasyn for
empiric coverage and patient was transitioned to 7 days po
augmentin for continued treatment. Urine cultures were negative
and blood culture had no growth at time of discharge.
He was encouraged to mobilize out of bed and ambulated as
tolerated postoperatively. Prior to discharge he was out of bed
ambulating independently with a steady gait.
Mr. ___ was tolerating a regular diet, his pain was well
controlled, hemodynamically stable, and out of bed ambulating
independently. He expressed the desire to return home and was
discharged on 1 week of antibiotics with follow up scheduled
with Dr. ___.
Medications on Admission:
none
Discharge Medications:
1. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 7 days.
Disp:*14 Tablet(s)* Refills:*0*
2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
3. docusate sodium 100 mg Capsule Sig: One (1) Capsule 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. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours)
as needed for pain.
Disp:*50 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital with acute appendicitis. You
were taken to the operating room and had your appendix removed
laparoscopically. You tolerated the procedure well and are now
being discharged home with the following instructions:
ACTIVITY:
Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
You may climb stairs.
You may go outside, but avoid traveling long distances until you
see your surgeon at your next visit.
Don't lift more than ___ lbs for 6 weeks. (This is about the
weight of a briefcase or a bag of groceries.) This applies to
lifting children, but they may sit on your lap.
You may start some light exercise when you feel comfortable.
You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
Heavy exercise may be started after 6 weeks, but use common
sense and go slowly at first.
HOW YOU MAY FEEL:
You may feel weak or "washed out" for 6 weeks. You might want to
nap often. Simple tasks may exhaust you.
You may have a sore throat because of a tube that was in your
throat during surgery.
You might have trouble concentrating or difficulty sleeping. You
might feel somewhat depressed.
You could have a poor appetite for a while. Food may seem
unappealing.
All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressings you have small plastic bandages
called steristrips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
Your incisions may be slightly red around the stitches. This is
normal.
You may gently wash away dried material around your incision.
It is normal to feel a firm ridge along the incision. This will
go away.
Avoid direct sun exposure to the incision area.
Do not use any ointments on the incision unless you were told
otherwise.
You may see a small amount of clear or light red fluid staining
your dressing or clothes. If the staining is severe, please call
your surgeon.
You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
Ove the next ___ months, your incision will fade and become
less prominent.
YOUR BOWELS:
Constipation is a common side effect of narcotic pain
medicaitons. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
If you go 48 hours without a bowel movement, or have pain moving
the bowels, call your surgeon.
PAIN MANAGEMENT:
It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
Your pain should get better day by day. If you find the pain is
getting worse instead of better, please contact your surgeon.
You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. Do not
take it more frequently than prescribed. Do not take more
medicine at one time than prescribed. Do not drink alcohol or
drive while taking narcotic pain medication.
Your pain medicine will work better if you take it before your
pain gets too severe.
Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
Remember to use your "cough pillow" for splinting when you cough
or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
*You are being given a prescription for antibiotics. Take the
entire prescription (for 1 week total) as instructed.*
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
DANGER SIGNS:
Please call your surgeon if you develop:
- worsening abdominal pain
- sharp or severe pain that lasts several hours
- temperature of 101 degrees or higher
- severe diarrhea
- vomiting
- redness around the incision that is spreading
- increased swelling around the incision
- excessive bruising around the incision
- cloudy fluid coming from the wound
- bright red blood or foul smelling discharge coming from the
wound
- an increase in drainage from the wound
Followup Instructions:
___
|
19992875-DS-15 | 19,992,875 | 20,870,047 | DS | 15 | 2160-04-19 00:00:00 | 2160-05-06 07:35:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal
Attending: ___.
Chief Complaint:
Reason for MICU transfer: monitoring s/p pericardial drainage
Major Surgical or Invasive Procedure:
Pericardiocentesis
Pericardial Window
History of Present Illness:
Mr ___ is ___ male with primary biliary cirrhosis on the
transplant list presenting with jaundice and abdominal pain; in
house found to have cardiac tamponade now transferred to the
MICU s/p pericardial drainage.
Per review of OMR patient was recently admitted from ___
with jaundice, body aches, and abodminal pain. He was discharged
to home. Since return home he notes persistence abdominal pain
and worsening jaundice with associated nausea, bodyaches,
hotflashes, loose stool. His tmax at home was 99.2. He also had
some chest pain which is stabbing and epigastric, and has
resolved. He has been using fentanyl patch and breakthrough
oxycodone for abdominal pain.
On further review, patient endorsed being homeless ___.
Also in prison ___. Found to be PPD + in prison and
treated with 9 months of INH. Says he completed course and
didn't miss doses. Denies pets or travel. No IVDU. HIV neg last
in ___. AMA + at 1:320 in past. Past neg SMA, ANCA, ___,
Histoplasmosis, quant gold. Endorses a ___ day viral illness
with fevers, myalgias, fatigue, cough in ___ of this year. Also
reports losing roughly 50lbs unintentionally over last year.
Reports dry cough for last few months and consistent night
sweats for last week. No known sick contacts and no travel.
In the ED, labs were significant for a Hct of 33.8 (down from
40.2 las discharge, but c/w recent prior baselines). INR was up
to 4.2 from 2.8 last week. Lytes were significant for Na+ of 132
(from 134 last week), and Cr of 0.7 (stable). AST/ALT were ___
both of which are stable. Tbili wsa 18.1 which is within recent
baselines over the past month. CXR was obtained which showed no
acute process. Abdominal u/s with dopplers showed no ascites,
portal vein patent, + splenomegaly.
On ___ patient triggered for tachycardia and low BP, he
received IVF as well as albumin. This morning exam notable for
pulsus of 15 on exam this morning. EKG with low voltages
throughout the pericardium, no alternans. Stat echocardiogram
demonstrated Large ?hemorrhagic partially organized pericardial
effusion with echocardiographic evidence of impaired
filling/tamponade physiology.
Decision made to proceed to ___ for drainage.
On arrival to the MICU, patient feeling groggy with no new chest
pain.
Past Medical History:
# PBC cirrhosis
# History of heavy ETOH use, sober ___ years
# Positive PPD with clinical findings consistent with LTBI
# Hyperlipidemia
# Osteoporosis
Social History:
___
Family History:
-Father: coronary artery disease, depression, diabetes, and
hypercholesterolemia.
-Mother had a brain aneurysm and hyperthyroidism.
Physical Exam:
ON ADMISSION
VS: 97.3 114/74 114 18 100%ra pulsus 18
GENERAL: ill, thin appearing, diffusely jaundiced, but NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae cteric, MMM
NECK: supple, JVP up to tragus
LUNGS: mild bibasilar crackles, good air movement, resp
unlabored,
HEART: tachy, regular, no MRG, nl S1-S2
ABDOMEN: scant bowel sounds, soft, midepigastric and RUQ
tenderness. Enlarged liver, no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, no asterixis.
moving alle xtremities
ON DISCHARGE
Pertinent Results:
ON ADMISSION
___ 07:00PM WBC-5.2 RBC-3.72* HGB-11.8* HCT-33.8* MCV-91
MCH-31.7 MCHC-34.9 RDW-15.0
___ 07:00PM NEUTS-75.2* LYMPHS-16.1* MONOS-6.8 EOS-0.9
BASOS-1.0
___ 07:00PM GLUCOSE-117* UREA N-11 CREAT-0.7 SODIUM-132*
POTASSIUM-3.8 CHLORIDE-99 TOTAL CO2-20* ANION GAP-17
___ 07:00PM ALT(SGPT)-99* AST(SGOT)-99* ALK PHOS-774* TOT
BILI-18.1*
___ 07:00PM LIPASE-25
___ 07:31AM ___ PTT-56.6* ___
___ 07:00PM ALBUMIN-3.5 CALCIUM-8.7 PHOSPHATE-2.6*
MAGNESIUM-2.2
NOTABLE STUDIES
Abdominal US ___. No ascites.
2. Splenomegaly.
Cytology Pericardial Fluid
NEGATIVE FOR MALIGNANT CELLS.
PA/LAT CXR ___. Small right pleural effusion. Right lung base opacity,
most likely
atelectasis, however, superimposed infection cannot be excluded.
2. Mild cardiomegaly and/or pericardial effusion new since
___. Consider
cardiac ultrasound for further assessment.
ECHO ___
The left ventricular cavity size is normal. The right
ventricular cavity is unusually small. No aortic regurgitation
is seen. Physiologic mitral regurgitation is seen (within normal
limits). There is a large pericardial effusion most prominent
inferior and lateral to the left ventricle and anterior to the
right atrium and right ventricle, with minimal around the apical
third of the ventricle. There is stranding within the
pericardial space c/w organization and some mild "ground glass"
appearance suggesting a bloody effusion. There is right
ventricular diastolic collapse, consistent with impaired
fillling/tamponade physiology. There is significant, accentuated
respiratory variation in mitral/tricuspid valve inflows,
consistent with impaired ventricular filling.
IMPRESSION: Large ?hemorrhagic partially organized pericardial
effusion with echocardiographic evidence of impaired
filling/tamponade physiology
PERICARDIOCENTESIS ___
FINAL DIAGNOSIS:
1. Successful pericardiocentesis with drainage of 500cc of blood
fluid
2. Residual loculated lateral pericardial effusion
3. Drain sutured in place to gravity
4. Surgical evaluation for residual effusion
ECHO ___
The left ventricular cavity size is normal. Systolic function is
abnormal, but cannot be well characterized due to tachycardia
and pericardial effusion. Right ventricular chamber size is
normal. Physiologic mitral regurgitation is seen (within normal
limits). There is a moderate sized inferolateral pericardial
effusion.
Compared with the prior study of earlier in the day, the
anterior pericardial effusion has largely resolved and the right
ventricular cavity is now normal in size. Tamponade physiology
is no longer suggested by transmitral Doppler and there is no
RA/RV diastolic collapse. The inferolateral effusion appears
similar.
ECHO ___
Overall left ventricular systolic function is normal (LVEF>55%).
Right ventricular chamber size is normal. with borderline normal
free wall function. There is abnormal septal motion/position.
There is a moderate sized pericardial effusion. Stranding is
visualized within the pericardial space c/w organization. No
right atrial or right ventricular diastolic collapse is seen.
IMPRESSION: There is a residual amount of fluid near the lateral
and inferolateral wall - it is similar to the amount of fluid in
this area before pericardiocentesis. The lateral wall of the
left ventricle moves vigorously towards the centroid of the LV
in diastole - this is probably due to left ventricular diastolic
"collapse" due to the nearby loculated pericardial flulid. The
basal free wall of the right ventricle appears tethered and as a
result RV systolic function is mildly impaired. There is no
evidence of RV or RA diastolic collapse and the fluid that was
previously anterior to the RV has largely resolved.
PORTABLE CXR ___
Moderate enlargement of the cardiomediastinal silhouette has
minimally
improved. There is no evident pneumothorax. Left chest tube
and a second
tube projecting over the heart are in unchanged position.
Enlarged right
pleural effusion is grossly unchanged allowing the difference in
positioning of the patient associated with adjacent atelectasis.
A rounded radiolucency projecting in the right lower hemithorax
is again noted, this could be due to air in the pleural space or
aerated lung surrounding by atelectasis.
CT CHEST ___
IMPRESSION:
1. Moderately large intermediate density pericardial effusion,
which is
likely hemorrhagic. Adjacent small locules of gas, likely
relate to recent
procedure.
2. Small left pneumothorax. Left-sided chest tube is in place
terminating at the left lung base.
3. Moderate non-hemorrhagic right and small left pleural
effusions. Adjacent areas of consolidations most likely
represent atelectasis
4. Splenomegaly.
Brief Hospital Course:
___ Male with Hx of Primary Biliary Cirrhosis who presented with
symptoms of abdominal pain, increased nausea, and loose ___-
hospital course c/b tachycardia and hypotension. He was found to
have a large hemorrhagic pericardial effusion with tamponade
physiology.
#Pericardial Effusion with Tamponade Physiology: Patient
presented with hypotension and tachycardia that was thought to
be from dehydration. ECG showed low voltage and subsequent ECHO
showed large loculated effusion with tamponade physiology.
Pulsus paradoxis prior to pericariocentesis was 30. Patient
underwent pericardiocentesis ___ and 500cc bloody fluid was
drained from anterior locuation. There was still residual fluid
in lateral and posterior pockets. Patient was monitored
overnight in MICU and taken ___ for a pericardial window where
the rest of the fluid was removed and two drains were placed.
Preliminery fluid results showed no malignant cells, gram
staining and culture thus far negative. Patient has a history of
a positive PD ___ while in prison. Subsequent Quantiferon test
in ___ was negative. Fluid was sent for ___ and ___, which was
negative. Given rather unrevealing work up, the hemopericardial
efussion was most likely secondary to recent viral infection
several weeks prior and elevated INR over 4 in setting of poor
GI vitamin absorption. He remained hemodynamically stabe the
reaminding of admission.
#Pleural Effusion: Patient had R sided pleural effusion on
persistent x-rays. X-rays after pericardial window showed "air
bubble" within this effusion. Subsequent CT chest showed this
was likely a non-hemorrhagic effusion with collapsed lung inside
of it. Respiratory status was stable following pericardial
window placement.
#C DIff Coltis: Patient's stool was sent on admission for his
non-specific GI illness and was positive for C Diff. He was
treated with a course of PO Vancomycin. Symptoms will be
resasess at hepatology follow up in 2 weeks.
#Primary Biliary Cirrosis: Patient was admitted with MELD 30. He
was placed on Vitamin K 5mg daily for 10 days and Ursodiol
dosing was decreased. His decompensated liver disease at
admission was thought to be secondary to either congestive
hepatopathy from tamponade physiology, lamictal use (d/c'ed ___, increased dosing of ursodiol causing decreased absorption of
fat soluble vitamins, C.diff infection, and progression of PBC.
His liver disease wsa improving at time of discharge with
downtrending bilirubin. He will follow up with the liver
___ further management of disease.
#Hyponatremia: Patient was mildly hyponatremic on admission.
This improved with albumin and normal saline. Urine lytes
suggested element of hypovolemia.
#Psych Issues: Patient formerly was on lamictal. He was
continued on his home risperidone. Mental status good this
admission.
#Pain Control: Patient was initially on Dilaudid PCA which was
converted to PO oxycodone. He was also maintained on his home
fentanyl patch. Pain was well controlled.
Transitional Issues
-Follow up final staining of pericardial fluid/pericardial
tissue
-Will complete a 2 week course of PO vancomycin for Cdiff and
follow up with hepatology
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 150 mg PO TID
2. Omeprazole 20 mg PO DAILY
3. Risperidone 2 mg PO HS
4. Ursodiol 600 mg PO QID
5. Acetaminophen 500 mg PO Q6H:PRN pain
Do not take more than 4 pills in 24 hours.
6. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral TID
7. Atorvastatin 20 mg PO DAILY
8. Fentanyl Patch 25 mcg/h TP Q72H
9. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
Do not take more than 4 pills in 24 hours.
2. Gabapentin 150 mg PO TID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four hours Disp
#*42 Tablet Refills:*0
4. Risperidone 2 mg PO HS
5. Ursodiol 300 mg PO QID
RX *ursodiol 300 mg 1 capsule(s) by mouth four times a day Disp
#*120 Capsule Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
7. Nystatin Oral Suspension 5 mL PO QID
RX *nystatin 100,000 unit/mL 5 ml by mouth four times per day
Disp #*280 Milliliter Refills:*0
8. Phytonadione 5 mg PO DAILY Duration: 10 Days
RX *phytonadione [Mephyton] 5 mg 1 tablet(s) by mouth daily Disp
#*6 Tablet Refills:*0
9. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*30 Packet Refills:*0
10. Prochlorperazine 25 mg PR Q12H:PRN Nausea
RX *prochlorperazine 25 mg 1 Suppository(s) rectally twice daily
Disp #*30 Suppository Refills:*0
11. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*60 Tablet Refills:*0
12. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six hours Disp
#*28 Capsule Refills:*0
13. Atorvastatin 20 mg PO DAILY
14. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit Oral TID
15. Outpatient Physical Therapy
Please continue to provide acute ___ for deconditioning 3x per
week.
16. Fentanyl Patch 25 mcg/h TP Q72H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pericardial effusion with cardiac tamponade
primary biliary cirrhosis with cirrhosis
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
because you had worsening skin discoloration, jaundice, and low
blood pressure. You were found to have collection of fluid
around your heart, and this was drained. The fluid studies and
the tissue biopsy of the fluid around your heart did not show
infection with bacteria, TB, or fungus and also did not show
features concerning for cancer including lymphoma. We think
that this happened because of inflammation following a viral
upper respiratory tract infection and then a subsequent bleed
into the inflamed tissue.
Your liver was worse during this admission, which can happen
when your body is trying to fight other infections and
inflammation as above. The liver tests are starting to slowly
improve, but you still have end-stage liver disease and will
need a transplant. You should continue to follow-up with the
liver transplant doctors.
___, you were found to have an infection in your colon
(intestines) which is treated with antibiotics. The name of the
bacteria causing this infection is called C. diff. You should
take this until ___.
Followup Instructions:
___
|
19992875-DS-16 | 19,992,875 | 28,963,342 | DS | 16 | 2160-05-25 00:00:00 | 2160-05-27 10:16:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal
Attending: ___
Chief Complaint:
abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
___ EGD
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a PMH of primary
biliary cirrhosis (on the transplant list), hemorrhagic
pericarditis s/p pericardial window (___), C. diff colitis
(treated with vanc PO in ___, now presenting with nausea,
vomiting and diarrhea. Symptoms began 24 hours prior to
admission associated with stomach cramping. Has been having ___
BMs / day. Also having N/V states "Can't keep anything down." No
melena. Some dark brown, loose stool. No BRBPR. No hemoptysis.
No chest pain or shortness of breath. No increase in abdominal
girth. Improved jaundice per father. ___ fevers and
chills. Pt has been feeling more fatigued over last several
weeks.
In the ED, triage vitals were: 97.6 67 113/73 17 100%. Labs were
remarkable for: WBC 3.4 with Eos 13%, H/H 12.3/37.2, plt 95; ALT
100, AST 102, ALK 568, TBil 14.3; lactate 0.9; ___ 63.3, PTT
64.6, INR 5.8. UA showed: dark amber urine with sp gr 1.006,
with no evidence of infection. Bedside abdominal ultrasound
showed no evidence of ascites or large pericardial effusion.
Patient was given ondansetron 2 mg IV. Hepatology consult
recommended checking stool for C. diff, and admission to
___. Prior to transfer, vital signs were: 97.4 61 99/61
18 99%.
On arrival to the floor, pt was AOx3 w/o asterixis. He is
breathing comfortably and complaining of some abdominal
cramping. No evidence of HE on exam.
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:
- primary biliary cirrhosis
- hemorrhagic pericarditis c/b tamponade s/p pericardial window
___
- History of heavy ETOH use, sober ___ years
- Positive PPD with clinical findings consistent with LTBI
- Hyperlipidemia
- Osteoporosis
Social History:
___
Family History:
-Father: coronary artery disease, depression, diabetes, and
hypercholesterolemia.
-Mother had a brain aneurysm and hyperthyroidism.
Physical Exam:
On admission:
VS: 98.4, 107/64, 62, 20, 98%RA
GENERAL: NAD. Jaundiced
HEENT: Sclera icteric. MMM. no oral ulcers
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: no ascites on exam, no fluid wave, BS+, generalized TTP
EXTREMITIES: no c/c/e
NEUROLOGY: no asterixis, concentration and attention normal on
exam
On discharge:
VS: Tc 98.6, 97/113 (97-113) 65 (60-83), 18, 100% RA.
GENERAL: NAD. Jaundiced
HEENT: Sclera icteric. MMM. no oral ulcers
CARDIAC: RRR with no excess sounds appreciated
LUNGS: CTA b/l with no wheezing, rales, or rhonchi.
ABDOMEN: no ascites on exam, no fluid wave, BS+, mild epigastric
tenderness
EXTREMITIES: no edema, + clubbing of fingernails
NEUROLOGY: no asterixis, concentration and attention normal on
exam
Pertinent Results:
On admission:
___ 09:05AM BLOOD WBC-2.7* RBC-4.14* Hgb-12.4* Hct-38.3*
MCV-93 MCH-30.1 MCHC-32.5 RDW-17.8* Plt Ct-95*
___ 09:05AM BLOOD ___
___ 09:05AM BLOOD UreaN-11 Creat-0.7 Na-137 K-4.0 Cl-99
___ 09:05AM BLOOD ALT-121* AST-117* AlkPhos-578*
TotBili-15.6*
___ 05:53PM BLOOD Albumin-3.9 Calcium-9.4 Phos-4.0 Mg-2.2
___ 09:05AM BLOOD Albumin-4.4
Studies:
KUB ___
FINDINGS: A large amount of stool is present throughout the
colon extending
into the rectosigmoid region. Scattered air-fluid levels are
also present
within non-distended loops of small bowel. There is no evidence
of free
intraperitoneal air. Prominent soft tissue in left upper
quadrant of the
abdomen probably relates to known splenic enlargement reported
on prior CT
scan. Within the imaged portion of the chest, note is made of
interstitial
opacities in the mid and lower lungs suggestive of interstitial
edema, as well
as a more focal opacity at the left lung base, which may reflect
atelectasis
and less likely a focal pneumonia or area of infarction. Small
left pleural
effusion is also demonstrated.
RUQ U/S ___
IMPRESSION:
1. No sonographic evidence for portal vein thrombosis.
2. Cirrhosis with splenomegaly. No liver lesions or ascites
detected.
3. Non-obstructing 1 cm right renal calculus.
GI bx pathology:
A. Mid-esophagus:
Squamous epithelium, within normal limits.
Scant detached debris with rare neutrophils.
B. Lower esophagus:
Mild acute esophagitis.
Special stains (GMS, PAS) are negative for fungal organisms.
C. Duodenum, second part:
Duodenal mucosa within normal limits.
___ EGD Impression:
Linear erosive esophagitis involving lower and upper esophagus
s/p biopsies. ___ B
Normal stomach. Gastic juice was collected for PH testing
Atrophic appearing duodenal mucosa with mild blunting s/p
biopsies
(biopsy)
Otherwise normal EGD to third part of the duodenum
Micro:
C. difficile DNA amplification assay (Final ___:
This test was cancelled because a FORMED stool specimen
was received,
and is NOT acceptable for the C. difficle DNA
amplification testing..
TEST CANCELLED, PATIENT CREDITED.
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ EKG
Sinus bradycardia. Otherwise, probably normal. Since the
previous tracing
of ___ the rate is slower. Otherwise, no change
On discharge:
___ 05:10AM BLOOD WBC-3.0* RBC-3.62* Hgb-11.8* Hct-32.9*
MCV-91 MCH-32.8* MCHC-36.0* RDW-17.7* Plt Ct-91*
___ 05:10AM BLOOD ___ PTT-35.5 ___
___ 05:10AM BLOOD Glucose-91 UreaN-10 Creat-0.7 Na-136
K-3.7 Cl-97 HCO3-27 AnGap-16
___ 05:10AM BLOOD ALT-77* AST-80* AlkPhos-466*
TotBili-21.3*
___ 05:10AM BLOOD Albumin-3.9 Calcium-9.1 Phos-2.9 Mg-2.2
Brief Hospital Course:
Mr. ___ is a ___ h/o of primary biliary cirrhosis (on the
transplant list), hemorrhagic pericarditis s/p pericardial
window (___), C. diff colitis (treated with vanc PO in
___, now presenting with nausea, vomiting and diarrhea, and
epigastric pain.
# Nausea / vomiting / Diarrhea (resolved), now constipation:
Initially concerning for infectious process especially repeat
C.diff infection, though no bowel movements in first ___ days of
admission despite aggressive bowel regimen. Patient could not
produce loose stool to send off for C. diff. No evidence of
peritonitis on exam and normal bowel sounds made SBO less
likely. Surgery team recommended empiric PO vancomycin, but Pt
w/out fever, leukocytosis, lower abdominal pain. KUB showed p
was full of stool. Pt may have had diarrhea secondary to
constipation (loose stool traversing past impacted stool).
Infectious stool studies were negative. Blood and urine cultures
were also negative. EGD showed erosive esophagitis which likely
was contributing to nausea. Constipation was the primary process
contributing to symptoms as nausea resolved with passing bowel
movements (given senna/colace/miralax/lactulose/dulcolax and
Moviprep. Patient was not on bowel regimen pre-admission while
on fentanyl patch and oxycodone. He was discharged with bowel
regimen.
# Epigastric pain, Esophagitis: Lipase normal. EKGs were
unremarkable. Pt previously had candidiasis of the esophagus on
EGD in ___, no varices. He was treated with 10 days of
fluconazole. ___ have had worsening partially treated ___
infection. He also has not been taking his prescribed
clotrimazole troches and patient was restarted on clotrimazole.
Another possibility was GERD/gastritis/esophagitis. EGD showed
erosive esophagitis and pathology showed acute esophagitis.
Patient was started on omeprazole BID, carafate BID, and
ranitidine (added on as patient with severe pain which subsided
with ranitidine). Epigastric pain also improved with passing BMs
and pt discharged with aggressive bowel regimen.
# Primary Biliary Cirrhosis- Pt on transplant list, admission
labs concerning for MELD of 36. Last admission pt had MELD of
30. RUQ u/s with dopplers ruled out portal vein thrombosis. No
hx per pt of HE, also no h/o ascites or SBP. While inhouse,
patient was ordered daily albumin levels given on transplant
list. Patient was continued on ursodiol and given lactulose PRN
at discharge to prevent further constipation. EGD on ___ did
report did not mention varices.
#Coagulopathy: Patient with labile INR ranging from ___. Pt with
h/o hemorrhagic pericardial effusion s/p pericardial window.
Will supplement with Vit K. Patient was given IV Vit K on ___
for INR>5 and started standing PO Vit K 5mg daily thereafter.
INR on admission=1.0.
# Thrombocytopenia- Plts on admission 95 which was decreased
from 200s. Stable in ___. Most likely related to acute
worsening of liver function. No petechiae on exam, h/h stable.
# HL- continued on atorvastatin.
Transitional issues:
-Patient discharged with bowel regimen: senna/Miralax standing
and lactulose PRN
-Patient has follow-up with PCP and hepatology
-___ started on standing PO Vit K 5mg daily
-Patient started on PPI, H2 blocker and carafate to control
acute erosive esophagitis
-Patient restarted on clotrimazole troches- patient told to ask
outpatient providers on duration of taking troches
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lorazepam 0.5 mg PO Q6H:PRN anxiety
2. Fentanyl Patch 25 mcg/h TP Q72H
due to be changed on ___. Atorvastatin 20 mg PO DAILY
4. Risperidone 2 mg PO DAILY
5. Ursodiol 300 mg PO QID
6. Calcium Carbonate 500 mg PO TID
7. Vitamin D 400 UNIT PO TID
8. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
9. Gabapentin 300 mg PO TID
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
hold for sedation or RR <10
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Fentanyl Patch 25 mcg/h TP Q72H
4. Gabapentin 300 mg PO TID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Risperidone 2 mg PO DAILY
7. Ursodiol 300 mg PO QID
8. Vitamin D 400 UNIT PO TID
9. Clotrimazole 1 TROC PO QID
RX *clotrimazole 10 mg One 10mg troche four times a day Disp
#*40 Each Refills:*0
10. Omeprazole 40 mg PO BID
RX *omeprazole 20 mg 2 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
11. Phytonadione 5 mg PO DAILY
RX *phytonadione [Mephyton] 5 mg 1 tablet(s) by mouth Daily Disp
#*20 Tablet Refills:*0
12. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17 g by
mouth Daily Disp #*20 Each Refills:*0
13. Ranitidine (Liquid) 150 mg PO BID
RX *ranitidine HCl 150 mg 1 capsule by mouth twice a day Disp
#*40 Capsule Refills:*0
14. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*40 Tablet Refills:*0
15. Sucralfate 2 gm PO BID
RX *sucralfate 1 gram 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
16. Lorazepam 0.5 mg PO Q6H:PRN anxiety
17. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
18. Lactulose 30 mL PO Q8H:PRN constipation.
RX *lactulose 10 gram/15 mL 30 ml by mouth Q8H PRN Disp #*1
Bottle Refills:*0
19. Ondansetron ___ mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg ___ tablet(s) by mouth Q8H PRN Disp
#*25 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Erosive esophagitis
Constipation
Primary biliary cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted for diarrhea and we were concerned that you
had C. difficile again. Our work-up showed that you had severe
constipation which likely allowed liquid stool to pass through
your GI tract and thus you presented with diarrhea. The x-ray of
your abdomen showed that you had a lot of stool throughout your
GI tract. Constipation is a common side effect of taking
narcotic pain medications. We are giving you senna and
polyethylene glycol [Miralax], which you will have to take on a
daily basis to help you pass stools while you are on the
fentanyl patch and oxycodone. We are also giving you a
prescription for lactulose which you can use as needed if you
remain constipated with the two agents above. Please stay
hydrated and physically active as well.
Your abdominal pain and nausea was likely related to severe
constipation and acid reflux. We also saw that you had an
inflamed esophagus, likely from excessive stomach acid. We
started you on omeprazole, sucralfate and ranitidine to help
control your symptoms.
START Phytonadione daily to help correct your abnormal clotting
from your liver disease.
START Senna and Miralax on a regular basis. Take lactulose as
needed if you need additional support to help you pass bowel
movements.
Followup Instructions:
___
|
19992875-DS-17 | 19,992,875 | 27,668,708 | DS | 17 | 2160-06-21 00:00:00 | 2160-07-01 21:02:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal
Attending: ___.
Chief Complaint:
Abdominal pain, weakness, and lethargy.
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old male with advanced PBC, listed for liver
transplant, and fairly recent hemorrhagic pericarditis s/p
pericardial window (___) who presents with abdominal pain,
weakness, and lightheadedness.
.
He was admitted last month from ___ to ___. He was doing
well after discharge until earlier today. He was eating brunch
when he developed lower abdominal pain, lightheadedness, and
fatigue. Usually has ___ abdominal pain but has now been
___.
.
He called the ___, who recommended that he come to
the ___ ED. Since his last admission, he has been on a bowel
regimen titrated to ___ BMs a day and has had 3 BMs so far
today. He denies any melena or hematochezia. He has alternating
diarrhea and constipation which is baseline for him. His stools
are gray, which is his baseline. He has noticed that his
jaundice and pruritus have been worsening.
.
He had two episodes of visual disturbance in which he saw black
spots while standing up to urinate. He felt lightheaded at the
time and these symptoms resolved when he finished urinating and
returned to bed.
.
Initial vitals in ED triage were T 98.8, HR 77, BP 135/65, RR
16, and SpO2 100% on RA. Exam was notable for jaundice. Labs
showed pancytopenia similar to recent values. His electrolytes
were unremarkable. His coags were elevated with INR 2.0 and PTT
60.9 (normal coags on ___. His LFTs were essentially
unchanged from ___, though still elevated compared to his
discharge on ___ with ALT 99, AST 130, ALK 384, and TBili
20.5. Albumin was normal at 4.1. Urinalysis was normal except
for large bilirubin. No imaging was performed.
He was given Oxycodone 10 mg PO for abdominal pain. He was
admitted to the ___ service for further management of
his abdominal pain and weakness. Vitals prior to floor transfer
were T 97.8, HR 63, BP 111/68, RR 16, and SpO2 100% on RA.
On reaching the floor, he reported
REVIEW OF SYSTEMS:
(+) Per HPI; also has had chronic chest discomfort since
pericardial window in ___ which has not changed
(-) No fevers. No headache. No SOB, cough, dysphagia. No
nausea/vomiting, melena, BRBPR. No hematuria, dysuria,
frequency.
Past Medical History:
# Primary Biliary Cirrhosis
-- listed for transplant and followed by Dr ___
# Hemorrhagic Pericarditis
-- c/b tamponade s/p pericardial window (___)
# Positive PPD
-- Treated with Isoniazid while incarcerated
# Esophageal Candidiasis
# Hyperlipidemia -- secondary to PBC
# Osteoporosis
# Bipolar Disorder
Social History:
___
Family History:
# Father: coronary artery disease, diabetes,
hypercholesterolemia, and depression
# Mother: brain aneurysm and hyperthyroidism
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.7 114/75 75 18 100%RA
Gen: Young male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Icteric sclera. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. No cervical lymphadenopathy. No carotid
bruits noted.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Soft bowel sounds, somewhat rigid abdomen without
rebound/guarding, no ascites, generalized tenderness to
palpation in lower quadrants
Ext: No C/C/E. Distal pulses intact radial 2+, DP 2+, ___ 2+.
Neuro: CN II-XII grossly intact. Strength ___ in all
extremities. No asterixis
DISCHARGE PHYSICAL EXAMINATION:
VS: 97.7 114/75 75 18 100%RA
Gen: Young male in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Icteric sclera. PERRL, EOMI. MMM, OP benign.
Neck: Supple, full ROM. No cervical lymphadenopathy. No carotid
bruits noted.
CV: RRR with normal S1, S2. No M/R/G. No S3 or S4.
Chest: Respiration unlabored, no accessory muscle use. CTAB
without crackles, wheezes or rhonchi.
Abd: Soft bowel sounds, somewhat rigid abdomen without
rebound/guarding, no ascites, generalized tenderness to
palpation in lower quadrants
Ext: No C/C/E. Distal pulses intact radial 2+, DP 2+, ___ 2+.
Neuro: CN II-XII grossly intact. Strength ___ in all
extremities. No asterixis
Pertinent Results:
ADMISSION LABS
===============
___ 06:00PM BLOOD WBC-2.2* RBC-3.55* Hgb-11.2* Hct-32.9*
MCV-93 MCH-31.7 MCHC-34.1 RDW-17.2* Plt ___
___ 06:00PM BLOOD Neuts-60 Bands-3 ___ Monos-11 Eos-3
Baso-0 ___ Myelos-0
___ 06:00PM BLOOD ___ PTT-60.9* ___
___ 06:00PM BLOOD Glucose-93 UreaN-7 Creat-0.6 Na-136 K-3.4
Cl-101 HCO3-23 AnGap-15
___ 06:00PM BLOOD ALT-99* AST-130* LD(___)-132 CK(CPK)-28*
AlkPhos-384* TotBili-20.5*
___ 06:00PM BLOOD Lipase-20
___ 06:00PM BLOOD Albumin-4.1
OTHER PERTINENT
================
___ 06:45AM BLOOD TSH-3.3
___ 06:00PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:45AM BLOOD CK-MB-1 cTropnT-<0.01
DISCHARGE LABS
================
___ 06:52AM BLOOD WBC-2.2* RBC-3.66* Hgb-11.5* Hct-34.2*
MCV-94 MCH-31.4 MCHC-33.6 RDW-16.8* Plt ___
___ 06:52AM BLOOD ___ PTT-46.8* ___
___ 06:52AM BLOOD Glucose-89 UreaN-8 Creat-0.7 Na-136 K-3.9
Cl-100 HCO3-25 AnGap-15
___ 06:52AM BLOOD ALT-91* AST-105* LD(LDH)-122 AlkPhos-398*
TotBili-21.6*
___ 06:52AM BLOOD Albumin-4.1 Calcium-9.1 Phos-2.8 Mg-2.3
URINE
======
___ 06:00PM URINE Color-AMBER Appear-Clear Sp ___
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-5.5 Leuks-NEG
MICROBIOLOGY
=============
___ Blood Culture, Routine-FINAL
___ STOOL C. difficile DNA amplification assay-FINAL;
FECAL CULTURE-FINAL; CAMPYLOBACTER CULTURE-FINAL
___ Blood Culture, Routine-FINAL
___ SWAB R/O VANCOMYCIN RESISTANT ENTEROCOCCUS-FINAL
{ENTEROCOCCUS SP.}
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
VANCOMYCIN------------ >256 R
___ URINE URINE CULTURE-FINAL
STUDIES
=========
EKG
===
Sinus rhythm. Normal ECG. Compared to the previous tracing of
___ the
rate has decreased. Otherwise, no diagnostic interim change.
Rate PR QRS QT/QTc P QRS T
68 ___ 36 50 64
RUQ U/S WITH DOPPLERS
IMPRESSION:
1. No sonographic evidence for a portal venous thrombosis.
Patent portal vein with hepatopetal flow.
2. Cirrhosis with unchanged splenomegaly, no ascites.
3. Incidental, nonobstructing 0.6 cm right renal stone.
KUB
===
FINDINGS: Frontal upright and supine radiographs demonstrate a
moderate
amount of stool throughout the colon extending to the
rectosigmoid junction. There are air-filled loops of small
bowel that are mildly distended. There is no abnormal air-fluid
levels or evidence of free intraperitoneal air. Prominent soft
tissues in the left upper quadrant of the abdomen is due to
splenic enlargement. There is a small left pleural effusion.
IMPRESSION: Moderate fecal load throughout the colon. No free
air
identified. Small left pleural effusion.
ECHO
====
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ Portable TTE
(Complete) Done ___ at 11:34:53 AM FINAL
Referring Physician ___
___ of Gastroenterol
___ Status: Inpatient DOB: ___
Age (years): ___ M Hgt (in): 72
BP (mm Hg): 119/69 Wgt (lb): 142
HR (bpm): 81 BSA (m2): 1.84 m2
Indication: Chest pain. Pericarditis. Pericardial effusion.
ICD-9 Codes: 786.51, 423.9, 424.0
___ Information
Date/Time: ___ at 11:34 ___ MD: ___
___, MD
___ Type: Portable TTE (Complete) Sonographer: ___,
___
Doppler: Full Doppler and color Doppler ___ Location: ___ Floor
Contrast: None Tech Quality: Adequate
Tape #: ___-0:00 Machine: E9-1
Echocardiographic Measurements
Results Measurements Normal Range
Left Atrium - Long Axis Dimension: 3.2 cm <= 4.0 cm
Left Atrium - Four Chamber Length: 4.2 cm <= 5.2 cm
Right Atrium - Four Chamber Length: 4.3 cm <= 5.0 cm
Left Ventricle - Septal Wall Thickness: 1.0 cm 0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness: 1.1 cm 0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension: 4.7 cm <= 5.6 cm
Left Ventricle - Ejection Fraction: 60% >= 55%
Left Ventricle - Stroke Volume: 86 ml/beat
Left Ventricle - Cardiac Output: 6.96 L/min
Left Ventricle - Cardiac Index: 3.78 >= 2.0 L/min/M2
Left Ventricle - Lateral Peak E': 0.14 m/s > 0.08 m/s
Left Ventricle - Septal Peak E': 0.11 m/s > 0.08 m/s
Left Ventricle - Ratio E/E': 6 < 15
Aorta - Sinus Level: 2.6 cm <= 3.6 cm
Aorta - Ascending: 2.5 cm <= 3.4 cm
Aortic Valve - Peak Velocity: 1.4 m/sec <= 2.0 m/sec
Aortic Valve - LVOT VTI: 19
Aortic Valve - LVOT diam: 2.4 cm
Mitral Valve - E Wave: 0.7 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 1.17
Mitral Valve - E Wave deceleration time: 201 ms 140-250 ms
Findings
This study was compared to the prior study of ___.
LEFT ATRIUM: Normal LA size.
RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size.
LEFT VENTRICLE: Normal LV wall thickness, cavity size, and
global systolic function (LVEF>55%). TDI E/e' < 8, suggesting
normal PCWP (<12mmHg). No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTA: Normal aortic diameter at the sinus level. Normal
ascending aorta diameter.
AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR.
MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. ___
LV inflow pattern for age.
TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial
TR. Indeterminate PA systolic pressure.
PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet.
No PS. Physiologic PR.
PERICARDIUM: No pericardial effusion.
Conclusions
The left atrium is normal in size. Left ventricular wall
thickness, cavity size, and global systolic function are normal
(LVEF>55%). Tissue Doppler imaging suggests a normal left
ventricular filling pressure (PCWP<12mmHg). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are structurally normal. Mild (1+) mitral
regurgitation is seen. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
there is less mitral regurgitation. A bubble study was not
performed. Other findings are similar.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
======================
Mr. ___ is a ___ year old gentleman with advanced PBC, listed
for liver transplant, and fairly recent hemorrhagic pericarditis
s/p pericardial window (___) who presented with abdominal
pain, weakness, and lightheadedness. His abdominal pain was
likely from constipation. His lightheadedness was presyncopal in
nature and improved by discharge.
ACTIVE ISSUES
==============
# Abdominal Pain due to constipation: He reported post-prandial
abdominal pain without rebound/guarding. LFTs and Tbili were
largely unchanged from baseline, though INR was elevated in the
setting of stopping PO vitamin K. He actually had a recent
admission with abdominal pain which was attributed to
constipation; he had an abdominal x-ray done which showed feces
throughout the colon.RUQ ultrasound with doppler was not
concerning for thrombotic event. Stool studies, including c.
diff, were not revealing. Bowel regimen was uptitrated with BID
miralax (for stool bulking), senna, lactulose.
# Lightheadedness: He reported presyncopal symptoms on two
occasions while urinating, another time while at ___ eating
a meal, and once while eating during this admission. History was
most consistent with vasovagal symptoms. His orthostatics were
negative twice. EKG without new changes. Cardiac enzymes were
flat. Given history of hemorrhagic pericarditis s/p window, with
coagulopathy, and a great deal of ___ concern regarding
lightheadedness, he underwent TTE to evaluate for pericardial
effusion, which did not show any accumulation of fluid. Of note
he did not have physiology concerning for significant
pericardial effusion. He was encouraged to hydrate daily with
fluids such as gatorade.
CHRONIC ISSUES
===============
# Coagulopathy: INR on previous admission ranged ___ but on
recent discharge had been 1. He was treated until recently with
daily vitamin K (hepatologist discontinued his vitamin K
recently). INR elevation likely from discontinuation of vitamin
K, though worsening liver synthetic function also possible.
# Pancytopenia: CBC, WBC, and platelets were largely within
recent baseline.
# Primary Biliary Cirrhosis: He has advanced PBC and is
currently listed for transplant. His MELD score on admission was
26. Recent EGD on ___ did not show evidence of varices.
Albumin 4.1 and his coagulopathy was previously corrected fully
with Vitamin K, suggesting relatively intact synthetic function.
He was continued on ursodiol 300mg q6h.
# Gastritis / Esophagitis: Continued on home omeprazole,
ranitidine, sucralfate, and clotrimazole troches.
# History of recent hemorrhagic pericarditis: Please see
discussion above. He is s/p pericardial window ___ and
reports has had chronic chest pain ever since. Avoid NSAIDs due
to liver disease. EKG, echo not concerning for repeat
effusion/pericarditis.
# Hyperlipidemia: He has highly elevated cholesterol due to his
PBC, and most recent lipid panel on ___ with TC 724, ___
311, HDL 12, and LDL 141. The benefit of statins in PBC is
unclear, and statins can certainly be associated with liver
injury. He reports that his hepatologist discontinued his home
atorvastatin, and this was held in house as well.
# Vitamin D Deficiency: His last Vitamin D level on ___ was
undetectable. He was continued on cholecalciferol and calcium
carbonate.
# Chronic Pain: There was concern that his narcotics could be
contributing to fecal loading despite bowel regimen. He was
continued on home regimen, but bowel regimen was uptitrated. He
was managed with fentanyl patch, gabapentin, and oxycodone.
# Bipolar Disorder: Continued on home risperidone.
TRANSITIONAL ISSUES
====================
- Code status: Full code, confirmed.
- Emergency contact: Father ___ ___.
- Studies pending on discharge: All finalized.
- Noted to have constipation, so bowel regimen was increased.
- We re-educated on low sodium diet (appears to be not fully
compliant with low sodium diet; ie, eating at ___ and
___).
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 20 mg PO DAILY
2. Calcium Carbonate 500 mg PO TID
3. Fentanyl Patch 25 mcg/h TP Q72H
4. Gabapentin 300 mg PO TID
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Risperidone 2 mg PO DAILY
7. Ursodiol 300 mg PO QID
8. Vitamin D 400 UNIT PO TID
9. Clotrimazole 1 TROC PO QID
10. Omeprazole 40 mg PO BID
11. Phytonadione 5 mg PO DAILY
12. Polyethylene Glycol 17 g PO DAILY
13. Ranitidine (Liquid) 150 mg PO BID
14. Senna 1 TAB PO BID
15. Sucralfate 2 gm PO BID
16. Lorazepam 0.5 mg PO Q6H:PRN anxiety
17. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
18. Lactulose 30 mL PO Q8H:PRN constipation
19. Ondansetron ___ mg PO Q8H:PRN nausea
Discharge Medications:
1. Calcium Carbonate 500 mg PO TID
2. Clotrimazole 1 TROC PO QID
3. Fentanyl Patch 25 mcg/h TP Q72H
4. Gabapentin 300 mg PO TID
5. Lorazepam 0.5 mg PO Q6H:PRN anxiety
6. Omeprazole 40 mg PO BID
7. Ondansetron ___ mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. Ranitidine (Liquid) 150 mg PO BID
10. Sucralfate 2 gm PO BID
11. Ursodiol 300 mg PO QID
12. Senna 1 TAB PO BID
13. Risperidone 2 mg PO DAILY
14. Vitamin D 400 UNIT PO TID
15. Vitamin D 50,000 UNIT PO 1X/WEEK (FR)
16. Lactulose 30 mL PO Q8H:PRN constipation
17. Polyethylene Glycol 17 g PO BID
You can decrease the frequency of this medicine if you are
having loose, watery stools.
RX *polyethylene glycol 3350 [Laxative PEG 3350] 17 gram/dose 1
packet by mouth twice a day Disp #*60 Packet Refills:*0
18. Docusate Sodium 100 mg PO BID
You can stop this medicine if you are having loose, watery
stools.
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Constipation
.
Secondary: primary biliary cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___.,
It was a pleasure taking part in your care at ___. You were
admitted because of abdominal pain and a lightheaded feeling.
You underwent studies which showed you did not have any
concerning issues with your heart. We checked blood and urine
and could not find evidence of infection. Your abdominal studies
were not concerning, and we think your abdominal pain was
related to constipation. You were monitored and improved.
.
It is important for you to stay well-hydrated. You should have
at leave 2 liters (64oz) or water or Power Aid per day. You also
should have a low-salt diet. Be careful when you eat out as most
___ put a lot of salt in their food. Change positions (ie
stand up) slowly to prevent feeling lightheaded.
Followup Instructions:
___
|
19992875-DS-18 | 19,992,875 | 21,441,737 | DS | 18 | 2160-09-11 00:00:00 | 2160-09-11 13:36:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / rifampin / Lamictal
Attending: ___.
Chief Complaint:
Elevated INR, Blood coating stools
Major Surgical or Invasive Procedure:
Liver transplant
History of Present Illness:
___ M with Primary Biliary Cirrhosis, Hx of hemorrhagic
pericarditis, +PPD s/p INH, esophageal candidiasis, and bipolar
disorder currently hospitalized for elevated INR and treated for
constipation, now pre-op for liver transplant. He has
persistent
bilirubinemia and MELD was 20 on ___.
He was admitted on ___ with an INR 4.7 and gross blood on rectal
exam and given 10mg IV vitamin K and 1 unit FFP in the ED. His
INR is now 1. His left sided abdominal pain, likely due to
severe
constipation, is improving, and he is receiving an aggressive
bowel regiment (Moviprep) with 8 non-bloody ___ BMs
yesterday. He reports pruritis and dark urine. Eating well and
denies N/V or F/C.
Past Medical History:
primary biliary cirrhosis (on transplant list), hx heavy
alcohol abuse (sober 5+ years), recent hemorrhagic pericarditis
c/b tamponade s/p pericardial window, hx positive PPD (likely
LTB, Tx with INH while incarcerated), hyperlipidemia,
osteoporosis, bipolar disorder, ADHD, Hx of alcohol abuse,
hemorrhoids
s/p pericardial window ___, s/p L leg surgery after MVC,
liver biopsy (___)
Social History:
___
Family History:
No family Hx of liver disease.
Father: History of prostate and Head & neck cancer.
Mother: ___ from brain aneurysm.
Pertinent Results:
___ 05:00AM BLOOD WBC-1.9* RBC-3.37* Hgb-11.1* Hct-32.2*
MCV-96 MCH-33.0* MCHC-34.6 RDW-16.2* Plt Ct-93*
___ 05:30AM BLOOD WBC-2.4* RBC-3.29* Hgb-10.7* Hct-31.5*
MCV-96 MCH-32.7* MCHC-34.0 RDW-15.8* Plt Ct-99*
___ 05:50AM BLOOD WBC-3.3*# RBC-3.12* Hgb-10.3* Hct-28.7*
MCV-92 MCH-32.9* MCHC-35.7* RDW-15.8* Plt ___
___ 05:13AM BLOOD WBC-2.1* RBC-2.91* Hgb-9.4* Hct-26.7*
MCV-92 MCH-32.1* MCHC-35.0 RDW-15.5 Plt ___
___ 05:36AM BLOOD ___ PTT-26.5 ___
___ 09:30PM BLOOD ___ PTT-32.3 ___
___ 12:10PM BLOOD ___ PTT-43.5* ___
___ 05:30AM BLOOD ___ PTT-36.8* ___
___ 05:50AM BLOOD Glucose-99 UreaN-11 Creat-0.7 Na-140
K-4.0 Cl-104 HCO3-27 AnGap-13
___ 09:30PM BLOOD Glucose-224* UreaN-11 Creat-0.6 Na-134
K-4.0 Cl-99 HCO3-23 AnGap-16
___ 05:30AM BLOOD Glucose-92 UreaN-12 Creat-0.8 Na-136
K-3.6 Cl-98 HCO3-23 AnGap-19
___ 05:50AM BLOOD ALT-217* AST-61* AlkPhos-99 TotBili-4.1*
___ 05:13AM BLOOD ALT-238* AST-75* AlkPhos-92 TotBili-4.8*
___ 05:41AM BLOOD ALT-296* AST-105* AlkPhos-96 TotBili-5.2*
___ 06:02AM BLOOD ALT-300* AST-131* AlkPhos-99 TotBili-6.0*
___ 05:36AM BLOOD ALT-389* AST-257* LD(LDH)-240 AlkPhos-105
Amylase-11 TotBili-8.0*
___ 05:38PM BLOOD ALT-429* AST-355* LD(LDH)-280*
AlkPhos-110 Amylase-8
___ 12:20PM BLOOD ALT-397* AST-376* AlkPhos-117
TotBili-9.9*
___ 03:48AM BLOOD ALT-386* AST-387* AlkPhos-123
TotBili-10.3* DirBili-6.3* IndBili-4.0
___ 09:30PM BLOOD ALT-422* AST-520* AlkPhos-125
TotBili-11.1* DirBili-6.9* IndBili-4.2
___ 01:45AM BLOOD ALT-100* AST-125* AlkPhos-256*
TotBili-31.7*
___ 05:30AM BLOOD ALT-108* AST-142* AlkPhos-260*
TotBili-30.2*
Brief Hospital Course:
___ is a ___ year old male with Primary Biliary
Cirrhosis, Hx of hemorrhagic pericarditis, +PPD s/p INH,
esophageal candidiasis, and bipolar disorder who was
hospitalized for elevated INR and treated for constipation, now
pre-op for liver transplant. He had persistent bilirubinemia
and MELD was 20 on ___. He underwent a deceased donor liver
transplant (piggyback, portal vein to portal vein, celiac trunk
to replaced right hepatic artery, common bile duct to common
bile duct) on ___. The donor was CDC high-risk because of a
positive CMV IgM titer with a history of a recent viral illness.
Surgeon was Dr. ___ assisted by Dr. ___.
Two ___ drains were placed. A lateral drain was placed to the
bare area of the liver and the medial drain was behind the
porta. During the operation his EBL was 2L, he received 4U
PRBCs, 3 platelets, ___ FFP and 3L of IVF. He received induction
immunosuppression (SoluMedrol 500mg x1, MMF 1000mg x1). He was
transferred intubated to the SICU postop per protocol. He was
subsequently extubated the same evening and remained stable.
Postop liver duplex demonstrated normal arterial waveforms in
the right, main, and left hepatic arteries, and patent portal
and hepatic veins. Splenomegaly was unchanged. JP drain outputs
were non-bilious. LFTs decreased each day.
He was transferred out of the SICU on the following day and
began a clear diet. By post-op day 3 his diet was advanced to
regular diet and he begain PO pain medication. His medial JP
drain was removed on post-op day 4, however, his lateral JP
drain continued to have high output (1200cc). Output decreased
to less than 500cc/day by postop day 7. JP drain was removed on
___ and site sutured. This remained dry. Incision was open to
air and without redness or drainage.
___ cleared him for home. He was ambulating independently.
Immunosuppression consisted of Cellcept, steroid taper, and
tacrolimus dose-adjusted based on serum levels. He also
received prophylaxis Bactrim ss, fluconazole and valgan 900 qD.
Valcyte was increased to 900mg bid as donor was CMV positive . A
CMV viral load was drawn on ___.
___ followed for hyperglycemia. However, he required minimal
sliding scale insulin with glucoses ranging between low 100s and
an occasional 170-190. He was provided with a glucometer and was
able to do fingersticks. He will log his glucose results. He did
well with medication teaching.
On the day of discharge (___), Prograf level was 21. 2. He was
instructed to hold pm dose ___ and am dose ___ then decrease
to 4mg bid with next trough level on am ___ at ___
___ lab.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Calcium Carbonate 500 mg PO TID
2. Clotrimazole 1 TROC PO QID
3. Fentanyl Patch 25 mcg/h TP Q72H
HOLD for sedation, RR < 12
4. Gabapentin 300 mg PO TID
5. Lorazepam 0.5 mg PO Q6H:PRN anxiety
6. Omeprazole 40 mg PO BID
7. Ondansetron ___ mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
HOLD for sedation, RR < 12
9. Ranitidine (Liquid) 150 mg PO BID
10. Sucralfate 2 gm PO BID
11. Ursodiol 300 mg PO QID
12. Senna 1 TAB PO BID
13. RISperidone 2 mg PO DAILY
14. Vitamin D 400 UNIT PO DAILY
15. Lactulose 30 mL PO DAILY
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
Hold if having loose bowel movements
2. Omeprazole 40 mg PO BID
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q 4 hours Disp #*80
Tablet Refills:*0
4. RISperidone 2 mg PO DAILY
5. Vitamin D 400 UNIT PO DAILY
6. Fluconazole 400 mg PO Q24H
7. Mycophenolate Mofetil 1000 mg PO BID
8. PredniSONE 20 mg PO DAILY
taper per schedule
9. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
10. ValGANCIclovir 900 mg PO BID Duration: 14 Days
decrease to daily dosing after ___. Tacrolimus 0 mg PO Q12H Duration: 2 Doses
HOLD ___ dose ___ and AM ___. Tacrolimus 4 mg PO Q12H
start ___ ___. Gabapentin 300 mg PO BID
for neuropathy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
severe constipation
coagulopathy secondary to vitamin K deficiency
primary biliary cirrhosis
orthotopic liver transplant ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ arranged. You will receive a call to arrange a home
visit.
Please call the transplant clinic at ___ for fever >
101, 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, or any other
concerning symptoms.
You will have labwork drawn every ___ and ___ at the
___ Lab (First Floor) with results to the
transplant clinic.
On the days you have your labs drawn, do not take your prograf
until your labs are drawn. Bring your prograf with you so you
may take your medication as soon as your labwork has been drawn.
Please 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. The
staples are removed approximately 3 weeks following your
transplant.
No tub baths or swimming
No driving if taking narcotic pain medications
Please avoid direct sun exposure. Wear protective clothing and a
hat, and always wear sunscreen when you go outdoors.
Please drink enough fluids to keep your urine light in color.
Your appetite will return with time. Eat small frequent meals,
and you may supplement with things like carnation instant
breakfast or Ensure.
Please check your blood sugars and blood pressure at home.
Report consistently elevated values to the transplant clinic
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:
___
|
19992875-DS-21 | 19,992,875 | 27,965,926 | DS | 21 | 2160-12-29 00:00:00 | 2160-12-31 19:20:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ yo M with PBC s/p liver transplant on ___, c/b lower
extremity DVT on ___, currently on coumadin p/w
fever, chills and body ache.
Patient c/o 3 days of cough, chills and myalgias. Cough is
productive of a little sputum, no hemoptysis. He's had chills
for the last 3 days, but yesterday recorded fever of 101 at
home. He endorses headache and sinus congestion, no neck pain or
stiffness. He also c/o sore throat, substernal and epigastric
pain/burning that is similar to his past episodes of esophageal
candidiasis. No shortness of breath. He denies dysuria, but
endorses urinary frequency. He also notes loose stools for the
last week, but attributes it to taking scheduled Senna and
Colace. He notes some nausea, but no vomiting, no RUQ pain.
Denies any increased abdominal girth, melena or bloody stools.
He reports compliance with all his medications, no recent travel
or sick contacts.
He called his transplant coordinator for worsening malaise and
fever, and she advised him to come to ___ for evaluation.
In the ED intial vitals were: 98.1 140 130/74 22 98%
Exam was significant for epigastric and RUQ tenderness.
Patient was evaluated by Hepatology and Transplant teams who
recommended thorough infectious work-ups. CXR with possible LLL
and/or retrocardiac opacity. RUQ U/S with dopplers showed no
signs of hemmorhage or abscess. CT Ab/Pelvis with contrast
without any acute intrabdominal process. UA w/o pyuria and blood
Cx pending.
Patient was given 1g vanc, 2g cefe, 500mg azithro for possible
HCAP.
On the floor, patient c/o general malaise, but remains afebrile.
Review of Systems: as per HPI, all other systems reviewed and
were negative.
Past Medical History:
-Primary biliary cirrhosis now s/p orthotopic liver transplant
(D+ R + CMV )
-Alcohol abuse (abstinent ___ years)
-Hemorrhagic pericarditis c/b tamponade s/p pericardial window
___
-Positive PPD (likely LTB, Tx with INH while incarcerated)
-Hyperlipidemia
-Osteoporosis
-Bipolar disorder
-ADHD
-Hemorrhoids
-s/p L leg surgery after MVC
-s/p liver biopsy ___
-s/p liver transplant ___
Social History:
___
Family History:
No family Hx of liver disease.
Father: History of prostate and Head & neck cancer.
Mother: ___ from brain aneurysm.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.6 116/85 103 20 100% on RA
General- Alert, oriented, no acute distress
HEENT- PERLL, Sclera anicteric, MMM, oropharynx clear, no sinus
tenderness
Neck- supple, JVP not elevated, no LAD, but mild submental TTP
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, mild TTP in epigastrum and RUQ, no rebound or
guarding, non-distended, no ascites, bowel sounds present,
well-healed scar
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM:
Vitals- 98.2, 84-93, 117-133/72-79, 99-100 on RA
General- Alert, oriented, no acute distress
HEENT- PERLL, Sclera anicteric, MMM, oropharynx clear w/o
erythema or exudate, no sinus tenderness
Neck- supple, JVP not elevated, no LAD, but mild submental TTP
Lungs- Clear to auscultation bilaterally, no wheezes
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, nontender, no rebound or guarding, non-distended,
no ascites, bowel sounds present, well-healed scar
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
=========================
LABS ON ADMISSION:
=========================
=========================
LABS ON DISCHARGE:
========================
Brief Hospital Course:
Mr. ___ is a ___ gentleman w/ PBC s/p DCD liver transplant
___ c/b ___ DVT and candidal esophagitis admitted due to
fever, malaise, and myalgias.
# Fever -
Symptoms included general malaise and myalgias with mild cough,
sore throat, and resolving diarrhea. Exam was non-focal. Resp
viral panel was negative. Urine legionella negative. CXR
without clear consolidation. CT Ab/Pelvis without signs of
abscess or other acute process. Blood cultures negative. CMV
VL negative. Urine benign. Stool studies including c. difficile
were negative. Symptoms most consistent with respiratory viral
infection. Symptoms resolved without antibiotics or
intervention.
# Neutropenia -
Neutropenic with ANC 500 on ___. Pt. has been neutropenic
several times since transplant. Most likely cause is
valgancyclovir, but may also be due to high doses of
immunosuppresants. Given that CMV VL negative and pt. has
completed full course of valgancyclovir, valgancyclovir was
discontinued.
# S/p Liver Transplant for Primary Biliary CIrrhosis -
DCD, CMV ab (+) liver transplant ___. Post-transplant course
complicated by lower extremity DVT ___ and candidal
esophagitis ___. Pt. was continued on immunosuppressive
therapy with tacro and Myfortic. He was continued on dapsone
prophylaxis. Valgancyclovir discontinued as discussed above.
# H/o latent TB -
Pt. continued on isoniazid. Pyridoxine added.
# DVT - Pt. on coumadin with subtherapeutic INR on admission.
Increased coumadin as needed.
# Bipolar disorder -
Pt. continued on home risperidone.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dapsone 100 mg PO DAILY
2. Gabapentin 300 mg PO BID
3. Isoniazid ___ mg PO DAILY
4. Myfortic (mycophenolate sodium) 360 mg oral BID
5. Omeprazole 20 mg PO BID
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. RISperidone 3 mg PO DAILY
8. Tacrolimus 3 mg PO Q12H
9. ValGANCIclovir 900 mg PO Q24H
10. Warfarin 2 mg PO DAILY
11. Senna 1 TAB PO BID
12. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Medications:
1. Dapsone 100 mg PO DAILY
2. Gabapentin 300 mg PO BID
3. Isoniazid ___ mg PO DAILY
4. Myfortic (mycophenolate sodium) 360 mg oral BID
5. Omeprazole 20 mg PO BID
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. RISperidone 3 mg PO DAILY
8. Tacrolimus 4 mg PO Q12H
RX *tacrolimus 1 mg 4 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
9. Warfarin 3 mg PO DAILY16
RX *warfarin 1 mg 3 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Pyridoxine 50 mg PO DAILY
RX *pyridoxine 50 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Senna 1 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Presumed viral upper respiratory infection
Secondary diagnosis:
Status post liver transplant ___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ due to fevers. You were initially
given antibiotics, but after careful evaluation it was felt your
infection was more likely a simple viral infection, and so you
were taken off antibiotics. You did well off antibiotics. Your
symptoms improved and you had no more fevers.
We did notice that at the time of discharge you had a very low
white blood cell count. This is likely due to the
immunosuppresant medications you are taking to prevent rejection
of your transplanted liver. Please avoid uncooked foods and
large crowds where you may be exposed to sick individuals.
It was a pleasure taking care of you. We wish you all the best.
Sincerely,
Your medicine team at ___
Followup Instructions:
___
|
19992875-DS-23 | 19,992,875 | 22,729,360 | DS | 23 | 2161-05-16 00:00:00 | 2161-05-17 07:42:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam
Attending: ___
Chief Complaint:
Fevers/Chills
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ hx of PBC s/p liver transplant in ___ donor CMV+ c/b CMV
infection and neutropenia (thought to be a result of CMV and
immunosuppression after extensive workup). p/w fevers, chills,
myalgias, cough in setting of neutropenia (ANC 386 at ___) so
patient transferred here.
Pt recently completed a course of Valcyte and INH/B6 for
treatment of latent TB. Pt is currently on Neupogen 300mcg
weekly for known Neutropenia.
In the ED, initial vitals were 98.4 88 127/80 18 100%. CBC with
pancytopenia, ___, ANC 618. Lytes and LFTs normal. INR
2.5. CXR appeared normal as did RUQ u/s. Patient given 2g
Cefepime and admitted to the floor.
On the floor, he reports that for 4-days, he has had fevers,
chills, cough, runny nose, and watery eyes. Fever peaked at
___. No abdominal pain, chest pain, mouth sores. +occasional
diarrhea. Has not had sick contacts. Did not receive the flu
vaccine as it is a live virus.
ROS: per HPI, denies headache, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, BRBPR, melena, dysuria.
Past Medical History:
-Primary biliary cirrhosis now s/p orthotopic liver transplant
(D+ R + CMV )
-Neutropenia c/b neutropenic fever
-DVT ___
-Alcohol abuse (abstinent ___ years)
-Hemorrhagic pericarditis c/b tamponade s/p pericardial window
___
-Positive PPD (likely LTB, Tx with INH while incarcerated)
-Hyperlipidemia
-Osteoporosis
-Bipolar disorder
-ADHD
-Hemorrhoids
-s/p L leg surgery after MVC
-s/p liver biopsy ___
-s/p liver transplant ___
Social History:
___
Family History:
Remarkable only for father with history of
prostate and head and neck cancer and mother died of brain
aneurysm.
Physical Exam:
ADMISSION:
VS: 98.1, 119/70, 80, 20, 100RA
General: Pleasant man, lying in bed, NAD
HEENT: EOMI, sclera anicteric, MMM without any sores or facial
tenderness
Neck: No LAD
CV: RRR no m/r/g
Lungs: CTA b/l no w/r/r
Abdomen: Large, well healed scar in URQ. NTND, +BS
Ext: No edema
Neuro: A and O x3
Discharge:
VS:98.4 Tm98.6 67 (60s-100) 103/54 (100-120/50-70) 18 100% RA
General: Pleasant thin man, lying in bed, pale, NAD
HEENT: sclera anicteric, MMM, no oropharyngeal sores.
CV: RRR no m/r/g
Lungs: CTA b/l no w/r/r
Abdomen: soft NTND large, well healed scar in RUQ. +BS
Ext: WWP
Neuro: AAO x3,
Pertinent Results:
ADMISSION:
============
___ 08:30PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-<1
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 08:30PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:30PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+
___ 08:30PM NEUTS-34* BANDS-1 ___ MONOS-16* EOS-5*
BASOS-3* ___ MYELOS-0 NUC RBCS-1*
___ 08:30PM WBC-1.8* RBC-3.64* HGB-10.5* HCT-31.5* MCV-86
MCH-29.0 MCHC-33.5 RDW-16.0*
___ 08:30PM ALBUMIN-4.3 CALCIUM-8.8 PHOSPHATE-3.4
MAGNESIUM-1.8
___ 08:30PM LIPASE-20
___ 08:30PM ALT(SGPT)-18 AST(SGOT)-25 ALK PHOS-91 TOT
BILI-0.8
___ 08:30PM GLUCOSE-116* UREA N-10 CREAT-0.8 SODIUM-133
POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-22 ANION GAP-12
___ 08:40PM LACTATE-1.1
___ 09:30PM ___ PTT-42.6* ___
DISCHARGE:
=============
___ 05:00AM BLOOD WBC-6.7 RBC-3.46* Hgb-10.4* Hct-31.2*
MCV-90 MCH-29.9 MCHC-33.3 RDW-16.7* Plt ___
___ 05:00AM BLOOD Neuts-70 Bands-0 Lymphs-15* Monos-8 Eos-2
Baso-1 ___ Myelos-2* NRBC-2* Other-2*
___ 05:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-1+
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Ovalocy-3+
Target-OCCASIONAL Ellipto-OCCASIONAL
___ 05:15PM BLOOD ___ 07:20AM BLOOD ___ ___
___ 05:20AM BLOOD Ret Man-4.4*
___ 05:00AM BLOOD Glucose-84 UreaN-10 Creat-0.8 Na-138
K-4.0 Cl-103 HCO3-26 AnGap-13
___ 05:00AM BLOOD ALT-18 AST-33 AlkPhos-107 TotBili-0.7
PERTINENT LABS/MICRO:
=======================
CMV Viral Load (Final ___:
CMV DNA not detected.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture for further
information.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
IMAGING:
=============
CXR ___
PA and lateral views of the chest were provided demonstrating no
focal consolidation, effusion or pneumothorax. The
cardiomediastinal
silhouette appears normal. Subtle opacities projecting over the
lower lungs are most compatible with subsegmental atelectasis.
No effusion or
pneumothorax is seen. Biapical pleural parenchymal scarring is
noted.
RUQ doppler ___
Color Doppler sonogram with spectral analysis of the hepatic
vasculature was performed. The main portal vein is patent with
normal
hepatopetal flow. The left portal, right anterior and right
posterior portal veins are patent with normal forward flow. The
left, middle and right hepatic veins are patent with normal
waveforms. The main hepatic artery has brisk systolic upstroke
and forward flow in diastole with RI 0.82, previously 0.63.
The right and left hepatic arteries have brisk systolic upstroke
with forward flow in diastole with RIs 0.68 and 0.70,
respectively, previously 0.62 and 0.56, respectively. The IVC
has normal color flow and normal waveform.
Brief Hospital Course:
___ yo M with PBC s/p liver transplant on ___, c/b
neutropenia and CMV viremia p/w neutropenic fever
#) Neutropenic Fever: Patient presented with neutropenic fever
with an ANC of 618 that downtrended to a nadir of 60. His viral
swab and and blod/urine cultures were negative. His CMV viral
load was undetectable and his Valgancyclovir was stopped. He was
seen by Heme/onc who performed a bone marrow biopsy. His
Neutropenia is thought most likely due to combination of CMV and
immunosuppressive effect of medications. He was started on
daily neupogen and his ANC trended up. His cefepime and daposone
were stopped. ANC on discharge was 4690. He was discharged with
once weekly neupogen
#) S/p liver transplant ___ PBC: Patient had a transplant in
___. He was continued on tacrolimus with levels checked. He
was continued on dapsone for prophylaxis which was then stopped
when his ANC improved.
#) History of DVT: Chronic. Coumadin was stopped as patient had
DVT in post-surgical setting and was maintained on coumadin for
>6 months.
#) CMV viremia: Viral load was undetectable and his
valgancyclovir was stopped.
#) Mood disorder: Continued Risperidone 3mg qhs
#CODE: Full
Name of health care proxy: ___
Relationship: father
Phone number: ___
Cell phone: ___
**Transitional Issues**
-continue to monitor tacrolimus level
-trend ___ and consider further workup of neutropenia if does
not improve
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Dapsone 100 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Gabapentin 300 mg PO BID
4. Omeprazole 20 mg PO BID
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. RISperidone 3 mg PO HS
7. Tacrolimus 1 mg PO Q12H
8. Warfarin 3 mg PO DAILY16
9. ValGANCIclovir 900 mg PO Q12H
10. Neupogen (filgrastim) 300 mcg/0.5 mL injection 1x/week
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Gabapentin 300 mg PO BID
3. Omeprazole 20 mg PO BID
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Tacrolimus 1 mg PO Q12H
6. Neupogen (filgrastim) 300 mcg/0.5 mL injection 1x/week
7. RISperidone 3 mg PO HS
8. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*14 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Neutropenic fever
s/p liver transplant
h/o CMV viremia
Secondary:
H/O DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
It was a pleasure taking care of you during your admission. You
came to the hospital because you had fever, chills, and malaise.
You were found to be neutropenic (low white count). We started
you on antibiotics to cover you for an infection. You had
several cultures and tests looking for an infection and we did
not find a cause of your fever. Your CMV viral load was
undetectable and your valcyte was stopped. You had a bone marrow
biopsy that is not back yet. You were given a medication to help
bring up your white counts and they improved. We stopped your
antibiotics including your dapsone.
Your warfarin was stopped as you no longer need it to prevent
blood clots.
Please follow up with your appointments below and continue to
get your blood draws as previously scheduled.
Please look at your medication list as we have stopped several
of your medications including: valcyte, warfarin, and dapsone.
Followup Instructions:
___
|
19992875-DS-30 | 19,992,875 | 29,454,637 | DS | 30 | 2162-09-18 00:00:00 | 2162-09-18 16:32:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam
Attending: ___.
Chief Complaint:
1 week malaise, diarrhea, on routine lab draw found to have
transaminitis
Major Surgical or Invasive Procedure:
Transjugular liver biopsy
Colonoscopy x2 (poor prep the first time)
Magnetic resonance cholangiopancreatography
History of Present Illness:
___ yo M w/ h/o PBC s/p liver tx ___ from ___+ donor and history
of acute rejection ___ sent to the ED after being noted to have
elevated transaminases with concern for rejection.
Patient presented for routine lab draw and was noted to have new
transaminitis, and then over the phone with transplant nurse, he
admitted to a week long history of fatigue and two days of
malaise with tremors. Pt. also reported abdominal pain, nausea,
and loose, black stools, though negative guaiac test in clinic.
He denied any fevers or sweats. He has been taking his
medications as directed with the assistance of his father.
Normal appetite. Labs drawn revealed elevated LFTs (ALT 55, AST
41, AP 171), elevated tacrolimus (7.4 with goal ___, and stable
H/H (14.1/40.2).
Of note, pt's post-transplant course has been complicated by
mild acute cellular rejection in ___ ___s a
hemorrhagic pericarditis with recurrent pericarditis. He has
also had leukopenia and diarrhea while on CellCept and is
currently maintained on tacrolimus and prednisone for his immune
suppression. He has also had post-transplant CKD with baseline
creatinine of 1.2-1.6.
In the ED on ___, initial vitals were 97.7 82 128/93 16
100%.
- On labs the following day, pt. was noted to have tacro level
5.5 (after decrease in dose to 1mg BID).
- RUQ US with patent hepatic vasculature, CXR w/o acute
intrathoracic process.
- Pt. received home medications, with tacro dose decreased to
1mg BID, and oxycodone for pain.
VS prior to transfer 98.1 64 118/65 18 99% RA.
On arrival to the floor, pt. reports feeling well. He has some
mild abdominal pain but reports that it is well controlled.
Past Medical History:
-Primary biliary cirrhosis now s/p orthotopic liver transplant
(D+ R + CMV )
-Neutropenia c/b neutropenic fever
-DVT ___
-Alcohol abuse (abstinent ___ years)
-Hemorrhagic pericarditis c/b tamponade s/p pericardial window
___
-Positive PPD (likely LTB, Tx with INH while incarcerated)
-Hyperlipidemia
-Osteoporosis
-Bipolar disorder
-ADHD
-Hemorrhoids
-s/p L leg surgery after MVC
-s/p liver transplant ___
Social History:
___
Family History:
Father (living): coronary artery disease, diabetes,
hypercholesterolemia, and depression. Prostate and head and neck
cancer
Mother (deceased): brain aneurysm and hyperthyroidism
Physical Exam:
ADMISSION:
VS: 97.7, 51, 117/85, 20, 100 on RA
GEN: A and O x3; well appearing, comfortable, in no acute
distress.
HEENT: Eyes are anicteric without conjunctival injection.
Oropharynx is clear. Moist mucous membranes.
NECK: supple without lymphadenopathy, thyromegaly or thyroid
nodules.
LUNGS: Clear to auscultation bilaterally.
CV: Heart has normal S1, S2. There is no pericardial friction
rub heard.
ABDOMEN: soft, nontender, nondistended. There is no
significant hepatosplenomegaly.
EXT: WWP. No lower extremity edema.
DISCHARGE:
VS: 97.7,110s/70s, 70s, 18, 99 RA
GEN: A&O x3; lying in bed, no acute distress
HEENT: Eyes are anicteric without conjunctival injection.
Oropharynx is clear. Moist mucous membranes.
NECK: supple without lymphadenopathy, thyromegaly or thyroid
nodules.
LUNGS: Clear to auscultation bilaterally.
CV: Heart has normal S1, S2. No pericardial friction rub heard.
ABDOMEN: soft, mildly tender in epigastric region. No
significant hepatosplenomegaly.
EXT: WWP. No lower extremity edema.
NEURO: A&Ox3, CNII-XII grossly intact, no flapping
Pertinent Results:
ADMISSION:
___ 12:15AM BLOOD WBC-4.0 RBC-4.67 Hgb-14.1 Hct-40.2 MCV-86
MCH-30.2 MCHC-35.1 RDW-15.0 RDWSD-46.9* Plt Ct-93*
___ 12:15AM BLOOD Neuts-50.8 ___ Monos-9.3 Eos-1.5
Baso-1.8* Im ___ AbsNeut-2.02 AbsLymp-1.42 AbsMono-0.37
AbsEos-0.06 AbsBaso-0.07
___ 12:15AM BLOOD ___ PTT-28.4 ___
___ 12:15AM BLOOD Plt Ct-93*
___ 12:15AM BLOOD Glucose-108* UreaN-11 Creat-1.3* Na-140
K-3.8 Cl-107 HCO3-20* AnGap-17
___ 12:15AM BLOOD ALT-55* AST-41* AlkPhos-171* TotBili-0.4
___ 12:15AM BLOOD Albumin-4.5 Calcium-9.2 Phos-2.8 Mg-1.8
___ 09:15AM BLOOD tacroFK-5.5
___ 12:22AM BLOOD Lactate-1.0
Studies:
___ RUQ U/S:
Liver echotexture is normal. There is no evidence of focal liver
lesions or biliary dilatation. There is no ascites, right
pleural effusion or sub- or ___ fluid
collections/hematomas.
Patent hepatic vasculature with appropriate waveforms.
___ CXR:
No acute cardiopulmonary process.
___ MRCP
1. Status post orthotopic liver transplant with mild
intrahepatic biliary ductal dilatation and a transition point
identified between the native and transplant bile ducts. It is
unclear whether these findings are chronic in nature or could
reflect a stricture at the surgical anastomosis.
2. Transplanted liver parenchyma is normal with no focal mass,
abscess or biliary collection.
3. Splenomegaly.
4. Persistent increased opacity in the left lower lobe, as seen
on CT examination from ___.
RECOMMENDATION(S): Consider ERCP for direct assessment of
biliary anastomotic caliber if there is clinical suspicion for
biliary stricture.
___ transjugular liver biopsy path results:
Poor sample; unclear if findings reflect overall picture. No
bile ductular proliferation, cholestasis or lymphocytic damage
in this biopsy, but some rare neutrophils in portal tracts. No
fatty change or viral inclusions.
DISCHARGE
___ 04:25AM BLOOD WBC-2.8* RBC-4.18* Hgb-12.5* Hct-36.6*
MCV-88 MCH-29.9 MCHC-34.2 RDW-14.9 RDWSD-47.4* Plt Ct-66*
___ 04:25AM BLOOD Plt Ct-66*
___ 04:25AM BLOOD Glucose-89 UreaN-10 Creat-1.0 Na-140
K-3.6 Cl-105 HCO3-22 AnGap-17
___ 04:25AM BLOOD ALT-85* AST-72* AlkPhos-144* TotBili-0.4
___ 04:25AM BLOOD Albumin-3.9 Calcium-9.3 Phos-2.9 Mg-1.6
___ 04:25AM BLOOD tacroFK-6.7
Brief Hospital Course:
Mr. ___ is a ___ y/o gentleman w/ hx hemorrhagic pericarditis
s/p pericardial window, PBC s/p liver transplant from CMV+ donor
in ___ c/b mild acute rejection ___ and CMV viremia who p/w 1
month intermittent diarrhea and 1 week of abdominal pain and
malaise, admitted with new transaminitis and elevated (to 7.4)
tacro level. Tacro level was decreased to 1 mg BID, prednisone
continued at 5 mg daily. Liver biopsy was poor sample but did
not show rejection. Colonoscopy was grossly normal but biopsy
results pending. CMV VL < 137, started on valganciclovir 900 mg
daily with plan to continue until colonoscopy biopsy results
return. MRCP on ___ showed evidence of biliary stricture at
site of anastomosis; will be arranged for ERCP as outpatient.
# Transaminitis:
MRCP showing concern for biliary stricture at anastomosis site -
likely etiology. Differential for new transaminitis also
includes cellular rejection (liver biopsy ___, path results do
not show rejection but poor quality sample), infection (CMV VL
<137 but colonoscopy biopsy results pending at time of
discharge), or med toxicity (though no significant new meds.)
RUQ U/S reassuring with patent hepatic vasculature. Discharging
on valgancyclovir 900 mg po qd - can discontinue if pathology
results negative. CMV VL level will need to be drawn again on
___. Continued prednisone 5 mg daily and decreased tacro from
1.5 mg BID to 1 mg BID given high levels (___.)
# Biliary stricture - mild intrahepatic biliary ductal
dilatation and transition point at anastamosis site noted on
MRCP on ___. Will follow up with ERCP as outpatient with
scheduling arranged by liver transplant team. Will hold aspirin
5 day prior to procedure and a few days after procedure
(discussed with cardiologist Dr. ___ and use tramadol for
pericarditis pain during that period.
# Hx PBC s/p transplant - on tacro and prednisone. Continued
prednisone 5 mg daily and decreased tacro from 1.5 mg BID to 1
mg BID given high levels (___.)
CHRONIC:
# Chronic pericarditis: Recurrent chest pain, full cardiac
workup negative, has been on aspirin high-dose three times a
day, previously 650 mg three times a day, recently increased to
975 mg three times daily the past week and colchicine 0.6 mg
twice a day.
- continued home aspirin and colchicine
# GERD - continued home omeprazole and ranitidine
# Osteoporosis - continued home calcium and vitamin D
# COPD (stable, mild) - continued home salmeterol
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Docusate Sodium 200 mg PO BID:PRN constipation
3. FoLIC Acid 1 mg PO DAILY
4. Gabapentin 600 mg PO BID
5. Omeprazole 40 mg PO BID
6. PredniSONE 5 mg PO DAILY
7. Ranitidine 75 mg PO HS:PRN heartburn
8. Aspirin 975 mg PO Q8H
9. Prochlorperazine 10 mg PO BID:PRN nausea/vomiting
10. Tacrolimus 1.5 mg PO Q12H
11. Colchicine 0.6 mg PO BID
12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
13. Vitamin D 800 UNIT PO DAILY
14. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
15. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
2. Calcium Carbonate 500 mg PO DAILY
3. Colchicine 0.6 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 600 mg PO BID
6. Omeprazole 40 mg PO BID
7. PredniSONE 5 mg PO DAILY
8. Ranitidine 75 mg PO HS:PRN heartburn
9. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
10. Vitamin D 800 UNIT PO DAILY
11. Docusate Sodium 200 mg PO BID:PRN constipation
12. Aspirin 975 mg PO Q8H
13. Tacrolimus 1 mg PO Q12H
RX *tacrolimus 0.5 mg 2 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*11
14. ValGANCIclovir 900 mg PO Q24H
RX *valganciclovir 450 mg 2 tablet(s) by mouth daily Disp #*10
Tablet Refills:*0
15. Ferrous Sulfate 325 mg PO DAILY
16. TraMADOL (Ultram) 50 mg PO Q8H:PRN pain Duration: 10 Days
RX *tramadol 50 mg 1 tablet(s) by mouth q8h prn Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Transaminitis
Biliary stricture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you had symptoms of
diarrhea, abdominal pain and fatigue with elevated liver
function test levels. We were initially concerned about a liver
transplant rejection, an infection, or a problem with your
biliary system. We did several tests to evaluate for these
possibilities. Your liver biopsy did not show rejection. Your
tests for infection were negative. You test for CMV showed a
very low level of virus in the blood; we started treatment but
will only continue it if your biopsy results show evidence of
CMV disease. Your colonoscopy results are still pending. You
also had an MRCP (magnetic resonance cholangiopancreatography)
to evaluate for biliary problems. This showed changes in your
biliary ducts that could explain your lab abnormalities and
symptoms, we would like to evaluate it further with an ERCP
(endoscopic retrograde cholangiopancreatography), a procedure
that involves putting a flexible tube in the upper part of your
GI tract. This procedure will be done as an outpatient, and it
will be arranged for you by the liver team. You will be
contacted with the details.
We continued your home immunosuppressants tacrolimus and
prednisone and are discharging you on your home medications
though we decreased the tacro level to 1 mg BID because your
level was high. In preparation for the ERCP, you will be asked
to stop taking your aspirin for 5 days prior to the procedure
and a few days after the procedure, but until you hear the date
of the ERCP from the liver team, you can continue to take your
home aspirin dose. During the period that you are not taking
your aspirin, you can take tramadol instead for pain. We are
giving you a prescription for tramadol but please do not take it
until you stop taking your aspirin for the procedure.
It was a pleasure taking care of you.
Sincerely,
Your ___ liver team
Followup Instructions:
___
|
19992875-DS-32 | 19,992,875 | 25,002,205 | DS | 32 | 2162-11-15 00:00:00 | 2162-11-19 21:36:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ M w/ hx of PBC (s/p liver transplant), prior
DVT (on lovenox), bipolar disorder, hyeperlipidemia and
hemorrhagic pericarditis (in ___, s/p pericardial window
iso
tamponade), who presents with chest pain.
Chest pain started suddenly, at rest; pain is constant, worse
when sitting up and better when lying down. He denies dyspnea.
Pain feels similar to his prior episodes that were provisionally
identified as recurrent pericarditis.
No new medications started except for Abilify (last week).
He denies any preceding fever, but does endorse some chills. No
nausea/vomiting/diarrhea. All other ROS negative.
Past Medical History:
-Primary biliary cirrhosis now s/p orthotopic liver transplant
(D+ R + CMV )
-Neutropenia c/b neutropenic fever
-DVT ___
-Alcohol abuse (abstinent ___ years)
-Hemorrhagic pericarditis c/b tamponade s/p pericardial window
___
-Positive PPD (likely LTB, Tx with INH while incarcerated)
-Hyperlipidemia
-Osteoporosis
-Bipolar disorder
-ADHD
-Hemorrhoids
-s/p L leg surgery after MVC
-s/p liver transplant ___
Social History:
___
Family History:
Father (living): coronary artery disease, diabetes,
hypercholesterolemia, and depression. Prostate and head and neck
cancer
Mother (deceased): brain aneurysm and hyperthyroidism
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 97.0 degrees Fahrenheit, BP: 133/96 mmHg, HR 63 bpm,
RR 16 bpm, O2: 99 % on RA.
Gen: Pleasant, calm
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: Supple, No LAD. Normal carotid upstroke without bruits. No
thyromegaly.
CV: PMI in ___ intercostal space, mid clavicular line. RRR.
normal S1,S2. No murmurs, rubs, clicks, or gallops
LUNGS: CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND. No HSM. Abdominal aorta was not
enlarged
by palpation.
EXT: WWP, NO CCE. Full distal pulses bilaterally.
SKIN: No rashes/lesions, ecchymoses.
NEURO: A&Ox3. CN ___ grossly intact.
PSYCH: Mood and affect were appropriate.
DISCHARGE PHYSICAL EXAM:
VS: T 97.6-98.2 HR ___ BP ___ RR 18 SpO2 96-99% RA
General: Well-appearing in NAD
HEENT: Sclera anicteric, conjunctivae noninjected. MMM, no OP
lesions
CV: RRR, no m,r,g. No tenderness to palpation of chest wall.
Lungs: LCTAB. No wheezing, crackles, or rhonchi.
Abdomen: Soft, nondistended, tender to palpation in LUQ. No
guarding or rebound.
Ext: Warm, well-perfused. No ___ edema
Neuro: A&O x3. No asterixis. Moving all extremities with
purpose, no facial asymmetry.
Skin: No overt jaundice.
Pertinent Results:
ADMISSION LABS
___ 02:42AM BLOOD WBC-2.5* RBC-4.63 Hgb-13.8 Hct-40.5
MCV-88 MCH-29.8 MCHC-34.1 RDW-14.5 RDWSD-46.1 Plt Ct-66*
___ 02:42AM BLOOD Neuts-33.9* ___ Monos-9.9 Eos-2.0
Baso-1.6* Im ___ AbsNeut-0.86* AbsLymp-1.32 AbsMono-0.25
AbsEos-0.05 AbsBaso-0.04
___ 02:42AM BLOOD Glucose-77 UreaN-13 Creat-1.2 Na-139
K-3.8 Cl-106 HCO3-24 AnGap-13
___ 02:42AM BLOOD Albumin-4.3
___ 04:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-2.0
___ 02:42AM BLOOD ALT-51* AST-38 AlkPhos-82 TotBili-0.3
___ 02:42AM BLOOD Lipase-23
___ 09:45AM BLOOD cTropnT-<0.01
___ 02:42AM BLOOD cTropnT-<0.01
___ 02:42AM BLOOD tacroFK-4.2*
DISCHARGE LABS
___ 05:09AM BLOOD WBC-2.3* RBC-4.43* Hgb-13.3* Hct-39.0*
MCV-88 MCH-30.0 MCHC-34.1 RDW-14.6 RDWSD-46.6* Plt Ct-64*
___ 05:09AM BLOOD ___ PTT-57.6* ___
___ 05:09AM BLOOD Glucose-86 UreaN-10 Creat-1.1 Na-141
K-3.9 Cl-107 HCO3-23 AnGap-15
___ 05:09AM BLOOD Albumin-4.5 Calcium-9.4 Phos-3.2 Mg-1.9
___ 05:09AM BLOOD ALT-42* AST-28 LD(LDH)-182 AlkPhos-77
TotBili-0.3
___ 05:09AM BLOOD tacroFK-4.9*
IMAGING
Chest X ray ___: FINDINGS:
Normal heart size, mediastinal and hilar contours. No focal
consolidation,
pleural effusion or pneumothorax. Multiple healed right-sided
rib fractures
are noted which appear new from ___.
IMPRESSION:
No acute process. Multiple healing right-sided rib fractures.
TTE ___:
FOCUSED STUDY/LIMITED VIEWS: Regional left ventricular wall
motion is normal. Overall left ventricular systolic function is
normal (LVEF>55%). Right ventricular chamber size and free wall
motion are normal. The mitral valve leaflets are structurally
normal. There is no mitral valve prolapse. Mild (1+) mitral
regurgitation is seen. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the comparable findings are similar.
MICROBIOLOGY
URINE CULTURE (Final ___: NO GROWTH.
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.
This test has been verified for use in the ___ patient
population.
Brief Hospital Course:
___ is a ___ year old man with h/o primary biliary
cirrhosis s/p orthotopic liver transplant from CMV+ donor ___
complicated by mild cellular rejection and bile duct obstruction
s/p ERCP ___ who also has a history of idiopathic,
hemorrhagic pericarditis/pericardial effusion s/p pericardial
window who presented with recurrent chest pain.
# Chest pain. His pain was consistent with episodes of pain
described in the past. He was on treatment for pericarditis with
high dose aspirin (975 mg TID) and colchicine. He was also on
prednisone 5 mg daily for his transplant. On presentation, he
had negative troponins x2 and an EKG nonconcerning for ACS.
Cardiology was consulted in the ED and thought his pain was
likely to be noncardiac but recommended a TTE which showed no
pericardial effusion and no WMA. He did have a chest X ray
showing multiple healed right-sided rib fractures that appeared
to be new from ___ but the patient denied any recent trauma
and stated he had sustained these fractures many years ago (most
from mixed martial arts). Concerning causes of chest pain were
ruled out and his pain resolved within a few days of
presentation.
# Abdominal pain, nausea, diarrhea. Mr. ___ reports a long
history of alternating diarrhea and constipation. He complained
of diffuse, generally left-sided abdominal pain on admission as
well as diarrhea. On the following day, he was complaining of
constipation. His liver enzymes were at baseline during the
hospitalization. He had a terminal ileum and colon biopsy done
___ showing no abnormalities. Urine culture negative.
# Difficulty urinating. On admission, Mr. ___ reported
difficulty initiating urination although denied incomplete
voiding or dysuria. UA unremarkable and urine culture negative.
Symptoms resolved with IV hydration.
# History of Liver Transplant secondary to PBC. Transplanted
___. LFTs at baseline. Not concerned for rejection at this
time. He was continued on immunosuppression with tacrolimus and
prednisone.
Chronic issues:
# GERD. He was continued on home ranitidine and omeprazole.
# Peripheral neuropathy. He was continued on home gabapentin and
tramadol.
# Iron deficiency anemia. Hgb was above recent baseline. He was
continued on iron supplementation.
Transitional issues:
#CODE STATUS: Full
# Patient describes a history of diarrhea and constipation
alternating. ___ warrant outpatient evaluation for irritable
bowel syndrome.
# Patient reported being out of tramadol written by PCP, ___.
___ was written for enough to treat his pain through the
weekend until his appointment on ___.
# Please follow up CMV viral load
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Calcium Carbonate 500 mg PO DAILY
3. Colchicine 0.6 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Tacrolimus 1 mg PO Q12H
6. Ferrous Sulfate 325 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Gabapentin 600 mg PO BID
9. Omeprazole 40 mg PO BID
10. PredniSONE 5 mg PO DAILY
11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
12. Ranitidine 150 mg PO QHS
13. Vitamin D 800 UNIT PO DAILY
14. TraMADOL (Ultram) 50 mg PO TID:PRN pain
15. Ondansetron 4 mg PO Q8H:PRN nausea
16. Aspirin EC 975 mg PO TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. Calcium Carbonate 500 mg PO DAILY
3. Colchicine 0.6 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Ferrous Sulfate 325 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Gabapentin 600 mg PO BID
8. Omeprazole 40 mg PO BID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. PredniSONE 5 mg PO DAILY
11. Ranitidine 150 mg PO QHS
12. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
13. Tacrolimus 1 mg PO Q12H
RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
14. TraMADOL (Ultram) 50 mg PO TID:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth three times a day Disp
#*10 Tablet Refills:*0
15. Vitamin D 800 UNIT PO DAILY
16. Aspirin EC 975 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Chest pain
Secondary diagnosis:
liver transplant recipient
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care while you were
hospitalized at the ___. You
were in the hospital because of chest pain. There was no
evidence by our test results that you were having a heart attack
and your heart looked normal on imaging with no evidence of an
effusion. We do not know what is causing your chest pain but are
reassured that it is unlikely to be a heart problem. You should
continue to take the aspirin and colchicine that you have been
taking.
Again, it was a pleasure taking care of you. We wish you all the
best in the future.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19992875-DS-34 | 19,992,875 | 29,951,097 | DS | 34 | 2163-04-03 00:00:00 | 2163-04-03 17:04:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam / risperidone
Attending: ___.
Chief Complaint:
Bright red blood per rectum with abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of PBC s/p
OLT in ___ and recent admission for BRBPR/abdominal pain found
to have an anal skin tag/condyloma on sigmoidoscopy now s/p
excision on ___ who presents with one episode of BRBPR. He
has not had any recent bleeding. This episode occurred this
afternoon and was approximately one cup of bright red blood per
rectum not mixed with stool. He then developed lower abdominal
cramping. No further BMs or bleeding subsequently. Mild nausea
but no vomiting, no fevers. He was seen at ___ and was
referred here for further work up as patient is liver transplant
recipient.
He is followed by Dr. ___ saw him today in clinic for
follow up of chest pain. This is thought to be due to
chondrochondritis. He is on tramadol, high dose aspirin, and
colchicine for this.
In the ED, initial vitals were: T 96.6, HR 72, BP 133/88, RR
18, SaO2
100% RA.
- Labs were notable for: WBC 3.1 (stable), H/H 13.9/40.8, plts
84 (stable), Cr 1.3 (stable); RUQ with Dopplers showed normal
transplanted liver, splenomegaly.
- Rectal exam notable for intact suture, no masses or
hemorrhoids, dark stool guaiac positive
- Patient was given: tacrolimus 1 mg, morphine 4 mg, and
Zofran.
- Consults: Transplant surgery, who recommended inpatient
colorectal surgery consult; GI, who recommended hepatology
consult
On the floor, patient continued to report mild lower abdominal
pain and chest pain. No nausea currently. He does have an
appetite but has not eaten today.
Review of systems:
(+) Per HPI. Chronic chills, chronic shortness of breath.
(-) Denies fever, night sweats, recent weight loss or gain.
Denies headache, cough, vomiting, diarrhea, constipation. No
recent change in bowel or bladder habits. No dysuria.
Past Medical History:
PAST MEDICAL HISTORY:
PBC s/p deceased liver donor tx ___
Neutropenia
DVT ___
Prior alcohol abuse now abstinent
Hemorrhagic pericarditis c/b tamponade with pericardial window
___
Positive PPD s/p INH
HLD
Osteoporosis
Bipolar disorder
Hemorrhoids
ADHD
PTSD
Social History:
___
Family History:
Father (living): coronary artery disease, diabetes,
hypercholesterolemia, and depression. Prostate and head and neck
cancer
Mother (deceased): brain aneurysm and hyperthyroidism
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 97.3, HR 57, BP 114/81, RR 18, SaO2 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, severe pain to palpation of right costochondral
junctions
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Scar present, soft, bowel sounds present,
nondistended, tender to palpation diffusely though no rebound or
guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Rectal: skin tag removal site intact without bleeding or signs
of infection, external hemorrhoids appreciated, old blood in
rectal vault without masses.
DISCHARGE PHYSICAL EXAM:
Vitals: T 97.5/97.4, 105-117/59-70, HR 62-80, RR 18, O2 Sat
>97% RA
General: Well-appearing, NAD.
HEENT: MMM, PERRL, EOMI w/o nystagmus.
Lungs: CTAB
CV: RRR, normal S1 and S2 appreciated. No murmurs, rubs,
gallops.
Abdomen: Soft, non-distended, mild tenderness to deep palpation
of the bilateral LLQ and suprapubic region. Normal bowel sounds.
Ext: Warm, well-perfused. No edema. Bilateral pulses +2
Pertinent Results:
ADMISSION LABS:
___ 08:25PM BLOOD WBC-3.1* RBC-4.66 Hgb-13.9 Hct-40.8
MCV-88 MCH-29.8 MCHC-34.1 RDW-14.7 RDWSD-46.9* Plt Ct-84*
___ 08:25PM BLOOD Neuts-48.9 ___ Monos-9.7 Eos-3.9
Baso-1.9* Im ___ AbsNeut-1.51* AbsLymp-1.09* AbsMono-0.30
AbsEos-0.12 AbsBaso-0.06
___ 08:00AM BLOOD ___ PTT-28.9 ___
___ 08:25PM BLOOD Glucose-91 UreaN-19 Creat-1.3* Na-141
K-4.1 Cl-108 HCO3-22 AnGap-15
___ 08:00AM BLOOD ALT-37 AST-33 LD(LDH)-189 AlkPhos-77
TotBili-0.5
___ 08:00AM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.8 Mg-1.8
___ 08:00AM BLOOD tacroFK-6.0
IMAGING / STUDIES:
RUQ US ___
IMPRESSION:
1. Unremarkable liver transplant with patent hepatic vasculature
and normal waveforms.
2. Splenomegaly.
GU Ultrasound ___
FINDINGS:
The right kidney measures 9.3 cm and contains a simple appearing
1.1 cm lower pole cyst. The left kidney measures 9.7 cm. There
is no hydronephrosis, stones, or masses bilaterally. Normal
cortical echogenicity and corticomedullary differentiation are
seen bilaterally.
The bladder is normal in appearance. Postvoid images of the
bladder were not obtained secondary to the patient's inability
to void. Calculated prostate volume is 22 cc.
IMPRESSION:
Normal appearance of the bilateral kidneys.
DISCHARGE LABS:
___ 08:00AM BLOOD WBC-1.9* RBC-4.43* Hgb-13.3* Hct-40.0
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.6 RDWSD-48.4* Plt Ct-64*
___ 08:00AM BLOOD ___ PTT-27.9 ___
___ 08:00AM BLOOD Glucose-102* UreaN-20 Creat-1.0 Na-142
K-3.6 Cl-109* HCO3-24 AnGap-13
___ 08:00AM BLOOD ALT-37 AST-29 AlkPhos-82 TotBili-0.4
___ 08:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.7
___ 08:00AM BLOOD tacroFK-6.0
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of PBC s/p
OLT in ___ and recent admission for BRBPR/abdominal pain found
to have an anal skin tag/condyloma on sigmoidoscopy now s/p
excision on ___ who presents with one episode of BRBPR.
# BRBPR: Patient with single episode of BRBPR, possibly related
to recent excision of anal skin tag/condyloma. Examination of
the area showed intact excision site without active bleed. He
also had associated lower abdominal pain of unclear etiology. No
recent fevers or diarrhea to suggest infectious or inflammatory
etiology. After his anal tag excision he reports regular soft
stools without straining. H&H on admission at baseline.
Potentially diverticular bleed vs. vascular malformation. Rectal
exam with old blood in rectal vault without active bleeding or
mass. He did not have any further bleeding during admission and
his lower abdominal pain was controlled with home tramadol Q6H.
Recommend outpatient colonoscopy and continued Metamucil use.
His high dose ASA was stopped in the setting of recurrent GI
bleeds.
# Abdominal pain: Continued despite resolution of BRBPR.
Patient with similar presentation in ___ with work-up (CT
A/P, stool studies) unrevealing aside from sigmoidoscopy showing
rectal erythema and perianal skin tag/condyloma. RUQ ultrasound
with Dopplers in the ED was normal. Patient complained of
urinary hesitancy on ROS but was voiding without difficulty. GU
ultrasound showed normal kidneys bilaterally and bladder with
normal prostate mass of 22cc. Post-void bladder was not
visualized as patient did not void. Low suspicion for bladder
obstruction as cause of supra-pubic pain. He was instructed to
seek urology referral should his urinary symptoms persist or
worsen.
# Acute kidney injury: Patient noted to have mild ___ on
admission labs. Likely from hypovolemia in the setting of high
dose NSAIDs. Serum Cr normalized to 1.1 on discharge; no
evidence of renal pathology on GU U/S (___). He was
discharged off aspirin as above.
# PBC s/p liver transplant in ___ from CMV+ donor, cellular
rejection in ___ ___s a hemorrhagic pericardial
effusion with recurrent pericarditis: RUQ ultrasound with
Dopplers in the ED was normal. LFTs normal. Continued home
tacrolimus 1 mg PO Q12H. Tacro level 6.0 on admission. Continued
prednisone 5 mg daily.
# Costochondritis: Followed by Dr. ___ in cardiology. On
high dose ASA, prednisone, and tramadol, recently increased from
TID to QID. Pain is at baseline on admission. His high dose ASA
was held and tramadol continued. He was discharged off of
aspirin as above.
# Pericarditis: Followed by Dr. ___ in cardiology. On high
dose ASA and colchicine. Pain at baseline on admission and his
colchicine was continued but ASA stopped as above.
# Thrombocytopenia: Patient presented with chronic low platelet
count around baseline. Chronic thrombocytopenia likely due to
liver disease and immunosuppression. His platelets were
monitored without acute event. Of note high dose ASA in setting
of thrombocytopenia likely contributing to recurrent GIB.
# Bipolar disorder: Continued home ARIPiprazole
# COPD: Continued home albuterol, salmeterol.
# GERD: Continued home omeprazole 40mg BID, ranitidine 150mg
qHS
# Chronic Neuropathic Pain: Continued Gabapentin 600mg BID
TRANSITIONAL ISSUES:
- Patient discharged off of aspirin given GIB. Please address
restating or alternative therapy at next cardiology appointment.
- Recommend outpatient colonoscopy for evaluation of likely
distal GIB. Follow up scheduled with GI.
- Patient continued on tramadol QID for pain control.
- Recommend urology follow up for lower urinary tract symptoms
if persistent.
- H&H stable throughout admission. Please re-check at GI follow
up appointment if continued GI bleeding.
- Patient continued on tacrolimus during admission with random
level of 6.0. LFTs normal.
CODE: Full (confirmed)
CONTACT: ___ (father) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. ARIPiprazole 20 mg PO QHS
3. Calcium Carbonate 500 mg PO DAILY
4. Colchicine 0.6 mg PO BID
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Gabapentin 600 mg PO BID
7. HydrOXYzine 25 mg PO QHS:PRN insomnia
8. Omeprazole 40 mg PO BID
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Ranitidine 150 mg PO QHS
11. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
12. Vitamin D 800 UNIT PO DAILY
13. PredniSONE 5 mg PO DAILY
14. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
15. Tacrolimus 1 mg PO Q12H
16. Aspirin 975 mg PO TID
17. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN dyspnea
2. ARIPiprazole 20 mg PO QHS
3. Colchicine 0.6 mg PO BID
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Gabapentin 600 mg PO BID
6. HydrOXYzine 25 mg PO QHS:PRN insomnia
7. Omeprazole 40 mg PO BID
8. Ondansetron 4 mg PO Q8H:PRN nausea
9. PredniSONE 5 mg PO DAILY
10. Ranitidine 150 mg PO QHS
11. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
12. Tacrolimus 1 mg PO Q12H
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
14. Vitamin D 800 UNIT PO DAILY
15. Benefiber Clear SF (dextrin) (wheat dextrin) 3 gram/3.5 gram
oral DAILY
16. Calcium Carbonate 500 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Gastrointestinal Bleed
Abdominal Pain
SECONDARY:
H/O Primary biliary cirrhosis s/p liver transplant
Urinary hesitancy
Chronic pericarditis
Costochondritis
Bipolar disorder
COPD
GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care here at ___
___.
You were admitted with rectal bleeding and abdominal pain. We
checked you blood counts and everything was stable. Your recent
skin tag removal site looked good and was not actively bleeding.
You did not have another episode of bleeding and recovered
without incident. An ultrasound of your liver was normal and you
were kept on your home tramadol for pain.
You also were noted to have some difficulty initiating
urination. You had an ultrasound done of your kidneys and
bladder which was also normal. You prostate on ultrasound was a
normal size. If you continue to have urinary symptoms please see
your PCP about referral to urology. ___ clinic number:
___.
You were discharged with the follow up appointments scheduled
below,. Please make sure to attend these appointments because
you will likely need a colonoscopy aks an outpatient. If you
have another single episode of bleeding please call your
gastroenterologist.
Please continue taking your medications as prescribed but stop
taking your aspirin until you see your cardiologist. You can
continue taking your tramadol every 6 hours as needed.
Thank you for choosing ___ for your healthcare needs.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19992875-DS-36 | 19,992,875 | 29,765,419 | DS | 36 | 2163-11-13 00:00:00 | 2163-11-17 11:44:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam / risperidone /
mushrooms
Attending: ___
Chief Complaint:
Abdominal pain, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M w/ PMH PBC s/p liver transplant ___, pericarditis,
bipolar disorder, COPD, with recent admission at ___ for
diarrhea who re-presents with ongoing diarrhea and muscle aches.
He reports that he is having watery diarrhea ___ per day. He
has aches all over his body and feels weak. He also endorses
tinnitus. He says this feels similar to when he had CMV
infection in the past. He did not hear the results of his
colonoscopy yet.
Of note, his colonoscopy biopsies showed active colitis
throughout the colon. CMV testing was pending.
In the ED, initial vitals were: T97.0 HR67 BP115/96 RR18
O2Sat100% RA.
Labs notable for WBC 2.9, ANC 1260, Plt 93, Cr 1.1, HCO3 21.
Patient was given 4 mg IV morphine and 4 mg Zofran.
Decision was made to admit for continued diarrhea.
Vitals prior to transfer: T98.4 HR50 BP112/82 RR16 O2Sat100%
RA.
On the floor, he reported that he had ongoing abdominal pain,
nausea, and body aches. He reports that he has not started any
new medications except for 1 dose of Adderall last week.
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:
PAST MEDICAL HISTORY:
PBC s/p deceased liver donor tx ___
Neutropenia
DVT ___
Prior alcohol abuse now abstinent
Hemorrhagic pericarditis c/b tamponade with pericardial window
___
Positive PPD s/p INH
HLD
Osteoporosis
Bipolar disorder
Hemorrhoids
ADHD
PTSD
Social History:
___
Family History:
Father (living): coronary artery disease, diabetes,
hypercholesterolemia, and depression. Prostate and head and neck
cancer
Mother (deceased): brain aneurysm and hyperthyroidism
Physical Exam:
================
ADMISSION EXAM:
================
Vital Signs: 97.6 115/77 53 18 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, most tender over epigastric area and LLQ with
voluntary guarding, but diffusely mildly tender to palpation,
non-distended, bowel sounds present, no organomegaly, no rebound
or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
================
DISCHARGE EXAM:
================
VS - T 97.9 HR 67 BP 110/78 RR 18 02 99% sat on RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: +BS Soft, mild diffuse tenderness to palpation most in
epigastric region, minimal distension, no organomegaly, no
rebound or guarding . Large RUQ scar.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, No focal deficits.
Pertinent Results:
================
ADMISSION LABS:
================
___ 08:05PM WBC-2.9* RBC-5.05 HGB-15.0 HCT-42.9 MCV-85
MCH-29.7 MCHC-35.0 RDW-15.7* RDWSD-47.9*
___ 08:05PM NEUTS-43.1 ___ MONOS-10.3 EOS-1.7
BASOS-1.4* IM ___ AbsNeut-1.26*# AbsLymp-1.25 AbsMono-0.30
AbsEos-0.05 AbsBaso-0.04
___ 08:05PM ___ PTT-28.2 ___
___ 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:05PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:05PM ALT(SGPT)-37 AST(SGOT)-27 ALK PHOS-120 TOT
BILI-0.4
___ 08:05PM LIPASE-24
___ 08:05PM ALBUMIN-4.3
___ 08:05PM GLUCOSE-88 UREA N-15 CREAT-1.1 SODIUM-137
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-15
================
DISCHARGE LABS:
================
___ 04:40AM BLOOD WBC-3.2* RBC-4.71 Hgb-13.9 Hct-40.7
MCV-86 MCH-29.5 MCHC-34.2 RDW-15.4 RDWSD-48.0* Plt Ct-78*
___ 04:40AM BLOOD Glucose-96 UreaN-14 Creat-1.0 Na-139
K-3.9 Cl-102 HCO3-25 AnGap-16
___ 04:17AM BLOOD ALT-34 AST-32 LD(LDH)-192 AlkPhos-110
Amylase-23 TotBili-0.4
___ 04:40AM BLOOD Calcium-8.9 Phos-3.5 Mg-1.9
___ 04:40AM BLOOD tacroFK-6.3
==============
MICROBIOLOGY:
==============
___ 5:05 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
MICROSPORIDIA STAIN (Final ___: NO MICROSPORIDIUM
SEEN.
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ ___ ___ 10AM.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C. difficile by the Illumigene
DNA
amplification. (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.
___ CRYSTALS PRESENT.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
O&P MACROSCOPIC EXAM - WORM (Final ___: NO WORM
SEEN.
___ 8:25 pm BLOOD CULTURES x2
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
=================
IMAGING/STUDIES:
=================
EKG ___: Sinus rhythm with non-specific T wave flattening
in leads aVL and V2. There is early R wave progression in the
precordium. Compared to the previous tracing of ___ the
previously seen T wave inversions are no longer present.
KUB ___ FINDINGS:
There is gas distending the colon. The colon does not exceed
4.5-5 cm in
caliber. There is gas in scattered nondilated small bowel
loops. Supine assessment limits detection for free air; there
is no gross pneumoperitoneum. A surgical clip is seen in the
right upper quadrant.
There are degenerative changes in the femoroacetabular joints.
There are no unexplained soft tissue calcifications or
radiopaque foreign bodies.
IMPRESSION: No radiographic evidence of toxic megacolon.
Brief Hospital Course:
___ y/o M with ___ PBC s/p liver transplant in ___, bipolar
disorder, pericarditis p/w worsening abdominal pain, chest pain,
diarrhea. Patient was recently admitted and discharged from
___ for the same complaint on ___. Colonoscopy was
performed on ___ and showed colitis. Stool studies were positive
of C diff on this admission (previously negative on prior
admission). Therefore, patient was started on vancomycin PO on
___ for treatment of C diff colitis with plans to complete a
14-day total course. Abdominal pain and diarrhea gradually
improved during the admission. Patient maintained good PO intake
throughout admission.
# Diarrhea ___ to C diff Colitis: Patient presented again to the
ED on ___ for worsening abdominal pain, nausea, diarrhea (7
watery BMs daily). He was recently discharged on ___ for the
same complaint. Repeat stool studies were obtained that returned
positive for C diff on ___. CMV stains of colonoscopy specimens
were negative. Antibiotic therapy was started with PO vancomycin
since patient had no elevated WBC count or ___. Nausea was
managed with PRN Zofran with good effect. During admission,
patient had gradual improvement in abdominal pain/diarrhea. KUB
was ordered to r/o toxic megacolon and showed only distended
bowel loops with gas. Gradually pain improved with PRN
acetaminophen, simethicone, dicyclomine, tramadol. On discharge,
patient was tolerating regular diet with good PO intake and
diarrhea/abdominal pain were improving. He was discharged with a
script to complete a full 14-day course of PO vancomycin at
home.
================
Chronic Issues
================
#PBC S/P OLT WITH CMV+ DONOR C/B CELLULAR REJECTION,
HEMORRHAGIC
PERICARDITIS, RECURRENT PERICARDITIS: No active issues while
inpatient. Patient continued on home tacrolimus/prednisone doses
and daily tacro levels were appropriate. Daily LFTs were also
WNL.
#THROMBOCYTOPENIA. Stable throughout admission. Patient has
known chronic thrombocytopenia likely due to liver disease vs
immunosuppression.
#BIPOLAR DISORDER. No acute issues. Recently off of Abilify.
Monitored without need to restart therapy.
#GERD: Stable. Possibly contributing to abdominal pain as
described above with C diff infection. Continued on home
omeprazole 40mg BID, ranitidine 150mg qHS.
#CHRONIC NEUROPATHIC PAIN: Stable. Continued on home Gabapentin
600mg BID
#COPD: No SOB throughout admission. Continued home albuterol
prn
TRANSITIONAL ISSUES:
[ ] Complete Vancomycin 125 mg PO Q6H x 14 days
(___)
[ ] Follow up with PCP, ___.
[ ] Full Code (confirmed)
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Aspirin 650 mg PO BID
2. Colchicine 0.6 mg PO BID
3. Gabapentin 600 mg PO BID
4. Omeprazole 40 mg PO BID
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. PredniSONE 5 mg PO DAILY
7. Ranitidine 150 mg PO QHS
8. Tacrolimus 1 mg PO QPM
9. Tacrolimus 1 mg PO QAM
10. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
11. DICYCLOMine 20 mg PO TID abdominal pain
12. IBgard (peppermint oil) 90 mg oral TID:PRN abdominal pain
Discharge Medications:
1. Simethicone 80 mg PO QID pain
RX *simethicone 80 mg 1 tablet by mouth QID PRN Disp #*60 Tablet
Refills:*0
2. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*40 Capsule Refills:*0
3. DICYCLOMine 20 mg PO TID abdominal pain
You may continue to take this medication as needed for abdominal
pain.
RX *dicyclomine [Bentyl] 20 mg 1 tablet(s) by mouth TID PRN Disp
#*30 Tablet Refills:*0
4. Aspirin 650 mg PO BID
5. Colchicine 0.6 mg PO BID
6. Gabapentin 600 mg PO BID
7. Omeprazole 40 mg PO BID
8. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*0
9. PredniSONE 5 mg PO DAILY
10. Ranitidine 150 mg PO QHS
11. Tacrolimus 1 mg PO QAM
12. Tacrolimus 1 mg PO QPM
13. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
14. HELD- IBgard (peppermint oil) 90 mg oral TID:PRN abdominal
pain This medication was held. Do not restart IBgard until you
discuss this with your transplant doctor.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES: C. diff Colitis
SECONDARY DIAGNOSES: PBC s/p liver transplant ___,
Neutropenia, DVT ___, HLD, HLD, Osteoporosis, Bipolar
disorder, Hemorrhoids, ADHD, PTSD
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 ___.
Why you were in the hospital:
- You were having abdominal pain and diarrhea and your
colonoscopy results showed inflammation in your colon. This was
due to an infection in your colon with C. Diff.
What was done while you were in the hospital:
- You were started on an antibiotic called vancomycin and were
given medications for your nausea and pain.
What you need to do when you go home:
- You will continue taking antibiotics for your C. diff
infection through ___ (10 more days).
- Please follow up with your primary ___ doctor's office on
___.
- Please also follow up with your liver transplant doctor, ___.
___ on ___.
It was a pleasure taking ___ of you at ___ Deaconess.
___,
Your ___ ___ Team
Followup Instructions:
___
|
19992875-DS-38 | 19,992,875 | 26,793,370 | DS | 38 | 2163-12-26 00:00:00 | 2163-12-26 17:13:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam / risperidone /
mushrooms
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo man with PBC s/p liver transplantation in
___ (on tacrolimus/ prednisone), pericarditis complicated by
tamponade with pericardial window, bipolar disorder, & recurrent
C
Difficile with recent hospitalization, who presents with
diarrhea, nausea, vomiting, and abdominal pain.
He reports that his diarrhea had improved by the time of his
last discharge from the hospital. However, it started to
increase in frequency once he got home. He reports that he did
not change his diet at all. No sick contacts. Has not consumed
any raw or undercooked shellfish or other food. His bowel
diarrhea is watery and non-bloody. He reports he has anywhere
from ___ bowel movements per day. He reports his vomit is
non-bloody and non-bilious. Denies fever, chills, chest pain,
shortness of breath.
Past Medical History:
PAST MEDICAL HISTORY:
PBC s/p deceased liver donor tx ___
Neutropenia
DVT ___
Prior alcohol abuse now abstinent
Hemorrhagic pericarditis c/b tamponade with pericardial window
___
Positive PPD s/p INH
HLD
Osteoporosis
Bipolar disorder
Hemorrhoids
ADHD
PTSD
Social History:
___
Family History:
Father (living): coronary artery disease, diabetes,
hypercholesterolemia, and depression. Prostate and head and neck
cancer
Mother (deceased): brain aneurysm and hyperthyroidism
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
VITAL SIGNS - 97.7 PO 104 / 69 L Lying 60 18 98 RA
GENERAL - Appears stated age in NAD
HEENT - neck supple, PERRLA, EOMI, no appreciable cervical or
supravlavicular LAD. mucous membranes dry.
CARDIAC - S1/S2, bradycardic, regular rhythm
PULMONARY - CTAB
ABDOMEN - one large surgical scar on L side of abdomen. Well
healed. Tender to palpation in the epigastric area and the LUQ
EXTREMITIES - No edema, well-perfused
SKIN - no bruising or notable rashes.
NEUROLOGIC - A&O x 3, normal gait, ___ strength in upper and
lower extremities
DISCHARGE PHYSICAL EXAM
======================
VITAL SIGNS - 97.5 PO 121 / 85 56 18 97 ra
GENERAL - lying in bed, sleeping
HEENT - neck supple, PERRLA, EOMI, no appreciable cervical or
supravlavicular LAD. Area of mild erythema periortibally on
lateral left eye has resolved. Mild tenderness to palpation over
erythema and also posterior auricular lymph nodes have resolved.
CARDIAC - S1/S2, bradycardic, regular rhythm
PULMONARY - CTAB
ABDOMEN - one large surgical scar on L side of abdomen. Well
healed. Tender to palpation in the epigastric area and the LUQ
EXTREMITIES - No edema, well-perfused
SKIN - no bruising or notable rashes.
NEUROLOGIC - A&O x 3, normal gait, ___ strength in upper and
lower extremities
Pertinent Results:
ADMISSION LAB RESULTS
===================
___ 09:00AM BLOOD WBC-3.1* RBC-4.93 Hgb-15.0 Hct-43.7
MCV-89 MCH-30.4 MCHC-34.3 RDW-15.2 RDWSD-48.1* Plt ___
___ 09:00AM BLOOD Neuts-49.3 ___ Monos-10.3 Eos-1.6
Baso-2.3* Im ___ AbsNeut-1.53* AbsLymp-1.10* AbsMono-0.32
AbsEos-0.05 AbsBaso-0.07
___ 09:00AM BLOOD ___ PTT-25.7 ___
___ 09:00AM BLOOD Glucose-77 UreaN-11 Creat-1.2 Na-136
K-4.4 Cl-103 HCO3-16* AnGap-21*
___ 09:00AM BLOOD ALT-25 AST-34 AlkPhos-98 TotBili-0.8
___ 09:00AM BLOOD Albumin-4.0 Calcium-8.9 Mg-1.9
___ 09:12AM BLOOD Lactate-1.0
DISCHARGE LAB RESULTS
====================
___ 04:52AM BLOOD WBC-3.3* RBC-4.65 Hgb-13.9 Hct-40.1
MCV-86 MCH-29.9 MCHC-34.7 RDW-14.5 RDWSD-45.1 Plt Ct-96*
___ 04:52AM BLOOD ___ PTT-32.1 ___
___ 04:52AM BLOOD Glucose-77 UreaN-10 Creat-1.3* Na-137
K-4.6 Cl-101 HCO3-25 AnGap-16
___ 04:52AM BLOOD ALT-18 AST-18 AlkPhos-98 TotBili-0.6
___ 04:52AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.1
MICROBIOLOGY
============
___ Stool Culture
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
___ C diff: Negative
___ Urine culture: Negative
___ Blood culture: Pending
IMAGING
=======
___ Chest X-Ray:
Faint linear densities in the lower lungs likely reflect
platelike atelectasis. The lungs are otherwise clear. There is
stable prominence of the mediastinal silhouette, which has
been previously assessed by CT chest from ___. The
heart size is
normal. Bony structures are intact. No free air below the
right hemidiaphragm.
___ Abdominal X-Ray:
Supine and upright views of the abdomen pelvis were provided.
Bowel gas pattern is unremarkable without signs of ileus or
obstruction. No free air is seen below the right hemidiaphragm.
No worrisome calcifications. The imaged osseous structures
appear intact. There is a mild dextroscoliosis of the
thoracolumbar spine, apex at L1. A clip again noted in the
right upper quadrant.
___ RUQ Ultrasound with 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 24.
Appropriate arterial waveforms are seen in the right hepatic
artery and the left hepatic artery with resistive indices of
0.74, and 0.79, 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.
Brief Hospital Course:
Mr. ___ is a ___ man with PBC s/p liver transplantation in
___ (on tacrolimus/prednisone), pericarditis complicated by
tamponade with pericardial window, bipolar disorder, & recurrent
C Difficile with recent hospitalization, who presents with
worsening diarrhea, n/v, and abdominal pain.
# Diarrhea, Nausea, Vomiting: The patient initially presented
with abdominal pain, vomiting x3 the night prior to admission,
and reports of increase in diarrhea. There was initial concern
for toxic megacolon or SBO. However, ___ ruled out those
etiologies. It was thought that this may either be viral
gastroenteritis or relapsed C. Diff infection. Flex
sigmoidoscopy on previous hospitalization showed active colitis
with focal superficial features suggestive of a component of
ischemic type injury. Stool studies were sent including
norovirus NAAT, and C. Diff which were negative. The patient's
last bowel movement was in the emergency department. He did not
have one for three days after that. The patient had still not
had a bowel movement on the day of discharge, so he was given
senna, colace, and miralax.
#Cellulitis: The patient had some erythema and swelling without
warmth over the lateral left ___ area. He remained
afebrile. ID was consulted for questionable cellulitis since the
patient was at a higher risk for infection given
immunosuppression. A diagnosis of pre-septal cellulitis was
made, and the patient was started on Bactrim. He was sent home
on Bactrim 1 DS tab BID x 7 days to finish the course for facial
cellulitis.
# PBC s/p orthotopic liver transplant with CMV+ donor
complicated by cellular rejection: The patient was continued on
his home tacrolimus/prednisone and tacrolimus troughs were
checked daily; they ranged from ___.
# Normocytic Anemia: The patient's hemoglobin dropped from 15 to
12.8 the day after admission. This was likely dilutional given
that the patient received IV fluids in the ED. Hemolysis labs
were negative. Iron deficiency labs ___ ferritin, but
otherwise normal.
# Thrombocytopenia: Patient has known chronic thrombocytopenia
likely due to liver disease, immunosuppression and
hypersplenism.
# Bipolar Disorder: The patient was recently taken off Abilify.
He was monitored during his hospitalization, and there were no
acute issues.
# GERD: Stable. Possibly contributing to abdominal pain as
described above. He was continued on his home ranitidine 150mg
qHS, maalox PRN.
# Chronic neuropathic pain: He was continued on his home
Gabapentin 600mg BID.
# COPD: There was no SOB throughout the admission. He was
continued on home albuterol PRN
TRANSITIONAL ISSUES
====================
-Patient will follow up with Dr. ___ as outpatient to monitor
alternating diarrhea and constipation.
-Consider follow up colonoscopy in several months to monitor for
resolution of active colitis.
-Patient will be discharged on Bactrim 1 DS tab BID for total
course of 7 days (end date ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 650 mg PO BID
2. Colchicine 0.6 mg PO BID
3. Gabapentin 600 mg PO BID
4. PredniSONE 5 mg PO DAILY
5. Ranitidine 150 mg PO QHS
6. Tacrolimus 1 mg PO QPM
7. Tacrolimus 1 mg PO QAM
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
9. Ondansetron 4 mg PO Q8H:PRN nausea
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*45 Capsule Refills:*0
2. Senna 8.6 mg PO BID
RX *sennosides 8.6 mg 1 tablet by mouth twice a day Disp #*45
Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*11 Tablet Refills:*0
4. Aspirin 650 mg PO BID
5. Colchicine 0.6 mg PO BID
6. Gabapentin 600 mg PO BID
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. PredniSONE 5 mg PO DAILY
9. Ranitidine 150 mg PO QHS
10. Tacrolimus 1 mg PO QPM
11. Tacrolimus 1 mg PO QAM
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Diarrhea
SECONDARY DIAGNOSIS
====================
Chronic pain
Primary Biliary Cirrohsis S/P Liver Transplant
Cellular Rejection
Anemia
Bipolar Disorder
Gastroesophageal Reflux Disease
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were admitted to ___.
Why were you admitted?
======================
You had abdominal pain, diarrhea, nausea and vomiting
What did we do for you?
=======================
-We gave you fluids because of dehydration from diarrhea and
vomiting.
-We sent off tests of your stool to ensure you do not have
another infection. The tests that did come back were negative.
Some of the other cultures were still pending at time of
discharge.
What should you do when you get home?
=====================================
-Continue to take your anti-nausea medication before meals when
you are feeling nauseous.
-We suggest that you follow the "BRAT" diet until you feel
better. This consists of bananas, rice, applesauce and toast.
You can advance your diet when you feel you are able
-Expect to have loose stools, up to 1 or 2 per day, for the
next few months. Your colon is still recovering from your
Clostridium
difficile infection in ___.
- Call the doctor if you have 6 or more loose stools per day.
- Attend a follow-up appointment with your primary care doctor.
- Attend a follow-up appointment with your liver transplant
doctor.
- Consider seeing a pain specialist to help treat your multiple
causes of pain.
It was a pleasure taking part in your care.
Your ___ Team
Followup Instructions:
___
|
19992875-DS-43 | 19,992,875 | 24,912,961 | DS | 43 | 2166-04-30 00:00:00 | 2166-04-30 19:01:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam / risperidone /
mushrooms / propofol
Attending: ___.
Chief Complaint:
Weakness
Major Surgical or Invasive Procedure:
Endoscopy ___
colonoscopy ___
History of Present Illness:
Patient is a ___ male with a past medical history
significant for liver transplant in ___ for PBC, hemorrhagic
pericarditis in ___ status post pericardial window, MI x2 in
___, IBS versus Crohn's, osteoporosis with multiple
pathological
fractures presenting to the emergency department with
generalized
weakness and found to have an ___.
Patient had a colonoscopy performed approximately 2 weeks ago.
At
this time the patient did receive propofol. Per review of
records, it seems that the patient became hypoxic and the
colonoscopy was not performed. Upon awakening, the patient noted
some chest pain and shortness of breath. For this the patient
was
taken to ___. He was observed for 1 day from the
fifth
to the sixth of this month. At that time, the patient's
creatinine was noted to be 1.6. The patient was discharged in
stable condition.
Patient states that today he developed generalized weakness. He
does not note any focal weakness. The patient describes
dizziness
upon standing up quickly. This dizziness is not related to rapid
movements of the head. The patient does not have dizziness here
in the emergency department. The patient notes that he has not
been eating or drinking well for the past 2 weeks and that he
has
had some diarrhea over the past two weeks. The patient does not
note any new cough or any urinary changes. He does have some
nausea but no vomiting. The patient has some chills but no
fever.
Patient does not have any chest pain. He does describe some
shortness of breath.
Patient presented to an outside hospital where he was noted to
have an increase in his creatinine to 2.0. Patient was
transferred here for further workup given this was where he had
his liver transplant.
Patient presents to us in no acute distress. He states that he
has been compliant with all of his medications. He is on
immunosuppression at this time consisting of tacrolimus and
prednisone.
Past Medical History:
- attention deficit hyperactivity disorder
- bipolar disorder
- hemorrhoids
- history of alcohol abuse
- history of deep vein thrombosis in ___
- history of hemorrhagic pericarditis complicated by cardiac
tamponade status post pericardial window in ___, recurrent
pericarditis in ___
- history of neutropenia complicated by neutropenic fever
- history of positive tuberculin skin test status post INH
- hyperlipidemia
- osteoporosis
- primary biliary cirrhosis status post orthotopic liver
transplant
- PULMONARY NODULE
- CHRONIC OBSTRUCTIVE PULMONARY DISEASE
- ALTERNATING CONSTIPATION/DIARRHEA, ?IBS vs chrons
- HISTORY OF CAD W/ MI x2 in ___
- T1 COMPRESSION FRACTURE, T6 BURST FRACTURE
Social History:
___
Family History:
Noncontributory to the patients current admission,
Father passed away from head and neck cancer
Physical Exam:
Admission Exam:
==================
VITALS: Reviewed in OMR
___: Weight: 172.2
GEN: Alert, cooperative, no distress, appears stated age
HENT: NC/AT, MMM. Nares patent, no drainage or sinus
tenderness. no teeth, and normal gums normal.
EYES: PERRL, EOM intact, conjunctivae clear, no scleral
icterus.
NECK: No cervical lymphadenopathy. No JVD, Neck supple,
symmetrical, trachea midline.
LUNG: CTA ___, good air movement, no accessory muscle use
HEART: RRR, Normal S1/S2, No M/R/G
BACK: Symmetric, no curvature. ROM normal. No CVA tenderness.
ABD: Soft, non-tender, non-distended; nl bowel sounds; midline
well healed scar, no rebound or guarding, no organomegaly
GU: Not examined
EXTRM: Extremities warm, no edema, tender to palpation over the
left shin, no cyanosis, positive ___ pulses bilaterally
SKIN: Skin color and temperature, appropriate. No rashes or
lesions
NEUR: CN II-XII intact grossly. Moving all extremities,
strength, sensation equal and intact throughout.
PSYC: Mood and affect appropriate
Discharge Exam:
================
Gen: NAD
HENT: NC/AT, sclerae anicteric, normal conjunctivae, oropharynx
clear, MMM
LUNG: CTAB, no increased work of breathing
HEART: RRR, normal S1/S2, no m/r/g
ABD: Soft, non-tender, non-distended
EXTRM: Warm, DP pulses 2+ bilaterally, no edema
SKIN: Well-healed scar along upper spine, well-healed scar over
RUQ of abdomen
NEUR: AOx3
Pertinent Results:
Admission labs:
==================
___ 11:15PM BLOOD WBC-2.8* RBC-4.67 Hgb-10.8* Hct-36.8*
MCV-79* MCH-23.1* MCHC-29.3* RDW-17.4* RDWSD-49.3* Plt ___
___ 11:15PM BLOOD Neuts-36.2 ___ Monos-15.2*
Eos-5.1 Baso-2.2* Im ___ AbsNeut-1.00* AbsLymp-1.11*
AbsMono-0.42 AbsEos-0.14 AbsBaso-0.06
___ 11:15PM BLOOD Plt ___
___ 11:15PM BLOOD Glucose-87 UreaN-15 Creat-1.7* Na-142
K-4.3 Cl-109* HCO3-24 AnGap-9*
___ 11:15PM BLOOD ALT-20 AST-24 CK(CPK)-33* AlkPhos-131*
TotBili-0.3
___ 11:15PM BLOOD Lipase-19
___ 11:15PM BLOOD cTropnT-<0.01
___ 06:15PM BLOOD cTropnT-<0.01
___ 11:15PM BLOOD Albumin-3.8 Calcium-8.6 Phos-3.5 Mg-1.8
___ 04:27AM BLOOD calTIBC-283 VitB12-440 Folate-8 Hapto-47
Ferritn-23* TRF-218
___ 11:15PM BLOOD Osmolal-283
___ 06:13AM BLOOD TSH-2.6
___ 06:13AM BLOOD Cortsol-<0.3*
___ 05:20PM BLOOD Cortsol-0.5*
___ 07:45PM BLOOD Cortsol-0.8*
___ 09:38AM BLOOD tacroFK-2.9*
Key labs:
===================
___ 04:27AM BLOOD Ret Aut-2.2* Abs Ret-0.09
___ 05:20PM BLOOD Cortsol-0.5*
___ 07:45PM BLOOD Cortsol-0.8*
___ 04:36AM BLOOD tacroFK-3.3*
___ 11:23AM BLOOD CMV VL-DETECTED,
___ 05:31AM BLOOD CMV VL-DETECTED,
___ 07:45PM BLOOD ALDOSTERONE-Test
___ 05:20PM BLOOD ALDOSTERONE-Test
___ 05:20PM BLOOD ACTH - FROZEN-Test
Discharge labs:
======================
___ 04:36AM BLOOD WBC-3.6* RBC-4.32* Hgb-9.8* Hct-33.0*
MCV-76* MCH-22.7* MCHC-29.7* RDW-17.8* RDWSD-48.1* Plt Ct-95*
___ 05:31AM BLOOD Neuts-44.3 ___ Monos-12.9 Eos-1.2
Baso-1.6* Im ___ AbsNeut-1.13* AbsLymp-1.00* AbsMono-0.33
AbsEos-0.03* AbsBaso-0.04
___ 04:36AM BLOOD Plt Ct-95*
___ 04:36AM BLOOD Glucose-106* UreaN-13 Creat-1.4* Na-138
K-4.4 Cl-107 HCO3-21* AnGap-10
___ 05:09AM BLOOD ALT-18 AST-21 AlkPhos-109 TotBili-0.4
___ 04:36AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.9
Imaging:
====================
___ Dupplex abdominal Doppler
1. Patent hepatic vasculature with appropriate waveforms.
Please note that the left hepatic artery was not able to be
visualized secondary to poor acoustic windows and patient
breathing.
2. Splenomegaly.
___ TTE
Prominent epicardial fat without clear pericardial effusion.
Mild global right ventricular hypokinesis. Low normal global
left ventricular systolic function.
___ EGD
Ring in the distal esophagus
Normal mucosa in the whole stomach
normal mucosa in the duodenum
___ Colonoscopy
High residue material and unable to visualize adequately
Normal as far as visualized. Not adequate for screening
purposes. Terminal ileum was not intubated due to patient
discomfort
Path:
=====================
___ GI mucosal biopsy
1. Terminal ileum:
Terminal ileal mucosa, within normal limits.
2. Colon:
Colonic mucosa with patchy moderately active colitis (multiple
neutrophilic crypt abscesses), focal
basal crypt regeneration, and scattered prominent basal
apoptotic debris; no definitive evidence of
chronic colitis, granulomas, or viral inclusions/cytopathic
effect are identified.
Immunostain for cytomegalovirus is in progress and the results
will be reported in a revised report.
Note: The colonic mucosal biopsy findings are favored to
represent an acute infectious colitis versus
a drug-induced change. Correlation with clinical and laboratory
findings is needed.
___ GI biopsy
1. Esophagus, biopsy:
- Squamous mucosa with active erosive esophagitis.
- Numerous Herpes simplex virus viral cytopathic changes
(confirmed by HSV I/II immunostain) .
2. Stomach, biopsy:
- Antral and corpus mucosa within normal limits.
___ GI Biopsy
1. Duodenum, biopsy:
-Duodenal mucosa with crypt regeneration (non-specific),
otherwise within normal limits.
-CMV immunostain highlights rare positive cells in the lamina
propria (see note).
Note: The clinical significance of this finding is uncertain,
since no significant duodenitis is identified.
2. Random colon, biopsy:
-Colonic mucosa within normal limits.
-Immunohistochemical stain for CMV is negative with adequate
controls.
Brief Hospital Course:
PATIENT SUMMARY
=================
Patient is a ___ male with a past medical history
significant for liver transplant in ___ for PBC, hemorrhagic
pericarditis in ___ status post pericardial window, MI x2 in
___, IBS versus Crohn's, osteoporosis with multiple
pathological
fractures who presented to the emergency department with
generalized
weakness and was found to have an ___. Diagnosed with secondary
adrenal insufficiency and CMV. Treated for both. Colonoscopy and
EGD unrevealing.
Transitional Issues
===================
[] Prednisone course:
7.5mg for three days (___) then 5mg daily
[] Will need f/u CMV viral titers until negative
[] discharge tacro dosing of 1 mg BID discharge tacro level of
3.3
[] Patient ASA reduced to 325mg daily from BID dosing and
continue colchicine 0.6 bid due to his history of pericarditis.
Will need follow up arranged with Dr. ___ likely
discontinuation or downtitration of medications. Unable to reach
via E-mail
==============
Active Issues
==============
#Weakness
#Anemia
#Orthostasis
#Exertional dyspnea
Patient presented with recent weakness, exertional dyspnea, with
initial differential including worsening anemia, dehydration,
infectious process, cardiac etiology, and adrenal insufficiency.
Patient has baseline
pancytopenia (see below) but with an acute drop in Hgb shortly
after admission from 11 to 9.5, and from recent baseline ~13 in
___.
Remained hemodynamically stable. No overt bleeding, melena, or
hematochezia. EGD and colonoscopy on ___, revealing no
inflammation or source of bleeding. Alternating diarrhea and
constipation chronic ("since forever") per patient, with no
acute change.. CXR and abdominal US unremarkable (aside from
splenomegaly on US). AM cortisol <0.3, with further testing
consistent with adrenal insufficiency that may be have
contributed to overall weakness.
#CMV Viremia
#CMV Duodenal infection
Patient presents with the symptoms, discussed below, raising
concern for CMV infection. CMV titer returned as detectable, but
below 1.7 on two separate titers which does not meet criteria
for induction therapy. Endoscopic biopsy of the duodenum
revealed positive staining for CMV without evidence of
inflammation, which is of unclear significance. Given the
overall clinical picture discussed below, in addition to the CMV
viral load and biopsy findings, valganciclovir treatment was
initiated with 450mg bid (dose reduced for renal function) for
28 days as is recommended for treatment.
#Secondary Adrenal insufficiency
Low morning cortisol, low ACTH and cosyntropin stimulation test
results obtained when he received corticosteroids on the day of
the stim test, and values were also obtained 2 hours after
adminisration of cosyntropin, making these less reliable.
However
it seems very likely that he is adrenally insufficient. We
ultimately increased his prednisone dosing to 10mg daily while
treating for CMV with slower taper to 7.5mg x3 days and back to
5mg daily given worsening nausea with quick taper.
___
Patient admitted with ___, pre-renal in setting of poor PO
intake and diarrhea. Peaked at 2.0, subsequently downtrended to
1.4. Baseline appeared to range 0.6 to 0.9. No major electrolyte
abnormalities. Per Dr. ___ for discharge with current Cr
elevation with follow up outpatient.
#PBC s/p DDLT
#immunosuppression
#Leukopenia/pancytopenia
Patient reported he has had pancytopenia since his liver
transplant ___ years ago. This is likely immunosuppressive effect
from his Tacrolimus resulting in chronic iatrogenic
myelosuppression. He had a workup for this including BM-biopsy
in ___ iso CMV viremia, which was non-revealing. CMV viral load
this admission was Detected, discussed above. Acute on chronic
anemia was further evaluated as above.
#Hx pericarditis with loculated pericardial effusion
Patient has a history of hemorrhagic pericarditis c/b tamponade
s/p pericardial window ___ and recurrent pericarditis
___
and moderate pericardial effusion seen on TTE on ___. The
patient has no new chest pain or pressure symptoms and does not
endorse any tachycardia or palpitations. Repeat TTE showed no
effusion. Patient was continued on colchicine and ASA though
dose of ASA reduced to 325mg daily for GI protection as unclear
why such high dose has been maintained and unable to reach
outpatient providers.
==============
Chronic Issues
==============
#Osteoporosis
Per OMR review, has had since before his liver transplant so
likely not related to prednisone.
#Bipolar
Continued home bupropion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO BID
2. Atorvastatin 10 mg PO QPM
3. BuPROPion (Sustained Release) 300 mg PO QAM
4. Colchicine 0.6 mg PO BID
5. DICYCLOMine 20 mg PO TID:PRN diarrhea
6. Docusate Sodium 100 mg PO BID:PRN Constipation - First Line
7. Gabapentin 800 mg PO BID
8. Pantoprazole 40 mg PO Q12H
9. PredniSONE 5 mg PO DAILY
10. Ranitidine 150 mg PO DAILY
11. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
12. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
13. Tacrolimus 0.5 mg PO QPM
14. Tacrolimus 1 mg PO QAM
15. Naloxone Nasal Spray 4 mg IH ONCE MR1
Discharge Medications:
1. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
2. ValGANCIclovir 450 mg PO Q12H Duration: 28 Days
RX *valganciclovir 450 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Aspirin 325 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. PredniSONE 7.5 mg PO DAILY
RX *prednisone 5 mg 1.5 tablet(s) by mouth once a day for 3 days
then one tablet daily thereafter Disp #*30 Tablet Refills:*0
6. Tacrolimus 1 mg PO QAM
RX *tacrolimus 1 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
7. Tacrolimus 1 mg PO QPM
8. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
9. Atorvastatin 10 mg PO QPM
10. BuPROPion (Sustained Release) 300 mg PO QAM
11. Colchicine 0.6 mg PO BID
12. DICYCLOMine 20 mg PO TID:PRN diarrhea
13. Naloxone Nasal Spray 4 mg IH ONCE MR1
14. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
15. Ranitidine 150 mg PO DAILY
16. HELD- Gabapentin 800 mg PO BID This medication was held. Do
not restart Gabapentin until seen by PCP
___:
Home
Discharge Diagnosis:
#Adrenal Insufficiency
#Anemia
#CMV viremia
#CMV duodenitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for weakness
What was done for me while I was in the hospital?
We found that your adrenal glands were not working very well and
we gave you steroid medication
We performed an endoscopy and colonoscopy to look for evidence
of inflammation in you GI tract
We found that you are infected by a virus that can cause GI
symptoms and started you on the appropriate treatment
What should I do when I leave the hospital?
-Please take all of your medications and keep all of your
appointments
- Dr. ___ will contact you with an appointment
- The Endocrinology department is working on scheduling an
earlier appointment for you as well.
*****Prednisone course****
7.5mg for three days (___) then 5mg daily
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19992875-DS-44 | 19,992,875 | 21,570,862 | DS | 44 | 2166-07-19 00:00:00 | 2166-07-19 18:48:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / rifampin / Lamictal / lorazepam / risperidone /
mushrooms / propofol
Attending: ___
Chief Complaint:
Generalized Weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with a past medical history significant for
liver transplant in ___ for PBC, hemorrhagic pericarditis in
___ s/p pericardial window, MI x2 in ___, IBS vs Crohn's
disease, osteoporosis with multiple pathological fractures who
presents for generalized weakness.
Notably, the pt was admitted recently to ___
___,
at which time his presenting symptoms was also weakness. Work up
was significant for ___, adrenal insufficiency, and CMV viremia.
He underwent a colonoscopy and EGD that were unrevealing. The pt
was treated w/ steroids and valganciclovir and his Cr improved
to
baseline by time of discharge.
The pt now complains of about 2 days of generalizes weakness and
fatigue. Prior to that, he was in his usual state of health.
Also
endorses low appetite, nausea, and some abdominal discomfort
without vomiting or change in bowel movements. The pt was
initially seen at ___ where labs, flu swab, UA, and
CXR were reportedly unremarkable with the exception of elevated
Cr to 1.8. He was given 100 mg of Hydrocort for concerns of
adrenal insufficiency. The pt was then transferred to ___ for
continued care.
In the ED, initial VS were T 96.7, HR 64, BP 140/70, RR 16, O2
98% on RA.
Exam was notable for diffuse abdominal tenderness.
Labs were significant for:
- Pancytopenia with WBC 2.7, Hbg 9.0, Plts 89
- Otherwise normal chemistry panel (Cr 1.2) LFTs, coags,
lactate,
and U/A negative
Studies included:
- CT A&P with no acute intra-abdominal process
- RUQ US w/ doppler with high resistance waveform in the main
hepatic artery with diminished antegrade diastolic flow as well
as interval decrease in peak systolic velocity (31.3 cm/s);
nonvisualization of the right or left hepatic arteries; patent
portal veins; and splenomegaly
The pt was continued on his home medications. He was transferred
to the Heparorenal service for further management.
On arrival to the floor, the pt endorsed the above history.
Aside
from the weakness, nausea, and abdominal pain, the pt denied
having and fevers, chills, vomiting, cough, or urinary
frequency.
He also denied any new medications, recent travel, or sick
contacts.
REVIEW OF SYSTEMS:
==================
Per HPI, otherwise, 10-point review of systems was within normal
limits.
Past Medical History:
- Attention deficit hyperactivity disorder
- Bipolar disorder
- Hemorrhoids
- History of alcohol abuse
- History of deep vein thrombosis in ___
- History of hemorrhagic pericarditis complicated by cardiac
tamponade status post pericardial window in ___, recurrent
pericarditis in ___
- History of neutropenia complicated by neutropenic fever
- History of positive tuberculin skin test status post INH
- Hyperlipidemia
- Osteoporosis
- Primary biliary cirrhosis status post orthotopic liver
transplant
- Pulmonary nodule
- COPD
- Alternating constipation/diarrhea, ? IBS vs Crohn's Disease
- CAD s/p MI x 2 in ___
- T1 compression fx, T6 burst fracture
- T4-8 FUSION (___)
- LIVER TRANSPLANT (___)
Social History:
___
Family History:
Noncontributory to the patients current admission,
Father passed away from head and neck cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: T 97.9, BP 137/90, HR 75, RR 18, O2 98% on RA
GENERAL: Alert and interactive, NAD
CARDIAC: RRR, no m/r/g
LUNGS: CTAB, no wheezes or crackles
ABDOMEN: Soft, tenderness to palpation diffusely, worse in
midline, nor rebound or guarding, BS+
EXTREMITIES: Trace edema in ___
SKIN: Warm, no rashes
NEUROLOGIC: AOx3, CNII-XII intact, moving extremities, gait
deferred
DISCHARGE PHYSICAL EXAM:
========================
24 HR Data (last updated ___ @ 812)
Temp: 97.5 (Tm 98.6), BP: 138/97 (114-139/83-97), HR: 67
(61-74), RR: 18 (___), O2 sat: 98% (97-98), O2 delivery: Ra
HEENT: NC/AT EOMI sclera nonicteric MMM no oropharyngeal
erythema
Neck: No thyromegaly, no thyroid nodules
CV: RRR S1/S2 normal
RESP: CTAB
ABD: TTP periumbilical. soft, nondistended.
BACK: Diffuse tenderness to palpation at flanks, paraspinal,
spinous processes inferior to rib borders
EXT: No C/C/E
Pertinent Results:
ADMISSION LABS:
===============
___ 05:40AM tacroFK-3.2*
___ 03:04AM LACTATE-1.1
___ 03:00AM CK(CPK)-38*
___ 03:00AM cTropnT-<0.01
___ 03:00AM TSH-3.2
___ 03:00AM T4-3.9* T3-68*
___ 01:30AM ___ PTT-26.8 ___
___ 12:05AM URINE HOURS-RANDOM
___ 12:05AM URINE UHOLD-HOLD
___ 12:05AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:30PM GLUCOSE-95 UREA N-15 CREAT-1.2 SODIUM-143
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-26 ANION GAP-10
___ 10:30PM estGFR-Using this
___ 10:30PM ALT(SGPT)-17 AST(SGOT)-17 ALK PHOS-106 TOT
BILI-0.3
___ 10:30PM LIPASE-18
___ 10:30PM cTropnT-<0.01
___ 10:30PM ALBUMIN-3.8 CALCIUM-8.9 PHOSPHATE-3.0
MAGNESIUM-1.9
___ 10:30PM WBC-2.7* RBC-4.11* HGB-9.0* HCT-31.4* MCV-76*
MCH-21.9* MCHC-28.7* RDW-16.6* RDWSD-45.4
___ 10:30PM NEUTS-48.9 ___ MONOS-12.5 EOS-1.1
BASOS-1.1* IM ___ AbsNeut-1.33* AbsLymp-0.98* AbsMono-0.34
AbsEos-0.03* AbsBaso-0.03
___ 10:30PM PLT COUNT-89*
PERTINENT STUDIES:
==================
___ DOPP ABD/PEL
1. High resistance waveform in the main hepatic artery with
diminished
antegrade diastolic flow as well as interval decrease in peak
systolic
velocity (31.3 cm/s), represents a change from ultrasound of ___ and is concerning for possible occlusion.
Recommend clinical correlation with LFTs and CT angiogram.
2. Patent portal veins.
3. Splenomegaly.
___ ABD & PELVIS WITH CO
1. No acute intra-abdominal process.
2. Unremarkable appearance of the liver transplant. The
transplant main
hepatic artery appears patent to level of the liver hilum.
Suboptimal
evaluation of the hepatic arterial vasculature on this non
dedicated study.
3. Splenomegaly.
___ ABD & PELVIS
1. Main, left and right hepatic arteries are patent and appear
similar to CTA
from ___ with no evidence of focal stenosis.
2. Stable pancreatic cystic lesion is likely a side-branch IPMN
and can be
re-evaluated at next follow-up.
Brief Hospital Course:
___ is a ___ year-old male w/ hx of PBC s/p liver
transplant (___), hemorrhagic pericarditis s/p window, CAD c/b
MI x 2 (___), IBS vs Crohn's disease, OA, and pancytopenia who
presented with generalized weakness, malaise, and dyspnea on
exertion. Of note this is his second hospitalization for similar
presentation in the last several months. Workup here as detailed
below was largely unremarkable, with greatest suspicion for
endocrine or psychosomatic etiology of his weakness.
TRANSITIONAL ISSUES:
====================
[ ] Consider broader endocrine workup for fatigue including
testosterone testing, FSH/LH
[ ] If workup for other organic causes is negative, consider
psychiatric etiology given recent life stressors and possible
referral to psychiatry
[ ] We were unable to provide an appointment with cardiology
while inpatient; please ensure patient follows up with
cardiology for his history of pericarditis and reported MI
history
[ ] Recommend ___ week follow-up of thyroid function tests
[ ] For sick day dosing, recommend prednisone increase from 5 to
10mg dosing for ___ days, after which he can be tapered back to
5mg.
ACUTE ISSUES:
=============
#Fatigue
Patient presented with several weeks of worsening fatigue
without frank weakness, associated with vague diffuse aching and
tenderness across his torso. This is his second admission in
several months for similar complaints. During his prior
admission, there were concerns for adrenal insufficiency given
low AM cortisol and ACTH levels although these were checked at
suboptimal timings around the time of steroid administration.
For this hospitalization, he presented to ___ where
due to concern of adrenal insufficiency he was given 100mg
hydrocortisone and transferred to ___ for further management
and continuity of care. Workup here notable for low repeat AM
cortisol (although now in setting of hydrocortisone
administration), normal TSH with low T3/T4, negative CMV viral
load and culture data. He additionally had CTA abdomen to
evaluate hepatic vasculature (admission RUQ US with decreased
velocities) which was unremarkable. Other endocrine etiologies
were currently left unexplored. He has had prior cardiac
coronary cath in ___ which was unremarkable. Of note,
patient's father recently passed away ~3 months ago which has
been a significant life stressor and associated with
subjectively depressed mood, anhedonia, sleep disturbance, and
decreased energy levels.
- Started on prednisone 10mg on date of admission for sick day
dosing. He was told to taper back to 5mg over two days at
discharge.
#Acute Kidney Injury
Patient with baseline serum creatinine of 1.0, increased to 1.6
which resolved with IV albumin administration, and subsequently
again to 1.3 with IVF administration. Likely in setting of poor
PO intake and unrelated to ongoing above pathology. Not on
diuretics.
#Primary Biliary Cirrhosis s/p Deceased Donor Liver Tx ___
Maintained on tacrolimus 1mg BID. Prednisone dosing as above.
CHRONIC ISSUES:
===============
# H/o pericarditis
Pt found to have hemorrhagic pericarditis c/b tamponade s/p
pericardial window in ___ with recurrent pericarditis in ___
and moderate pericardial effusion seen on TTE in ___.
Resolved on recent TTE ___.
- Continue home colchicine 0.6mg BID
- Continue home ASA (full dose)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. BuPROPion (Sustained Release) 300 mg PO QAM
3. Colchicine 0.6 mg PO BID
4. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
5. Pantoprazole 40 mg PO Q24H
6. Ranitidine 150 mg PO DAILY
7. Tacrolimus 1 mg PO QAM
8. Tacrolimus 1 mg PO QPM
9. Senna 8.6 mg PO BID
10. DICYCLOMine 20 mg PO BID diarrhea
11. Gabapentin 800 mg PO BID
12. Naloxone Nasal Spray 4 mg IH ONCE MR1
13. Aspirin 325 mg PO DAILY
14. PredniSONE 5 mg PO DAILY
15. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
17. DICYCLOMine 10 mg PO DAILY:PRN Abd pain/cramping
Discharge Medications:
1. Ursodiol 500 mg PO BID
2. Aspirin 325 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. BuPROPion (Sustained Release) 300 mg PO QAM
5. Colchicine 0.6 mg PO BID
6. DICYCLOMine 20 mg PO BID diarrhea
7. DICYCLOMine 10 mg PO DAILY:PRN Abd pain/cramping
8. Gabapentin 800 mg PO BID
9. Naloxone Nasal Spray 4 mg IH ONCE MR1
10. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First
Line
11. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
12. Pantoprazole 40 mg PO Q24H
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
14. PredniSONE 5 mg PO DAILY
Please start this on ___. Ranitidine 150 mg PO DAILY
16. Tacrolimus 1 mg PO QAM
17. Tacrolimus 1 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
#Fatigue
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Thank you for coming to ___ for your care. Please read the
following instructions carefully:
Why was I admitted to the hospital?
-You were admitted to the hospital because you have been having
shortness of breath with activities, general feelings of
weakness, and pain throughout her back and abdomen.
What was done for me while I was here?
-We performed several blood tests and a CAT scan to ensure that
there are no serious or life-threatening causes of your symptoms
-We believe that the issues you are currently having will be
better addressed with the doctors in ___
What do I need to do when I leave the hospital?
-Please take your medications as listed below
-Tomorrow, please take 7.5mg of prednisone, and you can resume
your normal dose of 5mg daily on ___
-Please keep your appointments as listed below
-It is very important that you continue to follow with the
cardiologist due to your history of pericarditis. The
information to contact their office is below
We wish you the best with your care!
- Your ___ care team
Followup Instructions:
___
|
19994233-DS-9 | 19,994,233 | 29,338,696 | DS | 9 | 2184-02-16 00:00:00 | 2184-02-16 16:03:00 |
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, speech difficulty
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is an ___ year old woman who presents with acute
onset right sided weakness and speech difficulty since this
evening. She has a history of AF on warfarin, prior "stroke"
(that was a "bleeding" type without residual deficits), HTN, HL,
reportedly dementia, and left-sided breast cancer. She was well
earlier today but supposedly had fallen: she has a small
laceration overlying her right eyebrow, but she did not recall
how or when she fell or any details of this (she could not
describe them to her daughter or subsequently to me). She went
to a medical appointment with her daughter at 4PM when her INR
was checked and was 1.7. Her daughter reports that the
physicians have been aiming for a number on the lower end of the
therapeutic range, so no dose change was made. She returned home
with her daughter who left her in her room around ___. A few
minutes later (sometime before ___), her daughter her a "thud."
She went to her mother's room and found her on the floor, unable
to move her right side or speak clearly. EMS was called and
brought her to the ED immediately. She arrived as a Code Stroke
and was found to have a large left frontal parietal hemorrhage.
On neurologic review of systems, the patient denies headache,
lightheadedness, or confusion. Denies difficulty with producing
or comprehending speech.
Endorses dysarthria. Denies loss of vision, blurred vision,
diplopia, vertigo,
tinnitus, hearing difficulty, or dysphagia. Endorses muscle
weakness.
Endorses loss of sensation. Denies bowel or bladder incontinence
or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss. Denies chest pain,
palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain. Denies dysuria or hematuria. Denies myalgias, arthralgias,
or rash.
Past Medical History:
-ICH (___): unknown location, no residual deficits
-Dementia
-AFib (on Coumadin)
-HTN
-Hyperlipidemia
-h/o left BrCa (surgically resected)
Social History:
___
Family History:
Unknown whether there is h/o stroke or other neurologic illness
Physical Exam:
========================
ADMISSION PHYSICAL EXAM:
========================
VS T: unmeasured HR: 83 BP: 132/87 RR: 12 SaO2: 100% RA
General: NAD, lying in bed with hard collar, elderly woman.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: hard collar in place
Cardiovascular: Irregularly irregular rhythm, no M/R/G
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema, palpable radial/dorsalis pedis
pulses
Skin: Dry, excoriated; left breast surgically removed
___ Stroke Scale - Total [14]
1a. Level of Consciousness - 0
1b. LOC Questions - 0
1c. LOC Commands - 0
2. Best Gaze - 1
3. Visual Fields - 2
4. Facial Palsy - 3
5a. Motor arm, left - 0
5b. Motor arm, right - 4
6a. Motor leg, left - 0
6b. Motor leg, right - 2
7. Limb Ataxia - 0
8. Sensory - 1
9. Language - 0
10. Dysarthria - 1
11. Extinction and Neglect - 0
Neurologic Examination:
- Mental Status - Awake, alert, oriented x name, age, month.
Attention to examiner easily attained ___ requires effort to
maintain. Structure of speech demonstrates diminished fluency
with single words and short phrases, intact repetition, and
possible diminished verbal comprehension of commands and
questions. Content of speech demonstrates intact naming (watch,
glasses) and no paraphasias. Normal prosody. Moderate
dysarthria. No evidence of hemineglect.
- Cranial Nerves - [II] PERRL 2->1 brisk. Diminished blink to
threat on the right upper and lower quadrants - right homonymous
hemianopia. [III, IV, VI] Some right horizontal gaze limitation,
conjugate, otherwise EOMI, no nystagmus. [V] Corneals present
bilaterally, but pin/pain sensation diminished on the right
face. [VII] Right forced eyelid closure weakness, right lower
face
paralysis with volitional smile. [VIII] Hearing intact to finger
rub bilaterally. [IX, X] Palate elevation symmetric. [XI]
SCM/Trapezius strength ___ bilaterally. [XII] Tongue midline.
- Motor - Normal bulk, flaccid left arm. Right arm and right leg
drop to the bed immediately when testing drift. No tremor or
asterixis on the left.
=[Delt] [Bic] [Tri] [ECR] [IO] [IP] [Quad] [Ham] [TA] [Gas]
[___]
[C5] [C5] [C7] [C6] [T1] [L2] [L3] [L5] [L4] [S1] [L5]
L 5 5 5 5- 5 5 5 5 5- 5 5
R 0 0 0 0 0 2 2 1 1 1 2
- Sensory - Diminished sensation to pin/pain on the right face
and arm, withdraws to noxious stimuli in the right leg. Left
face/arm/leg sensation intact. Unable to test proprioceptive due
to inattention versus verbal comprehension deficit.
- Reflexes
=[Bic] [Tri] [___] [Quad] [Gastroc]
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response extensor on right, mute on left.
- Coordination - Unable to assess at the time of examination due
to inattention versus verbal comprehension deficit.
- Gait - Unable to assess at the time of examination.
========================
DISCHARGE PHYSICAL EXAM:
========================
More awake, answering questions in ___ word sentences. Still
demonstrates left gaze preference but able to cross midline and
looks rightward. Spontaneous movement of the left extremities at
least antigravity, with some spontaneous movements of her Right
Lower Extremity (able to wiggle toes, internally rotate her
foot; RUE remained plegic. Lungs now clear in all fields.
Pertinent Results:
ADMISSION LABS:
-WBC-10.2 RBC-4.25 Hgb-13.3 Hct-40.1 MCV-94 MCH-31.4 MCHC-33.3
RDW-13.2 Plt ___
-Neuts-82.9* Lymphs-11.1* Monos-5.3 Eos-0.3 Baso-0.4
-___ PTT-34.0 ___
-Glucose-115* Na-142 K-4.2 Cl-96 calHCO3-30 UreaN-21*
-ALT-18 AST-22 AlkPhos-58 TotBili-0.4
-cTropnT-<0.01
-UA: Color-Yellow Appear-Clear Sp ___ Blood-NEG
Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG
Urobiln-NEG pH-8.0 Leuks-NEG RBC-1 WBC-1 Bacteri-FEW Yeast-NONE
Epi-<1 TransE-<1 Mucous-RARE
STROKE LABS:
-%HbA1c-6.8* eAG-148*
-Triglyc-114 HDL-56 CHOL/HD-2.7 LDLcalc-72
-TSH-3.8
NCHCT (___): Limited evaluation due to patient's positioning.
Large intraparenchymal hemorrhage centered in the left
frontoparietal region with associated vasogenic edema, and
adjacent subarachnoid and subdural hemorrhage. There is mild
associated mass effect with 3 mm rightward shift of normally
midline structures. ___ consider MRI for further charaterizaion
to exclude underlying mass, if clinically indicated.
CT C-SPINE (___):
1. No evidence of acute fracture or malalignment. Multilevel
degenerative disc disease.
2. Heterogeneous, enlarged thyroid gland likely reflective of
multinodular goiter. Clinical correlation recommended.
MRI W/WO GAD ___, prelim): Large left parietal
intraparenchymal hematoma with subarachnoid and subdural blood
products without evidence of definite underlying mass. At least
2 foci of chronic intraparenchymal hemorrhagic products and old
subarachnoid blood products. The presence of these findings
suggest amyloid angiopathy, however other etiologies such as
hypertensive hemorrhage is also possible. However, a follow-up
after resolution of the blood products is advised to exclude an
underlying lesion.
CXR (___): Heart size is top-normal. The thoracic aorta is
mildly tortuous with atherosclerotic mural calcifications. Lungs
are clear. There is no pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
Brief Hospital Course:
Ms. ___ is an ___ yo RH F with h/o AFib (on Coumadin, INR
1.7), dementia, prior ICH (no residual deficits), HTN, HLD and
left BrCa who presented with right sided weakness and speech
difficulty starting at 1730 on ___, found to have a large
left front-parietal intraparenchymal/lobar hemorrhage.
# NEURO: NCHCT on arrival to the ED showed a large left-sided
intraparenchymal/lobar hemorrhage. INR was 1.7 on admission, so
anticoagulation was aggressively reversed with Profilnine, 10
units vitamin K and 2 units FFP while in the ED. She was
admitted to the Neuro ICU for further monitoring. Follow-up MRI
showed a large left parietal IPH with subarachnoid and subdural
blood products, as well as at least 2 foci of chronic IPH and
old SAH, supporting amyloid angiopathy as likely etiology of the
bleed. Overnight in the ICU her neurologic exam remained stable.
On HD #2 she was transferred to the floor where repeat head CT
showed a stable IPH and stable ventricular size. Her neurologic
exam was initially notable for significant somnolence (able to
open eyes to vigorous stimulation and lift left hand but
otherwise unable to follow commands), but by discharge was more
awake, answering questions in ___ word sentences. Left gaze
preference was still noted but is able to cross midline to gaze
rightward. Spontaneous movement of the left extremities at least
antigravity. Some spontaneous movements of Right Lower Extremity
(wiggling toes), internal rotation; RUE plegic. Lungs clear.
# CARDIAC: In the ICU, home medications were held, but after
transfer to the floor, Mrs. ___ home cardiac medications
(Lasix, atenolol and lisinopril) were restarted via NGT. She did
have one episode of desaturations and respiratory distress and
responded well to Lasix IV boluses.
# RENAL: The patient initially had low UOP in ICU, likely
related to CHF and this improved with initiation of Lasix. Her K
was repleted as needed.
# ENDO: The patient was started on an insulin sliding scale but
had normal serum glucose. Her serum HgbA1C% was 6.8. Her statin
was held while here given the concern it could increase the risk
of intracranial hemorrhage but was restarted at discharge.
# PULM: The patient had no active respiratory issues in the ICU
but on the floor did have desaturations one evening that
responded to IV Lasix. In addition, there was concern for an
aspiration PNA based on CXR so the patient was started on a 10
day course of Unasyn (1st dose ___ which was then changed to
Augmentin and Azithromycin PO on ___ for 5 additional days.
# ID: The patient had a fever on ___, with negative urine and
blood cultures but CXR concerning for a retrocardiac opacity.
Given the concern for an aspiration PNA based on CXR between ___
and ___, the patient was started on the above 10d regimen.
# FEN/GI: The patient initially was given IVF and then an NGT
was placed. The patient passed the speech and swallow for pureed
foods and nectar thickened liquids.
# TRANSITIONS OF CARE:
- Will restart ASA 81mg daily on ___, which is 10 days
after bleed. Coumadin will not be continued due to unfavorable
risk/benefit ratio given that she has amyloid angiography and
hx of two ICH.
- Completing 10 day course of antibiotics for concern for
aspiration PNA. Changed from 5 days of Unasyn to
Augmentin/Azithromycin for 5 more days.
- Will follow up with Dr. ___
___ on Admission:
Warfarin 2.5 and 3 mg alternating daily doses
Furosemide 40mg daily
Digoxin 125mcg daily
Simvastatin 20mg daily
Atenolol 50mg daily
Lisinopril 20mg daily
Donepezil 10mg daily
Discharge Medications:
1. Digoxin 0.125 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Potassium Chloride (Powder) 40 mEq PO DAILY
Hold for K > 6
6. Nystatin 500,000 UNIT PO Q8H
7. Heparin 5000 UNIT SC TID
8. Insulin SC Sliding Scale Fingerstick QACHS, Insulin SC
Sliding Scale using REG Insulin
9. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
10. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 5 Days
11. Azithromycin 250 mg PO Q24H Duration: 5 Days
12. ASA 81mg to be restarted on ___
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary:
1) Intraparenchymal hemorrhage
2) Amyloid angiopathy
Secondary:
1) Hypertension
2) Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear ___,
___ were admitted because ___ had right sided weakness and
difficulty speaking and ___ were found to have a bleed in your
brain. We think the most likely reason ___ had the bleed was
because ___ have a condition called amyloid angiopathy that
makes your blood vessels very fragile. ___ cannot cure this
condition but ___ can try to prevent further bleeds by
controlling your blood pressure and staying off medications that
thin your blood, like Coumadin. As ___ have heart problems, we
would like ___ to restart Aspirin 81mg about 10 days after your
bleed.
We also noted that on ___, your chest x-ray demonstrated
pneumonia that may have been due to the aspiration of gastric
contents. We started ___ on IV antibiotics which were able to
be changed to oral antibiotics on your discharge.
Otherwise, please continue your medications as prescribed and
follow-up with your primary care doctor and neurologist.
Followup Instructions:
___
|
19994379-DS-14 | 19,994,379 | 27,052,619 | DS | 14 | 2131-05-21 00:00:00 | 2131-05-21 15:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / oxycodone
Attending: ___.
Chief Complaint:
Back pain
Major Surgical or Invasive Procedure:
___: Thoracentesis w chest tube insertion
___: Thoracentesis w chest tube insertion
History of Present Illness:
___ male history of afib, ___, previous lumbar and
cervical spine surgeries by Dr. ___ osteomyelitis
___, and HFrEF who presents now with one half weeks of
worsening back pain. He was seen prior to arrival at ___
___ emergency room where he was found to have had a
CT of
lumbar spine concerning for discitis at L1-L2 with epidural
abscess and probable to level as well as the pathologic
fractures involving the L1-L2 vertebral bodies. Patient
transferred to ___ for further
management. Workup prior to arrival notable for white blood cell
count 7.96, hemoglobin 11.6, hematocrit 34.6, MCV 107, platelet
count 178,
neutrophils 81%, ESR 17, normal range ___, GFR 38, BUN 49,
glucose 110, creatinine 1.76, calcium 8.9, sodium 142, potassium
4.1, chloride 105, bicarb 25, bilirubin 0.6, alk phos 168, AST
11, ALT 15, CRP 36.6. He was transferred from OSH after CT
L-spine showed L1-2 discitis, osteomyelitis and pathologic
fracture.
He presents today with low back and hip pain for the past
several months which has worsened over the past 4 days. He
reports intermittent weakness of the left lower extremity when
changing from seated to standing which resolves with ambulation.
Denies paresthesias or other weakness, intermittent bowel
incontinence at baseline and no other bowel/bladder symptoms.
Denies fevers/chills. He has recent falls due to losing his
balance while walking and carrying large items but is unable to
elaborate on this. Patient states he has a long history of
chronic hip/back pain. His typical pain is bilateral hip, front
think and buttock "shock like pain" without radiation that is
daily, intensifies with movement (worst in AM when getting out
of bed and out of a
chair) and when laying flat. He typically takes ___ advil in the
morning before he gets out of bed but this doesn't help very
much. He reports he has never tried typical neuropathic pain
agents. He describes worsening of the pain for the last ___
months without a clear provoking etiology. For the last ___
days,
he has noted working shock like pain especially in hips and a
mild ache in his mid back. He does report he fell up the stairs
3 weeks ago while carrying packages (the weight carried him
forward) and he landed on his chest but did not note worsening
in his chronic pain at that time. He specifically denies chest
pain, dyspnea, jaw/arm pain, diaphoresis, nausea recently or
today. He
denies recent fevers, chills, night sweats, weight loss. He
reports he has had two episodes of spinal infection and was
unsure of his symptoms at that point. Patient denied any saddle
anesthesia, urinary retention, bowel or bladder incontinence, or
fevers. Patient did describe intermittent weakness of left lower
extremity and numbness of the whole leg that occurs with
position but none now.
Past Medical History:
Afib on warfarin
CAD s/p stent placement
CHF with EF ___
mitral valve prolapse
HTN
HLD
depression
chronic neck pain secondary to cervical disc disease
multiple spine surgeries including fusion of L-S1 laminectomy
cholecystectomy
Total knee replacement
B/l shoulder surgery
Social History:
___
Family History:
Mother: alive, age ___. Macular degeneration
Father: deceased in ___. ?brain tumor and heart issues
Physical Exam:
ADMISSON PHYSICAL EXAM
=====================
VITALS: 98.1 110 / 61 87 20 97 2LNc
GENERAL: Alert and interactive. In no acute distress.
HEENT: Normocephalic, atraumatic. Pupils equal, round
bilaterally, extraocular muscles intact. Sclera anicteric and
without injection. Moist mucous membranes, good dentition.
Oropharynx is clear.
NECK: No JVD.
CARDIAC: Irreg irreg rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process 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. ___ strength throughout, patient
grimacing when checking hip flexion. Normal sensation. AOx3.
DISCHARGE PHYSICAL EXAM:
=========================
VITALS: 97.7 PO 99/61 L Lying 80 18 92 2L
GENERAL: Laying in bed, NAD
HEENT: EOMI grossly, anicteric sclera, MMM
HEART: Irregular rhythm, normal S1/S2, no murmurs, gallops, or
rubs.
LUNGS: Diffusely decreased breath sounds
ABDOMEN: Normoactive bowel sounds. Soft, distended, tympanic,
nontender in all quadrants, no rebound/guarding.
EXTREMITIES: no cyanosis, clubbing, or edema, moving all 4
extremities with purpose, warm w good cap refill
NEURO: A/O X3 (person, place, time)
Pertinent Results:
___
=====================
___ 11:30PM BLOOD WBC-7.3 RBC-3.18* Hgb-11.5* Hct-34.1*
MCV-107*# MCH-36.2*# MCHC-33.7 RDW-16.2* RDWSD-62.9* Plt ___
___ 11:30PM BLOOD Neuts-77.1* Lymphs-10.3* Monos-10.0
Eos-1.4 Baso-0.8 Im ___ AbsNeut-5.63 AbsLymp-0.75*
AbsMono-0.73 AbsEos-0.10 AbsBaso-0.06
___ 11:30PM BLOOD ___ PTT-28.8 ___
___ 11:30PM BLOOD Glucose-102* UreaN-44* Creat-1.5* Na-144
K-3.5 Cl-103 HCO3-24 AnGap-17
___ 01:35PM BLOOD Calcium-8.5 Phos-4.2 Mg-1.2*
___ 01:35PM BLOOD VitB12-321
___ 07:12AM BLOOD TSH-1.6
___ 11:30PM BLOOD CRP-50.0*
___ 05:30PM BLOOD Cortsol-19.6
___ 07:56PM BLOOD CK-MB-3 cTropnT-0.46* ___
___ 06:27AM BLOOD ALT-30 AST-27 AlkPhos-191* TotBili-0.5
___ 03:00PM BLOOD calTIBC-251* Ferritn-829* TRF-193*
___ 01:35PM BLOOD SED RATE- 46
MICROBIOLOGY
=====================
___ 2:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 2:33 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ STOOL C. difficile DNA amplification assay- POSITIVE
___ 2:35 pm PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ MRSA SCREEN- NEGATIVE
___ Blood Culture x2: NO GROWTH
___ 10:35 am PLEURAL FLUID PLEURAL FLUID.
**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.
___ Blood Culture x2: NO GROWTH, Routine-FINAL INPATIENT
___ URINE CULTURE- NO GROWTH
___ Blood Culture x2 NO GROWTH
PLEURAL FLUID ANALYSIS:
=======================
___ 10:35AM PLEURAL TotProt-2.4 Glucose-90 Creat-3.5
LD(___)-104 Albumin-1.2 ___ Misc-BODY FLUID
___ 10:35AM PLEURAL TNC-62* RBC-___* Polys-4* Lymphs-75*
Monos-8* Atyps-8* Macro-5* Other-0
___ 02:35PM PLEURAL TotProt-1.7 Glucose-89 Creat-1.6
LD(___)-103 Albumin-1.1 Cholest-20
___ 02:35PM PLEURAL TNC-49* ___ Polys-23* Lymphs-74*
Monos-2* Macro-1*
___ CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS.
___ CTYOLOGY: NEGATIVE FOR MALIGNANT CELLS.
DISCHARGE LABS:
================
___ 04:35AM BLOOD WBC-7.1 RBC-2.53* Hgb-8.8* Hct-27.3*
MCV-108* MCH-34.8* MCHC-32.2 RDW-16.7* RDWSD-66.0* Plt ___
___ 04:35AM BLOOD Glucose-88 UreaN-20 Creat-1.2 Na-140
K-4.1 Cl-100 HCO3-26 AnGap-14
___ 04:35AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.1
IMAGING
======================
MRI spine ___ IMPRESSION:
1. Study is degraded by motion and by lumbar spinal fusion
hardware artifact.
2. Cervical degenerative disc disease as detailed above, without
high-grade
spinal canal narrowing or cord signal abnormality. There is
severe neural
foraminal narrowing at multiple levels.
3. Mild thoracic degenerative disc disease, without high-grade
spinal canal or neural foraminal narrowing.
4. Loculated right pleural effusion basilar right lower lobe
could reflect
atelectasis, however pneumonia cannot be excluded. Chest CT is
suggested.
5. Instrumented lumbar fusion at L4-S1, interbody fusion graft
at L3-4 with
partial osseous fusion, and solid osseous fusion of the L2-3
level as detailed above.
6. L1-2 disc extrusion with superior migration results in severe
spinal canal narrowing. There is probable impingement of the
traversing L2 and possibly other nerve roots. Allowing for
difference technique, finding may be slightly progressed
compared to ___ prior exam.
7. Within limits of study, no definite evidence of
discitis-osteomyelitis, or epidural abscess.
8. Probable subacute to chronic oblique fracture of the superior
endplate of L2 with lateral extension through the lateral
vertebral body.
9. Right L1-2 and bilateral L2-3 Severe neural foraminal
narrowing.
CXR ___ IMPRESSION:
There is a mild to moderate layering right pleural effusion.
There is dilation of colon at the splenic fracture.
CT A/P ___ IMPRESSION:
1. Volume loss in the right lower lobe may represent atelectasis
or infection.
Please correlate with clinical status.
2. No retroperitoneal hematoma or free intra-abdominal fluid.
3. Intermediate density fluid in the bladder may represent
delayed excretion
of iodinated contrast from prior CT study or hemorrhage
products. Please
correlate with visual inspection of the urine or urinalysis.
4. Moderate right pleural effusion.
TTE ___ IMPRESSION:
Normal left ventricular cavity size with regional systolic
dysfunction most c/w CAD (mid-LAD distribution vs. Takotsubo
CM). Moderate mitral regurgitation. Mild pulmonary artery
systolic hypertension. Mild-mderate tricuspid regurgitation.
Abdominal x-ray ___ IMPRESSION:
Gaseous distension of the colon, appearing unchanged compared to
the recent CT scan
DX PELVIS & FEMUR ___: No fracture of the bilateral femurs.
CT CHEST ___:
1. Mild to moderate right pleural collection containing
loculated fluid and air with a chest tube in situ.
Mild-to-moderate free-flowing left pleural effusion.
2. Bilateral patchy peripheral ground-glass opacities are
concerning for an atypical infection. Presence of interlobular
septal thickening may be
secondary to pulmonary edema. Clinical correlation is
recommended.
3. Mild mediastinal and hilar lymphadenopathy is nonspecific and
could be
related to infections.
PORTABLE ABDOMEN ___
Interval improvement of dilation of large bowel, however large
bowel dilation has not resolved.
There is no evidence of intraperitoneal free air.
Brief Hospital Course:
PATIENT SUMMARY:
================
Mr. ___ is a ___ year old man with w/ HFrEF, CAD s/p stent,
atrial fibrillation on Xarelto, ___ syndrome, CKD, chronic
neck pain ___ cervical disc disease and multiple spine surgeries
including fusion of L-S1 laminectomy who presented to OSH with
___ weeks of worsening back pain and left hip pain, transferred
for spine eval, with MRI negative for infection, admitted for
pain management. Hospital course was complicated by oliguric
renal failure in setting of contrast load on ___ and NSAID
use, and hypotension in setting of receiving entresto and
diuresis, requiring transfer to the MICU for worsening hypoxia
and persistent hypotension. He was found to have R side pleural
effusion with improvement after chest tube placement x2 ___,
removed, replaced ___. Further hospital course complicated by
C difficile.
ACUTE ISSUES:
=============
#Hypoxemia
#Right pleural effusion
#Concern for RLL PNA
#Trapped lung
On arrive to ED at ___, pt noted to be developing progressive
hypoxemia requiring nasal cannula in setting of developing
oliguric renal failure. Suspected multifactorial due to PNA,
pleural effusion, & pulmonary edema from volume overload.
Effusion likely chronic per review of imaging, and potentially
has formed fibrosis causing trapped lung. s/p R side chest tube
___, which was removed same day after minimal draining,
replaced ___ for reaccumulation and quickly removed again. CT
chest ___ also indicated possible atypical PNA, completed 7 day
course of cefepime for HAP (___), transitioned briefly to
ceftriaxone/azithro (___). He was also found to have e/o
volume overload in setting of diuretic held and receiving IVF
for hypotension. Hypoxia improved somewhat with gentle diuresis,
and home Lasix was restarted three days prior to discharge with
stable volume status and oxygen requirement. At time of
discharge, he is still requiring oxygen although has decreased
from 4L to 1.5-2L. Likely will remain dependent on oxygen until
decortication after rehab. Eventual plan is to likely
decortication per IP, who will follow outpt with patient in 4
weeks, when he will also receive a chest CT.
#Hypotension
#History of Hypertension
Initially suspected PNA & Entresto use I/s/o sepsis. Entresto
and diuretics were held. Per nephrology, sacubitril's inhibition
of neprilysin leads to increase in several vasoactive substances
including BNP and bradykinin which are vasodilators, and likely
culprits for what appears to be his prior distributive
hypotension. Metoprolol succinate home dose is 225 mg; he was
switched to metoprolol succinate 50mg daily with good blood
pressure and HR control. BP remained stable 99-103/62-70 since
___. Discussed ___ meds with outpatient cardiologist
Dr. ___ requested that patient remain on BB and at least
a low-dose ACEi if tolerated. Started lisinopril 2.5mg daily on
___, patient tolerating well on discharge. Holding home
entresto on discharge.
#C difficile infection
Pt w frequent loose stools that developed during
hospitalization, found to be cdiff+ on ___ and started on PO
vanc ___. Switched to PO flagyl (___) as infection not
considered to be complicated, for 10d course ending ___.
___
#?CKD
Likely multifactorial from CIN (given contrast on ___ at OSH),
NSAID-use, valsartan in Entrosto +/- ATN. Cr 1.5 on admission
___ and peaked to 3.4. Creatinine stable around 1.2-1.4 for
the week prior to discharge, baseline unknown but likely has
some underlying mild CKD.
#Acute on chronic back pain
#Hip/leg pain
Patient with hx of multiple prior spinal surgeries with hardware
in place and spinal osteomyelitis/discitis/epidural abscess in
___. He presented with 4 days of worsening back pain. CRP 50,
concerning for infectious process, however MRI showed no e/o
infection. Spine surgery consulted and no acute intervention
needed. XR b/l femur showed generalized degenerative changes
throughout b/l SI joints, hip joints, and pubic symphysis. No
fracture. Etiology of pain unclear but likely multifactorial
from DJD and frequent surgeries. Managed with lidocaine patches,
acetaminophen standing, and tramadol PRN.
CHRONIC ISSUES:
===============
#HFrEF, CAD
#Troponinemia
Pt with hx of CAD and HFrEF 35%, likely iCMP. Troponins mildly
elevated in setting ___ to 0.46 without CK-MB elevation or
ischemic changes on EKG. Continued home ASA 81mg and
atorvastatin 10mg PO QD. For preload, held home metolazone given
hypotension, diuresis as above. Home metop dosing was changed as
above. Held home entresto given ___ and hypotension as above,
started 2.5mg lisinopril for afterload mgmt per outpatient
cardiologist. Will have outpatient followup.
#Afib (CHADS2VASC = 3)
Anticoagulation was briefly held for chest tube placement, after
which home Xarelto was held. Home metoprolol changed as above,
discharged on 50 mg succinate daily with good rate control.
___ syndrome
Pt dx during an admission in ___. Was monitored during
hospitalization, especially in setting of receiving narcotics,
with some abdominal distension noted. KUB obtained ___ showed
interval improvement in colonic distention from prior imaging.
#Gout: Continued home allopurinol ___ mg QD
#Depression: Continued home sertraline 50 mg PO QD
#GERD: Continued home omeprazole 20 mg PO QD
#Acute on chronic macrocytic anemia MCV elevated from last
admission: Continued Ferrous Sulfate 65 mg PO DAILY
TRANSITIONAL ISSUES:
======================
NEW MEDICATIONS
-Acetaminophen 1g TID (for pain)
-Calcium carbonate 500mg QID PRN (heartburn)
-Ipratropium-Albuterol Neb Q4H PRN (SOB, wheezing)
-Lidocaine 5% patch QPM (for pain)
-Lisinopril 2.5mg PO daily (for CHF, HTN)
-Flagyl 500mg PO Q8H (cdiff, abx course ___
-Ondansetron ODT 8mg PO Q8H PRN (nausea, vomiting)
-Tramadol 50mg PO Q4H PRN (moderate pain)
-Tramadol 50mg PO BID PRN (severe pain)
-Oxygen support (usually on ___ NC)
CHANGED MEDICATIONS
-Metoprolol succinate XL 50mg PO daily (changed from 125 QAM and
100 QPM given hypotension)
STOPPED/HELD MEDICATIONS
-Metolazone 2.5mg PO every other day (held for hypotension, ___
-Sacubitril-Valsartan 24mg-26mg BID (held for hypotension, ___
OTHER:
[ ]Will follow-up with interventional pulm and Thoracics in 4
weeks for chest CT and to discuss need for decortication of
fibrotic trapped lung
[ ]S/P R side chest tube ___
[ ]Please discuss mgmt. of patient's HTN and CHF, his BPs
remained soft (100s/50s) throughout hospitalization despite
___ agents had been held for a week.
[ ___ appt w PCP/cardiology Dr. ___ on ___
[ ___ appt with IP to be scheduled, likely ___ as pt has chest
CT scheduled that day
[ ]Pt being discharged to rehab on oxygen ___ NC). If unable
to wean at rehab, will need home O2 as well.
[ ___ need further titration of pain medication with increased
activity at rehab.
#code status: full
#contact: ___ ___ (daughter)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Sertraline 50 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Metolazone 2.5 mg PO EVERY OTHER DAY
7. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
8. Metoprolol Succinate XL 125 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO QHS
10. Ferrous Sulfate 65 mg PO DAILY
11. magnesium chloride 1250 oral DAILY
12. Rivaroxaban 20 mg PO DAILY
13. Furosemide 80 mg PO QAM
14. Furosemide 40 mg PO QPM
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing
4. Lidocaine 5% Patch 1 PTCH TD QPM
5. Lisinopril 2.5 mg PO DAILY
6. MetroNIDAZOLE 500 mg PO Q8H
___ - ___
7. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting
8. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
hold for somnolence or RR<12
RX *tramadol 50 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*18 Tablet Refills:*0
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Allopurinol ___ mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. Atorvastatin 10 mg PO QPM
13. Ferrous Sulfate 65 mg PO DAILY
14. Furosemide 80 mg PO QAM
15. Furosemide 40 mg PO QPM
16. magnesium chloride 1250 oral DAILY
17. Omeprazole 20 mg PO DAILY
18. Rivaroxaban 20 mg PO DAILY
19. Sertraline 50 mg PO DAILY
20. HELD- Metolazone 2.5 mg PO EVERY OTHER DAY This medication
was held. Do not restart Metolazone until until you talk to your
cardiologist
21. HELD- Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID This
medication was held. Do not restart Sacubitril-Valsartan
(24mg-26mg) until you talk to you cardiologist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary
-Acute hypoxemic respiratory failure
-Chronic pleural effusions
-Trapped lung, R side
-Hypotension
-Acute kidney injury
-Cdiff infection
-Acute on chronic back, hip pain
SECONDARY
-Heart failure with reduced ejection fraction
-Coronary artery disease
-Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you were having terrible back
pain and the doctors at the ___ hospital were concerned you
might have an infection in your back.
While you were here, we did not see any evidence of infection in
your back, but we did notice you had fluid behind your lungs
(pleural effusions). We drained these, treated you for
pneumonia, and gave you oxygen to support your breathing.
We also noticed that your blood pressure was very low. We
stopped your blood pressure medications for a little while, and
restarted some of them at lower doses. Your cardiologist should
talk to you about these at your follow-up appointment next week.
When you leave, you will go to rehab to work on your strength
and mobility. You will continue to use your oxygen until you
feel more comfortable off of it.
It was a pleasure to care for you. We wish you the best in your
recovery.
___ Medicine Care Team
Followup Instructions:
___
|
19994379-DS-15 | 19,994,379 | 27,334,101 | DS | 15 | 2131-06-21 00:00:00 | 2131-06-21 14:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / oxycodone
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ YO M with afib on rovarozaban, CAD s/p stent placement, HFrEF
(EF ___, mitral valve prolapse, HTN, HLD, depression,
multiple spine surgeries, cholecystectomy who presents from
rehab
with dyspnea, felt to be in acute heart failure exacerbation ___
holding of diuretic regimen at rehab in setting of hypotension.
He brought in from rehab with concern of shortness of breath and
increased pleural effusion on CXR at rehab.
Per ED notes:
He's had recent hospitalization for hypoxemia, pneumonia and
right sided pleural effusion. He had a chest tube placed x2 by
IP
with fluid consistent with HF and concern for trapped lung as
well. Patient treated with abx for presumed pneumonia and
discharged to rehab on 1.5-2L NC. While in rehab weaned off O2
by
___ but started to have new O2 requrimenet yesterday that
increased to 2L NC again today. SOB worse with movement. No
chest
pain, fever/chills/ night sweates or new cough. Notes increase
in
abdominal distension though diarrhea has improved now while he
remains on antibiotics for c.diff. Notes weight gain of ~15 lbs
with dry weight of 205 and 220 this am at rehab
In the ED initial vitals were:
97.9 86 107/57 22 99% 2L NC
ED exam notable for:
Gen:NAD, breathing comfortably on 2L O2, AOx3
CV: irregularly irregular, no murmurs, JVD to jawline
Pulm: Decreased right sided lower breath sounds, no crakcles
Abd: soft, significantly distended, no peritoneal signs,
non-tender,
___: 3+ edema bilaterally up to the low thigh
Labs/studies notable for:
6.7 > 8.___.7 < ___
------------<116 AGap=14
5.4 23 1.1
Trop-T: <0.01
proBNP: ___
Lactate:2.6
CXR notable for:
FINDINGS:
AP portable upright view of the chest. No significant change
from recent prior exam with loculated right pleural effusion
tracking circumferentially with a similar overall pattern.
Opacities within the right lung again noted.
Left lung is grossly clear. The heart appears mildly enlarged.
Mediastinal contour stable. Imaged bony structures are intact.
Multiple surgical anchors are noted at bilateral humeral heads.
IMPRESSION:
No significant interval change.
Patient was given:
___ 16:28 IV Furosemide 80 mg
Patient was seen by cardiology:
Per Cards ED evaluation:
"Patient presenting with likely primarily CHF exacerbation.
Patient unclear if he has been taking diuretics appropriately,
which could be precipitant. Given this is the primary reason for
admission, his reduced EF, and some concern that diuresis was
being held at rehab due to hypotension."
Recommended admission to Cardiology.
Per ED assessment:
"Likely HFrEF exacerbation with weight gain and increase in
shortness of breath and ___ edema. AM Lasix held for a few days
while in rehab given soft BP that may have caused volume
overload. Will touch base wit IP re worsening shortness of
breath
and history of concern for trapped lung and placement of chest
tube. CXR without evidence of new consolidation or significantly
worsening pulm edema though has right sided pleural effusion
tracking circumferentially. Clinically without fever, new cough,
or sputum production concerning for pneumonia. No evidence of
pericardial effusion on bedside echo. No ascites on bedside echo
either. Abdominal distenstion without n/v and with regular bowel
movement unlikely caused by obstruction though has history of
___ syndrome."
Of note, patient is s/p discharge on ___ after presenting to
OSH with ___ weeks of worsening back pain and left hip pain,
transferred
for spine eval, with MRI negative for infection, admitted for
pain management. Hospital course was complicated by oliguric
renal failure in setting of contrast load on ___ and NSAID
use, and hypotension in setting of receiving entresto and
diuresis, requiring transfer to the MICU for worsening hypoxia
and persistent hypotension. He was found to have R side pleural
effusion with improvement after chest tube placement x2 ___,
removed, replaced ___. Further hospital course complicated by
C difficile.
Vitals on transfer:
97.6 109 100/76 22 94% 3L NC
On the floor...
He reports he was at rehab and things were going fairly well. He
reported they took him off O2 on ___ through the weekend until
___ (back on O2). He reports that he didn't have much
activity
over the weekend, but this Am he reported that he felt more SOB
and was sent back.
He reports he feels "bloated" but denies weight gain; he reports
his weight at rehab was 223-224; he doesn't remember what his
weight was when he got to rehab (?220). He reports his dry
weight
is about 205 lbs.
He reports his SOB has been going on "for a long time"; he first
noticed it a few months. He reports some improvement after his
chest tubes; he reported once he was active at rehab his
respiratory symptoms had improved. Denies CP, but does report
occasional "palpitations" but he denies attributing this to his
afib (and reports it has seemed to have gotten better.)
Rpeorts some lightheadedness this AM. Denies LOC. Reports
significant leg swelling.
Denies recent infections, cough or cold symptoms.
Denies abd pain, n/v but reports some nausea with c diff
medication but none in the past two days. Reports + diarrhea at
admission today x2. He reports this seems like his C. diff
symptoms. Denies dysuria. Denies blood in stool or urine.
Past Medical History:
PAST MEDICAL HISTORY:
=======================
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD s/p stent placement
- CHF with EF ___
- Afib on warfarin
- mitral valve prolapse
3. OTHER PAST MEDICAL HISTORY
depression
chronic neck pain secondary to cervical disc disease
multiple spine surgeries including fusion of L-S1 laminectomy
cholecystectomy
Total knee replacement
B/l shoulder surgery
c diff infection ___
Social History:
___
Family History:
Mother: alive, age ___. Macular degeneration
Father: deceased in mid ___. ?brain tumor and heart issues
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
=================================
VS: Temp: 98.4 (Tm 98.4), BP: 103/74 (90-134/49-87), HR: 111
(111-148), RR: 26 (___), O2 sat: 93% (86-97), O2 delivery:
2LNC
(2LNC-3L), Wt: 218 lb/98.88 kg
GENERAL: Well developed, well nourished M, sitting at bedside in
NAD. Oriented x3. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. EOMI grossly.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP to angle of mandible at 90 degrees
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. irregularly irregular rate, Tachycardic.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. diminished lung sounds R
lung extending up to mid lung fields. no crackles appreciated
bilaterally; no wheezes.
ABDOMEN: Soft, non-tender, mildly distended
EXTREMITIES: extremities slightly cool perfused. 3+ pitting
edema
to knees bilaterally
DISCHARGE PHYSICAL EXAMINATION:
=================================
PHYSICAL EXAM:
VS: 98.3 90/52 89 18 94% Ra
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric
NECK: supple, JVP to 10 cm
LUNGS: Decreased BS in RLL, no wheezing
CV: Irrregular, tachycardic, ___ pansystolic murmur at apex and
LLSB
ABD: mild distention, non-tender, and soft, normoactive BS
EXT: Warm, non-edematous bilaterally, non-tender
NEURO: No gross motor or coordination abnormalities
Pertinent Results:
ADMISSION LABS
========================
___ 12:50PM BLOOD WBC-6.7 RBC-2.63* Hgb-8.9* Hct-27.7*
MCV-105* MCH-33.8* MCHC-32.1 RDW-16.2* RDWSD-62.4* Plt ___
___ 12:50PM BLOOD Neuts-76.2* Lymphs-7.2* Monos-13.8*
Eos-1.4 Baso-0.9 Im ___ AbsNeut-5.08 AbsLymp-0.48*
AbsMono-0.92* AbsEos-0.09 AbsBaso-0.06
___ 12:50PM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-135
K-5.4* Cl-98 HCO3-23 AnGap-14
___ 12:50PM BLOOD CK(CPK)-42*
___ 06:20AM BLOOD ALT-<5 AST-9 LD(LDH)-180 AlkPhos-94
TotBili-0.7
___ 12:50PM BLOOD CK-MB-2 proBNP-6666*
___ 12:50PM BLOOD cTropnT-<0.01
___ 09:35PM BLOOD Calcium-8.9 Phos-2.6* Mg-1.2*
___ 01:11PM BLOOD Lactate-2.6* K-5.1
___ 01:34PM BLOOD Lactate-1.8
PERTIENT LABS
========================
___ 06:20AM BLOOD calTIBC-212* VitB12-498 Folate-3
Ferritn-500* TRF-163*
___ 06:50AM BLOOD Vanco-66.0*
DISCHARGE LABS
========================
___ 08:10AM BLOOD WBC-7.2 RBC-2.55* Hgb-8.2* Hct-26.0*
MCV-102* MCH-32.2* MCHC-31.5* RDW-17.0* RDWSD-63.9* Plt ___
___ 08:10AM BLOOD Plt ___
___ 08:10AM BLOOD ___ PTT-35.1 ___
___ 08:10AM BLOOD Glucose-93 UreaN-31* Creat-1.7* Na-136
K-3.9 Cl-93* HCO3-30 AnGap-13
___ 02:11AM BLOOD ALT-<5 AST-11 LD(LDH)-217 AlkPhos-79
TotBili-1.0 DirBili-0.4* IndBili-0.6
___ 08:10AM BLOOD Calcium-8.9 Phos-4.1 Mg-1.7
IMAGING
========================
CXR ___
AP portable upright view of the chest. No significant change
from recent
prior exam with loculated right pleural effusion tracking
circumferentially with a similar overall pattern. Opacities
within the right lung again noted. Left lung is grossly clear.
The heart appears mildly enlarged. Mediastinal contour stable.
Imaged bony structures are intact. Multiple surgical anchors
are noted at bilateral humeral heads.
CT CHEST ___
Persistent large and probably loculated right hydropneumothorax,
probably
reflecting chronic restrictive right pleural thickening, in
combination with severe lower lobe atelectasis. No contributory
bronchial obstruction. Severe coronary atherosclerosis. Mild
cardiomegaly. Substantially improved bilateral airspace
pulmonary abnormality, nature
indeterminate, could be post infectious or slow to resolve
hemorrhage.
KUB ___
Colonic obstruction, worse than on prior examination. There is
an abrupt
cutoff of the colonic dilatation in the proximal descending
colon, as on prior
CT. The possibility of a stricture at this level is suggested.
No free air
on supine.
CT A/P ___. Colonic distension is minimally increased since the prior
study measures
approximately 8.1 cm, previously measured 7 cm with smooth
tapering in the
proximal descending colon is suggestive ___ syndrome. No
gross
stricture identified.
2. Small bowel is normal caliber. No evidence of bowel
obstruction.
3. Air-fluid levels within the colon suggests a diarrheal state.
4. Partially visualized known right hydropneumothorax.
5. Ground-glass opacifications in the visualized central left
lower and
anterior left upper lobe are nonspecific and may reflect an
infectious or
inflammatory process.
CT CHEST ___. Extensive progression of more confluent areas of ground-glass
opacification
in a peribronchovascular distribution involving the entire left
lung since the
prior study of ___, raises concern for infection.
Asymmetric
pulmonary edema could also be considered..
2. Overall stable appearance moderate right hydropneumothorax
and associated
collapse of the left lower lobe.
3. Slightly increased size of small left pleural effusion.
CXR ___
FINDINGS:
The heart size is enlarged, stable in appearance as compared to
___. Re-demonstrated are bilateral parenchymal opacities,
unchanged with
associated air bronchograms, more prominent on the right. There
is a
loculated right pleural effusion, no left pleural effusion.
There is near
complete atelectasis with the right lower lobe. There is
unchanged over
distention of the stomach. There is no pneumothorax.
IMPRESSION:
In comparison to the prior radiograph dated ___,
there is stable
appearance of near complete right lower lobe atelectasis with a
now larger
loculated right pleural effusion. Persistent bibasilar
opacities.
MICROBIOLOGY
========================
Blood Cx ___: No growth
Blood Cx ___: No growth
Blood Cx ___: No growth
Urine Cx ___: No growth
MRSA Screen ___: Negative
C. Difficile ___: Negative
Brief Hospital Course:
BRIEF HOSPITAL COURSE
===================================
___ yo M with atrial fibrillation on rivaroxaban, CAD s/p stent
placement, HFrEF
(EF ___, mitral valve prolapse, HTN, HLD, depression,
multiple spine surgeries, cholecystectomy who presents from
rehab with dyspnea and weight gain consistent with acute heart
failure exacerbation likely secondary to missed diuretic doses
at rehab (held for SBP < 100), treated with a Lasix drip to
euvolemia. Once euvolemic, he still required 2L O2 and thoracic
surgery was consulted for possible intervention for trapped
lung. While awaiting intervention, patient had a vagal episode
followed by hypotension and bradycardia requiring ICU admission.
There was suspicion of GI bleed and he was transfused 2u pRBCs.
He was briefly on pressors but was able to be quickly weaned. On
transfer back to the floor, he continued diuresis but repeat
chest CT showed increased ground glass opacities of the left
lung concerning for infection versus pulmonary edema, so he was
treated for HAP with vancomycin, ceftazidime and azithromycin.
With antibiotics and diuresis, his dyspnea, hypoxia improved.
___ Course:
Mr. ___ is a ___ man with A fib on rivaroxaban, CAD s/p
PCI/stent, chronic systolic congestive heart failure (LV EF
___, mitral valve prolapse, hypertension, hyperlipidemia,
and other issues admitted with acute pulmonary edema attributed
to acute on chronic systolic congestive failure, with his
hospital course complicated by GI bleeding and vasovagal event
resulting in bradycardia to ___ when using the commode on ___.
He recovered spontaneously without atropine. He subsequently
became progressively hypotensive to ___, lactate 6.9, hgb
drop 6.1 from 7.4. Dark brown, guaiac + stool. GI and ACS were
consulted who did not recommend immediate intervention. KUB w/o
free air. On arrival to the MICU, patient was awake and
mentating well. Complaining mostly of back pain. Cdiff was
ordered given for significant abdominal distention.
Norepinephrine max 0.15 mcg/kg/hr, nurse was able to quickly
wean to .04 prior to receiving blood. He was transfused with
2uPRBC and 1U FFP, chased with 100 mg Lasix. He was weaned off
Levophed prior to transfer.)
===============
ACTIVE ISSUES:
===============
#Heart failure with reduced ejection fraction, acute
decompensation:
Patient with history of heart failure with reduced ejection
fraction secondary to ischemic cardiomyopathy. Patient presented
with >20lbs weight gain from dry weight and increased SOB,
consistent with heart failure exacerbation likely secondary to
missed diuretic doses at rehab (held for SBP < 100). He was
treated with a lasix drip 20 mg/hr and lasix boluses of 160 mg
IV to euvolemia. He was unable to tolerate a Persantine MIBI due
to back pain, despite pre-medication. He was changed to
Torsemide 60mg daily and remained euvolemic, however this dose
was changed to 40mg daily given creatinine up to 1.7 (from
baseline 1.2). He was discharged on diuretic regimen torsemide
40 mg daily.
His metoprolol was uptitrated and he was discharged on
metoprolol succinate XL 50 mg BID. Lisinopril 2.5 mg daily was
HELD due to ___ on CKD (see below). Spironolactone could not be
added on to regimen due to low blood pressure and increase in
creatinine after two doses.
#Hypoxemia:
#Right pleural effusion/Trapped lung:
#Pneumonia:
Patient developed trapped lung as complication of anterior
approach to L2-L3 fusion. Patient was hypoxic during last
admission due in part to trapped lung and right sided pleural
effusion, and he had chest tube placed x 2. Thoracic surgery was
consulted, and deferred intervention urgently given poor
clinical status. ___ benefit from VATS vs possible open
thoracotomy decortication of entrapped right lung. Toward end of
hospital course, patient developed more SOB and hypoxia
requiring up to 4L NC. Repeat CT chest suggested increased
ground glass opacities of left lung concerning for infection vs
pulmonary edema, stable hydropneumothorax. Completed a course of
vancomycin/ceftazidime/azithromycin (___). MRSA
screen was negative. After management with antibiotics and
diuresis, patient's oxygen requirement decreased to 96% RA.
However, patient did occasionally require ___ with exertion
(desat to 87%). Thoracic surgery and IP will follow up as
outpatient.
#Atrial fibrillation:
Patient's rates were well controlled after up-titrating
metoprolol to succinate XL 50 mg BID (HR ___, peaked in 130s
with significant exertion). Patient was on metoprolol XL 225mg
daily prior to last admission, which was decreased to 50mg daily
at discharge ___. This had been further reduced to 12.5mg at
rehab prior to this admission. He was continued on Rivaroxaban
20 mg PO QHS and Metop XL 50mg BID.
#C diff infection:
Patient was diagnosed with C. difficile during last admission,
and planned to complete PO flagyl 10 day course on ___. Per
rehab records, it was unclear whether he completed this course.
Given he reported ongoing diarrhea on admission, he was treated
with a second 10 day course of PO vancomycin to ensure complete
treatment, with course from ___. C. diff negative on
___.
#Abdominal distention with Ogilvies:
Pt with known history of ___ syndrome. He was noted to
have prominent abdominal distention without pain, constipation,
or other concerning signs. Had CT abdomen consistent with
Ogilvies. A bowel regimen was continued. Abdominal distention
improved.
___ on CKD:
Baseline 1.2, initially uptrended in the setting of diuresis
despite appearing overloaded on exam, possibly related to ATN in
setting of transient hypotension from valsalva, bradycardic
episode. Cr improved later with continued diuresis but increased
again on ___ possibly in the setting of starting
spironolactone, which was discontinued. On ___, a vancomycin
level was checked which was elevated at 66. Creatinine started
to increase 48 hours after this, and additionally patient was
given Spirinolactone x 2 days. Likely both of these insults
explain the worsening ___. His lisinopril was stopped and
Torsemide was decreased to 40mg daily. On discharge, Cr 1.7
(baseline 1.2). Patient euvolemic and I/Os and weight stable,
however Torsemide was decreased due Cr 1.7. It is expected that
patient's creatinine will start to improve ___ weeks after
Vancomycin, Spirinolactone, Lisinopril were stopped, and
Torsemide decreased. A post void residual was 21. Patient should
avoid all NSAIDs going forward.
#Macrocytic Anemia:
Noted to have macrocytic anemia with hemoglobin ___ during
admission. Prior to transfer to ICU, he was noted to have guaiac
positive stool with hemoglobin drop and was transfused 2u pRBCs.
Iron studies showed an Fe/TIBC 22%, consistent with mild iron
deficiency. B12 and folate were normal. Methylmalonic acid was
WNL. His Ferrous Sulfate 325 mg PO DAILY was continued at
discharge. Please re-check iron studies to ensure no iron
toxicity on supplemental iron and discontinue supplemental iron
when iron replete. If within goals, pt may be further evaluated
for MDS.
# Shock, hypotension, lactic acidosis (resolved):
Patient developed hypotension and bradycardia in setting of
valsalva c/w vagal event. However, had persistent hypotension
after event with elevated lactate to 6.9 and hgb drop to from
7.4 to 6.1, guaiac positive stools, cool extermities, and volume
overload with elevated JVP. Initially, concern for hemorrhagic
shock (Hgb drop and guaiac positive stools) vs abdominal
ischemia (distended abdomen, lactate) vs cardiogenic shock
(cool, elevated JVP, increased BNP). Levophed was maxed, but
rapidly weaned off prior to any other treatments. Lactate also
resolved prior to any other treatments. ACS and GI were
consulted for concern for abdominal compartment syndrome vs
ischemia, but felt that exam was not concerning. He received 2U
pRBC and 1U FFP chased with 100mg IV lasix with good Hgb
response. No further signs of bleeding. Weaned off of pressors
and was warm on exam.
================
CHRONIC ISSUES:
================
#Chronic back pain:
#Hip/leg pain:
Per last discharge summary, patient has history of multiple
prior spinal surgeries with hardware in place. No evidence of
infection during last admission. Etiology of pain is unclear but
likely multifactorial from degenerative disc disease and
frequent surgeries. He was continued on lidocaine patches,
acetaminophen standing, gabapentin, and tramadol prn. His
neurologic exam was intact. Consider chronic pain clinic
outpatient for possible injection/nerve block.
#Gout:
Continued allopurinol ___ mg daily
#Depression:
Continued Sertraline 50 mg PO DAILY
TRANSITIONAL ISSUES:
=============================
[ ] DISCHARGE WEIGHT: 89.3 kg (196.87 lb)
[ ] DISCHARGE DIURETIC: Torsemide 40 mg daily
[ ] DISCHARGE ANTICOAGULATION: Rivaroxaban 20 mg PO QHS
[ ] DISCHARGE BUN/CR: ___
[ ] FOLLOW UP LABORATORY TESTING: Recheck Chem 10, monitor
lytes and creatinine ON ___.
[ ] If Cr continues to uptrend, >2, would refer to Nephrology.
[ ] Please continue to monitor weights and volume overload. Call
Cardiology office with > 3 lb weight change.
[ ] Please ensure follow-up with thoracic surgery and
interventional pulmonology (appointments scheduled) for trapped
lung.
[ ] Please continue to monitor heart rates and atrial
fibrillation. Metoprolol was uptitrated with improvement in
rates (final dose Metop XL 50mg BID).
[ ] Torsemide reduced to 40 mg daily due to uptrending Cr
[ ] Rivaroxaban dosing continued given GFR > 50, but may need to
reduce dose if Cr continues to uptrend >1.7.
[ ] Holding lisinopril due to ___ on CKD. Please restart
lisinopril 2.5mg daily if Cr normalizes.
[ ] Please re-check iron studies to ensure no iron toxicity on
supplemental iron and discontinue supplemental iron when iron
replete.
[ ] Follow up on macrocytic anemia with further work up (?MDS).
[ ] Please continue to counsel patients to avoid NSAIDs given
his heart failure diagnosis and history of NSAID implicated
acute tubular necrosis during last admission.
[ ] Consider adding spironolactone as tolerated by creatinine to
optimize HF regimen.
[ ] Please note that Tramadol and Gabapentin were decreased
given delirium earlier in hospitalization; pain was
appropriately controlled at these smaller doses.
[ ] Atorvastatin was increased to 40mg QPM this hospitalization.
# CODE STATUS: FULL CODE
# CONTACT:
Name of health care proxy: ___
Relationship: daughter
Phone number: ___
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO QPM
4. Furosemide 80 mg PO QAM
5. Furosemide 40 mg PO QPM
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Rivaroxaban 20 mg PO QHS
8. Sertraline 50 mg PO DAILY
9. Acetaminophen 1000 mg PO TID
10. Calcium Carbonate 500 mg PO QID:PRN heartburn
11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing
12. Lidocaine 5% Patch 1 PTCH TD QPM
13. Lisinopril 2.5 mg PO DAILY
14. MetroNIDAZOLE 500 mg PO Q8H
15. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting
16. TraMADol 100 mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
17. Ferrous Sulfate 325 mg PO DAILY
18. Pantoprazole 40 mg PO Q24H
19. Hydrocerin 1 Appl TP DAILY dry skin
20. Cholestyramine 2 mg gm PO BID
21. Gabapentin 300 mg PO TID
22. Milk of Magnesia 30 mL PO QHS:PRN constipation
23. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
upset stomach
24. Bisacodyl ___AILY:PRN constipation
25. Docusate Sodium 100 mg PO TID:PRN constipation
26. Senna 17.2 mg PO QHS:PRN constipation
27. melatonin 3 mg oral QHS:PRN
28. Vancomycin Oral Liquid ___ mg PO Q6H
29. Magnesium Oxide 400 mg PO DAILY
30. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
Discharge Medications:
1. Torsemide 40 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Gabapentin 300 mg PO BID
5. Metoprolol Succinate XL 50 mg PO BID
6. TraMADol 75 mg PO BID:PRN Pain - Moderate
7. Acetaminophen 1000 mg PO TID
8. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
upset stomach
9. Aspirin 81 mg PO DAILY
10. Bisacodyl ___AILY:PRN constipation
11. Calcium Carbonate 500 mg PO QID:PRN heartburn
12. Cepacol (Sore Throat Lozenge) 1 LOZ PO Q2H:PRN sore throat
13. Cholestyramine 2 mg gm PO BID
14. Docusate Sodium 100 mg PO TID:PRN constipation
15. Ferrous Sulfate 325 mg PO DAILY
16. Hydrocerin 1 Appl TP DAILY dry skin
17. Ipratropium-Albuterol Neb 1 NEB NEB Q4H:PRN SOB, wheezing
18. Lidocaine 5% Patch 1 PTCH TD QPM
19. Magnesium Oxide 400 mg PO DAILY
20. melatonin 3 mg oral QHS:PRN
21. Milk of Magnesia 30 mL PO QHS:PRN constipation
22. Ondansetron ODT 8 mg PO Q8H:PRN nausea, vomiting
23. Pantoprazole 40 mg PO Q24H
24. Rivaroxaban 20 mg PO QHS
25. Senna 17.2 mg PO QHS:PRN constipation
26. Sertraline 50 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
=============
- Heart failure with reduced ejection fraction, acute on chronic
- Atrial fibrillation
- Trapped lung, right pleural effusion
- Pneumonia
- Anemia
- ___ syndrome
- Acute on chronic kidney disease
Secondary:
==================
- C. difficile colitis
- Chronic back pain
- Gout
- Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital because you were short of
breath.
What happened while I was in the hospital?
- You were found to have a lot of extra fluid in your body, so
you were started on Lasix (a water pill). The fluid built up in
your body because of your heart failure.
- The thoracic surgery team evaluated your lung, and you should
follow-up with them to discuss possible surgery for your lung.
- You were treated with an antibiotic for a c. diff infection in
your bowel.
- You were briefly treated in the intensive care unit for low
blood pressure and low heart rates.
- You developed a pneumonia in the hospital, which was treated
with antibiotics.
What should I do when I go home?
- Please take all your medicines as described in this discharge
paperwork.
- Please keep all your appointments with your doctors, as listed
below.
- You should not take any Advil, ibuprofen, Aleve or other pain
relievers in the medication family called NSAIDS (non-steroidal
anti-inflammatory drugs).
- Please weigh yourself every morning, and call MD if weight
goes up more than 3 lbs in 1 day or is steadily increasing. Your
weight at discharge was 89.3 kg (196.9 lb).
It was a pleasure to participate in your care, and we wish you
all the best.
Sincerely,
Your ___ team
Followup Instructions:
___
|
19994505-DS-13 | 19,994,505 | 23,109,063 | DS | 13 | 2185-11-12 00:00:00 | 2185-11-12 17:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Face pain and bleeding status post fall, Subarachnoid Hemorrhage
Major Surgical or Invasive Procedure:
Right lateral canthotomy
History of Present Illness:
HPI: ___ w DM, CHF w ___ placement, PVD s/p R BKA on ASA/plavix
xfer from OSH s/p unwitnessed fall at nursing home with +LOC c/b
severe oropharyngeal/sinus hemorrhage. Patient found down at
nursing home with copious blood from nose and oropharynx. Taken
by ambulance to ___ for evaluation. On arrival, patient A&Ox3
with non-focal examination however, continued to have profuse
hemorrage from oropharynx and emergently intubated for airway
protection and worsening hypotension (SBP ___. Notably, patient
DNR/DNI at nursing home but participated in coherent
conversation
with ED attending regarding rescinding his DNR/DNI in this acute
setting with which his wife concurred via telephone. Coffee
ground material suctioned upon OGT placement. Also noted to have
severe R proptosis w elevated IOP for which he received R
lateral
canthotomy. Resuscitated with 4 pRBC, 1 PLT, ___ FFP and 3L
crystalloid with stabilization of BP. Subsequent radiographic
studies demonstrated multiple R sided facial fx's and small R
SAH.
Past Medical History:
1. CARDIAC RISK FACTORS: +Diabetes, +Dyslipidemia
2. CARDIAC HISTORY:
- Cardiomyopathy LVEF 35%
- LBBB type intraventricular conduction delay
- Transient complete heart block
3. OTHER PAST MEDICAL HISTORY:
- PVD
- s/p R BKA
- GERD
- Cataract
- Glaucoma
Social History:
___
Family History:
Father died at ___, Mother died of cancer.
Physical Exam:
On D/C, physical Exam:
T Ax 94.5 HR 62 BP 106/60 RR 14 100 RA O2 Sa
Gen: AO to person, unaware of location or date. Interactive but
poor attention span
HEENT: Patient has diffuse bruise, swelling over right
perioribital area. Has improved markedly from admission.
Unable to ascertain vision or color acuity due to mental status.
PERRLA. Subconjunctival hemorrhage present in Right eye.
CV: RRR, distant heart sounds, ___ S2 murumur
Chest: Lungs CTA-B, slight bruises diffusely
Abd: Soft, non tender, nondistended. Normoactive bowel sounds.
Ext: R BKA. Bruises in various locations.
Neuro: AOx1, moves all exts independently and with ___ strength.
Skin: Diffuse bruises over significant portion of body.
Improving over past week.
Pertinent Results:
ICD was interrogated by EP on ___. Normal ICD function and
lead parameters. No ventricular arrhythmia >194bpm were
recorded. No AT/AF episodes were recorded.
TTE: ___ The left atrium is moderately dilated. The right
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 mildly dilated. Overall
left ventricular systolic function is severely depressed (LVEF=
15%) secondary to severe hypokinesis to akinesis of all segments
and relative preservation of the basal-mid lateral wall. A left
ventricular mass/thrombus cannot be excluded
CT SINUS/MANDIBLE/MAXIL ___ IMPRESSION:
1. Bilateral medial maxillary sinus wall fractures, right
anterior maxillary
sinus wall fracture, right orbital floor fracture, and right
orbital hematoma.
2. Radiopaque density in the right facial soft tissues may
represent a
radiopaque foreign body.
CT C-Spine W/o contrast ___:
FINDINGS: There is no acute fracture or malalignment. The
vertebral heights are preserved. There is no prevertebral soft
tissue abnormality. The patient is intubated. Blood/mucus is
seen in the nasopharynx, oropharynx and hypopharynx. There are
moderate degenerative changes of the cervical spine, most
prominent at C5-6 to C6-7. The visualized lung apices are
grossly clear.
The thyroid is unremarkable. There is opacification of the right
mastoids.
IMPRESSION: No fracture or malalignment. Moderate degenerative
changes.
CT Head w/o Contrast ___:
FINDINGS: There is a small right temporal subarachnoid
hemorrhage (601B, 77). No other areas of hemorrhage are
identified. Hypodense area in the right frontal lobe reflect a
chronic infarction. Periventricular white matter
hypodensities are most consistent with chronic small vessel
ischemic disease.
The ventricles and sulci are enlarged consistent with atrophy.
The fractures of the bilateral medial maxillary sinus walls and
right anterior maxillary sinus wall and right orbital floor are
better seen on dedicated facial CT. The mastoid air cells are
well aerated. The ventricles and sulci are mildly enlarged
consistent with atrophy.
IMPRESSION:
1. Small subarachnoid hemorrhage in the right temporal lobe.
2. Hypodense area in the right frontal lobe represents a
chronic infarction.
CT Chest/Abd/Pelvis ___:
FINDINGS: Thyroid is normal. There is no axillary, mediastinal
or hilar
lymphadenopathy. The heart is moderately enlarged and there are
pacemaker wires in place. The aorta is normal in caliber and
there is no evidence of dissection. There is no central filling
defect in the pulmonary arteries. No pericardial effusion. The
esophagus is normal and contains an enteric tube. There are
dependent streaky consolidation, which may represent a
combination of atelectasis and aspiration. No pneumothorax or
pleural effusion.
ABDOMEN: The liver is normal in appearance without evidence of
injury. The gallbladde contains gallstones, but otherwise
unremarkable. The spleen is normal. The adrenal glands are
normal. The right kidney has a scarring at the lower pole.
There is a small subcentimeter hypodensity in the left kidney,
too small to characterize. No hydronephrosis. No evidence of
kidney injury. The pancreas is normal. The stomach is normal.
The small bowel is normal. he colon is unremarkable. The
appendix is normal. There is no free fluid. No free air. No
mesenteric or retroperitoneal lymphadenopathy.
PELVIS: The bladder is normal. It contains a Foley catheter.
The rectum is normal. There is no free fluid in the pelvis.
The prostate and seminal vesicles are normal. No pelvic or
inguinal lymphadenopathy.
There is moderate atherosclerotic disease of the aorta but the
aorta is normal in caliber.
BONES: No fracture is identified.
IMPRESSION: No injury to the chest, abdomen or pelvis. Streaky
opacities in the lungs bilaterally may represent a combination
of atelectasis and aspiration.
___ Swallow Evaluation:
SUMMARY / IMPRESSION:
Pt presents with decreased alertness/responsiveness and overt
s/sx of aspiration during today's bedside swallowing evaluation.
Pt does not yet appear safe for PO intake. We will follow up to
repeat the bedside swallow evaluation.
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt
Ct
___ 01:33 10.3 3.23* 10.2* 30.8* 95 31.5 33.0 15.5 173
___ 01:33 ___ 19.1* PTT 28.4 INR 1.8
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 01:33 135*1 42* 1.5* 150* 4.0 111* 25
18
___ 05:30PM CK(CPK)-46*
___ 05:30PM CK-MB-3 cTropnT-0.01
___ 01:59PM TYPE-ART PO2-108* PCO2-45 PH-7.46* TOTAL
CO2-33* BASE XS-6
___ 01:59PM GLUCOSE-155* K+-4.0
___ 01:59PM GLUCOSE-155* K+-4.0
___ 01:59PM freeCa-1.15
___ 09:39AM CK-MB-3 cTropnT-<0.01
___ 09:39AM CK-MB-3 cTropnT-<0.01
___ 02:57AM TYPE-ART TIDAL VOL-500 PEEP-5 O2-50 PO2-195*
PCO2-41 PH-7.46* TOTAL CO2-30 BASE XS-5 -ASSIST/CON
INTUBATED-INTUBATED
___ 02:57AM LACTATE-1.3
___ 02:57AM LACTATE-1.3
___ 02:57AM freeCa-1.09*
___ 02:42AM GLUCOSE-180* UREA N-31* CREAT-1.1 SODIUM-140
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-13
___ 02:42AM CK-MB-3 cTropnT-<0.01
___ 02:42AM ALBUMIN-3.3* CALCIUM-8.5 PHOSPHATE-3.3
MAGNESIUM-2.0
Brief Hospital Course:
Mr. ___, an ___ w DM, CHF w ___ placement, PVD s/p R BKA on
ASA/plavix
xfer from OSH s/p unwitnessed fall at nursing home with +LOC c/b
severe oropharyngeal/sinus hemorrhage on ___. Patient found
down at
nursing home with copious blood from nose and oropharynx. Taken
by ambulance to ___ for evaluation. On arrival, patient A&Ox3
with non-focal examination however, continued to have profuse
hemorrage from oropharynx and emergently intubated for airway
protection and worsening hypotension (SPB ___. Notably, patient
DNR/DNI at nursing home but participated in coherent
conversation
with ED attending regarding rescinding his DNR/DNI in this acute
setting with which his wife concurred via telephone. Coffee
ground material suctioned upon OGT placement. Also noted to have
severe R proptosis w elevated IOP for which he received R
lateral
canthotomy. Resuscitated with 4 pRBC, 1 PLT, ___ FFP and 3L
crystalloid with stabilization of BP. Subsequent radiographic
studies demonstrated multiple R sided facial fx's and small R
SAH. Details of these studies can be found in the results
section
Mr. ___ was admitted to the ICU on ___. ICD was
interrogated by EP on ___. Normal ICD function and lead
parameters. No ventricular arrhythmia >194bpm were recorded. No
AT/AF episodes were recorded. He remained on a ventilator and
pressors overnight in the ICU while neurochecks were done every
4 hours to monitor his status.
On ___ an attempt to extubate Mr. ___ was made, but he was
reintubated in the evening due to mental status changes.
On ___, a repeat head CT scan demonstrated no bleeding or CVA.
A bronchoscopy done at this time demonstrated a moderate sized
blood clot in left bronchus, otherwise the airways were clear
without mucous or erythema. On this day the patient was also
weaned from his pressors, and given 20 mg of Lasix for diuresis.
On ___. The patient self extubated himself and was able to
tolerate this without incident. He was AO x1-2, and was aware
of his own name and his wife's. Plastic surgery signed off
stating no need of operative repair of facial fractures or to
repair right lateral canthotomy unless symptomatic while
recovering. Pt may follow up in plastic surgery clinic ___
weeks after discharge.
On ___ following a family discussion with the ICU team, a
decision was made to make the patient DNR/DNI. A CT-scan on
___ showed no fracture or malalignment in the patient's
c-spine.
On ___, the patient was transferred to a regular floor. He
was still on unasyn and NPO. Per a family discussion with Dr.
___ patient was made CMO. The patient also failed a
bedside speech and swallow evaluation on ___.
Following a second family meeting on ___, where the family's
wishes in the patient's best interests were again explored, it
was determined the family wished to continue with CMO, and in
spite of the risk of aspiration, continue feeding him in order
to make him as comfortable as possible. Case management began
searching for a nursing home facility or hospice to transition
him from the hospital to an environment mroe conducive to the
family's wishes.
On discharge it was determined that the patient would be CMO,
and was attempting a regular diet in spite of a failed
speech/swallow test. He may follow up as needed with various
services, though no definite follow up appointments have been
arranged. Ophtho evaluated the patient prior to his discharge,
and recommended Erythromycin ointment BID to both eyes and to R
lateral canthotomy site. Only as requested or tolerated as
patient is comfort measures only. No acute ophthalmic
interventions indicated.
Family advised of patient condition and expectations and is in
agreement with plan for CMO, DNR/DNI. Pt discharged on ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Furosemide 80 mg PO DAILY
4. Lisinopril 2.5 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO DAILY
7. Lumigan (bimatoprost) 0.03 % ophthalmic QPM
8. TraZODone 50 mg PO HS
9. Finasteride 5 mg PO DAILY
10. Carvedilol 6.25 mg PO BID
11. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
12. Docusate Sodium 100 mg PO BID
13. Restasis (cycloSPORINE) 0.05 % ophthalmic Q12 HRS
14. Gabapentin 100 mg PO TID
15. Klor-Con (potassium chloride) 20 mEq oral BID
16. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP BOTH EYES BID
4. Restasis (cycloSPORINE) 0.05 % ophthalmic Q12 HRS
5. Carvedilol 6.25 mg PO BID
6. Docusate Sodium 100 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Gabapentin 100 mg PO TID
9. Klor-Con (potassium chloride) 20 mEq oral BID
10. Furosemide 80 mg PO DAILY
11. TraZODone 50 mg PO HS
12. Timolol Maleate 0.25% 1 DROP BOTH EYES BID
13. Simvastatin 40 mg PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Lumigan (bimatoprost) 0.03 % ophthalmic QPM
16. Lisinopril 2.5 mg PO DAILY
17. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES BID Duration:
7 Days
___ also apply to right lateral canthotomy site
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subarachnoid Hemorrhage, Retrobulbar hematoma status post
lateral canthotomy, Right orbital floor fracture.
Discharge Condition:
Fair, Family requests Comfort Measures Only
Mental Status: Confused - always.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Level of Consciousness: Lethargic but arousable.
Discharge Instructions:
1. Safest diet recommendation remains NPO
2. Given goals of care and family wish to try "comfort feeding",
offering Pt a modified PO diet to reduce but not eliminate
aspiration risk, suggest:
- PO diet: nectar thick liquids and pureed solids
- PO medications : crushed in puree
3. Strict aspiration precautions:
a. 1:1 supervision with all PO's
b. DO NOT FEED Pt during apneic moments
c. sit fully upright
d. have suction present at bedside during all PO trials
e. make sure Pt is fully awake, alert, and attentive prior
to offering PO's
f. only offer small single bites/sips
4. Aggressive Q4 oral care
5. If plan to d/c home, family/caregivers ___ need education to
carryover modified diet and aspiration precautions at home
- if to be d/c's home Pt should obtain home suction
Followup Instructions:
___
|
19994588-DS-10 | 19,994,588 | 28,352,743 | DS | 10 | 2194-07-07 00:00:00 | 2194-07-07 22:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
confusion, worsening weakness
Major Surgical or Invasive Procedure:
Therapeutic thoracentesis ___
History of Present Illness:
___ F w/ PMHx of Stage IV NSCLC (adenoCA) s/p whole brain
radiation (completed 1 week ago) brought in from home by her son
and ___ because of somnolence and increased shortness of
breath. All history is from her daughter (primary caregiver) and
son (at the bedside), as patient unable to answer questions.
Since radiation, patient has had a progressive functional
decline, requiring help to sit up and assistance walking (person
and cane). One month ago she could walk with assistance, but
this has declined to the point that she has not been out of bed
for a couple of days. She is not on home oxygen. Family has
noticed increased frequency of her chronic cough, now wet
sounding, but patient has not been able to cough up sputum. No
fever, though patient continuously complains of cold. ___ edema,
rashes. No headaches. No dysuria, hematuria, but has new
incontinence to urine x2 days. + diarrhea with incontinence. No
melena. Has stopped eating x2 days, and has very little fluid
intake.
.
Of note, she was seen in clinic ___ when her exam was notable
for a marked decrease in her performance status, attributed to
whole-brain radiation. She was advised to continue erlotinib,
but deemed not a candidate for other chemotherapy.
Past Medical History:
Past Oncologic History:
- presented with cough in ___. Due to marked dyspnea on
exertion and persistent cough, she had CT in ___ which showed a
hilar soft tissue mass, right pleural effusion and bilateral
pulmonary nodules.
- She underwent EBUS/biopsies and pathology demonstrated
non-small cell lung cancer favoring adenocarcinoma.
- PET/CT scan demonstrated her pulmonary disease and multiple
osseous metastases. Brain MRI was negative. She was found to
have 2 EGFR mutations: G719A mutation in Exon 18 and S768I
mutation in Exon 20. She began erlotinib in ___.
- After complaining of a headache in ___, MRI brain
demonstrated brain metastases. She completed whole brain
radiation with Dr. ___ on ___.
- Admitted for confusion and weakness after completing whole
brain radiation therapy, found to have UTI. After a family
meeting, discharged home with home hospice.
Other PMH:
- Meningioma
- GI bleed
- Thyroid nodule
- Hypertension
- hypercholesterolemia
- tremor
- right total knee replacement
- s/p thyroid surgery, recently being treated for
hyperthyroidism
- tremor predominant ___ disease, managed on zonesamide
Social History:
___
Family History:
There is no family history of lung cancer or any major history
of disease. Most of her family lives in ___ and she is not
aware of their health status.
Physical Exam:
Vitals - T: 97.5 BP: 124/62 HR: 80 RR: 18 02 sat: 100% on RA
GENERAL: Lying in bed mumbling answers to son, does not obey any
commands. Opens eyes with stimulation of extremities.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes. No pressure ulcers.
HEENT: AT/NC, pupils reactive when eyes opened, tracks movement,
anicteric sclera, pink conjunctiva, patent nares. Dry mucous
membranes, will not open mouth, has apparent poor dentition.
NECK: supple, no LAD, JVP flat at 45 degrees
CARDIAC: RRR, S1/S2, no mrg. Has pain with palpation of sternum.
LUNG: poor effort, clear anteriorly, decreased at bilateral
bases posteriorly
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities, no cyanosis, clubbing or edema, no
obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: will not obey any commands. Toes downgoing bilaterally.
Withdraws all extremities to stimuli. Normal tone.
.
Vitals 98 110/56 70 16 96% RA
GENERAL: Lying in bed, alert and awake, smiles when she sees the
medical team.
SKIN: warm and well perfused, no rashes.
HEENT: pupils reactive, tracks movement. poor dentition.
CARDIAC: RRR, S1/S2, no mrg.
LUNG: poor effort, clear anteriorly, decreased at bilateral
bases
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
M/S: moving all extremities but moving upper extremities more
than lower extremities, no cyanosis, clubbing or edema, no
obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: increased tone in lower extremities bilaterally. Will
obey simple commands such as squeezing fingers but does not
consistently follow other commands.
Pertinent Results:
admission labs:
___ 11:15AM BLOOD WBC-7.4 RBC-3.93* Hgb-12.5 Hct-39.1
MCV-99* MCH-31.8 MCHC-32.0 RDW-13.5 Plt ___
___ 11:15AM BLOOD Neuts-83.9* Lymphs-9.7* Monos-4.5 Eos-0.8
Baso-1.2
___ 11:15AM BLOOD ___ PTT-27.3 ___
___ 11:15AM BLOOD Glucose-119* UreaN-19 Creat-0.7 Na-139
K-4.0 Cl-108 HCO3-21* AnGap-14
___ 11:15AM BLOOD ALT-26 AST-49* AlkPhos-93 TotBili-0.9
___ 11:15AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.2 Mg-2.1
___ 08:14AM BLOOD Hapto-218*
___ 11:15AM BLOOD TSH-0.54
microbiology:
___ 01:40PM URINE Blood-NEG Nitrite-POS Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-8* pH-7.0 Leuks-SM
___ 01:40PM URINE RBC-<1 WBC-41* Bacteri-MANY Yeast-NONE
Epi-1
UCx ___: SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S 4 S
CEFAZOLIN------------- <=4 S <=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
NITROFURANTOIN-------- <=16 S 128 R
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
BCx ___: negative x2
Pleural fluid ___ : 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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
Cytology
Pleural Fluid ___: POSITIVE FOR MALIGNANT CELLS,
consistent with metastatic adenocarcinoma.
IMAGING:
___ CXR: Large right-sided pleural effusion. Suspicious
nodule projecting over the right upper lobe.
___ CTA chest:
1. No evidence of pulmonary embolism.
2. Large right-sided pleural effusion, but not significantly
changed, with associated atelectasis involving portions of the
right lung. Small pericardial and left-sided pleural effusions
are also present.
3. Widespread blastic metastases and suspected malignant
involvement of the mediastinum and right hilum, but assessed
very recently with PET-CT imaging where the degree of disease
activity was more optimally characterized.
4. Secretions or debris in the trachea.
5. Vascular calcifications including coronary artery
calcifications.
6. Large left-sided thyroid nodule.
___ CT head: 1. No acute intracranial process.
2. Stable olfactory groove meningioma.
3. Bone metastasis in the right parietal bone. Parenchymal brain
metastases are not explicitly demonstrated on this study because
it is a non-constrast
examination, but there is no evidence for significant edema or
mass effect.
___ MR thoracic/lumbar spine:
1. No evidence of cord compression.
2. Limited evaluation of the spine demonstrates new lesions at
T6, T12, L4,
L5 and S1 vertebral bodies, highly suspicious for metastatic
disease.
3. Multilevel degenerative changes of the lumbar spine as
described above,
worse at L4-L5 and L5-S1 levels.
4. Large right pleural effusion and small left pleural effusion.
___ CXR: As compared to the previous radiograph, the patient
has undergone right thoracocentesis. Right pleural effusion has
substantially decreased. The remaining effusion is limited to
the costophrenic sinus. There is no evidence of pneumothorax or
other complications.
Brief Hospital Course:
___ female with metastatic NSCLC with brain mets s/p whole
brain radiation, with diffuse bony metastases, here with new
confusion and progressive weakness/fatigue in last few weeks and
new shortness of breath. Found to have UTI, treated with IV
antibiotics with improvement in mental status. However, given
the poor functional status after her recent radiation therapy,
patient was thought not to be a candidate for chemotherapy.
Family meeting was had discussing the poor prognosis given her
disease progression on Tarceva, and no further chemotherapy
option. Family decided to transition her to home hospice.
# Toxic metabolic encephalopathy: Thought to be multifactorial,
with UTI, dehydration and brain metastases +/- radiation all
contributing. Patient started on ceftriaxone for UTI with
improvement in mental status per family. Patient's family denies
that she has been taking large amounts of narcotics which could
have contributed to her mental status changes. Neurology was
consulted and EEG was done, which showed diffuse slowing
consistent with toxic metabolic encephalopathy. MRI of brain and
spine were ordered but patient was not able to tolerate the
procedure. As family wanted to focus more on patient's comfort,
repeat attempt for MRI was not made in setting of patient's
prior agitation.
# Urinary tract infection: does not have any history of
resistant infections. She was treated with ceftriaxone 1 gm
Q24hrs x7 days. Urine cultures showed klepsiella and e. coli
that were sensitive to ceftriaxone.
# Weakness/incontinence: patient with worsening
weakness/fatigue, concerning for cord compression/issues
initially, difficult to get good neuro exam with patient's
language barrier and mental status. As patient's mental status
improved, she began moving all of her extremities spontaneously
in bed, though she was weaker in lower extremities consistent
with family's report. Given patient's complaint of numbness in
right lower chest area, MRI of spine was done which did not show
cord compression. Physical therapy evaluated the patient and
recommended discharge to rehab. However, as patient was being
transitioned to hospice, she was discharged home with hospice
following.
# Chest pain: patient complained of chest pain on admission,
likely from sternal mets. EKG unchanged, troponin negative x3.
Patient was maintained on tylenol and morphine prn for pain.
# Shortness of breath: patient had acute on chronic worsening of
cough and symptomatic SOB at home. CTA chest shows worsening of
disease, no PE or PNA. Pt does have chronic pleural effusion on
imaging. Patient treated with prn nebs with some improvement.
Thoracentesis was done on ___ with subjective improvement in
breathing. Patient's O2 sat remained stable on RA.
# Choking/Dysphagia: as patient's mental status cleared up, she
started eating, however nursing noted that patient seemed to be
choking on the thin liquid. Speech and swallow evaluated the
patient and recommended soft/dysphagia diet with nectar thick
liquid. However, prior to discharge, she was noted to have
difficulty even with soft food and was further downgraded to
ground diet. The risk of aspiration was discussed with family
member and she was educated on different kind of foods that
would be safer for the patient to eat.
# Goals of care: family meeting had on ___ where her
prognosis was discussed. Unfortunately, patient's tumor has
progressed on Tarceva, and given her poor functional status at
this time after radiation therapy, patient is not a candidate
for chemotherapy. This was discussed with the family members and
information about hospice was given. Family stated their focus
on taking her home and making her comfortable.
TRANSITIONAL ISSUES:
[ ] Patient discharged home with home hospice, but further
discussions regarding code status are needed.
Medications on Admission:
Amlodipne (2.5mg tablet) 1 tablet by mouth once a day for blood
pressue
Calcium carbonate-vitamin D3 (600mg) 1 tablet by mount twice a
day as needed for bones.
Carvedilol (6.25mg) 1 tablet by mount twice a day.
Codeine-guaifenesin (100mg-10mg/5ml liquid) ___ by mouth
every 4 hours as needed for cough. Hold for sedation,
confusion.
Dextran 70-hypromellose (artificial 30-drop tears drops) One
drop 4 times a day.
Erlotinib (Tarceva) 100 mg 1 table by mouth daily.
Food supplemental, Lactose-free (Ensure) 1 can - 3 times a day.
Hydrocodone-acetaminophen (Vicodin) 5mg-500mg tablet. take 2
tablets by mouth every 6 hours as needed for pain relieve.
Lidocaine (Lidoderm) 5% (700mg/patch) Adhesive medicated patch.
Apply in AM, remove in ___ once a day as needed for pain.
Losartan 50mg tablet 1 tablet by mouth once a day for high blood
pressure
Methimazole 5mg 0.5 tablet by mouth daily.
Omeprazole 20mg capsule, Delayed Release (E.C.) 1 capsule by
mouth twice a day for heartburn and acid.
Ondarsetron 4mg tablet, Rapid dissolved 1 tablet by mouth every
8 hours as need for nausea.
Oxycodone 5mg tablet 1 or 2 tablets by mouth every 4 hours as
needed.
Pravastatin 20mg tablet 1 tablet by mouth at bedtime.
Zonisamide 25mg capsule 1 capsule by mouth twice a day.
Discharge Medications:
1. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day.
3. codeine-guaifenesin ___ mg Tablet Sig: One (1) Tablet PO
every ___ hours as needed for cough: instead of
codeine-guaifenasin liquid. .
Disp:*30 Tablet(s)* Refills:*0*
4. dextran 70-hypromellose Drops Sig: One (1) Ophthalmic
four times a day: for dry eyes.
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
6. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. methimazole 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
8. ondansetron 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet,
Rapid Dissolves PO every eight (8) hours as needed for nausea.
9. oxycodone 5 mg Tablet Sig: ___ Tablets PO every four (4)
hours as needed for pain.
10. Tums 200 mg calcium (500 mg) Tablet, Chewable Sig: ___
Tablet, Chewables PO four times a day as needed for stomach
upset.
Disp:*60 Tablet, Chewable(s)* Refills:*0*
11. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) neb Inhalation every six (6) hours as
needed for shortness of breath, wheezing or cough.
Disp:*60 nebs* Refills:*0*
12. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every
eight (8) hours as needed for fever or pain.
Disp:*60 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: toxic metabolic encephalopathy secondary to
urinary tract infection, metastatic nonsmall cell lung cancer
with metastases to the brain
Secondary Diagnosis: ___ disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___ was a pleasure to take care of you at ___
___. You were brought in because of worsening
confusion and weakness. You were found to have a urinary tract
infection and were treated with IV antibiotics.
These CHANGES were made to your medications:
STOP Calcium carbonate and vitamin D3
STOP Vicodin
STOP Prilosec (omeprazole)
STOP Pravastatin
STOP Zonisamide
START tums as needed for stomach upset
START Duonebs (albuterol-ipratropium) every 6 hours as needed
for wheezing, cough or shortness of breath
START tylenol ___ mg every 6 hours as needed
CHANGE codeine-guaifenasin liquid to tablet
Hospice will also bring a medication kit for other symptom
management and will teach you how to use it at home.
Followup Instructions:
___
|
19994592-DS-13 | 19,994,592 | 22,001,973 | DS | 13 | 2134-04-09 00:00:00 | 2134-04-09 09:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ woman with a past medical history
of bipolar disorder, OSA, GERD, and anemia; presenting with
confusion for 3 days. History is difficult to obtain due to
patient confusion, language barrier with family (despite
translator), and records scattered across multiple providers
___, new PCP and new psychiatrist).
She was brought to the ED by her family for 3 days of confusion.
Her husband says that she has been walking around the house
"like
a zombie", "not making any sense" when she speaks, not eating,
bathing, or sleeping. Family also notes intermittent outbursts
of arm raising and shaking that is nonsynchronized, nonrhythmic,
and resembles a protracted startle response (which they
demonstrated).
Her husband believes her symptoms are the result of recent
medication changes by a new psychiatrist she is seeing. At a
recent PCP ___ visit on ___ she was noted to be alert
and oriented with an essentially normal exam. She complained of
15 days of headache at that time. She was referred to a new
psychiatrist, who the husband says she saw on ___ and
who
reportedly changed her medications. The husband believes her
altered mental status is result of the medication changes but he
does not know specifically what these are. He believes she may
be taking too many of some of her medications. The OMR note on
___ noted she was taking lithium 600mg BID, but apparently this
has been stopped at present (-- her husband did not bring the
medication and her serum level is low.)
In the ED a CT head revealed a left posterior fossa mass
consistent with a meningioma, exerting mass-effect on the left
cerebellum causing edema and minor distortion of the fourth
ventricle. Neurosurgery was consulted and they did not think
that this mass was related to her alterations in mental status,
so neurology was consulted.
Past Medical History:
-Bipolar disorder
-OSA
-GERD
-Anemia
-Hyperlipidemia
-Hepatic steatosis
Social History:
___
Family History:
Mother with hypertension. Maternal grandfather with CAD. Aunt
with colon cancer.
Physical Exam:
Admission Physical Exam:
Vitals: T:98.8 P:99 BP:143/72 r:20 SaO2:100%
General: Awake, frequently moving in bed. Inattentive and not
cooperative with exam.
HEENT: NC/AT, no scleral icterus noted.
Neck: Supple.
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR
Abdomen: Obese, soft, NT/ND.
Neurologic:
-Mental Status: Alert, not oriented no self, place, situation;
said "I don't know" in ___ these questions but replied yes
to
whether her name was ___. Profoundly inattentive,
continuously moving in bed and unable to cooperate with exam.
-Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally.
-Motor: Moved all extremities equally.
-Sensory: Reacted to light touch in all extremities.
-Coordination: Appeared able to grab bed rails with both hands
without apparent ataxia.
-Gait: Able to stand unassisted. Stable gait, short steps.
Discharge Physical Exam:
Vitals: Tm 37.2, HR 65-87, BP 75-175/46-155, RR ___, >97% RA
General: Awake, lying in bed quietly, NAD
HEENT: NC/AT, no scleral icterus noted.
Neck: Supple.
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR
Abdomen: Obese, soft, NT/ND.
Neurologic:
-Mental Status: Awake, alert, refuses to participate with exam;
looks away to avoid eye contact
-Cranial Nerves: PERRL, EOM appear intact. BTT bilaterally.
-Motor: Moved all extremities equally antigravity
-Sensory: Withdraws to light touch in all extremities.
-Coordination: No truncal ataxia, no dysmetria reaching for
objects
Pertinent Results:
___ 05:15AM BLOOD WBC-8.8 RBC-4.44 Hgb-11.3 Hct-36.6 MCV-82
MCH-25.5* MCHC-30.9* RDW-18.8* RDWSD-56.3* Plt ___
___ 05:48PM BLOOD Neuts-63.2 ___ Monos-9.9 Eos-0.8*
Baso-0.5 Im ___ AbsNeut-8.24* AbsLymp-3.28 AbsMono-1.29*
AbsEos-0.11 AbsBaso-0.07
___ 08:23PM BLOOD ___ PTT-29.6 ___
___ 05:15AM BLOOD Glucose-107* UreaN-10 Creat-0.7 Na-142
K-3.3 Cl-107 HCO3-23 AnGap-15
___ 06:35AM BLOOD ALT-19 AST-21 CK(CPK)-404* AlkPhos-67
TotBili-0.4
___ 05:15AM BLOOD Calcium-9.4 Phos-3.0 Mg-2.1
___ 06:35AM BLOOD TSH-1.2
___ 08:00PM BLOOD Lithium-0.2*
___ 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:08AM BLOOD Lactate-1.1
CXR:
FINDINGS:
There are low lung volumes.No definite focal consolidation is
seen. There is
no large pleural effusion or pneumothorax. The cardiac
silhouette is mildly
enlarged, likely accentuated by low lung volumes and AP
technique.
Mediastinal contours unremarkable. No pulmonary edema is seen.
IMPRESSION:
Low lung volumes without focal consolidation or pleural effusion
seen.
CT Head ___:
FINDINGS:
Abutting the superolateral left cerebellar hemisphere and the
tentorium, there
is a 3.2 x 2.6 x 2.8 cm dense lesion with adjacent vasogenic
edema with
resultant mass effect on the quadrigeminal plate cistern and
fourth ventricle.
No evidence of herniation currently.
There is no evidence of acute 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.
IMPRESSION:
A dense mass abutting the tentorium and left cerebellar
hemisphere with
adjacent vasogenic edema and mass effect effacing the fourth
ventricle and
quadrigeminal plate cistern, most likely represents meningioma.
No current
herniation. Recommend MRI with intravenous contrast for further
evaluation,
if no contraindication.
MRI Brain ___:
FINDINGS:
In the left posterior fossa, there is a round 3.2 x 2.9 x 3.0 cm
dural-based
mass inseparable from the left tentorium, abutting the
superolateral aspect of
the left cerebellar hemisphere, presumably meningioma. It is
isointense to
gray matter on T1 and T2 weighted imaging with homogeneous avid
enhancement.
There is regional T2 prolongation within the left cerebellar
hemisphere
consistent with vasogenic edema with and mild effacement of the
fourth
ventricle. No hydrocephalus. No evidence of hemorrhage or
infarction.
The left transverse sinus is hypoplastic. The left distal
transverse sinus
and sigmoid sinus do not enhance and may be compressed or
occluded by the
presumed meningioma. The left internal jugular vein traits
postcontrast
enhancement. The remainder of the dural venous sinuses are
patent.
IMPRESSION:
Dural-based mass in the left posterior fossa, consistent with a
meningioma.
There is regional vasogenic edema with mild effacement of the
fourth ventricle
but no obstructing hydrocephalus. No definite enhancement of
the distal left
transverse sinus and sigmoid sinus which may be severely
compressed with
occlusion a possibility. There is reconstitution of contrast
enhancement of
the left internal jugular vein.
Brief Hospital Course:
Ms. ___ is a ___ woman with a history of bipolar
disorder who presented with headache and increasing psychosis in
the setting of medication non-compliance. Her exam was notable
for limited speech output, paranoia and paratonia without clear
focal neurologic deficits. CT demonstrated a left posterior
fossa mass adjacent to the cerebellum with MRI confirming the
diagnosis of meningioma (3.1 x2.6cm enhancing extra-axial mass
abutting tentorium and left cerebellum), which per Neurosurgery
required no acute surgical intervention and will be followed
over time as an outpatient.
She remained in a state of decompensated psychosis and
Psychiatry recommended restarting her home Invega (paliperidone)
9mg daily, as she was likely non-compliant with this medication.
She had notably last had this medication filled on ___ in
quantity of 30 and there were still 20 pills left in bottle she
brought with her to the hospital. EKG with QTc 473msec. She
remained afebrile with stable vital signs throughout her
admission and she is medically cleared for discharge. She will
be discharged to ___
accepting MD ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. paliperidone 9 mg oral DAILY
2. Omeprazole 20 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. paliperidone 9 mg oral DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
meningioma, psychosis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted due to concern for a mass in the brain
(cerebellum) that was found to be a meningioma. No surgical
intervention was required and you will be followed as an
outpatient by Neurosurgery. You were seen by Psychiatry who
recommended restarting your home paliparidone (Invega) and your
medications will continued to be titrated at ___
___.
Best,
Your ___ Neurology Team
Followup Instructions:
___
|
19994730-DS-20 | 19,994,730 | 28,502,826 | DS | 20 | 2169-09-03 00:00:00 | 2169-09-10 10:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Dr ___ is a ___ yo man with stage IVB Hodgkin lymphoma s/p 6
cycles of chemotherapy with AVD (bleomycin held due to depressed
DLCO at baseline) starting in ___ of this year. On ___
started the second cycle with the addition of bleomycin. He has
tolerated the
chemotherapy overall well, without significant side effects.
Patient presenting with R sided chest wall pain wrapping around
torso and right upper quadrant pain, that began earlier this
week and is not improving. He has tried som heat pads,
flexeril, percocet, and dexamethasone for pain without relief.
He denies any N/V/D, constipation, worsening pain with food,
fever, sweats, chills. He also complains of being tired.
In the ER the patient received morphine for pain. He also had
an episode of shaking chills and a temp of 100.8 which came down
to 99 within the hour.
ROS: otherwise negative
Past Medical History:
Past oncologic history:
Hodgkin's Lymphoma diagnosed ___ after presenting with
fatigue, night sweats and increased lymphadenopathy.
Started on AVD (modified ABVD) on ___
.
Past Medical History:
-Left neck adenopathy s/p biopsy negative for malignancy in ___
-Sarcoidosis - diagnosed in ___ based on hilar lymphadenopathy
and erythema nodosum. Treated with steroids with resolution of
symptoms. In ___ in the setting of lymphadenopathy he
had an ACE level of 114.
-Pulmonary Embolism ___
-glucose intolerance
Social History:
___
Family History:
No family history of colon, lung, pancreatic, blood cancer.
Physical Exam:
PHYSICAL EXAM:
VS 98.2, 150/87, 102, 18, 98% RA weight 227
GEN: AAOx3, NAD
HEENT: PERRLA, EOMI, MMM, no thrush, no OP erythema or lesions
NECK: supple, no LAD, no JVD
___: RRR, no m/r/g
LUNGS: reg resp rate, breathing unlabored, no accessory muscle
use, lungs clear to auscultation bilaterally
ABD: soft, NABS , mild left upper quadrant tenderness without
rebound or guarding
Chest: mild R sided lower rib pain chest and back
ext: 2+ pulses, no c/c/e
Skin: no rashes
neuro: CN ___ intact, strength ___ in UE and ___ bilat. LTSI in
UE and ___. finger to nose intact, rapid alt. movements intact,
heel to shin intact, gait normal, no pronator drift, no
asterixis.
DISCHARGE PHYSICAL EXAM:
VS 98.5, 108/70, 85, 18, 98% RA
GEN: AAOx3, NAD
HEENT: PERRLA, EOMI, MMM, no thrush, no OP erythema or lesions
NECK: supple, no LAD, no JVD
___: RRR, NS1S2, no m/r/g
LUNGS: reg resp rate, breathing unlabored, no accessory muscle
use, lungs clear to auscultation bilaterally
ABD: soft, non-tender,normoactive bowel sounds, no masses, no
HSM
ext: 2+ pulses, no c/c/e
Skin: crusted R T9 dermatomal herpetic rash, resolving
neuro: CN ___ intact, strength ___ in UE and ___ bilat
Pertinent Results:
ADMISSION LABS:
___ 10:10AM WBC-4.3 RBC-3.15* HGB-10.3* HCT-30.5* MCV-97
MCH-32.7* MCHC-33.7 RDW-18.5*
___ 10:10AM NEUTS-87.1* LYMPHS-6.4* MONOS-3.8 EOS-1.8
BASOS-0.9
___ 10:10AM PLT COUNT-162
___ 10:10AM ___ PTT-29.9 ___
___ 10:10AM GLUCOSE-242* UREA N-11 CREAT-0.8 SODIUM-138
POTASSIUM-3.9 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17
___ 10:10AM ALT(SGPT)-45* AST(SGOT)-24 ALK PHOS-163* TOT
BILI-0.3
___ 09:44AM LACTATE-2.5*
___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-300 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 01:00PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 01:00PM URINE RBC-0 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:10AM LIPASE-30
DISCHARGE LABS:
___ 07:50AM BLOOD WBC-4.0 RBC-2.98* Hgb-9.4* Hct-28.4*
MCV-95 MCH-31.4 MCHC-33.0 RDW-17.7* Plt ___
___ 07:50AM BLOOD Neuts-78.8* Lymphs-17.0* Monos-3.5
Eos-0.5 Baso-0.3
___ 07:50AM BLOOD ___ PTT-43.8* ___
___ 12:40PM BLOOD LMWH-PND
___ 07:50AM BLOOD Glucose-147* UreaN-14 Creat-0.8 Na-140
K-4.6 Cl-106 HCO3-24 AnGap-15
___ 07:50AM BLOOD ALT-44* AST-25 LD(LDH)-219 AlkPhos-246*
TotBili-0.3
___ 07:30AM BLOOD GGT-409*
___ 07:50AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.0
___ 04:20AM BLOOD TSH-7.6*
___ 03:59AM BLOOD T4-8.9
RUQ U/S:Study Date of ___
IMPRESSION: 1. Gallbladder sludge without evidence of
cholecystitis.
2. Splenomegaly. 3. Hyperechoic area in the left lobe of the
liver is also seen on the CT from the same day. Differential
includes old lymphomatous infiltration, area of greater fatty
infiltration, or possibly an unusual appearance of a benign
lesion such as an atypical hemangioma could be considered.
There has been no definite recent change although the lesion is
easier to visualize on this study. If further characterization
is desired, then MR imaging may be useful.
CXR Chest: Study Date of ___
IMPRESSION:
Patchy new left mid and lower lung opacities, typical in
morphology for
atelectasis, although an infectious etiology is difficult to
completely
exclude based on the imaging.
CT Chest and Abdomen Study Date of ___
IMPRESSION:
1. Chronic pulmonary embolism with no evidence of new acute
pulmonary
embolism.
2. Geographical distribution of a hypodense area in the left
lobe of the
kidney, also seen on the ultrasound of the same day. While the
relative
degree of ___ is more striking on today's exam, the
etiology is uncertain. This was not avid on recent PET scan.
Differential includes old lymphomatous infiltration with marked
atrophy involving the left lobe or atrophy of other etiology;
there may be relative fatty infiltration at the site and an
unusual benign lesion such as a hemangioma could also be
involved.
3. Overall, extensive mediastinal, retroperitoneal, celiac and
pelvic
lymphadenopathy appears to be stable to slightly decreased in
size since the PET-CT from ___.
4. Splenomegaly.
5. No acute intra-abdominal or intrathoracic process to explain
the patient's pain.
___ Radiology CHEST (PA & LAT)
FINDINGS: Since the prior radiograph there are now small
bilateral pleural effusions. Left retrocardiac opacity likely
represents lower lobe pneumonia. There is no pneumothorax. The
cardiomediastinal silhouette is similar in appearance to the
prior radiograph. Bony structures are intact.
IMPRESSION:
1. Interval development of bilateral pleural effusions.
2. Retrocardiac opacity likely represents left lower lobe
pneumonia.
___ Radiology CHEST (PA & LAT)
FINDINGS: PA and lateral chest radiographs are obtained. Heart
is normal size and cardiomediastinal contours are unchanged.
Lungs do not demonstrate significant changes compared to the
prior radiograph. Opacification of the left base represents
atelectasis or consolidation. Persistent small right pleural
effusion with increased small left pleural effusion. No
pneumothorax.
IMPRESSION:
1. Persistent small pleural effusions bilaterally.
2. Left lower lobe atelectasis or consolidation.
MICRO:
___ 4:19 pm Direct Antigen Test for Herpes Simplex Virus
Types 1 & 2
Negative for Herpes simplex by immunofluorescence.
___ 4:19 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___: POSITIVE FOR VARICELLA ZOSTER.
Brief Hospital Course:
# Paroxysmal Atrial Fibrillation: Patient has history of atrial
fibrillation in setting of Hodgkin's lymphom diagnosis. He
experienced intermittent atrial fibrillation starting ___
with rates up to 150's. He had numerous conversions into and out
of afib: he was first converted to sinus rhythm with 5mg IV
metoprolol, however went back into atrial fibrillation with
rates in the 130's to 150's. He was converted a second time with
IV diltiazem drip, but returned to ___ fibrillation after
trying to transition to PO diltiazem. He was rate controlled on
metoprolol 25mg Q6H, and self-converted to sinus rhythm
overnight ___. With recommendations from cardiology, he
was also started on sotalol 80mg BID for addtional rate control.
His blood pressures were supported with IV fluid boluses, and he
never require pressors. He had been on lovenox for PE in
___, and was increased from 75mg to 100mg BID to account
for his weight.
# Abdominal Pain: LUQ abdominal pain and rib pain. Laboratory
values notable for mildly elevated alk phos, ALT and lactic acid
(2.5). Per ___ records, his Alk Phos had been elevated in the
past few months, likely secondary to his chemotherapy. RUQ
ultrasound showed biliary sludge without any evidenc of
cholecystitis. No acute processes seen on CXR. CT abdomen and
chest notable for hypodense area in liver, chronic PE and stable
LAD. ECG NSR without any evidence of ischemia. Patient spiked
fever to 102.7 and was started on Unasyn and cultured.
Antibiotics were subsequently discontinued due to low suspicion
for infection. Etiology unclear, but no evidence of acute
processes; may have been due to mild ileus from chemotherapy.
# Zoster: Patient had right sided chest pain wrapping around
torso during week prior to admission. He developed a herpetic
rash in T9 dermatome during admission consistent with zoster.
He was seen by dermatology who did a biopsy (positive for
varicella zoster) and was started on IV acyclovir 1000mg q8hrs
and put on precautions. The rash did not disseminate and
crusted over prior to discharge. He was subsequently
transitioned to PO acyclovir 800 mg PO 5x/day and will complete
total 10 days.
# Hodgkin's Lymphoma: Patient has stage IV Hodgkin's lymphoma.
He is being treated by Dr. ___ with a modified ABVD. He
finished his last infusion of chemotherapy on ___. He will
continue prophylaxis with bactrim SS daily and complete course
of acycovir for zoster. He will complete 7 days of neupogen
treatment starting 24 hours after infusion and follow up with
Dr. ___ in ___.
Transitional Issues:
-lovenox dosing and duration of treatment, to be discussed as
outpatient with Dr. ___ up with Dr. ___ GGT, unknown etiology
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Allopurinol ___ mg PO DAILY
2. Enoxaparin Sodium 70 mg SC Q12H
3. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*2
2. Enoxaparin Sodium 100 mg SC Q12H
RX *enoxaparin 100 mg/mL inject 1 syringe subcutaneous every 12
hours Disp #*60 Syringe Refills:*2
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Prochlorperazine 10 mg PO Q6H:PRN nausea
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth once a day Disp #*42 Tablet Refills:*0
6. Acyclovir 800 mg PO 5X/DAY
RX *acyclovir 800 mg 1 tablet(s) by mouth five times a day Disp
#*25 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 200 mg PO Q8H
please hold for sedation
RX *gabapentin 100 mg 2 capsule(s) by mouth every eight (8)
hours Disp #*90 Capsule Refills:*0
RX *gabapentin 100 mg 2 capsule(s) by mouth every eight (8)
hours Disp #*180 Tablet Refills:*2
9. Sotalol 80 mg PO BID
please hold for HR < 60
RX *sotalol 80 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*2
10. Omeprazole 40 mg PO DAILY:PRN reflux
11. Dexamethasone 4 mg PO BID Duration: 2 Days
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
12. Filgrastim 480 mcg SC Q24H Duration: 7 Days
take for 7 days after chemotherapy
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: atrial fibrillation, abdominal pain, herpes zoster
Secondary: Hodgkin's Lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dr. ___,
___ was a pleasure taking care of you at ___
___. You were admitted for abdominal pain of unclear
etiology. You also developed atrial fibrillation during your
admission which has converted back into sinus rhythm. On
discharge you will need to follow up with Dr. ___
cardiology. Please call his office to make a follow up
appointment in the next two weeks. You will also follow up with
Dr. ___ as detailed below.
New/Changed Medications:
-Sotalol 80 mg PO BID
-dexamethasone 4 mg PO BID for 2 days
-enoxaparin 100 mg/mL subcutaneous injection every 12 hours
-acyclovir 800 mg tab 5 times per day for 5 days (last day ___
___
-gabapentin 100 mg, 2 tabs every 8 hours
-neupogen 480 mcg/1.6mL one time daily for 7 days after chemo
Followup Instructions:
___
|
19994772-DS-23 | 19,994,772 | 29,199,248 | DS | 23 | 2181-04-02 00:00:00 | 2181-04-02 15:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Keflex
Attending: ___.
Chief Complaint:
Headache, nausea, and vomiting
Major Surgical or Invasive Procedure:
___: Suture closure of open temporal lobe incision by
neurosurgery
___: R craniectomy and wound revision
History of Present Illness:
This is a ___ year old female with a history of recurrent
glioblastoma in the right frontal lobe who is s/p radiation,
resection, and chemotherapy (see complete oncologic history
below) presenting with headache, nausea, and vomiting. Her
symptoms began around noon on day prior to admission; she called
Dr. ___ who recommended she present to the emergency
department. Her aunt drove her to the ED. She denied taking
any medications at home to treat her symptoms. She reports
fevers, chills, and photophobia associated with her symptoms but
denies abdominal pain, diarrhea, neck stiffness. She does
report a history of migraines and feels her symptoms are similar
to prior migraines. She received morphine, zofran, and decadron
in the ED and was transferred to the floor for further
management of her symptoms. Review of systems otherwise
negative for chest pain, chest pressure, shortness of breath,
numbness, tingling, weakness, dysuria.
Past Medical History:
___ with a history of recurrent glioblastoma in the right
frontal lobe s/p(1) a subtotal resection by Dr. ___ on
___, and
(2) received temozolomide chemo-irradiation from ___ to
___ to 6000 cGy,
(3) resection of recurrent tumor by Dr. ___ on
___,
(4) Portacath placement on ___,
(5) started NovoTTF-100A on ___, and
(6) started bevacizumab on ___.
-hyperlipidemia
Social History:
___
Family History:
non-contributory
Physical Exam:
*Admission Physical*
VS: temp 99.3, BP 133/76, HR 91, RR 20, 94% RA
Gen: Caucasian female, somnolent but arousable
HEENT: Anicteric
Neck: mild pain along lateral neck musculature, but able to
touch chin to chest
Cardiac: Nl s1/s2 RRR no murmurs appreciable
Pulm: lungs clear bilaterally
Abd: soft and nontender with normoactive bowel sounds
Ext: warm and well perfused
Neuro: nonfocal - no neurologic deficits evident
*Discharge Physical*
A&O X3
R pupil slugish, PERRL
CN II-XII intact
Cardiac: Nl s1/s2 RRR no murmurs appreciable
Pulm: lungs clear bilaterally
Abd: soft and nontender with normoactive bowel sounds
MAE and FC
Sensation intact
Incision healing well, there was no drainage noted.
Pertinent Results:
*Admission Labs*
___ 12:20AM BLOOD WBC-14.4*# RBC-3.85* Hgb-13.0 Hct-35.6*
MCV-93 MCH-33.8* MCHC-36.5* RDW-12.8 Plt ___
___ 12:20AM BLOOD Neuts-86.4* Lymphs-7.2* Monos-5.6 Eos-0.6
Baso-0.2
___ 12:20AM BLOOD Glucose-140* UreaN-18 Creat-0.7 Na-140
K-3.7 Cl-106 HCO3-22 AnGap-16
___ 12:20AM BLOOD ALT-19 AST-18 LD(LDH)-180 AlkPhos-85
TotBili-0.3
___ 12:20AM BLOOD Lipase-32
___ 05:52AM BLOOD Calcium-9.1 Phos-1.8*# Mg-1.9
___ 12:37AM BLOOD Lactate-1.7
*CSF*
___ 11:22AM CEREBROSPINAL FLUID (CSF) ___ RBC-375*
Polys-93 ___ ___ 11:22AM CEREBROSPINAL FLUID (CSF) TotProt-590*
Glucose-1 LD(LDH)-57
___ 11:23AM CEREBROSPINAL FLUID (CSF) WBC-7800 RBC-250*
Polys-90 ___ Monos-8 Basos-1
___ 03:43PM (CSF) BACTERIAL MENINGITIS ANTIGEN PANEL-PND
___ 11:48AM CEREBROSPINAL FLUID (CSF) Bacterial ID by
PCR-PND
*Urine*
___ 09:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 09:00PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
*Discharge Labs*
XXXXXXXXXXXXXXXXXXXXXXXXXX
*Microbiology*
___ Blood Culture: Negative
___ Blood Cultures: Pending
___ CSF Cryptococcal antigen: Negative
___ CSF Culture: 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI
IN PAIRS.
No Growth on Fluid culture or fungal culture as of
___ Urine Culture: Negative
___ C diff amplification: Negative
___ Wound culture from temporal lobe drainage: Coag negative
staph (rare)
*Cytology*
___: CSF negative for malignant cells
*Imaging*
___ CT Head w/o Contrast:
Large region of encephalomalacia is seen involving most of the
right frontal lobe and extends to the right lateral ventricle
with ex vacuo
dilatation. There is no hemorrhage, edema, shift of midline
structures, or
evidence of acute infarction. The basal cisterns are patent and
gray-white
matter differentiation is preserved. Post-surgical changes from
prior right frontoparietal craniotomy are noted. The visualized
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear.
IMPRESSION:
1. No acute hemorrhage or mass effect.
2. Large area of encephalomalacia in the right frontal lobe at
the site of
multiple prior resections.
___ MRI Head w/ and w/o contrast:
There is a large resection cavity in the right frontal lobe
without
any nodular enhancement. The postoperative cavity appears to
have minimally increased in size. There is a right frontal
cranioplasty. No fluid collection is noted superficial or deep
to the cranioplasty. There are no foci of restricted
diffusion. There is a stable infiltrative signal
abnormality along the margin of the operative cavity and
extending into the
corpus callosum on the left frontal lobe which could represent
combination of post-treatment changes and infiltrative neoplasm.
No evidence for acute
ischemia or hydrocephalus is seen.There is mild meningeal
enhancement, which could be postoperative in nature, but this
should be correlated with CSF studies. Ventricles are unchanged
in size and configuration.
IMPRESSION: Postoperative changes in the right frontal lobe,
but no definite evidence for infection noted. There is mild
meningeal enhancement, which could be postoperative in nature,
but this should be correlated with CSF studies.
___ CXR Portable: In comparison with study of ___, there
are substantially lower lung volumes, which may account for much
of the apparent increase in
transverse diameter of the heart. No evidence of vascular
congestion. There is some retrocardiac opacification medially.
It is unclear how much of this could represent some volume loss
or even consolidation in the lower lobe and how much could
merely be a manifestation of low lung volumes and the supine
portable technique. If clinically possible, lateral view would
be extremely helpful.
The right IJ catheter extends to about the level of the
cavoatrial junction or possibly in the upper portion of the
right atrium itself.
___ CXR PA/Lat: In comparison with study of ___, the patient
has taken a much better inspiration. Again there is an area of
increased opacification in the retrocardiac region with poor
definition of the descending aorta. Although this could merely
reflect atelectasis, the possibility of supervening pneumonia
would have to be considered in the appropriate clinical setting.
___ MRI C-spine (patient did not tolerate, stopped early):
Severely limited study due to motion artifact. Although there
are no findings to suggest epidural abscess, the study must be
considered nondiagnostic.
___: Non-Contrast Head CT
Status post right frontal craniectomy and drainage catheter
placement in a right frontal post-operative cystic collection
with interval decrease in size of a fluid collection.
___: Non-Contrast Head CT
Increased size of right frontal postoperative cystic fluid
collection from the most recent prior head CT of ___
without significantly increased mass effect. Status post right
frontal craniectomy with unchanged position of drainage
catheter.
___ bilateral lower extremity doppler ultrasound
IMPRESSION:
No evidence of deep vein thrombosis in the either leg.
Brief Hospital Course:
___ year old female with history of recurrent glioblastoma
present with worsening headache, nausea, fevers and vomiting.
#Bacterial Meningitis: Patient with worsening mental status
overnight of admission. Complaining of severe neck pain on
morning of ___ with difficulty moving without pain. Unable to
cooperate for Kernig's and Brudzinski's signs. Spiking fevers to
low 100s. LP performed ___ showing very high protein (590) and
very low glucose (1). Gram stain showed 4+pmns and 1+ GPCs in
clusters. ID was consulted for help with antibiotic coverage and
etiology of symptoms and meningitis. Patient was started on
vancomycin and meropenem for broad coverage. Vancomycin was
adjusted over several days for goal trough level of ___.
Patient continued to spike fevers during adjustment period as
initial troughs were low. WBC count initially elevated but
returned to normal on antibiotics. MRI head with and without
contrast was performed ___ which did not show any evidence of
intracranial abscess to explain ongoing fevers in spite of
antibiotics. MRI of whole spine attempted ___ given ongoing
fevers and concern for possible epidural abscess but patient did
tolerate MRI which was non-diagnostic. Culture of CSF did not
grow any organisms in spite of fact that patient was not on
antibiotics prior to LP. Her mental status waxed and waned with
periods of alertness and periods of extreme fatigue and
difficulty arousing patient. Narcotic pain meds were held as
these seemed to worsen her attention and alertness. Patient's
fevers subsided on ___.
Patient's parietal lobe incision from ___ was seen to be
leaking on HD1 with fluctuance anterior to incision at level
parietal bone. This was thought to be likely source of
meningitis given communication of CSF with outside world. She
was seen by neurosurgery who oversewed the wound where CSF
leakage was occuring on ___. Her wound reopened with continued
leakage on ___ and she was again seen by neurosurgery who
recommended she lay on her left side (opposite the incision).
Revision of surgery was initially held given recent Avastin and
active meningitis.
Given concern for ongoing fevers initially while on broad
spectrum antibiotics, evaluation of other etiologies were
performed. Patient was negative for C diff (had had diarrhea),
had no clear pneumonia on CXR, and no evidence of malaria on
thick and thin smear (given recent trip to ___).
.
#Anemia: Patient with baseline anemia w/ hct of 35. Acute hct
drop to 30 on admission but stable during hospital course. No
evidence of bleeding at site of LP. No other source of bleeding.
Would benefit from follow-up of Hct as outpatient to make sure
it is not continuing to trend down.
.
# History of recurrent glioblastoma: - s/p radiation, resection
and chemotherapy, currently on bevicizumab. Last resection was
on ___. Follow-up MRI in ___ showed multifocal residual tumor
at the resection margins, including possible subpial
involvement, superiorly, and subependymal involvement, dorsally.
Patient was continued on keppra for seizure prophylaxis.
Bevicizumab and TTF were held while inpatient. Neurosurgery was
consulted as above for leakage from previous incision site over
right parietal lobe.
.
# Hyperlipidemia: Patient was continued on home simvastatin.
# Code Status - FULL
Transitional Issues:
[ ] Antibiotic course
[ ] When to restart Avastin and ___
On ___, patient was transferred to the ___ and taken to
the ___ for revision of incision and R craniectomy. There were no
complications intraoperatively. A drain was placed in the R
frontal cyst and skin was closed. Patient was extubated and
transferred to the ICU for close monitoring. She is HOB>60
degrees and drain is leveled at 10cmH2O. Head CT was done and
showed post-operative changes. The bone flap was sent to
microbiology for culture. Gram staining was unable to be
performed secondary to the size of the specimen.
On ___, she remained neurologically stable. There was scant
cyst drainage into the drain. ID was consulted and recommended
continuing her antibiotics at the current regimen, Meropenum and
Vancomycin for 3-weeks. Sh was also fit for a helmet.
On ___ her vancomycin was increased to 1gram q8h per ID
recommendations and she was started on salt tabs. Her vancomycin
was subsequently changed back to 750mg q8hours later in the day.
On ___ her vancomycin trough was 8.3 and he dose was increased
to 1.5mg q12hours. Her drain was clamped. Her incision remained
dry and her exam remained stable.
On ___ PTT was elevated to 44, SQ heparin was decreased to BID
dosing. Drain remained clamped. She was written for transferred
to SDU.
On ___ we discontinued her drain and transferred to the floor.
On ___ she was stable. She was screened for rehab. Incision was
clean and dry.
On ___ the meropenem was discontinued, HCP updated. Sent urine
and ordered LENIS for an axillary temp of 99.9. D/C'd ivf. LENIS
were negative. Screened for SNF.
On ___ she remained afebrile. Waiting for rehab placement
On ___ she was refusing Salt tabs
On ___ She accepted to take sodium tabs, NA continues to
decrease.
On ___ sutures were removed. Na remained within normal limits.
On ___ Patient is being discharged to rehab in stable
condition.
Medications on Admission:
CELECOXIB [CELEBREX] - Celebrex ___ mg capsule. 1 capsule(s) by
mouth twice a day
LEVETIRACETAM - levetiracetam 500 mg tablet. 1 tablet(s) by
mouth
twice a day
OXYCODONE - oxycodone 5 mg tablet. one tablet(s) by mouth every
4
hours as needed for severe headaches - (Prescribed by Other
Provider)
RANITIDINE HCL [ZANTAC] - Zantac 150 mg tablet. 1 tablet(s) by
mouth once a day - (Prescribed by Other Provider)
SIMVASTATIN - simvastatin 10 mg tablet. one tablet(s) by mouth
daily - (Prescribed by Other Provider)
Medications - OTC
ACETAMINOPHEN - acetaminophen 325 mg tablet. one tablet(s) by
mouth every 4 hours as needed for mild headache - (Prescribed
by
Other Provider)
ASCORBIC ACID [VITAMIN C] - Dosage uncertain - (Prescribed by
Other Provider)
B COMPLEX VITAMINS [B COMPLEX] - Dosage uncertain - (Prescribed
by Other Provider)
CHOLECALCIFEROL (VITAMIN D3) [VITAMIN D3] - Dosage uncertain -
(Prescribed by Other Provider)
DOCUSATE SODIUM [COL-RITE] - Col-Rite 100 mg capsule. 1
capsule(s) by mouth twice a day as needed for constipation -
(Prescribed by Other Provider)
MELATONIN - Dosage uncertain - (Prescribed by Other Provider)
MULTIVITAMIN,TX-MINERALS [MULTI-VITAMIN HP/MINERALS] - Dosage
uncertain - (Prescribed by Other Provider)
OMEGA-3 FATTY ACIDS-VITAMIN E [FISH OIL] - Dosage uncertain -
(Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. LeVETiracetam 500 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Heparin 5000 UNIT SC BID
6. Heparin Flush (10 units/ml) 5 mL IV PRN line flush
7. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port
8. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
9. Megestrol Acetate 800 mg PO DAILY
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Sodium Chloride 2 gm PO TID
12. Famotidine 20 mg PO BID
13. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
14. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
15. Glucose Gel 15 g PO PRN hypoglycemia protocol
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Bacterial meningitis
Secondary: Glioblastoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
It was a pleasure taking care of you during your admission. You
were admitted with nausea, vomiting, fevers and headaches. A
lumbar puncture was performed which showed bacterial meningitis
(an infection of the lining around your brain). You were treated
with vancomycin and meropenem (antibiotics) and your fevers and
thinking slowly improved.
Your infection was thought to be due to an opening in the head
incision from your previous surgery. You were seen by
neurosurgery who sutured the wound closed to prevent further
bacteria from getting in.
Please take all of your medications as prescribed.
Followup Instructions:
___
|
19994772-DS-24 | 19,994,772 | 29,219,051 | DS | 24 | 2181-05-01 00:00:00 | 2181-05-02 21:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Keflex
Attending: ___.
Chief Complaint:
Aletered mental status and fever
Major Surgical or Invasive Procedure:
___ Neurosurgery for craniectomy wound washout
History of Present Illness:
___ is a ___ woman with past medical
history of glioblastoma and resection x2, chemotherapy and
radiation with recent admission from ___ for bacterial
meningitis with right craniectomy and wound revision who
presents from ___ with altered mental
status and fever. Patient's brother, ___, states that since
yesterday she has had a low grade fever and the nurse had
reported her being less alert and attentive. Her brother states
that she recovered back to baseline after the first two
surgeries but has not since the third. She has been more
lethargic though making some progress with rehab. She has had a
decreased appetite but will eat when spoon-fed. Patient states
she has a headache and chills but denies SOB, chest pain,
abdominal pain, nausea, vomiting or diarrhea.
In the ED, initial vital signs were: temperature 99.4 F, pulse
88, blood pressure 106/67, respiration 20 and oxygen saturation
99% in room air. She then spiked fever to 102.3 F. Dr. ___
___ from neurology was consulted and requested stat lumbar
puncture which was positive for protein 244, glucose 16, WBC 382
with 83% polys. UA large leukocytes, positive nitrites, >182 WBC
and few bacteria. Patient was given 1 dose of vancomycin and
ceftriaxone, Tylenol and ketorlac. Possible CSF leakage was
noted out of right craniectomy incision so neurosurgery was
called to evaluate the patient who then performed a bedside
closure. Vital signs on transfer: Temperature 98.6 F, pulse 93,
blood pressure 91/46, respiration 12 and oxygen saturation 98%
in room air.
On the floor, vital signs were: Temperature 98.7 F, blood
pressure 116/83, respiration 16, O2 saturation 99% in room air.
Patient denies headache, neck stiffness or nausea although there
is a pool of vomit next to her. She is shivering and feels cold.
She does not respond to most questioning.
Review of sytems:
(+) Per HPI
(-) Denies nausea or abdominal pain.
Past Medical History:
PAST MEDICAL HISTORY:
Recurrent glioblastoma in the right frontal lobe s/p a subtotal
resection by Dr. ___ on ___, and
(2) received temozolomide chemo-irradiation from ___ to
___ to 6000 cGy,
(3) resection of recurrent tumor by Dr. ___ on
___,
(4) Portacath placement on ___,
(5) started NovoTTF-100A on ___, and
(6) started bevacizumab on ___.
-hyperlipidemia
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vital Signs: Temperature 98.7 F, pulse 98, blood pressure
116/83, respiration 16 and O2 saturation 99% in room air
General: Alert to person and ___. Nods in affirmation to ___
___. Shivering.
HEENT: Right temporal incision scar with stitches in place
mid-incision, no active drainage. Sclera anicteric, MMM,
oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Cardiovascular: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops. Right chest portacath.
Abdomen: soft, diffusely tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Genitourinary: no foley
Extremities: warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neurological Examination: Cranial nerves ___ grossly intact,
moving four extremities spontaneously, not cooperative with
motor exam or ___ assessment
DISCHARGE PHYSICAL EXAMINATION:
General: Very pleasant, tired appearing, slow to respond to
questions
HEENT: Right temporal incision scar with stitches in place
mid-incision, no active drainage, wound clean and dry. Sclera
anicteric, MMM, oropharynx clear
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Cardiovascular: Regular rate and rhythm, normal S1 + S2, no
murmurs, rubs, gallops. Right chest portacath.
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Genitourinary: no foley
Extremities: warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neurological Examination: Cranial nerves ___ grossly intact,
moving four extremities spontaneously, strength ___ in upper
extremities, 4+/5 in lower extremities bilaterally.
Pertinent Results:
ADMISSION LABS
___ 03:39PM BLOOD WBC-10.7 RBC-4.02* Hgb-13.1 Hct-36.8
MCV-92 MCH-32.5* MCHC-35.5* RDW-12.7 Plt ___
___ 03:39PM BLOOD Neuts-84.7* Lymphs-8.9* Monos-5.8 Eos-0.3
Baso-0.4
___ 05:35AM BLOOD Plt ___
___ 10:07AM BLOOD ___ PTT-28.1 ___
___ 03:39PM BLOOD Glucose-109* UreaN-9 Creat-0.6 Na-133
K-4.1 Cl-103 HCO3-19* AnGap-15
___ 04:30AM BLOOD Calcium-10.3 Phos-3.8 Mg-2.0
DISCHARGE LABS:
___ 05:49AM BLOOD WBC-8.1 RBC-3.72* Hgb-12.3 Hct-34.8*
MCV-94 MCH-33.2* MCHC-35.5* RDW-14.0 Plt ___
___ 06:22AM BLOOD Neuts-83.8* Lymphs-9.7* Monos-5.9 Eos-0.4
Baso-0.3
___ 05:49AM BLOOD Plt ___
___ 05:49AM BLOOD Glucose-96 UreaN-14 Creat-0.4 Na-136
K-4.1 Cl-105 HCO3-24 AnGap-11
___ 04:02AM BLOOD ALT-22 AST-13 AlkPhos-46 TotBili-0.4
___ 05:49AM BLOOD Calcium-9.4 Phos-2.1* Mg-2.6
CSF STUDIES:
___ - WBC 268 RBC 0 Polys 88 Lymphs ___ Monos 6 Tprot 244 Gluc
16
Herpes simplex virus - negative
MICROBIOLOGY:
___ 6:45 pm CSF;SPINAL FLUID TUBE 3.
**FINAL REPORT ___
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to hematology for a quantitative white blood cell
count..
___ BLOOD CULTURE:
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ 8 I
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 2 S
VANCOMYCIN------------ 1 S
IMAGING/STUDIES
___ MRI HEAD W/ and W/O CONTRAST
Study somewhat limited by motion artifact, but there appears to
be a mild decrease in the intensity of enhancement around the
surgical site and within the occipital horns of the lateral
ventricles. Slow diffusion material in the occipital horns
appears unchanged. These findings are consistent with
intraventricular infection. No new abnormalities are detected.
___ CT HEAD
1. New pneumocephalus layering within the large right frontal
cyst, which is stable in size from the pre-operative exam.
2. New thin 5 mm fluid collection with an air-fluid level in
the subcutaneous tissues along the craniectomy bed.
3. No evidence of acute hemorrhage.
MRI of spine ___
1. Somewhat motion limited study.
2. No evidence of epidural abscess discitis osteomyelitis in the
cervical thoracic and lumbar region.
3. No evidence of cord compression or abnormal signal within the
spinal cord.
4. Mild enhancement of the lumbar nerve roots consistent with
patient's history of meningitis.
5. Areas of apparent increased signal within the lower lumbar
spinal canal on post gadolinium sagittal T1 images are
artifactual.
Brief Hospital Course:
___ is a ___ woman with glioblastoma,
status post resection x2, chemo, radiation, recent admission for
bacterial meningitis, presents from rehabilitation with altered
mental status and fever. She was found to have bacterial
meningitis from direct inoculation, now s/p washout of wound on
___ by neurosurgery.
1. Bacterial Meningoencephalitis: Likely bacterial based on high
protein, low glucose, neutrophil predominance on CSF sample.
Likely source is outside communication via open craniectomy
wound and patient continued to have clear leakage from wound.
Underwent washout of wound by neurosurgery on ___. HSV
negative, gram stain without organisms, CSF culture negative.
Now has cognitive slowing, consistent with parenchymal
involvement / encephalitis. Family meeting held ___ ___, aunt, brother, and husband outlined the poor
prognosis and it was decided to transition the patient to
hospice.
- Continue empiric treatment with vancomycin ___ to
___ and meropenem ___ to ___ for 3 week course
per ID (finish on ___. Covering for pseudomonas given
that patient was living in a nursing home (avoided cephalosprins
given Keflex allergy).
- ID recommended follow-up in ___ weeks, but family declined.
Phone number for ___ clinic is ___
- Please check weekly CBC with diff, chem7 and LFTs while on
antibiotics.
- Dr. ___ from neurosurgery is to remove sutures on
___, please do not change the dressing on the wound. If
leaking or concerns about the wound please call ___ to
confirm appointment with Dr. ___.
2. Bacteremia: Blood culture 1 out of 2 bottles on ___ grew
gram(+) cocci in clusters, now speciated with coag negative
staph, which is likely a contaminant, sensitive to vancomycin.
All other blood cultures negative
3. UTI: UA suggestive of UTI but UCx never sent before
antibiotics started.
- Patient is being treated with meropenem already
4. Recurrent Glioblastoma/Goals of Care: She is status post
radiation, resection
and chemotherapy, was on bevicizumab. Last tumor resection was
on ___, had wound revision and craniectomy on ___.
Follow-up MRI in ___ showed multifocal residual tumor at the
resection margins, including possible subpial involvement,
superiorly, and subependymal involvement, dorsally. MRI on
___ with signs of infection but no new abnormalities.
Goals of care discussion was held with patient's family on
___. Dr. ___ that the patient would likely
eventually succumb to infection or blood clots. Given recurrent
CNS infections, she will be unable to continue treatment for
glioblastoma. The family stated that patient previously
expressed a desire to go to an ___ facility at the
end of life. The plan is to complete her course of antibiotics
for her current infection, and eventually transfer to an
___ facility.
-Continue Keppra for seizure prophylaxis
-Continue dexamethasone 4mg q8h PO
-Code status affirmed DNR/DNI status
TRANSITIONAL ISSUES
CODE: DNR/DNI
EMERGENCY CONTACT: Aunt ___ (health care proxy)
___
- Neurosurgical wound to be managed by neurosurgery. Sutures
should be removed in clinic on ___
- Please check CBC/diff, chem7, and LFTs weekly while on
antibiotics
- Patient would like to transition to inpatient hospice after
completion of this course of antibiotics
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. LeVETiracetam 500 mg PO BID
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Insulin SC Sliding Scale using REG Insulin
6. Megestrol Acetate 800 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN nausea
8. Sodium Chloride 2 gm PO TID
9. Famotidine 20 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. LeVETiracetam 500 mg PO BID
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
reflux
7. Dexamethasone 4 mg PO Q8H
8. Meropenem ___ mg IV Q8H
9. Omeprazole 40 mg PO DAILY
10. Vancomycin 1500 mg IV Q 12H
11. Famotidine 20 mg PO BID
12. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Meningoencephalitis
Wound infection
Secondary diagnoses:
Glioblastoma
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair. Wear helmet when out of bed
Discharge Instructions:
Dear Ms ___,
You were hospitalized for fevers and confusion, and were found
to have meningoencephalitis, an infection of the fluid
surrounding your brain, and of the brain tissue itself.
Neurosurgery cleaned the wound during this hospitalization, and
the sutures will be removed at the neurosurgery appointment on
___. You will complete a 3 week course of antibiotics for
this infection.
According to the wishes you and your family communicated to us,
you will be transferring to a ___ facility with a focus on
treating any symptoms of pain or discomfort.
It was a pleasure being involved in your care,
Your ___ Team
Followup Instructions:
___
|
19994873-DS-16 | 19,994,873 | 29,045,765 | DS | 16 | 2160-03-09 00:00:00 | 2160-03-09 13:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
primidone
Attending: ___
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man s/p fall from standing. His wife
was in the same room and heard him fall, but does not know if
there was a associated syncope or seizure activity. OSH CT
showed a small SAH and R clavulcular frx. He was transferred to
___ for further care.
Past Medical History:
PMH: hypercholesterolemia, HTN, afib, arthritis, adenocarcinoma
lung, squamous cell face, left knee surgery, DM ___, CVA,
Sick sinus syndrome, essential tremor, recurrent falls.
PSH: Cholecystectomy, lung tumor removal
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Temp: 98.1 HR: 94 BP: 142/89 Resp: 16 O(2)Sat: 95 Normal
Constitutional: Comfortable
HEENT: small skin abrasion lateral to right eyebrow, no
active bleeding, Extraocular muscles intact
No C-spine tenderness
Chest: Clear to auscultation, no chest wall tenderness
Cardiovascular: Regular Rate and Rhythm
Abdominal: Nontender, Soft
GU/Flank: No costovertebral angle tenderness
Extr/Back: Right clavicle swelling and tenderness, pain with
ROM.
Skin: Warm and dry
Neuro: Speech fluent, moves all extremities except for right
arm, answering questions and following commands
appropriately, no focal neurological deficits
Psych: Normal mentation, Normal mood
___: No petechiae
Discharge Physical Exam:
VS: 97.4 PO 138 / 82 102 18 96 Ra
GENERAL: Elderly gentleman in NAD, daughter and wife at bedside
HEENT: dried scabs on R side of forehead, EOMI, PERRL, anicteric
sclera, pink conjunctiva, MMM, poor dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: irregularly irregular, S1/S2, no murmurs, gallops, or
rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose; lower legs both cool to touch
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact, strength ___ x ___xam
limited by clavicle fracture
SKIN: forehead lesions as above, cool ___ as above
Pertinent Results:
ADMISSION LABS:
===============
___ 05:28AM BLOOD WBC-5.2 RBC-3.95* Hgb-13.6* Hct-38.7*
MCV-98 MCH-34.4* MCHC-35.1 RDW-12.2 RDWSD-44.3 Plt ___
___ 04:29AM BLOOD WBC-7.0 RBC-4.06* Hgb-13.9 Hct-39.4*
MCV-97 MCH-34.2* MCHC-35.3 RDW-12.3 RDWSD-43.9 Plt ___
___ 04:29AM BLOOD ___ PTT-28.4 ___
___ 05:28AM BLOOD Glucose-152* UreaN-20 Creat-0.8 Na-136
K-4.0 Cl-98 HCO3-30 AnGap-12
___ 04:29AM BLOOD Glucose-111* UreaN-21* Creat-0.9 Na-139
K-3.5 Cl-100 HCO3-29 AnGap-14
___ 04:29AM BLOOD cTropnT-<0.01
___ 04:29AM BLOOD Calcium-8.7 Phos-3.4
DISCHARGE LABS:
==============
___ 05:04AM BLOOD WBC-6.2 RBC-3.88* Hgb-13.3* Hct-37.1*
MCV-96 MCH-34.3* MCHC-35.8 RDW-12.1 RDWSD-42.1 Plt ___
___ 05:04AM BLOOD Glucose-171* UreaN-13 Creat-0.8 Na-135
K-4.0 Cl-97 HCO3-28 AnGap-14
___ 05:04AM BLOOD Calcium-8.1* Phos-3.2 Mg-1.9
___ 05:28AM BLOOD VitB12-552
MICRO:
=====
Urine Culture: No Growth
IMAGING/STUDIES:
================
___ CXR:
IMPRESSION:
Increased heart size, mild pulmonary vascular congestion.
Suggestion of pleural effusion. Basilar opacity, likely
atelectasis, repeat lateral radiograph suggested. Acute or
subacute fracture distal right clavicle.
NCHCT ___:
Acute subarachnoid hemorrhage involving the right hemisphere,
the
magnitude of which is mild. No midlines shift. Age-related
atrophy and chronic white matter ischemic changes, no evidence
of
additional acute intracranial abnormality.
CT C-spine ___:
Marked degenerative disease, no definite fracture, soft tissues
unremarkable.
XR R shoulder ___:
Distal right clavicular fracture. No dislocation or shoulder or
humerus fracture.
Brief Hospital Course:
___ HTN, DM, Afib (not on AC), hx ___ presenting s/p
fall c/b SAH and clavicular fracture, initially admitted to ___
and subsequently transferred to medicine for fall/?syncope
workup.
ACUTE ISSUES
============
# SAH/R clavicular fracture: Pt initially presented to ___
where CT imaging showed small right new acute subdural
hemorrhage. Xray imaging showed new acute right clavicle
fracture. He was transferred to ___ for neurosurgical
evaluation. Neurosurgery was consulted and recommended no
intervention, frequent neurologic monitoring, and maintain
systolic blood pressure less than 160. Initially admitted to
surgery service. No neurosurgical intervention needed as SAH
small and stable. R clavicular fracture nonoperative. Sling
provided as needed for comfort. No need for keppra prophylaxis
per neurosurgery. Pt was on q4h neuro checks. He exhibited no
neurologic deficits, and did not require additional medication
for blood pressure control. ___ was consulted and recommended
discharge to rehab.
# Fall/syncope workup: Patient transferred to medicine service
for further workup of recent falls. Orthostatics positive. Pt
maintained on telemetry without arrhythmias noted (besides his
baseline Afib). TTE was ordered, but patient and family wished
to be discharged to rehab prior to the completion of this study.
This can be completed as an outpatient. No further
falls/syncope. B12 normal and infectious workup negative
(negative blood/urine cultures, CXR). Continued home florinef
(which was started for orthostatic hypotension).
# Afib: Pt not anticoagulated in setting of recent falls (was
previously on Eliquis, stopped in ___ due to falls).
Maintained good rate control on home meds and did not require
any further intervention.
# Urinary retention: Patient retained urine during
hospitalization, requiring foley catheter. Tamsulosin started.
UA with neg nit/leuks, 3 RBCs, 1 WBC. Foley catheter able to be
removed and patient voided without issue before discharge.
CHRONIC ISSUES
==============
# Hx ___: Continued home AED. According to outpatient
neurologist and family, pt's possible seizures are typically
characterized by aphasia and confusion. No concerning neuro
changes while in-house.
#Afib: Pt was previously on eliquis, but this was stopped I/s/o
frequent falls. Continued home propranolol (this is prescribed
for essential tremor but may be contributing to rate control).
HR was well controlled.
#HTN, HLD: continue home propranolol and simvastatin
#DM: ISS while in house
# Goals of care: Palliative care consulted per patient's family
request for more information about hospice. We confirmed pt's
DNR/DNI status, and filled out a MOLST with him before
discharge.
TRANSITIONAL ISSUES:
[] Consider obtaining TTE as an outpatient for further workup of
falls.
[] Pt noted to have incidental thrombocytopenia while admitted.
Platelets 121 on discharge. HCV negative. He had no evidence of
active bleeding other than provoked SAH as above. Consider
ongoing monitoring of platelets as an outpatient.
[] Clavicle fracture: pt should avoid lifting with R arm, but
ROM exercises as tolerated are fine
#Code Status: DNR/DNI (confirmed with patient and family)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 20 mg PO QPM
2. Propranolol 10 mg PO DAILY
3. Valproic Acid ___ mg PO Q8H
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Nexium 40 mg Other DAILY
6. 70/30 20 Units Breakfast
70/30 10 Units Bedtime
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
3. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol
4. Docusate Sodium 100 mg PO BID
5. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
6. Glucose Gel 15 g PO PRN hypoglycemia protocol
7. Heparin 5000 UNIT SC BID
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Senna 8.6 mg PO BID:PRN constipation
10. Tamsulosin 0.4 mg PO QHS
11. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth q6 hours
Disp #*16 Tablet Refills:*0
12. 70/30 20 Units Breakfast
70/30 10 Units Bedtime
13. Fludrocortisone Acetate 0.1 mg PO DAILY
14. Nexium 40 mg Other DAILY
15. Propranolol 10 mg PO DAILY
16. Simvastatin 20 mg PO QPM
17. Valproic Acid ___ mg PO Q12H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Subarachnoid hemorrhage
R Clavicular fracture
Fall
Secondary diagnoses:
Hypertension
Diabetes
Atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dr. ___,
You were admitted to the Acute Care Trauma Surgery Service at
___ after a fall that caused a small bleed in your head
and a right clavicle fracture. You were seen and evaluated by
the neurosurgery team for your head bleed and no intervention
was needed. Your clavicle fracture is stable and will continue
to heal without surgical intervention. Please continue to avoid
using your right arm for activity but range of motion exercises
as tolerated are okay. Wear your sling for comfort as needed.
The medical team was contacted to further evaluate for
underlying causes of your falls. You chose not to stay for an
echocardiogram of your heart. This can be done as an outpatient.
Thank you for allowing us to participate in your care.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19995012-DS-13 | 19,995,012 | 23,737,876 | DS | 13 | 2161-02-16 00:00:00 | 2161-02-16 14:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Penicillins / Percocet / metformin
Attending: ___
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Diagnostic coronary angiogram
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is.free of significant disease.
* Left Anterior Descending
The LAD has mid 40% stenosis.
* Circumflex
The Circumflex has origin 40% stenosis.
The ___ Marginal has origin 50% stenosis.
* Right Coronary Artery
The RCA is very difficult to engage. Non-selective angiography
shows mid ___ stenosis.
The Right PDA is a small vessel and the distal RCA is possibly
occluded before a small RPL branch.
Impressions:
1. Moderate 3 vessel CAD with possible branch occlusion of
distal RCA. There are no good targets for PCI or surgery.
Recommendations
1. Medical therapy,
History of Present Illness:
This patient is a ___ year old female who complains of headache
following a fall at a casino three days ago, injuring the left
side of her face. She has poor recall of the circumstances and
since has had left sided headaches and facial pain. She reports
three weeks of dyspnea and non-productive cough for which she
saw her PCP one week ago.
Past Medical History:
diabetes
hypothyroidism
hypertension
obesity
arthritis, chronic pain
-s/p:
bilateral TKRs
hernia repair x5
cholecystectomy
Social History:
___
Family History:
Family history of arthritis
Physical Exam:
On Admission:
PHYSICAL EXAMINATION
Temp: 98.9 HR: 72 BP: 153/69 Resp: 16 O(2)Sat: 99 Normal
Constitutional: Comfortable
HEENT: abrasion over her left zygoma, Pupils equal, round
and reactive to light, Extraocular muscles intact
diffuse C-spine tenderness
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Extr/Back: No cyanosis, clubbing or edema
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mentation
___: No petechiae
ECG
Heart Rate: 70
Rhythm: Sinus
Ischemia: None
ECG Axis: Normal
Intervals: Normal
Comparison to prior results: Same
At Discharge:
VS: T 98 HR 70 RR 18 BP 138/78 97% RA
tele: SR 70-90's
General: no c/o discomfort currently, asking why her BP was so
high post procedure and her severe headache cause
HEENT: no JVP appreciated. supple, thick neck, no masses
CHEST: CTAB
CV: RRR no m/r/g
ABD: Soft, obese, NT, +BS
Skin: Warm and dry, R radial access site with gauze and Tegaderm
c/d/I, no erythema or excess warmth
Neuro: Grossly N/V/I, moving all 4 extremities, thoughts linear,
crosses hemispheres, answering questions appropriately
Pertinent Results:
LABS ON ADMISSION:
___ 09:30AM BLOOD WBC-6.3 RBC-3.96 Hgb-11.9 Hct-36.9 MCV-93
MCH-30.1 MCHC-32.2 RDW-13.2 RDWSD-45.1 Plt ___
___ 09:30AM BLOOD Neuts-59.3 ___ Monos-8.1 Eos-2.2
Baso-1.0 Im ___ AbsNeut-3.71 AbsLymp-1.79 AbsMono-0.51
AbsEos-0.14 AbsBaso-0.06
___ 09:30AM BLOOD ___ PTT-34.3 ___
___ 09:30AM BLOOD Glucose-169* UreaN-10 Creat-0.7 Na-139
K-3.6 Cl-100 HCO3-23 AnGap-20
___ 09:30AM BLOOD cTropnT-<0.01
___ 04:30PM BLOOD cTropnT-<0.01
___ 09:30AM BLOOD proBNP-111
___ 09:30AM BLOOD Calcium-8.8 Phos-3.1 Mg-1.6
LABS AT DISCHARGE:
___ 06:00AM BLOOD WBC-10.6* RBC-3.78* Hgb-11.9 Hct-35.1
MCV-93 MCH-31.5 MCHC-33.9 RDW-13.5 RDWSD-46.5* Plt ___
___ 06:00AM BLOOD ___ PTT-33.3 ___
___ 06:00AM BLOOD Glucose-209* UreaN-12 Creat-0.8 Na-136
K-4.4 Cl-98 HCO3-19* AnGap-23*
___ 06:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-1.7
CATHETERIZATIN REPORT ___:
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery
The LMCA is.free of significant disease.
* Left Anterior Descending
The LAD has mid 40% stenosis.
* Circumflex
The Circumflex has orign 40% stenosis.
The ___ Marginal has oirigin 50% stenosis.
* Right Coronary Artery
The RCA is very difficult to engage. Non-selective angiography
shows mid ___ stenosis.
The Right PDA is a small vessel and the distal RCA is possibly
occluded before a small RPL branch.
Impressions:
1. Moderate 3 vessel CAD with possible branch occlusion of
distal RCA. There are no good targets for PCI or surgery.
Recommendations
1. Medical therapy,
CARDIAC PERFUSION STUDY ___:
SUMMARY FROM THE EXERCISE LAB:
For pharmacologic stress dipyridamole was infused intravenously
for
approximately 4 minutes at a dose of 0.142
milligram/kilogram/min. 1 to 2
minutes after the cessation of infusion, the stress dose of the
radiotracer was injected. She had no anginal symptoms or
ischemic ECG changes.
TECHNIQUE:
ISOTOPE DATA: (___) 31.9 mCi Tc-99m Sestamibi Stress; DRUG
DATA: (Non-NM admin) Dipyridamole; Following intravenous
infusion of the pharmacologic agent, Tc-99m sestamibi was
administered intravenously. Stress images were obtained
approximately 30 minutes following tracer injection.
Resting perfusion images were obtained on a subsequent day with
Tc-99m
sestamibi. Tracer was injected approximately 45 minutes prior to
obtaining the resting images.
Imaging protocol: Gated SPECT.
This study was interpreted using the 17-segment myocardial
perfusion model.
FINDINGS:
The image quality is adequate but limited due to soft tissue and
breast
attenuation.
Left ventricular cavity size is normal.
Rest and stress perfusion images reveal a reversible, mild
reduction in photon
counts involving the entire inferior wall.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 57% with an
EDV of 77 ml.
IMPRESSION:
1. Reversible, medium sized, mild perfusion defect involving the
RCA territory.
2. Normal left ventricular cavity size and systolic function.
CT HEAD w/o CONTRAST ___:
COMPARISON: CT head without contrast ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass.
There is
prominence of the ventricles and sulci suggestive of
involutional changes.
There is no evidence of fracture. Small mucous retention cyst
is noted in the right anterior ethmoid sinus. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. No acute intracranial process.
CT C-SPINE w/o CONTRAST ___:
FINDINGS:
Alignment is normal. No fractures are identified. There is no
prevertebral
soft tissue swelling. Degenerative changes notable for disc
bulges and
thickening of the ligamentum flavum. Disc protrusion at C2-3
and C3-4 effaces the ventral CSF and may contact the ventral
aspect of the cord.
Thyroid is small but grossly unremarkable. Lung apices are
notable for a 3 mm right apical nodule (3:70), unchanged from
prior.
IMPRESSION:
No acute fracture or malalignment of the cervical spine.
A 3 mm right apical pulmonary nodule unchanged since prior ___.
RECOMMENDATION(S): If patient has risk factors such as smoking
or malignancy, ___ year followup suggested for followup of a 3 mm
right apical pulmonary nodule. Otherwise no additional imaging
necessary.
CT SINUS ___:
FINDINGS:
There is no facial bone fracture. Pterygoid plates are intact.
There is no mandibular fracture and the temporomandibular joints
are anatomically aligned. The orbits are intact. The globes and
extra-ocular muscles are unremarkable.
There is no orbital hematoma.
Included paranasal sinuses are clear besides a mucous retention
cyst in the right maxillary sinus. Included extracranial soft
tissues are unremarkable.
IMPRESSION:
No fracture.
CXR PA & LATERAL ___:
FINDINGS:
Slightly lower lung volumes on the current exam. Lungs remain
clear without consolidation, effusion, or edema.
Cardiomediastinal silhouette is stable. Atherosclerotic
calcifications seen at the aortic arch. No acute osseous
abnormalities, hypertrophic changes again noted in the spine.
IMPRESSION:
No acute cardiopulmonary process.
Brief Hospital Course:
The patient presented to the ED complaining of a headache, SOB
and facial pain following a fall at a casino several days
earlier. She reports no significant headaches in the past and
when quizzed regarding her blood pressure control states she
checks her pressure at home and it typically runs in the 120's
systolic. She was subsequently transferred to the ___ for
further observation until she underwent numerous studies include
a pharmacological stress test indicating a mild perfusion
defect. It was suspected given her history that she could have
coronary artery disease. She underwent catheterization on
___ and had three vessel moderate disease not obstructive or
amenable to PCI or surgery and to continue/enhance medical
management, particularly in light of her other co-morbidities
including obesity and diabetes. She was expected to discharge
home following the catheterization but reported a severe
headache and had a high blood pressure running to 230/97. She
was subsequently triggered and had vomiting. She was given
Zofran, Hydralazine and persistently hypertensive. A nitro drip
was started and she was given Ativan to help with her anxiety
and her nausea, which subsequently resolved. She was started on
Atorvastatin and Metoprolol. Her blood pressure normalized by
the early morning hours on ___ and her nitro drip was
discontinued. At the time of discharge, her blood pressure was
ranging in the 130's systolic. She had no further headache, was
tolerating her diet and voiding without difficulty. She was
counseled regarding lifestyle changes, management of blood
pressure and close follow up with her physicians. Her headache
was felt to be multi-factorial, including her NPO status until
her late day catheterization, and her high blood pressures,
which likely exist at home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 100 mg PO DAILY
2. Sucralfate 1 gm PO QID
3. Levothyroxine Sodium 125 mcg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. GlipiZIDE 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Metoprolol Tartrate 25 mg PO BID
4. Cyanocobalamin 1000 mcg PO DAILY
5. GlipiZIDE 5 mg PO DAILY
6. Levothyroxine Sodium 125 mcg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Sucralfate 1 gm PO QID
Discharge Disposition:
Home
Discharge Diagnosis:
NEW:
Abnormal stress test:
Cardiac Cath: multivessel moderate disease, no obstructive CAD
w/o good targets for PCI or surgery - manage medically
PRIOR:
DM Type 2
Hypertension
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
VS: T 98 HR 70 RR 18 BP 134/65 97% RA
tele: SR 70-90's
LABS: Na2+ 136; K+ 4.4; Cl- 98; HCO3 19; BUN 12; Cr 0.8; Ca2+
9.1; P 3.8; Mg2+ 1.7
PHYSICAL EXAM:
Gen: ___ yr old woman in NAD. Seen post-procedure. She is alert
and oriented and resting comfortably with no CP, SOB,
palpitations or dizziness
Neck: No JVD appreciated
Lungs: CTAB, no wheezing or rhonchi
Heart: S1S2 regular, no MRG
Abd: soft, obese, non-tender, BS +
PV: right radial site is soft with no bleeding or hematoma.
gauze and Tegaderm c/d/I. Good CSM to wrist. Pedal pulses
palpable. No clubbing, cyanosis or edema
Neuro: Alert and oriented x 3. No focal deficits or asymmetries
noted.
A/P: ___ from ED after + pharm stress showing a 'reversible,
medium sized, mild perfusion defect involving the RCA
territory'. Initially presented with left sided headache s/p
fall at a casino on ___ with ongoing sharp left-sided
headaches and facial pain. Her head CT was negative. At that
time, she complained of dyspnea with exertion, prompting cardiac
workup. EKG: NSR @ 70, NA/NI, no ischemia or ectopy, Trop-
negative x2. She underwent a coronary angiogram, which showed
moderate 3 vessel CAD
#. CAD
-start ASA 81
-start Atorvastatin (escripted to her pharmacy)
-start Metoprolol 25 mg bid (escripted to her pharmacy)
-follow up with Dr. ___ in ___ wks
#. DM A1C 7.3%
-cont Glipizide
-heart healthy carb consistent diet
#. Hypertension
-cont Losartan
-Added Metoprolol
#. Disp
-DC home
Discharge Instructions:
You were admitted overnight to our cardiac direct access unit
for monitoring due to your symptoms of shortness of breath and
abnormal stress test. You had an elevated blood pressures that
required some additional medication. We also imaged your head
which was negative for any bleeding or stroke.
You had a cardiac catheterization which showed that you had some
blockages in 3 of your heart arteries. Because of these
blockages, you were started on a low dose Aspirin, Atorvastatin
and Metoprolol. You will follow up with Dr. ___ in ___ weeks.
Activity restrictions and care of our wrist site will be
included in your discharge instructions.
Please follow up with your PCP within the next ___ weeks for
continued outpatient management.
Followup Instructions:
___
|
19995012-DS-14 | 19,995,012 | 27,305,089 | DS | 14 | 2161-05-01 00:00:00 | 2161-05-02 13:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Ace Inhibitors / Penicillins / Percocet / metformin
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___ incisional hernia repair with underlay mesh, lipoma
excision
History of Present Illness:
Ms. ___ is a ___ year old female with history of NIDDM, CAD
(cath ___ and PDA occlusion not amenable to
revascularization), hyperlipidemia
presents with abdominal pain and acute onset diarrhea starting
at 7pm last evening. She denies nausea or vomiting. She has
never experienced similar episodes; however, she continues to
pass flatus and have bowel movements. She continues to have pain
but has been alleviated with medication. The pain is constant in
her abdomen and has not remitted.
Past Medical History:
diabetes
hypothyroidism
hypertension
obesity
arthritis, chronic pain
-s/p:
bilateral TKRs
hernia repair x5
cholecystectomy
Social History:
___
Family History:
Family history of arthritis
Physical Exam:
Admission Physical Exam:
Vitals: 97.8 63 179/78 18 100%RA
GEN: AOx3, NAD, obese
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, tender over paramedian incision +guarding, no
rebound,
unable to reduce as the exam is limited by pain, 2 separate
hernias appreciated on exam.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 97.6, 147/73, 60, 20, 95% RA
Gen: A&O x3
CV: HRR
Pulm: CTAB
Abd: soft, NT/ND. Midline incision w/ staples, OTA
Ext: No edema
Pertinent Results:
___ 12:25AM BLOOD WBC-11.1* RBC-3.88* Hgb-11.3 Hct-35.4
MCV-91 MCH-29.1 MCHC-31.9* RDW-13.1 RDWSD-43.2 Plt ___
___ 10:46AM BLOOD WBC-9.6 RBC-3.64* Hgb-10.7* Hct-33.6*
MCV-92 MCH-29.4 MCHC-31.8* RDW-13.1 RDWSD-44.3 Plt ___
___ 10:00PM BLOOD WBC-12.8* RBC-3.71* Hgb-11.1* Hct-34.2
MCV-92 MCH-29.9 MCHC-32.5 RDW-13.2 RDWSD-44.6 Plt ___
___ 05:16AM BLOOD WBC-13.3* RBC-3.60* Hgb-10.8* Hct-33.5*
MCV-93 MCH-30.0 MCHC-32.2 RDW-13.4 RDWSD-45.4 Plt ___
___ 05:40AM BLOOD WBC-9.6 RBC-3.21* Hgb-9.5* Hct-30.0*
MCV-94 MCH-29.6 MCHC-31.7* RDW-13.2 RDWSD-45.5 Plt ___
___ 06:15AM BLOOD WBC-8.7 RBC-2.97* Hgb-8.9* Hct-27.9*
MCV-94 MCH-30.0 MCHC-31.9* RDW-13.2 RDWSD-45.9 Plt ___
___ 05:30AM BLOOD WBC-7.6 RBC-2.99* Hgb-8.9* Hct-27.9*
MCV-93 MCH-29.8 MCHC-31.9* RDW-13.1 RDWSD-44.5 Plt ___
___ 05:30AM BLOOD Glucose-147* UreaN-7 Creat-0.7 Na-139
K-3.7 Cl-102 HCO3-27 AnGap-14
___ 06:15AM BLOOD Glucose-140* UreaN-6 Creat-0.7 Na-140
K-3.4 Cl-102 HCO3-24 AnGap-17
___ 05:40AM BLOOD Glucose-143* UreaN-7 Creat-0.8 Na-138
K-3.3 Cl-100 HCO3-25 AnGap-16
___ 05:16AM BLOOD Glucose-155* UreaN-12 Creat-1.0 Na-144
K-4.0 Cl-106 HCO3-24 AnGap-18
___ 10:00PM BLOOD Glucose-214* UreaN-15 Creat-1.0 Na-139
K-3.2* Cl-103 HCO3-21* AnGap-18
___ 05:30AM BLOOD Calcium-8.3* Phos-2.5* Mg-1.7
___ 06:15AM BLOOD Calcium-7.7* Phos-2.5* Mg-1.8
___ 05:40AM BLOOD Calcium-7.5* Phos-2.6* Mg-1.4*
CT A/P:
1. Re-demonstrated are 2 midline, ventral abdominal wall
hernias-the hernia located more cranially contains a small
segment of the nonobstructed transverse colon, while the hernia
located caudally contains a small portion of a small bowel loop.
There is trace fluid within the hernial sac containing the
small bowel however no transition point or other evidence to
suggest bowel obstruction noted. There has been prior mesh
repair of the ventral abdominal wall and the mesh is located
inferior to the latter hernial sac.
2. Mild hepatic steatosis, extensive sigmoid diverticulosis,
severe
atherosclerotic calcification of the abdominal aorta and its
branches with
focal narrowing (up to 50%) at the origin of the celiac artery
are additional incidental findings.
Brief Hospital Course:
Ms. ___ is a ___ year old female who presented to the
Emergency Department on ___ with abdominal pain. The
patient was evaluated by the Acute Care Surgery Service and a CT
scan of abdomen and pelvis was obtained. These images revealed
an incarcerated hernia. Given these findings, the patient was
taken to the operating room for repair. There were no adverse
events in the operating room; please see the operative note for
details. She was extubated, taken to the PACU until stable, then
transferred to the surgical floor for observation.
The patient was alert and oriented throughout hospitalization;
pain was initially managed with IV Tylenol and Dilaudid and then
transitioned to oral Tylenol and Tramadol once tolerating a
diet.
The patient remained stable from a cardiovascular standpoint;
vital signs were routinely monitored.
She remained stable from a pulmonary standpoint; vital signs
were routinely monitored. Good pulmonary toileting, early
ambulation and incentive spirometry were encouraged throughout
hospitalization.
The patient was initially kept NPO. On POD1 diet was advanced to
clears with good tolerability. On POD2 the patient tolerated a
regular diet. Patient's intake and output were closely monitored
She has a midline incision to her abdomen with staples that are
clean, dry and intact (will be removed at follow up appointment
with Dr. ___. Her bowel function returned and began to
pass gas and have bowel movements.
The patient's fever curves were closely watched for signs of
infection, of which there were none.
The patient's blood counts were closely watched for signs of
bleeding, of which there were none.
The patient received subcutaneous heparin and ___ dyne boots
were used during this stay and was encouraged to get up and
ambulate as early as possible.
The patient was seen and evaluated by physical therapy who
recommended discharge to home with continued home physical
therapy.
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:
AMMONIUM LACTATE - ammonium lactate 12 % topical cream. apply to
dry skin on feet but not between toes twice a day
ATORVASTATIN - atorvastatin 80 mg tablet. 1 tablet(s) by mouth
once a day
ERGOCALCIFEROL (VITAMIN D2) - ergocalciferol (vitamin D2) 50,000
unit capsule. 1 capsule(s) by mouth 1 week for 40 weeks get
repeat level when this is completed - (Not Taking as
Prescribed)
FLUTICASONE - fluticasone 50 mcg/actuation nasal
spray,suspension. 2 sprays(s) each nostril daily as needed for
congestion or post nasal drip for 2 weeks
GLIPIZIDE - glipizide 5 mg tablet. One tablet(s) by mouth daily
HYDROCORTISONE - hydrocortisone 2.5 % topical ointment. apply
pea
size to affected area every day after bathing for 14 days, then
as needed for itching
ISOSORBIDE MONONITRATE - isosorbide mononitrate ER 30 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth daily
LEVOTHYROXINE - levothyroxine 150 mcg tablet. 1 tablet(s) by
mouth daily This is an INCREASED dose
LOSARTAN - losartan 100 mg tablet. 1 tablet(s) by mouth once a
day
METOPROLOL TARTRATE - metoprolol tartrate 25 mg tablet. 1
tablet(s) by mouth twice a day
PENCICLOVIR [DENAVIR] - Denavir 1 % topical cream. apply to lips
every 2 hours until cold sores resolve - (Not Taking as
Prescribed: discontinued)
SUCRALFATE - sucralfate 1 gram tablet. 1 tablet(s) by mouth tid
before meals and hs tell her to take about 30min before meals.
STOP THE PANTAPROZOLE
Medications - OTC
ASPIRIN - aspirin 81 mg tablet,delayed release. 1 Tablet(s) by
mouth once a day - (Not Taking as Prescribed)
BLOOD SUGAR DIAGNOSTIC [ONETOUCH ULTRA TEST] - OneTouch Ultra
Test strips. Use as directed for blood sugar monitoring twice a
day and as needed. Dx Code: 250.00 - (Not Taking as Prescribed:
discontinued)
BLOOD-GLUCOSE METER [ONETOUCH ULTRA2] - OneTouch Ultra2 kit. Use
as directed for blood sugar monitoring twice a day and as needed
Dx Code: 250.00 - (Not Taking as Prescribed: discontinued)
CAMPHOR-MENTHOL [ANTI-ITCH (MENTHOL/CAMPHOR)] - Anti-Itch
(menthol/camphor) 0.5 %-0.5 % lotion. apply to affected areas as
needed as needed for itch disp qs for 30 days - (Pt denies
taking) (Not Taking as Prescribed: discontinued)
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000
mcg tablet. 1 tablet(s) by mouth daily
LANCETS [ONETOUCH ULTRASOFT LANCETS] - OneTouch UltraSoft
Lancets. Use as directed for blood sugar monitoring twice a day
and as needed Dx Code: 250.00 - (Not Taking as Prescribed:
discontinued)
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*20 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*20 Capsule Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
4. TraMADol ___ mg PO Q6H:PRN Pain - Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
RX *tramadol 50 mg ___ tablet(s) by mouth every six (6) hours
Disp #*15 Tablet Refills:*0
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 80 mg PO QPM
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. GlipiZIDE 5 mg PO DAILY
9. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
10. Levothyroxine Sodium 150 mcg PO DAILY
11. Losartan Potassium 100 mg PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Ventral hernia, lipoma of the abdominal wall
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 ___ on
___ with abdominal pain. You were evaluated by the Acute
Care Surgery Service and after a CT scan was done, we found a
piece of your bowel was entrapped in your stomach lining. We
took you to the operating room and repaired this. You tolerated
the procedure well and are now being discharged home to continue
your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
It was a pleasure being part of your care!
Followup Instructions:
___
|
19995127-DS-11 | 19,995,127 | 21,801,907 | DS | 11 | 2138-03-11 00:00:00 | 2138-03-11 15:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Atorvastatin
Attending: ___.
Chief Complaint:
depression, anorexia, with cough
Major Surgical or Invasive Procedure:
biopsy of lung mass (left upper and left lower lobes), via
bronchoscopy
History of Present Illness:
PCP: ___ MD
CC: ___ mood, decreased appetite, found to have new chest
mass
HISTORY OF PRESENT ILLNESS: This is an ___ yom with PMH of
hypertension, hyperlipidemia, and hyperthyroidism status post
RAI ablation on ___ who presents with worsening fatigue
and insominia over ___ weeks. He says that his appetite had
generally been good but this morning reported poor appetite and
became suddenly tearful. He has also had decreasing interest in
his activities over this time. He denies hallucinations,
suicidal ideation, or homicidal ideations. Ultimately given his
progressing symptoms, he went to the emergency department. The
patient has no psychiatric history.
While in the ED, pt had a CT head given concern for AMS, which
showed no acute intracranial process but chronic microvascular
ischemic changes with global atrophy. He also had CXR done which
showed 6.2 x 5 cm mass projecting to the superior segment of the
left lower lobe, concerning for malignancy particularly with
calcified pleural plaques. CT chest was obtained which confirmed
8.5 cm left upper and lower lobe mass, infiltrating the
mediastinum with loss of fat planes with the, esophagus, and
occluding a short segment of the left lower lobe pulmonary
artery with distal reconstitution.
Psych saw the patient who felt he did not meet ___
criteria. He was admited to medicine given finding of new mass
and for medical clearance prior to ___ bed search. They
recommended starting mirtazapine for sleep/depression.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
PAST MEDICAL HISTORY:
Hypertension
Hyperlipidemia
Left common iliac anneurysm
hyperthyroidism status post RAI ablation on ___
Social History:
___
Family History:
FAMILY HISTORY:
-Thyroid issues in his cousins
-Lung cancer in his sister.
Physical Exam:
ADMISSION
PHYSICAL EXAM:
VS: 98.3 129/56 83 16 955 ra
GENERAL: well appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, JVP normal
LUNGS: CTA bilat, no wheezes or crackles
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
PSYCH: Affect appropriate, speech fluent, denying SI/HI
DISCHARGE
PE:98.1 119/77 83 20 97%RA
GENERAL: NAD,
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, JVP normal
LUNGS:some ronchi
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities
PSYCH: Affect appropriate, speech fluent,
Pertinent Results:
ADMISSION LABS
___ 02:07PM BLOOD WBC-7.7 RBC-5.32 Hgb-14.0 Hct-44.4 MCV-84
MCH-26.3* MCHC-31.6 RDW-14.5 Plt ___
___ 02:07PM BLOOD Glucose-109* UreaN-21* Creat-1.1 Na-135
K-5.3* Cl-97 HCO3-30 AnGap-13
___ 08:11AM BLOOD Calcium-8.8 Phos-4.0 Mg-2.1
___ 02:07PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
IMAGING
CXR ___
A mass is present in the superior segment of the left lower lobe
and therefore malignancy must be considered. Elsewhere, the
left lung appears clear. There is no effusion. Calcified
pleural plaque is present in the right mid zone. The right lung
appears clear.
Some tracheal displacement to the right is present at the
thoracic inlet
probably due to thyroid, but lymph nodes should also be
considered.
IMPRESSION: Left lung mass. CT should be performed.
CT chest ___. 8.5 cm (in longest dimension) left upper and lower lobe mass
traverses the major fissure, infiltrates the mediastinum with
loss of fat planes with the esophagus, and occludes a short
segment of the left lower lobe pulmonary artery with distal
reconstitution. Mild narrowing of the left upper and lower lobe
airways without lobar collapse. Mild surrounding septal
thickening could reflect postobstructive changes or lymphangitic
tumor spread.
Esophageal compression and thickening from the mass, correlate
for history of dysphagia.
2. Pleural plaques with subpleural reticulations consistent with
asbestosis from prior exposure as well as moderate emphysema.
3. Heterogeneous enlarged left thyroid gland as before status
post recent
radioactive iodine therapy.
4. Unchanged left adrenal nodularity. While the nodules were of
indeterminate density on prior non-contrast abdominal CT
examinations, stability in size since ___ suggests benignity.
5. Mild heterogeneity in the T3 vertebral body is nonspecific
and can be
correlated with bone scan if indicated.
Preliminary findings were discussed with Dr. ___ by Dr. ___
at 2215 on
___ by phone.
Final Report
HISTORY: Mass on chest radiograph.
TECHNIQUE: CT images were obtained through the chest after the
uneventful
intravenous administration of 75 cc of Omnipaque contrast media.
Multiplanar
reformations were prepared.
COMPARISON: ___, CT abdomen ___
FINDINGS: The left thyroid lobe remains heterogeneous and
enlarged as on
previous studies in this patient status post recent radioactive
iodine therapy on ___ (2:2). The aorta and major
branches are patent and normal in caliber with mild
atherosclerotic calcifications. The heart and pericardium are
unremarkable without pericardial effusion. The previously
described anterior mediastinal lesion concerning for thymoma has
resolved.
An 8.5 x 6.8 x 6.0 cm mass (602b:49 and 2:30) traverses the left
major fissure involving superior segment of the left lower lobe
as well as the inferior aspect of the apicoposterior segment of
the left upper lobe. The mass exerts marked local mass effect
resulting in segmental occlusion of the left lower lobe
pulmonary artery with distal reconstitution (2:32 and 601b:32),
mild attenutation of the left upper lobe airways and moderate
compression of the left lower lobe bronchus without lobar
collapse. Mild septal thickening and ground glass opacity along
the lateral and inferior aspect of the lesion could reflect
lymphangitic spread of tumor, mild atelectasis or
postobstructive changes.
The lesion drapes along 180 degrees of the descending thoracic
aortic
circumference with somewhat blurred fat planes (2:26) and
extends along the medial aspect of the posterior pleura at the
site of a calcified pleural plaque without accompanying pleural
effusion. A confluent soft tissue projection extends from the
lesion into the mediastinum measuring 3.7 x 4.2 cm (2:24) with
anterior and rightward displacement of the carina and esophagus
and mild attenuation of the left mainstem bronchus. The
esophagus appears compressed with circumferential esophageal
mural thickening noted slightly more distally (2:27). Multiple
subcentimeter right upper paratracheal lymph nodes are notable
in number (2:14).
Moderate predominantly centrilobular emphysema is unchanged.
Bilateral
calcified pleural plaques and a predominantly basilar subpleural
interstitial abnormality is consistent with the previous
diagnosis of asbestosis. The trachea and right-sided airways
appear patent to the segmental level. A right major fissural 5
mm nodule is unchanged (4:104).
Although this study is not tailored for subdiaphragmatic
evaluation the imaged upper abdomen reveals unchanged nodularity
in the lateral limb of the left adrenal gland measuring 9 mm and
body of the left adrenal gland measuring 12 mm (2:61 and 58),
which is stable.
OSSEOUS STRUCTURES: No definite lytic or blastic bony lesion is
seen to
suggest malignancy with mild heterogeneity in the T3 vertebral
body of
uncertain significance.
IMPRESSION:
1. 8.5 cm left upper and lower lobe mass traverses the major
fissure,
infiltrates the mediastinum with loss of fat planes with the
esophagus, and
occludes a short segment of the left lower lobe pulmonary artery
with distal
reconstitution. Mild narrowing of the left upper and lower lobe
airways
without lobar collapse. Mild surrounding septal thickening could
reflect
postobstructive changes or lymphangitic tumor spread.
2. Esophageal compression and thickening from the mass,
correlate for history
of dysphagia.
3. Pleural plaques with subpleural reticulation consistent with
asbestosis
from prior exposure.
4. Moderate emphysema.
5. Heterogeneous enlarged left thyroid gland as before status
post recent
radioactive iodine therapy.
6. Unchanged left adrenal nodularity. While the nodules were of
indeterminate
density on prior non-contrast abdominal CT examinations,
stability in size
since ___ suggests benignity.
7. Mild heterogeneity in the T3 vertebral body is nonspecific
and can be
correlated with bone scan if indicated.
Preliminary findings were discussed with Dr. ___ by Dr. ___
at 2215 on
___ by phone.
CT head
FINDINGS: There is no acute intracranial hemorrhage, mass
effect, edema or
Preliminary Reportmajor vascular territorial infarct. The
ventricles and sulci are mildly
Preliminary Reportprominent, compatible with age-related global
atrophy. There are
Preliminary Reportmoderate-to-significant periventricular and
subcortical white matter
Preliminary Reporthypodensities, nonspecific, but most likely
representing chronic microvascular
Preliminary Reportischemic changes. The gray-white matter
differentiation is preserved.
Preliminary ReportThere is no acute skull fracture. There is
scattered ethmoidal mucosal
Preliminary Reportthickening. The remaining visualized paranasal
sinuses and mastoid air cells
Preliminary Reportare clear.
Preliminary ReportIMPRESSION:
Preliminary Report1. No acute intracranial process. No
intracranial hemorrhage.
Preliminary Report2. Chronic microvascular ischemic changes with
global atrophy.
Brief Hospital Course:
___ year old man with known hypertension, hyperthyroidism (s/p
RAI ablation in ___, presents with worsening symptoms of
depression, insomnia, weight loss now found to have large,
likely malignant lung mass.
# New lung mass: The patient was found to have a lung mass on
imaging on admission, and further history is notable for cough,
as well as poor appetite which could be attributable to his lung
mass in addition to suspected depression. Of note, he has a
history of asbestos exposure, as used to work in a ___ and
was a smoker from the age of ___. On imaging, the lesion
appeared suspicious for malignancy with evidence of compression
of surrounding structures and mention of adjacent lymph nodes.
He denies hemoptysis, no difficulty swallowing, and denies a
productive cough. CT head showed no suspicious lesions.
Interventional pulmonary was consulted for biopsy which was
performed on ___ and patient will follow up with the
interdisciplinary lung clinic in the next 2 weeks. He was made
NPO the night before biopsy and there were no complications of
the procedure. Head MRI and PET scan ordered while here as
outpatient, and we discussed with Dr ___ the
suspected diagnosis.
# Depression: The patient reported recent difficulty sleeping
consistent with insomnia, poor appetite, decreased interest, and
tearfulness consistent with depression. Psych saw the patient in
the ED and recommended mirtazapine 15mg qhs for his symptoms. He
will follow-up with his internist for ongoing discussion of his
depression and to assist in determining what his further needs
might be.
# Hyperthyroidism s/p RAI ablation: TSH <0.02 FreeT4 1.5,
currently has subclinical hyperthyroidism. We continued his
recent propranolol 10mg po daily. We understand that he has
endocrinology f/u in ___.
# HTN: We continued his home enalapril 10mg daily
# HL: We continued his home pravastatin 40mg daily
# BPH: Continued home tamsulosin 0.4mg daily. Continued home
finasteride 5mg daily
TRANSITIONAL ISSUES
#f/u head MRI (ordered as outpatient)
#f/u PET (ordered as outpatient)
#f/u endobronchial biopsy and EBUS TBNA reports.
#lung mass: will f/u with lung clinic as per interventional
pulmonology
-will need PET and brain MRI at some point after biopsy to
continue with staging
#patient will call to make an appointment with Dr ___
psychiatry, psychiatry requests that PCP prescribe ___ from
now till his appointment.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 10 mg PO DAILY
hold for sbp<100
2. Finasteride 5 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU BID
4. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp<100
5. Pravastatin 80 mg PO DAILY
6. Propranolol 10 mg PO BID
hold for sbp<100, hr <60
7. Tamsulosin 0.4 mg PO HS
8. Aspirin 325 mg PO PRN headache
9. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Enalapril Maleate 10 mg PO DAILY
hold for sbp<100
2. Finasteride 5 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp<100
4. Multivitamins 1 TAB PO DAILY
5. Pravastatin 80 mg PO DAILY
6. Propranolol 10 mg PO BID
hold for sbp<100, hr <60
7. Tamsulosin 0.4 mg PO HS
8. Aspirin 325 mg PO PRN headache
9. Fluticasone Propionate NASAL 1 SPRY NU BID
10. Mirtazapine 15 mg PO HS
RX *mirtazapine 15 mg 1 tablet(s) by mouth take at night before
bed Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
primary: lung mass, depression
secondary: hyperthyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
It was a true pleasure caring for you here at the ___. You
came to the hospital because you had weight loss and you werent
feeling right. While you were here we had psychiatrists see you
and they felt that you likely have depression. On imaging a mass
was seen in your lung. We had the specialists biopsy the lung.
You will follow up with the lung clinic when you go home. They
will call you but if you don't hear from them by ___ you
can all them at ___.
You will have imaging done (see below) this week to see if there
is any cancer anywhere else.
Also while you were here you were seen by psychiatry for
depression. You need to call them (see below) to make an
appointment.
Followup Instructions:
___
|
19995127-DS-13 | 19,995,127 | 24,770,079 | DS | 13 | 2138-05-19 00:00:00 | 2138-05-20 13:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Atorvastatin
Attending: ___.
Chief Complaint:
Near syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is an ___ year-old retired ___ with a history
of pAF, formerly HTN, and recent diagnosis of SCLC (___) who
recently finished his third cycle of carboplatin-etoposide and
pegfilgrastim on ___ who presents with the chief complaint
of near-syncope.
Mr. ___ has never had near syncope or hypotension previously,
and in fact has had hypertension in the past. On ___, be
felt lightheaded after standing and fell on his right flank.
There was no LOC, palpitations, chest pain, or headstrike. He
received carboplatin 330mg (___), etoposide 150mg IV ___,
___
In the MICU his BPs were ___ and received 3 L of NS in
successive boluses with response of his blood pressure to
relative normotension to ___. Of note, he has been
serially tested for orthostatic vital signs and has been
markedly orthostatic each time. PCP had planned to start
midodrine, fludcrocortisone for his hypotension, and this
regimen was started in the MICU with response of blood pressure.
Initially there was concern for pneumonia based on his CT, but
on final read his findings were unchanged and likely due to his
underlying malignancy. He has been afebrile, and infecious
work-up has been negative. Antibiotics were given initially
empirically, but have been discontinued.
Past Medical History:
- Formerly hypertension (likely underlying physiolgoy has
changed and will no longer be hypertensive)
- Hyperlipidemia
- Left common iliac anneurysm
- Hyperthyroidism status post RAI ablation on ___
- BPH
PAST ONCOLOGIC HISTORY:
- ___: presented with symptoms of insomnia, depression, was
noted to have an abnormal CXR and subsequent CT chest showed an
8.1 cm mass in the left upper and left lower lobe which
infiltrated the mediastinum and caused compression on the
esophagus.
- ___: bronchoscopy and biopsy proved to be small cell
carcinoma which was positive for TTF-1, CD56 and synaptophysin
and negative for p63, LCA and chromogranin.
- ___: PET showed no other sites of metastatic disease.
- ___: Brain MRI with 3-mm enhancing focus in the left
cerebellar hemisphere concerning for metastasis
- ___: Cycle 1 Carboplatin AUC 5/Etoposide 100 mg/m2
- ___: admission for cough, malaise, admission
complicated by febrile neutropenia and thrombocytopenia, and
new-onset atrial fibrillation
- ___: Cycle 2 Carboplatin AUC 3.75/Etoposide 75 mg/m2 (25%
dose reduction in both drugs)
- ___: Chest CT with improvement in mediastinal mass; MRI
with improvement in cerebellar lesion
- ___: Cycle 3 of carboplatin/etoposide
- ___: Admission for profound orthostatic intolerance,
started on midodrine, fludricortisone. Also pancytopenic and
neutropenic, with slow recovery in cell counts.
Social History:
___
Family History:
- Thyroid issues in his cousins
- Lung cancer in his sister.
- Daughter with metastatic breast cancer
- No history of heart disease
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T 98.6 HR 79-105, BP 88/42-124/49, RR 13, SaO2 98% on RA
Wgt (current): 81.1 kg (admission): 78 kg
General: Cachectic-appearing man in no apparent distress sitting
in chair with wife at side.
HEENT: EOMI, MMM
Neck: No JVD
Lungs: CTAB
CV: RRR currently, no m/r/g. PMI nondisplaced.
Back: Scattered nevi on back but no ecchymosis of R flank seen.
No tenderness to palpation of beck.
Abdomen: Soft, nontender, nondistended.
Ext: Nonedeamtous, WWP.
Skin: No rashes appreciated
Neuro: Intact strength and sensation in lower and upper
extremities. CN II-XII grossly intact. No obvious ataxia.
Orthostatics (___)
Standing: BP 64/palp HR 130
Orthostatics (___)
Standing: BP 88/54 HR 119
Orthostatics (___)
Supine: BP 96/54 HR 74
Sitting: BP 104/50 HR 81
Standing: 104/52 HR 101
DISCHARGE PHYSICAL EXAM
Vitals: T 98.5 BP 106/62 HR 106 RR 12 SaO2 98% on RA
General: Cachectic-appearing man in no apparent distress sitting
in bed.
HEENT: EOMI, MMM
Neck: Jugular veins flat.
Lungs: CTAB
CV: RRR currently, no m/r/g. PMI nondisplaced.
Abdomen: Soft, nontender, nondistended.
GU: Foreskin slightly edematous. Slightly erythematous folds in
between foreskin and glans with smegma and suggestion of
mycosis.
Ext: Nonedeamtous, WWP.
Neuro: A&Ox3. Moving all four extremities spontaneously, follows
commands.
Pertinent Results:
___ 11:00AM BLOOD WBC-63.1*# RBC-3.86* Hgb-10.2* Hct-32.1*
MCV-83 MCH-26.4* MCHC-31.8 RDW-18.5* Plt ___
___ 07:30PM BLOOD WBC-45.6* RBC-3.48* Hgb-9.3* Hct-29.1*
MCV-83 MCH-26.7* MCHC-32.0 RDW-19.0* Plt ___
___ 04:45AM BLOOD WBC-33.7* RBC-3.40* Hgb-9.0* Hct-27.7*
MCV-82 MCH-26.6* MCHC-32.6 RDW-19.2* Plt ___
___ 03:19AM BLOOD WBC-19.2* RBC-3.70* Hgb-9.7* Hct-30.5*
MCV-82 MCH-26.2* MCHC-31.9 RDW-19.0* Plt ___
___ 08:00AM BLOOD WBC-1.2*# RBC-3.48* Hgb-9.1* Hct-29.8*
MCV-86 MCH-26.3* MCHC-30.7* RDW-18.9* Plt ___
___ 07:35AM BLOOD WBC-1.0* RBC-3.36* Hgb-8.8* Hct-27.7*
MCV-82 MCH-26.3* MCHC-32.0 RDW-18.8* Plt ___
___ 06:10AM BLOOD WBC-1.0* RBC-3.02* Hgb-8.0* Hct-24.6*
MCV-82 MCH-26.6* MCHC-32.6 RDW-18.8* Plt ___
___ 07:10AM BLOOD WBC-0.8* RBC-3.20* Hgb-8.5* Hct-26.1*
MCV-82 MCH-26.7* MCHC-32.7 RDW-18.8* Plt Ct-81*
___ 06:30AM BLOOD WBC-2.0*# RBC-2.91* Hgb-7.6* Hct-24.4*
MCV-84 MCH-26.1* MCHC-31.1 RDW-18.7* Plt Ct-59*
___ 11:00AM BLOOD Glucose-141* UreaN-22* Creat-0.9 Na-136
K-4.1 Cl-98 HCO3-25 AnGap-17
___ 03:19AM BLOOD Glucose-86 UreaN-16 Creat-0.7 Na-137
K-4.2 Cl-100 HCO3-29 AnGap-12
___ 06:10AM BLOOD Glucose-85 UreaN-14 Creat-0.6 Na-138
K-3.6 Cl-101 HCO3-29 AnGap-12
___ 06:30AM BLOOD Glucose-82 UreaN-11 Creat-0.7 Na-139
K-3.6 Cl-101 HCO3-31 AnGap-11
___ 08:00AM BLOOD TSH-3.4
___ 06:10AM BLOOD Cortsol-13.0
DISCHARGE LABS:
___ 07:20AM BLOOD WBC-3.9*# (58% PMNs) RBC-3.02* Hgb-8.2*
Hct-24.8* MCV-82 MCH-27.0 MCHC-33.0 RDW-19.1* Plt Ct-44*
CT CHEST WITH INTRAVENOUS CONTRAST (___): Heterogeneous
enlargement of the left thyroid gland is stable compared to
prior examination. Aside from known tumor, remaining
mediastinal lymph nodes are subcentimeter and appear unchanged
compared to prior examination. No supraclavicular or axillary
lymphadenopathy is identified. The heart size is normal, and
there is no pericardial effusion. Thoracic aorta is
non-aneurysmal and patent.
Known small cell lung carcinoma within the posterior segment of
the left upper lobe and within the superior segment of the left
lower lobe is similar to recent prior examination from 11 days
prior. Inferior portion measures 26 x 31 mm as compared to 23 x
25 mm previously. Superior portion measures 44 x 27 mm as
compared to 48 x 27 mm previously (2A:54). The superior segment
left lower lobe bronchus continues to contain tumor, however, is
not fully occluded, unchanged. Tumoral invasion and thrombus
within the left lower lobe pulmonary artery appears unchanged
(2A:60). The remainder of the pulmonary arterial tree is widely
patent without sign of superimposed acute pulmonary embolism.
No distal propagation of tumoral thrombus is evident. Irregular
opacities within the posterior right upper lobe (2A:46 and 54)
are stable compared to prior examination, are are likely
infectious or inflammatory in etiology. Previously described
sub-3-mm pulmonary nodules are not well characterized on this
examination likely due to differences in technique. No new
suspicious pulmonary nodule or mass is identified. Diffuse
emphysema is unchanged. Numerous calcified pleural plaques are
unchanged and consistent with asbestosis. There is mild basilar
atelectasis.
CT ABDOMEN WITH INTRAVENOUS CONTRAST: Focal irregular arterial
enhancement within the hepatic dome is not seen on delayed phase
imaging and likely reflects a perfusional abnormality. No
suspicious hepatic lesion is identified. Hepatic veins and
portal venous system are grossly patent. No intra- or
extra-hepatic biliary ductal dilatation is identified. Tiny
hypodense foci within the gallbladder may reflect
nitrogen-containing stones. The gallbladder is otherwise
unremarkable. The spleen, pancreas, and right adrenal gland are
normal. An 11 mm indeterminate left adrenal nodule is stable
dating back to ___, likely a small adenoma. The kidneys
enhance symmetrically without suspicious focal lesion or
hydronephrosis. Subcentimeter hypodensities within the left
kidney remain too small to characterize, though likely small
cysts. No perinephric fluid collection or hydronephrosis is
evident. No pathologically enlarged mesenteric or
retroperitoneal lymph nodes are identified. The stomach and
small bowel loops are normal in caliber and configuration
without evidence of obstruction or inflammation. The appendix
is visualized and is normal. No abdominal free fluid or free
air is evident. The abdominal aorta and branch vessels are
non-aneurysmal and patent. Redemonstrated is aneurysmal
dilatation of the left common iliac artery measuring 4.2 x 4.5
cm. Thrombosis of >75% of the left common iliac aneurysm is
stable. Distal flow is preserved to the left external iliac,
internal iliac, and common femoral artery.
CT PELVIS WITH INTRAVENOUS CONTRAST: Rectum and colon are
normal in caliber and configuration without evidence of
obstruction or inflammation. A Foley catheter and a small
amount of air are seen within the urinary bladder. Prostatic
enlargement is unchanged from prior. A hypodense lesion within
the anterior aspect of the prostate gland is stable and likely
represents a small cyst (2B:185). There is no pelvic free
fluid. No pathologically enlarged pelvic or inguinal lymph
nodes are identified.
BONES AND SOFT TISSUES: No bone destructive lesion or acute
fracture is
identified. Heterogeneity of the sacrum is unchanged compared
to ___,
findings consistent with a benign process. No bone destructive
lesion is
identified.
IMPRESSION:
1. Stable small cell lung carcinoma within the left upper and
lower lobes with invasion into the mediastinum. Ongoing tumoral
invasion into the left
lower lobe bronchus and left lower lobe pulmonary artery.
Findings are
unchanged compared to recent prior examination from ___.
2. No superimposed acute pulmonary embolism
3. Ground-glass nodules within the right upper lung persist,
though are
likely infectious/inflammatory in etiology. Attention on
followup is
recommended. Additional millimeteric pulmonary nodules not seen
likely due to technical differences.
5. Stones in an otherwise normal gallbladder.
6. Stable 11-mm left adrenal lesion, likely an adenoma.
7. Stable 4.5-cm partially thrombosed left common iliac
aneurysm
8. Stable prostatic enlargement with an anterior prostatic
cyst.
9. Stable heterogeneous enlargement of the left lobe of the
thyroid gland which can be characterized by ultrasound if it has
not been done previously.
Brief Hospital Course:
#) ORTHOSTATIC INTOLERANCE: The new-onset of orthostatic
hypotension, given the temporal relationship to his chemotherapy
and underlying malignancy make these the most likely culprits.
* Chemotherapy-induced autonomic neuropathy: his carboplatin
regimen is well known to cause peripheral sensory neuropathy,
and has been described to cause autonomic neuropathy. However,
he developes appropriate tachycardic response to orthostasis,
arguing against dysautonomia. Etoposide is not known to cause
neuropathy, and mainly manifets with GI upset.
* Paraneoplastic syndrome: Commonly seen in lung cancers
(particularly small cell), these tumors secrete ___ antibody
can cause autonomic neuropathy (23% of cases). However, this is
usually associated with cerebellar degeneration, which he does
not demonstrate since he has no ataxia, dysmetria, or nystagmus.
INTERVENTIONS:
Mr. ___ was started on midodrine, fludricortisone, and salt
tablets with modest response in blood pressure. He was unable
to tolerate salt tabs (had emesis), so these were discontinued.
His tamsulosin was held due to possible contribution of
orthostasis, and he experienced some worsening of his urinary
retention, but was still able to void without significant
difficulty.
He subsequently was able to maintain BP 88/50 when standing and
without lightheadedness, which was a large improvement from his
64/palp orthostatic readings immediately after being called out
of the ICU. On the day prior to discharge, his standing vitals
were BP 104/52 with HR 101 which he maintained for two minutes
without lightheadedness.
#) LEUKOCYTOSIS -> PANCYTOPENIA: Initially with leukocytosis on
admission, likely due to pegfilgrastim therapy, with WBC 60K.
His antibiotics were discontinued and was afebrile and without
systemic signs of infection. His cell lines declined and became
profoundly neutropenic, but never manifested a fever. After
speaking to his outpatient oncology providers, no further
pegfilgrastim was indicated in the short term.
#) ATRIAL FIBRILLATION, PAROXYSMAL: Sinus rhythm while here.
Family decided not to pursue anticoagulation given limited
prognosis. They had been told he likely had ___ months to live
and perhaps ___ months with chemothearpy. Thus, they decided
against anticoagulation despite his CHADS2 score of 2.
#) BALANITIS: Patient noted to have swollen glans penis and
mycotic-appearing foreskin, so he was given fluconazole x 1.
TRANSITIONAL ISSUES
===================
** Patient is thrombocytopenic (platelets = 44,000 on
discharge). Please monitor closely for signs of bleeding, or
headache (which could represent intracranial hemorrhage since he
has known brain metastasis).
[ ] Please check a CBC in 3 days and fax results to his heme/onc
physicians: Dr. ___ at fax number ___. Dr.
___ phone # is ___.
- At night: Patient should be in bed, supine with HOB ~20
degrees with compression stockings OFF.
- During the day: Patient should be OOB to chair as much as
possible with compression stockings ON.
- He should be continued on midodrine, fludricortisone, and
monitored for chest pain, palpitations, as well as supine
hypertension.
- Be VERY careful with changes in position since he has become
profoundly orthostatic with rapid changes in position. Until he
becomes more stable he should NOT be stood with assist until he
receives his AM midodrine.
[ ] Please continue to up-titrate his fludricortisone with
increases of 0.1mg per week with a maximum dose of 1.0 mg. This
should be titrated to increase his blood pressure, targeting
specifically his BP while standing to be above > 90/60 and/or
without symptoms of hypoperfusion (lightheadedness, dizziness,
etc.)
[ ] Please monitor for worsening signs of urinary retention. We
stopped his tamsulosin while in ___ since we thought it could
be contributing to his orthostatic hypotension, but we
anticipated that it may worsen urinary retention.
Pt. was seen and examined on ___. Agree with resident
evaluation and plan as above.
- ___, MD signed electronically.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY:PRN constipation
2. Docusate Sodium 100 mg PO BID
3. Finasteride 5 mg PO DAILY
4. Fluticasone Propionate NASAL 1 SPRY NU BID
5. Mirtazapine 50 mg PO HS
6. Pravastatin 80 mg PO DAILY
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
8. Senna 2 TAB PO BID
9. Tamsulosin 0.4 mg PO HS
10. traZODONE 50 mg PO HS
11. Nystatin Oral Suspension 5 mL PO TID
12. Polyethylene Glycol 17 g PO DAILY
13. Aspirin 81 mg PO DAILY
14. Hydrochlorothiazide 50 mg PO DAILY
15. Levothyroxine Sodium 25 mcg PO DAILY
16. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Finasteride 5 mg PO DAILY
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Nystatin Oral Suspension 5 mL PO TID
9. Polyethylene Glycol 17 g PO DAILY
10. Prochlorperazine 10 mg PO Q6H:PRN nausea
11. Senna 1 TAB PO BID
12. Fludrocortisone Acetate 0.2 mg PO DAILY
13. Midodrine 10 mg PO TID
14. traZODONE 25 mg PO HS:PRN Insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Orthostatic intolerance
Small cell lung carcinoma
Pancytopenia (including neutropenia), chemotherapy-related bone
marrow suppression.
Atrial fibrillation, paroxysmal
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 ___
___. You were admitted for dizziness and were found
to have a condition called orthostatic hypotension. This means
that your blood pressure falls dramatically when you stand up.
We think this may be related to your chemotherapy regimen. We
started you on some medicines to increase your blood pressure
which helped you stay without lightheadness when you stand.
Followup Instructions:
___
|
19995258-DS-2 | 19,995,258 | 26,871,572 | DS | 2 | 2130-06-15 00:00:00 | 2130-06-15 15:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
anastrozole / Augmentin / barocat / Latex, Natural Rubber
Attending: ___.
Chief Complaint:
complicated diverticulitis
Major Surgical or Invasive Procedure:
___: exploratory laparotomy, complicated sigmoid colectomy,
ileocecectomy, and total abdominal hysterectomy and bilateral
salpingo-oopherectomy with diverting loop ileostomy
History of Present Illness:
___ hx of sigmoid diverticulitis in ___, breast ca presents
with
over 1wk of LLQ abdominal pain, N/V and imaging consistent with
large bowel obstruction and a focal thickening of sigmoid colon
concerning for a diverticular stricture vs malignant
obstruction.
Colorectal surgery is consulted for a surgical evaluation.
Patient reports she has had an uncomplicated sigmoid
diverticulitis ___ where she was admitted to ___ medicine
service for about 2 days and resolved with antibiotics. She
subsequently underwent a colonoscopy at the time that showed
diverticulosis and no other abnormalities. She has been feeling
well until about 4 weeks ago, had a similar LLQ abdominal pain
and was seen by her PCP and underwent ___ CT ___ scan which
showed
a focal thickening in the sigmoid colon and a proximal
obstruction. She was sent home with 5 days of Cipro/Flagyl and
feeling better however started having recurrent crampy LLQ
abdominal pain, nausea, vomiting and ostipation. She presented
to
___ ED where she underwent a CT A/P w/IV contrast which
showed a worsened large bowel obstruction at a focal thickening
of the sigmoid colon. She was transferred to ___ ED for
further
management. Upon transfer, patient had normal vitals, labs only
notable for elevated lipase at 587. She currently endorses
stable
LLQ pain, no nausea, last passed flatus yesterday, last BM 2
days
ago. She denies any fevers, chills, night sweats, weight loss
or
bloody stools
Past Medical History:
sigmoid diverticulitis ___
HTN, HL
Mitral valve prolapse.
Autoimmune disorder of unclear etiology, manifesting as
neutrophilic dermatosis, diagnosed in ___ for which she is
under
the care of Dr. ___ and ___ recently Dr.
___.
Social History:
___
Family History:
The patient's mother developed breast cancer at
age ___. Her father had lymphoma at age ___. She underwent
BRCA1-2 testing drawn on ___ at ___, which was
negative. She is of ___ ethnic background.
Physical Exam:
afebrile, vital signs stable
General: well appearing, NAD
HEENT: normocephalic, atraumatic, no scleral icterus
Resp: breathing comfortably on room air
CV: regular rate and rhythm on monitor
Abdomen: soft, NT, ND, incision clean, dry, intact
Brief Hospital Course:
Mrs. ___ presented to the emergency department with
abdominal pain and imaging consistent with complicated
diverticulitis with a malignant vs inflammatory stricture on
___. She underwent a sigmoidosocopy on ___ which
showed a 3 cm stricture that decompressed with rectal tube in
the proximal sigmoid colon. NGT was placed and the patient was
kept NPO. The decision was made to take her to the operating
room on ___ for Sigmoid colectomy, ileocecectomy,
TAH/BSO, and diverting loop ileostomy. The procedure was
complicated by intraoperative blood loss of 1.2L. She remained
hemodynamically unstable with pressor requirement in the
immediate post operative period, thus she was transferred to the
surgical ICU for further management.
Neuro: Pain was initially controlled with dilaudid PCA until
the patient had return of bowel function. At this point the
patient was transitioned to PO pain meds.
CV: The patient was hemodynamically unstable after the OR with
persistent tachycardia and hypotension requiring pressors,
likely secondary to post operative systemic inflammatory
response. She was resuscitated with chrystalloid and colloid,
and her lactate normalized by the end of post op day 1. She no
longer required pressors to maintain her pressure by the end of
post operative day one, and her tachycardia resolved by post
operative day 2.
Pulm: She was extubated in the PACU after her operation. She
had a persistent oxygen requirement until post operative day 3
when she was able to be weaned off of oxygen. She was
transferred to the floor on post operative day 3.
GI: Diet was advanced in a stepwise fashion until the patient
was tolerating a regular diet without difficulty.
GU: foley was removed on POD 2, patient voided appropriately
without issue.
ID: Due to presumed intra-abdominal contamination from the
visualized abscesses, she was started on a 7 day course of
antibiotics. When she was tolerating a regular diet, she was
transitioned to PO antibiotics. Previna vac was used over her
wound until post operative day 5. It was removed on the day of
discharge.
Heme: No major issues.
On POD 5, the patient was discharged to home. At discharge, the
patient was tolerating a regular diet, passing flatus, stooling,
voiding, and ambulating independently. The patient will
follow-up in the clinic in ___ weeks. This information was
communicated to the patient directly prior to discharge.
[ ] Post-Operative Ileus resolving w/o NGT
[ ] Post-Operative Ileus requiring management with NGT
[ ] UTI
[ ] Wound Infection
[ ] Anastomotic Leak
[ ] Staple Line Bleed
[ ] Congestive Heart failure
[ ] ARF
[ ] Acute Urinary retention, failure to void after Foley D/C'd
[ ] Acute Urinary Retention requiring discharge with Foley
Catheter
[ ] DVT
[ ] Pneumonia
[x] Abscess
[ ] None
Social Issues Causing a Delay in Discharge:
[ ] Delay in organization of ___ services
[ ] Difficulty finding appropriate rehabilitation hospital
disposition.
[ ] Lack of insurance coverage for ___ services
[ ] Lack of insurance coverage for prescribed medications.
[ ] Family not agreeable to discharge plan.
[ ] Patient knowledge deficit related to ileostomy delaying
discharge.
[x] No social factors contributing in delay of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Influenza Vaccine Quadrivalent 0.5 mL IM NOW X1
Start: ___, First Dose: Next Routine Administration Time
2. Lisinopril 10 mg PO DAILY
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Lisinopril 10 mg PO DAILY
2. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 80 mg ___ tablet(s) by mouth every six (6)
hours Disp #*100 Tablet Refills:*0
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*4 Tablet Refills:*0
4. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL ___aily Disp #*25 Syringe
Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*6 Tablet Refills:*0
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*45
Tablet Refills:*0
7. Psyllium Wafer ___ WAF PO BID
RX *psyllium [Metamucil] 1.7 g ___ wafer(s) by mouth twice a day
Disp #*100 Wafer Refills:*0
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. Medical Assist Device: Commode
please provide patient with commode upon discharge
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
recurrent diverticulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
___ were admitted to the hospital after an exploratory
laparotomy, complicated sigmoid colectomy, ileocecectomy, and
total abdominal hysterectomy and bilateral salpingo-oopherectomy
with diverting loop ileostomy. ___ have recovered from this
procedure well and ___ are now ready to return home. Samples
from your colon were taken and this tissue has been sent to the
pathology department for analysis. ___ will receive these
pathology results at your follow-up appointment. If there is an
urgent need for the surgeon to contact ___ regarding these
results they will contact ___ before this time. ___ have
tolerated a regular diet, passing gas and your pain is
controlled with pain medications by mouth. ___ may return home
to finish your recovery.
Please monitor your bowel function closely. ___ may or may not
have had a bowel movement prior to your discharge which is
acceptable, however it is important that ___ have a bowel
movement in the next ___ days. After anesthesia it is not
uncommon for patients to have some decrease in bowel function
but ___ should not have prolonged constipation. Some loose stool
and passing of small amounts of dark, old appearing blood are
expected. However, if ___ notice that ___ are passing bright red
blood with bowel movements or having loose stool without
improvement please call the office or go to the emergency room
if the symptoms are severe. If ___ are taking narcotic pain
medications there is a risk that ___ will have some
constipation. Please take an over the counter stool softener
such as Colace, and if the symptoms do not improve call the
office. If ___ have any of the following symptoms please call
the office for advice or go to the emergency room if severe:
increasing abdominal distension, increasing abdominal pain,
nausea, vomiting, inability to tolerate food or liquids,
prolonged loose stool, or extended constipation.
___ have an ileostomy. The most common complication from a new
ileostomy placement is dehydration. The output from the stoma is
stool from the small intestine and the water content is very
high. The stool is no longer passing through the large intestine
which is where the water from the stool is reabsorbed into the
body and the stool becomes formed. ___ must measure your
ileostomy output for the next few weeks. The output from the
stoma should not be more than 1200cc or less than 500cc. If ___
find that your output has become too much or too little, please
call the office for advice. The office nurse or nurse
practitioner can recommend medications to increase or slow the
ileostomy output. Keep yourself well hydrated, if ___ notice
your ileostomy output increasing, take in more electrolyte drink
such as Gatorade. Please monitor yourself for signs and symptoms
of dehydration including: dizziness (especially upon standing),
weakness, dry mouth, headache, or fatigue. If ___ notice these
symptoms please call the office or return to the emergency room
for evaluation if these symptoms are severe. ___ may eat a
regular diet with your new ileostomy. However it is a good idea
to avoid fatty or spicy foods and follow diet suggestions made
to ___ by the ostomy nurses.
Please monitor the appearance of the ostomy and stoma and care
for it as instructed by the wound/ostomy nurses. ___ stoma
(intestine that protrudes outside of your abdomen) should be
beefy red or pink, it may ooze small amounts of blood at times
when touched and this should subside with time. The skin around
the ostomy site should be kept clean and intact. Monitor the
skin around the stoma for bulging or signs of infection listed
above. Please care for the ostomy as ___ have been instructed by
the wound/ostomy nurses. ___ will be able to make an appointment
with the ostomy nurse in the clinic 7 days after surgery. ___
will have a visiting nurse at home for the next few weeks
helping to monitor your ostomy until ___ are comfortable caring
for it on your own.
___ have a long vertical incision on your abdomen that is closed
with staples. This incision can be left open to air or covered
with a dry sterile gauze dressing if the staples become
irritated from clothing. The staples will stay in place until
your first post-operative visit at which time they can be
removed in the clinic, most likely by the office nurse. Please
monitor the incision for signs and symptoms of infection
including: increasing redness at the incision, opening of the
incision, increased pain at the incision line, draining of
white/green/yellow/foul smelling drainage, or if ___ develop a
fever. Please call the office if ___ develop these symptoms or
go to the emergency room if the symptoms are severe. ___ may
shower, let the warm water run over the incision line and pat
the area dry with a towel, do not rub.
No heavy lifting for at least 6 weeks after surgery unless
instructed otherwise by your surgical team. ___ may gradually
increase your activity as tolerated but clear heavy exercise
with your surgical team.
___ will be prescribed a small amount of the pain medication
oxycodone. Please take this medication exactly as prescribed.
___ may take Tylenol as recommended for pain. Please do not take
more than 4000mg of Tylenol daily. Do not drink alcohol while
taking narcotic pain medication or Tylenol. Please do not drive
a car while taking narcotic pain medication.
Thank ___ for allowing us to participate in your care! Our hope
is that ___ will have a quick return to your life and usual
activities. Good luck!
Followup Instructions:
___
|
19995478-DS-21 | 19,995,478 | 24,108,472 | DS | 21 | 2128-07-02 00:00:00 | 2128-07-02 19:23:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Pneumococcal Vaccine
Attending: ___.
Chief Complaint:
s/p MVC with intrusion into driver's side
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p MVC restr driver with intrusion, L comminuted clavicle
Fx, small R abdominal hematoma extending to L iliacus with ?
bone fragment vs small extrav by R iliac crest, L5 R TP Fx
Past Medical History:
PMH: chron MRSA, A fib, ?CKD, pulmonary infection
PSH: hx RLL resection
Social History:
___
Family History:
Noncontributory
Physical Exam:
Exam at discharge:
Vitals: 98.0F, HR 60, RR 18, SpO2 97% RA, BP 148/74
Gen app: sitting upright in bedside chair, appears comfortable,
NAD
HEENT: EOMI, PERRL. There is erythema of the left eye but no
drainage or pain. Vision grossly intact. Oral mucosa pink and
moist.
Neck: trachea midline
CV: RRR, no m/r/g
Lungs: CTA
Abd: bowel sounds present. Soft, NT.
Extrem: warm, well-perfused
Neuro: CN II-XII intact. Sensation intact and symmetric
throughout. Strength ___ in all muscle groups, except for LUE,
which was unable to be tested ___ presence of sling. Gait
intact.
Skin: large ecchymosis at left upper chest and over the left
shoulder.
Pertinent Results:
On admission:
___ 10:44AM BLOOD WBC-9.0 RBC-4.32* Hgb-13.8 Hct-42.9
MCV-99* MCH-31.9 MCHC-32.2 RDW-12.6 RDWSD-46.0 Plt ___
___ 10:44AM BLOOD ___ PTT-37.3* ___
___ 10:44AM BLOOD UreaN-19
___ 05:00AM BLOOD Calcium-9.1 Phos-3.8 Mg-2.1
On day of discharge:
___ 03:20PM BLOOD Hct-37.6*
___ 05:00AM BLOOD WBC-8.9 RBC-3.69* Hgb-11.9* Hct-36.8*
MCV-100* MCH-32.2* MCHC-32.3 RDW-12.7 RDWSD-46.6* Plt ___
Brief Hospital Course:
Pt brought to ___ via EMS after ___ where pt was the driver of
a car that was T-boned with intrusion into the driver's side.
Found to have L comminuted and displaced clavicular fx, L5 right
transverse process fx, and R abdominal wall hematoma. On CT
abdomen/pelvis, there was a small hyperdense area in the R low
abdomen that was felt to represent either a bone fragment or
possible extravasation of IV contrast. Given that pt was on
Eliquis, the pt was admitted for observation. His hematocrits
were trended and initially dropped from 42.9 on arrival to 36.8.
Subsequent labs demonstrated stable hemocrit with last value
prior to discharge 37.6. He was seen and evaluated by the
orthopedic service for his clavicle fracture. They recommended
sling for the L arm and follow up in their clinic in 2 weeks.
His pain was well controlled with Tylenol alone. He was doing
well and was discharged to home. He was instructed to stop his
Eliquis until he sees his cardiologist.
Medications on Admission:
Eliquis
Bactrim
Discharge Medications:
Bactrim
Discharge Disposition:
Home
Discharge Diagnosis:
1. s/p motor vehicle collision
2. Displaced comminuted left clavicle fx
3. Right abdominal wall hematoma
4. L5 right transverse process fx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You came to the hospital after a car accident. You were found
to have a broken left collarbone, a broken piece of bone in your
low back, and a blood collection in your right abdomen. You
were monitored overnight to ensure there was no evidence of
continued bleeding. Your blood counts decreased initially but
were stable on repeat lab work. You were discharged to home in
stable condition. You should not restart your Eliquis unless
told to do so by your cardiologist. You should keep your left
arm in the sling until told otherwise by the orthopedic surgeons
at your follow up appointment. You may take Tylenol for the
pain. You should take no more than 3,000mg of Tylenol per day.
Followup Instructions:
___
|
19995593-DS-17 | 19,995,593 | 27,238,804 | DS | 17 | 2110-11-20 00:00:00 | 2110-11-23 09:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Lipitor
Attending: ___
Chief Complaint:
Code Stroke
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ left handed man with a past
medical history of HTN, PAD, CAD, CHF, MCI and multiple prior
TIA with recent Right CEA who presents following 3 events of
transient left leg weakness. Neurology is consulted due to
concern for TIAs.
History is gathered primarily from his wife, who is present at
bedside.
The reported history begins in ___. perhaps on the ___,
Mr. ___ was walking in the park and had sudden onset of
gait change. She reports it as a fenestrating and side
stepping, unsteady gait due to an acute onset of left leg
weakness. He took approximately 12 steps, before falling and
EMS was called. By the time they arrived approximately 5 minutes
later, he was
already back at baseline. He was evaluated at the hospital and
underwent CT imaging before being discharged home.
Approximately 6 days later, while at a friends house, he had
another similar episode. He was walking up the stairs and
suddenly had onset of left leg weakness. He left leg collapsed
and he fell, with subsequent Left cheek and eye eccymosis. He
was evaluated at the hospital.
The next day, he had a somewhat different episode. While
attempting to get out of the car to go into a restaurant, he
found to could not get up out of the car. It is not entirely
clear if it was due to left leg weakness. This weakness lasted
20 minutes and then spontaneously resolved. He was admitted to
the hospital and reportedly found to have b/l carotid stenosis
(R 70%, left 50%). He underwent an outpatient Right CEA on ___, without complication.
He was without further episodes until approximately a month
later. He is here in Mass visiting his newly born grand child.
On ___, while attempting to get out of a boat, he had
onset of the left leg weakness and could not stand. It lasted
15 min and then resolved.
Then, on ___, he had another episode of left leg weakness,
lasting ___ minutes.
Finally, om the day of his presentation, at 320pm, he once again
had onset of left leg weakness. He was unable to get out of the
car. It lasted approximately 25 minutes and then resolved. It
was for this, he presented to our ED. He was unable to
coordinate his leg.
With all of his episodes, there were no associated sensory
change. No known weakness of any other extremities. There were
no preceding auras, sensory changes, or unusual sensations. The
events always happened suddenly and resolved suddenly. No
warning symptoms
When he presented to our ED, a code stroke was called.
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 other focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention.
On general review of systems, the pt denies recent fever or
chills. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Denies rash.
Past Medical History:
- Congestive heart failure
- B/L Carotid stenosis- s/p CEA on right.
- PAD with Claudication
- COPD
- OSA on CPAP
- CAD- s/p CABG and Stents
- HTN
- Atrial Fibrillation
- Mild Cognitive Impairment
Social History:
___
Family History:
- Mother ___ from stroke at ___. brother with ___.
family hx of cad.
Physical Exam:
ADMISSION EXAM
Vitals:
T= 98.3 HR 75 BP 142/75 RR 18 Satting 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: WWP. ___ stockings in place.
Neurologic:
-Mental Status: Alert, oriented x 2 (Thinks it is the ___.
History is entirely related by his significant other, but he is
able to clarify points when directly asked. 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 from NIHSS. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Attentive, able to name ___
backward without difficulty. Pt. was able to register 3 objects
and recall ___ at 5 minutes. The pt. had very limited knowledge
of current events ("there is something going on in the ___, but there is always something going on in the ___
___".
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 2 to 1mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI with endgaze nystagmus b/l. Normal saccades.
V: Facial sensation intact to light touch, pinprick 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 bilaterally.
XII: Tongue protrudes in midline, and deviates side to side w/o
difficulty.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
- Plantar response was upgoing on left, equiv on right.
- Crossed Adductors are present.
-Sensory: No deficits to light touch, pinprick, cold sensation.
States he cannot feel vibration at all at the great toes, but
feels it at the ankles. No extinction to DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
DISCHARGE EXAM:
R hand with 6cm x 7cm hematoma at site of prior IV.
Neuro exam unchanged.
Pertinent Results:
ADMISSION LABS: ___
WBC-5.8 RBC-3.13* Hgb-9.0* Hct-29.2* MCV-93 RDW-17.2* Plt ___
Neuts-73.6* Lymphs-16.0* Monos-6.9 Eos-1.9 Baso-0.2 NRBC-0.3* Im
___
AbsNeut-4.24 AbsLymp-0.92* AbsMono-0.40 AbsEos-0.11 AbsBaso-0.01
___ PTT-38.6* ___
Glucose-95 UreaN-38* Creat-1.2 Na-141 K-4.7 Cl-105 HCO3-27
AnGap-14
Calcium-9.1 Phos-3.3 Mg-2.2
ALT-38 AST-72* AlkPhos-219* TotBili-0.8
Albumin-3.6 ___ 07:04AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9
UA: bland
urine/serum tox: Negative
STROKE RISK FACTORS:
Cholest-146 Triglyc-86 HDL-34 CHOL/HD-4.3 LDLcalc-95
%HbA1c-5.2 eAG-103
IMAGING:
CXR ___
Heart size and mediastinum are mildly enlarged. The patient is
after median sternotomy and CABG. Lung volumes are preserved.
Mild interstitial changes are noted bilaterally, potentially
representing chronic changes but mild interstitial edema is a
possibility. No definitive focal consolidations to suggest
infectious process demonstrated. No pleural effusion or
pneumothorax.
CT Head ___
There is no evidence of acute major vascular territorial
infarction,
hemorrhage, edema, or mass. Bilateral periventricular and
subcortical white matter hypodensities are nonspecific but may
be the sequela of chronic small vessel ischemic changes.
Prominence of the ventricles and sulci are compatible with age
related involutional changes. Atherosclerotic calcifications
are noted within the bilateral carotid siphons. No osseous
abnormalities seen. There is mild mucosal thickening within the
bilateral maxillary and ethmoid sinuses. Sphenoid sinuses are
clear. Mastoid air cells and middle ear canals are clear. The
orbits are unremarkable.
CTA Head/Neck ___. No evidence of aneurysm or vascular malformation
2. Atherosclerotic irregularity and narrowing of the left
distal intracranial vertebral artery and basilar artery.
3. Patient is status post right carotid endarterectomy with
expected
postsurgical changes including a patulous vessel and small
dissections at the proximal and distal anastomoses.
4. Calcification of the left carotid bifurcation with resulting
35-40%
narrowing of the proximal left internal carotid artery.
5. Enlarged pulmonary artery compatible with pulmonary arterial
hypertension.
RECOMMENDATION(S): Interlobular septal thickening, mosaic
attenuation, and mildly enlarged mediastinal and hilar lymph
nodes are noted in the included lung fields which could be seen
in the setting of pulmonary edema. Clinical correlation is
recommended.
MRI Head ___
There is no evidence of hemorrhage, edema, masses, mass effect,
midline shift or infarction. The ventricles and sulci are normal
in caliber and
configuration. There is periventricular and subcortical white
matter
hyperintensity on the FLAIR images suggesting chronic small
vessel ischemia. There appears to be at least three small holes
(suggestive of small chronic infarcts) in the right distal ACA
territory. No osseous abnormalities seen. The paranasal sinuses,
mastoid air cells, and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable. The
visualized portion of the vascular flow foids are preserved.
IMPRESSION: 1. Findings suggesting chronic small vessel
ischemia, in particular involving the right distal ACA territory
Otherwise normal study with no evidence of hemorrhage or
infarction
Brief Hospital Course:
Mr. ___ is an ___ left handed man with a past
medical history of atrial fibrillation on dabigatran, HTN, PAD,
CAD on plavix, CHF, mild cognitive impairment and multiple prior
TIAs with recent right CEA who presented following three
stereotyped episodes of left leg weakness without sensory change
or other symptoms. On examination, the strength of his left leg
was full. CTA demonstrated an occlusion vs flow-limiting
stenosis in the right ACA. MRI demonstrated no acute infarct but
there was evidence of small vessel stroke and at least three
very small chronic infarcts in the right ACA territory. His
symptoms were thought to represent symptomatic hypoperfusion of
the mesial right frontal lobe due to the stenosis of the right
ACA. He was started on dipyrimadole 75 mg BID as a vasodilator
which he tolerated well. This was done as a attempt and trial to
see if one could get the distal ACA to be more dilated and
potentially overcome the intrinsic narrowing or stenosis within
this vessel In addition, we continued with all of his other
medications. He was able to ambulate without becoming
symptomatic. He was seen by physical and occupational therapy
who cleared him for home. His dabigatran and plavix were
continued. He was also advised that in case that these episodes
happened again, she should lower himself to the ground, lie flat
on the ground and try to elevate his legs in order to increase
cerebral perfusion pressure.
He was noted to be hypertensive to the 170s during his
hospitalization on his home medications so his losartan dose was
increased to 75 mg daily.
=
=
=
=
=
=
================================================================
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 = 95) - () 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 - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Clopidogrel 75 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Metoprolol Tartrate 50 mg PO BID
4. Sertraline 75 mg PO DAILY
5. Tamsulosin 0.4 mg PO BID
6. Furosemide 60 mg PO DAILY
7. Losartan Potassium 50 mg PO DAILY
8. Potassium Chloride 20 mEq PO BID
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Dabigatran Etexilate 150 mg PO BID
3. Furosemide 60 mg PO DAILY
4. Losartan Potassium 75 mg PO DAILY
RX *losartan 25 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
5. Metoprolol Tartrate 50 mg PO BID
6. Potassium Chloride 20 mEq PO BID
Hold for K >
7. Sertraline 75 mg PO DAILY
8. Tamsulosin 0.4 mg PO BID
9. Dipyridamole 75 mg PO BID
RX *dipyridamole 75 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
right ACA stenosis
hypertension
congestive heart failure
Multiple prior strokes
Extensive small vessel disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came into the hospital because you were having symptoms of
left leg weakness. We looked at the blood vessels in your brain
and saw that there was a narrowing in the blood vessel that goes
to the area that controls your leg. We believe that the episodes
of weakness in your leg are because blood is not flowing as well
to this area of your brain.
For this reason we have started a medication to open up the
blood vessels in your brain. If your symptoms come back you
should sit down or lie flat with your feet up. When you are
getting up to a standing position, please do not go immediately
from lying down to standing as your blood pressure can drop when
this happens and provoke symptoms.
You should also exercise this leg to improve the representation
of your leg muscles in the brain as this will help to protect
the function of the leg.
We spoke with the Neurosurgeons about your case. At this time we
would like to try medical therapy first because the risks of
medical therapy are lower than those of surgical intervention.
If this therapy does not work we can reassess.
We have made the following changes to your medications:
- Started dipyrimadole to improve the blood flow to your brain
- Increased your losartan to 75 mg daily
You should take your other medications as prescribed.
Here you had some bleeding where you were stuck with a needle!
This bleeding was not dangerous. However you should be aware
that because of the medications you are taking (pradaxa and
plavix) you are at risk of bleeding. If you have any fall,
particularly if you hit your head, you should come to the
emergency department for evaluation in case you are having any
bleeding in the head. If you cut yourself please apply pressure
and elevate the cut area as much as possible to help the
bleeding stop. If you have blood in your stool, black sticky
stool, or vomit blood you should seek medical attention
immediately.
You are here visiting from ___. We will provide the
information regarding your hospitalization to your primary care
physician and neurologist in ___.
It has been a pleasure taking care of you.
- The ___ Deaconess ___ team
Followup Instructions:
___
|
19995595-DS-14 | 19,995,595 | 21,784,060 | DS | 14 | 2126-11-12 00:00:00 | 2126-11-12 18:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
heparin
Attending: ___.
Chief Complaint:
Abdominal aortic aneurysm rupture with hemodynamic instability
Major Surgical or Invasive Procedure:
___ INFRARENAL PROXIMAL AORTIC CUFF X 4, OPEN ABDOMEN FOR
WASHOUT OF HEMATOMA
___ ABDOMINAL WASHOUT, LOA, ABTHERA PLACEMENT
___ ABDOMINAL WASHOUT, CLOSURE OF ABDOMEN
History of Present Illness:
HPI:
Mr. ___ is a ___, former smoker, with PVD s/p
aortobifemoral bypass (___ ___ vs ___ per wife), who presented
to the OSH with sudden onset abdominal pain this morning. He
underwent a CTA which showed a disrupted proximal anastomosis of
the aorto-femoral graft with rupture. Additionally he has a
right groin pseudoaneurysm between the right limb of the
aort-bifemoral
graft with the native artery which appears contained. He was
therefore transferred to ___ for further management. On
Medflight, he became hypotensive with worsening abdominal
distention and was given a total of 4u pRBC and ___ FFP. He was
taken directly to the OR for definitive treatment.
Past Medical History:
PMH:
afib, stroke (no neuro deficits ___, PVD, HTN
PSH:
- aortobifemoral bypass ___ vs ___
- >___nd endovascular procedures
including left iliac artery stent, fem-fem bypass, ultimately
resulting in R BKA
Social History:
___
Family History:
FH:
unknown
Physical Exam:
Physical Exam: ON ARRIVAL
Vitals: HR 112 BP 135/110
GEN: in acute distress, conversant
CV: tachycardic
PULM: no respiratory distreess
ABD: tense, distended abdomen, tender to palpation
Ext: No ___ edema, ___ warm and well perfused
Pulses: R: p/d/BKA L: p/d/d/d
ON DISCHARGE
***************
Pertinent Results:
___ 05:37AM BLOOD WBC-8.7 RBC-3.49* Hgb-9.7* Hct-33.4*
MCV-96 MCH-27.8 MCHC-29.0* RDW-21.0* RDWSD-74.2* Plt ___
___ 05:37AM BLOOD ___ PTT-33.4 ___
___ 05:37AM BLOOD Glucose-96 UreaN-41* Creat-0.8 Na-138
K-5.0 Cl-97 HCO3-27 AnGap-14
___ 05:37AM BLOOD Calcium-8.8 Phos-5.6* Mg-2.2
___ 06:41AM BLOOD calTIBC-332 Ferritn-277 TRF-255
Brief Hospital Course:
Mr. ___ is a ___ PVD s/p aortobifemoral bypass (___) who
presented to the OSH with sudden onset of abdominal pain with
CTA confirming p/w ruptured ___ anastomosis. He was transfused
4u rPBC 2uFFP in medflight with worsening hypotension. He was
taken immediately to the OR where he underwent infrarenal ___
aortic cuff x4 w open abdomen (see op note for further
details). He was transferred to the ICU in critical condition.
He was started on fondaparinux prophylaxis due to his history of
HIT. His respiratory status was tenuous and he frequently
desatted and required increasing FiO2 while he remained
intubated. Pulmonology was consulted and he was started on
Lasix. During this initial post-op period his antibiotic
coverage was adjusted as appropriate and he was started on tube
feeds. He had a TTE that showed a PFO, but cardiology did not
feel that any intervention was necessary at this time. He
returned to the OR on POD4 for an abdominal washout, lysis of
adhesions, and abthera placement. Following his second trip to
the OR he had continued PRN Lasix requirements in the ICU. Two
days following this he became febrile and his R IJ line had
evidence of pus when it was removed, so a L IJ was placed. His
fevers continued and he was taken back to the OR again for
another washout and at this time his abdomen was closed. After
this third trip to the OR he was persistently hypertensive and
required nicardipine for BP control. In the following days the
ICU team attempted to wean him from the vent but it was not well
tolerated. He also went into Afib and was started on metoprolol.
He continued to be febrile so a CTA of his torso was obtained,
but it showed no obvious source of infection that would explain
his fevers. On POD12 from his original operation he was
extubated, but developed respiratory distress and needed to be
reintubated. The following day he continued to be febrile so ID
was consulted. The following day he went into Afib with RVR
again and was started on a dilt drip. He had an echo for
unexplained hypotension which didn't show a cardiac cause, but
revealed a thrombus in his IJ. At this time he was also
transitioned to bivalirudin for a short period before being
restarted on fondaparinux. On POD16 from his original operation
he was successfully extubated and his oxygen requirements were
subsequently weaned down. His mental status then became one of
his chief issues, as he would only occasionally follow commands
and would not communicate in any meaningful manner. His fevers
subsided and on POD18 he was transferred to the VICU.
While on the floor in the VICU his blood pressure and mental
status were his main issues. Vascular medicine provided
assistance with his anti-hypertensive regimen, which needed to
be adjusted multiple times for adequate control. Neurology was
consulted for his altered mental status, which they attributed
to delirium secondary to an extended ICU stay. Additionally, ACS
was consulted for placement of a PEG tube as he would likely
need long term feeding access due to his mental status.
Ultimately, his family opted not to go through with the PEG so
that they could avoid reintubation, so his feedings were
continued with the Dobhoff. Neurology attributed his mental
status to delirium related to his prolonged ICU stay, so
delirium precautions were put in place. His mental status began
to improve and he became more conversant and oriented as time
progressed. Vascular medicine continued to be involved in his
care and he was diuresed as necessary. On hospital day ___ he had
a brief run of afib that was seen on telemetry, but had no
further issues with afib afterwards. On hospital day ___ he was
hemodynamically stable and his mental status continued to
improve so he was determined to be fit for discharge. His
discharge was ultimately delayed due to difficulties with
finding rehab placement, but by hospital day 27 case management
had found a rehab facility and he was transferred there with
plans to follow up with vascular surgery clinic for re-imaging
of his abdomen.
Medications on Admission:
Lisinopril
Lovastatin
Gabapentin
Prilosec
Warfarin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Artificial Tears Preserv. Free ___ DROP BOTH EYES Q4H:PRN
dry eyes
4. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
6. Captopril 37.5 mg PO TID
RX *captopril 25 mg 1.5 tablet(s) by mouth three times a day
Disp #*135 Tablet Refills:*0
7. CARVedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
9. Docusate Sodium (Liquid) 100 mg PO BID
10. Fondaparinux 7.5 mg SC DAILY
RX *fondaparinux 7.5 mg/0.6 mL 1 once a day Disp #*30 Syringe
Refills:*0
11. Ipratropium-Albuterol Neb 1 NEB NEB Q4H
12. Metoclopramide 10 mg PO Q6H
13. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
14. QUEtiapine Fumarate 12.5 mg PO QHS agitation
15. Senna 8.6 mg PO BID
16. Divalproex (DELayed Release) 500 mg PO BID
17. Gabapentin 800 mg PO TID
18. Lovastatin 40 mg oral DAILY
19. Memantine 10 mg PO DAILY ___
20. Memantine 5 mg PO DAILY AM
21. Omeprazole 20 mg PO DAILY
22. Warfarin 2 mg PO 5X/WEEK (___)
23. Warfarin 4 mg PO 2X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Abdominal Aortic Aneurysm Rupture
Peripheral Vascular Disease
Anemia secondary to rupture requiring transfusion
Oliguria
Pleural effusions with pulmonary edema requiring diuresis
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:
Mr. ___-
It was a pleasure taking care of you at ___
___. You were admitted to the hospital after
transfer from an outside institution for ruptured abdominal
aortic aneurysm. You underwent emergent repair which required
placement of a graft in you aorta. You also required an
incision made into your abdomen to release the blood that
collected after the rupture.
Please follow the recommendations below to ensure a speedy and
uneventful recovery.
Division of Vascular and Endovascular Surgery
Endovascular Abdominal Aortic Aneurysm Repair Discharge
Instructions
PLEASE NOTE: After endovascular aortic repair (EVAR), it is very
important to have regular appointments (every ___ months) for
the rest of your life. These appointments will include a CT
(CAT) scan and/or ultrasound of your graft. If you miss an
appointment, please call to reschedule.
WHAT TO EXPECT:
Bruising, tenderness, and a sensation of fullness at the groin
puncture sites (or incisions) is normal and will go away in
one-two weeks
CARE OF THE GROIN PUNCTURE SITES:
It is normal to have mild swelling, a small bruise, or small
amounts of drainage at the groin puncture sites. In two weeks,
you may feel a small, painless, pea sized knot at the puncture
sites. This too is normal. Male patients may notice some
swelling in the scrotum. The swelling will get better over
one-two weeks.
Look at the area daily to see if there are any changes. Be
sure to report signs of infection. These include: increasing
redness; worsening pain; new or increasing drainage, or drainage
that is white, yellow, or green; or fever of 101.5 or more. (If
you have taken aspirin, Tylenol, or other fever reducing
medicine, wait at least ___ hours after taking it before you
check your temperature in order to get an accurate reading.)
FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or
incision)
If you have sudden, severe bleeding or swelling at either of
the groin puncture sites:
-Lie down, keep leg straight and apply (or have someone apply)
firm pressure to area for ___ minutes with a gauze pad or
clean cloth.
-Once bleeding has stopped, call your surgeon to report what
happened.
-If bleeding does not stop, call ___ for transfer to closest
Emergency Room.
You may shower 48 hours after surgery. Let the soapy water
run over the puncture sites, then rinse and pat dry. Do not rub
these sites and do not apply cream, lotion, ointment or powder.
Wear loose-fitting pants and clothing as this will be less
irritating to the groin puncture sites.
MEDICATIONS
Take aspirin daily. Aspirin helps prevent blood clots that
could form in your repaired artery.
It is very important that you never stop taking aspirin or
other blood thinning medicines-even for a short while- unless
the surgeon who repaired your aneurysm tells you it is okay to
stop. Do not stop taking them, even if another doctor or nurse
tells you to, without getting an okay from the surgeon who first
prescribed them.
You will be given prescriptions for any new medication started
during your hospital stay.
Before you go home, your nurse ___ give you information about
new medication and will review all the medications you should
take at home. Be sure to ask any questions you may have. If
something you normally take or may take is not on the list you
receive from the nurse, please ask if it is okay to take it.
PAIN MANAGEMENT
Most patients do not have much pain following placement of the
stent alone. You had an abdominal incision in addition to this,
so recovery may take longer. Your puncture sites may be a
little sore. This will improve daily. If it is getting worse,
please let us know.
You will be given instructions about taking pain medicine if
you need it.
ACTIVITY
You must limit activity to protect the puncture sites in your
groin. For ONE WEEK:
-Do not drive
-Do not swim, take a tub bath or go in a Jacuzzi or hot tub
-Do not lift, push, pull or carry anything heavier than five
pounds
-Do not do any exercise or activity that causes you to hold your
breath or bear down with your abdominal muscles.
-Do not resume sexual activity
Discuss with your surgeon when you may return to other regular
activities, including work. If needed, we will give you a
letter for your workplace.
It is normal to feel weak and tired. This can last six-eight
weeks, but should get better day by day. You may want to have
help around the house during this time.
___ push yourself too hard during your recovery. Rest when
you feel tired. Gradually return to normal activities over the
next month.
We encourage you to walk regularly. Walking, especially
outdoors in good weather is the best exercise for circulation.
Walk short distances at first, even in the house, then do a
little more each day.
It is okay to climb stairs. You may need to climb them slowly
and pause after every few steps.
BOWEL AND BLADDER FUNCTION
You should be able to pass urine without difficulty. Call you
doctor if you have any problems urinating, such as burning,
pain, bleeding, going too often, or having trouble urinating or
starting the flow of urine. Call if you have a decrease in the
amount of urine.
You may experience some constipation after surgery because of
pain medicine and changes in activity. Increasing fluids and
fiber in your diet and staying active can help. To relief
constipation, you may talk a mild laxative. Please take to
your pharmacist for advice about what to take.
SMOKING
If you smoke, it is very important that you STOP. Research
shows smoking makes vascular disease worse. This could increase
the chance of a blockage in your new graft. Talk to your
primary care physician about ways to quit smoking.
Followup Instructions:
___
|
19996783-DS-16 | 19,996,783 | 22,140,408 | DS | 16 | 2188-04-24 00:00:00 | 2188-04-24 15:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, abdominal discomfort
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ y/o M with PMhx of HTN, NIDDM, pituitary macroadenoma and
recently diagnosed pancreatic mass causing biliary obstruction
s/p recent ERCP with stent who returns after discharge with
nausea, abd discomfort and inability to tolerate much po. Pt
reports feeling much better after ERCP with stent and felt
return
of appetite. He went home and ate well initially. However, he
soon developed abd discomfort and intractable nausea. He tried
simethicone without any relief and was unable to sleep because
of
symptoms. He returned to the ED and was found to have mild
dehydration, acute on chronic hyponatremia and persistent LFT
abnormalities. He was able to have a BM in the ED which
provided some relief. He has not eaten much all day and feels
some improvement in symptoms. Denies any nausea currently and
abd discomfort has improved. He is concerned about how to
manage symptoms at home and feels his stomach may be blocked up.
Denies any CP, SOB, cough, LH, HA, congestion, dysuria,
hematuria, rash or abd pain currently. He has not noticed and
worsening in ___ edema and is wearing TEDs currently.
Past Medical History:
NIDDM
HTN
Recently Dx with large pancreatic mass causing biliary
obstruction now s/p ERCP with stent, final path pending though
prelim + adenocarcinoma
Social History:
___
Family History:
none relevant to current presentation
Physical Exam:
PE: ___ Temp: 98.3 PO BP: 133/75 L Lying HR: 91 RR: 18
O2 sat: 100% O2 delivery: Ra
GEN: pleasant elderly Asian male in NAD
HEENT: MMM
CV: RRR
RESP: CTAB no w/r
ABD: distended, mild TTP over RUQ but no rebound, BS present
GU: no foley
EXTR: thin, trace ankle edema bilaterally, TEDS in place
NEURO: alert, appropriate, oriented x 3
Pertinent Results:
___ 07:20AM BLOOD WBC-9.1 RBC-3.19* Hgb-8.3* Hct-26.0*
MCV-82 MCH-26.0 MCHC-31.9* RDW-16.1* RDWSD-47.8* Plt ___
___ 07:15AM BLOOD WBC-9.6 RBC-3.04* Hgb-8.0* Hct-23.8*
MCV-78* MCH-26.3 MCHC-33.6 RDW-15.7* RDWSD-43.9 Plt ___
___ 08:55AM BLOOD WBC-9.6 RBC-3.59* Hgb-9.5* Hct-28.0*
MCV-78* MCH-26.5 MCHC-33.9 RDW-15.7* RDWSD-43.5 Plt ___
___ 06:47AM BLOOD WBC-9.8 RBC-3.13* Hgb-8.2* Hct-24.5*
MCV-78* MCH-26.2 MCHC-33.5 RDW-15.5 RDWSD-42.9 Plt ___
___ 08:55AM BLOOD Neuts-84.4* Lymphs-7.4* Monos-6.4
Eos-0.8* Baso-0.2 Im ___ AbsNeut-8.11* AbsLymp-0.71*
AbsMono-0.62 AbsEos-0.08 AbsBaso-0.02
___ 07:20AM BLOOD Glucose-129* UreaN-13 Creat-0.7 Na-130*
K-3.8 Cl-91* HCO3-24 AnGap-15
___ 07:15AM BLOOD Glucose-158* UreaN-13 Creat-0.6 Na-131*
K-3.7 Cl-95* HCO3-24 AnGap-12
___ 10:25PM BLOOD Glucose-260* UreaN-15 Creat-0.8 Na-129*
K-3.8 Cl-92* HCO3-24 AnGap-13
___ 10:20AM BLOOD Glucose-208* UreaN-17 Creat-0.9 Na-126*
K-5.0 Cl-92* HCO3-20* AnGap-14
___ 06:47AM BLOOD Glucose-104* UreaN-9 Creat-0.6 Na-131*
K-3.9 Cl-93* HCO3-21* AnGap-17
___ 07:20AM BLOOD ALT-43* AST-29 AlkPhos-217* TotBili-2.0*
___ 07:15AM BLOOD ALT-47* AST-31 AlkPhos-235* TotBili-2.1*
___ 10:20AM BLOOD ALT-59* AST-57* AlkPhos-286* TotBili-2.5*
___ 06:47AM BLOOD ALT-59* AST-44* LD(LDH)-218 AlkPhos-291*
TotBili-3.0*
___ 10:20AM BLOOD Lipase-61*
KUB:
IMPRESSION:
Nonspecific bowel gas pattern. Stomach is mildly dilated. No
evidence of
small-bowel obstruction. Gas and stool filling the large bowel
loops
Brief Hospital Course:
___ y/o M with NIDDM, HTN and recently diagnosed pancreatic
cancer
causing biliary obstruction s/p ERCP with stent who returns with
nausea and decreased ability to tolerate po.
#possible functional duodenal/gastric outlet obstruction
#Pancreatic adenocarcinoma
#Nausea/abd discomfort: mass invasion of duodenum may be
causing functional gastric outlet obstruction. Pt's symptoms
improved with decreased PO intake, after ERCP, and after BM, gas
may be contributing. Pt tolerated better PO during admission.
D/w Pt importance of
nutrition and taking what he is able to tolerate and to
supplement with ensure or boost if needed. Nutrition consulted.
Discussed attempting a liquid diet if he is unable to tolerate
solid food. Discussed symptom control with ___, simethicone,
bowel regimen. Discussed case with oncology and ERCP teams. Plan
for outpt onc f/u (as already arranged ___ and per ERCP team,
no significant intestinal stricture noted on ERCP to intervene
upon at this time.
#Hyponatremia/SIADH: clinically euvolemic now and Na improved on
repeat labs likely because pt was taking decreased PO. Na stable
during admission without IVF or fluid restriction.
#anemia-no clear evidence of bleeding. Trend/monitor. Outpt f/u.
#NIDDM: Restarted home oral agents on DC. If PO intake over the
long run becomes an issue, he may need to DC some of these
agents.
#Pituitary Macroadenoma: outpt f/u
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
2. Polyethylene Glycol 17 g PO BID
3. Senna 17.2 mg PO BID
4. Simethicone 40-80 mg PO QID:PRN stomach upset
5. Simvastatin 10 mg PO QPM
6. glimepiride 4 mg oral DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID W/MEALS
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
you may purchase over the counter
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth daily Disp #*20
Tablet Refills:*0
3. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
RX *bisacodyl [Dulcolax (bisacodyl)] 5 mg ___ tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
4. glimepiride 4 mg oral DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral TID W/MEALS
7. Polyethylene Glycol 17 g PO BID
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17gm
powder(s) by mouth daily Refills:*0
8. Senna 17.2 mg PO BID
RX *sennosides [Senna-Gen] 8.6 mg 1 tab by mouth twice a day
Disp #*60 Tablet Refills:*0
9. Simethicone 40-80 mg PO QID:PRN stomach upset
10. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
pancreatic cancer
nausea
constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted for evaluation and treatment of abdominal
pain/bloating and nausea and decreased ability to eat and drink
likely secondary to your pancreatic cancer and also some
constipation. For this, you were evaluated by the nutritionist
and we discussed using supplements such as boost or ensure if
you are unable to eat and drink well. Please try to eat and
drink as you are able. You may need to have a liquid or a softer
diet if you feel unable to eat and drink well. You will meet
with the cancer doctors this week to discuss the next steps in
your treatment.
Followup Instructions:
___
|
19996783-DS-17 | 19,996,783 | 21,880,161 | DS | 17 | 2188-05-19 00:00:00 | 2188-05-20 07:45:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest Pain, SOB
Major Surgical or Invasive Procedure:
EGD with duodenal stenting ___
History of Present Illness:
Mr. ___ is an ___ year-old gentleman with hypertension,
hyperlipidemia, T2DM and recently diagnosed pancreatic ductal
adenonocarcinoma with biliary/duodenal involvement who presents
with nausea, vomiting, chest pain and shortness of breath.
Per ED report he presented to ED complaining of shortness of
breath and chest discomfort since the morning of ___ via son as
interpreter. He also had intermittent diarrhea and nausea.
ED initial vitals were 97.1 106 114/63 18 99% RA
Prior to transfer vitals were 97.7 103 113/56 16 100% RA
Exam in the ED showed : "Gen: Comfortable, appears chronically
ill but in no acute distress. HEENT: NC/AT. EOMI. Neck: No
swelling. Cor: RRR. No m/r/g. Pulm: CTAB, Nonlabored
respirations. Abd: Soft, NT, ND. Ext: No edema, cyanosis, or
clubbing. Skin: No rash, skin pale Neuro: AAOx3. Gross
sensorimotor intact. Psych: Normal mentation. "
ED work-up significant for:
-CBC: WBC: 5.2. HGB: 8.3*. Plt Count: 206. Neuts%: 90*.
-Chemistry: Na: 125*. K: 4.0 . Cl: 86*. CO2: 13* . BUN: 21*.
Creat: 1.0. Ca: 8.0*. Mg: 1.2*. PO4: 3.3.
-Lactate:4.4-> 1.9
-Coags: INR: 2.1*. PTT: 31.6.
-UA: WBC 4, Gluc 300, Ket 40, UA
-EKG read as "sinus, ischemia:non-specific"
-TnT: 0.02
-CT Torso: "1. Small, subsegmental right lower lobe pulmonary
embolus. No evidence of right heart strain or definite pulmonary
infarction. 2. ___ and ground-glass opacities most
conspicuous at left lung base and lingula, appear similar to ___ and are likely infectious or inflammatory. 3. No
significant interval change in the large hypoenhancing mass
arising from the head of the pancreas. Peripancreatic adenopathy
is overall minimally increased. The mass invades the second and
third portion of the duodenum resulting in upstream obstruction
which appears progressed in comparison to the prior examination.
There has been interval CBD stent placement with decompression
of
the intrahepatic biliary tree and expected pneumobilia, however
there is extensive soft tissue at the inferior ostium of the
stent and partial or pending obstruction can't be excluded. The
mass again obliterates the main portal vein, but the aorta and
encases the SMA. 4. 8 mm right middle lobe pulmonary nodule,
unchanged from ___. 5. Multiple bilateral old rib
fractures are noted."
-CT head: No acute intracranial hemorrhage
-___: negative
ED management significant for:
-Medications: MgSO4 2g iv, CTX 1g, Levofloxacin 750mg iv,
enoxaparin 60mg sc x1
Patient had bed assignment 15:56, accepted by HMED. First
documented vital signs at 1823. Patient transferred from HMED to
this writer at 20:00, signout out as stable.
When asked about his symptoms patient reports having had an
episode of nausea, diarrhea and malaise on ___ that
subsided. On the morning of ___ he woke up with nausea, chest
pain and shortness of breath. He tried to eat but could not as
he
vomited. He also reports having 2 episodes of loose stool. He
felt unwell and had prominent malaise and was brought in to ED
by
son. Here he continues to feel unwell, no longer has shortness
of
breath or chest discomfort. He feels much better than in the
morning.
Patient denies fevers/chills, night sweats, headache, vision
changes, dizziness/lightheadedness, weakness/numbnesss, cough,
hemoptysis, chest pain, abdominal pain, nausea/vomiting,
diarrhea, hematemesis, hematochezia/melena, dysuria, hematuria,
and new rashes.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
1. Cardiac Risk Factors
-Hypertension
-Hyperlipidemia
-DM2
2. Cardiac History
-None
3. Other PMH
-Stage III/IV pancreatic adenocarcinoma
-Pituitary macroadenoma complicated by ___
Social History:
___
Family History:
No known family history of malignancy. His mother lived to ___
years. His father died at a young age of unknown causes. He
had 4 brothers and 3 sisters most of whom lived to their ___.
He has 2 sons without health concerns.
Physical Exam:
ADMISSION PHYSICAL
=================
VS: T:97.9, BP: 109/58, HR: 97, RR: 17, O2: 100% RA
GENERAL: Chronically ill appearing, NAD
HEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM
NECK: Supple. No appreciable JVD.
CARDIAC: RRR, +S1/2, no murmurs, rubs, gallops
LUNGS: CTAB
ABDOMEN: Soft, NTND, +BS
EXTREMITIES: Warm, 1+ symmetric pitting edema upto knees
SKIN: no rashes
PULSES: symmetric distal pulses
DISCHARGE PHYSICAL
=================
VS: ___ 0511 Temp: 97.8 PO BP: 90/54 R Lying HR: 114 RR: 16
GENERAL: Chronically ill appearing, cachectic, NAD
HEENT: NC/AT, Sclera anicteric, PERRL, EOMI, dry MM
NECK: Supple. No appreciable JVD
CARDIAC: sinus tachycardia, +S1/2, no murmurs, rubs, gallops
LUNGS: CTAB
ABDOMEN: Distended. Epigastric TTP throughout. No rebound or
guarding
EXTREMITIES: Warm, 1+ symmetric pitting edema upto knees
SKIN: no rashes
PULSES: symmetric distal pulses
Pertinent Results:
ADMISSION LABS
=============
___ 05:25AM BLOOD WBC-5.2 RBC-3.26* Hgb-8.3* Hct-25.3*
MCV-78* MCH-25.5* MCHC-32.8 RDW-15.3 RDWSD-42.7 Plt ___
___ 05:25AM BLOOD Neuts-90* Bands-3 Lymphs-7* Monos-0 Eos-0
Baso-0 ___ Myelos-0 AbsNeut-4.84 AbsLymp-0.36*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 05:25AM BLOOD Hypochr-1+* Anisocy-NORMAL Poiklo-1+*
Macrocy-NORMAL Microcy-3+* Polychr-NORMAL Burr-1+*
___ 05:25AM BLOOD ___ PTT-31.6 ___
___ 05:25AM BLOOD Glucose-297* UreaN-21* Creat-1.0 Na-125*
K-4.0 Cl-86* HCO3-13* AnGap-26*
___ 05:25AM BLOOD CK(CPK)-58
___ 05:25AM BLOOD CK-MB-5
___ 05:25AM BLOOD cTropnT-0.02*
___ 09:56PM BLOOD CK-MB-40* MB Indx-13.6* cTropnT-1.37*
___ 05:25AM BLOOD Calcium-8.0* Phos-3.3 Mg-1.2*
___ 05:31AM BLOOD Lactate-4.4* Na-122* K-3.8
___ 08:09AM URINE Color-Yellow Appear-Clear Sp ___
___ 08:09AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-300* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:09AM URINE RBC-1 WBC-4 Bacteri-NONE Yeast-NONE
Epi-<1
___ 08:09AM URINE CastHy-35*
___ 08:09AM URINE Mucous-RARE*
___ 08:09AM URINE Hours-RANDOM Na-80
___ 08:09AM URINE Osmolal-405
PERTINENT RESULTS
================
___ 05:28AM BLOOD ___
___ 04:46AM BLOOD ___ 05:28AM BLOOD Ret Aut-0.4 Abs Ret-0.01*
___ 03:56AM BLOOD CK-MB-24* MB Indx-11.8* cTropnT-1.92*
___ 05:28AM BLOOD calTIBC-101* VitB12-324 Hapto-347*
Ferritn-695* TRF-78*
___ 11:30AM BLOOD ___ pO2-165* pCO2-20* pH-7.34*
calTCO2-11* Base XS--12 Comment-GREEN TOP
___ 08:52AM BLOOD Lactate-1.9
___ 11:30AM BLOOD Lactate-7.6*
___ 07:30PM BLOOD Lactate-1.8
___ 12:18PM BLOOD Lactate-2.3*
___ 09:12PM BLOOD Lactate-1.4
___ 12:04PM BLOOD Lactate-2.2*
MICRO
=====
___ 11:18 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:13 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:45 am BLOOD CULTURE #2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) @12:26
(___).
__________________________________________________________
___ 5:25 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES
=======
CXR PA and LAT ___
An infrahilar opacity best seen on lateral view is unchanged
from ___. In the appropriate clinical setting this may
represent pneumonia, although this could represent atelectasis
given low volumes.
CTA Chest, CT Abdomen ___. Small, subsegmental right lower lobe pulmonary embolus. No
evidence of right heart strain or definite pulmonary infarction.
2. ___ and ground-glass opacities most conspicuous at
left lung base and lingula, appear similar to ___ and are
likely infectious or inflammatory.
3. No significant interval change in the large hypoenhancing
mass arising from the head of the pancreas. Peripancreatic
adenopathy is overall minimally increased. The mass invades the
second and third portion of the duodenum resulting in upstream
obstruction which appears progressed in comparison to the prior
examination. There has been interval CBD stent placement with
decompression of the intrahepatic biliary tree and expected
pneumobilia, however there is extensive soft tissue at the
inferior ostium of the stent and partial or impending
obstruction can't be excluded. The mass again obliterates the
main portal vein, abuts the aorta and encases the SMA.
4. 8 mm right middle lobe pulmonary nodule, unchanged from ___.
5. Multiple bilateral old rib fractures are noted.
CT Head w/o Contrast ___. No acute intracranial process.
2. Paranasal sinus retention cysts, similar to previous study.
___ ___
No evidence of deep venous thrombosis in the lower extremities.
TTE ___
The left atrial volume index is normal. There is normal left
ventricular wall thickness with a normal cavity size. There is
mild regional left ventricular systolic dysfunction with
near-akinesis of the distal ___ of the left ventricle (distal
LAD territory; see schematic) and preserved/normal contractility
of the remaining segments. The visually estimated left
ventricular ejection fraction is 40%. No thrombus or mass is
seen in the left ventricle. Normal right ventricular cavity size
with normal free wall motion. The aortic sinus diameter is
normal for gender with normal ascending aorta diameter for
gender. The aortic arch diameter is normal. There is no evidence
for an aortic arch coarctation. The aortic valve leaflets (3)
are mildly thickened. There is no aortic valve stenosis. There
is no aortic regurgitation. The mitral leaflets are mildly
thickened with no mitral valve prolapse. There is mild [1+]
mitral regurgitation. The tricuspid valve leaflets appear
structurally normal. There is trivial tricuspid regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
IMPRESSION: Adequate image quality. Mild regional left
ventricular systolic dysfunction most consistent with coronary
artery disease (LAD distribution). Mild mitral regurgitation.
CXR ___
Patchy retrocardiac opacity, potentially atelectasis with
infection or aspiration not excluded in the correct clinical
setting. Marked distension of the stomach.
Abdomen Xray ___
Massive distention of the stomach for which nasogastric tube
decompression is recommended. No evidence for small or large
bowel obstruction.
Abdomen Xray ___
NG tube in the stomach loops back into the still esophagus.
Improvement of the gastric distension.
Abdomen Xray ___
Massive distention of the stomach similar in appearance to study
of ___ with duodenal air-fluid levels compatible with
gastric outlet obstruction.
CXR ___
Extensive dilatation of the stomach is re-demonstrated with the
stomach bubble approaching 27 x 19 cm. NG tube tip is
projecting over the stomach bubble left basal consolidation is
most likely representing atelectasis. Right PICC line tip is at
the cavoatrial junction no appreciable pleural effusion
demonstrated.
CXR ___ (NG Placement)
Extensive dilatation of the stomach is re-demonstrated with the
stomach bubble approaching 27 x 19 cm. NG tube tip is
projecting over the stomach bubble left basal consolidation is
most likely representing atelectasis. Right PICC line tip is at
the cavoatrial junction no appreciable pleural effusion
demonstrated.
EGD ___
Large gastric ulcer. Malignant duodenal sweep ulcer. Duodenal
stricture s/p placement of uncovered duodenal stent.
DISCHARGE LABS
=============
___ 06:26AM BLOOD WBC-6.7 RBC-3.66* Hgb-10.7* Hct-32.5*
MCV-89 MCH-29.2 MCHC-32.9 RDW-21.2* RDWSD-59.5* Plt ___
___ 06:26AM BLOOD Glucose-186* UreaN-32* Creat-1.6* Na-137
K-5.1 Cl-107 HCO3-17* AnGap-13
___ 06:26AM BLOOD Calcium-7.8* Phos-4.4 Mg-2.0
Brief Hospital Course:
Mr. ___ is a ___ year old male with PMHx of stage III/IV
pancreatic adenocarcinoma, DM2, Hyponatremia, SIADH who
presented with a 1-day history of chest pain and shortness of
breath found to have anterior missed STEMI s/p medical
management (high risk for PCI, missed window, no symptoms),
hospital course complicated by GI bleed in the setting of
anticoagulation with heparin and known active malignancy with
gastric and duodenal ulcerations, now s/p 5U PRBC with improved
hemodynamics, evidence of gastric obstruction likely ___
malignancy s/p palliative duodenal stent discharged to hospice
care.
ACUTE ISSUES:
============
#GOC
Mr. ___ presented with known advanced pancreatic cancer on
palliative chemotherapy, complicated by symptomatic gastric
outlet obstruction. Patient was also noted to have a GI bleed in
the setting of anticoagulation for STEMI and small subsegmental
PE. Several goals of care discussions were held with the
patient's son and the patient was made DNR/DNI based on these
conversations. Goals of care discussions included patient's
primary oncologist as well as the inpatient palliative care
team. He was screened for hospice eligibility and is now being
discharged to hospice care.
#Melena
#Acute Blood Loss Anemia
Hospital course complicated by GI bleed requiring 5U PRBC total.
The patient had a GI bleed was secondary to known necrotic
gastric and duodenal malignant ulcerations. Patient's
anticoagulation as well as antiplatelet therapy (started for
medical management of STEMI) were held in the setting of an
active GI bleed. Gastroenterology was consulted and placed a
palliative uncovered duodenal stent via EGD for symptomatic
relief of gastric outlet obstruction.
#Bilious emesis
#Gastric outlet obstruction
The ___ hospital course was complicated by gastric
obstruction in setting of known pancreatic malignancy invading
duodenum and KUB revealed severely distended stomach without
evidence of small or large bowel obstruction. Patient underwent
EGD with palliative duodenal stenting with marked improvement in
symptoms. An NG tube was also placed prior to stenting and was
removed once stent was placed.
___
Patient was noted to have ___ on presentation. This was
thought to be likely in the setting of hypotension and decreased
PO intake secondary to gastric obstruction. He was managed
supportively. His creatinine initially improved with fluids
however had a repeat ___ likely in the setting of hypotension
with Cr 1.6 at discharge.
#STEMI
The patient presented with 1 day history of chest pain and was
initially admitted to oncology service but was transferred to
CCU after EKG showing STE in V2-V3 and troponin elevation at
1.02. Onset of symptoms occurred ___ hours prior to
presentation and given complex comorbidities and complete
resolution of symptoms, cardiac cath was deferred and medical
management was pursued. A TTE showing mild regional LV systolic
dysfunction in LAD distribution with EF 40%. The patient was
initially started on heparin drip and on dual anti platelet
therapy but these were deferred in the setting of GI bleed.
Metoprolol and lisinopril were not started due to hypotension
and significant GI bleed per above.
# Small Subsegmental Pulmonary Embolus
On admission, there was evidence of small sub-subsegmental PE on
CTA chest. He was started on anticoagulation for STEMI that
would also cover small segmental PE, however given active GI
bleed, continuation of anticoagulation was deferred.
# Hyponatremia
# ___
Patient presented with known history of hyponatremia thought to
be SIADH in the setting of a macroadenoma in the pituitary.
Sodium was trended daily and improved with IVF and PO intake
# Possible LLL Pneumonia, CAP
Patient was initially started on a 5 day course of ceftriaxone
and briefly broadened to vancomycin and cefepime. However given
lack of fevers, leukocytosis, clinical signs of pneumonia, the
patient's antibiotics were stopped and he was closely monitored.
# H. pylori Infection
The patient was continued on metronidazole QID, tetracycline
QID, omeprazole,
bismuth x 2 weeks (___)
# Pancreatic Adenocarcinoma, Stage III-IV
# Functional Gastric Outlet Obstruction
Recently diagnosed with stage III-IV pancreatic adenocarcinoma
(7.5cm) obliterating SMV and encasing SMA on cycle 1 of
palliative gemcitabine (first/last dose ___. CT torso ___
again with large hypodense mass in pancreatic head invading
second and third portions of the duodenum. Possible or impending
obstruction of CBD stent also noted. Patient underwent
palliative duodenal stenting.
CHRONIC ISSUES:
===============
# Type 2 Diabetes Mellitus
Patient had known history of type 2 diabetes. He was on a
regimen of metformin and glimepiride at home. These oral
hypoglycemics were held in the inpatient setting and the patient
was started on insulin sliding scale.
# Pituitary Macroadenoma
14mm non-enhancing lesion in anterior right pituitary noted on
MRI ___. Thought to possibly be cystic. Further management
not within goals of care.
TRANSITIONAL ISSUES
===================
[]Pain control: Recommend titration of pain control to make
patient comfortable
[]Nausea/Vomiting: Recommend use of anti-emetics/benzodiazepines
to aggressively control symptoms
# CODE: DNR/DNI, MOLST in chart
# CONTACT/HCP: ___ (son, lives with him) ___ ___
(son) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 4 mg PO Q8H:PRN nausea
2. Bismuth Subsalicylate 15 mL PO QID
3. Simethicone 120 mg PO QID:PRN gas
4. MetroNIDAZOLE 250 mg PO QID
5. Omeprazole 20 mg PO DAILY
6. glimepiride 4 mg oral DAILY
7. Tetracycline 500 mg PO QID
8. Nephrocaps 1 CAP PO DAILY
Discharge Medications:
1. GlipiZIDE XL 2.5 mg PO DAILY
2. HYDROmorphone (Dilaudid) 0.5-1 mg IV Q3H:PRN Pain - Moderate
3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Mild
4. Sucralfate 1 gm PO QID
5. Bismuth Subsalicylate 15 mL PO QID
6. Ondansetron 4 mg PO Q8H:PRN nausea
7. Simethicone 120 mg PO QID:PRN gas
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
=================
Acute blood loss anemia
Upper GI bleed
Gastric outlet obstruction
Thrombocytopenia
Leukocytosis
Acute Kidney Injury
STEMI
Pulmonary embolus, small sub-submental
Hyponatremia
SIADH
Left lower lobe pneumonia, community-acquired
Secondary Diagnoses
===================
Pancreatic adenocarcinoma, stage IIIIV
H pylori infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital!
Why was I admitted?
You were admitted to the hospital because had a heart attack
What happened while I was admitted?
-You had a heart attack and were given blood thinning
medications
-You had a stent placed in your stomach to help with nausea and
vomiting
-You were given blood back because you were bleeding
What should I do after I leave the hospital?
-Spend time with your family and loved ones
We wish you the very best!
Your ___ Care Team
Followup Instructions:
___
|
19996902-DS-9 | 19,996,902 | 23,688,425 | DS | 9 | 2156-09-25 00:00:00 | 2156-09-28 20:56:00 |
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:
Left lower quadrant pain
Major Surgical or Invasive Procedure:
CT guided drainage ___
History of Present Illness:
___ G1P0010 with T1DM, p/w 2 wks of n/v/loose stools, RUQ pain,
and LLQ progressive crampy pain. No f/c at all. Was in her
usual state of health prior to 2 wks ago. Nausea came first,
does not seem to be assoc w/pain, which was mild at first and
felt like usual ovulatory/premenstrual cramp, but only on left.
GI sxs peaked ___ wks ago, and today all sxs feel much improved.
However, seen by PCP ___ and +chlamydia cervical culture, did
not fill doxy Rx due to access issues. Monogamous with partner
who is out of state for work right now. Outpt PUS today showed
concern for ___, so sent in for eval. Outpt RUQ US showed
?___.
Of note, ran out of Lantus so only took 18u of her usual 32u
today. Also no Humalog, decreased PO so did not cover crackers.
ROS: No dysuria but feels some incomplete void, though voiding
normal amounts. No dyspnea/CP. No back pain, no weight or
appetite changes, no night sweats. Has occ constipation and
diarrhea, chronically.
Past Medical History:
GYN Hx:
- LMP ___
- menses q month regular, x5-6 days nl flow
- severe dysmenorrhea -> ibuprofen
- no dyspareunia, postcoital or intermenstrual bleeding
- occ yeast infxns treated with monistat
- no other hx STI/PID or abnl Pap, last Pap ___ neg
OB Hx:
- G1 TAb 12 wks in ___, office MVA not well-tolerated, followed
by same-day D&E for rPOC
MED Hx:
- asthma, off symbicort, no hosp/intub
- T1DM dx ___ ago, NPDR, reg eye exams, sees ___
- depression previously seeing psychotherapist
SURG Hx:
- necrobiosis lipoidica excision from shin (___)
- LSC CCY (___)
- MVA -> D&E (___)
Social History:
___
Family History:
no known GYN or colorectal malignancies
Physical Exam:
On admission:
98.4 74 134/87 16 100RA
NAD NARD
RRR, CTAB
No CVAT
Abd soft ND, mild TTP and fullness in LLQ, no R/G
Ext NT NE
SSE no cervicitis or discharge, nl mucosa
BME mild focal CMT, RV ut, adn masses/ttp not appreciated
On discharge:
AF VSS
NAD
RRR
CTAB
Abd soft, mildly TTP LLQ, no r/g
GU no VB
Ext no TTP, no edema
Pertinent Results:
CBC
___ 06:05PM BLOOD WBC-11.5* RBC-3.82* Hgb-11.3* Hct-34.6*
MCV-91 MCH-29.6 MCHC-32.8 RDW-13.2 Plt ___
___ 06:00AM BLOOD WBC-10.6 RBC-3.82* Hgb-11.4* Hct-34.5*
MCV-90 MCH-29.8 MCHC-32.9 RDW-13.5 Plt ___
___ 06:03AM BLOOD WBC-8.4 RBC-3.84* Hgb-10.8* Hct-34.9*
MCV-91 MCH-28.0 MCHC-30.9* RDW-13.4 Plt ___
___ 06:05AM BLOOD WBC-8.4 RBC-3.91* Hgb-11.2* Hct-35.1*
MCV-90 MCH-28.7 MCHC-32.0 RDW-14.1 Plt ___
Chem
___ 06:05PM BLOOD Glucose-340* UreaN-9 Creat-0.6 Na-135
K-4.6 Cl-97 HCO3-28 AnGap-15
___ 06:00AM BLOOD Glucose-195* UreaN-6 Creat-0.4 Na-139
K-4.2 Cl-102 HCO3-28 AnGap-13
___ 06:05AM BLOOD Glucose-143* UreaN-10 Creat-0.6 Na-135
K-4.2 Cl-99 HCO3-29 AnGap-11
___ 06:00AM BLOOD %HbA1c-10.5* eAG-255*
LFTs
___ 06:05PM BLOOD ALT-61* AST-58* AlkPhos-138* TotBili-0.3
___ 06:00AM BLOOD ALT-68* AST-63* AlkPhos-127*
___ 06:03AM BLOOD ALT-80* AST-63* LD(LDH)-265* AlkPhos-125*
TotBili-0.2
___ 06:05AM BLOOD ALT-85* AST-66*
___ 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE HAV Ab-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 06:00AM BLOOD HCV Ab-NEGATIVE
___ 06:00AM BLOOD HCG-<5
___ 08:55AM BLOOD HIV Ab-NEGATIVE
Fluid analysis
PELVIC FLUID COLLECTION.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
Blood Culture, Routine (Final ___: NO GROWTH.
IMAGING
Abd U/S, ___:
FINDINGS:
The liver demonstrates diffusely hypoechoic appearance with mild
prominence of the portal triads consistent with "starry sky"
appearance. There is no evidence of focal liver lesions. There
is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is resected. The pancreas is
within normal limits. The right kidney measures 10.3 cm and left
kidney measures 11.6 cm. There is a mild central
hydronephrosis in the left kidney. There is no evidence of
stones or masses bilaterally. The spleen measures 9.4 cm.
Aorta and IVC unremarkable.
IMPRESSION:
1. Hypoechoic appearance of the liver with prominent portal
triads, which is known as "starry sky" appearance. Ffurther
correlation is recommended with liver function tests.
2. Mild left mild hydronephrosis.
PUS, ___
FINDINGS:
The uterus is measuring 7.7 x 2.4 x 5.8 cm. The endometrium is
5 mm and
homogeneous in appearance.
The right ovary is enlarged and located to the right posterior
to the uterus. Arizing and medial to the right ovary a cystic
lesion with multiple septations and a low-level echoes is seen
measuring 7 x 4.1 x 7 cm. There is most probably representing
a hemorrhagic cyst.
The left adnexa located above the left iliac vessels and lateral
to the sigmoid colon. The overall ___ of the left adnexa
is 8.5 x 5.5 x 7.2 cm and contains multiple septations, some of
the with vascularity. Prominent vascularity of adjacent sigmoid
is also seen.
There is no free fluid in the pelvis.
IMPRESSION:
1. There is a cyst with hemorrhagic contents is in the right
ovary with measurements as above. Due to large size follow up
is recommended in 6 weeks.
2. Complex adnexal mass on the left adjacent to the sigmoid
colon with
secondary inflammation. Due to known hstory of current
chlamydia infection, findings are consistent with tubo-ovarian
abscess.
CT pel, ___:
FINDINGS:
The small and large bowel are unobstructed. There is colonic
wall thickening adjacent to the left adnexal abscess. There is
diffuse mesenteric and omental edema, likely related to pelvic
inflammation. In the region of the left adnexa there is a 3.1 x
3.2 x 5.2, cm fluid collection with thick enhancing rim which is
indistinguishable from the left ovary. Medial to this there is
a thin-walled fluid collection measuring 3.5 x 3.3cm. In the
pelvic cul-de-sac, there is a 3.3 x 5.5 x 6.1 cm rim enhancing
fluid collection consistent with abscess. Normal appearance of
the right adnexa.
No significant osseous or vascular abnormalities.
There is a prominent left internal iliac node which is likely
reactive to
pelvic inflammation.
IMPRESSION:
1. Pelvic cul-de-sac abscess would likely be accessible with CT
guidance. The left adnexal presumed abscess which is
indseparable from the ovary also likely amenable to CT-guided
drainage.
2. The midline fluid collection without a thick rim may
represent a
noninfected cystic structure and would be very difficult to
access with CT or ultrasound guidance.
3. Diffuse mesenteric and omental edema likely related to pelvic
inflammation.
Brief Hospital Course:
On ___, Ms. ___ was admitted to the gynecology service
from the ED for LLQ pain and findings of left adnexal mass with
multiple septations on PUS in the setting of untreated
chlamydia, raising the concern for ___. She was also found to
have some RUQ pain and elevated liver enzymes in the ED.
# LLQ ___:
Upon admission, the patient had mild LLQ tenderness and CMT. She
had a mild leukocytosis and was afebrile. Given her untreated
chlamydia and findings on U/S, she was presumed to have ___
and was admitted for IV antibiotics and pain control. She
remained NPO/IVF on HD1 in the event that the adnexal collection
was amenable to drainage. IV gentamicin and clindamycin were
started empirically. Other possible diagnoses including adnexal
torsion, malignancy, ectopic pregnancy, diverticulitis/pelvic
abscess were considered and evaluated for. Additional imaging
with CT abd/pel was performed and demonstrated three areas
within the pelvis concerning for pelvic abscesses. It was felt
that the pelvic cul-de-sac and left ovarian fluid collections
were amenable to CT-guided drainage; the third more midline
fluid collection was more consistent with non-infected cystic
structure and was also felt to be difficult to access for
drainage.
On ___, the patient underwent CT-guided drainage of the
pelvic cul-de-sac abscess and a drain was left in place. The
left adnexal collection could not be drained or aspirated.
Additional attempts to drain the left adnexal collection were
not made. The drain was left in place and continued to have
minimal output; the drain was discontinued on ___ prior to
discharge. Fluid cultures were obtained at the time of drainage,
and prior to discharge, the gram stain was negative and the
culture demonstrated no growth. On day of discharge (___),
the patient remained afebrile with minimal abdominal tenderness.
She was transitioned to po doxycycline for a 2 week course of
antibiotics. She had outpatient follow-up scheduled at time of
discharge.
# Transaminitis:
At time of presentation, the patient complained of mild RUQ
tenderness and labs were obtained in the ED which demonstrated a
mild transaminitis. A RUQ U/S was significant for a "starry sky"
appearance, but was otherwise unremarkable. The differential at
time of admission included a reactionary response to capsular
inflammation (eg ___, acute hepatitis or hepatic
congestion. Hepatitis serologies and HIV were negative. Liver
enzymes were trended and remained stable. Given that the patient
developed no signs of liver function compromise, it was felt
that her transaminitis was likely secondary to capsular
inflammation relating to her PID.
# T1DM:
On admission, the patient's FSBG was poorly controlled; she
reported a home regimen of Lantus 32u qAM and HISS with a
correction of 1:25 and ___ 1:9. A HbA1c was 10.5, which was
consistent with her outpatient values. A ___ consult was
obtained on ___ in order to optimize her insulin regimen,
but while NPO on day of admission, her insulin regiment was
initially Lantus 18u with HISS. After being seen by ___, the
patient was recommended to receive her full dose of Lantus even
while NPO given her poorly controlled FSBG. On ___, her
Lantus was eventually increased to 36u given persistently
elevated FSBG. She was discharged home on this regimen plus the
recommendation to change her ___ to 1:8. Upon discharge, she
was instructed to follow-up with ___.
On ___, the patient was discharged home on oral antibiotics,
specifically doxycycline for a 2 week course. She had an
outpatient appointment scheduled prior to discharge.
Medications on Admission:
Lantus, humalog, ASA 81mg, albuterol
Discharge Medications:
1. Lantus 36 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus] 100 unit/mL ___aily
before breakfast Disp #*1 Vial Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PID
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with pelvic inflammatory disease (PID) with a
tubo-ovarian abscess (___). This is likely a result of
Chlamydia. You were treated with IV antibiotics and the ___ was
drained under CT guidance. You should continue your antibiotics.
You received a script for Chlamydia for your partner and he
should take this to prevent re-infection for you.
Followup Instructions:
___
|
19997367-DS-21 | 19,997,367 | 27,185,507 | DS | 21 | 2127-05-12 00:00:00 | 2127-05-12 20:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro Cystitis / Dilaudid / Mexiletine / Bactrim / Avelox /
Levaquin / Amoxicillin / Oxycodone / Hydrochlorothiazide /
Minocycline / Cleocin / Percocet / vancomycin
Attending: ___.
Chief Complaint:
Hemoptysis and melanotic stools
Major Surgical or Invasive Procedure:
EGD with MAC Anesthesia
History of Present Illness:
Ms. ___ is a ___ with a PMHx of AML (sp T-cell depleted
allogenic BMT in ___, CKD, lymphoproliferative disorder,
hypogammaglobulinemia, ___ PEA arrest cb anoxic brain injury
(___), severe MR ___ MVR), hemochromatosis (cb cirrhosis and
encephalopathy), recurrent pleural effusions, and varices sp
GIB, recently admitted for endocarditis/septic shock, who
presented with hemoptysis and melanotic stools.
She was at ___ following her recent admission for
endocarditis and septic shock, while on PCN. She began noticing
some dyspnea on exertion when working there with ___. She also
noted that her legs and feet were more swollen ___ dependent
edema and she was started on Lasix. At rehab, she was sitting at
dinner on ___ and coughed after she took a bite. Following the
cough, blood gushed from her mouth. She could not quantify the
amount of blood, but noted that it covered the entire anterior
aspect of her shirt. Blood also flowed from her nose
continuously. Pressure was applied with a towel until the
ambulance arrived and bleeding had stopped on arrival in the ED.
She denied any recent trauma, cough, congestion, sore throat, or
bleeding conditions. Also, of note, she has had ___ dark stools
at rehab. She denied constipation, diarrhea, abdominal pain, and
dysuria.
In the ED, initial VS were: T 100, P ___, BP 104/83 (SBP
90-104), R 20 O2 Sat 100% on 5L. She had a small amount of dark
red stool in ED. Her HCT dropped from 32 to 25. Brown stool,
guiaic positive. Labs were also remarkable for WBC 13.8. She
received 2U PRBC with increase of HCT to 32.4. CXR showed R
pleural effusion and increased R atelectasis (she has had
recurrent pleural effusions that are tapped as treatment). There
was also a new perihilar parenchymal opacity (cw PNA or
aspiration). She received pantoprazole, azithro and CTX.
On arrival to the floor, she was hemodynamically stable. She had
a recurrence of the bleeding from the right nares in the evening
of ___. She also noted some pain in her feet from dependent
edema.
Past Medical History:
- Severe mitral stenosis (area < 1.0cm2) s/p MVR ___/b AMS, recurrent pleural effusions, pneumonia,
septic shock with bacteremia, and GI bleed due to varices
- Presumed diastolic dysfunction
- PEA arrest in ___. Husband resuscitated her. Found to be
in complete heart block s/p pace maker placement. Anoxic brain
damage with short term memory loss.
- Left breast cancer status post mastectomy with radiation
therapy in ___ and ___.
- AML - in CCR, s/p Cy/TBI conditioning and allogeneic T-cell
depleted allogeneic bone marrow transplant from sister in
___.
- BMT complicated by lymphoproliferative disorder status post
tonsillectomy and Rituxan in ___, ITP s/p Rituxan in ___
without recurrence, and hypogammaglobulinemia requiring monthly
IVIG.
- Basal cell carcinoma with excision in ___.
- Iron overload diagnosed by liver biopsy in ___ and
undergoing periodic phlebotomy
- cirrhosis due to hemachromatosis c/b varices, UGI bleed,
hepatic encephalopathy
- obstrucitve airway disease per PFTs
- recurrent pleural effusions s/p pleurX catheter (___), last
thoracentesis ___ (800cc drained)
Social History:
___
Family History:
Breast cancer in mother and sister.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T: 97.6 BP: 105/53 P: 90 R: 19 O2: 99% 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, ___ systolic murmur
LUSB, no rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, trace PE in ___ b/l, no
clubbing or cyanosis
Neuro: CN II-XII intact, strength ___ in UE and ___ b/l
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Tm: 98.7 BP: 80-90s/40-50s, P: 60s R: ___, O2: 99%
(2L). General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, no blood in nares or oropharynx, MMM
Neck: supple, JVP not elevated, no LAD
Lungs: Tachypnic, rales in right base ___ way up, clear to
auscultation otherwise, no wheezes or rhonchi
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic murmur
LUSB, no rubs/gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, trace PE in ___ b/l, no
clubbing or cyanosis
Neuro: CN II-XII intact, strength ___ in UE and ___ b/l
Pertinent Results:
ADMISSION LABS
==============
___ 12:05AM BLOOD WBC-13.8* RBC-2.87* Hgb-7.5* Hct-24.9*
MCV-87 MCH-26.1* MCHC-30.1* RDW-18.8* Plt ___
___ 12:05AM BLOOD Neuts-89.9* Lymphs-4.3* Monos-5.3 Eos-0.3
Baso-0.2
___ 09:05AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+
Macrocy-OCCASIONAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL Burr-OCCASIONAL Tear Dr-NORMAL
___ 12:05AM BLOOD ___ PTT-33.4 ___
___ 12:05AM BLOOD Glucose-175* UreaN-26* Creat-1.0 Na-136
K-3.5 Cl-94* HCO3-31 AnGap-15
___ 12:05AM BLOOD ALT-17 AST-26 AlkPhos-353* TotBili-0.5
___ 12:05AM BLOOD Albumin-3.2*
___ 11:15PM BLOOD Type-MIX pO2-52* pCO2-39 pH-7.48*
calTCO2-30 Base XS-5 Comment-GREEN TOP
___ 11:15PM BLOOD freeCa-1.13
NOTABLE LABS
============
___ 05:17AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.7
___ 09:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 09:30PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 09:30PM URINE RBC-4* WBC-22* Bacteri-NONE Yeast-NONE
Epi-1
___ 07:40PM BLOOD Vanco-32.8*
___ 05:59AM BLOOD Vanco-34.5*
___ 06:00AM BLOOD Vanco-29.1*
DISCHARGE LABS
==============
___ 06:00AM BLOOD WBC-7.2 RBC-3.33* Hgb-9.3* Hct-30.8*
MCV-93 MCH-28.1 MCHC-30.3* RDW-19.3* Plt ___
___ 06:00AM BLOOD Glucose-115* UreaN-14 Creat-1.1 Na-138
K-3.5 Cl-104 HCO3-26 AnGap-12
___ 06:00AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.9
MICRO
=====
___ 8:54 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ =>32 R
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ =>32 R
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
Blood cultures pending.
IMAGING
=======
CXR ___
As compared to the previous radiograph, there is a slight
increase in extent of a pre-existing right pleural effusion. The
areas of atelectasis on the right are also increasing. On the
left, and new perihilar parenchymal opacity has occurred that
could represent pneumonia or aspiration. Normal size of the
cardiac silhouette. Unchanged left pectoral pacemaker and right
Port-A-Cath.
CXR ___
As compared to the previous radiograph, the lung volumes have
minimally
decreased, causing an apparent increase in radiodensity at the
right lung
base. However, there is no new focal parenchymal opacity and no
progression of the pre-existing changes. No pulmonary edema.
Borderline size of the cardiac silhouette. Unchanged alignment
of the sternal wires.
CT chest with contrast ___
1. Multifocal dependently distributed peribronchiolar
consolidations, several of which have a rounded configuration,
but none of which demonstrate cavitation. Observed findings
favor multifocal aspiration/aspiration pneumonia, but septic
emboli are also possible given history of endocarditis.
2. Decrease in extent of multiloculated right pleural effusion
compared to
___, but very minimal increase in small left effusion.
Small
pericardial effusion.
3. Similar mediastinal lymphadenopathy compared to ___,
but slight
increase in right hilar lymphadenopathy.
4. Basilar predominant septal thickening, most likely due to
hydrostatic
edema.
EGD ___
2 cords of small, grade I-II varices were seen in the distal
esophagus. Snakeskin appearance of the mucosa was noted in the
stomach body. These findings are compatible with moderate portal
hypertensive gastropathy. A few small angioectasias which were
bleeding were seen in the duodenal bulb. An Argon-Plasma
Coagulator was applied for hemostasis successfully.
CXR ___
Interval increase in size of moderate right and small left
pleural effusions, with bibasilar atelectasis.
Brief Hospital Course:
ASSESSMENT AND PLAN: Ms. ___ is a ___ with a PMHx of AML
(sp T-cell depleted allogenic BMT in ___, CKD,
lymphoproliferative disorder, hypogammaglobulinemia, ___ PEA
arrest cb anoxic brain injury (___), severe MR ___ MVR),
hemochromatosis (cb cirrhosis and encephalopathy), recurrent
pleural effusions, and varices sp GIB, recently admitted for
endocarditis/septic shock, who presented with hemoptysis and
melanotic stools.
ACUTE ISSUES
============
# Hemoptysis/melanotic stools: On initial presentation, the
patient reported coughing up blood as well as blood draining
from the nose. In the ED, it was noticed that she had melanotic
stools and she recollected that her stools had a similar
appearance for ___ days prior. The differential included
recurrent variceal bleed (variceal bleed with banding ___
___, cavitating pneumonia ___ seeding from S. bovis
bacteremia and/or recurrent pleural effusion c/b empyema, or
septic emboli. She was placed on a PPI and octreotide drip for a
possible recurrent GI bleed. She was also started on
propranolol, which could only be given with SBP > 90 (her SBPs
run low, 80s-100s, on midodrine 10mg TID). Stools were guaiac
positive and stool cultures were negative for Shigella,
salmonella, campylobacter. Interventional pulmonology was
consulted. Bedside ultrasound and CT chest with contrast did not
show much interval change in pleural effusions compared to
previous and there was no evidence of PE or septic emboli.
Hepatoology was also consulted and EGD was performed. EGD
demonstrated two bleeding varices in the distal esophagus and
angioectasias in the proximal duodenum, and treatment with
thermal probe was completed. At discharge, her stools were less
frequent, more formed, and lighter in color. She will be
continued on pantoprazole 40mg BID and propranolol 20mg TID with
the holding parameter of SBP <90.
# S. bovis bacteremia/endocarditis: With recent hospitalization
at the end ___ for S. bovis bacteremia and shortness of
breath with exertion, her coverage was broadened from
penicillin, initially to ceftraiaxone and azithromycin, and then
vancomycin and zosyn to protect against HCAP after ID
consultation. Her vancomycin was originally 1g q12h, but trough
was supratherapeutic and her dose was changed to 1g q24h on
___. Her dose was held on ___ and ___ to allow the vancomycin
trough to enter a therapeutic range. Her zosyn was originally
4.5g q6h, but was also converted to 2.25g q6h on ___. She has
received zosyn without interruption. At discharge, her
vancomycin trough should be repeated, both vancomycin and zosyn
should be continued through ___.
# VRE UTI: Final urine cultures grew VRE > ___ colonies, but
the pt remained asymptomatic. For this reason, there was no
clinical indication to start antibiotics, but the patient should
continue to be monitored for symptoms.
# Recurrent pleural effusions: The patient has had ongoing
shortness of breath, especially with exertion. She has had
recurrent pleural effusions drained in the past, and prior
effusions have been complicated in that they have grown S. bovis
and resulted in empyema requiring 2 chest tubes removed on
___. Repeat CXR demonstrated worsening effusion. However,
interventional pulmonology performed a bedside ultrasound, which
did not show effusions large enough to drain. Chest CT with
contrast showed small, loculated effusions. She was monitored
with serial CXR. At discharge, her shortness of breath had not
worsened, though she should have close follow-up to ensure
drainage at the appropriate time.
# Cirrhosis ___ hemochromatosis c/b encephalopathy: The patient
has a longstanding hx of cirrhosis secondary to hemochromatosis
complicated by encephalopathy. She has not had SBP, recent MELD
score of 10. Because of her cirrhosis, she has a chronically
elevated AST and alk phos. No evidence of ascites. Hepatology
was consulted, and PPI BID and propranolol were initiated. She
will be continued on pantoprazole 40mg BID and propranolol 20mg
TID with the holding parameter of SBP <90. While lactulose and
rifaxamin were initially held due to diarrhea and nausea, these
medications were restarted at discharge and should be titrated
to ___ bowel movements daily.
CHRONIC ISSUES
==============
# AML: Pt is s/p transplant (___) c/b lymphoproliferative
disorder, ITP, and hypogammaglobulinemia, currently on monthly
IVIG. Contact was made with her outpatient oncologist, Dr.
___ she received IVIG treatment as an inpatient on
___. Her acyclovir was continued in-house and at
discharge.
# CHF and hx of MVR: The patient has a hx of severe mitral
regurgitation, s/p MVR. Most recent TTE/TEE demonstrated
preserved EF.
# CKD: Patient's baseline has been 1.2-1.7 over the past year.
Through her course in the hospital, she has had no interval
worsening of her CKD, with Cr ranging from 0.8-1.1.
TRANSITIONAL ISSUES
===================
# Pt should continue on pantoprazole 40mg PO daily and
propranolol 20mg PO TID.
# Pt should continue IV abx of vancomycin 1g IV q24h and zosyn
2.25g q6h through ___. Repeat vancomycin level to ensure
therapeutic range.
# Pt should follow-up regarding variceal GI bleed at the ___
___ with an appointment on ___.
# Pt was started on pantoprazole 40mg BID and propranolol 20mg
TID. Propranolol should be held if pt SBP < 90.
# Monitor for UTI symptoms, as patient's final urine culture
grew out VRE.
# Follow up on final blood cultures
# Pt noted to have R hilar LAD and bronchial wall thickening on
CT from this admission, consider follow-up imaging if indicated
# Emergency contact: ___ Relationship: husband
Phone number: ___ Cell phone: ___
# Code: Full
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. FoLIC Acid 1 mg PO DAILY
3. Midodrine 10 mg PO TID
4. Pantoprazole 40 mg PO Q24H
5. Sucralfate 1 gm PO QID
6. Acetaminophen 500 mg PO Q6H:PRN pain
7. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
8. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Gabapentin 100 mg PO HS
11. Baclofen 5 mg PO BID
12. Spironolactone 25 mg PO DAILY
13. Rifaximin 550 mg PO BID
14. Phosphorus 500 mg PO DAILY
15. Ondansetron ___ mg PO Q8H:PRN nausea
16. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN
hemorrhoids
17. Furosemide 20 mg PO DAILY
18. Potassium Chloride 20 mEq PO BID
19. Aspirin EC 81 mg PO DAILY
20. Penicillin G Potassium 3 Million Units IV Q4H
21. Lactulose 30 mL PO DAILY
22. Lorazepam 0.25 mg PO BID:PRN anxiety
23. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
24. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN pain
2. Acyclovir 400 mg PO Q8H
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
4. FoLIC Acid 1 mg PO DAILY
5. Lactulose 30 mL PO DAILY
6. Midodrine 10 mg PO TID
7. Rifaximin 550 mg PO BID
8. Sucralfate 1 gm PO QID
9. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
10. Pantoprazole 40 mg PO Q24H
11. Phosphorus 500 mg PO DAILY
12. Potassium Chloride 20 mEq PO BID
13. Spironolactone 25 mg PO DAILY
14. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION BID
15. Piperacillin-Tazobactam 4.5 g IV Q6H
16. Propranolol 20 mg PO TID
17. Vancomycin 1000 mg IV Q 12H
18. Multivitamins W/minerals 1 TAB PO DAILY
19. Ondansetron ___ mg PO Q8H:PRN nausea
20. Gabapentin 100 mg PO HS
21. Hydrocortisone (Rectal) 2.5% Cream ___ID PRN
hemorrhoids
22. Aspirin EC 81 mg PO DAILY
23. Baclofen 5 mg PO BID
24. Furosemide 20 mg PO DAILY
25. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
26. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN SOB
27. Lorazepam 0.25 mg PO BID:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
1. Variceal bleed
SECONDARY DIAGNOSES
===================
1. S. bovis bacteremia
2. Recurrent pleural effusions
3. Acute myeloid leukemia
4. Diastolic congestive heart failure
5. Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you during your stay at ___.
You were recently admitted because of an episode of coughing up
blood and dark stools. In determining the source of this
bleeding, imaging and endoscopy was performed. CT scan of the
lungs did not show any bleeding site and pleural effusions were
not large enough to tap. An endoscopy revealed bleeding varices,
which were treated with a thermal laser. You were also treated
for a GI bleed with octreotide, propranolol, and pantoprazole to
decrease bleeding from the GI tract. At discharge, you have been
scheduled for follow-up at the ___. Because you will
have 5 more days of IV antibiotic therapy, you have also been
scheduled to follow-up with infectious disease physicians.
Sincerely,
Your ___ care team
Followup Instructions:
___
|
19997367-DS-22 | 19,997,367 | 22,967,208 | DS | 22 | 2127-05-27 00:00:00 | 2127-05-27 19:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro Cystitis / Dilaudid / Mexiletine / Bactrim / Avelox /
Levaquin / Amoxicillin / Oxycodone / Hydrochlorothiazide /
Minocycline / Cleocin / Percocet / vancomycin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ with PMH significant for recent admission for endocarditis
(pulmonic valve), dCHF, cirrhosis c/b variceal bleed, and AML
___ BMT who presented to ___ for dyspnea. Patient developed
throat and chest tightness, associated with shortness of breath.
She was reportedly very anxious with labored breathing. EMS was
activated. She was given albuterol nebs, SL nitro, ASA 325mg,
vicodine, and ativan with some relief of symptoms. She was
placed on O2 for comfort.
In the ED, initial vitals were: T97.6 P72 BP90/50 RR14 98% 2L.
Labs were notable for WBC 6.8, H/H 8.5/28.9, K 5.0, Cr 1.0. EKG
showed paced rhythm with RBBB. CXR showed stable bilateral
pleural effusions. The patient was given lasix 20mg IV, unknown
response. Vitals prior to transfer were: P70 BP107/73 RR18.
Upon arrival to the floor, patient reports progressive worsening
of dyspnea on exertion. She notes orthopnea, has used ___
pillows over past few months, weight gain, and increased
peripheral edema. She reports recurrent pleural effusions
secondary to her heart. The pleural effusions are drained
intermittently for symptoms. Last drainage was 3 months ago. She
does not like taking lasix or spironolactone as she already
makes several trips to the bathroom due to lactulose. No recent
fever, chills, cough, chest pain, palpitations, abdominal pain,
hematochezia, melena, or dysuria.
On review of systems, s/he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, myalgias, joint
pains. All of the other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
paroxysmal nocturnal dyspnea, and syncope or presyncope.
Past Medical History:
- Severe mitral stenosis (area < 1.0cm2) ___ MVR ___/b AMS, recurrent pleural effusions, pneumonia,
septic shock with bacteremia, and GI bleed due to varices
- Presumed diastolic dysfunction
- PEA arrest in ___. Husband resuscitated her. Found to be
in complete heart block ___ pace maker placement. Anoxic brain
damage with short term memory loss.
- Left breast cancer status post mastectomy with radiation
therapy in ___ and ___.
- AML - in CCR, ___ Cy/TBI conditioning and allogeneic T-cell
depleted allogeneic bone marrow transplant from sister in
___.
- BMT complicated by lymphoproliferative disorder status post
tonsillectomy and Rituxan in ___, ITP ___ Rituxan in ___
without recurrence, and hypogammaglobulinemia requiring monthly
IVIG.
- Basal cell carcinoma with excision in ___.
- Iron overload diagnosed by liver biopsy in ___ and
undergoing periodic phlebotomy
- cirrhosis due to hemachromatosis c/b varices, UGI bleed,
hepatic encephalopathy
- obstrucitve airway disease per PFTs
- recurrent pleural effusions ___ pleurX catheter (___), last
thoracentesis ___ (800cc drained)
Social History:
___
Family History:
Breast cancer in mother and sister.
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
VS: T97.5 BP109/48 P78 RR20 100%3L Wt 55.9kg
General: Chronically ill appearing, sad affect, no acute
distress.
HEENT: Pupils equal and reactive to light. Oropharynx clear.
Neck: JVP at 8cm.
CV: RRR, normal S1, S2. ___ systolic murmur loudest at LLSB.
Lungs: Bibasilar crackles, L>R.
Abdomen: +BS, soft, nondistended, nontender to palpation.
GU: No foley.
Ext: Warm and well perfused. Pulses 2+. 1+ pitting edema up to
knees bilaterally.
Neuro: A+Ox3. Moves all extremities grossly.
Skin: No rash.
PHYSICAL EXAMINATION ON DISCHARGE:
VS: Weight 51.6 ___ yesterday, 55.9 on admit) BP 83-99/42-54 P
___ RR 18 94% RA
General: Elderly female, in NAD
HEENT: NC/AT, EOMI, sclera anicteric
Neck: JVP 2-3cm above clavicle at 45 degrees
CV: RRR, normal S1, S2. ___ systolic murmur loudest at LUSB.
Lungs: Mild bibasilar crackles. No w/r.
Abdomen: +BS, soft, nondistended, nontender to palpation.
Ext: Warm and well perfused. Pulses 2+. Edema decreased from 2
days ago, currently trace-to-1+ edema to ankles.
Neuro: A+Ox3. moving all extremities, speech fluent.
Skin: No rash.
Pertinent Results:
LABS ON TRANSFER
___ 09:10AM BLOOD WBC-6.8 RBC-3.17* Hgb-8.5* Hct-28.9*
MCV-91 MCH-26.9* MCHC-29.5* RDW-18.2* Plt ___
___ 09:10AM BLOOD Neuts-79.2* Lymphs-9.0* Monos-9.6 Eos-1.8
Baso-0.5
___ 09:10AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-OCCASIONAL
Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-1+
Ovalocy-OCCASIONAL
___ 09:10AM BLOOD Plt ___
___ 09:10AM BLOOD Glucose-107* UreaN-22* Creat-1.0 Na-137
K-5.0 Cl-104 HCO3-23 AnGap-15
___ 09:10AM BLOOD ALT-41* AST-56* AlkPhos-417* TotBili-0.5
___ 09:10AM BLOOD Lipase-46
___ 09:40AM BLOOD ___ 09:10AM BLOOD Albumin-3.6
___ 09:20AM BLOOD Lactate-1.3
LABS ON DISCHARGE
___ 06:00AM BLOOD WBC-6.7 RBC-3.07* Hgb-8.1* Hct-27.1*
MCV-88 MCH-26.4* MCHC-29.9* RDW-18.1* Plt ___
___ 09:30PM BLOOD Glucose-170* UreaN-29* Creat-1.2* Na-136
K-4.1 Cl-97 HCO3-28 AnGap-15
___ 09:30PM BLOOD Calcium-9.7 Phos-2.9 Mg-2.3
STUDIES
EKG ___ 9:11:36 AM
Atrial sensed, ventricularly paced rhythm. Underlying rhythm is
sinus rhythm. Compared to the previous tracing of ___ there
is no significant diagnostic change.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
72 ___ 51 -95 63
CXR ___
FINDINGS:
Compared with prior, there has been no significant interval
change. Right chest wall port and left chest wall dual lead
pacing device are again seen. Partially loculated right-sided
pleural effusion persists. Probable small left effusion is
partially loculated laterally. Right basilar opacities medially
may be due to atelectasis, similar to prior. The
cardiomediastinal silhouette is unchanged, mitral valve
prosthesis again noted. Surgical clips seen in the right upper
quadrant. No acute osseous abnormalities.
IMPRESSION:
No significant interval change. Bilateral effusions. Right
medial basilar opacity potentially atelectasis noting that
infection is not excluded.
Brief Hospital Course:
___ with complicated medical history including recent
admission for variceal bleed and endocarditis, dCHF, and
cirrhosis of unknown etiology who presents due to CHF
exacerbated.
ACTIVE PROBLEM
# Heart Failure:
She was transferred on 3L O2 by NC, which was easily weaned.
Symptomatically she improved over the course of one day. Her
shortness of breath was believed to be due to heart failure due
to diastolic dysfunction vs restrictive cardiomyopathy (history
of hemachromatosis) given evidence of HF on history and exam
(med noncompliance, weight gain, orthopnea, increased ___ and
EF of >55% in ___. Her diuretic dose had been decreased
recently from Torsemide 40mg BID to Lasix 20mg daily and she
endorsed not having taken her diuretics as she already spent too
much time in the bathroom with the lactulose. She has recurrent
pleural effusions and is periodically drained by IP. They were
consulted and felt that her pleural effusions were stable from
the last time she was seen and drainage was not indicated at
this time and not likely to help symptoms. She was diuresed
with IV lasix with her weight decreasing from 55.9kg on admit to
51.7kg on discharge. She was discharged on lasix 40mg PO BID.
She is seen by Dr. ___.
# Vaginal Lesions:
Small, non-palpable dark purple pinpoint lesions (?purpura) seen
on inner labia, found incidentally when placing foley.
Asymptomatic, unclear etiology. Denies any recent sexual
activity. Follow up arranged with ___.
# Deconditioning:
Was admitted from rehab, where she was scheduled to be
discharged home on day of/day after admission. Seen by ___,
provided a walker with plan for home ___ services.
CHRONIC PROBLEMS
# Cirrhosis:
Cirrhosis secondary to hemochromatosis, complicated by
encephalopathy and variceal bleed. No history of SBP. ___
Classification A, MELD score 8. Patient currenly A+O, without
signs of encephalopathy. Home doses of propranalol, midodrine,
pantoprazole, lactulose, rifaxamin, and spironolactone were
continued.
# AML:
Pt is ___ transplant (___) c/b lymphoproliferative disorder,
ITP, and hypogammaglobulinemia. She receives monthly IVIG, last
on ___. Patient seen by Dr. ___. Anemic, borderline
thrombocytopenic-- both stable compared to last 3 months.
===================================================
TRANSITIONAL ISSUES
===================================================
Ms. ___ is a ___ yo woman with cirrhosis ___ hemochromatosis,
CHF, recent hospitalization for endocarditis (on pulmonic
valve), severe MR ___ MVR, h/o PEA arrest c/b heart block ___
PPM, AML ___ BMT who was admitted for CHF exacerbation.
[ ] Diuresis: From past records, it appears she was on torsemide
40mg BID in the past, but at her previous discharge was sent
home on lasix 20mg. Patient has GI upset with torsemide,
therefore we will discharge on lasix 40mg BID.
[ ] Chronic pleural effusion: Seen by IP for intermittent
drainage. IP did not feel she would benefit from thoracentesis
during hospitalization.
[ ] Vaginal lesions: Seen incidentally when placing a foley.
Appointment made with the ___ further
evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO HS:PRN PRN
4. Midodrine 10 mg PO TID
5. Rifaximin 550 mg PO BID
6. Sucralfate 1 gm PO QID
7. Phosphorus 500 mg PO DAILY
8. Potassium Chloride 20 mEq PO BID
9. Spironolactone 25 mg PO DAILY
10. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION BID
11. Propranolol 20 mg PO TID
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Gabapentin 100 mg PO HS
14. Aspirin EC 81 mg PO DAILY
15. Baclofen 5 mg PO BID
16. Furosemide 20 mg PO DAILY
17. Pantoprazole 40 mg PO Q12H
18. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
19. Ondansetron 4 mg PO Q8H:PRN nausea
20. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob
21. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
22. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
23. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
24. Senna 8.6 mg PO HS:PRN constipation
25. Milk of Magnesia 30 mL PO Q6H:PRN constipation
26. Fleet Enema ___AILY:PRN constipation
27. Bisacodyl ___AILY:PRN constipation
28. Lorazepam 0.25 mg PO BID:PRN anxiety
29. Acetaminophen 325-650 mg PO Q4H:PRN pain
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Aspirin EC 81 mg PO DAILY
3. Baclofen 5 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO BID
RX *furosemide 20 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
6. Gabapentin 100 mg PO HS
7. Lactulose 30 mL PO HS:PRN PRN
8. Lorazepam 0.25 mg PO BID:PRN anxiety
9. Midodrine 10 mg PO TID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Propranolol 20 mg PO TID
13. Rifaximin 550 mg PO BID
14. Spironolactone 25 mg PO DAILY
15. Sucralfate 1 gm PO QID
16. Acetaminophen 325-650 mg PO Q4H:PRN pain
17. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
18. Bisacodyl ___AILY:PRN constipation
19. DiphenhydrAMINE 25 mg PO HS:PRN insomnia
20. Fleet Enema ___AILY:PRN constipation
21. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
22. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN sob
23. Milk of Magnesia 30 mL PO Q6H:PRN constipation
24. Ondansetron 4 mg PO Q8H:PRN nausea
25. Phosphorus 500 mg PO DAILY
26. Potassium Chloride 20 mEq PO BID
Hold for K >
27. Senna 8.6 mg PO HS:PRN constipation
28. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
INHALATION BID
29. Zolpidem Tartrate 5 mg PO HS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Heart Failure, Diastolic Dysfunction vs Constrictive
Cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you at ___
___. You were transferred due to shortness of breath,
which we believe was due to fluid overload. To remove fluid, we
used intravenous diuretic medication. Interventional Pulmonology
also reviewed your studies and imagine and felt that removing
fluid from your lungs was not indicated at this time as your
pleural effusions were stable from the last time they saw you.
Your dose of lasix was increased to prevent fluid build up in
the future, please take 40mg of furosemide (lasix) twice a day.
It will be important to follow up closely with your
Cardiologist. An appointment was made for ___
at 12:30, please see below for more information.
Please weigh yourself every morning and call your cardiologist
if your weight changes by more than 2 pounds in 24 hours or more
than 5 lbs in a week. This can be a sign of fluid build up.
During this stay, we also noted some asymptomatic vaginal
lesions. A follow up appointment with the woman's health center
was made to further evaluate these as an outpatient. The
appointment information is included below.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
19997367-DS-23 | 19,997,367 | 27,445,461 | DS | 23 | 2127-08-21 00:00:00 | 2127-09-01 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro Cystitis / Dilaudid / Mexiletine / Bactrim / Avelox /
Levaquin / Amoxicillin / Oxycodone / Hydrochlorothiazide /
Minocycline / Cleocin / Percocet / vancomycin
Attending: ___.
Chief Complaint:
Dyspnea/Confusion
Major Surgical or Invasive Procedure:
There were no major surgical or invasive procedures.
History of Present Illness:
___ with PMHx of AML s/p allo ___, MV stenosis s/p mitral valve
replacement, recent pulmonic endocarditis, dCHF, heart block s/p
cardiac pacemaker, and cirrhosis c/b multiple variceal bleeds,
who is admitted with an episode of dyspnea and possible
confusion.
Per ED report, the patient's husband notice she was 'not acting
like herself' while having dinner at 6pm day prior to admission.
He reported that she had some difficulty getting up from the
table, had trouble following commands, and was weak. He also
felt she was short of breath and confused, and decided to bring
her to the ED.
In the ED, initial VS were 97.7, HR 94, BP 107/49, RR 22, O2
100%RA. Patient was noted to be alert, oriented to place and
self, but was having difficulty following commands. Initial labs
were notable for Na 131, Cr 1.3, HCT 30.7, lactate 2.2, and AP
205. Remainder of CBC, Chem10, trops x1, and LFT's were
unremarkable. UA showed 40RBC with <1 epi and negative nitrates.
Head CT and CXR were negative for acute process. Patient was
admitted to ___ for further management.
On arrival to the floor, patient is without complaint. She
reports she chronically gets DOE while walking up the stairs at
her house, and did report some prolonged dyspnea today during
dinner. She denies any worsened issues with confusion, although
does suffer from some short term memory loss. She also notes
several weeks of diarrhea, but reports this resolved three weeks
ago. She since denies any signficant diarrhea or consitpation.
She also denies recent fevers or chills. No ST. No cough. No
frank chest pain. No nausea, vomiting, or abdominal pain. She
reports her appetite is good. No dysuria. She does note chronic
neuropathy of the arms and legs, for which she takes gabapentin
and also some chronic very mild pleuritic chest pain. She also
occaisionally has nocturnal hand and leg cramps. ROS is
otherwise unremarkable.
Past Medical History:
PAST ONCOLOGIC HISTORY:
-Left breast cancer status post mastectomy with radiation
therapy in ___ and ___.
-AML status post allogeneic T-cell depleted bone marrow
transplant from a sibling donor in ___.
-Post-transplant lymphoproliferative disorder status post
tonsillectomy and Rituxan in ___.
-ITP, treated with Rituxan in ___ without
recurrence.
-Chronic sinus infections and sinusitis receiving monthly
intravenous gamma globulin to improve her B-cell activity.
-Basal cell carcinoma with recent excision in ___.
PAST MEDICAL/SURGICAL HISTORY:
Cardiac
-- PEA arrest in ___. Husband resuscitated her. Found to be
in complete heart block s/p pace maker placement. Anoxic brain
damage with short term memory loss.
-- Severe mitral stenosis (area < 1.0cm2) s/p MVR ___/b AMS, recurrent pleural effusions, pneumonia,
septic shock with bacteremia, and GI bleed due to varices
-- Chronic diastolic heart failure
--PV endocarditis in ___ in setting of Strep bovis bactermia
(completed AbX course)
Hematologic/Oncologic
-- Left breast cancer status post mastectomy with radiation
therapy in ___ and ___.
--AML - in CCR, s/p Cy/TBI conditioning and allogeneic T-cell
depleted allogeneic bone marrow transplant from sister in
___.
--___ disorder post allo, now status post
tonsillectomy and Rituxan in ___
--ITP s/p Rituxan in ___
without recurrence
--Hypogammaglobulinemia requiring monthly IVIG.
- Basal cell carcinoma with excision in ___.
GI
--Cirrhosis (hemachromatosis) c/b varices, variceal hemorrhage,
and hepatic encephalopathy
Pulm
--Obstrucitve airway disease per PFTs
--Recurrent pleural effusions s/p pleurX catheter (___), last
thoracentesis ___ (800cc drained). Now resolved
PAST SURGICAL HISTORY:
--Hysterectomy ___.
--Ovarian cysts and remaining ovarian tissue removed ___ and
___.
--Discography and diskectomy ___.
--Sinus surgery with biopsy ___.
--Cataract surgery, right on ___ and left on ___.
--Status post diagnostic and therapeutic pars plana vitrectomy
on the left to rule out lymphoma on ___.
--Status post replacement of breast implants with correction of
contractures and radiation skin damage on ___.
--Mitral valve replacement: ___
Social History:
___
Family History:
Father with MS. ___, denies sister and mother having cancer
despite prior documentation.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: 98.7 HR 75 BP 98/60 RR 18 O2 98%RA
Gen: Pleasant, calm, AAOx3, NAD
HEENT: No conjunctival pallor. No icterus. MMM. OP clear.
NECK: No signficant JVD.
CV: Normocardic, regular. Normal S1,S2. Loud holosytolic murmur
throughout the pericardium
LUNGS: Nonlabored on RA. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Soft, NT, ND.
EXT: WWP. No ___ edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3. Able to ___ backwards. Follows simple commands.
CN III-XII intact. Has antigravity strength in all limbs. FTN
normal. Gait deferred
LINES: Right POC c/d/i
DISCHARGE PHYSICAL EXAM
=======================
Vitals: 97.9-99.0, 93-101/39-56, 74-78, 20, 94-96% on RA.
Gen: Pleasant appearing female laying in bed in NAD.
HEENT: Moist mucous membranes, no oropharyngeal lesions.
NECK: No signficant JVD.
CV: Regular rate and rhythm, S1 and S2 present, loud
holosystolic murmur throughout the precordium.
LUNGS: Clear to auscultation except for crackles noted at the
right lower base. No evidence of wheezing.
ABD: soft, non-tender, non-distended, no rebound or guarding. No
fluid wave noted of abdomen.
EXT: Trace pedal edema.
SKIN: No rashes/lesions, petechiae/purpura ecchymoses.
NEURO: A&Ox3.
LINES: Right POC c/d/i
Pertinent Results:
ADMISSION LABS
==============
___ 10:39PM BLOOD WBC-7.1 RBC-3.87* Hgb-9.5* Hct-30.7*
MCV-80* MCH-24.7* MCHC-31.1 RDW-18.1* Plt ___
___ 10:39PM BLOOD Neuts-84.7* Lymphs-9.0* Monos-5.9 Eos-0.3
Baso-0.2
___ 10:39PM BLOOD Plt Smr-LOW Plt ___
___ 10:39PM BLOOD Glucose-195* UreaN-30* Creat-1.3* Na-131*
K-3.4 Cl-94* HCO3-24 AnGap-16
___ 10:39PM BLOOD ALT-24 AST-40 AlkPhos-205* TotBili-1.1
___ 10:39PM BLOOD Lipase-44
___ 10:39PM BLOOD cTropnT-<0.01
___ 06:01AM BLOOD cTropnT-<0.01
___ 10:39PM BLOOD Albumin-3.6 Calcium-9.4 Phos-2.7 Mg-2.2
___ 10:39PM BLOOD TSH-3.6
___ 10:46PM BLOOD Lactate-2.3*
___ 07:16AM BLOOD Lactate-1.8
DISCHARGE LABS
==============
___ 12:07AM BLOOD Albumin-3.2* Calcium-9.0 Phos-3.1 Mg-2.1
___ 12:07AM BLOOD ALT-21 AST-24 LD(LDH)-295* AlkPhos-165*
TotBili-0.6
___ 12:07AM BLOOD Glucose-139* UreaN-30* Creat-1.1 Na-139
K-3.4 Cl-104 HCO3-24 AnGap-14
___ 12:07AM BLOOD ___ PTT-50.4* ___
___ 12:07AM BLOOD WBC-6.4 RBC-3.79* Hgb-9.2* Hct-29.9*
MCV-79* MCH-24.2* MCHC-30.7* RDW-18.0* Plt ___
IMAGING
=======
___: CT HEAD WITHOUT CONTRAST
IMPRESSION: No significant intracranial abnormality. Volume
loss out of proportion to patient age.
___: CHEST (PA and LATERAL)
IMPRESSION: No definite acute cardiopulmonary process. Right
basilar changes appear chronic.
___: ECHOCARDIOGRAM
The left atrium is elongated. 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 normal (LVEF>55%). There is no ventricular septal
defect. There is abnormal septal motion/position. The aortic
valve is not well seen. No masses or vegetations are seen on the
aortic valve, but cannot be fully excluded due to suboptimal
image quality. There is probably mild aortic valve stenosis). A
bioprosthetic mitral valve prosthesis is present. The prosthetic
mitral leaflets appear normal. The transmitral gradient is
normal for this prosthesis. No masses or vegetations are seen on
the mitral valve, but cannot be fully excluded due to suboptimal
image quality. No mitral regurgitation is seen. No masses or
vegetations are seen on the tricuspid valve, but cannot be fully
excluded due to suboptimal image quality. Tricuspid
regurgitation is present but cannot be quantified. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
clear change.
___: LUNG SCAN
IMPRESSION: Low likelihood ratio for acute pulmonary embolism.
___: ULTRASOUND ABDOMINAL
IMPRESSION: No intra-abdominal ascites.
MICROBIOLOGY
============
___: BLOOD CULTURE PENDING
___: BLOOD CULTURE PENDING
___: URINE CULTURE
Time Taken Not Noted Log-In Date/Time: ___ 6:35 am
URINE
URINE CULTURE (Preliminary):
KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML..
Cefepime sensitivity testing confirmed by ___.
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
_______________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>___ R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
___ with PMHx of AML s/p allo ___, MV stenosis s/p mitral valve
replacement, recent pulmonic endocarditis, dCHF, heart block s/p
cardiac pacemaker, and cirrhosis c/b multiple variceal bleeds,
who is admitted with an episode of dyspnea and possible
confusion which has resolved.
# DYSPNEA: Patient with chronic DOE being evaluated as an
outpatient. Generally thought due to HFpEF, although patient
does not appear clincally overloaded at this time. Patient also
with known obstructive disease but is not taking her inhalers at
home. However, lung physical exam was relatively unremarkable
except for right lower lobe crackles. V/Q scan obtained which
indicated "Low likelihood ratio for acute pulmonary embolism."
Echo also obtained which did not reveal any acute changes from
___. Based on our evaluation and clinic notes from pulmonary,
it appears as though this shortness of breath is likely
multifactorial that had been worked up as an outpatient. Appears
resolved as her shortness of breath was stable and back at
baseline at the time of discharge. She was given duonebs as
needed for dyspnea.
# URINARY TRACT INFECTION: Likely the cause of altered mental
status. Patient's urinary tract infection grew >100,000
klebsiella pneumonia resistant to ceftriaxone but sensitive to
nitrofurantoin. She was prescribed nitrofurantoin 100 milligrams
every 12 hours for a total course of seven days with end date on
___. During hospitalization, as her urinary tract
infection was treated, her mental status improved. She was not
confused at the time of discharge.
# CONFUSION/WEAKNESS: Patient with a reported acute episode of
confusion and weakness the night prior to presentation. During
hospitalization she remained alert and oriented x 3. Neurology
was consulted during hospitalization and they did not believe
there was an ischemic cause of the confusion and did not believe
an MRI was necessary. CT of head did not reveal significant
intracranial abnormality although did note volume loss out of
proportion to patient's age. An echocardiogram was also obtained
and did not reveal any worsening of her diastolic heart failure.
Additionally her liver disease (secondary to hemochromatosis)
appeared well compensated during hospitalization with no
evidence of asterixis. As noted above, patient was diagnosed
with a urinary tract infection. As this urinary tract infection
was treated her confusion resolved. She was alert and oriented x
3 and was not confused at the time of discharge.
# ACUTE ON CHRONIC KIDNEY DISEASE: Cr 1.1 at time of discharge.
Ranged between 1.1-1.3 during hospitalization. Patient's with
variable baseline. Has been up to 1.2-1.7 over the past year,
although was lower recently. Creatinine remained stable during
hospitalization.
CHRONIC ISSUES
==============
# CIRRHOSIS: Due to hemochromatosis. Has had multiple episodes
of variceal hemorrhage, last in ___. Most
recent GI note from ___ mentions plan for outpatient EGD
with banding. During hospitalization, there was no evidence of
GI bleed as H/H remained stable. Not currently concerned about
active GIB. Also with history of HE, and will monitor as above.
Notably, patient denies taking lactulose, rifampin, lasix, and
spironolactone, despite med list. INR 1.4. She was continued on
her home medications of propanolol 20 mg PO tid and midodrine 10
mg PO TID. Ultrasound of abdomen was obtained which showed no
intra-abdominal ascites.
# CHRONIC DIASTOLIC HEART FAILURE: Most recent echo ___
showed LVEF>55% with functional mitral valve prosthetic, but was
notable for likely PV endocarditis which has already been
treated. During hospitalization she remained euvolemic. Due to
concern that weakness was secondary to worsening heart failure
an echocardiogram was obtained on ___ which did not show acute
changes from ___. LVEF was maintained at >55%.
# HISTORY OF COMPLETE HEART BLOCK/ARREST: Patient is permanently
paced and remained on telemetry. There were no worrisome
telemetry alarms.
# ACUTE MYELOID LEUKEMIA: Pt is s/p transplant (___) c/b
lymphoproliferative disorder, ITP, and hypogammaglobulinemia,
currently on monthly IVIG. She was continued on her home
acyclovir during hospitalization.
# ANEMIA: Likely multifactorial, patient currently at recent
baseline.
TRANSITIONAL ISSUES
===================
#ANTIBIOTIC REGIMEN: Nitrofurantoin 100 milligrams PO BID for
total course of 7 days with end date on ___.
#MEDICATION RECONCILIATION: Please discuss home medications and
which medications she is truly taking at home as denies taking
lactulose, rifampin, lasix, and spironolactone, despite being on
home medication list.
#CODE STATUS: FULL CODE.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Aspirin EC 81 mg PO DAILY
3. Baclofen 5 mg PO BID
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO BID
6. Gabapentin 100 mg PO HS
7. Lactulose 30 mL PO HS:PRN PRN
8. Lorazepam 0.25 mg PO BID:PRN anxiety
9. Midodrine 10 mg PO TID
10. Multivitamins W/minerals 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Propranolol 20 mg PO TID
13. Sucralfate 1 gm PO QID
14. Acetaminophen 325-650 mg PO Q4H:PRN pain
15. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
16. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
17. Milk of Magnesia 30 mL PO Q6H:PRN constipation
18. Potassium Chloride 20 mEq PO BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q4H:PRN pain
2. Acyclovir 400 mg PO Q8H
3. Aspirin EC 81 mg PO DAILY
4. Baclofen 5 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. Gabapentin 100 mg PO HS
7. Lorazepam 0.25 mg PO BID:PRN anxiety
8. Midodrine 10 mg PO TID
9. Pantoprazole 40 mg PO Q12H
10. Propranolol 20 mg PO TID
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN sob
12. Furosemide 40 mg PO BID
13. Hydrocortisone (Rectal) 2.5% Cream 1 Appl PR PRN hemorrhoids
14. Lactulose 30 mL PO HS:PRN PRN
15. Milk of Magnesia 30 mL PO Q6H:PRN constipation
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Potassium Chloride 20 mEq PO BID
18. Sucralfate 1 gm PO QID
19. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *nitrofurantoin monohyd/m-cryst 100 mg 1 capsule(s) by mouth
every 12 hours Disp #*14 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
URINARY TRACT INFECTION
SHORTNESS OF BREATH
SECONDARY DIAGNOSIS
===================
CIRRHOSIS
DIASTOLIC HEART FAILURE
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted after an episode of shortness of breath and
confusion. During your admission you were diagnosed with a
urinary tract infection. This was sensitive to a medication
called nitrofurantoin (macrobid). The urinary tract infection
was likely the cause of your confusion. Please continue taking
the antibiotic nitrofurantoin (macrobid) 100 milligrams EVERY 12
HOURS for a total of seven days with end date on ___.
You were seen by neurology who did not believe you had a stroke
as the cause of your confusion.
Your shortness of breath remained at baseline during your
hospitalization with no further worsening of your shortness of
breath.
Please continue to take your medications as prescribed.
Weigh yourself every morning, call MD if weight goes up more
than 3 lbs, since you are currently taking a diuretic medication
(furosemide).
It was a pleasure taking care of you during your
hospitalization. We wish you all the best!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19997538-DS-21 | 19,997,538 | 26,704,044 | DS | 21 | 2168-11-03 00:00:00 | 2168-11-03 12:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Per admission note: ___ Hx rectal CA s/p robotic LAR, diverting
loop ileostomy
(reversed), repair L ureteral injury in ___ now presenting
with abdominal pain and N/V.
Sudden onset crampy, intermittent LLQ abdominal pain at 11 AM
today that worsened during the day. Emesis x 3, bilious.
+chills,
no fevers. Denies nausea now. +flatus, multiple BMs last night
He completed FOLFOX about 3 weeks ago. Denies history of prior
bowel obstructions.
In the ED, NGT was placed with 300 cc of light-colored output.
Patient received 8 mg of IV morphine and 2 mg IV dilaudid.
Past Medical History:
PMH: rectal CA, HTN, DM
PSH:
___: Reversal of ileostomy and placement of left internal
jugular Port-A-Cath
___: Robotic low anterior resection, diverting loop
ileostomy, repair of left ureteral injury.
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
VS: 98.5, 104, 134/71, 18, 95% RA
Gen - NAD
Heart - borderline tachycardic, regular rhythm
Lungs - CTAB
Abdomen - soft, mildly distended, tender to deep palpation on
the
left, no rebound or guarding, well-healed abdominal incisions
Extrem - warm, no edema
========================
Discharge Physical Exam:
98.1, 132/86, 104, 18, 100%/RA
GEN: NAD, A&Ox3
HEENT: NCAT, EOMI
CV: RRR, No JVD
PULM: normal excursion, no respiratory distress
ABD: soft, mild distension, non tender, no rebound, no guarding
EXT: WWP, no CCE, 2+ B/L radial
NEURO: A&Ox3, no focal neurologic deficits
PSYCH: normal judgment/insight, normal memory, normal
mood/affect
Pertinent Results:
___ 06:59AM BLOOD WBC-6.3 RBC-3.14* Hgb-9.4* Hct-29.1*
MCV-93 MCH-29.9 MCHC-32.3 RDW-13.4 RDWSD-45.4 Plt ___
___ 06:40AM BLOOD WBC-6.6 RBC-3.25* Hgb-9.8* Hct-30.5*
MCV-94 MCH-30.2 MCHC-32.1 RDW-13.3 RDWSD-45.9 Plt ___
___ 07:00AM BLOOD WBC-7.1 RBC-3.29* Hgb-10.1* Hct-30.9*
MCV-94 MCH-30.7 MCHC-32.7 RDW-13.7 RDWSD-46.5* Plt ___
___ 05:22AM BLOOD WBC-8.9 RBC-3.32* Hgb-10.1* Hct-30.9*
MCV-93 MCH-30.4 MCHC-32.7 RDW-14.1 RDWSD-47.7* Plt ___
___ 02:45PM BLOOD WBC-12.8* RBC-3.69* Hgb-11.1* Hct-33.8*
MCV-92 MCH-30.1 MCHC-32.8 RDW-13.7 RDWSD-45.9 Plt ___
___ 02:45PM BLOOD Neuts-87.1* Lymphs-6.7* Monos-4.1*
Eos-1.1 Baso-0.5 Im ___ AbsNeut-11.16* AbsLymp-0.86*
AbsMono-0.53 AbsEos-0.14 AbsBaso-0.06
___ 06:59AM BLOOD Glucose-165* UreaN-10 Creat-0.9 Na-143
K-4.3 Cl-102 HCO3-29 AnGap-12
___ 06:40AM BLOOD Glucose-178* UreaN-15 Creat-1.0 Na-147
K-4.3 Cl-105 HCO3-30 AnGap-14
___ 07:00AM BLOOD Glucose-121* UreaN-21* Creat-0.9 Na-147
K-4.3 Cl-105 HCO3-33* AnGap-9*
___ 05:22AM BLOOD Glucose-146* UreaN-32* Creat-1.2 Na-142
K-4.7 Cl-105 HCO3-24 AnGap-13
___ 02:45PM BLOOD Glucose-195* UreaN-24* Creat-1.0 Na-140
K-5.4 Cl-109* HCO3-16* AnGap-15
___ 02:45PM BLOOD ALT-21 AST-24 AlkPhos-138* TotBili-0.7
___ 02:45PM BLOOD Lipase-155*
___ 06:59AM BLOOD Calcium-8.8 Phos-4.1 Mg-1.7
___ 06:40AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.6
___ 07:00AM BLOOD Calcium-9.3 Phos-3.8 Mg-1.5*
___ 05:22AM BLOOD Calcium-9.3 Phos-4.1 Mg-1.4*
___ 02:45PM BLOOD Albumin-4.4
___ 02:53PM BLOOD Lactate-1.7
Brief Hospital Course:
Mr. ___ presented to the emergency department at ___
___ on ___ with complaints of abdominal
pain, nausea, and vomiting. The patient underwent a CT scan that
showed High-grade small-bowel obstruction with abrupt transition
point in the right lower quadrant and possible internal hernia,
as
described above. The patient was examined by and admitted to the
colorectal surgery service for further management. The patient
had a nasogastric tube for bowel decompression, was given bowel
rest, intravenous fluids, and symptom management. His abdominal
exam was monitored closely which improved daily. The output from
the nasogastric tube was very high with greater than 2500cc
output daily and the patient required intermittent IV fluid
boluses. On ___, the patient had a bowel movement. On ___, the
nasogastric tube output decreased significantly. He was given a
clamping trial with residual gastric output of 100cc, the tube
was sequentially removed. The patient was later advanced to and
tolerated a regular diet. On ___, the patient was discharged
to home. At discharge, he was tolerating a regular diet, passing
flatus, voiding, and ambulating independently.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril 40 mg PO DAILY
2. Gabapentin 300 mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. amLODIPine 5 mg PO DAILY
5. GlipiZIDE 10 mg PO BID
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Gabapentin 300 mg PO DAILY
4. GlipiZIDE 10 mg PO BID
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital for a small bowel obstruction.
You were given bowel rest, intravenous fluids, and a nasogastric
tube was placed in your stomach to decompress your bowels. Your
obstruction has subsequently resolved after conservative
management. You are tolerating a regular diet, passing gas and
your pain is controlled with pain medications by mouth.
If you have any of the following symptoms please call the office
or go to the emergency room if severe: increasing abdominal
distension, increasing abdominal pain, nausea, vomiting,
inability to tolerate food or liquids, prolonged loose stool, or
extended constipation.
Thank you for allowing us to participate in your care, we wish
you all the best!
Followup Instructions:
___
|
19997540-DS-3 | 19,997,540 | 29,178,502 | DS | 3 | 2154-03-03 00:00:00 | 2154-03-03 11:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
food impaction
Major Surgical or Invasive Procedure:
endoscopy with intubation - ___
History of Present Illness:
___ with no significant medical history presents with a piece of
steak stuck in his throat.
He was eating dinner at a ___ the evening of
admission when, at about 10:30pm, a piece of steak lodged in his
throat. He could recall no inciting event. He had no difficulty
breathing, but could not clear the bolus despite drinking water.
He had no difficulty breathing. Given his inability to clear the
bolus and increasing difficulty swallowing fluids, he was taken
to the ED.
In the ED, initial vitals 5 98.8 78 129/74 16 100% RA. He
developed nausea and was eventually unable to clear even his own
saliva, spitting it up to an emesis basin. He vomited several
times, both after drinking and due to pooling secretions. He
received glucagon x 1 and nitroglycerin x 1. Neither were
effective in loosening the GE junction sufficiently to allow
passage of the bolus. He also received Zofran 4 mg IV and Reglan
10mg IV for nausea management. GI was consulted who recommended
immediate endoscopy to clear the bolus. He was taken to the OR
for removal.
Given concern for airway protection after his recent meal,
Anaesthesia intubated the patient. He recieved Versed 2mg IV,
fentanyl 250mcg IV, propofol and succinylcholine induction.
Immediately after intubation his esophageal musculature relaxed
and the bolus spontaneously passed into the stomach. Endoscopy
revealed a large amount of food in the stomach, including the
recently passed bolus, esophagitis, and possible mild furrowing
of the esophagus. There was no sign of obstruction or stricture.
He received 700cc IVF during the procedure. He tolerated it
well, was extubated easily.
In the PACU, he recovered swiftly and was able to tolerate small
sips of water without pain or nausea. He received Zofran 4mg IV
x1 for prophylaxis of possible post-anaesthesia nausea/emesis.
He was resting comfortably with slight neck stiffness.
Past Medical History:
Herpes on finger
H/o appendicitis s/p appendectomy
Social History:
___
Family History:
+Cardiovascular diseases, no GI diseases in the family
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: ___ 97.8 130/61 62 16 100% RA
GENERAL: NAD, awake and alert
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender and supple, no LAD, no JVD. No pain to palpation
of posterior neck.
CARDIAC: RRR, nl S1 S2, no MRG
LUNG: CTAB, no rales wheezes or rhonchi, no accessory muscle use
ABDOMEN: +BS, soft, non-tender, non-distended, no rebound or
guarding, no HSM
EXT: warm and well-perfused, no cyanosis, clubbing or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII tested and intact, strength and gait testing
deferred
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
DISCHARGE PE:
VS: 98.4, 53, 129/61, 16, 100% RA
General: well-appearing young male, in NAD
HEENT: MMM with small <1cm ecchymosis to L of uvula in posterior
oropharynx
Neck: supple, nontender, no LAD
CV: RRR, no murmurs
Lungs: CTAB
Abd: soft, NT, ND, +BS
Ext: no ___ edema
Ext: no ___ edema
Pertinent Results:
EGD:
There was some possible mild furrowing in the esophagus.
Esophagitis
Food in the stomach
Otherwise normal EGD to third part of the duodenum
.
CXR, prelim: No radiopaque foreign body identified
Brief Hospital Course:
___ with no significant medical history presents with a piece of
steak stuck in his throat.
.
# Food impaction: No evidence of obstruction or stricture. The
patient's food bolus spontaneously passed following anaesthesia
without apparent damage to the esophagus. He had no respiratory
compromise, and his nausea resolved with passing of the bolus
into the stomach. He has no history of similar events. Aside
from mild esophagitis, there is no evidence of structural
problem. Pt started on BID PPI. Will need repeat EGD in ___
weeks after PPI for reassessment of distal esophagus and
biopsies for EoE. Pt felt well the AM after admission and
tolerated PO challenge.
.
# HSV treatment: The patient has an HSV vesicle on his finger,
for which is under treatment with acyclovir for a planned 5 day
course. He completed the course of acyclovir during his
admission.
.
>> Transitional issues:
- ___ in GI in ___ for repeat scope
- PCP ___ recommended
- Pt adamant about rapid discharge on ___ AM as he was
feeling very well. Team requested he wait for attending
evaluation but he insisted on immediate discharge AMA.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
___dmitted on day 5
Discharge Medications:
1. Omeprazole 20 mg PO BID
Take until a repeat endoscopy is done in ___ weeks.
RX *omeprazole 20 mg 1 capsule,delayed ___ by
mouth twice a day Disp #*120 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
food bolus impaction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure caring for you at ___
___. You came to the hospital after getting a piece
of steak stuck in your throat that you were unable to clear.
This was removed with an endoscopy. There was no evidence of a
narrowing of your esophagus that would make you more likely to
have future problems with food getting stuck. There was mild
irritation of the esophagus from the piece of steak. You will
need a repeat endoscopy in ___ weeks; until that time, please
use omeprazole (Prilosec) to treat this irritation.
You can avoid future problems with food being stuck in your
esophagus by eating smaller bites and chewing more thoroughly.
Please follow-up at the appointments listed below. Please see
the attached list for updates to your home medications. Please
start takeing Omeprazole 20mg twice daily for the irritation in
your esophagus.
You chose to leave before seeing the attending. We suggested you
wait for attending evaluation but you wanted to leave.
Followup Instructions:
___
|
19997886-DS-16 | 19,997,886 | 20,793,010 | DS | 16 | 2186-12-10 00:00:00 | 2186-12-14 17:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
All allergies / adverse drug reactions previously recorded have
been deleted
Attending: ___
Chief Complaint:
abdominal distension
Major Surgical or Invasive Procedure:
Diagnostic and therapeutic paracentesis bedside ___
Diagnostic and therapeutic paracentesis bedside ___
___ TIPS ___
Central venous line insertion ___
Diagnostic paracentesis ___
History of Present Illness:
___ year old man with PBC c/b esophageal varices and ascites and
schizoaffective disorder who presented to clinic yesterday with
worsening abdominal distention in the setting of not taking his
diuretics. He has lost a tremendous
amount of weight and he has not been able to eat.
Per OMR on ___, his PCP spoke to him because she had
received an email from his psychiatrist that he reported that he
is no longer taking his Lasix due to concerns that it is an
amphetamine and concerns about dizziness. At that point he
agreed
to restart his Lasix and spironolactone but his PCP did not feel
confident in him following through with this. On ___
there is a note from his psychiatrist that he had been seen in
the ___ ED 3 days prior with dizziness causing him to be unable
to ambulate. He was seen by ___, labs were checked, and he was
discharged home. He had self decreased his Seroquel from 300 to
200 mg qHS and his psychiatrist recommended decreasing his
lamotrigine from 200 to 100 due to the concern that dizziness
may
have been related to this medication. A serum level of the
medication was checked while he was on 200 mg which was within
normal limits and thus it was felt that the lamotrigine was less
likely to be causing his dizziness.
On ___ he was seen by psychiatry at which point he had
been doing "all right" on the reduced doses of his psychiatric
medications.
In the ED initial vitals: Temperature 97.4, heart rate 97, blood
pressure 143/91, respiratory rate 18, 98% on room air
- Exam notable for: Tense, distended abdomen, non-tender.
Breathing comfortable on room air with crackles at bilateral
bases
- Labs notable for:
CBC: Hemoglobin 12.9, otherwise unremarkable
Chem7: Unremarkable
LFTs: Unremarkable, except for albumin of 3.1
Coags: Not obtained
Ascites: TNC of 685, 6% polys
Urinalysis: 9 WBCs, 0 epis, 10 ketones, few bacteria, negative
nitrite
- Imaging notable for:
RUQUS with Doppler:
1. Cirrhosis with large ascites.
2. Patent portal vein.
CXR: Low lung volumes without focal consolidation or pulmonary
edema.
- Patient was given: Nothing
- ED Course: Patient underwent diagnostic and therapeutic
paracentesis for 2 L with improvement in symptoms.
On arrival to the floor he says he feels better after
therapeutic
paracentesis. He says that last ___ he started to feel
tired
and fatigued and had some shortness of breath which has been
worsening over the last 6 months or so. He can only walk about
7
blocks before feeling tired and short of breath at this time.
He
does state that he feels that the diuretics are making him dizzy
and so he has been only taking them about twice a week. He
denies dysuria, urinary frequency, hematuria, hematochezia,
melena. He endorses swelling around his ankles. He endorses
chills but no fevers. He says that over the last ___ weeks he
only ate ___ boosts per day in addition to some juice and coffee
and water. He says that he has been doing this in order to make
his stool softer and is afraid to eat regular food because it
will make him constipated. He says he did have a soft bowel
movement over the weekend but still feels constipated. He does
say that people have told him that he looks much thinner than
previously.
Past Medical History:
BPH
Depression
Schizoaffective disorder
Colon polyps
Portal hypertensive gastropathy
Primary biliary cirrhosis complicated by ascites s/p banding and
ascites
Chronic cough, improved
Social History:
___
Family History:
Father died from complications from polio. His
mother died at the age of ___ and she had a tumor removed at some
point (he thinks from her abdomen). Brother with stage IV rectal
cancer who recently underwent surgery. He was diagnosed with
colon cancer in his late ___.
Physical Exam:
ADMISSION EXAM:
===============
VS: 98.1F, 129/84, HR 77, RR 18, on room air
GENERAL: NAD, appears markedly cachectic with muscle wasting and
temporal wasting
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: Breathing comfortable on room air, crackles at the bases
of his lungs bilaterally
ABDOMEN: distended but soft, nontender in all quadrants, no
rebound/guarding, normoactive bowel sounds, right sided para
site
with bloody bandage in place
EXTREMITIES: 2+ pitting edema to the knees bilaterally
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
DISCHARGE EXAM:
===============
VS: 24 HR Data (last updated ___ @ 2340)
Temp: 98.3 (Tm 100.3), BP: 127/72 (112-127/68-72), HR: 105
(82-105), RR: 20 (___), O2 sat: 91% (89-100), O2 delivery: 2 L
Nc
Fluid Balance (last updated ___ @ 530)
Last 8 hours Total cumulative 873ml
IN: Total 873ml, TF/Flush Amt 447ml, IV Amt Infused 426ml
OUT: Total 0ml, Urine Amt 0ml
Last 24 hours Total cumulative 2001ml
IN: Total 4061ml, PO Amt 120ml, TF/Flush Amt 748ml, IV Amt
Infused 3193ml
OUT: Total 2060ml, Urine Amt 2060ml, Flexiseal 0ml
GEN: Elderly, frail man, lying in bed, appears uncomfortable
HEENT: Anicteric sclerae. NG tube in place, dried blood in
nares.
CV: Normal rate and rhythm. Grade ___ systolic murmur.
Lungs: Clear to auscultation bilaterally without wheezes,
rhonchi, or rales in anterior fields.
Abdomen: Hyperactive bowel sounds throughout. Soft.
Significantly
distended, tympanitic to percussion. Mildly tender to deep
palpation diffusely, no rebound or guarding.
Extremities: Warm. No pitting edema.
Neuro: Alert. Oriented to self, place ___ building"). Not
oriented to year. Does not answer all questions or follow
commands appropriately. Dysarthric. No asterixis appreciated.
Pertinent Results:
ADMISSION LABS:
===============
___ 05:53PM WBC-7.4 RBC-4.41* HGB-12.9* HCT-41.4 MCV-94
MCH-29.3 MCHC-31.2* RDW-17.3* RDWSD-60.1*
___ 05:53PM PLT COUNT-183
___ 05:53PM NEUTS-72.6* LYMPHS-15.0* MONOS-11.2 EOS-0.8*
BASOS-0.3 IM ___ AbsNeut-5.36 AbsLymp-1.11* AbsMono-0.83*
AbsEos-0.06 AbsBaso-0.02
___ 05:53PM GLUCOSE-76 UREA N-14 CREAT-0.8 SODIUM-139
POTASSIUM-4.8 CHLORIDE-102 TOTAL CO2-27 ANION GAP-10
___ 05:53PM ALT(SGPT)-32 AST(SGOT)-38 ALK PHOS-109 TOT
BILI-1.5
___ 05:53PM proBNP-560*
___ 05:53PM LIPASE-15
___ 05:53PM ALBUMIN-3.1* CALCIUM-9.1 PHOSPHATE-2.7
MAGNESIUM-2.2
PERTINENT LABS:
===============
___ 07:05PM BLOOD 25VitD-49
___ 04:41AM BLOOD CRP-52.0*
___ 02:12PM ASCITES TNC-1131* RBC-120* Polys-48* Lymphs-2*
Monos-10* Mesothe-5* Macroph-32* Other-3*
___ 03:40PM URINE RBC-65* WBC-83* Bacteri-FEW* Yeast-NONE
Epi-<1
DISCHARGE LABS:
===============
___ 03:51AM BLOOD WBC-15.5* RBC-2.80* Hgb-8.4* Hct-27.1*
MCV-97 MCH-30.0 MCHC-31.0* RDW-21.0* RDWSD-73.1* Plt ___
___ 03:51AM BLOOD ___ PTT-46.5* ___
___ 07:58AM BLOOD Glucose-150* UreaN-28* Creat-0.7 Na-150*
K-4.1 Cl-114* HCO3-23 AnGap-13
___ 03:51AM BLOOD ALT-27 AST-42* AlkPhos-109 TotBili-3.0*
DirBili-0.9* IndBili-2.1
___ 07:58AM BLOOD Calcium-9.0 Phos-2.5* Mg-2.1
___ 06:18AM BLOOD ___ pO2-206* pCO2-38 pH-7.42
calTCO2-25 Base XS-0 Comment-GREEN TOP
___ 10:32AM BLOOD Lactate-2.1*
PERTINENT MICROBIOLOGY:
=======================
__________________________________________________________
___ 10:52 pm STOOL CONSISTENCY: LOOSE Source:
Stool.
C. difficile PCR (Pending):
__________________________________________________________
___ 9:45 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 9:30 pm BLOOD CULTURE Source: Line-CVL.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:40 pm URINE Source: Catheter.
URINE CULTURE (Pending):
__________________________________________________________
___ 5:13 pm MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
__________________________________________________________
___ 2:12 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
Fluid Culture in Bottles (Pending): No growth to date.
__________________________________________________________
___ 2:12 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 11:44 am
STOOL CONSISTENCY: FORMED Source: Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
NEGATIVE.
(Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of C.
difficile and detects both C. difficile infection (CDI)
and
asymptomatic carriage.
A negative C. diff PCR test indicates a low likelihood of
CDI or
carriage.
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 11:03 am
URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 9:13 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 4:30 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES
PERITONEAL FLUID.
**FINAL REPORT ___
Fluid Culture in Bottles (Final ___: NO GROWTH.
__________________________________________________________
PERTINENT IMAGING:
===================
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
IMPRESSION:
1. Limited evaluation of the left hepatic lobe due to poor
sonographic
windows.
2. Cirrhosis with large volume ascites.
3. Patent portal vein.
Transthoracic Echocardiogram Report ___
IMPRESSION: Normal biventricular cavity sizes and
regional/global biventricular systolic function. Mild mitral
regurgitation. Dilated thoracic aorta.
CT CHEST W/CONTRAST Study Date of ___
IMPRESSION:
Mild-to-moderate diffuse interstitial lung disease may explain
chronic cough.
NS IP is the most likely diagnosis alternatively severe
elevation of the
diaphragm due to ascites may be triggering coughing.
Fusiform aneurysm noncalcified ascending thoracic aorta, 50 mm
diameter.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
IMPRESSION:
1. Cirrhotic liver without focal liver lesions. Evaluation for
HCC is limited
on this portal venous phase contrast-enhanced study. Recommend
further
evaluation a dedicated liver CT which includes the noncontrast,
arterial, and 3 minutes delayed phases. The portal venous phase
does not need to be
repeated.
2. Large volume ascites, splenomegaly, and portosystemic varices
compatible with sequela of portal hypertension.
3. Multiple pancreatic cystic lesions better evaluated on MR,
likely represent side branch IPMNs. Recommend attention on
follow-up imaging.
4. Please refer to separate report of CT chest performed on the
same day for description of the thoracic findings.
TIPS Study Date of ___
FINDINGS:
1. Pre-TIPS right atrial pressure of 11 mm Hg and
balloon-occluded portal
pressure measurement of 31 mm Hg resulting in portosystemic
gradient of 20
mmHg.
2. CO2 portal venogram predominantly shunted into alternative
hepatic veins with minimal opacification of the portal vein.
3. Contrast enhanced portal venogram showing patent portal
venous system and hepatopetal flow.
4. Post-TIPS portal venogram showing predominant flow of
contrast through the TIPS.
5. Post-TIPS right atrial pressure of 14 mm Hg and portal
pressure of 20 mmHg resulting in portosystemic gradient of 6
mmHg.
6. Right upper quadrant ultrasound demonstrated trace ascites,
too small
volume for paracentesis
IMPRESSION:
Successful transjugular intrahepatic portosystemic shunt
placement with
decrease in porto-systemic pressure gradient from 20 to 6 mmHg.
DUPLEX DOPP ABD/PEL Study Date of ___
IMPRESSION:
Patent TIPS in this baseline ultrasound. Velocities as
reported.
CT ABD & PELVIS WITH CONTRAST Study Date of ___
IMPRESSION:
1. No evidence of perforation. Air and fluid filled mildly
dilated colon.
2. Patent TIPS
3. Cirrhosis and findings compatible with portal hypertension.
Interval
decrease in extent of abdominopelvic ascites.
4. Unchanged pancreatic hypodensities, presumably reflecting
IPMNs.
PORTABLE ABDOMEN Study Date of ___
IMPRESSION:
Dilated colonic bowel loops measuring up to 10 cm. Evaluation
for small bowel dilatation is limited.
CHEST (PORTABLE AP) Study Date of ___
IMPRESSION:
1. Unchanged bibasilar opacities may represent atelectasis or
pneumonia/aspiration.
2. Mild interstitial pulmonary edema.
3. Multiple dilated colonic loops.
MR HEAD W & W/O CONTRAST Study Date of ___
IMPRESSION:
Moderately motion limited exam. No evidence for an acute
infarction or other acute intracranial abnormalities.
Brief Hospital Course:
BRIEF DISCHARGE SUMMARY
=========================
Mr. ___ is a ___ man with PBC c/b cirrhosis (c/b
esophageal varices and ascites) and schizoaffective disorder who
presented from clinic with worsening abdominal distension in the
setting of not taking his diuretics due to dizziness. We found
that he had lost a tremendous amount of weight and was fearful
of eating because of chronic constipation. Given his anorexia
and significant weight loss, there was concern for malignancy. A
CT torso showed no evidence of cancer. We placed a feeding tube
and had it advanced post-pyloric and initiated tube feeds for
nutrition. We did a TTE that showed no significant cardiac
abnormalities and did two bedside paracenteses for comfort. We
recommended a TIPS procedure, which was done on ___ after Mr.
___ son was able to visit from ___. His post-TIPS
course was complicated by ongoing fluid overload, and septic
shock secondary to spontaneous bacterial peritonitis. After
discussion with his family, patient was transitioned to comfort
care and was discharged to hospice.
TRANSITIONAL ISSUES
===================
[ ] NG tube to suction kept in place at discharge for symptom
relief of colonic and intestinal distension.
ACTIVE ISSUES
=============
#Primary biliary cholangitis
#Acute decompensated cirrhosis
#Refractory ascites s/p TIPS
MELD 12 and CHILDS B on admission. Presented with large volume
ascites in the setting of not taking diuretics due to persistent
dizziness. RUQUS showed no evidence of PVT, infectious workup
was negative, and he had no signs of bleeding. He had a
paracentesis in the ED to remove 2L fluid which resulted in
significant improvement in symptoms. He was actively diuresed
with IV furosemide, which removed significant volume clinically
but caused low blood pressures (systolics ___, asymptomatic).
Additional large volume paracenteses were performed for ongoing
reaccumulation of ascites. Patient underwent a TIPS procedure on
___. His post-TIPS course was complicated by volume overload
requiring additional diuresis, hepatic encephalopathy requiring
lactulose and rifaximin, and septic shock secondary to SBP (see
below). Given his poor prognosis, a discussion was held with his
sister and son, and the decision was made to transition the
patient to comfort care and discharge to hospice.
#Septic shock
#Spontaneous bacterial peritonitis
#Hospital acquired pneumonia
Patient developed fever, hypotension, and tachycardia,
concerning for infection. Infectious workup was significant for
ascites fluid with PMN>250. Patient was transferred to the ICU
and maintained on pressors. Patient was started on antibiotics
for SBP. Chest imaging was also concerning for a pulmonary
consolidation, so he was maintained on broad spectrum
Vancomycin, cefepime, and metronidazole. He was stabilized and
transferred back to the general medical floor. Antibiotics were
discontinued after patient was transitioned to comfort care.
#Acute colonic pseudoobstruction
Patient developed worsening abdominal distension and tenderness.
Imaging revealed dilated colonic bowel loops measuring up to
10cm. Patient was evaluated by the surgical service, who
recommended strict NPO and maintaining NG tube to suction for
decompression.
#Severe malnutrition
#Weight loss
Reported purposeful food restriction because of concern for
constipation and that he was mostly drinking Ensures. His
significant weight loss raised concern for malignancy and he had
a CT torso, which showed no evidence of cancer. A colonoscopy
was deferred given his significant improvement with treatment of
his liver disease. Nutrition was consulted and a dobhoff was
placed (and advanced post-pyloric) to initiate tube feeds. Tube
feeds were subsequently held after development of acute colonic
pseudoobstruction.
#Dyspnea
#Lower extremity edema
Appeared significantly volume overloaded on exam with crackles
in bilateral bases, subjective shortness of breath, and 2+
pitting edema to his knees bilaterally. Likely in the setting of
not taking his diuretics due to persistent dizziness. His
symptoms improved with diuresis and therapeutic paracentesis.
BNP and TTE on admission were unremarkable so there was less
concern for a cardiogenic cause of his volume overload. Given
diuretic intolerance, a TIPS procedure was performed. He had
ongoing peripheral edema after his TIPS that required diuresis.
#Asymptomatic bacteriuria
UA showed pyuria and bacteriuria but patient had no symptoms.
Treatment was therefore deferred.
CHRONIC ISSUES
===============
#Depression
#Schizoaffective disorder
Continued home seroquel 100mg QHS. Psychiatry initially
recommended continuing the seroquel and then follow up after
discharge to consider cross downtitration with another
medication as seroquel can be constipating. However, after
discussion with the family, patient was transitioned to comfort
care, and this plan was not undertaken. Of note, we discontinued
his home lamotrigine per recommendation from his outpatient
psychiatrist Dr. ___ due to conflicting reports about whether
he was taking/stopping/restarting this medication. Per Dr.
___, patient is not a good candidate for lamotrigine with
risk of abrupt start/stop and risk for SJS.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. LamoTRIgine 100 mg PO DAILY
3. QUEtiapine Fumarate 100 mg PO DAILY
4. Spironolactone 50 mg PO DAILY
5. Ursodiol 500 mg PO BID
6. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
7. Calcium Carbonate 500 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. Polyethylene Glycol 17 g PO BID
10. Vitamin A ___ UNIT PO DAILY
Discharge Medications:
1. rifAXIMin 550 mg PO BID
2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
3. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
4. QUEtiapine Fumarate 100 mg PO DAILY
Discharge Disposition:
Expired
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
ACUTE DECOMPENSATED CIRRHOSIS
SECONDARY DIAGNOSES
===================
PRIMARY BILIARY CHOLANGITIS
LIVER CIRRHOSIS
ASCITES
SPONTANEOUS BACTERIAL PERITONITIS
ACUTE COLONIC PSEUDOOBSTRUCTION
SEPTIC SHOCK
SEVERE MALNUTRITION
WEIGHT LOSS
ANOREXIA
SHORTNESS OF BREATH
LOWER EXTREMITY EDEMA
ASYMPTOMATIC BACTERIURIA
CONSTIPATION
DEPRESSION
SCHIZOAFFECTIVE DISORDER
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr ___,
It was our pleasure to take care of you at ___. You came to
the hospital because your abdomen was getting very big.
WHAT HAPPENED IN THE HOSPITAL?
- We removed extra fluid from your belly through a procedure
known as a paracentesis
- You had a TIPS procedure, which was done to help reduce the
amount of fluid that built up in your belly
- We treated you for an infection in the fluid in your belly.
You were briefly in the intensive care unit because the
infection made you very sick.
- We placed a tube through your nose into your stomach to remove
the gas and help make you feel more comfortable
- We discussed with you and your family and decided to no longer
perform any invasive procedures, and rather to focus on symptom
management and helping you feel comfortable.
- You were discharged to hospice.
WHAT SHOULD YOU DO WHEN YOU LEAVE?
- You should enjoy spending time with your family
We wish you the best,
Sincerely,
Your care team at ___
Followup Instructions:
___
|
19998330-DS-19 | 19,998,330 | 23,137,777 | DS | 19 | 2178-10-15 00:00:00 | 2178-10-15 13:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ history of sleep apnea on CPAP, A. fib on Coumadin, COPD (1L
O2 NC at home), diabetes on insulin, CHF presents with
hypoglycemic episode after being discharged from hospital
yesterday ___ after a MICU admission for hypercarbic
respiratory failure. This AM, she took both her Lantus 60U and
10U of regular insulin for an AM FSG of 259, but did not eat
anything b/c she was in a hurry to get to her PCP's appt. About
2 hrs after taking her insulin, she was found walking around and
confused (per the daughter, however, the pt was found down in
the hallway by a neighbor). EMS was called by her husband and
she was found to have a fingerstick glucose of 21. She was given
an amp of D50, after which her mental status improved, and her
repeat blood glucose was in the 200s. She denies any recent
fevers or chills; she was recently hospitalized for hypercarbic
respiratory failure thought to be secondary to a COPD
exacerbation, and she was intubated from ___. She was
initially on ABx but they were d/c'd during hospitalization. No
cough. No SOB per patient. No Abd pain/N/V/D/changes in bowel or
bladder habits, no dysuria.
In the ED, initial VS were: 96.2 89 134/46 20 96%. She was
lethargic, but arousable, A+O x1. She had a FSBG of 71 and was
given repeat D50, 290 on repeat. Repeat at 1455 was 22. She was
given another amp of D50, and was started on a D5 drip. Pt was
hypercarbic on ABG even when sitting up and talking. On 1L O2 NC
92-94%.
On arrival to the MICU, the pt is comfortable and has no
complaints. ROS negative. Pt remarked that she has never had a
problem with hypoglycaemia in the past.
Review of systems:
Per HPI
Past Medical History:
- COPD on home oxygen-dependent
- Obstructive sleep apnea with BiPAP at night
- Type 2 diabetes mellitus, on insulin
- Atrial fibrillation on coumadin
- Diastolic congestive heart failure
- Diverticulitis s/p colostomy, then s/p reversal
- OSA, on BiPAP
- Obesity
- Anemia of chronic disease
- Hypertension
- Dyslipidemia
- Chronic kidney insufficiency stage III in f/u renal ___
- GERD
Social History:
___
Family History:
No history of CKD, lung disease, or malignancies.
Physical Exam:
General: Alert, oriented x3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear but with
macroglossia, EOMI, PERRL
Neck: supple, JVP could not be assessed due to habitus
CV: Regular rate and rhythm, normal S1 + S2, 2+ systolic murmur
at RUS border
Lungs: Clear to auscultation bilaterally but with decreased
breath sounds throughout, only mild wheezes in RUL field, no
crackles
Abdomen: soft, non-distended; multiple surgical scars; bowel
sounds present, no organomegaly, no tenderness to palpation, no
rebound or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation. Can say days of wk backwards without
difficulty.
Pertinent Results:
___ 07:00AM BLOOD WBC-6.5 RBC-2.92* Hgb-7.8* Hct-26.2*
MCV-90 MCH-26.8* MCHC-29.9* RDW-16.1* Plt ___
___ 06:55AM BLOOD WBC-6.7 RBC-2.90* Hgb-7.8* Hct-26.4*
MCV-91 MCH-26.8* MCHC-29.4* RDW-15.4 Plt ___
___ 06:00AM BLOOD WBC-5.7 RBC-3.08* Hgb-8.2* Hct-28.1*
MCV-91 MCH-26.5* MCHC-29.1* RDW-15.2 Plt ___
___ 05:08AM BLOOD WBC-5.1 RBC-2.88* Hgb-7.7* Hct-26.4*
MCV-92 MCH-26.9* MCHC-29.3* RDW-15.3 Plt ___
___ 03:23AM BLOOD WBC-6.1 RBC-2.90* Hgb-7.8* Hct-26.4*
MCV-91 MCH-26.7* MCHC-29.4* RDW-15.1 Plt ___
___ 01:35PM BLOOD WBC-6.6 RBC-3.24* Hgb-8.3* Hct-29.6*
MCV-91 MCH-25.6* MCHC-28.0* RDW-14.9 Plt ___
___ 01:35PM BLOOD Neuts-72.2* ___ Monos-4.9 Eos-2.3
Baso-0.3
___ 07:00AM BLOOD ___ PTT-49.4* ___
___ 06:55AM BLOOD Plt ___
___ 06:55AM BLOOD ___
___ 06:00AM BLOOD Plt ___
___ 06:00AM BLOOD ___ PTT-48.5* ___
___ 07:00AM BLOOD Glucose-134* UreaN-45* Creat-1.8* Na-144
K-4.6 Cl-98 HCO3-38* AnGap-13
___ 06:55AM BLOOD Glucose-154* UreaN-52* Creat-1.9* Na-146*
K-5.0 Cl-102 HCO3-35* AnGap-14
___ 06:00AM BLOOD Glucose-248* UreaN-61* Creat-2.0* Na-145
K-4.4 Cl-99 HCO3-36* AnGap-14
___ 05:08AM BLOOD Glucose-120* UreaN-62* Creat-2.4* Na-143
K-4.7 Cl-100 HCO3-34* AnGap-14
___ 03:23AM BLOOD Glucose-79 UreaN-64* Creat-1.9* Na-142
K-5.4* Cl-102 HCO3-35* AnGap-10
___ 11:18PM BLOOD Glucose-124* UreaN-64* Creat-1.9* Na-145
K-4.8 Cl-101 HCO3-38* AnGap-11
___ 01:35PM BLOOD Glucose-123* UreaN-68* Creat-2.1* Na-148*
K-4.4 Cl-103 HCO3-35* AnGap-14
___ 01:35PM BLOOD TSH-1.2
.
___ EKG:
Atrial fibrillation with a controlled ventricular response. Left
axis
deviation. Left anterior fascicular block. There is a late
transition with
small R waves in the anterior leads consistent with possible
infarction.
Non-specific ST-T wave changes. Compared to the previous tracing
of ___
atrial fibrillation is new.
.
___ CXR:
IMPRESSION: Mild pulmonary vascular congestion with small
bilateral pleural
effusions. Bibasilar airspace opacities may reflect
atelectasis.
Brief Hospital Course:
ACTIVE ISSUES:
## Hypoglycemia: Most likely due to taking home dose of Lantus
60U in setting of lack of oral intake on the day of admission
and mild renal failure with associated decreased insulin
clearance. There was no sign of infectious etiology. TSH and AM
Cortisol were normal. She was started on a D10 drip in the ICU
until fingersticks stabilized. Despite excellent oral intake on
the floor, her Insulin requirements initially remained
relatively minimal compared to her home dose. ___ was
consulted and recommended a lower dose of basal insulin at [3
uptitrated to 8 units on the day of discharge per ___
recommendations, received 5units QHS ___. They also
recommended that a DDPV-4 inhibitor that does not require renal
clearance and recommended linagliptin 5mg daily to start upon
discharge. She should follow up with ___ upon discharge from
rehab facility. Would check finger sticks QIDACHS at this time.
## Atrial fibrillation: Rate controlled and in sinus rhythm. Her
INR was elevated on admission 3.2 and then increased to 4.6. Her
Warfarin 6mg was held until the INR trended down and was
restarted at 5mg on ___. Given that pt was supratherapeutic
today ___. Her dose should be held on ___ and restarted at 3mg
warfarin daily when INR is <3 (possibly on ___ with close INR
monitoring. Her BB was continued at the equivalent home dose.
She was discharged on her home dose.
.
## Sleep apnea on CPAP: CPAP was continued at night during
admission. Patient and her family spoke of the need for a new
machine as the current machine is not operating correctly.
CHRONIC ISSUES:
## COPD (2L O2 NC at home): Continued home nebs, maintained on
supplemental O2 for goal saturation 88-90% Pt is on 1L o2 at
home.
## Primary respiratory acidosis with compensatory metabolic
alkalosis: Likely chronic in setting of her COPD. Respiratory
status appeared stable.
## Chronic diastolic CHF: No active issues during this
admission. Home cardiac meds were continued.
## Stage 3 CKD, baseline Cr 1.8: Cr upon admission was 2.1 and
peaked at 2.4, which was thought to be aberrant since it rose
and improved without any intervention. 1.8 on day of DC.
## Anemia: normocytic, chronic. Likely related to CKD and
diabetes. Hct remained stable during admission without any
transfusion requirement. Can consider further work up as an
outpatient such as iron studies and colonoscopy. 26.2 on
discharge.
## Glaucoma: Continued latanoprost, apraclonidin, prednisolone.
TRANSITIONS OF CARE:
-Per PCP, pt needs pulmonary rehab given that this is her third
admission. She also needs a new CPAP machine, and per her
family's report, the pt will need assistance to work through
insurance and other issues in order to get the machine provided.
Case mgmt and social work were consulted, and in the meantime
the pt was approved for ___ skilled nursing, given
concern for her ability to care for herself. She will require
confirmation that she has adequate CPAP machinery at home or at
___. Pt will need close glucose monitoring while her
regimen is being titrated. She will also need INR monitoring and
adjustment of her warfarin dosing prn.
-hydralazine increased, coumadin decreased, glargine decreased,
linagliptin added to medication regimen
-Pt will need PCP and ___ follow up arranged at the time of
DC from rehab
Medications on Admission:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
4. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.
5. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Left Eye Ophthalmic DAILY (Daily).
6. Lantus 100 unit/mL Solution Sig: Sixty (60) units
Subcutaneous once a day.
7. ipratropium-albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution
for Nebulization Sig: One (1) unit Inhalation every four (4)
hours as needed for shortness of breath or wheezing.
8. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Capsule Inhalation once a day.
10. apraclonidine 0.5 % Drops Sig: One (1) Drop Left Eye
Ophthalmic DAILY (Daily).
11. latanoprost 0.005 % Drops Sig: One (1) Drop Right Eye
Ophthalmic HS (at bedtime).
12. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ INH Inhalation every ___ hours as needed for shortness of
breath or wheezing.
13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) INH Inhalation twice a day.
14. warfarin 6 mg Tablet Sig: One (1) Tablet PO Q 4 pm.
15. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H
16. Home Oxygen 1 Liter/min
17. Outpatient Pulmonary Rehab
18. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
Discharge Medications:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous
at bedtime.
3. linagliptin
Linagliptin 5mg daily
4. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily): left eye.
8. Combivent ___ mcg/actuation Aerosol Sig: One (1)
Inhalation every ___ hours as needed for shortness of breath or
wheezing.
9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) drop
Ophthalmic once a day.
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for HTN: increased from q8 at home.
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): right eye.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. humalog sliding scale
QID ACHS. Please see attached sheet
17. warfarin
Please start warfarin 3mg daily when INR is <3. Please check INR
___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypoglycemia
.
Chronic
COPD
CKD
HTN
diastolic CHF
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 Intensive Care Unit at ___
___ for treatment of low blood sugar, which
was likely due to taking your Insulin without eating anything
the following day. The ___ saw you during
this admission and recommended reducing dose of your long-acting
insulin (Lantus) to 8 units daily. They also recommended that
you start another medication for your blood sugar called,
linagliptin 5mg daily
.
MEDICATION CHANGES:
- Your Lantus dose was decreased from 60 units daily to 8 units
daily
- you were started on linagliptin
- your hydralazine was increased to four times a day
Followup Instructions:
___
|
19998330-DS-20 | 19,998,330 | 21,135,114 | DS | 20 | 2178-10-25 00:00:00 | 2178-10-25 21:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Endotracheal intubation
History of Present Illness:
___ year-old woman with a history of severe COPD (1L O2 at home,
baseline pCO2 = 70. Multiple recent admissions including ___
requiring intubation), OSA on CPAP, afib on coumadin, IDDM,
diastolic CHF, admitted to ___ for hypercarbic respiratory
failure in setting of COPD exacerbation.
Of note, pt has had two recent admissions. On ___, she was
admitted with hypercarbic respiratory acidosis ___ COPD
exacerbation, requiring intubation. She was readmitted to ___
on ___ for hypoglycemia.
This morning, pt was found at nursing home to be less arousable
and with difficulty breathing. O2 sat 99% but EtCO2 low ___,
started on CPAP by EMS and improved symptoms. On arrival to ED,
patient confused, but reports increased SOB and difficulty
breathing. Denies CP, abdominal pain, cough or recent fever.
In the ED, initial VS were: BP 140s/70s, HR in ___, sating in
___ on CPAP, on arrival to ED he was switched to BiPAP at ___,
30% FiO2. Initial ABG done 10 min after started on bipap was
7.21/99/119/42. RR ___ on BiPAP, arousable, knows she's in
the hospital. She was given 500mg Azithromycin and 125mg IV
solumedrol. EKG shows afib with rate of 68, no STTW changes.
Trop was 0.03, INR was 1.9, CBC without leukocytosis and anemia
at baseline. Chem 10 pending at time of transfer. CXR showed
small bilateral effusions + increase pulm vascular congestion,
difficult to assess for any infiltrates. BNP was also almost 3K
with baseline at 300-500.
Past Medical History:
- COPD on home oxygen-dependent
- Obstructive sleep apnea with BiPAP at night
- Type 2 diabetes mellitus, on insulin
- Atrial fibrillation on coumadin
- Diastolic congestive heart failure
- Diverticulitis s/p colostomy, then s/p reversal
- OSA, on BiPAP
- Obesity
- Anemia of chronic disease
- Hypertension
- Dyslipidemia
- Chronic kidney insufficiency stage III in f/u renal ___
- GERD
Social History:
___
Family History:
No history of CKD, lung disease, or malignancies.
Physical Exam:
ADMISSION EXAM:
Vitals: 98.9, 73, 180/84, rr 12, 100% 40% FiO2
General: Intubated
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP difficult to assess, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: breath sounds are decreased at right base. no crackles or
wheezes
Abdomen: soft, non-distended, bowel sounds present, no
organomegaly, no tenderness to palpation, no rebound or guarding
GU: foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: sedated grossly intact
DISCHARGE EXAM:
VS: O2 sat mid 90's on 2L, Wt 162#
GEN: NAD
CHEST: CTAB
Pertinent Results:
___ 08:54PM TYPE-ART TIDAL VOL-380 PEEP-5 O2-30 PO2-73*
PCO2-50* PH-7.46* TOTAL CO2-37* BASE XS-9 -ASSIST/CON
INTUBATED-INTUBATED
___ 07:07PM TYPE-ART TEMP-36.7 ___ TIDAL VOL-350
PEEP-5 O2-40 PO2-85 PCO2-63* PH-7.37 TOTAL CO2-38* BASE XS-7
INTUBATED-INTUBATED
___ 06:49PM GLUCOSE-220* UREA N-55* CREAT-2.1* SODIUM-136
POTASSIUM-5.9* CHLORIDE-96 TOTAL CO2-26 ANION GAP-20
___ 06:49PM CALCIUM-9.6 PHOSPHATE-4.1 MAGNESIUM-2.0
___ 06:45PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 06:45PM URINE BLOOD-TR NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 06:45PM URINE RBC-7* WBC-2 BACTERIA-FEW YEAST-NONE
EPI-1 TRANS EPI-<1
___ 06:45PM URINE HYALINE-5*
___ 06:45PM URINE WBCCLUMP-RARE MUCOUS-RARE
___ 03:28PM LACTATE-1.0
___ 02:43PM ___ PO2-83* PCO2-114* PH-7.17* TOTAL
CO2-44* BASE XS-8 COMMENTS-GREEN TOP
___ 02:42PM TYPE-ART PO2-119* PCO2-99* PH-7.21* TOTAL
CO2-42* BASE XS-7 INTUBATED-NOT INTUBA
___ 02:30PM GLUCOSE-193* UREA N-53* CREAT-2.1* SODIUM-141
POTASSIUM-5.4* CHLORIDE-96 TOTAL CO2-37* ANION GAP-13
___ 02:30PM cTropnT-0.03*
___ 02:30PM proBNP-___*
___ 02:30PM WBC-6.5 RBC-3.02* HGB-7.9* HCT-27.9* MCV-92
MCH-26.1* MCHC-28.2* RDW-15.1
___ 02:30PM NEUTS-76.3* LYMPHS-16.7* MONOS-4.6 EOS-1.8
BASOS-0.5
___ 02:30PM PLT COUNT-397
___ 02:30PM ___ PTT-50.6* ___
___ 05:32AM BLOOD ___ pO2-243* pCO2-70* pH-7.35
calTCO2-40* Base XS-10
___: BLOOD CULTURES: NO GROWTH TO DATE ON DAY OF DISCHARGE
___: URINE CULTURE: Negative
___: MRSA SCREEN: Negative
CXR ___: Pulmonary edema, small bilateral effusions. If
there is oncern for pneumonia, recommend repeat chest radiograph
post-diuresis.
ECHO ___: IMPRESSION: Moderate LVH, normal regional LV wall
motion, and hyperdynamic LV systolic function. No significant
valvular disease. Moderate pulmonary hypertension.
Compared with the findings of the prior study (images reviewed)
of ___, there is moderate pulmonary hypertension but no
evidence of resting LVOT obstruction. The rest of the findings
are similar.
Brief Hospital Course:
___ year-old woman with severe COPD, OSA, afib, chronic diastolic
heart failure was admitted for acute hypercarbic respiratory
failure in the setting of her home BIPAP machine not functioning
properly. She was intubated in the ED and admitted to the ICU.
She quickly improved and was extubated the next day.
Antibiotics, steroids, and furosemide were stopped because her
presentation was not consistent with pneumonia or COPD flare.
She was stable while on BIPAP and then she was transferred to
the floor. On the floor she was at her baseline. She was
discharged with a new, functional BIPAP machine.
# Hypercarbic respiratory failure. ABG revealed peak pCO2 114.
She improved with intubation and mechanical ventilation.
# Severe COPD: Peak pCO2 114. Per pulmonary sleep service, she
should be on BIPAP with backup rate. Continue advair and other
regular inhalers and nebulizers. Patient will be seen in ___
clinic with close follow-up.
# Mild acute diastolic heart failure. CXR revealed mild
pulmonary vascular congestion. She was given some IV lasix while
in the ICU. On the floor she was euvolemic and continued on her
PO lasix. Continue benazepril and metoprolol.
# Atrial fibrillation: Rate controlled, in afib. Pt was
subtherapeutic on admission with INR of 1.9. Of note, during
admission of ___, her home dose was decreased from 5mg to 3mg
daily. When INR dipped below 2.0, warfarin was increased back to
5mg daily
# Sleep apnea on BiPAP
# Stage 3 CKD, stable.
# Anemia: normocytic, chronic. At baseline.
# Glaucoma: Continued latanoprost, apraclonidin, prednisolone.
# DM type II, on insulin, uncontrolled with complications,
stable
# Code status: Full code
TRANSITIONAL ISSUES:
- INR re-check on ___
- F/u in ___ clinic
- Consider pulmonary rehab
- F/u Blood cultures ___
Medications on Admission:
1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
2. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous
at bedtime.
3. linagliptin
Linagliptin 5mg daily
4. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day.
5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
6. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
7. apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily): left eye.
8. Combivent ___ mcg/actuation Aerosol Sig: One (1)
Inhalation every ___ hours as needed for shortness of breath or
wheezing.
9. prednisolone acetate 1 % Drops, Suspension Sig: One (1) drop
Ophthalmic once a day.
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
11. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
12. hydralazine 25 mg Tablet Sig: One (1) Tablet PO every six
(6) hours as needed for HTN: increased from q8 at home.
13. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime): right eye.
15. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
16. humalog sliding scale
QID ACHS. Please see attached sheet
17. warfarin
Please start warfarin 3mg daily when INR is <3. Please check INR
___
Discharge Medications:
1. BiPAP Machine
BiPAP ST ___ with backup rate of 8 with humidification and 3L
O2 titrated, Fisher and Paykel FFM, ICD9: 518.83 (chronic
respiratory failure).
2. Oxygen
Continuous oxygen ___ Liters/min for portability, pulse dose
system. Goal O2 sat 88-92%. ICD9: 491.21
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. Lantus 100 unit/mL Solution Sig: Eight (8) units Subcutaneous
at bedtime.
5. linagliptin 5 mg Tablet Sig: One (1) Tablet PO once a day.
6. benazepril 40 mg Tablet Sig: One (1) Tablet PO once a day.
7. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
8. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO twice a day.
9. apraclonidine 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY
(Daily).
10. Combivent ___ mcg/actuation Aerosol Sig: One (1)
inhalation Inhalation every ___ hours as needed for shortness of
breath or wheezing.
11. prednisolone acetate 1 % Drops, Suspension Sig: One (1) Drop
Ophthalmic DAILY (Daily).
12. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
13. fluticasone-salmeterol 500-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation BID (2 times a day).
14. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS
(at bedtime).
16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day) as needed for constipation.
17. Humalog 100 unit/mL Solution Sig: sliding scale as directed
Subcutaneous QAC and QHS.
18. warfarin 5 mg Tablet Sig: One (1) Tablet PO at bedtime.
19. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig:
One (1) Cap Inhalation DAILY (Daily).
20. Outpatient Lab Work
Check INR ___. Please fax the results to your PCP, ___.
___ at ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Acute hypercarbic respiratory failure
SECONDARY DIAGNOSES:
- Chronic obstructive pulmonary disease
- Obstructive sleep apnea
- Chronic diastolic heart failure
- Atrial fibrillation
- Chronic kidney disease, stage III
- Anemia
- Diabetes mellitus type II on insulin
- Glaucoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with respiratory failure and required
intubation (breathing tube) with mechanical ventilation. The
breathing tube was removed when you improved and you were then
further treated with BiPAP for your chronic respiratory
conditions.
HEART FAILURE MANAGEMENT INSTRUCTIONS:
Weigh yourself every morning. Call your doctor if your weight
goes up more than 3 lbs above your baseline (or lowest regular)
weight.
COPD AND SLEEP APNEA INSTRUCTIONS:
Use your BiPAP machine every night while you sleep.
ANTICOAGULATION INSTRUCTIONS:
You should go to the laboratory to have your INR re-checked on
___ at the ___ when you come in for your ___. Have the lab
fax the results should be faxed to your PCP, ___ at
___.
MEDICATION CHANGES:
- STOPPED Hydralazine
- No other changes were made to your medication regimen.
Followup Instructions:
___
|
19998350-DS-4 | 19,998,350 | 27,108,332 | DS | 4 | 2128-02-22 00:00:00 | 2128-02-24 09:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old gentleman with DMII and hypertension presented with
Substernal chest pain associated with SOB since the night prior
to day of admission, on/off for few seconds, worse with movement
or exertion. Reproducible pain with palpation of right chest
wall whenever having the pain. No history of chest trauma. No
diaphoresis, pain radiation or coughing. No presyncope or
symptoms with exertion. No PND, orthopnea or lower extremity
swelling. He has history of prior stress test in ___,
reportedly normal per in Atrius records. No prior history of
similar symptoms.
.
In the ED, initial vitals were 98.2 73 135/68 20 99% he
reported pain ___. Labs and imaging significant for Cr 1.0,
Trop < 0.01 x1, EKG showed NSR at 74 with LAE, LVH with strain,
TWI in II, II, aVL, V4-V6. Compaired with prior ___, TWI in
V4-V6 appear deeper. Her CXR showed moderately enlarged cardiac
silhouette (likely LVH), no CHF, no PTX; Patient given ASA
325mg, Nitro 0.4mgSL x2 without improvment in pain, the then
developed headache, he was given morphine 4mg IV with improvment
in chest pain, now only with chest pain when moving.
Cards seen the patient in the ED and recommended admission on
telemetry for observation with stress test.
.
Vitals on transfer were 98.1,79, 122/70, 19, 98%RA
.
On arrival to the floor, patient had 2 episodes of ___ seconds
of right lower chest pain that resolved spontaneously, otherwise
no complaints.
.
REVIEW OF SYSTEMS
On review of systems, he denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. he denies recent fevers, chills or rigors.
he denies exertional buttock or calf pain. All of the other
review of systems were negative.
.
Cardiac review of systems is notable for absence of dyspnea on
exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema,
palpitations, syncope or presyncope.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS: +Diabetes, -Dyslipidemia, +Hypertension
2. CARDIAC HISTORY:
-CABG:
-PERCUTANEOUS CORONARY INTERVENTIONS:
-PACING/ICD:
3. OTHER PAST MEDICAL HISTORY:
Chronic intractable pain
Colonic Adenoma
Vitamin D Deficiency
OBESITY - MORBID
ANEMIA, UNSPEC
SLEEP APNEA
ASTHMA
Impulse control disorder
Social History:
___
Family History:
Father Cancer; ___ - Unknown Type; Hypertension
Mother Alive CAD/PVD
Physical Exam:
Admission physical exam:
VS: T=98 BP=154/79 HR=80 bpm regular, RR= 14 O2 sat=100%RA
GENERAL: obese ___ gentleman in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 4 cm above sternal angle at 45 degrees.
CARDIAC: normal RR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. obese. No HSM or tenderness. + BS
EXTREMITIES: No c/c/e.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
.
Discharge physical exam:
VS: T=98.2 BP=144/81 (120's-150's/___'s-___'s), HR=67 (___)
bpm regular, RR= 14 O2 sat=96%RA
GENERAL: obese ___ gentleman in NAD. Oriented x3.
Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK: Supple with JVP of 4 cm above sternal angle at 45 degrees.
CARDIAC: normal RR, normal S1, S2. No m/r/g. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. obese. No HSM or tenderness. + BS
EXTREMITIES: No c/c/e.
PULSES:
Right: Carotid 2+ DP 2+ ___ 2+
Left: Carotid 2+ DP 2+ ___ 2+
Pertinent Results:
CBC:
___ 08:45AM BLOOD WBC-5.6 RBC-4.97 Hgb-13.1* Hct-39.8*
MCV-80* MCH-26.3* MCHC-32.8 RDW-13.4 Plt ___
.
Blood chemistry:
___ 08:45AM BLOOD Glucose-109* UreaN-14 Creat-1.0 Na-143
K-4.6 Cl-107 HCO3-30 AnGap-11
___ 06:20AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.9
.
Cardiac markers:
___ 01:50PM BLOOD CK-MB-6 cTropnT-<0.01
___ 08:45AM BLOOD cTropnT-<0.01
___ 08:45AM BLOOD CK-MB-7
___ 08:45AM BLOOD CK(CPK)-594*
___ 01:50PM BLOOD CK(CPK)-557*
.
Stress echo ___
The patient exercised for 7 minutes and 0 seconds according to a
Modified ___ treadmill protocol ___ METS) reaching a peak
heart rate of 130 bpm and a peak blood pressure of 160/90 mmHg.
The test was stopped at the patient's request. This level of
exercise represents a poor exercise tolerance for age. In
response to stress, the ECG showed non-diagnostic ST changes in
the setting of baseline abnormalities (see exercise report for
details). There is resting mild hypertension. The blood pressure
response to stress was blunted. Target heart rate was not
achieved. Echo images were acquired within 53 seconds after peak
stress at heart rates of 127 - 98 bpm. These demonstrated
appropriate augmentation of all left ventricular segments. There
was augmentation of right ventricular free wall motion.
IMPRESSION: Poor functional exercise capacity. Non-diagnostic
ECG changes in the setting of baseline abnormalities and the
absence of 2D echocardiographic evidence of inducible ischemia
to achieved workload. Resting hypertension. Abnormal hemodynamic
response to physiologic stress (blunted blood pressure
response). Target heart rate not achieved. Mild symmetric left
ventricular hypertrophy
.
Stress Test report ___:
INTERPRETATION: This ___ yo man with h/o HTN, NIDDM, former
smoker,
obesity, and family h/o premature CAD was referred to the lab
for
evaluation of chest discomfort. The patient exercised for 7
minutes of a
Modified ___ protocol and was stopped at the patient's request
for
fatigue. The peak estimated MET capacity was 4.9, which
represents a
poor exercise tolerance for his age. There were no reports of
chest,
back, neck, or arm discomforts during the study. There were
marked TWI
in the inferolateral leads at baseline, which did not normalize
with
exercise. At peak exercise, there was 0.5-1 mm ST segment
depression in
the inferolateral leads, resolving back to baseline by 2 minutes
of
recovery. Rhythm was sinus with no ectopy. The heart rate
response was
appropriate during exercise and recovery. Mild resting
hypertension with
a blunted blood pressure response during exercise.
IMPRESSION: In the presence of baseline STT abnormalities,
non-specific
EKG changes in the absence of anginal type symptoms at a
moderate
cardiac demand and poor functional capacity. Blunted blood
pressure
response to exercise in the setting of baseline hypertension.
Study
limited by patient's request. Echo report sent separately.
Brief Hospital Course:
___ year old gentleman with DMII and hypertension presented with
reproducible right lower sternal chest pain, negative troponins
and normal exercise test in ___, found to have slightly deeper
T wave inversions in V4-V6, was admitted to rule out ACS and to
have stress test. Stress echo was pursued which was not very
conclusive, however not concerning of coronary artery disease.
Discharged home in stable condition.
.
# CORONARIES: normal exercise test per report in ___. chest
pain atypical, very brief, reproducible. Tpn x2 negative. EKG
changes slightly worse given the worsened TWI in v4-v6. Atenolol
was held prior to ___ test. Stress echo was not very
conclusive (please see results section). We continued amlodipine
and hydrochlorothiazide for hypertension. Atenolol was resumed
on discharge after the stress test. We did not initiate statin
given his LDL in ___ was < 100. He is not no ACEi given
severe nausea in the past.
.
# DM-II: well controlled, last HA1c is 6.6%, on metformin. We
held metformin while in hospital and placed him on insulin
sliding scale. Metformin was resumed on discharge.
.
# Hypertension: on amlodipine and atenolol and HCTZ at home.
Held atenolol as above.
Medications on Admission:
-Cholecalciferol (Vitamin D3) 1,000 unit Cap 1 (One) Capsule(s)
by mouth once a day
-Hydrochlorothiazide 25 mg Tab 1 (One) Tablet(s) by mouth once a
day
-Amlodipine 10 mg Tab 1 (One) Tablet(s) by mouth once a day
-atenolol 25 mg Tab Oral 1 Tablet(s) Once Daily
-metformin 500 mg Tab Oral 1 Tablet(s) Once Daily
-Sildenafil (VIAGRA) 100 mg Oral Tablet (occasional use, last
use ___ month ago)
-Albuterol Sulfate (PROAIR HFA) 90 mcg/Actuation Inhalation HFA
Aerosol Inhaler inhale 2 puffs by mouth every 4 to 6 hours AS
NEEDED
Discharge Medications:
1. cholecalciferol (vitamin D3) 1,000 unit Capsule Sig: One (1)
Capsule PO once a day.
2. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
3. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day.
4. atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day.
5. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day.
6. sildenafil 100 mg Tablet Sig: One (1) Tablet PO once a day as
needed for erectile dysfunction: occasional use.
7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig:
Two (2) puff Inhalation every ___ hours as needed for shortness
of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
Chest pain - muskuloskeletal
Hypertension
.
Secondary Diagnoses:
Diabetes
Anxiety
Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr ___,
.
It was great pleasure taking care of you as your doctor.
.
As you know you were admitted to ___
___ chest pain. Your pain is believed to be
muskuloskeletal and not from your heart given the description of
your pain.
.
You had a stress echo test which was not very conclusive.
However, the findings were not concerning of heart vessel
disease.
.
We did not make changes in your medication list. Please continue
to take them the way you were taking prior to admission.
.
Please follow with your appointment as illustrated below.
Followup Instructions:
___
|
19998444-DS-11 | 19,998,444 | 21,096,018 | DS | 11 | 2155-06-10 00:00:00 | 2155-06-12 16:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo w/ETOH pancreatitis presents with abd pain and nausea
consistent with pancreatitis flare. Pt was dx in ___ with
chronic pancreatitis. Followed with GI (Dr. ___ and has
had stent placement in the past. However last stents in ___
increased his pain and were removed. He has been having
increasing frequency of flares for several months requiring
multiple admissions to multiple hospitals, most recently
admitted to ___ and discharged 3 days ago. Was tolerating PO
at that time and discharged with plan to get second opinion from
BID as outpatient. However on the day of admission pt developed
nausea and epigastric pain which radiates to his back. Denies
emesis, diarrhea, constipation, CP, SOB.
Pt does endorse an 80lb unintentional weight loss over the past
year which has not yet been evaluated.
All other ROS negative except as above.
Past Medical History:
-chronic ETOH pancreatitis
-h/o alcohol abuse, no use since ___
-GERD
-Hirshprung's
-- s/p colectomy as infant
-Multiple Hernias with repair in ___ and ___
-Tremor
-DJD of back
-- s/p L4&L5 laminectomy
-depression/axiety
Social History:
___
Family History:
mom w/GERD
Physical Exam:
Admission PE
VS 97.6 72 162/98 95% on RA Pain ___
GEN: nad, lying in bed
HEENT: op clear, mmm
NECK: no LAD, supple
CHEST: ctab
SKIN: no rashes or bruises
CV: rrr no m/r/g
ABD: hypoactive BS, nondistended, soft, tender RUQ
EXT: wwp, no e/c/c
NEURO: alert, answers questions apprpropriately, moving all
extremities
PSYCH: appropriate, cooperative
.
Discharge PE
VSS
General: AAOX3, somewhat tired but otherwise wnl
Abdomen: active BS X4, no HSM, mild point TTP in the right
periumbilical area
Pertinent Results:
___ 09:50PM GLUCOSE-119* UREA N-16 CREAT-0.7 SODIUM-141
POTASSIUM-4.1 CHLORIDE-106 TOTAL CO2-26 ANION GAP-13
___ 09:50PM ALT(SGPT)-52* AST(SGOT)-27 ALK PHOS-67 TOT
BILI-0.3
___ 09:50PM LIPASE-45
___ 09:50PM WBC-10.5 RBC-5.24 HGB-15.6 HCT-46.2 MCV-88
MCH-29.7 MCHC-33.7 RDW-13.7
.
RUQ US ___
IMPRESSION:
1. No sonographic evidence of cholelithiasis.
2. Splenomegaly.
.
AXR ___
IMPRESSION: Dilated loops of small and large bowel, concerning
for possible
cecal volvulus. Recommend followup CT scan to further
characterize. These
findings were communicated with Dr. ___ at 4:50
p.m. today.
.
___ CXR
IMPRESSION: No acute cardiopulmonary process. No evidence of
free air.
.
CT AP ___
IMPRESSION:
1. No acute abdominal pathology, especially no evidence of
bowel obstruction.
2. No CT evidence of acute or chronic pancreatitis.
.
Scrotal US ___
IMPRESSION: Normal scrotal ultrasound without evidence of
testicular mass or
torsion.
.
___, RF and ANCA negative
.
Hepatitis A, B and C serologies negative
.
TTG-negative
.
___ 06:10
IGG SUBCLASSES 1,2,3,4
Test Result Reference
Range/Units
IMMUNOGLOBULIN G SUBCLASS 1 310 L 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 208 L 241-700 mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 57 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 16.6 4.0-86.0 mg/dL
IMMUNOGLOBULIN G, SERUM 639 L ___ mg/dL
.
Porphobilinogen Screen NEGATIVE
.
___ 7:38 am SEROLOGY/BLOOD CHEM# ___ ___.
**FINAL REPORT ___
HELICOBACTER PYLORI ANTIBODY TEST (Final ___:
NEGATIVE BY EIA.
(Reference Range-Negative).
.
TFT's wnl
.
Brief Hospital Course:
___ yo w/ previous diagnosis of ETOH pancreatitis presents with
nausea and abdominal pain consistent with pancreatitis flare
with a normal lipase and CT showing no evidence of chronic
pancreatitis.
.
# Abdominal pain with prior diagnosis of alcoholic related
chronic pancreatitis:
The patient has a history of abdominal pain and a diagnosis of
pancreatitis going back to ___ which prior to this admission
has been managed by outside providers. He has had an increase
in his flares recently and this has caused him to go to multiple
hospitals for this. As evidence by the records obtained from
his outside GI physician, ___ has had several
stents placed with varying degrees of success. He has also had
imaging done outside that has not shown findings consistent with
chronic pancreatitis. As a result, the differential diagnosis
of his abdominal pain was broadened to include cecal volvulus,
constipation related, acute intermittent porphyria, autoimmune
vasculitis or SLE/RA related, hernia related, PUD or IBS/IBD.
GI was consulted in house and advised checking a TTG for celiac
disease (negative) ESR/CRP (CRP was elevated) and IGG4 for
autoimmune pancreatitis (negative). Due to persistent abdominal
pain, the patient got a plane film abdominal XR which showed
findings suggestive of cecal volvulus. A CT of the abdomen and
pelvis was obtained which was negative for an acute process.
These films were reviewed with the radiologist to evaluate a
narrowed and dilated segment near the patients prior colostomy
but they felt this was just several slices missed in the CT
scanner. The patient also had a RUQ US which was wnl.
Hepatitis serologies, RF, ___ and ANCA were also done and were
negative. H. pylori serology was negative. The patient
endorsed persistent pain and was treated with a morphine pca for
several days and made npo and given IV fluids. The patients
pain marginally improved. His diet was slowly advance, which he
tolerated well. He was discharged home on a bland diet and a
PPI BID. He should follow closely with a pancreas specialist
for further evaluation.
.
# History of alcoholism with persistent pain without an obvious
organic cause:
The patient reports not using alcohol since ___. The patients
family voiced some concerns about narcotic/opioid dependence.
In addition, after extensive evaluation and conservative
management, the patient was still requiring high dose of IV
morphine (in the 200-300 mg IV range in 24 hours) from his PCA
without any obvious cause. The pain service was consulted and
they advised using gabapentin, Tylenol and discontinuing the pca
and using both long and short acting morphine. The day
following removal of the PCA, the patient had a minimal narcotic
requirement. Thus, he was sent home with just short acting
morphine for breakthrough pain in addition to a lower dose of
gabapentin to prevent sedation. He was also sent home with
NSAID's, tramadol and a bowel regimen.
.
# Urinary retention
The patient has had issues with this in the past without any
obvious cause. His retention was exacerbated with his high
narcotic use. A Foley needed to be placed. The patient was
weaned off his narcotics and his Foley was then taken out. He
was able to urinate on his own
.
# Schistocytes on automated smear and persistent abdominal pain
with weight loss
The hematology/oncology service was consulted for further
evaluation of an occult malignancy vs. a hematologic process
that was causing the patients symptoms. The patients smear was
reviewed by the hematology team and it was negative for
schistocytes. They recommended checking urine PBG (was
negative) and a testicular US for occult malignancy (negative).
Can consider checking 24 hr urine test for ALA, PBG, and total
porphyrins as an outpatient. LDH was also normal and the
patients smears did not show any signs of MDS or
myeloproliferative disorder.
.
# Dysthymia
The patient endorsed depressed mood without SI or HI.
Psychiatry was consulted per pain recommendations and they
recommended d/c of the patients hydroxyzine and starting Remeron
at night. The patient should follow up with his psychiatrist as
an outpatient.
.
# Transitional Issues:
-Follow up with PCP ___ ___ weeks, Psychiatry in ___ weeks and GI
in ___ weeks
.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Duloxetine 60 mg PO DAILY
2. Omeprazole 20 mg PO BID
3. Creon 12 1 CAP PO TID W/MEALS
4. HydrOXYzine 50 mg PO QHS:PRN insomnia
5. Propranolol 10 mg PO TID
6. Nicotine Patch 21 mg TD DAILY
Discharge Medications:
1. Duloxetine 60 mg PO DAILY
2. Omeprazole 20 mg PO BID
3. Creon 12 1 CAP PO TID W/MEALS
4. Propranolol 10 mg PO TID
5. Nicotine Patch 21 mg TD DAILY
6. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*100 Tablet Refills:*0
7. Bisacodyl 10 mg PO DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
9. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
10. Gabapentin 300 mg PO TID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*90 Capsule Refills:*0
11. Ibuprofen 600 mg PO Q8H:PRN moderate pain
RX *ibuprofen 200 mg 3 tablet(s) by mouth every eight (8) hours
Disp #*100 Tablet Refills:*0
12. Mirtazapine 7.5 mg PO HS
RX *mirtazapine 7.5 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
13. Morphine Sulfate ___ 15 mg PO Q6H:PRN severe pain
RX *morphine 15 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
14. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 packet by mouth once a
day Disp #*30 Packet Refills:*0
15. Tamsulosin 0.4 mg PO HS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once a day Disp #*30
Tablet Refills:*0
16. TraMADOL (Ultram) 50 mg PO Q8H:PRN moderate pain
RX *tramadol 50 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
acute on chronic abdominal pain of unknown etiology, possibly
due to fecal loading and constipation
.
Secondary Diagnosis:
Depression
Anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for management of acute on chronic abdominal
pain, and you improved with IVF, bowel rest, and pain control.
You saw the GI physicians during your course and got a CT scan
which did not show any acute changes. You were also seen by the
Hematology team who recommended a scrotal ultrasounds. This was
also normal. You were able to tolerate a diet, your pain was
controlled on by mouth medications and were agreeable to
discharge. You should follow up with your physicians as
scheduled below.
.
Medication Changes:
1) please stop your hydroxyzine
2) remeron 7.5 QHS
3) tylenol ___ Q8H standing for pain
4) ibuprofen 600 Q6H prn mild pain
5) gabapentin 300 TID, standing for pain
6) tramadol 50 Q6H prn moderate pain
7) morphine ___ 15 mg PO Q6H prn severe pain
8) docusate 100 mg BID, standing for constipation
9) miralax 17 g QD prn, please take when no BM X2 days
10) bisacodyl 10 mg QD prn, please take when no BM X 2 days
11) finasteride 5 QD for urinary retention
12) flomax .4 QD, for urinary rention
Followup Instructions:
___
|
19998444-DS-13 | 19,998,444 | 29,729,593 | DS | 13 | 2156-01-15 00:00:00 | 2156-01-15 23:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
Abdominal pain, alcohol binge
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: Mr. ___ is a ___ man with a h/o childhood
Hirshsprung's s/p
resection, EtOH abuse, and GERD with multiple recent
hospitalizations for recurrent abdominal pain, who p/w
periumbilical abdominal pain after an alcohol binge. He said
the pain began yesterday evening after he drank ___ beers and
several glasses of hard liquor as a way of coping with stress.
He reports a history of chronic pancreatitis s/p ERCP with stent
placement that transiently improved his symptoms. He had a
second ERCP with sphincterotomy and biliary/PD stent placement,
but had the stents removed when his postprandial abdominal pain
did not resolve. He has had numerous CTs, MRIs, and MRCPs at
many different hospitals per outpatient GI docs report without
evidence for acute or chronic pancreatitis on those evaluations.
Last hospitalization for abdominal pain was in ___ at
___ for which he was conservatively managed with analgesia and
IVFs with subsequent improvement and resolution of symptoms. Of
note, he also says he underwent an inguinal hernia repair ___
one to date) on ___ at an OSH c/b immediate readmission for
abdominal pain.
On admission, he reports inability to tolerate POs, with some
intermittent constipation, but no D/N/V/F/C. No AH/VH/SI/HI.
Last bowel movement was yesterday and was nonbloody. No
CP/SOB/F/C.
In the ED, initial vitals: 8 96.8 101 128/77 20 96% RA. He was
given IVF, pain control, and made NPO with negative RUQ u/s for
any e/o CBD dilatation or gallstones. However there was
splenomegaly.
Transfer vitals were: Vitals prior to transfer: 7 98.1 72 142/70
18 100%. On arrival to the floor, still c/o epigastric
abdominal pain ___. No N/V/F/C. No tremors or AH/VH/SI/HI.
Last bowel movement was yesterday and was nonbloody.
Past Medical History:
-h/o alcohol abuse, no use since ___
-GERD
-Hirshprung's
-s/p colectomy as infant
-Multiple Hernias with repair in ___ and ___
-Tremor
-DJD of back
-s/p L4&L5 laminectomy
-depression/axiety
-inguinal hernia repair in ___
Social History:
___
Family History:
mother w/GERD
Physical Exam:
PHYSICAL EXAM:
VS - Temp 97.8 F, BP 118/65, HR 86, R 16, O2-sat 94%RA
GENERAL - NAD, A&Ox3
HEENT - NC/AT, EOMI, sclerae anicteric, dry MM
NECK - supple, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft, TTP over supraumbilical area, R costal
margin, and inguinal area. Well-healed surgical scars. No
rebound/guarding, no CVAT.
EXTREMITIES - WWP 2+ peripheral pulses bilaterally, no c/c/e.
SKIN - no concerning rashes or lesions, all existing scars were
free of any evidence of disease.
NEURO - CNII-XII grossly intact, motor function grossly normal.
Pertinent Results:
___ 08:15AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 08:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 07:08AM LACTATE-2.1*
___ 06:28AM GLUCOSE-119* UREA N-14 CREAT-0.7 SODIUM-146*
POTASSIUM-3.6 CHLORIDE-108 TOTAL CO2-22 ANION GAP-20
___ 06:28AM ALT(SGPT)-21 AST(SGOT)-21 ALK PHOS-83 TOT
BILI-0.2
___ 06:28AM LIPASE-35
___ 06:28AM ALBUMIN-4.4 CALCIUM-9.0 PHOSPHATE-3.9
MAGNESIUM-2.2
___ 06:28AM ___
___ 06:28AM WBC-8.5 RBC-5.01 HGB-14.9 HCT-45.2 MCV-90
MCH-29.7 MCHC-33.0 RDW-13.2
___ 06:28AM NEUTS-55.1 ___ MONOS-5.6 EOS-5.9*
BASOS-1.3
___ 06:28AM PLT COUNT-205
Imaging
IMPRESSION:
1. Normal gallbladder and CBD.
2. Splenomegaly.
Brief Hospital Course:
___ man with a h/o childhood Hirshsprung's s/p
resection, EtOH abuse, and GERD who p/w periumbilical abdominal
pain after an alcohol binge.
# Abdominal Pain: Patient was admitted on ___ for epigastric
abdominal pain after alcohol binge, without evidence of acute
pancreatitis clinically, on imaging or by laboratory studies
(CBC, lipase, LFTs, LDH wnl on admission). No AH/VH/tremors.
No hernias on exam. In the ED, he was started on IVF, pain
control with IV morphine, and made NPO for bowel rest. RUQ u/s
was performed and was negative for CBD dilatation or gallstones.
His symptoms improved with pain control with oxycodone 5 mg,
and we advanced his diet gradually from clears to regular diet,
which he tolerated well.
# Substance abuse/dependence: Recurrent lapses of alcohol
binging followed by acute abdominal pain, but no h/o withdrawal
seizures. Binge drinking as a way to cope with stressors at
home. Patient endorses a history of EtOH abuse, with recent
rebounding of multiple episodes of abuse. There is a history of
opiate abuse as well. He did not exhibit any symptoms of
withdrawal during his hospitalization from ___, and was
scoring a CIWA of 0. He was supplemented with folate, thiamine,
and MVI.
# h/o urinary retention during prior hospitalizations. Patient
reported that foley catheter was helpful in the past. Given his
history of urinary retention, we monitored daily his I/Os with
special attention to UOP.
# Depression/Anxiety: No SI or HI on admission. Reports
intermittently taking cymbalta at home due to insurance issues.
We continued him on his cymbalta with good effect.
# GERD: Patient has a history of GERD. We continued him on his
home PPI during his hospitalization.
Transitional Issues:
1. f/u with Gastroenterology re: recurrent abdominal pain
2. f/u with PCP
___ on ___:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Gabapentin 300 mg PO BID
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Creon 12 1 CAP PO TID W/MEALS
5. Duloxetine 60 mg PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Creon 12 1 CAP PO TID W/MEALS
3. Duloxetine 60 mg PO DAILY
4. Gabapentin 300 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin [Chewable Multi Vitamin] 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*3
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___
___. You came in with abdominal pain.
While you were here, we controlled your pain, gave you fluids,
and had you not eat to allow your bowel to rest. You improved
with pain control, fluids, and bowel rest such that you were
able to tolerate food without increased pain. There were no
concerning events on your abdominal ultrasound and lab testing
was all reassuring. It is important that you do not consume
alcohol, as this can trigger these episodes of abdominal pain.
We would like you to follow up with gastroenterology and PCP
following your discharge for further management and evaluation
of your recurrent abdominal pain. No changes were made to your
home medications.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19998497-DS-7 | 19,998,497 | 27,909,016 | DS | 7 | 2144-01-17 00:00:00 | 2144-01-17 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
___ L hip TFN
History of Present Illness:
___ with PMH significant for R THA ___ ___ at ___)
complicated by perioperative MI and ___ 6 presents as OSH
transfer complaining of L hip pain. Patient was attempting to
use the bathroom at approximately 630PM tonight when she missed
the toilet bowl and fell onto her L hip. She denies headstrike
or LOC and experienced immediate onset of L hip pain. She was
taken initially to ___ in ___ where ED workup
included L hip films that reportedly revealed a L
intertrochanteric hip fracture. She was subsequently
transferred to ___ for further management.
Past Medical History:
Cardiac Risk Factors: +Diabetes, +Dyslipidemia, +Hypertension
.
Percutaneous coronary intervention, in ___, anatomy as
follows: 3VD CAD s/p NSTEMI with BMSx2 to LCx and RCA
(___),
rota-ablation and DES to mid LAD on (___), DES to mid RCA
(___), DES to diagonal-2 and OM-2 (___).
.
Additional Past Medical/Surgical History:
- Hyperlipidemia
- Hypertension
- Diabetes, type II
- CRI (baseline creatinine 1.3-1.4)
- Peripheral arterial disease
- Paget's disease
- Osteoporosis
- Arthritis
- Mild Mitral Valve Prolapse
- S/P cataract surgery
- S/P right hip replacement on ___
- Hysterectomy
Social History:
___
Family History:
No family history of heart disease. Lung ca in father, gastric
cancer in mother. Sister with angina now s/p pacemaker. Son
alive and healthy.
Physical Exam:
admit:
GEN: Well appearing, NAD
AVSS
Left lower extremity:
Skin intact
Tenderness to palpation appreciated over the anterior and
lateral hip
Pain with movement of the LLE
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
d/c:
GEN: Well appearing, NAD
AVSS
Left lower extremity:
incision c/d/i
___ fire
+SILT SPN/DPN/TN/saphenous/sural distributions
___ pulses, foot warm and well-perfused
Pertinent Results:
___ 11:29AM URINE HOURS-RANDOM
___ 11:29AM URINE UHOLD-HOLD
___ 01:40AM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 01:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 01:40AM URINE RBC-1 WBC-60* BACTERIA-FEW YEAST-NONE
EPI-<1
___ 12:40AM GLUCOSE-197* UREA N-46* CREAT-1.4* SODIUM-141
POTASSIUM-4.4 CHLORIDE-107 TOTAL CO2-21* ANION GAP-17
___ 12:40AM estGFR-Using this
___ 12:40AM CK(CPK)-133
___ 12:40AM CK-MB-6 cTropnT-<0.01
___ 12:40AM WBC-12.4*# RBC-2.92* HGB-9.0* HCT-27.6*
MCV-95# MCH-30.7 MCHC-32.4 RDW-13.3
___ 12:40AM NEUTS-88.2* LYMPHS-7.9* MONOS-2.8 EOS-0.7
BASOS-0.3
___ 12:40AM PLT COUNT-171
___ 12:40AM ___ TO PTT-UNABLE TO ___
TO
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have L hip fx and was admitted to the orthopedic surgery
service. The patient was taken to the operating room on
___ for L hip TFN, 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 rehab
was appropriate. Pt w some word finding difficulty AM of POD1 -
head CT at that time was negative, likely delayed anesthetic
effect. Pt also w anemia at baseline, exacerbated by surgery -
was transfused 1u PRBC intraoperatively as well as 2u PRBC
post-operatively with appropriate bump in Hct which then
remained stable. 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 WBAT in the LLE, and will be
discharged on lovenox 40mg x2wks 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. Clopidogrel 75 mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Rosuvastatin Calcium 40 mg PO DAILY
4. Aspirin 81 mg PO BID
5. Vitamin D 1000 UNIT PO DAILY
6. Docusate Sodium 100 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO BID
2. Atenolol 50 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Rosuvastatin Calcium 40 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Acetaminophen 1000 mg PO Q8H
8. Ciprofloxacin HCl 250 mg PO Q24H Duration: 7 Days
9. Enoxaparin Sodium 40 mg SC Q24H Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
10. Senna 1 TAB PO BID
11. Milk of Magnesia 30 ml PO BID:PRN Constipation
12. Polyethylene Glycol 17 g PO DAILY
13. OxycoDONE (Immediate Release) 2.5 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
L intertrochanteric hip fracture
Discharge Condition:
stable
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:
- 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.
ACTIVITY AND WEIGHT BEARING:
- WBAT LLE
Physical Therapy:
Activity: Activity: Out of bed w/ assist
Right lower extremity: Full weight bearing
Left lower extremity: Full weight bearing
Encourage turning, deep breathing and coughing qhour when awake.
Treatments Frequency:
Site: L HIP
Description: s/p l HIP TFN, CDI
Care: Daily dressing changes
Followup Instructions:
___
|
19999068-DS-14 | 19,999,068 | 21,606,769 | DS | 14 | 2161-09-02 00:00:00 | 2161-09-02 14:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
alcohol withdrawal, delirium tremens
Major Surgical or Invasive Procedure:
endotracheal intubation ___
History of Present Illness:
Pt is a ___ yo male with a h/o etoh abuse transferred from ___
___ for etoh withdrawal and question of intraventricular
hemorrhage. Pt was found down with a right forehead abrasion and
reported at the OSH that he tripped and fell on pavement. He
denies any loss of consciousness. Head and C-spine at the OSH
were concerning for possible intraventricular hemmorhage. He was
hypertensive, tachycardic and hyperpertensive and there was
concern for alcohol withdrawal and he was given 1 mg of ativan
at the OSH before transfer. His potassium was also found to be
2.9 and he was given 40 mEq K in his IVF.
.
On arrival to ___, his initial VS were 150, RR: 22, BP:
152/93, O2Sat: 97 on 2 L NC. He was tremulous and agitated
requiring 5 people to place him in restraints. In the ED he was
given 28 mg of IV lorazepam within the first 30 minutes. He
received a total of 36 mg iv lorazepam. His OSH head showed
focal rounded area of hyperdenisity within temporal horn of L
lateral ventricle, may represent acute IV
hemorrhage.Neurosurgery evaluated the pt and recommended loading
with dilantin 750 mg iv x1. He also received IVF with thiamine
and folic acid. Repeat K here was 3.6. Prior to transfer his, BP
dropped to 50/57 and his dilantin infusion was slowed. His VS
prior to transfer were: 98 °F, P: 67, RR: 15, BP: 89/58, O2 Sat
100% on 2 L NC.
.
On arrival to the ICU, patient was tremulous, unable to assess
for pain.
Past Medical History:
EtOH dependence, h/o withdrawal
Hypertension
GERD
HCV
Social History:
___
Family History:
noncontributory
Physical Exam:
On admission:
Vitals: T: 96.9 BP: 133/82 P: 95 R: 10 O2: 98% 2L NC
General: tremulous on arrival and mumbled speech then obtunded
HEENT: large contusion over right forehead, Sclera anicteric,
dry MM, oropharynx clear
Neck: c- collar in place
Lungs: Clear to auscultation over anterior chest
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Pupils 3 mm ->1 mm bilaterally, equally reactive,
initially moving all extremites with tremor, then with rest,
withdraws to pain equally in all extremities
.
Pertinent Results:
ADMISSION LABS:
___ 03:45AM BLOOD WBC-6.1 RBC-3.67* Hgb-12.3* Hct-36.8*
MCV-100* MCH-33.6* MCHC-33.4 RDW-12.2 Plt ___
___ 03:45AM BLOOD Neuts-78.9* Lymphs-11.9* Monos-8.3
Eos-0.2 Baso-0.7
___ 03:45AM BLOOD ___ PTT-27.3 ___
___ 03:45AM BLOOD Glucose-139* UreaN-7 Creat-0.8 Na-136
K-3.6 Cl-100 HCO3-22 AnGap-18
___ 03:45AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.4*
TOXICOLOGY:
___ 03:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
MICROBIOLOGY:
MRSA SCREEN: NEGATIVE
IMAGING:
___ CXR: Compared to the previous radiograph, there is a
subtle right medial and basal opacity, consistent with
aspiration in the appropriate clinical setting. Otherwise,
unchanged normal chest radiograph with normal size of the
cardiac silhouette. The observation was made at 10:08 a.m. on
___ and the findings were communicated at the same
time to the referring physician, ___ the findings were
discussed over the telephone.
___ CXR: AP single view of the chest has been obtained with
patient in
semi-upright position. Comparison is made with the next previous
similar
study of ___. On previous examination identified
right lower
parenchymal density partially overshadowed by the heart contours
and
apparently located in the right lower lobe posterior segment has
cleared up. No new pulmonary abnormalities are identified and no
pulmonary vascular congestion is found. Similar as on the
preceding examination of ___, there is a rounded mass
overlying the contour of the ascending arch. This abnormality
has not changed significantly since yesterday. Comparison with a
supine chest examination transferred from ___,
this mass is new. Unfortunately, the transferred image is not
identified by date.
___ CXR: Patient with alcohol withdrawal and concern for
aortic
dissection, intubated for sedation for CT.
Comparison is made with prior study performed five hours
earlier.
ET tube tip is in standard position, 4.2 cm above the carina.
There are lower lung volumes with increasing bibasilar
opacities. There is no evident pneumothorax. Cardiomediastinal
silhouette is unchanged.
___ CTA CHEST: 1. No acute aortic pathology. No CT
abnormality to account for the radiographic abnormality
described on chest radiographs ___.
2. Bibasilar atelectasis with volume loss in the lower lobes
bilaterally.
Supervening aspiration cannot be excluded. No pneumonia.
Secretions in the left main stem bronchus.
3. 4-mm right middle lobe nodule. If the patient has no risk
factors for
malignancy, no followup is needed. If the patient has risk
factors for
malignancy, followup with dedicated chest CT in one year is
recommended if there is no prior imaging documenting stability.
4. Fatty liver.
___ CT HEAD: IMPRESSION: Study is somewhat limited by
motion; within this limitation, no acute abnormality is seen.
ATTENDING NOTE: Study limited. Outside CT shows blood near left
temporal horn which is not apparent on current study. The scalp
hematoma is decreased.
.
___ CT HEAD:
IMPRESSION: No acute intracranial hemorrhage or mass effect.
Previously seen left temporal horn blood products are no longer
present.
Brief Hospital Course:
HOSPITAL COURSE:
Patient is a ___ yo male with history of alcohol abuse who was
brought to OSH after fall and found to be in ETOH withdrawal at
OSH with question of intraventricular hemorrhage and transferred
to ___ for further eval who required 36 mg iv lorazepam in the
ED for signs of ETOH withdrawal, intubated for CTA given concern
for question of aortic dissection and for increasing agitation.
Patient was kept on propofol and IV ativan prn while intubated.
He was started on standing ativan for agitation and extubated
successfully on ___.
.
# Alcohol withdrawal/Delirium Tremens: Patient had evidence of
delirium tremens and severe alcohol withdrawal in the ED with
tachycardia to 150s, BP to 153/93, agitation and question of
hallucinations. He received 36 mg iv lorazepam in ED. Patient
was first maintained on IV ativan prn on CIWA, however, he
required increasing doses of IV ativan, up to 16 mg at a time.
He was intubated and placed on propofol gtt with prn ativan for
increasing agitation, and for the need for CTA of chest (as
below) given question of aortic dissection. His agitation and
ativan requirement decreased over time and he was started on
standing PO ativan and extubated successfully. He was started
and continued on thiamine, folate and MVI daily. His Mg and K
were repleted aggressively throughout the hospital stay. He
required intermittent doses of IV haldol for acute agitation. Pt
remained stable and was transferred to the floor ___.
.
# Intraventricular hemorrhage vs contusion s/p fall: Patient
presenting to outside ED with evidence of trauma given his large
R forehead hematoma and lacerations on extremities. CT head was
done at OSH and showed possibility of intraventricular
hemorrhage and transferred to ___ for neurosurgery eval.
Patient seen in ED by neurosurgery who reviewed the imaging,
which showed a hypodensity in R temporal horn. C-spine was
cleared by CT and by exam. It was thought to be due to artifact
and no hemorrhage seen. He had no edema on head CT from OSH.
Neurosurgery recommended Dilantin 100 mg q8hrs x7 days for
prophylaxis. Patient had an episode of oversedation and
unresponsive, and given change on neuro exam on ___, repeat
head CT was obtained without acute abnormality. Had f/u head CT
on ___, which continues to show no evidence of acute
abnormaility or bleed.
.
# Question of aortic dissection: Patient has a new finding on
CXR of potential aortic dissection. Given discordant blood
pressure of 150/90 right arm and 130/85 left arm, and as patient
was unable to relate clear history given his agitation, he was
intubated and CTA of chest was obtained. The imaging did not
show aortic dissection.
.
# History of GERD: Pt has hx of GERD per OSH, on pantoprazole
daily per OSH record. He was continued on pantoprazole in house.
.
# Social: patient reports living in a house with a girlfriend,
and also reports a daughter. Unable to contact any of these
people, social work was consulted to assist with locating family
members and to assist with his alcohol dependence. Daughter was
able to be located, is amenable to becoming health care proxy.
#Conjunctivitis: erythema, injection, and exudate on R eye
present on ___. Rx for erythromycin drops started
Medications on Admission:
none known
Discharge Medications:
1. erythromycin 5 mg/gram (0.5 %) Ointment Sig: One (1)
Ophthalmic QID (4 times a day).
Disp:*1 tube* Refills:*0*
2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*0*
3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Alcohol withdrawal
Acute delirium
HCV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Discharge Instructions:
You were admitted with a fall while intoxicated. You were sent
here as there was concern that you had bleeding in your brain.
Your follow-up head imaging showed resolution of bleeding in
your brain. You were briefly on precautionary (prophylactic)
anti-seizure medication. You were seen by the S/W regarding
your alcohol abuse history, and you were provided with
information regarding resources for alcohol abuse treatment.
You Should not be driving.
Medication changes:
STARTED Thiamine and Folate
Started Erythromycin eye ointment
Followup Instructions:
___
|
19999287-DS-7 | 19,999,287 | 22,997,012 | DS | 7 | 2197-07-31 00:00:00 | 2197-08-01 17:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
___
1. Flexible and rigid bronchoscopy
2. Cryodebridement and cryobiopsies of LMSB tumor
3. APC
4. EBUS TBNA 10L
5. Deployment and revision of 14 x 30 covered Ultraflex LMSB
stent
History of Present Illness:
Ms. ___ is a ___ with a history of COPD, T1 N0 poorly
differentiated squamous cell carcinoma s/p RUL lobectomy and
mediastinal LN dissection in ___ recent recurrence s/p
Cyberknife and now with mediastinal and hilar LAD concerning for
progression of disease who was scheduled for an IP procedure
___ who presents with worsening shortness of breath over the
past few days.
In review of her records, a PET-CT from ___ showed
a lesion in the left lower lobe which may represent residual
squamous cell carcinoma and FDG avid left hilar adenopathy which
almost certainly represents nodal metastases from this lesion.
There is also definite narrowing of the left upper lobe bronchus
and possibly some narrowing of the left lower lobe bronchus. Dr.
___ IP was following with a plan for bronchoscopy with
biopsy and possible dilatation and stent placement if the
bronchoscopy confirms significant bronchial narrowing. She has
had a three-segment resection on the right and now has
significant bronchial narrowing on the left radiographically.
She was seen recently at ___ at ___ and treated with
azithromycin and prednisone which finished ___. ___ she saw
Rad-Onc here (had recently been treated with Cyberknife) and
they are planning further chemo/xrt pending her bx results.
Per her nephew who was with her in the ED, he had been
encouraging her to seek care of the past few days for
hemoptysis, and convinced her to call EMS today. When they
arrived she was satting in the 70's which improved to low 80's
after a neb. On arrival in our ED initial vitals were 98.9, 108,
125/54, 20, 87% Non-Rebreather. On exam she was using accessory
muscles, but clear on exam. CXR was concerning for hilar mass.
IP was contacted since she was scheduled for stent placement
today; they will keep her on the schedule, suggested Heliox if
necessary. She was tried on non-invasive but was dyssynchronous
and sats decreased to 70's and was put back on a non-rebreather
where she is satting low 90's, still using accessory muscles.
Received cefepime and vancomycin for post-obstructive pneumonia,
vancomycin ordered. Has 2 18g IV's. Per ED she is confirmed full
code, okay to intubate. Labs in our ED significant for WBC 20.2,
hgb 14.5, plt 308, 86%N. VBG ___ then 7.49/31, INR 1.2, blood
and urine cx obtained. Lactate 1.8.
On arrival to the MICU she complains of continued shortness of
breath and some chest/back pain worsened with cough and deep
breaths.
Review of systems:
(+) Per HPI, in addition some weight loss
(-) Denies fever, chills, night sweats. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denies palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
COPD, Pulmonary function tests on ___ showed an FEV1 of
1.13 L or 49% of predicted and compatible with severe
obstructive ventilatory defect.
HLD
DM
arthritis
h/o spine surgery
SCC / lung cancer s/p VATS and mediastinal LN dissection ___,
with recurrence s/p Cyberknife ___
Social History:
___
Family History:
Non-contribitory
Physical Exam:
Admission Physical Exam:
=========================
Vitals- T: 98.4 HR 100 bp 106/86 rr 21 sat 88% on NRB
GENERAL: Alert, oriented, speaking in short sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: no wheezes or crackles, slightly diminished on the L side
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
NEURO: aox3, mae
Discharge Physical Exam:
=========================
Vitals: 98.4, afebrile overnight, 126/71; ___ 86;
___ 16 96% 3L
GENERAL: Alert, oriented, speaking in short sentences
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: rhonchi bilaterally, no wheezing, decreased breath sounds
on the R
CV: Regular rate and rhythm, normal S1 S2, 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
NEURO: aox3, no focal deficits
Pertinent Results:
Admission labs:
================
___ 03:10AM BLOOD WBC-20.2*# RBC-4.50 Hgb-14.5 Hct-41.8
MCV-93# MCH-32.2* MCHC-34.6 RDW-13.4 Plt ___
___ 03:18AM BLOOD Lactate-1.8
___ 03:18AM BLOOD ___ pO2-32* pCO2-31* pH-7.49*
calTCO2-24 Base XS-0
___ 03:10AM BLOOD Glucose-136* UreaN-18 Creat-0.9 Na-135
K-4.6 Cl-98 HCO3-22 AnGap-20
___ 03:20AM BLOOD ___ PTT-27.5 ___
Discharge labs:
================
___ 08:00AM BLOOD WBC-9.6 RBC-3.47* Hgb-11.0* Hct-32.8*
MCV-95 MCH-31.8 MCHC-33.6 RDW-14.0 Plt ___
___ 08:00AM BLOOD Glucose-98 UreaN-9 Creat-0.7 Na-138 K-4.1
Cl-104 HCO3-27 AnGap-11
___ 08:00AM BLOOD Calcium-9.7 Phos-3.1 Mg-1.9
RELEVANT LABS:
===============
___ WBC-20.2
___ WBC-9.6
___ ___ pO2-32* pCO2-31* pH-7.49* calTCO2-24 Base XS-0
Images:
A chest x-ray on ___ showed a 2.2 x 1.4 cm opacity over
the left cardiac apex and possible other small nodules in the
left lower lobe. PET CT on ___ showed a stable FDG-avid
nodule in the right lobe of the thyroid with an SUV of 8.4;
there was a 2.4 x 1.9 cm spiculated nodule with a contiguous
satellite nodule in the left lower lobe with SUV of 15.4; there
were no other FDG-avid nodules and there was no mediastinal or
hilar adenopathy; there were no abdominal, pelvic, or bone
metastases.
___:
CT scan of the chest on ___, showed no pulmonary
embolism; there was a 3.7 x 2.5 cm left lower lobe lung mass;
there was 4 x 2 cm left hilar adenopathy.
CXR ___:
IMPRESSION:
1. New upper lobe collapse and some lower lobe atelectasis
around a large obstructing left hilar mass.
2. Probable small bilateral pleural effusions.
PATH: ___:
lung, left mainstem tumor, biopsy: squamous cell carcinoma,
invasive, moderately to poorly differentiated
Procedures
___ Bronchoscopy
Recommendations:The patient was brought to the OR and placed
supine. After adequate anesthesia was obtained the trachea was
intubated with ___ 12 ventilating rigid bronchoscope. Jet
ventilation was established. The airways were inspected. There
was obstructing clot in the LMSB which was removed with
cryodebridement. There was an underlying obstructing LMSB tumor
with 80% occluding which was bleeding. Topical epinephrine was
applied and hemostasis was achieved with APC. EBUS TBNA sampled
were obtained at 10L. The airway was balloon dilated to 15. The
tumor was then cyrodebrided and cryobiopsied. A 14x30mm covered
Ultraflex was deployed, repositioned and balloon dilated. There
was a fracture of a subsegmental carina at in the LLL.
Hemostasis was confirmed, secretions were cleared and the
bronchoscope was removed. The patient was extubated in the OR
and transported back to the MICU in stable condition:
Procedures:
1. Flexible and rigid bronchoscopy
2. Cryodebridement and cryobiopsies of LMSB tumor
3. APC
4. EBUS TBNA 10L
5. Deployment and revision of 14 x 30 covered Ultraflex LMSB
stent
Brief Hospital Course:
Ms. ___ is a ___ with a history of poorly differentiated
squamous cancer of the lung s/p VATS in ___ with recurrence s/p
Cyberknife ___ who presented with shortness of breath
and was found to have post-obstructive pneumonia in the setting
of reccurent poorly differentiated squamous cell lung cancer.
# Hypoxia: Initially admitted to MICU requiring NRB; discharged
to home on 3L O2. Likely due to both poor reserve (s/p VATS on
R) and new partial obstruction of airways from recurrent SCC on
Left with some resulting post-obstructive collapse and
post-obstructive pneumonia. Discharged on home O2 and home COPD
meds. Will ___ with rad-onc, med-onc, and IP as an outpt
as outlined below.
# Recurrent poorly differentiated squamous cell Ca of lung: s/p
yCberknife ___. Bronch ___ with SCC. Has outpt
___ in place to discuss salvage chemo/radiation as well as
further metastic work-up (brain MRI). Discharged on home O2.
# Pneumonia: Initially treated with vancomycin/cefepime in ED
for post-obstructive pneumonia, and IP report with purulence
seen on bronch. Afebrile, VSS, WBC trended down. Discharged PO
levaquin through ___
#COPD: Continued on home meds + duonebs
#HTN. Normotensive since transfer to medicine; continued on home
dose amlodipine
Health Care Proxy: patient completed HCP paperwork on this
admission, designating her sister as her HCP and her nephew as
her alternate HCP.
GOC: pt is full code at this time. A MOLST form was provided to
the patient. She will further consider her wishes and will
discuss with her outpatient providers at ___
TRANSITIONAL ISSUES:
======================
# Levofloxacin 750 mg PO/NG DAILY through ___ for a total of
8 days antibiotics
# Hx of several months of intermittent mild vaginal bleeding.
Per pt, normal pap ___ year ago. Consider further work-up as outpt
# Follow up in place with IP and Onc to coordinate outpatient
chemo/radiation
# discharged with home O2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tiotropium Bromide 1 CAP IH DAILY
2. Amlodipine 5 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Dexamethasone 4 mg PO ONLY ON DAYS OF CYBERKNIFE TREATMENT
5. Lorazepam 0.5 mg PO 30 MINUTES PRIOR TO CYBERKNIFE
6. Ascorbic Acid Dose is Unknown PO DAILY
7. Bisacodyl 5 mg PO DAILY:PRN constipation
8. Vitamin D Dose is Unknown PO DAILY
9. Lactobacillus acidoph-L. bifid unknown oral daily
10. Polyethylene Glycol 17 g PO Frequency is Unknown
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Bisacodyl 5 mg PO DAILY:PRN constipation
3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
4. Tiotropium Bromide 1 CAP IH DAILY
5. Levofloxacin 750 mg PO DAILY Duration: 3 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
6. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB
RX *albuterol sulfate 90 mcg 1 puff IH Q6H:PRN Disp #*1 Inhaler
Refills:*3
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Post-obstructive pneumonia
Recurrent poorly differentiated squamous cell carcinoma of lung
Secondary:
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you during your recent
hospitalization. You were admitted because you had pneumonia in
the setting of recurrent lung cancer. The pulmonary team placed
a stent in one of the branches of your lung to help keep it open
with the hope of preventing future obstructive pneumonias and
preventing the cancer from collapsing your lung again. We're
treating your pneumonia with antibiotics; please continue to
take the Levaquin for 2 more days through ___. We have
arranged ___ at the multi-disciplinary thoracic ___
clinic to plan outpatient treatment for your recurrent lung
cancer. We have also arranged for you to have supplemental
oxygen at home to help with your breathing.
Please take your medications as directed and ___ with your
doctors as ___ below.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
19999784-DS-7 | 19,999,784 | 26,194,817 | DS | 7 | 2119-07-02 00:00:00 | 2119-07-03 16:21:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
LLE weakness, dysphagia
Major Surgical or Invasive Procedure:
Lumbar puncture
Bone marrow biopsy
History of Present Illness:
___ is a ___ year-old right-handed male without
___
medical history who presents to the ED for evaluation of LLE
weakness.
He was seen in ___ outpatient clinic this morning for evaluation
of new dysphasia and dysphonia (began ___. He reports
that he had gone to bed the previous day feeling normal but woke
up with new difficulty swallowing as well as a change in his
voice (more raspy, hoarse). With regards to his dysphagia, he
describes feeling that solids "won't go down...the food gets
stuck" but he has not had any difficulties with liquids. He was
seen by a community physician who told him that he likely had
sinus disease and recommended a few days of Sudafed. When the
symptoms persisted and he had lost 15 pounds due to difficulty
eating, he had a video swallow test performed ___, see below)
which revealed "significant oropharyngeal and esophageal
dysphagia most notable for diffuse right-sided weakness." This
prompted referral to ___ clinic, where he was seen today and
diagnosed with right vocal fold paralysis. He was noted to have
LLE weakness, so was prompted to come to the ED for further
evaluation.
He reports that the LLE weakness began gradually, probably over
the ___. This did not impair him in any way until the last
week of ___ when he was unable to stand up from a squatting
position without the use of his hands. Overall, his weakness has
been progessively worsening since that time. In particular, he
notices difficulty with lifting his left leg up in order to
cross
it over the right leg, difficulty going upstairs > downstairs --
and needs to hold onto the railing for both. He is able to stand
up out of a chair without difficulty but cannot stand from the
floor. He has not had any foot drop or toe stubbing. He has not
had any difficulty with the right leg or either arm.
On neuro ROS, Mr. ___ denies headache, loss of vision,
blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal numbness or
parasthesiae. No bowel or bladder incontinence or retention.
On general review of systems, this is notable for +
unintentional
weight loss over the past 2 weeks (15 pounds), which he
attributes to his dysphagia. He has also noticed saliva pooling
in his mouth which he sometimes has difficulty swallowing. He
has
been coughing more, but he attributes this to the irritation in
his throat, as he has not had any nasal congestion or "deep
cough."
He denies recent fever or chills. No night sweats. 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:
Tobacco use disorder
Social History:
___
Family History:
- Great nephew ___ years) with recently diagnosed epilepsy
- Father (now deceased) had prostate cancer.
Physical Exam:
ADMISSION Physical Exam:
============================
Vitals ___, time: 14:23):
T: 98.6
HR: 80
RR: 18
BP: 161/100
SaO2: 100% on RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, full ROM
Pulmonary: breathing comfortably on RA
Cardiac: warm and well-perfused with brisk capillary refill
Abdomen: ND
Extremities: + signficant atrophy of the left thigh. No C/C/E
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact 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. The pt had good knowledge of
current events. There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Fundoscopic
exam revealed no disc blurring, 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 at rest and
upon activation.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically. + gag on the left,
equivocal on the right
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline; + fasciculations.
-Motor: Normal tone throughout. Significantly decreased bulk in
the L thigh. No pronator drift bilaterally. No adventitious
movements, such as tremor, noted. No asterixis noted. ___
strength throughout with the following exceptions:
- Bilateral abductor pollicis brevis: 4+/5
- Left IP: 2+/5
- Left Quad: 2+/5
- Left Hamstring: 4+/5
- Left ___: 4+/5
Reflexes:
Bi ___ Pat Ach
L 3 3 tr* 1
R 3 3 2* 1
*: with reinforcement
Of note: + spread (finger flexion) in the bilateral UE reflexes
Plantar response was upgoing in the left, mute on the right.
___: negative
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Romberg absent.
DISCHARGE Physical Exam:
========================
Vitals: T: 98.6 BP: 113/79 HR: 98 RR: 18 SpO2: 99% RA
General: awake, cooperative, NAD
HEENT: NC/AT, no scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Alert, cooperative. Language is fluent with
intact comprehension. Able to follow both midline and
appendicular commands.
-Cranial Nerves: PERRL (3 to 2 mm ___. EOMI without nystagmus.
Face symmetric at rest and with activation. Hearing intact to
conversation. Palatal elevation symmetric. Tongue protrudes in
midline.
-Motor: No pronator drift bilaterally. No adventitious
movements,
such as tremor, noted.
Delt Bic Tri WrE FE IP Quad Ham TA Gastroc
L 5 ___ 5 4+ 3 5 5 5
R 5 ___ ___ 5 5 5
-Sensory: Intact to LT throughout. No extinction to DSS.
-DTRs:
Bi ___ Pat Ach
L 2 2 1 1
R 2 2 1 1
-Coordination: No intention tremor or dysmetria on FNF
bilaterally.
Pertinent Results:
ADMISSION LABS:
===============
___ 04:30PM URINE HOURS-RANDOM
___ 04:30PM URINE HOURS-RANDOM
___ 04:30PM URINE HOURS-RANDOM
___ 04:30PM URINE UHOLD-HOLD
___ 04:30PM URINE GR HOLD-HOLD
___ 04:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 04:10PM GLUCOSE-89 UREA N-13 CREAT-1.0 SODIUM-143
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-15
___ 04:10PM estGFR-Using this
___ 04:10PM CALCIUM-10.1 PHOSPHATE-3.7 MAGNESIUM-2.2
___ 04:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 04:10PM WBC-3.3* RBC-5.41 HGB-14.8 HCT-44.9 MCV-83
MCH-27.4 MCHC-33.0 RDW-13.4 RDWSD-40.1
___ 04:10PM NEUTS-53.8 ___ MONOS-6.9 EOS-0.6*
BASOS-0.6 IM ___ AbsNeut-1.78 AbsLymp-1.25 AbsMono-0.23
AbsEos-0.02* AbsBaso-0.02
___ 04:10PM PLT COUNT-241
INTERVAL LABS:
==============
___ 05:40AM BLOOD calTIBC-251* VitB12-722 Ferritn-172
TRF-193*
___ 01:14PM BLOOD ANCA-NEGATIVE
___ 10:34AM BLOOD CEA-3.4
___ 01:14PM BLOOD RheuFac-<10 ___
___ 02:40PM BLOOD CRP-1.5
___ 05:25AM BLOOD ___ Fr K/L-1.1
___ 10:34AM BLOOD PEP-ABNORMAL B IgG-2326* IgA-204 IgM-44
IFE-MONOCLONAL
___ 01:14PM BLOOD C3-114 C4-20
___ 02:40PM BLOOD HIV Ab-NEG
___ 04:10PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 10:34AM BLOOD QUANTIFERON-TB GOLD-Test
___ 10:34AM BLOOD TOXOCARA (T. CANIS & T. CATI)
ANTIBODY-Test
___ 10:34AM BLOOD CA ___ -Test
___ 01:14PM BLOOD RO & ___
___ 01:14PM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN
BLOT-Test
___ 01:14PM BLOOD ANGIOTENSIN 1 - CONVERTING ___
___ 02:40PM BLOOD SED RATE-Test
___ 02:40PM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-CANCELLED
___ 02:40PM BLOOD ENCEPHALOPATHY, AUTOIMMUNE EVALUATION,
SERUM-PND
___ 10:00AM URINE U-PEP-NO PROTEIN IFE-NEGATIVE F
___ 10:00AM URINE Hours-RANDOM Creat-153 TotProt-12
Prot/Cr-0.1
___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-6* RBC-1 Polys-2
___ Monos-9 Promyel-0 Plasma-3 Other-0
___ 04:55PM CEREBROSPINAL FLUID (CSF) TNC-18* RBC-4 Polys-4
___ Monos-6 Eos-1 Plasma-2 Other-0
___ 04:55PM CEREBROSPINAL FLUID (CSF) TotProt-114*
Glucose-63 ___ Misc-BODY FLUID
___ 04:55PM CEREBROSPINAL FLUID (CSF) BETA 2
MICROGLOBULIN-Test
___ 04:55PM CEREBROSPINAL FLUID (CSF) CA ___
___ 04:55PM CEREBROSPINAL FLUID (CSF) VDRL-Test
___ 04:55PM CEREBROSPINAL FLUID (CSF) TOXOPLASMA GONDII BY
PCR-Test
___ 04:55PM CEREBROSPINAL FLUID (CSF) HERPES SIMPLEX VIRUS
PCR-Test Name
___ 04:55PM CEREBROSPINAL FLUID (CSF) CYTOMEGALOVIRUS DNA,
QUALITATIVE, PCR-Test
___ 04:55PM CEREBROSPINAL FLUID (CSF) ANGIOTENSIN 1
CONVERTING ENZYME-Test
___ 04:55PM CEREBROSPINAL FLUID (CSF) BORRELIA BURGDORFERI
ANTIBODY INDEX FOR CNS INFECTION-CANCELLED
IMAGING:
========
+ MRI of L-spine notable for mild expansion in T2/STIR
hyperintensity of the distal lumbar spinal cord with
differential
including infectious, inflammatory etiologies, or intramedullary
neoplasm. On the contrast-enhanced study, this is described as
1.5 x 0.6 x 0.5 cm with associated cord expansion and extensive
leptomeningeal involvement extending superiorly and inferiorly
beyond the margins of the intramedullary lesion with possible
involvement of the adjacent nerve roots. Abnormal bone marrow
signal diffusely is also noted.
Brief Hospital Course:
BRIEF HOSPITAL COURSE
Mr. ___ was admitted to the Neurology service for evaluation
of subacute progressive LLE weakness as well as dysphagia and
dysphonia, found on ENT evaluation to be due to right-sided
vocal cord paralysis. Despite initial concern for motor neuron
disease, his EMG instead revealed a moderate to severe, chronic
and ongoing left L4-L5 radiculopathy, without electrophysiologic
evidence for a more generalized disorder of motor neurons or
their axons.
Follow-up MR imaging of the neuraxis was notable for:
1. Multilevel patchy cervical vertebral body T1 hypointensities
with possible minimal postcontrast enhancement concerning for a
potential marrow infiltrative process;
2. A 1.5 x 0.6 x 0.5 cm T12-L1 intramedullary enhancing focus
with surrounding
STIR/T2 signal abnormality and associated cord expansion, along
with extensive leptomeningeal involvement and possible
involvement of the adjacent nerve roots.
These findings were concerning for infectious, inflammatory, or
neoplastic processes. Inflammatory evaluation revealed
unremarkable CSF ACE, ESR, CRP, and SS-A and SS-B Ab. Infectious
evaluation revealed negative Lyme serologies, CSF culture,
RPR/VDRL, Toxoplasma serologies and CSF PCR, HSV/CMV PCR,
QuantiFERON Gold, and HTLV I/II Ab.
Neoplastic evaluation revealed negative ___ and CSF cytology
and flow cytometry. CT chest/abdomen/pelvis was also negative
for additional malignancy. SPEP, however, revealed a monoclonal
gammopathy, though with negative skeletal survey and absence of
renal findings to suggest multiple myeloma; in consultation with
the Hematology/Oncology service, a bone marrow-biopsy was
obtained that preliminarily revealed plasma cells as well as
abnormal proliferation of lymphocytes concerning for lymphoma.
As it remained unclear whether the bone marrow findings could
also be implicated in the intramedullary spinal cord lesion and
leptomeningeal/radicular enhancement seen on imaging, the
Hematology/Oncology and Neuro-oncology teams deferred inpatient
treatment in lieu of close outpatient follow-up for repeat
imaging, repeat lumbar puncture, and follow up of molecular
testing.
With respect to Mr. ___ leg and vocal cord symptoms, these
may be related to the leptomeningeal/nerve root infiltrative
process noted on imaging. During admission he also developed
mild hyperreflexia and spasticity in the RLE (without weakness),
indicating myelopathy, in line with cord signal abnormalities
seen on imaging. Accordingly, Mr. ___ was evaluated by ___ and
SLP as an inpatient, with plans for outpatient follow-up. Mr.
___ was cleared for a regular diet and advised to turn his
head to the right to facilitate swallowing.
TRANSITIONAL ISSUES:
===================
[] Follow-up outpatient MRI.
[] Follow up with Neuro-oncology and Hematology/Oncology as
noted above.
[] Follow up final report from bone marrow biopsy as well as
serum autoimmune encephalopathy panel.
[] Outpatient ___ and SLP follow up as noted above.
Medications on Admission:
None
Discharge Medications:
1. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1 (One)
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*0
2.Outpatient Physical Therapy
Diagnosis: Left leg weakness, L4/L5 radiculopathy
3.Outpatient Speech/Swallowing Therapy
Diagnosis: right vocal cord paralysis, dysphonia
Please continue to evaluate and treat dysphagia and dysphonia
Discharge Disposition:
Home
Discharge Diagnosis:
Lumbar Radiculopathy
Lumbar myelopathy
Intramedullary intradural spinal cord lesion
Vocal cord paralysis
Monoclonal gammopathy
Suspected lymphoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ for
evaluation of difficulty swallowing and speaking, as well as
left leg weakness. Imaging of your spine showed an area of
swelling and inflammation affecting your spinal cord and
surrounding coverings; blood and cerebrospinal fluid tests did
not show signs of an infection or inflammation, so there is
concern that the spine findings may be due to cancer. Although
imaging of your chest, abdomen, and pelvis did not show signs of
additional cancer, your bone marrow did have abnormal blood
cells (lymphocytes) that could reflect lymphoma.
In order to further direct treatment of your spinal cord lesion,
a follow-up appointment has been scheduled for you with Dr. ___
in Neruo-oncology; you are also scheduled for a repeat MRI the
day prior. A follow-up appointment was also requested with
Hematology/Oncology regarding your bone marrow biopsy findings;
you may call ___ to follow up on this appointment with
Drs. ___.
Please also follow-up with a speech and swallow specialist for
your voice as well as swallowing function and for speech
therapy. We have written a prescription for outpatient speech
therapy. Your follow-up is being coordinated by ___.
Please call the number below (under recommended follow-up
section) to follow-up regarding your appointment.
It was a pleasure taking care of you at ___.
Sincerely,
Neurology at ___
Followup Instructions:
___
|
19999828-DS-6 | 19,999,828 | 29,734,428 | DS | 6 | 2147-08-04 00:00:00 | 2147-08-12 15:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Lamictal / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Enterocutaneous/enteroatmospheric fistula
Major Surgical or Invasive Procedure:
___:
1. Split-thickness skin graft, left and right thigh to
abdominal bowel site and closure of intestinal fistula.
2. VAC sponge 20 x 15 cm.
History of Present Illness:
Ms. ___ is a ___ F w/hx of Afib on diltizaem, Factor V not
on anticoagulation, diverticulosis, HTN, COPD and DMII who
presents with abdominal pain and an abdominal wound site with
exposed mesh. She reports a complex surgical history including
laparoscopic cholecystectomy in ___ followed by ___
Procedure for diverticulitis ___ with colostomy take down
___. After this procedure she states she developed a large
ventral hernia and underwent open VHR with cadaveric underlay
mesh and prolene overlay mesh ___ c/b skin dehiscence
beginning in ___ and progressing until today, despite
multiple debridements at ___ and the use of a
wound vac, which was last used 2 mo ago.
She presents to the ED for follow up of her ventral hernia since
the wound continues to expand and has become more painful. 3
weeks ago, Ms. ___ developed pain at the RUQ of the wound
that has since progressed and intermittent nausea without
vomiting. This morning at 7 am she changed her dressings and
noticed brown, foul-smelling staining in the middle of the mesh
and a "nipple-like" protrusion that resolved. At 8pm in the ED,
her 12x17 cm open wound with visible mesh currently had more
brown staining than this morning. When she pressed on the edges
of her wound, which is tender and erythematous
circumferentially, pus drained out at the 10 o'clock position.
She was given dilute barium contrast PO for a CT +IV +oral
contrast; CTAP was not read as showing enterocutaneous fistula.
However, after drinking the contrast the patient began to leak
feculent material that appeared to be succus mixed with
contrast.
.
She smokes recreational marijuana which help curb the nausea,
which allows her to eat. She is passing flatus and has regular
BM, though she notes her stools are hard and she has felt
constipated since her last hernia repair (___). She is
afraid to strain while going to the bathroom because of the
pressure it puts on her hernia. She has not had any fevers,
chills, diarrhea, constipation different from baseline, SOB,
chest pain, or urinary symptoms.
.
Past Medical History:
PMH
a fib on diltiazem
Factor V Leiden deficiency
diverticulosis (with diverticulitis episodes)
SBO (___)
gallstones
HTN
COPD
anxiety
sciatica
scoliosis
varicose veins
DMII
PSH
cholecystectomy ___, ___
umbilical hernia repair ___, ___
Left ventral hernia c/b SBO s/p colostomy (___)
colostomy reversal ___, ___
ventral hernia repair w/ mesh ___, ___
ventral hernia repair, debridement ___, ___)
Social History:
___
Family History:
- both parents and multiple siblings have DVTs ___ Factor V
Leiden deficiency
Physical Exam:
Discharge Physical Exam:
VS: T: 98.1 PO BP: 110/74 R Sitting HR: 81 RR: 18 O2: 96% Ra
GEN: A+Ox3, NAD
HEENT: normocephalic, atraumatic
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended. Area of wound with skin graft about
14x16 cm, skin graft approximately 90% taken, left and right
edges still not taken up skin graft, but edges beginning to scar
down.
EXT: wwp, no edema b/l. B/l thigh donor sites OTA, healing w/
no s/s infection
Pertinent Results:
ADMISSION LABS:
___ 06:04PM BLOOD WBC-9.5 RBC-4.08 Hgb-9.9* Hct-32.3*
MCV-79* MCH-24.3* MCHC-30.7* RDW-15.8* RDWSD-45.4 Plt ___
___ 06:04PM BLOOD Neuts-46.9 ___ Monos-14.4*
Eos-2.5 Baso-0.6 Im ___ AbsNeut-4.47 AbsLymp-3.35
AbsMono-1.37* AbsEos-0.24 AbsBaso-0.06
___ 06:04PM BLOOD ___ PTT-28.4 ___
___ 06:04PM BLOOD Glucose-152* UreaN-11 Creat-0.7 Na-136
K-4.7 Cl-98 HCO3-24 AnGap-14
IMAGING:
___: CT Abdomen/Pelvis:
1. No enterocutaneous fistula or small-bowel obstruction
identified.
2. Open anterior abdominal wall wound measuring up to 14.5 x
16.1 cm with
moderate soft tissue thickening along the lateral borders.
Small focus of
subcutaneous air tracking along the right superior border
suggests increasing wound extension.
___: Abdominal x-ray:
No enterocutaneous fistula demonstrated radiographically.
Consider a
fistulogram for this purpose.
___: Dx Portable PICC:
Right PICC in the mid SVC. No acute cardiopulmonary process.
___: Abdominal x-ray:
No acute abnormality with nonobstructive bowel gas pattern.
Interval
placement of wound VAC which projects over the mid abdomen.
___: CXR:
No acute cardiopulmonary process.
___ 10:16 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Brief Hospital Course:
Ms. ___ is a ___ year old female with a history of multiple
prior abdominal surgeries most recently a ventral hernia repair
at ___ (___) who presented to ___
___ on ___ with an open abdominal wound,
exposed mesh, and a low output entero-atmospheric fistula. She
was admitted to the Acute Care Surgery Service for further
management.
The patient was kept NPO and initiated on TPN. She was started
on octreotide for a short time period to help reduce fistula
output. Plastic surgery was consulted to evaluate the patient in
preparation for eventual abdominal wall reconstruction and
offered to be available to assist with surgery when needed.
Wound care nursing was also asked to assist with optimizing the
patient's abdominal dressing, and a large wound manager was
applied and placed to wall suction with good result.
On ___, the patient was taken to the operating room and
underwent an abdominal skin graft with anterior bilateral thigh
donor sites. For details of the procedure, please see the
surgeon's operative note. The patient tolerated the procedure
well without complication and was taken to the post anesthesia
care unit in stable condition.
The patient was placed on bedrest precautions and then activity
restrictions were liberalized and the patient ambulated. ___
was d/c'd and she voided appropriately. She was started on a
regular diet which she tolerated and TPN was d/c'd. WBC was
elevated on POD #3 and so PICC was d/c'd a fever work-up was
sent and urine culture was positive for e.coli (sensitive to
cipro). She was started on a 7 day course of cipro and WBC
normalized.
The patient's skin graft took approximately 90%. Non-adherent
dressing were placed over the wound while ambulating and left
open to the air for periods of time while in bed to let the
graft dry.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home with ___ services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
acetaminophen PRN
albuterol (proair)
aspirin 81
atorvastatin 20
suboxone
Clonidine 0.2 TID
Diltiazem 120mg 24 hour capsule
Colace
Flonase
Glipizide
Ibuprofen
Metformin 500mg daily
omeprazole 20mg daily
trazodone 50mg daily
umeclidinium 62.6 mcg/actuation
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 250 mg PO Q12H
Closely monitor your blood sugars to assess for low blood sugar
while taking this medication
RX *ciprofloxacin HCl 250 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*9 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
Hold for loose stool
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
Reason for PRN duplicate override: d/c oxycodone
Take lowest effective dose. Patient may request partial fill.
RX *hydromorphone 2 mg ___ tablet(s) by mouth every four (4)
hours Disp #*20 Tablet Refills:*0
5. Atorvastatin 20 mg PO QPM
6. CloNIDine 0.2 mg PO TID
7. Diltiazem Extended-Release 120 mg PO DAILY
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY PRN
9. GlipiZIDE 5 mg PO DAILY
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Topiramate (Topamax) 50 mg PO BID
13. TraZODone 50 mg PO QHS:PRN PRN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Giant abdominal hernia with exposed bowel and intestinal
fistula.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___ with a
large abdominal hernia after multiple prior surgeries. You had
a fistula (an abnormal connection between the bowel and the
skin) from the wound. You were initially placed on TPN to
receive nutrition. You were later taken to the operating room
and you underwent skin grafting from your thighs to your
abdominal wound to protect the exposed bowel to prevent another
fistula and also to close
the current fistula. You tolerated this procedure well and your
graft has mostly taken. You are now tolerating a regular diet,
low residue diet. You were found to have a urinary tract
infection and were started on a 1 (one) week course of an
antibiotic, called ciprofloxacin. You will have a nurse visit
you at home to check up on you to evaluate your wound and also
help with your dressing changes. You are ready to be discharged
home to continue your recovery.
Please note the following discharge instructions:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
19999987-DS-2 | 19,999,987 | 23,865,745 | DS | 2 | 2145-11-11 00:00:00 | 2145-11-11 13:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
ICH
Transfer from OSH
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ woman with a history of lymphoma who
presents as a transfer from ___ with a L occipital
hemorrhage. Per EMS report, she was last seen normal by her
husband at 11:30 this am. She said she was going to bed for a
little while, and then when her husband went to check on her
around 2pm he found her lying on the bed, non-verbal, and
drooling from the mouth with a small tongue laceration. He
called
EMS, and upon their arrival she was noted to have some left arm
weakness and a leftward gaze preference. BP was 162/104 with
pulse 140. FSBS was 217. She was somewhat combative and there
was
also some unclear concern for a ?dystonic reaction, for which
she
was given 50mg benadryl IV. Upon arrival to ___ she was
reportedly awake and groaning and initially seemed to be
protecting her airway. T was 100.6, BP 99/83, and O2 sats were
in
the 70's on RA which improved to 95% on 4L NC. She subsequently
was noted to have left eye twitching for which she was given
ativan 1mg x 2. CT head showed a L occipital hemorrhage
measuring
5 x 3.9 x 2.1cm with mild surrounding edema and focal mass
effect. She was subsequently intubated and transferred to ___
for further management.
Currently pt is intubated and sedated and no family is present
to
corroborate history. Attempted to reach husband ___ at both
numbers provided but with no response.
ROS currently unable to be obtained from pt.
Past Medical History:
Lymphoma, s/p remission since ___
Esophageal ulcer
Anxiety/depression
Hypothyroidism
R ankle fusion
Anemia
Social History:
___
Family History:
Unknown
Physical Exam:
Physical Exam:
Vitals: T: not recorded P ___ BP 118/83 RR 18 O2 100% on
ventilator
General: Intubated and sedated.
HEENT: NC/AT, no scleral icterus noted, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds,
Extremities: No C/C/E bilaterally
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Intubated and sedated on fentanyl/midazolam, no
response to voice or sternal rub
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 1.5 to 1mm and brisk.
III, IV, VI: Gaze midline and conjugate, negative Doll's
V: Corneals absent
VII: Face appears symmetric with ETT.
VIII: Unable to assess
IX, X: +Strong gag
XI: Unable to assess
XII: Unable to assess
-Motor: Normal bulk, flaccid tone throughout. No withdrawal to
noxious stimulation. When suctioned has a strong gag response
and
briefly lifts both arms.
-Sensory: Slight grimace to noxious stimulation
-DTRs: ___ throughout
-___: Unable to assess
-Gait: Unable to assess
Pertinent Results:
___ 08:27PM TYPE-ART RATES-18/ TIDAL VOL-400 PEEP-5
O2-100 PO2-439* PCO2-51* PH-7.31* TOTAL CO2-27 BASE XS--1
AADO2-227 REQ O2-46 -ASSIST/CON INTUBATED-INTUBATED
___ 07:49PM ___ PH-7.21* COMMENTS-GREEN-TOP
___ 07:49PM GLUCOSE-134* LACTATE-1.7 NA+-148* K+-5.2*
CL--102 TCO2-30
___ 07:49PM HGB-14.3 calcHCT-43 O2 SAT-72 CARBOXYHB-2 MET
HGB-0
___ 07:49PM freeCa-1.12
___ 07:45PM UREA N-18 CREAT-1.4*
___ 07:45PM estGFR-Using this
___ 07:45PM LIPASE-26
___ 07:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 07:45PM URINE HOURS-RANDOM
___ 07:45PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:45PM WBC-13.5* RBC-4.07* HGB-14.1 HCT-42.2
MCV-104* MCH-34.7* MCHC-33.5 RDW-15.7*
___ 07:45PM PLT COUNT-136*
___ 07:45PM ___ PTT-31.2 ___
___ 07:45PM ___
___ 07:45PM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 07:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-5.5 LEUK-NEG
___ 07:45PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-0
ECHO ___
The left atrium is elongated. Left ventricular wall thicknesses
are normal. The left ventricular cavity size is normal. There is
mild regional left ventricular systolic dysfunction with
hypokinesis of the distal inferior wall and apex (LVEF 55%).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are mildly thickened.
Trivial mitral regurgitation is seen. The estimated pulmonary
artery systolic pressure is normal. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. No intracardiac source of
embolus identified. Preserved global left ventricular systolic
function with hypokinesis of the distal inferior wall and true
apex. No clinically significant valvular disease. Mildly dilated
descending thoracic aorta.
CTA ___
IMPRESSION:
1. Unchanged 3.9 x 2.2 cm left occipital intraparenchymal
hemorrhage. No
midline shift. No intraventricular hemorrhagic extension.
2. Normal CTA head and neck, without aneurysm, dissection,
vascular
malformation or significant atherosclerotic disease.
MRI ___. Large left occipital intraparenchymal hemorrhage, unchanged
and with
persistent mass effect on to the adjacent parenchyma. No
midline shift or
intraventricular hemorrhagic extension. No acute infarcts or
definite
postcontrast enhancement.
2. A small DVA traversing in the vicinity of the left occipital
intraparenchymal hemorrhage. The presence of a nearby DVA
favors the
differential of cavernous malformation (hemangioma cavernoma)
which
hemorrhaged.
3. A punctate susceptibility artifact in the left temporal
lobe, could
represent either a second cavernoma or an old microhemorrhage.
Angiogram ___
___ underwent cerebral angiography which failed to
reveal a source of hemorrhage in the left occipital lobe. There
was a vein
which appeared slightly early in the left vertebral artery
injection draining
into the left superior sagittal sinus; however, this was not
consistent with
an AVM and angiogram should be repeated in a month's time after
the mass
effect from the hematoma has resolved.
___ 07:45PM URINE GRANULAR-60*
Brief Hospital Course:
This is a ___ year old woman with a history of Lymphoma who
presents with confusion and unresponsiveness and found to have a
left occipital hemorrhage. The patient was in bed on the morning
of ___ when her husband heard the dog barking in that room. When
he went in he saw she was sitting on the side of the bed and
when he asked her what was wrong she said she didn't know. He
went to get a facecloth for her and when he returned she was on
the floor and one side of her face was twitching. She did not
respond at that time. EMS brought her to OSH where she has left
eyelid twitching, left gaze preference and got ativan x1. CT
showed a left occipital bleed.
NEURO: Patient was transfered to ___ Neuro ICU. She had an MRI
which showed, in addition to bleed, a small DVA adjacent to
bleed which increases probability of cause of bleed bring
cavernous malformation. Her CTA showed otherwise normal vessels.
Stroke work up revealed A1c 5.1, LDL 100. Due to concern for
vascular malformation of reversible cerebral vasoconstriction,
angiogram was performed and was negative. She should have a
repeat MRI 1 month after hematoma has resolved, and possibly
another angiogram based on those results. Due to concern for
seizure the patient was started on Keppra. This was transitioned
to trileptal after discoverning that the patient had recently
been depressed. The patient became dizzy and diaphoretic after
initiation of Trileptal to she remained on only Keppra and
warned to talk to her doctor if he psychiatric symptoms
worsened. She had an EEG which preliminarily showed generalized
slowing. Formal read to follow.
While patient initially had done well with ___ and OT, on ___
she became vertiginous, diaphoretic and anxious. We initially
thought this was due to Trileptal but even after stopping this
she continued to have this reaction upon sitting up in bed on
___. Her orthostatics were negative and she did not have
nystagmus during the vertigo. For several minutes she appeared
very anxious, said her husband's name was ___ and that she
lived at "___". She also developed some varying tremors.
This may still have been due to trileptal as well as a
psychiatric element to her symptoms. We have therefore restarted
her Cymbalta and Effexor (had been held in ICU then patient
declined to restart because she was feeling well).
ID: The patient had leukocytosis on presentation and blood
cultures were positive from ___ with gram pos cocci so she was
started on vancomycin. Subsequent blood cultures were negative
so vancomycin was stopped after 3 days. Urinalysis was also
positive and culture grew Klebsiella so she was started on
ceftriaxone. This was switched to bactrim on discharge.
CARDS: The patient had a troponin elevation to 1.39 on
presentation. EKG showed no acute ST or T changes. Echo showed
hypokinesis of the inferior wall and apex. She was started on
metoprolol for presumed CAD on the recommendation of cardiology.
Troponin trended down to 1.13.
RESP: The patient arrived intubated. She was extubated on the
evening of ___. While in the ICU the patient had stridor and was
placed on BiPAP then face mask overnight.
TOX/METAB: The patient had mildly elevated LFTs and Utox
positive for methadone, barbiturates, cannabinoids at ___.
Repeat here was positive for benzos and barbiturates. Patient
denied substance abuse.
TRANSITION OF CARE:
FULL code
End bactrim in the evening ___
Titrate up psych meds as needed
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 150 mg PO DAILY
2. Duloxetine 60 mg PO BID
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
5. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Duloxetine 60 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Venlafaxine XR 150 mg PO DAILY
5. Acetaminophen 650 mg PO Q6H:PRN headache
6. Heparin 5000 UNIT SC TID DVT prophylaxis
7. LeVETiracetam 1000 mg PO BID
8. Metoprolol Tartrate 12.5 mg PO BID
9. Sulfameth/Trimethoprim DS 1 TAB PO BID
10. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN headache
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left Occipital bleed
UTI- Klebsiella
Troponin elevation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
awake, alert oriented to ___ and date. R lower homonymous
hemianopsia, end gaze nystagmus, full strength.
Discharge Instructions:
You came to the hospital because of a bleed in your brain. You
had an MRI, a CTA and an angiogram to try to determine the cause
of this bleed but unfortunately we cannot say what the cause is.
It is possibly an abnormal formation of blood vessels. You will
need to have a repeat MRI in 1 month in order to investigate
this further (once the blood in your brain has disapated) and
possibly another angiogram. We think that you may have had a
seizure caused by the blood in your brain and will remain at
risk for seizures in the coming months. Because of this we have
started you on an antiepileptic drug called Keppra
(Levetiracetam). Please be aware that this medication can
worsening depression/irritability. Let your doctor know if you
notice this and you could be switched to another medication such
as Lamictal.
While you were here we also treated you for a urinary tract
infection. You will complete Bactrim for this on ___. You were
also treated for bacteria in the blood but this is more likely
to have been a contaminate at the time of collection and not a
true infection.
Finally, your cardiac enzymes were elevated on admission. This
may have been due to the bleed but may also have been from a
mild heart attack. You should follow up with cardiology once you
are discharged and continue metoprolol as directed.
Followup Instructions:
___
|
Subsets and Splits