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10109899-DS-14 | 10,109,899 | 24,286,545 | DS | 14 | 2162-09-07 00:00:00 | 2162-09-10 14:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee Sting
Attending: ___.
Chief Complaint:
Shortness of breath, wheezing
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old female with history of OSA, allergies/?asthma who
presents with worsening shortness of breath/wheezing over the
last two months. Patient is known to have allergies during the
warmer months that respond to intra-nasal steroids. However,
since ___, the patient has had persistent cough and wheezing.
Inhaler therapy was uptitrated with no effect. In early ___,
she failed an empiric course of azithromycin. A subsequent chest
x-ray at the end of ___ showed a right basilar opacity
concerning for pneumonia. She was placed on prednisone and
augmentin with some effect, but quickly had recurrence of her
symptoms. A repeat CXR on ___ showed resolution of the
pneumonia. However, she called her PCP ___ 1 week ago to report
that her symptoms of shortness of breath had again worsened.
Today, given lack of improvement on max inhalers, the patient
was referred to the ED for further management.
In the ED, initial VS were temp 98.2, HR 70, BP 138/74, RR 20,
92% RA. Exam notable for diffuse inspiratory and expiratory
wheezes.
Labs showed serum bicarbonate 35, creatinine 0.9, BNP 1739,
normal CBC. UA showed few bacteria, moderate Leuk, and 14 WBC
Imaging showed low lung volume with atelectasis but no obvious
pneumonia. Patient received several duonebs, 125mg
methylprednisolone, IV magnesium, and oral lorazepam.
Transfer VS were HR 81, BP 143/70, RR- 18, 93% RA.
Decision was made to admit to medicine for further management.
On arrival to the floor, patient confirms the above history. On
the floor, she denies previous history of asthma and states she
only recently within the last few months began taking inhalers.
She has a 60 pk year hx of smoking but quick many years ago. No
fevers/chills.
Past Medical History:
-chronic / recurrent hyponatremia: hospitalized for Na 121 in
___ and Na 125 in ___. Final dx unclear, attributed to
polydipsia plus thiazide
-HTN
-posterior circulation TIA: MRI negative stroke (___)
-hypothyroidism
-depression/anxiety
-osteoporosis c/b thoracic compression fractures, followed by
neurosurg
Social History:
___
Family History:
Father had an MI in his late ___ and mother had an MI in her
late ___. No apparent history of endocrinopathies.
Physical Exam:
====================
ADMISSION EXAM
====================
VS: 97.4 168/82 83 18 90%RA
GENERAL: Elderly appearing female in NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM,
good dentition
NECK: nontender supple neck, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diffuse inspiratory and expiratory wheezes with coarse
breath sounds and decreased air movement. No respiratory
distress.
ABDOMEN: obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact. No focal deficits.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
======================
DISCHARGE EXAM
======================
VS: Tmax 97.5 BP 120-130/70-80s HR ___ RR 18 ___ on RA
GENERAL: Elderly appearing female in NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: Diffuse expiratory wheezes; good air movement. No
respiratory distress. No crackles, rhonchi.
ABDOMEN: obese, nondistended, +BS, nontender in all quadrants,
no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: CN II-XII intact. No focal deficits.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
====================
ADMISSION LABS
====================
___ 11:40AM WBC-8.3 RBC-4.35 HGB-13.2 HCT-41.8 MCV-96
MCH-30.3 MCHC-31.6* RDW-12.4 RDWSD-43.8
___ 11:40AM NEUTS-61.5 ___ MONOS-10.0 EOS-4.4
BASOS-1.5* IM ___ AbsNeut-5.08 AbsLymp-1.85 AbsMono-0.83*
AbsEos-0.36 AbsBaso-0.12*
___ 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-MOD
___ 11:35AM URINE RBC-2 WBC-14* BACTERIA-FEW YEAST-NONE
EPI-0
___ 11:35AM URINE HYALINE-1*
___ 11:40AM PLT COUNT-282
___ 11:40AM proBNP-1739*
___ 11:40AM GLUCOSE-80 UREA N-16 CREAT-0.9 SODIUM-139
POTASSIUM-4.2 CHLORIDE-95* TOTAL CO2-35* ANION GAP-13
___ 12:26PM LACTATE-1.4
___ 03:48PM ___ PO2-29* PCO2-57* PH-7.35 TOTAL
CO2-33* BASE XS-2
ABG ___:
___ 01:43PM BLOOD Type-ART pO2-62* pCO2-48* pH-7.43
calTCO2-33* Base XS-6
=====================
PERTINENT LABS
=====================
___ 11:40AM BLOOD proBNP-1739*
___ 07:15AM BLOOD ANCA-NEGATIVE B
=====================
DISCHARGE LABS
=====================
___ 07:30AM BLOOD WBC-10.9* RBC-4.15 Hgb-12.8 Hct-39.9
MCV-96 MCH-30.8 MCHC-32.1 RDW-13.0 RDWSD-45.5 Plt ___
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD Glucose-78 UreaN-23* Creat-0.8 Na-136
K-3.8 Cl-95* HCO3-28 AnGap-17
___ 07:30AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.2
=====================
MICROBIOLOGY
=====================
___ 11:35 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 11:50 am BLOOD CULTURE
Blood Culture, Routine (Pending): NO GROWTH TO DATE
=======================
IMAGING/STUDIES
=======================
CXR ___ IMPRESSION:
Low lung volumes with atelectasis. No convincing evidence to
suggest
pneumonia.
CT CHEST NONCONTRAST ___ IMPRESSION:
1. Multiple new centrilobular ground-glass nodules and bilateral
lower lobe segmental bronchial wall thickening and secretions,
consistent with small airway inflammation. Recommend
correlation for asthma and/or allergies.
2. No evidence of interstitial lung disease, central obstructing
lesion or pulmonary edema.
3. Right lower lobe atelectasis, could be related to
diaphragmatic/phrenic nerve dysfunction. Consider sniff test
for further evaluation.
RECOMMENDATION(S): Consider sniff test for further evaluation
of right hemidiaphragm function.
Brief Hospital Course:
HOSPITAL COURSE
===============
___ w/ PMH allergies, asthma, OSA, HTN, HFpEF presented with few
month history of worsening SOB, wheezing. Patient has been seen
by her PCP multiple times for this complaint. She has tried
multiple antibiotic courses without improvement as well as oral
steroids with brief response. Patient carries a presumptive
diagnosis of asthma. On admission, patient was diffusely
wheezing with coarse breath sounds maintaining sats in low ___
on 2L NC - RA. CXR negative for signs of infection. CT chest
most consistent with asthma/allergy with small airway
inflammation. Patient was treated for asthma vs COPD
exacerbation with Duonebs, Advair, oral prednisone with 60mg PO
QD. Pulmonology was consulted who felt the patient's
presentation likely represented atypical asthma given
eosinophilia vs COPD with possible microaspiration events.
Patient improved on oral steroids and maintained O2 sats on room
air including ambulatory O2 sat of 94-95% RA. Patient was
scheduled to follow up as an outpatient with pulmonology clinic
and obtain formal PFTs. Speech and swallow bedside eval showed
no evidence of aspiration.
ACTIVE ISSUES
=============
# Wheezing/Shortness of breath: Per chart review, patient has
history of asthma, on Symbicort. She has had little improvement
with outpatient antibiotics and oral steroids. Differential was
broad and included atypical infection, refractory obstructive
lung disease, atypical asthma (eosinophilic asthma given
increased eosinophils) or other inflammatory process. CXR was
unremarkable. VBG and ABG consistent with CO2 retention with
mild hypoxemia. CT chest consistent with asthma/allergy. Patient
improved on oral prednisone 60mg PO QD. Plan is to tape
prednisone 10mg Q2 days until done. Antibiotics were not given
since no evidence of infection on history or imaging.
Pulmonology was consulted who felt etiology may be atypical
asthma given eosinophilia vs COPD vs possible eosinophilic
syndromes. Presentation could also be due to microaspiration,
however, bedside speech and swallow test normal. No evidence of
pulmonary edema on CT. Patient was able to maintain O2 sats on
room air at rest and with ambulation. She was discharged to
follow up with pulm as an outpatient for formal PFTs.
# Sleep Apnea: Received CPAP per respiratory therapy while
inpatient.
# Hypertension: Continued on home amlodipine, HCTZ.
# Basal ganglia and lacunar infarcts: Unclear timeline, patient
unable to verify history. Continued on ASA 81 as prevention of
CV events.
# Anxiety/Depression/Psych: No active issues. Continued home
meds: DULoxetine 40 mg PO DAILY, MethylPHENIDATE (Ritalin) 5 mg
PO BID, Mirtazapine 7.5 mg PO QHS, RisperiDONE 2 mg PO QHS.
# Hypothyroidism: Continued Levothyroxine Sodium 125 mcg PO
DAILY.
# GERD: Continued Omeprazole 20mg PO QD.
# Continued home meds as below: (consider discontinuation to
lower pill burden if able)
- Clorazepate Dipotassium 3.75 mg PO QID
- Oxybutynin 5 mg PO QAM
- Pramipexole 0.25 mg PO QHS
- Topiramate (Topamax) 50 mg PO BID
- Calcium Carbonate 500 mg PO BID
- Vitamin D 1000 UNIT PO DAILY
- Ascorbic Acid ___ mg PO DAILY
- Multivitamins 1 TAB PO DAILY
- Senna 17.2 mg PO QHS
- Docusate Sodium 100 mg PO BID
TRANSITIONAL ISSUES
===================
- MEDICATION CHANGES:
--Ipratropium-Albuterol Inhalation Spray 1 INH Q6H CHANGED TO
Ipratropium-Albuterol Neb 1 NEB Q6H
--Methylphenidate dose CHANGED to 10mg QAM and 5mg Noon
- Patient to have formal PFT's performed.
- Consider referral to GI for outpatient esophageal dysmotility
evaluation given concern for possible microaspiration.
- Vaccinations: Patient received Prevnar in ___ and Fluzone
___. Pneumovax due for update in ___.
- Consider sniff test for further evaluation of right
hemidiaphragm function (See CT Chest read).
- PREDNISONE TAPER:
___ Prednisone 50mg Once per Day
___ Prednisone 40mg Once per Day
___ Prednisone 30mg Once per Day
___ Prednisone 20mg Once per Day
___ Prednisone 10mg Once per Day
STOP prednisone on ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 2.5 mg PO DAILY
2. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
3. Clorazepate Dipotassium 3.75 mg PO QID
4. DULoxetine 40 mg PO DAILY
5. Hydrochlorothiazide 25 mg PO DAILY
6. Ipratropium-Albuterol Inhalation Spray 2 INH IH Q6H
7. Levothyroxine Sodium 125 mcg PO DAILY
8. MethylPHENIDATE (Ritalin) 5 mg PO BID
9. Mirtazapine 7.5 mg PO QHS
10. Omeprazole 20 mg PO DAILY
11. Oxybutynin 5 mg PO QAM
12. Pramipexole 0.25 mg PO QHS
13. RisperiDONE 2 mg PO QHS
14. Topiramate (Topamax) 50 mg PO BID
15. Aspirin 81 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Ascorbic Acid ___ mg PO DAILY
18. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
19. Multivitamins 1 TAB PO DAILY
20. Senna 17.2 mg PO QHS
21. Docusate Sodium 100 mg PO BID
22. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
23. Lisinopril 40 mg PO DAILY
24. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection 1 mL thigh once
PRN bee sting
25. Zolpidem Tartrate 10 mg PO QHS
26. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Discharge Medications:
1. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
RX *ipratropium-albuterol 0.5 mg-3 mg (2.5 mg base)/3 mL 1
ampule nebulizer every six (6) hours Disp #*120 Ampule
Refills:*0
2. PredniSONE 50 mg PO DAILY Duration: 2 Doses
RX *prednisone 10 mg 5 tablet(s) by mouth DAILY Disp #*25 Tablet
Refills:*0
3. MethylPHENIDATE (Ritalin) 10 mg PO QAM
4. MethylPHENIDATE (Ritalin) 5 mg PO NOON
5. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
6. amLODIPine 2.5 mg PO DAILY
7. Ascorbic Acid ___ mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
10. Clorazepate Dipotassium 3.75 mg PO QID
11. Docusate Sodium 100 mg PO BID
12. DULoxetine 40 mg PO DAILY
13. EpiPen (EPINEPHrine) 0.3 mg/0.3 mL injection 1 mL thigh
once PRN bee sting
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY as needed
15. Hydrochlorothiazide 25 mg PO DAILY
16. Levothyroxine Sodium 125 mcg PO DAILY
17. Lisinopril 40 mg PO DAILY
18. Mirtazapine 7.5 mg PO QHS
19. Multivitamins 1 TAB PO DAILY
20. Omeprazole 20 mg PO DAILY
21. Oxybutynin 5 mg PO QAM
22. Pramipexole 0.25 mg PO QHS
23. RisperiDONE 2 mg PO QHS
24. Senna 17.2 mg PO QHS
25. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID
26. Topiramate (Topamax) 50 mg PO BID
27. Vitamin D 1000 UNIT PO DAILY
28. Zolpidem Tartrate 10 mg PO QHS
29.Nebulizer
Please provide Nebulizer
Use as directed
Quantity: 1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnoses: Asthma, Dyspnea
Secondary Diagnoses: Obstructive Sleep Apnea, Hypertension,
Diastolic Heart Failure, Migraine Headaches
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 ___.
WHY YOU WERE ADMITTED TO THE HOSPITAL:
=======================================
- You were having shortness of breath and wheezing.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
==============================================
- You were given an oral steroid called prednisone to decrease
inflammation in your lungs.
- You had a CT scan of your chest.
- You saw the pulmonary doctors who ___ follow up with you
outside the hospital.
WHAT YOU NEED TO DO WHEN YOU GO HOME:
======================================
- Please continue to take you medications as prescribed.
- We increased your Ritalin to 10mg in the morning and 5mg at
noon
- We provided you with a nebulizer and medication for the
nebulizer
- Please go to your follow up appointments as outlined below.
- You are being discharged with a prescription for prednisone.
Please follow these instructions to gradually decrease the dose
you are taking:
___ Prednisone 50mg Once per Day
___ Prednisone 40mg Once per Day
___ Prednisone 30mg Once per Day
___ Prednisone 20mg Once per Day
___ Prednisone 10mg Once per Day
STOP prednisone on ___.
It was a pleasure taking care of you!
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10109899-DS-16 | 10,109,899 | 22,481,282 | DS | 16 | 2163-09-27 00:00:00 | 2163-09-27 17:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee Sting
Attending: ___.
Chief Complaint:
Constipation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with past medical
history of hypertension, HFpEF, OSA on CPAP, COPD, prediabetes
who presents after 8 days of constipation with E.D. course
complicated by left facial droop and hypoxemia to mid-80s on RA.
The patient says that at baseline she has about 2 bowel
movements
per week. In the past week she has not had any bowel movements
despite taking her daily MiraLAX at home, milk of magnesia, and
2
enemas in the past 2 days. She says that she feels very
distended
in her abdomen but she still continues to pass gas.
She denies any bright red blood per rectum, melena, nausea,
vomiting, decreased appetite, dysuria, urinary retention, loose
stools previously or small amounts of loose stools currently.
She says that there has not been any changes in her medications
and she does not take any pain medications that would cause her
to be constipated.
While she was being brought in by EMS, she was also noted to
have
a left facial droop greater than right. Patient denies a history
of strokes and denies a history of left facial droop. She also
denies headaches, weakness in any of her limbs or face, slurring
of words or word finding difficulties.
No hospitalizations in the last 3 months.
She has had previous hospitalizations for asthma/COPD overlap
syndrome and chronic aspiration (last in ___. During this
hospital stay, she was slow to respond to prednisone 40 mg qd
but
responded briskly to 80mg qd, and continued to have
desaturations
with ambulation requiring NC O2.
Her prior imaging was not suggestive of EGPA or ABPA,
but does confirm emphysema. She also has recurrent aspiration
from esophageal reflux.
H/o cough, denies fevers/chills.
In the ED:
- Initial vital signs were:
Pain 4 Tc: 98.9 HR 66 BP 112/71 RR 18 95% RA
- Exam notable for:
Lung sounds with diffuse wheezes and restricted air movement.
- Labs were notable for:
Trop-T: <0.01
Lactate:1.0
proBNP: 417
Bicarb 35
Cl 94
- Studies performed include:
ECG unchanged
X-ray with infiltrates and spine sign
- Patient was given:
Given steroids, azithromycin, ceftriaxone for COPD exacerbation.
___ 15:08POLactulose 30 ___
___ 15:08PRFleet Enema (Saline) 1 Enema
___ 21:16IHAlbuterol Inhaler 2 PUFF
___ 21:17NEBIpratropium-Albuterol Neb 1 NEB
___ 21:17PO/NGAtorvastatin 10 mg
___ 21:17PO/NGClorazepate Dipotassium 3.75 mg
___ 21:17PO/NGMirtazapine 7.5 mg
___ 21:17PORisperiDONE 2 mg
___ 21:17POZolpidem Tartrate 5 mg
___ 21:36PO/NGPramipexole .25 mg
___ 06:07NEBIpratropium-Albuterol Neb 1 NEB
___ 08:23IHAlbuterol Inhaler 2 PUFF
___ 08:23PO/NGPolyethylene Glycol 17 g
___ 08:23PO/NGamLODIPine 2.5 mg
___ 08:23PO/NGClorazepate Dipotassium 3.75 mg
___ 08:23PO/NGHydrochlorothiazide 25 mg
___ 08:23PO/NGLevothyroxine Sodium 137 mcg
___ 08:23PO/NGMethylPHENIDATE (Ritalin) 2.5
___ 08:23PO/NGMontelukast 10 mg
___ 08:23PO/NGTopiramate (Topamax) 25 mg
___ 08:28PODULoxetine 40 mg
___ 09:23POAzithromycin 1000 mg
___ 09:23POPredniSONE 60 mg
___ 11:27PO/NGClorazepate Dipotassium 3.75 mg
___ 11:27IHAlbuterol 0.083% Neb Soln 1 NEB
___ 11:27IVCefTRIAXone
___ 11:29IHIpratropium Bromide Neb 1 Neb
___ 11:49IVCefTRIAXone 1 g
___ 12:00NEBIpratropium-Albuterol Neb
___ 16:40PO/NGClorazepate Dipotassium 3.75 mg
___ 16:40IHAlbuterol 0.083% Neb Soln 1 NEB
___ 16:40IHIpratropium Bromide Neb 1 Neb
- Consults: ___, Case Management
- Vitals on transfer: Afebrile HR 81 BP 114/64 RR 18 94% 4LNC
Hypoxic to the mid ___ on room air
Upon arrival to the floor, the patient reports that she had a
very large bowel movement in the E.D.. She also notes that while
in the E.D., she was consuming something (does not remember
what)
and she felt like she was choking/coughing, which is consistent
with her previous chronic aspirations. Of note, she does not use
her CPAP machine because she's afraid of it being an infectious
source. (During her ___ admission, someone was supposed to
clean it, but never did. Her daughter threw it out.) Also of
note, she has been on a long steroid taper (through pulm) and
she
last took 2.5 mg prednisone in ___. She is not
complaining of any dyspnea, has not been coughing recently or
bringing up any sputum. She feels at her baseline. She was told
not to ambulate until ___ saw her but feels like she would
tolerate ambulating okay.
Past Medical History:
-chronic / recurrent hyponatremia: hospitalized for Na 121 in
___ and Na 125 in ___. Final dx unclear, attributed to
polydipsia plus thiazide
-HTN
-posterior circulation TIA: MRI negative stroke (___)
-hypothyroidism
-depression/anxiety
-osteoporosis c/b thoracic compression fractures, followed by
neurosurg
Social History:
___
Family History:
Father had an MI in his late ___ and mother had an MI in her
late ___. No apparent history of endocrinopathies.
Physical Exam:
Admission Physical Exam:
==========================
VITALS: Afebrile, 101/59, Sat 94% on 5L, HR 76, RR 18
General appearance: Obese, cushingoid appearing woman lying in
bed
HEENT: PERRLA, EOMI, moist mucous membranes, JVP difficult to
assess due to body habitus
Cardiovascular: Regular rate and rhythm, no murmurs rubs or
gallops
Lungs: Diffuse bilateral end-expiratory wheezes, no rhonchi or
rales
Abdomen: Normoactive bowel sounds, soft, obese, non-distended,
nontender to palpation in all 4 quadrants
Extremities: No lower leg edema
Neuro:
On initial testing, patient with forehead-sparring mild left
facial droop, but by end of interview, on repeat testing CN
II-XII intact
5 out of 5 strength in bilateral upper and extremities on
flexion
and extension, lower extremities bilaterally antigravity,
sensation intact to light touch bilaterally, gait deferred,
alert and oriented A&Ox3, able to say the days of the week
backwards
Discharge Physical Exam:
==========================
___ ___ Temp: 97.5 PO BP: 161/91 Lying HR: 78 RR: 18 O2
sat: 90% O2 delivery: Ra
General appearance: Obese, chronically ill-appearing woman
HEENT: PERRLA, EOMI, MMM, no JVP
Cardiovascular: RRR, no murmurs rubs or gallops
Lungs: Diffuse b/l high-pitched end-expiratory wheezes, no
rhonchi or rales
Abdomen: NABS , soft, obese, non-distended, nontender to
palpation in all 4 quadrants
Extremities: No ___ edema. No cyanosis or clubbing.
Pertinent Results:
Admission Labs:
================
___ 01:30PM BLOOD WBC-8.3 RBC-4.02 Hgb-11.9 Hct-37.4 MCV-93
MCH-29.6 MCHC-31.8* RDW-13.3 RDWSD-45.5 Plt ___
___ 01:30PM BLOOD Neuts-69.4 Lymphs-18.2* Monos-10.0
Eos-1.4 Baso-0.8 Im ___ AbsNeut-5.77 AbsLymp-1.52
AbsMono-0.83* AbsEos-0.12 AbsBaso-0.07
___ 01:30PM BLOOD Glucose-147* UreaN-12 Creat-0.8 Na-139
K-3.8 Cl-94* HCO3-35* AnGap-10
___ 01:30PM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
Notable Labs:
=============
___ 09:27AM BLOOD cTropnT-<0.01
___ 09:27AM BLOOD proBNP-417*
___ 09:33AM BLOOD Lactate-1.0
Discharge Labs:
================
___ 08:00AM BLOOD WBC-12.1* RBC-4.00 Hgb-11.8 Hct-37.4
MCV-94 MCH-29.5 MCHC-31.6* RDW-13.7 RDWSD-46.7* Plt ___
___ 08:00AM BLOOD Glucose-72 UreaN-16 Creat-0.8 Na-141
K-4.1 Cl-93* HCO3-35* AnGap-13
___ 08:00AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2
Imaging:
==========
Chest X Ray ___
IMPRESSION: Bibasilar opacities likely atelectasis, difficult to
exclude a superimposed pneumonia in the correct clinical
setting.
Brief Hospital Course:
Summary:
-----------
Ms. ___ is a ___ year-old woman with a history of
COPD, chronic aspiration, chronic constipation, hypertension,
who presented to the Emergency Department after 8 days of
constipation, and was found to be hypoxemic and wheezing
concerning for an acute on chronic asthma/COPD exacerbation.
ACUTE ISSUES:
=============
#Hypoxemia
#Aspiration
#Acute on chronic COPD/Asthma exacerbation: The patient was
noted to have a baseline oxygen saturation of 94% without oxygen
at home. Pt presented with hypoxia with ambulation and diffuse
wheezing on lung examination. The most likely etiology for the
patient's hypoxia was thought to be COPD exacerbation with URI
and also recent discontinuation of a prolonged prednisone taper
as an outpatient. There was a low clinical suspicion for
pneumonia. She was experiencing cold symptoms on admission,
which may have triggered her COPD exacerbation. In addition, she
was recently tapered off steroids, and this was a concern for
her outpatient pulmonologist. Due to her history of chocking and
coughing after ingestion speech and swallow was consulted and
evaluated the patient at the bedside. They recommended against
straws, and a soft dysphagia diet. Upon discharge, she was
asymptomatic from a respiratory standpoint, but was diffusely
wheezing on exam. Upon discharge, ambulatory O2 sat was greater
than 90%. She will continue azithromycin 250 mg PO daily and
prednisone 60 mg daily until ___. Per her outpatient
pulmonologist, she will continue a prednisone taper and be
started tioptropium on discharge.
#Insomnia: She reported insomnia after trazadone was stopped on
___
following PACT medication reconciliation. She was likely having
trouble sleeping due to steroids. She was continued on home
Ambien, and managed on trazadone while admitted.
#Left facial droop: The patient was noted to have a transient
asymmetrical facial drop while in the emergency department.
There was no evidence of facial droop, palsy, or NLF flattening
on serial exams. Review of records revealed this issue was
documented in ___ as a transient issue. There was a very low
clinical suspicion for TIA.
#Constipation: The patient reported a baseline of 2 bowel
movements weekly Although this was the reason she presented.
This issue resolved in the Emergency Department with increased
bowel regimen. Her home bowel regimen was continued, and
lactulose was added with good effect.
#Safe Discharge
There was initial concern that patient may require
rehabilitation. It was noted that she lives at home alone, with
a home health aide 2 days per week for 4 hours who helps with
cooking, cleaning and bathing. Physical therapy was consulted
and cleared for discharge home with services.
CHRONIC ISSUES:
===============
#Hypertension
She was continued on her home amlodipine, hydrochlorothiazide,
and lisinopril during her admission.
#Anxiety/Depression
She was continued on duloxetine, methylphenidate, mirtazapine,
risperidone, zolpidem, trazodone, clorazepate, and pramipexole
during her admission. As mentioned above, she reported insomnia
after trazadone was stopped on ___ following PACT medication
reconciliation. She was continued on zolpidem for insomina.
#Hypothyroidism
She was continued on her home levothyroxine during her
admission.
#GERD
She was continued on her home omeprazole regimen.
#Urinary retention
She was continued on oxybutynin.
#Hyperlipidemia
She was continued on atorvastatin.
TRANSITIONAL ISSUES:
====================
#Obstructive Sleep Apnea not on CPAP: After her hospitalization
in ___, she was supposed to get CPAP cleaned, but it never
happened and given fear of infection, her daughter threw it out.
Please help this patient acquire another CPAP machine.
#Polypharmacy/medication review: ___ medication reconciliation
showed discrepancies in her outpatient medication list and
medications filled at her pharmacy. For instance, OMR/PAML
listed trazodone, but neither ___ nor ___ has filled
for over a year and a half. Outpatient follow up to consolidate
and review her medications may be beneficial.
#Aspiration precautions: Per nutrition, recommend 1) Diet:
Soft solids with thin liquids 2) Medications: Whole embedded in
puree 3) Oral care: TID 4) Aspiration Precautions: - Fully
upright for all PO intake, - NO STRAWS, - Small bites/sips, -
Alternate bites/sips, - Swallow x2 per sip of liquid
[] New medications:
- Prednisone taper: 40mg x 4 days. 30 x 4 days, 20 x 4 days, 10
x
4 days, 5 x 4 days, then 2.5 for a week
- Azithromycin 250 mg daily until ___
- Tiotropium Bromide 1 cap IH daily
#CODE: Full (presumed)
#CONTACT/health care proxy: ___ Relationship: son
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. mepolizumab 100 mg subcutaneous every 4 weeks
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. amLODIPine 2.5 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. DULoxetine 40 mg PO DAILY
8. Hydrochlorothiazide 25 mg PO DAILY
9. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
10. Lisinopril 40 mg PO DAILY
11. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
12. Mirtazapine 7.5 mg PO QHS
13. Montelukast 10 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. Pramipexole 0.25 mg PO QPM
16. RisperiDONE 2 mg PO QHS
17. Topiramate (Topamax) 25 mg PO DAILY
18. Vitamin D 1000 UNIT PO DAILY
19. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
20. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
21. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
22. Zolpidem Tartrate 5 mg PO QHS
23. Atorvastatin 10 mg PO QPM
24. Clorazepate Dipotassium 3.75 mg PO BID
25. Levothyroxine Sodium 137 mcg PO QAM 30 MINUTES BEFORE
BREAKFAST
26. MethylPHENIDATE (Ritalin) 5 mg PO QPM
27. Omeprazole 20 mg PO DAILY
28. Oxybutynin 5 mg PO DAILY
29. Multivitamins W/minerals 1 TAB PO DAILY
30. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
31. Senna 17.2 mg PO QHS
32. DULoxetine 60 mg PO QPM
Discharge Medications:
1. Bisacodyl 10 mg PO DAILY
RX *bisacodyl 5 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing/sob
3. Lactulose 15 mL PO DAILY
RX *lactulose 10 gram/15 mL (15 mL) 15 ml by mouth once a day
Disp #*30 Package Refills:*0
4. PredniSONE 2.5 mg PO DAILY Duration: 7 Doses
Start: After 5 mg DAILY tapered dose
This is dose # 6 of 6 tapered doses
RX *prednisone 2.5 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
5. PredniSONE 60 mg PO DAILY Duration: 1 Day
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
6. PredniSONE 40 mg PO DAILY Duration: 4 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 6 tapered doses
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*8
Tablet Refills:*0
7. PredniSONE 30 mg PO DAILY Duration: 4 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 2 of 6 tapered doses
RX *prednisone 10 mg 3 tablet(s) by mouth once a day Disp #*12
Tablet Refills:*0
8. PredniSONE 20 mg PO DAILY Duration: 4 Doses
Start: After 30 mg DAILY tapered dose
This is dose # 3 of 6 tapered doses
RX *prednisone 20 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
9. PredniSONE 10 mg PO DAILY Duration: 4 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 4 of 6 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
10. PredniSONE 5 mg PO DAILY Duration: 4 Doses
Start: After 10 mg DAILY tapered dose
This is dose # 5 of 6 tapered doses
RX *prednisone 5 mg 1 tablet(s) by mouth once a day Disp #*4
Tablet Refills:*0
11. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 cap
INH once a day Disp #*30 Capsule Refills:*0
12. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
14. amLODIPine 2.5 mg PO DAILY
15. Ascorbic Acid ___ mg PO DAILY
16. Aspirin 81 mg PO DAILY
17. Atorvastatin 10 mg PO QPM
18. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
19. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral BID
20. Clorazepate Dipotassium 3.75 mg PO BID
21. Docusate Sodium 100 mg PO BID
22. DULoxetine 40 mg PO DAILY
23. DULoxetine 60 mg PO QPM
24. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
25. Hydrochlorothiazide 25 mg PO DAILY
26. Levothyroxine Sodium 137 mcg PO QAM 30 MINUTES BEFORE
BREAKFAST
27. Lisinopril 40 mg PO DAILY
28. mepolizumab 100 mg subcutaneous every 4 weeks
29. MethylPHENIDATE (Ritalin) 10 mg PO DAILY
30. MethylPHENIDATE (Ritalin) 5 mg PO QPM
31. Mirtazapine 7.5 mg PO QHS
32. Montelukast 10 mg PO DAILY
33. Multivitamins W/minerals 1 TAB PO DAILY
34. Omeprazole 20 mg PO DAILY
35. Oxybutynin 5 mg PO DAILY
36. Polyethylene Glycol 17 g PO DAILY
37. Pramipexole 0.25 mg PO QPM
38. RisperiDONE 2 mg PO QHS
39. Senna 17.2 mg PO QHS
40. Topiramate (Topamax) 25 mg PO DAILY
41. Vitamin D 1000 UNIT PO DAILY
42. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
===================
COPD Exacerbation
Aspiration
Constipation
Secondary Diagnosis:
=======================
Obstructive Sleep Apnea (Not on CPAP)
HTN
Anxiety
Depression
Hypothyroidism
GERD
Hyperlipidemia
Urinary Retention
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. ___,
WHY WERE YOU ADMITTED?
- Your oxygen levels were low
WHAT WAS DONE FOR YOU WHILE YOU WERE HERE?
- You were treated for worsening of your lung disease
- Your swallowing was evaluated, and you were choking when you
used straws
WHAT SHOULD YOU DO WHEN YOU GO HOME?
- Continue to take your medications as prescribed. You will take
a medication azithromycin for one more day (tomorrow). You will
also be on a prednisone taper (instructions below) and we will
start you on a new inhaler called tiotropium.
- Go to your follow up appointments with all of your doctors
- Stop using straws for drinking
It was a pleasure taking care of you, and we wish you well!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10109899-DS-17 | 10,109,899 | 24,741,636 | DS | 17 | 2163-11-06 00:00:00 | 2163-11-06 16:09:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bee Sting
Attending: ___
Chief Complaint:
Inability to stand from Couch
Major Surgical or Invasive Procedure:
ERCP - ___
History of Present Illness:
Ms. ___ is a ___ woman with past medical
history of hypertension, HFpEF, OSA on CPAP, COPD,
anxiety, and prediabetes who presented to the ED on ___ with
difficulty of getting up from a sitting position off of the
couch. Patient noted weakness in her legs and called ___. Due to
her weakness patient was brought to the ED where it was found
that she had RUQ pain on exam, but denied pain at baseline.
Patient notes no change in color of stools, but does note some
loose stools for the last 3 days.
** In the ED patient had RUQ pain, was found with
hyperbilirubinemia and had an US consistent with pancreatic mass
causing blockage to biliary system. Mass is concerning for
malignancy **
Patient notes she lives alone in her apartment and has a
visiting nurse who comes twice a week that does "everything" for
her. She notes she otherwise can get up and get dressed on her
own and also cooks her own meals.
She has a significant list of medications that she notes she
takes, but cannot name most of the tablets, but knows about the
injectables. Patient does note she uses a pill box but also
notes some of her meds are packaged.
This morning patient so sleepy I was unable to awaken her
effectively (she would awaken then fall back asleep).
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
-chronic / recurrent hyponatremia: hospitalized for Na 121 in
___ and Na 125 in ___. Final dx unclear, attributed to
polydipsia plus thiazide
-HTN
-posterior circulation TIA: MRI negative stroke (___)
-hypothyroidism
-depression/anxiety
-osteoporosis c/b thoracic compression fractures, hx/ L scapula
fracture; followed by neurosurg --> She had three-week reclast
infusions
-dCHF - although last echo in our system is from ___
-Degenerative Joint Disease
-Stress Incontinence
-Sensorineural Hearing loss assymetric, ___
- PUD
-Migraines (NO OPIOIDS)
-Gait disturbance
-Restless Leg Syndrome
-Parkinsonianism
-Bilateral Basal Ganglia and R Thalamic Lacunar Infarcts
-Colonic Adenoma, hx/ colitis
-Dilated esophagus: esophageal manometry showed ineffective
contractions of the esophagus and only 1 normal parasystolic
contraction. her diagnosis is ineffective esophageal motility
___.
-Chronic Constipation
-COPD
-Obesity
-Pre-diabetes
-High functioning Schizophrenia or Bipolar disorder (Spoke with
Patient's Psychiatrist Dr. ___ ___
Social History:
___
Family History:
Father had an MI in his late ___ and mother had an MI in her
late ___.
Physical Exam:
On Admission:
VITALS: Afebrile and vital signs stable
24 HR Data (last updated ___ @ 843) Temp: 97.7 (Tm 97.7),
BP: 143/87 (140-143/76-87), HR: 72 (60-72), RR: 16, O2 sat: 97%
(95-97), O2 delivery: 2L NC
GENERAL: Elderly appearing. NAD around 9AM examination
EYES: icteric sclera. pupils equally round
ENT: Small oropharynx. Dry. Mallampati IV
CV: Heart regular, no murmur. No JVD
RESP: Moderate air movement. Prolonged expiratory phase with
slight end-expiratory wheeze. No crackles.
GI: Abdomen soft, non-distended, Tender RUQ without guarding.
MSK: ___ strength in extremities throughout.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI, non focal
PSYCH: pleasant, appropriate affect
Pertinent Results:
ADMISSION LABS:
___ 07:52PM BLOOD WBC-11.4* RBC-3.77* Hgb-11.0* Hct-33.6*
MCV-89 MCH-29.2 MCHC-32.7 RDW-14.3 RDWSD-46.0 Plt ___
___ 07:52PM BLOOD Neuts-74.0* Lymphs-11.5* Monos-13.2*
Eos-0.2* Baso-0.5 Im ___ AbsNeut-8.47* AbsLymp-1.31
AbsMono-1.51* AbsEos-0.02* AbsBaso-0.06
___ 07:58PM BLOOD ___ PTT-25.6 ___
___ 07:52PM BLOOD Glucose-122* UreaN-17 Creat-1.1 Na-129*
K-5.1 Cl-87* HCO3-24 AnGap-18
___ 07:52PM BLOOD ALT-86* AST-135* AlkPhos-683*
TotBili-5.2* DirBili-2.4* IndBili-2.8
___ 07:52PM BLOOD Albumin-3.3* Calcium-9.6 Phos-3.7 Mg-2.1
OTHER PERTINENT LABS:
___ 05:50AM BLOOD cTropnT-<0.01 proBNP-1153*
___ 09:25AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
IgM HBc-NEG IgM HAV-NEG
___ 05:50AM BLOOD CEA-251.2*
___ 09:25AM BLOOD ___
___ 09:25AM BLOOD IgG-727
___ 07:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS* Barbitr-NEG Tricycl-NEG
___:25AM BLOOD HCV Ab-NEG
___ 05:50AM BLOOD ___
CXR - IMPRESSION:
Limited study due to low lung volumes in kyphotic patient.
Re-demonstrated
chronic deformities of the left ribcage and left scapula. No
new focal
consolidation seen.
CT Head - IMPRESSION:
No acute intracranial process.
RUQ U/S - IMPRESSION:
1. Hypoechoic mass in the region of the pancreatic head
measuring up to 3.6 cm
concerning for malignancy. Severe upstream pancreatic ductal
dilatation.
Severe intra and extrahepatic biliary dilatation. Contrast
enhanced CT or MRI
is recommended for further evaluation, if no clinical
contraindication to
contrast.
2. Multiple hypoechoic mass within liver, concerning for
metastases.
3. Sludge within the gallbladder, but no evidence of acute
cholecystitis.
CT Chest - IMPRESSION:
-Extensive pulmonary embolism involving both the right and left
main pulmonary
arteries extending into the lobar and segmental branches. Right
heart strain
is suggested. No evidence of pulmonary infarct.
-No evidence of intrathoracic metastasis.
CT A/P - IMPRESSION:
1. Ill-defined pancreatic uncinate mass with locally invasive
disease
involving the SMA and SMV as detailed above.
2. Numerous ill-defined hypodense lesions throughout the liver
are highly
concerning for liver metastases.
3. Enlarged upper retroperitoneal and mesenteric lymph nodes
some of which
appear necrotic.
TTE - IMPRESSION: Mild right ventricular free wall hypokinesis
with evidence of pressure overload. Severe pulmonary
hypertension. Normal left ventricular systolic function.
Possible atrial septal defect vs. stretched patent foramen ovale
(saline contrast may be considered if clinically indicated).
Compared with the prior study (images reviewed) of ___,
the right ventricle appears hypokinetic and severe pulmonary
hypertension is detected (previous images suboptimal for
comparison however).
CYTOLOGY REPORT - Final
SPECIMEN(S) SUBMITTED: COMMON BILE DUCT BRUSHINGS
DIAGNOSIS:
Common bile duct stricture, brushings:
POSITIVE FOR MALIGNANT CELLS.
- Adenocarcinoma.
SPECIMEN DESCRIPTION:
Received: brush in Cytolyt.
Prepared: 1 monolayer, 1 cell block
CLINICAL HISTORY:
___ year old female with history of COPD and allergies, presents
with weakness, and right upper
quadrant pain. ALT 86, AST 135, ALP 683, TB-5.2, DB-2.4.
Hypoechoic mass in the region of the
pancreatic head measuring up to 3.6 cm concerning for
malignancy. Severe upsteam pancreatic
ductal dilatation. Severe intra and extrahepatic biliary
dilatation. Multiple hypoechoic mass within
liver, concerning for metastases.
Fellow(s): ___, MD
CYTOLOGY REPORT - ___
SPECIMEN(S) SUBMITTED: FINE NEEDLE ASPIRATION, liver mass
DIAGNOSIS:
Liver mass, FNA:
POSITIVE FOR MALIGNANT CELLS.
- Metastatic adenocarcinoma with necrosis, see note.
Note: The prepared cell block has high tumor cellularity. On
immunohistochemistry, the tumor cells
are positive for CK7 (diffuse), positive for CK20 (rare), and
CDX2 (rare). The morphology and
immunoprofile are consistent with spread from a carcinoma of
pancreaticobiliary or upper
gastrointestinal origin. The tumor cells in this specimen
morphologically resemble those in the
concurrent common bile duct brushing (___-___).
SPECIMEN DESCRIPTION:
Received: in Cytolyt.
Prepared: 1 monolayer, 1 cell block
CLINICAL HISTORY:
___ year old female with history of COPD and allergies, presents
with weakness, and right upper
quadrant pain. ALT 86, AST 135, ALP 683, TB-5.2, DB-2.4.
Hypoechoic mass in the region of the
pancreatic head measuring up to 3.6 cm concerning for
malignancy. Severe upsteam pancreatic
ductal dilatation. Severe intra and extrahepatic biliary
dilatation. Multiple hypoechoic mass within
liver, concerning for metastases.
Fellow(s): ___, MD
Brief Hospital Course:
Ms. ___ is a ___ woman with past medical
history of hypertension, HFpEF, OSA on CPAP, COPD, anxiety, and
prediabetes who presented to the ED on ___ with difficulty of
getting up from a sitting position off of the couch, found to
have biliary obstruction with pancreatic mass noted on imaging.
She is now s/p ERCP with biopsy of pancreatic mass and biliary
stent placement. Her course has been complicated by persistent
acute on chronic hypoxic respiratory failure thought to be
related to known chronic persistent asthma/COPD, but incidental
finding of multiple pulmonary emboli with evidence of right
heart strain noted on staging CT chest.
# Hepatobiliary cancer, locally invasive to liver
# Biliary obstruction
# Jaundice
Underwent ERCP with biopsy and stent placement on ___ pm.
Underwent ERCP with biopsy and stent placement. Locally invasive
to SMA/SMV and RP/mesenteric lymph nodes per staging CTA. CT
chest with incidental PE's as below, but no obvious metastatic
involvement noted. Biopsy returned consistent with metastatic
adenocarcinoma of biliary tree, metastasized to liver. Spoke to
Oncology fellow (Dr. ___ over the phone who recommended
outpatient follow for discussing various management options.
# Acute Pulmonary emboli
# Right heart strain
Incidentally noted on staging CT chest overnight on ___.
Patient with ongoing acute on chronic hypoxic respiratory
failure which was initially attributed to her known chronic
persistent asthma/COPD. She has a significant component of
pulmonary hypertension as well as evidence of right heart strain
on imaging, but her O2 requirement has been stable and she has
been hemodynamically stable since admission (though functionally
bed-bound). She was initially started on heparin gtt, but has
since been transitioned to Lovenox 80 mg q12h which will be
continued at discharge.
# Polypharmacy
Patient is on quite a few sedating medications,
anticholinergics, and stimulating medications. Discussed with
psychiatrics which meds would be best to pair off first. Due to
inability to wake up on morning of admission, her home zolpidem
has been discontinued and currently still holding mirtazapine
and methylphenidate (which will be held at discharge). Patient's
outpatient psychiatrist is Dr. ___ - recommend follow
up as outpatinet.
# Depression
# Anxiety
# High functioning schizophrenia or bipolar disorder
- Continued home Duloxetine (40 qAM, 60 qPM)
- Continued long acting benzos
- Continued Risperidone
# Refractory COPD/Asthma:
Followed by Dr. ___ in ___. Continued Low dose Pred qD.
Continue inhalers while inpatient. Patient gets mepolizumab
q4weeks. Most recently ___. Resume as outpatient.
# HTN :
Initially held BP meds as dry on admission and then resumed them
throughout hospital course.
# Hypothyroidism
Continued levothyroxine
# dCHF - no treatment at this time
# Migraines - continue Topamax. Prochlorperizine
# Urinary incontinence - continue Oxybutynin (frequency changed)
# RLS - Continue pramipexole
Transition of care:
-Oncology will contact patient with an appointment to set up
care.
-Follow up with psychiatrist to adjust psychiatry meds
-Continue Lovenox for PE in the setting of malignancy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 5 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. RisperiDONE 2 mg PO QHS
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN Dyspnea
5. amLODIPine 2.5 mg PO DAILY
6. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
7. Clorazepate Dipotassium 3.75 mg PO BID
8. DULoxetine 60 mg PO QHS
9. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1
10. Hydrochlorothiazide 25 mg PO DAILY
11. Levothyroxine Sodium 137 mcg PO DAILY
12. mepolizumab 100 mg subcutaneous Every 4 weeks
13. Omeprazole 20 mg PO DAILY
14. Pramipexole 0.25 mg PO QHS
15. Prochlorperazine 5 mg PO Q8H:PRN Headache
16. Tiotropium Bromide 1 CAP IH DAILY
17. Topiramate (Topamax) 25 mg PO BID
18. Zolpidem Tartrate 10 mg PO QHS
19. Acetaminophen 1000 mg PO Q6H:PRN Pain - Moderate
20. Ascorbic Acid ___ mg PO DAILY
21. Aspirin EC 81 mg PO DAILY
22. Bisacodyl 5 mg PO DAILY:PRN Constipation
23. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral BID
24. Multivitamins 1 TAB PO DAILY
25. Senna 8.6 mg PO BID:PRN Constipation
26. Mirtazapine 7.5 mg PO QHS
27. MethylPHENIDATE (Ritalin) 10 mg PO QAM
28. Montelukast 10 mg PO DAILY
29. DULoxetine 40 mg PO QAM
30. Ditropan XL (oxybutynin chloride) 5 mg oral DAILY
31. Atorvastatin 10 mg PO QPM
32. Lactulose 30 mL PO BID
33. Docusate Sodium 100 mg PO BID
34. Polyethylene Glycol 17 g PO DAILY
35. MethylPHENIDATE (Ritalin) 5 mg PO NOON
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze
2. Enoxaparin Sodium 80 mg SC Q12H
3. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
4. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
Dyspnea
5. Oxybutynin 5 mg PO BID
6. Acetaminophen 650 mg PO TID
7. Bisacodyl ___AILY:PRN Constipation - Second Line
8. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE MR1:PRN Anaphylaxis
9. Albuterol Inhaler ___ PUFF IH Q6H:PRN Dyspnea
10. amLODIPine 2.5 mg PO DAILY
11. Aspirin EC 81 mg PO DAILY
12. budesonide-formoterol 160-4.5 mcg/actuation inhalation BID
13. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral BID
14. Clorazepate Dipotassium 3.75 mg PO BID
15. Docusate Sodium 100 mg PO BID
16. DULoxetine 60 mg PO QHS
17. DULoxetine 40 mg PO QAM
18. Hydrochlorothiazide 25 mg PO DAILY
19. Levothyroxine Sodium 137 mcg PO DAILY
20. Lisinopril 40 mg PO DAILY
21. mepolizumab 100 mg subcutaneous Every 4 weeks
22. Montelukast 10 mg PO DAILY
23. Multivitamins 1 TAB PO DAILY
24. Omeprazole 20 mg PO DAILY
25. Polyethylene Glycol 17 g PO DAILY
26. Pramipexole 0.25 mg PO QHS
27. PredniSONE 5 mg PO DAILY
28. Prochlorperazine 5 mg PO Q8H:PRN Headache
29. RisperiDONE 2 mg PO QHS
30. Senna 8.6 mg PO BID:PRN Constipation
31. Tiotropium Bromide 1 CAP IH DAILY
32. Topiramate (Topamax) 25 mg PO BID
33. 160-4.5 mcg/actuation inhalation BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cancer in the biliary system with local metastases
Acute pulmonary Embolism
Depression/Anxiety/High functioning schizophrenia or bipolar
disorder
Refractory COPD/Asthma
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You presented to the hospital with weakness and were found to
have a pancreatic mass causing bile duct blockage. You had a
stent placed for this blockage, and you had biopsies sent.
Unfortunately, these biopsies were consistent with a cancer
arising from the bile ducts. CT scans showed evidence that this
cancer has spread locally. There was also evidence of blood
clots in your lungs, for which you were started on blood
thinning medications.
The oncologists have recommended outpatient follow up with an
oncologist. An appointment will be set up for you to follow up
with an oncologist to discuss your cancer.
Followup Instructions:
___
|
10110107-DS-13 | 10,110,107 | 23,646,062 | DS | 13 | 2138-10-11 00:00:00 | 2138-10-11 18:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
PEA arrest
Major Surgical or Invasive Procedure:
Cardiac Catheterization ___
History of Present Illness:
___ y/o male with HTN, HLD, DM, bladder cancer, found cyanotic
and unresponsive in running car outside of hospital, valet
notified and Code Blue was called. Code Team arrived and started
CPR, patient brought into hospital with CPR ongoing. Unknown
down time, unknown initial rhythm. IO placed in left leg for
access. Patient received ongoing CPR, 1x round epinephrine, 2g
calcium, magnesium. ROSC obtained with narrow complex
tachycardia and ectopy. Intubated by anesthesia team, difficult
anterior airway. After intubation, patient gagging and
hypertensive to SBP >220. Given 100mg propofol push and started
on drip. After push patient now hypotensive to SBP ___, will
continue low dose propofol and give IVF. ___ CVL, IV right
and left 18 gauge, IO left leg. Received 2L in ED. On fentanyl
and propofol.
Of note, patient is husband of patient in neuro ICU.
In the MICU, he was extubated after just a few hours of
intubation. Head CT was
negative, CTA was negative for PE. Workup thus far has been
negative.
Past Medical History:
DM2
HTN
HLD
Bladder CA
OA
Social History:
___
Family History:
Noncontributory
Physical Exam:
ED:
Constitutional: Unresponsive
HEENT: Normocephalic, atraumatic, cyanosis to the face
Chest: Bilateral breath sounds present after intubation
Cardiovascular: Palpable pulses with CPR in progress
Abdominal: Soft
Neuro: Unresponsive
Psych: Unresponsive
Admission Exam:
GEN: WDWN adult man sitting in bed, maintaining eye contact
HEENT: NCAT, sclerae anicteric, normal conjunctivae, PERRL,
EOMI,
oropharynx clear, intubated
CV: RRR, normal S1/S2, no m/r/g
RESP: CTAB, no increased work of breathing
GI: Soft, ___, normoactive BS
MSK: Warm, DP pulses 2+ bilaterally, no edema
NEURO: Alert, following commands, CN grossly intact
Discharge:
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
DERM: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission Labs:
___ 12:46PM ___
___
___ 12:46PM cTropnT-<0.01
___ 12:46PM ALT(SGPT)-24 AST(SGOT)-51* ALK ___ TOT
___
___ 12:46PM ___ UREA ___
___ TOTAL ___ ANION ___
___ 12:56PM ___
___ 03:10PM ___
___ 03:10PM ___
___
___ 03:10PM ___
___
___ 11:05PM URINE ___
___
Notable Tests:
CT Head with Contrast
1. No acute intracranial abnormality. Please note MRI of the
brain is more sensitive for the detection of acute infarct.
2. Approximate 1 cm left frontal ___ calcified
structure. While
finding may represent dural calcification, calcified meningioma
is not
excluded on the basis of this examination.
CTA Chest:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Right lower lobe atelectasis.
3. Appropriately positioned endotracheal tube. Partly imaged,
mildly
distended stomach. Partially imaged enteric tube.
Catheterization:
No angiographically apparent coronary artery disease.
CXR:
Comparison to ___. No relevant change is seen.
Minimal left basilar atelectasis. No pleural effusions. No
pneumonia, no pulmonary edema. Borderline size of the cardiac
silhouette. No pneumothorax.
All blood and urine cultures negative.
Brief Hospital Course:
TRANSITIONAL ISSUES
===================
[ ] PCP - ___ up regarding Opioid Use Disorder and pain
contract
[ ] Prolactin noted to be elevated during admission. Consider
repeating and working up further as outpatient.
[ ] CT head revealed possible meningioma
PATIENT SUMMARY
===============
Mr. ___ is a ___ ___ with a past medical history of
DM2, HTN, HLD, who was admitted to the hospital for ___
care after PEA arrest.
ACUTE ISSUES
============
#S/P PEA Arrest
Mr. ___ was found in his vehicle in the parking garage by valet
staff. He was found to be unresponsive, and and was thought to
be found moments after arrest because he was able to drive up to
the valet. Notably, vomit was found in his vehicle. True down
time unknown. It is not clear if the patient experienced a true
arrest. Blood pressures were labile upon admission, but
continued to be stable to mildly hypertensive in the hospital.
Extensive cardiac ___ was performed - TTE showed some focal
dyskinesia and stunning consistent with longstanding coronary
disease in the setting of CPR. Troponins were negative, and EKG
did not show signs of ischemia. A cardiac catheterization was
performed, showing no coronary artery disease. Infectious workup
was all negative. Notably, toxicology screen was positive for
benzos and oxycodone. He says he takes these medications at home
for his chronic sciatica. In the hospital, he had multiple
transient episodes of disorientation, one of which promptly
resolved with Narcan administration. Patient admitted to having
his wife's home oxycodone with him in the hospital for his knee
pain. It is possible that original arrest was secondary to
aspiration and respiratory arrest in the setting of over
sedation.
# ___
Patient was found to have a creatinine of 1.5 on admission,
which improved over the course of his hospitalization. His
baseline Creatinine is ___ was likely ___ in
etiology, and has since resolved.
CHRONIC ISSUES
==============
# DM2
While in the hospital, patient was on an insulin sliding scale,
home metformin was held. Restarted at discharge.
# HTN
Continued on home lisinopril.
# HLD
Continued on home atorvastatin.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Xultophy 100/3.6 (insulin ___ 100 ___
mg /mL (3 mL) subcutaneous QHS
4. Diazepam 5 mg PO DAILY:PRN anxiety
5. Lumigan 0.03% Ophth (*NF*) 1 drop Other DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Naloxone Nasal Spray 4 mg IH ONCE MR1 Duration: 1 Dose
RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasal once
Disp #*1 Spray Refills:*0
3. Atorvastatin 40 mg PO QPM
4. Lisinopril 10 mg PO DAILY
5. Lumigan 0.03% Ophth (*NF*) 1 drop Other DAILY
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Xultophy 100/3.6 (insulin ___ 100 ___
mg /mL (3 mL) subcutaneous QHS
8. HELD- Diazepam 5 mg PO DAILY:PRN anxiety This medication was
held. Do not restart Diazepam until you talk with your primary
care physician
___:
Home
Discharge Diagnosis:
Cardiac Arrest
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
- You were admitted because your heart stopped, and you
experienced a cardiac arrest.
What happened while I was in the hospital?
- You underwent extensive testing to determine the cause of your
cardiac arrest, all of which returned negative. You were also
seen by the neurologists, who did not believe there was any
neurologic cause to your symptoms. Your symptoms were ultimately
thought to be due excess use of opioid medications.
What should I do after leaving the hospital?
- Please take your medications as listed in discharge summary
and follow up at the listed appointments.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10110363-DS-3 | 10,110,363 | 21,842,992 | DS | 3 | 2167-06-22 00:00:00 | 2167-06-22 20:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
AMS, New ___ with ischemic stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH Atrial Fib and recently discovered metastatic pancreatic
CA who initially presented with altered mental status, found to
have large ___ and ischemic stroke. Recently found to have
widely metastatic pancreatic cancer to liver and including
pleural mets. Went to PCP office to have INR check prior to
biopsy. Acting strange in PCP office with AMS, EKG showed
dynamic ischemic changes. Sent to the ED, CT Torso including CTA
showed small peripheral PEs but more importantly a large ___
with evidence of parietal lobe infarct as well.
In the ED, initial VS were: 13:52 0 96.2 80 142/103 18. Upon
arrival patient complains of feeling lightheaded and general
malaise. Patients heart rate went into the 120s while in the ED
and he had chest tightness. No accompanying fevers/chills, cough
or dysuria.
In the MICU, neurology was consulted and discovered homonymous
hemianopsia and antegrade amnesia. He was changed to Lovenox
from Heparin drip without plan to restart Coumadin. Patient had
ongoing chest pain with stable EKG depressions. CP thought most
likely liver pain from metastatic disease and cardiology
consulted who did not feel strongly about EKG changes being
ischemic.
Review of Systems:
(+) Per HPI
Patient complaining of some RUQ pain/CP but otherwise is
inattentive and cannot complete a full ROS
Past Medical History:
Pancreatic mass
Liver metastases
Atrial fibrillation
HYPERTENSION - ESSENTIAL
HYPERCHOLESTEROLEMIA
PULMONIC VALVE ATRESIA, CONGENITAL
BASAL CELL CARCINOMA recurrent rt post auricular area, r chin
COLONIC POLYPS/ ADENOMAS
DIVERTICULOSIS
DISLOCATION - SHOULDER
Cataract
Lentigo maligna
Basal cell carcinoma-lt lat inf neck ___
Social History:
___
Family History:
Mother with breast cancer age ___ but lived til her ___
Paunt with breast cancer age ___
2 sisters of which one sister with hx of colon cancer in her ___
No hx of pancreatic cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 116 133/85 12 96%RA
General: Alert, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP flat, dry mucus membranes, no LAD, scar along
left neck, supraclavicularly.
CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Tender to deep palpation, non-distended, bowel sounds
present, no organomegaly, no rebound or guarding. No sister ___
___ nodule.
GU: no foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, although left ankle deformed and swollen, non painful.
Neuro: CNII-XII intact, although right eye-lid slightly lower
than left while resting, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, normal
finger-nose-finger. Patient able to stand without drifting. No
clonus on extremities.
DISCHARGE PHYSICAL EXAM:
VITALS: 99, 98.3, 121/7., 101, 89, 94% RA
General: Alert, oriented to person and place and year, not date
or day, NAD
HEENT: Sclera anicteric, EOMI, PERRL, Supple, MMM
CV: tachycardic, normal S1 + S2, ___ crescendo decrescendo
murmur loudest at RUSB and III/VI holosystolic murmur at apex,
no rubs, gallops
Lungs: CTAB, no w/r/r
Abdomen: NT, ND, normoactive bowel sounds, no organomegaly, no
rebound or guarding.
Ext: WWP, 2+ pulses, no clubbing, cyanosis or trace b/l edema,
although left ankle deformed and swollen, non painful.
Neuro: oriented to person and place and year, not date or day,
CN II-XII intact, able to name objects, repeat ___ at 5 minutes,
normal strength and sensation
Pertinent Results:
ADMISSION:
___ 02:15PM BLOOD WBC-18.4* RBC-4.58* Hgb-13.8* Hct-43.2
MCV-94 MCH-30.1 MCHC-31.9 RDW-12.4 Plt ___
___ 02:15PM BLOOD Neuts-87.9* Lymphs-5.3* Monos-6.3 Eos-0.2
Baso-0.3
___ 02:15PM BLOOD ___ PTT-29.3 ___
___ 09:20PM BLOOD ___ 02:15PM BLOOD Glucose-78 UreaN-27* Creat-0.9 Na-136
K-4.0 Cl-96 HCO3-30 AnGap-14
___ 02:15PM BLOOD ALT-91* AST-106* AlkPhos-219* TotBili-1.0
___ 02:15PM BLOOD cTropnT-0.11*
___ 02:15PM BLOOD Albumin-3.8
___ 02:42PM BLOOD ___
___ 02:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
OTHER RELEVANT:
___ 04:29AM BLOOD WBC-13.5* RBC-4.18* Hgb-12.6* Hct-39.3*
MCV-94 MCH-30.1 MCHC-32.0 RDW-13.1 Plt ___
___ 02:45AM BLOOD PTT-95.6*
___ 09:20PM BLOOD CK-MB-23* MB Indx-15.8* cTropnT-0.34*
proBNP-4812*
___ 02:45AM BLOOD CK-MB-27* MB Indx-15.9* cTropnT-0.52*
___ 01:41PM BLOOD CK-MB-16* MB Indx-15.2* cTropnT-0.45*
___ 06:30AM BLOOD CK-MB-3 cTropnT-0.69*
___ 04:25PM BLOOD CK-MB-3 cTropnT-0.84*
___ 08:00AM BLOOD CK-MB-2 cTropnT-0.82*
___ 02:31PM BLOOD Lactate-2.4*
___ 09:45PM BLOOD Lactate-1.6
Discharge:
___ 06:10AM BLOOD WBC-14.1* RBC-3.97* Hgb-11.9* Hct-37.2*
MCV-94 MCH-30.0 MCHC-32.0 RDW-13.5 Plt ___
___ 06:10AM BLOOD Glucose-98 UreaN-28* Creat-0.9 Na-136
K-4.3 Cl-103 HCO3-28 AnGap-9
___ 08:00AM BLOOD ALT-57* AST-68* CK(CPK)-25* AlkPhos-180*
TotBili-0.9
___ 06:10AM BLOOD Calcium-7.7* Phos-2.0* Mg-2.2
___ CT HEAD NON-CON:
IMPRESSION:
1. No acute intracranial hemorrhage.
2. Hypodensity of the left occipital lobe suggests subacute left
PCA stroke.
3. Luminal hyperdensity of the basilar artery may represent
atherosclerotic
disease though acute clot is not excluded. Further evaluation
with CTA or MRA could be considered if there is high clinical
concern.
4. Mild opacification of the inferior left mastoid air cells may
represent
inflammation.
___ CXR:
IMPRESSION:
1. Mild bilateral interstitial pulmonary edema.
2. Mild degenerative changes in the glenohumeral joints
bilaterally.
___ CTA CHEST:
IMPRESSION:
1. Filling defect in the left atrial appendage compatible with
clot.
2. Small subsegmental pulmonary emboli in the right middle and
lower lobes without evidence of acute right heart strain.
3. Septal thickening and peribronchovascular interstitial
edema.
4. Multiple subpleural and parenchymal pulmonary nodules
measuring up to 7 mm in the right lower lobe and 6 mm in the
left lower lobe along with enlarged paraesophageal and
subcarinal lymph nodes compatible with intra thoracic metastatic
disease.
5. Pancreatic tail mass compatible with primary malignancy and
innumerable hepatic hypodensities compatible with extensive
hepatic metastases.
___ ECHO:
The left atrium is markedly dilated. The right atrium is
markedly dilated. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses are normal. The left
ventricular cavity size is normal. There is mild global left
ventricular hypokinesis (LVEF = 50 %). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. The right ventricular cavity is mildly dilated with
borderline normal free wall function. The aortic root is mildly
dilated at the sinus level. The ascending aorta is mildly
dilated. The aortic valve leaflets are moderately thickened.
There is mild aortic valve stenosis (valve area 1.2-1.9cm2).
Trace aortic regurgitation is seen. The mitral valve leaflets
are mildly thickened. There is no mitral valve prolapse.
Moderate (2+) mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is no pericardial effusion.
KUB ___ - FINALIZED
A non-obstructive bowel gas pattern is visualized. No free
intraperitoneal air is evident. Residual oral contrast is
present within numerous diverticula in the abdomen and pelvis.
Lumbar scoliosis is present with accompanying degenerative
changes. Widespread vascular calcifications are also noted
throughout the abdomen. Within the imaged portion of the lower
chest, note is made of cardiomegaly.
Brief Hospital Course:
___ PMH Atrial Fib and recently discovered metastatic pancreatic
CA presents with tachycardia and lightheadedness found to have
new sub acute stroke and subsegmental pulmonary emboli as well
as clot in left atrial appendage.
ACUTE ISSUES:
# Subacute L PCA stroke: Non-con CT head and neurology stroke
consult assessment most consistent with embolic disease from
left atrial appendage clot with subsequent hippocampal and
occipital infarcts resulting in confusion and anterograde
amnesia. His BP was initially permitted to be elevated for
permissive HTN, however after work-up suggested subacute rather
than acute time course, BP was more aggressively controlled in
setting of his demand cardiac ischemia. He was managed with
therapeutic anticoagulation (heparin drip transitioned to
lovenox) and had some improvement evidenced by asking
appropriate questions and interacting appropriately however
remained with frequent disorientation and word-finding
difficulties. Will continue lovenox, asa, and simvastatin. Will
need neurology follow-up.
# Left atrial appendage clot: Evidenced on CTA imaging.
Represents the likely source of PCA stroke via embolic disease.
Unfortunately due to this stroke was not a candidate for tPA.
Patient was deamed not candidate for tpa given metastatic
pancreatic cancer. Initially treated with heparin drip and
transitioned to therapeutic BID Lovenox. Patient and family
understand severity of this finding.
# Type II MI/ Troponinemia: Rate related ischemia based on EKG
ST depresions and troponin leak likely from demand in setting of
tachycardia. Seen by ___ cardiology who agreed that ACS was
not likely and much more consistent with Type II MI. Rates
improved on po metoprolol and diltiazem, which may need further
up-titration. Will remain on metoprolol, diltiazem, ASA, statin.
Will need follow-up with At___ cardiology.
# Afib with RVR: CHADS II score of 4 for HTN, Age and recent
stroke, was subtherapeutic on warfarin at home (last home dose
___ and INR 1.5). Improved with metoprolol and diltiazem as
above, may need further adjustment and Atrius cardiology
follow-up. Will continue therapeutic lovenox.
# Small subsegmental pulmonary emboli in the right middle and
lower lobes: Oxygenation stable in hospital. As above, will
continue therapeutic lovenox.
# Hypercoagulable state: Evidenced by multiple thromboembolic
phenomena including subsegmental PEs, left atrial appendage
clot, and PCA stroke. Likely secondary to pancreatic carcinoma
with metastatic disease burden. Will continue therapeutic
lovenox.
# Orthostasis by SBP and symptoms: Resolved. Was likely due to
poor po intake.
# Likely Stage IV pancreatic cancer in tail of pancreas: patient
with lung and liver nodules. Plan was to start intravenous
gemcitabine 800 mg/m2 given intravenously on Day 1 and Day 8
during a 21 day cycle for palliative intent following tissue
diagnosis, though his clinical status prevented this while in
the ICU. Seen by ___, MD, ___. Will need
follow-up with Oncology and possibly palliative care to further
define goals of care and role of palliative chemotherapy. On day
of discharge family meeting was held discussing his recent
history and plan of care moving forward. They are understanding
of disease burden and understand the options of potential signle
agent chemotherapy vs no chemotherapy and moving towards
palliative care. In either case, Palliative care may be
beneficial in consultation.
# Leukocytosis: Non-localizing history save for stable abdominal
discomfort, attributed to cancer. UA negative. Has been
afebrile. Blood cultures x2 negative to date.
# Pain: Continued home pain reg:
- Acetaminophen 650 mg PO/NG QHS with gabapentin
- Gabapentin 300-600 mg PO/NG Q8H
- Morphine Sulfate ___ 15 mg PO/NG Q3H:PRN pain Hold for
sedation/ RR<10
# Insomnia/Anxiety: Chronic, stable, continued Clonazepam 1mg PO
BID:PRN
# Facial rash: Chronic, stable held metroNIDAZOLE *NF* 0.75 %
Topical BID
Nystatin-Triamcinolone Cream 1 Appl TP BID while inpatient
TRANSITIONAL ISSUES:
# Subacute stroke: Will need neurology follow-up.
# A-fib and Type II MI: ___ need further adjustment of
metoprolol and diltiazem. Will need follow-up with Atrius
cardiology.
# Presumed pancreatic carcinoma, stage IV: Will need oncology
follow-up with Dr. ___ possibly with palliative care to
further define goals of care and role of palliative
chemotherapy.
# Cultures: Follow-up for final report, ordered for
leukocytosis.
# Pain: ___ benefit from adjustment of pain meds and use of
long-acting opioids.
#CODE: Full Code (FICU Confirmed)
#EMERGENCY CONTACT: Wife ___ ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Morphine Sulfate ___ 15 mg PO Q3H:PRN pain
Hold for sedation/ RR<10
2. Simvastatin 20 mg PO DAILY
3. Clonazepam 1 mg PO BID
HOld for sedation/ RR<10
4. Acetaminophen 650 mg PO QHS
with gabapentin
5. Warfarin 5 mg PO DAILY16
per INR
6. Gabapentin 300-600 mg PO TID
7. Temazepam ___ mg PO HS:PRN insomnia
HOld for sedation/ RR<10
8. Atenolol 50 mg PO BID
HOld for HR<60, SBP<100
9. metroNIDAZOLE *NF* 0.75 % Topical BID
to face
10. Nystatin-Triamcinolone Cream 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 650 mg PO BID:PRN pain
2. Clonazepam 1 mg PO BID
HOld for sedation/ RR<10
3. Gabapentin 300-600 mg PO TID
4. metroNIDAZOLE *NF* 0.75 % Topical BID
to face
5. Morphine Sulfate ___ 15 mg PO Q3H:PRN pain
Hold for sedation/ RR<10
6. Temazepam ___ mg PO HS:PRN insomnia
HOld for sedation/ RR<10
7. Aspirin 325 mg PO DAILY
8. Atorvastatin 40 mg PO DAILY
9. Diltiazem Extended-Release 240 mg PO DAILY
10. Docusate Sodium 200 mg PO BID
11. Enoxaparin Sodium 100 mg SC Q12H
12. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
13. Metoprolol Succinate XL 200 mg PO BID
hold for BP<100, HR<60
14. Nystatin-Triamcinolone Cream 1 Appl TP BID
15. Bisacodyl ___AILY:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
___
Discharge Diagnosis:
pulmonary embolism
cerebrovascular accident (posterior cerebral artery infarction)
metastatic pancreatic cancer
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure participating in your care at ___. You were
admitted since you were acting confused, and you were found to
have evidence of a blood clot in your lungs ("pulmonary
embolism") as well as a stroke. You were placed on a blood
thinner ("lovenox") to treat this. You will go to a rehab
center to help you regain your functional abilities.
Followup Instructions:
___
|
10110584-DS-8 | 10,110,584 | 20,222,612 | DS | 8 | 2121-12-19 00:00:00 | 2121-12-20 18:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___
Chief Complaint:
Right Groin Pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ y/o female with HTN, COPD not on supplementary
O2, hypothyroidism, h/o lumbar stenosis s/p L4-L5 decompression,
L5-S1 laminectomy in ___, well-differentiated clear cell
carcinoma s/p L nephrectomy (at ___ in ___, history of
recurrent UTIs who presents with R groin pain.
She says that since the surgery, she has had pain in this
location and however was always able to manage it by changing
position and applying ice to the area. However, she came to the
ED because the pain suddenly became severe and she was not able
to ambulate well. She had recently been to a rehab after her
spinal surgery and was able to walk well with intermittent
assistance of a cane. However, she required two canes given the
worsening pain yesterday. She denied numbness/tingling.
Additionally, She stated having a history of recurrent UTI's
but she does not recall having any resistant organisms. She says
that usually she denies symptoms of UTI and does not know when
she has them. This time, she had been developing some urinary
incontinence and frequency though no burning sensation. Denies
fever/chills and had not taken her temperature. She denies
change in appetite, n/v, abdominal pain. No problems with bowel
movements.
Past Medical History:
Past medical history is significant for heart disease;
hypertension; gallstones; renal carcinoma, status post
nephrectomy; thyroid disease; depression and anxiety.
Surgical history includes appendectomy in ___, cholecystectomy
in ___, and nephrectomy for carcinoma in ___. She says that
after nephrectomy she was in the intensive care unit for three
days.
Social History:
___
Family History:
Family history is significant for carcinoma in her sisters.
___, her son also was diagnosed with renal carcinoma and
also underwent a nephrectomy and adjuvant treatments.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.5 159/93 74 20 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Back: no CVA tenderness, well-healed longitudinal scar at lumbar
region from prior spinal surgery
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper extremities, ___
strength lower left extremity, ___ in R hip flexor due to pain
but otherwise ___ in right lower extremity
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3 133/82 59 18 99% RA
General: NAD
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally no wheezing or rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly. Abdominal
scars present
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin-Musculoskeletal: improving intertrigo bilateral axilla and
inferior mammary folds. Lidocaine patch over lateral thigh.
Right hip flexion is 4+ with pain
Left hip flexion is 5+
Strength with knee extension and flexion 5+ bilaterally
Strength with ankle dosri and plantarflexion 5+ bilaterally
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS:
___ 09:30AM GLUCOSE-85 UREA N-31* CREAT-1.5* SODIUM-135
POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17
___ 09:30AM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.3
___ 09:30AM CALCIUM-9.6 PHOSPHATE-3.8 MAGNESIUM-2.3
___ 11:00PM URINE HOURS-RANDOM CREAT-134 SODIUM-54
POTASSIUM-78 CHLORIDE-34
___ 11:00PM URINE UHOLD-HOLD
___ 11:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 11:00PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 11:00PM URINE HYALINE-12*
___ 11:00PM URINE MUCOUS-RARE
___ 09:10PM GLUCOSE-110* UREA N-36* CREAT-1.7* SODIUM-137
POTASSIUM-4.6 CHLORIDE-98 TOTAL CO2-24 ANION GAP-20
___ 09:10PM WBC-15.8*# RBC-4.35 HGB-13.9 HCT-42.7# MCV-98
MCH-32.0 MCHC-32.6 RDW-13.7 RDWSD-49.2*
___ 09:10PM NEUTS-82.5* LYMPHS-10.1* MONOS-6.3 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-13.06* AbsLymp-1.60 AbsMono-1.00*
AbsEos-0.00* AbsBaso-0.04
PERTINIENT IMAGING:
___
Hip and Pelvis Xrays:
IMPRESSION:
No acute fracture or dislocation.
___
CTU abd/pelvis w/o contrast:
1. Status post post L4 through L5 posterior fusion with a rim
enhancing fluid collection which measures up to 6.8 cm in
craniocaudal dimension, at the level of presumed surgical site
in the lower lumbar spine, with surrounding soft tissue swelling
and fat stranding. Findings could reflect a postsurgical
collection. However, a super infection/abscess cannot be
entirely excluded. An additional focus of air is noted at the
L4-L5 intervertebral disc space. Correlation with surgical
history is recommend.
2. No acute intra-abdominal findings.
3. Status post left nephrectomy, no evidence of local recurrence
in this limited noncontrast examination.
4. Multiple scattered calcifications in the liver spleen and
pancreas, could reflect prior granulomatous exposure.
___
U/S Lower Extremity (focus femoral triangle)
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
___
MRI Musculoskeletal Pelvis w/&w/o
IMPRESSION:
-No bony lesion to explain the patient's groin pain seen. Mild
degenerative changes in the bilateral hip joints.
-Diverticulosis without evidence of diverticulitis.
-Fibroid uterus.
DISCHARGE LABS:
___ 06:43AM BLOOD WBC-9.0 RBC-4.20 Hgb-13.3 Hct-42.2
MCV-101* MCH-31.7 MCHC-31.5* RDW-13.9 RDWSD-51.3* Plt ___
___ 06:43AM BLOOD Glucose-85 UreaN-26* Creat-1.2* Na-139
K-4.9 Cl-104 HCO3-21* AnGap-19
Brief Hospital Course:
This is a ___ y/o female with HTN, COPD not on supplementary O2,
hypothyroidism, h/o lumbar stenosis s/p L4-L5 decompression,
L5-S1 laminectomy in ___, well-differentiated clear cell
carcinoma s/p L nephrectomy (at ___ in ___, history of
recurrent UTIs who presents with R groin pain.
#RIGHT GROIN PAIN
On admission Ms. ___ pain was minimal to moderate and was
mostly exacerbated by movement. Over her first night of
admission her pain substantially increased to pain at rest that
was severely limiting w/r/t range of motion and ADLs. Could no
longer weight bear. All pertinent imaging over the course of her
first two days were negative for soft and bony tissue masses,
thrombosis, aneurysm, hernias, fractures and ischemic changes.
Orthopedic surgery was consulted and agreed with our planned
imaging. Only relevant positive findings were spinal changes
consitent with post operative change and mild-moderate DJD of
bilateral femoral-acetabular joints.
During her course Ms. ___ remained afebrile. Her exam
continued to evolve over her hospitalization. On HD 3 she had
pain to the point of tears which resolved with IV dilaudid. She
was trialed on nightly gabapentin for presumed nerve pain, which
was discontinued, as well as the narcotic pain regimen, d/t
delirium. On the day of discharge the patient was tolerating her
pain well on PO tylenol and was discharged to rehab to continue
her physical therapy and improvement in ADL's.
#UTI
Patient presented with symptoms of increased frequency of
urination. Typically presents with ASx bacturia. No dysuria. She
was successfully treated with daily IV ceftriaxone and her
leukocytosis on admission was rapidly resolved.
___
Patient with creatinine to 1.7 from last discharge creatinine to
1.1 with poor reserve hiven h/o nephrectomy. Her creatinine
remained stable at 1.5 with antibiotic therapy. Discharge
creatinine was 1.2 and given previous OMR data it is believed
that she likely has CKD which should be followed up on in the
outpatient setting.
Chronic issues:
# H/o lumbar spine stenosis s/p L4-L5 decompression, L5-S1
laminectomy in ___. Seen by ortho-spine during
hospitalization who believed this played no part in current
admission. Will f/u as outpatient.
# Hypertension:
- Continued amlodipine, metoprolol
# Hyperlipidemia;
- Continued pravastatin
# Hypothyroidism
- Continued Synthroid
# Depression/anxiety
- Continued fluoxetine
TRANSITIONAL ISSUES:
1. UTI - pt completed 5 day course of ceftriaxone
2. Right groin pain - pain significantly limited ADLs and
dramatically affected quality of life. All pertinent imaging
negative. Pt will be discharged to rehab for further therapy
with her mobility and was tolerating pain on tylenol and
tramadol
Code: full
3. The patient had ___ during her admission with creatinines
ranging from 1.2-1.7. Based on previous admissions it is
believed she does have some component of CKD and should have
this follow-up by her PCP.
4. Code status on discharge: DNR/DNI
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Fluoxetine 60 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
6. Simvastatin 20 mg PO QPM
7. Acetaminophen 325-650 mg PO Q6H
8. Amlodipine 5 mg PO DAILY
9. Metoprolol Succinate XL 50 mg PO DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
3. Amlodipine 5 mg PO DAILY
4. Fluoxetine 60 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Simvastatin 20 mg PO QPM
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Miconazole Powder 2% 1 Appl TP BID
11. Lidocaine 5% Patch 1 PTCH TD QPM
12. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Osteoarthritis
Acute kidney injury
Chronic Issues:
H/o lumbar spine stenosis s/p L4-L5 decompression
Hypertension
Hyperlipidemia
Hypothyroidism
Depression/anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to the ___
___ right groin pain. During your initial work up of this
pain we discovered and treated a urinary tract infection. Your
groin pain worsened and we performed multiple imaging studies
which revealed no evidence of a blood clot in the vein of your
leg near your groin or fractures, massess or areas of poor blood
supply. Additional testing to examine the soft tissues around
your groin and leg revealed no bony or soft tissue mass
associated with the area, but did note evidence of degenerative
joint disease in both hips. This information was known to you
already from prior testing.
It is most likely that this pain is due to osetoarthritis in
combination with nerve irritation which contributed to your pain
and muslce spasms. We treated this with pain medication and
physical therapy decided that you should be spend a short time
in rehab getting stronger before going home.
Additionally, it is important that you follow-up with your
primary care provider and orthopedic surgeons following your
discharge from rehab.
It was a pleasure to meet you and participate in your care.
Best,
Your ___ Team
Followup Instructions:
___
|
10110584-DS-9 | 10,110,584 | 24,580,984 | DS | 9 | 2125-12-09 00:00:00 | 2125-12-09 17:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
adhesive tape
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
liver biopsy ___
History of Present Illness:
___ yo F with hx of LB dementia, renal cell ca s/p
nephrectomy, here with abdominal pain.
Patient lives at ___. She says she has had 15 pound
weight loss over past 8 months which she attributes to anorexia.
She denies f/c/n. She says she was at a barbecue on ___,
after
which she vomited NBNB once. Since then she has had sharp,
intermittent RLQ pain radiating upto her right shoulder. She
says
this improves with tylenol. During this time, she has also had
dysuria. SHe says she urinated twice per day and then 6 times at
night, and then in the past day had not urinated and feels
bloated.
On ROS, she also reports baseline SOB with getting dressed and
walking in her room as well as dry cough. She also feels
depressed about living at a nursing home. She says she has 1
bowel movement per day but has noticed some of this have been
dark.
Past Medical History:
Past medical history is significant for heart disease;
hypertension; gallstones; renal carcinoma, status post
nephrectomy; thyroid disease; depression and anxiety.
Surgical history includes appendectomy in ___, cholecystectomy
in ___, and nephrectomy for carcinoma in ___. She says that
after nephrectomy she was in the intensive care unit for three
days.
Social History:
___
Family History:
Family history is significant for carcinoma in her sisters.
___, her son also was diagnosed with renal carcinoma and
also underwent a nephrectomy and adjuvant treatments.
Physical Exam:
ADMISSION EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: bruise on left arm POA
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
DISCHARGE EXAM:
VS 97.6 PO ___ 18 96 RA
GENERAL: Elderly female, alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. No HSM
GU: No suprapubic fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: bruise on left arm POA
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: calm and cooperative
Pertinent Results:
=========
ADMISSION LABS:
___ 07:50PM BLOOD WBC-22.5* RBC-3.49* Hgb-9.9* Hct-31.2*
MCV-89 MCH-28.4 MCHC-31.7* RDW-15.5 RDWSD-50.5* Plt ___
___ 07:50PM BLOOD Neuts-85.4* Lymphs-2.8* Monos-10.3
Eos-0.6* Baso-0.2 Im ___ AbsNeut-19.21* AbsLymp-0.64*
AbsMono-2.32* AbsEos-0.14 AbsBaso-0.04
___ 07:50PM BLOOD Glucose-87 UreaN-21* Creat-1.2* Na-133*
K-4.7 Cl-101 HCO3-18* AnGap-14
___ 07:50PM BLOOD ALT-34 AST-46* AlkPhos-299* TotBili-1.0
___ 07:50PM BLOOD Lipase-57
___ 07:50PM BLOOD cTropnT-<0.01
=========
IMPORTANT INTERIM RESULTS:
___ 04:40AM BLOOD calTIBC-153* Ferritn-469* TRF-118*
___ 04:40AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.0 Iron-25*
___ 04:40AM BLOOD CEA-3.9
___ 02:01AM BLOOD Lactate-1.8
=========
MICRO:
___ 3:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
=========
DISCHARGE LABS:
___ 04:35AM BLOOD WBC-18.1* RBC-3.65* Hgb-10.1* Hct-33.2*
MCV-91 MCH-27.7 MCHC-30.4* RDW-15.4 RDWSD-51.3* Plt ___
___ 04:35AM BLOOD Glucose-86 UreaN-23* Creat-1.1 Na-140
K-4.9 Cl-104 HCO3-22 AnGap-14
___ 04:35AM BLOOD ALT-39 AST-56* AlkPhos-353* TotBili-0.6
=========
IMAGING:
___ CXR:
No pneumonia or evidence of cardiac decompensation.
New right lower lobe atelectasis or scarring. This examination
neither suggests nor excludes the diagnosis of acute pulmonary
embolism.
___ CT ABDOMEN/PELVIS:
1. Multiple new hypodense lesions scattered throughout the liver
measure up to
5.5 cm and cause several areas of moderate intrahepatic biliary
ductal dilatation, likely secondary to obstructive compression.
This is highly suspicious for a metastatic process given history
of clear cell renal carcinoma.
2. No acute findings in the abdomen or pelvis.
3. Additional chronic findings are not significantly changed
from ___.
___ CT CHEST:
1. Several subcentimeter pulmonary nodules, may be concerning
for
metastatic disease. Three-month follow-up chest CT is
recommended.
2. Small right pleural effusion.
3. No suspicious mediastinal mass or lymphadenopathy.
Brief Hospital Course:
Ms. ___ is an ___ F with hx ___ body dementia,
renal cell carcinoma s/p left nephrectomy, here with right sided
abdominal pain found to have a UTI and new liver lesions
concerning for metastatic disease.
ACUTE/ACTIVE PROBLEMS:
#RUQ Abdominal pain:
#New liver lesions:
Radiographically concerning for metastatic disease. Her pain is
primarily in the RUQ, which is likely due to liver capsular
distention, more than UTI as she denies any dysuria and pain is
not in bladder, kidney appears normal on the right side. Patient
has refused screening colonoscopy for many years and that is a
potential primary source. No other metastatic or primary lesions
seen in abdomen. CEA within normal limits. CT chest with several
sub-centimeter pulmonary nodules, concerning for metastatic
disease. She underwent ultrasound-guided liver biopsy on ___,
results pending at discharge.
#UTI:
U/A positive, WBC 22.5 on admission (neutrophil predominance).
Given my suspicion that her abdominal pain is actually due to
liver pain/malignancy rather than urine this could just
represent colonization, however she does have peripheral
leukocytosis and only has one kidney (on the right side), so
very reasonable to treat. Urine culture grew e coli and she was
switched to cipro to complete 7 day course for complicated UTI
(only one kidney).
# New Normocytic Anemia:
Hgb 9.9 on admission, previously had been around 13. Iron
studies suggestive of anemia of inflammation.
TRANSITIONAL ISSUES:
- WBC remains elevated to 18 on discharge but improving.
Recommend repeat CBC within one week
- Follow up liver biopsy pathology results next week
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Amlodipine 5 mg PO DAILY
3. Fluoxetine 40 mg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Simvastatin 5 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild/Fever
10. Senna 8.6 mg PO QHS:PRN Constipation - First Line
11. rivastigmine tartrate 1.5 mg oral Q12H
12. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
13. Nystatin Cream 1 Appl TP QDAY PRN itching under breasts
14. Milk of Magnesia 30 mL PO QDAY PRN Constipation - First
Line
15. melatonin 5 mg oral QPM:PRN insomnia
16. Lidocaine 5% Patch 1 PTCH TD QAM lower back pain
17. Cyanocobalamin 250 mcg PO DAILY
18. Docusate Sodium 100 mg PO DAILY
19. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H Duration: 4 Days
2. Acetaminophen 650 mg PO Q8H
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
4. Amlodipine 5 mg PO DAILY
5. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
6. Aspirin 81 mg PO DAILY
7. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
8. Cyanocobalamin 250 mcg PO DAILY
9. Docusate Sodium 100 mg PO DAILY
10. FLUoxetine 40 mg PO DAILY
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Lidocaine 5% Patch 1 PTCH TD QAM lower back pain
13. melatonin 5 mg oral QPM:PRN insomnia
14. Metoprolol Succinate XL 25 mg PO DAILY
15. Milk of Magnesia 30 mL PO QDAY PRN Constipation - First
Line
16. Nystatin Cream 1 Appl TP QDAY PRN itching under breasts
17. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
18. rivastigmine tartrate 1.5 mg oral Q12H
19. Senna 8.6 mg PO QHS:PRN Constipation - First Line
20. Vitamin D 1000 UNIT PO DAILY
21. HELD- Simvastatin 5 mg PO QPM This medication was held. Do
not restart Simvastatin until liver function normalizes
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Liver lesions
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
___,
You were admitted to the hospital for pain in your abdomen, and
were found to have both a urinary tract infection as well as new
lesions in your liver. You had a liver biopsy, the results of
which are pending. You will finish a course of oral antibiotics
on discharge.
It was a pleasure taking care of you!
Sincerely, your ___ Team
Followup Instructions:
___
|
10110724-DS-16 | 10,110,724 | 29,881,025 | DS | 16 | 2179-02-22 00:00:00 | 2179-02-23 20:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of sinus bradycardia presents after having a
fall at home. The morning of presentation around 1:40AM, the
patient was going to the bathroom. While turning to leave the
bathroom, he suddenly fell. The details of what happened are
unclear as the patient gives a slightly different version than
what his family reports.
Per the patient, he was not sure if he was feeling lightheaded
or dizzy prior to the fall. He says that in the process of
turning to leave, he just suddenly fell, and he was able to get
up off the ground afterwards with no specific symptoms.
However, per the patient's daughter, who lives with him, she
heard a loud thump sound and woke up. She found her father on
the ground, halfway in the bathroom and halfway out. She
believes he had hit his head. He appeared confused and very weak
at that time. He needed assistance to get up off the ground and
was able to finally walk over to the bedroom after some time.
There, he subsequently had 3 (he reports 2) episodes of
vomiting.
Because of the fall, he went to see his PCP, who performed an
EKG in the office that showed atrial fibrillation with slow
ventricular rate, and subsequently sent him into the ED for EP
evaluation.
In the ED, initial vitals were: 98.1 88 134/70 20 99% RA.
Exam notable for "CTAB, irregularly irregular tachycardia,
abdomen soft and NT, neuro non-focal, gait normal, atraumatic."
EKG read as "102, A-Fib, Left axis, prolonged QTC 462."
Patient received: IVF NS 1000 mL.
Vitals prior to transfer were: 97.7 85 121/67 15 98% RA.
On arrival to the floor, patient reports feeling fine with no
specific symptoms. He says he exercises quite frequently, about
5 times a week at the gym and runs about 1 hour each time. He
does not get short of breath or symptomatic during exercise.
In further discussion with the patient's daughter, she says the
patient is quite stoic and tries to downplay his symptoms. For
example, a year ago, he had a fall after working outside and
tried to hide the fact and the resulting bruising.
REVIEW OF SYSTEMS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
BRADYCARDIA
MEMORY LOSS
SLEEP DISORDER
HYPERCHOLESTEROLEMIA
H/O ELEVATED BLOOD PRESSURE
CYST REMOVAL IN RIGHT ARM
Social History:
___
Family History:
His father probably died of a stroke, age not given.
His mother died at the age of late ___, he said she was sick
for a few days but does not know the reason. There is a family
history of diabetes in a nephew, heart disease and stroke,
though
he is not specific.
Physical Exam:
ON ADMISSION:
=============
Vitals: T 97.5 BP 109/59 HR 43 RR 18 SAT 98% on RA; Wt: 87.6 kg
Gen: In no acute distress, pleasant
HEENT: EOMI, PERRL, oropharynx clear, MMM
Neck: Supple, JVP is flat
Cardiac: Regular rhythm at a slow rate, normal S1 and S2, no
murmurs
Pul: CTAB, no wheezes or crackles
Abd: +BS, soft, non-tender, non-distended
Ext: warm, well perfused, no edema
Skin: no significant rashes
Neuro: Grossly nonfocal, moving extremities symmetrically
ON DISCHARGE:
=============
Vitals: 97.8 160/87 50 18 98%CPAP on RA;
Gen: NAD, pleasant sitting up in bed
HEENT: MMM
Neck: JVP is flat
Cardiac: irregular, brady, normal S1 and S2, no murmurs
Pul: CTAB, no wheezes or crackles
Abd: soft, non-tender, non-distended
Ext: warm, well perfused, no edema
Pertinent Results:
ON ADMISSION:
=============
___ 05:40PM URINE HOURS-RANDOM
___ 05:40PM URINE HOURS-RANDOM
___ 05:40PM URINE UHOLD-HOLD
___ 05:40PM URINE GR HOLD-HOLD
___ 05:40PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:40PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:25PM GLUCOSE-112* UREA N-18 CREAT-0.9 SODIUM-140
POTASSIUM-4.6 CHLORIDE-106 TOTAL CO2-25 ANION GAP-14
___ 04:25PM estGFR-Using this
___ 04:25PM CALCIUM-9.1 PHOSPHATE-3.7 MAGNESIUM-2.1
___ 04:25PM WBC-6.1 RBC-4.50* HGB-13.8 HCT-41.7 MCV-93
MCH-30.7 MCHC-33.1 RDW-15.0 RDWSD-51.2*
___ 04:25PM NEUTS-29.5* LYMPHS-53.2* MONOS-11.2 EOS-5.3
BASOS-0.8 AbsNeut-1.78 AbsLymp-3.22 AbsMono-0.68 AbsEos-0.32
AbsBaso-0.05
___ 04:25PM PLT COUNT-147*
ON DISCHARGE:
=============
___ 07:00AM BLOOD WBC-5.1 RBC-4.23* Hgb-12.9* Hct-39.1*
MCV-92 MCH-30.5 MCHC-33.0 RDW-14.8 RDWSD-49.8* Plt ___
___ 07:00AM BLOOD Glucose-99 UreaN-15 Creat-0.9 Na-142
K-4.1 Cl-107 HCO3-27 AnGap-12
___ 07:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.9
___ 08:10AM BLOOD TSH-3.3
___ 05:40PM URINE Color-Straw Appear-Clear Sp ___
___ 05:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
PERTINENT TESTS:
===============
___ Head W/O Contrast:
FINDINGS:
There is no evidence of acute major infarction, hemorrhage,
edema, or large
mass. The ventricles and sulci are mildly enlarged in size and
configuration,
consistent with age related involution. There is no acute
fracture. There
patient has had prior sinus surgery. There is mucosal
thickening in the
ethmoid air cells and frontal sinus. There is also
opacification of the right
mastoid air cells. The remainder of the paranasal sinuses are
clear. The
orbits are unremarkable.
IMPRESSION: No acute intracranial process.
___ 19:29 CT C-Spine W/O Contrast:
FINDINGS:
There is no evidence of cervical spine fracture. There are mild
multilevel
degenerative changes. There is no evidence of critical canal or
neuroforaminal narrowing. The bones are demineralized. There
is no gross
evidence of infection. A 6 mm hypodense left thyroid nodule
requires no
specific followup. Lung apices are clear.
IMPRESSION: No cervical spine fracture or malalignment.
___ Chest (Pa & Lat): PA and lateral views of the chest
provided. The heart is mildly enlarged. The hila appear slightly
engorged. There is no convincing evidence for edema or
pneumonia. No large effusion or pneumothorax. The mediastinal
contour is unchanged. Bony structures appear intact.
IMPRESSION: Cardiomegaly with pulmonary vascular congestion.
___ TTE:
IMPRESSION: Normal study. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
Mild-moderate mitral regurgitation with normal valve morphology.
Mild-moderate aortic regurgitation.l Mild pulmonary artery
systolic hypertension. Mildly dilated ascending aorta Increased
PCWP. No structural cardiac cause of syncope identified.
Compared with the prior study (images reviewed) of ___,
the severity of mitral regurgitation is increased, the ascending
aorta is now mildly dilated, and increased PCWP is now
suggested. The other findings are similar.
Cardiovascular ReportECGStudy Date of ___ 2:26:17 ___
Atrial fibrillation with comparable block versus atrial flutter.
Compared to
the previous tracing probably no significant change other than
that atrial
activity may be more prominent. Ventricular premature beat or
aberrant atrial
premature beat is no longer seen. Clinical correlation is
suggested.
TRACING #2
Intervals Axes
RatePRQRSQTQTc (___) PQRST
___
Cardiovascular ReportECGStudy Date of ___ 10:57:40 AM
Atrial fibrillation with a variable ventricular response. Left
anterior
fascicular block. Right bundle-branch block. Consider left
ventricular
hypertrophy. Other ST-T wave abnormalities. Compared to the
previous tracing
of ___ atrial fibrillation is new, axis is more leftward.
ST-T wave
abnormalities are more promiennt. Clinical correlation is
suggested.
TRACING #1
Intervals Axes
RatePRQRSQTQTc (___) PQRST
___ ___
Cardiovascular ReportStressStudy Date of ___
EXERCISE RESULTS
RESTING DATA
EKG: SB, IACD, APDS, Q W I,L, IVCD, RBBB
HEART RATE: 54BLOOD PRESSURE: 154/100
PROTOCOL MODIFIED ___ - TREADMILL /
STAGETIMESPEEDELEVATIONHEARTBLOODRPP
(MIN)(MPH)(%)RATEPRESSURE
___
___
TOTAL EXERCISE TIME: 12.5% MAX HRT RATE ACHIEVED: 91
SYMPTOMS:NONE
ST DEPRESSION:NONE
INTERPRETATION: This ___ year old man with PAF and recent
syncopal
episode during micuration was referred to the lab for evaluation
of
bradycardia. The patient exercised for 12.5 minutes of a
modified ___
protocol and stopped for fatigue. The estimated peak MET
capacity was
12.5 which represents an excellent functional capacity for his
age. No
arm, neck, back or chest discomfort was reported by the patient
throughout the study. There were no significant ST segment
changes
during exercise or in recovery. The rhythm was sinus with
frequent
isolated apbs, multiple ___ beat runs of PSVT, possible MAT and
an 8
second run of regular PSVT in late recovery. Occasional isolated
vpbs
throughout the study. Resting HTN with an exaggerated BP
response to
exercise with an appropriate HR response. Appropriate
hemodynamic
response to recovery.
IMPRESSION: NS PSVT, reg and irreg in the absence of pause,
angina, ST
segment changes or dizziness. Nuclear report sent separately.
Radiology ReportCARDIAC PERFUSIONStudy Date of ___
SUMMARY OF DATA FROM THE EXERCISE LAB:
Exercise protocol: Modified ___ duration: 12.5 min
Reason exercise terminated: Fatigue
Resting heart rate: 54
Resting blood pressure: 154/100
Peak heart rate: 137
Peak blood pressure: 220/90
Percent maximum predicted HR: 91
Symptoms during exercise: No anginal symptoms
ECG findings: No ischemic changes
TECHNIQUE:
ISOTOPE DATA: (___) 11.0 mCi Tc-99m Sestamibi Rest;
(___) 31.9 mCi
Tc-99m Sestamibi Stress; Resting perfusion images were obtained
with Tc-99m
sestamibi. Tracer was injected approximately 45 minutes prior
to obtaining the
resting images.
At peak exercise, approximately three times the resting dose of
Tc-99m sestamibi
was administered IV. Stress images were obtained approximately
45 minutes
following tracer injection.
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
attenuation.
Left ventricular cavity size is increased.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 54% with an
EDV of 148 ml.
IMPRESSION:
1. Normal myocardial perfusion.
2. Increased left ventricular cavity size with normal systolic
function.
Compared with the study of ___, the left ventricular
cavity size is
larger.
Brief Hospital Course:
___ yo M with history of bradycardia and sleep apnea on CPAP,
presented for a first episode of syncope that occurred following
urination.
#Syncope: Patient presents with one episode of syncope after
urination, in the absence of prior similar episodes. Patient has
a history of asymptomatic bradycardia for years. The details of
the fall are not exact, but given the lack of prodromal symptoms
and some weakness after the event, syncope is most likely
related to arrhythmia and the added vagal tone of micturition
might have contributed to a syncopal event. Per report, patient
had slow conduct AF on EKG in the PCP office, but EKG in ED
showed AF wRVR. The patient remained asymptomatic throughout his
hospitalization. On telemetry, his heart rate remained in the
40-50s and no AF w/RVR or conversion pauses were detected. Echo
showed worsening mild-moderate mitral regurgitation with normal
valve morphology, mild-moderate aortic regurgitation, and mild
pulmonary artery systolic hypertension. TSH was normal. Stress
test and nuclear imaging showed no evidence of ischemia. Patient
was started on lisinopril for his hypertension. He was given a
___ of hearts monitor. He will need to follow up with
cardiology as an outpatient.
#Sleep apnea: continued CPAP at night.
***TRANSITIONAL ISSUES:***
-A ___ of hearts monitor placed for 2 weeks, please follow up
results
-Monitor the recurrence of AF w/RVR and consider placement of
pacemaker in case conversion pauses or symptoms occur
- Patient started lisinopril please follow up chem 7 in on week
-Make sure patient uses CPAP every day
-Follow up with cardiology
Medications on Admission:
-Aspirin 81 mg PO DAILY
-Vitamin D 1000 UNIT PO DAILY
-Flomax
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Outpatient Lab Work
I10 Hypertension- Please obtain Chem 7 on ___ and fax
results to ___ ___, MPH
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Syncope
SECONDARY DIAGNOSES:
Bradycardia
Sleep apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You came to the hospital because you fell down. We suspected
that the fall is related to a problem in the heart. We monitored
your heart and did several tests in order to know the reason of
your fall. Your heart rate was found to occasionally be slow and
irregular. Otherwise, there were no other abnormal findings on
your heart tests that could explain your fall. We placed a heart
monitor for 2 weeks so we can watch for any abnormality in the
heart rhythm.
Make sure to use your CPAP every night when you sleep, because
the sleep apnea might predispose for heart rhythm problems.
Also, try to limit your caffeine and alcohol intake and make
sure to remain well hydrated throughout the day.
You were started on a medication to treat your high blood
pressure. You will need to have lab tests next week. Please make
sure to follow-up with a cardiologist and your primary care
doctor as scheduled.
It was a pleasure taking care of you!
-Your ___ team
Followup Instructions:
___
|
10110742-DS-5 | 10,110,742 | 25,989,257 | DS | 5 | 2137-12-10 00:00:00 | 2137-12-10 13:00:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RIght femoral neck fracture
Major Surgical or Invasive Procedure:
Right Total Hip Arthroplasty
History of Present Illness:
Patient is a ___ y.o. male presents s/p fall with R wrist, hip,
and knee pain. Today he slipped on black ice outdoors and
landed onto right side. Denies HS/LOC, back pain, neck pain,
numbness/tingling. He endorses Right wrist pain, knee pain, hip
pain and inability to ambulate. He was brought by his brother
who is chief of EMS in ___ to the ___ where
imaging revealed hip fracture and orthopedics consulted. At
baseline, the pt lives independently and remains active. He was
subsequently transferred to ___ as the patient was considering
a THA and there were no staff available at ___ or ___ able
to perform the procedure.
Past Medical History:
None
Social History:
___
Family History:
Noncontributory
Physical Exam:
Gen: elderly male, no acute distress
Neuro: alert and interactive
CV: palpable DP pulses bilaterally
Pulm: no respiratory distress on room air
RLE: dressing CDI, SILT: ___, Fires ___,
palpable DP
Pertinent Results:
___ 06:00AM BLOOD WBC-17.8* RBC-3.59* Hgb-11.2* Hct-34.1*
MCV-95 MCH-31.2 MCHC-32.8 RDW-13.0 RDWSD-44.8 Plt ___
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 right femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right total hip arthroplasty
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight-bearing as tolerated in the right lower extremity, and
will be discharged on lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every
12 hours as needed for constipation Disp #*20 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC Q24H
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg subcutaneous nightly Disp #*14
Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
for pain Disp #*50 Tablet Refills:*0
5. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth every 12 hours
as needed for constipation Disp #*20 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- weight-bearing as tolerated right lower extremity, posterior
hip precautions
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.\
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
Physical Therapy:
weight-bearing as tolerated right lower extremity, posterior hip
precautions
Treatments Frequency:
Physical therapy
Followup Instructions:
___
|
10110843-DS-14 | 10,110,843 | 23,376,934 | DS | 14 | 2163-02-19 00:00:00 | 2163-02-21 23:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of recurrent pancreatitis s/p prophylactic
laparoscopic cholecystectomy on ___ at ___ presents with
acute onset of abdominal pain and is transferred from ___
___ for further care.
In regards to her history of pancreatitis, the patient had her
first episode in ___, for which she was hospitalized in
___, and no clear etiology was found. Her
second episode was in ___, and she was hospitalized
at ___, where she had reportedly normal abdominal
ultrasound and MRCP results. She was on atorvastatin at that
time, which was stopped.
Since her discharge after the operation, she has been having
some cough with green sputum and chills but no fevers when
measured. This morning while at church, she had acute onset of
sharp epigastric abdominal pain that radiated to her back, very
similar to her previous pain from pancreatitis. She went home to
toast and yogurt, which only seemed to make it. The pain was
associated with nausea. She has not had any fevers, diarrhea,
chest pain, palpitations, or shortness of breath. She has been
having normal bowel movements with no blood in it.
At ___, labs showed: WBC 12.12, Hgb 15.6, Hct
44.3, Plt 227, INR 1.0, Na 141, K 3.8, Cl 105, CO2 30, glucose
100, BUN 19, Cr 0.80, Ca 9.1 Mg 2.0, T bili 0.5, D bili 0.1, t
protein 7.6, albumin 4.1, alk phos 68, ast 21, alt 33, lipase
___.
She received 1 mg IV Dilaudid, 4mg IV Zofran, and was
transferred to ___ given recent surgery.
In the ED, initial vitals: T 97.6 HR 64 BP 142/64 RR 18 SAT 95%
RA.
- Exam notable for: RUQ and epigastric tenderness. Surgical
site without erythema or induration.
- Labs notable for: WBC 11.0, lipase ___, lactate 1.3,
otherwise normal chemistry, LFTs, and CBC.
- Imaging notable for CT evidence of acute pancreatitis.
- Pt given: IVF 1000 mL NS.
- Vitals prior to transfer: T 98.0 HR 68 BP 116/69 RR 16 SAT
100% RA.
General Surgery Service was consulted in ED and recommended
keeping patient NPO with IVF and admitting to medicine for
further work up of pancreatitis.
On arrival to the floor, pt reports mild improvement in her
abdominal pain, but having a new headache. She is anxious to
know what she can do to prevent another episode.
ROS:
(+) per HPI. No fevers, night sweats, or weight changes. No
changes in vision or hearing, no changes in balance. No
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No nausea or vomiting. No diarrhea or
constipation. No dysuria or hematuria. No hematochezia, no
melena. No numbness or weakness, no focal deficits.
Past Medical History:
-Laparoscopic cholecystectomy (with Dr. ___ at ___
on ___
-Recurrent pancreatitis of unclear etiology
-Fibroids s/p hysterectomy
-Unilateral oophorectomy
-Spine surgery for disc disease
-Tonsillectomy
Social History:
___
Family History:
Has 2 healthy sons. Sister with history of acute pancreatitis
that resolved after cholecystectomy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals- T 98.3 BP 114/71 HR 73 RR 18 SAT 95% RA
General- Alert, oriented, lying in bed, no acute distress but
appears uncomfortable
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple
Lungs- bibasilar inspiratory crackles
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, significant tenderness to light palpation in
epigastric and RUQ region, no rebound tenderness or guarding;
well healed lap ports
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- 98.3 ___ 18 93% RA
General- Alert, oriented, lying in bed, NAD
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple
Lungs- bibasilar inspiratory crackles
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, +BS, mild TTP in epigastrium and RLQ, no rebound
tenderness or guarding; well healed laparoscopic incision sites
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
PERTINENT LABS:
==================
___ 10:20PM BLOOD WBC-11.0*# RBC-4.67 Hgb-14.9 Hct-43.1
MCV-92 MCH-31.9 MCHC-34.6 RDW-12.8 RDWSD-42.9 Plt ___
___ 10:20PM BLOOD Neuts-56.3 ___ Monos-4.8* Eos-1.7
Baso-0.4 Im ___ AbsNeut-6.18* AbsLymp-3.99* AbsMono-0.53
AbsEos-0.19 AbsBaso-0.04
___ 10:20PM BLOOD ___ PTT-33.6 ___
___ 10:20PM BLOOD Glucose-113* UreaN-19 Creat-0.7 Na-139
K-3.9 Cl-104 HCO3-23 AnGap-16
___ 10:20PM BLOOD ALT-24 AST-23 AlkPhos-63 TotBili-0.6
___ 10:20PM BLOOD Albumin-4.5
___ 05:19AM BLOOD Calcium-8.9 Phos-4.0 Mg-1.9
___ 10:35PM BLOOD Lactate-1.3
___ 10:20PM BLOOD Triglyc-185*
___ 10:20PM BLOOD ___ 05:45AM BLOOD Lipase-135*
PERTINENT IMAGING:
==================
CT Abdomen/pevis ___:
FINDINGS:
LOWER CHEST: There is bibasilar dependent atelectasis. Mild
atherosclerotic
calcifications of the coronary arteries are noted. There is no
pericardial or
pleural effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
Hypodensities are noted in segments 4A and 2, incompletely
characterized but
likely represents. There is no evidence of intrahepatic or
extrahepatic
biliary dilatation. The gallbladder is surgically absent and
the portal vein
is patent.
PANCREAS: There is extensive peripancreatic stranding
surrounding an edematous
pancreas compatible with acute pancreatitis. There is fluid
layering along
the bilateral Gerota's fascia and tracking inferiorly into the
pelvis. The
body of the pancreas appears atrophic. No abscess or other
organized fluid
collection is identified at this time. Stranding extends into
the periportal
space as well as the mesentery and retroperitoneum.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: The kidneys are of normal and symmetric size with
normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis.
There is no
perinephric abnormality.
GASTROiNTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The
colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is a
small amount of free fluid within the pelvis.
REPRODUCTIVE ORGANS: The uterus is not clearly identified. No
adnexal mass is
seen.
LYMPH NODES: There are scattered enlarged periportal and
periperipancreatic
lymph nodes. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Degenerative changes are seen throughout the thoracic and lumbar
spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
Edematous pancreas with extensive peripancreatic stranding and
fluid
compatible with acute pancreatitis. No definite CT evidence of
necrosis or
organized collection is identified at this time.
CXR ___:
IMPRESSION:
Heart size and mediastinum are stable. There is new right upper
lung linear
opacity in left basal linear opacity consistent most likely with
interval
development of atelectasis. Infectious process would be less
likely2 such as
pneumonia and aspiration is another possibility to consider. No
appreciable
pleural effusion demonstrated.
PERTINENT MICRO
========================
___ 11:31 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
Brief Hospital Course:
___ with history of recurrent pancreatitis s/p prophylactic
laparoscopic cholecystectomy on ___ at ___ presents with
acute onset of epigastric abdominal pain with elevated lipase
and CT findings of edematous pancreas with fat stranding,
consistent with recurrent episode of acute pancreatitis.
ACTIVE ISSUES:
==================
# Recurrent Acute Pancreatitis, Mild
Etiology initially thought to be due to biliary sludging and/or
microlithiasis, for which she had a laprascopic cholecystectomy
as prophylaxis for future episodes. Unfortunately she is now
re-admitted with pancreatitis, suggesting
sludging/microlithiasis are not the underlying etiology. She
does not drink EtOH, but her history of smoking is a major
predisposing factor. Otherwise, in the past, triglycerides and
calcium levels have been normal. She is not on any specific
predisposing medications. No anatomic abnormalities seen with
previous imaging; however, patient is not sure if she has had an
MRCP (her PCP has no records of this within the last ___ years).
Patient remembers undergoing an open MRI in the past and
declined an MRCP on this admission due to severe claustrophobia.
BISAP score of 1 on admission for age > ___. Surgery evaluated
her given her recent CCY; they felt this was not likely related
to her recent surgery. Her pain resolved rapidly with IVF and
pain medications. The day after admission, her diet was
advanced to clears. The following day, she tolerated a regular
diet and was discharged home.
# Diarrhea:
Patient experienced 4 episodes of liquid stools while an
inpatient. Given her recent surgery and exposure to
perioperative ABx, C diff was sent, which was negative.
CHRONIC ISSUES:
=================
# Smoking
Patient reported good motivation to quit smoking. She declined
a nicotine patch.
# CODE STATUS: Full (confirmed)
# CONTACT: ___ (___, ___, ___ (son, HCP-
___
TRANSITIONAL ISSUES:
====================
- Patient needs an MRCP or EUS as an outpatient to further
evaluate for structural causes of pancreatitis including
pancreatic masses, ductal strictures, or calculus.
- Patient's home Valsartan was held on this admission due to
normotension
- Patient expressed interest in and motivation for smoking
cessation. She declined smoking cessation aids on this
admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 40 mg PO DAILY
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1500 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Magnesium Oxide 400 mg PO DAILY
7. Fish Oil (Omega 3) 1000 mg PO BID
8. Vitamin B Complex 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*21 Tablet Refills:*0
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium Carbonate 1500 mg PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Magnesium Oxide 400 mg PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Vitamin D ___ UNIT PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg ___ tablet(s) by mouth every 8 hours Disp
#*21 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Acute pancreatitis
Secondary: Recurrent pancreatitis, current smoking, history of
fibroids
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was our pleasure caring for you at ___
___. You were transferred here from ___
___ with an episode of pancreatitis. This episode was
relatively mild compared with your previous episodes. We put
you on bowel rest and gave you fluids through the IV and pain
medication, and your symptoms improved. We discussed the
possibility of getting an MRI to look for the cause of your
multiple episodes of pancreatitis, but you opted to do this as
an outpatient. When you were feeling better, we advanced your
diet and you were discharged home. Because you had some
diarrhea while in the hospital, we tested for a cause of
infectious diarrhea called Clostridium difficile, and this was
negative. Your diarrhea should resolve on its own as you eat
more solid foods; if it does not, please discuss this with your
primary care doctor.
Thank you for allowing us to participate in your care
Followup Instructions:
___
|
10111112-DS-12 | 10,111,112 | 23,834,763 | DS | 12 | 2146-07-18 00:00:00 | 2146-07-18 18:49:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine /
Morphine
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with essential thrombocythemia referred to ED for large
bilateraly pulmonary emboli found in V/Q scan. She has had
worsening dyspnea and hypoxia for over 4 weeks. Her pain began
suddenly while she was working in ___ on ___. She had also
noted some URI symptoms. She was seen in ___ and started
on steroids after a CT scan showed possible viral bronchiolitis.
Her dyspnea did not improve over the last couple weeks. Two days
ago, she was found to be hypoxic at home to mid ___ and she was
referred for a V/Q scan. Yesterday's V/Q scan showed large
bilateral pulmonary emboli.
.
In the ED, she was 98% on room air. She was started on a heparin
drip and admitted to medicine. On transfer, vitals are 98.5 68
123/61 14 97%RA.
.
On arrival to the floor, she is feeling well. She denies dyspnea
or chest pain.
Past Medical History:
Hypertension
osteoarthritis
essential thrombocythemia
chronic kidney disease (Cr ~1.5)
PAST SURGICAL HISTORY:
C-section
cholecystectomy
tonsillectomy
adenoidectomy.
Social History:
___
Family History:
She has an uncle with tuberculosis when he was a
young man, but she was not exposed to tuberculosis. Her mother
had cardiovascular disease and breast cancer. Otherwise, no
history of any pulmonary issues in her first-degree relatives.
Physical Exam:
VS - 98.6 148/70 68 16 94%
GEN - well-appearing NAD
HEENT - no lymphadenopathy
CV - RRR no murmurs
LUNGS - CTA b/l
ABD - soft non tender
EXT - no edema, no calf tenderness
SKIN - warm and dry
Pertinent Results:
___ 06:49AM BLOOD WBC-4.9 RBC-2.09* Hgb-8.4* Hct-25.0*
MCV-119* MCH-40.3* MCHC-33.8 RDW-15.2 Plt ___
___ 12:25PM BLOOD Glucose-149* UreaN-40* Creat-1.5* Na-136
K-4.4 Cl-99 HCO3-25 AnGap-16
___ 06:49AM BLOOD LD(LDH)-433* TotBili-0.3 DirBili-0.1
IndBili-0.2
___ 12:25PM BLOOD ___ PTT-26.7 ___
___ 06:49AM BLOOD ___ PTT-29.5 ___
___ LUNG SCAN
Perfusion images in the same 8 views show several large
bilateral mismatched perfusion defects involving multiple
segments of both lungs.
Chest x-ray shows no pneumothorax, pleural effusion or focal
consolidation, only mild interstitial edema.
IMPRESSION: High probability of bilateral pulmonary emboli.
___ DOPPLERS
Grayscale and color Doppler sonograms with spectral analysis of
the
bilateral common femoral veins, superficial femoral veins,
popliteal veins, peroneal veins, and posterior tibial veins was
performed. There is normal compressibility, flow and
augmentation. One peroneal vein on the right and one posterior
tibial vein on the left were not visualized.
IMPRESSION: No DVT bilaterally. One right peroneal vein and one
left posterior tibial vein were not visualized.
Brief Hospital Course:
___ yo F with essential thrombocythemia and CKD admitted with
large bilateral pulmonary embolism.
.
# PULMONARY EMBOLI - Appeared to be subacute, occurring over the
last 5+ weeks with progressive dyspnea. Hemodynamically stable,
without tachycardia or hypoxia while at rest. Started on heparin
drip in the ED. Then transitioned to lovenox and warfarin on the
floor. Not hypoxic at rest but desatted to 90% while ambulating.
Also documented to be as low as 85% while at home. Discharged
home with home oxygen. Plan to have INR checked on ___ and
followed up with Dr. ___. Heme consult was called and felt
that cause was most likely thrombocythemia, and recommended
continuing hydrea.
.
# ESSENTIAL THROMBOCYTHEMIA - Has been on high dose hydrea for
many months, but platelets were still very elevated to the 900s.
Platelets are acutally normal on admission, which may be due to
consumption from large PE. Continued hydrea
# CKD - At baseline of 1.5. Renally dosed meds
.
# HTN - continued HCTZ and lisinopril
Medications on Admission:
HCTZ 12.5mg daily
Hydroxyurea 1000mg / 500mg QOD
Lisinopril 20mg daily
Prednisone taper
Ascorbic acid ___ daily
Calcium carbonate 1000mg daily
Vitamin D 1000u daily
Fish oil-DHA-EPA ___ daily
Discharge Medications:
1. Home Oxygen
2L/min via nasal cannula, to be worn with ambulation and at
night
Diagnosis: Pulmonary emboli. O2 saturation to 85% with
ambulation and while sleeping
2. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) injection
Subcutaneous Q12H (every 12 hours) for 1 weeks.
Disp:*14 injection* Refills:*0*
3. warfarin 2.5 mg Tablet Sig: Two (2) Tablet PO once a day.
Disp:*60 Tablet(s)* Refills:*0*
4. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO
DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. ascorbic acid 1,000 mg Tablet Sig: One (1) Tablet PO once a
day.
7. calcium carbonate 390 mg (1,000 mg) Tablet Sig: One (1)
Tablet PO once a day.
8. Vitamin D 1,000 unit Tablet Sig: One (1) Tablet PO once a
day.
9. omega 3-dha-epa-fish oil 1,200 (144-216) mg Capsule Sig: One
(1) Capsule PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
___:
Pulmonary Emboli
SECONDARY:
essential thrombocythemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were admitted to the hospital with pulmonary emboli that
were causing your shortness of breath. You were treated with
blood thinners which you will need to continue for at least ___
months.
Medication changes:
START warfarin 5mg daily (this will need to be adjusted based on
INR)
START lovenox 60mg twice daily (this can be stopped when your
INR is appropriate)
START home oxygen 2L/min when short of breath and when walking
You will need to have your INR checked on ___ ___ clinic.
Followup Instructions:
___
|
10111112-DS-14 | 10,111,112 | 29,481,082 | DS | 14 | 2149-05-04 00:00:00 | 2149-05-05 10:38:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine /
Morphine
Attending: ___.
Chief Complaint:
Fever
Malaise
LUQ Abdominal Pain
Major Surgical or Invasive Procedure:
___: Bone Marrow Biopsy
History of Present Illness:
___ with history of essential thrombocytosis c/b post-ET
myelofibrosis and unprovoked PE on coumadin and ASA, PVD, HTN,
and HLD who presents with 1 weeks of fevers and malaise.
Pt reports that she had a fever 1 week ago to 102.7. She had no
other asociated symptoms at that time, and the fever
self-resolved. She then had left sided pain, and another fever
to 101.5 the day of admission. She called her PCP, who insisted
she come to the ED for evaluation. Meanwhile, the pt denies any
dysuria, polyuria, or increased urgency. A very slight dry cough
but no SOB, no URI symptoms. Her daughter was sick recently with
a viral bronchitis. Otherwise, no sick contacts or recent
travel. Her most concerning symptoms are the L side pain in
addition to LOA and her stomach feeling "sensitive."
In the ED initial vitals were: 98.7 89 138/57 14 97% RA.
- Labs were significant for Cr 1.5 (b/l 1.7-2.2), lactate
normal, WBC 15.5 (b/l ___, Hct 31.2 (b/l low ___ but received
2 units pRBCs on ___, and plt 66 (recent b/l 50), INR 2.2.
- CXR showed new small L pleural effusion.
- Patient was given 1g IV CTX. Blood and urine cultures sent.
On the floor, pt appears comfortable other than her L side pain
which is mild. The pain is worse on inspiration. She did have 2
episodes of diarrhea last week which improved with immodium.
Review of Systems:
(+) per HPI. 10 point ROS otherwise negative.
Past Medical History:
Essential Thrombocytosis / Myelofibrosis (stopped aspirin and
ruxolitinib)
Pulmonary Embolism on warfarin
Peripheral Vascular Disease s/p RLE stent
HTN (off medications due to low BP)
HLD
pHTN
COPD Gold Stage I
CKD baseline Cr 1.5-1.9
Tonsillectomy-Adenoidectomy
C-Section
Cholecystectomy
Social History:
___
Family History:
She has an uncle with tuberculosis when he was a young man, but
she was not exposed to tuberculosis. Her mother had
cardiovascular disease and breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: 99.1, 82-89, 116-126/58-60, 18, 95% on RA, 150kg, no
strict I/Os
GENERAL: NAD, pleasant, AAOx3, pleasant and conversant
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
CARDIAC: RRR, no MRG
LUNG: diminished breath sounds at the L base. Otherwise CTAB, no
wheezes, rales, rhonchi, breathing comfortably without use of
accessory muscles
ABDOMEN: nondistended, +BS, pt reports that abdomen feels
diffusely "sensitive" to palpation, no rebound/guarding, no
hepatosplenomegaly, negative CVA tenderness
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulse on left, 1+ on right
NEURO: CN II-XII intact, motor and sensory grossly intact,
fluent speech
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAMINATION:
Vitals: Tc:99.5 Tm:100.3 HR:89(84-92) BP:122/68(112/58-120/58)
RR:18 O2:95% on RA Weight: Not recorded<-153.0<-153.7lbs
General: Well-appearing female sitting up in bed in NAD; Appears
comfortable and conversational
HEENT: PERRL, EOMI, MMM, clear oropharynx
CV: RRR S1, S2. I/VI murmur heard best at LUSB.
Respiratory: Clear to auscultation bilaterally; no wheezes,
rales, rhonchi
Abdomen: soft, nondistended; +BS, palpable spleen tip about 2cm
below costal margin, no tenderness to palpation
Extremities: WWP, no c/c/e
Lymph: No cervical or supraclavicular LAD
Skin: No rash or petechiae
Pertinent Results:
ADMISSION LABS:
___ 08:50PM BLOOD WBC-15.5* RBC-3.24*# Hgb-9.9*# Hct-31.2*#
MCV-96 MCH-30.5 MCHC-31.7 RDW-19.6* Plt Ct-66*
___ 08:50PM BLOOD Neuts-67 Bands-2 Lymphs-3* Monos-12*
Eos-4 Baso-0 ___ Metas-5* Myelos-0 Promyel-2* Blasts-5*
NRBC-14*
___ 08:50PM BLOOD Hypochr-1+ Anisocy-2+ Poiklo-OCCASIONAL
Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-OCCASIONAL
Stipple-OCCASIONAL Tear Dr-OCCASIONAL
___ 08:50PM BLOOD ___ PTT-33.0 ___
___ 08:50PM BLOOD Glucose-113* UreaN-28* Creat-1.5* Na-139
K-4.1 Cl-105 HCO3-22 AnGap-16
___ 09:02PM BLOOD Lactate-1.4
OTHER PERTINENT LABS:
___ 06:05AM BLOOD WBC-12.1* RBC-2.61* Hgb-8.0* Hct-24.5*
MCV-94 MCH-30.5 MCHC-32.5 RDW-18.0* Plt Ct-85*
___ 06:05AM BLOOD Neuts-71* Bands-2 Lymphs-14* Monos-8
Eos-4 Baso-0 ___ Myelos-1* NRBC-6*
___ 08:50PM BLOOD ___ PTT-33.0 ___
___ 05:35AM BLOOD ___
___ 05:55AM BLOOD ___ PTT-33.3 ___
___ 06:25AM BLOOD ___ PTT-38.1* ___
___ 07:20AM BLOOD ___ PTT-39.5* ___
___ 06:55AM BLOOD ___
___ 07:15AM BLOOD ___
___ 07:15AM BLOOD ___
___ 06:05AM BLOOD ___
___ 06:05AM BLOOD Glucose-104* UreaN-18 Creat-1.2* Na-140
K-3.8 Cl-107 HCO3-26 AnGap-11
___ 06:05AM BLOOD ALT-13 AST-14 LD(LDH)-492* AlkPhos-63
TotBili-0.9
___ 06:05AM BLOOD Calcium-7.6* Phos-3.8 Mg-1.8 UricAcd-7.9*
___ 05:55AM BLOOD Triglyc-165*
___ 07:15AM BLOOD CRP-62.0*
___ 07:15AM BLOOD HIV Ab-NEGATIVE
___ 07:15AM BLOOD ___
U/A: ___ 08:50PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 08:50PM URINE RBC-0 WBC-43* Bacteri-NONE Yeast-NONE
Epi-2 TransE-<1
U/A: ___ 12:57PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 12:57PM URINE RBC-0 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-1 TransE-<1
MICRO:
___ 1:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 7:15 am Immunology (CMV)
CMV Viral Load (Pending):
___ 5:47 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Pending):
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.
___ 11:16 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 12:57 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 8:50 pm URINE TAKEN FROM 68223D.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
(Reference Range-Negative).
Performed by Immunochromogenic assay.
A negative result does not rule out infection due to other
L.
pneumophila serogroups or other Legionella species.
Furthermore, in
infected patients the excretion of antigen in urine may
vary.
___ 8:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:50 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
IMAGING/STUDIES:
Echo (___): The left atrial volume index is mildly
increased. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). Right
ventricular chamber size and free wall motion are normal. The
ascending aorta is mildly dilated. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. No masses or
vegetations are seen on the aortic valve. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. No mass or vegetation is seen
on the mitral valve. There is mild pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is a trivial/physiologic pericardial effusion.
IMPRESSION: Normal global and regional biventricular systolic
function. No vegetations or clinically-significant valvular
disease seen. Mild pulmonary hypertension.
CT Chest w/o Contrast (___): New right lower lobe
peribronchial opacities consistent with infection. Stable lung
nodules. Enlargement of the pulmonary artery suggesting
pulmonary hypertension coronary calcification
CT Abd/Pelvis w/o Contrast (___):
1. Limited evaluation without IV contrast but no evidence of
pathology within the abdomen or pelvis to explain patient's
persistent fevers.
2. Splenomegaly with areas of infarction in the inferolateral
tip.
CXR (___): In comparison with the study of 11 7, there is
little change in the small left pleural effusion with mild
basilar atelectasis. Otherwise little change.
Splenic U/S (___): The spleen is enlarged measuring 20.3 cm
in length, previously 19.5 cm. The echotexture is homogeneous.
Renal U/S (___): Atrophic left kidney with minimally dilated
left collecting system similar in appearance to the prior CT
done in ___. No evidence of perinephric fluid collection or
abscess in either kidney. Splenomegaly measuring 20 cm.
CXR (___): New small left pleural effusion. No evidence of
pneumonia. Of note subtle infection may only be seen on CT
scan.
Brief Hospital Course:
Ms. ___ is a ___ year old with JAK2+ post-essential
thrombocythemia myelofibrosis, unprovoked PE(on coumadin) who
initially presented on ___ with malaise and fevers up to
102.7F started on ctx/azithromycin for presumed CAP, briefly
broadened with vancomycin for ongoing fevers, and subsequently
found to have splenic infarct on abdominal CT.
ACTIVE ISSUES:
# Fever/ malaise: Ms. ___ presented with fevers as high as
102.7F at home with dry cough and LUQ abdominal pain, worse with
deep inspiration. On presentation she had a fever of 101.8F.
Chest XRay on admission with small left pleural effusion, with
possible consolidation, so she was started empirically on
ceftriaxone and azithromycin for community acquired pneumonia.
Urinanalysis had large leuk esterase and 42 WBC, but cultures
without growth. There was concern that her fevers may also be
explained by transformation of her myelofibrosis to leukemia as
described below. After initiation of antibiotics, pt
defervesced, although on ___, she spiked another fever to
101.8F with a stable white count of 10, although with 13% bands.
Primary complaint was ongoing LUQ abdominal pain. She had no
shortness of breath and continued to have stable mild
nonproductive cough. She had a bone marrow on ___ as described
below, so due to concern for bacteremia, she was empirically
started on vancomycin. Renal and splenic ultrasounds were
performed, which showed splenomegaly up to 20cm. She had ongoing
low grade fevers to 100.5F, so CT abd/pelvis was performed which
revealed a LLL ground glass opacity in her lungs and a splenic
infarct. Infectious Disease was consulted and believed that her
possible pneumonia had been treated with five day course of
ctx/azithro, so all antibiotics were discontinued. Believed her
ongoing low grade fevers were most likely from splenic infarct,
as the patient otherwise felt well. On the day of discharge, her
cough was improved, she was afebrile, and her LUQ abdominal pain
was almost resolved. Blood cultures remained negative, and
preliminary respiratory viral swab remained negative.
# LUQ Abdominal Pain: Pt presenting with LUQ pain in the setting
of fevers. Splenic ultrasound indicated splenomegaly of 20cm,
and subsequent CT found splenic infarct. Echocardiogram without
vegetations to suggest embolic source. Pt was recently on
ruloxitinib, which was discontinued on ___. This can cause
rebound splenomegaly, and is likely the cause of her infarct and
fevers. Her pain improved dramatically during hospitalization,
and she was afebrile on day of discharge.
# Post-essential thrombocythemia myelofibrosis: Pt with history
of myelofibrosis and has been treated with ruloxitinib since
___. Discontinued by Dr. ___ in the setting of
thrombocytopenia on ___. Her counts remained stable during
admission, although there was concern for transformation to
leukemia with her ongoing thrombocytopenia and fevers. Her smear
did show immature leukocytes, which may be particularly
increased in the setting of a possible acute infection. Bone
marrow biopsy on ___ with preliminary report showing
myelofibrosis without evidence of leukemia. Final results still
pending at time of discharge.
# Elevated uric acid: Pt noted to have increased uric acid on
presentation up to 11.3. She was given some fluids intitially
and continued on her home allopurinol. This downtrended during
admission and was 7.9 on day of discharge.
CHRONIC ISSUES
# Hx of unprovoked PE: Continued on warfarin during admission.
Given 2mg po daily while on antibiotics, and her INR remained
between ___. On day of discharge, she was continued on her home
dose of 2.5mg po daily, with follow-up scheduled on ___ for
INR check.
***TRANSITIONAL ISSUES***
-Echo with mild pulmonary hypertension
-Pt should have INR checked on ___. INR had been trending down
off of antibiotics. ___ INR:2.0.
-Please follow-up on pending ___, CMV viral load, Respiratory
viral culture, blood cultures, and bone marrow biopsy results
-Pt should have Hgb/Hct checked as it had been trending down
during admission. No evidence of bleed.
-Aspirin, HCTZ, and lisinopril were continued to be held during
hospitalization as she had not been taking them when she came
in. These need to be reevaluated as outpatient
-Ruloxitinib held since ___ ___: Full
-Contact: ___ (daughter) Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
5. ruxolitinib 60 mg oral BID
6. Ascorbic Acid ___ mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Calcium Carbonate 600 mg PO DAILY
9. fish oil-dha-epa ___ mg oral daily
10. Loratadine 10 mg PO DAILY:PRN allergies
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Calcium Carbonate 600 mg PO DAILY
4. Warfarin 2.5 mg PO DAILY16
5. fish oil-dha-epa ___ mg oral daily
6. Loratadine 10 mg PO DAILY:PRN allergies
7. Outpatient Lab Work
Please draw ___, CBC on ___
ICD9: 453.40; 285.9
Please fax results to Dr. ___ at ___
Please fax results to Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Splenic infarct; Fevers; JAK2+ post-essential
thrombocythemia myelofibrosis
Secondary Diagnosis: History of pulmonary embolism; Elevated
uric acidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
You were admitted to ___
because you were having high fevers at home up to 102.7, as well
as left sided abdominal pain. You had a chest Xray which showed
a possible pneumonia so you were started on antibiotics just in
case, and your fever improved. There was concern that your
fevers may be from progression of your myelofibrosis, so you had
a bone marrow biopsy on ___. You tolerated this procedure
well. The preliminary report does not show any evidence of
leukemia.
For your abdominal pain, you had a CT scan which showed that you
had a large spleen. There was an area that had diminished blood
flow causing an infarct, which is likely the cause of your
abominal pain and fevers. Your antibiotics were stopped after a
five-day course for pneumonia, and you felt well with no further
fevers.
Please follow up with Dr. ___ on ___ at the appointment
scheduled below. You should also have your INR checked at this
visit to determine your warfarin dose.
It was a pleasure taking care of you,
Your ___ Team
Followup Instructions:
___
|
10111112-DS-15 | 10,111,112 | 23,643,056 | DS | 15 | 2150-02-28 00:00:00 | 2150-03-01 10:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine /
Morphine
Attending: ___.
Chief Complaint:
left foot bruise
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
___ year old female with history of essential thrombocythemia now
with post-ET myelofibrosis c/b bilateral PE in ___ maintained
on
warfarin now on ruloxitinib s/p right SFA balloon
angioplasty/stenting in ___ for PAD on the right presents
today with left foot swelling and ecchymosis x month. She states
that she hit back of ankle month ago and the pain has been
present since. Pt is on coumadin. Pt was seen by her PCP and
told she has a rash and should be using a steroid cream which
she has been putting on it x week. Pt denies any N/V/F/C/SOB/CP.
Pt has no other complaints at this time.
She was seen by her PCP ___ ___ at which time they documented pt
reporting striking her left ankle on the corner of the bed one
month ago and since then she has had a rash over the anterior
ankle with worsening swelling. No pain at that time. She was
given a steroid cream to try for inflammation over the rash on
the ankle.
REgarding her onc history, she did well on ruloxitinib in ___
but this was stopped due to thrombocytopenia but she then
developed spelnic infarcts ___ underlying myeloproliferative
neoplasm so ruloxitinib was resumed ___ with dose increase to
10 BID in mid ___.
ED COURSE:
v/s on arrival: 97.8 82 155/78 14 100%.
Labs: WBC 49 stable compared to prior in ___ of this
year. Plts down to 40 from 62 in ___. Hct at 39 from 45 in ___
but had been much lower previously. Also noted to have 1 blast
on diff but blasts seen previously on smear. INR 4.1.
Received 1g po APAP. XR showed No acute fracture
REVIEW OF SYSTEMS:
GENERAL: No fever, chills, night sweats, recent weight changes.
HEENT: No sores in the mouth, painful swallowing, intolerance to
liquids or solids, sinus tenderness, rhinorrhea, or congestion.
CARDS: No chest pain, chest pressure, exertional symptoms, or
palpitations.
PULM: No cough, shortness of breath, hemoptysis, or wheezing.
GI: No nausea, vomiting, diarrhea, constipation or abdominal
pain. No recent change in bowel habits, hematochezia, or melena.
GU: No dysuria or change in bladder habits.
MSK: No arthritis, arthralgias, myalgias, or bone pain.
DERM: Denies rashes, itching, or skin breakdown.
NEURO: No headache, visual changes, numbness/tingling,
paresthesias, or focal neurologic symptoms.
PSYCH: No feelings of depression or anxiety. All other review of
systems negative.
Past Medical History:
She has had essential thrombocythemia for many years
complicated by the development of pulmonary emboli in ___ for
which she is chronically maintained on warfarin. She was on
hydroxyurea until ___ (intolerant of anagrelide due to
vasomotor effects and migraine headaches), but developed
progressive thrombocytosis and dose-limiting anemia, which
prevented further dose escalation. After a bone marrow confirmed
the presence of myelofibrosis, she was initiated on ruxolitinib
(Jakafi) in ___ at a dose of 10 mg bid, which was
increased to 15 mg bid in ___. She had a good symptomatic
response to ruxolitinib along with normalization of her platelet
count from over a million/ul prior to therapy. She however
remained severely anemic requiring periodic (once every ___
weeks) red cell transfusions, usually for Hgb < ___ in
association with worsening symptoms. However after 1 unit of
blood on ___, her hct remained ~22 and she did not receive
any additional RBC transfusions until ___.
In ___, her platelet count declined without any change in her
overall clinical status. The severity of the thrombocytopenia
lead to the cessation of ruloxitinib and low-dose aspirin on
___. She then became ill with fever, LUQ abdominal pain,
and
malaise for which she was hospitalized from ___. CXR
showed a new small left pleural effusion and question of an
infiltrate. She was cultured and started on
ceftriaxone/azithromycin for presumed CAP, with vancomycin
briefly added for ongoing fevers. She was subsequently found to
have a splenic infarct on abdominal CT with ground glass opacity
in lung. Cultures returned negative. Given development of
progressive thrombocytopenia on ruloxitinib and concern for
progression of myelofibrosis to leukemia, a bone marrow was
performed which did not show significant changes from prior
exam.
Splenic ultrasound showed splenomegaly up to 20 cm. All
antibiotics ultimately were discontinued and the ongoing low
grade fevers and LUQ abdominal pain gradually resolved.
As the intermittent fevers and left upper quadrant pain were
felt
to be due to splenic infarcts secondary to the underlying
myeloproliferative neoplasm, ruloxitinib 15 mg bid was resumed
on
___ when her platelet count had risen to 136K.
When seen here on ___, CBC showed:
WBC 17.6 Hgb 9.5 Hct 28.3 MCV 90 Plt 58K
N:41 Band:0 ___ M:18 E:5 Bas:1 Atyps: ___ Metas: ___ Myelos: 6
Nrbc: 2 Other: 6 WBC: 2 Nrbc'S/100 Wbc'S Hypochr: 1+Anisocy:1+
Poiklo: 1+ Microcy: 1+ Ovalocy: 1+ Stipple: 1+ Tear-Dr: 1+
She was advised to reduce the dose of ruloxitinib to 10 mg bid;
an outside platelet count on ___ was 44K necessitating another
hold in the medication. Following this, she noted increasing
abdominal bloating particularly in the LUQ. After holding
ruloxitinib, her platelet count recovered but immediately
declined following resumption of 10 mg bid in ___. She also
developed early satiety, weight loss, and abdominal pain to an
enlarged spleen.
When seen back on ___, a followup abdominal ultrasound did
not
demonstrate any enlargement of her spleen compared to the prior
scan in ___. Labs showed: WBC 31.3 Hgb 12.1 Hct 39.1 MCV 90
Plt 62K
N:45 Band:3 ___ M:21 E:0 ___ Metas: ___ Myelos: 4 Promyel: 2
Blasts: 3 Nrbc: 8 Nrbc'S/100 WBCs Macrocy: 1+ Polychr: 1+
As her symptoms were likely due to hypersplenism due to the
underlying myeloproliferative neoplasm, ruloxitinib was
restarted
at a lower dose of 5 mg daily to try to palliate her symptoms
related to hypersplenism. This lower dose was selected due to
the
prior thrombocytopenia and her renal dysfunction (creatinine
clearance by Cock___-Gault Equation of 33.1 mL/min). Her
counts
have been followed closely and her dose was increased to 5 mg
bid, which she has been able to tolerate despite a platelet
count
that has ranged from 50-100K.
PAST MEDICAL HISTORY:
Essential Thrombocytosis / Myelofibrosis (stopped aspirin and
ruxolitinib)
Pulmonary Embolism on warfarin
Peripheral Vascular Disease s/p RLE stent
HTN (off medications due to low BP)
HLD
pHTN
COPD Gold Stage I
CKD baseline Cr 1.5-1.9
Tonsillectomy-Adenoidectomy
C-Section
Cholecystectomy
Social History:
___
Family History:
She has an uncle with tuberculosis when he was a young man, but
she was not exposed to tuberculosis. Her mother had
cardiovascular disease and breast cancer.
Physical Exam:
Admission Physical Exam:
VS: 98.5 120/60 72 18 95RA
Gen: well appearing, NAD
CV: RRR, no mrg
Resp: CTA ___, no wheezes/rhonchi
Abd: soft, nt, nd
Ext: no clubbing or cyanosis. L leg with ecchmyosis extending
from big toe to ankle, painful to touch and to movement. Pulses
palpable.
Neuro: no focal deficits, moves all 4 ext purposefully.
Discharge Physical Exam:
VS: 97.9-99.4 ___ 106-120/54-60 ___ 92-___
360/57// ___, no BM (24hr)
GENERAL: NAD, AOx3
HEENT: NC/AT, EOMI, PERRL, MMM
CARDIAC: RRR, normal S1 & S2, without murmurs
LUNG: clear to auscultation, no wheezes or rhonchi
ABD: +BS, soft except palpable firm spleen, NT/ND, no rebound or
guarding, two noted scabbing bruises at bilateral midclavicular
line under breasts
EXT: upper extremity edema resolved, bilateral 2+ lower
extremity edema, L foot with large healing ecchymosis extending
up to ankle now with dry peeling skin
PULSES: 2+DP pulses bilaterally
NEURO: CN II-XII intact, 3+ strength in upper extremity flexion
and extension, 2+ strength in lower extremity flexion and
extension
SKIN: Warm and dry
Pertinent Results:
ADMISSION LABS:
---------------
___ 10:30PM BLOOD WBC-49.5* RBC-4.35 Hgb-12.3 Hct-39.9
MCV-92 MCH-28.3 MCHC-30.8* RDW-21.3* RDWSD-69.0* Plt Ct-40*
___ 10:30PM BLOOD ___ PTT-57.9* ___
___ 10:30PM BLOOD Plt Ct-40*
___ 10:30PM BLOOD Glucose-105* UreaN-76* Creat-2.3* Na-136
K-5.2* Cl-106 HCO3-17* AnGap-18
IMAGES:
-------
FOOT X RAY ___
No acute fracture seen.
MR ___ ___
1. No MR evidence of osteomyelitis.
2. No joint effusion.
3. Circumferential subcutaneous edema.
4. No evidence of acute fracture, old injury of the medial
malleolus.
5. Mild tenosynovitis of the posterior tibial and peroneus
brevis tendons.
6. Paratenonitis of the Achilles tendon.
US Abd ___
1. Marked splenomegaly, unchanged.
2. Mildly increased periportal echoes within the liver, which
may indicate
mild periportal edema.
CT Abd ___
1. Massive splenomegaly, and diffuse sclerotic changes of the
bones have
progressed since ___ and likely related to patient's history of
hematologic disease.
2. Small ascites, anasarca.
CT Chest ___
1. Multiple areas of consolidation and ground-glass opacities
involving
bilateral lungs are consistent with multifocal pneumonia.
2. Enlarged main pulmonary artery is similar as before and may
reflect
underlying pulmonary hypertension.
KUB ___
No evidence of ileus or obstruction.
CXR ___
As compared to the previous radiograph, the signs indicative of
centralized pulmonary edema have increased in severity. In
addition, minimal blunting of the left costophrenic sinus has
newly appeared, suggesting the presence of a small pleural
effusion. Mild cardiomegaly persists. No pneumothorax. The
monitoring and support devices are constant.
CXR ___
Right internal jugular line tip is at the level of mid to lower
SVC. Heart size and mediastinum are stable. There is interval
progression of widespread parenchymal opacities concerning for
interval development of are drug toxicity within the lungs or
diffuse infectious process. Left pleural effusion is small to
moderate, unchanged as well as left retrocardiac consolidation
DISCHARGE LABS:
---------------
___ 04:58AM BLOOD WBC-57.5* RBC-2.25* Hgb-6.9* Hct-22.2*
MCV-99* MCH-30.7 MCHC-31.1* RDW-20.5* RDWSD-65.8* Plt Ct-18*
___ 04:58AM BLOOD Glucose-105* UreaN-34* Creat-1.6* Na-139
K-4.4 Cl-107 HCO3-23 AnGap-13
___ 04:58AM BLOOD ALT-16 AST-27 LD(LDH)-838* AlkPhos-163*
TotBili-1.9*
___ 04:58AM BLOOD Calcium-7.2* Phos-2.1* Mg-1.8
UricAcd-7.3*
Brief Hospital Course:
___ year old female with history of essential thrombocythemia now
with post-ET myelofibrosis c/b bilateral PE in ___ maintained
on warfarin now on ruloxitinib s/p right SFA balloon
angioplasty/stenting in ___ for PAD on the right presented
with left foot swelling and ecchymosis for the last month, which
has progressively grown in size. Course was complicated by
distributive shock thought to be secondary to jakafi withdrawal
syndrome.
INITIAL FLOOR AND MICU COURSE:
#Distributive Shock, Likely ___ Jakafi Withdrawal:
Prior to admission, she had swelling and ecchymosis on her left
foot x 1 month. She initially saw her PCP for this on ___
and was prescribed betamethasone which had little effect. She
was admitted for persistence of this rash. She also noted
chronic petechiae on her arms/legs which seemed to appear around
the time she initiated her JAK2 inhibitor. Given history of
trauma, elvated INR on admission, and low plts dermatology
thought the left foot rash was due to ecchymosis.
On admission, the patient's jakafi was held given that it was
not on formulary. She began to develop acutely worsening
thrombocytopenia and new worsened anemia, along with elevated
LFTs and hyperuricemia. Hematology consulted (Dr. ___ is her
___ hematologist). Smear revealed abnormal early myeloid
progenitors including blasts (stable from prior), but no
schistocytes. Coombs test negative. SPEP/UPEP unremarkable.
Spleen ultrasound showed unchanged splenomegaly. Given positive
hemolysis labs (hapto <5, Tbili 2.6, LDH in 800s), they were
concerned about MAHA and possible AML transformation. They
recommended rasburicase x1 given elevated uric acid to 10 (given
___.
The patient became newly hypoxic to 80% on RA and CXR showed
pulmonary edema with asymmetric right upper lobe airspace
disease. IV fluids were stopped. She was given lasix and was
maintained on 2L NC. On ___ she had worsening metabolic
acidosis with bicarb of 11, lactate of 6, VBG 7.___/11. She
also had leukocytosis to 70, creatinine of 2.5 (baseline
1.8-2.2), and glucose of 40. She was started on vanc and
meropenem and given dextrose bolus.
Renal consulted given ___ (non-oliguric) and metabolic acidosis.
Urine sediment was significant for numerous muddy brown casts
and few isomorphic RBCs. The recommended IV bicarb, workup for
vasculitis, check urine protein.
She was transferred to the ICU and given IV bicarb, platelets,
and FFP. Abx were switched to vanc and cefepime (from
meropenem). Given ongoing acidosis, worsening pulmnoary edema,
and for more fluids/producs, she was intubated. She required
pressors to maintain her blood pressures. She was started on
CVVH for her acidosis.
An infectious workup was largely negative, with no signs of
pulmonary, abdominal, urine or CNS infections seen on labs or
CT. The patient reported that she had been taking Jakafi until
her hospitalization. Further investigation into this medication
showed that there are several reports of Jakafi Withdrawal
Syndrome, which is characterized by "Acute relapse of
myelofibrosis symptoms (eg, fever, respiratory distress,
hypotension, DIC, multiorgan failure), splenomegaly, worsening
cytopenias, hemodynamic compensation, and septic shock-like
syndrome have been reported with treatment tapering or
discontinuation (___, ___. Symptoms generally return over
approximately 1 week." As no infectious source was identified,
the patient's distributive shock was attributed to this
syndrome. She was restarted on her home Jakafi, and a steroid
taper was started (ended ___.
While in the ICU, the patient required several platelet and RBC
transfusions. She continued to require CVVH. Her WBC increased
to >100, and the heme/onc service recommeneded no leukophoresis.
The patient slowly began to clinically improve. She was weaned
from pressors and extubated on ___. Her CVVH was stopped on ___
and antibiotics were stopped as no clear infectious source. The
patient remained stable enough to be transferred to the floor.
FLOOR COURSE:
#Anemia and thrombocytopenia: Pt developed worsening anemia and
thrombocytopenia on ___ with elevated uric acid and
hyperkalemia, concerning for hemolysis and uric acid
nephropathy. Patient was seen by hematology who recommended
continuation of her ruxolitinib with platelet and RBC
transfusions for platelets <10 and h/g ___. Patient will be
followed closely in outpatient setting to evaluate restarting
coumadin and management of ruxolitinib.
# CKD stage 3: Pt with baseline CKD; last Cr in ___ was
2.2. Pt had worsening renal failure, requiring CVVH
temporarily, secondary to distributive shock from ruxilitinib
withdrawal syndrome. Creatinine improved and was 1.6 on
discharge.
#Rash: Dermatology biopsied the patient's L foot rash to assess
for vasculitis. The results showed only ecchymosis. Rash was
monitored and remained stable for remainder of hospital course.
#Leukocytosis: Pt developed worsening leukocytosis, with wbc
count reaching 141.4 on ___. This was thought to be secondary to
MPN and jakofi withdrawal syndrome. Differential reveals 1-5%
blasts, which have been seen previously since ___. Bone marrow
biopsy was deferred as pt improved with resumption of jakofi.
Wbc trended down and was 57.5 on discharge.
# Bleeding/ecchymosis/Elevated INR: likely mild trauma without
fracture in setting of elevated INR. Pt previously took 5mg
warfarin daily. Warfarin was held while inpatient given
thrombocytopneia and stopped on discharge.
# Thrush - Patient found to have thrush on oncology floor, after
ICU admission and intubation. Starting on nystatin swish and
swallow QID. Patient should continue treatment in outpatient
setting
# Hyperuricemia - Attributed to Ja___ Withdrawal Syndrome.
Patient started on allopurinol ___ daily.
# pulmonary hypertension - Pt has a history of pHTN, likely
resulting from prior bilateral PE. Pt was intubated in ICU
given acidosis. Following extubtation, pt was weaned to room
air. CXR revealed mild pulmonary edema vs infection. Diuresis
was held as pt was breathing comfortably on room air and
continued to have ___. Infection was felt to be less likely as
wbc count trended down and pt remained afebrile without
productive sputum.
# GERD - Pt continued on PPI
# Essential Thrombocythemia/post-ET myelofibrosis - ruloxitinib
was restarted as above.
====================
Transitional Issues:
====================
- Patient should continue to use the Nystatin oral swish and
swallow medication 4 times/day until thrush resolves.
- Patient should followup with Dr. ___ in his clinic next week
and have cbc, chem-10 and LFTs checked.
- Patient had warfarin medication held due to low platelet
count. She should discuss with Dr. ___ restarting
this medication.
- Patient experienced elevated uric acid and was started on
200mg allopurinol. Her UA level and continued need for this
medication should be followed in the outpatient setting.
- Due to normalized blood pressures while in the hospital, the
patient's HCTZ and lisinopril. Restarting these medications
should be addressed in the outpatient setting.
- Due to transaminitis, atorvastatin held. Restarting this
medication should be address in outpatient setting.
- Patient was found to have ___ during hospital admission. It is
improving at time of discharge, but should be continued to be
monitored.
- Pt should be on strict fall precautions.
CODE: Full
EMERGENCY CONTACT HCP: ___ (daughter) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
2. Betamethasone Valerate 0.1% Ointment 1 Appl TP DAILY
3. ruxolitinib 10 mg oral BID
4. Tretinoin 0.025% Cream 1 Appl TP QHS
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Warfarin 5 mg PO DAILY16
7. Atorvastatin 10 mg PO QPM
8. Omeprazole 20 mg PO DAILY
9. Loratadine 10 mg PO DAILY
10. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 2 tablet by mouth Daily Disp #*30 Tablet
Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet by mouth Daily Disp #*30 Tablet
Refills:*0
3. Nystatin Oral Suspension 5 mL PO BID
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day
Refills:*0
4. ruxolitinib 10 mg oral BID
5. Betamethasone Valerate 0.1% Ointment 1 Appl TP DAILY
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. Loratadine 10 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Tretinoin 0.025% Cream 1 Appl TP QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Ruxolitinib withdrawal syndrome
Thrush
___
Secondary Diagnosis:
Essential throbocythemia
Myelofibrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Ms. ___,
You were admitted to ___ for evaluation of bruising, found to
have an elevated INR. Your warfarin and ruxolitinib were held
and you were seen by dermatology who verified that this was a
hematoma, or bruise. You then developed worsening anemia and
low platelets, as well as an elevated potassium, worsening
kidney function, and repiratory distress. You were transferred
to the ICU and intubate in order to stabilze your respiratory
status.
Ultimately, it was determined that these acute events were
caused by a ruxolitinib withdrawal syndrome. You were started
back on your medication and your status improved. You were
extubated and transferred to the oncology floor.
During your time on the oncology floor, you were found to have
thrush, a fungal infection in your mouth. You are being treated
with Nystatin oral medication, and should continue to take this
medication 4 times a day, until the infection resolves. You were
also seen by physical therapy who recommended discharge to a
rehabilitation facility in order to all you to continue to
regain strength and endurance.
It was a pleasure taking care of you,
The ___ Care Team
Followup Instructions:
___
|
10111112-DS-16 | 10,111,112 | 27,068,188 | DS | 16 | 2150-12-21 00:00:00 | 2150-12-21 20:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine /
Morphine
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
Therapeutic and diagnostic paracentesis (___)
History of Present Illness:
Ms. ___ is a ___ with essential
thrombocythemia/myelofibrosis and renal failure (HD in the
past),
presenting with shortness of breath. She has become extremely
dyspneic with any type of exertion, with speaking, and with
lying
down over the last 24 hours. She also has a nonproductive cough
and wheeze which is new for her and "muscular chest pain" from
coughing. She has known ascites, but has had worsening abdominal
distention for many weeks, accompanied by 15 lb weight gain and
bilateral lower extremity swelling that is also mildly worsened.
She has a chronic left-sided pleural effusion as well as a
splenomegaly from her myelofibrosis. She denies any fevers but
has frequent chills which are chronic. She has a history of a
DVT
and PE from her thrombocytosis for which she had been on
Coumadin
until ___.
In the ED, initial VS were:
100.5 85 99/49 24 99% RA
Labs were notable for: WBC 38.3 (ranged ___, Hb 6.3 (down
from 9.5 in ___, MCV 112, Nucleated RBC 46%, plt 57 (within
baseline range), INR 1.7, PTT 30.5, LFTs wnl, lactate 4.3, Cr
2.4, , D-dimer 1730, Trop-T 0.11, proBN___
Imaging included: CXR that showed possible R multilobar pna and
unchanged L pleural effusion
Consults called: none
Treatments received: Cefepime
On arrival to the floor, patient was pleasant and cooperative,
and endorsed the above history.
Past Medical History:
PAST ONCOLOGIC HISTORY
She has had essential thrombocythemia since prior to ___ and
was
diagnosed with post-essential thrombocythemia myelofibrosis
(JAK2
V617F+) in ___. She also has peripheral vascular disease s/p
stent in left leg. She sustained bilateral pulmonary emboli in
___ in the setting of marked thrombocytosis.
She was hospitalized from ___ with a non resolving
bruise on her distal left lower extremity in the setting of an
elevated INR and
thrombocytopenia. Warfarin and ruxolitinib were held, but she
developed a sudden drop in hgb/hct, elevated uric acid (for
which
she received a single dose of rasburicase), worsening
thrombocytopenia, renal failure, and respiratory distress. She
was transferred to the ICU where she required intubation,
pressers, and dialysis. It was determined that she had developed
ruxolitinib-withdrawal syndrome. She was started back on
ruloxitinib 10 mg bid via NG tube while intubated along with IV
corticosteroids and empiric antibiotics. Her clinical status
gradually improved, she was extubated and weaned from dialysis,
and transferred to the oncology floor where ruloxitinib was
continued. She improved and went to rehab for about a week
before
returning home.
When seen in followup following the hospitalization on ___,
she had continued swelling of her left lower extremity, A left
leg ultrasound was negative for a DVT. When seen back by Dr.
___ pulmonary on ___, it was noted that the moderate
sized left effusion had increased. The possibility of doing a
diagnostic and therapeutic thoracentesis in ___ clinic
was
raised, but this was deferred. When seen here on ___, she
had
developed progressive bilateral lower extremity edema and
shortness of breath on exertion; there however were no other
clear symptoms/signs of heart failure. An echocardiogram on
___ showed preserved regional and global biventricular
systolic function and mild pulmonary artery systolic
hypertension. A gentle trial of diuresis (20 mg furosemide every
other day) was initiated on the supposition that heart failure
might be contributing to the bilateral pedal edema. She was
referred for evaluation to Dr. ___ of cardiology. At her
visit on ___, the left sided pleural effusion was slightly
smaller; however ___ did not feel that the qod furosemide had
decreased the leg swelling nor had it helped her breathing. Her
JVP was low, creatinine was up slightly 1.9 to 2.3, and BNP was
down to 1419. Overall Dr. ___ not feel that congestive
heart failure was responsible for the edema. Furosemide was
discontinued on ___ due to continued rise in her serum
creatinine.
At her last visit here on ___, she was having worsening
constitutional symptoms with intermittent bouts of
chills/shivering that last minutes to hours. Acetaminophen
provided symptomatic relief and infection was felt unlikely due
to the intermittent nature of the symptoms. Her creatinine was
up
to 2.6 and she was encouraged to drink more fluids. She has
since
been seen back Dr. ___ pulmonary who noted some increase in
the left pleural effusion and she was set up for evaluation by
Dr. ___ interventional pulmonology for possible left chest
thoracentesis. She was also seen by Dr. ___ nephrology
and
Dr. ___ ___ due to the development of severe diarrhea ___
weeks ago. Workup for infectious etiologies and celiac disease
was negative; she was noted to have somewhat low levels of
immunoglobulins.
PAST MEDICAL HISTORY:
Essential Thrombocytosis / Myelofibrosis (stopped aspirin and
ruxolitinib)
Pulmonary Embolism on warfarin
Peripheral Vascular Disease s/p RLE stent
HTN (off medications due to low BP)
HLD
pHTN
COPD Gold Stage I
CKD baseline ___ cr
Tonsillectomy-Adenoidectomy
C-Section
Cholecystectomy
Social History:
___
Family History:
She has an uncle with tuberculosis when he was a young man, but
she was not exposed to tuberculosis. Her mother had
cardiovascular disease and breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T 98.3 BP 102/56 HR 84 RR 20 O2Sat 98% 3LNC
GENERAL: NAD, short of breath while sitting in bed
HEENT: NC/AT. MM dry. No OP lesions. Nasal mucosa pink, slight
clear discharge. No cervical, axillary, supraclavicular, or
inguinal LAD.
CARDIAC: Normal rate and regular rhythm. Nml S1-S2 No M/R/G. PMI
nondisplaced. 5cm JVP.
LUNG: Thorax symmetric with good expansion. Crackles on lower
left lobe. No wheezes/rhonchi. Dull to percussion on R lower
lobe.
ABD: Soft, distended, with normoactive BS. No
rebound/tenderness.
Splenomegaly. Negative ___.
EXT: WWP. 4+ pitting edema in BLE extending to knees. No
clubbing
or cyanosis. 2+ DP/radial pulses.
SKIN: Senile purpura on BUE, venous stasis dermatitis BLE
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, light touch sensation grossly intact throughout,
DTRs 2+ and symmetric, cerebellar (FTN,HTS) function intact. No
pronator drift. Gait not assessed.
DISCHARGE PHYSICAL EXAM
=======================
Physical Exam:
VS: T 98.0-99.0 BP: 90-102/35-60 HR: ___ RR 18 O2:92-96%RA
I/O 24hr: 1130/3120; cum net -4208, Orthostatic this AM: supine
BP 93/48, HR 91 to standing BP 90/40, HR 84
GENERAL: Chronically-ill appearing in NAD; no evidence of
increased WOB; resting comfortably
HEENT: NC/AT. MM dry. No OP lesions. Nasal mucosa pink, slight
clear discharge. No cervical, axillary, supraclavicular LAD.
CARDIAC: Normal rate and regular rhythm. Nml S1-S2 No M/R/G. JVP
flat.
LUNG: Faint crackles in the left base; otherwise clear to
auscultation
ABD: Soft, distended, with normoactive BS. No
rebound/tenderness. Splenomegaly. Negative ___.
EXT: WWP. 3+ pitting edema in BLE extending to thighs. No
clubbing or cyanosis. 2+ DP/radial pulses. PICC site
clean/dry/intact.
SKIN: Senile purpura on BUE, venous stasis dermatitis BLE.
NEURO: awake, A&Ox3, grossly intact
Pertinent Results:
ADMISSION LABS
==============
___ 11:56AM LACTATE-4.3*
___ 11:52AM GLUCOSE-112* UREA N-37* CREAT-2.4* SODIUM-143
POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-15* ANION GAP-20
___ 11:52AM estGFR-Using this
___ 11:52AM ALT(SGPT)-16 AST(SGOT)-39 ALK PHOS-230* TOT
BILI-1.4
___ 11:52AM cTropnT-0.11*
___ 11:52AM CK-MB-2 proBNP-3894*
___ 11:52AM ALBUMIN-3.4* CALCIUM-7.8* PHOSPHATE-3.5
MAGNESIUM-2.0
___ 11:52AM D-DIMER-1730*
___ 11:52AM WBC-38.8*# RBC-1.93* HGB-6.3* HCT-21.6*
MCV-112* MCH-32.6* MCHC-29.2* RDW-22.5* RDWSD-91.3*
___ 11:52AM NEUTS-40 BANDS-11* LYMPHS-9* MONOS-21* EOS-6
BASOS-4* ___ MYELOS-2* BLASTS-7* NUC RBCS-46*
AbsNeut-19.79* AbsLymp-3.49 AbsMono-8.15* AbsEos-2.33*
AbsBaso-1.55*
___ 11:52AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+
MACROCYT-OCCASIONAL MICROCYT-1+ POLYCHROM-OCCASIONAL
STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL
___ 11:52AM PLT SMR-VERY LOW PLT COUNT-57*#
___ 11:52AM ___ PTT-30.5 ___
MICROBIOLOGY
==============
UA (___): WNL
Blood culture (___): No growth.
Urine culture (___): Negative
Stool C. diff toxin (___) Positive
Urine Legionella Ag (___): Negative
Urine Strep pneumo Ag (___): Negative
Hepatitis serologies (___): pending
IMAGING
==============
CXR ___:
In comparison to prior study there is new multifocal opacity in
the right hemithorax. A moderate left pleural effusion with
associated compressive atelectasis is unchanged.
Cardiomediastinal silhouette is stable. There is no
pneumothorax.
CT Chest Noncontrast (___):
IMPRESSION:
1. Multifocal opacities in the right lung, consistent with
multifocal
pneumonia.
2. Small to moderate left pleural effusion with associated
atelectasis.
3. Enlarged pulmonary artery, suggestive of pulmonary artery
hypertension.
4. Massive splenomegaly and ascites.
5. Diffuse sclerotic bony changes reflective of known history of
myelofibrosis.
DUPLEX DOPP ABD/PEL (___):
IMPRESSION:
1. Patent hepatic vasculature.
2. Coarsened liver with moderate to large volume ascites.
3. Massive splenomegaly (20.9 cm).
OTHER STUDIES
==============
Cytology (___):
PERITONEAL FLUID:
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells, histiocytes, neutrophils, and red blood
cells.
Note: A Brown-Brenn (tissue Gram) stain is negative for
microorganisms. Also see associated
microbiology culture results for further characterization.
GRAM STAIN, Peritoneal Fluid (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
Fluid Culture in Bottles, Peritoneal Fluid, (___):
(Preliminary): NO GROWTH.
Cardiology
==============
ECHO (TTE) ___:
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion. PA
pressure 30, EF 65%.
DISCHARGE LABS
==============
___ 05:58AM BLOOD WBC-38.1* RBC-2.44* Hgb-7.4* Hct-24.7*
MCV-101* MCH-30.3 MCHC-30.0* RDW-25.7* RDWSD-93.2* Plt Ct-26*
___ 05:58AM BLOOD Plt Ct-26*
___ 05:58AM BLOOD Glucose-80 UreaN-40* Creat-2.5* Na-139
K-4.2 Cl-106 HCO3-21* AnGap-16
___ 05:58AM BLOOD Calcium-7.7* Phos-3.2 Mg-2.2
Brief Hospital Course:
Ms. ___ is a ___ with hx of essential thrombocythemia, now
with post-thrombocythemic myelofibrosis on ruloxitinib, with
known chronic pleural effusion, splenomegaly, ascites, mild
pulmonary HTN, and CKD, admitted with worsening shortness of
breath and abdominal distention, and found to have multifocal
PNA, worsening ascites and b/l leg swelling.
#Ascites ___ post-thrombycthemic myelofibrosis: Patient reports
gaining 15 lbs over the three weeks prior to admission. Her
worsening abdominal ascites was likely multifactorial, ___ to
post-thrombocythemic myelofibrosis and related extramedullary
hematopoiesis, and pulmonary HTN. RUQU/S (___) demonstrated
coarsened liver with moderate/large volume ascites, patent
PV/HA, and splenomegaly, and CT Chest noncon (___) showed
enlarged PA. Patient also had worsening left ___ swelling/L
pleural effusion and an ECHO on ___ showed preserved global
biventricular systolic function (EF>65%) and mild PA systolic
HTN (32 mmHg). ECHO ___ confirms PHTN, although PA pressures
30, EF 65%, unchanged from prior. Pt received para ___ (drained
1.5 L). Peritoneal fluid WBC 1638, albumin 1.1, SAAG 2.0, c/w
ascites ___ portal HTN. Positive for mesothelial cells,
histiocytes, neutrophils, and red blood cells, WBCs are likely
bystanders of post-thrombotic myelofibrosis. Peritoneal fluid
bacterial cx negative. Plt 45 from 38 after getting 1 bag plt
post-para, but dropped to ___ (see below). After para, started
patient on additional diuretic therapy PO
torsemide/spironolactone to reduce fluid retention, with goal
___. Cr has been better or equal to baseline throughout, at
2.5 on ___. Of note, patient became orthostatic on ___ ___ and
had to d/c standing torsemide for ___. Not orthostatic on ___,
but reduce torsemide dose from 40 mg PO to 20 mg PO QD for
discharge. Cumulative net neg -4208 cc for hospitalization and
-1725 for 24 hrs prior to discharge. Plan to continue
spironolactone to 100 daily and torsemide 20 mg qd, goal even.
Please monitor strict daily weights as outpatient ___, hold
torsemide if 3 lb wt loss/2 days and f/u with MD. ___ portal
HTN and liver pathology, ordered hepatitis serologies that are
still pending. Also scheduled outpatient hepatology ___,
___ consider evaluating for varices.
#Multifocal pneumonia, recurrent: Likely contributed to dyspnea.
Needed 2LNC on admission. Patient improved, and satting
comfortably on RA now. CXR/CT chest noncon showed confirmed R
multifocal PNA and unchanged L pleural effusion. PICC placed
___. UA WNL. UCx neg. BCx neg. Urine legionella and strep
pneumo Ag negative. Patient started on empiric HCAP treatment:
IV vancomycin, cefepime, levofloxacin PO, 15 day course (start
___, end ___, stopped vancomycin ___ ___ low concern for
MRSA, and will go home on cefepime IV/levofloxacin PO. Ordered
B-Glucan, Galactomannan ___ c/f fungal etiologies iso
immunocompromise, that need to be followed up. Patient also
scheduled for outpatient ___ with Dr. ___
pulmonologist.
#C difficile colitis: Patient noted loose stools throughout
admission. C diff toxin pos ___. Notably, patient had finished
course of metronidazole 1 week prior to admission. This may
represent a first recurrence of severe grade. Note that positive
toxin test may represent carrier status, but ___ patient on
Abx, started vancomycin. Patient should continue vanc 125 PO
q6h, 14 d course, start ___, end ___ (14 d after PNA
antibiotic course ends on ___.
#Pleural effusion: Not likely contributing to dyspnea. Per CT
chest noncom above, chronic L pleural effusion unchanged/simple,
unlikely empyema or ___ malignancy.
#Coagulopathy of liver disease: INR elevated to 1.7 on admission
(___). Received vitamin K PO (with good aborption) and INR has
been steady at 1.4 since ___. Plt 57 on admission, but
downtrended into after paracentesis on ___ to 35. Received 1
bag of plts, with plt rising to 45. However, dropped into mid 20
on ___. Held heparin subq and continued to hold even when plt up
to 26.
#Pulmonary HTN: Patient had elevated PA pressures on ECHO ___
as above. Possible contributor to cirrhosis/fluid retention.
ECHO on this admission shows PA pressure 30, EF 65%, essentially
unchanged from ___. Regardless, elevated PA pressures persist,
and are likely contributing to portal HTN. ___ consider calcium
channel blocker in the future
#Macrocytic Anemia: current Hb 7.4; Hb 8.5 post transfusion on
___, has been Hb ___ during hospitalization, down from 9.5 in
___, MCV 112. NRBC 46%. Likely ___ to splenic sequestration vs
marrow exhaustion/progressive mylofibrosis. Considered a
component of hemolytic anemia, but Haptoglobin <10 low, LDH
high. Direct/indirect Coombs test negative. Hemolysis likely ___
myelofibrosis. Likely contribution from Anemia of chronic
inflammation- Fe 79/wnl, TIBC 124/down, ferritin 692/high,
transferrin 90/low and hypothyroidism TSH 8.5. B12 and folate
wnl. Continued home folate in house.
#Post-thrombocythemic myelofibrosis: WBC elevated (~30s), but
lower than her baseline, and would have expected leukemoid
reaction in context of PNA. Suspect progressive marrow fibrosis.
LDH 507 from 582; uric acid 7.0 (___). Continued ruxolitinib,
but may consider reducing dose iso of persistent cytopenia/low
plt ~20 in outpatient follow up. Has follow up scheduled with
Dr. ___ next week.
CHRONIC
=============================
#CKD: Cr 2.5 today, had dropped to 2.3 with initiation of
diuresis, has been better or equal to baseline (2.5). Renally
dose meds in house.
#GERD: continued home omeprazole
#Gout: Continued home allopurinol, but not colchicine in house,
___ cytopenias. Recommend stopping colchicine as outpatient.
#Hyperlipidedemia: Continued home atorvastatin in house.
#Rhinitis: Continued home fluticasone in house.
TRANSITIONAL ISSUES
===================
- Discharge weight: 62.14 kg (136.99 lb)
- Patient was diuresed with torsemide and spironolactone to
reduce ascites. Became orthostatic day before discharge, and
dose of torsemide was reduced from 40mg to 20mg for discharge.
Please adjust as needed as outpatient. Cr 2.5 on discharge.
- Please monitor strict daily weights with a goal of net even.
If patient loses or gains >3lbs/2 days, please adjust diuretics
as needed.
- Please monitor CBC as outpatient
- In the context of the patient's immunocompromised status,
beta-glucan and galactomannan studies were sent as part of the
work up for patient's pneumonia, ___ c/f fungal etiologies.
These studies are pending on discharge -please follow them up
- Patient treated for HCAP. On 15 day course of IV cefepime/PO
levofloxacin (start ___, end ___ that will need to completed
as outpatient.
- Patient had positive C. diff, and was started on PO
vancomycin. Will need to continue until 14 days after HCAP abx
course ends; (start ___, end ___
- Patient is chronically anemic and thrombocytopenic, with Hb
___ and plt in low ___ throughout hospitalization. ___ want to
consider reducing dose of ruloxitinib (current 10 mg BID) in
outpatient setting.
- Patient has gout, but discontinued colchicine during admission
___ her cytopenias. Patient will continue on allopurinol.
- Patient scheduled to see hepatologist in context of portal HTN
and liver disease; may consider EGD to evaluate for varices ___
liver disease. Also should follow up hepatitis serologies
ordered on this admission.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY gout
2. Atorvastatin 10 mg PO QPM hyperlipidemia
3. FoLIC Acid 1 mg PO DAILY
4. ruxolitinib 10 mg oral BID ET/myelofibrosis
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY rhinitis
6. Colchicine 0.3 mg PO DAILY:PRN gout
7. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. CefePIME 1 g IV Q24H HCAP
RX *cefepime [Maxipime] 1 gram 1 gram IV Q24HR Disp #*7 Vial
Refills:*0
2. Allopurinol ___ mg PO DAILY gout
3. Atorvastatin 10 mg PO QPM hyperlipidemia
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY rhinitis
5. FoLIC Acid 1 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. ruxolitinib 10 mg oral BID ET/myelofibrosis
8. Vancomycin Oral Liquid ___ mg PO Q6H C diff, severe,
recurrent Duration: 23 Days
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*86 Capsule Refills:*0
9. Levofloxacin 750 mg PO Q48H HCAP
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q48Hr Disp #*3
Tablet Refills:*0
10. Spironolactone 100 mg PO DAILY
RX *spironolactone 100 mg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
11. Torsemide 20 mg PO DAILY
RX *torsemide 20 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSES
=================
Ascites ___ post-thrombycthemic myelofibrosis
Multifocal pneumonia, recurrent
C difficile colitis
Pleural effusion
Coagulopathy of liver disease
Pulmonary HTN
Macrocytic Anemia
Post-thrombocythemic myelofibrosis
SECONDARY DIAGNOSES
===================
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 Ms. ___,
You were admitted with worsening abdominal distention and
shortness of breath. During your hospitalization, we found out
that you had developed worsening ascites (fluid in your abdomen)
secondary to your myelofibrosis and your pulmonary hypertension.
We also found out that you had pneumonia. Both the pneumonia and
the ascites likely caused your worsened shortness of breath. For
the ascites, we treated you by draining fluid from your abdomen
(paracentesis) and with diuretics. We treated your pneumonia
with a course of antibiotics that you will need to continue as
an outpatient. You shortness of breath improved significantly
with these treatments. During your hospitalization, you had
loose stools, and we found that you may have C. difficile
colitis. We started you on an antibiotic to treat this, and you
will need to finish the course as an outpatient. Throughout your
admission, we continued to treat your myelofibrosis with
ruxolitinib.
You will need to follow up with your primary oncologist, your
pulmonologist, and a gastroenterologist/hepatologist upon
discharge. We have these appointments for you.
It was a pleasure taking care of you!
We wish you all the best,
Your ___ team
Followup Instructions:
___
|
10111112-DS-17 | 10,111,112 | 29,341,294 | DS | 17 | 2151-03-07 00:00:00 | 2151-03-07 14:37:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine /
Morphine
Attending: ___
Chief Complaint:
SOB, ___ edema, Ascites
Major Surgical or Invasive Procedure:
Diagnostic Paracentesis on ___: 2944 PMNs
Therapeutic Paracentesis on ___ (removed 3L) & ___
History of Present Illness:
Ms. ___ is a ___ y/o woman with essential
thrombocythemia/myelofibrosis and renal failure (HD in the
past), prior PE, mild COPD, presenting with 2 weeks of
progressive shortness of breath and weight gain.
The patient is followed closely by hematology/oncology and
hepatology. She was put on torsemide and spironolactone for
peripheral edema and weight gain. Given a subsequent rise in
serum creatinine, her diuretics had been stopped with subsequent
abdominal distention, increased peripheral edema and shortness
of breath. Dr. ___ patient to come to ED for
evaluation.
The patient states that her shortness of breath has gradually
worsened over the past 2 weeks. She denies chest pain. She
denies nausea, vomiting, diarrhea, hematochezia, melena. No
cough, no fever.
In the ED, initial vitals were: 97.4 74 104/57 22 95% RA
Exam notable for: ascites, nontender, pitting edema 3+ to knees
Labs notable for: WBC 56 (30N, 21B, 6L, ___, H/H 7.4/24.8, plt
64, Ap 261; Na 140, K 3.7, Cl 109, HCO3 17, BUN/Cr 55/2.2; INR
1.3; D-Dimer 1212; UA positive for trace leuks.
Imaging notable for:
- CXR (___): left sided pleural effusion.
- ECG (___): Sinus at 74 bpm, no acute ischemic changes
Liver was consulted and recommended: Admission to ET.
Patient was given: Nothing.
On the floor, the patient reports that her abdomen has been
more distended and her legs have gotten more swollen since
stopping the diuretics 2 weeks ago. She feels that the SOB is
due to her belly distention. Denies fevers/chills, SOB, CP,
abdominal pain.
Past Medical History:
PAST ONCOLOGIC HISTORY
She has had essential thrombocythemia since prior to ___ and
was
diagnosed with post-essential thrombocythemia myelofibrosis
(JAK2
V617F+) in ___. She also has peripheral vascular disease s/p
stent in left leg. She sustained bilateral pulmonary emboli in
___ in the setting of marked thrombocytosis.
She was hospitalized from ___ with a non resolving
bruise on her distal left lower extremity in the setting of an
elevated INR and
thrombocytopenia. Warfarin and ruxolitinib were held, but she
developed a sudden drop in hgb/hct, elevated uric acid (for
which
she received a single dose of rasburicase), worsening
thrombocytopenia, renal failure, and respiratory distress. She
was transferred to the ICU where she required intubation,
pressers, and dialysis. It was determined that she had developed
ruxolitinib-withdrawal syndrome. She was started back on
ruloxitinib 10 mg bid via NG tube while intubated along with IV
corticosteroids and empiric antibiotics. Her clinical status
gradually improved, she was extubated and weaned from dialysis,
and transferred to the oncology floor where ruloxitinib was
continued. She improved and went to rehab for about a week
before
returning home.
When seen in followup following the hospitalization on ___,
she had continued swelling of her left lower extremity, A left
leg ultrasound was negative for a DVT. When seen back by Dr.
___ pulmonary on ___, it was noted that the moderate
sized left effusion had increased. The possibility of doing a
diagnostic and therapeutic thoracentesis in ___ clinic
was
raised, but this was deferred. When seen here on ___, she
had
developed progressive bilateral lower extremity edema and
shortness of breath on exertion; there however were no other
clear symptoms/signs of heart failure. An echocardiogram on
___ showed preserved regional and global biventricular
systolic function and mild pulmonary artery systolic
hypertension. A gentle trial of diuresis (20 mg furosemide every
other day) was initiated on the supposition that heart failure
might be contributing to the bilateral pedal edema. She was
referred for evaluation to Dr. ___ of cardiology. At her
visit on ___, the left sided pleural effusion was slightly
smaller; however ___ did not feel that the qod furosemide had
decreased the leg swelling nor had it helped her breathing. Her
JVP was low, creatinine was up slightly 1.9 to 2.3, and BNP was
down to 1419. Overall Dr. ___ not feel that congestive
heart failure was responsible for the edema. Furosemide was
discontinued on ___ due to continued rise in her serum
creatinine.
At her last visit here on ___, she was having worsening
constitutional symptoms with intermittent bouts of
chills/shivering that last minutes to hours. Acetaminophen
provided symptomatic relief and infection was felt unlikely due
to the intermittent nature of the symptoms. Her creatinine was
up
to 2.6 and she was encouraged to drink more fluids. She has
since
been seen back Dr. ___ pulmonary who noted some increase in
the left pleural effusion and she was set up for evaluation by
Dr. ___ interventional pulmonology for possible left chest
thoracentesis. She was also seen by Dr. ___ nephrology
and
Dr. ___ GI due to the development of severe diarrhea ___
weeks ago. Workup for infectious etiologies and celiac disease
was negative; she was noted to have somewhat low levels of
immunoglobulins.
PAST MEDICAL HISTORY:
Essential Thrombocytosis / Myelofibrosis (stopped aspirin and
ruxolitinib)
Pulmonary Embolism on warfarin
Peripheral Vascular Disease s/p RLE stent
HTN (off medications due to low BP)
HLD
pHTN
COPD Gold Stage I
CKD baseline ___ cr
Tonsillectomy-Adenoidectomy
C-Section
Cholecystectomy
Portal hypertension due to myelofibrosis with diuretic
refractory ascites
Social History:
___
Family History:
She has an uncle with tuberculosis when he was a young man, but
she was not exposed to tuberculosis. Her mother had
cardiovascular disease and breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vital Signs: 98.3 124/56 86 22 98% 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, I/VI systolic
murmur heard best at RUSB, rubs, gallops
Lungs: decreased breath sounds at left base, otherwise CTA.
Abdomen: Soft, very distended abdomen, mildly tender to
palpation over LUQ. +Hepatomegaly on exam, difficult to
appreciate splenomegaly. + fluid wave.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 3+ pitting edema to knees,
edema extends up to mid thighs.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
=========================
Vital Signs: 98.4 108 / 43 73 18 96 RA
General: A&O x3. NAD. Attention intact (months of year backward)
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, improved
laceration of buccal mucosa, lesion on lower lip.
CV: Regular rate and rhythm, normal S1 + S2, II/VI systolic
murmur heard best at RUSB, rubs, gallops
Lungs: CTAB, small lung volumes
Abdomen: Firm, very distended abdomen, nontender to palpation.
Difficult to assess for organomegaly given distension.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 3+ pitting edema to knees,
edema extends up to mid thighs.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred. No asterixis.
Pertinent Results:
ADMISSION LABS
==============
___ 10:30PM BLOOD WBC-56.6* RBC-2.26* Hgb-7.4* Hct-24.8*
MCV-110* MCH-32.7* MCHC-29.8* RDW-21.0* RDWSD-80.7* Plt Ct-67*
___ 10:30PM BLOOD Neuts-30* Bands-21* Lymphs-6* Monos-13
Eos-3 Baso-1 ___ Metas-6* Myelos-13* Blasts-7* NRBC-9*
AbsNeut-28.87* AbsLymp-3.40 AbsMono-7.36* AbsEos-1.70*
AbsBaso-0.57*
___ 10:30PM BLOOD Hypochr-NORMAL Anisocy-3+ Poiklo-2+
Macrocy-2+ Microcy-NORMAL Polychr-1+ Stipple-1+ Tear Dr-1+
Pappenh-1+
___ 10:30PM BLOOD ___ PTT-32.6 ___
___ 10:30PM BLOOD Plt Smr-VERY LOW Plt Ct-67*
___ 10:30PM BLOOD Glucose-134* UreaN-55* Creat-2.2* Na-140
K-3.7 Cl-109* HCO3-17* AnGap-18
___ 10:30PM BLOOD ALT-16 AST-26 AlkPhos-261* TotBili-1.1
___ 10:30PM BLOOD Lipase-16
___ 10:30PM BLOOD proBNP-1496*
___ 10:30PM BLOOD Albumin-3.7 Calcium-8.0* Phos-4.8* Mg-2.4
___ 11:44PM BLOOD D-Dimer-1212*
___ 11:51PM URINE Color-Yellow Appear-Clear Sp ___
___ 11:51PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 11:51PM URINE RBC-2 WBC-15* Bacteri-NONE Yeast-NONE
Epi-<1
ASCITES
___ 06:55PM ASCITES WBC-4600* ___ Polys-64* Bands-3*
Lymphs-4* Monos-20* NRBC-1* Mesothe-2* Macroph-7*
___ 06:55PM ASCITES TotPro-1.9 Glucose-110 LD(LDH)-159
Albumin-1.4 Triglyc-29
DISCHARGE LABS
=============
___ 04:25AM BLOOD WBC-39.4* RBC-2.46* Hgb-7.6* Hct-24.9*
MCV-101* MCH-30.9 MCHC-30.5* RDW-22.4* RDWSD-80.6* Plt Ct-42*
___ 04:25AM BLOOD ___ PTT-35.7 ___
___ 04:25AM BLOOD Glucose-96 UreaN-41* Creat-1.9* Na-141
K-4.3 Cl-113* HCO3-18* AnGap-14
___ 04:25AM BLOOD ALT-19 AST-27 AlkPhos-247* TotBili-0.8
___ 04:25AM BLOOD Albumin-4.0 Calcium-8.1* Phos-3.1 Mg-2.2
MICRO
====
___ BLOOD CX - NEGATIVE
___ PERITONEAL FLUID CX- NEGATIVE
___ BLOOD CULTURE: NEGATIVE
___ URINE CULTURE:NEGATIVE
IMAGING
=======
___ CXR
Slight interval increase in the left-sided pleural effusion.
___ Liver US
1. Cirrhotic hepatic morphology. No concerning focal liver
lesions seen.
Patent portal vein with normal direction of flow.
2. Massive splenomegaly is unchanged. Small amount of ascites.
Brief Hospital Course:
___ lady with essential thrombocythemia/myelofibrosis w/
subsequent liver cirrhosis and CKD (HD in the past), prior PE,
mild COPD, presenting with 2 weeks of progressive shortness of
breath and weight gain in the setting of stopping diuretics 2
weeks ago for ___, which improved with paracentesis. Diagnostic
paracentesis on ___ was significant for SBP and patient was
treated with Ceftriaxone for 5 days and was discharged on
Ciprofloxacin prophylaxis; due to recurrent C. Diff she will be
kept on a prophylactic dose of PO Vancomycin.
#Cirrhosis decompensated by ascites: Cirrhosis likely secondary
to myelofibrosis, ___ MELD 16. Patient with large volume
ascites that was likely contributing to SOB on admission. She
develops renal decompensation when receiving diuretic therapy
diuretic therapy, so will proceed with weekly paracentesis to
relieve ascites. She received therapeutic para on ___ with 3.4L
removed and albumin repletion. Prior to discharge patient
received therapeutic paracentesis with 3L removed (___), with
plan to do weekly therapeutic paracenteses as an outpatient.
#SBP
Diagnostic paracentesis on ___ with 4600 WBCs and 64% polys in
setting of myelofibrosis with chronically elevated WBCs in
peritoneal fluid. She was treated for SBP with Ceftriaxone 2g (
___, will d/c with Cipro 500mg QD and Vanc 125mg bid PO
as suppressive therapy for recurrent C. Diff. She received
albumin on day 1 and day 3 of treatment.
#AOCKD: Patient with Cr 1.9 at time of discharge, baseline of
2.0. Had worsened to 3 on diuretics, so diuretics were held and
ascites was managed with paracentesis. Patient with persistent
lower extremity edema.
#Myelofibrosis: Likely related to
anemia/thrombocytopenia/leukocytosis. Most likely cause for
liver disease and renal disease. Evaluated by heme/onc on ___,
recommended Vit K 5mg x3d per heme/onc recs. She was continued
on home dose of ruxolitinib.
#Anemia: Patient w/ Hgb 7.4 and fluctuated throughout admission.
Likely secondary to myelofibrosis, but patient has not had a
recent surveillance EGD. Patient was transfused for Hb <7 and
received 3u pRBC during this admission.
#Thrombocytopenia: Plt 65 on arrival and downtrending to 46,
slightly higher than recent baseline. Most likely ___
myelofibrosis.
#Leukocytosis: Patient w/ elevated WBC counts at baseline, due
to myelofibrosis. Tap ___ with evidence of SBP, CXR without
PNA, blood cx and urine cx unremarkable. Unlikely to be related
to C. Diff, patient on Vancomycin prophylaxis.
#h/o Recurrent C Diff: Receiving PO vancomycin 125 mg PO/NG Q6H
while on CTX. Discussed suppression regimen with ID, on
discharge with Cipro will take 125bid PO Vanc as ppx dose.
CHRONIC ISSUES
==============
#GERD: continue home omeprazole.
#Gout: Continue home allopurinol.
#Hyperlipidedemia: Continue home atorvastatin in house.
#Rhinitis: Continue home fluticasone in house.
# CODE: Full Code (confirmed)
# CONTACT: Daughter ______), ___ ___
TRANSITIONAL ISSUES
===================
GENERAL
[ ] Weight at time of d/c 66.2kg
[ ] Creatinine at time of d/c 1.9
CIRRHOSIS
[ ] Weekly paracentesis for management of ascites
[ ] Stop diuretics due to prior intolerance, re-evalute need
given extensive lower extremity edema.
[ ] Requires surveillance EGD, no recent study
SBP
[ ] Continue Ciprofloxacin 500mg daily for SBP prophylaxis and
PO Vancomycin 125mg bid for recurrent C. Diff suppression
indefinitely
MYELOFIBROSIS
[ ] Close monitoring of CBC
# CODE: Full Code (confirmed)
# CONTACT: Daughter ___ (___), ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY gout
2. Atorvastatin 10 mg PO QPM hyperlipidemia
3. FoLIC Acid 1 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. ruxolitinib 10 mg oral BID ET/myelofibrosis
6. Spironolactone 25 mg PO DAILY
7. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
2. Phytonadione 5 mg PO DAILY Duration: 3 Doses
RX *phytonadione (vitamin K1) [Mephyton] 5 mg 1 tablet(s) by
mouth once Disp #*1 Tablet Refills:*0
3. Vancomycin Oral Liquid ___ mg PO BID
RX *vancomycin 125 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
4. Allopurinol ___ mg PO DAILY gout
5. Atorvastatin 10 mg PO QPM hyperlipidemia
6. FoLIC Acid 1 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. ruxolitinib 10 mg oral BID ET/myelofibrosis
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Diuretic refractory ascites due to cirrhosis from myelofibrosis
SECONDARY DIAGNOSIS
===================
Chronic Kidney Disease
Myelofibrosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ was a pleasure taking care of you at ___
___.
You were admitted after you came in short of breath with lots of
swelling in your legs and abdomen after you stopped your
recently prescribed diuretics (water pills) due to worse kidney
function (elevated creatinine).
We stopped the diuretics and decided to remove the fluid from
your belly with a needle every week (paracentesis). The fluid we
removed showed you had an infection so we treated you with an
antibiotic for 5 days. You will need lifelong daily antibiotics
to prevent infection of the fluid in the belly and clostridium
difficile (C Diff, a diarrheal illness).
Please follow up with:
1) Your primary care doctor next week ___ at 1:15pm
2) Make an appointment to get fluid taken out of your belly
every week by calling ___
3) Your liver doctor: Dr. ___ ___
We wish you the best of health,
Your ___ Care Team
Followup Instructions:
___
|
10111112-DS-18 | 10,111,112 | 26,631,649 | DS | 18 | 2151-05-13 00:00:00 | 2151-05-16 17:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Codeine /
Morphine
Attending: ___.
Chief Complaint:
Decompensated cirrhosis
Major Surgical or Invasive Procedure:
paracentesis ___
History of Present Illness:
Ms. ___ is a ___ y/o woman with essential
thrombocythemia/myelofibrosis and renal failure (HD in the
past), prior PE, mild COPD who presented to ED from clinic w/LLE
pain and swelling. Patient presented to clinic on day of
presentation for scheduled weekly paracentesis. Procedure was
uncomplicated and 1.8L fluid was removed. While in clinic
patient noted LLE pain and swelling, so she was referred to the
ED for r/o DVT by Dr. ___.
In the ED initial vitals: T 96.7 P 69 BP 109/45 RR 18 O2 99% RA
Pleural fluid studies revealed 2500 WBC, 53% poly's, consistent
with SBP. Patient underwent ___ Doppler which revealed...
She was given 50g Albumin (in addition to 25g received in
clinic), 2g Ceftrixone and admitted to ET for management of SBP
Past Medical History:
PAST ONCOLOGIC HISTORY
She has had essential thrombocythemia since prior to ___ and
was
diagnosed with post-essential thrombocythemia myelofibrosis
(JAK2
V617F+) in ___. She also has peripheral vascular disease s/p
stent in left leg. She sustained bilateral pulmonary emboli in
___ in the setting of marked thrombocytosis.
She was hospitalized from ___ with a non resolving
bruise on her distal left lower extremity in the setting of an
elevated INR and
thrombocytopenia. Warfarin and ruxolitinib were held, but she
developed a sudden drop in hgb/hct, elevated uric acid (for
which
she received a single dose of rasburicase), worsening
thrombocytopenia, renal failure, and respiratory distress. She
was transferred to the ICU where she required intubation,
pressers, and dialysis. It was determined that she had developed
ruxolitinib-withdrawal syndrome. She was started back on
ruloxitinib 10 mg bid via NG tube while intubated along with IV
corticosteroids and empiric antibiotics. Her clinical status
gradually improved, she was extubated and weaned from dialysis,
and transferred to the oncology floor where ruloxitinib was
continued. She improved and went to rehab for about a week
before
returning home.
When seen in followup following the hospitalization on ___,
she had continued swelling of her left lower extremity, A left
leg ultrasound was negative for a DVT. When seen back by Dr.
___ pulmonary on ___, it was noted that the moderate
sized left effusion had increased. The possibility of doing a
diagnostic and therapeutic thoracentesis in ___ clinic
was
raised, but this was deferred. When seen here on ___, she
had
developed progressive bilateral lower extremity edema and
shortness of breath on exertion; there however were no other
clear symptoms/signs of heart failure. An echocardiogram on
___ showed preserved regional and global biventricular
systolic function and mild pulmonary artery systolic
hypertension. A gentle trial of diuresis (20 mg furosemide every
other day) was initiated on the supposition that heart failure
might be contributing to the bilateral pedal edema. She was
referred for evaluation to Dr. ___ of cardiology. At her
visit on ___, the left sided pleural effusion was slightly
smaller; however ___ did not feel that the qod furosemide had
decreased the leg swelling nor had it helped her breathing. Her
JVP was low, creatinine was up slightly 1.9 to 2.3, and BNP was
down to 1419. Overall Dr. ___ not feel that congestive
heart failure was responsible for the edema. Furosemide was
discontinued on ___ due to continued rise in her serum
creatinine.
At her last visit here on ___, she was having worsening
constitutional symptoms with intermittent bouts of
chills/shivering that last minutes to hours. Acetaminophen
provided symptomatic relief and infection was felt unlikely due
to the intermittent nature of the symptoms. Her creatinine was
up
to 2.6 and she was encouraged to drink more fluids. She has
since
been seen back Dr. ___ pulmonary who noted some increase in
the left pleural effusion and she was set up for evaluation by
Dr. ___ interventional pulmonology for possible left chest
thoracentesis. She was also seen by Dr. ___ nephrology
and
Dr. ___ GI due to the development of severe diarrhea ___
weeks ago. Workup for infectious etiologies and celiac disease
was negative; she was noted to have somewhat low levels of
immunoglobulins.
PAST MEDICAL HISTORY:
Essential Thrombocytosis / Myelofibrosis (stopped aspirin and
ruxolitinib)
Pulmonary Embolism on warfarin
Peripheral Vascular Disease s/p RLE stent
HTN (off medications due to low BP)
HLD
pHTN
COPD Gold Stage I
CKD baseline ___ cr
Tonsillectomy-Adenoidectomy
C-Section
Cholecystectomy
Portal hypertension due to myelofibrosis with diuretic
refractory ascites
Social History:
___
Family History:
She has an uncle with tuberculosis when he was a young man, but
she was not exposed to tuberculosis. Her mother had
cardiovascular disease and breast cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 98; 77; 106/45; 19; 95% RA
General: Pleasant, well-appearing. NAD. AOx3
HEENT: EOMI. MMM. Anicteric sclera.
Neck: Supple.
Lung: Decreased breath sounds in Left lung base up to mid-lung.
Card: RRR. No MRG
Abd: Soft, moderately distended with +fluid wave. Nontender. No
HSM appreciated.
Ext: 2+ pitting edema to buttocks.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 01:47PM ASCITES WBC-2500* RBC-7750* POLYS-53*
LYMPHS-1* ___ MACROPHAG-46*
___ 05:35PM URINE MUCOUS-RARE
___ 05:35PM URINE GRANULAR-9* HYALINE-7*
___ 05:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 05:35PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 05:35PM ___ PTT-33.6 ___
___ 05:35PM PLT SMR-VERY LOW PLT COUNT-28*
___ 05:35PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+
MACROCYT-3+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL
SPHEROCYT-OCCASIONAL OVALOCYT-OCCASIONAL TEARDROP-OCCASIONAL
FRAGMENT-OCCASIONAL
___ 05:35PM NEUTS-50 BANDS-13* LYMPHS-6* MONOS-7 EOS-4
BASOS-0 ___ METAS-6* MYELOS-5* BLASTS-9* NUC RBCS-11*
AbsNeut-25.70* AbsLymp-2.45 AbsMono-2.86* AbsEos-1.63*
AbsBaso-0.00*
___ 05:35PM WBC-40.8* RBC-1.82* HGB-5.8* HCT-19.3*
MCV-106* MCH-31.9 MCHC-30.1* RDW-20.3* RDWSD-77.8*
___ 05:35PM ALBUMIN-4.0 CALCIUM-7.7* PHOSPHATE-4.0
MAGNESIUM-2.1
___ 05:35PM LIPASE-32
___ 05:35PM ALT(SGPT)-12 AST(SGOT)-26 ALK PHOS-244* TOT
BILI-1.0 DIR BILI-0.3 INDIR BIL-0.7
___ 05:35PM GLUCOSE-89 UREA N-43* CREAT-1.9* SODIUM-140
POTASSIUM-4.0 CHLORIDE-110* TOTAL CO2-14* ANION GAP-20
___ 06:06PM LACTATE-2.0
MICRO:
======
PERITONEAL FLUID CYTOLOGY ___: NEGATIVE FOR MALIGNANT CELLS
___ 1:26 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
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..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
BLOOD CULTURE (___): X3 - NO GROWTH TO DATE
___ 1:26 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Pending):
FLUID CULTURE (Pending):
ANAEROBIC CULTURE (Pending):
STUDIES:
========
ABD US ___. Technically successful ultrasound guided
diagnostic and therapeutic paracentesis.
2. 1.8 L of fluid were removed.
CXR ___ pleural effusion has worsened. Left basilar
consolidation, likely atelectasis, consider pneumonitis in the
appropriate clinical setting. Increased pulmonary vascularity.
CXR ___: IMPRESSION: Mildly worsened right apical opacity,
likely edema, consider pneumonitis
PleurX placement:FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated
pelvic ascites. A suitable target in the deepest pocket in the
right lower
quadrant was selected for PleurX catheter placement.
IMPRESSION: Successful peritoneal PleurX catheter placement
LABS ON DISCHARGE:
==================
___ 06:45AM BLOOD WBC-35.6* RBC-2.43* Hgb-7.2* Hct-23.8*
MCV-98 MCH-29.6 MCHC-30.3* RDW-21.3* RDWSD-75.7* Plt Ct-47*
___ 06:45AM BLOOD ___ PTT-34.9 ___
___ 06:45AM BLOOD Glucose-88 UreaN-43* Creat-1.9* Na-141
K-4.5 Cl-112* HCO3-17* AnGap-17
___ 06:45AM BLOOD ALT-12 AST-20 AlkPhos-279* TotBili-1.2
___ 06:45AM BLOOD Albumin-3.4* Calcium-7.7* Phos-3.7 Mg-2.0
Brief Hospital Course:
Ms ___ is a ___ PMHx essential
thrombocythemia/myelofibrosis, cirrhosis and renal failure (HD
in the past), prior PE, mild COPD who presented to ED from liver
clinic w/LLE pain and swelling, admitted for spontaneous
bacterial peritonitis vs secondary bacterial peritonitis.
Patient had routine therapeutic paracentesis on ___ but was
sent to ED for r/o DVT given LLE pain/swelling. ___ were
negative for DVT, but while in the ED patient's fluid studies
returned w/elevated WBC, predominantly PMN's, concerning for
peritonitis. Patient was admitted to ET service for management.
#SBP: Results from paracentesis performed in clinic on ___
revealed 2500 WBC (53% PMNs) concerning for SBP despite serum
WBC at baseline >20. Patient was started empirically on
ceftriaxone and was given albumin. Because of concern for
developing sepsis in the setting of rising lactate and
hypoxemia, prompting ICU transfer, Ms ___ was broadened to
Vanco/Zosyn on ___. Vancomycin was discontinued on ___.
Repeat diagnostic/therapeutic paracentesis for 2.4L on ___
revealed 3167 WBC with 70% polys. Infectious disease was
consulted who determined this was likely due to her elevated
peripheral WBC in setting of MF and did not represent persistent
infection. She was transitioned to Cefpodoxime for ppx, having
failed prophylactic ciprofloxacin.
#Hypoxemia: The night of admission Ms ___ received 75g
albumin in the setting ___ to 2.5 and volume overload. She
triggered for acute hypoxia, new O2 requirement to 3L and
tachycardia/fever. Lactate rose to 3.1 prompting ICU transfer,
broadening of antibiotics to vanco/zosyn, 80 iv Lasix, nebs for
treatment. Patient also received 2 u pRBC for acute anemia to
4.9. Respiratory status improved and allowed for her to return
to the floor. She has not had an oxygen requirement during the
remained of the stay and has remained stable from a respiratory
point of view.
#AOCKD: Cr elevated to 2.5 from baseline of 2. Etiology of Cr
rise attributed to ongoing infection. Cr trended back to
baseline during the hospitalization; 1.9 at discharge.
Nephrotoxins were avoided and meds were renally dosed.
#Epistaxis: Had a prolonged episode of epistaxis on ___.
Did not improve with packing, Afrin and pressure. ENT was
consulted and performed cauterization of 2 locations and packing
with resorbable material to good effect. Because of
thrombocytopenia and anemia, from blood loss, patient received
1u pRBC, 1u plt, 1u FFP. Bleeding stopped until the morning of
___ when it restarted after the packing came out, but it
responded to Afrin and pressure without complications.
#Anemia: acute blood loss (from epistaxis) on chronic anemia
secondary to myelofibrosis. Transfused PRN for Hgb goal >7.
#Cirrhosis: Complicated by portal hypertension and ascites
requiring frequent paracentesis given impaired renal function.
Patient was seen by palliative care during this hospitalization
and determined that she would like to have catheter placed to
drain ascites, preventing her from having to come to hospital
regularly for paracentesis. This was performed without
complication on ___. Patient wishes to continue coming to the
hospital if she feels unwell or has infection and does not wish
to be on hospice at this time. Palliative care and Dr. ___
will continue to re-address this issue with patient over time.
#Myelofibrosis, ET: with notable leukocytosis, thrombocytopenia,
anemia. Transfused prn for HGb>7, plt <10 or <50 with bleeding.
Home ruloxitinib was initially held but subsequently restarted
on ___.
Patient discharged to home ___ and close PCP/liver clinic
follow up.
Transitional Issues
====================
[] Medication Changes:
STOPPED Ciprofloxacin.
STARTED Cefpodoxime 200mg daily for prevention of SBP.
STARTED Nasal Mist spray to help prevent nosebleeds.
[] patient had episode of epistaxis requiring
cauterization/packing w/ENT. She should be seen by ENT as
outpatient if this issue persists.
[] Patient has follow up appointments with PCP and Dr. ___.
[] Patient has pleurex catheter in place which should be managed
by patient/family at home. ___ is in place to help with drain
initially and provide teaching.
[] Patient required platelet and PRBC transfusions during
hospitalization. She should follow up with her
hematology/oncology physician as outpatient and continue to
receive transfusion as needed.
# CODE: Full Code-patient completed MOLST form during this
hospitalization.
# CONTACT: Daughter ___), ___ ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. LOPERamide Dose is Unknown PO QID:PRN constipation
3. Allopurinol ___ mg PO DAILY
4. Colchicine 0.3 mg PO DAILY:PRN gout
5. ruxolitinib 10 mg oral BID
6. LORazepam 0.5 mg PO QHS:PRN insomnia
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. vancomycin 125 mg oral BID
9. Omeprazole 20 mg PO DAILY
10. Ciprofloxacin HCl 500 mg PO Q24H
11. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q24H
RX *cefpodoxime 200 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Sodium Chloride Nasal ___ SPRY NU QID:PRN dry nose
RX *sodium chloride [Saline Nasal] 0.65 % ___ spray nasal four
times a day Disp #*1 Spray Refills:*0
3. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever
4. LOPERamide 4 mg PO QID:PRN constipation
5. Allopurinol ___ mg PO DAILY
6. Colchicine 0.3 mg PO DAILY:PRN gout
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. LORazepam 0.5 mg PO QHS:PRN insomnia
10. Omeprazole 20 mg PO DAILY
11. ruxolitinib 10 mg oral BID
12. vancomycin 125 mg oral BID
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
Acute on chronic kidney disease
Spontaneous bacterial peritonitis
Prolonged Epistaxis
Acute blood loss anemia in the setting of chronic anemia
Hypoxic respiratory failure
SECONDARY DIAGNOSES
Myelofibrosis
Decompensated Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms ___,
It was a pleasure being a part of your care during your stay at
___!
Why were you hospitalized?
-Because you had many white blood cells on your paracentesis
counts, which were concerning for infection.
What was done for you this hospitalization?
-You were treated with antibiotics for your infection in your
abdomen.
-You had a nose bleed that continued for many hours; we gave you
blood products and had the Ear, Nose and Throat specialists see
you and stop the bleeding.
-You had an episode of trouble breathing and signs of systemic
infection, which caused you to go to the ICU. You made a rapid
recovery with the treatments we gave you and you came back to
the floor the next day.
-We gave you blood products as needed based on your labs.
-You had a catheter placed in your abdomen by Interventional
Radiology to drain your ascites fluid.
-You were seen by members of our palliative care team.
What should you do after you leave the hospital?
-Keep taking your meds as prescribed. New medications:
Cefpodoxime 200mg daily, Nasal Mist. You should stop taking
Ciprofloxacin.
-Follow up Dr. ___ in liver clinic and your primary care
physician (see appointments below).
-You will have nursing at home to help manage your drain.
If you develop fevers, chills, worsening abdominal pain, or
another persistent nose bleed, please call your doctor or return
to the Emergency Department.
We wish you the best!
Sincerely,
Your ___ team
Followup Instructions:
___
|
10111136-DS-23 | 10,111,136 | 29,438,205 | DS | 23 | 2172-03-06 00:00:00 | 2172-03-06 13:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ PMH end stage COPD on 5L NC at baseline presents with
SOB. Patient says that about a week ago he noticed that his
voice sounded hoarse, and he started feeling unwell with a dry
cough like he was coming down with a cold. Over the last few
days his cough has worsened and he has become short of breath.
This progressively worsened overnight. Sitting up decreased the
shortness of breath. He had to increase his baseline O2 from 5
L to 6 L at home earlier today. Since last night he began
coughing gray sputum today and has had decreased p.o. intake.
Denies fevers, chills, chest pain. He states that this feels
like his normal COPD exacerbation. At baseline, he has DOE with
exertion, and sometimes with talking and eating.
In the ED, initial vitals:
Pain 0 Temp 99.1 HR 115 BP 127/68 RR 26 O2sat 96% RA
- Exam notable for: Emaciated appearing. Breathing through
pursed lips. Decreased breath sounds bilaterally. Increased
respiratory rate and work of breathing.
- Labs notable for:
Cl 93 BUN 28 AG=19
WBC 11.0
Hg 10.7
Hct 34.6
Plt 329
___ 12.8 PTT 36.4 INR 1.2
pH 7.34 pCO2 71 pO2 19
Trop < 0.01
- Imaging notable for:
___ CXR (PA & LAT):
Patchy ill-defined opacity in the left lung base is concerning
for an area of infection. Additional interstitial opacities in
lung bases may reflect areas of atelectasis and scarring.
- Pt given:
___ 16:40 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 16:40 IH Ipratropium Bromide Neb 1 NEB ___
___ 17:15 IV MethylPREDNISolone Sodium Succ 125 mg
___
___ 17:15 IH Albuterol 0.083% Neb Soln 1 NEB
___
___ 17:15 IH Ipratropium Bromide Neb 1 NEB ___
___ 19:59 IV Azithromycin (500 mg ordered)
___ Started Stop
___ 20:00 IV CefTRIAXone 1 gm ___ Stopped
(1h ___
- Vitals prior to transfer:
98.0 107 137/72 28 98% 6L NC
On the floor, he reports that his breathing has improved
although he still feels short of breath at rest, which is not
typical for him.
Past Medical History:
-COPD/emphysema, on home O2 intermittently
-hypertension
-hypercholesterolemia
-osteoporosis
-right bundle-branch block
-colon cancer diagnosed in ___ status post resection
-infrarenal abdominal aortic aneurysm
-stable pulmonary nodules not requiring further imaging
-tracheobronchomalacia (80% expiratory luminal collapsibility in
the lower trachea and main bronchi)
PSH: Colon Ca resection ___
Social History:
___
Family History:
No family history of cancer. Father died in an accident on board
a ship. Mother died of natural causes at age ___. He is an
only child. MGM lived to be ___.
Physical Exam:
ADMISSION EXAM:
VITALS:97.8 104 138/72 RR:37-> 26 O2 94% 5L NC
General: Alert, oriented, mild respiratory distress, breathing
with pursed lips. thin, cachectic.
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Distant heart sounds, regular rate and rhythm, normal S1 +
S2, no murmurs, rubs, gallops
Lungs: Distant breath sounds throughout. No wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Distal lower extremities slightly cool, no clubbing,
cyanosis or edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, nonfocal exam. A+Ox3
==========================================
Pertinent Results:
ADMISSION LABS:
___ 04:15PM BLOOD WBC-11.0* RBC-3.72* Hgb-10.7* Hct-34.6*
MCV-93 MCH-28.8 MCHC-30.9* RDW-13.6 RDWSD-46.2 Plt ___
___ 04:15PM BLOOD Neuts-86.1* Lymphs-4.6* Monos-8.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-9.46* AbsLymp-0.50*
AbsMono-0.96* AbsEos-0.00* AbsBaso-0.01
___ 04:15PM BLOOD ___ PTT-36.4 ___
___ 04:15PM BLOOD Glucose-149* UreaN-28* Creat-0.9 Na-144
K-4.3 Cl-93* HCO3-32 AnGap-19*
___ 04:15PM BLOOD cTropnT-<0.01
___ 04:15PM BLOOD Calcium-10.1 Phos-4.5 Mg-2.1
___ 05:27PM BLOOD ___ pO2-19* pCO2-71* pH-7.34*
calTCO2-40* Base XS-7
=========================================
Brief Hospital Course:
___ w/ PMH end stage COP (on 5L NC at home) presenting with SOB
found to have COPD exacerbation.
At presentation on ___, the patient's clinical picture
(cough, breathing through pursed lips, leukocytosis) and left
lower lung opacity was consistent with COPD exacerbation
triggered by CAP, in the setting of the patient's known very
severe COPD (FEV1 24%). The patient's VBG at presentation was
notable for pH 7.34 and pCO2 71. He was admitted to the MICU for
further management. However, he did not require BiPAP or any
other form of either invasive or non-invasive ventilatory
support during his MICU stay. Instead, he was started on
steroids and duonebs, as well as ceftriaxone/azithromycin for
coverage of community-acquired pneumonia. With this treatment,
the patient's symptoms gradually improved. At the time of
transfer out of the MICU on ___, the patient was on his
baseline O2 of 5L and his pCO2 was measured as 63 on VBG. RSV
cultures were negative at the time of transfer. He reported his
breathing was back at baseline, and he was able to ambulate
without difficulty. He was discharged home on Levofloxacin
750mg PO daily and Prednisone 40mg PO daily for a total of 5
days of therapy. In addition, he was given an R for a nebulizer
machine and nebs to use on discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheezing
2. Atorvastatin 40 mg PO QPM
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Denosumab (Prolia) Dose is Unknown SC Frequency is Unknown
5. Ezetimibe 10 mg PO DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Hydrochlorothiazide 25 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Tiotropium Bromide 1 CAP IH DAILY
10. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral DAILY
11. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN shortness of
breath
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb inhaled every
four (4) hours Disp #*20 Vial Refills:*0
2. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
3. nebulizers miscellaneous ASDIR
RX *nebulizers Disp #*1 Each Refills:*0
4. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
5. Denosumab (Prolia) 60 mg SC ASDIR
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheezing
7. Atorvastatin 40 mg PO QPM
8. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -500 unit oral DAILY
9. Diltiazem Extended-Release 180 mg PO DAILY
10. Ezetimibe 10 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Hydrochlorothiazide 25 mg PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Tiotropium Bromide 1 CAP IH DAILY
15. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
COPD exacerbation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for an exacerbation of COPD and improved with
steroids and antibiotics.
Followup Instructions:
___
|
10111614-DS-16 | 10,111,614 | 22,951,202 | DS | 16 | 2172-05-02 00:00:00 | 2172-05-04 18:20:00 |
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:
___ year old male with NSIP presenting with 2 day h/o chest pain.
Pt was in his usual state of health until 3 days prior to
presentation when he developed sore throat, increased cough,
myalgias, fatigue and subjective fevers. No sick contacts, has
not received a flu shot. 2 days prior to presentation, he
developed midline pleuritic chest pain that was unrelated to
exertion or positional changes. Denies SOB, DOE, ___ edema,
palpitations, orthopnea, n/v/d. + Back and left shoulder pain.
He presented to his PCP office today and was referred to the ED.
In the ED, initial vitals were T 98.3 ___ 18 95% RA. Labs
were notable for trop <0.01, Cr 1.0, WBC 13. EKG showed diffuse
ST changes and a code STEMI was called. Pt underwent
catheterization which showed no evidence of coronary disease. He
was transferred to the cardiology inpatient service for further
management.
Past Medical History:
1. CARDIAC RISK FACTORS: none
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
-Left knee arthroscopy
-? NSIP
Social History:
___
Family History:
Mother had lung disease (pt describes as "arthritis of the
lung"), no astham or COPD. No family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise
non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 111/78 (106-112/71-81) 74 (69-74) 18 96 96-97% RA
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVP elevation at 90 degrees
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. TR band in place R wrist. 2+ distal SKIN:
No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES:
Right: DP 2+ ___ 2+
Left: radial 2+ DP 2+ ___ 2+
.
DISCHARGE PHYSICAL EXAM:
VS: 98.8 ___ 18 93-96% RA 100.6kg I 480 O 175
overnight
GENERAL: WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with no JVP elevation at 90 degrees
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominal bruits.
EXTREMITIES: No c/c/e. dressing right wrist c/d/i
Pertinent Results:
LABS:
___ 04:45PM GLUCOSE-74 UREA N-14 CREAT-1.0 SODIUM-140
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-27 ANION GAP-15
___ 04:45PM ALT(SGPT)-22 AST(SGOT)-21 ALK PHOS-69 TOT
BILI-0.9
___ 04:45PM cTropnT-<0.01
___ 04:45PM ALBUMIN-4.2 CALCIUM-9.3 PHOSPHATE-3.2
MAGNESIUM-2.2
___ 04:45PM D-DIMER-284
___ 04:45PM WBC-13.0*# RBC-5.13 HGB-16.2 HCT-49.2 MCV-96
MCH-31.5 MCHC-32.8 RDW-12.1
___ 04:45PM NEUTS-64.9 ___ MONOS-7.5 EOS-1.4
BASOS-0.9
___ 04:45PM PLT COUNT-211
___ 04:45PM ___ PTT-30.5 ___
___ 07:33AM BLOOD WBC-10.0 RBC-4.66 Hgb-14.8 Hct-44.8
MCV-96 MCH-31.8 MCHC-33.0 RDW-12.2 Plt ___
.
IMAGING/STUDIES:
Cardiac Catheterization ___
1. Selective coronary angiography of this right dominant system
demonstrated no angiographically significant flow-limiting
disease. The
LMCA, LAD, LCX and RCA were patent.
2. Limited resting hemodynamics revealed mildly elevated left
ventricular end diastolic pressures LVEDP 15 mmHg. Normal
systemic
arterial pressures at the central aortic level 117/70 mmHg.
3. Left ventriculography was deferred.
FINAL DIAGNOSIS:
1. Coronary arteries had no angiographically-significant
flow-limiting
disease.
2. Mild diastolic dysfunction.
.
CXR ___
1. There continues to be a patchy streaky opacity in the left
mid lung in a known area of interstitial fibrosis. Overall, it
appears to be slightly worse, although this could be related to
differences in technique. A superimposed infection cannot be
entirely excluded. The remaining lungs are otherwise grossly
clear. No evidence of pulmonary edema. Overall cardiac and
mediastinal contours are stable. No pleural effusions. No
pulmonary edema. No evidence of pneumothorax. Clinical
correlation is advised and further imaging evaluation with CT at
this time should be based on the clinical assessment.
.
TTE ___
The left atrium and right atrium are normal in cavity size. Left
ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The estimated cardiac
index is normal (>=2.5L/min/m2). Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
appear structurally normal with good leaflet excursion and no
aortic stenosis or aortic regurgitation. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved regional and global biventricular
systolic function. No pericardial effusion identified. Dilated
aortic root.
Brief Hospital Course:
___ with NSIP presenting with midline pleuritic chest pain and
diffuse ST changes in the setting of ILI, s/p cardiac cath.
# Pericarditis: Pt presented to ED after being referred from ___
office for 2 day h/o pleuritic chest pain. Pt underwent cardiac
catheterization shortly after arrival for ST elevation on EKG,
but there was no evidence of significant flow limiting disease.
Pt was low risk for PE by Well's Criteria, d-dimer<284, making
PE unlikely. CXR showed slightly worse left sided streaky
opacity compared to prior, possibly due to differences in
technique, no definite PNA. Pleuritic chest pain and diffuse ST
changes on EKG in the setting of ILI suggestive of pericarditis.
TTE showed no effusion, normal EF. He was discharged home on
colchicine and ibuprofen taper. An outpatient cardiac MRI was
ordered for definitive diagnosis in order to determine need for
continued colchicine and pt was advised to follow up with
cardiology within ___ months.
# Influenza like illness: Reported 3 day h/o cough, sore throat,
myalgias and low grade fevers concerning for influenza, so he
was placed on droplet precautions. Nasopharyngeal swab
insufficient for analysis. He remained afebrile throughout
admission and was treated symptomatically with ibuprofen.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Colchicine 0.6 mg PO BID
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth Two times a
day Disp #*60 Tablet Refills:*0
2. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth Daily Disp #*30
Capsule Refills:*0
3. Ibuprofen 100-600 mg PO Q8H Duration: 5 Weeks
Start taking 600mg every 8 hours x 1 week
Then take 400mg every 8 hours for 1 week
Then take 200mg every 8 hours for 1 week
Then take 200mg every 12 hours for 1 week
Then take 100mg once a day for 1 week
Then stop, unless otherwise directed by your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Pericarditis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___. You were admitted
to the hospital with chest pain. A cardiac catheterization
showed that your coronary arteries were not blocked and the pain
was not due to a heart attack. Your symptoms are likely due to
something called pericarditis, or inflammation of the lining
around your heart related to your recent viral illness.
We recommend that you have an MRI of your heart to definitively
diagnose pericarditis. In the meantime, you will need to take
ibuprofen according to the enclosed schedule for the next 5
weeks and colchicine twice a day which, depending on the results
of the MRI, you may need to take for at least one year.
Please follow up with your primary care doctor in the next ___
weeks and with cardiology in ___ months.
Please START taking:
1. Colchicine
2. Ibuprofen
3. Omeprazole
Followup Instructions:
___
|
10112163-DS-12 | 10,112,163 | 29,734,486 | DS | 12 | 2121-08-29 00:00:00 | 2121-08-29 15:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / lisinopril
Attending: ___.
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
Transesophageal Echocardiogram
History of Present Illness:
___ male PMHx HFrEF (27%), HIV (last CD4 reportedly
greater than 1000, undetectable viral load ___
presenting with dyspnea on exertion.
The patient was admitted to the ___ ___
weeks ago for CHF exacerbation. Since discharge he has
complained
of severe dyspnea on exertion on only able to walk 3 or 4 steps
befor getting winded. He reports orthopnea and has been
sleeping
on 6 pillows. No lower extremity edema. Denies shortness of
breath at rest.
No recent travel, leg swelling, recent travel/surgeries, or
personal family history of blood clots. Denies chest
pain/nausea/vomiting/diaphoresis/back pain/abdominal pain.
The patient was concerned that he was not discharged on oxygen,
he reports that his primary care doctor told him to go back to
the emergency room in order to receive oxygen treatments. He
wants to establish care at ___ so he came to be
emergency
room today and set of ___.
Exam notable for: Positive JVD, AAO x3, 2+ pulses bilaterally,
mid right minimal edema. Lungs CTAB
Labs notable for:
1. ___ 12:52PM BLOOD Glucose: 119* UreaN: 41* Creat: 1.6*
Na: 136 K: 4.4 Cl: 99 HCO3: 22 AnGap: 15
___ 12:52PM BLOOD proBNP: 5442*
___ 12:52PM BLOOD cTropnT: <0.01
___ 04:30PM BLOOD cTropnT: <0.01
___ 12:52PM BLOOD WBC: 8.9 RBC: 3.75* Hgb: 12.4* Hct: 37.9*
MCV: 101* MCH: 33.1* MCHC: 32.7 RDW: 14.0 RDWSD: 51.0* Plt Ct:
184
Images notable for: CXR with Moderate to severe cardiac
enlargement with mild interstitial pulmonary edema and small
bilateral pleural effusions. Streaky retrocardiac opacity,
likely
atelectasis
EKG: NSR rates 91 normal interval, PVCs and PACs, T wave
inversions in V3-V6
Patient was given: Lasix 40 IV
Vitals on transfer: 98.3 120/71 89 22 100% RA
Per review of ___ records, patient was diagnosed with
nonischemic
cardiomyopathy in ___, which the patient reported that he was
compliant medication for approximately ___ years at which point he
believes he was told his EF had recovered to normal and that he
was able to discontinue his cardiac medications. He said no
issues over the last at least ___ years to the last several
weeks.
He saw a cardiologist at ___ (Dr. ___ approximately 6 weeks
ago and was started him on losartan 50 mg daily. His symptoms
continued to worsen and he went to ___ ED for evaluation. He
underwent cardiac cath which showed mild pulmonary hypertension,
low cardiac index, and clean coronary arteries. During the
hospital edition he was started on metoprolol succinate 25 mg
daily and valsartan 40 mg. He was also started on Lasix 40 mg
p.o. twice daily. His estimated dry weight was 70 to 71 kg.
That hospitalization he also had a normal ferritin.
On the floor he reports he is feeling much better after
receiving
Lasix in the emergency room. Still feels slightly short of
breath though is able to lay back. Reports is been sleeping on
6
pillows since discharge.
Denies fever/chills/chest pain/cough/abdominal
pain/dysuria/bowel
bladder incontinence/myalgia/arthralgia.
Past Medical History:
PAST MEDICAL HISTORY:
1. CARDIAC RISK FACTORS
-HLD
2. CARDIAC HISTORY
- No CAD on cath ___
- EF 27% (___)
- Rhythm? AFib? Pacemaker?
- NICM
3. OTHER PAST MEDICAL HISTORY
HIV
Asthma
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
Admission Physical Examination:
===============================
VS: ___ Temp: 98.0 PO BP: 111/66 R Sitting HR: 77 RR:
18 O2 sat: 98% O2 delivery: RA
GENERAL: nad, a&oX3
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink.
NECK: Supple. JVP of 18cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. regular rate and rhythm. Normal S1, S2 III/VI holosystolic
murmur at apex
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: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Discharge Physical Examination:
===============================
Physical Exam:
24 HR Data (last updated ___ @ 923)
Temp: 97.9 (Tm 98.0), BP: 96/61 (90-119/48-81), HR: 101
(89-101), RR: 20 (___), O2 sat: 98% (96-100)
___ Total Intake: 1350ml PO Amt: 1350ml
___ Total Output: 2225ml Urine Amt: 2225ml
GENERAL: well appearing man
HEENT: No icterus or injection. MMM.
CARDIAC: JVP <10cm . RRR, normal S1/S2, ___ holosystolic murmur
best heard at apex radiating to axilla.
LUNGS: CTAB. no wheezes crackles or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. No clubbing, cyanosis, or
peripheral edema.
SKIN: No lesions or rashes.
Pertinent Results:
Admission labs:
================
___ 05:02PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 05:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:30PM cTropnT-<0.01
___ 12:52PM GLUCOSE-119* UREA N-41* CREAT-1.6* SODIUM-136
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-22 ANION GAP-15
___ 12:52PM estGFR-Using this
___ 12:52PM ALT(SGPT)-113* AST(SGOT)-112* ALK PHOS-98 TOT
BILI-0.8
___ 12:52PM cTropnT-<0.01
___ 12:52PM proBNP-5442*
___ 12:52PM CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-2.2
IRON-35*
___ 12:52PM calTIBC-328 VIT B12-1559* FERRITIN-112
TRF-252
___ 12:52PM WBC-8.9 RBC-3.75* HGB-12.4* HCT-37.9*
MCV-101* MCH-33.1* MCHC-32.7 RDW-14.0 RDWSD-51.0*
___ 12:52PM NEUTS-66.7 ___ MONOS-9.0 EOS-0.1*
BASOS-0.5 NUC RBCS-0.2* IM ___ AbsNeut-5.91 AbsLymp-2.05
AbsMono-0.80 AbsEos-0.01* AbsBaso-0.04
___ 12:52PM PLT COUNT-184
___ 12:52PM ___ PTT-26.6 ___
___ 12:52PM RET AUT-3.1* ABS RET-0.12*
Pertinent Studies:
==================
CXR ___
IMPRESSION:
Moderate to severe cardiac enlargement with mild interstitial
pulmonary edema and small bilateral pleural effusions. Streaky
retrocardiac opacity, likely atelectasis.
TTE ___
IMPRESSION: Mildly thickened mitral leaflets with discrete
flail/prolapse and eccentric jet of severe mitral regurgitation.
Left ventricular cavity dilation with modetate to severe global
hypokinesis in a pattern most c/w a non-ischemic cardiomyopathy.
Moderate pulmonary artery systolic hypertension. Right
ventricular cavity dilation with free wall hypokinesis. Biatrial
enlargement.
TEE ___:
IMPRESSION: Severe inferolaterally directed mitral regurgitation
due to restricted motion of the
posterior mitral valve leaflet ___ Class IIIB) failure
of mitral leaflet coaptation. Depressed
biventricular systolic function. Moderate tricuspid
regurgitation. Simple atheroma descending
thoracic aorta and aortic arch.
Discharge Labs:
___ 10:40AM BLOOD WBC-9.8 RBC-3.99* Hgb-13.0* Hct-40.4
MCV-101* MCH-32.6* MCHC-32.2 RDW-14.9 RDWSD-54.8* Plt ___
___ 06:47AM BLOOD Neuts-60.1 ___ Monos-11.3 Eos-2.1
Baso-0.7 Im ___ AbsNeut-4.33 AbsLymp-1.81 AbsMono-0.81*
AbsEos-0.15 AbsBaso-0.05
___ 10:40AM BLOOD ___
___ 12:52PM BLOOD Ret Aut-3.1* Abs Ret-0.12*
___ 10:40AM BLOOD Glucose-119* UreaN-35* Creat-1.2 Na-136
K-4.4 Cl-97 HCO3-25 AnGap-14
___ 10:40AM BLOOD ALT-42* AST-21 LD(LDH)-209 AlkPhos-152*
TotBili-0.4
___ 10:40AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.2
Brief Hospital Course:
Summary:
========
___ man with h/o non-ischemic cardiomyopathy,
well-controlled HIV, admitted for decompensated heart failure
and severe mitral regurgitation
#CORONARIES: Right dominant, LAD/RCA/LCX normal ___
#PUMP: LVEF 28% ___, severe MR confirmed by TEE
#RHYTHM: NSR
Transitional Issues:
====================
Discharge Weight: 159lbs
Discharge BUN/Cr: 35/1.2
Discharge Diurtetic: Torsemide 80mg
Code Status: Full
For PCP:
[] Please continue to monitor stability of blood pressure on new
regimen
[] Please consider reduction in acyclovir dosing. Currently on
treatment rather than suppressive dosing.
[] Please recheck BMP + Mg within 1 week of discharge.
[] Please ensure stability of patient's weight on discharge
diuretic dose
For Cardiology:
[] Please consider starting entresto if BP room, prior auth has
been approved at ___.
[] Consider adding spironolactone if BP allows
[]Please ensure stability of patient's weight on discharge
diuretic dose
Active Issues:
===============
#Acute on Chronic Heart Failure with Reduced LVEF (28%, ___
Class III-IV)
#Non-Ischemic Dilated Cardiomyopathy
#Severe Mitral Regurgitation
The patient presented with significant dyspnea at rest, severe
orthopnea, and PND. He appeared hypervolemic on examination and
was diuresed with IV Lasix. He had an echocardiogram which
showed biventricular dilatation and diffuse hypokinesis
consistent with a nonischemic cardiomyopathy, as well as severe
mitral regurgitation. Etiology for his dilated cardiomyopathy is
unclear. No evidence for ischemia or myocarditis given clean
coronary angiography at ___ and
negative repeat troponins at ___ and here. TSH wnl. Iron studies
consistent with mild deficiency, not hemochromatosis.He
underwent a transesophageal echocardiogram which confirmed
severe mitral regurgitation likely due to restricted motion of
the posterior mitral valve leaflet (particularly the P2/P3
scallops) ___ Class IIIb mitral regurgitation). He was
diuresed to euvolemia. He will be discharged on Torsemide 80mg.
Discharge weight 159lbs
#Acute on chronic kidney disease
Patient was admitted with a creatinine of 1.6 with a baseline
reported to be 1.1, though he was recently discharged from ___
with a creatinine of 1.4). The etiology of his acute kidney
injury was most likely cardiorenal syndrome in the setting of
heart failure exacerbation. Discharge creatinine was***
#Transaminitis
This is most likely due to hepatic congestion in the setting of
heart failure exacerbation. Improved with diuresis. His
hepatitis B serologies were consistent with clear infection,
hepatitis B viral load was not detected.
Chronic issues:
===============
#HIV
Continued on home antiretroviral medications. HIV viral load was
not detected.
#HSV prophylaxis
Due to his acute kidney injury, his home acyclovir prophylaxis
was renally dosed.
#Asthma
Continue home albuterol
#Hyperlipidemia
Continue home gemfibrozil.
#Moderate malnutrition in context of chronic illness
Nutrition consulted
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 40 mg PO DAILY
2. Acyclovir 800 mg PO TID
3. Furosemide 40 mg PO BID
4. melatonin 3 mg oral QHS
5. Metoprolol Succinate XL 25 mg PO DAILY
6. TraZODone 50 mg PO QHS
7. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing/dyspnea
8. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
9. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
10. Diphenoxylate-Atropine 1 TAB PO Q8H:PRN diarhea
11. Fexofenadine 180 mg PO DAILY:PRN allergies
12. Gemfibrozil 600 mg PO DAILY
13. Kaletra (lopinavir-ritonavir) 200-50 mg oral BID
14. Lexiva (fosamprenavir) 700 mg oral BID
15. Testosterone Gel 1% 50 mg TP DAILY
16. Calcium Carbonate 1000 mg PO DAILY
Discharge Medications:
1. Torsemide 80 mg PO DAILY
RX *torsemide 20 mg 4 tablet(s) by mouth once a day Disp #*120
Tablet Refills:*0
2. Valsartan 40 mg PO BID
RX *valsartan 40 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Acyclovir 800 mg PO TID
4. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing/dyspnea
5. Cyclobenzaprine 10 mg PO TID:PRN muscle spasms
6. Emtricitabine-Tenofovir alafen (200mg-25mg) *DESCOVY* 1 TAB
PO DAILY
7. Fexofenadine 180 mg PO DAILY:PRN allergies
8. Gemfibrozil 600 mg PO DAILY
9. Kaletra (lopinavir-ritonavir) 200-50 mg oral BID
10. Lexiva (fosamprenavir) 700 mg oral BID
11. melatonin 3 mg oral QHS
12. Metoprolol Succinate XL 25 mg PO DAILY
13. Testosterone Gel 1% 50 mg TP DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
==================
1) Acute on Chronic Heart Failure of Reduced Ejection Fraction
2) Mitral Regurgiation
3) Acute on Chronic Renal Failure
Secondary Diagnosis:
====================
1) Human Immunodeficiency Virus
2) Asthma
3) Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
DISCHARGE INSTRUCTIONS
==========================
Dear Mr. ___,
You were admitted to the hospital because you were short of
breath. Please see below for more information on your
hospitalization. It was a pleasure participating in your care!
We wish you the best!
-Your ___ Healthcare Team
What happened while you were in the hospital?
-We gave you medications to help you pee out extra fluids
-We identified that your heart is not pumping as well as it
should be.
-We gave you medications to lower your blood pressure
What should you do after leaving the hospital?
-You should call Dr. ___ to schedule an appointment within the
next week. It is very important for you to see Dr. ___ to have
lab tests drawn.
-See below for your scheduled appointments.
-Please take your medications as listed below and follow up at
the listed appointments.
-Your weight at discharge is 159lbs. Please weigh yourself today
at home and use this as your new baseline.
-Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 2 lbs in a day or 5
lbs in a week.
Followup Instructions:
___
|
10112392-DS-12 | 10,112,392 | 26,396,613 | DS | 12 | 2156-11-30 00:00:00 | 2156-12-01 13:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMHx of headaches, prediabetes, childhood polio
resulting in residual right leg weakness who was admitted with
altered mental status and a fall.
Per report, patient was at home alone and had a fall shortly
before dinner time. The patient does not remember anything about
these events. She knows that she was listening to a book on tape
at home alone earlier today. She does not think that she took
any of her medications. Patient's husband returned home to
notice blood in the bathroom and patient with nasal abrasion,
confused standing in the bedroom. He thinks that she was on the
toilet and fell forward, hitting her nose. Blood was not fresh
so he thinks this happened >30 minutes prior to him getting
home. Patient was confused when he got home. She embraced him
but had a blank stare on her face. Somnolence continued and the
patient was eventually brought into ___ for further
evaluation.
In the ED, initial vitals were: 98.7, 86, 154/60, 16, 100% RA
- Exam notable for: altered, not oriented
- Labs notable for: Cr 0.7, Lactate 1.7, CK 203, LFTs wnl.
Urine tox positive for opioids, CBC wnl
- Imaging was notable for: CT head, C spine no fractures of
acute process
- Neurology was consulted: Exam was notable for sleepy and
inattention with baseline RLE weakness. Recommend admission to
medicine for toxic metabolic work up, fall and EEG monitoring to
r/o seizure.
- Patient was given: Nothing
- Vitals prior to transfer: 98.3, 70, 146/72, 10, 99% RA
Upon arrival to the floor, patient reports the above history.
She is with her husband. She does not remember which medications
she has taken recently. Both her and her husband recently
returned from a 2 week trip to ___. They felt well during the
trip but since returning have both had a cough with runny noses.
Denies fevers, chills. No sick contacts. No past syncope. Did
have a fall several days ago at home but husband states this was
in the setting of her being clumsy. She has right lower
extremity weakness from polio
Past Medical History:
Migraine headaches
Prediabetes
Social History:
___
Family History:
No family history of seizures
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 98.1, 151/82, 73 18 98 ra
General: AOX3 but slow to respond to questions. frequent
blinking. dazed look on face.
HEENT: sclera anicteric, MMM, oropharynx clear, non tender
bilateral LAD
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
allops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no ebound tenderness or guarding, no organomegaly
Ext: right lower extremity with muscle atrophy compared with
left. decreased strength and sensation to light touch on right
lower extremity. no edema
Neuro: CNs2-12 intact, motor function grossly normal with
exception of right lower extremity. slow to respond to questions
DISCHARGE PHYSICAL EXAM:
========================
VS: T 98.4, HR 70, BP 134/82, RR 20, O2 99% RA
GENERAL: Lying in bed, appears comfortable, NAD
HEENT: NC/AT, sclerae anicteric, MMM
LUNGS: Clear to auscultation bilaterally, no w/r/r
HEART: RRR, normal S1/S2, no m/r/g
ABDOMEN: NABS, soft/NT/ND.
EXTREMITIES: WWP
NEURO: A&O x3, CN II-XII intact, strength ___ in UE bilaterally,
___ in LLE, RLE ___ hip flexion, ___ plantar/dorsiflexion
(chronic per pt). SILT. Able to do days of week backwards,
unable to do serial 7s.
Pertinent Results:
PERTINENT LABS:
===============
___ 11:15PM BLOOD WBC-6.4 RBC-3.85* Hgb-11.4 Hct-36.2
MCV-94 MCH-29.6 MCHC-31.5* RDW-14.5 RDWSD-50.2* Plt ___
___ 11:15PM BLOOD Neuts-74.8* Lymphs-18.8* Monos-4.8*
Eos-0.8* Baso-0.2 Im ___ AbsNeut-4.80 AbsLymp-1.21
AbsMono-0.31 AbsEos-0.05 AbsBaso-0.01
___ 11:15PM BLOOD ___ PTT-26.8 ___
___ 11:15PM BLOOD Glucose-216* UreaN-10 Creat-0.7 Na-136
K-4.0 Cl-101 HCO3-26 AnGap-13
___ 11:15PM BLOOD ALT-12 AST-16 CK(CPK)-203* AlkPhos-64
TotBili-<0.2
___ 11:15PM BLOOD cTropnT-<0.01
___ 11:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:20PM BLOOD Lactate-1.7
IMAGING/STUDIES:
================
CT HEAD ___:
1. No intracranial hemorrhage or fracture.
2. Paranasal sinus disease, suggestive of acute sinusitis.
CT C-SPINE ___:
No fracture or traumatic malalignment in the cervical spine
CXR ___:
No focal consolIdation.
Brief Hospital Course:
___ year-old woman with PMHx of headaches, prediabetes, childhood
polio resulting in residual right leg weakness who was admitted
with altered mental status and a fall.
#FALL: Unclear etiology of fall as patient does not remember
sequence of events and fall was not witnessed. Differential
includes syncopal episode vs. fall in the setting of physical
impairment exacerbated by encephalopathy as below, vs. less
likely seizure. Telemetry w/o arrhythmia and no history of
cardiac disease. Given lack of clear history unable to determine
whether more consistent with syncope or mechanical fall in
setting of encephalopathy. ___ and OT evaluated and felt that she
was at her baseline. They also felt that there was no
significant benefit to a cane or walker so they recommended that
the patient could return home safely.
#ENCEPHALOPATHY: Presented altered and inattentive on admission,
now largely resolved, but still without memory of events prior
to admission. CT head negative for acute process. CT head
negative for acute process. No fever or leukocytosis to suggest
infectious etiology. No hypoglycemia, not using insulin at home.
Evaluated by neurology in ED who recommended EEG to rule out
seizure, which was deferred to outpatient given low suspicion
for seizure and predominantly resolved encephalopathy. On
multiple sedating medications at home which could easily have
contributed to encephalopathy and lead to fall in setting of
baseline physical impairment. Additionally, encephalopathy may
be due to post-concussive syndrome after fall. Will need
outpatient EEG
#CHRONIC MIGRAINES/HEADACHES. Debilitating to the point that she
is limited in her ADLs. Currently only taking Tramadol per
report though does not recall full medication list. Currently
w/o headache, home tramadol held in setting of encephalopathy
#HYPERGLYCEMIA: Glucose elevated >200s on admission. Patient
denies diagnosis of diabetes though appears to previously have
been on insulin. Fingerstick 180 morning of discharge, should
have outpatient follow-up
TRANSITIONAL ISSUES:
[] Glucose elevated on admission to 200s, denies diagnoses of
diabete/prediabetes. Appears to have been on insulin in past.
Please evaluate and consider appropriate therapy.
[] Given suspicion for medication-related encephalopathy would
benefit from review of medications and minimizing sedating
medications as able.
[] Needs an outpatient EEG- nonurgent.
# CONTACT: Husband, cell: ___
# DISPO: Home
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
2. Baclofen Dose is Unknown PO DAILY:PRN Back Pain
3. Levothyroxine Sodium 25 mcg PO DAILY
4. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain - Moderate
5. TraZODone 300 mg PO QHS
6. Pravastatin 20 mg PO QPM
Discharge Medications:
1. Baclofen Dose is Unknown PO DAILY:PRN Back Pain
2. Levothyroxine Sodium 25 mcg PO DAILY
3. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
4. Pravastatin 20 mg PO QPM
5. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
6. TraZODone 300 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Fall
Encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
DISCHARGE WORKSHEET INSTRUCTIONS:
Dear Ms. ___,
It was a pleasure caring for you at ___
___!
WHY WERE YOU ADMITTED?
-You were confused and had a fall at home
WHAT HAPPENED IN THE HOSPITAL?
-Blood work did not show signs of infection
-CT scans showed no injuries to your head or neck
-Your confusion improved
-You were evaluated by physical and occupational therapy who
felt that you were at your baseline. You need to be more careful
with your medications that you take and be careful to use your
walking sticks at home especially at night.
WHAT SHOULD YOU DO AT HOME?
-Please follow-up with your primary care doctor as listed below
-___ will need an EEG as an outpatient. Your PCP should schedule
this for you.
Thank you for allowing us be involved in your care, we wish you
all the best!
Your ___ Team
Followup Instructions:
___
|
10112984-DS-3 | 10,112,984 | 28,460,904 | DS | 3 | 2160-08-09 00:00:00 | 2160-08-09 17:54:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo man w/ HTN, IDDM, ESRD on HD ___, severe PVD s/p BKA,
CAD of unclear extent), diastolic CHF (may no longer be
preserved EF), renal carcinoma s/p local radiofrequency ablation
of tumor without nephrectomy who presented to ___ w/
severe SOB and hypoxia, transferred to ___ w/ c/f NSTEMI on
heparin. In CHA ___, per report, he appeared acutely ill
tachypneic and orthopneic. He was severely SOB, and started on
CPAP. He was also given full dose aspirin and Cefepime per CHA
records for patchy lower lobe infiltrates on CXR.
EKG: NSR, old TWI lateral leads I and aVL, no evidence of
STEMI, anteroseptal MI, age undetermined. Limited bedside echo-
3 views only as patient could not lay down shows anteroseptal
akinesis. His troponin I was elevated to 2.43 and Cr 3.9. He was
urgently transferred to BI ___ for consideration of cardiac cath.
Per discussion with the nursing home, he has been coughing for
the last ___ days. No fevers at the nursing home. Sometimes not
oriented to place or time.
In the ___ initial vitals were: 98.0 88 109/67 18 98% Nasal
Cannula
Labs/studies notable for: lactate 1.1, Cr 4.7, trop 0.64, CK-MB
4, proBNP: >70000, INR: 1.3
Patient was: continued on heparin gtt
Vitals on transfer: 99 108/67 20 97% RA
Cardiology was consulted in the ___ and did a bedside ECHO which
showed-
Bedside TTE with poor windows, EF mildly reduced, unable to see
RV, no sig MR or AR. ?Thickened AV leaflets. No effusion. Unable
to clearly see WMA. They recommended continuing ASA and heparin
gtt and trending trops/MB.
On the floor, he is feeling well overall. He denies any CP at
all, and says he has not had any this entire time. He is not
sure why they transferred him from dialysis to the hospital. He
says that he was not feeling more SOB with dialysis. He endorses
an ongoing cough for the last couple of weeks; it has been dry
this entire time, he is not making sputum. He also endorses PND,
but says it is hard for him to distinguish waking up secondary
to coughing vs dyspnea. Also endorses some orthopnea. Says he
does not make much urine. He denies any nausea, vomiting,
diarrhea, abdominal pain, blood in stools or urine. Denies h/a
as well.
Past Medical History:
1. Coronary artery disease. Nuclear stress test in ___ shows
a large inferior infarct. Echocardiogram from ___ shows
inferior wall and apical wall motion abnormality. The patient
could not provide further information about the extent of his
cardiac disease. He has a sternal scar on his chest, suggesting
possible bypass surgery; however, he does not have sternal wires
on chest x-ray.
2. Severe peripheral vascular disease.
3. Hypertension.
4. Chronic renal failure on dialysis.
5. Diabetes.
6. Hyperlipidemia.
7. Renal cell carcinoma s/p local radiofrequency ablation of
tumor without nephrectomy
8. Anemia of chronic disease.
Social History:
___
Family History:
No family history of early MI, arrhythmia, heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
================================
VS: T98.8 BP 138/79 HR 80 RR 16 O2 SAT 96%on 2L (86% on RA)
Pt refused weight
GENERAL: WDWN man in NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP to earlobe when laying at 45'
CARDIAC: RRR, ___ SM at RUSB
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Very mild left base
crackles, but no wheezes or rhonchi.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Very trace LLE edema. No femoral bruits. R BKA
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Dry
skin on LLE.
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.4 ___ ___ 18 95 RA
Weight: -1.5 at hd (dry weight: 92.5-93kg)
GENERAL: pleasant man, sitting up in wheel chair, alert and
awake, A&Ox2, speaking in full sentences, in NAD.
HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, JVD improved from yesterday
CARDIAC: RRR, soft systolic murmur, no rubs/gallops.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Improvement in
bibasilar crackles. ABDOMEN: +BS, soft, NTND, no rebound or
guarding.
EXTREMITIES: Very trace LLE edema. R BKA with prosthetic leg in
place. femoral access sight without hematoma.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Dry
skin on LLE.
Pertinent Results:
ADMISSION LABS:
================
___ 04:30PM BLOOD WBC-7.1 RBC-3.01* Hgb-9.4* Hct-29.2*
MCV-97 MCH-31.2 MCHC-32.2 RDW-15.2 RDWSD-53.6* Plt ___
___ 04:30PM BLOOD Neuts-81.3* Lymphs-10.8* Monos-7.0
Eos-0.1* Baso-0.4 Im ___ AbsNeut-5.79 AbsLymp-0.77*
AbsMono-0.50 AbsEos-0.01* AbsBaso-0.03
___ 04:30PM BLOOD ___ PTT-38.1* ___
___ 04:30PM BLOOD Glucose-88 UreaN-27* Creat-4.7* Na-140
K-3.8 Cl-98 HCO3-24 AnGap-22*
___ 04:30PM BLOOD CK(CPK)-316
___ 04:30PM BLOOD CK-MB-4 proBNP->70000*
___ 04:30PM BLOOD cTropnT-0.64*
___ 04:30PM BLOOD Calcium-8.6 Phos-4.5 Mg-1.9
___ 04:40PM BLOOD Lactate-1.1
MICRO:
======
___ MRSA- positive.
IMAGING
=======
___ ECHO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy with normal cavity size. LV
visualization is suboptimal, but there is apparent mild regional
left ventricular systolic dysfunction with hypokinesis of the
mid- and distal septum and apical portions of the anteior and
inferior walls (mid-LAD territory). The remaining segments
contract normally (LVEF ~40%). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets are moderately thickened. There is no aortic valve
stenosis. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Mild (1+) mitral regurgitation is
seen. The estimated pulmonary artery systolic pressure is
normal. There is no pericardial effusion.
IMPRESSION: Mild regional left ventricular systolic
dysfunction, c/w CAD. Mild mitral regurgitation.
___ CT chest non con
IMPRESSION:
1. Bilateral ___, centrilobular, ground-glass
opacities, greatest at the left lower lobe, are most likely
infectious. Mildly prominent mediastinal lymph nodes, likely
reactive.
2. Cardiomegaly with moderate to severe coronary artery
calcifications, and minimal ascending aortic calcification..
3. Suggestion of pulmonary artery hypertension.
NOTIFICATION: The findings were discussed with ___,
M.D. by
___, M.D. on the telephone on ___ at 12:04
am, 10 minutes after discovery of the findings.
___ Lower extremity venous duplex.
Discharge LABS:
==============
___ 05:51AM BLOOD WBC-9.2 RBC-2.92* Hgb-9.0* Hct-28.1*
MCV-96 MCH-30.8 MCHC-32.0 RDW-15.6* RDWSD-55.7* Plt ___
___ 04:30PM BLOOD Neuts-81.3* Lymphs-10.8* Monos-7.0
Eos-0.1* Baso-0.4 Im ___ AbsNeut-5.79 AbsLymp-0.77*
AbsMono-0.50 AbsEos-0.01* AbsBaso-0.03
___ 05:51AM BLOOD Plt ___
___ 05:51AM BLOOD Glucose-145* UreaN-58* Creat-7.5* Na-141
K-4.7 Cl-95* HCO3-25 AnGap-26*
___ 06:20AM BLOOD ALT-18 AST-47* LD(LDH)-345* CK(CPK)-303
AlkPhos-48 TotBili-0.4
___ 09:27AM BLOOD cTropnT-0.74*
___ 05:51AM BLOOD Calcium-9.4 Phos-8.5* Mg-2.2
___ 08:59AM BLOOD %HbA1c-6.8* eAG-148*
Brief Hospital Course:
ASSESSMENT AND PLAN:
___ yo man w/ HTN, IDDM, ESRD on HD ___, severe PVD s/p BKA,
CAD of unclear extent, diastolic CHF (may no longer be preserved
EF), renal carcinoma s/p local radiofrequency ablation of tumor
without nephrectomy who presented to ___ w/ severe
SOB and hypoxia, transferred to ___ w/ c/f NSTEMI on heparin.
# CORONARIES: unknown
# PUMP: per ___ ECHO, preserved EF
# RHYTHM: sinus
# NSTEMI:
Patient likely is having type 2 demand ischemia in the setting
of acute heart failure exacerbation and having retention of his
troponins in the setting of CKD. EKG unchanged from prior in
___. While his troponins are elevated, baseline
troponin is unclear in the setting of his CKD. However, given
CAD history and symptoms prior to admission cannot rule out
ischemic disease. Troponin plateaued at .78. CKMB was negative.
Treated with aspirin/heparin drip/atorvastatin/isosorbide
dinitrate and metoprolol. Heparin drip stopped ___. Cardiac cath
showed mid LAD narrowing, total RCA narrowing and proximal LCx
narrowing. ECHO showed mild regional left ventricular systolic
dysfunction with EF 40%, c/w CAD. Mild mitral regurgitation.
After reviewing films with cardiac surgery and interventional
cardiology plan is for CABG next week.
# Pneumonia: He reported coughing three days prior to admission.
He continued to have coughing dyspnea, crackles, and wheezing
despite fluid removal with HD. ___ CT chest showed bilateral
___, centrilobular, ground-glass opacities, greatest at
the left lower lobe, are most likely infectious. Mildly
prominent mediastinal lymph nodes, likely reactive. He had no
leukocytosis and remained afebrile. He was treated with a 5 day
course of Levofloxacin 500 mg PO Q48H ending ___.
# Acute diastolic and systolic CHF exacerbation
He appeared volume overloaded on admission. New cough was though
to be partially secondary to fluid overload in setting of CHF
exacerbation. He has a history of HFpEF. As the patient was
anuric he required HD for fluid removal as well as placed on a
1L fluid restriction. During multiple HD sessions her reported
shortness of breath and chest discomfort. Troponins and ecg were
stable from prior. ___ echo showed EF 40% and Mild regional
left ventricular systolic dysfunction, c/w CAD. Mild mitral
regurgitation. Hypoxia gradually improved since admission with
HD fluid removal over many sessions and antibiotic course as
above.
# HTN: Decision was made to stop amlodipine given reduced EF and
well as Lisinopril in case it was contributing to his cough.
Pressure was controlled with fluid removal during HD as well as
hydralazine 50mg TID, metoprolol 25 mg /d, and isosorbide 30 mg
TID.
# CODE: full
TRANSITIONAL ISSUES:
-------------------
[]NSTEMI- treated medically. Plan for cardiac bypass surgery
___ due to multivessel disease. He will be discharged
and return to the hospital day of the surgery. Simvastatin
switched to atorvastatin.
[]CAD - Plan for bypass surgery as above.
[]Pneumonia- presented to hospital with cough. Infectious
process seen on CT. Will complete course of Levofloxacin on
___.
[]HTN- discontinued lisinopril and amlodipine. Discharge on
hydralazine, Lasix, labetalol and isosorbide mononitrate.
[]Mupirocin ointment to nares daily until ___
[]Chlorhexidine bath ___ evening prior to surgery
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Ferrous Sulfate 325 mg PO DAILY
3. Furosemide 80 mg PO DAILY
4. Nephrocaps 1 CAP PO DAILY
5. amLODIPine 5 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Lisinopril 5 mg PO DAILY
8. HydrALAZINE 10 mg PO TID
9. Isosorbide Dinitrate 10 mg PO TID
10. Calcium Acetate 667 mg PO TID W/MEALS
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Simvastatin 20 mg PO QPM
13. Bisacodyl 10 mg PR QHS:PRN constipation
14. Glargine 22 Units Bedtime
15. Labetalol 200 mg PO BID
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Benzonatate 100 mg PO TID:PRN cough
3. Levofloxacin 500 mg PO Q48H Duration: 2 Doses
please take one dose tomorrow (___) and another ___
(___)
4. Mupirocin Ointment 2% 1 Appl NU BID Duration: 5 Days
5. HydrALAZINE 50 mg PO TID
6. Glargine 22 Units Bedtime
7. Isosorbide Dinitrate 30 mg PO TID
8. Aspirin 81 mg PO DAILY
9. Bisacodyl 10 mg PR QHS:PRN constipation
10. Calcium Acetate 667 mg PO TID W/MEALS
11. Ferrous Sulfate 325 mg PO DAILY
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. Furosemide 80 mg PO DAILY
14. Labetalol 200 mg PO BID
15. Nephrocaps 1 CAP PO DAILY
16. sevelamer CARBONATE 800 mg PO TID W/MEALS
17. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you are told to do so by your
cardiologist
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis
=================
1) NSTEMI
Secondary
=========
1) Community acquired pneumonia
2) Acute Diastolic and Systolic Congestive Heart Failure
Exacerbation
3) HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___
___ was a pleasure taking care of you at the ___
___!
Why was I admitted to the hospital?
-You were admitted because you had shortness of breath. The
shortness of breath was likely due to a number of things
including a pneumonia, Heart failure, and a potential heart
attack.
What happened while I was in the hospital?
-You received antibiotics to treat the infection. Hemodialysis
was performed to remove fluid to help you breath better. In
addition you had an ultrasound of your heart which showed that
it has been weakened. You also had a procedure performed to
shoot dye into the vessels of your heart which showed that many
of the vessels are blocked. The cardiologist and cardiac
surgeons have recommended you have this repaired with surgery
because that is more effective than having stents placed.
What should I do after leaving the hospital?
-After you leave the hospital please attend your normal
hemodialysis on ___ and ___. You should return to
the hospital to have open heart surgery to repair your vessels
next ___. Please be there by 6am. You will be contacted
by the cardiac surgery team on ___ with more information
prior to the surgery.
Thank you for allowing us to be involved in your care, we wish
you all the best!
Your ___ Healthcare Team
Followup Instructions:
___
|
10113036-DS-10 | 10,113,036 | 21,335,145 | DS | 10 | 2111-02-13 00:00:00 | 2111-02-13 16:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Foot infection
Major Surgical or Invasive Procedure:
OR for R foot debridement ___
OR for R foot debridement ___
OR for R foot debridement, metatarsophalangeal joint, VAC,
___
OR for R foot debridement, washout, integra and VAC, ___
History of Present Illness:
___ man with atrial flutter on apixaban, HFpEF, gout,
HTN, and DM2 with charcot foot, recent metatarsal fracture with
Lisfranc injury, presenting with R foot infection refractory to
cephalexin.
He fell in the shower in ___ and hit the instep of his R
foot. Plain films revealed probable comminuted fractures of the
___ through ___ proximal metatarsal shaft, with gross
derangement
of the Lisfranc articulation and downward rotation of the
respective cuneiforms. He was prescribed a boot and instructed
to
avoid long periods of standing as possible.
Since then, he has had gradual development of pain, swelling and
redness. He saw his podiatrist on ___ who felt there was no
infection at that time and just recommended careful footcare. He
then was seen in PCP's office on ___ for 1 week of R knee pain.
He had arthrocentesis of 60 cc of "synovial-looking fluid," and
injection of cortisone. Synovial fluid studies returned with
3400
WBCs (PMN predominant), with many urate crystals. He was
prescribed tramadol for pain but received no other treatment.
He returned to his podiatrist on ___ with worsening of his R
foot redness. Podiatrist debrided the wound and noted: "Plantar
right midfoot with 3cm x 3cm post debridement with healthy
granular base skin ulceration. Moderate global right midfoot
edema with + ___ wound surrounding erythema and warmth compared
to last visit." He was started on Keflex for presumed cellulitis
with initial improvement, however today noticed significant
redness, pain, swelling around his right foot wound. Feels
feverish but denies chills, chest pain, shortness of breath.
This
morning also felt right knee pain similar to a prior episode of
gout.
In the ED, initial VS were:
97.0
94
104/54
18
100% RA
Exam notable for: bedside US with no drainable pocket. ___ pulses
dopplerable.
Labs showed: WBC 12.8, Cr 1.5, Bicarb 19 with AG 19 and lactate
2
Imaging: R foot XR concerning for osteomyelitis of the head of
the fifth metatarsal with extensive soft tissue gas within the
foot with swelling. R knee XR with Extensive degenerative
changes
and a small effusion.
Patient subsequently developed fever to 101.9.
Patient received: Vanc/CTX at 12AM, Vanc/Cefepime/Clinda 6AM, 2L
NS, 1g tylenol
Transfer VS were: ___ ___ Temp: 97.8 PO BP: 108/69 HR: 99
RR: 18 O2 sat: 95% O2 delivery: Ra
On arrival to the floor, patient confirmed the above history. He
noted that he had been improving until ___ when he noticed
increased swelling and pain after removing the boot (for his R
foot fracture). He reports that he currently only has R knee
pain, similar to prior episodes of gout, and no R foot pain. He
denied fever, chills, abdominal discomfort, other joint pain.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Paroxysmal AFib
HFpEF
HTN
DM2
Charcot foot
Gout
Social History:
___
Family History:
Father with recent CABG. Otherwise no family history of early
CAD, arrhythmias, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 1207)
Temp: 98.9 (Tm 98.9), BP: 132/75 (108-132/69-75), HR: 90
(90-99), RR: 18, O2 sat: 97% (95-97), O2 delivery: Ra, Wt:
344.14
lb/156.1 kg
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: R foot with erythema and ttp on plantar and lateral
aspects, R toes slightly cooler than foot, erythema on R shin,
venous stasis changes bilaterally, R knee with mild edema and
ttp
anteriorly and limited ROM due to pain though without erythema
PULSES: 2+ radial pulses bilaterally, 1+ DP bilaterally
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric, gross motor and sensation intact
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSCIAL EXAM
=======================
PHYSICAL EXAM:
24 HR Data (last updated ___ @ 758)
Temp: 98 (Tm 98.6), BP: 138/80 (115-162/70-83), HR: 74
(70-75), RR: 20 (___), O2 sat: 98% (96-99)
GENERAL: NAD
NECK: No JVD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB, no wheezes, no crackles
GI: soft, NTND
EXTREMITIES: R foot bandaged w/ wound integra and VAC in place.
Extremities were warm b/l. 1+ edema now in the lower
extremities, predominantly in the feet R>L. R knee is
non-erythematous, minimally edematous, non-tender to palpation.
Pertinent Results:
ADMISSION LABS
==============
___ 01:50AM BLOOD WBC-12.8* RBC-4.49* Hgb-11.1* Hct-35.4*
MCV-79* MCH-24.7* MCHC-31.4* RDW-15.4 RDWSD-43.8 Plt ___
___ 01:50AM BLOOD Plt ___
___ 10:20AM BLOOD Ret Aut-1.1 Abs Ret-0.04
___ 01:50AM BLOOD Glucose-171* UreaN-22* Creat-1.5* Na-131*
K-4.8 Cl-93* HCO3-19* AnGap-19*
___ 10:20AM BLOOD Calcium-8.8 Phos-3.3 Mg-1.8 Iron-14*
___ 02:11AM BLOOD SED RATE-Test
DISCHARGE LABS
==============
___ 09:24AM BLOOD WBC-7.6 RBC-3.51* Hgb-8.8* Hct-29.6*
MCV-84 MCH-25.1* MCHC-29.7* RDW-19.4* RDWSD-59.6* Plt ___
___ 09:24AM BLOOD Plt ___
___ 05:35AM BLOOD Ret Aut-2.0 Abs Ret-0.06
___ 06:12AM BLOOD Glucose-76 UreaN-34* Creat-1.4* Na-141
K-5.0 Cl-105 HCO3-22 AnGap-14
___ 06:19AM BLOOD Calcium-8.8 Phos-4.4 Mg-1.8
___ 05:35AM BLOOD VitB12-479 Ferritn-355
IMAGING
=======
___ FOOT AP,LAT & OBL RIGHT
IMPRESSION:
Findings concerning for osteomyelitis of the head of the fifth
metatarsal.
There is extensive soft tissue gas within the foot with
swelling. Surgical
consultation and further evaluation with MRI is recommended as
clinically
indicated.
___ KNEE (AP, LAT & OBLIQUE
FINDINGS:
No fracture or dislocation is seen. There is joint space
narrowing in the
tibiofemoral joint space compartments, more severe in the
lateral compartment.
There is tricompartmental osteophytosis. There is a small knee
effusion.
There is mild distortion of ___ fat pad. Incidental note is
made of a
fabella. No lytic or sclerotic lesions are identified. Bone
mineral density is within normal limits.
IMPRESSION:
No acute fracture or dislocation. Extensive degenerative
changes as described above.
___ MR FOOT ___ CONTRAST
FINDINGS:
The patient has a Charcot arthropathy with resultant
disorganization
fragmentation and sclerosis of the midfoot. There is plate of
the Lisfranc joint, association of the intercuneiform and
tarsometatarsal joints. There is extensive bone marrow
replacement on T1 weighted sequences involving the distal
cuboid, the navicular bone, the intermediate, medial and lateral
cuneiform and the base of the second through fifth metatarsals.
There is edema a more fluid sensitive sequences in a similar
distribution with slightly more extensive involvement of the
metatarsals. There is expected hyperenhancement of these bony
structures following contrast administration.
Given the extent of involvement, a Charcot arthropathy is
favored over acute osteomyelitis however there is an area of
devitalized tissue overlying the fifth metatarsal with
nonenhancement on the post-contrast images (10:25).
Multiple areas of markedly low signal intensity on all sequences
are
consistent with air given the appearances on the prior
radiographs (10:29).
This area of devitalized tissue partially surrounds the fifth
metatarsal
distally, however the bone marrow in the fifth metatarsal at
this level is
actually preserved (04:29).
More proximally in the midfoot there is a presumed skin ulcer
with devitalized tissue in the presumed sinus tract extending
along the plantar aspect of the lateral foot (10:21). On
postcontrast images a sinus tract appears to extend to the
plantar surface of the cuboid (10:20) where there is marrow
signal replacement and associated edema (4:20, 6:14). This area
is more suspicious for acute osteomyelitis.
Nonspecific marrow edema in the distal fibula, talus, calcaneus
is seen
without replacement of the normal T1 marrow signal, likely
reactive. There is a small tibiotalar joint effusion and a
small subtalar joint effusion.
At the first metatarsophalangeal joint there are multiple
erosions of the head of the first metatarsal (04:34, 33). There
is a small associated joint effusion. Although difficult to
evaluate bone marrow edema in the setting of a Charcot
arthropathy, there is relative sparing of the first metatarsal
head (6:3, 7:3) so an infective process is considered less
likely. This may reflect gout, correlate clinically.
There is severe fatty atrophy of the tarsal tunnel muscles.
There is
thickening and heterogeneity of the plantar fascia consistent
with plantar
fasciitis. This study is tailored to evaluate the foot rather
than the ankle, nonetheless there is tenosynovitis of the
peroneus longus and brevis tendons with an apparent longitudinal
split tear of peroneus brevis.
Diffuse soft tissue edema and hyper enhancement is nonspecific
but may reflect cellulitis.
IMPRESSION:
1. Devitalized tissue and ulceration involving the lateral and
plantar aspect of the midfoot. A sinus track along the plantar
aspect of the midfoot extends to the plantar surface of the
cuboid bone with underlying bone marrow edema, abnormal T1
signal and hyper enhancement suspicious for acute osteomyelitis
at this site.
2. Extensive marrow signal abnormalities in the navicular,
medial, lateral and intermediate cuneiform and second through
fifth metatarsals as described in detail above. Given the
multiple bones involved, the chronic fragmentation and
displacement, Charcot arthropathy is favored over an infectious
process. Difficult to exclude superimposed infection in the
setting of a Charcot arthropathy.
3. Apparent erosive arthropathy at the first metatarsophalangeal
joint, the lack of adjacent bone marrow edema makes an
infectious process and likely, correlate with any symptoms or
signs of chronic gout.
4. Peroneus longus and brevis tenosynovitis, tendinosis and a
longitudinal
split tear peroneus brevis.
5. Severe fatty atrophy of the muscles of the tarsal tunnel.
6. Marrow edema without corresponding loss of the T1 signal
intensity in the tibia talus and calcaneus likely reactive.
7. Diffuse soft tissue edema and hyper enhancement may reflect
cellulitis.
___ BILAT LOWER EXT VEINS
FINDINGS:
There is normal compressibility, flow, and augmentation of the
bilateral
common femoral, femoral, and popliteal veins. Normal color flow
and
compressibility are demonstrated in the posterior tibial vein.
The bilateral peroneal veins were not seen. Subcutaneous edema
was noted in the bilateral calf.
There is normal respiratory variation in the common femoral
veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
The bilateral peroneal veins were not seen. Otherwise, no
evidence of deep venous thrombosis elsewhere in the right or
left lower extremity veins.
Bilateral calf subcutaneous edema.
___ VENOUS DUP UPPER EXT BI
FINDINGS:
The right cephalic vein appears patent and measures 0.18 cm near
the shoulder, 0.13 cm in the upper arm, 0.14 cm in the mid upper
arm and 0.2 cm near the elbow. The right cephalic vein measures
0.45 cm in the upper forearm, 0.43 cm in the mid forearm and
0.35 cm near the wrist. There is a PICC line in the right
basilic vein which precludes evaluation.
The left cephalic vein is patent and measures 0.24 cm near the
shoulder, 0.22 cm in the mid upper arm, 0.33 cm in the distal
upper arm and 0.30 cm above the elbow. In the forearm, the left
cephalic vein measures 0.55 cm in the proximal forearm, 0.36 cm
in the mid forearm and 0.38 cm in the distal forearm. The
basilic vein is patent measuring 0.62 cm in the proximal upper
arm, 0.67 cm in the mid upper arm and 0.52 cm above the elbow.
IMPRESSION:
Patent veins in both upper extremities with measurements as
noted above.
MICRO
=====
___ 12:15 pm TISSUE Site: FOOT
BONE BIOPST, RIGHT LATERAL FOOT.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
BACTEROIDES FRAGILIS GROUP.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
Identification and susceptibility testing performed on
culture #
___ ___.
ANAEROBIC GRAM POSITIVE COCCUS(I).
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS. (formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH.
Identification and susceptibility testing performed on
culture #
___ ___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___ 12:00 pm TISSUE Site: FOOT #2 RIGHT LATERAL
FOOT.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Susceptibility testing performed on culture # ___
___.
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
CLINDAMYCIN MIC OF >= 1MCG/ML.
CEFTRIAXONE SUSCEPTIBILITY TESTING PERFORMED PER ___
___
(___) ON ___. CEFTRIAXONE test result performed
by Etest.
CEFTRIAXONE MIC OF 0.064 MCG/ML.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS ANGINOSUS (___)
GROUP
|
CEFTRIAXONE----------- S
CLINDAMYCIN----------- R
ERYTHROMYCIN---------- =>8 R
PENICILLIN G---------- 0.25 I
VANCOMYCIN------------ 0.5 S
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
Identification and susceptibility testing performed on
culture #
___-___ ___.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
___ 12:12 pm TISSUE Site: FOOT #3 RIGHT LATERAL
FOOT.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN
PAIRS.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
BETA STREPTOCOCCUS GROUP B. RARE GROWTH.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- 1 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Final ___:
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Final ___: NO FUNGUS ISOLATED.
Brief Hospital Course:
ADMISSION
=========
___ man with atrial flutter on apixaban, HFpEF, gout,
HTN, and DM2 with charcot foot, recent metatarsal fracture with
Lisfranc injury, who presented with R foot infection refractory
to cephalexin.
ACUTE ISSUES
============
#Diabetic foot skin and soft tissue infection
#Acute R cuboid bone osteomyelitis
#R Charcot arthropathy
Mr. ___ was admitted s/p a fall with comminuted fractures of
the ___ through ___ proximal metatarsal shaft, with gross
derangement of the Lisfranc articulation and downward rotation
of the respective cuneiforms; and, with a right mid-foot ulcer
that was refractory to cephalexin and office debridement. He was
started on empiric antibiotic coverage and taken to the OR on
___ by orthopedics for an evacuation of abscesses from dorsal
lateral right foot and excision down to inclusive of bone of the
necrotic foot, soft tissues and skin with a wound VAC placed.
His MRI was concerning for osteomyelitis w/ sinus tract
extending into the bone with underlying bone edema. Cultures
from the OR ___ grew MSSA, strep anginosis sensitive to
ceftriaxone, and Bacteroides. Strep anginosis oddly had
intermediate sensitivity to penicillin so sensitivities for
cefazolin were attempted but not standard so they were unable to
be obtained. We opted to obtain ceftriaxone sensitivities
instead; since this organism was sensitive to ceftriaxone we
decided that cefazolin would be sufficient to treat. He was
taken back to the OR on ___ by Plastic and Reconstructive
Surgery for an I&D of the right foot with excisional debridement
of skin and necrotic fat and placement of VAC dressing to right
foot. He was taken back to the OR on ___ for I&D of the right
foot wound, skin, subcutaneous tissue, fascia, muscle and bone;
and, excision of right fifth metatarsophalangeal joint. He was
taken back to the OR on ___ for application of Integra skin
substitute and negative pressure wound therapy. The plan will
likely be to return to the OR for further plastics intervention
in 4 weeks, coinciding with cessation of systemic antimicrobial
therapy. End date of antibiotics should be ___.
#Acute on Chronic Gout Flare
Mr. ___ had knee pain on admission and was given a loading
and maintenance dose of colchicine ___, which was
subsequently held in the setting of ___. He had a second gout
flare in the R knee and ankle that was treated with
intra-articular steroid injection ___, given colchicine loading
and 3-day maintenance dose but was held in setting of resolution
and concern for concurrent treatment with diltiazem. He had a
gout flare in the L wrist on ___ that was treated with
ibuprofen.
#Acute on Chronic Renal Failure
#Heart Failure w/ Preserved Ejection Fraction
#Lower Extremity Edema
Patient had an elevated Cr to 1.5 on arrival from a baseline
around 1.3. His ___ was initially suspected to be prerenal
azotemia, but did not resolve with fluids and urine lytes were
not consistent with this diagnosis. We suspect this is a mixed
picture ___ due to hypovolemia, septic ATN in the setting of a
diabetic foot infection and ATN due to cefazolin. His creatinine
responded to IV Lasix and he transitioned to his home dose of PO
Lasix.
#Microcytic Anemia
#Chronic Anemia
He was admitted with a hemoglobin of 11.1 which fell likely due
to repeated operations. His B12 and ferritin were within normal
limits, but the reticulocyte index of 0.6% indicated an
inadequate response to anemia, likely in the setting of chronic
disease.
#Malnutrition
He reported decreased appetite from his acute illness, with an
11.3% weight loss in 3 months. He was seen by nutrition, started
on a ___ Na/Heart Healthy diet after debridement; and
started on glucerna three times daily.
CHRONIC ISSUES:
===============
#AFlutter:
He remained in a sinus rhythm during this admission. He was
continued on a fractionated form of his home dilt SR 120mg PO
BID. His home apixiban 5mg daily was held for surgery, then
restarted.
#DM2
He was placed on his home glargine 80U qAM, humalog 20U with
each meal with an insulin sliding scale. His metformin was held
during his hospitalization.
#HTN:
We continued his home labetalol 200mg BID.
TRANSITIONAL ISSUES
===================
[ ] His STOP-Bang score is 7. He should have a sleep study as an
outpatient for evaluation for sleep apnea.
[ ] He will require a formal angiogram when his creatinine is
stable.
[ ] He should be started on allopurinol for gout prophylaxis as
an outpatient. Please check uric acid level after resolution of
current gout flare. He was also started on ibuprofen 800 TID
which should be discontinued after resolution of the current
gout flare.
[ ] He will need weekly labs per ID OPAT note: Weekly CBC with
differential, BUN, Cr and CRP while on antibiotics. End date for
antibiotics is ___.
[ ] Per Plastic Surgery, he will need hyperbaric oxygen at least
three times per week. His first visit is on ___ at 8:30 AM
at the ___ Wound Care and Hyperbaric Oxygen.
#CODE: Full
#CONTACT:
Name of health care proxy: ___
___: Sister
Cell phone: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 5 mg PO BID
2. Labetalol 200 mg PO BID
3. Levothyroxine Sodium 150 mcg PO DAILY
4. Bydureon (exenatide microspheres) 2 mg/0.65 mL subcutaneous
weekly
5. Furosemide 40 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
7. Glargine 80 Units Breakfast
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
8. Diltiazem 120 mg PO BID
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
2. Ibuprofen 800 mg PO Q8H Duration: 3 Days
3. MetroNIDAZOLE 500 mg PO Q8H
4. Multivitamins W/minerals Chewable 1 TAB PO DAILY
5. Glargine 80 Units Breakfast
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
6. Labetalol 400 mg PO BID
7. Apixaban 5 mg PO BID
8. Bydureon (exenatide microspheres) 2 mg/0.65 mL subcutaneous
weekly
9. Diltiazem 120 mg PO BID
10. Furosemide 40 mg PO DAILY
11. Levothyroxine Sodium 150 mcg PO DAILY
12. MetFORMIN XR (Glucophage XR) ___ mg PO DAILY
13.Outpatient Lab Work
ICD-9
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Cefazolin: WEEKLY: CBC with differential, BUN, Cr
OTHER MEDICATIONS: Flagyl
ADDITIONAL ORDERS:
*PLEASE OBTAIN WEEKLY CRP for patients with bone/joint
infections
and endocarditis or endovascular infections
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Severe right diabetic foot infection and osteomyelitis
SECONDARY DIAGNOSIS:
====================
Right knee gout flare
Right Charcot foot deformity
Acute on chronic renal failure
Chronic diastolic heart failure
Atrial flutter
Hypertension
Diabetes Mellitus type 2
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because your foot was
infected.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were started on antibiotics to treat the infection.
- You had multiple surgeries to remove infected tissue and bone.
- You were given medication to help you remove the extra fluid
in your legs.
- You were given medication to help control your gout flare.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Follow up with ___ Plastic and Reconstructive Surgery
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10113036-DS-12 | 10,113,036 | 21,746,949 | DS | 12 | 2111-06-27 00:00:00 | 2111-06-27 21:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
RLE pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old M w/ hx of type II DM, Charcot foot,
a flutter, and hx of complicated R foot abscess with
osteomyelitis s/p debridements/washouts as well as Integra
placement and hyperbaric oxygen treatments (___) presenting
with malaise for three days and RLE pain and redness for the
past
24 hours. He was recently discharged on ___ after being
treated for cellulitis with vanc/cefepime/flagyl --> Unasyn -->
Augmentin, which finished on ___.
He denies any trauma to the leg. He had two episodes of diarrhea
on ___, but these have since resolved. Of note, ___ contacted
Orthopedics at ___ to state concerns regarding non-compliance,
including not leaving his dressing in place, walking without a
walker, and not performing wound care. In addition, they felt he
was not managing his blood sugars well either. They have cut
down
their services from 3x/week to 1x/week because of this.
In the ED, he was afebrile with normal vital signs. Foot x-ray
looked relatively similar to before with no obvious
osteomyelitis. Given ___, he was given 1L NS. He was started on
cefepime for presumed cellulitis.
Upon arrival to the floor, the patient reports the above story.
His right calf is having a lot of pain right now. His ankle is
slightly swollen, but he states it varies a lot based on how
tightly he wraps it.
REVIEW OF SYSTEMS:
==================
A 10-point ROS was taken and is negative except otherwise stated
in the HPI.
Past Medical History:
- Atrial flutter
- HFpEF
- HTN
- Type 2 DM (c/b charcot neuropathy)
- Gout
Social History:
___
Family History:
Father with recent CABG. Otherwise no family history of early
CAD, arrhythmias, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VITALS: 98.2 135 / 63 100 18 95 Ra
GENERAL: Chronically ill obese male laying in bed in NAD
HEENT: PER. EOMI. MMM. L eye swollen with conjunctival
injection.
NECK: Unable to visualize JVP given habitus
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABD: Soft, non-tender, non-distended, bowel sounds present, no
organomegaly
EXT: RLE with 1+ pitting edema and tender erythema diffusely
throughout calf, borders outlined. R foot with dorsal ulcer that
is clean and without purulent drainage or bleeding. There is no
tracking from ulcer to calf redness. LLE with chronic venous
stasis changes. Unable to palpate DP pulses bilaterally but cap
refill ~2s. Charcot changes in feet bilaterally.
SKIN: Dry, scaly red rash on dorsum of hands (R>L). Lower
extremities as above.
NEURO: CNII-XII grossly intact, moves all four extremities.
Decreased sensation to LT in bilateral feet
Note contains an addendum. See bottom.
Note Date: ___ Time: ___
Note Type: Progress note
Note Title: Medicine Progress Note
Electronically signed by ___, MD on ___ at 1:35
pm Affiliation: ___
Electronically cosigned by ___, MD on ___ at
4:34 pm
============================================================
MEDICINE Progress Note
Date of admission: ___
===========================================================
PRIMARY CARE PHYSICIAN: ___)
CHIEF COMPLAINT: RLE pain
Time of Exam: 0730
INTERVAL EVENTS:
================
- Started on warm compresses yesterday for suspected area of
thrombophlebitis on medial upper leg
- Cellulitis continues to improve on IV cefazolin
- R knee seemed to be enlarging, c/ gout flare; reassuringly,
patient states pain has not been severe
- NAEO
SUBJECTIVE:
===========
Patient feeling well this morning, states that his leg seems to
be continuing to improve. Still has some moderate "discomfort"
at
the area of thrombophlebitis. Pain in lower leg has resolved,
and
he agrees that redness is improving. No other complaints -
denies
abdominal pain, N/V. Questions how often he should be getting
warm compresses for his leg, and states that he only received 1
total yesterday.
DISCHARGE PHYSICAL EXAM:
======================
VITALS: 24 HR Data (last updated ___ @ 818)
Temp: 97.7 (Tm 98.5), BP: 146/89 (145-171/88-94), HR: 77
(77-102), RR: 18 (___), O2 sat: 96% (94-98), O2 delivery: RA
GENERAL: Obese male sitting in bed in NAD, pleasant and alert
HEENT: PERRL. EOMI. MMM.
NECK: Unable to visualize JVP given habitus
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
LUNGS: CTAB, no wheezes, rales, rhonchi
ABD: Soft, non-tender, non-distended, bowel sounds present,
organomegaly not assessed due to body habitus
EXT:
- RLE: erythema and induration of anterior and lateral lower
leg,
improved from yesterday. 5-6cm area of resolving erythema of
medial upper calf, with palpable cord. TTP. Distinctly separate
from the resolving area of cellulitis in the lower leg. No
fluctuance, induration, or breakage of skin.
- Right knee: R>L knee swelling, with palpable effusion of the
right knee. Pain elicited with flexion and extension of the
right
knee, but ROM intact. No erythema of the knee.
- Right foot: Dorsal ulcer covered with clean dressing.
- LLE: chronic venous stasis changes stable since yesterday.
- B/l feet warm and well-perfused, with Charcot foot changes.
SKIN: Dry, scaly red rash on dorsum of hands (R>L), less red
than
yesterday. Lower extremities as above.
NEURO: Grossly intact, moves all extremities with purpose
Pertinent Results:
Admission Labs:
___ 01:35AM BLOOD WBC-9.6 RBC-3.62* Hgb-10.0* Hct-31.9*
MCV-88 MCH-27.6 MCHC-31.3* RDW-14.8 RDWSD-47.7* Plt ___
___ 01:35AM BLOOD Neuts-71.5* Lymphs-16.6* Monos-9.6
Eos-1.5 Baso-0.4 Im ___ AbsNeut-6.89* AbsLymp-1.60
AbsMono-0.93* AbsEos-0.14 AbsBaso-0.04
___ 02:46AM BLOOD Glucose-138* UreaN-58* Creat-2.9* Na-136
K-5.0 Cl-104 HCO3-18* AnGap-14
___ 07:40AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.2
___ 02:46AM BLOOD CRP-186.6*
___ 07:40AM BLOOD CRP-97.6*
___ 01:39AM BLOOD Lactate-1.4
Discharge Labs:
___ 07:25AM BLOOD WBC-6.4 RBC-3.65* Hgb-9.9* Hct-31.8*
MCV-87 MCH-27.1 MCHC-31.1* RDW-14.2 RDWSD-45.7 Plt ___
___ 07:25AM BLOOD Glucose-186* UreaN-33* Creat-1.7* Na-138
K-5.2 Cl-105 HCO3-21* AnGap-12
___ 07:25AM BLOOD Calcium-9.0 Phos-4.4 Mg-2.0
Microbiology:
___ BLOOD CULTURES
Blood Cultures, Routine (Pending): No growth to date.
Urine Studies:
___ 04:40PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 04:40PM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:40PM URINE RBC-92* WBC-5 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 04:40PM URINE CastHy-4*
Imaging:
___ AP,LAT & OBL RIGHT
IMPRESSION:
1. No definite evidence of new erosions to suggest
osteomyelitis.
2. Overall similar radiographic appearance of the right foot,
including severe
neuropathic changes of the midfoot and postsurgical changes
related to prior
excision of the right fifth MTP joint and multiple debridements
of the right
foot.
Brief Hospital Course:
Mr. ___ is a ___ year old M w/ hx of type II DM, Charcot foot,
a flutter, and hx of complicated R foot abscess with
osteomyelitis s/p debridements/washouts as well as Integra
placement and hyperbaric oxygen treatments (___) presenting
with malaise for three days and RLE pain and redness for 24
hours, with exam concerning for acute cellulitis.
ACUTE/ACTIVE PROBLEMS:
======================
# RLE cellulitis
# Thrombophlebitis
Patient recently completed a course of Augmentin on ___ for a
similar cellulitis. On admission, appeared to be a simple
cellulitis of right calf. Little suspicion for MRSA, as n
purulent discharge. Greatest suspicion was for Strep, given
recurrent cellulitis and decreased coverage of strep with his
recent regimen of augmentin. Cellulitis rapidly improved with
IV Vanc/Cefepime, narrowed to IV cefazolin on ___ he was
transitioned to PO Keflex on discharge. He was noted to have new
right medial calf redness with palpable cord on ___, suspicious
for thrombophlebitis; this resolved with hot compresses.
# Gout
Patient has history of gout, and required prednisone taper after
his last admission in ___. He developed worsening
right knee pain and swelling on ___, concerning for evolving
gout flare. He was treated with colchicine at a reduced dose on
___ (given that he is also on diltiazem, which interacts with
this medication). Pain in right knee improved afterward. On
advice of rheumatology, he was started on a prednisone taper on
___, to last 1 week. He will follow-up with rheum as an
outpatient, given his frequency of gout flares.
# Diabetic foot ulcer
Per his ___, he has had some difficulties caring for this at
home by himself. Wound appeared stable throughout admission, no
signs of purulence/infection. In discussion with patient's
orthopedist, he has had difficulty complying with wearing his
orthotic boot. He has follow-up with orthopedics, and a
prescription for a new orthotic boot.
# ___
Cr was 2.9 on admission, down-trended to 1.7 by the time of
discharge. Likely pre-renal in the setting of infection, or less
likely from valacyclovir treatment. Cr improved with some IV
fluids and good PO intake. He was continued on the valacyclovir
since he had only one more day to complete his course by the
time of discharge.
# Herpes keratitis
Diagnosed prior to admission, with c/o blurry vision that
improved throughout his hospitalization. Was maintained on
valacyclovir 1000mg BID, last dose will be ___ in the evening.
Was also continued on bacitracin ointment qhs and trifluridine
1% Ophthalmic Solution.
#Hyperkalemia
Patient's potassium was borderline high throughout admission,
ranging from 4.9-5.5. In review of records, appears that he has
run high in the past as well, ranging 4.6-5.4. EKG obtained on
___ did not show any T waves.
CHRONIC/STABLE PROBLEMS:
========================
# A flutter/a fib
- Continued on home apixaban for anticoagulation, and on home
labetalol and diltiazem for rate control.
# T2DM
- Continued home glargine 40 units qhs with 20 units Humalog qac
- Held home metformin, exenatide while admitted
- Losartan being held as outpatient
#HFpEF
- Initially held home lasix 40mg QD in setting of ___ should be
resumed ___, after he finishes valacyclovir treatment.
# HTN
- Continued home labetalol and diltiazem
- Resumed home hydralazine PRN on discharge
# Hypothyroidism
- Continued home levothyroxine
TRANSITIONAL ISSUES:
=====================
[ ] Patient discharged on Keflex, to complete a 14-day course of
antibiotics; last day is ___.
[ ] Lasix held on discharge given his ___ resume on ___,
___ (after he completes his course on ___.
[ ] Last dose of valacyclovir will be ___.
[ ] Should have ___ checked on ___ to confirm resolution of
___ and hyperkalemia.
[ ] Consider changing anti-hypertensive region; patient should
be on colchicine every other day for his gout, but this dose is
too high while he is also on diltiazem. In addition, his PRN
hydralazine may not be a practical home medication; this was
discontinued this admission, and his labetalol was increased to
600mg BID.
[ ] Patient discharged on prednisone taper for gout flare;
should take 10mg on ___, and 5mg daily from ___.
[ ] Patient will need continued follow-up with orthopedics for
maintenance of his diabetic ulcer; in particular, he will need
orthotic boot (has prescription already), and will need
continued education/reinforcement with regard to wearing this
boot.
[ ] Patient will need rheumatology follow-up given his recurrent
gout flares.
#CODE: Full, confirmed
#CONTACT:
Name of health care proxy: ___
___: Sister
Phone number: ___
Greater than 30 minutes was spent in care coordination
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO BID
2. Apixaban 5 mg PO BID
3. Labetalol 400 mg PO BID
4. Levothyroxine Sodium 175 mcg PO DAILY
5. Diltiazem Extended-Release 120 mg PO BID
6. Furosemide 40 mg PO DAILY
7. HydrALAZINE 10 mg PO DAILY:PRN SBP >160
8. MetFORMIN (Glucophage) 1000 mg PO BID
9. exenatide microspheres 2 mg/0.85 mL subcutaneous 1X/WEEK
10. Atorvastatin 40 mg PO QPM
11. ValACYclovir 1000 mg PO Q12H
12. Trifluridine 1% Ophth Soln. 1 DROP LEFT EYE QID
13. Bacitracin Ophthalmic Oint 1 Appl LEFT EYE QHS
14. Glargine 40 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
15. Ferrous Sulfate 325 mg PO BID
16. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
17. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 11 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth 4 times daily Disp
#*42 Capsule Refills:*0
2. Colchicine 1.2 mg PO ONCE Duration: 1 Dose
RX *colchicine 0.6 mg 2 capsule(s) by mouth once for gout flare
Disp #*30 Capsule Refills:*0
3. PredniSONE 10 mg PO DAILY Duration: 1 Day
Take on ___
RX *prednisone 10 mg 1 tablet(s) by mouth once Disp #*1 Tablet
Refills:*0
4. PredniSONE 5 mg PO DAILY Duration: 7 Days
Take ___
RX *prednisone 5 mg 1 tablet(s) by mouth once daily Disp #*7
Tablet Refills:*0
5. Labetalol 600 mg PO BID
RX *labetalol 300 mg 2 tablet(s) by mouth twice daily Disp #*120
Tablet Refills:*0
6. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
7. Allopurinol ___ mg PO BID
8. Apixaban 5 mg PO BID
9. Atorvastatin 40 mg PO QPM
10. Bacitracin Ophthalmic Oint 1 Appl LEFT EYE QHS
11. Diltiazem Extended-Release 120 mg PO BID
12. exenatide microspheres 2 mg/0.85 mL subcutaneous 1X/WEEK
13. Ferrous Sulfate 325 mg PO BID
14. Glargine 40 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
15. Levothyroxine Sodium 175 mcg PO DAILY
16. MetFORMIN (Glucophage) 1000 mg PO BID
17. TraMADol 50 mg PO DAILY:PRN Pain - Moderate
18. Trifluridine 1% Ophth Soln. 1 DROP LEFT EYE QID
19. ValACYclovir 1000 mg PO Q12H Duration: 1 Day
RX *valacyclovir [Valtrex] 1,000 mg 1 tablet(s) by mouth every
12 hours Disp #*3 Tablet Refills:*0
20. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until ___
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
=================
Cellulitis
Thrombophlebitis
Acute Gout Flare
Acute kidney injury
SECONDARY DIAGNOSIS
===================
HTN
Atrial fibrillation
Chronic diabetic foot ulcer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You had malaise, as well as redness of swelling of your right
leg, and were diagnosed with another bout of cellulitis.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your cellulitis was treated with IV antibiotics.
- You had another gout flare, and this was treated with
colchicine and a prednisone.
- Your blood pressure medications were changed; the dose of your
labetalol was increased, and your hydralazine was stopped.
- You were continued on valacyclovir for the herpes infection in
your eye.
- Your kidney function was worse than usual when you admitted,
so your Lasix was held. Your kidney function improved by time of
discharge.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Weigh yourself every morning, call MD if weight goes up or
down more than 3 lbs.
- Continue taking your valacyclovir through ___
- Continue taking the cephalexin (antibiotic for your
cellulitius) through ___
- You should continue taking prednisone for your gout flare;
take 10mg on ___, and 5mg daily from ___.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10113036-DS-13 | 10,113,036 | 24,053,360 | DS | 13 | 2111-07-24 00:00:00 | 2111-07-26 23:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R Foot Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old M w/ hx of type II DM, Charcot foot, a.
flutter, and hx of complicated R foot abscess with osteomyelitis
s/p debridements/washouts as well as Integra placement and
hyperbaric oxygen treatments (___) presenting with malaise
for
two days, subjective fevers and chills, and RLE pain and redness
for the past 24 hours. Also reports diarrhea since last night.
He
completed a course of amoxicillin 2 days ago. Seen in ___
clinic 2 days ago also with no complaints at the time and plan
for outpatient wound VAC.
Recently admitted on ___ with malaise for three days and RLE
pain and redness for 24 hours, with exam concerning for acute
cellulitis, of right calf. Cellulitis rapidly improved with IV
Vanc/Cefepime, narrowed to IV cefazolin on ___ he was
transitioned to PO Keflex on discharge. Of note, he had new
right medial calf redness with palpable cord on ___, suspicious
for thrombophlebitis; this resolved with hot compresses.
In the ED:
- Initial vitals:
T 98.7 HR 93 BP 98/64 RR 18 SPO2 98% RA
- Exam notable for:
General- NAD
HEENT- PERRL, EOMI, normal oropharynx
Lungs- Non-labored breathing, CTAB
CV- RRR, no murmurs, normal S1, S2, no S3/S4
Abd- Soft, nontender, nondistended, no guarding, rebound or
masses
Msk- No spine tenderness, moving all 4 extremities, mild
erythema
and swelling of the right distal calf, 3 cm by 4 similar ulcer
on
the lateral plantar aspect of his right foot, no purulence noted
Neuro-A&O x3, CN ___ intact, normal strength and sensation in
all extremities, normal speech
Ext- No edema, cyanosis, or clubbing
- Labs notable for:
CBC: WBC 15.9 Hb 9.6
CRP: 217.8
BMP: Na 130 BUN/Cr 46/2.6
Lactate: 1.1
- Imaging notable for:
+ R Foot AP, Lat :
1. Overall unchanged radiographic appearance of the right foot
including severe neuropathic changes of the midfoot and
postsurgical changes of the fifth metatarsophalangeal joint.
2. No evidence of osseous erosions to suggest osteomyelitis.
Soft tissue structures are unremarkable aside from a multiple
vascular calcifications.
- Pt given:
PO/NG Diltiazem 120 mg
SC Insulin 2 Units
PO/NG Labetalol 400 mg
PO/NG MetFORMIN (Glucophage) 1000 mg
IVF LR ( 1000 mL ordered)
IV Vancomycin (1000 mg ordered)
- Vitals prior to transfer:
T 98.3 HR 88 BP 108/68 RR 16 SPO2 97% RA
Upon arrival to the floor, the patient reports that he is
feeling
well and has no specific complaints at this time. He states that
he has had this done multiple times before and does not have
questions at this time. He denies pain, fever, chills, shortness
of breath, or chest pain. He endorses the above history.
Past Medical History:
- Atrial flutter
- HFpEF
- HTN
- Type 2 DM (c/b charcot neuropathy)
- Gout
Social History:
___
Family History:
Father with recent CABG. Otherwise no family history of early
CAD, arrhythmias, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: Reviewed in POE
GEN: Alert, oriented, resting comfortably no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL
NECK: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs,
rubs, gallops
PULM: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
ABD: 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. Mild erythema and swelling of the right distal
calf, 3 cm by 4 similar ulcer on the lateral plantar
aspect of his right foot, no purulence noted
SKIN: Warm, dry, no rashes or notable lesions other than noted
above
NEURO: A&O x3
DISCHARGE PHYSICAL EXAM
VITALS: 24 HR Data (last updated ___ @ 749)
Temp: 98.2 (Tm 98.3), BP: 166/97 (125-166/82-106), HR: 96
(69-96), RR: 18 (___), O2 sat: 98% (97-99), O2 delivery: RA
GEN: Alert, oriented, resting comfortably no acute distress
HEENT: Sclerae anicteric, MMM
NECK: Supple
CV: RRR, normal S1/S2, no m/r/g
PULM: CTAB, no r/r/w
ABD: Soft, NTND, BS+, no organomegaly, rebound or guarding
EXT: WWP, 2+ pulses, no clubbing, cyanosis. RLE receding area
of erythema, improved swelling, non-tender to palpation, dark
red
graft on R lateral foot with defect on lateral foot, ulcer on
the
lateral plantar aspect of R foot with minimal bleeding, no
purulence
SKIN: Warm, dry, no rashes or notable lesions other than noted
above
NEURO: Alert, oriented, answering questions appropriately,
moves
all extremities
Pertinent Results:
___ 03:30PM BLOOD WBC-15.9* RBC-3.59* Hgb-9.6* Hct-31.4*
MCV-88 MCH-26.7 MCHC-30.6* RDW-15.0 RDWSD-47.8* Plt ___
___ 05:37AM BLOOD WBC-9.7 RBC-3.47* Hgb-9.2* Hct-30.6*
MCV-88 MCH-26.5 MCHC-30.1* RDW-15.2 RDWSD-48.9* Plt ___
___ 06:12AM BLOOD WBC-10.0 RBC-3.82* Hgb-10.2* Hct-33.3*
MCV-87 MCH-26.7 MCHC-30.6* RDW-15.2 RDWSD-48.0* Plt ___
___ 06:19AM BLOOD WBC-8.7 RBC-3.57* Hgb-9.6* Hct-31.7*
MCV-89 MCH-26.9 MCHC-30.3* RDW-15.4 RDWSD-49.6* Plt ___
___ 05:37AM BLOOD WBC-10.8* RBC-3.89* Hgb-10.3* Hct-34.2*
MCV-88 MCH-26.5 MCHC-30.1* RDW-15.3 RDWSD-48.8* Plt ___
___ 03:30PM BLOOD Neuts-91.2* Lymphs-3.9* Monos-3.8*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-14.48* AbsLymp-0.62*
AbsMono-0.61 AbsEos-0.00* AbsBaso-0.05
___ 05:37AM BLOOD ___ PTT-28.1 ___
___ 03:30PM BLOOD Glucose-207* UreaN-46* Creat-2.6* Na-130*
K-5.3 Cl-97 HCO3-19* AnGap-14
___ 05:37AM BLOOD Glucose-226* UreaN-56* Creat-2.9* Na-133*
K-5.2 Cl-98 HCO3-18* AnGap-17
___ 06:12AM BLOOD Glucose-193* UreaN-57* Creat-2.4* Na-141
K-4.7 Cl-103 HCO3-20* AnGap-18
___ 06:19AM BLOOD Glucose-127* UreaN-53* Creat-2.0* Na-139
K-4.9 Cl-107 HCO3-18* AnGap-14
___ 05:37AM BLOOD Glucose-132* UreaN-40* Creat-1.7* Na-140
K-5.1 Cl-105 HCO3-21* AnGap-14
___ 05:37AM BLOOD ALT-11 AST-13 LD(LDH)-157 AlkPhos-211*
TotBili-0.3
___ 05:37AM BLOOD Albumin-3.1* Calcium-9.2 Phos-5.9* Mg-2.0
___ 06:12AM BLOOD Calcium-9.7 Phos-4.2 Mg-2.2
___ 06:19AM BLOOD Calcium-9.4 Phos-4.7* Mg-2.1
___ 05:37AM BLOOD Calcium-9.5 Phos-4.2 Mg-1.9
___ 03:30PM BLOOD CRP-217.8*
___ 05:37AM BLOOD Vanco-12.9
___ 03:42PM BLOOD Lactate-1.1
IMAGING:
========
Foot XR
1. Overall unchanged radiographic appearance of the right foot
including
severe neuropathic changes of the midfoot and postsurgical
changes of the
fifth metatarsophalangeal joint.
2. No evidence of osseous erosions to suggest osteomyelitis.
Soft tissue
structures are unremarkable aside from a multiple vascular
calcifications.
___ MR
1. Imaging findings are most compatible with neuropathic joint
rather than
osteomyelitis. Bone marrow signal appears similar to slightly
improved
compared to ___ with persistent increased STIR signal
hyperintensity
within the proximal shaft of the fifth metatarsal.
2. Postsurgical changes related to a fifth MTP joint excision
without evidence
of a focal fluid collection or ulceration.
3. Induration of the soft tissues of the lateral and plantar
aspect of the
foot appears similar to slightly improved compared to most
recent prior exam.
Brief Hospital Course:
___ gentleman with type II DM, Charcot foot, Aflutter,
complicated R foot abscess with osteo s/p debridements/washouts
+ Integra placement and hyperbaric oxygen treatments (___)
presenting with sepsis secondary to RLE cellulitis and
non-healing R plantar ulcer for ___ months.
ACUTE/ACTIVE PROBLEMS:
======================
Sepsis ___ RLE cellulitis and R plantar ulcer: Had previous
wound care by orthopedics/plastics and is now p/w several days
of RLE erythema and swelling in the setting of a non-healing
wound x ___ months, as well as subjective fevers/chills. Pt was
tachycardic with WBC of 15.9 and ___ on arrival. There was no
evidence of abscess, purulence, or drainable collection at the
site of the chronic R plantar ulcer. No e/o osteo on radiograph
or MRI foot. Suspec that recurrent cellulitis seeded from
plantar wound. Prior wound cx growing low levels anaerobic GPCs
+ Bacteroides. Initially on broad spectrum abx
Vanc/cefepime/flagyl narrowed to CTX/flagyl. BCx from ___
growing gram positive rods corynebacterium, most likely skin
contaminant. All subsequent BCx NGTD. Soft tissue infection
improved significantly over course of hospitalization and pt
switched to Augmentin on discharge. Pt was seen by plastic
surgery and has close follow up as they are considering a wound
closure given poor healing with frequent RLE cellulitis.
# ___: Concerning for acute renal failure, most likely pre-renal
etiology from acute infection, diarrhea reportedly prior to
admission, and brief hypotension to SBP ___ upon arrival to the
medicine floor on ___. Baseline Cr 1.7-2.2, presenting w/Cr of
2.6-->2.9. Improved after IV fluids back to baseline creatinine.
Elevated phosphorus improved with sevelamer. Also received
sodium bicarbonate for low bicarb which resolved as renal
function returned to baseline. Held home Lasix during
admission, will need to discuss with PCP at follow up whether to
resume.
#Gout: has had recurrent gout flares and was on a prednisone
taper (on day 3 of pred 20 daily) for a flare in R knee that
started a few days prior to presentation. Continued home
allopurinol and discontinued prednisone taper on admission but
given worsening R knee pain, pt received prednisone 40mg x 1 on
day of discharge with improved symptoms.
CHRONIC/STABLE PROBLEMS:
========================
# A flutter/a fib: Continued home apixaban, fractioned home
diltiazem, initially held home Labetalol for brief hypotension
on ___ but resumed on ___.
# T2DM: Continue home glargine 40 units QHS with 20 units
Humalog QAC and added humalog sliding scale. Resumed home
metformin and exenatide at discharge.
# HFpEF: patient has hx of HFpEF. Last echo was TEE in ___. Currently appears euvolemic and well compensated w/out
evidence of exacerbation at this time. Held home Lasix 40mg QD
in the setting of ___. Pt will discuss with PCP at follow up
next week with ___ to discuss restarting lasix.
# HTN: Initially held home labetalol given hypotension on
arrival to floor, resumed on ___ given HDS. Continued home
diltiazem in fractionated doses as above
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES:
====================
[ ] Patient discharged on Augmentin to complete 10 day total
course of antibiotics, last day ___.
[ ] Patient with non-healing right foot ulcer for ___ months,
has undergone many courses of antibiotics (most recently
amoxicillin prior to admission). Cellulitis this admission
likely seeded from open wound. At risk for continued skin and
soft tissue infections pending closure of the wound.
[ ] Patient's prednisone taper, for which he was prescribed
secondary to a gout flare, was discontinued on admission.
Patient received 2 doses of prednisone 40mg this admission.
Unable to receive NSAIDs or colchicine secondary to renal
dysfunction. ___ benefit from a prednisone taper once
antibiotics are completed and infection is cleared.
[ ] Lasix 40mg daily held during admission and on discharge
given ___. Patient euvolemic. Please check BMP, including Cr, K
at follow-up appointment and discuss whether to re-start.
[ ] Patient received Sodium Bicarbonate supplementation during
admission, may benefit from additional supplementation after
discharge. Would check BMP, including Cr, K at follow-up PCP
___
#CODE: Full, confirmed
#HCP: ___ (Sister) ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 40 mg PO DAILY
2. MetFORMIN (Glucophage) 1000 mg PO DAILY
3. exenatide microspheres 2 mg/0.85 mL subcutaneous 1X/WEEK
4. Trifluridine 1% Ophth Soln. 1 DROP LEFT EYE QID
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Labetalol 400 mg PO BID
7. Ferrous Sulfate 325 mg PO BID
8. Allopurinol ___ mg PO DAILY
9. Apixaban 5 mg PO BID
10. Atorvastatin 40 mg PO QPM
11. Bacitracin Ophthalmic Oint 1 Appl LEFT EYE QHS
12. Diltiazem Extended-Release 120 mg PO BID
13. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
14. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
15. Glargine 40 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every 12 hours Disp #*13 Tablet Refills:*0
2. Glargine 40 Units Bedtime
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Allopurinol ___ mg PO DAILY
5. Apixaban 5 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. Bacitracin Ophthalmic Oint 1 Appl LEFT EYE QHS
8. Diltiazem Extended-Release 120 mg PO BID
9. exenatide microspheres 2 mg/0.85 mL subcutaneous 1X/WEEK
10. Ferrous Sulfate 325 mg PO BID
11. Labetalol 400 mg PO BID
12. Levothyroxine Sodium 175 mcg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO DAILY
14. Trifluridine 1% Ophth Soln. 1 DROP LEFT EYE QID
15. HELD- Furosemide 40 mg PO DAILY This medication was held.
Do not restart Furosemide until you discuss with your doctor
16. HELD- PredniSONE 20 mg PO DAILY Duration: 1 Day
Tapered dose - DOWN This medication was held. Do not restart
PredniSONE until you discuss with your doctor
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
cellulitis
non-healing foot ulcer
SECONDARY DIAGNOSIS:
====================
Acute kidney injury
Gout
Atrial flutter/atrial fibrillation
Type 2 Diabetes Mellitus
Heart failure with preserved ejection fraction
Hypertension
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you at the ___
___.
Why did you come to the hospital?
- You had pain in your right foot, swelling and redness in your
right lower leg. You likely had a soft tissue infection.
What did you receive in the hospital?
- You received IV antibiotics to treat your infection.
- X-rays and MRI of the foot did not show any infection of the
bone.
- Your symptoms improved and you were ready to leave the
hospital.
What should you do once you leave the hospital?
- Please continue taking your medications as prescribed.
- Please continue taking Augmentin as prescribed until last day
___.
- Please attend any outpatient appointments you have upcoming
(see below).
- Please do not take Lasix/furosemide until you discuss with
your doctor.
- Weigh yourself every morning, call MD if weight goes up more
than 3 lbs in 1 day or 5 lbs in 1 week.
We wish you the best!
Your ___ Care Team
Followup Instructions:
___
|
10113036-DS-15 | 10,113,036 | 20,558,872 | DS | 15 | 2111-09-16 00:00:00 | 2111-09-16 12:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cellulitis of right leg
Major Surgical or Invasive Procedure:
Sharp debridement of R plantar wound at bedside
History of Present Illness:
Mr. ___ is a ___ year old male with a history of T2DM (A1c
7.5), stage 3 CKD (baseline Cr 1.8), charcot foot, aflutter on
Eliguis, and nonhealing right foot wound despite multiple
interventions by plastic surgery with course complicated by
history of osteomyelitis and recurrent cellulitis presenting
with fever and leg pain with redness and swelling.
Mr. ___ reports having multiple episodes of acute on chronic
cellulitis requiring IV antibiotics and overnight stays in the
emergency room. Yesterday, he noted worsening erythema and a
sensation of burning in his right lower extremity which prompted
him to go the the ED along with malaise and feeling hot and
cold. Most recently, he was diagnosed in the ED with superficial
cellulitis on ___ and treated with IV Unasyn and vancomycin
before being discharged on augmentin. An x-ray at this time was
negative for osteomyelitis.
The patient was discharged from the hospital yesterday. He was
admitted (___) on vascular surgery where he had RLE
angiogram in preparation for an upcoming free flap with plastics
on ___. Two days ago (___) Mr. ___ was taken to the
OR for angiogram and evaluation and possible intervention on his
RLE. He was found to have adequate arterial inflow to the foot
and pedal arch for healing. He saw his orthopedic surgery post
discharge yesterday and his leg looked good. When he went home
he felt warm, malaise, chills along with tingling in his leg.
This was reminiscent of previous cellulitis and thus he
presented to the ED.
Past Medical History:
- Type 2 DM
- CKD (baseline Cr 1.8)
- bilateral Charcot foot
- R plantar wound, s/p split-thickness skin graft
- Atrial flutter
- HFpEF
- HTN
- Gout
- Hypothyroidism
- Obesity
Social History:
___
Family History:
Father with CAD (not at a young age).
Physical Exam:
DISCHARGE PHYSICAL EXAM
VITALS: afebrile
CONSTITUTIONAL: obese man in NAD
EYE: sclerae anicteric, EOMI
ENT: audition grossly intact, MMM, OP clear
LYMPHATIC: No LAD
CARDIAC: RRR, no M/R/G, JVP not elevated, no edema
PULM: normal effort of breathing, LCAB
GI: soft, NT, ND, NABS
GU: no CVA tenderness, suprapubic region soft and nontender
MSK: no visible joint effusions or acute deformities.
NEURO: AAOx3. No facial droop, moving all extremities.
PSYCH: Full range of affect
SKIN: His bright erythema of the R calf/shin/dorsal and medial
foot has entirely resolved. Mild brawny discoloration. R plantar
surface with brown eschar. Open wound on plantar aspect of foot,
which appears clean and not infected.
Pertinent Results:
ADMISSION LABS
WBC 16.5 (85% neuts) Hgb 9.6 Hct 31.8 Plt 350
Creat 2.0 BUN 36 Ns 133 K 5.4 (whole blood) Cl 99 HCO3 20 AnGap
14
Ca 8.9 Phos 3.5 Mg 1.7, Lactate 1.7
Urine- moderate blood, 100 protein, negative nitrite and leuks
DISCHARGE LABS
___ 06:31AM BLOOD WBC-7.1 RBC-3.28* Hgb-8.5* Hct-28.1*
MCV-86 MCH-25.9* MCHC-30.2* RDW-17.2* RDWSD-54.6* Plt ___
___ 06:31AM BLOOD Glucose-266* UreaN-27* Creat-2.1* Na-140
K-4.5 Cl-103 HCO3-24 AnGap-13
BLOOD CULTURES
No growth three days
URINE CULTURE (unclear why sent)
ESBL Klebsiella bacteruria
Brief Hospital Course:
___ a-flutter (on Eliquis), HFpEF, HTN, DM2 (c/b CKD III,
neuropathy w/ R Charcot foot), R foot abscess (s/p operative
debridement, split-thickness skin graft; now w/ chronic
non-healing R plantar wound), admitted w/ recurrent RLE
cellulitis.
#RLE Cellulitis:
Patient initially had a superficial spreading bright-red
erythema around his calf, shin, and dorsomedial foot. The
plantar wound itself did not appear purulent, and as the
erythema receded with treatment, the affected area was clearly
not contiguous with the wound (although it was still the likely
site of entry). Based on this clinical appearance (and him
having no history of MRSA), he was de-escalated from vanc/Zosyn
to just Ancef 2g TID. Over four total days of antibiotics, the
erythema resolved, leaving only venous stasis changes. He is
discharged on Keflex, which he will take for four more days.
#NON-HEALING R PLANTAR WOUND
This did not appear clinically infected, although it is the
likely entry site for the causative pathogen of his cellulitis.
Recent angiogram showed good blood flow to the foot. Plan is for
upcoming free tissue transfer with plastics. He is on the OR
schedule for ___. Until then, he will continue
wound-care with a non-adherent betadine-soaked dressing and
compressive ACE wrap.
#HTN:
-Continue home labetalol
-Continue home diltiazem in fractionated doses
#Atrial Flutter:
- Continue home Eliquis
#Chronic diastolic HF
Currently euvolemic. JVP is low, but no exam findings to suggest
hypovolemia either.
-Continue home lasix 40 mg daily
#Diabetes: A1c 7.5
- Continued home glargine/meal time Humalog and SSI
- continue metformin; note that his renal function is BORDERLINE
for this med and it may soon need to be stopped.
#Hypothyroidism:
-Continued home levothyroxine
#Gout
-Continued home allopurinol
#ASYMPTOMATIC BACTERURIA
UA showed few bacteria and no pyuria. Urine culture was sent in
the ED, although he has no lower tract symptoms; this grew a
very nasty ESBL Klebsiella, sensitive only to amikacin. If he
ever does develop a UTI, note that he would need empiric
amikacin.
#MICROSCOPIC HEMATURIA
This non-smoking patient under ___ is probably at low enough risk
for bladder cancer that cystoscopy would not be needed, unless
the finding is persistent. No mass on ___ renal US.
***TRANSITIONAL ISSUES***
BP was slightly high (systolic intermittently around 160). If
this persists at clinic follow up, would increase
antihypertensives.
Note that his renal function is BORDERLINE for metformin and
this med may soon need to be stopped.
Repeat UA to make sure microscopic hematuria is not persistent.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Allopurinol ___ mg PO DAILY
3. Atorvastatin 40 mg PO QPM
4. Furosemide 40 mg PO DAILY
5. Labetalol 400 mg PO BID
6. Levothyroxine Sodium 175 mcg PO DAILY
7. Apixaban 5 mg PO BID
8. Diltiazem Extended-Release 120 mg PO BID
9. Ferrous Sulfate 325 mg PO DAILY
10. MetFORMIN (Glucophage) 1000 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Glargine 40 Units Breakfast
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 4 Days
Does not have to be EXACTLY every 6 hours. Suggest taking it
breakfast/lunch/dinner/bedtime
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*16 Capsule Refills:*0
2. Glargine 40 Units Breakfast
Humalog 20 Units Breakfast
Humalog 20 Units Lunch
Humalog 20 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Allopurinol ___ mg PO DAILY
5. Apixaban 5 mg PO BID
6. Atorvastatin 40 mg PO QPM
7. Diltiazem Extended-Release 120 mg PO BID
8. Ferrous Sulfate 325 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. Labetalol 400 mg PO BID
11. Levothyroxine Sodium 175 mcg PO DAILY
12. MetFORMIN (Glucophage) 1000 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
Greater than 30 minutes was spent discharging this medically
complex patient.
Discharge Disposition:
Home
Discharge Diagnosis:
Cellulitis
Charcot foot
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Please take KEFLEX (cephalexin) to continue treatment of your
cellulitis. Please take this right up until you return for your
procedure in four days time. Otherwise your meds are the same as
prior to admission.
On the morning of your surgery (___), make the following
changes to your meds:
- HOLD metformin
- HOLD furosemide (Lasix)
- HOLD apixaban (Eliquis)
- decrease your long-acting insulin dose by 25%
(If plastic surgery give you recommendations on what to do with
your meds, that supersedes my recommendations as above.)
For wound care, soak a non-adherent dressing in Betadine
(iodine-based antiseptic), cover with gauze, and wrap in an ACE
wrap. Do this daily (or more frequently as needed if the
dressing gets soaked or dirty).
Use your crutches and try not to bear weight on the foot. If you
do need to take a couple steps, try to walk on the heel or toe,
rather than step flat.
Followup Instructions:
___
|
10113224-DS-9 | 10,113,224 | 29,363,512 | DS | 9 | 2135-10-14 00:00:00 | 2135-10-15 07:18:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
latex
Attending: ___.
Chief Complaint:
Hand abscess
Cellulitis
Major Surgical or Invasive Procedure:
I&D ARM LEFT HAND AND FOREAR; fasciotomy left forearm; CTS
release; ulnar tunnel release; wide debridement of necrotic soft
tissue; application of VAC drainage system
History of Present Illness:
___ year old female w/PMH of IV drug abuse, depression, PTSD
presenting as transfer from ___ for concern for hand
abscess/cellulitis. Per patient, her symptoms were noted one
week
ago with what she assumed to be a mosquito bite after playing
softball. She was given Keflex/Bactrim at ___
on
___ and presented to ___ on ___ and was given
IV Vancomycin and the dose was not completed due to patient
having to leave for childcare issues. The blister on finger
spread to her palm and swelling ___ forearm. She represented to
___ on ___ and was transferred to ___ for
evaluation from hand surgery.
___ the ED, her vitals were T: 98.5, HR: 70, BP: 135/79, RR: 16,
O2: 99%. ___ the ED, she was given Dilaudid .5 mg X3, Tylenol
___
mg IV X1, Ceftriaxone 1 gm IV, Unasyn 3 gm X2.
Patient had incision and drainage by hand/ortho. Scant purulent
drainage after 3cm linear superifical incision with 11 blade
scapel. Copiously irrigated at bedside with sterile water.
Patient placed ___ volar resting splint with sterile bandage and
elevated per hand surgery note.
Denies chest pain, SOB, abdominal pain,
headaches/lightheadedness. Reports pain ___ her hand is ___ and
she is having some numbness/tingling ___ her hand.
All other systems reviewed and negative, specifically, denies:
visual changes, numbness/weakness, chest pain, shortness of
breath, fevers, nausea, vomiting, abdominal pain, diarrhea,
bleeding, rash.
LMP: ___ years ago, has Mirena device, reports she does not have a
gyn and has not followed up with a primary care physician for ___
long time.
PCP: Dr. ___ ___ ___ (___)
Past Medical History:
Past Medical History:
Major depressive disorder (recurrent without psychotic features)
PTSD
Alcohol abuse
Obsessive Compulsive Disorder
Past Surgical History:
-Car accident affecting right knee (had surgery for foreign
objects ___ right knee per patient) at ___
Social History:
___
Family History:
Family history:
Mother and Father : healthy
Sister and brother: healthy
Physical Exam:
Physical Exam:
T: 98.5, BP: 123/80, HR: 60, RR: 16, O2: 97% RA
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions, no supraclavicular or cervical lymphadenopathy, no JVD,
no carotid bruits, no thyromegaly or palpable thyroid nodules
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RRR, NS1/S2, ___ systolic murmur
Gastrointestinal: nd, +b/s, soft, nt, no masses or HSM
___: no cyanosis, clubbing or edema, +2 DP pulses
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout.
Psychiatric: pleasant, appropriate affect
left hand: bandaged post procedure
Discharge physical exam:
Vitals: Afebrile, SBP 100-128, P 60-80, RR 18, 100 RA
Gen: Lying ___ bed ___ no apparent distress
HEENT: Anicteric, eyes conjugate, MMM, no JVD
Cardiovascular: RRR no MRG, nl. S1 and S2
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, non-tender, non-distended, bowel sounds
present, no HSM
MSK: No edema
Skin: Left hand wrapped ___ extensive dressings, no more
woundVAC.
Neurological: Alert, interactive, speech fluent, face symmetric,
moving all extremities
Psychiatric: pleasant, appropriate affect
Pertinent Results:
___ 06:15AM BLOOD WBC-7.9 RBC-4.42 Hgb-12.7 Hct-38.6 MCV-87
MCH-28.7 MCHC-32.9 RDW-14.2 RDWSD-45.9 Plt ___
___ 06:20AM BLOOD WBC-8.6 RBC-4.42 Hgb-13.1 Hct-38.5 MCV-87
MCH-29.6 MCHC-34.0 RDW-14.2 RDWSD-46.0 Plt ___
___ 03:00PM BLOOD WBC-9.4 RBC-3.98 Hgb-11.8 Hct-34.6 MCV-87
MCH-29.6 MCHC-34.1 RDW-14.3 RDWSD-45.8 Plt ___
___ 06:00AM BLOOD WBC-12.8* RBC-4.07 Hgb-11.9 Hct-35.6
MCV-88 MCH-29.2 MCHC-33.4 RDW-14.1 RDWSD-45.1 Plt ___
___ 11:40AM BLOOD WBC-12.4* RBC-4.13 Hgb-12.1 Hct-36.5
MCV-88 MCH-29.3 MCHC-33.2 RDW-14.5 RDWSD-46.2 Plt ___
___ 02:15AM BLOOD WBC-13.6* RBC-4.31 Hgb-12.4 Hct-37.6
MCV-87 MCH-28.8 MCHC-33.0 RDW-14.2 RDWSD-45.7 Plt ___
___ 02:15AM BLOOD Neuts-79.4* Lymphs-14.5* Monos-4.6*
Eos-1.0 Baso-0.1 Im ___ AbsNeut-10.81* AbsLymp-1.97
AbsMono-0.63 AbsEos-0.14 AbsBaso-0.02
___ 06:20AM BLOOD Plt ___
___ 03:00PM BLOOD Plt ___
___ 06:00AM BLOOD Plt ___
___ 11:40AM BLOOD Plt ___
___ 02:15AM BLOOD Plt ___
___ 02:15AM BLOOD ___ PTT-31.7 ___
___ 06:15AM BLOOD Glucose-98 UreaN-9 Creat-0.5 Na-142 K-4.1
Cl-104 HCO3-23 AnGap-15
___ 06:20AM BLOOD Glucose-93 UreaN-7 Creat-0.6 Na-140 K-4.0
Cl-102 HCO3-23 AnGap-15
___ 03:00PM BLOOD Glucose-94 UreaN-6 Creat-0.4 Na-142 K-4.0
Cl-105 HCO3-24 AnGap-13
___ 06:00AM BLOOD Glucose-122* UreaN-6 Creat-0.5 Na-140
K-3.8 Cl-103 HCO3-24 AnGap-13
___ 11:40AM BLOOD Glucose-142* UreaN-5* Creat-0.6 Na-138
K-3.4 Cl-97 HCO3-24 AnGap-17*
___ 06:15AM BLOOD ALT-18 AST-32 AlkPhos-57 TotBili-0.3
___ 06:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9
___ 06:20AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8
___ 06:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9
___ 06:20AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8
___ 03:00PM BLOOD Calcium-8.9 Phos-3.7 Mg-1.7
___ 06:00AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.8
___ 11:40AM BLOOD Calcium-8.7 Mg-2.0
___ 11:40AM BLOOD HCG-<5
___ 02:15AM BLOOD CRP-48.6*
___ 11:40AM BLOOD HIV Ab-NEG
___ 03:15AM BLOOD Vanco-12.8
___ 11:40AM BLOOD Vanco-6.1*
___ 11:40AM BLOOD HCV Ab-POS*
___ 06:00AM BLOOD HCV VL-7.2*
___ 02:21AM BLOOD Lactate-1.5
IMPRESSION:
Diffuse soft tissue swelling about the hand. No radiopaque
foreign body is identified.
Micro:
___ 10:35 am SWAB LEFT CARPARL TUNNEL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
1+ (<1 per 1000X FIELD): BUDDING YEAST.
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. MODERATE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
A swab is not the optimal specimen for recovery of
mycobacteria or
filamentous fungi. A negative result should be
interpreted
with
caution. Whenever possible tissue biopsy or aspirated
fluid should
be submitted.
FUNGAL CULTURE (Preliminary):
___ 10:47 am SWAB
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
WOUND CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary):
___ 10:47 am TISSUE L CARPAL TUNNEL TISSUE.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
Reported to and read back by ___ ___ ___
13:05.
TISSUE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
SENSITIVITIES PERFORMED ON CULTURE # ___ ___.
ANAEROBIC CULTURE (Preliminary):
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary):
Time Taken Not Noted ___ Date/Time: ___ 9:32 am
SWAB Source: Hand.
**FINAL REPORT ___
WOUND CULTURE (Final ___:
STAPH AUREUS COAG +. SPARSE GROWTH.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 4 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.___: Tenosynovium, left hand: skin and subq tissue with
abundant acute and chronic inflammation, tissue necrosis, and
abscess formation
Brief Hospital Course:
___ year old female w/PMH of major depressive disorder without
psychotic features, anxiety, PTSD admitted with deep left
hand/forearm infection and tenosynovitis.
# Deep left hand MRSA infection: underwent I+D by hand surgery
on ___ ___ ER and then s/p I&D arm left hand and forearm and
fasciotomy left forearm, CTS release, ulnar tunnel release, wide
debridement of necrotic soft tissue, application of VAC drainage
system on ___. Initially on IV Unasyn and started on IV
Vancomycin on ___, post-procedure broadened antibiotics to IV
Vancomycin and IV Zosyn. Given MRSA positive from wound culture
on ___, continued on IV Vancomycin, and Zosyn discontinued on
___. Infectious disease consult team followed her during her
hospital stay. She went for repeat I&D on ___, finally returned
to the OR on ___ for closure of her wound and removal of the
wound VAC. Given her IV drug use history, infectious disease
team recommended converting her to p.o. Bactrim on discharge,
and she will complete a two-week course of this
post-operatively, with day 1 being considered ___. She was care
connected for follow-up with infectious disease and plastic
surgery services following her discharge. She will go home on a
short, 1 week supply of oxycodone.
#Major Depression:
#PTSD:
#Hx of alcohol and IV drug abuse:
-Appreciate psychiatry following, per recs have changed meds to
Prozac 60 mg daily, Gabapentin 200 mg TID, Prazosin 6 mg qhs,
and Wellbutrin 100 mg daily. Recommended reinitiation of
Thorazine at 25 mg QHS, with up titration to 100 mg QHS on
discharge
-Confirmed appointment at ___ ___ at 2 p.m.,
however has not been seen by psychiatry NP ___ ___, is seeing a
new psychiatrist at next appointment.
#Hx of IV drug abuse: Patient denies recent IV drug abuse.
Cocaine positive ___ urine tox, however patient reports only
using marijuana recently.
-Patient reports not having PCP that has seen her ___ several
years
-HIV negative
-Hepatitis C antibody positive, Hepatitis C viral load positive
at 7.2. This will be followed up during her after hospital
appointment with Infectious Diseases
Transitional Issues:
- Hand Surgery f/u
- Infectious Disease f/u for MRSA Wound Infection and New
Diagnosis of Hep C
- Wound Care at home through ___
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 300 mg PO TID
2. Omeprazole 20 mg PO DAILY
3. FLUoxetine 60 mg PO DAILY
4. BuPROPion 100 mg PO DAILY
5. Prazosin 6 mg PO QHS
6. ChlorproMAZINE 50 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Pain Relief] 500 mg ___
tablet(s) by mouth three times a day Disp #*180 Tablet
Refills:*2
2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
take only as needed
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*50 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 1 powder(s) by mouth
daily Refills:*0
4. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*14 Tablet Refills:*0
5. Sulfameth/Trimethoprim DS 2 TAB PO BID Duration: 14 Days
Take through ___
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 2 tablet(s) by
mouth twice a day Disp #*50 Tablet Refills:*0
6. BuPROPion 100 mg PO DAILY
7. ChlorproMAZINE 50 mg PO BID
8. FLUoxetine 60 mg PO DAILY
9. Gabapentin 300 mg PO TID
10. Omeprazole 20 mg PO DAILY
11. Prazosin 6 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Hand abscess
Cellulitis
New diagnosis of Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You were hospitalized for hand abscess/cellulitis. You were
given IV antibiotics while you were hospitalized and had surgery
for your left hand infection. You will need to follow-up with
primary care, orthopedics, and psychiatry as an outpatient. You
also have a new diagnosis of Hepatitis C and will need to
follow-up with infectious disease as an outpatient.
We wish you all the best ___ your recovery.
Best wishes,
Your ___ team
Followup Instructions:
___
|
10113381-DS-12 | 10,113,381 | 20,850,207 | DS | 12 | 2168-10-12 00:00:00 | 2168-10-13 19:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Celebrex / Naproxen / Salsalate
Attending: ___.
Chief Complaint:
Nausea/vomiting.
Major Surgical or Invasive Procedure:
Bedside I/D of inferior portion of wound with drainage of 25 cc
seroma.
History of Present Illness:
Ms. ___ is a ___ year-old G0 ___ s/p TAH/BSO, omentectomy,
ileocecetomy with reanastomosis who presented for nausea,
vomiting, abdominal pain, and SOB ___. She reported having
one episode of emesis ___, and then again on ___, she
continued to feel nauseous and had not had much to eat. She
denied any chest pain or diaphoresis upon presenting. Given that
these symptoms were similar to what she felt when she was
diagnosed with NSTEMI, she called and presented for evaluation.
Overall, she was feeling better upon being admitted to the ED.
She had a mild headache which improved shortly after presenting
to the ED, and she denied any dysphagia, focal numbness
orweakness, or difficulty emptying her bladder. At the time she
continued to have incisional pain and had pain in the area of
her inferior incision since it was I&D'ed in the office by Dr.
___ on ___, and she continued taking keflex as prescribed.
She reported passing flatus and had a BM ___. She denied any
fevers or dizziness but had subjective chills ___.
Past Medical History:
hypertension
hyperlipidemia
GERD
borderline anemia
Gastritis related to ASA, NSAIDs
subclinical hypothyroidism
DJD
obesity
Past Surgical History: Confirmed with HCP
s/p b/l total knee
s/p T&A
cataract surg ___
s/p breast biopsy
Social History:
___
Family History:
Mother died from CAD with history of hypertension and first MI
in
her ___, also pacemaker. Father died of pneumonia with a
history
of hypertension. One brother died from stomach CA and emphysema
and another brother, who was ___ impaired, died of a MI
Also family history of macular degeneration.
Physical Exam:
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
pulm: clear to auscultation bilaterally
abd: soft, nontender, nondistended. Superior aspect of abdominal
wound without erythema or induration, with woundvac in place.
Inferior aspect of wound with serous drainage, packed with plain
gauze with bandage in place without erythema or purulent
drainage. Middle portion of incision healing well without
erythema or induration.
___: nontender, nonedematous
Pertinent Results:
___ Blood cultures drawn, results pending at time of discharge.
___ CT Abdomen showed (prelim read, final pending at discharge):
1. Rim enhancing fluid collection with surrounding fat stranding
in the midline anterior abdominal wall at the level bladder,
about 10 cm inferior to
the umbilicus. Findings consistent with an abscess versus
possible postsurgical changes.
2. Trace ascites and intra-abdominal fat stranding, while
findings may be postsurgical cannot rule out an infectious
process in the right clinical setting. No drainable collection
is seen intra-abdominally.
Brief Hospital Course:
Ms. ___ was admitted to the gynecology oncology service on
___ with nausea and vomiting, also found to have a
subcutaneous abscess on her lower abdominal incision. She was
previously discharged from the gynecology oncology service on
___ after sub-optimally debulked ex-lap, BSO, TAH,
omentectomy, ileocecectomy with primary re-anastomosis for
likely ovarian cancer. Please see previous discharge summary for
full details.
Her hospital course is detailed as follows. Due to the patient's
history of NSTEMI with only presenting symptom of nausea, an ECG
was obtained and cardiac enzymes were negative x3. Blood
cultures were drawn prior to initiation of IV ciprofloxacin and
flagyl due to a wound culture on ___ at the time of incision and
drainage of a lower incision abscess that was positive for
E.coli. CT scan of the abdomen at the time of admission showed
continued fluid collection, which was further drained on ___
with drainage of a 25cc seroma with some purulent discharge.
Intravenous antibiotics were continued for 48 hours and then
transitioned to oral antibiotics to be continued upon discharge
for a total of 10 days. The superior portion of her abdominal
incision continues to improve with the woundvac in place.
The patient's nausea improved shortly after her admission and by
hospital day 2 she was tolerating oral intake with only a
complaint of constipation. She was then discharged home in
stable condition with a rigorous bowel regimen, oral antibiotics
for a total of 10 days of treatment and outpatient follow-up
scheduled.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 25 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Ranitidine 150 mg PO DAILY
5. Zolpidem Tartrate 5 mg PO HS:PRN Insomnia
6. Vitamin D 1000 UNIT PO DAILY
7. Atorvastatin 80 mg PO DAILY
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Hydrochlorothiazide 12.5 mg PO DAILY
3. Lisinopril 5 mg PO DAILY
4. Ranitidine 150 mg PO DAILY
5. Zolpidem Tartrate 5 mg PO HS:PRN Insomnia
6. Aspirin 81 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth three times a
day Disp #*60 Capsule Refills:*2
9. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 to 2 softgel by mouth twice a
day Disp #*40 Capsule Refills:*2
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 to 1 tablet(s) by mouth every six (6)
hours Disp #*10 Tablet Refills:*0
11. Ciprofloxacin HCl 500 mg PO Q12H Duration: 8 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*16 Tablet Refills:*0
12. Atorvastatin 80 mg PO DAILY
13. I-Caps (antiox#10-om3-dha-epa-lut-zeax) ___ mg oral 1
capsule daily
14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit oral
daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subcutaneous abscess on lower incision.
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 gynecologic oncology service after
undergoing the procedures listed below. You have recovered well,
and the team feels that you are safe to be discharged home.
Please follow these instructions:
* No heavy lifting of objects >10lbs for 4 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
Abdominal instructions:
* Take your medications as prescribed.
* Do not drive while taking narcotics.
* Do not combine narcotic and sedative medications or alcohol.
* Do not take more than 4000mg acetaminophen (APAP) in 24 hrs.
* No strenuous activity until your post-op appointment.
* Nothing in the vagina (no tampons, no douching, no sex) for 8
weeks.
* No heavy lifting of objects >10 lbs for 6 weeks.
* You may eat a regular diet.
* It is safe to walk up stairs.
.
Incision care:
*Wound vac of superior portion of wound to be changed every 3
days by at home nursing staff until wound is completely healed.
Most recently changed ___.
*Packing of inferior portion of wound to be done once a day by
at home nursing staff until wound is completely healed.
.
To reach medical records to get the records from this
hospitalization sent to your doctor at home, call ___.
.
Call your doctor at ___ for:
* fever > 100.4
* severe abdominal pain
* difficulty urinating
* vaginal bleeding requiring >1 pad/hr
* abnormal vaginal discharge
* redness or drainage from incision
* nausea/vomiting where you are unable to keep down fluids/food
or your medication
* chest pain or difficulty breathing
* onset of any concerning symptoms
Followup Instructions:
___
|
10113381-DS-13 | 10,113,381 | 24,304,543 | DS | 13 | 2173-04-09 00:00:00 | 2173-04-09 14:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Celebrex / Naproxen / Salsalate / atorvastatin
Attending: ___.
Chief Complaint:
Left periprosthetic femur fracture
Major Surgical or Invasive Procedure:
___: ORIF left distal femur fracture
History of Present Illness:
Patient is ___ with a PMH of HLD, HTN, A. fib on Eliquis who
presents as a transfer from OSH distal femur fracture s/p fall.
Patient states she was making her bed this morning when her left
foot got caught on the bed and she fell onto her left hip.
Denies
head strike or LOC. Currently complaining of left thigh and knee
pain that is worse with ambulation. Denies any numbness or
paresthesias. Denies neck or back pain. No CP or SOB.
Patient went to OSH and had x-rays done which showed a
transverse
comminuted fracture of the distal femur at the level of the left
knee prosthesis. Transferred here for further eval.
Past Medical History:
ACTINIC KERATOSES
ANEMIA
ATYPICAL CHEST PAIN
CATARACTS
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
GASTRITIS
HYPERLIPIDEMIA
HYPERTENSION
OBESITY
OSTEOARTHRITIS
POSTHERPETIC NEURALGIA
SHOULDER PAIN
PELVIC MASS
OVARIAN CANCER
AORTIC REGURGITATION
CONGESTIVE HEART FAILURE
H/O CHANGED BOWEL HABITS
H/O HYPERGLYCEMIA
H/O TOBACCO ABUSE
Social History:
___
Family History:
NC
Physical Exam:
Exam: Well appearing woman NAD
MSK left lower extremity:
Fires ___
SILT sural, saphenous, superficial peroneal, deep peroneal and
tibial distributions
Dorsalis pedis pulse 2+ with distal digits warm and well
perfused
Incisional dressing with some serosanguineous drainage
Pertinent Results:
___ 09:26AM BLOOD WBC-6.2 RBC-2.77* Hgb-7.6* Hct-24.1*
MCV-87 MCH-27.4 MCHC-31.5* RDW-14.7 RDWSD-47.2* Plt ___
___ 06:35AM BLOOD WBC-6.7 RBC-2.71* Hgb-7.6* Hct-23.7*
MCV-88 MCH-28.0 MCHC-32.1 RDW-14.6 RDWSD-46.6* Plt ___
___ 07:07AM BLOOD Glucose-98 UreaN-23* Creat-1.0 Na-144
K-4.1 Cl-106 HCO3-29 AnGap-9*
___ 07:07AM BLOOD Calcium-8.0* Phos-2.1* Mg-2.0
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left periprosthetic femur fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for ORIF left femur, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
Patient was transfused 1 unit of packed red cells on ___.
Patient had an appropriate hematocrit response to 25 and
remained stable thereafter. She remained hemodynamically stable
and looked well on exam.
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
partial weightbearing in the left lower extremity, and will be
discharged on her home dose of Eliquis for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Gabapentin 100 mg PO BID
3. Hydrochlorothiazide 12.5 mg PO QAM
4. Metoprolol Succinate XL 50 mg PO DAILY
5. Pravastatin 80 mg PO QPM
6. Ranitidine 150 mg PO DAILY
7. Apixaban 5 mg PO BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
Partial fill ok. No driving/heavy machinery. Wean.
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Apixaban 5 mg PO BID
7. Furosemide 20 mg PO DAILY
8. Gabapentin 100 mg PO BID
9. Hydrochlorothiazide 12.5 mg PO QAM
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Pravastatin 80 mg PO QPM
12. Ranitidine 150 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left periprosthetic femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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:
-Partial weightbearing left lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This is
an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Do NOT get splint wet.
DANGER SIGNS:
Please call your PCP or surgeon's office and/or return to the
emergency department if you experience any of the following:
- Increasing pain that is not controlled with pain medications
- Increasing redness, swelling, drainage, or other concerning
changes in your incision
- Persistent or increasing numbness, tingling, or loss of
sensation
- Fever ___ 101.4
- Shaking chills
- Chest pain
- Shortness of breath
- Nausea or vomiting with an inability to keep food, liquid,
medications down
- Any other medical concerns
FOLLOW UP:
Please follow up with your Orthopaedic Surgeon, Dr. ___. You
will have follow up with ___, NP in the
Orthopaedic Trauma Clinic 14 days post-operation for evaluation.
Call ___ to schedule appointment upon discharge.
Please follow up with your primary care doctor regarding this
admission within ___ weeks and for any new medications/refills.
THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB
Physical Therapy:
Partial weightbearing left lower extremity
No other activity or range of motion restrictions
No braces, casts, splints
Treatments Frequency:
Skin staples or sutures to be removed at 2-week follow-up
Followup Instructions:
___
|
10113512-DS-15 | 10,113,512 | 24,931,866 | DS | 15 | 2121-12-02 00:00:00 | 2121-12-06 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
morphine
Attending: ___.
Chief Complaint:
obstructing stone
Major Surgical or Invasive Procedure:
Right-sided percutaneous nephrostomy tube placement with the
tube entering the kidney in the lower pole calyx and the pigtail
in the renal pelvis
History of Present Illness:
Ms. ___ is a ___ y/o female with a past medical history of
nephrolithiasis, DM (insulin dependent) c/b nephropathy and
neuropathy, HTN and HLD who presented on ___ with nausea,
vomiting and flank pain and was found to have an obstructing
stone and a UTI. Patient was transferred to the FICU on ___
with hypotension. In brief, the patient presented on ___ with
the above symptoms and was found to have a mild leukocytosis,
___ with Cr 1.8 (up from baseline 1.3-1.5) and a positive UA.
CTU was performed which showed 4mm proximal right ureteral stone
with mild to moderate right hydronephrosis, with mild right
perinephric stranding. Also with b/l nephrolithiasis. Given that
her symptoms were consistent with an obstructing stone and UA
c/f UTI. The patient was admitted to the urology service and was
started on ceftriaxone and tamsulosin and was NPO for PCN on
___. She was broadened to vancomycin given the concern for
clinical decline. Her blood cultures returned positive for GNRs.
On ___ she went to ___ for right sided PCN. Prior to the
procedure the patient was hypotensive with SBPs in the ___ and
HRs 140s. During the procedure the patient's SBPs were ___
with HRs 100-130s. She received 1mg versed, 100mcg fentanyl. In
the PACU the patient's SBP was in the ___ and she received 2L NS
with SBPs ___. She was placed in trendelburg position and
developed mild left sided chest pain due to positioning. EKG
showed NSR no ST changes. Given the hemodynamic disturbances the
patient was transferred to the ICU for closer monitoring.
On arrival to the FICU, T 98.3, BP 105/62, HR 122, 91-95% 2L NC.
Patient was mentating appropriately and denied pain.
Past Medical History:
HTN
DM c/b neuropathy, insulin dependent
CKD with microalbuminuria
b/l tubal ligation
nephrolithiasis s/p b/l lithotripsies, PCN on left for
obstructive uropathy
HLD
Social History:
___
Family History:
Non-contributory
Physical Exam:
======================
EXAM ON ADMISSION
======================
Vitals: T 98.3, BP 105/62, HR 122, 91-95% 2L NC.
GENERAL: A+Ox3, NAD
HEENT: PERRL, EOMI, sclera anicteric, oropharynx with MMM
NECK: no JVD
LUNGS: CTAB, no w/r/r
CV: tachycardic, regular, no murmurs
ABD: soft, tender to palpation in RUQ, no rebound or guarding,
normal bowel sounds, no hepatomegaly
EXT: no peripheral edema, warm and well perfused, 2+ peripheral
pulses
======================
EXAM ON DISCHARGE
WDWN, nad, avss
abdomen soft, nt/nd
extremities w/out edema, pitting, pain
PCN in place,secured
Pertinent Results:
___ CTU abd/pelvis w/o contrast:
1. 4 mm proximal right ureteral stone with mild to moderate
right hydronephrosis. Mild right perinephric stranding.
2. Bilateral nephrolithiasis, as above.
___ 06:35AM BLOOD WBC-11.0* RBC-3.10* Hgb-9.5* Hct-28.7*
MCV-93 MCH-30.6 MCHC-33.1 RDW-13.2 RDWSD-44.3 Plt ___
___ 05:44AM BLOOD WBC-16.9* RBC-3.00* Hgb-9.2* Hct-27.5*
MCV-92 MCH-30.7 MCHC-33.5 RDW-12.9 RDWSD-43.1 Plt ___
___ 04:56AM BLOOD WBC-16.4*# RBC-2.76* Hgb-8.5* Hct-25.8*
MCV-94 MCH-30.8 MCHC-32.9 RDW-13.1 RDWSD-44.8 Plt ___
___ 11:20AM BLOOD WBC-11.2*# RBC-3.98 Hgb-12.3 Hct-36.4
MCV-92# MCH-30.9 MCHC-33.8 RDW-12.4 RDWSD-41.1 Plt ___
___ 11:20AM BLOOD Neuts-78.2* Lymphs-15.0* Monos-4.9*
Eos-0.7* Baso-0.8 Im ___ AbsNeut-8.78* AbsLymp-1.69
AbsMono-0.55 AbsEos-0.08 AbsBaso-0.09*
___ 06:20PM BLOOD ___ PTT-34.1 ___
___ 06:35AM BLOOD Glucose-131* UreaN-15 Creat-1.2* Na-134
K-4.2 Cl-104 HCO3-22 AnGap-12
___ 05:44AM BLOOD Glucose-102* UreaN-17 Creat-1.2* Na-136
K-3.9 Cl-106 HCO3-20* AnGap-14
___ 06:02AM BLOOD Glucose-164* UreaN-23* Creat-2.4* Na-137
K-4.6 Cl-106 HCO3-14* AnGap-22*
___ 11:20AM BLOOD Glucose-215* UreaN-22* Creat-1.8* Na-133
K-4.9 Cl-97 HCO3-19* AnGap-22*
___ 12:53PM BLOOD ALT-14 AST-28 AlkPhos-85 TotBili-0.8
___ 06:35AM BLOOD Calcium-8.7 Mg-1.6
___ 05:44AM BLOOD Calcium-7.7* Phos-3.5 Mg-2.0
___ 06:02AM BLOOD Calcium-7.7* Phos-5.1* Mg-0.9*
___ 02:28PM URINE Color-Straw Appear-Hazy Sp ___
___ 11:20AM URINE Color-Yellow Appear-Cloudy Sp ___
___ 02:28PM URINE Blood-MOD Nitrite-POS Protein-TR
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 11:20AM URINE Blood-LG Nitrite-POS Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG
___ 02:28PM URINE RBC-76* WBC-79* Bacteri-FEW Yeast-NONE
Epi-1
___ 11:20AM URINE RBC->182* WBC->182* Bacteri-MOD
Yeast-NONE Epi-15
___ 02:28PM URINE WBC Clm-MOD Mucous-RARE
___ 11:20AM URINE WBC Clm-OCC Mucous-FEW
___ 11:20AM URINE UCG-NEG
___ 2:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
ESCHERICHIA COLI. FINAL SENSITIVITIES.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ 0633 ON ___
- ___.
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
___ 11:20 am URINE TAKEN 66864M.
**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------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 4:56 am BLOOD CULTURE Source: Venipuncture.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Brief Hospital Course:
Ms. ___ is a ___ y/o female with a past medical history of
nephrolithiasis, DM (insulin dependent) c/b nephropathy and
neuropathy, HTN and HLD who presented on ___ with nausea,
vomiting and flank pain and was found to have an obstructing
stone with hydronephrosis, ___ and a UTI. Patient underwent
right sided PCN on ___ and required a stay in the unit for
persistent hypotension.
# Severe sepsis ___ GNR bacteremia from likely UTI:
On admission, patient was found to have nausea, vomiting, and
flank pain. She underwent a renal ultrasound, which showed an
obstructing right-sided stone. A u/a was positive for a UTI. She
was admitted to the urology service and was started on
ceftriaxone and tamsulosin. She was then broadened to vanc as
she remained tachycardic and hypotensive. The patient underwent
___ placement of a nephrostomy tube on ___, but
afterwards was found to be perisisently tachycardic and
hypotensive with SBPs in the ___. An EKG showed NSR with no ST
changes. She was transfered to the ICU for further management.
On transfer, the patient was afebril, BP 105/62, HR 122, and
satting in the low ___ on 2L NC. A lactate was found to be 2.5.
She was continued on vanc, and cefepime was started in place of
ceftriaxone. The patient received several boluses of IVF to keep
her MAPS>65.
On ___, her WBC increased from 5.5 to 16.4. Urine cultures
returned positive for pan sensitive e. coli and the patient was
was transitioned to ceftriaxone for coverage.
# Hypoxemia
Following the patient's PCN, had a new oxygen requirement, which
increased throughout the day on ___. A CXR was suggestive of
fluid overload in the setting of multiple IVF boluses given for
sepsis and hypotension. She was given lasix 20mg IV, with a
following UOP of >500cc. However, she remained hypoxic, and
reported difficulty breathing. An EKG showed a RBBB, unknown if
changed from prior (EKG in ED had no mention of RBBB.) No ST
changes were noted. The patient was then diuresed again an had
excellent UOP. She was then weaned to RA and satting in the
mid-90___.
# Hypotension: The patient was hypotensive on presentation to
the FICU, but responsive to multiple fluid boluses likely
secondary to sepsis. By the second day of antibiosis the
patient's MAP's were persistently >65 without additional IVF
support.
# Acute renal failure: baseline creatinine around 1.3, presented
with a creatinine 3.0. Most likely ___ obstructive uropathy and
underwent right PCN as above. Alternative etiologies include
hypovolemia and possible ATN given sepsis. Creatinine
downtrended with PCN and treatment of sepsis.
# UTI: +UA, culture pending. Has a history of pansensitive
klebsiella but no history of resistent organisms. Initial broad
spectrum tx as above but quickly narrowed to ceftriaxone given
pan-sensitive e. coli result on culture.
# Anion-gap acidosis: likely ___ lactate elevation. Glucose wnl
and DKA unlikely.
Acidosis improved with continued antibiosis and fluid support.
# DM c/b neuropathy and nephropathy: patient received ___ dose
lantus prior to PCN. She was restarted on her home lantus the
second day of her ICU stay given resumption of PO intake
# HLD: continued on home statin
Ms. ___ was admitted to Dr. ___ for
nephrolithiasis management with a known obstructing stone. She
was admitted, given intravenous antibiotics and on hospital day
two taken uregntly to the OR for decompression. She was
recovered in the FICU as noted above where she remained until
POD2, HD3.
The postoperative course was essentially uncomplicated and she
was diuresed in the FICU and her tachycardia monitored. She was
gradually advanced in diet and at discharge, the patient had
pain well controlled with oral pain medications, was tolerating
regular diet, ambulating without assistance, and voiding without
difficulty. Oral pain medications along with explicit
instructions to follow-up were provided. She was discharged
home with the PCN in place and ___ services. She will follow up
as directed.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 12.5 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Gabapentin 300 mg PO QHS
4. Glargine 42 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
5. Omeprazole 20 mg PO DAILY
6. Cyanocobalamin Dose is Unknown PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Gabapentin 300 mg PO QHS
3. Glargine 42 Units Breakfast
Humalog 10 Units Breakfast
Humalog 10 Units Lunch
Humalog 10 Units Dinner
4. Omeprazole 20 mg PO DAILY
5. Cyanocobalamin 50 mcg PO DAILY
RESUME HOME DOSE
6. Hydrochlorothiazide 12.5 mg PO DAILY
7. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin [Flomax] 0.4 mg ONE capsule(s) by mouth Daily
Disp #*30 Capsule Refills:*1
8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q4hrs
Disp #*45 Tablet Refills:*0
9. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
complete this entire Rx even if you feel better
RX *ciprofloxacin HCl [Cipro] 500 mg ONE tablet(s) by mouth
twice a day Disp #*14 Tablet Refills:*0
10. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg ONE capsule(s) by mouth
twice a day Disp #*60 Capsule Refills:*1
11. Acetaminophen 650 mg PO Q6H:PRN pain or fever
12. Bisacodyl 10 mg PO DAILY:PRN constipation
13. Calcium Carbonate 1250 mg PO QID:PRN heartburn, calcium
repletion
14. Senna 8.6 mg PO DAILY constipation
Discharge Disposition:
Home With Service
Facility:
___
___:
UROSEPSIS, OBSTRUCTING NEPHROLITHIASIS, ACUTE KIDNEY INJURY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
PCNL & NEPHROLITHIASIS:
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month; this may be related to the passage of stone fragments or
the indwelling ureteral stent.
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-Ureteral stents MUST be removed or exchanged and therefore it
is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor. HOLD ASPIRIN and aspirin containing products for one
week unless otherwise advised.
-IBUPROFEN (the ingredient of Advil, Motrin, etc.) may be taken
even though you may also be taking Tylenol/Acetaminophen. You
may alternate these medications for pain control. For pain
control, try TYLENOL FIRST, then ibuprofen, and then take the
narcotic pain medication as prescribed if additional pain relief
is needed.
-Ibuprofen should always be taken with food. Please discontinue
taking and notify your doctor should you develop blood in your
stool (dark, tarry stools)
-You MAY be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
-Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and available over the counter.
The generic name is DOCUSATE SODIUM. It is recommended that you
use this medication.
-Do not eat constipating foods for ___ weeks, drink plenty of
fluids to keep hydrated
-No vigorous physical activity or sports for 4 weeks and while
Foley catheter is in place.
-You will be discharged home with the PERCUTANEOUS NEPHROSTOMY
(PCN)
-You can expect to see occasional blood in your urine and to
possibly experience some urgency and frequency over the next
month
-The kidney stone may or may not have been removed AND/or there
may fragments/others still in the process of passing.
-You may experience some pain associated with spasm of your
ureter.; This is normal. Take the narcotic pain medication as
prescribed if additional pain relief is needed.
-PCNs/Ureteral stents MUST be removed or exchanged and therefore
it is IMPERATIVE that you follow-up as directed.
-Do not lift anything heavier than a phone book (10 pounds)
-You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve
-Resume your pre-admission/home medications EXCEPT as noted. You
should ALWAYS call to inform, review and discuss any medication
changes and your post-operative course with your primary care
doctor.
-No vigorous physical activity or sports for 4 weeks and while
PCN is in place. You should NOT drive while taking narcotic
pain medication and while the PCN is in place.
-Please refer to the provided nursing instructions and handout
on PCN care, waste elimination, dressing changes.
PERCUTANEOUS NEPHROSTOMY (PCN) TUBE INSTRUCTIONS FOR CARE---FOR
FAMILY:
Please leave PCN tube to external gravity drainage.
Catheter flushing: If there are excessive blood clots or debris
or thick urine within the connecting tubing, this can be gently
flushed as needed to promote clearing. Use normal saline filled
syringes provided by nursing.
Change every 3 days, if soiled/saturated, as needed: Gently
cleanse around the skin entry site of the catheter with gentle
soap w/ warm water. Dry and apply gauze dressing.
Catheter security: a) EVERYDAY you must check to be sure the
catheter, the connecting tubing and the drainage bag are
securely attached to the patient and are not kinked. b) If the
catheter appears to be pulling "out", please notify
Interventional Radiology.
c) If the catheter pulls out, please notify Interventional
Radiology within 8 hours. SAVE THE CATHETER for inspection--DO
NOT throw
it away.
Call Interventional Radiology/Angio for ANY catheter related
questions or problems. ___ or Fellow/Resident (pager#
___
Followup Instructions:
___
|
10113857-DS-10 | 10,113,857 | 27,855,685 | DS | 10 | 2123-12-03 00:00:00 | 2123-12-04 08:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
Augmentin / albuterol
Attending: ___
Chief Complaint:
L foot infection
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This is a ___ y/o M patient with a pMHx of DM, HTN, renal
failure, and HL who is s/p angio and left ___ toe amp and heel
debridement on ___ with Dr. ___. He handled the
surgery
well with no complications. He was discharged from the
hospital's
vascular surgery service on ___ with antibiotics and f/u
scheduled as well as daily ___ dressing changes and a wound vac
for his L heel. Pt. returns to the ED this evening after going
home and he states that he noticed a small amount of blood in
the bandage and "freaked out". He then presented back to the ED.
Pt. states that he was told upon arrival that he had a fever. He
did not notice any drainage from the heel, just from the ___
digit amp site. He denies anypain from the foot but admits to
N/F/V.
Past Medical History:
Diabetes
HTN
Renal failure
Social History:
___
Family History:
Family History
Mother-diabetes
Father-Lung cancer
Physical Exam:
Gen: AAOx3, NAD
VSS, Afebrile
Cardio: RRR
Pulm: No respiratory distress
Abd: soft, NT, ND
Extremities: L ___ amp site skin edges well coapted , no
drainage. Heel ulcer has granular/fibrotic base, minimal
serosanguinous drainage.
Pertinent Results:
___ 09:35AM BLOOD WBC-15.4* RBC-3.13* Hgb-8.4* Hct-26.0*
MCV-83 MCH-26.9* MCHC-32.3 RDW-13.8 Plt ___
___ 10:30AM BLOOD WBC-17.4* RBC-2.96* Hgb-7.9* Hct-24.5*
MCV-83 MCH-26.8* MCHC-32.4 RDW-13.6 Plt ___
___ 07:01AM BLOOD WBC-16.3* RBC-2.99* Hgb-8.0* Hct-24.8*
MCV-83 MCH-26.6* MCHC-32.1 RDW-13.7 Plt ___
___ 05:05PM BLOOD WBC-22.5* RBC-3.31* Hgb-8.9* Hct-27.1*
MCV-82 MCH-26.9* MCHC-32.9 RDW-13.7 Plt ___
___ 01:10AM BLOOD WBC-24.2* RBC-3.27* Hgb-8.9* Hct-27.0*
MCV-83 MCH-27.2 MCHC-33.0 RDW-13.5 Plt ___
___ 07:25AM BLOOD WBC-16.3* RBC-3.01* Hgb-8.1* Hct-25.5*
MCV-85 MCH-26.9* MCHC-31.8 RDW-13.5 Plt ___
___ 07:01AM BLOOD Neuts-83.6* Lymphs-9.2* Monos-5.2 Eos-1.3
Baso-0.7
___ 01:10AM BLOOD Neuts-89.1* Lymphs-5.3* Monos-4.4 Eos-0.5
Baso-0.7
___ 09:35AM BLOOD Plt ___
___ 10:30AM BLOOD Plt ___
___ 07:01AM BLOOD Plt ___
___ 05:05PM BLOOD Plt ___
___ 01:10AM BLOOD Plt ___
___ 01:10AM BLOOD ___ PTT-32.8 ___
___ 07:25AM BLOOD Plt ___
___ 07:25AM BLOOD ___ PTT-30.5 ___
___ 09:35AM BLOOD Glucose-126* UreaN-27* Creat-2.7* Na-142
K-3.5 Cl-108 HCO3-23 AnGap-15
___ 10:30AM BLOOD Glucose-186* UreaN-26* Creat-2.7* Na-136
K-3.4 Cl-108 HCO3-21* AnGap-10
___ 07:01AM BLOOD Glucose-95 UreaN-26* Creat-2.7* Na-138
K-3.5 Cl-107 HCO3-20* AnGap-15
___ 05:05PM BLOOD Glucose-80 UreaN-26* Creat-2.5* Na-137
K-3.5 Cl-105 HCO3-23 AnGap-13
___ 01:10AM BLOOD Glucose-96 UreaN-28* Creat-2.5* Na-138
K-3.7 Cl-107 HCO3-18* AnGap-17
___ 07:25AM BLOOD Glucose-92 UreaN-27* Creat-2.7* Na-138
K-3.8 Cl-108 HCO3-21* AnGap-13
___ 09:35AM BLOOD Calcium-7.8* Phos-3.6 Mg-1.7
___ 07:01AM BLOOD Calcium-8.0* Phos-4.6* Mg-1.8
___ 05:05PM BLOOD Calcium-8.3* Phos-3.9 Mg-1.7
___ 07:25AM BLOOD Calcium-8.0* Phos-4.0 Mg-1.6
___ 01:22AM BLOOD Lactate-1.0
43cm single lumen non-heparin dependant power right basilic PICC
terminates in the upper SVC per Dr. ___. Catheter wire was
removed before CXR was obtained.
Brief Hospital Course:
Pt. was admited on ___ after presenting to the ED
for minimum strikethough to his dressing. Upon arrival to the ED
the patient was having fevers to 102. He also had chills, nausea
and vomitting. He was admitted to the podiatric surgery service
and was started on IV antibiotics. His WBC trended down and a
PICC was placed as was a wound VAC. Before placing PICC, renal
was consulted to discuss placement given that pt. does have
stage 4 CKD. It was decided that we would place the PICC for a 2
week course of IV antibiotics. He was discharged to a rehab
facility to recieve Vancomycin in stabile condiditon with VSS
and afebrile. He will remain NWB and have VAC changes every
third day.
Medications on Admission:
calcium acetate 667mg q3d\
Vit D 1000unit PO qd
desipramine 25mg night time
furosemide 120mg q1d
lisinopril 10mg q1d
lispro 12 before breakfast
lispro 4 before dinner
metoprolol succinate 75 mg q1d
NPH 40 before breakfast
NPH 6 before dinner
simvastatin 40 at night time
pletal 100PO qd
aspirin 81mg daily
docusate sodium [Colace] 100 mg q3d
polyethylene glycol 3350 [Miralax] 1 pack daily
sennosides [senna] 40 in the morning
Discharge Medications:
1. Vancomycin 1000 mg IV Q 24H
RX *vancomycin 1 gram 1 g IV once a day Disp #*14 Vial
Refills:*0
2. Vitamin D 1000 UNIT PO DAILY
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
4. Simvastatin 10 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. PleTAL (cilostazol) 100 mg ORAL DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Lisinopril 10 mg PO DAILY
9. Glargine 36 Units Bedtime
Humalog 5 Units Breakfast
Humalog 5 Units Lunch
Humalog 5 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
10. Furosemide 120 mg PO DAILY
11. Desipramine 25 mg PO HS
12. Calcium Acetate 667 mg PO TID W/MEALS
13. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left leg cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the podiatric surgical service after you
presented to the ED with concerts regarding your amputation site
and presenting with fevers, chills and nausea and vomitting. You
were admitted to the floor and were administered IV antibiotics.
Your pain was controlled and your blood markers indicative of
infection decreased. You had a wound VAC placed and had a
bedside debridement performed. You had a PICC line placed by the
IV PICC team and will be given 2 weeks of IV antibiotics.
Please fill your previous Rx given to you by the vascular
surgery department for Pletal, and toradol. You do not need to
fill the antibiotic Rx, previously given to you as you will now
be taking Vancomycin via your PICC.
You are to remain Non-weight bearing to your left foot.
Please keep your current dressing in place, clean, dry and
intact. You will have a VAC placed at rehab, which will be
changed every third day. Plkease keep the dressing over your ___
digit amputation site, clean dry and intact. This can be changed
every other day.
Please keep all follow up appointments
Followup Instructions:
___
|
10113857-DS-13 | 10,113,857 | 27,005,154 | DS | 13 | 2124-01-29 00:00:00 | 2124-01-29 22:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Augmentin / albuterol
Attending: ___.
Chief Complaint:
Right lower extremity pain
Major Surgical or Invasive Procedure:
___ Diagnsotic angiogram
History of Present Illness:
___ w/h/o DM, leukocytoclastic vasculitis, s/p L BKA on ___,
recent admission for flare of LCV p/t ER today after noting pain
and numbness in his foot starting yesterday night ~ midnight.
He states that he felt the leg get cool either. He was direct
to the ER by his ___. He otherwise states that he has
been doing well, his BKA site is healing. He has no f/c/ns. He
is non ambulatory at baseline but uses his RLE to pivot into his
wheel chair.
Past Medical History:
PMH:
Pooly controlled diabetes, retinopathy,
nephropathy, obesity, hypertension, hyperlipidemia, kidney
failure, pripheral vascular disease, history of PE
PSH:
___: LLE ___ toe amputation and debridement of L heel ulcer
___: LLE angiogram revealing of patent L SFA and profunda,
patent popliteal artery with AT as 1-vessel runoff
___: ___ a. angioplasty, peroneal a. angioplasty (at ___
Pilonidal cyst removal
Social History:
___
Family History:
Family History
Mother-diabetes
Father-Lung cancer
Physical Exam:
Vitals: 98.6 82 168/99 16 100% RA
GEN: NAD
CV: RRR
Abd: S, NT/ND
Ext: L BKA site c/d/i, ___ with erythematous rash at ankle,
significant pitting edema of RLE as well as calf tenderness ___
strength with plantar flexion, 3+/5 strength with dorsiflexion.
+sensation
Pulses: Fem DP ___
L: p BKA
R: p d d
Labs:
143 | 108 | 46 AGap=17
---------------<96
3.8 | 22 | 2.4
___: 11.9 PTT: 30.7 INR: 1.1
ON DISCHARGE:
Vital signs stable
GEN: NAD
CV: RRR
Abd: S, NT/ND
Ext: L BKA site c/d/i, ___ with erythematous rash at ankle,
significant pitting edema of RLE as well as calf tenderness ___
strength with plantar flexion, 3+/5 strength with dorsiflexion.
+sensation
Pulses: Fem DP ___
L: p BKA
R: p d d
Pertinent Results:
___ 01:25PM BLOOD Hct-25.1*
___ 03:40PM BLOOD ___ PTT-132.5* ___
___ 03:40PM BLOOD ___ PTT-132.5* ___
___ 06:31AM BLOOD Glucose-124* UreaN-35* Creat-2.1* Na-139
K-4.0 Cl-109* HCO3-21* AnGap-13
___ 06:31AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.1
___ ___ M ___ ___
VWNOUA DUPLEX
There is normal compression, color flow, and augmentation of the
common
femoral vein; proximal, mid and distal superficial femoral vein
as well as the popliteal vein. The peroneal and posterior
tibial veins were not seen. There is normal phasicity of the
common femoral veins bilaterally.
IMPRESSION:
No evidence of right lower extremity DVT. Peroneal and
posterior tibial veins were not seen.
Brief Hospital Course:
The patient was admitted to the vascular surgery service on
___. He was anticoagulated on heparin and was brought to
the operating room ___ for Right Lower Extremity
diagnostic angiogram, which revealed
R Prof, SFA and Pop patent. 2 vessel run-off through
good AT and mildly diseased ___ (PR occluded)
He was normalized that evening on his home medications and a
regular diet, and was discharged POD1, ___.
Medications on Admission:
1. Acetaminophen 650 mg PO ONCE h/a Duration: 1 Dose
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
5. Desipramine 25 mg PO HS
6. Metoprolol Tartrate 100 mg PO BID
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO ONCE h/a Duration: 1 Dose
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO DAILY
4. Clobetasol Propionate 0.05% Cream 1 Appl TP BID
5. Desipramine 25 mg PO HS
6. Metoprolol Tartrate 100 mg PO BID
7. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
peripheral arterial disease
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:
It was a pleasure taking care of you at the ___
___ for your right foot pain. Due to your
history ov vascular disease you were placed on a heparin drip.
Your angiogram of your right lower extrmity was diagnostic only.
You did not have any intervention performed. Your heparin drip
was discontinued. There are no urgent or emergent vasuclar
needs at this time. You are being discharged ot home with
visiting nurse services
Followup Instructions:
___
|
10113898-DS-18 | 10,113,898 | 27,529,166 | DS | 18 | 2112-11-20 00:00:00 | 2112-11-20 13:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Rigid Bronchoscopy with EBUS guided biopsy and bare metal
tracheal stent x 2
History of Present Illness:
The patient is a ___ year old female with history of HTN and
mediastinal mass who is transfered to the MICU for monitoring
after rigid bronchoscope EBUS with biopsy and placement of 2
uncovered metal stents.
The patient had recent history of cough and dyspnea when bending
over that did not respond to a course of treatment for
bronchitis Z-pack followed by Keflex with prednisone taper which
improved her breathing, but once off the medication, her
symptoms worsened. CT chest on ___ showed a heterogeneous
enhancing, smoothly marginated right paratracheal mass without
calcifications. The lesion measured 6.6 x 7.3 x 10 cm. The
mass deviated the trachea to the left and moderately narrowed
the trachea.
She was seen in ___ clinic today with plan to place upper airway
stent and do biopsies. She is status post rigid bronchoscopy
EBUS with biopsy of medialstinal mass and placement of 2
uncovered bare metal stents 4cm each.
On arrival to the MICU, vitals 97.7, 69, 120/72, 15, 97% on face
mask. She has throat pain but otherwise denies, chest pain,
shortness of breath, hemoptysis, fevers, or chills.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache. Denies cough, shortness of breath, or
wheezing. Denies chest pain, chest pressure, palpitations, or
weakness. Denies nausea, vomiting, diarrhea, constipation,
abdominal pain, or changes in bowel habits. Denies dysuria,
frequency, or urgency. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
1. Mediastinal Mass
2. Hypertension.
3. Gastroesophageal reflux.
4. Seasonal allergies.
Social History:
___
Family History:
Diabetes, migraines and heart disease.
Physical Exam:
ADMISSION AND DISCHARGE
Vitals- 97.7, 69, 120/72, 15, 97%
General - patient appears uncomfortable
HEENT - NC/AT, EMOI, PERRL, OP clear, MMM
Neck - neck palpation not done due to concern for stent
migration
CV - RRR, nl s1 s2, no r/m/g
Lungs - CTAB. no wheezing, crackles or rhonchi.
Abdomen - NABS, NTND
Ext - no edema
Neuro - A&Ox3, CN II-XII grossly intact. Strength and sensation
grossly intact
Pertinent Results:
ADMISSION LABS:
___ 04:00PM BLOOD WBC-9.4 RBC-4.49 Hgb-14.0 Hct-40.4 MCV-90
MCH-31.1 MCHC-34.5 RDW-12.4 Plt ___
___ 04:00PM BLOOD ___ PTT-31.9 ___
___ 04:00PM BLOOD UreaN-12 Creat-0.8 Na-142 K-3.2* Cl-102
HCO3-29 AnGap-14
___ 04:00PM BLOOD Calcium-9.3 Phos-3.2 Mg-2.2
___ 04:00PM BLOOD TSH-2.0
___ 04:00PM BLOOD HCG-<5
___ 04:00PM BLOOD AFP-2.2
.
DISCHARGE LABS:
___ 05:42AM BLOOD WBC-9.9 RBC-4.17* Hgb-13.0 Hct-36.8
MCV-88 MCH-31.1 MCHC-35.3* RDW-12.8 Plt ___
___ 05:42AM BLOOD ___ PTT-28.2 ___
___ 05:42AM BLOOD Glucose-157* UreaN-10 Creat-0.7 Na-137
K-4.5 Cl-105 HCO3-23 AnGap-14
___ 05:42AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
.
___
FNA - results PENDING
Brief Hospital Course:
___ year old female with mediastinal mass and HTN status post
EBUS guided biopsy and bare metal stent placement x 2.
# Mediastinal mass. The mass appears to extend from the thyroid
and is concerning for thyroid malignancy. The patient underwent
rigid bronchoscopy on ___ with EBUG guided biopsy and
placement of 2 4cm bare metal tracheal stents. The patient was
monitored overnight in the ICU and had no acute respiratory
issues whatsoever. The anticipated post-rigid bronchoscopy
throat pain was more than adequately controlled with Lidoneb and
IV dilaudid. She was discharged home with viscious Lidocaine,
Vicodin, and Zofran. Interventional Pulmonary will arrange
follow up with the patient and she was given their number to
facilitate making a post-discharge appointment. Patient was
previously on Prednisone for treatment of asthma vs bronchitis
and this medication was discontinued given her dyspnea was
related to a mediastinal mass compressing her airway, and
Prednisone does not treat that.
# HTN. Resarted Atenolol at discharge.
# GERD. Restarted Omeprazole at discharge.
TRANSITIONAL ISSUES:
- follow up FNA results from ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. PredniSONE 30 mg PO DAILY
Tapered dose - DOWN
Discharge Medications:
1. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every
eight (8) hours Disp #*21 Tablet Refills:*0
2. Atenolol 50 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Hydrocodone-Acetaminophen (5mg-500mg) 1 TAB PO Q6H:PRN pain
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
every six (6) hours Disp #*28 Tablet Refills:*0
5. Lidocaine Viscous 2% 20 mL PO TID:PRN pain
please swish can swallow
RX *lidocaine HCl 20 mg/mL please swish and swallow three times
a day Disp #*1 Bottle Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Mediastinal mass
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear ___,
___ was a pleasure to participate in your care during your stay
at the ___. You were admitted
so the mass in your chest can be biopsied and stents can be
placed to help you breath. The procedure went well.
The interventional pulmonologist working with Dr. ___ will
contact you regarding follow up appointments. If they do not
call in the next few days, please call ___.
You should be able to eat normally. Please take the Vicodin and
Liodcaine solution to help you with your pain. We anticipate
mild pain that should improve quickly.
Please call the interventional pulmonologists or come to the ED
if you feel sudden worsening of your breathing.
We wish you the best,
Your ___ ICU team
Followup Instructions:
___
|
10114694-DS-6 | 10,114,694 | 22,418,467 | DS | 6 | 2163-04-02 00:00:00 | 2163-04-02 17:41:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Tylenol
Attending: ___.
Chief Complaint:
Polysubstance overdose, transferred from ___
Major Surgical or Invasive Procedure:
Extubated ___ (intubated prior to transfer)
History of Present Illness:
___ male w/ history of IVDU, Hep C, HIV, ERCP s/p Stent, bipolar
w/ multiple prior psych hospitalizations presenting with concern
for overdose with suicidal intent. He was initially brought to
___ by EMS after his wife found him snorting his
medications and appearing agitated. Upon arrival to ___, he
denied suicidal or homicidal ideation but fell asleep after ___
words. Medications found by his bedside include gabapentin,
Seroquel, duloxetine, suboxone, and clonidine.
A pill count was performed and, per report from OSH and EMS,
these are the estimates regarding how many pills he took:
- Duloxetine 60 mg - 21 pills
- Clonidine 0.3 mg - 22 pills
- Suboxone ___ - 26 pills
Other pills include Seroquel, Gabapentin
At ___ patient was given 0.4 and 4 mg narcan with no
improvement, not protecting airway with shallow respirations and
pill fragments ___ mouth so intubated for airway protection.
___, the patient had an episode of sinus bradycardia
to 45, so was given 1mg atropine. Hypothermic to 35C so given
warm fluids and external warming.
___ the ED, initial vitals: T 35.7, HR 56, BP 95/75, RR 16, Sat
100% (intubated)
Labs notable for:
- 6.4 > 12.7 < 152
- Utox (+) for benzos, cocaine, and methadone
- Stox (-) for ASA, ETOH, APAP, Benzo, Barbit, Tricyc
- VBG: 7.33/57
- Lactate 1.3
- CK 113
Imaging:
- NCHCT with no acute intracranial abnormality
- CXR: Endotracheal tube tip terminates 4.5 cm cranial to the
carina, satisfactory. Upper enteric tube tip lies just proximal
to the GE junction and should be advanced by roughly 7 cm. Heart
size is normal. Cardiomediastinal silhouette and hilar contours
are grossly preserved. There is no focal consolidation. There is
no large effusion or pneumothorax.
Patient received:
- Propofol gtt
- Bicarb/D5W gtt
- 1L NS
- 0.5mg atropine x2
Vitals on transfer: T 37.1, HR 63, BP 105/71, RR 18, Sat 100%
(intubated)
Upon arrival to ___, patient was intubated and sedated. Unable
to participate ___ further history.
Past Medical History:
- HCV
- HIV
- Bipolar disorder
- Prior ERCP s/p stenting
- Wrist surgery
Social History:
___
Family History:
Unable to assess
Physical Exam:
ADMISSION EXAM:
===============
VITALS: 97.8, 102/72, 55, Sat 100% (CMV, PEEP 5, FiO2 50%, TV
500)
GENERAL: Intubated and sedated.
HEENT: Sclera anicteric, PERRL, ETT ___ place.
NECK: JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Bradycardic. Regular rate and rhythm, normal S1 S2, no
murmurs, rubs, gallops.
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No visible rashes or ecchymoses.
NEURO: Sedated, reactive pupils.
ACCESS: 2 PIV
DISCHARGE EXAM:
==============
VITALS: ___ 1221 Temp: 98.3 PO BP: 129/81 HR: 78 RR: 18 O2
sat: 96% O2 delivery: Ra
GENERAL: alert, awake, no acute distress
HEENT: Sclera anicteric
NECK: JVP not elevated
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops.
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: No visible rashes or ecchymoses.
NEURO: AAO x 3, non focal
Pertinent Results:
ADMISSION:
==========
___ 02:52PM BLOOD WBC-6.4 RBC-4.18* Hgb-12.7* Hct-39.0*
MCV-93 MCH-30.4 MCHC-32.6 RDW-14.1 RDWSD-48.0* Plt ___
___ 02:52PM BLOOD ___ PTT-33.0 ___
___ 04:00AM BLOOD Glucose-74 UreaN-10 Creat-0.5 Na-134*
K-4.0 Cl-101 HCO3-20* AnGap-13
___ 02:52PM BLOOD ALT-9 AST-17 CK(CPK)-113 AlkPhos-48
TotBili-0.3
___ 04:00AM BLOOD Calcium-7.0* Phos-2.0* Mg-1.2*
___ 02:52PM BLOOD Albumin-3.7
___ 02:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:03PM BLOOD Type-MIX pO2-41* pCO2-57* pH-7.33*
calTCO2-31* Base XS-1 Intubat-INTUBATED
___ 03:03PM BLOOD Glucose-117* Lactate-1.3 Na-143 K-4.9
Cl-103
___ 03:03PM BLOOD freeCa-1.20
PRIOR TO ICU TRANSFER:
======================
___ 02:47AM BLOOD WBC-15.2* RBC-3.65* Hgb-11.0* Hct-34.4*
MCV-94 MCH-30.1 MCHC-32.0 RDW-13.5 RDWSD-46.7* Plt ___
___ 02:47AM BLOOD Glucose-89 UreaN-12 Creat-0.8 Na-144
K-3.9 Cl-108 HCO3-22 AnGap-14
___ 02:47AM BLOOD ALT-9 AST-20 LD(LDH)-286* AlkPhos-53
TotBili-0.7
___ 02:47AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.7
___ 11:30PM BLOOD Vanco-<4.0*
___ 04:20AM BLOOD ___ pO2-55* pCO2-52* pH-7.39
calTCO2-33* Base XS-4
RELEVANT LABS:
==============
___ 02:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
MICROBIOLOGY:
=============
___ 10:49 am SPUTUM Site: ENDOTRACHEAL
Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): BUDDING YEAST.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
KLEBSIELLA PNEUMONIAE. SPARSE GROWTH.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| KLEBSIELLA PNEUMONIAE
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- <=0.25 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S <=1 S
LEVOFLOXACIN----------<=0.12 S
MEROPENEM------------- <=0.25 S
OXACILLIN------------- 0.5 S
PIPERACILLIN/TAZO----- 8 S
TETRACYCLINE---------- <=1 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S <=1 S
___ 12:09 pm URINE Source: Catheter.
URINE CULTURE (Preliminary):
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 CFU/mL.
Susceptibility testing requested per ___
(___) ___.
RADIOLOGY:
==========
___ CHEST (PORTABLE AP)
IMPRESSION:
Endotracheal tube tip terminates 4.5 cm cranial to the carina,
satisfactory.
Upper enteric tube tip lies just proximal to the GE junction and
should be
advanced by roughly 7 cm. Heart size is normal.
Cardiomediastinal silhouette and hilar contours are grossly
preserved. There is no focal consolidation.
There is no large effusion or pneumothorax.
___ CHEST (PORTABLE AP)
IMPRESSION:
The NG tube has been removed. Lungs are low volume with
bibasilar
atelectasis. Heart size is normal. No pneumothorax is seen
___ CT HEAD W/O CONTRAST
IMPRESSION:
No acute intracranial abnormality
___ CHEST (PORTABLE AP)
IMPRESSION:
The NG tube has been removed. Lungs are low volume with
bibasilar
atelectasis. Heart size is normal. No pneumothorax is seen
DISCHARGE LABS:
___ 05:46AM BLOOD WBC-7.6 RBC-3.71* Hgb-11.1* Hct-33.5*
MCV-90 MCH-29.9 MCHC-33.1 RDW-13.8 RDWSD-45.5 Plt ___
___ 05:46AM BLOOD Glucose-99 UreaN-11 Creat-0.6 Na-148*
K-3.7 Cl-110* HCO3-23 AnGap-15
___ 05:46AM BLOOD Calcium-8.3* Phos-3.3 Mg-2.0
___ 02:52PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Brief Hospital Course:
FICU Course
___ male w/ history of IVDU, Hep C, HIV, ERCP s/p Stent, bipolar
w/ multiple prior psych hospitalizations, who was transferred
from ___ after polysubstance overdose. Patient was found
snorting medications and agitated at home. Unclear exactly what
he took, but nearby pills included duloxetine, clonidine,
suboxone, gabapentin, and Seroquel. Utox positive for benzos,
cocaine, and methadone. He was intubated for airway protection.
Was bradycardic requiring clonidine both at OSH and ___ ___ ED.
Received 1x dose atropine. QRS interval was monitored and he was
given bicarb gtt. He remained stable. Respiratory and mental
status improved and he was able to be extubated. He did require
some on going doses of Seroquel and haldol for agitation.
Patient then became febrile day of extubation. Sputum increased.
CXR was read as clear by radiology, but may have had more
opacity ___ left lower lobe. Sputum sample grew MSSA. Infectious
work up was otherwise less revealing. He was treated with
vancomycin and ceftazadime. He remained hemodynamically stable
and was transferred to the floor.
Medical Floor Course:
___ male w/ history of IVDU, Hep C, ?HIV, ERCP s/p Stent, bipolar
w/ multiple prior psych hospitalizations, who was transferred
from ___ after polysubstance overdose.
ACTIVE ISSUES
#Polysubstance overdose
Patient found snorting medications and agitated at home. Unclear
exactly what he took, but nearby pills included duloxetine,
clonidine, suboxone, gabapentin, and Seroquel. Utox positive for
benzos, cocaine, and methadone. Intubated for airway protection.
Extubated with stable respiratory status. Psych was following
during the hospitalization and on ___ psych felt that he had
cleared enough and evaluated. They felt that he was not a danger
to himself or others and did not require an inpatient
psychiatric hospitalization and he could be discharge from a
psych standpoint. They felt this was an unintentional overdose
and he was not an increased risk to himself above his substance
abuse. We discussed medication management and resumed his
suboxone at home dose and his Seroquel at 200mg daily (decreased
form home 800mg). Recommended holding home duloxetine,
clonidine, and gabapentin until follow up with outpatient
provider ___ ___ couple of days.
I presented our thoughts to the patient and discussed possible
staying overnight for further monitoring but the patient
declined as he reported he had a ___ at 0900 with his
suboxone provider ___ ___ and he wanted to keep that appointment.
He requested I not update his family as he preferred to discuss
this with them.
He knew where he was going and planned on taking a commuter rail
to home. He was able to articulate how to get there and
demonstrated he had sufficient funds for the ticket. He was
thankful for the care provided. He reported he planned on going
straight to ___ to get his antibiotics on discharge.
We offered the patient assistance with a partial program or
voluntary inpatient evaluation and the patient declined. He
reported that he had a plan ___ place and would not be using any
more.
# Sepsis due to
# PNA : Fever, increased WBC and increased secretions on ___.
His sputum Cx (obtained while intubated) was notable for MSSA
and kleb PNA. Based on sensitivities once his WBC normalized he
was started on Augmentin for 5 additional days for a total of 8
day course. We discussed staying ___ the hospital to monitor
following the change but the patient declined.
# Concern for UTI: Given repeat as negative U/A makes CAUTI less
likely and CoNS a
possible contaminate. Will elect to stop IV vanco and use PO
Augmentin to cover kelb and MSSA PNA. If repeat Urine Cx grows
CoNS then will restart treatment. Source of sepsis likely PNA
given culture. Discussed this with the patient and confirmed
contact information. Patient preferred to go home rather than
await follow up culture.
#h/o IVDU, on suboxone
- Held suboxone on presentation and resumed on D?C. I called the
office of his suboxone provider who confirmed the dose and that
he was due for a urine test on ___ as the patient reported.
#?HIV
- Unclear if patient has a history of this, per ICU notes he has
a h/o HIV but patient denies it. He was instructed to follow up
with his outpatient provider.
#HCV
- unclear whether has been treated. The patient was informed and
requested to follow up with his PCP.
#Bipolar disorder
- Resumed seroqel at 200mg PO QHS on discharge per discussion
with psych. He should follow up
#Anxiety
- Holding home clonidine i/s/o polysubstance overdose. He will
follow up as an outpatient.
Greater than 30 minutes spent ___ care coordination and
counseling on the day of discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Naproxen 500 mg PO Q12H
2. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID
3. DULoxetine 30 mg PO DAILY
4. Gabapentin 400 mg PO TID
5. QUEtiapine extended-release 800 mg PO QHS
6. CloNIDine 0.2 mg PO TID
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*10 Tablet Refills:*0
2. QUEtiapine extended-release 200 mg PO QHS
RX *quetiapine 200 mg 1 tablet(s) by mouth at bedtime Disp #*4
Tablet Refills:*0
3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID
4. HELD- CloNIDine 0.2 mg PO TID This medication was held. Do
not restart CloNIDine until you follow up with your PCP and
___.
5. HELD- DULoxetine 30 mg PO DAILY This medication was held. Do
not restart DULoxetine until you follow up with your PCP and
___.
6. HELD- Gabapentin 400 mg PO TID This medication was held. Do
not restart Gabapentin until you follow up with your PCP and
___.
7. HELD- Naproxen 500 mg PO Q12H This medication was held. Do
not restart Naproxen until you follow up with your PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
Unintentional Overdose
Pneumonia
Bipolar disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___,
You were hospitalized after you overdosed on some medications.
You were intubated and treated for the overdose. You improved
and the breathing tube was removed. You were seen by psychiatry
and felt to not need an inpatient psychiatric hospitalization.
You were found to have a pneumonia and were started on Augmentin
to treat this. It is important to take all your medication as
prescribed.
Please follow up as noted below.
Followup Instructions:
___
|
10114736-DS-3 | 10,114,736 | 21,428,253 | DS | 3 | 2166-05-11 00:00:00 | 2166-05-11 15:57:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
latex
Attending: ___
Chief Complaint:
left face and arm numbness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo woman with a history of epilepsy who
presents with right hand and face numbness and tingling.
When she woke up this morning she had tingling in her right 4
and
5 fingers at 5 am. She says this came and went. She went to the
gym at 7:30 am and was feeling normal apart from intermittent
hand symptoms, then returned home to pack for a trip. Then her
right tongue and gums were tingling and numb, like novocaine.
Then the right side of the face was numb. This lasted ___
minutes total. She went to ___ at 10:30 am, right when these
symptoms occurred. The hand symptoms resolved while in the
___. She has never had these symptoms before.
She has had a few colds and lost her voice twice this ___.
Her
last cold was 2 weeks ago.
She has occasional heart palpitations. She also had these today.
Her neurologist used to be Dr. ___ she said moved on to
do geriatrics.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness. No
bowel or bladder incontinence or retention. Denies difficulty
with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness.
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:
PMHx:
-Epilepsy - started at age ___, controlled on Depakote until age
___. She was told she had petit mal seizures, with staring and
behavioral arrest. She was told she had an enlarged blood vessel
in the left side of her brain. Her last seizure was ___ years
ago.
-Hypothyroidism
-Right cholesteotoma s/p multiple resections
-C-sections x 3
-Moles removed, no skin cancers
Social History:
___
Family History:
Family Hx:
- Mother - seizures, renal aneurysm
- Brother - alcohol withdrawal seizures
- Brother - alcohol withdrawal seizures
- Sister - alcohol withdrawal seizures
- Brother - cirrhosis, seizures
- Brother - hypothyroidism
- Father - abdominal aortic aneurysm
- Paternal aunt - aortic arch aneurysm
- Maternal grandmother - cerebral aneurysm
- ___ aunt - ___ disease
- Niece - craniopharyngioma
Physical ___:
Vitals:
97.7 70 111/67 20 97% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, MMM
Neck: Supple
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. Pt. was able to name both high and low frequency
objects. Speech was not dysarthric. Able to follow both midline
and appendicular commands. Attentive, able to name ___ backward
without difficulty. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch and pinprick in all
distributions
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: right side diminished hearing.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious
movements,
such as tremor, noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5
R ___ ___ ___ 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3 3 3 3 2
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are
present.
-Sensory: No deficits to light touch, pinprick, proprioception
throughout.
-Coordination: No intention tremor noted. No dysmetria on FNF or
HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing.
-Other: right ulnar tinel's negative
##Discharge Exam##
Awake, alert, fluent. PERRL, EOMI, face symmetric, tongue
midline, strength ___ throughout without sensory abnormality. No
drift. No dysmetria or tremor. Normal tandem and heel-to-toe
gait.
Pertinent Results:
___ 07:55AM BLOOD WBC-4.4 RBC-4.16 Hgb-11.5 Hct-36.1 MCV-87
MCH-27.6 MCHC-31.9* RDW-13.4 RDWSD-42.0 Plt ___
___ 07:55AM BLOOD ___ PTT-31.7 ___
___ 07:55AM BLOOD Glucose-114* UreaN-11 Creat-0.9 Na-136
K-4.0 Cl-103 HCO3-25 AnGap-12
___ 07:55AM BLOOD ALT-12 AST-16 LD(LDH)-132 AlkPhos-40
TotBili-0.9
___ 07:55AM BLOOD Albumin-4.4 Calcium-9.3 Phos-3.3 Mg-2.0
___ ___ MRI
. Focal area of FLAIR hyperintensity corresponding to the
hyperdensity seen
in the left parietal lobe on prior CT without associated
susceptibility on
gradient echo imaging, slow diffusion or abnormal enhancement.
This is
indeterminate and likely small focus of mineralization.
2. Otherwise, unremarkable MRI of the brain without acute
intracranial
abnormality.
3. Findings of prior right sided mastoidectomy.
___ Head CT/CTA (prelim read)
No occlusion, aneurysm, or dissection is identified in the major
intracranial
and cervical or arteries.
Brief Hospital Course:
Ms. ___ was admitted to the neurology service following an
episode of unilateral sensory facial and hand sensory changes.
MRI with a cerebellar DVA and a likely small L parietal
mineralization in what was likely a prominent vessel. Head
CT/CTA negative. She had complete resolution of her symptoms
upon evaluation in the ___ and they did not occur. Neurologic
exam remained normal.
Upon further history taking, she reported that she has monthly
headaches just prior to her menses with aura of flashing lights.
She is just about to have onset of menses and took ibuprofen
this morning to try to prevent a migraine and then went on to
have these sensory changes. Given this history, normal
neurologic exam, and reassuring neuroimaging, it is most likely
that this event represents a complex migraine. No further
evaluation or work-up is needed at this time. Patient was
discharged to home.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Medications:
1. Levothyroxine Sodium 88 mcg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
complex migraine with aura
developmental venous anomaly - seen on MRI brain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
___ were admitted to the Neurology service at ___ after
presenting with right hand and face numbness and tingling. We
believe this was a complex migraine. ___ did not experience a
headache because ___ had taken ibuprofen. A CT scan of your
brain and MRI brain showed a small area of calcification on the
left. This is NOT an area of bleeding as was originally
concerned at the outside hospital. We also do NOT think this
was a seizure. We did see the abnormal blood vessel on the left
side of your brain and this is a "developmental venous anomaly"
which has likely been present since ___ were born and does not
need further investigation. It is not an aneurysm.
We wish ___ the best,
___ Neurology Team
Followup Instructions:
___
|
10114825-DS-18 | 10,114,825 | 24,797,756 | DS | 18 | 2179-07-13 00:00:00 | 2179-07-13 19:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / vancomycin / Bactrim / Keflex
Attending: ___.
Chief Complaint:
Right ankle fracture
Major Surgical or Invasive Procedure:
Right ankle ORIF
History of Present Illness:
___ female history of asthma who presents with the above
fracture s/p mechanical fall. Patient was walking downstairs
when she tripped over the last ___ stairs and sustained a
twisting injury to her right ankle. Noticed immediate pain and
deformity. She denies head strike or loss of consciousness.
Denies pain elsewhere. Endorses some numbness and tingling in
her foot.
Past Medical History:
MENOMETRORRHAGIA
DEPRESSION
CHILD ABUSE
ASTHMA
SEXUALLY TRANSMITTED DISEASE
URINARY TRACT INFECTION
YEAST
LACTOSE INTOLERANCE
IRON DEFICIENCY ANEMIA
ALLERGIC RHINITIS
FOOD ALLERGY
Social History:
___
Family History:
Noncontributory
Physical Exam:
General: Well-appearing, breathing comfortably
Focused MSK Exam:
Right Lower Extremity:
- Splint c/d/i
- ___ firing
- SILT SPN/DPN distributions
- Toes warm and well-perfused
Brief Hospital Course:
Ms. ___ presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have posterior lateral right distal tibia and fibular
fractures and was admitted to the orthopedic surgery service.
The patient was taken to the operating room on ___ for
right ankle ORIF, which the patient tolerated well. For full
details of the procedure please see the separately dictated
operative report. The patient was taken from the OR to the PACU
in stable condition and after satisfactory recovery from
anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given ___ antibiotics and anticoagulation
per routine. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
nonweightbearing and splint in the right lower extremity, and
will be discharged on lovenox for 2 weeks then transition to
aspirin 325 mg daily for two weeks for DVT prophylaxis. The
patient will follow up with Dr. ___ routine. A
thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course including reasons
to call the office or return to the hospital, and all questions
were answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ferrous Sulfate 325 mg PO TID
Discharge Medications:
1. Aspirin EC 325 mg PO DAILY
Please start in 2 weeks after you complete the lovenox. Continue
taking for 2 weeks.
2. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL ___t bedtime Disp #*14
Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
6. Senna 8.6 mg PO BID
7. Ferrous Sulfate 325 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Posterior lateral right distal tibia and fibular fractures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
-Nonweightbearing right lower extremity
MEDICATIONS:
1) Take Tylenol ___ every 6 hours around the clock. This
is an over the counter medication.
2) Add oxycodone as needed for increased pain. Aim to wean
off this medication in 1 week or sooner. This is an example on
how to wean down:
Take 1 tablet every 3 hours as needed x 1 day,
then 1 tablet every 4 hours as needed x 1 day,
then 1 tablet every 6 hours as needed x 1 day,
then 1 tablet every 8 hours as needed x 2 days,
then 1 tablet every 12 hours as needed x 1 day,
then 1 tablet every before bedtime as needed x 1 day.
Then continue with Tylenol for pain.
3) Do not stop the Tylenol until you are off of the narcotic
medication.
4) Per state regulations, we are limited in the amount of
narcotics we can prescribe. If you require more, you must
contact the office to set up an appointment because we cannot
refill this type of pain medication over the phone.
5) Narcotic pain relievers can cause constipation, so you
should drink eight 8oz glasses of water daily and continue
following the bowel regimen as stated on your medication
prescription list. These meds (senna, colace, miralax) are over
the counter and may be obtained at any pharmacy.
6) Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
7) Please take all medications as prescribed by your
physicians at discharge.
8) Continue all home medications unless specifically
instructed to stop by your surgeon.
ANTICOAGULATION:
- Please take lovenox 40mg qhs for 2 weeks, then aspirin 325 mg
daily for 2 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower.
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
none
- 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
Pt is expected to need less than 30 days of rehab
Physical Therapy:
Please refer to last ___ note assessment and plan
Treatments Frequency:
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Incision may be left open to air unless actively draining. If
draining, you may apply a gauze dressing secured with paper
tape.
- Splint must be left on until follow up appointment unless
otherwise instructed.
- Please keep plaster splint dry, using a protective bag or
covering if necessary to shower.
Followup Instructions:
___
|
10115044-DS-22 | 10,115,044 | 25,373,695 | DS | 22 | 2186-12-12 00:00:00 | 2186-12-12 21:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abd pain
Major Surgical or Invasive Procedure:
Liver lesion biopsy
History of Present Illness:
___ with DM2 and HTN who p/w abdominal pain and diarrhea in
the setting of liver masses newly seen on imaging. She had onset
of sharp, lower abdominal pain one month ago. Associated
symptoms
include nausea, fatigue, weight loss and increasing abdominal
girth. She denies f/c (although "always cold"), CP, SOB, cough,
bloody or black stool. She reports distant vaginal spotting
several years ago but none in some time.
Initially she attributed her pain to constipation, but this did
not improve with laxatives. Imaging was performed which showed
liver masses concerning for possible cholangio. Bx was
scheduled. However, the bx was cancelled due to HTN of SBP >200.
On follow up she was started on Carvedilol which she has NOT
started yet (she had not been taking her amlodipine but is now
taking it again).
On ___ she had worsening abdominal pain. By phone her PCP
office
recommended laxatives. Later on ___ she had resumption of
non-loose BM. At 0200 on ___, she had recurrent severe
abdominal
pain (consistent w/ above in location) and diarrhea. She
presented to ___ where CT abd was performed and she was
transferred here for further evaluation.
In the ED case was discussed with hepatology and ___. US was
performed. Of note, pt denies recent travel, sick contacts, and
hx of IVDU. She
has never had a colonoscopy. Hospitalization and liver bx was
recommended.
Past Medical History:
DM2
HTN
OA
Lumbar radiculopathy
HSV 2
increased weight
mastoid
surgery
abnormal Pap with colposcopy in ___ subsequent Paps were
normal.
Social History:
___
Family History:
Mother HYPERTENSION
MYOCARDIAL INFARCTION
Father NATURAL CAUSES
Daughter OVARIAN CANCER
Physical Exam:
ADMISSION EXAM:
GEN: well nourished in NAD
HEENT: NC/AT, MMM, OP clear, anicteric sclera, EOMI
NECK: supple no LAD
CV: soft ___ SEM in LUSB, RRR
PULM: CTAB no wheeze or crackles
GI: soft, mild periumbilical TTP +BS no rebound or guarding. neg
___ sign
EXT: warm well perfused no pitting edema
SKIN: no rashes or ecchymoses noted
NEURO: fluent speech, awake and alert, CN II-XII intact
PSYCH: appropriate affect
DISCHARGE EXAM:
Vitals: ___ 2337 Temp: 98.5 PO BP: 139/66 L Lying HR: 60
RR: 18 O2 sat: 99% O2 delivery: Ra
GENERAL: Alert, in NAD
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: Heart regular, loud systolic murmur
RESP: Lungs clear to auscultation with good air movement
bilaterally.
GI: Abdomen soft, slightly distended, no TTP today. soft
umbilical hernia, which she states feels at baseline. Bowel
sounds present.
SKIN: No rashes or ulcerations noted
LYMPH: no supraclavicular nodes palpated
EXTREMITIES: mild symmetric edema b/l in lower extremities.
NEURO: Alert, oriented, face symmetric, speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
Pertinent Results:
Notable labs:
CEA 5.8
AFP 1.6
CA ___ 257
___ MRI:
IMPRESSION:
1. Large dominant heterogeneous mass at the dome straddling
the right and left lobe of the liver, measuring 14 cm x 14 cm x
9 cm, demonstrating filling in post gadolinium injection. There
is associated thrombosis of the middle hepatic vein. This likely
represents a cholangiocarcinoma. However,
hepatocellular carcinoma or a mixed tumor cannot be excluded.
Recommend biopsy for confirmation.
2. Multiple satellite nodules (at least 15) within the liver.
Enlarged hypervascular lymph nodes are also seen in the
gastrohepatic region, porta hepatis and aortocaval region.
3. T11 4 mm enhancing lesion, incompletely evaluated on today's
examination.
4. Small amount of ascites.
5. A few cystic lesions are seen scattered in the pancreas
measuring up to 5 mm in the uncinate process, most likely
representing side-branch intraductal papillary mucinous
neoplasms (IPMNs).
6. Uncomplicated cholelithiasis.
___ CT ABD ___:
Conclusion:
1. Large conglomerate liver mass, may represent either primary
liver
tumor or confluent metastasis. There are additional small
lesions
scattered in left and right lobes of liver.
2. Ascites, without definite evidence of advanced peritoneal
carcinomatosis or omental infiltration. Early peritoneal
carcinomatosis could not be excluded.
3. Thickened endometrial stripe, this could represent
hypertrophy or
endometrial malignancy. Gynecologic referral for tissue sampling
should be considered.
4. Collapsed, thickened large bowel, this might represent mild
diffuse
pan colitis, advise clinical correlation. Consider
pseudomembranous or
C. difficile toxin related colitis.
5. Large gallstone, without clear evidence for acute
cholecystitis. 2
lung metastases in the RUL, RML. Medial segment RML atelectasis
adjacent to the diaphragm.
6. Additional incidental findings, as outlined above.
___ RUS US:
IMPRESSION:
1. Heterogeneous liver with multiple masses, better appreciated
on the prior MRI and CT.
2. Distended gallbladder with cholelithiasis and gallbladder
sludge as seen on prior MRI. No specific sonographic findings
for acute cholecystitis.
3. No biliary dilatation or choledocholithiasis identified.
4. Splenomegaly. Small amount of ascites.
___ LENIS
Slightly limited study due to shadowing of the bilateral
proximal femoral
veins due to extensive calcifications of the adjacent arteries.
Within this limitation, no evidence of deep venous thrombosis in
the right or left lower extremity veins.
Admisssion labs:
___ 07:58AM BLOOD WBC-9.5 RBC-4.83 Hgb-11.7 Hct-38.3
MCV-79* MCH-24.2* MCHC-30.5* RDW-14.9 RDWSD-42.6 Plt ___
___ 07:58AM BLOOD Glucose-159* UreaN-11 Creat-0.9 Na-138
K-3.5 Cl-105 HCO3-22 AnGap-11
___ 07:58AM BLOOD ALT-9 AST-74* AlkPhos-108* TotBili-1.2
___ 07:58AM BLOOD Albumin-3.1*
___ 07:58AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-POS*
Discharge labs:
___ 07:05AM BLOOD WBC-8.0 RBC-4.50 Hgb-11.0* Hct-35.6
MCV-79* MCH-24.4* MCHC-30.9* RDW-15.1 RDWSD-43.0 Plt ___
___ 07:05AM BLOOD ___ PTT-33.9 ___
___ 07:05AM BLOOD Glucose-120* UreaN-14 Creat-1.0 Na-141
K-4.1 Cl-105 HCO3-26 AnGap-10
___ 08:18AM BLOOD ALT-7 AST-62* LD(LDH)-304* AlkPhos-101
TotBili-1.0
Pending results:
Liver biopsy pathology
CT chest final read
Brief Hospital Course:
___ is a ___ woman with DM2, HTN, whose recent course
was notable for subacute abdominal pain and constipation, found
to have a large liver mass and lung masses on imaging, who
presented with new onset diarrhea after initiating laxatives,
now s/p liver biopsy, the prelim report from which suggests
likely cholangiocarcinoma.
#Suspected metastatic cholangiocarcinoma
Patient with subacute abdominal pain, found to have large liver
mass with satellite lesions, AST elevation, small amount of
ascites, suspected lung mets, and T11 lesion.
Given radiographic presentation and elevated CA ___, metastatic
cholangiocarcinoma seemed the most likely underlying diagnosis.
Preliminary path of liver bx points to this dx. Pt's abdominal
pain was adequately controlled once diarrhea improved. Provided
supportive care, Tylenol, held NSAIDs, held ASA. Trended LFTs.
Given prelim path results, we had a ___ family discussion. Onc
requested CT chest for staging and scheduled a ___ outpt f/u
appt in multidisciplinary liver tumor clinic.
# Subacute abdominal pain
# BM changes
#?Rectal thickening
Patient reported diarrhea prior to presentation, which was after
starting bisacodyl for constipation. She also continued to
endorse lower abdominal discomfort, which was worse at time of
diarrhea. CT potentially consistent with c diff, although her
diarrhea improved before a sample could be sent and other
clinical features did not suggest c diff. It is unclear whether
she has true rectal thickening that may related to her
metastatic cancer, but this could be investigated further if
lower GI symptoms persist. She was discharged with PRN milk of
magnesia since she found the effects of bisacodyl too strong.
# DM2:
Patient on 50 U BID of 70/30 at home plus sliding scale. Her
insulin was reduced dramatically due to hypoglycemia in house.
It is unclear what her needs will be at home. She was discharged
on 70/30 10 U BID plus sliding scale. She will keep a close eye
on glucose levels at home and titrate accordingly, calling PCP
if any issues. She was counseled and expressed a good
understanding of this plan.
#HTN:
Better controlled now s/p initiation of carvedilol as intended
by PCP (but pt had not started). Previously was poorly
controlled w/ documented BP in the 200s. Continue HCTZ,
Amlodipine, Carvedilol.
#Thickened endometrial stripe
- ___ consider further evaluation pending oncologic plan for
suspected cholangio
==============================
TRANSITIONAL ISSUES:
- multidisciplinary liver tumor clinic on ___ for suspected
metastatic cholangiocarcinoma
- follow-up chest CT read and final pathology from liver biopsy
- consider further evaluation of rectal thickening, particularly
if persistent lower GI symptoms
- consider further evaluation of thickened endometrial stripe if
appropriate
- titration of insulin regimen (decreased for now)
- titration of antihypertensive regimen
==============================
>30 minutes in patient care and coordination of discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen w/Codeine 1 TAB PO DAILY:PRN Pain - Moderate
2. amLODIPine 10 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Ibuprofen 600 mg PO DAILY:PRN Pain - Mild
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Aspirin 81 mg PO DAILY
7. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
8. 70/30 50 Units Breakfast
70/30 50 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
9. CARVedilol 6.25 mg PO BID
Discharge Medications:
1. Milk of Magnesia 30 mL PO Q12H:PRN Constipation - First Line
RX *magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 ml by
mouth up to twice daily as needed Refills:*2
2. 70/30 10 Units Breakfast
70/30 10 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
3. Acetaminophen w/Codeine 1 TAB PO DAILY:PRN Pain - Moderate
4. amLODIPine 10 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. CARVedilol 6.25 mg PO BID
RX *carvedilol 6.25 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
7. Hydrochlorothiazide 25 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Suspected cholangiocarcinoma
Abdominal pain
Constipation
Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Ms. ___,
You presented to ___ for abdominal pain and a biopsy of your
liver. Unfortunately, the liver biopsy shows cancer. Imaging of
your lungs showed spots that raise a concern of your cancer
having spread. This is called metastasis. A follow-up
appointment has been scheduled for ___. Please see below
for details of that appointment.
During your hospitalization, we also managed the changes to your
bowel movement. You came in with diarrhea after taking laxatives
recommended by your primary care doctor. During your
hospitalization this issue resolved, but you then had
constipation and associated abdominal pain. We will prescribe
milk of magnesia. Please take this as needed for constipation.
We also made a change to your diabetes management. During the
hospitalization, you had episodes of low blood sugar. So we
decreased the insulin that you take from 50 units twice daily to
10 unit twice daily for now. This will probably need continued
adjustment, as we discussed. If your glucose levels are running
high then you can carefully increase the dose, but if the
glucose levels are low, then you should reduce the dose. You can
talk to your primary care doctor further with any questions. You
should call your doctor or call ___ if you have very low or very
high blood sugar. You can continue your sliding scale without
any changes.
Finally, your blood pressure has been high recently, so your
primary care provider started ___ third blood pressure medication,
carvedilol. We gave this medication to you in addition to your
usual two blood pressure medications, amlodipine and
hydrochlorothiazide. Your blood pressure was well-controlled on
the three medications. Please continue taking all three
medications as prescribed and follow-up with your primary care
provider.
Please continue all other home medications as you usually take
them. It has been a pleasure taking care of you and we wish you
the best. Sincerely,
The ___ Team
Followup Instructions:
___
|
10115156-DS-10 | 10,115,156 | 22,801,147 | DS | 10 | 2141-10-20 00:00:00 | 2141-10-26 16:03:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
___ L2-4 XLIF
___ L2-5 Posterior lumbar laminectomy and fusion
History of Present Illness:
___ female presents with back pain and frequent falls. The
patient has experienced multiple frequent falls over the past ___
years. She also endorses low back pain and bilateral groin pain.
She denies any bowel or bladder incontinence. She went to an OSH
today in the setting of a recent fall where an MRI was obtained
that was concerning for canal stenosis at L3-L4 and she was
transferred to ___ for further management. She denies any
bowel
or bladder incontinence or saddle anesthesia.
Past Medical History:
HTN, Hyperlipidemia
Social History:
___
Family History:
n/a
Physical Exam:
AFVSS
General: Well-appearing female in no acute distress.
Spine Exam:
Motor: D B T WrE FFl IO IP Q HS TA ___ FHL
R: ___ ___ ___ 5
L: ___ ___ ___ 5
Sensory: C4 C5 C6 C7 C8 T1 L3 L4 L5 S1 S2
R: nl nl nl nl nl nl nl nl ___
L: nl nl nl nl nl nl nl nl nl nl nl
Reflexes: B BR Pa Ac
R: 1+ 1+ 2+ 1+
L: 1+ 1+ 2+ 1+
___: neg
Clonus:neg
Babinski: neg
Post op
- Incisions are clean and approximated
- motor is full bilaterally and sensory intact to light touch
DISCHARGE EXAM:
VITALS :l 98.5 PO 158 / 83 L Lying 79 20 93 Ra
Gen: NAD, A/O x2 and hospital
HEENT: Anicteric, PER, EOM intact, MMM, oropharynx without
erythema or exudate
Neck: no JVD, normal size thyroid gland
CV: RRR, S1/S2 noted, no murmurs/gallops
Pulm: Clear bilaterally
GI: +BS, soft, not tender, no organomegaly
GU: Foley in place
Skin: no lesions
Lymph: No occipital, preauricular, submandibular, submental,
anterior/posterior cervical, supraclavicular, axillary LAD
MSK: Warm, no edema, 2+ pedal pulses
Neuro: ___. Patient intermittently obeying commands. Able to
converse with short answers. Purposefully moving all
extremities
Pertinent Results:
___ 03:10PM GLUCOSE-93 UREA N-14 CREAT-0.5 SODIUM-144
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
___ 03:10PM WBC-8.7 RBC-4.51 HGB-13.3 HCT-39.2 MCV-87
MCH-29.5 MCHC-33.9 RDW-13.0 RDWSD-40.6
___ 03:10PM ___ PTT-29.1 ___
___ 03:10PM PLT COUNT-218
___ 02:05PM URINE COLOR-Yellow APPEAR-Cloudy* SP
___
___ 02:05PM URINE BLOOD-MOD* NITRITE-POS* PROTEIN-30*
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG*
___ 02:05PM URINE RBC->182* WBC->182* BACTERIA-FEW*
YEAST-NONE EPI-0
___ 02:05PM URINE WBCCLUMP-OCC* MUCOUS-OCC*
___ 11:23AM ___ TEMP-37.0 COMMENTS-GREEN TOP
___ 11:23AM LACTATE-1.4
___ 09:50AM GLUCOSE-106* UREA N-15 CREAT-0.5 SODIUM-143
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-27 ANION GAP-14
___ 09:50AM estGFR-Using this
___ 09:50AM URINE HOURS-RANDOM
___ 09:50AM URINE UHOLD-HOLD
___ 09:50AM WBC-9.1 RBC-4.69 HGB-13.6 HCT-40.7 MCV-87
MCH-29.0 MCHC-33.4 RDW-13.0 RDWSD-40.8
___ 09:50AM NEUTS-79.3* LYMPHS-10.2* MONOS-9.0 EOS-0.7*
BASOS-0.2 IM ___ AbsNeut-7.19* AbsLymp-0.92* AbsMono-0.81*
AbsEos-0.06 AbsBaso-0.02
___ 09:50AM PLT COUNT-229
___ 09:50AM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 09:50AM URINE BLOOD-NEG NITRITE-POS* PROTEIN-TR*
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-SM*
___ 09:50AM URINE RBC-0 WBC-7* BACTERIA-MANY* YEAST-NONE
EPI-<1
___ 09:50AM URINE MUCOUS-RARE*
DISCAHRG LABS:
___ 07:07AM BLOOD WBC-7.1 RBC-3.80* Hgb-11.0* Hct-33.6*
MCV-88 MCH-28.9 MCHC-32.7 RDW-13.4 RDWSD-43.5 Plt ___
___ 07:07AM BLOOD Glucose-101* UreaN-12 Creat-0.5 Na-147
K-3.7 Cl-106 HCO3-28 AnGap-13
___ 07:07AM BLOOD Calcium-8.9 Phos-3.7 Mg-1.7
KEY IMAGING STUDIES:
MRI SPINE ___: Spot view shows the lower lumbar spine, with
discogenic and facet degenerative changes. Assessment of fine
bony detail is limited by fluoroscopic technique. No radiopaque
hardware identified on this view
___ SPINAL FLUORO WITHOUT R: Spot view shows the lower
lumbar spine, with discogenic and facet degenerative changes.
Assessment of fine bony detail is limited by fluoroscopic
technique. No radiopaque hardware identified on this view.
CXR ___ are no prior chest radiographs available for
review.
Lung volumes are extremely low. Right basal opacification is
almost certainly atelectasis. Less clearly seen consolidation
in the left lower lobe and in the lingula, obscuring the left
heart border, could be atelectasis or pneumonia. Vascular
congestion in the left lung is probably positional. Pleural
effusions are likely, but not large. No pneumothorax.
___ CTA CHEST: 1. Acute PE involving the distal right main
pulmonary artery extending to the lobar and proximal segmental
branches of the right upper and lower lobes.
2. No evidence of right ventricular strain.
3. No evidence of pulmonary hemorrhage/infarction.
CXR ___: Comparison to ___. Stable low lung
volumes. Stable elevation of the bilateral hemidiaphragms with
formation of relatively extensive areas of basilar atelectasis.
Moderate cardiomegaly persists. Mild to moderate pulmonary
edema is visualized.
___ CT HEAD: 1. Postsurgical changes, encephalomalacia anterior
frontal lobe the surgical bed. Presumed dural thickening deep
to the craniotomy, residual or recurrent meningioma cannot be
excluded on this scan.
2. No evidence of acute intracranial process. Severe chronic
small vessel
ischemic changes
MICROBIOLOGY
OTHER STUDIES:
eeg ___: This is an abnormal continuous ICU EEG monitoring
study because
of diffuse right hemispheric slowing, indicative of focal
cerebral dysfunction in this region. There are abundant right
frontotemporal spikes and rare left frontal temporal spikes,
indicating regions with increased epileptogenic potential. The
background is otherwise slow and disorganized, best seen in the
left hemisphere, consistent with mild to moderate encephalopathy
which is a nonspecific finding that can be associated with
toxic/metabolic derangement, medication effect, or anoxia. There
are no electrographic seizures.
EEG ___: This is an abnormal continuous ICU EEG monitoring
study because
of diffuse right hemispheric slowing, indicative of focal
cerebral dysfunction in this region. There are right
frontotemporal spikes and rare left frontal temporal spikes,
indicating regions of potentially epileptogenic cortex; however,
these discharges are less frequent compared to the previous
days' recording. The background is otherwise slow and
disorganized, best seen in the left hemisphere, consistent with
mild to moderate encephalopathy which is a nonspecific finding
that can be associated with toxic/metabolic derangement,
medication effect, or anoxia. There are no electrographic
seizures.
ECHO ___: The left atrium is mildly dilated. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). Doppler parameters are indeterminate for
left ventricular diastolic function. Right ventricular chamber
size and free wall motion are normal. The 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 pulmonary artery systolic pressure could not be
determined. There is an anterior space which most likely
represents a prominent fat pad.
IMPRESSION: Suboptimal image quality. Normal biventricular
regional/global systolic function. No specific echocardiographic
evidence of right ventricular strain noted.
___. difficile DNA amplification assay-FINAL
negative
___ SCREENMRSA SCREEN-FINAL
negative
___ CULTUREBlood Culture, Routine-FINAL
negative
___ CULTUREBlood Culture, Routine-FINAL
negative
___ PLASMA REAGIN TEST-FINAL
negative
___ CULTUREBlood Culture, Routine-FINAL
negative
___ CULTUREBlood Culture, Routine-FINAL
negative
___ CULTURE-FINAL
negative
___ CULTURE-FINAL
negative
___ CULTUREBlood Culture, Routine-FINAL
negative
___ CULTUREBlood Culture, Routine-FINAL
negative
___ CULTURE-FINAL
grew ESCHERICHIA COLI
Brief Hospital Course:
Ms. ___ is a ___ year old female with history of hypertension,
hyperlipidemia, prediabetes, seizure disorder, and frequent
falls who initially presented with back pain and bilateral groin
pain to an OSH in setting of a recent fall, where an MRI was
obtained that was concerning for L3-L4 spinal stenosis. She
denied any bladder or bowel incontinence however given
concerning MRI findings, was transferred to ___ for further
management. During her admission she was treated for the
following:
# Spinal stenosis: Patient was admitted to Ortho Spine on ___
for possible surgical intervention given gait difficulties with
acute MRI findings. Patient underwent first step L2-L4 XLIF on
___. On POD0, patient spiked a fever to 101.5, with new
leukocytosis of 12.2 up from 8.4. She was diagnosed with a UTI
(see UTI below). Her post op care is also complicated by a PE
and delirium (see below)
# UTI
# Sepsis: The patient developed fever and shortness of breath,
her CXR was negative and her UA was positive. therefore she was
treated for a UTI with IV ceftriaxone. However, due to
continuous fevers despite CTX, her antibiotic was switched to
cefepime which improved her fever. Her urine culture from ___
grew ESCHERICHIA COLI.
# Pulmonary embolism: the patient developed PE in her immediate
post-op recovery phase which manifested as hypoxia and shortness
of breath. CXr was negative and a CTA of the chest confirmed
acute PE involving the distal right main pulmonary artery
extending to the lobar and proximal segmental branches of the
right upper and lower lobes she was started on heparin and was
placed on 4L NC initially. Once her condition stabilized was
started on apixaban and her O2 requirement was reduced and she
was weaned off to RA 2 days prior to discharge. She underwent
echo which did not show evidence of right heart strain.
# Encephalopathy: Her post op course was also complicated by
worsening confusion. She was also combative, with aggressive
behavior. Her CT head was negative for a bleed and Geriatrics
was consulted. Code purple was called on ___ and patient
received Haldol and Ativan. Patient has subsequently been
managed with zyprexa for delirium. She was started on trazodone
for sleep and restarted on a lower dose of her fluoxetine. He
delirium improved on a daily basis and she was stable for > 24
on the day of discharge and was able to say the days of the week
backwards. The delirium was likely secondary to her UTI which
was treated with cefepime IV.
Transitional issues:
[ ] please follow up mental status and monitor for signs of
delirium. may requeir alteration in antipsychotic medication as
needed
[ ] the patient has urine retention and a foley was placed.
Flomax was started. attempt a voiding trial in 3 days from
discharge.
[ ] her sodium levels are on the high end of normal and she was
given free water to correct that. please check her sodium level
on ___
[ ] she was found to have a PE on this admission and was
discharged on 10mg of apixaban BID. Please transition to 5mg
apixaban BID on ___
[ ] the patient has high INR likely from nutritional deficiency,
and starting apixaban. Please check INR in 1 weeks
[ ] conside C. diff infection if diarrhea develops as she was on
broad spectrum Abx while in hospital.
[ ] due to chronic anemia, please follow-up CBC (rec once per
week at rehabilitation)
[ ] Ensure age-appropriate screenings including colonoscopy are
up
to date
[ ] Can consider starting aspirin for prophylaxis once medically
stable, no more surgeries are planned, and Hgb has been stable.
code status: full
contact: Name of health care proxy: ___
Relationship: Niece
Phone number: ___
___ on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Divalproex (EXTended Release) 500 mg PO BID
3. Quinapril 20 mg PO DAILY
4. FLUoxetine 40 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Vitamin D Dose is Unknown PO DAILY
7. Vitamin B Complex 1 CAP PO DAILY
8. Grape Seed (grape seed extract) unknown oral DAILY
9. Fish Oil (Omega 3) 1000 mg PO BID
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Apixaban 5 mg PO BID Duration: 1 Dose
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
3. Apixaban 10 mg PO BID Duration: 1 Day
RX *apixaban [Eliquis] 5 mg 2 tablet(s) by mouth once at night
Disp #*1 Tablet Refills:*0
4. OLANZapine 2.5 mg PO BID
RX *olanzapine 2.5 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
5. OxyCODONE (Immediate Release) 2.5-5 mg PO BID:PRN Pain -
Moderate
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
6. Tamsulosin 0.4 mg PO QHS
7. TraZODone 25 mg PO QHS insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
8. FLUoxetine 10 mg PO DAILY
9. Atorvastatin 10 mg PO QPM
10. Divalproex (EXTended Release) 500 mg PO BID
11. Quinapril 20 mg PO DAILY
12. Vitamin B Complex 1 CAP PO DAILY
13. HELD- Fish Oil (Omega 3) 1000 mg PO BID This medication was
held. Do not restart Fish Oil (Omega 3) until primary care
provider
14. HELD- Grape Seed (grape seed extract) unknown oral DAILY
This medication was held. Do not restart Grape Seed until
primary care provider
15. HELD- Vitamin D Dose is Unknown PO DAILY This medication
was held. Do not restart Vitamin D until primary care provider
___:
Extended Care
Facility:
___
Discharge Diagnosis:
primary diagnosis.
lumbar stenosis
UTI
delirium
pulmonary embolism
hypernatremia
coagulopathy
secondary diagnosis:
HTN
HLD
preDM
Seizure Disorder
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 ___,
___ was a pleasure taking care of you at the ___. Your were
admitted due to back pain and underwent spinal surgery on
___. You underwent completed the first phase of the surgery
successfully. You on the day of your surgery you developed a
fever and we found that you have a urine tract infection which
was treated with IV antibiotics. We also noticed that your
oxygen saturation was low and an imaging of the chest showed
that you had a clot in the lungs which was treated with IV blood
thinners. You were then transitioned to oral blood thinners
called apixaban that you will continue to take twice a day with
a dose of 5mg. you will need the apixaban lifelong. We also
added some medication that will help you sleep during the night
and prevent delirium.
Please find ___ some instructions from our spine surgery
colleagues regarding your surgery and follow up.
It was a pleasure taking care of you at the ___.
We wish you all the best.
Your ___ team
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Spine surgery recommendations:
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Lumbar Decompression With Fusion:
You have undergone the following operation: Lumbar Decompression
With Fusion
Follow-up Appointments
After you are discharged from the hospital and settled at home
or rehab, please make sure you have two appointments:
1.2 week post-operative wound check visit after surgery
2.a post-operative visit with your surgeon for ___ weeks after
surgery.
You can reach the office at ___ and ask to speak
with your surgeons surgical coordinator/staff to schedule or
confirm your appointments
Wound Care
If not already done in the hospital, remove the incision
dressing on day 2 after surgery.
You may shower day 3 after surgery. Starting on this ___ day,
you should gently cleanse the incision and surrounding area
daily with mild soap and water, patting it dry when you are
finished.
Some swelling and bruising around the incision is normal. Your
muscles have been cut, separated and sewn back together as part
of your surgical procedure. You will leave the hospital with
back discomfort from the surgical incision. As you become more
active and the incision and muscles continue to heal, the
swelling and pain will decrease.
Have someone look at the incision daily for 2 weeks. Call the
surgeons office if you notice any of the following:
___ redness along the length of the incision
___ swelling of the area around your incision
___ from the incision
___ of your extremities greater than before surgery
___ of bowel or bladder control
___ of severe headache
___ swelling or calf tenderness
___ above 101.5
Do not soak or immerse your incision in water for 1 month. For
example, no tub baths, swimming pools or jacuzzi.
Activity Guidelines
You MAY be given a RIGID BRACE that you will wear whenever
sitting up, standing, or walking. You will wear it for ___
weeks after surgery. See the last page of these instructions for
details on wearing the brace.
Avoid strenuous activity, bending, pushing or holding your
breath. For example, do not vacuum, wash the car, do large
loads of laundry, or walk the dog until your follow-up visit
with your surgeon.
Avoid heavy lifting. Do not lift anything over ___ pounds for
the first few weeks that you are home from the hospital.
Increase your activities a little each day. Walking is good
exercise. Plan rest periods and try to avoid hills if possible.
Remember, exercise should not increase your back pain or cause
leg pain.
Reaching: When you have to reach things on or near the floor,
always squat (bending the knees), rather than bending over at
the waist.
Lying down: when lying on your back, you may find that a pillow
under the knees is more comfortable. When on your side, a
pillow between the knees will help keep your back straight.
Sitting: should be limited to ___ minutes at a time for the
first week. Slowly increase the amount of sitting time,
remembering that it should not increase your back pain.
Stairs: use stairs only once or twice a day for the first week,
or as directed by the surgeon. Climb steps one at a time,
placing both feet on the step before moving to the next one.
Driving: you should not drive for ___ weeks after surgery. You
should discuss driving with your surgeon /nurse practitioner
/physician ___. You may ride in a car for short distances.
When in the car, avoid sitting in one position for too long.
If you must take long car rides, do not ride for more than 60
minutes without taking a break to stretch (walk for several
minutes and change position.).
Sexual activity: you may resume sexual activity ___ weeks after
surgery (avoiding pain or stress on the back).
Reduction in symptoms: patients who have experienced back and
radiating leg pain for a short window of time before surgery
should anticipate a significant decrease in pre-operative
symptoms. If the pain has been present for a longer period
(months to years), the pre-operative symptoms will recover on a
more gradual basis week by week. It is not practical to expect
immediate relief of symptoms. Routinely, pain will gradually
improve on a weekly basis, weakness on a monthly basis, and
numbness in a range of 6 months to ___ year.
Physical Therapy
Outpatient Physical Therapy (if appropriate) will not begin
until after your post-operative visit with your surgeon. A
prescription is needed for formal outpatient therapy.
You may be given simple stretching exercises or a prescription
for formal outpatient physical therapy, based on what your needs
are after surgery.
Medications
You will be given prescriptions for pain medications and stool
softeners upon discharge from the hospital.
Pain medications should be taken as prescribed by your surgeon
or nurse practitioner/ physician ___. You are allowed to
gradually reduce the number of pills you take when the pain
begins to subside.
If you are taking more than the recommended dose, please
contact the office to discuss this with a practitioner ___
medication may need to be increased or changed).
Constipation: Pain medications (narcotics) may cause
constipation. It is important to be aware of your bowel habits
so you ___ develop severe constipation that cannot be treated
with simple, over the counter laxatives.
Most prescription pain medications cannot be called into the
pharmacy for renewal. The following are 2 options you may
explore to obtain a renewal of your narcotic medications:
1.Call the office ___ days before your prescription runs out and
speak with office staff about mailing a prescription to your
home/pharmacy. (Prescriptions will not be sent by Fed Ex/UPS)
2.Call the office 24 hours in advance and speak with our office
staff about coming into the office to pick up a prescription.
If you continue to require medications, you may be referred to
a pain management specialist or your medical doctor for ongoing
management of your pain medications
Avoid NSAIDS for ___ weeks post-operative. These medications
include, but are not limited to the following:
1.Non-steroidal Anti-inflammatory drugs: Advil, Aleve, Cataflam,
Clinoril, Diclofenac, Dolobid, Feldene, Ibuprofen, Indocin,
Medipren, Motrin, Nalfon, Naprosyn, Nuprin, Relafen, Rufen,
Tolectin, Toradol, Trilisate, Voltarin
Blood Clots in the Leg
1.It is not uncommon for patients who recently had surgery to
develop blood clots in leg veins.
Symptoms include low-grade fever, and/or redness, swelling,
tenderness, and/or an
aching/cramping pain in your calf.
You should call your doctor immediately if you have these
symptoms.
To prevent blood clots in legs, try walking and/ or pumping
ankles several times during the day.
If the blood clot breaks free from the leg vein, it can travel
to the lungs and cause severe breathing difficulty and/or chest
pain. If you experience this, call ___ immediately.
Questions
Any questions may be directed to your surgeon or physician
___.
1.During normal business hours (8:30am- 5:00pm), you can call
the office directly at ___. Turn around time for a
phone call is 24 hours. After normal business hours, you can
call the on-call service and we will get back to you the next
business day.
If you are calling with an urgent medical issue, please tell
the coordinator that it is an urgent issue and needs to be
discussed in less than 24 hours (i.e. pain unrelieved with
medications, wound breakdown/infection, or new neurological
symptoms).
Lumbar Corset or (TLSO) Brace Guidelines
You MAY have been given a rigid brace that you will wear for
___ weeks after surgery.
You should put on your brace as you have been instructed by the
orthotist (brace maker). Instructions will be reviewed in the
hospital by the nursing staff and Physical Therapist.
It is a good idea to start practicing with your brace before
surgery (putting it on/taking it off, sitting, standing,
walking, and climbing steps with the brace) so you can assist
with your post-operative care in the hospital.
Keep the name and phone number of the person who fitted and
dispensed your brace close by in case you need to have the brace
checked and/or adjusted.
You should always have a barrier between your surgical incision
and the brace. For example, you may want to put on a light
t-shirt and then the brace before getting dressed for the day.
During periods of rest, take off the brace and expose the
incision to the air by lying on your side for a few hours. This
will reduce the chance of your wound breaking down.
1.The brace must be worn at all times with the following 3
exceptions: 1.Lying flat in bed during a rest period or at
night to sleep.
2.Getting out of bed at night to go to the bathroom, returning
to bed immediately when you are finished.
3.Showering. You may wish to use a shower chair to help prevent
bending/twisting while bathing. You should have someone help
wash your back and legs.
Followup Instructions:
___
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10115513-DS-17 | 10,115,513 | 24,907,785 | DS | 17 | 2164-09-14 00:00:00 | 2164-09-21 17:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nortriptyline
Attending: ___.
Chief Complaint:
L thigh pain, inability to walk
Major Surgical or Invasive Procedure:
___: Spinal stimulator removal
___: CT Lumbar Myelogram
History of Present Illness:
___ year old gentleman with history of chronic lower back pain
secondary to work-related injury (started ___ with L4-L5
microdiscectomy ___ and spinal cord stimulator ___, with
numerous facet injections, currently followed by Dr. ___
pain ___ who presented to ED with atraumatic left leg pain.
This occurred on ___ when ___ attempted to stand and
had acute onset left leg pain encompassing his entire left
quadriceps. At home, ___ attempted to control the pain with left
over oxycontin, Q2H ibuprofen, as well as Lidoderm patches.
Initially pain resolved, but occurred again on ___ in a
similar fashion. On ___, ___ reports the pain was so severe
now ___ is unable to walk, and ___ presented to ___. At
___ received vicodin but did not have his pain
controlled. This ultimately prompted him to present to the
emergency room last evening. ___ denies any new worsening
weakness or sensation changes. The pain is a constant
stabbing/throbbing sensation and ___ in severity. No real
alleviating or exacerbating factors except when ___ attempts to
walk. Due to the pain, ___ has been unable to put pressure on the
leg and has been unable to ambulate since ___. Denies any
fevers, chills, night sweats, nausea, vomiting, diarrhea, chest
pain, chest pressure. Denies urinary or stool incontinence.
Denies perianal numbness. ___ is only able to lay on the left
side as this resolves the pain.
Of note, patient usually does not require pain medication and
only uses ibuprofen 800 mg as needed for back pain over the last
several years.
In the ED, initial VS were: pain 5, Temp 96.4, HR 60, BP 160/92,
RR 16, Pulse Ox 97% on RA. Labs were notable for normal CBC and
normal chemistry panel. ___ received 5 mg Morphine sulfate x 3.
Due to uncontrolled pain ___ was admitted to Medicine service for
pain control.
On arrival to the floor, patient is laying on his left side and
notes being in significant pain in the left thigh. ___ was able
to reconfirm history as above. ___ also mentioned that ___ most
recently received bilateral facet cortisone injection to left
lower back in ___. ___ follows with Dr. ___ in chronic pain
clinic routinely.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
-Abnormal Liver Function Tests
-Atypical Nevi
-Back Pain: MRI ___: L3-L4, ___ disc disease, radiculopathy
treated with L4-L5 disecectomy ___. Had MRI ___ showing
post-surgical changes at L4-L5, possible small residual disc
material in the midline.
-Peripheral Neuropathy (L leg secondary neuropathy after lumbar
microdisecectomy.
-Degenerative joint disease (L knee; s/p arthroscopy)
-Depression
-Diabetes Type II
-Eczema
-Hyperlipidemia
-Hypertension
-Obesity.
-Low Back Pain
-Leg Pain
-Vitamin D Deficiency
Social History:
___
Family History:
F: died at ___, alcoholic, hypertension, CVA.
Mother, living ( ___: hypercholesterolemia, disk
disease, ADH breast.
MGM: died, alzheimers, htn, PUD.
MGF: died, DM, CAD, spinal stenosis.
PGM: died at ___.
PGF: died at ___ prostate CA.
Sister and
brother alive and well.
Son: ___ disease. No family history of early prostate CA or
colon CA.
Physical Exam:
Physical Exam on Admission:
VS: 97.9, 163/94, 60, 20, 96% on RA.
GENERAL: Middle aged gentleman laying in bed on left side,
resting comfortably although does appear in discomfort when
trying to move to his back or any other position.
HEENT: PERRL, EOMI, moist mucous membranes.
NECK: supple, no elevated JVD.
CARDIAC: RRR, S1/S2, no murmurs, rubs or gallops.
LUNG: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
ABDOMEN: soft, non-tender, non-distended, no rebound or
guarding, normoactive bowel sounds.
EXTREMITIES: No lower extremity edema. Warm and well perfused.
Fasciculations/spasm of the quadriceps is appreciated.
NEURO: AAOx3, CN II-XII intact. Strength in right lower
extremity ___ to flexion and extension at knee and ankle. 2+
reflexes at R patella. LLE ___ power on dosiflexion and
plantarflexion. 1+reflexes at L patella. Has decreased sensation
in the left lower extremity which also is his baseline. Straight
leg test questionably positive.
BACK: Palpation of midline spine reveals minimal tenderness
which is near his baseline. Spinal stimulator noted to left of
lumbosacral region. Surgical scars from prior neurosurgery
stable.
SKIN: Nevi located on the back.
=
================================================================
Physical Exam on Discharge:
VS: 98.0, 120-150s/60-80s, 60-80s, 20, 96% on RA.
GENERAL: Middle aged gentleman laying in bed on left side,
appearing comfortable
HEENT: PERRL, EOMI, moist mucous membranes.
NECK: supple, no elevated JVD.
CARDIAC: RRR, S1/S2, no murmurs, rubs or gallops.
LUNG: Clear to auscultation bilaterally, no wheezes, rales or
rhonchi.
ABDOMEN: soft, non-tender, non-distended, no rebound or
guarding, normoactive bowel sounds.
EXTREMITIES: No lower extremity edema. Warm and well perfused.
Symmetrical upper and lower legs. +Severe TTP in L thigh with
some interval improvement. +TTP in bilateral upper buttocks.
NEURO: AAOx3, CN II-XII intact. Strength in right lower
extremity ___ to flexion and extension at knee and ankle. 2+
reflexes at R patella. LLE ___ power on dorsiflexion and
plantarflexion. 1+reflexes at L patella. Has decreased sensation
in the left lower extremity which also is his baseline.
Wide-based gait.
BACK: Palpation of midline spine reveals minimal tenderness
which is near his baseline. No palpable protrusions in the lower
back. Midback wound c/d/I, with residual blood but confined
within gauze.
SKIN: Nevi located on mid back.
Pertinent Results:
Labs on Admission:
___ 10:05PM BLOOD WBC-6.2 RBC-5.35 Hgb-15.1 Hct-44.9 MCV-84
MCH-28.2 MCHC-33.6 RDW-13.0 RDWSD-39.4 Plt ___
___ 10:05PM BLOOD Plt ___
___ 10:05PM BLOOD Glucose-101* UreaN-18 Creat-1.0 Na-140
K-3.4 Cl-98 HCO3-30 AnGap-15
___ 10:05PM BLOOD Calcium-9.5 Phos-4.2 Mg-2.2
___ 09:45AM BLOOD LD(LDH)-180 CK(CPK)-152
___ 09:45AM BLOOD CRP-0.8
___ 10:05PM BLOOD CRP-0.7
___ 10:05PM BLOOD GreenHd-HOLD
___ 09:45AM BLOOD SED RATE-Test
=============================================================
Labs on Discharge:
___ 06:43AM BLOOD WBC-13.1*# RBC-4.96 Hgb-14.0 Hct-42.5
MCV-86 MCH-28.2 MCHC-32.9 RDW-13.2 RDWSD-41.2 Plt ___
___ 06:43AM BLOOD Plt ___
___ 06:43AM BLOOD Glucose-116* UreaN-18 Creat-1.1 Na-138
K-3.8 Cl-99 HCO3-29 AnGap-14
___ 06:43AM BLOOD Calcium-9.5 Phos-4.0 Mg-2.7*
=============================================================
Micro: None
=============================================================
Clinical Studies/Imaging:
MRI: ___
IMPRESSION:
1. Findings of arachnoiditis unchanged since the CT myelogram of
___.
2. Left lateral disc bulges and protrusions at L2-3 and L3-4
compromising the exiting nerve roots.
3. Disc protrusion with surrounding scar encroaching on the
thecal sac and the left L5 nerve root at L4-5.
4. Subcutaneous soft tissue likely scarring in the midline and
T12 and L1. This is presumably related to the spinal stimulator
placement.
CXR: ___
IMPRESSION:
Compared to prior chest radiographs ___.
Heart size top-normal. Lungs clear. Mild bilateral hilar
fullness is stable since ___, probably due to mildly enlarged
central pulmonary arteries, rather than lymph node enlargement.
There is no pleural effusion.
CT Myelogram: ___
IMPRESSION:
1. Multilevel degenerative changes of the lumbar spine as
described, including interval increase in the size of a left
paracentral disc protrusion at L4-L5 in comparison to ___
lumbar spine MRI, which results in increased impingement of the
traversing left L5 nerve root and progressive mild-to-moderate
right neural foraminal, moderate left neural foraminal, and mild
spinal canal stenosis.
2. Postsurgical changes related to prior L4-5 laminectomy.
3. Transitional anatomy with pseudoarticulation of left L5
transverse process with the sacrum.
4. Spinal stimulator as described.
CT L Spine with Contrast: ___
IMPRESSION:
1. Postsurgical changes identified at L4/L5 level, consistent
with bilateral laminectomies, spinal cord stimulator appears in
place, entering posterior to T11/T12 level interspinous process.
No fractures of the lumbar spine are identified.
2. Degenerative changes throughout the lumbar spine remain
relatively stable since the prior MRI of the lumbar spine, with
persistent focal protrusion at L4/L5 level.
CT Pelvis: ___
IMPRESSION:
1. No fracture or dislocation.
2. Mild degenerative changes of bilateral hips, SI joints and
pubic symphysis.
3. No obvious abnormality along the expected course of the
femoral nerves
bilaterally. Note that direct evaluation of the femoral nerve
on CT is
limited.
EKG: ___
Sinus rhythm. Normal ECG. Compared to the previous tracing of
___ no
change.
Xray Hip: ___
IMPRESSION:
1. No fracture seen.
Brief Hospital Course:
___ year old gentleman with history of chronic lower back pain
secondary to work-related injury (started ___ with L4-L5
microdiscectomy ___ and spinal cord stimulator ___, with
left foot drop, currently followed by Dr. ___ pain clinic,
admitted for atraumatic left thigh pain likely related due to
L4-L5 disc protrusion.
#L2-L3 and L4-L5 Lateral Disc Herniation: Patient has a history
of chronic LBP from work-related injury s/p L4-L5
microdiscectomy in ___ and spinal stimulator palcemen tin ___,
who was admitted for acute onset of L anterior and lateral thigh
pain (overlapping the quadriceps muscle). ___ has never had thigh
pain before and denied any traumatic injury. A CT lumbar
demonstrated a large central disc bulge at the L4-L5 level which
effaces the anterior CSF space and contacts the thecal sac. In
order to better visualize the lesion, a CT Myelogram was
obtained on ___ and showed a left paracentral disc
protrusion at L4-L5, resulting in increased impingement of the
traversing left L5 nerve root. The chronic pain service was
consulted and believed the anatomy of the lesion does not
perfectly correspond to the distribution of the thigh pain. The
orthopedic spine surgery team was consulted and recommended an
MRI in order to better characterize the lesion. However, patient
was unable to have an MRI due to his spinal stimulator. After
multiple discussions with Dr. ___ spine) and Dr. ___
___ pain), patient decided to have the spinal stimulator
removed in order to obtain an MRI. Patient tolerated the spinal
stimulator removal procedure by chronic pain service well
(___). ___ underwent an MRI on ___ which demonstrated
lateral L2-L3 and L4-L5 disc herniation, which was compressing
the exiting nerve roots. Dr. ___ the MRI and
believed this was the source of his L thigh pain. Patient will
undergo surgical intervention at a date to be determined by Dr.
___ pre-op evaluation. The orthopedic surgery team
will call him regarding pre-operative planning. In order to
facilitate the process for surgery, a CXR and UA were obtained
for pre-operative evaluation, and were negative. For pain
control, patient was discharged on gabapentin 800mg TID (started
by pain service) and dilaudid 2mg PO Q8H PRN severe
breakthrough. Patient will follow-up with chronic pain service.
___ was evaluated by physical therapy who recommended outpatient
___ follow-up. At the time of discharge, patient was fully
ambulatory with persistent L thigh pain.
#Hypertension: Patient was intermittently hypertensive during
this hospitalization, which was likely ___ to pain. Patient was
continued on home metoprolol, and his lisinopril was increased
from 5mg to 10mg for several days but resumed to 5mg on the day
of discharge. Patient's blood pressure was 120s-150s/60s-80s at
the time of discharge (final BP 137/62). This was communicated
via email to patient's primary care physician in order to
facilitate the transition of care.
#Hyperglycemia: Patient has a A1C 6.2%, which is diagnostic of
pre-diabetes. Patient will follow-up with his primary care
physician in the outpatient setting.
#Hyperlipidemia: continue atorvastatin 10 mg PO daily.
It was a pleasure to care for him during this hospitalization.
=
=
=
=
================================================================
Transitional Issues:
1. Follow-up regarding patient's L thigh pain, thought ___ L2-L3
and L4-L5 lateral disc herniation. Patient will undergo surgery
with Dr. ___ the week of ___. ___ will be
contacted by the orthopedics department with pre-operative
details. Pre-operative testing including Chest Xray and UA were
pending at the time of discharge.
2. Patient was started on gabapentin 800md TID by the chronic
pain service. ___ was discharged on dilaudid 2mg PO Q8H for
interim pain control until surgery (15 tabs).
3. Patient was diagnosed with pre-diabetes (A1C 6.2%).
4. After discussing with Dr. ___, patient was continued
on aspirin 81mg daily (instead of 325mg).
5. Follow-up on blood pressure. Patient was intermittently
hypertensive likely ___ pain. Blood pressure was
120s-150s/60s-80s at the time of discharge.
# CODE: Full code (confirmed)
# CONTACT: ___ (brother): ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. albuterol sulfate 90 mcg/actuation inhalation 2 puffs Q4H PRN
shortness of breath/wheezing
2. Atorvastatin 10 mg PO QPM
3. Ibuprofen 800 mg PO BID:PRN back pain
4. Lisinopril 5 mg PO DAILY
5. Metoprolol Succinate XL 200 mg PO DAILY
6. Sildenafil 25 mg PO WEEKLY
7. Aspirin 325 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Vitamin E 800 UNIT PO DAILY
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 10 mg PO QPM
3. Lisinopril 5 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Vitamin E 800 UNIT PO DAILY
6. albuterol sulfate 90 mcg/actuation inhalation 2 puffs Q4H PRN
shortness of breath/wheezing
7. Ibuprofen 800 mg PO BID:PRN back pain
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Sildenafil 25 mg PO WEEKLY
10. Gabapentin 800 mg PO TID
RX *gabapentin 800 mg 1 tablet(s) by mouth Three times daily
Disp #*30 Tablet Refills:*0
11. HYDROmorphone (Dilaudid) 2 mg PO Q8H:PRN breakthrough pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth Every 8
hours as needed for severe pain Disp #*15 Tablet Refills:*0
12. Acetaminophen 650 mg PO Q6H
13. Outpatient Physical Therapy
Outpatient physical therapy
L2-L3 and L3-L4 Lateral Disc Herniation
ICD 10: M51.9
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses:
1. L lateral L2-L3 and L3-L4 disc herniation
2. L5 disc herniation near thecal sac
3. L thigh pain
4. Pre-diabetes
Secondary Diagnoses:
1. Hypertension
2. Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Mr. ___,
It was a pleasure to care for you during this hospitalization.
You were admitted after you presented with new L thigh pain. We
performed a CT scan that demonstrated a L4-L5 disc herniation.
The orthopedic surgeons evaluated you and recommended a CT
Myelogram which confirmed these findings but is not optimal in
evaluating the nerve roots. As a result, it was recommended that
you undergo an MRI. In order to undergo this study, the chronic
pain service needed to remove your spinal stimulator. You
tolerated this procedure well and completed the MRI of your
lumbar spine. The imaging showed a far lateral disc herniation
at the L2-L3 level and L3-L4 level that was compressing the
exiting nerve roots. Dr. ___ the MRI and believed
that your left thigh pain was due to the compression of these
nerve roots. ___ recommended surgical treatment, which will occur
some time next week. In order to prepare you for surgery, we
obtained a chest Xray and urinary test, which were pending at
the time of discharge. You will be contacted by the orthopedics
department with additional pre-operative instructions, please
follow them as instructed. Additionally, please be sure to not
eat starting at midnight before the day of your surgery.
For pain control, we prescribed you Tylenol ___ every 6 hours
as needed, ibuprofen 800mg twice daily as needed, gabapentin
800mg three times daily, and Dilaudid 2mg every 8 hours as
needed for pain. Please do not drive while taking gabapentin and
dilaudid, and stop taking them if you start to feel drowsy.
If you suddenly experience any bowel or bladder incontinence, or
acute worsening of your existing back pain, please call ___ or
present to the nearest emergency room immediately.
During this admission, you were diagnosed with pre-diabetes.
Please follow-up with your primary care doctor about this and
aim for optimal blood sugar control.
Finally, we contacted your primary care doctor (___), and
was recommended to continue you on a lower dose of aspirin
(81mg) instead of 325mg. Please continue to take this daily.
It was a pleasure to care for you during this admission.
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10115593-DS-9 | 10,115,593 | 20,387,556 | DS | 9 | 2115-09-19 00:00:00 | 2115-09-19 19:28:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ Wound exploration, repair of CSF leak
History of Present Illness:
___ POD ___ s/p L5-S1 discectomy on ___ who presents with 1 day
of worsenin headache and low grade fevers. ___ states that
she was doing well post-op for the first 24 hours until her pain
began to increase. Approximately 24 hours ago she developed a
worsening, pulsating headache and photophobia and had a temp at
home of 100.6. She states that her headache is only relieved
when she lies flat. She denies any weakness, numbness or vision
changes, but does complain of nausea since she increased her
oxycodone.
Past Medical History:
L5-S1 discectomy ___, b/l carpal tunnel release, 2x C-section
Social History:
___
Family History:
NC
Physical Exam:
AVSS
Well appearing, NAD, comfortable
BUE: SILT C5-T1 dermatomal distributions
BUE: ___ Del/Tri/Bic/WE/WF/FF/IO
BUE: tone normal, negative ___, 2+ symmetric DTR
bic/bra/tri
All fingers WWP, brisk capillary refill, 2+ distal pulses
BLE: SILT L1-S1 dermatomal distributions
BLE: ___ ___
BLE: tone normal, no clonus, toes downgoing, 2+ DTR knee/ankle
All toes WWP, brisk capillary refill, 2+ distal pulses
Brief Hospital Course:
Patient was admitted to the ___ Spine Surgery Service and
taken to the Operating Room for the above procedure after
failing a trial of conservative management of her presumed
occult CSF leak. MRI demonstrated postoperative changes but no
frank CSF collection. Refer to the dictated operative note for
further details. The surgery was without complication and the
patient was transferred to the PACU in a stable condition.
TEDs/Pneumoboots were used for postoperative DVT prophylaxis.
Intravenous antibiotics were continued for 24hrs postop per
standard protocol. Initial postop pain was controlled with a
PCA. Diet was advanced as tolerated. The patient was
transitioned to oral pain medication when tolerating PO diet.
Foley was removed on POD#2. Physical therapy was consulted for
mobilization OOB to ambulate. Hospital course was otherwise
unremarkable. On the day of discharge the patient was afebrile
with stable vital signs, comfortable on oral pain control and
tolerating a regular diet.
Medications on Admission:
Oxycodone, Ibuprofen
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
3. Diazepam 5 mg PO Q6H:PRN soasm
Discharge Disposition:
Home
Discharge Diagnosis:
CSF leak
Discharge Condition:
Stable
Ambulating
Discharge Instructions:
You have undergone the following operation: Wound exploration
and repair of CSF leak
Immediately after the operation:
Activity: You should not lift anything greater than 10 lbs
for 2 weeks. You will be more comfortable if you do not sit or
stand more than ~45 minutes without moving around.
Rehabilitation/ Physical Therapy:
___ ___ times a day you should go for a walk for
___ minutes as part of your recovery. You can walk as much as
you can tolerate.
___ Limit any kind of lifting.
Diet: Eat a normal healthy diet. You may have some
constipation after surgery.
Brace: You do not need a brace.
Wound Care: Remove the dressing in 2 days. If the
incision is draining cover it with a new sterile dressing. If
it is dry then you can leave the incision open to the air. Once
the incision is completely dry (usually ___ days after the
operation) you may take a shower. Do not soak the incision in a
bath or pool. If the incision starts draining at anytime after
surgery, do not get the incision wet. Cover it with a sterile
dressing. Call the office.
You should resume taking your normal home medications.
You have also been given Additional Medications to control
your pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in narcotic prescriptions
(oxycontin, oxycodone, percocet) to the pharmacy. In addition,
we are only allowed to write for pain medications for 90 days
from the date of surgery.
Follow up:
___ Please Call the office and make an appointment
for 2 weeks after the day of your operation if this has not been
done already.
___ At the 2-week visit we will check your
incision, take baseline X-rays and answer any questions. We may
at that time start physical therapy.
___ We will then see you at 6 weeks from the day
of the operation and at that time release you to full activity.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound
Followup Instructions:
___
|
10115923-DS-9 | 10,115,923 | 28,388,616 | DS | 9 | 2186-07-25 00:00:00 | 2186-08-08 13:15:00 |
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:
___ drainage catheter placement
History of Present Illness:
___ presents to the ___ ER with a 2 weeks history of RLQ.
Patient states he was in usual state of health when he began
noticing a dull pain in his RLQ. The pain is constant and
worsens
when he is sleeping on that side. The pain has not changed since
he first noticed it two weeks ago. He otherwise feels well and
denies fevers, chills, nausea, vomiting, changes in his bowel
movements or melena/BRBPR.
Past Medical History:
HTN, Prostate CA
Past Surgical History: Excision of calcified gland on left neck
Family History:
Noncontributory
Physical Exam:
Upon presentation to ___:
Vitals: T 97.6 P 80 BP 125/83 RR 18 O2 100%
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mild tenderness to palpation in the
RLQ,
no rebound or guarding, firmness to palpation in the RLQ,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 10:33AM GLUCOSE-115* UREA N-22* CREAT-1.0 SODIUM-139
POTASSIUM-5.5* CHLORIDE-98 TOTAL CO2-29 ANION GAP-18
___ 10:33AM ALT(SGPT)-23 AST(SGOT)-33 ALK PHOS-127 TOT
BILI-0.6
___ 10:33AM LIPASE-25
___ 10:33AM ALBUMIN-3.6
___ 10:33AM WBC-10.1# RBC-5.05 HGB-13.9* HCT-43.4 MCV-86
MCH-27.6 MCHC-32.1 RDW-13.5
___ 10:33AM NEUTS-72.2* ___ MONOS-6.1 EOS-0.3
BASOS-0.4
___ 10:33AM PLT COUNT-362
___ 10:33AM ___ PTT-27.4 ___
Brief Hospital Course:
He was admitted to the Acute Care Surgery team and was made NPO,
given IV fluids and started on IV antibiotics. CT of the abdomen
and pelvis revealed an 8.4 x 4.1 cm rim enhancing RLQ abscess.
Interventional Radiology was consulted for placement of pelvic
drain which took place on ___. Serial exams were followed
closely and as his exams improved his diet was slowly advanced.
His antibiotics were changed to oral form once he was able to
tolerate a regular diet. He was provided teaching regarding
drain care and was set up with home services for ongoing
teaching with the drain.
A follow up appointment in ___ clinic was scheduled for patient
prior to discharge.
Medications on Admission:
Atenolol 100', HCTZ 25', Lisinopril 40', Viagra prn,
Aleve prn
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Atenolol 100 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 7 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*14 Tablet Refills:*0
4. Hydrochlorothiazide 25 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H Duration: 7 Days
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*21 Tablet Refills:*0
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours Disp
#*20 Tablet Refills:*0
9. Docusate Sodium 100 mg PO BID:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
___:
Pelvic abscess
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 a pelvic abscess
requiring that a drainage catheter be placed into this
collection of fluid. This catheter will stay in place for a few
weeks. It is that every morning you measure the amount of fluid
that is coming from the catheter and write this information
down. Maintian a daily log of the amounts and be sure to bring
this inforamtion withyou to your clinis appointment.
You are being treated with a 7 day course of antibiotics - be
sure to complete all of the medications as prescribed.
It is being recommended that you have a colonoscopy in the next
___ weeks. This can be arranged through your PCP at your appt
with him on ___.
You may resume your usual home medications that have been
prescribed for you.
If taking narcotics for pain control AVOID driving, operating
heavy machinery, drnking alcohol and/or illicit drugs while on
these medications.
Take a stool softnere and laxative to prevent constipation while
on narcotic pain medications.
Followup Instructions:
___
|
10115962-DS-10 | 10,115,962 | 24,064,363 | DS | 10 | 2125-10-17 00:00:00 | 2125-10-18 05:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Nsaids / Cymbalta / Methadone / bee stings
Attending: ___.
Chief Complaint:
Left knee pain
Major Surgical or Invasive Procedure:
Left quadriceps tendon re-rupture
History of Present Illness:
The patient is a ___ male with a history of chronic
pain, morbid obesity s/p RYGB and panniculectomy, and left
quadriceps tendon rupture s/p repair ___ at ___ who
presents s/p mechanical fall with left knee pain.
Post-operatively, the patient was instructed to keep his LLE in
___ brace locked in extension. Per the patient, he was
exiting his car without the ___ brace on and tripped on a
rock, sustaining a hyperflexion injury as he fell backwards. He
had immediate onset of pain and inability to bear weight. He did
not strike his head or lose consciousness. He denies pain in any
other anatomic location. He denies numbness, paresthesias or
weakness.
Past Medical History:
1. Obesity s/p gastric bypass surgery in ___
- lost 170 lbs since surgery
2. h/o Bleeding Ulcer in ___. Benign Hypertension
4. h/o Obstructive Sleep Apnea
- improved since bypass surgery
5. GERD
6. Back Pain
- improved since bypass surgery
7. Osteoarthritis
8. Left shoulder pain s/p arthroscopy ___ for rotator cuff
repair.
9. s/p Multiple Shoulder surgeries, most recently in ___
for various rotator cuff tears
10. Anemia (takes iron)
Social History:
___
Family History:
Both parents deceased.
Father: died at age ___ with premature heart disease and stroke
Mother: age ___ with cancer (? ovarian), arthritis and obesity.
Physical Exam:
Vital signs: AVSS
Left lower extremity:
6cm incision over anterior knee well healing.
No drainage, erythema.
Palpable defect superior to patella
No ___ tenderness to palpation.
Unable to perform active extension at knee
___ motor intact ___
S/S/SP/DP/T sensation intact to light touch
2+ DP, WWP toes
Pertinent Results:
___ 09:50AM GLUCOSE-101* UREA N-21* CREAT-1.2 SODIUM-141
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-30 ANION GAP-16
___ 09:50AM estGFR-Using this
___ 09:50AM WBC-13.6* RBC-5.37 HGB-13.1* HCT-42.7 MCV-79*
MCH-24.4* MCHC-30.7* RDW-14.5
___ 09:50AM NEUTS-82.9* LYMPHS-11.7* MONOS-3.9 EOS-1.0
BASOS-0.5
___ 09:50AM PLT COUNT-444*
___ 09:50AM ___ PTT-32.6 ___
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have re-rupture of a recently repair left quadriceps tendon
rupture and was admitted to the orthopedic surgery service. The
patient was taken to the operating room on ___ for Left
revision quad tendon repair and ex-fix, 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.
Musculoskeletal: Prior to operation, patient was ___ LLE. After
procedure, patient's weight-bearing status was transitioned to
___ LLE. Throughout the hospitalization, patient worked with
physical therapy.
Neuro: Post-operatively, patient's pain was controlled by
Dilaudid PCA, as well as patient's home oxycontin 60mg BID. He
was subsequently transitioned to oxycodone with good effect and
adequate pain control.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
Hematology: The patient was not transfused blood. Hematocrits
remained stable.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
GI/GU: A po diet was tolerated well. Patient was also started
on a bowel regimen to encourage bowel movement. Intake and
output were closely monitored.
ID: The patient received perioperative antibiotics. The
patient's temperature was closely watched for signs of
infection.
Prophylaxis: The patient received enoxaparin during this stay,
and was encouraged to get up and ambulate as early as possible.
At the time of discharge on ___, the patient was doing
well, afebrile with stable vital signs, tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The incision was clean, dry, and intact without
evidence of erythema or drainage; the extremity was NVI distally
throughout. The patient was given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient will be continued on chemical DVT
prophylaxis for 2 weeks post-operatively. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of breath,
wheezing
2. Lisinopril 20 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN Pain
5. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
6. Venlafaxine XR 150 mg PO DAILY
7. Temazepam 15 mg PO HS:PRN Insomnia
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN Shortness of breath,
wheezing
2. Lisinopril 20 mg PO DAILY
3. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
4. Temazepam 15 mg PO HS:PRN Insomnia
5. Docusate Sodium 100 mg PO BID
6. Enoxaparin Sodium 40 mg SC QPM Duration: 2 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
7. Hydrochlorothiazide 25 mg PO DAILY
8. Venlafaxine XR 150 mg PO DAILY
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
Discharge Disposition:
Home
Discharge Diagnosis:
Left quad tendon re-rupture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take lovenox 40mg daily for 2 weeks
WOUND CARE:
- 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, in ex fix
Physical Therapy:
- WBAT LLE, in ex fix (no ROM of knee)
Treatments Frequency:
- 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.
Followup Instructions:
___
|
10115962-DS-12 | 10,115,962 | 28,601,092 | DS | 12 | 2125-11-04 00:00:00 | 2125-11-04 11:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Nsaids / Cymbalta / Methadone / bee stings
Attending: ___.
Chief Complaint:
Left leg pain, infection
Major Surgical or Invasive Procedure:
External Fixation Removal, Irrigation and Debridement of pin
sites
History of Present Illness:
___ w/ hx of chronic pain, morbid obesity, recently admitted for
repair of rerupture of L quad tendon w/ placement of ex-fix and
subsequently readmitted for pain control presents to ED with
increased pain and drainage around pin sites. He was seen in ED
three days ago for similar complaints and discharged home on
Bactrim/Keflex. He reports increase in drainage, swelling, pain
since discharged. Denies fevers, chills, CP, SOB, abd pain. Has
felt fatigued. No weakness, numbness.
Past Medical History:
1. Obesity s/p gastric bypass surgery in ___
- lost 170 lbs since surgery
2. h/o Bleeding Ulcer in ___. Benign Hypertension
4. h/o Obstructive Sleep Apnea
- improved since bypass surgery
5. GERD
6. Back Pain
- improved since bypass surgery
7. Osteoarthritis
8. Left shoulder pain s/p arthroscopy ___ for rotator cuff
repair.
9. s/p Multiple Shoulder surgeries, most recently in ___
for various rotator cuff tears
10. Anemia (takes iron)
Social History:
___
Family History:
Both parents deceased.
Father: died at age ___ with premature heart disease and stroke
Mother: age ___ with cancer (? ovarian), arthritis and obesity.
Physical Exam:
Well appearing man in NAD
Left lower extremity:
Staple line over anterior knee C/D/I, well healing.
Ex-fix in place w/ clean distal pin sites w/o erythema,
drainage. Proximal pin sites w/ surroinding tenderness, edema,
induration. Erosion of skin surrounding pins w/ small amount of
purulent drainage. +erythema.
Moderate edema of L knee.
No ___ tenderness to palpation.
___ fire
S/S/SP/DP/T sensation intact to light touch
2+ DP, WWP toes
Pertinent Results:
___ 12:18PM LACTATE-2.3*
___ 12:10PM GLUCOSE-100 UREA N-31* CREAT-1.8* SODIUM-140
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-27 ANION GAP-16
___ 12:10PM CRP-80.3*
___ 12:10PM WBC-12.0* RBC-4.27* HGB-10.6* HCT-34.5*
MCV-81* MCH-24.9* MCHC-30.8* RDW-13.9
___ 12:10PM NEUTS-78.0* LYMPHS-15.6* MONOS-4.4 EOS-1.7
BASOS-0.3
___ 12:10PM PLT COUNT-493*
___ 12:10PM SED RATE-78*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have infection at his LLE ex fix proximal pin sites and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for LLE removal of ex fix
and I&D of ex fix sites, which the patient tolerated well (for
full details please see the separately dictated operative
report). The patient was taken from the OR to the PACU in stable
condition and after recovery from anesthesia was transferred to
the floor. The patient was initially given IV fluids and IV
pain medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home was
appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge on ___, POD#1, 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 left lower extremity,
and will be discharged on Lovenox for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
See OMR.
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB/wheezing
2. Hydrochlorothiazide 25 mg PO DAILY
3. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
5. Pregabalin 75 mg PO TID
6. Temazepam 15 mg PO HS:PRN insomnia
7. Venlafaxine XR 150 mg PO DAILY
8. Lisinopril 20 mg PO DAILY
9. Enoxaparin Sodium 40 mg SC QPM Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 syringe SC QPM Disp #*14 Syringe
Refills:*0
10. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Quad tendon rupture s/p repair and ex fix, now with ex fix
proximal pin site infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
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 in ___ brace
Physical Therapy:
- WBAT LLE in ___ brace at all times
Treatments Frequency:
- No dressing is needed if wound is not draining
Followup Instructions:
___
|
10116054-DS-18 | 10,116,054 | 28,557,795 | DS | 18 | 2168-08-08 00:00:00 | 2168-08-08 13:40:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with history of CAD,
HLD, NAFLD, GERD, COPD, former smoker, CVID on IVIG who presents
less than 1 week after recent discharge with similar complaints
of increasing sputum production, cough, and shortness of breath.
Patient was recently discharged from here on ___. She states she
completed her course of antibiotics and prednisone taper but as
soon as she stopped the antibiotics, she again began to feel
unwell and this has been progressively worsening. She describes
paroxysmal episodes of severe shortness of breath which include
chest tightness as well as feeling like her throat is closing
up.
She states she has been having increasing difficulty clearing up
secretions. She notes that she develops significant anxiety when
she develops the acute episodes of shortness of breath because
she feels like she can't breathe and notes that the nebulizers
don't really provide relief. She also notes that the oral
prednisone hasn't been helping but the IV solumedrol does help
quite a bit. She has an upcoming appointment with both ENT and
pulmonology but states she felt like she couldn't make it until
then. She went to urgent care this morning and asked for refills
on the cefpodoxime and azithromycin which she states provided
her
significant relief when she was recently discharged on them. She
was given new prescriptions and also went home to take both the
antibiotics and more prednisone which she had a little bit left
of at home. She took all of these but was still feeling like she
couldn't wait to be seen in clinic because her breathing
continued to be significantly impaired so she had her husband
call an ambulance and they brought her to the ___.
Past Medical History:
- CAD
- HLD
- COPD
- CVID on IVIG
- NAFLD
- GERD
Social History:
___
Family History:
FAMILY HISTORY: No known family history of immunodeficiency.
- Mother: ___ disease
- Father: Lung cancer
- Brother: CAD s/p MI
- Sister: CAD, thyroid disease
- Daughter: ___ disease
Physical Exam:
___ 1132 Temp: 98.2 PO BP: 139/69 HR: 77 RR: 18 O2 sat: 93%
O2 delivery: RA
GENERAL: Alert and in anxious/emotional distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, No JVD. Radial and DP pulses
present.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Patient has forceful expirations with some
wheezing. No crackles. Breathing is non-labored. Coughs with
deep inspiration.
GI: Abdomen is soft, non-distended, non-tender to palpation.
Bowel sounds present.
GU: No suprapubic tenderness
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Anxious. Alert, oriented, face symmetric, gaze conjugate,
speech fluent, moves all limbs
PSYCH: pleasant
Pertinent Results:
___ 07:30AM BLOOD WBC-13.5* RBC-3.65* Hgb-10.9* Hct-33.4*
MCV-92 MCH-29.9 MCHC-32.6 RDW-16.8* RDWSD-56.4* Plt ___
___ 07:30AM BLOOD Glucose-114* UreaN-22* Creat-1.0 Na-144
K-4.8 Cl-104 HCO3-20* AnGap-20*
___ 08:40PM BLOOD ___ PTT-20.1* ___
___ 07:30AM BLOOD ALT-18 AST-16 LD(LDH)-333* AlkPhos-76
TotBili-0.2
___ 07:30AM BLOOD Albumin-4.0
___ 07:55AM BLOOD IgG-515* IgA-61* IgM-19*
___ 09:40PM BLOOD Lactate-1.9
Micro:
___ 8:40 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending):
___ 8:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
PREVIOUS MICROBIOLOGY DATA:
===========================
___ 10:37 am BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE LLL,BAL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___:
SPECIMEN COMBINED WITH SAMPLE # ___ ___.
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 10:37 am BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE LLL,BAL.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Pending):
___ 10:36 am Rapid Respiratory Viral Screen & Culture
BRONCHIAL LAVAGE RUL,BAL AND LLL BAL.
**FINAL REPORT ___
Respiratory Viral Culture (Final ___:
No respiratory viruses isolated.
Culture screened for Adenovirus, Influenza A & B,
Parainfluenza type
1,2 & 3, and Respiratory Syncytial Virus..
Detection of viruses other than those listed above will
only be
performed on specific request. Please call Virology at
___
within 1 week if additional testing is needed.
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information.
___ 10:36 am BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE RUL,BAL.
VIRAL CULTURE: R/O CYTOMEGALOVIRUS (Preliminary):
No Cytomegalovirus (CMV) isolated.
CYTOMEGALOVIRUS EARLY ANTIGEN TEST (SHELL VIAL METHOD) (Final
___:
Negative for Cytomegalovirus early antigen by
immunofluorescence.
Refer to culture results for further information.
___ 10:36 am BRONCHOALVEOLAR LAVAGE
BRONCHIAL LAVAGE RUL,BAL.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT WITH
OROPHARYNGEAL FLORA.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 CFU/mL Commensal Respiratory Flora.
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis is strongly suspected,
contact the
Microbiology Laboratory (___).
Immunofluorescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii).
FUNGAL CULTURE (Preliminary):
YEAST.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 4:18 pm SPUTUM Source: Induced.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Pending):
___ 6:43 am SPUTUM Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
___ 11:26 am SPUTUM Source: Induced.
GRAM STAIN (Final ___:
>25 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
FUNGAL CULTURE (Preliminary):
GRAM STAIN OF THIS SPECIMEN INDICATES CONTAMINATION WITH
OROPHARYNGEAL SECRETIONS AND INVALIDATES RESULTS.
Specimen is only screened for Cryptococcus species. New
specimen is
recommended.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
Other Pertinent Studies:
CTA with no evidence of pulmonary embolism. Somewhat
triangular-shaped soft tissue density abutting the pleural
surface of the right upper lobe measuring 3.9 cm transversely by
1.6 cm in AP by 2.3 cm in craniocaudal extent most likely
infectious representing right upper lobe pneumonia. Malignancy
would seem unlikely but not excludable. Follow-up radiography to
document complete clearing is suggested.
Prior IMAGING:
==============
- CXR (___):
IMPRESSION: No prior chest radiographs available. Cardiac
silhouette is obscured by mediastinal fat deposition, mildly
enlarged if at all. Otherwise normal mediastinal and hilar
contours. Lungs fully expanded and clear. No pleural
abnormality.
- CXR (___):
IMPRESSION: Comparison to ___. No relevant change is
seen. Borderline size of the cardiac silhouette. No pulmonary
edema, no pleural effusions. No pneumonia. Normal hilar and
mediastinal contours.
- CT chest w/o contrast ___
IMPRESSION:
1. New bronchocentric nodular ground-glass opacity in the
inferior segment of the right upper lobe with possible early
cavitation is concerning for an infectious process, particularly
tuberculosis, given the patient's immunocompromised state.
However, per discussion with the patient's care
team, patient is quantiferon negative.
2. Additional bronchocentric ground-glass opacity is present in
the left upper lobe, consistent with an additional site of
infection.
- PFTs ___:
FEV1 1.91 (85%), FVC 2.36 (80%), FEV1/FVC: 81 (107%)
Brief Hospital Course:
___ female with history of CAD, HLD, NAFLD, GERD, COPD,
former smoker, CVID on IVIG who presents less than 1 week after
recent discharge with similar complaints of increasing sputum
production, cough, and shortness of breath.
This remains a challenging case given repeated presentations to
urgent care and hospital admissions with confusing/overlapping
diagnoses. She has been on numerous courses of antibiotics and
steroids over the past several months. She continues to complain
of worsening shortness of breath and cough with reported fevers
(99.9F) at home though afebrile throughout hospitalization.
There does seem to be an element of anxiety contributing to her
episodic symptoms (some associated symptoms of chest tightness,
flushing, and throat closing seem to be consistent with a panic
attack), but remains difficult to tease out the cause from the
effect when compared to pulmonary causes of dyspnea. Vocal cord
dysfunction or esophageal spasm remain in the differential.
Empiric antibiotics with IV unasyn for aspiration pneumonia were
discontinued per recommendations of pulmonary medicine. No
additional steroids were given after emergency room per
pulmonary recommendations. Patient was continued on Advair,
DuoNebs, guaifenesin, Flonase, PPI, and Duonebs q6hr with
acapella after to clear secretions. Patient was evaluated by
interventional pulmonary medicine for lung biopsy at the request
of pulmonary medicine. Patient is scheduled for lung biopsy as
outpatient on ___.
Patient's course has been complicated by worsening frequency of
anxiety. She is on mirtazapine at night for depression issues
and insomnia. She responds well to Ativan when taken as
inpatient and will be prescribed a short course of Ativan as
bridge to additional outpatient therapy with the goal of
preventing a repeat hospitalization(patient instructed to use
medication only for severe panic episodes). Psychiatry consult
was placed to establish care, but patient requested discharge
and reports she will follow with her PCP for outpatient
referral.
Hospital course, assessments, and discharge plans discussed with
patient and family who expressed understanding and agree with
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Cyclobenzaprine 10 mg PO DAILY:PRN Headache
4. Fluticasone Propionate NASAL 2 SPRY NU BID
5. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
6. GuaiFENesin ER 1200 mg PO Q12H
7. Metoprolol Tartrate 25 mg PO BID
8. Mirtazapine 7.5 mg PO QHS
9. Polyethylene Glycol 17 g PO DAILY
10. Esomeprazole 80 mg Other BID
11. Loratadine 10 mg PO DAILY
12. Tiotropium Bromide 1 CAP IH DAILY
13. Magnesium Oxide 1600 mg PO DAILY
14. azelastine 137 mcg (0.1 %) nasal BID
15. Repatha SureClick (evolocumab) 140 mg/mL subcutaneous EVERY
2 WEEKS
16. Hydrochlorothiazide 12.5 mg PO DAILY
17. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheezing/SOB
18. Bengay Cream 1 Appl TP BID
19. Acetaminophen 1000 mg PO TID
Discharge Medications:
1. LORazepam 1.0 mg PO BID:PRN Severe anxiety/panic attack
2. Acetaminophen 1000 mg PO TID
3. azelastine 137 mcg (0.1 %) nasal BID
4. Bengay Cream 1 Appl TP BID
5. Cyclobenzaprine 10 mg PO DAILY:PRN Headache
6. Esomeprazole 80 mg Other BID
7. Fluticasone Propionate NASAL 2 SPRY NU BID
8. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
9. GuaiFENesin ER 1200 mg PO Q12H
10. Hydrochlorothiazide 12.5 mg PO DAILY
11. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN Wheezing/SOB
12. Loratadine 10 mg PO DAILY
13. Magnesium Oxide 1600 mg PO DAILY
14. Metoprolol Tartrate 25 mg PO BID
15. Mirtazapine 7.5 mg PO QHS
16. Polyethylene Glycol 17 g PO DAILY
17. Repatha SureClick (evolocumab) 140 mg/mL subcutaneous EVERY
2 WEEKS
18. Tiotropium Bromide 1 CAP IH DAILY
19. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until instructed by interventional pulmonary
after procedure.
20. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until instructed by interventional
pulmonary medicine after your procedure.
Discharge Disposition:
Home
Discharge Diagnosis:
Shortness of breath
History of mucous plugging and microaspiration
CVID
COPD physiology
Possible vocal cord dysfunction
Anxiety
Coronary artery disease
Essential hypertension
Hyperlipidemia
GERD
Insomnia
Hypomagnesemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted with acute on chronic shortness of breath in
the setting of lung pathology of unclear etiology. The next step
in management as determined by pulmonary specialists is to do a
lung biopsy on ___. Your medical course has been
complicated by worsening anxiety, which we hope to address in
parallel to the medical issue.
You will hold your aspirin and Plavix through the procedure.
Please restart as instructed by interventional pulmonologist.
It was a pleasure meeting you.
Your ___ care team
Followup Instructions:
___
|
10116085-DS-18 | 10,116,085 | 24,145,114 | DS | 18 | 2190-04-25 00:00:00 | 2190-04-30 21:06:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / Sulfadiazine
Attending: ___
Chief Complaint:
right sided chest pain
Major Surgical or Invasive Procedure:
1. laceration repair of left ear avulsion
History of Present Illness:
___ year old male with history of hypertension presenting with
crush injury at construction site after roll over injury by
"three-ton roller." Patient reportedly had a piece of
construction equipment roll up onto his right side over his
chest and shoulder. Reportedly no loss of consciousness. Arrives
satting 93% on 4L NC. Right-sided chest pain. Large left-sided
facial laceration.
Past Medical History:
PMH: HTN
PSH: ventral hernia repair, L testicular cyst removal
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam: ___
VS: Afebrile, HD stable
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL. Bandage in place over left forehead/ear laceration.
CHEST: Clear to auscultation bilaterally, (-) cyanosis. TTP over
right chest an shoulder with crush marks, soft mass left axilla
ABDOMEN: (+) BS x 4 quadrants, soft, mildly tender to palpation
incisionally, non-distended.
EXTREMITIES: Warm, well perfused, pulses palpable, increased
swelling right leg
US done left leg swelling: no DVT
Pertinent Results:
CT head and max/face ___:
1. No acute intracranial abnormality.
2. Large left facial laceration with underlying subcutaneous
emphysema and
hematoma.
3. Tiny fractures with a tiny displaced fragments of cortex from
left frontal bone.
4. Status-post right maxillary sinus surgery with pansinus
disease worst in the right maxillary sinus.
CT c-spine ___:
1. No acute cervical spine abnormality. Degenerative changes
include
posterior osteophytosis causing mild to moderate vertebral canal
narrowing at C5-C6.
2. Incidental note made of right-sided thyroid nodules measuring
up to 2.3 cm. Recommend correlation with prior imaging, if
available, or dedicated
ultrasound in the outpatient setting.
3. A left facial laceration is better evaluated on a same day a
maxillofacial CT.
CT Torso ___:
1. Anterior right third through seventh rib fractures. Only the
fourth rib fracture is minimally displaced. No pneumothorax.
2. Possible nondisplaced sternum fracture involving the
posterior cortex.
Alternatively, this could be caused by a vascular channel or
nutrient foramen.
3. Multiple small right chest wall subcutaneous contusions.
4. Right-sided thyroid nodules measuring up to 2.3 cm.
Recommend nonurgent outpatient ultrasound if not previously
performed.
5. Extensive sigmoid diverticulosis without diverticulitis.
RECOMMENDATION(S): Right-sided thyroid nodules measuring up to
2.3 cm.
Recommend nonurgent outpatient ultrasound if not previously
performed.\
___ CXR:
IMPRESSION: No pneumothorax. Rib fractures better assessed on
same-day CT exam.
Extremity films:
Left upper extremity and clavicles ___- no fractures.
Left elbow ___: Two calcific structures measuring 2 mm
projecting over the soft tissue posterior to the olecranon on
the lateral view ; findings could represent avulsed fragments
versus retained foreign bodies. No acute fracture seen
elsewhere. Posterior elbow soft tissue swelling with couple
foci of soft tissue gas, which may relate to laceration.
Right upper extremity and clavicles ___- no fractures.
Right elbow ___: No definite acute fracture. Numerous punctate
radiodensities projecting over the soft tissue lateral and
anterior to the distal lateral humerus, nonspecific but
concerning for retained foreign bodies.
Left ankle and femur ___- no fractures. Diffuse soft tissue
swelling at L ankle.
RELEVANT LABS:
troponins ___: <0.01 x 3
CK: ___ pm->4450 ___ am
___ 04:20AM BLOOD WBC-9.3 RBC-3.12* Hgb-9.9* Hct-31.5*
MCV-101* MCH-31.7 MCHC-31.4* RDW-13.5 RDWSD-49.6* Plt ___
___ 06:00AM BLOOD Glucose-155* UreaN-10 Creat-0.7 Na-133
K-3.8 Cl-97 ___ AnGap-13
US: left lower ext: ___
No evidence of deep venous thrombosis in the left lower
extremity veins.
Brief Hospital Course:
Mr ___ is a ___ year old male who was admitted to the trauma
surgery service for management of injuries after sustaining a
crush injury by a 3-ton roller at his construction site. His
imaging demonstrated the following injuries and was otherwise
negative for traumatic injury: right rib fractures (number 3 to
7), non-displaced sternal fracture, and left ear avulsion. The
plastic surgery service repaired the laceration to the left ear
and forehead in the emergency room- they also placed a JP drain
which they removed prior to discharge. For the patient's rib and
sternal fractures, his pain control was optimized and he was
encouraged to use incentive spirometry to improve his breathing.
Additionally, he was monitored closely for crush injury and the
development of compartment syndrome. CK lab values were trended
and peaked at 4450, then downtrended appropriately after IV
fluid hydration. His troponins were trended in the setting of
probably sternal fracture and repeatedly negative. His renal
function was normal throughout his stay and he maintained good
urine output. However, he required placement of a special foley
___ Fr courde) by the urology service secondary to a urethral
stricture from prior prostate surgery. He was started on a 3-day
course of ciprofloxacin for this instrumentation. The foley
catheter was removed 5 days post insertion and he was able to
void spontaneously.
On HD #8 the patient was noted to have left leg pain and
swelling. He underwent an US which showed no DVT. At the same
time, he was noted to have localized swelling left axilla,
thought to be related to a hematoma. Ice packs were applied to
decrease and for comfort.
The patient was discharged home with ___ services on ___ in
stable condition. His vital signs were stable and he was
afebrile. He was tolerating a regular diet and voiding without
difficulty. He was ambulatory and maintaining an oxygen
saturation of 92% room air. His rib pain was controlled with
oral analgesia. ___ services were provided him to assist him in
his care. Follow-up appointments were made with the the Plastic
and Acute care surgery services. An appointment was made for
the patient to follow-up with his primary care provider.
Discharge instructions were reviewed and questions answered.
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.
Incidental finding on CT scan right-sided thyroid nodules
measuring up to 2.3 cm.
Recommend correlation with prior imaging
Medications on Admission:
lisinopril 10mg daily, gabapentin 600 mg PO BID, duloxetine 20mg
PO BID, Tylenol ___ PO daily
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
as pain decreases, may take Tylenol as needed instead of around
the clock
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 3 ml NEB every six
(6) hours Disp #*30 Vial Refills:*0
3. Docusate Sodium 100 mg PO BID
Take for constipation caused by your pain medication. Hold for
loose stools.
4. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % apply to affected area once a day Disp #*15
Patch Refills:*0
5. Milk of Magnesia 30 mL PO DAILY:PRN constipation
Take for constipation caused by your pain medication. Hold for
loose stools.
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
Take for constipation caused by your pain medication. Hold for
loose stools.
8. DULoxetine 20 mg PO BID
9. Gabapentin 600 mg PO BID
10.Nebulizer
Dx: Pulmonary Contusions, COPD
Length of need: 13 months
Inhalation Drug needed: Albuterol 0.083% Neb Soln 1 NEB IH Q6H
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. crush injury
2. right rib fractures ___. non-displaced sternal fracture
4. left ear avulsion
5. laceration right arm
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 trauma surgery service for management
of your injuries after you sustained a crush injury. Your
imaging demonstrated the following injuries: right rib fractures
(number 3 to 7), non-displaced sternal fracture, and left ear
avulsion. The plastic surgery service repaired the laceration to
your ear and forehead- they also placed a drain which they
removed prior to discharge. For your rib and sternal fractures,
you received pain medication and were encouraged to use
incentive spirometry to improve your breathing. You are being
discharged home in stable condition. Please follow the
directions below:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Incision Care:
*Please call your doctor or nurse practitioner if you have
increased pain, swelling, redness, or drainage from the incision
site.
*Avoid swimming and baths until your follow-up appointment.
*You may shower, and wash surgical incisions with a mild soap
and warm water. Gently pat the area dry.
*If you have staples, they will be removed at your follow-up
appointment.
*If you have steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
Rib Fractures:
* Your injury caused multiple rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
Followup Instructions:
___
|
10116129-DS-14 | 10,116,129 | 20,698,381 | DS | 14 | 2164-11-28 00:00:00 | 2164-11-30 07:07:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Small Bowel Obstruction
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y.o. M prior VHR w/ mesh and SBR in ___ p/w SBO with TP
at recurrent VH
Past Medical History:
None
Social History:
___
Family History:
N/A
Physical Exam:
General Male Exam
GENERAL APPEARANCE: Well developed, well nourished, alert and
cooperative, and appears to be in no acute distress.
HEAD: normocephalic.
EYES: PERRL, EOMI. Fundi normal, vision is grossly intact.
EARS: External auditory canals and tympanic membranes clear,
hearing grossly intact.
NOSE: No nasal discharge.
THROAT: Oral cavity and pharynx normal. No inflammation,
swelling, exudate, or lesions. Teeth and gingiva in good general
condition.
NECK: Neck supple, non-tender without lymphadenopathy, masses or
thyromegaly.
CARDIAC: Normal S1 and S2. No S3, S4 or murmurs. Rhythm is
regular. There is no peripheral edema, cyanosis or pallor.
Extremities are warm and well perfused. Capillary refill is less
than 2 seconds. No carotid bruits.
LUNGS: Clear to auscultation and percussion without rales,
rhonchi, wheezing or diminished breath sounds.
ABDOMEN: Positive bowel sounds. Soft, nondistended, nontender.
No guarding or rebound. No masses.
MUSKULOSKELETAL: Adequately aligned spine. ROM intact spine and
extremities. No joint erythema or tenderness. Normal muscular
development. Normal gait.
BACK: Examination of the spine reveals normal gait and posture,
no spinal deformity, symmetry of spinal muscles, without
tenderness, decreased range of motion or muscular spasm.
EXTREMITIES: No significant deformity or joint abnormality. No
edema. Peripheral pulses intact. No varicosities.
LOWER EXTREMITY: Examination of both feet reveals all toes to be
normal in size and symmetry, normal range of motion, normal
sensation with distal capillary filling of less than 2 seconds
without tenderness, swelling, discoloration, nodules, weakness
or deformity; examination of both ankles, knees, legs, and hips
reveals normal range of motion, normal sensation without
tenderness, swelling, discoloration, crepitus, weakness or
deformity.
NEUROLOGICAL: CN II-XII intact. Strength and sensation symmetric
and intact throughout. Reflexes 2+ throughout. Cerebellar
testing normal.
SKIN: Skin normal color, texture and turgor with no lesions or
eruptions.
PSYCHIATRIC: The mental examination revealed the patient was
oriented to person, place, and time. The patient was able to
demonstrate good judgement and reason, without hallucinations,
abnormal affect or abnormal behaviors during the examination.
Patient is not suicidal.RECTAL: Good sphincter tone with no
anal, perineal or rectal lesions. Prostate is not tender,
enlarged, boggy, or nodular.
GENITALIA: Genital exam revealed normally developed male
genitalia. No scrotal mass or tenderness, no hernias or inquinal
lymphadenopathy. No perineal or perianal abnormalities are seen.
No genital lesions or urethral discharge.
Pertinent Results:
___ 04:48AM GLUCOSE-110* UREA N-27* CREAT-1.1 SODIUM-139
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-26 ANION GAP-11
___ 04:48AM CALCIUM-8.1* PHOSPHATE-3.5 MAGNESIUM-1.9
___ 04:48AM WBC-5.9 RBC-4.38* HGB-14.4 HCT-42.5 MCV-97
MCH-32.9* MCHC-33.9 RDW-13.2 RDWSD-47.2*
___ 04:48AM PLT COUNT-235
___ 08:21PM LACTATE-2.7*
___ 05:56PM GLUCOSE-117* UREA N-32* CREAT-1.3* SODIUM-138
POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-21* ANION GAP-19*
___ 05:56PM estGFR-Using this
___ 05:56PM ALT(SGPT)-17 AST(SGOT)-25 ALK PHOS-55 TOT
BILI-2.2*
___ 05:56PM LIPASE-17
___ 05:56PM ALBUMIN-4.1
___ 05:56PM WBC-6.8 RBC-4.61 HGB-15.1 HCT-44.2 MCV-96
MCH-32.8* MCHC-34.2 RDW-13.0 RDWSD-45.1
___ 05:56PM NEUTS-69.3 LYMPHS-13.5* MONOS-16.7* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-4.74 AbsLymp-0.92* AbsMono-1.14*
AbsEos-0.01* AbsBaso-0.02
___ 05:56PM PLT COUNT-238
___ 05:56PM ___ PTT-25.7 ___
Brief Hospital Course:
The patient was admitted to the floor from the ED. On CT of the
abdomen, it was noted that the SBO was likely related to
adhesions at the abdominal wall, mall bowel anastomosis intact
and widely patent, and bladder wall thickening w/ possible
cystitis. On ___ we performed a contrast follow-through study
which was negative, we removed the patients NG tube that was
placed in the ED initially, we subsequently advanced the patient
to a regular diet and d/c'd the patients IV. On ___, the
patient tolerated a regular diet, was voiding spontaneously,
walking without assistance, and pain was controlled. The patient
was instructed to follow up with ACS in clinic in two weeks.
Medications on Admission:
None
Discharge Medications:
None
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 ___ and
underwent non-operative treatment for small bowel obstruction.
You are recovering well and are now ready for discharge. Please
follow the instructions below to continue your recovery:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
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:
___
|
10116310-DS-13 | 10,116,310 | 27,906,419 | DS | 13 | 2186-05-03 00:00:00 | 2186-05-04 09:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Meperidine / Nitroimidazole Derivatives / Codeine /
Flagyl / Penicillins / Vancomycin / Morphine Sulfate /
oxycodone-acetaminophen / Vicodin / Bactrim
Attending: ___.
Chief Complaint:
Acute Renal Failure, Cellulitis, Nausea, Vomitting, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old Female with metastatic breast cancer s/p lumpectomy
in ___ with metasteses to the pelvis (currently receiving
Faslodex initally every 2 weeks now monthly, last dose ___
who presented to her primary care clinic 5 days prior to
admission with complaint of right foot pain, associated with
erythema and pain. Right foot x-rays did not show a fracture or
osteomyelitis. She was given Bactrim on ___ for a presumed
cellulitis but discontinued the antibiotic because it gave her
GI upset. She reports nausea, vomitting and diarhea, which is
causing her to be dehydrated. She does not feel she was able to
keep up with her fluid losses, but does not "feel dry"
currently. She reports the nausea and vomitting are only
nightly.
She returned to the clinic 2 more times and was told to go to
the ED for further management with IV antibiotics and to rule
out osteomyelitis. In the ED vitals were: 98.1 60 105/57 18
100%. ED labs were drawn at she was found to be in acute renal
failure and had a drop in her hematocrit. Pertient ED labs
included: K 5.4, bicarb 17, BUN 30, creatinine 2.7, H/H
8.7/27.7. She received IV clindamycin in ED before being
admitted to the medicine service for further management of her
acute renal failure and cellulitis.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. h/o breast Ca ___. s/p R. lumpectomy and RT
4. ___ esophagus
5. diverticulitis.
6. h/o cholecystectomy
7. h/o peripheral vascular disease, carotid artery disease (40%
and 50% stenosis), followed by Dr ___.
8. Chronic renal insufficiency (gradual rising creatinine levels
(between 1.2-1.9)
9. Smoker x 30+ years.
10. Temporal arteritis
11. nontoxic multinodular goiter
Social History:
___
Family History:
Sons (twins) - esophageal CA
Mother - CAD, MI
Sister - "spinal cancer"
Physical Exam:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: + Nausea, + Vomitting, + Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
PHYSICAL EXAM:
VSS: 97.9, 120/40, 60, 16, 99%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE, Right foot swollen with erythema
NEURO: CAOx3, Non-Focal
PHYSICAL EXAM at discharge
Vitals: 98 170/60 67 18
I/O: ___ since midnght
GENERAL - well-appearing woman in NAD, comfortable, appropriate
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear, wearing
dentures
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS -good air movement bilaterally, resp unlabored, no
accessory muscle use
HEART - RRR, nl S1-S2
ABDOMEN - soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES - trace R foot swelling, erythma on foot has
resolved, dystrophic nails bilaterally
SKIN - dry skin on bilateral legs, arms and back, scattered
telegiectasias on back
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait not
assessed
Pertinent Results:
___ 02:20PM BLOOD WBC-8.1 RBC-3.19* Hgb-8.7* Hct-27.7*
MCV-87 MCH-27.1 MCHC-31.3 RDW-15.0 Plt ___
___ 07:15AM BLOOD WBC-7.2 RBC-2.85* Hgb-7.8* Hct-25.0*
MCV-88 MCH-27.5 MCHC-31.3 RDW-15.5 Plt ___
___ 05:10PM BLOOD WBC-5.9 RBC-2.89* Hgb-7.8* Hct-25.1*
MCV-87 MCH-26.9* MCHC-30.9* RDW-15.3 Plt ___
___ 07:05AM BLOOD WBC-5.8 RBC-2.74* Hgb-7.4* Hct-23.8*
MCV-87 MCH-27.0 MCHC-31.2 RDW-15.5 Plt ___
___ 01:40PM BLOOD Hct-24.8*
___ 02:20PM BLOOD Glucose-87 UreaN-30* Creat-2.7*# Na-134
K-5.4* Cl-103 HCO3-17* AnGap-19
___ 09:40PM BLOOD Glucose-96 UreaN-32* Creat-2.5* Na-140
K-5.6* Cl-109* HCO3-19* AnGap-18
___ 07:15AM BLOOD Glucose-81 UreaN-30* Creat-2.3* Na-141
K-5.3* Cl-112* HCO3-18* AnGap-16
___ 05:10PM BLOOD Glucose-98 UreaN-27* Creat-1.8* Na-140
K-4.6 Cl-110* HCO3-19* AnGap-16
___ 07:05AM BLOOD Glucose-80 UreaN-21* Creat-1.5* Na-141
K-4.6 Cl-111* HCO3-19* AnGap-16
___ 01:40PM BLOOD Creat-1.4*
___ 06:50AM BLOOD Glucose-84 UreaN-17 Creat-1.4* Na-143
K-4.6 Cl-110* HCO3-22 AnGap-16
___ 07:15AM BLOOD Calcium-8.5 Phos-5.4*# Mg-2.2
___ 07:05AM BLOOD Calcium-8.7 Phos-4.7* Mg-2.1
___ 02:20PM BLOOD Hapto-352* Ferritn-38
FOOT AP,LAT & OBL RIGHT Clip # ___
Final Report
IMPRESSION: Mild dorsal soft tissue swelling. No subcutaneous
gas or erosive lesion. No fracture or dislocation.
ECG Study Date of ___ 10:38:44 ___
Sinus bradycardia. Atrio-ventricular conduction delay. Right
bundle-branch
block. Borderline left atrial abnormality. Diffuse non-specific
ST segment
changes. Low voltage in precordial leads. Compared to the
previous tracing
of ___ sinus tachycardia is no longer appreciated.
TRACING #1
Intervals Axes
Rate PR QRS QT/QTc P QRS T
45 ___ 59 0 42
ECG Study Date of ___ 8:53:10 AM
Sinus bradycardia. Right bundle branch block. Q-T interval
prolongation.
Non-specific ST segment changes in lateral and high lateral
leads.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
55 ___ ___
Brief Hospital Course:
Hospitalization in brief:
___ year old woman with history of metastatic breast cancer s/p
lumpectomy in ___ and mets to the pelvis (currently using
Faslodex every month, last dose was ___, COPD, who presented
to the ED with R leg cellulitis and was found to have acute
renal failure secondary to dehydration. Her course was
complicated by hyperkalemia and pulmonary edema.
Active Issues:
1. Acute Renal Failure due to Dehydration
Due to her recent vomitting and diarrhea it was likely her acute
renal failure was secondary to dehydration. She was treated
with IV fluids and her creatinine improved. Nephrotoxic and
renally excreted medications were held.
2. Nausea, Vomitting causing Dehydration
She was treated with Zofran and IV hydration. Her symptoms had
resolved at the time of discharge.
3. Cellulitis Foot
Her x-ray showed no evidence of osteomylitis. Her cellulitis
was treated with PO clindamycin and had resolved at the time of
discharge.
4. Hyperkalemia
Her hyperkalemia was treated with kayexalate. Repeat EKGs did
not show changes associated with hyperkalemia. EKGs
demonstrated prolonged Qtc interval (450-460) so medications
that are known to prolong the Qtc were held.
5. Pulmonary Edema
After receiving IV fluids the patient had some difficulty
breathing and a chest x ray was done, which showed pulmonary
edema. Her pulmonary edema was treated with PO lasixs and at
the time of discharge the patient had no difficulty breathing or
shortness of breath.
Chronic Issues:
5. Anemia of chronic disease
Her hematocrit has varied between ___ over the last ___ years,
which is likely a side effect of the chemotherapy and chronic
disease. During this admission her hematocrit felll slightly
which was thought to be due to the aggressive hydration she was
receiving.
6. Breast Cancer with metasteses to pelvis
Stable during this admission. During this admission she
continued treatment with letrozole [Femara] 2.5 mg and Faslodex.
Transitional Issues:
Follow up: PCP -- to access to kidney function, and f/u
prolonged Qtc
Pending labs: none
Incidental findings: none
Code status: DNR
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Amlodipine 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Fulvestrant 250 mg IM Q1MO Duration: 1 Doses
4. letrozole *NF* 2.5 mg Oral daily
5. Lisinopril 20 mg PO DAILY
6. Lorazepam 0.5 mg PO Q4H:PRN anxiety
7. Ranitidine 150 mg PO BID
8. Sulfameth/Trimethoprim SS 2 TAB PO BID
9. Aspirin 81 mg PO DAILY
10. Calcium Carbonate 600 mg PO DAILY
11. Vitamin D 3000 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 600 mg PO DAILY
RX *calcium carbonate 600 mg (1,500 mg) 1 Tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
3. Lorazepam 0.5 mg PO HS:PRN anxiety
4. Ranitidine 150 mg PO BID
5. Vitamin D 3000 UNIT PO DAILY
6. Amlodipine 5 mg PO DAILY
7. Atenolol 12.5 mg PO DAILY
RX *atenolol 25 mg 0.5 (One half) Tablet(s) by mouth daily Disp
#*15 Tablet Refills:*0
8. letrozole *NF* 2.5 mg Oral daily
9. Fulvestrant 250 mg IM Q1MO Duration: 1 Doses
10. Outpatient Lab Work
Chem-7 on ___. Please fax results to Dr. ___ at
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Cellulitis
Acute renal failure
Hyperkalemia
Anemia
Hypertension
Secondary:
Breast Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure to participate in your care at ___. You
came to the hospital because of a skin infection on your right
foot. Your skin infection improved with antibiotics. While in
the hospital we found that you had acute kidney injury, which we
treated by stopping some of your medications and giving you
fluids. We think you had this problem because you were
dehydrated.
You also had an elevated potassium level in the hospital, which
we treated by giving you fluids and giving you a medication
(kayexylate) to decrease the amount of potassium in your body.
You were also found to be anemic during your hospitalization
because your red blood cell count was low, however it was
improved at the time you were released from the hospital.
You will need to follow up with your primary doctor because of
your kidney problem. You will be given a prescription to have
your blood drawn. You should have your blood drawn a few hours
before your appointment with your primary doctor on ___.
Followup Instructions:
___
|
10116310-DS-16 | 10,116,310 | 22,838,844 | DS | 16 | 2187-09-28 00:00:00 | 2187-09-29 11:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ampicillin / Meperidine / Nitroimidazole Derivatives / Codeine /
Flagyl / Penicillins / Vancomycin / Morphine Sulfate /
oxycodone-acetaminophen / Vicodin / Bactrim
Attending: ___.
Chief Complaint:
Hyperkalemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with metastatic ER/PR positive, HER-2/neu neg breast
cancer on weekly taxol (most recently on ___ and CKD
Stage III who presents with hyperkalemia. She was to obtain her
weekly taxol on day of admission, when her routine lab work
showed K 6.8. She did have one episode of dyspnea after walking
from one room to the next in her home this morning, which is new
but an isolated incidence. She denies any chest pain,
palpitations, dizziness, urinary or bowel symptoms (last BM was
this morning). No fever, nausea, diarrhea, or headache, no ___
swelling or pain. Denies any fall or injury.
Last discharged from hospital ___, found to have
asymptomatic UTI, ___, and hyperkalemia thought secondary to her
acute on chronic renal failure. Her lower extremity pain and
swelling was thought secondary to gout and she was treated with
a
course of prednisone. She was also found to be hypocalcemic,
hypomagnesemic. She was discharged off of lasix.
ED course:
15:48 0 97.6 70 153/49 18 100% 0
--17:12 IVs: Start IV Fluid (Common) NS 1000 mL bolus Total:
1000
17:37 INSULIN 5 UNIT IV Single Dose
17:37 Calcium Gluconate 1 gm IV
17:37 Dextrose 50% 25 gm IV
17:12 Furosemide 40 mg IV
Review of Systems: As per HPI. She states that she had good PO
intake with no odynophagia or dysphagia. No BRBPR, melena. All
other systems negative.
Past Medical History:
1. Hypertension
2. Hypercholesterolemia
3. h/o breast Ca ___ ER/PR+, HER2/NEU-. s/p R. lumpectomy and
RT. Followed by Dr. ___. A CT scan of the thorax in ___
identified a distinct osteolytic lesion in the posterior left
ilium that was also seen on a prior MRI that was done to image
the avascular necrosis. A CT-guided biopsy on ___
confirmed metastatic cancer consistent with breast origin. It
was ER positive, PR positive. She has since taken
Faslodex/denosumab, and most recently has been on Taxol since
___.
4. ___ esophagus
5. diverticulitis.
6. h/o cholecystectomy
7. h/o peripheral vascular disease, carotid artery disease (40%
and 50% stenosis), followed by Dr ___.
8. Chronic renal insufficiency (gradual rising creatinine levels
(between 1.2-1.9)
9. Smoker x 30+ years.
10. Temporal arteritis
11. nontoxic multinodular goiter
Social History:
___
Family History:
Sons (twins) - esophageal CA
Mother - CAD, MI
Sister - "spinal cancer"
Physical Exam:
ADMISSION EXAM:
--------------
T97.8, 140/50, HR 66, 16, 100%RA
GEN: NAD
HEENT: PERRL, EOMI, MMM, dentures in place. Oropharynx clear, no
cervical ___: CTAB, no wheezes, rales or rhonchi.
Chest: Left port in place, no surrounding erythema, TTP, or
swelling.
CV: RRR with III/VI SEM best heard at RUSB, nl S1 S2. JVP<7cm
ABD: normal bowel sounds, non-tender, not distended
EXTR: Warm, well perfused. No edema. 2+ pulses.
NEURO: alert and appropriate, motor grossly intact
DISCHARGE EXAM:
--------------
98.9 120/58 ___ 16 99%RA
GEN: Alert, oriented, NAD
HEENT: Dry tongue, no scleral icterus
CV: RRR, ___ SEM, no JVD
PULM: CTAB
ABD: Soft, nt, nd, no masses, multiple well-healed surgical
scars
EXT: no edema, normal pulses, osteoarthritic changes of MTP
joints
Pertinent Results:
ADMISSION LABS
--------------
___ 04:55PM K+-6.2*
___ 04:30PM GLUCOSE-100 UREA N-24* CREAT-1.7* SODIUM-140
POTASSIUM-7.1* CHLORIDE-108 TOTAL CO2-23 ANION GAP-16
___ 04:30PM CALCIUM-9.0 PHOSPHATE-3.6 MAGNESIUM-2.2
___ 04:30PM WBC-7.9 RBC-3.19* HGB-9.0* HCT-29.3* MCV-92
MCH-28.2 MCHC-30.8* RDW-19.3*
___ 04:30PM NEUTS-77.3* LYMPHS-15.6* MONOS-4.1 EOS-2.6
BASOS-0.3
___ 04:30PM PLT COUNT-582*
___ 01:45PM ALT(SGPT)-14 AST(SGOT)-19 ALK PHOS-87 TOT
BILI-0.2
___ 01:45PM ALBUMIN-3.4* CALCIUM-8.5 PHOSPHATE-3.0
MAGNESIUM-2.2
PERTINENT LABS
--------------
___ 05:30AM BLOOD CK-MB-2
___ 05:30AM BLOOD Hapto-428*
___ 12:00PM BLOOD Cortsol-17.2
___ 05:30AM BLOOD RENIN-PND
___ 05:58AM BLOOD ALDOSTERONE-PND
___ 09:00AM URINE Hours-RANDOM UreaN-411 Creat-158 Na-78
K-75 Cl-84
DISCHARGE LABS
--------------
___ 05:58AM BLOOD WBC-7.6 RBC-2.93* Hgb-8.1* Hct-26.7*
MCV-91 MCH-27.6 MCHC-30.2* RDW-20.2* Plt ___
___ 01:00PM BLOOD UreaN-24* Creat-1.6* Na-140 K-4.8 Cl-109*
HCO3-19* AnGap-17
MICRO
-----
NONE
IMAGING
-------
___ CT A/P
PRELIMINARY REPORT
FINDINGS:
The lower chest is unremarkable.
ABDOMEN: Multiple hypodense liver metastases are present. The
gallbladder is not well seen. There is no bile duct dilation.
The spleen is unremarkable. The pancreas contains coarse
calcifications, which can be seen in patients with chronic
pancreatitis. The kidneys contain multiple large simple cysts
and several higher density cysts which are not fully
characterized on this non contrast study. There is no
hydronephrosis. There is no adrenal nodule.
The stomach, small bowel, and large bowel are normal in caliber,
without wall thickening. There is no ascites, fluid collection,
pneumoperitoneum, or focal mesenteric fat stranding. There is no
lymphadenopathy. The abdominal aorta is normal in caliber.
PELVIS: The urinary bladder and rectum are unremarkable. There
are no stones within either ureter or within the bladder. The
there is no pelvic free fluid, lymphadenopathy, or mass. The
uterus and ovaries are not seen.
MUSCULOSKELETAL: Diffuse skeletal metastatic disease is still
present.
IMPRESSION:
No adrenal nodules are present. Incompletely characterized
diffuse metastatic disease.
-----------
EKG: Sinus rhythm. Compared to the previous tracing there is no
significant change.
Brief Hospital Course:
A&P: ___ yo ER/PR+, HER2/NEU neg breast Ca on taxol (last ___,
CKDIII who presents with persistent hyperkalemia of unclear
etiology.
#Hyperkalemia: Most likely related to CKD as labs showed no
evidence of hemolysis, rhabdomyolysis, pseudohyperkalemia
secondary to platelet activation, or inappropriate urinary
potassium secretion. Moreover, cortisol was normal, making
adrenal insufficiency unlikely. There was no evidence of adrenal
metastasis on the abd/pelvis CT. She may have either
hypoaldosteronism or hyporeninism superimposed on her CKD.
Aldosterone and renin were sent and were pending at discharge.
She had no recent use of NSAIDs, ___, K-sparing diuretics,
or K supplementation prior to admission (diet was stable). Her
potassium improved with IV fluid and furosemide. Heparin was
held but this was thought to be an unlikely cause of acquired
hypoaldosteronism.
#SOB/COPD: GOLD II. Not on home O2 or inhalers. Last PFTs ___
showed FEV1/FVC 74%. Complained of DOE the day prior to
admission, but no clear source. Did not have cough, orthopnea,
chest pain here. CK-MB was normal. EKG without ischemia
#BREAST CA: Has Stage IV ER/PR+ HER2/NEU- cancer metastatic to
bone/liver. Taxol postponed day prior to admission given
hyperkalemia. Had plan to restart Taxol as outpatient. Her home
pain medications (fentanyl, lidocaine, tramadol) were continued
#HTN: continued amlodipine, held atenolol given hyperK. This was
NOT restarted on discharge and she was instructed to follow up
with her PCP.
#PVD/CAD: No hx of MI. Takes 81mg ASA for primary prevention.
Continued
TRANSITIONAL ISSUES:
-restart taxane therapy
-follow up ___
-follow up outpatient K, restart beta blocker if felt indicated
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. Fentanyl Patch 12 mcg/h TD Q72H
5. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
6. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety/nausea
7. Prochlorperazine 10 mg PO Q6H:PRN n/v
8. Vitamin B Complex 1 CAP PO DAILY
9. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Fentanyl Patch 12 mcg/h TD Q72H
4. Lorazepam 0.5-1 mg PO Q4H:PRN anxiety/nausea
5. Omeprazole 20 mg PO DAILY
6. Prochlorperazine 10 mg PO Q6H:PRN n/v
7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
8. Vitamin B Complex 1 CAP PO DAILY
9. Furosemide 20 mg PO DAILY
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
10. Outpatient Lab Work
please get a chemistry panel including sodium, potassium,
chloride, bicarbonate, BUN, and creatinine on ___.
Please report results to the ___ oncology department attn Dr.
___, phone number ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Hyperkalemia
SECONDARY:
Breast cancer
Chronic kidney disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
It was a pleasure taking care of you during your recent
hospitalization. You were admitted because your potassium was
high. We gave you medications to decrease it, but it is probably
because your kidneys are not working as well as they should. It
is important that you take the lasix (also called furosemide)
every day until your doctor tells you otherwise in order to help
you urinate out the potassium. Please make sure you drink plenty
of water or you will get dehydrated because of the lasix making
you urinate. Please avoid the foods that are on the list of
high-potassium foods that we gave you.
It is very important that you have your potassium checked on
___ and call your doctor later that day for that
result (Dr. ___. We will give you a prescription for you to
get your labs drawn.
We had you STOP your atenolol. This medication can build up in
the body if your kidneys are not working properly. You will need
to discuss what to do about this with your doctor at your next
appointment.
Followup Instructions:
___
|
10116409-DS-22 | 10,116,409 | 20,541,656 | DS | 22 | 2156-07-05 00:00:00 | 2156-07-05 17:56:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
shellfish / some type allergy medicine / Xolair / Mucinex /
fosaprepitant
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ year old female with a PMH of locally
advanced pancreatic cancer (s/p 5C FOLFOX + SRS, recently
admitted for pancreatitis ___ who presents on this
admission with acute abdominal pain. Patient was last discharged
from the hospital on ___ after she had a CPN which worked well
for roughly 1 week then her pain returned. She was re-imaged in
the outpatient setting and pancreatic findings were unchanged.
She was prescribed oxycontin which was uptitrated.
On this admission, patient returns with abdominal pain lasting 3
days. She has had worsening central abdominal pain that radiates
to the back, no longer responding to home long- and short-acting
opioids taken RTC. She has had poor appetite, nausea, malaise,
and poor oral intake over last 3d. Went for EUS/celiac plexis
neurolysis yesterday ___ with no relief of symptoms,
therefore,
she was transferred to ED for pain control, eval, and admit
OMED.
In the ED, she denied CP, palpitations, dyspnea, cough, new
abdominal pain (eg different from usual pancreatic ca pain),
dysuria, or constipation from opioids. Initial vitals: 97.5 55
133/70 18 95% RA. WBC 19 (baseline ___, Hgb 13, plt 503, LFTs
with AP 140 otherwise normal, CHEM wnl, UA with + ketones and
+urobilinogen, otherwise normal. CXR without acute process, KUB
with nonspecific nonobstructive bowel gas pattern, no
pneumoperitoneum. Patient was given morphine, oxycontin,
oxycodone, and normal saline then admitted to OMED as unable to
tolerate PO.
At arrival to the floor, patient reports that pain is better
(___). She reports malaise, nausea and anorexia. She denies
vomit, diarrhea or constipation. Her last bowel movement was ___
days ago.
Past Medical History:
As per admitting MD:
"PAST ONCOLOGIC HISTORY (Per OMR, reviewed):
___ was diagnosed with a pancreatic body mass in the
setting of new-onset diabetes a year prior and one-week history
of postprandial epigastric pain with nausea and weight loss
including 30 pounds over the past year in the setting of dietary
changes for diabetes control. CTA showed a faint ill-defined
hypodensity in the pancreatic body, concerning for tumor process
as well as constipation. EUS by Dr. ___ on ___
confirmed the presence of a well-defined 2.3 x 1.7 pancreatic
body mass with FNA suspicious for neoplasm with the differential
including solid pseudopapillary tumor versus well-differentiated
adenocarcinoma. Preop CTA in preparation for elective Whipple
showed a 2.2 cm anteriorly exophytic cystic structure with
regional adenopathy was soft tissue encasing the common hepatic
artery extending posteriorly to the origin of the celiac axis
and nearly encasing the proximal left gastric artery.
Due to these findings, surgery canceled. Repeat EUS on ___ again revealed a 3.5 cm mass encasing the celiac axis,
question of a 1.5 cm right lower lobe lesion and fiducials were
placed but no biopsy. Port placed ___ in preparation for
likely treatment.
Seen at our pancreatic cancer multidisciplinary, conference on
___. Recommendation was for an EUS guided biopsy.
This was done on ___. There was a 2.5 cm x 3.1 cm
ill-defined mass in the body of the pancreas this was biopsied
with a 22-gauge sharp core needle. Pathology revealed a
pancreatic ductal adenocarcinoma arising in a background of
likely mucinous epithelial neoplasm with dysplasia.
Admitted C1D1 of FOLFOX after allergic reaction to Emend. Has
done well on Aloxi.
C3D1 delayed d/t vaginal bleeding. She had previously had a
uterine polyp. She saw her gynecologist who indicated could do
an endometrial biopsy if bleeding.
___ cyberknife to primary requiring IVF on last day.
PAST MEDICAL HISTORY (Per OMR, reviewed):
- Severe TBM and status post Y stent in ___, removed
eight days later due to intolerability
- OSA on CPAP
- Diabetes type 2 diagnosed in ___ while on steroids
- Chronic leukocytosis, thrombocytosis since ___
- History of splenectomy in ___ for spontaneous splenic rupture
- Depression
- Anxiety
- Atrophic Gastritis
- GERD
- Osteoarthritis/C5-C6 spondylosis
- History of Graves status post RAI
- Fatty liver and hemangiomas
- Thoracic outlet syndrome, status post rib resection
"
Social History:
___
Family History:
Father with gastric cancer. He was a heavy smoker and drinker.
No other known family history"
Physical Exam:
Admission
=========
GENERAL: Ill-appearing lady, in mild distress lying in bed
HEENT: Anicteric, PERLL, Mucous membranes dry.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Midly distended, hypoactive bowel sounds, soft, generalized
tenderness, more profound in lower abdomen and flanks. No
guarding, no palpable masses, no organomegaly.
BACK: Point tenderness in lower back.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout.
Discharge
=========
Temp: 98.2 PO BP: 1012/56 HR: 56 RR: 18 O2 sat: 94% O2 delivery:
2lnc
GENERAL: NAD
HEENT: Anicteric, PERLL, Mucous membranes dry.
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Midly distended, hypoactive bowel sounds, soft, generalized
tenderness, more prominent in the RUQ. No guarding, no palpable
masses, no organomegaly.
BACK: Point tenderness in lower back.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness.
NEURO: Alert and oriented, good attention, linear thought
process. CN II-XII intact. Strength full throughout.
Pertinent Results:
Admission
=========
___ 02:50PM BLOOD WBC-19.0* RBC-4.22 Hgb-13.0 Hct-39.9
MCV-95 MCH-30.8 MCHC-32.6 RDW-13.5 RDWSD-46.5* Plt ___
___ 02:50PM BLOOD Neuts-70.5 ___ Monos-7.2 Eos-0.2*
Baso-0.4 Im ___ AbsNeut-13.36*# AbsLymp-4.04* AbsMono-1.36*
AbsEos-0.04 AbsBaso-0.08
___ 02:50PM BLOOD Glucose-121* UreaN-11 Creat-0.6 Na-139
K-4.5 Cl-101 HCO3-23 AnGap-15
___ 02:50PM BLOOD ALT-20 AST-32 AlkPhos-140* TotBili-0.4
___ 02:50PM BLOOD Lipase-9
___ 02:50PM BLOOD Albumin-3.9 Calcium-9.5 Phos-3.8 Mg-1.8
DISCHARGE
=========
___ 05:12AM BLOOD WBC-12.2* RBC-3.25* Hgb-10.0* Hct-31.2*
MCV-96 MCH-30.8 MCHC-32.1 RDW-13.9 RDWSD-49.1* Plt ___
___ 05:12AM BLOOD Glucose-84 UreaN-11 Creat-0.7 Na-142
K-4.1 Cl-104 HCO3-27 AnGap-11
___ 05:12AM BLOOD Calcium-8.6 Phos-4.5 Mg-1.8
MRI SPINE ___
=====================
1. No evidence for spine metastasis.
2. Changes related to known pancreatic cancer better seen on
prior CT.
3. Degenerative changes spine.
4. Mild-to-moderate central canal narrowing L4-L5 level.
5. Severe left L4-5 foraminal narrowing.
6. Small volume pleural fluid. Patchy lung opacities, likely
atelectasis
and/or edema. Consider infection, chest PA lateral, if
clinically
appropriate.
Abd x-ray ___
=====================
There are no abnormally dilated loops of large or small bowel.
There is no
free intraperitoneal air. There are degenerative changes at the
pubic
symphysis. Multiple surgical clips project over the midline of
the upper
abdomen. There are no unexplained soft tissue calcifications or
radiopaque foreign bodies.
IMPRESSION:
1. Nonspecific, nonobstructive bowel gas pattern.
2. No pneumoperitoneum.
Brief Hospital Course:
___ PMH locally advanced pancreatic cancer (s/p 5C FOLFOX + SRS,
recently admitted for pancreatitis ___ who presents on
this
admission with persistent acute abdominal pain.
Patient was admitted from clinic after persistant pain despite a
second Celiac plexus neurolysis procedure. There was not concern
for abdominal perforation on imaging or laboratory testing. An
MRI of the spine was performed as the patient was also
complaining of back pain which showed no metastatic disease.
The patient was initially started on a morphine PCA with
improvement of her pain, however, the patient had refractory
pain upon switching to her oral regimen. A multimodal approach
to the patient's pain was taken with the input of the palliative
care consult service. Her home SSRI dose was increased. In
addition, the patient was started on Ativan to help with anxiety
related to perseveration on her disease. In addition, the
patient started Ritalin for her fatigue and depression symptoms.
Radiation oncology was consulted to see if there was a role for
palliative radiation. However, given her recent radiation and
lack of significant progression of her tumor burden on recent
imaging this was not seen to be an option.
TRANSITIONAL ISSUES
Discharge Pain regimen:
- OxyCODONE SR (OxyconTIN) 50 mg PO Q8H
- OxyCODONE (Immediate Release) ___ mg PO/NG Q4H:PRN Pain -
Moderate
- Gabapentin 600 mg PO/NG TID
Please obtain repeat CT abd/pelvis to assess for disease
progression ~ ___
Please obtain outpatient PET CT as prior imaging demonstrated
lung nodules concerning for metastasis
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO BID
2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
3. Levothyroxine Sodium 25 mcg PO DAILY
4. LORazepam 1 mg PO BID:PRN anxiety/insomnia
5. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
6. TraZODone 100 mg PO QHS
7. Creon ___ CAP PO QIDWMHS
8. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
9. Polyethylene Glycol 17 g PO DAILY
10. Simethicone 40-80 mg PO QID:PRN gas bubble
11. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
12. Escitalopram Oxalate 10 mg PO DAILY
13. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every eight (8) hours Disp #*42 Tablet
Refills:*0
2. Escitalopram Oxalate 20 mg PO DAILY
RX *escitalopram oxalate 20 mg 1 tablet(s) by mouth once a day
Disp #*14 Tablet Refills:*0
3. MethylPHENIDATE (Ritalin) 7.5 mg PO QAM
RX *methylphenidate HCl 5 mg 1.5 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
4. MethylPHENIDATE (Ritalin) 7.5 mg PO NOON
5. Narcan (naloxone) 4 mg/actuation nasal Overdose
Administered as directed for suspected overdose then call ___
RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasal Once,
may repeat once Disp #*2 Spray Refills:*2
6. OxyCODONE SR (OxyconTIN) 50 mg PO Q8H
RX *oxycodone [OxyContin] 20 mg 2.5 tablet(s) by mouth every
eight (8) hours Disp #*105 Tablet Refills:*0
7. LORazepam 0.25 mg PO Q6H:PRN anxiety
RX *lorazepam 0.5 mg 0.5 (One half) tablet by mouth every six
(6) hours Disp #*28 Tablet Refills:*0
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*84 Tablet Refills:*0
9. TraZODone 50 mg PO QHS:PRN Insomnia
RX *trazodone 50 mg 1 tablet(s) by mouth hs Disp #*14 Tablet
Refills:*0
10. Creon ___ CAP PO QIDWMHS
11. Docusate Sodium 100 mg PO BID:PRN constipation
12. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth three times a day
Disp #*42 Capsule Refills:*0
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 25 mcg PO DAILY
15. mometasone 50 mcg/actuation nasal DAILY:PRN congestion
16. Omeprazole 20 mg PO BID
17. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
18. Polyethylene Glycol 17 g PO DAILY
19. Pravastatin 20 mg PO QPM
20. Prochlorperazine 10 mg PO Q8H:PRN nasuea/vomiting
21. Simethicone 40-80 mg PO QID:PRN gas bubble
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Advance Pancreatic Cancer
Chronic abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Hello Ms. ___,
You came to the hospital because you were having severe
abdominal and back pain. You underwent an MRI of your spine
which showed no cancer in your spine. You were given pain and
anxiety medications and we increased the dose of your
antidepressant and your symptoms improved.
Your follow up appointments and discharge medications are
detailed below.
We wish you the best!
Your ___ Care team
Followup Instructions:
___
|
10116621-DS-11 | 10,116,621 | 28,927,488 | DS | 11 | 2130-08-25 00:00:00 | 2130-08-26 16:27:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / peanut
Attending: ___
Chief Complaint:
Chest and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with H/O CAD (s/p 3 DES in mid-distal AV groove
RCA and in the distal AV groove RCA between the RPDA and RPL1
and DES to mid RPDA ___, chronic back pain, diastolic heart
failure/HFpEF (EF >60%), DJD, diabetes mellitus with
nephropathy, hyperlipidemia, hypertension, peripheral arterial
disease, prostate cancer, sleep apnea, GERD, ___ esophagus
and anxiety, presenting with chest and abdominal pain.
Patient says that he developed chest and abdominal pain 5 months
ago. He noted worsening shortness of breath with ambulation. He
underwent cardiac catheterization on ___, during which time
he had 3 DES placed in the RCA over 2 successive procedures on
the same day with a significant amount of radiation exposure. He
says that since the stents were placed, he had no resolution of
his symptoms. He also had worsening abdominal pain. He underwent
a CTA abdomen and pelvis to look for abdominal angina, and no
flow limiting lesions were seen. He had a doctor's appointment
today, did more walking than normal and developed shortness of
breath, chest pressure, and abdominal pain. He denied nausea,
sweating, or palpitations during the episodes. He states he just
feels weak and uncomfortable. He states that, per his cardiac
medication instructions, he took 3 nitroglycerin without relief,
at which point he presented to the Emergency Department. He
denies pain elsewhere. He has had no worsening orthopnea, sleeps
flat at baseline. He has noted lightheadedness and dizziness in
the morning when standing up quickly. Since his PCIs in ___,
he has had elevated Cr.
In the ED, initial vitals were: T 97.5 HR 80 BP 134/85 RR 18
SaO2 100% on RA. Labs were significant for WBC 6, H/H 12.4/37.5,
plt 213. BUN 44, Cr 1.7 (baseline 1.2-1.5), Troponin-T <0.01.
CXR negative for cardiopulmonary process. EKG with HR 57, sinus
rhythm, T wave inversions in aVL, normal intervals and axis. No
ST elevations and unchanged from prior tracing. The patient was
given 1L NS and Morphine 2 mg IV x2. Vitals prior to transfer
were T 97.9 HR 66 BP 143/73 RR 18 SaO2 99% on RA.
Upon arrival to the cardiology ward, vitals T 97.8, BP 173/95,
HR 63, RR 18, SaO2 97% on RA. Patient was complaining of chest
pain, epigastric, radiating around both sides towards his back,
as well as chest pressure. He rated it as ___ at rest, which is
slightly worse than baseline. He was given hydralazine 25 mg PO
for hypertension and additional morphine 2 mg which he says
helped for a little bit. Chest pain returned, EKG unchanged and
at baseline. He was given nitroglycerin SL x3 with minimal
effect. He remained hemodynaimcally stable. He was also given
Maalox. Repeat troponin negative.
Past Medical History:
1. CAD RISK FACTORS:
- Hypertension
- Hyperlipidemia
- Diabetes on insulin/metformin
2. CARDIAC HISTORY:
- PUMP FUNCTION: EF >60% on ___
- Cardiac catheterization in ___, done for recurrent chest pain
and depressed ejection fraction, showed mild disease of the LAD
and RCA.
- S/P 3 DES to the RCA in ___
- CHF/HFpEF
- DJD
- PAD s/p prior intervention
- ___ esophagus
- Reflux
- Prostate Ca
- Anxiety
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission
General: Overweight middle aged white man, alert, oriented,
lying in bed comfortably, talking in full sentences, in no acute
distress
Vitals: T 97.8, BP 173/95, HR 63, RR 18, SaO2 97% on RA
HEENT: Sclera anicteric, mucous membranes moist, oropharynx
clear, EOMI, PERRL
Neck: Supple, JVP difficult to assess due to body habitus
CV: intermittently bradycardic, regular rhythm, normal S1 + S2;
no murmurs, rubs, or gallops
Lungs: Clear to auscultation bilaterally--no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, hypoactive bowel
sounds, no organomegaly, no rebound or guarding
GU: No Foley
Ext: Warm, well perfused, 2+ pulses; no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
At discharge
General: in NAD
Vitals: T 97.4 Tmax 98.0 HR ___ BP ___ RR ___
SaO2 96-100% on RA
Last 8 hours I/O: 1400/bathroom privileges
24 Hr I/O: 1240/1200
Lungs: CATB
CV: RRR, S1, S2; no no murmurs, rubs or gallops
Abdomen: BS+, soft, non-tender, not distended
Ext: warm without edema
Pertinent Results:
___ 07:30PM BLOOD WBC-6.0 RBC-4.36* Hgb-12.4* Hct-37.5*
MCV-86 MCH-28.4 MCHC-33.1 RDW-13.7 RDWSD-42.0 Plt ___
___ 07:30PM BLOOD Neuts-34 Bands-0 Lymphs-59* Monos-2*
Eos-4 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-2.04 AbsLymp-3.60
AbsMono-0.12* AbsEos-0.24 AbsBaso-0.00*
___ 07:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:30PM BLOOD ___ PTT-26.9 ___
___ 07:30PM BLOOD Glucose-165* UreaN-44* Creat-1.7* Na-138
K-4.2 Cl-103 HCO3-23 AnGap-16
___ 07:30PM BLOOD ALT-34 AST-25 AlkPhos-46 TotBili-0.4
___ 07:30PM BLOOD Lipase-49
___ 07:30PM BLOOD Albumin-4.2 Phos-2.9
___ 07:30PM BLOOD cTropnT-<0.01
___ 03:55AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-90
___ 04:50PM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:45AM BLOOD WBC-5.0 RBC-4.61 Hgb-13.0* Hct-39.7*
MCV-86 MCH-28.2 MCHC-32.7 RDW-13.7 RDWSD-42.4 Plt ___
___ 07:45AM BLOOD ___ PTT-40.9* ___
___ 07:45AM BLOOD Glucose-138* UreaN-20 Creat-1.3* Na-138
K-4.2 Cl-101 HCO3-26 AnGap-15
___ 07:45AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
ECG ___ 7:20:40 AM
Sinus bradycardia. Consider left atrial abnormality. Possible
prior inferior wall myocardial infarction. Poor R wave
progression. Non-specific lateral T wave abnormalities. Compared
to the previous tracing of ___ bradycardia is new.
CHEST (PA & LAT) ___ 4:32 ___
The lungs are clear. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities identified.
IMPRESSION: No acute cardiopulmonary process.
Pharmacological Nuclear Stress Test ___
This was an inactive ___ year old DM2 man with CAD (MI/Stent
___, HTN, HLD, remote smoking and a BMI of 37, who was
referred to the lab from the ED after negative serial cardiac
markers for an evaluation of exertional dyspnea and chest
discomfort. He received 0.142mg/kg/min of IV Persantine infused
over 4 minutes. He complained of ___ chest pressure and
shortness of breath at rest, which remained unchanged throughout
the duration of the study. There were no significant changes in
ST segments or T waves noted during the infusion or in recovery.
The rhythm was sinus with no ectopy seen throughout the duration
of the study. The heart rate and blood pressure responded
appropriately to the Persantine infusion. At 2 minutes post
infusion, 125mg IV Aminophylline was given to prevent any
potential Persantine side effects.
IMPRESSION: No ischemic ECG changes noted in the presence of
non-anginal
type symptoms. Appropriate hemodynamic response to Persantine.
IMAGING:
The image quality is adequate but limited due to soft tissue
attenuation and motion. There is activity adjacent to the heart
in the stress images.
Left ventricular cavity size is increased.
Rest and stress perfusion images reveal a reversible, mild
reduction in photon counts involving the mid and basal inferior
wall.
Gated images reveal hypokinesis of the mid and basal inferior
wall.
The calculated left ventricular ejection fraction is 46% with
an EDV of 110 ml.
IMPRESSION:
1. Reversible, small, mild perfusion defect involving the RCA
territory.
2. Increased left ventricular cavity size. Mild systolic
dysfunction with hypokinesis of the mid and basal inferior wall.
In the setting of recent MI, the perfusion defect may
represent microvascular dysfunction.
Compared with prior study of ___, the defect now
appears reversible.
CTA Chest ___
The aorta and its major branch vessels are patent, with no
evidence of stenosis, occlusion, dissection, or aneurysmal
formation. There is no evidence of penetrating atherosclerotic
ulcer or aortic arch atheroma present. Coronary artery
calcifications noted. Scattered calcifications of the thoracic
aorta and great vessels. There is common origin of the
brachiocephalic and left common carotid arteries.
Right upper lobe subsegmental pulmonary embolus (03:85). The
main and right pulmonary arteries are normal in caliber, and
there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy. The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no
pleural effusion.
Bilateral dependent hypoventilatory/atelectatic changes. The
airways are otherwise patent to the subsegmental level.
Limited images of the upper abdomen demonstrates an exophytic
cyst in the upper pole the left kidney, seen best on coronal
imaging. The liver demonstrates decreased attenuation, likely
secondary to fatty liver. Replaced left hepatic artery.
No lytic or blastic osseous lesion suspicious for malignancy
is identified.
IMPRESSION:
1. Right upper lobe subsegmental pulmonary embolus. No imaging
evidence of right heart strain.
2. Hepatic Steatosis.
Brief Hospital Course:
___ with CAD (s/p 3 DES in mid-distal AV groove RCA and in the
distal AV groove RCA between the RPDA and RPL1 and DES to mid
RPDA in ___ during 2 successive procedures during the same
day with significant fluoroscopic radiation exposure) presenting
with persistent chest and abdominal pain.
# Chest and abdominal pain: This pain is chronic and did not
improve after ___ in ___. His ECG remained
unchanged and his troponins were negative, arguing against
ongoing ischemia which would be expected to result in cardiac
myonecrosis. Pharmacological vasodilator nuclear stress test
showed small reversible defect that was felt unlikely to be
contributing to chest pain and was more likely a false positive
result from endothelial dysfunction after his recent ___ MI
and from the PCIs themselves. There was no improvement in pain
with SL NTG or other long acting anti-anginal agents. Pain,
therefore, felt to be less likely from cardiac ischemia. Patient
underwent CTA to look for pulmonary embolus or aortic
dissection. A small RUL subsegmental pulmonary embolus was
noted on CTA; given its size, this was again felt to be unlikely
explanation for extent of pain. Highest suspicion is for GI
etiology. He was treated with omeprazole, GI cocktail, and
sucralfate. Sucralfate was most helpful in resolving symptoms
(although not consistently or persistently), so he was given
sucralfate to take as an outpt. He will have a GI work up
(EGD/Colonoscopy) as outpt to further investigate possible GI
etiology of pain.
# Pulmonary embolus: RUL subsegmental PE found on CTA. No
evidence of right heart strain. Normal hemodynamics. Patient was
started on warfarin with an enoxaparin bridge and encouraged to
undergo colonoscopy as part of age-appropriate cancer screening.
Transitional issues:
- Small pulmonary embolus confirmed on chest CT. Patient started
on warfarin with enoxaparin bridge. Goal INR ___. Will follow
with ___ clinic in ___
- Patient is now on triple anticoagulation (for his recent DES).
Please monitor closely for evidence of bleeding.
- Suspect GI etiology for chest/epigastric pain. EGD scheduled
as next step in work-up.
- CODE STATUS: full code
- CONTACT: ___ (wife, HCP) ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Escitalopram Oxalate 10 mg PO DAILY
3. Glargine 50 Units Bedtime
4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
9. Omeprazole 20 mg PO DAILY
10. Prasugrel 10 mg PO DAILY
11. Ranolazine ER 500 mg PO BID
12. Aspirin 325 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Atorvastatin 80 mg PO QPM
3. Escitalopram Oxalate 10 mg PO DAILY
4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
8. Omeprazole 20 mg PO DAILY
9. Ranolazine ER 500 mg PO BID
10. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
Do Not Crush
11. Amlodipine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
12. Enoxaparin Sodium 100 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL 1 ml injection twice daily Disp #*60
Syringe Refills:*0
13. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times daily Disp
#*120 Tablet Refills:*1
14. Warfarin 5 mg PO DAILY16
RX *warfarin 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
15. Glargine 50 Units Bedtime
16. Prasugrel 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
-Chest pain
-Pulmonary embolism
-Coronary artery disease with prior stenting
-Chronic left ventricular diastolic heart failure
-Degenerative joint disease
-Diabetes mellitus with nephropathy
-Stage 3 chronic kidney disease
-Hyperlipidemia
-Hypertension
-Peripheral arterial disease
-Sleep apnea
-Gastroesophageal reflux disease
-___ esophagus
-Anxiety
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 recurrent chest pain. Your
EKG was reassuring and your cardiac enzymes were normal. This
reassured us that the pain was unlikely to be related to cardiac
ischemia. You underwent a CT scan of your chest that showed
evidence of a small blood clot in the lungs. This may be
contributing to your pain. You were started on anticoagulation
(blood thinner) for the clot and will need to continue on this
for the next few months at least, and follow up with the clinic
in ___. We do suspect that there may be another source for
your pain, so it is important that you ___ with the
gastroenterologists for an upper endoscopy. We have started you
on the medication sucralfate to help with your abdominal pain.
It was a pleasure taking care of you. We wish you all the best.
Followup Instructions:
___
|
10116898-DS-18 | 10,116,898 | 22,177,826 | DS | 18 | 2171-04-20 00:00:00 | 2171-04-20 17:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
indomethacin
Attending: ___
Chief Complaint:
RLE pain, erythema and swelling
Major Surgical or Invasive Procedure:
___ L elbow bursa fluid aspiration
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
.
Date: ___
Time: 1205 AM
_
________________________________________________________________
PCP:
___ - ___
___
___, ___
___
___
Close
.
CC:RLE swelling x 2 weeks
L elbow swelling and erythema x one month
_
________________________________________________________________
HPI:
___ with HTN, HLD p/w painful, erythematous area down the
anterior right thigh medial aspect of right knee, and anterior
aspect of lower leg x 17 days. Patient states it began on
___, shortly after a drive to ___. He had an US on
___ which demonstrated superficial phlebitis. He was
started on high dose ibuprofen for L elbow bursitis 600 mg on
___. He was then started on ibuprofen 800 mg ___
for the leg pain. He developed a cough one week - 10 days after
the plane ride to ___ where sat close to a fellow passenger
who also had URI sx. He travelled to ___ in the beginning of
___. His cough was productive of white -> colored to white
phlegm. He has not had fevers but he has had chills and sweats.
His wife and son also developed a cold/cough/URI sx. His elbow
bursitis improved but then worsened again. He states that his
leg has become progressively more inflamed, red, and painful;
unable to ambulate secondary to pain at this point. Also with
swollen erythematous left elbow for one month. Patient reported
some exertional dyspnea to the ED clinician but he denies
exertional dyspnea to me and reports exertion and respiration
trigger coughing fits which make it difficult to breathe. Denies
fever but endorses diaphoresis. Denies chest pain. No dysuria,
hematuria, rash, back pain.
Margins of erythematous region on right leg marked, margins also
marked for left elbow
labs
=================================
In ER: (Triage Vitals:98.9|95 |135/77|16 100% RA Tmax in ED =
99.9)
Meds Given:
Acetaminophen 1000 mg|Vancomycin| Fluids given: 3L
Radiology Studies:US/CTA
consults called: None
.
PAIN SCALE: ___
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [+] per HPI
CARDIAC: [X] All normal
GI: As per HPI
GU: [X] All normal
SKIN: [+] Per HPI
MUSCULOSKELETAL: [+] per HPI
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
RENAL STONES
PRESBYCUSIS- uses b/l hearing aides
HYPERLIPIDEMIA
COLON CANCER s/p resection at ___. He did not require
chemotherapy.
COLONIC POLYPS
HYPERTENSION
RENAL LITHIASIS
=============
Surgical History
PARTIAL ___
RENAL STONE RETROGRADE
TONSILLECTOMY
Social History:
___
Family History:
Father___'S DISEASE- died of dementia ___
MGMTHROAT CANCER
MGFCOLON CANCER
Mother: Still alive but had lupus in the past.
PGFCEREBROVASCULAR ACCIDENT
Physical Exam:
ADMISSION:
Vitals: 97.9 PO 152 / 95 68 18 96 RA
CONS: NAD, comfortable appearing
HEENT: anicteric MMM
CV: s1s2 rr no m/r/g
RESP: CTAB but repiration results in spasms of coughing with an
occasional wheeze
GI: +bs, soft, NT, ND, no guarding or rebound
back:
MSK:no c/c/e 2+pulses
SKIN: R ___ with area of erythema from mid thigh to ankle,
clearly demarcated with pen. 2+ DPP b/l
L olecranon with well circumscribed region of erythema. Not
tender to palpation.
No pain with active and passive full range of motion
Palpable superficial cord, tender to palpation
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative
LAD: No cervical LAD
Pertinent Results:
___ 07:20PM URINE HOURS-RANDOM
___ 07:20PM URINE UCG-NEGATIVE
___ 07:20PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 07:20PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 07:20PM URINE RBC-4* WBC-3 BACTERIA-NONE YEAST-NONE
EPI-0
___ 07:20PM URINE MUCOUS-FEW
___ 05:36PM LACTATE-1.8
___ 05:30PM GLUCOSE-153* UREA N-13 CREAT-1.2 SODIUM-136
POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16
___ 05:30PM estGFR-Using this
___ 05:30PM estGFR-Using this
___ 05:30PM cTropnT-<0.01
___ 05:30PM ALBUMIN-3.6
=====================
ADMISSION CTA:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Low attenuation of the liver suggesting steatosis.
3. A 2.0 cm lesion within the right lobe of the liver appears to
demonstrate peripheral puddling, likely a hemangioma.
================
ADMISSION ___ US:
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
======================
___ RLE US
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Thrombophlebitis of superficial right lower extremity vein in
the thigh corresponding to area of patient redness and pain.
___ 06:40AM BLOOD WBC-6.2 RBC-4.25* Hgb-12.5* Hct-38.0*
MCV-89 MCH-29.4 MCHC-32.9 RDW-12.2 RDWSD-39.8 Plt ___
___ 06:40AM BLOOD WBC-6.2 RBC-4.25* Hgb-12.5* Hct-38.0*
MCV-89 MCH-29.4 MCHC-32.9 RDW-12.2 RDWSD-39.8 Plt ___
___ 06:33AM BLOOD WBC-8.0 RBC-4.11* Hgb-12.0* Hct-36.6*
MCV-89 MCH-29.2 MCHC-32.8 RDW-12.4 RDWSD-40.6 Plt ___
___ 06:40AM BLOOD Plt ___
___ 06:40AM BLOOD Glucose-138* UreaN-15 Creat-1.2 Na-141
K-3.9 Cl-102 HCO3-26 AnGap-17
___ 06:40AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.4
___ 05:30PM BLOOD D-Dimer-___*
___ 07:00PM BLOOD Vanco-11.3
Brief Hospital Course:
The patient is a ___ ___ old male with significant PMH of gout,
HLD who presents with RLE swelling x 2 weeks.
# RlE cellulitis.
# RLE thrombophlebitis.
___ US negative for any ___ cyst or DVT. Exam was most
consistent with cellulitis which showed improvement on IV
vancomycin. He was transitioned to oral antibiotics and
discharged to continue a total 7day course. He was also treated
supportively for RLE thrombophlebitis with NSAIDs and warm
compresses. He will be taking Keflex and doxycyline on
discharge, keel leg elevated when in bed.
# L ELBOW BURSITIS.
# GOUT
At admission, pt with full ROM of joint without pain. He had a
very significant bursitis not responsive with conservative
management. He underwent bursal fluid aspirate by Rheumatology
on ___ fluid analysis showed crystals c/w gout. He was
placed on allopurinol;he agreed with colchicine and has been
able to tolerate it for last 2 days. BID dosing of colchicine
for 5 days then once a day till sees rheumatology outpatient and
till goal uric less than 6. Rheumatology to f/u with patient 2
weeks post-discharge.
# COUGH.
Most likely post viral. Pt was prescribed azithromycin on
___. We discussed that he most likely had a viral
syndrome and as such abx are not indicated. CTA negative for
pulmonary infection. He completed his outpatient course of
azithromycin on ___, and was otherwise treated supportively
with cough suppressants.
# LIVER LESION. Probable hemangioma seen on CT chest. Pt will
need outpatient US study to confirm. PCP notified of finding.
#HLD. Continued statin
***TRANSITIONAL ISSUES***
- Patient to follow-up with Rheumatology in 2 weeks
post-discharge
-f/u with PCP and keep leg elevated
-discuss with PCP abnormal ___ results re: possible liver
?hemangioma
Medications on Admission:
Medications - Prescription
ALLOPURINOL - allopurinol ___ mg tablet. 1 tablet(s) by mouth
once a day for a week then increase to 2 tabs daily
AZITHROMYCIN - azithromycin 250 mg tablet. 2 tablet(s) by mouth
daily on day one then 1 tablet by mouth daily for 4 days
IBUPROFEN - ibuprofen 800 mg tablet. 1 tablet(s) by mouth three
times a day
SIMVASTATIN - simvastatin 20 mg tablet. 1 (One) tablet(s) by
mouth once a day
-----------
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 (One) capsule(s) by mouth four times a
day Disp #*16 Capsule Refills:*0
2. Colchicine 0.6 mg PO BID
Take one pill twice a day for next 5 days then change to once
daily
RX *colchicine 0.6 mg 1 (One) capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Doxycycline Hyclate 100 mg PO Q12H
RX *doxycycline hyclate 100 mg 1 (One) capsule(s) by mouth twice
a day Disp #*8 Capsule Refills:*0
4. Terbinafine 1% Cream 1 Appl TP BID
use it twice a day for your feet
RX *terbinafine HCl [Antifungal (terbinafine)] 1 % apply twice a
day twice a day Refills:*0
5. Allopurinol ___ mg PO DAILY
6. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
7. HELD- Simvastatin 20 mg PO QPM This medication was held. Do
not restart Simvastatin until you see your pcp
___:
Home
Discharge Diagnosis:
Lower extremity cellulitis-superficial thrombophlebitis
Cough likely due to viral Upper respiratory infection
Left elbow bursitis
Acute gout flare up
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
You were admitted with RLE redness/pain and noted to have lower
extremity cellulitis. You received iv abx and you improved. you
are being discharged on a course of po antibiotic.
You also had left elbow bursitis and acute gout flare up being
treated with colchicine.
It was a pleasure caring for you,
Your ___ Care Team
Followup Instructions:
___
|
10117130-DS-12 | 10,117,130 | 24,247,140 | DS | 12 | 2200-08-03 00:00:00 | 2200-08-03 17:57:00 |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
Magnesium Citrate
Attending: ___
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
___: Coronary artery bypass graft x3, left internal mammary
artery to left anterior descending artery, saphenous
vein grafts to the distal right coronary artery and
ramus branch.
History of Present Illness:
Mr ___ is a ___ yr old man with a PHH of diabetes and
hyperlipidemia who presented to the ER with intermittent chest
burning with radiation to his arms. His trop was negative,
however, his EKG showed changes in AVR. He underwent a stress
test, which was notable for ischemic changes and angina and a
hypotensive response to exercise. He was transferred to the
___ holding area for coronary angiogram.
Past Medical History:
1. DMII- dx age ___ but only started glyburide ___. Thrush-HIV neg due to high ___
3. hyperlipidemia
4. Rectal CA-dx ___ as invasive rectal CA on colonoscopy done
to evaluate rectal bleeding, with metastatic workup thus far
negartive-started neoadjuvent 5- ___ and ___ ___ with plan
for 6 weeks
5. Suspected histoplasmosis-found on CT as part of metastatic
workup, path revealed caseating granuloma with budding yeast
6. VATs LLL weg resection with LN bx and portacath
___
Social History:
___
Family History:
No family history.
Physical Exam:
Admit PE:
Pulse:88 Resp: 15 O2 sat:94%RA
B/P ___
Height: 6'1" Weight:200 lbs
General:
Skin: Dry [x] intact [x] Well healed old ostomy site right UQ,
well healed left anterior chest wall incision
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [x] No edema
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right: 1+ Left: 1+
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Carotid Bruit Right:- Left:-
Discharge PE:
Pulse:81, SR Resp: 16 O2 sat:93%RA
B/P ___
Height: 6'1" Weight: 89.1kg (preop 90.72kg)
General:WDWN, NAD
Skin: Dry [x] intact [x] Well healed old ostomy site right UQ,
well healed left anterior chest wall incision
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Sternum: healing well, no erythema or drainage [x]
Heart: RRR [x] Irregular [] Murmur [] grade ______
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel
sounds+[x]
Extremities: Warm [x], well-perfused [x]
Edema: trace BLE [x]
___ incision: healing well, no erythema or drainage [x]
Neuro: Grossly intact [x]
Pulses:
DP Right: 1+ Left: 1+
___ Right: 1+ Left: 1+
Radial Right: 1+ Left: 1+
Pertinent Results:
PA/LAT CXR ___: IMPRESSION: Compared to chest radiographs,
since ___, most recently ___.
Moderately severe bibasilar atelectasis has progressed. Small
bilateral
pleural effusions are larger. No pneumothorax. No pulmonary
edema. Normal postoperative cardiomediastinal silhouette.
.
TEE (intraop) ___, PRELIMINARY:
Conclusions
PRE-BYPASS: The left atrium is normal in size. No thrombus is
seen in the left atrial appendage. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
No regional wall motion abnormalities appreciated. Right
ventricular chamber size and free wall motion are normal. The
ascending, transverse and descending thoracic aorta are normal
in diameter and free of atherosclerotic plaque. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis. The mitral valve leaflets are
structurally normal. No mitral regurgitation is seen. There is
no pericardial effusion.
POST-BYPASS: Patient is in NSR. Biventricular function is
intact.. Valvular function is unchanged. Aorta remains intact
s/p decannulation. CO is 5.6 L/min.
.
Cardiac Catheterization: Date: ___ ___
Dominance: Right
* Left Main Coronary Artery
The LMCA is free of angiographic CAD.
* Left Anterior Descending
The LAD is totally occluded just after the origin and fills by R
> L collaterals. There is also diffuse 80%
mid stenosis but distal vessel is a good graft target.
There is a large trifurcating ramus intermedius. The upper pole
has 70-80% stenosis.
* Circumflex
The Circumflex is a small vessel with 70-80% proximal stenosis.
* Right Coronary Artery
The RCA has diffuse proximal 70% and diffuse distal 80% stenosis
with good distal targets.
LABS:
Admit:
___ 06:10PM BLOOD WBC-8.0 RBC-4.17* Hgb-14.0 Hct-40.9
MCV-98 MCH-33.6* MCHC-34.2 RDW-11.4 RDWSD-41.1 Plt ___
___ 09:34PM BLOOD ___ PTT-27.5 ___
___ 06:10PM BLOOD Glucose-272* UreaN-15 Creat-0.8 Na-133
K-4.8 Cl-97 HCO3-23 AnGap-18
___ 09:21AM BLOOD ALT-14 AST-13 AlkPhos-82 TotBili-1.1
___ 06:10PM BLOOD cTropnT-<0.01
___ 09:21AM BLOOD Albumin-4.5 Calcium-9.8 Phos-3.4 Mg-2.1
Cholest-280*
___ 09:21AM BLOOD %HbA1c-7.5* eAG-169*
___ 09:21AM BLOOD Triglyc-122 HDL-66 CHOL/HD-4.2
LDLcalc-190*
Discharge:
___ 06:25AM BLOOD WBC-9.1 RBC-2.89* Hgb-9.6* Hct-29.8*
MCV-103* MCH-33.2* MCHC-32.2 RDW-10.9 RDWSD-41.1 Plt ___
___ 01:30AM BLOOD ___ PTT-31.8 ___
___ 06:25AM BLOOD Glucose-135* UreaN-18 Creat-0.5 Na-133
K-3.8 Cl-95* HCO3-27 AnGap-15
___ 05:08AM BLOOD ALT-16 AST-14 LD(LDH)-163 CK(CPK)-92
TotBili-1.8*
___ 05:08AM BLOOD CK-MB-<1 cTropnT-0.01
___ 06:25AM BLOOD Mg-2.0
Brief Hospital Course:
The patient was brought to the Operating Room on ___ where
the patient underwent Coronary artery bypass graft x3, left
internal mammary artery to left anterior descending artery,
saphenous vein grafts to the distal right coronary artery and
ramus branch. Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable, weaned from inotropic and
vasopressor support. Beta blocker was initiated and the patient
was gently diuresed toward the preoperative weight. The patient
was transferred to the telemetry floor for further recovery.
Chest tubes and pacing wires were discontinued without
complication. Due to elevated blood sugars, ___ team
recommended stopping PO medications and he is now being managed
with 20units lantus qHS, 11 units Humalog TID with meals and
additional Humalog sliding scale coverage AC/HS as needed. He
is being asked to follow up with his PCP ___ 2 days for close
glucose management with recommended 1 month Endocrinology follow
up. The patient was evaluated by the physical therapy service
for assistance with strength and mobility. By the time of
discharge on POD 4, the patient was ambulating freely, the wound
was healing and pain was controlled with oral analgesics. The
patient was discharged to home with ___ services in good
condition with appropriate follow up instructions.
Medications on Admission:
1. LOPERamide 2 mg PO TID:PRN diarrhea
2. SITagliptin 100 mg oral DAILY
3. Atorvastatin 10 mg PO QPM
4. glimepiride 4 mg oral DAILY
Discharge Medications:
1. Aspirin EC 81 mg PO DAILY
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. Furosemide 20 mg PO DAILY Duration: 7 Days
RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
4. Glargine 20 Units Bedtime
Humalog 11 Units Breakfast
Humalog 11 Units Lunch
Humalog 11 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Insulin SC Sliding Scale
Breakfast Lunch Dinner
Bedtime
Glucose Insulin Dose Insulin Dose Insulin Dose
Insulin Dose
71-150 mg/dL 0 Units 0 Units 0 Units 0
Units
151-200 mg/dL 2 Units 2 Units 2 Units 0
Units
201-250 mg/dL 4 Units 4 Units 4 Units 2
Units
251-300 mg/dL 6 Units 6 Units 6 Units 3
Units
301-350 mg/dL 8 Units 8 Units 8 Units 4
Units
351-400 mg/dL 10 Units 10 Units 10 Units 5
Units
> 400 mg/dL 12 Units 12 Units 12 Units 6
Units
PLEASE HOLD SCHEDULED HUMALOG WHEN NOT EATING.
5. Metoprolol Tartrate 75 mg PO QID
RX *metoprolol tartrate 75 mg 1 tablet(s) by mouth four times a
day Disp #*120 Tablet Refills:*1
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
7. Potassium Chloride 10 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 10 mEq 1 tablet(s) by mouth daily Disp
#*7 Tablet Refills:*0
8. Atorvastatin 80 mg PO QPM
9. LOPERamide 2 mg PO TID:PRN diarrhea
10. HELD- glimepiride 4 mg oral DAILY This medication was held.
Do not restart glimepiride until your PCP or diabetes doctors
___ to restart
11. HELD- SITagliptin 100 mg oral DAILY This medication was
held. Do not restart SITagliptin until your PCP or diabetes
doctors ___ to restart
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary artery disease s/p revascularization
Diabetes Type 2
Hyperlipidemia
Hypertension
Family hx of premature CAD
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral narcotic analgesics
Sternal Incision - healing well, no erythema or drainage
Lower leg Incision - healing well, no erythema or drainage
Edema - 1+ BLE
Discharge Instructions:
Please shower daily including washing incisions gently with mild
soap, no baths or swimming, and look at your incisions
Please NO lotions, cream, powder, or ointments to incisions
Each morning you should weigh yourself and then in the evening
take your temperature, these should be written down on the chart
No driving for approximately one month and while taking
narcotics, will be discussed at follow up appointment with
surgeon when you will be able to drive
No lifting more than 10 pounds for 10 weeks
Please call with any questions or concerns ___
**Please call cardiac surgery office with any questions or
concerns ___. Answering service will contact on call
person during off hours**
Followup Instructions:
___
|
10117273-DS-11 | 10,117,273 | 25,087,476 | DS | 11 | 2188-04-29 00:00:00 | 2188-04-29 14:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / heparin
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
TIPS, PVT thrombectomy/thrombolysis, paracentesis - ___
History of Present Illness:
___ with a PMH of ETOH cirrhosis c/b ascites, SBP, esophageal
varices s/p banding, rectal varices, non-occlusive PVT, DM who
p/w melena.
On ___ pt had black stools and bright red blood. He
presented to ___ ED on ___ and ended up being admitted to ___
ICU for GIB ___. He underwent EGD/colonoscopy which per pt
showed nothing on endoscopy but revealed large rectal varices.
Pt
had paracentesis for 7L while inpatient. He received 4U pRBC
while inpatient. Stools improved to brown prior to discharge.
Pt reports he saw Dr. ___ in clinic after discharge, though
no
corresponding OMR note.
On ___ pt reports his stool turned black again, denies
bright red blood.
Pt endorses some lightheadedness, chronic sinus headaches.
Denies
CP/SOB, abdominal pain, dysuria/urinary frequency.
In the ED, initial vitals: ___ 95 100/65 18 96% RA
Exam notable for:
General: Comfortable, lying in bed, awake and alert, slightly
pale
Head/eyes: Normocephalic/atraumatic. Pupils equal round and
reactive to light.
ENT/neck: Oropharynx within normal limits. Neck supple.
Chest/Resp: Breathing comfortably on room air. Lungs clear to
auscultation bilaterally.
Cardiovascular: Regular rate and rhythm. Normal S1 and S2.
GI/abdominal: Distended, soft, nontender
Rectal: Black stool, guaiac positive
GU/flank: No CVA tenderness
Musc/Extr/Back: No peripheral edema. Moving all extremities
Skin: Warm and dry
Psych: Normal mood, normal mentation
Labs notable for:
1) BMP: Na 133, K 4.2, Cl 92, HCO3 28, BUN 13, Cr 0.9
2) CBC: WBC 6.1, Hb 9.6, plt 110
3) LFT: ALT 21, AST 31, AP 194, Tbili 1.8, Lipase 34, Albumin
3.3
4) INR 1.4
5) UA: bland
6) Ascites: WBC 191, 24 PMN
7) Lactate 1.4
Imaging notable for:
1) CT A/P: Non-occlusive PVT progressed since ___,
cirrhosis,
splenomegaly and ascites
2) CXR: No acute process
Pt given:
___ 14:17 IV Pantoprazole 40 mg
___ 14:17 IV CefTRIAXone
___ 14:48 IV CefTRIAXone 1 gm
___ 18:44 SC Insulin
___ 22:07 SC Insulin 2 Units
___ 23:00 SC Insulin 25 Units
___ 23:11 TD Nicotine Patch 21 mg/day
Consults:
1) GI: Concerning for LGIB iso known rectal varices vs
PUD/gastritis. Continue CTX, PPI IV BID. Perform infectious work
up for ascites.
Upon arrival to the floor, the patient reports he has had 4 dark
black BM today.
Past Medical History:
ETOH Cirrhosis c/b ascites, esophageal varies s/p banding, HE,
SBP
Rectal Varices
DM2
Obesity
Restless leg syndrome
Prostate cancer s/p prostatectomy
Social History:
___
Family History:
Father- CVA
Mother- ___, lung cancer
PGF- stroke
Physical Exam:
ADMISSION PHYSICAL EXAM:
=======================
VITALS: PO 107 / 70 L Sitting ___ RA
GEN: NAD, sitting up in bed
HEENT: PERRL, EOMI, no scleral icterus, OP clear
NECK: Supple
CARD: RRR, S1 + S2 present, SEM ___ LUSB
PULM: CTAB, crackles at bases, no wheezes, breathing comfortably
on RA
ABD: soft, distended, nontender, no rebound/guarding
EXT: WWP, 3+ pitting edema b/l
NEURO: AOx3, ___ strength ___
DISCHARGE PHYSICAL EXAM
=======================
VS:97.5 PO 110 / 56 85 18 96 RA
Gen: NAD
CV: RRR, normal s1/s2, systolic ejection murmur
Lungs: On RA. Diminished breath sounds, but poor inspiratory
effort.
GI: Soft, ttp near RLQ, mildly distended. Ecchymoses near lower
R. flank.
Ext: 1+ pitting edema to bilateral ankles, warm, well perfused
Neuro: A&Ox3, no asterixis
Pertinent Results:
ADMISSION LABS:
===============
___ 04:46PM BLOOD WBC-8.9 RBC-3.66* Hgb-10.6* Hct-34.6*
MCV-95 MCH-29.0 MCHC-30.6* RDW-18.9* RDWSD-62.2* Plt ___
___ 04:46PM BLOOD ___
___ 04:46PM BLOOD UreaN-10 Creat-0.9 Na-137 K-4.2 Cl-94*
HCO3-30 AnGap-13
___ 04:46PM BLOOD ALT-23 AST-33 AlkPhos-187* TotBili-2.2*
DirBili-1.0* IndBili-1.2
___ 04:46PM BLOOD Albumin-3.5
___ 04:46PM BLOOD AFP-5.3
DISCHARGE LABS:
==============
___ 06:29AM BLOOD WBC-6.8 RBC-2.97* Hgb-8.7* Hct-29.4*
MCV-99* MCH-29.3 MCHC-29.6* RDW-22.9* RDWSD-73.0* Plt Ct-42*
___ 06:29AM BLOOD ___ PTT-35.1 ___
___ 06:29AM BLOOD Glucose-126* UreaN-10 Creat-0.9 Na-139
K-5.0 Cl-101 HCO3-26 AnGap-12
___ 06:29AM BLOOD ALT-15 AST-26 LD(LDH)-349* AlkPhos-194*
TotBili-3.2*
___ 06:29AM BLOOD Albumin-3.5 Mg-1.9
PERTINENT MICRO:
================
___ 02:52PM ASCITES TNC-191* RBC-422* Polys-24* Lymphs-5*
Monos-9* Mesothe-7* Macroph-55*
___ 2:52 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
___ Blood cultures x2: NGTD
___ Urine culture: negative
___ 4:57 pm PERITONEAL FLUID PERITONEAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
PERTINENT IMAGING:
=================
___ CXR:
Possible retrocardiac opacity may reflect atelectasis or
pneumonia.
___ CT A/P w/ contrast:
1. Nonocclusive portal venous thrombus involving the left portal
vein, main
portal vein, SMV, distal splenic vein and portosplenic
confluence. Of note,
this has progressed since ___ when the distal main
portal and left
portal veins were not involved.
2. Findings of cirrhosis with portal hypertension including
splenomegaly and
increased degree of ascites.
___ RUQUS DUPLEX
1. Patent TIPS with elevated velocities proximally, but more
normal in the mid
and distal portions, with velocities as reported above.
2. Mild ascites.
3. Splenomegaly.
4. Cholelithiasis and sludge.
___ TTE: LVEF 58%. Mild symmetric left ventricular hypertrophy
with normal cavity size and regional/
global biventricular systolic function. Mild aortic stenosis.
Mild aortic regurgitation. Mild mitral and
tricuspid regurgitation.
Compared with the prior TTE (images not available for review) of
___, aortic valve gradients are
slightly higher, although AS severity remains mild.
Brief Hospital Course:
___ with EtOH cirrhosis (c/b ascites, SBP, esophageal varices
s/p banding, rectal varices), non-occlusive PVT, prostate cancer
s/p prostatectomy and DM2 who was admitted for melena initially
concerning for rectal variceal bleed vs. PUD/gastritis. At time
of admission, he underwent CTA on ___ which showed increase in
size of thrombosis involving left portal vein, main portal vein,
SMV, distal splenic vein, and portosplenic confluence.
Subsequently, he underwent TIPS approach with placement of a
lysis catheter in his portal vein on ___ and subsequently
went back for completion of his TIPS and embolization of rectal
and paraumbilical veins on ___.
His hospital course was c/b prolonged intubation likely ___
volume overload from transfusions given during TIPS, and then
hypotension. He was diuresed and extubated ___, and weaned off
pressors. He underwent ___ paracentesis (2.3L fluid), c/b small
hematoma within R. external oblique muscle (seen on ___ CT). He
was started on warfarin on ___. His hep gtt was discontinued on
___ as patient developed HITT (HIT antibodies positive, 4T score
=5). He was discharged on warfarin 3mg daily with repeat labs
the ___ following discharge (___). Melena/hematochezia
resolved after rectal varices embolization.
ACUTE ISSUES:
=============
#Melena:
Patient presented from outpatient hepatology appointment with
melena. Of note, he had been hospitalized earlier in the month
at ___ for lower GI bleed. He underwent push enteroscopy ___
showing 2 cords of grade I non-bleeding esophageal varices and
portal gastropathy without stigmata of bleeding. He had no
further melena. He underwent TIPS placement and embolization of
rectal and paraumbilical veins on ___. He completed a 7-day
course of IV ceftriaxone (___) for SBP prophylaxis and was
continued on PPI bid.
#PVT:
CTA on ___ demonstrated increase in size of thrombosis
involving left portal vein, main portal vein, SMV, distal
splenic vein and portosplenic confluence. He underwent TIPS
placement and clot lysis on ___. He was bridged to warfarin
with plan for 3 month course.
#Hypotension:
Occurred while in MICU and thought to be a combination of blood
loss during recurrent procedures, sequential LVPs and underlying
cirrhosis. He received 2u of PRBCs while in the MICU. He was
started on midodrine and weaned off levophed on ___. Continued
on midodrine 20mg tid with SBPs in the 90-110s.
# Heparin-induced thrombocytopenia:
Acute on chronic thrombocytopenia with >50% decrease in
platelets after initiation of heparin. 4T score was 5. HIT Ab
positive, so hep d/c'ed on ___. Smear showed no evidence of
hemolysis.
# External oblique muscle hematoma
CT shows hematoma at R. external oblique after para. Treated
with prn acetaminophen. Pain improved.
#EtOH cirrhosis:
Patient presented with MELD 16 and Child Class B on admission.
His EtOH cirrhosis has been complicated by ascites, esophageal
varices s/p banding, rectal varices, HE, and SBP. He underwent
push enteroscopy per above that showed nonbleeding grade 1
esophageal varices and portal gastropathy. He went down to ___
___ for TIPS, variceal embolization and therapeutic
paracentesis was also done with removal of 6L. His home
furosemide, spironolactone, and propranolol were held in the
setting of bleed. Propanolol was discontinued indefinitely at
discharge (s/p TIPS) and he was restarted on Lasix
20/spironolactone 50mg (prior home dose: Lasix 40/spirono ___.
CHRONIC/RESOLVED ISSUES:
=========================
# Alcohol use disorder
Drinking 1 pint vodka/daily prior to admission (last drink in
___, no history of withdrawal. Did not score on CiWA scale.
Seen by Social Work and continued on MVI, thiamine, folate. Pt
declined Rx for EtOH cravings.
# At risk for malnutrition
Seen by Nutrition - he was continued on thiamine, folic acid,
multivitamin.
#DM2:
Continued home ___ - 40u qAM, 15u qPM. Also on ISS in house.
#RLS:
Continued home ropinirole.
#Depression:
Continued home citalopram, duloxetine, gabapentin.
#Tobacco use disorder:
Nicotine patch while inpatient. At discharge, he said he had
nicotine patches at home and did not need refills.
# CODE: FULL CODE (confirmed)
# CONTACT: ___ (wife) ___
TRANSITIONAL ISSUES:
===================
New medications: Warfarin 3 mg daily, lactulose 30 mg TID,
thiamine 100 mg daily, midodrine 20 mg TID
Changed medications: furosemide 20 mg, spironolactone 50 mg
Stopped medications: propranolol
MELD-Na at discharge: 22
weight at discharge:175.99 lb
[]Repeat labs: CMP, LFTs, INR on ___. Fax labs to:
Dr ___, Fax ___: ___.
[]PCP to manage INR
[]Repeat RUQUS w/ Doppler ___ months (___) s/p TIPS on
___
[]Will need to be on warfarin x total 12 weeks (day 1: ___
[]Wean midodrine as tolerated
[]Given HITT this admission, patient should not receive heparin
products any more.
[]Off propranolol forever.
[]Will need follow up CT imaging for subcentimeter indeterminate
lesion within segment VI had no correlate on prior CT from ___ and is stable in size and appearance compared to
prior ultrasound from ___ (not seen on the most recent
prior ultrasound of ___.
[]Please continue to encourage smoking cessation (on nicotine
patch in-house but declined getting a script for it)
[]Please continue to support alcohol abstinence
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Citalopram 20 mg PO DAILY
3. Gabapentin 300 mg PO DAILY
4. Pantoprazole 40 mg PO Q12H
5. Propranolol 40 mg PO DAILY
6. rOPINIRole 0.25 mg PO QAM
7. Spironolactone 100 mg PO DAILY
8. Vitamin B Complex 1 CAP PO DAILY
9. ___ 75 Units Breakfast
___ 30 Units Bedtime
10. Multivitamins 1 TAB PO DAILY
11. Loratadine 10 mg PO DAILY
12. DULoxetine 30 mg PO DAILY
13. FoLIC Acid 1 mg PO DAILY
14. melatonin 3 mg oral QHS
15. Furosemide 40 mg PO DAILY
16. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
Discharge Medications:
1. Lactulose 30 mL PO TID
2. Midodrine 20 mg PO TID
3. Nicotine Patch 14 mg/day TD DAILY
4. Thiamine 100 mg PO DAILY
5. Warfarin 3 mg PO DAILY16
6. Furosemide 20 mg PO DAILY
7. ___ 75 Units Breakfast
___ 30 Units Bedtime
8. Spironolactone 50 mg PO DAILY
9. Ciprofloxacin HCl 500 mg PO Q24H
10. Citalopram 20 mg PO DAILY
11. DULoxetine 30 mg PO DAILY
12. FoLIC Acid 1 mg PO DAILY
13. Gabapentin 300 mg PO DAILY
14. Loratadine 10 mg PO DAILY
15. melatonin 3 mg oral QHS
16. Multivitamins 1 TAB PO DAILY
17. Pantoprazole 40 mg PO Q12H
18. rOPINIRole 0.25 mg PO QAM
19. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
20. Vitamin B Complex 1 CAP PO DAILY
21.Outpatient Lab Work
Obtain CMP, LFTs, INR. Fax labs to: Dr ___
___: ___, Fax ___:
___. ___
ICD-10-CM Diagnosis Code ___.60
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
-Melena
-Alcoholic cirrhosis
-Rectal varices
-Portal vein thrombosis
SECONDARY:
-Type 2 diabetes
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 your hospitalization
at ___!
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- Because you had blood in your stools.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- We obtained images that showed clots in the veins going from
the gut to the liver, as well as very swollen veins in your
bottom.
- The radiology doctors removed the ___ from your gut/liver
veins. They did a procedure called TIPS which connects two of
your veins in your liver. This prevents fluid from building up
in your belly. They also closed off some of the blood vessels in
your rectum (bottom), so that you do not bleed from this area.
- We started you on a blood-thinning medication called
warfarin. You will need to take this every day, starting
___. Take 3mg daily for now and let your primary
care doctor adjust the dose later on.
- You need to get your labs checked on ___. Your
primary care doctor ___ tell you how much warfarin you should
be taking.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below).
Here are the changes we made:
New medications:
-- Warfarin (or Coumadin) was started to keep your blood
thin. DO NOT take it today, but start taking 3 mg every day on
___. You can take it any time of day.
-- Lactulose: take 30mg three times a day
-- Thiamine: 100 mg every day (can take in the morning)
-- Midodrine: 20 mg three times a day
Changed medications:
-- we decreased your doses of furosemide to 20 mg and of
spironolactone to 50 mg
Stopped medications:
-- we stopped your propranolol because you don't need it
after your TIPS
- Keep your follow-up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds in 1 day or 5 pounds in 3 days.
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
We wish you the best!
Sincerely,
- Your ___ Care Team
Followup Instructions:
___
|
10117273-DS-12 | 10,117,273 | 25,864,134 | DS | 12 | 2188-06-08 00:00:00 | 2188-06-09 21:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / heparin
Attending: ___.
Chief Complaint:
MELENA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year-old man w/ EtOH cirrhosis s/p TIPS,
Esophageal and Rectal varices s/p banding & embolization, PVT
and HITT on Warfarin, who presented with 2 days of melena.
The day prior to admission, he noted black stools in the
morning.
Reports ___ episodes of loose black stools over the course of
the
day, and a similar number the day of presentation. No
hematemesis. No dizziness/LH. He denies fever, chills, dyspnea,
abdominal pain, nausea, vomiting. He denies any ill contacts.
Denies changes in medication or diet. Denies any alcohol in the
past 10 months. Denies feelings of confusion.
He has been taking lactulose for several months now and has had
no significant changes; prior to development of loose black
stools he was having ___ BMs/day.
Of note, he has had a somewhat inconsistent alcohol story over
the past few admissions. He gave the same answer to me and the
RN
today (no alcohol in 10 mo / ___ year). However, when last
admitted
in ___, he reported that he was actively drinking 1 pint of
liquor daily to the MD and reported none in a year to the RN.
In the ED,
- Initial Vitals: T 97.8, HR 89, BP 107/41, RR 18, O2 96%RA
Upon arrival to the floor, the patient reports that apart from
loose black stools he feels well on the whole.
Past Medical History:
ETOH Cirrhosis c/b ascites, esophageal varies s/p banding, HE,
SBP
Rectal Varices
DM2
Obesity
Restless leg syndrome
Prostate cancer s/p prostatectomy
Social History:
___
Family History:
Father- CVA
Mother- ___, lung cancer
PGF- stroke
Physical Exam:
ADMISSON EXAM:
==============
VS: ___ 0311 Temp: 98.2 PO BP: 107/64 HR: 83 RR: 16 O2
sat:
91% O2 delivery: Ra
Gen: Ill-appearing man, seated on bed.
Eyes: Sclerae anicteric. PERRLA. EOMI.
HENT: NC/AT.
CV: NR, RR. Nl S1, S2. III/VI systolic murmur throughout
precordium.
Resp: CTAB.
GI: Soft, nontender, nondistended. No ascites.
Msk: Trace ___ edema.
Skin: No rashes/lesions.
Neuro: Alert. Oriented to name, location. Says "4" to month and
___ to year. No asterixis.
Psych: Pleasant, appropriate.
DISCHARGE EXAM:
===============
VS: ___ 0718 Temp: 97.6 PO BP: 103/60 R Lying HR: 66 RR:
16
O2 sat: 94% O2 delivery: Ra
Gen: Elderly M in NAD
Eyes: Sclerae anicteric. PERRLA. EOMI.
HENT: NC/AT.
CV: NR, RR. Nl S1, S2. III/VI systolic murmur throughout
precordium.
Resp: CTAB.
GI: Soft, nontender, nondistended. No ascites.
Msk: Trace ___ edema.
Skin: No rashes/lesions.
Neuro: Alert. AAOx2. Grossly intact otherwise. No asterixis.
Psych: Pleasant, appropriate.
Pertinent Results:
ADMISSION LABS:
==============
___ 12:18AM BLOOD WBC-6.7 RBC-2.98* Hgb-8.8* Hct-28.7*
MCV-96 MCH-29.5 MCHC-30.7* RDW-22.3* RDWSD-77.7* Plt Ct-65*
___ 12:18AM BLOOD Neuts-74.9* Lymphs-12.8* Monos-8.8
Eos-2.2 Baso-0.9 Im ___ AbsNeut-5.03 AbsLymp-0.86*
AbsMono-0.59 AbsEos-0.15 AbsBaso-0.06
___ 12:18AM BLOOD ___ PTT-34.1 ___
___ 12:18AM BLOOD Plt Ct-65*
___ 12:18AM BLOOD Glucose-212* UreaN-17 Creat-0.8 Na-136
K-4.5 Cl-99 HCO3-28 AnGap-9*
___ 12:18AM BLOOD ALT-19 AST-27 AlkPhos-195* TotBili-1.6*
___ 12:18AM BLOOD Albumin-3.0*
___ 04:21PM BLOOD ___ pO2-35* pCO2-53* pH-7.39
calTCO2-33* Base XS-5 Comment-GREEN TOP
IMAGING:
=======
___ RUQUS:
FINDINGS:
The liver appears diffusely coarsened and nodular consistent
with known
cirrhosis. No focal liver lesions are identified. There is
trace ascites.
There is stable splenomegaly, with the spleen measuring 16.6
cm.
There is no
intrahepatic biliary dilation. The CHD measures 17 mm.
Cholelithiasis without
gallbladder wall thickening.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 63 cm/sec, previously 87 cm/sec
Proximal TIPS: 140 cm/sec, previously 227cm/sec
Mid TIPS: 205 cm/sec, previously 134 cm/sec
Distal TIPS: 191 cm/sec, previously 122 cm/sec
Flow within the left portal vein is towards the TIPS shunt.
Flow
within the
right anterior portal vein is towards the TIPS. Appropriate
flow is seen in
the hepatic veins and IVC.
PANCREAS: The 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: The spleen measures 16.6 cm in length.
KIDNEYS: Limited views of the kidneys demonstrate no
hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are
within
normal
limits.
IMPRESSION:
1. Patent TIPS.
2. Cholelithiasis without gallbladder wall thickening.
___ CT A/P:
FINDINGS:
Lungs: The visualized lung bases are within normal limits,
except for
subsegmental atelectasis.
Liver: Cirrhotic morphology of the liver, with no suspicious
liver lesion. A
long-term stable hypodensity seen in segment 5 measuring 1.0
cm.
A few
calcified granulomas are seen in the liver.
Biliary: There is no intrahepatic or extrahepatic bile duct
dilatation. The
gallbladder contains a small gallstone, without wall
thickening.
Spleen: The spleen is enlarged measuring 16.4 cm in AP
dimension. A calcified
granuloma is again seen. Stable wedge-shaped linear structure
at
the upper
aspect of the spleen, possibly representing a small infarct.
Pancreas: Unremarkable. There is no pancreatic duct dilatation.
Adrenal glands: Unremarkable.
Urinary: A 7 mm nonobstructing caliceal stone is seen in the
lower pole of the
right kidney. Bilateral hypodensities are seen in the kidneys,
likely
representing cortical cysts. There is no hydronephrosis.
Pelvis: The urinary bladder is unremarkable. The distal ureters
are
unremarkable. A small amount of fluid is seen surrounding the
liver, unchanged
compared to previously
The prostate is not visualized. A nodule is seen at the
expected location of
the left seminal vesicle, unchanged compared to ___
CT.
Gastrointestinal: The bowel is within normal limits, except for
colonic
diverticulosis. There is no evidence of bowel dilatation or
obstruction.
Vascular: There are severe atherosclerotic calcifications of
the
abdominal
aorta.
A TIPS is seen and is patent.
Stable nonocclusive thrombus in the left portal vein (series
303, image 42)
and right portal vein (series 303, image 44).
Stable nonocclusive thrombus in the main portal vein extending
to the splenic
confluence and SMV.
Multiple embolization devices are seen throughout mesenteric
and
perirectal
vessels consistent with prior embolization. Mild perigastric,
perisplenic and
aortocaval varices are again noted.
Lymph nodes: A borderline 1.0 cm left external iliac lymph node
is seen.
Small retroperitoneal lymph nodes not meeting criteria for
pathologic
enlargement are seen. There is nonspecific mild fat stranding
surrounding the
abdominal aorta..
Bone and soft tissues: There is no suspicious bone lesion.
Degenerative disc
disease is seen at L5-S1. An umbilical hernia containing fat is
seen.
Right abdominal wall intramuscular lesion measuring 2.2 cm x
1.3
cm,
previously 2.6 cm x 1.7 cm, slightly decreased, and likely
representing a
resolving hematoma.
IMPRESSION:
1. Stable nonocclusive thrombus in the left portal vein (series
303, image 42)
and right portal vein (series 303, image 44). Stable
nonocclusive thrombus in
the main portal vein extending to the splenic confluence and
SMV. Patent TIPS.
No additional thrombus seen in the visualized veins.
2. Right abdominal wall intramuscular lesion measuring 2.2 cm x
1.3 cm,
previously 2.6 cm x 1.7 cm, slightly decreased, and likely
representing a
resolving hematoma.
3. Cirrhotic morphology of the liver, with no suspicious liver
lesion.
Splenomegaly. Small amount of perihepatic fluid.
4. 7 mm nonobstructing caliceal stone in the right kidney. No
hydronephrosis.
5. Uncomplicated cholelithiasis.
DISCHARGE LABS:
==============
___ 05:39AM BLOOD WBC-4.9 RBC-3.43* Hgb-10.0* Hct-33.3*
MCV-97 MCH-29.2 MCHC-30.0* RDW-21.4* RDWSD-75.5* Plt Ct-36*
___ 05:39AM BLOOD ___ PTT-33.2 ___
___ 05:39AM BLOOD Glucose-133* UreaN-8 Creat-0.8 Na-140
K-4.4 Cl-98 HCO___-32 AnGap-10
Brief Hospital Course:
Mr. ___ is a ___ w/ EtOH cirrhosis s/p TIPS, esophageal
and rectal varices s/p banding & embolization, PVT/SMVT
possible
HITT on warfarin, who presented with 2 days of melena. He was
subsequently found to have dark stools c/w melena. He was
monitored for several days and was seen to have stable vitals
and H/H. It was thought to be unlikely that he was having a
hemodynamically significant GIB. He was discharged and will
follow up in liver clinic with Dr. ___.
# EtOH cirrhosis w/ prior rectal varices s/p clipping and TIPS
# PVT s/p TIPS on systemic AC with warfarin
# Melena: Patient admitted with several days of melena and some
concern for an upper GIB. There was concern initially that this
might represent a variceal bleed, so the patient was started on
an octreotide drip. He was also started on and IV PPI and IV
CTX
for SBP ppx (transitioned to his home cipro at the time of
discharge). He had been on warfarin for a PVT and had an INR of
1.9 on admission. This medication was held, but he did not have
his INR reversed. He also had known portal hypertensive
gastropathy. He was monitored with serial CBCs for several days
and demonstrated a stable H/H. He was taken off of his
octreotide gtt and IV PPI and restarted on his home diuretics,
which he tolerated prior to discharge. His discharge H/H was
___. His symptoms were thought to be likely due to mild
oozing in the setting of his known portal hypertensive
gastropathy. On the day of discharge, he was noted by the RN to
have "normal" colored stool w/ a few "dark flecks in it." He
was
hemodynamically stable otherwise. He was instructed to return
to
the ED should he develop any red flag symptoms concerning for
bleeding.
# Hepatic encephalopathy: Patient initially presented with mild
altered mental status thought to be ___ HE. This improved with
lactulose. He was discharged on his home lactulose/rifaximin.
# PVT: CTA on ___ demonstrated increase in size of thrombosis
involving left portal vein, main portal vein, SMV, distal
splenic vein and portosplenic confluence. He underwent TIPS
placement and clot lysis on ___. He was bridged to warfarin
with plan for ___uring this admission, repeat
imaging revealed stable thrombus in the previously visualized
vessels. He will be discharged off of coumadin due to concern
over possible bleeding but should follow up with his outpatient
providers to decide on additional AC.
# HITT: Patient noted during previous admission to have acute
on
chronic thrombocytopenia with >50% decrease in platelets after
initiation of heparin. 4T score was 5. HIT Ab positive, so hep
d/c'ed on ___. Smear showed no evidence of hemolysis. Heparin
products avoided during this admission.
CHRONIC ISSUES
==============
# T2DM
- Placed on HISS while in house
# RLS
- Continued home ropinorol
# Tobacco Use
- Nicotine patch while in house
TRANSITIONAL ISSUES
===================
[] Discharge H/H ___. He should have a repeat H/H drawn
upon
follow up to ensure no concern for ongoing bleeding.
[] Warfarin initially started iso PVT stopped during this
admission. Originally started on a projected 3 month course
(which was to begin at the beginning of ___. He had this
stopped during this admission. This will be held until the
patient can discuss ongoing AC w/ his outpatient providers.
[]Repeat RUQUS w/ Doppler ___ months (___) s/p TIPS on
___
[]Please continue to encourage smoking cessation (on nicotine
patch in-house)
[]Please continue to support alcohol abstinence
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Citalopram 20 mg PO DAILY
3. DULoxetine 30 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Gabapentin 300 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. rOPINIRole 0.25 mg PO QAM
10. Spironolactone 50 mg PO DAILY
11. Loratadine 10 mg PO DAILY
12. melatonin 3 mg oral QHS
13. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
14. Vitamin B Complex 1 CAP PO DAILY
15. Lactulose 30 mL PO TID
16. Midodrine 20 mg PO TID
17. Nicotine Patch 14 mg/day TD DAILY
18. Thiamine 100 mg PO DAILY
19. Warfarin 3 mg PO DAILY16
20. rifAXIMin 550 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Citalopram 20 mg PO DAILY
3. DULoxetine 30 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Gabapentin 300 mg PO DAILY
7. Lactulose 30 mL PO TID
8. Loratadine 10 mg PO DAILY
9. melatonin 3 mg oral QHS
10. Midodrine 20 mg PO TID
11. Multivitamins 1 TAB PO DAILY
12. Nicotine Patch 14 mg/day TD DAILY
13. Pantoprazole 40 mg PO Q12H
14. rifAXIMin 550 mg PO BID
15. rOPINIRole 0.25 mg PO QAM
16. Spironolactone 50 mg PO DAILY
17. Thiamine 100 mg PO DAILY
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
19. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Melena
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
======================
DISCHARGE INSTRUCTIONS
======================
Dear Mr. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted to the hospital because you were having dark
stools concerning for a GI bleed.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were observed and given medications in case you were
having an active GI bleed.
- You were noted to have stable blood counts for several days in
the hospital and had an improvement in the amount of dark stool
you were having. It was thought to be unlikely that you were
having a significant, dangerous GI bleed.
- You were discharged to follow up with your PCP and liver
doctor, ___.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Please take your medications and go to your follow up
appointments as described in this discharge summary.
- If you experience any of the danger signs listed below, please
call your primary care doctor or go to the emergency department
immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10117273-DS-14 | 10,117,273 | 27,763,784 | DS | 14 | 2188-07-12 00:00:00 | 2188-07-13 07:26:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril / heparin
Attending: ___
Chief Complaint:
GI bleed
Major Surgical or Invasive Procedure:
___ EGD
___ ___ Venography
___ Capsule endoscopy
History of Present Illness:
___ with history of EtOH cirrhosis, complicated by ascites,
esophageal varices status post banding, HE, and SBP, portal vein
thrombus status post TIPS placement and lysis, type II DM,
prostate cancer status post prostatectomy, and HIT, who
presented
following several episodes of melena.
Patient reports being in his usual state of health until AM of
___, when he had a single episode of melena. Dark in
appearance
and sticky per patient. Associated lower abdominal cramping and
nausea. Over the course of the next two days had a total of
___
episodes of melena. Denies epigastric pain, light-headedness,
hematemesis, vomiting, or dizziness, although overall he does
feel more weak. With regards to his cirrhosis, since restarting
his diuretic on ___ his abdominal distention and lower
extremity edema have improved. Mental status is unchanged, and
denies any episodes of confusion.
Recently admitted ___ with presyncope, likely secondary
to orthostasis. Orthostatic vital signs demonstrated a 20 point
drop in systolic BP despite being on midodrine 20mg TID. Felt to
be secondary to hypovolemia in the setting of diuretic use,
which
were held on discharge. Hospitalization otherwise notable for
acute on chronic anemia, requiring one blood transfusion.
In the ED, initial VS were notable for;
Temp 97.5 HR 50 BP 139/63 RR 18 SaO2 96% RA
Examination notable for;
Comfortable appearing, weak when sitting upright, RRR, no
murmurs/rubs/gallops, mild bibasilar crackles,
distended/non-tender abdomen, trace-1+ pitting edema of
bilateral
lower extremities.
Labs were notable for;
WBC 8.7 Hgb 7.7 Plt 92
___ 15.2 PTT 35.5 INR 1.4
Na 138 K 4.9 Cl 104 HCO3 27 BUN 24 Cr 0.9 AnGap 7
ALT 12 ALP 187 Tbili 1.8 Alb 3.0
Urine studies were unremarkable.
ECG with sinus rhythm at 85 bpm, left axis deviation, normal
intervals, Q wave inferiorly, left atrial enlargement, abnormal
R-wave progression, no ischemic changes.
Liver/Gallbladder US demonstrated patent TIPS with lower and
improved velocities proximally, normal velocities throughout the
TIPS, and a 6mm round echogenic focus in the gallbladder.
Patient was given;
- IV pantoprazole 40mg
- IV ceftriaxone 1g
- IV ondansetron 4mg
- IV octreotide drip 50mcg/hr
- Nicotine patch 14mg/day
- Acetaminophen 650mg
- Rifaximin 550mg
- Midodrine 20mg
Vital signs on transfer notable for;
Tenp 98.6 HR 94 BO 100/59 RR 17 SaO2 93% RA
Upon arrival to the floor, patient repeats the above story. Had
one further episode of melena in the ED, with some streaks of
bright red blood along stool. Reports some mild cramping in
lower
abdomen, but otherwise no issues. Denies light-headedness or
epigastric pain.
10-point review of systems otherwise negative.
Past Medical History:
-ETOH Cirrhosis c/b ascites, esophageal varies s/p banding, HE,
SBP
-Portal Vein Thrombus: CTA on ___ demonstrated increase in size
of thrombosis involving left portal vein, main portal vein, SMV,
distal
splenic vein and portosplenic confluence. He underwent TIPS
placement and clot lysis on ___.
-Rectal Varices
-DM2
-Obesity
-Restless leg syndrome
-Prostate cancer s/p prostatectomy
-possible HITT: Noted on admission ___: Acute on chronic
thrombocytopenia with >50% decrease in platelets after
initiation
of heparin. 4T score was 5. HIT Ab positive
Social History:
___
Family History:
Father with history of CVA. Mother with history of lung cancer.
Paternal grandfather with stroke.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: Temp: 98.7 BP: 119/67 HR: 88 RR: 18 SaO2 94% RA
GENERAL: lying comfortably in bed, no acute distress
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: RRR, S1 and S2 normal, soft systolic murmur loudest over
aortic area
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, mildly distended, BS normoactive
EXTREMITIES: warm, well perfused, trace lower extremity edema
NEURO: A/O x3, moving all four extremities with purpose, CNs
grossly intact, no asterixis
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 412)
Temp: 98.9 (Tm 98.9), BP: 102/58 (92-122/50-67), HR: 57
(57-72), RR: 18 (___), O2 sat: 92% (91-97), O2 delivery: RA,
Wt: 173.6 lb/78.74 kg
GENERAL: lying comfortably in bed, no acute distress
HEENT: AT/NC, no conjunctival pallor, anicteric sclera, MMM
NECK: supple, non-tender, no JVP elevation
CV: RRR, S1 and S2 normal, soft systolic murmur loudest over
aortic area
RESP: CTAB, no wheezes/crackles
___: soft, non-tender, mildly distended, BS normoactive
EXTREMITIES: warm, well perfused, trace lower extremity edema
NEURO: A/O x3, moving all four extremities with purpose, CNs
grossly intact, no asterixis
Pertinent Results:
ADMISSION LABS
===============
___ 02:45PM BLOOD WBC-8.7 RBC-2.60* Hgb-7.7* Hct-25.5*
MCV-98 MCH-29.6 MCHC-30.2* RDW-21.0* RDWSD-74.3* Plt Ct-92*
___ 02:45PM BLOOD ___ PTT-35.5 ___
___ 02:45PM BLOOD Glucose-178* UreaN-24* Creat-0.9 Na-138
K-4.9 Cl-104 HCO3-27 AnGap-7*
___ 02:45PM BLOOD ALT-12 AlkPhos-187* TotBili-1.8*
___ 02:45PM BLOOD Albumin-3.0*
___ 05:12AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.8
DISCHARGE LABS
===============
___ 05:12AM BLOOD WBC-5.6 RBC-2.82* Hgb-8.3* Hct-27.5*
MCV-98 MCH-29.4 MCHC-30.2* RDW-21.2* RDWSD-67.2* Plt Ct-68*
___ 05:12AM BLOOD ___ PTT-34.2 ___
___ 05:12AM BLOOD Glucose-50* UreaN-6 Creat-0.9 Na-142
K-4.3 Cl-101 HCO3-30 AnGap-11
___ 05:12AM BLOOD ALT-14 AST-30 AlkPhos-134* TotBili-3.7*
___ 05:12AM BLOOD Albumin-3.3* Calcium-8.5 Phos-2.7 Mg-1.8
___ 06:39AM BLOOD calTIBC-207* Ferritn-40 TRF-159*
IMAGING/STUDIES
================
___ CXR
IMPRESSION:
No evidence of focal consolidation or pulmonary edema.
___ Duplex
IMPRESSION:
1. Patent TIPS with lower and improved velocities proximally,
normal
velocities throughout the TIPS.
2. 6 mm round echogenic focus in the gallbladder may represent a
polyp versus nonmobile gallstone. Attention on follow up.
___ EGD
Normal mucosa in the whole esophagus and examined duodenum. Mild
erythema, friability, and petechiae in the stomach antrum
compatible with GAVE.
___ Portal venography
1. Pre intervention right atrial pressure of 3 mmHg and portal
venous pressure of 16 mmHg for a gradient of 13 mm Hg
2. Portal venogram showing patent portal vein with some
irregularity in the main portal vein which was felt to
potentially represent thrombus. The TIPS was noted to be widely
patent and there were no varices identified.
3. Post mechanical portal thrombectomy with mild improvement in
the appearance of the portal vein which was again noted to be
widely patent.
4. Post TIPS plasty portal venogram demonstrating rapid flow
through the TIPS which was widely patent.
5. Post intervention right atrial pressure of 6 mmHg and portal
pressure of 16 mmHg resulting in portosystemic gradient of 10
mmHg.
Final read of capsule endoscopy still pending at time of
discharge, but on wet read, a small amount of oozing from portal
hypertensive gastropathy.
Brief Hospital Course:
___ with history of Childs B EtOH cirrhosis, decompensated by
ascites, esophageal varices status post banding, HE, and SBP,
portal vein thrombus status post TIPS placement and lysis, type
II DM, prostate cancer status post prostatectomy, and HIT, who
presented following several episodes of melena, with acute blood
loss anemia. Patient underwent EGD which did not show any spots
of active bleeding, as well as venography with ___ which did not
show any new varices. He subsequently underwent capsule
endoscopy which showed oozing from portal hypertensive
gastropathy. Given that bleeding appeared intermittent, Hgb was
stable and patient was hemodynamically stable, patient was
discharged home with plan for close follow up.
====================
TRANSITIONAL ISSUES:
====================
[] Please obtain repeat Hgb at post-discharge follow up
appointment to ensure stability of blood counts in light of
recent GI bleeding.
[] If repeat episodes of GI bleeding, will need to consider
further procedures to assess for a source (e.g., colonoscopy +/-
push enteroscopy).
====================
ACUTE/ACTIVE ISSUES:
====================
# Melena
# Acute on Chronic Anemia
Patient presented with two days of multiple episodes of melena,
with associated abdominal cramping and generalized fatigue.
Found to have ___ point drop in Hgb from his recent baseline ~8.
He required 2 transfusions of pRBC and was kept on octreotride
gtt, ceftriaxione, and IV pantoprozole while actively bleeding.
Patient underwent EGD ___ which showed GAVE but no clear source
of bleed. He subsequently underwent venography with ___ showing
patent TIPS and portosystemic gradient of 10mm Hg. He then
underwent capsule endoscopy which showed some oozing from portal
hypertensive gastropathy. Given several days without melena and
with stable H/H, he was discharged with plans for close
outpatient follow up.
-- Discharge Hgb: 8.3
# EtOH cirrhosis (Childs B)
# Ascites
# HE
# History of varices
MELD-Na 14 on admission. No evidence of decompensation. RUQUS
demonstrated patent TIPS with normal velocities. His home
diuretics were held in setting of GI bleed but restarted at time
of discharge given normotension. We continued his home lactulose
30ml TID and rifaximin 550mg BID. He is not on any beta blocker
despite known hx of varices because of history of severe
orthostatic hypotension requiring midodrine. Home ciprofloxacin
for SBP prophylaxis was held while on ceftriaxone, but was
resumed when ceftriaxone was stopped at the time of discharge.
# Portal vein thrombus status post TIPS and lysis
History of same in ___ of this year. Initially plan was for
three months of anticoagulation with warfarin, however this was
held given multiple recent episodes of GI bleeding.
======================
CHRONIC/STABLE ISSUES:
======================
# Depression/Anxiety- continued citalopram 20mg daily,
duloxetine 30mg daily
# Chronic pain- continued gabapentin 300mg QHS
# Orthostatic hypotension- continued midodrine 20mg TID
# Type II DM- continued glargine 10 units QHS and Humalog ISS
==============
CORE MEASURES:
==============
#CODE STATUS: Full (confirmed)
#CONTACT: ___, wife, ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 500 mg PO Q24H
2. Citalopram 20 mg PO DAILY
3. DULoxetine 30 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Gabapentin 300 mg PO QHS
6. Lactulose 30 mL PO TID
7. Loratadine 10 mg PO DAILY
8. Midodrine 20 mg PO TID
9. Multivitamins 1 TAB PO DAILY
10. Pantoprazole 40 mg PO Q12H
11. rifAXIMin 550 mg PO BID
12. Thiamine 100 mg PO DAILY
13. Vitamin B Complex 1 CAP PO DAILY
14. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
15. melatonin 3 mg oral QHS
16. ___ 60 Units Breakfast
___ 30 Units Dinner
17. Furosemide 20 mg PO DAILY
18. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. ___ 60 Units Breakfast
___ 30 Units Dinner
2. Ciprofloxacin HCl 500 mg PO Q24H
3. Citalopram 20 mg PO DAILY
4. DULoxetine 30 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 20 mg PO DAILY
7. Gabapentin 300 mg PO QHS
8. Lactulose 30 mL PO TID
9. Loratadine 10 mg PO DAILY
10. melatonin 3 mg oral QHS
11. Midodrine 20 mg PO TID
12. Multivitamins 1 TAB PO DAILY
13. Pantoprazole 40 mg PO Q12H
14. rifAXIMin 550 mg PO BID
15. Spironolactone 50 mg PO DAILY
16. Thiamine 100 mg PO DAILY
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
18. Vitamin B Complex 1 CAP PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
==================
Acute blood loss anemia on chronic anemia secondary to
gastrointestinal bleeding
Childs Class B Alcoholic 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 ___
___.
WHY WAS I IN THE HOSPITAL?
===========================
- You were admitted for black stools and a drop in your blood
count
WHAT HAPPENED TO ME IN THE HOSPITAL?
=====================================
- While you were in the hospital, we gave you two blood
transfusions because your blood count was low.
- You had an endoscopy to look for the source of your bleeding.
This did not show any clear site of bleeding. You underwent
another procedure called a capsule endoscopy, which involved
swallowing a tiny camera, to look for a source of bleeding. This
showed a little bit of oozing that seems to be starting and
stopping from some spots in your stomach.
- You did not have any more bleeding in your stool and your
blood count was stable, so we felt it was safe for you to go
home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
=============================================
- If you notice you are having black stools again, please stop
your diuretics and call your liver doctor right away
- You must never drink alcohol again or you will die
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- If you experience any of the danger signs listed below
please, especially further blood in your stools or black tarry
stools, call your liver doctor or come to the emergency
department immediately.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10117508-DS-10 | 10,117,508 | 20,560,939 | DS | 10 | 2140-01-19 00:00:00 | 2140-01-19 08:31:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left breast pain and redness
Major Surgical or Invasive Procedure:
Bedside left breast drain placement
History of Present Illness:
___ with left breast DCIS s/p ___ mastectomy and tissue
expander followed by ___ TE to implant exchange presenting
with left breast pain and fever. Started last night around
8:30pm with subjective fever, chills, sweats, neck and breast
pain. Did not take temperature. Noticed some redness around her
left breast which became more painful with "pressure" like
feeling. She felt subjetive fevers again this AM and went to
her
PCP where temp was 99.3 and was recommended to come to ED. About
1.5 weeks ago, she was feeling ill with vomiting and diarrhea
and
headaches which resolved after 1 day. She denies cough,
abdominal pain, shortness of breath, sick contacts or recent
travel. She still has occasional diarrhea.
Past Medical History:
history of depression
.
PSH: right breast biopsies
Social History:
___
Family History:
Significant for breast cancer and stroke
Physical Exam:
AFVSS
NAD, A&O, well appearing
Breathing comfortably on RA
RRR peripherally
L breast with slight circumferential blanching erythema. Mildly
TTP. Drain in place through central incision. Serous output.
Extremities are WWP.
Pertinent Results:
___ 02:10PM NEUTS-85.2* LYMPHS-9.5* MONOS-4.8 EOS-0.2
BASOS-0.2
___ 02:10PM WBC-21.2* RBC-4.02* HGB-12.6 HCT-35.0* MCV-87
MCH-31.4 MCHC-36.0* RDW-13.2
___ 02:10PM HCG-<5
___ 02:10PM estGFR-Using this
___ 02:10PM GLUCOSE-108* UREA N-9 CREAT-0.6 SODIUM-137
POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16
___ 02:44PM LACTATE-2.3*
___ 04:00PM URINE MUCOUS-RARE
___ 04:00PM URINE RBC-<1 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-5
___ 04:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 04:00PM URINE UCG-NEGATIVE
___ 10:22 am FLUID,OTHER Site: BREAST
Source: Left Breast Seroma.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary):
STAPH AUREUS COAG +. SPARSE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Brief Hospital Course:
The patient presented as a same day admission from the ED for
left breast cellulitis and drainage. The patient was initially
placed on broad spectrum antibiltics including vancomycin for
MRSA coverage. The patient was taken for breast ultrasound on
HD2 where a collection was noted and was subsequently drained
with fluid sent for cultures. A JP drain was placed and remained
in for the duration of her hospitalization. Cultures grew MSSA
and patient was narrowed to IV Nafcillin, which the patient
tolerated well. She was initially intermittently febrile but she
defervesced with tylenol. She was treated non-operatively and
her left breast implant remained in place for the duration of
her hospitalization.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs, tolerating a regular diet, ambulating
without assistance, voiding without assistance, and pain was
well controlled. The left breats erythema had markedly improved,
though still present. Tenderness about the left breast was also
improved. Her drain remained in place entering the left breast
at the site of her previous incision. Output was approximately
60cc/24 period prior to discharge and was noted to be strictly
serous. The patient was given written instructions concerning
precautions and the appropriate follow-up care. The patient will
be continued on oral antibiltics for MSSA, specifically a 10 day
course of Dicloxacillin. She will follow up with Dr. ___ at her
already scheduled appointment on ___ for re-evaluation.
She was counseled to present to the ED with any increased
drainage, purulence, fevers, erythema, etc. All questions were
answered prior to discharge and the patient expressed readiness
for discharge.
Medications on Admission:
oxycodone 5 mg tablet. ___ tablet(s) by mouth q 4 hrs
tamoxifen 20 mg tablet. 1 tablet(s) by mouth daily
tramadol 50 mg tablet. ___ tablet(s) by mouth every q6
docusate sodium 100 mg BID
IBUPROFEN
LACTOBACILLUS COMBINATION NO.4 [PROBIOTIC]
MULTIVITAMIN [DAILY MULTI-VITAMIN]
VITAMIN B COMPLEX [B-COMPLEX]
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain, fever
2. Tamoxifen Citrate 20 mg PO DAILY
3. DiCLOXacillin 500 mg PO Q6H Cellulitis
RX *dicloxacillin 500 mg 1 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left breast cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted on ___ for observation/treatment of a
chest/breast cellulitis. Please follow these discharge
instructions:
.
-Continue to monitor your left breast area for continued
improvement. If the redness and swelling increase, please call
the doctor's office to report this.
-Should you have fevers and chills, please call the doctor's
office immediately to report.
-Continue Dicloxacillin until you are asked to stop them.
-You may consider eating a probiotic yogurt daily to replace the
'good' bacteria in your intestinal tract. If you cannot
tolerate yogurt then you may buy 'acidophilus' over the counter
as a supplement choice. Acidophilus is a 'friendly' bacteria
for your gut.
-If you start to experience excessive diarrhea, please call the
doctor's office to report this.
-Do not overexert yourself and no strenuous exercise for now.
-You may take either tylenol or advil (ibuprofen) for your
discomfort. Take as directed.
.
DRAIN DISCHARGE INSTRUCTIONS:
1. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day.
4. A written record of the daily output from each drain should
be brought to every follow-up appointment. Your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
4. You may shower daily. No baths until instructed to do so by
Dr. ___.
.
You are being discharged with drains in place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
___
|
10117734-DS-8 | 10,117,734 | 24,389,181 | DS | 8 | 2112-12-12 00:00:00 | 2112-12-12 21:04:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ speaking woman w/ chest pain and difficulty breathing
x4 days.
___ is a ___ house ___ for a family in ___. The
family is on vacation here in ___ and brought her a long.
Over
the last 4 days she has developed gradually worsening chest pain
and dyspnea along with a productive cough and wheezing.
Yesterday
she was brought to urgent care where she was given and inhaler.
However, on day of presentation her symptoms worsened so she was
sent to the ED.
In the ED,
- Initial Vitals:
98.3, 138, 157/94, 28, 98% nebulizer
- Exam:
tachypneic
diffuse expiratory wheezing
- Labs:
Green top VBG: 7.34/___/30
CBC: 12.9/15.1/___.3/360
Chem: 139/3.9/100/20/7/0.7/158, AG=19
Trop<0.01 x2
U/A: Leuk est lg, nit neg, WBC 19
Lactate 2.5
- Imaging:
CTA:
1. Limited assessment of the distal segmental and subsegmental
pulmonary arterial branches due to suboptimal timing of the
contrast bolus and respiratory motion. Within this limitation,
no
evidence of pulmonary embolism
to the proximal segmental level or aortic abnormality.
2. Bilateral upper lobe and lingular ground-glass opacities may
reflect early infection.
3. Diffuse airway wall thickening with scattered mucous plugging
suggestive of bronchitis.
4. Possible hepatic steatosis.
- Interventions:
LR 1L
Methylpred 125mg
Stacked duonebs & albuterol
CTX/Azithromycin
Patient was on ___ NC satting 92-98%, but clinically was
tachypneic so she was ultimately placed on BiPAP
HR remained tachycardic through ED course, ECG c/w sinus
tachycardia
On arrival to the ICU:
In discussion with her and her employer:
She has been living with her employer in ___ for the last ___
years serving as a maid and helping to care for their daughter
who is age ___ with a renal transplant. She has never been ill in
this time frame and does not take medications.
She came to ___ 2 weeks ago. It is not clear to me whether
this is vacation or planned to be permanent as she shies away
from answering this fully. About a week ago the daughter became
ill with cough, dyspnea, wheezing. She has since been slowly
improving.
However, 4 days ago, patient developed sore throat, cough,
sputum, wheezing. 2 days ago were seen in our ED and given
albuterol for presumed bronchitis.
She worsened with albuterol and represented as noted above.
She reports to me that she has a husband ___ and a
daughter of her own. She initially asked that we inform them,
but
that they were in the Philipines. She subsequently declined to
provide us with their contact info. Her employer encouraged her
to do so, but she reported to us that she has had some
conflict(?) and is no longer in contact with them/does not have
their contact info. Will note that she did have ___ up on
messaging and evidently had been texting him recently despite
what she verbally reports.
Both she and her employer deny fever, ns, chills, weight loss /
B
symptoms. Employer is not aware of prior TB testing.
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
Reports no medical history
Social History:
___
Family History:
denies
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: 157/84, HR 129, 100% on BiPAP, RR 23
GEN: anxious, mildly tachypneic on BiPAP
HEENT: MM dry
CV: tachycardic, difficult to appreciate MRG
PULM: restricted air movement, diffuse end expiratory wheezing,
bibasilar crackles
GI: S/ND/NT
EXT: WWP, non-edematous
DISCHARGE PHYSICAL EXAM:
======================
GENERAL: Well-appearing young woman sitting up in bed no acute
distress
HEENT: PER, EOMI. Sclera anicteric and without injection. MMM.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Bibasilar crackles heard. No wheezing or rhonchi. Good
air movement throughout otherwise. No accessory muscle use
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 grossly Intact. Moves all extremities.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:31PM ___ PO2-65* PCO2-37 PH-7.41 TOTAL CO2-24
BASE XS-0
___ 08:05PM GLUCOSE-146* UREA N-5* CREAT-0.6 SODIUM-139
POTASSIUM-4.9 CHLORIDE-102 TOTAL CO2-21* ANION GAP-16
___ 08:05PM CALCIUM-8.8 PHOSPHATE-2.8 MAGNESIUM-2.4
___ 08:05PM WBC-9.5 RBC-4.78 HGB-13.9 HCT-43.1 MCV-90
MCH-29.1 MCHC-32.3 RDW-12.9 RDWSD-42.4
___ 08:05PM NEUTS-90.9* LYMPHS-7.6* MONOS-0.9* EOS-0.1*
BASOS-0.2 IM ___ AbsNeut-8.65* AbsLymp-0.72* AbsMono-0.09*
AbsEos-0.01* AbsBaso-0.02
___ 08:05PM PLT COUNT-352
___ 08:05PM ___ PTT-28.5 ___
___ 06:53PM TYPE-ART PO2-214* PCO2-37 PH-7.39 TOTAL
CO2-23 BASE XS--1
___ 06:53PM LACTATE-1.9
___ 02:12PM LACTATE-2.5*
___ 01:55PM cTropnT-<0.01
___ 02:05PM ___ PO2-55* PCO2-49* PH-7.32* TOTAL
CO2-26 BASE XS--1
___ 11:20AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG*
___ 11:20AM URINE RBC-4* WBC-19* BACTERIA-FEW* YEAST-NONE
EPI-5
___ 10:08AM ___ PO2-30* PCO2-47* PH-7.34* TOTAL
CO2-26 BASE XS--1 COMMENTS-GREEN TOP
___ 10:05AM GLUCOSE-158* UREA N-7 CREAT-0.7 SODIUM-139
POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-20* ANION GAP-19*
___ 10:05AM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-81 TOT
BILI-0.5
___ 10:05AM LIPASE-15
___ 10:05AM cTropnT-<0.01
___ 10:05AM ALBUMIN-5.3* CALCIUM-9.9 PHOSPHATE-4.4
MAGNESIUM-1.9
___ 10:05AM WBC-12.9* RBC-5.24* HGB-15.1 HCT-47.3* MCV-90
MCH-28.8 MCHC-31.9* RDW-12.9 RDWSD-42.5
___ 10:05AM NEUTS-72.3* LYMPHS-17.7* MONOS-6.6 EOS-2.9
BASOS-0.2 IM ___ AbsNeut-9.34* AbsLymp-2.29 AbsMono-0.86*
AbsEos-0.38 AbsBaso-0.03
___ 10:05AM PLT COUNT-360
DISCHARGE LABS:
===============
___ 06:35AM BLOOD WBC-17.1* RBC-4.40 Hgb-12.4 Hct-40.3
MCV-92 MCH-28.2 MCHC-30.8* RDW-13.2 RDWSD-44.7 Plt ___
___ 06:35AM BLOOD Glucose-100 UreaN-14 Creat-0.6 Na-142
K-4.0 Cl-106 HCO3-23 AnGap-13
IMAGING:
========
___ CHEST
IMPRESSION:
1. Limited assessment of the distal segmental and subsegmental
pulmonary
arterial branches due to suboptimal timing of the contrast bolus
and
respiratory motion. Within this limitation, no evidence of
pulmonary embolism
to the proximal segmental level or aortic abnormality.
2. Bilateral upper lobe and lingular ground-glass opacities may
reflect early
infection.
3. Diffuse airway wall thickening with scattered mucous plugging
suggestive of
bronchitis.
4. Possible hepatic steatosis.
___ (PA & LAT)
FINDINGS:
Heart size is normal. The mediastinal and hilar contours are
normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality.
MICROBIOLOGY:
=============
___ 12:10 am SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and >10 epithelial cells/100X field.
Gram stain indicates extensive contamination with upper
respiratory
secretions. Bacterial culture results are invalid.
PLEASE SUBMIT ANOTHER SPECIMEN.
RESPIRATORY CULTURE (Final ___:
TEST CANCELLED, PATIENT CREDITED.
__________________________________________________________
___ 6:44 pm Rapid Respiratory Viral Screen & Culture
Source: Nasopharyngeal swab.
Respiratory Viral Culture (Preliminary):
Respiratory Viral Antigen Screen (Final ___:
Negative for Respiratory Viral Antigen.
Specimen screened for: Adeno, Parainfluenza 1, 2, 3,
Influenza A, B,
and RSV by immunofluorescence.
Refer to respiratory viral culture and/or Influenza PCR
(results
listed under "OTHER" tab) for further information..
__________________________________________________________
___ 1:55 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 10:02 am BLOOD CULTURE
Blood Culture, Routine (Preliminary): No growth to date.
__________________________________________________________
___ 11:20 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
Ms. ___ is a previously healthy ___ female who is
presenting with chest pain and difficulty breathing for 4 days,
found to have community-acquired pneumonia and likely viral
bronchitis.
ACUTE ISSUES
=======================
# Community acquired pneumonia
# Acute hypoxic respiratory failure, resolved
Imaging notable for possible pneumonia and likely bronchitis.
This was likely triggered by a viral infection. Infection
control was involved as pt traveled from ___ as we result,
MERS was sent, however was unable to be completed. The
respiratory viral panel was negative. Pt was initially started
on ceftriaxone and azithromycin and IV steroids. Ceftriaxone was
then narroed to levofloxacin to complete a 7-day course. Pt was
then transitioned to IV steroids and prednisone 40mg PO to
complete a ___lbuterol nebulizers as needed
# Sinus tachycardia, resolved:
Likely secondary to critical illness.
TRANSITIONAL ISSUES:
====================
[ ] Patient is being discharged on Levofloxacin to complete a
7-day course of therapy (last day of treatment ___.
[ ] Patient is being discharged on Prednisone 40mg PO to
complete a 5 day course of therapy (last day of treatment ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Albuterol Inhaler 1 PUFF IH Q6H:PRN shortness of breath
RX *albuterol sulfate 90 mcg 1 puff inhaled every six (6) hours
Disp #*1 Inhaler Refills:*0
2. LevoFLOXacin 750 mg PO DAILY Duration: 3 Days
Start taking on ___
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*3
Tablet Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 1 Day
Start taking on ___
RX *prednisone 20 mg 2 tablet(s) by mouth once Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Community Acquired Pneumonia
SECONDARY DIAGNOSIS:
====================
Sinus Tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- You were having shortness of breath and chest pain
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- You likely had a respiratory illness
- We treated you with antibiotics, inhalers and steroids.
- You improved and were ready to go home
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Seek medical attention if you have new or concerning symptoms
or you develop worsening shortness of breath, chest pain, change
in sputum production.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10117812-DS-14 | 10,117,812 | 29,475,932 | DS | 14 | 2117-02-24 00:00:00 | 2117-02-24 19:12:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
anemia
Major Surgical or Invasive Procedure:
EGD on ___ showed medium non-bleeding esophageal varices and PHG
History of Present Illness:
___ w h/o Hep C (untreated), ETOH cirrhosis (MELD 13 in ___,
25 on admission decompensated by ascites, ___ edema, no known h/o
varices or HE), severe alcoholic hepatitis, bipolar 2 disorder,
ADHD, with recent admission for alcoholic hepatitis with course
complicated by acute blood loss anemia (thought ___ recurrent
epistaxis), hospital-acquired pneumonia treated with cefepime,
and ___ concerning for HRS, who presents with worsening anemia
as
an outpatient unresponsive to blood transfusions.
Ms. ___ was recently admitted to ___ (___) with
alcoholic hepatitis (DF of 44, MELD 30, not requiring steroids)
during which her course was complicated by melena and recurrent
epistaxis. Epistaxis was thought to be the source of her melena
during admission, however also some concern for GI source. She
was treated with IV PPI, octreotide, FFP, and vitamin K
challenge, as well as Afrin and Rhino-rocket per ENT for
epistaxis. She required total 4U PRBC during that admission
(last
on ___, with stable HgB at 7.2 prior to discharge.
She was subsequently discharged to ___ on
___
with plan for follow up with hepatology. Since discharge she has
been noted to have donwtrending HgB at rehab with HgB 6.6 on
___
s/p 2 u PRBCs, with repeat (7.8 (___) --> 8.3 ___ AM) --> 8.0
___ ___ --> 7.6 (___). Since discharge she has continued to
have mild epistaxis, but had not noticed any melena. FOBT at
rehab and ED have been negative. She also denies any hemoptysis,
hematemesis, hematuria, or bleeding elsewhere. She has not had
menses since last ___. She has chronic abdominal pain,
mostly
LLQ, but no new pain, N/V, or abdominal distention. She does
have
significant lower extremity edema with 8lb weight gain 180.8 -->
188.5lbs) since discharge.
She has not had prior EGD or colonoscopy. She was scheduled for
screening EGD ___ but had not followed up.
Past Medical History:
ADHD, predominantly inattentive type
Pap smear abnormality of cervix with LGSIL
Tobacco dependence
Abdominal pain, right lower quadrant
Bipolar II disorder
Rectal fissure
Gartner duct, cyst
Strabismus
Dry eyes
Keratitis sicca
Major depression
Acute hepatitis C virus infection, genotype 1a
___ positive, ?lupus diagnosis in past
Iron excess
Cirrhosis
Alcohol abuse, in remission
Hemochromatosis carrier
Social History:
___
Family History:
Biological mother w etoh abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: T: 98.3, BP: 108/62, HR: 95, RR: 18, 99% RA
GENERAL: NAD, jaundiced
HEENT: AT/NC, EOMI, PERRL, icteric sclera, pink conjunctiva,
MMM,
dry scabs at corners of mouth, poor dentition
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: soft but distended, tender to palpation in all
quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 3+ pitting edema to the waist
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: ___ 0721 Temp: 98.9 PO BP: 99/52 R Lying HR: 97 RR: 18
O2 sat: 97% O2 delivery: Ra
HEENT: AT/NC, EOMI, icteric sclera, pink conjunctiva, MMM,
dry scabs at corners of mouth, poor dentition
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: +BS, caput medusae, soft but distended, mildly tender
to
palpation in all quadrants most in LLQ, no rebound/guarding, no
hepatosplenomegaly
EXTREMITIES: 3+ pitting edema to the waist
NEURO: A&Ox3, moving all 4 extremities with purpose, no
asterixis
SKIN: warm and well perfused, jaundiced, no excoriations or
lesions
Pertinent Results:
ADMISSION LABS
==============
___ 11:45AM BLOOD WBC-8.4 RBC-2.37* Hgb-7.9* Hct-23.6*
MCV-100* MCH-33.3* MCHC-33.5 RDW-UNABLE TO RDWSD-UNABLE TO Plt
___
___ 11:45AM BLOOD Neuts-61.1 Lymphs-16.8* Monos-16.8*
Eos-4.4 Baso-0.5 Im ___ AbsNeut-5.15 AbsLymp-1.41
AbsMono-1.41* AbsEos-0.37 AbsBaso-0.04
___ 11:45AM BLOOD ___ PTT-37.9* ___
___ 11:45AM BLOOD Glucose-90 UreaN-12 Creat-1.1 Na-138
K-3.3* Cl-107 HCO3-18* AnGap-13
___ 11:45AM BLOOD ALT-17 AST-83* AlkPhos-148* TotBili-9.4*
___ 11:45AM BLOOD Lipase-72*
___ 11:45AM BLOOD Albumin-2.4*
___ 06:45PM BLOOD calTIBC-105* VitB12-667 Folate->20
Ferritn-370* TRF-81*
___ 06:45PM BLOOD Ethanol-NEG
MICRO
=====
___ 3:22 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 1:10 am URINE Source: ___.
**FINAL REPORT ___
REFLEX URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ Blood Cultures: NGTD
IMAGING
=======
RUQ U/s ___. Cirrhotic liver with trace ascites. There is mild
splenomegaly.
2. No visualized portal vein thrombosis. There is new reversal
of portal
venous directional flow, likely sequela of portal hypertension.
3. Redemonstration of a gallbladder containing intraluminal
sludge with wall thickening, which is likely due to
third-spacing.
4. No findings to suggest biliary obstruction.
DISCHARGE LABS
==============
___ 06:47AM BLOOD WBC-8.6 RBC-2.43* Hgb-8.0* Hct-23.8*
MCV-98 MCH-32.9* MCHC-33.6 RDW-23.7* RDWSD-83.4* Plt ___
___ 06:47AM BLOOD ___ PTT-36.0 ___
___ 06:47AM BLOOD Glucose-77 UreaN-11 Creat-1.1 Na-137
K-3.6 Cl-107 HCO3-18* AnGap-12
___ 06:47AM BLOOD ALT-16 AST-77* AlkPhos-160* TotBili-7.8*
___ 06:47AM BLOOD Albumin-2.4* Calcium-7.9* Phos-3.9 Mg-1.8
Brief Hospital Course:
SUMMARY:
___ woman with past medical history of Hepatitis C
(untreated), alcoholic cirrhosis decompensated by ascites and
edema and recent admission for alcoholic hepatitis with course
complicated by acute blood loss anemia (thought ___ recurrent
epistaxis), hospital-acquired pneumonia (treated with cefepime),
and ___ concerning for HRS, who re-presents with worsening
anemia as an outpatient unresponsive to transfusions. EGD on ___
showed medium non-bleeding esophageal varices and PHG,
subsequently started on nadolol as well as ___ diuretics
for her fluid overload. She received a total of 1 u PRBCs (___)
and HgB has remained stable throughout admission.
ACTIVE ISSUES
=============
#Anemia
Admitted with macrocytic anemia non-responsive to outpatient
blood transfusions. Recently discharged with HgB 7.2 --> 7.9
despite 2U pRBCs as an outpatient. Likely related to liver
dysfunction, alcohol use/nutritional deficiency, as well as
acute blood loss anemia from recurrent epistaxis and subsequent
melena. Underwent EGD ___ showing medium non-bleeding esophageal
varices and PHG. Also with normal B12, folate. Ferritin not low
to indicate ___. Hemolysis labs negative. Most likely that her
presenting anemia was secondary to epistaxis and oozing from
PHG. She received 1 U PRBC during this admission for slow drop,
stable since. Patient started on nadolol 20mg QHS for variceal
bleed prophylaxis, which may need to be titrated upwards as an
outpatient though her blood pressures have been low in the ___
systolic. Hgb on discharge 8.
#Hep C/EtOH Cirrhosis
MELD 25 decompensated in the past by ascites, ___ edema. No known
history of HE, SBP, varices (although has not had EGD), or SBP.
Infectious workup negative with normal CXR, BCx. Currently LFTs
stable from prior admission and bilirubin down-trending. On
admission, significantly volume overloaded with weight up 8lbs
since ___ discharge. Increased diuretics as per section below.
Patient continued on lactulose. Bleeding as above with EGD
showing medium varices, PHG, started on nadolol.
#Fluid Overload
Patient was fluid overloaded on exam with 3+ pitting edema and
moderate amount of ascites likely in the setting of her
diuretics being held previously, restarted at low dose. In
addition, was started on sodium bicarbonate during last
admission for metabolic acidosis per nephrology. Sodium
bicarbonate unfortunately has a large amount of sodium and
therefore likely cancels out her diuretics' effects and is
contributing to her current volume status. Patient to be
discharged on furosemide 80mg daily and spironolactone 200mg
daily both to be taken at the same time in the morning. Her
sodium bicarbonate was discontinued.
#Acute Kidney Injury
#Hepatorenal Syndrome
Cr 1.1 on admission, stable. Unresponsive to albumin challenge
on last admission, started on midodrine. Patient continued on
midodrine during this admission. Cr 1.1 on discharge.
#Hx of alcoholic hepatitis, resolving
Patient has history of alcoholic hepatitis in ___ treated
with course of prednisolone and more recently ___ which did
not require steroids (DF 44). Currently LFTs stable and
bilirubin down-trending from prior admission. Her alcoholic
hepatitis continues to resolve which is reassuring. ALT/AST on
discharge ___. Tbili on discharge 7.8.
#Moderate Malnutrition
Patient had Dobhoff tube placed last admission, but self d/ced
and not replaced when able meet nutritional needs by PO with
supplementation. Seen by nutrition who recommends feeding tube
placement, which patient refused at this time. Patient continued
on multivitamin, thiamine, and folate. Will continue Ensure
clears, 6 supplements daily.
CHRONIC/STABLE ISSUES
=====================
#Non-anion gap metabolic acidosis
HCO3 stable from recent discharge. Had been on sodium
bicarbonate since last admission, which has since been
discontinued as the large amount of salt is likely contributing
to her fluid overload. Will need outpatient nephrology follow-up
after discharge. HCO3 on discharge 18.
#Alcohol Abuse Disorder
Patient with recent alcohol use, no symptoms of withdrawal. Last
reported drink ___.
#Hepatitis C
Not treated. HCV VL 2.6. Will need outpatient treatment.
#Bipolar Disease
#ADHD
Not currently on medications for this.
#Back pain
Continue home low dose oxycodone.
TRANSITIONAL ISSUES:
[ ] Discharge Hgb 8.0
[ ] Dischage INR 2.1
[ ] Discharge HCO3 18
[ ] Discharge Cr 1.1
[ ] Discharge ALT/AST: ___
[ ] Discharge Tbili: 7.8
[ ] Patient will need repeat labs on ___: CBC, Chem-10, LFTs.
[ ] Patient discharged on higher doses of diuretics: furosemide
80mg daily and spironolactone 200mg daily. Close monitoring of
her electrolytes including potassium and bicarbonate is
important.
[ ] Patient with 3+ pitting edema and moderate ascites on
discharge, diuretics ___ need to ensure improvement
in volume status and titrate diuretics accordingly as an
outpatient.
[ ] Patient to weigh herself every day, if increases by 3 or
more pounds, then she should be seen by a provider.
[ ] Patient with metabolic acidosis, initially started on sodium
bicarbonate, discontinued on this admission as contributing to
volume overload. Would benefit from outpatient nephrology
consult.
[ ] Patient discharged on nadolol 20mg QHS after EGD showed
medium varices. Will need to titrate as an outpatient. Can
consider increasing to 40mg if blood pressures allow.
[ ] Please continue to support patient in her alcohol cessation.
#CODE STATUS: FULL CODE (presumed)
#EMERGENCY CONTACT: ___, father ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins 1 TAB PO DAILY
2. Vitamin D 400 UNIT PO DAILY
3. Thiamine 100 mg PO DAILY
4. Sodium Bicarbonate 650 mg PO BID
5. Midodrine 5 mg PO TID
6. Lactulose 30 mL PO TID
7. FoLIC Acid 1 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Furosemide 40 mg PO DAILY
10. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
Discharge Medications:
1. Nadolol 20 mg PO QHS
RX *nadolol 20 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
2. Spironolactone 200 mg PO DAILY
RX *spironolactone 100 mg 2 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
3. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. FoLIC Acid 1 mg PO DAILY
5. Lactulose 30 mL PO TID
6. Midodrine 5 mg PO TID
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO DAILY
9. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
10. Thiamine 100 mg PO DAILY
11. Vitamin D 400 UNIT PO DAILY
12.Supplements
ICD10: E44.0
Please provide 6 ENSURE CLEAR daily x 30 packs of 6 ENSURE to
provide 1 month of supplements.
Refills: 6
13.Outpatient Lab Work
Date: ___, ICD10: K70.31
Labs: CBC, Chem-10, LFTs
Please fax to ATTN: ___., ___.
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute on Chronic Anemia
Esophageal Varices
SECONDARY DIAGNOSES
===================
Alcoholic Cirrhosis
Hepatitis C Cirrhosis
Moderate Malnutrition
Fluid overload
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because you had low blood
counts and were requiring many blood transfusions.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You had an upper endoscopy where a camera looked into your
stomach. It showed varices (big veins) in your esophagus. These
varices can be dangerous because they can bleed, which can be
very serious and even life-threatening. You were prescribed a
new medication called nadolol to help reduce your risk of
bleeding.
- You received 1 blood transfusion.
- You received medications to decrease the amount of fluid in
your legs and belly.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Take all of your medications as prescribed (listed below)
- Keep your follow up appointments with your doctors
- Please stick to a low salt diet and monitor your fluid intake
- Please continue to abstain from alcohol. Your liver is already
very damaged and if you drink more, then it will continue to get
worse and your symptoms will be worse.
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Team
Followup Instructions:
___
|
10117812-DS-15 | 10,117,812 | 26,571,680 | DS | 15 | 2117-04-27 00:00:00 | 2117-04-27 22:32:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
anasarca
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w h/o Hep C (untreated), ETOH cirrhosis (MELD 13 in ___,
22 on admission decompensated by ascites, ___ edema, no known h/o
varices or HE), severe alcoholic hepatitis, bipolar 2 disorder,
ADHD, with recent admission for alcoholic hepatitis sent in from
liver service due to worsening anasarca in the setting of
hepatorenal syndrome.
In brief, patient was recently admitted in ___ for acute
on
chronic anemia. Work up at that time was notable for EGD with
non-bleeding varices and PHG and she was initiated on nadolol.
Her anemia was believed to be multifactorial at that time in the
setting of liver dysfunction, alcohol use, and intermittent
melena from source above. Hospital course otherwise notable for
decompensated cirrhosis with volume overload believed to be
secondary to initiation of sodium bicarbonate requiring
increased
diuretics on discharge. Patient Cr was 1.1 on admission ___
from:0.6) and she was continued on midodrine
After discharge her diuretics were increased to Lasix ___
300 daily she was found to have a creatinine of 2.0 on ___
at
which time her diuretics were held. Rshowed creatinine of 1.7.
At
which time she was recommended to present to the ED for further
management.
In the ED:
- Initial vital signs were notable for: T: 97.5; HR: 65; BP:
106/59
- Exam notable for: Fluid wave, diffusely tender,
- Labs were notable for: Hemoglobin: 7.3 (unknown baseline?);
Cr:
1.6; T bili 4.3 (direct: 2.8)
- Studies performed include: RUQUS Cirrhotic liver, without
evidence of focal lesion.
-Patent portal vein with hepatopetal flow, previously
hepatofugal.
-Gallbladder sludge with wall thickening likely secondary to
third spacing. No
evidence of acute cholecystitis.
Upon arrival to the floor, patient endorses the above history
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
ADHD, predominantly inattentive type
Pap smear abnormality of cervix with LGSIL
Tobacco dependence
Abdominal pain, right lower quadrant
Bipolar II disorder
Rectal fissure
Gartner duct, cyst
Strabismus
Dry eyes
Keratitis sicca
Major depression
Acute hepatitis C virus infection, genotype 1a
___ positive, ?lupus diagnosis in past
Iron excess
Cirrhosis
Alcohol abuse, in remission
Hemochromatosis carrier
Social History:
___
Family History:
Biological mother w etoh abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
___ Temp: 98.1 PO BP: 112/64 R Lying HR: 70 RR:
18 O2 sat: 99% O2 delivery: RA Dyspnea: 0 RASS: 0 Pain Score:
___
GENERAL: Alert and interactive, though intermittently tangential
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Soft but distended. Tender on LUQ. No organomegaly.
EXTREMITIES: 3+ edema through upper thigh
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. +asterixis
DISCHARGE PHYSICAL EXAM:
=========================
VS: 24 HR Data (last updated ___ @ 520)
Temp: 99.4 (Tm 99.4), BP: 128/70 (127-136/70-78), HR: 95
(79-95),
RR: 18 (___), O2 sat: 94% (94-96), O2 delivery: Ra, Wt: 186.9
lb/84.78 kg
GENERAL: Alert and interactive, sitting up in bed
HEENT: NCAT. PERRL, EOMI. Sclera icteric, no injection.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Mild crackles in bl bases, up to mid-lung field on the
left. No wheezes or rhonchi. No increased work of breathing, no
accessory muscle use.
ABDOMEN: Abd distention. TTP in left upper/mid quadrant,
endorses
left-sided pain with palpation of the right lower to mid abdomen
as well, otherwise non-tender. No guarding. BS+. Prominent
vessels with stable red/pink skin changes.
EXTREMITIES: 3+ edema through upper thigh with dependent edema
and red/pink skin changes in ___, no open wounds or ulcers.
NEUROLOGIC: A&Ox3. moving all extremities. answering questions
appropriately and mentating well. +asterixis mild.
Pertinent Results:
ADMISSION LABS
================
___ 08:29AM BLOOD WBC-6.9 RBC-2.17* Hgb-7.3* Hct-23.5*
MCV-108* MCH-33.6* MCHC-31.1* RDW-18.3* RDWSD-71.7* Plt ___
___ 08:29AM BLOOD Neuts-57.6 ___ Monos-18.5*
Eos-1.7 Baso-0.6 Im ___ AbsNeut-3.96 AbsLymp-1.46
AbsMono-1.27* AbsEos-0.12 AbsBaso-0.04
___ 08:29AM BLOOD ___
___ 08:29AM BLOOD UreaN-17 Creat-1.6* Na-137 K-4.0 Cl-101
HCO3-23 AnGap-13
___ 08:29AM BLOOD ALT-18 AST-67* AlkPhos-232* TotBili-4.3*
DirBili-2.8* IndBili-1.5
___ 08:29AM BLOOD Calcium-8.1* Phos-4.3 Mg-1.6
___ 08:29AM BLOOD Ethanol-NEG
Discharge Labs
================
___ 06:05AM BLOOD WBC-7.1 RBC-2.45* Hgb-8.0* Hct-25.7*
MCV-105* MCH-32.7* MCHC-31.1* RDW-19.7* RDWSD-74.1* Plt ___
___ 06:05AM BLOOD ___ PTT-45.7* ___
___ 06:05AM BLOOD Glucose-86 UreaN-26* Creat-1.6* Na-146
K-4.0 Cl-118* HCO3-13* AnGap-15
___ 06:05AM BLOOD ALT-7 AST-33 AlkPhos-109* TotBili-2.7*
___ 06:05AM BLOOD Calcium-8.6 Phos-3.2 Mg-1.7
Other Pertinent Studies
=========================
___ 05:50AM BLOOD proBNP-1667*
___ 08:29AM BLOOD 25VitD-31
___ 06:35AM BLOOD HAV Ab-Borderline
___ 05:36AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 05:36AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-4* pH-6.0 Leuks-TR*
___ 05:36AM URINE RBC-3* WBC-7* Bacteri-FEW* Yeast-NONE
Epi-19
___ 05:36AM URINE CastHy-17* CastOth-NONE
___ 05:36AM URINE Mucous-RARE*
___ 05:36AM URINE Hours-RANDOM UreaN-404 Creat-324 Na-<20
___ 05:36AM URINE Osmolal-409
___ 02:15PM ASCITES TNC-341* RBC-7047* Polys-57* Lymphs-20*
Monos-0 Basos-2* Macroph-21*
___ 02:15PM ASCITES TotPro-0.4 Glucose-121 Creat-1.6
LD(LDH)-89 Amylase-4 TotBili-0.3 Albumin-<0.2
___ 2:15 pm PERITONEAL FLUID PERITONEAL FLUID .
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 05:18PM ASCITES TNC-148* RBC-922* Polys-1* Lymphs-15*
___ Mesothe-4* Macroph-80* Other-0
___ 05:18PM ASCITES TotPro-1.8 Glucose-96 Albumin-0.8
___ 5:18 pm PERITONEAL FLUID PERITONEAL 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, if applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 4:21 pm BLOOD CULTURE - No growth
___ 1:00 am BLOOD CULTURE - No growth
___ 6:50 am BLOOD CULTURE - No growth
___ 01:13AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 01:13AM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln-2* pH-5.5 Leuks-NEG
RBC-8* WBC-5 Bacteri-FEW* Yeast-NONE Epi-12
___ 01:13AM URINE CastHy-74* Mucous-RARE*
___ 12:08PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 12:08PM URINE Blood-SM* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-10* Bilirub-SM* Urobiln-2* pH-6.0 Leuks-SM*
RBC-5* WBC-10* Bacteri-FEW* Yeast-NONE Epi-25
___ 12:08PM URINE CastHy-21* Mucous-RARE*
Relevant Imaging
=================
CXR (___) - Mild atelectasis in the bases.
Liver/Gallbladder Ultrasound (___)
1. Cirrhotic liver, without evidence of focal lesion.
2. Patent portal vein with hepatopetal flow, previously
hepatofugal.
3. Gallbladder sludge with wall thickening likely secondary to
third spacing. No evidence of acute cholecystitis.
CXR (___)
Heart size is enlarged but stable. There has been development
of moderate pulmonary edema and patchy opacity at the right
base. Follow-up to resolution is recommended. There are no
pneumothoraces.
KUB (___)
Single distended large bowel loop within the right hemiabdomen
without
evidence of free intraperitoneal air.
CXR (___)
Comparison to ___. Lung volumes remain low. The
patient is rotated. Moderate cardiomegaly persists. Today's
image shows evidence of mild pulmonary edema. No pneumothorax.
No pneumonia.
CT Abd/Pelvis w/o contrast (___)
1. Dilated loops of small bowel, with air fluid levels and
without a transition point, are suggestive of an ileus.
Evaluation of the large bowel is limited.
2. Large volume ascites diffusely within the abdomen and
anasarca is
consistent with third spacing.
3. The liver has a nodular contour consistent with cirrhosis.
There are multiple serpiginous vessel consistent with varices.
Evaluation for focal masses or lesions is limited in this
noncontrast enhanced study.
4. Please refer to dedicated CT chest for further
characterization.
CT Chest w/o contrast (___)
- Small bilateral pleural effusions with bibasilar atelectasis
left greater than right. Mild diffuse interstitial edema with
subsegmental atelectasis in the left lower lobe. No evidence of
pneumonia.
- Evidence of anasarca.
- Ascites.
- Small mediastinal lymph nodes are most likely reactive.
Brief Hospital Course:
SUMMARY:
====================
___ w h/o Hep C (untreated), ETOH cirrhosis (MELD 23 on
admission) decompensated by ascites, ___ edema, severe alcoholic
hepatitis, bipolar 2 disorder, ADHD, with recent admission for
alcoholic hepatitis and HRS presenting with decompensated
cirrhosis with ___ c/f HRS as well as hypervolemia in setting of
holding home diuretics. Hospital course c/b fevers of unknown
origin, completed a 7-day course of cefepime. Renal function
initially worsened i/s/o infection however eventually improved
with albumin.
Transitional Issues
====================
[] Diuretics were held this admission and discontinued on
discharge due to inability to tolerate and development of likely
hepatorenal syndrome
[] Will likely require LVPs as outpatient given ascites and no
longer on diuretics
[] Treated with octreotide for likely HRS, discontinued prior to
discharge
[] Patient will need BMP within the next week to monitor renal
function, electrolytes - will likely need ongoing monitoring
thereafter
[] Required several blood transfusions during admission without
evidence of overt bleed other than small volume epistaxis - will
need CBC within the next week and monitoring going forward
[] Nadolol was held during admission given likely HRS - consider
risk/benefits given hx medium varices
[] Pt with asterixis throughout admission despite frequent
lactulose, however remained cognitively intact - may consider
other etiology for asterixis other than HE
[] Pt with anasarca during admission - BNP elevated 1600s in
setting ___ - may consider repeating as outpatient
[] Outpatient Phosphatidylethanol from ___ unable to be
completed due to interference - may consider repeat testing in
the future
[] Hx untreated Hep C. HCV VL 2.6. Consider outpatient
treatment.
[] Bicarb low this admission c/w NAGMA - if remains low on
follow up consider working up for RTA.
Discharge MELD: 21
Discharge Cr: 1.6
Discharge Hgb: 8
Discharge Weight: 187 lbs
Last paracentesis: ___, 3L removed
ACUTE ISSUES:
=============
#Acute Kidney Injury
#c/f Hepatorenal Syndrome
Pt with recent hospitalization with significant ___ ultimately
believed to be secondary to HRS for which she was started on
midodrine. She then had what was perceived to be a pre-renal ___
i/s/o outpatient uptitration of diuretics with subsequent
sustaining of renal injury in setting of holding home diuretics
and worsening of lower extremity edema and ascites. Her weight
is additionally up 8 lb over the week prior to admission,
however, was consistent with discharge weight from last
admission. This admission, urine and serum studies were
consistent with a pre-renal etiology. Patient was treated with
albumin, as well as octreotide and increased doses of midodrine.
Initially, kidney function worsened, possibly due to sepsis or
vancomycin-mediated kidney injury in setting of supratherapeutic
vanc levels. Urine was spun and revealed hyaline casts, thought
to be ___ HRS. Cr subsequently improved with treatment of
infection and continued albumin. Therefore, midodrine was
decreased back to home dose of 5mg TID and octreotide was
discontinued prior to discharge. Patient's creatinine was
monitored with several days without albumin supplementation and
with encouraging protein/ensure intake, and Cr remained
relatively stable. Patient had decreased UOP throughout
admission. Diuretics were held throughout admission and
subsequently discontinued on discharge.
#Fever
Unknown origin. Temperature spiked to 102.8 on ___ overnight,
and again to
101.4 on ___ overnight. No localizing symptoms other than
abdominal pain, no leukocytosis. Admission blood cultures, UA
wnl. Pt was started on broad spectrum antibiotics
vanc/cefepime/flagyl. SBP was considered given ascites and
abdominal pain. Diagnostic para ___ with 148 WBC and 1% polys,
not consistent with SBP, although was started on abx 12 hours
prior to paracentesis. BCx no growth. UA with few bacteria, sm
leuks, but negative nitrite - UCx not processed. CT chest
without pna. CT A/P without clear source of infection. Patient
was later narrowed to cefepime for total of ___nd
remained afebrile throughout treatment.
#HepC/EtOH Cirrhosis
MELD 23 on admission. Decompensated in the past by ascites, ___
edema. No known
history of SBP. Recent EGD ___ with medium varices, PHG. LFTs
on admission stable from prior admission and bilirubin
down-trended, however significantly volume overloaded secondary
to holding of home diuretics vs EtOH use. History of HE with
asterixis on exam. Was given lactulose with subsequent frequent
stooling, however continued to have asterixis despite wnl mental
status. Otherwise, diuresis was held during admission in setting
of likely HRS per above, discontinued on discharge. Had
significant anasarca with 3+ pitting edema in ___ and
dependent edema in the thighs. Had paracentesis ___ with 3L
removed, diagnostic para negative for SBP. Otherwise, nadolol
was held during admission in setting of likely HRS. Pt did not
develop significant bleed during this admission, however did
require several blood transfusions per below.
#Anasarca
Likely ___ holding diuretics in the setting ___ and likely
HRS. Also likely worsened by decreased UOP throughout admission.
BNP was elevated to 1667, however was measured in the setting of
an ___, so likely inaccurate. Diuretics were held during
admission and on discharge per above, with plan for LVPs as
outpatient.
#Acute on Chronic Anemia
#Epistaxis
Extensive history of anemia with EGD as above. Extensive work up
prior admission showing likely nutritional deficiency as well as
PHG. Hemoglobin was mildly decreased from baseline this
admission with no evidence of overt bleeding. Iron studies, B12,
folate all wnl in ___. Required 3u pRBC total this admission
with appropriate Hgb response each time. Last transfusion was
___. Pt had mild epistaxis this admission, however not
significant enough to cause Hgb drop. CBC was closely monitored
with plan for outpatient monitoring after discharge.
#Abdominal Pain
Pt with mild abd pain on admission, mostly in LUQ at site of
prior rib fracture. Later developed diffuse abdominal pain
associated with distention and fevers. Diagnostic para ___
without evidence of SBP, although was started on abx >12 hours
prior to tap. Patient was treated with cefepime for total of 7
day course with resolution of diffuse abdominal pain. Otherwise,
KUB had no evidence of free air. CT A/P with likely ileus. Pt
continued to stool, and had one episode of vomiting which later
resolved. CT also with large ascites, which was felt to be
contributing to abdominal discomfort. Patient declined
additional LVP while inpatient and elected to do an outpatient
paracentesis after discharge. Patient was continued on home
oxycodone 2.5mg q6h prn, as well as acetaminophen 650mg q8h prn.
#Non anion gap metabolic acidosis
Bicarb low this admission, unclear etiology given no diarrhea
above baseline on lactulose, no excessive NS repletion. Will
monitor as outpatient and consider RTA workup if remains low.
#Moderate Malnutrition
Patient had Dobhoff tube placed in ___ but self d/ced.
Patient had good PO intake throughout admission. Provided with 6
ensures per day and continued on multivitamin, folate and
thiamine supplementation.
CHRONIC ISSUES
================
#Hx of alcoholic hepatitis
H/o alcoholic hepatitis in ___ treated with course of
prednisolone and more recently ___ which did not require
steroids (DF 44). This admission, LFTs were stable and bilirubin
had down-trended from prior admission. Likely representing
resolving alcoholic hepatitis. LFTs were monitored throughout
admission.
#Alcohol Use Disorder
Patient with recent alcohol use, no symptoms of withdrawal. Last
reported drink 3 weeks prior to admission. Pt was continued on
thiamine, folate, and multivitamins per above. Social work was
consulted and provided patient with resources. Per patient, she
will enroll in outpatient program near her home. Otherwise per
chart, outpatient phosphatidylethanol from ___ unable to be
completed due to interference.
#Hepatitis C
Not treated. HCV VL 2.6. Plan for outpatient treatment.
#Bipolar Disease
#ADHD
Not currently on medications.
#Back pain
Continue home low dose oxycodone.
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. FoLIC Acid 1 mg PO DAILY
2. Furosemide 80 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Midodrine 5 mg PO TID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO DAILY
7. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
8. Thiamine 100 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10. Nadolol 20 mg PO QHS
11. Spironolactone 200 mg PO DAILY
Discharge Medications:
1. Lidocaine 5% Patch 1 PTCH TD QAM pain
apply one patch per day max
RX *lidocaine [Aspercreme (lidocaine)] 4 % 1 patch once a day
Disp #*30 Patch Refills:*0
2. FoLIC Acid 1 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Midodrine 5 mg PO TID
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO DAILY
7. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain -
Moderate
8. Thiamine 100 mg PO DAILY
9. Vitamin D 400 UNIT PO DAILY
10.Outpatient Lab Work
___: CBC, CMP, LFTs, ___
ICD: ___
FAX RESULTS TO: ___ ___, ___
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute Kidney Injury
Secondary Diagnosis: Decompensated Cirrhosis
Anasarca
History of alcoholic hepatitis
Moderate Malnutrition
Anemia
Epistaxis
Alcohol Use Disorder
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You were admitted to the hospital because of an acute kidney
injury.
WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL?
- You received fluids, albumin, and medication to treat your
acute kidney injury
- You received antibiotics for an infection
- You saw a social worker who provided you with resources to
maintain sobriety
- You were seen by a nutritionist who recommended you drink 6
ensures per day and take in a lot of protein.
- You improved and were ready to leave the hospital.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- You must never drink alcohol again
- Please enroll in AA and work with your primary care doctor to
determine the best strategy to help you stay sober
- Take all of your medications as prescribed
- Keep your follow up appointments with your doctors
- Weigh yourself every morning, before you eat or take your
medications. Call your doctor if your weight changes by more
than 3 pounds
- Please stick to a low salt diet and monitor your fluid intake
- Please maintain a high protein diet and continue to drink
ensures
- If you experience any of the danger signs listed below please
call your primary care doctor or come to the emergency
department immediately.
- PLEASE GET YOUR LABWORK DONE THIS ___ USING THE
PRESCRIPTION WRITTEN FOR BLOOD WORK.
It was a pleasure participating in your care. We wish you the
best!
- Your ___ Care Team
Followup Instructions:
___
|
10118190-DS-14 | 10,118,190 | 20,393,246 | DS | 14 | 2140-12-19 00:00:00 | 2140-12-19 13:58:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
increase in back pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male with hx of scoliosis, sciatica, and chronic back pain
and weakness presenting with increase in pain.
Pt reports that for the past ___ year he has not been able to walk
due to progressive back weakness (prior to this was able to walk
with leaning on wife for help.) Since ___ he has been bedbound.
He had a recent fall forward out of his wheelchair. This caused
severe pain in the "tailbone" whenever he sits with pressure on
it or if he turns or moves and places pressure on it. He denies
loss or change in sensation, denies b/b incontinence. He has
been taking roxanol 3 times a day (25ml?) for the pain without
any othermedications with it.
He presented today as he cannot take the pain at home any
longer.
10 systems reviewed and are negative except where noted in the
HPI above
Past Medical History:
scoliosis, back brace for a period of time as a teenage
pt reports he developed sciatica with 1 leg being weak, then the
other leg as well
wheelchair bound currently
more than ___ year ago was walking only with great deal of
assistance
Social History:
___
Family History:
mother with "bad back"
Physical Exam:
Physical Exam:
Afeb VSS
Cons: NAD, lying in bed
Eyes: PERRL, EOMI, no sclera icterus
ENT: MMM, poor dentition
Neck: nl ROM, no goiter
Lymph: no cervical LAD
Cardiovasc: rrr, no murmur, no edema
Resp: CTA B
GI: +bs, soft,nt, nd
MSK: +kyphosis and scoliosis noted
Skin: left buttock with mild abrasion
abrasion with some skin tearing at sacrum
___ muscle atrophy
Neuro: sensation intact B ___, feet externally rotated, but able
to rotate
Psych: pleasant, somewhat child like affect
Pertinent Results:
___ 11:35AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
.
CT L-SPINE W/O CONTRAST:
FINDINGS:
There are 5 lumbar type vertebrae; L5 is partially sacralized.
The bones are demineralized. There is mild diffuse loss of
height in the L3, L4 and L5 vertebral bodies, unchanged. There
is anterior wedging of the L2 vertebral body, slightly increased
since ___ radiographs. There is a fracture line parallel to
the superior endplate (501b:45, 500b:22), with minimal sclerosis
along the fracture line compatible with either remodeling in
response to a subacute fracture, or acute impaction of fracture
fragments. There is no retropulsion.
There is unchanged mild retrolisthesis at L2-3, L3-4, and L4-5,
a
dextroscoliosis centered at L1-2, and a kyphotic curvature
centered at L2-3.
There is multilevel disc space narrowing and vacuum phenomenon,
not
significantly changed from the prior radiograph.
At T12-L1, there is no significant spinal canal or neural
foraminal narrowing.
At L1-L2, a small disc bulge causes minimal spinal canal
narrowing.
At L2-3, there is a small disc bulge, facet arthropathy, and
mild
retrolisthesis causing mild central canal narrowing, and mild
left neural
foraminal narrowing.
At L3-4, there is mild spinal canal narrowing due to a disc
bulge, facet
arthropathy and mild retrolisthesis. There is mild right and
mild to moderate left neural foraminal narrowing.
At L4-5, there is severe spinal canal narrowing due to posterior
epidural
lipomatosis, a disc bulge, facet arthropathy, and mild
retrolisthesis. There is also severe right and
moderate-to-severe left neural foraminal narrowing.
At L5-S1, there is a large disc bulge with endplate osteophytes,
and facet arthropathy, with moderate spinal canal narrowing and
severe bilateral neural foraminal narrowing.
Psoas muscles appear asymmetric due to scoliosis. The imaged
portions of the liver demonstrate fatty infiltration. Punctate
right renal hilus
calcifications could be vascular or could represent
nonobstructing stones. The imaged abdominal aorta and iliac
arteries are extensively calcified.
IMPRESSION:
1. Acute-on-chronic or subacute compression fracture of L2
vertebral body without retropulsion, which demonstrates
increased anterior loss of height since ___. The preliminary
report stated that there was no acute fracture; the final
interpretation was discussed by Dr. ___ with Dr. ___ at
5:44 pm on ___ via telephone.
2. Unchanged mild diffuse loss of height in the L3 through L5
vertebral
bodies.
3. Multilevel degenerative disease with severe spinal stenosis
at L4-5.
4. Partially sacralized L5.
5. Hepatosteatosis.
6. Non-obstructing right renal stones versus arterial
calcifications.
Brief Hospital Course:
___ male with longstanding hx ___ weakness, DJD of the
lumbar spine here with worsening sacral pain a few weeks after a
fall and worsening function.
acute issues
# Lumbar Compression Fracture: CT shows (see above) with
Acute-on-chronic or subacute compression fracture of L2
vertebral body without retropulsion, which demonstrates
increased anterior loss of height since ___. He was seen by
the Spine service pt in the ED. That recommended to have a brace
(now in place). They recommended pain control and ___. ___
d/w the pt further about surgical options as an outpatient. They
do not feel that urgent surgery is indicated and pt and surgery
are both hesitant to pursue any surgical interventions.
.
# ETOH Abuse: Pt with multiple ED visits per his listed PCP.
.
# Small areas of skin breakdown--POA. likely abrasions from
scooting around. duoderm to protect
.
Transitional issues: outpt f/u with spine. f/u with PCP.
- Direct verbal signout provided to accepting phyisican at
rehab, Dr. ___. In addition I spoke with the patients
listed PCP ___ that has not met the pt.
Medications on Admission:
Morphine Sulfate
Tylenol
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Morphine Sulfate (Oral Soln.) 10 mg PO Q4H:PRN pain
RX *morphine 15 mg 1 tab by mouth q4hr Disp #*30 Tablet
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Lumbar Vertebral Compression Fractures
- ETOH abuse
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
You were admitted with acute back pain. You were noted to have
lumbar compression fractures and scoliosis. A back brace and
outpatient surgical follow-up was recommended.
Followup Instructions:
___
|
10118201-DS-21 | 10,118,201 | 28,761,568 | DS | 21 | 2156-03-02 00:00:00 | 2156-03-02 11:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o poorly differentiated neuroendocrine tumor or anal
cancer with mets to pancreas s/p distal
pancreatectomy/splenectomy and transanal excision of mass
(___) presents with abdominal pain. Per discharge summary,
patient had a pancreatic stump leak and was discharged with a
JP. She was seen in clinic on ___ and her JP was taken out
(eating regular food, very low output JP approximately 1
teaspoon/day).
The patient did well for a few hours then suddenly developed
band like abdominal pain L>R with some radiation to the back and
pain in the left shoulder. No f/c. No diarrhea. Some burping
which helped with pain. No nausea/emesis. +flatus.
Since being here in the ED, patient has felt slightly better.
Continues to have similar pain but decreased in intensity.
Past Medical History:
Past Medical History:
hypertension and nephrolithiasis.
Surgical history:
appendectomy via ___ incision for perforated
appendicitis in ___, EUA and biopsy of the anal mass done last
___,full colonoscopy, which otherwise was negative that was
done in ___.
Social History:
___
Family History:
bladder cancer in her brother. lung cancer, skin cancer and
prostate cancer.
Physical Exam:
Prior discharge:
VS: 98.4, 74, 115/71, 16, 96%RA
GEN: Pleasant with NAD
CV: RRR
PULM: CTAB
Abd: soft, nontender/nondistended. Left subcostal incision open
to air with steri strips and c/d/i. Old LLQ JP drain site with
dry dressing and c/d/i.
EXTR: Warm no c/c/e
Pertinent Results:
___ 10:15AM BLOOD WBC-9.7 RBC-2.89* Hgb-8.8* Hct-26.6*
MCV-92 MCH-30.4 MCHC-33.0 RDW-13.9 Plt ___
___ 10:15AM BLOOD Glucose-109* UreaN-10 Creat-0.8 Na-140
K-4.4 Cl-104 HCO3-29 AnGap-11
___ 10:15AM BLOOD ALT-3 AST-26 AlkPhos-185* TotBili-0.3
___ 10:15AM BLOOD Albumin-3.4* Calcium-8.6 Phos-3.6 Mg-1.8
___ 06:45AM URINE Color-Straw Appear-Clear Sp ___
___ 06:45AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM
___ 06:45AM URINE RBC-1 WBC-19* Bacteri-FEW Yeast-NONE
Epi-13
___ 06:45AM URINE Mucous-OCC
___ ABD CT:
IMPRESSION:
1. Small fluid collection in the distal pancreas in the
resection bed is
likely post-surgical. Associated mesenteric stranding in the
upper left and mid abdomen is anticipated after recent surgical
procedure but postsurgical pancreatitis and/or superimposed
infection cannot be excluded with this appearance.
2. Bilateral pars articularis defect of L5 resulting in grade 1
anterolisthesis of L5 on S1.
3. Punctate calcified gallstone. Normal gallbladder.
Brief Hospital Course:
The patient s/p distal pancreatectomy and splenectomy on
___ was readmitted to the ___ Surgical Service for
evaluation of the new onset of abdominal pain after removal of
the JP drain. On admission abdominal CT scan was obtained and
demonstrated normal postoperative changes. Patient was afebrile
with WBC within normal limits. The patient was started on clears
and diet was well tolerated. Abdominal pain subsided and was
well controlled with PO pain medication. On HD # 2, diet was
advanced to regular, patient remained afebrile with minimal
postoperative pain along incision line. She was discharged home
in stable condition.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
Colace 100", oxycodone ___ mg q4 PRN, pantoprazole 40', senna
PRN, valsartan 160'
Discharge Medications:
1. Valsartan 160 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
3. Acetaminophen 325-650 mg PO Q6H:PRN headache/pain/fever
4. Docusate Sodium 100 mg PO BID
5. Metoclopramide 10 mg PO QIDACHS
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain s/p recent abdominal surgery (___)
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 ___ with abdominal
pain after JP drain removal. Your pain is improved and you are
now safe to return home:
.
PLease call ___. ___ office at ___ if you have any
questions or concerns.
.
Please call your doctor or nurse practitioner if you experience
the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain is not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Followup Instructions:
___
|
10119094-DS-8 | 10,119,094 | 24,446,921 | DS | 8 | 2146-12-05 00:00:00 | 2146-12-16 14:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Flexeril
Attending: ___.
Chief Complaint:
Chest Pain, Diaphoresis
Major Surgical or Invasive Procedure:
Left Cardiac Catheterization and PCI (3 BMS to RCA)
History of Present Illness:
Ms. ___ is a ___ year old woman with history of HLD, HTN,
atypical chest pain, possible TIA's, and rheumatic fever with
known heart murmur who presents with chest pain, nausea, and
diaphoresis with exertion since ___.
She experienced ___ sharp chest pain in the ___ her chest
and below her left breast starting on ___. She was exerting
herself by moving bozed and had gone up and down several flights
of steps 10 times. She was drenched in sweat, had the substernal
and left sided chest pain, and experienced nausea but no
vomiting. She then experienced the pain again on ___ at
church, along with the nausea and vomiting again. She stated she
had pain going into her left jaw as well. She forgot she had
nitro and did not try taking it.
On ___ she went to her PCP's office, where he noticed
inverted T waves on EKG and referred her to the ED. On
presentation to the ED her vitals were 98.1, 80, 172/101, 18,
97% on RA. She was given aspirin, Nifedipine CR 30mg,
metoprolol succinate 100mg, and clopidogrel 600mg. A heparin
drip was recommended and offered, but she declined due to
concern about bleeding (she had a history of a GI bleed).
Upon arriving to the floor, her vitals were 98.0, 190/96, 78,
20, 98% on RA.
She states that overall she hasn't been feeling 100% since her
fall on ice last ___. She also states she's been having
subjective fevers with sweats since then. She also states she
has lower extremity edema after a day of activity. She denies
orthopnea or paroxysmal dyspnea.
Past Medical History:
- HLD on atorvastatin
- HTN on metoprolol succinate 100mg daily
- OA has been on tramadolin the past
- PUD on nexium 40mg daily
- Atypical chest pain in ___
- Rectal bleeding
- H/O Rheumatic fever when she was ___ or ___, has had heart murmur
since
- possible history of 4 "mini-strokes"
- previously diagnosed with bipolar disorder, not on medication
for it
Social History:
___
Family History:
Brother had 3 vessel CABG at age ___, motehr had heart disease
and several strokes, father was killed at war.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
Weight 70.1kg, T 98.0, BP 190/96, HR 78, RR 20, O2 sat 98% on RA
General: NAD, well appearing, sitting in bed in no acute
distress
HEENT: MMM, sclera non-icteric, EOMI, PERRLA
Neck: full range of motion, JVP WNL
CV: regular rate, rhythm generally regular with few early beats.
___ early systolic murmur heard best at RUSB with radiation into
the neck. No rubs/gallops.
Lungs: CTAB no W/R/R
Abdomen: soft, nontender, non-distended, + BS
Ext: Trace edema at ankles, non-pitting. Warm, well perfused. No
cyanosis or clubbing.
Neuro/Psych: A&Ox23. Labile affect. Pressured speech,
circumferential speech. tearful at times.
Skin: Unremarkable
Pulses: 2+ DP and radial pulses bilaterally.
PHYSICAL EXAM ON DISCHARGE:
VS: Wt= 70.9kg T= 97.8 BP= 117-166/74-92 HR= 70 (one 38 episode,
otherwise) ___ RR= 16 O2 sat= 100% on RA
General: NAD. Well-appearing, sitting in bed in no acute
distress.
HEENT: MMM, sclera non-icteric.
Neck: Full range of motion. JVP WNL
CV: Regular rate, rhythm generally regular with few early beats.
___ early systolic murmur heard best at RUSB with radiation into
the neck. ___ late systolic murmur heart at ___. No
rubs/gallops.
Lungs: CTAB no W/R/R
Abdomen: Soft, non-tender, non-distended. + BS
Ext: Trace edema at ankles, non-pitting. warm, well perfused. No
cyanosis or clubbing.
Neuro/Psych: A&O x 3. Labile affect. Pressured speech,
circumferential speech, easily derailed.
Skin: Unremarkable
Pertinent Results:
LABS ON ADMISSION
___ 02:45PM BLOOD WBC-9.2 RBC-4.41 Hgb-13.5 Hct-41.8 MCV-95
MCH-30.5 MCHC-32.2 RDW-12.8 Plt ___
___ 02:45PM BLOOD Neuts-50.5 Lymphs-43.6* Monos-4.4 Eos-0.8
Baso-0.7
___ 02:45PM BLOOD ___ PTT-30.1 ___
___ 02:45PM BLOOD Glucose-133* UreaN-13 Creat-0.8 Na-139
K-3.4 Cl-99 HCO3-29 AnGap-14
___ 02:45PM BLOOD cTropnT-<0.01
___ 09:20PM BLOOD cTropnT-<0.01
___ 06:15AM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD CK-MB-3
___ 05:55AM BLOOD cTropnT-<0.01
LABS ON DISCHARGE
___ 05:55AM BLOOD WBC-7.2 RBC-3.93* Hgb-12.2 Hct-36.7
MCV-93 MCH-31.0 MCHC-33.3 RDW-13.6 Plt ___
___ 05:55AM BLOOD Plt ___
___ 06:40AM BLOOD ___ PTT-30.1 ___
___ 05:55AM BLOOD UreaN-13 Creat-0.7 Na-138 K-4.4 Cl-102
HCO3-26 AnGap-14
___ 06:40AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.1
STUDIES
CARDIAC CATHETERIZAION ___
Cardiac Catheterization & Endovascular Procedure Report
Procedures: Catheter placement, Coronary Angiography
Indications: CAD, Unstable angina.
Hemodynamic Measurements (mmHg)
Baseline
Site ___ ___ End Mean A Wave V Wave HR
___
Contrast Summary
Contrast Total (ml): Optiray (ioversol 320 mg/ml)210
Radiation Dosage
Effective Equivalent Dose Index (mGy) 497.487
Radiology Summary
Total Runs
Total Fluoro Time (minutes) 26.7
Findings
ESTIMATED blood loss: 50 cc
Hemodynamics (see above):
Coronary angiography: right dominant
LMCA: No angiographic CAD
LAD: Mid 80% at D2 bifurcation; Distal 60%
LCX: Mild irregularities
RCA: 99% mid; Diffuse mid distal 70-80%
Interventional details
We opted to perform PCI of the RCA as the likely culprit.
Heparin
additional ___ units for ACT ___. Change for 6 ___ AR2 guide
which provide fair support but did not engage fully until wire
advanced. Lesion crossed with Whisper wire to distal RCA and
diseased segments pre-dilated with 2.0 x 15 and 2.25 x 20 NC
balloons at ___ ATM. This revealed severe diffuse disease not
amenable to spot stenting. We opted for bare metal stents given
questions of compliance and prior history of GI bleed. We
deployed a 2.5 x 26, 3.0 x 30 and 3.0 x 12 Integrity bare metal
stent at 12 ATM. The segments were post-dilated with 3.0 x 15
NC
balloon at ___ ATM. Final angio showed 0% residual, TIMI 3
flow, and no residual stenosis.
Assessment & Recommendations
1. Severe 2 vessel CAD
2. Successful bare metal stent RCA
3. Consider staged PCI of LAD versus medical Rx and PCI if
fails.
CXR (PA AND LAT) ___
FINDINGS:
Heart size is top normal. Mediastinal and hilar contours are
unremarkable.
Pulmonary vasculature is normal. Lungs are clear. No pleural
effusion or
pneumothorax is seen. No acute osseous abnormalities
demonstrated. Minimal
degenerative changes are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
STRESS TESTING ___
___ ___ ___
Cardiovascular ReportStressStudy Date of ___
EXERCISE RESULTS
RESTING DATA
EKG: SINUS WITH FREQUENT VPBS AND LVH WITH REPOL ABNL
HEART RATE: 88BLOOD PRESSURE: 160/84
PROTOCOL GERVINO - TREADMILL
STAGETIMESPEEDELEVATIONHEARTBLOODRPP
(MIN)(MPH)(%)RATEPRESSURE
___
___
TOTAL EXERCISE TIME: 8.25% MAX HRT RATE ACHIEVED: ___
ST DEPRESSION:EQUIVOCAL
INTERPRETATION: ___ with history of HTN, HL, bipolar disorder
and
previous abnormal stress test presenting with accelerating
anginal type
symptoms. Patient exercised for 8 minutes and 15 seconds on a
Gervino
protocol representing a fair exercise tolerance for her age;
approximately ___ METS. No chest, back, neck, or arm discomfort
was
reported. At baseline, patient had evidence of LVH with
repolarization
abnormalities. The ST-segment changes are uninterpretable for
ischemia.
She also had frequent VPBs that decreased with exercise and
returned
during recovery. In addition, isolated ABPs were noted. Baseline
systolic hypertension with an appropriate blood pressure and
heart rate
response to exercise.
IMPRESSION: Fair exercise tolerance. No anginal symptoms with ST
segment
changes that are uninterpretable in the presence of baseline ECG
abnormalities. Echo report sent separately.
ECHOCARDIOGRAM ___
Echocardiographic Measurements
ResultsMeasurementsNormal Range
Left Ventricle - Septal Wall Thickness:
1.0 cm0.6 - 1.1 cm
Left Ventricle - Inferolateral Thickness:
*1.3 cm0.6 - 1.1 cm
Left Ventricle - Diastolic Dimension:
*6.2 cm<= 5.6 cm
Left Ventricle - Ejection Fraction:
40%>= 55%
Left Ventricle - Lateral Peak E':
*0.06 m/s> 0.08 m/s
Left Ventricle - Septal Peak E':
*0.07 m/s> 0.08 m/s
Left Ventricle - Ratio E/E':
*15< 13
Aortic Valve - Peak Velocity:
*2.8 m/sec<= 2.0 m/sec
Aortic Valve - Peak Gradient:
*31 mm Hg< 20 mm Hg
Aortic Valve - Mean Gradient:
20 mm Hg
Aortic Valve - LVOT diam:
2.2 cm
Aortic Valve - Valve Area:
*1.1 cm2>= 3.0 cm2
Mitral Valve - E Wave:1.0 m/sec
Mitral Valve - A Wave:1.1 m/sec
Mitral Valve - E/A ratio:0.91
Findings
This study was compared to the prior study of ___.
LEFT VENTRICLE: Mild symmetric LVH. Moderately dilated LV
cavity. Moderately depressed LVEF. No resting LVOT gradient.
RIGHT VENTRICLE: Normal RV chamber size and free wall motion.
AORTIC VALVE: Moderate AS (area 1.0-1.2cm2) Trace AR.
MITRAL VALVE: Mild to moderate (___) MR.
___: No pericardial effusion.
GENERAL COMMENTS: The patient appears to be in sinus rhythm.
REGIONAL LEFT VENTRICULAR WALL MOTION:
Basal InferoseptalBasal AnteroseptalBasal Anterior
Basal InferiorBasal InferolateralBasal Anterolateral
Mid InferoseptalMid AnteroseptalMid Anterior
Mid InferiorMid InferolateralMid AnterolateralSeptal
ApexAnterior Apex
Inferior ApexLateral ApexApex
N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic
Conclusions
The patient exercised for 8 minutes and 15 seconds according to
a Gervino treadmill protocol ___ METS) reaching a peak heart
rate of 123 bpm and a peak blood pressure of 208/86 mmHg. The
test was stopped because of fatigue. This level of exercise
represents a fair exercise tolerance for age. The exercise ECG
was uninterpretable due to resting ST-T wave changes (see
exercise report for details). There is resting systolic
hypertension. There were normal blood pressure and heart rate
responses to stress.
.
Resting images were acquired at a heart rate of 82 bpm and a
blood pressure of 160/84 mmHg. These demonstrated regional mild
symmetric left ventricular hyptrophy with a mildly dilated
cavity and mild regional systolic dysfunction with hypokinesis
of the basal to mid inferior wall. The remaining segments are
mildly hypokinetic (LVEF = 35 %). There is no pericardial
effusion. Resting E/e' is >=13 suggesting PCWP>18 mmHg. Doppler
demonstrated mild to moderate aortic stenonsis, trace aortic
regurgitation and mild to moderate mitral regurgitation or no
resting LVOT gradient.
Echo images were acquired within 53 seconds after peak stress at
heart rates of 118 - 98 bpm. These demonstrated no new regional
wall motion abnormalities. Baseline abnormalities persist with
appropriate augmentation of other segments.
IMPRESSION: Fair functional exercise capacity. Uninterpretable
ECG changes with resting regional systolic dysfunction (LCx/RCA
territory) without inducible ischemia to achieved workload.
Resting hypertension. Mild to moderate mitral regurgitation at
rest. Mild to moderate aortic stenosis.
Compared with the resting pictures from the prior study (images
reviewed) of ___ the left ventricular cavity is more
dilated, systolic function is slightly less, regional function
is similar, there is more mitral regurgitation, and the aortic
stenosis has progressed.
Brief Hospital Course:
Ms. ___ is a ___ year old woman with history of HLD, HTN,
atypical chest pain, possible TIA's, rheumatic fever with mod AS
and mild-mod MR, decreased LVEF and CAD who presents with
exertional chest pain and was found to have lesions in the RCA
(99%) and LAD (80%), now s/p 3 BMS to the RCA.
# Chest Pain/CAD: Troponins negative x3, with stress ECHO that
showed no new regional wall motion abnormalities and stable,
fixed inferior wall hypokinesis. Cardiac cath showed lesions in
RCA and LCA. At that time 3 BMS placed to RCA, with plan for
medical management vs staged PCI for LAD lesion at the
discretion of her outpatient cardiologist. Bare metal stents
chosen due to history of GI bleed and Ms. ___ preference
to minimize anticoagulation. Discharged on plavix 75mg, aspirin
81mg, atorvastatin 80mg. Will require dual anti-platelet
therapy for minimum 1 month, length of time to be determined by
outpatient cardiologist.
# Reduced systolic function: EF now 35% (down from 40%) on
stress ECHO. Likely ischemic cardiomyopathy given 99% RCA
lesion. She does report symptoms of DOE and lower extremity
edema; however, she does not have any evidence of volume
overload on exam and denies orthopnea. Lisinopril 5mg was
started and Metoprolol succinate 100mg was continued. CAD
addressed as described above.
# HTN: Metoprolol, lisinopril as discussed above.
# GERD/PUD: Remote h/o GIB. Currently, no evidence of bleed and
GI symptoms well-controlled. On nexium at home, given
omeprazole while inpatient due to nexium being non-formulary.
Her PCP was contacted regarding her history of GIB and was
agreeable to dual antiplatelet therapy and PCI.
# CODE: Discussed on admission, with Ms. ___ expressing her
desire to be DNR/DNI (reversed for procedure and subsequent 24
hours)
======================================
TRANSITIONAL ISSUES
======================================
Ms. ___ is a ___ year old woman with history of HLD, HTN,
atypical chest pain, possible TIA's, rheumatic fever with mod AS
and mild-mod MR, decreased LVEF and CAD who presents with
exertional chest pain and was found to have lesions in the RCA
(99%) and LAD (80%), now s/p 3 BMS to the RCA.
-- Unstable Anglina/CAD: LHC ___ with 3 BMS placed to 99%
RCA. 80% LAD lesion was not stented at this time. She received
clopidogrel 600mg prior. Discharged on 75mg plavix and aspirin
81mg daily. Statin changed to atorvastatin 80mg daily.
[ ] Plan for medical management of 80% LAD lesion vs staged PCI
per outpatient cardiologist (___)
[ ] DAPT for minimum 1 month for 3 BMS, duration to be
determined by Dr. ___.
-- Compensated systolic dysfunction due to ischemic
cardiomyopathy:
Stress ECHO shows EF 35%, as well as stable, fixed inferior wall
hypokinesis. No reversible wall motion abnormalities.
-continued metoprolol succinate 100mg daily
-Started lisinopril 5mg daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO DAILY
2. esomeprazole magnesium 40 mg oral daily
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Aspirin 81 mg PO DAILY
6. Restasis (cycloSPORINE) 0.05 % ophthalmic 1 drop once a day
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
4. Clopidogrel 75 mg PO DAILY Duration: 1 Month
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
5. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
6. Esomeprazole Magnesium 40 mg ORAL DAILY
7. Restasis (cycloSPORINE) 0.05 % ophthalmic 1 drop once a day
8. Metoprolol Succinate XL 100 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*21 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of your at ___
___. You were admitted for chest pain. To evaluate
this, a stress test was performed which revealed some
abnormalities concerning for coronary artery disease. A cardiac
catheterization confirmed that obstructive coronary artery
disease was present in 2 places, and bare metal stents were
placed in one obstructed coronary artery to stent it open and
allow blood to flow through. The other area of narrowing will be
medically managed, with the possibility of percutaneous
intervention in the future. This was not done at this time as
it was a smaller lesion and due to limitations on radiation
exposure in a short time period.
Because stents were placed, it will be very important to
continue both the plavix (clopidogrel) 75mg daily and aspirin
81mg daily until instructed otherwise by your cardiologist.
This reduced the risk that the artery will become re-obstructed,
which could lead to a heart attack.
Because the ultrasound of your heart (echocardiogram) showed
decreased left ventricular ejection fraction (the amount of
blood pumped with each heartbeat), we started you on a
medication called Lisinopril that has been shown to be
beneficial for decreased heart squeeze. Please continue to take
your metoprolol, as this has also been shown to be beneficial.
Please follow up closely with your primary care doctor and your
cardiologist within one week. See below for appointment
details.
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10119094-DS-9 | 10,119,094 | 29,995,182 | DS | 9 | 2150-12-09 00:00:00 | 2150-12-27 06:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Erythromycin Base / Flexeril / Plavix
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENTING ILLNESS:
___ yo F, hx of CAD (s/p 3 BMS in ___, HTN, HLD, bipolar
disorder, presents with chest pain. Patient presented to her PCP
the day of admission and described 5 weeks of intermittent
midsternal chest pain, with significant worsening in the last 3
days. Patient first noted the pain about 5 weeks ago when
traveling in ___. It is substernal pressure, associated
with nausea and diaphoresis. Is worse with exertion, improves
with rest. Sometimes improves with nitroglycerin but not always
with 1. Patient often takes 3. She sometimes has similar pains
while lying in bed at night.
At PCP's office today, EKG was done which was found to have new
lateral ST depressions, sent here for cardiac evaluation.
In the ED initial vitals were: T 97.2, HR 60, BP 174/62, 99% RA
EKG: SR, ST depressions I, aVL, V4-5, N axis, N intervals
Labs/studies notable for: Lactate 1.3, K 3.4, Trop <0.01, CK
185,
MB 3
Patient was given: aspirin 324mg, heparin 850u/hr and
pantoprazole
Currently the patient is chest pain free. She denies any cough,
abdominal pain, nausea, vomiting, diarrhea, dysuria, hematuria.
She denies any dark or bloody stools recently. Denies any
history
of stroke.
On ROS, patient additionally endorses a flu-like illness several
weeks ago. Describes fatigue, sore throat, enlarge lymph nodes.
Is worried about lymphoma because has a brother that died of
lymphoma. Says she has one remaining lymph node in her axilla.
REVIEW OF SYSTEMS:
Full review of systems negative except as mentioned in HPI.
Past Medical History:
- Hypertension
- Dyslipidemia on ezetemibe
- Coronary artery disease with BMS to RCA in ___, BMS to
LAD and POBA of D2 in ___. Cath in ___ showed moderate
mid LAD proximal to stent and 50-60% RCA in-stent restenosis.
- Dr. ___ in ___ recently advised her to get another
cath but patient declined
- Last echo described below, normal EF, moderate-severe AS. ___
gradient 0.8-1.0
- Bipolar disorder
- PUD, hx of bleeding ulcer
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: reviewed in ED dash, BP on admission to floor notable for
SBP
192.
GENERAL: Well developed, well nourished woman in NAD. Oriented
x3. Mood, affect appropriate, somewhat tangential but
redirectable.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP of 15 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. Crescendo
decrescendo murmur best heart at RUSB. No rubs, or gallops.
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: Warm, well perfused. 1+ pitting edema to knees. No
clubbing, cyanosis.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS: 24 HR Data (last updated ___ @ 855)
Temp: 98.0 (Tm 98.2), BP: 139/69 (138-177/69-90), HR: 64
(56-79), RR: 18 (___), O2 sat: 95% (95-100), O2 delivery: RA
GENERAL: Well developed, well nourished woman in NAD. Oriented
x3. Mood, affect appropriate, somewhat tangential but
redirectable.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP not elevated
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. ___ systolic
murmur RUSB.
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: Warm, well perfused. 1+ pitting edema to lower
shins. No clubbing, cyanosis.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
Pertinent Results:
ADMISSION LABS
==============
___ 02:18PM BLOOD WBC-9.3 RBC-3.98 Hgb-12.2 Hct-37.0 MCV-93
MCH-30.7 MCHC-33.0 RDW-13.8 RDWSD-46.4* Plt ___
___ 02:18PM BLOOD Neuts-47.6 ___ Monos-9.3 Eos-0.6*
Baso-0.3 Im ___ AbsNeut-4.43 AbsLymp-3.91* AbsMono-0.87*
AbsEos-0.06 AbsBaso-0.03
___ 02:18PM BLOOD Glucose-85 UreaN-17 Creat-1.1 Na-138
K-4.7 Cl-98 HCO3-28 AnGap-12
___ 02:18PM BLOOD CK(CPK)-185
___ 02:18PM BLOOD CK-MB-3
___ 02:18PM BLOOD cTropnT-<0.01
___ 02:55PM BLOOD Lactate-1.3 K-3.4
OTHER PERTINENT LABS
====================
___ 09:25PM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS
==============
___ 07:30AM BLOOD WBC-8.2 RBC-3.71* Hgb-11.2 Hct-35.1
MCV-95 MCH-30.2 MCHC-31.9* RDW-14.1 RDWSD-48.7* Plt ___
___ 07:30AM BLOOD Glucose-89 UreaN-21* Creat-1.1 Na-140
K-4.8 Cl-102 HCO3-27 AnGap-11
___ 07:30AM BLOOD Calcium-9.7 Phos-3.4 Mg-1.9
Imaging/studies:
=============
Exercise ECG stress ___:
IMPRESSION: Fair exercise tolerance for age. Atypical symptoms
reported
at peak exercise in the setting of diffuse ST segment changes
that are
uninterpretable for ischemia in the presence of baseline LVH and
repolarization abnomalities. Resting systolic blood pressure
with an
increase in systolic blood pressure noted with exercise. Peak
exercise
heart rate was somewhat blunted in the presence of beta blocker
therapy.
Brief Hospital Course:
___, hx of CAD (s/p 3 BMS in ___, moderate to severe AS, HTN,
HLD, bipolar disorder, presents with worsening chest pain for
the last 5 weeks. Negative trops x2, EKG with repolarization
abnormalities in the setting of HTN and LVH.
====================
ACTIVE/ACUTE ISSUES:
====================
# Chest pain
# CAD s/p BMS
Chest pain likely secondary to hypertension on admission, with
negative troponin x2, and EKG changes similar to prior with
likely repolarization abnormality in setting of HTN. On
admission, patient was hypertensive to 190s but exam
unremarkable except for ___ systolic murmur over RUSB. Exercise
ECG and pMIBI stress were unremarkable. Continued medical
management of CAD with ASA 81mg, atorvastatin 40mg, and
metoprolol tartrate 25mg TID as well as BP control, as outlined
below.
# Hypertension
Presented with SBP 190s. BPs were initially controlled on
admission with hydralazine 10mg PRN. Restarted home lisinopril
40 mg tablet daily and home metoprolol as above. Started
chlorthalidone 25mg daily, in place of HCTZ, with plan to check
electrolytes as outpatient.
# Hyperlipidemia
Previously taking atorvastatin 20mg. Increased to 40mg QHS
during admission. Continued home ezetimibe 10mg daily.
# Aortic Stenosis
Patient with moderate to severe AS with area 1cm. Continued to
treat HTN as above and will need close follow-up with a repeat
echo as an outpatient.
======================
CHRONIC/STABLE ISSUES:
======================
# Bipolar Disorder (per chart)
Currently not on any treatment. Denied hallucination, delusion,
SI. Tangential in thought process. Consideration of outpatient
psychiatry referral, although patient has previously refused.
# Axillar lymph node
Patient endorsed lymph node in axilla. Encouraged f/u as
outpatient
====================
TRANSITIONAL ISSUES:
====================
- discharge creatinine 1.1
MEDICATION CHANGES:
[] increased atorvastatin to 40mg daily
[] started chlorthalidone 25mg daily
[] stopped hydrochlorothiazide 12.5mg
[] CHEST PAIN: if recurrent symptoms, consider re-evaluation of
her aortic stenosis once blood pressure control has been
optimized
[] HTN: closely monitor BP with titration of medications to
obtain normotension
[] LABS: will need repeat Chem10 within one week to ensure
stable renal function/electrolytes
[] BIPOLAR DISORDER: recommend outpatient neuropsychiatric
evaluation if patient amenable
[] AXILLARY LN: follow-up enlarged lymph node as outpatient to
ensure resolution
===============================
# CODE STATUS: Full
# CONTACT: ___
___ on Admission:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
4. Lisinopril 40 mg PO DAILY
5. Esomeprazole Magnesium 40 mg ORAL DAILY
6. Restasis (cycloSPORINE) 0.05 % ophthalmic 1 drop once a day
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Hydrochlorothiazide 12.5 mg PO DAILY
9. Ezetimibe 10 mg PO DAILY
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Chlorthalidone 25 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Esomeprazole Magnesium 40 mg ORAL DAILY
5. Ezetimibe 10 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Lisinopril 40 mg PO DAILY
8. Metoprolol Succinate XL 75 mg PO DAILY
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Restasis (cycloSPORINE) 0.05 % ophthalmic 1 drop once a day
11. TraZODone 50 mg PO QHS:PRN insomnia
12.Outpatient Lab Work
Please obtain Chem10 within one week and fax results to
___
Discharge Disposition:
Home
Discharge Diagnosis:
==================
PRIMARY DIAGNOSES:
==================
Chest pain coronary artery disease status post bare-metal stent
hypertension
Hyperlipidemia
Aortic Stenosis
====================
SECONDARY DIAGNOSES:
====================
Bipolar disorder
Axillary lymph node -unspecified
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
WHY WAS I IN THE HOSPITAL?
==========================
- You were admitted because you had chest pain
WHAT HAPPENED IN THE HOSPITAL?
==============================
- You had an EKG and blood tests which were negative for a heart
attack.
- You underwent a stress test to see if your pain was related to
blocked arteries in your heart. Because this was negative, we
think your pain was likely due to your aortic stenosis.
- You were given medications to prevent further symptoms.
WHAT SHOULD I DO WHEN I GO HOME?
================================
- It is important you arrange follow-up with your PCP within one
week
- You also need to arrange follow-up with your cardiologist next
week
- It is important you continue to take all your medications as
prescribed
It was a pleasure taking care of you!
Your ___ Healthcare Team
MEDICATION CHANGES:
[] increased atorvastatin to 40mg daily
[] started chlorthalidone 25mg daily
[] stopped hydrochlorothiazide 12.5mg daily
Followup Instructions:
___
|
10119234-DS-6 | 10,119,234 | 22,784,276 | DS | 6 | 2133-08-24 00:00:00 | 2133-09-04 14:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
DISCHARGE EXAM:
GENERAL: Alert and in no apparent distress, speaking full
sentences
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: intermittent coughing, otherwise CTAB, fair air movement
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs, sensation to light touch grossly
intact throughout
PSYCH: pleasant, appropriate affect
PERTINENT LABS:
___ 06:05PM BLOOD WBC-20.1* RBC-4.31* Hgb-11.8* Hct-36.5*
MCV-85 MCH-27.4 MCHC-32.3 RDW-13.8 RDWSD-42.8 Plt ___
___ 06:05PM BLOOD Glucose-95 UreaN-18 Creat-0.8 Na-135
K-4.0 Cl-99 HCO3-22 AnGap-14
___ 06:05PM BLOOD cTropnT-<0.01
___ 09:00PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 10:11 am SPUTUM
Source: Expectorated.
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND
CLUSTERS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
RESPIRATORY CULTURE (Final ___: MODERATE GROWTH Commensal
Respiratory Flora.
CT chest w/o contrast
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: Visualized thyroid
appears
unremarkable. There is no axillary or supraclavicular
lymphadenopathy.
Evaluation of the base of the neck and right shoulder is limited
by right
shoulder hemiarthroplasty.
UPPER ABDOMEN: Visualized portion of the abdomen appears
unremarkable.
MEDIASTINUM: A 0.9 cm subcarinal lymph node may be reactive.
Prominent 0.9 cm AP window lymph nodes are also likely reactive.
HILA: Evaluation for hilar lymphadenopathy is limited on this
noncontrast
scan.
HEART and PERICARDIUM: The heart is not enlarged. Trace
pericardial fluid is likely physiologic. Moderate coronary
artery and mild aortic valve
calcifications are seen. PLEURA: There is a trace left pleural
effusion. No right pleural effusion. No pneumothorax.
LUNG:
1. PARENCHYMA: There are severe bilateral centrilobular
emphysema most
notable in the upper lobes. There is dense consolidation of the
left upper lobe concerning for lobar pneumonia. There are also
opacities in the apical left lower lobe concerning for infection
(2; 27).
2. AIRWAYS: The airways are patent to the subsegmental level
bilaterally.
3. VESSELS: The aorta and pulmonary arteries are normal in
caliber. There is moderate atherosclerotic calcification in the
aortic arch.
CHEST CAGE: Patient is status post right shoulder
hemiarthroplasty.No
suspicious osseous lesion is identified.
IMPRESSION:
1. Interval left upper lobe consolidation and opacities in the
apical segment of the left lower lobe, concerning for infection
given localized appearance rather than vaping related lung
injury which typically demonstrates a diffuse pattern. Follow
up chest CT 8 weeks after treatment for pneumonia is
recommended.
2. Severe bilateral upper lobe centrilobular emphysema.
Brief Hospital Course:
___ yo M PMHx COPD (not on home oxygen), HTN who presented with
malaise and cough, found to have sepsis (tachycardia, elevated
WBC) ___ CAP. He was treated with IV transitioned to PO
antibiotics at discharge.
# Sepsis
# CAP
# history of vaping ___ products:
Patient presented with signs of sepsis. A CT chest was obtained
which showed pneumonia. He was started on IV antibiotics with
improvement. At the time of discharge, his sputum culture was
growing gram positive cocci in pairs and clusters so he was
discharged on clindamycin to cover for possible MRSA (pending
final sputum cx results) and levofloxacin. He would benefit
from a repeat CT chest in ___ weeks to ensure resolution of
pneumonia. Given the patient's history of vaping, there was
initially some concern for a vaping-related component, however,
overall clinical presentation and CT scan more consistent with
CAP. He was counseled on vaping cessation.
# HTN: continued home lisinopril
# CV: continued home atorvastatin, aspirin
TRANSITIONAL ISSUES:
[] Repeat CT chest in 8w to ensure resolution of pneumonia
> 30 min spent in discharge planning and counseling
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin EC 81 mg PO QHS
2. Atorvastatin 10 mg PO QPM
3. Lisinopril 10 mg PO QHS
Discharge Medications:
1. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg 1 capsule(s) by mouth TID PRN Disp #*30
Capsule Refills:*0
2. Clindamycin 600 mg PO/NG Q8H
RX *clindamycin HCl 300 mg 2 capsule(s) by mouth three times a
day Disp #*30 Capsule Refills:*0
3. LevoFLOXacin 500 mg PO DAILY
RX *levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
4. Aspirin EC 81 mg PO QHS
5. Atorvastatin 10 mg PO QPM
6. Lisinopril 10 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Community acquired pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You came to the hospital with coughing and an abnormal X-ray.
You were diagnosed with pneumonia. You were treated with
intravenous antibiotics and improved. At discharge, you are
being switched to the pill form of the antibiotics. Please
continue to take these antibiotics through ___.
While you were in the hospital you underwent a CT scan which
showed pneumonia and emphysema. You should have another CT scan
in 8 weeks to ensure the pneumonia has completely cleared up.
This can be arranged with your primary care doctor.
Please follow-up with your primary care doctor within 7 days.
We wish you the best in your recovery!
-- Your ___ medical team
Followup Instructions:
___
|
10119391-DS-29 | 10,119,391 | 28,577,408 | DS | 29 | 2196-12-11 00:00:00 | 2197-01-12 10:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toprol XL / Univasc / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Fall, UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH bipolar disorder on lithium, tardive dyskinesia,
CVA, h/o falls who presented from home after an unwitnessed
fall.
Mz. ___ has a history of falls and reports feeling dizzy
after trying to get out of bed this am. She tried to break her
fall with her bed but ended up on the floor. She denies losing
consciousness, chest pain, sweating/tachycardia before. She did
not have any bowel movements before or after fall. She was
found
by her family who brought her to ED. She has no h/o seizure nor
syncope.
According to notes patient had an unwitnessed fall at home on
the
ground for an unknown period of time she denies head strike but
she has baseline dementia. She is only complaining of right
forearm pain. According to reports she was then later found by
her son who found her on the ground. She states she was also
dizzy which caused her to fall.
Of note, family reports she often has worsening confusion and
balance issues when she has UTIs. Only recent medication change
has been trial of decreased lithium dose to 150mg once daily
with
addition of Seroquel and clonazepam BID. This lithium dose was
increased back to 150mg BID to start ___ per outpatient
psychiatry due to unclear reason per daughter (there was "an
issue" perhaps better known to her other sister).
In the ED, initial vitals were: T: 97.9 HR: 70 BP: 100/64
RR:
18 SO2: 100% RA
- Exam notable for: Regular rate and rhythm, moving all
extremities, no tenderness to palpation over the midline.
- Labs notable for: Hgb: 10.0 (baseline ___, BUN: 26, crt 0.7
CK: 652 Lithium: 0.4 ___: <0.01 UA: Appear Hazy Leuk Lg
Nitr Pos WBC 97 Bact Few
- Imaging was notable for: CT head without acute process. CT
___ with no evidence of fracture or prevertebral swelling of
the cervical
- Patient was given:
___ 13:44 IV LORazepam .5 mg ___
___ 14:23 IM Haloperidol 5 mg ___
___ 15:02 IM Haloperidol 5 mg ___
___ 16:00 IV CefTRIAXone ___ Started
___ 16:18 IV LORazepam .5 mg ___
___ 16:30 IV CefTRIAXone 1 g ___ Stopped
(___)
- ED Resident on call unable to confirm why patient was agitated
and placed in restraints these were removed by 19:00 when ED
resident assumed care.
Upon arrival to the floor, patient confirms history as above
denies any pain or current dizziness, requested water.
Past Medical History:
# Bipolar D/O
# Tardive dyskinesia
# Hypothyroidism
# DM2
# s/p CVA
# h/o C1 fracture/cervical spondolysis
# recurrent UTI
# HyperPTH
# Nephrogenic DI
# Vit B12 deficiency
# Anemia
# OA
# Osteoporosis
# Urinary incontinence
# Constipation
.
Social History:
___
Family History:
Mother - died from MI in ___
Father - died from MI in ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITAL SIGNS: 98.3 PO 107 / 58 67 18 98 2L
GENERAL: Elderly woman, no apparent distress pressured speech,
tangential, macroglossia/edentulous
HEENT: NCAT, JVP flat, moist mucosa, macroglossia
CARDIAC: RRR, ___ SEM ___ no rubs nor gallops
LUNGS: CTAB, no distress
ABDOMEN: soft ___
EXTREMITIES: warm, well perfused, trace edema upper and lower
extremities
NEUROLOGIC: ___ intact, oriented to self not palce nor year,
tremulous without asterixiis
SKIN: +axillary sweat, scattered bruises
LYMPH: Left axillary node chronic per outpatient records
DISCHARGE PHYSICAL EXAM
=======================
VS: BP 143/87 HR 90 RR 20 O2 sat 100% RA
GENERAL: Elderly woman, no apparent distress,
macroglossia/edentulous
HEENT: L eye anisocoria, oval shaped pupil. NCAT, JVP flat,
moist mucosa, macroglossia
CARDIAC: RRR, ___ SEM ___ no rubs nor gallops
LUNGS: CTAB, no distress
ABDOMEN: soft ___
EXTREMITIES: B/L knee deformities c/w OA, WWP, trace edema upper
and lower extremities
LYMPH: Left axillary node chronic per outpatient records
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD ___
___ Plt ___
___ 01:00PM BLOOD ___
___ Im ___
___
___ 01:00PM BLOOD ___ ___
___ 01:00PM BLOOD Plt ___
___ 01:00PM BLOOD ___
___
___ 01:00PM BLOOD ___ CK(CPK)-652* ___
___
___ 01:00PM BLOOD ___
___ 01:00PM BLOOD cTropnT-<0.01
___ 01:00PM BLOOD ___
___ 01:00PM BLOOD ___
INTERIM LABS:
___ 06:53AM BLOOD ___
___ 01:00PM URINE ___ Sp ___
___ 01:00PM URINE ___
___
___ 01:00PM URINE ___
___
___ 01:00PM URINE ___
MICROBIOLOGY:
___ 1:00 pm URINE SOURCE: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
DISCHARGE LABS:
___ 01:20PM BLOOD ___
___ Plt ___
___ 01:20PM BLOOD Plt ___
___ 01:20PM BLOOD ___
___
___ 01:20PM BLOOD ___
Brief Hospital Course:
SUMMARY
=======
___ w/ PMH bipolar disorder on lithium, tardive dyskinesia, CVA,
h/o falls who presented from home after an unwitnessed fall,
found to have fluctuating mental status and UTI. Negative CT
Head. ___ cx grew E. coli ___. Originally treated with
CTX transitioned to cefpodoxime on discharge with plans to
complete 7d course. The patient improved over the next two days
with mental status returning to baseline. ___ saw her and felt
safe for her to go home with home ___ and ___.
ACUTE ISSUES
============
# S/p FALL: She presented with an unwitnessed fall, likely
mechanical fall vs
orthostasis vs confusion from UTI. Per daughter, pt routinely
falls when confused with UTI. There was low suspicion for
cardiac
etiologies or PE given history and stable vital signs. She
refused orthostatics and telemetry. CT head and neck without
acute issues. No events on
tele overnight. She was discharged to home with ___ following ___
visits.
# UTI: multiple UTIs in past, most recently E. coli sensitive to
CTX. UA with nitrite positive ___. She was transitioned from
ceftriaxone to cefpodoxime 200mg BID set to end ___.
CHRONIC ISSUES
==============
# BPD: continued on home lithium, seroquel, clonazepam.
Regarding
lithium will continue at anticipated full dose given no ___ or
obvious overt toxicity. Lithium level was 0.4 during admission.
- continue home lithium, seroquel, clonazepam
- transitional issue: ___ dosing with Dr. ___
# h/o CVA: no deficits at baseline, continue home aspirin 25
___ 200 mg
# h/o hypothyroid: cont home levothyroxine 50mcg
# h/o anemia: macrocytic at baseline no evidence of active bleed
-cont home B12
TRANSITIONAL ISSUES:
=======================
MEDICATIONS:
- New Meds: Cefpodoxime (7d course ___
- Stopped/Changed Meds: None
___
- Follow up: PCP
- ___ required after discharge: None
- Incidental findings:
1) CT C spine with severe multilevel degenerative changes
2) CXR with chronic degenerative disease at both shoulders again
noted
with resorptive changes at the humeral head
# CODE: full (confirmed)
# CONTACT: ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 0.5 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Lithium Carbonate 150 mg PO BID
4. Omeprazole 20 mg PO DAILY
5. Polyethylene Glycol 17 g PO DAILY
6. QUEtiapine Fumarate 50 mg PO QHS
7. Simvastatin 20 mg PO QPM
8. Cyanocobalamin ___ mcg PO DAILY
9. Pyridoxine 100 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
Last dose in the evening on ___
RX *cefpodoxime 100 mg 1 tablet(s) by mouth q12 Disp #*8 Tablet
Refills:*0
2. ClonazePAM 0.5 mg PO DAILY
3. Cyanocobalamin ___ mcg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Lithium Carbonate 150 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY
8. Pyridoxine 100 mg PO DAILY
9. QUEtiapine Fumarate 50 mg PO QHS
10. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Urinary tract infection
# ___ fall
# Toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear ___,
You came to ___ because you had a fall at home. You were found
to have urinary tract infection. Please see more details listed
below about what happened while you were in the hospital and
your instructions for what to do after leaving the hospital.
It was a pleasure participating in your care. We wish you the
best!
Sincerely,
Your ___ Care Team
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL:
- You had a head and spine scan which showed no fracture
- You had a urine culture which showed an infection
- You were treated with antibiotics
- You improved considerably and were ready to leave the hospital
WHAT SHOULD YOU DO WHEN YOU LEAVE THE HOSPITAL:
- Please follow up with your primary care doctor and other
health care providers (see below)
- Please take all of your medications as prescribed (see below).
- Seek medical attention if you have confusion, dizziness, or
other symptoms of concern.
Followup Instructions:
___
|
10119391-DS-34 | 10,119,391 | 24,883,591 | DS | 34 | 2198-03-30 00:00:00 | 2198-03-31 16:02:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toprol XL / Univasc / Sulfa (Sulfonamide Antibiotics) /
nitrofurantoin
Attending: ___.
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o dementia, bipolar disorder, T2DM, hypothyroidism,
CVA, and recurrent UTIs presents to the ED with c/o worsening
mental status and tardive dyskinesia which is characteristic for
when she has an infection. The daughters at bedside state that
she has had worsening symptoms for several weeks. She was
diagnosed with a UTI and put on Linezolid, however they felt
that this medicine made her more agitated and she was not
sleeping well. Despite working with her PCP and therapist and
increasing her nighttime Seroquel, the patient continued to be
increasingly altered so they brought her to the emergency
department for further evaluation. The patient is a very poor
historian but
answers "yes" when asked about chest or abdominal pain.
In the ED:
Initial vital signs were notable for: 99.3 85 135/74 16 94% RA
Exam notable for:
- Appears frail, oral tardive dyskinesia
Labs were notable for: Hgb 9.2, Cl 112, BUN 32, Cr 1.0
Studies performed include:
U/A: Many WBCs, nitrite positive
CXR: No acute cardiopulmonary abnormality. Hiatal hernia.
EKG: NSR @ 76, normal axis, normal intervals, TWI in III
(unchanged from ___
Patient was given: Clonazepam 0.5mg x3, Lithium 150mg,
Quetiapine
75mg, Simvastatin 20mg, Linezolid ___, Pyridoxine 100mg,
omeprazole 20mg, IVF
Consults: None
Vitals on transfer: 99.6 75 117/52 22 98% RA
Upon arrival to the floor, patient with severe tardive
dyskinesia
and mostly unable to answer questions.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
Schizoaffective disorder, bipolar type
Hypothyroidism
Type 2 diabetes
Tardive dyskinesia
Recurrent UTIs
Recurrent falls of unclear etiology
Status post CVA
History of C1 fracture/cervical spondylolysis
Vitamin B12 deficiency
Anemia
Osteoarthritis
Osteoporosis
Constipation
Seizures - undetermined type, with aura, ?every month
Social History:
___
Family History:
Mother - died from MI in ___
Father - died from MI in ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 98.7 149 / 76 80 18 95 RA
GENERAL: Uncomfortable, unintentionally moving extremities and
face, Unable to answer questions
HEENT: Face and tongue with uncontrolled fasciculations
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Anterior lung fields clear to auscultation bilaterally.
No
wheezes, rhonchi or rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash.
NEUROLOGIC: Unable to assess CNs or orientation. Moving all
extremities.
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 1203)
Temp: 98.9 (Tm 98.9), BP: 108/68 (108-129/58-69), HR: 84
(78-84), RR: 24 (___), O2 sat: 95% (92-99), O2 delivery: Ra
GENERAL: Dressed in clothes, ready to go home, unintentionally
moving extremities and face stable from yesterday, decreased
from
admiossion.
HEENT: Face and tongue with uncontrolled fasciculations,
surgical
pupil left eye
NECK: No JVD.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Anterior lung fields clear to auscultation bilaterally.
No
wheezes, rhonchi or rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: No clubbing, cyanosis, or edema.
SKIN: Warm. No rash. Scattered ecchymosis, worst on inner arm
NEUROLOGIC: Unable to assess CNs. Able to move all 4
extremities,
___ strength, equal in 4 extremities
Pertinent Results:
ADMISSION LABS
===============
___ 09:17PM BLOOD WBC-8.0 RBC-3.04* Hgb-9.7* Hct-31.8*
MCV-105* MCH-31.9 MCHC-30.5* RDW-15.5 RDWSD-59.1* Plt ___
___ 09:17PM BLOOD Neuts-83.9* Lymphs-8.9* Monos-6.6
Eos-0.0* Baso-0.3 Im ___ AbsNeut-6.72* AbsLymp-0.71*
AbsMono-0.53 AbsEos-0.00* AbsBaso-0.02
___ 09:17PM BLOOD Glucose-103* UreaN-38* Creat-1.2* Na-145
K-4.4 Cl-110* HCO3-23 AnGap-12
___ 10:00PM URINE RBC-50* WBC->182* Bacteri-MANY*
Yeast-NONE Epi-0
___ 10:00PM URINE Blood-SM* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 10:00PM URINE WBC Clm-MANY*
INTERVAL LABS
==============
___ 05:44AM BLOOD Hypochr-NORMAL Anisocy-OCCASIONAL
Poiklo-OCCASIONAL Macrocy-1+* Microcy-NORMAL Polychr-NORMAL
Ovalocy-OCCASIONAL Burr-OCCASIONAL
___ 05:44AM BLOOD Ret Aut-0.8 Abs Ret-0.02
___ 05:44AM BLOOD ___ 05:59AM BLOOD Hypochr-NORMAL Anisocy-2+* Poiklo-1+*
Macrocy-2+* Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-1+*
Bite-OCCASIONAL
___ 05:44AM BLOOD calTIBC-213* ___ Folate-7
Hapto-<10* Ferritn-153* TRF-164*
___ 07:49AM BLOOD TSH-0.36
___ 10:47AM BLOOD Lithium-0.4*
___ 05:44AM BLOOD HEPARIN DEPENDENT ANTIBODIES-TEST
___ 09:17PM BLOOD Plt ___
___ 08:35AM BLOOD Plt ___
___ 10:47AM BLOOD Plt ___
___ 07:49AM BLOOD Plt ___
___ 05:48AM BLOOD Plt ___
___ 05:55AM BLOOD Plt ___
___ 05:58AM BLOOD Plt ___
___ 05:44AM BLOOD Plt ___
___ 05:59AM BLOOD Plt ___
___ 10:15AM BLOOD Plt ___
___ 05:48AM BLOOD Osmolal-326*
___ 02:11PM URINE Hours-RANDOM UreaN-508 Creat-56 Na-45
K-18 TotProt-19 Prot/Cr-0.3*
___ 02:11PM URINE Osmolal-351
___ 10:00PM URINE Blood-SM* Nitrite-POS* Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 10:00PM URINE RBC-50* WBC->182* Bacteri-MANY*
Yeast-NONE Epi-0
DISCHARGE LABS
==============
___ 10:15AM BLOOD WBC-7.0 RBC-2.50* Hgb-7.9* Hct-26.1*
MCV-104* MCH-31.6 MCHC-30.3* RDW-15.2 RDWSD-58.0* Plt ___
___ 10:15AM BLOOD Glucose-133* UreaN-23* Creat-0.7 Na-143
K-4.7 Cl-109* HCO3-24 AnGap-10
___ 10:15AM BLOOD Calcium-9.4 Phos-2.5* Mg-2.2
MICRO
======
__________________________________________________________
___ 2:11 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 11:32 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 10:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL.
Identification and susceptibility testing performed on
culture #
___ COLLECTED ON ___.
__________________________________________________________
___ 9:17 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 8:46 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:10 pm URINE
**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------------ 8 S
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING/STUDIES
===============
CXR ___
FINDINGS:
Chronic elevation of the right hemidiaphragm. No focal
consolidations. No
pulmonary edema. Unchanged appearance of the cardiomediastinal
silhouette.
No pleural effusion. No pneumothorax. Note is made of a
moderate hiatal
hernia.
IMPRESSION:
No acute cardiopulmonary abnormality. Hiatal hernia.
CXR ___:
Lungs are low volume. There is persistent subsegmental
atelectasis in the
left lung base the retrocardiac a opacity in the left paraspinal
region
corresponds to the hiatus hernia. Lungs are clear. There are
extensive
degenerative changes involving the left shoulder joint with near
complete
resorption of the left humeral head. There also extensive
degenerative
changes involving the right shoulder joint. Cardiomediastinal
silhouette is
stable. No pneumothorax is seen
HEAD CT W/O CONTRAST ___:
Severely limited study with significant patient motion despite
repeat attempts
at imaging. Within this limitation, there is no large
intracranial
hemorrhage. However cannot exclude small peripheral
intracranial hemorrhage
based on the limitations.
Brief Hospital Course:
PATIENT SUMMARY
================
___ with PMHx of dementia, schizoaffective disorder (bipolar
type) on chronic lithium, tardive dyskinesia (thought due to
olanzapine, stelazine), T2DM, hypothyroidism, and recurrent UTIs
presents to the ED with worsening confusion and tardive
dyskinesia likely due to UTI, course complicated by fall and
hypernatremia in the setting of likely nephrogenic diabetes
insipidus.
ACUTE ISSUES:
=============
# Toxic metabolic encephalopathy
# Dementia with delirium
# Tardive dyskinesia
Patient presented with worsening of oropharyngeal movements as
well as acute encephalopathy. NCHCT was negative for large bleed
on admission and later during the hospitalization, although both
were limited by her tardive dyskinesia. The etiology of her
worsening encephalopathy is likely due to underlying infection.
She had started empiric linezolid as an outpatient for a UTI in
the setting of recent MDR enterococcus UTI. Urine cultures grew
out E coli only resistant to cipro, so her antibiotics were
narrowed to ceftriaxone then augmentin, and her movements and
encephalopathy gradually improved to her baseline. Her
medications were initially converted to IV (clonazepam converted
to lorazepam) due to her significant oropharyngeal movements and
concern that she could not take PO. However with input from
family and speech and swallow, she was able to take PO
medications crushed in applesauce despite her significant TD. In
discussion with her outpatient psychiatrist Dr. ___
consult psychiatry, she was given an additional mid-day dose of
clonazepam to help with her TD, and occasional additional doses
of quetiapine to help with anxiety.
# Fever
# E coli UTI
Urine from ___ outpatient urine culture growing E coli only
resistant to cipro. She had ___ empirically started on linezolid
given history of enterococcus UTI only sensitive to linezolid
from ___ hospitalization, however switched this ___ to
ceftriaxone for a 10 day course. This was switched to augmentin
on ___ due to concern for ceftriaxone-induced
thrombocytopenia. She will complete her 10 day course on ___.
She spiked a fever to 100.8 on ___, but then was afebrile for
the rest of her hospital course.
# Acute Hypernatremia
# Partial nephrogenic diabetic insipidus
Acute hypernatremia to 159 on ___. This is likely due to
decreased access to free water and underlying partial
nephrogenic diabetes insipidus in the setting of chronic lithium
use. Per family, she drinks fluids constantly at home while
independent yet supervised ___ by family, and therefore likely
can compensate for her nephrogenic DI at home. During this
hospitalization she had decreased access to free water due to
worsened TD, making her unable to vocalize her thirst, position
herself to safely drink, and reach for water. Nephrology was
consulted this hospitalization and agreed that she likely has
partial nephrogenic diabetes insipidus, but that normally is
able to compensate appropriately.
# Fall
On ___, patient found half out of bed, as she had accidentally
maneuvered between rails of low bed, with her head on ground (on
mats set up by bed) with legs still in bed. Neuro exam remained
nonfocal, and Non-contrast head CT was negative for large bleed,
although limited due to TD and motion artifacts. Seizure side
bed pads were installed on the low bed with bed alarm and mats
by the sides of the bed. On ___, she again slid out of low bed
feet first on to mat, found sitting on ground when bed alarm
went off. She denied any pain. Seizure pads were not on bed at
the time. Family was made aware of both incidents, and have
discussed at length necessary precautions to ensure she is safe
at home when she returns. ___ had recommended rehab, but it was
thought by the family and medical team that the patient would
best succeed at home with ___ care. ___ worked with the family
on day of discharge to reinforce safe transfers and minimization
of risks while at home.
# ___:
Her baseline Creatinine appears to be 0.7. She presented with Cr
of 1.2, likely pre-renal in the setting of poor PO intake due to
increased TD symptoms and UTI as above. Her Cr improved
throughout the hospitalization and she received intermittent
IVF.
# Macrocytic Anemia:
On recent admission in ___ B12 and folate wnl. Denies
alcohol use and no signs of liver disease. Ferritin elevated, so
likely has element of anemia of chronic disease, but this does
not explain macrocytosis. PPIs can decrease absorption of B12,
which
was normal on last admission, but unclear when she started this
medication. Nadir of HgB at 7.9 on ___, and smear with
Anisocytes, poiklocytes, Macrocytes, Ovalocytes, and Burr cells.
Low suspicion for hemolysis in absence of schistocytes or
rituclocytosis and with normal Tbili. Since her HgB began to
recover, did not ask hematology to review her smear. She had
significant number of blood draws for monitoring hypernatremia,
so this likely contributed to the downtrend in her Hgb.
# Thrombocytopenia
Developed over 4 days during this admission, nadir to 108 on
___. 4t score ___, but HIT antibody negative. Other possible
etiology is ceftriaxone-induced, so her antibiotics were
switched on ___, and her thrombocytopenia improved and was
within normal limits on day of discharge.
# Oropharyngeal dysphagia
# Hypogylcemia
# Concern for malnutrition
Hypoglycemic ___ (not on insulin) in setting of poor PO
intake. Speech and swallow was consulted, and recommended
liquidized pureed solids/nectar thick liquids with medications
crushed. Despite these measures, the patient remains at risk for
choking and silent aspiration. These risks were discussed at
length with daughter/HCP on ___. The family will attempt to
adhere to SLP-recommended texture restrictions and will begin
crushing medications in applesauce. Some of her medications were
switched to formulations that can be crushed. Her HCP ___
recognizes, acknowledges, and accepts the risk of aspiration
despite these precautions, and confirmed that a feeding tube is
not within the patient's GOC.
# Goals of care
As above, spoke with daughter, patient, and son ___ about goals
of care after hospitalization. Although ___ recommends rehab, the
goal is to get the patient home, where her daughter ___ (HCP)
cares for her ___. She is close to her baseline with respect to
her movements, and will likely do better at home with family
where she has ___ care than in rehab where she will likely
still have free water access problems. Feeding tube was
discussed as above, and was not within the patient's goals of
care. Code status was discussed with ___, and the patient
remains full code.
CHRONIC ISSUES:
===================
# Schizoaffective disorder, bipolar type:
Patient is followed by Dr. ___ as an outpatient, and she
has been maintained on lithium with a recent decrease in her
dose. Her level was 0.8 on ___. In discussion with Dr.
___ was maintained on her current dose of lithium.
There is suspicion for lithium-induced nephrogenic diabetes as
above, however the patient appears to be able to compensate for
this with water intake as above.
# Prior CVA, with late effects: continued home
aspirin-dipyridamole.
# Hypothyroidism: continued home levothyroxine (IV when couldn't
take PO)
# Hyperlipidemia: simvastatin continued
# GERD: continued home omeprazole, although noted that this can
decrease the absorption of B12 and contributing to her
macrocytic anemia.
TRANSITIONAL ISSUES
===================
[] Patient should have access to free water at home to prevent
hypernatremia due to nephrogenic diabetes insipidus.
[] Patient is at high risk to fall, especially in the setting of
weakness after hospitalization and incomplete resolution of her
tardive dyskinesia. Risks should be minimized at home to prevent
falls.
[] For UTI, patient will finish antibiotic course of
Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H on ___
# CODE STATUS: Full (confirmed)
# CONTACT: daughter ___, ___
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. Cyanocobalamin ___ mcg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Omeprazole 20 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY
5. Pyridoxine 100 mg PO DAILY
6. Simvastatin 20 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. aspirin-dipyridamole ___ mg oral BID
9. Linezolid ___ mg PO Q12H
10. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
11. Lithium Carbonate 150 mg PO QHS
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
13. Docusate Sodium 100 mg PO BID
14. Senna 8.6 mg PO BID:PRN Constipation
15. ClonazePAM 0.25 mg PO AM
16. ClonazePAM 0.5 mg PO QHS
17. QUEtiapine Fumarate 100 mg PO QHS
18. ClonazePAM 0.25 mg PO AFTERNOON:PRN agitation
19. QUEtiapine Fumarate 25 mg PO DAILY PRN paranoia
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 4 Days
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*5 Tablet Refills:*0
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
5. aspirin-dipyridamole ___ mg oral BID
6. ClonazePAM 0.25 mg PO AM
7. ClonazePAM 0.5 mg PO QHS
8. ClonazePAM 0.25 mg PO AFTERNOON:PRN agitation
9. Cyanocobalamin ___ mcg PO DAILY
10. Docusate Sodium 100 mg PO BID
11. Levothyroxine Sodium 50 mcg PO DAILY
12. Lithium Carbonate 150 mg PO QHS
13. Omeprazole 20 mg PO BID
14. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
15. Polyethylene Glycol 17 g PO DAILY
16. Pyridoxine 100 mg PO DAILY
17. QUEtiapine Fumarate 100 mg PO QHS
18. QUEtiapine Fumarate 25 mg PO DAILY PRN paranoia
19. Senna 8.6 mg PO BID:PRN Constipation
20. Simvastatin 20 mg PO DAILY
21. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
================
E coli urinary tract infection
SECONDARY DIAGNOSES
====================
Toxic metabolic encephalopathy
Tardive dyskinesia
Nephrogenic diabetes insipidus
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 privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- Your mouth movements (tardive dyskinesia) were getting worse,
and you were confused.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- Your urine cultures grew out E coli, so your antibiotic was
changed to one that works best against E coli
- We talked with your outpatient psychiatrist as well as our
psychiatry team in the hospital, and some of the timing of your
medications were changed in order to better help your tardive
dyskinesia and your anxiety.
- Your sodium level in your blood was elevated. This can happen
in people who take lithium if they can't drink enough water.
Since it was harder for you to drink water in the hospital, we
gave you some water through the IV.
- Some of your blood counts were a little low (red blood cells
and platelets). The low platelets might have been because of the
antibiotics that you were on. We switched the antibiotics, and
your platelet count improved.
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.
-Make sure you drink plenty of water during the day while you
are at home.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10119391-DS-35 | 10,119,391 | 26,812,710 | DS | 35 | 2198-04-20 00:00:00 | 2198-04-20 22:52:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Toprol XL / Univasc / Sulfa (Sulfonamide Antibiotics) /
nitrofurantoin
Attending: ___.
Chief Complaint:
AMS
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o dementia, bipolar
disorder,
T2DM, hypothyroidism, CVA, recurrent UTIs, and recent admission
from ___ for confusion and worsening tardive dyskinesia
attributed to E coli UTI, who re-presents to the ED with
worsening mental status, agitation, and tardive dyskinesia.
Briefly, the patient was admitted from ___ for altered
mental
status and worsening tardive dyskinesia ultimately attributed to
E coli UTI, with improvement of her symptoms following treatment
of her infection. She was initially treated with linezolid given
history of MDR enterococcus UTI and was subsequently narrowed to
ceftriaxone and was discharged on a course of augmentin to be
completed on ___. Hospital course was complicated by
hypernatremia attributed to decreased free water intake,
underlying partial nephrogenic DI in the setting of chronic
lithium, and multiple falls.
She was discharged from the hospital on ___ to home with her
daughters, who are with her ___. Of note there was discussion
about rehab at the time of discharge per ___ recommendations,
however the family at that time felt their ultimate goal was to
get the patient home and decision was made with medical team
that
patient may be safer at home under ___ care. On arrival to the
ED on admission her daughters report that the patient has not
returned to her baseline mobility (still using a wheelchair),
and
over the past few days has become increasingly agitated and
frequently tries to get out of her chair or bed without
assistance. Unfortunately there seems to have been inadequate
support from ___ and ___. In this setting they are concerned that
she is not safe at home. Her daughters additionally note that
she
has had worsening symptoms of insomnia, paranoia, visual
hallucinations after recent discharge from the hospital for
treatment of recurrent UTIs. They deny any fevers, falls at
home.
Per discussion with outpatient psychiatrist Dr. ___ by the ED: Pt's baseline is some irritability, but
family has able to care for her adequately in the past. In
recent
weeks-months, she has been intermittently far form her baseline
in the setting of frequent UTI.
In the ED:
- Initial vital signs were notable for:
T97.3 HR77 BP127/95 RR17 O2-96 on RA
- Exam notable for:
- Labs were notable for:
H/H 9.1/30.6
Troponin-T 0.06
UA: >183 WBC, few bacteria, neg nitrites
- Patient was given:
___ 15:20 IM OLANZapine 5 mg
- Consults: Psychiatry
Upon arrival to the floor, she is lying peacefully in bed but
becomes agitated with interaction. She is unable to provide any
history or reliably answer questions but denies pain.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
Schizoaffective disorder, bipolar type
Hypothyroidism
Type 2 diabetes
Tardive dyskinesia
Recurrent UTIs
Recurrent falls of unclear etiology
Status post CVA
History of C1 fracture/cervical spondylolysis
Vitamin B12 deficiency
Anemia
Osteoarthritis
Osteoporosis
Constipation
Seizures - undetermined type, with aura, ?every month
Social History:
___
Family History:
Mother - died from MI in ___
Father - died from MI in ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T97.9 BP112/66 HR72 RR17 O2-95
GENERAL: Agitated, cachectic.
HEENT: NCAT. PERRL, EOMI. Sclera anicteric and without
injection.
MMM. Frequent repetitive mouth and tongue movements.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. Normal work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No palpable organomegaly. No
suprapubic tenderness.
EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial
2+
bilaterally.
SKIN: Warm. No rashes.
NEUROLOGIC: Oriented to self and to hospital in ___.
Agitated,
crying out intermittently. Difficult to understand speech in
setting of tardive dyskinesa. Squeezes finger on command.
DISCHARGE PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 815)
Temp: 98.1 (Tm 98.1), BP: 103/45 (103-146/45-92), HR: 76
(67-76), RR: 18, O2 sat: 95% (94-95), O2 delivery: RA
GENERAL: lying on her side in bed, awake and alert, speaking
clearly
HEENT: Very dry lips and tongue, frequent repetitive mouth and
tongue movements.
LUNGS: no respiratory distress
ABDOMEN: non distended
NEUROLOGIC: Frequent limb movement without purpose
Pertinent Results:
ADMISSION LABS:
================
___ 01:29PM BLOOD WBC-7.9 RBC-2.81* Hgb-9.1* Hct-30.6*
MCV-109* MCH-32.4* MCHC-29.7* RDW-16.8* RDWSD-67.2* Plt ___
___ 01:29PM BLOOD Glucose-107* UreaN-28* Creat-0.9 Na-145
K-4.4 Cl-109* HCO3-23 AnGap-13
___ 01:29PM BLOOD ALT-22 AST-43* CK(CPK)-128 AlkPhos-64
TotBili-0.4
___ 01:29PM BLOOD cTropnT-0.06*
___ 07:50PM BLOOD CK-MB-3 cTropnT-0.06*
___ 04:47AM BLOOD cTropnT-0.05*
___ 01:29PM BLOOD Albumin-4.2 Calcium-10.5* Phos-3.4 Mg-2.4
___ 04:47AM BLOOD Folate-12
___ 06:03AM BLOOD %HbA1c-4.6 eAG-85
___ 06:03AM BLOOD Triglyc-140 HDL-54 CHOL/HD-2.4 LDLcalc-46
___ 06:10AM BLOOD TSH-2.0
LATEST LABS PRIOR TO DISCHARGE:
___ 11:03AM BLOOD WBC-10.2* RBC-2.66* Hgb-8.9* Hct-32.6*
MCV-123* MCH-33.5* MCHC-27.3* RDW-17.1* RDWSD-77.2* Plt ___
___ 05:52AM BLOOD Glucose-88 UreaN-21* Creat-0.6 Na-156*
K-3.8 Cl-124* HCO3-24 AnGap-8*
___ 05:52AM BLOOD LD(LDH)-308*
___ 09:01AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.2
MICROBIOLOGY:
================
___ 6:29 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
IDENTIFICATION AND Susceptibility testing requested per
___
ON ___ AT 11:52.
___ ALBICANS. >100,000 CFU/mL.
Yeast Susceptibility:.
Fluconazole MIC OF 0.5 MCG/ML SUSCEPTIBLE.
Results were read after 24 hours of incubation.
test result performed by Sensititre.
___ - STOOL CDIFF PCR POSITIVE, TOXIN NEGATIVE
IMAGING:
==========
___ MRI head without contrast IMPRESSION:
1. Please note the study is suboptimal due to extensive motion
artifact which limits evaluation of intracranial structures.
2. Within these limitations, several areas of high signal on the
diffusion weighted images are seen in the left cerebellum are
seen without definite correlate on the ADC sequences. While
these lesions could represent subacute infarcts, other lesions
are not excluded given degree of motion and a repeat study may
be helpful for further characterization.
RECOMMENDATION(S): A repeat study when patient is more
cooperative would be helpful to better characterize the left
cerebellar lesions.
___ ECHO:
The left atrial volume index is normal. The interatrial septum
is dynamic, but not frankly aneurysmal. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
suboptimal image quality to assess regional left ventricular
function. Overall left ventricular systolic function is
hyperdynamic. The visually estimated left ventricular ejection
fraction is 75%. There is no resting left ventricular outflow
tract gradient. Normal right ventricular cavity size with normal
free wall motion. The aortic sinus diameter is normal for gender
with normal ascending aorta diameter for gender. The aortic arch
diameter is normal. The aortic valve leaflets (3) are mildly
thickened. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened.
There is trivial mitral regurgitation. The tricuspid valve
leaflets are mildly thickened with systolic prolapse. There is
physiologic tricuspid regurgitation. The estimated pulmonary
artery systolic pressure is normal. There is no pericardial
effusion. Compared with the prior TTE (images not available for
review) of ___, the findings are similar.
Brief Hospital Course:
PATIENT SUMMARY FOR ADMISSION:
================================
___ with h/o dementia, bipolar disorder, T2DM, hypothyroidism,
CVA, recurrent UTIs, and recent admission from ___
forconfusion and worsening tardive dyskinesia attributed to E
coli UTI, who represents to the ED with worsening mental status,
agitation, and tardive dyskinesia found to have
subacutecerebellar stroke.
Ultimately, due to a persistent decline in mental status and
failure to thrive, especially with regard to severe malnutrition
and cachexia, the medical team, psychiatry team, and geriatric
service met with the family and it was determined that the
patient would benefit most from home hospice.
ACUTE ISSUES:
=============
# Failure to thrive:
# Severe malnutrition:
As noted above, the patient has lost nearly 20 lbs over the last
several months, weighing in at no more than 60 lbs at discharge
(bed weights only). Goal is for discharge home to home hospice
given her subacute decline. She was made DNR/DNI/DNH during this
hospitalization.
# Subacute Encephalopathy: Notably per family, Ms. ___ has
not been at baseline since ___ admission. CT head with
findings consistent with subacute cerebellar stroke which
islikely significant cause of recent mental status change in
thesetting of underlying dementia, significant past psychiatric
history and delirium. She was evaluated by Neurology but
ultimately able to tolerate very little imaging. EEG was
completed and without evidence of seizure. MRI/MRA attempted but
extremely limited study. She was treated for a yeast UTI and
electrolytes optimized and ultimately her mental status did not
improve.
#Sub acute cerebellar stroke: Neurology consulted. Patient has
history of TIAs and notably was on aspirin and statin while this
occurred. Stroke pathology likely large factor in patient's step
wise decline. Lipid panel and A1c WNL. No abnormality on TTE or
telemetry.
# Hypernatremia: Due to poor PO intake, intermittently received
D5W with improvement. Na peaked at 156.
# Recurrent Urinary Tract Infections, history of MDR infection:
Patient with history of persistently positive UA and MDR
infections. Has previously grown E. Coli frequently
(intermittently resistance to cipro/Bactrim). Urine culture from
___ notable for ___ yeast given attempt to correct any
underlying cause of altered mental status she was given a course
of Fluconazole 100mg daily for 10 days.
CTU was not completed while inpatient due to patient's inability
to tolerate advanced imaging.
# Diarrhea: several loose episodes. C. diff PCR positive, toxin
negative, thus did not treat for active infection. Holding bowel
regimen.
# Macrocytic Anemia On recent admission B12 and folate wnl.
Ferritin elevated, so likely has element of anemia of chronic
disease, no active bleeding or evidence of hemolysis. Unclear
etiology of this finding however received folate
supplementation.
# Oropharyngeal dysphagia, Severe Protein calorie malnutrition:
Risk for aspiration was discussed with patient's family during
last hospitalization and her HCP ___ confirmed that feeding
tube is not within her GOC and would lead to potentially worse
outcomes in the setting of possibly progressed dementia.
CHRONIC ISSUES:
===============
# Schizoaffective disorder, bipolar type: Follows with Dr.
___ as outpatient. Medications per psychiatry
recommendations while inpatient and titrated to:
- Lithium 150 mg daily
- Quetiapine 50 mg QHS + 25 mg BID:PRN agitation
- Clonazepam 0.25 mg BID and 0.5 mg QHS
# Prior CVA, with late effects: Continued home
aspirin-dipyridamole
# Hypothyroidism: continued home levothyroxine
# Hyperlipidemia: switched to high dose atorvastatin iso CVA
# GERD:
- Continue lansoprazole
TRANSITIONAL ISSUES:
========================
Code status: DNR/DNI/DNH
___, DAUGHTER, ___
DISPO: home hospice
Medications to consider discontinuing pending family preference:
- Lithium 150 mg daily
- Atorvastatin 40 mg QHS (may help with stroke prevention)
- Levothyroxine 50 mg daily
- Fluconazole 100 mg daily x 14 days (final day ___
- Lansoprazole oral disintegrating tab 30 mg daily
- Dipyridamole-Aspirin 1 CAP BID (may help with stroke
prevention)
Medications to consider restarting pending family preference
(note these were discontinued a few days prior to discharge to
minimize pill burden):
- Cyanocobalamin 2,000 mcg PO daily
- Multivitamins with minerals 1 tab PO daily
- Pyridoxine 100 mg PO daily
- Vitamin D 1,000 mg PO daily
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. ClonazePAM 0.25 mg PO AM
3. ClonazePAM 0.5 mg PO QHS
4. ClonazePAM 0.25 mg PO AFTERNOON:PRN agitation
5. Cyanocobalamin ___ mcg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Levothyroxine Sodium 50 mcg PO DAILY
8. Lithium Carbonate 150 mg PO QHS
9. Omeprazole 20 mg PO BID
10. Polyethylene Glycol 17 g PO DAILY
11. Pyridoxine 100 mg PO DAILY
12. QUEtiapine Fumarate 100 mg PO QHS
13. Senna 8.6 mg PO BID:PRN Constipation
14. Simvastatin 20 mg PO DAILY
15. Vitamin D 1000 UNIT PO DAILY
16. Multivitamins W/minerals 1 TAB PO DAILY
17. OxyCODONE (Immediate Release) 5 mg PO BID:PRN Pain -
Moderate
18. QUEtiapine Fumarate 25 mg PO DAILY PRN paranoia
19. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
20. Dipyridamole-Aspirin 1 CAP PO BID
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
RX *atorvastatin 40 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
2. Fluconazole 100 mg PO Q24H Duration: 14 Days
RX *fluconazole 40 mg/mL 2.5 mL(s) by mouth daily Refills:*0
3. ClonazePAM 0.25 mg PO BID
RX *clonazepam 0.25 mg 1 tablet(s) by mouth twice daily at 8AM
and noon Disp #*14 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
RX *polyethylene glycol 3350 17 gram 1 packet by mouth daily
Disp #*14 Packet Refills:*0
5. QUEtiapine Fumarate 50 mg PO QHS
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
6. QUEtiapine Fumarate 25 mg PO BID:PRN agitation
RX *quetiapine 25 mg 1 tablet(s) by mouth twice daily Disp #*14
Tablet Refills:*0
7. ClonazePAM 0.5 mg PO QHS
RX *clonazepam 0.5 mg 1 tablet(s) by mouth at bedtime Disp #*7
Tablet Refills:*0
8. Dipyridamole-Aspirin 1 CAP PO BID
RX *aspirin-dipyridamole 25 mg-200 mg 1 capsule(s) by mouth
twice daily Disp #*14 Capsule Refills:*0
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
RX *lansoprazole 30 mg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
10. Levothyroxine Sodium 50 mcg PO DAILY
RX *levothyroxine 50 mcg 1 tablet(s) by mouth daily Disp #*7
Tablet Refills:*0
11. Lithium Carbonate 150 mg PO QHS
RX *lithium carbonate 150 mg 1 capsule(s) by mouth at bedtime
Disp #*7 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
==================
Subacute encephalopathy in the setting of dementia
Cerebral vascular accident
Failure to thrive
Severe malnutrition
SECONDARY:
==================
Tardive dyskinesia
Schizophrenia vs bipolar disorder
Hypernatremia
Recurrent urinary tract infection, ___
Oropharyngeal dysphagia
GERD
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Discharge Instructions:
Dear ___,
You were admitted to ___
because you were confused.
While you were here, you had a cat scan of your head which
showed that you had a stroke.
We gave you medicines to help make you feel better.
Your family and your doctors decided that ___ be happiest
at home with home ___. These doctors and ___ help
manage any symptoms that you have.
It was a pleasure taking part in your care. We wish you all the
best.
Sincerely,
The team at ___
Followup Instructions:
___
|
10119514-DS-28 | 10,119,514 | 20,157,432 | DS | 28 | 2192-05-25 00:00:00 | 2192-05-27 16:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Cough/SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo ___ speaking male with a history of sCHF, HTN, and
poorly controlled Type 2 DM, who presents with fever to 38C and
cough. His reports that his cough developed 2 weeks ago
developed worsening cough last pm, SOB and felt ill. The cough
is nonproductive, no hemoptysis but is associated with nasal
congestion and complicated by chest and abdominal pain when
coughing. The patient denies new leg swelling, weight gain,
abdominal, orthopnea and PND. He denies changes in his
medications. He denies any nausea, vomiting, diarrhea, dysuria,
or bloody stool. Reports adequate PO intake over the past few
days.
In the ED, initial VS: 98.6 88 150/90 14 100% 15L ___ 256. CXR
and U/A failed to show signs of infection and an abdominal CT
was negative for intraabdominal processes.
Past Medical History:
* Hypertension
* Hypercholesterolemia
* Type 2 DM (HgA1c 5.8 in ___
* Coronary Artery Disease s/p MI (___) with BMS to LAD +
another
stent on ___
* Systolic CHF (LVEF 30% in ___
* Mild dementia
* Anxiety
* Schatzki's Ring s/p dilation via EGD
* Left humeral osteochondroma
* Internal hemorrhoids vs. anal fissure
* Benign Prostatic Hyperplasia s/p prostatectomy
* Nodular basal cell carcinoma (removed)
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM:
VS - Temp:98.3 BP:144/76 HR:76 RR:20 O2sat:3L FSBG:157
GENERAL - NAD, uncomfortable, ill appearing appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MM dry
NECK - supple, no thyromegaly, no JVD
LUNGS - course breath sounds but no crackles, wheezing or
decreased breath sounds
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - +BS, soft, RLQ+LLQ+RUQ tenderness, no rebound, some
guarding
EXTREMITIES - WWP, bilateral trace ___ edema, 2+ peripheral
pulses (radials, DPs)
NEURO - awake, A&Ox3, CNs II-XII grossly intact, L arm abduction
weak and unable to abduct arm to 90 degrees. ___ strength 4+/5
throughout and equal bilaterally.
Pertinent Results:
___ 10:22PM URINE HOURS-RANDOM
___ 10:22PM URINE GR HOLD-HOLD
___ 10:22PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 10:22PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30
GLUCOSE-150 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 10:22PM URINE RBC-2 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:22PM URINE MUCOUS-RARE
___ 08:23PM LACTATE-2.1*
___ 08:20PM GLUCOSE-215* UREA N-16 CREAT-1.2 SODIUM-134
POTASSIUM-4.9 CHLORIDE-98 TOTAL CO2-25 ANION GAP-16
___ 08:20PM ALT(SGPT)-26 AST(SGOT)-32 ALK PHOS-50 TOT
BILI-0.7
___ 08:20PM ALBUMIN-4.6 MAGNESIUM-2.0
___ 08:20PM WBC-14.7*# RBC-4.97 HGB-14.9 HCT-45.8 MCV-92
MCH-29.9 MCHC-32.4 RDW-13.5
___ 08:20PM NEUTS-69.0 ___ MONOS-7.8 EOS-0.6
BASOS-0.4
___ 08:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 08:20PM PLT SMR-NORMAL PLT COUNT-171
___ 08:20PM ___ PTT-21.6* ___
Brief Hospital Course:
Mr. ___ was admitted on ___ with SOB, cough and fever
to 38C. He was started on levofloxacin, but transitioned to CTX
+ azithromycin to avoid delirium. He continued to have fever
until ___. Two CXR were performed and showed no PNA or
pulmonary edema. An abdominal CT with IV contrast was performed
due to complaints of abdominal pain. The CT was negative for
intraabdominal pathology. On ___, he was discharged after his
hypoxia improved. He went home on azithromycin for a full ___ut the ceftriaxone was stopped.
Active Issues:
### Cough: The elevated WBC on admission and history of fever to
38C at home suggested infection. The lack of pulomonary edema on
CXR and ___ edema made heart failure less likely. Treated with
ceftriaxone/azithro while an inpatient. He was discharged to
complete a course of azithromycin. All cultures were negative.
### Hyponatremia: On admission NA 131, likely hypovolemic in the
setting of infection with UA SG greater than assay. After 500cc
NS IV fluid, Na was corrected.
###Abdominal pain: No pathology on CT abdomen. Likely ___
constipation with a component of muscular strain from coughing.
Partially resolved after BMs.
### HTN: currently mildly hypertensive, continued lisinopril,
metoprolol, held lasix out of concern for dehydration. Restarted
lasix on DC.
# DM2: Hyperglycemia in the setting of infection. Held
glyburide/sitaGLIPtin to avoid hypoglycemia while admitted. On
ISS and while on floor. D/Ced on home meds.
Inactive issues:
# BPH: continued finasteride, tamsulosin
# Dementia: continued memantidine, olanzapine
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Family/CaregiverwebOMR.
1. Finasteride 5 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Lisinopril 20 mg PO DAILY
4. MEMAntine *NF* 10 mg Oral bid
5. Metoprolol Succinate XL 25 mg PO DAILY
6. OLANZapine 5 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. Polyethylene Glycol 17 g PO BID
9. Simvastatin 20 mg PO DAILY
10. Tamsulosin 0.4 mg PO HS
11. Aspirin 81 mg PO DAILY
12. Cyanocobalamin 1000 mcg PO DAILY
13. Docusate Sodium 100 mg PO BID
14. Hydrocortisone Acetate Suppository ___ID
15. Simethicone 120 mg PO BID
with meals
16. Meclizine 12.5 mg PO Q8H:PRN dizziness
17. sitaGLIPtin *NF* 50 mg Oral daily
18. traZODONE 50 mg PO HS
19. Acetaminophen 500 mg PO Q4H:PRN pain/fever
20. Glargine 20 Units Bedtime
21. Acetaminophen w/Codeine Elixir ___ mL PO Q4H:PRN pain
Acetaminophen 300 mg/Codeine 30 mg in each 12.5 mL of elixir (1
tablet)
22. Lorazepam 0.25 mg PO BID
23. FoLIC Acid 1 mg PO DAILY
24. GlipiZIDE 5 mg PO BID
Discharge Medications:
1. Acetaminophen 500 mg PO Q4H:PRN pain/fever
2. Aspirin 81 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Hydrocortisone Acetate Suppository ___ID
7. Lisinopril 20 mg PO DAILY
8. Meclizine 12.5 mg PO Q8H:PRN dizziness
9. MEMAntine *NF* 10 mg Oral bid
10. OLANZapine 5 mg PO HS
11. Omeprazole 20 mg PO DAILY
12. Polyethylene Glycol 17 g PO BID
13. Simethicone 120 mg PO BID
with meals
14. Simvastatin 20 mg PO DAILY
15. Tamsulosin 0.4 mg PO HS
16. traZODONE 50 mg PO HS
17. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *azithromycin 250 mg once a day Disp #*3 Tablet Refills:*0
18. Benzonatate 100 mg PO TID
RX *benzonatate 100 mg three times a day Disp #*9 Capsule
Refills:*0
19. Acetaminophen w/Codeine Elixir ___ mL PO Q4H:PRN pain
Acetaminophen 300 mg/Codeine 30 mg in each 12.5 mL of elixir (1
tablet)
20. FoLIC Acid 1 mg PO DAILY
21. Furosemide 40 mg PO DAILY
22. GlipiZIDE 5 mg PO BID
23. Lorazepam 0.25 mg PO BID
24. Metoprolol Succinate XL 25 mg PO DAILY
25. sitaGLIPtin *NF* 50 mg Oral daily
26. Glargine 20 Units Bedtime
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Bronchitis
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 Medicine Service at ___ for shortness
of breath and cough. While in the hospital you were treated with
antibiotics for a possible respiratory infection. A CT scan of
you abdomen was performed and showed no signs of infection and
chest x-rays showed no evidence of pneumonia. You are now being
discharged on continued antibiotics (Azithromycin). You should
continue taking this medication until you have completed the
entire course. You should also contact your PCP later this week
to arrange a follow-up appointment. You have a history of heart
failure and should weigh yourself every morning and call your
PCP if your weight goes up more than 3 lbs.
Followup Instructions:
___
|
10119514-DS-30 | 10,119,514 | 24,542,641 | DS | 30 | 2193-01-14 00:00:00 | 2193-01-14 16:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
zopidem
Attending: ___.
Chief Complaint:
headache, weakness, left arm pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old ___ man with dementia, DM, and CAD s/p
PCI to LAD, who presents with multiple complaints. As patient is
demented and unable to provide much history, information was
obtained via EMS records and his daughter ___. Per report, he
triggered his life alert bracelet and upon questioning by EMS
reported worsening of his chronic headaches, generalized
weakness, and left arm/shoulder pain. Per his daughter, he
___ been himself the past few days, has been more confused,
less active, weak to the point that he was unable to feed
himself. He ___ reported any chest pain or seemed more SOB.
.
In the ED his EKG showed a new RBBB (compared to last ekg in
___, with TWI anteriorly and small STD laterally. Trop
0.02. He was given 325mg ASA. CT head neg for acute process.
Past Medical History:
- Dementia
- Anxiety
- CAD with h/o anteroseptal wall MI s/p BMS to LAD in ___
(p-MIBI ___ showed stable focal perfusion defects, LVEF 30%)
- Systolic HF (EF 35% in ___
- DM type 2
- Hypertension
- Hyperlipidemia
- BPH s/p prostatectomy
- Internal hemorrhoids
- Chronic headaches
- Schatzki's Ring s/p dilation via EGD
- Left humeral osteochondroma
- Nodular basal cell carcinoma (removed)
Social History:
___
Family History:
Unable to obtain due to patient's dementia.
Physical Exam:
ADMISSION EXAM:
VS: Tm 98.1, BP 122-142/62-70, P 56-58, R 18, 96-97% RA
GENERAL: NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: Supple, no JVD
HEART: RRR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN: NABS, soft/NT/ND, no masses or HSM, no rebound/guarding
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
MUSCULOSKELETAL: Left shoulder with full ROM, no pain on
palpation or movement
SKIN: No rashes or lesions
NEURO: Alert, oriented x0, CN II-XII grossly intact, strength
___ throughout, sensation grossly intact, normal gait
.
DISCHARGE EXAM:
VS: Tm 98.1, BP 106-148/44-96, P ___, R 18, 94-98% RA
GENERAL: NAD, comfortable, appropriate
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK: Supple, no JVD
HEART: RRR, nl S1-S2, no MRG
LUNGS: CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN: NABS, soft, nontender
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
MUSCULOSKELETAL: Left shoulder with full ROM, no pain on
palpation or movement
SKIN: No rashes or lesions
NEURO: Alert, oriented x0, CN II-XII grossly intact, strength
grossly intact, sensation grossly intact, normal gait
Pertinent Results:
ADMISSION LABS:
___ 05:50PM BLOOD WBC-7.1 RBC-4.81 Hgb-15.2 Hct-45.6 MCV-95
MCH-31.6 MCHC-33.3 RDW-13.0 Plt ___
___ 05:50PM BLOOD Glucose-284* UreaN-18 Creat-1.2 Na-137
K-4.8 Cl-100 HCO3-31 AnGap-11
___ 05:50PM BLOOD ALT-21 AST-21 AlkPhos-53 TotBili-0.3
___ 05:50PM BLOOD Albumin-4.2 Calcium-8.9 Phos-4.0 Mg-2.1
___ 06:06PM BLOOD Lactate-1.5
___ 06:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
.
PERTINENT LABS:
___ 05:50PM BLOOD cTropnT-0.02*
___ 03:19AM BLOOD cTropnT-0.01
___ 01:20PM BLOOD cTropnT-0.01
.
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-7.0 RBC-4.90 Hgb-15.5 Hct-47.0 MCV-96
MCH-31.7 MCHC-33.0 RDW-12.9 Plt ___
___ 07:45AM BLOOD Glucose-241* UreaN-19 Creat-1.0 Na-136
K-4.6 Cl-100 HCO3-25 AnGap-16
___ 07:45AM BLOOD Calcium-9.1 Phos-3.3 Mg-2.0
.
MICROBIOLOGY: none
.
EKG: Sinus rhythm at 60 bpm, new RBBB with associated
repolarization abnormalities, evidence of old anterior MI. Very
minimal ST depressions in lateral chest leads.
.
IMAGING:
___ CXR: Frontal and lateral views of the chest provided
demonstrate persistent mild cardiomegaly, though no definite
signs of pneumonia, effusion or pneumothorax. Low lung volume
limits the evaluation. ___ be mild interstitial edema.
.
___ CT Head w/o con: No acute intracranial hemorrhage.
Metallic foreign body in left sphenoid bone is unchanged.
.
___ TTE: 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 is mildly
dilated. There is severe regional left ventricular systolic
dysfunction with hypokineis of the mid septal segments and
akinesis of all apical segments and true apex (LVEF ___. No
masses or thrombi are seen in the left ventricle. Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). The right ventricular cavity is mildly dilated
with mild global free wall hypokinesis. The ascending aorta is
mildly dilated. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. Mild (1+) aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Trivial mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Biatrial enlargement. Mildly dilated left ventricle
with severe regional left ventricular systolic dysfunction as
described above. Increased left ventricular filling pressure.
Mildly dilated right ventricle with mild global hypokinesis.
Mildly dilated ascending aorta. Mild aortic regurgitation.
Moderate pulmonary artery systolic hypertension. Compared with
the prior study (images reviewed) of ___, the global left
ventricular systolic function has minimally decreased (LVEF
previously 35%); the regional wall motion abnormalities are
similar.
Brief Hospital Course:
___ year old man with dementia, DM, HTN, systolic heart failure,
and CAD s/p PCI to LAD, who presented with a headache, weakness,
and left arm/shoulder pain and was found to have a new right
bundle branch block (RBBB) on ekg.
.
ACTIVE ISSUES:
.
# RBBB: After discussion with cardiology, the RBBB is likely due
to progressive conduction system disease. There is no evidence
of active ischemia and cardiac enzymes were negative. The
patient had a nuclear stress test in ___ which showed fixed
defects but no reversible defects. He had a repeat
echocardiogram during this admission which showed stable fixed
wall motion abnormalities with a stable EF (___).
.
# CAD s/p BMS to LAD with systolic heart failure: No chest pain
or signs of ACS and patient appears euvolemic. We continued
medical management with aspirin, simvastatin, metoprolol,
lisinopril, and furosemide. In addition, we added spironolactone
given his depressed EF, and Imdur.
.
# Headache: Per the patient's daughter these are chronic,
relieved with tylenol prn. CT head negative for acute findings.
.
# Weakness: Unclear etiology. No focal neurologic deficits and
CT negative for acute process. No signs of infection or
metabolic abnormalities. Symptoms seems to resolve during this
admission.
.
# Left shoulder/arm pain: No deficits or pain on musculoskeletal
examination so we did not obtain an x-ray. No signs of ACS as
discussed above. Unclear etiology though seemed to resolve
during this admission.
.
CHRONIC ISSUES:
.
# Dementia: Severe, patient is alert and oriented x0 though was
pleasant with no agitation. We continued memantine, mirtazapine,
and risperidone.
.
# DM: Complicated by peripheral neuropathy. We continued home
doses of glipizide, metformin, and gabapentin.
.
# HTN: Well controlled. We continued home doses of metoprolol,
lisinopril, and furosemide, and added spironolactone and Imdur
as noted above.
.
# BPH: We continued tamsulosin and finasteride.
.
# Contact Information: Daughter ___ ___
.
# Code Status: Full Code (confirmed with patient's daughter)
Medications on Admission:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Finasteride 5 mg PO DAILY
3. Folastin *NF* (folic acid-vit B6-vit B12) 2.5-25-2 mg Oral
daily
4. Furosemide 20 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. GlipiZIDE XL 5 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD DAILY
to back of neck
8. Lisinopril 20 mg PO DAILY
9. Memantine 10 mg PO BID
10. MetFORMIN (Glucophage) 500 mg PO DAILY
11. Metoprolol Succinate XL 25 mg PO DAILY
12. Mirtazapine 15 mg PO HS
13. Polyethylene Glycol 17 g PO BID
14. Risperidone 0.5 mg PO DAILY
15. Simvastatin 20 mg PO DAILY
16. Tamsulosin 0.4 mg PO DAILY
17. traZODONE 100 mg PO HS
18. Aspirin 81 mg PO DAILY
19. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral BID
20. Cyanocobalamin 1000 mcg PO DAILY
21. Docusate Sodium 100 mg PO DAILY
22. Ferrous Sulfate 325 mg PO DAILY
23. Hydrocortisone Oint 1% 1 Appl TP ___ TIMES DAILY
24. psyllium seed (sugar) *NF* 1 tablespoon Oral daily
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Gabapentin 300 mg PO TID
7. GlipiZIDE XL 5 mg PO DAILY
8. Lidocaine 5% Patch 1 PTCH TD DAILY
to back of neck
9. Lisinopril 20 mg PO DAILY
10. Memantine 10 mg PO BID
11. MetFORMIN (Glucophage) 500 mg PO DAILY
12. Mirtazapine 15 mg PO HS
13. Polyethylene Glycol 17 g PO BID
14. Risperidone 0.5 mg PO DAILY
15. Tamsulosin 0.4 mg PO DAILY
16. traZODONE 100 mg PO HS
17. Heparin 5000 UNIT SC TID
18. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit Oral BID
19. Cyanocobalamin 1000 mcg PO DAILY
20. Ferrous Sulfate 325 mg PO DAILY
21. Folastin *NF* (folic acid-vit B6-vit B12) 2.5-25-2 mg Oral
daily
22. Hydrocortisone Oint 1% 1 Appl TP ___ TIMES DAILY
23. Metoprolol Succinate XL 25 mg PO DAILY
24. psyllium seed (sugar) *NF* 1 tablespoon Oral daily
25. Simvastatin 20 mg PO DAILY
26. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
27. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
New right bundle branch block
Discharge Condition:
Mental Status: Demented, oriented x0
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
.
You were admitted to the hospital after you had a headache, arm
pain, and weakness. Your ekg (a picuture of the heart) was
slightly changed but you did not have a heart attack. The
cardiologists evaluated you and recommended starting two new
medications (spironolactone and Imdur) which are good for your
heart. It is unclear what caused your symptoms but they have
resolved.
Followup Instructions:
___
|
10119554-DS-4 | 10,119,554 | 20,303,886 | DS | 4 | 2115-11-12 00:00:00 | 2115-11-12 12:50:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Back pain, leg weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI(4): ___ with history of metastatic rectal adencocarcinoma
(dx in ___ with enlarging sacral mass, recently admitted to
___ for palliative radiation therapy discharged on
___, who presented here as a transfer from ___ after
re-presenting there with ongoing back pain and new onset leg
weakness with difficulty walking.
The patient reports 2 months of ongoing bilateral lumbar back
pain with pain radiating down bilateral posterior legs. He was
hospitalized and discharged yesterday from ___ and
was started on palliative radiation therapy for the sacral mass.
He reports that the pain was slightly improved and he was even
able to walk on the day of discharge. But at home he developed
worsening pain and difficulty walking due to weakness in his b/l
___.
Of note, the patient was initially diagnosed with adenocarcinoma
of the rectum in ___, at which time he had chemotherapy and
radiation therapy, but did not complete radiation due to
inability to tolerate. Had surgical resection but no
postoperative adjuvant chemotherapy. During last hospitalization
he was started on palliative radiation therapy by ___
his sacral mass which had shown interval increase in size 6.9cm
on CT ___. His primary oncologist is Dr ___ at ___.
On arrival to the ED,
initial vitals were: 97.2 88 114/90 18 96% RA
Code cord was called and L Spine MRI was ordered.
L spine MRI showed no cord compression, but did find the
following:
"Lobulated, heterogeneous low signal mass with peripheral
enhancement centered in the distal left sacrum involving the
left
greater than right S3 foramina measuring approximately 7.7 x 5.2
x 4.9 cm (05:44). Intrinsic signal of the mass suggests
hemorrhage and necrosis. There is intraspinal extension of the
mass through the sacral spinal canal with extension superiorly
to
the L4-5 level with compression of the posterior thecal sac.
The
intraspinal component of the mass appears similar with
peripheral
enhancement and likely central necrosis and hemorrhage." Also
showed: Central disc protrusion at L4-L5 with moderate spinal
canal stenosis and severe bilateral neural foraminal stenosis.
Given no cord compression, patient was admitted to medicine for
pain control. The final read had not yet resulted until he was
on
the floor, at which time neurosurgery was called,
recommendations
currently pending.
On arrival to the floor, the patient reports ongoing pain and
weakness specifically trying to "push down on the gas petal". He
reports that he usually lives alone in a ___ story apartment but
has been having to stay with his sister due to his leg weakness.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
-Metastatic rectal cancer dx in ___, chemo/radiation at that
time, s/p surgical resection, now w/ enlarging sacral mass as of
___ CT scan. Underwent palliative radiation during past
admission ___ at ___.
Social History:
___
Family History:
Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
Admission:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. Colostomy bag with brown soft stool. Urostomy
tube in place as well, draining normal appearing urine.
GU: No suprapubic fullness or tenderness to palpation
MSK: Tender to palpation along Sacral spine centrally.
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, Bilateral ___ with ___ strength in every maneuver
except plantarflexion, which was ___ strength on the R, ___ on
the L.
PSYCH: pleasant, appropriate affect
Discharge:
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. Colostomy bag with brown soft stool. Urostomy
tube in place as well, draining normal appearing urine.
GU: No suprapubic fullness or tenderness to palpation
MSK: Tender to palpation along Sacral spine centrally.
SKIN: On L buttock/sacrum, there is a 2 cm area of confluent
vesicles without significant surrounding erythema, tender to the
touch.
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, Bilateral ___ with ___ strength in every maneuver
except plantarflexion, which was ___ strength on the R, ___ on
the L.
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission:
___ 02:27AM GLUCOSE-87 UREA N-25* CREAT-1.1 SODIUM-136
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-22 ANION GAP-15
___ 02:27AM estGFR-Using this
___ 02:27AM ALT(SGPT)-69* AST(SGOT)-29 ALK PHOS-168* TOT
BILI-0.4
___ 02:27AM ALBUMIN-2.9* CALCIUM-8.7 PHOSPHATE-4.2
MAGNESIUM-2.1
___ 02:27AM WBC-7.4 RBC-3.91* HGB-8.6* HCT-28.0* MCV-72*
MCH-22.0* MCHC-30.7* RDW-17.9* RDWSD-46.2
___ 02:27AM NEUTS-63.2 ___ MONOS-8.1 EOS-2.8
BASOS-0.3 IM ___ AbsNeut-4.68 AbsLymp-1.53 AbsMono-0.60
AbsEos-0.21 AbsBaso-0.02
___ 02:27AM PLT COUNT-509*
___ 02:27AM ___ PTT-30.8 ___
Discharge:
___ 04:40AM BLOOD WBC-9.0 RBC-4.24* Hgb-9.4* Hct-30.3*
MCV-72* MCH-22.2* MCHC-31.0* RDW-17.9* RDWSD-45.6 Plt ___
___ 04:40AM BLOOD Neuts-71.0 Lymphs-17.0* Monos-7.3 Eos-1.0
Baso-0.2 Im ___ AbsNeut-6.36* AbsLymp-1.52 AbsMono-0.65
AbsEos-0.09 AbsBaso-0.02
___ 04:40AM BLOOD Plt ___
___ 04:40AM BLOOD ___ PTT-76.1* ___
___ 04:40AM BLOOD Glucose-111* UreaN-27* Creat-0.9 Na-137
K-4.9 Cl-100 HCO3-23 AnGap-14
Imaging:
Final Report
EXAMINATION: MR CODE CORD COMPRESSION PT27 MR SPINE
INDICATION: ___ year old man with metz Ca, urostomy/colostomy,
enlarging
sacral mass. new to system with bilateral leg weakness// r/o
cord involvement
r/o cord involvement
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR
technique,
followed by axial T2 imaging.
COMPARISON: None.
FINDINGS:
The study is mildly degraded by motion artifact.
There is grade 1 anterolisthesis at L4-L5, likely degenerative.
The spinal
cord appears normal in caliber and configuration. There are
incidental
hemangiomas at the T11, L1, and L5 inferior endplates. There is
T2 and T1
hyperintense signal within the sacrum, compatible with post
radiation changes.
Otherwise, vertebral body and intervertebral disc signal
intensity appear
normal. There is central disc protrusion at L4-L5 and L5-S1
causing moderate
spinal canal stenosis and severe bilateral neural foraminal
stenosis at L4-L5.
There is no definite evidence of infection.
There is a lobulated, heterogeneous low signal mass with
peripheral
enhancement centered in the distal left sacrum involving the
left greater than
right S3 foramina measuring approximately 7.7 x 5.2 x 4.9 cm
(05:44).
Intrinsic signal of the mass suggests hemorrhage and necrosis.
There is
intraspinal extension of the mass through the sacral spinal
canal with
extension superiorly to the L4-5 level with compression of the
posterior
thecal sac. The intraspinal component of the mass appears
similar with
peripheral enhancement and likely central necrosis and
hemorrhage. There is
partial visualization of the bladder mass with possible
posterior extension to
the seminal vesicles (08:44). This is not fully evaluated.
There is severe left hydroureteronephrosis to level of the
bladder.
IMPRESSION:
1. Lobulated, heterogeneous 7.7 cm left sacral mass involving
the left greater
than right S3 foramina and with extension into the adjacent left
piriformis
muscle. There is additional extension into the sacral spinal
canal superiorly
to the L4-5 level with posterior compression of the thecal sac.
The mass
enhances peripherally with intrinsic signal suggestive of
hemorrhage and
necrosis.
2. Partial visualization of the bladder mass with possible
extension
posteriorly . Pelvic MRI or comparison to prior imaging can be
performed for
better characterization of the mass, if clinically indicated.
3. No evidence of abnormal cord signal or cord compression.
4. No suspicious bony abnormalities of the lumbar and upper
sacral spine
5. Central disc protrusion at L4-L5 with moderate spinal canal
stenosis and
severe bilateral neural foraminal stenosis.
6. Severe left hydroureteronephrosis.
RECOMMENDATION(S): Pelvic MRI or comparison to prior imaging
for better
characterization of the bladder and sacral mass.
CXR
IMPRESSION:
The tip of the left subclavian Port-A-Cath projects over the
distal SVC. No
pneumothorax.
___ 02:27AM BLOOD ALT-69* AST-29 AlkPhos-168* TotBili-0.4
MICRO
=====================
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___:
Negative for Varicella zoster by immunofluorescence.
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
**FINAL REPORT ___
Direct Antigen Test for Herpes Simplex Virus Types 1 & 2
(Final
___:
Reported to and read back by ___ ___ (___) ON
___ @
3:10PM.
POSITIVE FOR HERPES SIMPLEX TYPE 2 (HSV2).
Viral antigen identified by immunofluorescence.
Brief Hospital Course:
___ with history of metastatic rectal adencocarcinoma (dx in
___ with enlarging sacral mass, recently admitted to ___
___ for palliative radiation therapy discharged on ___,
who presented here as a transfer from ___ after
re-presenting there with ongoing back pain and
new onset leg weakness with difficulty walking, evaluated by
neurosurgery, no cord compression.
ACUTE/ACTIVE PROBLEMS:
#Metastatic rectal adenocarcinoma
#Sacral mass with spinal canal involvement
#radicular back pain
___ weakness: Patient was discharged from ___ on
___, then represented to the ED the same day with ongoing
lumbar back pain and bilateral leg weakness preventing him from
walking. He was transferred urgently to ___ ED where an urgent
MRI showed: "Lobulated, heterogeneous 7.7 cm left sacral mass
involving the left greater than right S3 foramina and with
extension into the adjacent left piriformis muscle. There is
additional extension into the sacral spinal canal superiorly
to the L4-5 level with posterior compression of the thecal sac.
The mass enhances peripherally with intrinsic signal suggestive
of hemorrhage and necrosis. Central disc protrusion at L4-L5
with moderate spinal canal stenosis and severe bilateral neural
foraminal stenosis.
" Given the MRI findings and his progressive weakness with
plantarflexion specifically which would indicate S5 nerve root
issue. His weakness has worsened over the last 3 days prior to
admission but is stable today as compared to yesterday. There is
no acute cord compression, but I suspect that he his radicular
symptoms are related to nerve root compression. Neurosurgery
evaluated him on ___ and feel that there is no indication
for neurosurgical intervention and recommend continued radiation
therapy for this mass. I
spoke with ___ radiation oncologist, who agreed to
continue treatment upon transfer back to ___. He
was accepted by the hospitalist at ___ as well. I explained
this to the patient and he is in agreement. He has ongoing
severe pain, moderately well controlled with oxycontin 30 mg bid
standing, oxycodone 10 mg q3h prn for severe pain, and IV
dilaudid 2 mg q2 prn for
breakthrough pain. We also Continued dexamethasone 4 mg daily as
per prior home medication
regimen. ___ should be consulted given his lower extremity
weakness to determine safest discharge plan. He will likely need
a few radiation treatments to see if he can get symptomatic
relief which may help his ability to walk.
#Primary HSV2 infection: Incidentally noted a 2 cm localized
confluent vesicular rash, DFA showed HSV2. Given lack of
complicated features, disseminated symptoms and that this is
local, as well as the fact that this patient is not
immuncompromised as he is not on chemotherapy, can initiate
Acyclovir regimen with a more conservative duration of 10 days
(can be as short as 5 days).
-Acyclovir 400 mg q8h x10 days (___)
CHRONIC/STABLE PROBLEMS:
#Constipation: continue senna and colace
Transitional Issues:
[] See Data section for full MRI report, but it also reads: "
Consider Pelvic MRI or comparison to prior imaging for better
characterization of the bladder and sacral mass."
More than 30 minutes were spent preparing this discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Senna 17.2 mg PO QHS
4. Dexamethasone 4 mg PO DAILY
5. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Acyclovir 400 mg PO Q8H Duration: 10 Days
2. Heparin 5000 UNIT SC BID
3. HYDROmorphone (Dilaudid) ___ mg IV Q2H:PRN BREAKTHROUGH PAIN
4. OxyCODONE (Immediate Release) 10 mg PO Q3H:PRN Pain - Severe
Reason for PRN duplicate override: Alternating agents for
similar severity
5. OxyCODONE SR (OxyCONTIN) 30 mg PO Q12H
6. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
7. amLODIPine 10 mg PO DAILY
8. Dexamethasone 4 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Senna 17.2 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: #Metastatic rectal adenocarcinoma
#Sacral mass with spinal canal involvement
#radicular back pain
___ weakness:
#Primary HSV2 infection:
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Discharge Instructions:
Dear Mr. ___,
You were admitted to ___ because you had increasing pain and
weakness in your back and legs. You had an MRI which showed the
mass that we already knew was there but your spinal cord was
fine. You should continue to see the radiation oncology doctors
for ___ at ___.
Followup Instructions:
___
|
10119692-DS-16 | 10,119,692 | 29,109,151 | DS | 16 | 2142-06-09 00:00:00 | 2142-06-09 15:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Amoxicillin / Penicillins / Betadine / latex / aspirin /
ibuprofen
Attending: ___.
Chief Complaint:
Pain around abdominal wound and some erythema noted at inferior
aspect of wound.
Major Surgical or Invasive Procedure:
1) Debridement and placement of a vacuum-assisted closure
(___)
2) VAC change on open wound on abdomen (___)
3) wound debridement and VAC change (___)
4) s/p delayed primary closure of her abdominal wound. She
underwent washout, debridement, old JP removal, and placement of
two new JP's (superior and inferior abdominal incision). Urology
changed the urostomy foley (___)
History of Present Illness:
___ with a history of urogenital reconstruction at birth s/p
urostomy placement and multiple urinary procedures, and a
history of a ventral hernia, now s/p ventral hernia repair and
panniculectomy by Dr. ___ reposition of urostomy by Dr.
___ on ___. She presents with pain surrounding her
urostomy site, multiple areas of epitheliolysis over abdominal
incision and an area of erythema at inferior aspect of abdominal
incision. No fevers, chills.
Past Medical History:
PAST MEDICAL HISTORY:
DM, HTN previously - none since weight loss
.
PAST SURGICAL HISTORY:
- urogenital reconstruction - birth
- oophorectomy/hysterectomy ___
- urostomy revision ___
- hernia repair #1 - ___ repair #2 - ___
- hernia repair #3 ?w/mesh - ___ ___
- hernia repair #4 - ___ ___ Ventral hernia repair,
spigelian hernia repair, bilateral component separation.
Internal corset mesh repair, panniculectomy, Complex
reconstruction of ileostomy, Complex revision of a cutaneous
urostomy.
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission:
99.8 90 114/73 16 98% RA
Gen: NAD, A+Ox3
CV: RRR
Pulm: No respiratory distress
Abd: Soft, NT, ND
3x7cm area of epitheliolysis adjacent to the R aspect of the
wound above her ostomy, and a 10x8cm area of epitheliolysis over
her inferior pannus adjacent to the R aspect of her wound, now
with slight sloughing off of epidermal layer.
Tenderness to palpation of the adbomen and some superficial
erythema ___ the distribution of her urostomy adhesive dressings.
Fibrinous drainage from the R lateral aspect of her urostomy at
the junction with the skin.
Erythema to the R of her inferior aspect of the abdominal wound
overlying her remaining lower abdomen/mons pannus.
Drains ___ place with scant serosanguinous output.
Ext: WWP, no c/c/e
On Discharge:
AVSS
Gen: NAD, A+Ox3
Pulm: No respiratory distress
Abd: Soft, NT, ND
Abdominal brace intact with no strikethough. Hole through brace
allowing urostomy bag to exit freely. Drains ___ place with scant
serosanguinous output.
Ext: WWP, no c/c/e
Pertinent Results:
ADMISSION LABS:
___ 12:30PM URINE HOURS-RANDOM
___ 12:30PM URINE UCG-NEGATIVE
___ 12:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:30PM URINE BLOOD-TR NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
___ 12:30PM URINE RBC-2 WBC-14* BACTERIA-FEW YEAST-NONE
EPI-0
___ 12:30PM URINE MUCOUS-RARE
___ 12:22PM LACTATE-1.1
___ 12:10PM GLUCOSE-92 UREA N-26* CREAT-1.0 SODIUM-146*
POTASSIUM-4.1 CHLORIDE-112* TOTAL CO2-24 ANION GAP-14
___ 12:10PM estGFR-Using this
___ 12:10PM WBC-10.7# RBC-3.41* HGB-9.7* HCT-30.6* MCV-90
MCH-28.4 MCHC-31.7 RDW-15.1
___ 12:10PM NEUTS-78.5* LYMPHS-14.6* MONOS-3.9 EOS-2.8
BASOS-0.2
___ 12:10PM PLT COUNT-451*#
___ 12:10PM ___ PTT-27.6 ___
.
DISCHARGE LABS:
.
MICROBIOLOGY:
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED BELOW, THEY ARE NOT
PRESENT ___
this culture..
PSEUDOMONAS AERUGINOSA. SPARSE GROWTH.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
COLISTIN AND FOSFOMYCIN SENSITIVITY REQUESTED PER ___
___
___ ___.
Colistin & FOSFOMYCIN sensitivity testing performed by
___
___. Colistin = SENSITIVE. ZONE SIZE FOR FOSFOMYCIN
IS 21MM.
Zone size determined using a method that has not been
standardized
for this drug- organism combination and for which no
CLSI or
FDA-approved interpretative standards exist. Interpret
results
with caution.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
AMIKACIN-------------- 4 S
CEFEPIME-------------- 32 R
CEFTAZIDIME----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM------------- 8 R
PIPERACILLIN/TAZO----- R
TOBRAMYCIN------------ =>16 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___ 8:25 am
TISSUE Site: ABDOMEN
FAT NECROSIS LOWER ABDOMINAL WOUND CULTURE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
___ Reported to and read back by ___ AT 2:10
___.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
MIXED BACTERIAL FLORA.
Due to mixed bacterial types [>=3] an abbreviated
workup is
performed; all organisms will be identified and
reported but only
select isolates will have sensitivities performed.
ESCHERICHIA COLI. HEAVY GROWTH.
CEFEPIME sensitivity testing confirmed by ___.
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
Piperacillin/Tazobactam sensitivity testing confirmed
by ___
___.
ENTEROCOCCUS FAECIUM. QUANTITATION NOT AVAILABLE.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PSEUDOMONAS AERUGINOSA
| | ENTEROCOCCUS
FAECIUM
| | |
AMIKACIN-------------- 4 S
AMPICILLIN------------ =>32 R =>32 R
AMPICILLIN/SULBACTAM-- 8 S
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- S 16 I
CEFTAZIDIME----------- 16 R =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R =>4 R
GENTAMICIN------------ <=1 S =>16 R
LINEZOLID------------- 2 S
MEROPENEM-------------<=0.25 S 8 R
PENICILLIN G---------- =>64 R
PIPERACILLIN/TAZO----- <=4 S R
TOBRAMYCIN------------ <=1 S =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
VANCOMYCIN------------ =>32 R
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
.
___ 8:23 am SWAB Site: ABDOMEN
DEEP ABDOMINAL COLLECTION CULTURE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. MODERATE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
(___).
ESCHERICHIA COLI. SPARSE GROWTH.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
(___).
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
Audiology report ___:
Impression:
"B/L conductive hearing loss and Eustachian tube dysfunction.
Anticipate minor communication difficulties at this time."
Imaging:
___ Chest xray:
The right PICC line now terminates ___ the lower SVC.
Brief Hospital Course:
Ms. ___ was evaluated ___ the emergency department by the
plastic surgery team and was found to have an abdominal wound
infection and dehiscence. She was admitted to the plastic
surgery service for further management. Upon admission, it was
evident that there were areas of full thickness skin necrosis
around the abdominal Incision/wound that would necessitate
debridement. She was initially given vancomycin & cefazolin ___
order to treat the cellulitis surrounding the areas of necrosis
with good effect. Ms. ___ home medications were continued
throughout this admission.
.
Once the cellulitis had improved, she was taken to the operating
room on ___ for debridement of the areas of necrotic skin
and placement of a wound VAC. She tolerated the procedure well
and underwent routine post procedure recovery ___ the PACU. She
was transferred back to the plastic surgery floor after
recovery. She continued on vancomycin & cefazolin. Cultures from
the OR grew multi-drug resistant strains of E.coli and
pseudomonas, as well as VRE. At this point an infectious
disease consult was requested. Based upon ID recommendations,
vancomycin and cefazolin were discontinued ___ favor of cefepime
2gr q8h (slow infusion over 3h) and Amikacin IV. Renal labs and
amikacin levels were followed closely and amikacin was dose
adjusted, as needed. A PICC line was placed on ___ for
purposes of continued antibiotic therapy and blood draws x 2
weeks on outpatient basis. A baseline hearing test was obtained
on ___ as recommended by Infectious Disease (Amikacin is
ototoxic drug so hearing needs to be monitored). Hearing test
revealed eustachian tube dysfunction with conduction loss due to
ear drum pressure bilaterally. An ENT consult was requested to
see if there was anything to be done about the increase
pressure. ENT did not have any recommendations an an inpt and
suggested a repeat hearing test after her antibiotic course.
They also recommended a f/u appointment ___ about 1 month with
Dr. ___.
The patient was unable to tolerate a bedside VAC dressing change
despite pre-medication and IV dilaudid given during attempted
dressing change. She was taken back to the OR on ___ for VAC
dressing change as well as Urostomy appliance change and she
tolerated this well. On ___, patient was again taken back to
OR for further wound debridement and VAC change. A small amount
of necrotic tissue was debrided along the wound edges. Mesh was
palpable to the right inferolateral portion of the wound. Dr.
___ the ___ Disease team was able to view the wound
___ the OR. ___ addition, an area of breakdown was noted just to
the right of the urostomy and this was reported to Urology. On
___, patient was again taken to OR for delayed primary
closure of her abdominal wound. She underwent washout,
debridement, old JP removal, and placement of two new JP's
(superior and inferior abdominal incision). Urology was present
to assess urostomy and peristomal area of breakdwon and changed
the urostomy foley.
.
Ms. ___ had a good deal of pain at her urostomy site since
admission that she felt was due to the presence of a Foley
catheter ___ the urostomy. Urology felt that this was within
expected limits and recommended pain control and continuing the
Foley catheter for at least 2 weeks. Wound/Ostomy RNs helped
manage Ostomy pouch changes and treatment of developing wound
beneathy Ostomy pouch adhesive wafer.
.
Pain control was an ongoing issue with Ms. ___. Her pain
was initially treated with dilaudid 6mg PO Q3H PRN which she
took very regularly, ___ addition dilaudid IV for breakthrough,
tylenol around the clock, valium for abdominal spasms and
neurontin around the clock. By hospital day #12, this regimen
was no longer effective so MS contin 15mg po Q12H was added and
dilaudid PO PRN dose was reduced to ___ mg Q3H prn. However,
patient complained that MS contin made her too sleepy so she
requested this be discontinued ___ favor of returning to her
prior regimen of dilaudid 6mg PO Q3H prn.
.
She demonstrated no signs of sepsis during her admission. Blood
cultures were all negative. Urine cultures demonstrated mixed
bacterial flora that urology felt is likely due to chronic
colonization; no specific treatment was undertaken.
.
She was subsequently discharged home on hospital day ___. At the
time of hospital discharge, Ms. ___ was afebrile with
normal and stable vital signs. She was independently ambulatory
and moving bowels and urostomy was draining good amounts of
urine.
Medications on Admission:
Omeprazole 20 mg PO TID
HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
Docusate Sodium (Liquid) 100 mg PO BID
Acetaminophen 650 mg PO Q6H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*0
3. Diazepam 5 mg PO Q6H
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Gabapentin 600 mg PO TID nerve pain
6. Heparin 5000 UNIT SC TID
7. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
8. Omeprazole 20 mg PO DAILY
9. CefePIME 2 g IV Q8H
Projected End Date: ___ (2 weeks)
10. Amikacin 1000 mg IV Q24H Duration: 2 Weeks
Projected End Date: ___ (2 weeks)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Skin/Tissue necrosis ___ the abdomen.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Personal Care:
1. Leave your abdominal incision open without a dressing.
2. Clean around the drain site(s), where the tubing exits the
skin, with soap and water.
3. Strip drain tubing, empty bulb(s), and record output(s) ___
times per day.
4. A written record of the daily output from your drain should
be brought to every follow-up appointment. Your drains will be
removed as soon as possible when the daily output tapers off to
an acceptable amount.
5. You may shower daily. No baths until instructed to do so by
Dr. ___.
6. Wear your binder at all times so support your incision.
7. Your foley will remain ___ place for about another 2 weeks.
UROSTOMY:
-You should keep the catheter ___ place to drain your urine from
your urostomy.
-If your urine outputs stops then you should gently flush the
catheter as instructed by Urology team.
-If you cannot get the urine to flow and experience abdominal
pain and distention then you should go to the Emergency
Department.
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage ___
strenuous activity until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain. You may switch to Tylenol or Extra Strength Tylenol
for mild pain as directed on the packaging.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high ___ fiber.
6.Continue your antibiotic as prescribed.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or wound vac
3. Severe nausea and vomiting and lack of bowel movement or gas
for several days.
4. Fever greater than 101.5 oF
5. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep ___ fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change ___ your symptoms, or any new symptoms that
concern you.
.
DRAIN DISCHARGE INSTRUCTIONS
You are being discharged with drains ___ place. Drain care is a
clean procedure. Wash your hands thoroughly with soap and warm
water before performing drain care. Perform drainage care twice
a day. Try to empty the drain at the same time each day. Pull
the stopper out of the drainage bottle and empty the drainage
fluid into the measuring cup. Record the amount of drainage
fluid on the record sheet. Reestablish drain suction.
Followup Instructions:
___
|
10119692-DS-17 | 10,119,692 | 23,775,644 | DS | 17 | 2142-06-19 00:00:00 | 2142-06-19 13:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Amoxicillin / Penicillins / Betadine / latex / aspirin /
ibuprofen
Attending: ___.
Chief Complaint:
2 days of erythema, pain, and induration localized to her left
lower abdomen.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F with a history of urogenital reconstruction at birth s/p
urostomy placement and multiple urinary procedures, and a
history of a ventral hernia, s/p ventral hernia repair and
panniculectomy by Dr. ___ reposition of urostomy by Dr.
___ on ___. She re-presented on ___ with an abdominal
wound infection and dehiscence. She was admitted to the plastic
surgery service at that time and underwent the following
procedures:
.
1) Debridement and placement of a vacuum-assisted closure
(___)
2) VAC change on open wound on abdomen (___)
3) wound debridement and VAC change (___)
4) s/p delayed primary closure of her abdominal wound. She
underwent washout, debridement, old JP removal, and placement of
two new JP's (superior and inferior abdominal incision). Urology
changed the urostomy foley (___)
.
Cultures from the OR grew multi-drug resistant strains of E.coli
and pseudomonas, as well as VRE. Based upon ID recommendations,
the patient was started on cefepime and Amikacin IV. A PICC line
was placed with the plan for her to continue on these
antibiotics until ___. The patient was discharged to
___ on ___.
.
The patient now presents with concern for increasing redness and
tenderness of the left lower abdomen for the past 2 days. She
endorses chills for the same time period. She otherwise denies
nausea or vomiting, and reports good PO intake. She does note
ongoing difficulty managing her urostomy appliance, and states
that urine "constantly" leaks from the bag and soaks her
incision site.
Past Medical History:
PAST MEDICAL HISTORY:
DM, HTN previously - none since weight loss
.
PAST SURGICAL HISTORY:
- urogenital reconstruction - birth
- oophorectomy/hysterectomy ___
- urostomy revision ___
- hernia repair #1 - ___
- hernia repair #2 - ___
- hernia repair #3 ?w/mesh - ___ ___
- hernia repair #4 - ___ ___ Ventral hernia repair,
spigelian hernia repair, bilateral component separation.
Internal corset mesh repair, panniculectomy, Complex
reconstruction of ileostomy, Complex revision of a cutaneous
urostomy.
Social History:
___
Family History:
Noncontributory
Physical Exam:
On Admission:
98.4 95 98/64 16 100% RA
Gen: NAD, A+Ox3
CV: RRR
Pulm: No respiratory distress
Abd: Sutures in place to incision, intact with mild amount of
serosanguinous drainage from mid-portion of incision. Erythema
and induration of left lower abdomen, with associated focal
tenderness. No palpable fluid collection. Open wound to right
side of urostomy. Urostomy appliance not adherent to medial
abdominal wall despite multiple attempts to correct this.
Pertinent Results:
ADMISSION LABS:
___ 09:50PM PLT SMR-NORMAL PLT COUNT-342
___ 09:50PM NEUTS-59.9 ___ MONOS-5.9 EOS-6.3*
BASOS-0.3
___ 09:50PM WBC-7.6 RBC-2.86* HGB-7.9* HCT-25.1* MCV-88
MCH-27.8 MCHC-31.7 RDW-15.3
___ 09:50PM GLUCOSE-99 UREA N-28* CREAT-1.1 SODIUM-139
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-21* ANION GAP-17
___ 09:53PM LACTATE-1.0
___ 12:59AM URINE MUCOUS-RARE
___ 12:59AM URINE RBC-1 WBC-30* BACTERIA-FEW YEAST-NONE
EPI-0 TRANS EPI-<1
___ 12:59AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-SM
___ 12:59AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:59AM URINE UCG-NEG
___ 12:59AM URINE HOURS-RANDOM
.
DISCHARGE LABS:
___ 07:15AM BLOOD Hct-24.8*
___ 06:00AM BLOOD Glucose-91 UreaN-33* Creat-1.0 Na-141
K-4.4 Cl-108 HCO3-24 AnGap-13
___ 07:15AM BLOOD Calcium-9.5 Phos-4.9* Mg-2.0
.
Renal Ultrasound (___)
Normal renal ultrasound. No evidence of hydronephrosis.
Brief Hospital Course:
The patient was admitted to the plastic surgery service on
___ for observation and treatment of erythema, pain and
induration over her left lower abdominal suture line.
.
Neuro: The patient received IV pain medication for breakthrough
pain but otherwise was maintained on her prior pain regimen with
good effect and adequate pain control.
.
CV: The patient was stable from a cardiovascular standpoint;
vital signs were routinely monitored.
.
Pulmonary: The patient was stable from a pulmonary standpoint;
vital signs were routinely monitored.
.
GI/GU: The patient was maintained on a regular diet, which was
tolerated well. She was also maintained on a bowel regimen to
encourage bowel movement. Patient maintained a catheter to her
urostomy site which drained through a ostomy bag into a foley
bag. Leakage of urine from around the wafer was a problem prior
to admission and continued to be a problem while inpatient.
Wound/Ostomy nurses visited with patient frequently to try and
fashion a pouch system for her without leakage. The leakage
problems were on the medial side of the pouch because the
incisional area has several small creases where the pouch edge
lies. After discussion with patient's Urologist, Dr. ___
was decided that removal of the catheter should be attempted.
On ___, Urology removed the catheter and the urostomy was
closely monitored and had ample urine output. Creatinine
remained at baseline of 0.9 - 1.0. Renal ultrasound on ___
___ was unremarkable for hydronephrosis. The wound/ostomy nurses
again worked closely with the patient to devise a pouch system
that did not leak. Intake and output were closely monitored.
.
ID: The patient was maintained on her antibiotic course as
recommended by Infectious Disease. Amikacin and cefepime were
continued and vancomycin was added upon admission but then
discontinued in the setting of a rise in creatinine and no clear
evidence of cellulitis. Antibiotic were give via ___ line
until patient complained of pain at the ___ site on hospital
day#2 and the ___ was discontinued. Antibiotics were then
given peripheral IV for the remainder of the course. The
patient's temperature was closely watched for signs of
infection.
.
Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
.
At the time of discharge on hospital day # 7, the patient was
doing well, afebrile with stable vital signs, tolerating a
regular diet, ambulating, her urostomy was putting out ample
clear yellow urine to patent ostomy pouch, and pain was well
controlled. Her abdominal suture line was intact with a small
ischemic area noted just inferior to the ostomy pouch that is
producing serous fluid. Redness, pain and swelling are improved
from admission. Patient will have follow up with Dr. ___ on
this ___ and a follow up hearing test in a couple of weeks.
She should have follow up with Dr. ___ in 1 month. Patient
was strongly encouraged to find a PCP for ongoing care.
Medications on Admission:
1. Acetaminophen 1000 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Gabapentin 600 mg PO TID
4. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
5. Lorazepam 0.5 mg PO Q6H
6. Omeprazole 20 mg PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*120 Tablet Refills:*2
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
3. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
once a day Disp #*30 Tablet Refills:*2
4. Gabapentin 600 mg PO TID
RX *gabapentin 600 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*2
5. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Q3H
Disp #*126 Tablet Refills:*0
6. Lorazepam 0.5 mg PO Q6H
RX *lorazepam 0.5 mg 1 Q6H by mouth anxiety, insomnia Disp #*40
Tablet Refills:*2
7. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*2
8. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*30 Tablet Refills:*2
9. Sofsorb pads
Sofsorb Pads: REF 46-102
Apply to abdominal incision daily.
10. Aquacel AG Rope
Aquacel AG Rope
Apply to peristomal wound daily.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal incision inflammation due to urostomy leakage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Personal Care:
1. You may dress your lower abdominal incision with clean dry
dressing daily and as needed to absorb drainage.
2. You may shower daily. No baths until instructed to do so by
Dr. ___.
3. Wear your binder at all times so support your incision.
4. UROSTOMY:
- Change your appliance as needed.
- The 9 o'clock incision should be cleansed with saline, filled
with Aquacel AG rope, and secured with Steri strips then covered
with pouch.
- If you cannot get the urine to flow and experience abdominal
pain and distention then you should go to the Emergency
Department.
.
Activity:
1. You may resume your regular diet.
2. DO NOT lift anything heavier than 5 pounds or engage in
strenuous activity until instructed by Dr. ___.
.
Medications:
1. Resume your regular medications unless instructed otherwise
and take any new meds as ordered.
2. You may take your prescribed pain medication for moderate to
severe pain.
3. Take prescription pain medications for pain not relieved by
tylenol.
4. Take Colace, 100 mg by mouth 2 times per day, while taking
the prescription pain medication. You may use a different
over-the-counter stool softener if you wish.
5. Do not drive or operate heavy machinery while taking any
narcotic pain medication. You may have constipation when taking
narcotic pain medications (oxycodone, percocet, vicodin,
hydrocodone, dilaudid, etc.); you should continue drinking
fluids, you may take stool softeners, and should eat foods that
are high in fiber.
6. You have been provided with 2 refills on each of your
prescriptions with the exception of dilaudid which is not
refillable without a paper script. This should give you 3 months
of medication until you find a PCP. You will need to establish
a PCP as soon as possible in order to get your medications once
these refills run out.
.
Call the office IMMEDIATELY if you have any of the following:
1. Signs of infection: fever with chills, increased redness,
swelling, warmth or tenderness at the surgical site, or unusual
drainage from the incision(s).
2. A large amount of bleeding from the incision(s) or wound vac
3. Severe nausea and vomiting and lack of bowel movement or gas
for several days.
4. Fever greater than 101.5 oF
5. Severe pain NOT relieved by your medication.
.
Return to the ER if:
* If you are vomiting and cannot keep in fluids or your
medications.
* If you have shaking chills, fever greater than 101.5 (F)
degrees or 38 (C) degrees, increased redness, swelling or
discharge from incision, chest pain, shortness of breath, or
anything else that is troubling you.
* Any serious change in your symptoms, or any new symptoms that
concern you.
Followup Instructions:
___
|
10119863-DS-4 | 10,119,863 | 26,756,106 | DS | 4 | 2131-03-05 00:00:00 | 2131-03-20 10:19:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
___ with hx of CAD s/p prior PCIs and 5vCABG, HTN, HLD, OSA
on CPAP, obesity, early dementia, and presyncope ___ SSS vs.
vagally mediated syncope pending PPM, presenting with abdominal
pain.
History is obtained from review of ED notes, cardiology consult
note, and - to a limited extent - from patient, who has short
term memory loss. HPI as reported in cardiology consult note
obtained with assistance from pt's wife, who is not at bedside
to
corroborate details at time of pt's arrival from ED to floor at
2
am.
Pt reports that he presented to the hospital for "dizzy spells."
When asked about abdominal pain, he initially states, "I don't
remember," then later states that he does recall that he had
abdominal pain. For this reason, admitting MD relies on
excellent
and detailed ED cardiology note, which reports: "The patient was
in his normal state of health until about 36 hours prior to
presentation. At that point, he began having lower abdominal
pain, band involving b/l LQ without radiation to back, legs, or
chest. He denies any other associated symptoms and denies any
ameliorating or exacerbating factors (including eating) but has
essentially had persistent pain from the past 36 hours. He has
had intermittent waves of worsening pain, cannot qualify nature,
so bad that it prevents him from sleeping. He did not have any
nausea until day of presentation (detailed below) and
chronically
has loose stools without any worsening of this stooling over the
past few days."
Pt denies any associated chest pain/pressure, SOB/DOE,
orthopnea,
PND, increased ___ swelling, palpitations. Per notes, he last
moved his bowels on day of presentation, and reportedly has
pretty consistent BRBPR, small volume ___ known hemorrhoids
being
worked up by CRS. Per notes, hemorrhoids are too large to band
and surgery deferred until his presyncope is worked up.
On day of presentation, pt was brought to ED by his wife for
persistent, progressive abdominal pain. Per notes, en route to
the ED, the patient began feeling sudden onset lightheadedness,
nausea, and diaphoresis, similar to his chronic episodes
attributed to possible low heart rates. This episode lasted only
5 minutes, reportedly shorter than and less severe than prior.
He
is followed by EP (Dr. ___, with plan for PPM
placement in the near future (based on note dated ___.
Past Medical History:
1. CAD s/p CABGx5 (___), cath ___ vd w/ patent grafts to
D1/RPDA and LAD; occluded graft to CX/OM1 and LPL only mild
disease in the native system.
2. obesity
3. BPH
4. hyperlipidemia
Social History:
___
Family History:
Father died at age ___ from MI.
PGF had MI at age ___.
Sister with breast CA.
Mother died from "old age" at ___ years-old, but also had breast
CA.
Physical Exam:
Admission Physical Exam:
VS: ___ 0225 Temp: 98.2 PO BP: 140/76 HR: 64 RR: 20 O2 sat:
93% O2 delivery: RA
GEN: delightful elderly male, sleeping comfortably, awakens
easily to verbal stimuli, alert and interactive, comfortable, no
acute distress
HEENT: PERRL, anicteric, conjunctiva pink, oropharynx without
lesion or exudate, moist mucus membranes, ears without lesions
or
apparent trauma
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: clear to auscultation bilaterally without rhonchi,
wheezes, or crackles
GI: soft, TTP at RUQ and epigastrium, without rebounding or
guarding, nondistended with normal active bowel
sounds, no hepatomegaly
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: A&Ox3, able to recite months of the year forwards and
backwards without error or delay, cranial nerves II-XII grossly
intact, strength and sensation grossly intact
PSYCH: normal mood and affect
Discharge Physical Exam:
VS: 97.6 PO 125 / 60 L Lying 62 18 92 Ra
GENERAL: Looking well.
HEART: Regular rate and rhythm.
LUNGS: Clear to auscultation bilaterally.
ABDOMEN: Soft. Nondistended, nontender. Laparoscopic sites
healing well, OTA.
EXTREMITIES: Reveals no edema.
Pertinent Results:
LABS:
___ 05:40AM BLOOD WBC-12.4* RBC-3.96* Hgb-12.4* Hct-38.0*
MCV-96 MCH-31.3 MCHC-32.6 RDW-13.2 RDWSD-46.6* Plt ___
___ 07:03AM BLOOD WBC-6.9 RBC-4.33* Hgb-13.1* Hct-41.2
MCV-95 MCH-30.3 MCHC-31.8* RDW-12.9 RDWSD-45.2 Plt ___
___ 07:21AM BLOOD WBC-7.6 RBC-3.76* Hgb-11.4* Hct-35.7*
MCV-95 MCH-30.3 MCHC-31.9* RDW-13.0 RDWSD-44.9 Plt ___
___ 04:00AM BLOOD WBC-9.7 RBC-3.77* Hgb-11.7* Hct-35.7*
MCV-95 MCH-31.0 MCHC-32.8 RDW-13.0 RDWSD-44.9 Plt ___
___ 07:05AM BLOOD WBC-11.3* RBC-3.92* Hgb-12.0* Hct-36.9*
MCV-94 MCH-30.6 MCHC-32.5 RDW-13.1 RDWSD-45.1 Plt ___
___ 07:15AM BLOOD WBC-16.4* RBC-4.25* Hgb-13.0* Hct-40.2
MCV-95 MCH-30.6 MCHC-32.3 RDW-13.2 RDWSD-46.4* Plt ___
___ 10:25AM BLOOD WBC-14.8* RBC-4.78 Hgb-15.0 Hct-45.9
MCV-96 MCH-31.4 MCHC-32.7 RDW-13.4 RDWSD-47.8* Plt ___
___ 07:15AM BLOOD ___ PTT-27.6 ___
___ 10:38AM BLOOD ___
___ 05:40AM BLOOD Glucose-117* UreaN-9 Creat-0.8 Na-142
K-4.3 Cl-101 HCO3-25 AnGap-16
___ 07:03AM BLOOD Glucose-87 UreaN-7 Creat-0.9 Na-146 K-4.2
Cl-104 HCO3-28 AnGap-14
___ 04:00AM BLOOD Glucose-90 UreaN-8 Creat-0.8 Na-138 K-4.1
Cl-100 HCO3-28 AnGap-10
___ 07:05AM BLOOD Glucose-76 UreaN-10 Creat-0.9 Na-139
K-4.1 Cl-100 HCO3-29 AnGap-10
___ 07:15AM BLOOD Glucose-97 UreaN-10 Creat-0.8 Na-137
K-4.1 Cl-98 HCO3-27 AnGap-12
___ 10:25AM BLOOD Glucose-116* UreaN-10 Creat-1.0 Na-139
K-4.5 Cl-100 HCO3-25 AnGap-14
___ 05:40AM BLOOD ALT-62* AST-91* AlkPhos-98 TotBili-0.8
___ 07:05AM BLOOD ALT-11 AST-15 AlkPhos-80 TotBili-2.4*
___ 07:15AM BLOOD ALT-13 AST-16 AlkPhos-90 TotBili-3.1*
___ 10:25AM BLOOD ALT-19 AST-21 AlkPhos-108 TotBili-2.7*
___ 07:05AM BLOOD Lipase-55
___ 10:25AM BLOOD Lipase-189*
___ 11:00AM BLOOD cTropnT-<0.01
___ 04:00AM BLOOD Calcium-8.6 Mg-2.0
___ 07:15AM BLOOD Calcium-9.0 Phos-2.6* Mg-1.9
___ 09:20PM BLOOD Lactate-1.2
___ 10:30AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-TR* Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 10:30AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 9:14 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
=============================================================
RADIOLOGY:
___ MRCP:
1. Technically suboptimal study due to motion artifact.
2. Cholelithiasis with no evidence of choledocholithiasis.
3. Findings of interstitial edematous pancreatitis again noted.
___ CT A/P:
1. Mild fat stranding about the pancreatic head and uncinate
process,
concerning for acute pancreatitis. Homogeneous pancreatic
parenchyma. No
evidence of pancreatic necrosis or other pancreatitis
complication.
2. New 10 mm subpleural left lower lobe pulmonary nodule.
Recommend follow-up chest CT in 3 months.
___ CXR:
1. Linear opacities in lung fields likely represent
scarring/atelectasis. No focal consolidation.
2. Break in the inferior-most sternal wire, unchanged from ___.
Remaining sternotomy wires are intact.
Brief Hospital Course:
Patient was admitted to medicine service. We started IV fluids
for conservative treatment of pancreatitis. GI was consulted for
pancreatitis and recommended MRCP, which showed gallstones as
the most likely cause of pancreatitis. Patient improved with
conservative treatment of pancreatitis. Cardiology was called
for pre-op clearance given complex cardiac history. It was
decided that he does not need workup or PPM before surgery. ACS
consulted and performed cholecystectomy before discharge. Pt
stable for outpatient follow up with PCP.
On ___ the patient was taken to the operating room with the
Acute Care Surgery team and underwent laparoscopic
cholecystectomy. Please see operative report for details.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Ranitidine 150 mg PO BID
2. Donepezil 10 mg PO QHS
3. Citalopram 15 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Lisinopril 2.5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*5 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
4. Senna 8.6 mg PO BID:PRN Constipation
5. Tamsulosin 0.4 mg PO QHS
Please discuss need to continue with your primary care.
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at bedtime Disp #*14
Capsule Refills:*0
6. Atorvastatin 40 mg PO QPM
7. Citalopram 15 mg PO DAILY
8. Donepezil 10 mg PO QHS
9. Lisinopril 2.5 mg PO DAILY
10. Ranitidine 150 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Gallstone pancreatitis
Acute Cholecystitis
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Confused - sometimes.
Discharge Instructions:
Dear Mr. ___,
You were admitted to the hospital with abdominal pain and found
to have pancreatitis likely due to gallstones blocking the flow
of bile. You received IV fluids to treat the pancreatitis and
recovered well. Your stones seemed to pass on their own and your
blood levels normalized. You were then taken to the operating
room and had your gallbladder removed laparoscopically. You
tolerated the procedure well and are now ready to be discharged
from the hospital.
You were seen by the heart doctors before surgery who recommend
no changes to your current medications. You should continue to
follow up with Dr. ___ as previously scheduled.
You are now doing better, tolerating a regular diet, and ready
to be discharged to home to continue your recovery from surgery.
Please note the following discharge instructions:
ACTIVITY:
o Do not drive until you have stopped taking pain medicine and
feel you could respond in an emergency.
o You may climb stairs.
o You may go outside, but avoid traveling long distances until
you see your surgeon at your next visit.
o Don't lift more than ___ lbs for 4 weeks. (This is about
the weight of a briefcase or a bag of groceries.) This applies
to lifting children, but they may sit on your lap.
o You may start some light exercise when you feel comfortable.
o You will need to stay out of bathtubs or swimming pools for a
time while your incision is healing. Ask your doctor when you
can resume tub baths or swimming.
HOW YOU MAY FEEL:
o You may feel weak or "washed out" for a couple of weeks. You
might want to nap often. Simple tasks may exhaust you.
o You may have a sore throat because of a tube that was in your
throat during surgery.
o You might have trouble concentrating or difficulty sleeping.
You might feel somewhat depressed.
o You could have a poor appetite for a while. Food may seem
unappealing.
o All of these feelings and reactions are normal and should go
away in a short time. If they do not, tell your surgeon.
YOUR INCISION:
o Tomorrow you may shower and remove the gauzes over your
incisions. Under these dressing you have small plastic bandages
called steri-strips. Do not remove steri-strips for 2 weeks.
(These are the thin paper strips that might be on your
incision.) But if they fall off before that that's okay).
o Your incisions may be slightly red around the stitches. This
is normal.
o You may gently wash away dried material around your incision.
o Avoid direct sun exposure to the incision area.
o Do not use any ointments on the incision unless you were told
otherwise.
o You may see a small amount of clear or light red fluid
staining your dressing or clothes. If the staining is severe,
please call your surgeon.
o You may shower. As noted above, ask your doctor when you may
resume tub baths or swimming.
YOUR BOWELS:
o Constipation is a common side effect of narcotic pain
medications. If needed, you may take a stool softener (such as
Colace, one capsule) or gentle laxative (such as milk of
magnesia, 1 tbs) twice a day. You can get both of these
medicines without a prescription.
o If you go 48 hours without a bowel movement, or have pain
moving the bowels, call your surgeon.
PAIN MANAGEMENT:
o It is normal to feel some discomfort/pain following abdominal
surgery. This pain is often described as "soreness".
o Your pain should get better day by day. If you find the pain
is getting worse instead of better, please contact your surgeon.
o You will receive a prescription for pain medicine to take by
mouth. It is important to take this medicine as directed. o Do
not take it more frequently than prescribed. Do not take more
medicine at one time than prescribed.
o Your pain medicine will work better if you take it before your
pain gets too severe.
o Talk with your surgeon about how long you will need to take
prescription pain medicine. Please don't take any other pain
medicine, including non-prescription pain medicine, unless your
surgeon has said its okay.
o If you are experiencing no pain, it is okay to skip a dose of
pain medicine.
o Remember to use your "cough pillow" for splinting when you
cough or when you are doing your deep breathing exercises.
If you experience any of the following, please contact your
surgeon:
- sharp pain or any severe pain that lasts several hours
- pain that is getting worse over time
- pain accompanied by fever of more than 101
- a drastic change in nature or quality of your pain
MEDICATIONS:
Take all the medicines you were on before the operation just as
you did before, unless you have been told differently.
If you have any questions about what medicine to take or not to
take, please call your surgeon.
Followup Instructions:
___
|
10119910-DS-22 | 10,119,910 | 21,317,576 | DS | 22 | 2192-02-17 00:00:00 | 2192-02-18 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:
altered mental status
Major Surgical or Invasive Procedure:
Intubation (___)
Central line placement (___)
Foley catheter placement (___)
History of Present Illness:
Mr. ___ is a ___ gentleman with a history of
Alzheimer's dementia, seizure disorder (none recently per
records), HTN, DMII, prostate cancer, PAD c/b dry gangrene L
second toe w/ recent admission ___ - ___ for SFA-DP bypass
(course c/b NSTEMI, ___, R thigh hematoma, and proteus
bacteremia) on ASA and plavix, who presented from his nursing
home with altered mental status and was found to have an IPH and
a pulmonary embolism.
In ED initial VS notable for Tmax 100.2, HR 110s, SpO2 88% on
non-rebreather, and BP of 75/56
Exam was notable for an unresponsive patient who does not
withdrawal to noxious stimuli, reactive and equal pupils,
diminished breath sounds, and soft, non-distended abdomen.
Labs significant for:
- WBC 8.5
- Hgb 6.3 (recent baseline 8 - 9)
- Plt 490
159|118|76 <288
5.3|19|2.8 (creatinine 0.7 on ___
- INR 1.8
- ALT 21, AST 68, Tbili 0.4
- Alb 2.6
- Lipase 176
- CK 761
- MB 2, TropT 0.12
- proBNP 713
- Lactate 8.4 --> 2.6 with fluids
- U/A trace ketones, neg leuks, neg nitrite, neg bacteria
- Blood and urine culture pending
Patient was given:
- Vancomycin
- Zosyn
- 1L NS
- Norepinepherine
- 1uPRBC
The patient was intubated without difficulty (7.5 ETT) for
hypoxemic respiratory failure and altered mental status. He was
sedated with fentanyl and midazolam.
Imaging notable for:
- NCHCT for AMS: Large acute left frontal IPH with adjacent mass
effet on frontal horn of the left lateral ventricle. No midline
shift.
- CTA C/A/P to eval for hemorrhage, vs infectious source, vs PE:
acute R lower lobar pulmonary embolism, reactive hilar nodes,
LLL opacity concerning for aspiration/pna. There was no evidence
of hemoperitoneum or acute intra-abdominal pathology.
- EKG: Sinus tachycardia, no ischemic changes
Consults:
- PULMONARY EMBOLISM: recommended TTE (Cardiology fellow
attempted at bedside and was unable to obtain adequate windows
so formal TTE ordered), LENIs, anticoagulation when safe from
neuro perspective, and consider IVC filter if can not be
anticoagulated.
- NEUROSURGERY: No neurosurgical intervention recommended.
Continue Keppra 1g BID and Dilantin 100mg QAM/200mg QPM, INR <
1.8, HOLD anticoagulation, and keep SBP goal < 160
- NEUROLOGY: recommended a non-urgent MRI/MRA followed by an
cvEEG, q2h neuro checks, bedrest, HOLD asa and antiplatelets,
and SBP goal < 150.
VS prior to transfer:
98.2 104 105/57 18 100% Intubation
On arrival to the MICU, patient is sedated and intubated. He has
norepinephrine gtt , midazolam, and 1uPRBCs.
REVIEW OF SYSTEMS: Unable to obtain as patient is sedated and
intubated
Past Medical History:
-Alzheimer's, dementia
-Hyperlipidemia
-Hypertension
-prostate cancer
-GERD
-depression, anxiety
-Seizure disorder - no seizure ___ years
-Hepatitis C
-Borderline/Pre- Diabetes Mellitus (A1c on ___ was 6.4)
Social History:
___
Family History:
Unable to obtain
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: 98.2 104 105/57 18 100% Intubated
GENERAL: intubated and sedated
HEENT: Sclera anicteric, dry mucous membranes
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-distended, bowel sounds present, no guarding, no
organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
RECTAL: Normal tone. Melena present.
NEURO: Somnolent. Does not withdraw to pain in UEs or LEs.
DISCHARGE PHYSICAL EXAM
========================
___ 0723 Temp: 99.4 PO BP: 148/71 HR: 90 RR: 18 O2 sat: 98%
O2 delivery: Ra
GENERAL: Lying awake in bed, in NAD
HEENT: EOMI, anicteric sclera, MMM, asymmetric face (baseline),
thrush improving
HEART: RRR, nl S1/S2, no murmurs, gallops, thrills, or rubs
LUNGS: CTAB anteriorly, no wheezes, rales, rhonchi
ABDOMEN: Soft, non-tender, non-distended, normal bowel sounds
EXTREMITIES: No clubbing, cyanosis, or lower extremity edema; L
foot swollen, pulses palpable; L second toe with mild pain on
medial side with palpation
NEURO: Alert and oriented to self, facial asymmetry (noted
previously) but symmetric smile; follows commands
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
================
___ 02:00PM BLOOD WBC-8.5 RBC-2.22* Hgb-6.3* Hct-23.5*
MCV-106* MCH-28.4 MCHC-26.8* RDW-21.5* RDWSD-79.7* Plt ___
___ 02:00PM BLOOD ___ PTT-26.3 ___
___ 02:00PM BLOOD Glucose-288* UreaN-76* Creat-2.8* Na-159*
K-5.3 Cl-118* HCO3-19* AnGap-21*
___ 02:00PM BLOOD ALT-21 AST-68* CK(CPK)-761* AlkPhos-123
TotBili-0.4
___ 02:00PM BLOOD Lipase-176*
___ 02:00PM BLOOD CK-MB-2 proBNP-713
___ 02:00PM BLOOD cTropnT-0.12*
___ 02:44AM BLOOD CK-MB-6 cTropnT-0.07*
___ 02:44AM BLOOD Albumin-2.6* Calcium-8.6 Phos-2.0* Mg-2.1
___ 02:38PM BLOOD Type-ART pO2-469* pCO2-37 pH-7.33*
calTCO2-20* Base XS--5 Intubat-INTUBATED
___ 02:19PM BLOOD Lactate-8.4*
PERTINENT IMAGING:
==================
CT Head
1. Large acute/subacute left frontal intraparenchymal hemorrhage
with adjacent
mass effect on the frontal horn of the left lateral ventricle.
No midline
shift.
2. Possible burr hole in the left frontal region, correlate with
history of prior surgery.
CT TORSO
1. There is acute pulmonary embolism in the right lower lobar
artery.
2. Prominent hilar nodes likely reactive.
3. Left lower lobe opacities concerning for aspiration or
pneumonia.
4. No evidence of hemoperitoneum or acute intra-abdominal
pathology.
5. Diverticulosis without evidence of diverticulitis.
___ ECHO
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. There is moderate symmetric left
ventricular hypertrophy. The left ventricular cavity size is
normal. Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Physiologic mitral regurgitation is seen (within
normal limits). There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Moderate basal septal hypertrophy with normal
cavity size and hyperdynamic regional/global systolic function.
No definite pathologic valvular flow identified. Mild pulmonary
artery systolic hypertension.
___ MRI MRA BRAIN and NECK
1. Left frontal intraparenchymal hematoma demonstrates acute and
subacute
blood products. There is no distinct area of enhancement seen
in addition to
the blood products to suggest an underlying lesion. However, in
the presence
of hematoma evaluation is limited and a follow-up examination
should be
obtained for further confirmation.
2. Findings suggesting chronic hemorrhage in the right temporal
region.
3. No other areas of abnormal enhancement. No acute infarcts.
4. MRA neck demonstrates areas of stenosis in the right cervical
internal
carotid artery and absence of flow in the left cervical internal
carotid
artery which is visualized distally in the V3 segment
demonstrating
atherosclerotic disease.
5. Intracranial atherosclerotic disease as described
predominantly involving the precavernous, cavernous and
supraclinoid internal carotid arteries right greater than left
side with moderate stenosis on the right.
___ EEG
IMPRESSION: This is an abnormal continuous ICU video-EEG
monitoring study due to the presence of slow background activity
which is indicative of mild- moderate diffuse encephalopathy. It
is nonspecific in etiology but common causes are medications
effect, toxic metabolic disturbances and infections. This
recording captured two pushbutton activations for unclear
reasons. There were no epileptiform discharges or electrographic
seizures. Compared to the previous day's recording, this
recording is somewhat improved.
___ Arterial graft study- Patent SFA-DP bypass graft with
waveforms and velocities as described above.
15 cm heterogeneous fluid collection within the distal thigh,
anterior to the bypass graft without internal vascularity.
___ L foot XR- Cortical discontinuity involving the distal
tuft of distal phalanx of the second toe with some apparent
destruction of subjacent trabecula. Although this could reflect
a subacute fracture, osteomyelitis could have this appearance in
the appropriate clinical setting. Recommend clinical
correlation.
___ MR ___ foot- 1. T1 hypointense signal in the second distal
phalanx with associated marrow edema and enhancement, findings
which can be seen in the setting osteomyelitis if there is an
associated ulcer. However, in the absence of a skin ulcer, more
likely differential considerations would include changes related
to gangrene, Raynaud's phenomenon, or trauma.
2. Of note, similar signal is seen in the distal phalanx of the
first toe. Multifocality makes osteomyelitis somewhat less
likely unless it is
hematogenous spread.
3. Nonenhancing T1 hypointense marrow signal at the first
metatarsal head. This is of uncertain etiology or significance,
but may reflect the unusual instance of subchondral
osteonecrosis in this location. No articular surface collapse
at the first metatarsal head is identified.
4. Unusual pattern of patchy and somewhat serpiginous marrow
signal in the
visualized bones of the midfoot, not fully characterized. This
is also of
uncertain etiology, question osteonecrosis or contusions. It is
possible that more complete MR imaging through the foot could
help in further
characterization. No definite correlate on the radiographs is
identified.
5. Pronounced intramuscular and soft tissue edema and
enhancement, a
nonspecific finding. In the appropriate clinical setting, this
can that can be seen with myositis and cellulitis, but other
etiologies are not excluded.
================
DISCHARGE LABS:
================
___ 05:45AM BLOOD WBC-5.6 RBC-2.60* Hgb-7.6* Hct-24.6*
MCV-95 MCH-29.2 MCHC-30.9* RDW-17.8* RDWSD-59.7* Plt ___
___ 05:45AM BLOOD Glucose-166* UreaN-10 Creat-0.6 Na-136
K-4.4 Cl-97 HCO3-28 AnGap-11
___ 05:45AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.9
Brief Hospital Course:
Mr. ___ is a ___ gentleman with a history of
Alzheimer's dementia, seizure disorder (none recently per
records), HTN, DMII, prostate cancer, PAD c/b dry gangrene L
second toe w/ recent admission ___ - ___ for SFA-DP bypass
(course c/b NSTEMI, ___, R thigh hematoma, and proteus
bacteremia) on ASA and plavix, who presented from his nursing
home with altered mental status and was found to have an IPH and
a pulmonary embolism.
ACUTE ISSUES
#Shock
#Hypotension
The etiology of his hypotension was thought to be primarily due
to acute blood loss from an UGIB and severe volume depletion
from poor PO intake. He did have a small lobar PE, which was
unlikely hemodynamically significant (no evidence of RH strain
on echo or EKG). He was not able to be started on
anticoagulation because of the intraparenchymal hemorrhage. CT
scan showed a possible LLL aspiration pneumonia / pneumonitis so
sepsis was also considered as a potential factor and he was
started on vancomycin and cefepime. He required norepinephrine
on admission but was quickly weaned off after volume
resuscitation with IVF and PRBCs.
#Hypoxemic respiratory failure
The patient was hypoxemic to SpO2 80% on presentation. Given his
hypoxemia and AMS he was intubated for hypoxemic respiratory
failure and airway protection. The patinent's hypoxemia quickly
resolved with suction of secretions and he required minimal vent
settings. Sputum cultures, flu, and viral cultures were
negative. He was started on vancomycin and cefepime for HCAP
coverage given the possible pneumonia seen on CT chest. The
patient was extubated on HD2 after resolution of hypoxemia and
improvement in mental status.
#Pulmonary Embolism.
Patient was found to have a R lobar PE on CTA chest. A formal
TTE did not show any evidence of heart strain. Anticoagulation
was not given in the setting of an intraparenchymal hemorrhage.
LENIs were performed and were negative for DVT.
#IPH
#AMS
#Concern for seizure
Altered mental status was likely related to an acute IPH causing
significant mass effect but no midline shift. In addition, the
patient may have had a seizure given elevated lactate (up to 11)
and elevated CK. Neurosurgery evaluated the patient and
determined that he was not a surgical candidate. Neurology was
consulted and recommended to stop all anti-platelet therapy and
maintain his systolic blood pressure below 150. He received a
follow-up MRI brain and MRA neck that was notable for L frontal
IPH w/ acute and subacute products and no underlying lesion
suggesting chronic hemorrhage in R temporal region. MRA neck
showed areas of stenosis in the R cervical internal carotid
artery and absence of flow in the L cervical internal carotid.
In terms of the concern for seizure, he underwent EEG that did
not show any epileptiform activity. He was continued on his home
keppra and phenytoin and his mental status improved prior to
discharge. Of note, the patient's Plavix was held throughout his
hospitalization. Aspirin was restarted on ___ as per neurology
recs. The patient should never be restarted on Plavix or
anti-coagulation unless cleared by Neurology.
#Acute-on-chronic Anemia
#UGIB
Patient presented with a Hb of 6.3 from a baseline of ___ in the
setting of melena on rectal exam. He was given 2uPRBCs, IV PPI
BID, and octreotide. His Hb increased appropriately to his
transfusions and he did not have any episodes of melena during
hospitalization. He was transitioned to PO PPI BID. After
discussion with his family, it was determined that no further
workup (including endoscopy) would be pursued. His hemoglobin
remained stable throughout the remainder of his hospitalization
in the ___.
#ARF
Cr up to 2.8 from recent baseline of 0.7 on presentation. His
creatinine improved with volume resuscitation back to baseline.
#Hypernatremia
The patient presented with a sodium of 159. This was most likely
secondary to poor PO intake (given evidence of severe
malnutrition) in the setting of baseline dementia and AMS. He
was given D5W and transitioned to free water flushes in his
feeding tube and subsequently, his sodium returned to the normal
range. His sodium remained stable and within the normal range
for the remainder of his hospitalization.
#Left foot soft tissue swelling
___ toe cortical discontinuity and bony destruction
Patient with increased left foot swelling noticed on ___ with
xray concerning for soft tissue swelling and bony discontinuity
and destruction. Recent arterial bypass study showed normal
velocities (___). Etiology includes fracture vs. osteomyelitis
vs. post bypass complication. His pulses are palpable, and only
has mild pain on medial portion of digit. As per vascular not
likely related to bypass. MRI with foci in great toe and ___
digit that could be consistent with osteomyelitis vs. gangrene
vs. Raynaud's. Radiology felt that the imaging was most
consistent with osteonecrosis given the appearance and
distribution in the ___ and ___ toes. Vascular and podiatry felt
there was nothing to do for this as an inpatient, but vascular
they will continue to follow closely as an outpatient.
#Severe protein-calorie malnutrition
Patient has evidence of severe malnutrition which include low
albumin, macrocytosis, volume depletion, hypernatremia. He was
started on thiamine and folate. He was also started on tube
feeds. Speech and swallow evaluated the patient and recommended
a pureed, thin liquid diet. However, patient continued to have
poor PO intake and was kept on tube feeds.
-Continue reevaluation with SLP
# Paraphimosis
This was possibly related to Foley placement. Urology was
consulted and they recommended that a Foley catheter stay in for
1 week with Bacitracin TID. Foley was discontinued prior to
discharge.
CHRONIC ISSUES
#Alzheimer's, dementia -- Continued memantine
#Hyperlipidemia -- Held atorvastatin
#Hypertension -- Held antihypertensives iso shock
#prostate cancer -- in remission
#GERD -- PPI as above
#depression, anxiety -- held mirtazapine, c/w antiseizure meds
for mood stabilization
#Seizure disorder - no reported seizure ___ years -- Continued
home meds
#Borderline/Pre- Diabetes Mellitus (A1c on ___ was 6.4) --
ISS
TRANSITIONAL ISSUES
[] Does not require Plavix as no hard indication; restarted on
ASA monotherapy
[] Would avoid anticoagulation - amyloid, 2 large hemorrhages;
consider IVC filter
[] MRI w/ and w/o in x6-8 weeks to assess for underlying process
[] Neurology follow up in clinic already scheduled for ___
[] Please recheck LFTs after discharge in 1 week
[] Ongoing speech and swallow evaluations; based on results can
discuss long-term nutrition; will need to have goals of care
discussion with family if PO intake does not improve
[] Please do not retract foreskin due to paraphimosis; should
apply Bacitracin TID
[] Has vascular surgery follow-up on ___
[] Please complete course of nystatin for thrush
[] Monitor penile lesion and continue bacitracin to affected
area
#CONTACT: ___ (brother): ___ Daughter:
___ (___)
#CODE: FULL CODE (presumed)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. LevETIRAcetam 1000 mg PO BID
8. Acetaminophen 1000 mg PO BID
9. Aspirin 81 mg PO DAILY
10. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
11. Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI
12. dextran 70-hypromellose 0.1-0.3 % ophthalmic (eye) BID
13. Gabapentin 100 mg PO BID
14. Lisinopril 20 mg PO DAILY
15. magnesium hydroxide 400 mg (170 mg) oral DAILY
16. Memantine 10 mg PO DAILY
17. Mirtazapine 7.5 mg PO QHS
18. Phenytoin Sodium Extended 100 mg PO QAM
19. Phenytoin Sodium Extended 200 mg PO QPM
20. Ranitidine 150 mg PO QHS
21. TraZODone 50 mg PO QHS
22. NIFEdipine (Extended Release) 30 mg PO DAILY
Discharge Medications:
1. Bacitracin Ointment 1 Appl TP TID
2. Glargine 5 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
3. Nystatin Oral Suspension 10 mL PO QID
4. Pantoprazole 40 mg PO Q12H
5. Phenytoin Infatab 200 mg PO QPM
6. Phenytoin Infatab 100 mg PO QAM
7. Acetaminophen 1000 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Bisacodyl 10 mg PO DAILY:PRN Constipation - First Line
11. dextran 70-hypromellose 0.1-0.3 % ophthalmic (eye) BID
12. Docusate Sodium 100 mg PO BID
13. Gabapentin 100 mg PO BID
14. LevETIRAcetam 1000 mg PO BID
15. Lisinopril 20 mg PO DAILY
16. magnesium hydroxide 400 mg (170 mg) oral DAILY
17. Memantine 10 mg PO DAILY
18. Metoprolol Succinate XL 25 mg PO DAILY
19. Mirtazapine 7.5 mg PO QHS
20. Multivitamins W/minerals 1 TAB PO DAILY
21. Polyethylene Glycol 17 g PO DAILY
22. Ranitidine 150 mg PO QHS
23. HELD- Clonidine Patch 0.3 mg/24 hr 1 PTCH TD QFRI This
medication was held. Do not restart Clonidine Patch 0.3 mg/24 hr
until you speak with your doctors
24. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until you speak to the neurologists
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Intraparenchymal hemorrhage
Secondary:
Hypovolemic shock
Hypoxemic respiratory failure
Pulmonary embolism
Upper GI bleed
Acute kidney injury
Malnutrition
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you at ___
___.
Why was I in the hospital?
- You were found to be confused at your nursing home
What was done while I was in the hospital?
- You had a scan of your brain that showed an area of bleeding
- You had some bleeding from your GI tract and were given blood
for low blood counts
- You had a scan of your chest that showed a blood clot in your
lungs
- You initially were in the intensive care you where you had a
tube helping you breathe for a short period of time; you also
needed medication to keep your blood pressure at a good level
for a short period of time
- Your kidneys were injured; you received fluids and they
improved
- Your sodium levels were high, most likely because you were not
consuming enough fluid; you were given fluid and these levels
improved
What should I do when I get home from the hospital?
- Be sure to go to your follow-up appointments
- If you have fevers, chills, worsening confusion, headache,
vomiting, problems breathing, or generally feel unwell, please
call your doctor or call the emergency room
Sincerely,
Your ___ Treatment Team
Followup Instructions:
___
|
10119992-DS-14 | 10,119,992 | 21,252,040 | DS | 14 | 2151-08-15 00:00:00 | 2151-08-16 08:43:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / labetalol / clonidine / lisinopril
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ gentleman with past medical history relevant for
HFpEF (LVEF 62%), CAD s/p CABG (___) with LIMA-LAD, SVG-OM1,
SVG-RPDA-PLV), AS s/p 23mm ___ AVR (___), HIV on
HAART therapy, CKD3 (baseline Creatinine 2 to 2.5), DM type II,
NASH and ___ transferred from ___ after a fall down 3 steps
and
found to have 3 rib fractures.
He is found to be in HFpEF exacerbation and admitted to ___
service.
The patient fell on ___. He states that his fall was
mechanical and he tripped over 3 steps and then landed on his
right side. He denies head strike or LOC. No neck pain. His
thorax hurts, but he denies pain anywhere else.
He states that prior to this he was experiencing SOB with
exertion. He is not exactly sure when it started but knows it
started prior to the fall. He reports minimal weight gain
(cannot
quantify) but increased bilateral ___ edema as well as orthopnea.
Compliant with meds is fine per patient but PCP has raised
concerns in the past.
Denies fever or chills or cough.
Recent travel to the ___ last week.
He smoked 1 cigar a day for the past ___ years.
Alcohol use is 1 drink daily.
Recreational drug denied.
In the ED, on admission, he is hemodynamically stable although
SBP in the 180s on arrival. He is found to be in overload with
pitting ___ edema +2, CXR showing congestion and proBNP 9073.
Cardiology is consulted and recommended one time dose of Lasix
80mg IV and admission to ___ clinic.
Past Medical History:
PAST MEDICAL AND SURGICAL HISTORY:
CARDIOVASCULAR ISSUES: Severe AS s/p AVR (#23 SJM ___, CAD
s/p CABG ___ (LIMA-LAD, SVG-OM1, SVG-RDPA-PLV). HTN. HLD. PVD
s/p
R tibioperoneal PTA ___. HFpEF. 2+ MR. ___ subclavian
stenosis.
OTHER SIGNIFICANT ISSUES: HIV. CKD 3. Type II Diabetes. NASH
cirrhosis.
Social History:
___
Family History:
His father passed away from a MI in his ___.
Mother - history of PVD, died of pneumonia at age ___.
Sister - estranged.
Physical Exam:
ADMISSION EXAM
=================
Gen: Pleasant, calm. No acute distress.
NECK: no carotid bruit, JVP elevated to tragus
CV: RRR, ___ systolic murmur.
LUNGS: bilateral entry, discrete hypoventilation left base. No
wheezing
ABD: Soft, ND, NTTP, no r/g, BS+
EXT: well perfused, pitting edema 2+ until mid calves.
SKIN: intact
DISCHARGE EXAM
===================
Vitals: 98.0 116/56 95 18 91 Ra
Weight: 144.9 lbs
Gen: Pleasant, calm. No acute distress.
NECK: no carotid bruit, JVP elevated 8 cm above sternal border.
CV: RRR, ___ systolic murmur.
LUNGS: bilateral entry, discrete hypoventilation left base. No
wheezing
ABD: Soft, ND, NTTP, no r/g, BS+
EXT: well perfused, no pitting edema in left leg, 1+ in right
leg
(chronic from car accident per patient)
SKIN: intact
Pertinent Results:
ADMISSION LABS:
==================
___ 12:50AM WBC-4.6 RBC-2.66* HGB-8.7* HCT-28.2* MCV-106*
MCH-32.7* MCHC-30.9* RDW-13.4 RDWSD-52.3*
___ 12:50AM NEUTS-54.6 ___ MONOS-16.5* EOS-4.6
BASOS-0.4 IM ___ AbsNeut-2.51 AbsLymp-1.08* AbsMono-0.76
AbsEos-0.21 AbsBaso-0.02
___ 12:50AM PLT COUNT-149*
___ 12:50AM calTIBC-287 VIT B12-621 FOLATE->20
FERRITIN-163 TRF-221
___ 12:50AM ALBUMIN-3.4* IRON-41*
___ 12:50AM CK-MB-8 cTropnT-0.06* proBNP-9073*
___ 12:50AM ALT(SGPT)-48* AST(SGOT)-36 CK(CPK)-100 ALK
PHOS-135* TOT BILI-0.7
___ 12:50AM GLUCOSE-77 UREA N-55* CREAT-2.4* SODIUM-143
POTASSIUM-4.6 CHLORIDE-113* TOTAL CO2-17* ANION GAP-13
DISCHARGE LABS:
===================
___ 07:34AM BLOOD WBC-4.7 RBC-2.75* Hgb-9.0* Hct-28.0*
MCV-102* MCH-32.7* MCHC-32.1 RDW-13.1 RDWSD-48.8* Plt ___
___ 07:34AM BLOOD Glucose-82 UreaN-52* Creat-2.9* Na-139
K-4.2 Cl-100 HCO3-26 AnGap-13
___ 07:34AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.3
___ 07:59AM BLOOD %HbA1c-4.6 eAG-85
MICROBIOLOGY:
==================
___ 1:10 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGES/STUDIES:
==================
CXR ___ IMPRESSION:
1. Left lower lobe opacification most likely consistent with
combination of atelectasis and small effusion, however infection
cannot be excluded in the appropriate clinical setting.
2. Slightly diminished lung volumes with bibasilar atelectasis.
3. Chronic right-sided rib fractures.
BILATERAL LOWER EXT ULTRASOUND ___ IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity veins.
TTE ___ CONCLUSION:
The left atrial volume index is SEVERELY increased. The right
atrium is mildly enlarged. There is no evidence for an atrial
septal defect by 2D/color Doppler. There is mild symmetric left
ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Quantitative 3D volumetric left ventricular ejection fraction is
61 %. Left ventricular cardiac index is normal (>2.5 L/min/m2).
There is no resting left ventricular outflow tract gradient.
Normal right ventricular cavity size with normal free wall
motion. The aortic sinus diameter is normal for gender with
normal ascending aorta diameter for gender. The aortic arch
diameter is normal with a normal descending aorta diameter. An
aortic valve bioprosthesis is present. The prosthesis is well
seated with normal leaflet motion and gradient. The effective
orifice area index is moderately reduced (0.65-0.85 cm2/m2).
There is a valvular jet of mild [1+] aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is mild to moderate [___] mitral regurgitation.
The pulmonic valve leaflets are normal. The tricuspid valve
leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion.
IMPRESSION: Well seated, normal functioning aortic valve
bioprosthesis with normal gradient and mild valvular aortic
regurgitation. Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Mild-moderate mitral regurgitation. Mild pulmonary
artery systolic hypertension.
Brief Hospital Course:
Information for Outpatient Providers: TRANSITIONAL ISSUES:
- Discharge weight 115 lbs
- Discharge Cr 2.9
[ ] Check Cr and lytes on ___ (baseline Cr ___
[ ] Refer to outpatient psych clinic, would be a good candidate
for weekly therapy (possibly cognitive-based). Consider addition
of SSRI.
Mr ___ is a ___ gentleman with past medical history notable
for HFpEF (LVEF 62%), CAD s/p CABG (___) with LIMA-LAD,
SVG-OM1, SVG-RPDA-PLV), AS s/p 23mm ___ AVR (___),
HIV on HAART therapy, CKD3 (baseline Creatinine 2 to 2.5), DM
type II, NASH and ___ transferred from ___ after a fall
(___) down 3 steps and found to have 3 left rib fractures.
He was found to be in HFpEF exacerbation and sent to ___ for
management. He received diuresis with IV Lasix boluses (3x80mg
on ___ and 2x160mg on ___ and 160mg once on ___ with return
to euvolemic status on ___ at which point home Torsemide was
resumed.
# HFpEF exacerbation
Dry weight unknown. Has some chronic edema which seems to be
worse. JVP up to tragus. ProBNP 9073. CXR with congestion.
Triggers include 1) dietary indescretions on ___
versus 2) medication non-adherence (as previously raised by PCP)
and the patient confirms that he has not been taking some of his
medications (exluding HIV meds with which he has been adherent)
in the past few days prior to admission. ACS ruled out per EKG
and negative troponin x2, no worsening LVEF or worsening
valvular disease per TTE. No signs of PNA on exam or CXR, PE
less likely. Arrhythmia event possible but no event on telemetry
while inhouse. He received diuresis with Lasix boluses (3x80mg
on ___ and 2x160mg on ___. Discharged on home Torsemide 30mg
daily. Continued home Carvedilol 25mg BID, Hydralazine 100mg TID
and Amlodipine 5mg daily. Instructed on dietary salt restriction
<2mg daily. Outpatient follow up with ___ clinic NP planned for
___.
# ___ on CKD
Bl Cr ___. Admission Cr 2.4. Cr bumped to 2.9 on day of
discharge, likely in the setting of diuresis. Expect Cr to
normalize back to baseline while back on home Torsemide.
# HTN
Continued home antihypertensives. BP in the 120-140 SBP range
while inpatient. Continued home hydralazine 100mg TID,
carvedilol 25mg BID, amlodipine 5mg daily.
# Ischemic and valvular cardiomyopathy
Patient known for CAD s/p CABG (___) with LIMA-LAD, SVG-OM1,
SVG-RPDA-PLV). Patient also known for AS s/p 23mm ___
AVR (___). ACS ruled out per EKG and troponins 0.06 x2. TTE
on ___ showed normal LVEF 61% and well seated and functioning
bioprostetic aortic valve. Continued home aspirin and statin.
# Rib fracture
Seen by surgery in ED. Mechanical fall down ___ steps with
non-displaced ___ rib
fractures. No surgical intervention planned at this time.
Continued pain control with PRN Tylenol.
# Macrocytic Anemia
Worsening slowly in the past few months. Recent EGD & ___
showing erosive gastritis/some esophagitis and 2 polyps which
were removed. Macrocytosis itself could be ___ antiretroviral
regimen. Despite cirrhosis diagnosis, no hx of varices. Labs
show Ferritin: 163, calTIBC: 287, VitB12 and Folate wnl. Given
IV ferric gluconate 125mg x2.
# NASH Cirrhosis
Likely mixed secondary to HLD, DM, HIV. Documented to have NASH.
1. No hx of ascites
2. No history of SBP.
3. No hx of varices (last EGD ___
4. Screening: last U/S ___ unremarkable apart from known
gastritis.
# HIV
With regards to HIV, he is on HAAT. Recently in ___, he
was switched from ABC+3TC+DTG to a nucleoside-sparing regimen of
dolutegravir plus rilpivirine due to concern of increased risk
for cardiovascular disease in the setting of long term exposure
to abacavir. However, his Creatinine went from 2 (baseline) to
3.7 in ___, after a few months of this new regimen.
Therefore, he was switched him back to ABC+3TC+DTG. On ___
his Cr was 2.9. Plan to continue Home ABC+3TC+DTG.
# Depressed Mood
During last two days of hospitalization, patient reported
feeling very sad and lonely. He lost his partner ___ years ago
and has very few friends left. Psych was consulted and indicated
no concern for SI or harm to self/others. He goes to therapy
through ___ intermittently, but not weekly. The patient would
be interested in a consultation with a psychiatrist outpatient.
Plan is to connect him with ___ outpatient psych on discharge.
Inpatient psych said he may benefit from addition of a SSRI.
*Of note, the patient was noted to have type 2 DM in the past.
His HbA1c during this hospitalization was 4.6.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Acyclovir 400 mg PO BID
3. Aspirin 81 mg PO DAILY
4. BuPROPion (Sustained Release) 100 mg PO QAM
5. Dolutegravir 50 mg PO DAILY
6. LaMIVudine 100 mg PO DAILY
7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
8. Rosuvastatin Calcium 40 mg PO QPM
9. Cetirizine 10 mg PO DAILY
10. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. Vitamin D ___ UNIT PO 1X/WEEK (WE)
13. Torsemide 30 mg PO DAILY
14. CARVedilol 25 mg PO BID
15. HydrALAZINE 100 mg PO TID
16. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
You may buy this medicine (Tylenol) over the counter.
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg 2
tablet(s) by mouth every eight (8) hours Disp #*150 Tablet
Refills:*0
2. Abacavir Sulfate 600 mg PO DAILY
3. Acyclovir 400 mg PO BID
4. amLODIPine 5 mg PO DAILY
5. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
6. Aspirin 81 mg PO DAILY
7. BuPROPion (Sustained Release) 100 mg PO QAM
8. CARVedilol 25 mg PO BID
9. Cetirizine 10 mg PO DAILY
10. Dolutegravir 50 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU DAILY
12. HydrALAZINE 100 mg PO TID
13. LaMIVudine 100 mg PO DAILY
14. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
15. Rosuvastatin Calcium 40 mg PO QPM
16. Torsemide 30 mg PO DAILY
17. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute on chronic heart failure with preserved ejection fraction
Secondary diagnoses:
HIV
HTN
___
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Mr. ___,
It was a privilege caring for you at ___.
WHY WAS I IN THE HOSPITAL?
- You came to the hospital after suffering a fall, enduring 3
rib fractures. You were transferred from ___ for treatment of
your heart failure.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- You were found to have extra volume as a result of your heart
failure.
- You were giving a medication through the IV (lasix) to help
remove extra volume.
- You were seen by the psychiatry team.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
- Please attend your follow-up appointments as scheduled.
- Please return if you feel any chest pain or if you feel you
are short of breath.
- Your weight at discharge is 115 lbs.
- Please weigh yourself every day in the morning. Call your
doctor if your weight goes up by more than 3 lbs.
- Please follow up with outpatient psychiatry.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10119992-DS-15 | 10,119,992 | 25,316,635 | DS | 15 | 2151-09-02 00:00:00 | 2151-09-07 09:13:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Juluca / labetalol / clonidine / lisinopril
Attending: ___.
Chief Complaint:
Elevated creatinine
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH of HFpEF (LVEF 62%), CAD s/p CABG [___] with
LIMA-LAD, SVG-OM1, SVG-RPDA-PLV), AS s/p 23mm ___ AVR
(___), HIV on HAART therapy (CD4 ___, CKD3 (baseline
creatinine 2 to 2.5), DM type II, NASH, HTN, and recent
admission
for CHF now presents with ___.
Patient had recent admission ___nd found to
have 3 rib fractures, found to be in HFpEF exacerbation. During
his last admission ___, he received diuresis with IV Lasix
boluses (3x80mg) on ___ and 2x160mg on ___ and 160mg once on
___ with return to euvolemic status on ___ at which point
home
Torsemide was resumed. He was discharged with no changes to his
home medications. Baseline creatinine is ___. Admission Cr
2.4.
Cr bumped to 2.9 on day of discharge, likely in the setting of
diuresis. Expect Cr to normalize back to baseline while back on
home Torsemide. Weight down 10 pounds during the last admission
between ___ and ___ [124.1 to 114.86]. Although the patient
was discharged on his home medications, he states that he was
not
taking them prior to his admission, and has a history of medical
non compliance documented in his charts, with the exception of
his HIV medications. He began taking his medications after he
was
discharged. No change in any medications since he was
discharged,
including HIV medications.
He had a follow up appointment for his recent hospitalization
and
had labs checked ___ which showed a creatinine of 4.6 (up from
2.9 3 on ___.
In the ED
- Initial vitals were: 98.8, HR 60, BP 97/46, RR 18, 95% RA
BP 9:34: 97/46
BP 14:28 125/55
15:36 got fluids
- EKG: NSR, HR 63, PR 200, RBBB, LAFB, No STE
- Labs/studies notable for: cr: 4.6, BUN: 85, Mg: 3.1 P: 5.7,
Hg:
8.4
- Patient was given: 500 mL LR
Imaging: ___ Renal Artery Doppler
1. Diffusely echogenic kidneys with cortical thinning and
absence
of diastolic flow bilaterally, compatible with chronic medical
renal disease.
2. No evidence of hydronephrosis.
3. Echogenic structure along the posterior aspect of the
bladder,
which may represent a bladder fold. If macro or microhematuria
is
present, urology consultation is recommended
On the floor patient is stable. He says he has been more tired
recently, but denies any difficulty urinating, denies urinary
retention, difficulty initiating or maintain his stream,
dysuria,
hematuria. He denies increased urinary frequency and does not
awake in the night to urinate. He denies any fevers, suprapubic
pain, or abdominal pain. He denies any difficult passing stool,
with no straining. Denies hematochezia, melena, diarrhea,
constipation. Denies vomiting. He denies NSAID or PPI use.
Denies
any antibiotic use in the recent past. No new skin rashes. No
new
cough, myalgia, joint pains.
He has been experiencing SOB on exertion as well as
palpitations,
both of which started after his cruise and has persisted. No
chest pain, no orthopnea, no PND.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- HLD
- PVD s/p R tibioperoneal PTA ___
2. CARDIAC HISTORY
- HFpEF
- CAD s/p CABG [___] with LIMA-LAD, SVG-OM1, SVG-RPDA-PLV)
- AS s/p 23mm ___ AVR (___)
- Sinus Rhythm
- No pacemaker
- 2+ MR
- Probable L subclavian stenosis
OTHER SIGNIFICANT ISSUES:
- HIV
- CKD 3
- Type II Diabetes
- ___ cirrhosis.
Social History:
___
Family History:
His father passed away from a MI in his ___.
Mother - history of PVD, died of pneumonia at age ___.
Sister - estranged.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
VS: 98.5 130 / 103 64 16 95 RA
GENERAL: Well developed, well nourished 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: PMI located in ___ intercostal space, midclavicular
line. Regular rate and rhythm. Normal S1, S2. Third heart sound.
LUNGS: No chest wall deformities. Left sided tenderness IC
spaces
3 down. Respiration is unlabored with no accessory muscle use.
No
crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: WWP, trace pitting edema R>L (chronic per pt)
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
======================
PHYSICAL EXAMINATION:
=======================
24 HR Data (last updated ___ @ 725)
Temp: 99.0 (Tm 99.4), BP: 123/60 (123-154/55-69), HR: 68
(66-75), RR: 20 (___), O2 sat: 94% (94-97), O2 delivery: Ra
Fluid Balance (last updated ___ @ 549)
Last 8 hours Total cumulative -1090ml
IN: Total 0ml
OUT: Total 1090ml, Urine Amt 1090ml
Last 24 hours Total cumulative -1060ml
IN: Total 780ml, PO Amt 780ml
OUT: Total 1840ml, Urine Amt 1840ml
GENERAL: well appearing gentleman, sitting on edge of bed in
NAD
HEENT: JVP unable to assess
LUNGS: No crackles. No wheezes or rhonchi.
HEART: Normal rate. Regular rhythm. AV click.
ABDOMEN: soft, nontender, nondistended.
EXT: Warm, well-perfused. 2+ edema b/l R>L (chronic per pt,
post-car accident)
Pertinent Results:
ADMISSION LABS:
==============
___ 10:20AM GLUCOSE-92 UREA N-85* CREAT-4.6* SODIUM-136
POTASSIUM-5.3 CHLORIDE-97 TOTAL CO2-22 ANION GAP-17
___ 10:20AM estGFR-Using this
___ 10:20AM ALT(SGPT)-55* AST(SGOT)-42* LD(LDH)-260* ALK
PHOS-154* TOT BILI-0.4
___ 10:20AM CALCIUM-8.4 PHOSPHATE-5.7* MAGNESIUM-3.1*
___ 10:20AM TSH-1.0
___ 10:20AM WBC-6.0 RBC-2.59* HGB-8.4* HCT-26.5* MCV-102*
MCH-32.4* MCHC-31.7* RDW-13.2 RDWSD-48.7*
___ 10:20AM NEUTS-48.0 ___ MONOS-14.4* EOS-5.9
BASOS-0.3 IM ___ AbsNeut-2.87 AbsLymp-1.83 AbsMono-0.86*
AbsEos-0.35 AbsBaso-0.02
___ 10:20AM PLT COUNT-164
___ 01:44PM UREA N-80* CREAT-4.6*# SODIUM-131*
POTASSIUM-5.5* CHLORIDE-91* TOTAL CO2-26 ANION GAP-14
___ 01:44PM proBNP-2477*
DISCHARGE LABS:
===============
___ 07:08AM BLOOD WBC-5.4 RBC-2.55* Hgb-8.2* Hct-26.1*
MCV-102* MCH-32.2* MCHC-31.4* RDW-15.3 RDWSD-56.9* Plt ___
___ 07:08AM BLOOD Glucose-84 UreaN-40* Creat-2.8* Na-137
K-4.6 Cl-98 HCO3-26 AnGap-13
___ 07:08AM BLOOD Calcium-8.6 Phos-2.5* Mg-2.5
IMAGING:
========
___ CHEST W/O CONTRAST
IMPRESSION:
1. Mild bilateral ground-glass opacities likely reflect mild
pulmonary edema.
Moderate bilateral lower lobe atelectasis and small to
medium-sized bilateral
pleural effusions.
2. Severe acute appearing nondisplaced left lateral rib
fractures.
3. Morphological abnormality of the liver suggesting
fibrosis/cirrhosis.
___ (PORTABLE AP)
IMPRESSION: New pulmonary vascular congestion. Retrocardiac
opacities are re-demonstrated but decreased in density. No
large pleural effusion.
___ RENAL ARTERY DOPPLER
IMPRESSION:
1. Diffusely echogenic kidneys with cortical thinning and
absence of diastolic
flow bilaterally, compatible with chronic medical renal disease.
2. No evidence of hydronephrosis.
3. Echogenic structure along the posterior aspect of the
bladder, which may
represent a bladder fold. If macro or microhematuria is
present, urology
consultation is recommended.
MICROBIOLOGY:
=============
___ 10:09 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Brief Hospital Course:
SUMMARY:
___ w/ PMH of HFpEF, CAD s/p CABG x3 ___, with LIMA-LAD,
SVG-OM1, SVG-RPDA-PLV), AS s/p bioAVR ___, CKD3 (baseline
creatinine 2 to 2.5), HIV on HAART therapy (CD4 ___, DM
type II, NASH, HTN, and recent admission for CHF who originally
presented with soft BPs and ___ thought due to
overdiuresis/HD-mediated. Initially Cr improved with holding
home diuretic and BP meds, but then became volume-overloaded.
Diuresis initiated with IV Lasix 120 boluses, which was
complicated by worsening ___, eventual RHC ___ with normal
filling pressures CVP 7, PCWP 15. Course c/b hyperkalemia,
symptomatic bradycardia, hypotension, s/p CCU stay with CRRT
___. Pt improved and transferred to the floor with moderate
___ off RRT. Pt remained volume overloaded with 2+ ___ edema but
decision was made to diurese slowly with PO diuretic given the
tenuousness of his renal function and lack of symptoms. He was
started on torsemide 60 mg and net fluid balance was slightly
negative. After discussion of risks/benefits with pt, decision
was made to discharge home with ___ services and close f/u.
TRANSITIONAL ISSUES:
==================
General:
[] Post discharge labs: chemistry, CBC within 1 week to document
stability of Cr, electrolytes on diuretic and stable Hgb
[] F/u Appts: PCP, ___, Nephrology, Cardiology, ID
___:
[] Pt not fully euvolemic on d/c (persistent 2+ pitting edema
R>L, some chronic and not reversible) but decision was made to
diurese slowly with PO diuretic given he the tenuousness of his
renal function and lack of symptoms.
[] F/u volume status, chemistry and titrate diuretics
accordingly
[] F/u BPs and adjust afterload accordingly (may need less BP
meds) and consider cross titration from hydral to amlodipine
- Discharge weight: 126.2 lbs
- Discharge diuretic: Torsemide
- Discharge Cr: 2.8
# CKD
[ ] Follow up on renal artery doppler ultrasound completed on
___, specifically "Echogenic structure along the
posterior aspect of the bladder, which may represent a bladder
fold. If macro or microhematuria is present, urology
consultation is recommended."
OTHER:
[] Pt had slow decrease in Hgb during hospitalization requiring
1u PRBC, likely multifactorial but possibly slow GI bleed ___
known gastritis. He was started on PPI. Recheck CBC as outpt and
if persistent issue, consider GI referral for endoscopy.
[] Consider adding SSRI for depression, CBT/therapy, or referral
to psychiatry
[] Consider pulmonary function tests give dropping ambulatory
saturations and smoking history
======================
ACTIVE ISSUES:
Cardiac history includes CAD s/p CABG [___] with LIMA-LAD,
SVG-OM1, SVG-RPDA-PLV), AS s/p 23mm ___ ___,
HIV on HAART therapy (CD4 ___, CKD3 (baseline creatinine
2 to 2.5), DM type II, NASH, HTN.
___
Cr on admission 4.6 up from recent Cr 2.9 on ___ up from
baseline of 2.0-2.5. Most likely dx is pre-renal ___ iso
overdiuresis, supported by Cr increase on day of discharge from
last hospitalization, 10 lb diuresis in three days, recent new
medication compliance including torsemide 30 mg daily, and low
BNP ___ of prior admitting BNP). However the BUN:creatinine
ratio of less than 20 points away from this, as does the FEUREA
> 35, the patients elevated weight from discharge, normal urine
output per his report, and increased SOB indicating potential
overload. Other potential causes for elevated creatinine is an
ATN secondary to hypotension given his new home use of
amlodipine 5 daily, carvedilol 25 mg BID, and hydralazine 100 mg
TID. Renal US showing no hydronephrosis. No hx of PPI or NSAIDs.
Initially held home torsemide iso ___, was restarted during
admission. Renal was consulted and thought most likely etiology
was pre-renal in the setting of overdiuresis. However, despite
holding diuresis, the patient's Cr continued to rise so he had a
RHC on ___ that showed normal left and right heart filling
pressures. He was transferred to the CCU for CRRT because of
hyperkalemia causing bradycardia. After stabilizing, he was
transitioned back to the floor. His ___ increased and Cr
stabilized off of RRT. He was d/c at Cr 2.8 with close renal f/u
# HFpEF
# HTN
Hx of HFpEF (EF 61% ___ with recent exacerbation in ___
likely ___ dietary and med indiscretion. On admission, volume
data is mixed. Wt slightly elevated and CXR shows new pulmonary
congestion. Dry on exam and BNP decreased 50% from prior.
Preload: Held home Torsemide then restarted. Afterload:
Hydralazine, carvedilol, and amlodipine. Doses were actively
titrated during this admission. At discharge he was on:
torsemide 60mg daily, amlodipine 2.5mg daily, and hydralazine
25mg TID.
# Bradycardia
Patient newly bradycardic overnight on ___ with symptoms of
dyspnea. Thought to be likely ___ hyperkalemia vs. complication
from right heart cath. Patient given atropine x 2 with no
sustained
resolution. Patient was transferred to the CCU and placed on
dopamine and epinephrine gtts. Trialysis line and A-line were
placed on ___. He then converted on his own the morning of ___
with no further bradycardia thereafter. Drips were stopped. EP
decided to hold off on further intervention as this was though
to be ___ electrolyte imbalances. He was monitored on telemetry
and called out to the floor on ___.
#Dyspnea on exertion with hypoxia
SpO2 92% RA, ambulatory down to 88%. Likely ___ pulm edema, b/l
pleural effusions seen on CT Chest. These effusions were thought
to be due to a heart failure exacerbation.
CHRONIC ISSUES:
# CAD
Hx of CAD s/p CABG (___) with LIMA-LAD, SVG-OM1,
SVG-RPDA-PLV. Continued home aspirin and statin.
#S/p bioAVR
Hx of 23mm ___ AVR (___). TTE ___ with well
seated and functioning bioprostetic aortic valve. LDH and total
bilirubin normal.
# Rib fracture
Seen by surgery in ED during last admission. Mechanical fall
down ___ steps with non-displaced ___ rib fractures. No
surgical intervention planned. Pain was controlled with PRN
tylenol.
# Macrocytic Anemia
Recent EGD & ___ showing erosive gastritis/some esophagitis and
2 polyps which were removed. S/p IV ferric gluconate 125mg x2
last admission. Hgb at baseline in ___.
# NASH Cirrhosis:
Likely mixed secondary to HLD, DM, HIV. Documented to have NASH.
Well compensated.
# HIV
CD4 700 and VL ND in ___.
- Continue home Ddolutegravir 50 mg, abacavir 600 mg, lamivudine
50.
- Had to do reduced doses of acyclovir given poor GFR
# Depressed Mood
During hospitalization, patient reported feeling very sad and
lonely. He lost his partner ___ years ago and has very few
friends left. Psych was consulted during last admission and
indicated no concern for SI. He goes to therapy through ___
intermittently. During last admission patient was arranged to
see ___ outpatient psych on discharge. Continued home
bupropion. Consulted social work during this admission for
connection of services. Consider outpatient follow-up with
psychiatry, adding SSRI, and therapy
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Acyclovir 400 mg PO BID
3. amLODIPine 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. BuPROPion (Sustained Release) 100 mg PO QAM
6. CARVedilol 25 mg PO BID
7. Dolutegravir 50 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. HydrALAZINE 100 mg PO TID
10. LaMIVudine 100 mg PO DAILY
11. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
12. Rosuvastatin Calcium 40 mg PO QPM
13. Torsemide 30 mg PO DAILY
14. Cetirizine 10 mg PO DAILY
15. Vitamin D ___ UNIT PO 1X/WEEK (WE)
16. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
17. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
Discharge Medications:
1. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. amLODIPine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. HydrALAZINE 25 mg PO TID
RX *hydralazine 25 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
5. Abacavir Sulfate 600 mg PO DAILY
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
7. Acyclovir 400 mg PO BID
8. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
9. Aspirin 81 mg PO DAILY
10. BuPROPion (Sustained Release) 100 mg PO QAM
11. CARVedilol 25 mg PO BID
12. Cetirizine 10 mg PO DAILY
13. Dolutegravir 50 mg PO DAILY
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. LaMIVudine 100 mg PO DAILY
16. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
17. Rosuvastatin Calcium 40 mg PO QPM
18. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Acute Kidney Injury on Chronic Kidney Disease
# Chronic heart failure with preserved ejection fraction
# severe aortic stenosis s/p AVR
# CAD s/p CABG
# HTN
# PVD
# HIV
# CKD3
# DM2
# ___ 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 privilege caring for you at ___.
Please see below for more information on your hospitalization.
WHY WERE YOU ADMITTED TO THE HOSPITAL?
- Your kidney numbers were elevated.
WHAT WAS DONE WHILE YOU WERE IN THE HOSPITAL?
- We monitored your kidney function.
- We made changes to your blood pressure medications
- We made changes to your diuretic medications
- You were seen by the kidney doctors (___) who
recommend that you follow up with them shortly after discharge.
WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL?
- Take all of your medications as prescribed (listed below)
- Follow up with your doctors as listed below
- Weigh yourself every morning, seek medical attention if your
weight goes up more than 3 lbs from your discharge weight of 126
lbs.
- 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.
It was a pleasure taking part in your care here at ___!
We wish you all the best!
- Your ___ Care Team
Followup Instructions:
___
|
10119992-DS-16 | 10,119,992 | 20,137,492 | DS | 16 | 2151-09-15 00:00:00 | 2151-09-15 16:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___ / labetalol / clonidine / lisinopril
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH of HFpEF (LVEF 61%), CAD s/p CABG [___] with
LIMA-LAD, SVG-OM1, SVG-RPDA-PLV), AS s/p 23mm ___ AVR
(___), HIV on HAART therapy (CD4 ___, CKD3 (baseline
creatinine 2 to 2.5), DM type II, NASH, HTN with recent
admission
for ___ c/b bradycardia who presents with worsening SOB c/w
heart
failure exacerbation and concern for a pneumonia.
He initially presented to ___ with dyspnea and CXR was
concerning for pneumonia. He was also noted to be volume
overloaded on exam with bilateral lower extremity edema. He was
given ceftriaxone and azithromycin and was transferred to ___
as his care is here. On arrival to the ED, he notes SOB that has
been worsening over the past 2 days. He also endorses worsening
___ lower extremity edema, R>L. He denies CP, abdominal pain,
vomiting or diarrhea.
Of note, patient has multiple recent admissions including one
___nd found to have 3 rib fractures, found
to be in HFpEF exacerbation. During that admission, he received
diuresis with IV Lasix boluses (3x80mg) on ___ and 2x160mg on
___ and 160mg once on ___ with return to euvolemic status on
___ at which point home Torsemide was resumed.
He then had another admission ___ for soft BPs and ___
thought due to overdiuresis/HD-mediated. Initially Cr improved
with holding home diuretic and BP meds, but he then became
volume-overloaded. Diuresis was initiated with IV Lasix 120
boluses, which was complicated by worsening ___, eventual RHC
___
with normal filling pressures CVP 7, PCWP 15. Course c/b
hyperkalemia, symptomatic bradycardia, hypotension, s/p CCU stay
with CRRT ___. Pt improved and transferred to the floor with
moderate ___ off RRT.
Pt remained volume overloaded with 2+ ___ edema but decision was
made to diurese slowly with PO diuretic given the tenuousness of
his renal function and lack of symptoms. He was started on
torsemide 60 mg and net fluid balance was slightly negative.
After discussion of risks/benefits with pt, decision was made to
discharge home with ___ services and close f/u.
On arrival to the ED, vitals were notable for BP 146/73, HR 75,
RR 26 with O2 saturation of 97% on 3L NC. He later desaturated
and required BiPAP for increased work of breathing. He also
became hypertensive with SBP in the 190s, requiring
nitroglycerin
gtt. Labs were notable for Cr 2.6 (baseline ___, BUN 65, BNP
33286, CK 44, Trop 0.08 -> 0.09, lactate 0.8. A right ___ was
performed with no evidence of DVT and a complex popliteal cyst.
CXR performed demonstrating mild pulmonary edema and small left
pleural effusion. While in the ED, he was placed on a nitro gtt
for hypertension and was given 80mg IV Lasix x2. He also
received
vancomycin and cefepime for HAP coverage.
On arrival to the floor, he endorses the story as above. He
reports that since discharge, he initially was feeling well. He
notes that he was not weighing himself at home until about 1
week
prior to presentation. He also states that he missed a few doses
of ___ torsemide this past week due to his home being multilevel
and not wanting to walk downstairs to take his medications. The
day of presentation, his weight was 121 pounds. He notes that 2
days prior to presentation, he developed shortness of breath.
The
shortness of breath worsened, prompting presentation to ___ as
above.
Past Medical History:
1. CARDIAC RISK FACTORS
- Diabetes
- Hypertension
- HLD
- PVD s/p R tibioperoneal PTA ___
2. CARDIAC HISTORY
- HFpEF
- CAD s/p CABG [___] with LIMA-LAD, SVG-OM1, SVG-RPDA-PLV)
- AS s/p 23mm ___ AVR (___)
- Sinus Rhythm
- No pacemaker
- 2+ MR
- Probable L subclavian stenosis
OTHER SIGNIFICANT ISSUES:
- HIV
- CKD 3
- Type II Diabetes
- NASH cirrhosis.
Social History:
___
Family History:
Father - passed away from ___ in his ___.
Mother - history of PVD, died of pneumonia at age ___.
Sister - estranged.
Physical Exam:
Admission:
___ 1633 BP: 122/57 L Sitting HR: 71 RR: 20 O2 sat: 97% O2
delivery: 2L NC
GENERAL: Elderly man, sitting up in bed, tachypneic but appears
comfortable
HEENT: MMM
NECK: JVP 18cm
CARDIAC: Tachycardia, regular rhythm, no m/g/r
LUNGS: Tachypneic without use of accessory muscles, NC in place,
few bibasilar crackles
ABDOMEN: BS+, abdomen distended, soft, nontender to palpation
EXTREMITIES: Warm and well-perfused, 2+ pitting edema in
dependent areas of thighs bilaterally
SKIN: No significant skin lesions or rashes
PULSES: Distal pulses palpable and symmetric
Discharge:
___ 0723 Temp: 98.3 PO BP: 168/73 R Lying HR: 72 RR: 18 O2
sat: 99% O2 delivery: RA
GENERAL: NAD
NECK: No significant JVD appreciated
CARDIAC: Tachycardia, regular rhythm, no m/g/r
LUNGS: Decreased lung sounds in bases
EXTREMITIES: Warm and well-perfused, 1+ bilateral pitting edema
in calfs, worse on the right
Pertinent Results:
Admission Labs:
___ 10:40PM BLOOD WBC-6.9 RBC-2.60* Hgb-8.2* Hct-26.7*
MCV-103* MCH-31.5 MCHC-30.7* RDW-14.8 RDWSD-55.7* Plt ___
___ 08:10AM BLOOD ___ PTT-27.1 ___
___ 10:40PM BLOOD Glucose-112* UreaN-65* Creat-2.6* Na-143
K-5.1 Cl-108 HCO3-22 AnGap-13
___ 07:53AM BLOOD Calcium-8.9 Phos-4.7* Mg-2.9*
Discharge Labs:
___ 08:27AM BLOOD Calcium-8.9 Phos-3.7 Mg-2.1
___ 08:27AM BLOOD Glucose-84 UreaN-65* Creat-2.5* Na-141
K-4.4 Cl-101 HCO3-26 AnGap-14
___ 08:27AM BLOOD WBC-4.4 RBC-2.40* Hgb-7.6* Hct-24.0*
MCV-100* MCH-31.7 MCHC-31.7* RDW-14.0 RDWSD-51.1* Plt ___
Studies:
___ ___
1. No evidence of deep venous thrombosis in the right lower
extremity veins.
2. Complex 4.4 cm popliteal cyst.
___ CXR
Interval improvement in mild pulmonary edema and interval
decrease in the left pleural effusion, which is now small.
Brief Hospital Course:
Transitional Issues
===================
- Amlodipine increased from 2.5 to 10 mg daily and hydralazine
stopped. Follow up blood pressure at next visit with goal
systolic BP < 140
- F/u weight and chem-10 at next ___ appointment (on ___,
adjust torsemide as necessary
DISCHARGE WEIGHT: 115
DISCHARGE CREATININE: 2.5
DISCHARGE REGIMEN:
- PRELOAD: Torsemide 80 mg daily
- AFTERLOAD: Carvedilol 25 mg BID, Amlodipine 10 mg daily
- NHBK: Carvedilol 25 mg BID
Mr. ___ is a ___ year old man w/ PMH of HFpEF (LVEF 61%), CAD
s/p CABG [___] with LIMA-LAD, SVG-OM1, SVG-RPDA-PLV), AS s/p
23mm ___ AVR (___), HIV on HAART therapy (CD4 ___, CKD3 (baseline creatinine 2 to 2.5), DM type II, NASH,
HTN with recent admission for ___ c/b bradycardia who presented
with worsening SOB c/w heart failure exacerbation. He was
diuresed with IV Lasix to a dry weight of 115 lbs and discharged
on torsemide 80 mg daily.
CORONARIES: CAD s/p CABG [___] with LIMA-LAD, SVG-OM1,
SVG-RPDA-PLV); S/p 23mm ___ AVR (___)
PUMP: HFpEF EF 61%
RHYTHM: Sinus
ACTIVE ISSUES
==============
# Acute on Chronic HFpEF
# Hypoxic respiratory failure. Patient presented to OSH with
dyspnea and increase in bilateral ___ edema. On admission to
___ appeared volume overloaded with worsening LLE edema
and CXR showing pulmonary edema, pleural effusions. BNP elevated
to 33,000 (2500 on last presentation). Likely precipitant was
mis-use
of torsemide; pt usually leaves his medications
(except HAART) in his bedroom but spends most of his time on the
first floor of his apartment. He thus often forgets to go
upstairs to get his afternoon Torsemide and additional notes
that
he thinks he is taking Torsemide 20 mg TID instead of 60 mg
daily
as prescribed. Last discharge weight 126.2 lbs, though was not
felt to
be euvolemic on discharge. Was 115 lbs on discharge ___, which
is likely closer to d/c weight. On discharge ___ was 115 lbs
and euvolemic by exam. Diuresed with IV Lasix boluses until
euvolemic and then transitioned to PO Torsemide 80 mg. Continued
on home carvedilol. For blood pressure control, amlodipine
increased from 2.5 10 mg daily and hydralazine weaned and
ultimately stopped on ___.
#Concern for PNA
s/p ceftriaxone and azithromycin at ___ and Vancomycin in the
ED. CXR at ___ showed no clear opacity although did show
opacity at OSH. Also without cough, fever, or other signs of
pneumonia. Monitored for signs of infection for > 72 hours
in-house. Did not require abx.
#CKD
Cr peaked at 4.9 last admission. Discharged with Cr 2.8 and had
Cr 2.6 on admission, at new baseline (prior baseline 2.0-2.5).
CHRONIC ISSUES:
===============
# CAD
Hx of CAD s/p CABG (___) with LIMA-LAD, SVG-OM1,
SVG-RPDA-PLV.
Continued home aspirin and statin
# S/p bioAVR
Hx of 23mm ___ AVR (___). TTE ___ with well
seated and functioning bioprosthetic aortic valve.
# NASH cirrhosis
Likely mixed secondary to HLD, DM, HIV. Documented to have NASH.
Well compensated.
# Macrocytic anemia
Recent EGD & ___ showing erosive gastritis/some esophagitis and
2 polyps which were removed. Received IV ferric gluconate 125 mg
x2 at recent admission. Hgb at baseline in ___.
# HIV
CD4 700 and VL ND in ___.
Continued home dolutegravir 50 mg, abacavir 600 mg, lamivudine
50. Continued acyclovir.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Abacavir Sulfate 600 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
3. Aspirin 81 mg PO DAILY
4. BuPROPion (Sustained Release) 100 mg PO QAM
5. CARVedilol 25 mg PO BID
6. Cetirizine 10 mg PO DAILY
7. Dolutegravir 50 mg PO DAILY
8. Rosuvastatin Calcium 40 mg PO QPM
9. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
12. Vitamin D ___ UNIT PO 1X/WEEK (WE)
13. Pantoprazole 40 mg PO Q24H
14. amLODIPine 2.5 mg PO DAILY
15. HydrALAZINE 25 mg PO TID
16. Torsemide 60 mg PO DAILY
17. Acyclovir 400 mg PO BID
18. LaMIVudine 100 mg PO DAILY
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Torsemide 80 mg PO DAILY
3. Abacavir Sulfate 600 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
5. Acyclovir 400 mg PO BID
6. AndroGel (testosterone) 1 % (50 mg/5 gram) transdermal DAILY
7. Aspirin 81 mg PO DAILY
8. BuPROPion (Sustained Release) 100 mg PO QAM
9. CARVedilol 25 mg PO BID
10. Cetirizine 10 mg PO DAILY
11. Dolutegravir 50 mg PO DAILY
12. Fluticasone Propionate NASAL 2 SPRY NU DAILY
13. LaMIVudine 100 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
15. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID
16. Rosuvastatin Calcium 40 mg PO QPM
17. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
=======
# Acute on chronic diastolic heart failure
Secondary
=========
# Coronary artery disease
# Chronic kidney disease
# S/p bioAVR
# NASH cirrhosis
# HIV
# Severe malnutrition
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital because you were having
shortness of breath. Please see below for more information on
your hospitalization. It was a pleasure participating in your
care!
We wish you the best!
- Your ___ Healthcare Team
What happened while you were in the hospital?
- You were found to be in a heart failure exacerbation
- You underwent diuresis with IV furosemide and then were
transitioned back to your home Torsemide
- We adjusted your hydralazine and amlodipine as below
- You were improved significantly and were ready to leave the
hospital.
What should you do after leaving the hospital?
- Please take your medications as listed in discharge summary
and - Weigh yourself every morning. Your weight on discharge is
115. Please seek medical attention if your weight goes up more
than 3 pounds in one day (> 118 pounds) or more than 5 pounds
total (>120 pounds).
- 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.
Followup Instructions:
___
|
10120109-DS-10 | 10,120,109 | 22,197,111 | DS | 10 | 2171-04-29 00:00:00 | 2171-04-29 18:48:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / ibuprofen
Attending: ___.
Chief Complaint:
The patient is a ___ year old male who reports that last evening
he became suddenly SOB, sweaty, and clammy while at ___
house. At that time he used a fan to cool off and went home. He
then went home to sleep and continued to feel short of breath.
He reports he slept on his side because of SOB when laying flat.
In addition he has back pain that he refers to has "lung pain"
that he rates at ___ that started at the same time as his
shortness of breath and claminess yesterday evening. In addition
he notes weakness in both lower extremities that started today.
He also notes that at baseline he has pins and needles sensation
in right lower extremity from peripheral neuropathy. This
morning he subsequently went to the an OSH emergency room and
was transferred to ___ for further work up. At the OSH patient
thought to have large bilateral PE's and trop of 0.32.
He denies any fevers, nausea, vomitting, abdominal pain,
dysuria, chest pain, history of stroke, surgery in the last 2
months, hematoschezia, epistaxis, or history hypertension or
hypertesnive crisis. The patient does endorse a history of
hemorrhoids. In addition 2 weeks ago the patient traveled to
___ which was a 3 hour car ride but has not traveled recently.
He also endorses chronic back pain in his lumbar spine that is
currently ___.
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The patient is a ___ year old male who reports that last evening
he became suddenly SOB, sweaty, and clammy while at ___
___. At that time he used a fan to cool off and went home. He
then went home to sleep and continued to feel short of breath.
He reports he slept on his side because of SOB when laying flat.
In addition he has back pain that he refers to has "lung pain"
that he rates at ___ that started at the same time as his
shortness of breath and claminess yesterday evening. In addition
he notes weakness in both lower extremities that started today.
He also notes that at baseline he has pins and needles sensation
in right lower extremity from peripheral neuropathy. This
morning he subsequently went to the an OSH emergency room and
was transferred to ___ for further work up. At the OSH patient
thought to have large bilateral PE's and trop of 0.32.
He denies any fevers, nausea, vomitting, abdominal pain,
dysuria, chest pain, history of stroke, surgery in the last 2
months, hematoschezia, epistaxis, or history hypertension or
hypertesnive crisis. The patient does endorse a history of
hemorrhoids. In addition 2 weeks ago the patient traveled to
___ which was a 3 hour car ride but has not traveled recently.
He also endorses chronic back pain in his lumbar spine that is
currently ___.
Past Medical History:
CHRONIC LOW BACK PAIN
DEEP VENOUS THROMBOSIS
DEGENERATIVE JOINT DISEASE
DIABETES TYPE I
HYPERLIPIDEMIA
Social History:
___
Family History:
Mother with many clots throughout her lifetime. Starting getting
DVT's at age ___ diagnosed with pancreatic cancer at age ___.
Deceased from pancreatic cancer.
No other family history of heart or lung problems.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
==============================
Vitals:
Temp 98.0, HR 111, SpO2 90% non-rebreather + 6L NC, BP 128/98
Gen: sitting up in bed, appears anxious
HEENT: EOMI, PEERLA
Neck: no JVD
Cardiac: RRR, no murmurs
Respiratory: clear to auscultation bilaterally
Abd: soft, non-tender, normal bowels sounds
Extremities: 2+ peripheral pulses, trace edema to mid-shins
bilaterally
Neuro: CN II-XII intact, left lower extremity ___ strength,
right lower extremity ___ strength, "pins and needles sensation
on right lower extremity" and normal sensation in left lower
extremity
PHYSICAL EXAM ON DISCHARGE:
==============================
VS: Tm100 136/92-150/81 HR10___-124 RR20-24 ___ 4L NC (currently
92)
I/O ___ since midnight
Gen: sitting up in bed, no acute distress
Neck: no JVD
Cardiac: tachycardic, regular, no murmurs
Respiratory: clear to auscultation
Abd: soft, non-tender, normal bowels sounds
Extremities: 2+ peripheral pulses, no edema
Neuro: CN II-XII intact, left lower extremity ___ strength,
right lower extremity ___ strength, "pins and needles sensation
on right lower extremity" and normal sensation in left lower
extremity
Pertinent Results:
LABS ON ADMISSION:
========================
___ 03:45PM BLOOD WBC-9.1 RBC-5.22 Hgb-15.4 Hct-47.9 MCV-92
MCH-29.6 MCHC-32.2 RDW-12.7 Plt ___
___ 03:45PM BLOOD ___ PTT-88.1* ___
___ 07:13PM BLOOD ___ 03:45PM BLOOD Glucose-405* UreaN-15 Creat-0.9 Na-141
K-4.9 Cl-104 HCO3-23 AnGap-19
___ 03:45PM BLOOD Calcium-9.3 Phos-3.1 Mg-1.6
___ 07:36PM BLOOD ___ Temp-36.8 pO2-32* pCO2-37
pH-7.45 calTCO2-27 Base XS-0
LABS ON DISCHARGE:
========================
___ 06:15AM BLOOD WBC-10.8# RBC-5.24 Hgb-15.6 Hct-48.0
MCV-92 MCH-29.8 MCHC-32.5 RDW-12.5 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD Glucose-310* UreaN-17 Creat-0.9 Na-138
K-4.4 Cl-102 HCO3-22 AnGap-18
___ 06:15AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.7
STUDIES:
===========
CT chest with contrast ___ ___
There are large pulmonary emboli involving the main pulmonary
arteries extending in the bilateral upper lobes, right middle
lobe, and bilateral lower lobes. There is mild septal deviation
to the left. The aortia is of normal caliber. There is no
lymphadenopathy. The major airways are patent. There are
grounglass opacities in the left upper lobe. There is no pleural
effusion or pneumothorax. There is mild bibasilar subsegmental
atelectasis, scarring.
Impression:
Positive for pulmonary emboli with large clot burden.
Grounglass opacities in the left upper lobe, nonspecific, may be
infectious/inflammatory or atypical pulmonary infarct.
Echo ___:
Left ventricular wall thickness, cavity size and regional/global
systolic function are normal (LVEF >55%). The right ventricular
cavity is dilated with depressed free wall contractility. There
is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The aortic root is mildly
dilated at the sinus level. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Physiologic mitral regurgitation is seen (within
normal limits). There is severe pulmonary artery systolic
hypertension. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Dilated, hypokinetic right ventricle with abnormal
septal motion suggestive of right ventricular pressure/volume
overload (e.g. primary pulmonary process such as PE or COPD).
Mildly dilated aortic root. Severe pulmonary artery systolic
hypertension.
Lower extremity Doppler US:
Left deep venous thrombus within the proximal femoral vein
extending to
the popliteal vein, nonocclusive. Posterior tibial occlusive
thrombus
identified. Right popliteal deep venous non occlusive thrombus.
Brief Hospital Course:
The patient is ___ year old male who presented with one day
history of SOB found to have bilateral PE's at outside hospital,
troponin of 0.32, sinus tachycardia on ECG, and right
ventricular strain on Echo requiring transfer to CCU for
thrombolysis.
#Bilateral Pulmonary Embolisms:
Patient noted to have bilateral pulmonary embolism noted at
outside hospital to have bilateral pulmonary embolism. The
patient was transferred to the CCU for thrombolysis. The patient
was started on tPA protocol as follows: tPA 10mg IV over 1
minute then 40mg over 2 hours with continued Unfractionated
heparin at 1000u/hour with transition to weight based heparin
until therapeutic. Following this, the patient was started on
xarelto 15 mg BID on ___ for 3 weeks and then continued on
20 mg xarelto daily. Ambulating on 5L O2, he gets moderately SOB
but mainatins O2 sat > 88%. He has been instructed to use O2
with any exertion. The etiology of the patient's pulmonary
embolism and lower extremity DVT's was unclear but thought to be
due to possible factor V leiden deficiency and other work up
given family history in mother of recurrent DVT's as well as
recurrent DVT's in father. Plan for outpatient follow up with
Hem/Onc to address hypercoagulable work up with Factor V Leiden
and antiphospholipid syndrome. Patient also with plan to follow
up with Dr. ___ in ___ clinic.
#Hypoxia
Patient's hypoxia and oxygen requirement thought to be secondary
to bilateral pulmonary embolisms as above. The patient was
discharged with home oxygen requirement for sleep and
ambulation.
#Type II Diabetes with peripheral neuropathy
Patient continued on ISS and daily lantus and humalog. Metformin
held.
Gabapentin 100 mg TID continued
#HLD
Patient continued on simvastatin 40 mg daily.
#Chronic Low Back Pain
Patient with chronic low back pain. He was continued on tramadol
50 mg daily.
TRANSITIONAL ISSUES:
===========================
-Follow up with Hem/Onc as outpatient with work up for Factor V
Leiden Deficiency
-Follow up with Dr. ___ in ___ clinic
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. TraMADOL (Ultram) 50 mg PO TID PRN PAIN back pain
2. MetFORMIN (Glucophage) 1000 mg PO BID
3. HumaLOG (insulin lispro) ___ units subcutaneous TID
4. Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
lantus 25 Units Bedtime
5. Simvastatin 40 mg PO DAILY
6. Gabapentin 100 mg PO BID
Discharge Medications:
1. Gabapentin 100 mg PO BID
2. Humalog 15 Units Breakfast
Humalog 15 Units Lunch
Humalog 15 Units Dinner
lantus 25 Units Bedtime
3. Simvastatin 40 mg PO DAILY
4. TraMADOL (Ultram) 50 mg PO TID PRN PAIN back pain
5. Rivaroxaban 15 mg PO/NG BID
RX *rivaroxaban [Xarelto] 15 mg ONE tablet(s) by mouth twice a
day Disp #*38 Tablet Refills:*0
RX *rivaroxaban [Xarelto] 20 mg ONE tablet(s) by mouth DAILY
Disp #*30 Tablet Refills:*2
6. HumaLOG (insulin lispro) ___ units SUBCUTANEOUS TID
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg one tablet(s) by mouth DAILY Disp #*30 Tablet
Refills:*2
9. Oxygen
___ NP continuous. O2 sat < 86% RA. Pulse dose for
portability.
DX: 416 pulmonary embolus
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
Pulmonary embolism (bilateral)
Lower extremity DVT
Secondary
Hyperlipidemia
Type I Diabetes
chronic lower back 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 taking care of you at the ___. You came in
with shortness of breath and were found to have blood clots in
both of your lungs and both of your legs. We started a
medication called xarelto that you should take two times per day
with food for three weeks and then once every day indefinately.
This medication is a blood thinner that will help prevent more
clots from forming.
It has been a pleaure being involved in your care.
Followup Instructions:
___
|
10120109-DS-12 | 10,120,109 | 27,687,066 | DS | 12 | 2174-10-14 00:00:00 | 2174-10-14 22:10:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins / ibuprofen / Humalog
Attending: ___.
Chief Complaint:
RLE DVT
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with known protein C def, recurrent ___ on coumadin (&
lovenox d/t low INRs), DM2, & PVD s/p L ___ bypass (vein
graft) & L ___ toe amp 7 wks ago who p/w RLE DVT.
Past Medical History:
Type II DM, poorly controlled
DVT/PE on Coumadin (goal INR 2.5-3.5)
Tobacco abuse
Type 2 protein C deficiency
HLD
Lower extremity neuropathy
Chronic back pain from car accident in ___
HLD
CTEPH - s/p PTE at ___ in ___
___: Left superficial femoral artery to posterior
tibial artery bypass with in-situ vein, left fourth toe
amputation, angioscopy with lysis of valves.
Social History:
___
Family History:
Mother had recurrent ___, died of pancreatic cancer in her ___
but clots started in her ___. Father had PE around age ___ and
told patient he had Factor V Leiden. Grandfather with lung
cancer. There is no known family history of pulmonary
hypertension.
Physical Exam:
MR. ___ presented to the ED with RLE edema and pain, with US
showing DVT in the limb. He was admitted to the vascular surgery
service floor. Hemetology was consulted for anti-coagulation
recommendations given his acute DVT and known Protein-C
deficiency. Following heme consult recommendations, warfarin was
discontinued, he was started on lovenox 80mg BID. He will
continue at this dose until follow up with his outpatient
hematologist.
While, admitted, US duplex of graft was performed which revealed
that the graft was occluded. He was also noted to have a
dehiscent wound in anterior left leg, from previous bypass
surgical site. The wound did not look infected and was managed
routinely with wet-to-dry dressings.
He was discharged home on ___. At discharge, he was
tolerating a regular diet, ambulating at baseline levels, his
presenting complaint of leg pain was much improved. He will
continue at this dose until follow up with his outpatient
hematologist who can then decided when and what dose of coumadin
he should be on. He will also follow up with Dr. ___ in the
vascular surgery clinic about the occluded graft. These
intructions were conveyed to the patient who verbalized
understanding.
Pertinent Results:
___ 03:23PM ___ PTT-68.9* ___
___ 08:27AM ___ PTT-51.6* ___
___ 01:33AM ___ PTT-40.4* ___
___ 05:48PM LACTATE-1.0
___ 05:36PM GLUCOSE-415* UREA N-10 CREAT-0.5 SODIUM-132*
POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-25 ANION GAP-14
___ 05:36PM estGFR-Using this
___ 05:36PM WBC-8.0 RBC-4.62 HGB-13.2* HCT-39.6* MCV-86
MCH-28.6 MCHC-33.3 RDW-13.0 RDWSD-40.1
___ 05:36PM NEUTS-59.3 ___ MONOS-7.9 EOS-5.3
BASOS-0.8 IM ___ AbsNeut-4.74 AbsLymp-2.09 AbsMono-0.63
AbsEos-0.42 AbsBaso-0.06
___ 05:36PM PLT COUNT-195
___ 05:36PM ___ PTT-27.9 ___
Brief Hospital Course:
___ who presented with RLE DVT. He was previously on Coumadin
but was subtherapeutic and more recently on lovenox while that
level was being adjusted.
Hematology was consulted and recommended a higher dose of
lovenox 80 BID, followed by Coumadin after ___ weeks with a goal
INR of 2.5-3.5. They suggested he follow up with his outpatient
hematologist given this was the patient's preference. His right
leg was wrapped with ace bandage and elevated. Edema was
improved and he was in minimal pain at the time of discharge. We
suggested he continue this at home for symptomatic comfort.
His blood sugars were also very high (300s) and his insulin
regimen was adjusted to 20 lantus at night followed by 8 of
novolog with meals and additional novolog (sliding scale) 2
units for every 50 mg/dL above 150 mg/dL.
His left leg (bypass) was not symptomatic though his pulse exam
was different from prior (weak Doppler signal at ___, faint
signal over graft) and as such an arterial duplex was obtained
demonstrating graft occlusion. We discussed that may require
revision depending on his symptoms, and that for now
anticoagulation would be appropriate as his leg is not
threatened. He will see Dr. ___ in clinic next week for
further discussion.
The full recommendations from hematology and
___ services are reprinted here:
HEMATOLOGY RECOMMENDATIONS (Dr. ___:
- We agree with anticoagulation with IV heparin for now. In
case
there are no vascular interventions planned, we would recommend
switching to subcutaneous enoxaparin at dose of 1 mg/kg every 12
hours. We will recommend rounding off his dose to 80 mg every 12
hours (rather than 70 mg).
- We recommend anti-coagulation with only enoxaparin for the
next
___ weeks and holding warfarin during this time period.
- We recommend follow-up with his hematologist at ___ weeks
interval when he can be transitioned to warfarin for INR goal of
2.5-3.5. He will need overlap of warfarin with enoxaparin until
his INR is therapeutic on two successive blood draws which are
at
least 24 hours apart.
He expressed preference to follow-up with his outside hospital
hematologist, with whom he has a new patient appointment
scheduled in the next few weeks. We strongly emphasized
importance of attending that follow-up appointment.
- We will not recommend direct oral anticoagulants for this
gentleman due to inability to monitor drug levels and history of
recurrent ___.
- We will sign off for now. Please feel free to contact us with
any questions or concerns.
He was also seen by the ___ service for
uncontrolled blood sugars (in 300s). They recommended a new
regimen:
___ NOTE:
Increase to 20 units lantus q24 hours
Start fixed dose Novolog 8 units with meals (hold if not eating)
Novolog sliding scale, 2u per 50 mg/dL over 150mg/dL.
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Metoprolol Tartrate 25 mg PO BID
4. Enoxaparin Sodium 80 mg SC Q12H
5. Glargine 20 Units Bedtime
novolog 8 Units Breakfast
novolog 8 Units Lunch
novolog 8 Units Dinner
6. Atorvastatin 40 mg PO QPM
7. Cyclobenzaprine 5 mg PO TID:PRN pain/spasms
8. FLUoxetine 40 mg PO DAILY
9. Gabapentin 600 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Extensive DVT right leg
Graft thrombosis left bypass graft
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted for pain and swelling in your right leg. This
was found to be due to a large clot in your deep vein (common
femoral) down to your calf veins. You were seen by the
hematology service who recommended a higher dose of lovenox
(enoxaparin) for increased blood thinning to treat this.
You were also suspected based on our physical exam to have a
clot in your bypass graft on your left leg. This was confirmed
based on arterial ultrasound. This may ultimately need to be
treated or revised, but for now the lovenox (enoxaparin) is
optimal for it to settle down some bit.
Followup Instructions:
___
|
10120330-DS-6 | 10,120,330 | 21,812,195 | DS | 6 | 2173-03-14 00:00:00 | 2173-03-14 21:36:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Norvasc
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx of fibroids, anxiety presents with suprapubic
abdominal pain. She describes the pain as intermittent, sharp
suprapubic pain that has been occurring for several years with
progression over the last year, exacerbated by menses and
intercourse. She has known uterine fibroids and reports heavier
periods over the last several months, LMP 1.5 weeks ago. In the
last several months she has also experienced intermittent nausea
(~1x per week) and nonbilious, nonbloody emesis. She reports
that her current presentation is no different than the chronic
pain and nausea/vomiting that she has had over the last year;
she presents today because she wants "to get it under control."
Pt reports occasional chills, denies fevers, reports 20 lb
intentional weightloss over the last year. +Urinary frequency.
Not sexually active for several months. Denies vaginal
discharge, dysuria, urinary urgency.
Pt presented to ___ hosp ___ yesterday and recieved IV fluids
and antiemetics. CT with contrast showed an enlarged uterus with
2 cm hyperdense leiomyoma, no adnexal abnormality. Pt
re-presented to ___ today for continued abdominal pain and
nausea/vomiting where initial vs were:97.4 78 156/101 20 100%.
UA from ___ notable for nitrites and UCx + for E.Coli
>100,000 colonies, pt recieved ceftriaxone, bactrim and
ondansetron. Labs were notable for negative HCG and UA.
Transvaginal ultrasound revealed enlarged, fibroid uterus.
On arrival to the floor, VS 98.4 P 72 154/94 R 18 100% RA.
Patient reports continued nausea but would like to attempt PO
intake.
Past Medical History:
ObHx: ___ ___ VD with IOL for abruption/hemorrhage
___ FT VD c/b preterm labor/bedrest
Both pregnancies c/b hyperemesis
___ TAB
GynHx: Menarche age ___, q28-42d, lasts 6 d with heavy flow. Abnl
Pap with nl Paps since. No STIs.
MedHx: Allergy-induced asthma
Meds: PNV, compazine
Allergies: PCN-->rash
SurgHx: None
Social History:
___
Family History:
Negative for diabetes. Mother and brother both have HTN and HLD.
Sexually active with one male sexual partner, previously on ___
but now only condoms. Last intercourse several months ago.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 98.4 P 72 154/94 R 18 100% RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft, nondistended normoactive bowel sounds, + diffuse
tenderness to palpation, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
RECTAL: multiple perianal skin tags, decreased rectal tone,
small amount dark brown guiaiac neg stool
SKIN no ulcers or lesions
Pertinent Results:
___ 07:01PM LACTATE-0.9
___ 06:55PM GLUCOSE-63* UREA N-11 CREAT-0.9 SODIUM-140
POTASSIUM-3.6 CHLORIDE-106 TOTAL CO2-28 ANION GAP-10
___ 06:55PM ALT(SGPT)-18 AST(SGOT)-20 ALK PHOS-69 TOT
BILI-0.2
___ 06:55PM ALBUMIN-4.4
___ 06:55PM WBC-6.6 RBC-4.33 HGB-11.9* HCT-37.4 MCV-87
MCH-27.5 MCHC-31.8 RDW-14.4
___ 06:55PM NEUTS-56.4 ___ MONOS-5.9 EOS-2.3
BASOS-0.6
___ 06:55PM PLT COUNT-257
MICROBIOLOGY:
from ___:
URINE CULTURE ___
Organism 1 ESCHERICHIA COLI
COLONY COUNT: >100,000 CFU/ML
1. ESCHERICHIA COLI
___ M.I.C.
------ ------
AMIKACIN S <=2
AMPICILLIN S <=2
CEFAZOLIN S <=4
CEFOXITIN S <=4
GENTAMICIN S <=1
IMIPENEM S <=1
LEVOFLOXACIN S <=0.12
NITROFURANTION S <=16
TOBRAMYCIN S <=1
TRIMETHOPRIM/SULFA S <=20
IMAGING:
PELVIS U.S., TRANSVAGINAL; PELVIS, NON-OBSTETRIC; DUPLEX DOP
ABD/PEL LIMITED ___
Transabdominal ultrasound demonstrates an enlarged uterus
measuring
11.8 x 6.5 x 4.4 cm. Transvaginal ultrasound was performed for
better
visualization of the ovaries and adnexa. The endometrial stripe
is normal, measuring 15 mm. 2.1 x 2.0 x 1.8 cm left-sided
fibroid is noted. Scar from prior C-section is noted. The
right ovary is normal. The left ovary is not visualized, but
there is no abnormality seen in the adnexa. Again seen is a
prominent vessel in the right adnexa likely representing a slow
flowing vessel. There is trace free fluid. IMPRESSION:
1. Left ovary not visualized. Normal right ovary.
2. Fibroid uterus.
Brief Hospital Course:
___ with chronic abdominal pain, known uterine fibroids who
presented with several day h/o abdominal pain, nausea/vomiting
in the setting of E coli UTI.
# Abdominal pain: Pt reports chronic lower abdominal pain for at
least one year which is exacerbated by menses and intercourse
and that she presented for evaluation at this time not due to
any change in symptoms, but because she could no longer tolerate
her symptoms. She initially presented to ___ ___ with
abdominal pain, nausea/vomiting where CT was negative for acute
abdominal/pelvic process and she was treated with IVF and
antiemetics and discharged home. She re-presented to ___ the
following day for continued symptoms. Transvaginal US showed
fibroid uterus, normal right ovary, did not visualize the left
ovary but OB/GYN was consulted and had low suspicion for torsion
based on history and exam. Urine HCG was negative. As she was
not tolerating PO, the pt admitted medicine for pain control.
# UTI: Urine culture from ___ grew E coli sensitive to
fluoroquinolones. Although pt described her lower
abdominal/suprapubic pain as chronic, she endorsed urinary
frequency and nausea/vomiting which was considered attributable
to UTI. She was started on IV levofloxacin and transitioned to
ciprofloxacin the following day when she began to tolerate PO
intake. She was discharged with plan to complete 3 day
antibiotic course for uncomplicated UTI. A prescription was sent
electronically to her pharmacy after discharge as the pt called
and reportedly did not receive the paper copy.
# Diarrhea/Decreased rectal tone: Pt reported several year h/o
loose stools and intermittent fecal incontinence. She denied
urgency, but reported inability to prevent bowel movements at
times. She was found to have diminished rectal tone on exam with
dark brown, hemoccult negative stool. Decreased rectal tone
likely due to pelvic floor dysfunction given pt's prior vaginal
deliveries. She denied diarrhea during this admission.
# Uterine Fibroids: Pt found to have 2cm uterine fibroid on
imaging. She endorsed chronic abdominal pain exacerbated by
menses and intercourse as well as several months of heavy
menstrual bleeding and cramping. She was evaluted by OB/GYN in
the ___ and plans to follow up in clinic in the next week.
TRANSITIONAL ISSUES:
# GYN: Outpatient ___ of uterine fibroids and suspected
pelvic floor dysfunction
# Diarrhea: PCP ___ consider GI follow up if persists
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
2. Omeprazole 20 mg PO DAILY
3. Montelukast Sodium 10 mg PO DAILY
4. Felodipine 5 mg PO DAILY
Discharge Medications:
1. Felodipine 5 mg PO DAILY
2. Omeprazole 20 mg PO DAILY
3. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth twice a
day Disp #*2 Tablet Refills:*0
4. Fluticasone Propionate NASAL 2 SPRY NU DAILY
5. Montelukast Sodium 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to the hospital for stomach pain and were
found to have a urinary tract infection (UTI). You were treated
with IV antibiotics at first because of nausea and vomiting. You
received medication to control your nausea and you were able to
take oral antibiotics.
You should continue to take the oral antibiotic (ciprofloxacin)
for one more day (one pill tonight and one tomorrow morning).
Please continue to take your other regular medications as
prescribed. Since you preferred to schedule your ___
appointments with primary care and gynecology, please try to
schedule for appointments in the next week.
Followup Instructions:
___
|
10120372-DS-6 | 10,120,372 | 20,656,547 | DS | 6 | 2183-12-31 00:00:00 | 2184-01-01 16:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Demerol /
Bactrim / Flagyl / clindamycin
Attending: ___
Chief Complaint:
Fall with left chest and mid back pain.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presenting to the emergency department for pain in her mid
back and left chest after a fall yesterday at 3 pm. The patient
has been having intermittent episodes of dizziness with loss of
balance. She was attempting to take her boots off and fell
backwards. +HS, -LOC. She then complained of left chest and mid
back pain.
Past Medical History:
Asthma
Hypertension
Hypothyroidism
Social History:
___
Family History:
Noncontributory
Physical Exam:
T 97.5 BP 129/83 HR 80 RR 18 SatO2 92 RA
Alert and oriented
RRR
CTA bil
Chest tender to palpation on the left side
Tender to palpation of thoracic spine
Abdomen soft, non tender
Extremity no edema, no tenderness or deformity
Brief Hospital Course:
Ms. ___ is a ___ year old Female who presented to the ___
___ on ___ after a
fall from standing with complains of left posterior chest pain
and tenderness over the spine. Imaging confirmed a left rib
fracture and T6 through T8 and T11 compression fractures that do
not looked acute on CT but correlate with tenderness on exam.
The patient was admitted for pain control and evaluation by
Spine Surgery. Orthopedic surgery assessed the patient; no
neurological deficits and no retropulsion was identified on CT.
They recommended a TLSO brace and follow up in outpatient spine
clinic. The patient was placed on a regular diet, was given oral
pain medication and lidocaine patch, and an incentive spirometer
was provided to avoid spinting given her rib fracture. She was
given her home medications.
On ___ was able to tolerate a regular diet, get
out of bed and ambulate without assistance, void without issues,
and pain was controlled on oral medications alone. She was
deemed ready for discharge, and was given the appropriate
discharge and follow-up instructions including wearing her TLSO
brace at all times until follow up in the spine clinic.
Medications on Admission:
IRBESARTAN 150 MG daily
ESCITALOPRAM 20 MG QHS daily
BUPROPION HCL XL 450 MG QAM
QUETIAPINE FUMARATE 75 MG QAM and 100 mg QHS
TRIAMCINOLONE 0.1% PASTE
NYSTATIN-TRIAMCINOLONE CREAM
MUPIROCIN 2% OINTMENT
HYDROCORTISONE 2.5% OINTMENT
BETAMETHASONE DP 0.05% CRM
LEVOTHYROXINE 100 MCG DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 (One) tablet(s) by mouth every four (4)
hours Disp #*30 Tablet Refills:*0
4. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
5. Senna 8.6 mg PO BID:PRN Constipation - First Line
6. BuPROPion XL (Once Daily) 450 mg PO DAILY
7. Escitalopram Oxalate 40 mg PO DAILY
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Mupirocin Ointment 2% 1 Appl TP BID
11. QUEtiapine Fumarate 50 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Fall with Left 7th rib fracture
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 ___ after
a fall from standing and sustained Left 7th rib fracture. You
were observed and placed on a TLSO brace. You have now recovered
and are ready to be discharged. Please follow the instructions
below to continue your recovery:
* Your injury caused ____________ rib fractures which can cause
severe pain and subsequently cause you to take shallow breaths
because of the pain.
* You should take your pain medication as directed to stay ahead
of the pain otherwise you won't be able to take deep breaths. If
the pain medication is too sedating take half the dose and
notify your physician.
* Pneumonia is a complication of rib fractures. In order to
decrease your risk you must use your incentive spirometer 4
times every hour while awake. This will help expand the small
airways in your lungs and assist in coughing up secretions that
pool in the lungs.
* You will be more comfortable if you use a cough pillow to hold
against your chest and guard your rib cage while coughing and
deep breathing.
* Symptomatic relief with ice packs or heating pads for short
periods may ease the pain.
* Narcotic pain medication can cause constipation therefore you
should take a stool softener twice daily and increase your fluid
and fiber intake if possible.
* Do NOT smoke
* If your doctor allows, non-steroidal ___ drugs
are very effective in controlling pain ( ie, Ibuprofen, Motrin,
Advil, Aleve, Naprosyn) but they have their own set of side
effects so make sure your doctor approves.
* Return to the Emergency Room right away for any acute
shortness of breath, increased pain or crackling sensation
around your ribs (crepitus).
*Please wear your TLSO brace at all times until follow up in the
spine clinic.
Followup Instructions:
___
|
10120826-DS-5 | 10,120,826 | 27,121,829 | DS | 5 | 2185-02-21 00:00:00 | 2185-02-21 13:51:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ yo male with a history of prostate cancer
(s/p radiation), DM (Insulin Dependent), and HTN who presents
with acute abdominal pain since yesterday morning around 8AM
(approximately 19 hours ago)that began right after breakfast.
Prior to receiving morphine the pain was much worse. He
describes
the pain as to the right of his umbilicus and with some
radiation to his RLQ. No fevers, nausea, vomiting, or diarrhea.
+ Flatus normally
Past Medical History:
Past Medical History:
Insulin Dependent DM
HTN
Prostate cancer s/p radiation
Past Surgical History:
Tonsillectomy
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals:
Temp: 98 pulse: 60 BP: 124/62 RR: 18 98% RA
GEN: A&O, NAD
ABD: Soft, obese tenderness on deep palpation to right of
umbilicus, no rebound or guarding, no palpable masses or hernias
Discharge Physical Exam:
VS: T: 98.0, HR: 73, BP: 140/67, RR: 16, O2: 95% RA
GEN: A+Ox3, NAD
CV: RRR
PULM: CTA b/l
ABD: soft, non-distended, non-tender to palpation
EXTREMITEIS: warm, well-perfused, no edema b/l
Pertinent Results:
Labs:
___ 09:34AM GLUCOSE-235* UREA N-17 CREAT-0.8 SODIUM-136
POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-23 ANION GAP-19
___ 09:34AM CALCIUM-8.9 PHOSPHATE-3.9 MAGNESIUM-1.5*
___ 09:34AM WBC-3.9* RBC-3.40* HGB-10.8* HCT-30.5* MCV-90
MCH-31.8 MCHC-35.4 RDW-12.5 RDWSD-40.8
___ 09:34AM NEUTS-46.8 ___ MONOS-11.8 EOS-4.4
BASOS-0.5 IM ___ AbsNeut-1.83 AbsLymp-1.41 AbsMono-0.46
AbsEos-0.17 AbsBaso-0.02
___ 09:34AM PLT SMR-LOW PLT COUNT-93*
___ 12:10AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 12:10AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
___ 11:45PM LACTATE-2.2*
___ 11:25PM ALT(SGPT)-22 AST(SGOT)-41* ALK PHOS-60 TOT
BILI-0.4
___ 11:25PM LIPASE-33
___ 11:25PM ALBUMIN-4.1 CALCIUM-9.8 PHOSPHATE-4.3
MAGNESIUM-1.7
___ 11:15PM ___ PTT-30.0 ___
___ 09:43PM GLUCOSE-212* UREA N-25* CREAT-1.0 SODIUM-136
POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-24 ANION GAP-20
___ 09:43PM WBC-4.7 RBC-3.80* HGB-11.4*# HCT-34.2* MCV-90
MCH-30.0 MCHC-33.3 RDW-12.6 RDWSD-41.1
___ 09:43PM NEUTS-38.0 ___ MONOS-13.5* EOS-5.1
BASOS-0.8 IM ___ AbsNeut-1.80 AbsLymp-2.00 AbsMono-0.64
AbsEos-0.24 AbsBaso-0.04
___ 09:43PM PLT COUNT-128*
Imaging:
___: CT Abdomen/Pelvis:
1. Prominent appendix with possible hyperemic wall, without
surrounding fat stranding or fluid. These findings are
worrisome for early appendicitis.
2. Complex bilateral renal cysts incompletely evaluated on this
examination. Further evaluation with dedicated ultrasound is
recommended for better evaluation.
Brief Hospital Course:
Mr. ___ is an ___ y/o male with a hx of prostate cancer (s/p
radiation), DM (Insulin Dependent), and HTN who presented to
___ on ___ with acute abdominal pain x1 day after eating.
CT abdomen/pelvis demonstrated early appendicitis. The patient
was admitted to the Acute Care Surgical service for
non-operative management. Abdominal exam was benign. The
patient was written for PO ciprofloxacin and metronidazole and
was tolerating a regular diet.
On HD2, the patient's abdominal exam remained benign. The
patient received IV morphine for pain control on initial
presentation to the hospital, and was written for oral
acetaminophen and tramadol once tolerating a diet.
The remainder of the ___ hospital course is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet and early ambulation were encouraged throughout
hospitalization.
GI/GU/FEN: Patient's intake and output were closely monitored.
ID: The patient's fever curves were closely watched for signs of
infection. He received a prescription for oral ciprofloxacin
and metronidazole.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Losartan Potassium 50 mg PO DAILY
2. Metoprolol Tartrate 100 mg PO DAILY
3. MetFORMIN (Glucophage) 1000 mg PO BID
4. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous QHS
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*25 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO TID
do NOT drink alcohol while taking this medication
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*38 Tablet Refills:*0
4. TraMADol ___ mg PO Q4H:PRN Pain - Moderate
RX *tramadol 50 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
5. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL)
subcutaneous QHS
6. Losartan Potassium 50 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. Metoprolol Tartrate 100 mg PO DAILY
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:
Dear Mr. ___,
It was a pleasure caring for you at ___
___. You were admitted to the hospital with early
acute appendicitis which was managed conservatively without an
operation. You were started on oral antibiotics and continued
to tolerate a regular diet. Your pain is now better controlled
and you are ready to be discharged home. Please follow the
instructions below to ensure a safe recovery while at home:
Please call your doctor or nurse practitioner or return to the
Emergency Department for any of the following:
*You experience new chest pain, pressure, squeezing or
tightness.
*New or worsening cough, shortness of breath, or wheeze.
*If you are vomiting and cannot keep down fluids or your
medications.
*You are getting dehydrated due to continued vomiting, diarrhea,
or other reasons. Signs of dehydration include dry mouth, rapid
heartbeat, or feeling dizzy or faint when standing.
*You see blood or dark/black material when you vomit or have a
bowel movement.
*You experience burning when you urinate, have blood in your
urine, or experience a discharge.
*Your pain in not improving within ___ hours or is not gone
within 24 hours. Call or return immediately if your pain is
getting worse or changes location or moving to your chest or
back.
*You have shaking chills, or fever greater than 101.5 degrees
Fahrenheit or 38 degrees Celsius.
*Any change in your symptoms, or any new symptoms that concern
you.
Please resume all regular home medications, unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon.
Avoid driving or operating heavy machinery while taking pain
medications.
Followup Instructions:
___
|
10120826-DS-7 | 10,120,826 | 22,684,899 | DS | 7 | 2186-07-24 00:00:00 | 2186-07-29 08:35:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Lisinopril
Attending: ___.
Chief Complaint:
hematuria, urinary clot retention
Major Surgical or Invasive Procedure:
___: CYSTOSCOPY CLOT EVACUATION, BLADDER TUMOR RESECTION
AND FULGERATION
History of Present Illness:
This is a ___ year old male who
presents with history of prostate cancer who presents with
hematuria, clot retention. The patient was diagnosed with
___
3+4 prostate cancer in ___ and underwent XRT. His had PSA
recurrence in ___ which was treated with brachytherapy. His PSA
then rose again and he was started on ADT in ___, then to
abiraterone and prednisone in ___.
On ___ he underwent office cystoscopy with Dr. ___
and was found to have a small vascular L lateral wall bladder
mass. It was not actively bleeding at the time of cystoscopy but
did have an adherent clot. The patient was asymptomatic, denies
fever, chills, dysuria, nausea, abdominal and back pain. Last
night the patient woke up to void but was unable to urinate with
lower abdominal pressure, then began dribbling bloody urine
without control. He presented to the ER.
In the ER the patient was tachycardic and hypertensive. A 20fr
3-way catheter was placed draining bloody urine and VS
normalized. Urology was called and he was subsequently admitted
to Dr. ___.
Past Medical History:
PAST MEDICAL HISTORY:
PROSTATE CANCER
DIABETES MELLITUS
HYPERTENSION
PAST SURGICAL HISTORY:
TONSILLECTOMY
PROSTATE XRT
BRACHYTHERAPY
FEMUR XRT
Social History:
___
Family History:
Non-contributory
Physical Exam:
GEN: NAD, resting comfortably, AAO
HEENT: NCAT, EOMI, anicteric sclera
PULM: nonlabored breathing, normal chest rise
ABD: soft, NT, ND, no rebound/guarding, bladder not
palpably
distended
GU: circumcised penis, orthotopic meatus, penile shaft
without masses or lesions, foley has been removed. Voiding
independently; clear yellow uop.
EXT: WWP. No l/e e/p/c/d. No calf pain bilaterally.
Pertinent Results:
___ 05:55AM BLOOD WBC-5.6 RBC-2.71* Hgb-8.7* Hct-25.8*
MCV-95 MCH-32.1* MCHC-33.7 RDW-13.1 RDWSD-45.2 Plt ___
___ 01:40PM BLOOD Hct-28.3*
___ 05:36AM BLOOD WBC-5.6 RBC-2.84* Hgb-8.9* Hct-26.5*
MCV-93 MCH-31.3 MCHC-33.6 RDW-12.7 RDWSD-43.5 Plt ___
___ 05:28AM BLOOD WBC-5.4 RBC-3.13* Hgb-9.9* Hct-29.2*
MCV-93 MCH-31.6 MCHC-33.9 RDW-12.8 RDWSD-43.5 Plt ___
___ 09:27AM BLOOD WBC-5.6 RBC-3.56* Hgb-11.4* Hct-33.6*
MCV-94 MCH-32.0 MCHC-33.9 RDW-12.7 RDWSD-44.4 Plt ___
___ 09:27AM BLOOD Glucose-188* UreaN-19 Creat-0.9 Na-134*
K-5.5* Cl-100 HCO3-18* AnGap-16
___ 9:27 am URINE **FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
Mr. ___ was admitted to Dr. ___ service from the
ED. Continuous bladder irrigation and recurrent clot required
operative intervention. He was thus taken to the OR by Dr. ___
___ he underwent transurethral resection of bleeding bladder
tumor and clot evacuation. No concerning intraoperative events
occurred; please see dictated operative note for details. He
patient received ___ antibiotic prophylaxis. The
patient's postoperative course was uncomplicated. He received
intravenous antibiotics and continuous bladder irrigation
overnight. On POD1 the CBI was discontinued and Foley catheter
was removed. He voided without difficulty and his post-void
residuals were checked. His urine was clear and and without
clots. He remained a-febrile throughout his hospital stay. At
discharge, the patient had pain well controlled with oral pain
medications, was tolerating regular diet, ambulating without
assistance, and voiding without difficulty. He was given
pyridium and oral pain medications on discharge along with
explicit instructions to follow up in clinic with Dr. ___ in
about two weeks time, Dr. ___ as directed.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Omeprazole 20 mg PO DAILY
2. PredniSONE 10 mg PO DAILY
3. Zolpidem Tartrate 5 mg PO QHS
4. Acetaminophen 650 mg PO Q6H:PRN Pain or headache
5. Docusate Sodium 100 mg PO BID
6. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
7. Senna 8.6 mg PO DAILY
8. bicalutamide 50 mg oral DAILY
9. Losartan Potassium 50 mg PO DAILY
10. abiraterone 1000 mg oral per instructions
11. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Phenazopyridine 200 mg PO Q8H Duration: 3 Days
RX *phenazopyridine [Pyridium] 100 mg ONE tablet(s) by mouth
q8HRS Disp #*9 Tablet Refills:*0
2. abiraterone 1000 mg oral per instructions
3. Acetaminophen 650 mg PO Q6H:PRN Pain or headache
4. bicalutamide 50 mg oral DAILY
REVIEW this medication with your PCP
5. Docusate Sodium 100 mg PO BID
6. Glargine 56 Units Bedtime
Humalog 22 Units Breakfast
Humalog 22 Units Lunch
Humalog 24 Units Dinner
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
10. PredniSONE 10 mg PO DAILY
11. Senna 8.6 mg PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS
13. HELD- Losartan Potassium 50 mg PO DAILY This medication was
held. Do not restart Losartan Potassium until REVIEW this
medication with your PCP
___:
Home
Discharge Diagnosis:
hematuria
clot retention
bladder tumor
anemia of acute blood loss
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
These steps can help you recover after your procedure.
DO drink plenty of water to flush out the bladder.
DO avoid straining during a bowel movement. Eat
fiber-containing foods and avoid foods that can cause
constipation. Ask your doctor if you should take a laxative if
you do become constipated.
Don't take blood-thinning medications until your doctor says
it's OK.
Don't do any strenuous activity, such as heavy lifting, for
four to six weeks or until your doctor says it's OK.
Don't have sex. You'll likely be able to resume sexual
activity in about four to six weeks.
Don't drive until your doctor says it's OK. ___, you can
drive once your catheter is removed and you're no longer taking
prescription pain medications.
You may continue to periodically see small amounts of blood in
your urine--this is normal and will gradually improve. You may
have clear or yellow urine that periodically turns pink/red
throughout the healing process. Generally, the discoloration of
the urine is OK unless it transitions from ___,
___ Aid to a very dark, thick or like tomato juice
color
Resume your pre-admission/home medications EXCEPT as noted.
You should ALWAYS call to inform, review and discuss any
medication changes and your post-operative course with your
primary care team.
Unless otherwise advised, blood thinning medications like
ASPIRIN should be held until the urine has been clear/yellow for
at least three days. Your medication reconciliation will note
if you may resume aspirin or prescription blood thinners (like
Coumadin (warfarin), Xarelto, Lovenox, etc.)
If needed, you will be prescribed an antibiotic to continue
after discharge or save until your Foley catheter is removed
(called a trial of void or void trial).
You may be discharged home with a medication called PYRIDIUM
that will help with the "burning" pain you may experience when
voiding. This medication may turn your urine bright orange.
Colace has been prescribed to avoid post surgical constipation
and constipation related to narcotic pain medication.
Discontinue if loose stool or diarrhea develops. Colace is a
stool softener, NOT a laxative, and it is available
over-the-counter
AVOID STRAINING for bowel movements as this may stir up
bleeding. Avoid constipating foods for ___ weeks, and drink
plenty of fluids to keep hydrated
No vigorous physical activity or sports for 4 weeks or until
otherwise advised
Do not lift anything heavier than a phone book (10 pounds) or
participate in high intensity physical activity (which includes
intercourse) for a minimum of four weeks or until you are
cleared by your Urologist in follow-up
Acetaminophen (Tylenol) should be your first-line pain
medication. A narcotic pain medication may also be prescribed
for breakthrough or moderate pain.
The maximum daily Tylenol/Acetaminophen dose is 3 grams from
ALL sources.
Do not drive or drink alcohol while taking narcotics and do
not operate dangerous machinery.
WHEN YOU ARE DISCHARGED WITH A FOLEY CATHETER:
o-Please also reference the nursing handout and instructions on
routine care and hygiene
o-Your Foley should be secured to the catheter secure on your
thigh at ALL times until your follow up with the surgeon.
o-DO NOT allow anyone outside your urologist/team
representative remove your Foley for any reason.
o-Wear Large Foley bag for majority of time. The leg bag (if
provided) is for short-duration periods and the bag must be
emptied frequently.
o-Do NOT drive if you have a Foley in place (for your
safety-but of course you may be a passenger
Followup Instructions:
___
|
10120826-DS-8 | 10,120,826 | 23,274,807 | DS | 8 | 2188-03-25 00:00:00 | 2188-03-25 20:34:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lisinopril
Attending: ___
Chief Complaint:
lower ext weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
================================================================
Oncology Hospitalist Admission
Date: ___
================================================================
PRIMARY ONCOLOGIST: ___
PRIMARY DIAGNOSIS: Metastatic Prostate Cancer
TREATMENT REGIMEN: Previously Enzalutamide/Lupron
CHIEF COMPLAINT: Lower extremity weakness, back pain
HISTORY OF PRESENT ILLNESS:
___ PMH of Metastatic Prostate Cancer (previously
Enzalutamide/Lupron) presented to ED with worsening back pain
and
lower extremity weakness, found to have cord compression ___
metastatic disease, admitted to oncology for likely radiation in
morning
Of note, per recent oncology progress notes, patient's cancer
was
known to be progressing and he decided against further
chemotherapy. He was following up with his internal medicine
doctor at ___ who recommended hospice but patient had not yet
made a decision. On this admission he presented with lower
extremity weakness
Wife is bilingual and translated per patient's request
Patient reported that he has had progressive midline back pain
starting in his lower cervical region and radiating down his
spine which is ___ at its worst, and has been associated with
lower extremity weakness (Left worse than right) for past two
weeks. He noted that he was previously ambulatory but now uses a
walker. Reported that he takes fentayl and oxycodone for pain
which helps but did not alleviate the pain. However, after
receiving the dilaudid in the ED he had near complete resolution
of pain. Noted that he has dysthesias of his left arm but not
legs. Denied bowel or bladder incontinence.
In the ED, initial vitals: 98.6 73 134/44 16 97% RA. WBC 5.6,
Hgb 11.4, plt 180, Na 134, lactate 2.2, UA negative, coags wnl.
MRI T/L Spine:
Cord or cauda equina compression: yes
Cord signal abnormality: yes
Epidural collection: no
Osseous metastatic disease involving the T6 vertebral body and
its posterior elements has soft tissue components that extend
into the spinal canal and compress the spinal cord at the T6
level. This is associated with T2/STIR cord signal abnormality
(4:11, 7:27).
Multiple other sites of osseous metastatic disease are seen
throughout the spine. No other sites of spinal cord or cauda
equina compression seen.
Spine surgery was consulted and noted that will likely not be
operative candidate but wanted a repeat MRI with contrast to
better assess burden of metastatic disease before deciding.
Radiation oncology was consulted and noted that they would
likely
plan on radiation after ___ hours of high dose dexamethasone.
Patient was started on dexamethasone in ED, and given dilaudid
for pain control
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
As per last outpatient ___ clinic note:
longstanding history of prostate cancer that has metastasized to
bones. He has been on androgen deprivation since ___. He
has received palliative radiation for bony metastases. More
recently, due to rapid rising PSA and increasing pain in the
left
thigh, a bone scan was obtained in early ___ which did
show increased disease with a left femoral lesion worrisome for
pathological fracture. He underwent intramedullary pinning on
___. Meanwhile he was started on Abiraterone/Prednisone
___, and received radiation to the left femur completed
___. Today, he reports doing well with no significant
bone
pain in the neck or elsewhere. He reports very good appetite,
and has gained weight. He denies any nausea, or any
difficulties
taking abiraterone. Recent hematuria as described above, which
has resolved. He has no other complaints.
SUMMARY OF ONCOLOGY HISTORY:
___- diagnosed with prostate cancer, ___ 7, PSA 6.8; was
treated with external beam radiation by Dr. ___ at ___.
___- PSA gradually rose to 4.1; MRI raised a suspicion of
recurrent tumor locally in the prostatic bed it was biopsy
proven
recurrent prostate cancer. He received brachytherapy by Dr.
___. PSA declined to the lowest point 0.8 by ___, but
slowly rose thereafter.
___- PSA rose to 8.2, CT of abdomen and pelvis as well as
bone scan were negative, ADT was deferred.
___: PSA rose to 23, began Zoladex androgen deprivation.
___- PSA increased to 4.4, observed
___- PSA increased to 12.6, Casodex added
___- PSA decreased to 2.5
___- Underwent CT abd/pelvis in ___ for evaluation of
BRBPR- no abnormalities seen related to prostate cancer, no GI
abnormalities seen, no mention of bone disease.
___- PSA increased to 5 (pt missed Lupron injection in ___
___- he presented to PCP ___ left thigh and arm/shoulder
pain
for 2 weeks. Plain films demonstrated question of subtle
lesion/lucency in the proximal femoral shaft. Unremarkable
humerus and shoulder plain films.
___- bone scan with mets in proximal left femur and left
shoulder as well as abnormal spine activity most consistent with
metastases. Rib activity - right ninth rib, left 10th rib and
right third rib or fourth rib which
could be secondary to metastases and/or fractures. CT of left
shoulder on ___ showed mixed xlerotic and lytic lesion of
scapula extending to the glenoid consistent with metastasis.
___- radiation to the left shoulder by Dr. ___
___- started zometa infusion in addition to lupron
injection.
___- marked elevation of PSA from 2.8 in ___ to 29
___- bone scan showed progressive disease, left femur lesion
worrisome for pathological fracture.
___ - began abiraterone and prednisone.
___ - Intramedullary nail fixation for prophylactic
management of impending pathologic fracture of left femur by Dr.
___ at ___.
___ - radiation to left femur.
___ - cystoscopic resection of bladder tumor, pathology -
benign
___ - was referred to oral surgery at ___ concerning
possible
jaw bone necrosis vs osteomyelitis. Was prescribed amoxicilline
500 mg bid x 1 month in mid ___ surgery was discussed
which he declined. The left jaw pain has resolved after taking
antibiotics.
___ - bone scan at ___, compared to the bone scan of
___: There is more extensive uptake in the left
superolateral aspect of the calvarium, and new extensive uptake
in the left mandible. There is new or more extensive uptake in
the left shoulder, right distal clavicle and proximal humerus,
sternum, bilateral ribs, multiple levels of the thoracic and
lumbar spine, right sacrum, iliac bones, bilateral femurs, left
tibial plateau, and distal left tibial diaphysis.
___: follow up visit with Dr. ___ at ___, was offered
single fraction radiation of 800 cGy to the right humerus for
pain management on ___.
___: CT c/a/p -
1. Multiple bony metastases.
2. No significant adenopathy or evidence local extension of
prostate disease.
3. Renal cysts, known.
4. Small lung nodule.
5. Lung scarring, most advanced lingula.
6. Liver lesion smaller, presumably benign.
7. No compression of venous structures evident.
___: Enzalutamide was started to replace Abiraterone.
PAST MEDICAL HISTORY:
Hypertension, essential
Asthma
Hemorrhoids, internal
Optic nerve cupping, suspicious
Colonic adenoma
Radiation proctitis
Type 2 diabetes mellitus without complication, with long-term
current use of insulin
Glaucoma suspect of both eyes
Prostate cancer metastatic to bone
Pain medication agreement signed
Vitamin B12 deficiency
Social History:
___
Family History:
No hx of prostate cancer
Physical Exam:
Vitals: Temp: 98.6 (Tm 98.6), BP: 135/65, HR: 76, RR: 18, O2
sat:
95%, O2 delivery: ra
GENERAL: laying in bed, appears comfortable, NAD, pleasant, wife
at bedside
EYES: PERRLA, anicteric
HEENT: OP clear, MMM
NECK: supple, normal ROM
LUNGS: CTA b/l no wheezes/rales/rhonchi, normal RR, no
increased WOB
CV: RRR normal distal perfusion, no peripheral edema
ABD: Soft, NT, ND, normoactive BS, no rebound or guarding
GENITOURINARY: No foley or suprapubic tenderness
EXT: warm, no deformity, normal muscle bulk
NEURO: AOX3, fluent speech, has normal strength
in upper extremities but 4+/5 LLE which improved since admission
SKIN: warm, dry
Pertinent Results:
___ 05:30AM BLOOD WBC-6.6 RBC-3.38* Hgb-9.8* Hct-30.6*
MCV-91 MCH-29.0 MCHC-32.0 RDW-12.8 RDWSD-41.5 Plt ___
___ 05:30AM BLOOD Glucose-316* UreaN-21* Creat-0.7 Na-137
K-4.8 Cl-100 HCO3-24 AnGap-13
___ 05:30AM BLOOD Calcium-8.8
___ 05:25AM BLOOD PSA-115*
___
MRI T/L Spine
IMPRESSION: 1. Expansile osseous lesion involving the anterior
and posterior T6 vertebral body extends into the spinal canal
and focally compresses the spinal cord with central T2/water
IDEAL hyperintensity which extends in the central cord to the
T10 level. 2. Metastatic lesions in the lumbar spine and sacrum
appear new compared ___. None of these lesions
encroach on the spinal canal. 3. There are multilevel
degenerative changes of the lumbar spine, with moderate to
severe spinal canal narrowing at L4-5. 4. Limited imaging of the
cervical spine demonstrates T1 hypointense lesions in the C2 and
C4 vertebral bodies, suspicious for metastases. 5. Numerous
bilateral rib lesions, compatible with metastases. PREVALENCE:
Prevalence of lumbar degenerative disk disease in subjects
without low back pain: Overall evidence of disk degeneration 91%
(decreased T2 signal, height loss, bulge) T2 signal loss 83%
Disk height loss 58% Disk protrusion 32% Annular fissure 38%
___, et all. Spine ___ 26(10):___ Lumbar spinal
stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old ___, et al, Spine
Journal ___ 9 (7):___ These findings are so common in
asymptomatic persons that they must be interpreted with caution
and in context of the clinical situation.
Brief Hospital Course:
___ PMH of Metastatic Prostate Cancer (previously
Enzalutamide/Lupron) presented to ED with worsening back pain
and lower extremity weakness, found to have cord compression ___
metastatic disease.
# Back Pain
# Lower Extremity Weakness
# Malignant Cord Compression
Patient p/w back pain and lower extremity weakness, found to
have
metastatic lesion at T6 causing cord compression. He was seen
by neurosurgery and patient elected to forgo surgery. He agreed
to receive palliative XRT. His lower ext weakness improved
significantly nearly immediately and he decided to pursue
hospice.
Hospice screen him and accepted him. On discharge, we were
notified
he actually is not accepted at this time because he wanted to
continue the remaining sessions of XRT next week. They will
admit him to their services after his radiation next ___.
- cont dex 4 mg, tapered down to BID bc of hyperglycemia
- continue fentanyl patch
- ___ was being arranged for him but no agencies were responding
to our CM on this ___ afternoon so in respect for his wishes
to leave the hospital asap and considering his ability to care
for himself and his wife's support, they decided to not wait for
us to arrange ___ at home and went home w/o services.
# Metastatic Prostate Cancer
Pt has progressive disease and was clear at time of discharge
did not want any further chemotherapy. Was seen by SW and pt
decided that he wanted hospice.
# HTN
-Continue metoprolol/losartan
# ID-T2DM
Was seen by ___ for uncontrolled DM while on dex. Pt was
adamant he wanted to leave asap so they helped create a sliding
scale for him.
BILLING: >30 min spent coordinating care for discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 51 Units Bedtime
Humalog 32 Units Breakfast
Humalog 32 Units Lunch
Humalog 32 Units Dinner
2. Losartan Potassium 25 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Fentanyl Patch 50 mcg/h TD Q72H
6. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
Discharge Medications:
1. Dexamethasone 4 mg PO BID
RX *dexamethasone 4 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
2. Glargine 51 Units Bedtime
Humalog 32 Units Breakfast
Humalog 32 Units Lunch
Humalog 32 Units Dinner
3. Cyanocobalamin 1000 mcg PO DAILY
4. Fentanyl Patch 50 mcg/h TD Q72H
5. Losartan Potassium 25 mg PO DAILY
6. Metoprolol Succinate XL 100 mg PO DAILY
7. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
Cord Compression
Metastatic Prostate Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
You were admitted with a cord compression. You elected no
surgery. You had urgent radiation to your spine. You will
continue radiation next week for three sessions (mon, tue, NOT
wed, and then resume ___ for your last session). You also
were started on high dose steroids with dexamethasone. You need
this to help the swelling and your weakness. However it caused
an elevation of your sugars so we cut it down to 4 mg twice a
day (ideally every 12 hours). Please talk to your radiation
oncologist on how to reduce the dose. If it causes you
heartburn, let them know. Please keep an eye on your sugars and
follow the instructions you were given from the ___ diabetes
doctor.
Followup Instructions:
___
|
10121003-DS-21 | 10,121,003 | 23,255,269 | DS | 21 | 2155-10-28 00:00:00 | 2155-10-28 14:08:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
diarrhea
Major Surgical or Invasive Procedure:
___ line placement
History of Present Illness:
___ year old man with a past medical history of A. fib,
___ disease, glaucoma, HTN, DM with recent
hospitalization for ESBL scortal abscess c/b C diff who
presented w/ diarrhea x 2 weeks and cough. Per records patient
has had 4 BM per day, 3 today. This morning he developed
congestion, +cough, which was new and concerning so he was
brought to the ED.
No abd pain, no f/c, no n/v, no CP, no SOB. Pt stopped
antibiotics 2 weeks ago. Was treated for C.diff w/in the last 3
weeks, was neg last week.
Of note, He has a recent hospitalization for scotal abscess (+)
ESBL infection completion of ertapenem IV abx on ___ per Atrius
records, 2 weeks ago per ED records. This was complicated by C
diff infection previously on PO Vanc and IV Flagyl (negative
test at atrius ___
In the ED initial vitals were: 97.4 90 154/99 20 99%
- Labs were significant for lactate 5.3 -> 4, WBC 16.4, hgb 17.5
(baseline ___, Hct 52.1. Plt 125, N87% Na 137, K 4.7, Cr 1
(baseline 0.7), AST 53, ALT 9, PTT 70.9, INR 14.5
- Patient was given 1LnS, 10mg IV vitamin K
Vitals prior to transfer were: HR 93 172/103 18 95% Nasal
Cannula
On the floor, vitals were 98.5 ___ 98% 3L NC
Patient appears comfortable and denies SOB, CP, Fevers/Chills.
He endorses some faint abdominal pain, and coughing.
Past Medical History:
- ___ disease
- Dementia
- Nephrolithiasis
- Hemochromatosis
- BPH
- HTN
- Afib
- Thrombocytopenia
- Diabetes mellitus
- Severe stage glaucoma s/p multiple bilateral surgeries
(bilateral trabeculectomies and laser iridotomies)
- Blepharitis
- R Exotropia
- Diabetes mellitus
- Epididymitis
- S/P open right inguinal hernia repair - ___
- Lumbar radiculopathy
- OSTEOARTHRITIS, LOCALIZED PRIMARY - SHOULDER bilateral
advanced
- TOTAL HIP REPLACEMENT bilateral ___
- Gout
- FRACTURE - HUMERUS, HEAD
- Knee pain, right
Social History:
___
Family History:
No family history of sudden cardiac death or early MI.
Physical Exam:
Admission PE:
Vitals - 98.5 ___ 98% 3L NC
GENERAL: NAD, AAOx2
HEENT: AT/NC, anicteric sclera, EOMI, R pupil dilated 4mm, L
pupil 2mm (chronic), Dry MM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: irregular, regular rate, no m/r/g
LUNG: Diffuse rhonchi, airmovement throughout, without use of
accessory muscles
ABDOMEN: nondistended, +BS, mild tenderness in lower abdomen, no
rebound/guarding
GU: Erythematous scrotum L>R, nontender, posterior 2x2 open
sore, no drainage
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
NEURO: able to move all extremities, normal sensation,
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
.
Discharge PE:
Vitals: afebrile, 130-160s/60-80s, 60-80s, 20, 94% RA
I/O: 4BM yesterday
GENERAL: elderly man lying in bed, nontoxic, in NAD
HEENT: MMM, asymmetric pupils - R pupil dilated 4mm, L pupil 2mm
(chronic)
NECK: nontender supple neck
CARDIAC: regular, no murmurs appreciated
LUNGS: breathing comfortably, cough improved, CTAB
ABDOMEN: soft, NT, ND
GU: dressing in place in scrotal surgical defect
EXTREMITIES: no ___ edema
NEURO: A&Ox2 (does not know hospital, but knows ___
Pertinent Results:
Admission Labs:
___ 04:00PM BLOOD WBC-16.4*# RBC-4.90# Hgb-17.5# Hct-52.1*#
MCV-106* MCH-35.7* MCHC-33.5 RDW-14.1 Plt ___
___ 04:00PM BLOOD ___ PTT-70.9* ___
___ 04:00PM BLOOD Glucose-261* UreaN-26* Creat-1.0 Na-137
K-7.3* Cl-103 HCO3-19* AnGap-22*
___ 04:00PM BLOOD ALT-9 AST-53* AlkPhos-100 TotBili-0.4
___ 07:18AM BLOOD Calcium-8.8 Phos-2.6* Mg-1.6
___ 04:07PM BLOOD Lactate-5.3* K-4.7
___ 08:21PM BLOOD Lactate-4.0*
___ 01:12AM BLOOD Lactate-4.0*
___ 08:06AM BLOOD Lactate-2.5*
.
>> MICRO:
- bl cx ___ pending
- C diff ___ POSITIVE
- ucx ___
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
- stool cx ___ neg
.
>> IMAGING:
CXR ___: No acute intrathoracic process.
KUB: no megacolon
.
>> Discharge Labs:
___ 10:00AM BLOOD ___
Brief Hospital Course:
___ with h/o A. fib on warfarin, ___ disease, glaucoma,
HTN, DM with recent hospitalization for ESBL scrotal abscess
(s/p R hemi-scrotal exploration, I&D and scrotal debridement)
who presented w/ diarrhea x 2 weeks and cough and found to have
C diff and an e coli UTI.
.
# Severe C diff: C diff positive and pt with leukocytosis of 16
with elevated lactate on presentation. This is also considered
recurrence given recent reported C diff at rehab last month. Pt
put on PO Vanc with plan for course that will continue for 14d
after ABX course for UTI (end date ___. Diarrhea slowly
improving.
.
# UTI: UA grossly positive. Only past culture data is ESBL e
coli from scrotal abscess so covered broadly with meropenem
initially. Urine culture returned with > 100K e coli sensitive
only to ___ continued. D1 of ABX ___, plan
7d course to end ___ (will transition to ertapenem at
rehab). PICC placed.
.
# Hypovolemia: Pt initially with very dry MM and also
hemoconcentration with Hct to 52 from discharge Hct in low ___
in ___. BUN also elevated. S/p >3L IVF. Hypovolemia likely from
combination of poor PO intake + diarrhea.
.
# Lactic acidosis: Pt with lactate of 5.3 on presentation
associated with AG of 15. Likely from profound hypovolemia +/-
infection. No evidence of megacolon on KUB. Lactate has
downtrended to 2.5 after initial IVF resuscitation.
.
# Aspiration: Pt failed S&S eval. Video swallow done. Pt to do
honey-thickened liquids. Pt to have repeat video swallow in
___.
.
# Cough: Pt with wet cough but CXR clear.
.
# Recent scrotal abscess: Still relatively deep defect in
scrotum. Urology evaluated pt and felt granulation tissue
present and no acute concerns.
.
# Supratherapeutic INR: INR 14.5 on presentation, possibly from
poor nutrition, no recent med changes noted causing interaction.
Could also have been spurious. Pt s/p 10 IV vit K in the ED with
INR normalized to 1.3 after. Warfarin restarted ___, no need to
bridge with heparin given moderate CHADS score and no prior CVA
.
# Dementia: Pt is high-risk for delirium. Some disorientation
present throughout hospitalization.
# ___: cont Carbidopa-Levodopa
# Afib: Atrial Fibrillation with CHADS of 3 on coumadin. Per med
list not currently rate controlling meds and pt maintained
normal rates without need for meds.
# Diabetes- hold oral meds, ISS; restart home meds on discharge
# HTN- pt recently put on spironolactone, held given severe
hypovolemia on admission
# Glaucoma- continue home meds
# BPH- continue finasteride, flomax
.
>> Transitional issues:
# Code: DNR/DNI (no bipap)
# Emergency Contact: ___) ___
# Ertapenem to end ___. D/c PICC after
# PO Vanc until ___ (2wk course from after ertapenem)
# Please arrange repeat video swallow in ___
# INR monitoring for warfarin. Next INR ___. INR uptrended
quickly and was 4 on day of discharge. Hold warfarin on
discharge and restart only if INR on ___ has downtrended
appropriately. Would restart at 1mg daily (home dose was 2.5 and
was getting 2mg here that led to swift rise in INR).
# If SBPs running high, please consider non-diuretic
anti-hypertensive given pt high risk for hypovolemia
# Please check chem panel on ___. Please monitor potassium.
Discharged on 20mEq KCL PO daily. Please adjust pending lytes
and diarrhea output. Check lytes ___ weekly pending diarrhea
output. If no diarrhea, can likely stop supplemental KCl.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
3. Carbidopa-Levodopa (___) 1 TAB PO 1330, ___, ___
4. Carbidopa-Levodopa (___) 1.5 TAB PO 0930
5. TraMADOL (Ultram) 50 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QPM to Bilateral hips
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Tamsulosin 0.4 mg PO HS
10. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
11. Warfarin 2.5 mg PO DAILY16
12. TraZODone 25 mg PO HS:PRN insomnia
13. Acidophilus (L.acidoph &
___ acidophilus) 1 tab oral BID
14. Potassium Chloride 20 mEq PO DAILY
15. Spironolactone 25 mg PO DAILY
16. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
2. Carbidopa-Levodopa (___) 1 TAB PO 1330, ___, ___
3. Carbidopa-Levodopa (___) 1.5 TAB PO 0930
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
5. Finasteride 5 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Lidocaine 5% Patch 1 PTCH TD QPM to Bilateral hips
8. Tamsulosin 0.4 mg PO HS
9. TraZODone 25 mg PO HS:PRN insomnia
10. Acetaminophen 650 mg PO Q8H:PRN pain
11. Vancomycin Oral Liquid ___ mg PO Q6H
Last day ___.
12. Acidophilus (L.acidoph &
___ acidophilus) 1 tab oral BID
13. Ferrous Sulfate 325 mg PO DAILY
14. MetFORMIN (Glucophage) 500 mg PO BID
15. Ertapenem Sodium 1 g IV DAILY
Last day ___.
16. Potassium Chloride 20 mEq PO DAILY
Please adjust pending labs and diarrhea output. Please give as
powder.
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis: Severe C diff colitis, Complicated cystitis,
hypovolemia, lactic acidosis
Secondary diagnoses: dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
It was a pleasure taking care of you in the hospital. You were
admitted with diarrhea. You were found to have an infection call
C diff and were started on treatment. You were also found to
have a urinary tract infection that will be treated with 1 week
total of IV antibiotics.
You were also found to be very dehydrated when you came in.
Please make sure to stay hydrated after discharge.
Please follow-up at the appointments below. Attached is an
updated list of your medications on discharge.
Followup Instructions:
___
|
10121316-DS-9 | 10,121,316 | 20,600,733 | DS | 9 | 2156-10-17 00:00:00 | 2156-10-18 07:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
LLE pain and swelling
Major Surgical or Invasive Procedure:
1. Right peripherally inserted central catheter (PICC) placement
for venous access for blood draws and medication administration.
2. Right internal jugular central venous line placement for
venous access for blood draws and medication administration.
History of Present Illness:
___ ___ woman with a past medical history
significant for PVD, HTN, DM, and CLL who transferred from
___ for evaluation of LLE edema and pain.
Her PVD is s/p L femoral popliteal bypass ___ ___ and redo ___
___ at ___. She had an external iliac to profunda femoris
bypass with Dacron graft at ___ and 2 stents placed ___ her
common and external iliac on ___. Since then, patient has
been doing relatively well with baseline ambulation with cane
and assisted living with daughter. According to the daughter, 2
weeks prior to admission, Mrs. ___ lost several toe nails.
She also began to notice darker hyperpigmentation of the LLE
below the knee without pain or swelling. She noticed increasing
pain and swelling over the next few days. Her LLE pain and
swelling significantly worsened just prior to her admission when
her daughter called an ambulance and she was taken to ___ where
she was found to be febrile with leukocytosis to ~13. She was
started on vanc/CTX. OSH ED was unable to Doppler pulses, and
patient was sent to ___ for further evaluation by vascular
surgery. Overnight, patient received 3L IVF and was started on
zosyn/vancomycin.
She noted hyperalgesia, swelling, and associated fever. She
denied any chest pain, light-headedness or SOB. No n/v,
abdominal pain or dysuria.
Past Medical History:
CLL on Imbruvica
T2DM
PVD
HTN
CAD - inferior perfusion defect
PSHx:
Left fem-pop ___ with redo ___ ___nd iliac stenting at ___ on ___
Social History:
___
Family History:
No known family history. Father passed away from heart issue
when he was ___ yo.
Physical Exam:
ON ADMISSION:
Vital Signs: 99.0; 158/71; 81; 18; 95 RA
___: Alert, oriented, no acute distress. AO to month/year
(but not date) and city (but not ___.
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, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. No suprapubic
tenderness
Ext: 1+ edema ___ LLE, trace ___ RLE. Warmth and severe TTP ___
LLE. LLE pulses not dopplerable. Otherwise, no
clubbing/cyanosis.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
ON DISCHARGE:
Vitals- Tm 99.0 126-151/49-63 54-65 ___ 98-100% RA
___- Awake, AOx3, lying ___ bed. NAD
HEENT- OD: sclera injected around ___ improved. PERRL. EOMI.
MMM. Oropharynx clear
Neck- supple, no LAD.
Lungs- Breathing comfortably. Bilateral crackles at bases L>R
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- Soft, non-tender, non-distended, normoactive bowel
sounds, no rebound tenderness or guarding, no organomegaly
GU- no foley.
Ext- LLE hyperpigmentation beginning below the knee extending
distally and 1+ pitting edema. Leg continues to improve with
less edema, receding erythema within previously marked
boundaries. No purulence or open wounds.
Skin: R-PICC site is CDI
LLQ small superficial skin lesion under pannus. Area is dressed.
No pain, erythema, or bleeding.
Neuro- Baseline: speaking ___ full sentences and able to
comprehend speech. CN2-12 intact: Tongue and uvula midline,
palate elevates, turns head, no facial droop, turns head, and
shrugs. Mild postural tremor of left hand on extension.
Pertinent Results:
ADMISSION/NOTABLE LABS
======================
___ 10:30AM WBC-11.6* RBC-3.03* HGB-7.4* HCT-24.9*
MCV-82# MCH-24.4*# MCHC-29.7* RDW-19.9* RDWSD-58.8*
___ 10:30AM NEUTS-11* BANDS-0 LYMPHS-84* MONOS-5 EOS-0
BASOS-0 ___ MYELOS-0 AbsNeut-1.28* AbsLymp-9.74*
AbsMono-0.58 AbsEos-0.00* AbsBaso-0.00*
___ 10:30AM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-1+ SCHISTOCY-OCCASIONAL
TEARDROP-OCCASIONAL
___ 10:30AM PLT SMR-NORMAL PLT COUNT-228#
___ 10:30AM ___ PTT-44.1* ___
___ 08:47AM LACTATE-3.9*
___ 08:40AM GLUCOSE-143* UREA N-30* CREAT-1.3* SODIUM-140
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-20* ANION GAP-21*
___ 08:40AM CALCIUM-7.7* PHOSPHATE-2.7 MAGNESIUM-1.6
___ 08:47AM BLOOD Lactate-3.9*
___ 12:08PM BLOOD Lactate-1.9
___ 12:54AM BLOOD Lactate-1.3
___ 05:28AM BLOOD Lactate-1.0
___ 07:20AM BLOOD calTIBC-259* Ferritn-576* TRF-199*
___ 04:11AM BLOOD Hapto-363*
___ 12:00PM BLOOD cTropnT-0.03*
___ 12:00AM BLOOD cTropnT-0.04*
___ 05:35PM BLOOD cTropnT-0.01
___ 07:20AM BLOOD CK(CPK)-1643*
___ 12:28AM BLOOD CK(CPK)-863*
___ 06:20AM BLOOD ALT-31 AST-40 LD(LDH)-354* CK(CPK)-628*
AlkPhos-136* TotBili-0.4
___ 09:30AM BLOOD ALT-16 AST-22 LD(LDH)-375* CK(CPK)-80
AlkPhos-118* TotBili-0.3
___ 03:50PM BLOOD ___
___ 22:59 IgG 154* IgA 23* IgM 9*
___ 04:11 Recit % 1.0, Abs Ret0.03
MICROBIOLOGY: Except as noted below, all all other (numerous)
blood and urine cultures were negative at time of discharge.
___ 2:50 pm SPUTUM Source: Expectorated.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ CLUSTERS.
RESPIRATORY CULTURE (Final ___:
SPARSE GROWTH Commensal Respiratory Flora.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
___ 11:30 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
STUDIES
=======
Initial ___ admission workup:
-CXR showing bibasilar lung opacity, concerning for pneumonia ___
the correct clinical setting.
-LENIS showed no evidence of deep vein thrombosis ___ the left
lower extremity veins.
-ART DUP LLE: Per vascular surgery showed patency.
-ECG: Rate 68. NSR> L-axis deviation. TWI ___ I, aVL, V4-6. No
STE/STD, q-waves. TWI new since ___ EKG.
-ABI/PVR: Normal right resting ankle brachial index with
moderate severely decreased left resting ankle brachial index.
Given the appearance of the waveforms, there may be a high-grade
stenosis or occlusion at the level of the SFA.
CT LLE ___:
1. Evaluation of the vasculature is somewhat limited on this non
angiographic study. The external iliac stent appears to be
patent. The external iliac to profunda femoral is anastomosis
appears patent. These structures are better evaluated on the
concurrent ultrasound.
2. Extensive atherosclerotic calcification ___ all visualized
vessels with probable occlusion of the femoral artery
(superficial femoral).
3. Abnormal soft tissue attenuation material at the level of the
surgical anastomosis and extending more inferiorly. This is
nonspecific ___ appearance and may be related to prior surgery.
Superimposed infection cannot be excluded. No rim enhancing
fluid collection seen. No subcutaneous air seen.
4. Indeterminate left renal lesion measuring 1.4 cm, recommend
further evaluation with non urgent ultrasound.
5. Colonic diverticulosis without evidence of diverticulitis.
6. Fibroid uterus
7. Small retroperitoneal and left external iliac nodes do not
meet the CT size
criteria for pathologic enlargement.
8. Small left knee effusion
9. Dystrophic calcifications ___ the plantar aspect of the left
foot.
Head CT no contrast ___:
No intracranial abnormalities
CXR ___:
Progression of bibasilar opacities with small left pleural
effusion is worrisome for multifocal pneumonia and less likely
atelectasis.
CT Chest w/contrast ___:
mild atelectasis bilaterally, small bilateral pleural effusions
without specific predominance and without radiologic need for
tapping. Diffuse ground-glass opacities, although partly caused
by motion, could also reflect developing pneumonia.
CT abd and pelvis ___:
1. No evidence of retroperitoneal, or intraperitoneal hematoma.
2. Diffuse subcutaneous stranding throughout the proximal left
thigh as well as stranding at the left inguinal region,
presumably representing the vascular access site. These findings
may represent a combination of interspersed hematoma and/or
edema. However, no organized hematoma is identified. No
hematoma is visualized ___ the proximal right thigh.
3. Indeterminate 1 cm right adrenal nodule.
4. Additional incidental findings include small bilateral
pleural effusions, cholelithiasis without evidence of
cholecystitis, bilateral hypodense renal lesions containing
fluid density, most likely representing cysts, and multiple
calcified fibroids.
___ SHOULDER (AP, NEUTRAL & AXILLARY) SOFT TISSUE LEFT
IMPRESSION:
The AC joint is well maintained, though there are substantial
degenerative
changes ___ the glenohumeral joint. No evidence of acute
fracture or
dislocation, though if this is a serious clinical concern
cross-sectional
imaging could be obtained. Some irregularity of the
superolateral aspect of
the humeral head could be a reflection of previous episodes of
dislocation.
___ CHEST (PA & LAT)
IMPRESSION:
___ comparison with the study of ___, there again are low
lung volumes that
accentuate the transverse diameter of the heart. There has been
the
development of moderate pulmonary edema with bilateral basilar
opacifications
consistent with layering effusions and compressive atelectasis.
The given the
extensive pulmonary changes, ___ the appropriate clinical setting
it would be
difficult to exclude a superimposed infection, especially ___ the
absence of a
lateral view.
The right jugular catheter has been removed. The remaining
right PICC line
now has its tip within the right atrium.
Non-contrast head CT ___:
No acute intracranial abnormality.
cvEEG ___: Slow broad wave spikes, no seizure activity
CXR portable ___:
Previously reported pulmonary edema has resolved. Nonspecific
bibasilar opacities have also substantially improved. No
localized new or worsening opacities are identified to suggest a
new source of infection.
___ NCHCT, CTA head, CTA neck:
No acute intracranial processes concerning for hemorrhage or
stroke.
___: MR head w w/o contrast:
1. Study is moderately degraded by motion.
2. No evidence of infarction, hemorrhage, mass or edema.
3. Mild global cerebral atrophy and evidence of chronic small
vessel ischemic disease.
4. Mild bilateral maxillary sinus mucosal thickening.
___: CTA AORTA/BIFEM/ILIAC RUNOFF W/W&WO C AND RECONS
1. Mild-to-moderate narrowing of the branching of the femoral
profunda at distal end of the external iliac to profunda bypass
graft. Complete occlusion of the left superficial femoral artery
with reconstitution of the popliteal artery as well as several
collaterals from the level of the profunda.
2. Bilateral anterior tibial artery occlusion with
reconstitution of dorsalis pedis bilaterally
3. Severe to occlusive disease of posterior tibial artery
4. cardiomegaly
5. Pulmonary vascular congestion
6. Bilateral thyroid subcentimeter hypodense lesions, largest
measuring 4mm ___ the left thyroid lobe
7. 1.0 cm right adrenal nodule again demonstrated
8. Bilateral renal hypodense lesions likely representing cysts
9. Multiple calcified fibroids
10. Diverticulosis without evidence of diverticulitis
11. Extensive degenerative changes of the thoracolumbar spine
DISCHARGE LABS
==============
___ 06:07AM BLOOD WBC-38.2* RBC-2.69* Hgb-6.9* Hct-22.7*
MCV-84 MCH-25.7* MCHC-30.4* RDW-20.8* RDWSD-62.0* Plt ___
___ 06:07AM BLOOD Neuts-26* Bands-0 Lymphs-67* Monos-6
Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-9.93*
AbsLymp-25.59* AbsMono-2.29* AbsEos-0.00* AbsBaso-0.00*
___ 06:07AM BLOOD ___ PTT-34.7 ___
___ 06:07AM BLOOD Glucose-111* UreaN-29* Creat-0.7 Na-138
K-3.7 Cl-103 HCO3-25 AnGap-14
___ 06:07AM BLOOD Calcium-8.3* Phos-3.0 Mg-2.0
Brief Hospital Course:
Ms. ___ is a ___ ___ woman with a past
medical history significant for PVD, HTN, DM, and CLL who
transferred from ___ for evaluation of LLE
edema and pain concerning for cellulitis complicated by DM, PVD,
and CLL.
# Cellulitis
Painful, erythematous, edematous LLE consistent with soft tissue
infection. CT scan w/o e/o nec fasc. ___ ED, initially treated
with Vanc/Zosyn, switched to Vanc/Cefepime the following day.
Clindamycin was added to empirically cover for toxin-elaborating
organisms. Clindamycin and vancomycin was d/ced during hospital
course due to less concern for MRSA and toxin forming microbes
as patient's cellulitis improved. Cefepime was switched to
meropenem on day 12 due to concern for seizure risk and
ultimately patient's abx course was finished after a 14 day
course with resolution of cellulitis. Of note, pt continued to
have LLE pain while hospitalized, and CTA showed
"Mild-to-moderate narrowing of the branching of the femoral
profunda at distal end of the external iliac to profunda bypass
graft. Complete occlusion of the left superficial femoral artery
with reconstitution of the popliteal artery as well as several
collaterals from the level of the profunda." Of note, pt's
ibrutinib was initially held on admission, given concern for
immunosuppression and restarted on ___. Pt was also found to be
hypogammaglobulinemic, and she was given weekly IVIG x3 doses
per heme-onc.
# Left shoulder rash and pain: Shoulder pain began on day 11
(___) and an erythematous patch was noted at the inferior
border of the scapula extending past the axilla along the
inferolateral breast ___ a T4 dermatomal distribution. There were
no vesicles. Given history of shingles on her left hip/back,
acyclovir was started empirically for VZV. Patient's rash
improved after 1 day of acyclovir, which lowered index of
suspicion for VZV. However, given that patient had started on
acyclovir and improved, we decided to continue treatment with 7
day course of valacyclovir 1g q8h per ID. Shoulder pain and rash
had resolved at discharge
# Fever: Pt developed fevers on ___ and ___, with
TMax 102.4. Blood and urine cultures were unremarkable and CXR
was also unremarkable. No obvious localizing symptoms. Pt was
otherwise well and hemodynamically stable. Fevers were not felt
to be infectious ___ nature. Instead, they were felt to be more
likely ___ CLL vs delayed inflammatory reaction to IVIG (given
that fevers occurred ___ days after IVIG infusion each day).
# Altered mental status: On ___, patient had RUE shaking, oral
automatisms, and unresponsiveness which was concerning for
seizure with post ictal state ___ the setting of infection and
cefepime vs delirium. 48 hour cvEEG did not show seizure
activity, but slow wide wave spikes may be sign of decreased
seizure threshold. Cefepime was switched to meropenem due to
concern of seizure. Patient may also had superimposed delirium
___ the setting of older age, infection, and superinfection of
her left shoulder concerning for VZV shingles. Patient's mental
status returned to baseline the following day. On ___ nurse
noted patient was slumped to the left with a left facial droop
and was not responding to verbal commands, a code stroke was
called with negative head CT and CTA head/neck. MRI negative for
acute stroke, patient quickly returned to baseline and remained
so at hospital discharge. Pt was not felt to have had a seizure.
# CLL: Home ibrutinib was held on admission due to concern of
immunomodulatory effects but was restarted on ___ after consult
with hemotology/oncology. They were also consulted for the
presence of atypical lymphocytes on WBC differential on hospital
day 6. As per their note, no indications of Richter
transformation. Also found to have hypogammaglobunemia, which
may have been prolonging her infection recovery. Subsequently,
IVIG 25 g was administered on hospital days ___, ___, ___.
Outpatient hematologist is Dr. ___ (___) at
___ follow up on discharge.
# Normocytic anemia: Patient initially admitted with H/H ~7 and
was transfused 1uPRBC. Unclear etiology, but may be related at
least ___ part to CLL or Ibrutinib with reduced bone marrow
production consistent with her low reticulocyte count. However,
H/H dropped and brown guaiac positive stool on day 6 ___ the
setting of supratherapeutic INR, which was concerning for
bleeding and patient was given another unit PRBC. Also, CT
abd/pelvis was obtained which did not show any hematomas. There
was initial concern for upper GI bleed, so PPI was started.
Patient's H/H notably decreased from 7.6/24.6 -> 6.9/22.7 on the
day of discharge, felt to be more likely stochastic variation vs
mild hemolysis ___ the setting of IVIG the day prior.
# Peripheral vascular disease: History of PVD s/p multiple
surgeries for revision ___ LLE may be complicating clinical
picture of infection. Vascular surgery determined patent
vasculature and graft on admission. They have advised
anticoagulation with INR goal ___ while inpatient. Aspirin was
continued during this admission. Patient will follow up
outpatient.
# Labile INR: INR on admission was 4.8 likely elevated ___
setting of infection. INR elevated to 6.7, suspect due to
cefepime as it increases INR and possibly CLL on ibrutinib and
broad spectrum antibiotics w/ reduced dietary intake may be
contributing. Patient lost IV access on ___ and to obtain
R-IJ CVC placement, patient was given 2.5mg phytonadione and
FFP. INR dropped to 1.3 and was restarted on heparin drip with
bridge to warfarin. Pt's warfarin was titrated on admission, but
was downtrending at the time of discharge.
# Bilateral crackles: On admission CXR show bibasilar lung
opacities, follow up CXR/CT chest showed ground glass opacities
concerning for pneumonia. Because of rising WBC, Azithromycin
was started to cover for additional atypicals on top of the
cefepime/vancomycin pt was already receiving. However, given
patient was not coughing or dyspneic, there was low suspicion of
pneumonia and azithromycin was discontinued. Patient discharged
stable on room air.
# T2NSTEMI/CAD: On admission, ECG showed dynamic TWI ___
inferolateral leads and mild troponinemia, likely due to
increased demand ___ the setting of infection. Patient with known
inferior perfusion defect from prior MIBI. Statin was originally
discontinued due to increased CK levels, but was restarted once
CK levels normalized. Patient did not experience chest pain and
was discharged stable on atorvastatin, atenolol, ASA.
# Right ocular subconjunctival hemorrhage: Developed ___
hospital, seen by ophthalmology, who believe it is a benign
subconjunctival hemorrhage. Likely to take up to 2 weeks to self
resolve. Artificial tears administered, stable on discharge.
# LLQ skin ulcer: Underneath pannus, a small 1cm ulcer with no
purulence, erythema, or bleeding. Likely a sore from excess
moisture and friction from skin fold above. Miconazole powder
and dry dressings were started due to concern for fungal
infection, stable during hospital course and on discharge.
# HTN: high ___ the 180's but given clinical picture of
infection, initially held home medications. After patient's
infection was improving and blood pressures continued to remain
high, home hydrochlorothiazide was restarted. Patient discharged
with HCTZ and amlodipine.
# DM: A1C 6.6 ___ ___. Patient on home metformin, which was
held. Patient was on insulin sliding scale, but did not require
any insulin while hospitalized.
# Glaucoma: Stable. Continued home latanoprost and
brimonidine/timolol
# Depression: Home amitriptyline was continued.
# Facial Droop/UE weakness: Pt was thought to potentially a
Right facial droop on ___ when seen by ___ covering MD. CTA
head/neck and MRI head did not show e/o acute CVA. Neuro exam
was stable at the time of discharge.
TRANSITIONAL ISSUES:
=======================
[] f/u with outpatient oncologist, Dr. ___
[] f/u INR on ___. If INR <2, pt will need bridging
therapy until INR is therapeutic.
[] f/u H/H on ___. H/H
[]Recheck IgG, IgA, IgM levels on ___ at appointment with Dr.
___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 75 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Atenolol 12.5 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic DAILY
6. Gabapentin 300 mg PO QID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Hydrochlorothiazide 25 mg PO DAILY
9. Acetaminophen 650 mg PO Q8H pain
10. Docusate Sodium 100 mg PO BID Constipation
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Senna 8.6 mg PO BID:PRN constipation
13. ___ MD to order daily dose PO DAILY16
14. Multivitamins 1 TAB PO DAILY
15. MetFORMIN (Glucophage) 500 mg PO BID
16. Imbruvica (ibrutinib) 420 mg oral DAILY
17. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Miconazole Powder 2% 1 Appl TP TID
4. Omeprazole 40 mg PO DAILY
5. OxyCODONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 0.5 (One half) tablet(s) by mouth every six
(6) hours Disp #*12 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
8. Warfarin 4 mg PO DAILY16
RX *warfarin 4 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
9. Amitriptyline 75 mg PO QHS
10. Aspirin 81 mg PO DAILY
11. Atenolol 12.5 mg PO DAILY
12. Atorvastatin 40 mg PO QPM
13. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
14. Combigan (brimonidine-timolol) 0.2-0.5 % ophthalmic DAILY
15. Docusate Sodium 100 mg PO BID Constipation
16. Gabapentin 300 mg PO QID
17. Hydrochlorothiazide 25 mg PO DAILY
18. Imbruvica (ibrutinib) 420 mg oral DAILY
19. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
20. MetFORMIN (Glucophage) 500 mg PO BID
21. Milk of Magnesia 30 mL PO Q6H:PRN constipation
22. Multivitamins 1 TAB PO DAILY
23. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY:
Cellulitis
Chronic Lymphocytic Leukemia
Left Shoulder Rash
Anemia
SECONDARY:
Peripheral Vascular Disease
Hypertension
Coronary Artery Disease
Diabetes
Glaucoma
Depression
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking care of you.
Why you were here?
-You were admitted because of a skin infection of your left leg
called cellulitis.
What we did for you?
-We started you on antibiotics and gave you antibodies to boost
your immune system to help fight the infection
-You had a painful rash on your left shoulder that may be
shingles so we treated you with an antiviral medication called
valacyclovir
What should you do when you leave the hospital?
-Please take all your medications as prescribed.
-Follow up with your outpatient oncologist
We wish you the best,
Your ___ team
Followup Instructions:
___
|
10121634-DS-2 | 10,121,634 | 28,264,080 | DS | 2 | 2155-10-25 00:00:00 | 2155-10-25 13:44:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / oats
Attending: ___.
Chief Complaint:
leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ h/o IDDM, obesity, hypertension,
hyperlipidemia, GERD, anemia who presented for wound evaluation.
She reported that a week ago her dog caused her to trip and fall
onto her right leg. She noted a small wound at the time but she
was able to walk and did not sustain other injuries at that
time.
However, over the course of the week, she developed redness over
the right lateral shin extending to around to the calf, as well
as swelling of that leg. She noted chills today. She presented
to
___ where she was noted to have large
circumferential right lower leg redness c/f cellulitis. Bedside
US showed fluid collection/abscess in upper aspect of RL leg.
She
was referred to the ___ ED for IV abx and evaluation for
possible debridement/drainage by surgery.
In the ED, initial vital signs were notable for: Pain7, T98.3,
HR88, BP161/77, RR18, 99% RA
Exam notable for: Lower extremities are warm and well perfused.
The right lower extremity is erythematous, warm to the touch,
without a clear palpable fluctuant fluid collection. Sensation
and pulses are intact distally. The left lower external knee is
not swollen.
Labs were notable for:
WBC:6.4 Hgb:14.2 Plt:155
141|102| 15
-------------<246
4.8| 25|0.6
Ca: 9.9 Mg: 1.7 P: 3.6
Lactate:1.7
Creat:0.6
___: 12.5 PTT: 28.8 INR: 1.2
UA: neg
Studies performed include:
CT Lower Ext W/C Right:
1. Thin oblong collection of intermediate density fluid along
the
proximal anterior tibia measuring 7.1 cm in craniocaudal
___, compatible with a hematoma. No other focal fluid
collections.
2. Extensive subcutaneous edema throughout the right lower
extremity extending into the right foot. No subcutaneous
emphysema.
3. Small nonhemorrhagic right knee joint effusion.
Patient was given:
___ 14:11 IVF NS ___ Started
___ 15:19 IV Vancomycin 1000 mg
___ 16:27 IV MetroNIDAZOLE 500 mg
___ 17:01 IV CefTRIAXone 1 g
___ 18:42 IVF NS 1000 mL
___ 18:42 IVF NS 100mL/hr
Consults: surgery - not nec fasc, no drainable collection
Vitals on transfer: pain ___, T98.2, HR80, BP151/85, RR18, 99%
RA
Upon arrival to the floor, patient reports feeling better. She
thinks the redness in her leg has improved a bit. She reports
that since her fall a week ago, the swelling has come and gone
and she has been managing it conservatively with rest, ice,
elevation and Advil (up to 8/day). Soreness got worse over the
last 2 days and she woke up in pain this morning, which is what
prompted her to come to Urgent care and get it evaluated. She
denies any fevers and chills, and the remainder of her ROS is
negative. Reports her A1c has recently worsened (thinks it was
between 8 and 9% but is not sure).
Past Medical History:
HTN
HLD
IDDM
GERD
Social History:
___
Family History:
brother died of throat cancer age ___
mother at age ___ with lung problems
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS:98.6 PO 145/74 L Sitting 85 18 97%RA
GENERAL: Alert and interactive. In no acute distress. Morbidly
obese
HEENT: NCAT. 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.
LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
EXTREMITIES: Multiple ecchymoses to knee on RLE. Erythema from
ankle to just below knee anteriorly with tense edema in calf and
TTP. No open wounds. Distal pulses diminished on palpation, but
foot w/wp, cap refill preserved. no edema on L.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
DISCHARGE PHYSICAL EXAM
=======================
GENERAL: Alert and interactive. In no acute distress. Morbidly
obese
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally.
EXTREMITIES: Multiple ecchymoses to knee on RLE. Improving
erythema on RLE.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation. Gait is normal. AOx3.
Pertinent Results:
CT RLE
=======
1. Thin oblong collection of intermediate density fluid along
the proximal anterior tibia measuring 7.1 cm in craniocaudal
___, compatible with a hematoma. No other focal fluid
collections.
2. Extensive subcutaneous edema throughout the right lower
extremity extending into the right foot. No subcutaneous
emphysema.
3. Small non hemorrhagic right knee joint effusion.
Brief Hospital Course:
Ms ___ is a ___ h/o DM, HTN, HLD here w/ leg swelling and
redness after a fall diagnosed with cellulitis. She was treated
with broad-spectrum antibiotics with good clinical response
which was transitioned to PO antibiotics.
ACUTE ISSUES ADDRESSED:
=============
# Cellulitis
Erythema, significant swelling and TTP on exam but no systemic
symptoms or lab abnormalities. CT showing possible hematoma as
well as extensive subcutaneous edema but no evidence of
subcutaneous gas or necrotizing fasciitis. She was evaluated by
trauma surgery service. The patient was first treated with
vancomycin, ceftriaxone, and flagl which was narrowed to Ancef.
She had good clinical response and was discharged on PO Keflex
to finish a 7-day course (last day ___. Her pain was treated
with Tylenol. Final read of blood cultures was pending at
discharge.
CHRONIC ISSUES:
===============
# IDDM:
Continued home lantus 70 u daily with sliding scale insulin.
# HTN
Continued lisinopril 20 mg daily.
# HLD
Continued home simvastatin 20 mg daily
TRANSITIONAL ISSUES
===================
[] Cellulitis: evaluate for resolution of symptoms with
finishing her course of 7-day course of antibiotics. last day
___
#CODE: full code, confirmed
#CONTACT: ___, husband ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 70 Units Breakfast
2. Simvastatin 20 mg PO QPM
3. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Cephalexin 500 mg PO Q6H Duration: 5 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth four times a day
Disp #*20 Capsule Refills:*0
3. Glargine 70 Units Breakfast
4. Lisinopril 20 mg PO DAILY
5. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis
==============
Cellulitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Dear Ms. ___,
It was a pleasure taking part in your care here at ___!
Why was I admitted to the hospital?
- You were admitted for a skin infection in your leg.
What was done for me while I was in the hospital?
You received antibiotics.
What should I do when I leave the hospital?
-Please note any new medications in your discharge worksheet
-Your appointments are as below
-Take antibiotics through ___
Sincerely,
Your ___ Care Team
Followup Instructions:
___
|
10121836-DS-3 | 10,121,836 | 24,419,339 | DS | 3 | 2185-07-26 00:00:00 | 2185-07-26 15:39:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
R intertroch fracture
Major Surgical or Invasive Procedure:
R hip TFN short
History of Present Illness:
This is a ___ female who slipped on some tea tonight falling on
her right hip. She denies head strike, headache, neck pain, back
pain, chest pain, shortness of breath, abdominal pain nausea,
vomiting, numbness, weakness in her legs, fevers. No history of
previous hip fractures. Denies knee pain, ankle pain. She is
ambulatory without a walker at home.
Past Medical History:
Non-insulin-dependent diabetes, hypertension
Social History:
___
Family History:
NC
Physical Exam:
RLE:
Sensation intact, motor intact. Bruising around thigh/hip.
Dressings: C/D/I
Pertinent Results:
___ 06:15AM BLOOD Hct-27.8*
___ 06:35AM BLOOD Hct-23.1*
___ 04:55AM BLOOD Hct-24.0*
___ 05:45AM BLOOD Hct-25.4*
___ 05:45AM BLOOD WBC-9.6 RBC-2.79* Hgb-8.7* Hct-26.9*
MCV-97 MCH-31.2 MCHC-32.4 RDW-13.8 Plt ___
___ 09:20AM BLOOD WBC-9.4 RBC-3.62* Hgb-11.3* Hct-33.5*
MCV-93 MCH-31.2 MCHC-33.6 RDW-13.6 Plt ___
___ 10:56PM BLOOD WBC-12.6* RBC-4.14* Hgb-12.7 Hct-38.7
MCV-93 MCH-30.7 MCHC-32.9 RDW-13.8 Plt ___
___ 10:56PM BLOOD Neuts-82.1* Lymphs-10.9* Monos-5.4
Eos-1.0 Baso-0.6
___ 05:45AM BLOOD Glucose-204* UreaN-10 Creat-0.6 Na-136
K-3.7 Cl-101 HCO3-29 AnGap-10
___ 05:45AM BLOOD Glucose-284* UreaN-12 Creat-0.7 Na-136
K-4.5 Cl-101 HCO3-28 AnGap-12
___ 05:45AM BLOOD Calcium-8.0* Phos-1.9* Mg-1.7
___ 05:45AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.4*
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R intertroch fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for R hip TFN short , 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 a facility was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is WBAT in the right lower extremity,
and will be discharged on lovenox for DVT prophylaxis. The
patient will follow up in two weeks per routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 3 mg PO QHS
2. Amlodipine 2.5 mg PO DAILY
3. GlipiZIDE XL 10 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Sertraline 50 mg PO DAILY
7. Januvia (sitaGLIPtin) 50 mg oral daily
8. Aspirin 81 mg PO DAILY
9. Acetaminophen w/Codeine 1 TAB PO Q6H:PRN pain
10. VICOdin (HYDROcodone-acetaminophen) 7.5/325 mg oral 1 tablet
by mouth every 8 hours as needed for pain
11. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3)
600 mg(1,500mg) -200 unit oral twice daily
Discharge Medications:
1. Calcarb 600 With Vitamin D (calcium carbonate-vitamin D3) 600
mg(1,500mg) -200 unit oral twice daily
2. ALPRAZolam 3 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. GlipiZIDE XL 10 mg PO BID
5. Januvia (sitaGLIPtin) 50 mg oral daily
6. MetFORMIN (Glucophage) 1000 mg PO BID
7. Sertraline 50 mg PO DAILY
8. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*60 Tablet Refills:*2
9. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg SC QPM Disp #*14 Syringe
Refills:*0
10. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H:PRN Disp #*90
Tablet Refills:*0
11. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
12. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*21 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R intertroch fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
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
ANTIBIOTICS:
- Please take bactrim for 7 days (twice a day)
- Please take clindamycin for 7 days (Every 8 hrs)
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.
- Splint must be left on until follow up appointment unless
otherwise instructed
- Do NOT get splint wet
ACTIVITY AND WEIGHT BEARING:
- Weight bearing as tolerated Right Lower Extremity
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:
Please monitor blood pressure. Hold home lisinopril 40mg and
amlodipine 2.5 mg daily. When blood pressure is >130 systolic,
please ask MD to consider re-starting amlodipine; if blood
pressure continues to rise despite this medication, please
consider restarting lisinopril.
Dressing: DSD QD. ___ DC dressing changes once wound stops
draining.
Followup Instructions:
___
|
10121836-DS-4 | 10,121,836 | 20,311,493 | DS | 4 | 2187-01-03 00:00:00 | 2187-01-03 14:46:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Left intertrochanteric femur fracture
Major Surgical or Invasive Procedure:
Left hip short TFN for left intertrochanteric femur fracture
History of Present Illness:
HPI: ___ female presents with L hip fracture s/p mechanical fall.
She was stepping off a curb without her cane and fell onto her
left hip. Of note, she sustained a R intertrochanteric hip
fracture and underwent R TFN on ___ (Dr. ___.
She ambulates without assistance at home but normally uses a
cane
when ambulating outside.
Past Medical History:
Non-insulin-dependent diabetes, hypertension
Social History:
___
Family History:
NC
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left intertrochanteric femur fracture and was admitted
to the orthopedic surgery service. The patient was taken to the
operating room on ___ for Left hip short TFN, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
NVI distally in the left lower extremity, and will be discharged
on lovenox for DVT prophylaxis. The patient will follow up with
Dr. ___ per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 3 mg PO QHS
2. Amlodipine 2.5 mg PO DAILY
3. GlipiZIDE XL 5 mg PO DAILY
4. Lisinopril 40 mg PO DAILY
5. MetFORMIN (Glucophage) 1000 mg PO BID
6. Sertraline 75 mg PO DAILY
7. sitaGLIPtin 100 mg oral DAILY
8. Aspirin 81 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 3 mg PO QHS
2. Amlodipine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. GlipiZIDE XL 5 mg PO DAILY
5. Lisinopril 40 mg PO DAILY
6. Sertraline 75 mg PO DAILY
7. MetFORMIN (Glucophage) 1000 mg PO BID
8. sitaGLIPtin 100 mg oral DAILY
9. Docusate Sodium 100 mg PO BID
10. Enoxaparin Sodium 40 mg SC QPM Duration: 4 Weeks
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 MG SC QPM Disp #*28 Syringe
Refills:*0
11. Senna 8.6 mg PO BID
12. Hydrocodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain
RX *hydrocodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Q4H: PRN Disp #*60 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Left intertrochanteric femur fracture
Discharge Condition:
Mental status: AOX3; Ambulating with aid of ___ Overall: stable
to improved
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:
- WBAT LLE
MEDICATIONS:
- Please take all medications as prescribed by your physicians
at discharge.
- Continue all home medications unless specifically instructed
to stop by your surgeon.
- Do not drink alcohol, drive a motor vehicle, or operate
machinery while taking narcotic pain relievers.
- Narcotic pain relievers can cause constipation, so you should
drink eight 8oz glasses of water daily and take a stool softener
(colace) to prevent this side effect.
ANTICOAGULATION:
- Please take Lovenox 40mg daily for 4 weeks
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- No dressing is needed if wound continues to be non-draining.
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:
DSD q2-3 days. Sutures/staples will be removed at follow-up.
Elevation at rest.
Followup Instructions:
___
|
10122126-DS-4 | 10,122,126 | 21,265,562 | DS | 4 | 2171-03-19 00:00:00 | 2171-03-19 18:20:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lumbar Stenosis
Major Surgical or Invasive Procedure:
___ discectomy
History of Present Illness:
___ with 16 day history of left sided back and leg pain with
numbness of the lateral aspect of left foot. He describes the
pain as L LBP sharp, radiating down his L buttocks and hamstring
with numbness on the lateral aspect of his L lower leg to foot.
Worsened over the first week to the point where patient couldn't
walk when he went to ED in ___ where he was told he had
sciatica and was given pain meds. Two days prior to this
presentation he went ___ ED where he was told
again
he had sciatica after a CT scan and xray and was given pain
medications and told to rest. Patient is currently unable to
ambulate or stand up with mild relief of his pain with use of
Norco and muscle relaxant from ___ and Diazepam and oxycontin
from ___. He has also taken ibuprofen but found
only mild relief with return of symptoms after a short period of
time. Lying supine also provides some relief.
Past Medical History:
R shoulder surgery ___ years prior
All:
None
Social History:
___
Family History:
NC
Physical Exam:
T: 97.7 BP: 116/78 HR: 57 R 16 96 on RA O2Sats
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: PERRLA EOMI
Neck: Supple.
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, to
mm bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors.
BUE - Strength ___ throughout, SILT in all distributions, warm
and well perfused
RLE - Strength ___ throughout, SILT in all distributions, warm
and well perfused
LLE - Strength ___ throughout except for IP, hamstring, tib ant,
and ___ which are ___, sensation diminished on lateral aspect of
lower leg, foot, and sole of foot, can distinguish between blunt
and pinprick sensation on lateral leg but not foot or sole
Reflexes: Unable to assess due to patient's discomfort
Toes downgoing bilaterally
Coordination: normal on finger-nose-finger, rapid alternating
movements, heel to shin
EXAM ON DISCHARGE:
A&Ox3, BUE ___, RLE ___, LLE: IP ___ pain limited otherwise
full. Continue with some left leg pain and numbness but improved
from pre op.
Pertinent Results:
MR ___/ contrast:
Disc extrusion at L5-S1 which causes moderate spinal canal
stenosis and moderate to severe left neural foraminal stenosis
at
that level. No abnormal cord signal. No osseous abnormality.
Brief Hospital Course:
Mr. ___ presented on ___ with back and left leg pain. He was
found to have significant lumbar stenosis with disc herniation.
He was brought to the OR urgently for L5-S1 discectomy. His
intraoperative course was uneventful, please refer to the
operative note for further details. He was brought to the PACU
for recovery.
On ___, the patient was experiencing significant, his pain
medication was adjusted, with good relief. The patient expressed
readiness to be discharge home. He was discharged in stable
conditions, all follow up and instructions given.
Medications on Admission:
Diazepam Ibuprofen Oxycontin
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN for fever or pain
Please do not exceed more than 4 grams in 24hrs.
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Cephalexin 500 mg PO Q6H Duration: 24 Hours
RX *cephalexin 500 mg 1 capsule(s) by mouth Q 6hrs Disp #*3
Capsule Refills:*0
4. Cyclobenzaprine 5 mg PO TID
RX *cyclobenzaprine 5 mg 1 tablet(s) by mouth Q 8hrs. Disp #*60
Tablet Refills:*0
5. Docusate Sodium 100 mg PO BID
6. Famotidine 20 mg PO BID
Continue to take only while taking steroids, then stop.
RX *famotidine 20 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
7. Methylprednisolone 2 mg PO QID Duration: 4 Doses
This is dose # 4 of 7 tapered doses
Tapered dose - DOWN
8. Methylprednisolone 2 mg PO TID Duration: 3 Doses
This is dose # 5 of 7 tapered doses
Tapered dose - DOWN
9. Methylprednisolone 2 mg PO BID Duration: 2 Doses
This is dose # 6 of 7 tapered doses
Tapered dose - DOWN
10. Methylprednisolone 2 mg PO DAILY Duration: 1 Dose
This is dose # 7 of 7 tapered doses
Tapered dose - DOWN
11. Methylprednisolone 8 mg PO QID Duration: 4 Doses
This is dose # 1 of 7 tapered doses
RX *methylprednisolone [Medrol] 4 mg See taper tablet(s) by
mouth taper Disp #*60 Tablet Refills:*0
12. Methylprednisolone 6 mg PO QID Duration: 4 Doses
This is dose # 2 of 7 tapered doses
Tapered dose - DOWN
13. Methylprednisolone 4 mg PO QID Duration: 4 Doses
This is dose # 3 of 7 tapered doses
Tapered dose - DOWN
14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN pain
Please do not drive or operate mechanical machinery while taking
narcotics.
RX *oxycodone 5 mg ___ tablet(s) by mouth Q 4hrs Disp #*60
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Disc herniation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Discharge Instructions
Spine Surgery without Fusion
Surgery
Your dressing may come off on the second day after surgery.
Your incision is closed with staples. You will need staple
removal. Please keep your incision dry until staple removal.
Do not apply any lotions or creams to the site.
Please avoid swimming for two weeks after suture/staple
removal.
Call your surgeon if there are any signs of infection like
redness, fever, or drainage.
Activity
We recommend that you avoid heavy lifting, running, climbing,
or other strenuous exercise until your follow-up appointment.
You make take leisurely walks and slowly increase your
activity at your own pace. ___ try to do too much all at once.
No driving while taking any narcotic or sedating medication.
No contact sports until cleared by your neurosurgeon.
Medications
Please do NOT take any blood thinning medication (Aspirin,
Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon.
You may use Acetaminophen (Tylenol) for minor discomfort if
you are not otherwise restricted from taking this medication.
It is important to increase fluid intake while taking pain
medications. We also recommend a stool softener like Colace.
Pain medications can cause constipation.
When to Call Your Doctor at ___ for:
Severe pain, swelling, redness or drainage from the incision
site.
Fever greater than 101.5 degrees Fahrenheit
New weakness or changes in sensation in your arms or legs.
Followup Instructions:
___
|
10122182-DS-17 | 10,122,182 | 20,031,947 | DS | 17 | 2143-07-22 00:00:00 | 2143-07-22 21:01:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
codeine / hydrocodone / oxycodone
Attending: ___.
Chief Complaint:
Fevers, drain from old drain site
Major Surgical or Invasive Procedure:
___: CT-guided drainage of peripancreatic abscess.
History of Present Illness:
The patient is a ___ year old man with FAP who is POD14 from ex
lap, pancreas
sparing duodenectomy, distal gastrectomy, and cholecystectomy
for
biopsy-proven periampullary adenoma with high grade dysplasia.
He presents with a 24 hour history of abdominal pain, low grade
temperatures (Tmax 100.0 at home) and increased output from the
medial drain site. Of note, was discharged on ___ in good
condition and both his drains were removed prior to discharge.
He reports no change in appetite, no change in bowel function
(stools are loose at baseline as he is s/p colectomy ___ and
denies all symptoms until 24 hours prior to presentation. He
does endorse night sweats last night without rigors. He states
the output from the drain site is worse when he stands and
ambulates.
Past Medical History:
Familial Adenomatous polyposis s/p partial colectomy ___
Pancreas preserving dudenectomy distal gastrectomy ___
Social History:
___
Family History:
Father with FAP s/p colectomy and whipple. Brother with FAP s/p
subtotal colectomy. Mother with papillary thyroid cancer, father
with h/o mesothelioma.
Physical Exam:
T=98.1F; BP=125 / 77mmHg; HR=87x'; RR=18; O2Sat=96%RA
GENERAL: AOx3, NAD
HEENT: Normocephalic, atraumatic.
CARDIAC: Regular rate and rhythm, no murmurs/rubs/gallops.
LUNGS: No respiratory distress. Clear to auscultation
bilaterally. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowel sounds, non distended, non-tender to
palpation. Drain in situ. No erythema or discharge from wounds
EXTREMITIES: No clubbing, cyanosis, or edema.
Pertinent Results:
___ 07:48AM BLOOD WBC-5.7 RBC-3.07* Hgb-9.0* Hct-28.2*
MCV-92 MCH-29.3 MCHC-31.9* RDW-13.3 RDWSD-44.4 Plt ___
___ 05:50AM BLOOD WBC-7.6 RBC-3.71* Hgb-11.2* Hct-33.5*
MCV-90 MCH-30.2 MCHC-33.4 RDW-13.2 RDWSD-43.6 Plt ___
___ 04:19PM BLOOD WBC-11.8* RBC-4.35* Hgb-13.0* Hct-38.1*
MCV-88 MCH-29.9 MCHC-34.1 RDW-12.8 RDWSD-41.2 Plt ___
___ 04:19PM BLOOD Neuts-76.0* Lymphs-8.9* Monos-13.2*
Eos-0.2* Baso-0.2 Im ___ AbsNeut-8.99*# AbsLymp-1.05*
AbsMono-1.56* AbsEos-0.02* AbsBaso-0.02
___ 05:50AM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-128*
K-4.5 Cl-95* HCO3-26 AnGap-12
___ 04:19PM BLOOD Glucose-114* UreaN-15 Creat-0.9 Na-125*
K-4.8 Cl-91* HCO3-21* AnGap-18
___ 05:50AM BLOOD Calcium-8.0* Phos-3.8 Mg-2.1
___ 04:29PM BLOOD Lactate-1.3
___ 5:33 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
WORK UP PER ___ ___ ___.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
in this
culture.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Back
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
Reported to and read back by ___ ___
00:20.
WOUND CULTURE (Final ___:
HAFNIA ALVEI. SPARSE GROWTH.
HAFNIA ALVEI. SPARSE GROWTH. ___ MORPHOLOGY.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
HAFNIA ALVEI
| HAFNIA ALVEI
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
PIPERACILLIN/TAZO----- 8 S 16 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
EXAMINATION: CT-guided peripancreatic fluid collection drainage
INDICATION: ___ year old man with FAP s/p pancreas sparing
duodenectomy ___,
now with fever found to have intraabdominal abscess.// please
drain known
duodenectomy site abscess. Please send fluid for micro, gram
stain and
amylase. Thank you
COMPARISON: CT abdomen and pelvis ___
PROCEDURE: CT-guided drainage of peripancreatic collection.
OPERATORS: Dr. ___ trainee and Dr. ___
radiologist.
Dr. ___ supervised the trainee during the key
components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the
procedure were
explained to the patient. After a detailed discussion, informed
written
consent was obtained. A pre-procedure timeout using three
patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the CT scan
table. Limited
preprocedure CT scan was performed to localize the collection.
Based on the
CT findings an appropriate skin entry site for the drain
placement was chosen.
The site was marked. Local anesthesia was administered with 1%
Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___
needle was
inserted into the collection. A sample of fluid was aspirated,
confirming
needle position within the collection. 0.038 ___ wire was
placed through
the needle and needle was removed. This was followed by
placement of ___
Exodus pigtail catheter into the collection. The plastic
stiffener and the
wire were removed. The pigtail was deployed. The position of
the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 20 cc of purulent fluid was aspirated with a
sample sent for
microbiology evaluation. The catheter was secured by a StatLock.
The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate
post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.5 s, 29.2 cm; CTDIvol = 12.3 mGy
(Body) DLP = 344.1
mGy-cm.
2) Stationary Acquisition 6.1 s, 1.4 cm; CTDIvol = 64.0 mGy
(Body) DLP =
92.1 mGy-cm.
3) Spiral Acquisition 9.5 s, 29.2 cm; CTDIvol = 12.4 mGy
(Body) DLP = 346.5
mGy-cm.
Total DLP (Body) = 792 mGy-cm.
SEDATION: Moderate sedation was provided by administering
divided doses of 3
mg Versed and 150 mcg fentanyl throughout the total
intra-service time of 25
minutes during which patient's hemodynamic parameters were
continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Preprocedure CT re-demonstrates a peripancreatic fluid
collection, within
accessible component along the anterior margin the pancreas.
Pancreatic and
biliary stents again noted. Postsurgical changes noted along
the anterior
abdominal wall.
Intraprocedural CT fluoroscopy demonstrates appropriate
positioning of the
___ needle, wire, and catheter.
Postprocedure CT demonstrates appropriate positioning of the
pigtail catheter.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc// r picc 51cm iv ping
___ Contact
name: ___, ___: ___
IMPRESSION:
In comparison with the study ___, there is an placement
of a right
subclavian PICC line it extends to the upper right atrium. It
could be pulled
back approximately 3 cm if the desired position is at or above
the cavoatrial
junction.
Otherwise, the examination is within normal limits.
Brief Hospital Course:
The patient is a ___ year old man with FAP who was POD14 from ex
lap, pancreas sparing duodenectomy, distal gastrectomy, and
cholecystectomy forbiopsy-proven periampullary adenoma with high
grade dysplasia.
He presented on ___ with a 24 hour history of abdominal
pain, low grade temperatures (Tmax 100.0 at home) and increased
output from the medial drain site. Of note, was discharged on
___ in good condition and both his drains were removed prior
to discharge.
He reported no change in appetite, no change in bowel function
(stools are loose at baseline as he is s/p colectomy ___ and
denied all symptoms until 24 hours prior to presentation. He did
endorse night sweats last night without rigors. He stated that
the output from the drain site is worse when he stands and
ambulates.
CT scan on admission revealed 10x4 rim enhancing fluid
collection near duodenectomy site concerning for abscess.
Patient was started on Zosyn and ___ was consulted for possible
drainage.
Patient had temperature 101.4 and elevated WBC on admission.
Infectious Diseases was consulted to optimize antibiotic
regimen. On HD 2, patient underwent CT guided placement of an
___ pigtail catheter into the collection. Post procedure
patient was advanced to regular diet. He remained afebrile after
drain placement, and WBC returned to normal limits. Right-sided
PICC line was placed on ___
Fluid cultures at the time of discharge were:
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
FLUID CULTURE (Preliminary):
WORK UP PER ___ ___ ___.
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of P.aeruginosa,
S.aureus and beta hemolytic streptococci will be reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT in this
culture.
GRAM NEGATIVE ROD(S). MODERATE GROWTH.
ENTEROCOCCUS SP.. SPARSE GROWTH.
GRAM NEGATIVE ROD #2. RARE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
The patient was discharged home on ___. He will continue
on IV antibiotics, and his repeat CT scheduled on ___. Per ID,
he will be discharged on Ertapenem and Daptomycin Q/daily for 30
days each.
He will need laboratory follow-up with weekly CBC/Diff,
BUN/Creatinine, LFT's, and CK.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sulindac 150 mg PO DAILY
Discharge Medications:
1. Daptomycin 550 mg IV Q24H
RX *daptomycin 500 mg 500 mg IV once a day Disp #*30 Vial
Refills:*0
2. Docusate Sodium 100 mg PO BID
3. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose
RX *ertapenem [Invanz] 1 gram 1 g IV once a day Disp #*30 Vial
Refills:*0
4. Multivitamins 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. HELD- Sulindac 150 mg PO DAILY This medication was held. Do
not restart Sulindac until You discuss on your next follow-up
appointment
7.Outpatient Lab Work
Please draw the following labs on ___:
CBC with differential, BUN, Creatinine, AST, ALT, T Bili, AP,
CPK.
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
8.Outpatient Lab Work
Please draw the following labs on ___:
CBC with differential, BUN, Creatinine, AST, ALT, T Bili, AP,
CPK.
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
9.Outpatient Lab Work
Please draw the following labs on ___:
CBC with differential, BUN, Creatinine, AST, ALT, T Bili, AP,
CPK.
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
10.Outpatient Lab Work
Please draw the following labs on ___:
CBC with differential, BUN, Creatinine, AST, ALT, T Bili, AP,
CPK.
ALL LAB RESULTS SHOULD BE SENT TO:
ATTN: ___ CLINIC - FAX: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Intra abdominal abscess
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 evaluation
of fevers and leak from old JP site. CT scan on admission
revealed a rim enhancing fluid collection near duodenectomy site
concerning for abscess. You were started on antibiotics and
underwent CT-guided drainage. You will need antibiotics for a
few weeks after you are discharged, probably 4 weeks at least.
You are now safe to return home to complete your recovery with
the following instructions:
.
Please ___ Dr. ___ office at ___ or office nurses
at ___ if you have any questions or concerns.
.
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.
.
Wound care: Please continue to change dressing over your old JP
site daily.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
.
___ Drain Care: To bulb suction. Cleanse insertion site with mild
soap and water or sterile saline, pat dry, and place a drain
sponge daily and PRN. Monitor and record quality and quantity of
output. Empty bulb frequently. Ensure that the catheter is
secured to the patient.
Monitor for s/s infection or dislocation.
Followup Instructions:
___
|
10122182-DS-19 | 10,122,182 | 22,489,381 | DS | 19 | 2145-07-04 00:00:00 | 2145-07-04 12:24:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
codeine / hydrocodone / oxycodone
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___: Successful CT-guided placement of ___ pigtail
into peripancreatic collection.
.
___: Successful CT-guided placement of right upper quadrant
and right lower quadrant an 8 and ___ pigtail catheters,
respectively, into the anterior abdominal collection.
History of Present Illness:
Mr. ___ is a ___ man with a history of FAP s/p
pancreas-sparing duodenectomy, partial gastrectomy, and
cholecystectomy on ___, for high grade duodenal
dysplasia / duodenal adenomas, now more recently s/p
pancreaticojejunectomy with end to side pancreaticojejunostomy
and hepaticojejunostomy on ___. His post operative course
was complicated by dark serosanguinous output and sanguinous
output from his JP drains, with a Crit drop of 42 to 30, after
which they improved and stabilized at 35. His SQH was held ___
and restarted without event ___. He was discharged eventually
after the bleeding had resolved on ___.
After he went home, he notes increased pain overnight. Then this
morning, he was ambulating, with a sudden increase in his pain
to
___. The patient's wife called regarding the increased pain,
and he was instructed to take dilaudid between scheduled Tylenol
with explicit instructions to come to the ED if pain persists or
if there was a change in JP amount or color. She called back 30
minutes later saying that the pain was persistent, his HR was
110-120s, was very anxious. Per wife, the JP tubing had more
clots and some bright red blood was seen. They were instructed
to
come into the ED.
Patient presents to ED today with sinus tachycardia to 155. SBP
144 initially, but then became soft in the 100s. RR in the ___.
HR remained persistently elevated. His drains were seen to have
more bloody output compared to discharge, and a foul smell was
noted to come from the drain area. PIVs X 2 were placed, and
labs
were drawn, and the patient was given 1 unit of blood and 1 L
fluid bolus. Labs were concerning for lactate if ___, WC of ___
with
a left shift, lipase was in the 2000s. The Crit was unremarkable
at 41. CTA was done which demonstrated a collection concerning
for anastomotic leak vs. perforation. There was no evidence of
active extravasation.
Past Medical History:
Familial Adenomatous polyposis s/p partial colectomy ___
Pancreas preserving dudenectomy distal gastrectomy ___
Social History:
___
Family History:
Father with FAP s/p colectomy and whipple. Brother with FAP s/p
subtotal colectomy. Mother with papillary thyroid cancer, father
with h/o mesothelioma.
Physical Exam:
Prior to Discharge:
VS: 97.6, 95, 138/81, 16, 98% RA
GEN: Pleasant male without acute distress
HEENT: NC/AT, PERRL, EOMI, no scleral icterus
CV: RRR, no m/r/g
PULM: CTAB
ABD: Midline incision open to air with steri strips and c/d/I.
RLQ JP drain to bulb suction with small amount of purulent
fluid, site with drain sponge with erythema around. L flank ___
drain to bulb suction with purulent drainage, site c/c/I.
EXTR: Warm, no c/c/e
Pertinent Results:
RECENT LABS:
___ 03:01AM BLOOD WBC-7.2 RBC-3.18* Hgb-9.2* Hct-29.6*
MCV-93 MCH-28.9 MCHC-31.1* RDW-14.6 RDWSD-49.1* Plt ___
___ 03:01AM BLOOD Glucose-156* UreaN-16 Creat-0.6 Na-141
K-4.2 Cl-107 HCO3-25 AnGap-9*
___ 04:31AM BLOOD ALT-35 AST-23 AlkPhos-146* TotBili-0.3
___ 03:01AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.9
___ 11:06AM ASCITES ___
___ 01:38PM ASCITES ___
MICRO:
___ 11:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BACTEROIDES FRAGILIS GROUP.
Identification and susceptibility testing performed on
culture #
___ (___).
ANAEROBIC GRAM POSITIVE COCCUS(I).
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ (___) @08:07
(___).
___ 11:10 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
BACTEROIDES FRAGILIS GROUP.
Identification and susceptibility testing performed on
culture #
___ (___).
ANAEROBIC GRAM POSITIVE COCCUS(I).
(formerly Peptostreptococcus species).
NO FURTHER WORKUP WILL BE PERFORMED.
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ (___) @08:07
(___).
RADIOLOGY:
___ CTA ABD:
IMPRESSION:
1. A 11 cm x 5 cm x 8 cm irregular collection with debris and
gas adjacent to the presumed site of the pancreaticojejunostomy.
Adjacent to this collection, the medial wall of the jejunum is
not definitively visualized raising concern for anastomotic
leak. The medial drainage catheter seen to traverse this
collection though the tip extends inferiorly and terminates in
the right mid abdomen, inferior to the dominant component of the
collection.
2. Fluid seen tracking along the right paracolic gutter
extending into the
pelvis with enhancement of the peritoneum. Second, lateral
drainage catheter seen in association with the right paracolic
component.
3. Dilated small bowel loops throughout the abdomen and pelvis,
some with
apparent wall edema in the pelvis without evidence of
obstruction, potentially reactive.
4. Multiple mesenteric lymph nodes that are increased from prior
exam.
___ CT ABD:
IMPRESSION:
1. Significant decrease in the peripancreatic collection
containing the
pigtail drain.
2. Increase in smaller rim enhancing collection adjacent to the
hepatic
caudate lobe.
3. Significant increase in extensive rim enhancing fluid
associated with
anterior small-bowel loops just deep to the abdominal wall, much
of which
appears to be communicating. It is uncertain if this is
secondary to
pancreatic or biliary anastomotic leak but there are pockets of
fluid tracking near to the anastomoses. Additional percutaneous
drainage would be technically feasible if indicated though it
may not be definitive.
4. As previously mentioned, an anastomotic leak at the
pancreaticojejunostomy should be considered
___ CT ABD:
IMPRESSION:
1. Interval decrease in size of an anterior peripancreatic
collection adjacent to the pancreatic head, with a left pigtail
drain remaining in situ.
2. Near resolution of and anterior abdominal collection since ___,
following placement of 2 percutaneous pigtail catheters.
3. A collection abutting the caudate lobe has decreased in size,
currently 3.7 x 1.8 cm, previously 7.4 x 3.0 cm.
4. Two right-sided surgical drains are unchanged in position,
with only
minimal fluid at the tips.
5. No new abdominopelvic collection.
6. Unchanged peripancreatic stranding along the pancreatic body
and tail.
7. Moderate distention of multiple loops of small bowel, without
transition point, likely reflecting mild ileus.
8. Mild hepatic steatosis.
Brief Hospital Course:
The patient s/p pancreaticojejunostomy was readmitted to the
Surgical Oncology Service with increased abdominal pain and
tachycardia. On admission patient was afebrile, his HR was 155,
WBC ___ and lactate at 7. Abdominal CT scan on admission
demonstrated large irregular collection with debris and gas
adjacent to the presumed site of the pancreaticojejunostomy,
concerning for anastomotic leak or perforation. Patient was
started on broad spectrum antibiotics and ___ was consulted for
possible drainage/aspiration. Patient received 1L fluid bolus
and one unit of RBC. On ___ patient underwent CT guided
placement of ___ pigtail catheter into the collection.
Post procedure patient was transferred in ICU for further
management. He was started on Octreotide, continued on
Meropenem/Vancomycin. Blood cultures were positive for GPCs. On
___: PICC line was placed, TPN was started. Patient remained
afebrile, WBC down to 13K. On ___: Repeat CT scan demonstrated
significant decrease in the peripancreatic collection containing
the
pigtail drain; increase in smaller rim enhancing collection
adjacent to the hepatic
caudate lobe and significant increase in extensive rim enhancing
fluid associated with anterior small-bowel loops just deep to
the abdominal wall, much of which
appears to be communicating (please see Radiology report for
details). ___ was consulted for additional drain placement. On
___: patient underwent placement of ___ and ___ drains into
abdominal wall fluid collections. Vancomycin was discontinued,
NGT was removed. He continued on TPN and IVF.
On ___ Patient's diet was advanced to clears. he was
transferred to the floor on Meropenem, Octreotide and clears. On
the floor patient continue to progress with recovery. ID was
consulted and recommended to continue Meropenem. He was
transitioned to oral medications from IV. On ___: Octreotide
was discontinued as drains output decreased. On ___: Repeat CT
scan demonstrated decreased size in all intraabdominal fluid
collections. Two drains, which were placed in ___ were removed.
Diet was advanced to regular. Patient was transitioned to Zosyn
per ID recommendations. Patient developed nausea with small
emesis on ___ and diet was downed to clear liquids. Infectious
Diseases recommended continue Ertapenem after discharge for ___
weeks (course will be determine during follow up appointment).
On ___ patient JP 1 was discontinued. TPN was cycled for 12
hours overnight. On ___ patient was discharged home in stable
condition. Patient was instructed to check his blood sugar twice
a day; once before bedtime when on TPN; and second time 2 hours
after discontinue TPN in AM. He was provided with prescription
for glucometer and supply.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q6H
2. Aspirin 325 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
5. Metoclopramide 10 mg PO QIDACHS
Discharge Medications:
1. Ertapenem Sodium 1 g IV ONCE Duration: 1 Dose
RX *ertapenem 1 gram 1 g PICC once a day Disp #*28 Vial
Refills:*0
2. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe
RX *hydromorphone 2 mg ___ tablet(s) by mouth every 6 to 8 hours
Disp #*28 Tablet Refills:*0
3. OneTouch Delica Lancets (lancets) 33 gauge miscellaneous Q6H
RX *lancets [OneTouch Delica Lancets] 33 gauge 1 lancet every
six (6) hours Disp #*200 Each Refills:*0
4. OneTouch Verio Flex (blood-glucose meter) 1 Kit
miscellaneous Q6H
RX *blood-glucose meter [OneTouch Verio System] 1 kit every six
(6) hours Disp #*1 Kit Refills:*0
5. OneTouch Verio (blood sugar diagnostic) 1 Kit
miscellaneous Q6H
RX *blood sugar diagnostic [OneTouch Verio] 1 test strip every
six (6) hours Disp #*200 Strip Refills:*0
6. OneTouch Verio (blood sugar diagnostic) 1 test strip
miscellaneous Q6H
7. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
do not exceed more then 3000 mg/day
10. Metoclopramide 10 mg PO QIDACHS
11. Omeprazole 40 mg PO DAILY
12. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First
Line
13. HELD- Aspirin 325 mg PO DAILY This medication was held. Do
not restart Aspirin until further instructions
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1. Familial adenomatous polyposis s/p pancreaticoduodenectomy
2. Pancreatic fistula
3. Bacteremia with sepsis
4. Intra abdominal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___,
You were ___ to the surgery service at ___ after
pancreaticoduodenectomy with symptoms of sepsis. CT on admission
revealed pancreaticojejunostomy leak and large intra abdominal
abscess. You were treated with antibiotics and bowel rest. You
underwent multiple CT-guided procedure by ___. You were started
on long term antibiotics and provided with TPN for nutrition.
You are now safe to return home to complete your recovery with
the following instructions:
.
Please ___ Dr. ___ office at ___ option 4 if you
have any questions or concerns. During off hours: please ___
operator at ___ and ask to ___ team.
.
Please resume all regular home medications , unless specifically
advised not to take a particular medication. Also, please take
any new medications as prescribed.
Please get plenty of rest, continue to ambulate several times
per day, and drink adequate amounts of fluids. Avoid lifting
weights greater than ___ lbs until you follow-up with your
surgeon, who will instruct you further regarding activity
restrictions.
Avoid driving or operating heavy machinery while taking pain
medications.
Please follow-up with your surgeon and Primary Care Provider
(PCP) as advised.
.
Incision Care:
*Please ___ 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 steri-strips, they will fall off on their own.
Please remove any remaining strips ___ days after surgery.
.
JP Drain x 2 Care:
*Please look at the site every day for signs of infection
(increased redness or pain, swelling, odor, yellow or bloody
discharge, warm to touch, fever).
*Maintain suction of the bulb.
*Note color, consistency, and amount of fluid in the drain.
___ the doctor, ___, or ___ nurse if the amount
increases significantly or changes in character.
*Be sure to empty the drain frequently. Record the output, if
instructed to do so.
*You may shower; wash the area gently with warm, soapy water.
*Keep the insertion site clean and dry otherwise.
*Avoid swimming, baths, hot tubs; do not submerge yourself in
water.
*Make sure to keep the drain attached securely to your body to
prevent pulling or dislocation.
.
PICC Line:
*Please monitor the site regularly, and ___ your MD, nurse
practitioner, or ___ Nurse if you notice redness, swelling,
tenderness or pain, drainage or bleeding at the insertion site.
* ___ your MD or proceed to the Emergency Room immediately if
the PICC Line tubing becomes damaged or punctured, or if the
line is pulled out partially or completely. DO NOT USE THE PICC
LINE IN THESE CIRCUMSTANCES.Please keep the dressing clean and
dry. Contact your ___ Nurse if the dressing comes undone or is
significantly soiled for further instructions.
Followup Instructions:
___
|
10122297-DS-21 | 10,122,297 | 20,383,912 | DS | 21 | 2175-11-05 00:00:00 | 2175-11-05 19:42:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lightheadedness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
As per admitting MD:
___ yo male with a history of lung cancer who is admitted with
orthostatic hypotension. The patient was in clinic today and
became lightheaded while standing and was found to be
hypotensive
to the ___ and tachycardic to the 102s. He repots having similar
symptoms at home. He denies any headaches, fevers, shortness of
breath, or chest pain. He has been drinking and eating less than
usual. He also denies any nausea, diarrhea, dysuria, or rashes.
Of note he reported fecal incontinence in clinic. On admission
he
states he knew that he had to have a bowel movement he just
couldn't make it to the bathroom. This is also what he told the
ED. He denies any urinary incontinence or any true fecal
incontinence. He denies any numbness or weakness.
In the ED his vital signs and labwork were unremarkable. He had
previously received IV fluids in clinic. A CT torso was done
which showed decreased size of his lung masses but increased
size
of lymph nodes.
REVIEW OF SYSTEMS:
- All reviewed and negative except as noted in the HPI"
Past Medical History:
As per admitting MD:
"- Stage IV lung adenocarcinoma metastatic to brain
- ___: patient noticed several months of dizziness and
unsteady gait for which he presented to ___ ED. He
also had ___ weight loss, nausea, vomiting. Head CT showed 4
brain mass (4.7 mass in posterior R cerebellum, 1.8 cm mass in
inferior medial L cerebellum, 3.7cm mass in R temporal lobe with
adjacent nodule, and 3cm mass in L parietal occipital junction).
There was mass effect on ___ ventricle without dilation of ___
of
lateral ventricles. CT chest showed a 3.4 x 4 cm RUL mass with
hilar LAD. CT torso showed an adrenal lesion.
- ___ - ___: Admitted to ___ inpatient. Treated with
decadron and started empirically on keppra. Multidisciplinary
discussions were had surrounding care. Given that brain lesion
was not amenable to SRS, surgical resection was pursued.
- ___: resection of the R sided cerebellar lesion (Dr.
___
- ___: second craniotomy for resection of the 2
supratentorial
lesions
- ___ - ___: Completed 5 fractions of SRS to 2 cerebellar,
left occipital, and right parietotemporal lesions. Total 2500
cGy
- ___: C1D1 Carboplatin/pemetrexed
- ___: C2D1 Carboplatin/pemetrexed
- ___: CT scan with progressive disease
- ___: C3D1 ___, add pembrolizumab C1D1
- ___: C4C1 ___, C2D1 pembrolizumab
PAST MEDICAL HISTORY:
SCHIZOAFFECTIVE DISORDER
UMBILICAL HERNIA
BASAL CELL CARCINOMA"
Social History:
___
Family History:
As per admitting MD:
"He has two healthy brothers. His mother died at ___ with a
cancer,
details unknown. His father died at ___ with lung cancer"
Physical Exam:
Admission:
General: NAD
VITAL SIGNS: T 97.8 BP 102/62 HR 86 RR 18 O2 97%RA
HEENT: MMM, no OP lesions,
CV: RR, NL S1S2
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Alert and oriented, no focal deficits.
Discharge:
GENERAL: Well-appearing gentleman, sitting in chair, smiling
EYES: Anicteric, PERLLA
HEENT: Mucous membranes moist, oropharynx clear
CARDIAC: Regular rate and rhythm, no murmurs, rubs or gallops,
distal perfusion intact, no edema
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Non-distended, normal bowel sounds, soft, non-tender, no
guarding, no palpable masses, no organomegaly.
EXT: Warm, well perfused. No lower extremity edema. No erythema
or tenderness. normal muscle bulk no deformity
NEURO: Alert and oriented, good attention and linear thought
process. Strength full throughout. fluent speech
SKIN: No significant rashes.
Psych: Normal mood/affect
Pertinent Results:
Admission:
___ 12:40PM BLOOD WBC-4.2 RBC-3.50* Hgb-11.2* Hct-34.3*
MCV-98 MCH-32.0 MCHC-32.7 RDW-16.3* RDWSD-59.1* Plt ___
___ 06:30AM BLOOD ___ PTT-27.1 ___
___ 12:40PM BLOOD UreaN-8 Creat-1.0 Na-142 K-4.2
___ 06:30AM BLOOD Phos-4.0 Mg-2.0
___ 07:00AM BLOOD Cortsol-7.6
___ Stim Test:
___ 08:15AM BLOOD Cortsol-10.5
___ 08:50AM BLOOD Cortsol-25.0*
Discharge:
___ 08:15AM BLOOD WBC-4.3 RBC-3.22* Hgb-10.4* Hct-31.4*
MCV-98 MCH-32.3* MCHC-33.1 RDW-16.0* RDWSD-57.4* Plt ___
___ 08:15AM BLOOD Glucose-94 UreaN-6 Creat-0.8 Na-142 K-4.4
Cl-102 HCO3-28 AnGap-12
___ 08:15AM BLOOD Calcium-9.3 Phos-3.9 Mg-2.1
Microbiology:
___ 4:45 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
Brief Hospital Course:
___ PMH Schizoaffective disorder, metastatic NSCLC, who
presented to routine f/u with orthostatic hypotension, which
continued here, which was possibly related to psych medications,
so was started on fludrocortisone with plans for slow
uptitration in outpatient setting.
#Orthostatic hypotension
#Volume depletion
#Lightheadedness
Patient initially presented with lightheadedness and orthostatic
hypotension which initially appeared to improving/resolve with
IVF but then recurred and have been documented daily despite
robust PO food/fluids. While recurrence of orthostatic
hypotension may be ___ fluid depletion from coffee/caffeine
consumption, his AM cortisol was barely normal so had ___ stim
test which ruled out adrenal insufficiency. As per review of
current medications, Risperdal is a common cause of orthostatic
hypotension but was not changed as he has been well controlled
on it for over ___ yrs. Instead, TEDs were applied and he was
started on 0.1 fludrocortisone. In the 24 hrs after starting
such medication, he remained persistently orthostatic by numbers
but was asymptomatic. Since he was asymptomatic and effect may
not be seen for days, dose was maintained, and patient was
discharged with plan to have orthostatics trended by ___ and at
next ___ clinic appointment with fludrocortisone increased
as needed. If such measures do not adequately control symptoms
in the future, modification of psychiatric regimen may be
explored.
#Fecal incontinence:
Occurred during time in hospital under previous provider. Was
apparently a one time episode without explanation as he remained
"continent and has had solid bowel movements since the episode,
as well as normal neurological exam, and CT torso without
vertebral lesion with potential to impinge
on cord/cauda". During my time taking care of the patient he did
not have any further symptoms so further diagnostic efforts not
explored
#Metastatic NSCLC:
He was started on Carboplatin/pemetrexed on ___. Repeat
scans after 2 cycles showed progression. Given his tumor
genomics showed high tumor mutation burden, pembrolizumab was
added on ___. He was due for C5 pemetrexed and C3
pembrolizumab on ___ but was held for admission. Patient is to
see his outpatient oncology providers in 2 days following
discharge
#Schizoaffective disorder:
Was reportedly withdrawn on ___ prior to my taking over his
intpatient care, but was euthymic since. Daily home ___ services
were resumed. On day of discharge, patient was to meet with
outpatient psychiatric providers.
Transitional Issues:
1. Pt should have orthostatics trended by ___ and at next
___ clinic appointment with fludrocortisone increased as
needed. However, would only slowly go up on dosing as
fludrocortisone may interact with bupropion to lower seizure
threshold. If such measures do not adequately control symptoms
in the future, modification of psychiatric regimen may be
explored.
2. Patient is to see his outpatient oncology providers in 2 days
following discharge to discuss resuming chemotherapy
3. Patient had mild stable anemia during stay which needs to be
trended in outpatient setting to ensure remains stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 20 mg PO QPM
2. Benztropine Mesylate 0.5 mg PO BID
3. BuPROPion 150 mg PO BID
4. Citalopram 40 mg PO DAILY
5. Famotidine 20 mg PO BID
6. FoLIC Acid 1 mg PO DAILY
7. Ondansetron 8 mg PO Q8H:PRN Nausea
8. Prochlorperazine 10 mg PO Q8H:PRN Nausea
9. RisperiDONE 3 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Nicotine Polacrilex 2 mg PO Q1H:PRN Smoking Urge
Discharge Medications:
1. Fludrocortisone Acetate 0.1 mg PO DAILY
RX *fludrocortisone 0.1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Benztropine Mesylate 0.5 mg PO BID
5. BuPROPion 150 mg PO BID
6. Citalopram 40 mg PO DAILY
7. Famotidine 20 mg PO BID
8. FoLIC Acid 1 mg PO DAILY
9. Nicotine Polacrilex 2 mg PO Q1H:PRN Smoking Urge
10. Ondansetron 8 mg PO Q8H:PRN Nausea
11. Prochlorperazine 10 mg PO Q8H:PRN Nausea
12. RisperiDONE 3 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
orthostatic hypotension possibly ___ Risperdal
metastatic ___
Schizoaffective disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr ___
___ was a pleasure taking care of you while you were admitted to
___. As you know, you were admitted due to your blood
pressure being low when you change positions. It may be due to
your Risperdal, but we didn't change that medication because you
have been on it for ___ yrs. Instead we added a medication called
fludrocortisone that should help increase your blood pressure.
You will need to have your blood pressure checked by your
visiting nurse. In the next week if you continue to have blood
pressure changes with position changes, you may need to have the
dose increased. In the meantime, please continue to drink plenty
of fluids and eat foods with salt. Remember to take your time
when changing positions so that you don't get lightheaded.
Followup Instructions:
___
|
10122428-DS-22 | 10,122,428 | 20,966,529 | DS | 22 | 2154-09-29 00:00:00 | 2154-09-29 16:17:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Com___
Attending: ___.
Chief Complaint:
wound evaluation
Major Surgical or Invasive Procedure:
I&D/wash out of wound dehiscence ___
History of Present Illness:
___ year old woman with history of CVA on Plavix, diabetes on
insulin, and hypertension who presents for wound eval.
___ had an L3-L5 right-sided laminoforaminotomy and repair
of
spinal fluid leak performed on ___ with Dr. ___. She has
generally been doing well and required a short stay in rehab.
She had her sutures removed 1.5 weeks ago and yesterday noticed
some bleeding around the surgical site. She went to ___
where they noticed some wound dehiscence. A dressing was
applied
and she was referred here for evaluation. She denies any
increased drainage from the area. She denies any pain in the
area or any pus. No fevers, chills, nausea, vomiting. She has
baseline right hip pain and neuropathy in her bilateral lower
extremities which is unchanged. No new numbness, tingling,
weakness, saddle anesthesia, loss of bowel or bladder function.
She does endorse an intermittent, non-positional headache over
the last week that is currently not present.
With regard to her UTI - she states that while she was at rehab
following her spine surgery, the nurses noted urinary retention
of about 800 cc. A foley catheter was placed for four days and
she developed a burning sensation on the fourth day, at which
point it was removed. A few days later, she went to ___
because of a bad headache and was noted to have a UTI for which
she received two doses of ceftriaxone. However, UCx returned
positive for ___ E.coli, insensitive to CTX and sensitive to
Levofloxacin. She was started on Levofloxacin 750 mg q48h x 10
days (5 pills). She is no longer having dysuria though does feel
like she is having difficulty urinating and worries she may be
retaining again.
In the ED:
- Initial VS: AF 86 159/66 18 100% RA
- Exam notable for: Subcentimeter vertical dehisced wound over
the back. No clear active drainage. RRR, CTAB, no CVAT,
diffusely
tender abd, no focal pain
- Labs were notable for: BUN/Cr 46/1.6, K 5.1, glucose 259, HCO3
18, H/H ___, WBC 10.1, and normal coags. A UA was
contaminated with 9 epi cell/hpf so difficult to interpret
results (cloudy, large leusk, small blood, positive nitrites,
30+
protein, microscopy shows 6 RBC/hpf, > 182 wbc/hpf, and moderate
bacteria)
- Studies performed include a CXR which was unremarkable.
- Patient was given:
1. Amlodipine 2.5 mg PO
2. Lisinopril 10 mg PO
3. Lidocaine patch
4. Oxycodone 2.5 mg PO
5. 1L NS
6. Ceftriaxone 1 gm IV
7. Insulin 10U + 4U SC
8. Lansoprazole 30 mg SL
- Consults: orthopedics - requested that she be NPO after
midnight for OR tomorrow or ___ and admission to medicine for
management of her ___, UTI and hyperglycemia. They also
requested
that her Plavix be held.
Vitals on transfer: AF 61 170/66 16 98% RA
Upon arrival to the floor, ___ reveals that she has "been
better" and is quite nervous about what's going on. She is in
pain, but her hip is bothering her more than her back is (which
is fairly chronic for her). She requests two Tylenol and one
oxycodone. She would also like something to drink.
Of note, patient had a bad experience in the PACU during her
last
visit. She remembers waking up and screaming for hours and is
fearful this will happen again.
With regard to the patient's medication list - she is not
entirely sure what she is taking because several of her
medications were recently stopped/changed during her visit with
Dr. ___. She reports that the most up to date list is the
one
listed in ___ record. Plavix is not listed but she is
still taking it and does not recall her PCP stopping it. ___:
insulin, she usually takes about 4U BID of Humalin-N.
REVIEW OF SYSTEMS: notable for decreased appetite over the last
few years. Otherwise unremarkable.
Past Medical History:
CVA
Hypertension
Type II DM on insulin
T2DM on insulin
hypothyroidism
GERD
Esophageal dilation
Spinal stenosis
Chronic hip pain
L3-L5 right-sided laminoforaminotomy in ___
Social History:
___
Family History:
Not relevant to this hospitalization
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 98.3 188/78 85 20 100 RA
GENERAL: Pale older woman, sitting upright in bed. Alert and
interactive. In no acute distress. Anxious.
HEENT: MMM, sclera anicteric
CARDIAC: RRR, no murmurs
RESP: Clear to auscultation bilaterally.
ABDOMEN: soft, NT, ND
MSK: There is a 6 to 8 cm vertical incision over the lumbar
spine that is completely open with bloodsoaked dressing and some
blood clots. No erythema, fluctuance, or purulent drainage. No
spinous process tenderness.
SKIN: Warm. No edema.
NEUROLOGIC: AOx3, facial symmetry, moving extremities with
purpose
GU: straight cath revealed cloudy urine.
DISHCARGE PHYSICAL EXAM
=========================
PHYSICAL EXAM:
24 HR Data (last updated ___ @ 603)
Temp: 98.0 (Tm 100.0), BP: 137/73 (117-158/61-73), HR: 70
(69-91), RR: 20 (___), O2 sat: 96% (96-99), O2 delivery: Ra,
Wt: 166.01 lb/75.3 kg
GENERAL: Older woman, sitting in bed.
HEENT: dry lips, sclera anicteric
CARDIAC: regular rate, regular rhythm, no murmurs
RESP: Decreased breath sounds bilaterally at the bases
ABDOMEN: soft, NT, ND
MSK: Large dressing, c/d/i over back wound. No surrounding
erythema, fluctuance, or purulent drainage. No spinous process
tenderness.
SKIN: Warm. No edema.
NEUROLOGIC: AOx3, facial symmetry, moving extremities with
purpose
Pertinent Results:
ADMISSION LABS
===============
___ 01:52PM BLOOD WBC-10.1* RBC-3.44* Hgb-10.0* Hct-33.4*
MCV-97 MCH-29.1 MCHC-29.9* RDW-15.1 RDWSD-53.4* Plt ___
___ 02:02PM BLOOD ___ PTT-28.7 ___
___ 01:52PM BLOOD Glucose-259* UreaN-46* Creat-1.6* Na-143
K-5.1 Cl-110* HCO3-18* AnGap-15
___ 06:18AM BLOOD %HbA1c-7.1* eAG-157*
___ 11:04PM BLOOD Calcium-10.0 Phos-3.3 Mg-2.0
___ 11:33PM BLOOD Lactate-0.9
___ 11:33PM BLOOD ___ pO2-34* pCO2-45 pH-7.30*
calTCO2-23 Base XS--4 Comment-GREEN TOP
DISCHARGE LABS
===============
___ 06:50AM BLOOD WBC-7.8 RBC-2.55* Hgb-7.5* Hct-24.6*
MCV-97 MCH-29.4 MCHC-30.5* RDW-15.1 RDWSD-53.4* Plt ___
___ 06:50AM BLOOD Glucose-124* UreaN-29* Creat-1.3* Na-143
K-4.6 Cl-110* HCO3-19* AnGap-14
OTHER RELEVANT LABS
===================
___ at ___: E coli ___
M.I.C. Inter
------ -----
Amikacin <=2 S
Ampicillin >=32 R
Ampicillin/Sulb >=32 R
Cefazolin >=64 R
Ceftazidime 16 R
Ceftriaxone >=64 R
Ertapenem <=0.5 S
Gentamicin <=1 S
Imipenem <=0.25 S
Levofloxacin 1 S
Nitrofurantoin <=16 S
Pip/Tazo <=4 S
Tobramycin <=1 S
Trimeth/Sulfa <=20 S
IMAGING/STUDIES
================
CT L Spine with W Contrast ___
FINDINGS:
The patient is status post L3-4 hemilaminectomy. Posterior to
the spine
within the right paravertebral muscles extending from L1 to the
sacrum there
is simple fluid, which is likely postsurgical. Edema is seen
within the soft
tissues overlying the lumbar spine deep to the incision. A
small amount of
hyperdensity posterior to the L2 and L3 spinous processes may
represent
minimal blood products (301:87, 92). There is no evidence of
large hematoma.
There is mild dextroconvex scoliosis of the lumbar spine with
partial fusion
of the L2-3 vertebral bodies. Degenerative disc disease is
present, worst
around the curvature extending from L1 to L4. No fractures are
identified.
There is no evidence of severe spinal canal or neural foraminal
stenosis.
There is no prevertebral soft tissue swelling.
There are trace bilateral pleural effusions. Cholelithiasis is
noted. A
simple cyst is seen arising from the left kidney. There is
diverticulosis of
the colon without evidence of acute diverticulitis.
IMPRESSION:
1. Status post L3-4 hemilaminectomy with postsurgical changes
including fluid
within the right paravertebral muscles and overlying
subcutaneous edema. No
large hematoma.
2. Cholelithiasis without evidence of acute cholecystitis.
3. Trace bilateral pleural effusions.
CXR ___
IMPRESSION:
1. Peribronchial wall thickening consistent with
inflammatory/infectious
process.
2. Interval denser of the azygos lobe compared to previous
study. Pneumonia
of the azygos lobe cannot be excluded.
Brief Hospital Course:
BRIEF SUMMARY
==============
___ w/ HTN, T2DM, prior CVA, s/p L3-L5 spinal surgery ___, now
returning with wound dehiscence and plan for OR for I&D/washout
+ wound vac placement ___. Patient was also treated for ___ and
___ E. coli catheter associated UTI. Her hospital course was
complicated by post-op fever for which she was treated for a
pneumonia.
TRANSITIONAL ISSUES
=======================
[] Patient should follow up in Spine Clinic in 2 weeks after
post-op with Dr. ___. Sutures should remain in place until
ok'ed by Dr. ___.
[] Patient presented with ___ CAUTI and is now s/p Zosyn
course. She has required intermittent straight caths for urinary
retention. Please continue q6H bladder scans with intermittent
straight caths if bladder scan >500cc.
[] Held lisinopril and Lasix at discharge given normotension and
no evidence of volume overload on exam. Can ___ whether
patient will necessitate lisinopril eventually but would start
with low dose (10mg) given ___ on presentation.
[] At discharge no evidence of volume overload on exam,
therefore discontinued home Lasix. If medication is restarted,
recommend low dose ___ PRN for lower extremity edema.
[] She was started on tamulosin during admission for urinary
retention during admission iso recurrent urinary tract
infections. Please ___ the use of this medication as
patient mobilizes more and her urinary retention improves.
[] Patient reports that at home prior to presentation, she was
taking NPH 4 BID, her insulin regimen was changed during
hospitalization and these changes are reflected in her discharge
medications.
[] Patient previously on Plavix for history of CVA. Patient
definitely does not need DAPT anymore.
ACUTE ISSUES:
=============
# Wound dehiscence
Patient is s/p L3-L5 right-sided laminoforaminotomy and repair
of spinal fluid leak on ___ with Dr. ___ presented with
increased drainage from the wound and bilateral leg burning for
several days. She was found to have wound dehiscence over her
entire vertical lumbar incision. No concerning signs of
skin/soft tissue infection. She was neurovascularly intact. She
was admitted for I&D/washout in the OR. This occurred on ___.
During the operation she was found to have a dural leak which
was repair intraoperatively. Cultures from the OR only grew
diptheroids which were thought to be a contaminant. Her pain was
controlled with acetaminophen, oxycodone, and gabapentin.
# Catheter Associated Urinary tract infection
# Urinary retention
Patient developed urinary retention at her rehab for which a
foley catheter was placed, c/b CAUTI growing ___ E.coli at
___. She was prescribed levofloxacin on ___ to be
taken every other day for 10 days. On arrival, she had 1 more
day of this course. On presentation, patient denied dysuria or
urinary frequency though did note sensation of urinary
retention. UA in the ED was obtained and was contaminated with 9
epithelial cells/hpf though also with large leuks and positive
nitrites along with > 180/hpf of WBCs; she was given 1 dose of
CTX though notably her E.coli was not sensitive to this. Upon
arrival to the floor, bladder scan showed retention of 600cc.
She was treated with Zosyn (D1: ___ for 7 days given CAUTI
(___).
#Post Operative Fever
#Pneumonia
Patient developed fever to ___ overnight from ___.
Etiology of fever thought to be ___ pneumonia as CXR
demonstrating lingual consolidation. At the time of the fever,
patient was completing course of Zosyn for ___ UTI as noted
above. She completed 5 day course treatment for HCAP
(___).
# Acute kidney injury:
BUN/Cr 46/1.6 on arrival. Baseline appears somewhere between
1.1-1.3, though recently her creatinine was 1.5 per ___
records. Etiology may be secondary to increased dose of
Lisinopril ___ 40 mg up from 10 mg) vs urinary retention vs
poor PO intake and newly standing Lasix (changed from PRN). She
was given IVF and straight catheter was used intermittently for
urinary retention. At discharge, her lisinopril and Lasix were
held as patient largely normotensive and did not appear fluid
overloaded on exam. Discharge Cr was 1.3.
#Acute on Chronic Anemia
Patient with hgb drop from 8.5 to 7.4 on ___ and further to 6.5
on AM of ___ but to 7.0 on recheck. Patient s/p OR with ortho
on
___. Received 1u pRBC ___ with appropriate response, now
uptrending to 8.0 on ___. Patient HDS without evidence of
active
bleeding. CT of spine ___ without evidence of hematoma. Labs
inconsistent with hemolysis.
# Hypertension
Hypertensive on arrival, 170/66. Likely secondary to
anxiety/pain as this improved following Tylenol and oxycodone.
Her home amlodipine 10mg was continued once daily. Held home
lisinopril given ___ and pre-op and held after given
normotension. Started Tamsulosin 0.4 mg QHS as above given
urinary retention.
# Diabetes type II with hyperglycemia
Patient was hyperglycemic on arrival, recieved 14u insulin in
ED. At home, she states she takes 4u NPH BID. Here, she was
started on weight based lantus 10U QHS + ISS with good control
of sugars. HbA1c 7.1%. Regimen altered during hospitalization
# History of lower extremity edema
Had been prescribed Lasix PRN though recently changed to
standing. Appears euvolemic on exam. Held Lasix while admitted
given ___.
CHRONIC ISSUES:
===============
# History of CVA- Continued home aspirin 81 mg once daily. Held
home Plavix. Given age and time since CVA there was no clear
indication for DAPT for CVA. This likely just places patient at
higher risk of bleeding.
# GERD- Continued home lansoprazole 30 mg SL daily
# Hypothyroidism- Continued home levothyroxine 75 mcg daily
# Peripheral neuropathy- Dose reduced gabapentin from 300 mg TID
to ___ mg BID given renal function
CORE MEASURES
=============
#CODE: Full (presumed)
#CONTACT: ___
Relationship: son
Phone number: ___
___ on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Lisinopril 40 mg PO DAILY
3. Furosemide 20 mg PO DAILY swelling
4. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
5. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain -
Moderate
6. Gabapentin 300 mg PO TID
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. melatonin 3 mg oral QHS:PRN insomnia
11. Lidocaine 5% Ointment 1 Appl TP PRN pain
12. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
13. NPH 4 Units Breakfast
NPH 4 Units Dinner
Discharge Medications:
1. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
2. Senna 8.6 mg PO BID
3. Tamsulosin 0.4 mg PO QHS
4. Gabapentin 300 mg PO BID
5. Glargine 15 Units Bedtime
Humalog 4 Units Breakfast
Humalog 6 Units Lunch
Humalog 6 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
6. amLODIPine 10 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Levothyroxine Sodium 75 mcg PO DAILY
11. Lidocaine 5% Ointment 1 Appl TP PRN pain
12. melatonin 3 mg oral QHS:PRN insomnia
13. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
14. OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN Pain
- Moderate
15. HELD- Furosemide 20 mg PO DAILY swelling This medication
was held. Do not restart Furosemide until you are told to
restart by your PCP.
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSES
==================
Wound dehiscence
Urinary tract infection with ___ E. coli
Acute on Chronic Kidney Injury
SECONDARY DIAGNOSES
=====================
Hypertension
Type 2 Diabetes Mellitus
History of CVA
GERD
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
It was a pleasure caring for you at ___
___.
WHY WAS I IN THE HOSPITAL?
- You were admitted because the wound from your back surgery
was opening up. You also had a UTI.
WHAT HAPPENED TO ME IN THE HOSPITAL?
- While you were in the hospital, you were treated for a
urinary tract infection.
- You were seen by our orthopedic surgeons who took you back to
the operating room to repair the wound on your back.
- You were treated for a pneumonia infection and will complete
your antibiotics on ___.
- You were feeling better and we felt it was safe to send you
home.
WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL?
- Continue to take all your medicines and keep your
appointments.
We wish you the best!
Sincerely,
Your ___ Team
Followup Instructions:
___
|
10122428-DS-24 | 10,122,428 | 28,752,926 | DS | 24 | 2154-12-28 00:00:00 | 2154-12-28 14:29:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Surgical Site Infection, UTI
Major Surgical or Invasive Procedure:
JP drain removal
History of Present Illness:
___ year old Female sent from her SNF for concern that her JP
drain fell out the morning of admission. There is concern for a
surgical site infection. In brief she underwent a ___
laminectomy for spinal stenosis in ___ which was complicated
by wound dehiscence and a spinal leak, and was admitted in
___ for debridement and irrigation, with subsequent planned
debridement and paraspinus muscle flaps by PRS recently
(discharged ___ who was discharged with a JP-drain in place
which apparently became discharged the morning, and this
prompted transfer to ___ ED. Of note she also was noted with
a pneumonia at her SNF 2 days prior to transfer for which she
was placed on augmentin. The SNF notes purulent drainage in the
JP drain output.
Initial vitals in the ___ were 97.7, 64, 144/47, 20, 97%2LNC,
and the ED resident notes he was able to express purulent
material from the surgical site, but of course when the ___
consult saw the patient there was none to be expressed (since it
had already been expressed). The patient received IV NS and was
given a dose of Zosyn for concern for a deep surgical wound
infection. The remaining JP drain was removed by the PRS team.
Of note the patient presents with an indwelling foley catheter
from the SNF.
Past Medical History:
- Type 2 Diabetes
- CKD Stage 3
- Primary Hypertension
- HFpEF
- hypothyroidism
- urinary retention
- GERD
- Hx ischemic CVA with question of residual mild aphasia
- Hx L3-L5 hemilaminectomy/foraminotomy and repair of spinal
leak
(___)
- Hx L3 hemilaminectomy and repair of CSF leak with irrigation
and debridement (___)
Social History:
___
Family History:
Mother: ___ Cancer
Father: MI
Physical ___:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
Remainder of 10 point ROS negative except as noted
PHYSICAL EXAM:
VSS: 98.2, 188/68, 74, 18, 92%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3 although slightly confused [at 1:30am], Non-Focal
DERM: Surgical Site with erythema with sutures in place,
without drainage (see photo in OMR uploaded by ___ team)
Pertinent Results:
ADMISSION LABS:
___ 03:26PM BLOOD WBC-8.0 RBC-2.75* Hgb-7.8* Hct-26.4*
MCV-96 MCH-28.4 MCHC-29.5* RDW-17.4* RDWSD-60.2* Plt ___
___ 03:26PM BLOOD Neuts-69.2 Lymphs-18.1* Monos-8.8 Eos-2.9
Baso-0.5 Im ___ AbsNeut-5.56 AbsLymp-1.45 AbsMono-0.71
AbsEos-0.23 AbsBaso-0.04
___ 03:26PM BLOOD Glucose-81 UreaN-27* Creat-1.6* Na-141
K-4.4 Cl-108 HCO3-23 AnGap-10
___ 07:43PM BLOOD Lactate-0.9
___ 05:38PM URINE Color-Yellow Appear-HAZY* Sp ___
___ 05:38PM URINE Blood-NEG Nitrite-NEG Protein-70*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-5.5
Leuks-LG*
___ 05:38PM URINE RBC-86* WBC->182* Bacteri-MOD*
Yeast-MANY* Epi-1 TransE-<1
___ 05:38PM URINE CastHy-8*
___ 06:00PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 7:30 pm BLOOD CULTURE - pending
___ 5:38 pm URINE CULTURE - pending
CHEST (PA & LAT) Study Date of ___ 4:33 ___
IMPRESSION:
Cardiomegaly with pulmonary edema though improved since prior
and persistent bilateral pleural effusions.
CT L-SPINE W/ CONTRAST Study Date of ___ 8:33 ___
IMPRESSION:
1. Status post L3-4 and L4-___s recent
paraspinous muscle flap repair of dehisced lumbar surgical
wound. Expected postsurgical changes are seen within the
midline soft tissues extending from the L1-L5 levels.
Specifically, ill-defined enhancement throughout the surgical
bed may be postsurgical, but early developing phlegmon would be
difficult to exclude. Additionally, a 2.9 cm region of air
within the midline wound at the L1-2 level may also be
postsurgical, although abscess formation would be difficult to
exclude.
2. Sigmoid diverticulosis. Small volume pelvic free fluid
surrounding the
sigmoid colon is nonspecific but limits evaluation for acute
diverticulitis.
3. Bilateral pleural effusions.
Brief Hospital Course:
SUMMARY:
___ yo F PMHx HFpEF, HTN, T2DM, CKD, prior ischemic CVA,
hypothyroidism, and spinal stenosis s/p L3-4/L4-5
hemilaminectomy/ foraminotomy (___) c/b wound dehiscence and
spinal leak requiring debridement, ___ followed by
lumbar wound debridement and muscle flap closure s/p wound vac
placement with JP in ___, who presents from ___ after
JP drain became dislodged. PRS Surgery consulted. JP drain was
removed. There was no concern for surgical site infection per
PRS. Patient will follow-up with Plastic Surgery as an
outpatient.
___ HOSPITAL COURSE:
# s/p spine surgery
As above, patient is s/p lumbar wound debridement and muscle
flap closure (___), currently with JP in place. Her JP drain
became dislodged at her ___ facility so she was sent to ___.
Plastic Surgery was consulted. The JP drain was removed as it
had minimal drainage to date. Plastic Surgery team felt wound
was healing appropriately and they were not concerned for
surgical site infection. Patient should follow-up with Plastic
Surgery in the outpatient setting as scheduled. Plastics
recommends use of an air mattress, and daily wash of back
incision with soap and water and then apply a dry dressing. No
ointments or creams to surgical wound.
# Asymptomatic bacteriuria, pyuria
Patient with indwelling foley. She denied any symptoms of
dysuria, suprapubic pain, fevers, chills. No signs of systemic
illness. UA with pyuria but this is suspected to be chronic ___
indwelling foley. There was no concern for UTI based on
symptomatology. No indication for antibiotics as discussed with
___ Disease team.
# ? recent PNA
Carried diagnosis of pneumonia from SNF at admission. ___ team
reported cough, leukocytosis and right-sided infiltrate seen on
CXR ___ days prior to admission. Patient had been on Augmentin.
No further signs of pneumonia seen while inpatient at ___.
No infiltrate on CXR. Reasonable to continue course of
Augmentin for PNA after discharge.
# Pleural effusions
CXR with pulmonary edema and pleural effusion. These findings
appeared improved from prior hospitalization. Given that
patient was not SOB or hypoxic, continued home dose of
torsemide. Would recommend continued outpatient follow-up on
these findings with serial CXR. If effusions do not resolve
with torsemide treatment, consider Pulmonary involvement for
consideration of thoracentesis
# Primary Hypertension
Continued home Amlodipine, Hydralazine, metoprolol.
# Chronic Diastolic CHF
Continued Metoprolol, Torsemide
# Type 2 Diabetes with Diabetic Nephropathy
Continued Glargine, sliding scale insulin. Continued torsemide.
# Urinary Retention
Has chronic indwelling foley. Given pyuria, foley was exchanged
this admission. Prior plan had been to remove foley with
voiding trial. Recommend Urology follow-up after discharge.
Continued Tamsulosin.
# Chronic anxiety
Continued Escitalopram
# Hypothyroidism
Continued Levothyroxine
Full Code
Contact: ___ (son/HCP), ___
TRANSITIONAL ISSUES:
[] Follow-up with Urology for void trial
[] Serial Chest XRs to assess pleural effusion - if effusions do
not continue to improve with torsemide, consider Pulmonary
involvement for further diagnostics
> 30 minutes spent in discharge planning and counseling
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Acetaminophen 650 mg PO TID
2. amLODIPine 10 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Escitalopram Oxalate 10 mg PO DAILY
7. Heparin 5000 UNIT SC BID
8. HydrALAZINE 25 mg PO TID
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 17.2 mg PO BID
15. Tamsulosin 0.8 mg PO QHS
16. Torsemide 20 mg PO DAILY
17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
18. Vitamin D 1000 UNIT PO DAILY
19. Lidocaine 5% Patch 1 PTCH TD QPM
20. Lisinopril 30 mg PO DAILY
21. Gabapentin 300 mg PO BID
22. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
23. TraZODone 50 mg PO QHS:PRN insomnia
24. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 650 mg PO TID
3. amLODIPine 10 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Escitalopram Oxalate 10 mg PO DAILY
8. Gabapentin 300 mg PO BID
9. Heparin 5000 UNIT SC BID
10. HydrALAZINE 25 mg PO TID
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 75 mcg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QPM
16. Lisinopril 30 mg PO DAILY
17. Metoprolol Tartrate 25 mg PO BID
18. Polyethylene Glycol 17 g PO DAILY
19. Senna 17.2 mg PO BID
20. Tamsulosin 0.8 mg PO QHS
21. Torsemide 20 mg PO DAILY
22. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
23. TraZODone 50 mg PO QHS:PRN insomnia
24. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Status post spinal surgery
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Discharge Instructions:
Dear Ms. ___,
You came to the hospital after the JP drain in your spinal
surgical wound became dislodged. You were evaluated by our
Plastic Surgeons who removed the drain. The Plastic Surgery
team believes that your surgical wound is healing well and not
showing any signs of infection.
Followup Instructions:
___
|
10122838-DS-3 | 10,122,838 | 26,886,831 | DS | 3 | 2175-10-17 00:00:00 | 2175-10-17 19:55:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
R corona radiata ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ by ___ is an ___ yo RH M with a history of
parkinsonism, prostate cancer ___ ago, colon cancer s/p
curative resection ___ yrs ago, and basal cell carcinoma (last
resected ___ yrs ago), who presents with a R parietal IPH.
He was at his baseline at his nursing home (walks with a walker,
answers simple questions with ___ words, fed pureed foods) until
___ ___ when his son noticed a pronounced L lower facial
droop and diminished speech output. This progressed over the
course of the weekend to sleepiness, absence speech, and refusal
to eat or drink. On ___, he was transported to OSH ED evaluation
in ___. While there, he answered yes/no to direct questions
and followed commands when asked by his family per OSH records.
However, his family notes that he was not following commands all
day. NCHCT showed 1 x 1 cm R parietal mass with surrounding
hypodensity (suggestive of edema around bleed vs. bleed into a
pre-existing mass). VS at OSH notable for BP 180s/70s. He was
transiently on nicardipine gtt while there which was stopped on
arrival with stable BPs here ~120s/80s. His family notes that he
seems more alert now after receiving fluids at OSH.
ROS:
On neuro ROS, the pt's family does not endorse headache, loss of
vision, blurred vision, diplopia, dysarthria, dysphagia,
vertigo,
tinnitus or hearing difficulty. Denies difficulties producing or
comprehending speech. No bowel or bladder incontinence or
retention.
On general review of systems, the pt's family does endorse
recent
weight loss (though unclear if this is from diminished intake).
Family does not endorse recent fever or chills. No night sweats.
Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria.
Past Medical History:
- HTN (SBP 150s, not on anti-HTN medications)
- Parkinsonism, on Sinemet
- Colon Cancer s/p curative resection ___ yrs ago
- Prostate cancer
- Basal cell carcinoma (last resection ~ ___ yrs ago)
Social History:
___
Family History:
No family history of strokes, aneurysms, bleeding
disorders
Physical Exam:
======================================
ADMISSION PHYSICAL EXAM
======================================
98.4 76 130/54 12 95% RA (not on nicardipine gtt x 40 min)
General: Eyes closed, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: breathing comfortably on RA
Cardiac: regular
Abdomen: soft, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Does not open eyes spontaneously, with noxious,
or to command. Opens mouth and says "Ah" to command, and smiles
with examiner's attempt at a joke. Otherwise, does not follow
commands or have any speech output. Resists oculocephalics and
eye opening. Grimaces with noxious stim. Continues to point at
examiner and then his legs.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2 and brisk.
III, IV, VI: Patient does not open eyes, resists oculocephalics
and eye opening
V: Responds to touch across face
VII: Clear L lower facial weakness (UMN distribution)
VIII: Hearing intact to voice.
IX, X: Palate elevates symmetrically.
XII: Tongue protrudes in midline
-SensoriMotor: Diminished bulk throughout. Withdraws all
extremities briskly to light tactile stimulation.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Toes were withdrawal bilaterally.
-Coordination: could not assess given lack of patient
cooperation
-Gait: deferred given risk for fall
.
.
======================================
DISCHARGE PHYSICAL EXAM
======================================
Vitals 98.6 124/57 63 19 96%RA
General: Eyes closed, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: breathing comfortably on RA
Cardiac: regular
Abdomen: soft, nondistended
Extremities: no edema
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Does not open eyes spontaneously, with noxious,
or to command. Resists oculocephalics and eye opening. Grimaces
with noxious stim.
-Cranial Nerves:
II: PERRL 3 to 2 and brisk.
VII: Clear L lower facial weakness (UMN distribution)
-SensoriMotor: Diminished bulk throughout. Withdraws all
extremities briskly to light tactile stimulation. Grasping with
hands bilaterally. Resting tremor R > L
-Coordination: Not assessed
-Gait: deferred given risk for fall
Pertinent Results:
======================================
ADMISSION LABS
======================================
___ 08:02PM BLOOD WBC-7.5 RBC-4.25* Hgb-11.4* Hct-37.9*
MCV-89 MCH-26.8 MCHC-30.1* RDW-19.2* RDWSD-62.2* Plt ___
___ 08:02PM BLOOD ___ PTT-25.0 ___
___ 10:00AM BLOOD Glucose-68* UreaN-29* Creat-0.8 Na-150*
K-3.3 Cl-111* HCO3-25 AnGap-17
___ 10:34AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.2
___ 05:05AM BLOOD TSH-1.2
___ 10:00PM BLOOD ALT-6
___ 10:00AM BLOOD CK(CPK)-73
___ 10:34AM BLOOD CK(CPK)-73
___ 08:02PM BLOOD Lipase-60
___ 08:02PM BLOOD cTropnT-<0.01
___ 10:00AM BLOOD CK-MB-7 cTropnT-<0.01
.
.
======================================
DISCHARGE LABS
======================================
___ 05:00AM BLOOD WBC-10.7* RBC-3.84* Hgb-10.3* Hct-33.2*
MCV-87 MCH-26.8 MCHC-31.0* RDW-19.2* RDWSD-60.7* Plt ___
___ 05:00AM BLOOD Glucose-110* UreaN-26* Creat-0.7 Na-137
K-3.6 Cl-104 HCO3-22 AnGap-15
___ 05:00AM BLOOD Calcium-7.6* Phos-2.5* Mg-1.9
.
.
======================================
MICROBIOLOGY
======================================
___ 10:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
.
___ 4:19 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
.
.
======================================
IMAGING
======================================
CTA Head/Neck ___
IMPRESSION:
1. 1.0 x 1.3 cm parenchymal hyperdensity within the right mid
corona radiata with mild adjacent vasogenic edema, likely
representing an unchanged parenchymal hemorrhage
2. Small subacute to chronic lacune within the right thalamus.
3. Patent intracranial vasculature. Short-segment stenosis at
the right V3/V4 segment vertebral artery, likely at the dural
reflection. No evidence of aneurysm.
4. Diminutive left transverse sinus with absent filling of the
left sigmoid sinus and internal jugular vein, likely due to
phase of contrast.
5. Patent neck vasculature with 20% stenosis at the right
carotid bulb by
NASCET criteria. Moderate stenosis at the right vertebral artery
origin.
6. Heterogeneous sclerotic appearance the skullbase, mandible,
facial bones, visualized spine, and thoracic osseous structures
likely due to diffuse blastic neoplasm, likely prostate given
history of prostate cancer. Recommend clinical correlation.
7. Dental caries and periapical lucencies within the remaining
mandibular and maxillary teeth.
8. Aerosolized secretions within the distal trachea extending of
the mainstem bronchus consistent with mucus or aspiration.
9. Mild bronchial wall thickening and bronchiectasis within the
upper lobes likely secondary to chronic aspiration.
10. Scattered opacities within the right upper lobe bronchi and
scattered
small ground-glass opacities, likely representing aspiration
and/or developing pneumonia.
11. 2 mm hypodense nodule within the right thyroid lobe. Per
the ___
College of Radiology, thyroid nodules measuring less than 1.5 cm
in patient's greater than ___ years of age do not require imaging
follow up, in the absence of clinical risk factors.
12. Complete opacification of the right external auditory canal,
likely due to cerumen. Recommend correlation with direct
visualization, to exclude a mass.
RECOMMENDATION(S):
1. Recommend visualization of the right external auditory
canal.
2. 2 mm hypodense nodule within the right thyroid lobe. Per
the ___
College of Radiology, thyroid nodules measuring less than 1.5 cm
in patient's greater than ___ years of age do not require imaging
follow up, in the absence of clinical risk factors.
.
MRI Head ___
IMPRESSION:
1. No interval hemorrhage or evidence of acute infarction.
2. Unchanged right basal gangliar intraparenchymal hemorrhage
with mild associated vasogenic edema and no midline shift.
There is no definite enhancement seen surrounding or within the
hemorrhage. Follow-up examination after resolution of
hemorrhage should be obtained to exclude any underlying
abnormality.
.
CT Abd/Pelvis ___
IMPRESSION:
1. Diffuse sclerotic lesions in the spine, pelvis, and ribs
concerning for malignant disease, likely metastatic prostate
cancer.
2. Moderate right partially obstructive hydroureteronephrosis
either secondary to urothelial lesion or extrinsic compression
by adjacent soft tissue. Ureteroscopy is recommended.
.
CT Chest ___
IMPRESSION:
1. Extensive metastatic involvement of the bones, but no
pathologic fractures.
2. Right lower lobe pneumonia and atelectasis.
3. Small to moderate nonhemorrhagic pleural effusions.
4. Extensive coronary calcifications.
5. Please refer to the abdominal CT with the same date for
evaluation of intra-abdominal organs.
Brief Hospital Course:
Mr. ___ by ___ is an ___ yo RH M with a history of
parkinsonism, prostate cancer ___ ago s/p radical
prostatectomy, colon cancer s/p curative resection ___ yrs ago,
and basal cell carcinoma (last resected ___ yrs ago), who
presents with a R parietal IPH with first symptoms 4 days prior
to medical evaluation. His exam is notable for L lower facial
weakness (UMN distribution) and intermittent ability to follow
some midline commands.
His R parietal IPH could be associated with CAA, bleed into a
pre-existing mass (noting extensive cancer history), a
hypertensive bleed (though slightly unusual location), or bleed
into an ischemic infarct (though there is no evidence of
surrounding hypodensity in a clear vascular territory). MRI
Brain is not definitive but given widely metastatic cancer on CT
torso most likely represents mass with associated bleeding.
Neuro: P/w R corona radiata IPH on tx from OSH. Also has
advanced parkinsons. F/u CTA head/neck in ED with stable
parenchymal hemorrhage in R mid corona radiata, and also noted
to have widespread sclerotic/lytic bony lesions concerning for
prostate cancer
- Oncologic workup as below
- Continue home sinemet
CV: Hypertensive requiring prn IV hydral to meet SBP goals.
Started on captopril with good control, d/c'd prior to discharge
per health care proxy request in keeping with comfort measures.
ID: hypothermic, hemodynamically stable and lactate 1.7. CT
Chest ___ with RLL pneumonia and atelectasis -> Vanc/cefepime
started ___, d/c'd prior to discharge per health care proxy
request in keeping with comfort measures. Cultures pending at
discharge.
Oncologic: Patient with remote (___) hx of prostate cancer,
s/p radical resection and subsequent remission on subsequent
surveillance per family. Stopped PSA monitoring at ~age ___. Also
remote history of colon cancer s/p resection with subsequent
colonoscopies consistently negative per family. Concerning bony
lesions on CT head and CXR during current admission prompted CT
Torso ___ which demonstrated widespread sclerotic bony lesions
throughout spine, ribs, pelvis consistent with metastases, R
hydroureternephrosis and distal contrast cutoff and associated
soft tissue irregularities concerning for extrinsic compression
without complete obstruction secondary to lymph node
involvement, bilateral common iliac veins with ?thrombosis
- Discussed with oncology, patient is not a candidate for any
systemic therapy given age and overall functional status. No
significant pain issues which would indicate current role for
palliative radiation or other palliative procedures. Also
discussed with family who do not feel that further diagnostic
workup is indicated given his overall prognosis.
FEN/GI:
- Hypernatremic on presentation, clinically consistent with
hypovolemia, resolved with IVF/TF with FWF
- Failed swallow eval -> dobhoff with TF per nutrition
recommendations, d/c'd prior to discharge per health care proxy
request in keeping with comfort measures.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO QHS
2. Carbidopa-Levodopa (___) 1 TAB PO QID
3. Aspirin 325 mg PO DAILY
4. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Carbidopa-Levodopa (___) 1 TAB PO QID
2. Acetaminophen (Liquid) 1000 mg PO Q6H:PRN fever/pain
3. Care ___ Consult
Please consult Care ___ for hospice care
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Acute hemorrhagic stroke
- Dehydration
- Pneumonia
Secondary:
- Metastatic cancer
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Discharge Instructions:
Dear Mr. ___,
You were hospitalized due to symptoms of weakness resulting from
an ACUTE BLEEDING STROKE. The brain is the part of your body
that controls and directs all the other parts of your body, so
damage to the brain from being deprived of its blood supply can
result in a variety of symptoms.
Stroke can have many different causes, so we assessed you for
medical conditions that might raise your risk of having stroke.
A cat scan of you body showed what is very likely widespread
cancer. You did not want to undergo further diagnosis to find
out for sure if it was cancer and if so what type, since the
results were unlikely to change how you would be treated.
When you were admitted you were very dehydrated and not able to
swallow well as a result of your stroke. You received IV fluids
and a feeding tube was placed and you improved. You were also
found to have a pneumonia, you received IV antibiotics.
If you experience any of the symptoms below, please call your
hospice care team for information:
- 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
We appreciate you allowing us to care for you,
Your ___ Care Team
Followup Instructions:
___
|
10123220-DS-8 | 10,123,220 | 26,589,699 | DS | 8 | 2111-10-03 00:00:00 | 2111-10-03 15:30:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Versed
Attending: ___.
Chief Complaint:
right arm weakness
Major Surgical or Invasive Procedure:
anterior c4-7 and posterior decompression and fusion c4-T1
History of Present Illness:
Patient struck his head on counter and developed progressive arm
and hand weakness.
Past Medical History:
HTN
Social History:
___
Family History:
Non-contributory
Physical Exam:
Well developed white male in NAD
Collar in place. Significant wekaness ___ grip strength r hand
___ triceps/ ___ wrist extension
Intact leg strength
+ ataxia
Pertinent Results:
___ 09:44PM GLUCOSE-86 UREA N-25* CREAT-0.9 SODIUM-144
POTASSIUM-4.6 CHLORIDE-108 TOTAL CO2-26 ANION GAP-15
___ 09:44PM ___ PTT-33.9 ___
Brief Hospital Course:
Patietn was admitted and underwent a staged anterior C4-7
decompression and fusion as well as a C4-T1 decompression and
fusion. Post-operatively his dysphagia resolved over a couple of
days. He had a foley and drain which were discontinued prior to
discharge. He gained some increase in strength and had less
dysesthesias in his right hand at time of discharge.
Medications on Admission:
Atenolol 50 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Gabapentin 1200 mg PO TID
4. Multivitamins 1 TAB PO DAILY
5. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Gabapentin 1200 mg PO TID
4. Multivitamins 1 TAB PO DAILY
5. Triamterene-Hydrochlorothiazide (37.5/25) 1 CAP PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*100 Tablet Refills:*0
7. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Cervical Stenosis/ Myelomalacia
Discharge Condition:
Awake and alert/ambulating short distances/ collar in place/
limited right hand grip strength
Discharge Instructions:
You have undergone the following operation: ANTERIOR/POSTERIOR
Lumbar Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a brace. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Physical Therapy:
Wear collar when OOB/ bmbulate as tolerated/ exercise for right
hand and arm weakness
Treatments Frequency:
You have undergone the following operation: ANTERIOR/POSTERIOR
cervical Decompression With Fusion
Immediately after the operation:
-Activity: You should not lift anything greater than 10 lbs for
2 weeks. You will be more comfortable if you do not sit or stand
more than ~45 minutes without getting up and walking around.
-Rehabilitation/ Physical Therapy:
o2-3 times a day you should go for a walk for ___ minutes as
part of your recovery. You can walk as much as you can tolerate.
oLimit any kind of lifting.
-Diet: Eat a normal healthy diet. You may have some constipation
after surgery. You have been given medication to help with this
issue.
-Brace: You have been given a collar. This brace is to be worn
for comfort when you are walking. You may take it off when
sitting in a chair or while lying in bed.
-Wound Care: Remove the dressing in 2 days. If the incision is
draining cover it with a new sterile dressing. If it is dry then
you can leave the incision open to the air. Once the incision is
completely dry (usually ___ days after the operation) you may
take a shower. Do not soak the incision in a bath or pool. If
the incision starts draining at anytime after surgery, do not
get the incision wet. Cover it with a sterile dressing. Call the
office.
-You should resume taking your normal home medications. No
NSAIDs.
-You have also been given Additional Medications to control your
pain. Please allow 72 hours for refill of narcotic
prescriptions, so please plan ahead. You can either have them
mailed to your home or pick them up at the clinic located on
___ 2. We are not allowed to call in or fax narcotic
prescriptions (oxycontin, oxycodone, percocet) to your pharmacy.
In addition, we are only allowed to write for pain medications
for 90 days from the date of surgery.
Please call the office if you have a fever>101.5 degrees
Fahrenheit and/or drainage from your wound.
Followup Instructions:
___
|
10123421-DS-19 | 10,123,421 | 29,885,856 | DS | 19 | 2152-05-31 00:00:00 | 2152-06-06 21:11:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Digoxin / diltiazem / Diatrizoate Meglumine / Hydrocodone /
Methadone / propoxyphene
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
cardiac cath
History of Present Illness:
The patient is a ___ year old female with a history of AFib on
Warfarin, hypertension, and hyperlipidemia now with unstable
angina and an abnormal stress test yesterday at ___.
She first noted the onset of chest pain about two weeks ago.
She describes it as a central chest tightness without radiation
that comes on with minimal exertion and goes away after a few
minutes of rest. It is associated with dyspnea. Over the same
time period, she was having increased symptoms from her atrial
fibrillation with palpitations and tachycardia. Her Metoprolol
succinate dose was increased from 100 mg PO daily to 150 mg PO
daily and then to 200 mg PO daily. She saw her cardiologist,
Dr. ___ also arranged for a stress test at ___
___. The stress test was abnormal, and she was sent to the
___ for further evaluation. She was then transferred to
___ for further care.
.
In the ___ ___, she denied any current chest pain, tightness,
or dyspnea at rest. Initial vital signs were T 97.3, HR 90, BP
158/93, RR 16, and SpO2 100% on 2L. Labs were notable for
initial Troponin 0.01, second Troponin 0.02, mildly elevated K
5.4, and INR 1.6 below goal (held for likely cath). CXR showed
moderate cardiomegaly without edema. EKG showed atrial
fibrillation at 109 bpm, NA, NI, and nonspecific inferior ST-T
changes. She was seen by Cardiology in the ___, who recommended
admission and likely cardiac cath on ___.
.
She was admitted to Cardiology for further management of
unstable angina with positive stress testing. Vitals prior to
floor transfer were T 97.7 po, HR 103, BP 137/78, RR 28, and
SpO2 97% on RA. On arrival to the floor, she reported feeling
well with no current symptoms. In particular, cardiac review of
systems was negative for current chest pain or dyspnea,
paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope,
or presyncope. She does have mild ___ edema for which she takes
Furosemide 40 mg PO PRN. She has not needed any recently. When
tachycardic from her atrial fibrillation, she sometimes feels
palpitations, but does not have any currrently.
.
On further review of systems, she denies any prior history of
stroke, TIA, deep venous thrombosis, pulmonary embolism,
bleeding at the time of surgery, myalgias, cough, hemoptysis,
black stools, or red stools. She denies recent fevers, chills,
or rigors. She denies exertional buttock or calf pain.
Past Medical History:
# Cardiac Risk Factors: Dyslipidemia, Hypertension
# Atrial Fibrillation -- on Warfarin and Metoprolol
# Hypertension
# Hypercholesterolemia
# Osteoarthritis
# Left Knee Replacement -- about ___ years ago
# Breast Cancer -- s/p mastectomy ___, no recurrence
# Cholecystectomy -- many years ago
# thalessemia
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathy,
diabetes, DVT, PE, bleeding disorders, clotting disorders, or
cancer.
# Father -- MI at age ___, hypertension
# Mother -- ___
# Sister -- healthy
Physical ___:
On Admission:
VS: T 98.3, BP 139/106, HR 108, RR 18, SpO2 98% on RA, Wt 113.9
kg
Gen: Obese female in NAD. Oriented x3. Pleasant and appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. MMM, OP clear.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
No carotid bruits noted.
CV: Irregularly irregular and mildly tachycardic with normal S1,
S2. No M/R/G appreciated.
Chest: Respiration unlabored, no accessory muscle use. CTAB with
no crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly.
Abdominal aorta not enlarged by palpation.
Ext: WWP. Digital cap refill <2 sec. Ankle edema 1+
bilaterally. Distal pulses intact 2+ radial, palpable DP and
___.
Skin: No stasis dermatitis, ulcers, rashes, or other lesions.
Neuro: CN II-XII grossly intact. Moving all four limbs.
On Discharge:-
VS: 97.6 139-178/80-90's ___ RR-18 99% on RA 113.1kg
Gen: Obese female in NAD. Oriented x3. Pleasant and appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva without
pallor or injection. MMM, OP clear.
Neck: Supple. JVP not elevated. No cervical lymphadenopathy.
No carotid bruits noted.
CV: Irregularly irregular and mildly tachycardic with normal S1,
S2. No M/R/G appreciated.
Chest: Respiration unlabored, no accessory muscle use. CTAB with
no crackles, wheezes or rhonchi.
Abd: Normal bowel sounds. Soft, NT, ND. No organomegaly.
Abdominal aorta not enlarged by palpation.
Ext: WWP. Digital cap refill <2 sec. Ankle edema 1+
bilaterally. Distal pulses intact 2+ radial, palpable DP and
___. cath site c/d/i
Skin: No stasis dermatitis, ulcers, rashes, or other lesions.
Neuro: CN II-XII grossly intact. Moving all four limbs.
Pertinent Results:
On Admission:
___ 03:00PM BLOOD WBC-10.6 RBC-5.69* Hgb-11.5* Hct-36.5
MCV-64* MCH-20.1* MCHC-31.3 RDW-16.6* Plt ___
___ 03:00PM BLOOD Neuts-75.0* ___ Monos-4.1 Eos-1.1
Baso-0.2
___ 06:47PM BLOOD ___ PTT-25.9 ___
___ 03:00PM BLOOD Glucose-84 UreaN-24* Creat-1.0 Na-141
K-4.5 Cl-104 HCO3-25 AnGap-17
___ 03:00PM BLOOD cTropnT-0.01
___ 06:47PM BLOOD CK-MB-9
___ 06:47PM BLOOD cTropnT-0.02*
___ 08:05AM BLOOD CK-MB-6 cTropnT-0.03*
___ 07:05AM BLOOD cTropnT-0.03*
___ 08:05AM BLOOD Calcium-8.9 Phos-3.1 Mg-2.0
CXR (___):
PA AND LATERAL VIEWS OF THE CHEST: The heart size is moderately
enlarged.
The aorta is slightly unfolded. Hilar contours are normal.
Elevation of left hemidiaphragm is noted, with adjacent streaky
opacity in left lung base, likely reflective of atelectasis. No
pleural effusion, pulmonary edema, or pneumothorax is present.
Multiple clips are demonstrated within the left axilla, and the
patient appears to be status post left mastectomy. Multiple
clips are also seen within the upper abdomen, only on the
lateral view. There are no acute osseous abnormalities.
IMPRESSION: Moderate cardiomegaly, but no evidence for pulmonary
edema
Cardiac Cath (___):
COMMENTS:
1. Selective coronary angiography in this right dominant system
revealed
two vessel coronary artery disease. The LMCA was heavily
calcified with
a 30% ostial stenosis. The LAD was heavily calcified with a
proximal
tampering to 65%, multiple septal branches, a large D1 vessel, a
mid LAD
tapering to a diffusely diseased mid-distal LAD to 70% just
before a
modest D2 (which has an origin 50% stenosis). The apical
portion of the
LAD had a 85% stenosis with very apical LAD of larger caliver
than mid
LAD. Slow flow in noted consistent with microvascular
dysfunction. A
ramus intermedius of large caliber with a tortuous proximal
vessel and
terminal branches is also noted to have slow flow. The LCX had
a
retroflexed origin, modest caliver AV groove with a few tiny OM
branches. The RCA had an ostial 50% stenosis with proximal
ectasia and
diffuse plaquing throughout with a 30% stenosis of the proximal
and
mid-distal regions. Large AM branch, large RPDA with laterally
oriented sidebranch, large AV nodal branch, and large RPL are
noted.
2. Limited resting hemodynamics revealed a elevated left sided
filling
pressures with an LVEDP of 24mm Hg. Mild systemic arterial
systolic and
diastolic hypertension with a central aortic pressure of 162/102
mm Hg.
FINAL DIAGNOSIS:
1. Two vessel coronary artery disease with severe apical LAD
lesion and
diffusely disease mid-distal LAD not favorable for PCI due to
length of
disease or CABG given absense of graftable target in the
mid-distal LAD.
2. Severe systemic arterial hypertension.
3. Moderate left ventricular diastolic heart failure
Brief Hospital Course:
The patient is a ___ year old female with a history of AFib on
Warfarin, hypertension, and hyperlipidemia who presents with new
unstable angina and an abnormal stress test performed at ___
___.
.
#Unstable Angina/CAD- The patient reported new exertional chest
pain and SOB over the last two weeks prior to hospitalization.
A stress testing at ___ was reportedly positive, and
she was sent to ___ for further workup. She continued to have
chest pain with minimal exertional with no EKG changes. Her
troponin trending upward from 0.01->0.02->0.03->0.03. She was
taken for cardiac cath that revealed two vessel coronary artery
disease with severe apical LAD lesion and diffusely disease
mid-distal LAD not favorable for PCI due to length of disease or
CABG given absense of graftable target in the mid-distal LAD.
She was started on aspirin 325mg daily, clopidogrel 75mg daily,
atorvastatin 80mg dialy, and isosorbide mononitrate 30mg dialy.
She will need further medical optimization as an outpatient.
.
#. atrial fibrillation- The patient has a history of atrial
fibrillation treated with Warfarin, Metoprolol succ 200mg daily,
and Sotalol. She had inadequate rate control and was uptitrated
to metoprolol tartrate 200mg BID, which acheived good rate
control (80-90's on tele). Her INR was subtherapeutic at 1.6 on
initial labs, but was held pending cardiac cath. The patient
was started on Pradaxa 150mg BID the night after her cath. She
was discharged on sotalol 120mg BID and metoprolol succinate
400mg daily.
.
#. hypertension- The patient demonstrated elevated systolic
blood pressure to the 170-180's. She was started on lisinopril
and uptitrated to 20mg dialy prior to discharge. She was
discharged on metoprolol XL 400mg, Imdur 30mg daily, and
lisinopril 20mg daily for BP control. She should follow up with
her PCP for further optimization for her hypertension.
.
#. Hyperlipidemia:She has been on Simvastatin 80 mg, but will be
switched to Atorvastatin to optimize cardioprotection.
.
#. thalassemia- prior diagnosis. Her CBC demonstrated
microcytic anemia with HCT in mid to upper 30's. She should f/u
with her PCP for further evaluation and treatment.
Medications on Admission:
Warfarin 5 mg PO daily
Metoprolol succinate 200 mg PO daily
Sotalol 120 mg PO BID
Simvastatin 80 mg PO daily
Furosemide 40 mg PO EOD PRN ankle edema
Discharge Medications:
1. Pradaxa 150 mg Capsule Sig: One (1) Capsule PO twice a day.
Disp:*60 Capsule(s)* Refills:*2*
2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Disp:*30 Tablet(s)* Refills:*2*
3. sotalol 80 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day).
Disp:*90 Tablet(s)* Refills:*2*
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO once a day.
Disp:*30 Tablet, Chewable(s)* Refills:*2*
5. metoprolol succinate 200 mg Tablet Extended Release 24 hr
Sig: Two (2) Tablet Extended Release 24 hr PO once a day.
Disp:*60 Tablet Extended Release 24 hr(s)* Refills:*2*
6. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
7. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO once a day.
Disp:*30 Tablet(s)* Refills:*2*
9. furosemide 40 mg Tablet Sig: One (1) Tablet PO every other
day prn as needed for leg swelling.
Discharge Disposition:
Home
Discharge Diagnosis:
unstable angina
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
You were admitted to ___ for
chest pain. We treated you with medications for your chest pain
and then you underwent a cardiac cath. You cardiac cath
revealed 2 blockages that will be treated with medications. You
will need to start new medications (see below for details).
Please follow up with your primary care doctor and your
cardiologist.
Medication Changes:
START taking dabigatran (pradaxa) 150mg by mouth every 12 hours
START taking clopidogrel (plavix) 75mg by mouth daily
START taking lisinopril 20mg by mouth daily
START taking isosorbide mononitrate (imudr) 30mg by mouth daily
START taking aspirin 81mg by mouth daily
START taking atorvastatin 80mg by mouth daily
INCREASE metoprolol succinate to 400mg by mouth daily
STOP taking Warfarin
STOP taking simvastatin
Continue taking sotalol 120mg by mouth daily
Continue taking Furosemid 40mg by mouth as needed for ankle
edema
Followup Instructions:
___
|
10123924-DS-8 | 10,123,924 | 24,269,221 | DS | 8 | 2139-11-15 00:00:00 | 2139-11-15 14:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R thigh pain after fall
Major Surgical or Invasive Procedure:
ORIF with cerclage wire and plating
History of Present Illness:
___ yo female with dementia, PMH HTN, hypercholesterolemia,
anxiety, depression presenting after unwitnessed fall with right
thigh pain. Patient unable to explain circumstances but per
report, she was found down with R thigh pain, R thigh deformity,
inability to bear weight. Unknown HS or LOC. Brought to OSH,
CT
of head and neck obtained and negative. Found to have R
___ C periprosthetic femur fracture, transferred to ___
for further evaluation and management. She lives at an assisted
living facility, uses a walker for ambulation.
Past Medical History:
Dementia
HTN,
hypercholesterolemia,
anxiety,
depression
Social History:
___
Family History:
Noncontributory
Physical Exam:
No acute distress
Unlabored breathing
Abdomen soft, non-tender, non-distended
Incision clean/dry/intact with no erythema, minimal blood clots
at distal end of incision, minimal ecchymosis--examined on day
of discharge (___).
Right lower extremity fires ___
Right lower extremity SILT sural, saphenous, superficial
peroneal, deep peroneal and tibial distributions
Right lower extremity warm and well perfused
Pertinent Results:
Please see OMR for pertinent lab/radiology data.
Brief Hospital Course:
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R ___ C periprosthetic femur fracture and was
admitted to the orthopedic surgery service. The patient was
taken to the operating room on ___ for ORIF with cerclage
wiring and plating, 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 with thickened liquids and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation (Lovenox) per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was remarkable for post-operative blood loss anemia
requiring total of 4U PRBCs (2U on POD1, 2U on POD2). Follow-up
labs on ___ reported satisfactory increase in hematocrit
following transfusion.
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--although incontinent. The patient is
touch-down weight bearing in the right lower extremity, and will
be discharged on Lovenox for DVT prophylaxis for 4 weeks
post-operatively. The patient will follow up with Dr. ___
___ routine. Thorough instructions regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital were documented in discharge
paperwork. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care.
Medications on Admission:
Alendronate
Aspirin
Donepezil
Escitalopram
Risperidone
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Use Oxycodone for pain not relieved by Acetaminophen.
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*100 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
You may discontinue when no longer taking Oxycodone.
RX *docusate sodium [Colace] 100 mg 2 capsule(s) by mouth twice
daily Disp #*80 Capsule Refills:*0
3. Enoxaparin Sodium 40 mg SC DAILY
Start: ___, First Dose: Next Routine Administration Time
Take for 4 weeks post-operatively.
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneously daily Disp
#*25 Syringe Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
___ take before driving, operating machinery, or with alcohol.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours as needed
Disp #*40 Tablet Refills:*0
5. Senna 8.6 mg PO BID
You may discontinue when no longer taking Oxycodone.
RX *sennosides [senna] 8.6 mg 2 tablets by mouth every evening
Disp #*40 Tablet Refills:*0
6. Alendronate Sodium 70 mg PO QMON
7. Donepezil 5 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
R ___ mid-shaft femur fracture distal to stem
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY:
- You were in the hospital for orthopedic surgery. It is normal
to feel tired or "washed out" after surgery, and this feeling
should improve over the first few days to week.
- Resume your regular activities as tolerated, but please follow
your weight bearing precautions strictly at all times.
ACTIVITY AND WEIGHT BEARING:
- TDWB 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.
ANTICOAGULATION:
- Please take Lovenox daily for 4 weeks post-operatively.
WOUND CARE:
- You may shower. No baths or swimming for at least 4 weeks.
- Any stitches or staples that need to be removed will be taken
out at your 2-week follow up appointment.
- Please remain in your dressing and do not change unless it is
visibly soaked or falling off.
Physical Therapy:
Touch-down weightbearing of Right lower extremity
Treatments Frequency:
Dressing may be changed daily with dry sterile dressing and
tape. Please keep incision covered. OK to shower or sponge
bathe, but no baths or swimming. Patient needs to remain TDWB to
RLE at all times.
Followup Instructions:
___
|
10123949-DS-23 | 10,123,949 | 22,466,207 | DS | 23 | 2180-04-09 00:00:00 | 2180-04-25 14:16:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Levofloxacin
Attending: ___
Chief Complaint:
Chest pain.
Major Surgical or Invasive Procedure:
- None
History of Present Illness:
___ M ESRD on PD, PVD, HLD, DM1 p/w chest "tighthess" today at
work. According to th patient, he states that it came on when
he lifted his arms above his chest when he was demonstrating
something to his students. The pain resolved upon sitting down
& lowering his arms. He denies that the sensation was "pain" but
states that the discomfort was associated with inabilility to
take a full, deep breath due pleuritic pain. Describes pain as
"muscle cramping or strain" that was reproducible on elevating
his arms.
.
Pt denies dizziness, but has felt lightheaded today. He also
complains of the same type of discomfort in his lower back when
he stands for long periods.
.
The patient has had symptoms c/w URI for the past 3 weeks. It
started with a cough 3 weeks ago for which he was given a
Z-pack. This did not markedly improve his symptoms; ___ days
later he developed congestion, rhinorrhea, productive cough, &
HA. He went back to his PCP ___ & was given a 10 day
course of Augmentin. His symptoms have improved of the past ___
days. His son was recently sick with similar symptoms. He
denies fevers, chills, night sweats. He states that he has had
decreased PO intake over the past several days. There have been
no changes to his medications or PD schedule (QHS).
.
In the ED, an EKG was obtained which was unchanged from prior
(NSR). Pt was given 1L NS. Labs were notable for K = 5.9, INR =
5.5.. Given kayexalate.
.
REVIEW OF SYSTEMS:
(+): As above.
(-): Fevers, chills, sweats, nausea, vominting, abdominal pain,
diarrhea, dysuria, urinary urgency/frequency, headache.
Past Medical History:
- ESRD on PD
- HLD
- DM1 (diagnosed at ___) c/b retinopathy, neuropathy, nephropathy
- PVD s/p L metatarsal foot amputation & B/L ___ bypasses
- DVT on coumadin
- Celiac disease
- GERD
Social History:
___
Family History:
- Mother: HTN, DM2
- Father: CAD s/p CABG, DM2
Physical Exam:
ADMISSION PHYSICAL EXAM:
96.6 66 118/p 20 100/RA
GEN: Well-appearing man resting in bed in NAD
HEENT: NCAT, MMM, EOMI
NECK: Supple
COR: +S1S2, RRR, no m/g/r.
___: +PD catheter in RLL, +NABS in 4Q. Soft, slightly TTP over
PD ___.
EXT: WWP. S/p partial L foot amputation. Trace ___ edema
NEURO: MAEE
DISCHARGE PHYSICAL EXAM:
Pertinent Results:
ADMISSION LABS:
___ 01:05PM BLOOD WBC-5.3 RBC-3.02* Hgb-9.6* Hct-28.4*
MCV-94 MCH-31.7 MCHC-33.8 RDW-13.3 Plt ___
___ 01:05PM BLOOD Neuts-59.1 ___ Monos-4.0 Eos-3.6
Baso-0.6
___ 01:05PM BLOOD ___ PTT-47.3* ___
___ 01:05PM BLOOD Glucose-226* UreaN-68* Creat-11.4*#
Na-137 K-5.9* Cl-99 HCO3-26 AnGap-18
___ 01:05PM BLOOD CK-MB-7 cTropnT-0.11*
___ 01:05PM BLOOD CK-MB-7 cTropnT-0.11*
___ 01:05PM BLOOD cTropnT-0.11*
___ 09:20PM BLOOD CK-MB-6 cTropnT-0.10*
___ 06:35AM BLOOD CK-MB-4 cTropnT-0.10*
DISCHARGE LABS:
___ 06:35AM BLOOD WBC-5.0 RBC-2.98* Hgb-9.5* Hct-27.8*
MCV-93 MCH-31.8 MCHC-34.0 RDW-13.1 Plt ___
___ 06:35AM BLOOD ___ PTT-40.4* ___
___ 06:35AM BLOOD Glucose-200* UreaN-64* Creat-11.7* Na-136
K-4.7 Cl-99 HCO3-27 AnGap-15
___ 06:35AM BLOOD CK(CPK)-111
___ 06:35AM BLOOD CK-MB-4 cTropnT-0.10*
___ 06:35AM BLOOD Calcium-7.7* Phos-6.3*# Mg-2.2
STUDIES:
CXR (___): IMPRESSION: No acute cardiopulmonary process.
STRESS MIBI (___):
INTERPRETATION: ___ yo man with h/o PVD and s/p bilateral
bypasses,
ESRD on dialysis was referred to evaluate an atypical chest
discomfort
in the presence of elevated troponin, however flat CK. The
patient was
administered 0.142 mg/kg/min of Persantine over 4 minutes.
During the
procedure the patient reported an progressive, anterior chest
"ache"
with radiation into the lower jaw; peak intensity ___. These
symptoms
resolved quickly following the administration of 125 mg
Aminophylline IV
and were absent 5 minutes post-infusion. No significant ST
segment
changes were noted. The rhythm was sinus with no ectopy noted.
The heart
rate and blood pressure response to the Persantine infusion was
appropriate.
IMPRESSION: Persantine-induced anginal symptoms with no ischemic
ST
segment changes. Appropriate hemodynamic response. Nuclear
report sent
separately.
MYOCARDIAL PERFUSION STUDY (___):
IMPRESSION:
1) Normal myocardial perfusion without evidence of
reversibility.
2) Bilateral ventricular prominence with a LVEF of 45%.
3) Hypokinesis of the septal wall.
4) Evidence of ascites on raw data images.
Brief Hospital Course:
REASON FOR HOSPITALIZATION:
___ M with DM2 c/b ESRD on PD, PVD s/p bilateral bypasses p/w
atypical chest pain x1 day.
ACUTE DIAGNOSES:
# Chest Pain: Most likely to represent musculoskeletal chest
pain. However, given his long-standing DM1, he is at increased
risk for atypical chest pain. Troponin 0.l1, index flat which
was reassuring that his troponin elevation was due to reduced
clearance in the setting of ESRD. Stress MIBI obtained on
hospital day 2, which was unchanged from prior study in ___.
There were no new perfusion defects; no EKG changes although pt
did have persantine-induced anginal symptoms. He was continued
on ASA & plavix.
# Hyperkalemia: K was 5.9 on admission without EKG changes.
Received 1 dose of kayexalate. Pt was evaluated by the
nephrology service and PD was performed on the night of
admission.
CHRONIC DIAGNOSES:
# History of DVT: INR supratherapeutic on admission at 5.5.
Coumadin held during hospitalization with a plan to restart as
outpatient with INR testing at his PCP's office on the ___
following discharge.
# DM1: Pt was continued on home lantus & HSS
# PVD: Continued cilostazol.
# GERD: Continued ranitidine.
# HLD: Continued statin.
TRANSITIONAL ISSUES:
# Follow Up: Pt will arrange to follow up with his PCP on
discharge.
Medications on Admission:
- Coumadin 4 mg QD (2 mg on Sa, ___
- Cilostazol 100 mg BID
- Plavix 75 mg QD
- Atorvastatin 80 mg QD
- Metoprolol Tartrate 50 mg BID
- ___ Caps 1 capsule QD
- Ranitidine 300 mg TID
- Calcitriol 0.5 mcg QD
- Calcium Acetate 1334 mg TID AC
- Buproprion 200 mg QAM
- Sensipar 30 mg QD w food
- Augmentin 1 tab Q12H for 10 days (started ___
- Lantus 10 units QAM, 18 units QHS
- Humalog SS
Discharge Medications:
1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. cilostazol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
5. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID
(2 times a day).
6. ranitidine HCl 150 mg Tablet Sig: Two (2) Tablet PO DAILY
(Daily).
7. Medications
Humalog sliding scale
8. Medication
Lantus 10 units QAM, 18 units QHS
9. calcitriol 0.25 mcg Capsule Sig: Two (2) Capsule PO DAILY
(Daily).
10. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
11. bupropion HCl 100 mg Tablet Extended Release Sig: Two (2)
Tablet Extended Release PO QAM (once a day (in the morning)).
12. medication
RenoCaps 1 capsule QD
13. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily): with food.
14. clotrimazole 1 % Cream Sig: One (1) Appl Topical BID (2
times a day) for 1 weeks.
15. medication
Warfarin 2 mg on ___, then have your INR checked on ___
before taking additional doses.
16. losartan 50 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Atypical Chest Pain
SECONDARY DIAGNOSES:
- Chronic Renal Disease on peritoneal dialysis
- Diabetes Mellitus Type 1
- Peripheral Vascular Disease
- upper extremity DVT
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Discharge Instructions:
Mr. ___, it was a pleasure to participate in your care
while you were at ___. You came to the hospital because you
had chest pain on elevating your arms. While you were here, the
medical team was initially concerned that your chest you were
admitted to the hospital with chest pain. Blood tests showed
that you did not have active damage to your heart, and your EKG
was normal. You underwent a nuclear stress test, which was
unchanged from your prior study in ___. Your chest discomfort
was likely due to musculoskeletal pain/strain. You will have
several discharge appointments to go to.
No changes have been made to your medications
- Medications ADDED: None.
- Medications STOPPED:
---> You do not need to take Augmentin any longer
- Medications CHANGED:
---> Please stop taking warfarin until ___. Take 2
mg Warafin on ___ then have your INR checked at your PCP's
office on ___.
Followup Instructions:
___
|
10123949-DS-33 | 10,123,949 | 28,859,520 | DS | 33 | 2181-10-15 00:00:00 | 2181-10-16 16:15:00 |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
wheat / Levaquin / Protonix / Flagyl
Attending: ___
Chief Complaint:
Chest pain and shortness of breath
Major Surgical or Invasive Procedure:
___ Left heart cardiac catheterization
___ Left heart cardiac catheterization with DES to left
circumflex
History of Present Illness:
Mr ___ is a ___ year old man with PMHx significanft for
IDDM, PVD, ESRD on home peritoneal dialysis who presents from
home by EMS with dyspnea followed by chest pain radiating to
left shoulder this morning. He reports that he felt short of
breath at 0830 in the AM following his dwell and then had onset
of the chest pain at aproxamently 1200. Resolved 30 minutes
later after EMS gave him NTG x 2 and ASA 325mg. He is awaiting
kidney and pancreas transplant. He was discharged recently for
PD site cellulitis at the end of ___ and per his wife the
patient has been extermmely fatigued since the end of ___
of ___. No fever or chills, nausea or vomiting. No abdominal
pain.
In the ED, initial vitals were: 98.5F, HR 95, BP 175/103, RR 18,
98 RA. He recieved 1L NS bolus x 4, Metoprolol 50mg PO x 1, and
his chest pain resolved. His labs were notable for an elevated
troponin to 0.23 (near where his prior troponins have been) but
normal CKMB of 8. Per ER report the EKG was unchanged from
prior. Of note had cardiac perfusion study ___ which was
normal.
On arrival on the floor the patient reports that he feels
fatigued, but denies SOB, chest pain, or any other symtpoms.
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 chest pain
currently, dyspnea on exertion, paroxysmal nocturnal dyspnea,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Past Medical History:
- IDDM since age ___ c/b retinopathy, neuropathy, nephropathy
- ESRD (on peritoneal dialysis)
- HLD
- PVD
- depression
- celiac disease
___
- Angioplasty of distal SFA (___)
- Right heel debridement (___)
- Removal of PD catheter ___, replaced ___
- Insertion PD catheter ___
- Partial incision Rt AV graft ___
- Tunneled R IJ HD catheter ___
- RUE AV graft ___
- Angioplasty R distal SFA ___
- Arthroplasty and debridement R ___ PIP joint ___
- Right CFA to AT artery BPG with NRSVG ___
- Arteriogram RLE ___
- Angioplasty of R SFA ___
- Debridement and closure of L TMA ___, Left SFA to peroneal
BPG using NR L basilic vein ___
- Thrombectomy of L SFA to ___ BPG revision/distal anastomosis
___
- Distal L SFA to ___ BPG with NRSVG
- Angiograms RLE/LLE ___
- Right knee surgery
Social History:
___
Family History:
FAMILY HISTORY:
Mother: HTN, DM2
Father: CAD s/p CABG, DM2
Physical Exam:
Exam on Admission:
VS: 97.9-98.3, 140-184/95-121, 64-74, ___, 98-100% RA
General: fatigued man, resting comfortably in bed, not very
interactive
HEENT: PERRL, EOMI, normal oropharynx
CV: RRR, III/VI holosystolic murmur best heard at RUSB
Neck: supple, no JVD appreciated
Lungs: Lungs are clear bilaterally anteriorly and laterally,
otherwise difficult to examine
Abdomen: soft, non-tender/non-distended, normal bowel sounds
Ext: no edema, some hyperpigmentation bilaterally lower ext,
warm, well perfused, post tib pulses palpable bilaterally, s/p
left forefoot amputation
Neuro: A&O x 3, no focal sensory or motor deficits
Skin: no rashes, quarter sized ulcer on right heel, erythema, no
pus or bleeding
Exam on Discharge:
VS: 97.7-98, 90-98/45-46, 67-72, ___, 95-99% RA
Wt wt not taken this am 80.0<--82.4<--82.7 <-- 84.7
Net neg 2.7 L in 24hrs
Tele: NSR
General: NAD, sitting at edge of bed working with ___
HEENT: PERRL, EOMI, normal oropharynx
CV: RRR, II/VI holosystolic murmur best heard at apex, but also
heard throughout precordium with radiation to the axilla
Neck: supple, no JVD appreciated
Lungs: Lungs are clear bilaterally
Abdomen: soft, non-tender/non-distended, normal bowel sounds, no
erythema or bleeding around PD site
Ext: trace edema to right foot, right arm, improved, some
hyperpigmentation bilaterally lower ext, post tib pulses
palpable bilaterally though 1+, radial pulses 2+ bilaterally,
s/p left forefoot amputation
Neuro: A&O x 3, no focal sensory or motor deficits
Skin: no rashes, quarter sized ulcer on right heel, erythema, no
pus or bleeding, dry bandaged
Pertinent Results:
Labs on Admission:
___ 03:25PM ___ PTT-30.4 ___
___ 03:25PM NEUTS-59.9 ___ MONOS-5.1 EOS-4.5*
BASOS-0.7
___ 03:25PM WBC-6.5 RBC-3.59* HGB-10.9* HCT-32.0* MCV-89
MCH-30.4 MCHC-34.1 RDW-15.5
___ 03:25PM ALBUMIN-3.1*
___ 03:25PM CK-MB-8
___ 03:25PM cTropnT-0.23*
___ 03:25PM LIPASE-99*
___ 03:25PM ALT(SGPT)-94* AST(SGOT)-66* CK(CPK)-86 ALK
PHOS-406* TOT BILI-0.1
___ 03:25PM GLUCOSE-316* UREA N-112* CREAT-14.1*#
SODIUM-127* POTASSIUM-5.2* CHLORIDE-91* TOTAL CO2-18* ANION
GAP-23*
___ 05:12PM LACTATE-2.2*
Interval Labs:
___ 03:00PM BLOOD WBC-4.4 RBC-2.91* Hgb-9.0* Hct-25.8*
MCV-89 MCH-30.8 MCHC-34.8 RDW-15.5 Plt ___
___ 03:20AM BLOOD WBC-5.8 RBC-3.37* Hgb-10.1* Hct-29.7*
MCV-88 MCH-30.1 MCHC-34.1 RDW-15.2 Plt ___
___ 03:00PM BLOOD ___ PTT-21.9* ___
___ 03:20AM BLOOD ___ PTT-34.3 ___
___ 03:00PM BLOOD Glucose-125* UreaN-97* Creat-12.2*#
Na-130* K-7.0* Cl-97 HCO3-21* AnGap-19
___ 04:45PM BLOOD Na-129* K-6.6* Cl-96
___ 09:40PM BLOOD Na-129* K-4.9 Cl-95*
___ 03:20AM BLOOD Glucose-235* UreaN-92* Creat-11.4*
Na-128* K-6.2* Cl-93* HCO3-21* AnGap-20
___ 04:52AM BLOOD Na-130* K-4.7 Cl-94*
___ 03:00PM BLOOD ALT-61* AST-36 CK(CPK)-93 AlkPhos-321*
TotBili-0.2
___ 03:20AM BLOOD ALT-56* AST-37 CK(CPK)-79 AlkPhos-308*
___ 02:27AM BLOOD CK-MB-11* MB Indx-11.2* cTropnT-0.33*
___ 03:00PM BLOOD CK-MB-10 MB Indx-10.8* cTropnT-0.38*
___ 03:20AM BLOOD CK-MB-8 cTropnT-0.36*
Labs on Discharge:
___ 05:54AM BLOOD WBC-5.9 RBC-3.18* Hgb-9.8* Hct-28.1*
MCV-88 MCH-30.9 MCHC-35.0 RDW-15.1 Plt ___
___ 06:30AM BLOOD ___ PTT-40.9* ___
___ 06:30AM BLOOD Glucose-239* UreaN-63* Creat-9.8* Na-129*
K-4.5 Cl-92* HCO3-25 AnGap-17
___ 06:30AM BLOOD Calcium-7.2* Phos-5.0* Mg-1.9
Imaging:
CXR ___: IMPRESSION:
No acute cardiopulmonary process.
Free intraperitoneal air compatible with patient's history of
peritoneal
dialysis.
Left Heart Cath ___: Findings
ESTIMATED blood loss: 10 ml
Hemodynamics (see above): elevated filling pressures, LVEDP of
20 mmHg
Coronary angiography: right dominant
LMCA: normal
LAD: 50-60% proximal
LCX: 70% mid with haziness (likely culprit)
RCA: proximal 20%
Assessment & Recommendations
1.LCX likely culprit, though tx uncertain (CABG vs PCI,
drug-eluting stent vs bare metal stent,..)
2.Medical therapy until all these issues sorted out
Brief Hospital Course:
Patient is a ___ yo male with IDDM, PVD, ESRD on PD, who presents
to ED after SOB and chest pain radiating to left shoulder,
relieved by NTG and ASA 325mg, with Troponin T 0.23-->0.33,
NSTEMI.
Active Issues:
# NSTEMI: Patient had episode of chest pain uptrending
troponin. EKG on presentation had new Q wave in III/AVF,
consistent with NSTEMI. He was started on heparin drip, ASA
325mg, Atorvastatin 80mg and continued on doses of home
anti-hypertensives. A PICC line was placed for adminsitration
of heparin as well as blood draws, with approval from renal, as
patient is a difficult stick. He was taken to cardiac cath on
___ and was found to have mid vessel, 70% hazy stenosis. He
had additional ostial 40% stenosis of LAD and mid vessel 40%
eccentric. The patient did well after cath. No intervention
was performed at that time as the choice of intervention was
deferred until appropriate intervention in this patient was
discussed with transplant team, to ensure patient could remain
on SKP transplant list. On ___ patient was taken back to
cath lab and DES was placed in the LCX. Patient again tolerated
the procedure well. His coumadin was re-started after procedure
for patient's peripheral vascular disease, to maintain his
bypass grafts. He remained inpatient for titration of Coumadin
as patient cannot be bridged with Lovenox ___ his ESRD.
Discharged with rx for 15 Nitro 0.3 SL in case of chest pain.
# ESRD on PD: Renal consulted and followed throughout
admission. Patient continued PD while inpatient per their
recommendations. As an outpatient he is on the transplant list
with goal of kidney and/or kidney/pancreas transplant. In the
ED on admission patient was given 3L IVF. He noted some
increase in his weight as well as some edmea in his right arm
and foot. The dialysate was titrated per renal to take
additional fluid off during the patient's admission. He
tolerated PD well throughout though occasionally had some
sensation of discomfort secondary to the dialysate fluid. He
continued on his home reigmen of Calcium Acetate, Nephrocaps.
His chronic anemia was stable throughout admission.
# Transaminitis: With persistently elevated Alk phos normally,
increased on admission to 406 from 275 in ___ with
additional elevations in ALT/AST to 94/66 respecitvely. Unclear
etiology, but patient was very hypertensive on initial
presentation so may have been some ischemic damage. Enzymes
trended down over admission, closer to baseline elevations, and
patient was never symptomatic with abdominal pain. Consider
repeating LFTs as outpatient.
Chronic Issues:
# IDDM: On Glargine and carb counts. Had some elevated blood
sugars while on higher concentrate of dextrose dialysate. Was
on gluten free, low salt, low K, low phos diet. Was seen by
nutrition as inpatient to better educate patient on dietary
options.
# PVD: Patient follows with vascular and podiatry. Normally on
Coumadin for bypass but INR is not therapeutic at this time.
Lower extremity ulcer on right heal that does not appear
infected. Wound care consult placed and dry bandaging was
recommended. Patient post-cardiac intervention was restarted on
Coumadin, titrated to therapeutic INR which was 2.2 on
discharge. He was discharged on 3mg dose as concern with rapid
rise in INR that he would become supratherapeutic if continued
on 5mg dose. INR check to take place at PCP on ___.
# Depression: patient on wellbutrin as outpatient, on admission
appeared fatigued with flat affect. Continued on Wellbutrin SR
200mg daily as per outpatient. Over hospital course, affect
improved, patient felt better and was more interactive.
Transitional Issues:
# INR check ___
# Cardilogy F/U to Dr. ___
# Cardiac Rehab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. cilostazol *NF* 100 mg Oral BID Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
6. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. Metoclopramide 10 mg PO QIDACHS
8. Metoprolol Tartrate 50 mg PO BID
9. Nephrocaps 1 CAP PO DAILY
10. Ranitidine 150 mg PO DAILY
11. Warfarin 4 mg PO DAILY16
Discharge Medications:
1. Outpatient Lab Work
On ___, please have INR checked and sent to:
Dr. ___
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. BuPROPion (Sustained Release) 200 mg PO QAM
5. Calcium Acetate ___ mg PO TID W/MEALS
6. cilostazol *NF* 100 mg Oral BID Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
7. Glargine 20 Units Breakfast
Glargine 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
8. Metoprolol Tartrate 50 mg PO BID
9. Warfarin 3 mg PO DAILY16
RX *warfarin [Coumadin] 3 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
10. Metoclopramide 10 mg PO QIDACHS
11. Nephrocaps 1 CAP PO DAILY
12. Ranitidine 150 mg PO DAILY
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. Lactulose 30 mL PO DAILY
15. Losartan Potassium 50 mg PO DAILY
16. Clopidogrel 75 mg PO DAILY
17. Gentamicin 0.1% Cream 1 Appl TP AS NEEDED WITH PD DRESSING
CHANGES.
18. Nitroglycerin SL 0.3 mg SL PRN chest pain
RX *nitroglycerin [Nitrostat] 0.3 mg 1 tablet sublingually every
5 minute Disp #*15 Tablet Refills:*0
19. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: NSTEMI s/p DES to LCx
SECONDARY DIAGNOSES: hypertension, ESRD on PD
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 with chest
pain, and were found to have had a small heart attack (non-ST
elevation myocardial infarction or "NSTEMI"). You had a
drug-eluting stent placed in one of your coronary arteries (the
left circumflex). You stayed with us until your INR (warfarin
level) was at a therapeutic level.
You must take both your aspirin 81mg and clopidogrel 75mg
(Plavix) every day for at least the next year, or else your
artery will block again. Repeat blockage can lead to further
heart attacks and even death.
Please see attached for an updated list of your medications, and
see below for information regardingyour follow-up appointments.
Wishing you all the best!
Followup Instructions:
___
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Subsets and Splits