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10123949-DS-36	10,123,949	23,813,195	DS	36	2182-01-20 00:00:00	2182-01-21 15:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Levaquin / Protonix / Flagyl Attending: ___ Chief Complaint: Hypoglycemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ with h/o ESRD on nightly PD, DM I, CAD who is here with hypoglycemia. Patient was at the library with his son this afternoon when he felt tingling in his legs, and became diaphoretic. Similar to previous episodes of hypoglycemia. He tried apple sauce, 3 mountain ___, multiple packets of sugar and was still symptomatic. EMS on scene found him altered with FSG of 71. Received 3 tubes or oral glucose hich increased his FSG to 101. Patient attribute many factors to his hypoglycemia. His appetite is poor at times, increased physical activity, he doesn't eat regular meals, he wake up late this morning at approximately noon and didn't have breakfast or lunch and gave himself his morning lantus of 10 and also a correction novolog of 10 for a FSG reading of over 500. Last night he took 20 units of L and no NPH and used a bag of high dextrose solution and 1 bag of low destrose. He is also completing a course of intraperitoneal vancomycin and ceftazidime for his secondary peritonitis. He feels the antibiotics is also decreasing his appetite. In ED, upon reviewing his glucometer he has ___ readings per day. Per his wife, he doesn't check his FSG as often as he should but has multiple meters. He's had increased episodes over the last several months (4 episodes, last a about a week ago where he was low to ___ in the evening where he gave himself glucagon). In addition his glucose has been hard to control as he often has to use high destrose solutions to control his volume. Home regimen: Lantus 20 units QHS, 10 units QAM; 24 units QHS if using high dextrose solution NPH 4 units with PD (though patient has been using it PRN based on dextrose solution) Sort acting: 1:15 carb ratio; 1:40 correction ratio Denies fevers, chest pain, chest pressure, shortness of breath, cough, urinary symptoms, abdominal pain, constipation. +loose stools but no watery diarrhea, melana, hematochezia. Hypoglycemia felt ___ poor PO intake today and continued correction. He is admitted to medicine for further evaluation. ED course: Exam and labs largely unremarkable, CXR wnl. ___ 270 prior to transfer. On the floor he feels well, no complaints. 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: Mother: HTN, DM2 Father: CAD s/p CABG, DM2 Physical Exam: ADMISSION PHYSICAL EXAM: Vitals- fs 230 98.2 144/73 85 18 100ra GEN: well appearing male HEENT: MMM, OP clear CV: RRR, mid-peaking systolic murmur PULM: CTAB ABD: NABS, NTND, PD cath site c/d/i EXT: right arm former graft site with no thrill. no c/c/e NEURO: A&Ox3 DISCHARGE PHYSICAL EXAM: Vitals- T98.3, BP132-144/51-73, HR85, RR18, 99RA, BG231-265 General- Alert oriented, no acute distress, laying in bed HEENT- moist mucous membranes, sclera anicteric CV- RRR, normal S1/S2, ___ systolic murmur heard throughout precordium, radiating to axilla Lungs- Clear to auscultation, no wheezes, rales, rhonchi Abdomen- Normal bowel sounds, nontender, nondistended GU- No Foley Ext- Room temp lower extremities, left foot with toes amputated and looks clean. Neuro- minimal sensation in feet Pertinent Results: ADMISSION LABS: ___ 08:30PM BLOOD WBC-11.9# RBC-3.63 Hgb-10.5* Hct-33.8* MCV-93 MCH-29.0 MCHC-31.1 RDW-14.8 Plt ___ ___ 08:30PM BLOOD Glucose-297* UreaN-70* Creat-12.3# Na-139 K-4.0 Cl-103 HCO3-20 AnGap-20 ___ 08:30PM BLOOD Calcium-8.2* Phos-5.5* Mg-2.3 ___ 08:30PM BLOOD CK(CPK)-204 DISCHARGE LABS: ___ 06:25AM BLOOD WBC-6.5 RBC-3.31* Hgb-9.7* Hct-30.5* MCV-92 MCH-29.4 MCHC-31.9 RDW-14.5 Plt ___ ___ 06:25AM BLOOD ___ PTT-45.5* ___ ___ 06:25AM BLOOD Glucose-266* UreaN-69* Creat-13.1* Na-135 K-4.7 Cl-98 HCO3-22 AnGap-20 ___ 06:25AM BLOOD Calcium-7.7* Phos-5.4* Mg-2.1 CARDIAC ENZYMES: ___ 12:45PM BLOOD CK-MB-13* MB Indx-9.6* cTropnT-0.30* ___ 06:25AM BLOOD CK-MB-14* cTropnT-0.29* ___ 08:30PM BLOOD CK-MB-22* MB Indx-10.8* cTropnT-0.29* URINE: ___ 12:05AM URINE Color-Straw Appear-Clear Sp ___ ___ 12:05AM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG ___ 12:05AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-<1 ___ CXR No acute cardiopulmonary process. Brief Hospital Course: ___ with type 1 diabetes, CAD s/p stents, ESRD on home PD, admitted with hypoglycemia. # Hypoglycemia. Etiology is poor PO intake and overcorrection of insulin. Glucose on EMS arrival was 71. This was after several glucose packets, sodas, and apple sauce, so nadir was likely much lower. He was symptomatic with leg weakness and diaphoresis. Infectious workup with UA, CXR was negative. No fever. Mild leukocytosis to 11.9 which improved to 6.5 the next day, perhaps due to mild stress and hemoconcentration. He improved with regular PO intake and changes to insulin regimen. Fingersticks were back to baseline after admission. He was seen by ___ and Nutrition teams. Insulin recommendations per ___: Lantus 10 units qAM, use 1:15 ___, 1:CF 1:50 (not 1:40), correct to ___ (not ___. At bedtime, take Lantus 20 or 24 units depending on PD dextrose solution. Take NPH 4 units at start of PD every night. If AM glucose above >200 in AM after PD, then increase NPH by 1 unit/week for better glycemic control. # Demand ischemia. Patient also had some elevated troponins (0.30 range) consistent with prior numbers given renal disease. However, he did have elevated CK-MB to 22 on admission, which downtrended to 14 and then 13. 2 ECGs were unchanged from prior. He did not have any chest pain or shortness of breath. This may represent demand ischemia in the setting of stress from hypoglycemia. ### TRANSITIONAL ISSUES ### He was advised to stop fluconazole as the course has been completed per Nephrology. Otherwise, continue all medications, with insulin changes as above and holding of coumadin on day of discharge (___) for high INR 3.8 (likely due to interaction with fluconazole). Advised to seek medical care if he develops chest pain, shortness of breath, lightheadedness, diaphoresis, or other concerning symptoms. Follow up INR check at ___ ___ office on ___ at 11:45 AM. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. BuPROPion (Sustained Release) 200 mg PO DAILY 3. Calcium Acetate ___ mg PO TID W/MEALS 4. cilostazol 100 mg oral BID 5. Docusate Sodium 100 mg PO BID:PRN constipation 6. Clopidogrel 75 mg PO DAILY 7. Gentamicin 0.1% Cream 1 Appl TP PRN QID PRN during PD dressing changes 8. Isosorbide Mononitrate 30 mg PO DAILY 9. Lactulose 30 mL PO DAILY 10. Metoclopramide 10 mg PO QIDACHS 11. Metoprolol Tartrate 50 mg PO BID 12. Nephrocaps 1 CAP PO DAILY 13. Ranitidine 150 mg PO DAILY 14. Senna 1 TAB PO BID:PRN constipation 15. Glargine 10 Units Breakfast Glargine 20 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 16. Losartan Potassium 50 mg PO DAILY 17. Nitroglycerin SL 0.3 mg SL PRN chest pain 18. Fluconazole 200 mg PO Q24H 19. sevelamer CARBONATE 1600 mg PO TID W/MEALS 20. Calcitriol 0.5 mcg PO DAILY 21. Warfarin 1 mg PO DAILY16 22. Amlodipine 10 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. BuPROPion (Sustained Release) 200 mg PO DAILY 4. Calcitriol 0.5 mcg PO DAILY 5. Calcium Acetate ___ mg PO TID W/MEALS 6. cilostazol 100 mg oral BID 7. Clopidogrel 75 mg PO DAILY 8. Docusate Sodium 100 mg PO BID:PRN constipation 9. Gentamicin 0.1% Cream 1 Appl TP PRN QID PRN during PD dressing changes 10. Isosorbide Mononitrate 30 mg PO DAILY 11. Metoclopramide 10 mg PO QIDACHS 12. Metoprolol Tartrate 50 mg PO BID 13. Losartan Potassium 50 mg PO DAILY 14. Nephrocaps 1 CAP PO DAILY 15. Nitroglycerin SL 0.3 mg SL PRN chest pain 16. Ranitidine 150 mg PO DAILY 17. sevelamer CARBONATE 1600 mg PO TID W/MEALS 18. Senna 1 TAB PO BID:PRN constipation 19. Lactulose 30 mL PO DAILY 20. Warfarin 1 mg PO DAILY16 21. Glargine 10 Units Breakfast Glargine 20 Units Bedtime NPH 4 Units Bedtime Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1) Hypoglycemia 2) Type 1 diabetes 3) Demand ischemia SECONDARY: 1) Coronary artery disease 2) End stage renal disease, on nighttime peritoneal dialysis 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 take care of you at ___ ___. You were admitted to the hospital because of hypoglycemia (low glucose). You were treated with glucose and your blood glucose improved and your symptoms resolved. We had the ___ diabetes team provide you with insulin recommendations. We also had a dietician review some nutrition recommendations and diet with you. You had some elevated cardiac enzymes, but with no chest pain and an ECG without change from prior studies. This was most likely related to some decreased blood flow to your heart from a hypoglycemic event (demand ischemia). Please stop the fluconazole. You have completed the course. Insulin recommendations: Lantus 10 units qAM, use 1:15 ___, 1:CF 1:50 (not 1:40), correct to ___ (not ___. At bedtime, take Lantus 20 or 24 units depending on PD dextrose solution. Take NPH 4 units at start of PD every night. If AM glucose above >200 in AM after PD, then increase NPH by 1 unit/week for better glycemic control. Hold ___ ___ coumadin and restart ___ with dose of 1mg daily until your INR check with Dr. ___ on ___ at 11:45 AM. Followup Instructions: ___
10123949-DS-37	10,123,949	24,460,648	DS	37	2182-04-01 00:00:00	2182-04-04 19:55:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Levaquin / Protonix / Flagyl Attending: ___. Chief Complaint: Epistaxis Major Surgical or Invasive Procedure: ___: Right IJ placement under ___ guidance History of Present Illness: This is a ___ y/o man with PMHx with h/o ESRD on nightly PD, DM I, CAD s/p PCI (DES to ___ presenting with epistaxis and DKA. He presented to the ED for management of his nose bleed, which had resolved by the time he was evaluated in the ED. However, he was noted to be in DKA, which is the reason for his admission to the MICU. In the ED, initial VS were: T 98.1 HR 90 BP 173/89 RR 16 O2 Sat 95% RA Labs were notable for INR 1.9, BG >500, Trop 0.52, Na 127, K 5.8, HCO3 11, BUN 148, Cr 20 and VBG ___. CXR showed mild pulmonary edema. A R IJ was placed due to difficulty obtaining IV access. He was given Ca gluconate. Renal was consulted and recommended PD today. He was started on Insulin gtt and admitted to the MICU. On arrival to the MICU, initial VS were: T 98 BP 161/94 HR 80 RR 16 O2 Sat 95% RA He endorsed ___ ___ like chest pain that he does not think is similar to his angina. He denies SOB, lightheadedness or palpitations. No radiation to the arm or jaw. 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: Mother: HTN, DM2 Father: CAD s/p CABG, DM2 Physical Exam: ============================= ADMISSION PHYSICAL EXAM: ============================= T 98 BP 161/94 HR 80 RR 16 O2 Sat 95% RA General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP to the angle of the mandible Lungs- Bibasilar rales anteriorly, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal ============================= DISCHARGE PHYSICAL EXAM: ============================= VS - 97.8 119/70 77 18 96&RA BG 93-252 General: NAD, A+OX3 HEENT: PERRL, EOMI, anicteric sclera Neck: supple, RIJ in place, dressing c/d/i without signs of infection CV: RRR, ___ crescendo-decrescendo murmur with radiation to carotids heard @ RUSB, ___ blowing murmur heard best @ apex of heart Lungs: CTAB, no wheeze Abdomen: +BS, soft, NT/ND GU: no foley Ext: left leg w/ toe amputations, +1 distal pulses, RUE w/ +1 pitting edema around arm but with intact pulses and without palpable cords, bilateral upper extremities equal in temperature Neuro: CNII-XII intact Pertinent Results: ============================= ADMISSION LABS: ============================= ___ 06:00AM BLOOD WBC-5.7 RBC-3.50* Hgb-10.1* Hct-31.9* MCV-91 MCH-28.8 MCHC-31.5 RDW-14.1 Plt ___ ___ 06:00AM BLOOD Neuts-62.6 ___ Monos-4.2 Eos-3.8 Baso-1.1 ___ 06:00AM BLOOD ___ PTT-42.0* ___ ___ 06:00AM BLOOD Glucose-541* UreaN-148* Creat-20.2# Na-127 K-5.8* Cl-89* HCO3-11* AnGap-33* ___ 12:38PM BLOOD Calcium-6.6* Phos-7.9# Mg-2.0 ___ 06:00AM BLOOD WBC-5.7 RBC-3.50 Hgb-10.1* Hct-31.9* MCV-91 MCH-28.8 MCHC-31.5 RDW-14.1 Plt ___ ___ 06:00AM BLOOD ___ PTT-42.0* ___ ___ 06:00AM BLOOD Glucose-541* UreaN-148* Creat-20.2# Na-127 K-5.8* Cl-89* HCO3-11* AnGap-33* ___ 06:00AM BLOOD CK(CPK)-286 ___ 12:38PM BLOOD CK(CPK)-255 ___ 06:00AM BLOOD CK-MB-19* MB Indx-6.6* cTropnT-0.52* ___ 12:38PM BLOOD CK-MB-16* MB Indx-6.3* cTropnT-0.48* ___ 12:38PM BLOOD Calcium-6.6* Phos-7.9# Mg-2.0 ___ 02:52AM BLOOD PTH-1435 ___ 08:02AM BLOOD Glucose-GREATER TH Lactate-1.3 ___ 08:18AM BLOOD O2 Sat-84 ___ 08:20PM BLOOD freeCa-0.92* ============================= DISCHARGE LABS: ============================= ___ 05:10AM BLOOD WBC-7.4 RBC-2.93* Hgb-8.4* Hct-25.8* MCV-88 MCH-28.6 MCHC-32.4 RDW-14.1 Plt ___ ___ 05:31AM BLOOD ___ PTT-34.9 ___ ___ 05:31AM BLOOD Glucose-52* UreaN-80* Creat-13.1* Na-134 K-4.3 Cl-94* HCO3-25 AnGap-19 ___ 05:31AM BLOOD Calcium-7.1* Phos-6.4* Mg-1.9 ============================= IMAGING: ============================= ___ RUE US: FINDINGS: Soft tissue edema is noted in the right upper extremity. The right subclavian, internal jugular, axillary, brachial and basilic veins are patent with normal flow and compression and no findings to suggest deep vein thrombosis. A right fistula graft is noted. There is atherosclerosis of the right common carotid artery. IMPRESSION: No findings to suggest right upper extremity deep vein thrombosis. ___ CXR: Mild interstitial edema. ___ TTE: Mild symmetric left ventricular hypertrophy with regional dysfunction and mildly depressed global systolic function. Mild aortic stenosis. At least moderate mitral regugitation. ============================= MICROBIOLOGY: ============================= ___ Blood cx pending ___ Dialysate 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. ASCITES ANALYSISWBCRBCPolysLymphsMonosMesothe ___ 20:17 7304583 5* 111 ___ Dialysate fluid GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ASCITES ANALYSISWBCRBCPolysLymphsMonosMesothe 54545012252 11* ___ Fluid Culture in Bottles (Preliminary): NO GROWTH. ___ Urine cx: No Growth ============================= PERTINENT: ============================= ___ 02:52AM BLOOD ALT-20 AST-14 LD(LDH)-206 AlkPhos-260* TotBili-0.1 ___ 02:52AM BLOOD ___-1435* ___ 02:52AM BLOOD 25VitD-11* Brief Hospital Course: ============================= PRIMARY REASON FOR ADMISSION ============================= This is a ___ year old male with past medical history of end stage renal disease on peritoneal dialysis, type I diabetes, coronary artery disease status post stent placement (DES to ___ presenting with epistaxis found to be in diabetic ketoacidosis. ============================= ACTIVE ISSUES ============================= # Type I diabetes complicated by diabetic ketoacidosis: The patient presented with diabetic ketoacidosis. He was transitioned off insulin drip to lantus/sliding scale successfully. Patient to will follow up with ___ outpatient. He periodically refused insulin for blood sugar management while hospitalized. A trigger for his DKA was unidentified. # End stage renal disease on peritoneal dialysis: hyperkalemia, acidosis on presentation. Initial peritoneal dialysis fluid concerning for peritonitis with WBC 730 and he initially was started on vancomycin and fluconazole with ceftazidime PD dwellings but a repeat sample prior to antibiotics came back at 54 WBC with 50 %PMN so antibiotics stopped on ___. He was started on a 1 liter fluid restriction per Renal recommendation and put on 3 days of aluminum. He will continue nightly peritoneal dialysis at home. # Troponin elevation: Likely related to demand ischemia in the setting of pulmonary edema and known coronary artery disease. Last catheterization in ___ with 70% left circumflex and 40% serial left anterior descending lesions. Clinically, he remained chest pain free during his admission. ECG was without ST-T segment changes. Cardiology did not feel that this was thombosis and recommended discontinuing heparin drip, but to continue warfarin and clopidogrel. LVEF >45% on TTE. He will follow up with cardiology as an outpatient. # Right upper extremity swelling: Secondary to soft tissue edema. This was symptomatically controlled with ACE wrap and elevation. There was no evidence of deep vein thrombosis on extremity ultrasound. # Depression: Patient with passive suicidal ideation. Social work was consulted for support. # Epistaxis: resolved after presentaion. Likely related to aspirin, clopidogrel and warfarin use. Hemoglobin was stable during hospital course. ============================= CHRONIC ISSUES ============================= # Coronary artery disease: continued home aspirin, clopidogrel, statin, ___, and beta-blocker. # History of deep vein thrombosis: Remote. On lifelong warfarin. He was continued on warfarin. INR was subtherapeutic on discharge after becoming supratherapeutic during his hospitalization. His INR levels will need to be monitored as an outpatient. # Hypertension: he was continued on home antihypertensives. ============================= TRANSITIONAL ISSUES ============================= - peritoneal dialysis at night - monitor blood sugars, 10 units lantus in the morning and 18 units lantus at night - INR 1.7 on day of discharge, instructed to take 2 mg ___ and ___ for follow up INR ___. - outpatient psychiatry evaluation for passive suicidal ideation ============================== PENDING RESULTS: ============================== Microbiology ___ 12:36 DIALYSIS FLUID FUNGAL CULTURE ___ 12:36 FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles ___ 08:21 BLOOD CULTURE Blood Culture, Routine ___ 08:21 BLOOD CULTURE Blood Culture, Routine Medications on Admission: The Preadmission Medication list is accurate and complete. 1. sevelamer CARBONATE 1600 mg PO TID W/MEALS 2. cilostazol 100 mg oral BID 3. Aspirin 81 mg PO DAILY 4. Simvastatin 5 mg PO DAILY 5. Amlodipine 10 mg PO DAILY 6. NovoLOG FLEXPEN (insulin aspart) 100 unit/mL subcutaneous up to 40units/day 7. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL) subcutaneous up to 50 units/day 8. Clopidogrel 75 mg PO DAILY 9. HumuLIN N (NPH insulin human recomb) 100 unit/mL subcutaneous 8 units at bedtime 10. Glucagon Emergency (glucagon (human recombinant)) 1 mg injection as directed 11. Losartan Potassium 50 mg PO DAILY 12. Metoprolol Tartrate 50 mg PO BID 13. Calcium Acetate 1334 mg PO TID W/MEALS 14. Gentamicin 0.1% Cream 1 Appl TP QID PD changes 15. BuPROPion 200 mg PO QAM 16. Warfarin 1 mg PO DAILY16 17. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY RX amlodipine 10 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Aspirin 81 mg PO DAILY 3. BuPROPion 200 mg PO QAM RX bupropion HCl 200 mg 1 tablet extended release(s) by mouth qAM Disp #30 Tablet Refills:0 4. cilostazol 100 mg oral BID RX cilostazol 100 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 5. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 6. Gentamicin 0.1% Cream 1 Appl TP QID PD changes RX gentamicin 0.1 % apply to PD catheter site four times a day Disp #1 Tube Refills:0 7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY RX isosorbide mononitrate [Imdur] 30 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #30 Tablet Refills:0 8. Losartan Potassium 50 mg PO DAILY RX losartan [Cozaar] 50 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 9. Metoprolol Tartrate 50 mg PO BID RX metoprolol tartrate 50 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 10. sevelamer CARBONATE 1600 mg PO TID W/MEALS RX sevelamer carbonate [Renvela] 800 mg 2 tablet(s) by mouth TID with meals Disp #60 Tablet Refills:0 11. Simvastatin 5 mg PO DAILY RX simvastatin 5 mg 1 tablet(s) by mouth at bedtime Disp #30 Tablet Refills:0 12. Warfarin 2 mg PO DAILY16 13. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation RX bisacodyl 5 mg 1 tablet,delayed release (___) by mouth daily Disp #30 Tablet Refills:0 14. Calcitriol 0.5 mcg PO DAILY RX calcitriol 0.5 mcg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 15. Docusate Sodium 100 mg PO BID:PRN constipation RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 16. Lactulose 30 mL PO Q4H:PRN constipation RX lactulose 10 gram/15 mL 15 mL by mouth daily Disp #30 Unit Refills:0 17. Nephrocaps 1 CAP PO DAILY RX B complex-vitamin C-folic acid [Renal Caps] 1 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 18. Calcium Acetate 1334 mg PO TID W/MEALS RX calcium acetate 667 mg 2 capsule(s) by mouth TID with meals Disp #90 Tablet Refills:0 19. Glucagon Emergency (glucagon (human recombinant)) 1 mg injection as directed RX glucagon (human recombinant) [Glucagon Emergency] 1 mg 1 mg sc as needed Disp #1 Kit Refills:0 20. Glargine 10 Units Breakfast Glargine 18 Units Dinner Insulin SC Sliding Scale using HUM Insulin 21. Metoclopramide 5 mg PO QIDACHS RX metoclopramide HCl 5 mg 5 mg by mouth QIDACHS Disp #50 Tablet Refills:0 22. Nitroglycerin SL 0.3 mg SL PRN chest pain RX nitroglycerin [Nitrostat] 0.3 mg 0.3 mg sublingually q5min x 3 Disp #20 Tablet Refills:0 23. Ranitidine 150 mg PO DAILY RX ranitidine HCl 150 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 24. Senna 1 TAB PO BID Constipation RX sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp #30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. diabetic ketoacidosis 2. epistaxis 3. End stage renal disease, on peritoneal dialysis SECONDARY: 4. Peripheral vascular disease 5. coronary artery disease 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 to the hospital because you had a bloody nose. You were then found to be in diabetic ketoacidosis. You were originally in the intensive care unit on an insulin drip. You were transitioned off the insulin drip to a basal-bolus regimen. It is important to follow up with your diabetes doctor at ___. Your INR was 1.7 on your day of discharge. You will take 2mg of coumadin tonight and ___. You should have your INR checked on ___. Dr. ___ follow your INR, like he normally does. For your right arm swelling, you can wrap an ace bandage around it and elevate it above the level of your heart. Thank you for choosing ___. Followup Instructions: ___
10123949-DS-39	10,123,949	25,762,958	DS	39	2182-10-26 00:00:00	2182-10-31 11:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Levaquin / Protonix Attending: ___. Chief Complaint: Left lower extremity infection Hemodialysis tunneled cathether tip infection Major Surgical or Invasive Procedure: ___: Left Lower Extremity Wound Debridement ___: Exchange of a left tunneled subclavian dialysis catheter with a non-tunneled temporary dialysis catheter ___: Tunneled dialysis line placement History of Present Illness: Mr. ___ is a ___ w/ PMH of DMI, severe PVD s/p bypass, ESRD on HD MWF, CAD s/p AVR/CABG on ___ at ___ presents for evaluation of LLE wound (L calf vein harvest site for CABG). Pt underwent AVR and CABG on ___ ___ with harvest of vein from left calf. He did well postop and was discharged to ___ on ___. In the rehab, he was not allowed to use insulin pump and thus, his BG were often 400+ (at home mostly ~ 140). His wound healing deteriorated about 2 weeks ago and opened during a ___ session. The rehab has been packing the left calf wound x1 week but it was becoming more concerning for infection. He saw his cardiac surgeon today and was recommended to go to ED for further evaluation. He reports pain but no increased swelling, fever, or worsening chills (has chills chronically). Has not been on ABX for a few weeks now. Per report, he also has bilateral heel pressure wounds that are not open nor draining, as well as a sacral decubitus ulcer. In the ED initial vitals were: 98.8 78 140/84 16 96%. - Labs were significant for for WBC 13.5 (41.8% PMNs, 49.4% Lymphs), H/H 7.8/26.1, K 5.4, BUN/Cr 40/7.0, INR 1.9. Lactate 1.3. BCx was drawn. - Patient was given Vanc 1g and Oxy 5mg. Vascular surgery was consulted in the ED and wound was debrided at bed side. Vitals prior to transfer were: 100.1 88 121/80 18 96% RA. On the floor, VS are 99.9 138/86 89 18 95% on RA and finger stick 234. He reports fatigue and pain ___ in the ___. He denies chest pain or dyspnea. Review of Systems: (+) per HPI (-) fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: - 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: Mother: HTN, DM2 Father: CAD s/p CABG, DM2 Physical Exam: Admission Physical Exam: PHYSICAL EXAM: Vitals - VS are 99.9 138/86 89 18 95% on RA and finger stick 234. GENERAL: NAD, flat affect HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, surgical scar noted LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: distended, hypoactive BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: L foot is s/p TMA, well-healed. Left heel ulcer with eschar, ~1x1 cm. Left calf w/ ~30cm wound from CABG vein harvest site, open with fibrinous and purulent exudate, light green, foul-smelling, thick. Eschar present in medial aspect of left calf wound. Right heel ulcer without eschar, covering entire surface of heel with separation of superficial layers, no evidence of infection present. Right foot with substantial peripheral edema. Bilateral lower and upper extremities with diffuse scarring from former vein harvest procedures. Discharge Physical Exam: Vitals- 98.6 98.4 156/56, 88, 18, 97%RA General- Alert, oriented, no acute distress HEENT- AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition Lung - CTAB, no rhonchi, wheezes, rales CV - RRR, normal S1 + S2, prosthetic valve click Abdomen - soft, non-tender, non-distended, bowel sounds present Skin: Anterior chest with xeroform dressing on top of CABG site, no spreading erythema. New tunneled HD line site w/ no erythema. Some 5mm erythema around previous tunneled cathether exit site, unchanged Ext- R boot in place by podiatry -- L heel with non stageable ulcers, dry with eschar -- Wound vac in place of LLE wound. Some mild erythema around wound vac from adhesive irritation. wound healing well Neuro- motor function and sensation grossly normal Pertinent Results: CBC: ___ 08:20AM BLOOD WBC-15.0* RBC-3.39* Hgb-9.4* Hct-32.2* MCV-95 MCH-27.6 MCHC-29.0* RDW-16.3* Plt ___ ___ 07:25AM BLOOD WBC-12.3* RBC-3.02* Hgb-8.4* Hct-28.7* MCV-95 MCH-27.7 MCHC-29.2* RDW-16.3* Plt ___ ___ 09:08AM BLOOD WBC-15.3* RBC-3.27* Hgb-9.1* Hct-31.0* MCV-95 MCH-27.8 MCHC-29.3* RDW-16.3* Plt ___ ___ 07:10AM BLOOD WBC-14.0* RBC-3.11* Hgb-8.9* Hct-29.9* MCV-96 MCH-28.5 MCHC-29.6* RDW-16.2* Plt ___ ___ 09:30AM BLOOD WBC-13.7* RBC-3.21* Hgb-9.1* Hct-30.8* MCV-96 MCH-28.4 MCHC-29.6* RDW-16.1* Plt ___ ___ 08:00AM BLOOD WBC-11.2* RBC-3.15* Hgb-9.2* Hct-30.5* MCV-97 MCH-29.3 MCHC-30.3* RDW-16.0* Plt ___ ___ 06:25AM BLOOD WBC-12.2* RBC-3.07* Hgb-8.6* Hct-29.4* MCV-96 MCH-28.0 MCHC-29.3* RDW-16.1* Plt ___ ___ 07:10AM BLOOD WBC-14.3* RBC-2.82* Hgb-8.1* Hct-27.1* MCV-96 MCH-28.5 MCHC-29.7* RDW-16.4* Plt ___ ___ 11:45AM BLOOD WBC-12.9* RBC-2.89* Hgb-8.6* Hct-27.7* MCV-96 MCH-29.6 MCHC-30.9* RDW-16.5* Plt ___ ___ 05:53PM BLOOD WBC-12.7* RBC-3.17# Hgb-9.1# Hct-30.5# MCV-96 MCH-28.8 MCHC-30.0 RDW-16.7* Plt ___ ___ 06:30AM BLOOD WBC-14.6* RBC-2.45* Hgb-7.1* Hct-23.7* MCV-97 MCH-28.8 MCHC-29.8* RDW-17.1* Plt ___ ___ 06:20AM BLOOD WBC-14.4* RBC-2.48* Hgb-7.0* Hct-23.8* MCV-96 MCH-28.2 MCHC-29.4* RDW-16.9* Plt ___ ___ 06:40AM BLOOD WBC-13.5* RBC-2.49* Hgb-6.9* Hct-24.1* MCV-97 MCH-27.6 MCHC-28.5* RDW-16.8* Plt ___ ___ 08:03AM BLOOD WBC-13.0* RBC-2.63* Hgb-7.4* Hct-25.3* MCV-96 MCH-28.2 MCHC-29.3* RDW-17.0* Plt ___ ___ 08:00AM BLOOD WBC-13.8* RBC-2.84* Hgb-8.0* Hct-27.5* MCV-97 MCH-28.2 MCHC-29.1* RDW-17.1* Plt ___ ___ 12:20PM BLOOD WBC-13.7* RBC-2.69* Hgb-7.6* Hct-25.9* MCV-96 MCH-28.3 MCHC-29.4* RDW-16.5* Plt ___ ___ 06:36PM BLOOD WBC-13.5# RBC-2.69# Hgb-7.8# Hct-26.1 MCV-97# MCH-29.0 MCHC-29.9# RDW-16.9 Plt ___ ___ 07:25AM BLOOD Neuts-41.2* Lymphs-47.1* Monos-5.0 Eos-5.5* Baso-1.2 ___ 06:36PM BLOOD Neuts-41.8* Lymphs-49.4* Monos-6.3 Eos-1.8 Baso-0.8 . Coags: ___ 08:20AM BLOOD ___ PTT-77.2* ___ ___ 07:25AM BLOOD ___ PTT-122.7* ___ ___ 09:08AM BLOOD ___ PTT-75.9* ___ ___ 07:10AM BLOOD ___ PTT-115.9* ___ ___ 09:30AM BLOOD ___ PTT-81.9* ___ ___ 04:20AM BLOOD ___ PTT-46.1* ___ ___ 06:25AM BLOOD ___ PTT-32.9 ___ ___ 02:33AM BLOOD ___ PTT-90.8* ___ ___ 02:20AM BLOOD ___ PTT-38.0* ___ ___ 08:15AM BLOOD ___ PTT-31.6 ___ ___ 06:20AM BLOOD ___ PTT-36.9* ___ ___ 10:00AM BLOOD ___ PTT-59.5* ___ ___ 01:41AM BLOOD ___ PTT-45.9* ___ ___ 02:20PM BLOOD ___ PTT-60.7* ___ ___ 06:36PM BLOOD ___ PTT-42.4* ___ . Chemistry: ___ 08:20AM BLOOD Glucose-88 UreaN-20 Creat-5.7# Na-138 K-4.3 Cl-101 HCO3-27 AnGap-14 ___ 07:25AM BLOOD Glucose-138 UreaN-27* Creat-7.6# Na-141 K-4.5 Cl-102 HCO3-29 AnGap-15 ___ 09:08AM BLOOD Glucose-55 UreaN-22* Creat-6.0# Na-139 K-4.3 Cl-102 HCO3-26 AnGap-15 ___ 07:10AM BLOOD Glucose-211 UreaN-34* Creat-8.7# Na-141 K-4.7 Cl-103 HCO3-28 AnGap-15 ___ 09:30AM BLOOD Glucose-175 UreaN-28* Creat-7.3# Na-142 K-4.4 Cl-103 HCO3-28 AnGap-15 ___ 08:00AM BLOOD Glucose-386 UreaN-21* Creat-5.3# Na-138 K-4.6 Cl-98 HCO3-29 AnGap-16 ___ 06:25AM BLOOD Glucose-201 UreaN-30* Creat-6.9# Na-138 K-5.1 Cl-98 HCO3-26 AnGap-19 ___ 07:10AM BLOOD Glucose-70 UreaN-21 Creat-5.3# Na-138 K-4.5 Cl-101 HCO3-30 AnGap-12 ___ 11:45AM BLOOD Glucose-64 UreaN-37* Creat-8.1# Na-135 K-5.4 Cl-98 HCO3-28 AnGap-14 ___ 05:53PM BLOOD Glucose-115* UreaN-31* Creat-7.0# Na-137 K-5.0 Cl-99 HCO3-27 AnGap-16 ___ 06:40AM BLOOD Glucose-171 UreaN-39* Creat-7.5# Na-138 K-5.4 Cl-101 HCO3-29 AnGap-13 ___ 08:03AM BLOOD Glucose-219* UreaN-30* Creat-5.8* Na-140 K-4.8 Cl-102 HCO3-28 AnGap-15 ___ 12:20PM BLOOD Glucose-119* UreaN-52* Creat-8.3# Na-135 K-5.7 Cl-98 HCO3-26 AnGap-17 ___ 06:10PM BLOOD Glucose-152* UreaN-40* Creat-7.0# Na-135 K-5.4 Cl-99 HCO3-26 AnGap-15 ___ 07:25AM BLOOD ALT-13 AST-18 AlkPhos-172* TotBili-0.1 . ___ 08:20AM BLOOD Calcium-8.7 Phos-4.6* Mg-2.2 ___ 07:25AM BLOOD Calcium-8.3* Phos-6.0* Mg-2.3 ___ 06:40AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.1 ___ 08:03AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0 ___ 08:00AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.3 ___ 12:20PM BLOOD Calcium-8.6 Phos-3.4# Mg-2.2 ___ 06:27PM BLOOD Lactate-1.3 . Vanc trough ___ 07:56AM BLOOD Vanco-17.3 ___ 06:22AM BLOOD Vanco-14.1 ___ 06:26AM BLOOD Vanco-16.6 ___ 11:45AM BLOOD Vanco-20.2* ___ 06:20AM BLOOD Vanco-10.2 ___ 08:03AM BLOOD Vanco-<1.7* Imaging: ___ Tunneled dialysis line placement: IMPRESSION: Successful exchange of existing left subclavian vein temporary dialysis catheter for a tunneled access catheter through the left subclavian vein approach. The tip is located in the right atrium and the catheter is ready for use. ___ Right upper extremity ultrasound: IMPRESSION: No evidence of deep vein thrombosis in the right upper extremity. ___ Dialysis line exchange: IMPRESSION: Exchange of a left tunneled subclavian dialysis catheter with a non-tunneled temporary dialysis catheter. The catheter is ready for use. ___ Bilateral upper extremity venous duplex IMPRESSION: No suitable venous conduit for AV fistula noted in bilateral upper extremities. Microbiology: FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH ___ 5:23 pm TISSUE LEFT CALF TISSUE. GRAM STAIN (Final ___: 3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. ___ AND IN PAIRS. Reported to and read back by ___ ON ___ @ 835 ___. TISSUE (Final ___: 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. ENTEROCOCCUS SP.. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| ENTEROCOCCUS SP. \| \| AMPICILLIN------------ <=2 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN------------- 0.5 S PENICILLIN G---------- 8 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. FUNGAL CULTURE (Preliminary): Reported to and read back by ___. ___ @ 15:32 ON ___. ___ ALBICANS. POTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL ELEMENTS SEEN. ___ 10:22 am ABSCESS Source: Left HD catheter tunnel. FINAL REPORT ___ GRAM STAIN (Final ___: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. WOUND CULTURE (Final ___: NO GROWTH. ANAEROBIC CULTURE (Final ___: NO GROWTH. ___ 10:22 am BLOOD CULTURE Source: Line-dialysis #1. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 12:15 pm BLOOD CULTURE #1. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH ___ 6:10 pm BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. Brief Hospital Course: ___ w/ PMH of DMI, severe PVD s/p bypass, ESRD on HD MWF, CAD s/p AVR/CABG on ___ at OSH presented with L calf vein harvest site dehiscence and infection s/p debridement on ___, s/p wound vac on ___. # LLE dehiscence with infection s/p OR debridement s/p wound vac: left calf vein harvest site for ___ complicated by dehiscence, and infection s/p OR debridement and culture on ___ and s/p wound vac on ___. Pt started on vancomycin/zosyn on admission on ___. OR wound culture grew MSSA and enterococcus. Pt discharged on vancomycin and ceftazidime(HD dosing)for a total course of two weeks from exchange of original tunneled line with temporary HD cathether line(day ___ day ___/last ___ per ID recommendation. Pt will have wound vac changes MWF(specific settings included in transiational issues below) and f/u with vascular surgery after discharge. Pain was well controlled with oxycontin and prn oxycodone. BCx from ___ and ___ were negative on discharge. Wound was inspected on discharge by vascular surgery and found to be healing well. #?Dailysis tunneled line infection: Increasing erythema around HD tunnled line noted on ___ with pus expressed, concerning for infection. Exchange of a left tunneled subclavian dialysis catheter with a non-tunneled temporary dialysis catheter done on ___. No culture data available from removal of suspected infected line. On ___, successful exchange of existing left subclavian vein temporary dialysis catheter for a tunneled access catheter through the left subclavian vein approach. Per ID, vancomycin/ceftazidime course as described above will also cover emperic treatment for suspected original dialysis line infection. # DMI: poorly controlled with blood glucose in 400s since residing at ___ where he was not allowed to use his insulin pump. FSG on admission to the floor 234. During hospitalization, diabetes initially managed with lantus and insulin sliding scale. Patient initially had episodes of hypoglycemia in the setting of poor PO intake most likely due to poor appetite from acute sickness and worsening depression. Patient was followed by ___ diabetes team, and daily lantus/sliding scale insluin regimen adjusted per team recommendations. Patient was started on insulin pump on ___. On discharge, patient had good blood glucose control using insulin pump. # Depression/Anxiety: Pt with a history of depression, initially noted to have worsening flat affect and depressed mood during hospitalization. He was occasionally irritable, refusing some medical interventions. Home wellbutrin and loarazepam were continued. No active SI/HI during hospitalization. Psychiatry was consulted. Current presentation, per psychiatry, consistent with acute depressive syndome with psychological(low mood, aparthy, irritability, pessimism), behavioral (crying spells, interpersonal friction, social withdrawal), and somatic (fatigue, insomnia, appetite changes) disturbances in the setting of acute on chronic medical illness. His lorazepam frequency was increased(BID to TID prn). Trazodone switched to 100 QHS. Patient had flat affect on discharge but had improved appetite and PO intake. Chronic: # ESRD on HD: Underwent HD during hospitalization. Scheduled regularly for MWF. Will follow up with transplant surgery in a few weeks. Continued nephrocaps, calcitriol, and calcium acetate # CAD s/p AVR and CABG: No cardiac symtoms during hospitalization. - coumadin was held and on heparin periprocedurally for OR debridement and ___ HD tunnel site re-siting, and replacement. Coumadin restarted after procedures and discharged on 3mg. Discharge INR was 1.1. Pt was bridged with heparin. Sternal CABG site wound was evaluated by wound care and found to be healing well. Continue wound care, sternal precautions, asa, metoprolol, simvastatin. ======================================== Transitional Issues ======================================== -Pt on warfarin for mechanical aortic valve(goal INR ___ ___ notes where patient had CABG w/ AVR, would recommend 2.5-3.5 given AVR with mechanical valve). Discharge warfarin dose 3mg QD. INR on discharge 1.1. Bridged with heparin until INR theraputic range for 24 hours. -Started vancomycin and zosyn since ___, transitioned to vancomycin+ceftazidime HD dosing on discharge for a total course of two weeks from exchange of original tunneled line with temporary HD cathether line(day ___ day 14/last ___ per Infectious Disease consultants. - Insulin pump restarted during admission. Patient able to titrate dose. Scheduled for follow up with ___ endocrinology - Wound care for sternal and leg wounds. Has follow up with CT surgeon for post-op care - Forefoot weight bearing on RLE, WBAT on LLE, sternal precautions Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium Acetate 667 mg PO TID W/MEALS 2. Omeprazole 20 mg PO DAILY 3. Metoprolol Tartrate 25 mg PO TID 4. Warfarin 1 mg PO DAILY16 5. Simvastatin 20 mg PO DAILY 6. Aspirin 81 mg PO DAILY 7. BuPROPion 200 mg PO DAILY 8. Calcitriol 0.5 mcg PO DAILY 9. Gabapentin 100 mg PO DAILY 10. Lactulose 20 mL PO DAILY 11. Metoclopramide 10 mg PO BREAKFAST 12. Nephrocaps 1 CAP PO DAILY 13. melatonin 5 mg oral QHS 14. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezes 15. Ipratropium Bromide Neb 1 NEB IH Q6H 16. Lorazepam 0.5 mg PO BID:PRN anxiety 17. Nitroglycerin SL 0.4 mg SL PRN chest pain 18. TraZODone 75 mg PO HS:PRN insomnia Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. BuPROPion 200 mg PO DAILY 3. Calcitriol 0.5 mcg PO DAILY 4. Calcium Acetate 667 mg PO TID W/MEALS 5. Gabapentin 100 mg PO DAILY 6. Lactulose 15 mL PO DAILY 7. Lorazepam 0.5 mg PO TID:PRN anxiety 8. Nephrocaps 1 CAP PO DAILY 9. Omeprazole 20 mg PO DAILY 10. Simvastatin 20 mg PO DAILY 11. TraZODone 100 mg PO HS insomnia 12. Warfarin 3 mg PO DAILY16 13. Metoprolol Succinate XL 75 mg PO DAILY 14. Acetaminophen 1000 mg PO Q8H 15. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 16. Heparin IV Sliding Scale Initial Bolus: 6000 units IVP Initial Infusion Rate: 1450 units/hr Start: Now Target PTT: 60 - 100 seconds 17. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal Rates: Midnight - 8am: .8 Units/Hr 8am - 8pm: 1 Units/Hr 8pm - midnight: .8 Units/Hr Meal Bolus Rates: Breakfast = 1:18 Lunch = 1:18 Dinner = 1:18 High Bolus: Correction Factor = 1:40 Correct To mg/dL 18. Mupirocin Ointment 2% 1 Appl TP BID 19. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 20. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 21. Senna 8.6 mg PO BID 22. melatonin 5 mg oral QHS 23. Metoclopramide 10 mg PO BREAKFAST 24. Nitroglycerin SL 0.4 mg SL PRN chest pain 25. CefTAZidime 1 g IV POST HD (___) Duration: 8 Days 1g after HD on M, W 2g after HD on F 26. Vancomycin IV Sliding Scale Start: Today - ___, First Dose: Next Routine Administration Time If unable to monitor pre-HD trough, give 1g M, 500mg W&F after HD Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left lower extremity infection Hemodialysis tunneled cathether tip infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted to ___ for infection of your left lower leg wound. We started you on antibiotics for the infection, and the vascular surgery team removed some of the infected tissue and put on a wound vaccum to facilitate wound healing and closure. The tip of your tunneled hemodialysis cathether site was infected, thus, the interventional radiology team removed the infected tip with the cathether and placed a different tunneled cathether line. Your diabetes was initially managed with different doses of your home lantus with insulin adminstration as needed. You were restarted on insulin pump before discharge with good blood glucose control. Please attend your multiple follow up appointments as scheduled below. Sincerely, Your ___ medical team Followup Instructions: ___
10123949-DS-40	10,123,949	23,147,995	DS	40	2182-11-08 00:00:00	2182-11-08 15:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: wheat / Levaquin / Protonix Attending: ___. Chief Complaint: R sided weakness Major Surgical or Invasive Procedure: Chest tube placement/removal Wound vac changes TEE History of Present Illness: ___ is a ___ with a history of diabetes c/b ESRD on HD, CAD s/p CABG and prosthetic AVR, peripheral vascular disease, recently complicated by multiple infections who presents with new R-sided weakness and difficulty with speech. He went to sleep last night in his normal state of health. He awoke this morning at 3 AM and noticed that he had difficulty manipulating his remote control to turn on the television. He was able to grasp it in his hand, but he could not press any of the buttons. He then went back to sleep. In the morning, he awoke and could not move his R arm or leg, and he felt that his speech was slow. He alerted his nurse, who brought him to the emergency department. He arrived after 8AM; his last known normal was therefore bedtime the previous night. He denies any paroxysmal neurological symptoms such as loss of vision, vertigo, numbness, weakness, parasthesias or clumsiness. He has not been out of bed and therefore cannot assess his gait. Over the past few months he has had multiple medical problems. Three months ago he presented to an outside hospital for chest pain and ended up undergoing CABG with prosthetic aortic valve placement due to bicuspid aortic valve. While he was at rehab, he developed a wound on his L calf (unclear etiology at this time) which was complicated by infection. He was admitted to ___, where he underwent debridement and wound vac placement and was started on vancomycin and zosyn. Wound cultures were positive for coag negative staph and enterococcus. During that hospitalization he was also noted to have a soft tissue infection at the site of his hemodialysis catheter; the catheter was "resited" and replaced. Blood cultures during that hospitalization were negative. He was transitioned to vanc/ceftazidime on discharge with a plan to complete a 2-week course after HD catheter replacement (___). Since discharge he has been afebrile. Yesterday, he reports that at the nursing facility they had a hard time measuring his blood pressures but he had no symptoms of hypotension. In addition to his L leg wound he has several other lesions without evidence of infection on discharge, including a R heel wound, sternal post-surgical wound at the apex of the incision, and a sacral decubitus ulcer. Neuro ROS is pertinent as above. On general review of systems, he denies recent fever or chills. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - CAD-s/p stenting in ___, CABG at ___ in ___ ___: - ESRD-now on HD, previously on PD - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ - HLD - PVD-extensive vascular reconstruction/bypass of lower extremities - depression - celiac disease - recurrent pleural effusion since CABG PSH: - ___ CABG with prosthetic AVR for bicuspid aortic valve - ___ LHC with DES to left circumflex - R distal SFA angioplasty (___) - R heel debridement (___) - placement/replacement of PD catheter (___) - partial excision R AV graft ___ - tunneled R IJ HD catheter ___ - RUE AV graft ___ - R distal SFA angioplasty ___ - arthroplasty R ___ PIP joint, debridement of R ___ toe ___ - R CFA to AT artery BPG with NRSVG ___ - R SFA angioplasty ___ - L TMA ___ (c/b infection, s/p debridement and closure) - L SFA to peroneal BPG procedures for PVD ___ - R knee surgery Social History: ___ Family History: - Father with CAD, CABG. Grandfather with CAD, Great-grandfather with hypertension. Physical Exam: Admission Exam: T 99.0 HR 101 BP 161/72 RR 18 SpO2 97% General: Awake, alert, intermittently tearful and frustrated with speech and weakness but in NAD. HEENT: NC/AT Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Chest: Midline incision. Central area of scab without fluctuance or purulence. Bandage in place over apex of incision. Exit site of prior hemodialysis catheter is visible and is greenish in color. Pulmonary: Normal work of breathing. Vesicular breath sounds bilaterally, no wheezes or crackles appreciated. Cardiac: S1/S2 appreciated, RRR, no M/R/G. Abdomen: soft, nontender, nondistended Extremities: Multiple vascular surgery scars noted. Ample edema in RUE. Chronic venous stasis chages appreciated in visible parts of RLE. Skin: Lesions as above. PICC in place in L arm without erythema, fluctuance or tenderness. Neurologic: -Mental Status: Alert, oriented x 3. Became intermittently tearful and frustrated while repeating history. Language is reduced in fluency with intact repetition. Comprehension lightly reduced (touched L earlobe instead of R in multistep command). Normal prosody. There were no intermittent paraphasic errors, more phonoemic than semantic. Pt. was able to name both high and low frequency objects on the ___ naming scale. Able to read but substituted words in sentences. Speech was mildly dysarthric with difficulty with sibilants. Able to follow both midline and appendicular commands. Attentive, able to name ___ backwards to ___ before getting stuck with words which sounded like ___ "___." Pt. was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm, both directly and consentually; brisk bilaterally. VFF to confrontation with finger counting. No extinction to DSS. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch, pinprick in all distributions. VII: Mild facial asymmetry with R droop greater in lower distributions, R nasolabial fold flattening. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline, and is equal ___ strength bilaterally as evidenced by tongue-in-cheek testing. -Motor: Normal tone throughout. Lower extremities decreased in bulk. No pronator drift on L, could not lift R to perform. No tremor noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5- ___ ___- 5- 5 5 absent R ___- ___ ___- * * 0 0 * could not assess due to wound dressings and supportive boot for R heel ulcer movment limited by wound vac in place at L ankle * limited by weight of boot on ankle -DTRs: Bi Tri ___ Pat Ach L 2 1 2 1 ** R 2 1 2 1 * - Plantar response could not be assessed. -Sensory: Reports no deficits to light touch, pinprick or pinprick under visual stimulation, but when eyes are closed does not register any sensory input on the R side of his body. Proprioception was absent on the R side and intact only to large movements in the L thumb. L toes surgically absent. -Coordination: No intention tremor, no dysdiadochokinesia noted on L side although movements are slow. No dysmetria on FNF on L. Sensorimotor ataxia on R arm. Cannot perform HKS bilaterally. -Gait: Not tested. Discharge Exam: T 98.5 BP 114/93-136/38 HR ___ RR 18 Multiple wounds. Alert, oriented x3. Intact repetition, comprehension, naming. Language non-fluent. No dysarthria. VFF, EOMI, R face droop, tongue midline. R strength diffusely ___, L strength ___ when patient able to participate fully. R side diminished sensation to fine touch, temperature. Intact finger nose testing on L. Gait not tested. Pertinent Results: ___ CT Head No acute intracranial abnormality. ___ CXR 1. Left PICC terminating within the left axillary vein. 2. Large left pleural effusion has enlarged since ___. ___ CTA Head/Neck 1. No evidence of acute intracranial hemorrhage or mass effect. 2. No evidence of hemodynamically significant stenosis or pathologic large vessel occlusion within the head or neck. ___ CXR Evidence for interval placement of a pigtail catheter in the left pleural space with and substantial reduced affection of the large pleural effusion. Small pneumothorax is present The right lung is clear. ___ TTE The left atrium is mildly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast with maneuvers. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF=55%). There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the basal inferior wall. Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. No mitral valve abscess is seen. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.]. No vegetation/mass is seen on the pulmonic valve. There is a small pericardial effusion without evidence for tamponade. Compared with the prior study (images reviewed) of ___ there has been interval placement of a mechanical aortic valve. Transvalvular gradients are normal. Prosthetic aortic valve endocarditis is best excluded with TEE, however. Regional and global left ventricular systolic function have improved. There is more mitral regurgitation. The small pericardial effusion is new. Other findings are similar. ___ CXR As compared to the previous radiograph, no relevant change is seen. The small left basal pneumothorax, seen at the level of the costophrenic sinus, is constant in appearance. Unchanged position of the left pigtail catheter. Minimal re-expansion edema on the left. Normal size of the cardiac silhouette. Unchanged alignment of the sternal wires. Unremarkable and unchanged appearance of the right lung. ___ CT Head Subtle hyperdensity in the left posterior frontal lobe best visualized on image on series 2, image ___. MRI can help for further assessment. No acute hemorrhage. ___ MRI Brain Subacute infarct involving the posterior frontal lobe with additional punctate areas of slow diffusion in the more anterior/superior frontal lobe, suggesting a thromboembolic source. ___ TEE No mass/thrombus is seen in the left atrium or left atrial appendage. No mass or thrombus is seen in the right atrium or right atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). 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 to 35 cm from the incisors. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: No cardiac source of embolus identified. Normally functioning mechanical AVR. No significant native valve pathology. ___ CXR 1. Interval removal of the left pigtail catheter, with worsening layering left pleural effusion. 2. Stable small left basilar pneumothorax. ___ 07:20AM BLOOD WBC-13.4* RBC-3.25* Hgb-8.7* Hct-29.3* MCV-90 MCH-26.8* MCHC-29.7* RDW-15.7* Plt ___ ___ 07:20AM BLOOD ___ PTT-46.6* ___ ___ 07:20AM BLOOD Glucose-110* UreaN-41* Creat-6.8# Na-139 K-4.7 Cl-100 HCO3-28 AnGap-16 ___ 07:20AM BLOOD Calcium-9.3 Phos-5.5 Mg-2.3 ___ 04:43AM BLOOD %HbA1c-6.2* eAG-131* ___ 04:43AM BLOOD Triglyc-50 HDL-46 CHOL/HD-1.8 LDLcalc-29 ___ 04:43AM BLOOD TSH-5.4* Brief Hospital Course: ___ is a ___ man with a history of uncontrolled type 1 diabetes with multiple complications, ESRD on HD, diffuse atherosclerotic disease including CAD s/p CABG and PVD s/p multiple bypass grafts, mechanical aortic valve on coumadin/heparin gtt, and recent history of soft tissue infections for which he was receiving vanc/ceftazidime. He presented with a new R-sided weakness and mild aphasia concerning for a subcortical stroke. MRI confirms stroke in L frontal lobe affecting white matter tracts. The patient complained of worsening symptoms for several days after initial presentation; in small vessel strokes it is possible to have some expansion of the stroke. Since the decending motor fibers are likely affected, it is unlikely that the patient will return back to his baseline strength prior to the stroke. MRI ___ showed a subacute infarct involving the posterior frontal lobe with additional punctate areas of slow diffusion in the more anterior/superior frontal lobe, suggesting a thromboembolic source. Certainly inflammation can lead to hypercoagulability. There was low concern for infection as blood cultures NGTD, but as pt was on IV abx, blood cultures may have been sterilized. Blood cultures will be repeated prior to discharge. TEE negative for mechanical valve endocarditis/thrombus/abscess. NEURO: Stroke - LDL 29, HbA1c 6.2. On statin and insulin - pump discontinued due to variable po intake and patient inability to manage pump. ___ following was following in house. Recommend Lantus 19 units at night + sliding scale; decrease Lantus to 16 units at night on SunTueThur prior to HD on MWF. - TTE does not show thrombus or new wall motion abnormalities - TEE does not show mech valve endocarditis/thrombus/abscess - Continue aspirin 81 mg, warfarin - currently holding for supratherapeutic INR. Need to check INR daily and once po intake stable, every 2 days, and adjust warfarin dose accordingly. - ___ - recommend discharge to acute rehab - Precautions: falls and aspiration ___: CAD, s/p CABG. Bicuspid aortic valve, s/p prosthetic AVR. - warfarin for mech AV - as above - pt had troponinemia with troponins uptrending but then flat, EKG with non-specific T wave inversions in precordial leads, pt asymptomatic. Although has ESRD (elevated trops at baseline) and recent CABG so grafts should be patent, it is possible that the patient has a graft down. Given risk factors, have increased statin to Atorva 80 mg, started metoprolol for HR control, could start nifedipine 30 mg daily but pt currently has controlled BP. - Telemetry did not show afib - goal SBP 120-140 PSYCH: Patient with known depression, has been seen by psych service during prior admissions. He is intermittently tearful and anxious, alternating with depression. - will continue current meds - social work consulted to help with coping PULM: recurrent pleural effusion, but asymptomatic. Occurred ___, possibly due to surgery although these tend to be bilateral and transudative. It is possible for effusion to be unilateral; exudate may be due to changes in fluid post-HD. - chest tube removed per patient request - CXR shows L pleural effusion slightly worse, L ptx stable - if patient becomes symptomatically short of ___ need repeat CXR and possibly another chest tube ENDO: poorly controlled diabetes - HbA1c 6.2, has been much higher in past - Finger sticks QID and Insulin as above RENAL: ESRD, on HD - On hemodialysis MWF, has been receiving on schedule. - check CMP pre-HD Toxic/Metabolic: - LFTs: CK, Alk phos elevated, others wnl ID: Continues with leukocytosis but no fevers nor evidence of sepsis. - vancomycin and ceftazidime stopped ___, as per ID recs. Will repeat blood cultures on ___. These will need to be followed up. - TEE as above - Continue wound care MWF for wound vac changes - wound care for sacral decubitus ulcer - blood cultures NGTD GI: - PRN laxatives - PPI home dose F/E/N: - Gluten free diet, Renal Frappe with Beneprotein TID, Nephrocaps daily. AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes [performed and documented by admitting resident] () No 2. DVT Prophylaxis administered by the end of hospital day 2? (x) Yes - () No 3. Antithrombotic therapy administered by end of hospital day 2? (x) Yes - () No 4. LDL documented (required for all patients)? (x) Yes (LDL = 29) - () No 5. Intensive statin therapy administered? (x) Yes - () No [if LDL >= 100, reason not given: ____ ] (intensive statin therapy = simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL >= 100) 6. Smoking cessation counseling given? () Yes - (x) No [if no, reason: (x) non-smoker - () unable to participate] 7. Stroke education given (written form in the discharge worksheet)? (x) Yes - () No (stroke education = personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) 8. Assessment for rehabilitation or rehab services considered? (x) Yes - () No [if no, reason not assessed: ____ ] 9. Discharged on statin therapy? (x) Yes - () No [if LDL >= 100 or on a statin prior to hospitalization, reason not discharged on statin: ____ ] 10. Discharged on antithrombotic therapy? (x) Yes [Type: (x) Antiplatelet - () Anticoagulation] - (x) No 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No [if no, reason not discharge on anticoagulation: ____ ] - (x) N/A Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain/fever>100.5 2. Bisacodyl 10 mg PO DAILY:PRN constipation 3. Metoprolol Succinate XL 75 mg PO DAILY 4. Mupirocin Ointment 2% 1 Appl TP BID 5. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 6. Senna 8.6 mg PO BID 7. Lactulose 15 mL PO DAILY 8. Lorazepam 0.5 mg PO Q8H:PRN anxiety 9. Warfarin 3 mg PO DAILY16 10. Aspirin 81 mg PO DAILY 11. Calcitriol 0.5 mcg PO DAILY 12. Calcium Acetate 667 mg PO TID W/MEALS 13. Gabapentin 100 mg PO TID 14. melatonin 5 mg oral QHS 15. Metoclopramide 10 mg PO DAILY 16. Nephrocaps 1 CAP PO DAILY 17. Omeprazole 20 mg PO DAILY 18. Pravastatin 40 mg PO HS 19. BuPROPion 100 mg PO BID 20. Heparin IV No Initial Bolus Initial Infusion Rate: ___ units/hr 21. Vancomycin 1000 mg IV HD PROTOCOL 22. CefTAZidime 1 g IV POST HD (___) 23. Insulin Pump SC (Self Administering Medication)Insulin Aspart (Novolog) (non-formulary) Basal rate minimum: 0.8 units/hr Basal rate maximum: 1.0 units/hr Bolus minimum: 1:18 units Bolus maximum: 1:18 units Target glucose: ___ Fingersticks: QAC and HS 24. OxycoDONE Liquid 5 mg PO Q4H:PRN pain Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain/fever>100.5 2. Aspirin 81 mg PO DAILY 3. Bisacodyl 10 mg PO DAILY:PRN constipation 4. BuPROPion 100 mg PO BID 5. Calcitriol 0.5 mcg PO DAILY 6. Calcium Acetate 667 mg PO TID W/MEALS 7. Gabapentin 300 mg PO MWF POST-HD 8. Lactulose 15 mL PO DAILY 9. Lorazepam 0.5 mg PO Q8H:PRN anxiety 10. Metoclopramide 5 mg PO TID 11. Nephrocaps 1 CAP PO DAILY 12. Omeprazole 20 mg PO DAILY 13. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H RX oxycodone [OxyContin] 10 mg 1 tablet(s) by mouth every 12 hours Disp #60 Tablet Refills:11 14. Senna 8.6 mg PO BID 15. Atorvastatin 80 mg PO DAILY 16. QUEtiapine Fumarate 12.5 mg PO DAILY 2 HOURS PRIOR TO TRAZODONE 17. TraZODone 100 mg PO HS 18. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth Q6H as needed Disp #30 Tablet Refills:2 19. Metoprolol Succinate XL 200 mg PO DAILY 20. Mupirocin Ointment 2% 1 Appl TP BID 21. Warfarin 3 mg PO DAILY16 start warfarin dose when INR drops to between ___. 22. Glargine 19 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute ischemic stroke Brain embolism from a prosthetic valve End stage renal disease on hemodialysis Wound infections Coronary artery disease s/p bypass grafting Bicuspid aortic valve s/p mechanical aortic valve Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were hospitalized due to symptoms of R sided weakness and loss of sensation resulting from an ACUTE ISCHEMIC STROKE, a condition in which a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. The brain is the part of your body that controls and directs all the other parts of your body, so damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: Immobility after surgery, multiple infections, high cholesterol, vascular disease We are changing your medications as follows: Stop ceftazidime and vancomycin Change from pravastatin to atorvastatin 80 mg daily Start quetiapine 12.5 mg at night for sleep Change gapapentin to post-HD Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization. Followup Instructions: ___
10123949-DS-41	10,123,949	28,284,803	DS	41	2182-12-14 00:00:00	2182-12-14 15:15:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: wheat / Levaquin / Protonix Attending: ___ Chief Complaint: Right Arm and Leg Pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old man with a past medical history of DM, CAD s/p stents, bicuspid aortic valve s/p prosthetic valve replacement on coumadin, recent L MCA distribution (parietal) embolic stroke (___), ESRD on HD, PAD with multiple bypass grafts who presents from rehab with increased weakness of his right side. Per rehab notes, on nursing eval at midnight, patient with increased pain and worsening right sided weakness, unknown time last known at baseline. Per the patient, whereas he had been able to wiggle his fingers on the right side a few days after arriving at rehab, he is no longer able to do so. Even with looking at rehab notes, it is entirely unclear as to exactly when this occurred. He is also complaining of increased pain on the right side of his body, mostly in the right wrist and ankle, which started two days ago and has gradually worsened. He was sent to the ___ ED and called as a code stroke. SBP in the 150s, HR 74, fingerstick blood glucose in the 170s. EKG normal. Currently, he is in distress due to pain, and due to concern over the inabliity to move the fingers on his right side. He is refusing ultrasound of the right upper extremity. He was last admitted at the end of ___, when he had presented with R-sided weakness and difficulty with speech. He was a found to have a subacute infarct involving the posterior frontal lobe, with additional punctate areas of slow diffusion in the more anterior/superior frontal lobe, suggesting a thromboembolic source. He was continued on warfarin. Past Medical History: - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - CAD-s/p stenting in ___, CABG at ___ in ___ PMH: - ESRD-now on HD, previously on PD - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ - HLD - PVD-extensive vascular reconstruction/bypass of lower extremities - depression - celiac disease - recurrent pleural effusion since CABG PSH: - ___ CABG with prosthetic AVR for bicuspid aortic valve - ___ LHC with DES to left circumflex - R distal SFA angioplasty (___) - R heel debridement (___) - placement/replacement of PD catheter (___) - partial excision R AV graft ___ - tunneled R IJ HD catheter ___ - RUE AV graft ___ - R distal SFA angioplasty ___ - arthroplasty R ___ PIP joint, debridement of R ___ toe ___ - R CFA to AT artery BPG with NRSVG ___ - R SFA angioplasty ___ - L TMA ___ (c/b infection, s/p debridement and closure) - L SFA to peroneal BPG procedures for PVD ___ - R knee surgery Social History: ___ Family History: - Father with CAD, CABG. Grandfather with CAD, Great-grandfather with hypertension. Physical Exam: Admission Physical Exam (discharge exam is lower below): General: Awake, crying in pain. HEENT: MMM Neck: Supple Pulmonary: CTA bilaterally Cardiac: RRR Abdomen: soft Extremities: No edema. amputation of left foot. Black eschar on right heel, painful. Pain to palpation of right calf, entire right arm. Right arm with 1+ pitting edema, also non-pitting edema, and warm, tender. Skin: no rashes or lesions noted. Skin lesions noted on nursing admission examination: 1. L Plantar heel deep tissue injury 2. R heel stage III-IV pressure ulcer 3. sacrum, unstageable pressure ulcer Neurologic: -Mental Status: Alert, oriented x 3. Moaning in pain which limits ability to get history. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. No anomia. Able to read without difficulty. Speech mildly dysarthric, although difficult to tell as he is crying. Able to follow both midline and appendicular commands. The pt had good knowledge of current events. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Decreased bulk throughout. Decreased tone in RUE. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. The left side is full. The right side is diffusely ___. -Sensory: Slightly decreased sensation to light touch over the right hemibody. -DTRs: 3+ right upper extremity, 1+ LUE, 0 bilateral lower extremities. Plantar response not assessed. -Coordination: No tremor or dysmetria on the left upper extremity. -Gait: Not tested. ================================================================ Discharge Physical Exam: Notable for improvement in R sided weakness. Please note that his exam can be very participation dependent and if his not complying can appear totally flaccid w/ 0s on right side: RUE: ___ at deltoid, ___ at biceps, ___ at Triceps, ___ at finger flexion. Can wiggle fingers weakly on right. RLE: ___ at hip flexion, ___ at quad, ___ at hamstring, ___ at foot dorsi and plantar flexion. Pertinent Results: ___ 02:06AM GLUCOSE-283* UREA N-44* CREAT-5.4# SODIUM-136 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-28 ANION GAP-14 ___ 02:06AM estGFR-Using this ___ 02:06AM ALT(SGPT)-21 AST(SGOT)-21 CK(CPK)-35 ALK PHOS-227* TOT BILI-0.1 ___ 02:06AM LIPASE-10 ___ 02:06AM cTropnT-0.78* ___ 02:06AM CK-MB-4 ___ 02:06AM ALBUMIN-2.8* ___ 02:06AM WBC-10.9 RBC-3.14* HGB-8.1* HCT-27.6* MCV-88 MCH-25.7* MCHC-29.1* RDW-18.1* ___ 02:06AM NEUTS-51.6 ___ MONOS-6.3 EOS-5.5* BASOS-1.0 ___ 02:06AM PLT COUNT-365 ___ 02:06AM ___ PTT-40.5* ___ CT Head ___: IMPRESSION: 1. No acute intracranial abnormality, with evolving focal encephalomalacia involving the posterior left frontal lobe. 2. Dense calcifications of the intra-and extracranial vessels,, likely related to the underlying ESRD on dialysis Right Upper Extremity X-Ray (___) IMPRESSION: No fracture or dislocation. Right Upper Extremity Doppler Ultrasound (___) IMPRESSION: No evidence of deep venous thrombosis in the right upper extremity. The cephalic vein is not visualized. Again demonstrated is a right sided abandoned dialysis graft. Brief Hospital Course: # Post Stroke Pain. Patient was admitted in stable condition. XRay and US of right upper extremity ruled out bony abnormality and venous thrombosis, respectively. Given location of lesion, timing of pain onset and absence of structural or vascular abnormality, a diagnosis of Post-Stroke Pain Syndrome was made. In consultation with Pain Team, Amitriptyline was initiated and Gabapentin was uptitrated. Additional modifications were made to the patient's pain management regimen in consultation with the pain team, including discontinuing Fentanyl patch and adjusting Oxycodone administration to better fit the patient's acute pain symptoms. Per pain recommendations, gabapentin may be uptitrated to a total of 300mg TID. Patient's INR was supratherapeutic during admission. Warfarin was therefore held. INR at discharge was 3.8. Decubitus ulcers were identified on admission examination: 1. L Plantar heel deep tissue injury 2. R heel stage III-IV pressure ulcer 3. sacrum, unstageable pressure ulcer These were managed with the assistance of our wound care specialists and were stable. # Type 1 Diabetes- Difficult to control blood sugars On admission, patient was continued on his home insulin regimen. However, his sugars were highly variable, with episodes of symptomatic hypoglycemia into the ___ and episodes of hyperglycemia into the low 400s despite stable regimen. ___ Diabetes Service was consulted and aided in management. Per their thoughts, he is now a very brittle diabetic given his ESRD (role of kidney in gluconeogenesis, increased insulin resistance). His discharge regimen was ISS (as provided in paperwork plus basal lantus. He is to receive 10u Lantus in qAM and 14u Lantus qPM daily. Please note, this lantus regimen was changed on the day of discharge per ___ recommendations. # Prosthetic Aortic Valve - On coumadin, goal INR ___. Medications on Admission: - Aspirin 81 mg PO DAILY - Warfarin 3 mg PO DAILY16 - Atorvastatin 80 mg PO DAILY - Amlodipine 2.5mg dialy - Metoprolol Succinate 200mg PO DAILY - Seroquel 25mg PO DAILY - BuPROPion 100 mg PO BID - Remeron 7.5mg QHS - Tylenol ___ Q6H PRN - Gabapentin 300 mg PO MWF POST-HD - Fentanyl patch 12mcg/hr Q72hrs - Oxycodone 7.5mg TID - Lorazepam 0.5 mg PO Q8H:PRN anxiety - Metoclopramide 5 mg PO TID before meals - Nephrocaps 1 CAP PO DAILY - Calcium Acetate 667 mg PO TID W/MEALS - Ergocalciferol 50,000U weekly on ___ - Glargine 25 Units before breakfast - Humalog sliding scale - Omeprazole 20 mg PO DAILY - Lactulose 15 mL PO QID - Senna 8.6 mg PO BID - Bisacodyl 5mg daily Discharge Medications: 1. Amlodipine 2.5 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Bisacodyl 5 mg PO DAILY 5. BuPROPion 100 mg PO BID 6. Calcium Acetate 667 mg PO TID W/MEALS 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 8. Lactulose 15 mL PO QID 9. Lorazepam 0.5 mg PO Q4H:PRN anxiety 10. Metoclopramide 5 mg PO TID 11. Metoprolol Succinate XL 200 mg PO DAILY 12. Mirtazapine 7.5 mg PO HS 13. Nephrocaps 1 CAP PO DAILY 14. Omeprazole 20 mg PO DAILY 15. QUEtiapine Fumarate 12.5 mg PO DAILY 16. Senna 8.6 mg PO BID 17. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) 18. Warfarin 3 mg PO DAILY16 INR Goal: ___. Amitriptyline 75 mg PO HS 20. Docusate Sodium 100 mg PO BID 21. Gabapentin 300 mg PO BID ___ 22. Gabapentin 300 mg PO QPM ON ___ 23. Gabapentin 600 mg PO DAILY ON ___ 24. Fentanyl Patch 12 mcg/h TD Q72H RX fentanyl [Duragesic] 12 mcg/hour chronic pain q72hours Disp #5 Patch Refills:0 25. Lantus (insulin glargine) 10 u subcutaneous qAM 26. Polyethylene Glycol 17 g PO DAILY:PRN constipation 27. Ondansetron 4 mg IV Q8H:PRN nausea 28. Acetaminophen 650 mg PO Q6H:PRN Fever/pain 29. Lidocaine 5% Ointment 1 Appl TP DAILY:PRN Dressing Change 30. Glucose Gel 15 g PO PRN hypoglycemia protocol 31. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol 32. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 33. OxycoDONE (Immediate Release) 7.5 mg PO Q4H:PRN breakthrough pain RX oxycodone [Oxecta] 7.5 mg 1 tablet(s) by mouth every four (4) hours Disp #20 Tablet Refills:0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Post Stroke Pain Syndrome Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were admitted with complaints of severe right arm pain. Our evaluation determined that this was consistent a diagnosis of Post-Stroke Pain Syndrome. To treat this syndrome, in consultation with the ___ pain team, a new medication (Amitriptyline) was started and your Gabapentin was increased. These changes can take some time to take effect. However, we were pleased to find that your pain improved significantly prior to discharge. Your INR was above goal range during this admission. Therefore your Warfarin was held. It should be resumed once your INR is again in goal range (i.e. ___. Upon admission several decubitus ulcers were identified. These were managed with the help of our wound care specialists. Medication Changes: NEW MEDICATION: Amitriptyline to treat post-stroke pain syndrome CHANGED MEDICATION: Gabapentin (increased) to treat post-stroke pain syndrome Followup Instructions: ___
10123949-DS-44	10,123,949	20,216,545	DS	44	2183-07-26 00:00:00	2183-07-26 16:28:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Levaquin / Protonix / Flagyl Attending: ___. Chief Complaint: fever, cough, and shortness of breath Major Surgical or Invasive Procedure: angioplasty and balloon dilation of the SVC ___ History of Present Illness: Mr. ___ is a ___ year old man with history of ESRD on HD, DM1, CAD s/p AVR and CABG, PAD, and CVA with right-sided weakness who presented with fever, cough, and shortness of breath. He reports that he was at an AV Care appointment regarding his RUE edema, and he was asked to come to the ED for evaluation of his respiratory symptoms. He described progressive shortness of breath over the course of one month, first only noted at night and requiring oxygen only at night, and progressing to requiring oxygen throughout the day (2L). He noted concurrent worsening in right arm and leg edema. He also noted several days of nonproductive cough, fever of 101, and malaise. Sick contacts include his roommate at rehab who reportedly developed similar symptoms before he did. He denied associated nausea, headache, rash, chest pain, or myalgias. He endorsed diarrhea. During his ___ ___ admission, he was noted to have RUE swelling, and had no evidence of DVT on imaging, no SVC based on CTA and vascular surgery consult. Pt underwent venoplasty of the right subclavian and brachiocephalic veins on ___ with subsequent reduced swelling and pain on RUE. On discharge, he still had RUE swelling, and was planned to be managed with HD and per the referral note, the central vein angioplasty will need to be repeated. In the ED, initial VS were 0 98.9 80 144/81 16 99% 2L Labs significant for absence of leukocytosis, Hgb 9 (at baseline), Cr 6.4 (at recent baseline ___, INR 2, lactate 1.3, and negative flu A/B swabs. Imaging significant for CXR with mild pulmonary edema. Received Metoclopramide 10 mg PO ONCE, CefePIME 2 g IV ONCE, and Vancomycin 1000 mg IV ONCE. Transfer VS were 99.3 76 147/82 22 100% Nasal Cannula On arrival to the floor, patient voices no complaints and answers minimal questions. When pressed, he endorses fever, nonproductive cough, and RUE swelling, however, his answers are short. REVIEW OF SYSTEMS: Per HPI Past Medical History: - recent embolic stroke (___) with persistent right sided weakness - ESRD-now on HD, previously on PD - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ - HLD - depression - celiac disease - recurrent pleural effusion since CABG - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - CAD-s/p stenting in ___, CABG at ___ in ___ ___: - ___ CABG with prosthetic AVR for bicuspid aortic valve - ___ LHC with DES to left circumflex - R distal SFA angioplasty (___) - R heel debridement (___) - placement/replacement of PD catheter (___) - partial excision R AV graft ___ - tunneled R IJ HD catheter ___ - RUE AV graft ___ - R distal SFA angioplasty ___ - arthroplasty R ___ PIP joint, debridement of R ___ toe ___ - R CFA to AT artery BPG with NRSVG ___ - R SFA angioplasty ___ - L TMA ___ (c/b infection, s/p debridement and closure) - L SFA to peroneal BPG procedures for PVD ___ - R knee surgery Social History: ___ Family History: Father with CAD, CABG. Physical Exam: DMISSION PHYSICAL EXAM: VS: 99.3 82 154/89 20 100/3L GENERAL: Uncomfortable appearing, coughing, eyes closed, refuses physical exam ___: AT/NC EXTREMITIES: RUE is markedly edematous, slightly tender, not erythematous. Left foot is s/p forefoot amputation; heel ulcer undergoing dressing change. NEURO: limited by patient refusal, but speech fluent. per ___ d/c summary: "CN II-XII intact. Weak grasp on right hand." DISCHARGE PHYSICAL EXAM: VS: 98.7 88 134/67 18 95% ra GENERAL: NAD, eyes closed, slightly more cooperative with exam, relative to prior ___: AT/NC EXTREMITIES: RUE is markedly edematous, slightly tender, not erythematous. R radial pulse 2+. Left foot is s/p forefoot amputation NEURO: limited by patient cooperation. speech fluent. cannot lift RUE or maintain it elevated when I lift it up. Pertinent Results: LABS ON ADMISSION ___ 02:08PM BLOOD WBC-7.9 RBC-2.89* Hgb-9.1* Hct-27.0* MCV-93 MCH-31.6 MCHC-33.9 RDW-16.1* Plt ___ ___ 02:08PM BLOOD Neuts-64.6 ___ Monos-6.8 Eos-4.3* Baso-0.6 ___ 02:08PM BLOOD ___ PTT-39.8* ___ ___ 02:08PM BLOOD Plt ___ ___ 01:37PM BLOOD Glucose-80 UreaN-39* Creat-6.4# Na-135 K-5.9 Cl-95* HCO3-27 AnGap-19 ___ 01:37PM BLOOD Calcium-8.2* Phos-4.5 Mg-2.4 ___ 02:22PM BLOOD Lactate-1.3 K-4.7 LABS ON DISCHARGE ___ 06:06AM BLOOD WBC-7.9 RBC-2.86* Hgb-8.9* Hct-26.8* MCV-94 MCH-31.2 MCHC-33.3 RDW-15.8* Plt ___ ___ 08:00AM BLOOD ___ PTT-33.8 ___ ___ 06:06AM BLOOD Plt ___ ___ 06:06AM BLOOD Glucose-55* UreaN-43* Creat-6.1* Na-139 K-4.5 Cl-100 HCO3-28 AnGap-16 ___ 06:06AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.4 MICRO ___ 1:37 pm BLOOD CULTURE Blood Culture, Routine (Pending): STUDIES CHEST (PA & LAT) Study Date of ___ FINDINGS: AP upright and lateral views of the chest provided. Midline sternotomy wires and prosthetic cardiac valve are again noted. There is a left subclavian dialysis catheter with its tip in the low SVC in the region of the cavoatrial junction. Patient is rotated to the right limiting assessment. There is mild pulmonary edema noted with hilar engorgement. No large effusion is seen. Please note lateral view limited due to motion artifact. No large pneumothorax. The imaged osseous structures appear grossly intact. IMPRESSION: Mild pulmonary edema. No definite signs of pneumonia though post diuresis chest radiograph may be obtained to further assess. UNILAT LOWER EXT VEINS RIGHT Study Date of ___ No evidence of deep venous thrombosis in the right lower extremity veins. AV FISTULOGRAM ___: RUE venogram with severe stenosis of the SVC. Treated with plasty of SVC with 12 mm balloon, post PTA venogram showed improved flow. VENOUS DUP EXT UNI (MAP/DVT) LEFT Study Date of ___ FINDINGS: The left subclavian vein shows normal respiratory variation. LEFT: The left cephalic vein is not visualized secondary to history of harvest. The left basilic vein is partially thrombosed. The radial artery measures 0.21 cm. The brachial artery is duplicated with vessels measuring 0.37 cm and 0.16 cm. There are significant calcifications within the left radial artery. Mild calcifications are seen in the duplicated brachial arteries. IMPRESSION: 1. Partial thrombosis of the left basilic vein. 2. Prior harvest of the left cephalic vein. 3. Patent radial and duplicated brachial arteries. Brief Hospital Course: Mr. ___ is a ___ with history of ESRD on HD, DM1, CAD s/p CABG and AVR, PAD, and CVA with right-sided weakness who presented with fever, cough, and shortness of breath, likely ___ URI and volume overload given his ESRD, respectively. He was also noted to have persistent RUE swelling, and in the ___ suite, severe stenosis of the SVC, treated with angioplasty and balloon dilation. He was also noted to have new RLE swelling, and an ultrasound was obtained that showed no DVT. He underwent LUE vein mapping as well. Active issues: #Viral URI: Patient presenting with fever and nonproductive cough, without leukocytosis or radiographic evidence of pneumonia. Flu negative. Viral URI likely, especially given reported sick contact, his roommate, at rehab. Has been afebrile here. In the emergency department, he was treated with vancomycin/cefepime x1 for suspected HCAP, but this was not continued. His cough was treated with Dextromethorphan-Guaifenesin (Sugar Free); Benzonatate 100 mg PO TID. By the time of discharge, he had never been febrile and his cough seemed improved, though not completely resolved. #Hypoxia: Patient reporting 2L oxygen requirement over the past month, and shows signs of volume overload on physical exam and on imaging. Now on room air s/p HD. #RUE edema: During his ___ admission, he had no evidence of DVT on imaging, no SVC based on CTA and vascular surgery consult. Pt underwent venoplasty of the right subclavian and brachiocephalic veins on ___ with subsequent reduced swelling and pain on RUE. On discharge, he still had RUE swelling, and was planned to be managed with HD and repeat angioplasty. On ___ he underwent RUE venogram notable for severe stenosis of the SVC. Treated with plasty of SVC with 12 mm balloon, post PTA venogram showed improved flow. Interventional radiology consultants scheduled a repeat venogram to assess for restenosis. ACE wraps and compression were recommended on discharge. #RLE edema: Likely ___ volume overload given RUE as well and ESRD; INR 2 on admission. However, patient was still at risk for DVT given immobility, so was evaluated with ___ which was negative. #ESRD/HD: TTS schedule, etiology is T1DM. He was treated with HD in the hospital, most recently on ___, and since he missed his outpatient appointment for LUE vein mapping, it was obtained during this hospitalization. #ANEMIA: Hgb at recent baseline. He received epo at HD. #HTN/VASCULAR: Mild hypertension in the setting of volume overload, treated with HD. #T1DM: Complicated by since age ___ c/b retinopathy, neuropathy, nephropathy. Home lantus, ISS were continued, as were gabapentin and tylenol for neuropathy. #Hx of AVR for bicuspid aortic valve: It was unclear from conflicting records whether his valve is bioprosthetic or mechanical; recent records made reference to a goal INR range of ___, and INR was 2 on admission. Repeat INR was 1.8, likely due to missing a dose on the day of initial presentation to the hospital, and due to poor access, his INR was also drawn later than usual. On ___, he was given an extra one time dose of 1mg warfarin, in addition to his usual dose of 5mg, since his INR was again 1.8. On the day of discharge, INR was 2.1. He was discharged on home warfarin 5 mg daily, and his facility was instructed to continue warfarin 5 mg daily and recheck INR on ___. Chronic issues: #History of L heel pressure ulcer- During his ___ admission, he was evaluated by podiatry twice, who recommended no surgical intervention. He received bactrim/augmentin for diabetic foot ulcer empirical therapy x 7 days. (___). During this admission, he received daily dressing changes with santyl. #PVD: S/p multiple bypass interventions in the setting of severe peripheral vascular disease. Home medications were continued: Atorvastatin 80mg daily, ASA 81mg daily, Cilostazol 100mg BID #Hx of delirium: During prior admission. Not an active issue during this hospitalization. Sedating medications were avoided. #CAD s/p CABG: Home medications were continued: Metoprolol succinate 200mg daily, Lisinopril 20mg daily, ASA 81mg daily #S/p CVA: With residual right sided weakness, worse in setting of acute RUE edema. Patient not participatory with full neuro exam, however, he reported that the weakness in his right arm is chronic. Managment of HTN, CAD, DM as above. #Hx of GERD and possible gastroparesis: Continued home medications Transitional issues: -INR should be checked on ___ for a target INR ___ -Interventional radiology perform a repeat venogram, scheduled for ___ (see appointments, for details) -Compression dressing should be applied to edematous RUE Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. BuPROPion 100 mg PO BID 6. cilostazol 100 mg oral BID 7. Divalproex (EXTended Release) 500 mg PO QHS 8. Docusate Sodium 100 mg PO DAILY 9. Doxazosin 1 mg PO HS 10. Gabapentin 200 mg PO QHS 11. Lisinopril 20 mg PO DAILY 12. Metoclopramide 5 mg PO TID 13. Metoprolol Succinate XL 200 mg PO DAILY 14. Nephrocaps 1 CAP PO DAILY 15. Omeprazole 20 mg PO DAILY 16. Ondansetron 4 mg PO Q8H:PRN nausea 17. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) Th 18. Warfarin 5 mg PO DAILY16 19. Collagenase Ointment 1 Appl TP DAILY 20. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100 mcg/mL injection 1X/WEEK 21. Bisacodyl 5 mg PO DAILY 22. Glargine 10 Units Breakfast Glargine 10 Units Dinner Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 23. Calcium Acetate 667 mg PO TID W/MEALS 24. Calcium Carbonate 1000 mg PO TID 25. Lidocaine 5% Patch 1 PTCH TD Frequency is Unknown 26. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 27. FoLIC Acid 1 mg PO DAILY 28. Mirtazapine 15 mg PO QHS 29. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q4H:PRN cough Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. Bisacodyl 5 mg PO DAILY 6. BuPROPion 100 mg PO BID 7. Calcium Acetate 667 mg PO TID W/MEALS 8. Calcium Carbonate 1000 mg PO TID 9. cilostazol 100 mg oral BID 10. Collagenase Ointment 1 Appl TP DAILY 11. Dextromethorphan-Guaifenesin (Sugar Free) 5 mL PO Q4H:PRN cough 12. Divalproex (EXTended Release) 500 mg PO QHS 13. Docusate Sodium 100 mg PO DAILY 14. Doxazosin 1 mg PO HS 15. FoLIC Acid 1 mg PO DAILY 16. Gabapentin 200 mg PO QHS 17. Glargine 10 Units Breakfast Glargine 10 Units Dinner Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner Insulin SC Sliding Scale using HUM Insulin 18. Lidocaine 5% Patch 1 PTCH TD QAM 19. Lisinopril 20 mg PO DAILY 20. Metoclopramide 5 mg PO TID 21. Nephrocaps 1 CAP PO DAILY 22. Omeprazole 20 mg PO DAILY 23. Ondansetron 4 mg PO Q8H:PRN nausea 24. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) Th 25. Warfarin 5 mg PO DAILY16 26. Benzonatate 100 mg PO TID RX benzonatate 100 mg 1 capsule(s) by mouth three times a day Disp #30 Capsule Refills:*0 27. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100 mcg/mL injection 1X/WEEK 28. Metoprolol Succinate XL 200 mg PO DAILY 29. Mirtazapine 15 mg PO QHS 30. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnoses: Severe stenosis of the SVC, treated with angioplasty and balloon dilation End stage renal disease on hemodialysis Viral upper respiratory infection Secondary diagnoses: Type 1 diabetes Coronary artery disease s/p AVR and CABG Peripheral artery disease Cerebrovascular accident (CVA) with right-sided weakness Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. ___, It was a pleasure taking care of you at ___. You were admitted with fever, cough, and right arm swelling. We think your fever and cough were from a viral infection that will get better, and we treated you with cough medicine. You did not have a fever in the hospital and we did not think you have pneumonia. The interventional radiologists dilated a blood vessel to improve your right arm swelling, and want to check again in a few weeks to make sure the vessel does not get narrow again (see scheduled appointments). This may have contributed to your right arm swelling, but so can kidney disease, so the renal dialysis team helped you with dialysis and removing extra fluid. You also had a vein mapping study of your left arm. When you return to rehabilitation, please continue to take your medications as prescribed and follow up with your doctors. ___ wishes, Your ___ Team Followup Instructions: ___
10123949-DS-47	10,123,949	23,761,871	DS	47	2183-10-07 00:00:00	2183-10-09 21:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Levaquin / Protonix / Flagyl Attending: ___. Chief Complaint: fever, lethargy Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMHx ESRD on HD ___, currently with L tunnelled subclavian line), T1DM, CAD s/p AVR and CABG, PAD, CVA with R-sided weakness, prior SVC and R bracheocephalic vein stenosis, and celiac disease who presents from his nursing facility for fever and lethargy. He has had fevers to 102 since yesterday following dialysis. His normal HD schedule is ___ as noted above; however, he was felt to still be volume overloaded following his ___ session. He had a short session on ___. In the ED, initial VS 98.1 74 136/71 16 99% on RA. His initial FSBG was 47 while enroute to the hospital for which he received juice. Exam was notable for chronic and well-appearing ulcer of her R heel and R shin. A RIJ was placed for access and his L tunneled HD line was removed and the tip sent for culture. Labs were notable for K 6.2 which improved to 4.6 following HD in the ED; he also received 2 doses of kayexalate. Lact wnl. WBC 12.3 (67.4% neuts), H/H 9.4/29.8, Plt 139. LFTs showed ALT 55, AST 44, AP 203, Tbili wnl. CXR showed no evidence of PNA. He received vancomycin x 1 during HD and zosyn x 1 in the ED. Prior to transfer, he had a FSBG to 64 which improved to 118 with glucose gel. Vitals prior to transfer 97.7, 79 149/79 18 98% RA. Upon arrival to the floor, pt feels exhausted though denies any specific pain. He does not presently feel febrile. No cough, SOB, abdominal pain, diarrhea/constipation. Feels that his HD line site is not tender or painful. Past Medical History: PAST MEDICAL HISTORY: - recent embolic stroke (___) with persistent right sided weakness - ESRD-now on HD, previously on PD - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ - HLD - depression - celiac disease - recurrent pleural effusion since CABG - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - CAD-s/p stenting in ___, CABG at ___ in ___ PAST SURGICAL HISTORY: - ___ CABG with prosthetic AVR for bicuspid aortic valve - ___ LHC with DES to left circumflex - R distal SFA angioplasty (___) - R heel debridement (___) - placement/replacement of PD catheter (___) - partial excision R AV graft ___ - tunneled R IJ HD catheter ___ - RUE AV graft ___ - R distal SFA angioplasty ___ - arthroplasty R ___ PIP joint, debridement of R ___ toe ___ - R CFA to AT artery BPG with NRSVG ___ - R SFA angioplasty ___ - L TMA ___ (c/b infection, s/p debridement and closure) - L SFA to peroneal BPG procedures for PVD ___ - R knee surgery Social History: ___ Family History: Father with CAD, CABG. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 98 157/86 81 18 95/RA General: Sleepy limited to engage but in no acute distress HEENT: Sclera anicteric, EOMI, PERRL Neck: Supple, RIJ in place CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: No ___ edema but clean based ulcers on R shin and heel Neuro: CNII-XII grossly intact, moving extremities DISCHARGE PHYSICAL EXAM Vitals: 96.6\| Tm 100.2\| 70-90\| 102-159/80-100\| 18\| 99% on RA General: AO x 3, in NAD, uncomfortable on bed HEENT: EOMI, MM CV: RRR, no murmurs rubs or gallops Lungs: CTAB anteriorly Abdomen: soft, non-distended, non-tender Ext: non-edematous, non-erythematous Neuro: CN ___ intact, weakness of right UE and ___. Strength ___ left UE and left ___. Strength ___ right UE and left ___. Sensation intact to soft touch in bilateral UE and ___. Skin: left upper chest with dialysis port. Left heel with ulceration approximately 3 cm x 4 cm. Right shin with ulceration (bandaged) Pertinent Results: ON ADMISSION ___ 12:00PM BLOOD WBC-12.3# RBC-3.00 Hgb-9.4* Hct-29.8* MCV-99* MCH-31.3 MCHC-31.5* RDW-15.7* RDWSD-56.7* Plt ___ ___ 12:00PM BLOOD Plt ___ ___ 12:00PM BLOOD Glucose-55* UreaN-56* Creat-7.5# Na-137 K-6.2 Cl-99 HCO3-21* AnGap-23* ___ 12:00PM BLOOD ALT-55* AST-44* AlkPhos-203* TotBili-0.1 ___ 12:00PM BLOOD Albumin-3.8 ___ 12:33PM BLOOD Lactate-1.0 ON DISCHARGE ___ 05:48AM BLOOD WBC-5.8 RBC-2.92* Hgb-9.1* Hct-28.7* MCV-98 MCH-31.2 MCHC-31.7* RDW-15.2 RDWSD-54.9* Plt ___ ___ 05:48AM BLOOD Plt ___ ___ 05:48AM BLOOD ___ PTT-47.4* ___ ___ 05:48AM BLOOD Glucose-210* UreaN-40* Creat-4.2# Na-136 K-4.3 Cl-97 HCO3-26 AnGap-17 ___ 05:48AM BLOOD Albumin-3.7 Calcium-8.4 Phos-4.8 Mg-2.4 MICROBIOLOGY Blood cx x 4: pending C. diff: negative IMAGING: [___] CXR New right internal jugular central venous line terminates at the cavoatrial junction. Low lung volumes, with continued mild interstitial pulmonary edema. No new focal consolidation or pneumothorax. Brief Hospital Course: BRIEF HOSPITAL COURSE: ___ PMHx ESRD on HD (L tunnelled subclavian line), T1DM, CAD s/p AVR and CABG, PAD, CVA with R-sided weakness, prior SVC and R brachiocephalic vein stenosis, and celiac disease presenting with fever/lethargy. ACUTE ISSUES: # Fever: DDX includes possible catheter-related blood stream infection vs chronic skin ulcerations on lower extremities vs colitis/proctitis . No other obvious sources of infection. Neither HD site nor skin ulcerations appear infected. CXR negative. Tm of 100.2 on ___, afebrile throughout remainder of admission. New onset diarrhea and rectal pain on ___ C. diff negative, rectal exam w/o abnormalities. WBC downtrending from admission of 12.3 to 5.8 on discharge. Treated empirically with ceftazidime and vancomycin x 2 days, discontinued after 48 hrs afebrile. . #Rectal pain: presented on ___ (day 2 of admission), described as a pain within the rectum with tenesmus-like sensation. Occurred following multiple diarrheal bowel movements overnight. Self-resolved in ___ of ___. Rectal exam w/o abnormality, rectal tone present and no fistula tracts or other abnormalities found. Low threshold for CT abdomen/pelvis w/ contrast if recurrence of pain. . CHRONIC ISSUES: # ESRD on HD ___ T1DM: Dialyzed on ___ and ___ . # Hypoglycemia: T1DM on insulin. Placed on home insulin of 12 of Lantus at bedtime. . # ESRD on HD ___ T1DM: Dry weight per OMR ~ 81 kg. Hyperkalemic to 5.9 on ___. Continued HD schedule of 3x/week on ___ . # H/o AVR for bicuspid aortic valve Mechanical valve. On 6mg warfarin, monitored elsewhere. ___ ___ (___ home records) receives 6mg of warfarin. Last INR of 2.63 on ___. INR today of 2.0. Daily INR, goal ___ per Chest recommendations for mAVR . # HTN: Continue home BP meds . # PVD: Leading to ulceration on R leg. Continue home meds including Cilostazol . # Pressure ulcers: Does not appear infected at this time. Continue wound care . # .CAD s/p CABG Continue home metop . # s/p CVA : Continue ASA . # Anemia : Chronic, longstanding, at baseline. On Aranesp . # GERD : Continue home omeprazole . TRANSITIONAL ISSUES - Please provide wound care for area of skin breakdown on lower back - Please follow up with your primary care physician # CODE STATUS: Full Code # CONTACT: WIFE ___: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. BuPROPion 100 mg PO BID 6. Calcium Carbonate 1000 mg PO TID:PRN acid reflux 7. Cilostazol 100 mg PO BID 8. Collagenase Ointment 1 Appl TP DAILY 9. Divalproex (EXTended Release) 500 mg PO DAILY 10. Doxazosin 1 mg PO HS 11. FoLIC Acid 1 mg PO DAILY 12. Gabapentin 200 mg PO QHS 13. Lisinopril 20 mg PO DAILY 14. Metoclopramide 5 mg PO TID 15. Metoprolol Succinate XL 200 mg PO DAILY 16. Mirtazapine 30 mg PO QHS 17. Nephrocaps 1 CAP PO DAILY 18. Omeprazole 20 mg PO DAILY 19. Ondansetron 4 mg PO Q8H:PRN nausea 20. sevelamer CARBONATE 1600 mg PO TID W/MEALS 21. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100 mcg/mL injection 1X/WEEK 22. Bisacodyl 5 mg PO DAILY 23. Docusate Sodium 100 mg PO DAILY 24. Lidocaine 5% Patch 1 PTCH TD QAM 25. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 26. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) 27. Glargine 10 Units Breakfast Glargine 10 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner Insulin SC Sliding Scale using HUM Insulin 28. Warfarin 6 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. BuPROPion 100 mg PO BID 6. Calcium Carbonate 1000 mg PO TID:PRN acid reflux 7. Cilostazol 100 mg PO BID 8. Collagenase Ointment 1 Appl TP DAILY 9. Divalproex (EXTended Release) 500 mg PO DAILY 10. Doxazosin 1 mg PO HS 11. FoLIC Acid 1 mg PO DAILY 12. Gabapentin 200 mg PO QHS 13. Glargine 12 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 14. Lidocaine 5% Patch 1 PTCH TD QAM 15. Lisinopril 20 mg PO DAILY 16. Metoclopramide 5 mg PO TID 17. Mirtazapine 30 mg PO QHS 18. Nephrocaps 1 CAP PO DAILY 19. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 20. Omeprazole 20 mg PO DAILY 21. Ondansetron 4 mg PO Q8H:PRN nausea 22. sevelamer CARBONATE 1600 mg PO TID W/MEALS 23. Warfarin 6 mg PO DAILY16 24. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 100 mcg/mL injection 1X/WEEK 25. Bisacodyl 5 mg PO DAILY 26. Docusate Sodium 100 mg PO DAILY 27. Metoprolol Succinate XL 200 mg PO DAILY 28. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary - Fever - Pressure ulcer, stage 1 Secondary Diagnosis: - End stage renal disease requiring hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you. You were transferred to the hospital for fevers and lethargy. We were concerned about possible infection and completed a thorough workup that included laboratory tests and a chest x-ray. Fortunately, all of these were normal and you continued to improve clinically. As such, we felt comfortable discharging you home. Thank you for allowing us to care for you! Your ___ Care Team Followup Instructions: ___
10123949-DS-49	10,123,949	20,015,523	DS	49	2184-02-11 00:00:00	2184-02-12 16:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Levaquin / Protonix / Flagyl Attending: ___. Chief Complaint: Worsening foot pain Major Surgical or Invasive Procedure: Angioplasty (___): 1. Ultrasound-guided access to the left common femoral artery and placement of a ___ sheath. 2. Selective catheterization of the right SFA ___ order vessel. 3. Abdominal aortogram. 4. Right lower extremity angiogram. 5. Treatment of right AT occlusion with a 3 mm balloon. Foot Debridement (___): 1. Debridement of ulceration down to and including bone of the ___ metatarsal, right foot. History of Present Illness: ___ PMHx for CAD, significant PVD s/p multiple interventions, ESRD on HD, with stable bilateral foot ulcers who presents to the ED with several days of increasing right foot pain. Patient has a history of significant bilateral lower extremity vascular disease that resulted in a left sided TMA, L SFA to peroneal BPG procedures for PVD ___, and right R CFA to AT artery BPG with NRSVG ___. Patient has seen Dr. ___ in clinic and have stable bilateral foot ulcers managed by the wound care at his rehab facility. The patient states that he has been experiencing worsening pain for the past ___ days with reddish-yellowish drainage. He also had a fever to 101 on ___. Patient presented to BI ED ___ for increasing swelling, redness and drainage from eschar on the lateral aspect of right foot. Foot xray was concerning for osteomyelitis of ___ phalanx. Podiatry was consulted and recommended admission for IV antibiotics. Patient has poor access and the ED attempted peripheral access and EJ with no success. Patient refused CVL and admission during that visit. The patient left AMA with PO clindamycin with plans to coordinate IV antibiotics during dialysis. Patient instructed to return earlier if foot worsened or fever at home. Today patient had 100 fever at home. The patient's nurse called his vascular surgeon, Dr. ___ advised he present to BI for admission and IV abx. He then represented today and agreed to admission. In the ED, initial vitals were: 97.5 72 135/80 18 100% RA - Labs were significant for K of 5.8, sodium 129, lactate of 0.9, H/H at baseline. INR in the ED was 9.8 on ___, not rechecked today. - Given poor access a central line was placed; CXR confirmed placement. - The patient was given: 1mg PO lorazepam, 1g IV vancomycin, and 1g IV cefepime. Upon arrival to the floor, the patient is feeling about baseline. Reports chronic cough, non-productive. Pain at right leg controlled. No significant complaints. REVIEW OF SYSTEMS: (+) Per HPI (-) Otherwise negative. Past Medical History: PAST MEDICAL HISTORY: - Osteomyelitis - recent embolic stroke (___) with persistent right sided weakness - ESRD-now on HD ___, has tunneled HD catheter - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ - HLD - depression - celiac disease - recurrent pleural effusion since CABG - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - CAD-s/p stenting in ___, CABG at ___ in ___ PAST SURGICAL HISTORY: - ___ Rt small toe debridement - ___ R Pop Artery/AT angioplasty - ___ CABG with mechanical AVR for bicuspid aortic valve - ___ LHC with DES to left circumflex - R distal SFA angioplasty (___) - R heel debridement (___) - placement/replacement of PD catheter (___) - partial excision R AV graft ___ - tunneled R IJ HD catheter ___ - RUE AV graft ___ - R distal SFA angioplasty ___ - arthroplasty R ___ PIP joint, debridement of R ___ toe ___ - R CFA to AT artery BPG with NRSVG ___ - R SFA angioplasty ___ - L TMA ___ (c/b infection, s/p debridement and closure) - L SFA to peroneal BPG procedures for PVD ___ - R knee surgery Social History: ___ Family History: Father with CAD, CABG. Physical Exam: ADMISSION EXAM: =============== Vitals: 97.8 158/85 70 20 99% RA FSG 353 General: Alert, oriented, no acute distress HEENT: PERRL, MMM. Neck: Has Right IJ line in place. Has left sided tunneled central HD line on chest. CV: Regular rate and rhythm, mechanical S2, no m/r/g Lungs: bibasilar crackles Abdomen: Soft, non-tender, non-distended GU: No foley Ext: No edema. No sensation below ankles b/l. On left has TMA. On right has ulceration at heel, superficial. Has right ___ toe ulcer, black eschar over, with purulent drainage underneath. Neuro: Limited mobility of right arm and leg DISCHARGE EXAM: =============== Vitals: Tm:98.9 BP:142/79 (125-142/66-79) ___ R:18 O2:96% RA General: NAD HEENT: Sclera anicteric, MMM Lungs: Clear to auscultation anteriorly, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops. Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Dressing over Rt foot w/ace bandage covering erythematous wound from debrided area or Rt lateral foot, mild tenderness w/movement Neuro: Limited mobility of right arm and leg Pertinent Results: ADMISSION LABS: =============== ___ 06:10PM BLOOD WBC-9.2 RBC-3.41* Hgb-11.1* Hct-34.4* MCV-101* MCH-32.6* MCHC-32.3 RDW-15.1 RDWSD-55.3* Plt ___ ___ 06:10PM BLOOD Neuts-61.9 ___ Monos-7.6 Eos-4.1 Baso-0.4 Im ___ AbsNeut-5.68# AbsLymp-2.38 AbsMono-0.70 AbsEos-0.38 AbsBaso-0.04 ___ 06:10PM BLOOD ___ PTT-63.9* ___ ___ 06:10PM BLOOD Glucose-252* UreaN-28* Creat-5.0# Na-128 K-4.7 Cl-90* HCO3-25 AnGap-18 ___ 07:55PM BLOOD CRP-33.6* ___ 06:24PM BLOOD Lactate-1.4 IMAGING: ======== SURGICAL PATH (___): 1) Bone, right fifth toe base proximal phalanx, excision:1. Bone with reparative changes, and intramedullary fibrosis and granulation tissue with acute and chronic inflammation. 2. Cartilage with degenerative changes. 2) Bone, right fifth toe proximal margin, excision: Bone with reparative changes and focal intramedullary fibrosis and granulation tissue with some acute and mostly chronic inflammation. FOOT 2 VIEWS RIGHT Study Date of ___ Cortical indistinctness involving the lateral aspect of the base of the proximal phalanx of the fifth toe is concerning for osteomyelitis. CHEST (PORTABLE AP) Study Date of ___ Right IJ central venous catheter positioned appropriately. ART DUP EXT LOW/BILAT COMP Study Date of ___ 1. The right 1 femoral to anterior tibial artery bypass graft is not visualized and suspected to be occluded. The right the vessels are significantly calcified with flow velocities throughout and an occluded posterior tibial artery below the knee. 2. The left SFA to peroneal bypass graft is not seen and suspected occluded. This was on this side are also diffusely calcified with continuous flow and at least 2 vessel runoff but generally slow velocities. ART EXT (REST ONLY) Study Date of ___ 1. Moderate bilateral aortoiliac disease 2. Associated bilateral tibial disease. ___ DUP EXTEXT BIL (MAP/DVT) Study Date of ___ The saphenous veins could not be identified bilaterally which may be related to prior surgery or intervention. VENOUS DUP UPPER EXT BILATERAL Study Date of ___ Patent basilic and cephalic veins in the right and patent basilic vein in the left. The cephalic vein was not seen at the level of the left arm. For detailed measurements please refer to sonographer report in PACs. TTE (___): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. Right ventricular chamber size is normal The diameters of aorta at the sinus, ascending and arch levels are normal. A bileaflet aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of ___, no clear focal wall motion is seen. ART EXT (REST ONLY) Study Date of ___ Mulitlevel, moderately severe PVD. The right forefoot perfusion is significantly improved compared to the prior study. FOOT 2 VIEWS RIGHT Study Date of ___ Status post resection of the fifth metatarsal head and fifth proximal phalangeal base with adjacent wound VAC device in place. The bones are diffusely osteopenic. There is no acute fracture or dislocation. Postsurgical changes again noted at the PIP joint of the second ray. Vascular calcification noted. MICROBIOLOGY: ============ Blood Cultures (___): Negative Wound Culture (___): FOOT CULTURE Source: right lateral foot ulcer. *FINAL REPORT ___ WOUND CULTURE (Final ___: ___. SPARSE GROWTH. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. STAPH AUREUS COAG +. RARE 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 + \| \| CEFEPIME-------------- <=1 S CEFTAZIDIME----------- 16 R CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S CLINDAMYCIN----------- <=0.25 S ERYTHROMYCIN---------- <=0.25 S GENTAMICIN------------ <=1 S <=0.5 S LEVOFLOXACIN---------- <=0.12 S MEROPENEM-------------<=0.25 S OXACILLIN------------- 0.5 S PIPERACILLIN/TAZO----- <=4 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=0.5 S DISCHARGE LABS: =============== ___ 05:30AM BLOOD WBC-7.4 RBC-2.87 Hgb-9.4* Hct-29.4* MCV-102* MCH-32.8* MCHC-32.0 RDW-16.3* RDWSD-60.5* Plt ___ ___ 05:30AM BLOOD ___ PTT-38.6* ___ ___ 05:30AM BLOOD Glucose-271* UreaN-41* Creat-6.5# Na-139 K-4.7 Cl-98 HCO3-26 AnGap-20 Brief Hospital Course: Mr. ___ is a ___ w/PMHx of CAD s/p CABG, mechanical aortic valve on coumadin, significant PVD s/p multiple interventions, ESRD on HD, stable bilateral foot ulcers who presented to the ED with several days of increasing right foot pain and purulent drainage concerning for osteomyelitis, was started on broad spectrum Abx, vascular studies showed poor circulation, vascular surgery performed angioplasty ___ and developed post procedure CP that day, which resolved with stable CKMB and no focal wall abnormalities seen on TTE. With circulation reestablished, podiatry debrided the osteomyelitis site, had wound vac placed. Will f/u w/ID as outpatient for f/u Abx course. ACTIVE ISSUES: ============== # Osteomyelitis: Patient presented with increased right foot pain, erythema, edema and drainage from the eschar on the lateral aspect of his right foot. Appeared grossly infected with purulent drainage. Foot xrays were concerning for osteomyelitis. Pt was started on Vanc/Cefepime, later switched to Vanc/Ceftaz. Vascular Surgery was consulted, requested further imaging to evaluate blood flow to the area. Arterial vascular studies showed poor perfusion. Had Rt AT and popliteal artery angioplasty on ___ and was started on Plavix in addition to his ASA, developed some chest pain after the procedure per below. Pt's wound Cx from the site grew morganella, ___ to cipro, resistant to Ceftaz, and sparse MSSA and Diptheroids, pt's Ceftaz switched to PO Cipro. Repeat ABI showed improved circulation. With improved blood flow, Podiatry took pt for debridement on ___, sent samples to path/micro, thought had clear margins, put pt on a wound vac. Pt was continued on heparin gtt throughout admission and then restarted on coumadin before DC. ID was consulted for Abx recs, recommended 6 wk course of Abx, which may be truncated pending OR path at OPAT f/u. RESOLVED ======== # Chest pain: Pt developed chest pain, pleuritic in nature, after his surgery. PE was unlikely as pt was therapeutic on heparin gtt, throughout his admission. Cardiac CP was also high on ddx given his many risk factors. Troponins were found to be mildly elevated from his baseline and peaked at 1.94 the next day, CKMB was wnl and peaked at 9, Cardiology was consulted, did not think cp was cardiac etiology, EKGs were grossly unchanged, trops thought to be due to stress/infection, TTE was wnl and didn't show wall motion abnormalities. GERD was also high on ddx given epigastric pain as well. Patient was already on ASA, Plavix, beta blockade, Omeprazole. Pt received 3x doses Nitro SL on ___ day of chest pain. # Fevers: Pt presented with fevers on admission at Rehab and in ED, were most likely ___ to foot infection/osteomyelitis. ROS negative for other infxn etiology, CXR w/o PNA. Had a chronic HD line in place that could also serve as a nidus of infection, but it didn't appear to be infected. Pt was afebrile since admission. Was on Abx for osteomyelitis per above. # Hyperkalemia: Patient presented with a K of 5.8 in the ED, was likely due to CKD, now resolved. EKG showed no acute changes, hyperkalemia resolved with initial HD session, got scheduled ___ HD. # Elevated INR: Patient was with an elevated INR in the ED on his initial visit from ___, though when he represented it was now <2. Pt had significant bleeding with CVL placement in the ED. He remained HD with blood counts at baseline during this hospitalization. CHRONIC ======= # DM1: was started on home glargine 16u qhs and SSI, glargine was increased to 20u toward end of admission ___ elevated FSGs. # Mechanical aortic valve: Last TTE showed good heart function, as did TTE on this admission. Was on warfarin for anticoagulation, good INR at last DC, goal INR ___, was placed on heparin gtt ___ to surgeries over his admission, was restarted on coumadin and DC'd heparin on ___ when INR was 2.1, pt was DC'd w/INR between ___. # ESRD on HD ___: Continued nephrocaps, sevelamer # HTN: continued home lisinopril, metoprolol, amlodipine # CAD/PVD: continued aspirin, statin, cilostazol, warfarin. Pt was started on Plavix this admission s/p angio per Vascular Surg # HLD: continued atorvastatin # Depression: Continued bupropion, divalproex # GERD: continued omeprazole # Celiac disease: continued gluten free diet TRANSITIONAL ISSUES* -Pt was started on Plavix (___) s/p angio per vascular surgery -Pt was started on Vancomycin w/HD and PO Cipro to continue until ___ depending on culture/pathology results per ID -Pt connected with OPAT for weekly labs while on Antibiotics -Pt was placed on heparin gtt during his admission for AC ___nd Coumadin was held for his Vascular/Podiatry procedures, was discharged with INR goal ___ -Pt was started on Oxycodone for pain related to osteomyelitis -Pt developed chest pain after his procedure, had mildly elevated trops from basline that trended down, EKGs and TTE were unconcerning, Cards evaluated, thought may be MSK related pain and increased trops ___ stress/surgery/infxn -On week of DC, pt getting ___ HD instead of ___ due to the holiday schedule -Pt would benefit from possible Psych/SW eval for disease coping and depression # CODE STATUS: Full, confirmed # CONTACT: ___ (wife) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Docusate Sodium 100 mg PO DAILY 5. BuPROPion 100 mg PO BID 6. Cilostazol 100 mg PO BID 7. Divalproex (EXTended Release) 500 mg PO DAILY 8. Doxazosin 1 mg PO HS 9. FoLIC Acid 1 mg PO DAILY 10. Lisinopril 20 mg PO DAILY 11. Metoclopramide 5 mg PO TID 12. Metoprolol Succinate XL 200 mg PO DAILY 13. Mirtazapine 30 mg PO QHS 14. Nephrocaps 1 CAP PO DAILY 15. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 16. Omeprazole 20 mg PO DAILY 17. Ondansetron 4 mg PO Q8H:PRN nausea 18. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) 19. Amlodipine 10 mg PO DAILY 20. sevelamer CARBONATE 2400 mg PO TID W/MEALS 21. Gabapentin 300 mg PO QHS 22. Glargine 16 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 23. Warfarin 6 mg PO DAILY16 Discharge Medications: 1. Acetaminophen 650 mg PO Q4H:PRN pain 2. Amlodipine 10 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 80 mg PO QPM 5. BuPROPion 100 mg PO BID 6. Cilostazol 100 mg PO BID 7. Divalproex (EXTended Release) 500 mg PO DAILY 8. Docusate Sodium 100 mg PO DAILY 9. Doxazosin 1 mg PO HS 10. FoLIC Acid 1 mg PO DAILY 11. Gabapentin 300 mg PO QHS 12. Glargine 16 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 13. Lisinopril 20 mg PO DAILY 14. Metoclopramide 5 mg PO TID 15. Metoprolol Succinate XL 200 mg PO DAILY 16. Mirtazapine 30 mg PO QHS 17. Nephrocaps 1 CAP PO DAILY 18. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 19. Omeprazole 20 mg PO DAILY 20. Ondansetron 4 mg PO Q8H:PRN nausea 21. sevelamer CARBONATE 2400 mg PO TID W/MEALS 22. Vitamin D 50,000 UNIT PO 1X/WEEK (TH) 23. Warfarin 6 mg PO DAILY16 24. Vancomycin 1000 mg IV HD PROTOCOL 25. Clopidogrel 75 mg PO DAILY 26. Ciprofloxacin HCl 500 mg PO Q24H 27. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain RX oxycodone 5 mg 1 tablet(s) by mouth q6h PRN Disp #15 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY: Osteomyelitis Peripheral Vascular Disease ESRD on HD SECONDARY: DM1 HTN CAD/HLD Depression GERD Celiac Dz Discharge Condition: Activity Status: Out of Bed with assistance to chair or wheelchair. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear Mr. ___, You were admitted to ___ for foot pain that was concerning for a skin infection that had penetrated the bone. You were started on IV antibiotics and your fevers stopped. You were seen by our Vascular Surgery team who did an angioplasty surgery to open up the arteries in your legs which did not have good flow when you came in. After the surgery, you had some chest pain that was concerning for a heart attack, though our cardiologists didn't think you had one. Our Podiatry surgeons saw you and removed some of the infected part of your Right foot/toe and placed a wound drain on your foot after your vascular surgery. Our Infectious Disease doctors examined ___ and recommended for you to continue the antibiotics that you were on for at least a few more weeks after you go back to rehab and they will decide exactly how long you take them once you follow up with them in clinic. You got regularly scheduled dialysis while you were here. It was a pleasure taking care of you! We hope the PATS win on ___! Your ___ Team Followup Instructions: ___
10123949-DS-56	10,123,949	20,875,376	DS	56	2185-11-18 00:00:00	2185-11-19 14:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Flagyl / Levaquin / Protonix / gluten Attending: ___. Chief Complaint: Chest pain found to be in DKA Major Surgical or Invasive Procedure: None History of Present Illness: ___ w/ PMH IDDM c/b retinopathy, neuropathy, pressure ulcers, ESRD (anuric) on HD ___, hx L embolic CVA w/ residual R hemiparesis, CABG/AVR (ASA, Coumadin), celiac disease, hx fungal peritonitis associated w/ PD catheters, hx infected dialysis grafts, PVD s/p multiple stents, L toe amputations, as well as recent 20-day admission (d/c ___ for AMS, DKA, right lateral knee ulceration with osteomyelitis in setting of infected hardware s/p debridement and hardware removal, transferred from nursing home for chest pain, found to be in DKA. Since his prior discharge to ___ (___), he had been feeling similar to his baseline until 2 nights prior to admission when he reports having dinner and waking up a few hours later with nausea/vomiting. Since that time he's felt generally unwell with abdominal pain and feeling constipated. The day prior to admission he had dialysis (so did not receive his 10u AM glargine). He returned around noon. He did not eat lunch due to nausea and subsequently had an episode of emesis. He was given Zofran. Around 10pm he developed chest pressure, ___, nonradiating, left-sided. He was reportedly (per facility nursing) offered a pain pill. He feels as though nothing was done. He called the ambulance himself to take him to ___. He reportedly received 324 asa, 1 nitro sl prior to arrival. He is not sure if he's had chest discomfort like this before. He also reports constipation and abdominal bloating; he had a small bowel movement here but it has been very hard. Of note, his wife describes some baseline confusion and is not sure if all of his story is accurate (particularly the n/v over the past 2 nights). Past Medical History: PAST MEDICAL HISTORY: Left preretinal hemorrhage Atrial fibrillation AVR with goal INR 2.5-3.5 IDDM since age ___ c/b retinopathy, neuropathy, nephropathy ESRD- HD T/R/Sa, has tunneled HD catheter CAD-s/p stenting in ___, CABG at ___ in ___ Embolic stroke (___) with persistent right sided weakness, CVA in the right parietal lobe (___) Fungal peritonitis associated with PD ___ History of infected AV graft in right upper ___ fibular head lateral malleolus osteomyelitis treated s/p debridement HLD Depression Celiac disease Recurrent pleural effusion since CABG PAST SURGICAL HISTORY: ___ R ankle ulcer debridement ___ Rt small toe debridement ___ R Pop Artery/AT angioplasty ___ CABG with mechanical AVR for bicuspid aortic valve ___ LHC with DES to left circumflex R distal SFA angioplasty (___) R heel debridement (___) Placement/replacement of PD catheter (___) Partial excision R AV graft ___ tunneled R IJ HD catheter ___ RUE AV graft ___ R distal SFA angioplasty ___ arthroplasty R ___ PIP joint, debridement of R ___ toe ___ R CFA to AT artery BPG with NRSVG ___ R SFA angioplasty ___ L TMA ___ (c/b infection, s/p debridement and closure) L SFA to peroneal BPG procedures for PVD ___ R knee surgery Social History: ___ Family History: Father with CAD, CABG. Physical Exam: ADMISSION EXAM: GENERAL: Tired-appearing, well-nourished, no acute distress. Pallid. HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear NECK: JVP not elevated, no LAD LUNGS: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, mechanical flow murmur radiating to carotids and in all precordial fields. No rubs, gallops. ABD: soft, non-tender, non-distended, bowel sounds hypoactive but present. No rebound tenderness or guarding EXT: Warm, well perfused. No toes on left foot. Otherwise no clubbing, cyanosis. SKIN: Sternotomy keloid present. Left and right access sites dressed, c/d/i, NEURO: Left facial droop and fixed left pupil (reports no vision). Moving all limbs against gravity. DISCHARGE EXAM: VITALS: 98.2 PO 175 / 90 71 18 99 Ra GENERAL: Alert, oriented, no acute distress HEENT: MMM, EOMI, PERRL, neck supple. CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2 w/mechanical click. No murmurs, rubs, gallops. LUNGS: CTAB ABDOMEN: Soft, non-distended, non-tender in all quadrants, no rebound or guarding. Bowel sounds present EXTREMITIES: Warm, well perfused, no edema. Missing all digits on L foot. Knee brace over R knee. NEURO: Strength ___ in LLE, unable to lift R knee against gravity (consistent w/baseline). ACCESS: ACCESS: 1) L-side HD tunneled cath, 2) PICC: R IJ ___ dual lumen (can keep in for ___ year unless he develops complications) Pertinent Results: ADMISSION LABS: ___ 07:25AM ___ PTT-40.5* ___ ___ 07:25AM PLT COUNT-367 ___ 07:25AM NEUTS-69.0 ___ MONOS-5.1 EOS-1.8 BASOS-1.1* IM ___ AbsNeut-6.53# AbsLymp-2.15 AbsMono-0.48 AbsEos-0.17 AbsBaso-0.10 ___ 07:25AM WBC-9.5 RBC-2.80* HGB-8.3* HCT-28.2* MCV-101* MCH-29.6 MCHC-29.4* RDW-14.8 RDWSD-55.2* ___ 07:25AM ALBUMIN-3.9 CALCIUM-8.4 PHOSPHATE-3.7 MAGNESIUM-2.4 ___ 07:25AM CK-MB-8 ___ ___ 07:25AM cTropnT-1.70* ___ 07:25AM ALT(SGPT)-9 AST(SGOT)-14 CK(CPK)-83 ALK PHOS-282* TOT BILI-0.2 ___ 07:25AM estGFR-Using this ___ 07:25AM GLUCOSE-594* UREA N-25* CREAT-4.0* SODIUM-133 POTASSIUM-5.0 CHLORIDE-88* TOTAL CO2-12* ANION GAP-33* ___ 07:31AM LACTATE-1.3 ___ 08:47AM O2 SAT-74 ___ 08:47AM ___ TEMP-37.0 PO2-45* PCO2-32* PH-7.24* TOTAL CO2-14* BASE XS--12 INTUBATED-NOT INTUBA ___ 11:43AM GLUCOSE-517* UREA N-28* CREAT-4.4* SODIUM-136 POTASSIUM-3.8 CHLORIDE-91* TOTAL CO2-13* ANION GAP-32* ___ 12:03PM ___ PO2-39* PCO2-34* PH-7.31* TOTAL CO2-18* BASE XS--8 ___ 01:53PM CK-MB-9 cTropnT-2.17* ___ 01:53PM GLUCOSE-376* UREA N-29* CREAT-4.5* SODIUM-139 POTASSIUM-3.7 CHLORIDE-95* TOTAL CO2-19* ANION GAP-25* ___ 02:05PM ___ PO2-39* PCO2-42 PH-7.34* TOTAL CO2-24 BASE XS--2 ___ 03:00PM PTT-150* ___ 05:30PM GLUCOSE-126* UREA N-31* CREAT-4.8* SODIUM-142 POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-25 ANION GAP-19* ___ 05:33PM TYPE-MIX PO2-33* PCO2-50* PH-7.37 TOTAL CO2-30 BASE XS-1 ___ 07:30PM GLUCOSE-152* UREA N-30* CREAT-5.0* SODIUM-142 POTASSIUM-4.3 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17* ___ 07:47PM ___ PO2-33* PCO2-51* PH-7.40 TOTAL CO2-33* BASE XS-4 ___ 11:15PM PTT-86.3* ___ 11:15PM GLUCOSE-133* UREA N-12 CREAT-2.2# SODIUM-142 POTASSIUM-3.5 CHLORIDE-101 TOTAL CO2-31 ANION GAP-10 ___ 11:21PM ___ PO2-31 PCO2-54* PH-7.41 TOTAL CO2-35* BASE XS-7 DISCHARGE LABS: ___ 05:01AM BLOOD WBC-5.9 RBC-2.57* Hgb-8.0* Hct-25.1* MCV-98 MCH-31.1 MCHC-31.9* RDW-15.0 RDWSD-52.6* Plt ___ ___ 06:47AM BLOOD ___ PTT-89.4* ___ ___ 12:00PM BLOOD K-4.7 MICROBIOLOGY: ___ Blood cx: No growth IMAGING: ___ CXR: IMPRESSION: No acute cardiopulmonary abnormality. Brief Hospital Course: ___ with h/o IDDM (c/b retinopathy, neuropathy, pressure ulcers), ESRD (anuric, on HD ___, hx L embolic CVA (w/residual R hemiparesis), CABG/AVR (ASA, Coumadin), celiac disease, hx fungal peritonitis associated w/ PD catheters, hx infected dialysis grafts, PVD (s/p multiple stents, L toe amputations), as well as recent 20-day admission (d/c ___ for AMS, DKA, right lateral knee ulceration with osteomyelitis in setting of infected hardware s/p debridement and hardware removal, transferred from nursing home for ___ found to be in DKA. # DKA: # IDDM: Patient initially presented with DKA and was started on insulin gtt in ED. On this admission, unclear trigger for DKA. He is currently on vancomycin and unasyn (___nding ___ for right knee osteomyelitis on last admission. Blood cultures were sent in ED; CXR without obvious consolidation; no UA given anuric. Does have multiple pressure ulcers (ankle, sacrum) as possible sources of infection. Of note, d/t labile blood glucose with lows in ___, he was last discharged on a reduced insulin per ___ it is unclear if he usually gets his AM insulin before dialysis, but this was held. Insulin gtt was administered per DKA protocol, AG closed on ___ and patient was bridged with SC insulin. Blood sugars were labile throughout the admission. His discharge insulin regimen is: Lantus 10U QAM and 6U QPM with an insulin sliding scale. # Subtherapeutic INR # Mechanical AVR: Goal INR 2.5-3.5. During prior hospitalization, INR fluctuated (initially 8.2, requiring vitamin K; then subtherapuetic requiring heparin gtt). Patient was restarted on home warfarin dose of 2mg daily prior to discharge (dc INR = 2.5). Subtherapeutic INR of 2.0 on arrival. Patient was bridged with heparin gtt and warfarin was increased to 3mg PO QD. Heparin was stopped on ___ when INR was 2.5. #CHEST PAIN, concerning for #NSTEMI, Type II in the setting of #Hx CABG: Initial troponin elevation was lower than prior. EKG without ST changes. Elevation likely due to DKA and ESRD. Heparin gtt was continued as above and warfarin was titrated to goal INR 2.5-3.5. # R Lateral Knee Ulceration # Osteomyelitis: Patient is s/p surgical hardware removal (___) and bone biopsy, positive for MRSA, moderate E.coli, sparse Klebsiella, mixed flora. Vancomycin and unasyn were continued with plan for x6 week course (tentative end date ___. Ortho was consulted and there was low suspicion for wound infection or recurrent skin breakdown. # ESRD: HD ___ through left subclavian tunneled HD line. Transplant nephrology was following. Nephrocaps, sevelemir, calcitriol were continued. Patient had partial dialysis session on ___ for hyperkalemia. He should resume full dialysis session as scheduled on ___. # Normocytic anemia: Patient presented with Hb 8.3, which is his baseline. Remained stable with no evidence of active bleeding. Per renal, patient has been receiving Epo and Aranesp 80mg IV weekly as OP. ================= CHRONIC ISSUES ================= # HTN: Home nifedipine and carvedilol were continued # Depression: Home buproprion, duloxetine, and mirtazapine were continued # Bilateral eye itchiness # Vitreous hemorrhage: Continue eyedrops: artificial tear ointment, Ketorolac drops, Naphazoline-Pheniramine drops # Bilateral Achilles Decubitus Ulcers: Present on prior admission. Wound care was consulted for PRN dressing changes # GERD: Continued home famotidine TRANSITIONAL ISSUES: ================================= [] Patient should not be getting fleet enema [] Plan for follow up with Dr. ___ in 1 weeks (appointment scheduled) [] Consider Pharmacologic stress test for CAD [] Vancomycin dosed with HD and Unasyn after HD, end date for ABX ___. [] Would consider removal of PICC line once patient completes antibiotic course [] Received partial dialysis on ___, please complete full dialysis on ___ [] Consider uptitrating on anti-depressant [] Warfarin increased to 3mg daily for INR goal 2.5-3.5. Please monitor INR and titrate warfarin as appropriate. # CONTACT: HCP: ___ (wife) ___ # CODE STATUS: Full (confirmed) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Bisacodyl ___AILY:PRN constipation 5. BuPROPion 100 mg PO BID 6. Calcitriol 0.5 mcg PO DAILY 7. Carvedilol 37.5 mg PO/NG BID 8. Cilostazol 100 mg PO BID 9. Docusate Sodium 100 mg PO DAILY 10. DULoxetine 20 mg PO DAILY 11. Famotidine 20 mg PO DAILY 12. FoLIC Acid 1 mg PO DAILY 13. Gabapentin 100 mg PO DAILY 14. Lidocaine 5% Patch 1 PTCH TD QPM 15. Mirtazapine 30 mg PO QHS 16. Nephrocaps 1 CAP PO QHS 17. NIFEdipine CR 90 mg PO DAILY 18. Senna 8.6 mg PO BID:PRN Constipation 19. sevelamer CARBONATE 2400 mg PO TID W/MEALS 20. Warfarin 2 mg PO DAILY16 21. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 22. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q6H:PRN Eye pain 23. Ampicillin-Sulbactam 3 g IV Q24H 24. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye pain 25. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN itchy eyes 26. Ondansetron 8 mg PO Q8H:PRN nausea 27. TraMADol 50 mg PO BID 28. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 29. Vancomycin 1000 mg IV HD PROTOCOL 30. Ferrous GLUCONATE 324 mg PO DAILY 31. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 32. LORazepam 0.5 mg PO 3X/WEEK (___) 33. Milk of Magnesia 30 mL PO QHS:PRN constipation 34. Phytonadione 2.5 mg PO DAILY:PRN For INR > 7.5 35. Lactulose 30 mL PO DAILY:PRN constipation 36. Glargine 10 Units Breakfast Glargine 5 Units Bedtime Humalog 5 Units Breakfast Humalog 5 Units Lunch Humalog 5 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Warfarin 3 mg PO DAILY16 2. Acetaminophen 1000 mg PO Q8H 3. Ampicillin-Sulbactam 3 g IV Q24H 4. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye pain 5. Artificial Tears Preserv. Free ___ DROP BOTH EYES PRN itchy eyes 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Bisacodyl ___AILY:PRN constipation 9. BuPROPion 100 mg PO BID 10. Calcitriol 0.5 mcg PO DAILY 11. Carvedilol 37.5 mg PO BID 12. Cilostazol 100 mg PO BID 13. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 14. Docusate Sodium 100 mg PO DAILY 15. DULoxetine 20 mg PO DAILY 16. Famotidine 20 mg PO DAILY 17. Ferrous GLUCONATE 324 mg PO DAILY 18. FoLIC Acid 1 mg PO DAILY 19. Gabapentin 100 mg PO DAILY 20. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q6H:PRN Eye pain 21. Lactulose 30 mL PO DAILY:PRN constipation 22. Lidocaine 5% Patch 1 PTCH TD QPM 23. LORazepam 0.5 mg PO 3X/WEEK (___) 24. Milk of Magnesia 30 mL PO QHS:PRN constipation 25. Mirtazapine 30 mg PO QHS 26. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 27. Nephrocaps 1 CAP PO QHS 28. NIFEdipine CR 90 mg PO DAILY 29. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 30. Ondansetron 8 mg PO Q8H:PRN nausea 31. Phytonadione 2.5 mg PO DAILY:PRN For INR > 7.5 32. Senna 8.6 mg PO BID:PRN Constipation 33. sevelamer CARBONATE 2400 mg PO TID W/MEALS 34. TraMADol 50 mg PO BID 35. Vancomycin 1000 mg IV HD PROTOCOL Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: - DKA Secondary Diagnosis: - Osteomyelitis s/p debridement and hardware removal - AVR on warfarin - ESRD on HD - GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, You were hospitalized at ___. Why did you come to the hospital? ================================= - You came to the hospital because you were having chest pain. You were found to be in DKA. What did we do for you? ======================= - You were admitted to the ICU and given IV insulin for your DKA. Once your blood sugars stabilized, you were transferred to the general medicine unit. - We continued your antibiotics for your joint infection - You were given IV heparin because your INR was below 2.5. - We increased your warfarin dose because your INR was too low. What do you need to do? ======================= - It is very important that you continue to manage your blood sugars closely. - It is also important that you continue working with physical therapy to get stronger - You should continue your IV antibiotics for the infection - You should follow-up with Dr. ___ information below.) - You should follow-up with Infectious Disease (appointment information below.) It was a pleasure caring for you. We wish you the best! Sincerely, Your ___ Medicine Team Followup Instructions: ___
10123949-DS-58	10,123,949	25,322,219	DS	58	2186-03-09 00:00:00	2186-03-10 10:11:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Flagyl / Levaquin / Protonix / gluten Attending: ___. Chief Complaint: shortness of breath, DKA Major Surgical or Invasive Procedure: Right sided chest tube placement History of Present Illness: Patient is a ___ yo man w/ ___ IDDM c/b retinopathy, neuropathy, pressure ulcers, ESRD (anuric) on HD ___, hx L embolic CVA w/ residual R hemiparesis, CABG/AVR (ASA, Coumadin), celiac disease, hx fungal peritonitis associated w/ PD catheters, hx infected dialysis grafts, PVD s/p multiple stents, L toe amputations recent 20-day admission (d/c ___ for AMS, DKA, right lateral knee ulceration with osteomyelitis in setting of infected hardware s/p debridement and hardware removal, as well as hospital stay from ___ for DKA and from ___ for nausea/vomiting, subtherapeutic INR and vitreous hemorrhage presents today with SOB and right-sided chest pain . Patient states he was doing relative well at the nursing home. He bumped the right side of his chest while transferring few days ago and states he has experienced difficulty breathing ever since in addition to a cough. He also endorses pain with deep inspiration. Otherwise he denies any CP, abdominal pain, change in BM. Denies any melena or hematochezia. Patient is also on an insulin drip and states he is compliant with his current regimen. Denies any recent change in dosages. Denies any recent illness, fevers or chills. Past Medical History: - Left preretinal hemorrhage - Atrial fibrillation - AVR with goal INR 2.5-3.5 - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - ESRD- HD T/R/Sa, has tunneled HD catheter - CAD-s/p stenting in ___, CABG at ___ in ___ - Embolic stroke (___) with persistent right sided weakness, CVA in the right parietal lobe (___) - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ fibular head lateral malleolus osteomyelitis treated s/p debridement - HLD - Depression - Celiac disease - Recurrent pleural effusion since CABG Social History: ___ Family History: Father with CAD, CABG. Physical Exam: ADMISSION PHYSICAL EXAM: ========================= VITALS: Reviewed in metavision GENERAL: Alert, oriented to place, time and person. HEENT: MMM, EOMI, PERRL, neck supple. CARDIOVASCULAR: Regular rate and rhythm, normal S1, S2 w/mechanical click. No murmurs, rubs, gallops. LUNGS: CTAB. Right sided chest tube in placed draining 500 cc of serosanguineous fluid. No chest wall crepitus. No other evidence of trauma. ABDOMEN: Soft, non-distended, non-tender in all quadrants, no rebound or guarding. Bowel sounds present. Patient tentative on exam but no overt tenderness or pain. EXTREMITIES: Warm, well perfused, no edema. Missing all digits on L foot. Knee brace over R knee. NEURO: Strength ___ in LLE, unable to lift R knee against gravity (consistent w/baseline). ACCESS ?? L-side HD tunneled cath, R double lumen subclavian. Insertion site clean, dry, intact. DISCHARGE PHYSICAL EXAM ======================= Vitals- 24 HR Data (last updated ___ @ 556) Temp: 97.5 (Tm 97.8), BP: 156/86 (110-156/67-89), HR: 57 (57-63), RR: 18 (___), O2 sat: 96% (94-97), O2 delivery: RA, Wt: 185.19 lb/84.0 kg GENERAL: lying in bed HEENT: L eye minimally swollen, R eye with erythema, trouble opening both eyes due to pain CARDIAC: Regular rhythm, normal rate, mechanical heart sounds LUNGS: Breath sounds present bilaterally, auscultated anteriorly. No wheezes, rhonchi or rales. chest tube removal site c/d/I, currently covered ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. Tympanic to percussion. No organomegaly. EXTREMITIES: Clean dressing over right knee. Toe amputations on left foot. No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. SKIN: No evidence of ulcers, rash or lesions suspicious for malignancy NEUROLOGIC: Moving all 4 extremities with purpose, did not participate in exam Pertinent Results: ADMISSION LAB RESULTS ===================== ___ 03:48PM ___ PTT-45.3* ___ ___ 03:48PM PLT COUNT-394# ___ 03:48PM NEUTS-66.0 ___ MONOS-9.5 EOS-2.1 BASOS-0.8 IM ___ AbsNeut-5.44 AbsLymp-1.74 AbsMono-0.78 AbsEos-0.17 AbsBaso-0.07 ___ 03:48PM WBC-8.2# RBC-3.37# HGB-10.0# HCT-32.9# MCV-98 MCH-29.7 MCHC-30.4 RDW-15.9* RDWSD-57.0* ___ 03:48PM ALBUMIN-3.5 CALCIUM-8.3* PHOSPHATE-7.6* MAGNESIUM-2.1 ___ 03:48PM CK-MB-8 cTropnT-2.08* ___ 03:48PM ALT(SGPT)-10 AST(SGOT)-11 CK(CPK)-56 ALK PHOS-292* TOT BILI-0.3 ___ 03:48PM GLUCOSE-317* UREA N-33* CREAT-5.8# SODIUM-139 POTASSIUM-4.7 CHLORIDE-91 TOTAL CO2-18* ANION GAP-30* ___ 04:04PM ___ PO2-43* PCO2-45 PH-7.28* TOTAL CO2-22 BASE XS--5 ___ 04:07PM LACTATE-1.7 DISCHARGE LABS: =============== ___ 06:45AM BLOOD WBC-6.9 RBC-3.02* Hgb-8.9* Hct-30.4* MCV-101* MCH-29.5 MCHC-29.3* RDW-17.6* RDWSD-65.2* Plt ___ ___ 06:45AM BLOOD ___ PTT-41.8* ___ ___ 06:45AM BLOOD Glucose-286* UreaN-58* Creat-7.7# Na-140 K-6.2 Cl-99 HCO3-21* AnGap-20* Brief Hospital Course: ___ man with a history of DMI, ESRD (anuric) on HD, CVA, CAD, PVD, celiac disease, and recent admissions for AMS, DKA, and R knee osteomyelitis with infected hardware (___), DKA and subtherapeutic INR (___), and nausea/vomiting with subtherapeutic INR (___) who presents from rehab with dyspnea and right-sided chest pain and was found to have a massive hemothorax in the setting of supratherapeutic INR and DKA course complicated by a painful left blind eye with neovascular glaucoma . ACUTE ISSUES: ============= # Hemothorax The patient presented with shortness of breath and chest pain. He was found to have a massive right-sided hemothorax that developed after relatively minor trauma in the setting of supratherapeutic INR at warfarin. A chest tube was placed by thoracic surgery. His breathing improved and the chest tube was removed on ___. Serial chest x-rays were obtained that showed re-expansion of the lung. #Hypotension The patient was briefly hypotensive while in the ICU and was briefly on pressors. This was suspected to be secondary to sepsis vs obstructive picture from hemothorax and he was initially started on IV antibiotics (vancomycin and cefepime, ___. He was quickly weaned off of pressors and IV antibiotics were discontinued. #Painful blind left eye #Neovascular glaucoma The patient developed severe eye pain during hemodialysis on ___. Opthomology was consulted and found elevated eye pressures consistent with glaucoma. He was given timolol eye drops and IV acetazolamide to lower intraocular pressures. He was also given pain medications. His eye pressures lowered over the next few days. He was seen by a retinal specialist while inpatient who recommended thorazine intraocular injections to decrease intraocular pressures. This did not resolve his pain and he received a retrobulbar alcohol injection with some improvement. He was evaluated for enucleation, but this was deferred. #DMI #DKA The patient presented with blood glucose >300 and an anion gap metabolic acidosis with an anion gap of 30. He was started on an insulin drip in the MICU and his blood sugars quickly normalized. His anion gap closed and he was transitioned to subcutaneous insulin. His blood sugars were labile during this admission and his long-acting and short-acting insulin regimen was titrated by ___. #AVR on warfarin The patient presented with a hemothorax in the setting of a supratherapeutic INR. His INR at rehab was elevated to ~8 reportedly, likely in the setting of poor PO intake. His warfarin was held initially until his INR became subtherapeutic. He was started on a heparin drip while his INR was <2. His warfarin was adjusted until his INR was therapeutic. #Acute on chronic anemia The patient has baseline anemia in the setting of his ESRD. His hemoglobin was slightly lower this admission in the setting of hemothorax. His CBC was monitored daily and he was continued on iron supplementation and Epogen. CHRONIC ISSUES: =============== #ESRD on HD The patient was continued on HD. There was some concern that fluid shifts with HD might be contributing to increased ocular pressures and his HD was adjusted. He was continued on nephrocaps, calcitriol, and sevalmer. #Diabetic retinopathy #Vitreous hemorrhage #Anterior chamber inflammation The patient was continued on his artificial tears, ketorolac, dorzolamide, and brimonidine eye drops. His prednisolone eye drops were increased in frequency due to his increased eye pain. #CAD He was continued on atorvastatin and aspirin. #Diabetic neuropathy He was continued on gabapentin. #History of right knee osteomyelitis He was continued on neomycin-polymyxin-bacitractin ointment and wound care as well as a lidocaine patch. #Depression #Anxiety He was continued on buproprion, mirtazapine, and duloxetine. TRANSITIONAL ISSUES: ==================== **GOAL INR ___ [] The patient's INR goal has been previously stated to be either ___ or 2.5-3.5 rather inconsistently. Upon a chart review, he was discharged after his index CVA with an INR goal of ___ since his stroke was most likely vessel-to-vessel as opposed to cardioembolic. [] The patient had difficult to control INRs while inpatient, please follow his INRs daily and titrate his warfarin until stable x3 days. Then check his INR weekly and adjust warfarin accordingly. Please ensure the patient is eating a steady diet as poor PO intake can result in widely fluctuating INRs. [] The patient had difficult to control blood glucose while inpatient. Please monitor his blood sugars with meals and before bedtime. [] The patient experienced a painful left blind eye and right corneal abrasion while inpatient, please ensure he attends follow-up appointments with ophthalmology. [] The patient had acute on chronic anemia as an inpatient. Please check his CBC in ~1 week to ensure stability. [] The patient was discharged with a subclavian central line. Please pull this in the next few weeks once his INR is stable and he can get peripheral labs. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 5. Bisacodyl ___AILY:PRN constipation 6. BuPROPion 100 mg PO BID 7. Calcitriol 0.5 mcg PO 3X/WEEK (___) 8. Carvedilol 37.5 mg PO BID 9. Cilostazol 100 mg PO BID 10. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 11. Docusate Sodium 100 mg PO BID 12. DULoxetine 20 mg PO 3X/WEEK (___) 13. Famotidine 20 mg PO DAILY 14. Ferrous GLUCONATE 324 mg PO DAILY 15. FoLIC Acid 1 mg PO DAILY 16. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q12H:PRN Eye pain 17. Lidocaine 5% Patch 1 PTCH TD QPM 18. LORazepam 0.5 mg PO 3X/WEEK (___) 19. Mirtazapine 30 mg PO QHS 20. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 21. Nephrocaps 1 CAP PO QHS 22. NIFEdipine CR 90 mg PO DAILY 23. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 24. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q12H:PRN for severe pain 25. Senna 8.6 mg PO BID:PRN Constipation 26. sevelamer CARBONATE 2400 mg PO TID W/MEALS 27. TraMADol 50 mg PO BID 28. Phytonadione 1.25 mg PO Q72H PRN For INR > 8 29. ___ MD to order daily dose PO DAILY16 30. Benzonatate 100 mg PO TID 31. GuaiFENesin 5 mL PO Q4H:PRN cough 32. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 33. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE Q12H 34. Cephalexin 500 mg PO Q8H 35. BuPROPion XL (Once Daily) 300 mg PO DAILY 36. Collagenase Ointment 1 Appl TP DAILY 37. LOPERamide 2 mg PO QID:PRN diarrhea 38. Gabapentin 100 mg PO TID Discharge Medications: 1. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE QID Duration: 3 Days 2. Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line flush 3. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Severe Reason for PRN duplicate override: Alternating agents for similar severity RX hydromorphone 2 mg ___ tablet(s) by mouth four times a day Disp #14 Tablet Refills:0 4. Glargine 10 Units Breakfast Glargine 7 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Sodium Chloride 0.9% Flush 10 mL IV Q8H and PRN, line flush Subclavian line - prn and every shift 6. Timolol Maleate 0.5% 1 DROP LEFT EYE ASDIR L eye BID 7. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q2H 8. Artificial Tear Ointment 1 Appl BOTH EYES PRN eye pain 9. Aspirin 81 mg PO DAILY 10. Atorvastatin 40 mg PO QPM 11. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 12. Bisacodyl ___AILY:PRN constipation 13. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 14. BuPROPion 100 mg PO BID 15. Calcitriol 0.5 mcg PO 3X/WEEK (___) 16. Carvedilol 37.5 mg PO BID 17. Cilostazol 100 mg PO BID 18. Collagenase Ointment 1 Appl TP DAILY 19. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 20. Docusate Sodium 100 mg PO BID 21. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE Q12H 22. DULoxetine 20 mg PO 3X/WEEK (___) 23. Famotidine 20 mg PO DAILY 24. Ferrous GLUCONATE 324 mg PO DAILY 25. FoLIC Acid 1 mg PO DAILY 26. Gabapentin 100 mg PO TID 27. GuaiFENesin 5 mL PO Q4H:PRN cough 28. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q12H:PRN Eye pain 29. Lidocaine 5% Patch 1 PTCH TD QPM 30. LOPERamide 2 mg PO QID:PRN diarrhea 31. LORazepam 0.5 mg PO 3X/WEEK (___) 32. Mirtazapine 30 mg PO QHS 33. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 34. Nephrocaps 1 CAP PO QHS 35. NIFEdipine CR 90 mg PO DAILY 36. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 37. Phytonadione 1.25 mg PO Q72H PRN For INR > 8 38. Senna 8.6 mg PO BID:PRN Constipation 39. sevelamer CARBONATE 2400 mg PO TID W/MEALS 40. TraMADol 50 mg PO BID 41. ___ MD to order daily dose PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: ================== HEMOTHORAX SUPRATHERAPEUTIC INR FOR AVR DKA PAINFUL BLIND EYE SECONDARY DIAGNOSES: ==================== DIABETES MELLITUS, TYPE 1 CORNEAL ABRASION END STAGE RENAL DISEASE HYPERTENSION Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure being involved in your care. Why you were admitted to the hospital: ====================================== You were admitted to the hospital because you had difficulty breathing and pain in your chest and were found to have blood on your right lung. You also were found to have very high blood sugars and a condition called diabetic ketoacidosis and required an insulin drip briefly. What happened in the hospital: ============================== - A chest tube was placed to drain blood on your right lung. - Your insulin was changed to improve your blood sugar levels. - Your warfarin was changed to make sure you weren't at risk of bleeding or clotting. - You initially developed worse left eye pain and were seen by ophthalmology. They determined that you had a painful eye from your diabetic eye disease and treated you with eye drops and two IV medication injections to lower pressure in your eye and reduce inflammation and pain. You subsequently had right eye pain, and were found to have a corneal abrasion, or scrape on the outside of your eye, and you were given a short course of ointment. This should continue to improve. - You continued to receive hemodialysis. What to do when you leave the hospital: ======================================= - Attend all of your follow-up appointments, including opthamology, as described below. - Take all of your medications as described below. - Please continue to have your INR levels measured and have your warfarin changed as needed. We wish you the best! Your ___ Team Followup Instructions: ___
10123949-DS-59	10,123,949	24,524,130	DS	59	2186-04-07 00:00:00	2186-04-07 17:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Flagyl / Levaquin / Protonix / gluten Attending: ___. Chief Complaint: Fever, hypotension Major Surgical or Invasive Procedure: ___ Right subclavian tunneled HD line placement History of Present Illness: ___ with DM1, CAD s/p CABG, CVA w/residual R-sided weakness, ESRD on HD, recently diagnosed L eye glaucoma w/associated blindness and severe pain,presenting from his SNF with fever up to ___ today and hypotension. He denies cough, abdominal pain, n/v/d, chest pain, shortness of breath, light-headedness. He also denies chills, pain at the site of his line. His biggest complaint is L eye pain, which he says has been constant since he was discharged. There has been no change in the quality of the pain, and he denies neck pain/stiffness. He was scheduled for dialysis today, but missed this due to his fever and being sent to the ED. Of note, patient was admitted from ___ through ___ for R-sided hemothorax I/s/o supratherapeutic INR after bumping his chest. He had a chest tube placed which was removed on ___. His hospital course was complicated by new onset neovascular glaucoma in his L eye, managed with timolol eye drops, IV acetazolamide, thorazine injections, and retrobulbar alcohol injection. His pain was also managed with dilaudid. He He was noted to be in DKA on admission as well, and was briefly on an insulin drip. In ED initial VS: 101.8 89 86/50 16 99% RA Exam significant for diffuse course breath sounds in the lower lung fields, worse on the right. NTND abd. Stage 1 sacral decub, stage 1 indented sacral decub, RUE swelling compared to left with palpable graft stent in upper arm. Labs significant for: WBC 13.2, lactate 2.5, K 3.7, Plt 125, INR 1.3 Patient was given: vancomycin and cefepime, as well as 4L IVF. Despite the IVF, his SBP remained in the ___, and he was started on levophed with good response. Imaging notable for: CXR: Right lower lobe hazy opacity could represent pneumonia in appropriate clinical setting. No pulmonary edema. RUENI: No DVT Consults: Renal HD, no urgent HD needs. VS prior to transfer: 98 78 126/56 15 100% On arrival to the MICU, patient reports severe pain in his eye and back which is chronic. He had been refusing dilaudid in the ED because he was concerned about hypotension. At his SNF, he states he has been taking 8mg dilaudid every 4 hours. Past Medical History: - Left preretinal hemorrhage - Atrial fibrillation - AVR with goal INR 2.5-3.5 - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - ESRD- HD T/R/Sa, has tunneled HD catheter - CAD-s/p stenting in ___, CABG at ___ in ___ - Embolic stroke (___) with persistent right sided weakness, CVA in the right parietal lobe (___) - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ fibular head lateral malleolus osteomyelitis treated s/p debridement - HLD - Depression - Celiac disease - Recurrent pleural effusion since CABG Social History: ___ Family History: Father with CAD, CABG. Physical Exam: ADMISSION PHYSICAL EXAM ====================== VS: Temp: 101.8 HR: 89 BP: 86/50 Resp: 16 O2 Sat: 99 GENERAL: Lying in bed eyes shut, mild distress HEENT: ___ eyes without conjunctival injection. L eye with large, non-reactive pupil. R pupil reactive. EOMI. No meningismus. CARDIAC: RRR, mechanical S2 with SEM best heard at ___ LUNGS: Breath sounds present bilaterally, auscultated anteriorly. No wheezes, rhonchi or rales. CHEST: L-sided tunneled line w/o erythema or tenderness. R subclavian CVL mildly erythematous, non-tender, no purulence. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Toe amputations on left foot. No clubbing, cyanosis, or edema. SKIN: Stage 2 decubitus ulcer. NEUROLOGIC: Moving all 4 extremities with purpose, did not participate in exam, no focal CN deficits DISCHARGE PHYSICAL EXAM ======================== VS: T 97.8 PO BP 124 / 77 HR70 RR18 96 Ra GENERAL: middle aged man lying in bed, no distress CARDIAC: RRR, mechanical S2 with SEM best heard at ___ LUNGS: CTAB when listening anteriorly, breathing comfortably on RA without use of accessory muscles ABDOMEN: Active bowels sounds, soft, non distended, non-tender to deep palpation in all four quadrants EXTREMITIES: Toe amputations on left foot. No clubbing, cyanosis, or edema. NEUROLOGIC: Alert, oriented, moving all extremities with purpose, no facial asymmetry ACCESS: R subclavian tunneled HD line in place, site non-tender without erythema or purulence Pertinent Results: ADMISSION LABS ============== ___ 07:50AM BLOOD WBC-13.2# RBC-3.39 Hgb-9.4* Hct-31.2* MCV-92# MCH-27.7 MCHC-30.1* RDW-15.9* RDWSD-53.3* Plt ___ ___ 07:50AM BLOOD Neuts-87.7* Lymphs-7.3* Monos-4.2* Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.56# AbsLymp-0.96 AbsMono-0.55 AbsEos-0.00* AbsBaso-0.03 ___ 07:50AM BLOOD ___ PTT-25.1 ___ ___ 07:50AM BLOOD Glucose-162* UreaN-36* Creat-6.7* Na-135 K-3.7 Cl-93* HCO3-22 AnGap-20* ___ 07:50AM BLOOD ALT-9 AST-15 AlkPhos-209* TotBili-0.4 ___ 07:50AM BLOOD Albumin-3.2* Calcium-8.4 Phos-4.5 Mg-1.7 ___ 07:58AM BLOOD ___ pO2-70* pCO2-37 pH-7.40 calTCO2-24 Base XS-0 Comment-GREEN TOP ___ 07:58AM BLOOD Lactate-2.5* IMAGING ======= PORTABLE CXR ___ Right lower lobe hazy opacity could represent pneumonia in appropriate clinical setting. No pulmonary edema. U/E U/S ___. No evidence of deep vein thrombosis in the right upper extremity. 2. Nonvisualized right cephalic vein, likely utilized for a prior AV fistula which appears thrombosed. MRI SACRUM ___ -Increased fluid signal in the subcutaneous fat overlying the coccyx predominantly to the right of midline may be inflammatory/reactive to underlying ulcer. No evidence of osteomyelitis however. -Sacroiliac articular cortical irregularity may be sequela of prior sacroiliitis or hyperparathyroidism. No subchondral edema to suggest active sacroiliitis or septic arthritis. -Diffuse nonspecific soft tissue edema. TTE ___ The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is ___ mmHg. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 55 %). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. A mechanical aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trace aortic regurgitation is seen. [The amount of regurgitation present is normal for this prosthetic aortic valve.] The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Well seated, normal functioning mechanical AVR.Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Mild mitral regurgitation. Compared with the prior study (images reviewed) of ___, the findings are similar. TEE ___ There is no evidence for an atrial septal defect by 2D/color Doppler. Global systolic function is normal (LVEF greater than 55%). The right ventricle has normal free wall motion. There are simple atheroma in the aortic arch and simple atheroma in the descending aorta. A mechanical aortic valve prosthesis is present. The prosthesis is well seated with normal leaflet motion. No masses or vegetations are seen on the aortic valve. No abscess is seen. There is no aortic regurgitation. The mitral leaflets appear structurally normal with no mitral valve prolapse. No masses or vegetations are seen on the mitral valve. No abscess is seen. There is moderate [2+] mitral regurgitation. No masses/vegetations are seen on the pulmonic valve. The tricuspid valve leaflets appear structurally normal. No mass/vegetation are seen on the tricuspid valve. No abscess is seen. There is mild [1+] tricuspid regurgitation. There is no pericardial effusion. IMPRESSION: Good image quality. No valvular vegetations visualized. Well seated mechanical aortic valve prosthesis with normal leaflet motion. Moderate mitral regurgitation MICRO ====== ___ Blood cx: ** ___ Blood cx: ___ Blood cx: ___ Blood cx: ___ 7:00 pm CATHETER TIP-IV Source: right SC CVL. FINAL REPORT ___ WOUND CULTURE (Final ___: STAPH AUREUS COAG +. >15 colonies. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations RIFAMPIN should not be used alone for therapy. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| STAPHYLOCOCCUS, COAGULASE NEGATIVE \| \| CLINDAMYCIN-----------<=0.25 S =>8 R ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S 4 S LEVOFLOXACIN---------- 0.25 S =>8 R OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S 2 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S 1 S ___ Blood culture: Negative ___ Blood culture: Negative ___ Blood culture: Negative ___ Blood culture: Negative ___ 8:28 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. SENSITIVITIES PERFORMED ON CULTURE # ___ (___). Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT 0145. GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. ___ 7:50 am BLOOD CULTURE FINAL REPORT ___ Blood Culture, Routine (Final ___: STAPH AUREUS COAG +. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. RIFAMPIN should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ ON ___ AT 0145. GRAM POSITIVE COCCI IN CLUSTERS. Anaerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN CLUSTERS. DISCHARGE LABS: =============== ___ 07:45AM BLOOD WBC-6.8 RBC-3.23* Hgb-8.9* Hct-30.5* MCV-94 MCH-27.6 MCHC-29.2* RDW-17.3* RDWSD-59.2* Plt ___ ___ 07:45AM BLOOD Glucose-72 UreaN-37* Creat-4.2*# Na-143 K-4.7 Cl-100 HCO3-28 AnGap-15 ___ 07:45AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2 Brief Hospital Course: Mr. ___ is a ___ year-old male with a past medical history of end-stage renal disease on hemodialysis, mechanical aortic valve, atrial fibrillation, and type I diabetes mellitus who initially presented with fevers and hypotension, found to have a methicillin-resistant staph aureus bloodstream infection secondary to a line infection. ACTIVE ISSUES: =============== # Septic Shock # Methicillin-resistant staph aureus blood stream infection Patient presented with fevers and hypotension and was found to be in septic shock secondary to a methicillin-resistant staph aureus blood stream infection, likely secondary to his right subclavian central line (pt. had previously refused line removal during his most recent hospitalizations). On ___ blood cultures demonstrated staph aureus resistant to oxacillin. ID was consulted. Other sources were exonerated including urine culture, negative sacral MRI (no evidence of osteomyelitis), and CXR demonstrated potential consildation, although PNA was thought to be a less likely source. He was treated with vancomycin, given during HD, to be continued for a four-week course. His right subclavian line and tunneled hemodialysis line were removed. He was given a line holiday and initially had a temporary trialysis line placed, which was removed on ___ and replaced with a new tunneled HD line on ___. Patient underwent TTE and TEE, both of which were negative for valvular vegetations. # Mechanical prosthetic aortic valve replacement # Paroxysmal atrial fibrillation # Subtherapeutic INR Patient presented with INR 1.3 (goal ___ despite mechanical AVR given prior history of multiple spontaneously bleeds in the past). His home warfarin was initially held in the setting of line removal/replacement. He was then started on a heparin drip as a bridge to warfarin. The INR became therapeutic on ___, and the heparin drip was discontinued. #Left Eye pain Patient reported severe eye pain on presentation that had been steadily worsening since his last discharge, requiring uptitration of dilaudid. He had undergone ETOH retrobulbar injection ___ with little improvement in his pain. Ophthalmology was consulted in the emergency department and recommended enucleation as the definitive treatment. Pain thought to be related phthisis and rubeosis. The patient wished to obtain a second opinion before undergoing enucleation. He was seen by palliative care while inpatient for discussion of pain management. He was initially treated with IV dilaudid and standing Tylenol, with no improvement in his pain. Ultimately, pain did not improve with narcotics and patient was continued on standing Tylenol and gabapentin was increased from 100 mg daily to 100 mg TID. Home dilaudid, tramadol and oxycontin were stopped. he was continued on fluoxetine and Tylenol as well. The patient was set up with an appointment to see palliative care upon discharge and was maintained on his home gabapentin and eye drops. He has a follow up appointment scheduled with Mass Eye and Ear on ___. Pt also reported R eye discomfort and visual changes. He wishes to undergo cataract surgery. A cardiac risk assessment letter was written prior to discharge. # Diabetic ketoacidosis # Type I diabetes mellitus Patient developed mild diabetic ketoacidosis in the setting of not receiving insulin for several hours upon initial arrival. He was treated with an insulin drip, and his DKA then resolved. Ultimately, he was transitioned back to his home insulin. # Hypertension Initially held home carvedilol and nifedipine in the setting of shock; re-started once hemodynamically stable. Patient remained hypertensive (systolic BPS 160s-180s). His home dose of carvedilol was restarted, and Nifedipine was increased to qDaily (from only administered on HD days). He remained intermittently hypertensive with this new regimen, and it was recommended to f/u potential medication adjustments as an outpatient. He has become hypotensive at the end of HD sessions in the past, so his BP should be closely monitored. # Normocytic Anemia Patient presented with slowly downtrending Hgb, to 7.4 from 9.4 on admission. Baseline appears to be around 8.5, but has dropped to high-7's in the past. He had no evidence of active bleeding during his admission, and hemolysis labs and iron studies were negative. A smear was negative for schisotsytes. His anemia was attributed to his renal failure, and hemoglobin remained stable throughout the rest of his admission. (See transitional issue) # Thromboycytopenia Patient developed mild thrombocytopenia to 122, likely in the setting of infection and septic shock. Resolved with initiation of antibiotics for blood stream infection. CHRONIC/STABLE ISSUES: ====================== # Coronary artery disease status post coronary artery bypass graft Continued home aspirin and atorvastatin. # End-stage renal disease on hemodialysis The renal dialysis team was notified of his admission, and patient continued to receive dialysis sessions every ___, ___, and ___. He was continued on his home calcitriol, sevelamer, nephrocaps, folic acid, and iron. # Sacral decubitus ulcers Wound care was consulted, and patient was continued on his home collagenase. # Gastroesophageal reflux disease Continued home famotidine. # Depression Continued home duloxetine, mirtazapine, and bupoprion. # Anxiety Continued home Ativan. TRANSITIONAL ISSUES: ==================== Discharge INR: 2.2 NEW MEDICATIONS: [ ] Vancomycin with HD per HD protocol Start Date: ___ Projected End Date: ___ CHANGED MEDICATIONS: [ ] Gabapentin was increased from 100 mg daily to 100 mg TID [ ] Nifedipine was increased from 90 mg on non HD days to daily [ ] Acetaminophen 1000 mg TID STOPPED MEDICATIONS: [ ] Benzonatate 100 mg TID [ ] Hydromorphone 4 mg PO q 3 hrs PRN [ ] Oxycontin 10 mg PO q 12 hours [ ] Tramadol 50 mg q 4 hours PRN [ ] Check labs WEEKLY starting ___ until ___: CBC with differential, BUN, Cr, Vancomycin trough ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ []High grade MRSA bacteremia: 4 weeks of IV vanc ___ to ___, end date to be guided by ID as outpatient) [] Check INR on ___ and titrate warfarin dose as needed to maintain INR ___. Patient received 3 mg of warfarin ___ and ___. [] INR Goal: On this hospitalization, my team reached out to his PCP, ___, and rehab facility. No individual identified as following INR. INR goal ___ at this time. Pt. with multiple spontaneous bleeds. Would benefit from INR 2.5 to 3.5 for optimal CVA risk reduction (especially given prior CVA, afib, and mechanical AVR). However, HAS-BLED score high risk for major bleeding. Given labile INR, renal failure, elevated major bleed risk and hx. of multiple spontaneous bleeds, will keep INR goal at ___ currently. If INR < 2.0, bridging with lovenox or heparin until INR is therapeutic is indicated. This should be re-evaluated as an outpatient [] Please ensure follow up with Mass Eye and Ear for second opinion regarding left eye treatment options [] Please ensure follow up with palliative care for ongoing discussion of pain management [] Please consider EPO treatment for normocytic anemia [] Consider adjusting medication for hypertension - Communication: ___ Relationship: WIFE/HCP Phone number: ___ - Code: Full code confirmed. Family meeting held with palliatve care Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Artificial Tear Ointment 1 Appl BOTH EYES QID 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 5. Bisacodyl ___AILY:PRN constipation 6. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 7. Calcitriol 0.5 mcg PO DAILY 8. Carvedilol 37.5 mg PO BID 9. Collagenase Ointment 1 Appl TP DAILY 10. Docusate Sodium 100 mg PO BID 11. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE Q12H 12. DULoxetine 20 mg PO DAILY 13. Ferrous GLUCONATE 324 mg PO DAILY 14. FoLIC Acid 1 mg PO 3X/WEEK (___) 15. Gabapentin 100 mg PO DAILY 16. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q12H:PRN Eye pain 17. Lidocaine 5% Patch 1 PTCH TD QPM 18. LOPERamide 2 mg PO QID:PRN diarrhea 19. Mirtazapine 30 mg PO QHS 20. Nephrocaps 1 CAP PO QHS 21. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q2H 22. Senna 8.6 mg PO QHS Constipation 23. sevelamer CARBONATE 2400 mg PO TID W/MEALS 24. Timolol Maleate 0.5% 1 DROP LEFT EYE ASDIR L eye BID 25. Cilostazol 100 mg PO BID 26. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 27. Famotidine 20 mg PO DAILY 28. GuaiFENesin 5 mL PO Q4H:PRN cough 29. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 30. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 31. Phytonadione 1.25 mg PO Q72H PRN For INR > 8 32. ___ MD to order daily dose PO DAILY16 33. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE QID 34. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN Pain - Severe Reason for PRN duplicate override: Alternating agents for similar severity 35. Sodium Chloride 0.9% Flush 10 mL IV Q8H and PRN, line flush 36. Heparin Flush (10 units/ml) 1 mL IV DAILY and PRN, line flush 37. Glargine 10 Units Breakfast Glargine 7 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 38. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H 39. Polyethylene Glycol 17 g PO BID:PRN constipation 40. LORazepam 0.5 mg PO Q8H:PRN anxiety 41. BuPROPion (Sustained Release) 100 mg PO BID 42. Benzonatate 100 mg PO TID 43. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough 44. Florastor (Saccharomyces boulardii) 250 mg oral BID 45. NIFEdipine (Extended Release) 90 mg PO DAILY 46. TraMADol 50 mg PO Q4H:PRN Pain - Moderate Discharge Medications: 1. Acetaminophen 1000 mg PO TID 2. Vancomycin-Heparin Lock (For HD/Pheresis Catheters) 12.___AILY 3. Gabapentin 100 mg PO TID 4. Glargine 10 Units Breakfast Glargine 7 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Artificial Tear Ointment 1 Appl BOTH EYES QID 6. Aspirin 81 mg PO DAILY 7. Atorvastatin 40 mg PO QPM 8. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 9. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE QID 10. Bisacodyl ___AILY:PRN constipation 11. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 12. BuPROPion (Sustained Release) 100 mg PO BID 13. Calcitriol 0.5 mcg PO DAILY 14. Carvedilol 37.5 mg PO BID 15. Cilostazol 100 mg PO BID 16. Collagenase Ointment 1 Appl TP DAILY 17. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 18. Docusate Sodium 100 mg PO BID 19. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE Q12H 20. DULoxetine 20 mg PO DAILY 21. Famotidine 20 mg PO DAILY 22. Ferrous GLUCONATE 324 mg PO DAILY 23. Florastor (Saccharomyces boulardii) 250 mg oral BID 24. FoLIC Acid 1 mg PO 3X/WEEK (___) 25. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough 26. GuaiFENesin 5 mL PO Q4H:PRN cough 27. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q12H:PRN Eye pain 28. Lidocaine 5% Patch 1 PTCH TD QPM 29. LOPERamide 2 mg PO QID:PRN diarrhea 30. LORazepam 0.5 mg PO Q8H:PRN anxiety 31. Mirtazapine 30 mg PO QHS 32. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 33. Nephrocaps 1 CAP PO QHS 34. NIFEdipine (Extended Release) 90 mg PO DAILY 35. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 36. Phytonadione 1.25 mg PO Q72H PRN For INR > 8 37. Polyethylene Glycol 17 g PO BID:PRN constipation 38. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q2H 39. Senna 8.6 mg PO QHS Constipation 40. sevelamer CARBONATE 2400 mg PO TID W/MEALS 41. Sodium Chloride 0.9% Flush 10 mL IV Q8H and PRN, line flush 42. Timolol Maleate 0.5% 1 DROP LEFT EYE ASDIR L eye BID 43. ___ MD to order daily dose PO DAILY16 44.Outpatient Lab Work ICD10 code: A41.02 sepsis due to MRSA WEEKLY starting ___ until ___: CBC with differential, BUN, Cr, Vancomycin trough ALL LAB RESULTS SHOULD BE SENT TO: ATTN: ___ CLINIC - FAX: ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: - Septic shock - Methicillin-resistant staph aureus bloodstream infection - Diabetic ketoacidosis Secondary diagnosis: - End-stage renal disease requiring hemodialysis - Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Mr. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you were having fevers and a low blood pressure. You were found to have an infection in your blood. WHAT WAS DONE FOR YOU IN THE HOSPITAL? - The infection in your blood was likely caused by one of the lines you had in one of your blood vessels. These lines were removed and a new line was placed so you could continue getting dialysis. - You were treated for your infection with antibiotics. - Your eye pain was treated with pain medications while you were here. - You continued to receive dialysis sessions. - Your blood pressure improved and your home blood pressure medication regimen was re-started. WHAT SHOULD YOU DO WHEN YOU GO HOME? - You should continue taking your medications as prescribed. You will continue to receive vancomycin (the antibiotic that is treating your infection) with dialysis sessions for four weeks total. - You should follow up with your eye doctor, who can discuss what options you have regarding your left eye pain. We have set up an appointment for you (see below for details). - You should continue going to dialysis every ___, and ___. -You should follow up with your nephrologist to adjust your blood pressure medication. It was a pleasure taking care of you, and we wish you well! Sincerely, Your ___ Team Followup Instructions: ___
10123949-DS-61	10,123,949	26,796,872	DS	61	2186-06-07 00:00:00	2186-06-07 21:17:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Flagyl / Levaquin / Protonix / gluten / levofloxacin Attending: ___. Chief Complaint: Hematemesis, Hyperglycemia Major Surgical or Invasive Procedure: ___ - Left subclavian single lumen power Port-a-cath placement History of Present Illness: ___ yo male with T1DM, CAD s/p stents and subsequent CABG, AF, s/p mAVR, CVA w/ residual R-sided weakness, ESRD on HD TTS, recently diagnosed L eye glaucoma w/ associated blindness and severe pain who presents from ___ where he resides for longterm care for coffee ground emesis x3 just before 7am on the day of presentation. He received compazine and Zofran without improvement in his nausea. His INR was 5.0 on ___. His FSBS was >500 and was given 12u of Humalog at his facility prior to transfer. He is also reporting abdominal pain and diarrhea but cannot provide much more history this. In the ED: Initial vital signs were notable for: 98.1 80 159/74 18 100% RA. Exam notable for: Vitals stable. No acute distress. Sleeping. Grimaces in pain on palpation of left side of abdomen and epigastric region, but abdomen soft and non-distended. Extremities warm. Sternotomy wound with keloid scar. Guaiac positive brown stool. Labs were notable for: INR 4.4 Hgb 8.9/Hct 29.1 Glu >500 AG 20 HCO3 25 Lactate 2.1 Cr 4.4 VBG: pH 7.36 pCO2 48 Studies performed include: Patient was given: ___ 13:08 SC Insulin Lispro 10 UNIT ___ ___ 13:08 IVF NS ___ Started ___ 13:53 IV HYDROmorphone (Dilaudid) .5 mg ___ ___ 13:55 IV HYDROmorphone (Dilaudid) .5 mg ___ ___ 13:56 IVF NS 500 mL ___ Stopped (___) ___ 16:20 IV HYDROmorphone (Dilaudid) 1 mg ___ ___ 16:23 SC Insulin Lispro 15 UNIT ___ ___ 18:42 SC Insulin 22 UNIT ___ ___ 18:42 SC Insulin 10 UNIT ___ ___ 18:46 IV LORazepam 1 mg ___ Consults: None Vitals on transfer: 98.7 73 145/50 18 97% RA. Upon arrival to the floor, the patient confirms the history above. He is sleeping, with some responses. Complaining of eye pain and pain on his backside. No other complaints. Past Medical History: - Left preretinal hemorrhage - Atrial fibrillation - AVR with goal INR 2.5-3.5 - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - ESRD- HD T/R/Sa, has tunneled HD catheter - CAD-s/p stenting in ___, CABG at ___ in ___ - Embolic stroke (___) with persistent right sided weakness, CVA in the right parietal lobe (___) - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ fibular head lateral malleolus osteomyelitis treated s/p debridement - HLD - Depression - Celiac disease - Recurrent pleural effusion since CABG Social History: ___ Family History: Father with CAD, CABG. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: 98.2 159/85 63 18 96 RA GENERAL: NAD, sleeping HEENT: L eye with clouding of pupil, consistent with glaucoma. R pupil 3-4 mm and reactive. Sclera anicteric. NECK: Supple CARDIAC: RRR, loud S2, I-II/VI systolic ejection murmur heard best of RUSB LUNGS: Clear anteriorly ABDOMEN: +BS, soft, NT, ND EXTREMITIES: R>L UE edema. 2+ edema of RLE. LLE in cast SKIN: Warm DISCHARGE PHYSICAL EXAM: ======================= VS: Temp 97.7 BP 164/84 HR 67 RR 18 99% on Ra GENERAL: NAD. Lying comfortably in bed. HEENT: NC/AT. MMM. NECK: Supple CARDIAC: RRR with normal S1 and S2. II/VI systolic murmur over RUSB. No rubs or gallops. LUNGS: Normal respiratory effort. CTAB without wheezes, rales or rhonchi over anterior chest. ABD: Soft, NT/ND, normoactive BS. No guarding or masses. EXT: LLE in cast. Amputation of all toes on the left. 2+ nonpitting edema over RUE. No BLE edema. NEURO: Alert and interactive. Moves LUE/LLE. RUE/RLE lay motionless. SKIN: Warm, dry. No rashes. Pertinent Results: ADMISSION LABS: ============== ___ 01:00PM BLOOD WBC-9.3 RBC-3.15* Hgb-8.9* Hct-29.1* MCV-92 MCH-28.3 MCHC-30.6* RDW-17.3* RDWSD-58.9* Plt ___ ___ 01:00PM BLOOD Neuts-75.8* Lymphs-11.9* Monos-11.8 Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.05* AbsLymp-1.11* AbsMono-1.10* AbsEos-0.00* AbsBaso-0.02 ___ 01:00PM BLOOD Glucose-603* UreaN-42* Creat-4.4* Na-136 K-3.8 Cl-91* HCO3-25 AnGap-20* ___ 01:00PM BLOOD ALT-9 AST-11 AlkPhos-277* TotBili-0.2 ___ 01:00PM BLOOD Lipase-6 ___ 01:00PM BLOOD Albumin-3.3* Calcium-8.5 Phos-4.5 Mg-2.1 ___ 03:55PM BLOOD Glucose-486* Lactate-2.1* PERTINENT LABS: ============== ___ 01:00PM BLOOD Lipase-6 ___ 08:08PM BLOOD ___ pO2-59* pCO2-52* pH-7.35 calTCO2-30 Base XS-1 ___ 12:55AM BLOOD ___ pO2-50* pCO2-60* pH-7.31* calTCO2-32* Base XS-1 Comment-GREEN TOP ___ 11:18AM BLOOD ___ pO2-120* pCO2-45 pH-7.41 calTCO2-30 Base XS-3 ___ 03:55PM BLOOD Glucose-486* Lactate-2.1* ___ 03:55PM BLOOD Hgb-9.1* calcHCT-27 DISCHARGE LABS: ============== ___ 05:14AM BLOOD WBC-5.8 RBC-3.05* Hgb-8.6* Hct-28.6* MCV-94 MCH-28.2 MCHC-30.1* RDW-18.7* RDWSD-62.8* Plt ___ ___ 05:14AM BLOOD ___ PTT-73.5* ___ ___ 05:14AM BLOOD Glucose-188* UreaN-63* Creat-4.9# Na-142 K-5.6 Cl-100 HCO3-25 AnGap-17 ___ 05:14AM BLOOD Calcium-8.4 Phos-4.3 Mg-2.5 PERTINENT IMAGING: ================ ___ LUE DVT Ultrasound: 1. No evidence of deep vein thrombosis in the right upper extremity. 2. Chronic occluded AV fistula. 3. Mild subcutaneous edema in the medial aspect of the right forearm. ___ Port Placement: Successful placement of a single lumen chest power Port-a-cath via the left subclavian venous approach. The tip of the catheter terminates in the right atrium. The catheter is ready for use. ___ LUE DVT Ultrasound: 1. No evidence of deep vein thrombosis in the right upper extremity. 2. Unchanged chronically occluded AV graft and subcutaneous edema within the medial right upper arm. Brief Hospital Course: Mr. ___ is a ___ yo male with a hx of T1DM, CAD s/p stents and subsequent CABG, s/p mAVR, CVA w/ residual R-sided weakness, ESRD on HD, left eye painful blindness who presented with coffee ground emesis in the setting of supratherapeutic INR, found to have hyperglycemia concerning for DKA, since improved. He then add issues with access (see below), which improved after port placement. He was subsequently started on a heparin drip and transitioned back to warfarin. ACUTE ISSUES: ============= #DM Type I #DKA The patient has a history of diabetes mellitus type I with several admissions for DKA requiring insulin gtt. Presented this admission with a BS >500, metabolic acidosis, and AG 20, concerning for DKA after starting prednisone on ___ or ___. He was given lantus and multiple doses of lispro in the ED with subsequent improvement and progression to hypoglycemia briefly requiring a D5W drip. ___ was consulted and followed. His regimen was altered as needed and he was ultimately discharged on glargine 10 units AM and 5 units ___ as well as SSI. He should follow up with his endocrinologist at ___ for further management. #Hematemesis #Chronic anemia Presented after three episodes coffee ground emesis in setting of supratherapeutic INR (~5) and DKA as describe above. Stool guiaic positive. Hgb 8.9 on admission, baseline between ___. Etiology was felt to be due to elevated INR, esophagitis seen on EGD on ___ and vomiting from DKA. He was started on a BID PPI and then narrowed to daily dosing. He was switched back to his home H2 blocker at discharge. H/H has remained stable and he had no further episodes of hematemesis. #Supratherapeutic INR #Mechanical AVR #CAD s/p CABG History of mechanical AVR with labile INR as well as previous spontaneous bleeding. INR goal had been changed from 2.5-3.5 to ___ given bleeding risk, as described by prior providers. Per facility records, his INR was 5 on ___ and 4.4 on presentation. INR downtrended to 1.6 after holding warfarin in the setting of bleeding. There was then difficulty obtaining labs due to poor access, difficult blood draws, and then patient refusal. Attempt was made to begin heparin bridge to warfarin though patient initially refused to avoid further lab draws. Given lack of labs, he was given lose-dose warfarin while waiting for access. Once his port was placed on ___, he was started on a heparin gtt while bridging to warfarin. Additionally, he was continued on his home aspirin, atorvastatin, and carvedilol. #Access During the hospitalization, there was significant issues obtaining reliable access and blood draws, which limited medical options, including a heparin gtt. Review of OMR showed the patient had recurrent admissions, often with access issues. Extensive discussions occurred between the patient, his wife and a ___ medical team, including the primary team, both his inpatient and outpatient nephrologist, interventional radiology, and venous access. Ultimately, the decision was made to move forward with a left chest port. Despite knowing the risk of infection and possible loss of future dialysis access sites, the patient wished to move forward with port placement as a way to significantly improve his quality of life. #Joint pain Per his wife, the patient had recent bilateral upper extremity joint pain prior to admission. He reportedly had lab work done at his outside facility and there was concern for rheumatoid arthritis. He was started on prednisone on ___ or ___ though no clear diagnosis yet after discussions with the outside facility. The patient was asymptomatic here and did not wish to continue prednisone. Home hydromorphone dose was decreased at discharge given minimal improvement with this medication. CHRONIC ISSUES ============== # ESRD on HD Received dialysis on ___, and ___ without issues. He was also continued on his come calcitriol, sevelamer, nephrocaps, folic acid and iron. #Hypertension Hospitalization complicated by hypertension with SBP up to 170-180s despite dialysis and carvedilol. After discussion with nephrology, the patient was started on lisinopril. Additionally, his home nifedipine was restarted. BP improved though intermittently remained elevated. He should follow up with his PCP and nephrology for further management. # Depression # Anxiety He was continued on his home duloxetine, mirtazapine, bupoprion. Lorazepam titrated to 0.5mg q8hrs PRN eye pain, anxiety. TRANSITIONAL ISSUES: ================== [ ] Follow up blood pressure, titrate medications as necessary. Patient previously taking nifedipine only on HD days. Given elevated BP despite HD, he was started on this daily. He was also started on lisinopril 5mg daily. Continue to titrate as needed. [ ] INR at discharge: 2.4 ; Warfarin regimen: 3 mg daily [ ] Prednisone held at discharge. If prednisone is restarted, increase insulin regimen to match blood sugars [ ] Home pain medication regimen decreased given minimal improvement with this medications while hospitalized. Discharged on lorazepam 0.5mg q8hrs PRN and hydromorphone ___ q8hrs PRN. Continue to titrate these medications as needed for symptomatic management. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 1000 mg PO TID 2. Artificial Tear Ointment 1 Appl BOTH EYES QID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 6. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE QID 7. Bisacodyl ___AILY:PRN constipation 8. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 9. BuPROPion (Sustained Release) 100 mg PO BID 10. Calcitriol 0.5 mcg PO DAILY 11. Cilostazol 100 mg PO BID 12. Collagenase Ointment 1 Appl TP DAILY 13. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 14. Docusate Sodium 100 mg PO BID 15. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE Q12H 16. DULoxetine 20 mg PO DAILY 17. Ferrous GLUCONATE 324 mg PO DAILY 18. FoLIC Acid 1 mg PO 3X/WEEK (___) 19. Gabapentin 100 mg PO TID 20. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q12H:PRN Eye pain 21. Lidocaine 5% Patch 1 PTCH TD QPM 22. LOPERamide 2 mg PO QID:PRN diarrhea 23. LORazepam 0.5 mg PO Q8H:PRN eye pain 24. Mirtazapine 30 mg PO QHS 25. Nephrocaps 1 CAP PO QHS 26. Polyethylene Glycol 17 g PO BID:PRN constipation 27. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q2H 28. Senna 8.6 mg PO QHS Constipation 29. sevelamer CARBONATE 2400 mg PO TID W/MEALS 30. Timolol Maleate 0.5% 1 DROP LEFT EYE ASDIR L eye BID 31. ___ MD to order daily dose PO DAILY16 32. Carvedilol 37.5 mg PO BID 33. Florastor (Saccharomyces boulardii) 250 mg oral BID 34. GuaiFENesin 5 mL PO Q4H:PRN cough 35. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough 36. LORazepam 1 mg PO BID anxiety 37. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 38. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 39. Phytonadione 1.25 mg PO Q72H PRN For INR > 8 40. NIFEdipine (Extended Release) 90 mg PO DAILY 41. PredniSONE 30 mg PO DAILY Tapered dose - DOWN 42. PredniSONE 20 mg PO DAILY Tapered dose - DOWN 43. PredniSONE 10 mg PO DAILY Tapered dose - DOWN 44. Ondansetron 4 mg PO Q8H:PRN Nausea 45. Ranitidine 150 mg PO BID 46. HYDROmorphone (Dilaudid) 4 mg PO Q8H 47. HYDROmorphone (Dilaudid) 4 mg PO Q3H:PRN Pain - Moderate 48. Glucagon 1 mg IM Q15MIN:PRN Hypoglycemia 49. Glargine 10 Units Breakfast Glargine 7 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Medications: 1. Lisinopril 5 mg PO DAILY 2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 3. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN Pain - Moderate RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every 8 hours Disp #5 Tablet Refills:0 4. Glargine 10 Units Breakfast Glargine 5 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Warfarin 3 mg PO DAILY16 6. Artificial Tear Ointment 1 Appl BOTH EYES QID 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 10. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE QID 11. Bisacodyl ___AILY:PRN constipation 12. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 13. BuPROPion (Sustained Release) 100 mg PO BID 14. Calcitriol 0.5 mcg PO DAILY 15. Carvedilol 37.5 mg PO BID 16. Cilostazol 100 mg PO BID 17. Collagenase Ointment 1 Appl TP DAILY 18. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 19. Docusate Sodium 100 mg PO BID 20. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE Q12H 21. DULoxetine 20 mg PO DAILY 22. Ferrous GLUCONATE 324 mg PO DAILY 23. Florastor (Saccharomyces boulardii) 250 mg oral BID 24. FoLIC Acid 1 mg PO 3X/WEEK (___) 25. Gabapentin 100 mg PO TID 26. Glucagon 1 mg IM Q15MIN:PRN Hypoglycemia 27. Guaifenesin-Dextromethorphan 10 mL PO Q4H:PRN cough 28. GuaiFENesin 5 mL PO Q4H:PRN cough 29. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q12H:PRN Eye pain 30. Lidocaine 5% Patch 1 PTCH TD QPM 31. LOPERamide 2 mg PO QID:PRN diarrhea 32. LORazepam 0.5 mg PO Q8H:PRN eye pain, anxiety RX lorazepam 0.5 mg 1 tablet by mouth every 8 hours Disp #5 Tablet Refills:0 33. Mirtazapine 30 mg PO QHS 34. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 35. Nephrocaps 1 CAP PO QHS 36. NIFEdipine (Extended Release) 90 mg PO DAILY 37. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain 38. Ondansetron 4 mg PO Q8H:PRN Nausea 39. Phytonadione 1.25 mg PO Q72H PRN For INR > 8 40. Polyethylene Glycol 17 g PO BID:PRN constipation 41. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE Q2H 42. Ranitidine 150 mg PO BID 43. Senna 8.6 mg PO QHS Constipation 44. sevelamer CARBONATE 2400 mg PO TID W/MEALS 45. Timolol Maleate 0.5% 1 DROP LEFT EYE ASDIR L eye BID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: #Primary: Diabetic ketoacidosis Hematemesis #Secondary: Diabetes mellitus type I Chronic anemia Supratherapeutic INR Mechanical aortic valve repair Coronary artery disease End stage renal disease Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___! Why you were admitted to the hospital: - You were vomiting and not feeling well What happened while you were here: - You were found to be in diabetic ketoacidosis (high blood sugars affecting your body) - You were treated with insulin and your blood sugars improved - Your INR (measure of warfarin dose) was found to be elevated - We had trouble obtaining lab work. After many discussions with you, and several of your inpatient and outpatient providers, ___ port was placed - You were started on a heparin drip while waiting for your INR to come back into normal range What you should do once you return home: - Please continue taking your medications as prescribed - Please follow up at the appointments outlined below Sincerely, Your ___ Care Team Followup Instructions: ___
10123949-DS-62	10,123,949	27,537,146	DS	62	2186-08-11 00:00:00	2186-08-11 17:16:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: wheat / Flagyl / Levaquin / Protonix / gluten / levofloxacin Attending: ___. Chief Complaint: Left lower extremity pain Major Surgical or Invasive Procedure: Left eye enucleation performed ___ by Dr. ___ ___ of Present Illness: ___ with PMH of DM 1, CAD s/p stent and CABG, AF, s/p mechanical AVR, CVA w/ residual R-sided weakness, ESRD on HD (TTS), L eye glaucoma a/w blindness and severe pain with recent admission for DKA and hematemesis iso supratherapuetic INR who presents today with severe L leg pain for 8 hours. At 1500, he had gradual onset of an achy pain in his left lower leg distal to the knee that has progressed to extreme, excruciating pain. The pain is similar to his prior episode of gangrenous toes that required amputation. He denies any recent fevers, chills, nausea or vomiting. He denies any overlying erythema or changes in skin coloration. He recently had a cast removed 10 days ago from his LLE with some scabbing but no acute changes. He denies any HA, URI symptoms, CP, dyspnea, palpitations, back pain, abdominal pain, hematochezia or rashes. In the ED: Initial vital signs were notable for: T 99.7, HR 87, BP 144/94, RR 19, O2 sat 100% on RA Exam notable for: A&Ox3 writhing in pain HEENT: injected L eye (baseline) CV: RRR with nl S1S2 no MRG Chest wall: port with no surroudning erythema in Left chest wall Resp: CTAB ABd: NTND MSK: LLE: normal color, non-palpable DP or ___, dopplerable ___ and DP with normal sensation throughout RLE: strong palpable ___ and DP with normal sensation and motor function Labs were notable for: - CBC: 7.8/___/180 - Coags: ___ 39.7/PTT 52.8/INR 3.7 - BMP: ___ - CRP 16.7 Studies performed include: - Arterial duplex of LLE: Limited assessment of the left lower extremity in the expected area of the SFA graft which appears patent. - CTA lower extremities with and without contrast: LEFT: Extensive atherosclerosis. Patent SFA, popliteal artery. Contrast seen in posterior tibial artery. Peroneal artery markedly attenuated until distal lower extremity but appears to have contrast on delayed axial images - very slow flow. Anterior tibial artery markedly atherosclerotic but appears to of contrast on delayed axial images - very slow flow. RIGHT: Extensive atherosclerosis. 3 vessel runoff seen. Attenuated peroneal artery. Dorsalis pedis and plantar vessels have contrast. Patient was given: - IV dilaudid 1mg x3, IV dilaudid 0.5mg - Zofran 4mg x2 - Ativan 1mg - Insulin 22 units, 8 units, 4 units - Sevelamer 800mg x2 - Amlodipine 10mg - ASA 81 - Bupropion 100mg - Plavix 75mg - Metop succ 200mg - Omeprazole 20mg - Folic acid - Lisinopril 20mg - Oxycodone 5mg x2 Consults: - Renal: HD tomorrow - Vascular: admit to medicine. Graft patent, good distal signals of DP and ___, no vascular intervention indicated. Symptoms likely not due to graft. Vitals on transfer: T 99.1 BP 192/90 HR 70 RR 20 O2 sat 95% on RA Upon arrival to the floor, the patient is yelling in excruciating pain. States he is having pain in his left knee radiating down into the left foot that feels like when "I get to get my left toes amputated." The light is very bothersome and is painful when switched on. Requesting to keep the lights off. He has not had any fevers, chills, night sweats, shortness of breath, chest pain, abdominal pain, diarrhea, or rashes. Of note, this is his ___ admission to ___ over the last year. Spoke with patient's wife, ___, who stated that ___ afternoon started to have leg pain that was uncontrollable. approximately 2pm that day. She notes that it takes a while to manage his pain and then he goes into "overdose." He has no vision in his left eye due to a "blood blister" and was told he would need to have it removed. Because the pain in his eye subsided and the risk that surgery would not entirely remove his pain, he decided not to remove the left eye. Has been following with ___ ophthalmology. Despite repeated efforts (4 calls to his facility requesting fax), unable to obtain accurate list of medications. Past Medical History: - Left preretinal hemorrhage - Atrial fibrillation - AVR with goal INR 2.5-3.5 - IDDM since age ___ c/b retinopathy, neuropathy, nephropathy - ESRD- HD T/R/Sa, has tunneled HD catheter - CAD-s/p stenting in ___, CABG at ___ in ___ - Embolic stroke (___) with persistent right sided weakness, CVA in the right parietal lobe (___) - Fungal peritonitis associated with PD ___ - History of infected AV graft in right upper ___ fibular head lateral malleolus osteomyelitis treated s/p debridement - HLD - Depression - Celiac disease - Recurrent pleural effusion since CABG Social History: ___ Family History: Father with CAD, CABG. Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VITALS: 24 HR Data (last updated ___ @ 2352) Temp: refused all vitals (Tm 99.1), BP: 162/80(162-192/80-90), HR: 70, RR: 20, O2 sat: 95%, O2 delivery: Ra, Wt: 191.14 lb/86.7 kg GENERAL: Appears uncomfortable, yelling in pain HEENT: Maintaining eyes closed due to pain NECK: Thyroid non palpable, no lymphadenopathy CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally anteriorly at mid-axillary and mid-clavicular lines ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. EXTREMITIES: Right arm edematous ___ graft harvesting, pain over anterior left knee, no posterior knee or leg pain bilaterally. SKIN: No obvious rashes. upper and lower extremities cool but with strong dopplerable distal pedal pulses. No mottling. No erythema, lower extremity edema, bullae, necrosis or ecchymosis, or crepitus NEUROLOGIC: Sensation diminished over L5 and S1 bilaterally. ======================= DISCHARGE PHYSICAL EXAM ======================= Vitals: T 98.4 BP 123/78 HR 72 RR 18 O2 96% on RA General: Middle-aged man, lying in bed, more engaged today, awake HEENT: Opened R eye, normal sclera, surgically absent L eye c/d/I, decreased swelling of L eyelid, L eye open Resp: clear anteriorly, posterior exam clear but limited by positioning, normal work of breathing CV: RRR, nml S1/S2, ___ systolic murmur unchanged GI: Soft, non-tender, non-distended, no guarding, +BS. MSK: LLE amputation with dressing present. No erythema, bullae, vesicles, or ulceration. 2+ right pedal edema, stable. SKIN: Dressing c/d/I over left heel, mild serous drainage, 2-3cm area of erythema with minimal skin breakdown. 3cm mild erythema R knee. Significant RUE edema. Sacrum with erythema, unchanged, dressing c/d/I. Pertinent Results: ADMISSION LABS: ============== ___ 04:44AM BLOOD WBC-8.3 RBC-3.89* Hgb-11.0* Hct-35.3* MCV-91 MCH-28.3 MCHC-31.2* RDW-18.1* RDWSD-60.2* Plt ___ ___ 04:44AM BLOOD Neuts-75.2* Lymphs-13.9* Monos-9.4 Eos-0.5* Baso-0.5 Im ___ AbsNeut-6.26* AbsLymp-1.16* AbsMono-0.78 AbsEos-0.04 AbsBaso-0.04 ___ 04:44AM BLOOD Glucose-143* UreaN-34* Creat-5.5* Na-140 K-5.0 Cl-95* HCO3-21* AnGap-24* ___ 07:10AM BLOOD Calcium-8.9 Phos-5.3* Mg-2.3 ___, PTT: ============== ___ 11:25PM BLOOD ___ PTT-52.8* ___ ___ 04:44AM BLOOD ___ PTT-46.0* ___ ___ 05:34AM BLOOD ___ PTT-91.8* ___ ___ 05:08AM BLOOD ___ PTT-37.0* ___ ___ 06:50AM BLOOD ___ PTT-40.7* ___ ___ 06:40AM BLOOD ___ PTT-66.3* ___ ___ 06:40AM BLOOD ___ PTT-45.4* ___ ___ 03:45AM BLOOD ___ PTT-46.1* ___ ___ 06:30AM BLOOD ___ PTT-44.8* ___ ___ 12:19AM BLOOD ___ PTT-60.2* ___ ___ 04:43AM BLOOD ___ PTT-143.6* ___ ___ 12:24PM BLOOD ___ PTT-84.5* ___ ___ 05:32AM BLOOD ___ PTT-35.3 ___ ___ 03:38AM BLOOD ___ PTT-37.8* ___ ___ 05:22AM BLOOD ___ PTT-41.4* ___ ___ 01:23PM BLOOD ___ PTT-37.6* ___ ___ 05:05AM BLOOD ___ PTT-55.5* ___ ___ 12:25AM BLOOD ___ PTT-71.2* ___ ___ 07:30AM BLOOD ___ PTT-71.4* ___ ___ 05:57AM BLOOD ___ PTT-118.0* ___ ___ 02:07PM BLOOD ___ PTT-150* ___ DISCHARGE LABS: ================ ___ 05:26AM BLOOD WBC-5.9 RBC-3.72* Hgb-10.6* Hct-34.6* MCV-93 MCH-28.5 MCHC-30.6* RDW-19.6* RDWSD-66.6* Plt ___ ___ 05:26AM BLOOD ___ PTT-61.1* ___ ___ 05:26AM BLOOD Glucose-220* UreaN-17 Creat-4.3# Na-144 K-4.5 Cl-101 HCO3-29 AnGap-14 ___ 05:26AM BLOOD Calcium-8.7 Phos-4.7 Mg-2.1 MICROBIOLOGY: ================ ___ Blood culture: No growth ___ Blood culture: No growth ___ Blood culture: No growth ___ Blood culture: No growth IMAGING: ================ ___ CXR (portable) Right IJ central venous catheter tip is in the high right atrium. Left subclavian Port-A-Cath tip is in the mid to low SVC. Heart size is nrmal. Mediastinal wires are intact. There is borderline vascular congestion without frank interstitial edema. Linear scarring in the right midlung field is unchanged. There is no focal consolidation. There is no large effusion or pneumothorax. ___ Arterial duplex lower extremities The left distal SFA demonstrates wall-to-wall color flow and normal arterial waveforms. The distal SFA graft appears patent with wall to wall color flow and arterial waveforms. Distal to the graft, the calf artery is also patent with color flow and arterial waveform. ___ CTA lower extremities w/ & w/o contrast 1. Patent left lower extremity femoral arteries and graft. Markedly attenuated and atherosclerotic left anterior tibial and peroneal arteries with slow flow as above but appear patent. Patent left posterior tibial artery. 2. Three-vessel runoff in the right lower extremity as above. Ectatic right common femoral artery, unchanged. Occlusion of the popliteal artery with reconstitution to provide three-vessel runoff in the right lower extremity as above. 3. Bilateral, trace nonhemorrhagic pleural effusions with minimal relaxation atelectasis in the lower lobes, improved from prior. ___ EKG HR 82, PR 137, QRS 92, QT 367, QTc 405/429 (___) Brief Hospital Course: Mr. ___ is a ___ yo male with a history of T1DM, CAD s/p stents and subsequent CABG, mechanical AVR, CVA w/residual right-sided weakness, ESRD on HD, PVD, and left eye blindness who initially presented with left lower extremity pain, found to resolve but then developed severe left eye pain refractory to topical steroids and systemic opioids, s/p oculoplastic surgery (enucleation) with Dr. ___ on ___ with planned readmission back to ___ after procedure. ACUTE ISSUES: ============= #Glaucoma #Left Eye Pain Patient has history of left eye blindness and glaucoma, with recurrent episodes of debilitating left eye pain. He has been followed by ophthalmology in the past, and received alcohol-based retrobulbar injections that provided temporary pain relief. While admitted, he had a flare of left eye pain that was very severe. Ophthalmology was consulted and recommended a regimen of eye drops (prednisolone, ketorolac, atropine, dorzolamide, timolol, brimonidine). He was offered another retrobulbar alcohol injection for the eye, but deferred because they have not consistently helped. His pain regimen was developed with consultation of the Chronic Pain Service, who had followed with Mr. ___ before. His pain remained refractory to up-titration of oral hydromorphone with IV hydromorphone for breakthrough pain. Ultimately, patient decided to proceed with left eye enucleation with Dr. ___ on ___ due to severe refractory pain. Post-operatively, he experienced near-total relief of his prior left eye pain, though with normal post-operative irritation. A pressure patch was placed on the left eye perioperatively. Dorzolamide, ketorolac, and prednisolone eye drops were continued for the right eye per ophthalmology recs. At time of discharge, he had been transitioned to a regimen of acetaminophen 1000 mg PO q8h as needed for pain. Eye stitches taken out ___. For eye drops, he was continued only on dorzolamide BID to the Right eye only with no drops for the left eye, per ophtho recs. #Left Leg Pain #PVD s/p let toe amputation Mr. ___ has a history of PVD status post left toe amputation. His initial left lower extremity pain on presentation started after dialysis on ___. It radiated from the left knee into his foot and was non-reproducible on palpation. He had strong pulses on Doppler, with CTA showing extensive atherosclerotic changes but no new occlusion. Presentation not thought to be consistent with DVT or necrotizing fasciitis as his INR was supra-therapeutic and he had no fevers, chills, erythema, crepitus, or bullae. He also had no obvious evidence of ulcers, gangrene, or symptoms of ischemic rest pain. Given its radiating nature, pain was thought to be consistent with severe neuropathy. His pain eventually stabilized to baseline while on pain regimen as described above. He was continued on home duloxetine and cilostazol. Gabapentin was ultimately discontinued when his leg pain resolved. Home Plavix was held perioperatively and then resumed per discussion with vascular surgery. #DM Type I He has a history of Type I diabetes complicated by retinopathy, neuropathy, and vascular disease, with recent admission for diabetic ketoacidosis. His sugars were labile this admission given his limited oral intake in the setting of pain, ranging from ___ - mid ___. His insulin was adjusted as necessary, with consultation from the ___ diabetes ___. Ultimately, he was discharged on a regimen of Lantus 4U nightly and Tradjenta (lingagliptin) 5mg once daily in the morning, with no need for Humalog insulin. #Anticoagulation #Mechanical AVR #CAD s/p CABG #Hx embolic CVA: He has history of a mechanical aortic valve with labile INR as well as previous spontaneous bleeding. INR goal had been changed from 2.5 - 3.5 to 2.0 - 3.0 given his bleeding risk as described by prior providers. When first admitted, his INR was supra-therapeutic and his warfarin was held; once his INR downtrended, his warfarin was re-started with dose adjustments recommended by our pharmacy team. ___, we held his warfarin per cardiology's recommendation and started heparin once INR fell below 2.3. He was maintained on a heparin drip requiring frequent adjustments for supratherapeutic PTT. Post-operatively on ___, he was re-started on warfarin in consultation with ophthalmology, with heparin bridging until achievement of therapeutic INR. INR goal ___ was confirmed in consultation with cardiology with possible increase back to 2.5-3.5 in the outpatient setting. We continued his home aspirin. #Hypotension #Hypertension He presented as hypertensive and continued to have high-ranging systolic blood pressures while admitted; this was thought to be due primarily as reaction to pain. We initially continued his carvedilol 37.5 mg BID, nifedipine 90 mg on non-HD days, and lisinopril 5 mg daily. Blood pressure normalized post-operatively with improved pain control. However, subsequently required overnight observation in ICU on ___ due to new-onset hypotension refractory to fluid resuscitation on the floor. Hypotension was likely secondary to medication effect iso ESRD (4 antihypertensives, benzodiazepines, gabapentin). He then became hypertensive after holding lisinopril, amlodipine, carvedilol, and nifedipine. Home medications were gradually re-introduced and his blood pressure was closely followed. Ultimately, he was stabilized on a regimen of amlodipine 10mg daily, carvedilol 37.5mg BID, and lisinopril 5mg PO daily. Nifedipine was discontinued. #Somnolence #Respiratory acidosis. Respiratory acidosis developed acutely ___ (VBG pH 7.31, pCO2 56, pO2 78), with respiratory rate ___. Most likely etiology respiratory depression from opioid intoxication, due to chronically high doses of opioids for eye pain in setting of ESRD. Received Narcan on floor 0.04/0.04/0.1 mg with stabilization of respiratory status. He was observed overnight in the ICU ___ as above. Opioids were held and patient did not require further opioids given improvement in eye pain. Respiratory depression did not recur. He was closely monitored for signs and symptoms of opioid withdrawal. At time of discharge, he was at baseline level of alertness with normal respiratory status. #Constipation, diarrhea, abdominal discomfort New liquid diarrhea on ___, without accompanying signs/symptoms of infection or other GI symptoms. Suspect secondary to mild opioid withdrawal iso opioid discontinuation following resolution of eye pain. No other symptoms of withdrawal, diarrhea resolved, subsequently developed occasional constipation. No fever, leukocytosis, or tenderness on abdominal exam, and infectious work-up was not pursued given rapid resolution of symptoms. Provided symptomatic treatment as needed. #Pressure ulcers Closely monitored stage 2 pressure ulcers on left heel and sacrum and stage 1 pressure ulcer on lateral right knee. Managed with daily wound care, pressure off-loading, and frequent repositioning. CHRONIC ISSUES ============== # ESRD He received dialysis on ___, and ___ per his schedule while admitted. Nephrology followed him throughout his admission. We continued his sevalemer for phosphate balance, which was increased to 2400mg PO TID with meals, and treated him with epoetin for his anemia per nephrology recommendations. #Anemia: Normocytic, most likely anemia of chronic disease/CKD, ferritin was normal in ___, lower suspicion for iron deficiency anemia. Continued epoetin while inpatient as above. Hemoglobin nadir 9.8, baseline approximately 11.2. No gastrointestinal symptoms or hemodynamic instability to suggest occult bleed. Hematocrit and hemoglobin were closely followed. #Nausea #Emesis Fluctuating nausea throughout admission with occasional small-volume emesis, symptoms largely post-prandial. Most likely secondary to gastroparesis iso long-standing DM with additional contributions from opioids. Responded well to intermittent odansetron use with reassuring abdominal exam and no other associated symptoms. Also restarted home metoclopramide. QTC 393 on ___. # Nutrition Intermittent poor PO intake, leading to labile blood glucose. Liberalized diet to Regular/Gluten free diet while inpatient per nutrition recs. Also trialed metoclopramide as above. # Goals of care # History of suicidal ideation, depression, anxiety Patient previously expressed passive SI, and he has been followed by psych. We continued home duloxetine, mirtazapine, and bupropion while admitted. EKG ___ showed QTc 393. Reported stable mood without depression at time of discharge, with improvement following resolution of eye pain. Per discussions with wife ___, numerous prior conversations with palliative care and family about code status, but Mr. ___ reluctant to engage in conversations in recent months due to severe eye pain. Mood feels stable with relief of eye pain, and he expressed preference for no further palliative care discussions while inpatient. We encouraged continued family discussions on an outpatient basis. TRANSITIONAL ISSUES ================= - Discharge Hgb/Hct: 10.___.6 - Discharge ___: 2.7 on 1 mg wafarin daily - Due for INR check ___, goal INR 2.0-3.0 - Pain regimen: Acetaminophen 1000 mg PO/NG Q8H. No longer requiring opioids or gabapentin. - Discharge insulin regimen: Lantus 4U HS and Tradjenta (linagliptin) 5mg once daily in the morning; this oral med is safe in ESRD, no need for Humalog insulin. - Discharge blood pressure regimen: STOPPED nifedipine. Discharged on a regimen of amlodipine 10mg daily, carvedilol 37.5mg BID, and lisinopril 5mg PO daily. - Eye care: Continue on Dorxolomide BID right eye only. Stop prednisolone and Ketorolac OD. No need for eye drops to left eye. Appointments: - Scheduled for ophthalmology follow-up with Dr. ___ ___ on ___ at 10:30AM - Please schedule PCP appointment with Dr. ___, ___. - Please schedule ___ Diabetes Clinic follow-up within 2 weeks of discharge given intensive insulin regimen adjustment required this admission, Dr. ___, ___. - Please schedule cardiology follow-up within 1 week of discharge for optimization of blood pressure regimen and continued warfarin titration, Dr. ___, ___. - Suggest continuing to discuss goals of care on an outpatient basis given frequent readmissions and deteriorating clinical status. If desired, ___ follow up in palliative care clinic with Ms. ___, NP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atorvastatin 40 mg PO QPM 3. Atropine Sulfate Ophth 1% 1 DROP LEFT EYE BID 4. Bacitracin Ophthalmic Oint 1 Appl RIGHT EYE QID 5. Bisacodyl ___AILY:PRN constipation 6. Brimonidine Tartrate 0.15% Ophth. 1 DROP LEFT EYE BID 7. BuPROPion (Sustained Release) 100 mg PO BID 8. Calcitriol 0.5 mcg PO DAILY 9. Carvedilol 37.5 mg PO BID 10. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE BID 11. DULoxetine 20 mg PO DAILY 12. Ferrous GLUCONATE 324 mg PO DAILY 13. Gabapentin 100 mg PO TID 14. Glucagon 1 mg IM Q15MIN:PRN Hypoglycemia 15. Ketorolac 0.5% Ophth Soln 1 DROP BOTH EYES Q12H:PRN Eye pain 16. Lidocaine 5% Patch 1 PTCH TD QPM 17. Mirtazapine 30 mg PO QHS 18. Naphazoline-Pheniramine Ophth. Solution 1 DROP BOTH EYES QID:PRN Itchy eyes 19. Nephrocaps 1 CAP PO QHS 20. Ondansetron 4 mg PO Q8H:PRN Nausea 21. Polyethylene Glycol 17 g PO BID:PRN constipation 22. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP LEFT EYE BID 23. sevelamer CARBONATE 2400 mg PO TID W/MEALS 24. Timolol Maleate 0.5% 1 DROP LEFT EYE ASDIR L eye BID 25. Ranitidine 150 mg PO BID 26. LOPERamide 2 mg PO QID:PRN diarrhea 27. FoLIC Acid 1 mg PO DAILY 28. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 29. Florastor (Saccharomyces boulardii) 250 mg oral BID 30. Cilostazol 100 mg PO BID 31. NIFEdipine (Extended Release) 90 mg PO DAILY 32. Lisinopril 5 mg PO DAILY 33. Warfarin 1.25 mg PO DAILY16 34. GuaiFENesin 5 mL PO Q4H:PRN cough 35. HYDROmorphone (Dilaudid) 4 mg PO Q8H:PRN Pain - Moderate 36. LORazepam 0.5 mg PO Q8H:PRN eye pain, anxiety 37. darbepoetin alfa in polysorbat 100 mcg/mL injection 1X/WEEK 38. Vitamin D ___ UNIT PO 1X/WEEK (MO) 39. Insulin SC Sliding Scale Insulin SC Sliding Scale using HUM Insulin 40. Glargine 22 Units Bedtime 41. PrednisoLONE Acetate 1% Ophth. Susp. 1 DROP RIGHT EYE QID 42. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 43. Clopidogrel 75 mg PO DAILY 44. Artificial Tear Ointment 1 Appl BOTH EYES DAILY:PRN eye pain Discharge Medications: 1. amLODIPine 10 mg PO DAILY 2. linaGLIPtin 5 mg oral QAM 3. Metoclopramide 5 mg PO BID nausea with meals as needed for nausea 4. Glargine 4 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Warfarin 1 mg PO DAILY16 6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild 7. Aspirin 81 mg PO DAILY 8. Atorvastatin 40 mg PO QPM 9. Bisacodyl ___AILY:PRN constipation 10. BuPROPion (Sustained Release) 100 mg PO BID 11. Calcitriol 0.5 mcg PO 3X/WEEK (___) 12. Carvedilol 37.5 mg PO BID 13. Cilostazol 100 mg PO BID 14. Clopidogrel 75 mg PO DAILY 15. darbepoetin alfa in polysorbat 100 mcg/mL injection 1X/WEEK 16. DiphenhydrAMINE 25 mg PO Q6H:PRN Eye itchiness 17. Dorzolamide 2% Ophth. Soln. 1 DROP LEFT EYE Q12H 18. DULoxetine 20 mg PO DAILY 19. Ferrous GLUCONATE 324 mg PO 3X/WEEK (___) 20. Florastor (Saccharomyces boulardii) 250 mg oral BID 21. FoLIC Acid 1 mg PO DAILY 22. Glucagon 1 mg IM Q15MIN:PRN Hypoglycemia 23. GuaiFENesin 5 mL PO Q4H:PRN cough 24. Lidocaine 5% Patch 1 PTCH TD QPM 25. Lisinopril 5 mg PO 3X/WEEK (___) 26. LOPERamide 2 mg PO QID:PRN diarrhea 27. Mirtazapine 30 mg PO QHS 28. Nephrocaps 1 CAP PO QHS 29. Polyethylene Glycol 17 g PO BID:PRN constipation 30. Ranitidine 150 mg PO BID 31. sevelamer CARBONATE 2400 mg PO TID W/MEALS 32. Vitamin D ___ UNIT PO 1X/WEEK (MO) Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left eye pain s/p enucleation Chronic Glaucoma Secondary: Hypertension Type 1 DM Nausea Leg pain ESRD Discharge Condition: Mental Status: Alert and oriented. Ambulatory Status: Cannot ambulate, has residual R sided weakness from CVA, uses wheel-chair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care here at ___. Why was I admitted to the hospital? You were admitted to the hospital because of very severe pain in your left leg. What was done for me while I was in the hospital? While you were in the hospital, your leg was evaluated and found to have good blood flow. That was reassuring, as poor blood flow can cause very severe pain and gangrene as you mentioned you had experienced before. You were given pain medication through both IV and pills to help with the pain you developed in your left eye, and were followed by our ophthalmology team who recommended eye drops that could help. When these treatments were unable to relieve your pain, the left eye was removed by our eye surgeons. You were also given insulin for your diabetes and taken to dialysis per your schedule. You were also given medications to treat nausea and diarrhea. Your heart and blood pressure medications were stopped when your blood pressure became too low, and they were slowly re-started while we monitored your blood pressure. What should I do when I leave the hospital? - Please continue to take all of your medications as prescribed and keep all of your appointments. We wish you the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10123997-DS-13	10,123,997	22,701,140	DS	13	2196-12-03 00:00:00	2196-12-09 22:07:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ with stage III recurrent lung CA s/p chemotherapy and depression who presents with progressive dyspnea and dry cough. She last saw her oncologist on ___ where it was noted that an acute episode of dyspnea delayed cycle 4 of chemotherapy. At that time, it was thought that her CT showed response to chemo and that SOB was likely related to anxiety. Since this visit she has had progressive dyspnea and dry cough. Initially able to walk several blocks however now only able to walk several feet. No PND, orthopnea, ___ edema, hemoptysis, CP or fevers. Given progression of symptoms she presented to the ED for evaluation. In the ED, initial VS were 37 90 120/80 18 94% 2L. Labs were at baseline. She underwent a CXR which showed worsening mass and ?lymphangitic spread. Patient was then admitted to OMED for further management. On arrival to the floor, patient reports continues to have dyspnea at rest. Past Medical History: PAST ONCOLOGIC HISTORY Presented to her PCP ___ ___ with one month of dry cough and shortness ob breath. She had a chest xray done which showed LLL opacity and consolidation and was prescribed a 5-day course of antibiotics. However, her symptoms persisted and on ___ she underwent a chest CT, which was notable for LLL collapse due to left hilar mass with peribronchial components and adenopathy involving at least the subcarinal and ipsilateral paraesophageal mediastinum, and left hilus. On ___, the patient underwent endoscopy with debridement of the occluding tumor from the L main stem and EBUS-TBNA from stations 11r and 7. Pathology confirmed poorly differentiated spindle cell neoplasm with necrosis. There were up to 30 per 10 high power fields. The tumor cells were positive for cytokeratin cocktail, cytokeratin MNF-116, and p63. TTF-1 and CK5/6 are negative. Areas also showed weak, focal positivity for actin, desmin, CD34, and S100. These findings were consistent with sarcomatoid carcinoma of the lung. Level 7 LN cytology was positive, 11R negative for involvement. On ___, the patient had a PET/CT which showed a 5.9 x 5.5 highly avid LLL mass with at least two adjacent L subcarinal and paraesophageal nodes, FDG-avid, the largest measuring 21 x 12 mm. An MRI of the brain ruled out CNS involvement. Thus, the patient was diagnosed with Stage IIIA (T2N2) disease. - ___ C1D1 Cisplatin/Etoposide with concurrent XRT. - ___ C2D1 Cisplatin/Etoposide with concurrent XRT. - ___ C2D8 Cisplatin held due to thrombocytopenia. - ___ Completed XRT. - ___ C1D1 Cisplatin/Etoposide (Days ___, 21-week cycles) - ___ C2D1 Cisplatin/Etoposide (Days ___, 21-week cycles) - ___: Underwent L thoracentesis, cytology negative for malignant cells - ___: Pleurex placed - ___: CT shows persistent obstruction of the left lower lobe bronchus with distal mucoid impaction and atelectasis. Unchanged mediastinal lymphadenopathy. - ___: Pleurex removed - ___: CT showed slight interval increase in the size of the left lower lobe obstructive and peribronchial soft tissue with slight interval increase in the degree of left lower lobe atelectasis. Increased acentric irregular soft mass in the left main pulmonary artery concerning for tumor invasion given increase in size and irregular margins. Slight increase in 4 mm right upper lobe pulmonary nodules, minimal increase in subcarinal adenopathy an unchanged upper paratracheal lymph nodes. - ___: Bronch with FNA of Lung right upper paratracheal mass was POSITIVE FOR MALIGNANT CELLS, consistent with poorly differentiated squamous cell carcinoma. - ___: C1D1 ___ (AUC 5)/taxol - ___: C2D1 ___ (AUC 5)/taxol - ___: Neulasta (nadir ANC with C1 was 950) -___: CT showed overall mixed response with slight interval increase in the size of eccentric soft tissue mass involving the left pulmonary artery with an increase in intravascular component, stable 4 mm right upper lobe pulmonary nodule, slight decrease in the size of right paratracheal and AP window lymphadenopathy, relatively stable size of the left lower lobe obstructive endo and peribronchiolar soft tissue with increase in the degree of left lower lobe atelectasis. -___: Cycle 3, day 1 ___. Enoxaparin was initiated for PE versus tumor thrombus noted on CT. -___: Neulasta. -___: C4 delayed ___ new episodes of SOB -___: CT showed continued improvement in left hilar and mediastinal mass with some decrease both in size and extent of invasion of the left pulmonary artery. Left bronchial tree is fully patent. Persistent considerable left lower lobe consolidation and small left pleural effusion. Some of this is presumably radiation effect. Severe emphysema. Moderately severe pulmonary fibrosis. -___: C4D1 ___ PAST MEDICAL AND SURGICAL HISTORY: - Depression - Lung Cancer as above - Hx of thyroid nodule and thyrotoxicosis - L Meniscus tear Social History: ___ Family History: Positive for lung cancer and breast cancer in some of her 13 siblings, patient cannot recall further details. Her ___ year old daughter had breast cancer and lymphoma. Physical Exam: ADMISSION: Vitals: T:98.2 P:104 BP:143/67 RR:22 O2: 93 3L General: Ill-appearing, sleeping but arousable, no acute distress HEENT: PERRL, R drifting gaze, sclera anicteric, dry mucous membranes, oropharynx clear, some small petichae post oropharynx Neck: 1cm LN lat to R SCM, shotty cervical LNs, supple Lungs: R lung clear to auscultation, L lung scattered crackles and decreased breath sounds , no wheeze, rales, rhonchi CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops Abdomen: Soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: No obvious rashes. Cutaeous lesion on L upper chest Neuro: R-deviating gaze, tongue deviation to L, sensation grossly intact, RUE strength ___, LUE ___, RLE ___ strength, LLE ___, sensation grossly intact DISCHARGE: VS: None, pt is CMO Gen: Somnolent but arousable. Resp: On nonrebreather, 15L Pertinent Results: ADMISSION: ___ 03:00PM LACTATE-1.4 ___ 02:45PM GLUCOSE-112* UREA N-12 CREAT-0.8 SODIUM-142 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-18 ___ 02:45PM estGFR-Using this ___ 02:45PM WBC-6.2 RBC-2.73* HGB-9.0* HCT-27.4* MCV-101* MCH-32.9* MCHC-32.7 RDW-14.0 ___ 02:45PM NEUTS-86.0* LYMPHS-6.1* MONOS-6.1 EOS-1.5 BASOS-0.3 ___ 02:45PM PLT COUNT-120* ___ 02:45PM ___ PTT-31.1 ___ INTERIM: ___ 07:25AM BLOOD ALT-19 AST-13 AlkPhos-80 TotBili-0.5 ___ 07:25AM BLOOD proBNP-___* DISCHARGE: MICRO: ___ BLOOD CXS NEG IMAGING: ___ CXR IMPRESSION: Interval progression in size of left retrocardiac mass with increased right lung interstitial opacities concerning for lymphangitic carcinomatosis. ___ CTA IMPRESSION: 1. 2.7 x 1.4 cm left hilar mass with irregular encroachment of the left pulmonary artery appearing stable since the prior CT from ___. Stable prominent prevascular and paratracheal lymph nodules. 2. Worsening left lower lobe collapse, which may be obscuring increased posterior extension of the left hilar mass. 3. Worsened small bilateral non-hemorrhagic pleural effusions. 4. Increased multifocal bilateral densities, including a new 1.1 cm right upper lobe nodule favors infection given short-interval development, however, aggressive neoplastic spread cannot be excluded. Recommend short-term follow CT following resolution of acute symptoms. 5. Background moderate centrilobular emphysema and peripheral pulmonary fibrosis. ___ ECHO Conclusions The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with basal inferior and inferolateral hypokinesis. There is no ventricular septal defect. The right ventricular cavity is mildly dilated with borderline normal free wall function. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSINO: regional left ventricular systolic dysfunction as described above. Moderate to severe mitral regurgitation. Mild aortic regurgitation. Moderate pulmonary hypertension. ___ CT CHEST IMPRESSION: 1. Heterogeneous opacification of the right lung with ground glass and septal thickening, but areas of spared lung and with patchy consolidative opacities, which have worsened since prior exam one week prior, suggesting an acute process such as pneumonia. Asymmetric edema, inflammatory pneumonitis or sequelae of drug toxicity are less common etiologies which can be otherwise considered if infection is not likely on clinical grounds. Carcinomatosis is difficult to exclude but rapid on-site in the acute setting makes other etiologies perhaps more likely. 2. Treated left hilar mass is unchanged from prior exam. 3. Consolidation likely representing postobstructive atelectasis is again seen in the left lower lobe, improved from prior exam. 4. Small moderate right pleural effusion, increased from prior exam. Stable small left pleural effusion. Brief Hospital Course: ___ with stage III recurrent lung CA s/p chemotherapy and depression who presents with progressive dyspnea and dry cough found to have progression of disease on CXR. # Dyspnea: Initial CXR raised concern for lymphangetic spread of her disease. A CT chest showed progression of her lung cancer, emphysema, peripheral pulmonary fibrosis and possible infection. She was started on ceftriaxone/azithromycin. Pulmonology was consulted, who recommended continuing broad spectrum antibiotics, diuresis, steroids; pt not a candidate for bronch. Her abx were broadened to cefepime/vancomycin/levofloxacin/bactrim. She was started on steroids or possible drug toxicity/COPD flare. She was also diuresed (BNP was elevated, Echo EF 55-60%). There was no evidence of PE on CTA. Despite these interventions her respiratory status worsened, and she progressed to requiring 15L nonrebreather to maintain O2 sats in low ___. With the help of the palliative care team, a family meeting was held where it was decided to transition her to comfort care. She was made CMO, and transitioned to hospice on ___. # Lung CA: s/p s/p C2 Cisplatin/Etoposide, XRT, ___. Palliative Care following. Treatment as above; transition to CMO. # Difficulty urinating: voiding, but has noticed increased difficulty. Possibly ___ morphine; pt discharged to hospice w/ foley catheter. # PE history: Eenoxaparin d/c'd when made CMO. # Depression: sertraline d/c'd when made CMO. #Goals of care. Pt transitioned to CMO and transitioned to hospice on ___ as above. Family in agreement with comfort care. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob 2. Enoxaparin Sodium 80 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 3. Lorazepam 0.5 mg PO Q8H:PRN anxiety 4. Ondansetron 8 mg PO Q8H:PRN nausea 5. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain 6. Sertraline 150 mg PO DAILY 7. Tiotropium Bromide 1 CAP IH DAILY 8. Aspirin 81 mg PO DAILY 9. Acetaminophen Dose is Unknown PO Q6H:PRN pain Discharge Medications: 1. Acetaminophen 325 mg PO Q6H:PRN pain 2. Lorazepam 0.5 mg PO Q4H:PRN anixety 3. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea, cough 4. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough 5. Morphine Sulfate (Oral Soln.) ___ mg PO Q1H:PRN dyspnea 6. Polyethylene Glycol 17 g PO DAILY 7. PredniSONE 30 mg PO DAILY 8. Ondansetron 8 mg PO Q8H:PRN nausea 9. Sodium Chloride Nasal ___ SPRY NU QID:PRN dryness Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Pneumonia Lung cancer COPD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Dear Ms. ___, It was a pleasure treating you at ___. You were admitted to the hospital with cough and shortness of breath. You were given antibiotics to treat a lung infection. You were also given steroids and other medications to help improve your breathing, as well as diuretics to treat whatever fluid might be contributing to your symptoms. Unfortunately your breathing did not improve; we believe your symptoms may represent a progression of your underlying cancer. Even if not, the process has not been responsive to our treatments. We met with your family to discuss your care options, which is what you indicated was your wish (you declined to participate in the meeting). We decided with your family to focus on treatments aimed at symptom relief; you were discharged home with hospice care. Please take your medications as prescribed and followup at the medical appointments listed below. We wish you the best. Followup Instructions: ___
10124346-DS-5	10,124,346	21,387,191	DS	5	2131-07-03 00:00:00	2131-07-04 23:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sanctura XR / Augmentin Attending: ___. Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catherization without intervention History of Present Illness: Ms. ___ is an ___ year old woman with h/o CAD w/BMS to LAD in ___ with instent restenosis ___ with DES placed, hypothyroidism, and recurrent UTIs who presents with chest pain. She an episode of light headedness/weakness and ___ chest pain, which was non radiating, substernal chest pain. Associated with shortness of breath. This occurred when she was rising from a chair. Pain felt similar to previous angina but less severe. It lasted 10 minutes. She took one aspirin 325. She called her ___ who recommended that she be evaluated by a physician. As she was not able to get her doctors' office, she called ___. In the ED, initial vitals were 98.6 66 134/82 18 97% RA and she was chest pain free. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, -Hypertension 2. CARDIAC HISTORY: - PERCUTANEOUS CORONARY INTERVENTIONS: NSTEMI s/p BMS to LAD ___, DES to LAD in stent restenosis in ___ 3. OTHER PAST MEDICAL HISTORY: 1. Recurrent urinary tract infection, followed by ___. 2. History of bronchitis. 3. Hypercholesterolemia. 4. Bilateral chronic venous insufficiency. 5. Hypothyroidism. 6. Depression. 7. Anemia. 8. Hearing loss. 9. Insomnia. 10. History of vaginal prolapse. PAST SURGICAL HISTORY: 1. Cholecystectomy. 2. TAH/BSO. Social History: ___ Family History: Mother died age ___ "old age." Father died age ___ of colon cancer. Both were in a nursing home and died within 12 days of one another. Physical Exam: Admission: VS: Wt= 160 lbs T= 97.9 BP= 117/61 HR= 64 RR= 18 O2 sat=100% RA General: Appears younger than stated age and in no distress HEENT: AT/NC, no slcera icterus, no conjunctival palor, dry mucous membranes Neck: Supple, JVP estimated to 8 cm CV: RRR, soft heart sounds, no murmurs appreciated Lungs: Comfortable on RA, Crackles at bilateral bases that cleared somewhat with coughing Abdomen: Soft, non tender non distended GU: Deferred Ext: WWP, compression stockings in place Neuro: Alert, oriented to person, place, time, situation, fluent, moving all extremities spontaneously, ambulating with cane Skin: Clean/dry intact PULSES: ___ 1+ bilaterally, femoral 2+ bilaterally, no bruits Discharge: T: 97.2 BP: 100-160s/60-70s HR: 60-80s RR 18, 97% on RA General: Appears younger than stated age and in no distress HEENT: AT/NC, no slcera icterus, no conjunctival palor, dry mucous membranes Neck: Supple, JVP estimated to 8 cm CV: RRR, soft heart sounds, no murmurs appreciated Lungs: Comfortable on RA, Crackles at bilateral bases that cleared somewhat with coughing Abdomen: Soft, non tender non distended GU: Deferred Ext: WWP, trace edema, right groin site with with tegederm in place, no induration or hematoma, minimal staining on dressing Neuro: Alert, oriented to person, place, time, situation, fluent, moving all extremities spontaneously, ambulating with cane Skin: Clean/dry intact PULSES: ___ 1+ bilaterally, femoral 2+ bilaterally, no bruits Pertinent Results: Admission: ___ 11:30AM BLOOD WBC-4.8 RBC-3.79* Hgb-10.4* Hct-32.8* MCV-87 MCH-27.4 MCHC-31.7 RDW-15.3 Plt ___ ___ 11:30AM BLOOD Glucose-105* UreaN-22* Creat-1.6* Na-139 K-4.6 Cl-107 HCO3-22 AnGap-15 ___ 11:30AM BLOOD cTropnT-<0.01 ___ 05:17PM BLOOD CK-MB-2 cTropnT-<0.01 ___ 06:35AM BLOOD CK-MB-3 cTropnT-<0.01 Discharge: ___ 06:37AM BLOOD WBC-4.2 RBC-3.84* Hgb-10.2* Hct-32.9* MCV-86 MCH-26.6* MCHC-31.0 RDW-15.2 Plt ___ ___ 06:37AM BLOOD Glucose-106* UreaN-15 Creat-1.5* Na-140 K-4.3 Cl-108 HCO3-23 AnGap-13 UA/UC ___ 07:40PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG Urine culture - mixed Cardiac catherization: Coronary angiography: right dominant LMCA: normal LAD: normal; stent widely patent LCX: normal RCA: normal Brief Hospital Course: Active Issues: # Chest pain: She was chest pain free throughout her admission. Given her high risk history of in stent restenosis and her description of the chest pain as similar to her previous angina, she was taken for cardiac catherization. Her stent was widely patent and no other significant disease was noted. She was continued on her home metoprolol, atorvastatin, and clopidogrel. Her aspirin was dose reduced from 325 mg to 81 mg as she is now more that 1 month out from any acute coronary syndrome. Her lisinopril was held due to acute kidney injury. # Orthostasis: She was orthostatic on admission, which resolved with fluids. This was most likely caused by poor PO intake as she reported only drinking ___ glasses of fluid daily recently. Her constellation of symptoms which featured chest pain and presyncope while standing may have been due to her orthostasis. She was encouraged to drink ___ glasses of water daily. # Acute kidney injury: Noted to have an increased creatinine from 1.0 to 1.5 on admission. She had recently been taking trimethoprim-sulfamethoxazole which can increase creatinine without true kidney injury, however, given her orthostasis, this was also concerning for prerenal injury. Her creatinine did not improve significantly with either stopping her antibiotic or fluids. She will have close follow up with her PCP to recheck creatinine. Her lisinopril was held. # Dysuria - She had recently started on trimethoprim-sulfamethoxazole for dysuria with a urine culture sent by her ___. She was initially treated with ceftriaxone, as her trimethoprim-sulfamethoxazole was held as above. When these culture results were obtained and they were noted to be only contamination, her antibiotics were stopped. She also had a negative culture and UA while hospitalized. Chronic issues: # Frequent urinary tract infections - There had been discussion of starting antibiotic prophylaxis. This issue was deferred to her PCP and ___. # Hypothyroidism - Continued on home medications. Transitional issues: - Lisinopril has been held pending reassessment of her creatinine at her PCP's office on ___ - Frequent urinary tract infections and the consideration of prophylactic antibiotics. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO QHS 2. Aspirin 325 mg PO DAILY 3. Atorvastatin 40 mg PO QPM 4. Clopidogrel 75 mg PO DAILY 5. Cranberry Concentrate (cranberry conc-ascorbic acid;<br>cranberry extract) 500 mg oral daily 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Lisinopril 2.5 mg PO DAILY 8. Metoprolol Succinate XL 12.5 mg PO DAILY 9. Mirtazapine 15 mg PO HS 10. Pantoprazole 40 mg PO Q24H 11. Tolterodine 2 mg PO BID 12. Estring (estradiol) 2 mg vaginal 3 months 13. Nitroglycerin SL 0.4 mg SL PRN chest pain 14. Sulfameth/Trimethoprim DS 1 TAB PO BID Discharge Medications: 1. Acetaminophen 650 mg PO QHS 2. Atorvastatin 40 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Mirtazapine 15 mg PO HS 7. Tolterodine 2 mg PO BID 8. Cranberry Concentrate (cranberry conc-ascorbic acid;<br>cranberry extract) 500 mg oral daily 9. Estring (estradiol) 2 mg vaginal 3 months 10. Nitroglycerin SL 0.4 mg SL PRN chest pain 11. Pantoprazole 40 mg PO Q24H 12. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet,chewable(s) by mouth daily Disp #30 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Orthostatic hypotension Secondary: Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your hospitalization at the ___. You came to the hospital because of chest pain. You had a cardiac catherization which showed that your arteries and stent are stable. It does not seem that your heart was the cause of your feeling poorly. It is most likely that your symptoms were from not drinking much water and having increased urination. You did improve with fluids that we gave you. Your kidney function was slightly worse than normal during your hospital stay. For this reason, we are stopping your lisinopril until you see Dr. ___ she rechecks your labs. We checked you for a urinary tract infection, and you did not have one. We discontinued your bactrim. We are also decreasing the dose of your aspirin because high dose aspirin is no longer needed. Recommendations for self-care: -Drink about 5 glasses of water a day -Have you labs checked at Dr. ___ office on ___ -Follow up with your doctors ___, ___ Followup Instructions: ___
10124346-DS-6	10,124,346	20,904,650	DS	6	2132-07-22 00:00:00	2132-07-22 19:32:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sanctura XR / Augmentin Attending: ___. Chief Complaint: Fall and Influenza Major Surgical or Invasive Procedure: None History of Present Illness: Mrs ___ is a ___ female with a history of NSTEMI s/p PCI and hypothyroidism who presents to the ___ ED after a fall. She reports that she had the onset of a dry non-productive cough on ___ which persisted and then suddenly worsened on ___. Acommpanied with runny nose, sinus pressure and occasional headache. Denies fevers or chills, myalgias/arthralgias, sore throat, change in oral intake, or skin rashes. No CP or SOB, although she reports over the past several months she has had earlier shortness of breath with less intense exertion. She reports that on the evening of ___ she was returning to her home when she fell while closing her apartment door. She reports falling directly on to her back and denies any head strike. She does not report any prodromal symptoms: she denied feeling dizzy, lightheaded, vertigo, pre-syncope, palpiations. She says she remembers the fall in its entirety. She had immediate back pain. She did not have any fecal or urinary incontinence at that time. Denies bite marks/oral ___ or any jjerking of the limbs/seizure activity. She attempted to stand but everything was too far for her to reach so she was reduced to crawling around. Later in ___ evening, sometime after the falls he had the ened to deficate/urinate but was unable to make it to the bathroom and so went on the floor. She was found in the mornining by the staff at her assited living facility who brought her to the ___ ED. Patient ED COURSE In the ED, initial vitals were: 100.8 85 142/64 16 100% RA Labs notable for flu positive, Cr 1.2, plat 140 Ht 32. Pt was given 1L NS, tamiflu 75, morphine tylenol. Patient was deemed safe for discharge in the ED until her flu swab returned positive. For this reason she was admitted to the floor. Vitals prior to transfer 99.2 80 101/35 16 98% RA Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: PAST MEDICAL HISTORY NSTEMI s/p BMS to LAD ___ DES to LAD in stent restenosis in ___ Dyslipidemia Recurrent UTI History of bronchitis. Hypercholesterolemia. Bilateral chronic venous insufficiency. Hypothyroidism. Depression. Anemia. Hearing loss. Insomnia. History of vaginal prolapse. PAST SURGICAL HISTORY Cholecystectomy TAH/BSO. Social History: ___ Family History: Mother died age ___ "old age." Father died age ___ of colon cancer. Both were in a nursing home and died within 12 days of one another. Physical Exam: ADMISSION PHSYICAL EXAM Vitals: 97.8 120/57 71 19 97/2L General: Alert, oriented, NAD HEENT: NCAT; no markings on back of head. Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: Supple, JVP not elevated, no LAD CV: RRR, nl S1 + S2, no g/r/m no JVD radial and DP pulses 2+ b/l Lungs: CTAB with fair aeration in all fields, slightly decreaed in lower zones, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Back: there is mild spinous process tenderness of the the lower thoracic/upper lumbar regions. No evidence of displacement or step off. No parasopinal tenderness, no CVA tenderness GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. DISCHARGE PHYSICAL EXAM: Vitals: T97.4, BP 115/49, P69, R20, Sa 96 RA General: Alert, oriented, NAD HEENT: NCAT; MMM, oropharynx clear, EOMI, PERRL CV: RRR, nl S1 + S2, no g/r/m no JVD radial and DP pulses 2+ b/l Lungs: CTAB with fair aeration in all fields, slightly decreaed in lower zones, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding Back: there is mild spinous process tenderness of the the lower thoracic/upper lumbar regions. No evidence of displacement or step off. No parasopinal tenderness, no CVA tenderness Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally Pertinent Results: ADMISSION LABS: ___ 01:00PM BLOOD WBC-5.0 RBC-3.79* Hgb-10.3* Hct-32.2* MCV-85 MCH-27.2 MCHC-32.1 RDW-15.9* Plt ___ ___ 01:00PM BLOOD Neuts-80.9* Lymphs-14.6* Monos-4.1 Eos-0.1 Baso-0.3 ___ 01:00PM BLOOD Plt ___ ___ 01:00PM BLOOD Glucose-134* UreaN-15 Creat-1.2* Na-139 K-3.8 Cl-103 HCO3-20* AnGap-20 ___ 01:00PM BLOOD CK(CPK)-576* ___ 01:00PM BLOOD HoldBLu-HOLD ___ 01:10PM BLOOD Lactate-1.9 ___ 01:35PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 01:35PM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-1 ___ 02:00PM OTHER BODY FLUID FluAPCR-POSITIVE * FluBPCR-NEGATIVE IMAGING: CHEST CXR ___ FINDINGS: Cardiac silhouette is top-normal to mildly enlarged. There is no pulmonary edema. There is mild elevation of the right hemidiaphragm. No definite focal consolidation is seen. There is no pleural effusion or pneumothorax. Mediastinal contours are stable. IMPRESSION: No acute cardiopulmonary process. CT HEAD W/O CONTRAST ___ FINDINGS: There is no hemorrhage, acute large vascular territorial infarction, or brain edema. The basal cisterns are patent. There is no shift of normally midline structures. Mild prominence of the ventricles and sulci is compatible with age related involutional change. Mild periventricular white matter hypodensities are likely the sequelae of chronic small vessel ischemic change. There is minimal mucosal thickening of the right maxillary sinus and ethmoid air cells, otherwise the imaged paranasal sinuses and mastoid air cells are clear. The patient is status post bilateral lens removal, otherwise the globes and bony orbits are unremarkable. There is no acute fracture. IMPRESSION: No acute intracranial process. CT T-SPINE FINDINGS: There is no evidence of fracture or subluxation. There is no evidence of critical central spinal canal narrowing. There is no paraspinal soft tissue swelling or hematoma. The partially-imaged unopacified mediastinal great vessels are unremarkable. There is no significant mediastinal lymphadenopathy by CT size criteria. The major airways and central branches are patent. Motion artifact obscures much of the lower lobe lung parenchyma however, within this limitation, the lungs appear clear without focal consolidation. There is no pleural effusion. Incidentally noted is a large hiatus hernia. The partially imaged upper abdominal solid and hollow viscous organs are otherwise unremarkable. IMPRESSION: 1. No acute fracture or subluxation. 2. Incidentally noted large hiatus hernia. CT C-SPINE FINDINGS: There is no acute fracture. There is no prevertebral soft tissue swelling or hematoma. There are moderate degenerative joint changes of the cervical spine, with multilevel intervertebral disc height loss. There is minimal C5-6 retrolisthesis, which appears degenerative in nature; this, and a prominent C6-7 posterior intervertebral osteophyte results in moderate central spinal canal narrowing at these levels. Multilevel uncovertebral osteophytes and facet joint hypertrophy result in moderate neural foraminal narrowing worst at C5-6. IMPRESSION: 1. No acute fracture. Mild C5-6 retrolisthesis is likely degenerative in nature. No prevertebral soft tissue swelling or hematoma. 2. Multilevel degenerative changes, as above. CT L-SPINE FINDINGS: There is no evidence of acute fracture. There is mild degenerative change of the lumbar spine. There is grade 1 L4-5 anterolisthesis, which appears degenerative in nature, with resultant mild-to-moderate central spinal canal narrowing at that level. There is no paraspinal hematoma or edema. There is no evidence of infection or neoplasm. Incidentally noted is marked rectosigmoid colonic diverticulosis without evidence of diverticulitis. Otherwise, the partially-imaged solid and hollow viscous organs of the abdomen and pelvis are unremarkable. IMPRESSION: 1. No acute fracture. No paraspinal hematoma or edema. 2. Lumbar spine degenerative changes, including grade 1 L4-5 anterolisthesis resulting in mild to moderate central spinal canal narrowing at that level. 3. Rectosigmoid diverticulosis. DISCHARGE LABS: ___ 07:33AM BLOOD WBC-3.0* RBC-3.91* Hgb-10.5* Hct-33.5* MCV-86 MCH-26.9* MCHC-31.4 RDW-15.7* Plt ___ ___ 07:33AM BLOOD Plt ___ ___ 07:33AM BLOOD Glucose-109* UreaN-14 Creat-0.9 Na-142 K-3.9 Cl-108 HCO3-21* AnGap-17 ___ 06:39AM BLOOD 25VitD-27* Brief Hospital Course: PATIENT Mrs ___ is a ___ year old female with a history of NSTEMI and hypothyroidism who presents after fall and found to be flu positive. ACUTE ISSUES # Influenza: Patient with a preceding week of URI-like symptoms but overall atypical presentation. Low grade fevers in the ED and on hospital floor, but otherwise hemodynamically stable. Received full dose oseltamivir in the ED and then transitioned to renally dosing while on the floor. Patient initially with an oxygen requirement but was transitioned off on the floor. Patient discharged to complete a total five day course of oseltamivir as an outpatient. # Fall: Patient's fall is mechanical in nature per her description of events. It is possible her influenza may have contrubted, but there was no evidence of syncope or seizure. Patient with significant back pain; no red flag symptoms for cord compromise and C/T/L films demonstrated no fracture. Treated symptomatically for back pain with lidocaine patches and acetominophen. Evaluated by ___ while inpatient and it was determined that patient could go home without need for home ___ or ___ rehab. CHRONIC ISSUES: # CKD: At baseline during hospitalization # CAD: continued ASA and plavix, atorva and metoprolol # Hypothyroidism: continued home synthroid TRANSITIONAL ISSUES: # Patient diagnosed with influenza while inpatient and started on a 5 day course of oseltamivir (renally dosed). Patient to complete a total 5 day course (last dose ___. # Please consider providing influenza prophylaxis to all of Mrs ___ close contacts within the past week. # Patient noted to have pancytopenia thought to be secondary to acute viral illness. Please check CBC at next clinic appointment to check for resolution. # No medication changes were made during this hospitalization # Code: DNR/DNI (confirmed with patient) # Contact: Patient. HCP is daughter ___ (Phone number: ___, Cell phone: ___, ___ work ___ Alternate is son ___ ___ ___ on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO QHS 2. Atorvastatin 40 mg PO QPM 3. Clopidogrel 75 mg PO DAILY 4. Levothyroxine Sodium 75 mcg PO DAILY 5. Metoprolol Succinate XL 12.5 mg PO DAILY 6. Mirtazapine 15 mg PO HS 7. Tolterodine 2 mg PO BID 8. Cranberry Concentrate (cranberry conc-ascorbic acid;<br>cranberry extract) 500 mg oral daily 9. Estring (estradiol) 2 mg vaginal 3 months 10. Nitroglycerin SL 0.4 mg SL PRN chest pain 11. Pantoprazole 40 mg PO Q24H 12. Aspirin 81 mg PO DAILY Discharge Medications: 1. OSELTAMivir 75 mg PO Q24H Duration: 4 Days RX oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth daily Disp #2 Capsule Refills:*0 2. Acetaminophen 650 mg PO QHS 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Clopidogrel 75 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Levothyroxine Sodium 75 mcg PO DAILY 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Mirtazapine 15 mg PO HS 10. Pantoprazole 40 mg PO Q24H 11. Cranberry Concentrate (cranberry conc-ascorbic acid;<br>cranberry extract) 500 mg oral daily 12. Myrbetriq (mirabegron) 0 U ORAL ONCE Duration: 1 Dose 13. Nitroglycerin SL 0.4 mg SL PRN chest pain 14. Tolterodine 2 mg PO BID 15. Estring (estradiol) 2 mg vaginal 3 months Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Fall Influenza 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 ___, ___ were brought to the hospital because ___ experienced a fall at home. ___ were evaluated with blood tests and imaging of ___ spine and head. It was determined that while ___ were having back pain, ___ did not have any bone fractures in your back (spine), nor did ___ have any injury or bleeding in the head. Our labratory tests determined that ___ had influenza and that this was likely responsible for the cold-like symptoms ___ have been experiencing for the past several days. ___ were started on a course of an anti-viral medication to help treat the influezna. Please take all medications as prescribed and keep all scheduled appointments. Should ___ experience a recurrence of the same symptoms that brought ___ to the hospital, develop any of the warning signs listed below, or have any other symptoms that concern ___, please seek medical attention. It was a pleasure taking care of ___! Your ___ Care Team Followup Instructions: ___
10124367-DS-25	10,124,367	27,078,967	DS	25	2170-01-11 00:00:00	2170-01-14 23:54:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catheterization with drug-eluting stent placed History of Present Illness: ___ PMH of CAD s/p CABG (___) and multiple PCIs most recently ___, GERD, HTN, HLD, CKD who complains of chest pain. States that he woke up from sleep about ___nd went to ___ ___ ED. He states that they "stabilized" him, gave him aspirin and when they told him his troponins were elevated and they were concerned he was having a heart attack he left because he's had all his care at ___ and wanted to come here. He went home to get his things then presented to ___ ED. In the ED, initial vitals were T97.8 P55 BP158/90 RR18 O2 sat 100% RA. Patient stated that his pain at the most was ___, currently ___. Labs were notable for Cr 1.5 and troponin 0.79, MB 82. EKG showed NSR 60, QTC 450, TWF V5, TWI V6. CXR showed no acute process. He was given morphine, but refused nitro and would only agree to taking tylenol. Vitals prior to transfer: Pain 5 T98 P73 BP132/113 RR18 O2 sat 100% RA On arrival to the floor: Pain 5 T97.9 BP 176/102 P70 RR18 O2 sat 99RA. 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, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. Coronary artery disease status post CABG in ___ with a LIMA to the left anterior descending artery, saphenous vein graft to the OM-1, and a saphenous vein graft to the PDA. Non-Q-wave myocardial infarction in ___ with direct stenting of the saphenous vein graft, OM, which was found to be occluded as well as the saphenous vein graft to the PDA. Repeat cardiac catheterization in ___ with totally occluded saphenous vein grafts to the OM, which was successfully stented. Reapeat catheterization in ___ with native stenting of the R-PL. Repeat catheterization in ___ with severe native CAD, as well as known occluded saphenous vein graft to the PDA, a proximal 80% stenosis of the saphenous vein graft to OM and distal 90% instent restenosis and a widely patent LIMA to left anterior descending artery. The saphenous vein graft to OM was successfully treated with PTCA and brachytherapy, however he had recurrent CP later the same day, with cath revealing acute thrombosis of intervened SVG to OM - stent placed. 2. Hypertension 3. Hypercholosterolemia 4. Gastroesophageal reflux disease. 5. Status post left shoulder surgery. 6. Status post right rotator cuff surgery. Social History: ___ Family History: Father died from MI at age of ___, mother died from nonalcoholic cirrhosis Physical Exam: INITIAL PHYSICAL EXAM =============== VS: Pain 5 T97.9 BP 176/102 P70 RR18 O2 sat 99RA General: Overweight, middle aged male, resting in bed eating a sandwhich, NAD HEENT: NCAT, PERRLA, MMM, sclera anicteric Neck: supple, no thyroid enlargement or LAD, could not assess JVP ___ habitus CV: RRR, normal S1/S2, no m/r/g Lungs: CTAB no wheezing, rales, rhonchi Abdomen: Obese, soft, NT/ND, +BS no rebound or guarding, no appreciable hepatomegaly or splenomegaly GU: No foley Ext: trace ___ edema, no clubbing or cyanosis 2+ DP pulses bilaterally Neuro: CN II-XII grossly intact, strength and sensation grossly normal, gait not assessed Skin: WWP, no rashes or lesions DISCHARGE PHYSICAL EXAM ================ VS: Tm 100.8 ___ p64-78 R18 99%RA General: Overweight, middle aged male, resting in bed, NAD HEENT: NCAT, PERRLA, MMM, sclera anicteric Neck: supple, No JVD CV: RRR, S1/S2, no m/r/g Lungs: CTAB no wheezing, rales, rhonchi Abdomen: Obese, soft, NT/ND Ext: trace ___ edema, no clubbing or cyanosis 2+ DP pulses bilaterally Neuro: strength and sensation grossly normal Skin: WWP, no rashes or lesions. Well healed sternal CABG scar Pertinent Results: INITIAL LAB RESULTS ================= ___ 04:50PM BLOOD WBC-7.2 RBC-5.06 Hgb-15.5 Hct-46.0 MCV-91 MCH-30.6 MCHC-33.7 RDW-12.4 Plt ___ ___ 06:00PM BLOOD ___ PTT-31.6 ___ ___ 04:50PM BLOOD Glucose-90 UreaN-17 Creat-1.5* Na-139 K-4.3 Cl-99 HCO3-29 AnGap-15 ___ 01:40AM BLOOD CK(CPK)-1390* ___ 09:00AM BLOOD CK(CPK)-1122* ___ 11:45AM BLOOD CK(CPK)-1036* ___ 09:10PM BLOOD CK(CPK)-777* ___ 06:30AM BLOOD CK(CPK)-618* ___ 04:50PM BLOOD cTropnT-0.79* ___ 01:40AM BLOOD CK-MB-78* MB Indx-5.6 cTropnT-1.94* ___ 09:00AM BLOOD CK-MB-43* MB Indx-3.8 cTropnT-2.29* ___ 11:45AM BLOOD CK-MB-37* MB Indx-3.6 cTropnT-2.26* ___ 09:10PM BLOOD CK-MB-17* MB Indx-2.2 cTropnT-1.98* ___ 06:30AM BLOOD CK-MB-12* MB Indx-1.9 cTropnT-2.02* ___ 04:50PM BLOOD Calcium-9.9 Phos-3.9 Mg-2.1 IMAGING ================== ___ CXR FINDINGS: Patient is status post median sternotomy and CABG. The cardiac silhouette is mildly enlarged. The aorta is tortuous. No focal consolidation is seen. There is no pleural effusion or pneumothorax. Evidence of DISH is seen along the thoracic spine. IMPRESSION: No acute cardiopulmonary process. ___ Cardiac Echo The left atrium is mildly dilated. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesis of the basal and mid inferior/inferolateral walls, which are thinned, and basal inferoseptum. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %). The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Mild LV dysfunction with regional variation as noted, consistent with CAD. Pulmonary artery systolic and diastolic hypertension. Compared with the prior study (images reviewed) of ___, LV contrast was used on current exam. Overall LV function and wall motion are similar. Right ventricle is not well seen on the current exam. ___ Cardiac Catheterization Assessment & Recommendations 1. Severe native vessel disease. Known occluded vein grafts. Patent LIMA. 2. Successful PTCA and stenting of the distal LMCA into the LCX with 3.5x16 mm Premier drug-eluting stent postdilated to 4.0 then to 5.0 with IVUS guidance. 3. Successful deployment ___ Angioseal to the R CFA. 4. ASA 325 mg po daily x3 months then 81 mg daily indefinitely. 5. Clopiodogrel 600 mg po loading dose then 75 mg daily for a minimum of 12 months (possibly lifelong). 6. Global CV risk reduction strategies. DISCHARGE LAB RESULTS ================= ___ 06:30AM BLOOD WBC-7.5 RBC-4.75 Hgb-14.4 Hct-43.4 MCV-91 MCH-30.4 MCHC-33.2 RDW-12.4 Plt ___ ___ 06:30AM BLOOD ___ PTT-30.0 ___ ___ 06:30AM BLOOD Glucose-97 UreaN-14 Creat-1.4* Na-138 K-4.1 Cl-100 HCO3-27 AnGap-15 ___ 06:30AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.3 Brief Hospital Course: Mr. ___ is a ___ year old gentleman with a PMH of CAD s/p CABG (___) and multiple PCIs most recently ___, GERD, HTN, HLD, CKD who presented with chest pain and was found to have an NSTEMI. ACUTE ISSUES # NSTEMI: The patient has a significant cardiac history s/p CABG with multiple PCIs who initially presented with CP and was found to have an NSTEMI with EKG changes inferolaterally. Cardiac catheterization revealed severe native vessel disease, and a drug eluting stent was placed at the distal LMCA into the LCX. He was continued on his home Atorvastatin, Metoprolol, Aspirin, and Plavix. Of note, despite his chest pain he refused sub-lingual nitroglycerin or morphine as he said they did not relieve his pain. He was started on a nitroglycerin drip with some relief in chest pain. CHRONIC ISSUES # HTN: The patient presented with a significantly elevated blood pressure, likely in the setting of pain. He was continued on his home Lisinopril and Metoprolol. A nitroglycerin drip was started for further chest pain and blood pressure control. # CKD: The patient has a known diagnosis of chronic kidney disease, and his creatinine was at his baseline of 1.5. His Cr was trended and remained stable. # GERD: The patient has a known diagnosis of GERD and was continued on his home PPI. # HLD: The patient has a known diagnosis of HLD and was continued on his home statin. TRANSITIONAL ISSUES: 1) Patient continued to have noncardiac chest pain after the procedure (EKGs and re-trending of enzymes normal). Please consider GI workup versus pericarditis if it continues. 2) ASA 325 mg po daily x3 months then 81 mg daily indefinitely. 3) Clopiodogrel 600 mg po loading dose then 75 mg daily for a minimum of 12 months (possibly lifelong). 4) Global CV risk reduction strategies. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clopidogrel 75 mg PO DAILY 2. Atorvastatin 40 mg PO DAILY 3. Lisinopril 40 mg PO DAILY 4. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 5. Furosemide 20 mg PO DAILY 6. Aspirin 325 mg PO DAILY 7. Metoprolol Tartrate 50 mg PO BID 8. NexIUM (esomeprazole magnesium) 40 mg oral BID Discharge Medications: 1. Furosemide 20 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. NexIUM (esomeprazole magnesium) 40 mg oral BID 4. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY 5. Aspirin 325 mg PO DAILY 6. Atorvastatin 80 mg PO DAILY RX atorvastatin 80 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 7. Clopidogrel 75 mg PO DAILY 8. Metoprolol Succinate XL 200 mg PO DAILY RX metoprolol succinate 200 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Non-ST-elevation myocardial infarction, Chest Pain SECONDARY: Hypertension, Gastroesophageal Reflux Disease, Chronic Kidney Disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___ ___. You were admitted for a heart attack, for which a cardiac cath was performed. You received a drug-eluting stent (DES) to help open a blockage. It is VERY important that you never miss ___ dose of aspirin and clopidogrel (Plavix) without discussing with your cardiologist. Please review the medications changes below carefully Followup Instructions: ___
10124428-DS-11	10,124,428	25,968,315	DS	11	2137-03-23 00:00:00	2137-03-24 17:09:00	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: ___: ___ RT PCN placement History of Present Illness: ___ year old lady with reported history of nephrolithiasis, hypertension, fibromyalgia, and depression who presented with AMS, found to have urosepsis with obstructive R ureteral stone. History is obtained from HCP/emergency contact ___ reports speaking to patient on ___ when patient reported feeling ok, but that over the weekend, ___ was reporting feeling unwell. This AM, when patient's personal care assistant came over (described as "the girl who helps shop"), ___ was found to be confused, "talking gibberish", hence EMS was called and patient was taken to ___. In retrospect, ___ recalls that perhaps 3 weeks ago, ___ reported feeling "weird", having feeling similar to her old kidney stone (was hospitalized at ___ ___ years ago), and wonders if ___ had a brewing infection since then. At ___, initial vitals with T 101.5, HR 141, BP 86/64, RR 33, SpO2 92% on 5L NC. Labs there with WBC 18.8 Hgb 12.0 Plt 55 24% bands vBG 7.32/ ___ \| 96 \| 103 ---------------- Anion gap = 26 5.0 \| 15 \| 4.0 AST 208 ALT 88 AlkPhos 196 Alb 3.4 Troponin T < 0.01 U/A ___, +nitr, 4+ bactermia, WBC and RBC both TNTC CXR: Hypoinflated, grossly clear lungs. There is note of EKG with atrial fibrillation (not available for review) Of note, baseline labs from ___ with Cr 0.7, Hgb 12.7, and plt 365 She was given 3L IVF and started on ceftriaxone, given haloperidol and Ativan for agitation, then transferred to us for CT scan and ICU care. In the ED, initial vitals were: T 97.7 HR 133 BP 102/52 93% 4L NC Due to increased work of breathing and concern that patient would tire out, she was placed on NRB for pre-oxygenation and intubated. - Labs notable for: WBC 12.7 Hgb 9.7 Plt 44 90% neutrophils 143 \| 112 \| 99 53 AGap=21 ------------- 5.3 \| 9 \| 3.5 Troponin 0.01 U/A >182 WBC, 8 WBC large leuk, pos nitr, pos ketone, ABG 7.16/pCO2 36/pO2 206, HCO3 14 (post intubation on TV 350 PEEP 5 RR 26% 100% FiO2) - Imaging was notable for: EKG per my read: Sinus tachycardia, rate 144, normal axis, prolonged QTc, borderline LAE, early R wave progression, TW flattening I, aVL, V5-V6 CT A/P without contrast: There is a 1.0 cm calculus at the right ureteropelvic junction with upstream mild to moderate hydroureteronephrosis. Bilateral perinephric stranding. CXR: 1. Interval repositioning of endotracheal tube, now in appropriate position. 2. No significant interval change in lung findings, including bibasilar patchy opacities which may reflect atelectasis or aspiration in the proper clinical setting. RIJ and a L radial A-line were placed. Patient was given: vancomycin 1 gm, cefepime 2 gm, vasopressin 2.4, phenylephrine 4.28, levophed 0.12, LR 2 L, calcium gluconate 2 gm, fentanyl/midazolam. ___ was consulted for urgent perc nephrostomy tube placement; a ___ R PCN was placed with scant bloody output. Past Medical History: Per report by ___- Fibromyalgia Hypertension Depression Nephrolithiasis, hospitalized ___ years ago at ___ Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM VITALS: Reviewed in MetaVision. GENERAL: Intubated, sedated HEENT: No scleral icterus, no JVD PULMONARY: CTA anteriorly CHEST: Tachycardic but regular, no m/r/g appreciated ABDOMEN: Soft, obese, nontender EXTREMITIES: No c/c/e, lukewarm to touch SKIN: No rashes appreciated NEURO: PERRLA, but intubated and sedated DISCHARGE PHYSICAL EXAM GENERAL: Alert to person only PULMONARY: CTAB, no wheezing CHEST: Regular rate and rhythm, no m/r/g appreciated ABDOMEN: Soft, obese, no CVAT, nephrostomy tube in place draining yellow urine, dressing c/d/i EXTREMITIES: No ___ edema SKIN: No rashes appreciated NEURO: AOx2 Pertinent Results: ADMISSION LABS: =============== ___ 07:45PM BLOOD WBC-12.7* RBC-3.64* Hgb-9.7* Hct-30.1* MCV-83 MCH-26.6 MCHC-32.2 RDW-15.3 RDWSD-46.3 Plt Ct-44* ___ 07:45PM BLOOD Neuts-90* Bands-1 Lymphs-4* Monos-5 Eos-0* Baso-0 AbsNeut-11.56* AbsLymp-0.51* AbsMono-0.64 AbsEos-0.00* AbsBaso-0.00* ___ 07:45PM BLOOD ___ PTT-24.8* ___ ___ 07:45PM BLOOD ___ D-Dimer-7606* ___ 07:45PM BLOOD Glucose-53* UreaN-99* Creat-3.5* Na-143 K-5.3 Cl-112* HCO3-9* AnGap-21* ___ 02:37AM BLOOD ALT-59* AST-144* LD(LDH)-496* AlkPhos-214* TotBili-1.0 ___ 07:45PM BLOOD cTropnT-<0.01 ___ 07:45PM BLOOD Calcium-6.8* Phos-5.1* Mg-2.1 ___ 07:45PM BLOOD Hapto-446* ___ 02:37AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-7* Tricycl-POS* ___ 07:07AM BLOOD Vanco-14.8 ___ 08:03PM BLOOD pO2-69* pCO2-26* pH-7.26* calTCO2-12* Base XS--13 ___ 08:03PM BLOOD Lactate-1.4 STUDIES: ======== CHEST (PORTABLE AP) Study Date of ___ Bibasilar patchy opacities may reflect atelectasis or aspiration proper clinical setting. CT ABD & PELVIS W/O CONTRAST Study Date of ___ There is a 1.0 cm calculus at the right ureteropelvic junction with upstream mild to moderate hydroureteronephrosis. Bilateral perinephric stranding. PERC NEPHROSTO Study Date of ___ 1. Ultrasound images demonstrate hyperechoic needle tip within the dilated inferior posterior calyx. 2. Nephrostogram demonstrated dilated renal collecting system with abrupt cut off of contrast in the proximal ureter consistent with known obstructive stone. 3. Final image demonstrates 8 ___ nephrostomy tube in appropriate positioning. IMPRESSION: Successful placement of 8 ___ nephrostomy on the right. ABDOMEN US (COMPLETE STUDY) PORT Study Date of ___ 1. Liver parenchyma is within normal limits, without evidence of focal hepatic lesions. 2. No evidence of hydronephrosis or nephrolithiasis bilaterally. 3. Trace right pleural effusion. BILAT LOWER EXT VEINS PORT Study Date of ___ No evidence of deep venous thrombosis in the right or left lower extremity veins. ___ CT head IMPRESSION: There is no evidence of acute intracranial process or hemorrhage. ___ CT abd/pelvis 1. Previously noted 7 mm right proximal ureteric calculi is essentially unchanged in position. 2. There has been interval placement of a right percutaneous nephrostomy tube with resultant decompression of the right renal collecting system. 3. No right para or perirenal collections. 4. Non dependent ground-glass opacities in the right middle lobe and lingula is nonspecific, but may represent aspiration if the patient was in the prone position for a prolonged time period. Consider atypical infection in the differential diagnosis. 5. Presumed exophytic fibroid from the uterus for which pelvic ultrasound can be performed for confirmation. ___ CTA chest: 1. No pulmonary embolism 2. Fluid overload appears moderately improved. ___ opacities at the right lung base and right middle lobe as well as ground-glass opacities in the periphery of the left upper lobe may be infectious or inflammatory. These were likely present on the prior examination, but obscured by respiratory motion. Trace bronchial thickening and mucous plugging also appears similar to prior. 3. Small pericardial effusion appears increased from ___. 4. Mild enlargement of the ascending aorta measuring up to 4.1 cm, unchanged from ___. ___ TTE: The left atrial volume index is normal. The right atrium is mildly enlarged. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is suboptimal image quality to assess regional left ventricular function. Overall left ventricular systolic function is normal. Quantitative biplane left ventricular ejection fraction is 74 %. 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 mildly dilated ascending aorta. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. There is trivial mitral regurgitation. The tricuspid valve leaflets appear structurally normal. There is physiologic tricuspid regurgitation. The estimated pulmonary artery systolic pressure is normal. There is a small circumferential pericardial effusion. There are no 2D or Doppler echocardiographic evidence of tamponade. PERICARDIUM: Small effusion. Circumferential effusion. No 2D/Doppler evidence of tamponade. Anterior fat pad ___ Video swallow evaluation: Trace aspiration with thin liquids. No other evidence of penetration. Low risk for aspiration Discharge Labs =============== ___ 06:05AM BLOOD WBC-10.2* RBC-3.16* Hgb-8.6* Hct-28.3* MCV-90 MCH-27.2 MCHC-30.4* RDW-19.4* RDWSD-62.3* Plt ___ ___ 05:57AM BLOOD Neuts-66.1 ___ Monos-7.1 Eos-0.8* Baso-0.7 AbsNeut-7.87* AbsLymp-2.79 AbsMono-0.84* AbsEos-0.09 AbsBaso-0.08 ___ 03:33AM BLOOD Hypochr-2+* Anisocy-1+* Poiklo-1+* Macrocy-1+* Ovalocy-1+* Target-1+* ___ 06:05AM BLOOD Plt ___ ___ 06:05AM BLOOD ___ PTT-22.5* ___ ___ 06:05AM BLOOD Glucose-92 UreaN-9 Creat-0.8 Na-144 K-4.0 Cl-109* HCO3-25 AnGap-10 ___ 02:57AM BLOOD ALT-26 AST-33 AlkPhos-104 TotBili-0.3 ___ 06:05AM BLOOD Calcium-8.8 Phos-3.6 Mg-1.9 ___ 05:57AM BLOOD ___ Folate-5 Brief Hospital Course: Summary Statement ================== ___ year old lady with reported history of nephrolithiasis, hypertension, fibromyalgia, and depression who presented with AMS, found to have urosepsis with obstructive R ureteral stone and course complicated by VAP and toxic metabolic encephalopathy. Active Issues ============== # Septic shock #E. Coli blood stream infection # Urinary tract infection with obstructive R ureteral stone Patient presented with septic shock ___ UTI with obstructive R ureteral stone. She had fever, tachycardia, and hypotension initially requiring 3 pressors. She underwent perc nephrostomy tube ___. Urine and blood culture grew pan-sensitive E. coli. She was treated with vanc/ceftaz initially, subsequently narrowed to CTX after culture data. She continued to spike fevers and repeat imaging concerning for VAP as noted below. She was rebroadened to vanc/ceftazadime and will plan to complete a week of IV antibiotics, ending on ___. After completing her course of antibiotics for the fact the patient was transitioned to ceftriaxone for which she completed a 14-day course. The patient had a persistent leukocytosis but urine cultures were repeated and negative. The patient was switched to ciprofloxacin on ___ and will remain on this antibiotic until the stone is removed per urology. # Fever # Ventilator Associated Pneumonia After initial stabilization, patient had persistent fevers and sinus tachycardia later this admission despite being on appropriate abx for UTI. Suspected etiology unclear whether potentially she could have a retained stone representing lack of source control, or whether other etiologies in play. CT concerning for possible VAP and she her antibiotics were broadened to vanc/ceftazadime and she completed a 7 day course on ___. Her fevers resolved with treatment of infection. The patient was weaned to room air for which she remained for the duration of her hospitalization. # Acute hypoxemic hypercarbic respiratory failure: Patient initially intubated in ED for work of breathing and tachypnea. Initial CXR with atelectasis, no focal consolidation; may have contribution of pulm edema from aggressive fluid resuscitation. She received intermittent boluses of IV Lasix with improvement in oxygenation/ventilation and was extubated on ___. She was weaned to RA with treatment of PNA. #Tachycardia The patient was intermittently tachycardic throughout her hospitalization. Initially the tachycardia was felt to be from underlying septic shock from urinary source as well as VAP. However these had resolved and the patient continued to have low level tachycardia near 100. This was initially thought to be withdrawal from her beta-blocker and it was subsequently restarted. The patient was not taking adequate p.o. and the patient's heart rate increased to the 120s. She was given 2 L of lactated Ringer's and her heart rate decreased. Given the concern for arrhythmias, ECG was ordered which showed normal sinus rhythm without ischemic changes. The patient underwent CTA chest which did not show any pulmonary emboli. The patient was monitored on telemetry and noted to have decreasing trajectory of her heart rates. # Thrombocytopenia: Plt 44 on arrival here, baseline 300s in ___. Plt since downtrending to low of ___ AM. No e/o DIC, no e/o hemolysis on labs hence TTP/HUS lower on differential despite anemia/ thrombocytopenia/ ___. No recent exposure to heparin as presented from home; HIT unlikely. Heme/onc consulted, think thrombocytopenia most likely ___ bone marrow suppression iso sepsis with possible contribution from vanc. Her thrombocytopenia improved with treatment of her infection. Discharge platelets 271. # ___: Cr on presentation 4.0, recent baseline unclear (but was 0.7 back in ___, since improving with IVF and s/p ___ nephrostomy tube. Suspect pre-renal in setting of sepsis + possible obstructive component. The patient's Cr improved and on discharge her Cr was 0.8. # Anion gap metabolic acidosis # NAGMA AGMA initially iso renal failure with contribution from possibly starvation ketosis; lactate flat. Subsequently with NAGMA thought iso renal failure and large fluid resuscitation with NS. She was treated with bicarb with improvement. # Acute toxic metabolic encephalopathy: Patient presented with AMS in setting of septic shock, also with contribution of gabapentin + carisoprodol accumulation in setting of renal failure. Found to have hypoactive delirium in the ICU, briefly requiring Seroquel 25 mg nightly. Patient slowly improved with treatment of infection. Home amitriptyline was continued after improvement. The patient continued to have a waxing and waning mental status after transition out of the ICU. Infectious workup was negative and the patient's mental status slowly improved. Upon discharge the patient continued to improve but was not back to baseline. # Hypernatremia # Oral pharyngeal dysphagia Patient was found to have a peak sodium of 153 in the setting of NPO. NPO given poor swallow reflex ___ fatigue. Speech and swallow team was consulted with recommendations for feeding tube, however patient and HCP refused. She was given D5W as needed with improvement of her sodium. The patient was evaluated on multiple occasions by speech-language pathology who slowly advanced her diet however the patient continued to have poor p.o. intake. The patient and the healthcare proxy were again consulted with the benefits of a feeding tube which the primary team strongly recommended. After prolonged discussions the patient healthcare proxy agree that it would not be within the patient's wishes to have a feeding tube placed. Speech-language pathology was consulted again and the patient underwent video swallow study and was upgraded to a regular diet with thin liquids by cup. #Pericardial effusion: The patient was noted to have a pericardial effusion that was evident on CT chest done for pulmonary embolism. The patient had continued tachycardia and repeat CT a chest demonstrated worsening of pericardial effusion. Patient then underwent echocardiogram on ___ which demonstrated a small pericardial effusion with no tamponade physiology. EKG done here did not show any signs of pericardial effusion such as uniform low voltage, pr depression or electrical alternans. TRANSITIONAL ISSUES =================== #Kidney stone #PCN [] Patient is to follow-up with urology regarding management of PCN and stone removal. [] chronic suppressive therapy with ciprofloxacin 250 mg twice daily until stone passes or is removed. [] ID to set up follow up in ___ clinic #?AFib [] Patient was reported to have atrial fibrillation in the ED at OSH, however this was never observed during this hospitalization. Anticoagulation was deferred given her afib was not observed. #Pericardial effusion []Repeat echocardiogram in ___ weeks or patient symptomatic for resolution of tamponade. #nutrition []follow up on nutrition as an outpatient for adequate caloric intake #CODE STATUS: Full #CONTACT: ___ ___ >30 minutes spent on complex discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen w/Codeine 1 TAB PO BID:PRN Pain - Moderate 2. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety 3. carisoprodol 350 mg oral DAILY 4. Amitriptyline 50 mg PO QHS 5. Atorvastatin 40 mg PO QPM 6. Lisinopril 40 mg PO DAILY 7. amLODIPine 5 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Gabapentin 800 mg PO QID Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN nasuea 3. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 4. Ciprofloxacin HCl 250 mg PO Q12H 5. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third Line 6. amLODIPine 10 mg PO DAILY 7. Gabapentin 300 mg PO TID 8. Amitriptyline 50 mg PO QHS 9. Atorvastatin 40 mg PO QPM 10. Lisinopril 40 mg PO DAILY 11. Metoprolol Succinate XL 100 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS: ================= Nephrolithiasis Septic shock secondary to urinary tract infection SECONDARY DIAGNOSES: ===================== Ventilator associated pneumonia Acute hypoxemic hypercarbic respiratory failure Toxic metabolic encephalopathy Thrombocytopenia Oral pharyngeal dysphagia Hypernatremia Acute kidney injury Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, WHY WERE YOU ADMITTED TO THE HOSPITAL? - You were admitted to the hospital because you had a fever and altered mental status. WHAT HAPPENED WHILE YOU WERE IN THE HOSPITAL? -You were found to have a severe infection due to the blockage from your kidney stone. -You underwent a procedure called a percutaneous nephrostomy to drain the urine in your kidney above the kidney stone. -You were given artificial hydration because you are eating was poor. -You were given antibiotics and a breathing tube given your severe infection. -You improved and were ready to leave the hospital. WHAT DO YOU NEED TO DO WHEN YOU LEAVE THE HOSPITAL? - Please take all of your medications as prescribed and go to your follow up appointments with your doctors ___ below) - Seek medical attention if you have new or concerning symptoms It was a pleasure participating in your care. We wish you the best! - Your ___ Care Team Followup Instructions: ___
10124500-DS-3	10,124,500	28,359,046	DS	3	2163-07-26 00:00:00	2163-07-26 16:34:00	Name: ___ ___ No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Abdominal pain s/p TACE procedure Major Surgical or Invasive Procedure: ___: EGD . ___: ___ line placement History of Present Illness: Ms. ___ is a ___ year old female with ___ who underwent TACE procedure at ___ on ___ who then presented to ___ on ___ with asymptomatic embolization of her GDA causing pancreatic necrosis. She has been seen in the liver transplant clinic at ___ for workup; she has chronic hepatitis B and a lesion meeting criteria for HCC. She presented to ___ and had elevated AFP and lesion 2.3x2.4cm, biopsy not diagnostic, and lesion in transplant clinic found to be 1.4x1.2cm. The lesion increased in size to 3.9cm in segment VI/VII and so she met criteria for OPTN and is undergoing workup for transplant. She has no known varices. History obtained in part from medical records. The patient underwent TACE at ___ on ___ and was doing fine. She had a staging chest CT routinely done yesterday at ___ that showed pancreatic necrosis likely from GDA embolization so she was called in and is admitted to the hepatology service. ___ surgery is consulted for this. She speaks mainly ___ but denies abdominal pain. Review of systems was otherwise negative. Past Medical History: Chronic hepatitis B Cirrhosis Hepatocellular carcinoma Hypothyroidism PAST SURGICAL HISTORY: 1. Status post partial hepatectomy (segments V/VI) for liver cancer ___ ___ 2. Open cholecystectomy ___ ___ Social History: ___ Family History: Significant family history for liver cancer in mother and two siblings had liver cancer also. Her father had a stroke. Physical Exam: ==================== On admission ==================== VS: 98.2 PO 93 / 62 91 16 100 Ra GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM NECK: supple, no LAD, no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, tender in right abdomen, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: no cyanosis, clubbing, or edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose SKIN: warm and well perfused, no excoriations or lesions, no rashes ==================== At Discharge ==================== VS: Temp 98.1 HR 108 BP 110/69 RR 18 SpO2 94% RA GENERAL: NAD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: normal respiratory effort ABDOMEN: soft, nondistended, non-tender, no rebound/guarding, no hepatosplenomegaly SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: Admission: ___ 09:00PM BLOOD WBC-19.6# RBC-3.92 Hgb-11.9 Hct-35.9 MCV-92 MCH-30.4 MCHC-33.1 RDW-12.7 RDWSD-42.4 Plt ___ ___ 09:00PM BLOOD Glucose-132 UreaN-8 Creat-0.7 Na-133 K-5.1 Cl-91* HCO3-26 AnGap-16 ___ 09:00PM BLOOD ALT-40 AST-55* AlkPhos-138* TotBili-1.0 ___ 09:27AM BLOOD Lipase-92* ___ 09:00PM BLOOD Albumin-3.0* ___ 04:30AM BLOOD PREALBUMIN-4 Discharge: ___ 08:16AM BLOOD WBC-10.3* RBC-3.36* Hgb-10.4* Hct-32.0* MCV-95 MCH-31.0 MCHC-32.5 RDW-13.4 RDWSD-46.8* Plt ___ ___ 09:04AM BLOOD Glucose-159* UreaN-10 Creat-0.4 Na-135 K-4.2 Cl-98 HCO3-24 AnGap-13 ___ 04:07AM BLOOD ALT-29 AST-45* AlkPhos-301* TotBili-0.5 ___ 09:04AM BLOOD Calcium-8.7 Phos-3.1 Mg-2.2 ___ CT abdomen/pelvis IMPRESSION: 1. The pancreatic head has necrosis with adjacent multiloculated acute necrotic collection. The pancreatic duct is non-dilated and is visualized to the level of the pancreatic neck. The duct likely drains into the acute necrotic collection. No evidence of extra-luminal gas. 2. Compared to ___, again seen is a 3.3 x 2.2 cm segment VI/VII lesion, previously characterized as an OPTN 5b hepatocellular carcinoma with new central fat. This lesion is likely post-TACE, though no records are available at the time of dictation to confirm this suspicion. ___ CT abdomen/pelvis 1. Evaluation of the pancreatic head necrosis and acute peripancreatic necrotic collection is limited by noncontrast study. Given the limitation, pancreatic head necrosis is stable. Acute necrotic collection has decreased in size. 2. Circumferential wall thickening of the descending duodenal wall without extraluminal air or contrast extravasation. No free air or portal venous gas. 3. Cirrhotic liver with a unchanged hypoattenuating lesion in segment VI/VII with central fatty component. 4. Small bilateral pleural effusion, more on the right. Brief Hospital Course: The patient is a ___ year old female with a history of hepatitis B cirrhosis and ___ s/p recent TACE procedure on ___ who presented to the ED after having a staging CT (transplant evaluation) demonstrating necrotic pancreatic head and pancreatitis as a complication of TACE. Surgery was consulted regarding her pancreatic necrosis. Their impression was that this was a complication of embolization of her GDA and that there was no urgent surgical intervention. Therefore, the patient was admitted to the medicine service for further evaluation and monitoring. Upon arrival to the medicine floor, patient endorsed malaise, fever, abdominal pain radiating to the back. Lab findings were significant for a leukocytosis and neutrophils predominance along with CT findings suggestive of pancreatitis and necrotic pancreatic head. Patient was started on ciprofloxacin 400 mg BID and flagyl 500 mg q8hr IV (D1 ___ and was made NPO on 125 mL/hr LR. On ___ patient was transferred to ___ surgery service due to concern that the patient was at high risk for acute decompensation. The patient underwent an EGD on ___ for assessment of the duodenal mucosa and placement of an nasojejunal feeding tube. The patient was found to have an ulcer in the second portion of her duodenum, likely in the setting of the acute ischemic event she incurred after her TACE procedure. The feeding tube was placed successfully, however, it became dislodged in the recovery room when the patient had an episode of emesis, and the tube was removed in this setting. Based on the EGD imaging, it was unclear whether the patient's ulcer was perforated. So, the patient underwent a CT abdomen with PO contrast, which demonstrated no duodenal perforation. Given high risk for bowel perforation with duodenal ulcer, we did not request that GI attempt nasojejunal feeding tube placement a second time. The patient instead underwent PICC line placement on ___ and was started on TPN for nutrition. Her leukocytosis and abdominal pain gradually improved on IV antibiotics and TPN. Her blood glucose was initially elevated on TPN, ___ was consulted and assisted in optimizing her insulin regimen throughout the remainder of her hospital course. The patient underwent several teaching sessions with the ___ infusion company and with the ___ for home blood glucose monitoring while on TPN. These sessions were performed via ___ interpreter. The patient was deemed ready for discharge to home on ___ with ___ home ___ for continued PICC and blood glucose education and assistance. She was instructed to continue on a clear liquid diet for 3 weeks until she is seen in Dr. ___ with a repeat abdominal CT scan. #HCC: s/p TACE, followed at ___. - Outpatient follow-up - Should also attend follow up appointment with Interventional Radiology at #HBV: - Continue Tenofovir Disoproxil (Viread) 300 mg PO daily Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tenofovir Disoproxil (Viread) 300 mg PO DAILY 2. Levothyroxine Sodium 25 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 2. Alcohol Pads (alcohol swabs) 1 pad topical Q6H RX alcohol swabs [Alcohol Pads] 1 pad every six (6) hours Disp #1 Box Refills:0 3. BD Insulin Syringe Ultra-Fine (insulin syringe-needle U-100) 0.5 mL 31 gauge x ___ miscellaneous Q6H RX insulin syringe-needle U-100 [CareTouch Insulin Syringe] 30 gauge x ___ 1 syronge with needle every six (6) hours Disp #1 Box Refills:2 4. FreeStyle Lancets (lancets) 28 gauge miscellaneous Q6H RX lancets [FreeStyle Lancets] 28 gauge 1 lancet every six (6) hours Disp #1 Box Refills:2 5. FreeStyle Lite Strips (blood sugar diagnostic) 1 test strip miscellaneous Q6H RX blood sugar diagnostic [FreeStyle Lite Strips] 1 strip every six (6) hours Disp #1 Box Refills:2 6. HumuLIN R U-100 (insulin regular human) 100 unit/mL injection Q6H RX insulin regular human [Humulin R U-100] 100 unit/mL 30 units TPN QD and Q6H Disp #2 Vial Refills:5 7. Multivitamins W/minerals Liquid 15 mL PO DAILY RX multivit-mins-ferrous gluconat [multivitamin with minerals] 9 mg iron/15 mL 15 mL by mouth once a day Refills:0 8. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:10 9. Levothyroxine Sodium 25 mcg PO DAILY 10. Tenofovir Disoproxil (Viread) 300 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Hepatocellular carcinoma 2. Pancreatic necrosis s/p TACE 3. Duodenal ulcer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to ___ for evaluation of new onset abdominal pain s/p TACE procedure on ___. Abdominal CT on admission demonstrated pancreatic head necrosis. You underwent EGD, which demonstrated duodenal ulcer, repeat CT was negative for perforation. You were started on TPN and antibiotics. You are now safe to be discharge home to continue you recovery with further instruction. . Please ___ Dr. ___ office at ___ or office nurse at ___ if you have any questions or concerns. . Please ___ 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. ___ 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. . General Discharge Instructions: 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. . 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. Thank you for allowing us to participate in your care! Sincerely, Your ___ Team Followup Instructions: ___
10124807-DS-19	10,124,807	28,379,577	DS	19	2114-07-27 00:00:00	2114-07-28 09:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins Attending: ___. Chief Complaint: J-tube clogging Major Surgical or Invasive Procedure: J-tube replacement on ___ History of Present Illness: This is a ___, with esophageal adenocarcinoma, presenting to the ER after clogging of his J tube. Patient had T3N2 esophageal adenocarcinoma diagnosed in ___ ___ with no metastatic disease on PET in ___. Biopsy and imaging consistent with at least Stage IB disease (T3NxM0) as during the EUS three abnormal lymph nodes were visualized in the lower paraesophageal mediastinum and perigastric region. Patient had J-tube placed on ___ to aid with feeding. Patient refers having a zofran pill put in the J tube this morning that clogged it. Patient also complaining of increse swalloging problem of his saliva. Pateint was tolerant of food yestarday but started being unable to tolerate saliva, which has been getting worse. Patient complaining also of some nausea with this symptoms. In the ED, initial vitals: 97.3 72 100/60 18 100% RA - Pt given: 4mg IV zofran x1 and 1L NS x1. ___ were consulted and decided patient should be admitted for J-tube replacement as they were unable to unclog it at bedside. - Vitals prior to transfer: 98 55 105/45 16 96% RA On the floor, patient reports improvement of his symptoms. Past Medical History: -esophageal cancer -Mild cerebral palsy -Hyperlipidemia, did not require treatment -BCC removed from right jaw Social History: ___ Family History: -Father had prostate cancer -Mother had breast cancer metastatic to lungs and bones Physical Exam: ADMISSION PHYSICAL: Vitals: 98 55 105/45 16 96% RA HEENT: o/p clear, mucous membranes moist, sclera anicteric, conjunctiva pink, CV: S1, S2, RRR, no m/r/g CHEST: CTAB, normal WOB ABDOMEN: S, NT, ND, BS+, no palpable hepatosplenomegaly BACK: no spinal or cva tenderness EXTREMITIES: WWP, no pitting edema of ___: slight tremor of the hands DISCHARGE PHYSICAL: HEENT: o/p clear, mucous membranes moist, sclera anicteric, conjunctiva pink, CV: S1, S2, RRR, no m/r/g CHEST: CTAB, normal WOB ABDOMEN: S, NT, ND, BS+, no palpable hepatosplenomegaly. Replaced J-tube flushing BACK: no spinal or cva tenderness EXTREMITIES: WWP, no pitting edema of ___: slight tremor of the hands Pertinent Results: ___ 12:15PM PLT COUNT-186 ___ 12:15PM NEUTS-81.2* LYMPHS-7.1* MONOS-9.9 EOS-0.7* BASOS-0.4 IM ___ AbsNeut-3.68 AbsLymp-0.32* AbsMono-0.45 AbsEos-0.03* AbsBaso-0.02 ___ 12:15PM WBC-4.5 RBC-3.47* HGB-11.4* HCT-34.1* MCV-98 MCH-32.9* MCHC-33.4 RDW-15.9* RDWSD-54.9* ___ 12:15PM CALCIUM-10.1 PHOSPHATE-3.5 MAGNESIUM-2.5 ___ 12:15PM GLUCOSE-99 UREA N-20 CREAT-0.8 SODIUM-141 POTASSIUM-4.9 CHLORIDE-105 TOTAL CO2-24 ANION GAP-17 OPERATIVE REPORT: FINDINGS: 1. Existing 14 ___ surgically placed jejunostomy within the small bowel 2. Replacement of tube with a new 14 ___ modified ___ with tip in the small bowel. IMPRESSION: Successful exchange of a jejunostomy tube for a new ___ Fr modified ___ tube. The tube is ready to use. Brief Hospital Course: Mr. ___ is a ___ male with locally advanced esophageal cancer, with surgically placed ___ Fr Jtube now clogged after administering pill through it, being admitted for observation before he has his J-tube replaced. #J-TUBE CLOGGED: Patient had J-tube placed on ___ for aiding with feeding. Has been working ok until last night when he placed pill in it. Bedside clogging failed. J-tube was replaced successfully and he will need follow up in 3 months for repeat replacement. # Locally advanced esophageal cancer: Finished chemotherapy and radiation per the CROSS trial, plan to be followed esophagectomy. Followed by Dr. ___ at ___. He is followed by surgery with goal esophagectomy after completion of chemotherapy and radiation # Nutrition: Tube feedings with Osmolite 1.5 goal 120cc/hr over 12 hours once J-tube replaced # Normocytic anemia: Not microcytic, normal RDW. Likely anemia of chronic disease. Pt not symptomatic. TRANSITIONAL ISSUES: -f/u with PCP next week -___ follow up in 3 months for J-tube replacement # EMERGENCY ___ ___ (Wife) # CODE STATUS: Full confirmed NOTE: This patient was admitted and then discharged on the same hospital day without being formally staffed by an attending physician due to an error in communication. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. OxycoDONE Liquid ___ mg PO Q4H:PRN pain 3. Lorazepam 0.5 mg PO BID nausea 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. Osmolite 1.5 Cal (nutritional supplements) 120 cc J-tube 12 hours/day 6. Docusate Sodium (Liquid) 100 mg PO BID 7. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain 2. Docusate Sodium (Liquid) 100 mg PO BID 3. Lorazepam 0.5 mg PO BID nausea 4. Ondansetron 4 mg PO Q8H:PRN nausea 5. Osmolite 1.5 Cal (nutritional supplements) 120 cc J-tube 12 hours/day 6. OxycoDONE Liquid ___ mg PO Q4H:PRN pain 7. Prochlorperazine 10 mg PO Q6H:PRN nausea Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: J-tube blockage Esophageal Ca 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 having you here at the ___. You were admitted for a J-tube replacement procedure after your J-tube became clogged. THis procedure was successfully completed and you were discharged home. You will be contacted by the interventional radiology team for a follow up appointment in 3 months to replace J-tube. Please keep your follow up appointment below. Followup Instructions: ___
10124825-DS-21	10,124,825	27,890,366	DS	21	2123-03-27 00:00:00	2123-03-27 13:56:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: nausea, gait unsteadiness, dysarthria Major Surgical or Invasive Procedure: ___ occipital craniotomy History of Present Illness: Neurology at bedside for evaluation after code stroke activation within: 1 minutes on ___ ___ Stroke Scale Score: 2 t-PA given: No Reason t-PA was not given or considered: pt out of stroke window and low NIHSS . I was present during the CT scanning and reviewed the images instantly within 20 minutes of their completion. Reason for Consult: CODE STROKE HPI: The pt is a ___ year-old R-handed man with unknown PMHx (hasn't seen a doctor in ___ who presents as a code stroke for nausea, gait unsteadiness and dysarthria. . Pt reports that he was well until 7pm on ___ when he suddenly felt dizzy, nauseated and unsteady on his feet. 911 was called and he was brought to ___. There, they got labs, which were unremarkable. At 21:35 he then had the sudden onset of "garbled speech" after eating an icecream. He was then unable to lift his L arm or L leg, and was sent for ___, which per report was negative, and when he came out of the scanner, he was able to lift his L side again. He was sent here for further management. . In our ED, he was noted to be hypertensive up to the low 200's (but mostly in the 180's). He was also noted to be dysarthric but otherwise had an essentially normal exam (unable to walk him because of dizziness). He was sent to a CT, CTA and CTP, which showed a clot in his R vertebral artery with some possible extension to the basilar. He was put on heparin and admitted to the neurology SDU. . On neuro ROS, the pt reports dizziness and difficulty walking as above, denies headache, new loss of vision (had R retinal detachment), blurred vision, diplopia, dysphagia, tinnitus or hearing difficulty. Denies difficulties producing (other than the slurred speech) or comprehending speech. Denies focal weakness, numbness, parasthesiae. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: detached retina in his R eye Social History: ___ Family History: (obtained from sister), mother had a stroke at age ___, but live 9 more years, also had DM2. Father had DM2, died at age ___ from CHF. Pt's sister and brother both have DM2 and afib. Pt's brother had a cerebral aneurysm that burst, but he survived (with short term memory loss) Physical Exam: ADMISSION EXAM Physical Exam: Vitals: T: 97.6 P: 75 R: 20 BP: 175/112 SaO2: 98% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: (If applicable) ___ Stroke Scale score was 2: 1a. Level of Consciousness: 0 1b. LOC Question: 0 1c. LOC Commands: 0 2. Best gaze: 0 3. Visual fields: 0 4. Facial palsy: 0 5a. Motor arm, left: 0 5b. Motor arm, right: 0 6a. Motor leg, left: 0 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: 2 11. Extinction and Neglect: 0 -Mental Status: Alert, oriented x 3. Able to relate history without difficulty (although slurred speech made understanding him difficult). Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was very dysarthric, but still intelligible. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages, but was limited as pt's pupils constricted to a very small diameter. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. -DTRs: Bi Tri ___ Pat Ach L 1 1 1 1 0 R 1 1 1 1 0 Plantar response was withdrawal bilaterally. -Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF bilaterally. -Gait: Pt refused "I'm too dizzy" Pertinent Results: Admission Labs: ___ 12:40AM WBC-12.9* RBC-6.51* HGB-14.9 HCT-47.4 MCV-73* MCH-22.9* MCHC-31.4 RDW-15.9* ___ 12:40AM NEUTS-86.1* LYMPHS-11.0* MONOS-1.7* EOS-0.5 BASOS-0.8 ___ 12:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG ___ 12:40AM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-1 ___ 12:40AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 12:40AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:57AM GLUCOSE-159* NA+-148* K+-3.4 CL--105 TCO2-21 ___ 05:40AM TSH-1.1 ___ 05:40AM %HbA1c-5.9 eAG-123 ___ 05:40AM CK-MB-29* MB INDX-9.5* cTropnT-0.29* ___ 12:45PM CK-MB-36* MB INDX-9.2* cTropnT-0.52* ___ 12:45PM CK(CPK)-392* ___ 06:12PM OSMOLAL-302 ___ 06:12PM CK-MB-31* MB INDX-7.0* cTropnT-0.51* ___ 06:12PM CK(CPK)-440* ___ 11:04PM OSMOLAL-305 ___ 11:04PM CK(CPK)-358* ___ 10:09AM BLOOD CK-MB-24* cTropnT-1.98* ___ 02:05AM BLOOD CK-MB-19* MB Indx-2.2 cTropnT-3.17* ___ 01:47AM BLOOD CK-MB-7 cTropnT-3.54* ___ 04:51AM BLOOD cTropnT-2.57* ___ 06:05AM BLOOD cTropnT-1.93* ___ 04:02AM BLOOD cTropnT-1.45* ___ 08:55AM BLOOD CK-MB-3 cTropnT-0.10* ___ 06:58AM BLOOD ALT-52* AST-29 AlkPhos-224* TotBili-0.3 ___ 06:58AM BLOOD Glucose-125* UreaN-22* Creat-0.7 Na-145 K-4.1 Cl-108 HCO3-31 AnGap-10 ___ 06:58AM BLOOD ___ PTT-54.3* ___ ___ 06:58AM BLOOD WBC-10.6 RBC-4.76 Hgb-10.3* Hct-35.7* MCV-75* MCH-21.6* MCHC-28.8* RDW-15.3 Plt ___ ___ 05:40AM BLOOD calTIBC-381 VitB12-314 Folate-14.1 Ferritn-135 TRF-293 ___ 05:40AM BLOOD %HbA1c-5.9 eAG-123 ___ 05:40AM BLOOD Triglyc-48 HDL-49 CHOL/HD-4.3 LDLcalc-153* MICROBIOLOGY: Urine Cultures: Negative on ___ Blood Cultures: Negative on ___, ___. Coag negative staph grew out on ___. Stool C Diff: Negative on ___ and ___ ECG Sinus rhythm with premature atrial contractions. Probable left atrial abnormality. Left bundle-branch block. Cannot exclude inferior wall myocardial infarction, age indeterminate. Extensive baseline artifact. Q-T interval prolongatkon. No previous tracing available for comparison. ___ CTA/CTP Head 1. Occluded Right V1 and V2 vertebral artery segments likely secondary to thrombosis superimposed over atherosclerotic changes, however possibility of underlying dissection can not be excluded. 2. High grade stenosis at left vertebral artery origin. 3. Old infacrt in left parietal region. MRI may be obtained if there is concern for posterior circulation stroke. 4. Left thyroid nodule, may be non emergently evaluated with neck ultrasound. ___ ECG Sinus rhythm. Left atrial abnormality. Left bundle-branch block. Cannot exclude an inferior fwall myocardial infarction. Non-specific lateral ST-T wage changes which may be due to intraventricular conduction delay. Compared to tracing #1 atrial eactopy is absent. ___ CXR IMPRESSION: Diffuse bilateral opacities with hazy pulmonary vasculature likely represents pulmonary edema; however, concurrent pneumonia cannot be excluded. Recommend repeat conventional radiographs when feasible. ___ MRI Brain Early acute infarction in the right cerebellum, involving the right ___ territory with few regions of susceptibility artifact, likely representing hemorrhagic transformation. There appears to be a segmental occlusion of the right V4 segment. ___ Portable NCHCT: Appearance of right cerebellar infarct is more pronounced with slightly increased leftward shift of midline. Mass effect and distortion of the fourth ventricle persistent though not appreciably changed from the prior exam. No hemorrhage or new area of infarct. ___ TTE Moderate regional and global left ventricular systolic dysfunction c/w multivessel CAD. No cardiac source of embolism identified (suboptimal bubble study as patient is ventilated and unable to cooperate with maneuvers). Mild pulmonary artery systolic hypertension. ___ CXR: As compared to the previous radiograph, there is no relevant change. The monitoring and support devices are constant. Unchanged moderate cardiomegaly. Mild bilateral pleural effusions. No focal parenchymal opacity suggesting pneumonia. No relevant fluid overload. ___ CT/CTA: Increased density of blood products within right cerebellar hemisphere infarct and increased conspicuity of subdural blood tracking along the tentorium and falx is concerning for ongoing hemorrhage. Two or three hypodense foci at the left internal capsule and left parasagittal parietal region likely represent evolving infarcts, as not seen on earlier imaging. Attention on close f/u. CXR ___: In comparison with study of ___, the left IJ catheter is at the junction of the brachiocephalic vein and SVC. There is continued enlargement of the cardiac silhouette with possible mild elevation of pulmonary venous pressure. No evidence of acute focal pneumonia. ___ ___: New layering fluid in the right maxillary antrum and bilateral sphenoid air cells is non-specific. However, given other evidence of inflammatory sinus disease and the relative paucity of layering fluid in the nasopharynx and nasal cavity, the findings favor acute inflammation, superimposed on pre-existent sinus disease. Expected evolution of right cerebellar infarct with early encephalomalacia and resolution of small central hemorrhage. No new hemorrhage or infarction. Brief Hospital Course: See above history of the present illness for more historical information. In essence, Mr. ___ had neglected any routine medical care for almost a decade and a half prior to this admission. On the day of his admission, he had experienced nausea, dysarthria and gait ataxia with transient left sided weakness and was found to have R vertebral artery thrombus and R cerebellar acute cerebral infarction on MRI. [] Acute Cerebral Infarction, Increased ICP - The patient was found to have a R vertebral artery occlusion for which he was started on a Heparin infusion (PTT goal 50-70). His level of consciousness became more depressed, however, and his MRI revealed extensive infarction of the R cerebellum (and likely right lateral medulla) causing mass effect on the fourth ventricle. He developed a motor paralysis of left face, arm, and leg, and slowly regained some function in left toes and shoulder during his recovery. He was started on mannitol and 3% normal saline as hyperosmolar therapy. Neurosurgery was consulted and opted to perform an occipital craniotomy for decompression. He was intubated and sedated for this procedure. He was continued on mannitol post-op as there appeared to still be severe mass effect on the fourth ventricle. This was stopped after one day as he became hyperosmolar and hypernatremic and was diuresing appropriately. On ___, a repeat non-contrast head CT showed subdural blood tracking along the tentorium and posterior falx without mass effect. Subdural blood continued to be noted on follow-up CT on ___, again without new mass effect. The etiology of his stroke is thought to be either artery-to-artery embolism from neck atherosclerosis or cardioembolic (low LVEF versus atrial fibrillation). Ultimately, he was transferred back to the floor on our step down unit. He received a follow up NCHCT which showed the presence of blood in the posterior fossa. The heparin drip was stopped transiently, and a repeat scan showed no worsening in bleeding. His heparin drip was restarted. Ultimately, he was started on daily warfarin. His heparin was discontinued as his CTA showed a resolution of his vertebral artery thrombosis. He was discharged on ASA 81mg while on warfarin. He is required to stay on aspirin given his history of CAD. [] NSTEMI - Initially, on admission, he was found to have a LBBB and elevated troponins to 0.52 or so. He was seen by cardiology who deferred intervention given his current stroke and the fact that he was already on a heparin drip. We started additional beta blockade and aspirin at that time, and tried to reduce his myocardial oxygen demand. While in the ICU, in the acute setting, he did at one point develop atrial fibrillation with RVR and was placed on an amiodarone drip. His cardiac enzymes were found to be elevated to a peak of 3.54. He did have evidence of inferior ischemia and a LBBB. Cardiology was re-consulted, and a subsequent TTE revealed a depressed LVEF 30% and inferolateral wall motion abnormalities. Once again, he was managed with beta blockade, and when possible (there was a period post-op when he could not be on antithrombotics), antiplatelet and statin therapy. [] Infection: While in the ICU, he developed fevers and an elevated WBC. An endotracheal sputum sample grew out Enterobacter aerogenes. This was treated with 2 weeks of tobramycin and cephalosporin IV. While on this aggressive regimen, he continued to spike recurrent fevers with a stable white blood cell count. He was cultured multiple times with no obvious organisms identified. He displayed some diarrhea requiring a rectal tube/flex-aseal which was not C-diff positive. Ultimately, we checked a CT sinus which showed acute on chronic sinusitis. Interestingly, once his NG tube was removed and he received a PEG, his fevers stopped. His mental status also improved significantly. He completed his antibiotic regimen of cefepime/tobramycin on ___. PICC line was subsequently removed. [] Swallowing: He was evaluated by speech/swallow on several occasions but failed his evaluations due to his lethargy. Ultimately we decided to place a PEG tube. [] Pulm: While he was extubated successfully in the ICU, he would be chronically tachypneic on the floor and display coarse upper airway sounds and gurgling. He required frequent suctioning of his upper airway oropharyngeal secretions. We placed a nasal trumpet even to separate his tongue from his tight airway and access his secretions. Once again, this type of fast breathing with excess secretions improved significantly after removing his NG tube. His trumpet was removed and his oxygen requirement improved. TRANSITIONAL CARE ISSUES: [] Please monitor INR closely - on coumadin with an aspirin bridge, INR was 1.3 on discharge [] Neurosurgery follow up: Mr. ___ needs to return to see Dr. ___ in 4 weeks [] Please be sure to have Mr. ___ follow up with ___ ___ from the Division of Stroke Neurology [] Mr. ___ had a transthoracic echocardiogram during his admission which showed no evidence of a cardiac source for his stroke. However a bubble study was unable to be performed at the time to evaluate for PFO. He will need a repeat echo at some point after discharge with a bubble study to complete his cardiac work-up. [] Left Thyroid Nodule - An incidental finding of a left thyroid nodule was found on a CTA of the Neck. This can be followed up by his primary care physician as an outpatient. [] Mr. ___ was noted to desaturate occasionally during sleep. He should have a sleep study performed as an outpatient to evaluate for sleep apnea. DISCHARGE NEUROLOGIC EXAMINATION: Awake, alert and oriented to his name. Has difficulty with the date. Hypophonic. Weak cough. EOMI, PERRL, symmetric face. Left>Right mild-moderate UMN pattern of weakness. Areflexic throughout, normal sensation. No frank dysmetria. Medications on Admission: None Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. warfarin 1 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 ___. 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. tobramycin sulfate 40 mg/mL Solution Sig: One (1) Injection Q24H (every 24 hours): Last dose ___. 5. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q8H (every 8 hours): Last dose ___. 6. HydrALAzine ___ mg IV Q6H PRN SBP > 170 7. sodium chloride 0.9 % 0.9 % Parenteral Solution Sig: 10ml Intravenous PRN as needed for flush. 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours) as needed for pain/fever. 11. Norvasc 10 mg Tablet Sig: Two (2) Tablet PO once a day. 12. hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 13. Ondansetron ___ mg IV Q6H:PRN nausea 14. metoprolol tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 15. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 16. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 17. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right vertebral artery thrombosis and resultant ___ infarction Hypertension Coronary Artery Disease Hyperlipidemia Atrial fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___: It was a pleasure to care for you during your hospitaliztion at ___. You were brought to our hospital after you developed nausea, difficulty speaking and difficulty walking. We performed several tests including CT and MRI scans of your brain. We found that you had a stroke of a part of your brain called the CEREBELLUM on the right side. Strokes affecting this portion of the brain can interfere with your coordination and motor skills, and can at times cause weakness. To relieve the swelling in the area of the brain, you received medical and surgical therapy. You were briefly placed on blood thinning medication. - You received a PEG tube (percutaneous gastrostomy) to allow us to safely deliver medications and nutriion (tube feeds). This was done since your stroke likely affected your ability to swallow safely. It is possible that your swallowing function will improve over time. You will be continually reassessed for improving swallow function. - We placed a PICC line (peripherally placed intravenous central catheter) which is a strong IV line that can be used to deliver IV medications - You completed a course of antibiotics for a pneumonia that you developed while you were on the mechanical breathing machine. - Your oxygen levels were noted to drop occasionally when you were sleeping - should have a sleep study done at some point after your discharge to evaluate for sleep apnea - Please do not hesitate to contact us if you have any questions or concerns. We ask that you follow up with your doctors as listed below. - Please come to your nearest ED if you experience any of the below listed unexplained signs and symptoms. - Our physical therapists felt that you would benefit from a stay at an acute rehabilitation facility. We were able to organize this for you. Please follow up with your primary care physician once you have completed your rehab. Followup Instructions: ___
10124885-DS-12	10,124,885	20,490,662	DS	12	2146-05-21 00:00:00	2146-05-21 16:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Compazine / prochlorperazine Attending: ___ Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Coronary angiogram ___ with deployment of a drug-eluting stent in the diagonal and negative pressure wire interrogation of the circumflex artery History of Present Illness: Mr. ___ is a ___ yo man with H/O CAD s/p MI with PCI of LCX ___, arterial hypertension and dyslipidemia who presented to the emergency department with chest pain. The patient reports several episodes of central chest pain with exertion which first occurred several weeks ago. He describes the pain as sharp and non-radiating. It lasts around 2 minutes and improves with rest. There is nothing else but exertion that brings the pain on. He denied associated shortness of breath, diaphoresis, nausea or vomiting. He stated that for the first time today the pain lasted longer than usual (about 5 minutes) and was radiating to his back. He also noted mild epigastric pain today. Of note the patient had undergone stress echocardiography in early ___ to ___ METs with no evidence of ischemia. In the ED initial vitals were: T 98.4 HR 72 BP 154/85 RR 20 SaO2 99% on RA. Labs/studies notable for:TropT 0.01 CK-MB 3. Vitals on transfer: BP 137/67 HR 62 RR 13 SaO2 99% on RA. After arrival to the cardiology ward, the patient reported feeling well. He denied headache, shortness of breath, chest pain, palpitation, nausea, vomiting, diarrhea, dysuria. REVIEW OF SYSTEMS: Complete ROS obtained and was otherwise negative. Past Medical History: 1. CAD RISK FACTORS - Coronary artery disease presenting with back pain and vomiting, diagnosed with STEMI, proximal CX treated with 3.0 x 18 mm Bx Velocity Hepacoat stent ___ - Hypertension - Mixed dyslipidemia ___ TChol 102, HDL 35, LDL 33, ___ 169) 2. CARDIAC HISTORY - CABG: None - PERCUTANEOUS CORONARY INTERVENTIONS: BMS (HepaCoat) LCX ___ - PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY Right calf pain (neurogenic claudication versus vascular claudication suspected) Social History: ___ Family History: Mother and father underwent coronary bypass surgery. Physical Exam: On admission GENERAL: Well-developed, well-nourished middle aged white man in NAD. Mood, affect appropriate. VITALS: BP 137/67 HR 62 RR 13 SaO2 99% on RA HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no pallor or cyanosis of the oral mucosa. NECK: Supple. CARDIAC: RRR, normal S1, S2. No murmurs, rubs, gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, not distended. No HSM. EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits. SKIN: Psoriatic skin lesion on extensor surfaces of arms and legs. PULSES: Radialis and tibialis posterior pulses palpable bilaterally. At discharge GENERAL: Well-developed, well-nourished. NAD. Mood, affect appropriate. VS: T 98.0 BP 130/74 HR 54 RR 17 SaO2 97% on RA HEENT: NCAT. Sclera anicteric. No pallor or cyanosis of the oral mucosa. NECK: Supple. CARDIAC: RRR, normal S1, S2. No murmurs, rubs, gallops. No thrills, lifts. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles, wheezes or rhonchi. ABDOMEN: Soft, non-tender, not distended. No HSM. EXTREMITIES: No clubbing, cyanosis or edema. No femoral bruits. SKIN: Psoriatic skin lesion on extensor surfaces of arms and legs. PULSES: Radialis and tibialis posterior pulses palpable bilaterally. Pertinent Results: ___ 05:15PM BLOOD WBC-7.2 RBC-5.12 Hgb-14.5 Hct-43.7 MCV-85 MCH-28.3 MCHC-33.2 RDW-13.0 RDWSD-39.5 Plt ___ ___ 05:15PM BLOOD Neuts-63.9 ___ Monos-6.9 Eos-0.8* Baso-0.7 Im ___ AbsNeut-4.61 AbsLymp-1.98 AbsMono-0.50 AbsEos-0.06 AbsBaso-0.05 ___ 05:15PM BLOOD Glucose-98 UreaN-28* Creat-1.5* Na-141 K-4.4 Cl-102 HCO3-28 AnGap-11 ___ 05:15PM BLOOD Calcium-9.7 Phos-3.6 Mg-2.1 ___ 05:15PM BLOOD cTropnT-<0.01 Discharge Labs: ___ 06:30AM BLOOD WBC-5.8 RBC-5.14 Hgb-14.4 Hct-43.8 MCV-85 MCH-28.0 MCHC-32.9 RDW-13.2 RDWSD-40.6 Plt ___ ___ 06:30AM BLOOD Glucose-106* UreaN-26* Creat-1.5* Na-144 K-5.0 Cl-108 HCO3-24 AnGap-12 ___ 06:30AM BLOOD Calcium-9.2 Phos-4.0 Mg-2.4 ___ CHEST (PA & LAT): The lungs are clear without focal consolidation. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are unremarkable. No pulmonary edema is seen. Anterior bridging osteophyte is seen at at least 1 level at the mid to lower thoracic spine. IMPRESSION: No acute cardiopulmonary process. ___ Cardiac Catheterization Coronary Anatomy Dominance: Right The LMCA had no angiographically apparent CAD. The LAD had mild luminal irregularities. TheDiagonal had a 95% stenosis. The Cx had a 50% stenosis at the site of previous stenting with mild disease thereafter. The RCA was a large ectatic vessel with moderate diffuse plaquing and 80%stenosis in a1 mm vessel. Interventional Details A pressure tipped wire was advanced through a guiding catheter into the distal LCX vessel(s). Measurements of FFR were made during hyperemia induced by intravenous Adenosine. The FFR pre adenosine was 0.98. After Adenosine the lowest ratio was 0.89. The wire was then removed. A 6 ___ EBU3.5 guiding catheter was used to engage the LMCA and provided adequate support. A 180 cm Runthrough guidewire was then successfully delivered across the lesion. Predilated with a 2.0 mm balloon and then deployed a 2.5 x 20 mm Synergy stent which was postdilated with a 2.5 mm and then a 2.75 mm NC balloon at high pressure. The wire was redirected into a small lower pole but a 2.0 mm balloon could not be delivered and given small caliber of the vessel the decision was made manage this medically rather than deform the stent with balloon inflation. Final angiography revealed normal flow, no dissection and 20% stenosis in stent IMPRESSIONS: 1. Successful DES in the diagonal. 2. Negative pressure wire interrogation of the Cx. Brief Hospital Course: ___ with history of CAD s/p DES to RCA in ___, hypertension, hyperlipidemia who presented from home with exertional chest pain despite a negative stress echocardiogram 10 days earlier. Coronary angiography showed a 90% lesion in diagonal branch which was stented with a drug-eluting stent. Investigations/Interventions: 1. Coronary artery disease, unstable angina: p\Patient has history of CAD s/p DES to RCA in ___. Patient had recently undergone negative stress echo as outpatient ___ but presented with exertional chest pain. EKG, troponin unremarkable on admission. Given persistent symptoms consistent with ischemia, decision made to pursue coronary angiogram. This showed a diagonal with 95% stenosis which was stented with one DES. The Cx had 50% stenosis at the site of previous stenting with mild disease thereafter (no intervention as pressure wire evaluation was negative for ischemia). The RCA was a large ectatic vessel with moderate diffuse plaquing and 80% stenosis in a 1 mm vessel (no intervention). He was loaded with clopidogrel and scheduled to start clopidogrel 75 mg daily. His lipid therapy was also switched from atorvastatin to rosuvastatin 40 mg a day given progression of disease despite a good lipid profile. He will follow up with Dr. ___ ongoing management of CAD, hyperlipidemia, and possible addition of PCSK-9 inhibitor. 2. CKD: of unknown etiology, possibly hypertensive. Baseline Cr 1.5 with eGFR 48 mL/min/1.73m2. He was given pre- and post-angiography hydration. He is instructed to have lab draws of BMP on ___, results of which Dr. ___ will follow up. Transitional Issues: [] Clopidogrel 75 mg daily initiated [] Atorvastatin switched to rosuvastatin [] Patient instructed to have lab draws of BMP on ___ [] Patient discharged after hours, instructed to arrange follow up with outpatient providers (primary team also will help with this) # Code: Full (confirmed) # Contact: ___ (wife) ___, ___ (daughter) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Atorvastatin 80 mg PO QPM 2. Sertraline 75 mg PO DAILY 3. Metoprolol Succinate XL 100 mg PO DAILY 4. Desonide 0.05% Cream 1 Appl TP BID 5. Halobetasol Propionate 0.05 % topical BID 6. Lisinopril 20 mg PO DAILY 7. Aspirin 81 mg PO DAILY 8. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Discharge Medications: 1. Clopidogrel 75 mg PO DAILY to prevent stent thrombosis RX clopidogrel 75 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 2. Rosuvastatin Calcium 40 mg PO QPM RX rosuvastatin 40 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 3. Aspirin 81 mg PO DAILY 4. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID 5. Desonide 0.05% Cream 1 Appl TP BID 6. Halobetasol Propionate 0.05 % topical BID 7. Lisinopril 20 mg PO DAILY 8. Metoprolol Succinate XL 100 mg PO DAILY 9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 10. Sertraline 75 mg PO DAILY 11.Outpatient Lab Work I25.1 Coronary Artery Disease Please obtain BMP and call Dr. ___ ___ with results Discharge Disposition: Home Discharge Diagnosis: -Coronary artery disease -Dyslipidemia -Hypertension -Stage 3 chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were hospitalized with chest pain and underwent a coronary angiogram. This demonstrated a tightening in one of the arteries surrounding your heart, so we placed a stent. You are starting a new medication called Plavix which is vital to preventing another heart attack. Please call your PCP and Dr. ___ to schedule follow up appointments. It was a pleasure taking care of you! Your ___ team Followup Instructions: ___
10124890-DS-10	10,124,890	23,933,770	DS	10	2170-02-10 00:00:00	2170-02-10 12:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: gluten Attending: ___. Chief Complaint: Ongoing diarrhea and escalating malnutrition Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is a ___ female with the past medical history of recent diagnosis of celiacs disease who presents with ongoing diarrhea. She developed diarrhea symptoms for a few months, but these were much worse in ___. She normally receives her care in ___ and ___ been admitted to their hospital twice. About 2 weeks ago, she underwent endoscopy and was diagnosed with Celiac disease. She switched to a gluten-free diet, but has not seen a significant difference in her symptoms. Diarrhea occurs ___, moderate in severity, no associated blood, and exacerbated by eating. She notes some nausea but takes Zofran for this on occasion. She went to her outpatient GI MD 2 days prior to admission, and when labs came back abnormal, she was told to come to ___ because of the celiac program here. She states that her outpatient GI MD is wondering whether she needs to have PPN or TPN as a bridge. She also notes that she has had significant edema over the past few weeks. This is to the point where she gained back much of the 15 pounds she lost initially, but gained much of it back as water weight. The edema makes ambulating difficult, to the point where she has been unable to walk well. She denies having any abdominal pain recently and also denies having any fevers. Past Medical History: Celiac disease Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION EXAM: GENERAL: Alert and in no apparent distress, fatigued 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 rate; normal perfusion, no appreciable JVD RESP: Symmetric breathing pattern with no stridor. Breathing is non-labored GI: Abdomen soft, non-distended, non-tender, no hepatosplenomegaly appreciated. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, normal muscle tone, decreased bulk SKIN: Significant edema is present in UE and ___, no ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: normal thought content, logical thought process, appropriate affect Discharge Exam: 98.0 PO 112 / 69 106 18 99 RA 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 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. Significant 1+ pitting edema to hips bilaterally and both upper extremities with 1+ edema worse on RUE. Edema also at hips bilaterally PSYCH: pleasant, appropriate affect NEUROLOGIC: MENTATION: alert and cooperative. Oriented to person and place and time. Pertinent Results: ADMISSION LABS ___ 07:00AM BLOOD WBC-9.6 RBC-4.71 Hgb-12.5 Hct-35.3 MCV-75* MCH-26.5 MCHC-35.4 RDW-16.5* RDWSD-44.5 Plt ___ ___ 07:00AM BLOOD Glucose-75 UreaN-12 Creat-0.6 Na-127* K-3.4* Cl-94* HCO3-17* AnGap-16 ___ 07:00AM BLOOD ALT-75* AST-73* AlkPhos-218* TotBili-0.5 ___ 07:00AM BLOOD Albumin-1.5* Calcium-7.0* Phos-3.1 Mg-1.4* ___ 06:30PM BLOOD VitB___* Folate-4 ___ 06:30PM BLOOD Triglyc-72 ___ 06:30PM BLOOD 25VitD-5* ___ 07:00AM BLOOD CRP-7.8* ___ 07:00AM BLOOD tTG-IgA-GREATER THAN ASSAY ___ EXAMINATION: CT enterography INDICATION: ___ year old woman with Celiac disease, severe malabsorption, and abnormal LFTs.// CT enterography. Assess extent of bowel involvement. Look for any unexpected intrabdominal pathology that would change differential diagnosis. TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired through the abdomen and pelvis following intravenous contrast administration with split bolus technique. Oral contrast was administered. Coronal and sagittal reformations were performed and reviewed on PACS. DOSE: Acquisition sequence: 1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4 mGy-cm. 2) Stationary Acquisition 21.7 s, 0.2 cm; CTDIvol = 366.6 mGy (Body) DLP = 73.3 mGy-cm. 3) Spiral Acquisition 8.2 s, 53.5 cm; CTDIvol = 9.5 mGy (Body) DLP = 504.0 mGy-cm. Total DLP (Body) = 579 mGy-cm. COMPARISON: No relevant comparison. FINDINGS: LOWER CHEST: There are small bilateral pleural effusions with compressive subsegmental atelectasis.. ABDOMEN: HEPATOBILIARY: There is diffuse hepatic steatosis evidenced by regions of sparing. The presence of fat limits the evaluation for focal lesions. The gallbladder is within normal limits. There is small to moderate ascites throughout the abdomen. PANCREAS: Unremarkable. SPLEEN: Unremarkable. ADRENALS: Unremarkable. URINARY: Bilateral kidneys are unremarkable. No hydronephrosis. GASTROINTESTINAL: There is moderate gastric distension and mild distal esophageal dilatation, the latter could represent reflux or delayed emptying from gastric distension. There is no small bowel obstruction. There is jejunization of the ileum and hyperenhancement of the bowel wall, reflective of celiac disease. The jejunal loops demonstrate mild loss of the folds and multiple segments resemble the ileum. There are prominent mesenteric lymph nodes measuring up to 1.0 cm (series 5; image 73), which are most likely reactive. There is no free intraperitoneal air. PELVIS: There is a small amount of simple free fluid in the pelvis. The uterus and adnexa are unremarkable for age. LYMPH NODES: No enlarged retroperitoneal or inguinal lymph nodes are seen VASCULAR: There is no abdominal aortic aneurysm. The mesenteric vasculature is patent BONES: There is no evidence of worrisome osseous lesions . SOFT TISSUES: Severe subcutaneous soft tissue edema is noted. There is also deep and intermuscular soft tissue edema. IMPRESSION: 1. Marked dilatation of the stomach could be correlated with gastroparesis. There is mild dilatation of the distal esophagus which could be due to reflux or secondary to gastric distension. 2. "Jejunization'' of the ileum likely reflecting known celiac disease. Numerous nonenlarged mesenteric lymph nodes, likely reactive. 3. Small pleural effusions, small amount of ascites and extensive subcutaneous soft tissue edema most likely secondary to third spacing. 4. Hepatic steatosis. ___ Imaging UNILAT UP EXT VEINS US EXAMINATION: UNILAT UP EXT VEINS US RIGHT INDICATION: ___ year old woman with R sided PICC// RUE edema, worsening, rule out DVT TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper extremity veins. COMPARISON: None. FINDINGS: A right PICC line is visualized with nonocclusive adherent thrombus along the line within the basilic vein. There is normal flow with respiratory variation in the right subclavian vein. The right internal jugular and axillary veins are patent, show normal color flow and compressibility. The right brachial and cephalic veins are patent, compressible and show normal color flow and augmentation. IMPRESSION: 1. Adherent nonocclusive basilic vein thrombus along the right upper extremity PICC line. 2. No evidence of deep vein thrombosis in the right upper extremity. Brief Hospital Course: ___ year old female with history of ___ new celiac disease diagnosis who presented with persistent diarrhea and found to have celiac crisis. #Celiac crisis #Severe protein-calorie malnutrition Patient with continued diarrhea complicated by severe electrolyte disturbance and severe protein calorie malnutrition. On admission, albumin was 1.5 with diffuse third spacing due to oncotic edema. She is cachectic and her presumed dry weight is probably far below her ideal weight. She has been on a gluten-free diet for a couple weeks but symptoms have not resolved. ___ GI team believes this is all because damage to the small bowel is sufficiently profound that she needs time to regenerate her villi/mucosa. - ___ sent their small bowel biopsy results to us for review. Our pathologist's report shows celiac disease (duodenal mucosa with focally subtotal villous atrophy, patchy crypt hyperplasia, and markedly increased intraepithelial lymphocytes. - Continue PO gluten free diet plus lipid free TPN at home - Thiamine, Vitamin supplementation via TPN at home - prednisone 60 mg daily was given inpatient and continued on discharge. Taper regimen to be adjusted by her GI doctor as outpatient (has appointment ___ - PCP ppx with ___ was stopped due to transaminitis - PPI was given high dose prednisone #Transaminitis -No bilirubin elevation -Had slow rise in AST, ALT, possibly due to lipids in TPN as it got much better once lipids were removed from the TPN -A workup with ceruloplasmin, ___, EBV/CMV/HSV. AMA, ___, viral hepatitis, TSH were unremarkable. -RUQ US showed steatosis, without PVT by doppler #RUE swelling. -No pain or erythema but is on the side of PICC line. -US RUE to ruled out DVT but showed superficial thrombophlebitis (nonocclusive thrombus in basilic vein) -Warm compresses, elevate RUE #Anasarca #Hypoalbuminemia -likely secondary to malnutrition and low oncotic pressure with low albumin -Did well with IV albumin and IV diuresis as inpatient. Changed to oral Lasix for discharge. Greater than 30 minutes was spent on discharge planning and coordination Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron ODT 4 mg PO Q8H:PRN nausea 2. Potassium Chloride 40 mEq PO BID 3. magnesium chloride 128 mg oral DAILY 4. Multivitamins 1 TAB PO DAILY 5. FoLIC Acid 1 mg PO DAILY 6. Vitamin D 400 UNIT PO DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild RX acetaminophen [Acetaminophen Extra Strength] 500 mg 2 tablet(s) by mouth every six (6) hours Disp #30 Tablet Refills:0 2. Furosemide 20 mg PO DAILY RX furosemide 20 mg 1 tablet(s) by mouth DAILY Disp #30 Tablet Refills:0 3. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet(s) by mouth DAILY Disp #30 Tablet Refills:0 4. PredniSONE 60 mg PO DAILY RX prednisone 20 mg 3 tablet(s) by mouth DAILY Disp #60 Tablet Refills:0 5. Thiamine 100 mg PO DAILY RX thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth DAILY Disp #30 Tablet Refills:0 6. Vitamin A ___ UNIT PO DAILY Duration: 15 Days RX vitamin A 10,000 unit 1 capsule(s) by mouth DAILY Disp #30 Capsule Refills:0 7. FoLIC Acid 1 mg PO DAILY 8. magnesium chloride 128 mg oral DAILY 9. Multivitamins 1 TAB PO DAILY 10. Ondansetron ODT 4 mg PO Q8H:PRN nausea 11. Vitamin D 400 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Celiac crisis Severe malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Instructions: Dear Ms. ___, It was a pleasure to be a part of your care team at ___ ___. ==================================== Why did you come to the hospital? ==================================== -You had an acute flare of celiac disease (called a 'celiac crisis') ==================================== What happened at the hospital? ==================================== -You were treated with nutritional support. This required Total Parenteral Nutrition (TPN) which is IV administration of nutrients. This is needed on discharge to home as well, because the celiac disease had caused so much gut swelling and damage that it will take a long time for the gut mucosa to recover. That means currently, even though you are able to eat a gluten free diet without diarrhea, not all of your required nutrients are being absorbed effectively. Your vitamin levels across the board were very low due to the difficulty with your gut absorbing nutrients. -You were also treated with steroid medication that tells the immune system to calm down (immunosuppressant medication), to help reduce the ongoing damage to your gut mucosa. -You did have elevation of your liver blood tests. They were mildly abnormal. It is thought to be due to the inclusion of lipids in your TPN. When they were excluded, your liver tests got much better. -You did need medication to help get rid of excess fluid built up in your extremities. You will take oral Lasix medication at home to help with this. Your PCP can help determine when you don't need this medication anymore. -Your GI doctor ___ see you in the office on ___. Your GI doctor ___ help manage the TPN regimen at home. He will also help determine when you can have your steroid medication dose reduced. ================================================== What needs to happen when you leave the hospital? ================================================== -Please see your GI doctor as planned in 2 days from now. -Get your blood drawn in the morning of ___, to test for your electrolytes and liver tests for your GI doctor to follow up. -___ taking all medications as prescribed, and the TPN at home. -Continue to adhere to gluten free diet. -Follow with your primary care doctor as scheduled to help determine when you can stop the oral Lasix medication. -You had swelling in the right upper arm where you have the PICC IV line placed. There is superficial thrombophlebitis there; having a foreign object in the vein can cause inflammation of the surface veins and there was a small clot formed there. It can resolved on its own usually, but you need to pay attention to any signs for the possibility that a deeper clot can develop. -Keep the right upper extremity elevated throughout the day and use warm or cold compresses to reduce the swelling. -If you notice increase in swelling, or new redness or warmth, or any fever or shortness of breath, palpitations, then you must return to the emergency department to have the right arm evaluated for development of a deep vein clot, because that can be an emergency problem. It was a pleasure taking care of you during your stay! Sincerely, Your ___ team Followup Instructions: ___
10125252-DS-9	10,125,252	28,943,109	DS	9	2115-08-31 00:00:00	2115-08-31 19:48:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: Blood transfusion History of Present Illness: ___ year old F with HTN, DM, breast ca s/p partial mastectomy and radiation, and iron deficiency anemia who presents with fatigue and chest pain. Pt reports feeling fatigued with moderate exertion for the past week. Whenever, she has been going up the stairs at her home she says she feels like she needs to rest. She denies any significant dyspnea. On the morning of admission, she experienced sharp chest pain over the L pectoral area which was worse with deep inspiration. No radiation. She went to the urgent care clinic at ___ and had labs which showed worsened anemia. CT PE was also arranged which was negative for clot and no infiltrates to explain her pain. She was sent to the ED for further evaluation where her vital signs were stable. ECG was unremarkable and troponins were negative x 2. Her hemoglobin was down to 6.4 whereas her recent outpatient baseline from ___ was 8.4. GUAIAC was negative. She was admitted for management of her symptomatic anemia. She denies BRBPR. She says her periods are moderate, going through ___ pads per day. Last period was at the beginning of this month. No easy bruising or jaundice. ROS: negative except as above Past Medical History: HTN DM on oral meds Breast CA T1c, N0 R breast s/p partial mastectomy and radiation Social History: ___ Family History: No history of anemia or hemoglobinopathy. Physical Exam: Admission: Vitals: 98.5 112/62 93 18 96%RA HEENT: moist mm, no jaundice CV: rrr, flow murmur Pulm: clear b/l Abd: soft, nontender, nondistended Ext: no edema Neuro: alert and oriented x 3, no focal deficits Discharge: AVSS Unchanged rr, nl rate, flow murmur Pertinent Results: ___ 02:15PM WBC-7.5 RBC-3.91* HGB-7.5* HCT-26.2* MCV-67* MCH-19.1* MCHC-28.4* RDW-17.7* ___ 02:15PM NEUTS-71.0* ___ MONOS-5.1 EOS-0.9 BASOS-0.4 ___ 02:15PM PLT COUNT-247 ___ 08:15PM WBC-9.8 RBC-3.48* HGB-6.4* HCT-22.5* MCV-65* MCH-18.5* MCHC-28.5* RDW-17.1* ___ 08:15PM PLT COUNT-228 ___ 03:18PM ___ PTT-24.4* ___ ___ 08:15PM cTropnT-<0.01 ___ 02:15PM cTropnT-<0.01 ___ 02:15PM GLUCOSE-139* UREA N-15 CREAT-0.9 SODIUM-138 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-24 ANION GAP-17 CTA Chest: No CTA evidence of pulmonary emboli. No acute abnormality in the chest. There are postradiation changes anteriorly on the right. Thyroid is enlarged. Please correlate clinically. CXR: No acute cardiopulmonary process. Brief Hospital Course: ___ with HTN, DM, breast malignancy who presents with months of dyspnea on exertion progressed over the last week with fatigue and pleuritic chest pain. # Anemia, iron deficiency: She has severe iron deficiency anemia which is symptomatic. She has developed this anemia over the past year (last CBC was 26.7 in ___. She was treated with 1 u PRBC and then started on TID oral ferrous sulfate supplementation (with bowel regimen). The need for a work up include GI (of note, was guaiac negative), and possibly gyn follow up were stressed. In addition, she may need IV iron infusion given her severe deficiency. She will follow up with her PCP who can arrange further follow up. Her family was also notified of her necessary follow up. In addition, she was notified of warning symptoms for anemia. # HTN: # DM2: She was continued on her home medications. Her metformin was restarted at discharge. # Breast cancer: On tamoxifen which was continued. Transitional issues: work up of iron deficiency anemia. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Enalapril Maleate 20 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 4. Tamoxifen Citrate 20 mg PO DAILY 5. Pravastatin 40 mg PO DAILY 6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS Discharge Medications: 1. Enalapril Maleate 20 mg PO DAILY 2. Hydrochlorothiazide 25 mg PO DAILY 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 4. Pravastatin 40 mg PO DAILY 5. Tamoxifen Citrate 20 mg PO DAILY 6. MetFORMIN XR (Glucophage XR) 1000 mg PO BID 7. Ferrous Sulfate 325 mg PO TID RX ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth three times a day Disp #90 Tablet Refills:0 8. Senna 8.6 mg PO BID:PRN constipation RX sennosides [senna] 8.6 mg ___ tab by mouth twice a day Disp #60 Tablet Refills:0 9. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #60 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Anemia Iron deficiency 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 symptomatic anemia (low red blood cell count). This is likely due to low iron stores. This is a known issues and you need to complete the work up for the anemia including GI evaluation and possibly gynecology evaluation. In addition, you will need to take iron supplementation. The iron supplementation is essential but may make you constipation. If you get constipation please take stool softeners and laxative. If this continues please discuss with your primary care physician. Followup Instructions: ___
10125734-DS-21	10,125,734	27,298,072	DS	21	2171-09-08 00:00:00	2171-09-08 20:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: left lower quadrant pain Major Surgical or Invasive Procedure: None History of Present Illness: see admission H&P Past Medical History: see admission H&P Social History: ___ Family History: see admission H&P Physical Exam: On day of discharge: VS: T 98.3, HR 83, BP 105/62, RR 18, O2 99% RA Gen: well-appearing, no acute distress, comfortable in bed and ambulating Resp: nl resp effort Abd: soft, thin, non-distended, minimal left lower quadrant tenderness -- improved from prior, no rebound or guarding Pelvic: deferred Pertinent Results: ___ 12:55AM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 12:55AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG ___ 11:27PM ___ PTT-28.9 ___ ___ 10:49PM GLUCOSE-86 UREA N-9 CREAT-0.7 SODIUM-137 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-24 ANION GAP-17 ___ 10:49PM ALT(SGPT)-30 AST(SGOT)-23 LD(LDH)-187 ALK PHOS-52 TOT BILI-0.5 ___ 10:49PM ALBUMIN-4.2 ___ 10:49PM HCG-<5 ___ 10:49PM WBC-8.4 RBC-3.59* HGB-10.9* HCT-33.4* MCV-93 MCH-30.4 MCHC-32.6 RDW-11.9 RDWSD-40.2 ___ 10:49PM NEUTS-68.1 ___ MONOS-7.6 EOS-0.1* BASOS-0.4 IM ___ AbsNeut-5.75 AbsLymp-1.97 AbsMono-0.64 AbsEos-0.01* AbsBaso-0.03 ___ 10:49PM PLT COUNT-210 Pelvic Ultrasound ___: Report pending. Per verbal discussion with radiologist, persistent dilated tubular structure in left adnexa. Fluid appears mostly simple with small amount of debris. Ddx includes hydrosalpinx vs hematosalpinx vs pyosalpinx. Normal ovaries. Brief Hospital Course: The patient initially presented to urgent care on ___ morning with acute onset of left lower quadrant pain, associated nausea and vomiting, and one episode of diarrhea. she was transferred to ___, where she underwent a pelvic ultrasound, renal ultrasound and CT scan. Her CT scan noted a 10cm x 4cm (in maximum dimension) tubular fluid-filled structure in the left adnexa, consistent with the fallopian, tube, wrapping posteriorly around the uterus. Her WBC was 11. She had no fever and normal vital signs. She received 1 dose of IV doxycycline. She received 2 doses of IV morphine with improvement in her pain, and 1 dose of IV Zofran, with resolution in her nausea and vomiting. She was transferred to ___ for concern for a tubo-ovarian abscess. Upon arrival to the ___ ER, she noted overall improvement in her pain. She required one additional dose of IV morphine, and subsequently only had left lower quadrant achy pain. She had no further nausea, emesis, diarrhea, and was feeling hungry. Her WBC was 8. Her vital signs continued to be normal. On exam, she had mild left lower quadrant tenderness, with no distension or rebound or guarding. On bimanual exam, she had minimal left adnexal tenderness with no fullness or mass appreciated. Her cervical LEEP site appeared to be healing well, without evidence of infection, and she had no cervical motion tenderness or uterine tenderness. Overall, her clinical picture was inconsistent with a tubo-ovarian abscess. However, given the CT findings and mild tenderness on exam, the decision was made to treat for possible pyosalpinx and admit for IV antibiotics. She was given 1 dose of IV gentamicin (24 hour dosing) and 3 doses of IV Clindamycin. She was observed inpatient for almost 24 hours. Her pain essentially resolved and she was comfortable in bed and ambulating throughout the day. She tolerated a regular diet. She required no pain medicines or anti-emetics. She had no abnormal discharge or bleeding. She underwent a repeat pelvic ultrasound on ___, which showed a persistent dilated fallopian tube containing simple fluid with a small amount of debris. The final report was not yet available but per verbal discussion with the radiologist, this could represent a hydrosalpinx, hematosalpinx, or a pyosalpinx. Given that she never had a fever or significant leukocytosis, her pain improved quickly and her exam remained reassuring and improved overall, it was felt to be less likely that she had a true pyosalpinx or tubo-ovarian abscess. However, given the presence of debris in the fluid and possibility of an infection that improved with IV antibiotics, the decision was made to continue treatment with oral antibiotics (Doxycycline and Metronidazole) for 14 days. She was discharged home in stable condition. She was recommended to follow-up with her primary gynecologist in the next ___ weeks, or sooner if she developed concerning symptoms or signs, which were discussed with her. Medications on Admission: None Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days Take with food to avoid GI upset. 3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild 4. MetroNIDAZOLE 500 mg PO BID Duration: 14 Days Discharge Disposition: Home Discharge Diagnosis: Left lower quadrant pain Left adnexal fluid filled structure, likely hydrosalpinx, possible hematosalpinx or pyosalpinx Possible intermittent torsion of tube Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the gynecology service after presenting with left lower quadrant pain, found to have a likely dilated fallopian tube. You underwent a pelvic ultrasound, renal ultrasound and CT scan of your abdomen/pelvis. Your ovaries appeared normal on the scans. There was concern for an infection within the fallopian tube, or possible tubo-ovarian abscess, so antibiotics were started. You received 1 dose of IV doxycycline, 1 dose of IV Gentamicin (24-hour dosing), and 3 doses of IV Clindamycin. Your symptoms significantly improved over the course of a day and you required no additional pain medications or anti-nausea medications. A repeat U/S on ___ showed a persistently dilated fallopian tube which contains simple fluid with a small amount of debris. This may represent a hydrosalpinx (simple fluid alone), hematosalpinx (blood-filled tube), or a pyosalpinx (pus in the fluid). Given that you never had a fever, your blood counts remained normal, your exam was reassuring without evidence of significant infection, and your symptoms improved so quickly, we have a low suspicion for a serious infection in the tube. However, we recommend treating you for a presumed infection, with continuation of oral antibiotics (Doxycycline and Metronidazole) for 14 days. We also recommend you follow-up with your primary gynecologist in the next ___ weeks, or sooner if you develop concerning symptoms or signs. Overall, you have recovered well and the team believes you are safe to be discharged home. Please call our office with any questions or concerns. Please follow the instructions below. General instructions: * Take your medications as prescribed and complete the whole course of antibiotics, even if you feel better. Your antibiotics have been faxed to the ___ at ___, ___, ___. * Avoid intercourse or strenuous exercise until you follow-up with your gynecologist. You may walk up and down stairs and be active throughout the day. * Take ibuprofen and Tylenol as needed for discomfort. * You may eat a regular diet. Call your doctor for: * fever > 100.4F * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * nausea/vomiting where you are unable to keep down fluids/food or your medication If you have questions or concerns, or would like to speak the doctors that were involved in your care here, or your doctor would like to, please call our clinic at ___. To reach medical records to get the records from this hospitalization at ___ sent to your doctor at home, call ___. Since you were also in the ER at ___, you may also call ___ to get those records. This is where you had a pelvic ultrasound, renal ultrasound, and CT scan on ___. It was a pleasure taking care of you! -Your Ob/Gyn team ___, and others) Followup Instructions: ___
10126501-DS-5	10,126,501	20,777,622	DS	5	2110-03-05 00:00:00	2110-03-06 20:29:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine Attending: ___ Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ female with hx of Afib (on Coumadin), mechanical mitral valve replacement, seizure disorder with ___ years of no seizures, and hypertension, who was transferred from ___ with altered mental status, dizziness in the setting of possible excess accidental tramadol or metoprolol use. Reportedly, yesterday (___) when the patient's son went to check on her, the patient seemed "off". She reportedly felt dizzy and lightheaded so he took her to ___. Per daughter, ___, Ms. ___ has become notably more forgetful over the past week (she forgot about her husband's ___ session that had been a "big deal"), although over the past few years she had been repeating stories and sometimes forgetting her appointments. She had also told her daughter she was feeling "sick" with non-focal symptoms in the past few weeks, but she currently insists she was "simply wiped out and overwhelmed" due to her husbands' health ___ disease, currently hospitalized for ?PNA) and their recent move to ___ (moved ___. She manages her own medications and reports she takes them as directed. However, she does report that she could not remember if she took her tramadol yesterday. Per nursing at ___, she is intermittently confused and forgetful. She also has poor PO intake in the past few months and only has a chocolate shake on some days. Per pt, has lost about 20lb since ___ (132lb to 114lb). She reports not feeling hungry and having no desire to eat. She also reports the difficulty of sitting in a chair to have meals due to her back pain. Per OSH notes, her initial exam had been notable for bradycardia and hypotension and her neurological exam had been nonfocal except for mild dysarthria. NIHSS was 2 for sedation-related dysarthria and CVA was deemed less likely. She had explicitly denied taking extra beta blocker. She had a reassuring CT head, CXR without CHF, stable cardiomegaly. Her labs had been notable for subtheraputic phenytoin level, INR 5.6, negative lactate / troponin, mild hypokalemia, stable anemia. Serum tox negative for ASA/ETOH/APAP. Her BPs had remained low despite initial 500cc IVF. She was also given 2x 0.5mg atropine to good effect, calcium gluconate 1g, suggesting a responsive beta blocker toxidrome as contributor to her presentation. She received a total of 1.5L IVF. Given lack of ICU/dedicated cardiology beds, she was transferred to ___ for further management. Past Medical History: Atrial Fibrillation (On warfarin) Atrial Flutter CHF Mitral Valve replacement (mitral regurgitation) - ___ Seizure disorder stable on phenobarbital and Dilantin HTN Chronic Back pain Spinal Stenosis Melanoma ___ excision (___) Basal cell cancer ___ excision (___) Hypothyroidism Osteoporosis GERD Glaucoma Macular degeneration Breast cancer ___ right mastectomy (___) Meningioma ___ craniotomy and resection (___) Cholecystectomy (___) Social History: ___ Family History: - Father: ___ aneurysm - Mother: ___ - Sister: "Heart condition" - Brother: ?MI - passed away due to a "heart condition" Physical Exam: ADMISSION PHYSICAL EXAM: ========================= Vital Signs: 97.9 PO 138/98 88 18 95% Ra General: Thin lady, alert, oriented, in some distress on movement HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP elevated to 8 cm, no LAD CV: Irregularly irregular, normal S1 + S2, Mechanical, Diastolic click in left mid clavicular region. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema MSK: No CVA tenderness, no point tenderness to palpation. Neuro: Moderate hearing loss bilaterally, "unable to puff out cheeks" CNs otherwise intact, ___ strength upper/lower extremities, 2+ reflexes bilaterally, gait deferred. Moderate proprioception deficits on bilateral lower extremities. Mental Status: Alert and oriented X3. Able to recall 2 out of 3 objects. Able to name months of the year backwards. Unable to count number of quarters in $2.25. DISHCARGE PHYSICAL EXAM ========================= Vital Signs: Tm:98.8, Tc: 98.3; 110s-130s/50s-90s; 70s-90s; ___ 97% Ra General: Anxious appearing, thin lady, alert, oriented, HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP elevated to 8 cm, no LAD CV: Irregularly irregular, normal S1 + S2, Mechanical, Diastolic click in left mid clavicular region. Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema MSK: No CVA tenderness, no point tenderness to palpation. Neuro: Moderate hearing loss bilaterally, ___ strength upper/lower extremities, 2+ reflexes bilaterally; Gait deferred. Moderate proprioception deficits on bilateral lower extremities. Mental Status: Alert and oriented X3. Able to recite months of the year backwards with one mistake - missed ___. Pertinent Results: ADMISSION LABS: ======================== ___ 11:59PM BLOOD WBC-3.0# RBC-3.62 Hgb-10.2* Hct-32.9* MCV-91 MCH-28.2 MCHC-31.0* RDW-14.3 RDWSD-47.5* Plt ___ ___ 11:59PM BLOOD Neuts-52.8 ___ Monos-10.6 Eos-2.3 Baso-1.3* Im ___ AbsNeut-1.60 AbsLymp-0.98* AbsMono-0.32 AbsEos-0.07 AbsBaso-0.04 ___ 11:59PM BLOOD ___ PTT-47.5* ___ ___ 11:59PM BLOOD Glucose-90 UreaN-10 Creat-0.6 Na-135 K-5.7* Cl-105 HCO3-21* AnGap-15 ___ 09:25AM BLOOD ALT-22 AST-31 LD(LDH)-299* AlkPhos-77 TotBili-0.3 ___ 09:25AM BLOOD Albumin-3.9 Calcium-8.7 Phos-3.8 Mg-1.9 ___ 12:04AM BLOOD %HbA1c-5.1 eAG-100 ___ 09:25AM BLOOD Phenyto-5.6* ___ 12:33AM BLOOD ___ pO2-28* pCO2-51* pH-7.31* calTCO2-27 Base XS--2 MICROBIOLOGY: - UA ___ at 3:30 am: 7 RBC, 122 WBC, Few bacteria and 20 epithelial celsl - UA ___ at 6:40 am: 3 RBCs, 4 WBC, no bacteria, and 2 epithelial cells. - UCx negative DISCHARGE LABS: ========================= ___ 06:45AM BLOOD WBC-4.7 RBC-3.75* Hgb-10.8* Hct-34.0 MCV-91 MCH-28.8 MCHC-31.8* RDW-14.7 RDWSD-48.7* Plt ___ ___ 06:45AM BLOOD ___ PTT-46.3* ___ ___ 06:45AM BLOOD Glucose-97 UreaN-7 Creat-0.6 Na-144 K-3.6 Cl-107 HCO3-22 AnGap-19 ___ 06:45AM BLOOD Calcium-8.6 Phos-3.3 Mg-2.2 IMAGING: ========================= ___ CT HEAD WITHOUT CONTRAST: No acute intracranial process. CTA HEAD: The vessels of the circle of ___ and their principal intracranial branches are patent. The dural venous sinuses are patent. CTA NECK: The carotid and vertebral arteries and their major branches are patent. EKG (___): Irregularly irregular, no ischemic changes Brief Hospital Course: Ms. ___ is an ___ female with hx of Afib on Coumadin, MR ___ replacement, mod-severe tricuspid regurgitation, seizure disorder with ___ years of no seizures, presenting with altered mental status, dizziness in the setting of possible excess accidental tramadol or metoprolol use. #Toxic Metabolic Encephalopathy #Medication Side effect #Hypotension #Bradycardia Patient thought to have memory issues at baseline per her assisted living facility and her daughter, but she currently manages her own medications without the aid of a pill box. Her acute presentation was thought to be secondary to taking her medications (metoprolol, tramadol). She also admits to taking extra tramadol due to stresses at home. Her recent cognitive decline also is likely related to adjustment (husband with advanced ___ and moving to a new assisted living facility) and depression. Neurology was consulted and they didn't believe her current presentation was consistent with a seizure given her stable regimen with no seizures for many years. She had a CTA head and neck which was negative for acute process. Her initial UA was contaminated and her second UA was not c/w UTI. She denies urinary symptoms and she was not treated for a UTI. Her blood pressure, heart rate and mental status returned to baseline during her hospital course. It was decided that she should no longer be managing her medications given her presentation. Her daughter agreed to manage her medications at home and the patient was amenable to the arrangement. #Anxiety/Depression #Chronic Back Pain Patient also has chronic back pain since ___ and has followed with many specialists. She takes tramadol and tizanidine daily at baseline. These were discontinued during hospital course given concern for contribution to altered mental status. Her back pain was managed primarily with Tylenol, heat packs and lidocaine patch which helped greatly. There is a strong component of anxiety and depression to her back pain. No chart diagnosis, but apparent issues with anxiety through talking to patient's family members. She has declined psychiatry follow-up at this point. #Mechanical mitral valve #Atrial fibrillation #Supratherapeutic INR Patient also had supratherapeutic INR, which she is on for mechanical mitral valve and atrial fibrillation. Her warfarin was held initially and then resumed. Hep gtt was also started as she became subtherapeutic. She was discharged on warfarin 2 mg PO daily with lovenox bridge. Her home metoprolol Succinate XL 25 mg was initially held due to bradycardia but resumed prior to discharge. #Seizure disorder She has been stable on current regimen (reports no seizures ___ years). Neurology consulted, who did not believe her current presentation was consistent with a seizure. Phenytoin levels were subtherapeutic at 5.6. Her home Phenobarbital 32.4 mg PO QHS and Phenytoin Sodium Extended 100 mg PO BID were continued. #Chronic Systolic heart failure (EF 39%): She has a history of systolic heart failure with EF 39% in ___, mod-sev TR. She was euvolemic on exam with no extremity edema and clear lungs, but had JVD, which is most likely ___ TR. Her home Ramipril 2.5 mg was continued on admission. Initially her metoprolol Succinate XL 25 mg and furosemide 20 mg were held on admission, but resumed during hospital course. . TRANSITIONAL ISSUES: ==================== # NEW MEDICATIONS: lovenox 80 mg SC daily until therapeutic INR of 2.5-3.5 # STOPPED MEDICATIONS: tramadol, tizanidine [] Please check INR ___. Please call ___ ___ to report results for adjustment in Coumadin. [] CTA head and neck: It did show Incidental 2 mm aneurysm is seen arising from the supraclinoid left internal carotid artery. [] New intention tremor: Please follow-up as an outpatient. [] Please consider SSRI as outpatient vs. CBT/talk therapy for significant anxiety/depression. # CODE: full (presumed) # CONTACT/HCP: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 2 mg PO DAILY16 2. Ramipril 2.5 mg PO DAILY 3. Phenytoin Sodium Extended 100 mg PO BID 4. Tizanidine 2 mg PO BID:PRN pain 5. TraMADol 50 mg PO TID:PRN Pain - Moderate 6. Timolol Maleate 0.25% 1 DROP BOTH EYES BID 7. PHENObarbital 32.4 mg PO BID 8. Furosemide 20 mg PO DAILY 9. Levothyroxine Sodium 50 mcg PO DAILY 10. Lidocaine 5% Patch 1 PTCH TD QPM 11. Klor-Con M20 (potassium chloride) 20 mEq oral daily 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Cyanocobalamin 1000 mcg PO DAILY 14. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral daily Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H pain 2. Enoxaparin Sodium 80 mg SC DAILY Start: ___, First Dose: Next Routine Administration Time RX enoxaparin 80 mg/0.8 mL ___aily Disp #10 Syringe Refills:*0 3. Lidocaine 5% Ointment 1 Appl TP ONCE Duration: 1 Dose 4. Cyanocobalamin 1000 mcg PO DAILY 5. Furosemide 20 mg PO DAILY 6. Klor-Con M20 (potassium chloride) 20 mEq oral daily 7. Levothyroxine Sodium 50 mcg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QPM 9. Metoprolol Succinate XL 25 mg PO DAILY 10. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral daily 11. PHENObarbital 32.4 mg PO QHS 12. Phenytoin Sodium Extended 100 mg PO BID 13. Ramipril 2.5 mg PO DAILY 14. Timolol Maleate 0.25% 1 DROP BOTH EYES BID 15. Warfarin 2 mg PO DAILY16 16.Outpatient Lab Work Please check INR ___. Please call ___ ___ to report results for adjustment in Coumadin. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: Toxic metabolic encephalopathy Medication side effect Secondary Diagnosis: Atrial Fibrillation Mechanical Mitral Valve Low back Pain Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at ___! Why was I in the hospital? - You were feeling dizzy and confused - Your symptoms are thought to be due to your medications and stress What happened while I was in the hospital? - You had imaging of your ___ which showed you did not have a stroke. You do have a small enlarged blood vessel and you need to have follow-up imaging to monitor the blood vessel. What should I do now that I am going home? - Please take all your medicines exactly as prescribed. Your daughter and visiting nurse ___ help you take your medication. - Please call ___ to schedule an appointment for a new primary care doctor. - Please follow-up with a neurology specialist ___ doctor) to monitor the blood vessels in your ___. We wish you the best! - Your ___ Team Followup Instructions: ___
10126501-DS-6	10,126,501	23,167,022	DS	6	2110-03-27 00:00:00	2110-03-27 14:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Codeine / lidocaine / Penicillins / Bisphosphonates Attending: ___. Chief Complaint: Left hip pain Major Surgical or Invasive Procedure: Left hip cephallomedullary nail History of Present Illness: This ___ year old woman with history notable for MVR/afib on Coumadin had a mechanical fall from her walker early this morning. She believes the wheel of her walker got caught on the wheel of her bed. She does not remember the position she was in when she fell. She had acute onset of severe left hip pain radiating toward the knee. Pain is constant, dull, and worse with any movement. She denies any numbness or weakness. She has been feeling very depressed, as she unfortunately just lost her husband ___ days ago. Past Medical History: Atrial Fibrillation (On warfarin) Atrial Flutter CHF Mitral Valve replacement (mitral regurgitation) - ___ Seizure disorder stable on phenobarbital and Dilantin HTN Chronic Back pain Spinal Stenosis Melanoma s/p excision (___) Basal cell cancer s/p excision (___) Hypothyroidism Osteoporosis GERD Glaucoma Macular degeneration Breast cancer s/p right mastectomy (___) Meningioma s/p craniotomy and resection (___) Cholecystectomy (___) Social History: ___ Family History: - Father: ___ aneurysm - Mother: ___ - Sister: "Heart condition" - Brother: ?MI - passed away due to a "heart condition" Physical Exam: NAD Breathing comfortably LLE: Dressings intact Fires ___ SILT DPN/SPN Foot warm 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 hip fracture and was admitted to the orthopedic surgery service. She was seen preoperatively by the medicine team for preop optimization as well as recommendations regarding anticoagulation for her mechanical valve. Her INR was reversed with vitamin K and were checked serially so that a heparin drip was started when her INR was below 2.5. The patient was taken to the operating room on ___ for a cephallomedullary nail 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 and her warfarin was restarted the evening after surgery. She was also seen by social work regarding grief and coping given the recent loss of her husband the day before her fall. 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 operative extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: Warfarin Ramipril Phenytoin sodium Tizanidine Tramadol Timolol Phenobarbital Furosemide Levothyroxine Lidocaine patch Metoprolol Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Docusate Sodium 100 mg PO BID 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate RX oxycodone 5 mg ___ tablet(s) by mouth q4 hours Disp #50 Tablet Refills:0 4. Tamsulosin 0.4 mg PO QHS 5. Phenytoin Infatab 150 mg PO BID RX phenytoin [Dilantin Infatabs] 50 mg 3 tablet(s) by mouth twice daily Disp #180 Tablet Refills:2 6. Furosemide 80 mg PO DAILY 7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 8. Levothyroxine Sodium 50 mcg PO DAILY 9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Back pain 10. Metoprolol Succinate XL 25 mg PO DAILY 11. PHENObarbital 32.4 mg PO DAILY 12. Ramipril 2.5 mg PO DAILY 13. ___ MD to order daily dose PO DAILY16 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Left intertrochanteric hip fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: Weight bearing as tolerated MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please change dressing only as needed for soiled dressing. 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 PLEASE OBTAIN DILANTIN LEVEL on ___. Contact patient's neurologist with result. ___ ___ Physical Therapy: Weight bearing as tolerated Treatments Frequency: -Dressing changes as needed for soiled dressing -Frequent INR draws. Patient needs to have therapeutic INR 2.5-3.5 Followup Instructions: ___
10127469-DS-11	10,127,469	21,405,846	DS	11	2162-12-13 00:00:00	2162-12-14 13:27:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Augmentin Attending: ___ Chief Complaint: Abdominal pain, fevers Major Surgical or Invasive Procedure: Nasogastric tube insertion History of Present Illness: Ms. ___ is a ___ PMHx for rectal cancer s/p neoadjuvant chemoXRT c/b SB perf w/fecal peritonitis s/p exlap, TI resection, end ileostomy/mucus fistula ___. Patient also developed radiation induced necrosis s/p open proctosigmoid resection with end colostomy ___ who returns from rehab with fever/abdominal pain/hyperglycemia/Afib with RVR. Of note, patient developed atrial fibrillation with RVR during last hospital course and was discharged to rehab on ___ on Diltiazem for rate control. She was also discharged on TPN. During the rehab course, her healthy care proxy states that shes been having episodes of low grade fever up to 100 with worsening abdominal pain in the past week. Her healthy care proxy also notes that at rehab patient's heart rate has not been well controlled. Of note, patient's admission blood glucose was in the 400s. The health care proxy states that patient's sugar was overall poorly controlled at rehab. Due to her baseline status and concurrent issues, patient was brought to ___ for further management. Patient currently denies fever/chills/nausea/vomiting, but does endorse mild abdominal pain along incision site. Past Medical History: PSH: TAH-BSO (___), appendectomy (___) ONCOLOGIC HISTORY: Rectal cancer stage IIIB (T3N1M0) - ___ Colonoscopy showed a fungating and frond-like/villous 5 cm mass of malignant appearance was found in the proximal rectum at a distance between 8 cm and 13 cm. The mass caused a partial obstruction. Biopsy showed high grade dysplasia. - ___ MR pelvis showed an upper rectal mass extending to the rectosigmoid junction. There is invasion into the left mesorectal fat, but with the mass remaining at least 19 mm away from the CRM. The mass appears contained within the muscularis propria at the level of the peritoneal reflection. Scarring and distortion of the peritoneal reflection with tethering of the rectosigmoid junction against a loop of ileum, possibly the sequela of prior hysterectomy, inflammation, or burned out endometriosis. Four left mesorectal lymph nodes measuring up to 4 mm, without abnormal morphology, but suspicious based on proximity to the area of extramural tumor extension. Imaging clinical stage T3N1. CT torso without evidence of distant metastatic disease. - ___ Initial Med Onc visit, offered enrollment in PROSPECT. Elected for standard of care. - ___ Start XRT with ci5FU 225 mg/m2/day - ___ Complete XRT with 50.5 Gy to the pelvis, complete chemotherapy - ___ Presented with ileal perforation from radiation enteritis PMHx: - a-fib (dx ___ - PE (dx ___ - migraines - HTN - HLD - ___ with resultant CKD - Depression Social History: ___ Family History: No cancer in the family. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.8 96 127/60 24 99% 2LNC General: NAD HEENT: atraumatic Neck: supple, left port on chest CV: RRR Lungs: CTABL Abdomen: soft, midline wound open with packing, ostomy x2. right ostomy with output, left ostomy not GU: foley Ext: no edema Neuro: intact Skin: maculopapular rash DISCHARGE PHYSICAL EXAM: Vitals: Tm98.3, 130/84, 92, 20, 99% on RA General: Chronically Ill appearing. Laying in bed. HEENT: Sclera anicteric, EOMI, PERRL, moist mucous membranes Lungs: CTAB anteriorly CV: RRR, S1 S2. no murmurs/rubs/gallops Abdomen: +BS. Soft. (+) ileostomy filled with liquid stool output. Ext: WWP Skin: Vitilgo of hands, elbows and knee caps. Pertinent Results: ADMISSION LABS: ___ 01:32AM BLOOD WBC-27.6# RBC-2.61 Hgb-7.8* Hct-24.6* MCV-94 MCH-29.9 MCHC-31.7* RDW-14.7 RDWSD-50.2* Plt ___ ___ 01:32AM BLOOD Neuts-85.8* Lymphs-7.0* Monos-5.4 Eos-0.3* Baso-0.3 Im ___ AbsNeut-23.66# AbsLymp-1.93 AbsMono-1.50 AbsEos-0.08 AbsBaso-0.07 ___ 01:32AM BLOOD ___ PTT-36.9* ___ ___ 01:32AM BLOOD Glucose-137* UreaN-27* Creat-0.6 Na-141 K-3.5 Cl-102 HCO3-28 AnGap-15 ___ 01:32AM BLOOD ALT-55* AST-43* AlkPhos-250* TotBili-0.3 ___ 01:32AM BLOOD cTropnT-<0.01 ___ 01:32AM BLOOD Lipase-14 ___ 01:32AM BLOOD Albumin-2.1* Calcium-8.8 Phos-3.5 Mg-1.4* DISCHARGE LABS: ___ 06:00AM BLOOD WBC-28.7* RBC-2.87* Hgb-8.2* Hct-25.4* MCV-89 MCH-28.6 MCHC-32.3 RDW-16.4* RDWSD-53.5* Plt ___ ___ 05:00AM BLOOD Hypochr-OCCASIONAL Anisocy-1+ Poiklo-2+ Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-NORMAL Schisto-OCCASIONAL Burr-1+ ___ 06:00AM BLOOD Glucose-119* UreaN-23* Creat-1.6* Na-131* K-3.8 Cl-94* HCO3-24 AnGap-17 ___ 06:36AM BLOOD ALT-51* AST-37 AlkPhos-174* TotBili-0.1 ___ 06:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.7 IMAGING/STUDIES CTA ABDOMEN/PELVIS ___ 1. No evidence of pneumoperitoneum or drainable fluid collection in the abdomen or pelvis. Small amount of free fluid in the presacral space and right upper abdomen. 2. No bowel obstruction or evidence of oral contrast leak. 3. Soft tissue emphysema, fluid, and edema involving the mid abdomen directly under the skin staples with a small component also seen superiorly. 4. Persistent small bilateral nonhemorrhagic pleural effusions with compressive atelectasis. New non-enhancing bilateral airspace consolidation which could reflect pneumonitis or sequelae of pulmonary embolus, incompletely imaged on this abdomen/pelvis exam. If concern of pulmonary embolus, a dedicated Chest CT for PE can be performed. 5. Degenerative changes at L5-S1 with disc protrusion. CXR ___ 1. Catheter tip projects over the expected region of the mid to upper SVC. 2. Bibasilar pneumonia increased since ___. 3. Persistent small left pleural effusion and atelectasis. 4. Mild interstitial edema, improved. CXR ___ Feeding tube with the wire stylet in place passes into the stomach and out of view. Left subclavian infusion port ends in the upper SVC. Severe bilateral pulmonary consolidation has remained stable since earlier in the day, substantially worsened since ___. Whether it is pneumonia or pulmonary hemorrhage or pulmonary edema is radiographically indeterminate. Moderate bilateral pleural effusions have increased during the day. Heart shadow is now entirely obscured. There is no pneumothorax. B/L ___ ___ 1. No evidence of deep venous thrombosis in the right or left lower extremity veins. 2. Extensive bilateral subcutaneous soft tissue edema. On the left, there is fluid tracking into the deeper fascia layers. Complete GU US ___ The right kidney measures 11.5 cm. The left kidney measures 10.6 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is moderately well distended and normal in appearance. Ureteral jets were not able to be visualized. Patient was unable to cooperate with voiding and postvoid measurements due to confusion. MRI Pelvis w/ contrast ___ 1. Significant thickening of the wall of the rectal pouch, likely due to post radiation changes. No evidence of recurrent tumor in the pouch. 2. The mucosa along the superior aspect of the pouch is irregular, and there is a moderate amount of ill-defined fluid in the presacral space superior to the pouch, which is similar in amount to the prior CT from ___. While no discrete dehiscence is identified, given this persistent fluid, one cannot be excluded with certainty. If desired, this could be further evaluated with a pouch-o-gram. 3. Significant thickening of the vaginal wall and bladder wall, likely due to post radiation changes. No fistula is identified. 4. Significant edema in the musculature and soft tissues of the pelvis, likely from postradiation changes. No well-defined fluid collection to suggest an abscess. CXR ___ New moderate edema. Persistent small left pleural effusion and atelectasis. ECHO ___ The left atrium is elongated. 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%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the abdominal aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Mild mitral regurgitation with normal valve morphology. Mild pulmonary artery systolic hypertension. Compared with the prior study (images reviewed) of ___, the estimated PA systolic pressure is now slightly higher. , CT CYSTOGRAM ___ 1. No evidence of extraluminal contrast from the bladder to suggest a leak or fistula. 2. Post-surgical changes in the bowel without evidence of obstruction or drainable fluid collection. RENAL US ___ The right kidney measures 11.4 cm. The left kidney measures 10.4 cm. There is no hydronephrosis, stones, or masses bilaterally. Normal cortical echogenicity and corticomedullary differentiation are seen bilaterally. The bladder is decompressed with Foley in place. CT Head w/o contrast ___ IMPRESSION: No acute intracranial abnormality. Age related volume loss and likely sequela of chronic small vessel ischemia. Partially opacified mastoid air cells, left greater than right, may reflect prolonged supine position. CYSTOGRAM ___ IMPRESSION: No evidence of bladder leak of fistula. MRI PELVIS ___ 1. No rectovaginal or rectovesical fistula. No focal fluid collection. 2. Posttreatment changes at the proctectomy site with interval improvement of presacral and subcutaneous edema. RENAL US ___ No evidence of hydronephrosis. Mildly increased bilateral renal cortical echogenicity is suggestive of underlying medical renal disease. WBC SCAN ___ IMPRESSION: 1. Likely worsening dental infection of the left mandible. 2. Improved midline abdominal tracer uptake. CT MANDIBLE ___ 1. Evaluation of the dentition is severely limited due to streak artifact. 2. Periapical lucency surrounding the left mandibular canine, representing bony erosion, possibly due to infection, which likely corresponds with the area of increased radiotracer uptake on the nuclear medicine exam. 3. No evidence of abscess or mandibular mass. 4. Impacted tooth within the left mandibular ramus. MICRO / PATHOLOGY: SKIN BIOPSY x2 ___ Skin, left arm, punch biopsy: - Sparse perivascular dermatitis with leukocytoclasia and rare eosinophils. Note: Given the clinical suspicion, a very early stage leukocytoclastic vasculitis is possible, albeit typical changes are not appreciated. The differential diagnosis include a hypersensitivity reaction. Initial and level sections reveal a sparse perivascular infiltrate of lymphocytes, neutrophils and eosinophils. Leukocytoclasia is noted very focally. There are extravasated red blood cells, but changes of vascular damage with fibrin extravasation are not prominent. URINE CULTURE: ___ 1:48 pm URINE Source: Catheter. URINE CULTURE (Preliminary): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION INTERPRET RESULTS WITH CAUTION. IDENTIFICATION AND Susceptibility testing requested by ___ ______ ___. ENTEROCOCCUS FAECIUM. ~5000/ML. STAPHYLOCOCCUS, COAGULASE NEGATIVE. ~1000/ML. ___. 10,000-100,000 ORGANISMS/ML.. VIRIDANS STREPTOCOCCI. QUANTITATION NOT AVAILABLE. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECIUM \| AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 128 R TETRACYCLINE---------- =>16 R VANCOMYCIN------------ =>32 R C-DIFF ASSAY ___ 6:13 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 2:35 am BLOOD CULTURE Source: Line-POC. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:50 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT ___ C. difficile DNA amplification assay (Final ___: Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ___ 10:00 am BLOOD CULTURE Source: Line-PORT. Blood Culture, Routine (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL MORPHOLOGIES. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. VIRIDANS STREPTOCOCCI. Isolated from only one set in the previous five days. Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE COCCI IN PAIRS AND CHAINS. GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by ___ ___ 9:15AM ___. ___ 9:20 am BLOOD CULTURE Blood Culture, Routine (Pending): ___ BLOOD CULTURE PENDING ___ BLOOD CULTURE PENDING Brief Hospital Course: ___ ___ only) PMHx for rectal cancer s/p neoadjuvant chemoXRT c/b SB perf w/fecal peritonitis s/p exlap, TI resection, end ileostomy/mucus fistula ___. Patient also developed radiation induced necrosis s/p open proctosigmoid resection with end colostomy ___ who returned from rehab with fever, abdominal pain, hyperglycemia, and Afib with RVR. Found to have pneumonia on admission CXR and required ICU admission. # Pneumosepsis / Hypoxemia: CXR on admission to ICU with ___ with bibasilar pneumonia which worsened significantly in first 48 hours c/b bilateral effusions, and rising leukocytosis. She required ICU admission witH IVF, IV antibiotics and 4L O2. She was started on Vanc, Cefepime and Metronidazole and completed a full course for HCAP, 14 days, on ___. CT abdomen/pelvis showed b/l pleural effusions in lung bases with compressive atelectasis, also found to have b/l airspace consolidation thought to be pneumonitis vs. sequelae of prior pulmonary embolism. She was transferred to the medical oncology floor where she recovered back to baseline and was not requiring O2 on discharge. # ___: Patient with rising Cr on ___ without clear etiology. Nephrology was consulted and reported gross hematuria with microscopic evidence of glomerular dysfunction/disease or muddy brown casts but sediment very cellular so it was difficult to assess. Renal ultrasound ___ w/o signs of hydronephrosis/hydroureter, but absent ureteral jets. Urology consulted and foley placed with mild improvement. Given absent ureteral jets and previous radiation therapy, on ___ Urology and Renal in agreement to empirically stent both ureters with resultant mild reduction in Cr. Nephrology felt that there was no role for biopsy at this time as felt there is not glomerular process and biopsy would be high risk. The possibility of HD was broached and everyone agreed that if it came to it, she would want hemodialysis but fortunately she did not require HD since her ileostomy output was sufficient to reduce potassium. Her Cr began to improve but again started to rise when she lost her NG tube and underwent PO trial. NG tube was reinserted and she was given daily IV fluids with significant improvement in her Cr after about one week. Likely multifactorial in nature an discharged with improving Cr. # Leukocytosis: Patient with persistent neutrophilic predominant leukocytosis despite treatment for infection. Work up for infectious source after completed of HCAP treatment was negative. Patient previously on TPN long term and at risk for fungemia but without growth on blood cultures. Repeat CXRs were improved, c-diff and stool cultures were continuously negative blood cultures were negative throughout admission and urine cultures grew mixed flora despite clean catch with speciation (per request) growing E. fecalis but reportedly no predominant culture on plate. Infectious disease was consulted and did not recommend empiric treatment for UTI without specific bacterial species. Thorough work up for fistula including MRI x2, CT cystogram x2 was negative. Tagged white blood cell scan x2 showed resolving inflammation at abdominal wound site and enhancement at mandible. CT mandible showed bone necrosis and possible infection so dental and Oral-Maxillofacial surgery were consulted but did not recommend intervention at this time due to lack of clinical symptoms and fact that the finding is chronic per the patient. Dental and OMFS both felt that the patient did not have any evidence of a dental infection. Differential, smear and red blood cells normal in morphology. Given elevated CRP, ESR and degree of generalized inflammation seen on pelvic MRI and stability of leukocytosis it is likely this is secondary to stress of severe chronic illness as well as continued inflammation. Will require continued monitoring as leukocytosis no resolved at the time of discharge. # Dysuria and hematuria: Patient with intermittent bladder spasm and hematuria likely secondary to foley placement irritating known radiation cystitis seen on MRI ___. Infection ruled out as above. However, of note one urine culture that was collected in a bed pan did grow VRE but repeat cultures were all mixed flora. Her gross hematuria resolved with foley removal but microscopic hematuria persisted likely from cystitis as no evidence of dysmorphic RBCs on urine microscopy. Infectious disease did not recommend empiric treatment for UTI at this time and fistula work up was negative as above. Patient incontinent into diaper given limited mobility. Will require frequent changes and encouragement to use commode as physical function improves. # Acute on Chronic Anemia: patient with acute blood loss visible from GU tract and history of chronic anemia. No other obvious source of bleeding and ostomy output guaiac negative, reticulocyte count appropriately elevated. Phlebotomy also likely contributing to anemia. She required transfusion about once weekly but remained stably low. Required 6 total on this admission. Will need continued monitoring weekly. # Lower Abdominal/Rectal Pain / low back pain: Initially likely secondary to proctatitis/cystitis seen on imaging as well as abdominal wounds. However, now bedbound status and depression undoubtedly contributing. She was treated with dialudid ___ PO Q3H PRN pain, tramadol 50 BID, and belladonna and opium PR for rectal pain. Pain improved but still intermittent on discharge. # FTT/Protein-calorie malnutrition and deconditioning: Patient without apatite and poor mood contributing to malnutrition. Required tube feeds ___, attempted PO trial but unable to keep up with nutritional needs due to poor apatite and unwillingness to feed herself despite being able to take PO without difficulty. Restarted tube feeds ___ until tube fell out. Repeat PO trial more successful but ultimately required re-placement of NG tube on ___. She was given nepro tube feeds and free water flushes. She was also supplemented with IV normal saline. She was suplemeted with Zinc since she was found to be deficient. # Delirium/ Depression: Patient at high risk for delirium given age, not native ___ speaking, bedbound. She was started on sertraline 25mg daily for depression with good effect. She was also given mirtazapine to 30 QHS for sleep and she worked with physical therapy throughout admission. She was walking with walker and 2 person assist prior to DC. # Bowel perforation s/p ostomy: Patient with history of bowel perforation with colostomy and end ileostomy. Has healing midline wound and surgery was following during admission. Her wounds were healing well upon discharge and wet to dry dressing changes daily. # Narrow complex tachycardia: Patient diagnosed with afib on previous hospitalization, discharged to rehab on diltiazem. Continues to have intermittent paroxysmal episodes of SVT with HR to the 150s. EKG / TELE with suggestion of MAT in addition to a-fib. She was continued on diltiazem 90mg Q6H and her metoprolol was increased to 25 BID on ___. She was monitored on telemetry and found to be in sinus rhythm with intermittent a-fib with good HR control prior to discharge. # Pulmonary Embolism: Patient with known stable PE. Dx ___. On warfarin previously but stopped on admission due to hypercoagulability from malnutrition then started on heparin ggt. Heparin continued for ___ as above and ultimately transitioned to lovenox on ___ with does ttratin based on LMWH level. Discharged on lovenox 80 daily. Will need to check LMWH level ___ hours after administration if Cr <1.3 and may need to increase dose to achieve goal 0.6-1.0. # Rectal cancer: Patient with h/o rectal cancer s/p ___ treatment and XRT complicated by toxic levels of therapy because of a thymidylate synthase mutation found after treatment. Course complicated by SB perf w/fecal peritonitis s/p exlap, TI resection, end ileostomy/mucus fistula ___. Patient also developed radiation induced necrosis s/p open proctosigmoid resection with end colostomy ___. She was treated with curative intent and essentially is in remission at this time but dealing with complications of therapy. There is no indication for antineoplastic therapy at this time. We will readdress her antineoplastic plan going forward. Her tumor remains in situ and has been irradiated. # Rash: Patient with intermittent petechial rash noted on previous admission thought to be related to hypersensitivity reaction to PCN or cephalosporin, reported decreased in rehab but recurred during this hospitalization. Allergy noted in OMR attributed to augmentin may have cross reaction. Dermatology consulted and biopsied with results consistent with likely very early stage leukocytoclastic vasculitis. Thorough autoimmune work up negative. Resolved upon discharge, continue to monitor. TRANSITIONAL ISSUES: - Patient with ___ during hospitalization, Cr stable at 1.6 at time of discharge. Still with good urine output. Please continue to monitor Cr, K, phos weekly. - Patient therapeutic on lovenox 80mg once daily. Factor Xa level 0.75 on discharge, within therapeutic range (0.6-1.0). If significant change in Cr, please re-check factor Xa level ___ hours after dose administration and titrate Lovenox as needed. If Cr continues to be stable, could consider transitioning her to oral anticoagulation. - Patient with known a-fib diagnosed on last admission. Paroxyzmal and well controlled on diltiazem and metoprolol. Please continue to monitor heart rate. - Patient with known radiation cystitis, please avoid foley placement as it will aggravate cystitis and cause hematuria. - Patient incontinent into diaper, requires frequent changing and monitoring. Encourage commode use as function status improves. - Patient with known radiation proctitis causing rectal spasm, belladonna and opium suppositories help, also discharged with pain medication. - Patient with poor motivation and depression. Please STRONGLY encourage continued participation in physical therapy and PO intake. - Patient discharged with NG tube for tube feeds to meet adequate nutrition goals. See below for tube feed recommendations. Please encourage continued PO intake and remove NG tube when eating and drinking adequately on her own. - Patient with known anemia likely secondary to renal failure and phlebotomy. Required intermittent PRBCs while inpatient, please monitor H&H weekly. - Patient with known leukocytosis of unknown cause, thought to be secondary to non-infectious inflammatory causes. Please monitor for fever and signs of infection. - Patient with healing abdominal wounds, colostomy and end-ileostomy: WOUND INSTRUCTUONS: - Please clean and pack abdominal would with wet to dry dressings daily. - Please clean and cover ostomy stoma (no output) with adaptic and gauze daily. - Please drain ostomy bag BID or more frequently if needed. Replace ostomy bag once weekly or if leaking. # CODE: Full Code # CONTACT/HCPs: ___ (son) ___ and ___ (son) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Diltiazem 60 mg PO Q6H 2. Dronabinol 2.5 mg PO BID 3. Miconazole Powder 2% 1 Appl TP PRN ostomy applianct change 4. Nitroglycerin Ointment 0.2% 1 in PR Q12H 5. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain 7. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion 8. Warfarin 2 mg PO DAILY16 9. Ondansetron 8 mg PO Q8H:PRN nausea 10. butalbital-acetaminophen-caff 50-325-40 mg oral TID:PRN 11. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea 12. LOPERamide 2 mg PO QID:PRN diarrhea 13. Prochlorperazine 10 mg PO Q6H:PRN nausea 14. lidocaine 4 % topical BID:PRN 15. Acetaminophen 650 mg PO Q6H:PRN pain 16. Docusate Sodium 100 mg PO BID 17. Aspirin 81 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Diltiazem 90 mg PO Q6H 3. Prochlorperazine 10 mg PO Q6H:PRN nausea 4. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion 5. Belladonna & Opium (16.2/30mg) 1 SUPP PR TID 6. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat irritation 7. Enoxaparin Sodium 80 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 9. Megestrol Acetate 400 mg PO DAILY 10. Mirtazapine 30 mg PO QHS 11. Omeprazole 40 mg PO DAILY 12. Psyllium Powder 1 PKT PO TID thicken ostomy output 13. Ranitidine 75 mg PO QHS 14. Sertraline 25 mg PO DAILY 15. Simethicone 80 mg PO QID:PRN GAS 16. Sodium Bicarbonate 1300 mg PO BID 17. TraMADOL (Ultram) 50 mg PO BID 18. Zinc Sulfate 220 mg PO DAILY Duration: 4 Months 19. Ondansetron 8 mg PO Q8H:PRN nausea 20. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 21. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oropharyngeal discomfort/irritation 22. Metoprolol Succinate XL 50 mg PO DAILY Hold for SBP < 90, HR < 55 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSES: Acute on chronic kidney disease Rectal cancer s/p resection, chemo and radiation Failure to thrive SECONDARY DIAGNOSES: Hematuria Small vessel vasculitis Anemia Depression Leukocytosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair, walking a few steps with two person assist and chair for breaks. Discharge Instructions: Dear Ms. ___, It was a pleasure participating in your care here at ___ ___. You came to us for fever, abdominal pain, hyperglycemia, and Afib with RVR. You were first admitted to the ICU where you were started on antibiotics and given diuretic medications to help with your low oxygen. You were transferred to the medicine floor where you were continued on antibiotics and were monitored carefully. Your labs were concerning for very decreased kidney function. Your ureters were stented and this helped with your kidney function. You also had blood in your urine, likely from inflammation in your bladder, which resolved when they foley catheter was removed. Your heart was also monitored for a rapid and irregular heart rate called atrial fibrillation and, although there were times when your heart rate was fast, you were discharged with a normal heart rate. You were also given nutrition through a ___ tube and you worked with physical therapy to increase your strength. You were discharged with this tube in place for continued nutrition because you are not yet able to support your own nutrition. Please take all of your medications as prescribed and attend your follow up appointments as scheduled below. Thank you for choosing ___ for your healthcare needs. Sincerely, Your ___ Team. Followup Instructions: ___
10127469-DS-12	10,127,469	26,610,237	DS	12	2163-01-09 00:00:00	2163-01-13 07:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Augmentin Attending: ___. Chief Complaint: abnormal labs Major Surgical or Invasive Procedure: Infrarenal Denali IVC filter ___ History of Present Illness: Ms. ___ is a ___ ___ woman with a history of rectal cancer s/p neoadjuvant chemoXRT c/b SB perf w/fecal peritonitis s/p exlap, TI resection, end ileostomy/mucus fistula, radiation induced necrosis s/p open proctosigmoid resection with end colostomy ___ and recent prolonged OMED admission for pneumosepsis and ___ (discharged on ___ who presents from rehab with ___ and clogged NGT. Routine labs at rehab showed a rising creatinine (discharge Cr 1.6). Per patient's son, her NGT became clogged yesterday and she has taking very minimal food/liquid by mouth. He had concerns about her treatment at rehab (dressing changes, ___, etc). She has reportedly not complained of dysuria, fever/chills, or abdominal pain. In the ED, the patient declined any complaints and wanted to go home. In the ED, initial vital signs were: T 97.9 HR 90 BP 110/90, RR 18, SaO2 98% RA. Labs were notable for stable WBC 29.7 (stable), stable H/H, plts 596, Na 128, BUN 93, Cr 3.3 (baseline 1.6), HCO3 26 (AG 18). CXR showed a patchy left base opacity, which may be chronic. Patient was given 1L NS, CTX 1 gm, and linezolid ___ mg. NGT was cleared after manipulation. After discussion with OMED, patient was admitted to medicine as no active oncologic issues. Upon arrival to the floor, patient appeared well. Unable to obtain history as phone ___ had a difficult time understanding the patient. Past Medical History: PSH: TAH-BSO (___), appendectomy (___) ONCOLOGIC HISTORY: Rectal cancer stage IIIB (T3N1M0) - ___ Colonoscopy showed a fungating and frond-like/villous 5 cm mass of malignant appearance was found in the proximal rectum at a distance between 8 cm and 13 cm. The mass caused a partial obstruction. Biopsy showed high grade dysplasia. - ___ MR pelvis showed an upper rectal mass extending to the rectosigmoid junction. There is invasion into the left mesorectal fat, but with the mass remaining at least 19 mm away from the CRM. The mass appears contained within the muscularis propria at the level of the peritoneal reflection. Scarring and distortion of the peritoneal reflection with tethering of the rectosigmoid junction against a loop of ileum, possibly the sequela of prior hysterectomy, inflammation, or burned out endometriosis. Four left mesorectal lymph nodes measuring up to 4 mm, without abnormal morphology, but suspicious based on proximity to the area of extramural tumor extension. Imaging clinical stage T3N1. CT torso without evidence of distant metastatic disease. - ___ Initial Med Onc visit, offered enrollment in PROSPECT. Elected for standard of care. - ___ Start XRT with ci5FU 225 mg/m2/day - ___ Complete XRT with 50.5 Gy to the pelvis, complete chemotherapy - ___ Presented with ileal perforation from radiation enteritis PMHx: - a-fib (dx ___ - PE (dx ___ - migraines - HTN - HLD - ___ with resultant CKD - Depression -Infrarenal Denali IVC filter ___ Social History: ___ Family History: No cancer in the family. Physical Exam: ADMISSION PHYSICAL VITALS: T 98.2, HR 108, BP 111/52, RR 18, SaO2 97% RA, weight 55.1 kg GENERAL: Well-appearing elderly woman, NAD HEENT: NC/AT, no conjunctival pallor or scleral icterus, PERRLA, EOMI, OP clear NECK: Supple, no JVD CARDIAC: Tachycardic, regular rhythm, no m/r/g PULMONARY: Breathing comfortably, scattered rhonchi anteriorly, no wheezes or crackles appreciated ABDOMEN: Two stoma (one with ostomy bag in place), open midline wound with granulation tissue with serous drainage, nontender, no surrounding erythema, +BS, thin, mildly distended EXTREMITIES: Warm, well-perfused, no edema SKIN: Abdominal wounds as above NEUROLOGIC: Unable to evaluate DISCHARGE PHYSICAL: Vitals: 98.5 ___ 121/61 16 98% RA ostomy output: 200cc since midnight, 1225cc yesterday GENERAL: NAD, lying in bed, appears comfortable HEENT: no scleral icterus, NGT in place CARDIAC: regular rhythm, no m/r/g PULMONARY: Breathing comfortably, no crackles, wheezes, or rhonchi ABDOMEN: stoma RLQ with gas and liquid stool in bag. Mild TTP diffusely, no rebound or peritoneal signs EXTREMITIES: Warm, well-perfused, no edema Pertinent Results: ADMISSION LABS =============== ___ 04:17PM BLOOD WBC-29.7* RBC-2.79* Hgb-8.0* Hct-24.4* MCV-88 MCH-28.7 MCHC-32.8 RDW-15.9* RDWSD-51.4* Plt ___ ___ 04:17PM BLOOD Neuts-89* Bands-1 Lymphs-6* Monos-3* Eos-0 Baso-0 ___ Metas-1* Myelos-0 AbsNeut-26.73* AbsLymp-1.78 AbsMono-0.89* AbsEos-0.00* AbsBaso-0.00* ___ 04:17PM BLOOD ___ PTT-33.0 ___ ___ 04:17PM BLOOD Glucose-121* UreaN-93* Creat-3.3# Na-128 K-3.9 Cl-85* HCO3-26 AnGap-21* ___ 04:17PM BLOOD Calcium-9.3 Phos-6.6# Mg-1.8 ___ 04:27PM BLOOD Lactate-1.2 ___ 09:15PM URINE RBC->182 WBC->182* Bacteri-MOD Yeast-NONE Epi-0 ___ 09:15PM URINE Blood-LG Nitrite-NEG Protein-300 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 09:15PM URINE Color-Red Appear-Cloudy Sp ___ PERTINENT LABS =============== ___ 04:17PM BLOOD WBC-29.7* RBC-2.79* Hgb-8.0* Hct-24.4* MCV-88 MCH-28.7 MCHC-32.8 RDW-15.9* RDWSD-51.4* Plt ___ ___ 03:52AM BLOOD WBC-26.1* RBC-2.37* Hgb-6.7* Hct-20.7* MCV-87 MCH-28.3 MCHC-32.4 RDW-15.9* RDWSD-50.7* Plt ___ ___ 10:13AM BLOOD WBC-31.0* RBC-2.32* Hgb-6.7* Hct-21.1* MCV-91 MCH-28.9 MCHC-31.8* RDW-16.2* RDWSD-53.6* Plt ___ ___ 06:00AM BLOOD WBC-28.2* RBC-2.29* Hgb-6.8* Hct-20.9* MCV-91 MCH-29.7 MCHC-32.5 RDW-15.4 RDWSD-51.2* Plt ___ ___ 06:15AM BLOOD WBC-18.7* RBC-2.27* Hgb-6.8* Hct-21.2* MCV-93 MCH-30.0 MCHC-32.1 RDW-15.2 RDWSD-51.3* Plt ___ ___ 04:17PM BLOOD Glucose-121* UreaN-93* Creat-3.3# Na-128 K-3.9 Cl-85* HCO3-26 AnGap-21* ___ 05:59AM BLOOD Glucose-88 UreaN-16 Creat-1.3* Na-137 K-3.6 Cl-101 HCO3-25 AnGap-15 DISCHARGE LABS =============== ___ 06:51AM BLOOD WBC-24.2* RBC-2.77* Hgb-8.1* Hct-26.0* MCV-94 MCH-29.2 MCHC-31.2* RDW-14.6 RDWSD-50.4* Plt ___ ___ 06:51AM BLOOD Glucose-107* UreaN-18 Creat-1.8* Na-136 K-3.4 Cl-96 HCO3-30 AnGap-13 ___ 06:51AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.6 MICROBIOLOGY =============== Time Taken Not Noted Log-In Date/Time: ___ 10:33 pm URINE ADDED TO GRAY HOLD ___. FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. __________________________________________________________ ___ 4:17 pm BLOOD CULTURE #1 SOURCE: VENIPUNCTURE. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. IMAGING =============== ___ CXR FINDINGS: Left-sided Port-A-Cath distal tip is similar position as compared to prior studies. Enteric tube courses below the level the diaphragm, at terminating in the expected location of the stomach. Patchy left base opacity is re-demonstrated. No pleural effusion or pneumothorax is seen. The cardiac and mediastinal silhouettes are stable. IMPRESSION: Patchy left base opacity may be chronic. ___ IVC GRAM FINDINGS: 1. Patent normal sized, non-duplicated IVC with single bilateral renal veins and no evidence of a clot. 2. Successful deployment of an infra-renal Denali IVC filter. ___ KUB FINDINGS: Bilateral double-J ureteral stents are in similar position to the prior study. In the interval there has been placement of an IVC filter which projects to the right of the spine at the L3-L4 level. A Dobbhoff tube terminates in the stomach. There are multiple loops of air-filled dilated small bowel measuring up to 5.2 cm and a few scattered air-fluid levels. There is no evidence of pneumatosis or free air. IMPRESSION: Several dilated loops of air-filled small bowel worrisome for small bowel obstruction. ___ CT ABD/PELVIS IMPRESSION: 1. Multiple dilated small bowel loops up to 3.9 cm with transition in the left hemipelvis, compatible with small bowel obstruction. No evidence of perforation. 2. Postsurgical changes from end ileostomy and proctosigmoidectomy. Perirectal fat stranding and small amount of free fluid is again visualized which may be postsurgical, difficult to evaluate on this noncontrast study. 3. Bilateral double-J ureteral stents in place with persistent mild collecting system dilatation. 4. Trace bilateral pleural effusion. Brief Hospital Course: ___ ___ speaking female with h/o rectal cancer s/p neoadjuvant chemoXRT c/b SB perf w/fecal peritonitis s/p exlap, TI resection, end ileostomy/mucus fistula, radiation induced necrosis s/p open proctosigmoid resection with end colostomy ___ who presents from rehab with clogged NGT and ___. Of note, patient also has chronic leukomoid reaction ___ abdominal surgery (after extensive w/u) and chronic hematuria with clots due to radiation cystitis. Patient's ___ was improved with IV fluid and NGT was unclogged. Patient required multiple blood transfusions attributed to her chronic hematuria and it was decided that an IVC filter should be placed in order to discontinue anticoagulation (for history of DVT/PE). Hospitalization was further complicated by an SBO which required NGT suction and resolved. ACUTE ISSUES ___: Cr 3.3 on admission, up from discharge Cr 1.6. Per son, NGT clogged the day prior to admission and patient takes very minimal po by mouth. Given history of poor po and hyponatremia, most likely etiology ___ is pre-renal, this is further supported by the quick improvement of the patient's Cr after receiving IV fluid boluses. Of note, ureteral stents were placed during last admission and patient has gross hematuria, stable from that admission. Nephrology felt that there was no role for biopsy at that time as they did not believe she had a glomerular process and thought that biopsy would be high risk. Improved to 2.0 on ___ and was continuing to downtrend and was 1.9 at time of discharge. #Chronic anemia: Hg at baseline upon admission (~8), however it began to downtrend and was 6.7 on morning of ___. Per previous discharge summary she had required 6u pRBCs over the course of her last hospitalization. Likely secondary to intermittent GU bleeding and chronic disease. Hemodynamically stable. Patient was on lovenox as an outpatient given her history of multiple PEs. On admission, patient was started on a heparin gtt given her ___. Stool was guiac negative. The patient continued to have severe hematuria with clots, requiring 1u pRBCs on ___ and ___ with appropriate response. It was decided that given her severe radiation cystitis that an IVC filter should be placed in order to hopefully improve her hematuria and decrease her transfusion requirement. IVC filter was placed on ___ without complication. Hgb 6.8 on ___ was transfused again with appropriate response. Plan is to follow up with outpatient oncologist for transfusions PRN. #Dysuria/hematuria: During last admission, patient had intermittent bladder spasm and hematuria likely secondary to Foley placement irritating known radiation cystitis seen on MRI ___. Urinalyses during last admission were all positive but urine cultures remained negative (aside from one growing E. fecalis but no predominant culture on plate). These positive urinalyses were not treated per ID's recommendations. U/A on admission is also positive; unclear if patient is having any urinary symptoms. She received CTX and linezolid in the ED. Urine Cx grew mixed flora c/w contamination which is c/w prior Cxs. Pt has been having gross hematuria with passing of clots. After discussing with urology this is expected given radiation cystitis in setting of anticoagulation. #Small Bowel Obstruction: On ___ NGT was replaced with dobhoff tube to improve comfort and avoid nasal septum irritation. On ___, the patient had multiple episodes of large volume, non-bloody, bilious emesis yesterday. KUB was c/f SBO and the Dobhoff was replaced with NGT which was placed to wall suction with output of 200cc gastric contents. Surgery was made aware who recommended trial of IVF with intermittent wall suction of NGT. On ___, patient had increased abdominal pain and went into afib with RVR to 130s. IVF was increased and RVR broke with metoprolol. CT confirmed SBO with no evidence of perforation. Over the next ___ hrs the patient's abdominal pain improved with increased ostomy output and decreased NGT output. On ___ into ___, pt. tolerated clamp trial and tube feeds were restarted. #Afib: Patient was initially anticoagulated on lovenox at home for DVT/PE but switched to heparin gtt given her ___. Given her chronic anemia and hematuria it was decided to discontinue anticoagulation and to place an IVC filter (see above). Patient had afib with RVR on ___ with rates in 130s in the setting of worsening SBO and abdominal pain. Trigger likely pain or decreased CCB and BB absorption in setting of SBO. RVR broke with IV metoprolol and IVF. SBO resolved. -IVC filter, no anticoagulation -Continue diltiazem and metoprolol #Failure to thrive: NGT was placed ___ during last hospitalization due to poor PO intake in setting of increased caloric needs. It was found to be clogged at rehab but was unclogged in the ED at presentation. NGT replaced with Dobhoff on ___ and then replaced again on ___ for SBO (see above). PO trial was initiated on ___ but patient's intake was not sufficient. Tube feeds were continued. Consider switching to Dobhoff if tube feeds will be needed long term. Patient declined another NGT placement while in the hospital. #Goals of Care: Patient is s/p resection of rectal cancer. Her therapeutic course was complicated by a very rare thymidylate synthase mutation, which has prevented her body from repairing after radiation and chemotherapy. This had led to complications such as her bowel perforation (requiring resection and ostomy) and cystitis (now with chronic hematuria). The patient currently does not have any acute medical issues and this was discussed with family. It was agreed that the best thing for the patient would be intensive rehabilitation in order to try and regain some of the patient's strength, which was consistent with her goals of care. This was discussed in a family meeting on ___, please see dedicated family meeting note for further details. #Leukocytosis: WBC stably elevated. Patient underwent extensive work-up for persistent neutrophilic predominant leukocytosis during last admission, which was negative (blood cultures, stool cultures and C. diff, urine cultures (see above), MRI, CT cystogram, tagged WBC scan, CT mandible -> possible infection but negative evaluation by Dental and OMFS). ___ d/w ___ oncologist this is thought to be from a chronic leukomoid reaction due to her multiple abdominal surgeries. #History of PE: On Lovenox for anticoagulation at home. Was initially changed to heparin gtt given ___, however due to worsening hematuria, IVC filter was placed. #Bowel perforation s/p ostomy: Patient with a history of bowel perforation with colostomy and end ileostomy. Her midline abdominal wound is healing and there is no evidence of infection. #Rectal cancer: Patient with h/o rectal cancer s/p ___ treatment and XRT complicated by toxic levels of therapy because of a thymidylate synthase mutation found after treatment. Course complicated by SB perf w/fecal peritonitis s/p exlap, TI resection, end ileostomy/mucus fistula ___. Patient also developed radiation induced necrosis s/p open proctosigmoid resection with end colostomy ___. She was treated with curative intent and essentially is in remission at this time but dealing with complications of therapy. There is no indication for antineoplastic therapy at this time. Her antineoplastic plan will be readdressed by her outpatient providers. TRANSITIONAL ISSUES: [ ] Follow up with Dr. ___ Name: ___ Location: ___ HEMATOLOGY/ONCOLOGY Address: ___ Phone: ___ Fax: ___ [ ] Please check Hgb once or twice per week. Patient will be set up for outpatient blood transfusions through Dr. ___. [ ] Please check Copper level [ ] Please repeat Chem 7 in one week. ___ need to adjust Bicarb supplementation. [ ] Patient can be transitioned to long acting metoprolol and diltiazem [ ] PATIENT HAD AN IVC FILTER PLACED. DISCUSSION ABOUT REMOVAL (DEPENDING ON GOALS OF CARE) SHOULD OCCUR WITH ___. ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Diltiazem 90 mg PO Q6H 3. Prochlorperazine 10 mg PO Q6H:PRN nausea 4. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion 5. Belladonna & Opium (16.2/30mg) 1 SUPP PR TID 6. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat irritation 7. Enoxaparin Sodium 80 mg SC Q24H Start: ___, First Dose: Next Routine Administration Time 8. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain 9. Megestrol Acetate 400 mg PO DAILY 10. Mirtazapine 30 mg PO QHS 11. Omeprazole 40 mg PO DAILY 12. Psyllium Powder 1 PKT PO TID thicken ostomy output 13. Ranitidine 75 mg PO QHS 14. Sertraline 25 mg PO DAILY 15. Simethicone 80 mg PO QID:PRN GAS 16. Sodium Bicarbonate 1300 mg PO BID 17. TraMADOL (Ultram) 50 mg PO BID 18. Zinc Sulfate 220 mg PO DAILY 19. Ondansetron 8 mg PO Q8H:PRN nausea 20. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 21. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oropharyngeal discomfort/irritation 22. Metoprolol Succinate XL 50 mg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain 2. Belladonna & Opium (16.2/30mg) 1 SUPP PR TID RX belladonna alkaloids-opium [Belladonna-Opium] 30 mg-16.2 mg 1 suppository(s) rectally three times a day Disp #30 Suppository Refills:0 3. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN throat irritation 4. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID 5. Diltiazem 90 mg PO Q6H 6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain RX hydromorphone 2 mg ___ tablet(s) by mouth every four (4) hours Disp #30 Tablet Refills:0 7. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN oropharyngeal discomfort/irritation 8. Mirtazapine 30 mg PO QHS 9. Prochlorperazine 10 mg PO Q6H:PRN nausea 10. Ranitidine 75 mg PO QHS 11. Sertraline 25 mg PO DAILY 12. Simethicone 80 mg PO QID:PRN GAS 13. Sodium Bicarbonate 1300 mg PO BID 14. Sodium Chloride Nasal ___ SPRY NU QID:PRN nasal congestion 15. TraMADOL (Ultram) 50 mg PO BID:PRN pain RX tramadol 50 mg 1 tablet(s) by mouth twice a day Disp #30 Tablet Refills:*0 16. Zinc Sulfate 220 mg PO DAILY 17. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 18. Lidocaine Jelly 2% 1 Appl TP BID:PRN nasal irritation 19. Metoprolol Tartrate 25 mg PO Q6H 20. Ondansetron 8 mg PO Q8H:PRN nausea Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Acute Kidney Injury Hematuria Small bowel obstruction SECONDARY DIAGNOSIS Rectal cancer s/p resection Small bowel perforation Atrial Fibrilation Chronic anemia Hematuria SECONDARY DIAGNOSIS Leukocytosis History of Pulmonary embolism Discharge Condition: Mental Status: Clear and coherent. ___ SPEAKING) Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Ms. ___, It was a pleasure taking care of you during your hospital stay. You came to the hospital because you were dehydrated because your feeding tube was clogged. You were also found to have increased bleeding from your bladder. We placed a filter in your vein to prevent further blood clots in order for use to stop your blood thinner to help decrease the bleeding from your bladder. We also replaced your feeding tube and you developed a bowel obstruction, which resolved. We had a family meeting with your family and your oncologist where it was decided that the best thing for you would be to go to rehab in order to try and improve your strength. Your discharge appointments and medications are detailed bellow. We wish you the best! Your ___ Care team Followup Instructions: ___
10127552-DS-9	10,127,552	25,186,732	DS	9	2110-12-02 00:00:00	2110-12-02 13:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Leg weakness Major Surgical or Invasive Procedure: ___ - C8 tumor resection, C7-T1 laminectomy, C5-T2 fusion History of Present Illness: Mr. ___ is a ___ year old gentleman who presents with worsening right foot weakness since ___. An orthopedic specialist felt this was likely neurological and arranged for a cervical MRI. Imaging showed a likely C8 Schwannoma invading and eroding the right C7/T1 neuroforamin, extending into the dura and compressing the cervical cord. He denies any bladder or bowel incontinence. The patient now presents to the ___ ED for further neurosurgical evaluation. Past Medical History: Elevated cholesterol, hypertension Social History: ___ Family History: NC Physical Exam: EXAM ON ADMISSION: O: T:97.8 BP: 129/79 HR: 70 R:18 O2Sats:98% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___, equal, reactive EOMs: intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G R 5 5 5 5 5 5 4+ 5 2 2 4 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right ___ 3 3 Left ___ 3 3 Propioception intact Toes downgoing bilaterally Rectal exam normal sphincter control --------- EXAM ON DISHCARGE: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: ___, equal, reactive EOMs: intact Neck: Supple. Posterior incision c/d/I Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G R 5 5 5 5 5 5 5 5 5 5 5 L 5 5 5 5 5 5 5 5 5 5 5 Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Propioception intact Toes downgoing bilaterally Pertinent Results: CHEST (PRE-OP AP ONLY) PORT Study Date of ___ 5:06 ___ IMPRESSION: No cardiomegaly or features of decompensation. No pneumonia. Indeterminate small 3 mm probable pulmonary nodule in the lateral aspect of the left upper lobe for which dedicated CT chest is advised. CT CERVICAL W&W/O CONSTRAST Study Date of ___ 3:12 ___ IMPRESSION: 1. Dental amalgam streak artifact limits study. 2. Moderate multilevel degenerative changes are noted in the cervical spine, as described above. 3. Patient's known C7-T1 right epidural enhancing soft tissue mass not visualized on current examination, with C7 right ventral vertebral body remodeling. CERVICAL SINGLE VIEW IN OR Study Date of ___ 4:40 ___ IMPRESSION: Fluoroscopic images show early steps in a posterior C7-T1 laminectomy. Further information can be gathered from the operative report. CT C-SPINE W/O CONTRAST Study Date of ___ 9:34 AM IMPRESSION: 1. Status post C7-T2 laminectomy and placement of spine stabilization hardware from C5-T2, without evidence of complication. Postsurgical changes, as described above. 2. Moderate multilevel degenerative changes in the cervical spine and upper thoracic spine, as described above. MR CERVICAL SPINE W/O CONTRAST Study Date of ___ 11:03 AM IMPRESSION: Examination incomplete in this patient unable to tolerate image acquisition. Evaluation for residual tumor is suboptimal in the absence of contrast. 1. Postsurgical changes secondary to removal of C8 schwannoma include C7 and T1 laminectomies and posterior spinal fusion spanning levels C5 through T2 with resultant edema in the paraspinal soft tissues. Mixed density fluid collection at the surgical site posteriorly deforms the thecal sac and abuts the spinal cord extending from the C6-T4 levels. 2. There is focal increased T2 signal within the spinal cord at the C7-T1 level, which can be seen on outside hospital examination of ___ secondary to mass effect from the schwannoma. The spinal cord is now decompressed and it is uncertain whether there is any interval change in the degree of cord signal. 3. A 6 x 7 mm nodule lateral to the C7 cord within the spinal canal (series 4, image 30), presumably representing residual lesion along the nerve roots. Brief Hospital Course: Mr. ___ was admitted to neurosurgery service on ___ for management of his C8 intradural tumor. He was started on Decadron and admitted to floor for preoperative work up. #Intradural tumor: CT of cervical and thoracic spine was obtained for preoperative planning and was notable to degenerative changes of both cervical and thoracic spine. The patient was taken to the OR and underwent C8 tumor resection, C7-T1 laminectomy, C5-T2 posterior fusion by Dr. ___. Please see separately dictated operative report for full detail. His foley was removed on POD#1, and initially required straight catheterization for urinary retention. He was subsequently able to void independently. The patient was continued on dexamethasone postoperatively, which was tapered over the course of admission and completed prior to discharge. #Activity: Following surgery, the patient was able to mobilize as tolerated with cervical collar in place. He will plan to continue cervical collar for a total of 10 days following surgery. The patient was evaluated by physical and occupational therapy, who recommended discharge to rehabilitation. #Lung nodule: A pre-op CXR showed 3mm nodule in LUE and he was recommended for CTA chest as an outpatient. #Dispo: The patient should follow up with Dr. ___ in 3 months with a CT of the cervical spine as well as an MRI with and without contrast. Medications on Admission: carvedilol 25 mg tablet oral 1 tablet(s) Twice Daily fenofibrate 48 mg tablet oral 1 tablet(s) Once Daily Discharge Medications: 1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild 2. Cyclobenzaprine 10 mg PO TID:PRN Muscle Spasms 3. Docusate Sodium 100 mg PO BID 4. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Moderate 5. Senna 8.6 mg PO QHS 6. TraMADol 50 mg PO Q6H:PRN Pain - Moderate 7. Carvedilol 25 mg PO BID 8. Fenofibrate 48 mg PO DAILY 9.Rolling Walker DX: Cervial neural sheath tumor ___: 13 months PX: Good Discharge Disposition: Extended Care Facility: ___ for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: C8 Schwannoma 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: Cervical Laminectomy and Fusion Surgery Your dressing was removed on the second day after surgery. Your incision is closed with sutures. You will need suture removal 14 days after surgery. Do not apply any lotions or creams to the site. Please keep your incision dry until removal of your sutures. Please avoid swimming for two weeks after suture removal. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity You should wear your cervical collar when out of bed for comfort for 10 days after surgery. The collar helps with healing and alignment of the fusion. You may remove your collar briefly for skin care (be sure not to twist or bend your neck too much while the collar is off). It is important to look at your skin and be sure there are no wounds of the skin forming. We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your ___ 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. Do NOT smoke. Smoking can affect your healing and fusion. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc until cleared by your neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. 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: ___
10127712-DS-13	10,127,712	28,323,151	DS	13	2188-10-15 00:00:00	2188-10-16 13:06:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Intermittent epigastric pain Major Surgical or Invasive Procedure: ___: Laparoscopic Cholecystectomy ___: Endoscopic Ultrasound History of Present Illness: ___ with hx of obesity presenting with intermittent epigastric pain x4 episodes. Pt describes 4 episodes of eating food, followed by epigastric tightness and pain. Episodes have occurred weekly x3 weeks, typically associated with meaty/fatty food. He has experimented with a vegan diet, lost 60 lbs, then resumed regular diet and regained the weight over the past 6 months. He was at a BBQ 2 days prior to presentation, ate meat and cheese, and subsequently had epigastric pain with emesis x5-6 episodes. On the day of presentation, had sausages and ___ muffin with butter, tabasco sauce, corn beef hash, then went for a ___pigastric tightness started 1.5 hours after eating. He lay down to nap after his walk, and immediately noted upon waking epigastric tightness and burning with deep inhalation. He drank water with the intention of precipitating emesis because the emesis has in the past ultimately relieved the pain. Zofran and morphine in ED provided some relief. He describes pain with the ___ u/s. He had a BM the night prior to presentation which was dark but not black, but prior to that had gone a day without BM, which is unusual for him. Emesis has always been nonbloody, although did look like tomato soup, orangy, like "lobster bisque." His weight has fluctuated in setting of major dietary changes. He describes epigastric pain as throbbing, constant, prevents him from sleeping, ___. He feels subjective fevers, denies chills. Endorses intermittent headaches over the past 3 months, which he associates with dietary changes. VS 97.4, 71, 169/82, 100% RA Exam: nontoxic, uncomfortable RRR no murmur CTAB abd s/tender in epigastrum, ___ no ___ edema Labs notable for WBC 7.2, Hb 14.9, plt 215, chem 7 WNL ALT 425, AST 182, alk phos 182, Tbili 2.7 ___ ultrasound: 1. Cholelithiasis without evidence of cholecystitis. 2. Top normal spleen size. Received morphine sulfate 4 mg IV x1, Zofran 4 mg IV, 1L NS On arrival to the floor, pt endorses ___ pain, which is dramatically improved compared to prior. He continues to have discomfort with deep inspiration but this has also improved. ROS: all else negative Past Medical History: Obesity Hypertension - not on meds, trying to control with lifestyle changes Social History: ___ Family History: Both parents have had CCYs. Father had cancer, sounds like prostate cancer (robotic surgery for removal). Siblings in good health. Physical Exam: VS 98.8 PO 158 / 93 Manual 63 16 98 RA Gen: Obese male lying in bed, alert, interactive, talkative, NAD HEENT: PERRL, EOMI, clear oropharynx, MMM, anicteric sclera Neck: supple, no cervical or supraclavicular adenopathy CV: RRR, ___ systolic murmur at RUSB, no rubs or gallops Lungs: CTAB, no wheeze or rhonchi Abd: soft, obese, nondistended, trace TTP at ___ and epigastrium, negative ___ sign, +BS GU: No foley Ext: WWP, no clubbing, cyanosis or edema Neuro: grossly intact Skin: No rashes or lesions appreciated Discharge Physical Exam: General: A+Ox3, NAD CV: RRR PULM: CTA b/l ABD: soft, mildly distended, mildly tender to palpation at incisions. Laparoscopic wounds with steri-strips, gauze and tegaderm c/d/I. ___ JP drain with moderate amount of serosanguinous drainage in the bulb. Extremities: reveal no edema b/l Pertinent Results: ___ 07:04PM GLUCOSE-111* UREA N-12 CREAT-1.0 SODIUM-140 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16 ___ 07:04PM estGFR-Using this ___ 07:04PM ALT(SGPT)-425* AST(SGOT)-182* ALK PHOS-182* TOT BILI-2.7* ___ 07:04PM LIPASE-35 ___ 07:04PM ALBUMIN-4.6 ___ 07:04PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 07:04PM WBC-7.2 RBC-4.99 HGB-14.9 HCT-45.0 MCV-90 MCH-29.9 MCHC-33.1 RDW-12.7 RDWSD-41.9 ___ 07:04PM NEUTS-77.9* LYMPHS-13.2* MONOS-6.8 EOS-1.3 BASOS-0.7 IM ___ AbsNeut-5.61 AbsLymp-0.95* AbsMono-0.49 AbsEos-0.09 AbsBaso-0.05 ___ 07:04PM PLT COUNT-215 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 06:45 4.1 4.85 14.5 43.5 90 29.9 33.3 12.5 41.1 202 ___ 07:25 4.0 4.60 13.7 41.3 90 29.8 33.2 12.6 41.3 193 ___ 06:50 4.3 4.63 13.9 42.1 91 30.0 33.0 12.9 42.5 207 COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt Ct ___ 06:45 4.1 4.85 14.5 43.5 90 29.9 33.3 12.5 41.1 202 ___ 07:25 4.0 4.60 13.7 41.3 90 29.8 33.2 12.6 41.3 193 ___ 06:50 4.3 4.63 13.9 42.1 91 30.0 33.0 12.9 42.5 207 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 06:45 ___ 138 4.0 100 26 16 ___ 07:25 ___ 136 4.1 ___ ___ 06:50 ___ 140 4.4 ___ Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap ___ 06:45 ___ 138 4.0 100 26 16 ___ 07:25 ___ 136 4.1 ___ ___ 06:50 ___ 140 4.4 ___ ___ u/s ___: Final Report EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) INDICATION: History: ___ with ___ pain // ? gall stones, cholecystitis TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were obtained. COMPARISON: None. FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 6 mm. GALLBLADDER: Cholelithiasis without gallbladder wall thickening. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 13 cm. KIDNEYS: Limited views of the right kidney show no hydronephrosis. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: 1. Cholelithiasis without evidence of acute cholecystitis. 2. Top normal spleen size. MRCP: ___: 1. No intra or extrahepatic bile duct dilation. No obstructing ductal stone or mass. 2. Small stones are seen within the gallbladder. Mild gallbladder wall edema and enhancement are present, however, the gallbladder is not distended. The findings could reflect mild chronic cholecystitis. Brief Hospital Course: Mr. ___ is a ___ male who presented to ___ on ___ with report of ___ recurrent episodes of post-prandial epigastric and ___ pain over the past 3 weeks, triggered by a fatty meals. Tbili was elevated to 4.7, concerning for choledocholithiasis. On HD1, the patient had a gallbladder US which revealed cholelithiasis without evidence of acute cholecystitis. He was admitted to the medical for serial abdominal exams, to trend LFTs, and plan was to consult ERCP for further evaluation. On HD2, the patient underwent MRCP which revealed cholelithiasis and no intrahepatic or CBD dilation. On HD3, the patient underwent EUS which showed no identifiable stone. This finding was suggestive of a passed stone. The Acute Care Surgery service was consulted on HD3 for consideration of cholecystectomy. Other medical issues discussed with the patient by the Medical Service included: 1) Hypertension- recommended starting blood pressure medication in addition to diet and exercise. Patient aware and plans to follow-up with PCP. 2) Obesity- recommended nutrition counseling The patient consented for surgery and, on HD5, the patient underwent laparoscopic cholecystectomy. A ___ drain was placed and assessed for color and consistency. The patient tolerated the surgical procedure well (reader, please refer to operative note for details). After a brief, uneventful stay in the PACU, the patient arrived on the floor on IV fluids. Pain was managed with oral oxycodone and acetaminophen. The patient was hemodynamically stable. 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 with ___ services to monitor the patient's drain output. 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. This patient is not taking any preadmission medications Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild 2. Docusate Sodium 100 mg PO BID please hold for loose stool RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #20 Capsule Refills:0 3. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain - Moderate do NOT drink alcohol or drive while taking this medication RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #5 Tablet Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute Cholecystitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. ___, You were admitted to ___ and diagnosed with acute cholecystitis, an inflammation of your gallbladder. You had a MRCP and an endoscopically performed ultrasound study which revealed gallstones within gallbladder. You were taken to the operating room and had your gallbladder removed laparoscopically. The surgery went well, and you are now ready to be discharged home with visiting nurse services to continue your recovery. Listed below are some directions for your recovery process: 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. YOUR ABDOMINAL DRAIN: You will be discharged home with an abdominal drain in your right lower abdomen. This drain will continue to relieve some of the post-operative fluid that may accumulate in your abdomen over the next week. It will be reassessed and likely discontinued when you return to the ___ clinic for a follow up appointment. The drain may be uncomfortable but it is an important part of your recovery. If there is any green or yellow fluid visible in your drain bulb, please call the ___ service phone number listed below. If there is any increasing redness or drainage of yellow/green material around the site of the drain exiting the abdomen, please also call the phone number below. A visiting nurse will be appointed to you to help you care for this drain. Followup Instructions: ___
10128191-DS-21	10,128,191	24,307,094	DS	21	2175-01-17 00:00:00	2175-01-17 14:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Weakness Major Surgical or Invasive Procedure: ___: Bedside debridement of right foot ___: 1. Right foot ___ metatarsal osteomyelitis debridement 2. Excisional debridement right foot ulcer to muscle History of Present Illness: ___ male past medical history significant for recent DVT, ___, on Xarelto and prednisone, as well as foot ulcers, presents with an episode of weakness. The patient has been in his normal state of health, when today he had an episode of weakness and feeling generally unwell. He endorses transient shortness of breath, which has since resolved. The patient denies chest pain, current shortness of breath, worsening foot pain. Of note, he has two ulcers on his right lower extremity. He is being followed for this with a plan for surgery in the near future. The daughter states that she believes the surrounding erythema has spread, but denies changes in swelling. In the ED, initial vitals were: 100.6 120 116/63 25 93% Nasal Cannula Exam notable for warmth, swelling, erythema over right foot concerning for cellulitis Labs notable for: WBC 24.7 (88% PMNs) normal H/H and platelets Cr 1.3 Lactate 3.4 INR 2.0 U/A with moderate blood, 30 protein, 29 RBCs Imaging: CXR showed no PNA. ___ (R) showed chronic nonocclusive thrombusFoot XR with no fracture, no osteo, ?subcutaneous gas between toes. CTA chest showed no PE although could not be excluded due to limited exam. Patient was given vanc/zosyn and 3L NS. Vitals prior to transfer: 98.8 88 113/57 14 95% RA On the floor, the patient tells the story as above. ROS: (+) Per HPI Past Medical History: - Eosinophilic granulomatosis with polyangiitis (___ - COPD - HTN - Polyneuropathy - Chronic right leg ulcer - History of DVT Social History: ___ Family History: No known family history of bleeding/clotting disorders. Physical Exam: Admission exam: Temp: 100.6 HR: 120 BP: 116/63 Resp: 25 O(2)Sat: 93 Low 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 GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Discharge exam: Vitals: P 97.8, BP 114/69, HR 68, RR 22, O2 94% RA General: Alert, oriented, no acute distress, pleasant in conversation HEENT: Sclera anicteric, dry mucous membranes, oropharynx clear, EOMI, PERRL NECK: Supple, no JVD, no LAD CV: Regular rate and rhythm, distant heart sounds, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no rales or ronchi Abdomen: Soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: No foley Ext: Warm and well perfused, RLE wrapped with kerlix as per podiatry. Neuro: AOx3, decreased sensation to light touch to ankle bilaterally, otherwise non-focal. Pertinent Results: Admission labs: ___ 09:24PM BLOOD WBC-24.7# RBC-4.65 Hgb-14.4 Hct-45.0 MCV-97 MCH-31.0 MCHC-32.0 RDW-13.8 RDWSD-49.2 Plt ___ ___ 09:24PM BLOOD Neuts-88.4* Lymphs-2.6* Monos-7.6 Eos-0.1* Baso-0.2 Im ___ AbsNeut-21.81# AbsLymp-0.64 AbsMono-1.87* AbsEos-0.03* AbsBaso-0.05 ___ 09:24PM BLOOD ___ PTT-27.2 ___ ___ 09:24PM BLOOD Glucose-83 UreaN-23* Creat-1.3* Na-134 K-4.3 Cl-99 HCO3-21* AnGap-18 ___ 09:24PM BLOOD Glucose-83 UreaN-23* Creat-1.3* Na-134 K-4.3 Cl-99 HCO3-21* AnGap-18 ___ 05:41AM BLOOD Calcium-7.7* Phos-2.2* Mg-1.9 ___ 09:28PM BLOOD Lactate-3.4* Pertinent labs: ___ 05:41AM BLOOD ___ ___ 09:24PM BLOOD Cortsol-17.2 ___ 06:35AM BLOOD CRP-89.7* ___ 09:24PM BLOOD CRP-130.8* ___ 03:38PM BLOOD Lactate-2.2* ___ 06:38AM BLOOD Lactate-3.1* ___ 10:30PM BLOOD Lactate-3.1* ___ 01:43PM BLOOD Lactate-4.4* ___ 12:39AM BLOOD Lactate-2.6* ___ 01:51AM BLOOD Lactate-2.7* ___ 09:28PM BLOOD Lactate-3.4* ___ 06:35AM BLOOD SED RATE-Test 108 ___ 12:31AM BLOOD SED RATE-Test 53 Discharge labs: ___ 05:20AM BLOOD WBC-13.4* RBC-3.89* Hgb-12.0* Hct-37.0* MCV-95 MCH-30.8 MCHC-32.4 RDW-13.8 RDWSD-47.8* Plt ___ ___ 06:12AM BLOOD Neuts-83.3* Lymphs-6.1* Monos-6.7 Eos-2.3 Baso-0.3 Im ___ AbsNeut-10.63* AbsLymp-0.78* AbsMono-0.86* AbsEos-0.29 AbsBaso-0.04 ___ 05:20AM BLOOD Glucose-91 UreaN-20 Creat-1.0 Na-138 K-4.1 Cl-107 HCO3-23 AnGap-12 ___ 05:20AM BLOOD Calcium-8.6 Phos-3.0 Mg-2.1 Wound culture (___): WOUND CULTURE (Final ___: STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SULFA X TRIMETH sensitivity testing performed by ___ ___. ___ SPECIES. RARE GROWTH. sensitivity testing performed by Microscan. CEFEPIME MIC<=2MCG/ML. MEROPENEM MIC<=1MCG/ML. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + \| SHEWANELLA SPECIES \| \| CEFEPIME-------------- S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=4 S CIPROFLOXACIN--------- <=0.5 S CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S <=1 S IMIPENEM-------------- 2 S LEVOFLOXACIN---------- 0.25 S <=1 S MEROPENEM------------- S OXACILLIN------------- 0.5 S PIPERACILLIN/TAZO----- <=8 S TETRACYCLINE---------- =>16 R TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- S <=2 S Wound culture (___): TISSUE (Final ___: STAPH AUREUS COAG +. RARE GROWTH. SENSITIVITIES PERFORMED ON CULTURE # ___ (___). STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. Sensitivity testing per ___ ___. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE \| CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. Studies: LENIs (___): 1. Chronic appearing nonocclusive thrombus involving the right common femoral, superficial femoral, and popliteal veins, with overall similar distribution as compared ___. 2. Chronic appearing nonocclusive thrombus involving the left common femoral vein. 3. Left popliteal vein and calf veins are not well evaluated. CTA Chest (___): 1. No evidence of pulmonary embolism to the lobar level. Assessment of the segmental and subsegmental pulmonary arteries is limited due to respiratory motion artifact. Equivocal filling defects within right lower lobe segmental and left lower lobe subsegmental pulmonary arteries are in areas were there is a large amount respiratory artifact. However, in this patient with a history of chronic deep vein thrombosis, pulmonary embolism is not excluded. 2. Trace right pleural effusion with adjacent atelectasis. 3. There is diffuse ectasia of the ascending thoracic aorta. 4. Small hiatal hernia. Arterial ultrasound (___): No evidence of arterial insufficiency to the lower extremities bilaterally at rest. MRI Foot (___): 1. Marrow changes in the fourth metatarsal head most worrisome for osteomyelitis/septic arthritis with adjacent 1.3 x 0.7 cm superficial subcutaneous fluid collection at the fourth web space. 2. Prominent phlegmon/early fluid collection between the first and second metatarsals as detailed above. Foot xray (___): Status post partial resection of the fourth metatarsal head related to known septic arthritis/ osteomyelitis. Postoperative change and packing at the first intermetatarsal space without evidence of erosion. Brief Hospital Course: ___ year-old male with past medical history significant for recent DVT on rivaroxaban, ___, as well as chronic R foot ulcers who presented with weakness and was found to have two ulcers of the ___ digit on the right foot, an abscess in the first inter-webspace, and a right heel ulcer. #Osteomyelitis of ___ metatarsal head: He was initially febrile with an elevated lactate (peak to 4.4), so he was aggressively resuscitated with IV fluids. He was started on IV Vanc/Zosyn on ___. Lower extremity dopplers were negative for ischemia. Podiatry was consulted and did a bedside debridement on ___, from which cultures grew shewanella and MSSA. An MRI confirmed osteomyelitis of the ___ metatarsal head, and ESR (53) and CRP (130.8) were elevated. He was taken to the OR by podiatry on ___ for right foot ___ metatarsal head debridement. Repeat cultures from ___ grew MSSA and coag negative staph. He was narrowed to Ceftriaxone 2g IV daily and a PICC was placed. By discharge, his condition improved greatly: he was afebrile, his white count, CRP, and lactate had decreased considerably, and he was hemodynamically stable. He will follow-up with podiatry in 1 week and will be followed by OPAT by ID. He was evaluated by ___, who cleared him for rehab. He will be discharged to a rehab facility. ___: His admission creatinine was 1.3, up from a baseline of 0.9-1.0. The likely cause is prerenal azotemia due to decreased PO intake, secondary to his chief complaint of weakness. He was aggressively hydrated with IV fluids and at discharge, his creatinine had improved to 1.0. His lisinopril was held as an inpatient, but was restarted on discharge. #Hx of DVT: He has a history of DVTs for which he is on rivaroxaban. LENIs on admission showed chronic thrombi, and he was continued on his rivaroxaban. #COPD: History of COPD with no acute exacerbations during this hospitalization. There was initial concern for VTE and PE, but CTA Chest was normal. We continued his albuterol inhaler ___: He has a history of ___ treated with prednisone. We continued his home prednisone 9 mg PO daily. Transitional issues: - Discharge labs: CRP 89.7, ESR 108, WBC 13.4 - Follow-up in one week with Dr. ___ Podiatry - Follow-up on ___ with Dr. ___ ID - Weekly labs: CBC with differential, BUN, Cr, AST, ALT, TB, ALK PHOS,ESR, CRP. Faxed to "ATTN: ___ CLINIC" - FAX: ___ - Strictly non weight-bearing on right foot - Wound care recs as per Podiatry: "Betadine packing to ___ webspace incision, betadine adaptic overlying plantar skin incision with dry sterile dressing" - PICC placed, continue Ceftriaxone 2g IV daily for 6 weeks (started ___ -Patient restarted on Lisinopril during this hospitalization, consider checking potassium in a week. # CODE: Full (presumed) # CONTACT: ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 2.5 mg PO DAILY 2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN pain 3. PredniSONE 9 mg PO DAILY 4. Rivaroxaban 20 mg PO DAILY 5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB Discharge Medications: 1. CefTRIAXone 2 gm IV Q24H 2. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB 3. Lisinopril 2.5 mg PO DAILY 4. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO DAILY:PRN pain 5. PredniSONE 9 mg PO DAILY 6. Rivaroxaban 20 mg PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary diagnosis: Osteomyelitis of the ___ metatarsal head Secondary diagnosis: CKD History of DVTs ___ syndrome COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted to ___ for an episode of weakness and ulcers on your foot. You had a fever and signs of infection, likely caused by the foot ulcers. You were treated with IV fluids and seen by our Podiatry and Infectious Disease teams. You had two procedures performed by Podiatry to manage the infection on your right foot. You were started on IV antibiotics to control the infection. Your condition improved by the time of discharge, but you will need IV antibiotics for 6 weeks to fully treat the infection. It is also extremely important that you continue to not bear weight on your right foot to allow it to heal. You will have a follow-up appointment with Dr. ___ in 1 week, and you will be followed in Infectious Disease clinic as well. It was a pleasure to participate in your care. Sincerely, Your ___ team Followup Instructions: ___
10128874-DS-14	10,128,874	23,063,778	DS	14	2158-06-17 00:00:00	2158-06-17 21:43:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo male with hx of hypertension and hyperlipidemia on aspirin who presented as transfer from ___ after a mechanical fall at home. The patient is very independent, and lives by himself. He reports that he was with his son walking into his house with groceries when he lost balance and fell on his left side. His son helped him up and he proceded to walk back into the house. He reports having left and right sided pain after the fall. His son called his PCP and he was referred to ___, where he was found to have a R parietal contusion on CT. He was subsequently transferred to ___ for neurosurgical eval. He denied any LOC or seizures. Reported feeling weak prior to falling, but denies light-headedness or dizziness. He had a repeat CT head on arrival which showed unchanged appearance of the right parietal small subdural hematoma and associated contusion. He is now being admitted to the Neurosurgery Team. Past Medical History: Hyperlipidemia Hypertension Humerus fracture S/p R nephrectomy (donated to his sister with ESRD) S/p total knee replacement Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION EXAM: AVSS Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. AxOx3 follows commands throughout PERRL, EOMI, FSTM No drift MAE ___ sensation intact to light touch DISCHARGE EXAM: Vitals: Tc:98.2 Tm:98.4 HR:75(64-104) BP:135/69(102/55-135/69) RR:18 O2:98%RA not acc I/O due to condom cath leakage General: Well-appearing elderly man in NAD; conversational and pleasant; laying in bed and appears comfortable HEENT: MMM; OP clear; NC/AT; PERRL; EOMI Lymph: No lymphadenopathy; neck supple CV: S1S2 RRR II/VI systolic ejection murmur heard best over RUSB; no rubs or gallops Lungs: CTAB, although diminished breath sounds throughout; no wheezes, rales, or rhonchi Abdomen: Soft, nontender, nondistended; +BS Ext: Bilateral knee scars with deformities consistent with prior knee replacement; Not tender to palpation; R trochanter with swelling, but nontender to palpation; Left gluteal and lateral thigh with overlying ecchymosis without significant tenderness to palpation; somewhat firm to palpation; left heal with medial ecchymosis without tenderness to palpation; Left ankle with full ROM. Neuro: Grossly intact Pertinent Results: ADMISSION LABS: ___ 06:35PM BLOOD WBC-10.2 RBC-3.81* Hgb-10.8* Hct-31.4* MCV-83 MCH-28.3 MCHC-34.3 RDW-14.3 Plt ___ ___ 06:35PM BLOOD Neuts-84.7* Lymphs-7.6* Monos-6.2 Eos-1.3 Baso-0.2 ___ 06:35PM BLOOD ___ PTT-29.7 ___ ___ 06:35PM BLOOD Glucose-90 UreaN-20 Creat-0.9 Na-137 K-4.3 Cl-101 HCO3-25 AnGap-15 ___ 06:35PM BLOOD cTropnT-<0.01 OTHER PERTINENT LABS: ___ 01:25PM BLOOD WBC-9.5 RBC-3.00* Hgb-8.4* Hct-25.5* MCV-85 MCH-27.8 MCHC-32.7 RDW-14.2 Plt ___ ___ 08:58AM BLOOD WBC-6.3 RBC-2.73* Hgb-7.6* Hct-22.9* MCV-84 MCH-27.8 MCHC-33.1 RDW-14.3 Plt ___ ___ 08:28AM BLOOD WBC-5.7 RBC-2.78* Hgb-8.2* Hct-23.4* MCV-84 MCH-29.5 MCHC-35.0 RDW-14.8 Plt ___ ___ 03:40PM BLOOD WBC-6.0 RBC-3.15* Hgb-8.9* Hct-27.0* MCV-86 MCH-28.2 MCHC-32.8 RDW-15.7* Plt ___ ___ 08:55AM BLOOD WBC-5.1 RBC-2.79* Hgb-7.9* Hct-24.1* MCV-86 MCH-28.4 MCHC-33.0 RDW-15.3 Plt ___ ___ 01:14PM BLOOD Hgb-8.4* Hct-25.4* ___ 07:44AM BLOOD WBC-4.0 RBC-2.73* Hgb-7.8* Hct-23.3* MCV-85 MCH-28.6 MCHC-33.6 RDW-15.1 Plt ___ ___ 07:44AM BLOOD Glucose-89 UreaN-24* Creat-0.8 Na-141 K-4.0 Cl-105 HCO3-29 AnGap-11 ___ 08:28AM BLOOD LD(LDH)-154 TotBili-0.7 ___ 08:28AM BLOOD Hapto-218* IMAGING: ECG (___): Sinus rhythm with baseline artifact. Left axis deviation. Left anterior fascicular block. Leftward precordial R wave transition point. Diffuse non-diagnostic repolarization abnormalities. Left anterior fascicular block Intervals Axes Rate PR QRS QT/QTc P QRS T 96 ___ 87 -66 95 CT Head w/o Contrast (___): FINDINGS: Small right parietal subdural hematoma and/or associated contusion are unchanged compared to the prior study. No new hemorrhage is identified. Brain atrophy seen. Small vessel disease noted. A right temporal pole incidental arachnoid cyst is again seen. The visualized paranasal sinuses are clear. No skull fracture is seen. IMPRESSION: Unchanged appearance of the right parietal small subdural hematoma and/ or associated contusion. No new abnormalities are seen. CT ABDOMEN/PELVIX (___): FINDINGS: The descending thoracic aorta appears aneurysmally dilated, measuring 4.2 x 3.9 cm (3:1). There are trace bilateral pleural effusions. The lung bases are otherwise clear. Limited imaging of the heart reveals no pericardial effusion or cardiomegaly. Relative hypodensity of the chambers compared to the myocardium suggests underlying anemia. CT ABDOMEN: The lack of intravenous contrast limits evaluation of the solid organs. The liver, gallbladder, pancreas, spleen and adrenal glands are normal. The patient is status post right nephrectomy. There is no left hydronephrosis or renal calculi. There are multiple exophytic or partially exophytic lesions arising from the left kidney, the largest of which can't be accurately characterized as simple renal cysts. A 2.0 x 1.5 cm hyperdense partially exophytic lesion (3:28) may represent a cyst with proteinaceous/hemorrhagic contents. There is no retroperitoneal or abdominal adenopathy. No free air or free fluid is present. There is fusiform dilation of the abdominal aorta measuring up to 3.6 x 3.3 cm (03:36) in the infrarenal abdominal aorta. There is arteriomegaly of the iliac arteries. The stomach and intra-abdominal loops of bowel are normal caliber. CT PELVIS: The remainder of the bowel is normal. The prostate is mildly enlarged. The bladder is normal. There is no free pelvic fluid. There is no inguinal or pelvic adenopathy. There is a left inguinal hernia containing loops of large bowel without apparent bowel wall thickening, edema or surrounding fluid/stranding. OSSEOUS STRUCTURES AND SOFT TISSUES: No concerning osteoblastic or osteolytic lesion identified. There is a fracture of the left transverse process of the L1 vertebra. There is a large predominantly hyperdense fluid collection in the soft tissues of the left buttock consistent with hematoma measuring 220.5 x 9.4 x 3.9 cm (602a: 38) with fluid tracking into the lateral/anterior aspect of the left thigh. IMPRESSION: 1. Large 20.5 x 9.4 x 3.9 cm hematoma in the soft tissues of the left buttock with fluid tracking into the lateral aspect of the left thigh. 2. Acute or subacute fracture of the left transverse process of L1. 3. No evidence of solid organ injury in the abdomen or pelvis as best can be assessed on this nonenhanced study. 4. Aneurysmal dilation of the descending thoracic aorta and infrarenal abdominal aorta with arteriomegaly of the iliac arteries. 5. Left inguinal hernia containing loops of large bowel without evidence of complication. ECHO (___): The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Technically suboptimal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. Aortic valve sclerosis. Mild pulmonary artery systolic hypertension. Mildly dilated aortic sinus. Brief Hospital Course: Mr. ___ is a ___ yo male with hx of htn presenting after a fall at home in the setting of increased falls, now found to have worsening anemia with large left gluteal hematoma. ACTIVE ISSUES: # Right Parietal Subdural Hematoma: Pt presenting after sustaining a likely mechanical fall at home, reportedly on his left side. He reported hitting his head, but denied loss of consciousness. Initially went to an outside hospital, where a CT revealed a small right parietal subdural hematoma. The patient was transferred to ___ to neurosurgery for further management. His home aspirin was held. On the neurosurgery team, a repeat head CT showed a stable right parietal subdural hematoma. His neurologic exam remained completely intact. He was given tylenol and oxycodone as needed for pain. On presentation he was started on levetiracetam 500mg po BID for 10 day course to prevent seizures. He had no neurologic change or any seizures during admission. He should continue to take levetiracetam through ___, and follow up with Dr. ___ in neurology with a CT scan prior to appointment. His aspirin was discontinued in the setting of multiple bleeds, and no history of CAD. # Left Gluteal Hematoma: During admission, pt noted to have falling H/H from 10.8/31.4 on presentation, which is around baseline, to 7.6/22.9. The patient also briefly became hypotensive with SBP in the mid ___, which responded to IVF. He was given 1 unit of blood with insufficient rise in Hgb. Due to concern for bleeding of unknown source, the patient was transferred to the medicine service. On evaluation the patient was guaiac negative. CT scan of abd/pelvis revealed a large 20.5 x 9.4x 3.9 cm hematoma in the left buttock. His H/H remained stable and he was monitored closely during his hospitalization. His H/H trended slowly down although remained stable at around ___ prior to discharge. The patient should have CBC checked on ___, and should follow-up with his PCP after rehab for hematoma. # Increased falls at home: During hospitalization, pt noted to have increased falls at home, also per daughter's report. Worse with bending foward, causing syncope. Current fall appears to be mechanical without significant prodromal symptoms, although in the setting of prior falls concerning for a possible cardiac cause. His nifedipine was held as it was thought that it could be contributing to his falls. Echo demosntrated some aortic valve sclerosis without significant stenosis. Also with mild pulmonary hypertension. Orthostatic blood pressure stable during admission and he was discharged to rehab on ___. # L1 Transverse Process Fracture: Noted on CT of abdomen/pelvis to have a fracture of the L1 transverse process. Neurosurgery evaluated and felt nothing to be done. No instability based on location of fracture, and no significant pain. # Hypertension: At home on nifedipine ER 30mg po daily. The patient's nifedipine was held during admission due to concern it could be contributing to syncope. His blood pressure remained stable with systolics in the 110-130s during hospitalization, therefore this medication was not restarted. CHRONIC ISSUES: # Hyperlipidemia: Continued on home pravastatin 20mg po daily *TRANSITIONAL ISSUES* -CT findings also demonstrated an aneurysmal dilation of the descending thoracic aorta and infrarenal abdominal aorta with arteriomegaly of the iliac arteries measuring 3.6x3.3cm. This should be monitored as outpatient. -CT also showed a 2.0 x 1.5 cm hyperdense partially exophytic lesion (3:28) may represent a cyst with proteinaceous/hemorrhagic contents. -In addition, also demonstrated left inguinal hernia containing loops of large bowel without evidence of complication. -Pt should continue to take leviteracetam 500mg po BID to complete a 10 day course (last day ___ -Please follow-up in four weeks with Dr. ___. Pt should have head CT done before procedure -Stopped aspirin during admission as not needed for primary prevention, and due to risk for bleed -Stopped nifedipine as could be contributing to falls at home. BP stable during admission and should be rechecked as outpatient. -Please draw CBC on ___ to monitor that hemoglobin and hematocrit are stable - Code: DNR/DNI - Emergency Contact: Pt's son ___ ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Pravastatin 20 mg PO DAILY 3. Acetaminophen 650 mg PO Q4H 4. Docusate Sodium 100 mg PO BID:PRN constipation 5. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral Daily 6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H PRN bronchospasm 7. Senna 8.6 mg PO QHS 8. NIFEdipine CR 30 mg PO DAILY 9. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q4H 2. Docusate Sodium 100 mg PO BID:PRN constipation 3. Pravastatin 20 mg PO DAILY 4. Senna 8.6 mg PO QHS 5. LeVETiracetam 500 mg PO BID Please take this medication through ___. 6. Multivitamins 1 TAB PO DAILY 7. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150 mg-unit-mg-mg oral Daily 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H PRN bronchospasm 9. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H:PRN severe pain Please hold for oversedation Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Right parietal subdural hematoma; left gluteal hematoma Secondary Diagnosis: Frequent falls; hypertension; fracture of transverse process of L1 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 ___ after you fell in your driveway at home and hit your head. You first went to another hospital where they found that you had a small bleed in your head from the fall. They transferred you to ___ to be evaluated by neurosurgery. A repeat CT scan of your head showed that the bleed was stable, so there was no intervention to be done. You were started on a medication called levetiracetam to prevent seizures. You did not have seizures during your hospitalization. XRays of your hip also showed that you did not have a fracture. When you were here, it was noted that your blood counts were decreasing and you needed to be transfused 1 unit of blood. You were transferred to the medicine service for evaluation of blood loss. A CT scan of your abdomen and pelvis showed that you had a large blood collection called a hematoma in your left buttock. Your blood counts remained stable, we monitored you during the admission. You were evaluated by physical therapy during your admission, and it was recommended that you go to rehab to work on getting stronger after your fall. You should also follow-up with Dr. ___ in 4 weeks. You should get a CT scan of your head before this appointment to make sure that the bleed in your head has not progressed. Please continue to take leviteracetam 500mg twice/day through ___. We stopped your aspirin and nifedipine as you do not need these medications anymore. We also recommend the following: Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications *Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. *You have been discharged on Keppra (Levetiracetam). This medication helps to prevent seizures. Please continue this medication as indicated on your discharge instruction. It is important that you take this medication consistently and on time. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptom after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. It was a pleasure taking care of you, Your ___ Team Followup Instructions: ___
10129052-DS-18	10,129,052	20,235,284	DS	18	2174-02-16 00:00:00	2174-02-16 22:12:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Moexipril Attending: ___. Chief Complaint: Left Hand Pain and Swelling Major Surgical or Invasive Procedure: None History of Present Illness: Ms. ___ is an ___ with history of severe seronegative rheumatoid arthritis, migratory monoarthritis, and temporal arteritis, currently on daily prednisone, hydroxychloroquine, and methotrexate, who presents for with left hand swelling. The patient states that late last night around she began to experience swelling of the dorsal ulnar aspect of the left hand. She denies any distal paresthesia or anesthesia in the digits, although does endorse marked discomfort with range of motion of the MCP and PIP joints. She denies any pain with range of motion of the left wrist. She denies any trauma, fevers, chills, nausea, vomiting. The patient has a history of difficult-to-control seronegative rheumatoid arthritis since ___ (on prednisone and hydroxychloroquine since that time) with migratory monoarthritis diagnosed in early ___ (then started on methotrexate). Review of OMR notes multiple episodes of right wrist swelling which has been attributed to her rheumatoid disease, the last of which noted in ___. In ___, the patient was started on adalimumab. The patient was recently admitted in ___ for swollen ankle thought to be due to RA and was discharged on prednisone taper and has been taking prednisone 7.5mg since ___. In the ED, initial vital signs were 98.7 104 172/92 18 97%. Initial labs demonstrated a mild leukocytosis 13.4k (no left shift), unremarkable coags, unremarkable chem-10, and normal lactate. CRP was elevated to 26, ESR 46. An XR of the arm demonstrated soft tissue swelling without evidence of osteomyelitis. Hand surgery was consulted and thought that her presentation was most consistent with an RA flare, though infection could not be excluded. They did not think a washout was indicated. The patient was given vancomycin and ceftriaxone and admitted for further management. Upon arrival to the floor, initial vital signs were T 99.4 BP 148/67 P 77-101 R 20 O2Sat 97% RA The patient c/o of some tenderness of her left hand, and some tingling of her b/l fingers which has been chronic. She does have some discomfort in her knees which has been chronic as well. No other complaints upon arrival to the floor. Review of Systems: (+) Per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Past Medical History (per OMR, confirmed with patient): 1. Temporal arteritis (confirmed on biopsy ___, treated with steroids ___ 2. Seronegative rheumatoid arthritis (initially presented ___ for R middle MCP swelling and polyarticular swelling of ___ MCPs and tender PIPs on ___. Neg RF and CCPs, x-rays showed no chondrocalcinosis. Started prednisone 5mg and Plaquenil 300mg on ___ with improvement, later stopped prednisone. On ___ had new skin rash on dorsum of hands possibly ___ Plaquenil, briefly held med. 3. Migratory monoarthritis: p/w episode of severe R hip pain on ___ that resolved with ___. Seen on ___ after episode of R hand cellulitis for which admitted to ___ and treated with abx, had minor wrist swelling, rheum thought could be partly ___ gout/pseudogout. Uric acid 4.3, X-rays without chondrocalcinosis, ESR decreased to 67 and CRP to 7.6. Since then had had acute episodes of joint swelling involving wrists in alternating pattern. On ___ had R wrist arthrocentesis (dry tap). On ___ it was concluded that this was expression of her seronegative RA so started MTX 10mg daily. No recurrent episodes of monoarthritis on ___ so increased MTX to 12.5mg and reduced prednisone to 5mg. In ___ had swelling of L wrist, R knee, and R ankle so recommended anti-TNF (Enbrel) but pt deferred, increased pred to 10mg and cont MTX 12.5mg. On ___ p/w R shoulder, ___ hand pain, so continued MTX 12.5mg but reduced pred to 7.5mg daily (per pt request), again refused anti-TNF agent adamently. 4. Osteopenia. Initiated alendronate in ___ when started treatment for temporal arteritis. Bone densitometry ___, T-score of the lumbar spine +1.4, femoral neck -0.2 consistent with osteopenia. Alendronate was discontinued on ___. 5. Plaquenil monitoring. Last ophthalmologic exam ___. 6. Osteoarthritis of the knees. 7. Right middle flexor tendonitis, resolved. 8. Hypothyroidism 9. Hypertension 10. Hyperlipidemia 11. Sarcoidosis (dx ___, s/p LN biopsy, in remission) Social History: ___ Family History: Mother: DM Daughter: thyroid problems Physical Exam: INITIAL PHYSICAL EXAM General: Alert, Oriented, NAD HEENT: NC/AT, sclera anicteric, MMM Neck: supple CV: systolic murmur, regular rate and rhythm Lungs: clear to auscultation b/l, no wheezes, rales, or rhonchi Abdomen: obese, soft, NT, ND GU: No foley Ext: warm and well perfused, no ___ edema. LEFT HAND -warm and erythema along dorsal aspect of ___, and ___ digits -erythema along palmar aspect of ___ digit Neuro: Normal mentation, normal speech Skin: As above DISCHARGE PHYSICAL EXAM Vitals: T 98.5 BP 142-155 P ___ R 20 O2Sat 95% RA General: Alert, Oriented, NAD HEENT: NC/AT, sclera anicteric, MMM Neck: supple CV: regular rate and rhythm, no rubs or gallops appreciated Lungs: clear to auscultation anteriorly, no wheezes, rales, or rhonchi Abdomen: obese, soft, NT, ND GU: No foley Ext: warm and well perfused, no ___ edema. LEFT HAND -minimal erythema along dorsal aspect of ___, and ___ digits -minimal erythema along palmar aspect of ___ digit Neuro: Normal mentation, normal speech Skin: As above Pertinent Results: INITIAL LAB RESULTS ___ 08:00AM BLOOD WBC-13.4* RBC-4.18* Hgb-13.1 Hct-38.5 MCV-92 MCH-31.5 MCHC-34.1 RDW-13.8 Plt ___ ___ 08:00AM BLOOD Neuts-66.9 ___ Monos-5.7 Eos-2.0 Baso-1.2 ___ 08:00AM BLOOD ___ PTT-32.8 ___ ___ 08:00AM BLOOD Plt ___ ___ 08:00AM BLOOD ESR-46* ___ 08:00AM BLOOD Glucose-147* UreaN-15 Creat-0.8 Na-134 K-3.4 Cl-93* HCO3-27 AnGap-17 ___ 08:00AM BLOOD ALT-21 AST-30 AlkPhos-60 TotBili-0.5 ___ 08:00AM BLOOD Albumin-4.3 Calcium-9.3 Phos-3.6 Mg-1.9 ___ 02:26PM BLOOD PTH-75* ___ 08:00AM BLOOD CRP-26.0* ___ 08:22AM BLOOD Lactate-1.8 ___ 04:19PM URINE Color-Straw Appear-Clear Sp ___ ___ 04:19PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG IMAGING ___ Left Hand XRAY IMPRESSION: 1. No radiographic evidence of osteomyelitis. 2. Mild DJD as described above. 3. Diffuse demineralization without specific signs of rheumatoid arthritis. DISCHARGE LAB RESULTS ___ 06:35AM BLOOD WBC-10.2 RBC-3.90* Hgb-11.9* Hct-36.6 MCV-94 MCH-30.6 MCHC-32.6 RDW-13.6 Plt ___ ___ 06:35AM BLOOD Plt ___ ___ 06:35AM BLOOD Glucose-92 UreaN-15 Creat-0.6 Na-136 K-3.6 Cl-99 HCO3-30 AnGap-11 ___ 06:35AM BLOOD Calcium-9.0 Phos-2.7 Mg-1.9 Brief Hospital Course: Ms. ___ is an ___ with RA and migratory monoarthritis on prednisone, Humira, MTX, and hydroxychloroquine who presents with left hand swelling and pain. ACUTE ISSUES #) Left Hand Swelling and Pain Patient presented with left hand swelling and pain consistent with prior episodes of RA flare. Rheumatology was consulted and recommended starting a prednisone burst at 15mg and tapering down. Upon starting the prednisone burst, the patient experienced symptomatic improvement in her swelling, erythema, and pain. She remained clinically stable and was discharged with a prednisone taper. Per the rheumatology consult team, her weekly methotrexate dose was increased from 12.5mg/wk to 15mg/wk. She has a follow-up appointment with Dr. ___ with plans for further management. # RA, Migratory Monoarthritis The patient's left hand swelling likely represented an acute flare of her RA. Thus her RA and migratory monoarthritis were managed as above, and continuing her home medications including hydroxychloroquine. CHRONIC ISSUES #)Hypothyroidism The patient has a known diagnosis of hypothyoidism and was continued on her home levothyroxine. #) Hypertension The patient has a known diagnosis of HTN and remained stable on her home hydrochlorothiazide. #) Hyperlipidemia The patient has a known diagnosis of hyperlipidemia and remained clinically stable on her home statin. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Humira (adalimumab) 40 mg/0.8 mL subcutaneous every other week 2. clobetasol 0.05 % topical BID itchy areas on hands and feet 3. Fluocinonide 0.05% Ointment 1 Appl TP BID 4. FoLIC Acid 1 mg PO DAILY 5. Hydrochlorothiazide 25 mg PO DAILY 6. Hydroxychloroquine Sulfate 200 mg PO DAILY 7. Levothyroxine Sodium 100 mcg PO DAILY 8. Methotrexate 12.5 mg PO 1X/WEEK (___) 9. Nyamyc (nystatin) 100,000 unit/gram topical BID 10. PredniSONE 7.5 mg PO DAILY 11. Tylenol Arthritis Pain (acetaminophen) 650 mg oral BID-TID 12. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral BID 13. Alendronate Sodium 70 mg PO QTUES Discharge Medications: 1. Methotrexate 15 mg PO 1X/WEEK (___) 2. PredniSONE 7.5 mg PO DAILY Please take 10mg on ___ through ___, then return to 7.5mg daily. RX prednisone 10 mg 1 tablet(s) by mouth once a day Disp #3 Tablet Refills:*0 3. FoLIC Acid 1 mg PO DAILY 4. Hydrochlorothiazide 25 mg PO DAILY 5. Hydroxychloroquine Sulfate 200 mg PO DAILY 6. Levothyroxine Sodium 100 mcg PO DAILY 7. calcium carbonate-vitamin D3 500 mg(1,250mg) -200 unit oral BID 8. clobetasol 0.05 % topical BID itchy areas on hands and feet 9. Fluocinonide 0.05% Ointment 1 Appl TP BID 10. Humira (adalimumab) 40 mg/0.8 mL subcutaneous every other week 11. Nyamyc (nystatin) 100,000 unit/gram topical BID 12. Tylenol Arthritis Pain (acetaminophen) 650 mg oral BID-TID 13. Alendronate Sodium 70 mg PO QTUES 14. PreserVision AREDS 2 (vit C,E-Zn-coppr-lutein-zeaxan) 250-200-40-1 mg-unit-mg-mg oral 2 BID Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary diagnosis: Rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___: It was a pleasure caring for you during your stay at ___ ___. You were admitted because you were experiencing left hand swelling and pain. The rheumatologists came to see you, and we think this is most likely a flare of your rheumatoid arthritis. Some of your medications have been changed, please see the medication page for your new regimen. Appointments have been made on your behalf, please see below for details. It has been a pleasure participating in your care, thank you for choosing ___! Followup Instructions: ___
10129052-DS-21	10,129,052	26,848,471	DS	21	2176-08-14 00:00:00	2176-08-14 20:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Penicillins / Codeine / Moexipril Attending: ___. Chief Complaint: Ruptured L iliac artery aneurysm Major Surgical or Invasive Procedure: Endovascular repair ruptured internal iliac aneurysm History of Present Illness: Vascular Surgery emergently consulted by ED for eval of active extravasation from iliac artery aneurysm. Pt was in usual state of health until yesterday evening, when she developed some dull lower abdominal pain with nausea. Upon awakening this morning, pt reported feeling lightheaded with standing, continued to have abdominal pain, contacted her son who brought her to ED. ED obtained CT A/P as part of workup for ? diverticulitis vs ischemic bowel, revealed active bleeding from iliac artery aneurysm. Pt does not report any symtpoms today other than as mentioned above. Interview was truncated in order to accommodate need for emergent operative intervention. Past Medical History: Temporal arteritis, Seronegative rheumatoid arthritis, Osteopenia, Hypothyroidism, Hypertension, Hyperlipidemia, Sarcoidosis, Osteoarthritis of the knees PSH: Hysterectomy, appendectomy, cervical node biopsy Social History: ___ Family History: NC Physical Exam: Exam on admission Vitals: BP 144/86 HR 93 RR 20 O2 sat 98 RA GEN: A&O, NAD HEENT: No scleral icterus, mucus membranes moist CV: RRR PULM: Clear to auscultation b/l ABD: Soft, nondistended, tender to palpation in lower quadrants, no rebound or guarding, normoactive bowel sounds, no palpable masses Neuro: Grossly intact Ext: No ___ edema, ___ warm and well perfused Exam on discharge: Vitals: 99.4 86 138/68 16 98%RA Gen: AOx3, NAD HEENT: sclera nonicteric, MMM CV: RRR Pulm: no respiratory distress Abd: soft, nontender, nondistended, no rebound/guarding Groin: bilateral groin puncture sites clean and dry Pulses: R: P/D/D/D L: P/D/D/D Neuro: no focal neurological deficits Pertinent Results: CT abd/pelvis ___ 1. Ruptured, 7.3 cm, left internal iliac artery aneurysm with a large volume hemorrhage in the pelvis. 2. 3.0 cm left common iliac artery aneurysm just proximal to the bifurcation. 3. Hyperdense material within the distal colon could reflect ingested hyperdense material or reflect interposition of the collapsed bowel walls; however, intramural bleeding is not excluded. Labs ___ 11:52PM GLUCOSE-154* UREA N-6 CREAT-0.5 SODIUM-133 POTASSIUM-3.9 CHLORIDE-99 TOTAL CO2-23 ANION GAP-15 ___ 11:52PM CALCIUM-9.3 PHOSPHATE-2.5* MAGNESIUM-1.9 ___ 11:52PM HCT-34.7 ___ 10:01PM TYPE-ART PO2-106* PCO2-35 PH-7.44 TOTAL CO2-25 BASE XS-0 ___ 10:01PM GLUCOSE-139* ___ 09:23PM ___ PH-7.47* COMMENTS-GREEN TOP ___ 09:23PM freeCa-1.00* ___ 08:56PM POTASSIUM-4.4 ___ 08:56PM MAGNESIUM-2.1 ___ 08:56PM HCT-33.6# ___ 05:09PM TYPE-ART O2-100 PO2-454 PCO2-38 PH-7.42 TOTAL CO2-25 BASE XS-0 AADO2-209 REQ O2-44 VENT-CONTROLLED ___ 05:09PM GLUCOSE-143* LACTATE-3.5* K+-3.1* ___ 05:09PM HGB-8.1* calcHCT-24 ___ 05:09PM freeCa-1.00* ___ 04:56PM GLUCOSE-153* UREA N-7 CREAT-0.5 SODIUM-134 POTASSIUM-3.1* CHLORIDE-101 TOTAL CO2-24 ANION GAP-12 ___ 04:56PM CALCIUM-7.5* PHOSPHATE-2.7 MAGNESIUM-1.3* ___ 04:56PM WBC-10.4* RBC-2.41# HGB-7.8# HCT-22.7# MCV-94 MCH-32.4 MCHC-34.4 RDW-13.4 RDWSD-46.1 ___ 04:56PM PLT COUNT-130* ___ 04:56PM ___ PTT-150* ___ ___ 04:16PM PO2-216* PCO2-48* PH-7.34* TOTAL CO2-27 BASE XS-0 INTUBATED-INTUBATED ___ 04:16PM GLUCOSE-138* LACTATE-3.1* NA+-128* K+-3.2* CL--101 ___ 04:16PM HGB-8.4* calcHCT-25 ___ 04:16PM freeCa-1.00* ___ 02:45PM TYPE-ART PO2-344* PCO2-37 PH-7.39 TOTAL CO2-23 BASE XS--1 ___ 02:45PM GLUCOSE-151* LACTATE-4.6* NA+-129* K+-3.3 CL--99 ___ 02:45PM HGB-9.2* calcHCT-28 ___ 02:45PM freeCa-1.03* ___ 02:17PM TYPE-ART PO2-237* PCO2-50* PH-7.32* TOTAL CO2-27 BASE XS-0 ___ 02:17PM GLUCOSE-160* LACTATE-4.0* NA+-128* K+-3.7 CL--97 ___ 02:17PM HGB-11.3* calcHCT-34 ___ 02:17PM freeCa-1.04* ___ 02:17PM WBC-15.3* RBC-3.31* HGB-10.7* HCT-30.9* MCV-93 MCH-32.3* MCHC-34.6 RDW-13.2 RDWSD-45.3 ___ 02:17PM NEUTS-82.0* LYMPHS-11.2* MONOS-6.1 EOS-0.0* BASOS-0.1 IM ___ AbsNeut-12.56# AbsLymp-1.72 AbsMono-0.94 AbsEos-0.00* AbsBaso-0.02 ___ 02:17PM PLT COUNT-198 ___ 02:17PM PLT COUNT-198 ___ 02:17PM ___ PTT-32.6 ___ ___ 02:17PM ___ 10:45AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 10:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 10:45AM URINE RBC-8* WBC-1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 10:45AM URINE HYALINE-37* ___ 10:45AM URINE MUCOUS-MANY NSQ EPI-<1 ___ 08:08AM LACTATE-3.3* ___ 08:00AM cTropnT-<0.01 ___ 08:00AM WBC-11.5* RBC-3.81* HGB-12.3 HCT-36.1 MCV-95 MCH-32.3* MCHC-34.1 RDW-13.2 RDWSD-45.1 ___ 08:00AM NEUTS-64.9 ___ MONOS-6.0 EOS-1.7 BASOS-0.3 IM ___ AbsNeut-7.45* AbsLymp-3.04 AbsMono-0.69 AbsEos-0.20 AbsBaso-0.03 ___ 08:00AM PLT COUNT-213 ___ 08:00AM ___ PTT-24.8* ___ Brief Hospital Course: The patient presented to the emergency department and was evaluated by the Vascular Surgery Team. The patient was found to have a ruptured left iliac artery aneurysm and taken emergently to the operating room on ___ for endovascular repair ruptured internal iliac aneurysm, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken to the PACU in stable condition. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications. The patient was given ___ antibiotics and anticoagulation per routine. The patient was noted on POD1 to have tachycardia, abdominal pain and rising WBC count and was started on Cipro/Flagyl for a 7 day course. She also complained of some distention-a KUB that showed no obstructive signs. Her symptoms improved by POD2. She has persistent sinus tachycardia despite negative work-up. She was therefore started on metoprolol 12.5 BID for rate control. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry, her groin site sable without expanding hematoma, and the patient had no issues voiding. The patient may ambulate as tolerated. She was discharge home with services after clearance from physical therapy. The patient will follow up with Dr. ___ in 2 weeks 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: Alendroante 70mg weekly, folic acid 1mg', golimumab monthly, hctz 25', ketoconazole, levothyroxine 100mcg', methotrexate 15mg PO weekly (every ___, nystatin powder, prednisone 5mg', apap 650', vitamins Discharge Medications: 1. Acetaminophen 650 mg PO TID pain RX acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours Disp #30 Tablet Refills:0 2. Atorvastatin 40 mg PO QPM RX atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:3 3. Ciprofloxacin HCl 500 mg PO/NG Q12H RX ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every 12 hours Disp #11 Tablet Refills:0 4. PredniSONE 5 mg PO DAILY 5. MetroNIDAZOLE 500 mg PO TID RX metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8 hours Disp #16 Tablet Refills:0 6. Metoprolol Tartrate 12.5 mg PO BID RX metoprolol tartrate 25 mg 0.5 (One half) tablet(s) by mouth twice a day Disp #60 Tablet Refills:*2 7. Levothyroxine Sodium 100 mcg PO DAILY 8. FoLIC Acid 1 mg PO DAILY 9. Alendronate Sodium 70 mg PO WEEKLY 10. golimumab 12.5 mg/mL injection Monthly 11. Hydrochlorothiazide 25 mg PO DAILY 12. Ketoconazole 2% 1 Appl TP BID apply topically twice a day to left foot Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ruptured Left iliac artery aneurysm Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were hospitalized for a ruptured left iliac aneurysm which was repaired on ___. You did well after the operation and you are now ready for discharge home. Please see the following directions regarding your post-hospitalization care. MEDICATIONS: Continue all other medications you were taking before surgery, unless otherwise directed You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort WHAT TO EXPECT AT HOME: It is normal to have slight swelling of the legs: Elevate your leg above the level of your heart (use ___ pillows or a recliner) every ___ hours throughout the day and at night Avoid prolonged periods of standing or sitting without your legs elevated It is normal to feel tired and have a decreased appetite, your appetite will return with time Drink plenty of fluids and eat small frequent meals It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication ACTIVITIES: When you go home, you may walk and go up and down stairs You may shower (let the soapy water run over groin incision, rinse and pat dry) Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) After 1 week, you may resume sexual activity After 1 week, gradually increase your activities and distance walked as you can tolerate No driving until you are no longer taking pain medications CALL THE OFFICE FOR: ___ Numbness, coldness or pain in lower extremities Temperature greater than 101.5F for 24 hours New or increased drainage from incision or white, yellow or green drainage from incisions Bleeding from groin puncture site FOR SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call ___ for transfer to closest Emergency Room. Sincerely, ___ Vascular Surgery Followup Instructions: ___
10129052-DS-22	10,129,052	21,463,945	DS	22	2177-09-17 00:00:00	2177-09-17 14:16:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Penicillins / Codeine / Moexipril Attending: ___. Chief Complaint: Weakness, fall Major Surgical or Invasive Procedure: None History of Present Illness: ___ y.o F with history of rheumatoid arthritis on MTX/monthly simponi, HTN, hypothyroidism, and cognitive decline, brought in by EMS, for evaluation of weakness over the past two days and a fall, found to have a urinary tract infection. The patient reports two days of feeling more fatigued and less active, without specific symptoms. Last night, she had a fall on the bathroom floor, which she can not remember the details. She slept on the floor, where her family found her this morning. She was subsequently brought to the ED by EMS. In the ED, initial VS were 97.6 99 131/52 16 99% RA. ED course notable for fever to 101.5. She received 500 mL IV NS, 1 g ceftriaxone (18:15), and 650 mg PO acetaminophen. Neurologic exam in the ED was nonfocal Labs notable for CBC with WBC to 11.8, normal H/H, normal BMP. Negative urine and serum toxicology. Troponin negative x 1. Lactate of 1.8. UA was grossly positive with large leukesterase, moderate blood, positive nitrates, and < 1 epithelial cell. CXR without acute pulmonary process. Of note, CT head and neck were initially ordered and then subsequently discontinued. VS upon transfer were 101.5 89 150/51 16 95% RA. I interviewed the patient with her son present. The patient reported the story as above. She states that last night she fell asleep on the couch, was possibly trying to move to her bed, when she fell onto the ground. She does not remember the details of her fall. She is unsure if she slipped or why she fell. Her son reports that she has life alert, but she did not press the button. Instead, he called her the next morning. She answered her cell phone and told him that she had fallen and couldn't get up. She denies any preceding symptoms such as chest pain, shortness of breath, lightheadedness. She is unsure if she lost consciousness. She denies head strike or any particular pain at the moment. She reports she was in her usual state of health. She denies recent fevers, chills, abdiminal pain, dysuria, urinary frequency, diarrhea, constipation, worsening joint pain, headache, dizziness, numbness. ROS: Pertinent positives and negatives as noted in the HPI. She denies recent fevers, chills, abdominal pain, dysuria, urinary frequency, diarrhea, constipation, worsening joint pain, headache, dizziness, numbness. All other systems were reviewed and are negative. Past Medical History: - HTN - Hypothyroidism - Cataracts - Osteopenia - Sarcoidosis - Temporal Arteritis ___ - Osteoarthritis - Hyperlipidemia - Seronegative Rheumatoid Arthritis: Neg RF and CCPs, x-rays in he past showed no chondrocalcinosis. Has been treated with Plaquenil, Humira, MTX and prednisone in the past. Currently on MTX and SIMPONI. - Ruptured Left Iliac Artery Aneurysm s/p repair in ___ - Dementia Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: ADMISSION EXAM VITALS: 100.6PO 119 / 65 R 89 18 94 RA GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils pinpoint but reactive ENT: Ears and nose without visible erythema, masses, or trauma. Mucous membranes dry CV: Heart regular, + systolic murmur best heard at the RUSB RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored GI: Abdomen soft, non-distended, nontender except in suprapubic region GU: + suprapubic tenderness to palpation MSK: Neck supple, moves all extremities, ___ strength in bilateral grip strength, extension/flexion at elbow, ___ strength in hip flexion and dorsiflexion BACK: No CVA tenderness, + midline cervical tenderness SKIN: No rashes or ulcerations noted NEURO: Alert, oriented to year but not month, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect DISCHARGE EXAM VITALS: AVSS, mildly hypertensive now, no longer orthostatic GENERAL: Alert and in no apparent distress EYES: Anicteric, pupils pinpoint but reactive ENT: Ears and nose without visible erythema, masses, or trauma. MMM. OP clear. CV: Heart regular, + systolic murmur best heard at the RUSB RESP: Lungs clear to auscultation with good air movement bilaterally. Breathing is non-labored. GI: Abdomen soft, non-distended, nontender GU: No foley MSK: Neck supple, moves all extremities, ___ strength in bilateral grip strength, extension/flexion at elbow, ___ strength in hip flexion and dorsiflexion BACK: No CVA tenderness, + midline cervical tenderness SKIN: No rashes or ulcerations noted NEURO: Alert, oriented to year but not month, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout PSYCH: pleasant, appropriate affect Pertinent Results: LABS ON ADMISSION Heme/Chem ___ 11:00AM BLOOD WBC-11.8# RBC-3.98 Hgb-12.7 Hct-37.2 MCV-94 MCH-31.9 MCHC-34.1 RDW-13.0 RDWSD-44.7 Plt ___ ___ 11:00AM BLOOD ___ PTT-28.0 ___ ___ 11:00AM BLOOD Glucose-123 UreaN-17 Creat-0.8 Na-137 K-3.6 Cl-93* HCO3-26 AnGap-18* ___ 11:00AM BLOOD ALT-17 AST-31 CK(CPK)-321* AlkPhos-70 TotBili-0.6 ___ 11:00AM BLOOD cTropnT-<0.01 ___ 10:20PM BLOOD cTropnT-<0.01 ___ 11:00AM BLOOD CK-MB-3 proBNP-301 ___ 07:50AM BLOOD Calcium-8.2* Phos-2.2* Mg-1.9 ___ 11:00AM BLOOD TSH-0.51 ___ 11:00AM BLOOD CRP-119.9* ___ 11:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 11:18AM BLOOD Lactate-1.8 Urine ___ 03:10PM URINE Color-Yellow Appear-Hazy* Sp ___ ___ 03:10PM URINE Blood-MOD* Nitrite-POS* Protein-30* Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG ___ 03:10PM URINE RBC-15* WBC->182* Bacteri-FEW* Yeast-NONE Epi-<1 TransE-4 ___ 03:10PM URINE WBC Clm-MOD* Mucous-MANY* LABS ON DISCHARGE ___ 07:42AM BLOOD WBC-11.1* RBC-3.81* Hgb-12.1 Hct-35.6 MCV-93 MCH-31.8 MCHC-34.0 RDW-13.2 RDWSD-45.2 Plt ___ ___ 07:42AM BLOOD Glucose-91 UreaN-12 Creat-0.5 Na-142 K-4.0 Cl-103 HCO3-25 AnGap-14 ___ 08:00AM BLOOD CK(CPK)-302* ___ 08:00AM BLOOD Phos-2.1* MICROBIOLOGY 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--------- 0.5 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING AND OTHER PERTINENT STUDIES THIS ADMISSION CXR ___ No acute cardiopulmonary process Right Knee Plain Film ___ Interval progression of degenerative changes in the right knee since prior exam in ___. No definite fracture or dislocation is identified. Head and Neck CT No acute abnormalities Left shoulder 3 views No fracture or dislocation, ___ view limited EKG Sinus rhythm, left axis deviation, delayed R wave progression, no ST segment changes. Brief Hospital Course: This is an ___ with RA/Sarcoid/OA, HTN, HL, hypothyroidism, and cognitive decline, brought in by EMS for evaluation of weakness for two days and an unwitnessed fall, found to have a UTI with sepsis. # Sepsis secondary to # Urinary Tract Infection: Patient presenting with fever, leukocytosis, and a grossly positive UA, with likely UTI and urine now growing FQ susceptible E coli. Physical exam initially notable for suprapubic tenderness, resolved with antibiotics. Treated initially with ceftriaxone, subsequently transitioned to ciprofloxacin. Planned to treat for a total course of 7 days antibiotics (so 5 more days of cipro at DC) for complicated urinary tract infection given relative immunosuppression in the setting of treatment for rheumatoid arthritis. - Complete course of cipro - F/u finalized blood cultures # Unwitnessed fall versus syncope # Orthostatic hypotension: Patient with cognitive impairment, currently at baseline, presenting with an unwitnessed fall. EKG without concern findings, troponin negative x2, and no events on telemetry at 24 hours. Orthostatics + on the morning of admission suggesting sepsis induced hypovolemia and orthostatic syncope. Low suspicion for cardiac etiology given lack of cardiac history and likely concomitant infection with hypovolemia/orthostasis. Vital signs improved with IVF and holding HCTZ, and by discharge she trended to her usual hypertensive proclivities. Given her age and her presentation with orthostatic hypotension, HCTZ was discontinued in favor of low dose amlodipine. - F/u with PCP for BP check and medication titration - Home ___ coordinated at discharge # Weakness # Hypophosphatemia # Mild rhabdo: She reports some down time after her fall. Phos was low and CPK was elevated. These abnormalities could contribute to her subjective weakness. She was treated with phosphorus supplementation with improvement in phos. Her CK improved with IVF and holding atorvastatin. Given her age, weakness, and CK elevation Atorvastatin was discontinued. - F/u with PCP for reconsideration of statin - Home ___ # Shoulder pain, limitation of ROM: Films negative. Improving symptoms during her time here. Likely a rotator cuff injury. - Continue APAP as needed - No RX provided as patient can take OTC - Home ___ # Cervical spinal tenderness: C spine CT negative. No longer focally tender, no longer reporting neck pain. - Continue APAP as above # Cognitive Decline: Patient with reported cognitive decline and PCP notes indicating dementia, with home services to assist in cooking and medication management. No changes here. # Rheumatoid arthritis: Stable, no concern for flare. She takes methotrexate weekly and Simponi monthly, with her most recent injection a few days prior to admission. - Continue folic acid 1 mg daily - Hold methotrexate until NEXT week - advised she discuss with Dr ___ be in her blister pack for NEXT ___ - Hold Simponi until after treatment for UTI and discussion with Dr ___ # HTN: No evidence of major hemodynamic instability related to her sepsis or ongoing infection. Medication changes: - Discontinued HCTZ due to orthostasis - Continued home metoprolol - Started low dose amlodipine. # Hypothyroidism: Stable, though TSH somewhat below goal. Continued home levothyroxine. - F/u with PCP for discussion of medication adjustment # HL: Stable - Discontinued atorvastatin for now as above # Hx of iliac artery aneurysm s/p repair/graft: Pt due for repeat CT scan upcoming this week. All medications were reconciled with ___, changes reconciled with ___, and I received confirmation that they will home deliver her new medications and updated blister packs TONIGHT. Discussed contingencies with her son in case meds are not delivered - he expressed understanding and was thankful. Billing: >30 minutes spent coordinating discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FoLIC Acid 1 mg PO DAILY 2. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___) 3. Levothyroxine Sodium 200 mcg PO 1X/WEEK (___) 4. Methotrexate 15 mg PO 1X/WEEK (___) 5. Hydrochlorothiazide 25 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Golimumab 50 mg IV EVERY 4 WEEKS (___) 8. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. amLODIPine 2.5 mg PO DAILY RX amlodipine 2.5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days RX ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice a day Disp #9 Tablet Refills:0 3. FoLIC Acid 1 mg PO DAILY 4. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___) 5. Levothyroxine Sodium 200 mcg PO 1X/WEEK (___) 6. Metoprolol Succinate XL 25 mg PO DAILY 7. HELD- Golimumab 50 mg IV EVERY 4 WEEKS (___) This medication was held. Do not restart Golimumab until you have completed treatment for your UTI and spoken with Dr ___. 8. HELD- Methotrexate 15 mg PO 1X/WEEK (___) This medication was held. Do not restart Methotrexate until you have completed treatment for your UTI and spoken with Dr ___. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Weakness with fall Orthostatic hypotension Hypovolemia Sepsis due to urinary tract infection (UTI) Mild rhabdomyolysis / elevated muscle enzymes Shoulder pain Rheumatoid arthritis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted with weakness and an unwitnessed fall along with a fever. You were found to have a urinary tract infection and you were treated with antibiotics. You improved with treatment. You were seen by the physical therapists who worked with you and recommended you go home with home physical therapy. Your blood pressure was a bit low when you stood up and this was thought to be caused by not having enough fluid; it improved with giving you fluids. I have made some modifications to your medication list and sent these to ___. Please make sure to take your medications as prescribed and please make sure to follow up closely with your primary care doctor and your Rheumatologist who can advise you further on medication changes if necessary. Followup Instructions: ___
10129052-DS-23	10,129,052	26,352,938	DS	23	2179-02-10 00:00:00	2179-02-10 06:58:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Codeine / Moexipril Attending: ___. Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: Right hip ORIF with cephalo-medullary nail, ___ History of Present Illness: HPI: ___ presenting to ED after a fall in which pt was unable to get up. Pt walked out back porch and had a fall ___ unknown cause. Pt is not on blood thinners and cannot remember if there was any LOC. Pt has pain in R hip afterwards. Pt has nl mental status at baseline. Pt walks without help at baseline and lives alone. Past Medical History: - HTN - Hypothyroidism - Cataracts - Osteopenia - Sarcoidosis - Temporal Arteritis ___ - Osteoarthritis - Hyperlipidemia - Seronegative Rheumatoid Arthritis: Neg RF and CCPs, x-rays in he past showed no chondrocalcinosis. Has been treated with Plaquenil, Humira, MTX and prednisone in the past. Currently on MTX and SIMPONI. - Ruptured Left Iliac Artery Aneurysm s/p repair in ___ - Dementia Social History: ___ Family History: Reviewed and found to be not relevant to this illness/reason for hospitalization. Physical Exam: AVSS GEN: well appearing, NAD CV: regular rate PULM: non-labored breathing on room air Right lower extremity: Shortened and externally rotated SILT sural/saphenous/tibial/deep peroneal/superficial peroneal distributions ___ Warm and well perfused, +dorsalis pedis pulse Pertinent Results: ___ 04:38AM BLOOD WBC-11.4* RBC-3.18* Hgb-9.9* Hct-28.6* MCV-90 MCH-31.1 MCHC-34.6 RDW-15.8* RDWSD-50.3* Plt ___ ___ 04:38AM BLOOD Glucose-122* UreaN-6 Creat-0.5 Na-142 K-3.0* Cl-103 ___ AnGap-13 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 a right intertrochanteric proximal femur fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for cephalo-medullary nail, 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. She has syncopal episode on ___ in which she was found in bed, nonresponsive. She quickly regained consciousness. She was assessed by the inpatient geriatrics consult, who felt this event was syncopal in the setting of pain, under resuscitation, and anemia. She received 1 unit of packed red blood cells for hemoglobin of 7.4 at this time and her blood count responded appropriately. The remainder of her hospital course was unremarkable. 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 weightbearing as tolerated in the right lower extremity, and will be discharged on enoxaparin 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: 1. AMLODIPINE 10 mg PO DAILY 2. GOLIMUMAB once monthly injection 3. LEVOTHYROXINE 75 mcg PO DAILY 4. METHOTREXATE SODIUM, 2.5 mg tablet, 5 tablet(s) by mouth every week on ___ 5. METOPROLOL SUCCINATE, 25 mg, daily Discharge Medications: 1. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 2. Calcium Carbonate 500 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS 5. OxyCODONE (Immediate Release) 2.5 mg PO Q6H:PRN Pain - Moderate 6. Ramelteon 8 mg PO QHS; Should be given 30 minutes before bedtime. Melatonin 3mg can be substituted 7. Senna 8.6 mg PO BID 8. TraZODone 25 mg PO QHS:PRN insomnia 9. Vitamin D 400 UNIT PO DAILY 10. amLODIPine 10 mg PO DAILY 11. Levothyroxine Sodium 75 mcg PO DAILY 12. METOPROLOL SUCCINATE, 25 mg, daily 13. GOLIMUMAB once monthly injection 14. METHOTREXATE SODIUM, 2.5 mg tablet, 5 tablet(s) by mouth every week on ___ Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Right intertrochanteric femur fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: -Weightbearing as tolerated 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 enoxaparin oxycodone daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Incision may be left open to air unless actively draining. If draining, you may apply a gauze dressing secured with paper tape. - Splint must be left on until follow up appointment unless otherwise instructed. - Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever ___ 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Physical Therapy: Weightbearing as tolerated, range of motion as tolerated right lower extremity Treatments Frequency: Physical therapy Staples will be removed at clinic follow-up Followup Instructions: ___
10129119-DS-10	10,129,119	22,141,961	DS	10	2178-12-22 00:00:00	2178-12-24 18:24:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: s/p fall, rib fractures, hemopneumothorax Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ year old male with a history of atrial fibrillation on coumadin, EtOH abuse c/b withdrawal seizures currently on phenobarbital, who sustained a fall down ___ steps in his home, with subsequent right-sided rib fractures (ribs ___ in the setting of a supratherapeutic INR of 6.0 on admission. He was also found to have a positive EtOH. He received 1L NS and was brought to ___. In the ED, he was found to have R sided subcutaneous emphysema on exam, and was hemodynamically stable (98% on 2LNC). Given his supratherapeutic INR and small hemopneumothorax, a chest tube was deferred. He was given one dose of lorazepam for presumed alcohol withdrawal. He was sent to the TSICU/SICU for further management. He received PTCC/KCentra for reversal of his INR to 1.2. His hospital course was complicated by symptomatic alcohol withdrawal, requiring a phenobarbital drip per protocol. He was also noted to be hyponatremic to 119 on admission (first diagnosed with hyponatremia in ___, 123 at that time). Past Medical History: Afib (on warfarin) HTN CHF Alcohol abuse (drinks 6 pack of beer daily, 8 pack on weekends) Social History: ___ Family History: Non-contributory Physical Exam: On admission: VS - Afebrile, hemodynamically stable, SpO2 98% on 2LNC General: NAD HEENT: NCAT CV: Irreg irreg Lungs: CTAB, Crepitus over R chest, TTP R back Abdomen: soft, NT/ND GU: N/A Ext: Warm well perfused On discharge: VS- Tmax 98.5, Tcurr 98.0, BP 121/50 (107-138/40-71), HR 60 (56-83), RR 18, SpO2 100% RA (98-100% RA) I/O: ___ + BM x 1 Weight: 56.9 kg (same as ___ when first came to the floor) General: NAD, just woken up HEENT: NC/AT, purplish bruising on nose Neck: Supple, full range of motion, no LAD Chest: Large hematoma, purple, with subcutaneous emphysema on R chest/ R flank. Stable since yesterday, decreased since 3 days prior. Non-tender. CV: Irregularly irregular, tachycardic, no murmurs, rubs, or gallops; no JVD Lungs: Expiratory wheezing in the R mid and lower lung fields, slightly coarse breath sounds throughout Abdomen: Soft, non-tender, non-distended, normoactive bowel sounds, GU: No CVA tenderness, no suprapubic tenderness, no foley Ext: No cyanosis, clubbing, or edema Neuro: A&Ox3, CN II-XII grossly intact Skin: No excoriations, lesions, or rashes. Pertinent Results: On admission: ___ 11:30AM BLOOD WBC-10.6 RBC-3.67* Hgb-13.0* Hct-39.3* MCV-107* MCH-35.4* MCHC-33.1 RDW-14.5 Plt ___ ___ 11:30AM BLOOD Neuts-81.7* Lymphs-11.7* Monos-5.3 Eos-0.9 Baso-0.4 ___ 11:30AM BLOOD ___ PTT-47.3* ___ ___ 11:30AM BLOOD Glucose-108* UreaN-7 Creat-0.9 Na-119* K-7.5 (hemolyzed)* Cl-94* HCO3-15* AnGap-18 ___ 12:48PM BLOOD K-4.4 ___ 11:30AM BLOOD ALT-34 AST-90* AlkPhos-56 TotBili-0.7 ___ 11:30AM BLOOD Lipase-28 ___ 11:30AM BLOOD Albumin-3.4* ___ 07:40PM BLOOD Calcium-7.9* Phos-4.2 Mg-1.4* ___ 11:30AM BLOOD ASA-NEG Ethanol-69* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 12:00PM URINE Color-Straw Appear-Clear Sp ___ ___ 12:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG In the interim: ___ 11:30AM BLOOD ___ PTT-47.3* ___ ___ 03:25PM BLOOD ___ PTT-33.4 ___ ___ 07:40PM BLOOD ___ PTT-32.6 ___ ___ 04:02AM BLOOD ___ PTT-34.8 ___ ___ 10:43AM BLOOD ___ PTT-31.3 ___ ___ 05:26AM BLOOD ___ PTT-33.4 ___ ___ 06:35AM BLOOD ___ PTT-36.4 ___ ___ 04:40AM BLOOD ___ PTT-34.7 ___ ___ 06:25AM BLOOD ___ PTT-31.4 ___ ___ 06:25AM BLOOD Glucose-89 UreaN-8 Creat-1.0 Na-132* K-3.8 Cl-97 HCO3-28 AnGap-11 On discharge: ___ 07:00AM BLOOD WBC-4.2 RBC-2.34* Hgb-8.5* Hct-25.1* MCV-107* MCH-36.2* MCHC-33.7 RDW-15.2 Plt ___ ___ 07:00AM BLOOD ___ PTT-39.0* ___ ___ 07:00AM BLOOD Glucose-81 UreaN-9 Creat-0.9 Na-133 K-4.1 Cl-99 HCO3-28 AnGap-10 ___ 07:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.5* MICROBIOLOGY: ___ 12:00 pm URINE *FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING and other studies: ECG Study Date of ___ 11:21:54 AM Atrial fibrillation with a relatively rapid ventricular response. Delayed R wave progression in the precordial leads. Peaked T waves in the anterior leads. Probable prior anteroseptal myocardial infarction. Low QRS voltage in the limb leads. No previous tracing available for comparison. Intervals Axes Rate PR QRS QT/QTc P QRS T 87 0 78 392/439 0 31 61 CXR (___): IMPRESSION: Right rib fractures with subcutaneous gas and a small right apical pneumothorax. Right basilar opacity could represent an effusion or hemothorax. CT head w/o contrast (___): IMPRESSION: 1. No acute intracranial process. 2. Global involutional changes, slightly advanced for age. 3. Nasal bone fractures could be old, clinical correlation suggested. CXR (___): IMPRESSION: As compared to the previous radiograph, there is unchanged evidence of displaced right rib fractures and a right hema toe thorax. The extent of the fluid component of the hemothorax, however, has substantially increased. The soft tissue air collection on the right is constant in appearance. Unchanged appearance of the cardiac silhouette and of the left lung. CXR (___): IMPRESSION: No relevant change as compared to the previous examination. Known multiple rib fractures. Known soft tissue air collections on the right. The right lung apex re-confirms the presence of a millimetric pneumothorax without evidence of tension. The extent of the right pleural effusion has minimally increased. Unchanged appearance of the cardiac silhouette and of the left lung. CXR (___): IMPRESSION: There is small bilateral pleural effusions right greater than left and a small right lateral pneumothorax there is a moderate amount of right-sided subcutaneous emphysema there is volume loss in the right lower lobes. Compared to the prior study the right-sided pneumothorax is slightly larger. CXR (___): IMPRESSION: Multiple right-sided rib fractures are again visualized. There is a moderate right-sided effusion. And a small right pneumothorax there is also small left effusion compared to the study from the prior day, the effusions have slightly increased. TTE (___): Conclusions: The left atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate (___) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: ___ y/o male with history of A-fib on warfarin, s/p fall with multiple R sided rib fractures (ribs ___, who presented with hemopneumothorax. ACUTE ISSUES: #Rib fractures, hemopneumothorax: In the setting of a supratherapeutic INR to 6.0 on admission, his rib fractures and hemopneumonthorax were managed conservatively. He also had a CT head without contrast on admission, because it was unclear if he had hit his head during the fall; imaging was negative for any intracranial bleed, and demonstrated old nasal bone fractures s/p a hockey injury ___ years ago. Thoracostomy/ pigtail catheter was deferred for the hemopneumothorax. His respiratory status was closely monitored, and he received almost daily CXRs. He was transferred from the SICU to the regular medical floor after remaining hemodynamically stable for 3 days. On exam, he continued to have a right flank/back hematoma with significant subcutaneous emphysema/crepitus. His exam remained stable over the course of his admission. In the setting of an increasing effusion noted on CXR the day prior to discharge, he received an echocardiogram to determine the status of his heart failure. EF was noted to be >55%. He continued to saturate well on room air. He has close follow-up scheduled with his cardiologist. His rib fracture pain was controlled with Dilaudid, transitioned to Oxycodone, and Tylenol. #Supratherapeutic INR: Patient's INR was 5.4-6.0 on presentation. He received KCentra/PTCC for reversal, and was reversed to 1.2. He also received 2 mg of Vitamin K x 1. In the setting of his recent trauma, bridging him with heparin was deferred. His warfarin was re-started at his home dosing of 2.5 mg PO qday on hospital day #3. He continued to be subtherapeutic, and he received one dose of 4 mg PO. He was still subtherapeutic at 1.3 on the morning of discharge, and was continued on his home 2.5 mg PO qday regimen, to be closely followed by his cardiologist. #Hyponatremia: Patient's serum sodium on admission was 119. Of note, he does have chronic hyponatremia, first diagnosed in ___, where his serum sodium was noted to be 123. Per our review of his records, the etiology has not been previously worked up, but it is likely secondary to his chronic alcohol abuse vs. hypovolemic hyponatremia. He received maintenance fluids during his stay in the ICU, which were discontinued on the floor. SIADH and other central etiologies were investigated during this admission. He received a gentle fluid bolus of 250cc, with no change noted in his sodium. TSH and cortisol levels were also checked, and were within normal limits. To that end, he was fluid restricted to less than 2L/day. By time of discharge his serum Na had nearly normalized, with Na of 133, further supporting a diagnosis of hyponatremia ___ beer potomania. CHRONIC ISSUES: #Atrial fibrillation: Due to initial EKG with relatively rapid ventricular response, patient was initially controlled with Metoprolol ___ mg IV q6hr. After appropriate control was achieved (rate 100s-110s), he was transitioned to Metoprolol 50 mg PO BID. He was eventually discharged on Metoprolol XL 100 mg PO qday. #HTN: His home Lisinopril 2.5 mg PO qday was continued throughout this admission. #Congestive Heart Failure: His last echocardiogram prior to this admission was ___ year. In the setting of a new effusion noted on x-ray the day prior to discharge, he received a TTE in-house, which demonstrated LVEF > 55%. He was fluid restricted to <2 L while in-house. He does have close cardiology follow-up scheduled. #Hx of alcohol abuse: Patient was initially thought to be confused and symptomatic due to alcohol withdrawal upon presentation in the ICU. He was started on a phenobarbital drip per protocol, and was transitioned to PO phenobarbital. He completed the full taper while in-house. Alcohol cessation was encouraged, and mandated immediately after discharge while on narcotics for pain control. He was thrombocytopenic this admission, likely secondary to his alcohol use. #> 30 ppd smoking history: Patient was given a nicotine patch. TRANSITIONAL ISSUES: - Patient will need his INR and warfarin dosing monitored closely upon discharge, with goal INR of 2 to 3 in the setting of atrial fibrillation. - Repeat evaluation of sodium is advised to ensure stability post discharge. - Continued encouragement of alcohol cessation is advised. - Home metoprolol was uptitrated in the setting of rapid atrial fibrillation to 150s, possibly precipitated by pain and/or alcohol withdrawal; further titration is needed in the outpatient setting. - No pending studied at the time of discharge. - Code status: FULL CODE (confirmed). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 2.5 mg PO DAILY 2. Metoprolol Succinate XL 25 mg PO DAILY 3. Warfarin 2.5 mg PO DAILY16 (every day except ___ Discharge Medications: 1. Lisinopril 2.5 mg PO DAILY 2. Nicotine Patch 21 mg TD DAILY RX nicotine 21 mg/24 hour 1 patch once a day Disp #30 Patch Refills:0 3. Metoprolol Succinate XL 100 mg PO DAILY RX metoprolol succinate 100 mg 1 tablet(s) by mouth once a day Disp #30 Tablet Refills:0 4. Outpatient Lab Work please check INR on and fax results to Dr ___ at ___ by ___. icd-9 code: ___ 5. Warfarin 2.5 mg PO DAILY16 6. Acetaminophen 650 mg PO Q8H pain RX acetaminophen 650 mg 1 tablet(s) by mouth three times a day Disp #42 Tablet Refills:0 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain RX oxycodone 5 mg 1 tablet(s) by mouth four times a day Disp #16 Tablet Refills:*0 Discharge Disposition: Home Discharge Diagnosis: Primary: Traumatic rib fractures Hemopneumothorax Hyponatremia Secondary: Atrial fibrillation Hypertension History of alcohol use 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 admission to ___. After you fell at home, you sustained rib fractures in ribs ___ on your right side. You developed a combination of blood and air in the chest due to the fractures and the fall. You were treated with rest and pain control. Your breathing continued to remain stable during your admission, and there were no signs of active bleeding. You had repeat chest x-rays, which showed that the blood and air on your right side were stable. It is very important that you avoid combining pain medications and alcohol since the combination can cause dangerous side effects, including oversedation and difficulty breathing. Your INR was found to be high on admission and was lowered with medication. You were restarted on your warfarin when safe. Please take your warfarin as prescribed and follow up with your doctor to have your INR checked at your previous schedule. It is important to seek immediate medical attention if you hit your head or notice excessive bleeding of any kind. On admission, your sodium level was also found to be low. Per your records, it seems that your sodium level has been low since at least ___. Your sodium was stably slightly low at discharge. Please see the following recommendations from the surgeons who care for you: -You have sustained a rib fracture which can cause severe pain and subsequently cause you to take shallow breaths because of the pain. -You should take your pain medicine as prescribed in order to stay ahead of the pain otherwise you will not be able to take deep breaths. If the pain medicine is too sedating, (making you sleepy) take half the dose and call your doctor. -___ is a complication of rib fractures. In order to decrease your risk you must use your incentive spirometer (plastic breathing machine) 4 times per hour while awake. A good rule is if you are watching TV to use it with every commercial. This will help expand the small airways in your lungs as well as help you to bring up secretions that can pool in the lungs and cause infectin. -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 help ease the pain. -Narcotic pain medicine can cause constipation therefore you should take a stool softener twice a day and increase your fluid and fiber intake. -DO NOT SMOKE. Smoking always has negative health consequences, but is particularly dangerous during the period of your recovery from a rib fracture. -Return to the emergency room right away if you develop any acute shortness of breath, increased pain or crackling sensation around your ribs. Followup Instructions: ___
10129124-DS-7	10,129,124	25,476,866	DS	7	2121-07-09 00:00:00	2121-07-09 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: Transfer from ___ ED for fall with headstrike. Admitted from our ED for pneumonia sine pneumonia. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr ___ is a ___ with ___ disease, dementia, chronic aspiration/dysphagia, prior colon cancer, recent UTI with hospitalization notable for toxic/metabolic encephalopathy and deconditioning, who is admitted after a mechanical fall with headstrike while at rehab. Patient is a poor historian. History is per his daughter and the RN at the ___. He was at rehab for deconditioning after a recent hospital stay for UTI. He was steadily improving toward his goal of being discharged home. This morning, per reports, he dropped his urinal and while reaching down for it he fell forward with headstrike. He denies LOC, and per reports this was a mechanical fall. He had a laceration and so was sent to the ___, where laceration was stapled. Head CT was performed and was negative, but for some reason he was transferred to ___ for "high risk of intracranial bleeding." In our ED, Head CT was reportedly confirmed as negative. He had entirely normal vitals, SaO2 of 94-95% RA. Labs were unremarkable. CXR negative. Coarse breath sounds were noted, though these are chronic per RN at ___. He was inexplicably started on antibiotics and admitted for pneumonia, in spite of above. In speaking with daughter and rehab RN, patient has had ronchorous coarse breath sounds for quite some time. They think it is related in some part to chronic aspiration. He has been following up with SLP and has had his diet advanced from pureed to a more diced diet. He does have intermittent cough. ROS: Unobtainable owing to mental status. Past Medical History: Paroxysmal AF on Coumadin ___ disease Dementia with very poor memory, AAOx1-2 baseline Very soft voice/hypophonia Aspiration pneumonia; diced solids / nectar thick liquids Toxic/metabolic encephalopathy Anemia, presumably related to hospitalizations No known history of heart or other lung diseases Past surgical history: Back surgeries (at least 3 of them) Colon cancer s/p partial colectomy Knee arthroscopy Social History: ___ Family History: No family history of heart or lung disease. + Family history of ___ disease. Physical Exam: Exam on admission: Vitals AVSS, breathing comfortably on RA Gen NAD, minimally interactive Abd soft, NT, ND, bs+ CV RRR, no MRG Lungs somewhat coarse breath sounds bilaterally, transmitted upper airway sounds Ext WWP, no edema Skin no rash, anicteric GU no foley Eyes EOMI HENT MMM, OP clear Neuro nonfocal, moves all extremities; resting tremor noted, AAOx2 Psych somewhat flattened affect Pertinent Results: Labs from admission: ___ 09:45PM BLOOD WBC-7.8 RBC-3.88* Hgb-11.8* Hct-35.0* MCV-90 MCH-30.4 MCHC-33.7 RDW-14.5 Plt ___ ___ 09:45PM BLOOD Neuts-76.6* Lymphs-15.1* Monos-5.4 Eos-2.5 Baso-0.4 ___ 09:45PM BLOOD ___ PTT-36.3 ___ ___ 09:45PM BLOOD Glucose-85 UreaN-12 Creat-0.8 Na-134 K-3.6 Cl-102 HCO3-23 AnGap-13 ___ 09:45PM BLOOD ALT-9 AST-14 CK(CPK)-33* AlkPhos-76 TotBili-0.4 ___ 09:45PM BLOOD Lipase-47 ___ 09:45PM BLOOD Albumin-3.6 ___ 11:55PM BLOOD Lactate-1.4 CXR from admission: Clear lungs. EKG from admission: TWI in I, L. Poor baseline. Repeat Head CT ___ There is no acute hemorrhage, edema, mass effect, midline shift. The ventricles and sulci are normal in size and configuration for the age. The basal cisterns are patent and there is normal gray-white matter differentiation. No acute fracture on the routine images provided Repaired left frontal scalp laceration. Imaged paranasal sinuses are clear. IMPRESSION: No acute intracranial hemorrhage or mass effect . Brief Hospital Course: ___ with ___ disease, dementia, chronic aspiration/dysphagia, prior colon cancer, recent UTI with hospitalization notable for toxic/metabolic encephalopathy and deconditioning, who is admitted after a mechanical fall with headstrike while at rehab. # Very soft voice/hypophonia - at baseline. # Chronic aspiration/dysphagia - Continued diet of diced solids / nectar thick liquids for now # Fall with headstrike: Simple mechanical fall. Patient placed on fall precautions. Needs staple removal in ___ days. Repeat Head CT does not show any evidence of bleed. # ___ disease # Dementia with very poor memory # History of toxic/metabolic encephalopathy: Currently stable, near baseline. # Paroxysmal AF on Coumadin: He had AF during hospitalization for his colectomy, in setting of massive aspiration pneumonia requiring intubation. - Continued coumadin, goal INR ___ aspirin dose reduced to 81mg from 325 mg to reduce risk of bleeding. If patient does not have any strong indications for aspirin therapy would consider stopping it - Seems like risks of anticoagulation might outweigh benefits in patient with dementia and at high risk for falls. Urge outpatient providers to ___ the risks/benefits of anticoagulation. Code: DNR/DNI confirmed. Contact: Daughter and HCP, ___ @ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Warfarin 8.5 mg PO DAILY16 2. Omeprazole 20 mg PO DAILY 3. Aspirin 325 mg PO DAILY 4. Multivitamins W/minerals 1 TAB PO DAILY 5. Acetaminophen 1000 mg PO Q6H 6. Docusate Sodium 100 mg PO BID 7. Ropinirole 3 mg PO TID 8. Carbidopa-Levodopa (___) 1 TAB PO TID Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Fall ___ Disease History of Atrial Fibrillation Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were transferred to ___ for evaluation after a fall in which you hit your head. You had a CT scan here that did not show any bleeding. Please discuss with your doctors whether ___ should remain on coumadin. Please have your staples removed in two weeks. Followup Instructions: ___
10129167-DS-19	10,129,167	28,940,207	DS	19	2139-02-22 00:00:00	2139-02-22 16:22:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: RUQ pain, nausea and vomiting. Major Surgical or Invasive Procedure: Ercp ___ History of Present Illness: ___. female G1P1 at one month post-partum s/p laparoscopic cholecystectomy 3 days ago at OSH presented to ED with RUQ pain, nausea and vomiting. She was tranferred for elevated LFTs and evaluation by ERCP. Past Medical History: Post partum 1 month ago Lap Chole ___ Social History: ___ Family History: Non-contributory Physical Exam: General: all normal, denies fever/chills/fatigue/malaise, denies wt gain/loss HEENT: all normal, denies changes in vision/hearing Respiratory: all normal, denies SOB/DOE/cough/wheeze/hemoptysis/pain Cardiac: all normal, denies angina/palpitations GI: as noted in HPI GU: all normal, denies dysuria Physical Exam: T: 99.3 P: 111 BP: 118/82 RR: 16 O2sat: 100% on RA General: awake, alert, NAD HEENT: NCAT, EOMI, anicteric Heart: RRR Lungs: normal excursion, no respiratory distress Back: no vertebral tenderness, no CVAT Abdomen: soft, ND, moderate tenderness in RUQ, laparoscopy incisions c/d/i Extremities: WWP, no CCE, no tenderness Pertinent Results: On Admission: ___ WBC-4.5 RBC-4.62 Hgb-12.3 Hct-37.3 MCV-81* MCH-26.6* MCHC-33.0 RDW-14.9 Plt ___ PTT-32.3 ___ Glucose-95 UreaN-3* Creat-0.5 Na-144 K-3.8 Cl-106 HCO3-26 AnGap-16 ALT-354* AST-346* AlkPhos-437* TotBili-3.2* Lipase-96* Albumin-4.1 VitB12-533 HCG-LESS THAN 5 Lactate-0.9 At Discharge: ___ WBC-4.3 RBC-4.25 Hgb-11.4* Hct-35.9* MCV-84 MCH-26.9* MCHC-31.9 RDW-15.2 Plt ___ Glucose-75 UreaN-5* Creat-0.6 Na-138 K-4.8 Cl-104 HCO3-22 AnGap-17 ALT-193* AST-88* AlkPhos-399* TotBili-1.2 Albumin-3.2* Calcium-8.6 Phos-3.7 Mg-1.9 . Blood cultures PENDING at discharge Brief Hospital Course: ___ y/o female admitted through the ED from OSH with RUQ pain, nausea and vomiting, 1 month post partum and 3 days post op from lap cholecystectomy. Patient was made NPO and was hydrated. A CT was performed showing mild intra- and extra-hepatic biliary dilatation and ___ stranding which is likely post-operative. There was no evidence of a stone on the CT, but due to symptoms, an ERCP was requested, and was performed on ___. During the ERCP, there was a filling defect, and with the abnormal LFTs, and clinical picture, a sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A small stone and sludge were extracted successfully using a balloon catheter. Excellent flow of bile and contrast were seen after stone extraction. The patient remained NPO overnight and was well hydrated. The following day, she was started back on a clear diet, then tolerated a regular lunch and was feeling well. She is discharged to home, blood cultures drawn on admisison are pending at the time of discharge. LFTs have improved significantly after the ERCP. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Senna 1 TAB PO BID:PRN Constipation 3. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB/Wheeze RX albuterol sulfate 90 mcg 1 PUFF IH q 6 hours Disp #1 Inhaler Refills:*1 Discharge Disposition: Home Discharge Diagnosis: cholangitis cholelithiasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call Dr. ___ office ___ if you have any of the following symptoms: temperature of 101 or greater, chills, nausea, vomiting, inability to eat, jaundice (yellowing or skin or whites eyes), itching, increased abdominal pain or distension, incision redness/bleeding or drainage, constipation or diarrhea. -you may shower with soap and water, rinse incision and pat dry. Do not apply powder or lotion to incision. -no heavy lifting/straining. Do not lift anything heavier than 5 pounds. Followup Instructions: ___
10129197-DS-12	10,129,197	22,654,366	DS	12	2151-07-07 00:00:00	2151-07-08 08:36:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Chills, subjective fevers Major Surgical or Invasive Procedure: ERCP (___) Joint aspiration, left knee (___) Joint aspiration, right knee (___) Aspiration, hepatic abscess (___) History of Present Illness: ___ year old male presents from ___ for chills. He had an elevated alkaline phosphatase level measured in primary care provider's office, so his doctor suggested he come to the ED for further workup. He reports sweats over past ___ days, worsening last night, denies abdominal pain. Seen ___ for 4 day history of subjective fevers, night sweats and dry cough. Outpatient CXR showed no acute abnormality, thought to possibly be viral syndrome. He was also seen ___ for nausea and vomiting thought to be due to viral gastroenteritis and is currently resolved. In the ED, initial vitals were: 0 97.8 95 113/69 18 100% - Labs were significant for alk phos 413, ALT 71, Lactate .9, WBC 11.9, H/H ___, Cr. .9 Lipase 24 Vitals prior to transfer were: 98.8 85 118/72 16 98% RA Upon arrival to the floor, sweats for 10 days mostly at night, never measured an objective fever. no pain anywhere. No recent vomiting or nasuea. No dysuria, chest pain. He has had a chronic dry cough for ___ months, he had an CXR 2 days ago which as clear, feels like his breathing is "fast." Past Medical History: Essential hypertension Aneurysm, aortic Thrombophlebitis / Phlebitis - DEEP - patient reports no DVT or PE history Varicose veins Atrial fibrillation - Patient not familiar with this diagnosis Vitamin D deficiency Pseudogout Achilles rupture, left Social History: ___ ___ History: Father died of cancer Mother still alive ___ heathy Physical Exam: ON ADMISSION Vitals: 99.1 105/66 80 18 97%RA General: Alert, oriented, no acute distress, speaking comfortably HEENT: Sclera anicteric, MMM, 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, negative murphys sign, no organomegaly, no rebound or guarding GU: No foley Ext: Warm, well perfused, swelling and echymosis around left ankle 2+ pulses Neuro: grossly intact ON DISCHARGE Vitals- Tc 97.4 Tm 98.7 BP 98-147/77-89 HR 75-102 RR ___ SpO2 95-99%RA General- Alert, oriented, no acute distress HEENT- Sclerae anicteric, MMM, oropharynx clear Neck- supple Lungs- CTAB, no wheezes, rales or rhonchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, normoactive bowel sounds present, no rebound tenderness or guarding Ext- warm, well perfused, no clubbing or cyanosis. Knees mildly swollen at suprapatellar region but not warm. Minimal swelling bilaterally in ankles. Neuro- EOMI, tongue midline, face symmetric, motor function grossly normal Pertinent Results: ON ADMISSION ___ 08:45PM BLOOD WBC-11.6* RBC-4.37* Hgb-13.0* Hct-39.7* MCV-91 MCH-29.7 MCHC-32.7 RDW-13.5 RDWSD-45.3 Plt ___ ___ 08:45PM BLOOD Neuts-64.6 ___ Monos-10.1 Eos-2.6 Baso-0.6 Im ___ AbsNeut-7.46* AbsLymp-2.38 AbsMono-1.17* AbsEos-0.30 AbsBaso-0.07 ___ 08:45PM BLOOD Plt ___ ___ 08:45PM BLOOD Glucose-96 UreaN-20 Creat-0.9 Na-140 K-4.1 Cl-104 HCO3-25 AnGap-15 ___ 08:45PM BLOOD ALT-71* AST-33 AlkPhos-413* TotBili-0.5 ___ 08:45PM BLOOD Lipase-24 GGT-547* ___ 08:45PM BLOOD Albumin-3.8 ___ 08:54PM BLOOD Lactate-0.9 ON DISCHARGE ___ 06:08AM BLOOD WBC-11.1* RBC-4.30* Hgb-12.7* Hct-38.4* MCV-89 MCH-29.5 MCHC-33.1 RDW-13.2 RDWSD-43.2 Plt ___ ___ 06:08AM BLOOD Plt ___ ___ 06:08AM BLOOD ___ PTT-26.8 ___ ___ 06:08AM BLOOD Glucose-108* UreaN-21* Creat-0.6 Na-141 K-3.8 Cl-104 HCO3-24 AnGap-17 ___ 06:13AM BLOOD ALT-24 AST-13 AlkPhos-200* TotBili-0.4 ___ 06:08AM BLOOD Calcium-8.7 Phos-2.8 Mg-1.5* ___ 06:31AM BLOOD calTIBC-226* Ferritn-417* TRF-174* ___ 06:35AM BLOOD PTH-79* ___ 06:35AM BLOOD 25VitD-6* IMAGING/STUDIES: ___ MRCP 1. Choledocholithiasis with a 13 mm stone in the distal common bile duct causing moderate extrahepatic and mild intrahepatic biliary dilatation. 2. 1.9 cm hepatic abscess in the left lobe 3. Cholelithiasis ___ CXR No acute focal consolidation. ___ ERCP - A periampullary diverticulum was seen. - Successful biliary cannulation was achieved with the sphincterotome. - A single 12 mm round stone that was causing partial obstruction was seen at the biliary tree. There was moderate post obstructive dilation. - A biliary sphincterotomy was performed. - Because of the large size of the stone, a biliary sphincteroplasty was then performed using a CRE balloon from 10-12mm - The stone was the extracted using a balloon. Several other balloon sweeps were performed and completion cholangiogram was normal. - Otherwise normal ERCP to ___ part of duodenum. MICROBIOLOGY ___ Blood culture - negative ___ Left knee joint fluid - 4+ PMNs, no microorganisms, no growth to date ___ Blood cultures - no growth to date ___ Liver abscess tissue - gram stain negative, no growth to date ___ Liver abscess aspirate - gram stain negative, no growth to date Brief Hospital Course: ___ with hypertension and history of pseudogout who presented with ongoing chills and elevated alkaline phosphatase with CBD dilation on US, found to have cholodocholithiasis on MRCP, s/p ERCP. Also found to have a hepatic abscess discharged on 14-days ertapenem. Hospitalization complicated by acute, polyarticular pseudogout treated with joint aspiration, colchicine, and steroids. ACTIVE ISSUES: #Choledocholithiasis MRCP visualized a 1.3cm stone in the common bile duct. Patient underwent ERCP with stone removal and sphincterotomy. He had no complications. He was advised to avoid NSAIDs for 7 days following the procedures. He will need outpatient referral to a general surgeon for cholecystectomy. # Hepatic abscess A small hepatic abscess was seen on MRCP. This was too small to place a drain, but was aspirated by ___. Because the aspirate was bloody without frank pus, ___ also took a biopsy of the abscess tissue. He was initially placed on ceftriaxone and metronidazole. However, the day after the procedure he had fevers and hypotension so was broadened to vancomycin, cefepime, and metronidazole. Infectious workup was otherwise negative. Gram stains and cultures had no growth. Pathology of the tissue showed inflammation suggestive of chronic, active cholestasis with abscess formation. It was felt that this abscess formed from contiguous spread in the setting of cholodocholithiasis. The patient was seen by ID who recommended a 14-day course of IV antibiotics, and he was discharged on ertapenem. He will follow-up with ID on day 15 for repeat imaging and determination of the final antibiotic course. # Acute polyarticular pseudogout During period of immobility as inpatient, patient's left knee had a pseudogout flare, which was drained by Rheumatology and confirmed presence of positively birefringent rhomboid crystals without bacterial growth. During this admission, pseudogout spread to patient's right knee, both ankles, hips and right wrist. Workup for secondary causes were only revealing for hypomagensemia, so he was discharged on oral magnesium. He was started on treatment dose colchicine without significant improvement, so IV methylprednisolone was started with rapid improvement in his symptoms. He will continue a prednisone taper as an outpatient, and with resolution of the flare change to daily colchicine dosing for prophylaxis. CHRONIC ISSUES: #Hypertension Lisnopril was held when septic, but restared upon discharge. He did report a chronci cough on review of systems, which may be related to lisinopril. TRANSITIONAL ISSUES: - Needs referral to general surgeon for cholecystectomy within ___ weeks. - Continue colchicine BID until current episode resolves, then decrease to 1 tab daily thereafter. - Will continue on a prednisone taper for 10 days for pseudogout flare (see medication list for taper details). - No NSAIDs until off of steroids. - PICC line was placed and he will complete 14 days of antibiotics. He was discharged on ertapenem daily, ___ is ___. He is scheduled to see Dr. ___ in ___ clinic on ___ for determination of final antibiotic course. - Patient should see his rheumatologist Dr. ___ 2 weeks after discharge. - Full Code Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 10 mg PO DAILY 2. Indomethacin 25 mg PO DAILY Discharge Medications: 1. Lisinopril 10 mg PO DAILY 2. Colchicine 0.6 mg PO BID Once the flare has resolved, change to once a day dosing. RX colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth twice a day Disp #60 Tablet Refills:0 3. Crutches Diagnosis: pseudogout (ICD___: 712.3) Prognosis: good Length of need: 13 months 4. Vitamin D 50,000 UNIT PO 1X/WEEK (WE) Duration: 7 Weeks RX ergocalciferol (vitamin D2) 50,000 unit 1 capsule(s) by mouth every ___ for 7 weeks Disp #7 Capsule Refills:0 5. Ertapenem Sodium 1 g IV DAILY Duration: 13 Doses You will receive this at the ___. 6. PredniSONE 60 mg PO DAILY Duration: 2 Doses Start: Today - ___, First Dose: First Routine Administration Time This is dose # 1 of 4 tapered doses RX prednisone 10 mg 6 tablet(s) by mouth daily x2 days, 4 tabs daily x3 days, 2 tabs daily x3 days, 1 tab daily x3 days Disp #33 Tablet Refills:0 7. PredniSONE 40 mg PO DAILY Duration: 3 Doses Start: After 60 mg DAILY tapered dose This is dose # 2 of 4 tapered doses 8. PredniSONE 20 mg PO DAILY Duration: 3 Doses Start: After 40 mg DAILY tapered dose This is dose # 3 of 4 tapered doses 9. PredniSONE 10 mg PO DAILY Duration: 3 Doses Start: After 20 mg DAILY tapered dose This is dose # 4 of 4 tapered doses 10. Magnesium Oxide 400 mg PO DAILY RX magnesium oxide 400 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY Choledocholithiasis Acute pseudogout Hepatic abscess SECONDARY Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent, use of crutches. Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care at ___ ___. You were admitted for chills and an elevated level of alkaline phosophatase, a liver enzyme. You were found to have a stone in your bile duct. To remove the stone, you had an ERCP. You will need to have your gallbladder removed within the next few weeks, as this is the source of stones that can block the bile duct, but this can be done as an outpatient. In addition, a small liver abscess was seen on your MRI and was aspirated for testing. We did not identify a specific organism, but you will need at least 14 days total of IV antibiotics. You will receive an antibiotic called ertapenem once a day through a ___ line at the ___ here at ___. You will see the infectious disease doctors in ___ before the completion of this course of antibiotics, and they will determine if you need to remain on antibiotics longer. You will also have re-imaging of your liver at that time. Finally, you had multiple joints that became swollen. Joint aspirations were done in both of your knees, confirming that you had a pseudogout flare. The rheumatologists recommend you take short-term steroids for the pseudogout flare and continue to take colchicine (instead of indomethacin) to prevent future flares. While you are on steroids, do not take any NSAIDs (Advil, ibuprofen, indomethacin, Motrin). We ordered a few lab tests and did not find any underlying problems that would be the cause of your pseudogout. However, the rhematologists believe that due to the stress of your other health issues, the pseudogout may have spread. We found that you are Vitamin D deficient. You will take high-dose Vitmain D once a week for 7 weeks to replete your levels. You also had low magnesium, so we recommend you take a daily magnesium supplement. It is important to meet with your primary care doctor and rheumatologist to talk about this hospitalization and ensure your ongoing health. In addition, please have your doctor refer you to a general surgeon for gallbladder surgery within the next few weeks. We wish you a safe and healthy return home. Sincerely, Your ___ Team Followup Instructions: ___
10129254-DS-14	10,129,254	24,703,145	DS	14	2189-03-08 00:00:00	2189-04-10 22:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: caffeine / Dolobid / shellfish derived / sodium benzoate / Vivarin Attending: ___ Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: EGD colonoscopy History of Present Illness: ___ M with recent admission for ___ transferred from ___ due to ___ of 18 in setting of recent hospitalizations and surgeries. the patient is presenting with increased epigastric/abdominal pain ___ x 2 days. States no nausea, vomiting, fevers or chills. Passing flatus and belching but no BM in one day. No CP, SOB, or urinary symptoms. Pt received 2 L NS, morphine and dilaudid at ___ and is still expressing ___ pain. The patient was admitted ___ when he originally presented to an outside hospital with abdominal pain found to have an ischemic bowel. He has had multiple abdominal surgeries complicated by acute renal failure temporarily requiring continuous ___ hemofiltration which resolved, fungemia, and bacteremia. Procedures include the following: - Small bowel resection x 2 (___) - Cholecystecomy (___) - Right femoral dialysis catheter (___) - Endotracheal intubation - Bowel re-anastomosis, closure of abdomen - Continuous ___ hemofiltration He was then readmitted ___ for abdominal pain but tolerated his diet and was dicharged. There was concern for malingering during this hospitalization. In the ED, initial vs were: 98.0 100 149/90 16 100% RA. Labs were remarkable for WBC of 11, hct of 30 (baseline), electrolytes normal, lactate 1.0. Patient was given no medications. Surgery was consulted and recommended "admit to medicine, recommend scope from below to evaluate for evidence of ischemia, recommend scope from above to evaluate for ulcer disease, serial exams. No acute surgical issue at this time." Vitals on Transfer:95 130/89 16 99% RA Past Medical History: DM HTN HLD NSTEMI, reportedly when he was ___, he does not know if stents were placed. BPH asthma anxiety depression R thumb ORIF S/p bowel resection and exlap on ___ S/p cholecystectomy on ___ S/p exlap and reanastamosis on ___ S/p exlap and closure ___ Social History: ___ Family History: His father died of an MI. Physical Exam: ADMISSION PHYSICAL EXAM 95 130/89 16 99% RA General- Alert, orientedx3, in no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal . DISCHARGE PHYSICAL EXAM Vitals- 97.8 131/93 82 18 97RA General- Alert, orientedx3, in no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1, S2, no murmurs, rubs, gallops Abdomen- soft, mildly tender along midline, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal Pertinent Results: ADMISSION LABS ___ 03:20AM BLOOD WBC-11.0# RBC-3.78* Hgb-9.7* Hct-30.1* MCV-80* MCH-25.6* MCHC-32.2 RDW-14.8 Plt ___ ___ 03:20AM BLOOD Neuts-74.7* ___ Monos-5.4 Eos-0.1 Baso-0.4 ___ 03:20AM BLOOD ___ PTT-32.9 ___ ___ 03:20AM BLOOD Glucose-111* UreaN-10 Creat-0.9 Na-140 K-3.5 Cl-106 HCO3-26 AnGap-12 ___ 03:20AM BLOOD Albumin-2.9* Calcium-8.3* Phos-3.0 Mg-1.9 ___ 03:33AM BLOOD Lactate-1.0 DISCHARGE LABS ___ 06:00AM BLOOD WBC-4.9 RBC-3.93* Hgb-9.9* Hct-31.4* MCV-80* MCH-25.3* MCHC-31.7 RDW-14.7 Plt ___ ___ 06:00AM BLOOD Glucose-83 UreaN-7 Creat-0.9 Na-142 K-3.5 Cl-108 HCO3-26 AnGap-12 ___ 06:00AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.___BD/PELVIS W CONTRAST "Abdomen with contrast: Stable linear atelectasis in lung bases. Unremarkable lower visualized pericardium. No focal solid mass lesions in liver. Gallbladder has previously been removed. Spleen is not enlarged and unchanged splenules are seen. Head body and tail of pancreas are normal. Left and right adrenal glands are normal. No solid mass lesions in the kidneys. No hydronephrosis. Prior bowel resection with anastomotic sutures noted in left mid abdomen. No free fluid or nodes are seen in the upper abdomen. Incidental note made of replaced right hepatic artery. The extent of abnormal pathology in the terminal ileum has increased. An approximately 25 cm length of ileum now demonstrates progressive wall thickening with edema and ___ enteric stranding and fluid. No intramural gas or venous gas is seen. Multiple enlarged lymph nodes are again seen arising from this area tracking up the root of the mesentry. The remaining bowel is unremarkable. Pelvis with contrast: Loops of bowel in the pelvis are unremarkable. Pelvic solid organs unremarkable the bladder wall is normal. No free fluid is seen in the deep pelvis. No inguinal adenopathy is seen. No concerning lytic or blastic abnormalities are seen in the skeleton. An incidental lipoma is seen in the mid ascending colon. The major vessels arising from the aorta are all widely patent. No intraluminal filling defects are seen in any of the major vessels. The superior mesenteric vein is widely patent throughout its course. Likely progression ischemic change involving the terminal ileum 1 with increase in the extent length of involvement, increase in the ___ enteric inflammation and free fluid and increase in the extent of wall thickening" EGD "1. Duodenal mucosa with chronic, focally and mildly active duodenitis. 2. No neoplasm identified; no submucosa present for evaluation. Additional levels were examined." Brief Hospital Course: ___ with recent admission for ischemic colitis s/p small bowel resection and re-anastamosis ___ presented with progressively worsening abdominal pain/pressure that is continued today. # Dodenitis: Pt presents with mid-epigastirc pain, EGD ___ revealed duodenitis, suggestive of h. pylori. Biopsy was obtained and sample sent for h. pylori. Pt was started on omeprazole. # Distal and Terminal ileum ischemia - Pt presents with mid-epigastric pain. Per CT on this admission, ischemia of distal and terminal ileum was noted. Lactate was 1.0. Surgery was consulted and felt that there is no urgent indication for surgical intervention at the moment. Pt's pain remained stable and well controlled on home reigimen. Serial abdominal exam remains non-acute throughout the hospitalization. Pt will follow up with surgery as an outpatient. # HTN: Pt was continued on home doses of lisinopril and amlodipine, in place of home nebivolol, pt was treated with metoprolol. No hypertensive urgency or emergency during this hospitalization CHORNIC ISSUES # HLD: - continue home rosuvastatin # DM: Holding home metformin while hospitalized, on SSI, sugars well-controlled - Continue humalog sliding scale # anxiety/depression: - continue home celexa, buspirone, quetiapine. # asthma: - continue home flovent, albuterol Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing 2. Amlodipine 5 mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. BusPIRone 10 mg PO TID 5. Citalopram 20 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Fluticasone Propionate 110mcg 2 PUFF IH BID 8. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain 9. QUEtiapine Fumarate 50-100 mg PO QHS:PRN insomnia 10. Rosuvastatin Calcium 40 mg PO DAILY 11. Senna 1 TAB PO BID:PRN constipation 12. Acetaminophen 650 mg PO Q6H:PRN pain 13. Simethicone 120 mg PO QID:PRN bloating, abd pain 14. Bystolic (nebivolol) 10 mg Oral daily 15. Lisinopril 40 mg PO DAILY 16. MetFORMIN (Glucophage) 850 mg PO BID Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN pain RX acetaminophen 650 mg 1 tablet extended release(s) by mouth every 6 hours Disp #28 Tablet Refills:0 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheezing 3. Amlodipine 5 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. BusPIRone 10 mg PO TID 6. Citalopram 20 mg PO DAILY 7. Docusate Sodium 100 mg PO BID 8. Fluticasone Propionate 110mcg 2 PUFF IH BID 9. Lisinopril 40 mg PO DAILY 10. QUEtiapine Fumarate 50-100 mg PO QHS:PRN insomnia 11. Rosuvastatin Calcium 40 mg PO DAILY 12. Senna 1 TAB PO BID:PRN constipation 13. Simethicone 120 mg PO QID:PRN bloating, abd pain 14. Bystolic (nebivolol) 10 mg Oral daily 15. MetFORMIN (Glucophage) 850 mg PO BID 16. OxycoDONE (Immediate Release) ___ mg PO Q8H:PRN pain 17. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN breakthrough pain RX hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth every hours Disp #36 Tablet Refills:0 18. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule,delayed ___ by mouth daily Disp #30 Capsule Refills:*0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS Duodenitis Distal and Termianl ileum ischemia Secondary Diagnosis HTN HL DM anxiety/depression asthma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It has been our pleasure to take care of you. You were admitted because of your ongoing abdominal pain. We scanned you and found that parts of you bowel is lacking oxygen, which has been an ongoing issue for you. We also did a scope, and found that your stomach and part of your intestine is inflammed. We think it may be related to a bug called H. pylori, and we have started you on a medication called omeprazole to help protect your intestine. You should follow up with your primary care provider on further treatments Your surgeon does not think that there are surgeries indicated at the moment, and they will follow up with you closely as an outpatient. Followup Instructions: ___
10129815-DS-22	10,129,815	29,313,907	DS	22	2138-04-14 00:00:00	2138-04-14 09:37:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: PSYCHIATRY Allergies: Codeine / Pitocin Attending: ___. Chief Complaint: "I don't feel anything anymore I don't even bother any more..they treat everything with a pill and get me out of the way and don't even care..I developed cancer in my lungs it was removed ___ years ago I fought my way through it its just been one thing after another..I was treated with a cyberknife I fought my way through that..I'm angry ..I had a seizure recently I don't care." Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ yo cauc. female with no known previous psychiatric history (though noted by her pyschiatrist and PCP to have ___ diathesis towards mood lability/anger) until she developed intense anger and agitation in the setting of a brain tumor s/p cyberknife surgery in ___. She also developed cognitive (difficulty remembering) and behavioral changes since ___ after radiation tx. The radiation treatment caused brain swelling, which had to be treated by steroids, and the patient developed manic/paranoid symptoms. She was treated with Zyprexa, which helped, but was eventually stopped due to "fogginess" and weight gain. Her mood had reportedly been improving until about ___ weeks prior to admission, when the patient had a seizure and had to be admitted to the neuro ICU (then transferred to a SNF in ___. Since the seizure, the family has noticed that she has become increasingly anxious, negative and fatalistic, not sleeping and quite hopeless. Additionally, she times where she has "out of control" rage. The patient is currently followed psychiatrically by Dr. ___. Since her decline, she has continued to feel disempowered and rageful, especially regarding her family. The patient blames her family for "enjoying" making her helpless and feels that don't care. She said "I lose my temper and they think their life is in danger." She also notes that they "only notice her when she's upset, and think she's "good" if she's simply quiet. She said " I'm angry but I feel I have a right to be they {family} don't feel I have a right to angry." The patient said she now feels that she would have "done my whole life differently I would have not have married my current husband I thought he would be a father to my ___. and he was not.All my energy went to giving him an new life." The patient's family met with Dr. ___ the patient on ___ and they reported tht the patient reports feeling humiliated and distressed being in ___ but denies that she is suicidal.A number of alternatives were discussed including an evaluation for an inpatient psychiatric admission or possible psychiatric consult at the ___.The patient was also evaluated by Dr. ___ today who recommended medications changes and for her to be evaluated for inpatient level of care as he thought she was severely depressed. Past Medical History: PSYCHIATRIC HISTORY (INCLUDE PRIOR HOSPITALIZATIONS, OUTPATIENT TREATMENTS, MEDICATION/ECT HISTORY, RESPONSE TO TREATMENT, HISTORY OF HOMICIDAL/SUICIDAL/ASSAULTIVE BEHAVIOR): * Psychiatrist ___ @ ___ * Dr. ___ x1 ___ for consultation dx her with depression and recommended inpatient hospitalization * no prior hospitalizations, no hx of sib, sa or si * ___ psych consult ___ for behavioral and personality changes in the context of menigioma s/p cyberknife and and steroid tx * Patient has been seeing a therapist ___) for multiple years PAST MEDICAL HISTORY (INCLUDE HISTORY OF HEAD TRAUMA, SEIZURES, OR OTHER NEUROLOGIC ILLNESS): * PCP ___ @ ___ ___ * Neurologist ___ @ ___ * hx of adenocarcinoma of the lung dx ___ * hypothyroidism * ICA aneurysm * meningioma s/p cyber knife surgery * ulcerative colitis * s/p melanoma of the foot * HTN * Hyperlipdemia * anemia * hx ___ edema * diastolic dysfunction * seizure with admission to ___ ICU on ___ {MRI/MRA} at that time did not show any new growth of the meningioma Social History: ___ Family History: Daughter has borderline personality disorder and has had multiple hospitalizations Physical Exam: ROS: History of recent seizure Denied: Weakness, Numbness, Headaches, Intolerance to heat/cold, Vision changes, Hearing changes, Olfactory changes, SOB, Chest pain, Abdominal pain, N/V, Diarrhea/Constipation, Dysuria/Polyuria, Joint/Limb/Back pain, Swelling or new rashes PHYSICAL EXAMINATION: VS: BP: 160/89 HR: 91 temp: 98.4 resp: 16 O2 sat: 98 height: 5'0" weight: 158 MENTAL STATUS EXAM: --appearance: good grooming with poor eye contact --behavior/attitude: cooperative but guarded and slightly withdrawn, occasional grimace appearing slightly annoyed/frustrated/amused by questions; exhibited no PMR, PMA --speech: rate and tone slowed --mood (in patient's words): "shit" --affect: dysphoric constricted affect; congruent with stated mood --thought content (describe): perseverative on her distrust and anger, did not want to talk, no delusions or paranoia --thought process: linear --perception: without AH, VH, --SI/HI: without SI; no HI; verbalized no safety plan, did not feel safe ___ lack of trust --insight: fair to poor --judgment: poor COGNITIVE EXAM: --orientation: alert to person, place, situation, knew it was ___, but not date --attention/concentration: able to recite MOYB --memory (ball, chair, purple): registered ___, recalled ___, with cues ___ --calculations: quarters in $2.75 = 11 --language: grossly intact --fund of knowledge: ___ -> ___ -> ___ -> forget --proverbs: "cry over spilt milk," = "don't cry over things that have already happened and that you have not control over" --similarities/analogies: "apples to oranges" = fruit PE: General: Well-nourished, in no distress. HEENT: Normocephalic. PERRL, EOMI. Oropharynx clear. Neck: Supple, trachea midline. No adenopathy or thyromegaly. Back: No significant deformity, no focal tenderness. Lungs: Clear to auscultation; no crackles or wheezes. CV: Regular rate and rhythm; no murmurs/rubs/gallops Abdomen: Soft, large, nontender, nondistended; no masses or organomegaly. Extremities: No clubbing, cyanosis, or edema. Skin: Warm and dry, no rash or significant lesions. Neurological: Cranial Nerves- I: Not tested II: Pupils equally round and reactive to light bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor- Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. Sensation- Intact to light touch Pertinent Results: ___ 03:35PM URINE COLOR-Yellow APPEAR-Hazy SP ___ ___ 03:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD ___ 03:35PM URINE RBC-1 WBC-3 BACTERIA-NONE YEAST-NONE EPI-14 ___ 12:57PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG ___ 12:00PM GLUCOSE-145 UREA N-19 CREAT-1.1 SODIUM-138 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 ___ 12:00PM ALT(SGPT)-22 AST(SGOT)-18 ALK PHOS-102 TOT BILI-0.2 ___ 12:00PM ALBUMIN-4.6 CHOLEST-221* ___ 12:00PM VIT B12-747 FOLATE-15.6 ___ 12:00PM %HbA1c-6.3* eAG-134* ___ 12:00PM TRIGLYCER-133 HDL CHOL-59 CHOL/HDL-3.7 LDL(CALC)-135* ___ 12:00PM TSH-3.0 ___ 12:00PM CRP-3.2 ___ 12:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ___ 12:00PM WBC-6.8 RBC-4.08* HGB-12.3 HCT-36.7 MCV-90 MCH-30.2 MCHC-33.6 RDW-14.5 ___ 12:00PM NEUTS-86.5* LYMPHS-8.7* MONOS-4.6 EOS-0.2 BASOS-0.1 Cardiac Enzymes ___: Trop < 0.01 EKGs: ___ WITH CHEST PAIN: Sinus rhythm, normal axis, normal PR/QRS intervals, Q wave in III, equivocal Q wave in aVF, T wave inverted III, poor R wave progression. No ST elevation or depression. This EKG is essentially the same as a ___ EKG Repeat EKGs on ___ and ___ with recurrent episodes of chest pain were unchanged. CXR ___: New poorly defined right juxta-hilar opacity, possibly due to an early/focal pneumonia given clinical suspicion for pneumonia. However, recurrent malignancy is an additional consideration, particularly considering adjacent persistent enlargement and increased density of the right hilum. Management recommendation for this finding is treatment for pneumonia with short-term followup radiographs. However, as there is reportedly also a potential clinical concern for aortic dissection, an immediate chest CTA should be considered as a CXR is not sufficiently sensitive or specific for detecting or excluding this diagnosis. Chest CTA ___: 1. No aortic dissection or pulmonary embolism. 2. Stable post-surgical appearance of right upper lobectomy with associated asymmetric aeration. 3. Likely underlying small vessel and/or airway disease. 4. Unchanged scattered subpleural pulmonary nodules under 4 mm. 5. Slight increase of a small pericardial effusion. 6. Interval increase in severity of wedge deformities involving the superior endplate of T6 and inferior endplate of T5 as compared to ___. EEG ___: Abnormal EEG due to the bursts of multifocal slowing described above. They suggest multifocal subcortical dysfunction. At this age, her vascular disease is the most common explanation. Nevertheless, there were no areas of persistent focal delta slowing to suggest larger structural abnormalities. There were no clearly epileptiform features. Brief Hospital Course: The pt was admitted to psychiatry for worsening depression and affective destabilization following numerous medical problems and polypharmacy treatment. PSYCHIATRIC #) DEPRESSION Ms. ___ presented with the following depressive sx: Sadness (chronic feelings of sadness, not being herself, withdrawing from activities) Anhedonia (no interest in music/art/literature - previous hobbies once thoroughly enjoyed) Dec'd sleep (trouble falling asleep and staying asleep. early morning awakening) Feeling worthless (stating "I am nothing..a non-person") Dec'd concentration (describes not being able to follow books or even find her home at times) Passive suicidal ideation (did not feel like life was worth living and that she was only "existing" and not living) We started her on Escitalopram at 10mg and she showed some improvement. By the end of her hospitalization, Mrs. ___ was feeling more confidant about returning home. Her sadness improved to the point that she felt more hopeful about the future and looked forward to specific events. She was not suicidal and was able to gain a good night's sleep on the nights prior to her discharge. She has some fears that she will never be the person she once knew herself to be, but she is optimistic that she can go home and enjoy life. Specifically, she is looking forward to: spending time on her terrace, walking through the public garden, eating at her favorite ___, enjoying her art, and spending time with family. Mrs. ___ held some realistic apprehensions about returning home as she has not been there in a while. She was able to discuss these fears with staff and reflect on the progress she's made. She has met her CM, her psychotherapist, and her family many times in the hospital now, and she feels like she will have many supports upon return home to make the transition smoothe. We talked about increasing the Lexapro to 20mg during her hospitalization, but Mrs. ___ was opposed to this and engaged in lengthy and meaningful conversations with us about how she did not want to rely on medications to feel better. She agreed to c/w 10mg, but she wanted to wait until she had a chance to return home, enjoy some simple pleasures, and try to keep making forward progress before increasing the medication. Since her mood was improving on the unit, we respected her wish to leave the medication at its current dose. Mrs. ___ understood and agreed that if she were to revert to thoughts about life not being worth living, hopelessness for her future, extreme negetavism (anhedonia/anergia/apathy), then the medication should be increased. #) MOOD LABILITY AND DISINHIBITION While Ms. ___ mood instability and personality changes are likely ___ an underlying depression with superimposed head trauma (cyber knife surgery), her multiple medications could also be contributing. Keppra has been known to be associated with increased behavioral issues, and so it was discontinued. The neurology consult service evaluated the patient and initially recommended depakote for ease of inpatient titration, but due to patient and family preference, pt was started on lamictal for seizure prophylaxis and mood stability. The lamictal began at 25mg daily and was titrated at one week to 50mg (titration on ___ with no adverse side effects. Mrs. ___ and ___ family were advised of the risks including but not limited to ___, and they were advised to notify medical professionals immediately if a rash develops. The Lexapro was also tolerated well with no adverse effects. During her admission, Mrs. ___ was initially loud, angry, and highly disinhibited with staff and her family. She yelled insults at various people and ruminated on how life was now meaningless and how she had no future. While she was never suicidal, she talked about having no meaning, "just existing" and described herself as a "non-person." Once the keppra was stopped and meds were adjusted as above, Mrs. ___ showed quick resolve of her symptoms. She was upset with her family, whom she perceived as "blaming" her for uncharacteristic behavior. During a family meeting meeting (see below) with most of the family, however, the patient showed significant appropriate emotion and experienced a turning point in her mood and attitude. From that date forward, she was more accepting of care, worked with the treatment team, and accepted help and encouragement from her family. #) NEUROPSYCHIATRIC As a result of the neuropsychiatric changes that Ms. ___ had following her cyberknife surgery, it was recommended that she undergo some neuropsych testing to better assess her executive functioning abilities and cognition. In addition, she has described past episodes to us where she would be standing outside on ___ and feel confused, overwhelmed, and unable to find her apartment building. In addition, it is also concerning that she reports a signficant reduction in her ability to concentrate since her surgery. For example, she can no longer read or even focus on books on tape. Due to her depression which is still resolving, we decided to defer neuropsych testing to the outpatient setting. Mrs. ___ agreed to this. She and her family also shared that in the past, neuropsych testing was attempted (around ___ s/p cyberknife) but the patient had been unable to tolerate the lengthy evaluation. GENERAL MEDICAL CONDITIONS #) CHEST PAIN On the unit, Ms. ___ CP that radiated to her back x 2 days. We w/u 2 sets of cardiac enzymes (all negative) and EKGs were reassuring for no acute infarction. She also had a CXR which revealed: New poorly defined right juxta-hilar opacity, possibly due to an early/focal pneumonia given clinical suspicion for pneumonia. However, recurrent malignancy is an additional consideration, particularly considering adjacent persistent enlargement and increased density of the right hilum. In follow-up to this, we did a CT-Chest and CTA to r/o aortic dissection/PE/effusions/new mass. CTA - Chest findings: IMPRESSION: 1. No aortic dissection or pulmonary embolism. 2. Stable post-surgical appearance of right upper lobectomy with associated asymmetric aeration. 3. Likely underlying small vessel and/or airway disease. 4. Unchanged scattered subpleural pulmonary nodules under 4 mm. 5. Slight increase of a small pericardial effusion. 6. Interval increase in severity of wedge deformities involving the superior endplate of T6 and inferior endplate of T5 as compared to ___. Basically, imaging findings yielded no concerning acute changes. Internal medicine consulted and followed the patient closely during her hospitalization. Over the course of the hospitalization, Ms. ___ had several episodes of recurrent chest pain with stable EKG's and negative cardiac biomarkers. She had some relief with NTG 0.4mg SL. Medicine recommended stress testing on outpatient due to her multiple risk factors for cardiac disease and to give nitroglycerin as needed for intermittent chest pain. They ultimately opined that the pain was likely ___ musculoskeletal causes and degenerative changes to her bones and spine. #) HYPOTHYROIDISM/HTN/HYPERCHOLESTEROLEMIA/GERD Mrs. ___ was continued on her home medications and had no acute exacerbations of these conditions. #) SEIZURE Due to her recent seizure, and worsened mood/increased behavioral changes after her seizure in ___, consulted neurology to help with management. Goal was to taper off Keppra, as it is associated with mood changes/behavioral dysregulation, and initiate a different anti-convulsant/mood stabilizer. Neurology consultation reviewed records from ___ and while no epileptic activity was seen. She had an EEG (20 minute) completed at ___ which likewise captured no electrical abnormalities. Neurology recommended initiating the Lamictal and they will f/u on an outpt basis with Mrs. ___. The patient was seizure free in the hospital. #) CONSULTS -Internal Medicine - as above -Neurology - as above -Occupational Therapy - assessed home safety on ___ and determined no imminent safety risks, although it's recommended that a home safety evaluation occur -Physical Therapy - reviewed pt on ___ and cleared for d/c to home with no acute ___ needs. -Neuropsychology - determined that pt would benefit from assessment as outpatient once depression lifts more. She is scheduled for futher testing on ___. PSYCHOSOCIAL #) FAMILY MEETINGS -The first family meeting was held on the date of the pt's admission with her daughter, ___. ___ expressed concerns about how her mother has gradually deteriorated since her cyberknife surgery in ___. She expressed a great deal of affect and confusion over how to best care for her mother. The team provided supportive interventions and decided to assign a point person to keep daily contact with the family to keep them updated on the pt's progress and team recommendations. Although the family are highly stressed, they were very thankful for team's input and care of the pt. #) TEAM MEETINGS -An interdisciplinary team meeting was held with the following people on ___: ___ (daughter), ___ (unlicensed Psychotherapist), ___ (psychiatrist) and ___ MD, HMSIII, LICSW, and RN CM. Mrs. ___ sat through the entire meeting, but she was angry and upset during it. She expressed ambivalence about her care and had a very bleak outlook for her future. -Another meeting was held with ___ moderating the family's visit on ___. This meeting lasted for > 3 hours and was significant for marking a turning point in the patient's outlook and mood. During the meeting she visited ___ her husband, ___, and daughters, ___ and ___. Mrs. ___ was not angry, but she did express some of her discontent with being placed on the psychiatric unit. By the end of the meeting, she was embracing her children and husband, and she shared how scared she has felt. Mrs. ___ also revealed during that meeting that she never fully understood what the meningioma/adenocarcinoma meant (incl path results) and she shared that she worried she was terminal from those illnesses and facing death at any moment. She was greatly relieved to have some clarity on the status of her health. From that meeting forward, she readily accepted her family's visits and showed great improvements in her mood. -The team met with the Geriatric CM that the family hired, ___, to discuss d/c planning and the pt's status. Mrs. ___ was involved in this meeting and enjoyed meeting the CM. She felt comfortable with her and optimistic that this plan would be helpful to her healthy living in the environment. LEGAL STATUS The pt remained on a CV throughout the duration of her hospitalization. RISK ASSESSMENT Mrs. ___ has experienced a substantial depressive episode and has some increased risk for self-harm, but at this time that risk is determined to be low. Non-modifiable risk factors incl; race, age, multiple medical problems and her husband's own advancing age ___ yo) and declining health. She has also suffered an insult to her frontal lobe from the meningioma and cyberknife tx that occurred in ___ which can impair her judgment and behavior at times. In her favor, Mrs. ___ has a very supportive family, is feeling less depressed now, and has no suicidal thoughts/intent/behaviors. She is complying with medication recommendations which will protect her from future depressive episodes, and she is hopeful for her future. Although she has many medical co-morbidities, she has extensive wrap-around care that has been arranged at ___ to maximize her healthcare, and she also will have the support of a ___ and a full-time geriatric case ___. She will also continue to receive support from her long-time psychotherapist, who has agreed to visit the patient's home 3x/week for therapy. Mrs. ___ is sober from illicit substances/etoh, and she has good premorbid functioning with a very high level of education, many accomplishments, varied interests in culture, and she practices daily excersizes including yoga, meditation, walking and swimming, which are all protective to her mental health. Mrs. ___ is aware of her supports and how to contact them in the event that her depression worsens or she has any thoughts of harming herself. Mrs. ___ currently has a fair prognosis. She will continue to struggle with narcissistic injuries as her age progresses and she requires ongoing medical care for her comorbidities. She also is at considerable risk for having continued outbursts and disinhibition due to her frontal lobe injury. However, consistency in care and ample wrap-around supports will contribute to her improvements and fair prognosis. At this time, the least restrictive setting of care is the outpatient setting. Medications on Admission: -ATORVASTATIN 10 mg Tablet PO daily -FUROSEMIDE 20 mg Tablet 1 to 2 Tabs PO daily -HYDROCORTISONE 100 mg/60 mL Enema one Enema(s) PR BID -LEVOTHYROXINE 112 mcg PO daily -METOPROLOL SUCCINATE ER 25 mg PO daily -OMEPRAZOLE Delayed Release 20 mg PO daily -SULFASALAZINE - 500 mg Tablet - two Tablet(s) PO BID -VALSARTAN 160 mg Tablet PO daily -KEPRRA 500mg bid recently started @ ___ -ASCORBIC ACID 1,000 mg Tablet PO daily -CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 600 + D(3)] 600 mg calcium-200 unit Capsule - 1 Capsule(s) PO BID, 2 hours after other meds -LACTOBACILLUS ACIDOPHILUS PO BID (not in pharmacy) -MULTIVITAMIN-MINERALS-LUTEIN [CENTRUM SILVER] PO daily -POTASSIUM CHLORIDE 40mEQ daily Discharge Medications: 1. LaMOTrigine 50 mg PO DAILY 2. Levothyroxine Sodium 112 mcg PO DAILY 3. Metoprolol Succinate XL 25 mg PO DAILY 4. Multivitamins 1 TAB PO DAILY 5. Nitroglycerin SL 0.4 mg SL PRN Chest Pain Give one dose now, can repeat x 2 PRN every 5 minutes 6. Omeprazole 20 mg PO DAILY 7. SulfaSALAzine_ 1000 mg PO BID with breakfast and dinner 8. Valsartan 160 mg PO DAILY 9. Vitamin D 200 UNIT PO BID 2 hrs after other meds with calcium carbonate 10. Ascorbic Acid ___ mg PO DAILY 11. Atorvastatin 10 mg PO DAILY 12. Calcium Carbonate 1500 mg PO BID 2 hrs after other meds with Vit D 13. Escitalopram Oxalate 10 mg PO DAILY 14. Furosemide 20 mg PO DAILY MRx1 if pt requests Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Depression secondary to a ___ medical condition Discharge Condition: Stable Pt is well appearing. She is in no acute distress, smiling, cordial, and has no abnormal movements. Pt is mobilizing around the unit without problem. Her mood is 'better' and she is showing a bright and reactive affect. Thought process and content are linear and devoid of any substantial deficits. She has no suicidal or homicidal thoughts and is showing signs of future orientation including excitement about returning home. The patient's speech is soft, and she is alert and oriented. There is improving insight and judgment Discharge Instructions: -Please follow up with all outpatient appointments as listed - take this discharge paperwork to your appointments. -Please continue all medications as directed. -Please avoid abusing alcohol and any drugs--whether prescription drugs or illegal drugs--as this can further worsen your medical and psychiatric illnesses. -Please contact your outpatient psychiatrist or other providers if you have any concerns. -Please call ___ or go to your nearest emergency room if you feel unsafe in any way and are unable to immediately reach your health care providers. It was a pleasure to have worked with you, and we wish you the best of health. Followup Instructions: ___
10130010-DS-6	10,130,010	24,810,808	DS	6	2170-09-23 00:00:00	2170-09-23 13:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: R ankle pain Major Surgical or Invasive Procedure: Right ankle ex-fix, ___, ___ History of Present Illness: ___ year-old male, healthy, who suffered a fall from approximately 12 feet height injuring his right lower extremity. Patient works in ___ and was at the top of a ladder when he fell from 12 feet striking his right lower extremity on the ground. He denies head strike or loss of consciousness. He denies trauma or injury elsewhere. He presents with deformity and pain at the distal right tibia and fibula. X-rays obtained at outside hospital are revealing for comminuted distal tibia-fibula fracture. Patient was noted to have small area of skin dimpling on the medial side of the right ankle on presentation. Vital signs stable upon arrival. ___ 15 Patient denies numbness, tingling, weakness, head strike, LOC, or other injuries --- denies back, hip, knee pain. Past Medical History: H pylori Social History: ___ Family History: non-contributory Physical Exam: AVSS General: No acute distress RLE: Ex-fix pins with dressings clean dry and intact Fires ___ SILT throughout foot WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a right pilon fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for external fixator application, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the right lower extremity, and will be discharged on enoxaparin for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation 3. Docusate Sodium 100 mg PO BID 4. Enoxaparin Sodium 40 mg SC QHS RX enoxaparin 40 mg/0.4 mL 40 mg sc q4h prn Disp #27 Syringe Refills:0 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX oxycodone 5 mg ___ tablet(s) by mouth q4h prn Disp #24 Tablet Refills:0 6. Senna 8.6 mg PO BID 7. TraZODone 50 mg PO QHS:PRN Insomnia 8. Vitamin D 1000 UNIT PO DAILY 9. Pantoprazole 40 mg PO Q24H Discharge Disposition: Home Discharge Diagnosis: Right pilon 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: -Nonweightbearing right lower extremity oxycodone oxycodone in ex fix 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 enoxaparin 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. 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 Pin Site Care Instructions for Patient and ___: For patients discharged with external fixators in place, the initial dressing may have Xeroform wrapped at the pin site with surrounding gauze. Often, the Xeroform is used in the immediate post-op phase to allow for control of the bleeding. The Xeroform can be removed ___ days after surgery. If the pin sites are clean and dry, keep them open to air. If they are still draining slightly, cover with clean dry gauze until draining stops. If they need to be cleaned, use ___ strength Hydrogen Peroxide with a Q-tip to the site. Call your surgeon's office with any questions. THIS PATIENT IS EXPECTED TO REQUIRE ___ DAYS OF REHAB Physical Therapy: NWB RLE Treatments Frequency: Pin Site Care Instructions for Patient and ___: For patients discharged with external fixators in place, the initial dressing may have Xeroform wrapped at the pin site with surrounding gauze. Often, the Xeroform is used in the immediate post-op phase to allow for control of the bleeding. The Xeroform can be removed ___ days after surgery. If the pin sites are clean and dry, keep them open to air. If they are still draining slightly, cover with clean dry gauze until draining stops. If they need to be cleaned, use ___ strength Hydrogen Peroxide with a Q-tip to the site. Call your surgeon's office with any questions. Followup Instructions: ___
10130111-DS-17	10,130,111	27,485,248	DS	17	2157-08-21 00:00:00	2157-08-21 16:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: cerebellar stroke Major Surgical or Invasive Procedure: ___ PEG tube placement History of Present Illness: ___ with PMHx of multiple cardiac stents placed several years ago on no medications woke up at 5am this am with nausea + vomiting. He felt dizzy and ill all day (vx3). At 3pm, he noticed that the left side of his face was numb. He is unsure if this was an acute change or if he just happened to notice it at that time. At 6pm, his wife came home and realized that he was doing poorly so she called EMS. He was transported to ___. CT there showed old left BG infarct. He exam is unknown but he was transferred to ___ question brainstem infarction. Neurology was consulted for management of acute stoke. He has never had any symptoms of acute neurological deficits in the past. On neuro ROS, (+) vertical diplopia (+) left sided facial droop, (+) dysarthria, (+) left sided weakness, (+) left sided hearing loss, (+) drowsy. The pt denies headache, loss of vision, blurred vision, diplopia, dysphagia, lightheadedness, tinnitus. Denies difficulties comprehending speech. No bowel or bladder incontinence or retention. On general review of systems, (+) N/V that has since resolved, (+) intermittent chest pain. the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: Cardiac stents placed at ___ several years ago. He thinks that he was on plavix afterwards. No recent medical follow up. Social History: ___ Family History: - mom: early ___ - dad: died at ___ from MI - Brothers: 1. ___, died after stroke with severe disability; 2. 58 ___ 3. 50, healthy - Sister: ___, lung and breast ca Physical Exam: ADMISSION GENERAL EXAM: - Vitals: 98.2 61 138/88 14 97%RA - General: Cooperative, drowsy - HEENT: NC/AT - Neck: Supple, no carotid bruits appreciated. No nuchal rigidity - Pulmonary: CTABL - Cardiac: RRR, no murmurs - Abdomen: soft, nontender, nondistended - Extremities: no edema, pulses palpated - Skin: no rashes or lesions noted. NEURO EXAM: - Mental Status: Drowsy, oriented to day, month, year, thinks he is at ___ but easily corrected. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. Speech dysarthric. Able to follow both midline and appendicular commands. - Cranial Nerves: R pupil 5->3 brisk, L pupil 3->2 brisk, VFF to confrontation. EOMI with left rotational nystagmus, horizontal nystagmus to the right, vertical nystagmus on up and down gaze. Decreased BTT on the left. Facial sensation intact to light touch. Left facial droop. reports decreased hearing on the left. Decreased tongue protrusion strength in cheek on the left. Absent gag on the left. - Motor: Normal bulk and tone throughout. Left arm raise with pronation. No adventitious movements such as tremor or asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 5- 4+ ___- 5 4+ 5- 5- 5 5 4 R 5 ___ ___ 5 5 5 5 5 4 - Sensory: Decreased sensation of light touch on the left arm/leg. No extinction to DSS. - DTRs: Bi Tri ___ Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was extensor on the right, mute on the left - Coordination: Left ataxia on FNF and HKS bilaterally. DISCHARGE PHYSICAL EXAM Mental Status: alert, awake, speech dysarthric but fluent. Cranial Nerve: pt with complete left facial weakness with incomplete eye closure and significant facial droop. Mild conjunctival erythema on left eye. Significant nystagmus with eye movements, worse when looking to left compared to right gaze; vertical nystagmus on upgaze/downgaze. Patient has left ___ nerve palsy and complains of double vision when looking to left. Motor: on confrontational testing, strength is full throughout. Coordination: ataxia on left arm/leg; rebound with arm tapping. Gait: deferred. Pertinent Results: ___ 11:00PM BLOOD WBC-12.5* RBC-4.73 Hgb-14.0 Hct-43.2 MCV-91 MCH-29.5 MCHC-32.3 RDW-14.1 Plt ___ ___ 11:00PM BLOOD Neuts-78.3* Lymphs-15.7* Monos-5.4 Eos-0.5 Baso-0.1 ___ 11:00PM BLOOD ___ PTT-26.6 ___ ___ 11:00PM BLOOD Glucose-152* UreaN-17 Creat-0.9 Na-142 K-3.8 Cl-108 HCO3-24 AnGap-14 ___ 04:43AM BLOOD ALT-17 AST-12 LD(LDH)-171 AlkPhos-65 TotBili-0.4 ___ 11:00PM BLOOD CK-MB-3 cTropnT-0.05* ___ 04:43AM BLOOD CK-MB-3 cTropnT-0.04* Stroke Labs: Cholest-189 Triglyc-119 HDL-37 CHOL/HD-5.1 LDLcalc-128 %HbA1c-6.4* eAG-137* TSH-0.64 Tox Screen: ASA-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG IMAGING: ___ CTH 1. Stable appearance of the large left cerebellar infarct with stable mass effect on the fourth ventricle, brainstem, and quadrigeminal plate cistern. 2. Stable size of the supratentorial ventricles. 3. Due to artifacts through the posterior fossa on the current and prior studies, punctate microhemorrhages in the left cerebellar infarcts are difficult to exclude. ___ CTH 1. No significant interval change in the known left cerebellar infarct since ___. 2. No evidence of obstruction. ___ CTH 1. Stable appearance of the acute infarct of the left cerebellum, with unchanged degree of mass effect on the adjacent brainstem. 2. No evidence of hemorrhagic conversion. 3. Stable size and configuration of the ventricles, with persistent ex vacuo dilatation of the frontal horn of the left lateral ventricle. ___ CT Head: chronic left BG infarct, new left cerebellar infarct CTA: decreased flow through the basilar artery, possible occlusion of the left vertebral artery. MRI/MRA: 1. Extensive area of subacute ischemia is re- demonstrated on the left cerebellar hemisphere, involving the left middle cerebellar peduncles, with no evidence of hemorrhagic transformation. 2. Chronic areas of ischemia are identified in the area of the left caudate nucleus, causing ex vacuo dilatation of the left frontal ventricular horn, with susceptibility changes suggesting chronic hemorrhagic changes. 3. Severe segmental narrowing of the basilar artery with almost complete occlusion. There is also diffuse narrowing with areas of stenosis and post stenotic dilatation throughout the circle of ___, likely consistent with severe arteriosclerotic disease. 4. Arteriosclerotic disease is identified at the cervical carotid bifurcations, more severe on the left, causing significant stenosis at the origin of the left external carotid artery and moderate narrowing at the origin of the left internal carotid artery. Cardiac Imaging: TTE ___: Top normal left ventricular cavity size with regional systolic dysfunction most c/w multivessel CAD with apical mural THROMBUS. Moderate pulmonary artery systolic hypertension. Dilated thoracic aorta. CXR ___: In comparison with the study of ___, there again is mild asymmetry of opacification at the right base. Again, this most likely represents atelectatic change, though in the appropriate clinical setting superimposed pneumonia could be considered. No evidence of vascular congestion or pleural effusion. Video Swallow ___: Aspiration of nectar thick consistency with trace aspiration of honey consistency. Brief Hospital Course: TRANSITIONAL ISSUES =================== -INR on discharge was 2.8. Discharged on 4mg warfarin. Please continue to monitor INR and adjust warfarin as necessary. -Pt should continue on combined ASA and warfarin therapy per cardiology recommendations, until further instruction. -Pt should follow-up with scheduled outpatient cardiology after rehab for continued monitoring of depressed EF and intracardiac thrombus. He will also receive a scheduled TTE at this time for interval assessment of cardiac function. -Pt is being treated for UTI with cefpodoxime until ___. -Strict NPO until further swallow evaluation -Pt was orthostatic and free water flushes through PEG tube have been increased. ___ increase water flushes prn until improvement. ******************* ___ yo man with PMHx of multiple cardiac stents placed several years ago but otherwise minimal medical follow up on no medications woke up with nausea + vomiting found to have an acute cerebellar infarct on CT. On admission, he had progressing decreased level of consciousness, nystagmus in all directions (rotational with left gaze), multiple cranial nerve findings, and left sided weakness. # NEURO: He was found to have left cerebellar and brainstem infarct. Given the location and concern for swelling, he was monitored in ICU and was started on hyperosmolar therapy for worsening neurologic examination. His exam improved and stabilized. He was found to have an intracardiac mural thrombus and was started on therapeutic heparin gtt with plans to transition to coumadin. MRA (___) of head and neck confirms left cerebellar and brainstem subacute infarct and left carotid arteriosclerosis. He failed formal swallow evaluation as well as video swallow on two occassions. An NG tube was placed multiple times, but secondary to delirium he pulled out his NG tube as well as IV lines. He was made NPO and ultimately underwent PEG placement on ___. Pt has also been started on risk factor modification medications for HTN, HLD. # PSYCH: Hyperactive delirium Pt displayed agitation at nighttime pulling on IV lines and PEG tube concerning for hyperactive delirium. Psychiatry was consulted and recommended initiation of trazodone with prn olanzapine during the day. He did well on this combination of medications without further episodes of agitation. His QTc was monitored as it was prolonged (last EKG showing QTc of 447 on ___. # CV: intramural thrombus, CAD Patient was found to have intracardiac mural thrombus and was started on therapeutic heparin which was transitioned to lvoenox and coumadin. Lovenox was stopped when his INR became therapeutic. Cardiology recommended continuing aspirin and coumadin given his significant CAD history. He is set up with cardiology appointment at ___, with plans for repeat echocardiogram to evaluate the intramural thrombus. Further decisions regarding anticoagulation should be made at that time. # ID: Patient had leukocytosis but no fevers, infectious work up showed UTI. He is being treated with cefpodoxime x7 days, course to finish on ___. # Nutrition: patient is strict NPO at this time given silent aspiration. He will need further swallow therapy and repeat evaluation. He is tolerating bolus feeding through PEG tube without difficulty. Medications on Admission: none Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Acute acute left sided cerebellar/brainstem infarct Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were hospitalized due to symptoms of weakness and decreased level of consciousness resulting from an ACUTE ISCHEMIC STROKE, a condition in which a blood vessel providing oxygen and nutrients to the brain is blocked by a clot. Damage to the brain from being deprived of its blood supply can result in a variety of symptoms. Stroke can have many different causes, so we assessed you for medical conditions that might raise your risk of having stroke. In order to prevent future strokes, we plan to modify those risk factors. Your risk factors are: -Intracardiac thrombus -Hypertension -Atherosclerosis We are changing your medications as follows: -Started: Atorvastatin 80 qd, Aspirin 81mg qd, Lisinopril 5mg qd, Metoprolol 12.5mg bid, Warfarin 5mg qd Please take your other medications as prescribed. Please followup with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - sudden partial or complete loss of vision - sudden loss of the ability to speak words from your mouth - sudden loss of the ability to understand others speaking to you - sudden weakness of one side of the body - sudden drooping of one side of the face - sudden loss of sensation of one side of the body - sudden difficulty pronouncing words (slurring of speech) - sudden blurring or doubling of vision - sudden onset of vertigo (sensation of your environment spinning around you) - sudden clumsiness of the arm and leg on one side or sudden tendency to fall to one side (left or right) - sudden severe headache accompanied by the inability to stay awake It was a pleasure providing you with care during this hospitalization. Followup Instructions: ___
10130348-DS-21	10,130,348	24,286,651	DS	21	2197-05-29 00:00:00	2197-05-29 17:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Codeine / Erythromycin Base / lisinopril Attending: ___ Chief Complaint: Dyspnea on Exertion, Missed STEMI Major Surgical or Invasive Procedure: Left Cardiac Catheterization and ___ in mid-distal LAD History of Present Illness: Ms. ___ is a ___ with PMH of CKD, HTN, recurrent UTI's, who presents with shortness of breath and fatigue on exertion x 2 days. 3 days prior to presentation, patient was playing the slots at ___, sitting down, asymptomatic. She got up from sitting and noticed she'd become acutely short of breath when walking. Denied any chest pain or pressure, indigestion, nausea, vomiting, diaphoresis, dizziness, palpitations. Noted only DOE and significant fatiue with exertion. Patient felt at baseline at rest. After 2 days of symptoms, patient began to worry that symptoms could be a sign of something more serious and so called ___ at 2am. She was recommended to go to the ED. Denies fever/chills, cough, ___ swelling. Has seen Dr. ___ previously in consultation for mild-moderate AS. . In the ED, initial vitals were 98.6 89 136/85 20 100%. ECG showed RBBB with TWI in V2-V3 (c/w prior), STE in V3-V5. Labs and imaging significant for trop 0.84, BNP 9735, Cr 2.2 (baseline Cr 2.1-2.5). UA suggestive of possible UTI. Exam was notable for guaiac negative. Patient given heparin gtt, plavix, ASA, and transferred to cath lab. In cath lab, 80% stenosis of mid-distal LAD noted and was stented with 1 ___. ECG s/p cath unchanged from admission ECG. . On arrival to the floor, patient is comfortable, lying flat, without complaints. Past Medical History: 1. CARDIAC RISK FACTORS: -Diabetes, -Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: - Nephrostomy tubes, bilateral (placed ___ - Neurogenic bladder - Pyocystis - Chronic renal insufficiency (baseline 2.1-2.5) - Mild-moderate aortic stenosis - h/o frequent UTIs - Hypertension - Squamous cell carcinoma of the vagina, s/p vaginal XRT ___, s/p vaginectomy ___ - carpal tunnel disorder, b/l, s/p bilateral correction - s/p TAH-BSO/fibroids ___ - s/p bunionectomy - right knee replacement Social History: ___ Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Denies CVA, DM, HTN, HL. Physical Exam: Admission Exam: VS: 98.6, 125/76, 84, 16, 98%RA GENERAL: WDWN elderly F in NAD. Oriented x3, pleasant. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP not elevated. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. ___ systolic murmur loudest at RUSB and LUSB. No 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, minimal crackles at bases posteriorly, no wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. Bilateral nephrostomy tubes draining clear yellow urine. No tenderness or erythema at exit sites. GROIN: c/d/i right groin without erthema or tenderness. EXTREMITIES: No c/c/e. 2+ pulses of DP and ___ b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. Discharge Exam: 98.6, 96/53 (96-138/53-77), 65 (60-80s), 18, 96%RA GENERAL: WDWN elderly F in NAD. Oriented x3, pleasant, sharp. Mood, affect appropriate. NECK: Supple with JVP not elevated. CARDIAC: RR, normal S1, S2. ___ systolic murmur loudest at RUSB and LUSB. No r/g. LUNGS: CTAB, no rales, wheezes or rhonchi. ABDOMEN: Soft, NTND. Bilateral nephrostomy tubes draining clear yellow urine. No tenderness or erythema at exit sites. GROIN: c/d/i dressing over right groin without erthema or tenderness. EXTREMITIES: No c/c/e. 2+ pulses of DP and ___ b/l Pertinent Results: Admission Labs: ___ 07:30AM BLOOD WBC-5.1 RBC-3.75* Hgb-10.3* Hct-32.8* MCV-88 MCH-27.4 MCHC-31.3 RDW-16.2* Plt ___ ___ 07:30AM BLOOD Neuts-65.7 ___ Monos-4.1 Eos-2.7 Baso-0.7 ___ 08:08AM BLOOD ___ PTT-33.6 ___ ___ 07:30AM BLOOD Glucose-105* UreaN-43* Creat-2.2* Na-141 K-3.6 Cl-104 HCO3-23 AnGap-18 ___ 06:15PM BLOOD CK(CPK)-176 ___ 07:30AM BLOOD CK-MB-8 proBNP-9735* ___ 07:30AM BLOOD cTropnT-0.84* ___ 03:30PM BLOOD CK-MB-6 Cardiac Enzymes/BNP: ___ 07:30AM BLOOD CK-MB-8 proBNP-9735* ___ 07:30AM BLOOD cTropnT-0.84* ___ 03:30PM BLOOD CK-MB-6 ___ 06:15PM BLOOD CK-MB-6 cTropnT-0.76* ___ 06:45AM BLOOD CK-MB-5 cTropnT-0.71* Pertinent Labs: ___ 07:30AM BLOOD Cholest-229* ___ 07:30AM BLOOD Triglyc-131 HDL-49 CHOL/HD-4.7 LDLcalc-154* ___ 07:30AM BLOOD %HbA1c-5.7 eAG-117 Left nephrostomy tube: ___ 07:45AM URINE Color-Straw Appear-Hazy Sp ___ ___ 07:45AM URINE Blood-SM Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 07:45AM URINE RBC-5* WBC-88* Bacteri-FEW Yeast-OCC Epi-0 Right nephrostomy tube: ___ 07:45AM URINE Color-Straw Appear-Clear Sp ___ ___ 07:45AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG ___ 07:45AM URINE RBC-2 WBC-52* Bacteri-FEW Yeast-FEW Epi-<1 Discharge Labs: ___ 06:45AM BLOOD WBC-5.0 RBC-3.27* Hgb-9.0* Hct-29.0* MCV-89 MCH-27.5 MCHC-31.0 RDW-16.2* Plt ___ ___ 06:45AM BLOOD ___ PTT-59.7* ___ ___ 06:45AM BLOOD Glucose-94 UreaN-42* Creat-2.4* Na-142 K-4.6 Cl-108 HCO3-24 AnGap-15 ___ 06:45AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.1 Imaging: ___ Cardiac Catheterization: PRELIMINARY REPORT ___ COMMENTS: Initial angiography showed a 80% distal LAD stenosis. Given elevated troponin, DOE and ECG changes, we elected to proceed with PCI. Heparin was continued with a therapeutic ACT. A ___ XB LAD guiding catheter provided adequate support for the procedure. A Prowater wire crossed the lesion with minimal difficulty. The lesion was dilated with a 2.0x12mm Apex OTW balloon at 8 atms. A 2.5x16mm Promus Element ___ was deployed in distal LAD at 12 atms. The proximal and mid ___ segments were postdilated with a 2.5x8 mm NC Quantum apex balloon at ___ atms. Final angiography showed no residual stenosis, no angiographically apparent dissection and TIMI 3 flow. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 1 hour 8 minutes. Arterial time = 0 hour 57 minutes. Fluoro time = 14.8 minutes. Effective Equivalent Dose Index (mGy) = 1757 mGy. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 200 ml Premedications: ASA 325 mg P.O. Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin 2500 units IV Other medication: Lidocaine 10cc sq Nicardipine 200mcg ic Nitroglycerin 600mcg ic Cardiac Cath Supplies Used: - ALLEGIANCE, CUSTOM STERILE PACK - MERIT, LEFT HEART KIT COMMENTS: 1. Selective coronary angiography of this co-dominant system revealed 3 vessel CAD. The LM was very short, almost non-existant. The LAD had mild plaquing throughout with ___ proximally and 80% taper in mid to distal vessel; no substantive diagonal branches noted and no cut-off points were appreciated. The LCx was a large vesel with mild plaquing proxiamlly; the AV groove LCX has up to 30% in mid vessel and gives a small LPDA; the OM1 is a large bifurcating vessel with lots of tortuosity; it has 30% ostial and 60% at the bifurcation segment of its upper pole (this lesion extends into the branches originating from this bifurcation); the lower pole of OM1 has no angiographic abnormalities; the OM2 is a smaller vessel without obstructive disease. The RCA is a smaller vessel with 50-60% mid-lesion. 2. Limited resting hemodynamics revealed normal systemic arterial pressure of 138/75mmHg. 3. Successful PTCA and stenting of distal LAD with 2.5x16mm Promus Element drug eluting ___ postdilated proximally and mid with 2.5mm NC balloon. 4. Successful closure of right femoral arteritomy with ___ Exoseal closure device. FINAL DIAGNOSIS: 1. Three vessel CAD (moderate in LCx and RCA and severe in LAD). 2. Succesful PCI of LAD with DES. 3. Succesful closure of the RCFA with ExoSeal closure device. 4. IV fluids to maintain urine output >100cc/hr. 5. Aspirin 325mg daily minimum of 3 months then 162mg daily indefinetly and Clopidogrel (Plavix) 75mg daily starting tomorrow for a minimum of 12 months. 6. F/U as outpatient with Dr. ___ in 4 weeks. 7. Get TTE. 8. Set up for symptoms-limited non-imaging treadmill stress test as outpatient in preperation for cardiac rehab. ___ CXR: The lungs are clear without consolidation or edema. There is no pneumothorax of pleural effusion. The previously seen lingular pneumonia has resolved. The cardiomediastinal silhouette is normal. The osseous structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. ___ ECHO: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild to moderate regional left ventricular systolic dysfunction with akinesis of the distal third of the left ventricle with apical dyskinesis/aneurysm. The remaining segments contract well (LVEF 40%). The estimated cardiac index is high (>4.0L/min/m2). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta and aortic arch are mildly dilated. The descending thoracic aorta is mildly dilated. The abdominal aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is minimal aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is mild mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. CONCLUSIONS: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction and apical aneurysm c/w CAD (mid LAD distribution). Mild aortic valve stenosis. Mild pulmonary hypertension. Dilated thoracic aorta. Increased PCWP. Compared with the prior study (images reviewed) of ___ the regional LV systolic dysfunction is new and c/w interim ischemia/infarction. ___ Admission ECG: Sinus rhythm. Indeterminate axis. Right bundle-branch block. There is ST segment elevation in leads I, aVL and V3-V6. Consider extensive lateral myocardial infarction. Clinical correlation is suggested. Since the previous tracing of ___ right bundle-branch block, indeterminate axis and anterolateral ST segment elevation is now new. Clinical correlation is suggested. TRACING #1 Read by: ___. Intervals Axes Rate PR QRS QT/QTc P QRS T 90 ___ 75 0 42 ___ post cath ECG: Sinus rhythm. Q waves with ST segment elevation in leads I, II, aVL, aVF and leads V4-V6. Compared to tracing #2 probably no significant change. Clinical correlation is suggested. TRACING #3 Read by: ___. Intervals Axes Rate PR QRS QT/QTc P QRS T 89 ___ 85 138 59 ___ ECG: Sinus rhythm. Borderline P-R interval prolongation. Since the previous tracing the rate is slower. Q waves and ST segment elevations persist consisent with transmural lateral and inferior myocardial infarction. Clinical correlation is suggested. TRACING #4 Read by: ___. Intervals Axes Rate PR QRS QT/QTc P QRS T 73 ___ 70 0 41 Brief Hospital Course: Ms. ___ is a ___ with PMH of CKD, HTN, recurrent UTI's, who presented with shortness of breath and fatigue on exertion x 2 days found to have a missed STEMI with 80% stenosis of mid-distal LAD, now s/p ___, being discharged on coumadin for resultant left ventricular aneurysm. . # STEMI/Left Ventricular Aneurysm: Patient came in for DOE and was noted to have a missed STEMI with elevations most significantly in I, II, and V4-V6 indicating anterior or antiolateral infarction. Troponins 0.84, which presumably had trended down from the acute event several days prior. Patient had leftsided cardiac catheterization which showed 80% stenosis of mid-distal LAD with ___. Cath report indicated no residual stenosis, but did not comment on post intervention flow. No lesions of the diagonal branch noted. ECG s/p cath was unchanged from admission ECG, with persisent ST elevations in above mentioned leads. Heparin ggt was started given persistent ECG changes. Troponins trended down. Left ventricular aneurysm was noted on subsequent cardiac echo. Patient was started on warfarin 3mg daily and discharged with cardiology and ___ ___ clinic follow up. Plan for at least 3 months of anticoagulation to prevent thrombus formation and embolic stroke. Patient noted a history of retinal hemmorhage of the left eye ___ years prior. Risks and benefits of anticoagulation were discussed and it was decided that the patient would continue to warfarin managment for 3 months. Patient was additionally medically managed with metoprolol, atorvastatin (LDL 154), ASA 325, plavix 75. Unfortunately, Ms. ___ was unable to tolerate lisinopril (has significant diarrhea with ACEI and ARBs, see below). HbgA1c 5.7%. . # PUMP: BNP on admission was 9735, patient appeared clinically euvolemic during the admission. Echo showed an EF of 40%, with moderate regional LV dysfunction. She was started on metoprolol 12.5mg BID. Unfortunately, she does not tolerate ACEI or ARBs (see above). . # Chronic kidney disease: baseline Cr 2.1-2.5. Despite IV contrast during cardiac catheterization, patient's creatinine remained within her baseline during the admission. She was given post-cath hydration for a day. On discharge, her creatinine was 2.4. . # Recurrent UTI's/Ptocystitis/nephrostomy tubes: Pt with nephrostomy tubes and known pyocystis. Ms. ___ has had several episodes of UTIs with severe dysuria and pelvic pain associated with production of a small volume of foul-smelling, cloudy urine. This admission UA was positive, however patient denied such symptoms, so antibioitics were deferred. She is followed by urology for this. She had a straight catheterization this admission with ciprofloxacin 500mg PO once given prior to the procedure. . # HTN: Blood pressures this admission were well managed on the following regimen: chlorthalidone 12.5mg daily, spironolactone 12.5 daily, metoprolol tartrate 12.5 BID. Her home nifedipine 60 mg ER BID was stopped with the addition of the beta blocker. On discharge, metoprolol was converted to succinate 25mg daily. Briefly lisinopril was administered, however the patient developed significant diarrhea, so this was discontinued. She has a history of diarrhea with ACEI and ARBs previously. . # Mild-moderate Aortic stenosis: Echo this admission showed valve area of 2.0cm2, peak velocity of 2.3m/sec, peak gradient 21, mean gradient 11. This issue was not actively addressed during this admission. . Transitional Issues: CODE: Full Code EMERGENCY CONTACT: Daughter ___, ___ Patient has been set up with Post Discharge Primary Care follow up and will be followed by ___ clinic. She additionally has cardiology follow up with Dr. ___. She will likely need a repeat echo in ___ to assess for improvement in wall kinesis and for reevaluation of LV aneurysm. Patient will be anticoagulated for atleast 3 months to prevent aneurysmal clot formation. Ms. ___ is concerned about developing another retinal hemmorhage on anticoagulation, and would like to take warfarin for as short a time as possible. Medications on Admission: calcitriol 0.25 mcg Capsule 1 Capsule(s) 3x/week MWF chlorthalidone 25 mg Tablet 0.5 (One half) Tablet(s) by mouth daily nifedipine 60 mg Tablet Extended Rel 24 hr BID spironolactone 25 mg Tablet 0.5 (One half) Tablet(s) Qday acetaminophen [Tylenol Arthritis] aspirin 325 mg Tablet daily cholecalciferol (vitamin D3) [Vitamin D3] lactobacillus rhamnosus GG [Probiotic] omega-3 fatty acids-vitamin E [Fish Oil] Discharge Medications: 1. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO Three times a week: Take on ___. 2. chlorthalidone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Tylenol Arthritis 650 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO every eight (8) hours as needed for pain. 5. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 7. lactobacillus rhamnosus GG Oral 8. omega-3 fatty acids-vitamin E Oral 9. metoprolol succinate 25 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 10. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 11. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:30 Tablet(s) Refills:2 12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: Take as directed by the anticoagulation nurses at ___. Disp:30 Tablet(s) Refills:2 13. Outpatient Lab Work ___ Blood work: Draw INR and fax results to "The ___ ___ clinic" and Dr. ___ at ___, Fax# ___. ICD9 code: ______) Aneurysm of heart (wall) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis: ST-elevation Myocardial Infarction, Left Ventricular Wall aneurysm Secondary: Chronic Kidney Disease Hypertension Hyperlipidemia Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because you had a heart attack. A heart attack is when one of the arteries in your heart becomes blocked. You underwent a cardiac catheterization, a procedure that looks at the arteries in your heart. During the catheterization, we found a blockage in one of the arteries in your heart, which we opened with a ___. In order to prevent any complication with the ___, you will need to take Plavix, a medication to prevent blood clots, every day for the next year. It is also important that you take aspirin 325mg daily for at least the next 3 months. After that, your cardiologist may instruct you to decrease it to 162mg daily. We did an echocardiogram of your heart which showed that your heart is not pumping as well as it used to. We started you on lisinopril, a medication that will help maintain your heart function. However you had significant diarrhea, and so we are unable to continue this medication. The echocardiogram also showed that you have an aneurysm in your heart muscle, which increases your risk for blood clots. We started you on warfarin (coumadin), a medication to prevent blood clots. Warfarin also increases your risk for bleeding. You will need to follow-up with your doctor on ___ regular basis to monitor your warfarin. Talk to your doctor if you experience fatigue, chest pain, shortness of breath, weight gain, palpitations. The following changes have been made to you home medication regimen: START Warfarin 2.5mg daily by mouth START Clopidogrel 75mg daily by mouth START Metoprolol Succinate 25mg daily by mouth START Atorvastatin 80mg daily by mouth STOP Nifedipine 60 mg Tablet Extended Rel 24 hr twice daily Please make sure to have your labs drawn in the morning at ___ on ___. The results will be faxed to your PCP's office and you will be contacted by them in the event that your warfarin dose needs to be changed. Followup Instructions: ___
10130573-DS-6	10,130,573	25,964,565	DS	6	2138-03-06 00:00:00	2138-03-19 22:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: seizures, concern for status epilepticus Major Surgical or Invasive Procedure: Intubation and subsequent extubation History of Present Illness: HPI: Ms ___ is a ___ year old right handed woman with a history of seizures, leukodystrophy, dementia, feeding tube, presenting as a transfer from ___ for status epilepticus. This history was taken over the phone from her Daughter; ___ ___. She lives at home with her and the patients husband who are her primary care givers. She is bedbound at baseline with quadraparesis with prominent rightsided weakness. This morning she was scheduled to see ___ today to have G tube replace at 3 pm. This morning she had a questionable small seizure with non responsiveness and quivering of her lips but it was short lived. Daughter; felt she had a low grade temp and a mild cough, but no overt illness. On the way to ___ she went into a generalized tonic clonic seizure at 2:30 pm with was refractory to 5 mg of ativan, she was intubated at 3:30 for airway protection and was given a paralytic so it was unclear if she was still seizing. They got a head ct and transferred her to ___ for further management. lidocaine 70 mg IV x ___ Fentanyl 120 mcg IV x 1 Rocuronium 36 mg IV x 1 Propofol gtt 10 mg / kg/ min Zosyn 3.375 g IV x 1 sq As far as her seizure history, they have been fairly well controlled on Dilantin, with her lat seizure being months ago. They are often generalized and recover her to come to the emergency room. Seizure began around the beginning of her mental decline and discovery of her leukodystrophy back in ___, she did have one seizure requiring intubation at that time. Regarding her Leukodystrophy, she had genetic testing at ___ and ___ ___, she was tested for common for leukodystrophies and "they all came up negative." But cognitive decline started in ___ with slurred speech and weakness on one side, and wasn't sure if it was MS or strokes and then had as seizure, has continued to decline and has been bedbound for about ___ years. Currently, her neurologic baseline is that she has some movement of limbs, weaker on right side; does move a little bit, but not much, she fidgets a lot with her hands, rips blankets off and tips. Her Primary Contacts: Lives Daughter: ___ ___ Husband: ___ ___ Past Medical History: 1. Cerebral leukodystrophy described above 2. Seizure disorder. 3. COPD, history of CO2 retention. 4. Depression. 5. Status post NCR. 6. Recurrent UTIs. 7. Chronic dysphagia and history of aspiration pneumonias PSH: Status post right hip fracture and status post ORIF, ORIF for right ankle fracture. Social History: ___ Family History: She is adopted, no family history is available Physical Exam: Physical Exam on Admission: Vitals: T: 98.1 P:72 R:12 BP:126/72 SaO2:100% General: intubated HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, Pulmonary: Lungs CTA Cardiac: RRR Abdomen: soft, NT/ND, Extremities:cold feet bilaterally Skin: no rashes or lesions noted. . Neurologic: -Mental Status: obtunded grimaces to noxious no eye opening. -Cranial Nerves: PERRL 3 to 2mm and brisk, + brisk corneals bilaterally, + gag, face symmetric -Motor: withdraws left side to noxious, intermittent rhytmic shaking of the left arm. -___ throughout Physical Exam on Transfer: General: awake and alert, NAD HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple Pulmonary: Lungs CTA Cardiac: RRR Abdomen: soft, NT/ND Extremities: no edema Skin: no rashes or lesions noted. . Neurologic: -Mental Status: Awake and alert, able to state name and answer a few simple questions, follows basic commands. -Cranial Nerves: PERRL, EOMI with limited rightward gaze, ?partial INO, VFF, R facial droop. -Motor: Quadriparetic, weaker on R. Able to lift b/l arms anti-gravity and wiggles toes b/l. -DTRs: ___ throughout. L toe down, R toe up. Physical Exam on Discharge: ???????????? Pertinent Results: ___ 06:45PM WBC-17.7* RBC-4.18* HGB-14.0 HCT-41.5 MCV-99* MCH-33.5* MCHC-33.7 RDW-12.3 ___ 06:45PM NEUTS-91.6* LYMPHS-5.0* MONOS-3.0 EOS-0.2 BASOS-0.2 ___ 06:45PM PLT COUNT-229 ___ 06:45PM GLUCOSE-126* UREA N-17 CREAT-0.4 SODIUM-136 POTASSIUM-4.1 CHLORIDE-98 TOTAL CO2-25 ANION GAP-17 ___ 06:45PM estGFR-Using this ___ 07:00PM LACTATE-2.7* ___ 07:48PM O2 SAT-98 ___ 07:48PM LACTATE-1.6 ___ 07:48PM TYPE-ART RATES-16/ TIDAL VOL-450 PEEP-5 O2-100 O2 FLOW-7 PO2-366* PCO2-35 PH-7.50* TOTAL CO2-28 BASE XS-4 AADO2-314 REQ O2-58 -ASSIST/CON INTUBATED-INTUBATED ___ 11:04PM URINE MUCOUS-RARE ___ 11:04PM URINE RBC-103* WBC-7* BACTERIA-NONE YEAST-NONE EPI-1 ___ 11:04PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR ___ 11:04PM URINE COLOR-Yellow APPEAR-Clear SP ___ CT head ___: IMPRESSION: No acute intracranial process. Severe chronic small vessel disease and atrophy. CXR ___: FINDINGS: AP portable supine chest radiograph obtained. The endotracheal tube is seen with its tip residing approximately 3.4 cm above the carina. The NG tube courses into the left upper abdomen. Contrast is seen within large bowel loops in the right upper quadrant. Linear areas of plate-like atelectasis in the right and left lower lungs are noted. There is no large consolidation or signs of CHF. No definite pneumothorax is present. The heart and mediastinal contours appear grossly unremarkable aside from atherosclerotic calcifications of the aortic knob. No definite displaced rib fractures are seen. IMPRESSION: Appropriately positioned endotracheal and nasogastric tubes. CXR ___: FINDINGS: As compared to the previous radiograph, the endotracheal tube and the nasogastric tube are in unchanged position. There is unchanged mild elevation of the right hemidiaphragm. The pre-existing right basal atelectasis is improved. Retrocardiac atelectasis is unchanged. Unchanged size of the cardiac silhouette. No newly appeared focal parenchymal opacities. Brief Hospital Course: ___ right handed woman with a history of seizures, leukodystrophy, dementia, and G tube placement who presented as a transfer from ___ for status epilepticus. She had a GTC yesterday afternoon which was refractory to 5mg of ativan and was subsequently intubated and paralyzed. Head CT showed severe chronic small vessel disease and atrophy but no acute intracranial process. Upon transfer she was continuing to have some intermittent rhythmic movements of the left hand. She was admitted to the neuro ICU for close monitoring. ICU and Hospital course: #Neuro: She was continued on her home Dilantin as well as a propofol drip overnight and had no further evidence of seizure activity. She was maintained on continuous EEG monitoring which showed L sided slowing with polymorphic delta compared with R sided theta but no epileptiform activity. She was extubated in the am of ___ and quickly returned to her baseline, able to answer simple questions appropriately and follow basic commands. Dilantin level was 15.4. She received an extra 200mg dilantin on ___ and her home dose was increased to 100mgQAM/200QPM 5x/wk rather than 4x/wk, with 100mg BID 2x/wk. Etiology of her seizure is somewhat unclear at this point. Infectious w/u has been negative thus far; it is possible she could have had an underlying low grade viral URI given her recent hx of cough. Labs unremarkable except for leukocytosis which is now downtrending. The patient was transferred to the floor in good condition. The patient was extubated the day after admission and did well over the weekend, however on ___ the patient spiked a temp and was found to have a white count of 19 (see below). She began having more seizures that responded acutely to ativan. She was frequently somnolent following the seizures - which had a unique semiology, including rather purposeful picking at covers and items real and imagined on her bed, waving her hand in the air as if being attacked by flies, and looking off into the corner of the room, often up and to the left. She received several boluses of Dilantin and her dose was increased to 300 mg total daily. A steady level was difficult to obtain and she was switched to infatabs that could be crushed and administered via g-tube. The patient tolerated this transition well with improved level. Her medications and seizures were discussed with her daughter and husband who care for her, as well as her primary doctor who has been managing her dilantin. Plan was made to continue at 300 mg total daily with plans to recheck the level in the week following discharge. The patient did generally well through the rest of her hospitalization with a single seizure the day prior to discharge for which she received an extra dose of dilantin with a level up to 14.4 on discharge. # Infectious disease: She initially had some low grade fevers with a Tmax of 100.3. UA and CXR were unremarkable. Blood cultures were negative. She was continued on her home Bactrim for chronic UTI. On transfer to the floor she became more somnolent related in part to being post-ictal and also due to a new fever up to 103, as well as an elevated WBC count and inflammatory markers. A CXR revealed bilateral aspiration pneumonias, likely related to her seizures. These were treated with empiric antibiotics with significant clinical improvement withing 36 hours. A PICC line was placed and Cefepime and Vanco were coursed conitnued for 4 more days following discharge (~ 10 day course). # FEN/GI: She was maintained NPO as at baseline does not take anything by mouth. She received her medications and tube feeds via her PEG. Her temporary PEG tube was replaced by ___ aas it had fallen out the week prior and was due to be replaced as an outpatient. A foley had been placed there temporarily. The patient tolerated the new tube well. # Cardiovascular: She was maintained on telemetry monitoring. She was continued on her home antihypertensives. # Pulmonary: She was successfully extubated on ___ and remained stable from a respiratory standpoint. CXR was clear. Subsequent aspiration PNA as above. #CODE: full confirmed with family Contact: Lives w/ Daughter: ___ ___ Husband: ___ ___ The patient was discharged home in improved condition with ___ and a plan to complete her antibiotic course, continue on dilantin and follow-up with her primary doctor. Medications on Admission: 1. metoprolol 25 mg twice daily 2. vitamin B12 tablet 1000 mcg daily 3. alendronate 70 mg every ___ 4. doxepin 25 mg q.p.m. 5. Advair Diskus one inhalation twice daily 6. Methenamine hippurate 500 mg twice daily 7. Paroxetine 10 mg every morning 8. Dilantin liquid ___ mg q am and MWF takes 100 mg in the evening, T,TH, F, ___ 200 in the evening. 9. Ranitidine 300 mg at bedtime 10. Spiriva one inhalation daily. levocarnitine, Discharge Medications: 1. Alendronate Sodium 70 mg PO QFRI 2. CefePIME 1 g IV Q12H RX cefepime 1 gram twice a day Disp #8 Each Refills:0 3. Phenytoin Infatab 100 mg PO QAM Start now, Crushed tabs. RX Dilantin Infatabs 50 mg twice a day Disp #180 Each Refills:4 4. Tiotropium Bromide 1 CAP IH DAILY 5. Vancomycin 1000 mg IV Q 12H Duration: 5 Days RX vancomycin 1 gram twice a day Disp #8 Each Refills:0 6. Docusate Sodium 100 mg PO BID 7. Doxepin HCl 25 mg PO HS 8. Paroxetine 10 mg PO DAILY 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 10. Cyanocobalamin 1000 mcg PO DAILY 11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation 12. Metoprolol Tartrate 25 mg PO BID hold for SBP < 100, HR < 60 13. Outpatient Lab Work Please draw Dilantin level prior to one of her scheduled doses to get a trough level (prior to pulling PICC line). Send results to PCP, ___, ___, fax ___. 14. Lorazepam ___ mg PO Q4H:PRN seizures RX lorazepam 1 mg q1 hr as needed Disp #12 Each Refills:1 15. Phenytoin Infatab 200 mg PO QPM Crushed tabs via G-tube Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: 1. Status epilepticus, 2. Leukodystrophy Discharge Condition: Mental Status: Confused. Level of Consciousness: Alert and interactive, perseverative, intermittently follows commands. Activity Status: Out of Bed with assistance to chair or wheelchair. Neuro: Mental status as above, intermixed appropriate and inappropriate responses to questions, pseudobulbar. CNs intact. Strength is at least antigravity and against some resistance in all extremities, left greater than right. Discharge Instructions: Ms. ___ was admitted to ___ on ___ after a prolonged seizure. She was initially admitted to the ICU,, requiring a mechanical respirations while her seizures came under control. She was transferred to the floor and had another seizure and subsequently developed bilateral aspiration pneumonias. She was treated with IV antibiotics and her Dilantin was increased. A large IV was placed for her to get medicine at home and her G-tube was replaced. Because we had trouble maintaining an accurate level with her Dilantin we switched to the infatabs and increased her dose to 100 mg in the morning and 200 mg in the evening every day. Her level the morning of discharge was 11.2 and she was given an extra 200 mg, which should bring her level up above 15. Next week she should follow up with her primary doctor and get a level drawn. The Visiting nurses who will remove her PICC line may be able to do this for you. Followup Instructions: ___
10130585-DS-2	10,130,585	27,470,349	DS	2	2151-01-04 00:00:00	2151-01-04 13:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: SOB Major Surgical or Invasive Procedure: US guided Liver biopsy ___ 4 units PRBC transfusion ___ History of Present Illness: ___ w/ poor medical follow up presents with leg swelling and SOB. 30lb weight loss since ___ also with night sweats and generalized weakness. Prior to this was active, biking daily. Now unable to shovel drive way or walk up his 3 flights of stairs at home. Several weeks of leg swelling, scrotal swelling progressively worse. SOB on exertion, none at rest. Also with abd bloating, distension, anorexia for 1 weeks, gas pains. Has not seen a doctor in ___ years. No colonoscopy In ED pt found to be severely anemic (Hgb 4) with elevated LFTs. GI consulted, no emergent need to scope. Started PPI gtt. Transfused 1unit. Vitals prior to transfer:98.5 102 124/67 20 99%ra Currently, pt has no acute complaints. ROS: per HPI, denies fever, chills, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: none (patient has not seen MD in ___ years) patient's sister reports he has years of severe, untreated depression Social History: ___ Family History: mom colon ca ___ (in her ___ father parkinsons GM ___ Physical Exam: VS: 98.3 119/71 94 18 100%ra PAIN: 0 GENERAL: cachetic, NAD, comfortable, appropriate HEENT: NC/AT, sclerae pale, MMM, OP clear LAD: no cervical, axillary or inguinal adenopathy HEART: regular, tachycardic, nl S1-S2, no MRG LUNGS: CTAB, good air movement, resp unlabored, no accessory muscle use ABDOMEN: NABS, soft, distended, firm palpable liver edge in mid abd, diffusely tender to deep palpation, rebound/guarding EXTREMITIES: 3+ pitting edema to abdomen, 2+ peripheral pulses (radials, DPs) SKIN: no rashes or lesions NEURO: awake, alert, follows commands Pertinent Results: ___ 05:15PM GLUCOSE-137* UREA N-23* CREAT-0.9 SODIUM-139 POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-19* ANION GAP-18 ___ 05:15PM ALT(SGPT)-99* AST(SGOT)-160* ___ ALK PHOS-642* TOT BILI-2.5* DIR BILI-1.9* INDIR BIL-0.6 ___ 05:15PM LIPASE-41 ___ 05:15PM cTropnT-<0.01 ___ 05:15PM proBNP-222* ___ 05:15PM ALBUMIN-3.2* ___ 05:15PM WBC-12.8* RBC-2.43* HGB-4.1* HCT-16.7* MCV-69* MCH-16.8* MCHC-24.5* RDW-21.8* ___ 05:15PM NEUTS-87* BANDS-0 LYMPHS-4* MONOS-6 EOS-1 BASOS-2 ___ MYELOS-0 NUC RBCS-1* ___ 05:15PM PLT SMR-NORMAL PLT COUNT-404 ___ 05:15PM ___ PTT-29.4 ___ TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are structurally normal. 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: Normal global and regional biventricular systolic function. Normal diastolic function. Mild mitral regurgitation. CT TORSO: 1. Marked hepatomegaly secondary to multiple enhancing masses. In the setting of apparent focal narrowing of the distal third of the descending colon, metastatic colon cancer could be a consideration in addition to other metastases or HCC. A liver biopsy is recommended for more definitive diagnosis, and colonoscopy could be considered pending initial pathology results. 2. Moderate pelvic ascites. Trace intra-abdominal ascites. 3. No intrathoracic metastases detected. Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct ___ 06:15 13.8* 3.42* 7.8* 26.8* 78* 22.6* 28.9* 22.2* 241 Pathology Examination Name ___ Age Sex Pathology # ___ MRN# ___ ___ ___ Male ___ ___ Report to: ___. ___ ___ by: ___. ___ SPECIMEN SUBMITTED: LIVER CORE BX (1 JAR) Procedure date Tissue received Report Date Diagnosed by ___ ___. ___ DIAGNOSIS: Liver, needle core biopsy (A): Metastatic adenocarcinoma, morphologically consistent with colonic origin. No residual liver parenchyma is seen. Immunohistochemical stains will be reported in an addendum. Clinical: ___ year old male, multiple liver lesions, rule out malignancy. ___: The specimen is received in one formalin-filled container, labeled with the patient's name, ___ and the medical record number. It consists of multiple pale white tissue cores measuring up to 1.0 cm in length x 0.1 cm in diameter, entirely submitted in cassette A. Brief Hospital Course: ___ w/ no medical care x ___ years presents with liver mets, profound anemia, hepatomegaly, B symptoms. 1. Metastatic malignancy to Liver: CT torso with multiple enhancing masses, concerning for malignancy. Hep B and C serologies negative. US guided biopsy on ___ revealed initial findings suggestive of colon etiology. Because this would be Stage IV colon cancer, he did not warrant colonoscopy as per GI team. Oncology was made aware, and suggested outpatient follow up next week with further treatment decisions as per pathology results. I reviewed CT films with ___ team who did not feel there was anything amenable to mechanical decompression 9no biliary dilation). Obstructive labs due to diffuse liver tumor burden. 2. Profound Microcytic Anemia: Components of chronic disease, iron deficiency and chronic blood loss. Transfused four units of PRBCs on ___ with improvement of Hgb from 4.1 to 7.6 and symptomatic improvement. GI consulted. Given guaic positive stools, family history of colon cancer and area of colonic thickening seen on CT torso, concern for metastatic colon cancer. HCT remained stable. he was started on PPI and iron. # Peripheral Edema: Severe. Multifactorial in the setting of ___ malnutrition and mechanical compression from massive hepatomegaly. UA not suggestive of nephrotic syndrome. TTE without heart failure. Started lasix diuresis on ___, but this was later discontinued. # CODE STATUS: Full # Communication: Family and patient aware of diagnosis. ONC transitional care issues addressed, f/u appointment made. New PCP updated, too. Family aware of and already getting appropriate colon cancer screening. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. This patient is not taking any preadmission medications Discharge Medications: 1. Ferrous Sulfate 325 mg PO DAILY RX ferrous sulfate [Iron (ferrous sulfate)] 325 mg (65 mg iron) 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Omeprazole 40 mg PO DAILY RX omeprazole 40 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:0 Discharge Disposition: Home Discharge Diagnosis: Malingnant neoplasm -- likely colon Metastasis to liver Iron deficiency anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with weight loss, painless jaundice, severe anemia and multiple masses in your liver. You received blood transfusion. Initial liver mass biopsy results suggests findings consistent with metastatic colon cancer. You were seen by the GI team, and will need to follow up with GI Oncology. A treatment plan will be made according to final pathology results. Followup Instructions: ___
10130751-DS-15	10,130,751	20,254,619	DS	15	2156-04-29 00:00:00	2156-04-30 13:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Celexa / meperidine / citalopram Attending: ___. Chief Complaint: fever Major Surgical or Invasive Procedure: n/a History of Present Illness: HISTORY OF PRESENT ILLNESS: Ms. ___ is a ___ history of HTN, HLD, asthma, IBS, chronic neck and back pain, presenting with fever, productive cough, and shortness of breath. Patient states that over the last 2 days she noticed new fevers measured T104 at home that have been persistent, in addition to worsening fatigue, dry cough and shortness of breath. Also with nausea with 3 episodes of non-bloody emesis that started last night. She has also had 8 episodes of watery diarrhea that started day of admission. Given her symptoms she has had very poor PO intake. States the last time she ate food was on ___ and only has been having a couple glasses of water a day, admits that she has not been drinking enough water. She subsequently presented to her PCP ___ ___ where she was given 1L NS and albuterol nebulizer. She had CXR performed that was normal. Her rapid influenza test was negative however given suspicion for influenza she was started on Tamiflu. She was also previously seen on ___ with URI type symptoms and dry cough and was treated for bronchitis with prednisone and amoxicillin of which she completed a 7 day course. She states that her symptoms completely went away after treatment for bronchitis, however is now experiencing the above symptoms over the last several days. She also recently travelled to ___ from ___ in ___. She was not sick during this trip and did not have any symptoms including diarrhea shortly after her return. She denies any myalgias or arthralgias. Currently no other URI type symptoms no sore throat, congestion or rhinorrhea. No sick contacts. In the ED: Initial vital signs were notable for: T 103 HR 76 BP 130/68 RR 22 O2 92%RA Exam notable for: Gen: appears uncomfortable HEENT: PERRL, no photosensitivity CV: RRR, no m/r/g Pulm: CTAB, no w/r/r Abd: soft, tender to palpation in epigastrium and RUQ, voluntary guarding, no rebound Back: no CVA tenderness Extr: wwp Skin: no visible rash Labs were notable for: - WBC 15.2 with 87.8% neutrophils, Hb 11.6, PLT 338 - Na 137, K 2.9, Cl 92, bicarb 23, BUN 10, Cr 1.3, glucose 139, AG 22 - Ca 9.1, Mg 1.8, P 1.2 - AST 107, other LFTs normal - Lactate 1.2 - Flu negative - UA: Small blood, 100 protein, ketone 40, few bacteria Studies performed include: CXR: Patchy opacity projecting over the right lower lung, which could reflect aspiration or pneumonia in the appropriate clinical setting. RUQUS: No evidence of cholelithiasis or acute cholecystitis. Patient was given: ___ 02:18 PO Acetaminophen 1000 mg ___ 02:55 IVF LR ___ 02:55 IH Ipratropium-Albuterol ___ 05:04 PO Potassium Chloride 40 mEq O ___ 05:43 PO Doxycycline Hyclate 100 mg ___ 06:34 IV CefTRIAXone ___ 06:40 IVF D5NS + 40 mEq Potassium Chloride ___ Started 250 mL/hr ___ 10:21 IH Albuterol 0.083% Neb Soln 1 NEB ___ 10:31 PO Acetaminophen 1000 mg ___ 12:28 PO/NG Neutra-Phos 2 PKT ___ 14:14 NEB Ipratropium-Albuterol Neb 1 NEB ___ 15:07 IV Potassium Phosphate 30 mmol ___ 16:12 PO Potassium Chloride 40 mEq ___ 16:13 PO/NG OxyCODONE (Immediate Release) 5 mg ___ 16:13 PO/NG Acetaminophen 650 mg ___ 16:13 PO/NG OSELTAMivir 75 mg ___ 16:15 IV Ondansetron 4 mg ___ 18:44 IV Ketorolac 15 mg ___ 18:45 PO/NG Ranitidine 150 mg ___ 19:05 PO Ibuprofen ___ 19:05 IVF 40 mEq Potassium Chloride / D5NS Started 150 mL/hr ___ 19:20 PO Doxycycline Hyclate 100 mg Consults: None Vitals on transfer: T 98.8 HR 89, BP 128/77 RR 18 O2 96% RA Subjective: Upon arrival to the floor, patient confirms the above. Mainly confirms that she has had persistent (not cyclical fever), diffuse weakness, dry cough, and shortness of breath with difficulty breathing. Denies any chest pain or shortness of breath with exertion. Has some slight nausea, although no emesis since last night. Continuing to have watery diarrhea 8 episodes so far today. No urinary symptoms. Past Medical History: HTN Asthma Social History: ___ Family History: HTN, CA, Lung disease Physical Exam: ADMISSION PHYSICAL EXAM: VITALS: ___ Temp: 98.8 PO BP: 128/77 L Lying HR: 89 RR: 18 O2 sat: 96% O2 delivery: 18 Gen: Comfortable, tired appearing HEENT: NC/AT, PERRL, EOMI Lungs: RLL rales, otherwise clear no wheezes or rhonchi CV: RRR, no m/r/g Abd: Soft, NT/ND. Normoactive bowel sounds Ext: Warm. 2+ peripheral pulses no c/c/e Neuro: CN II-XII grossly intact, no focal neurological deficits Skin: No skin lesions DISCHARGE PHYSICAL EXAM: VITALS:98.2 bp 128 / 82 hr: 78 rr: 18 o2 SAT:97% on room air Gen: Comfortable HEENT: NC/AT, PERRL, EOMI Lungs: CTAB CV: RRR, no m/r/g Abd: Soft, NT/ND. Normoactive bowel sounds Ext: Warm. 2+ peripheral pulses no c/c/e Neuro: CN II-XII grossly intact, no focal neurological deficits Skin: No skin lesions Pertinent Results: ADMISSION LABS =============== ___ 02:00AM BLOOD WBC-15.2* RBC-4.18 Hgb-11.6 Hct-34.0 MCV-81* MCH-27.8 MCHC-34.1 RDW-13.2 RDWSD-39.1 Plt ___ ___ 02:00AM BLOOD Neuts-87.8* Lymphs-6.6* Monos-4.7* Eos-0.0* Baso-0.2 Im ___ AbsNeut-13.32* AbsLymp-1.00* AbsMono-0.71 AbsEos-0.00* AbsBaso-0.03 ___ 02:00AM BLOOD ___ PTT-35.4 ___ ___ 02:35AM BLOOD Glucose-139* UreaN-10 Creat-1.3* Na-137 K-2.9* Cl-92* HCO3-23 AnGap-22* ___ 02:35AM BLOOD ALT-34 AST-107* AlkPhos-98 TotBili-1.2 ___ 02:35AM BLOOD Albumin-3.9 Calcium-9.1 Phos-1.2* Mg-1.8 ___ 07:58PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG ___ 07:58PM BLOOD HCV Ab-NEG DISCHARGE LABS ================ ___ 06:05AM BLOOD WBC-7.9 RBC-3.72* Hgb-10.1* Hct-31.0* MCV-83 MCH-27.2 MCHC-32.6 RDW-13.5 RDWSD-41.1 Plt ___ ___ 07:40AM BLOOD Neuts-70.3 Lymphs-18.9* Monos-7.5 Eos-1.5 Baso-0.2 Im ___ AbsNeut-5.70 AbsLymp-1.53 AbsMono-0.61 AbsEos-0.12 AbsBaso-0.02 ___ 06:05AM BLOOD Plt ___ ___ 06:05AM BLOOD ___ PTT-35.9 ___ ___ 06:05AM BLOOD Glucose-96 UreaN-9 Creat-0.8 Na-141 K-4.2 Cl-102 HCO3-25 AnGap-14 ___ 06:05AM BLOOD ALT-64* AST-243* AlkPhos-128* TotBili-0.4 PERTINENT IMAGING ================= CXR: Patchy opacity projecting over the right lower lung, which could reflect aspiration or pneumonia in the appropriate clinical setting. RUQUS: No evidence of cholelithiasis or acute cholecystitis. Brief Hospital Course: Ms. ___ is a ___ history of HTN, HLD, asthma, IBS, chronic neck and back pain, presenting with fever, productive cough, and shortness of breath, and diarrhea found to have RLL consolidation on CXR. Urine legionella POSITIVE, so treating with high dose azithromycin IV (stopped ceftriaxone) TRANSITIONAL ISSUES: =================== [] follow up LFT's, were elevated upon discharge as can occur with legionella clinical course [] holding statin given elevated LFT's, may consider restarting once they normalize ACUTE ISSUES: ============= #Legionella pneumonia #Hypoxia respiratory failure Several days high-spiking fever measured T 104 at home with fatigue, dry cough, and shortness of breath and n/v, diarrhea. CXR showing RLL opacification and urine Legionella (+) consistent with Legionella PNA. Possibly contracted while on trip to ___. Treated with azithromycin which was subsequently changed to levofloxacin for 2 week total course (day ___, last day ___, guaifenesin, Tessalon perles #Pleuritic chest pain Midsubsternal, most likely from frequent cough and PNA. EKG nonischemic. #Diarrhea Had loose watery stools up to 8/day which improved with azithromycin course. Most likely from Legionella. C. diff negative #AST elevation Perhaps ___ Legionella. RUQUS normal. CHRONIC/RESOLVED ISSUES: ======================== ___ (resolved) - Baseline Cr 0.9-1.1. Presented with Cr 1.3, likely pre-renal as resolved with IVF. #Poor nutrition: resolved #Coagulopathy - resolved elevated INR Likely from vitamin K deficiency from poor PO intake, improved with vit K #HTN : Held home atenolol, lisinopril and chlorthalidone given ___, volume down, and with underlying infection #HLD Held home pravastatin given transaminitis #Vitamin D deficiency: Continued home vitamin D #Chronic Pain Has chronic neck and back pain, continued home oxycodone PRN Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Potassium Chloride 20 mEq PO BID 2. OSELTAMivir 75 mg PO Q12H 3. ValACYclovir 500 mg PO Q24H 4. Lisinopril 10 mg PO DAILY 5. Pravastatin 40 mg PO QPM 6. oxyCODONE-acetaminophen ___ mg oral Q6H:PRN pain 7. atenolol-chlorthalidone 100-25 mg oral DAILY 8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 9. Qvar RediHaler (beclomethasone dipropionate) 80 mcg/actuation inhalation BID 10. Cetirizine 10 mg PO DAILY 11. Vitamin D 1000 UNIT PO DAILY 12. Multivitamins 1 TAB PO DAILY Discharge Medications: 1. GuaiFENesin ER 600 mg PO Q12H RX guaifenesin 200 mg 3 tablet(s) by mouth every twelve (12) hours Disp #30 Tablet Refills:0 2. LevoFLOXacin 750 mg PO Q24H Please continue to take this antibiotic until ___ RX levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #9 Tablet Refills:0 3. atenolol-chlorthalidone 100-25 mg oral DAILY 4. Cetirizine 10 mg PO DAILY 5. Lisinopril 10 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. oxyCODONE-acetaminophen ___ mg oral Q6H:PRN pain 8. Potassium Chloride 20 mEq PO BID Hold for K > 9. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q6H:PRN 10. Qvar RediHaler (beclomethasone dipropionate) 80 mcg/actuation inhalation BID 11. ValACYclovir 500 mg PO Q24H 12. Vitamin D 1000 UNIT PO DAILY 13. HELD- Pravastatin 40 mg PO QPM This medication was held. Do not restart Pravastatin until instructed by your doctor 14.Outpatient Lab Work A48.1 Please check LFTs (AST, ALT, ALP, Tbili) on ___. Fax results to ___ attn: ___, MD Discharge Disposition: Home Discharge Diagnosis: legionella Discharge Condition: good Discharge Instructions: Dear ___, ___ was a privilege taking care of you at ___ ___. WHY WAS I ADMITTED TO THE HOSPITAL? =================================== - You were admitted because you were having cough and fevers WHAT HAPPENED WHILE I WAS IN THE HOSPITAL? ========================================== - We treated you for an infection that you tested positive for, called Legionella, with antibiotics. WHAT SHOULD I DO AFTER I LEAVE THE HOSPITAL? ============================================ - Please continue to take all your medications and follow up with your doctors at your ___ appointments. We wish you all the best! Sincerely, Your ___ Care Team Followup Instructions: ___
10131237-DS-14	10,131,237	23,193,728	DS	14	2123-05-01 00:00:00	2123-05-02 15:42:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: doxycycline Attending: ___ Chief Complaint: fevers Major Surgical or Invasive Procedure: none History of Present Illness: ___ with hx of angioimmunoblastic T-cell lymphoma presenting on C2D16 of CHOEP-14 who presented to clinic yesterday with Dr. ___ f/u where he complained of R groin pain. CT scan demonstrated R inguinal hernia with fat and incidentally found a acute PE in the segmental pulmonary artery of the right lower lobe. Patient was then started on treatment dosing of enoxaparin and sent home. Yesterday evening, patient noticed that he was feeling warm and subsequently felt chills. His wife took his temperature at home, found to be 101. He then called the ___ clinic who suggested that he come to the ED for further evalation. In the ED, vitals 99.9 120 130/74 20 99% RA. Patient overall felt better with no further episodes of chills. Labs notable for WBC 40.9 with left shift (in setting of Neupogen), negative U/A, negative flu, negative lactate. Review of CT chest with no evidence of PNA. Patient was given IVF, vancomycin/cefepime x 1, and given immunosuppressed host in setting of fever, was admitted to the ___ service. On the floor, vitals 98.1 121/80 109 20 100%RA. Patient denies any further episodes of chills, no URI symptoms, dysphagia, odynophagia, cough, abdominal pain, diarrhea, rashes, chest pain, or dyspnea. He does endorse sick contacts at home (son with viral gastroenteritis), however no recent travel. He overall felt better today and states that the frequency of his night sweats have decreased after the initiation of chemotherapy. Past Medical History: PAST ONCOLOGIC HISTORY: ___: Underwent cervical mediastinoscopy and excisional biopsy of left paratracheal nodes with results c.___ angioimmunoblastic T-cell lymphoma. Pt did have TCR clonality studies positive. ___: Normal LDH. ___: Echo demonstrated normal LVEF. HIV, HepB and HepC serologies were normal. ___: PET demonstrated extensive lymphadenopathy involving all nodal chains from the neck to the inguinal regions. Of note, the adenopathy in the left side of the neck was highly FDG avid(SUVmax ranging up to approximately 17), while the adenopathy elsewhere in the body showed only mild to moderate FDG avidity (SUVmax ranging up to approximately 6). ___: BM biopsy did not show any involvement with lymphoma. Final Stage: Angioimmunoblastic T-cell lymphoma Stage III Age <___ LDH normal PS 1 No extranodal sites involvement No BM involevemnt Ki-67 not calculated Normal platelet count IPI score: 1 confers a low risk category with a predicted CR rate of 38%, ___ years DFS and OS of 32 and 58% respectively. PIT score is 1 (age <___, LDH normal, PS 1, negative BM involvement) with a predicted CR rate of 31%, ___ years DFS and OS of 29 and 75% respectively. PAST MEDICAL/SURGICAL HISTORY: -Lyme disease Social History: ___ Family History: His father died of lung cancer, having had a stroke at ___; he had been a heavy smoker. His mother had anemia, but was otherwise healthy. He has two brothers and three sisters. One sister has colitis and another had breast cancer. A brother has ___ disease. One brother had been diagnosed with "histiocytosis" in his ___ and received chemotherapy and radiation therapy; he was eventually diagnosed with esophageal cancer and died. Physical Exam: ADMISSION EXAM: ======================= VITALS: 98.1 121/80 109 20 100%RA Gen: WDWN ___. A&O x 3 in NAD. lying in bed comfortably HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: supple, JVP flat LYMPH: shoddy LN in the cervical, supraclavicular, and inguinal. non-tender. CV: RRR. S1/S2. no m/g/r LUNGS: mild crackles at L base, otherwise clear ABD: soft, NTND. +BS. no guarding/rebound. no appreciable HSM EXT: WWP. mild swelling in R inguinal region, tender to palpation with hernia partially reducible. SKIN: scattered petichiae in the ___ bilaterally NEURO: A&Ox3. DISCHARGE EXAM: ======================= VITALS: 98.4 (98.6) 110/58 (90-110/50-60) 65 (60-90) 18 97%RA I/O: 3440/BRP // 480/0 WEIGHT: 168.9 lb Gen: WDWN ___. A&O x 3 in NAD. lying in bed comfortably HEENT: No conjunctival pallor. No icterus. MMM. OP clear. NECK: supple, JVP flat LYMPH: shoddy LN in the cervical, supraclavicular, and inguinal. non-tender. CV: RRR. S1/S2. no m/g/r LUNGS: mild crackles at L base, otherwise clear ABD: soft, NTND. +BS. no guarding/rebound. no appreciable HSM EXT: WWP. mild swelling in R inguinal region, tender to palpation with hernia reducible. SKIN: scattered petichiae in the ___ bilaterally NEURO: A&Ox3. Pertinent Results: ADMISSION EXAM: =========================== ___ 08:35AM BLOOD WBC-53.3# RBC-3.72 Hgb-11.2* Hct-33.2* MCV-89 MCH-30.1 MCHC-33.8 RDW-14.9 Plt ___ ___ 08:35AM BLOOD Neuts-52 Bands-14* Lymphs-6* Monos-8 Eos-3 Baso-0 ___ Metas-5* Myelos-8* Promyel-3* Blasts-1* NRBC-1* ___ 08:35AM BLOOD Plt Smr-NORMAL Plt ___ ___ 08:35AM BLOOD UreaN-22* Creat-0.9 Na-138 K-4.2 Cl-103 HCO3-28 AnGap-11 ___ 08:35AM BLOOD ALT-19 AST-20 LD(___)-563* AlkPhos-100 TotBili-0.2 ___ 08:35AM BLOOD TotProt-6.9 Albumin-4.0 Globuln-2.9 Calcium-9.4 Phos-4.5 Mg-2.3 INTERIM LABS: =========================== ___ 01:40AM BLOOD WBC-40.9* RBC-3.39* Hgb-10.4* Hct-29.9* MCV-88 MCH-30.7 MCHC-34.8 RDW-16.4* Plt ___ ___ 06:00AM BLOOD WBC-21.4* RBC-3.57* Hgb-10.9* Hct-31.6* MCV-89 MCH-30.6 MCHC-34.6 RDW-15.5 Plt ___ ___ 06:00AM BLOOD ALT-16 AST-16 LD(LDH)-328* AlkPhos-65 TotBili-0.2 ___ 01:40AM BLOOD IgG-872 IgA-216 IgM-387* ___ 01:47AM BLOOD Lactate-0.9 ___ 01:40AM URINE Color-Straw Appear-Clear Sp ___ ___ 01:40AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 02:00AM OTHER BODY FLUID FluAPCR-NEGATIVE FluBPCR-NEGATIVE DISCHARGE LABS: ============================ ___ 04:55AM BLOOD WBC-21.1* RBC-3.28* Hgb-10.4* Hct-28.9* MCV-88 MCH-31.6 MCHC-35.8* RDW-15.5 Plt ___ ___ 04:55AM BLOOD Neuts-75* Bands-4 Lymphs-6* Monos-7 Eos-0 Baso-0 ___ Metas-5* Myelos-2* Promyel-1* ___ 04:55AM BLOOD Glucose-114* UreaN-23* Creat-0.7 Na-137 K-4.4 Cl-104 HCO3-26 AnGap-11 ___ 04:55AM BLOOD Calcium-8.5 Phos-4.8* Mg-2.2 UricAcd-5.2 IMAGING: ============================ CT Chest with Contrast (___): 1. Findings compatible with acute pulmonary embolism in the right lower lobe as described above. 2. Interval improvement in the extensive lymphadenopathy in the neck and chest with decrease in both size and number of these lymph nodes. 3. Mixed response of diffuse pulmonary nodules. While some of the previously seen nodules have resolved or decreased in size, others are stable with scattered pulmonary nodules new since ___. However, overall there appears to be grossly decreased number of pulmonary nodules. 4. Please refer to separate portal CT abdomen pelvis performed on the same date for discussion of subdiaphragmatic findings. CT Pelvis with Contrast (___): 1. New right lower lobe pulmonary embolus as described above. For more detailed evaluation of thoracic findings, please see separate CT chest dictation. 2. New fat containing right inguinal hernia. 3. Decrease in size of bilateral external iliac and para-aortic lymph nodes. No new enlarged lymph nodes. ECG ___: Baseline artifact. Sinus rhythm. Probably within normal limits. No previous tracing available for comparison. Rate PR QRS QT/QTc P QRS T 96 150 86 ___ 23 41 ___ ___: 1. No evidence of deep venous thrombosis in the right lower extremity veins. 2. Prominent lymph nodes in the right inguinal area at the site of the patient's pain, consistent with known lymphoma and prior imaging. MICROBIOLOGY: ============================ BCx x 2: NGTD UCx: negative Brief Hospital Course: ___ with hx of angioimmunoblastic T-cell lymphoma s/p 2 cycles of CHOEP-14 presenting with fevers and chills. # fevers: Patient is an immunocompromised host, currently on Neopogen. Patient had no localizing signs or symptoms of infection. Etiology most like acute viral process given sick contacts at home. Patient was started on vancomycin/cefepime, however was discontinued with negative cultures. Patient remained afebrile throughout hospitalization with CT torso with no evidence of infection. EBV viral load negative -f/u blood cultures # angioimmunoblastic T-cell lymphoma, stage III: s/p excisional biopsy of paratracheal LN (TCR positive) and no BM involvement now s/p C2 of CHOEP-14. Tolerating chemo well. States that his night sweats have no decreased. Started C3 of CHOEP (day ___ = ___. Quantitative immunoglobulins normal and direct coombs negative. Continued prophylaxis with acyclovir and bactrim upon discharge. # acute segmental PE: seen incidentally on chest CT. Patient with no complaints of dyspnea. Hemodynamcially stable. He was continued on BID lovenox. # pulmonary nodules: Initially seen on CT, again on PET with mild avidity for FDG, now again seen on CT on ___ with new nodules observed. Concerning for potential spread of lymphoma vs other infectious etiology in setting of immunocompromised state. Pulmonary was consulted and recommended serial staging of nodules with staging of lymphoma. # R inguinal hernia: Patient presented with R groin pain. U/S showed no evidence of DVT. CT demonstrated R inguinal hernia with fat (no bowel). Hernia reducible. Seen by surgery who recommend f/u for surgical repair once chemotherapy is completed. - f/u w/ Dr. ___ as outpatient - supportive briefs Transitional Issues: ========================= Transitional Issues: -will need f/u with Dr. ___ for f/u in R inguinal repair -will need supportive briefs for inguinal hernia -patient had several lung nodules noted on chest CT; pulmonary team recommends serial imaging with further staging of his lymphoma and that if they enlarge, to consider further work-up by pulmonary -f/u EBV viral load and BCx that were pending on discharge -full code -contact: wife (___): ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q6H:PRN nausea 2. PredniSONE 100 mg PO ASDIR 3. Lorazepam 0.5 mg PO Q6H:PRN anxiety 4. Docusate Sodium 100 mg PO BID 5. Polyethylene Glycol 17 g PO DAILY:PRN constipation 6. Senna 8.6 mg PO BID:PRN constipation 7. Filgrastim 480 mcg SC ASDIR 8. Enoxaparin Sodium 80 mg SC Q12H Start: ___, First Dose: Next Routine Administration Time 9. Ranitidine 150 mg PO BID 10. Acyclovir 400 mg PO Q8H 11. Ciprofloxacin HCl 500 mg PO ASDIR 12. Sulfameth/Trimethoprim SS 1 TAB PO DAILY Discharge Medications: 1. Acyclovir 400 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 80 mg SC BID Start: ___, First Dose: Next Routine Administration Time 4. Lorazepam 0.5 mg PO Q6H:PRN anxiety 5. Ondansetron 4 mg PO Q6H:PRN nausea 6. Polyethylene Glycol 17 g PO DAILY:PRN constipation 7. PredniSONE 100 mg PO ASDIR 8. Ranitidine 150 mg PO BID 9. Senna 8.6 mg PO BID:PRN constipation 10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 11. Filgrastim 480 mcg SC ASDIR 12. Ciprofloxacin HCl 500 mg PO ASDIR take BID on days 6 through 13 of each chemotherapy cycle Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: -fever -angioimmunoblastic T-cell lymphoma Secondary Diagnosis: -acute pulmonary embolism -right inguinal hernia 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 to the hospital after experiencing fevers and chills at home. Given that you are undergoing chemotherapy and that your immune system is low, you were admitted to the hospital to make sure that your fever was treated appropriately. Your labs did not show any obvious signs of infection and the scans of your lungs did not show any pneumonia, although it did show a new clot in your lung (pulmonary embolism) that was then treated with a blood thinner (Lovenox). You were started on antibiotics and continued to remain afebrile. The pulmonary doctors came to ___ the nodules in your lungs seen in your CT scan and recommended that these should be evaluated with further imaging down the line. Given that your fevers improved, you were started on the second cycle of chemotherapy on ___. In regards to your groin pain, the surgeons came to evaluate you and suggest that after completing chemotherapy to come to their clinic to have the hernia further evaluated and ultimately fixed. In the meantime, avoid any heavy lifting or straining. Please follow-up with the appointments listed below and take your medications as instructed below. Wishing you the best, Your ___ team Followup Instructions: ___
10131445-DS-12	10,131,445	25,666,320	DS	12	2139-02-20 00:00:00	2139-02-21 07:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: left flank pain Major Surgical or Invasive Procedure: ___: Cystoscopy, left retrograde pyelogram, left ureteroscopy, left ureteral stent placement WITH string externalized. History of Present Illness: This is a ___ year old female with a history of nephrolithiasis who presents with left flank pain, nausea, emesis. Reports in otherwise normal state of health until this morning when she awoke with severe left flank pain and nausea. Went to her college health clinic who prescribed pyridium with no improvement in her pain. She was then sent to ___ ED. She reports a few days of frequency and dysuria prior to onset of left flank pain starting today. Denies fevers/chills, angina/dyspnea, prior GU surgery, gross hematuria. She has a history of nephrolithiasis never requiring a procedure. She reports improvement in left flank pain and nausea with medications in the ER. She has been started on ceftriaxone for empiric UTI coverage. Past Medical History: Nephrolithiasis 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, overweight, non-tender BACK: mild L>R CVA tenderness GU: left ureteral stent string externalized and taped to leg EXT: WWP Pertinent Results: ___ 11:57AM URINE BLOOD-LG* NITRITE-POS* PROTEIN-30* GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD* UROBILNGN-4* PH-6.0 LEUK-SM* ___ 11:57AM GLUCOSE-109* UREA N-12 CREAT-0.9 SODIUM-142 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-22 ANION GAP-16 ___ 11:57AM WBC-11.1* RBC-4.22 HGB-12.5 HCT-36.9 MCV-87 MCH-29.6 MCHC-33.9 RDW-12.6 RDWSD-40.1 Brief Hospital Course: Ms. ___ was admitted to Dr. ___ for nephrolithiasis management with a known 3mm left ureterovesicular junction partially obstructing calculus and nitrite positive urinalysis. She was covered empirically with IV ceftriaxone. On ___, she underwent cystoscopy, left ureteroscopy, and left ureteral stent placement with the stent string externalized at the end of the case. For further case details, please see separately dictated operative report. She tolerated the procedure well and recovered in the PACU before transfer to the general surgical floor. Overnight, the patient was hydrated with intravenous fluids and received appropriate perioperative prophylactic antibiotics. On POD#1 she was afebrile, voiding without difficulty, pain was controlled, and she had no new complaints. She was discharged with the ureteral stent externalized and plan for removal in the office in 3 days, along with a course of antibiotics. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Tri-Legest Fe (norethindrone-e.estradiol-iron) ___ /1mg-35mcg (9) oral ASDIR Discharge Medications: 1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild Reason for PRN duplicate override: Alternating agents for similar severity 2. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild RX ibuprofen 600 mg one tablet(s) by mouth Q8HRS Disp #25 Tablet Refills:0 3. Oxybutynin 5 mg PO Q8H:PRN bladder spasms RX oxybutynin chloride 5 mg ONE tablet(s) by mouth Q8HRS Disp #10 Tablet Refills:0 4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity RX oxycodone 5 mg one tablet(s) by mouth Q4-6HRS Disp #10 Tablet Refills:0 5. Phenazopyridine 100 mg PO Q8H:PRN dysuria Duration: 3 Days RX phenazopyridine 100 mg ONE tablet(s) by mouth Q8HRS Disp #9 Tablet Refills:0 6. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days RX sulfamethoxazole-trimethoprim 800 mg-160 mg ONE tablet(s) by mouth twice a day Disp #10 Tablet Refills:0 7. Tamsulosin 0.4 mg PO QHS RX tamsulosin 0.4 mg ONE capsule(s) by mouth DAILY Disp #6 Capsule Refills:0 8. Tri-Legest Fe (norethindrone-e.estradiol-iron) ___ /1mg-35mcg (9) oral ASDIR Discharge Disposition: Home Discharge Diagnosis: NEPHROLITHIASIS History of left ureteral calculus, passed ureteral calculus. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -You can expect to see occasional blood in your urine and to possibly experience some urgency and frequency over the next month; this may be related to the passage of stone fragments or the indwelling ureteral stent. -The kidney stone may or may not have been removed 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. Your ureteral stent is attached to a string that is transurethral. DO NOT PULL OR MANIPULATE. NOTHING PER VAGINA (including tampons) while ureteral stent in place. -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. -You may be given prescriptions for a stool softener and/or a gentle laxative. These are over-the-counter medications that may be health care spending account reimbursable. -Colace (docusate sodium) may have been prescribed to avoid post-surgical constipation or constipation related to use of narcotic pain medications. Discontinue if loose stool or diarrhea develops. Colace is a stool-softener, NOT a laxative. -Senokot (or any gentle laxative) may have been prescribed to further minimize your risk of constipation. -Do not eat constipating foods for ___ weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks and while Foley catheter is in place. Followup Instructions: ___
10131647-DS-21	10,131,647	23,709,958	DS	21	2147-05-10 00:00:00	2147-05-10 16:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Septic Shock, Pneumonia Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ with past medical history of alcohol use disorder, COPD, hypothyroidism, seizure disorder, depression/anxiety who presents as a transfer from ___ s/p fall, found to be acutely intoxicated with tachycardia, hypoxia, and concern for sepsis. Patient states that her boyfriend called ___ because she wasn't feeling well, had been drinking vodka, and having increased falls recently. She was brought to ___ where she was found to have a likely LLL pneumonia. Also noted to be tachycardic with a leukocytosis to 19, lactate of 5.2, alcohol level 380. She was given ceftriaxone/levofloxacin, 3L LR, Mg repletion, Ativan 2mg. Patient became hypoxic to 80's on room air, sats improved on 4L NC. No ICU beds in ___ so patient transferred to ___. Patient arrived to ___ ED extremely drowsy, occasionally opening eyes to verbal stimuli but felt to be an unreliable historian at this time iso intoxication and sedation from medication. Found to de-sat on RA to 89%, placed on 4L NC and improved to 97%. In the ED, - Initial Vitals: T 98.7, HR 124, BP 115/83, RR 12, Sat 88% 2L NC - Labs: VBG 7.36/46/51/27, lactate 5.2 LFTs AST 20, ALT 11, AP 106, TBili 0.2 CBC - WBC 13.9, Hgb 10.9, Hct 32.8, Plt 98 Coags - ___ 10.5, PTT 30.5, INR 1.0 Serum Tox - Negative Urine Tox - Negative Trop - negative UA - trace leuk, trace protein, 1 WBC, Hyaline Casts Na 143, K 4.8, Cl 104, HCO3 27, BUN 18, Cr 1.2, Gluc 99 - Imaging: ___ CXR from AJ: Upright AP and lateral views. Oxygen tubing overlies the chest. Mild chronic deformity of the posterior aspect of the right 7th rib from old fracture. Mildly coarse markings throughout the lungs and mild linear opacities at the lung bases, similar to prior studies. Cardiac and mediastinal contours appear stable. Deformity of the sternum from prior fracture. - Consults: None - Interventions: 1000mL NS On arrival to ___ patient reports that she feels "discombobulated" from being moved around so much. She appears somnolent, talking with her eyes closed for much of the interview. Taking long pauses to answer questions, needs redirection. Reports that she's been having more falls lately at least daily if not multiple times per day for "awhile". She states that she has pain all over her body from her falls but that her head currently hurts the most, mainly on the left side. She has also been feeling unwell for the last few days. States that she has a cough, nonproductive but that she can feel mucus in her chest, ongoing since ___, unchanged. Also has daily subjective fevers/chills for "months". Endorses 2 days of multiple episodes of watery diarrhea, no blood with bowel movements. Also endorsing intermittent nausea with dry heaving. Patient reports daily alcohol use though states that her drinking has been less over the last week limited to 2 nips of vodka and 1 beer daily. She was not able to quantify how much she was drinking before 1 week ago. ROS: Positives as per HPI; otherwise negative. Past Medical History: Alcohol Use Disorder Seizure Disorder COPD Hypothyroidism Depression Anxiety Social History: ___ Family History: Noncontributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VS: Reviewed in Metavision GEN: Lying in bed, somnolent, no apparent distress EYES: Sclera anicteric, PERRLA, EOMI HENNT: NC/AT, MMM, OP Clear CV: Tachycardic, regular, no m/g/r RESP: Decreased breath sounds L > R at bases GI: Soft, nondistended, mildly tender to palpation epigastric/RUQ MSK: no clubbing/cyansosis/edema, +2 ___ pulses bilaterally SKIN: no rashes/bruising noted NEURO: Somnolent but arousable, answers questions appropriately but delayed responses, AAOx2 (did not know date), face symmetric, moving all extremities with purpose DISCHARGE EXAM: VITALS: 98.8 PO 126 / 80 93 18 92 Ra GENERAL: Alert and in no apparent distress; tolerating room air during our conversation EYES: Anicteric, pupils equally round ENT: Ears and nose without visible erythema, masses, or trauma. Oropharynx without visible lesion, erythema or exudate; has a right submental tender LN, ~1cm CV: Heart regular, ___ systolic mm, no S3, no S4. No JVD. No ___ edema RESP: CTAB; Breathing is non-labored GI: Abdomen soft, non-distended, non-tender to palpation. Bowel sounds present. GU: No suprapubic fullness or tenderness to palpation MSK: Neck supple, moves all extremities, strength grossly full and symmetric bilaterally in all limbs SKIN: No rashes or ulcerations noted NEURO: Alert, oriented, face symmetric, gaze conjugate with EOMI, speech fluent, moves all limbs, sensation to light touch grossly intact throughout. No tremor PSYCH: pleasant, appropriate affect Pertinent Results: ADMISSION LABS: =============== ___ 09:45PM BLOOD WBC-12.4* RBC-3.31* Hgb-11.1* Hct-33.0* MCV-100* MCH-33.5* MCHC-33.6 RDW-15.1 RDWSD-55.6* Plt ___ ___ 09:45PM BLOOD Neuts-64 Bands-8* ___ Monos-5 Eos-0* ___ Metas-2* AbsNeut-8.93* AbsLymp-2.60 AbsMono-0.62 AbsEos-0.00* AbsBaso-0.00* ___ 09:45PM BLOOD Glucose-92 UreaN-6 Creat-0.4 Na-140 K-3.8 Cl-98 HCO3-28 AnGap-14 ___ 09:45PM BLOOD ALT-26 AST-84* LD(LDH)-347* AlkPhos-135* TotBili-0.9 ___ 09:45PM BLOOD Albumin-3.0* Calcium-7.4* Phos-2.2* Mg-1.5* ___ 06:09PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ 10:39PM BLOOD ___ pO2-36* pCO2-53* pH-7.36 calTCO2-31* Base XS-2 ___ 06:09PM BLOOD Lactate-5.2* ___ 10:39PM BLOOD Lactate-3.4* ___ 07:00PM URINE Blood-NEG Nitrite-NEG Protein-TR* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-TR* ___ 07:00PM URINE RBC-0 WBC-2 Bacteri-NONE Yeast-NONE Epi-1 ___ 07:00PM URINE CastHy-22* ___ 07:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG DISCHARGE LABS: =============== ___ 07:15AM BLOOD WBC-10.6* RBC-2.82* Hgb-9.4* Hct-29.1* MCV-103* MCH-33.3* MCHC-32.3 RDW-16.2* RDWSD-61.3* Plt ___ ___ 07:15AM BLOOD ___ PTT-33.1 ___ ___ 07:15AM BLOOD Glucose-115* UreaN-7 Creat-0.4 Na-137 K-4.4 Cl-97 HCO3-30 AnGap-10 ___ 07:15AM BLOOD Calcium-8.8 Phos-5.0* Mg-1.5* MICROBIOLOGY: ============= ___ 7:00 pm URINE FINAL REPORT ___ URINE CULTURE (Final ___: NO GROWTH. ___ 11:48 pm URINE Source: Catheter. FINAL REPORT ___ Legionella Urinary Antigen (Final ___: NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. ___ 6:22 am MRSA SCREEN Source: Nasal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 2:04 am STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FINAL REPORT ___ C. difficile PCR (Final ___: NEGATIVE. (Reference Range-Negative). The C. difficile PCR is highly sensitive for toxigenic strains of C. difficile and detects both C. difficile infection (CDI) and asymptomatic carriage. A negative C. diff PCR test indicates a low likelihood of CDI or carriage. ___ Urine culture URINE CULTURE (Final ___: ESCHERICHIA COLI. 10,000-100,000 CFU/mL. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI \| AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S Blood culture ___ - pending Blood culture ___ - pending Urine culture ___ - pending UA ___ negative IMAGING: ======== ___ CXR from ___: Upright AP and lateral views. Oxygen tubing overlies the chest. Mild chronic deformity of the posterior aspect of the right 7th rib from old fracture. Mildly coarse markings throughout the lungs and mild linear opacities at the lung bases, similar to prior studies. Cardiac and mediastinal contours appear stable. Deformity of the sternum from prior fracture. ___ CTA 1. Pulmonary embolism in a few subsegmental and segmental branches of the right pulmonary artery without evidence of right heart strain. 2. Enlarged main pulmonary artery measuring 37 mm suggesting pulmonary hypertension. 3. Diffuse centrilobular pulmonary nodules and scattered ground-glass opacification in bilateral lungs likely represent an infectious process such as multifocal pneumonia. However, respiratory bronchiolitis cannot be excluded. 4. Moderate hepatic steatosis. ___ CXR: IMPRESSION: Heart size and mediastinum are stable. Multifocal consolidations are similar to previous chest CT from ___. There is no appreciable pleural effusion. There is no pneumothorax. ___ Bilateral ___ Doppler US: IMPRESSION: Deep venous thrombosis of 1 of the 2 left posterior tibial veins. No evidence of deep venous thrombosis in the right lower extremity veins. Brief Hospital Course: Ms. ___ is a ___ with past medical history of alcohol use disorder, COPD, hypothyroidism, seizure disorder, depression/anxiety who presents as a transfer from ___ s/p multiple falls, found to be acutely intoxicated with tachycardia, hypoxia, likely pneumonia and concern for sepsis/septic shock. ACUTE ISSUES =========== #Community Acquired Pneumonia #Sepsis Patient with possible LLL pneumonia on CXR from OSH. Has been feeling ill for "few days" prior to admission. Endorsing cough w/ mucus in chest, fevers/chills, nausea, diarrhea. lactate elevated to 5 at OSH, persistently elevated to 5 in ED here suggesting end organ damage. Admitted s/p 3L IVF, received additional 2L with downtrending lactate, BPs stable, never requiring pressors. Received CTX/Levofloxacin at OSH which was continued. Strep pneumo, legionella, RVP, blood cultures, urine culture, was found to have GPC growing at OSH. ID was consulted on the floor and was not concerned by final cutlure of ___ bottles Strep mitis, which was not found in BID cultures. On floor transitioned to Ceftriaxone, dropping vanco (MRSA swab neg) and levaquin. She completed the ceftriaxone course while inpatient. O2 needs weaned on the floor and she was breathing comfortably on room air on discharge. #Sinus tach PE vs volume depletion vs withdrawal. Persisted despite withdrawal management and fluids, so thought more likely ___ to PE. Stables in ___ on discharge. #Hypoxia #Multiple Subsegmental PEs Patient persistently tachycardic to 110-120s despite 5L IVF. EKG w/ sinus tachycardia. Patient not febrile, not complaining of pain so CTA Chest obtained which showed filling defects in 2 segmental right middle lobe pulmonary arteries, several subsegmental arteries of the right lower lobe, segmental artery in the left upper lobe. PE without clear provoking source, no hx clots in past, no recent long travel, no known active malignancy. Started on heparin gtt while in ICU then ultimately transitioned to po anticoagulation with rivaroxaban, completing introduction BID dosing at the time of DC. Weaned off O2 and worked well with ___, recommending home with home ___. #Intoxication #Alcohol Use Disorder Patient w/ history alcohol use disorder, reported heavy alcohol use recently though patient stating less over last week prior to admission. EtOH at OSH 380. Was given high dose thiamine, folate, MVI. Loaded with phenobarb then redosed ___. On floor, CIWA continued but received no further dosing. No complications noted. #Elevated LFTs Possibly mild alcoholic hepatitis given AST:ALT ratio vs mild shock liver iso septic shock. Downtrended without issue. No further workup #Diarrhea Unclear chronicitiy, per pt occurs on and off at home. C.diff negative. Resolved. #bacteriuria: some burning with urination but there was no inflammatory reaction in UA. UCx did grow Ecoli with numerous resistances. ID not concerned and initially elected not to broaden coverage. However, given persistent symptoms, discharged with three day course of Bactrim. CHRONIC ISSUES ============= #Depression #Anxiety -Continued home citalopram, mirtazapine #Hypothyroidism -continued home synthroid 75mcg daily, thyroid levels c/w mild hypothyroid while in house #Seizure Disorder Never on AED. Continued to monitor for seizure activity TRANSITIONAL ISSUES: ====================== RECOMMENDATION(S): 1.A follow up chest CT is recommended in ___ weeks after treatment of acute pulmonary process taken for resolution. 2. Radiological evidence of fatty liver does not exclude cirrhosis or significant liver fibrosis which could be further evaluated by ___. This can be requested via the ___ (FibroScan) or the Radiology Department with either MR ___ or US ___, in conjunction with a GI/Hepatology consultation" * Ensure resolution of urinary symptoms s/p antibiotic treatment. Patient needs sleep study as an outpatient to evaluate for OSA. PCP follow up scheduled on ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Citalopram 20 mg PO DAILY 2. Mirtazapine 15 mg PO QHS 3. TraZODone 100 mg PO QHS 4. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 5. Multivitamins 1 TAB PO DAILY 6. Levothyroxine Sodium 75 mcg PO DAILY 7. Naproxen 500 mg PO Q12H:PRN Pain - Mild Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN Pain - Mild/Fever RX acetaminophen 650 mg 1 tablet(s) by mouth every 6 hours as needed Disp #30 Tablet Refills:2 2. FoLIC Acid 1 mg PO DAILY RX folic acid 1 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:1 3. Rivaroxaban 15 mg PO BID pulmonary embolism Duration: 21 Days with food RX rivaroxaban [Xarelto] 15 mg (42)- 20 mg (9) 1 tablets(s) by mouth twice daily Disp #32 Dose Pack Refills:0 4. Rivaroxaban 20 mg PO DAILY RX rivaroxaban [Xarelto] 20 mg 1 tablet(s) by mouth once daily Disp #30 Tablet Refills:1 5. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 3 Days RX sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by mouth twice daily Disp #5 Tablet Refills:0 6. Thiamine 100 mg PO DAILY RX thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Citalopram 20 mg PO DAILY 8. Levothyroxine Sodium 75 mcg PO DAILY 9. Mirtazapine 15 mg PO QHS 10. Multivitamins 1 TAB PO DAILY 11. Naproxen 500 mg PO Q12H:PRN Pain - Mild 12. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation Q4H:PRN 13. TraZODone 100 mg PO QHS Discharge Disposition: Home With Service Facility: ___ ___ Diagnosis: Pulmonary embolism Pneumonia Urinary tract infection Discharge Condition: Stable Mentating appropriately Ambulatory Discharge Instructions: You were admitted for several serious issues - a pneumonia that has been treated with antibiotics. Also affecting your lungs and breathing was a blood clot that had traveled there from your leg. You were treated with blood thinners and oxygen through your nose, which improved gradually. You will need to continue the rivaroxaban. Initially this will be at 15mg TWICE a day until ___. On ___ you should switch to the 20mg pill ONCE per day. Please also take Bactrim as prescribed for a total of three days, ending ___, for your urinary tract infection. When you see your primary care doctor, please ask to get a sleep study to evaluate for obstructive sleep apnea. This is a condition when your oxygen levels decrease during sleep, and we saw some evidence for it in the hospital. However, the evaluation for this condition is tested as an outpatient. It was a pleasure taking care of you. Sincerely, Your ___ team Followup Instructions: ___
10131707-DS-7	10,131,707	25,176,043	DS	7	2167-07-24 00:00:00	2167-07-24 15:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: multiple / Amoxicillin / baclofen / Cephalexin / doxycycline / Erythromycin Base / Hydralazine / Meperidine / Polystyrene Sulfonate / povidone-iodine / valproic acid / Verapamil / Nifedipine / cefuroxime / Labetalol / ciprofloxacin / omeprazole / loratadine / loratadine / amlodipine / metformin / sumatriptan / fexofenadine / bee venom (honey bee) / esomeprazole / Penicillins / Sulfa(Sulfonamide Antibiotics) / IV Dye, Iodine Containing Contrast Media Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: intubation right femoral cvc ___- RIGHT CHEST PORT CATHETER FIBRIN SHEATH STRIPPING AND REMOVAL OF RIGHT GROIN CVL History of Present Illness: Ms. ___ is a ___ year old female with Factor V Leiden and multiple prior pulmonary emboli who was transferred from ___ to ___ ED for evaluation of pleuritic chest pain radiating to the back and dyspnea. Per the record she also had two days of flank pain radiating to the groin, and dysuria. She was transferred for a study to rule out pulmonary embolism. She is anticoagulated on coumadin, currently with an INR of 2.2. Vitals at ___: bp 149/96, p 72, rr 18, sat 98%, t 98.4 . Her initial ___ ED vitals were: 98.1 76 184/83 16 98%. Based on her symptomotology, aortic dissection became a concern. In the ED she was electively intubated because she is clautrophobic and needed the MRI. An MRA was contraindicated due to the risk for gadolinium induced nephrogenic systemic sclerosis. A TEE was considered; however, this would not interrogate the entire aorta and there is report that the patient also had two days of flank pain. Transfer vitals: 136/84, p 74, bp 136/84, rr 16, o2 sat 99% on cmv/ac . On arrival to the MICU, she was intubated and sedated. Past Medical History: 1. Factor V Leiden gene mutation 2. Pulmonary emboli 3. IDDM 4. Hypertension 5. ESRD on HD via left subclavian HD line, schedule unknown 6. Hypothyroidism 7. Atrial myxoma s/p resention 8. atrial fibrillation 9. Reflex sympathetic dystrophy/chronic regional pain syndrone 10. Fasciotomy of right forearm ___, left forearm ___ 11. Permanent IVF filter placed on ___ Social History: ___ Family History: She denies a family history of kidney disease. Father had MI and CABG in his ___. No FH of premature CAD, SCD, or arrhythmia. Physical Exam: ADMISSION EXAM: 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, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM: General: NAD AOx3 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, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, +CVA tenderness on left that is stable x4 days GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, ___ strength upper/lower extremities, grossly normal sensation Pertinent Results: ADMISSION LABS: ___ 04:55PM BLOOD WBC-5.3 RBC-3.50* Hgb-10.2* Hct-31.5* MCV-90 MCH-29.0 MCHC-32.3 RDW-19.4* Plt ___ ___ 04:55PM BLOOD Neuts-59.7 ___ Monos-5.0 Eos-14.2* Baso-1.0 ___ 04:55PM BLOOD ___ PTT-33.7 ___ ___ 04:55PM BLOOD Glucose-132* UreaN-29* Creat-6.2* Na-136 K-5.3* Cl-100 HCO3-23 AnGap-18 ___ 04:55PM BLOOD cTropnT-<0.01 ___ 06:08AM BLOOD CK-MB-3 cTropnT-0.22* ___ 12:12PM BLOOD CK-MB-4 cTropnT-0.20* ___ 04:55PM BLOOD CK(CPK)-39 ___ 06:08AM BLOOD CK(CPK)-90 ___ 12:12PM BLOOD CK(CPK)-103 . DISCHARGE LABS: . ___ URINE CULTURE (Final ___: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. ___ 06:04AM BLOOD WBC-4.5 RBC-3.36* Hgb-10.4* Hct-31.0* MCV-92 MCH-31.0 MCHC-33.6 RDW-18.3* Plt ___ ___ 06:04AM BLOOD ___ PTT-40.9* ___ ___ 06:48AM BLOOD ___ PTT-133.1* ___ ___ 05:12AM BLOOD ___ PTT-147.1* ___ ___ 06:04AM BLOOD Glucose-140* UreaN-52* Creat-8.6# Na-138 K-5.4 Cl-98 HCO3-28 AnGap-17 ___ 06:04AM BLOOD Calcium-9.8 Phos-8.0* Mg-2.3 . IMAGING: ___ CXR: Single portable view of the chest. No prior. Endotracheal tube is seen with tip approximately 5 cm from the carina. Nasogastric tube is also seen with side port in the region of the GE junction. Left-sided central venous catheter is seen with tip in the right atrium. Right-sided subclavian line is seen with tip in the mid SVC. Lungs are grossly clear, given significant rotation and portable supine technique. Median sternotomy wires again seen. Cardiac silhouette is enlarged but likely accentuated due to technique and positioning. Osseous and soft tissue structures are unremarkable. IMPRESSION: Endotracheal tube tip approximately 5 cm from the carina. . ___ MRA Torso: 1. No MR evidence for aortic dissection. 2. No central pulmonary embolism in the main, right or left pulmonary arteries, the lobar and smaller order pulmonary arteries cannot be assessed on this non-contrast study. 3. Right lower lobe atelectasis or consolidation. 4. Multiple renal cysts with small shrunken kidneys consistent with the patient's chronic renal disease. 5. Positioning of the central venous catheters is not clear, at least one catheter appears to terminate in the right atrium or extend into the IVC. Recommend a chest radiograph to confirm catheter tip placement. TTE (Complete) Done ___ The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is probably mildly depressed with mid anteroseptal hypokinesis but views are suboptimal for assessment of wall motion. Right ventricular chamber size is normal with mildly depressed function (but views are subopitmal). The aortic valve leaflets (probably 3) appear structurally normal with good leaflet excursion. The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a trivial/physiologic pericardial effusion. An small (approximately 1 cm diameter) echodense structure is visualized posterior to the left atrium in a modified four chamber view which represent a portion of a wall of a pulmonary vein. No definite intracardiac mass identified but views are suboptimal. If clinically indicated, a transesophageal echocardiographic examination is recommended. CHEST (PORTABLE AP) Study Date of ___ INDICATION: Evaluate right Port-A-Cath and central venous catheter locations due to positioning within the right atrium noted prior MRI of the chest. COMPARISON: Chest radiogram from ___ and MRA of the torso from ___. FINDINGS: A bedside AP radiograph of the chest demonstrates that the double-lumen catheter terminates well within the right atrium, approximately 7 cm below the expected location of the cavoatrial junction. It is unchanged in position from the prior study. The right subclavian line terminates in the mid SVC, also unchanged. The patient has been extubated. The lungs are clear. There continues to be enlargement of the right atrium. There is no pneumothorax or pleural effusion. Pulmonary vascularity is normal. Sternotomy cerclage wires are intact. IMPRESSION: The double-lumen Port-A-Cath should be retracted approximately 7 cm to ensure proper positioning in the lower one-third of the SVC. ___ Radiology RENAL U.S. FINDINGS: The right kidney measures 9 cm. The left kidney measures 9.5 cm. Several cysts are seen in both kidneys. A 1.9 cm left upper pole cyst has a single septation. The bladder is clear. There is no stone, mass or hydronephrosis in either kidney. IMPRESSION: No hydronephrosis, stone or perinephric fluid collection. ___ Radiology CHEST (PA & LAT) Two views of the chest were obtained. The lungs are well expanded and clear without pleural effusion or pneumothorax. The heart is normal in size with normal cardiomediastinal contours. Right-sided Port-A-Cath and left-sided hemodialysis catheter are in unchanged position. Cardiac size is stably enlarged. Brief Hospital Course: HOSPITAL COURSE: Ms. ___ is a ___ year old female with Factor V Leiden and multiple prior pulmonary emboli who was transferred from ___ for evaluation of pleuritic chest pain radiating to the back and dyspnea. Ruled out for serious thoracic pathology (PE/dissection/ACS). MWF HD was continued throughout stay on floors. Given hx of Factor V Leiden, started on Heparin drip with bridging to warfarin. Reported constant left flank pain. In conjunction with falling hemoglobin, this prompted CT Abd/Pelv which ruled out retroperitoneal bleed. Transfused one unit and hemoglobin was stabilized for remainder of admission. While waiting for INR to become therapeutic, previous UCx grew >100,000 CFUs Enterococcus, treated with vancomycin at HD. INR became therapeutic x3 days, heparin gtt stopped and pt was discharged on day 14 of admission with followup with ___ ___ MD in ___. ACTIVE ISSUES: Chest Pain: The patient described substernal chest pain radiating to her back that was worrisome for PE, acute MI, or aortic dissection. Patient was electively intubated in the ED and subsequent MRI negative for aortic dissection or large pulmonary embolism. Recurrent subsegmental pulmonary embolism possible as patient has had this occur on warfarin with therapeutic INR and with IVC filter in place. Acute myocardial infarction was also a concern. Initial ECG was within normal limits; however, serial ECG showed development of IVCD with no overt ischemic changes. Troponin was initially negative; however, cTropnT < 0.01 --> 0.22 --> 0.20 with negative CK-MB index. Other points in the differential would include pericarditis or myocarditis given troponin leak. Non-cardiac or pulmonary etiologies could be esophageal spasm. The patient has a history of an atrial myxoma so that was also on the differential. An ECHO was performed given concern for ischemia or atrial myxoma and showed mild symmetric LVH with LV systolic function probably mildly depressed with mid anteroseptal hypokinesis, mildly depressed RV funtion and no definite intracardiac mass. Views were all suboptimal though. The patient was evaluated by cardiology who recommended that the patient follow up as an outpatient for possible stress test. Flank Pain: The patient complained or left sided flank pain. She has a history of pyelonephritis. UA and culture on admission were normal, however the patient continued to have flank pain so a renal ultrasound was ordered and a repeat urinalysis and culture. A renal ultrasound revealed no hydronephrosis, stone or perinephric fluid collection. Subsequent UCx grew >100,000 Enterococcus but patient clinically stable and afebrile. Regardless, treated with vancomycin at HD. Hypertension/Hypotension: Home anti-hypertensive medications were initially held due to borderline blood pressures. She was started on metoprolol 25 mg XL per cardiology recommendation for history of atrial fibrillation as well and tolerated this well initially. However, complaints of dizziness on standing prompted reduction of antihypertensive dosing. At d/c Lisinopril was 20mg daily, Metoprolol was 12.5mg daily. Factor V Leiden gene mutation with multiple pulmonary emboli: We initially held warfarin while ruling out aortic dissection, but then restarted it after MRI was negative. The patient was subsequently started on a heparin drip due to high risk of clot and subtherapeutic INR. INR increased slowly and became therapeutic x3 days before discharge. ESRD: Patient was seen and evaluated by renal and dialyzed per home ___ schedule without complication. INACTIVE ISSUES: Pain control: Patient tolerated home dose of q3h 20mg Dilaudid. IDDM: The patient was placed on a sliding scale. Atrial fibrillation- The patient has history of atrial fibrillation related to atrial myxoma in the past. She was seen and evaluated by cardiology who recommended metoprolol xl 25 mg. EKG's performed and telemetry monitoring revealed sinus rhythm. The patient was anticoagulated as described above. Hypothyroidism: There was no evidence of clinical hypothyroidism and the patient was continued levothyroxine. TRANSITIONAL ISSUES: f/u dosing on antihypertensives/cardiac meds Please note we discontinued digoxin and propranolol and went down on lisinopril and metoprolol. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. HYDROmorphone (Dilaudid) 20 mg PO Q3H pain 2. Nephro-Vite NF* (B complex-vitamin C-folic acid) 0.8 mg Oral daily 3. Lisinopril 40 mg PO BID 4. Digoxin 0.125 mg PO MWF 5. sevelamer CARBONATE 1600 mg PO TID W/MEALS 6. Levothyroxine Sodium 125 mcg PO DAILY 7. Propranolol LA 120 mg PO DAILY 8. Montelukast Sodium 10 mg PO DAILY 9. Aciphex NF (RABEprazole) 20 mg Oral daily 10. Lantus Solostar NF (insulin glargine) 30 units Subcutaneous HS 11. NovoLOG NF (insulin aspart) sliding scale Subcutaneous slidinc scale 12. Doxazosin 2 mg PO HS 13. Lorazepam 1 mg PO Q6H:PRN anxiety 14. Promethazine 25 mg PO Q6H:PRN nausea 15. Ondansetron 8 mg PO BID:PRN nausea 16. Frova NF (frovatriptan) 2.5 mg Oral PRN migraines 17. Xopenex Neb NF 1.25 mg/0.5 mL Inhalation Q4H PRN 18. Ferrous Sulfate 325 mg PO DAILY 19. DiphenhydrAMINE 50 mg PO Q4H:PRN itching 20. Docusate Sodium 100 mg PO BID 21. Denavir NF (penciclovir) 1 % Topical q6h rash 22. Warfarin Dose is Unknown PO DAILY16 Based on INR 23. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Docusate Sodium 100 mg PO BID 2. Ferrous Sulfate 325 mg PO DAILY 3. HYDROmorphone (Dilaudid) 20 mg PO Q3H pain 4. Levothyroxine Sodium 125 mcg PO DAILY 5. Lisinopril 20 mg PO DAILY hold for SBP < 100 6. Lorazepam 1 mg PO Q6H:PRN anxiety 7. Metoprolol Succinate XL 12.5 mg PO DAILY hold for SBP < 100 or HR < 60 8. Warfarin 8 mg PO DAILY16 9. Xopenex Neb NF 1.25 mg/0.5 mL Inhalation Q4H PRN 10. Aspirin 81 mg PO DAILY 11. Aciphex NF (RABEprazole) 20 mg Oral daily 12. Denavir NF (penciclovir) 1 % Topical q6h rash 13. DiphenhydrAMINE 50 mg PO Q4H:PRN itching 14. Doxazosin 2 mg PO HS 15. Frova NF (frovatriptan) 2.5 mg Oral PRN migraines 16. Lantus Solostar NF (insulin glargine) 30 units Subcutaneous HS 17. Montelukast Sodium 10 mg PO DAILY 18. Nephro-Vite NF (B complex-vitamin C-folic acid) 0.8 mg Oral daily 19. Ondansetron 8 mg PO BID:PRN nausea 20. Promethazine 25 mg PO Q6H:PRN nausea 21. Propranolol LA 120 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Atypical chronic chest pain Factor V Leiden with history of PEs (+IVC filter) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, Thank you for choosing us for your care. You were admitted for chest pain that, in conjunction with your Factor V Leiden, was concerning for a pulmonary embolism. We have done many tests to rule out this possibility, as well as other dangerous conditions causing chest pain including aortic dissection and heart attack. To do one of these tests, we needed to sedate and intubate you. Despite the extensive workup we are unsure what is causing your chest pain and shortness of breath at this time. You also reported burning on urination and left sided flank pain. We performed a CT scan to make sure there was no bleeding into your flank. This was negative. We performed several tests to rule out a UTI or an infection of your kidney, which can present with flank pain. Your urine grew some bacteria, but this can be common in people dependent on dialysis. Regardless, we have treated it with vancomycin. In the hospital we have continued to give you dialysis to compensate for your chronic kidney disease. Please continue to do so at your usual dialysis center. We had been anticoagulating you on heparin while we waited for your warfarin to raise your INR above 2.0. Please continue to take your warfarin after discharge to maintain an INR above 2.0. We have made an appointment with your primary care doctor ___ in ___. Please see her to adjust your medications. We have lowered your dose of Lisinopril to 20mg daily and your dose of Metoprolol to 12.5mg daily. We have STOPPED your digoxin. Please do not continue to take it. Please continue to take your other medications as you had before you went to ___. Followup Instructions: ___
10132365-DS-3	10,132,365	24,668,665	DS	3	2180-02-21 00:00:00	2180-02-21 14:44:00	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: Mr. ___ is a ___ with PMH of HTN, HLD, DM, CKD presents for evaluation of dyspnea for the past ___s unsteadiness upon awakening this morning. The patients states that for the past 2 weeks he has had dyspnea on exertion which is new for him (specifically after 5 minutes on treadmill needs to stop). He denies any chest pain, f/c, cough, sore throat, congestion, rhinorrhea, myalgias. He has a had a flu shot this year and does not have any sick contacts. He has not had this problem before and has no known CHF/COPD (recent echo ___ with EF >55%). This morning he noticed when he stood up his legs felt wobbly and went away when he stopped walking. He says he is still having this problem but it goes away at rest. No h/a, visual changes, other weakness, numbness, n/v. He does not feel like the room is spinning. He has been eating and drinking normally but has felt a bit "dry" lately and recently started a new BP medication. In the ED, initial VS were 97.7 63 156/61 18 95%. Orthostatics negative. Exam notable for elderly man in no distress, RRR with II/VI systolic murmur over aortic valve. No JVD. Lungs CTAB, abdomen benign. Neuro exam normal. 1+ peripheral edema. Labs showed WBC 11.7, Cr 1.9, BUN 54, K 5.2, lactate 0.9, trop<0.01. Blood cultures x2 pending. CXR showed findings consistent with right lower lobe pneumonia on the setting of right lower lobe bronchiectasis and peribronchial thickening suggestive of bronchitis. Received got vancomycin 1g, cefepime 2g. Transfer VS were 64 158/60 18 94% RA. Decision was made to admit to medicine for further management. On arrival to the floor, patient reports feeling short of breath but improved on oxygen. He has had unsteadiness for several days as well, as described above. Past Medical History: Type II diabetes mellitus (on oral hypoglycemics) Chronic kidney disease stage III Hypertension CAD (Presumed remote coronary artery disease with mild reversible anterior wall defect. No chest pain with usual activities.) Shortness of breath likely secondary to diastolic dysfunction. (Has been stable.) Hyperlipidemia Obstructive sleep apnea chronic allergic rhinitis Superficial bladder cancer (no e/o recurrence) Social History: ___ Family History: Negative for anything new. He does have a daughter who suffers with stage IV melanoma. Physical Exam: Admission exam: VS - 97.8 198/76 77 12 94% on 2L General: well-appearing man, appears younger than stated age, in no distress, on oxygen, responding to questions appropriately HEENT: EOMI, PERRLA. left-sided ptosis, noted on prior exams. Neck: supple, reduced range of motion (at ___ per pt), bilateral carotid bruits (L>R) CV: regular rate, rhythm, with a ___ systolic flow murmur heard at RUSB. Lungs: clear to auscultation bilaterally Abdomen: soft, non-tender, normoactive bowel sounds, no HSM GU: deferred Ext: warm, well-perfused, 2+ DP, ___ pulses, evidence of osteoarthritis at multiple joints Neuro: AOx3, CN II-XII intact. impaired hearing. moving all extremities freely. strength ___. Skin: diffuse sun damage, no rashes. Discharge exam: VS - 97.5 153/68(150-190/60-70) 69(60-70) 18 97% on RA General: well-appearing man, appears younger than stated age, in no distress, sitting in chair, responding to questions appropriately HEENT: EOMI, PERRLA. left-sided ptosis, noted on prior exams. Neck: supple, reduced range of motion (at ___ per pt), bilateral carotid bruits (L>R) CV: regular rate, rhythm, with a ___ systolic flow murmur heard at RUSB. Lungs: clear to auscultation bilaterally Abdomen: soft, non-tender, normoactive bowel sounds, no HSM GU: deferred Ext: warm, well-perfused, 1+ edema, 2+ DP, ___ pulses, evidence of osteoarthritis at multiple joints Neuro: AOx3, CN II-XII intact. impaired hearing. moving all extremities freely. strength ___. Skin: diffuse sun damage, no rashes. Pertinent Results: Admission labs: ___ 01:15PM BLOOD WBC-11.7* RBC-3.04* Hgb-9.7* Hct-28.8* MCV-95 MCH-31.9 MCHC-33.7 RDW-14.3 Plt ___ ___ 01:15PM BLOOD Neuts-70.5* ___ Monos-8.4 Eos-2.2 Baso-0.3 ___ 01:15PM BLOOD Glucose-111* UreaN-54* Creat-1.9* Na-144 K-6.1* Cl-114* HCO3-18* AnGap-18 ___ 01:26PM BLOOD Lactate-0.9 K-5.2* ___ 01:15PM BLOOD cTropnT-<0.01 Discharge labs: ___ 05:50AM BLOOD WBC-8.7 RBC-3.05* Hgb-9.7* Hct-28.4* MCV-93 MCH-31.7 MCHC-34.0 RDW-14.0 Plt ___ ___ 05:50AM BLOOD Glucose-110* UreaN-52* Creat-1.7* Na-143 K-4.7 Cl-112* HCO3-20* AnGap-16 CXR ___: right lower lobe pneumonia on the setting of right lower lobe bronchiectasis and peribronchial thickening suggestive of bronchitis. Brief Hospital Course: Brief hospital course: Mr. ___ is a ___ with PMH of HTN, HLD, DM, CKD who presents for evaluation of dyspnea for the past ___s unsteadiness upon awakening this morning. # Community-acquired pneumonia: Patient presenting with two weeks of dyspnea, in setting of leukocytosis, and with radiographic evidence of RLL pneumonia. His presentation is consistent with community-acquired pneumonia as he has not been hospitalized for 72 hours within the past 3 months (ED visit to ___ for hyperkalemia without extended admission). He does not have diagnosed sCHF (recent echo ___ or evidence of volume overload on exam to suggest CHF exacerbation. He does not have evidence of tachycardia or hypoxia or risk factors to suggest increased suspicion of pulmonary embolism (Well's criteria of 0). He meets CURB-65 criteria with two points for urea>20 and age>___, and as such should be admitted for pneumonia. For hospitalized patients on general wards, the IDSA/ATS guidelines recommend an antipneumococcal fluoroquinolone (eg levofloxacin) for a minimum of five days. Most recent QTc 427 on EKG in emergency room (fluoroquinolones can cause a prolonged QT interval). The patient does not have risk factors for drug-resistant pathogens (pseudomonas, MRSA). Received empiric vanc/cefepime in ED. Respiratory status improved overnight after admission, off oxygen by morning, breathing subjectively improved, hypoxia improved. Narrowed to levofloxacin, which is appropriate for CAP in hospitalized patients on general wards; for a minimum of five days. Discharged on levofloxacin 750mg q48 (renal dosing) for seven day course antibiotics, to ___. # Hypertension: Continued chlorthalidone 25mg daily (helps with hyperkalemia), amlodipine 10mg daily, and carvedilol 12.5mg daily. Held lisinopril 40mg daily as is likely exacerbating hyperkalemia # Unsteadiness: Resolved with treatment of infection. Evaluated by ___ and cleared for discharge home. ___ be related to recent infection. Patient with active lifestyle at baseline, particularly for age. # Hyperkalemia: Patient with recent history of hyperkalemia in past month. Metformin had been stopped and lisinopril was decreased by outpatient PCP. K 5.2 on admission. Held lisinopril and hyperkalemia resolved. Discharged off lisinopril. See transitional issues below. # OSA: Continued home CPAP. Tele for continuous O2 monitoring. # Hyperlipidemia: continued atorvastatin 20mg daily # Diabetes mellitus: Patient had been on oral hypoglycemics at home, metformin recently discontinued in setting of hyperkalemia. Humalog ISS while inpatient. # Chronic kidney disease: Creatinine consistent with baseline (1.8-2.0), no evidence of ___. TRANSITIONAL ISSUES: [] Discharged on 7 day course levofloxacin (750mg q48hrs due to renal function), Last day ___. [] Patient with hyperkalemia on admission. This has been a chronic issue due to lisinopril. We discontinued his lisinopril and informed his PCP who will follow up on his potassium, blood pressure, and anti-hypertensives. [] Blood pressure medications at discharge: chlorthalidone 25mg, amlodipine 10mg daily, carvedilol 12.5mg bid. ___ need further anti-hypertensive adjustment outpatient. [] Please consider repeating CXR within ___ of resolution of symptoms of pneumonia to evaluate bronchiectasis. # CODE: DNR/DNI confirmed with patient and wife ___ form signed with PCP Dr ___ # EMERGENCY CONTACT HCP: ___ (wife) ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lisinopril 40 mg PO DAILY 2. TraMADOL (Ultram) 50 mg PO TID:PRN back pain 3. Chlorthalidone 25 mg PO DAILY 4. Carvedilol 12.5 mg PO BID 5. Amlodipine 10 mg PO DAILY 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Atorvastatin 20 mg PO DAILY 8. azelastine 137 mcg nasal bid 9. Aspirin 81 mg PO DAILY 10. guanFACINE 1 mg oral qpm 11. Acyclovir 400 mg PO BID 12. loteprednol etabonate 0.5 % ophthalmic qam 13. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES QAM 14. Acetaminophen 500 mg PO BID Discharge Medications: 1. Acetaminophen 500 mg PO BID 2. Acyclovir 400 mg PO BID 3. Amlodipine 10 mg PO DAILY 4. Aspirin 81 mg PO DAILY 5. Atorvastatin 20 mg PO DAILY 6. Carvedilol 12.5 mg PO BID 7. Chlorthalidone 25 mg PO DAILY 8. Lidocaine 5% Patch 1 PTCH TD QAM 9. TraMADOL (Ultram) 50 mg PO TID:PRN back pain 10. Levofloxacin 750 mg PO Q48H RX levofloxacin 750 mg 1 tablet(s) by mouth every other day Disp #2 Tablet Refills:*0 11. azelastine 137 mcg nasal bid 12. guanFACINE 1 mg oral qpm 13. loteprednol etabonate 0.5 % ophthalmic qam 14. Polymyxin B -Trimethoprim Ophth Soln 1 DROP BOTH EYES QAM Discharge Disposition: Home Discharge Diagnosis: primary diagnosis: community acquired pneumonia hyperkalemia obstructive sleep apnea secondary diagnosis: hypertension 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 take part in your care at ___. You were admitted to the hospital for shortness of breath and unsteadiness. You were found to have a pneumonia and treated with antibiotics. You were evaluated by physical therapy who cleared you to be discharged home. You will continue the oral antibiotics (levofloxacin) for a total of 5 days. We stopped your lisinopril because it is causing your potassium to be too high. Dr ___ will follow up on your blood pressure and make any necessary medication changes. You should follow up with your PCP and continue your medications. We wish you all the best. -Your ___ care team Followup Instructions: ___
10132419-DS-15	10,132,419	23,821,029	DS	15	2149-01-12 00:00:00	2149-01-12 21:13:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: PPM placement ___ Blood Transfusion History of Present Illness: Mr. ___ is ___ with history of dementia (AAOx2 at baseline), HTN, HLD who was sent in from his ___ with SOB and chest pain. Per EMS, the patient reported having chest pain and shortness of breath at the NH. He also endorsed having L shoulder pain. The patient's pain resolved prior to transport to the ED. As per EMS, the patient was still complaining of SOB en route. Initial VS in the ED: 98.3 52 170/69 16. While in the ED, the patient was noted to deny any chest pain. Unclear if his pain was associated with exertion. He denied any fever, chills, nausea, vomit, or diarrhea. EKG while in the ED notable for LAD with occassional PVCs. Labs in the ED notable for trop of 0.13, and he started on heparin drip and given ASA 325 mg. On arrival to the floor, the patient reports feeling well. Denies any chest pain or tightness, no shortness of breath. Reports feeling comfortable. His only complaint is that he feels somewhat cold. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes -, Dyslipidemia +, Hypertension + 2. OTHER PAST MEDICAL HISTORY: cholelithiasis HTN HLD dementia Social History: ___ Family History: non contributory Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=98.4 BP= 165-184/50-55 HR= 55 RR=20 O2 sat=100%RA General: pleasant, well appearing, NAD, AAOx2 (oriented to self and place, not date), appropriately answering some questions HEENT: OP clear, no lesions, bilateral surgical pupils, MMM Neck: JVP 9cm CV: RRR, S1, S2 with resp variation, ___ LSB systolic murmur Lungs: very limited exam with poor air entry Abdomen: soft, NT, ND, BS+, large, obese, well healed surgical scars GU: no foley Ext: bilateral 2+ edema, Neuro: AxOx2, motor strength not tested Skin: sebhorreic keratoses PULSES: 1+ ___, 2+ radial pulses . . DISCHARGE PHYSICAL EXAM: VS: 98.4 129-173/57-59 ___ 18 97%RA Wt: refused General: NAD, AAOx2 (oriented to self and place, not date) HEENT: OP clear, no lesions, bilateral surgical pupils, MMM Neck: JVP 7cm CV: RRR, S1, S2 with resp variation, ___ LSB systolic murmur Chest: PPM in place, dressing c/d/i, no tenderness, no ecchymosis Lungs: Crackles at bases. No wheezes. Abdomen: Soft, NT, ND, BS+, large, obese GU: no foley Ext: Bilateral trace edema Neuro: AxOx2, motor strength not tested Skin: Sebhorreic keratoses, gluteal fold erythema with dressing in place PULSES: 1+ ___, 2+ radial pulses Pertinent Results: Admission Labs: ___ 09:42AM BLOOD WBC-11.3* RBC-3.44* Hgb-8.6* Hct-26.2* MCV-76* MCH-25.1* MCHC-33.0 RDW-14.2 Plt ___ ___ 09:42AM BLOOD Neuts-88.4* Lymphs-6.4* Monos-4.6 Eos-0.2 Baso-0.3 ___ 11:47PM BLOOD PTT-55.2* ___ 09:42AM BLOOD Glucose-114* UreaN-34* Creat-2.0* Na-139 K-3.9 Cl-105 HCO3-23 AnGap-15 ___ 09:42AM BLOOD CK(CPK)-466* ___ 09:42AM BLOOD CK-MB-9 proBNP-1234* ___ 09:42AM BLOOD cTropnT-0.06* Trop trend: ___ 09:42AM BLOOD cTropnT-0.06* ___ 04:10PM BLOOD cTropnT-0.13* ___ 01:47AM BLOOD CK-MB-8 cTropnT-0.19* ___ 08:50AM BLOOD CK-MB-8 cTropnT-0.22* Imaging: CXR: Mild bibasilar atelectasis. No acute cardiopulmonary abnormality otherwise demonstrated. . ECHO: The left atrium is moderately dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The descending thoracic aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral regurgitation. Brief Hospital Course: Mr. ___ is ___ with history of dementia (AAOx2 at baseline), HTN, HLD who was sent in from his ___ with SOB and chest pain, found to have NSTEMI which was medically managed, course complicated by tachy-brady syndome s/p PPM and GI bleed. . # NSTEMI: The patient ruled in for NSTEMI with trop of 0.16. Given the patient's dementia and goals of care, it was decided that medical management would be the best option. He was loaded with Plavix and completed 48 hours on a heparin gtt. He had an ECHO done which showed normal systolic function. - follow up with cardiology . # Tachy-brady syndrome: Patient found to have episodes of atrial fibrillation with rapid ventricular response in addition to episodes of bradycardia. Goals of care discussion elicited that it would be in the patient's benefit to undergo PPM placement. PPM was placed on ___ without complication. After PPM placement beta blockade was initiated to control further episodes of afib with rapid ventricular response. . # Kidney injury: Patient with acute kidney injury in ___ was 1.4 that per office records he was supposed to repeat and had not, of unclear etiology despite multiple attempts to elucidate prior baseline and course of kidney injury. Patient was admitted with Cr of 2.0 and thiazide was held. FeNa was 0.57% with urine sodium of 58. He responded minimally to fluid challenge. Upon discharge, Cr was 2.6. - recommend repeat labs drawn in one week to monitor Cr, labs to be sent to MD following at ___ . # HTN: The patient was initially continued on metoprolol and amlodipine when he was first admitted. His thiazide was held in the setting of his kidney injury. After developing bradycardic episodes metoprolol was held until PPM placed and then restarted. Hydralazine was increased for improved BP control. . # Anemia/GI bleed: Patient was noted to have downtrending hematocrit and guaiac positive stool. He received 1u PRBCs and his hematocrit stabilized. GI was consulted, who felt risk of colonoscopy in the initial 30 day period from ___ outweighed potential benefits. Colonoscopy was deferred to the outpatient setting should the family wish to pursue it. - f/u with GI for colonoscopy 3 weeks after discharge . # Alzheimer's dementia: The patient has a history of Alzheimer's dementia, AAOx2 at his baseline. While in house, he was continued on his home medications, donepezil, memantine, and olanazapine. Delirium precautions were taken, including minimizing tethers, ensuring adequate pain control, frequent reorientation, and orientation to day/night cycle. . # Delirium: Patient developed delirium, likely in the setting of PPM placement and extended hospital stay. Per family, patient had become combative in the past and often a sign the patient had the urge to urinate. No evidence of infection or leukocytosis, and delirium resolved with frequent reorientation. . # Depression: Continued on his home citalopram 20 mg daily. . # Fungal infection: The patient was noted to have fungal infection in skin folds and he was continued on antifungal powder. . # GERD: The patient's omeprazole was changed to pantoprazole in the setting of starting Plavix and the potential interactions between plavix and omeprazole. . Transitional Issues: - Contacts: Dr. ___ ___ - Code: DNR/DNI - follow up with cardiology - f/u with GI for colonoscopy 3 weeks after discharge - recommend repeat labs drawn in one week to monitor Cr, labs to be sent to MD following at ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Donepezil 5 mg PO HS 2. Aspirin 81 mg PO DAILY 3. Citalopram 20 mg PO DAILY 4. Docusate Sodium 100 mg PO BID 5. Calcium Carbonate 500 mg PO DAILY 6. Acetaminophen 650 mg PO Q4H:PRN pain 7. Artificial Tears 2 DROP BOTH EYES TID 8. OLANZapine 5 mg PO DAILY 9. Hydrochlorothiazide 12.5 mg PO DAILY please hold for SBP<100 10. HydrALAzine 10 mg PO Q6H please hold for SBP<100 11. Atorvastatin 20 mg PO HS 12. Omeprazole 20 mg PO DAILY 13. Amlodipine 10 mg PO DAILY please hold for SBP<100 14. Memantine 5 mg PO BID 15. Ketoconazole 2% 1 Appl TP BID 16. Metoprolol Tartrate 25 mg PO BID 17. Clotrimazole Cream 1 Appl TP BID rash 18. PreserVision AREDS NF (vitamins A,C,E-zinc-copper) ___ unit-mg-unit Oral DAILY 19. Nystop NF (nystatin) 100,000 unit/gram Topical BID rash Discharge Medications: 1. Clopidogrel 75 mg PO DAILY RX clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 2. Acetaminophen 650 mg PO Q4H:PRN pain 3. Amlodipine 10 mg PO DAILY 4. Artificial Tears 2 DROP BOTH EYES TID 5. Aspirin 325 mg PO DAILY RX aspirin 325 mg 1 tablet,delayed release (___) by mouth daily Disp #30 Tablet Refills:0 6. Atorvastatin 80 mg PO HS RX atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 7. Calcium Carbonate 500 mg PO DAILY 8. Citalopram 20 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Donepezil 5 mg PO HS 11. Ketoconazole 2% 1 Appl TP BID 12. Memantine 5 mg PO BID 13. OLANZapine 5 mg PO DAILY 14. Pantoprazole 40 mg PO Q24H RX pantoprazole 40 mg 1 tablet,delayed release (___) by mouth daily Disp #30 Tablet Refills:0 15. Clotrimazole Cream 1 Appl TP BID rash 16. Nystop NF (nystatin) 100,000 unit/gram Topical BID rash 17. PreserVision AREDS NF (vitamins A,C,E-zinc-copper) ___ unit-mg-unit Oral DAILY 18. Metoprolol Tartrate 200 mg PO BID RX metoprolol tartrate 100 mg 2 tablet(s) by mouth twice a day Disp #120 Tablet Refills:0 19. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY RX isosorbide mononitrate 60 mg 1 tablet extended release 24 hr(s) by mouth daily Disp #30 Tablet Refills:0 20. HydrALAzine 100 mg PO Q8H RX hydralazine 100 mg 1 tablet(s) by mouth every 8 hours Disp #90 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: primary diagnosis: NSTEMI, acute on chronic kidney injury Secondary diagnosis: Alzheimer's dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you while you were admitted to ___. You were admitted to the hospital because you had a heart attack. We started you on blood thinning medications to help treat your heart attack and adjusted your blood pressure medications. You also had an abnormal heart rhythm that required a pacemaker. You tolerated the procedure well. You were also admitted with worsening kidney injury which was noted in a previous doctor's visit in ___. This may be because you are not eating and drinking as well as you once were. Your blood levels dropped and you were found to have occult blood in your stool. The gastroenterologists were consulted and did not feel it would be necessary to intervene so soon after your heart attack due to the risks. You should follow up with the gastroenterologists in the next few weeks if you wish to pursue colonoscopy to find the source of the bleeding. You received a blood transfusion and your blood levels stabilized. Please see the attached sheet for your updated medication list. Please make sure to follow up with your doctors. Followup Instructions: ___
10132489-DS-4	10,132,489	20,721,274	DS	4	2163-11-28 00:00:00	2163-12-07 10:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ G3P1 at 33+0 with 3 weeks of left ankle redness and swelling that has been gradually worsening. Seen by PCP on ___, dx with cellulitis, given 1g of IM Ceftriaxone and Rx for Keflex. Told to F/U today. Pt didn't pick up Keflex until this AM and only had one dose prior to F/U appointment. Cellulitis worsening. Sent to ED for ___ for r/o DVT but transferred to OB Triage for further evaluation. Pt denies inciting event. No bite, cut or scratch. Denies fever or drainage. Denies CTX, VB or LOF. +AFM. Past Medical History: PNC: -___: ___ by ___ -Labs: O+/Ab-/HBsAg-/RPRNR/RI/HIV/GBSunk -Screening: LR ___! -FFS: WNL, anterior placenta -GLT: passed -EFW: ___ 81%ile -Issues: AMA h/o C/S, desires TOLAC, consent signed desires permanent sterilization PPBTL consent signed primary language ___. Declines interpreter. OBHx: -___ pLTCS fetal intolerance of labor remote from delivery 41+3, ___ -TAB -current GynHx: fibroids (current posterior left 2x2cm), h/o chlamydia PMH: h/o ASD s/p closure in ___, sickle cell trait PSH: pLTCS, D&C Meds: PNV NKDA SHx: denies ___ ___ Exam: Admission Exam: ___ 15:59Temp.: 98.0°F ___ 17:24BP: 107/63 (72) ___ ___: 92 -Gen: NAD, well appearing -Abd: gravid, soft, NT -NST: 125, mod var, +accels, occasional shallow variables -Toco: initially irritable, then flat after IVF/rest -TAUS: VTX, BPP ___, MVP 6 Discharge Exam: Gen: appears comfortable. VS: 98.1, 111/76, 85, 18, 99% Abd: soft, gravid, NT Ext: L lower extremity, erythema/tenderness at outlined area medially; regressed from outlined area laterally. no calf tenderness Pertinent Results: ___ 04:00PM BLOOD WBC-6.9 RBC-3.67* Hgb-11.4 Hct-32.7* MCV-89 MCH-31.1 MCHC-34.9 RDW-13.5 RDWSD-43.9 Plt ___ ___ 04:00PM BLOOD Neuts-67.0 ___ Monos-7.2 Eos-0.6* Baso-0.6 Im ___ AbsNeut-4.65 AbsLymp-1.53 AbsMono-0.50 AbsEos-0.04 AbsBaso-0.04 ___ 04:00PM BLOOD Glucose-67* UreaN-6 Creat-0.4 Na-138 K-4.8 Cl-106 HCO3-22 AnGap-10 Brief Hospital Course: Ms. ___ is a ___ yo G3p1 admitted to the Antepartum service for management of her left ankle cellulitis. Of note, she had received 1 dose of IM ceftriaxone on ___ ___s a dose of PO Keflex x1 (___) in the outpatient setting. She was started on IV ceftriaxone 1g Q8H (___) and admitted. On ___, her cellulitis was improving, and she had remained afebrile throughout the course of her admission. She was discharged home with a course of PO antibiotics. Discharge Medications: 1. Cephalexin 500 mg PO Q6H 2. Prenatal Vitamins 1 TAB PO DAILY Discharge Disposition: Home Discharge Diagnosis: pregnancy at 33w1d lower extremity cellulitis Discharge Condition: stable Discharge Instructions: You were admitted to the antepartum floor for treatment of your left lower extremity cellulitis (infection). You received 2 doses IV antibiotics and your infection improved significantly. It is very important that you continue taking the antibiotics as prescribed. You had no obstetric concerns while you were here and fetal testing was reassuring. Followup Instructions: ___
10132628-DS-22	10,132,628	25,596,068	DS	22	2135-08-21 00:00:00	2135-08-21 16:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Iodine-Iodine Containing / Darvon / Penicillins / Tetracycline / Erythromycin Base Attending: ___. Chief Complaint: R second toe swelling and pain Major Surgical or Invasive Procedure: ___- Right second toe amputation History of Present Illness: ___ with history of chronic pain and RA (Embrel and methotrexate) who presents 8 months status post a horse stepping on her for with an open wound on her right second toe, and significant swelling and erythema of the toe. Seen at ___ today for episodic visit and referred to the ED for evaluation. States that would has intermittently appeared to heal, then worsen. Patient denies any recent fevers or chills. Has not in any way felt ill. Only complaint has been toe. Also, patient has not taken/received either of her immunosupressants for several weeks. She stopped taking them given concern about her foot and fear of developing and infection while immunosuppressed. In the ED, initialy vitals: ___ pain, T 98.4, HR 81, BP 148/90, RR 18, 97% on RA. Labs notable for leukocytosis to 14.6 with 75.2N, 16.5 bands, CRP 7.4, Chem 7 unremarkable. Lactate 2.1. Blood culture sent. Wound cultures sent. Xray showed concerns for progression to osteomyelitis. Seen by podiatry however patient was refusing any type of surgical intervention. Podiatry rec admission to medicine for IV abx. Patient ordered for Cipro/Flagyl and vancomycin in the ED however ___ only notes having received flagyl. Upon arrival to the floor, patient ambulating in room and feels stable. Still thinking about what she would want to have done re operation, abx. Past Medical History: Past medical history is significant for: 1. Deep venous thrombosis ___ years ago. 2. Question of factor V Leiden deficiency. 3. Rheumatoid arthritis, seropositive. 4. Rotator cuff tear. 5. Left knee pain. 6. Bilateral carpal tunnel. 7. Back pain. 8. History of heart murmur. 9. Hypercholesterolemia. 10. Migraines. 11. History of gastroesophageal reflux. 12. Osteopenia. 13. Chronic pain with narcotic agreement. 14. Peptic ulcer disease. 15. Nephrolithiasis. Past Surgical History: 1. Hysterectomy for question of uterine cancer. 2. Rotator cuff surgery. 3. Gastrectomy for non-healing ulcer Social History: ___ Family History: Family history is significant for a sister with either uterine or ovarian cancer. Her son evidently has factor V Leiden deficiency and has had multiple complications of this. He also had gastric ulcers. Her mother may have had gastric ulcers as well. There is no history of gastrinoma or other endocrine diseases or cancers. There is a history of heart disease in her family. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: 98 52 153/85 18 99%RA General: Thin middle-aged woman sitting up in bed, wearing horse socks and clogs, alert, oriented, no acute distress, wanting to leave the hospital as soon as she can HEENT: sclera anicteric, MMM, oropharynx clear, poor dentition (dentures on top) Neck: supple, JVP not elevated, no LAD Lungs: wheezes on expiration throughout. CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: 2+ DP and ___ pulse on right. Normal capillary refill. Normal sensation (tender to palpation). Significant swelling and erythema around right second toe, with superficial ulcer on medial aspect. Neuro: CNs2-12 intact, motor function grossly normal DISCHARGE PHYSICAL EXAM Vitals: 98.5 97.8 77 (58-78) 115/60 (94-121/57-67) 18 95-98%RA General: Thin middle-aged woman sitting up in bed, reading the bible, alert, oriented, no acute distress, but irritable and sad affect, complaining of inadequate pain relief HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated Lungs: clear to auscultation b/l CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: Right foot wrapped in ACE bandage s/p second toe amputation Neuro: CNs2-12 intact, motor function grossly normal, gait deferred LABS: Reviewed, please see OMR. Pertinent Results: ================ ADMISSION LAB RESULTS ================ ___ 07:55PM WBC-14.6# RBC-3.87 HGB-12.3# HCT-37.3 MCV-96# MCH-31.8# MCHC-33.0 RDW-14.1 RDWSD-49.5* ___ 07:55PM NEUTS-75.2* LYMPHS-16.5* MONOS-6.1 EOS-1.2 BASOS-0.3 IM ___ AbsNeut-10.97* AbsLymp-2.41 AbsMono-0.89* AbsEos-0.17 AbsBaso-0.04 ___ 07:55PM CRP-7.4* ___ 07:55PM GLUCOSE-105* UREA N-21* CREAT-0.8 SODIUM-138 POTASSIUM-3.6 CHLORIDE-98 TOTAL CO2-27 ANION GAP-17 ___ 08:14PM LACTATE-2.1* ============== DISCHARGE LAB RESULTS ============== ___ 06:52AM BLOOD WBC-8.1 RBC-3.27* Hgb-10.1* Hct-32.5* MCV-99* MCH-30.9 MCHC-31.1* RDW-14.6 RDWSD-52.9* Plt ___ ___ 06:52AM BLOOD Glucose-77 UreaN-18 Creat-0.8 Na-138 K-4.4 Cl-102 HCO3-27 AnGap-13 ___ 06:52AM BLOOD Calcium-9.0 Phos-4.1 Mg-2.0 ============== IMAGING ============== ___, Xray, right foot: Four views of the right second toe provided. Since the prior exam, the appearance of the mid phalanx of the second ray appears somewhat truncated along the proximal and mid aspect. While loss of bone in the setting of osteomyelitis is a potential concern, findings are indeterminate. Would recommend MRI to further assess. ___, MRI: 1. Osteomyelitis of the second proximal and middle phalanges, with preservation of bone marrow signal of the distal phalanx and of the metatarsal head. Trace fluid in the second MTP joint may be reactive or infected. 2. Bone marrow signal changes of the tibial sesamoid likely due to stress related changes, seen with sesamoiditis. These are not reflective of osteomyelitis. 3. Juxta articular erosion at the medial first metatarsal head, either related to mechanical stress from hallux valgus, or prior episode of gout. This is not compatible with a rheumatoid erosion. This does not appear to be an active process. ___, U/S aorta and branches: Significant atherosclerotic calcifications in the abdominal aorta without evidence of aneurysm. ___, CXR: A right-sided PICC is in-situ, this terminates very distally in the SVC, possibly in the right atrium. This could be safely withdrawn by 2.5 cm to be well seated in the SVC. Lung volumes are within normal limits. The trachea is central. The cardiomediastinal contour is normal. The heart is not enlarged. No consolidation, pneumothorax or pleural effusion seen. Moderate atherosclerotic calcification in the aortic arch. There has been interval resolution of the previously demonstrated atelectasis at the bilateral lung bases. [NOTE: PICC WAS PULLED BY 2.5 CM AFTER THIS REPORT] Brief Hospital Course: ___ with history of chronic pain and rheumatoid arthritis (on etanercept and methotrexate) who presents 8 months after a horse stepped on her foot, with a poorly healing, swollen, and erythematous wound on her right second toe, diagnosed on MRI as osteomyelitis. #Toe Wound - Her R second toe was erythematous and swollen, with an ulcer that could not be probed to bone. Xray was indeterminate, but MRI showed osteomyelitis. She had a slightly elevated CRP of 7.4, and had WBC 14.6 on admission, downtrending to 10.3 the next day and then within the normal range. Wound culture grew Group B Strep and Coag-negative Staph. A PICC was placed and she was started on IV vancomycin and PO ciprofloxacin. Her toe was amputated by podiatry on ___, and she was switched to PO levofloxacin for a total 7 day course (day ___ = ___. #HTN - Pt was mildly hypertensive to 150s in ED and on admission to the floor. Likely in setting of acute pain. Does not have history of HTN. Will be followed by her PCP ___. CHRONIC ISSUES: #Chronic pain - has narcotic plan on file. Home regimen was continued, with additional breakthrough oxycodone for pain related to the amputation. #Nicotine addiction: Pt desires to quit. She was provided with a nicotine patch and lozenges prescription. #GERD - continue omeprazole 40mg qD #Rheumatoid arthritis - we held immunosupressants in setting of acute illness #Concern for AAA - a faint bruit was heard on exam, so we ordered an abdominal U/S, which was reassuring. There is calcification, but no aneurysm. TRANSITIONAL ISSUES -Pt should take a 7 day course PO levofloxacin (day ___ for toe infection. -Pt was discharged with a prescription for a nicotine patch (14mg) and lozenges PRN. She desires to quit smoking. -Pt was given an increased oxycodone 10mg Q8H PRN prescription to treat pain from the amputation for 10 days, #30. Continue long-acting MS ___ as prescribed by narcotics agreement and short-acting oxycodone after current oxycodone finishes. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ondansetron 4 mg PO Q12H:PRN nausea 2. Methotrexate 25 mg IM QWEEK 3. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain 4. etanercept 50 mg/mL (0.98 mL) subcutaneous qweek 5. Ferrous Sulfate 325 mg PO DAILY 6. Multivitamins 1 TAB PO DAILY 7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain 8. Omeprazole 40 mg PO DAILY 9. FoLIC Acid 1 mg PO DAILY 10. butalbital-aspirin-caffeine 50-325-40 mg oral Q4H:PRN headache 11. Calcium Carbonate 500 mg PO Q24H 12. Vitamin D 1000 UNIT PO DAILY 13. Morphine SR (MS ___ 45 mg PO NOON 14. Morphine SR (MS ___ 60 mg PO Q12H 15. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough Discharge Medications: 1. Calcium Carbonate 500 mg PO Q24H 2. Ferrous Sulfate 325 mg PO DAILY 3. FoLIC Acid 1 mg PO DAILY 4. Lidocaine 5% Patch 1 PTCH TD QAM:PRN pain 5. Morphine SR (MS ___ 45 mg PO NOON 6. Morphine SR (MS ___ 60 mg PO Q12H 7. Multivitamins 1 TAB PO DAILY 8. Omeprazole 40 mg PO DAILY 9. Ondansetron 4 mg PO Q12H:PRN nausea 10. Vitamin D 1000 UNIT PO DAILY 11. Nicotine Patch 14 mg TD DAILY RX nicotine 14 mg/24 hour Apply 1 patch once a day Disp #14 Patch Refills:2 12. butalbital-aspirin-caffeine 50-325-40 mg oral Q4H:PRN headache 13. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough 14. etanercept 50 mg/mL (0.98 mL) subcutaneous qweek 15. Methotrexate 25 mg IM QWEEK 16. Levofloxacin 500 mg PO Q24H Duration: 6 Days RX levofloxacin 500 mg 1 tablet(s) by mouth once a day Disp #6 Tablet Refills:0 17. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain RX oxycodone 10 mg 1 tablet(s) by mouth every eight (8) hours Disp #30 Tablet Refills:0 18. Nicotine Lozenge 2 mg PO Q8H:PRN smoking urge RX nicotine (polacrilex) 2 mg Take 1 lozenge three times a day Disp #96 Lozenge Refills:0 Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Osteomyelitis Toe amputation SECONDARY DIAGNOSES: Rheumatoid Arthritis Chronic Pain Gastroesophageal reflux Hyperlipidemia Migraines Osteoarthritis Nicotine addiction Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because of the wound on your toe. An MRI showed that you have osteomyelitis, or an infection of the bone. We placed a PICC line (peripherally inserted central catheter) so that you can receive IV antibiotics. After discussing the options with the podiatry service (foot doctors), you also decided to go ahead with an amputation of the toe. The operation went well; they removed all infected bone. As a result, you can go home with antibiotic pills, instead of needing IV treatment. Therefore, we pulled out your PICC line. While you were here, we also did an ultrasound of your abdomen, which found that you did not have an aortic aneurysm (outpouching of your aorta). Please keep your main dressing on your toe until your Podiatry appointment. You may use dry sterile dressings over it. It was a pleasure taking care of you. Best wishes, Your ___ care team Followup Instructions: ___
10132759-DS-4	10,132,759	24,406,934	DS	4	2178-06-03 00:00:00	2178-06-04 11:36:00	Name: ___. Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ciprofloxacin Attending: ___. Chief Complaint: Syncope after exertion Major Surgical or Invasive Procedure: None. History of Present Illness: ___ with history of HTN, who presents with syncope. ___ states he was in his usual state of health, ate dinner and ___ glasses of wine night prior at 7PM, did not eat or drink after that before going to the gym this AM for a 50 minute workout, mostly lifting moderate amounts. At baseline he is very active and able to climb 3 flights of stairs without any chest pain, shortness of breath, palpitations, nausea, vomiting or lightheadedness. Toward end of his workout today he began to feel nauseated while standing. He sat down and immediately ___ and syncopized for duration of ___ seconds. He was lowered to the ground without head strike. Legs were elevated and he regained consciousness. No significant confusion afterward and was following commands. He was not noted to be making any involuntary movements or have loss of bowel or bladder function. He denies any history of similar episodes. ROS before/during/after the syncopal episode is otherwise negative for any chest pain, palpitations, shortness of breath, or pain in the neck or back. He denies any recent GI illness, dysuria, abdominal pain, dizziness, headaches, or focal neurological signs/symptoms. . ED Course: ___ presented hypotensive (84/53) with HR 60, O2 94%RA, and afebrile (T 97.6). He noteably had a lactate of 6.1, which improved to 2.7 after 1 hour with hemodynamic stabilization with 1L NS. ___ BP improved to ___ with IVF, but his heart rate noteably remained in the ___. He was given ASA 325mg. Troponin x2 was negative, with EKG: SR 62 NA/NI. CTA was negative for PE. CXR was negative for significant mediastinal widening. ___ was deemed to require admission given syncope in the setting of exertion. Past Medical History: PAST MEDICAL HISTORY: #Negative stress test per ___ in ___; performed for unclear reasons #Hypertension - ___ BP 130s/90s, started ACE, baseline BPs 120s/80s #Gout - On maintenance meds, no recent flares. #Shingles #Basal cell carcinoma - Multiple face/arm #Hypercholesterolemia - on statin #Nephrolithiasis - x1 episode in the past #Osteoarthritis #Sleep apnea - not on CPAP #Polycythemia - ___ referred to Hematologist after epistaxis and finding of slighly high h/h, father had h/o PV. W/u by Dr. ___ was negative for ___, attributed to hemoconcentration. PAST SURGICAL HISTORY: s/p subtotal cholecystectomy with residual gallstones in remaining gallbladder ___ yrs ago at ___ s/p total knee replacement s/p hand surgery s/p arthroscopy for R knee soft tissue injury Social History: ___ Family History: No FH of CAD, sudden death Mother (___ Father (___) - aortic aneurysm Brother (___ age ___ - dx w/ late stage colon ca at age ___ Physical Exam: ADMISSION PHYSICAL EXAM: Vitals - 98.5 Supine: BP 144/90 HR 60; Standing: 158/91, 56 97%RA General- Alert, oriented, no acute distress. HEENT- Sclera anicteric, MMM, oropharynx clear. Some redundancy of oropharyngeal/neck soft tissues w/o any mouth breathing. Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Faint heart sounds, borderline brady rate, normal rhythm, normal S1 + S2, no murmurs, rubs, or gallops Abdomen- Obese, soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly. A RUQ surgical scar. GU- no foley Ext- A superficial ___ varicosity noted on right anterior thigh, stable per ___ w/o evidence of thrombosis. Bilat ___ Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- ___ intact, motor function grossly normal. No dizziness or unsteadiness upon standing. Normal gait, including ___, no loss of balance. DISCHARGE PHYSICAL EXAM: PHYSICAL EXAM: Vitals - 98.5 Sitting: 120/77 50 97%RA I/O: In 120 PO; Out ? *Stable, unchanged General- Alert, oriented, no acute distress. HEENT- Sclera anicteric, MMM, oropharynx clear. Some redundancy of oropharyngeal/neck soft tissues w/o any mouth breathing. Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Faint heart sounds, borderline brady rate, normal rhythm, normal S1 + S2, no murmurs, rubs, or gallops Abdomen- Obese, soft, ___, bowel sounds present, no rebound tenderness or guarding, no organomegaly. A RUQ surgical scar. GU- no foley Ext- A superficial ___ varicosity noted on right anterior thigh, stable per ___ w/o evidence of thrombosis, without swelling or tenderness in the calves. Bilat ___ Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- ___ intact, motor function grossly normal. No dizziness or unsteadiness upon standing. Normal gait, including ___, no loss of balance. Pertinent Results: LABS ON ADMISSION/ED: ___ 09:50AM BLOOD ___ ___ Plt ___ ___ 09:50AM BLOOD ___ ___ ___ 09:50AM BLOOD ___ ___ ___ 09:50AM BLOOD Plt ___ ___ 09:50AM BLOOD ___ ___ ___ 09:50AM BLOOD cTropnT-<0.01 ___ 10:03AM BLOOD ___ ___ 11:04AM BLOOD ___ LABS DURING HOSPITAL COURSE AND UPON DISHARGE: ___ 04:45PM BLOOD cTropnT-<0.01 ___ 08:07PM BLOOD ___ ___ 05:05AM BLOOD ___ ___ ___ 05:05AM BLOOD ___ MICRO: ___ Blood Cx PENDING IMAGING/STUDIES: ___ ED EKG: SR 62 NA/NI ___ CTA Chest w/ and w/o contrast IMPRESSION: No pulmonary embolus or other findings to explain symptoms. ___ AP CXR FINDINGS: Frontal and lateral views of the chest. The appearance of the mediastinum is unchanged, accounting for differences in technique. There is no pleural effusion, pneumothorax or focal airspace consolidation. Bibasilar atelectasis is present. The heart size is normal. The hilar structures are unremarkable. IMPRESSION: Unchanged, ___ mediastinum. Brief Hospital Course: ___ with history of HTN presented with syncope on exertion. # Syncope: Given the ___ has been somewhat deconditioned from his baseline exertion level (1 month), did not eat or drink since 7PM night before, and had a moderately intense anaerobic workout, in the setting of likely high vagal tone and resting heart rate, and recently starting tamsulosin which can lower BP, he likely experienced syncope secondary to orthostatic hypotension. His blood pressure was noted to be in the systolic of 90 per EMS note which increased to SBP>100 with 1L IVF. He was no longer orthostatics on admission to medicine service; Cardiac cause less likely given the fact that ___ at baseline is very active and not limited by any cardiac symptoms. His EKG did not show signs of ischemia and two sets of troponins negative. He was monitored overnight on tele without any events. ___ BP is running high after stabilization, so he can likely tolerate Tamsulosin for mild BPH symptoms, just reiterated need to stay hydrated at all times, take frequent breaks during exercise, as this medication can make low BP due to dehydration even worse. # Lactic acidosis: ___ noted to be hypotensive with HR 60 upon admission to ED, with lactate 6.1. Downtrended to 2.7 with IVF and hemodynamic stabilization which is reassuring. His lactate as well as renal function normalized after 2L of NS. Transition of Care: - f/u PCP - ___ discharged on Zolpidem 5mg qHS, down from 10mg qHS on admission given recent FDA warning against higher doses - No other medication changes were made during this hospitalization # CODE STATUS: Full (confirmed) # CONTACT: Wife, ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Tamsulosin 0.4 mg PO DAILY 2. Aspirin 81 mg PO DAILY 3. Moexipril 15 mg PO DAILY 4. Simvastatin 40 mg PO DAILY 5. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 6. Allopurinol ___ mg PO DAILY 7. Ursodiol Dose is Unknown PO BID 8. Acetaminophen 650 mg PO Q6H:PRN aches and pains Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN aches and pains 2. Allopurinol ___ mg PO DAILY 3. Aspirin 81 mg PO DAILY 4. Moexipril 15 mg PO DAILY 5. Simvastatin 40 mg PO DAILY 6. Tamsulosin 0.4 mg PO DAILY 7. Zolpidem Tartrate 5 mg PO HS:PRN insomnia 8. Ursodiol 300 mg PO BID Discharge Disposition: Home Discharge Diagnosis: 1. Syncope due to orthostasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you during your recent hospitalization at ___ between ___ and ___. You were admitted because you fainted after exercising. We belive your fainting was secondary to be dehydrated with contributions from tamsulosin. Your blood tests and blood pressure improved after receiving intravenous fluids. Your labs and EKG did not reveal any cardiac causes. You were monitored overnight in the hospital without any recurrent symptoms. Please keep yourself hydrated and follow up with your PCP. You should seek immediate medical care if you experience chest pain, shortness of breath, palpitations, dizziness, fainting, headaches or any other new or concerning symptoms. Followup Instructions: ___
10132833-DS-18	10,132,833	24,015,490	DS	18	2137-10-29 00:00:00	2137-10-29 11:09:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: chest pressure Major Surgical or Invasive Procedure: cardiac catheterization ___ History of Present Illness: Dr. ___ is a ___ with h/o HTN, HLD, T2DM, nonalcoholic steatohepatitis, who presents with chest pain. Yesterday while at a lawyer's office drawing up her will, she experienced some substernal chest tightness. Reported substernal heaviness ___, no radiation, no diaphoresis, no n/v, no shortness of breath. Hadn't had breakfast so took tums and prilosec without improvement. Ate soup and crackers. Pressure was not relieved. Saw only four scheduled office patients and then went home early to rest. Pain was relieved resting on couch (lasted from 11am-4pm). Slept all night but pressure again started this morning in the shower, ___. Last felt pressure at 8am. Went to PCP and ECG showed some changes with very slight ST elevation in V2-V3. Was given ASA 325mg and referred to ED. . In the ED, initial vitals were 98 75 161/79 12 100%. Labs and imaging significant for trop 0.27, CK 198, MB 12, MBI 6.1. Creatinine was normal, lytes normal, CBC normal. ECG showed sinus NA NI NSST changes no STEMI. CXR showed mild cardiomegaly without signs of acute decompensation. Cardiology was consulted and recommended admission to ___, with plan for catheterization. Patient given plavix 600mg po x1, and started on heparin gtt. She had already received 325mg ASA this am at PCP's office. Guaiac negative. Vitals on transfer were Temp: 98.2 °F (36.8 °C), Pulse: 63, RR: 14, BP: 138/71, Rhythm: Normal Sinus Rhythm, O2Sat: 100% 2L NC, Pain: 0. . On arrival to the floor, patient is s/p catheterization with clean coronaries. Some wall motion abnormalities seen in the lateral walls, not at the apex. Patient is comfortable without chest pain (none since 8am this morning). Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, + Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: - nonalcoholic steatohepatitis - Diabetes Type 2 - HTN - HLD - Bell's palsy - Carpal Tunnel Syndrome - L hip OA - L hip trochanteric bursitis - GERD Social History: ___ Family History: Father: CAD in ___, Mother: htn No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam: VS: 98.8, 148/65, 78, 97%RA GENERAL: WDWN middle aged woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP not elevated. 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. EXTREMITIES: No c/c/e. radial right wrist band SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ ___ 2+ Left: DP 2+ ___ 2+ Discharge Exam: VS: 97.8, 114/71 (114-150s/60-80s), 50-60s, 20, 98%RA Weigth 82.5kg GENERAL: WDWN middle aged woman in NAD. Oriented x3. Mood, affect appropriate. NECK: Supple with JVP not elevated. CARDIAC: PMI located in ___ intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. radial right wrist band removed, c/d/i dressing placed. Pertinent Results: Admission Labs: ___ 10:50AM BLOOD WBC-7.4 RBC-4.34 Hgb-12.7 Hct-39.5 MCV-91 MCH-29.3 MCHC-32.1 RDW-14.1 Plt ___ ___ 10:50AM BLOOD Neuts-64.5 ___ Monos-2.6 Eos-1.0 Baso-0.7 ___ 10:50AM BLOOD ___ PTT-34.7 ___ ___ 10:50AM BLOOD Glucose-101* UreaN-13 Creat-0.6 Na-141 K-4.2 Cl-104 HCO3-24 AnGap-17 ___ 10:50AM BLOOD CK(CPK)-198 ___ 10:50AM BLOOD CK-MB-12* MB Indx-6.1* ___ 10:50AM BLOOD cTropnT-0.27* ___ 10:50AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8 Cardiac Enzyme trend: ___ 10:50AM BLOOD CK-MB-12* MB Indx-6.1* ___ 10:50AM BLOOD cTropnT-0.27* ___ 07:19AM BLOOD CK-MB-6 Discharge Labs: ___ 07:19AM BLOOD WBC-7.3 RBC-4.45 Hgb-13.3 Hct-41.1 MCV-92 MCH-29.8 MCHC-32.3 RDW-14.1 Plt ___ ___ 07:19AM BLOOD ___ PTT-34.3 ___ ___ 07:19AM BLOOD Glucose-112* UreaN-11 Creat-0.6 Na-141 K-4.3 Cl-103 HCO3-28 AnGap-14 ___ 07:19AM BLOOD CK(CPK)-135 ___ 07:19AM BLOOD CK-MB-6 ___ 07:19AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.9 ___ Cardiac Catheterization: PRELIMINARY REPORT PROCEDURE: 1. Selective coronary angiography was performed in multiple projections via the right radial artery using a ___ Jacky catheter advanced to the ascending aorta through a 6 ___ introducing sheath and using manual contrast injections. 2. Left heart catheterization and left ventriculography was performed in ___ and ___ views using a 5 ___ pigtail cathter advanced to the left ventricle through a 6 ___ introducing sheath and using power injection of contrast. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: m2 HEMOGLOBIN: gms % FICK PRESSURES LEFT VENTRICLE {s/ed} 180/28 195/34 AORTA {s/d/m} 180/89/124 195/88/136 CARDIAC OUTPUT HEART RATE {beats/min} 76 90 RHYTHM SINUS SINUS TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 36 minutes. Arterial time = 27 minutes. Fluoro time = 8.1 minutes. Effective Equivalent Dose Index (mGy) = 881 mGy. Contrast injected: Omnipaque, vol 126 ml Premedications: Midazolam 0.5 mg IV Fentanyl 25 mcg IV Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin ___ units IV Other medication: Diltiazem 500 MCG IA x1 Nitroglycerine 200 MCG IV x1 COMMENTS: 1. Selective coronary angiography in this right dominant system demonstrated no angiographically significant coronary disease in the LMCA, LAD, LCX or RCA. 2. Limited resting hemodynamics revealed severe systemic arterial hypertension with an opening central aortic blood pressure of 180/89 mMHg. The LVEDP was severely elevated at 28 mmHg. Post LV gram severe systemic arterial hypertension persisted with a central aortic blood pressure of 195/88 mmHg. The post LV gram LVEDP was mildly elevated from baseline at 34 mmHg. 3. Left ventriculography in the ___ and ___ views demonstrated mild LV systolic dysfunction with an EF of 50%. The mid anterolateral and mid inferior walls were hypokinetic, although the true apex had normal wall motion. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Mild LV systolic and diastolic dysfunction with an elevated LVEDP of 28 mmHg. 3. Severe systemic arterial hypertension. 4. Possible stress induced cardiomyopathy vs. hypertensive cardiomyopathy. ___ CXR: PA and lateral views of the chest were obtained. The heart is mildly enlarged. There is no sign of pulmonary edema or heart failure. No pleural effusion. No pneumothorax. Mediastinal contour is unremarkable. Bony structures are intact. No free air below the right hemidiaphragm. IMPRESSION: Mild cardiomegaly without signs of acute decompensation. Brief Hospital Course: Ms. ___ is a ___ with h/o HTN, HLD, DM, nonalcoholic steatohepatitis, who presents with chest pressure of one day duration, who was found to have nonspecific ECG changes and troponin leak, concerning for NSTEMI. . # Chest pressure: Dr. ___ presented with ___ chest pressure at rest, and found to have troponin of 0.27, with CKMB 12 and Cardiac index of 6.1. ECG showed nonspecific changes. Pt was given plavix and heparin gtt in ED and taken straight to cardiac catheterization which showed normal coronary arteries, mild LV systolic and diastolic dysfunction with an elevated LVEDP of 28 mmHg, severe systemic arterial hypertension. Etiology of symptoms and findings is unclear but possibly stress induced cardiomyopathy vs. hypertensive cardiomyopathy vs. focal myocarditis vs. recanalized coronary artery vs. vasospasm. Left ventricular venogram showed mild anterolateral and mid inferior hypokinesis, with normal kinesis of the apex. Unclear etiology for hypokinesis at this point, given location is not classic for ___. Patient was monitored on telemetry overnight without events. No further chest pressure. CKMB the morning was discharge decreased to 6. Patient was started on ASA 81 and metoprolol 12.5mg BID with good BP and HR control. Continued on home dose ___ and ___ 20mg daily. She was given nitro SL prn for chest pain as well. Patient was instructed to follow up with a cardiologist. She prefered Dr. ___ to set her up with a cardiologist. She was requested to schedule the appointment to be seen within 2 weeks. A repeat echo should be performed and her outpatient cardiologist can consider a cardiac MRI to evaluate for subendocardial infarction for further evaluation, though this would not likely change management. . # PUMP: No TTE in our system, but pt had stress echo in ___, with preserved EF. LV gram today showed preserved ejection fraction as well. Patient appeared euvolemic throughout the admission. . # Diabetes: Most recent A1c 6.6% in ___ per PCP notes, pt states she has had more recent A1c 5.6 on Metformin. On admission, held metformin given large dye load and managed with HISS. Home metformin restarted on discharge. . # HTN: Per PCP notes, diagnosed as essential HTN. On arrival to the floors, pt has elevated BP to systolic 170s initially, improved to 140s without meds. Metoprolol 12.5mg BID was added to regimen of losartan 25mg daily for improved BP control and cardiac remodeling in the event that Dr. ___ a cardiac event. Dr. ___ will follow up with PCP for BP check. . # HLD: Continued home ___ 20mg daily, Gemfibrozil, Zetia. . # GERD: Continued omeprazole (pt uses prn). . # Nonalcoholic steatohepatitis: Not actively managed this admission. Transitional Issues: Dr. ___ will follow up with PCP at scheduled appointment in 2 weeks. Blood pressure should be checked at this time. Consider increasing Losartan to 50mg daily if elevated. Dr. ___ was requested to have Dr. ___ her to a cardiologist, with the plan to be seen within ___. She requires a repeat cardiac echo. Cardiac MRI can be considered to evaluate for infarction/myocardial changes, though this will likely not cahnge management. She was started on ASA 81mg daily and metoprolol succinate 25mg daily this admission. Nitro SL prn for chest pain. Medications on Admission: - Vitamin D 1000 units daily - Gemfibrozil 600mg BID - Omeprazole 20mg daily - Cozaar 25mg daily - Metformin 500mg BID - ___ 20mg daily - Zetia 10mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:30 Tablet, Chewable(s) Refills:2 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. metoprolol succinate 25 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 8. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) tablet Sublingual once a day as needed for chest pain: Take one tablet every 5 minutes for up to 3 tablets for chest pressure/pain. Disp:50 tablets Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary: Left Ventricular Dysfunction (recanalized coronary obstruction vs. vasospasm) Secondary: Diabetes Hypertension Hypercholesterolemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Dr. ___, ___ was a pleasure taking care of you during this admission. You came to the hospital for chest pressure. You were found to have an elevation in your cardiac enzymes. You had a cardiac catheterization that showed the coronaries were clean, but you had mild anterolateral and mid inferior hypokinesis of the left ventricle. We are unsure what caused these findings, but are concerned that you either had an obstruction that resolved or a coronary vasospasm. You were feeling better, and we started you on a low dose of Metoprolol. You should have cardiology follow up, which Dr. ___ set up. You should additionally have a repeat cardiac echo and can consider having your cardiologist order a cardiac MRI for you within the next two weeks to further evaluate for possible myocardial infarction. If you would like to schedule this here, the phone number is ___. We have also sent the cardiac MRI department an email to notify that you may be calling in the next week to set this up. If you decide not to make this appointment please call to let them know. The following medications were changed during this admission: - START Metoprolol XL 25mg daily - START Aspirin 81mg daily - START sublingual nitroglycerin 1 tablet every 5 minutes, up to 3 successive tablets (total of 15minutes), for chest pain as needed. Please continue the other medications you were taking during this admission. You may want to discuss increasing your Losartan with your primary care doctor if your blood pressure continues to be elevated. Followup Instructions: ___
10133075-DS-9	10,133,075	24,506,507	DS	9	2180-08-22 00:00:00	2180-08-23 05:40:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: facial cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: ___ with ___ ___ pituitary adenoma, HTN, DM recently underwent cyber-knife tx for five days (last day ___, discharged ___ after presenting with blurry vision found to have ___ related glucose intolerance and was started on Metformin, Humalog, Lantus. Also started on HCTZ for HTN. Patient states 2 days ago she noticed L cheek swelling with mild discomfort that worsened significantly today. She attributed it to tooth pain and tried oragel. Area of swelling increased in size and induration with some warmth over the past 24 hours. No overlying skin breakdown, discoloration, redness, or drainage. Only barrier impairment is facial rash/acne present since starting cyberknife and white plaques in her mouth. She chews her cheek at nighttime. No hx of trauma. Denies odynophagia, dysphagia, fever, chills, cough, neck pain, hearing or visual changes. In the ED, VS: 97.1 105 142/97 18 99%RA. Labs notable for WBC 24.7. CT sinuses showed soft tissue swelling over L maxilla, no abscess formation c/w cellulitis. Pt tx with IVF, Vancomycin 1g IV x 1, Unasyn 3g IV x 1 and toradol for pain. Will admit to medicine for IV abx and further monitoring. Vitals prior to transfer 96.8 92 134/90 14 100%. On arrival to the floor, pt feels well. Pain is improved. REVIEW OF SYSTEMS: (+) (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: -Hypertension -Cushings related glucose intolerance -ACTH secreting pituitary adenoma with trans-sphenoidal resection x 2 ___ and ___. -Persistent Cushings Disease: final cyberknife ___ Social History: ___ Family History: Parents and siblings all healthy Physical Exam: ADMISSION PHYSICAL EXAM VS - 98.4 139/90 94 18 98/RA GENERAL - well-appearing female in NAD, comfortable, appropriate, cushinoid signs including stria, central obesity, acne, facial rounding HEENT - PERRL, EOMI, diffuse acneiform rash over face, indurated swelling of L cheek nonerythematous, mild tenderness to palpation, no fluctuance, white plaques scattered over bucchal mucosa. No tooth abscess or tenderness noted. No gum swelling or tenderness. NECK - supple, L sided cervical lymphadenopathy LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait DISCHARGE PHYSICAL EXAM VS - 98.2 117/71 76 18 100%RA fss 143-260 GENERAL - well-appearing female in NAD, comfortable, appropriate, cushinoid signs including stria, central obesity, acne, facial rounding HEENT - PERRL, EOMI, diffuse acneiform rash over face, indurated swelling of L cheek nonerythematous, mild tenderness, no fluctuance. Swelling and tenderness with improvement since admission. Previous white plaques resolved. No tooth abscess or tenderness noted. No gum swelling or tenderness. NECK - supple, L sided cervical lymphadenopathy LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, steady gait Pertinent Results: ADMISSION LABS ___ 11:40AM BLOOD WBC-24.7* RBC-4.92 Hgb-14.3 Hct-43.6 MCV-89 MCH-29.0 MCHC-32.7 RDW-15.5 Plt ___ ___ 11:40AM BLOOD Neuts-87.8* Lymphs-6.3* Monos-5.5 Eos-0.2 Baso-0.2 ___ 11:40AM BLOOD Glucose-145* UreaN-24* Creat-1.1 Na-131* K-5.6* Cl-104 HCO3-19* AnGap-14 ___ 05:50AM BLOOD Calcium-8.4 Phos-3.5 Mg-1.9 ___ 09:19PM BLOOD Lactate-2.9* ___ 06:45AM BLOOD Lactate-1.9 DISCHARGE LABS ___ 06:30AM BLOOD WBC-21.0* RBC-4.70 Hgb-13.8 Hct-42.4 MCV-90 MCH-29.4 MCHC-32.6 RDW-15.6* Plt ___ ___ 06:30AM BLOOD Glucose-134* UreaN-17 Creat-0.9 Na-137 K-4.6 Cl-96 HCO3-27 AnGap-19 URINE ___ 11:40AM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM ___ 11:40AM URINE RBC-1 WBC-7* Bacteri-NONE Yeast-NONE Epi-2 MICRO ___ CULTUREBlood Culture, Routine-PENDING ___ CULTUREBlood Culture, Routine-PENDING IMAGING ___ CT SINUS/MADIBLE/MAXIL IMPRESSION: 1. Soft tissue fat stranding overlying the left anterior masseter without a fluid collection to indicate an abscess. This is compatible with cellulitis. 2. Mild left maxillary sinus mucosal thickening, without fluid to suggest acute infection. The roots ___ #16 extend into the left maxillary sinus. 3. Postsurgical changes in the nasal cavity and sphenoid/ethmoid sinuses. Soft tissue contents of the sella would be better assessed by MRI, if indicated. Brief Hospital Course: ___ yo F with h/o ___ Disease undergoing radiation with dexamethasone supplementation who presents with L facial cellulitis. # facial cellulitis: No evidence of systemic effects - normal vitals, afebrile. Most likely infectious source is skin flora. No evidence of preexisting trauma, break in skin, infection, or inflammation. Tooth without tenderness and no abscess noted. Gums also without swelling or tenderness. Unlikely for cheek to be affected with cyberknife. Per CT scan, soft tissue fat stranding seen which was c/w cellulitis without evidence of an abscess. CT also noted that the nerve roots of left ___ #16 extend into the left maxillary sinus, which may be the point of entry for infection. Patient was started on vancomycin and switched to augmentin to complete a 7 days course of antibiotic treatment. She was advised to make an appointment with her dentist for evaluation of her teeth especially ___ #16. At discharge, her L cheek swelling and pain had improved and she stated that her dentist appointment is scheduled for tomorrow. Pain was controlled with oxycodone-acetaminophen. # Cushings related glucose intolerance: In the setting of ___ Disease and exogenous steroids. Previous recent presentation, pt had AG acidosis, pseudohyponatremia, ketonuria, hyperglycemia - none currently. During her previous hospitalization she was started on lantus, SS, and metformin. Her lytes have been normal during this admission with no ketonuria. Her blood glucose was at high as 270 during admission, but trended down to the 130s-160s. Her FSS rnged from 140s-260. She was continued on the lantus 16 units at night and sliding scale as needed. Her metformin was held. # Thrush: noticed to have thrush on admission which is likely related to glucose impairment and cushings. She was started on nystatin swish/spit and the thrush resolved by discharge. # CKD: patient creatinine remained at her baseline throughout her hospitalization. # Leukocytosis: Likely from dexamethasone and cellulitis. UA unremarkable and with no URI or UTI symptoms. # Pituitary adenoma: The patient is undergoing cyberknife radiation. On ketoconazole as adrenal enzyme inhibitor (cortisol biosynthesis inhibitor). She is currently on a dexamethasone taper and due to taper off by ___. She has follow up with endocrinologist on ___. # Hypertension: continued on home ___ # TRANSITIONAL ISSUES -please recheck CBC and ensure that WBC continues to trend down (patient is on Dexamethasone and tapering off by ___ -please ensure patient has followed up with her dentist -please check L facial cellulitis and ensure that it is improving -patient to complete 7 day course of Augmentin -please follow up with pending blood culture Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Hydrochlorothiazide 25 mg PO DAILY 2. Ketoconazole 400 mg PO TID 3. Omeprazole 20 mg PO DAILY 4. Glargine 16 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 5. Multivitamins 1 TAB PO DAILY 6. MetFORMIN (Glucophage) 1000 mg PO BID 7. Dexamethasone 1 mg PO DAILY Duration: 3 Days ___ Tapered dose - DOWN 8. Dexamethasone 0.5 mg PO DAILY Duration: 3 Days ___ Tapered dose - DOWN Discharge Medications: 1. Dexamethasone 1 mg PO DAILY Duration: 3 Days ___ Tapered dose - DOWN 2. Hydrochlorothiazide 25 mg PO DAILY 3. Glargine 16 Units Bedtime 4. Ketoconazole 400 mg PO TID 5. Multivitamins 1 TAB PO DAILY 6. Omeprazole 20 mg PO DAILY 7. 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 8. Dexamethasone 0.5 mg PO DAILY Duration: 2 Days ___ Tapered dose - DOWN 9. MetFORMIN (Glucophage) 1000 mg PO BID 10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN pain please take as needed for pain. DO NOT take tylenol while taking this medication RX oxycodone-acetaminophen 2.5 mg-325 mg 1 tablet(s) by mouth every six hours as needed for pain Disp #20 Tablet Refills:0 11. FreeStyle Control NF (blood glucose control high&low) Miscellaneous QID RX blood glucose control high&low [FreeStyle Control] four times a day Disp #30 Not Specified Refills:0 12. Docusate Sodium 100 mg PO BID RX docusate sodium 100 mg 1 capsule(s) by mouth twice a day Disp #30 Capsule Refills:0 13. Ondansetron 4 mg PO Q8H:PRN nausea RX ondansetron 4 mg 1 tablet(s) by mouth every 8 hours Disp #15 Tablet Refills:0 14. Freestyle InsuLinx Test Strips NF* (blood sugar diagnostic) use as directed Miscellaneous four times a day RX blood sugar diagnostic [Freestyle InsuLinx Test Strips] use as directed eight times daily Disp #1 Box Refills:*3 Discharge Disposition: Home Discharge Diagnosis: PRIMARY: facial cellulitis SECONDARY: ___ syndrome secondary to pituitary adenoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you during your stay at ___ ___. You were admitted to the hospital because of swelling in your left cheek. Imaging of your cheek showed signs of cellulitis (infection and inflammation of your soft tissues). You were treated with antibiotics. Please continue to take the antibiotic for a total of 7 days (last day on ___. The image also showed that the root nerves of your left molar tooth extend to your sinus. It is possible that the infection may have originated from there. As a result, you should call and make an appointment to see your dentist this week. Please continue to taper down your prednisone as directed. Continue taking your medications as directed by your primary care physician and endocrinologist. Followup Instructions: ___
10133363-DS-4	10,133,363	24,023,873	DS	4	2113-02-01 00:00:00	2113-02-02 15:25:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: ___: Hysteroscopy with D+C History of Present Illness: ___ with history of AFib on apixaban and ?CHF (no TTE or prior records) presenting with dyspnea for 2d, in the setting of increased sodium intake and recent Lasix dose adjustment. Pt reports she was at the ___ nursing facility and felt short of breath, especially with exertion. Pt noted that her Lasix was recently adjusted from 40 to 60 mg (although the medication list from the nursing facility suggests that her dose has decreased from 40mg to 20 mg on ___. Pt also complains of increased bilateral lower extremity edema and swelling in the R hand. Denies chest pain, dizziness, headache, cough, dysuria. - In the ED, initial vitals were: 98, 108/64, 96, 20, 98% 3L nc - Exam was notable for: - Gen: Breathing comfortably on 3L O2 NC - VS: Stable - CV: Irregularly irregular, no M/R/G - Resp: Decreased breath sounds b/l posteriorly in the lower lobes. - Abd: soft, NTND - Ext: 2+ pitting edema in ___ b/l and R hand. - Labs were notable for: proBNP 5581, TnT 0.01, lactate 1.1, BUN 26, Cr 1.2, Hb 10.2, Hct 33.9, ___ 17.7, PTT 31.6, INR 1.6 - Studies were notable for: CXR with mild interstitial pulmonary edema, patchy opacities at each lung base and focal posterior midlung opacity likely due to atelectasis vs infection, EKG with irregularly irregular rhythm but without ST changes - The patient was given: IV furosemide 20mg On arrival to the floor, patient is on 3L nc and complaining of shortness of breath when lying down. Otherwise, no complaints. She reports that she has had a long history of heart failure. At baseline, she does not use oxygen and takes furosemide 40mg a day. She thinks this may have changed recently based on something she heard in the ED, but is unsure. She has not seen her cardiologist, Dr. ___ in the past year, and she has not been to her PCP within the last six weeks. Last year, she lost 40lbs with a low sodium diet. She was down to 302lbs, but then after her most recent hospital discharge, she went to a SAR, and her diet has been much worse. She has gained 25 lbs in the past 6 weeks. Her dyspnea began within the past seven days. She also reports orthopnea and paroxysmal nocturnal dyspnea. For her afib, she takes apixaban twice a day, atenolol, and diltiazem extended release. For her hypothyroidism, she takes levothyroxine. She also has chronic wounds secondary to venous stasis. For her wounds, she has had general nursing caring for them at the SAR. She does not ambulate much and has had difficulty with ADLs. She was also recently admitted for vaginal bleeding ___. GYN saw her post-discharge for an endometrial biopsy but were unable to perform one due to patient body habitus. GYN recommended if the bleeding occurred again, she should restart the Provera course. Her bleeding did stop after Provera initially, but when she stopped taking Provera, she began to bleed again. She has had this new vaginal bleeding for the past week, and she has been taking the new course of Provera for about 5 days. Past Medical History: - atrial fibrillation - renal mass s/p R nephrectomy (benign per patient) - hypercholesterolemia - hypothyroidism - chronic lymphedema of lower extremities - neuropathy - CHF Social History: ___ Family History: - heart disease - father - died of colon cancer at age ___ - mother lived to be ___ Physical Exam: ADMISSION PHYSICAL EXAM: ======================== VITALS: T 97.5, 77, 135/84, 18, 95% on 3L nc GENERAL: Alert and interactive. In no acute distress. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. Unable to assess JVD due to body habitus. CARDIAC: Irregularly irregular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Increased work of breathing. Clear to auscultation bilaterally. Decreased breath sounds at bases bilaterally. No ABDOMEN: Normal bowels sounds, moderately distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: Pitting edema throughout legs bilaterally. Lower legs are bandaged. Cannot assess DP pulses ___ bandaging. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. Normal sensation. DISCHARGE PHYSICAL EXAM ======================== VITLAS: T 98.0, BP 106 / 65, HR 96, RR 18, SpO2 92% on RA GENERAL: NAD, alert and conversational HEENT: AT/NC, anicteric sclera, MMM NECK: supple, no JVP appreciated CV: Irregular rate, S1/S2, holosystolic murmur PULM: Breathing comfortably on RA. No wheezes. Mild crackles at bases. GI: abdomen soft, nondistended, nontender in all quadrants, no rebound/guarding. EXTREMITIES: No edema above compression wrapping below knees, bilaterally. Erythematous skin under wrapping bilaterally. No cyanosis/clubbing. PULSES: 2+ radial pulses bilaterally NEURO: A+Ox3, moving all 4 extremities with purpose, face symmetric. Stable neuropathy of b/l feet Pertinent Results: =============== ADMISSION LABS: ___ ___ 06:55PM URINE COLOR-Red* APPEAR-Cloudy* SP ___ ___ 06:55PM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-100* GLUCOSE-NEG KETONE-10* BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-MOD* ___ 06:55PM URINE RBC->182* WBC->182* BACTERIA-MOD* YEAST-NONE EPI-0 ___ 06:55PM URINE WBCCLUMP-MANY* ___ 03:19PM LACTATE-1.1 ___ 03:14PM GLUCOSE-112* UREA N-26* CREAT-1.2* SODIUM-140 POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-28 ANION GAP-7* ___ 03:14PM cTropnT-<0.01 ___ 03:14PM proBNP-5581* ___ 03:14PM WBC-8.0 RBC-3.21* HGB-10.2* HCT-33.9* MCV-106* MCH-31.8 MCHC-30.1* RDW-15.7* RDWSD-60.7* ___ 03:14PM NEUTS-70.0 LYMPHS-15.4* MONOS-8.4 EOS-5.3 BASOS-0.6 IM ___ AbsNeut-5.61 AbsLymp-1.23 AbsMono-0.67 AbsEos-0.42 AbsBaso-0.05 ___ 03:14PM PLT COUNT-230 ___ 03:14PM ___ PTT-31.6 ___ ======================== PERTINENT INTERVAL LABS: ======================== ___ 07:44AM BLOOD VitB12-712 Folate->20 ___ 04:56AM BLOOD ALT-7 AST-9 AlkPhos-123* =============== DISCHARGE LABS: =============== ___ 07:25AM BLOOD WBC-8.9 RBC-3.12* Hgb-9.8* Hct-32.1* MCV-103* MCH-31.4 MCHC-30.5* RDW-15.2 RDWSD-57.0* Plt ___ ___ 07:25AM BLOOD Glucose-109* UreaN-17 Creat-1.2* Na-149* K-3.9 Cl-102 HCO3-30 AnGap-17 ___ 07:25AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.7 ___ 03:08PM BLOOD Na-140 ================ IMAGING STUDIES: ================ CXR (___): IMPRESSION: 1. Findings consistent with mild interstitial pulmonary edema. 2. Patchy opacities at each lung base which are probably due to atelectasis although an infectious cause cannot be excluded. 3. Focal posterior midlung opacity, compatible with atelectasis although infection cannot be excluded. TTE (___): IMPRESSION: Poor image quality. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Technically suboptimal to exclude focal wall motion abnormality. Dilated right ventricle. Moderate to severe pulmonary hypertension. At least moderate tricuspid regurgitation. ============= MICROBIOLOGY: ============= ___ 6:55 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------------ 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 ============= PATHOLOGY: ============= ENDOMETRIAL CURETTAGE FOR POSTMENOPAUSAL BLEEDING PATHOLOGIC DIAGNOSIS: Endometrial curettage: -Endometrium showing focal gland crowding with mucinous metaplasia; see note. -Endometrial polyp. -Benign endometrium with changes consistent with progestin effect. Note: The finding is of unclear significance in the context of progestin therapy. Rebiopsy after termination of progestin therapy should be considered as clinically indicated. ___ 03:14PM ___ PTT-31.6 ___ Brief Hospital Course: Ms. ___ is a ___ year old female with history of HFpEF, CKD, post-menopausal bleeding, and AFib on apixaban who presented with dyspnea in the setting of dietary indiscretion and recent Lasix dose adjustment. She was treated for CHF exacerbation with IV Lasix gtt, initially requiring ICU admission for BiPap. Pt's diuretic was changed to Torsemide 80 mg daily prior to discharge. She was also treated for CAP with 5d course azithromycin/ceftriaxone. Admission was complicated by vaginal bleeding requiring hysteroscopy and D&C by GYN, which revealed an endometrial polyp. Pt was breathing on RA, euvolemic, stable Cr, with no vaginal bleeding on day of discharge. TRANSITIONAL ISSUES ================== [] Please check patient's weight and Cr. Patient's diuretic was changed from furosemide 40 mg daily to torsemide 80 mg daily. [] Please check K and Mg, as patient is on torsemide. [] Endometrial biopsy revealed benign endometrium with changes consistent with progrestin effect (patient was previously on medroxyprogesterone). Consider re-biopsy now that medroxyprogesterone therapy has been discontinued, if patient develops recurrent vaginal bleeding. [] Please f/u cardiology recommendations. Patient has an appointment on ___. [] Please f/u GYN recommendations. Patient has an appointment on ___. [] Please consider outpatient sleep study, as patient likely has underlying obesity hypoventilation syndrome and obstructive sleep apnea that is playing a large role in her respiratory status and oxygen requirement. [] TTE showed pulmonary hypertension [] Na mildly elevated on the day of discharge MEDICATION CHANGES ================= - Patient's diltiazem XR 120 QD, atenolol 50 mg QPM, and atenolol 100 mg QAM were stopped. - Patient was started on 300 mg Metoprolol succinate XR QAM. - Medroxyprogesterone was discontinued. ACUTE ISSUES ============ # Acute on chronic HFpEF # Mixed hypoxemic hypercarbic respiratory failure Patient presented with 2 days of dyspnea in setting of increased sodium intake and change in lasix dose. Weight on presentation was 326 lb from reported dry weight of ~302 lb. CXR with mild interstitial pulmonary edema, patchy opacities at each lung base and focal posterior midlung opacity likely due to atelectasis vs infection. Initially required BiPap in ICU. Treated for pneumonia with azithromycin and ceftriaxone x5 days. Transferred to the floor. Initially on lasix drip that was maxed at 40cc/hr. She diuresed well with goal net negative 2L. Cardiology was consulted. Due to increasing Cr and worsening metabolic alkalosis, patient was switched to Torsemide 80mg PO daily. On discharge, subjective shortness of breath is much improved, satting well on RA. # Post-Menopausal Vaginal bleeding Patient with history of post-menopausal bleeding. Has seen GYN here but has failed to tolerate outpatient hysteroscopy. GYN consulted inpatient as bleeding ongoing. Continued on medroxyprogesterone during admission. Once stable, GYN took patient to OR on ___ for hysteroscopy and D+C which showed large clot in the uterus and an endometrial polyp. Endometrial biopsy was taken, which showed changes consistent with progrestin effect. Medroxyprogesterone was stopped on ___, and bleeding discontinued. GYN to follow as an outpatient. # Acute on Chronic kidney disease Baseline 1.0-1.2. Uptrended to 1.6 in setting of diuresis. Diuresis deesclated during this time. At time of discharge, Cr 1.2. # Atrial fibrillation on apixaban CHADS2-VASc score is 5, on apixaban. Follows with cardiologist Dr. ___ at ___ but has been lost to follow up for past year due to immobility and difficulty with ADLs. She has had softer SBPs <100 during this admission and her home Diltiazem/Metoprolol was intermittently held. Her HRs ranged between ___. Apixaban continued, held 48hr pre-GYN procedure but restarted afterward. Switched to metoprolol succinate 300mg qAM and discontinued diltiazem in the setting of the softer BPs and to simplify her regimen. Her BP and HR stabilized on Metoprolol succinate. #Metabolic Alkalosis Patient with worsening metabolic alkalosis during this admission likely in setting of Lasix diuresis. Likely worsened by compensetory met alkalosis in setting of chronic respiratory acidosis. Started acetazolamide on ___. HCO3 downtrended and acetazolamide discontinued. Stable on discharge. CHRONIC/STABLE ISSUES ==================== CHRONIC/STABLE ISSUES: # Macrocytic Anemia Baseline Hgb ___, currently near baseline and stable. Ddx includes folate def, B12 def, hypothyroidism, reticulocytosis from recent vaginal bleeding, alcohol/liver disease. Folate/B12/TSH/retics/LFTs wnl. Stable HGB at discharge. # Coagulopathy Noted to have elevated INR. Ddx includes apixaban, vitamin K deficiency, chronic liver disease. In this case, likely due to nutrition and apixaban use. # Hypothyroidism Patient continued on home levothyroxine. TSH 0.97 on ___. # Gout Patient continued on home allopurinol # Hyperlipidemia Patient continued on home statin Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Allopurinol ___ mg PO DAILY 2. Apixaban 5 mg PO BID 3. Atenolol 100 mg PO QAM 4. Atenolol 50 mg PO QPM 5. Atorvastatin 20 mg PO QPM 6. FoLIC Acid 1 mg PO DAILY 7. Levothyroxine Sodium 200 mcg PO DAILY 8. Multivitamins 1 TAB PO DAILY 9. Vitamin D 1000 UNIT PO DAILY 10. Furosemide 40 mg PO DAILY 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. Diltiazem Extended-Release 120 mg PO DAILY 13. MedroxyPROGESTERone Acetate 20 mg PO DAILY Discharge Medications: 1. Metoprolol Succinate XL 300 mg PO DAILY 2. Torsemide 80 mg PO DAILY 3. Allopurinol ___ mg PO DAILY 4. Apixaban 5 mg PO BID 5. Atorvastatin 20 mg PO QPM 6. Fish Oil (Omega 3) 1000 mg PO DAILY 7. FoLIC Acid 1 mg PO DAILY 8. Levothyroxine Sodium 200 mcg PO DAILY 9. Multivitamins 1 TAB PO DAILY 10. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ ___ Diagnosis: Primary diagnoses ================== Acute on chronic Heart Failure with Preserved Ejection Fraction Hypoxemic hypercarbic respiratory failure Postmenopausal Vaginal Bleeding Pneumonia Obesity Hypoventilation Syndrome Metabolic Alkalosis Acute on Chronic Kidney Disease Atrial Fibrillation Chronic issues =================== Hypothyroidism Macrocytic anemia Gout Hyperlipidemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Ms. ___, It was a pleasure taking care of you at the ___ ___. Why did you come to the hospital? - You came to hospital because you were having trouble breathing. What did you receive in the hospital? - You were first treated in the Intensive Care Unit to get more advanced breathing treatments and then you were able to be treated on the general medical floor - You received high doses of a diuretic (water pill) to make you urinate out all the fluid that was in your lungs and causing your leg swelling - You were also given antibiotics for a pneumonia in your lungs - You also were seen by the OB/GYN team who took you for a procedure to help stop your vaginal bleeding and to figure out what was causing it. What should you do once you leave the hospital? - Make sure to weigh yourself every day. If your weight goes up by 3 lb, please call your doctor. - Please take your medications as prescribed and go to your future appointments which are listed below. We wish you all the best! - Your ___ Care Team Followup Instructions: ___
10133478-DS-4	10,133,478	20,755,810	DS	4	2181-04-07 00:00:00	2181-04-07 20:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Nausea, vomiting, chest pain Major Surgical or Invasive Procedure: None History of Present Illness: ___ yo female w/ PMH pAF on amiodarone, coumadin, ocular melanoma metastatic lung s/p resection and liver mets managed locally with cybernife, RFA, presents to the ED w/ sudden onset nausea, vomiting, palpitations and chest pain. Pt states she was out to dinner with friends when she suddenly did not feel well. She was very nauseous and vomited up her dinner. Her friend / oncologist Dr. ___ was out to dinner with her and noted her pulse to be rapid at the time and urged her to come to the emergency room. Recent airplane travel but not exceeding 6 hours. Denies recent leg swelling/pain. Denies previous DVT/PE. States that she has been feeling palpitations now for several months but had always attributed it to anxiety and was taking ativan for her symptoms. She has had a.fib for several yrs and her ___ cardiologist told her she was cured of it but that she would have to take amiodarone for the rest of her life. She also endorses chronic abdominal pain that has been going on for several weeks. She states that it is aggrevated by eating and her appetite has been diminished. She denies change in bowel movements during this time. She denies any history of CAD, MIs, orthopnea, CHF. In the ED intial vitals were: 96.7 135 132/76 20 99% RA - Labs were significant for: D-Dimer: 275 Trop-T: <0.01 140 ___ AGap=17 ------------< 4.4 24 0.8 estGFR: 70 / >75 (click for details) Ca: 8.9 Mg: 2.4 P: 3.5 ALT: 47 AP: 239 Tbili: 0.2 Alb: 4.5 AST: 50 LDH: Dbili: TProt: ___: Lip: 85 wbc8.6 h/h 12.6/39.2 plt 243 N:72.0 L:14.8 M:11.7 E:1.2 Bas:0.3 ___: 19.9 PTT: 37.5 INR: 1.9 - Patient was given 10mg IV diltiazem and 325mg ASA, her HR improved and she was sent to the floor. Review of Systems: (+) per HPI (-) fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: 1. Spindle type B choroidal melanoma diagnosed in ___, treated with enucleation of the right eye. 2. One year of adjuvant low-dose IL-2. 3. Recurrence of tumor in the lung in ___, for which she underwent resection of an isolated pulmonary nodule from her right lower lobe. 4. ECOG ___ trial, HLA-A2 negative limb. 5. Hepatic metastases documented by biopsy and treated with RFA in ___. a.fib on warfarin and amiodarone Social History: ___ Family History: Mother passed away in ___ of cerebral hemmorhage, father died of CAD. Physical Exam: ADMISSION: Vitals - T98.4 BP: 140/65 HR:114 RR:18 02 sat:96%RA GENERAL: NAD, lying flat in bed HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: ireg tachy rate, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, TTP in epigastric area, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE: Vitals - T98.6 BP: 118/46 HR70 RR:18 02 sat:96%RA GENERAL: NAD, appears comfortable HEENT: AT/NC, EOMI, MMM, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, slightly tender to palpation diffusely, no rebound/guarding EXTREMITIES: moving all extremities well, no cyanosis, clubbing or edema PULSES: 2+ DP pulses bilaterally NEURO: CN grossly intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: ADMISSION LABS: ___ 11:30PM BLOOD WBC-8.6 RBC-4.16* Hgb-12.6# Hct-39.2 MCV-94# MCH-30.3# MCHC-32.2 RDW-13.5 Plt ___ ___ 11:30PM BLOOD Glucose-102* UreaN-16 Creat-0.8 Na-140 K-4.4 Cl-103 HCO3-24 AnGap-17 ___ 11:30PM BLOOD Albumin-4.5 Calcium-8.9 Phos-3.5# Mg-2.4 ___ 11:30PM BLOOD ALT-47* AST-50* AlkPhos-239* TotBili-0.2 ___ 11:30PM BLOOD Lipase-85* ___ 11:30PM BLOOD ___ PTT-37.5* ___ ___ 11:30PM BLOOD cTropnT-<0.01 ___ 11:48PM BLOOD D-Dimer-275 RELEVANT LABS AND TREND LABS: ___ 11:48PM BLOOD D-Dimer-275 ___ 11:30PM BLOOD TSH-5.6* ___ 10:43AM BLOOD T4-6.7 ___ 11:30PM BLOOD cTropnT-<0.01 ___ 10:43AM BLOOD CK-MB-1 cTropnT-<0.01 DISCHARGE LABS: ___ 10:43AM BLOOD WBC-5.1 RBC-3.71* Hgb-11.2* Hct-34.8* MCV-94 MCH-30.2 MCHC-32.2 RDW-13.3 Plt ___ ___ 10:43AM BLOOD Glucose-96 UreaN-11 Creat-0.6 Na-144 K-4.3 Cl-111* HCO3-25 AnGap-12 ___ 10:43AM BLOOD ALT-38 AST-32 AlkPhos-183* TotBili-0.2 ___ 10:43AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.2 ___ 10:43AM BLOOD ___ PTT-37.6* ___ IMAGING: CXR ___: No acute cardiopulmonary process. RUQ US ___: 1. No cholelithiasis or cholecystitis. 2. Evaluation of the hepatic parenchyma for suspected metastases is limited by technique. The possibility of isoechoic nodules is difficult to exclude. If evaluation of the patient's known hepatic metastases is clinically indicated, a multiphase CT of the liver is recommended. Brief Hospital Course: ___ yo female w/ PMH pAF on amiodarone, coumadin, ocular melanoma metastatic lung s/p resection and liver mets managed locally with cybernife, RFA, presented to the ED w/ sudden onset nausea, vomiting, palpitations and chest pain, found to have atrial fibrillation with RVR. # Atrial fibrillation with RVR: Patient presented with chest pain in the setting of Afib with RVR. Pt on amiodarone and warfarin for a.fib. Had not been on a beta blocker or calcium channel blocker in the past. Per hx seems like pt has been going into RVR for several months now and has been attributing it to anxiety and taking ativan. Received diltiazem 10mg IV in the ED with good response. Chest pain resolved as HR improved. EKG during RVR was significant for ST depessions in II, V3-6. She converted back to sinus rhythm. Troponins negative x 2. TSH slightly elevated, free T4 WNL. She was started on metoprolol for continued rate control, and discharged on metoprolol succinate 25mg daily. She will f/u with cardiologist in ___. # Abdominal pain: Pt has had chronic abdominal pain over past few months. Pt had elevated transaminases, alk phos and lipase. LFTs downtrended. RUQ US showed no cholecystitis or cholelithiasis, normal pancreas, no bile duct dilation. Diffuse abdominal pain and elevated LFTs may be due to patient's known hepatic metastases. TRANSITIONAL ISSUES: - Consider uptriting metoprolol. - Workup chronic abdominal pain. - TSH slightly elevated 5.6. F/u free T4 (currently pending). Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral daily 2. Warfarin 2.5 mg PO DAILY16 3. Multivitamins 1 TAB PO DAILY 4. Slow Release Iron (ferrous sulfate;<br>ferrous sulfate dried;<br>ferrous sulfate, dried) 160 mg (50 mg iron) oral daily 5. Ascorbic Acid ___ mg PO DAILY 6. Amiodarone 200 mg PO DAILY 7. Lorazepam 1 mg PO DAILY:PRN anxiety 8. Zolpidem Tartrate 5 mg PO HS 9. Isosorbide Mononitrate Dose is Unknown PO BID 10. Benzonatate 100 mg PO TID Discharge Medications: 1. Amiodarone 200 mg PO DAILY 2. Benzonatate 100 mg PO TID 3. Lorazepam 1 mg PO DAILY:PRN anxiety 4. Multivitamins 1 TAB PO DAILY 5. Warfarin 2.5 mg PO DAILY16 6. Zolpidem Tartrate 5 mg PO HS 7. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 (One) tablet extended release 24 hr(s) by mouth once a day Disp #30 Tablet Refills:*0 8. Ascorbic Acid ___ mg PO DAILY 9. Calcium 500 + D (calcium carbonate-vitamin D3) 500 mg(1,250mg) -400 unit oral daily 10. Isosorbide Mononitrate 0 mg PO BID 11. Slow Release Iron (ferrous sulfate;<br>ferrous sulfate dried;<br>ferrous sulfate, dried) 160 mg (50 mg iron) oral daily Discharge Disposition: Home Discharge Diagnosis: Atrial fibrillation with RVR Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. ___, It was a pleasure participating in your care at ___. You were admitted to the hospital with a fast heart rate. You received medication to slow down your heart rate, and your heart rhythm returned to a regular rhythm. We have added a medication metoprolol to control your heart rate (see list below). Please continue your other medications as you have been taking. Please follow up with your doctors in ___. Followup Instructions: ___
10133631-DS-12	10,133,631	20,514,903	DS	12	2148-05-07 00:00:00	2148-05-07 22:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ male with a PMH of HTN, obesity, smoking, hyperlipidemia, family history of stroke, mitral valve repair (on Coumadin) who presented to the ED for an episode of chest pain. He says a large amount of chest pressure starting around 9PM last night while he was having an argument with his wife. Says the pain/pressure did not radiate anywhere and that he felt somewhat short of breath, which was relieved when he took a puff from his asthma inhaler. He came to the ED and the pain resolved while he was waiting to be seen. He has never experienced this type of episode before. He had a negative stress test earlier this year. Of note, he says he has been under a great deal of stress at work recently. Says that he gets pneumonia almost yearly. Usually presents with cough, SOB, fever. Patient denies any nausea, vomiting, cough nor does he have any fevers. No sick contacts. In the ED, initial vital signs were: Pain: 6 T:98.8 HR:81 BP:142/91 RR:17 O2sat: 100% RA - Exam notable for 1+ pedal edema to the midshin; lungs clear bilaterally - Labs were notable for nl WBC (6.3); Cr 1.4; Trops were neg x2; ProBNP 148; Hb 12.5; - Studies performed include CXR showing left lower lobe pneumonia and mild pulmonary vascular congestion; - Patient was given aspirin 324mg, fluticasone, spironolactone 25mg, allopurinol ___, digoxin .25mg, lisinopril 40mg, diltiazem 240mg, insulin, ceftriaxone, IV azithromycin, - Vitals on transfer: Pain:0 T:98.3 HR:67 BP:158/63 RR:20 O3sat:95% RA Upon arrival to the floor, the patient was clinically stable and confirmed the above history. Past Medical History: Obesity HTN hyperlipidemia IDDM Gout Sleep apnea on CPAP Osteoarthritis Atrial flutter Pulmonary hypertension Diastolic heart failure Mitral valve replacement CKD (stage 3, GFR ___ ml/min) Colon adenoma Asthma Social History: ___ Family History: prostate cancer, lung cancer, HTN Physical Exam: Admission Physical Exam =======================\ Vitals- T:98.0 BP:158/68 HR:63 RR:18 T:98% RA GENERAL: AOx3, NAD; conversant, able to sit up in bed comfortably HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric. Moist mucous membranes NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. Tympanic to percussion. No organomegaly. EXTREMITIES: Bilateral 1+ edema in lower extremities. Pulses DP bilaterally. SKIN: red/purple scaly rash on shins bilaterally NEUROLOGIC: CN2-12 intact. ___ strength througout. Normal sensation. Discharge Physical Exam ========================= Vitals- T:98.2 BP:138/77 HR:67 RR:18 O2:97 RA GENERAL: AOx3, NAD; conversant, overweight; able to sit up in bed comfortably HEENT: Normocephalic, atraumatic. Pupils equal, round, and reactive bilaterally, extraocular muscles intact. No conjunctival pallor or injection, sclera anicteric. Moist mucous membranes NECK: Thyroid is normal in size and texture, no nodules. No cervical lymphadenopathy. CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops. No JVD. LUNGS: Decreased breath sounds over left lower lobe posteriorly. No wheezes, rhonchi or rales. ABDOMEN: Obese normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. Tympanic to percussion. No organomegaly. EXTREMITIES: Bilateral 1+ edema in lower extremities. Pulses DP bilaterally. SKIN: sternotomy scar; red/purple scaly rash on shins bilaterally NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal sensation. Pertinent Results: Admission Labs =============== ___ 01:04AM BLOOD WBC-6.3 RBC-4.49* Hgb-12.5* Hct-40.3 MCV-90 MCH-27.8 MCHC-31.0* RDW-14.9 RDWSD-49.1* Plt ___ ___ 01:04AM BLOOD Neuts-60.3 ___ Monos-6.7 Eos-6.2 Baso-0.3 Im ___ AbsNeut-3.80 AbsLymp-1.64 AbsMono-0.42 AbsEos-0.39 AbsBaso-0.02 ___ 01:04AM BLOOD Glucose-82 UreaN-18 Creat-1.4* Na-138 K-4.5 Cl-100 HCO3-25 AnGap-18 ___ 01:04AM BLOOD proBNP-148 ___ 01:04AM BLOOD cTropnT-<0.01 ___ 07:42AM BLOOD cTropnT-<0.01 ___ 01:04AM BLOOD Glucose-82 UreaN-18 Creat-1.4* Na-138 K-4.5 Cl-100 HCO3-25 AnGap-18 Discharge Labs ============== ___ 07:45AM BLOOD ___ PTT-39.5* ___ ___ 07:45AM BLOOD WBC-5.7 RBC-4.28* Hgb-11.9* Hct-38.6* MCV-90 MCH-27.8 MCHC-30.8* RDW-14.9 RDWSD-49.1* Plt ___ ___ 07:45AM BLOOD Glucose-105* UreaN-17 Creat-1.5* Na-139 K-4.4 Cl-102 HCO3-26 AnGap-15 Microbiology ============= ___ Blood Cultures x2 - No growth to date Imaging ============= ___ CXR IMPRESSION: 1. Left lower lobe pneumonia. 2. Mild pulmonary vascular congestion, with no overt pulmonary edema. Brief Hospital Course: Mr. ___ is a ___ male with a PMH of HTN, obesity, smoking, hyperlipidemia, family history of stroke, mitral valve repair (on Coumadin) who presented to the ED after an episode of acute chest pain. He had a neg cardiac work-up but CXR showed evidence of LLL pneumonia, although had no clinical signs or sxs. Was started on now on ceftriaxone and azithromycin for empiric treatment of CAP. #Pneumonia: CXR showed evidence of left lower lobe consolidation. He denied cough, SOB, fevers/chills. Afebrile with normal WBC count. Started on treatment for CAP and transitioned to oral antibiotics to complete 5 day therapy of azithyromycin and cefpodoxime on ___. #Chest pain: Experienced acute episode of chest pain yesterday evening that self-resolved upon arrival to ED. Description of heavy chest pressure while agitated sounds like angina, but cardiac work-up has been neg (neg trops x2, EKG showed no ischemic changes. Patient had a neg stress test earlier this year. No history of prior episodes. Could be related to his recent pneumonia. #CKD: history of stage 3 CKD secondary to diabetes/HTN. Cr. of 1.4 on admission with recent baseline 1.5-1.7. #HTN: continued home antihypertensives; lisinopril, diltiazem HCl #Diabetes: continued insulin during hospital stay. #Hyperlipidemia: continued home pravastatin. #Sleep apnea: used home CPAP #Mitral valve replacement: continued on warfarin. INR on discharge 1.9 Patient reports is goal is from 1.8 to 2. Continued warfarin at home doses. #Diastolic CHF: continued on lisinopril, aspirin, torsemide #Gout: continued home allopurinol #Asthma: Albuterol and fluticasone PRN #Transitional issues: [] F/u with cardiology outpatient [] f/u INR as patient on ___ [] repeat CXR in 6 weeks to evaluate resolution of pneumonia #Code Status: full code #Emergency Contact/HCP: ___ (wife) ___ ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Spironolactone 25 mg PO DAILY 2. Lisinopril 40 mg PO DAILY 3. Warfarin 7.5 mg PO 5X/WEEK (___) 4. Warfarin 10 mg PO 2X/WEEK (___) 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Pravastatin 80 mg PO QPM 7. Torsemide 20 mg PO DAILY 8. Triamcinolone Acetonide 0.1% Cream 1 Appl TP Frequency is Unknown 9. Vitamin D 1000 UNIT PO DAILY 10. Aspirin 81 mg PO DAILY 11. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma 12. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 13. Iron Polysaccharides Complex ___ mg PO BID 14. Lispro Protamine / Lispro 50/50 22 Units Breakfast Lispro Protamine / Lispro 50/50 22 Units Dinner 15. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous unknown 16. Sildenafil 20 mg PO Frequency is Unknown 17. econazole 1 % topical BID Discharge Medications: 1. Azithromycin 250 mg PO Q24H Duration: 4 Doses RX azithromycin 250 mg 1 tablet(s) by mouth daily Disp #3 Tablet Refills:0 2. Cefpodoxime Proxetil 400 mg PO Q12H RX cefpodoxime 200 mg 2 tablet(s) by mouth twice a day Disp #14 Tablet Refills:0 3. Lispro Protamine / Lispro 50/50 22 Units Breakfast Lispro Protamine / Lispro 50/50 22 Units Dinner 4. Sildenafil 20 mg PO DAILY:PRN As needed for erectile dysfunction 5. Triamcinolone Acetonide 0.1% Cream 1 Appl TP BID 6. Albuterol Inhaler 2 PUFF IH Q4H:PRN asthma RX albuterol sulfate [Proventil HFA] 90 mcg 2 puff INH every 4 hours Disp #1 Inhaler Refills:*0 7. Aspirin 81 mg PO DAILY 8. Diltiazem Extended-Release 240 mg PO DAILY 9. econazole 1 % topical BID 10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 11. Iron Polysaccharides Complex ___ mg PO BID 12. Lisinopril 40 mg PO DAILY 13. Pravastatin 80 mg PO QPM 14. Spironolactone 25 mg PO DAILY 15. Torsemide 20 mg PO DAILY 16. Victoza 2-Pak (liraglutide) 0.6 mg/0.1 mL (18 mg/3 mL) subcutaneous unknown 17. Vitamin D 1000 UNIT PO DAILY 18. Warfarin 7.5 mg PO 5X/WEEK (___) 19. Warfarin 10 mg PO 2X/WEEK (___) Discharge Disposition: Home Discharge Diagnosis: PRIMARY: Pneumonia SECONDARY: Atypical chest pain CKD Stage 3 DM 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 pleasure taking care of you at ___ ___ ___. You were hospitalized for chest pain. You underwent cardiac testing that was normal. You were found to have pneumonia. You were treated with antibiotics and you symptoms improved. Please continue to take your medications as prescribed. Please follow up with your doctors as ___. Sincerely, Your ___ Team Followup Instructions: ___
10133751-DS-11	10,133,751	22,697,228	DS	11	2111-12-31 00:00:00	2111-12-31 11:37:00	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 ankle pain and bleeding. Right ankle traumatic arthrotomy; Right open talus fracture; Right closed pseudojones fracture Major Surgical or Invasive Procedure: Status post I&D, L ATFL repair, closure ___, ___. History of Present Illness: REASON FOR CONSULT: Right ankle pain and bleeding. Right ankle traumatic arthrotomy; Right open talus fracture; Right closed pseudojones fracture HPI: ___ M with no significant past medical history presents with right ankle pain and bleeding after a twisting event. Patient was playing volleyball today when he jumped and landed onto another player's foot. His foot immediately inverted and popped. He noted immediate onset bleeding and pain. He was unable to ambulate. He did not strike his head or lose consciousness. There is no presyncopal symptoms preceding the event. He denies numbness and tingling in extremity. He denies pain elsewhere. He denies headache, back pain, neck pain, chest pain, shortness of breath, abdominal pain, nausea, and other medical complaints. Past Medical History: None Social History: Patient lives in ___ with his 2 children. Denies tobacco, marijuana, and illicit drug use. Drinks 2 drinks of alcohol per week. Works as a ___ in a ___. Physical Exam: Right lower extremity: -Transverse laceration from anterior to posterior over the lateral malleolus that measures approximately 12 cm in length. The skin edges are not dusky. Patient is firing peroneals, digitorum digitorum longus, and flexor digitorum longus to all toes. Fires ___. SILT S/S/SP/DP/T distributions. 1+ ___ pulses, WWP Brief Hospital Course: The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have a Right ankle pain and bleeding. Right ankle traumatic arthrotomy; Right open talus fracture; Right closed pseudojones fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for I&D, L ATFL repair, closure, 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 (2 postoperative doses of IV Ancef) and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is nonweightbearing in the left lower extremity, and will be discharged on Lovenox for 2 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: None Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Docusate Sodium 100 mg PO BID 3. Enoxaparin Sodium 40 mg SC DAILY RX enoxaparin 40 mg/0.4 mL 40 mg subcutaneously Nightly Disp #14 Syringe Refills:0 4. Milk of Magnesia 30 ml PO BID:PRN Constipation 5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX oxycodone 5 mg ___ tablet(s) by mouth q4 PRN Disp #40 Tablet Refills:0 6. Senna 17.2 mg PO BID Discharge Disposition: Home Discharge Diagnosis: R traumatic arthrotomy, talar avulsion Discharge Condition: AVSS NAD, A&Ox3 LLE: In cast that is clean dry and intact. Fires exposed toes, sensation intact light touch and exposed toes, warm and well-perfused exposed toes. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - NWB LLE in cast 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 daily for 2 weeks Followup Instructions: ___
10134173-DS-13	10,134,173	25,844,372	DS	13	2185-06-06 00:00:00	2185-06-07 20:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Tetracycline Attending: ___. Chief Complaint: black stools Major Surgical or Invasive Procedure: ___ Esophagogastroduodenoscopy (EGD) History of Present Illness: ___ yo man w/ hx of pancreatic CA s/p Whipple in ___ presents with 5 days of black, tarry stools. Pt was in USOH until 5 days PTA when he noticed dark black stools. Stools were loose and malodorous, no bright red blood. Also noticed that he was having BM more often, and also having the urge to have BM whenever he urinated. Then 4 days ago, he was walking with a friend and fell down, breaking two bones in his left hand. He doesn't recall if he felt dizzy/lightheaded before his fall, but he denies loss of consciousness. The black stools continued, and 2 days ago he had extreme nausea and cramping mid abdominal pain. Says he "felt sick" and laid on the bathroom floor for about an hour, but he did not vomit. On ROS, he endorses occasional mid-abd cramping that has been off and on for "quite some time". Also has been feeling dizzy when he stands up since the black stools started. Denies chest pain, shortness of breath, vomiting, palpitations, diaphoresis, or fever/chills. He has taken a few motrin for the pain from his hand fracture, but otherwise he does not use NSAIDs much. Does drink a glass of vodka on a nearly nightly basis. No h/o ulcer disease, not on anticoagulation. After 5 days of dark stools, his family urged him to see his PCP, who saw occult blood on rectal exam and immediately sent him to the ED for evaluation. . In the ED, initial VS were 97.8, 61, 111/75, 16, 100%. Exam was notable for black, guaiac + stool on rectal exam. NG lavage was clear. Labs were remarkable for a hct of 31.2, down from a baseline of around 40. BUN slightly elevated at 23. GI was consulted in the ED, who felt he should be admitted for EGD tomorrow. He was started on a PPI drip and then admitted to the medicine service. Vitals on transfer were 97.8, HR 58, BP 130/86, RR 16, O2sat 100 % RA. . Currently, he is comfortable and in good spirits with his wife and daughter at bedside. He has no new complaints. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, vomiting, BRBPR, hematochezia, dysuria, hematuria. Past Medical History: 1. Pancreatic cancer s/p whipple in ___ 2. History of elevated PSA with biopsy in ___ without evidence of cancer. Has had elevated PSAs for a number of years, has an ultrasound scheduled with urology on ___. Thyroid nodule biopsy, approximately six to ___ years ago 4. Right inguinal hernia repair in ___ 5. MIBI in ___ with Ejection fraction of 63% 6. Stapedectomy for wire in his ear in the ___ 7. Right shoulder replacement in ___ Social History: ___ Family History: ___, CABG, pancreatic cancer. Mother-Age is ___. Has history of hypertension. Physical Exam: ADMISSION PHYSICAL EXAM: VS - Temp 97.7F, BP 134/93, HR 67, R 20, O2-sat 98% RA GENERAL - well-appearing middle aged man in NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, no JVD, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - active BS, soft/ND, mildly tender to palpation in mid to left epigastrium, no rebound or guarding. Large well-healed scar from whipple EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - no rashes or lesions LYMPH - no cervical LAD NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength ___ throughout RECTAL: dark black/brown liquidy stool around anus and inside rectal vault, no abnormalities palpated on internal exam DISCHARGE PHYSICAL EXAM: No stool on rectal exam, otherwise unchanged Pertinent Results: LABS: On admission: ___ 03:30PM BLOOD WBC-8.0 RBC-3.29* Hgb-10.4* Hct-31.2# MCV-95 MCH-31.6 MCHC-33.2 RDW-13.8 Plt ___ ___ 03:30PM BLOOD Neuts-62.1 ___ Monos-4.6 Eos-2.7 Baso-1.2 ___ 03:30PM BLOOD ___ PTT-31.0 ___ ___ 03:30PM BLOOD Glucose-96 UreaN-23 Creat-0.9 Na-141 K-4.1 Cl-109* HCO3-22 AnGap-14 ___ 03:39PM BLOOD Glucose-86 Lactate-1.9 Na-141 K-3.9 Cl-110* calHCO3-20* ___ 03:39PM BLOOD Hgb-10.7* calcHCT-32 On discharge: ___ 08:25AM BLOOD WBC-5.1 RBC-3.21* Hgb-10.2* Hct-29.0* MCV-91 MCH-31.9 MCHC-35.3* RDW-14.5 Plt ___ MICRO: none IMAGING: ___ EGD: Abnormal mucosa in the esophagus (biopsy) Erosion in the fundus Granularity, friability and erythema in the duodenal bulb compatible with duodenitis Ulcers in the proximal jejunum Mild friability and congestion in the stomach compatible with mild gastritis (biopsy) Otherwise normal EGD to jejunal limbs ___ Left hand xray: Three views of the left wrist are partially obscured by overlying cast. No fracture is identified. There are severe degenerative changes of the first CMC joint. No compariosn exams available ___ Left fingers xray: Four views of the scaphoid demonstrate severe degenerative changes of the first CMC joint. The exam is otherwise normal. There is no fracture, dislocation, or bone destruction. Brief Hospital Course: ___ yo man w/ hx of pancreatic CA s/p ___ in ___ presents with 5 days of black, tarry stools concerning for upper GI bleed. ACTIVE ISSUES BY PROBLEM: # GI bleed: dark tarry stools concerning for upper GI bleed, though NG lavage in ED was negative. Had a number of risk factors for upper GI bleed, including fairly heavy hard alcohol use ___ vodkas per night), recent NSAIDs, and past surgical anastomosis from whipple. GI was consulted in the ED, and plan was made to perform an EGD the following morning. No red blood or maroon stools on rectal exam, so lower GI source seemed highly unlikely and colonoscopy was not performed. He was started on a PPI gtt overnight, made NPO, and type and screen was sent. Hct monitoring overnight showed a hct drop from 31 -> 26, so he was transfused 1 unit PRBCs. He remained hemodynamically stable. In the AM, he underwent EGD, which showed erosions, ulcers, and friable mucosa throughout the stomach, duodenum and jejunem (especially at sites of anastamosis). No active bleeding was seen, but the tissue was quite friable and bled easily when poked, so this was thought to be the source of bleeding. Biopsies were taken from the abnormal mucosa. He was continued on PPI gtt through the next morning, and diet was advanced. Hct remained stable on numerous checks for 24 hours, and the dark stools slowed to 1-2/day. He was discharged on pantoprazole 40mg BID PO with instructions to avoid alcohol, NSAIDs, and acidic foods. He will follow up with his PCP for repeat hct check and may return to GI PRN for return of symptoms. He will be contacted with the results of his biopsies in 2 weeks. # Hand injury: seen at OSH ED on the day prior to admission for hand pain after his fall 4 days prior, and he was told he had 2 broken bones in his hand. The hand was splinted, and he was to return to see ortho the following day, but then he was admitted at ___. Inpatient ortho consult obtained, and new xrays were performed, which did not show evidence of fracture. He was put into a new orthoplasty splint and will follow up with Dr. ___ on ___. INACTIVE ISSUES: # Pancreatic cancer s/p whipple: appears to be in remission, had recent MRI for work up of abdominal pain with no evidence of recurrence. He should continue with outpatient follow up. TRANSITIONAL ISSUES: - GI bleed: started on pantoprazole BID, instructed to avoid alcohol and NSAIDs. Does not need to follow up with GI unless symptoms recur. He should have a repeat hct check at next PCP ___. Will be contacted in 2 weeks with results of biopsy. - Hand injury: no fracture seen, will follow up with ortho on ___ - FULL CODE this admission Medications on Admission: Fish oil cholecalciferol (vitamin D3) 2,000 unit daily coenzyme Q10 100 mg Capsule 1 Capsule(s) by mouth once a day (OTC) magnesium multivitamin ?Bromolene - some herbal medication given to him by a chiropractor, unsure of name ___: 1. Fish Oil Oral 2. cholecalciferol (vitamin D3) 2,000 unit Capsule Sig: One (1) Capsule PO once a day. 3. coenzyme Q10 100 mg Capsule Sig: One (1) Capsule PO once a day. 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: UPPER GI BLEED HAND FRACTURE Secondary Diagnosis: ANEMIA PANCREATIC CANCER Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the ___ from ___ to ___ for a bleed in your gastrointestinal tract. You were given IV protonix then transitioned to an oral form to decrease the acid production in your stomach and help reduce the bleeding. You were given a blood tranfusion because your blood count had been low. You also underwent an endoscopy to look at your stomach and small intestines, which showed areas of ulceration and erosion near the connection site from your prior Whipple procedure. This was believed to be the cause of your bleed, but there was no active bleeding at the time. We monitored your blood count and it was stable prior to discharge. The GI doctors ___ be in touch within the next few weeks with the results of your biopsy. Please follow up with your primary doctor, ___ your symptoms don't resolve. He can refer you back to GI if you need to be re-evaluated. In order to prevent further stomach bleeding, it will be important for you to take a new medication called omeprazole, which will help reduce the acid in your stomach. You also should take care to avoid alcohol and NSAIDs like ibuprofen, as these are very rough on the stomach lining. Avoid acidic foods and drinks, like citrus fruits and coffee, and eat a bland diet to avoid irritating your stomach further. While you were here, you were also seen by a hand surgery for your hand injury and were put in hard splint. They will see you for follow up in clinic on ___. It was a pleasure participating in your care. The following changes were made to your medications: START pantoprazole 40 mg twice daily (to help protect your stomach) It was a pleasure to take care of you at ___! Followup Instructions: ___
10134485-DS-16	10,134,485	26,177,897	DS	16	2166-09-07 00:00:00	2166-09-10 19:38:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: transient right arm numbness and right neck pain Major Surgical or Invasive Procedure: None History of Present Illness: HPI: ___ is a ___ year old lady with history of recent left vertebral dissection without associated ischemia on aspirin 81 mg daily who presents with transient right arm numbness and right neck pain found to have new right proximal V2 vertebral dissection at ___ and transferred here for further management. Per patient and review of record, she was totally healthy up until about 3 weeks ago. She had not been doing any preceding heavy lifting, straining, exercising, or going to ___. She awoke one day several weeks ago with a stiff neck on the left side. It was getting worse as the weeks went on and she developed a throbbing holocephalic headache. She was getting weird noises in her left ear. She would get a rush and feel lightheaded upon standing. She ultimately went to ___ on ___ where she had a CTA which showed left V3-4 dissection. MRI was without infarct. She was transferred to ___ with normal neurologic exam. She was given aspirin 81 mg daily and discharged. Since discharge she has been doing well. She has not missed any doses of her aspirin. She did try cocaine for the first time last night around 11P but felt well. She went to bed and then awoke this morning with right arm numbness/tingling. She got up and moved around and eventually the numbness resolved after ___ minutes. She also noticed she had right neck pain which felt "exactly like" the other dissection which worried her. She also got a posterior bioccipital throbbing headache. She went to ___ where CTA showed a right proximal V2 dissection. She was subsequently transferred to ___. On arrival to ___ she is just having some right neck and shoulder pain. She has a mild occipital headache. She denies changes in vision, dysphagia, changes in voice, double vision, dizziness, recurrence of numbness/tingling or weakness. ROS: She has not had recent fevers or chills, infectious symptoms. Other ROS as above. Past Medical History: PMH: left vertebral dissection Social History: ___ Family History: Mother and father have alcohol and drug problems. Brother had seizure in the setting for concussion. No family history of strokes, blood vessel problems, connective tissue disease, Marfan, Ehlers Danolos. Physical Exam: Vitals: Temp Pulse RR BP Rhythm O2 sat O2 flow Pain 98.5 80 16 131/92 MAP: 105.0 99 General: Awake, cooperative HEENT: NC/AT, no scleral icterus noted Neck: Supple, no carotid bruits appreciated. Right trap ttp. Pulmonary: Normal work of breathing. Abdomen: Soft, non-distended. Extremities: No ___ edema. Hyperextensible left thumb, fingers. Skin: No rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Able to name both high and low frequency objects. Able to read without difficulty. No dysarthria. Able to follow both midline and appendicular commands. There was no evidence of apraxia or neglect. -Cranial Nerves: II, III, IV, VI: PERRL 5 to 3mm and brisk. EOMI without nystagmus. Normal saccades. VFF to confrontation. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii bilaterally. XII: Tongue protrudes in midline with good excursions. Strength full with tongue-in-cheek testing. -Motor: Normal bulk and tone throughout. No pronator drift. No adventitious movements, such as tremor or asterixis noted. [Delt][Bic][Tri][ECR][FEx][IP][Quad][Ham][TA][Gas] L 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, vibration, or proprioception throughout. No extinction to DSS. -Reflexes: [Bic] [Tri] [___] [Pat] [Ach] L 2 2 2 3 2 R 2 2 2 3 2 Plantar response was flexor bilaterally. -Coordination: No intention tremor. Normal finger-tap bilaterally. No dysmetria on FNF or HKS bilaterally. -Gait: Good initiation. Narrow-based, normal stride and arm swing. DISCHARGE No acute distress, breathing comfortably on room air, extremities warm and well-perfused, non-edematous. Awake, alert, oriented to date and location. Attentive throughout exam. Language fluent without errors. EOM full range and conjugate. Mild right ptosis. Face symmetric. Full strength throughout. No dysmetria on finger-nose-finger. Pertinent Results: ___ 04:00PM BLOOD Neuts-59.3 ___ Monos-6.2 Eos-3.7 Baso-0.4 Im ___ AbsNeut-6.89* AbsLymp-3.49 AbsMono-0.72 AbsEos-0.43 AbsBaso-0.05 ___ 04:00PM BLOOD WBC-11.6* RBC-4.17 Hgb-12.2 Hct-37.5 MCV-90 MCH-29.3 MCHC-32.5 RDW-12.9 RDWSD-42.6 Plt ___ ___ 04:00PM BLOOD ___ PTT-30.4 ___ ___ 04:00PM BLOOD Glucose-77 UreaN-6 Creat-0.6 Na-141 K-3.7 Cl-105 HCO3-22 AnGap-14 ___ 07:00AM BLOOD Calcium-9.4 Phos-4.3 Mg-1.9 ___ 07:00AM BLOOD TSH-2.6 ___ 04:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Tricycl-NEG ___ Imaging MR HEAD W/O CONTRAST 1. No acute infarct or intracranial hemorrhage. 2. There are 2 punctate FLAIR hyperintensities of the right frontal lobe and right postcentral gyrus, nonspecific. These could represent slow flow through venous vessels and likely artifactual. Differential consideration of sequela of prior trauma, infectious/inflammatory etiology, chronic headache, or small vessel ischemic disease are considered less likely. These are not in a distribution compatible with demyelinating process. 3. Additional findings described above. ___ Cardiovascular Transthoracic Echo Report MPRESSION: Normal biventricular cavity sizes and regional/global biventricular systolic function.No valvular pathology or pathologic flow identified. Normal estimated pulmonary artery systolicpressure. No evidence for right-to-left intracardiac shunt at rest or with maneuvers Brief Hospital Course: AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic Attack 1. Dysphagia screening before any PO intake? (x) Yes, confirmed done - () Not confirmed () No. If no, reason why: 2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not (I.e. bleeding risk, hemorrhage, etc.) 3. Antithrombotic therapy administered by end of hospital day 2? () Yes - (x) No. If not, why not? (I.e. bleeding risk, hemorrhage, etc.) 4. LDL documented? (x) Yes (LDL = ) - () No 5. Intensive statin therapy administered? (simvastatin 80mg, simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg, rosuvastatin 20mg or 40mg, for LDL > 70) () Yes - (x) No [if LDL >70, reason not given: not atherosclerotic-related, no stroke [ ] Statin medication allergy [ ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 6. Smoking cessation counseling given? (x) Yes - () No [reason () non-smoker - () unable to participate] 7. Stroke education (personal modifiable risk factors, how to activate EMS for stroke, stroke warning signs and symptoms, prescribed medications, need for followup) given in written form? (x) Yes - () No 8. Assessment for rehabilitation or rehab services considered? () Yes - (x) No. If no, why not? (patient at baseline functional status) 9. Discharged on statin therapy? () Yes - (x) No [if LDL >70, reason not given: [ ] Statin medication allergy [x ] Other reasons documented by physician/advanced practice nurse/physician ___ (physician/APN/PA) or pharmacist [ ] LDL-c less than 70 mg/dL 10. Discharged on antithrombotic therapy? (x) Yes [Type: (ASA)] 11. Discharged on oral anticoagulation for patients with atrial fibrillation/flutter? () Yes - () No - If no, why not (I.e. bleeding risk, etc.) (x) N/A ___ is a ___ year old woman with history of possible recent left vertebral dissection without associated ischemia, discharged on aspirin 81 mg daily, who presents with transient right arm numbness and right neck pain and found to have new right proximal V2 vertebral dissection. MRI performed and did not show evidence of acute ischemic stroke. Recommended MRA head/neck with fat sat to further evaluate dissections given that her clinical symptoms did not correlate with CTA findings, but patient left against medical advice as she did not have child care at home. We discussed with her that she must present urgently to the ED if she experiences any additional neurological symptoms. We counseled her against additional drug use. Our concern is for an underlying connective tissue disease if she does indeed have multiple recurrent dissections on aspirin 81mg. We discussed with her that we would recommend staying for MRA head and neck as this may change our management plan; we would consider anticoagulation if she truly has two dissections (but would like not start this if the dissection extends intracranially). We have ordered the MRA of the head and neck as an outpatient to be completed prior to a neurology follow up arranged with Dr. ___ on ___. TRANSITIONAL ISSUES - LDL 118. Please continue to lifestyle changes and lipid lowering therapy, if appropriate. Continue to counsel on smoking cessation and substance use. - Scheduling outpatient MRA head/neck with fat sat to evaluate for vertebral artery dissection. Decision for anti-platelet vs anticoagulation pending results of this scan. - Follow up with stroke neurology Dr. ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Vertebral artery dissection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized due to symptoms of neck pain and left arm numbness. Initially, there was concern for a stroke (a condition where a blood vessel providing oxygen and nutrients to the brain is blocked by a clot). You had a CT scan that showed another vertebral artery dissection, which can cause stroke. A dissection occurs when the blood vessel that supplies your brain tears allowing blood to enter the wall. We recommended that you stay for an additional MRI of your brain, but you requested to leave against medical advice. You will need to have the MRA of the head and neck completed BEFORE your neurology follow up appointment on ___. Please do not use any other drugs such as cocaine as these may predispose you to dissection. Your risk factors are: - Vertebral Artery Dissection - Hyperlipidemia We are not changing your medications Please take your other medications as prescribed. Please follow up with Neurology and your primary care physician as listed below. If you experience any of the symptoms below, please seek emergency medical attention by calling Emergency Medical Services (dialing 911). In particular, since stroke can recur, please pay attention to the sudden onset and persistence of these symptoms: - Sudden partial or complete loss of vision - Sudden loss of the ability to speak words from your mouth - Sudden loss of the ability to understand others speaking to you - Sudden weakness of one side of the body - Sudden drooping of one side of the face - Sudden loss of sensation of one side of the body Sincerely, Your ___ Neurology Team Followup Instructions: ___
10134507-DS-9	10,134,507	22,862,516	DS	9	2149-04-12 00:00:00	2149-04-13 08:33:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: Right leg swelling and depressed mental status Major Surgical or Invasive Procedure: None History of Present Illness: The patient is a ___ year-old female with hx of hep C cirrhosis, h/o remote IVDU on methadone, anxiety and depression, who was transferred from ___ and p/w red, swollen, tender, weeping right leg and fluctuating levels of alertness. The patient noted that her b/l ___ are often swollen and red, but not as painful or with drainage. She denied trauma to area, fevers, chills, headache, cough, SOB, abdominal pain, N/V/D, or dysuria. She has been taking lactulose and spironolactone but admits to irregularity of her regimen due to distaste for the lacutulose. She has also been on methadone for many years and no recent Rx changes per recent OMR notes. She denied alcohol use and illicit drugs and smokes a few cigarettes/day. In the ED, VS: 97.1 80 111/61 18 95%. She was somnolent, arousable to voice and oriented x 3 and answered appropriately, but often drifted to sleep every few sec. B/l ___ stasis derm changes were present, but anterior RLE was warm, edematous, erythematous, tender, and weeping without an obvious skin break. Labs from ___ showed a lactate 1.3, etoh <3, LFTs at her baseline, ___ of RLE was neg for DVT and incidental reflux seen at femoral jxn wh/ can contribute to varicosities. Her UA was unremarkable and she received CTX x1. Review of sytems: (+) Per HPI (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Ten point review of systems is otherwise negative. Past Medical History: -hep C cirrhosis ___ -h/o remote IVDU (quit ___ on methadone -S/P ERCP ___ CBD dilatation 15mm, stone fragments and sludge removed. -S/P HYSTERECTOMY ___ -S/P TUBAL LIGATION -IRRITABLE BOWEL SYNDROME ___ -ANXIETY -BARTHOLIN'S CYST -DEPRESSION -GASTRITIS ___ Noted on ___ EGD. -GASTROESOPHAGEAL REFLUX ___ Grade A on EGD ___ -GASTROPARESIS ___ Reported as severe per ___ EGD report -GASTROPATHY ___ Portal hypertensive gastropathy noted on ___ EGD. -HEMORRHOIDS ___ External, noted on ___ flex sig. -HIATAL HERNIA ___ Noted on ___ EGD. -TOBACCO ABUSE -ECTOPIC PREGNANCY ___ -HYSTERECTOMY (STATUS CERVIX UNKNOWN) ___ -ASTHMA -H/O DIVERTICULITIS ___ Per patient. -H/O ECTOPIC PREGNANCY -H/O PEPTIC ULCER DISEASE ___ ulcers in antrum noted on EGD ___. Biopsies benign, H. pylori stain negative. EGD ___ - negative for ulcers or varices Social History: ___ Family History: Estranged from her family. Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: 97.1 \| 80 \| 120/80 \| 12 \| 95%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, symmetricall dilated pupils, reactive to light. Smooth beefy tongue, moist, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Distant breath sounds (limited exam), clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, discrete collateral circulation, BS+, no flank dullness, soft, non-tender, no palpable organomegaly Ext: WWP, 1+ bilateral lower extremity edema. LLE distal venous insufficiency chronic changes. RLE w/venous insufficiency changes but also 20x12cm erythematous, warm, tender indurated plaque with weaping. Skin: As described above Neuro: AOx3, no asterixis, no gross focal findings DISCHARGE PHYSICAL EXAM: Vitals: Tc 98.1, Tm 98.3, HR: 71-92, BP: 112-132/52-91, RR: ___, O2: 94-100% RA General: Sitting up, alert, no acute distress HEENT: Sclera anicteric, MMM, PERRL. Neck: supple, JVP not elevated Lungs: Clear to auscultation bilaterally, though distant CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, BS+, soft, non-tender, no masses or organomegaly Ext: WWP, 2+ bilateral lower extremity edema. RLE demonstrates resolution of cellulitis with minimal erythema and edema. Non-tender. Signs of chronic venous changes remain. Neuro: A+Ox3. No gross focal findings. Pertinent Results: ADMISSON LABS: ___ 04:50PM BLOOD WBC-5.0 RBC-3.93* Hgb-13.3 Hct-41.9 MCV-107* MCH-33.8* MCHC-31.7 RDW-13.8 Plt Ct-80* ___ 04:50PM BLOOD Neuts-24* Bands-0 Lymphs-57* Monos-6 Eos-3 Baso-0 Atyps-9* ___ Myelos-1* ___ 04:50PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-NORMAL ___ 06:45AM BLOOD ___ PTT-39.1* ___ ___ 04:50PM BLOOD Glucose-81 UreaN-10 Creat-0.7 Na-141 K-3.7 Cl-101 HCO3-33* AnGap-11 ___ 04:50PM BLOOD ALT-55* AST-73* AlkPhos-157* TotBili-0.5 ___ 06:45AM BLOOD Albumin-2.6* Calcium-7.7* Phos-2.8# Mg-1.8 ___ 04:50PM BLOOD VitB12-1435* ___ 04:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ___ 04:58PM BLOOD Lactate-1.1 ___ 02:25PM URINE Color-Straw Appear-Clear Sp ___ ___ 02:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 02:25PM URINE Hours-RANDOM ___ 02:25PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-POS NOTABLE LABS: ___ 07:45AM BLOOD AFP-68.7* ___ 05:15AM BLOOD Vanco-19.4 ___ 08:08AM BLOOD ___ pO2-78* pCO2-54* pH-7.38 calTCO2-33* Base XS-4 Comment-GREEN TOP DISCHARGE LABS: ___ 06:55AM BLOOD WBC-5.0 RBC-3.99* Hgb-13.4 Hct-43.1 MCV-108* MCH-33.5* MCHC-31.0 RDW-14.4 Plt Ct-82* ___ 06:55AM BLOOD Glucose-68* UreaN-14 Creat-0.8 Na-137 K-3.6 Cl-100 HCO3-33* AnGap-8 ___ 06:55AM BLOOD ALT-69* AST-104* LD(LDH)-390* AlkPhos-143* TotBili-0.6 ___ 06:55AM BLOOD Albumin-3.1* Calcium-8.5 Phos-2.8 Mg-1.9 MICRO: ___ 4:50 pm BLOOD CULTURE #1. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 5:40 pm BLOOD CULTURE #2. FINAL REPORT ___ Blood Culture, Routine (Final ___: NO GROWTH. ___ 8:10 pm MRSA SCREEN Source: Rectal swab. FINAL REPORT ___ MRSA SCREEN (Final ___: No MRSA isolated. ___ 8:09 pm SWAB Source: Rectal swab. FINAL REPORT ___ R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final ___: No VRE isolated. IMAGING: Liver US: 1. Echogenic liver consistent with fatty infiltration. 2. Mild splenomegaly 3. Patent portal vein. 4. No intrahepatic biliary dilatation. The extrahepatic common bile duct is again noted to be enlarged measuring up to 1.3 cm. MRI abd with and without contrast: 1. No concerning hepatic mass. Replaced right hepatic artery arising from the SMA. 2. Unchanged, mildly prominent CBD, without obstructing stone or mass. Brief Hospital Course: ___ former IVDU on methadone w/hx of HCV cirrhosis, asthma/?COPD, also recurrent lower extremity cellulitis who was transfered from ___ with RLE cellulitis and encephalopathy at OSH. #RLE CELLULITIS: The patient initially presented with an erythematous, edematous, warm, tender, weeping ~20cmx15cm lesion on her right leg suggestive of cellulitis. She was initially covered with vancomycin and ceftriaxone. Blood cultures were negative and coverage was narrowed to Keflex and doxycycline. The cellulitic lesion was nearly resolved completely at time of discharge. #PORTOSYSTEMIC ENCEPHALOPATHY: The patient came in with fluctuating mental status, likely from HCV cirrhosis and use of several sedating medications. Hepatology was consulted regarding the patient's cirrhosis and it was recommended to increase the patient's lactulose to 30ml q2h initially. The patient had a good response to this, and the dose was scaled back to q6h following 6BM in one night. The patient was informed of the goal BM frequency at ___ BM/day. She was also started on rifaximin 550mg BID. The patient had also been taking 130mg of methadone, hydroxyzine, and prn ativan. The hydroxyzine was discontinued and the methadone dose was lowered by 10mg /day down to 100mg. With these medication changes, the patient's mental status improved significantly. #HCV CIRROSIS: While bilateral lower extremity edema and encephalopathy suggested possible worsening of HCV cirrhosis, the cirrhosis was not decompensated given normal Tbili lack of significant ascites on exam and on RUQ U/S. History of a liver lesion, which could not be seen on ultrasound, led to a workup for ___. While the AFP was elevated (chronically), an MRI of the abdomen did not demonstrate any concerning mass. Her spironolactone was continued in-house to help resolve some of the ___ edema. Lasix was held due to hypotension in the setting of both diuretics. Her mental status and ___ edema improved through the course of her admission and she will see Hepatologist Dr. ___ as an outpatient. #METHADONE USE: The patient has distant history of IVDU and chronic methadone management. Her dose of 130mg daily was confirmed with ___ (___). In the setting of depressed mental status, slow tapering of methadone dosing was initiated. The dose was decreased by 10mg/day to 100mg. Her mental status improved and she was maintained at the 100mg dose as an inpatient. Social work has followed up with ___ concerning the reduced dosing regimen and a letter detailing the doses of methadone for the patient while in-house was sent. #ANXIETY / DEPRESSION: She has been stable on her home regimen per her psychiatrist and PCP, and she should continue her use of lamotrigine for depression and clonazepam prn for anxiety. #TOBACCO USE: Continue to use nicotine gum prn. Transitional Issues: -Follow-up appointment with hepatologist Dr. ___ scheduled. -Sleep study as outpt given O2 desaturation on tele over night -EGD one year to rescreen for varices -Medication changes: Methadone 130mg daily decreased to Methadone 100mg daily, doxycycline 100mg q12h and keflex ___ q6h scripts were given for an additional 4 days to complete a 10-day course of antibiotics, rifaximin 550mg was initiated (pharmacy will need a prior authorization for more than six doses), cyanocobalamin 100mg was initiated and script was given for high MMA result (480). # CODE: DNR, OK to in # CONTACT: ___, mother, ___ Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Lactulose 15 mL PO TID 2. LaMOTrigine 200 mg PO DAILY 3. HydrOXYzine 12.5 mg PO TID:PRN anxiety 4. Nicotine Polacrilex 2 mg PO Q4H:PRN craving 5. ClonazePAM ___ mg PO BID:PRN anxiety 6. Spironolactone 50 mg PO DAILY 7. Methadone 130 mg PO DAILY 8. Fluticasone Propionate 110mcg 1 PUFF IH BID 9. Omeprazole 20 mg PO DAILY 10. Amitriptyline ___ mg PO HS 11. FoLIC Acid 1 mg PO DAILY Discharge Medications: 1. Amitriptyline ___ mg PO HS 2. Fluticasone Propionate 110mcg 1 PUFF IH BID 3. FoLIC Acid 1 mg PO DAILY 4. Lactulose 30 mL PO Q6H RX lactulose 20 gram/30 mL 30 ml by mouth every 6 hours Refills:0 5. LaMOTrigine 200 mg PO DAILY 6. Spironolactone 50 mg PO DAILY 7. Omeprazole 20 mg PO DAILY 8. Nicotine Polacrilex 2 mg PO Q4H:PRN craving 9. Methadone 100 mg PO DAILY 10. Cephalexin 500 mg PO Q6H Duration: 4 Days RX cephalexin 500 mg 1 capsule(s) by mouth every 6 hours Disp #18 Capsule Refills:0 11. Doxycycline Hyclate 100 mg PO Q12H Duration: 4 Days RX doxycycline hyclate 100 mg 1 capsule(s) by mouth every 12 hours Disp #9 Capsule Refills:0 12. Rifaximin 550 mg PO BID RX rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily Disp #30 Tablet Refills:0 13. ClonazePAM 1 mg PO BID:PRN anxiety 14. Cyanocobalamin 100 mcg PO DAILY RX cyanocobalamin (vitamin B-12) 100 mcg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1. Right lower extremity cellulitis Secondary Diagnoses: 1. Portosystemic encephalopathy 2. HCV cirrhosis 3. opiate dependence 4. Anxiety and Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ were admitted to the hospital for a skin infection of the right lower leg and changes in alertness. We started ___ on antibiotics for the infection of right leg, which later improved. In the workup for confusion, it was likely a result of your cirrhosis and methadone dosing. We increased the number of times per day that ___ take lactulose and also added a new medication, rifaximin. ___ need to taka lactulose on a consistent basis so that ___ have 3 bowel movements per day. With regard to the methadone, we decreased your dose 10mg per day from 130 to 100 mg, and this change is being communicated with your outpatient provider via phone and letter. With these changes, your alertness and ability to think improved. ___ will need to take antibiotics for 4 more days. ___ MDs Followup Instructions: ___
10134648-DS-15	10,134,648	25,921,585	DS	15	2181-11-27 00:00:00	2181-11-27 10:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Transient right visual field loss. Major Surgical or Invasive Procedure: TEE with PFO with bidirectional flow. History of Present Illness: The patient is a ___ who was cutting tile yesterday and became disoriented. He said it felt like the room was moving (not spinning but moving when he knew it wasn't supposed to be), and that he didn't know where he was (knew he was in the bathroom but didn't understand why he was there or how he got there). He lost his balance briefly, and immediately noticed a sensation in his right hand that felt like an electric shock. This sensation went through his hand for ___ seconds and did not spread past the wrist. He then noticed a "blind spot in [his] right eye" and began to have a dull headache. He could not see things on his right side, even when he closed one eye, but instead saw black and white static. After an hour, the blind spot had subsided somewhat but there was still some visual impairment. He went to bed, and when he awoke the following morning he still had a headache and vision loss on the right side. He went to the nearest ___, had a CT scan, was sent to ___ ___ where he had an MRI, and was then transferred to the ___ as an atypical stroke presentation. On neurologic review of systems, the patient denies lightheadedness, or confusion. Denies difficulty with producing or comprehending speech. Denies loss of vision, blurred vision, diplopia, vertigo, tinnitus, hearing difficulty, dysarthria, or dysphagia. Denies focal muscle weakness, numbness, parasthesia. Denies loss of sensation. Denies bowel or bladder incontinence or retention. Denies difficulty with gait. On general review of systems, the patient denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgia or myalgias. Denies rash. Past Medical History: Migraine headaches with visual changes described as curving lines in the right visual field, occurring every 2 months without associated headaches. Social History: ___ Family History: Mother: breast CA ___: prostate CA MGm: DM type 2 Brother: (older) healthy Sister: (older) healthy No family history of thrombosis, coagulopathy, or miscarriages known to pt. Physical Exam: ======================= ADMISSION PHYSICAL EXAM ======================= Vitals: T: P: R: 16 BP: SaO2: General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, normal. S1S2, no M/R/G noted Abdomen: soft, NT/ND. Extremities: No ___ edema. Skin: no rashes or lesions noted. Neurologic: Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name ___ backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Patient was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. He was able to register 3 objects and recall ___ at 5 minutes. There was no evidence of apraxia or neglect. Cranial Nerves: II, III, IV, VI: PERRL 6 to 4mm and brisk. EOMI with 2 beats horizontal nystagmus. Normal saccades. VFF to confrontation; OD some loss of clarity on right hemi-field to facial inspection, OS without deficits. Visual acuity ___ bilaterally. V: Facial sensation intact to light touch in V1-V3 VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically, uvula midline. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Normal bulk without fasciculation, tremor, asterixis, or adventitious movement; tone normal throughout with no rigidity or spasticity. No pronator drift bilaterally. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ ___ 5 5 5 5 5 5 5 R 5 ___ ___ 5 5 5 5 5 5 5 Sensory: No deficits to light touch, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. DTRs: Bi Tri ___ Pat Ach L 2 2 2 3 1 R 2 2 2 3 1 Plantar response was flexor bilaterally. Coordination: No intention tremor, no dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. Gait: Good initiation. Narrow-based, normal stride and arm swing. Able to walk in tandem without difficulty. Romberg absent. ======================= DISCHARGE PHYSICAL EXAM ======================= Temperature: 97.8 Blood pressure: 117/54 Pulse: 83 Respiratory rate: 18 Oxygen saturation: 96% General physical examination: General: Comfortable and in no distress Head: No irritation/exudate from eyes, nose, throat Neck: Supple with no pain to flexion or extension Cardio: Regular rate and rhythm, warm, no peripheral edema Lungs: Unlabored breathing Abdomen: Soft, non tender, non distended Skin: No rashes or lesions Neurologic examination: Mental status: Patient is alert and fully oriented. Patient with fluid speech and no errors in language. Patient is able to express concerns and follow directions throughout examination without difficulty. Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch. VII: No facial droop, facial musculature symmetric. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. XI: ___ strength in trapezii and SCM bilaterally. XII: Tongue protrudes in midline. Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___ L 5 ___ 5 ___ 5 5 5 5 5 R 5 ___ 5 ___ 5 5 5 5 5 Sensory: No deficits to light touch throughout. Reflexes: Deferred. Coordination: No dysmetria on FNF. Gait: Deferred. Pertinent Results: Non-Contrast CT of Head ___: Outside study; No acute intracranial blood is appreciated. There is a 24mm region of hypodensity and decreased gray-white matter contrast in the left posterolateral parietal lobe and anterolateral occipital lobe extending from the cortex to the posterior aspect of the left lateral ventricle. MRI of Head ___: Outside study; diffusion-weighted imaging shows 23mm region of hyper intensity in the left posterolateral parietal lobe and anterolateral occipital lobe extending from the cortex to the posterior aspect of the left lateral ventricle. ADC shows hypo intensity corresponding to the region described above. CTA head and neck ___: 1. Early subacute infarction in the left parietal lobe, similar to the MRI from 1 day earlier. No acute hemorrhage. No significant mass effect. 2. Normal CTA of the head and neck without evidence for dissection. 3. Paranasal sinus disease. TEE ___: PFO with bidirectional flow, no thrombus MRV and lower extremity ultrasound studies: Negative for DVT %HbA1c-4.8 Triglyc-96 HDL-54 CHOL/HD-3.8 LDLcalc-132* TSH-3.8 Anti lupus, protein c, protein s, and anti thrombin negative Brief Hospital Course: Patient is a ___ year old male with no past medical history whom experienced a transient episode of right visual field loss whom was found to have a left parietooccipital stroke. Patient's neurologic examination was unremarkable on presentation and discharge. Patient had TEE and was found to have PFO. Patient had lower extremity ultrasound and CT pelvis and abdomen and no clots were found. Patient has pro coagulation workup, but to date lupus anticoagulant, protein c, protein s, and antithrombin is negative. Patient was discharged with aspirin 81 mg daily. Patient should follow up with primary provider as LDL 132 to discuss management options. Patient with no evidence of atherosclerotic disease on imaging. Medications on Admission: None reported Discharge Medications: 1. Aspirin 81 mg PO DAILY RX aspirin 81 mg 1 tablet(s) by mouth Daily Disp #30 Tablet Refills:*5 Discharge Disposition: Home Discharge Diagnosis: Left parietooccipital stroke. 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 developed transient right visual loss and were found to have an acute stroke in the region of the brain that is important in vision for the right eye. We have found that you have a patent foramen ovale in your heart and we have discussed how this could increase you risk of stroke. We have done imaging studies of your pelvis and lower extremities and did not find any blood clots. We are still awaiting the results from some laboratory studies that if positive could indicate that you are at increased risk of blood clotting and therefore having strokes. We have started you on aspirin 81 mg daily. This medication has been shown to reduce the risk of recurrence of stroke. Your cholesterol is on the high side and we recommend that you follow up with your primary care physician to discuss management options. We will follow up with you in clinic as scheduled below, but if one of your blood studies comes back sooner then we will contact you and plan/intervene accordingly. Thank you for allowing use to care for you, ___ Neurology Followup Instructions: ___
10134664-DS-17	10,134,664	28,886,120	DS	17	2163-01-15 00:00:00	2163-02-28 13:45:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: Boostrix Tdap Attending: ___. Chief Complaint: RLQ pain Major Surgical or Invasive Procedure: ___: Laparoscopic appendectomy History of Present Illness: ___ otherwise healthy who presents to the ED with appendicitis. Of significance, patient was doing well until 24 hours ago, when she started to experience first non-specific abdominal pain, with nausea, followed by localized RLQ abdominal pain. Patient had some chills, but denies fever, and continues to pass gas and have BM. Last meal was 24 hours ago. Patient underwent CT A/P, demonstrating dilated appendix with appendicolith with stranding around appendix. Patient had WBC of 13 as well. Past Medical History: PMH: hypothyroidism, kidney cyst, tinnitus, HSV 2 PSH: None Social History: ___ Family History: Non-contributory Physical Exam: Admission Physical Exam: Vitals: Stable General: AAOx3 Cardiac: Normal S1, S2 Respiratory: RA, equal breath sounds Abdomen: Soft, tender RLQ, no rebound or guarding Discharge Physical Exam: VS: T: 98.3 PO 102 / 67 76 16 98 RA GEN: A+Ox3, NAD HEENT: atraumatic CV: RRR, no m/r/g PULM: CTA b/l ABD: soft, mildly distended, non-tender to palpation. Laparoscopic incisions with steri-strips, gauze and tegaderm c/d/I, no s/s infection. EXT: wwp, no edema b/l Pertinent Results: IMAGING: ___: CT abdomen/pelvis: 1. Acute uncomplicated appendicitis. 2. Fibroid uterus. LABS: ___ 06:18AM GLUCOSE-113* UREA N-9 CREAT-0.9 SODIUM-135 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-21* ANION GAP-12 ___ 06:18AM ALT(SGPT)-9 AST(SGOT)-18 ALK PHOS-44 TOT BILI-0.6 ___ 06:18AM LIPASE-23 ___ 06:18AM ALBUMIN-4.2 ___ 06:18AM WBC-13.3* RBC-3.70* HGB-11.4 HCT-35.1 MCV-95 MCH-30.8 MCHC-32.5 RDW-14.0 RDWSD-48.7* ___ 06:18AM NEUTS-86.7* LYMPHS-6.3* MONOS-5.2 EOS-0.0* BASOS-0.4 IM ___ AbsNeut-11.49* AbsLymp-0.84* AbsMono-0.69 AbsEos-0.00* AbsBaso-0.05 ___ 06:18AM PLT COUNT-229 ___ 05:26AM URINE UCG-NEGATIVE ___ 05:26AM URINE COLOR-Yellow APPEAR-Clear SP ___ ___ 05:26AM URINE BLOOD-TR* NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG ___ 05:26AM URINE RBC-1 WBC-2 BACTERIA-NONE YEAST-NONE EPI-1 ___ 05:26AM URINE MUCOUS-RARE* Brief Hospital Course: The patient was admitted to the Acute Care Surgery service on ___ for evaluation and treatment of abdominal pain. Admission abdominal/pelvic CT revealed acute uncomplicated appendicitis WBC was elevated at 13.3. On HD1, the patient underwent laparoscopic appendectomy, which went well without complication (reader referred to the Operative Note for details). After a brief, uneventful stay in the PACU, the patient arrived on the surgical floor. The patient was hemodynamically stable. When tolerating a diet, the patient was converted to oral pain medication with continued good effect. Diet was progressively advanced as tolerated to a regular diet with good tolerability. The patient voided without problem. During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirometry, and actively participated in the plan of care. The patient received subcutaneous heparin and venodyne boots were used during this stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient was discharged home without services. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Levothyroxine 25 mcg DAILY Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever 2. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Second Line 3. Senna 8.6 mg PO BID:PRN Constipation - First Line 4. Levothyroxine Sodium 25 mcg 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 ___, ___ were admitted to ___ with acute inflammation of your appendix. ___ were taken to the operating room and had your appendix removed laparoscpically. This procedure went well. ___ are now tolerating a regular diet and your pain has improved. ___ are ready to be discharged home to continue your recovery. Please follow the discharge instructions below: Please follow up in the Acute Care Surgery clinic at the appointment listed below. ACTIVITY: o Do not drive until ___ have stopped taking pain medicine and feel ___ could respond in an emergency. o ___ may climb stairs. o ___ may go outside, but avoid traveling long distances until ___ see your surgeon at your next visit. o Don't lift more than ___ lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o ___ may start some light exercise when ___ feel comfortable. o ___ will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when ___ can resume tub baths or swimming. HOW ___ MAY FEEL: o ___ may feel weak or "washed out" for a couple of weeks. ___ might want to nap often. Simple tasks may exhaust ___. o ___ may have a sore throat because of a tube that was in your throat during surgery. o ___ might have trouble concentrating or difficulty sleeping. ___ might feel somewhat depressed. o ___ could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your surgeon. YOUR INCISION: o ___ may shower and tomorrow ___ may remove the gauzes over your incisions. Under these dressing ___ have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o ___ may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless ___ were told otherwise. o ___ may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your surgeon. o ___ may shower. As noted above, ask your doctor when ___ may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, ___ may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. ___ can get both of these medicines without a prescription. o If ___ go 48 hours without a bowel movement, or have pain moving the bowels, call your surgeon. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If ___ find the pain is getting worse instead of better, please contact your surgeon. o ___ will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if ___ take it before your pain gets too severe. o Talk with your surgeon about how long ___ will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your surgeon has said its okay. o If ___ are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when ___ cough or when ___ are doing your deep breathing exercises. If ___ experience any of the following, please contact your surgeon: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines ___ were on before the operation just as ___ did before, unless ___ have been told differently. If ___ have any questions about what medicine to take or not to take, please call your surgeon. Followup Instructions: ___
10135398-DS-19	10,135,398	28,054,572	DS	19	2153-10-18 00:00:00	2153-10-18 17:31:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Left Subdural Hematoma. Major Surgical or Invasive Procedure: ___ - Left Craniotomy for evacuation of Subdural Hematoma. History of Present Illness: This is a ___ y/o male who presents to ___ on ___ with a moderate TBI. Per report, the patient was walking intoxicated and was struck by slow moving vehicle, + head strike and LOC. He was brought to an OSH hospital were a head CT was obtained and showed a left SDH, parafalcine SDH and bi-frontal SAH. He was then transferred here to ___ for further evaluation and work up. Prior to transfer the patient received a Keppra load and mannitol. The patient endorses headaches, but not answering other questions, poor historian. Past Medical History: Unknown. Social History: ___ Family History: Unknown. Physical Exam: PHYSICAL EXAMINATION ON ADMISSION: GCS upon Neurosurgery Evaluation: 15 +ETOH Eye Opening: [ ]1 Does not open eyes [ ]2 Opens eyes to painful stimuli [ ]3 Opens eyes to voice [x]4 Opens eyes spontaneously Verbal: [ ]1 Makes no sounds [ ]2 Incomprehensible sounds [ ]3 Inappropriate words [x]4 Confused, disoriented [ ]5 Oriented Motor: [ ]1 No movement [ ]2 Extension to painful stimuli (decerebrate response) [ ]3 Abnormal flexion to painful stimuli (decorticate response) [ ___ Flexion/ withdrawal to painful stimuli [ ]5 Localizes to painful stimuli [x]6 Obeys commands Exam: Gen: WD/WN, comfortable, NAD. Extrem: warm and well perfused Neuro: Mental Status: Awake, alert, cooperative with exam, but agitated, and impulsive. Orientation: refusing to answer questions. Language: Speech is fluent, ___ speaking. If Intubated: [ ]Cough [ ]Gag [ ]Over breathing the vent Cranial Nerves: I: Not tested II: Right pupil irregular 4mm, left pupil 3-2. mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Unable to assess Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power ___ throughout. No pronator drift. Sensation: Intact to light touch. PHYSICAL EXAMINATION ON DISCHARGE: GCS 15 NAD, awake, alert intermittent agitation PERRL, EOMi, V1-3 intact, face moves symmetrically, symmetric palate elevation, full trapezius/SCM function, tongue protrudes midline. Normal muscle bulk/tone; ___ strength in BUE/BLE, no pronator drift Sensation intact to light touch Hemodynamically stable Unlabored breathing on RA Pertinent Results: ___ - HEAD CT WITHOUT CONTRAST: IMPRESSION: 1. Interval increase in the left subdural hematoma, now measuring 15 mm in maximum thickness, previously 5 mm. Hypodense components are concerning for active hemorrhage. New rightward shift of normally midline structures measures 6 mm. 2. Interval development of parenchymal hemorrhage in the bilateral frontal lobes. 3. New small amount of subarachnoid blood in the right marginal sulcus likely due to redistribution. 4. Subdural blood previously seen only overlying the right temporal lobe now extends superiorly along the right frontal and parietal lobes. ___ CT HEAD W/O CONTRAST (1730) 1. Status post left hemispheric craniotomy and evacuation of a left subdural hematoma. Improved left-to-right midline shift. 2. Stable subarachnoid hemorrhage. 3. Hemorrhage contusion ends involving bilateral frontal lobes, and right temporal lobe, 1 small focus is mildly more prominent since prior. ___ CT RIGHT LOWER EXTREMITIY 1. Complex fracture of the proximal tibia, with involvement of the metaphysis, and intraarticular extension in the medial, lateral tibial plateau. 2. Lipohemarthrosis. ___ CT HEAD W/O CONTRAST IMPRESSION: 1. Status post left hemispheric craniotomy and evacuation of left subdural hematoma, with interval evolution of expected postoperative changes. 2. A heterogeneous, predominately hyperdense extra-axial collection remains overlying the left cerebral convexity, with interval resolution of previously seen midline shift and mass effect on the left lateral ventricle. 3. Stable small right frontal subdural hematoma, extensive subarachnoid hemorrhage, and expected evolution of bifrontal and right temporal hemorrhagic contusions. 4. No new foci of hemorrhage or evidence of acute infarct ELBOW AP & LAT VIEWS RIGHT PORT Study Date of ___ 8:09 AM IMPRESSION: Unremarkable right elbow radiographs. HUMERUS (AP & LAT) RIGHT PORT Study Date of ___ 8:09 AM IMPRESSION: Widening of the right acromioclavicular joint may be an artifact related to projection but could reflect disruption of the acromioclavicular ligament. This could be clarified with bilateral AC joint views with and without weight-bearing when the patient's clinical condition improves. CT HEAD W/O CONTRAST Study Date of ___ 5:16 ___ IMPRESSION: 1. Suggestion of few punctate hemorrhages in the upper brainstem, not definitely seen on prior exams. Mildly enlarged right temporal lobe parenchymal hemorrhage. Slightly more prominent subdural hematoma overlying left frontal, parietal lobes, likely from redistribution. 2. Otherwise, there is no significant change in other areas of intracranial hemorrhage. There is no hydrocephalus. CT HEAD W/O CONTRAST ___ IMPRESSION: 1. Study is moderately degraded by motion. 2. Status post left craniotomy and evacuation of a subdural hematoma with expected postoperative changes. 3. Grossly stable left cerebral convexity 7 mm subdural hemorrhage. 4. Evolving bifrontal hemorrhagic contusions. 5. Grossly stable right parietal and temporal hemorrhages. RIGHT KNEE X-RAY: ___ IMPRESSION: Fractures of the distal femur, proximal tibia Small knee effusion. Brief Hospital Course: #Subdural Hematoma: The patient was transferred to ___ from ___ ___ on ___ after being struck by a motor vehicle. His head CT demonstrated bilateral frontal contusions and a small 5mm left subdural hematoma. He was admitted to the ___ overnight for close neurologic monitoring. On ___, the patient underwent a repeat non-contrast head CT which showed an increase in the left subdural hematoma from 5mm to 15 mm with new 6mm midline shift with blossoming of the bilateral frontal contusions. His neurologic examination deteriorated and he became non-verbal. He was taken emergently to the operating room and underwent a left craniotomy for evacuation of subdural hematoma with Dr. ___. Post-operative CT Head completed showing post-operative changes with decreased blood products in subdural space. Patient underwent a follow CT head on ___ that showed heterogenous collection overlying the left cerebral convexity with interval resolution of midline shift and reexpansion of lateral ventricle. Subdural drain was removed on ___. Post-pull head CT showed suggestion of new brainstem punctate hemorrhages, mild enlarge R temp lobe IPH, and slightly more prominent SDH likely from redistribution. On ___, the patient was transferred to the ___. He was continued on hypertonic saline and his Seroquel was increased. His daily EKG showed a QTC interval of 442. He completed his phenobarb taper. His sutures and staples were removed on ___. His AM serum sodium level was 133. His 3% hypertonic saline was decreased. On ___, the patient remained neurologically stable on examination with stable serum sodium levels; the 3% hypertonic saline gtt was discontinued. The patient continued to be stable from a neurosurgical perspective from this point until discharge. His Na level remained stable on ___ at 137. #Atrial fibrillation. New onset atrial fibrillation was identified during this admission. The patient was effectively rate-controlled for the duration of admission. He will continue on metoprolol 25 mg TID following discharge. #Agitation Significant agitation was noted postoperatively and the patient was initiated on precedex and subsequently seroquel. He remained in the ICU for close monitoring until ___, at which time he was transferred to the step down unit. Agitation continued and the patient required intermittent haloperidol for the duration of admission. Agitation increased following floor transfer and the patient made several attempts to leave against medical advice. Psychiatry was consulted for recommendations on ___. A team meeting to assess patient capacity was scheduled for ___ and the patient was deemed to not have capacity. The patient was evaluated for guardianship during this admission. He was ultimately discharged to home. #Right Bicondylar tibial plateau fracture: Orthopaedics consulted for management on admission (___). The patient was placed in a knee immobilizer and RLE made NWB. The patient was cleared for operative repair by orthopedics, but the patient was unable to consent given mental status. Given lack of emergent/acute nature of fracture, operative repair was deferred. The patient was non-compliant with NWB status and brace wearing during admission. Repeat tibial XR were obtained on ___ and redemonstrated fracture with knee effusion. The patient continues to be noncompliant with NWB status. Medications on Admission: unknown Discharge Medications: 1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild 2. CloNIDine 0.1 mg PO TID 3. Docusate Sodium 100 mg PO BID 4. Fludrocortisone Acetate 0.2 mg PO BID 5. FoLIC Acid 1 mg PO DAILY 6. Metoprolol Tartrate 25 mg PO TID 7. Ramelteon 8 mg PO QHS 8. Senna 8.6 mg PO QHS 9. Tamsulosin 0.4 mg PO QHS urinary retention 10. Thiamine 100 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Left subdural hematoma. Bilateral frontal contusions. Bicondylar right tibial plateau fracture Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Discharge Instructions Brain Hemorrhage with Surgery Surgery You underwent a surgery called a craniotomy to have blood removed from your brain. It is best to keep your incision open to air but it is ok to cover it when outside. Call your surgeon if there are any signs of infection like redness, fever, or drainage. Activity We recommend that you avoid heavy lifting, running, climbing, or other strenuous exercise until your follow-up appointment. You make take leisurely walks and slowly increase your activity at your own pace once you are symptom free at rest. ___ try to do too much all at once. No driving while taking any narcotic or sedating medication. If you experienced a seizure while admitted, you are NOT allowed to drive by law. No contact sports until cleared by your neurosurgeon. You should avoid contact sports for 6 months. Medications Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. You may use Acetaminophen (Tylenol) for minor discomfort if you are not otherwise restricted from taking this medication. What You ___ Experience: You may have difficulty paying attention, concentrating, and remembering new information. Emotional and/or behavioral difficulties are common. Feeling more tired, restlessness, irritability, and mood swings are also common. You may also experience some post-operative swelling around your face and eyes. This is normal after surgery and most noticeable on the second and third day of surgery. You apply ice or a cool or warm washcloth to your eyes to help with the swelling. The swelling will be its worse in the morning after laying flat from sleeping but decrease when up. You may experience soreness with chewing. This is normal from the surgery and will improve with time. Softer foods may be easier during this time. Constipation is common. Be sure to drink plenty of fluids and eat a high-fiber diet. If you are taking narcotics (prescription pain medications), try an over-the-counter stool softener. Headaches: Headache is one of the most common symptoms after a brain bleed. Most headaches are not dangerous but you should call your doctor if the headache gets worse, develop arm or leg weakness, increased sleepiness, and/or have nausea or vomiting with a headache. Mild pain medications may be helpful with these headaches but avoid taking pain medications on a daily basis unless prescribed by your doctor. There are other things that can be done to help with your headaches: avoid caffeine, get enough sleep, daily exercise, relaxation/ meditation, massage, acupuncture, heat or ice packs. When to Call Your Doctor at ___ for: Severe pain, swelling, redness or drainage from the incision site. Fever greater than 101.5 degrees Fahrenheit Nausea and/or vomiting Extreme sleepiness and not being able to stay awake Severe headaches not relieved by pain relievers Seizures Any new problems with your vision or ability to speak Weakness or changes in sensation in your face, arms, or leg Call ___ and go to the nearest Emergency Room if you experience any of the following: Sudden numbness or weakness in the face, arm, or leg Sudden confusion or trouble speaking or understanding Sudden trouble walking, dizziness, or loss of balance or coordination Sudden severe headaches with no known reason Orthopaedic Instructions: You suffered a fracture to your right knee (tibial plateau). Please follow your activity and weight-bearing instructions: - non-weight bearing right lower extremity in ___ brace locked in extension at all times. Followup Instructions: ___
10135557-DS-7	10,135,557	26,612,112	DS	7	2141-03-31 00:00:00	2141-03-31 11:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Dark urine Major Surgical or Invasive Procedure: endotracheal intubation - ___ ERCP - ___ History of Present Illness: Mr. ___ is a ___ homeless gentleman with a history of diastolic heart failure, CAD s/p CABG, polysubstance abuse, DM, COPD, syncope, OSA not on CPAP, and recent hospital admission for infected foot ulcer who was referred to an OSH ED for elevated bilirubin and was transferred here for emergent ERCP. He presented to his PCP yesterday for evaluation of dark urine. He initially refused ED evaluation but then agreed today. At the OSH ED, bilirubin was 15.9 and an ultrasound showed CBD dilatation of 2.2 cm with intrahepatic ductal dilation. Per report, a CT done in ___ did not show these changes. Patient received 2 L IVF and was transferred to ___ for possible ERCP. In the ambulance, patient became somnolent with soft BPs and he desatted to ___ on RA. On arrival to the ED, initial vitals: T 105 rectally, HR 105, BP 100/53, RR 23, SaO2 70% RA. The patient was extremely somnolent and minimally responsive. Placement of a nasal trumpet was attempted but patient became belligerent and pulled it out and then became somnolent again. It is unclear if he had any response to Narcan. Patient was intubated for declining mental status. A R IJ was placed. Labs were notable for: WBC 9.5, H/H 13.4/41.1, plts 148, Na 128, K 2.8, Cl 76, BUN/Cr ___, glucose 106, lactate 1.6, INR 1.2, fibrinogen 556, urine and serum tox screens negative. ALT 39, AST 73, TBili 15.4, AP 282, lipase 92, alb 3.2. Initial ABG after intubation was ___, which improved to ___ after decreasing FiO2 to 60% and increasing RR to 22. Patient was given Vancomycin, Zosyn, Versed, Fentanyl, Levophed, and 1L NS. He was evaluated by ERCP, who recommended ICU admission and urgent ERCP. On arrival to the MICU, patient is intubated and sedated. Past Medical History: - Diastolic heart failure - Coronary artery disease s/p CABG in ___ - Hepatitis C - Chronic pain - OSA not on CPAP - Chronic lower extremity swelling with leg ulcers - Hypertension - Elevated cholesterol - Alcohol abuse - Polysubstance abuse, including IV heroin - Low back pain, sciatica - Status post exploratory laparotomy in ___ status post a stab wound to the abdomen - Abdominal hernia - Diabetes mellitus type 2 Social History: ___ Family History: Patient with a family history of alcohol abuse, no liver disease, no cardiac disease. Paternal grandfather had DVTs and PE. Physical Exam: Admission exam: ==================== Vitals: T 98.9, HR 80, BP 106/59, SaO2 96% 60% FiO2 GENERAL: Intubated and sedated HEENT: Sclera icteric NECK: Supple, IJ in place LUNGS: Intubated, lungs clear anteriorly CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs, gallops ABD: +BS, distended, soft, nontender, ventral hernia, vertical abdominal scar, unable to evaluate organomegaly EXT: Warm, 3+ pitting edema bilaterally with venous stasis changes, healing non-infected ulcer on lateral aspect of left fifth toe SKIN: Jauncdiced, poorly demarcated erythema of left lower extremity, venous stasis changes bilaterally ACCESS: IJ, A-line Discharge Exam: Central lines removed AF 90-130/70-80s 70-80s Pox 96% on RA Pertinent Results: Admission labs: ==================== ___ 05:00PM BLOOD WBC-9.5 RBC-4.65 Hgb-13.4* Hct-41.1 MCV-88# MCH-28.8# MCHC-32.6 RDW-19.9* RDWSD-62.5* Plt ___ ___ 09:16PM BLOOD Neuts-77.4* Lymphs-7.4* Monos-13.9* Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.88* AbsLymp-0.95* AbsMono-1.77* AbsEos-0.02* AbsBaso-0.04 ___ 05:00PM BLOOD ___ PTT-29.6 ___ ___ 09:16PM BLOOD Glucose-151* UreaN-16 Creat-1.0 Na-128* K-2.7* Cl-82* HCO3-33* AnGap-16 ___ 05:00PM BLOOD ALT-39 AST-73* AlkPhos-282* TotBili-15.4* ___ 09:16PM BLOOD Calcium-7.6* Phos-4.3 Mg-1.0* Interval Labs ___ 06:50AM BLOOD Glucose-192* UreaN-14 Creat-0.6 Na-135 K-3.4 Cl-83* HCO3-40* AnGap-15 ___ 07:16AM BLOOD Glucose-177* UreaN-15 Creat-0.6 Na-136 K-3.3 Cl-83* HCO3-45* AnGap-10 Discharge Labs: ___ 07:12AM BLOOD WBC-3.0* RBC-5.00 Hgb-14.4 Hct-45.6 MCV-91 MCH-28.8 MCHC-31.6* RDW-19.3* RDWSD-64.4* Plt ___ ___ 07:12AM BLOOD Glucose-268* UreaN-11 Creat-0.5 Na-135 K-3.9 Cl-88* HCO3-40* AnGap-11 ___ 07:12AM BLOOD ALT-29 AST-44* AlkPhos-185* TotBili-3.2* ___ 07:12AM BLOOD Calcium-9.6 Phos-3.0 Mg-1.9 VBG ___ 11:13AM BLOOD ___ pO2-79* pCO2-62* pH-7.48* calTCO2-47* Base XS-18 Comment-___ MICROBIOLOGY: ===================== ___ Blood cultures pending IMAGING: ===================== OSH Abdominal Ultrasound (___) FINDINGS: The liver shows coarsened echotexture. There are multiple small gallstones. There is no gallbladder wall thickening or pericholecystic fluid. The CBD is dilated measuring 2.2 cm maximally. There is moderate intrahepatic biliary ductal dilation. This was not present on the prior CT examination. The spleen is enlarged, measuring 15.5 cm. The kidneys are normal in echogenicity and countour without hydronephrosis. The right kidney measures 15.5 cm. The left kidney measures 14.9 cm. The pancreas is not well seen due to overlying bowel gas. The proximal aorta and IVC are unremarkable. The mid to distal vessels are not seen due to overlying bowel gas. IMPRESSION: 1. Prominent biliary ductal dilation 2. Gallstones 3. Splenomegaly. Coarsened liver echotexture suspicious for cirrhosis. CXR ___ IMPRESSION: The patient is post CABG. A right IJ central venous catheter terminates at the mid SVC. The heart size is normal. The hilar and mediastinal contours are within normal limits. There is no pneumothorax, focal consolidation, or pleural effusion. The central pulmonary vessels are prominent, however, there is no pulmonary edema. ERCP report Limited exam of the esophagus was normal Mucosa: Stomach: Mucosa: Evidence of Bilroth 1 anatomy Duodenum: A clean based duodenal ulcer was found at D1 Major Papilla: A massive bulging of the major papilla was noted, with suggestion of an impacted stone Cannulation: Cannulation was extremely difficult due to scope position and the massive papilla. Partial cannulation was achieved with passage of a large amount of pus, suggestive of fulminant cholangitis. A small pre-cut sphincterotomy was made to facilitate deeper cannulation, after which a large stone was delivered, and deeper cannulation became possible. Biliary Tree/ Fluoroscopic interpretation: There was evidence of dilation of the CBD to 2 cm with several large filling defects. Limited contrast opacification was intended because of ongoing cholangitis. I supervised the acquisition and interpretation of the fluoroscopic images. The quality of the fluoroscopic images was good.@ Procedures: A sphincterotomy was performed in the 12 o'clock position using a sphincterotome. The sphincterotome was exchanged for an extraction balloon catheter. Balloon sweeps were performed which yielded copious pus, sludge, and stone fragments. A 5cm by ___ double pigtail biliary stent was placed successfully with an Oasis pushing catheter. Impression: Limited exam of the esophagus was normal Evidence of Bilroth 1 anatomy A clean based duodenal ulcer was found at D1 A massive bulging of the major papilla was noted, with suggestion of an impacted stone Cannulation was extremely difficult due to scope position and the massive papilla. Partial cannulation was achieved with passage of a large amount of pus, suggestive of fulminant cholangitis. A small pre-cut sphincterotomy was made to facilitate deeper cannulation, after which a large stone was delivered, and deeper cannulation became possible. There was evidence of dilation of the CBD to 2 cm with several large filling defects. Limited contrast opacification was intended because of ongoing cholangitis. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome. The sphincterotome was exchanged for an extraction balloon catheter. Balloon sweeps were performed which yielded copious pus, sludge, and stone fragments. A 5cm by ___ double pigtail biliary stent was placed successfully with an Oasis pushing catheter. Recommendations: NPO overnight with aggressive IV hydration with LR at 200 cc/hr If no abdominal pain in the morning, advance diet to clear liquids and then advance as tolerated No aspirin, Plavix, NSAIDS, Coumadin for 5 days. Continue antibiotics to complete a course for cholangitis and ICU care Repeat ERCP in 4 weeks for stent pull and re-evaluation. Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call ___ Brief Hospital Course: Summary Mr. ___ is a ___ homeless gentleman with a history of diastolic heart failure, CAD s/p CABG, polysubstance abuse, DM, COPD, syncope, OSA not on CPAP, and recent hospital admission for infected foot ulcer who was referred to an OSH ED for elevated bilirubin and was transferred here for emergent ERCP due to concern for cholangitis. Acute issues # Hypoxic respiratory failure Hypoxic on transport to ___. Intubated in ED and admitted to FICU. Respiratory failure most likely from flash pulmonary edema. Improved rapidly and extubated to room air next day. # Cholangitis # Septic shock Underwent urgent ERCP on admission on ___ showing large pus from CBD suggesting fulminant cholangitis. Large impacted stone was removed. Stent was placed. Needs removal in 4 weeks. Treated with IV zosyn and vancomycin (___-). Required levophed on admission which was stopped on ___ AM. Called out to floor on ___. He did very well on the medical floor, was hemodynamically stable. He was put on oral ciprofloxacin and will complete a 10 day course of antibiotics for his cholangitis. Afebrile on the medical floor and was watched for 2 days on oral antibiotics. No abdominal pain. He would like to return to ___ for CCY and will followup with surgeon Dr ___ on ___ as an outpatient to discuss. # Encephalopathy: transient AMS on admission likely from sepsis. This improved in ICU following ERCP. # History of alcohol abuse: Per patient's ex-wife, patient is a daily drinker for many years. Unclear if he has ever had withdrawal seizures or DTs. Did not show signs of withdrawal. At first he denied alcohol use to me, and then confided that he drinks ___ drinks a week. # Diastolic heart failure: - Torsemide initially held for shock. He was restarted on his home dose on arrival to the floor and then "urinated constantly". His exam revealed bilateral ___ edema but this appeared chronic, and he has significant venous stasis. His lab work revealed a metabolic alkalosis which appears to be a contraction alkalosis, so his torsemide was held on ___ and ___ and he will resume torsemide at 60 mg daily on ___. I have emailed his PCP to expedite ___ next week for lab check. He tells me that he takes his medications as prescribed, but I wonder if the reason for his heavy UOP on torsemide is because he is not compliant with the medication at home. # CAD: - metoprolol initially held for shock. He was normotensive on the floor without metoprolol so he was discharged with Toprol xl 25 mg daily. Prescription for this dose was sent to ___ ___. # Hypertension: As he was normotensive on the floor without any of his home blood pressure medications he was discharged on lisinopril 2.5 mg and a prescription for this was sent to ___ ___ # COPD: - Continue Fluticasone-Salmeterol Diskus and albuterol prn # DM: - He was on sliding scale insulin in the hospital and was told to resume glipizide at home. # Homelessness: chronic. Alternately stays with family and homeless shelter. # Anxiety: Patient expressed concerns about his medical conditions, and longevity. Discussed with him that abstaining from cigarette smoking and alcohol would add to his longevity, as would medical compliance. # Foot ulcer: Wrapped, does not appear infected. # CODE STATUS: After experiencing intubation in the ICU, the patient felt firmly that he did not want to be intubated again in the future. He is a DNR/DNI, and patient expressed clear understanding and desire for this. He tells me that he discussed this with his family. # Early Satiety: Patient endorses poor appetite, feeling "full". Advised to discuss with pCP. ? gastroparesis. Transitional issues - 1. Needs PCP ___ to adjust bp meds, torsemide, check chemistries. As he is homeless, difficult to set up ___ for medication monitoring and adjustment. 2. Needs surgical ___ for cholecystectomy 3. Needs ___ ERCP for stent removal 4. Needs treatment for tinea pedis and onychomycosis Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO QPM 4. Cephalexin 500 mg PO Q6H 5. Collagenase Ointment 1 Appl TP DAILY 6. Docusate Sodium 100 mg PO BID 7. Ferrous Sulfate 325 mg PO DAILY 8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 9. FoLIC Acid 1 mg PO DAILY 10. Gabapentin 1200 mg PO TID 11. GlipiZIDE 10 mg PO BID 12. Glycerin Supps 1 SUPP PR PRN constipation 13. Magnesium Oxide 800 mg PO BID 14. Metoprolol Succinate XL 100 mg PO BID 15. Multivitamins 1 TAB PO DAILY 16. Nicotine Patch 21 mg TD DAILY 17. Omeprazole 40 mg PO DAILY 18. Potassium Chloride 40 mEq PO BID 19. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 20. Senna 17.2 mg PO QHS:PRN constipation 21. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 22. Thiamine 100 mg PO DAILY 23. Torsemide 60 mg PO BID 24. Cyanocobalamin 1000 mcg PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q8H:PRN pain 2. Atorvastatin 80 mg PO QPM 3. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL BID 4. Cyanocobalamin 1000 mcg PO DAILY 5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 6. FoLIC Acid 1 mg PO DAILY 7. Gabapentin 1200 mg PO TID 8. Omeprazole 40 mg PO DAILY 9. Senna 17.2 mg PO QHS:PRN constipation 10. Thiamine 100 mg PO DAILY 11. GlipiZIDE 10 mg PO BID 12. Docusate Sodium 100 mg PO BID 13. Ferrous Sulfate 325 mg PO DAILY 14. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB 15. Magnesium Oxide 800 mg PO BID 16. Multivitamins 1 TAB PO DAILY 17. Glycerin Supps 1 SUPP PR PRN constipation 18. Collagenase Ointment 1 Appl TP DAILY 19. Aspirin 81 mg PO DAILY 20. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days 21. Lisinopril 2.5 mg PO DAILY take this in the morning 22. Metoprolol Succinate XL 25 mg PO DAILY take this in the evening 23. Potassium Chloride 40 mEq PO DAILY Hold for K > 24. Torsemide 60 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: 1. Cholangitis 2. CHF 3. COPD 4. Diabetes Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with cholangitis, or an infection in your bile duct. You were initially in the ICU and then transferred to the medical floor. We put you on oral antibiotics, and you remained stable. Please finish up four more days of antibiotics and I have sent the prescription to the ___ Pharmacy. Please followup with Dr ___ and with surgery regarding removal of your gallbladder. I have adjusted your blood pressure medication. Please restart your torsemide and potassium tomorrow, but just take 60 mg a day for now. I have sent prescriptions for lower doses of lisinopril and metoprolol to your pharmacy. Followup Instructions: ___
10135907-DS-21	10,135,907	25,335,150	DS	21	2124-10-11 00:00:00	2124-10-18 21:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Bilateral hand injury Major Surgical or Invasive Procedure: ___: Bilateral wrist exploration with bilateral wrist repair History of Present Illness: This is a ___ generally healthy male who presents via EMS with bilateral wrist injury. He works in ___ and had a plate glass fall onto his outstretched forearms. He had bleeding which was controlled with T-shirt tourniquet on scene but did not have any other injuries. The patient had significant bleeding from the left wrist and nursing asked the ED resident to rapidly evaluate the patient. On their evaluation there was significant bleeding from the left wrist, likely arterial. A left upper arm tourniquet was placed and a trauma basic was called. There was no active bleeding from the right wrist initially, however when the blood pressure cuff on the right arm went up there was significant bleeding noted in any tourniquet was placed. Trauma surgery evaluated the patient and hand surgery was consulted for potential repair of bilateral lacerations/deep structures in the OR. Patient is in excruciating pain to bilateral forearms L>R. Denies any other complaints at this time. Patient admits that he has a previous injury to the R hand where he punched through a wall and had surgical intervention. He is unable to fully flex his R hand ___ digit. Denies any n/v/f/c/sob. Past Medical History: Previous R hand injury 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 bilateral wrist lacerations with arterial bleeding and was admitted to the orthopedic surgery service. The patient was taken to the operating room for bilateral wrist exploration with arterial repair, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The ___ 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 activity as tolerated in both upper extremities, and will be discharged on aspirin for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Aspirin 325 mg PO DAILY Take for 4 weeks RX aspirin 325 mg 1 tablet(s) by mouth once a day Disp #28 Tablet Refills:0 3. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate RX oxycodone 5 mg 1 tablet(s) by mouth Every 6 hours as needed Disp #25 Tablet Refills:0 Discharge Disposition: Home Discharge Diagnosis: Bilateral wrist lacerations Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER HAND SURGERY: - You were in the hospital for hand surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - Activity as tolerated on both wrists, non-weight bearing on both hands (nothing heavier than a cup of coffee) MEDICATIONS: 1) Take Tylenol ___ every 6 hours around the clock. This is an over the counter medication. 2) Add *** 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 4 hours as needed x 1 day, then 1 tablet every 6 hours as needed x 1 day, then 1 tablet every 8 hours as needed x 2 days, then 1 tablet every 12 hours as needed x 1 day, then 1 tablet every before bedtime as needed x 1 day. Then continue with Tylenol for pain. 3) Do not stop the Tylenol until you are off of the narcotic medication. 4) Per state regulations, we are limited in the amount of narcotics we can prescribe. If you require more, you must contact the office to set up an appointment because we cannot refill this type of pain medication over the phone. 5) Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and continue following the bowel regimen as stated on your medication prescription list. These meds (senna, colace, miralax) are over the counter and may be obtained at any pharmacy. 6) Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. 7) Please take all medications as prescribed by your physicians at discharge. 8) Continue all home medications unless specifically instructed to stop by your surgeon. ANTICOAGULATION: - Please take aspirin 325 mg daily for 4 weeks ANTIBIOTICS: - You completed your postoperative antibiotics while admitted. 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. - If you have a splint in place, splint must be left on until follow up appointment unless otherwise instructed. Do NOT get splint wet. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns THIS PATIENT IS EXPECTED TO REQUIRE <30 DAYS OF REHAB FOLLOW UP: Please follow up with your Hand Surgeon, Dr. ___. 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. Followup Instructions: ___
10136083-DS-8	10,136,083	22,928,285	DS	8	2161-01-15 00:00:00	2161-01-17 21:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: NEUROLOGY Allergies: Penicillins / Toradol / scopolamine / Ticlid / iodine / Bactrim Attending: ___ Chief Complaint: left arm sensory changes Major Surgical or Invasive Procedure: Biopsy of C7-T1 lesion History of Present Illness: ___ is a ___ woman with complex PMH including extensive cardiac history with MI, CABG and stenting, total protectomy and colectomy with ileostomy complicated by short gut syndrome requiring portacath placement for home IV fluids, bladder stimulator (not MRI compatible) and recurrent infections including UTIs who was recently admitted for right arm pain, numbness and weakness concerning for brachial plexopathy. She underwent a CT-guided aspiration and biopsy of the right C7-T1 facet joint on ___. She was discharged yesterday (___) with the biopsy results pending. Today the joint fluid culture returned positive for Staph Aureus and she was called back to our ED. Since her discharge she reports that her pain has been well controlled and she notes some very mild improvement in the R hand. For detailed history please see most recent admission note (DC summary currently pending) On neuro ROS: the pt denies headache, loss of vision, blurred vision, diplopia, oscilopsia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. Denies difficulty with gait. On general ROS: 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, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: 1. HTN 2. HLD 3. CABG with V fib arrest and L main disease in ___, L main stent ___, repeat coronary artery stenting in ___ 4. Hx of small TIA, presenting with facial droop 5. Bacteremia due to PICC line and UTI in ___ 6. 2 episodes of MSSA bacteremia from an indwelling port ___ 7. ___ after proctectomy and complete colectomy ___ 8. Small ductus aneurysm 9. Paralyzed vocal cord 10. COPD 11. Hx of recurrent pneumonia 12. Short gut syndrome PSH: Port last replaced ___ CABG Complete proctectomy and colectomy, MRSA following this surgery Bladder augmentation and ileocystoplasty. Social History: ___ Family History: Non contributory. Physical Exam: General: Alert, well appearing, comfortably sitting in bed. No acute distress. HEENT: NCAT, no conjunctival injection, oropharynx clear. Cardiovascular: RRR. nl S1S2, no m/r/g. Pulmonary: CTAB. Chest: No port site erythema or tenderness. Back: No erythema, rash or lesions. No TTP on paraspinal muscles. Extremities: Right and left hands similar in appearance and fullness. Warm and well perfused. No clubbing, cyanosis, or edema. Skin: No rashes or lesions. Neuro: Mental Status: A&Ox3. Cooperative with exam, normal affect. Speech fluent. CN: PERRL, 5->3 bilaterally, brisk. EOM intact. No visual field deficits. Facial sensation to light touch intact and symmetric. Smile symmetric, eyes closed tightly. Palate rises symmetrically. Tongue midline, can move tongue side to side. ___ shoulder shrug bilaterally. MSK: Lateral rotation of head limited, pain with rotation to the right. Pain with chin to chest. Motor: Infraspinatus R 5-/L 5; deltoids R 4+/L 5; triceps R 4/L 5; biceps R 4/L 5; wrist extension R deferred/L 5; interosseous muscles R 3/L 5; finger extensors R 4/L 5; finger flexors R deferred/L 5; Abductor pollicis brevis R ___. L is ___ in all upper and lower extremities. RLE full strength. Reflexes: biceps R 3+/L 2+; triceps R 1/L 1; brachioradialis R 2+/L 2; patellar R 3/L 2; ankle R 2/L 2. Plantar downgoing bilaterally. Sensation: Full sensation to pinprick in LUE and bilateral lower extremities. Pinprick sensation decreased in right arm and hand. From right shoulder to wrist, pinprick sensation 50% that of left arm/hand. In right hand, pinprick sensation ___ that of left arm/hand/ Within right hand, pinprick sensation more pronounced in thumb and index finger compared to digits ___. Coordination: deferred Gait: Walked onto floor without assistance. DISCHARGE PHYSICAL EXAM: Afebrile, vitals within normal limits Gen: awake, alert, comfortable HEENT: NCAT CV: regular rate and rhythm, no murmurs/rubs/gallops Pulm: breathing non labored on RA Abdomen: soft, NT/ND Extremities: no edema Neurologic: -MS: awake, alert, oriented to self, place, ___, time and situation. Easily maintains attention to examiner, can say MOTY backwards without difficulty. Speech fluent, no dysarthria. -CN: gaze conjugate, ___, EOMI no nystagmus, face symmetric, tongue midline, palate elevates symmetrically -Motor: mildly decreased bulk, normal tone. Weakness in deltoids R 4+/L 5; triceps R 4/L 5; biceps R 4/L 5; interosseous muscles R 3/L 5; finger extensors R 4/L 5; finger flexors R 5/L 4; Abductor pollicis brevis R ___ strength in right upper and bilateral ___. -Reflexes: biceps R 3+/L 2+; triceps R 1/L 1; brachioradialis R 2+/L 2; patellar R 3/L 2; ankle R 2/L 2. Plantar upgoing on R, downgoing on L. - Sensation: Decreased sensation to pinprick (___) throughout entire left forearm in a patchy distribution that does not fit within any clear distribution and fluctuates. It is 25% in right pinky, thumb and index fingers, while 50% in remainder of hand. - Coordination: FNF intact bilaterally, no dysmetria - Gait: Walked onto floor without assistance. DISCHARGE PHYSICAL EXAM: General: Alert, well appearing, comfortably sitting in bed. No acute distress. HEENT: NCAT, no conjunctival injection, oropharynx clear. Cardiovascular: RRR. nl S1S2, no m/r/g. Pulmonary: CTAB. Chest: No port site erythema or tenderness. Back: No erythema, rash or lesions. No TTP on paraspinal muscles. Extremities: Right and left hands similar in appearance and fullness. Warm and well perfused. No clubbing, cyanosis, or edema. Skin: No rashes or lesions. Neuro: Mental Status: A&Ox3. Cooperative with exam, normal affect. Speech fluent. CN: PERRL, 5->3 bilaterally, brisk. EOM intact. No visual field deficits. Facial sensation to light touch intact and symmetric. Smile symmetric, eyes closed tightly. Palate rises symmetrically. Tongue midline, can move tongue side to side. ___ shoulder shrug bilaterally. MSK: Lateral rotation of head limited, pain with rotation to the right. Pain with chin to chest. Motor: Infraspinatus R 5-/L 5; deltoids R 4+/L 5; triceps R 4/L 5; biceps R 4/L 5; wrist extension R deferred/L 5; interosseous muscles R 3/L 5; finger extensors R 4/L 5; finger flexors R deferred/L 5; Abductor pollicis brevis R ___. L is ___ in all upper and lower extremities. RLE full strength. Reflexes: biceps R 3+/L 2+; triceps R 1/L 1; brachioradialis R 2+/L 2; patellar R 3/L 2; ankle R 2/L 2. Plantar downgoing bilaterally. Sensation: Full sensation to pinprick in LUE and bilateral lower extremities. Pinprick sensation decreased in right arm and hand. From right shoulder to wrist, pinprick sensation 50% that of left arm/hand. In right hand, pinprick sensation ___ that of left arm/hand/ Within right hand, pinprick sensation more pronounced in thumb and index finger compared to digits ___. Coordination: deferred Gait: Walked onto floor without assistance. DISCHARGE PHYSICAL EXAM: vitals within normal limits Gen: awake, alert, comfortable HEENT: NCAT CV: regular rate and rhythm, no murmurs/rubs/gallops Pulm: breathing non labored on RA Abdomen: soft, NT/ND Extremities: no edema Neurologic: -MS: awake, alert, oriented to self, place, ___, time and situation. Easily maintains attention to examiner, can say MOTY backwards without difficulty. Speech fluent, no dysarthria. -CN: gaze conjugate, ___, EOMI no nystagmus, face symmetric, tongue midline, palate elevates symmetrically -Motor: mildly decreased bulk, normal tone. Weakness in deltoids R 4+/L 5; triceps R 4/L 5; biceps R 4/L 5; interosseous muscles R 3/L 5; finger extensors R 4/L 5; finger flexors R 5/L 4; Abductor pollicis brevis R ___ strength in right upper and bilateral ___. -Reflexes: biceps R 3+/L 2+; triceps R 1/L 1; brachioradialis R 2+/L 2; patellar R 3/L 2; ankle R 2/L 2. Plantar upgoing on R, downgoing on L. - Sensation: Decreased sensation to pinprick (___) throughout entire left forearm in a patchy distribution that does not fit within any clear distribution and fluctuates. It is 25% in right pinky, thumb and index fingers, while 50% in remainder of hand. - Coordination: FNF intact bilaterally, no dysmetria - Gait: Walked onto floor without assistance. Pertinent Results: LP: WBC 0/RBC 0/protein 22/glucose 54/LD 13 gram stain negative cytology negative for malignancy MS profile negative Tissue culture negative Joint fluid culture pending at discharge TTE ___: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF = 65%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: no vegetations seen (best excluded by TEE) Interventional CT biopsy ___: A core bone biopsy could not be obtained at the C7-T1 right facet joint as the underlying bone was eroded and collapsed with minimal pressure. Approximately 1 cc of bloody fluid and 3 18 gauge core needle biopsy samples of the joint space were obtained, including a small amount of tissue and cartilage. These samples were sent for culture and Gram stain. KUB ___: Electronic device in the pelvis. Brief Hospital Course: Patient was re-admitted due to having positive joint fluid cultures from prior admission. These grew MRSA. Patient was clinically well, afebrile, without leukocytosis and with unchanged exam from discharge. ID was consulted to assist with management, who recommended treatment with IV vancomycin x6 weeks. She initially had supratherapeutic Vancomycin level but this was adjusted to obtain trough of 20 on Vancomycin 1g q24h. Patient's exam was stable from prior admission, notable for right arm/hand weakness and sensory changes. She had weakness of intrinsic muscles of hand, particularly finger extensors and flexors. She had sensory loss in the forearm, arm and armpit that fluctuated and did not fit within a particular neuroanatomic distribution. This was identical to her examination from prior admission. Transitional Issues: - Continue Vancomycin 1g IV q24h through ___ - To be followed by ID, obtain weekly CBC with differential, BUN, Cr, Vancomycin trough, AST/ALT, ESR/CRP - referred to ___ Adult congenital heart disease clinic. Will need radiology records sent to them via disk (request placed) ___ ___ - Follow up with Dr. ___ in clinic - Obtain an EMG (nerve conduction study) as an outpatient Medications on Admission: Aspirin 81 mg PO DAILY Calcium Carbonate 1500 mg PO DAILY Cyanocobalamin 1000 mcg IM/SC MONTHLY Diazepam 5 mg PO QHS Diphenoxylate-Atropine 2 TAB PO BEFORE EACH MEAL AND QHS Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID fluticasone 50 mcg/actuation inhalation DAILY Gabapentin 600 mg PO TID LoPERamide 2 mg PO QID:PRN constipation Metoprolol Succinate XL 25 mg PO DAILY Morphine SR (MS ___ 15 mg PO DAILY Multivitamins 2 TAB PO DAILY Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain Nortriptyline 10 mg PO QHS Pantoprazole 40 mg PO Q12H ProAir HFA (albuterol sulfate) 108 mcg inhalation Q4H:PRN Rosuvastatin Calcium 20 mg PO QPM Sertraline 50 mg PO DAILY spiriva Respimat (tiotropium bromide) 1.25 mcg/actuation inhalation DAILY Vitamin D 1000 UNIT PO DAILY Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Medications: 1. Vancomycin 1000 mg IV Q 24H RX vancomycin 1 gram 1 g IV every 24 hours Disp #37 Vial Refills:0 2. Gabapentin 900 mg PO TID RX gabapentin 300 mg 3 capsule(s) by mouth three times daily Disp #270 Capsule Refills:5 3. Aspirin EC 81 mg PO DAILY 4. Calcium Carbonate 1500 mg PO DAILY 5. Cyanocobalamin 1000 mcg IM/SC MONTHLY 6. Diazepam 5 mg PO QHS 7. Diphenoxylate-Atropine 2 TAB PO BEFORE EACH MEAL AND QHS 8. Fluticasone Propionate 110mcg 1 PUFF IH DAILY 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID 10. LOPERamide 2 mg PO QID:PRN constipation 11. Metoprolol Succinate XL 25 mg PO DAILY 12. Morphine SR (MS ___ 15 mg PO DAILY 13. Multivitamins 2 TAB PO DAILY 14. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain 15. Nortriptyline 10 mg PO QHS 16. Pantoprazole 40 mg PO Q12H 17. ProAir HFA (albuterol sulfate) 108 mcg inhalation Q4H:PRN shortness of breath 18. Rosuvastatin Calcium 20 mg PO QPM 19. Sertraline 50 mg PO DAILY 20. Spiriva Respimat (tiotropium bromide) 1.25 mcg/actuation inhalation DAILY 21. Vitamin D 1000 UNIT PO DAILY 22. Vitamin D ___ UNIT PO 1X/WEEK (___) Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Brachial plexitis Discharge Condition: Stable Discharge Instructions: Dear Ms ___, You were admitted to the hospital with weakness and sensory changes of your right hand and arm. To look into your symptoms, we did a number of laboratory tests looking for signs of infection, which were negative. We reviewed the images from your recent CT cervical spine with our radiology team and did not see any signs of an ongoing hematoma. We completed a spinal tap (lumbar puncture) to look for signs of infection, which we negative. You had a biopsy of the cervical area due to concerns for infection (osteomyelitis), which so far does not have any signs of infection. Moving forward, it will be important for you to follow up with Dr. ___ to discuss further treatment plan. It was a pleasure taking care of you. Sincerely, Your ___ care team Followup Instructions: ___
10136619-DS-11	10,136,619	29,900,232	DS	11	2140-11-13 00:00:00	2140-11-13 20:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: mussels Attending: ___. Chief Complaint: Left groin pain Major Surgical or Invasive Procedure: L5-S1 Level Epidural Steroid Injection History of Present Illness: ___ with hx of spinal stenosis, temporal arteritis, HTN/HL, depression/anxiety, s/p b/l hip repair ___ years prior, p/w bilateral low back/buttock pain. Pt reports acute worsening of bilateral low back/buttock pain today. Patient denies any trauma or falls, reports that today when she tried to walk had extreme pain in left lower groin. Worse than prior chronic pain. Most recent MRI ___ showed spinal stenosis. She denies urinary tension, bowel incontinence, saddle anesthesia. She denies weakness in her lower extremities but is unable to ambulate due to pain today. At baseline uses a cane or walker. Taking Vicodin without relief. No fever, chills or history of spinal abscess In the ED initial vitals were: 97.2 73 147/64 18 98% - Labs were significant for - Patient was given OxycoDONE (Immediate Release) 5 mg, Diazepam 5 mg, Lidocaine 5% Patch 1 PTCH, Acetaminophen 1000 mg Past Medical History: 1. Macular degeneration. The patient is undergoing eye injections. 2. Osteoporosis. 3. Hyperlipidemia. 4. Anxiety/depression. 5. Status post bilateral cataract surgeries. 6. Status post bilateral hip replacment more than ___ years ago at ___ and subsequent hip repair with last sugery ___ years ago 7. Hearing loss. The patient is deaf in her right ear and has a left hearing aid. 8. temporal arthritis c/b L eye blindness 9. HTN 10. TAH/BSO Social History: ___ Family History: Her mother died at age ___ due to cancer. Her father died at age ___. She has two sisters who are alive, one of whom has arthritis. She has a daughter, age ___, who is in good health. She has another daughter, age ___, who has multiple sclerosis. She had a son who died at age ___ due to cancer. There is a paternal family history of diabetes. Physical Exam: PHYSICAL EXAM ON ADMISSION: Vitals - 98 152/83 98 20 95RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BACK: no tenderness along spine or paraspinal muscles EXTREMITIES: tenderness at L groin, no surrounding swelling, erythema, bruising, or warmth no cyanosis, clubbing or edema, moving all 4 extremities with purpose PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes Spine exam: Examination somewhat difficult due to pain, particularly with active hip flexion on left, but without evidence of weakness. Vascular Radial: L2+, R2+ DPR: L2+, R2+ Motor- Delt Bic Tri WrE FFl FE IO IP glut Quad Ham TA Gastroc L ___ 5 R ___ 5 -Sensory: Sensory UE C5 (Ax) R nl, L nl C6 (MC) R nl, L nl C7 (Mid finger) R nl, L nl C8 (MACN) R nl, L nl T1 (MBCN) R nl, L nl T2-L2 Trunk R nl, L nl Sensory ___ L2 (Groin): R nl, L nl L3 (Leg) R nl, L nl L4 (Knee) R nl, L nl L5 (Grt Toe): R nl, L nl S1 (Sm toe): R nl, L nl S2 (Post Thigh): R nl, L nl -DTRs: Bi Tri ___ Pat Ach L ___ 2 2 R ___ 2 2 Babinski: downgoing Clonus: none Gait: Pain in left leg with standing but able to support weight without evidence of weakness . PHYSCIAL EXAM ON DISCHARGE Vitals - T 98.1 HR 70 (62-79) BP 135/66 (127-148/60-83) 98%RA GENERAL: NAD HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, limited cooperation with exam but breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding BACK: no tenderness along spine or paraspinal muscles EXTREMITIES: L groin without tenderness, swelling, erythema, bruising, or warmth no cyanosis, clubbing or edema, moving all 4 extremities with purpose, able to move bilateral lower extremities with at least 4+/5 strength, normal sensation to light touch, no pain on active hip flexion on left. Unable to elicit patellar reflexes bilaterally but limited by patient extending leg at the knees. PULSES: 2+ DP pulses bilaterally SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: LABS ON ADMISSION: ___ 08:50AM BLOOD WBC-8.7 RBC-4.19* Hgb-12.9 Hct-38.3 MCV-91 MCH-30.7 MCHC-33.6 RDW-16.3* Plt ___ ___ 08:50AM BLOOD Glucose-84 UreaN-27* Creat-1.0 Na-143 K-3.9 Cl-101 HCO3-36* AnGap-10 ___ 08:50AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.2 ___ 08:50AM BLOOD CRP-0.7 ___ 08:50AM BLOOD SED RATE-Test 4 . IMAGING: Lumbar Xray: There are 5 non-rib-bearing lumbar type vertebra. The lumbosacral junction is not well assessed due to overlying tissues. There is apparent mild loss in the vertebral body height of L5 from ___. Retropulsion is difficult to assess. The overall lumbar spine alignment is maintained. Moderate multilevel degenerative changes are evidenced by endplate sclerosis, osteophytosis and facet arthropathy. Bilateral hip prostheses are incompletely evaluated. There is a calcified aorta IMPRESSION: Mild loss in L5 vertebral body height from ___. Clinically correlate regarding need for additional imaging. MRI L SPINE W/O CONTRAST The alignment and configuration of the lumbar vertebral bodies appears maintained and unchanged since the prior examination, the conus medullaris terminates at the level of T12/L1 and is unremarkable. At T12/L1 level, again there is disc desiccation with no evidence of neural foraminal narrowing or spinal canal stenosis, mild unchanged articular joint facet hypertrophy is present. At L1/L2 level, there is disc desiccation and unchanged disc bulging, causing mild bilateral neural foraminal narrowing, apparently contacting the traversing nerve roots, moderate articular joint facet hypertrophy appears unchanged. In comparison with the prior examination, there is crowding and clumping of the nerve roots within the thecal sac (image 10, series 12). At L2/L3 level, again there is disc desiccation and disc bulging, causing bilateral neural foraminal narrowing and anterior thecal sac deformity, bilateral articular joint facet hypertrophy and ligamentum flavum thickening are unchanged, the degree of spinal canal narrowing appears relatively stable with crowding of the nerve roots within the thecal sac. At L3/L4 level, disc degenerative changes are seen, consistent with disc desiccation and disc bulging, causing bilateral neural foraminal narrowing and spinal canal narrowing, which appears slightly more severe in comparison with the prior study. Unchanged bilateral articular joint facet hypertrophy. At L4/L5 level, unchanged disc degenerative changes are present, consistent with disc desiccation and disc bulging, causing bilateral neural foraminal narrowing, more severe towards the left, associated articular joint facet hypertrophy ligamentum flavum thickening remain unchanged. At L5/S1 level, again shows a disc degenerative changes, disc bulging and bilateral neural foraminal narrowing, contacting the traversing nerve roots, unchanged articular joint facet hypertrophy and ligamentum flavum thickening. The sacroiliac joints are unremarkable. Again there is atrophy of the psoas muscles bilaterally, slightly more significant on the left. Note is made of areas of T2 low signal in the expected location of the gallbladder, suggesting gallstones (image 6, series 6, and image 5 series 6). IMPRESSION: 1. Multilevel degenerative changes throughout the lumbar spine appear relatively stable, however there is more crowding and clumping of the nerve roots at L2 level, suggesting increased in the spinal canal narrowing at this level. 2. Note is made of areas of T2 low signal in the expected location of the gallbladder, suggesting gallstones (image 6, series 6, and image 5 series 6), correlation with abdominal ultrasound is recommended if clinically warranted. BILAT HIPS (AP,LAT & AP PELVIS) XRAY There is a right hip arthroplasty which appears similar to previous, with superior positioning of the acetabular prosthesis, unchanged. Small amount of periprosthetic lucency at the acetabular cement osseous interface appears stable from previous. The right femoral stem appears well-seated. Fragmented cerclage wires at the right proximal femur are noted. These appear unchanged. Left hip arthroplasty with cerclage wires at the femoral shaft stable in appearance from previous. There may be slight contour deformity of the femoral shaft just distal to the tip of the femoral stem. Degenerative change in lower lumbar spine. IMPRESSION: 1. Essentially unchanged appearance of bilateral hip arthroplasties. 2. Lateral projection of the left hip suggests slight contour deformity of the proximal shaft at the tip of the femoral stem. Recommend repeat lateral view to include the distal stem and remaining femoral shaft. FEMUR (AP & LAT) LEFT XRAY There is slight irregularity along the anterior femoral cortex, just beyond the distal tip of the prosthetic femoral stem, similar in appearance compared to the radiograph performed earlier today, not significantly changed in appearance dating back through ___. There is no acute fracture or dislocation. The patient is status post total left hip arthroplasty, without evidence of hardware complication. There is generalized osteopenia. There is no left knee joint effusion. IMPRESSION: 1. No acute fracture or dislocation. Mild deformity along the anterior mid femoral cortex is long-standing, possibly related to remote trauma. Brief Hospital Course: ___ with history of spinal stenosis, temporal arteritis, HTN/HL, depression/anxiety, s/p b/l hip replacement and repair (last ___ years ago), p/w acute on chronic left groin pain limiting her ability to walk likely secondary to worsening spinal stenosis and impingement on L2 nerve root # L2 Radiculopathy- Patient had pain in left groin mainly w/ weight bearing. She had Xrays of her hips which were unchanged from prior. She was without point tenderness, fever, chills, CRP/ESR were normal, WBC was normal, and movement of hips did not elicit pain, so unlikely to be hip pathology or infection. In this patient with known spinal stenosis and MRI with worsenining of crowding and clumping of nerve roots around L2, it is likely that her pain is acute on chronic referred pain from L2 lumbar spinal nerve root compression. She was evaluated by spine and no indication for emergent surgical decompression. Pain may improve with conservative management and steroid injection and if not improved in 4 weeks can follow up with spine clinic (___). The patient required only tylenol for pain medication while inpatient. She was seen by Acute Pain Service and received an epidural steroid injection and will follow up in their clinic. She was seen by ___ and able to ambulate with walker and walk up stairs so was discharged home with ___ services. #Pain control - patient was with minimal to no pain at rest while inpatient. She does have acute on chronic pain from DJD. Patient only required tylenol while inpatient. It was recommended that she use tylenol as much as possible for pain control with limited opioid use. It was recommended that she not take NSAIDs given bleeding risk in an elderly patient on chronic steroids. # Constipation - required senna, miralax and dulcolax supp. # Insomnia - recently started on Mirtazapine 15 mg PO HS with plan to DC benzo by PCP so mirtazapine was continued while inpatient and Clonazepam dose was decreased from home dose of 0.5mg to 0.25mg QHS. This taper should be continued until follow up with PCP ___ ___ and then discontinued. # Depression - continued home Venlafaxine XR 150 mg PO DAILY # TA - baseline L eye blind. R eye with partial loss of vision from macular degeneration. Continued on prednisone 40mg daily with plan to taper per physicians at ___. # HTN - home hydrochlorothiazide most likely has decreased effectiveness given her reduced CrCl of 35. BP was well controlled while inpatient. HCTZ was discontinued on discharge given risk of dehydration and falls with plan for BP follow up with PCP. If antihypertensive is needed, could consider use of chlorthalidone. # Osteoporosis - patient recieved home Alendronate Sodium 70 mg PO QFRI and calcium and vitamin D. Transitional Issues - Please discontinue clonazepam on ___. Dose was tapered to 0.25mg QHS while inpatient to be continued on discharge for one week until ___. - HCTZ was discontinued on discharge due to likely decreased effectiveness given reduced CrCl and well controlled BP inpatient. Please recheck BP at follow up - Can consider switching alendronate to alternate bisphosphonate as it is not recommended with CrCl<35 - Pain control - tylenol was used for pain managment. It was recommended that the patient not take NSAIDs and to limit opioid use as much as possible Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Alendronate Sodium 70 mg PO QFRI 2. ClonazePAM 0.5 mg PO QHS 3. Hydrochlorothiazide 12.5 mg PO DAILY 4. Ibuprofen 800 mg PO Q8H:PRN pain 5. Mirtazapine 15 mg PO HS 6. Omeprazole 20 mg PO DAILY 7. Polyethylene Glycol 17 g PO DAILY 8. Venlafaxine XR 150 mg PO DAILY 9. PredniSONE 40 mg PO DAILY 10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q6H:PRN severe pain 11. Calcium Carbonate 500 mg PO DAILY 12. Fish Oil (Omega 3) Dose is Unknown PO DAILY Discharge Medications: 1. Alendronate Sodium 70 mg PO QFRI 2. Calcium Carbonate 500 mg PO DAILY 3. ClonazePAM 0.25 mg PO QHS Duration: 6 Days 4. Mirtazapine 15 mg PO HS 5. Omeprazole 20 mg PO DAILY 6. Polyethylene Glycol 17 g PO DAILY 7. PredniSONE 40 mg PO DAILY 8. Venlafaxine XR 150 mg PO DAILY 9. Acetaminophen 1000 mg PO TID 10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN severe pain 11. Fish Oil (Omega 3) 1000 mg PO DAILY 12. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Acute on chronic radiculopathy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear ___, ___ was a pleasure to take care of you at ___. You were admitted with severe left leg pain. You had an MRI which showed degenerative changes in your spine similar to your prior MRI but with more crowding and narrowing around the L2 nerve. You had Xrays of your hips which were stable from prior Xrays. You were seen by the Spine specialists who felt that there was no need for urgent surgery. While inpatient, you were seen by the Acute Pain Service who performed a steroid injection in your back. You had physicial therapy and it was recommended that you continue physicial therapy at home. While in the hospital, you only required tylenol for pain management. Please continue using tylenol for pain at home. Please avoid NSAIDs such as ibuprofen as they can cause bleeding in your GI tract, especially in combination with your steroids. Please try to avoid using your opioid medications as much as possible as it puts you at risk for falls. While in the hospital, we tapered your clonazepam to 0.25mg at night. You should continue taking this medication at 0.25mg until you see your primary care physician ___ ___ and then stop taking it at that time. You have a follow up appointment scheduled to see the acute pain service once discharged. Sincerely, Your ___ medical team Followup Instructions: ___
10136711-DS-15	10,136,711	27,096,616	DS	15	2157-12-18 00:00:00	2157-12-19 07:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Carbapenem / hydrochlorothiazide Attending: ___. Chief Complaint: bilateral lower extremity rash Major Surgical or Invasive Procedure: L knee arthrocentesis on ___ Dermatological biopsies of lower extremities ___ History of Present Illness: ___ ___ with ___ notable for IDDM (HbA1c = 7.8 ___ diabetic nephropathy (Cr 2.2), CAD, and psoriasis who is presenting withlower extremity rash for 1 month that persists despite outpatient treatment with clindamycin and dovenox. He was in his usual state of health until 1 month ago when he noticed an increasing, erythematous, burning, and pruritic rash below and behind his knees bilaterally. He has been off psoriatic medications for ___ years and reports this rash not at all like his psoriasis. His PCP and dermatologist ___ him clindamycin for a ___ompleted ___ and 10 day course of ciprofloxacin to end ___ for presumed cellulitis, however, he reports it has continued to worsen over the past 1 week. He describes a burning, constant pain that is worse with sitting and disrupts his sleep and ability to ambulate. The itching is severe to the point where he soaks his legs nightly in cold water for relief. He denies exudates and swelling, however, he notes that it bleeds when he itches it. Throughout all of this, he denies fevers and chills. ROS is positive for tinitus but otherwise negative for chest pain, SOB, abdominal pain, nausea, vomiting, diarrhea, and GU sxs. In the ED, initial vitals: 97.0 69 173/67 16 100% - Exam notable for: B/l lower extremity edema that is warm, erythematous - Labs notable for: WBC 12.1 w/ 78.7% neutrophils, H/H 13.3/38.8 w/ MCV 77, Cr 2.1, Chem 7 otherwise normal, and lactate 1.2. - Micro: Blood cultures x2 pending - Imaging: None - Consultants: None - Patient was given: Vancomycin 1000 mg IV - Vitals prior to transfer: 98 66 127/51 18 100% RA On arrival to the floor, pt reports continued itching, burning, and difficulty ambulating due to constant discomfort. ROS: Please refer to HPI for pertinent positives and negatives. 10 point ROS is otherwise negative. Past Medical History: CRI - baseline Cr. 1.8-2.0 Type 2 diabetes, last A1C ___ was 6.8% Psoriasis Hyperlipidemia Obesity Erectile dysfunction Peripheral neuropathy Social History: ___ Family History: Family hx: Notable for mother who had diabetes and complications of CAD in her ___. His father had CVA in his ___. He has 20 siblings. He said that majority have diabetes. Physical Exam: On Admission: Vitals: Tm/Tc 98.0 BP 112/57 HR 59 RR 18 SaO2 100% RA Wt: 98.9 kg General: AAOx3, comfortable appearing, in NAD HEENT: NCAT, EOMI, PERRL. Sclera anicteric, conjunctiva pink. MMM. OP clear. Neck: supple, no LAD, no JVP elevation Lungs: CTAB, no w/r/r CV: RRR, normal S1 and S2, no m/g/r Abdomen: NABS, soft, nondistended, nontender. No HSM. GU: no foley Ext: WWP. 2+ peripheral pulses. No edema. Bilateral lower extremities with large >10cm psoriatic plaques with erythema below and beneath the knee. No significant scaling. Within these plaques, there are annular ulcerations that are superficial and with exudate. There is no odor. There are multiple lesions on his lower extremities. His feet are warm, dry, and perfused. On Discharge: PHYSICAL EXAM: Vitals: Vitals: Tm/Tc 98.3, HR 57, BP 111/44, RR 20 SaO2 100% RA Wt: 98.9 kg (___) General: alert, oriented x3, sitting upright in bed comfortably HEENT: sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Erythematous macules scattered across abdomen. No TTP. Buttock: Erythematous macules scattered butt b/l of same appearance to those on abdomen. No TTP. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. Bilateral lower extremities with peeling skin and minimal erythema below and beneath the knee w/ no significant scaling. Within these patches and along shin/calf, there continue to be annular ulcerations that are superficial without exudate. His feet are warm, dry, and perfused. L knee non-erythematous w/ no appreciable effusion, not warm, able to tolerate active AND passive ROM to 120 degrees. Neuro: CNs2-12 intact, motor and sensory function grossly normal Pertinent Results: Labs on Admission: ================= ___ 12:53PM BLOOD WBC-12.1* RBC-5.04 Hgb-13.3* Hct-38.8* MCV-77* MCH-26.4* MCHC-34.3 RDW-14.5 Plt ___ ___ 12:53PM BLOOD Neuts-78.7* Lymphs-12.5* Monos-4.7 Eos-3.4 Baso-0.7 ___ 12:53PM BLOOD ___ PTT-29.5 ___ ___ 12:53PM BLOOD Plt ___ ___ 12:53PM BLOOD Glucose-77 UreaN-42* Creat-2.1* Na-141 K-4.4 Cl-106 HCO3-24 AnGap-15 ___ 06:47AM BLOOD Calcium-9.8 Phos-3.3 Mg-1.5* ___ 06:47AM BLOOD CRP-59.7* ___ 12:59PM BLOOD Lactate-1.2 Labs on Discharge: ================= ___ 07:06AM BLOOD WBC-7.1 RBC-4.60 Hgb-12.0* Hct-36.4* MCV-79* MCH-26.1 MCHC-33.0 RDW-13.7 RDWSD-38.9 Plt ___ ___ 07:06AM BLOOD Plt ___ ___ 07:25AM BLOOD Glucose-192* UreaN-73* Creat-2.5* Na-140 K-4.9 Cl-104 HCO3-25 AnGap-16 ___ 07:06AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.9 MICRO: ===== Joint fluid ___: WBC ___ RBC ___ Poly 91 Lymph 0 Mono 0 EOs Macro: 9 Crystal: Few Shape: Needle Locatio: I/E Birefri: Neg Comment: C/W Monosodium Urate Crystals Culture: No growth so far. IMAGING: ======= L knee Xray ___: There is a probable small joint effusion . No fracture or discrete lytic lesion is identified. No gross degenerative changes. Brief Hospital Course: ___ ___ with ___ notable for IDDM (HbA1c = 7.8 ___ diabetic nephropathy (Cr 2.2), CAD, and psoriasis who is presenting withlower extremity rash for 1 month that persists despite outpatient treatment with clindamycin and dovenox. ACTIVE ISSUES: ============= #Bilateral lower extremity rash His WBC was 12.1 w/ 78.7% neutrophils on admission, however, throughout his stay he was AVSS. He was placed on IV vancomycin and clindamycin and transitioned to doxycycline with a plan for a 7 day course. There was concern that there was erysipelas given the very erythematous warm nature superimposed on a rash of unknown etiology. This was supported with the improvement in the erythema and leukocytosis with the antibiotic treatment. Dermatology was consulted, who biopsied the lesions, and the pathology was pending at the time of discharge, but will be followed up by Dermatology at the next appointment. Apply mupricon to his legs BID. Benadryl and sarna were provided PRN for pruritus. # Gout of L knee. Orthopedics performed arthrocentesis, which showed WBC >50,000, multiple negatively birefringment crystals consistent with monosodium urate crystals. He was started on renally-dosed colchicine, which was continued at 0.3mg at the time of discharge. Colchicine should be stopped once his gout resolves and allopurinol should be started. # Psoriasis: Located on his stomach. Derm recommended going back on home clobesatol. CHRONIC ISSUES: ============== #IDDM: He was continued glargine 20 units QAM and humalog 10 units before breakfast # Tinitus: chronic issue that he reports from car accident. No additional recommendations. # CAD: He was continued home statin, lisinopril 10mg and ASA 325mg. He should not be on HCTZ. # GERD: He was continued home omeprazole TRANSITIONAL ISSUES: =================== - He developed gout is was discharged on prophylactic colchicine that is renally dosed. This was continued at 0.3mg at the time of discharge. Colchicine should be stopped once his gout resolves and allopurinol should be started. - Dermatology recommended follow-up (see appointment). - Antibiotic course is doxycycline 500mg BID for a total course of 7 days with last day on ___. - He was given 10mg lisinopril while inpatient per prior notes, however, he reports taking 20mg daily. His dose needs to be determined - He was given HCTZ x 1 but this was stopped given he reports having a rash when he was given this in the past. - His blood sugars were well-controlled on Lantus 20 units in AM and 10 units Humalog before breakfast. - CODE STATUS: Full (confirmed) - CONTACT: ___ ___ (daughter) Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Atenolol 50 mg PO DAILY 3. Pioglitazone 15 mg PO DAILY 4. Calcipotriene 0.005% Cream 1 Appl TP ONCE 5. clobetasol 0.05 % topical DAILY 6. Omeprazole 20 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. Aspirin 325 mg PO DAILY 9. Glargine 20 Units Breakfast Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 10 Units Dinner Insulin SC Sliding Scale using HUM Insulin 10. Lisinopril 10 mg PO DAILY Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Atenolol 50 mg PO DAILY 4. Glargine 20 Units Breakfast Humalog 10 Units Lunch Insulin SC Sliding Scale using HUM Insulin 5. Lisinopril 10 mg PO DAILY 6. Omeprazole 20 mg PO DAILY 7. Simvastatin 20 mg PO QPM 8. Acetaminophen 650 mg PO Q8H:PRN pain 9. Colchicine 0.3 mg PO DAILY 10. Calcipotriene 0.005% Cream 1 Appl TP ONCE 11. clobetasol 0.05 % topical DAILY 12. Pioglitazone 15 mg PO DAILY 13. Doxycycline Hyclate 100 mg PO Q12H RX doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day Disp #10 Tablet Refills:*0 14. Mupirocin Ointment 2% 1 Appl TP BID apply to legs Discharge Disposition: Extended Care Facility: ___ for Rehabilitation and Sub-Acute Care) Discharge Diagnosis: Primary Diagnoses: Rash of unknown etiology Gout Erysipelas Secondary Diagnoses: IDDM CKD Psoriasis Tinitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Mr. ___, It was a pleasure to care for you while you were at ___. You were admitted for a rash on your legs. We started you on IV antibiotics and changed them to oral doxycycline. You will take this for a total of 7 days (including the days in the hospital) until ___. Dermatology biopsied your rash and it was pending at the time of discharge. For the itching, we gave you benadryl (diphenhydramine) and sarna. For the pain, we gave you low dose tylenol, which helped your pain. While you were here, you developed left knee pain from gout. Orthopedics put a needle in your left knee and drained the fluid in there, a procedure called an arthrocentesis. This fluid had crystals in it, which confirmed the diagnosis of gout. For this, we gave you colchicine, which you should stop taking after your knee gets better. Please talk to your PCP about starting ___ (allopurinol) after the knee gets better to prevent gout from coming back. We had our physical therapists evaluate you, who recommended rehab tohelp build your strength back up. You will follow-up with your PCP and dermatologist (see below). -Your ___ care team Followup Instructions: ___
10136711-DS-16	10,136,711	20,017,382	DS	16	2160-11-25 00:00:00	2160-11-27 10:10:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Carbapenem / hydrochlorothiazide Attending: ___. Chief Complaint: Foot pain Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ IDDM c/b nephropathy Cr 2s at baseline and peripheral neuropathy, psoriasis, HLD, obesity, erectile dysfunction, and gout who presents with R foot pain. Patient reports foot pain for the past 4 days, R > L. Pain is located on the plantar surfaces of his bilateral feet, in his R and L ___ MTP. He also notes pain in his R elbow causing difficulty moving his RUE. He has had joint issues in the past in his ankles, but states this is more severe. This is also different than his baseline neuropathy. He has had severe difficulty walking because of this. He denies fevers, chills, chest pain, dyspnea, abdominal pain, NVD. Of note, he ran out of insulin 4 days ago, normally takes 30U lantus at bedtime and Humalog per a SS. He was not able to get a refill at the free pharmacy and could not afford the refill elsewhere. Patient did present with joint pain in admission in ___, found to have L knee effusion, evaluated with arthocentesis, which showed negatively birefringment crystal c/w gout. He was discharged on renally dosed cholchine, with plan for d/c and transition to allopurinol once flare resolves. Unclear if this was done as no prior rx for allopurinol on med list. In the ED, initial VS were: 97.6 89 137/97 16 100% RA - Exam notable for: tender R ankle, mild warmth - Labs showed: Hgb 11.8, WBC 10.2, Cr 2.8, AG 23, pH 7.34, lactate 1.3 --> pH 7.51, Cr 2.3, HCO3 18, AG 12 - Imaging showed: Foot x-ray with no acute fracture, severe degenerative changes of MTP joint and great toe IP joint - Consults: Orthopedics who had low suspicion for septic arthritis given polyarticular w/o joint effusion on their US, recommended podiatry f/u. ___ consulted who noted patient unable to ambulate ___ pain, will require SNF at discharge. CM consulted, found bed at ___ once stable for d/c. - Patient received: oxycodone, amlodipine 10mg, ASA 325mg, lisinopril 5mg, insulin gtt and IVF and KCl, then insulin 30U SQ Transfer VS were: 97.8 92 148/78 18 99% RA On arrival to the floor, patient reports continued bilateral foot pain and elbow pain. Past Medical History: - Gout - diagnosed on admission in ___, evaluated with joint tap which showed monosodium urate crystals - h/o bacteremia MRSA ___ - CKD Cr 2s at baseline - CAD (fixed inferior defect on stress MIBI) - T2DM - HLD - HTN - Psoriasis - Erectile Dysfunction Social History: ___ Family History: Family history of diabetes and vascular disease, per records. Physical Exam: ADMISSION PHYSICAL EXAM: VS: 99.3 180/89 93 20 96 Ra GENERAL: NAD HEENT: MMM NECK: no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: soft, NT, ND, NABS EXTREMITIES: no edema PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, decreased strength in RUE ___ pain, normal plantarflexion strength b/l. Normal sensation throughout SKIN: mild erythema overlying R elbow and L heel DISCHARGE PHYSICAL EXAM: VS: 98.4 PO 137 / 74 R Lying 87 17 96 Ra GENERAL: well-appearing older gentleman in NAD, lying in bed HEENT: NC/AT, sclerae anicteric HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi ABDOMEN: soft, non-tender to deep palpation, non-distended EXTREMITIES: no edema NEURO: A&O x 3, stable ROM at the R elbow with minimal pain, significant pain with dorsi- and plantarflexion of the foot, awake and conversant Pertinent Results: ADMISSION LABS ___ 09:47AM WBC-10.2* RBC-4.44* HGB-11.8* HCT-35.6* MCV-80* MCH-26.6 MCHC-33.1 RDW-13.4 RDWSD-38.6 ___ 09:47AM NEUTS-76.2* LYMPHS-12.5* MONOS-8.6 EOS-1.6 BASOS-0.6 IM ___ AbsNeut-7.76* AbsLymp-1.27 AbsMono-0.87* AbsEos-0.16 AbsBaso-0.06 ___ 09:47AM PLT COUNT-279 ___ 09:47AM ___ PTT-28.2 ___ ___ 09:47AM GLUCOSE-344* UREA N-81* CREAT-2.8* SODIUM-136 POTASSIUM-4.9 CHLORIDE-100 TOTAL CO2-13* ANION GAP-23* ___ 01:50PM URINE MUCOUS-RARE* ___ 01:50PM URINE HYALINE-1* ___ 01:50PM URINE RBC-1 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 ___ 01:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30* GLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG ___ 01:50PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 01:50PM URINE UHOLD-HOLD ___ 01:50PM URINE HOURS-RANDOM ___ 02:23PM LACTATE-1.8 K+-5.4* ___ 03:30PM ALBUMIN-3.2* CALCIUM-9.0 PHOSPHATE-4.2 MAGNESIUM-2.1 ___ 03:30PM CK-MB-<1 cTropnT-<0.01 proBNP-178 ___ 03:30PM ALT(SGPT)-33 AST(SGOT)-27 CK(CPK)-36* ALK PHOS-101 TOT BILI-0.4 ___ 07:25PM ___ PO2-32* PCO2-32* PH-7.32* TOTAL CO2-17* BASE XS--9 IMAGING: X-RAY OF THE FOOT: IMPRESSION: No acute fracture. Progress severe degenerative change of the great toe MTP joint and moderate degenerative change of the great toe IP joint. DISCHARGE LABS: ___ 06:35AM BLOOD WBC-10.3* RBC-4.34* Hgb-11.2* Hct-34.0* MCV-78* MCH-25.8* MCHC-32.9 RDW-13.2 RDWSD-37.9 Plt ___ ___ 06:35AM BLOOD Glucose-165* UreaN-77* Creat-2.5* Na-137 K-4.9 Cl-101 HCO3-22 AnGap-14 ___ 06:35AM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1 UricAcd-11.2* ___ 03:30PM BLOOD CK-MB-<1 cTropnT-<0.01 proBNP-178 ___ 06:10AM BLOOD RheuFac-12 ___ ___ 09:47AM BLOOD CRP-202.5* MICRO: ___ BCx: no growth (final) ___ BCx: no growth (final) ___ UCx: mixed bacterial flora (final). ___ 7:30 pm CATHETER TIP-IV Source: Left AC fossa IV line. WOUND CULTURE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >15 colonies. Brief Hospital Course: Mr. ___ is a ___ year old man with IDDM c/b nephropathy and peripheral neuropathy, psoriasis, HL, obesity, erectile dysfunction, and hx of gout who presented with polyarticular joint pain in his R elbow and bilateral heel/feet. His R elbow pain was likely ___ gout flare and resolved with colchicine and pain medication but his bilateral heel/foot pain is likely multifactorial ___ underlying arthritis with contribution from gout as well. His course has been complicated by DKA that resolved shortly after admission and ___ that improved prior to discharge. #R ELBOW + BILATERAL ANKLE/FOOT PAIN: Mr. ___ presented with polyarticular joint pain involving R elbow, L and R ankle and foot as well as R MTP. He was evalauted by orthopedics who had low suspicion for septic arthritis of these joints given his presentation and exam. Ortho also did not feel there was a effusion that could be tapped. This presentation was likely ___ polyarticular gout flare given that his Uric Acid was 11.2 and he is not only any urate lowering maintenance therapy. On admission, the patient had a CRP 202.5/ESR 110 and negative ___ and RF. He was started on colchicine and oxycodone with a partial response (his elbow pain and ROM improved) but persistent, debilitating pain in his bilateral feet and ankles and that limits his ability to walk. Rheumatology was consulted regarding this persistent b/l foot/ankle pain and recommended to begin a short prednisone taper and low dose of allopurinol (50mg daily). The latter medications were initiated on ___ and will be continued as below, with plans for the patient to f/up with Rheumatology in the outpatient setting. #IDDM C/B DKA: Patient with hyperglycemia and DKA presentation. He was started on insulin gtt, his acidosis improved and he was transitioned to basal dosing on ___. This was most likely due to an inability to refill all his insulin prescriptions due to cost at home. ___ Diabetes was consulted and modified patient's insulin regimen to Glargine 40 units QHS, 10 units with breakfast and lunch, 12 units of Humalog with dinner and HISS for correction. #ERYTHEMA OF THE SKIN OVER THE ANTECUBITAL: Patient with erythema of the skin overlying his previous IV site. Scant superficial pus centrally. Doxycycline 100mg Q12H was started with a plan to treat for 3 days (DAY ___, STOP ___. Please monitor for worsening of skin (i.e. recurrence of cellulitis) at the site for at least 3 days following discontinuation of antibiotics. At the time this discharge summary was signed, the catheter tip culture was growing coagulase negative staphylococcus (see results section above for details). ___ ON CKD: Cr elevated on initial admission, but improved s/p IVF in the ED. Likely was pre-renal in the setting of hyperglycemia. Once his Cr had remained stable X 2 days, home lisinopril and furosemide were restarted. He then developed worsened ___ with Cr to 2.8 so these medications were held as of ___. Cr was 2.5 on ___, lisinopril and furosemide were held at discharge pending resolution of his mild ___. #CAD: Per pharmacy, Mr. ___ is on ASA 325mg daily. His home pravastatin and aspirin 81mg were continued during admission. He was discharged on his home dose of aspirin 325mg daily and home pravastatin. #HYPERTENSION: Mr. ___ was on ___ and Furosemide which were managed as above. His amlodipine was continued throughout his admission and at discharge. Home fludricortisone was initially held. After discussion with outpatient nephrologist to clarify reason for fludricortisone outpatient, it was restarted on ___ (per nephrology, this medication at low-dose can be used in patients with Type IV RTA when ACE-inhibitor therapy also indicated in order to prevent hyperkalemia). #IRON DEFICIENCY: Home ferrous sulfate was continued #GERD: Home omeprazole and ranitidine were continued TRANSITIONAL ISSUES - Patient will need repeat electrolytes and Cr measured in ___ days. - Patient is being discharged OFF of home LISINOPRIL and FUROSEMIDE due to mild acute kidney injury while hospitalized. Please recheck his Cr within ___ days as above and consider restarting lisinopril if Cr returns to baseline (2.0). Cr at discharge 2.5. Will need to follow-up in the next ___ weeks with his Nephrologist at ___. - Patient's Uric Acid was 11.2 during this admission. He was started on allopurinol 50mg daily on ___. Please monitor Cr as above. - Based on Rheumatology recs, patient was started on prednisone taper as follows: 40mg/day on ___, 30mg/day X 2 days, 20mg/day X 1 day, 10mg/day X 1 day and then 5mg daily until Rheumatology f/up. - *WHILE PATIENT ON STEROIDS, PATIENT WILL RECEIVE INSULIN REGIMEN BELOW. PER ___ RECS, PLEASE CONSIDER NPH ___ UNITS DAILY IF HYPERGLYCEMIC WITH STEROIDS AND TITRATE DOWN AS STEROIDS TAPER* - Patient is being discharged on a higher dose of insulin than he was prescribed on admission (40 units of glargine at night and 10 units of humalog with breakfast/lunch + 12 units with dinner + Humalog sliding scale for correction). - Per records, patient has had difficulty affording insulin in the outpatient setting. Please continue to provide social work and resource support after discharge so patient can fill this medication. - Patient is being discharged on new Colchicine 0.3mg daily for management of his gout flare. - Patient is being discharged on new oxycodone 5mg Q6H for temporary pain management. - Patient is being discharged on new doxycycline 100mg Q12H for 2 more days to treat cellulitis of the L antecubital fossa. - Please consider if patient's aspirin dose can be safely decreased to 81mg daily. - F/up catheter tip wound culture. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Amlodipine 10 mg PO DAILY 2. Aspirin 325 mg PO DAILY 3. Lisinopril 5 mg PO DAILY 4. Omeprazole 20 mg PO DAILY 5. Acetaminophen 650 mg PO Q8H:PRN pain 6. Ferrous Sulfate 325 mg PO BID 7. Fludrocortisone Acetate 0.1 mg PO DAILY 8. Furosemide 20 mg PO BID 9. Glargine 20 Units Bedtime Novolog 20 Units Dinner Insulin SC Sliding Scale using UNK Insulin 10. Pravastatin 40 mg PO QPM 11. Ranitidine 150 mg PO BID Discharge Medications: 1. Allopurinol 50 mg PO DAILY 2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - Second Line 3. Colchicine 0.3 mg PO DAILY 4. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Doses 5. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Severe RX oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #12 Tablet Refills:*0 6. Polyethylene Glycol 17 g PO BID 7. PredniSONE 10 mg PO DAILY Duration: 1 Dose AFTER 20MG COMPLETE This is dose # 4 of 4 tapered doses Tapered dose - DOWN 8. PredniSONE 5 mg PO DAILY AFTER 10 MG COMPLETE This is the maintenance dose to follow the last tapered dose 9. PredniSONE 40 mg PO DAILY Duration: 2 Doses This is dose # 1 of 4 tapered doses 10. PredniSONE 30 mg PO DAILY Duration: 2 Doses AFTER 40MG COMPLETE This is dose # 2 of 4 tapered doses Tapered dose - DOWN 11. PredniSONE 20 mg PO DAILY Duration: 1 Dose AFTER 30MG COMPLETE This is dose # 3 of 4 tapered doses Tapered dose - DOWN 12. Ferrous Sulfate 325 mg PO DAILY 13. Glargine 40 Units Bedtime Humalog 10 Units Breakfast Humalog 10 Units Lunch Humalog 12 Units Dinner Insulin SC Sliding Scale using HUM Insulin 14. Acetaminophen 650 mg PO Q8H:PRN pain 15. Amlodipine 10 mg PO DAILY 16. Aspirin 325 mg PO DAILY 17. Fludrocortisone Acetate 0.1 mg PO DAILY 18. Omeprazole 20 mg PO DAILY 19. Pravastatin 40 mg PO QPM 20. Ranitidine 150 mg PO BID 21. HELD- Furosemide 20 mg PO BID This medication was held. Do not restart Furosemide until Creatinine returns to baseline 2.0 22. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do not restart Lisinopril until Cr returns to baseline of 2.0 Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary Diagnosis: Gout, Diabetic Ketoacidosis Secondary Diagnosis: Diabetes, Hypertension, Hyperlipidemia, Osteoarthritis 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 ___ ___. You were admitted with pain in your elbow and heels. The pain was primarily caused by a gout flare. You received colchicine and oxycodone and this pain improved. You will continue to improve with these medications and physical therapy while at rehab. Please take all your medications as prescribed and follow-up with your doctors at the ___ below. Best wishes, Your ___ Team Followup Instructions: ___
10136711-DS-17	10,136,711	29,236,046	DS	17	2161-12-28 00:00:00	2161-12-29 20:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Penicillins / Cephalosporins / Carbapenem / hydrochlorothiazide Attending: ___ Chief Complaint: Acute Kidney Injury Major Surgical or Invasive Procedure: None History of Present Illness: ___ man with a history of CKD stage 4, diabetes on insulin, coronary artery disease, gout who presents with polyarticular joint pain and is found to have renal failure. Pt is interviewed with phone interpreter. He presents to the ED for evaluation of L knee and R elbow pain, which he says started a few days ago. He has had no fevers or chills. He is able to walk on the knee and use the elbow. He denies trauma. He doesn't remember which medications he takes (unable to say if he has taken NSAIDS). Routine lab evaluation revealed creatinine 8.2 from 3.3 in ___ ___ records) and 2.5 last year. He reports that he has had trouble sleeping at night and is tired during the day. He also reports his appetite has been poor. He says his urine output has been good. No change in bowel habits. No chest pain or dyspnea. He was seen in clinic for plan for access for HD, but declined to schedule surgery for fistula creation. - In the ED, initial vitals were: T 96.5 HR 52 BP 99/33 RR18 100% RA - Exam was notable for: "L knee is more tender than R knee. L knee is warm to touch. All joints are without erythema. " - Labs were notable for: Creatinine 8.2 BUN 149 K 5.8 P: 8.8 Bicarbonate 11 AGap=22 Hgb 11.2 - Studies were notable for: Renal US 1. No evidence of renal stones or hydronephrosis demonstrated. 2. There is increased echogenicity of bilateral kidneys with loss of corticomedullary differentiation which may represent medical renal disease. CXR: IMPRESSION: No acute intrathoracic process. - The patient was given: ___ 17:49 PO OxyCODONE--Acetaminophen (5mg-325mg) 1 TAB ___ 23:25 PO Doxycycline Hyclate 100 mg ___ 00:27 PO/NG Sodium Bicarbonate 650 mg - Renal was consulted - please obtain CXR - renal u/s pending - please add on urine lytes - no urgent indications for HD - if no concern for volume overload, can consider 3 amps NaHCO3 (total 150meq) + D5W 1L IV, otherwise can start NaHCO3 650mg PO bid - renal consult will follow in AM - agree w/ admission to medicine" Past Medical History: - Gout - diagnosed on admission in ___, evaluated with joint tap which showed monosodium urate crystals - h/o bacteremia MRSA ___ - CKD Cr 2s at baseline - CAD (fixed inferior defect on stress MIBI) - T2DM - HLD - HTN - Psoriasis - Erectile Dysfunction Social History: ___ Family History: Family history of diabetes and vascular disease, per records. Physical Exam: ADMISSION ========= VITALS: ___ 0132 Temp: 97.6 PO BP: 129/72 HR: 63 RR: 17 O2 sat: 99% O2 delivery: RA FSBG: 133 GENERAL: Alert and interactive. In no acute distress. Laying flat comfortably HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: Clear to auscultation bilaterally. No wheezes, rhonchi or rales. No increased work of breathing. BACK: No CVA tenderness. ABDOMEN: Normal bowels sounds, non distended, non-tender to deep palpation in all four quadrants. No organomegaly. EXTREMITIES: No clubbing, cyanosis, or edema. Pulses DP/Radial 2+ bilaterally. His L knee has a small effusion, full ROM and no erythema. Mildly warm. R elbow with no effusion, erythema or warmth. SKIN: Warm. Cap refill <2s. No rashes. NEUROLOGIC: AOx3. CN2-12 intact. Moving all 4 limbs spontaneously. ___ strength throughout. Normal sensation. DISCHARGE ========= Vitals: Temp: 97.7 (Tm 98.8), BP: 165/76 (134-175/54-77), HR: 50 (50-53), RR: 16 (___), O2 sat: 99% (96-99), O2 delivery: Ra, Wt: 189.59 lb/86 kg GENERAL: Alert and interactive. In no acute distress. Lying comfortably in bed. HEENT: PERRL, EOMI. Sclera anicteric and without injection. MMM. NECK: No cervical lymphadenopathy. No JVD. CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No murmurs/rubs/gallops. LUNGS: 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: Nontender tophi along DIPs of hands. No joint swelling or tenderness. No peripheral edema NEUROLOGIC: A&Ox3. CN2-12 intact. Moving all 4 limbs spontaneously and antigravity. Pertinent Results: ADMISSION ========= ___ 05:30PM PLT COUNT-250 ___ 05:30PM NEUTS-60.0 LYMPHS-18.6* MONOS-9.4 EOS-6.8 BASOS-1.0 IM ___ AbsNeut-5.06 AbsLymp-1.57 AbsMono-0.79 AbsEos-0.57* AbsBaso-0.08 ___ 05:30PM WBC-8.4 RBC-4.02* HGB-11.2* HCT-32.6* MCV-81* MCH-27.9 MCHC-34.4 RDW-13.1 RDWSD-37.7 ___ 05:30PM CALCIUM-9.3 PHOSPHATE-8.8* MAGNESIUM-2.4 ___ 05:30PM estGFR-Using this ___ 05:30PM GLUCOSE-153* UREA N-149* CREAT-8.2# SODIUM-138 POTASSIUM-5.8 CHLORIDE-105 TOTAL CO2-11* ANION GAP-22* ___ 06:00PM URINE MUCOUS-RARE* ___ 06:00PM URINE RBC-7* WBC-8* BACTERIA-FEW* YEAST-NONE EPI-0 ___ 06:00PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-100* GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR* ___ 06:00PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 07:42PM K+-5.3 INTERVAL ======== ___ 09:22AM BLOOD C3-158 C4-52* ___ 09:22AM BLOOD RheuFac-<10 ___ ___ 03:08AM BLOOD CRP-65.9* ___ 07:30AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG ___ 07:05AM BLOOD ALT-37 AST-17 LD(LDH)-157 AlkPhos-116 TotBili-0.5 DISCHARGE ========= ___ 07:00AM BLOOD WBC-9.6 RBC-3.66* Hgb-10.2* Hct-30.9* MCV-84 MCH-27.9 MCHC-33.0 RDW-12.4 RDWSD-37.8 Plt ___ ___ 07:00AM BLOOD Glucose-157* UreaN-65* Creat-3.5* Na-143 K-4.5 Cl-102 HCO3-28 AnGap-13 IMAGING/REPORTS =============== ___ Renal US There is no hydronephrosis, definite stones, or worrisome masses bilaterally. Echogenic appearance of the renal cortex is concerning for chronic medical renal disease. The right kidney measures 9.7 cm and the left kidney measures 12.3 cm. The bladder is mostly decompressed. IMPRESSION: Echogenic appearance of the kidneys concerning for medical renal disease. No hydronephrosis. Limited evaluation of the bladder given decompressed state. ___ CXR: PA and lateral views of the chest provided. Low lung volumes. Lungs are clear. There is no focal consolidation, effusion, or pneumothorax. There are no signs of congestion or edema. The cardiomediastinal silhouette is normal. Imaged osseous structures are intact. No free air below the right hemidiaphragm is seen. Clips in the right upper quadrant noted. IMPRESSION: No acute intrathoracic process. Brief Hospital Course: Mr. ___ is a ___ year-old man with a history of IDDM, CAD, gout who is found to have acute on chronic renal failure. Nephrology was consulted and this was thought to be due to a combination of pre-renal etiology from a recent illness on vacation versus AIN from unclear antibiotic/treatment regimen. Steroids for possible AIN were considered but held due to stable clinical status and his kidney function slowly improved with supportive care over the course of his hospitalization. ACUTE/ACTIVE ISSUES =================== # ___ on CKD Last Cr 3.3 ___ (previously ~2s), up to 8.2 on admission. Suspect that he may have had an AIN given WBC casts and possible new medication exposure in the ___. There may also be a component of prerenal azotemia given improvement in Cr with IVF and relatively low urine Na. Uric acid nephropathy also possible given elevated serum urate but no crystals on light microscopy. ___, RF negative, Leptospira Ab pending on discharge. He was given bicarbonate and sevelamer for low bicarbonate and high phosphate on admission, but these were held on discharge as his renal function returned to its recent baseline. #DM2 On home Insulin regimen, ISS. Having trouble getting a glucometer at home. Diabetes educator consulted, will provide glucometer and a small supply of test strips today, and also his home sliding scale was discontinued, he will follow up in ___ ___ clinic for continued titration. CHRONIC/STABLE ISSUES ===================== # LFT Abnormalities, resolved Cholestatic predominant pattern of liver injury on admission. DDx includes drug reaction (in setting of ?AIN) or congestive hepatopathy given moderate hypervolemia on admission. No focal tenderness on exam c/w cholecystitis. LFTs resolved without intervention. Found to be Hep B non-immune. # Polyarticular joint pain (L knee, R elbow) # Gout Prior flare in ___, treated with short prednisone taper. Does not appear to have an acute gout flare on exam. - APAP 650mg q8h PRN - Held colchicine on discharge due to still slightly elevated renal function and already on allopurinol. # CAD: Continued home ASA and statin. # HTN: - Continued home amlodipine, carvedilol, and atenolol - Holding lisinopril until PCP/Nephrology follow up # Anemia: at baseline TRANSITIONAL ISSUES =================== [] Would repeat BMP within one week to ensure stability / return to baseline. [] Consider restarting lisinopril at follow up, also consider increasing this and decreasing/discontinuing carvedilol and atenolol give some episodes of sinus bradycardia while inpatient. [] Could restart daily colchicine as long as renal function returns to baseline / remains stable, but would consider holding it given already on allopurinol and no recent gout flairs. [] Should have hepatitis B vaccination as was found to be non-immune with no prior exposure this admission. [] See by diabetes educator for re-education about glucometer and pens. ISS discontinued due to concern for frailty/hypoglycemic events at home. He should continue to follow with them in clinic for insulin titration. # CODE: Full, presumed # CONTACT: Proxy name: ___ Relationship: daughter Phone: ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Atenolol 50 mg PO DAILY 2. amLODIPine 10 mg PO DAILY 3. Vitamin D ___ UNIT PO 1X/WEEK (MO) 4. Simvastatin 20 mg PO QPM 5. Omeprazole 20 mg PO DAILY 6. Glargine 26 Units Bedtime Humalog 4 Units Breakfast Humalog 4 Units Lunch Humalog 4 Units Dinner 7. Furosemide 20 mg PO DAILY 8. Fluticasone Propionate NASAL 2 SPRY NU DAILY 9. Calcitriol 0.25 mcg PO DAILY 10. Aspirin 325 mg PO DAILY 11. Allopurinol ___ mg PO EVERY OTHER DAY 12. Lisinopril 2.5 mg PO DAILY 13. CARVedilol 3.125 mg PO BID 14. Fish Oil (Omega 3) 1000 mg PO BID 15. Colchicine 0.3 mg PO ONCE Discharge Medications: 1. Glargine 20 Units Bedtime Humalog 2 Units Breakfast Humalog 2 Units Lunch Humalog 2 Units Dinner 2. Allopurinol ___ mg PO DAILY 3. amLODIPine 10 mg PO DAILY 4. Aspirin 325 mg PO DAILY 5. Atenolol 50 mg PO DAILY 6. Calcitriol 0.25 mcg PO DAILY 7. CARVedilol 3.125 mg PO BID 8. Fish Oil (Omega 3) 1000 mg PO BID 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. Furosemide 20 mg PO DAILY 11. Omeprazole 20 mg PO DAILY 12. Simvastatin 20 mg PO QPM 13. Vitamin D ___ UNIT PO 1X/WEEK (MO) 14. HELD- Colchicine 0.3 mg PO ONCE This medication was held. Do not restart Colchicine until Talking to your PCP ___ Nephrologist 15. HELD- Lisinopril 2.5 mg PO DAILY This medication was held. Do not restart Lisinopril until talking to your PCP ___ Nephrologist Discharge Disposition: Home Discharge Diagnosis: Acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (___ or cane). Discharge Instructions: ====================== DISCHARGE INSTRUCTIONS ====================== Dear Mr. ___, It was a pleasure caring for you at ___ ___. WHY WAS I IN THE HOSPITAL? - Your kidneys were not working well, and your potassium level was too high. WHAT HAPPENED TO ME IN THE HOSPITAL? - We gave you medicines to lower the potassium and make your kidneys work better. You were also seen by the kidney doctors. - Your kidney function slowly returned to normal with supportive care. - You were seen by our physical therapists who recommended a walker for you to use to maintain better balance. 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: ___
10136781-DS-15	10,136,781	26,967,395	DS	15	2162-10-07 00:00:00	2162-10-07 10:21:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Amoxicillin / Erythromycin Base / Peanut Attending: ___. Chief Complaint: Status-post MVC with polytrauma Major Surgical or Invasive Procedure: ___: Chest tube placement ___: 1. Open reduction internal fixation of symphysis fracture of the mandible. 2. Closed reduction maxillomandibular fixation of right subcondylar fracture. ___: left renal artery embolization History of Present Illness: ___ M with asthma and Klinefelter syndrome s/p MVA on ___. +LOC, intoxicated. Sustained multiple injuries including facial fractures, left rib fractures, left pneumothorax/hemothorax, Grade IV renal laceration, Grade I splenic laceration, left sacral, left acetabular, left superior pubic ramus, left inferior pubic ramus fractures. Right ___ and ___ metacarpal bone fractures. He was initially admitted to trauma SICU for hemopneumothorax to be monitored overnight and underwent evaluations by Plastics, Urology, Orthopedics, and OMFS services. Past Medical History: Mild asthma Klinefelter syndrome Social History: ___ Family History: Non-contributory Physical Exam: Upon discharge: Pertinent Results: ___ 04:54AM BLOOD WBC-9.5# RBC-3.62* Hgb-11.2# Hct-32.3 MCV-89 MCH-31.0 MCHC-34.8 RDW-12.4 Plt ___ ___ 04:54AM BLOOD Glucose-102* UreaN-15 Creat-0.9 Na-139 K-4.2 Cl-103 HCO3-31 AnGap-9 CT abdomen/pelvis: ___ 1.Extensive trauma to the chest includes multiple left-sided rib fractures, small to moderate left pneumothorax, left lung contusions and possible lacerations, and hemorrhagic left pleural effusion with evidence of active extravasation. 2.Small foci of air surround the aorta and the subdiaphragmatic region and are suggestive of either free air tracking along the pleural surface or injury to the duodenum or esophagus. Continued followup is recommended. 3.Grade 3 left renal laceration. There is also evidence of a clot in the left renal collecting system. Continued followup is recommended. 4.Hypodense foci throughout the spleen representative of grade 1 or 2 injuries consistent with contusions. Continued followup is recommended. 5. There is evidence of bowel wall thickening involving the small bowel in the left lower quadrant along with a small amount of hemoperitoneum, which raise suspicion for small bowel. Continued followup is recommended. 6. Multiple fractures including left third, fourth, sixth, seventh, eighth, ninth, tenth, and eleventh ribs, left sacral ala, left anterior acetabular wall, and left superior and inferior pubic rami fractures. CT Cspine: ___ No acute cervical spine fractures or abnormal alignment. Comminuted transverse fracture of the right mandibular ramus, with the superior segment medially angulated. CT Head: ___ 1. Laceration involving the left ear is noted. There is, however, no evidence of large intracranial hemorrhage or shift of the normally midline structures. 2. Hyperdense foci along the right tentorium are likely representative of beam hardening artifact. However, continued followup is recommended. C-xray (CT to water seal) ___: There is a left apical pneumothorax which is unchanged, remaining 1.6 cm in maximal span. There is stable left lower lobe atelectasis. Left chest tube is seen in place. There is no pleural effusion. CT Max/facial: ___ 1. Minimally-comminuted, transverse fracture at the right mandibular ramus. The right mandibular condyle remains in the glenoid fossa. Equivocal right temporal bone fractures at the right TMJ articulation surface. Moderate adjacent soft tissue hematoma/swelling around the mandibular rami fracture site. 2. Minimally-displaced, oblique mandibular symphyseal fracture. 3. Minimally displaced right temporal styloid process fracture. L hand xray: ___ Essentially non-displaced fractures of the second and fourth metacarpals. L Shoulder: ___: No fracture Brief Hospital Course: Mr. ___ was evaluated in the trauma bay status-post motor vehicle accident with radiographic and physical exam identifying the following injuries: Rib fractures ___, left Left pneumothorax, hemothorax Grade IV renal lac Grade I splenic lac Left sacral, left acetabular, left superior pubic ramus, and left inferior pubic ramus fractures Transverse fracture at the right mandibular ramus Right temporal styloid process fracture Patient was transferred to ___ in stable condition. The remainder of his course is described below by system. Neuro: Patient's pain was moderately controlled with dilaudid PCA. Due to multiple rib fractures, an epidural was placed for analgesia with good effect on HD2. This was removed on HD#4, and the patient was transitioned to oral pain medications with good effect. CV: The patient was stable from a cardiovascular standpoint; vital signs were routinely monitored. Resp: A left sided chest tube was placed in the trauma bay with return of sanginous fluid and resolution of his pneumothorax. The chest tube was kept on suction until HD 4 when it was placed to water seal after decreased output to 80cc in 24 hours. Aggressive pulmonary toilet was enforced and he was started on inhaled nebulizer treatments. A chest xray after placing the CT to suction showed remaining stable pneumothorax. His oxygen saturations remained stable and he remained without respiratory compromise. However, on ___ he became febrile to 101.7 and a chest xray was obtained that was consistent with pneumonia. He was empirically started on a 10-day course of levaquin for this at this time. His chest tube was removed in the interim, and the patient has maintained excellent O2 saturations without oxygen requirement. GI: Initial CT raised concern for a hollow viscus injury, however the patient's clinical exam was stable and without concern. He had no abdominal tenderness or pain with stable vital signs. His diet was advanced soon thereafter, and was later placed on full liquids per OMFS after ORIF of his mandibular fracture and closed reduction of his temporal styloid process fracture. He tolerated this well. He was instructed to follow-up in clinic the week after discharge. GU: A foley was placed in the trauma bay with initial hematuria which resolved gradually by ___. The foley was removed the following day ___, at which time he voided without difficulty. As noted on CT, the patient had a grade 4 renal laceration, which was evaluated by urology. Recommendations at this time remain to continue with conservative management as the patient's hematocrit and creatinine remained stable; however, he was noted to have frank blood and clots in his foley catheter on HD 6, and was consented for and underwent a left renal artery embolization by Interventional Radiology with no complications. His hematuria gradually settled to slightly-tinged urine, and a 3-way was placed by Urology for intermittent clots, which was attributed to the recent embolization. His foley catheter was then placed on continuous bladder irrigation with moderate resolution of his hematuria. Continuous bladder irrigation was removed the day of discharge with moderate resolution of his hematuria. The patient tolerated this well and was discharged to rehabilitation with a 3-way foley catheter in place and instructions on hand-irrigation to evacuate clot. Heme: The patient was noted to have a small grade I splenic laceration. Patient did not receive any transfusions in the ICU. HSC was started on HD #3 upon transfer to the floor. His hematocrit remained stable prior to discharge. ID: Patient was given a 7 day course of cephalexin for a left ear laceration that included cartilage. He was also started on a 10 day course of levofloxacin for pneumonia as noted above, and was afebrile prior to discharge without complaints of fevers, shortness of breath, or cough. Ortho: Ortho was consulted for management of a left acetabular fracture, sacral fracture, & pubic symphysis fracture. Their recommendation was for touch down weight bearing with plans to follow up in 2 weeks once his other injuries were stabilized. Plastic Hand was consulted for a cast to the right hand for non-displaced ___ & ___ metacarpal fractures. He was instructed to follow-up as an outpatient for re-assessment. The patient also had a left ear laceration that was repaired by the Plastic surgery service, and sutures were removed prior to discharge. Bacitracin was applied to the area daily. Prior to discharge, the patient was tolerating a regular full liquids diet, ambulating with a walker, voiding via his foley catheter, afebrile, and doing well. Medications on Admission: None Discharge Medications: 1. bacitracin zinc 500 unit/g Ointment Sig: One (1) Appl Topical QID (4 times a day). 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 3. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 4. chlorhexidine gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane BID (2 times a day). 5. docusate sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day). 6. acetaminophen 650 mg/20.3 mL Solution Sig: 20.3 mL PO Q6H (every 6 hours). 7. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 8. oxycodone 5 mg/5 mL Solution Sig: One (1) ___ PO every four (4) hours as needed for pain. 9. levofloxacin 250 mg/10 mL Solution Sig: Three (3) PO once a day for 3 days: 750mg once daily for ten days total, ___. 10. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection BID (2 times a day): this may be discontinued if the patient continues to ambulate at least tid. 11. metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours): to prevent nausea. 12. ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea: to prevent nausea. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath, wheezing. 14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 15. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for anxiety. Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: rib fractures left left pneumothorax, hemothorax grade IV renal lac grade I splenic lac Left sacral, left acetabular, left superior pubic ramus, and left inferior pubic ramus fractures transverse fracture at the right mandibular ramus right temporal styloid process fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires some assistance with walker Discharge Instructions: You were admitted to the hospital after sustaining significant injuries after a motor vehicle accident. You were found to have multiple left-sided rib fractures with bruising of your left lung, as well as blood and some air within your chest outside of your lungs. A chest tube was placed to remove this fluid, and this amount decreased significantly throughout your stay and was removed. You did not have any concern for additional oxygen requirement or need for intubation. You have a left ear laceration through cartilage that was evaluated and repaired by the Plastic Surgery service; you were placed on one week of antibiotics, and your sutures were removed prior to discharge. Your follow-up appointment is listed below. You have a right jaw fracture that was wired together by the Oral Maxillo-facial service, and have been placed on a liquid diet with ensure supplementation, which you are doing well with. Your follow-up appointment is listed below in the recommended follow-up section. You have fractures of your ___ and ___ fingers of your right hand, which were splinted by the Orthopedics service; Occupational Therapy has also been following you for ROM exercises and strengthening. You are allowed to touch-down weight bear on your left leg per Orthopedics recommendations. Follow-up appointment information is listed below. You were also noted to have pelvic fractures were evaluated by the Orthopedics service, and were deemed stable without need for operation. You are touch-down weight bearing on the LLE and may ambulate with a walker. You may follow-up in 2 weeks and call for an appointment at the number below. You have a very small laceration of your spleen which has been stable. You have a high-grade left kidney laceration for which a catheter was placed in your bladder for further monitoring, you initially had a significant amount of blood in your urine, but this too has slowly resolved during your stay; the Urology service was contacted, with recommendations to continue conservative care without the need for operation at this time. You have a 3-way foley catheter place, and the blood in your urine has decreased significantly. You remained on continuous bladder irrigation for a few days, but currently do not rely on this. You may require intermittent bladder irrigation by hand. This foley catheter may be removed in ___ days per urology recommendations. Please monitor your urine for increasing blood or clots and/or suprapubic or lower abdominal pain. 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 as tolerated with a walker 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. Followup Instructions: ___
10136839-DS-8	10,136,839	29,401,107	DS	8	2175-06-05 00:00:00	2175-06-05 13:08:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fatigue Major Surgical or Invasive Procedure: bone marrow biopsy ___ bone marrow biopsy ___ History of Present Illness: ___ yo male with no significant medical history who is admitted with acute leukemia. The patient states he has had increasing fatigue for the past three weeks but otherwise has felt ok. He went to the primary care clinic where labwork was done and he was found to have a leukocytosis of 100 and thrombocytopenia so he was referred to the ED. He denies any recent fevers, shortness of breath, congestion, nausea, diarrhea, or dysuria. He had a mild headache a few days ago and one brief episode of blurry vision a few days ago. Past Medical History: VENTRAL HERNIA s/p repair as a child LIPOMA Social History: ___ Family History: No history of cancer in the family Children: 3 children ages ___, ___, ___ 2 siblings, 1 sister and 1 brother, both healthy and live locally Physical Exam: ON ADMISSION: General: NAD VITAL SIGNS: T 98.6 BP 142/82 HR 74 RR 16 O2 99%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. Cranial nerves II-XII are within normal limits excluding visual acuity which was not assessed, no nystagmus; strength is ___ of the proximal and distal upper and lower extremities. ON DISCHARGE: VITAL SIGNS: 98.6 134/84 74 18 100RA HEENT: MMM, no OP lesions CV: RR, NL S1S2 PULM: CTAB, no w/r/r ABD: Soft, NTND, no masses or hepatosplenomegaly LIMBS: No edema, clubbing, tremors SKIN: No petechiae, purpura, ecchymoses. EXT: WWP, no swelling, No erythema. NEURO: Alert and oriented, moving all extremities equally and with purpose. EOMI. LINE: Temp CVL R chest, mild erythema but no induration or drainage, nontender LABS/STUDIES: Reviewed. See OMR. Pertinent Results: ADMISSION LABS: ___ 12:15PM BLOOD WBC-109.6* RBC-3.62* Hgb-11.5* Hct-34.3* MCV-95 MCH-31.8 MCHC-33.5 RDW-15.0 RDWSD-52.5* Plt Ct-26* ___ 12:15PM BLOOD Neuts-0 Bands-0 Lymphs-3* Monos-0 Eos-0 Baso-0 ___ Myelos-0 Blasts-97* Other-0 AbsNeut-0.00* AbsLymp-3.29 AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00* ___ 08:00PM BLOOD ___ PTT-23.7* ___ ___ 08:00PM BLOOD ___ ___ 08:00PM BLOOD QG6PD-12.6* ___ 12:15PM BLOOD Parst S-NEGATIVE ___ 08:00PM BLOOD Ret Man-0.9 Abs Ret-0.03 ___ 12:15PM BLOOD UreaN-15 Creat-1.1 Na-140 K-3.3 Cl-98 HCO3-24 AnGap-21* ___ 12:15PM BLOOD ALT-227* AST-75* CK(CPK)-204 AlkPhos-99 TotBili-0.5 ___ 12:15PM BLOOD TotProt-7.6 Albumin-4.8 Globuln-2.8 Calcium-9.2 ___ 08:00PM BLOOD Albumin-5.1 Calcium-9.6 Phos-3.8 Mg-2.4 UricAcd-7.0 ___ 12:15PM BLOOD TSH-1.9 ___ 12:15PM BLOOD CRP-34.0* ___ 12:15PM BLOOD HIV Ab-Negative DISCHARGE LABS: ___ 12:00AM BLOOD WBC-1.6* RBC-2.74* Hgb-8.1* Hct-23.6* MCV-86 MCH-29.6 MCHC-34.3 RDW-12.8 RDWSD-38.4 Plt ___ ___ 12:00AM BLOOD Plt Smr-NORMAL Plt ___ ___ 12:00AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL ___ 12:00AM BLOOD ___ 08:00PM BLOOD QG6PD-12.6* ___ 12:00AM BLOOD Glucose-117* UreaN-14 Creat-0.9 Na-139 K-4.2 Cl-99 HCO3-27 AnGap-17 ___ 12:00AM BLOOD ALT-109* AST-37 AlkPhos-134* TotBili-0.3 ___ 12:00AM BLOOD Calcium-9.3 Phos-4.8* Mg-2.2 ___ 07:47AM BLOOD Vanco-19.9 ___ 05:00PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-1* Polys-0 ___ ___ 05:00PM CEREBROSPINAL FLUID (CSF) IPT-DONE ___ 05:00PM CEREBROSPINAL FLUID (CSF) TotProt-61* Glucose-58 ___ 05:00PM CEREBROSPINAL FLUID (CSF) CSF HOLD-PND MICRO: blood cx ___ x3, ___ x1, ___ x1, ___ - no growth mycolytic blood cx ___: NGTD urine cx: ___: no growth cdiff: ___: negative urine legionella ag, RPR, cryptococcal ag, Strongyloides Antibody,IgG, Coccidioides Ab, Complement Fixation and Immunodiffusion, Blastomyces Quantitative Antigen, Anaplasma phagocytophilum (human granulocytic Ehrlichia agent) IgG/IgM, ___ Fever Ab IgG, IgM: all neg CMV IgG ANTIBODY (Final ___: POSITIVE FOR CMV IgG ANTIBODY BY EIA. galactamannan, beta glucan ___: neg ___ 12:15 pm SEROLOGY/BLOOD FINAL REPORT ___ LYME SEROLOGY (Final ___: EQUIVOCAL BY EIA. CONFIRMED AS POSITIVE BY WESTERN BLOT. Refer to outside lab system for complete Western Blot results. ___ 12:15 LYME DISEASE ANTIBODY, IMMUNOBLOT Test Name Flag Results Unit Reference Value --------- ---- ------- ---- --------------- Lyme Disease Ab, Immunoblot, S IgG Immunoblot Negative kDa Negative IgG Band(s): p41 IgM Immunoblot AB Positive kDa Negative IgM Band(s): p41, p23, Interpretation -------------- Consistent with early infection with Borrelia burgdorferi. A new serum specimen should be submitted in ___ days to demonstrate seroconversion of IgG. IgM blot criteria is of diagnostic utility only during the first 4 weeks of early Lyme disease. PATHOLOGY: ___ Bone marrow: HYPERCELLULAR BONE MARROW WITH INVOLVEMENT BY ACUTE MYELOID LEUKEMIA. SEE NOTE. Note: By flow cytometry, the blast are myeloperoxidase positive, but lack CD34 and ___. ___ with cytogenetic/molecular study and clinical findings for aa definitive classification. Immunophenotyping: CD45-bright, low side scatter gated lymphocytes comprise 2.5% of total analyzed events. Of these, B-cells are less than 1%, polytypic and do not express aberrant antigens. T cells comprise 66% of lymphoid gated events, express mature lineage antigens CD3, CD5, CD2, CD7 and have a helper cytotoxic ratio of 1.5 (usual range in blood 0.7-3.0). There is an expanded population of double-negative (CD4-, CD8-) cells comprising 6.5% of CD3(+) T cells. CD56(+) CD3(-) natural killer cells are 12% of gated lymphocytes. Cell marker analysis demonstrates that the majority (95%) of the cells isolated from this bone marrow are in the CD45-dim/low side-scatter "blast" region. They express CD38 along with myeloid associated antigens cytoplasmic MPO, CD117 (subset 58%), CD33 (dim), CD13 (dim). There is dim subset CD64 expression, as well as aberrant CD56. They lack B and T cell associated antigens, are CD10 (cALLa) negative and are negative for CD14 and CD11b. Blast cells comprise 95% of total analyzed events. INTERPRETATION Immunophenotypic findings consistent with involvement by acute myeloid leukemia. Please correlate with morphologic, cytogenetic and molecular findings. Cytogenetics: 46,XY[20] Normal male karyotype. NEG for: CBFB REARRANGEMENT, RUNX1T1/RUNX1, BCR/ABL, CEBPA.. NPM + FLT3 ITD positive** RAPID HEME PANEL ---------------- Result: Average coverage: 1437X >200X coverage: 87.9% <50X coverage: 4.7% (A high quality sample/run has >90% of the amplicons with >200X coverage) Pathogenic Variants: NPM1 NM____ c.859_860insTCTG p.___>9 - in 40.3% of 206 reads TET2 ___ c.___>T p.___ - in 98.0% of 401 reads Read count analysis shows loss of TET2 on chr 4q. The following FLT3-ITD is identified: ITD size Start Pos ITD Sequence 45 ___ ATATTCTCTGAAATCAACGTAGAAGTACTCATTATCTGAGGAGCG ___ (Day14) Bone marrow: MARKEDLY HYPOCELLULAR BONE MARROW WITH NO MORPHOLOGIC EVIDENCE OF ACUTE MYELOID LEUKEMIA; SEE NOTE. Note: A significant blast population is not seen on the aspirate material or the core biopsy. Both are hypocellular and show scattered plasma cells, histiocytic cells, occasional non-blast myeloid precursors and occasional mature megakaryocytes. Morphologic features of acute myeloid leukemia are not present. Correlation with clinical, flow cytometry, and cytogenetic findings is recommended. Immunophenotyping: 0-color analysis with linear side scatter vs. CD45 gating is used to evaluate lymphocytes, blasts, plasma cells. This is a limited leukemia follow-up panel. A major subset of the acquired events are in the low light scatter cell debris lysed cell region with only 84.0% of nondebris cells. The viability of the analyzed nondebris events done by 7-AAD is 97%. CD45-bright, low side-scatter gated lymphocytes comprise 72%. of total analyzed events. Cell marker analysis demonstrates that a subset (0.9%) of the cells isolated rom this bone marrow are in the CD45-dim side scatter "blast" region. They express immature antigens CD34, ___, CD11b. They lack myeloid and B and T cell associated antigens, are CD10 (cALLa) negative, and are negative for CD33, CD64, CD14, cTdT, cMPO. INTERPRETATION Immunophenotypic findings consistent with involvement by a small population of blasts with a phenotype at variance with that seen at diagnosis, suggesting normal regenerative blasts. Correlation with clinical findings and morphology (see separate pathology report ___ is recommended. Cytogenetics: 46,XY[6] Normal male karyotype. IMAGING: CHEST (PORTABLE AP) ___ No focal consolidation is seen. There is no pleural effusion or pneumothorax. The cardiac and mediastinal silhouettes are unremarkable. Anterior left costochondral calcification is seen in the mid to lower left hemi thorax. TTE ___ The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. Normal left ventricular wall thickness, cavity size, and regional/global systolic function (biplane LVEF = 69 %). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal study. Normal biventricular cavity sizes with preserved regional and global biventricular systolic function. No structural heart disease or pathologic flow identified. Compared with the report of the prior study (images unavailable for review) of ___, the findings are similar. RUQ US ___ LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is no ascites. BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 0.2 cm . GALLBLADDER: There is no evidence of stones or gallbladder wall thickening. 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: Normal echogenicity, measuring 14.8 cm. KIDNEYS: Right kidney measures 12.1 cm. Left kidney measures 13.5 cm. No nephrolithiasis or hydronephrosis. Normal corticomedullary differentiation. RETROPERITONEUM: The visualized portions of aorta and IVC are within normal limits. IMPRESSION: Normal abdominal ultrasound. CT ABD & PELVIS WITH CONTRAST ___ No acute intra-abdominal process. CT CHEST W/CONTRAST ___ 1. Right upper lobe ___ airspace opacities may represent aspiration or early pneumonia. 2. 6 mm left lower lobe pulmonary nodule. UNILAT LOWER EXT VEINS US LEFT ___ Probable nonocclusive DVT in the left gastrocnemius vein. No other acute or occlusive DVT identified. UNILAT LOWER EXT VEINS US LEFT ___ The left gastrocnemius vein is compressible with evidence of slow intermittent flow. No definite thrombus is seen. Brief Hospital Course: ___ with no significant past medical history presents with three weeks of fatigue and fever, found on labs to have leukocytosis to 100K, neutropenia, and thrombocytopenia with new diagnosis of AML. # AML: Patient presented with fatigue, some headache and occasional blurred vision found to have leukocytosis to 100K with high circulating blasts concerning for acute leukemia. No signs/symptoms of hyperviscosity syndrome. Started on allopurinol and IVF and labs were monitored closely. On initial presentation had mild DIC requiring transfusion of cryoprecipitate but without bleeding complications. Awaiting leukemia diagnosis, required leukopheresis given persistent leukocytosis despite hydrea. Bone marrow bx path consistent with AML,. +NPM, +FLT3 ITD. Cytogenetics showed normal karyotype. Underwent induction chemotherapy with 7+3, D14 marrow was ablative. Search was initiated for unrelated marrow donor as his two siblings were not matches. His counts improved and his ANC was >1000 on discharge. He had an LP prior to discharge with his CSF showing protein 61, WBC 3, RBC 1, lymphs 78, and monos 22 with pending cytology and immunophenotyping. #Neutropenic Fever: Presented with several weeks of fever and fatigue. Cultures and CXR unrevealing. Started empirically on vanc/cefepime initially. Again developed fever during chemotherapy course. Repeat infectious w/u showed new tree in ___ opacities in RUL concerning for early PNA s/p azithro x ___lso started empirically on posaconazole for fungal coverage, but was ultimately held for transaminitis. Having loose stools, cdiff neg. Lyme IgM from ___ positive, consistent with early lyme disease but on treatment w/ cefepime. Fungal markers were negative. He was afebrile on discharge, off antibiotics for >24 hours. #Transaminitis: Had transaminitis on initial presentation ( ALT 227, AST 75). RUQ US neg. Thought to be leukemia related, resolved with induction chemotherapy. ALT/AST started trending up again on D16, so posaconazole was held. He was switched to micafungin, but then switched to fluconazole as per hospital protocol. His LFTs continued to trend down to baseline on discharge. #DVT: Reported new LLE pain on ___, US showed Nonobstructive DVT below the knee. Anticoagulation contraindicated given thrombocytopenia. Subsequently c/o L ankle and foot swelling, f/u US showed no definitive thrombus. Resolved without any subsequent issues. # Folliculitis: New erythematous, skin lesion noted on posterior right upper arm, may be from folliculitis but given new leukemia diagnosis concern for possible leukemia cutis. Per dermatology, likely folliculitis. Treated with clindamycin lotion and resolved. TRANSITIONAL ISSUES: - Noted on CT chest to have 6 mm left lower lobe pulmonary nodule. For low risk patients, follow-up at 12 months. - Repeat bone marrow biopsy needs to be done outpatient - Follow-up outpatient with Men's Health clinic for testosterone supplementation - Pending CSF cytology and IPT. Patient to follow up in ___ clinic. Please review these results at this visit - HEME ONC FOLLOW UP: Patient to follow up with Dr. ___ on ___ or ___ - CODE: Full - Contact: ___ (wife, HCP) ___ ___ on Admission: The Preadmission Medication list is accurate and complete. 1. Ferrous Sulfate 325 mg PO DAILY 2. Multivitamins 1 TAB PO DAILY 3. Testosterone Cypionate WEEKLY Discharge Medications: 1. Multivitamins 1 TAB PO DAILY 2. Ferrous Sulfate 325 mg PO DAILY 3. Testosterone Cypionate WEEKLY Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: acute myeloid leukemia SECONDARY DIAGNOSIS: neutropenic fever, transaminitis, deep vein thrombosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital because you were very tired and were found to have a very high white blood cell count. You were diagnosed with acute myeloid leukemia and underwent chemotherapy. You were given strong antibiotics for infection because your immune system was very weak and were given transfusions of blood and platelets as needed. You recovered from the infection and were discharged home after your immune system started to recover. It was pleasure to be involved in your care, Your ___ Care Team Followup Instructions: ___
10137137-DS-19	10,137,137	20,750,480	DS	19	2191-02-15 00:00:00	2191-02-16 19:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: chest pain and shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 1 liner: ___ yo woman with a history of HTN, HL who presents to the ED with 3 days of sharp chest pain. Chronology of present illness: -___ hour flight from ___ to ___ -___ patient developes acute onset shart left sided chest pain while on the telephone. Resolves spontaneously. -___ patient again has sharp left sided chest pain radiant down her left arm while doing the dishes. -___ patient attempts to walk the 1 mile between her home and her daughter's develops significant chest pressure "like someone pushing on my chest", SOB and DOE, has to sit down on the sidewalk. -___ patient seen in the ___ emergency department, found to have bilateral pulmonary emboli involving the right main pulmonary artery and all segmental pulmonary arteries. -___ patient started on heparin gtt and admitted to medicine. . ROS: per HPI, also notable for the abscence of hemoptysis, cough, fevers, chills, leg swelling or tenderness, diaphoresis. Past Medical History: -s/p hysterectomy -HTN -HL -Anxiety -glucose intolerance diet controlled Social History: ___ Family History: Family History: no hx of clotting, bleeding disorders or sudden death. Physical Exam: ADMISSION EXAM: Vitals- 98.7, 160/92, 65, 20, 97% 4L General- Alert, oriented, no acute distress HEENT- Sclera anicteric, MMM, oropharynx clear Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU- no foley Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro- CNs2-12 intact, motor function grossly normal DISCHARGE EXAM: Vitals- 98.2, 119/73, 58, 16, 95RA General- Alert, oriented, no acute distress Neck- supple, JVP not elevated, no LAD Lungs- Clear to auscultation bilaterally, no wheezes, rales, ronchi CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen- soft, non-tender, non-distended Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: ADMISSION LABS: ___ 12:44PM BLOOD WBC-6.1 RBC-4.28 Hgb-13.0 Hct-40.2 MCV-94 MCH-30.5 MCHC-32.4 RDW-12.8 Plt ___ ___ 12:44PM BLOOD ___ PTT-31.3 ___ ___ 12:44PM BLOOD Glucose-146* UreaN-25* Creat-0.9 Na-140 K-3.8 Cl-101 HCO3-27 AnGap-16 ___ 12:44PM BLOOD proBNP-1109* ___ 12:44PM BLOOD cTropnT-<0.01 ___ 07:25PM BLOOD cTropnT-<0.01 . INTERIM LABS ___ 07:25PM BLOOD ___ PTT-90.2* ___ ___ 07:30AM BLOOD ___ PTT-34.6 ___ ___ 07:55AM BLOOD ___ PTT-39.9* ___ . IMAGING EKG ___: Sinus rhythm with baseline artifact. Left atrial abnormality. Complete left bundle-branch block. Probable underlying left ventricular hypertrophy. Inferior Q waves and slow R wave progression are non-diagnostic in this context. No previous tracing available for comparison. Clinical correlation is suggested. ___ ___ CXR ___: There is minor streaky opacification of the lung bases suggesting minor atelectasis. No definite consolidation is present. There is no pulmonary edema, pleural effusion or pneumothorax. A rounded dense 2.9 cm lesion projects over the right mediastinal border and is consistent with a relatively large but highly calcified mediastinal lymph node. The cardiomediastinal silhouette is otherwise normal. IMPRESSION: 1. Calcified mediastinal lymph node suggesting a prior granulomatous process. 2. Streaky right basilar opacity suggesting minor atelectasis. CTA CHEST ___: CHEST: The thyroid is normal. Several mediastinal and hilar calcified lymph nodes are present, measuring up to 1.7 cm in the right paratracheal station. Otherwise, no axillary, supraclavicular, mediastinal, or hilar enlarged lymph nodes. Filling defects are present in the bilateral pulmonary arteries, compatible with bilateral pulmonary emboli. Thrombus is seen in the right main pulmonary artery extending into all right segmental branches. Thrombus is also seen in the left upper and lower segmental branches. There is relative enlargement of the right ventricle, indicating right heart strain. The main pulmonary artery measures 3.3 cm, indicating mild pulmonary hypertension. Scattered aortic vascular calcifications are present. There is no evidence of acute aortic injury. The great vessels are otherwise unremarkable. The pericardium is intact without effusion. Bilateral peripheral parenchymal opacities are seen at the dependent portion of the lung bases, most compatible with dependent atelectasis. A 1.4-cm right middle lobe pulmonary nodule (3:40) is present, without prior studies for comparison. No pleural effusion is present. The liver contains a calcified 3-mm granuloma. The visualized upper abdominal organs are otherwise unremarkable. OSSEOUS STRUCTURES: Multilevel thoracic spine degenerative changes are present with anterior osteophytosis and vacuum phenomenon in the lower intravertebral thoracic space. IMPRESSION: 1. Bilateral pulmonary emboli involving all pulmonary lobes with evidence of right heart strain and mild pulmonary artery hypertension. 2. 1.4-cm right middle lobe pulmonary nodule or node. Further evaluation with prior examinations or additional modalities may be obtained after resolution of acute issues. Alternatively, follow-up CT in 3 months with IV contrast may be obtained. 3. Peripheral parenchymal opacities at bilateral dependent lung bases, most compatible with atelectasis. 4. Several calcified medistinal and hilar lymph nodes, likely prior granulomatous disease. ECHO ___: The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is ___ mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. There is mild global left ventricular hypokinesis (LVEF = 40 %). Right ventricular chamber size is normal with focal hypokinesis of the apical free wall. There is abnormal septal motion/position. 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 borderline pulmonary artery systolic hypertension. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with abnormal septal motion and mild global hypokinesis c/w diffuse process. Right ventricular free wall hypokinesis. Borderline pulmonary artery hypertension. CLINICAL IMPLICATIONS: Based on ___ AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: Assessment and Plan: ___ yo woman w/ HTN, HL presenting with chest pain after long plane flight found to have large right and left sided pulmonary clot burden. . PE: patient with large clot burden on CTA chest, likely provoked given reccent long distance travel. Multiple episodes of unprovoked chest pain in the days prior to admission were felt to represent discrete embolic events with clearance of distal clot burden as patient was without evidence of peripheral edema or leg pain at the time of presentation. in the emergency department the patient was started on heparin drip which was discontinued on arrival to the medical floor in favor of enoxaparin bridge to coumadin. Her EKG was notable for a LBBB morphology making electrophysiologic determination of right heart strain difficult, though CTA showed a right ventricular volume equivalent to the left ventricular cavity. Cardiac biomarkers were not elevated and patient had no evidence on exam of right sided heart failure. Given her large clot burden an ECHO was performed to assess right heart function and was read as mild symmetric left ventricular hypertrophy with abnormal septal motion and mild global hypokinesis c/w diffuse process. Right ventricular free wall hypokinesis. Borderline pulmonary artery hypertension. Clinically the patient appeared very well and was assessed by physical therapy without concern. The patient received 6 mg coumadin on hospital day 1 and 2 and 2.5 mg on hospital day 3 with an INR of 1.6. Further INR checks and coumadin doses were coordinated with the patient's PCP at ___. Patient was discharged with 60 mg BID enoxaparin bridge and 2 mg coumadin tablets with a scheduled INR check on ___ and PCP follow up on ___. . HTN: stable, continued home losartan and HCTZ . HL: stable, continued home atorvastatin. . ANXIETY: stable, continued home citalopram. . TRANSITIONAL ISSUES: -patient's coumadin dose to be managed by PCP, confirmed with Dr. ___ discharged with ___ services to administer lovenox injections -incidental finding of a 1.3 cm right sided lung nodule was made on Chest CT with recommended follow up in 3 months, PCP informed of finding. -patient is a full code Medications on Admission: -HCTZ 25 mg daily -Losartan 50 mg daily -Citalopram 20 mg daily -Lipitor 20 mg daily -MVI daily -ASA 81 mg daily Discharge Medications: 1. enoxaparin 60 mg/0.6 mL Syringe Sig: Sixty (60) mg Subcutaneous Q12H (every 12 hours) for 5 days: use until instructed by your primary care doctor. Disp:10 syringes Refills:0 2. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 4. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 ___: your primary care doctor ___ determine future doses. Disp:30 Tablet(s) Refills:0 7. Outpatient Lab Work Please have an INR check on ___. Call your doctor to arrange this. Name: ___ Address: ___ Phone: ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY: -Pulmonary embolism SECONDARY: -hypertension -diet controlled diabetes -hyperlipidemia -anxiety 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 while you were admitted to ___. You were admitted for evaluation of your chest pain and shortness of breath. You were found to have a large blood clot in your lungs called a pulmonary embolism. You will need to take a blood thinner every day for the next several months to treat this. The dose of this blood thinner called coumadin will be adjusted by your pcp and you ___ need frequent blood checks to help him adjust the dose. You will also need to give yourself injections with a medication called enoxaparin until your coumadin level becomes therapeutic. Your primary care doctor ___ help you manage this transition. The following changes were made to your medications: -START Enoxaparin 60 mg injection twice a day until instructed by your doctor. -___ coumadin 2 mg daily, with future doses to be determined by your primary care doctor. -___ all your other home medications. Followup Instructions: ___
10137146-DS-9	10,137,146	29,831,158	DS	9	2145-04-11 00:00:00	2145-04-12 07:16:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Hypercalcemia Major Surgical or Invasive Procedure: None History of Present Illness: ___ PMH of Anxiety, Recently Diagnosed breast cancer (presumed T3N0), admitted for hypercalcemia As per review of notes, patient recently diagnosed with right sided breast cancer. Biopsy of 6cm mass in right breast ___ was consistent with ILC, Gr 2 ER+PR+HER2 neg. U/S of axilla and opposite breast without disease. Patient was without symptoms of metastatic disease but had yet to have staging CT torso + bone scan. Labs drawn in clinic revealed hypercalcemia so patient was referred to our ED. Pt reports that she was feeling fine and is in her usual state of health. She denied any progression in asymmetry of her breasts. Denied any weight loss, fatigue, decreased appetite. Reported that she was without constipation, bony pain, headache, mood changes. Denied fever or chills. In the ED, initial vitals: 98.5 ___ 18 96% RA. Patient noted to be quite anxious on arrival, which improved with time, as did her HR, which was 105 on re-check. CBC normal, AST 121, ALT 48, AP 184, Lip 78, Alb 4.6, TBili 0.6, Ca ___, Mg 1.9, Phos 1.9, CHEM with HCO3 of 21, PTH 5 EKG: Sinus tachycardia, low voltage pre-cordial leads with poor r wave progression. ED team spoke to Dr ___ At___ oncology who agreed with admission. Patient was given normal saline. Past Medical History: PAST ONCOLOGIC HISTORY: Per last outpatient ___ clinic note: " ___ Noted R breast asymmetry. Bilateral ___ tomo and bilateral breast ultrasound on ___ revealed a highly suspicious spiculated mass in the right breast at the area of concern at 10:00 4 cm from the nipple measuring 5.8 cm. Shadowing extends into the subareolar tissue. There may be a second mass at 3:00 4 cm from the nipple measuring 25 mm but it may all represent a single process. US right axilla was negative. Review of imaging at conference ___ suggests the R breast mass may extend to the pectoralis. The left breast was felt to be negative. ___ US guided bx of right breast mass @ 3:00 4 cm from the nipple revealed invasive lobular carcinoma, Gr 2, ER+ (90%, moderate), PR+ (95%, strong). US guided bx of the right breast mass @ 10:00 4 cm from the nipple revealed ILC. No LVI seen. ___ MedOnc and breast surgery consults. She has a little bruising at the biopsy site but otherwise no pain.No arm or axillary sx. She thinks the mass may have been growing over the month since she noticed it" PAST MEDICAL HISTORY: Anxiety Breast Cancer as above Social History: ___ Family History: Per ___ medical record: depression Mother depression Father melanoma Father teratoma removed from ovary Sister ___ Sister lung cancer ___ Grandfather lung cancer ___ Grandfather ___ Paternal Grandmother liver cancer ___ Grandmother Physical ___: ADMISSION PHYSICAL EXAM: Vitals: ___ 0226 Temp: 98.5 PO BP: 134/94 HR: 108 RR: 18 O2 sat: 98% O2 delivery: RA GENERAL: sitting in bed, appears comfortable, NAD, pleasant, husband at bedside EYES: PERRLA, anicteric HEENT: OP clear, MMM NECK: supple, normal ROM LUNGS: CTA b/l, no wheezing, rales, rhonchi, normal RR CV: RRR no m/r/g, normal distal perfusion, no edema ABD: Soft, NT, ND, normoactive BS, no rebound or guarding GENITOURINARY: no foley or suprapubic tenderness EXT: warm, no deformity, normal muscle bulk SKIN: warm, dry, no rash NEURO: AOx3, fluent speech DISCHARGE PHYSICAL EXAM: Vitals: T 98.6, BP 124/70, HR 114, RR 18, O2 sat 97 RA GENERAL: In NAD HEENT: PERRLA, anicteric, OP clear, MMM NECK: No palpable lymphadenopathy, no JVD LUNGS: CTAB, no crackles/wheezing/rhonchi CV: RRR, no m/r/g ABD: Soft, NTND EXT: Warm, well perfused, no ___ edema SKIN: No visible rashes NEURO: A&Ox3, CN II-XII intact, motor and sensation grossly intact Pertinent Results: ___ 08:09PM BLOOD WBC-6.1 RBC-4.50 Hgb-13.7 Hct-41.7 MCV-93 MCH-30.4 MCHC-32.9 RDW-12.5 RDWSD-42.6 Plt ___ ___ 08:00AM BLOOD ___ PTT-23.8* ___ ___ 08:09PM BLOOD Glucose-115* UreaN-8 Creat-0.6 Na-136 K-4.3 Cl-98 HCO3-21* AnGap-17 ___ 08:09PM BLOOD ALT-48* AST-121* AlkPhos-184* TotBili-0.7 ___ 08:09PM BLOOD Albumin-4.6 Calcium-14.0* Phos-1.9* Mg-1.9 ___ 06:37AM BLOOD Albumin-3.6 Calcium-12.0* Phos-2.3* Mg-1.5* ___ 08:00AM BLOOD TSH-5.7* ___ 08:00AM BLOOD Free T4-1.1 ___ 08:12PM BLOOD PTH-5* ___ 08:00AM BLOOD 25VitD-6* ___ 08:34AM BLOOD freeCa-1.66* CT C/A/P: 1. 4 mm pulmonary nodule in the left lower lobe. 2. Multiple lytic lesions seen throughout the thoracic skeleton are highly suspicious for osseous metastases. 3. Large irregular soft tissue mass in the right breast with associated biopsy clips and soft tissue inflammatory change. This mass is seen to tether the right pectoralis major muscle. 1. Extensive and confluent, peripherally enhancing hypodensities throughout the liver are highly suspicious for metastatic disease. There is trace perihepatic ascites. 2. The main portal vein and right portal vein branches are patent, however the left portal vein is not definitively visualized. The hepatic veins are not well seen. The intrahepatic IVC is markedly attenuated although it remains patent superiorly and inferiorly. 3. Numerous lytic lesions throughout the lumbar spine and pelvic bones as described above, highly suspicious for metastatic disease. 4. Indeterminate lesions in the upper pole of the left kidney as described above. A wedge-shaped opacity in the interpolar region of the left kidney may reflect sequelae of prior vascular insult or infection. 5. Small volume pelvic ascites may be physiologic in a patient of this age. 6. Gallbladder wall thickening likely related to underlying liver dysfunction. Brief Hospital Course: Ms. ___ is a ___ year old woman with a recent diagnosis of breast cancer who presented with asymptomatic hypercalcemia, found to have metastatic disease including lytic lesions to bone. TRANSITIONAL ISSUES ==================== [] Lab check on ___ to trend calcium levels [] Will need bisphosphonate infusion in ___ wks, last received ___ [] TSH mildly elevated at 5.7, with free T4 1.1. Recommend repeat TSH in ___ wks [] Started on vitamin D supplements Discharge labs: Ca ___, PO4 2.3 ACUTE ISSUES ============== #Acute Hypercalcemia #Breast cancer Presented with asymptomatic hypercalcemia to 14 from clinic. Her labwork was otherwise remarkable for low vitamin D and a low PTH. Given a recent diagnosis of breast CA, the concern was for hypercalcemia of malignancy. A CT C/A/P found extensive lytic metastasis in her T, L spine and pelvis. She received IVF and pamidronate on ___. Her calcium levels decreased and she felt well. Recheck labs will be obtained for ___. She will be started on treatment for her cancer as an outpatient after discussion with her outpatient oncologist. #Hypophosphatemia ___ hypercalcemia, repleted orally. #Transaminitis Presented with asymptomatic ALT/AST elevation, concerning for possible metastatic disease. A CT A/P confirmed metastasis to her liver. CHRONIC ISSUES =============== #Anxiety Continued home fluoxetine #Insomnia Continued home gabapentin CORE MEASURES: #HCP/Contact: Husband ___ is HCP, ___ #Code: presumed FULL Medications on Admission: The Preadmission Medication list is accurate and complete. 1. FLUoxetine 30 mg PO DAILY 2. Gabapentin 100 mg PO QHS Discharge Medications: 1. LORazepam 1 mg PO Q6H:PRN Anxiety Duration: 3 Days RX lorazepam 1 mg 1 mg by mouth every six (6) hours Disp #12 Tablet Refills:0 2. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral DAILY RX cholecalciferol (vitamin D3) 1,000 unit 1 tablet(s) by mouth once a day Disp #90 Capsule Refills:3 3. FLUoxetine 30 mg PO DAILY 4. Gabapentin 100 mg PO QHS 5.Outpatient Lab Work Check Ca, PO4 on ___ Hypercalcemia ___ Fax to ___, ATTN: Dr. ___, ___ Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS =================== Hypercalcemia of malignancy SECONDARY DIAGNOSIS ==================== Metastatic breast cancer Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. ___, You were admitted to the hospital because your calcium was elevated. WHAT HAPPENED IN THE HOSPITAL? Unfortunately, you were found to have cancer spread to your bone, which raised your calcium levels. You were treated with fluids and medication to lower the calcium. WHAT ARE THE NEXT STEPS? - You will need labwork on ___ to check your calcium level - Please follow up with your oncologist to start treatment for your cancer - Please continue to take your medications as before It was a pleasure taking care of you, we wish you the very best! Your ___ Care Team Followup Instructions: ___
10137553-DS-22	10,137,553	24,893,925	DS	22	2136-11-23 00:00:00	2136-11-28 00:14:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / Thiazides / IV Dye, Iodine Containing Contrast Media / lisinopril / morphine / fentanyl / midazolam / benzocaine Attending: ___. Chief Complaint: BRBPR Major Surgical or Invasive Procedure: EGD, flexible sigmoidoscopy ___ History of Present Illness: ___ with PMH diverticulosis, COPD, CKD, HTN, depression, p/w 3 episode of BRBPR today. Patient reports has had some pain/pressure sensation in RLQ today, mostly with movement. Today had episode of large amount of bright blood when going to bathroom, blood mixed with stool x 3 times, last episode with some blood clots was at 1pm. Different than prior episode of diverticulosis in that she had no pain at that time. No melana, hematemesis. No fevers, chills, nausea, vomiting, CP/SOB. + mild lightheadedness but no headache, blurry vision, weakness. No ETOH or NSAID use. Patient presented to outpatient clinic and referred to ED. . On arrival to the ED, initial vitals were: 97.1, 99, 174/91, 14, 100%. Exam notable for guiac +bright red blood, no clots, no melena. Labs notable for Hct 33.8 is at baseline. Prior to transfer: 94, 191/79, 20, 99% RA. . Currently, no abdominal pain, chest pain, SOB, palpitations, dizziness. . ROS: per HPI, denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, melena, dysuria, hematuria. Past Medical History: 1. Glaucoma 2. ___ (needs E antigen negative blood for transfusions) 3. Stage III CKD, likely ___ HTN, baseline Cr ___ 4. COPD 5. Osteopenia 6. Intraductal papilloma of breast s/p lumpectomy for 0.6cm DCIS of left breast 7. HTN 8. HLD 9. DM 10. Mild plaque and stenosis (< 50%) of left and right internal carotid arteries (on carotid US ___ 11. Anemia, iron deficiency and CKD 12. Diverticulosis 13. Internal and external hemorrhoids 14. Depression 15. s/p hysterectomy, appendectomy Social History: ___ Family History: No colon cancer in family. Physical Exam: ADMISSION PHYSICAL EXAM: VS - 98.1 ___ 100ra--> 220/100 ___, HR 76 General: NAD HEENT: no scleral icterus, OP clear, surgical pupils Neck: supple, no JVD CV: RRR, nl S1 S2, ? S4 Lungs: CTABL Abdomen: soft, NT/ND. +BS. Ext: WWP, +2 pulses. No pedal edema. Neuro: A+Ox3, attentive. CN ___ intact. Motor and sensory function grossly intact. Skin: scattered hypopigmented patches DISCHARGE PHYSICAL EXAM: General: NAD HEENT: no scleral icterus, OP clear, surgical pupils Neck: supple, no JVD CV: RRR, nl S1 S2, ? S4 Lungs: scattered faint exp wheezes Abdomen: soft, NT/ND. +BS. Ext: WWP, +2 pulses. No pedal edema. Neuro: A+Ox3, attentive. grossly intact Skin: scattered hypopigmented patches Pertinent Results: ADMISSION LABS: ___ 03:37PM BLOOD ___ ___ Plt ___ ___ 03:37PM BLOOD ___ ___ ___ 03:37PM BLOOD ___ ___ ___ 08:05PM BLOOD ___ PERTINENT LABS: ___ 07:14AM BLOOD ___ ___ 07:30AM BLOOD ___ Free ___ ___ 07:14AM BLOOD TRYPTASE - 3 ( ___ ng/mL) ___ 04:00PM BLOOD TRYPTASE - 7 ( ___ ng/mL) DISCHARGE LABS: ___ 07:30AM BLOOD ___ ___ Plt ___ ___ 07:30AM BLOOD ___ ___ ___ 07:30AM BLOOD ___ ___ GI BLEEDING STUDY IMPRESSION: No evidence of active GI bleeding during the time of study. ___ CHEST (PORTABLE AP) Upper right hemithorax hyperlucency consistent with severe panlobular emphysema. Stable retrocardiac atelectasis. . ___ EGD report Findings: Esophagus:Normal esophagus. Stomach:Normal stomach. Duodenum: Flat Lesions A single small angioectasia was seen in the second part of the duodenum. ___ Electrocautery was applied for hemostasis successfully. Impression:Angioectasia in the second part of the duodenum (thermal therapy). Otherwise normal EGD to third part of the duodenum . Recommendations: Angioectasia unlikely to be the source of bleeding. Proceed to flexible sigmoidoscopy. . ___ colonoscopy report Findings: -Contents: Clotted blood was seen in the sigmoid colon and descending colon. -Mucosa: Normal mucosa was noted in the sigmoid colon, descending colon and transverse colon. Protruding Lesions. Small external hemorrhoids were noted. Recommendations: No evidence of ischemic colitis. -Favor left sided diverticular bleed as underlying etiology given blood in the left colon. -CTA if rebleeds to localize site for ___ embolization. - If bleeding persists and unable to embolize, will need to consult colorectal surgery for consideration of left hemicolectomy. Nonurgent outpatient colonoscopy for removal of cecal polyps noted on ___ exam. Brief Hospital Course: Mrs. ___ is an ___ with h/o diverticulosis, COPD, CKD, HTN, depression, p/w 3 episode of BRBPR ___. # BPBPR Patient presented with acute onset BRBPR on the morning of admission. She reported that this was similar to prior episodes of diverticular bleed, with the exception of sensation of abdominal pressure immediately prior to BMs with current episode. + dark stools, but no hematemesis. Although her presentation was felt most likely c/w LGIB, given chronic steroids use, she was initially maintained on IV PPI. She had a large bloody stool on ___, following which she had a Tagged RBC scan, which was negative. She received 1 unit of PRBCs ___. She underwent EGD and flexible sigmoidoscopy on ___. EGD identified angioectasia which was ___ but this was felt not to be the source of bleeding. ___ showed diverticuli, blood in colon, no mucosal changes c/f ischemia, and overall c/w diverticular bleed. She unfortunately had an allergic reaction following endoscopy (see below). Patient otherwise remained HD stable throughout her course. HCT 26.5 prior to discharge with no further episodes of GIB. She will ___ with PCP for repeat CBC and further evaluation. . # Anaphylaxis: Developed acute allergic reaction s/p ___. She received benadryl, albuterol and solumedrol and transferred to MICU for closer monitoring. Pt had tongue swelling, tachycardia, generalized pruritis. This may have been a reaction to benzocaine, fentanyl, midazolam. The patient stated that she had a similar reaction after a GI procedure in the past. She was treated with steroids & H2 blockers in the MICU. She had no further symptoms. Allergy was consulted, who recommended sending a tryptase level, fexofenadine and Ranitidine for 1 week, as well as steroid taper. Patient should follow up for outpatient allergy testing at ___ to further investigate cause of reaction. . # Severe HTN Patient p/w asymptomatic severe HTN w/ SBP>200. EKG with SR 78, LVH, ___ ST changes, unchanged from baseline. Cardiac and Neuro exam WNL. Used short acting Labetolol in acute setting given GI bleed. Improved on home Clonidine BID, Amlodipine daily, and Losartan daily. Her BP and electrolytes should be further monitored outpatient. . # Sinus tachycardia Patient intermittently noted to have ST. On ___ up to 130s with activity with no associated palpitations, lightheadedness, chest pain, hypoxia. Likely related to hypovolemia and albuterol use. Monitored overnight with no recurrent GIB. TFTs WNL. Encouraged oral hydration. Normalized prior to discharge. . # Stage III CKD Creatinine baseline of ___. Remained within baseline range throughout course. . # Normocytic Anemia ___ anemia likely ___ CKD. ___ ~30. Transfused 1 unit PRBCs on ___ in the setting of large bloody BM, but relatively stable thereafter. ___ with PCP for continued monitoring. . # COPD Intermittent note of mild wheezing on exam. Continued home ___, prednisone, albuterol PRN, and monteleukast, spiriva. Mild SOB at baseline prior to discharge. . # Glaucoma Continued dorzolamide and latanoprost eye drops . # Depression Continued home citalopram . # Osteopenia Continued calcium/vit D. . # HLD Continued rosuvastatin 20mg daily. . # Impaired fasting glucose Diabetic diet. . # Arthritis Continued home acetaminophen PRN. . TRANSITIONAL ISSUES: #CODE STATUS: DNR/DNI #CONTACT: ___, grandaughter/HCP; ___ - ___ tryptase levels - ___ with allergy outpatient for further testing - ___ with PCP - ___ BPs - repeat HCT at ___ appointment . Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Acetaminophen 500 mg PO Q6H:PRN joint pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob, wheeze 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheeze 4. Amlodipine 10 mg PO DAILY 5. Calcium Carbonate 500 mg PO BID 6. Cetirizine 10 mg Oral DAILY:PRN allergic rhinitis 7. Citalopram 20 mg PO DAILY 8. CloniDINE 0.1 mg PO BID 9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 10. Fluticasone Propionate NASAL 2 SPRY NU DAILY 11. ___ Diskus (500/50) 1 INH IH BID 12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 13. Montelukast Sodium 10 mg PO DAILY 14. Multivitamins 1 TAB PO DAILY 15. PredniSONE 5 mg PO EVERY OTHER DAY 16. PredniSONE 2.5 mg PO EVERY OTHER DAY 17. Rosuvastatin Calcium 20 mg PO DAILY 18. Tiotropium Bromide 1 CAP IH DAILY 19. Docusate Sodium 100 mg PO BID 20. Senna 1 TAB PO BID:PRN constipation 21. Vitamin D 1000 UNIT PO DAILY 22. Omeprazole 20 mg PO DAILY 23. Losartan Potassium 25 mg PO DAILY Discharge Medications: 1. Acetaminophen 500 mg PO Q6H:PRN joint pain 2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN sob, wheeze 3. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheeze 4. Amlodipine 10 mg PO DAILY 5. Citalopram 20 mg PO DAILY 6. CloniDINE 0.1 mg PO BID 7. Docusate Sodium 100 mg PO BID 8. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES BID 9. Fluticasone Propionate NASAL 2 SPRY NU DAILY 10. ___ Diskus (500/50) 1 INH IH BID 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS 12. Montelukast Sodium 10 mg PO DAILY 13. Omeprazole 20 mg PO DAILY 14. Rosuvastatin Calcium 20 mg PO DAILY 15. Senna 1 TAB PO BID:PRN constipation 16. Tiotropium Bromide 1 CAP IH DAILY 17. Vitamin D 1000 UNIT PO DAILY 18. Fexofenadine 60 mg PO BID RX fexofenadine 60 mg 1 (One) tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 19. Ranitidine 150 mg PO BID RX ranitidine HCl 150 mg 1 (One) tablet(s) by mouth twice a day Disp #30 Tablet Refills:0 20. Calcium Carbonate 500 mg PO BID 21. Multivitamins 1 TAB PO DAILY 22. PredniSONE 5 mg PO EVERY OTHER DAY Start on ___ after completing steroid taper 23. PredniSONE 2.5 mg PO EVERY OTHER DAY Start on ___ after steroid taper 24. PredniSONE 40 mg PO DAILY Duration: 3 Days RX prednisone 10 mg as directed tablet(s) by mouth once a day Disp #20 Tablet Refills:*0 25. PredniSONE 20 mg PO DAILY Duration: 2 Days Start: After 40 mg tapered dose 26. PredniSONE 10 mg PO DAILY Duration: 2 Days Start: After 20 mg tapered dose 27. Losartan Potassium 25 mg PO DAILY Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Lower gastrointestinal bleeding Anaphylaxis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms ___, You were admitted with lower intestinal bleeding. You required one blood transfusion due to this, but the bleeding then stopped and you remained stable. You had an endoscoopy that showed that the bleeding was likely from diverticuli. Unfortunately, you had an allergic reaction to one of the medications that you received during the procedure. You will need to follow up with an allergist for further evaluation. Followup Instructions: ___
10137890-DS-10	10,137,890	28,533,013	DS	10	2143-08-29 00:00:00	2143-08-29 18:47:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: ___ Attending: ___ Chief Complaint: Syncope Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. ___ is a ___ with a history of MS, DM and ___ transferred from ___ after a syncopal episode this morning. He got up in the middle of the night to use the bathroom when his wife heard a crash. He does not recall the event so he is unsure if he was straining, but he says that occasionally as a complication of his MS he has difficulty emptying his bladder and has to strain. His wife found him crouched over the vanity, and he then fell to the floor and hit his back. She said he was diaphoretic and she does not think he was breathing. He woke after she called his name and struck him on the shoulder. He was confused after he regained consciousness. He did not bite his tongue, have any convulsions, or any urinary incontinence. His wife called EMS who found him to have a BG of 260 and HR 34. He refused ambulance transfer to the hospital. He then tried to eat breakfast and vomited so his wife called EMS again and he was taken to ___ where he had a head CT (no acute process), CXR (mild atelectasis) and basic labs. EKG showed sinus bradycardia. ___ transferred him to ___ for further evaluation. In the ED, initial VS were 98.3 55 94/64 20 95% RA. Exam in the ED was notable for "HR is brady but regular rhythm, no murmurs rubs or gallops. Lungs CTAB. Abd soft nontender. Full pulses though feet are cool to the touch." His chemistry panel and CBC were unremarkable. Trop was <0.01. No new imaging was done and he was not given any medications. Cardiology was consulted and felt this was most likely vasovagal, but given his family history felt it was reasonable to admit him overnight to monitor on telemetry. Transfer VS were 98.4PO 135 / 92 67 22 95 RA On arrival to the floor, patient reports that he is feeling well. He denies any lightheadedness, dizziness, CP, SOB, cough, N/V/D. Past Medical History: MS HTN DM A-fib/A-tach Social History: ___ Family History: Both of the patient's parents had similar presentations and both needed pacemakers - wife thinks due to sick sinus syndrome Physical Exam: ADMISSION EXAM ============== VS: 98.4PO 135 / 92 67 22 95 RA ___: NAD, appears stated age HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM HEART: bradycardic but regular, no murmurs, rubs, gallops LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: NABS, soft, NT, ND, no rebound or guarding EXTREMITIES: no cyanosis, clubbing, or edema NEURO: A&Ox3, CN II-XII grossly intact, strength ___ bilateral upper and lower extremities SKIN: warm and well perfused, no excoriations or lesions, no rashes DISCHARGE EXAM ============== VITALS: 92 / 57 71 18 95 Ra ___: NAD HEENT: AT/NC, EOMI HEART: RRR, S1 + S2 present, no mrg LUNGS: CTAB, no wheezes/crackles, breathing comfortably on RA ABDOMEN: SNTND, no rebound or guarding EXTREMITIES: No cyanosis, clubbing, or edema NEURO: A&Ox3, CN II-XII grossly intact, ___ BUE/BLE, SILT BUE/BLE SKIN: WWP, no lesions/rashes, no ___ edema GU: No Foley Pertinent Results: ADMISSION LABS ============== ___ 05:44PM BLOOD WBC-7.8 RBC-3.99* Hgb-12.7* Hct-38.2* MCV-96 MCH-31.8 MCHC-33.2 RDW-12.7 RDWSD-44.8 Plt ___ ___ 05:44PM BLOOD Neuts-69.4 Lymphs-18.2* Monos-9.8 Eos-1.7 Baso-0.6 Im ___ AbsNeut-5.39 AbsLymp-1.41 AbsMono-0.76 AbsEos-0.13 AbsBaso-0.05 ___ 05:44PM BLOOD Plt ___ ___ 05:44PM BLOOD Glucose-139* UreaN-22* Creat-0.9 Na-142 K-4.6 Cl-104 HCO3-22 AnGap-16 ___ 05:44PM BLOOD cTropnT-<0.01 ___ 05:50PM BLOOD Lactate-1.0 MICRO ===== ___ URINE URINE CULTURE-FINAL NEG ___ BLOOD CULTURE Blood Culture, Routine-PENDING ___ BLOOD CULTURE Blood Culture, Routine-PENDING IMAGING ======= ___ MRI L-SPINE IMPRESSION: 1. Disc bulge and ligamentum flavum hypertrophy causing severe canal narrowing at L4-L5. 2. Degenerative changes causing mild bilateral neural foraminal narrowing at the L3-L4 and L4-L5 levels, which is severe at the right L4-L5 level. DISCHARGE LABS ============== ___ 05:15AM BLOOD WBC-8.0 RBC-3.91* Hgb-12.3* Hct-37.6* MCV-96 MCH-31.5 MCHC-32.7 RDW-13.0 RDWSD-45.5 Plt ___ ___ 05:15AM BLOOD Plt ___ ___ 05:15AM BLOOD Glucose-149* UreaN-28* Creat-0.9 Na-142 K-4.5 Cl-103 HCO3-20* AnGap-19* Brief Hospital Course: HOSPITAL COURSE =============== ___ of MS, DM and ___ transferred from ___ s/p syncopal episode, with history ___ vasovagal episode or arrhythmia. No arrhythmia found on telemetry, discharged on ___ of Hearts with cardiology f/u. ACTIVE PROBLEMS =============== # Syncope: Diaphoresis, n/v, dizziness and syncopal event iso going to the bathroom ___ vasovagal syncope. However, HR in 30___s 15 minutes after event would be atypical and more consistent with bradyarrhythmia. History of SSS requiring ___ in both parents, bradycardia and RBBB on EKG. No events on telemetry. No structural cardiac cause of syncope identified on TTE. Orthostatics negative. Discharged on ___ with cardiology f/u. # Bradycardia: Pt with HR of 34 associated with syncopal episode discussed above. At baseline HR in ___ ___, HR ___ during admission. Possibly bradycardia ___ atenolol vs. due to conduction delay given EKG notable for RBBB. Of note, pt does have family history of SSS requiring ___ in both parents. Stopped atenolol on discharge to be restarted per cardiology guidance. # Urinary retention. Likely ___ MS. ___ spinal stenosis given full strength in lower extremities, lack of back pain/radiculopathy, though pt does have mildly poor rectal tone. Foley placed and Flomax started on ___. Passed voiding trial on ___. MRI found canal narrowing from ligamentum flavium hypertrophy, neurosurgery saw patient and recommended outpatient follow-up. CHRONIC ISSUES ============== # Multiple Sclerosis: Followed by ___ neurology. Currently he walks with a cane and his symptoms are mostly occasional numbness, cramping, and fatigue. Continued home baclofen 20 mg QID and Modafinil 200 mg PO BID. Patient requested transfer to ___ Neurology on discharge. # HLD: Continued home ASA 81 mg and simvastatin 40 mg. # HTN: Held home atenolol. Normotensive # GERD: Continued home omeprazole. # Seasonal allergies: Continued home fluticasone. TRANSITIONAL ISSUES =================== [] New medications: Tamsulosin 0.4 mg PO QHS [] Stopped medication: Atenolol [] Follow-up appointment: PCP, ___ [] Brief episodes of a-fib in patient documentation prior to year ___, should discuss with cardiology whether anticoagulation indicated [] Cannot drive for 6 months due to syncopal episode For billing purposes only: >30 minutes spent on patient care and coordination on day of discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Aspirin 81 mg PO DAILY 2. Atenolol 12.5 mg PO DAILY 3. Finasteride 5 mg PO DAILY 4. MetFORMIN (Glucophage) 500 mg PO BID 5. Fluticasone Propionate NASAL 2 SPRY NU DAILY 6. Simvastatin 40 mg PO QPM 7. Omeprazole 20 mg PO DAILY 8. Modafinil 200 mg PO BID 9. Baclofen 20 mg PO QID 10. Calcium Carbonate 1250 mg PO DAILY Discharge Medications: 1. Tamsulosin 0.4 mg PO QHS RX tamsulosin 0.4 mg 1 capsule(s) by mouth Daily Disp #30 Capsule Refills:*0 2. Aspirin 81 mg PO DAILY 3. Baclofen 20 mg PO QID 4. Calcium Carbonate 1250 mg PO DAILY 5. Finasteride 5 mg PO DAILY 6. Fluticasone Propionate NASAL 2 SPRY NU DAILY 7. MetFORMIN (Glucophage) 500 mg PO BID 8. Modafinil 200 mg PO BID 9. Omeprazole 20 mg PO DAILY 10. Simvastatin 40 mg PO QPM 11. HELD- Atenolol 12.5 mg PO DAILY This medication was held. Do not restart Atenolol until you see a cardiologist. Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Primary Diagnosis ================= Syncope Urinary retention Secondary Diagnoses =================== Atrial tachycardia Multiple sclerosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___, You were admitted to the hospital after a syncopal (fainting) episodes. This may have been "vasovagal," which is common and caused unusual nerve activity. Or it could be caused by a cardiac arrhythmia. We monitored your heart rate her and didn't find see any problems, but we are discharging you with a portable heart monitor. You will wear this until you are seen by cardiology. You had some difficult urinating in the hospital. You briefly had a catheter in, but we were able to remove this before discharge. We started a new medication to assist with urinary flow. Due to your difficulty urinating, we checked an MRI of your lower spinal cord. There was some narrowing around the spinal cord, and we consulted the neurosurgeons, who recommended outpatient f/u. We were unable to schedule a neurology appointment by the time of discharge. Ff you would like to establish care with our neurology department you can contact them at ___. You will need to provide clinical notes in order to transfer your care. It was a privilege to care for you in the hospital, and we wish you all the best. Sincerely, Your ___ Team Followup Instructions: ___
10137916-DS-5	10,137,916	28,412,159	DS	5	2119-11-10 00:00:00	2119-11-10 19:51:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: shellfish derived / iodine Attending: ___. Chief Complaint: palpitations, suicidal ideation, suicide attempt Major Surgical or Invasive Procedure: none History of Present Illness: Ms. ___ is a ___ female with history of asthma, depression versus bipolar, prior suicide attempt who initially presented to the ED with N/V and poor po intake. Presentation was felt to represent viral gastroenteritis and she was treated supportively with IV hydration. While in the ED she endorsed suicidal ideation with recent suicide attempt. She was initially in ED obs after being evaluated by psychiatry who felt she met ___ criteria. While awaiting bed search for osych placement she developed worsening sinus tachycardia while in ED obs. This was initially somewhat fluid responsive but later noted to be persistent up to 140's, sinus tach throughout and decision made to admit to medicine for continued medical workup and clearance prior to inpatient psych placement. She later did report that she had intentionally ingested 30 pills of amphetamines in a suicide attempt. In the ED: VS: 97.3 114 141/75 18 100% RA; HR 85-140 sinus ECG: sinus tachycardia PE: VS notable for tachycardia, no fevers, Abd soft, nontender, nondistended Labs: d-dimer 862, Cr 0.6, WBC 11.7, utox/stox negative Imaging: CXR negative, LENIs negative for DVT bilaterally Impression: initial concern for gastroenteritis and dehydration, later endorsing recent suicide attempt and intentional amphetamine overdose, Interventions: Tylenol, Zofran, 4L of LR, Ativan 0.5 then 1mg x2, home meds Consults: psychiatry - meets ___ criteria, can give Ativan prn anxiety, 1:1 at all times, medical admission for clearance first given tachycardia Course: initially presenting with poor PO intake. Also endorsed overdosing on medications in SI attempt. Initially in ED observation for psychiatric evaluation the patient continued to be persistently tachycardic of unclear etiology., Despite IV fluid hydration and benzos. A d-dimer was obtained and was found to be elevated. We want to obtain a CTA to rule out PE but patient has an anaphylactic allergy to contrast dye. Therefore she will be admitted to medicine for VQ scan. Will obtain bilateral lower extremity ultrasounds. On arrival to the floor states suicide attempt was a week ago, last prior to this was ___ years ago. this time feels she has way too much on her plate, her therapist left and she is without one now. states she's had long-standing palpitations, told she had lupus and an extra valve in her heart, she does note that over the last month her palpitations have increased, she is labored with exertion more easily like when going up the stairs, doesn't feel lightheaded and denies chest pain. notes a strong family history of blood clots on both maternal and paternal sides of the family including an aunt and uncle, a grandfather and a grandmother. she takes ___, progestin only pill, has been on it for a year now. does also have a history of migraines. denies anxiety. doesn't smoke. notes a history of anaphylaxis to iodinated contrast, noted at ___ when she was a child. hasn't had a ct scan since. Past Medical History: Asthma Lupus Migraine headaches, ?h/o pseudotumor cerebri (pt reports h/o excess brain fluid found on imaging) Obesity Social History: ___ Family History: Reviewed and not relevant to chief complaint Physical Exam: ADMISSION EXAM: ================= VS: Temp: 98.0 PO BP: 134/94 HR: 137 RR: 24 O2 sat: 100% O2 delivery: RA Gen - obese, somewhat labored and very tachycardic with minimal movement Eyes - anicteric, PERRL ENT - MMM, OP clear Heart - regular, tachycardic 110 at rest shoots up to 140-170 with minimal movement Lungs - breathing mildly labored when speaking or moving Abd - soft, ntnd, no rebound or guarding Ext - no pedal edema Skin - no obvious skin rashes, normal skin turgor Vasc - WWP Neuro - A&Ox3, moving all extremities, strength equal Psych - calm, cooperative, linear thinking, able to contract for safety while here with sitter in room DISCHARGE EXAM: =================== VS: ___ 0737 Temp: 98.7 PO BP: 94/62 HR: 102 RR: 18 O2 sat: 96% O2 delivery: RA Gen - obese, no apparent distress, lying in bed comfortably Eyes - anicteric, PERRL ENT - MMM, OP clear Heart - regular, tachycardic, no murmurs, rubs or gallops Lungs - clear to auscultation bilaterally Skin - no obvious skin rashes, normal skin turgor Neuro - A&Ox3, moving all extremities, normal strength, normal gait, Psych - calm, cooperative, appropriately frustrated given clinical context Pertinent Results: ADMISSION LABS: ==================== ___ 09:44AM BLOOD WBC-11.7* RBC-4.11 Hgb-12.3 Hct-38.9 MCV-95 MCH-29.9 MCHC-31.6* RDW-14.2 RDWSD-49.4* Plt ___ ___ 09:44AM BLOOD Neuts-71.2* ___ Monos-4.7* Eos-0.1* Baso-0.3 Im ___ AbsNeut-8.29* AbsLymp-2.69 AbsMono-0.55 AbsEos-0.01* AbsBaso-0.04 ___ 09:44AM BLOOD Glucose-94 UreaN-9 Creat-0.8 Na-136 K-4.6 Cl-103 HCO3-15* AnGap-18 ___ 09:44AM BLOOD ALT-20 AST-33 AlkPhos-157* TotBili-0.2 ___ 09:44AM BLOOD ASA-NEG Acetmnp-NEG Tricycl-NEG ___ 04:06PM BLOOD ___ pO2-37* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 DISCHARGE LABS: ==================== ___ 06:47AM BLOOD WBC-7.6 RBC-3.85* Hgb-11.5 Hct-35.4 MCV-92 MCH-29.9 MCHC-32.5 RDW-14.0 RDWSD-47.7* Plt ___ ___ 06:47AM BLOOD Glucose-81 UreaN-12 Creat-0.9 Na-141 K-4.6 Cl-107 HCO3-21* AnGap-13 OTHER IMPORTANT INTERIM LABS: ==================== ___ 05:30AM BLOOD ___ PTT-33.2 ___ ___ 04:18PM BLOOD D-Dimer-862* ___ 05:30AM BLOOD Albumin-4.1 Calcium-9.3 Phos-3.7 Mg-1.8 ___ 04:06AM BLOOD TSH-4.1 ___ 05:30AM BLOOD T3-174 Free T4-1.8* ___ 07:25AM BLOOD Lactate-1.1 IMAGING/STUDIES: ==================== BILAT LOWER EXT VEINS ___ No evidence of deep venous thrombosis in the right or left lower extremity veins. CHEST XRAY PA/LAT ___ FINDINGS: Lungs are clear. There is no consolidation, effusion, or edema. Cardiomediastinal silhouette is within normal limits. No acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. No edema. LUNG V/Q SCAN ___ FINDINGS: Ventilation images demonstrate no focal defects. Perfusion images demonstrate no focal defects. Chest x-ray shows no acute cardiopulmonary process. IMPRESSION: Normal scan. No evidence of pulmonary embolism. TRANSTHORACIC ECHO ___ CONCLUSION: The left atrial volume index is normal. There is no evidence for an atrial septal defect by 2D/color Doppler. The estimated right atrial pressure is ___ mmHg. There is normal left ventricular wall thickness with a normal cavity size. There is normal regional and global left ventricular systolic function. The visually estimated left ventricular ejection fraction is >=55%. There is no resting left ventricular outflow tract gradient. No ventricular septal defect is seen. 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. There is a normal descending aorta diameter. There is no evidence for an aortic arch coarctation. The aortic valve leaflets (3) appear structurally normal. There is no aortic valve stenosis. There is no aortic regurgitation. The mitral valve leaflets appear structurally normal with no mitral valve prolapse. The transmitral E-wave deceleration time is short (<140ms). There is trivial mitral regurgitation. The pulmonic valve leaflets are normal. The tricuspid valve leaflets appear structurally normal. There is mild [1+] tricuspid regurgitation. The pulmonary artery systolic pressure could not be estimated. There is a trivial pericardial effusion. IMPRESSION: Normal left ventricular wall thickness and biventricular cavity sizes and regional/global systolic function. Brief Hospital Course: Ms. ___ is a ___ female with history of asthma, unipolar depression versus bipolar disorder, and a prior suicide attempt, who was admitted for further workup of sinus tachycardia and management of suicidal ideation with recent suicidal attempt with intentional overdose of amphetamines. ACUTE/ACTIVE PROBLEMS: #Sinus Tachycardia: Initially tachycardic in the 110s at rest, up to 140s with minimal movement. Patient states she has long-standing history of this but it has been significantly worse over the past month. Negative lower extremity bilateral venous doppler studies and negative V/Q scan for DVT/PE (allergic to iodine contrast therefore could not perform CTPA). Normal global heart function on TTE. Some of her worsening tachycardia as of late is likely due to ingestion of 30 pills of phentermine earlier this week, plus being on both ___ and ___ inhalers, plus possibly a primary sinus node issue or ?POTS (did have increase in HR to 137 on orthostatic VS without change in BP). Reassuringly has been in sinus throughout and hemodynamically stable. She is s/p 4L of LR in the ED and given continued even worsening tachycardia with no further evidence of hypovolemia on exam will hold further IVF. TSH wnl, free T4 very mildly elevated but normal T3 indicate overall normal thyroid function. Her heart rates improved significantly by the time of discharge, to around 100s (110s with activity). If this persists after discharge from psych facility, would recommend outpatient referral to cardiology to evaluate for primary sinus node dysfunction. #Suicidal Ideation / Suicide Attempt: #Intentional Overdose: Met ___ criteria on admission. Remained on 1:1 sitter and suicide precautions. Ultimately discharged to an inpatient psychiatric facility. Of note, Topamax has a black box warning for suicidal ideation, after discussion with patient this was discontinued, and she will discuss with her primary care doctor possible alternatives for migraine headaches. #Ketoacidosis: Unclear etiology, no ETOH ingestion, no DM, possibly starvation ketosis (positive urine ketones) but she reports eating well. Bicarb has been persistently mildly low, is well compensated on VBG. Lactate wnl. Would recommend CHRONIC/STABLE PROBLEMS: #Asthma - Continued home Advair, held albuterol inhaler to help mitigate tachycardia. #Migraines - Discontinued Topamax as above. TRANSITIONAL ISSUES: [ ] discuss with PCP alternatives for migraine prophylaxis, also discuss potential alternatives for weight loss if unable to go back on phentermine [ ] consider outpatient referral to cardiology if still tachycardic in a few weeks [ ] recheck chemistry in one week after hospital discharge, may fax results to patient's PCP ___ ___ attn: Dr. ___ ___. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Topiramate (Topamax) 25 mg PO DAILY 2. phentermine 37.5 mg oral DAILY 3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB Discharge Medications: 1. LORazepam 0.5 mg PO QHS:PRN anxiety/sleep 2. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB 3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID 4. HELD- phentermine 37.5 mg oral DAILY This medication was held. Do not restart phentermine until told safe to by your doctor Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Phentermine overdose Sinus tachycardia Depression and suicidal ideation 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 overdose of phentermine, which caused you to have a very fast heart rate. You had several tests to determine if your heart had ill-effect from the fast rate, which were all negative. You were determined to be medically stabilized, and are being sent to an inpatient psychiatric facility for treatment of depression. It was a pleasure taking care of you, Sincerely, your ___ Team Followup Instructions: ___
10138440-DS-19	10,138,440	29,282,662	DS	19	2161-10-04 00:00:00	2161-10-04 21:03:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: metformin Attending: ___. Chief Complaint: Lower extremity weakness Fall Major Surgical or Invasive Procedure: None History of Present Illness: Mr. ___ is a ___ with diabetic peripheral neuropathy who presents with back pain after a fall, transferred from ___ or T12 burst fracture. He reports progressive generalized weakness, primarily in his lower extremities bilaterally (unclear if primarily proximal or distal), in the ___ days preceding admission, coinciding with occasional dry heaving and slightly decreased PO intake, but no fevers, chills, sweats, URI symptoms, abdominal pain, loose stools, frank dysuria, myalgias, or new rashes. In the setting of prior prostate cancer, he typically urinates frequently, but has been experiencing occasional hesitancy/retention without bowel dysfunction or saddle anesthesia. He states that at baseline he is not weak and ambulates without assistance. He denies prior weakness, but on review of the OMR, he has undergone prior work-up for myasthenia ___ in the setting of horizontal diplopia, with negative serologic testing, but some evidence of "postsynaptic disorder of neuromuscular transmission" on EMG in ___. In addition, lumbar spine MRI was obtained by his primary care provider ___ ___ for lower extremity weakness, with evidence of degenerative changes at multiple levels. In the setting of progressive weakness, he contacted his primary care physician, ___ suggested that he seek medical attention in the ED. After a fall with prodromal lightheadedness, but no headstrike or loss of consciousness, he initially presented to ___, where thoracolumbar CT revealed T12 burst fracture, hence transferred to ___ for neurosurgical evaluation. In the ___ ED, he was afebrile and hemodynamically stable, with nonacute cervical spine and head CTs. Thoracolumbar MRI demonstrated a T12 burst fracture with approximately 3mm of retropulsion of a fracture fragment, with minimal narrowing and no cord signal abnormality. He was seen by the orthopedic service, with conservative management with TLSO for mobilization advised prior to admission for physical therapy evaluation. Past Medical History: Type 2 diabetes mellitus complicated by peripheral neuropathy Hypertension Chronic kidney injury Prostate cancer Skin cancer involving right ear status post operative removal in ___ Social History: ___ Family History: Father died of myocardial infarction at ___ years old. Physical Exam: On admission: Vitals - T:97.9 BP:169/95 HR:69 RR:20 02 sat:98% RA GENERAL: NAD, alert and oriented x 3, HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BACK: Point tenderness near T12 EXTREMITIES: 2+ pitting edema to knees bilaterally, ___ strength in all extremities both proximally and distally PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes At discharge: Vitals - 98.5, 148/87 (140s-160s), 63, 18, 98% RA GENERAL: NAD, alert and oriented x 3, HEENT: AT/NC, EOMI, PERRL, anicteric sclerae, pink conjunctivae, MMM, good dentition NECK: nontender supple neck, no LAD, no JVD CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably without use of accessory muscles ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly BACK: Point tenderness near T12 EXTREMITIES: ___ strength in all extremities both proximally and distally, light touch sensation grossly intact throughout, gait deferred, trace symmetric pitting edema bilaterally PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact SKIN: warm and well perfused, no excoriations or lesions, no rashes Pertinent Results: On admission: ___ 04:30AM BLOOD WBC-9.7 RBC-4.63 Hgb-14.0 Hct-39.0* MCV-84 MCH-30.2 MCHC-35.9# RDW-13.7 Plt ___ ___ 04:30AM BLOOD Glucose-157 UreaN-33* Creat-2.0* Na-142 K-5.2* Cl-102 HCO3-29 AnGap-16 ___ 04:30AM BLOOD Calcium-9.2 Phos-4.3 Mg-2.1 At discharge: ___ 06:50AM BLOOD WBC-6.9 RBC-4.53* Hgb-13.1* Hct-38.3* MCV-84 MCH-29.0 MCHC-34.3 RDW-14.4 Plt ___ ___ 06:50AM BLOOD Glucose-65* UreaN-33* Creat-2.0* Na-138 K-4.6 Cl-102 HCO3-28 AnGap-13 ___ 06:50AM BLOOD Calcium-9.7 Phos-5.1* Mg-2.1 ___ 12:48PM URINE Color-Yellow Appear-Clear Sp ___ ___ 12:48PM URINE Blood-TR Nitrite-NEG Protein-300 Glucose-70 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 12:48PM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 In the interim: ___ 06:45AM BLOOD Calcium-9.4 Phos-4.6* Mg-2.0 Cholest-216* ___ 06:45AM BLOOD Triglyc-262* HDL-41 CHOL/HD-5.3 LDLcalc-123 LDLmeas-126 ___ 12:01PM BLOOD calTIBC-251* VitB12-383 Folate-19.9 ___ Ferritn-533* TRF-193* ___ 11:02AM URINE Color-Yellow Appear-Clear Sp ___ ___ 11:02AM URINE Blood-SM Nitrite-POS Protein-600 Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG ___ 11:02AM URINE RBC-21* WBC-1 Bacteri-FEW Yeast-NONE Epi-0 Microbiology: Urine culture (___): STAPHYLOCOCCUS, COAGULASE NEGATIVE \| GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S NITROFURANTOIN-------- <=16 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 1 S Urine culture (___): Pending. Imaging: ___ MR ___ Spine without contrast: Burst fracture through the superior endplate of the T12 vertebral body with approximately 3 mm of retropulsion of the superior fracture fragment towards the canal. This fragment abuts the canal and causes minimal spinal canal narrowing without resultant cord signal abnormality. No additional spinal fractures are noted. There is no traumatic malalignment. ___ CT C-spine without contrast: 1. No cervical spine fracture or malalignment. 2. Focally moderate cervical degenerative changes at the level of C5-C6 with a combination of small eccentric osteophytes and a large posterior disc bulge causing at least moderate canal stenosis. If neurological symptoms are present, further evaluation with MR can be considered, if amenable. ___ CT Head without contrast: 1. No acute intracranial abnormality. 2. Stable calcified tiny left parietal meningioma. 3. Chronic left subinsular white matter lacune. ___ Renal ultrasound: 1. No hydronephrosis. 2. 2.8 cm right upper pole renal cyst. ___ TTE: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of ___ Brief Hospital Course: Mr. ___ is a ___ with diabetic peripheral neuropathy who initially presented to ___ with generalized weakness and back-pain post-fall, transferred for further management of T12 burst fracture. Active Issues: # T12 burst fracture: He was evaluated by the orthopedic spine service, with conservative management with ___ brace for mobilization advised. Pain was controlled with standing acetaminophen and tramadol as needed. Calcium and vitamin D therapies were initiated. At the suggestion of physical therapy, he was discharged to rehabilitation. He may benefit from outpatient osteoporosis evaluation. # Syncope/Pre-syncope: In the setting of prodromal lightheadedness, vasovagal event and orthostatic hypotension were felt to be possible precursors to his fall. Telemetry was without arrhythmias, and EKG was without acute ischemic changes. TTE demonstrated preserved LVEF without significant structural changes/valvulopathy. Peripheral neuropathy as below may contribute to his falls. # Lower extremity weakness: On review of the ___ Records, subjective lower extremity weakness with change in ambulatory functionality (now using walker) has been ongoing for some time, at least months, with reported progression over the past week, but preserved strength on exam. Lower extremity weakness was felt to reflect, at least in part, peripheral neuropathy from diabetes mellitus, with thoracolumbar MRI reassuring against cord/cauda compromise. He may benefit from outpatient neurologic evaluation after a stint at rehab. # Acute-on-chronic normocytic anemia: Hematocrit remained stable at 37-38 throughout admission, down from 47 in ___, with basic anemia work-up most consistent with anemia of chronic inflammation, likely due to chronic kidney injury; B12 and folate levels were unremarkable, and hemolysis studies were reassuring. There was low suspicion for acute blood loss in the absence of clear signs or symptoms. # Chronic kidney injury / CKD 3: Creatinine was found to be 2.0 on admission, up from baseline of 1.8 in ___, initially concerning for acute-on-chronic kidney injury, but perhaps reflecting new baseline renal function. In light of occasional urinary retention/hesitancy, renal ultrasound was obtained and reassuring against hydronephrosis. # Insulin-dependent diabetes diabetes mellitus: Home glargine was reduced from 42 units bid to 32 units bid due to occasional morning hypoglycemia to ___, seemingly due to poor oral intake in the hospital. Home Humalog with dinner was continued along with a gentle Humalog insulin sliding scale. Further titration may be needed in the outpatient setting as his diet is liberalized. # Coagulase negative Staph bacteriuria: In the setting of generalized weakness, urinalysis was checked and positive for nitrites, prompting initiation of empiric ceftriaxone, with subsequent transition to ciprofloxacin pending urine culture speciation and sensitivities. Urine culture ultimately grew out Coagulase negative Staph, felt to be a contaminant, with antibiotic therapy discontinued in the absence of clear urinary symptoms. Repeat urinalysis was negative for signs of infection prior to discharge, with urine culture pending. Inactive Issues: # Hypertension: Home lisinopril was held initially due to concern for acute-on-chronic kidney injury and resumed prior to discharge. # Chronic lower extremity edema: Home furosemide was held due to symptomatic orthostatic hypotension. TTE was without depressed LVEF or clear diastolic dysfunction, and he remained clinically euvolemic-appearing off furosemide throughout admission. # GERD: Home ranitidine was continued. Transitional Issues: - Follow up in orthopedic spine clinic in 4 weeks with standing lumbar films to determine ongoing need for ___ brace with mobilization. - He may benefit from outpatient osteoporosis evaluation. - Ensure resolution of microscopic hematuria in the outpatient setting, possibly due to straight catheterization at the outside hospital prior to admission; repeat urinalysis prior to discharge demonstrated 2 RBCs only. - Furosemide was held due to symptomatic orthostatic hypotension and may be resumed at primary care provider discretion in the event of significant peripheral edema. - He may benefit from outpatient surveillance of hematocrit, found to be 38-39 on this admission, down from 47 in ___, with basic anemia work-up on this admission most consistent with anemia of chronic inflammation, likely due to chronic kidney injury. - He may benefit from outpatient surveillance of chronic kidney injury, with creatinine of ___ on this admission, up from 1.8 in ___. - He may benefit from outpatient surveillance of fingerstick blood glucose, with episodes of morning hypoglycemia to ___ likely reflecting poor oral intake in the hospital, prompting gentle reduction in standing glargine doses. - He may benefit from outpatient neurology evaluation for lower extremity weakness. - He may benefit from lipid-lowering therapy at the discretion of his primary care provider as tolerated in light of fasting LDL of 123 on this admission. - Urine culture grew out coagulase negative Staph of unclear significance, prompting discontinuation of empiric antibiotic therapy for seemingly asymptomatic bacteriuria without SIRS/sepsis physiology; repeat urinalysis at discharge was negative for nitrites, leukocyte esterase, and bacteria, with repeat urine culture pending at discharge. - Code status: Full. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Ranitidine 300 mg PO DAILY 2. Glargine 42 Units Breakfast Glargine 42 Units Bedtime Humalog 20 Units Dinner 3. Lisinopril 20 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Aspirin 81 mg PO DAILY Discharge Medications: 1. Aspirin 81 mg PO DAILY 2. Lisinopril 20 mg PO DAILY 3. Ranitidine 300 mg PO DAILY 4. Acetaminophen 1000 mg PO Q8H 5. Calcium Carbonate 500 mg PO QID 6. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain RX tramadol 50 mg 0.5 (One half) tablet(s) by mouth every six (6) hours Disp #15 Tablet Refills:*0 7. Vitamin D 800 UNIT PO DAILY 8. Glargine 32 Units Breakfast Glargine 32 Units Bedtime Humalog 20 Units Dinner Insulin SC Sliding Scale using HUM Insulin Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: Primary: Status post fall T12 burst fracture Acute-on-chronic lower extremity weakness, likely due to diabetic peripheral neuropathy Orthostatic hypotension Secondary: Hypertension Diabetes mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, It was a pleasure taking part in your care during your admission to ___. As you know, you were admitted after a fall with a fracture in your thoracic spine (T12). You were seen by the orthopedic doctors, who recommended that you wear a brace while moving for at least the next 4 weeks pending follow-up in orthopedics clinic. Your weakness may relate to damage to the small nerves in your legs from diabetes; imaging of your back did not show compression of the large nerves as a cause of weakness. Please see the attached sheet for changes in your medications. Followup Instructions: ___
10138440-DS-20	10,138,440	24,744,029	DS	20	2162-11-23 00:00:00	2162-11-23 17:39:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: PODIATRY Allergies: metformin Attending: ___ Chief Complaint: R foot ulcer Major Surgical or Invasive Procedure: R foot debridment ___ RLE angio via left groin access ___ History of Present Illness: ___ y/o M with PMHx of IDDM, dCHF, HTN, HLD, Afib (on Apixaban) h/o gait disorder, prostate ca, h/o BCC, sp CCY, who presents with R foot abscess and cellulitis. Pt is followed by Dr. ___ at ___ in ___. He was seen on ___ and found to have a worsening ulceration on the R midfoot. The decision was made to have the patient admitted to ___ and to go for a formal debridement. The pt denies any N/V/F/C/SOB/CP Past Medical History: Type 2 diabetes mellitus complicated by peripheral neuropathy Hypertension Chronic kidney injury Prostate cancer Skin cancer involving right ear status post operative removal in ___ Social History: ___ Family History: Father died of myocardial infarction at ___ years old. Physical Exam: Admission Physical: Gen: Pleasant, AAOx3, NAD HEENT: moist mucous membranes Neck: Supple, Lungs: Clear to auscultation bilaterally without any audible wheezes, no crackles, no rhonchi Heart: RRR, no MRG, Abd: Obese, NT/ND, No rebound no guarding. Lower Ext: ___ pulses non-palpable but dopplerable. Gross sensation diminished. Ulceration with serosangunius and purulent drainage on plantar surface of the right foot with malodor and +PTB. There is significant ___ edema b/l. Discharge Physical: vitals:vss Gen: Pleasant, AAOx3, NAD HEENT: moist mucous membranes Neck: Supple, Lungs: Clear to auscultation bilaterally without any audible wheezes, no crackles, no rhonchi Heart: RRR, no MRG, Abd: Obese, NT/ND, No rebound no guarding. Lower Ext: ___ pulses non-palpable but dopplerable. Gross sensation diminished. Sutures intact to RLE with DSD in place and a bi-valve cast Pertinent Results: ___ 09:45PM BLOOD WBC-9.4 RBC-3.89* Hgb-10.9* Hct-33.2* MCV-85 MCH-28.0 MCHC-32.8 RDW-13.7 RDWSD-42.6 Plt ___ ___ 05:41AM BLOOD WBC-8.3 RBC-3.59* Hgb-9.9* Hct-30.1* MCV-84 MCH-27.6 MCHC-32.9 RDW-13.5 RDWSD-41.3 Plt ___ ___ 08:20AM BLOOD WBC-10.0 RBC-3.28* Hgb-9.2* Hct-27.9* MCV-85 MCH-28.0 MCHC-33.0 RDW-13.6 RDWSD-42.0 Plt ___ ___ 09:45PM BLOOD Glucose-96 UreaN-48* Creat-2.1* Na-141 K-4.7 Cl-106 HCO3-23 AnGap-17 ___ 05:41AM BLOOD Glucose-110* UreaN-44* Creat-1.8* Na-141 K-4.6 Cl-108 HCO3-23 AnGap-15 ___ 08:20AM BLOOD Glucose-135* UreaN-52* Creat-2.4* Na-139 K-4.7 Cl-107 HCO3-20* AnGap-17 TISSUE (Final ___: STAPHYLOCOCCUS, COAGULASE NEGATIVE. RARE GROWTH. Sensitivity testing per ___ ___. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems,carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Brief Hospital Course: The patient was admitted to the podiatric surgery service from the ___ Wound ___ on ___ for a R foot infection. On admission, he was continued on broad spectrum antibiotics. He was taking to the OR for Right foot debridement on ___. Pt was evaluated by anesthesia and taken to the operating room. There were no adverse events in the operating room; please see the operative note for details. Afterwards, pt was taken to the PACU in stable condition, then transferred to the ward for observation. Post-operatively, the patient remained afebrile with stable vital signs; pain was well controlled oral pain medication on a PRN basis. The patient remained stable from both a cardiovascular and pulmonary standpoint. We consulted the Infectious disease team to come evaluate you they recommend you were placed on Cefepime and flagyl while hospitalized and discharged with on ertapenem and daptomycin for antibiotics. We consulted the vascular surgery team to evaluate you and they recommended a RLE angio which was done on ___. His intake and output were closely monitored and noted to be adequtae. The patient received Apixiban throughout admission. The patient was subsequently discharged to home on POD 6 with NWB to the RLE in a bi-valve cast with use of the walker. The patient will be receiving infusions at ___ on ___ and ___ and will resume infusions on ___ at ___. The patient also know that if he cannot get his infusion on ___ at ___ then he has an order to come to ___ for a dose on ___. 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. BD Insulin Pen Needle UF Short (pen needle, diabetic) 31 gauge x ___ miscellaneous BID 2. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous QPM 3. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL) subcutaneous BID 4. Amlodipine 10 mg PO DAILY 5. Aspirin 81 mg PO DAILY 6. Atorvastatin 40 mg PO QPM 7. Carvedilol 12.5 mg PO BID 8. Furosemide 40 mg PO DAILY 9. Lisinopril 20 mg PO DAILY 10. Ranitidine 150 mg PO QPM 11. Apixaban 5 mg PO BID Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. Apixaban 5 mg PO BID 3. Aspirin 81 mg PO DAILY 4. Atorvastatin 40 mg PO QPM 5. Carvedilol 12.5 mg PO BID 6. Furosemide 40 mg PO DAILY 7. Lisinopril 20 mg PO DAILY 8. Ranitidine 150 mg PO QPM 9. BD Insulin Pen Needle UF Short (pen needle, diabetic) 31 gauge x ___ miscellaneous BID 10. HumaLOG KwikPen (insulin lispro) 100 unit/mL subcutaneous QPM 11. Lantus Solostar (insulin glargine) 100 unit/mL (3 mL) subcutaneous BID 12. Docusate Sodium 100 mg PO BID:PRN Constipation 13. Daptomycin 600 mg IV Q24H RX daptomycin [Cubicin] 500 mg 600 mg IV q24 hours Disp #50 Vial Refills:0 14. Ertapenem Sodium 1 g IV 1X Duration: 1 Dose RX ertapenem [Invanz] 1 gram 1 g IV q24 hours Disp #42 Vial Refills:0 Discharge Disposition: Home Discharge Diagnosis: Right foot 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: Mr. ___, It was a pleasure taking care of you at ___. You were admitted to the Podiatric Surgery service after your right foot surgery. You were given IV antibiotics while here. You are being discharged home with the following instructions: ACTIVITY: There are restrictions on activity. Please remain non weight bearing to your R foot until your follow up appointment. You should keep this site elevated when ever possible (above the level of the heart!) No driving until cleared by your Surgeon. PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: Redness in or drainage from your leg wound(s). New pain, numbness or discoloration of your foot or toes. Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. Exercise: Limit strenuous activity for 6 weeks. No heavy lifting greater than 20 pounds for the next ___ days. Try to keep leg elevated when able. BATHING/SHOWERING: You may shower immediately upon coming home, but you must keep your dressing CLEAN, DRY and INTACT. You can use a shower bag taped around your ankle/leg or hang your foot/leg outside of the bathtub. Avoid taking a tub bath, swimming, or soaking in a hot tub for 4 weeks after surgery or until cleared by your physician. MEDICATIONS: Unless told otherwise you should resume taking all of the medications you were taking before surgery. Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. DIET: There are no special restrictions on your diet postoperatively. Poor appetite is not unusual for several weeks and small, frequent meals may be preferred. FOLLOW-UP APPOINTMENT: Be sure to keep your medical appointments. If a follow up appointment was not made prior to your discharge, please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. This should be scheduled on the calendar for seven to fourteen days after discharge. Normal office hours are ___ through ___. PLEASE FEEL FREE TO CALL THE OFFICE WITH ANY OTHER CONCERNS OR QUESTIONS THAT MIGHT ARISE. Followup Instructions: ___
10138762-DS-8	10,138,762	24,312,685	DS	8	2138-05-23 00:00:00	2138-05-23 15:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Ankle fracture Major Surgical or Invasive Procedure: ORIF right ankle on ___ History of Present Illness: Mrs. ___ is a ___ who presents with R ankle pain following a fall as she was climbing her stairs. She had immediate pain, was able to crawl into bed, and pain was relieved with ibuprofen. Upon awakening unable to bear weight and presented to ED. No numbness, tingling. No HS or LOC, no CP/SOB/n/v/abdominal pain, pain in other extremities. Past Medical History: PMH: None PSH: Bilateral tubal ligation, uterine fibroid removal Social History: ___ Family History: n/p Physical Exam: PHYSICAL EXAMINATION in ADM: Vitals: 8 97.3 95 128/86 16 98% RA Right lower extremity: - Ankle swelling, skin intact. TTP both medially and laterally at ankle. No pain around the knee, femur, hip. - Soft, non-tender thigh and leg - Full, painless AROM/PROM of hip, knee. Unable to range ankle - ___ fire - SILT SPN/DPN/TN/saphenous/sural distributions - 1+ ___ pulses, foot warm and well-perfused PE in DC: AVSS NAD, A&Ox3 RLE Incision well approximated. Fires ___. SITLT s/s/dp/sp/tibial distributions. 1+ DP pulse, wwp distally. Pertinent Results: n/p 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 ankle fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ for ORIF right ankle, which the patient tolerated well. For full details of the procedure please see the separately dictated operative report. The patient was taken from the OR to the PACU in stable condition and after satisfactory recovery from anesthesia was transferred to the floor. The patient was initially given IV fluids and IV pain medications, and progressed to a regular diet and oral medications by POD#1. The patient was given ___ antibiotics and anticoagulation per routine. The patient's home medications were continued throughout this hospitalization. The patient worked with ___ who determined that discharge to home with ___ services was appropriate. The ___ hospital course was otherwise unremarkable. At the time of discharge the patient's pain was well controlled with oral medications, incisions were clean/dry/intact, and the patient was voiding/moving bowels spontaneously. The patient is NWB in the RL extremity, and will be discharged on Lovenox for DVT prophylaxis. The patient will follow up with Dr. ___ ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Multivitamins 1 TAB PO DAILY 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 #50 Tablet Refills:0 2. Docusate Sodium 100 mg PO BID RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #40 Capsule Refills:0 3. Enoxaparin Sodium 40 mg SC QHS Duration: 4 Weeks Start: Today - ___, First Dose: Next Routine Administration Time RX enoxaparin 40 mg/0.4 mL 0.4 ml SC at bedtime Disp #30 Syringe Refills:0 4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain RX oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours Disp #45 Tablet Refills:0 5. Senna 8.6 mg PO BID RX sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 by mouth twice a day Disp #40 Tablet Refills:*0 6. Multivitamins 1 TAB PO DAILY 7.Rolling Walker Dx: Ankle Fracture Px: Good ___: 13 Months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Ankle fracture Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: INSTRUCTIONS AFTER ORTHOPAEDIC SURGERY: - You were in the hospital for orthopedic surgery. It is normal to feel tired or "washed out" after surgery, and this feeling should improve over the first few days to week. - Resume your regular activities as tolerated, but please follow your weight bearing precautions strictly at all times. ACTIVITY AND WEIGHT BEARING: - non Weight Bearing in Right Lower Extremity MEDICATIONS: - Please take all medications as prescribed by your physicians at discharge. - Continue all home medications unless specifically instructed to stop by your surgeon. - Do not drink alcohol, drive a motor vehicle, or operate machinery while taking narcotic pain relievers. - Narcotic pain relievers can cause constipation, so you should drink eight 8oz glasses of water daily and take a stool softener (colace) to prevent this side effect. ANTICOAGULATION: - Please take Lovenox daily for 4 weeks WOUND CARE: - You may shower. No baths or swimming for at least 4 weeks. - Any stitches or staples that need to be removed will be taken out at your 2-week follow up appointment. - Please remain in your dressing and do not change unless it is visibly soaked or falling off. - 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 and any new medications/refills. Physical Therapy: NWB in RLE No ROM limit Keep in splint Treatments Frequency: Home ___ Followup Instructions: ___
10138917-DS-13	10,138,917	26,772,323	DS	13	2157-07-19 00:00:00	2157-07-19 18:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Fentanyl / foam bandage Attending: ___. Chief Complaint: SOB/anemia Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy (EGD) Colonoscopy Capsule Endoscopy History of Present Illness: Mr. ___ is a ___ year old male with poorly differentiated left lower lobe squamous cell cancer with metastatic brain lesions, on most recent chemo regimen of gemzar which finished in ___ and h/o cisplatin, pemetrexed, and zometa at ___ and whole brain/cervial spine radiation which finished today, now presenting from his radiation treatment with shortness of breath. They drew labs and found that he was anemic to Hct 20.1 and hyponatremic to 130. He has been having increased shortness of breath with minimal exertion (not at rest) as well as dizziness. He feels this SOB has increased since first noticing it on ___. His vitals were checked at clinic and he was afebrile, satting 96-97% on RA. Orthostatic vital signs were checked and normal. Dr. ___ (___ oncologist) was updated about his condition and recommended going to either the ___ or ___ ED. He came here due to proximity. He denies any blood in stool, hematemesis, abdominal pain, chest pain, fevers, or chills. He notes a productive cough w/ dark yellow sputum sometimes w/ blood streaks. He has some neck pain which improved w/ rads treatment. He notes feeling weak. . In the ED, initial vitals were: 98.8 110 118/60 22 96%. On exam, he was noted to be guaiac positive. CXR showed only progression of his known disease compared to previous study in ___. Labs were repeated and showed a Hct of 20.7. LDH/hapto were added on and pending on transfer. He was started on NS IVF for his hyponatremia. Most of the patient's most recent labs and imaging are in the ___/BWH system. On transfer, vitals were: 98.4 103 120/74 18 97%. Past Medical History: PAST ONCOLOGIC HISTORY: - Mr. ___ had upper respiratory infection symptoms in ___. Chest x-ray at that time was negative. These symptoms resolved, and he was subsequently diagnosed with strep throat in ___ ___ and ___, both treated with Augmentin. - In ___, he developed recurrent cough that did not improve despite use of Zyrtec, albuterol, and inhaled steroids. The cough continued to persist, and ___ CXR showed a large left lower lobe lung mass. CT of the chest also confirmed this finding, and he was referred to ___ where he was evaluated by Dr. ___. - ___ PET CT scan showed an intensely FDG avid left lower lobe lung mass, approximately 6.2 x 4.9 cm in size. ___ MRI of the brain was negative for metastatic disease. ___ biopsy of the left lower lobe mass showed a poorly differentiated squamous cell carcinoma. He underwent mediastinoscopy on ___ with 8 levels examined, with no malignancy identified in any lymph nodes. - He underwent a left thoracotomy and left lower lobectomy on ___ at ___. Pathology showed a 5.0 x 5.0 x 4.0 cm grade 3 pleomorphic primary mass. The mass was located within the bronchus, 0.3 cm from the nearest pleural surface, and 0.5 cm from the remaining bronchial margin. There were 2 nodules adjacent to the mass measuring 2 x 1 x 1 cm and 2.5 x 2 x 1.5 cm that appeared to involve the adjacent bronchi. There was positive lymphovascular invasion. Multiple lymph nodes examined, including 10L, 11L, 12L and 5 were negative. Pathologic staging was pT3 because of multiple nodules within the same lobe and pN0. - ___: 4 cycles of cisplatin 75mg/m2 and Taxotere 75mg/m2, given every 21 days, with no significant side effects - ___: upper respiratory tract infection - ___ CT chest with contrast showing no evidence of local tumor recurrence in the left hemithorax. In the right lung, there are two adjacent soft tissue nodules, which are new since ___, 1.1 cm wide in aggregate. Impression is that this would be an unusual presentation for metastasis, but that these require followup. Previously seen small nodules in the right lung otherwise are stable. There were no bony lesions. - ___ CT chest with contrast: multiple new or increased sites of disease in the chest. In the left lung base, there is a new 1.0 x 0.9 cm nodule. There is another new left lung nodule that measures 0.5 x 0.4 cm. There is enlargement of the subcarinal lymph node, currently 2.4 x 1.9 cm, previously 0.65 x 0.84 cm. This is a pleural deposit of disease that has significantly increased compared to before, currently 2.5 x 1.5 cm compared to 0.8 cm previously. There is a new nodule adjacent to the bronchus intermedius, 0.84 x 0.72 cm, subpleural right lower lobe nodule, 0.4 x 0.36 cm. Two new nodules in the right middle lobe measuring 0.2 x 0.5 cm and two nodules in the subpleural basal location in the right lower lobe, measuring 0.5 and 0.6 cm. The previously seen right lower lobe nodule has increased in size to 0.57 x 0.3 cm from 0.3 x 0.1 cm. Anterior mediastinal evaluation demonstrates suspected increased lymph node measuring 1.0 cm in diameter. - ___ - patient decided to transfer care to ___, started chemo regimen of carboplatin and altima after 2 cycles (6 weeks), CT showed no new lesions, but subcarinal lymph node grew in size - started on ___ ___ - was going to get started on MDX trial in ___, but found brain mets and bone scan showed worsening of L femural/ischion lesions - ___ started rads for bone lesions and underwent cyberknife on ___ -> if brain clear then would have started MDX two months later - had MRI on ___ which showed progression of brain masses - whole brain radiation started ___ and ended ___ . . PAST MEDICAL HISTORY: 1. Two episodes of vasovagal syncope in ___ and ___, which were thought to be due to fatigue and dehydration, stable. 2. History of BCG vaccination for tuberculosis; last PPD in ___, reportedly non-reactive despite hx of BCG, stable 3. Brief episode of atrial fibrillation as an inpatient following his left lobectomy, status post spontaneous reversion to normal sinus rhythm, stable. Social History: ___ Family History: Mother- did of ovarian CA in ___ Father- died of liver cirrhosis from Hep B Physical Exam: Vitals - T: 98.6 BP: 128/64 HR: 110 RR: 16 02 sat: 97% RA GENERAL: NAD SKIN: warm and well perfused, no excoriations or lesions, no rashes HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva, patent nares, MMM, good dentition, nontender supple neck, no LAD, no JVD CARDIAC: tachy, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, clubbing or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN II-XII intact, motor intact, sensation intact, coordination intact, refelexes 2+ throughout, no asterixis Discharge PE essentially unchanged, remains tachycardic with some increased work of breathing Pertinent Results: Labs ___ 11:39AM GLUCOSE-133* UREA N-16 CREAT-0.7 SODIUM-130* POTASSIUM-4.1 CHLORIDE-93* TOTAL CO2-24 ANION GAP-17 ___ 11:39AM HAPTOGLOB-454* ___ 11:39AM HAPTOGLOB-461* ___ 11:39AM OSMOLAL-268* ___ 11:39AM WBC-10.7# RBC-2.65# HGB-6.5# HCT-20.7# MCV-78# MCH-24.5# MCHC-31.5 RDW-16.4 ___ 11:39AM NEUTS-78.0* BANDS-0 LYMPHS-11.6* MONOS-8.5 EOS-1.7 BASOS-0.2 . ___ 11:39AM BLOOD WBC-10.7# RBC-2.65# Hgb-6.5# Hct-20.7# MCV-78# MCH-24.5# MCHC-31.5 RDW-16.4 Plt ___ ___ 03:32PM BLOOD WBC-10.4 RBC-2.55* Hgb-6.2* Hct-20.1* MCV-79* MCH-24.2* MCHC-30.6* RDW-16.3* Plt ___ ___ 06:30AM BLOOD WBC-7.1 RBC-2.81* Hgb-7.5* Hct-22.8* MCV-81* MCH-26.6* MCHC-32.8 RDW-15.7* Plt ___ ___ 12:40PM BLOOD Hct-24.3* ___ 05:26PM BLOOD Hct-24.4* ___ 07:50AM BLOOD WBC-8.5 RBC-2.85* Hgb-7.2* Hct-23.1* MCV-81* MCH-25.4* MCHC-31.3 RDW-16.2* Plt ___ ___ 05:00PM BLOOD WBC-9.4 RBC-3.55* Hgb-9.6# Hct-28.1 MCV-79* MCH-27.2 MCHC-34.3 RDW-16.4* Plt ___ ___ 07:35AM BLOOD WBC-10.0 RBC-3.51* Hgb-9.4* Hct-28.7* MCV-82 MCH-26.6* MCHC-32.6 RDW-16.5* Plt ___ ___ 05:00PM BLOOD Hct-29.2* ___ 12:09AM BLOOD Hct-28.5* ___ 07:10AM BLOOD WBC-10.6 RBC-3.67* Hgb-9.7* Hct-31.0* MCV-84 MCH-26.4* MCHC-31.3 RDW-16.7* Plt ___ ___ 12:45PM BLOOD WBC-10.9 RBC-3.58* Hgb-9.6* Hct-30.4* MCV-85 MCH-26.7* MCHC-31.4 RDW-16.4* Plt ___ ___ 07:15AM BLOOD WBC-8.0 RBC-3.38* Hgb-9.1* Hct-27.6* MCV-82 MCH-26.8* MCHC-32.8 RDW-16.3* Plt ___ ___ 06:45PM BLOOD WBC-7.8 RBC-3.32* Hgb-8.9* Hct-27.4* MCV-83 MCH-26.8* MCHC-32.4 RDW-16.1* Plt ___ ___ 07:11AM BLOOD WBC-6.1 RBC-3.40* Hgb-8.9* Hct-28.2* MCV-83 MCH-26.2* MCHC-31.7 RDW-16.2* Plt ___ ___ 12:45PM BLOOD WBC-7.1 RBC-3.52* Hgb-9.4* Hct-28.9* MCV-82 MCH-26.6* MCHC-32.4 RDW-16.1* Plt ___ . ___ 11:39AM BLOOD Neuts-78.0* Bands-0 Lymphs-11.6* Monos-8.5 Eos-1.7 Baso-0.2 ___ 03:32PM BLOOD Neuts-94.1* Lymphs-2.9* Monos-2.5 Eos-0.3 Baso-0.1 ___ 11:39AM BLOOD Glucose-133* UreaN-16 Creat-0.7 Na-130* K-4.1 Cl-93* HCO3-24 AnGap-17 ___ 06:30AM BLOOD Glucose-97 Creat-0.5 Na-131* K-3.9 Cl-96 HCO3-25 AnGap-14 ___ 05:26PM BLOOD Na-133 K-4.1 Cl-97 ___ 07:50AM BLOOD Glucose-103* UreaN-13 Creat-0.5 Na-130* K-3.9 Cl-95* HCO3-25 AnGap-14 ___ 07:35AM BLOOD Glucose-101* UreaN-15 Creat-0.5 Na-131* K-3.7 Cl-94* HCO3-24 AnGap-17 ___ 01:20PM BLOOD Glucose-161* UreaN-17 Creat-0.5 Na-132* K-4.4 Cl-97 HCO3-23 AnGap-16 ___ 05:00PM BLOOD Na-130* K-4.2 Cl-95* ___ 07:10AM BLOOD Glucose-98 UreaN-22* Creat-0.5 Na-132* K-4.0 Cl-96 HCO3-23 AnGap-17 ___ 07:15AM BLOOD Glucose-108* UreaN-21* Creat-0.5 Na-136 K-3.8 Cl-100 HCO3-24 AnGap-16 ___ 06:45PM BLOOD Glucose-115* UreaN-22* Creat-0.5 Na-136 K-4.5 Cl-100 HCO3-24 AnGap-17 ___ 07:11AM BLOOD Glucose-91 UreaN-20 Creat-0.5 Na-136 K-3.9 Cl-99 HCO3-26 AnGap-15 ___ 12:45PM BLOOD Glucose-152* UreaN-19 Creat-0.6 Na-132* K-3.7 Cl-95* HCO3-27 AnGap-14 . ___ 11:39AM BLOOD LD(LDH)-879* . ___ 06:30AM BLOOD ALT-20 AST-30 LD(LDH)-795* AlkPhos-50 TotBili-2.2* DirBili-0.5* IndBili-1.7 ___ 07:35AM BLOOD ALT-21 AST-34 AlkPhos-56 TotBili-0.9 DirBili-0.3 IndBili-0.6 . ___ 05:26PM BLOOD Iron-16* . ___ 07:10AM BLOOD Albumin-3.4* Calcium-8.7 Phos-3.3 Mg-2.3 ___ 12:45PM BLOOD Calcium-8.4 Phos-1.9* Mg-2.0 . ___ 05:26PM BLOOD calTIBC-311 Ferritn-136 TRF-239 . ___ 07:35AM BLOOD Hapto-461* ___ 11:39AM BLOOD Osmolal-268* ___ 06:30AM BLOOD Osmolal-269* . ___ 07:50AM BLOOD TSH-1.7 . ___ 07:50AM BLOOD Cortsol-9.8 . ___ 10:46AM URINE Osmolal-620 ___ 11:52AM URINE Osmolal-245 ___ 10:46AM URINE Hours-RANDOM Creat-40 Na-250 K-16 ___ 11:52AM URINE Hours-RANDOM Creat-33 Na-50 K-9 Cl-46 ___ 05:20PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 ___ 05:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG ___ 05:20PM URINE Color-Straw Appear-Clear Sp ___ . PARVOVIRUS B19 ANTIBODIES (IGG & IGM) Test Result Reference Range/Units PARVOVIRUS B-19 ANTIBODY 4.27 H (IGG) Reference Range <0.9 Negative 0.9-1.1 Equivocal >1.1 Positive IgG persists for years and provides life-long immunity. To diagnose current infection, consider a Parvovirus B19 DNA, PCR test. Test Result Reference Range/Units PARVOVIRUS B-19 ANTIBODY <0.9 (IGM) Reference Range <0.9 Negative 0.9-1.1 Equivocal >1.1 Positive Results from any one IgM assay should not be used as a sole determinant of a current or recent infection. Because IgM tests can yield false positive results and low levels of IgM antibody may persist for months post infection, reliance on a single test result could be misleading. If an acute infection is suspected, consider obtaining a new specimen and submit for both IgG and IgM testing in two or more weeks. To diagnose current infection, consider a parvovirus B19 DNA,PCR test. ___ 7:10 am SEROLOGY/BLOOD CHEM# ___ ___. *FINAL REPORT ___ HELICOBACTER PYLORI ANTIBODY TEST (Final ___: POSITIVE BY EIA. (Reference Range-Negative). Imaging CXR ___: IMPRESSION: Extensive metastatic disease to the lungs. Brief Hospital Course: The patient is a ___ year old male with poorly differentiated left lower lobe squamous cell cancer with metastatic brain lesions, on most recent chemo regimen of gemzar which finished in ___ and h/o cisplatin, pemetrexed, and zometa at ___ and whole brain/cervial spine radiation which finished today, admitted to ___ on ___ from his radiation treatment with shortness of breath. The patient was found to be anemia at the time of admission with hct 20.9. The patient received 2 units of PRBCs. The patient did not respond appropriately to these transfusions (20.1->24.3). After the first transfusiont there was a question of transfusion reaction since he had some reported hematuria, but this ended up being negative. He received 2 more PRBCs for hct 23.1. After passing several melanotic stools (___), GI was consulted. The patient was started on IV protonix drip for a presumed GI bleed. Considering the hematocrit drop and melena, GI decided to pursue an esophagogastroduodenoscopy (EGD) (___) to evaluate for any ulcers or source of bleeding. The study was normal and did not show a source of bleeding. He was transitioned IV protonix 40mg once daily. It was then decided to pursue a colonoscopy and also capsule study (___) to further evaluate for a source of bleeding. The colonoscopy showed a polyp, and polypectomy was performed, but was otherwise normal. The polyp was not thought to be a source of the bleeding. The preliminary read on the capsule study was normal. Several labs were sent off on the patient. Parvovirus was found to be negative, but H. pylori came back positive just before discharge. The patient will go home on triple therapy (protonix 40mg bid, amoxicillin 1g bid for 14 days, and clarithromycin 500mg bid for 14 days) as this could be causing ulcers not seen on EGD, colonoscopy, or with the capsule study. The patient was also noted to have hyponatremia during his stay. Urine osmolality after turning off IVFs was 245, but the patients sodium continued to be around 130. The patient is likely suffering from SIADH related to his underlying lung cancer, since other labs, inculding TSH and cortisol, were WNL. The patient was fluid restricted for the rest of his stay and his sodium improved until taking in the moviprep for his colonoscopy. The patient had SOB, and was found to have oxygen saturation in the ___ when ambulating. A prescription for home oxygen was given. This is likely related to the progression of his disease. The patient was afebrile during his entire stay and did not complain of any chest pain. At the time of discharge the patient was stable and doing well. He has close followup scheduled. Medications on Admission: 1. DICLOFENAC 2 grams topically to affected area four times a day as needed for pain 2. Fentanyl patch 12 mg q3days 3. LORAZEPAM 0.5-1 mg by mouth at bedtime as needed for insomnia 4. B COMPLEX VITAMINS by mouth daily 5. CHOLECALCIFEROL 2,000 unit by mouth daily 6. IBUPROFEN 600-800 mg by mouth twice a day as needed for pain 7. OMEGA-3 FATTY ACIDS 1,000 mg by mouth three times a day 8. ranitidine 150 qd 9. decadron 4mg qd 10. melatonin 3mg qd 11. guafenisin and dextromethorphan 12. saline nasal spray Discharge Medications: 1. lorazepam 0.5 mg Tablet Sig: ___ Tablets PO HS (at bedtime) as needed for insomnia. 2. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. sodium chloride 0.65 % Aerosol, Spray Sig: ___ Sprays Nasal QID (4 times a day) as needed for dry nares. 7. dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Disp:140 ml* Refills:0 8. Home Oxygen O2 supplementation 2L/min as needed Patient desaturates to 85% with ambulation. 9. fentanyl 12 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 10. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO three times a day. Disp:90 Tablet(s) Refills:2 11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day: take twice daily for 14 days with the antibiotics (end on ___, then take once daily. Disp:60 Tablet, Delayed Release (E.C.)(s) Refills:2 12. omega-3 fatty acids 1,000 mg Capsule Sig: One (1) Capsule PO three times a day. 13. amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO twice a day for 14 days. Disp:56 Capsule(s) Refills:0 14. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:28 Tablet(s) Refills:0 ***Interaction with Fentanyl and Clarithromycin noted. Discussed with pharmacist and left message for wife to discuss possibility of decreasing fentanyl patch to half the dose with Dr. ___ at appointment on ___ Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: anemia 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 ___ on ___ for workup of shortness of breath. Labwork showed that your red blood cell count was low (anemia). You were given 2 units of packed red blood cells after being admitted to the floor. Your symptoms only improved slightly overnight, so more labwork was sent off. There was also a question of whether or not you had a reaction to receiving the blood products. It was determined that you did not have a transfusion reaction. After you passed several very dark stools (melena), we asked our GI service to evaluate you. You were started on an IV proton pump inhibitor drip for a presumed GI bleed. Considering your hematocrit drop and passing melena, GI decided to pursue an esophagogastroduodenoscopy (EGD) to evaluate for any ulcer or source of bleeding. The study was normal and did not show a source of bleeding. You were transitioned to an IV proton pump inhibitor once daily. It was then decided to pursue a colonoscopy and also capsule study to further evaluate for a source of bleeding. The colonoscopy showed a polyp, which was removed, but was otherwise normal. The polyp was not thought to be a source of the bleeding. The preliminary read on your capsule study was normal. Your H. pylori antibody test was positive, which means that you are exposed to a bacteria that can predispose you to ulcers. Therefore, you will be given a treatment course of antibiotics for 14 days. You were also noted to have low sodium during your stay. After evaluating your labwork, it is thought that you have syndrome of inappropriate anti-diuretic hormone. This is likely related to your cancer and causes your body to retain more water than it should therefore dropping your sodium levels. You should try your best to restrict the amount of free water you take in to less than 1.5 liters per day, so your sodium levels do not fall. You will also continue to take iron supplementation since you were found to be iron deficient. When walking, your oxygenation saturation dropped to the mid ___. You will go home with supplemental oxygen. A prescription for physical therapy will be provided, and ___ will also set up home physical therapy. Medications: Start Iron 325mg three times a daily Start Protonix 40mg daily Start Home oxygen Start dextromethorphan-guaifenesin ___ mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed for cough. Start Saline Nasal Spray as needed for dry nose Start clarithromycin, amoxicillin, and pantoprazole for H. pylori exposure Stop ranitidine, since you are now on pantoprazole Stop Ibuprofen and all other NSAIDs. These can put you at risk for peptic ulcers You should set up a followup appointment with Dr. ___ a week. You preferred to make this appointment yourself, rather than have us set it up for you. You will need to followup with the GI Clinic which is listed below. Followup Instructions: ___
10138979-DS-6	10,138,979	20,742,047	DS	6	2170-05-09 00:00:00	2170-05-09 17:37:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ Chief Complaint: L2 burst fracture with retropulsion; T11 fragment Major Surgical or Invasive Procedure: None History of Present Illness: ___ s/p restrained driver involved in a single vehicle high speed MVC, self-extricated. Denies headstrike or LOC. He was transferred to the ED at ___ via ambulance for work-up. Upon arrival he underwent a CT of the torso which showed a L2 burst fracture with retropulsion and a T11 fragment. He denies pain, numbness, tingling or weakness of the bilateral upper extremities. He denies weakness, pain or tingling of the bilateral lower extremities but does endorse numbness. He describes left lower extremity numbness anteriorly and laterally from the hip to the knee and complete left foot numbness as well as right anterior and lateral leg numbness which radiates from the hip to the knee. He denies saddle anesthesia, rectal or urinary incontinence. Past Medical History: Hepatitis C Stab wound to lung requiring intervention in ___ Social History: ___ Family History: Unknown. Physical Exam: ------------- On admission: ------------- PHYSICAL EXAM: T: 98.6 BP: 161/91 HR: 69 RR: 14 O2Sats 98% RA Gen: Lying on stretcher with c/o lumbar back pain. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: D B T WE WF IP Q H AT ___ G R 5 5 5 5 5 4 4 5- 5 5 5 L 5 5 5 5 5 4 5 5 5 5 5 Sensation: Intact to light touch with decreased sensation from the hips to knees bilaterally and the left foot. Reflexes: B T Br Pa Ac Right ___ 0 0 Left ___ 0 0 Rectal exam normal sphincter control performed by ED resident ___, MD. ------------- On discharge: ------------- Pertinent Results: Please see OMR for pertinent results. Brief Hospital Course: Mr. ___ is a ___ yo M who presented to the ED following a restrained driver single vehicle MVC. On arrival he underwent a CT of the torso, which showed an L2 burst fracture with retropulsion and T11 fragment. He was admitted to the neuroscience floor. #L2 Fracture The plan for T2-L4 fusion and L1-L3 laminectomy was discussed with the patient who became increasingly agitated with the surgeon, nursing, and his girlfriend. He asked about non-surgical options, which included strict bed rest for 3 months. The risk of paralysis with bed rest verses surgery were discussed at length with the patient. He refused to have the procedure. Urgent MRI was ordered to further assess the injury to evaluate need for surgery, patient refused MRI. The patient refused to wear C-spine collar. The patient's behavior continued to escalate and he became more verbally abusive towards staff and his girlfriend, he then began throwing objects. Psych was consulted. The patient was given Valium, Dilaudid, and Oxycodone to manage agitation and pain. The patient requested transfer to ___ which was approved by Dr. ___. #Psych Due to increased agitation and patient request psych was consulted. They deemed him competent to make his own decisions. They recommended keeping pain controlled and allowing comforts such as eating to manage agitation. Additionally, they recommended a 1:1 sitter to make sure the patient did not get out of bed. The patient continued to increase in agitation and became more violent. He was put in seclusion and security was brought in. An EKG was attempted to establish a QTC, however, the patient refused aggressively. Medications on Admission: Denies Discharge Medications: none Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: L2 fracture with retropulsion Discharge Condition: Mental Status: acutely agitated. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Activity You have an unstable L2 fracture. You will have to be flat bedrest with logroll precaution. You are at risk for paralysis and nerve damage. Medications *Please do NOT take any blood thinning medication (Aspirin, Ibuprofen, Plavix, Coumadin) until cleared by the neurosurgeon. * You may take Ibuprofen/ Motrin for pain. 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. You have refused surgery at ___ where we proposed to do a T12 to L4 fusion with and L1-L3 laminectomy. Followup Instructions: ___
10139117-DS-22	10,139,117	22,598,112	DS	22	2156-02-19 00:00:00	2156-03-01 22:29:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending: ___. Chief Complaint: Syncope Major Surgical or Invasive Procedure: None History of Present Illness: This is a ___ gentleman with a pmhx. significant for ___ s/p left upper lobectomy, now with recurrence, who presents with syncope. Mr. ___ states that he was in his usual state of health until day of admission when he had trouble straightening out his back. He decided to lay down in bed for a while. He subsequently got up to go to the bathroom, and while he was on the toilet moving his bowels, he syncopized. The next thing the patient remembers is being helped into bed by his wife an an ___ who was doing work in their home. No chest pain, worsening shortness of breath, headache, nausea, vomiting, diarrhea. Mr. ___ was diagnosed with NSCLC in ___ and is s/p lobectomy and chemotherapy. He has had active surveillance since that time. There is suspicion that tumor is regrowing, and patient is being evaluated by thoracics and IP for biopsy. Patient was scheduled to have an MRI of his brain on day of admission to assess for mets to his brain. In the ED, initial vitals were: 97.6 77 124/53 16 100% ra. An EKG showed NSR without concerning ST changes. A CT head showed: no acute intracranial process." Creatinine was 2.7 from a baseline of 1.8, BUN was 73, and potassium was 5.5. Patient received lorazepam 3mg (home dose), tamsulosin, and amlodipine. He is admitted for syncopal work-up. On admission, vitals are: 97.8 77 131/62 12 100%. ROS: A 12-point review of systems is negative aside from what is described above. Past Medical History: --Stage II nonsmall cell lung cancer --COPD, tracheomalacia, and poor exercise tolerance in ___ to ___ --CAD --PVD --?TIA in ___ --HTN since age ___ --Hypercholesterolemia --CKD --External hemorrhoids --Hyperglycemia, diet controlled Social History: ___ Family History: Mother had HTN and CVA. Father had HTN and CAD. Physical Exam: ADMISSION PHYSICAL EXAM: 97.8 77 131/62 12 100%. Orthostatics: Lying 126/70 74, sitting 130/80 81, standing 158/70 85 GENERAL: Well appearing gentleman, no acute distress NECK: No cervical, submandibular, or supraclavicular LAD CHEST: Wheezing bilaterally, dullness in upper left >>R, scattered rhonchi CARDIAC: RRR, no MRG ABDOMEN: +BS, soft, non-tender, non-distended EXTREMITIES: No edema bilaterally NEURO: Alert and oriented, cranial nerves II-XII grossly intact bilaterally, patient with good muscle strength throughout SKIN: Warm and dry, some scattered seborrheic dermatosis on back DISCHARGE PHYSICAL EXAM VS AF 98 120/60 (120-160/50-70) 73 (70-80s) 18 98% RA I/O ___ +1 BM, guiac neg. GENERAL: Well appearing gentleman, no acute distress CHEST: Continued wheezing throughout, somewhat improved from prior exam, decreased BS on upper L, no rhonchi CARDIAC: RRR, no MRG ABDOMEN: soft, non-tender, non-distended EXTREMITIES: No cyanosis, clubbing, ___ edema NEURO: Alert and oriented, cranial nerves II-XII grossly intact. Pertinent Results: ___ 09:44PM URINE COLOR-Straw APPEAR-Clear SP ___ ___ 09:44PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG ___ 09:44PM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE EPI-0 ___ 09:44PM URINE MUCOUS-RARE ___ 03:48PM GLUCOSE-118* UREA N-73* CREAT-2.7* SODIUM-137 POTASSIUM-5.5* CHLORIDE-108 TOTAL CO2-22 ANION GAP-13 ___ 03:48PM estGFR-Using this ___ 03:48PM WBC-5.4 RBC-3.24* HGB-9.6* HCT-29.6* MCV-91 MCH-29.7 MCHC-32.6 RDW-14.4 ___ 03:48PM NEUTS-67.2 ___ MONOS-7.8 EOS-6.0* BASOS-0.3 ___ 03:48PM PLT COUNT-134* ___ 03:48PM ___ PTT-31.9 ___ ___: ___ male with syncopal episode, history of lung cancer with recent lobectomy. PA and lateral view of the chest compared to prior chest x-ray from ___ and chest CT from ___. Postoperative changes of left upper lobectomy are seen with left hemithorax volume loss and elevation of the hemidiaphragm as well as surgical chain sutures in the suprahilar region. There is increased nodular opacity in the postoperative bed, which was more clearly delineated by recent CT as suspicious for recurrent disease. The lungs are otherwise clear. Cardiomediastinal silhouette is unchanged. Osseous and soft tissue structures are unremarkable. IMPRESSION: No acute cardiopulmonary process. Findings again suspicious for recurrent disease abutting the surgical chain sutures of the left upper lobectomy. CT HEAD ___: There is no evidence of acute intracranial hemorrhage, mass effect, or shift of normally midline structures. There is no cerebral edema or loss of gray-white matter differentiation to suggest an acute ischemic event. Scattered hypodensities in periventricular white matter distribution likely reflect sequela of small vessel ischemic disease. There is no hydrocephalus. Basal cisterns are patent. No large intracranial mass is detected. There is mild mucosal thickening of maxillary sinuses. Otherwise, imaged paranasal sinuses appear well aerated. The orbits are normal in appearance. No acute fracture. No suspicious lytic or sclerotic bony lesion seen. IMPRESSION: No evidence of acute intracranial process. Specifically, no intracranial mass is detected; however, MRI is more sensitive for detection for small metastatic lesions. RENAL ULTRASOUND ___: No hydronephrosis. Slightly echogenic kidneys is compatible with medical renal disease. Brief Hospital Course: ___ PMH significant for ___ s/p lobectomy and chemotherapy, now with recurrence, admitted for syncope and acute renal failure. # Syncope: Likely vasovagal given that pt was having a bowel movement when he lost consciousness. Seizure unlikely w/ no post ictal state, no observed tonic/clonic movements. Cardiac biomarkers negative; EKG showed normal sinus rhythm, no signs of ischemia. Telemetry was discontinued after 24 hours of monitoring showed isolated episodes of nonsustained Vtach x 2, asymptomatic. Echo was performed, showing EF 50%, mild infralateral hypokinesis. Orthostatics were negative. Pt had no further episodes during his stay. # Acute on chronic kidney injury: Patient's admission creatinine of 2.7 was initially thought to be elevated from a baseline of 1.4-1.6. However, further review of pt's outside records revealed his Cr had been >2 prior to this hospitalization. FeNa 1.97%, likely not prerenal. Renal ultrasound showed no hydronephrosis. Etiology likely chronic HTN. Nephrotoxins held, meds renally dosed. Pt raised question of brain MRI to assess for metastases; renal consult team felt pt could likely get MRI without much further risk to kidneys. Pt chose to discuss decision further with his primary oncologist and pursue imaging as an outpatient if at all. # Thrombocytopenia to 134 with elevated INR. Fibrinogen was 298, speaking against DIC. Blood smear was bland, with no signs of hemolysis. INR possibly elevated from malnutrition. Both INR and platelets were stable at discharge; pt will follow up as outpatient. # NSCLC: Patient is s/p lobectomy and chemotherapy. Has been undergoing active surveillence, but appears as though tumor is growing. Evaluation can be performed by thoracics and IP as an outpatient, with possible brain MRI to evaluate for mets. All can be pursued as outpatient under supervision of primary oncologist. Medications on Admission: The Preadmission Medication list may be inaccurate and requires futher investigation. 1. Amlodipine 10 mg PO DAILY Please hold for SBP <100. 2. Atorvastatin 40 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Lorazepam ___ mg PO HS:PRN Insomnia Please hold for oversedation or RR <10. Patient already received on morning of ___. 5. Losartan Potassium 25 mg PO DAILY Please hold for SBP <100. 6. Tamsulosin 0.4 mg PO HS 7. Pantoprazole 40 mg PO Q12H 8. Tiotropium Bromide 1 CAP IH DAILY 9. Aspirin 81 mg PO DAILY 10. Calcium Carbonate 500 mg PO QID 11. Vitamin D 1000 UNIT PO DAILY 12. Docusate Sodium 100 mg PO BID 13. Multivitamins 1 TAB PO DAILY 14. Senna 1 TAB PO BID:PRN Constipation Discharge Medications: 1. Amlodipine 10 mg PO DAILY Please hold for SBP <100. 2. Atorvastatin 40 mg PO DAILY 3. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID 4. Lorazepam ___ mg PO HS:PRN Insomnia Please hold for oversedation or RR <10. Patient already received on morning of ___. 5. Tamsulosin 0.4 mg PO HS 6. Pantoprazole 40 mg PO Q12H 7. Tiotropium Bromide 1 CAP IH DAILY 8. Aspirin 81 mg PO DAILY 9. Calcium Carbonate 500 mg PO QID 10. Vitamin D 1000 UNIT PO DAILY 11. Docusate Sodium 100 mg PO BID 12. Multivitamins 1 TAB PO DAILY 13. Senna 1 TAB PO BID:PRN Constipation Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Syncope, neurocardiogenic Secondary: Chronic kidney disease, Stage IV Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. ___: It was a pleasure taking care of you during your stay at ___ ___ ___. You were admitted for a fainting episode that appeared to be benign. We found no evidence for cardiac or other dangerous cause for this episode. You were also found to have a worsening of your chronic kidney disease, so we did not perform the brain MRI you had been scheduled for. You can discuss the risks and benefits of this test with your primary oncologist. Followup Instructions: ___
10139228-DS-10	10,139,228	20,586,108	DS	10	2128-10-30 00:00:00	2128-10-30 20:02:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Ceftriaxone / Corticosteroids (Glucocorticoids) Attending: ___. Chief Complaint: free air Major Surgical or Invasive Procedure: Exploratory laparotomy, sigmoid resection and colostomy with closure of distal end and abdominal washout History of Present Illness: ___ with HIV on HAART who presents to the E.D. today with severe diffuse abdominal pain after inserting a dildo this morning at 11am. The patient reports he tripped and fell on the dildo and immediately had excruciating abdominal pain. He waited to see if it would resolve but the pain only grew in intensity and he finally came in to the ED at around 3pm. Past Medical History: PMH: HIV on HAART PSH: none Social History: ___ Family History: No h/o diverticulitis or IBD. Physical Exam: VS - 97.2 80 118/87 18 99%RA GEN - NAD, AOX3 HEENT - NCAT, EOMI, no scleral icterus, MMM ___ - RRR PULM - CTAB ABD - nondistended, ostomy functioning with stool in bag. EXTREM - warm, well-perfused; no peripheral edema Pertinent Results: ___ 09:22PM SODIUM-139 POTASSIUM-4.1 CHLORIDE-105 ___ 09:22PM MAGNESIUM-1.7 ___ 09:22PM HCT-41.7 ___ 03:08PM ___ COMMENTS-GREEN TOP ___ 03:08PM LACTATE-1.9 ___ 03:00PM GLUCOSE-162* UREA N-27* CREAT-0.9 SODIUM-140 POTASSIUM-4.4 CHLORIDE-100 TOTAL CO2-30 ANION GAP-14 ___ 03:00PM estGFR-Using this ___ 03:00PM ALT(SGPT)-26 AST(SGOT)-41* ALK PHOS-57 TOT BILI-4.0* ___ 03:00PM LIPASE-22 ___ 03:00PM ALBUMIN-4.7 ___ 03:00PM WBC-4.6 RBC-4.73 HGB-15.2 HCT-43.1 MCV-91 MCH-32.0 MCHC-35.2* RDW-14.5 ___ 03:00PM NEUTS-58.7 ___ MONOS-4.3 EOS-0.4 BASOS-0.2 ___ 03:00PM PLT COUNT-140* ___ 03:00PM ___ PTT-29.4 ___ Brief Hospital Course: The patient presented to Emergency Department on ___ . Pt presented with sigmoid perforation after traumatic insertion of foreign body into anus/rectum. Given findings, the patient was taken to the operating room for a sigmoid resection and colostomy with closure of distal end and abdominal washout. There were no adverse events in the operating room; please see the operative note for details. Pt was extubated, taken to the PACU until stable, then transferred to the ward for observation. Neuro: The patient was alert and oriented throughout hospitalization; pain was initially managed with a PCA and then transitioned to oral medications once tolerating a diet. CV: The patient remained stable from a cardiovascular standpoint; vital signs were routinely monitored. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet, early ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: The patient was initially kept NPO. Her ostomy output was monitored daily. Once the ostomy was functioning ther diet was advanced sequentially to a Regular diet, which was well tolerated. Patient's intake and output were closely monitored ID: The patient's fever curves were closely watched for signs of infection, of which there were none. HEME: The patient's blood counts were closely watched for signs of bleeding, of which there were none. Prophylaxis: The patient received subcutaneous heparin and ___ dyne boots were used during this stay and was encouraged to get up and ambulate as early as possible. At the time of discharge, the patient was doing well, afebrile and hemodynamically stable. The patient was tolerating a diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: alendronate 70 qweek, reyataz 300', klonopin 0.5-1.0'' prn anxiety, cyclobenzaprine 10''' prn, truvada 200-300', lunesta 2', vicodin prn back pain, norvir 100', viagra Discharge Medications: 1. Atazanavir 300 mg PO DAILY 2. Docusate Sodium 100 mg PO DAILY constipation RX docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #20 Capsule Refills:0 3. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY 4. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain RX hydrocodone-acetaminophen [Norco] 5 mg-325 mg ___ tablet(s) by mouth Q4-6H Disp #30 Tablet Refills:0 5. Milk of Magnesia 30 mL PO Q6H:PRN Constipation RX magnesium hydroxide [Milk of Magnesia] 400 mg/5 mL 30 ml by mouth every six (6) hours Refills:0 6. RiTONAvir 100 mg PO DAILY 7. Senna 8.6 mg PO BID:PRN constipation RX sennosides [senna] 8.6 mg 1 capsule by mouth twice a day Disp #30 Capsule Refills:0 8. Simethicone 40-80 mg PO QID:PRN gas pain RX simethicone [Gas Relief 80] 80 mg 1 tablet by mouth four times a day Disp #20 Tablet Refills:0 9. ClonazePAM 0.5 mg PO ONCE Duration: 1 Dose Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Sigmoid perforation 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 on ___ sigmoid perforation. You were admitted to the floor under the Acute Care Services. You were brought to the operating room for a sigmoid resection and colostomy with closure of distal end and abdominal washout. You have received instructions about the colostomy while in the hospital. You will also have visiting nurses to your house to help you with your colostomy care until you are comfortable to care for it yourself. 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 To the visiting nurses: Thank you for participating in the care of this patient. This patient has had multiple teaching sessions with both the Wound/Ostomy nurses and with the staff nurses and should have a good idea of how to care for their own ostomy. They have also been given several items that will assist them in their own care, such as instruction sheets, ostomy supplies, and ostomy output measuring tools. However, we would like to stress a few important points to assist you in the care of this patient. Bowel Function: Ø It is important to encourage the patient to monitor their bowel function closely every day. The patient should continue to record their ileostomy output (as much as physically possible) and the amount of fluid they have taken in, just as they were taught in the hospital. A urinal or hat should be used to record their ostomy output daily. o The patient has been taught to use a daily measurement chart to record their I&Os. This chart should be continued to be used at least until their follow-up appointment. If their ostomy output is less than 500 ml or greater than 1200 ml of liquid stool in a day, it is very important to call the doctors office with this information. o Continue to reinforce to the patient that the major risk with an ileostomy is dehydration related to fluid loses. Daily fluid intake is ___ glasses of fluids, including electrolyte enhanced beverages. In the hot weather, encourage them to take in increased amounts of fluid and closely measure their ileostomy output. o Watch for signs and symptoms of dehydration including: dry mouth or tongue, decrease in urination, urine darker in color, dizzy when he/she stands, cramps in his/her abdomen or legs, dizziness, increased thirst, or weakness. Stoma Care: Ø It is also important to monitor the appearance of the stoma. The tissue of the stoma should be moist, pink or red in color. o If the stoma has color changes from pink / red to dark purplish /blue in color, becomes swollen, or a large amount of continuous bleeding into the pouch, and or at the Mucocutaneous Junction (Stomal Incision). this is not normal. Call the patients doctors office for assistance. If you or the patient has any questions regarding the care of the patients ostomy, please refer to the instructions provided to the patient by the wound/ostomy nurses. ___ the patient develops the following bowel symptoms please call the surgeons office or go to the nearest emergency room if severe: increasing abdominal distension and cramps, nausea, vomiting, inability to tolerate food or liquids, decrease in ostomy output, or have no output from ostomy for ___ hours Followup Instructions: ___
10139228-DS-15	10,139,228	25,617,386	DS	15	2133-03-29 00:00:00	2133-04-03 17:13:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: SURGERY Allergies: Corticosteroids (Glucocorticoids) Attending: ___. Chief Complaint: abdominal pain, rectal bleeding Major Surgical or Invasive Procedure: ___ resection sigmoid perforation ___: VAC dressing placed History of Present Illness: ___ year old male with a history of depression, HIV, C. Diff colitis, who presents with abdominal pain and bright red blood per rectum. Patient reports that he inserted broom handle into his rectum approximately 3 hours ago in suicide attempt. He developed severe abdominal pain and bright red blood per rectum. He is known to the ___ service following a similar foreign body insertion in ___ with sigmoid perforation, ___ procedure and subsequent colostomy takedown. He was found to have peritonitis and evidence of bowel perforation on CT. He was planned for exploratory laparotomy, possible bowel resection, possible ostomy. Past Medical History: HIV, on HAART Primary hyperparathyroidism Osteopenia Lower back pain Anal squamous cell dysplasia Sigmoid colectomy with end colostomy s/p reversal after trauma that caused perforation Anxiety Depression History of LGIB Abdominal wall hernia s/p repair Intermittent thrombocytopenia Social History: ___ Family History: Mother ___ ___ CHRONIC OBSTRUCTIVE PULMONARY DISEASE BREAST CANCER HYPERTENSION HYPERCHOLESTEROLEMIA Father ___ ___ AMYOTROPHIC LATERAL SCLEROSIS LUNG CANCER CORONARY ARTERY DISEASE Brother Living ___ CHRONIC OBSTRUCTIVE PULMONARY DISEASE ASTHMA Sister Living ___ OBESITY HYPERTENSION HYPERCHOLESTEROLEMIA Physical Exam: PHYSICAL EXAMINATION: upon admission: ___ Temp: 98.0 HR: 73 BP: 149/120 Resp: 22 O(2)Sat: 93 Constitutional: Severely uncomfortable and pale in appearance. HEENT: Pupils equal, round and reactive to light, Extraocular muscles intact Dry mucous membranes. Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm, Normal first and second heart sounds Abdominal: Rigid and distended to palpation with guarding. Rectal: Scant bloody discharge, engorged external hemorrhoids. Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent Physical examination upon discharge: ___: vital signs: 98.4, hr=77, bp=116/72, rr=18, 96 % room air General: NAD HEENT: skin warm and dry, sclera anicteric CV: ns1, s2 LUNGS: clear ABDOMEN: soft, non-tender, VAC dressing mid-abdominal wound EXT: no pedal edema bil, no calf tenderness, + radial bil NEURO: alert and oriented x3, speech clear, no tremors Pertinent Results: ___ 07:04AM BLOOD WBC-7.5 RBC-2.62* Hgb-7.8* Hct-25.8* MCV-99* MCH-29.8 MCHC-30.2* RDW-15.8* RDWSD-56.6* Plt ___ ___ 06:44AM BLOOD WBC-8.4 RBC-2.47* Hgb-7.2* Hct-24.0* MCV-97 MCH-29.1 MCHC-30.0* RDW-15.9* RDWSD-55.4* Plt ___ ___ 06:15AM BLOOD WBC-7.3 RBC-2.55* Hgb-7.6* Hct-25.2* MCV-99* MCH-29.8 MCHC-30.2* RDW-16.0* RDWSD-57.2* Plt ___ ___ 08:58PM BLOOD WBC-10.0 RBC-3.62* Hgb-11.8* Hct-36.9* MCV-102* MCH-32.6* MCHC-32.0 RDW-13.5 RDWSD-50.8* Plt ___ ___ 06:10AM BLOOD Neuts-65 Bands-2 Lymphs-11* Monos-19* Eos-3 Baso-0 AbsNeut-1.34* AbsLymp-0.22* AbsMono-0.38 AbsEos-0.06 AbsBaso-0.00* ___ 07:04AM BLOOD Plt ___ ___ 06:44AM BLOOD ___ ___ 12:16PM BLOOD WBC-11.7# Lymph-16 Abs ___ CD3%-61 Abs CD3-1151 CD4%-29 Abs CD4-540 CD8%-32 Abs CD8-600 CD4/CD8-0.90 ___ 07:04AM BLOOD Glucose-88 UreaN-16 Creat-0.8 Na-138 K-4.7 Cl-103 HCO3-24 AnGap-11 ___ 06:44AM BLOOD Glucose-94 UreaN-12 Creat-0.7 Na-140 K-4.8 Cl-105 HCO3-24 AnGap-11 ___ 08:58PM BLOOD Glucose-176* UreaN-28* Creat-1.2 Na-142 K-4.2 Cl-105 HCO3-24 AnGap-13 ___ 05:02AM BLOOD CK(CPK)-54 ___ 07:04AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.0 ___ 05:02AM BLOOD HCV Ab-NEG ___ 12:16PM BLOOD HIV1 VL-Not Detect ___ 01:46AM BLOOD Lactate-1.6 ___ 03:06PM BLOOD Lactate-3.1* ___ 04:02AM BLOOD Hgb-8.7* calcHCT-26 ___ 05:11AM BLOOD freeCa-1.15 CT abd/pelvis: ___ 1. Large right pelvic hematoma and moderate volume pneumo-peritoneum and hemo-peritoneum, consistent with bowel perforation. Suspected site of perforation is along the right distal sigmoid colon/recto-sigmoid junction. 2. Small volume high-density material in the rectum may represent blood. Evaluation for active bleeding is limited on this single phase contrast study, though no active contrast extravasation is identified. 3. Marked proctitis and anusitis. ___: x-ray of the abdomen: Moderate amount of pneumoperitoneum indicative of bowel perforation. Please see report from same day CT abdomen and pelvis for further details. ___: CXR: Compared to most recent prior chest radiograph ___. Right IJ line ends in the upper SVC. ET tube in standard placement. Esophageal drainage tube is looped in the stomach and passes out of view. Borderline cardiomegaly and early pulmonary vascular engorgement are exaggerated by low lung volumes. No focal pulmonary abnormality. Normal mediastinal and hilar contours and pleural surfaces. ___: ABD. x-ray: Several dilated loops of small bowel, which may represent postoperative ileus or small bowel obstruction. ___: CT ABD and pelvis: 1. No evidence of anastomotic leak or organized abscess. 2. Essentially resolved right pelvic hematoma. Trace residual free-fluid. 3. Postsurgical ileus. 4. New small bilateral pleural effusions with moderate bibasilar atelectasis. US abdomen: ___: Minimally complex fluid collection in the right lower quadrant measuring up to 6 cm in size, likely resolving hematoma. Additionally 4 quadrant ultrasound demonstrates trace free fluid which appears simple Brief Hospital Course: Mr. ___ is a ___ year old male with a history of HIV, depression, prior suicide attempt via rectal foreign body insertion requiring ex lap, ___ procedure in ___ with subsequent colostomy takedown, prior C diff colitis. He presented to the emergency room on ___ with abdominal pain and BRBPR. He reported to his primary surgical team pre-operatively that he had inserted a broom handle per rectum in a suicide attempt in the evening of ___. He was tearful and reported to the ___ team that this was another suicide attempt. In the emergency room, his vital signs were stable. He was peritoneal on exam. Labs were significant for lactate of 2.8, WBCs of 10, H&H 11.8/36.9, and ___ to Cr 1.2 from baseline of 0.9. Cat scan of the abdomen/pelvis confirmed hemopneumo-peritoneum and suspected perforation site near the recto-sigmoid junction. He was taken emergently to the operating room. Based on the above findings, the patient was taken to the operating room where he underwent an exploratory laparotomy. He was found to have a sigmoid perforation and large pelvic hematoma. The colon perforation was resected with primary anastomosis. He was on multiple pressors during the procedure, and was taken to the intensive care unit for further resuscitation and stabilization. On POD#1 he was extubated. After extubation he was rapidly weaned from pressors. His ___ tube was removed and he had a return of bowel function. Shortly afterwards, he resumed a regular diet. He was transferred to the floor on ___. Psychiatry service was consulted because of the patient's suicidal ideation, and the patient was placed on 1:1 sitter with recommendations for admission to an in-patient psychiatric facility after medical clearance. On ___, the patient had a return of nausea with increased abdominal distension; a KUB revealed air fluid levels and the NGT was replaced. After return of bowel function, the ___ tube was again removed and the patient advanced to a regular diet. During his post-operative course, he experienced a bout of diarrhea. Stool cultures and c.diff were sent which were negative. The diarrhea resolved without treatment. On ___, he was febrile to 101.3 with purulent drainage from his incision. Imaging of the abdomen was done which revealed no abscess or anastomotic leak. Staples from the lower aspect of his wound were removed and a wet to dry dressing was applied. The wound was later covered with a VAC dressing. The patient was transferred to an in-patient psychiatric facility on ___. The 1:1 sitter order was discontinued. At the time of discharge, his vital signs were stable and he was afebrile. He was tolerating a regular diet and voiding without difficulty. He had return of bowel and bladder function and was ambulatory. A follow-up appointment was made in the Acute care clinic. Discharge instructions were reviewed and questions answered. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. BuPROPion XL (Once Daily) 300 mg PO DAILY 2. ClonazePAM 0.5 mg PO QHS:PRN insomnia 3. Multivitamins 1 TAB PO DAILY 4. Vitamin D ___ UNIT PO DAILY 5. Co Q-10 (coenzyme Q10) 10 mg oral DAILY 6. NAC (acetylcysteine) 600 mg oral DAILY 7. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg oral DAILY 8. Glutamine 5 gm PO DAILY Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. DiphenhydrAMINE 25 mg PO QHS:PRN sleep 3. DULoxetine 60 mg PO DAILY 4. Heparin 5000 UNIT SC TID 5. Ibuprofen 400 mg PO Q6H please take with food 6. Lidocaine 5% Patch 1 PTCH TD QAM 7. Lidocaine 5% Patch 1 PTCH TD QAM 8. LORazepam 0.5 mg PO Q4H:PRN anxiety 9. Ramelteon 8 mg PO QHS:PRN sleep Should be given 30 minutes before bedtime 10. TraMADol 50 mg PO Q4H:PRN Pain - Moderate Reason for PRN duplicate override: Alternating agents for similar severity 11. BuPROPion XL (Once Daily) 300 mg PO DAILY 12. ClonazePAM 0.5 mg PO QHS:PRN insomnia 13. Co Q-10 (coenzyme Q10) 10 mg oral DAILY 14. Genvoya (elviteg-cob-emtri-tenof ALAFEN) ___ mg oral DAILY 15. Glutamine 5 gm PO DAILY 16. Multivitamins 1 TAB PO DAILY 17. NAC (acetylcysteine) 600 mg oral DAILY 18. Vitamin D ___ UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: rectal perforation depression suicide ideation acute blood loss anemia diarrhea pneumoperitoneum hemoperitoneum ileus acute kidney injury chronic low back pain 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 abdominal pain and rectal bleeding after you reportedly inserted a broom handle into your rectum resulting in a perforation of the colon. You were taken to the operating room for a sigmoid resection. After your surgery you were monitored in the intensive care unit. After your vital signs stabilized, you were transferred to the surgical floor to continue with your recovery. During your hospitalization, you were followed by Psychiatry. A VAC dressing was placed over your wound to help facilitate wound healing. You are being discharged to the in-patient psychiatric service with the following instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: You experience new chest pain, pressure, squeezing or tightness. New or worsening cough, shortness of breath, or wheeze. If you are vomiting and cannot keep down fluids or your medications. You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. You see blood or dark/black material when you vomit or have a bowel movement. You experience burning when you urinate, have blood in your urine, or experience a discharge. Your pain in not improving within ___ hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. You VAC dressing should be changed every 3 days, black sponge, machine at 125mm hg, next vac change ___ Followup Instructions: ___
10139461-DS-10	10,139,461	22,000,499	DS	10	2153-01-08 00:00:00	2153-04-28 11:59:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: fevers and abdominal soreness Major Surgical or Invasive Procedure: ___ CT-guided drainage catheter placement into the subcapsular hepatic fluid collection History of Present Illness: ___ with known cholelithiasis reports one week of intermittent fevers and abdominal soreness. She presented to the ED approximately one week ago with complaints of epigastric/chest pain at which time gallstones were visible on CT but there were no signs of cholecystitis and workup of cardiac causes was negative. She reports fevers over the next few days prompting her to followup with her PCP 2 days where she was febrile, minimally tender in the RUQ and had evidence of hematuria. Her labs showed a WBC of 16.6. She was instructed to obtain a RUQ ultrasound and started on a course of ciprofloxacin. She presents to the ED today after RUQ ultrasound this morning was indicative of subcapsular liver collections/abcesses and a decompressed but inflammed-appearing gallbladder. Reports fevers, denies chills, nausea, vomiting, urinary symptoms or change in bowel habits. Overall feels well except for fevers and abdominal pain "only when pushed". Past Medical History: S/p Superficial parotidectomy HTN Social History: ___ Family History: daughter with gallstones s/p lap cholecystectomy ___ years ago Physical Exam: On admission: Vitals: 99.5 115 176/80 18 100 RA NAD, AAOx3 regular rythym, slight tachycardia unlabored respirations abdomen soft, tender to moderate palpation in right upper quadrant, no distention, no guarding, no rebound Pertinent Results: ___ Ultrasound abd: IMPRESSION: 1. Since the CT of ___, there is a new finding of subcapsular, debris- containing fluid collections along the right lobe of the liver, a finding that is concerning for subcapsular abscesses given the rapid interval appearance. The source is not clearly defined and could relate to the abnormal gallbladder (see #2) or bowel pathology (diverticulosis known from prior CT). Suggest further evaluation with CT. 2. Cholelithiasis and thickened and edematous gallbladder wall suggestive of cholecystitis, possibly chronic: the gallbladder is not distended to suggest acute cholecystitis although could have decompressed to the subhepatic space. No pericholecystic fluid is directly seen. 3. 1.4-cm left renal cyst in conjunction with the prior CT is consistent with a proteinaceous cyst and shows no suspicious features. 4. No evidence of hydronephrosis or stone within the right kidney as questioned. ___ CT ABD & PELVIS WITH CONTRAST: MPRESSION: 1. New subcapsular complex fluid collection posterior to the right lobe of the liver is concerning for subcapsular abscess given the clinical history of fevers and the rapid appearance since ___. It may also represent a biloma or hematoma. There is an apparent communication between one of the fluid collections and the contracted gallbladder which suggests a gallbladder source. 2. Cholelithiasis with contraction and edema of the gallbladder wall may represent cholecystitis favoring a chronic rather than acute etiology or, alternatively, perforation of the gallbladder. No intra-abdominal fluid collections are present. 3. 1.5 cm cystic lesion in the uncinate process of the pancreas is incompletely characterized. Consider eventual MRCP for further evaluation. ___ CT guided drainage: IMPRESSION: Successful CT-guided drainage catheter placement into the subcapsular hepatic fluid collection. White bile obtained. Microbiological results pending at this time. ___ 01:17PM WBC-10.5 RBC-4.12* HGB-11.5* HCT-34.0* MCV-83 MCH-28.0 MCHC-33.9 RDW-12.6 ___ 01:17PM NEUTS-91.6* LYMPHS-6.3* MONOS-1.4* EOS-0.4 BASOS-0.2 ___ 01:17PM PLT COUNT-343 ___ 01:17PM ___ PTT-35.3 ___ ___ 01:17PM CALCIUM-8.7 PHOSPHATE-3.7 MAGNESIUM-2.3 ___ 01:17PM GLUCOSE-109* UREA N-15 CREAT-0.8 SODIUM-136 POTASSIUM-3.7 CHLORIDE-101 TOTAL CO2-22 ANION GAP-17 ___ 01:17PM ALT(SGPT)-88* AST(SGOT)-84* ALK PHOS-114* TOT BILI-1.1 ___ 01:26PM LACTATE-1.3 ___ 04:40PM OTHER BODY FLUID TOT BILI-0.6 Brief Hospital Course: Ms. ___ was admitted under the Acute Care Service on ___ for management of her perforated gallbladder. She was taken to ultrasound and underwent an ultrasound guided drainage and drain placement into the subscapular hepatic fluid collection resulting from the gallbladder perforation. She was started empirically on IV zosyn while the cultures were pending. She was eventually transitioned to PO ciprofloxacin and flagyl for empiric coverage when tolerating PO's as cultures were still pending at time of discharge, with plan to complete a 2 week course of antibiotics at home. After the drainage her vital signs were routinely monitored and she remained afebrile and hemodynamically stable. Her WBC count trended downward from 10.5 on admission with a left shift to 7.3 at discharge. Her abdominal tenderness had improved significantly and she was tolerating a regular diet. She was noted to have diarrhea and a sample was sent to check for c. diff which was negative. She was feeling well and ambulating independently. On ___ she was discharged home with ___ services for drain care with the drain in place. She was instructed to follow up in ___ clinic 2 weeks after discharge. Medications on Admission: lisinopril 2.5 mg BID, MVI Discharge Medications: 1. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 2. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:28 Tablet(s) Refills:0 3. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks. Disp:42 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: perforated gallbladder 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 perforated gallbladder. You had the fluid around the gallbladder drained. You were treated with antibiotics. JP Drain Care: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___
10139461-DS-11	10,139,461	25,057,350	DS	11	2153-03-13 00:00:00	2153-03-14 23:18:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: abdominal pain, perforated gallbladder Major Surgical or Invasive Procedure: ___: open cholecystectomy History of Present Illness: ___ a history of cholelithiasis and perforated gallbladder s/p CT guided drainage on ___ who presents to the ED today with acute onset RUQ and epigastric pain. The pain does radiate to the back and is exacerbated by deep breaths. She notes that she had significant relief of her pain after CT guided drainage approximately two months ago and has felt well since that time until today. Of note, the drain initially put out bilious fluid for approximately one week after it was placed but has had very little output since that time. She denies arm or jaw pain, jaundice and is moving her bowels regularly. She does, however, endorse subjective fevers and chills. Past Medical History: PMH: HTN, cholelithiasis, palpitations PSH: parotidectomy, CT-guided drain placement Social History: ___ Family History: Notable for one brother and one sister with no medical problems. Both her parents are deceased, reportedly of "old age." There is no history of cancer, diabetes, coronary disease, strokes, sudden death, or other inherited medical problems. Physical Exam: Physical Exam on Admission: Vitals: 96.6 72 ___ RA GEN: A&O, mildly uncomfortable HEENT: No scleral icterus, mucus membranes moist CV: RRR, No M/G/R PULM: Clear to auscultation b/l, No W/R/R ABD: soft, mildly tender to palpation in the epigastrium and RUQ, no rebound or guarding Ext: No ___ edema, ___ warm and well perfused Pertinent Results: ___ 07:35PM BLOOD WBC-10.9 RBC-5.11# Hgb-14.2# Hct-41.0# MCV-80* MCH-27.8 MCHC-34.7 RDW-13.6 Plt ___ ___ 07:35PM BLOOD Neuts-88.2* Lymphs-8.4* Monos-1.7* Eos-0.9 Baso-0.7 ___ 05:30AM BLOOD ___ PTT-30.3 ___ ___ 01:56AM BLOOD ___ ___ 07:35PM BLOOD Glucose-157* UreaN-14 Creat-0.6 Na-137 K-3.6 Cl-99 HCO3-25 AnGap-17 ___ 07:35PM BLOOD ALT-19 AST-21 AlkPhos-85 TotBili-0.5 ___ 12:45PM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 ___ 06:40AM BLOOD WBC-5.3# RBC-3.60* Hgb-9.8* Hct-31.1* MCV-86 MCH-27.2 MCHC-31.5 RDW-13.8 Plt ___ ___ 01:56AM BLOOD ___ ___ 06:40AM BLOOD Glucose-143* UreaN-6 Creat-0.6 Na-140 K-3.9 Cl-108 HCO3-27 AnGap-9 Brief Hospital Course: The patient presented to the ___ Emergency Department on ___ for the above complaints. She was seen by members of the surgery staff in the ED and was subsequently admitted to the floor ___. She was scheduled for the OR on ___, but developed sinus tachycardia overnight. Her vitals were otherwise stable, blood pressure was normal, and urine output was normal. She continued to have tachycardia for the next day, and intravenous metoprolol was started to treat the tachycardia; she was asymptomatic of this. The tachycardia trended down and she no longer required metoprolol for rate control. She was taken to the OR on ___ for laparoscopic cholecystectomy, however given chronic inflammation the case had to be converted to open. A JP drain in the gallbladder fossa was left because of inflammation surrounding the gallbladder. She did well post-operatively but on ___ started to have tachycardia again with rate 110s-130s. On ___, she started to go into AFib with RVR in the 160s, was hemodynamically stable otherwise but was transferred to the surgical intensive care unit for further monitoring given no apparent history of atrial fibrillation. Started on 25mg IV diltiazem and standing PO regimen of 30mg q6h with improvement in HR to 100s. She was seen by the cardiology service who agreed with management as above. She converted into sinus rhythm. She was transferred back to the floor. She was continued on antibiotics cipro and flagyl given extensive inflammation and will complete a five day course. He diet was advanced to regular by the time of discharge, and she was tolerating this diet well. She was ambulating independently by the time of discharge. The output of the JP drain was minimal by the day of discharge, but was left in place given inflammation and will likely be removed in the office at time of followup. She will be discharged on diltiazem extended-release PO. A ___ of Hearts outpatient holter monitor was recommended by cardiology, and the patient will pick one up on ___ at the electrophysiology lab. She will followup with ACS Surgery and the Cardiology Service. She was discharged to home in stable condition on ___. She understood the plan for discharge to home and was in agreement. Medications on Admission: lisinopril 2.5'', MVI Discharge Medications: 1. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for Pain: Do not take Tylenol while taking this medicine. Do not drive while taking this medicine. Disp:40 Tablet(s) Refills:0 2. guaifenesin 100 mg/5 mL Syrup Sig: ___ MLs PO Q6H (every 6 hours) as needed for cough. 3. diltiazem HCl 120 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily). Disp:30 Capsule, Extended Release(s) Refills:2 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 2 days. Disp:4 Tablet(s) Refills:0 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 2 days. Disp:6 Tablet(s) Refills:0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: cholelithiasis and perforated gallbladder s/p CT guided drainage 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 a cholecystectomy. You have recovered well and are ready to continue your recovery at home. 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: Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. Avoid swimming and baths until your follow-up appointment. You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. If you have staples, they will be removed at your follow-up appointment. If you have steri-strips, they will fall off on their own. Please remove any remaining strips ___ days after surgery. JP DRAIN CARE: Please look at the site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warm to touch, fever). Maintain suction of the bulb. Note color, consistency, and amount of fluid in the drain. Call the doctor, ___, or ___ nurse if the amount increases significantly or changes in character. Be sure to empty the drain frequently. Record the output, if instructed to do so. You may shower; wash the area gently with warm, soapy water. Keep the insertion site clean and dry otherwise. Avoid swimming, baths, hot tubs; do not submerge yourself in water. *Make sure to keep the drain attached securely to your body to prevent pulling or dislocation. Followup Instructions: ___
10139504-DS-19	10,139,504	29,112,725	DS	19	2195-02-08 00:00:00	2195-02-11 20:30:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin Attending: ___. Chief Complaint: LLE cellulitis Major Surgical or Invasive Procedure: None History of Present Illness: ___ with a history of BPH and a recent hospitalization for LLE cellulitis, sent home on ___, presenting after a fall with persistent cellulitis. The patient was admitted at ___ from ___ to ___ for left lower extremity cellulitis, which was treated with cefazolin transitioned to clindamycin. On discharge he was set up with ___ services at home. He reports that he was unable to fill his clindamycin prescription and has not taken any antibiotics since discharge on ___. At home, he noticed that his wound had persistent drainage, and the area around the wound had increasing redness. The day of presentation, he tripped while en route to answering the door for ___ - he reports that his cane is poor quality and slips. No head strike, no LOC, no pain in the extremities after fall. EMS was called, who noted that the patient's house was dirty, with rats and trash. He was subsequently brought to ED by EMS. On ROS, the patient denies fever, chills, pain in the leg, chest pain, palpitations, SOB. Does report relatively limited PO intake at baseline. In the ED, initial vitals were: 99.4 94 127/49 16 95% RA Exam notable for cellulitis on LLE extending outside of prior border. New border demarcated in ED. Labs notable for hyperkalemia to 5.9, UA with few bacteria but no leuk/nitrites, lactate 1.8. WBC 2.9 w/ 75% neutrophils, CRP 8.0. Patient was given 1L IVF and vancomycin. Decision was made to admit for IV antibiotics and social evaluation. Past Medical History: 1. Left distal radius fracture (___) 2. Left hip displaced femoral neck fracture s/p hemiarthroplasty 3. History of bladder diverticulum 4. BPH w/ recurrent UTI's 5. Osteopenia Social History: ___ Family History: non-contributory Physical Exam: ADMISSION PHYSICAL EXAM ========================== VS: 98.1PO 140 / 71 75 19 100 RA Gen: Cachectic and pale but comfortable-appearing elderly male, responsive, not in distress HEENT: 3 cm mobile mass at the angle of the L mandible. CV: Normal S1S2, irregular sounding rhythm, no rubs or murmurs Pulm: Clear bilaterally to auscultation Abd: Soft, non-tender, non-distended Ext: S/P amputation of the R toes. Diminished DP pulses bilaterally with cool distal lower extremities. Left lower extremity with ___ pitting edema, 4 cm open abrasion on the left shin without drainage or purulence. Significant erythema with warmth in the area outlined on large area outlined on left shin, non-tender to palpation. ___ sign negative. Granulation tissue on anterior shin. Chronic venous stasis changes bilaterally. Toes without ulcers or skin breakage but with significant onycomycosis. Neuro: AOX3. CNII-XII grossly intact. Moving all extremities spontaneously. Psych: Appropriate but tangential speech, intellectualizes illness DISCHARGE PHYSICAL EXAM ========================== VS: T 97.9, BP 117/48, P 63, RR 18, SaO2 98% RA GEN: elderly-appearing gentleman, deconditioned, engaged, NAD HEENT: NCAT, EOMI, pupils 2mm b/l and minimally responsive to light, NECK: supple, no LAD, 4cm diameter mobile lipoma along PULM: CTAB CV: RRR, no M/R/G, nl S1/S2 ABD: soft, ND/NT EXT: Large area of erythema outlined in blue ink over extensor surface of LLE, extending from knee to malleolus, with 4 cm diameter open abrasion over L tibia overlain by granulation tissue. Erythematous area non-tender, slightly warm, and with 1+ pitting edema. Advanced onychomycosis of all LLE toenails. S/p amputation of all LRE toes. LRE non-edematous. ___ DPs diminished b/l. NEURO: ___ strength ___ hip extension/flexion, ___ knee extension/flexion, ___ plantarflexion/dorsiflexion b/l SKIN: ___ chronic venous stasis changes b/l, no rashes appreciated PSYCH: calm and engaged, speaks fluidly on range of abstract topics but redirectable Pertinent Results: ADMISSION LABS ====================== ___ 04:55PM BLOOD WBC-2.9* RBC-3.64* Hgb-11.1* Hct-33.9* MCV-93 MCH-30.5 MCHC-32.7 RDW-13.2 RDWSD-44.4 Plt ___ ___ 04:55PM BLOOD Neuts-75.7* Lymphs-12.2* Monos-11.5 Eos-0.0* Baso-0.3 Im ___ AbsNeut-2.16 AbsLymp-0.35* AbsMono-0.33 AbsEos-0.00* AbsBaso-0.01 ___ 04:55PM BLOOD Glucose-82 UreaN-45* Creat-1.4* Na-136 K-5.8* Cl-99 HCO3-20* AnGap-23* ___ 04:55PM BLOOD ALT-13 AST-50* CK(CPK)-320 AlkPhos-60 TotBili-0.4 DirBili-<0.2 IndBili-0.4 ___ 04:55PM BLOOD Albumin-3.7 Calcium-9.8 Phos-3.9 Mg-2.3 ___ 04:55PM BLOOD CRP-8.0* ___ 04:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG DISCHARGE LABS ======================= ___ 07:12AM BLOOD WBC-1.8* RBC-3.49* Hgb-10.7* Hct-33.3* MCV-95 MCH-30.7 MCHC-32.1 RDW-13.6 RDWSD-46.8* Plt ___ ___ 07:12AM BLOOD Glucose-82 UreaN-25* Creat-1.1 Na-139 K-4.1 Cl-106 HCO3-22 AnGap-15 ___ 07:12AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.1 MICROBIOLOGY ======================= ___ 4:58 pm BLOOD CULTURE Blood Culture, Routine (Pending): No growth to date. ___ 6:05 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). IMAGING ======================= ___ ___ IMPRESSION: Significant tibial arterial insufficiency to the lower extremities bilaterally. BILATERAL ___ venous US ___ IMPRESSION: 1. Nonocclusive deep vein thrombosis of one of the left posterior tibial veins within the mid calf. 2. No evidence of deep venous thrombosis in the rightlower extremity veins. Brief Hospital Course: ___ with a history of BPH and a recent hospitalization for LLE cellulitis, sent home on clindamcyin, presenting after a fall with persistent cellulitis. #LLE Cellulitis: Admitted for tx of LLE cellulitis from ___ after fall outdoors, and did not adhere to outpt PO clindamycin regimen after d/c due to inability to obtain meds. Re-presented with persistent erythema, edema, and warmth on exam surrounding healing 4cm diameter abrasion. Afebrile and HDS but leukopenic. No systemic symptoms. No abscesses. Treated initially with vancomycin, transitioned to keflex with improvement. Keflex will be continued for a total of 14 days. ___: Cr bump to 1.4 on admission from 1.1 baseline, likely pre-renal injury in the setting of infection and poor PO intake. Improved with IVF. #LLE DVT: Non-occlusive L posterior tibial vein DVT noted on lower extremity ultrasound. Given history of falls, risk likely outweighs benefit for distal-to-popliteal DVT. Decision was made not to anti-coagulate. #LLE Arterial Calcification: ___ revealed significant tibial arterial insufficiency b/l, and LLE ___ of 1.53, suggesting calcification of LLE vessels. Likely contributing to poor healing of abrasion, and may have predisposed pt to cellulitis. No indication for surgical intervention during admission. #S/p Fall at Home: #Home safety: Likely mechanical in nature. He says he tripped over cord as he was rushing to open his front door. Adamantly denies syncope or prodromal symptoms. ___ consulted and felt patient had no acute ___ needs. In larger context, he is likely approaching a point where safety at home will be an ongoing issue, and it was discussed with him about whether he is open to transitioning to assisted living. He is insistent on living at home, independently, and knows he needs to walk more and consume more calories to maintain his conditioning, but insists he will do it himself. Thus we will focus on risk reduction at home by setting up ___ and close Elder services visit ___ to assess home situation. #Weight loss According to bed weights on ___ and ___, patient has lost >15% of UBW over 8 days. While this discrepancy may be due in part to inaccuracy of bed scale, patient reports strict monitoring of caloric intake and minimal variety in diet. Concern high for eating disorder and/or reduced access to sufficient healthy food due to financial and logistical barriers. Patient was given multivitamin and thiamine during admisison. Will be set up with ___ and Elder Services as above. #Hyperkalemia: K initially 5.9. Likely attributable to ___, metabolic (lactic) acidosis and transcellular shift. Resolved with IL NS. #Benign Prostatic Hypertrophy: Held home dutasteride as is non-formulary; patient refused finasteride. #Anemia: Home ferrous sulfate continued. #Glaucoma: Continued home latanoprost TRANSITIONAL ISSUES: - Patient noted to be newly leukopenic during admisison. Please check CBC with diff at follow-up visit - Continue cephalexin 500mg q8h for a total of 14 days antibiotics - ___ set up for wound checks - Elder services to visit patient on ___ to assess for home safety - L posterior tibial DVT not anticoagulated given fall risk. Recommend repeat ___ in ___ months to assess propagation. - ___ shows severe peripheral vascular disease of L leg. Recommend vascular surgery referral as outpatient if poor wound healing. - Discussed with patient on transitioning to assisted living. He is not interested at this time. Recommend ongoing conversations on this issue. CODE STATUS: DNR/DNI (confirmed with patient) CONTACT/HCP: none. Patient with no friends or family members. Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Clindamycin 300 mg PO Q6H 2. Ferrous Sulfate 325 mg PO DAILY 3. dutasteride 0.5 mg oral DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Vitamin D ___ UNIT PO QMONTH Discharge Medications: 1. Cephalexin 500 mg PO Q8H 2. dutasteride 0.5 mg oral DAILY 3. Ferrous Sulfate 325 mg PO DAILY 4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 5. Vitamin D ___ UNIT PO QMONTH 6.straight cane Dx: L03.116 Px: good Duration: 13 months Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: PRIMARY DIAGNOSIS Cellulitis Mechanical Fall SECONDARY DIAGNOSIS L posterior tibial deep venous thrombosis Peripheral vascular disease Acute kidney injury Neutropenia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. EXT: Extensive erythema surrounded by blue ink over extensor surface of LLE, extending from 8cm below knee to malleolus, with 4 cm diameter open abrasion over L tibia overlain by granulation tissue. Erythematous region decreased in size from yesterday. Non-tender, slightly warm, and with 1+ pitting edema. ___ DPs diminished b/l. R leg atrophic compared to L. Discharge Instructions: Dear Mr. ___, It was a pleasure caring for you at ___. WHY YOU CAME TO THE HOSPITAL? You came because you fell down at home. WHAT WE DID FOR YOU? We saw that your cellulitis in the left leg was getting worse, because you were unable to fill your antibiotic prescription. We gave you antibiotics and your cellulitis started to improve. We set up ___ and Elder Services to visit you to give you assistance at home. You worked with physical therapy to improve your balance. We delivered your antibiotic to your bedside before you left. WHAT YOU SHOULD DO WHEN YOU GET HOME: - Continue taking cephalexin 500mg every 8 hours for 9 more days (end ___ - It's important to increase your calorie count by eating protein rich foods like eggs and meat. We recommend drinking ensure up to 3 times a day to help with this. - Elder services will come to your house on ___ to ensure it is safe to live in - We recommend transitioning to assisted living in the near future. - Please follow-up with your new primary doctor for ___ blood count check in the next week It was our pleasure caring for you. We wish you the best! Sincerely, Your ___ care team Followup Instructions: ___
10139504-DS-21	10,139,504	27,059,994	DS	21	2195-06-17 00:00:00	2195-06-18 13:01:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: Aspirin Attending: ___. Chief Complaint: unsafe living condition Major Surgical or Invasive Procedure: N/A History of Present Illness: Mr. ___ is a ___ y/o man with PMH of osteopenia with a history of falls and multiple fracture, BPH c/b recurrent UTIs, and recent admission to ___ for E. Coli bacteremia and concomitant C. Diff infection, presenting with cc of "living in a state of disrepair" 1 day after being discharged from ___. The patient was recently admitted to ___ between ___ and ___ after being found down by ___ in an incredibly cluttered and unsafe living environment. He was found to have hematuria ___ traumatic foley) and some form of SVT (?Aflutter with variable block) ___ E. Coli UTI and bacteremia. He was also found to have toxic metabolic encephalopathy, ___ infection and ___. He was initially treated with CTX, narrowed to cipro based on sensitivities and completed a 2 week course. He was given fluids, which helped resolve his UTI. For his SVT, he was started on metoprolol but not anticoagulated ___ frequent falls. His initial toxic metabolic encephalopathy also resolved at time of discharge. Lastly, his course was complicated by C. Diff, recurrent, treated with planned course of PO Vanco through ___ (2 weeks after completion of cipro). Per OMR, he had been doing well at ___ since discharge. However, his ___ went to see him on day of presentation (1 day following discharge from ___) and again found him to be living in unsafe environment. Per patient, he feels unjustly admitted. He states that he feels find, no complaints. Specifically denies any fevers, chills, chest pain, SOB, N/V, abdominal pains. He is making urine well without any dysuria or hematuria. No diarrhea, moving bowels every day. No hematochezia or melena. Denies any worsening swelling of his legs, states that they are always swollen, worse when he stands up, better when wrapped with elevation. He denies any pain in his calfs apart from baseline discomfort associated with the chronic ulcerations in his legs. He is very pleasant and happy to be here but upset that the ___ girl called the police" to bring him to the ED. He does add that over the past few weeks, he has been moving in and out of bed regularly, working with physical therapy and ambulating with his cane. In the ED, initial vitals: T 99, HR 80, BP 172/51, RR 20, 98% RA Exam notable for: -comfortable NAD, A&Ox3, very pleasant -lungs CTABL -abd soft/nt/nd -BLE with chronic erythema and thickening superficially, in a symmetric distribution, up to the mid-shin, with intact pulses, strength and sensation distally. Small edema noted. -RRR +S1S2 no m/r/g -no ST/CVAT Labs notable for: -CBC: WBC 4.2, Hgb 9.5 (baseline), Hct 29.2, Plt 200 -Chem10 notable for BUN/Cr 38/1.3 (baseline Cr 1) 142 / 105 / 38 -------------- 130 4.3 \ 23 \ 1.3 Ca: 9.4 Mg: 2.2 P: 3.6 - Imaging notable for LENIs showing: 1. Deep vein thrombosis in one of the left posterior tibial veins. 2. No DVT in the right lower extremity. 3. Severe bilateral calf edema. Pt given: - 500cc NS x1 - Vitals prior to transfer: 98.7, 81, 153/60, 18, 97% RA On the floor, he endorses the above history without any issues. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Past Medical History: 1. Left distal radius fracture (___) 2. Left hip displaced femoral neck fracture s/p hemiarthroplasty 3. History of bladder diverticulum 4. BPH w/ recurrent UTI's 5. Osteopenia Social History: ___ Family History: non-contributory Physical Exam: ADMISSION: ========== Vital Signs: 97.9 162/66 90 20 95 Ra General: Alert, oriented, no acute distress HEENT: NC/AT, +temporal wasting, loss of periorbital fat, sclerae anicteric, MMM, oropharynx clear but missing upper teeth with fair to poor dentition; EOMI, PERRL, neck supple, 3x5cm soft, fluid collection on left mid-mandible, which has been present for years per patient; NTTP, no overlying skin changes CV: Regular rate, normal S1 + S2 but with frequent ectopic beats, ___ SEM, best heard in LLSB, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, no r/g, BS+ GU: No foley Ext: Warm, well perfused, 2+ pulses, 1+ edema in b/l ___ up to knees (L slightly greater than R); minimally tender to palpation in b/l calves SKIN: chronic erythematous, blanching skin with well healed scabbed ulcers, no oozing or purulence, no bleeding consistent with chronic venous stasis changes Neuro: symmetric smile, eyebrow raise and palatal elevation; midline tongue on protrusion; strength ___ in b/l UE; ___ in b/l hip flexors; moving other parts of extremities well grossly; sensation to light touch grossly intact and symmetric in b/l UE, torso, and lower extremities DISCHARGE: ========== Vital Signs: 98.1 PO 160 / 58 R 67 12 95 RA General: Alert, oriented, no acute distress HEENT: NC/AT, +temporal wasting, loss of periorbital fat, sclerae anicteric, MMM, oropharynx clear but missing upper teeth with fair to poor dentition CV: Regular rate, normal S1 + S2 but with frequent ectopic beats, ___ SEM, best heard in LLSB, no rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi Abdomen: Soft, non-tender, non-distended, no r/g, BS+ GU: No foley Ext: Warm, well perfused, 2+ pulses, 1+ edema in b/l ___ up to knees (L slightly greater than R); minimally tender to palpation in b/l calves. s/p R midforefoot amputation. SKIN: chronic erythematous, blanching skin with well healed scabbed ulcers, no oozing or purulence, no bleeding consistent with chronic venous stasis changes Neuro: grossly intact Pertinent Results: ADMISSION LABS: =============== ___ 06:27PM PLT COUNT-200 ___ 06:27PM NEUTS-65.5 ___ MONOS-10.5 EOS-0.2* BASOS-0.5 IM ___ AbsNeut-2.76 AbsLymp-0.96* AbsMono-0.44 AbsEos-0.01* AbsBaso-0.02 ___ 06:27PM WBC-4.2 RBC-3.05* HGB-9.5* HCT-29.2* MCV-96 MCH-31.1 MCHC-32.5 RDW-14.8 RDWSD-51.4* ___ 06:27PM CALCIUM-9.4 PHOSPHATE-3.6 MAGNESIUM-2.2 ___ 06:27PM estGFR-Using this ___ 06:27PM GLUCOSE-130* UREA N-38* CREAT-1.3* SODIUM-142 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-23 ANION GAP-18 PERTINENT LABS: =============== ___ 08:20AM BLOOD WBC-3.7* RBC-2.99* Hgb-9.3* Hct-28.5* MCV-95 MCH-31.1 MCHC-32.6 RDW-14.9 RDWSD-52.0* Plt ___ ___ 08:15AM BLOOD Glucose-93 UreaN-33* Creat-1.1 Na-141 K-4.5 Cl-108 HCO3-20* AnGap-18 ___ 08:15AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.0 ___ 07:25AM BLOOD VitB___ IMAGING: ======== ___ Lower extremity U/S IMPRESSION: 1. Deep vein thrombosis in one of the left posterior tibial veins. 2. No DVT in the right lower extremity. 3. Severe bilateral calf edema. Brief Hospital Course: Mr. ___ is a ___ y/o man with PMH of osteopenia with a history of falls and multiple fracture, BPH c/b recurrent UTIs, and recent admission to ___ for E. Coli bacteremia and concomitant C. Diff infection, admitted 2 days after discharge from rehab due to concern over unsafe living conditions, incidentally found to have distal DVT. He was placed on apixaban while inpatient for his distal DVT, discontinued at discharge given location and risk of fall. Social work coordinated with elder services and health care proxy to create safe monitored home environment. TRANSITIONAL ISSUES: [] lower extremity ultrasound to monitor for extension of L posterior tibial DVT [] Consider initiation of anticoagulation with conversation with patient and health care proxy if the DVT is still present or progressing [] consider outpatient referral for neurocognitive eval [] Elder services was contacted on discharge of the patient to perform a home safety check on day after discharge Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 2. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever 4. Finasteride 5 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Metoprolol Succinate XL 25 mg PO DAILY Discharge Medications: 1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID RX dorzolamide 2 % 1 drop ophth to both eyes three times a day Disp ___ Milliliter Milliliter Refills:0 2. Finasteride 5 mg PO DAILY RX finasteride 5 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS RX latanoprost 0.005 % 1 drops ophth to both eyes at nighttime Refills:0 4. Metoprolol Succinate XL 25 mg PO DAILY RX metoprolol succinate 25 mg 1 tablet(s) by mouth daily Disp #30 Tablet Refills:0 5. Tamsulosin 0.4 mg PO QHS RX tamsulosin 0.4 mg 1 capsule(s) by mouth daily Disp #30 Capsule Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: Distal DVT Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. ___, You were admitted because your ___ services were worried about your living conditions. While you were in the hospital, you were found to have a blood clot in your leg. You were put on medication for this, which was discontinued at discharge. You will need to get a follow up ultrasound with your primary care doctor in 2 weeks. You were seen by physical therapy, social work and case management to help coordinate your care. It was a pleasure taking care of you! Your ___ Team Followup Instructions: ___
10139504-DS-23	10,139,504	23,099,959	DS	23	2195-09-15 00:00:00	2195-09-15 16:35:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending: ___. Chief Complaint: Found down, constipation and urinary retention Major Surgical or Invasive Procedure: None. History of Present Illness: ___ yo M with PMH HTN, multiple falls s/p fractures, BPH with recurrent UTIs and bacteremia, h/o Cdiff x2 who presents from patient's apartment found by friend in ___ seated and not ambulating subsequently BIBA to ___ for further evaluation. Per EMS report pt was found sitting on the ground by a friend, half clothed, and having difficulty ambulating. When interviewed by EMS pt still seated in his apartment, aox3, warm and dry, without complaint. Complaining of abdominal distention with constipation. Patient describes a ability to pass flatus but describes decreased bowel movements over the past week, worse in his usual chronic constipation. Patient denies any fevers or chest pain or shortness of breath. No belly pain. Per friend to EMS collateral, pt has apparently been through this scenario multiple times recently and has been refusing the services that have been offered however pt appearing to be unable to appropriately care for himself thus pt transported to ED without incident or change in status. In particular, patient had remarkably similar admission ___ after being found down, confused in his apartment where he was admitted with ___ and ___ to have type II NSTEMI. On this admission he underwent TTE which showed slightly reduced EF and likely WMA. He was seen by cardiology who recommended starting a statin and a stress test. Ultimately patient decided he would not want intervention should stress test be positive therefore test canceled. He was continued on aspirin and Plavix. ED COURSE: Exam notable for: VS: 96.6 69 145/41 18 98% RA Distended non tender abdomen bladder scan notable for PVR of 800 mL Labs showed: BUN/Cr: 41/1.3, nl blood glucose Hb 11.0 CK: 2925 -> ___ s/p 1L NS lactate 1.6 troponin 0.20 -> 0.21 (downtrending from prior admission) UA unremarkable. EKG: compared to ___ EKG there appears to be flattening T waves in lateral leads V4-V6 with <1mm ST depression as well as ?new biphasic nature of T wave in V2. There are no ST elevations Imaging Significant for: CT Ab Pelv: No acute abnormality, though moderate right and small left pleural effusions as well as new small volume ascites in ab/pelv. Massive prostate and bladder thickening and distension. Moderateleft hydroureteronephrosis w/o obstructing lesion. Partially thrombosed left common iliac aa aneurysm (chronic). Large stool burden. CT Head w/o abnl Patient received: 1L NS #Urology consulted for bladder distension and hydroureter and foley placed. On arrival to the floor, patient ___ feeling well. Rambling somewhat about the nature of being found at his apartment by ___, but redirectable and AOx3. Denies chest pain, palp, fever, chills, nausea and abdominal pain. REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as per HPI Past Medical History: Multiple falls/fractures L distal DVT posterior tibial ___ not treated given hx recurrent falls h/o Cdiff s/p vancomycin BPH with recurrent UTIs Social History: ___ Family History: Non contributory Physical Exam: ADMISSION PHYSICAL EXAM: ======================= VS: 98.7 PO 153 / 54 R Lying 76 18 94 Ra GENERAL: NAD, conversant. AOx3 ___, self, year, month, day of week (not day #) HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva, dry mucous membranes. halitosis. NECK: no JVD HEART: RRR, S1/S2, no murmurs, gallops, or rubs LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably ABDOMEN: minimally distended nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly EXTREMITIES: paper thin ___ skin b/l with areas of desquamation most notable on left distal extremity on posterior and lateral aspects. No areas of desquamation/bleeding. No areas of purulence or erythema. E/o of right TMA. PULSES: 2+ DP pulses bilaterally NEURO: A&Ox3, moving all 4 extremities with purpose DISCHARGE PHYSICAL EXAM ======================= reviewed in POE, wnl except for BP 156/61 GENERAL: NAD, lying in bed HEENT: NC/AT. No conjunctival pallor or injection, sclera anicteric and without injection. MMM, OP is clear. NECK: Supple. CARDIAC: RRR, no M/R/G. No JVD. LUNGS: CTAB ABDOMEN: Soft, mildly distended (unchanged), non-tender, +BS, No organomegaly. GU No suprapubic tenderness, foley in place - draining yellow urine. Blood around meatus appears old and unchanged EXTREMITIES: No c/c/e, wounds dressed NEUROLOGIC: AOx3. Moves all four extremities with purpose Pertinent Results: ASMISSION LABS ============== ___ 11:40AM BLOOD WBC-6.9 RBC-3.61* Hgb-11.0* Hct-34.7* MCV-96 MCH-30.5 MCHC-31.7* RDW-14.4 RDWSD-49.8* Plt ___ ___ 11:40AM BLOOD Neuts-81.1* Lymphs-9.6* Monos-8.7 Eos-0.0* Baso-0.3 Im ___ AbsNeut-5.56# AbsLymp-0.66* AbsMono-0.60 AbsEos-0.00* AbsBaso-0.02 ___ 11:40AM BLOOD Plt ___ ___ 11:40AM BLOOD Glucose-73 UreaN-41* Creat-1.3* Na-142 K-4.8 Cl-104 HCO3-22 AnGap-16 ___ 11:40AM BLOOD CK(CPK)-2925* ___ 11:40AM BLOOD CK-MB-49* MB Indx-1.7 ___ 05:51AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1 ___ 02:48PM BLOOD Lactate-1.6 PERTINENT INTERVAL RESULTS ========================== ___ 05:00AM BLOOD WBC-4.8 RBC-2.88* Hgb-9.2* Hct-28.0* MCV-97 MCH-31.9 MCHC-32.9 RDW-14.6 RDWSD-50.9* Plt ___ ___ 05:00AM BLOOD ___ PTT-29.5 ___ ___ 05:00AM BLOOD Glucose-102* UreaN-36* Creat-1.2 Na-144 K-4.5 Cl-107 HCO3-23 AnGap-14 ___ 10:55PM BLOOD CK(CPK)-1672* ___ 05:51AM BLOOD CK(CPK)-1246* ___ 05:00AM BLOOD LD(LDH)-260* CK(CPK)-573* TotBili-0.3 DirBili-<0.2 IndBili-0.3 ___ 05:05AM BLOOD CK(CPK)-224 ___ 10:55PM BLOOD CK-MB-23* MB Indx-1.4 cTropnT-0.21* ___ 02:03AM BLOOD cTropnT-0.21* DISCHARGE RESULTS ================= ___ 04:45AM BLOOD WBC-4.6 RBC-2.71* Hgb-8.6* Hct-26.4* MCV-97 MCH-31.7 MCHC-32.6 RDW-14.0 RDWSD-48.5* Plt ___ ___ 04:45AM BLOOD ___ PTT-31.9 ___ ___ 04:45AM BLOOD Glucose-94 UreaN-42* Creat-0.9 Na-138 K-4.9 Cl-103 HCO3-24 AnGap-11 ___ 04:45AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.1 URINE STUDIES ============= ___ 09:06PM URINE Color-Yellow Appear-Clear Sp ___ ___ 09:06PM URINE Blood-NEG Nitrite-NEG Protein-30* Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG ___ 09:06PM URINE RBC-1 WBC-2 Bacteri-FEW* Yeast-NONE Epi-<1 ___ 09:06PM URINE CastHy-4* MICROBIOLOGY ============ ___ 9:06 pm URINE **FINAL REPORT ___ URINE CULTURE (Final ___: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. IMAGING ======= cxr ___ IMPRESSION: Minimal patchy right basilar opacity could reflect atelectasis. Small left-sided pleural effusion. ct C-SPINE W/O contrast IMPRESSION: 1. No evidence of fracture or traumatic malalignment. 2. 3.9 cm fat containing lesion adjacent to the left minimal, unchanged, either a lipoma or low grade liposarcoma. 3. Diffuse subcutaneous edema. ct head w/o contrast IMPRESSION: No evidence of fracture or intracranial hemorrhage. ct abd/pelvis w/o contrast IMPRESSION: 1. No acute abnormalities within the abdomen or pelvis. 2. Diffuse anasarca with moderate right and small left pleural effusions, which have increased in size compared to prior. Small volume ascites throughout the abdomen and pelvis is new. 3. Massive prostatomegaly with bladder wall thickening and trabeculation, likely due to chronic bladder outlet obstruction. 4. Moderate left hydroureteronephrosis, unchanged compared to prior, without obstructing lesion identified. Urothelial thickening affecting the proximal left ureter should be correlated with urinalysis to exclude infection. 5. Unchanged partially thrombosed left common iliac artery aneurysm. 6. Unchanged numerous compression deformities throughout the lumbar spine. No evidence of acute fracture. 7. Large stool burden. Brief Hospital Course: ___ yo M with PMH HTN, multiple falls s/p fractures, BPH with recurrent UTIs and bacteremia, h/o Cdiff x2 who presents after being found by friend in apt not ambulating, found to have severe constipation and urinary retention w/mild ___ and mild rhabdomyolysis. ___ #Hydroureteronephrosis #Urinary retention #Severe BPH On admission, the patient presented with a mild ___ on CKD stage II - Cr 1.3, w/baseline Cr 1.1-1.2. This was likely multifactorial in the setting of pigment nephropathy from mild rhabdomyolysis, obstructive from BPH, and severe constipation. Urology was consulted for difficult Foley placement. Foley was successfully placed ___. His home finasteride and tamsulosin were continued. Following these interventions, the patient started auto-diuresing. Serum creatinine decreased to 0.9 on discharge. The Foley was left in place pending an outpatient voiding trial which was scheduled for ___ at the ___ ___ clinic. #Rhabdomyolysis #Hematuria The patient presented with dark red urine in foley tubing and collection bag. This was most likely in the setting of myoglobinuria. His initial CK was 2925 and his UA unremarkable. No IV fluids were administered to treat his mild rhabdomyolysis as a CT scan demonstrated signs of anasarca. His CK down trended during his hospital stay and normalized prior to discharge. Aspirin was continued as his hemoglobin remained stable. Of note, an allergy to aspirin was noted in his chart. It was confirmed with the patient that while he had an episode of hematuria on Aspirin several years ago, he has been taking Aspirin without signs or symptoms of an allergic reaction. During the course of his hospital stay he later developed hematuria which was likely secondary to difficult Foley placement. In this setting, Plavix and subcutaneous heparin were held. His urine subsequently cleared his hemoglobin remained stable. On discharge, there were no signs of active bleeding. The patient should be evaluated for recurrent hematuria during his outpatient urology follow-up next week and restarting Plavix should be considered. #Severe Constipation Patient has a history of chronic constipation. This is exacerbated by poor PO and fluid intake. Large stool burden was demonstrated on CT. He responded well to a bowel regimen. A TSH was 20, but FT4 within normal limits. No therapy for hypothyroidism was initiated. His current bowel regimen should be continued after discharge. #Fall #Safety The patient has been resistant to nursing home placement in the past. He does have home services and a very vigilant friend. However, he has demonstrated on multiple occasions that he is not able to manage at home. He was brought home from rehab the ___ night prior to this current admission and found down the following ___ morning. Patient will need long-term care. The discussion with the patient, his healthcare proxy, case management, and social work the decision was made to discharge him to long term care. STABLE ISSUES ============= #CAD #Troponinemia ___ presentation w/NSTEMI Type II. Trops peaked at 0.42. He underwent ECHO which showed slightly reduced EF and likely WMA. He was seen by cardiology who recommended starting a statin and a stress test. Ultimately patient decided he would not want intervention should stress test be positive therefore test canceled. Troponin 0.2 on admission (downtrending from ___ with EKG lateral T wave flattening comepared to ___. He was asymptomatic on admission and remained asymptomatic throughout his hospital stay. The troponin continue to down trend. It was unlikely that he had a new NSTEMI or ischemia. We continued aspirin, atorvastatin, Metoprolol succinate 25mg daily. Cardiology was contacted and it was confirmed that the patient should be restarted on Plavix given the absence of contraindications. Plavix was subsequently discontinued because of concern for active bleeding as described above. Consider restarting in clinic as above. #Chronic Systolic Heart Failure with Reduced EF Continued on metoprolol, ASA. During his current hospital admission, he presented with effusions bilaterally with mild interval worsening. He was asymptomatic and breathing comfortably on room air. He was auto diuresing well after placement of Foley. #coccyx ulcer, stage III #Bilateral ___ Wounds he presented with desquamated areas of the distal lower extremities. There were no signs of infection. Wound consult was requested. =============== CHRONIC ISSUES: =============== #Glaucoma -continued Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID -continued Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS #H/o arrhythmia h/o recent admission for possible aflutter. Decision not to anticoagulate and left on Toprol XL. -bblkr as above #Hx DVT Patient with DVT in left posterior tibial vein seen on ultrasound on ___ which was not treated in setting of multiple falls. Patient has not had significant HD instability, CP, SOB, or hypoxia to suggest PE. #Chronic Sacral ulcer Present on last admission. Previously required bedside debridement. -Continue previous outpatient follow-up MEDICATION CHANGES ================== - started Ascorbic Acid ___ mg PO/NG DAILY Duration: 14 Days; end date: ___ - started Multivitamins W/minerals 1 TAB PO DAILY - started Polyethylene Glycol 17 g PO/NG DAILY TRANSITIONAL ISSUES =================== - voiding trial 2:30 pm on ___ at the ___ clinic - please evaluate for recurrent hematuria. In the absence of recurrence, consider restarting Plavix - continue outpatient follow-up for chronic sacral ulcer - recommend repeat CBC in clinic for stability in the setting of hematuria during hospitalization Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 2. Finasteride 5 mg PO DAILY 3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 4. Metoprolol Succinate XL 25 mg PO DAILY 5. Tamsulosin 0.4 mg PO QHS 6. Atorvastatin 20 mg PO QPM 7. Senna 8.6 mg PO QHS 8. Bisacodyl ___AILY:PRN constipation 9. Docusate Sodium 100 mg PO BID 10. Aspirin 81 mg PO DAILY Discharge Medications: 1. Ascorbic Acid ___ mg PO DAILY Duration: 14 Days END: ___. Atorvastatin 20 mg PO QPM 3. Multivitamins W/minerals 1 TAB PO DAILY 4. Polyethylene Glycol 17 g PO DAILY 5. Senna 8.6 mg PO BID 6. Aspirin 81 mg PO DAILY 7. Bisacodyl ___AILY:PRN constipation 8. Docusate Sodium 100 mg PO BID 9. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID 10. Finasteride 5 mg PO DAILY 11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS 12. Metoprolol Succinate XL 25 mg PO DAILY 13. Tamsulosin 0.4 mg PO QHS Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: #Anemia #Hematuria ___ #Hydroureteronephrosis #Urinary retention #Severe BPH #Fall #Failure to thrive #Severe Constipation #CAD #Troponinemia #Chronic Systolic Heart Failure with Reduced EF #B/l Pleural Effusions #coccyx ulcer, stage III #B/L ___ Wounds Chronic issues: #Glaucoma #H/o arrhythmia #Hx DVT #Chronic Sacral ulcer Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. ___, It was a pleasure taking care of you at the ___ ___! Why was I admitted to the hospital? - You were admitted because you were found on the floor of your apartment. You were confused found to have consitipation and urinary retention. During your hospitalization, we placed a urine catheter to help with your urinary retention and gave you laxatives. - We were concerned about you safety at home. Together with you, your health care proxy, our social workers, and our case managers, we decided to discharge you to a long-term care facility to help you with your daily living activities. What should I do after leaving the hospital? - Please take your medications as listed in discharge summary and follow up at the listed appointments. - Please follow-up with urology on ___ at 2:30pm to assess whether you still need the urine catheter. Thank you for allowing us to be involved in your care, we wish you all the best! Sincerely, Your ___ Team Followup Instructions: ___
10139824-DS-14	10,139,824	24,791,154	DS	14	2152-01-04 00:00:00	2152-01-03 17:16:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___ ___ Complaint: Left LC-1 pelvic and Left acetabular fractures Major Surgical or Invasive Procedure: None History of Present Illness: ___ year old otherwise healthy male s/p fall from room ~20 feet onto his left side, striking his left shoulder first, then his left hip. No head strike, no LOC. He felt immediate pain in the right hip with inability to bear weight. He was taken to ___ in stable condition where CT Head/Neck/Chest/Abdomen and Pelvis revealed Left acetabular fractures as well as Left sacral ala fractures. He was transferred to ___ for further evaluation. ROS: No chest pain, shortness of breath, headache, vision change, abdominal pain, no weakness outside of H&P Past Medical History: s/p subtotal colectomy for precancerous polyps Social History: ___ Family History: NC Physical Exam: T-98.6 HR-90 BP-150/70 RR-18 SaO2-99% RA A&O x 3 Calm and comfortable BUE skin clean and intact Tenderness about L shoulder w/ ROM but no deformity, erythema, edema, induration or ecchymosis Arms and forearms are soft No pain with passive motion of L Elbow/Wrist or R Shoulder/Elbow/Wrist. Radial/Median/Ulnar/Axillary ___ EPL FPL EIP EDC FDP FDI fire 2+ radial pulses Fires biceps/triceps/deltoid Pelvis stable to compression but painful. BLE skin clean and intact No tenderness, deformity, erythema, edema, induration or ecchymosis Thighs and legs are soft No pain with passive motion Saph Sural DPN SPN MPN LPN ___ FHL ___ TA PP Fire 1+ ___ and DP pulses Pertinent Results: ___ 02:33PM WBC-16.3* RBC-4.47* HGB-13.5* HCT-38.6* MCV-87 MCH-30.1 MCHC-34.8 RDW-12.1 ___ 02:33PM PLT COUNT-356 ___ 02:33PM ___ PTT-26.6 ___ ___ 02:33PM GLUCOSE-123* UREA N-15 CREAT-0.9 SODIUM-140 POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-26 ANION GAP-16 ___ 03:01PM GLUCOSE-115* LACTATE-1.1 NA+-139 K+-3.8 CL--99 TCO2-26 Brief Hospital Course: Mr. ___ was admitted to the Orthopedic service on ___ for left acetabular and LC-I pelvic fractures after being evaluated in the emergency room. After carefully reviewing his X-Rays and pelvic CT scan, it was decided that his pelvic injuries would be treated non-operatively. He was made weight-bearing as tolerated in his lower extremities, had adequate pain management and worked with physical therapy while in the hospital. The remainder of his hospital course was uneventful and Mr. ___ is being discharged to home in stable condition. He will follow-up in the Orthopedic Trauma clinic in 2 weeks with repeat pelvic films. Medications on Admission: Simvastatin 40 mg qd Omeprazole Discharge Medications: 1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q4H (every 4 hours) as needed for pain for 2 weeks. Disp:60 Tablet(s) Refills:1 2. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: ___ MLs PO QID (4 times a day) as needed for Dyspepsia. 5. senna 8.6 mg Tablet Sig: ___ Tablets PO DAILY (Daily). 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 8. multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 9. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours) for 2 weeks. Disp:24 syringes Refills:0 12. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO BID (2 times a day) as needed for Dyspepsia. Disp:375 ML(s) Refills:1 Discharge Disposition: Home Discharge Diagnosis: Left LC-1 pelvic and Left acetabular 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: Activity: - Continue to be weight bearing as tolerated on your legs - You should not lift anything greater than 5 pounds. Other Instructions - Resume your regular diet. - Avoid nicotine products to optimize healing. - Resume your home medications. Take all medications as instructed. - Continue taking the Lovenox to prevent blood clots. You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so 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 narcotic (oxycontin, oxycodone, percocet) prescriptions to the pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. - Narcotic pain medication may cause drowsiness. Do not drink alcohol while taking narcotic medications. Do not operate any motor vehicle or machinery while taking narcotic pain medications. Taking more than recommended may cause serious breathing problems. - If you have questions, concerns or experience any of the below danger signs then please call your doctor at ___ or go to your local emergency room. Physical Therapy: Right lower extremity: Full weight bearing Left lower extremity: Full weight bearing Encourage turning, deep breathing and coughing qhour when awake. Followup Instructions: ___
10139983-DS-7	10,139,983	26,537,804	DS	7	2122-12-03 00:00:00	2122-12-03 14:08:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: CP: ___, MD CC: ___ Pain Major Surgical or Invasive Procedure: ERCP with sphincterotomy & stent placement History of Present Illness: Patient is profoundly encephalopathic, disoriented inattentive, confused. History obtained through her son who is an internist and is at patients bedside. Patient is an ___ with recently diagnosed Parkinsons ___ years prior well maintained on Sinemet who has been suffering from band-like abdominal pain described as pressure sensation across epigatrium in a band like disrivution over the past several years. She originally lived on a ranch in ___, only recently moving to the ___ area. Work up in ___ previously revealed gallstones and biliary dilatation beyond expected for age but otherwise nothing significant. Family declined MRCP given age, comorbidities and unlikely to change management. More recently her home ___ found her nauseas, vomiting and with worsening abdominal pain. No fevers at home, no chills reported. Reports constipation, passing hard stools recently. She was sent to the ED by home ___. In the ED, initial vitals were: Temp 99.1 HR 103 146/66 18 96%RA. Labs revealed elevated LFTs, WBC with leukocytosis and CT A/P revealed cholangitis with choledocholithiasis. ERCP was consulted who recommended admission and plan for ERCP in the AM. She was given IVFs and Ciprofloxacin prior to transfer. On the floor, patient is profoundly confused, thinks she is on an airplane but otherwise has no significant complaints and appears well. Review of systems: Unable due to mental status Past Medical History: ___ Disease with dementia, MOCA 13 History of gallstones Constipation Depression Anxiety Social History: ___ Family History: Mothers side with ___ Mellitus No hepatobiliary disease Physical Exam: Admission exam: Vitals: 98.1 136/61 87 16 97%RA Pain Scale: Unable General: Patient appears confused, disoriented, inattentive and tangential. She is lethargic, laying in bed covered with blankets but appears remarkably well given presentation for cholangitis. HEENT: Pale, sclera anicteric, dry MM, halitosis Neck: JVP low, no LAD appreciated Lungs: Clear to auscultation bilaterally, moving air well and symmetrically, no wheezes, rales or rhonchi appreciated CV: Tachycardic rate, regular rhythm, S1 and S2 hyperdynamic Abdomen: soft, tender to palpation in RUQ without rebound or guarding. Non-distended Ext: RUE swollen, tight but non-erythematous, non-tender to palpation. UE and ___ bilaterally are warm with good pulses. Neuro: Oriented to self only, inattentive, tangential, clearly off baseline per son ___: Vital Signs: T97.7 BP 144/64 P68 RR18 O2 sat 98%RA GEN: NAD, well-appearing CV: RRR s1s2 PULM: CTA anterior GI: normal BS, non-tender, non distended EXT: warm, no edema NEURO: alert, oriented x 2 (didnt ask date), answers ?appropriately, follows commands, close to baseline per family PSYCH: appropriate ACCESS: PIV FOLEY: absent Pertinent Results: Admission Labs ___ 04:20PM BLOOD WBC-19.5* RBC-4.93 Hgb-15.0 Hct-46.7* MCV-95 MCH-30.4 MCHC-32.1 RDW-14.2 RDWSD-49.1* Plt ___ ___ 04:20PM BLOOD Neuts-90.1* Lymphs-3.0* Monos-6.1 Eos-0.1* Baso-0.2 Im ___ AbsNeut-17.60* AbsLymp-0.59* AbsMono-1.19* AbsEos-0.02* AbsBaso-0.04 ___ 08:24PM BLOOD ___ PTT-30.7 ___ ___ 04:20PM BLOOD Glucose-136* UreaN-11 Creat-0.8 Na-137 K-4.3 Cl-98 HCO3-24 AnGap-19 ___ 04:20PM BLOOD Albumin-4.4 Calcium-10.3 Phos-2.8 Mg-2.3 ___ 04:20PM BLOOD ALT-141* AST-595* AlkPhos-162* TotBili-3.4* ___ 04:20PM BLOOD Lipase-18 ___ 08:15PM BLOOD Lactate-2.0 ___ 8:00 pm BLOOD CULTURE *FINAL REPORT ___ Blood Culture, Routine (Final ___: LACTOCOCCUS SPECIES. FINAL SENSITIVITIES. Sensitivity testing performed by Sensititre. CLINDAMYCIN <= 0.12 MCG/ML. Levofloxacin Sensitivity testing per ___ STACK ___. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ LACTOCOCCUS SPECIES \| CLINDAMYCIN----------- S ERYTHROMYCIN----------<=0.25 S LEVOFLOXACIN---------- 2 S PENICILLIN G---------- 0.5 S VANCOMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final ___: Reported to and read back by ___. ___ @ 1735 ON ___. GRAM POSITIVE COCCI IN PAIRS AND CHAINS Reports: # AXR (___): Severe colonic fecal loading. No radiographic evidence for small bowel obstruction. # Port CXR (___): Lung volumes are low with bibasilar atelectasis noted. No convincing evidence for pneumonia or edema. No large effusion or pneumothorax. The heart appears relatively normal in size. Mediastinal contour is unremarkable. The imaged bony structures are intact. No free air below the right hemidiaphragm is seen. # Abd/pelvic CT (___): 1. Acute cholangitis secondary to choledocholithiasis with stones seen within the distal CBD with moderate upstream intra and extrahepatic biliary ductal dilatation. 2. Massively distended gallbladder and dilated cystic duct, possibly due to the downstream obstruction, although somewhat unusual. Presence of pericholecystic fluid and gallbladder wall thickening raise concern for acute cholecystitis. 3. Large hiatal hernia. 4. Severe fecal loading extending into the rectum. . # ERCP (___): Multiple large stones were seen in the CBD. The CBD and CHD were dilated to 15 mm. A large cystic duct stone was seen compressing the CBD consistent with a Mirizzi's syndrome. A biliary sphincterotomy was performed with the sphincterotome. A sphincteroplasty was performed to 12 mm. Balloon sweeps were performed with removal of multiple large stones and copious pus. A ___ Fr x 5 cm double pigtail stent was successfully placed into the right hepatic duct. # LIVER OR GALLBLADDER US (SINGLE ORGAN) ___ INDICATION: ___ year old woman with ___ disease, admitted with biliary sepsis and choledocholithiasis, abd CT ___ showed massively distended GB and dilated cystic duct, s/p ERCP ___ with sphincterotomy stent placement but unable to remove stone from cystic duct, now clinically doing well // re-assess GB ducts post ERCP with stent placement COMPARISON: CT abdomen pelvis dated ___ FINDINGS: LIVER: The hepatic parenchyma appears within normal limits. The contour of the liver is smooth. An anechoic 2.1 cm simple cyst is seen in segment 5. There is no focal liver mass. The main portal vein is patent with hepatopetal flow. There is a small amount of ascites. BILE DUCTS: There is no intrahepatic biliary dilation and pneumobilia is now os seen. A stent is visualized in the common bile duct. The CBD measures 7 mm and contains a stent. GALLBLADDER: Stones and sludge are again seen within the gallbladder which is less distended though still thick-walled. Sonographic ___ sign was negative. PANCREAS: The pancreas is not well visualized, largely obscured by overlying bowel gas. SPLEEN: Normal echogenicity, measuring 8.8 cm. IMPRESSION: Interval decrease in intrahepatic and extrahepatic biliary dilation with expected pneumobilia post stenting. Stent seen within the gallbladder, which is less distended though still thick walled. Cholelithiasis. ___ 05:54AM BLOOD WBC-9.4 RBC-3.94 Hgb-12.1 Hct-37.1 MCV-94 MCH-30.7 MCHC-32.6 RDW-14.3 RDWSD-49.6 Plt ___ ___ 06:07AM BLOOD Glucose-100 UreaN-6 Creat-0.7 Na-139 K-3.2* Cl-106 HCO3-23 AnGap-13 ___ 07:05AM BLOOD ALT-25 AST-53* AlkPhos-147* TotBili-2.2* Brief Hospital Course: ___ with Parkinsons and dementia well maintained on Sinemet who presents with acute abdominal pain, nausea and vomiting, found to have sepsis due to cholangitis secondary to choledocholithiasis. # sepsis # cholangitis, choledocholithiasis # gram positive bacteremia Ms. ___ was admitted with temps in mid ___, tachycardia, leukocytosis with predominant PMNs, elevated LFTs. Blood cxs ___ positive for GPC pairs and chains. She had markedly dilated CBD with distal CBD stone and distended GB on Abd CT scan - all concerning for cholangitis +/- cholecystitis. She went for ERCP on ___ where there was evidence of ___ pus in CBD, s/p extraction of stones, sphincterotomy, CBD stent placement. There was also evidence of Mirizzi's syndrome - with cystic duct compressing the CBD. This stone could not be extracted and thus surgery was consulted. She was treated with IV vanco/cipro/flagyl. After the ERCP, her symptoms were much improved, and her abdominal pain/N/V entirely resolved by ___. No signs of cholecystitis were evident so cholecystostomy tube was not indicated. Surgery recommended follow up with Dr. ___ as an ___ for evaluation of elective cholecystectomy. Subsequent blood cultures from ___ and ___ were negative, and she remained afebrile and hemodynamically stable. The GPC from ___ blood culture was speciated on ___ as lactococcus, the clinical significance of which was unclear, and ID was consulted. Per ID, "Lactococcus is used in cheese making but can occasionally be a human pathogen, however is of low virulence. As her culture turned positive within 24h of admission in the setting of an intra-abdominal infection there is enough suspicion to diagnose a true blood stream infection." Sensitivities were requested from micro lab, and she was discharged on oral levofloxacin and metronidazole until ___ per ID recommendations. # Encephalopathy: Secondary to underlying sepsis. This resolved with ERCP and antibiotics. # Parkinsons Disease, Dementia - MOCA 13 # anxiety - Continue Sinemet per home regimen - Continue Venlafaxine # Constipation: Severe fecal loading on imaging. Treated with aggressive bowel regimen which was continued upon discharge. # Urinary retention: thought to be ___ severe constipation, foley was discontinued after BM was successful. Patient passed voiding trial and was discharged home w/o foley. Home trospium was continued as was held on initial presentation to the hospital and only resumed the day prior to discharge. It was felt not to be contributing to the retention that she developed. . #CODE STATUS: [X]DNR/DNI - MOLST completed and with PCP ___ on ___: The Preadmission Medication list is accurate and complete. 1. Polyethylene Glycol 17 g PO DAILY 2. Temazepam 15 mg PO QHS 3. melatonin 6 mg oral QHS:PRN insomnia 4. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS 5. Carbidopa-Levodopa (___) 1 TAB PO QID 6. Aspirin 81 mg PO DAILY 7. Cyanocobalamin 1000 mcg PO DAILY 8. Vitamin D 1000 UNIT PO DAILY 9. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 10. trospium 40 mg oral DAILY 11. Docusate Sodium 200 mg PO BID 12. Venlafaxine XR 37.5 mg PO DAILY Discharge Medications: 1. Carbidopa-Levodopa (___) 1 TAB PO QID 2. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS 3. Polyethylene Glycol 17 g PO DAILY 4. Venlafaxine XR 37.5 mg PO DAILY 5. Vitamin D 1000 UNIT PO DAILY 6. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500 mg(1,250mg) -200 unit oral DAILY 7. melatonin 6 mg oral QHS:PRN insomnia 8. Docusate Sodium 200 mg PO BID 9. Cyanocobalamin 1000 mcg PO DAILY 10. trospium 40 mg oral DAILY 11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation RX bisacodyl [Bisac-Evac] 10 mg 1 suppository(s) rectally daily Disp #30 Suppository Refills:0 12. Fleet Enema ___AILY:PRN constipation RX sodium phosphates [Disposable Enema] 19 gram-7 gram/118 mL 1 enema(s) rectally daily Refills:0 13. Senna 8.6 mg PO BID RX sennosides [Evac-U-Gen (sennosides)] 8.6 mg 1 tab by mouth twice a day Disp #60 Tablet Refills:0 14. Temazepam 15 mg PO QHS 15. Levofloxacin 500 mg PO Q24H Duration: 10 Days RX levofloxacin [Levaquin] 500 mg 1 tablet(s) by mouth daily Disp #10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: ___ Discharge Diagnosis: # sepsis # cholangitis # cystic duct stone with Mirizzi's syndrome Secondary: # metabolic encephalopathy # acute urinary retention # vasovagal presyncope # ___ disease # dementia Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure looking after you, Ms. ___. As you know, you were admitted with infection of the biliary ducts - arising from stones which were blocking the common bile duct. You underwent a procedure called ERCP - which helped to extract the stones. A biliary stent was also placed to help expedite clearance of any potential future stones. You were also treated with intravenous antibiotics with good response. You were able to tolerate a regular diet. You were not able to urinate so will be sent home with a urine catheter to be taken out as an outpatient. Please continue the antibiotics until ___. You will be encouraged to follow up with surgery for consideration of a cholecystectomy (removal of the gallbladder). Again, it was a pleasure looking after you and we wish you the best of luck! Followup Instructions: ___
10139983-DS-9	10,139,983	20,140,325	DS	9	2123-02-01 00:00:00	2123-02-01 12:26:00	Name: ___ Unit No: ___ Admission Date: ___ Discharge Date: ___ Date of Birth: ___ Sex: F Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending: ___. Chief Complaint: Right hip pain Major Surgical or Invasive Procedure: Right hip hemiarthroplasty ___ History of Present Illness: ___ with hx ___ disease, dementia presenting to the ED s/p fall. Son heard the patient fall at 4AM and rushed over. Has been complaining of R hip pain since the fall. Son reports likely mechanical fall. Patient has difficulty walking at baseline due to her ___ disease. In the ED, patient had work up which showed R femoral neck fracture. Orthopedic surgery consulted for further management. Past Medical History: PMH/PSH: ___ Disease with dementia choledocholithiasis s/p cholecystectomy Constipation Depression Anxiety MEDS: aspirin 81mg daily Milk of Mg 30cc daily prn constipation Miralax 17gm daily prn constipation Calcium, Vit D Docusate 200mg BID carbidopa-levodopa ___ QID carbidopa ER-levodopa 50/200mg QHS Cholecalciferol 1000unit daily ciclopirox 1% shampoo twice weekly Vit B12 hydrocortisone 2.5% topical daily ketoconazole 2% topical daily trospium 40mg QHS venlafaxine 37.5mg QAM Social History: ___ Family History: Mothers side with ___ Mellitus No hepatobiliary disease Physical Exam: Dressings c/d/I. Wound is well approximated without hematoma or induration. NVI distally. Brief Hospital Course: Hospitalization Summary (ED Admit) The patient presented to the emergency department and was evaluated by the orthopedic surgery team. The patient was found to have R femoral neck fracture and was admitted to the orthopedic surgery service. The patient was taken to the operating room on ___ R hip hemiarthroplasty 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 facility was appropriate. The ___ hospital course was otherwise unremarkable. She was found to have a UTI and was treated with Ceftriaxone 2g IV for three days. She was bloused once 500ml yesterday and blood pressure quickly improved. 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 WBAT in the RLE extremity, and will be discharged on Lovenox 40mg for 4 weeks for DVT prophylaxis. The patient will follow up with Dr. ___ routine. A thorough discussion was had with the patient regarding the diagnosis and expected post-discharge course including reasons to call the office or return to the hospital, and all questions were answered. The patient was also given written instructions concerning precautionary instructions and the appropriate follow-up care. The patient expressed readiness for discharge. Medications on Admission: aspirin 81mg daily Milk of Mg 30cc daily prn constipation Miralax 17gm daily prn constipation Calcium, Vit D Docusate 200mg BID carbidopa-levodopa ___ QID carbidopa ER-levodopa 50/200mg QHS Cholecalciferol 1000unit daily ciclopirox 1% shampoo twice weekly Vit B12 hydrocortisone 2.5% topical daily ketoconazole 2% topical daily trospium 40mg QHS venlafaxine 37.5mg QAM Discharge Medications: 1. Acetaminophen 1000 mg PO Q8H 2. Aspirin 81 mg PO DAILY 3. Carbidopa-Levodopa (___) 1 TAB PO QID 4. Carbidopa-Levodopa CR (50-200) 1 TAB PO QHS 5. Cyanocobalamin 100 mcg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Enoxaparin Sodium 40 mg SC QPM Start: Today - ___, First Dose: Next Routine Administration Time 8. Multivitamins 1 TAB PO DAILY 9. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain Duration: 10 Days 10. OxycoDONE (Immediate Release) 2.5 mg PO AT 9AM AND 5PM Duration: 5 Days 11. Pantoprazole 40 mg PO Q24H 12. trospium 40 mg oral QHS 13. Venlafaxine 37.5 mg PO DAILY 14. Vitamin D 800 UNIT PO DAILY Discharge Disposition: Extended Care Facility: ___ Discharge Diagnosis: R 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: - WBAT 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 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. DANGER SIGNS: Please call your PCP or surgeon's office and/or return to the emergency department if you experience any of the following: - Increasing pain that is not controlled with pain medications - Increasing redness, swelling, drainage, or other concerning changes in your incision - Persistent or increasing numbness, tingling, or loss of sensation - Fever > 101.4 - Shaking chills - Chest pain - Shortness of breath - Nausea or vomiting with an inability to keep food, liquid, medications down - Any other medical concerns FOLLOW UP: Please follow up with your surgeon's team (Dr. ___, with ___, NP in the Orthopaedic Trauma Clinic 14 days post-operation for evaluation. Call ___ to schedule appointment upon discharge. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Please follow up with your primary care doctor regarding this admission within ___ weeks and for and any new medications/refills. Physical Therapy: WBAT Treatments Frequency: Please change dressings daily with ABD and tape Followup Instructions: ___

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